All Themes

CMS is accelerating a structural pivot from legacy physician quality reporting toward accountable-care risk: proposed CY 2027 Medicare Physician Fee Schedule/MSSP changes would shift physician payment, phase out MIPS, and expand ACO participation, while LEAD applicants face near-term strategic choices between LEAD and MSSP as CMS finalizes participant lists and financial methodology. The operating tension is moving from “whether to take risk” to “which risk chassis to choose”—MSSP, LEAD, ACO REACH, or episode models such as CJR-X—with governance, coding accuracy, downside-risk mitigation, and home-based care partnerships becoming core capabilities rather than optional infrastructure. Early performance signals remain material: agilon reported its ACO REACH entities generated $229 million in gross savings and $54 million for the Medicare Trust Fund in 2024, reinforcing why CMS and market participants are pushing harder on scalable ACO models despite scrutiny over CMMI savings transparency and MA coding intensity ([agilon ACO REACH results](https://www.agilonhealth.com/news/press-release/agilon-health-reports-aco-reach-model-results-for-2024-performance-year/); [Wakely on LEAD risk strategy](https://www.wakely.com/blog/accepted-into-lead-now-what-aco-risk-mitigation-strategies-part-2/)).

CMS’s release of 2024 ACO REACH results reinforces that total-cost-of-care models remain central to Medicare cost strategy even as the model approaches its sunset: participants generated nearly $1B in net savings, while physician enablement groups such as agilon reported $229M in gross savings and $54M to the Medicare Trust Fund, sharpening the case for successor ACO models that preserve downside-risk incentives and primary-care-led cost management ([CMS savings coverage](https://news.google.com/rss/articles/CBMimAFBVV95cUxOSmhRVVVlX1BNblBYdGlGT19SNk4ydTNBelhteHgtLV81MmVINmVvdnFSQkZxMFVFRHpLelFfRTFmM05RZkV2UF9lYlRtZVlYVHl1a3lZelRwMV9PaEF3eEFlbmU4TUdUSG9LWXY4NUN2RXAwNEpHcTBwQWdkRGNRaFZkcVE3cVZ5NzhTR1N3bWtCbVpxdEFxYg?oc=5), [agilon results](https://www.agilonhealth.com/news/press-release/agilon-health-reports-aco-reach-model-results-for-2024-performance-year/)). At the same time, the Trump administration’s CMS is signaling a more aggressive

Care coordination is becoming the operational center of value-based care strategy, as CMS’ ACCESS Model moves chronic-condition management further toward tech-enabled, longitudinal support while ACO REACH savings results reinforce the business case for accountable-care infrastructure that can manage referrals, transitions, and specialist use at scale. Providers and risk-bearing partners are also tightening governance around episode and specialty models—CJR-X, kidney care, MSK, home health, and post-acute networks—because downstream visibility and referral discipline are increasingly decisive for total-cost performance, not just quality improvement. The strategic tension for VBC stakeholders is whether digital health firms, ACOs, and post-acute/home-based providers can integrate into physician workflows fast enough to meet CMS’ care-management expectations without adding fragmentation or administrative burden, particularly as [ACCESS launches in July](https://news.google.com/rss/articles/CBMiwgFBVV95cUxPdm0wY1I3d0IyR1UycEIxeGZZcWtaaDdrWDZpUEVXYVlWbHhSeHF2N20zRUNkU1pkTUE2NmtuV0p3TWtnUWl6cHJOOVM4elIwckZkQ0U2OWJiWklTTDVRbDFldTNDdkRKcjV3QmpQRWxHcFJEdllxbEpwdEhIdTJROVdCVVJCSWx)

CMS is signaling a Medicare VBC reset under the Trump administration: ACO REACH produced $988 million in 2024 Medicare savings before its scheduled sunset, strengthening the case for successor models even as CMS pivots toward new ACO constructs such as LEAD and proposed MSSP/physician payment reforms that would expand ACO participation and reduce reliance on MIPS. The strategic tension for ACOs, physician groups, and Medicare Advantage stakeholders is whether CMS uses these savings data to preserve advanced risk pathways while tightening payment accuracy—especially around MA coding intensity and CMMI financial transparency—rather than simply replacing one model with another. For providers, the near-term positioning question is how to bridge from ACO REACH into MSSP, LEAD ACO, or other downside-risk arrangements while aligning home-based care, specialty episodes, and governance infrastructure around CMS’s next Medicare payment architecture ([ACO REACH savings](https://www.healthcaredive.com/news/aco-reach-generates-more-savings-medicare/824965/); [MA coding intensity](https://www.kff.org/medicare/decoding-medicare-advantage-coding-intensity/)).

CMS’ proposed 2027 Medicare Physician Fee Schedule signals a major quality-measurement reset: the agency is moving to phase out MIPS, expand ACO participation, and reorient physician payment toward primary care and population-based accountability—changes that could strengthen ACO/home-based care partnerships but also expose providers to a 2027 fee cut and new performance-management demands ([Fierce Healthcare](https://news.google.com/rss/articles/CBMiywFBVV95cUxNT2dHa2MyVEVua1lDYWducm1nTVBZSl8weTJ3QU16czJ1TEVqMEMxT2ZJQU4xSjdRLXo2TEVDZzhJb3F6a2pHbzlMOXUzWFlFSGRSYjMyb0ZFcWZpSWlEZmpNTzVpVndtclh2T2Jhb2EyWllhVGRFc1RWZnlJYkhFQlhfZDVoMlFMajBlTU9yYnc0REFvdHVGOVNKVVE3U1Myd0lkY0x6VXZTd21kR3BTWDFNekQ0bTlMQmNGMzhLdVNMNEpFd0VoT3QzMA?oc=5)). In parallel, quality incentives remain financially material and politically contested: Medicare Advantage quality bonuses are

The Trump CMS’s WISeR Medicare AI prior authorization pilot has become the flashpoint for health IT in VBC: lawmakers are pressing CMS for more transparency on beneficiary delays and algorithmic oversight, while Senate Republicans blocked an effort to halt the test, signaling that AI-enabled utilization management is likely to remain part of Medicare payment-model experimentation despite provider and patient-access concerns ([Healthcare Dive](https://www.healthcaredive.com/news/democrat-letter-more-data-wiser-medicare-ai-prior-authorization/823581/)). At the same time, CMS ordering a corrective action plan for an AI vendor underscores a broader structural shift: interoperability and clinical AI are moving from “innovation” infrastructure to regulated operating infrastructure for risk-bearing entities, where fragmented data, weak AI governance, and poor point-of-care workflow integration can create financial, quality, and compliance exposure for ACOs, MA plans, and advanced primary care groups. The strategic divide is no longer whether to adopt AI, but whether organizations can pair it with accountable data governance, clinical validation, and care-team workflows fast enough to support attribution, quality capture, prior auth navigation, and population health performance ([Hospitalogy](https://hospitalogy.com/articles/2026-06-25/the-missing-infrastructure-for-value-based-care/)).

Revenue cycle integrity in Medicare is shifting from retrospective coding/payment disputes to more automated front-end utilization control, as the Trump administration’s CMS advances the WISeR AI prior authorization pilot while Senate Republicans blocked an effort to repeal it—intensifying the tension between payment accuracy, administrative burden, and beneficiary access in traditional Medicare. At the same time, Medicare Advantage remains under pressure from coding-intensity scrutiny, Star Ratings litigation, and diagnosis-validation disputes, underscoring that VBC organizations will need tighter documentation governance, audit readiness, and prior authorization operating models as CMS and plans push harder on risk-adjusted payment integrity and utilization management ([WISeR Senate vote](https://www.healthcaredive.com/news/senate-republicans-block-medicare-ai-prior-authorization-pilot-repeal-wiser/825523/); [MA coding intensity](https://www.kff.org/medicare/decoding-medicare-advantage-coding-intensity/)).

Population health management is increasingly being operationalized through condition-specific, risk-aligned specialty models rather than generic care management, with Strive Health’s value-based kidney care model emphasizing earlier CKD/ESKD identification, multidisciplinary coordination, conservative kidney management, and AI-enabled targeting to reduce avoidable utilization and total cost of care ([HCTTF case study](https://hcttf.org/a-better-model-for-kidney-care-earlier-identification-smarter-coordination-better-outcomes/)). At the same time, ACO enablement and Medicare chronic-care infrastructure are drawing new capital and platform competition—Pearl Health’s $110M raise and Innovaccer’s positioning around CMS ACCESS signal that vendors are racing to become the operating layer for attribution, risk stratification, care gap closure, and performance management in downside-risk environments. The strategic tension for health systems, payers, and ACOs is shifting from whether to pursue VBC to how much control to retain over enabling capabilities as specialty partners, digital MSK models, behavioral health integration, oncology collaborations, and post-acute visibility become central to managing longitudinal cost and quality.

CMS drug-pricing activity under the Trump administration is shifting from broad IRA implementation into operational pressure points for MA-PD, Part D, and Medicaid: MA plans are preparing for Part B negotiated drug prices, Part D sponsors are modeling rebate reallocation after final NAMBA/BBP release, and states are weighing new federal pharmacy demonstrations that could alter Medicaid purchasing and supplemental rebate strategy. At the same time, midsize biotechs are pressing the White House and HHS to pull back pending CMS pricing models, underscoring the core VBC tension: lower drug spend and tighter public purchasing leverage versus access, launch incentives, and the feasibility of outcomes-based contracting for high-cost therapies. For ACOs, MA plans, and Medicaid managed care organizations, the strategic imperative is to integrate pharmacy risk into total-cost-of-care models, benefit design, and manufacturer contracting rather than treating drug policy as a siloed PBM issue ([Avalere on Part B negotiated prices](https://advisory.avalerehealth.com/insights/part-b-negotiated-drug-prices-how-ma-plans-should-prepare); [CHCS on federal Medicaid pharmacy demonstrations](https://news.google.com/rss/articles/CBMitAFBVV95cUxOSlVNMW5YaElQXzQtTVJaWXctS1QzUjh3Rm43NHppaTFfRTJkRC1BTDN6eEJ6OThZT2VTVH

CMS’s proposed 2027 Medicare Physician Fee Schedule is emerging as a primary-care VBC pivot point, with payment changes that could strengthen internal medicine, support ACO participation, and make primary care practices more viable partners for home-based care and chronic disease management; ACP called the proposal a positive step for primary care, while home health stakeholders see potential for deeper ACO–home care alignment. At the same time, the Trump administration’s CMS ACCESS Model is testing a leaner chronic-disease management construct for Medicare beneficiaries, creating both opportunity and margin pressure for digital health vendors and physician groups as they assess whether lower per-patient payments can scale in value-based arrangements. The broader strategic signal is that Medicare primary care reform is moving on multiple tracks—fee schedule modernization, bipartisan accountable care legislation such as the Patients First Act, and CMMI experimentation—forcing ACOs, enablement companies, and provider groups to decide where to invest for downside-risk readiness and longitudinal population health infrastructure ([ACP on 2027 MPFS](https://www.acponline.org/acp-newsroom/acp-says-2027-medicare-payment-proposal-is-a-positive-step-for-internal-medicine-physicians); [CMS ACCESS digital health positioning](https://endpoints.news/how-digital-health-companies-are-planning-to-conquer-cms-access/)).

CMS is pushing Medicaid policy toward tighter eligibility and financing controls just as VBC models are expected to manage higher-acuity, socially complex populations: the Trump administration’s Medicaid work requirements rule, including medical frailty exemptions, is already facing litigation from 26 states, while stakeholders are warning that exemption workflows could create coverage churn for people with HIV, behavioral health needs, and other complex conditions. At the same time, CMS’ Medicaid state-directed payment proposal implementing reconciliation-law limits is intensifying pressure on state financing arrangements that many safety-net systems and Medicaid managed care VBC strategies rely on, creating a strategic tension between federal spending restraint and population-health investment capacity. For ACOs, Medicaid MCOs, and behavioral health providers, the near-term priority is building documentation, attribution, and risk-stratification infrastructure that can preserve coverage continuity and care management eligibility as Medicaid enrollment and spending baselines reset under the 2025 reconciliation law and related CMS rules ([KFF on Medicaid projections](https://www.kff.org/medicaid/how-has-projected-medicaid-spending-and-enrollment-changed-since-passage-of-the-2025-reconciliation-law/); [Healthcare Dive on state lawsuit](https://www.healthcaredive.com/news/states-sue-trump-administration-medicaid-work-requirements-rule/824060/)).

Medicaid managed care is entering a tighter-margin, more state-directed phase as CMS under the Trump administration moves to implement reconciliation-law limits on Medicaid state-directed payments, with hospitals, MCOs, and state Medicaid agencies recalibrating supplemental-payment strategies and network economics around the proposed rule ([Premier comments](https://premierinc.com/newsroom/policy/premier-comments-medicaid-managed-care-state-directed-payments-proposed-rule)). The pressure is already showing up in payer footprint decisions—Elevance is exiting D.C. Medicaid and weighing additional market exits—while CBO/KFF projections point to lower future Medicaid enrollment and federal spending, raising risk for VBC models that depend on stable attributed lives, behavioral-health integration, and predictable managed care rates ([KFF analysis](https://www.kff.org/medicaid/how-has-projected-medicaid-spending-and-enrollment-changed-since-passage-of-the-2025-reconciliation-law/)). At the same time, CMMI’s ACCESS behavioral-health model is drawing scrutiny over whether its economics can support provider participation, underscoring a broader tension: CMS wants more accountable, integrated Medicaid care, but states and plans are facing less fiscal room to fund the infrastructure VBC requires.

CMS is moving to rewire Medicare physician payment around value-based participation, with proposed reforms that would shift clinician incentives, phase down MIPS, and expand ACO pathways—creating new pressure for physician groups, home-based care providers, and health systems to align referral, attribution, and care-management infrastructure around ACO performance ([Fierce Healthcare](https://news.google.com/rss/articles/CBMiywFBVV95cUxNT2dHa2MyVEVua1lDYWducm1nTVBZSl8weTJ3QU16czJ1TEVqMEMxT2ZJQU4xSjdRLXo2TEVDZzhJb3F6a2pHbzlMOXUzWFlFSGRSYjMyb0ZFcWZpSWlEZmpNTzVpVndtclh2T2Jhb2EyWllhVGRFc1RWZnlJYkhFQlhfZDVoMlFMajBlTU9yYnc0REFvdHVGOVNKVVE3U1Myd0lkY0x6VXZTd21kR3BTWDFNekQ0bTlMQmNGMzhLdVNMNEpFd0VoT3QzMA?oc=5)). At the same time, CMS reported ACO REACH generated $988 million in net savings in 2024 even as the model approaches

CMS’s latest ACO REACH results sharpen the strategic tension for VBC organizations: the model delivered $988 million in Medicare savings in 2024, but it is still scheduled to sunset at year-end, forcing high-performing participants to plan transitions into MSSP, LEAD, or other accountable care pathways while preserving risk-adjustment, documentation, and care-management infrastructure. At the same time, scrutiny of Medicare Advantage coding intensity is reinforcing a broader payment-accuracy agenda under the Trump administration’s CMS leadership, making compliant diagnosis capture, longitudinal documentation, and defensible RAF performance central to both payer strategy and provider downside-risk readiness. For ACOs weighing LEAD versus MSSP, the near-term decision is becoming less about participation alone and more about capital protection, stop-loss design, and operational coding discipline as CMS finalizes program mechanics and stakeholders push for MSSP changes that improve predictability and participation incentives ([ACO REACH savings](https://www.healthcaredive.com/news/aco-reach-generates-more-savings-medicare/824965/); [MA coding intensity](https://www.kff.org/medicare/decoding-medicare-advantage-coding-intensity/)).

CMS is pushing digital health toward tighter accountability in Medicare: the ACCESS chronic disease model appears to create a much lower, outcomes-oriented revenue ceiling for digital health vendors, while proposed Medicare payment changes would restrict outsourced remote patient monitoring—signaling that the Trump administration’s CMS wants technology embedded in accountable clinical workflows rather than billed as stand-alone vendor activity. At the same time, integrated delivery systems and payers are positioning digital MSK and chronic-care models as VBC infrastructure, with Henry Ford Health, Health Alliance Plan, and Protera Health using digital clinical pathways, specialty triage, and wraparound services to manage total cost and outcomes in MSK care ([HCTTF case study](https://hcttf.org/implementing-value-based-musculoskeletal-care-in-integrated-health-systems-through-digital-clinical-models/)). For ACOs, MA plans, and risk-bearing providers, the strategic tension is shifting from “can digital tools generate reimbursable encounters?” to “can they demonstrate clinical ownership, utilization reduction, and population-level ROI under CMS payment scrutiny?” ([CMS remote monitoring proposal coverage](https://news.google.com/rss/articles/CBMirAFBVV95cUxQaV9SVmtGNFp2anZrMVVYVDNBODM3NnAyOEVYNGp2SXR4UFAtcWZ4OElzRlhBMklXczJCM1VUUkhPZTl1T0RFZ)

Medicare Advantage Stars are becoming a larger payment-integrity and legal-risk battleground as the Trump CMS faces challenges over Quality Bonus Program methodology, including post-Clover demands from SCAN and Alignment for broader recalculation, while Medicare is still projected to spend more than [$13 billion on MA quality bonuses in 2026](https://www.kff.org/medicare/medicare-will-spend-more-than-13-billion-on-the-medicare-advantage-quality-bonus-program-in-2026/). At the same time, scrutiny of MA coding intensity and in-home risk assessments is sharpening the strategic tension for plans and risk-bearing providers: defend accurate documentation of patient complexity while preparing for tighter CMS oversight of risk adjustment, Stars, and bonus payments. For VBC leaders, the signal is clear—Stars performance, coding governance, prior authorization operations, and documentation infrastructure are converging into a single enterprise risk and margin-management agenda rather than separate compliance functions.

ACO REACH is entering its sunset year with stronger evidence of Medicare savings—CMS reported $988M in 2024 savings, up from $695M in 2023—strengthening the case for preserving downside-risk, primary care–oriented ACO infrastructure even as CMMI transitions toward successor models like LEAD and organizations weigh MSSP versus LEAD participation decisions ([Healthcare Dive](https://www.healthcaredive.com/news/aco-reach-generates-more-savings-medicare/824965/)). At the same time, CMS’ proposed physician payment and MSSP changes signal a broader Trump administration push to expand ACO participation, reduce reliance on MIPS, and realign fee schedule incentives around accountable care—creating strategic pressure for health systems, physician groups, and enablement companies to reassess attribution, TIN participation, risk corridors, and home-based care partnerships before final rules and LEAD methodology are locked in ([Fierce Healthcare](https://news.google.com/rss/articles/CBMiywFBVV95cUxNT2dHa2MyVEVua1lDYWducm1nTVBZSl8weTJ3QU16czJ1TEVqMEMxT2ZJQU4xSjdRLXo2TEVDZzhJb3F6a2pHbzlMOXUzWFlFSGRSYjMyb0ZFcWZpSWlEZmpNTzVp

ACO REACH’s final-year performance is strengthening the strategic case for downside-risk ACOs just as CMS prepares to sunset the model and shift attention toward LEAD: CMS reported $988 million in 2024 net Medicare savings, up from roughly $695 million in 2023, giving participants and policymakers stronger evidence that the REACH chassis can generate material savings before its transition point ([Healthcare Dive](https://www.healthcaredive.com/news/aco-reach-generates-more-savings-medicare/824965/)). At the same time, organizations accepted into LEAD face an immediate portfolio decision—finalizing Participant TIN lists, waiting on financial methodology details, and choosing between LEAD and MSSP participation—creating near-term uncertainty around benchmarking, risk exposure, and capital requirements for ACO operators ([Wakely](https://www.wakely.com/blog/accepted-into-lead-now-what-aco-risk-mitigation-strategies-part-2/)). The broader signal for VBC stakeholders under the Trump CMS leadership team is that CMMI’s ACO strategy is moving from proof-of-concept savings toward model rationalization, with greater pressure to show transparent Trust Fund impact, scalable risk management, and durable provider participation.

Provider operations are being reshaped by workforce fragility across the VBC care continuum: direct care, long-term services and supports, behavioral health, and primary care all face capacity constraints that threaten home-based care, Medicaid HCBS, care management, and avoidable-utilization reduction strategies. The most VBC-relevant signal is that the direct care workforce remains low-wage, heavily Medicaid-dependent, and demographically vulnerable, making federal Medicaid or immigration policy changes material to ACOs, MA plans, and health systems relying on home- and community-based alternatives to institutional care ([KFF direct care workforce analysis](https://www.kff.org/medicaid/who-are-direct-care-workers-and-how-might-federal-policy-changes-impact-the-workforce/); [KFF immigrant health care workforce brief](https://www.kff.org/immigrant-health/the-role-of-immigrants-in-the-u-s-health-care-workforce/)). At the same time, provider organizations are shifting from episodic staffing fixes toward operating-model redesign: states are building behavioral health workforce pipelines, primary care advocates are pushing the “Triple Double” campaign to expand investment/access/workforce, and hospitals are being pressed to treat medical management as a workforce and productivity strategy rather than just an employee benefit. For VBC leaders, the strategic tension is clear: payment models increasingly depend on longitudinal care teams, telehealth-enabled access, AI-enabled workflow ROI, and community-based management, but the underlying labor supply

Bundled payment activity is shifting from legacy experimentation toward operational scale as CMS episode models—especially TEAM and the proposed/extended CJR-X construct—push hospitals, surgeons, CDI/coding teams, utilization management, and post-acute networks into tighter episode governance, documentation discipline, and discharge-pathway redesign. Health systems are positioning for mandatory episode accountability by investing in surgical performance analytics and partner infrastructure, as seen in [UCHealth’s Avant-garde Health partnership under CMS TEAM](https://news.google.com/rss/articles/CBMi4gFBVV95cUxOZk1lT1d6dmlTbzdkRnF6a0dWY1lQejRjSFBPQVQ3MjdLN2ZEMVQ4cTh2cDd4Vnp6S3ZqbGtKVllEVGh5RVhBalRhYzZVTjN3Z3lwSnN1Z0FSSk9FaF9MMHVOMm1DeFVYa0x6T3VQMTkzRVFtWWVZeGV1dkV1Zm92YVZNZlBMdEllT3h0LV9veGxiUGhQNkNGQzJsaHEyRDdvTUFLczJOLXVfbTZjX2d1QTJXSFR0Y3R4RnVDYjIzdmZDQ3A4c0huUERwX)

Behavioral health integration is moving from “access add-on” to core VBC infrastructure: Medicaid managed care contracts are increasingly embedding behavioral health through care coordination, quality measures, and payment requirements, while primary care–to–SUD referral models are being operationalized as population health workflows rather than standalone programs ([NASHP Medicaid managed care snapshot](https://nashp.org/snapshot-behavioral-health-integration-in-medicaid-managed-care/)). The strategic tension for ACOs, Medicaid plans, and provider groups is that demand is rising—988 volume continues to grow—just as states intensify Medicaid behavioral health enrollment scrutiny, fraud controls, and work-requirement planning, creating a tighter link between behavioral health network strategy, compliance infrastructure, HEDIS performance, and total-cost-of-care risk. Under the Trump administration’s CMS leadership, including CMS Administrator Dr. Mehmet Oz and CMMI Director Abe Sutton, the next phase of VBC positioning will likely reward organizations that can document closed-loop referrals, measurable behavioral-health outcomes, and defensible billing/payment integrity rather than simply expanding nominal behavioral health access ([NASHP SUD referral to treatment](https://nashp.org/connecting-primary-care-patients-to-substance-use-treatment-successful-referral-to-treatment/)).

Specialty VBC activity is shifting from broad primary-care risk toward condition-specific models in kidney disease, oncology, and dementia, with Interwell reporting savings and high quality performance in the Kidney Care Choices Model while expanding payer partnerships such as Cigna—evidence that specialty enablement platforms are becoming strategic infrastructure for MA, ACO, and commercial risk arrangements ([Interwell kidney results](https://news.google.com/rss/articles/CBMivgFBVV95cUxOYjlSVHZsSzFZS1F3WE1lWm9OcVR4bjJRdWtJTXA0djVJLTNLZk05dFdCcnl6d0ZWQmlEUzE1RzdNNVlkaXZ1eFZ0dmJ4YmNSZDVCNkkyRGdjV3JCN3VMMEMxS2xrejJMZUo2WUlXeDZuT3VkMzcxTEJmUjUwTW1MZ2hBZ3RZbUNFeXRYMHF2bl9nVE1tUzh1eFVBVTBMWUFTRm53eGZ4bmptWE02RlpNWkhsbHJIVkYzVF9udmp3?oc=5)). Oncology is similarly moving from legacy Oncology Care Model lessons toward tighter payer-provider collaboration, symptom monitoring, and patient-reported outcomes, while CMS-approved dementia model coding tied

CMS is signaling a more aggressive shift from fragmented fee-for-service incentives toward accountable, network-based payment: the proposed 2027 Medicare Physician Fee Schedule would increase support for primary care, move toward phasing out MIPS, and expand ACO participation, while ACO REACH’s reported nearly $1B in 2024 savings gives the Trump administration evidence to defend and scale risk-bearing models ([CMS physician pay/ACO proposal](https://news.google.com/rss/articles/CBMiywFBVV95cUxNT2dHa2MyVEVua1lDYWducm1nTVBZSl8weTJ3QU16czJ1TEVqMEMxT2ZJQU4xSjdRLXo2TEVDZzhJb3F6a2pHbzlMOXUzWFlFSGRSYjMyb0ZFcWZpSWlEZmpNTzVpVndtclh2T2Jhb2EyWllhVGRFc1RWZnlJYkhFQlhfZDVoMlFMajBlTU9yYnc0REFvdHVGOVNKVVE3U1Myd0lkY0x6VXZTd21kR3BTWDFNekQ0bTlMQmNGMzhLdVNMNEpFd0VoT3QzMA?oc=5), [ACO REACH savings](https://news.google.com/).

CMS is exerting tight federal control over the $50B Rural Health Transformation Program, including clawback threats, which is pushing states toward “safe” cost-containment strategies—such as shrinking inpatient capacity, regionalizing services, and investing in outpatient, digital, and care coordination infrastructure—rather than broad hospital stabilization grants. For VBC stakeholders, the strategic tension is whether rural funding becomes a bridge to population health capabilities, clinically integrated networks, and total-cost-of-care readiness, or simply accelerates service-line retrenchment without durable care model redesign. Bipartisan senators are pressing CMS to better target small rural providers and relax spending restrictions, signaling continued policy friction over whether the program should prioritize federal accountability or local flexibility in rural delivery transformation ([Modern Healthcare](https://news.google.com/rss/articles/CBMikgFBVV95cUxONGo4RTFMTE1ESVRLUGhpRjF0NXY2MmhTQWc0MVN6NVRQQU1nNGZ2OUtCYXBuSS1vYzFFclcwbkkyb0MzZ3lpTGFzUF9DTXQxeDktZl9WRkwxTi1TSUZ1V0NSZXBKM2dGVzhYSGYwUUswT2gwbEZpLUtiX0VyZV81ZE5wdnlWZFlfSnRRWFRyd2dtdw

Rising Marketplace affordability pressure—especially as subsidized ACA coverage becomes unaffordable for more households—signals renewed churn risk between commercial exchange coverage, Medicaid, and uninsurance, complicating payer and provider efforts to sustain longitudinal population-health management and VBC attribution stability. At the same time, the Trump administration’s control over the $50B Rural Health Transformation Program creates a major strategic lever for rural delivery redesign, with states, CMS/HHS, and local systems now competing over how funds are allocated across access stabilization, care infrastructure, and potentially value-based rural payment models ([KFF Health News](https://connect.kff.org/e3t/Ctc/RB+113/c1ThL04/VVtLrb55yhvbW8c2Tl43BgbyqW6fpr4J5QrBMVN4dVQ9-5nR3bW50kH_H6lZ3mJW66cZJ_5Fzc-nW5nGBFv6lkT94W7D2rFG1RtpGKW6rJZJr7_MBSqN570hPtBRRl2N3LHnD-fCjr5Vx1rcy1jHvVXVffWN62XFnL0W3155HV2bjPvBW4Sbtmk2nWZV-V9xtZS5Nd-RBW1D5X_G2mSrhJW935