Why Serious-Illness Alignment Is the Next Frontier in Value-Based Care

In almost every ACO or MA plan, a high-cost group of seriously ill members receives care that doesn’t align with their goals. They cycle through EDs, ICUs, and repeated hospitalizations—not from lack of care or compassion, but because the conversations that guide better decisions were never built into the system.

If you’re searching for the next meaningful lever for 2026 shared savings, it’s probably not in another dashboard or risk model. It’s in transforming advance care planning (ACP) from a one-off form into a core organizational capability.

When ACP becomes infrastructure (not paperwork) it strengthens the full value-based care engine. It improves quality metrics, boosts patient satisfaction, supports equity, reduces clinician burden, and brings teams into tighter alignment around what “right care” actually means for people living with serious illness.

The Blind Spot: Misaligned Care Drives Waste and Suffering

One in four Medicare dollars is spent in the last year of life. Leaders know this. What gets less attention is that much of this spend funds care patients would not choose if they’d had meaningful, structured discussions about their values and preferences.

Without that clarity, care defaults to:

• Repeated ED visits
• ICU stays that don’t improve quality of life
• Hospice referrals days (not months) before death
• Crisis family meetings where no one knows what the patient wanted
  

The human toll is devastating. The operational toll is equally damaging: inconsistent workflows, frustrated clinicians, unpredictable utilization, and flat quality scores.

Most organizations technically “have ACP,” but in practice ACP is still:

• A compliance checkbox
• A static form buried in the EMR
• A task assigned only to those “comfortable” with end-of-life conversations

ACP exists, but it doesn’t perform.

Why ACP Is the Untapped Lever for 2026

When ACP is continuous, digital, and integrated, it reshapes the last 12–24 months of life and strengthens the organization upstream.

It moves key metrics

• Fewer crisis-driven admissions
• Lower ICU use when it doesn’t align with goals
• Shorter terminal hospital stays
• Earlier, more appropriate hospice enrollment

It improves quality performance

ACP sits upstream of:

• CAHPS (communication, respect, trust)
• HEDIS/Stars (care coordination, serious illness, transitions)
• ACO quality metrics (goal alignment, hospice use, patient experience)

It aligns the organization

Effective ACP requires clear ownership, standardized workflows, and shared language across teams—driving cohesion across care management, palliative care, and serious-illness programs.

It reduces clinician burden

When clinicians know what matters most to the patient, they avoid crisis meetings, ethically fraught decisions, and emotionally draining conflicts.

It strengthens patient and family trust

Goal-concordant care feels humane, respectful, and clear. Families become advocates instead of feeling abandoned or confused.

ACP is not just a cost lever. It is a strategic alignment mechanism.

What’s Broken Today—and What Needs to Change

Most ACP programs fail for predictable reasons:

• Forms instead of conversations
• Scanned PDFs instead of structured data
• No clear owner
• No way to scale ACP across patient populations
• No workflows to revisit ACP as conditions change
• Documents not visible when clinicians need them

The system gives itself credit for “doing ACP,” but utilization, quality metrics, and serious-illness experiences stay the same.

The opportunity isn’t to do more ACP.
It’s to do ACP in a way that actually works.

The New Model: Digital, Data-Driven ACP as an Operational Strategy

If the traditional ACP model is static, fragmented, and paperwork-driven, the emerging model is the opposite: continuous, digital, data-driven, and tightly integrated into clinical operations.

This new model treats ACP as infrastructure—a core capability that underpins serious-illness care, quality performance, patient experience, and shared savings. It moves ACP from the margins of care delivery to the center of organizational strategy.

At its core, the modern ACP model does four things differently:

1. A Digital, On-Demand Patient Experience That Drives Real Engagement

Most patients don’t complete ACP because the traditional process is confusing, overwhelming, or inaccessible. The digital model flips that dynamic.

A modern ACP platform provides:

• Plain-language values exploration that helps patients think through independence, comfort, longevity, family considerations, and quality of life.
• Short, narrative education modules that demystify serious-illness choices.
• Scenario-based guidance that helps patients understand tradeoffs in a concrete, human way.
• Multilingual, culturally tailored content available on any device, anytime.
• Step-by-step preference capture that simplifies complex decisions.

This approach dramatically expands engagement—not just for the most proactive patients, but across entire populations, including those traditionally left out of ACP.

The result: More patients complete high-quality ACP, and more families walk into critical decisions with clarity instead of confusion.

2. Data Integration That Turns ACP into Actionable Intelligence

In the new model, ACP isn’t a scanned PDF. It is structured, interoperable data that flows across systems and surfaces at the moment of care.

A modern ACP program:

• Auto-generates state-compliant documents
• Pushes documents and structured fields directly into the EMR
• Makes key preferences easily visible to clinicians (“Goals Summary” view)
• Syncs ACP status with care management platforms
• Shares documents with family and surrogates

This is what transforms ACP from “something we collect” into something the system actually uses.

Clinicians stop asking, “Do we know what this patient wanted?”
And they start asking, “How do we honor what this patient already told us?”

3. Targeting High-Risk, High-Opportunity Members with Precision

Not every member needs ACP at the same intensity or at the same time.

The modern model uses data to identify where ACP can drive the greatest clinical and financial impact:

• Late-stage CHF, COPD, ESRD, oncology
• High-utilizer patterns (ED, inpatient, ICU)
• Members with recent declines or repeat hospitalizations
• High-risk VBC cohorts tied to shared-savings goals
• Patients approaching likely high-cost episodes

Instead of broad, unfocused outreach, the organization deploys ACP strategically—where it can shift utilization and experience fastest and most predictably.

This makes ACP not just compassionate, but operationally efficient.

4. Human Support Where It Matters Most

Digital tools scale ACP, but they don’t replace human connection. Koda’s modern model blends the two.

For members who need deeper support, ACP programs deploy:

• Navigators, ACP guides, care managers, or palliative-trained staff
• High-touch outreach for complex, high-risk patients
• Family-inclusive conversations
• Coaching around conflict, uncertainty, or grief
• Coordination with clinicians to ensure plans are feasible and aligned

This hybrid approach ensures that ACP is scalable for the population, personalized for those facing the most difficult decisions, and equitable for members who benefit from human guidance.

The ACP Flywheel

A simple mental model for leaders:

• Identify high-risk, high-opportunity members using claims and clinical data
• Engage them through digital tools + targeted human support
• Activate ACP by surfacing preferences inside workflows and at the point of care
• Measure impact on utilization, quality, and experience—and feed that insight back into targeting

This cycle strengthens over time. ACP becomes an engine, not a project.

[DOWNLOAD THE FULL ACP READINESS CHECKLIST]

Why 2026 Is the Time to Act

Three forces are converging:

• Tightening MSSP and REACH benchmarks
• Rising scrutiny on serious-illness care
• Aging populations and increasing chronic disease

ACP programs launched in 2026 will influence utilization and experience in the next 12–24 months—the exact window shaping 2027–2028 shared-savings results.

Waiting is not neutral. It’s costly.

Schedule your 2026 Strategy Session.