Care Coordination & Management

Care coordination is moving from “program design” to execution economics: Prisma Health’s clinically integrated network is using embedded care managers, hospital-based transitions nurses, ED navigators for high-utilizing Medicaid patients, and interdisciplinary Care Team Pods as a frontline operating model for population health, while independent practices are reassessing whether ACO participation can support that level of infrastructure. Medicaid and MA policy pressures are sharpening the stakes: North Carolina’s implementation planning for 2025 reconciliation-law Medicaid provisions amid budget shortfalls could disrupt coverage/access and care-management continuity, while UnitedHealthcare’s rollback of many pediatric prior authorizations and continued hospital pressure on Medicare Advantage signal payer attempts to reduce friction without conceding broader utilization-management control. For VBC leaders, the near-term implication is clear: success will hinge on proving that care-management staffing, social-needs workflows, and transitions infrastructure can lower avoidable ED/inpatient use fast enough to withstand Medicaid financing constraints and MA administrative tension. Prisma Health care model | North Carolina Medicaid changes