From fragmented outreach to coordinated action: building a value-based care operating model

Value-based care is operating at scale.

In 2026, 511 Accountable Care Organizations in the Medicare Shared Savings Program serve approximately 12.6 million people with traditional Medicare, the largest beneficiary population in program history. CMS reports approximately $2.5 billion in net Medicare savings and $4.1 billion in shared savings for the most recently reconciled performance year.

For health systems accountable for quality, utilization and total cost of care, that scale raises the operational bar. Performance increasingly depends on what happens between encounters: after discharge, before an avoidable emergency department visit or when a patient needs help following a complex care plan.

One integrated academic health system in Central Massachusetts addressed that challenge by connecting outreach, care navigation, clinical information and accountability into a more coordinated operating model.

Coordination matters more than program volume

Large health systems rarely lack teams focused on outcomes. Problems emerge when hospital staff, ambulatory practices, care managers, navigators and population health teams use different processes and priorities.

The health system found that outreach could remain fragmented even when individual teams performed well. Patients could be identified by multiple teams, referrals could lack clinical context, and those at greatest risk did not always rise to the top. More outreach was not the answer. Better orchestration was.

CMS describes coordinated care as a mechanism for reducing fragmentation, unnecessary utilization and duplicative services, while advanced primary care management emphasizes population-level risk stratification and care-gap identification.

Align teams around shared priorities

Leadership aligned teams around enterprise priorities, including chronic disease control, avoidable emergency department use, readmissions and patient flow. The 80/20 model standardizes roughly 80% around those priorities while allowing 20% to adapt for specific populations or care settings.

Quarterly cross-functional reviews shifted accountability from activity to impact. The question was no longer simply whether a patient was contacted, but whether the intervention changed what happened next.

The same principle shaped care transitions. The health system created a “care traffic control” function to maintain continuity after discharge. CMS’ Advanced Primary Care Management framework similarly combines chronic care management, transitional care management and digital communication while requiring practices to identify care gaps and risk-stratify populations.

Put limited capacity where it can change the outcome

Disease burden alone did not consistently identify patients who could benefit most from near-term intervention. The organization focused on patients at risk of returning to the hospital or emergency department and clarified when case managers, navigators and care managers should engage. Clearer roles reduced duplication, particularly during the first 90 days after discharge.

Humana’s 2026 Value-Based Care report found that Medicare Advantage members in value-based care had 13.4% fewer emergency department visits and 7.6% fewer hospital admissions than members outside value-based arrangements. The population differs, but the results reinforce the value of targeted coordination.

Turn data into action inside the workflow

Analytics created value when they changed operating decisions. When performance data challenged assumptions about where high-value referrals would originate, the team changed the workflow rather than protecting the original design.

CMS’ 2026 Medicare Physician Fee Schedule changes to the Shared Savings Program continue to emphasize chronic disease management, prevention and more efficient resource use.

The organization applied the same principle inside the electronic health record. A care-support flag used disease registries, eligibility criteria and payer requirements to indicate when support might be appropriate. Referral volume increased several-fold within approximately three months, creating a new constraint: capacity. Better identification only creates value when staffing and workflows can respond.

Connect coordination to sustainable performance

Over time, the health system reported improvement across emergency utilization, readmissions, care transitions, diabetes management, COPD-related emergency encounters and clinical documentation. Shared savings also improved over three consecutive years.

National results provide context. CMS reported approximately $2.5 billion in net Medicare savings from Shared Savings Program ACOs for performance year 2024. But a value-based contract does not create savings on its own. Performance depends on the operating decisions underneath it.

That will matter even more as accountable care expands. CMS’ Ambulatory Specialty Model, scheduled to begin in 2027, targets stronger upstream chronic disease management and care coordination to reduce avoidable hospitalizations and unnecessary procedures.

For health system leaders, the priority is an operating model that can identify the right patient, route support to the right team, adapt when data changes and turn information into coordinated action before risk becomes an avoidable event.