---
description: Four models compete for VBC dominance -- the integrated behemoth (Optum) the aligned partner (Devoted) the risk clearinghouse and the consumer health partner (Kaiser) -- with vertical integration winning on market share but facing antitrust headwinds that may favor partnership approaches
type: claim
domain: health
created: 2026-02-17
source: "SDOH/VBC research synthesis February 2026; Healthcare Dive Optum pricing study; DOJ antitrust investigations 2025; Devoted Health star ratings 2026"
confidence: likely
sourced_from:
- inbox/archive/health/2026-03-22-openevidence-sutter-health-epic-integration.md
---

# four competing payer-provider models are converging toward value-based care with vertical integration dominant today but aligned partnership potentially more durable

The competitive landscape for value-based care is consolidating around four structural models:

**The Integrated Behemoth** (Optum/UnitedHealth Group): The payer acquires and owns the provider network, PBM, pharmacy, and analytics stack -- achieving vertical integration through acquisition. Optum manages 4.7 million VBC patients, with $31 billion in provider acquisitions over two years. The model promises operational efficiency by keeping money in-house, but in practice a significant share of the profit comes from two arbitrage mechanisms: (1) retrospective chart reviews through owned providers to inflate CMS risk scores, and (2) above-market intercompany payments that game MLR requirements (UHC pays Optum providers 17% above competitors, rising to 61% in concentrated markets, shifting money between subsidiaries without real cost). DOJ antitrust probes are active. CVS/Oak Street ($10.6B acquisition) and Humana/CenterWell follow the same acquisition-based pattern. Kaiser/Risant ($3B capital commitment) is a different case -- Kaiser's integration is purpose-built and predates the acquisition era.

**The Aligned Partner** (Devoted Health model): The payer builds its own technology platform and care delivery capability from scratch (purpose-built full-stack integration) while also integrating deeply with independent providers through VBC contracts, shared technology, and aligned incentives. Unlike the Integrated Behemoth, this model does not rely on acquiring existing provider groups -- it preserves the provider ecosystem while augmenting it with AI-native tools. Lower antitrust risk and no dependence on coding arbitrage for profitability, but requires sustained trust-building. Devoted's 4.19 weighted star rating and 121% membership growth demonstrate the model can achieve quality outcomes through genuine care coordination rather than revenue engineering.

**The Risk Clearinghouse** (emerging): A platform enables risk-sharing between payers and providers without ownership. Technology-mediated, capital-light. Agilon Health attempted this but collapsed ($10B to $255M market cap) -- the model requires structural advantages beyond technology enablement.

**The Consumer Health Partner** (Kaiser evolution): Community-based, member-centric organization managing total health over a lifetime. The most transformative but requires the longest runway and deepest integration.

These four organizations plus subsidiaries comprised 70% of terminated MA plan members in 2025, indicating consolidation among winners. The structural question is whether acquisition-based vertical integration's market share advantage survives growing regulatory pressure (CMS chart review exclusion, antitrust enforcement, MLR scrutiny), or whether purpose-built and aligned models prove more durable at comparable outcomes.

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Relevant Notes:
- [[value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk]] -- the VBC transition these models compete to deliver
- Devoted Health proves that optimizing for member health outcomes is more profitable than extracting from them -- Devoted's specific competitive position within the aligned partner model
- [[healthcare is a complex adaptive system requiring simple enabling rules not complicated management because standardized processes erode the clinical autonomy needed for value creation]] -- the aligned partner model preserves clinician autonomy that vertical integration may erode
- [[CMS 2027 chart review exclusion targets vertical integration profit arbitrage by removing upcoded diagnoses from MA risk scoring]] -- CMS regulation specifically targeting the Integrated Behemoth model's coding arbitrage, which may accelerate the shift toward aligned partnership
- [[Devoted is the fastest-growing MA plan at 121 percent growth because purpose-built technology outperforms acquisition-based vertical integration during CMS tightening]] -- competitive evidence: Devoted growing 121% while UHC sheds 1M members and Humana faces $3.5B star headwind
- Devoteds Orinoco platform eliminates healthcare data silos by building a unified AI-native operating system from scratch rather than assembling from legacy components -- the technology architecture enabling the aligned partner model: purpose-built integration vs assembled-through-acquisition integration
- [[anti-payvidor legislation targets all insurer-provider integration without distinguishing acquisition-based arbitrage from purpose-built care delivery]] -- both proposed bills would ban the Integrated Behemoth and Aligned Partner models equally, failing to distinguish the structural abuse from the structural benefit
- [[Kaiser Permanentes 80-year tripartite structure is the strongest precedent for purpose-built payvidor exemptions because any structural separation bill that captures Kaiser faces 12.5 million members and Californias entire healthcare infrastructure]] -- Kaiser's Consumer Health Partner model is the strongest precedent for preserving purpose-built integration through regulatory cycles

Topics:
- health and wellness
