The Value-Based Care (VBC) Landscape: Models, Metrics, and What's Changing

Introduction

Value-based care (VBC) is transforming how healthcare is delivered and reimbursed in the United States. Unlike the traditional fee-for-service model that rewards volume, VBC ties payment to quality of care and patient outcomes[1][2]. The core idea is to achieve the Triple Aim of better patient health outcomes, improved patient experience, and lower costs[1]. (In fact, this has evolved into a “Quintuple Aim” adding provider well-being and health equity as goals[1].) For healthcare leaders, clinicians, payers, and partners across the care continuum, this shift presents both strategic opportunities and practical challenges. This article provides an in-depth look at VBC principles and policies, and examines how programs like remote monitoring, care management, and preventive services support VBC goals. The aim is to offer a strategic yet practical overview for healthcare stakeholders looking to navigate and succeed in a value-driven healthcare landscape.

Core Principles and Objectives of Value-Based Care

At its heart, value-based care seeks to maximize the value patients receive from healthcare. Value is commonly defined as the quality of care (outcomes, safety, service) relative to the cost of care over time[4]. In practice, this means focusing on:

• High-Quality Outcomes: Ensuring treatments are effective, safe, and evidence-based. The National Academy of Medicine’s STEEEP framework summarizes high-value care as Safe, Timely, Effective, Efficient, Equitable, and Patient-Centered[1]. For example, helping a diabetic patient achieve good blood sugar control with minimal side effects is high-value care, whereas poor control or avoidable complications signal low value.

• Patient Experience and Engagement: Improving the patient’s experience of care and satisfaction. VBC emphasizes person-centered care – care that is coordinated around patient needs and preferences[5][6]. This could mean better care coordination so patients don’t feel lost in the system, or involving patients in shared decision-making about their treatments.

• Cost Efficiency: Reducing unnecessary spending by avoiding waste, preventing hospitalizations, and eliminating services that don’t add value. For instance, ensuring medication regimens are optimized can prevent costly adverse events or admissions. Lowering the total cost of care per patient is a key objective, alongside maintaining or improving outcomes[4].

These elements correspond to the Triple Aim: (1) improve population health outcomes, (2) enhance the patient experience, and (3) reduce per-capita costs[1]. In VBC models, providers are rewarded for performance on these dimensions rather than volume of services. Metrics might include clinical indicators (e.g. blood pressure control rates), utilization measures (e.g. hospital readmission rates), and patient satisfaction scores. The ultimate mission of VBC is to align incentives so that what’s best for the patient’s health is also best for the providers’ reimbursement. This alignment encourages proactive, preventive care and better care coordination. Providers are prompted to minimize low-value or harmful interventions and focus on high-value activities that keep patients healthy[7].

In summary, the core principles of VBC revolve around “quality over quantity”: delivering better outcomes, better experiences, at lower cost. VBC typically depends on coordinated, team-based care that strengthens medication safety and adherence, preventive care, and chronic disease management across settings.

U.S. Policy and Regulatory Frameworks Supporting VBC

Over the past decade, U.S. health policy has aggressively pushed toward value-based models, creating frameworks and incentives that encourage healthcare organizations and providers to engage in VBC. Key developments include:

• Medicare and CMMI Initiatives: The Affordable Care Act (2010) established the Center for Medicare & Medicaid Innovation (CMMI) to test new payment and delivery models. Through CMMI, Medicare has piloted numerous VBC models (“Innovation Center models”) aimed at improving care coordination and outcomes[8]. For example, Accountable Care Organizations (ACOs) in Medicare Shared Savings Programs and CMMI demonstrations hold groups of providers accountable for the cost and quality of care for a population. Providers in ACOs share in savings if they meet quality and cost targets. CMMI has also tested primary care models such as the Comprehensive Primary Care Plus (CPC+) and Primary Care First, which provided care management payments to primary care practices. In these models, practices were required or encouraged to integrate comprehensive medication management. Notably, primary care clinics in CPC+ Track 2 had to provide comprehensive medication management (CMM) for high-risk patients (e.g. those recently discharged or in chronic care management)[10]. This illustrates how CMMI models can embed medication management and care coordination as components of advanced primary care.

• CMS Value-Based Programs: The Centers for Medicare & Medicaid Services (CMS) has implemented several value-based purchasing programs. While some target hospitals (e.g. Hospital Readmissions Reduction Program, Hospital Value-Based Purchasing), others affect ambulatory care. For instance, Medicare Advantage (Part C) and Part D Star Ratings include quality measures tied to medication adherence and MTM/Comprehensive Medication Review (CMR) completion, and Medicare Advantage includes preventive care measures such as adult immunization status[53][54]. Health plans have a strong incentive to improve these metrics to achieve high star ratings. Another example is MACRA’s Quality Payment Program (QPP) for Medicare Part B providers, which introduced Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Under MIPS, clinicians are measured on quality and improvement activities – some of which involve medication management (e.g. controlling diabetes or performing medication reconciliation post-discharge). Clinicians in APMs like ACOs or advanced primary care homes are exempt from MIPS but take on outcome-based accountability. In both cases, providers have financial incentives to improve clinical outcomes, preventive care delivery, and total cost of care performance.

• Care Management and Preventive Care Incentives: Medicare and other payers have expanded reimbursement pathways and quality incentives for care coordination and prevention (e.g., care management codes, transitional follow-up, and quality measures tied to outcomes and preventive services). These incentives support workflows designed to reduce avoidable utilization while improving patient outcomes and experience.

Table 1: Key Policies and Programs Enabling Value-Based Care in the U.S.

Table 1: Summary of major policies and programs that support value-based care in the U.S. These frameworks have collectively moved the system toward accountability for outcomes, patient experience, and total cost of care.

Programs Supporting VBC Goals

Healthcare organizations and care teams are implementing a variety of patient care programs that advance the goals of value-based care. Below we examine several key services – Remote Patient Monitoring (RPM), Chronic Care Management (CCM), Remote Therapeutic Monitoring (RTM), Transitional Care Management (TCM), Medication Therapy Management (MTM), Advanced Primary Care Models (APCM), and Immunizations – and how each aligns with VBC objectives. These services focus on proactive management of patients’ health, better care coordination, and prevention of adverse outcomes, all of which drive higher quality and lower costs.

Remote Patient Monitoring (RPM)

Remote Patient Monitoring involves the use of digital technologies to track patients’ health data outside of traditional clinical settings. For example, patients might use blood pressure cuffs, blood glucose monitors, or weight scales at home that transmit readings to their healthcare team. In practice, healthcare organizations may offer RPM services by enrolling patients with chronic conditions (like hypertension, diabetes, or heart failure) into monitoring programs. The care team helps set patients up with devices and regularly reviews the data, intervening or alerting the clinician if readings fall outside of targets.

Alignment with VBC: RPM directly supports the preventive, proactive care ethos of VBC. By catching issues early (e.g., detecting rising blood pressure or irregular glucose trends), the care team can adjust treatment or counsel the patient before a crisis occurs. This can reduce emergency visits and hospital admissions. In fact, studies show that home monitoring programs can significantly reduce hospital utilization for chronic disease patients[25]. For VBC arrangements where providers are accountable for outcomes and costs, avoiding a hospitalization due to timely intervention is a tangible win. Patients in RPM programs often feel more engaged in their care, which improves their experience (another VBC goal).

Chronic Care Management (CCM)

Chronic Care Management is a formal Medicare program (established 2015) that pays for ongoing care coordination for patients with multiple (typically 2 or more) chronic conditions. The service involves monthly follow-up with patients to ensure their conditions are managed – including medication management, self-care support, and coordination among providers. Each enrolled patient has a comprehensive care plan, and a clinician or care team member checks in regularly (often by phone).

Alignment with VBC: CCM is practically built for value-based care. It targets the 5% of patients who drive \~50% of costs – those with multiple chronic illnesses – and provides them extra support between doctor visits. By doing so, CCM aims to prevent complications and costly acute events. Medicare’s own analysis of the first two years of CCM found meaningful improvements: hospitalizations decreased nearly 5% and ED visits by 2.3% for Medicare beneficiaries receiving CCM, compared to similar patients not in the program[26]. Patients in CCM also had higher rates of preventive services and reported better satisfaction[27]. These outcomes translate to cost savings and better quality scores, directly serving VBC goals. In value-based contracts (like ACOs or capitated arrangements), reducing hospital and emergency utilization via CCM can generate significant savings. Quality metrics such as diabetes A1c control, blood pressure control, or medication adherence tend to improve with the frequent touchpoints that CCM provides.

Remote Therapeutic Monitoring (RTM)

Remote Therapeutic Monitoring is a newer concept, introduced by Medicare in 2022 via RTM CPT codes, designed to monitor patients’ responses to certain therapies outside the clinic. While RPM (above) focuses on physiologic data (like vitals), RTM can include tracking of symptoms, medication adherence, or therapy progress, often via patient-reported data or digital tools. RTM initially has been applied in contexts like musculoskeletal care (e.g., monitoring pain levels and exercise adherence for a physical therapy patient) and respiratory care (monitoring inhaler use and symptoms for an asthma patient). The structure is similar to RPM – data is collected between visits and healthcare providers engage patients based on that data, with an emphasis on improving adherence and outcomes of therapy.

Alignment with VBC: RTM is inherently aligned with value-based care because it extends care management beyond episodic visits and targets therapeutic outcomes and patient behavior. By tracking, for example, how often an asthma patient uses their rescue inhaler or a COPD patient’s reported symptom scores, providers can intervene earlier or tailor the treatment plan more precisely. The goal is to prevent exacerbations and complications, improving quality of life and reducing costly interventions (like hospital admissions for uncontrolled asthma). In value-based models, every prevented exacerbation or hospitalization is a win. RTM also fosters patient engagement; patients who know their data is being watched and that someone will follow up are more likely to adhere to therapy. Improved adherence and self-management result from that feedback loop – which is exactly what payers want to see under VBC (since medication non-adherence, for instance, is a major driver of poor outcomes and higher costs).

Transitional Care Management (TCM)

Transitional Care Management refers to the coordinated follow-up care of patients as they transition from an acute care setting (like a hospital) back to the community (home or long-term care). Medicare introduced TCM payment codes in 2013 (CPT 99495, 99496) to incentivize providers to actively manage these transitions. TCM generally includes: contacting the patient within 2 days of discharge, an office or telehealth visit within 7-14 days (depending on complexity), and medication reconciliation and management of the patient’s conditions during that transition period. The goal is to ensure patients don’t fall through the cracks after discharge – a time when they are vulnerable to complications and readmissions.

Alignment with VBC: High hospital readmission rates have been a big target in value-based care, as readmissions often indicate poor post-discharge follow-up and contribute to unnecessary costs. TCM directly aims to reduce readmissions and post-discharge adverse events by providing support in that critical 30-day window after hospitalization. Effective TCM can dramatically lower the chance a patient ends up back in the hospital. For example, one study in a Medicare value-based program found that when pharmacists were integrated into transitions of care, 90-day readmission rates dropped from 34.7% in the control group to 9.6% and 17.1% in pharmacist-integrated intervention arms[29]. This is a striking improvement, highlighting how robust transitional care can improve outcomes. Under Medicare value-based programs (like ACOs or bundled payment initiatives), avoiding a readmission within 30 days saves costs and often improves quality metrics (since readmission rates are a common metric). Hospitals also face readmission penalties in some cases; thus, strong TCM processes are both a quality and a financial imperative.

Medication Therapy Management (MTM)

Medication Therapy Management is a service model born out of Medicare Part D but also implemented in other contexts. Under Part D, MTM is a required program for eligible beneficiaries (those with multiple chronic diseases, multiple medications, and high drug costs) to ensure they receive an annual Comprehensive Medication Review (CMR) plus quarterly targeted medication reviews (TMRs)[58]. In practice, MTM involves a pharmacist (or other qualified provider) systematically reviewing all of a patient’s medications (prescription, OTC, supplements), identifying any drug therapy problems (like duplications, unnecessary meds, dosing issues, side effects, adherence barriers), and developing a plan in collaboration with the patient and prescribers to optimize the regimen. Patients receive a medication action plan and a personal medication list as takeaways from a CMR[58]. Beyond Part D, many healthcare organizations have implemented MTM or related Comprehensive Medication Management (CMM) services for their patients to improve medication outcomes.

Alignment with VBC: Medications are one of the most powerful tools to improve health – but when used inappropriately or not at all (non-adherence), they can also drive poor outcomes and wasted spending. MTM directly addresses the quality of medication use, which is a huge component of care quality for chronic disease. By engaging patients in discussions about their meds, identifying and resolving drug therapy problems, and ensuring each medication is actually needed and effective, MTM improves therapeutic outcomes and can prevent adverse events. This aligns with all three legs of the Triple Aim: better outcomes (e.g., controlled blood pressure, fewer asthma attacks), better experience (patients understand their therapy and feel supported), and lower costs (avoiding complications, ER visits, or duplicate therapies). Indeed, a strong MTM program can reduce hospitalizations and total healthcare expenditures, especially in high-risk patients. The Enhanced MTM model by CMMI was predicated on this – that investing more in MTM would pay off in “smarter spending, better care, healthier people”[35]. Early analyses of Enhanced MTM suggested improved adherence and some cost savings; one participating Part D plan reported fewer hospitalizations among patients receiving intensive MTM interventions (per CMS evaluation reports). Moreover, health plans’ Star Ratings heavily weigh medication-related outcomes – e.g., proportion of patients with diabetes, hypertension, cholesterol who are adherent to their meds. Pharmacies performing MTM contribute to improved adherence rates and gap closure in therapy (like suggesting a statin for a diabetic patient if missing). In value-based contracts, these translate to higher quality scores and possibly shared savings.

Advanced Primary Care Models (APCM) and Pharmacy Integration

“Advanced Primary Care Models” (APCM) is a broad term encompassing modern primary care delivery models that emphasize comprehensive, coordinated, and patient-centered care. This includes Patient-Centered Medical Homes (PCMH), the Primary Care First model, direct primary care practices, and the previously mentioned CMMI models like CPC+ that fall under advanced primary care. These models typically feature team-based care, enhanced access (like telehealth or after-hours options), a focus on preventive care, and alternative payment structures such as care management fees or capitation. The “advanced” aspect is moving away from reactive sick visits toward managing the health of a population with a proactive approach.

Alignment with VBC: APCMs are essentially the front-line implementation of value-based care in primary care settings. By providing coordinated, whole-person care (including managing chronic conditions, addressing social needs, and coordinating with specialists), these models aim for better outcomes and lower utilization of expensive downstream services. They also often operate under value-oriented payments: for example, a PCMH might get bonuses for high quality or shared savings if total cost of care for their patients stays below a benchmark. Pharmacist involvement has been identified as a key ingredient in many successful APCMs[36]. Why? Because medications are central to managing chronic diseases (like diabetes, hypertension, depression, etc.), and pharmacists bring specialized skills to manage those medications and ensure patients stay on therapy.

Immunizations and Preventive Services

Community-based care settings and access points have become major providers of immunizations and other preventive health services (such as screenings for diabetes, cholesterol, or bone density, and even minor acute care like strep or flu testing with treatment under protocol in some states). Focusing on immunizations: clinicians today administer a wide range of vaccines – from seasonal flu shots to COVID-19 vaccines, shingles, pneumonia, travel vaccines, and more.

Alignment with VBC: Preventive services like immunizations are some of the highest-value interventions in healthcare. They prevent disease, which in turn avoids costly downstream treatment and improves population health. Vaccinations for influenza, pneumonia, COVID-19, etc., directly reduce hospitalizations and save lives, especially in older or high-risk adults. Value-based care programs heavily encourage preventive care: for instance, Medicare Advantage Star Ratings include measures for flu vaccine uptake and other vaccinations, ACOs have quality measures for influenza and pneumococcal vaccination rates, and primary care medical homes get evaluated on preventive care delivery. Therefore, every vaccine given contributes to those quality goals. Higher immunization rates mean better quality scores and lower incidence of preventable illness – a clear win for VBC. During the COVID-19 pandemic, this became even more evident as health systems and payers relied on community access points to quickly vaccinate large portions of the population, thereby preventing hospital surges.

Convenient community sites can dramatically improve access to immunizations due to extended hours and convenience, reaching people who might not schedule a doctor’s appointment. Statistics illustrate this shifting landscape: by the 2020s, nearly half of adult flu vaccinations were being administered in pharmacies (46.3% in the 2020–21 season, up from 38.7% the prior year, with a corresponding drop in those given in physician offices) in a commercially insured U.S. adult population analysis[40]. This shift underscores how access points outside traditional physician offices can help achieve preventive care targets.

References

Sources:
- AMA – “What is value-based care? Key elements” (2024) – Definition of high-value care and Triple/Quintuple Aim[1].
- CMS – “Value-Based Care” – Explanation of VBC focusing on quality, performance, patient experience[2].
- CMS – “Chronic Care Management At-a-Glance” – Outcomes data showing CCM reduced hospitalizations \~5% and improved adherence[26].
- CMS CMMI – “Enhanced MTM Model” – Description of Part D Enhanced MTM incentives to improve MTM and outcomes[16][17].
- CMS – Star Ratings Technical Notes – Star Ratings measures for Medicare Advantage and Part D (including adherence and preventive care measures)[53].
- American Journal of Health-System Pharmacy (2024) – Study on pharmacist-integrated transitional care, showing major readmission reductions with pharmacist intervention[29].
- J Am Geriatr Soc (2017) – Pharm2Pharm study – 36% drop in med-related hospitalizations and 2.6:1 ROI with pharmacist transitional care[30][31].
- NACDS – Comments to HHS (2020) – Arguing inclusion of pharmacies in value-based enterprises due to their critical care coordination role[15].
- CPESN USA – Payer Solutions – Detailing pharmacy contributions to quality measures (adherence, BP, A1c, readmission avoidance) in ACOs and plans[9].
- CMS MTM evidence base – Summary of published MTM outcomes and utilization/cost impacts across programs[55].
- Place-of-vaccination analysis (commercially insured adults) – Data showing rising share of adult flu vaccines given in pharmacies (\~46% in 2020–21)[40].

[1] [4] [7] What is value-based care? These are the key elements | American Medical Association

https://www.ama-assn.org/practice-management/payment-delivery-models/what-value-based-care-these-are-key-elements

[2] [5] [6] [8] Value-Based Care | CMS

https://www.cms.gov/priorities/innovation/key-concepts/value-based-care

[3] Pharmacies' Role in the Value-Based Care Landscape

https://regional.nacds.org/wp-content/uploads/Pharmacies-Role-in-the-Value-Based-Care-Landscape.pdf

[9] [12] [13] [14] [28] [39] [42] [43] [51] Payer Solutions| CPESN

https://cpesn.com/solutions-payers

[10] accp.com

https://www.accp.com/docs/govt/ACCP_House_LHHS_Appropriations_CMMI_Letter_FINAL.pdf

[11] CPC+financials122017

https://www.cms.gov/priorities/innovation/files/x/cpcplus-paymentbrief.pdf

[15] [24] Pharmacies Essential to Value-Based Care, NACDS Tells HHS Inspector General | NACDS

https://www.nacds.org/pharmacies-essential-to-value-based-care-nacds-tells-hhs-inspector-general/

[16] [17] [21] [22] [35] Part D Enhanced Medication Therapy Management Model | CMS

https://www.cms.gov/priorities/innovation/innovation-models/enhancedmtm

[18] [19] [20] [32] [33] [34] Implications of the CMMI Enhanced Medication Therapy Management Program for the Future of Community Pharmacy | Pharmacy Times

https://www.pharmacytimes.com/view/implications-of-the-cmmi-enhanced-medication-therapy-management-program--on-the-future-of-community-pharmacy

[23] [PDF] Part D Enhanced Medication Therapy Management (MTM) Model

https://www.cms.gov/priorities/innovation/files/reports/mtm-firstevalrpt-fg.pdf

[25] Efficacy of Remote Health Monitoring in Reducing Hospital ... - PMC

https://pmc.ncbi.nlm.nih.gov/articles/PMC11437225/

[26] [27] WHAT IS CHRONIC CARE MANAGEMENT (CCM)?

https://www.cms.gov/files/document/chronic-care-management-glance.pdf

[29] Reducing readmissions with pharmacist-integrated care in Medicare value-based programs - PubMed

[30] [31] [48] Reductions in Medication-Related Hospitalizations in Older Adults with Medication Management by Hospital and Community Pharmacists: A Quasi-Experimental Study - PubMed

https://pubmed.ncbi.nlm.nih.gov/27714762/

[36] Medicare project helps put pharmacists in primary care

https://academic.oup.com/ajhp/article/73/6/346/5101730

[37] Integrating Ambulatory Care Pharmacists Into Value-Based Primary ...

https://journals.sagepub.com/doi/10.1177/21501319241312041

[38] [44] Recognizing Pharmacists in Value Based Care

https://www.ascp.com/page/5_1_25

[40] Trends and disparities in the utilization of influenza vaccines among commercially insured US adults during the COVID-19 pandemic - PMC

https://pmc.ncbi.nlm.nih.gov/articles/PMC8960160/

[41] Flu Vaccines Are a Go | Pharmacy Times

https://www.pharmacytimes.com/view/flu-vaccines-are-a-go

[46] [47] Leveraging Medication Adherence as a Value-based Healthcare ...

https://anewhealthrx.com/insights/leveraging-medication-adherence-as-a-value-based-healthcare-strategy/

[49] Expanding pharmacy’s role in value-based care | Medical Economics

https://www.medicaleconomics.com/view/expanding-pharmacy-s-role-in-value-based-care

[50] [PDF] Value-Based Contracting Framework - CPESN

https://cpesn.com/sites/default/files/2022-09/Value-Based%20Contracting%20Framework.pdf

[53] [PDF] Medicare Advantage and Part D Star Ratings Technical Notes (CMS)

[54] [PDF] Medicare Advantage and Part D Star Ratings Measures (CMS)

[55] [PDF] Medication Therapy Management: Evidence Base (CMS Innovation Center)

[56] An employer-based, pharmacist intervention model for patients with type 2 diabetes - PubMed

[57] The Asheville Project: long-term clinical, humanistic, and economic outcomes of a community-based MTM program for asthma - PubMed

[58] [PDF] Contract Year 2025 Medication Therapy Management (MTM) Program Submission Memo (CMS)

[59] Impact of clinical pharmacy interventions on medication error nodes (Int J Clin Pharm, 2016) - PubMed