Value-Based Care: Challenges and Opportunities in Medical Practices

I’m Dr. Allen Masry, MD, DFAPA, FASM, DAAP, the Medical Director of All in Solutions, a network of addiction treatment centers located in Florida, New Jersey, and California.

The use of value-based care can be seen directly in how our organization defines success in treating individuals for substance abuse as more than just achieving initial sobriety, but also through lower relapse rates, increased housing stability, decreased hospital emergency department usage, and better attendance and participation in individual and group therapies and peer support programs. I have been working with a number of individuals who were able to demonstrate their continued successful recovery from substance abuse by developing positive relationships with their families, demonstrating regular attendance at scheduled outpatient appointments, and also making progress toward meeting or exceeding established goals related to ongoing recovery.

One significant barrier to effectively tracking these additional measurable indicators of recovery has been that they often do not lend themselves well to timely measurement or tracking—particularly if the recovering individual is transitioning from one system to another (i.e., from detoxification services to inpatient/residential care, and then into outpatient care). At the same time, the value-based care model offers us as a multidisciplinary team unique opportunities. It promotes coordination among all members of our treatment team (psychiatry, counseling, case management, peer recovery coaching, etc.), and as such, provides us with the ability to provide a continuum of care which is truly centered around the needs of each patient versus providing episodic care during periods of crisis.

At The Family Doctor in Tucson, value-based care isn’t a buzzword we adopted to chase incentives, it’s literally the model the practice was built on. As a Direct Primary Care and concierge clinic, we charge a flat monthly membership based on age, and that single decision flips the whole economics of medicine. We don’t get paid more for ordering more tests or churning through 7-minute visits. We get paid to keep our patients healthy, accessible, and out of the ER. That’s value-based care in its purest form.

What it looks like day to day: appointments run 20 to 60 minutes, patients have the doctor’s personal cell number, same- or next-day scheduling is standard, and house calls are on the table. We pass through wholesale pricing on labs, radiology, and generic medications (up to 97% off), so the “value” isn’t theoretical, patients feel it in their wallet and in how quickly small issues get handled before they become big ones.

The biggest opportunity I see is with small business owners. Employers in Tucson are getting crushed by premium increases, and a DPC membership layered under a high-deductible plan delivers real primary care access at a predictable cost. Once a business owner runs the math, the conversation moves fast.

The challenge is education. Most people equate “healthcare” with “insurance,” so when we explain that membership covers unlimited visits and isn’t billed through insurance, the first reaction is skepticism. Our job, and honestly the part I spend the most time on, is making the tradeoffs crystal clear: you’re paying for time, access, and transparent pricing, not paperwork. Once a prospective member sits down for a tour or a call (en ingles o espanol), the model sells itself. The work is getting them to that first conversation, because trust in healthcare is built one honest explanation at a time.

As Practice Manager at Oak Health Center, I’ve overseen our growth from $1.3 million to $9 million in annual billing by focusing heavily on patient-centered, comprehensive outcomes. We manifest value-based care by expanding beyond standard therapy into specialized, integrated programs like TMS, Sleep, and Addiction Medicine to address the full spectrum of a patient’s needs.

The biggest opportunity here is offering simplified, holistic support across our five Southern California locations and statewide virtual services. The challenge, however, lies in maintaining seamless care coordination while scaling our provider team by nearly 400% to meet this demand.

To address this, we focused on rebuilding our internal workflows and improving cross-functional communication between administrative and clinical teams. Designing these thoughtful operational structures ensures our growing staff can collaborate easily, keeping the clinical focus entirely on patient wellness.

Value-based care, to me, means getting people *better*—not just keeping them coming back. When I founded Evolve, I deliberately rejected the high-volume “churn and burn” model where patients get a generic exercise sheet and a goodbye. Every patient gets one-on-one, hands-on treatment with a plan built around their specific dysfunction, not their diagnosis code.

The clearest example is how I approach complex cases like Ehlers-Danlos Syndrome. Most clinics avoid these patients because they’re hard and time-consuming. We lean in. The outcome justifies every extra minute—patients who’ve been bounced around for years finally make real progress because we’re treating root causes, not just managing symptoms.

The biggest challenge with value-based care in PT? Insurance doesn’t always reward it. Payers want to authorize the minimum visits possible, while real recovery—especially in chronic pain cases—takes time and clinical nuance. We fight that battle constantly, advocating for patients when authorizations fall short of what they actually need.

The opportunity, though, is that outcomes speak loudly. When patients recover fully and don’t revolve back through the system, that’s the argument for this model—and it’s one I’ve been making with every patient we treat for nearly 20 years.

Leading business development in post-acute home health for 15+ years—and spending a big chunk of that building referral networks across skilled nursing, hospice, and caregiver services—means value-based care isn’t abstract to me. It directly shapes how I build growth strategy.

The most concrete way I’ve seen it manifest is in how we structure referral relationships. Hospitals and discharge planners aren’t just moving patients—they’re being held accountable for readmission rates. So when I’m developing partnerships for Lucent, I’m not selling visits, I’m selling outcomes. Our coordinated model—skilled nursing, therapy, and caregiver services under one roof—makes it easier for referral partners to trust that transitions won’t fall apart at home.

The real opportunity I’ve identified is in care coordination across payer types. A lot of families use Medicare for skilled nursing post-discharge and private pay or VA benefits for daily caregiver support simultaneously. When those two tracks are siloed, patients fall through the gaps. Connecting them is where value-based care actually lives in home health.

The honest challenge is that the reimbursement structure still lags behind the philosophy. You can build a genuinely outcomes-driven model, but if your payer mix doesn’t reward continuity—just episodic visits—you’re fighting upstream. That tension between what’s clinically right and what gets reimbursed is something every home health operator is navigating right now.

Early in my career, the success of surgical procedures meant that patients were safely moved through surgery. However, value-based medicine shifts this further into the future. As a matter of fact, in bariatric surgery, we have been living with this approach for years. I have witnessed diabetic patients being off their medications after some time, high blood pressure being improved, and even improvements in sleep apnea.

The thing most people overlook is that surgery is just the beginning. Diet and behavior modification, follow-up, and perseverance are just as important as the operation itself. Without them, success won’t be sustainable.

It all comes down to measurement. Patients are not equal at the outset. One person loses more weight, another less but regresses their diabetes. The effects on quality of life, employability, self-confidence are intangible, but most meaningful.

This is an opportunity. Treating obesity early can avoid many years of chronic illness.

After all the years, the only really honest measurement is that patients are healthier years down the road.

In my practice, value-based care shows up most clearly in how we manage postoperative follow-up, because timely communication can prevent small issues from becoming bigger problems. We implemented a HIPAA-compliant platform that lets patients text us after surgery and sends after-hours voicemails as transcribed texts so I can triage concerns quickly. That has made follow-up feel more immediate and accessible, which supports both patient experience and clinical outcomes. One opportunity with this model is using digital tools to strengthen the human connection, not replace it, so patients feel supported and problems are addressed sooner.

Value-based care has become a much bigger conversation in behavioral health over the last several years, but many organizations are still being paid primarily on volume rather than outcomes.

What I’ve seen is that the organizations best positioned for value-based care are the ones already measuring outcomes consistently. If a program can’t demonstrate whether clients are improving, reducing substance use, avoiding higher levels of care, or remaining engaged in treatment, it’s difficult to have a meaningful conversation about value.

One of the biggest opportunities is aligning reimbursement with long-term recovery and clinical outcomes rather than simply paying for encounters. In behavioral health, success isn’t always reflected in the number of sessions delivered. It’s reflected in improved functioning, symptom reduction, housing stability, employment, reduced emergency department utilization, and sustained recovery.

The challenge is infrastructure. Many providers are still operating with fragmented technology, inconsistent documentation practices, and limited reporting capabilities. Collecting outcomes data is one thing. Turning that data into something payers trust and are willing to reimburse against is another.

The organizations that invest now in measurement-based care, outcomes tracking, and operational consistency will be in a much stronger position as value-based reimbursement continues to expand across behavioral health. In many ways, value-based care isn’t just a payment model. It’s a shift toward proving what works and being rewarded for delivering it.

As founder of Golden State Urology and a practicing urologist for over 21 years, value-based care has guided how I structure services around measurable patient outcomes rather than procedures performed.

We run post-FDA clinical trials for BPH that cover all appointments and tests at no cost to participants. This lets patients access emerging options while we gather real data on what actually improves urinary symptoms and quality of life.

The model creates a clear opportunity in my work as CMO at Promaxo. Pairing new imaging tools with daily clinical decisions helps us target treatments more precisely and avoid follow-up issues that drive up long-term costs.

At Davila’s Clinic, value-based care isn’t a buzzword, it’s the whole reason we built our practice the way we did. As a primary care facility in Weslaco, TX, we measure success by how healthy our patients stay over the long run, not by how many appointments we can churn through. That mindset shows up in everything from our preventive healthcare and wellness check-ups to our chronic disease management programs, where the real win is keeping someone out of the ER, not just treating them once they’re already there.

The clearest way it manifests is in time and access. We offer extended evening hours, 5:00 PM to 9:00 PM most weekdays, plus Saturday mornings, because value-based care falls apart if working families can’t actually get in the door. Add telemedicine and patient education with long-term care planning, and you’ve got a model that meets people where they are. When we sit down with a patient, we’re explaining tradeoffs honestly, why preventive screening today saves them money and suffering tomorrow. That trust, built through clear communication, is the engine that makes the whole thing work.

The biggest challenge? Patience, on everyone’s part. Value-based care rewards outcomes that take months or years to show up: better-managed blood pressure, fewer complications, healthier habits. In a world that wants instant results, you have to keep educating patients on why the slow, steady path pays off. It also means prioritizing carefully when resources are tight, focusing energy on the preventive work that prevents bigger problems downstream.

But the opportunity is enormous. When you align the practice’s incentives with the patient’s actual well-being, you get people who stay engaged, follow through, and genuinely trust their provider. For families across the Rio Grande Valley, that’s the difference between healthcare that reacts and healthcare that truly cares. That’s the bet we’ve made, and it’s paying off in healthier patients.

The test of value-based care for me in my own private practice is very simple: Is the patient no longer requiring me?

This may seem counter-intuitive for a private practitioner, but this is the one metric I can be assured of.

The larger shift in healthcare toward measuring outcomes will force all mental health practitioners to examine exactly what they deliver; right now, this is occurring with great fervor, partly because payers are beginning to measure the same.

The biggest challenge I see in this regard is that symptom improvement will be recorded as successful, regardless of whether the fundamental patterns that led to those symptoms persist.

For example, a patient who demonstrates improved results on a survey instrument yet continues to organize their entire life around their anxiety has not been cured.

In place of such an evaluation, I use behavioral range (i.e., whether behaviors were previously unavailable to them prior to treatment and, if so, whether they have sustained them) as an indicator of recovery.

Such distinctions rarely fit into neat billing codes.

Running Collective Counseling Solutions, which handles credentialing and billing for therapists across multiple states, puts me in a direct position to see value-based care in action through our focus on insurance-accepted services.

This shows up when we build referral streams with primary care physicians and hospital programs so clients get connected quickly to in-network therapists. The result is therapy centered on measurable progress like better family communication and daily functioning instead of volume of visits.

One opportunity I’ve noticed comes from our billing model where therapists collect copays at the point of service. This reduces delays in care and lets clinicians track real client improvements without insurance processing bottlenecks slowing things down.

To me, value-based care simply means putting the focus on long-term health outcomes rather than individual clinical encounters. This goes beyond increasing access to preventive services by supporting long-term continuity of care and other services, making them more available in ways that foster ongoing participation in care.

One big challenge is that many determinants of health exist outside the healthcare system, including stigma, access, and transportation. Alternatively, durable systems of support that enable leaving and returning to care with relative ease may lead to better outcomes over time.