Value-Based Care Strategy Forum
Reframing Value-Based Care:
Why the Future of Cost, Quality, and Sustainability Depends on the Ninety-Five Percent
Executive Reflections from the ICD Value-Based Care Conference
Prepared by: Kelly Hidde
Executive Summary
The ICD Value-Based Care Conference reaffirmed a hard truth facing U.S. healthcare. Although extraordinary resources are invested in managing the sickest patients, the long-term sustainability of the system depends on how effectively we prevent the remaining ninety-five percent from becoming the next high-cost cohort.
We all know the statistic: five percent of patients drive more than fifty percent of healthcare spending. But the conference pushed an even more urgent question to the forefront.
What if the real opportunity lies in shifting equal, or even greater, attention toward predicting, preventing, and stabilizing the ninety-five percent before they ever reach catastrophic cost and complexity?
Throughout the event, four themes emerged consistently.
- Early detection and early intervention are becoming the most powerful levers in cost containment and outcome improvement.
- Social determinants of health continue to accelerate disease progression and drive utilization.
- Patient-reported outcomes are rapidly becoming contract-defining metrics.
- Artificial intelligence, while operationally promising, has not yet demonstrated consistent, scalable improvement in clinical outcomes.
This paper reframes value-based care not as a system that reacts to disease, but one that intercepts risk before it becomes irreversible cost.
I. The National Cost Crisis and the Limits of Reactive Care
Healthcare spending in the United States now exceeds four trillion dollars annually, with Medicare accounting for one of the largest slices of the global economic pie. Employers face double-digit premium increases, and patients continue to absorb rising out-of-pocket costs.
Yet despite these investments:
- Outcomes remain inconsistent.
- Chronic disease prevalence continues to rise.
- Preventable utilization strains emergency departments and inpatient capacity.
- Physician burnout remains at alarming levels.
As conference leaders emphasized, the system’s challenge is not a lack of effort. It is a structural misalignment rooted in a reliance on late-stage intervention. Value-based care was created to correct this, yet too often it is still executed as a more coordinated version of reactive care.
Until this structural imbalance shifts, healthcare will remain locked in a cycle of high cost, high burnout, and uneven outcomes.
II. Why the Ninety-Five Percent Must Become the Strategic Center of Gravity
It is well understood that five percent of patients account for more than half of total spending, but the conference asked us to reconsider where real opportunity lies.
If care models continue to focus disproportionately on the five percent, the pipeline of rising-risk patients within the ninety-five percent will continue to refill the high-cost cohort indefinitely.
The ninety-five percent includes people with:
- Early-stage chronic disease
- Undiagnosed or under-managed conditions
- Lifestyle-driven risk
- Inconsistent primary care engagement
- Escalating social stressors
Without systematic early detection, ongoing surveillance, and preventive intervention, this population inevitably transitions into disability, polypharmacy, high-acuity utilization, and long-term dependency on complex care.
Managing cost after decompensation is no longer a sustainable strategy.
The ninety-five percent must become the primary design population of the future health system.
III. The Five Percent Still Matters, but Only as a Stabilization Strategy
The high-cost five percent requires:
- Intensive coordination
- Predictive modeling
- Behavioral health integration
- Comprehensive medication management
- Structured caregiver support
These patients often face multimorbidity and high SDoH burden, and their care will always be essential.
But the conference highlighted a crucial distinction.
Stabilizing the five percent saves lives.
Protecting the ninety-five percent saves the system.
Long-term sustainability depends entirely on slowing the flow of patients into the high-cost cohort.
IV. Social Determinants of Health: The Hidden Accelerator into Catastrophic Cost
The conference underscored the magnitude of SDoH on patient risk. Factors including housing instability, food insecurity, transportation challenges, income volatility, education gaps, and social isolation all accelerate movement from low-risk to high-cost status.
SDoH must be embedded directly into:
- Preventive outreach
- Risk stratification algorithms
- Clinical prioritization
- Care management workflows
Without early SDoH integration, health systems will always react to risk rather than get ahead of it.
V. Patient-Reported Outcomes Are Redefining Success
PROMs emerged as one of the strongest threads of the conference. They are no longer viewed as supplementary—they are becoming central performance metrics in value-based contracts.
Patients measure success through:
- Pain reduction
- Functional improvement
- Emotional well-being
- Ability to work
- Ability to live independently
These indicators often deteriorate well before claims or utilization patterns reveal a problem, making PROMs a powerful tool in preventive care.
The challenges remain real: survey fatigue, redundancies, and emotional variability. But the opportunity is clear. PROMs will reach full potential when used to:
- Detect early functional decline
- Trigger preventive pathways
- Guide timely intervention
CMS’s development of a national PROMs platform underscores the shift toward patient-centered metrics.
VI. Artificial Intelligence: Operational Promise, Limited Outcome Impact (So Far)
AI was discussed with refreshing honesty. While it has delivered meaningful improvements in efficiency—through documentation support, triage, message routing, and automation—it has not yet demonstrated reliable, large-scale improvement in clinical outcomes.
The gap is striking.
Primary care accounts for over 500 million visits annually, yet only a small fraction of AI investment goes toward primary care innovation. This mismatch reflects why AI’s potential remains untapped.
AI will become clinically transformative only when aligned with:
- Early detection
- Risk prediction
- Preventive intervention
- Care team integration
- Bias monitoring and performance surveillance
Until then, efficiency gains alone will not shift outcomes.
VII. The Care Team of the Future Must Be Built for Prevention
The ChenMed model showcased what a preventive care ecosystem looks like in practice. Their structure includes PCPs, care coordinators, pharmacists, dietitians, social workers, community navigators, and telemedicine support, all operating with frequent touchpoints and continuous risk stratification.
This model demonstrated that when teams are built for prevention rather than recovery, everything changes. Stabilization improves. Utilization becomes more predictable. Patient experience strengthens.
This is the future of multidisciplinary care.
VIII. Medicare Advantage Shows Prevention at Scale
Medicare Advantage organizations have become the most advanced operational examples of population-level prevention. They serve disproportionately high-risk populations and manage large SDoH burdens. Prevention in MA is not a preference. It is a financial and clinical necessity.
MA proves that modern value-based care succeeds when the system invests in preventing deterioration rather than responding to it.
IX. Leadership and Education Remain the Missing Infrastructure
Despite the evolution of value-based care, most clinicians and administrators have not been formally trained in:
- Population health strategy
- Risk economics
- Data-guided care orchestration
- Preventive care leadership
Population health is still a relatively young discipline. Leadership development has not kept pace with transformation.
The next decade will require leaders fluent in data, economics, human behavior, and clinical strategy, not just clinical excellence alone.
Strategic Imperatives for the Next Decade
Organizations should prepare by aligning strategy around these core imperatives:
- Design population health models around the ninety-five percent.
- Make early detection the foundation of care delivery.
- Use PROMs as leading indicators of decline.
- Integrate SDoH into every risk pathway.
- Deploy AI where it advances prevention and early detection.
- Build care teams for longitudinal stabilization.
- Develop leaders trained in data, economics, and systems thinking.
Conclusion
The ICD Value-Based Care Conference delivered a message that is both direct and transformative. The future of healthcare will not be won by managing decline. It will be won by preventing it.
The five percent will always require skilled stabilization, but the fate of the U.S. healthcare system—its affordability, workforce stability, clinical quality, and public trust—rests squarely on how effectively we support the ninety-five percent who still have the chance to avoid catastrophic cost and complexity.
Early detection is becoming the most powerful clinical intervention. Early intervention is becoming the most valuable clinical service. Prevention is no longer a philosophy. It is the economic engine of the future.
