It has been 20 years since the term “value-based care” (VBC) entered the health care lexicon.
VBC was supposed to transform health care. It promised to move the system away from fee-for-service (FFS), a model that rewards volume over outcomes, toward a future defined by prevention, efficiency, better patient results, reduced waste, and lower costs. Two decades later, that promise remains largely unfulfilled. Despite years of pilots, policy pushes, and payment reform, VBC still feels like a concept in transition, widely discussed, unevenly implemented, and not yet delivering on its full potential.
Why progress has stalled
There is no single reason VBC has not replaced FFS. There are many.
First, there is inertia. U.S. health care is one of the most complex industries in the world, with deeply entrenched stakeholders and misaligned incentives, and so system-wide transformation at that scale is inherently slow.
Second, the money has not fully moved. FFS remains dominant, and payment models drive behavior. While value-based payment (VBP) adoption is growing, it remains inconsistent, especially outside large, well-resourced systems. According to the Commonwealth Fund, VBP is catching on, with about half of primary care providers receiving some VBP revenue in 2025. But smaller and rural practices continue to lag, underscoring how uneven the transition remains.
There are also structural challenges: fragmented financing, uneven risk-sharing, limited patient engagement, and technology gaps. And critically, many clinicians still lack clear, actionable incentives tied directly to their day-to-day decision-making.
To be clear, progress is happening. More clinicians are participating in VBP models, and policymakers continue to push toward broader adoption. But the pace is slower than expected and the results are mixed.
The core problem: We never defined “value”
At its core, VBC’s biggest failure is conceptual. For 20 years, the industry has focused on how to pay for care, contracts, risk models, incentives, without clearly defining what “value” actually looks like at the point of care. We have redesigned reimbursement structures from the top down, but we have not sufficiently addressed how care is delivered, measured, and improved at the clinician level. And it is there, at the point of care, where value is ultimately created, or lost.
Why clinician behavior is the missing link
The success of VBC does not hinge on policy frameworks or payer contracts. It hinges on individual clinical decisions made every day.
Of course, clinicians operate within broader systems dictated by health plans, employer policies, and risk contracts, but they alone ultimately determine treatment pathways. Yet their decision-making is rarely measured or evaluated with enough precision to drive meaningful change. Most performance measurements happen at the aggregate level: populations, systems, or contracts. While useful for tracking trends, this does little to illuminate or influence individual clinician behavior.
This is the blind spot.
To truly deliver on VBC’s promise, better outcomes, lower costs, reduced waste, we need to start at the ground level by understanding and improving how clinicians practice.
The evidence gap hiding in plain sight
This is not about intent; it is about visibility. Many clinicians are not fully aligned with evidence-based guidelines, not because they reject them, but because they lack insight into their own practice patterns. Clinical guidelines are continuously updated, grounded in research, and widely available, yet adherence varies significantly.
The consequences are substantial. Patients may receive unnecessary or suboptimal care, increasing both risk and cost. At a system level, it contributes to an estimated 25 percent of U.S. health care spending being classified as waste, driven by overtreatment, care variation, and coordination failures. That figure nets out to hundreds of billions of dollars each year. Without visibility into these individual clinical patterns, improvement is largely left to chance.
Measurement is the path to real value
If VBC is to succeed, measurement must move closer to the point of care. By analyzing closed claims against standards of care guidelines, organizations can assess how closely clinicians align with evidence-based practices. More importantly, they can provide actionable feedback, helping clinicians understand how their decisions compare to peers and guidelines. That awareness alone can drive meaningful change. Layer in aligned incentives, through risk-based contracts or performance-based models, and behavior begins to shift more consistently. Not through mandates, but through insights, clarity, accountability, and alignment.
A more practical path forward
Twenty years of uneven progress does not mean VBC has failed. It means the approach needs to evolve.
The industry has spent too long trying to engineer value from the top down. The next phase must be built from the ground up. That means:
- Defining value: In terms of clinical decision-making
- Measuring performance: At the clinician level
- Providing transparency: Actionable insights to each clinician
- Aligning incentives: With evidence-based care
There is no viable alternative to VBC. The FFS model is increasingly unsustainable under rising cost pressures and growing demand. But if we continue to overlook the role of clinician behavior, we will continue to fall short.
The bottom line
Value-based care does not fail because the idea is flawed; it fails because execution has been incomplete.
Until we define, measure, and support value where it actually happens, at the point of care, we will not realize its full potential. The good news? The path forward is clearer than ever. The question is whether the industry is ready to take it.
Jeanne Cohen is the founder and CEO of Motive Medical Intelligence, a health care analytics company dedicated to improving quality, reducing costs, and advancing value-based care through transparent, clinician-level performance measurement. With decades of experience spanning health care, innovation and technology, evidence-based care, and data analytics, she is a recognized advocate for evidence-based clinical decision-making and accountability in health care. She studied at Bates College and Harvard University.
Under her leadership, Motive developed Practicing Wisely, which is helping the industry eliminate the $400 billion in annual waste in the U.S. health system, advancing the transition to high-value, patient-centered care, and achieving the quadruple aim. A published thought leader, Cohen is passionate about empowering clinicians with actionable insights that drive better patient care and a more sustainable health care system.
Her writing on physician-level measurement and value-based care has appeared in outlets including Insurance Thought Leadership, with “Physician performance measures must be transparent“; Patient Safety and Quality Healthcare, with “Healthcare leaders are overlooking the key to value-based care success: physician-level measurement“; and Healthcare IT News, with “Physician-level measurement needed for VBC to succeed.” She shares updates on LinkedIn.
