For more than a decade, the American healthcare debate has been asking the wrong question. In New York, the focus remains on cost, questioning why the nation’s largest Medicaid program spends billions while still struggling to deliver better outcomes. In response, the system has chased fraud, waste, and abuse, hunting for savings that barely register.
The answer isn’t complicated. It’s structural.
Medicaid rewards volume. More visits. More procedures. More admissions. More of everything except better outcomes. The system prioritizes quantity over quality, remaining blind to whether care actually prevents the chronic conditions driving 80% of healthcare costs.
We built a system designed to treat disease, not prevent it, and then questioned why costs keep rising. As New York faces a multibillion dollar budget gap and federal cuts threaten coverage for nearly half a million residents, this is a failure we can no longer afford.
America already tested a different path, and it worked. Yet the system has ignored the one model that achieves savings while creating healthier patients. It’s called value based care.
In 2014, New York State launched the Delivery System Reform Incentive Payment program, a $6.42 billion effort to redesign Medicaid by reducing avoidable hospital use and shifting care toward prevention, coordination, and accountability. Twenty five Performing Provider Systems were created to align fragmented providers around outcomes instead of activity. Most dissolved when the program ended. One did not.
SOMOS Community Care.
SOMOS is a nonprofit, physician led network of independent, community based doctors built to serve populations often left out of traditional systems. It recognizes that caring for vulnerable patients requires more than treatment. It requires prevention, education, and access.
SOMOS includes more than 2,500 healthcare providers serving over one million Medicaid and Medicare beneficiaries. Each day, physicians deliver culturally competent care to more than 30,000 patients across 900 clinics in New York City’s most underserved neighborhoods.
This infrastructure is the proof of concept New York set out to build, demonstrating that outcomes improve and costs decline when value based care is executed effectively and at scale.
Through SOMOS ACO, one of the highest performing accountable care organizations in the country, the network generates between $35 million and $48 million in annual savings while maintaining over a 90% quality score.
SOMOS Innovation builds on this foundation by integrating data, technology, and care design to extend what is delivering results. Real time insights, coordinated care teams, and community based interventions enable physicians to manage risk and improve quality across large populations.
Today, the model manages more than 20% of patients with diabetes, over 25% with cardiovascular disease, and nearly 12% with asthma. More than 153,000 patients are enrolled in structured chronic disease programs designed to stabilize conditions before they escalate.
Patients connected to coordinated care and social determinants of health support experience a 57% reduction in total medical spending. Emergency room utilization for diabetes patients is 35% lower, and hospital readmissions have declined by 22%.
The financial and clinical outcomes point in the same direction. Value based care produces tens of millions in savings by eliminating avoidable hospital stays.
That reality was tested under pressure during the COVID 19 pandemic. As access fractured and uncertainty spread, SOMOS physicians moved early and decisively, building a parallel system.
They deployed $40 million of physician earned revenue to fund testing, PPE, and food distribution, established 125 trilingual testing sites, administered millions of vaccines, and delivered over 2.5 million meals, all while 12 physicians lost their lives.
The state’s next chapter reflects this direction. Through the 1115 Waiver and the creation of Social Care Networks, New York has acknowledged that health outcomes begin in the communities where people live and are influenced by access to food, housing, and transportation. As both an Innovator and the Social Care Network lead entity for Bronx County, SOMOS is operationalizing a model that is delivering results.
Policy can set direction. Only trust drives transformation.
The Value Based Payment Innovator Program, which operates through the NYS Department of Health, is now incentivizing doctors, hospitals, and health plans to work together. The framework exists. The infrastructure exists. The results are measurable.
If New York is serious about Medicaid, it must rebuild trust with providers who understand the populations they serve by allowing them to enter value based, full risk contracts that enable holistic care for more patients.
With over half a million New Yorkers at risk of losing coverage due to federal cuts, success cannot be measured by how much care is delivered after people become sick. It must be measured by how effectively illness is prevented through care that is continuous, accountable, and rooted in the communities it serves. The question is no longer whether value based care works. It is whether the system is willing to follow the evidence.
By expanding the Innovator program, strengthening the Social Care Network, and empowering physician led networks, New York can move beyond cost management and build healthier communities for the future. Medicaid does not need another redesign.
It needs the discipline to align with what already works before more coverage is lost and the cost of inaction becomes irreversible.
