Let me start by providing some insight into how some of our programs work. We have a program with a healthcare organization in Pueblo, Colorado, that is focused primarily on chronic care for patients with diabetes, and the issue of food insecurity is a secondary attribute that they look for. Many of their patients have a very low income and are on Medicaid, and the organization sees addressing their dietary deficiencies as a way to help them lower their hemoglobin A1C levels.
The organization determines if a patient is food insecure and whether a Food RX, a voucher program, is appropriate for them. The patients are screened and managed by the care coordinators. Patients who qualify then receive the vouchers to purchase the healthy food.
We also have a different program here in Denver, where food insecurity is the primary attribute that they're looking at. Some of the patients have chronic conditions and some have other health conditions, but because of their food insecurity, the provider believes ensuring the family has food is very important for their care.
We have another program in the Philadelphia area that's a partnership between the clinic and the American Heart Association, and there, the focus is also on chronic care, with a focus on high blood pressure. And the providers have added diet as a component to see if they can help bring patients’ hypertension under control.
So you see providers with different priorities all looking at how food can help lower whatever the critical metrics are – whether its blood pressure, obesity or A1C.
Can you give a little more detail about these programs for finance leaders?
In Colorado, for example, they've adopted the Medicare alternative payment model [APM], and they have a scoring system that's driven by specific metrics. So for a diabetes patient, they measure in terms of reducing A1C. And these providers have added food as one of the components in the care regimen to try to reduce A1C. This can help the provider meet their APM targets.
That gives them a major incentive to work with us to provide patients with access to the food that will help them stay healthy.
So it's an investment in keeping patients healthy so that they don't need high-cost healthcare. The goal is to reduce the acute events.
Here in Denver, for example, we have worked with a clinic called Tepeyac Community Health Center, which serves a highly immigrant population. And before we got started, I was talking with the president of the organization about how we could use our technology to benefit them. And I mentioned to him that I would assume they routinely advise patients who have highly diet-dependent conditions like diabetes on what they should eat and not eat.
His answer surprised me. He said, "Absolutely. We send them to our dietician, who gives them this big sheaf of paper with images and recipes on it and a message that says, ‘Eat this and don’t eat this.’ But at the end of the day, we don’t know if they actually use those guidelines, or if the paperwork just ends up in the floor in the backseat of the car, being stepped on by their kids.”
It was an eye-opening recognition that they had almost zero insights into what patients were doing once they left the clinic.
With the food voucher or card programs, however, because of the reporting, you can actually see what these patients are buying when they go to the store.
So that kind of detailed reporting actually becomes a bridge between the doctor's office and the patients’ activity in the real world. When they come in for their regular visits, the caregivers can see what they bought at the store and discuss with them how they cooked it and who ate it.
How does the program work from the patient's perspective?
With card programs, the patient is issued a card they can carry with them to swipe at the point of sale, or POS. It's essentially a closed-loop debit card.
Card programs are great at very large scale. The big providers — United Healthcare, Humana, Cigna, Kaiser Permanente, for example all have some version of a card program for different programs. Many are for Medicare patients, for example, or they're part of the Medicare Advantage supplement programs for over-the-counter drugs. And in the past couple of years, they've added food benefits to those card programs.
While we are working with some providers to deploy card programs, most of our programs use electronic vouchers. The vouchers are issued electronically to the caregiver, which the has a file of digital vouchers. They can email vouchers to patients, but in most cases, because these are low-income patients, they usually print the vouchers, which the patient then takes to the grocery store. And each voucher has specific terms: it’s worth $10 and it's good for fresh produce and dry beans — or whatever is in the limited-spend catalog its barcode represents. The patients give the voucher to the cashier, who scans it, and the store keeps it, while the software captures the transaction, allowing for the detailed reporting that’s driven by an alphanumeric identifier on the voucher.
We don't see the patient's name, but the caregiver knows who the voucher ID represents and is able to see the date, the time the patient shopped and what they bought.
How is this technology evolving, and what approaches are most promising?
First, there is always going to be a role for cards, because cards can operate at scale and they are user-friendly for certain populations that may not be as tech savvy — particularly older consumers. But new mobile barcode-driven technology has the potential to replace programs that have had to use paper for transmitting the unit of value to the patient. The barcode on a smart phone has the ability to reach otherwise difficult-to-reach inner-city, urban and rural patients because they are increasingly likely to have smart phones. We will be testing this technology in Q4.
Ultimately, however, I think that the right approach has to be what I call “all of the above.”
There will be a role for paper programs because they're the cheapest. But they're labor intensive. The barcode programs can be a lot cheaper than cards, but they're not for everybody. Cigna, for example, is not going to issue 2 million barcodes a month, but they can issue a million cards. So when you look at that hierarchy of options, you can see this kind of proliferation of technologies that serve different segments.
Retailers like Walmart and Kroeger have been leaders in this space for a while, for example. But they don't touch every consumer, and they're not convenient to get to in some cases. And the consumers who are most at need are the ones who live in areas with the highest social determinants of health scores. So our commitment has to be to find strategies to bring technologies that work for those small, independent grocers that so often fill that gap because the majors retailers are not servicing their neighborhoods.
We need to able to access these retailers’ POS system if we are to reach the lower-income consumers who can benefit from participating in these programs. Upper-income families don’t need them so much because they don’t have the same problems with accessing healthy food.
The challenge is that it’s hard for a corner store to adopt a POS system that can process that transaction.
The card technology, for example, is very flexible, but it's extraordinarily expensive. It’s expensive for the healthcare provider to issue the cards and maintain the accounts. And it’s expensive for the retailer to do the integration.. Eventually, we see the mobile bar codes as a more efficient strategy to replace the paper voucher programs and provide access to smaller retailers who also happen to support the most at-risk communities.
It seems that participating in a program like this would give those small retailers to start to provide the healthier foods.
That’s true! If you can bring these programs into these smaller stores, you can increase their sales and turnover. Produce goes bad. So if you can help drive their sales, that incents the retailer. And if you can increase turnover, which means that that produce is less likely to go bad, that’s also going to benefit the retailer. Added to that, the retailer is helping improve the health equity of the neighborhood and improving its direct relationships with its customers. There is a lot of goodwill that goes back and forth in these programs. And that’s a message we want to take to the smaller stores.
What is your message for hospital and health systems around this issue?
One of the things that we've done is to partner with an organization that does processing for the federally funded SNAP [Supplemental Nutrition Assistance Program] and WIC [Special Supplemental Nutrition Program for Women, Infants and Children] in about 25,000 locations around the country. And they are almost exclusively bodegas, corner stores and small groceries. And we're working with them to integrate our technology to their system.
So with that effort, we are looking for healthcare organizations that are interested in reaching those inner-city areas, because we think that with the assistance of our transaction-processing partner, we can help them get to the inner-city areas that they can't reach right now.
Healthcare organizations can be on the receiving end of the POS data available through these programs that can help promote healthfulness in people who otherwise would have difficulty keeping healthy. That’s why I would encourage health system leaders to keep informed about this technology and its evolving potential.
a. For example, a 2020 article published by Brookings explores the “significant economic payoff” investing in health has for developing economies, for while the American Medical Association’s message at a 2015 health summit in Australia was, “Health is the greatest social capital a nation can have. Without a healthy, productive citizenship, a country can’t be economically stable.”