The contract is only the starting point
Performance depends on what happens between identifying a member’s needs and delivering care.
A health plan can expand its portfolio of risk-based contracts without improving its ability to manage care. A member flagged for follow-up still needs someone responsible for outreach, a provider who can act on the information and a way to establish whether the intervention helped.
For payers planning value-based care strategy in 2027, those connections deserve as much attention as the financial terms. The practical test of maturity is whether an organization can consistently translate population data into care, then demonstrate results that hold up under clinical and financial scrutiny.
Match financial risk to operational readiness
Greater accountability requires the resources to influence the outcomes being measured.
Value-based care arrangements distribute responsibility differently. Upside-only shared savings arrangements offer an opportunity to earn payments without sharing losses. Two-sided arrangements introduce downside exposure, while capitation provides prospective payments for a defined scope of care. These structures can overlap, and the details determine which costs and services a provider can reasonably influence.
A health plan VBC strategy should connect that exposure to operational capacity. A practice taking responsibility for total cost of care needs timely information about hospital use and care delivered outside its walls. It also needs resources for coordination between visits. Increasing financial accountability without addressing those requirements can leave providers carrying risk they have limited ability to manage.
Federal ACO models offer useful reference points, although their results should not be treated as evidence of commercial health plan performance. ACO REACH concludes at the end of 2026. Its successor, the Long-term Enhanced ACO Design model, or LEAD, is scheduled to run from January 2027 through December 2036. CMS describes prospective payments and a longer performance period among its features for supporting coordinated care.
The evidence also requires careful interpretation. CMS’s July 2026 ACO REACH update reported improved quality and reduced gross spending. Preliminary 2024 net savings for standard and new entrant ACOs, however, were not statistically significant. Gross spending reductions and net savings are different findings, and neither should be substituted for the other when making the case for a model.
Build population health around the next action
Integrated data becomes valuable when it changes who receives support and when.
Population health management needs to give care teams a usable view of the members for whom they are responsible. That means reconciling enrollment and attribution information with claims, clinical records and relevant care events. Teams also need to understand how current the information is. A discharge notification and a claim received weeks later serve different purposes.
Risk stratification should then guide an appropriate response. A ranking based on expected spending can support financial planning, but it does not by itself identify which members would benefit from a particular intervention. Plans should distinguish between predicting utilization and identifying an opportunity to improve care.
Consider a member with diabetes who has missed appointments and recently visited the emergency department. That combination could prompt outreach, but the next step depends on what the team learns. Difficulty obtaining medication requires a different response from a transportation barrier or an appointment that was completed but never appeared in the plan’s data. This is an illustrative workflow, rather than a claim about a specific program’s results.
Social determinants of health data can make that distinction more useful when it captures a member’s actual circumstances. Neighborhood-level information can inform planning; it should not be treated as confirmation of an individual’s needs. Screening and direct conversations can establish whether help is needed and what the member wants.
There is evidence for connecting identification to practical assistance. CMS’s final evaluation summary of the Accountable Health Communities model reported more than $200 million in net savings. The model screened over 1.1 million Medicare and Medicaid beneficiaries for core needs and connected eligible higher-risk participants with navigation support. That is evidence for the tested approach, rather than a guarantee that any social-needs program will produce comparable savings.
For payers, the operational implication is to track what happens after a referral. A directory entry or outreach attempt does not establish that a member received assistance. Care teams need visibility into unresolved needs, unsuccessful connections and services that lack capacity.
Follow the intervention through
A risk flag is the beginning of a care process.
For one priority population, trace the full sequence: who is identified, who owns the next action, whether the member receives support and what changes afterward. Breaks in that sequence reveal where a population health investment needs attention.
Connect quality measurement to payment
HEDIS supplies measurement standards; the contract determines the financial consequences.
HEDIS measures are used in health plan ratings, payment programs and value-based arrangements, according to NCQA. But HEDIS is not a single reimbursement formula. A contract must specify which measures apply, the eligible population, performance thresholds and how results affect payment.
Those mechanics matter when interpreting improvement. A better reported rate may reflect more completed care, more complete data capture or a combination of both. Payers and providers need to understand the source of the change before deciding which activities to expand. Financial results need similar discipline: savings against a contractual benchmark answer a different question from an evaluation estimating what would have happened without the intervention.
The move toward digital quality measurement makes data quality an immediate planning issue. NCQA continues to identify 2030 as its target for fully digital HEDIS, with implementation supported by testing and standards alignment. Digital reporting can support more timely information, but it still depends on reliable source data and correct measure logic.
For 2027, plans should pair formal reporting with operational measures that help teams intervene during the year. Time from discharge to outreach, unresolved referrals and delays obtaining follow-up care can reveal problems before an annual quality result arrives. These indicators support management; they do not replace the specifications used for contractual reporting.
Make provider participation workable
Shared accountability needs usable information and clear responsibility.
Provider partnerships become operational when both sides agree on the population, the information exchanged and who acts on it. A recurring care-gap report has limited value if the practice cannot reconcile it with its own records or determine which items require attention.
The same principle applies to member outreach. Plans and providers should establish who contacts the member, how completed work is communicated and how conflicting information is resolved. Otherwise, each organization can meet its internal activity targets while the member receives duplicate calls or an unresolved referral.
Payment timing also deserves attention. If an arrangement requires additional care coordination staff, the parties need to establish how that work will be funded before any year-end settlement. Prospective support, where included, should have a clear purpose and an agreed way to assess whether the added capacity improves care.
Regular performance reviews can then focus on decisions. When a result falls short, the discussion should distinguish among a data problem, limited service access, an intervention that did not work and a contract assumption that needs revision. Each requires a different response.
Bring the operational questions to HIMSS27
Use the conference to examine how data, payment and care delivery fit together.
Value-based care maturity is demonstrated through repeatable operations: identifying needs, supporting providers and measuring the effect of care. For payers preparing for 2027, the useful question is where those connections remain weak and what would make them work consistently across a larger population.
Register for HIMSS27 to connect with healthcare peers and explore the technology and partnerships supporting that work.