The Ghosts of Value-Based Care: A Dickensian Tale of Health System Renewal

In the spirit of Dickens's classic A Christmas Carol (Dickens, 1843), we reflect on healthcare through a lens of compassionate realism. Our system has battled many Cratchits and Tiny Tims (patients and families bearing the cost of a broken model). Even as challenges loom, a redemptive path emerges: value-based care. This vision puts health outcomes at the center (Teisberg et al., 2020) and offers hope for rebuilding trust in a weary system (Perlis et al., 2024). By weaving technology, team-based practices, and a renewed social conscience into care, we can begin to move from Scrooge-like isolation toward inclusive understanding and healing.

The Ghost of Care Past: From Fee-for-Service to Value

Once, healthcare was like Scrooge's counting house, driven by volume rather than human need. Every test, every procedure was billed, leaving little room for unbilled compassion. The fee-for-service model treated illness like an account statement, and even penalized providers who worked hardest for disadvantaged patients (Horstman, 2023). In effect, it treated symptoms instead of people, ignoring the social roots of sickness.

Yet even in those dark days, innovators showed a different way. Pioneer systems like Kaiser Permanente operated on capitated payments and invested in prevention. They proved that aligning incentives with health pays off: one analysis found Kaiser patients in value-based programs live six to eight years longer than average, thanks to earlier cancer diagnosis and superior chronic care (Feldheim, 2025). These stories glimmer like early carols, reminding us that success is measured by lives improved, not bills generated.

Those Dickensian "chains" of outdated billing can be cast aside. Value-based care defines healthcare value as the improvement in patient health per dollar spent (Teisberg et al., 2020). It asks: what will Scrooge give to lift Tiny Tim? The answer: a care system that invests in his health, arranging rides to appointments or social support if needed. In this model, providers are paid for keeping people well and addressing root causes of illness, rather than just treating end-stage symptoms (Horstman, 2023).

The Ghost of Care Present: Guilt, Growth, and Grit

Today's landscape offers both ghosts and hope. On one hand, experts acknowledge the limits of the old model: as one panel noted, "value-based payment has largely not improved access or health outcomes for populations with social risk factors" (Levins, 2025). Communities of color, rural areas, and high-need patients often feel left behind. This is our ghost of compassion ignored.

On the other hand, we see sparks of promise. Leaders debate fiercely: some decry design flaws, while others highlight early gains. For example, giving primary care teams accountability slowed spending. In 2024, Medicare spending for patients in one major ACO program grew 6.8%, versus 10% for others, a meaningful three-point gap in just one year (Levins, 2025). And on the ground, innovators target equity explicitly: some Medicaid value contracts now reward doctors for screening social needs and connecting patients to community resources (Elevance Health, 2023).

Importantly, the Ghost of Present also warns us about trust. A recent survey found Americans' trust in doctors and hospitals fell from about 71% in 2020 to 40% in 2024 (Perlis et al., 2024). When fewer than half the people believe their doctors are acting in their best interest, we face a crisis of faith. As Perlis and colleagues emphasize, "restoring trust may represent a public health imperative" (Perlis et al., 2024, p. e2424984). Value-based care can help by making healthcare feel less transactional and more relational: providers who spend extra time resolving patient concerns will be the ones rewarded, not the hurried (Elevance Health, 2023).

The Ghost of Care Future: Redemption and Renewal

Looking ahead, we imagine a redeemed system, one Dickens himself would celebrate. Care is truly equitable and person-centered: value contracts are written with a focus on ending disparities (Elevance Health, 2023). Payments fund community health workers, mental health support, or transportation programs when patients need them. Doctors are rewarded for closing care gaps, not punished for patients' hardships (Elevance Health, 2023; Horstman, 2023). As Dr. Elizabeth Teisberg reminds us, "We can achieve health and care equity only if we prioritize ending disparity in health outcomes" (Elevance Health, 2023).

In this hopeful future, technology and teamwork extend every doctor's reach. Integrated health data and even AI help find needs before they become crises (Feldheim, 2025). A patient with diabetes, for example, might receive automated reminders, community support, and timely medications because her care team is looking ahead. Hospitals partner with local organizations to keep seniors warm and fed before winter, preventing emergency visits. Patients who once distrusted the system now see it listening and adapting (Elevance Health, 2023).

This future also demands humility in communication. We must help people understand these changes. As one health equity researcher warns, "we have not done a great job" explaining value-based care to communities who trust the system the least (Elevance Health, 2023). That means asking people what matters to them and honoring their answers (Elevance Health, 2023). Only then can our measures truly reflect the outcomes that matter most to patients.

Redemption for All: Compassion with Backbone

Dickens's tale ends in joy and action, and ours can too. We have called on the ghosts of reform (data-driven evidence, community voices, and moral purpose) to guide us. But like Scrooge, we have a choice: return to the cold status quo, or embrace bold change. The path forward is mercy with a backbone: caring deeply about people's stories while also demanding accountability and smart stewardship (Teisberg et al., 2020).

This means supporting team-based care, addressing social needs as part of medicine, and keeping the patient's lived experience central. It means treating Tiny Tim's family with the same urgency and dignity as any paying customer, because ultimately everyone deserves care that sees them.

Imagine waking up on Christmas morning to a health system that truly sees every Tiny Tim: communities are healthier, costs are stable, and the most vulnerable are protected by a system that finally cares. In the words of Dickens's Tiny Tim, we all say, "God bless us, every one" (Dickens, 1843). The ghosts have spoken. Now let us write the next chapter of healthcare together, with empathy, resolve, and the courage to change.

References

Dickens, C. (1843). A Christmas Carol. Chapman & Hall.

Elevance Health. (2023, November 22). How value-based care can advance health equity. https://www.elevancehealth.com/

Feldheim, B. (2025, May 22). Outcomes over volume: How prevention powers value-based care. American Medical Association. https://www.ama-assn.org/

Horstman, C. (2023, August 15). Promoting health equity by changing how we pay for care. The Commonwealth Fund. https://www.commonwealthfund.org/

Levins, H. (2025, November 13). After fifteen years, is value-based care succeeding? Leonard Davis Institute of Health Economics. https://ldi.upenn.edu/

Perlis, R. H., Ognyanova, K., Uslu, A., Lunz Trujillo, K., Santillana, M., Druckman, J. N., Baum, M. A., & Lazer, D. (2024). Trust in physicians and hospitals during the COVID-19 pandemic in a 50-state survey of US adults. JAMA Network Open, 7(7), e2424984. https://doi.org/10.1001/jamanetworkopen.2024.24984

Teisberg, E., Wallace, S., & O'Hara, S. (2020). Defining and implementing value-based health care: A strategic framework. Academic Medicine, 95(5), 682–685. https://doi.org/10.1097/ACM.0000000000003122