At the Association for Value-Based Cancer Care conference in October, I participated in a panel on the sustainability of capitation in oncology. The consensus was simple: success demands collaboration between payers and providers, actuarial pricing and reconciliation accuracy and above all, transparency between those who hold the risk and those who deliver the care.
What Capitation Really Means in Practice
Capitation, at its core, means taking accountability for the total cost of care over a defined period—often measured per member per month (PMPM) or against a medical loss ratio (MLR) target. It’s not an episode of care, and it’s not a short-term cost control exercise. It’s a continuous balancing act between fair pricing, measurable outcomes, and enough flexibility to accommodate what no one can forecast: the next wave of new therapies, diagnostics, and patient needs.
When a provider enters a capitated contract, they effectively become an insurer. They’re responsible not only for delivering care but for managing the financial outcomes tied to that care. To do that effectively, they need actuarial insight, reliable data, and infrastructure that lets them see and act on performance.
That’s where many models falter. Capitation isn’t unsustainable because the math doesn’t work, it’s unsustainable when the math is unclear. Pricing risk without credible data, or measuring performance without shared transparency, creates a fragile system that erodes trust between partners.
What Capitation Really Means in Practice
Across sessions at AVBCC, a phrase kept coming to mind: the future of risk is math plus trust. Value-based care, whether fully capitated or a simple quality bonus program, works only when both sides operate from the same data and are incentivized toward the same outcomes. Mathematically, VBC sustainability depends on actuarial best practices: how well risk is priced, how effectively carve-outs and reinsurance are structured, and whether the model allows retrospective adjustment when trend outpaces forecast. But trust is what makes those mechanisms work in practice. It’s the confidence that payers and providers can interpret the same numbers, see them in real time, and act collaboratively rather than defensively.
Mark Cuban, who spoke about disruption through honesty, summed it up neatly: “Just tell the truth about prices and contracts, and everything starts to change.” That’s the same principle behind Arbital’s platform, creating neutral, shared visibility so that payers and providers can act on the same numbers, without hidden assumptions or delayed insights.
Oncology Is the Ultimate Stress Test
Nowhere is the challenge of capitation more visible than in oncology. Cancer care sits at the intersection of clinical innovation and financial uncertainty. Novel therapies arrive faster than most models can adapt, each bringing new cost structures, treatment durations, and patient outcomes.
To stay viable, oncology capitation requires flexibility: carve-outs for high-cost drugs, reinsurance for catastrophic cases, and retrospective trend adjustments that keep contracts fair even when the landscape shifts midstream. Actuarial precision isn’t optional, it’s the stabilizing force that keeps the model from collapsing under its own ambition.
The reward is predictability and, for providers, it can provide a greater opportunity to lead care delivery with greater autonomy. But those benefits only materialize when the deal structure supports both sides with clear terms, accurate pricing, and transparent data.
Redefining Quality Around Patient Goals
Another important shift in the discussion was how we define success. Traditional quality measures—utilization, readmissions, adherence— still matter, but they’re incomplete. Physicians at AVBCC emphasized a deeper form of quality: alignment with patient goals.
In oncology, where the treatment journey is often as personal as it is clinical, quality must include how decisions are shared, how outcomes align with what patients value, and how the system supports that human context. Capitation can enable that kind of care, but only when the analytics behind it preserve transparency and fairness.
Building Sustainable Partnerships
Every panel I attended circled back to one truth: value-based care doesn’t work on goodwill alone. Capitation only becomes sustainable when payers and providers operate as partners, not adversaries. That partnership is built through shared analytics, joint governance, and true understanding about how success is defined and distributed.
Capital investment and enablement remain prerequisites. Providers need actuarial and operational tools to manage risk confidently; payers need assurance that those systems can withstand real-world volatility. When both sides commit to data alignment and actuarial truth, trust follows naturally.
That’s why the “math plus trust” equation matters so much. Math makes risk measurable. Trust makes it actionable.
A Measured Path Forward
Capitation may never be simple, but it can be fair. It can create stability for payers, empowerment for providers, and better continuity for patients. That requires less focus on winning a contract and more on maintaining a relationship built on shared evidence and shared risk.
The next generation of value-based oncology models will succeed when three things align:
- Incentives that reward quality and stewardship equally.
- Data that both sides can rely on without translation.
- Pricing grounded in actuarial truth, not optimism.
At Arbital Health, our work sits at that intersection—combining transparent analytics, actuarial precision, and safeguards that allow providers to focus on care quality, not just cost containment.
Transparency isn’t just a principle; it’s infrastructure. When built into the system itself, it turns the math of risk into trust and trust into better care.
Learn how our value-based care actuaries can help your organization thrive in risk arrangements at ArbitalHealth.com/Learn-More >
Andrew Mackenzie
Chief Science Officer, Arbital Health
