For more than a decade, “value-based care” has been both the north star and the bottleneck of American health reform. Its promise is simple: reward outcomes, not volume. Its reality has been far messier. Despite years of pilot programs and broad consensus on its importance, true value-based transformation has reached only a fraction of the healthcare system. Why? The reasons value-based care hasn’t scaled aren’t political—they’re structural.
Recent reporting and federal analyses paint a sobering picture. MedCity News reporter Katie Adams notes that voluntary participation, misaligned incentives, metric overload, and employer disengagement are slowing adoption. Former athenahealth CEO Dr. Jonathan Bush adds that the system has become so entangled in outdated incentives that the only realistic path forward may be to “burn it down and build it new.” Despite widespread agreement on the need for change, few organizations have the appetite or capacity to start fresh.
Director of Boston University’s Health Reform Program, Dr. Alan Sager makes a similar argument from a different angle. Writing in CommonWealth Beacon, he calls Massachusetts “the easiest place to solve healthcare affordability” precisely because it already spends enough to cover everyone—but wastes up to half of that spending through inefficiency, paperwork, and misaligned incentives
Affordable health care for all. His point is not ideological. It’s architectural: when the system’s incentives and measurements are misaligned, no amount of money—or goodwill—can deliver consistent, affordable care.
The Systemic Barriers: Misalignment, Consolidation, and Measurement Overload
One of the most striking confirmations of Sager’s warning comes from the Government Accountability Office’s (2025) report, Estimates of the Extent and Effects of Physician Consolidation. The GAO found that nearly half of all physicians now work in hospital- or corporate-owned practices—up from less than 30 percent a decade earlier. This rapid consolidation has driven prices upward without commensurate improvements in quality. The report cites evidence that hospital-physician mergers increased spending and commercial insurance prices, largely due to services shifting to higher-cost hospital settings.
Consolidation isn’t inherently bad; coordinated systems can improve care continuity. However, the GAO found that quality gains are “less clear or unknown,” while administrative costs rise and patient access can suffer. In other words, we’ve built an integration machine without a performance engine.
Layered onto this is a growing concern about measurement overload. As highlighted in What’s Standing in the Way of Healthcare Payment Reform?, healthcare leaders note that decades of expanding metrics haven’t translated into better outcomes. Despite tracking hundreds of quality indicators—from flu shots to eye exams and discharge instructions—costs have continued to rise while access and satisfaction have declined. Many argue that it’s time to simplify: focus on total cost of care, patient experience, and a few meaningful indicators that actually reflect health and trust. In other words, we need fewer numbers and better measures.
In public remarks, Mona Siddiqui lamented that “we’ve created an enormous burden on the system without anybody being happy about it.” Former chief medical officer and director of CMS’ Center for Clinical Standards and Quality, Lee Fleisher agreed, noting that we still don’t measure what matters most—patient engagement and trust.
Together, these critiques point to a single diagnosis: the architecture of value-based care remains misaligned with its purpose. The policies reward participation, not transformation. The metrics measure compliance, not outcomes. The structures consolidate power, but not necessarily capability. The result is a system that’s expensive, data-rich, and insight-poor.
Design is the Missing Discipline
What these reports and commentaries share is a belief that our problem is not political will—it’s design literacy. Dr. Sager calls for planning before a crisis, warning that “it’s a bad idea to sew parachutes after the plane’s engine has stopped.” The GAO concludes that neither markets nor regulation alone can fix fragmentation; both need to be redesigned to promote transparency and accountability. Even Bush’s provocative “burn it down” metaphor is, at its core, a call for system redesign rather than policy overhaul.
The goal is not to assign blame but to diagnose friction. Policymakers, payors, and providers are all operating inside legacy systems built for a different era—fee-for-service logic, siloed data, and incentive asymmetry. A neutral, systems-engineering lens asks a different question: how might we redesign those interactions so that good behavior becomes the path of least resistance?
That’s where data and design intersect. Data clarifies reality; design structures behavior. Without both, the system defaults to inertia.
Where VBCTP Fits: Turning Analysis Into Action
At VBC Transformation Partners, we approach this challenge as a design problem, not a policy debate. Our work with independent physician groups, independent physician associations (IPAs), clinically integrated networks (CINs), and accountable care organizations (ACOs) shows that transformation succeeds only when organizations move through a disciplined, phased process:
- Clarity. We start with a diagnostic—Baseline VBC Health Analysis—to reveal where incentives, quality metrics, and data flows are misaligned. Rather than layering more measures, we identify the few that truly drive outcomes and revenue integrity.
- Alignment. Using those insights, we help groups redesign care models, workflows, and governance structures that align financial incentives with clinical mission. This phase often surfaces hidden leverage in payor contracts and population-health metrics.
- Execution. Finally, we guide teams through operational transformation—embedding change management, performance dashboards, and trust-building routines that turn insight into consistent performance.
This phased approach helps organizations build momentum without overwhelm. It’s designed to convert complexity into confidence—one measurable success at a time. In systems terms, it creates a feedback loop: better data → better decisions → better results → greater trust.
From Measurement Fatigue to Meaningful Value
What would it look like if value-based care were redesigned through this lens?
- Metrics as tools, not weapons. Reduce the number of measures, improve their fidelity, and align them directly with patient outcomes and staff experience.
- Data that builds trust. Use transparent analytics not to audit, but to inform shared decision-making between physicians and payors.
- Design that simplifies. Automate low-value administrative tasks and elevate the human work of care—listening, coordinating, healing.
- Accountability that empowers. Shift from punitive oversight to collaborative governance structures where all stakeholders co-own the results.
This is not a dream scenario. It’s what the best value-based organizations already do. They don’t chase every metric; they pick a few that matter and design their systems around them. They don’t view data as surveillance; they treat it as shared intelligence. They don’t wait for Washington to fix design flaws; they build better systems themselves.
The Path Forward
The convergence of these voices—academics, policymakers, innovators, and auditors—suggests an emerging consensus: the next leap in value-based care will be driven less by regulation and more by redesign. The question is not whether the system will evolve, but how gracefully.
If value-based care has stalled, it’s not because we lack conviction. It’s because we’ve mistaken measurement for management, and structure for strategy. As Alan Sager wrote, affordable, high-quality healthcare “should be the easiest aim to attain because we already spend enough”
Affordable health care for all. The challenge now is to spend—and measure—wisely.
VBCTP exists to make that possible: helping organizations align data, design, and delivery so that value-based care finally scales—not by burning it down, but by building it right.
