What Is Value-Based Care?

Imagine a patient, who we’ll call Maya, arrives in the emergency room barely able to catch her breath. Her legs are swollen almost double their usual size, her skin looks pale, and her eyes carry a deep exhaustion. When the clinical team assesses Maya, her blood pressure is very high, and she is able to tell you that she hasn’t seen a doctor in months, but she has chronic kidney disease. Now, with toxins building up in her blood, each breath is a struggle and confusion clouds her mind. Maya has an unplanned trip to the hospital; she’s in a kidney medical emergency, when chronic kidney disease has advanced to a dangerous, life-threatening state. She’s admitted to the intensive care unit with acute renal failure and stays in the hospital for nearly a month. 

Now imagine a different scenario for that patient. 

Maya has access to a primary care provider and regular nephrology visits. In one of her check-ins, the nephrologist notices that her kidney function is getting a bit worse. She and her clinical team decide the next step is dialysis, maybe a couple months down the line. So, they prepare early; they plant a fistula, the vascular access for dialysis, and work with Maya to determine whether she wants outpatient or home dialysis. Together with Maya, the team creates a plan of action over the next several months that takes into account Maya’s clinical needs and lifestyle. She doesn’t step foot in an ER. 

It’s clear the second scenario is significantly better for the patient. But it’s also better for the hospital or health system. A long length of stay in a hospital is very costly; the math between the scenarios adds up to more than one hundred thousand dollars for the first scenario versus maybe $20,000 for the second. And the first scenario is a ding on the hospital’s contractual performance. 

The two scenarios show the importance of value-based care. Value-based care moves away from the traditional “fee-for-service” model, where healthcare providers are paid for each test, visit, or procedure performed, regardless of the outcome. Instead, value-based care prioritizes outcomes, rewarding hospitals and clinicians for keeping patients healthy, managing chronic conditions effectively, and using resources wisely. It asks: Are we delivering better care, not just more care? 

At its core, value-based care aims to achieve what everyone in medicine wants: healthier patients, reduced health disparities, and financial sustainability for institutions that serve their communities. 

The patient perspective: Better care, better outcomes 

For patients, value-based care looks like more coordinated, proactive, and personal healthcare. Rather than waiting until problems become severe enough to require emergency care and hospitalization, care teams focus on prevention, early detection, and comprehensive care management. 

In systems like Boston Medical Center (BMC) Health System, this is a data-driven approach that allows providers and their teams, including patient navigators, care managers, and social workers to tackle both medical needs and barriers to health, such as access to transportation, nutritious food, or stable housing. Teams work to ensure care is culturally sensitive and meets patients where they are, supporting them in local community health centers and focusing on trust and continuity. 

This approach means patients are more likely to receive preventive screenings, have chronic conditions managed proactively, and benefit from care teams that communicate effectively across different specialties and settings. Value-based care also prioritizes patient satisfaction and experience as key metrics of success. 

When health intervention starts early—with, for example, cancer screenings or regular chronic disease management—patients experience better long-term outcomes while avoiding the trauma, complications, and costs associated with emergency care and extended hospital stays. 

Health system benefits: Sustainability through quality

For hospitals and health systems, value-based care offers a path toward financial sustainability while improving their core mission of patient care. By focusing on prevention and care coordination, health systems can decrease the likelihood of patients requiring expensive inpatient stays due to preventable complications. and avoid unnecessary emergency department visits 

Boston Medical Center Health System exemplifies this approach through its comprehensive value-based care initiatives. Its programs have demonstrated measurable success: closure of more than 4,500 cancer screening gaps over the last year and improved glycemic control for 450 patients with diabetes. In addition to improving patient care and experience, BMC’s value-based care approach and programs translate into millions of dollars saved for the health system. 

Central to successful value-based care implementation is robust data analytics. These programs leverage data from across the care continuum to identify gaps in care, predict health risks, and target interventions and resources where they can have the greatest impact. This data-driven approach allows care teams to be proactive rather than reactive, addressing health issues before they become costly emergencies. 

Risk adjustment helps ensure doctors and hospitals are paid fairly for caring for patients who are sicker or have more complicated needs, so providers aren’t penalized for serving those with higher risks. This is especially important for community health centers and essential hospitals that treat a high percentage of high-risk patients.

Community-centered implementation of value-based care

Effective value-based care extends beyond hospital walls to encompass entire care networks and communities. For example, community health centers play a critical role, providing culturally sensitive care in people’s neighborhoods and serving as bridges between acute care settings and the communities they serve. 

If we were to take the case of closing racial gaps in cancer screening, for example,  one strategic task of a value-based care team could be to go out into the communities and boost education and information from trusted sources on the importance of early detection, and even bring the screening to them through pop-up screenings, mobile care, and more. 

It’s critical to increase outreach and ensure that people who have historically not been able to access screenings, who weren’t aware of certain screenings, or who had hesitation for any variety of reasons can come in an receive this preventative care, improving community screening rates.

The path forward for value-based care

Value-based care offers a promising framework for creating more effective, equitable, and sustainable healthcare delivery. The transformation won’t happen overnight, but the early results suggest that value-based care isn’t just the future of healthcare—it’s the key to building healthier communities while ensuring the financial viability of the institutions that serve them. 

What could that look like? At BMC Health System, the value-based care team has three roles: supporting contractual performance and risk contracts; redesigning care delivery; and acting as an idea incubator to innovate solutions and export to population health teams to implement. 

The exciting part for the value-based care team is thinking about how the hospital can deliver care differently. Take Maya, for example, the patient with chronic kidney disease. Value-based care teams may look at her situation and ask: What are the barriers to patients like Maya? Why does this happen? 

They may look at the data and find out that primary care made a referral for Maya to a renal specialist, but Maya wasn’t able to get in for an appointment. So, value-based care teams may stand up a program with outbound outreach, where a community health worker calls patients with referrals to ask about their challenges in accessing care. Then, they may, for example, help them access transportation to an appointment or follow-up with the renal specialist. Once Maya does get into her specialist appointment, the team may monitor her to ensure she has a follow-up. Imagine then, upon monitoring, they find that Maya needs additional pulmonary medications—value-based care teams could implement a pharmacist model to ensure Maya and others like her not only get her medications, but knows how to use her inhaler through education, for example. 

Ultimately, it’s about breaking acute crisis-driven care and intervening earlier in the pipeline. It will benefit patients, who are getting what they need for their medical concerns and also their life circumstances. And in a current healthcare environment where primary care providers are burning out and the workforce is dwindling, reimagined care models can better support these critical physicians—reducing waste and inefficiencies in their processes and building more effective, prevention-focused healthcare.