5 Ways ACOs Are Unlocking Shared Savings Through Food-as-Medicine

In the value-based care era, Accountable Care Organizations (ACOs) are reimagining how to keep patients healthier—and reduce costs in the process. One powerful tool gaining traction? Food-as-Medicine.

No longer a buzzword, Food-as-Medicine is rapidly becoming a core strategy for ACOs looking to improve outcomes, close care gaps, and unlock shared savings. Here's how the most innovative ACOs are making it work.

1. Reducing Preventable Hospitalizations with Medically Tailored Meals

When patients with chronic conditions like diabetes, heart failure, or kidney disease receive meals designed by registered dietitians, the impact is measurable:

• Fewer Emergency Department visits

• Reduced hospital admissions

• Shorter lengths of stay

A landmark study from MANNA and the University of Pennsylvania found that medically tailored meals led to a 16% net savings in healthcare costs per patient. For ACOs, that translates directly into shared savings.

“We see time and time again that when patients are nourished properly, they heal faster, stay healthier longer, and need fewer interventions overall,” says Morgan Fereck, RDN, LDN, Lead Dietitian at OnPoint Nutrition. “The meals aren’t just convenient—they’re clinically strategic.”

2. Closing Quality Gaps Through Nutrition Counseling

ACO performance metrics are tightly tied to preventive care, chronic disease management, and patient engagement. Medical Nutrition Therapy (MNT) and 1:1 nutrition counseling are proving effective in:

• Lowering A1c levels

• Managing blood pressure

• Reducing BMI in at-risk patients

• Enhancing medication adherence

When nutrition services are proactively integrated into care teams, ACOs consistently see measurable gains across key quality metrics—including HEDIS and CMS Star ratings. These aren't just performance benchmarks—they directly determine bonus payments, shared savings, and contract renewals.Patients supported with Medical Nutrition Therapy (MNT) are more likely to meet diabetes management goals, lower blood pressure, and improve cholesterol—all of which feed into high-value indicators. For ACOs, this translates into better performance scores, stronger negotiating power with payers, and greater access to incentive pools.

“Nutrition counseling is the missing link in so many care plans,” notes Britney Bobrow, Director of Nutrition Services. “When patients get personalized support, it not only drives measurable outcomes—it builds confidence and sustainable change.”

3. Engaging Hard-to-Reach Populations with Food Incentives

For Medicaid ACOs and those serving dual-eligible populations, engagement isn’t just a challenge—it’s often the biggest barrier to impact. Traditional outreach efforts frequently fall short for individuals facing complex social and economic pressures. That’s where Food-as-Medicine steps in as a culturally competent, practical bridge to care.

Here’s how ACOs are using these programs to break through:

• Culturally relevant meals delivered to the doorstep

• Grocery vouchers tied to healthy eating goals

• Nutrition classes embedded in community partnerships

These interventions do more than just provide food—they address key social determinants of health like food insecurity, health literacy, and cultural disconnects in care. They also build trust, improve retention, and make patients feel seen and supported—especially in populations historically underserved by the healthcare system.

“Food is the most human entry point into healthcare,” explains Mark Redlus, CEO of LifeChef Health. “It creates a direct, tangible impact for people who may not otherwise engage with traditional care models. That’s where real transformation begins and we are driving that impact.”

4. Reducing Polypharmacy and Enhancing Care Coordination

When food becomes a clinical intervention—not just an afterthought— patients often show rapid improvements that lead to fewer medications, reduced complications, and tighter care coordination.

This shift is especially powerful for patients with multiple chronic conditions, where polypharmacy and provider fragmentation are the norm. ACOs embracing Food-as-Medicine are seeing tangible improvements by embedding nutrition earlier in the care plan—not later.

Here’s how it’s being operationalized:

• Integrated EHR systems now flag eligible patients for dietitian referral based on diagnosis codes, utilization history, or risk scores—ensuring no one falls through the cracks.
• Nutrition-first care pathways are being built into clinical protocols, with some ACOs trialing lifestyle intervention as a first-line defense before escalating to pharmaceuticals.
• Cross-disciplinary case reviews now include registered dietitians as standard participants, making nutrition and lifestyle planning part of the broader medical conversation—not a siloed add-on.

These strategies don’t just improve care—they streamline it. Patients with better nutritional support often reduce or eliminate the need for medications like insulin, statins, or diuretics. And because their symptoms are better managed, they generate fewer costly touchpoints—like ED visits, specialist consults, or duplicated labs.

For ACOs, the benefits go beyond improved health outcomes—they include lower PMPM (per member per month) costs, better care team alignment, and reduced provider burnout from managing preventable complications.

5. Leveraging Claims Data to Identify Food-Insecure Patients

Food insecurity isn’t always visible—but it’s deeply tied to chronic disease outcomes, medication adherence, and hospital utilization. That’s why forward-thinking ACOs are turning to data analytics to uncover hidden needs and deliver targeted, cost-effective nutrition support.

Instead of relying solely on self-disclosure or primary care screening, ACOs are building predictive frameworks using:

• ICD-10 Z codes—such as Z59.4 for food insecurity or Z60.2 for problems related to living alone—captured during clinical encounters, social work intakes, or discharge planning.

• Risk stratification models that flag members with diet-sensitive conditions (e.g., diabetes, CHF, CKD) and elevated readmission risk, helping to prioritize outreach.

• Patient-reported outcome measures (PROMs) and social needs assessments that integrate questions on food access, meal preparation capacity, and cooking resources.

These insights allow ACOs to move from blanket interventions to precision targeting—focusing efforts and resources where they’re most likely to prevent costly episodes and improve quality scores.

“The key is using clinical and social data together to create a full picture,” explains Britney Bobrow, Director of Nutrition Services. “Once we know who’s struggling with food access, we can intervene with tailored care—before that turns into a hospitalization or complication.”

The result? Lower spend per member, better patient engagement, and stronger performance in value-based contracts. Food-as-Medicine programs become not just a service—but a strategic lever.

The Path to Sustainable Savings Runs Through the Kitchen

Food-as-Medicine is more than a trend—it's a high-impact lever in population health. As ACOs face growing pressure to do more with less, integrating food-based interventions is proving to be a cost-effective, evidence-based strategy that benefits both patients and payer systems.

Interested in launching a Food-as-Medicine initiative? Partnering with registered dietitians and medically tailored meal providers is the first step toward sustainable change—and shared savings that last.

💡 Let’s Talk

Want to explore how your ACO can implement Food-as-Medicine programs? Contact us to learn how OnPoint Nutrition and LifeChef Health work together to deliver clinical nutrition counseling and medically tailored meals that move the needle.