Meeting the needs of socially vulnerable patients: Views of ACO leaders on moving from intent to action

The Centers for Medicare and Medicaid Services has placed growing emphasis on social drivers of health, but little is known about how accountable care organizations (ACOs) aim to meet the needs of vulnerable patients. During September-December 2022, we interviewed leaders of forty-nine ACOs participating in the Medicare Shared Savings Program (MSSP). Participants were asked about strategies to identify socially vulnerable patients, programs that addressed their needs, and Medicare reforms that could support their efforts. Seven themes emerged: ACOs were in the early stages of collecting social needs data; leaders were frustrated by an incomplete ability to act on such data; ACOs tended to stratify patients by medical, rather than social, risk; some ACOs have introduced pilot programs to address challenges, including social isolation and drug costs; programs were often payer agnostic; rural ACOs faced unique challenges; and Medicare reforms related to reimbursement, logistical support, quality metrics, and patient benefits could support ACO efforts. These findings suggest that the MSSP alone has not been sufficient to promote consistent investment in social needs provision at most ACOs. Policy makers may want to consider more direct support and incentives for health care organizations, or greater investment in non-health care sectors, to help socially vulnerable patients.