Jill Powelson, DrPH, MPH, MBA, RN, CPC, CPPM, is vice president at AMGA Consulting.
Five Steps to Prepare an Organization to Join an ACO
Five Steps to Prepare an Organization to Join an ACO
By Jill Powelson, DrPH, MPH, MBA, RN, CPC, CPPM
AMGA member University of Utah Health has been a high-performing health system demonstrating excellent health outcomes and has their own health plan, but they describe themselves as beginners in high-value care. John Barrett, MD, chair of the Department of Family & Preventive Medicine (DFPM) at the University of Utah, states, “We see that payment reform is coming, and we want to be prepared for CMS [Centers for Medicare & Medicaid Services] value initiatives, which are expected to ramp up significantly by the year 2030.”
The AMGA Value Care Network (VCN), in partnership with AMGA member Wilmington Health, estimates that, based on DFPM’s historical cost and quality performance for their traditional Medicare population, the group would have generated substantial shared savings in previous years. Jeff James, CEO of Wilmington Health, notes, “We first met the DFPM team at an AMGA conference. They are deeply committed to delivering proactive, evidence-based care and are well positioned to achieve high-quality outcomes and strong financial performance within the VCN Medicare Shared Savings Program Accountable Care Organization (MSSP ACO).”
Barrett and DFPM elected to join the VCN to accelerate their access to the subject-matter expertise and tools needed to enter a Medicare ACO, with a longer-term goal of participating in commercial risk arrangements, while also strengthening care delivery for their Medicare Advantage population.
As DFPM prepares to begin Medicare ACO participation in 2026, they will benefit from the experience of Wilmington Health, AMGA’s VCN partner with deep expertise in high-value care. Melissa Odom, COO of Wilmington Health and leader of the VCN MSSP ACO, identifies five key steps that are critical to preparing DFPM for successful ACO participation.
1) Governance, readiness, and ownership.
“The first step is establishing clear internal leadership and accountability for MSSP participation. A successful launch requires a defined executive sponsor and physician champion, along with named operational, analytics, and clinical owners who are responsible for moving work forward. Setting a consistent meeting cadence and decision-making structure early helps prevent stalled progress and ensures the right stakeholders are aligned on goals, timelines, and expectations before performance begins.”
2) Population definition and attribution strategy.
“Before any performance improvement work can happen, the organization needs a clear understanding of the Medicare population it will be accountable for in MSSP. This includes reviewing attribution and PCP alignment, identifying where care is occurring inside and outside the network, and evaluating referral and leakage patterns that may drive avoidable spend. When a group understands ‘who their ACO patients are’ and how they use care, it becomes much easier to prioritize changes that will matter most.”
3) Data foundation, dashboards, and core reporting.
“MSSP readiness depends on timely, actionable visibility into performance, which starts with establishing a reliable data foundation and a simple reporting cadence. The priority is not building perfect dashboards, but standing up the minimum viable set of reports that support decision making—such as attributed patient lists, high and rising risk patient identification, ED and inpatient utilization trends, and care gaps. From there, dashboards should be used to drive meaningful interventions (not just reporting), helping teams identify opportunities, focus effort where it matters most, and track improvement over time.”
4) Provider workflow, access, and network alignment.
“The biggest early gains often come from strengthening day-to-day clinical workflows and reducing avoidable utilization through better access and coordination. This includes improving post-hospital follow-up processes, establishing consistent referral patterns and preferred networks, creating clear pathways for urgent issues that can prevent unnecessary ED visits, and aligning providers around evidence-based approaches to high-impact conditions. These operational improvements are scalable and reduce friction across the practice—not just within a single team.”
5) Documentation, quality performance habits, and proper HCC coding.
“Even in Track A, groups benefit from building strong documentation and quality routines that support long-term success in value-based arrangements. This includes reinforcing annual reassessment of chronic conditions, improving problem list accuracy, and closing care gaps through consistent clinical processes. Proper HCC coding and accurate clinical documentation—supported by provider education and simple workflows—helps ensure chronic conditions are captured and assessed appropriately each year. Ongoing monitoring and feedback loops help embed these habits into everyday practice and create a durable foundation for future upside and potential progression into downside risk models.”
Building a Repeatable Rhythm
Once DFPM moves beyond the initial onboarding phase, the focus shifts from “getting stood up” to establishing a consistent cadence that drives performance throughout the year. Rather than waiting for final CMS reconciliation, the VCN monitors leading indicators that signal whether the ACO is trending in the right direction—such as attribution stability, utilization patterns (ED and inpatient), post-discharge follow-up performance, quality measure progress, and documentation/HCC reassessment completion. With dashboards and monthly performance reviews, the VCN team can identify where interventions are working, where additional support is needed, and which opportunities will have the biggest impact, allowing the team to course-correct early and stay on track well before shared savings results are finalized. Grounded in the belief that value-based dollars earned should remain with the providers and health systems generating that performance, this approach helps ensure that insights translate into meaningful action that strengthens outcomes, supports care teams, and preserves the financial rewards of high-quality care at the point of delivery.
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