The conditions for value-based care (VBC) have just shifted, as stronger financial results, improved data usability, and new long-term CMS incentives reshape what it takes for Accountable Care Organizations (ACOs) to compete and succeed. ACOs have had access to Centers for Medicare & Medicaid Services (CMS) claims data for years. What has made the difference is that latency, completeness, and tooling around it have caught up, turning a retrospective reporting feed into something operationally actionable. The most recent Medicare Shared Savings Program (MSSP) reporting posted the highest savings since the program’s inception: $2.5 billion in net savings to Medicare in 2024, with 75% of ACOs earning performance payments. A new 10-year risk model, Long-term Enhanced ACO Design (LEAD), is set to launch in 2027. The organizations that build the right operational foundation now will outperform the rest for the decade ahead.
That foundation is the day-to-day workflows that carry strategy across the goal line. In our previous piece, we made the case that VBC fails when operations have not caught up with the contract. So, what does the operating model actually need to do?
The bottleneck has moved
Five years ago, ACOs couldn’t see their populations, their attribution, or their performance with enough accuracy to manage them. Today, that challenge has been largely addressed. Claims data is more accessible, clinical data more connected, and benchmarks are more precise, giving ACOS a much clearer and actionable view of the populations they serve.
What has not improved at the same pace is execution. Even with better information available, many organizations will reach settlement with an incomplete picture of performance and are surprised by the outcome. Care teams interventions may arrive too late, not for lack of effort, but because the data and insights needed to act earlier are not always timely, connected, or easy to operationalize, As a result, and finance leaders may still struggle to answer questions that matter during the year: Are we on track? Where is risk concentrating? And is there still time to do something about it?
The bottleneck is now the connective tissue between insight and action. When that link is missing, four predictable failures follow. Here is what each looks like, and what the workflows look like when an organization solves them.
1. Knowing your position before the payer tells you
For some ACOs, settlement arrives too late. By the time the payer issues the check, the levers that could have changed the outcomes have all been pulled or missed.
What changes this is a rolling financial model that updates as the year develops, running inside the organization rather than receiving from outside. A finance leader managing three MSSP contracts and a Medicare Advantage shared-risk arrangement should be able to see, at any point in the year, where each contract sits against its benchmark, how incurred but not reported (IBNR) claims runout is shifting, where exposure is concentrating, and whether intermediate decisions — a care management investment, a coding initiative — are tracking toward a positive return.
With an internal model, the organization can do more than wait for year-end results. It can monitor performance throughout the year, identify where risk or opportunity is emerging, and take action while there is still time to influence the outcome. An internal model also gives leaders a stronger basis for validating, questioning, and challenging the final number at settlement. Instead of being something that is only measured after the fact, performance becomes something the organization can actively manage.
2. Managing performance at the provider-level
Portfolio dashboards work for board reporting but obscure the variance that drives ACO performance. The majority of controllable variance traces to specific provider behaviors: referral patterns, coding accuracy, care gaps like annual wellness visit (AWV) completion, and utilization decisions. None of that shows up at the portfolio level.
What changes this is provider-level visibility connected to the people who can act on it. A network medical director reviewing facility-level scorecards should see which providers are driving out-of-network referrals, which are completing AWVs at rates that protect risk adjustment integrity, and which referral patterns are pushing avoidable utilization into post-acute settings. A primary care lead should see the same view filtered to their panel: concrete, current, and tied to the actions available this month.
3. Closing the gap between care delivered and data acted on
Traditional adjudicated claims data lags care delivery by months. Organizations no longer have to accept that lag as a fixed condition. Fast Healthcare Interoperability Resources (FHIR)-based exchange, electronic health record (EHR) connections, and lab feeds now pull clinical signals into the same environment as claims, attribution, and contract performance, closing the window between when something happens to a patient and when a care team can respond.
In practice, this might mean a care manager sees the patient on their priority list before the 30-day readmission window closes. Open care gaps, suspected hierarchical condition categories (HCCs), and coding or documentation gaps reach care teams early enough to act on them. The goal is to deliver this intelligence within existing clinical workflows, at the point it can still influence a decision.
Getting there requires a data foundation that connects claims and clinical sources into a single, current patient view, and an architecture capable of delivering the right signal to the right person at the right stage of care.
4. Revenue capture as a discipline, not a year-end scramble
Two revenue gaps cost ACOs millions every performance year. Both are recoverable without requiring a new contract.
The first is risk adjustment integrity, defined by risk adjustment factor (RAF) accuracy, HCC suspecting (identifying conditions likely present but not yet formally documented), and coding performance that reflects the true clinical complexity of the population. The second is network retention, out-of-network leakage that would have been preventable with timely intervention. In most organizations, these are addressed in periodic projections: a coding sweep before submission deadlines, a leakage analysis before contract renewal.
What changes this is treating revenue recapture as a continuous discipline. Suspecting runs against current claims and clinical data. Coding guidance reaches care teams before the chart closes. Network signals reach managers when there is still time to redirect a referral pattern, not after the year has ended. Revenue capture runs as a managed function with owners, cadence, and measurable yield.
What ties the four workflows together
Each of these workflows can be solved in isolation. Most organizations have, in fact, solved at least one. What separates the organizations ready for full risk from those still building toward it is whether the four are connected by a shared data foundation: one where clinical, operational, and finance leaders see the same patient and the same financial position at the same time.
With that foundation, technology behaves like an operating system. Without it, even excellent tools produce conflicting answers and stranded work.
This is the practical reason that “buy more software” misses the point. The comes from integrating those capabilities across a single workflow that follows the patient, the contract, and the financial impact, so organizations can connect care decisions to performance outcomes and reimbursement.
What ready-for-risk organizations do differently
Organizations preparing for full risk through Medicare Advantage capitation, the LEAD model, and the next generation of ACO arrangements share a recognizable operating profile:
- They run their own financial model and treat the payer’s settlement as confirmation of a number they already know
- They manage at the provider level, because they know that is where variance lives
- They close the data-to-action gap by connecting clinical and claims sources into a current, unified view
- They treat revenue recapture as a year-round discipline owned by a named team
- They build on a shared data foundation so that clinical, financial, and operational decisions are made from one source of truth
The right tools, integrated and in the hands of the people who can act, do this work.
The work of the next decade
The strongest MSSP year in over a decade and a new 10-year risk model on the horizon are not coincidences. They mark the start of a phase in which VBC becomes structural. Organizations that have spent the last few years accumulating analytics will find that analytics alone cannot carry full risk.
An operating model can: workflows that turn financial visibility, provider performance, clinical data integration, and revenue capture into one connected system, run by accountable teams from a single shared view.
This is the operating model that Milliman MedInsight was built to support. A single platform connecting the four workflows above, backed by 75+ years of Milliman healthcare actuarial work.
