3 essential capabilities to scale impact and collaboration in VBC

Value-based care (VBC) entered the U.S. healthcare conversation in 2006 with Redefining Healthcare: Creating Value-Based Competition on Results, though its roots extend to earlier managed care and HMO models. The Affordable Care Act accelerated adoption in 2010 by adding financial incentives that encouraged healthcare organizations to move away from fee-for-service reimbursement and toward models tied to cost, quality and patient satisfaction. 

Today, VBC is nearing a tipping point: almost half of healthcare payments are tied to alternative payment models and more than 60% of 2023 healthcare spending was connected to a VBC model. Yet many payer and provider organizations still struggle to realize the full promise of value-based care because of persistent gaps in data, technology, operations and interoperability. Even so, enthusiasm for expanding VBC contracts and investing in risk-based programs remains strong. 

The next phase of VBC success depends on a few core priorities: 

• Overcoming technology, data and operations gaps with tools built for risk-based programs 
• Scaling effective programs across organizations 
• Enabling seamless collaboration among payers and providers 
• Investing in infrastructure that supports AI-driven decision making 

Despite challenges, stakeholders double down on VBC

VBC efforts continue to grow despite technology and operational barriers, signaling confidence in the model’s long-term benefits and a strategic shift away from volume-based care. Payers are investing because VBC offers: 

• Long-term cost containment potential  
• Compliance with regulatory and industry pressure for accountability and outcomes 
• Addressing consumer demand for better care and better patient experience 

But confidence alone is not enough. To unlock VBC’s full potential, payers must evolve their capabilities and focus on execution. 

Scalable, high-quality data infrastructure  

A strong data infrastructure is the foundation for risk-based programs. Payers and providers need enterprise data management systems that deliver integrated, longitudinal views from key sources, including: 

• Claims
• Clinical 
• Government (SDoH, CMS) 
• Pharmacy 

These systems must align with federal interoperability standards such as FHIR, support near-real-time data exchange and normalize and cleanse incoming data so it can be used across the organization’s entire IT ecosystem. They also need strong security and governance controls to support HIPAA compliance and broader regulatory requirements. 

Together, these capabilities create a holistic view of each patient or member, reducing blind spots that can affect care decisions and outcomes. High-quality integrated data also lays the groundwork for predictive insights and AI-enabled analytics. 

Collaboration across organizations

VBC requires collaboration among care teams and the broader ecosystem invested in patient health, including payers, providers and government programs. Collaboration is essential for shared care plans, transparent performance metrics and aligned incentives in risk-sharing contracts. 

Common barriers include siloed data, protections around sensitive or competitive information and misaligned workflows. 

The right software tools allow organizations to collaborate securely through permissions that protect essential data and support compliance for PHI. The result is better patient outcomes, fewer avoidable costs, higher care quality and improved patient satisfaction. 

AI and advanced analytics as force multipliers

AI is advancing quickly in healthcare, but many payer organizations still struggle to scale it across member populations. When implemented effectively, AI can: 

• Predict risk and future high costs 
• Stratify populations to ensure appropriate resources and interventions 
• Identify care gaps early  
• Automate workflows to optimize interventions and minimize resource constraints 

Properly deployed, AI helps shift care from reactive to proactive by identifying the right people, timing and interventions. It can also reduce administrative burden and improve resource allocation. However, AI depends on high-quality, integrated data; without that foundation, it becomes an expensive tool with limited impact. 

Operationalizing VBC at scale: Going from insights to action  

Organizations can take on risk confidently when they turn insights into timely, measurable actions that improve member health. This requires software with: 

• Integrated clinical decision support
• Seamless data sharing between analytics and care tools 
• Reporting tools designed to track performance and provide continuous feedback throughout a measurement year 

The result is faster intervention, better outcomes and more efficient use of limited resources. 

Unlocking the promise of VBC

Value-based care remains a critical path toward a more accountable, efficient and cost-effective U.S. healthcare system, even if results to date have been uneven. With strategic investments in enterprise data capabilities, collaborative care software and AI tools supported by appropriate safeguards, payers can lead to a more sustainable, insight-driven, patient-centered healthcare ecosystem. 

Want to explore how a fully integrated analytics, care and payment technology platform can transform your value-based care efforts? Cedar Gate Technologies, an IQVIA business, can help you compose a solution for every stage of the VBC journey.