Greg Johnson, MD, MBA, CMD spent years in geriatrics before arriving at value-based care. What he saw in those years — patients losing independence not because of a lack of clinical care, but because of gaps in coordination and support — shapes everything he believes about why the model matters.
The patient I still think about
I spent years in geriatrics. And there’s one image I still carry with me.
A patient in their late seventies. Sharp mind. A family who loved them. They had lost the ability to perform one activity of daily living (ADL) — something as simple as bathing independently. And from there, the trajectory shifted. Increasing dependence, caregiver strain, safety concerns—and ultimately they ended up in a long-term care facility. Tens of thousands of dollars a year, even then. Significantly more today.
They didn’t need to be there. What they needed was support. Coordination. Someone to simplify their medications, teach their family what to watch for, help them make trade-offs that kept them at home and kept them functioning. But none of that — none of it — has a billing code.
You can prescribe. You can refer. You can order a test. The system rewards all of those things. But the work that actually keeps a patient out of a nursing home? There’s no code for that.
That’s what I kept running into. I’d see a patient and think: I know exactly what this person needs. Then I’d have to answer a different question — what can I actually do within the constraints of the system I’m operating in?
The constraint isn’t clinical. It’s economic.
Fee-for-service medicine is built around what can be documented and billed. That’s not a criticism of the people who built it — it’s a description of its incentive structure. And incentive structures shape behavior, whether we intend them to or not.
In a fee-for-service world, a physician gets paid roughly the same whether they spend five minutes addressing a chief complaint or thirty minutes addressing everything that’s quietly building in the background. The system doesn’t reward the longer conversation. It doesn’t reward coordination with a patient’s other providers. It doesn’t reward calling a family member to make sure someone is actually taking their medication.
So those things happen less. Not because physicians don’t care — they care enormously. But because the model creates friction around everything that isn’t directly billable.
What changes when the incentive changes
Value-based care changes the equation. Not perfectly, and not overnight — but fundamentally.
When you’re accountable for the total cost and quality of care for a patient population, coordination stops being an unreimbursed extra and starts being core to the work. Supporting someone at home becomes more valuable than treating them in a facility. Teaching a patient to manage their chronic condition becomes an investment with a measurable return. The things that have always mattered clinically start to matter economically too.
When we’re good stewards of resources — when we’re not constrained purely by what we can bill for — we can do the things that actually keep people well.
That’s what drove me to value-based care. Not the contracts. Not the acronyms. The recognition that this model creates the space — and the incentive — to practice medicine the way most physicians went into medicine wanting to practice it.
What we’re still building toward
I want to be honest about where we are. Value-based care hasn’t solved the problem. There are years where the financial realities don’t align with the work being done, where rising costs in areas outside primary care’s control undermine performance, where the complexity of the model creates its own burden on the physicians we’re trying to support.
But the alternative — retreating to a purely transactional model that rewards volume over outcomes — isn’t actually an alternative. The economics of American healthcare don’t permit it. The primary care workforce shortage doesn’t permit it. The demographic reality of an aging population doesn’t permit it.
We’re building toward something better. We haven’t arrived. But every time we help a physician have the conversation that the fee-for-service model never gave them time to have — every time a patient stays home instead of ending up in a facility — I’m reminded of why this work matters.
There’s still no billing code for it. But in value-based care, the work that matters most finally counts.