Who's Getting Paid to Keep You Sick?
On the battle between profit and patients — and the model that could change everything
Two Models. One Big Fight.
Somewhere in a boardroom right now, a private equity firm is deciding how many ER visits is enough. They bought the emergency room. They pay the doctors. And they get paid every time you walk through that door.
That's Fee-for-Service (FFS) in a nutshell: the more you need, the more they earn. It's not conspiracy — it's just math. And the math is working against you.
The alternative? Value-Based Care (VBC) — a model where providers are compensated based on your outcomes, not the volume of services you consume. The idea is elegant: align the financial incentive with your health. Hospitals get paid to keep you healthy, not to keep you coming back.
"Hospitals being paid to keep you healthy may sound radical. That's because it is — and it shouldn't be."
We're Moving. But Barely.
According to the U.S. Department of Health and Human Services, the share of healthcare payments tied to value-based care reached 34% in 2017, up from 23% just two years prior. That's real momentum — but let's be honest about what the other number means.
66% of payments are still tied to volume. Two-thirds of the system still rewards quantity over quality, procedures over prevention, intervention over outcomes. One step forward, two steps back.
The Finance Bros Showed Up.
Private equity has been quietly buying up emergency rooms, physician groups, and urgent care chains across the country. Their job isn't medicine — it's returns. And returns come from billing, not from your blood pressure staying low.
As Marc Harrison outlined in his 2019 Harvard Business Review piece, A 5-Point Framework for Value-Based Health Care, the path forward requires fundamentally realigning incentives with outcomes. But when the entity controlling the doctors is an investment fund with a 5-year exit strategy, those incentives get complicated very fast.
The doctors aren't always the villains here — they're often caught between their instincts and their employers' spreadsheets. The system is the problem.
Utah Already Proved It Works.
At Intermountain Healthcare, they didn't wait for politicians to figure it out. They built a team-based care model focused on 31,000 patients with one guiding principle: prevention over intervention. The results?
60% decrease in hospital admissions
35% decrease in ER visits
20% decrease in monthly costs
And — most importantly — the patients are healthier
This isn't theoretical. It's not a promising pilot program from a research lab. It happened. The model works. The question is why we aren't scaling it — and the answer, unfortunately, keeps coming back to money.
The Unsexy Work Nobody Wants to Fund
Big Pharma breakthroughs are exciting. Surgical innovations make headlines. But food insecurity, housing instability, and social isolation — the so-called social determinants of health — are quietly driving outcomes in ways that no drug or procedure can fully fix downstream.
This is the "unsexy" work. There's no billing code for helping someone find stable housing. No investor deck gets funded around combating loneliness in elderly patients. Yet these factors are among the strongest predictors of who ends up in the ER, who manages their chronic illness, and who simply doesn't make it.
We've built a system that subsidizes the dramatic over the preventive. Every year we don't fix it, we're choosing profit over people — whether we mean to or not.
Prevention is boring. It's also the only thing that actually works at scale.
So Where Do We Go From Here?
Value-Based Care isn't radical. It's rational. It's proven. The data supports it. Intermountain Healthcare demonstrated it. The question isn't whether it works — it's whether the people writing the checks, lobbying the legislators, and buying up the ERs will allow it to scale.
Focusing on prevention lowers costs, improves lives, and reduces pressure on an already strained system. The model exists. The evidence is there. What's lagging is the political and financial will to let it win.
Until that changes, we'll keep doing this: one step forward, two steps back — while the billing department cashes in.
Inspired by Marc Harrison's "A 5-Point Framework for Value-Based Health Care" — Harvard Business Review, October 2019.
