High-Value Care: Time for a Reckoning, Not a Rerun

Katie Barone
Sep 9
3 min read

Originally published by HealthCorum

For over a decade, high-value care, better outcomes at lower costs, has cycled between buzzword and genuine priority, yet the industry remains stuck in a cycle of half-measures and unfulfilled promises. High-value networks, a cornerstone of this concept, are not new; they’ve been debated since the 1990s managed care era and rebranded under the Affordable Care Act (ACA). But with costs spiraling, transparency regulations exposing disparities, and patient expectations shifting, the time for a true reckoning has arrived. This isn’t about tweaking old models, it’s about embracing disruption, defining winners and losers, and centering patients in the redesign.

The First Wave: Why High-Value Care Fell Short

The early push for high-value care coincided with the rise of the Affordable Care Act, “Open Data”, ACOs, alternative payment models, and bundled payment initiatives. But in many cases, execution lagged ambition. Initiatives and data remained fragmented, benchmarks were poorly set, and incentives rarely aligned. And critically, many organizations lacked both the tools and the risk tolerance to commit to meaningful redesign.

In hindsight, what we called "high-value care" was often just utilization management in new clothes. The deeper issue was risk aversion. Providers, payers, and even patients clung to familiar fee-for-service models, fearing the uncertainty of value-based systems. High-value networks, which prioritize top-performing providers, were piloted but rarely scaled, as they threatened revenue for lower-performing hospitals and specialists. The result?

Why Now Might Be Different

The current cost environment is forcing hard conversations. Medicaid cuts are expected to drive more complex patients into commercial plans. Employer premiums continue to rise, and new transparency regulations are exposing wide variations in cost and outcomes, and patients, empowered by online tools and cost calculators, are increasingly vocal about value, demanding affordability without sacrificing quality.

What’s emerging now cannot be a rebranding of old efforts, but a shift in posture. Organizations are beginning to accept that creating high-value networks requires more than surface-level changes. It demands:

Identifying high-performing providers using transparent, risk-adjusted data.
Optimizing referral behavior at the individual and the system level.
Rebalancing networks with clear inclusion criteria and performance feedback loops.
Removing services that don’t deliver value, even if they are currently reimbursed.

Creating tiered access models where top performers are prioritized, and others are incentivized to improve.

This version of high-value care will not be universally welcomed. It will challenge assumptions, shift volume, and impact revenue. But it also has the potential to finally deliver on the original promise.

The risks are significant. Financially, providers may see short-term revenue drops as low-value services are cut or patient volume shifts. Reputationally, health systems risk backlash from excluded providers or communities tied to local hospitals. Operationally, building high-value networks demands investment in data infrastructure, care coordination, and patient engagement tools. Most critically, the industry must accept cultural risk, challenging the status quo of “all providers are equal” and confronting resistance from stakeholders accustomed to guaranteed revenue.

Turning Concept Into Execution

The infrastructure exists, EHRs, predictive analytics and continually advancing AI, and transparency tools are more robust than ever. But the challenge is execution. Pilot programs must scale, and tough choices must be made. For instance, a recent analysis of our national claims data showed that shifting volume away from just the bottom 8% of providers is correlated with a 5% reduction in total cost of care without compromising outcomes.