Twenty Years of Value-Based Care: Industry Leaders on What's Next

"Provider organizations already under financial stress might balk at adapting their contact centers to support VBC or population health capabilities, but they should be reassured that it's possible to incorporate proactive, value-driven processes without disrupting service or spending large amounts of time, resources, or budget.

"Modern customer experience (CX) technology makes customer service interactions not just efficient, but also profitable. The best example of that is how digitally savvy retail brands create upsell and cross-sell opportunities and tailor experiences based on customer preferences by integrating their contact centers and customer relationship management (CRM) systems."

"Value-based care has the right intentions but has been held back by the fundamental problem that all the coding systems underpinning it—including HCCs, quality measures, and risk adjustment—were designed as discrete transaction systems that don't communicate with one another, making truly integrated patient management nearly impossible.

"The real opportunity for 2026 and beyond is the convergence of ambient listening, large language models (LLMs), and a unified clinical data model that can finally bridge the gap between what a clinician documents and what the VBC system needs to act on.

"Until the industry stops trying to bolt value-based workflows onto a foundation built for fee-for-service billing transactions, progress will remain incremental at best."

"Now, 20 years into VBC, it can be said that the most significant issue is not a lack of effort—it is a lack of clarity. We have spent years redesigning payment models without ever truly defining what 'value' looks like at the point of care. As a result, progress has been uneven, and clinicians are often left without the visibility needed to change behavior in meaningful ways.

"The reality is that value is created—or lost—in individual clinical decisions, yet we rarely measure or support performance change at that level.

"If we want VBC to deliver on its promise, we need to shift from top-down reform to ground-level approaches that align actionable insights, incentives, and accountability around how care is actually delivered—by individual clinicians. Until we do that, the progress of VBC will be incremental and unsatisfactory."

"VBC has been 'the future of health care' for more than a decade, yet fee-for-service still dominates in many ways. The reason isn't a lack of ambition; it's a lack of infrastructure. The system was built around episodic visits, and you can't retrofit longitudinal, continuous care onto a model designed for transactions.

"In 2026, the organizations actually moving the needle aren't just signing new value-based contracts—they're doubling down on AI-powered infrastructure that makes continuous care an operational reality.

"But here's the challenge: most health systems don't have the capital budget or IT bandwidth to build that infrastructure themselves. The opportunity lies in connecting into what already exists—integrating with existing workflows, extending care teams into patients' homes between visits, and scaling outcomes without increasing costs or complexity.

"VBC doesn't need another pilot program. It needs infrastructure that health systems can seamlessly adopt."

"VBC continues to transition from an experimental program to mainstream practice, and with CMS mandating increased accountability from providers, watching from the sidelines is no longer an option.

"However, the more interesting shift isn't regulatory, but that AI clearly has a reimbursement rationale, not just a clinical one. With payment based on outcomes rather than encounters, tools that predict risk, close gaps, and keep people out of acute settings stop being operational overhead and start becoming a revenue strategy.

"The organizations that win this moment won't be defined by their compliance, but by how quickly they turn accountability into a competitive advantage and the benchmarks they achieve as early adopters."

"After 20 years, VBC is still treated as new. It isn't. We understand it—the issue is execution.

"Value-based care is not just a payment model; it is an operating model. Most of the industry isn't built to support it. Without access, continuity, and real infrastructure, it devolves into a documentation exercise—checking boxes and generating reports instead of delivering meaningful change.

"The concept doesn't fail because it's flawed. It fails because primary care is broken. Patients can't access care when they need it or on their schedule, so they delay care, skip preventive services, and leave chronic conditions unmanaged. Costs rise, and care becomes fragmented.

"This isn't a VBC problem—it's an access problem. Without easy engagement in primary care, nothing else works: not risk models, quality scores, or cost control.

"Primary care must meet people where they are—in the clinic, at home, virtually, and on demand. That's how outcomes improve and costs come down.

"The first 20 years were spent talking about VBC. The next 20 will be defined by who actually builds it."

"VBC was designed to align payment with the cost of outcomes, but the financial architecture of American health care still rewards volume over value.

"The concept has matured considerably over time, moving from quality reporting requirements through shared savings arrangements into genuine risk-bearing relationships and fully capitated models. What remains difficult to reconcile is that, despite all of this progress, the health care system still operates predominantly on fee-for-service logic, measured by revenue generation, provider participation in risk-bearing arrangements, and how clinical decisions are made at the point of care.

"Primary care and large integrated health systems have made meaningful progress, but post-acute and long-term care providers remain largely on the periphery of a transformation they are expected to help deliver.

"The next chapter of VBC will be defined less by the design of new payment models than by whether the data infrastructure exists to make those models work. The organizations that close the gap between data availability and clinical decision-making will be the ones that deliver on what value-based care was designed to achieve." 

"VBC was coined in 2006, the same year the oldest Baby Boomers turned 60. Now that generation poses a critical test for VBC. Boomers are growing older without sufficient infrastructure to support them. Moreover, the average age of a nursing home employee is 45 to 50 years, and we aren't seeing younger workers step in to replace those staff members.

"The pressure is on to improve outcomes for older adults through new care models and technology, including telehealth. It's clear that CMS is committed to its goal of having all providers affiliated with an accountable care organization or value-based initiative by 2030, with new models and innovations introduced almost quarterly.

"The right ACO partner can help close gaps in care, generate shared savings, and improve quality and outcomes for this vulnerable population."

"VBC has made enormous strides in how the industry thinks about outcomes, but there's a critical gap hiding in plain sight at the pharmacy counter.

"Patients are abandoning medications because of cost, and health plans have almost no visibility into what happens next. That missing data is quietly eroding the outcomes VBC models are built to protect.

"A patient who seeks an alternative affordability pathway isn't just saving money—they're signaling something important about their coverage and their health plan's performance."

"VBC has been the aspiration for more than a decade, yet much of the system still operates on volume-driven economics. The intent is right, but the infrastructure hasn't kept pace, especially in diagnostics.

"Laboratory testing influences roughly 70% of clinical decisions, yet it remains one of the least managed areas in health care. We're making coverage and payment decisions without a clear, evidence-based understanding of whether the right test is being ordered for the right patient at the right time.

"Until the industry brings diagnostic intelligence into the value-based equation, we're measuring outcomes without controlling one of the most significant inputs. In 2026, the priority should be closing that gap. Health plans need to apply precision to their laboratory benefit strategies by using evidence-based protocols and real-time clinical data to ensure testing drives better outcomes, not simply higher utilization.

"That's where VBC becomes real: when every test ordered has a clear line of sight to a clinical decision and a patient outcome.

"The next chapter of VBC will be defined by how well we manage complexity, not just cost. Genetic testing, molecular diagnostics, and precision medicine are advancing faster than most organizations can evaluate them.

"The organizations that integrate diagnostic intelligence into their value-based frameworks will be the ones that ultimately deliver on the promise of better care at lower cost. Without that layer, value-based care remains more aspiration than execution." 

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