---
type: source
title: "Health Affairs MTM Scaling: Simulation Projections vs. Evidence Gaps — Two Simultaneous Papers"
author: "Multiple authors (Health Affairs Journal)"
url: https://www.healthaffairs.org/doi/10.1377/hlthaff.2025.00161
date: 2025-04-01
domain: health
secondary_domains: []
format: journal-article
status: null-result
priority: medium
tags: [medically-tailored-meals, mtm, health-economics, simulation, modeling, evidence-gaps, scaling, cost-effectiveness]
processed_by: vida
processed_date: 2026-03-18
extraction_model: "anthropic/claude-sonnet-4.5"
extraction_notes: "LLM returned 2 claims, 2 rejected by validator"
---

## Content

Two simultaneous papers published in Health Affairs (April 2025) on scaling medically tailored meals:

**Paper 1: Simulation model (hlthaff.2024.01307)**
- Title: "Estimated Impact of Medically Tailored Meals on Health Care Use and Expenditures in 50 US States"
- State-specific simulation model examining nationwide MTM implementation for adults with diet-sensitive conditions
- Finding: MTMs would be cost-saving in nearly all US states
- Based on observational evidence of MTM impact extrapolated to full state populations

**Paper 2: Perspective/critique (hlthaff.2025.00161)**
- Title: "Modeling the Value of 'Food Is Medicine': Challenges and Opportunities for Scaling Up Medically Tailored Meals"
- Notes MTM programs are "rapidly expanding across the US and increasingly adopted by health care payers"
- Argues for "integrating real-world variations in MTM program design into future models, including dose, duration, and ancillary services"
- Calls for "quality informed by evidence-based standards and advancing patient-centered, equity-oriented approaches"
- Notes "expanding the analytical perspective beyond the health care system to include societal costs and benefits"
- The critique: current models don't reflect complexity of MTM interventions; evidence gaps remain around program design variations

**Cross-paper tension:**
The simulation model projects cost savings; the perspective paper notes the evidence base for those projections is insufficient. This is the same simulation-vs-RCT gap that exists for produce prescriptions and food pharmacies — but now within the MTM literature specifically.

**From related searches:**
- Maryland pilot RCT (2024, JGIM): 74 adults, frozen meals + dietitian calls for 6 months → null HbA1c result (-0.7% treatment vs. -0.6% control, not significant)
- FAME-D trial (ongoing): 200 adults, comparing MTMs to $40/month food subsidy
- Australian MTM trial (commenced Q1 2023, results anticipated March 2025): outcomes unknown

**Policy context at time of publication:**
- 16 states had active or pending Section 1115 waivers for FIM coverage
- CMS VBID termination was already announced but not yet effective
- MA plans were expanding food benefits voluntarily

## Agent Notes

**Why this matters:** The Health Affairs pair is the strongest evidence that the simulation-vs-RCT gap exists WITHIN the MTM category — not just between intervention types. The simulation model projects cost savings; the accompanying perspective paper acknowledges the evidence is thin. This mirrors the Tufts food-as-medicine simulation vs. JAMA null result pattern from Session 1. The pattern is systematic.

**What surprised me:** The Maryland MTM pilot (2024) — with the strongest intervention type, home-delivered pre-prepared meals AND dietitian support — ALSO showed null HbA1c improvement. This was not in any of the major searches from Session 1. It's the most important new finding in Session 2: even MTMs, which have the best observational evidence, show null clinical outcomes in controlled trials. The simulation-vs-RCT gap exists at every level of the FIM intervention ladder.

**What I expected but didn't find:** Positive MTM RCT evidence for HbA1c. I expected that the intervention-type hypothesis would rescue the food-as-medicine thesis — that if you go from produce vouchers to pre-prepared meals, you'd finally see HbA1c improvement. The Maryland pilot suggests you don't.

**KB connections:**
- Directly challenges whether existing food-as-medicine confidence levels are calibrated correctly
- Connects to the simulation-vs-RCT pattern flagged for Theseus (observational → confident prediction → RCT null result)
- The MTM hospitalization/cost data (49% fewer admissions in older studies) is separate from glycemic outcomes — may represent different mechanism (crisis prevention vs. metabolic management)

**Extraction hints:**
- The Maryland MTM pilot null result is extractable as a claim candidate: "Medically tailored meals — the most intensive food-as-medicine intervention — also show null HbA1c improvement in controlled trials, suggesting the clinical evidence gap is not resolved by increasing intervention intensity"
- The Health Affairs pair documents the simulation-vs-evidence gap within MTM literature
- Extract separately: the hospitalization/cost MTM evidence (where older observational studies show strong effects) vs. the glycemic MTM evidence (where RCTs show nothing)

**Context:** Health Affairs published both papers together deliberately — the simulation model and the critique of the simulation model. The journal was signaling that the field needs to reconcile its projection models with the evidence base. This is science doing its job.

## Curator Notes

PRIMARY CONNECTION: Food-as-medicine evidence claims — extends Session 1's produce prescription finding to MTMs
WHY ARCHIVED: Documents the simulation-vs-RCT gap at the highest level of FIM intervention intensity; the Maryland MTM pilot null result is the key new finding
EXTRACTION HINT: Focus on the Maryland MTM pilot null result (HbA1c -0.7% vs. -0.6%, not significant) — this is the strongest disconfirmation of the "better interventions fix the problem" hypothesis


## Key Facts
- Health Affairs published two simultaneous papers on MTM scaling in April 2025: a simulation model (hlthaff.2024.01307) and a perspective critique (hlthaff.2025.00161)
- The simulation model projected MTMs would be cost-saving in nearly all US states
- The perspective paper called for 'integrating real-world variations in MTM program design into future models, including dose, duration, and ancillary services'
- Maryland MTM pilot (2024, JGIM): 74 adults, frozen meals + dietitian calls for 6 months, HbA1c change -0.7% treatment vs -0.6% control (not significant)
- FAME-D trial ongoing: 200 adults, comparing MTMs to $40/month food subsidy
- Australian MTM trial commenced Q1 2023, results anticipated March 2025
- 16 states had active or pending Section 1115 waivers for FIM coverage at time of publication
- Older MTM observational studies showed 49% reduction in hospital admissions
