Merely saying your solution supports value-based care is often not enough. Health system buyers have heard that pitch before. What they’re increasingly looking for is alignment they can prove — in revenue models, workflows, and risk performance.
If you’re a digital health company trying to land or expand within US health systems, you’ll need more than clinical outcomes and an elegant UI. You’ll need to show up as a solution that helps your buyer succeed under value-based reimbursement — without putting fee-for-service revenue at risk. Let’s break down why this is the case and where the disconnect happens.
Why Value-Based Care Still Feels Ambiguous to Founders
Most provider organizations operate in a hybrid model. They often generate most of their revenue through fee-for-service billing, but they’re increasingly held accountable under value-based contracts. These include Merit-based Incentive Payment System (MIPS), Medicare Advantage Star Ratings, ACO REACH, and shared savings agreements with commercial payors.
That means your buyer is under pressure from both sides: generate enough CPT-coded visits to meet financial targets today, while also improving quality scores and managing total cost of care for long-term incentive payments.
You need to build your solution — and your pitch — around both. Because if it can’t support the dual incentives providers are juggling, you’re not solving the right problem.
What Health System Buyers Actually Evaluate
When health system executives ask how your solution supports value-based care, here’s what they’re really asking:
- Can this help us bill more effectively for existing or new services?
- Will this help us avoid penalties tied to readmissions or quality performance?
- Can we report the results to CMS or our payer partners with confidence?
- Does it work inside the clinical workflows we already use?
The buyer’s perspective is less about the elegance of your intervention and more about how that intervention gets documented and paid. You may think you’re selling care improvement, but they’re looking for a tool that delivers margin. There are thus three things you need to prove: operational fit, clinical impact to revenue, and low risk.
Step One: Prove Operational Fit
The best place to start is with workflow. Providers don’t want more friction. If your tool adds a new login, requires parallel documentation, or lives outside the EHR, you’re likely creating resistance.
Here’s what they want instead:
- Integration into Epic, Cerner, or other EHRs (or at minimum, data that flows into the chart)
- Documentation support that aligns to CPT codes (e.g., timestamped interventions, structured assessments)
- Reporting mechanisms for MIPS, HEDIS (Healthcare Effectiveness Data and Information Set), and other quality programs
If your solution supports services that are billable — like chronic care management (99490), transitional care (99495), or remote patient monitoring (99457) — make sure it enables documentation that supports those codes. That’s how you show up as operationally aligned.
Step Two: Tie Clinical Impact to Revenue
Clinical improvement is necessary, but not sufficient. You still have to tie your outcomes to reimbursement levers. Here’s what that looks like in practice:
- Does your tool help reduce readmissions? That helps hospitals avoid up to 3% penalties under the Hospital Readmissions Reduction Program (HRRP), a CMS initiative that reduces Medicare payments to hospitals with excess readmission rates for specific conditions.
- Does it support screenings or follow-ups? That affects HEDIS scores, Star Ratings, and the MIPS incentives.
- Does it help deliver billable services? Then it should support proper coding and billing for those CPT codes.
For example, a remote monitoring tool that prompts medication changes before an exacerbation may prevent an admission — improving cost performance under an Accountable Care Organization (ACO) contract. But if that same interaction is coded under 99457, it also generates monthly revenue today.
And you need both. You need to show how you help in the short term (through CPT billing and margin protection) and in the long term (by supporting shared savings or incentive payments).
Step Three: Meet the Buyer’s Risk Profile
Not all providers are all-in on capitation — yet. They’re experimenting. A few clinics or regions may be in ACO contracts or value-based arrangements, but fee-for-service is still the main source of cash flow.
That’s why your solution needs to flex across the reimbursement spectrum. If it only works in fully capitated models, your market size may be smaller than you think.
Instead, position your solution as one that supports:
- CPT-coded billing today
- Quality performance across MIPS or Medicare Advantage (MA) contracts
- Longer-term cost and utilization targets in ACO or Alternative Payment Model (APM) programs
In short, don’t make the provider change their business model to adopt your tool. Help them transition their model while keeping today’s margins intact.
Final Word: Value-Based Alignment Is a GTM Strategy
Treat value-based care like a revenue model, not a mission statement. The solutions that win are the ones that translate clinical actions into documented, billable, auditable value.
That means:
- Supporting workflows providers already use
- Enabling CPT billing and documentation
- Proving impact on MIPS, HEDIS, or shared savings
If you can do those things, you’re not just aligned with value-based care — you’re solving for it. And that’s what buyers will pay for.
How We Help
We work with digital health companies that are ready to align their solutions with the realities of healthcare reimbursement. That means:
- Repositioning your product in language health system buyers actually use
- Identifying CPT-coded revenue pathways your solution can support
- Building a go-to-market strategy that speaks to both fee-for-service and value-based incentives
- Enabling your team to speak confidently to ROI — both clinical and financial
Whether you’re looking to refine your sales narrative, land pilot programs with health systems, or prove ROI for investor diligence, we help you make the shift from mission-based to revenue-backed alignment. Because buyers aren’t just betting on your outcomes — they’re betting on your model.
If you need help with this, get in touch today.
