How independent practices lose shared savings before they earn them

Independent primary care practices do not need a physician enablement company to succeed in value-based care, and the ones leaning on intermediaries are handing over shared savings they could be reinvesting in their own operations. That is the argument behind the Value-Based Care Playbook, a free, open-source operating manual released by the nonprofit Ten Ten Ten.

"Unfortunately, what's happening is that they take a very large portion of the shared savings, so it does not truly help the primary care practice in the end," Jenn Block, PhD, MBA, who leads the value-based care initiative at Ten Ten Ten with Bhargav Raman, MD, MBA, told Physicians Practice. "They're losing out on money they could have had to reinvest in their own practice."

The playbook's first installment, available free on Ten Ten Ten's website, runs 71 pages and covers contract language, EMR configuration, care team design, risk stratification, documentation and physician incentives, with about 25 deeper-dive companion documents to follow. The nonprofit takes its name from its goal: top 10 health outcomes at 10 percent of GDP within 10 years.

Why value-based care, and why now

The playbook lands as independent practice keeps shrinking. Fewer than half of physicians, 47.4 percent, worked in practices of 10 or fewer doctors in 2024, down from roughly 80 percent in the early 1980s, a trend the American Medical Association's president called an "unraveling" driven by low payment, rising costs and administrative burden.

Federal data, meanwhile, keeps making primary care's case. In performance year 2024, Medicare Shared Savings Program ACOs earned a record $4.1 billion in performance payments, and ACOs composed predominantly of primary care clinicians generated $403 in net per capita savings versus $224 for those with fewer, according to CMS. "I always say, prove it. Show me the data," Block said, citing a physician-led ACO in Delaware whose shared savings exceeded its fee-for-service revenue for the first time.

The contract traps that erase shared savings

The playbook's starting point is blunt: a practice can perform extremely well and still not earn shared savings because of the contract it signed. Block said she has seen three traps repeatedly. Quality thresholds set as gates can wipe out shared savings even when a practice controls costs. Flat per capita benchmarks penalize practices with sicker panels, and rebasing means "you're penalized for doing well year over year." Attribution leakage, patients assigned to a practice that get their care elsewhere, is the quietest of the three but the one she hears about most.

Her first test of any payer: ask for the benchmark methodology and the historical data behind it. "If they won't share that, I would be very cautious about entering into a contract with them, because that sets everything for the future of how you earn your shared savings," Block said.

Why practices cannot code their way to success

The playbook splits value-based care into two parallel jobs: documenting patient complexity to set the benchmark, and reducing the cost of care measured against it. Documentation comes first for a new practice, Block said, but it is not the whole game.

"You cannot code your way to success. It's not possible," she said. "Practices that treat value-based care as a documentation project plateau in year two."

Raman said the industry's focus on risk scores has crowded out the harder work. "Year on year, the medical cost, which represents 75 to 80 percent of value-based care payments, increases, and if you don't control it, that 80 percent becomes something that's unsustainable over time," he said.

Incentives decide whether any of it happens, Block said: physicians paid purely on productivity drift back to volume no matter what they believe. Raman put it more pointedly: "If you give physician leaders the chance and the incentive to have better outcomes and lower costs, that's the way out of the rat race."

Fewer than 10 percent of patients drive 70 percent of costs

Primary care does not bill for roughly 80 percent of total cost of care, so the playbook's cost strategy comes down to concentration. "Since fewer than 10 percent of patients drive 70 percent of the total cost, that 10 percent is where you need to focus," Raman said.

The operational engine is deliberately low-tech: a named owner reviews the rising-risk list every Monday, and the team assigns owners for the top 15 to 20 patients at a weekly huddle. "This simple weekly ritual, if you do it consistently, will outperform the most sophisticated processes that you do inconsistently," Block said.

What practices should do in the next 90 days

The clock matters because the program landscape resets Jan. 1, 2027. ACO REACH concludes at the end of 2026 and is replaced by LEAD, a 10-year model with no benchmark rebasing that CMS designed to appeal to smaller, independent and rural practices, while the Medicare Shared Savings Program's one-sided risk window shrinks. Block called next year the most consequential for value-based care since shared savings began.

Her 90-day prescription is a baseline: quality performance from the EMR and payer portals, the attributed patient panel verified against the active panel, a documentation audit of 20 to 30 complex charts and a financial analysis from payers covering admissions, readmissions and risk adjustment factor.

"Every decision is based on numbers that most practices have never pulled, or asked to pull from their payer partners," Block said.

Ten Ten Ten's practice readiness assessment, like the playbook, is donor-supported and currently free for practices.