Car­ri­ers paid accord­ing to Rea­son­able and Cus­tom­ary fees.  Then they nego­ti­at­ed dis­counts and called them Pre­ferred Provider Orga­ni­za­tions.  Now they are tak­ing advan­tage of a new trend toward val­ue based reim­burse­ment.  Unit­ed­Health, the largest med­ical insur­ance car­ri­er in the coun­try, has announced that they will increase val­ue based pay­ments to doc­tors and hos­pi­tals by 20% — which trans­lates to more than $43 bil­lion.  Val­ue based pay­ments include pay for per­for­mance, patient cen­tered med­ical homes and Account­able Care Orga­ni­za­tions, all of which have been gain­ing favor on their own – now Unit­ed­Health can use all of them.  The changes keep on coming…along with provider pressure.