Here is a contradiction sitting at the center of most value-based organizations, in plain sight. The organization is paid to keep a population healthy and hold down total cost of care. The physicians inside it are still, overwhelmingly, paid to do more — more visits, more procedures, more RVUs.
You have signed a value contract and kept a volume paycheck. Then you wonder why behavior doesn’t change.
1. The incentive underneath the incentive
A value-based contract at the top of the house means little if the compensation model at the point of care still rewards volume.
Most physician compensation remains anchored to productivity — work RVUs and visit counts — even inside organizations that have taken on risk. That is not a criticism of physicians; it is the rational response to the signal they’re actually given. People optimize for how they’re paid, not for the mission statement.
So the organization holds population-level accountability while the individual clinician holds a volume incentive. The two point in opposite directions, and the point of care wins that argument every time.
2. Why this is a translation problem, not just a finance one
Fixing compensation isn’t only an actuarial exercise — it’s a clinical-trust exercise. Physicians have watched “value” initiatives come and go, and many reasonably fear that “value-based comp” is code for “work the same, get paid less.”
Bridging that requires someone who can speak both languages: translate the organization’s risk economics into what it means for a physician’s panel and paycheck, and translate physicians’ legitimate concerns back into a comp design that doesn’t quietly punish good medicine. Redesign without that translation breeds resentment and quiet non-participation.
3. What a coherent model actually balances
The goal isn’t to abolish productivity — it’s to stop letting it be the only thing that pays.
Blunt capitation can underserve; pure productivity overserves. A workable model usually blends a stable base with meaningful weight on the things value contracts actually reward — panel management, quality and outcomes, total-cost-of-care performance, and access — without making income so volatile that physicians can’t plan their lives.
The design details matter enormously, but the principle is simple: the individual’s incentives should rhyme with the organization’s accountability. Right now, for most, they don’t.
4. The specialists make it harder — and more important
This is hardest, and most consequential, on the specialty side, where productivity culture is strongest and where the majority of total cost of care is generated. You cannot bring specialty spend under management while every specialist in the building is paid purely to generate more of it.
That doesn’t mean imposing primary-care logic on surgeons. It means engaging specialists as clinical peers about the specific, credible ways their compensation can reward appropriateness and outcomes, not just throughput.
5. Where to start
Start by naming the contradiction honestly to your own physician leaders — most already feel it. Then map, service line by service line, where the comp model and the contract disagree, and prioritize the redesigns that close the widest gaps with the least disruption. And move deliberately: comp changes are among the most trust-sensitive decisions a health organization makes, and a clumsy rollout can set value-based care back years.
This is slow, human work. It is also the work that determines whether your value strategy is real or decorative.
Final Thoughts
You can have the most sophisticated risk contract in your market and still go nowhere if the people delivering the care are paid to pull the other way. Compensation is where strategy either becomes behavior or dies quietly.
As someone trained as a physician who moved into strategy, I’d put it this way: physicians aren’t resisting value-based care — they’re responding, rationally, to the incentive you actually put in front of them. Change the incentive, honestly and with their input, and the behavior follows. Leave it contradictory, and no amount of strategy decks will fix it.
If your organization holds value-based risk but pays its physicians for volume, your strategy and your incentives are fighting each other. At HealtheNomics I help organizations align physician compensation with value-based accountability — as a clinical-trust process, not just a spreadsheet.
Explore the services: https://healthenomics.com/services-2/
Request a strategy conversation: https://healthenomics.com/contact-us/
Connect on LinkedIn: https://www.linkedin.com/in/muhammad-ayoub-ashraf/
Website: https://www.drayoubashraf.com
Watch on YouTube: https://www.youtube.com/@HealtheNomics
