Redefining Value-Based Care Through Medicaid-Centered Innovation: Q&A with Dr. Sherri Onyiego

You’re absolutely right—Value-Based Care has become something of a buzzword in our industry, and its meaning can vary depending on who you ask. Some are even walking away from the term, not abandoning the concept, but rethinking the language and its application.

For Equality Health, Value-Based Care is at our core. It’s about shifting the focus from the entrenched fee-for-service volume-based model in America to quality care. VBC is an alternative payment model that is also transforming how care is delivered. It emphasizes proactive, coordinated, and patient-centered care, often involving care teams, data-driven decisions, and integrated services. The resulting care model shifts clinical approaches, where clinicians work proactively to improve people’s health outcomes – and population health – while also enhancing patient and provider experiences and reducing unnecessary costs.

At its core, VBC is about putting the patient at the center and rewarding providers for quality care, prevention, and chronic disease management. It’s a proactive model with a biopsychosocial approach, where we address social determinants of health (SDoH), as well as their complex interactions, to better design and coordinate healthcare delivery. When done right, it empowers providers, especially those in primary care, to build lasting relationships with their patients and address their needs in a more holistic, culturally relevant, and coordinated way.

First, it’s important to note that Equality Health has a Medicaid-first model, and we are a VBC enablement organization focused on helping independent Primary Care Providers (PCPs) to be successful in VBC.

We are deeply focused on closing care gaps and eliminating health inequities by transforming the healthcare experience for underserved communities, especially those covered under Medicaid. We focus on simplifying VBC for PCPs by delivering the resources, tools, and support they need to thrive in VBC environments.

Our enablement support to PCPs includes: risk-bearing financial support; CareEmpower, a proprietary VBC technology platform offered at no cost to in-network provider; practice performance managers, dedicated experts who train staff in cultural competence and CareEmpower, while consulting on ways to streamline clinical operations and create new proactive workflows; and community care teams.

A key differentiator is our community care teams, which include community health workers, care coordinators, nurse practitioners and even chaplains, who are extensions of the PCP’s clinic to work directly with patients and help navigate them through the complexities of the healthcare system. They also addressing SDoH—things like transportation, housing, food insecurity. This model strengthens the provider-patient relationship and ensures care is personalized, comprehensive, and equitable.

Primary care providers are the gatekeepers for managing complex conditions but are often under-resourced to fully implement alternative payment models such as VBC to their patient populations. Equality Health offers resources to help providers as they transition from Fee-For-Service to VBC by offering technology solutions, staffing needs, and clinical best practices. More specifically, the aforementioned resources are designed to set practices up for solution-oriented success by optimizing practice transformation workflows, conducting proactive panel management, panel attribution and risk stratification, determining patient engagement levels as well as deploying care coordination capabilities.

We believe enablement is everything in VBC and the specific space in which we work — Medicaid. You can’t expect PCPs to succeed in a new model without giving them the tools and support to thrive. At Equality Health, we view our role as an enablement partner. We don’t just hand PCPs a playbook—we’re on the field with them, helping them execute every day with technology, as well as the people to assist with clinical coaching, change management, as well as our community health team.

We provide a range of services to support PCP’s transition into VBC. That includes actionable data analytics through our platform, CareEmpower, to give providers insights into their patient populations.
We help them identify care gaps, understand performance metrics, and make data-driven decisions that change clinical workflows, drive a proactive care approach and improve outcomes. We offer hands-on coaching through Practice Performance Managers who work closely with clinics.

This full-spectrum of enablement services allow PCPs to stay independent, deliver high-quality care, and succeed financially in VBC contracts.

Medicaid populations are often the most vulnerable in our healthcare system, and historically, they’ve been underserved, overlooked and the costliest. There are many VBC organizations focused on Medicare and making the new payment model work for the senior population.

Focusing on Medicaid is a matter of health equity. These individuals face greater barriers to care including transportation issues, financial stress, housing instability, language barriers, a fear or cultural unacceptance of the healthcare system, among many others.

By focusing on Medicaid, we’re addressing this massive gap in the healthcare system. These populations stand to benefit the most from better coordinated, culturally responsive patient-centered care. They don’t just need a doctor’s visit—they need a new system that understands their reality and supports them in their daily lives and challenges.

Equality Health was built with this mission in mind. Our approach isn’t just about reducing the cost — it’s about creating lasting, generational health improvements for communities that have long been left behind.

Equality Health uses several KPIs and metrics to measure the success of value-based care initiatives, a couple to highlight include but not limited to:
11% reduction in Emergency Department utilization
Five-star outcomes for patients navigating chronic diseases

We are growing our network, too. As of the end of 2024, we are enabling more than 4,100 primary care providers (PCPs) and covering 735,000 lives across Arizona, Texas, Tennessee, Louisiana, and Virginia—a 28% expansion in our provider network over 2023.

Our CareEmpower technology is helping prioritize hundreds of thousands of opportunities to close care gaps and optimize a practice’s patient outreach. In 2024, Equality Health Network providers administered just shy of 500,000 wellness visits to members across the country. We’ve seen increased engagement in preventive screenings and follow-up care.

Value-Based Care is not a one-size-fits-all solution—it has to be adaptable, equitable, and community-centered. At Equality Health, we believe in lifting up the providers who know their communities best and empowering them to deliver the kind of care that truly makes a difference. That’s how we’re transforming health outcomes—one neighborhood, one provider, and one patient at a time.