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1/ There are lots of reasons why value-based care hasn't taken off the way everyone hoped, but I think provider consolidation is a big reason. Large hospitals that get most of their revenue from fee-for-service don't exactly have a huge incentive to shift
2/ Most providers "dip their toes" into value-based care arrangements - not taking any downside financial risk and only getting bonuses for meeting metrics. But to prove value-based care works you need to build workflows form the ground up for it + take on upside/downside risk
3/ Also with fewer providers, there are less people you can run experiments with and sometimes a provider will be running several experiments at the same time. It's hard to tell if things are working when there are so few players + so many confounding variables
4/ IMO this is why we need more SMB providers - more experiments, run simultaneously more providers leaning into upside/downside risk arrangements, deriving majority of their revenue from a value-based agreement, workflows that reflect that, etc.
5/ This is why I think we've seen the most "success" in value-based care in medicare advantage focused primary care. New practices that have built workflows from the ground up with the intent that they're taking the full financial risk of the patient as well.
