The shift to value-based care has never been straightforward. In 2026, it is more demanding than ever. Healthcare organizations are navigating fully implemented HCC V28 coding standards, rising Stars quality thresholds, tightening Medicare Advantage conditions, and MSSP benchmark resets that will lock in performance expectations for years ahead. The administrative burden on clinical teams has not decreased. If anything, the gap between organizations that adapted early and those still catching up is growing wider.
The strategies that make the difference are not new - but their urgency is. In my years leading value-based care organizations, including nine years at the helm of one of the nation's top-performing ACOs, I have seen the same three priorities determine whether organizations thrive or fall behind. They are as relevant in 2026 as they have ever been.
What you will learn
- Why HCC coding accuracy in 2026 is a financial priority, not just a compliance task - and how AI changes the calculus
- How AI-driven care gap identification is replacing manual data review for HEDIS and Stars performance
- Why the organizations performing best in VBC have invested in team culture as deliberately as they have invested in technology
- What the transition to V28 means for organizations still catching up - and what the fully implemented model requires now
- How breaking down clinical silos directly affects both physician retention and patient outcomes
1. Code smarter, not harder: what HCC accuracy requires in 2026
For value-based health care organizations to be financially sustainable, risk adjustment is essential. To quote the Centers for Medicare & Medicaid Services (CMS), risk adjustment aims to ensure that “doctors and other health providers are paid fairly for the people they treat — providers get paid more for patients who have more health problems than for healthy patients who may not need as many services.”
Risk adjustment relies heavily on the time-consuming process of hierarchical condition category (HCC) coding, which can come at the expense of the time primary care physicians dedicate to actually delivering patient care. The V28 model is now fully implemented. The dual-coding period is over, but its consequences are not - organizations that did not fully adapt their workflows during the transition are carrying incomplete coding into a year when benchmark accuracy matters more than ever. For MSSP ACOs approaching reset years, the RAF scores documented in 2026 will define the financial ceiling for their next multi-year agreement period. Incomplete coding is not just a compliance risk. It is a compounding revenue problem.
Coding often requires physicians and coders to deal with large and often overwhelming volumes of information, much of it spread across paper records, electronic health records, health information exchange feeds, claims data and other sources. Even though this data is digitized, much of it is still unstructured and unsearchable.
AI changes all of that, allowing for streamlined HCC coding. By analyzing all available patient data (regardless of format) to suggest diagnoses that were likely missed, AI can help clinicians ensure that their coding is complete while also saving valuable time. This can help health care organizations avoid the lost revenue that can result from incomplete HCC coding and allow physicians to focus more on delivering care. Ultimately, this benefits physician morale, health care organizations’ financial health and the quality of care that patients receive.
2. Beyond spreadsheets: AI-driven care gap management in 2026
Strong quality performance, including high Medicare Star Ratings and Healthcare Effectiveness Data and Information Set (HEDIS) scores, is another key tenet of value-based success. Not only does enhancing quality performance improve patient care, these measures can have a major financial impact. CMS offers significant incentives for strong quality performance, and it publishes annual data on health care organizations’ Star Ratings that can affect their future enrollment numbers.
Looking at the state of value-based care in the U.S. in general, there is significant cause for concern. Stars performance has continued to decline as quality thresholds have risen and the Health Equity Index - a new rewards methodology - begins affecting plans' 2027 ratings. For healthcare organizations in value-based contracts, the window to close care gaps before measurement deadlines is narrowing, and the financial stakes attached to Stars performance continue to grow.
Improving quality performance entails identifying and closing care gaps. That can be a major challenge, especially because of the volume of patient data at physicians’ fingertips.
Once care gaps are identified, closing them does not always require active steps such as preventive screenings. In many cases, a care gap can be closed by discovering evidence either that a patient has already received a certain intervention or that they’re ineligible for it. But making those kinds of determinations also often requires combing through and making sense of large volumes of patient data.
By analyzing patient data to identify and close care gaps, AI can empower health care organizations to improve their quality performance. It can also save significant time for clinicians, allowing them to focus more on patient care. As with streamlined HCC coding, this can benefit physicians, health care organizations and patients.
3. Breaking silos, building synergy: the team culture that VBC requires
Value-based care takes a more holistic approach to patient care than a conventional fee-for-service model. As a consequence, it requires more coordination, collaboration, cooperation and communication, not only among physicians, but also among other team members and with the patient.
Value-based care also places other demands on physicians. For instance, if a patient requests an appointment on short notice, accommodating that request, while likely inconvenient, can both improve health outcomes and save money. Agreeing to steps like these can sometimes help avoid unnecessary emergency room visits. The problem is that these higher expectations of physicians, combined with the increased administrative burden, can also increase the risk of clinician burnout.
In this challenging new reality, a culture of teamwork is required to help facilitate the necessary coordination, collaboration, cooperation and communication. It can also serve to boost morale across the entire clinical team.
Fostering teamwork entails strengthening clinicians’ sense of camaraderie and of being appreciated for their work. Having clearly defined procedures and organizational values can also help significantly with this effort, as can professional mentoring. Having physicians serve in leadership roles can also make a powerful difference, giving doctors a voice and helping ensure that organization-wide policies reflect an understanding of the day-to-day challenges they face.
In 2026, physician burnout remains one of the most acute operational risks in value-based care. Administrative burden has not decreased as VBC has matured, if anything, rising documentation requirements and coding complexity have increased it. Organizations that invest in the team infrastructure described here are not just protecting morale. They are protecting their coding accuracy, their care gap closure rates, and their capacity to perform under risk-bearing contracts year after year.
Dana McCalley, MBA, is the VP of Value-Based Care at Navina. She has 15-plus years in health care with a focus on quality improvement and risk adjustment. She led one of the nation’s top-performing accountable care organizations for nine years and was responsible for helping 700-plus clinicians provide care to 230,000 value-based patients.
This article was originally published in Medical Economics.
Key Takeaways
- HCC V28 is fully implemented. The dual-coding period is over. Organizations that have not fully adapted their workflows are losing ground on RAF accuracy with every quarter - and 2026 risk scores will lock in MSSP benchmarks for years ahead.
- Care gap closure in 2026 requires AI-assisted identification of existing evidence in the chart, not just new screenings. Organizations still working from spreadsheets are leaving quality performance - and Stars bonuses - on the table.
- Team-based care is not a philosophy. It is an operational structure with specific mechanisms: paired physician and operational leadership, defined procedures, professional mentoring, and formal channels for physician voice.
- Physician satisfaction is a VBC performance variable. Burned-out physicians document less accurately, close fewer care gaps, and leave organizations; disrupting the coordination and continuity that value-based models depend on.
- The organizations performing best in VBC in 2026 have invested in all three areas simultaneously. Coding technology without team culture produces low adoption. Team culture without data infrastructure produces effort without impact.
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