Value-based care was intended to improve patient outcomes by rewarding quality over quantity. Still, it’s become a tool for insurers to penalize providers, creating massive barriers to fair compensation. The shift from fee-for-service to value-based care was supposed to incentivize efficiency. And while many providers have been pressured to meet these demands, health insurers have exploited their efforts. They’ve used complex metrics to withhold payment, leaving providers to shoulder the burden of delays, denials, and excessive paperwork.
Insurers hold all the cards. And they’re playing for keeps.
Under the guise of promoting value-based care, Un-Covered has noticed that commercial insurers are increasingly focusing on data and algorithms that penalize providers for factors beyond their control. Now, providers’ reimbursement is left in the hands of an impersonal AI robot that holds them accountable to outcomes that don’t fully reflect the care they deliver.
Patient socioeconomic backgrounds and severity of their conditions are large drivers of health outcomes. Unfortunately, insurers are heavily influencing the algorithm and whether a provider meets the criteria to be paid in full. All too often, the answer is “no.”
Is it a design flaw or intentional?
This system has put providers in a tough spot. Every claim is scrutinized, every metric dissected, and every delayed or denied payment takes away from what truly matters: patient care. The industry calls it “risk-sharing.” We’ll call it what it really is: a cash cow for the insurance behemoths.
So who is the ultimate benefactor in this system design? It’s not the provider who must fight for payments. It’s not the patient whose care is now de-personalized so they can be part of a money-grabbing (err… saving) scheme. It’s the insurer.
The change needed is clear. Providers need to right the narrative on value-based care. Insurers are using the existing narrative as a tool to shift the financial burden onto providers, impacting patient care. Hospitals and health systems need to tell it like it is: arbitrary metrics and complex algorithms are not improving care. Rather, it’s punishing those who are doing the hard work.
Insurers must be held accountable for their role in creating this broken system. Until value-based care is recognized for what it is—a loophole to avoid paying providers—the promise of better healthcare for all will remain nothing more than a distant ideal.
