At one large primary care group, physicians earned extra pay for Saturday visit volume. Weekday work started sliding to the weekend, where it paid more. Meanwhile, the group's business development and sales staff were paid on patient volume, so they prioritized adding patients over whether the new business made financial sense. Patient count grew, but the line of business became unprofitable.

Both incentives rewarded volume in an organization whose largest revenue source, Medicare Advantage (MA), paid for managing chronically ill patients over time. The incentives were doing exactly what they were designed to do; the behavior they rewarded no longer matched how the organization made money or delivered care. Mark D. Kent, FACHE, FACMPE, who joined the group and led its recovery, traced both problems to the same source: The group had never deliberately designed or approved an operating model that matched how it was paid.

Kent, president of the care delivery organization at Alignment Health, used the group’s turnaround at his session at the 2026 MGMA Annual Conference to show what happens when payment changes faster than practice operations. The group had moved into value-based and risk-based contracts while its staffing, scheduling and clinical workflows still reflected fee-for-service.