Top ten essential value-based care fundamentals your practice cannot miss

Primary care has faced a challenging few years. V28, the new Medicare Advantage risk adjustment model from the Centers for Medicare & Medicaid Services (CMS), was phased in starting in 2024 and reached full implementation this year. It reduced risk scores by dropping codes and trimming coefficients, so the same patient panel now produces a lower risk adjustment factor than two years prior, in most cases. Many practices saw their top-line revenue decline: caring for the same patients with less money and a more difficult benchmark to meet. Then, utilization rebounded. Care deferred during the pandemic returned with patients being sicker and more expensive, and CMS also highlighted increased service use in this year’s payment calculations. Every dollar spent now counts against a benchmark that must be exceeded.

And now, relief, or what looks like it. The 2026 Medicare Advantage rate announcement finalized a 5.06% average payment increase, more than $25 billion in new money. After a brutal stretch, it feels like the tide turned.

It didn’t; it just paused. The 2027 rate announcement is already final, and the increase drops to 2.48%, less than half of this year’s. The generous year was a one-year event, not a trend, and the underlying structural pressures, such as a fully phased-in V28, elevated utilization, and a 2027 policy slate that shifts financial risk forward, are still in place. When the rate environment is generous, sloppy execution tends to go unnoticed. When it tightens next year, only the practices that focus on fundamentals will remain healthy.

This brings us to the 10 fundamentals a practice is most likely to overlook. None of them is new, but in a lean year, each can make the difference between a shared savings check and a shortfall.

1. Have every person practice at the top of their scope

Most practices in their first year of value-based care still operate like fee-for-service clinics, with physicians performing tasks that medical assistants, LPNs or RNs are fully qualified and legally permitted to perform. Standing orders for vaccines, screenings, gap documentation, social needs screening and point-of-care testing enable the team to act without a provider for every episode. A physician spending 45 minutes a day on delegable tasks is leaving six figures in recaptured capacity on the table each year and risking burnout.

2. ADT feeds are non-negotiable

Without an admission-discharge-transfer notification feed, you learn a patient was hospitalized only when the discharge summary arrives by fax 10 days later, which is far too late to act. The ADT feed distinguishes between transitions of care as active workflows and as mere wishes, making it the most under-requested, highly leveraged data source.

3. Code to the truth

This is not upcoding; it is ensuring the chart accurately reflects the patient's condition. A patient on insulin, a loop diuretic, an ACE inhibitor and a beta-blocker has a clinical history that should be captured in her diagnosis codes. If a chronic condition is not documented and coded each year, your benchmark will be artificially low, and you'll work harder than necessary to meet the savings goal. This is especially important now: V28 already lowered scores, so an under-documented panel starts the year at a disadvantage.

4. Run the morning huddle

Ten minutes before the day’s first patient, the care team reviews the day’s schedule, flags open gaps and transitions, and plans who will do what. It costs little and can start this week. A gap closed during a scheduled visit takes two minutes; the same gap addressed later requires a call, a callback, documentation and often another visit. Practices that skip the huddle don’t do less work. They do the same work later, and more expensively.

5. Understand the contract before you sign it

The most expensive mistake in value-based care is signing a contract you don’t fully understand. Your benchmark, your attribution method, your quality gates and whether you even receive the data to manage the population are set in the contract language, before you see a single patient. It makes no sense to spend months building workflows but skip the one document that determines whether good work can ever pay off.

6. Stratify the panel and concentrate on the few cost drivers

You cannot manage thousands of attributed lives in the same way. A small fraction of the panel accounts for most of the avoidable spending, and these are the patients who most need a care manager, a care plan and proactive contact. Practices that skip stratification spread their limited care management resources too thin, which is the same as having none.

7. Close the loop on transitions

The post-discharge two-day call. The highest-leverage transitions play is contact with patients within two business days of discharge: medication reconciliation, a red-flag check and scheduling a follow-up visit, with the highest-risk patients being seen within 48 hours. It is entirely practicable, but only if you have the ADT feed (see No. 2) to know the discharge happened. Readmissions are where benchmarks are won or lost, and the two-day call is where readmissions are prevented.

8. Activate patients before the gap opens, not after

Most practices do reactive, measure-driven outreach: a gap opens, and a reminder fires. The part they often overlook is the proactive approach, engaging patients before any gap report is issued, so the relationship is already established when you need it.

9. Measure it, and manage to the numbers

Practices meticulously manage their billing, but their value-based performance is rarely measured. A clear executive dashboard that displays clinical, financial, experience and operational metrics on a single screen turns “we’re doing value-based care” into “here’s where we’re on track and where we’re not.” What isn’t measured tends to drift, and in a lean year, that drift can be costly.

10. Make it the physicians’ program

This is the highest value item on this list. Value-based care dies when it’s run as an administrative initiative that the doctors merely tolerate. It works when physicians own the governance, see the data, and, most importantly, when the practice’s own compensation model rewards the outcomes the contract pays for. If your internal incentives still reward volume while your contract rewards value, the contract loses. Align them, or the rest of this list won’t matter.

None of this is exotic, and that is exactly the point. In a 5% year, a practice can skip half this list and still look fine. In a 2.5% year, that margin disappears. The rate environment varies from one cycle to the next. The fundamentals are the only part of value-based care a practice can truly control. Build for the lean year. It’s already on the calendar.

Jenn Block, PhD, MBA, and Bhargav Raman, MD, MBA, lead the Value-Based Care initiative at Ten Ten Ten, a nonprofit focused on improving U.S. health outcomes while reducing health care spending. Access the open-source VBC Playbook at https://tententen.org/our-work/value-based-care.