Contributor: Value-Based Care Isn’t Broken. Its Structure Is.

Over the past decade, value-based care (VBC) has proven it can improve outcomes and lower costs but only under the right conditions. We started exploring this topic in our previous series, and since then, the market has reached an inflection point. Many of the challenges outlined in our original articles—the missing patient, the quality illusion, the capacity shortage, and the complexity concern—have intensified.

This shift is happening at a moment of real economic pressure. Health system margins remain thin, labor costs are structurally higher, and models like Medicare Advantage are dominating growth. At the same time, reimbursement is tightening, organizations are absorbing losses, and utilization patterns are changing in ways that traditional models of care were not built to manage. Against that backdrop, the rural health funding bill gaining momentum is a live test of whether we will invest in the access, workforce, and infrastructure that make longitudinal accountability possible in the first place. The uncomfortable truth is that VBC is not failing because incentives are weak or data is scarce. It is failing because the industry is layering it onto operating models built for fee-for-service throughout, not longitudinal accountability.

Consider the signals. Fewer than 35% of physicians believe their revenue models support improving patient health. Only 45% of primary care physicians report they can consistently deliver proactive, preventive care. A total of 85% cite manual workflows as a major barrier to VBC execution. Meanwhile, even sophisticated organizations have retrenched, divesting accountable care organization assets, shuttering clinics, and writing down hundreds of millions in losses. These are not isolated missteps; they are structural stress fractures.

VBC can work at scale when it is intentionally designed as an operating system and not appended as a reimbursement overlay. Leaders who succeed will redesign roles, workflows, data flows, governance, and accountability around defined populations.

Flip the Script: From Incentives to Infrastructure

For a decade, the industry has debated risk corridors, benchmark mechanics, and bonus pools. Meanwhile, frontline clinicians can toggle between 57 quality measures across 7 contracts, interpret fragmented dashboards, and absorb risk they are structurally unequipped to manage.

We keep asking: How do we improve the incentives? We should be asking: Who owns execution? Where does accountability live?

High-performing models, such as some regional population-health integrators in Europe and relationship-based systems in the US, share a common trait: They were architected around populations, not retrofitted from volume infrastructure. The next phase of VBC requires discipline: applying it where it fits and designing differently where it does not.

Design for the Population, Not the Model

Let’s be clear, not every population is VBC-ready. Stable, geographically concentrated, and chronically engaged populations with strong primary care attachment are ideal candidates. Populations that are transient, socially unstable, and underutilized need access, trust, and continuity before being held fully accountable under VBC. A one-size-fits-all deployment strategy is not bold. It is reckless. If we don’t account for known constraints, we penalize providers who serve the most complex patients while also inviting cherry-picking and the inexcusable upcoding. If we design around them, we can unlock equitable performance and enable VBC to be a catalyst for meaningful improvement.

The New Village: Roles Built for Execution

Today’s VBC ecosystem includes payers, providers, regulators, employers, and technology vendors. But what it lacks is structural clarity. VBC introduces continuous clinical, financial, and quality accountability into care environments designed for episodic encounters. That mismatch produces overload.

The next chapter requires new and evolved players, what we call “The New VBC Village.”

1. The Value Operator

The Value Operator is an orchestrator who centrally owns contract translation, governance, data configuration, and implementation discipline. They arbitrate incentives across stakeholders and ensure contracts become workflows, not PDFs. Without a centralized owner, accountability diffuses. With one, VBC becomes executable.

2. The Health Outcomes Analyst

VBC asks clinicians to interpret attribution logic, reconcile risk scores, track leading indicators, and manage performance drift. The Health Outcomes Analyst serves as the translation layer between contracts, analytics, and care delivery. Employed by provider organizations but centrally trained, this role converts quality metrics into actionable clinical insights, identifies rising-risk patients before escalation, flags workflow friction between incentives and clinical reality, and ensures AI insights are clinically contextualized.

3. APP-Enabled Care Teams

Roughly a fourth of US health visits are now delivered by a non-physician, and when it comes to VBC, that is a structural advantage. Advanced Practice Providers (APPs) are protocol-driven and well-suited to longitudinal engagement. In a redesigned model, APPs manage preventive and chronic protocols, physicians focus on complex decision-making, analysts surface prioritized actions, and teams operate in pods, not silos. With this, capacity expands without reverting to volume dependency.

4. The Employer as Health Sponsor

Employers insure more than half of the commercially covered US population. Yet most remain passive purchasers. That era is ending. Forward-looking employers are aligning benefit design, plan selection, and targeted incentives to support defined VBC populations. They are encouraging early PCP attachment, redirecting wellness dollars into longitudinal care enablement, using claims transparency rights to demand performance, and offering engagement-based incentives. When employers shift from buyer to sponsor, demand-side pressure accelerates structural reform.

Collectively, these 4 roles set the foundation for a more cohesive and effective VBC ecosystem. Building on this reimagined structure, the path forward demands new action and strategic implementation. But there’s 1 other critical point: All this must be run across a single longitudinal patient record unifying claims, clinical, pharmacy, and outcomes data into 1 source of truth. AI cannot scale across disconnected platforms. Data that arrives 90 days late cannot drive prevention. A Value Platform must understand contract logic, attribution rules, incentive triggers, and route work to the right team in real-time.

What Health Organizations Can Do Now

The market does not need more pilots. It needs consistent execution with embedded contract logic, clear governance, fewer meaningful metrics, real-time data, feedback loops, and stable compensation models. Savings in VBC are not achieved through improved reporting alone, but by changing utilization patterns at scale, which can result in fewer avoidable admissions, earlier interventions, and stronger primary care anchoring.

For health organizations to succeed in the evolving VBC landscape, decisive action is required. They can take several practical steps now to improve VBC. First, they should identify and segment the patient populations that are most relevant for their specific goals, which helps guide risk strategy and enables targeted interventions. Redesigning care teams to focus on continuous, team-based care will support better outcomes. It’s also important to create a centralized Value Operator role to oversee execution, governance, and accountability, while embedding Health Outcomes Analysts into frontline teams to interpret data and measure results at the point of care. Deploying a unified Value Platform with built-in contract logic and real-time data integration allows for smarter, faster decision-making. Employers should be engaged as partners in health outcomes and incentive alignment. Finally, organizations need to move beyond small experiments and scale up with structured, governed processes, making VBC a foundational part of their operations rather than an add-on strategy.

By focusing on these actions, health organizations, and even states, can systematically build the infrastructure needed to move from pilots to true performance, achieving better outcomes for patients and sustainable success in value-based care. The next phase will depend on redesigning roles, aligning stakeholders, and operating as a coordinated system tailored to population needs, with VBC embedded as core infrastructure rather than layered onto legacy models.