Applied Policy attended the Virtual Value-Based Payment Summit from September 3–5, 2025, part of the Heritage VBC Conference Series. Produced by Global Health Care, LLC and sponsored by Heritage Provider Group, the summit brought together policymakers, health system leaders, and innovators to discuss the future agenda for value-based care (VBC) at the Center for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI).
The discussions revealed a clear shift: CMS is investing in technology to improve care while moving toward mandatory models, tightening oversight of Medicare Advantage (MA), and investing in data-driven technologies like AI.
CMMI STRATEGY: LEVERAGING TECHNOLOGY AND IMPROVING PATIENT-CENTERED CARE
During several sessions on CMMI strategy, speakers explored how innovation and technology can reshape care delivery and reduce burden. Abe Sutton (CMMI), interviewed by Mara McDermott (Accountable for Health), alongside panelists including Niall Brennan (Horizon BCBS), Andy Slavitt (Town Hall Ventures), Shannon Sartin (Datavant), and Mariann Yeager West (The Sequoia Project), highlighted the potential for technology to simplify navigation of the healthcare system. New tools could help patients more easily schedule appointments, verify whether a provider is in-network, or check prescription drug coverage. For providers, these solutions could reduce administrative workload, creating more time for patient care.
Speakers cautioned that implementing new technology must be done carefully, given the vulnerability of patients seeking care. Providing incorrect or incomplete information could erode trust and negatively impact health outcomes.
A separate discussion led by Dr. Bruce Leff (Johns Hopkins University School of Medicine), Dr. J. Cameron Muir (National Partnership for Healthcare & Hospice), and Dr. Sarah L. Szanton (Johns Hopkins School of Nursing) emphasized that the current landscape for in-home care is designed around payer and delivery system convenience rather than patient needs. To truly center care around the patient, panelists called for reducing silos, streamlining processes, and pursuing coding and billing reforms that better support in-home and community-based care.
MANDATORY MODELS ON THE HORIZON
The tone for the summit was set by sessions focused on CMS’s increasing reliance on mandatory programs. Boris Vabson (CMMI), Joe Albanese (Center for Medicare), and Dr. Michael Chernew (Harvard/MEDPAC), moderated by Jennifer Podulka (America’s Physician Groups), emphasized that voluntary models simply haven’t produced the level of savings needed to justify large-scale reforms.
Mandatory participation offers cleaner data for evaluation, prevents selection bias, and sends stronger market signals to providers and payers. This perspective is shaping new efforts like the Transforming Episode Accountability Model (TEAM) and the Wasteful and Inappropriate Service Reduction (WISeR) initiative, which rely on managed care tools such as prior authorization, narrow networks, and care coordination to control costs. While these tools support enhanced benefits, they come with trade-offs such as limited provider choice and potential delays—a balance CMS is attempting to improve through its prior authorization pledge to increase speed and transparency and reduce inappropriate denials.
Looking ahead, CMS is developing a reform framework centered on three pillars:
- Coverage policy to discourage low-value care,
- Utilization management that minimizes burden and delays, and
- Incentives and alternative payment models (APMs) that align payment with value and quality.
TEAM: REDEFINING SURGICAL EPISODES
A panel featuring Michael Barbati (Advocate Health), Bill Nordmark (Enlace Health), and Dr. Thomas Tsai (American College of Surgeons), moderated by Robert Mechanic (Institute for Accountable Care) described the Transforming Episode Accountability Model (TEAM) as a catalyst for cross-stakeholder collaboration among hospitals, health plans, and surgeons.
TEAM introduces shorter episode windows, shifting more decision-making authority directly to surgeons and creating a stronger need for collaboration between hospitals and the physicians providing the care. This change reflects lessons learned from prior voluntary models while fundamentally reshaping accountability. However, the move to regional benchmarks poses financial risks: the Institute for Accountable Care estimates that 63% of hospitals would lose money under TEAM, with some experiencing significant financial loss.
Panelists agreed that mandatory participation will drive deeper engagement across the health system.While payers struggled to form downstream relationships under voluntary models, they now have a stronger incentive to be active partners. TEAM may also urge hospitals to adopt standardized care pathways across all payers and patients.
To prepare, hospitals must identify and appropriately compensate physician leaders who can champion care redesign and engage peers in planning. Panelists emphasized that there is no one-size-fits-all approach—planning must reflect the unique needs of local patient populations and variations in procedure volumes. Finally, Barbati encouraged hospitals to “think like a payer”, using data to distinguish between true opportunities for improvement and normal fluctuations in volume.
WISER: INNOVATION OR RISK?
The Wasteful and Inappropriate Service Reduction (WISeR) model, set to launch January 1, 2026, will initially operate in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington, targeting 17 “low-value” or “high-risk” services for enhanced oversight.
During a panel featuring Seth Edwards (Population Health and VBC), Robert Homchick (Davis Wright Tremaine LLP), and Ashley Ridlon (Evolent), moderated by Aisha Pittman (NAACO), speakers voiced sharp concerns about the potential for WISeR to evolve into a tech-driven denial machine, delaying beneficiary access to necessary care. They warned that automating prior authorization decisions without sufficient human oversight could lead to constant denials and administrative burden for providers.
While AI will play a central role in reviewing flagged services, the model requires that a physician approve final decisions, providing a layer of clinical oversight. Providers will have the ability to request reassessment an unlimited number of times, offering a safeguard for patients and clinicians. However, stakeholders stressed that many operational details remain undisclosed, heightening the need for future guardrails, transparency, and strong federal oversight to ensure WISeR achieves its intended goals without harming patient care or exacerbating administrative delays.
MEDICARE ADVANTAGE: CONTAINING GROWTH, DRIVING VALUE
With Medicare Advantage (MA) now covering over 50% of Medicare beneficiaries, its reform was a major focus of the summit. In a session featuring Dr. Elizabeth Fowler (The Commonwealth Fund, former CMMI Director), Hoangmai (Mai) Pham (Institute for Exceptional Care), and William Shrank (Aradigm), moderated by Theresa Dreyer (Health Care Transformation Task Force), panelists addressed the challenges of rising MA costs, which are currently growing 6–8% annually. The discussion underscored that MA reform is now a top priority for CMMI, with significant ripple effects for traditional Medicare payment strategies and the broader shift toward VBC.
Speakers explained that past voluntary MA pilots were costly and largely ineffective, suffering from selection bias, where only motivated or well-resourced providers participated. This skewed results and made it difficult to measure true impact or generate savings. Voluntary models created spillover effects, where providers’ participation changed behavior for non-Medicare patients, complicating evaluations. CMMI is now pivoting to mandatory models while aligning with Congressional Budget Office (CBO) recommendations.
CMS is actively exploring mandatory downside-risk models for large health systems, global risk arrangements, and testing modernized fee schedules and payment structures to better control system-wide costs. While managed care tools like prior authorization, narrow networks, and care coordination are essential to managing costs and enhancing benefits, panelists emphasized the trade-offs, such as reduced provider choice and potential delays in patient care.
Reform priorities include updating risk adjustment methodologies, supporting delegated-risk arrangements with providers, and increasing oversight of plan-provider contracts—despite CMS’s limited authority under the “non-interference” clause. Panelists also stressed the importance of supporting safety-net and rural providers through rulemaking processes and avoiding undue burden on health systems already navigating financial pressures.
MSSP: BUILDING THE BACKBONE OF TRADITIONAL MEDICARE
Looking to the future of accountable care, CMS reaffirmed its ambitious goal for every traditional Medicare beneficiary to be aligned with an ACO by 2030. In a session moderated by Sean Cavanaugh (Aledade), panelists Dr. Bartley Bryt (Privia Health), Dr. Peggy Evans (Aledade), and Jessica Walradt (Northwestern Medicine) discussed strategies for achieving success under the Medicare Shared Savings Program (MSSP).
Chris Klomp (CMS), interviewed by Emily Brower (NAACO), highlighted MSSP’s central role in scaling VBC, emphasizing CMS’s vision to increase annual program savings tenfold. MSSP has consistently demonstrated cost-effectiveness, making it the cornerstone of CMS’s broader accountable care agenda.
Speakers shared operational best practices rooted in the quadruple aim, keeping cost and quality for both patients and providers at the center. Key strategies included fostering partnerships with community stakeholders, ensuring providers remain accountable for patients even outside the office, and using data-driven KPI monitoring to continuously refine performance. Health systems are also leveraging technology, such as Epic, to automate referrals and streamline information sharing, improving care coordination and reducing administrative burden.
Together, these efforts position MSSP as the backbone of traditional Medicare’s transition to VBC, setting the stage for comprehensive, system-wide transformation by 2030.
ARTIFICIAL INTELLIGENCE AND TECHNOLOGY
Artificial intelligence dominated one of the most forward-looking sessions, featuring Lisa Bari (Innovaccer), Tamra Ruymann (Physicians of Southwest Washington), and Jacob Shiff (CMMI), moderated by Dr. Brian Anderson (Coalition for Health AI).
Panelists framed AI’s role in three categories: boosting physician productivity, providing continuous patient support, and improving operational efficiency at care sites.
However, they warned that AI’s success hinges on high-quality, reliable data and incentives that align with VBC goals. When properly integrated, AI should “fade into the background,” seamlessly supporting clinicians. Without regulatory clarity, adoption will stall, and rushed deployment could harm patients or create new administrative burdens.
PREVENTION AND WHOLE HEALTH
A session moderated by Dr. Alice Chen (Centene) and featuring Dr. Kofi Essel (Elevance Health), Dr. Alyson Goodman (CDC), Dr. Jacob Mirsky (Lifestyle Medicine Consulting), and Dr. Laurie Whitsel (American Heart Association) explored prevention-focused care. Panelists discussed leveraging Food as Medicine and physical activity as a standard of care to improve population health and chronic disease management in VBC (VBC) models.
Speakers framed Food as Medicine as a key component of “whole health”, emphasizing the need to integrate nutritional interventions directly into clinical care while simultaneously addressing food insecurity, which remains a critical barrier for many patients. Similarly, efforts to make physical activity a standard of care are advancing through the development of implementation guides, performance measures, and reimbursement pathways, but success will depend on aligning incentives across payers and providers.
Shared medical appointments were highlighted as an effective and scalable care model. However, panelists acknowledged several barriers to scaling prevention strategies in VBC, including reimbursement delays and limitations, the data reporting burden, and persistent measurement and interoperability challenges. Overcoming these obstacles will require coordinated efforts among payers, providers, and policymakers. to realize the potential of whole-health prevention initiatives.
ENHANCING ONCOLOGY MODEL: ADVANCING VALUE-BASED CANCER CARE
The Enhancing Oncology Model (EOM) panel, featuring Misty Chicchirichi (Shenandoah Oncology), Dr. Anthony Lam (OPN Healthcare), and Dr. Samyukta Mullangi (Thyme Care), moderated by Purva H. Rawal, former Chief Strategy Officer at CMMI, focused on cancer care.
Panelists emphasized that VBC (VBC) in oncology is essential because cancer treatment is costly, highly variable, and financially burdensome for patients and the Medicare program. The previous Oncology Care Model (OCM) improved care coordination and delivery but ultimately failed to generate savings for Medicare.
EOM builds on OCM’s lessons by placing a greater emphasis on patient support, care navigation, and integration of social determinants of health (SDOH), while also requiring more extensive data collection and review. Although quality of care has remained consistent, panelists identified a persistent lag in data reporting as a major barrier to success.
Speakers stressed the urgent need for real-time clinical and financial data to inform prescribing and treatment decisions. They highlighted staff education and financial counseling, ensuring practices can help patients navigate both care and costs. Finally, the panel called for meaningful, actionable quality metrics that truly reflect outcomes and support continuous improvement in cancer care.
LOOKING AHEAD: A MORE AGGRESSIVE VALUE-BASED FUTURE
Closing sessions featuring Susan Dentzer (America’s Physician Groups), Adam Boehler (Rubicon Founders), Dr. Liz Fowler (The Commonwealth Fund, former CMMI Director), and others explored the broader trajectory of VBC (VBC) and its growing role in Medicare policy.
The next decade will be more aggressive, data-driven, and far less optional, as CMS shifts to mandatory models across both traditional Medicare and Medicare Advantage (MA). Voluntary models have proven difficult to make cost-effective. Mandatory participation will provide cleaner data, minimize selection bias, and send stronger signals to the market.
America’s Physician Groups offered specific reform recommendations, including site-neutral payment changes, restructuring cost and quality incentives within fee-for-service Medicare, simplifying prior authorization processes, improving risk adjustment, and stronger enforcement of fraud and abuse protections.
Prevention emerged as a key theme, with a focus on nutrition, vaccinations, and other strategies to keep populations healthy. Panelists also stressed the importance of investing in community health workers (CHWs) and care management programs, while acknowledging challenges like administrative complexity and the geographic and demographic heterogeneity of Medicaid populations.
A team-based care model was highlighted as critical, especially as patients may only see their provider in person once a year. Risk should be placed at the level of the provider or entity with the most control over outcomes, with upside risk incentives to drive engagement and accountability.
To prepare for this transformation, providers and payers must act now by investing in robust data and analytics systems, building cross-continuum relationships with community partners and stakeholders, and engaging clinicians in care redesign to ensure readiness for these new, mandatory VBC models.
