Value-based care is moving fast—but many providers are being asked to steer without a full dashboard. As financial accountability grows, the data needed to manage that risk often remains out of reach without payer-provider data sharing.
Theresa Hush’s recent piece on payer-provider collaboration puts this tension into focus. She highlights a persistent industry challenge: providers are increasingly accountable for cost and quality, yet lack access to the claims data that reveals cost drivers, utilization patterns, and complications. Without integration between clinical and cost data, providers are flying blind—unable to coordinate care, manage risk, or optimize performance under value-based models.
She’s clear about the risk—but also about the path forward. The gap between clinical and claims data isn’t just a technical limitation; it’s a strategic barrier that calls for alignment, creativity, and trust. At VBCTP, we see that same challenge and help provider groups respond not with frustration, but with action.
Why Data Silos Are a Systemwide Challenge
Today’s providers have made major strides in aggregating and analyzing electronic health record (EHR) data, but while EHRs offer valuable clinical insights within a given organization, they often leave out key pieces of the broader care picture.
For example:
- A patient may be hospitalized in another health system, and the discharge summary never makes it back.
- A specialist might adjust a medication, but the primary care provider isn’t notified.
- A recent ED visit, imaging study, or home health referral may not show up in the practice’s systems at all.
That’s where claims data becomes essential. It adds context: prior diagnoses, pharmacy fills, procedures, post-acute utilization, and more. Together, clinical and claims data offer a richer understanding of patient journeys and the ability to proactively manage risk. Together, clinical and claims data offer a more complete understanding of patient journeys. It’s just a stronger foundation for proactive, coordinated care.
This is the context in which providers are being asked to take on risk, improve outcomes, and reduce costs, but they often don’t have access to the full claims, utilization, or network data that determines whether they succeed or get penalized. That’s like flying a plane with half the instrument panel covered. It makes performance uneven, tracking difficult, and proactive management nearly impossible.
When data remains siloed, providers are left with only a partial view of a patient’s healthcare journey. That limited visibility makes it difficult to:
- Design effective care pathways—because you don’t know what treatments or tests have already occurred elsewhere
- Identify and address preventable complications—because early warning signs may live in claims, not your chart
- Coordinate follow-up and transitions of care—because discharge summaries or specialist notes may never arrive
- Track performance on cost-of-care metrics—because you can’t manage what you can’t measure
These gaps don’t just affect value-based contracts; they affect every provider, every day. Whether you're in a fee-for-service model or taking on risk, what you don’t see leads to missed opportunities, fragmented care, and mounting costs.
According to the Commonwealth Fund, administrative costs alone account for roughly 30% of excess U.S. health spending—split evenly between insurance-related processes and the burdens placed on providers themselves. Much of that is preventable—with better data flow, stronger alignment, and shared visibility across the care continuum. Add in prescription drug costs (10%), higher physician and nurse wages (15%), and medical equipment (under 5%), and you account for more than 60% of the spending gap between the U.S. and peer nations. That’s not just abstract waste. It translates into hundreds of billions of dollars that could be redirected toward coordinated care, patient access, and innovation.
This isn’t just a technical issue. It’s an industry-wide operational challenge with clinical, financial, and human consequences.
The Financial and Operational Realities for Providers
Many primary care groups would like to embrace risk-bearing models, but the economics must work. When the only available claims data applies to a fraction of their panel—typically just Medicare or Medicare Advantage patients—the investment in infrastructure becomes harder to justify (Hush, 2025).
As the American College of Physicians notes, incomplete risk adjustment can also make practices appear less efficient than they are—especially those serving underserved or high-complexity populations (ACP, 2025). That’s not a failure of effort; it’s a reflection of the data environment.
This dynamic presents a shared challenge: providers want to succeed in value-based care, and payers want aligned partners who can deliver results. The missing link is shared information.
The Pathways Toward Smarter Payer-Provider Data Sharing
There are encouraging signs of progress—and clear opportunities for thoughtful collaboration:
- Masked claims data can be shared in a way that protects proprietary rates but allows for outcome analysis
- Third-party data intermediaries can serve as trusted bridges between payers and providers.
- Bundled cost analytics can create alignment without requiring granular rate exposure
As Hush notes, “It requires only willingness and creativity to have that conversation.” The reality is, most providers aren’t at that table—yet.
Aligning Around the Data You Do Have
What is happening is a growing push to renegotiate contracts, take on risk, or improve performance under existing agreements. That’s where many practices hit a wall. Without full visibility into claims data or cost drivers, it’s hard to build a strong negotiating position—let alone track performance or advocate for fairer terms.
At VBCTP, we help providers bridge that gap. We equip practices with the insights, infrastructure, and financial modeling to make smarter decisions, advocate more confidently, and push for contracts that reflect the value they’re delivering.
What We Do: Empowering Providers, Supporting Collaboration
At VBC Transformation Partners, we help physician groups thrive in real-world conditions, whether claims data access is robust, limited, or somewhere in between.
Even in a fragmented data environment, we help you lead with insight and act with confidence. Here’s how:
- EMR-neutral, payor-agnostic data tools that bring clarity—even when claims data is limited
- Customized ROI and opportunity models to build internal buy-in and support payer engagement
- Workflow optimization that reduces burnout, improves documentation, and captures the value you're already delivering
- Strategic contract analysis that flags performance gaps and missed revenue opportunities in real time
- Population health and SDOH navigation tools to proactively manage risk and improve equity
- A proven, physician-led roadmap designed for your real-world constraints—not theoretical perfection
We don’t just advocate for data sharing—we help you meet it with strategy, technology, and support that works. We help providers make actionable use of the data they have now, while building toward more connected partnerships.
It’s Time to Align—Together
Value-based care is built on trust. We know that trust is built through alignment of goals, incentives, and information.
At VBCTP, we’re optimistic about what’s possible because we’ve seen how payer-provider alignment—not just in contracts, but in data—can drive meaningful progress. Reduced avoidable utilization. Improved equity. Lower total cost of care. Healthier populations.
Let’s keep building that path forward—together.
Ready to Move Forward?
Let’s talk about how you can strengthen your value-based care strategy through smarter use of data—today and tomorrow.
