Patient Centered Care Through Value Based Care, Social Determinants of Health, and Behavioral Health – 2025 Health IT Predictions

As we wrap up another year and get ready for 2025 to begin, it is once again time for everyone’s favorite annual tradition of Health IT Predictions! We reached out to our incredible Healthcare IT Today Community to get their insights on what will happen in the coming year and boy did they deliver. We in fact got so many responses to our prompt this year, that we have had to narrow them down to just the best and most interesting. Check out the community’s predictions down below and be sure to follow along as we share more 2025 Health IT Predictions!

Check out our community’s Value-Based Care, Social Determinants of Health, and Behavioral Health predictions:

Luke Hansen, MD, MHS, Chief Medical Officer at Arcadia
In 2025 and beyond, specialists will play a larger role in advancing value-based care (VBC). The big question is whether they may replace primary care in the driver’s seat. Historically, specialists have had limited incentives to participate in VBC, in part due to existing economics and less concerted performance measurement compared to primary care physicians. However, accelerating VBC transformation will undoubtedly require novel strategies that might not keep specialists in the back seat. In my work, I’m already seeing more provider organizations include specialists in their VBC incentive programs. Arrangements like specialist sub-capitation and shadow bundles specialty episode bundles nested inside a total cost of care contract can create meaningful ROI for specialists and incentivize VBC participation.

At the same time, interoperability and data analytics tools are maturing to the point where networks can access information about specialist performance. Combined with workflow tools that guide referrals, primary care physicians can more easily route patients to high-value specialists. These strategies, which align with recommendations from the CMS Innovation Center, can reduce the total cost of care while simultaneously improving patient outcomes.

Jake Pyles, CEO at CipherHealth
While traditionally led by progressive health systems, value-based care (VBC) is now being embraced by more “middle-of-the-pack” organizations, catalyzed by CMS and initiatives like the TEAM payment model. In 2025, expect this trend to grow as healthcare providers across the board, regardless of their previous VBC readiness, recognize the need to move beyond fee-for-service models. This shift signals that VBC is no longer an optional pathway but a requisite for sustainable, quality care across healthcare settings.

Dana McCalley, VP of Value-Based Care at Navina
In 2025, we can expect sustained momentum for value-based care, driven by advocacy groups pushing for a full transition and strengthened by bipartisan support. Medicare Advantage (MA) will likely see expanded backing, further solidifying its role as a cornerstone of value-based care. As MA enrollment grows and more plans embrace risk-sharing models, this sector will continue to drive innovation and demonstrate the tangible benefits of value-based approaches. While there may be concerns regarding the Affordable Care Act (ACA), its survival seems likely given its established infrastructure and widespread reliance. It’s possible that a renewed focus on cost efficiency and quality improvement could lead to even greater integration of value-based care models within ACA programs.

Jeff Smith, CEO at Bamboo Health
In 2025, healthcare organizations will turn increased attention to high-need, high-cost patients—those with complex comorbidities, behavioral health challenges and chronic conditions—who often have a total cost of care approximately 5 times their counterparts. Traditional metrics like HEDIS and Star Ratings, along with fundamentals like value-based care, remain essential, but for payers and providers seeking to make meaningful improvements, the path forward lies in prioritizing this high-impact population. Addressing social determinants of health (SDOH), such as transportation or food insecurity, will be crucial for creating equitable outcomes. Proactive care models designed around these needs will uncover actionable insights, reduce costs, and improve outcomes.

Laura Copeland, MD, CMIO at Healthtech Consultants, a Nordic Global Company
Patient-centered care (PCC) will move from a buzzword to a fully integrated model that prioritizes cultural competency and addresses social determinants of health. Healthcare systems will prioritize responsive workflows and shared decision-making, ensuring every patient feels seen, respected, and engaged. They will adopt workflows and technologies that recognize the profound influence of culture, values, and lived experiences on health outcomes. Digital health strategies, such as AI-powered tools and personalized patient portals, will not only enhance access and engagement but also respect and incorporate cultural beliefs, particularly for marginalized communities. By focusing on both human connection and the social factors affecting health, such as housing, education, and access to nutritious food, PCC will create a more equitable, compassionate, and effective healthcare system for all.

Sami Inkinen, Co-Founder and CEO at Virta Health
While healthcare AI has focused primarily on diagnosis and automating back office and support tasks, 2025 will mark a pivot toward AI-powered care, such as behavioral modification platforms that deliver personalized, adaptive lifestyle interventions. Evolving far beyond simple health tracking, new AI systems will leverage broader data sets to drive predictive, proactive interventions. This technology will drive behavior change at scale, making lifestyle approaches the most successful and scalable treatments for chronic illnesses.

Andrew Hines, Chief Technology Officer at Canvas Medical
There will be continued investment in the capacity and effectiveness of mental health care providers in 2025. We’re nowhere near the mental health supply capacity we need as a country, but with the vast investments in online mental health services, the demand is closer to being met and opens the door to addressing related conditions. So many health conditions involve mental and behavioral components, and continued effort here will be good for everyone.

Ed Jen, VP of Product, Patient Care Solutions and Platform at Interwell Health
Medical innovation, new medications, therapies, diagnostics, and devices have outpaced our healthcare payer system’s ability to pay for it, leading to an unsustainable healthcare system. In 2025, we will see more health leaders begin to realize the potential of value-based care as one of the only ways to reverse the uncontrolled growth in costs and make healthcare sustainable. More providers and payers will embrace these new models and with it accelerate digital transformation in healthcare that we have already seen in other industries.

Robert Connely, Global Market Leader for Healthcare at Pega
In 2025, AI will be the catalyst that transforms value-based care from a pilot initiative to a standard model across healthcare. By automating administrative tasks, effectively delivering truly real-time, personalized patient insights, and optimizing resources, AI will empower providers to focus on proactive, long-term patient outcomes rather than fee-for-service transactions. Machine learning models will track and evaluate real-world patient data and outcomes against financial value metrics supporting outcomes-based contracts while also detecting anomalies and potential fraud.

Generative AI can personalize patient education, tailoring information to each person’s needs and comprehension. Conversational AI chatbots can answer questions, reinforce learning, and provide reminders, helping patients stay engaged and follow their care plans. This shift will enable providers to deliver higher-quality care at lower costs, for any and all patients, not just the sickest or most costly, reshaping reimbursement models and making value-based care the dominant approach for improving outcomes and controlling healthcare costs.

Michael Poku, MD, MBA, Chief Clinical Officer at Equality Health
In 2025, Value-Based Care will reach a pivotal crossroads, especially for Medicaid populations. As we head into the new year, we face a stark disconnect between Medicaid reimbursement rates and the high acuity of patient needs, a gap widened by the end of the Public Health Emergency and Medicaid unwinding. Bridging the gap will require forward-thinking care models that leverage data science, advanced technology platforms, and Social Determinants of Health (SDoH) services.

On the technology front, near real-time data sharing, seamless interoperability, and predictive analytics will be more important than ever before to effectively meet the challenging needs of America’s most complex patients. As these new care models evolve and mature, they will accelerate the shift from fee-for-service, empowering providers from independent PCPs in disinvested communities to large health systems — to deliver proactive and holistic quality care to historically marginalized patients and everyone.

Jonathan Shoemaker, CEO at ABOUT Healthcare
In 2025, patient experience will be redefined by AI-driven tools that enable providers to deliver tailored engagement and simplify the patient journey. These healthcare operational systems will anticipate patient movement needs, guide complex care processes, and deliver actionable insights to manage the acute patient journey proactively. By reducing administrative burdens and enabling seamless communication, patient flow tools will enhance provider satisfaction and build loyalty ultimately improving the patient experience. This personalized, intuitive approach will improve outcomes while supporting healthcare organizations’ shift to value-based care.

Thank you so much to everyone who took the time out of their day to submit a prediction to us and thank you to all of you for taking the time to read this article! We could not do this without all of your support. What do you think will happen for Value-Based Care, Social Determinants of Health, and Behavioral Health in 2025? Let us know on social media. We’d love to hear from all of you!

Be sure to check out all of Healthcare IT Today’s Value-Based Care, Social Determinants of Health, and Behavioral Health content and our other 2025 Health IT Predictions.

As we wrap up another year and get ready for 2025 to begin, it is once again time for everyone’s favorite annual tradition of Health IT Predictions! We reached out to our incredible Healthcare IT Today Community to get their insights on what will happen in the coming year and boy did they deliver. We in fact got so many responses to our prompt this year, that we have had to narrow them down to just the best and most interesting. Check out the community’s predictions down below and be sure to follow along as we share more 2025 Health IT Predictions!

Check out our community’s Value-Based Care, Social Determinants of Health, and Behavioral Health predictions:

Luke Hansen, MD, MHS, Chief Medical Officer at Arcadia
In 2025 and beyond, specialists will play a larger role in advancing value-based care (VBC). The big question is whether they may replace primary care in the driver’s seat. Historically, specialists have had limited incentives to participate in VBC, in part due to existing economics and less concerted performance measurement compared to primary care physicians. However, accelerating VBC transformation will undoubtedly require novel strategies that might not keep specialists in the back seat. In my work, I’m already seeing more provider organizations include specialists in their VBC incentive programs. Arrangements like specialist sub-capitation and shadow bundles specialty episode bundles nested inside a total cost of care contract can create meaningful ROI for specialists and incentivize VBC participation.

At the same time, interoperability and data analytics tools are maturing to the point where networks can access information about specialist performance. Combined with workflow tools that guide referrals, primary care physicians can more easily route patients to high-value specialists. These strategies, which align with recommendations from the CMS Innovation Center, can reduce the total cost of care while simultaneously improving patient outcomes.

Jake Pyles, CEO at CipherHealth
While traditionally led by progressive health systems, value-based care (VBC) is now being embraced by more “middle-of-the-pack” organizations, catalyzed by CMS and initiatives like the TEAM payment model. In 2025, expect this trend to grow as healthcare providers across the board, regardless of their previous VBC readiness, recognize the need to move beyond fee-for-service models. This shift signals that VBC is no longer an optional pathway but a requisite for sustainable, quality care across healthcare settings.

Dana McCalley, VP of Value-Based Care at Navina
In 2025, we can expect sustained momentum for value-based care, driven by advocacy groups pushing for a full transition and strengthened by bipartisan support. Medicare Advantage (MA) will likely see expanded backing, further solidifying its role as a cornerstone of value-based care. As MA enrollment grows and more plans embrace risk-sharing models, this sector will continue to drive innovation and demonstrate the tangible benefits of value-based approaches. While there may be concerns regarding the Affordable Care Act (ACA), its survival seems likely given its established infrastructure and widespread reliance. It’s possible that a renewed focus on cost efficiency and quality improvement could lead to even greater integration of value-based care models within ACA programs.

Jeff Smith, CEO at Bamboo Health
In 2025, healthcare organizations will turn increased attention to high-need, high-cost patients—those with complex comorbidities, behavioral health challenges and chronic conditions—who often have a total cost of care approximately 5 times their counterparts. Traditional metrics like HEDIS and Star Ratings, along with fundamentals like value-based care, remain essential, but for payers and providers seeking to make meaningful improvements, the path forward lies in prioritizing this high-impact population. Addressing social determinants of health (SDOH), such as transportation or food insecurity, will be crucial for creating equitable outcomes. Proactive care models designed around these needs will uncover actionable insights, reduce costs, and improve outcomes.

Laura Copeland, MD, CMIO at Healthtech Consultants, a Nordic Global Company
Patient-centered care (PCC) will move from a buzzword to a fully integrated model that prioritizes cultural competency and addresses social determinants of health. Healthcare systems will prioritize responsive workflows and shared decision-making, ensuring every patient feels seen, respected, and engaged. They will adopt workflows and technologies that recognize the profound influence of culture, values, and lived experiences on health outcomes. Digital health strategies, such as AI-powered tools and personalized patient portals, will not only enhance access and engagement but also respect and incorporate cultural beliefs, particularly for marginalized communities. By focusing on both human connection and the social factors affecting health, such as housing, education, and access to nutritious food, PCC will create a more equitable, compassionate, and effective healthcare system for all.

Sami Inkinen, Co-Founder and CEO at Virta Health
While healthcare AI has focused primarily on diagnosis and automating back office and support tasks, 2025 will mark a pivot toward AI-powered care, such as behavioral modification platforms that deliver personalized, adaptive lifestyle interventions. Evolving far beyond simple health tracking, new AI systems will leverage broader data sets to drive predictive, proactive interventions. This technology will drive behavior change at scale, making lifestyle approaches the most successful and scalable treatments for chronic illnesses.

Andrew Hines, Chief Technology Officer at Canvas Medical
There will be continued investment in the capacity and effectiveness of mental health care providers in 2025. We’re nowhere near the mental health supply capacity we need as a country, but with the vast investments in online mental health services, the demand is closer to being met and opens the door to addressing related conditions. So many health conditions involve mental and behavioral components, and continued effort here will be good for everyone.

Ed Jen, VP of Product, Patient Care Solutions and Platform at Interwell Health
Medical innovation, new medications, therapies, diagnostics, and devices have outpaced our healthcare payer system’s ability to pay for it, leading to an unsustainable healthcare system. In 2025, we will see more health leaders begin to realize the potential of value-based care as one of the only ways to reverse the uncontrolled growth in costs and make healthcare sustainable. More providers and payers will embrace these new models and with it accelerate digital transformation in healthcare that we have already seen in other industries.

Robert Connely, Global Market Leader for Healthcare at Pega
In 2025, AI will be the catalyst that transforms value-based care from a pilot initiative to a standard model across healthcare. By automating administrative tasks, effectively delivering truly real-time, personalized patient insights, and optimizing resources, AI will empower providers to focus on proactive, long-term patient outcomes rather than fee-for-service transactions. Machine learning models will track and evaluate real-world patient data and outcomes against financial value metrics supporting outcomes-based contracts while also detecting anomalies and potential fraud.

Generative AI can personalize patient education, tailoring information to each person’s needs and comprehension. Conversational AI chatbots can answer questions, reinforce learning, and provide reminders, helping patients stay engaged and follow their care plans. This shift will enable providers to deliver higher-quality care at lower costs, for any and all patients, not just the sickest or most costly, reshaping reimbursement models and making value-based care the dominant approach for improving outcomes and controlling healthcare costs.

Michael Poku, MD, MBA, Chief Clinical Officer at Equality Health
In 2025, Value-Based Care will reach a pivotal crossroads, especially for Medicaid populations. As we head into the new year, we face a stark disconnect between Medicaid reimbursement rates and the high acuity of patient needs, a gap widened by the end of the Public Health Emergency and Medicaid unwinding. Bridging the gap will require forward-thinking care models that leverage data science, advanced technology platforms, and Social Determinants of Health (SDoH) services.

On the technology front, near real-time data sharing, seamless interoperability, and predictive analytics will be more important than ever before to effectively meet the challenging needs of America’s most complex patients. As these new care models evolve and mature, they will accelerate the shift from fee-for-service, empowering providers from independent PCPs in disinvested communities to large health systems — to deliver proactive and holistic quality care to historically marginalized patients and everyone.

Jonathan Shoemaker, CEO at ABOUT Healthcare
In 2025, patient experience will be redefined by AI-driven tools that enable providers to deliver tailored engagement and simplify the patient journey. These healthcare operational systems will anticipate patient movement needs, guide complex care processes, and deliver actionable insights to manage the acute patient journey proactively. By reducing administrative burdens and enabling seamless communication, patient flow tools will enhance provider satisfaction and build loyalty ultimately improving the patient experience. This personalized, intuitive approach will improve outcomes while supporting healthcare organizations’ shift to value-based care.

Thank you so much to everyone who took the time out of their day to submit a prediction to us and thank you to all of you for taking the time to read this article! We could not do this without all of your support. What do you think will happen for Value-Based Care, Social Determinants of Health, and Behavioral Health in 2025? Let us know on social media. We’d love to hear from all of you!

Be sure to check out all of Healthcare IT Today’s Value-Based Care, Social Determinants of Health, and Behavioral Health content and our other 2025 Health IT Predictions.