Value-based care is hard, but it’s worth getting right

For many clinicians, the moments from the exam room that stay with them are rarely the dramatic ones. They're the avoidable ones: the patient who lands in the emergency department over a weekend because no one caught the warning signs on Thursday, the medication that was never reconciled, the specialist visit that never got back to the person managing the whole picture. None of those failures are about the skill of any single clinician. They're about a system that pays for activity instead of outcomes, and that leaves everyone in it working harder than ever while patients still fall through the gaps.

That is the promise of value-based care: paying for health rather than volume and rewarding clinicians for keeping people well. But value-based primary care has stalled in so many places not because the payment model is wrong. It's that too many have approached it as a contract to manage rather than a system of care to build. Scaling it takes connecting the entire system—primary care, the health plan, in-home care, retail clinics and the neighborhood pharmacy—so that care is organized around one person rather than fragmented across wherever it happens to be delivered. That is what CVS Health is working to build. And it is hard.

Why scaling value-based primary care is hard

We should be clear about the difficulty, because the industry too often isn't. This is a challenging moment for value-based care—and it is challenging industry-wide. Three forces are converging at once: medical costs have risen as patients returned to care after the pandemic; reimbursement has lagged those costs; and the risk-adjustment models that underpin the sustainability of the model have changed. The result is outsized operational and financial pressure on value-based providers.

There is a more fundamental difficulty—one that never shows up in a contract. Value-based primary care only works when you have a panel of patients you know well, and that takes years to build, not quarters. A clinic isn't sustainable the day it opens; it becomes sustainable as relationships deepen, gaps in care close, and avoidable costs come down. We learned this at Oak Street Health. Our footprint grew quickly, and we have since moved from a clinic-growth mentality to a disciplined focus on strengthening performance in existing centers—deepening the panels in the clinics we already have rather than chasing new construction. It’s the less glamorous strategy. It’s also the right one.

In this environment, it is important to be precise about each patient's health needs so that care teams have an accurate picture of the people they serve. That work matters, and it demands rigor in how conditions are identified, documented and addressed. We have invested in AI-enabled tools to help meet that bar. But documentation accuracy is only the starting point. The durable work—the work that actually bends the cost curve—is medical cost management: keeping people out of the hospital, coordinating their specialists, managing their medications, and addressing the social barriers that drive avoidable utilization. That is harder, slower and less visible than administrative precision. It is also the only thing that makes value-based care worth doing.

Doing that at scale takes more than any single clinic or any single contract. In practice, it comes down to four things.

It takes shared accountability, not siloed contracts

Value-based contracts move accountability from the cost of a single service to the total cost of a patient's care: every admission, every specialist, every prescription, and the social factors that shape all of them. Making that work demands genuine alignment between payors and providers, who too often operate at arm's length on competing incentives. Oak Street Health is an all-payor model—built to deliver for every health plan and every patient, not any single relationship. When a health plan and a care team commit to the same goal for the same patient, with appropriate consent and safeguards, they can coordinate more closely, close gaps in care faster, and organize care around the person rather than the claim.

And it is working. At Oak Street Health, which is fully accountable for the total cost of care of the patients it serves, the model produces a 40% reduction in hospital admissions per thousand compared with traditional Medicare. These are not feel-good statistics: when patients stay healthier, every payor that partners with Oak Street benefits—and so do the patients themselves. Aetna is one example of that alignment, and the depth of that collaboration demonstrates what genuine payor-provider alignment can achieve. Oak Street’s model is designed to work across payors, with the same focus on improving outcomes and lowering avoidable costs for every patient it serves.

It takes a complete picture of the patient to successfully deliver value-based care

Most of what determines a patient's health never appears in a medical chart, and almost none of it surfaces in a 15-minute office visit. Nearly a third of Americans have no primary care physician, and one in three lives in a health care desert. Diet, housing, transportation, isolation, fall risk at home—these shape outcomes far more than most diagnoses, and they are invisible from behind a desk. And when we can’t see the full picture, value-based care falls apart.

That is why we go to people's homes. Through Signify Health, our clinicians conduct in-home health evaluations that can capture more than 300 clinical and social data points: early signs of chronic disease, mental and cognitive health concerns, mobility and safety risks, and barriers like food insecurity or unreliable transportation. Across the country, that adds up to roughly 3.5 million home visits a year—3.5 million chances to catch a risk before it becomes an emergency.

But data alone does not improve anyone's health. Action does. Signify Health is built to help close that loop: when a visit surfaces an unmet need or a care gap, our clinicians help connect the person to the next step in their care—so a risk spotted in the living room becomes a problem we help prevent rather than an emergency we meet in the hospital.

It takes the pharmacy—value-based care's most underused asset

Here is a fact that should reshape how we think about value-based care. A typical Medicare patient sees their primary care physician 7 times a year. They interact with their pharmacist far more often—and for many people, the pharmacist is the most trusted and most accessible clinician in their lives. Nearly 85% of Americans live within five miles of a CVS Pharmacy. In value-based care, access is not a coincidence. It is an asset.

With the patient's consent, the pharmacy can reinforce the care plan: medication management and adherence support the care team can act on, screenings and vaccinations that close gaps in care, and a pharmacist who is a genuine extension of a patient's primary care relationship rather than a transaction at a counter. When the pharmacy, the primary care clinic, the home visit and the health plan share the same goal for the same patient, the frequency of those pharmacy interactions stops being a missed opportunity and becomes connective tissue for the patient's care—and a direct lever on value-based outcomes.

It takes coordination that's built in, not bolted on

Coordinating care is operationally hard: electronic records still don't talk to each other cleanly, and the workforce is stretched thin. But for patients juggling multiple specialists, medications and follow-ups, coordination is the difference between a care plan that works and one that exists only on paper.

At Oak Street Health, where about 65% of our patients live with two or more chronic conditions, team-based care is the default: our teams coordinate actively with specialists, reinforce treatment plans, and provide transitional care after a hospitalization—the most fragile moment in a patient's journey—to prevent avoidable readmissions. Signify Health's care coordinators help members take the next best step, whether that is establishing a relationship with a primary care provider or connecting to their health plan's care-management resources. And our MinuteClinic primary care model—now available at more than 65% of our clinics—is helping people connect to longitudinal care close to home.

Underneath all of it is technology. AI is making integration real-time rather than aspirational. At Oak Street Health, an AI-enabled risk model helps care teams identify which patients are most likely to face a serious health event so we can reach them before they reach the hospital. The same capability stratifies the risks Signify surfaces in the home and connects fragmented records so a care team sees the whole patient rather than fragments. Used well—with clear safeguards for privacy and real clinical oversight—technology is not a substitute for the relationship between a patient and a care team; it is what gives that team the time, and the information, to do their jobs.

What it takes—and why it's worth it

Scaling value-based primary care takes shared accountability, a complete picture of each patient, the most frequent touchpoints in the system, and coordination built into every visit. It takes the patience and the honesty to do the real work—improving medical cost and integrating care—rather than treating payment reform as the finish line. We hold ourselves to a simple standard: the work has to translate into measurable outcomes for patients.

No single organization will fix American health care alone. It will take payors, providers, pharmacists and policymakers willing to do the hard work of integration, not just redesign payment models and hope the care experience changes on its own. But when value-based primary care is built on connected access, real insight into each patient, and coordination at its foundation, it can mean fewer avoidable hospital visits, better medication support, more connected follow-up and easier access to care. At CVS Health, that is the work underway: connecting care across the home, clinic, pharmacy and health plan so value-based primary care can become more accessible, more coordinated and more sustainable.