In 2024, the Medicare Shared Savings Program had its strongest year on record. Even then, roughly one in four participating ACOs did all the work and came away with nothing. These aren’t organizations that avoided risk — they signed the contracts, stood up the programs, hired the teams. And the pressure is only increasing: CMS’s new LEAD model, taking effect January 1, 2027, is designed to pull smaller and independent practices deeper into total cost-of-care arrangements. And the proposed Ambulatory Specialty Model would make risk mandatory for the specialists it covers. Medicare Advantage contracts, network affiliations, referral relationships: all increasingly carry risk terms, whether or not an organization ever registers as an ACO.
The perimeter of who’s carrying risk keeps expanding — pulling in specialists who were never part of these programs before — and the time horizons are stretching out across multi-year performance periods. Yet, the platforms most organizations are running on hasn’t expanded with it. Rather, provider organizations have added more to the stack – resulting in increasing overhead and operational complexity.
This adds to an estimated 30% of the $5 trillion[MP1] the U.S. spends on healthcare going to administrative overhead. Managing value is critical to the sustainability of the system, but more forms, more dashboards, and ever-changing reporting requirements are all adding financial and operational weight while displacing the most important thing: meaningful time between clinician and patient.
Can we simplify the value-based care stack and return that time and space while still managing risk and value? stack and return that time and space while still managing risk and value?
Where risk readiness begins
The first step is understanding what the stack actually is. Somewhere in the now decades-long shift to value-based care, the conversation started sounding a lot like the fee-for-service engine was simply being replaced. It wasn’t, and it isn’t. The two coexist. Providers in risk arrangements still have to submit accurate, timely claims. They still have to resolve denials, reconcile payments, and maintain payer enrollment and contracts. None of that went away when the shared savings contracts were signed. Whether that core revenue cycle management is solid is a big part of whether an organization is prepared to succeed in quality program management.
What changed is what’s riding on top of fee-for-service business as usual. Whereas a denial or a documentation gap used to be a cash flow problem, now it’s also a quality score, a risk adjustment factor, a shared savings calculation. The stakes on these operational basics went up substantially, and most organizations are buckling under a documentation and reporting load it was never built to carry.
Where VBC readiness is tested: documentation, reporting, and care coordination
There are three places where this managed risk strain most reliably shows up.
Risk-adjustment documentation is the first test. Capturing a patient’s full clinical complexity depends on complete, timely documentation housed within the clinical workflow, not a separate coding review weeks later. Under CMS rules, a chronic condition documented last year, but not re-entered this year, simply drops out of the risk score. One analysis of MSSP ACO data pegged the documentation swing at roughly $100 to $270 per patient per year for just a few points of accuracy. Across a full panel, that’s the difference between being ready for a risk contract and finding out, too late, you weren’t. A process that depends on a team of people chasing charts will work at 5,000 attributed lives, but won’t hold up to 50,000, and risk contracts have a way of growing exponentially faster than the teams assembled to manage them.
Quality reporting is the second. While healthcare has never been poor in dashboards, it has long experienced a shortage of workflows that activate their information. Rather than a separate, retroactive report, organizations need something care teams can act on during a visit, a view that surfaces the most relevant information from payers, referrals, and claims data. An organization can have every dashboard in the world and still not be ready, if none of it reaches a clinician in time to make a decision that lowers risk and improves metrics.
Partner-network care coordination is the third, because organizations are often accountable for care delivered by providers they don’t employ. Most only discover the gaps in that visibility after a contract has already exposed them, when the loop on a specialist referral isn’t closed, or a hospitalization isn’t reflected until the reconciliation. The readiness version of this is having that visibility before you’re financially accountable for it, not scrambling to build it in retrospect — after the first performance year makes clear what you’ve missed.
The compounding returns of operational readiness
There’s a reason to get this right now, beyond the immediate revenue. The organizations that invest in operational readiness today are building something that compounds. Clean, complete documentation and coding, sustained over multiple performance periods, creates a longitudinal picture of a patient population that becomes genuinely hard to replicate. It sharpens risk-adjustment accuracy year over year, and strengthens your negotiating position with payers. It also builds the only foundation AI and automation can reliably run on. Any intelligence layered on top of incomplete or inconsistent data just scales the challenge faster. As I wrote in my previous piece, buyers are increasingly judging technology on outcomes rather than features — and an agent is only as good as the data and context it can reach. Operational readiness is what turns its promise into meaningful performance.
The biggest cost of waiting to optimize isn’t this year’s shared savings left on the table. It’s falling further behind organizations whose operational foundation is already at work, generating returns that compound with time. For large organizations, risk is already here. For smaller and independent practices, it’s rapidly arriving. In both cases, the question is the same: are you pulling ahead, or just keeping up?
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