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How healthcare leaders are preparing for what’s next in value-based care
New CMS models are coming and the good news is that fundamentals haven’t changed.
Organizations already focused on accurate documentation, proactive care, and strong operational foundations are in a strong position to succeed as these changes roll out.
With that in mind, Navina recently hosted a webinar bringing together experienced policy experts to unpack what’s ahead—and how organizations can prepare.
Dana McCalley, VP of Value-Based Care at Navina, was joined by Kim Lynch, CEO of Metis Health and Former SVP of Aledade, and Zac Oty, Enterprise Solutions Engineer at Navina to discuss the direction taking shape across the industry and how leading organizations are approaching the changes to come.
Here are five key takeaways from that conversation.
The definition of success in value-based care is getting stricter
One of the clearest themes from the discussion is that CMS is continuing to push the industry toward outcomes-based care, and doing so in a way that is increasingly tied to real financial consequences.
Rewarding accountability. Proactive care. Accurate coding. Patient centralization. CMS has been moving steadily in this direction for over a decade. What’s changing now is the level of enforcement and alignment across programs.
“The general direction has continued to trend in all of these same ways,” said Kim Lynch. “The specifics have changed. The point is you have to be improving the care of the population. CMS is testing the financial ways to properly incentivize that.”
Whether it’s LEAD, Access, or updates to existing models, the underlying expectation is the same: organizations must be able to demonstrate that they are improving patient outcomes and not just delivering services.
Each model is pushing toward that goal in a slightly different way:
- LEAD: With the final announcement now released, LEAD is clearly positioned for organizations ready to take on greater accountability featuring two-sided risk, population-based payments, and more flexible attribution. The expectation is explicit: manage total cost and quality of care across your population, not just individual encounters.
- ACCESS: A more targeted model focused on specific chronic conditions like diabetes, hypertension, behavioral health, and MSK. It emphasizes measurable improvement in outcomes, with a strong lean toward technology-enabled care rather than adding more manual workflows or staffing.
- MSSP: The most established pathway into value-based care, centered on reducing total cost of care while maintaining quality performance. It offers a spectrum of risk, from upside-only to enhanced tracks with downside, making it a common entry point for organizations building their capabilities.
- REACH (sunsetting): ACO REACH introduced more advanced risk structures and capitation, but is now being phased out, reflecting CMS’s ongoing refinement of value-based models and paving the way for what comes next.
Organizations currently participating in REACH will need to evaluate their options and choose a path forward, whether that’s transitioning into LEAD, MSSP, or another model that aligns with their capabilities and strategy.
That shift has real implications for how care is delivered day-to-day. It requires:
- More proactive patient management
- Stronger care coordination
- And better visibility into patient populations
For organizations still optimizing for visit volume, this shift represents a necessary reset.
The move to encounter-based documentation is a turning point
Another major topic of discussion surfacing in the recent CMS Final Notice for Medicare Advantage was the proposed shift away from retrospective risk adjustment.
Under the new direction, diagnoses will need to be captured during the patient encounter itself, rather than identified later through chart reviews.
For many organizations, this represents a significant operational shift, especially given how heavily retrospective workflows have been relied upon historically.
But for others, it’s a welcome change.
“Documenting accurately in full at every visit is the standard,” said Kim Lynch. “I've been doing prospective risk adjustment coding for probably 12 or 13 years now. I'm not a fan of the retro, because it requires rework,” agreed Dana McCalley.
The takeaway is straightforward: organizations that already support clinicians with real-time insights and documentation workflows are ahead of the curve while those that don’t will need to adapt quickly.
LEAD and ACCESS reflect a broader shift in CMS strategy
LEAD, the successor to ACO REACH, is designed to bring more organizations into risk-based care by reducing some of the barriers that have held them back. It introduces a longer timeline, more flexibility, and new opportunities, particularly for groups that haven’t previously participated in risk.
At the same time, the ACCESS model takes a different approach, focusing on specific chronic conditions and tying payment directly to measurable improvements.
What stood out in the conversation is how these models complement each other:
- LEAD focuses on population-level accountability
- Access focuses on condition-level outcomes
Together, they signal a more nuanced approach from CMS, one that allows organizations to engage in value-based care in multiple ways, depending on their capabilities.
Financial strategy matters as much as clinical strategy
Beyond policy and clinical workflows, a significant portion of the discussion focused on economics, specifically, how different models impact cash flow, risk, and long-term sustainability.
One of the key distinctions highlighted was between shared savings models like MSSP and more advanced risk models that include capitation.
In MSSP, organizations often wait 18–24 months to see financial returns. In contrast, models with capitated payments offer more predictable cash flow, but come with greater upfront risk.
That trade-off is substantial.
For some organizations, predictability is critical. For others, the ability to invest earlier in infrastructure and care delivery can outweigh the added risk.
“Do you want capitated payments, or do you want to stick with fee-for-service and receive a bonus in a year and a half?” noted Zac Oty.
There’s no universal right answer, but there is a clear need for intentional financial planning.
Organizational readiness is the real differentiator
Perhaps the most important insight from the webinar is that success in value-based care isn’t determined only by which program you choose but also by whether your organization is ready for it.
Throughout the discussion, speakers emphasized the importance of foundational capabilities:
- Understanding your patient panel
- Tracking performance in real time
- Managing different populations and contracts effectively
- Aligning clinical workflows with financial incentives
Organizations that have these elements in place have options and they can evaluate programs like LEAD or MSSP from a position of strength.
Those that don’t may find themselves taking on more risk than they can manage.
This is especially important given the pace of change. With programs evolving, and sometimes even phasing out completely, organizations need to build systems that are durable and diversified, not just compliant with a single model.
What this means in practice
As this discussion made clear, while the details of specific programs will continue to evolve, the fundamentals haven’t changed.
Organizations that focus on accurate documentation, proactive care, and strong operational foundations will be well-positioned, regardless of changes.
In the words of Dana McCalley “It doesn't matter if CMS changes and drops all of these new programs. From my perspective, if you have a very strong foundation, it really is the framework that will help you be successful in all of these things as long as you are doing what needs to be done.”
Across all the expected changes, a few things are becoming clear:
- The standard for performance is getting tighter, especially when it comes to outcomes
- The expectation to capture the full clinical picture during the visit is pivotal
- More organizations are being pulled into risk, whether they planned for it or not
- Programs will continue to change as CMS tests and refines what works
- Strong operations and the right technology are becoming essential to keep up
For healthcare leaders, the challenge is understanding both these changes and what they mean for your organization.
That includes where you are today, where you want to be, and how different models might fit into that path, even before every detail is finalized.
As CMS releases more information, we’ll continue to break down what it means for value-based care and how organizations are approaching it.
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