Value-based contracts (VBCs), or performance-based managed entry agreements, are regularly proposed as important instruments to achieving sustainable access to innovative medicines, but still few seem to be implemented. Various factors leading to the success or failure of VBCs have been reported in the literature. However, the standpoint has been mainly academic, with little insight into where the interested parties (pharma and payers) should focus their efforts to make these arrangements happen. This paper is revisiting the conceptual framework for VBCs to inject a needed dose of pragmatism, based on extensive experience of the authors in these approaches when working with payers and pharma companies. It will identify, in a structured way, the incentives and hurdles most heavily involved in successful VBCs, clarify when payers want to consider and pursue these agreements, and delve into attitudes to risk sharing and the dynamics of negotiation. To provide richness to the analysis, the EU and US markets will be contrasted, since their respective payer philosophies are distinct in various ways. The current practices of pricing and reimbursement/coverage in both markets will first be considered. Changes needed in the ways of thinking and infrastructure will then be proposed: among others, these include consortium/partnerships approaches to build integrated, suitable data platform (e.g. to support indication-based pricing) or (in the US) finding practical ways to bridging from traditional formulary-based contracting to (truly) value-based contracting. The thesis will conclude with a summary of ‘best scenarios’ to illustrate the roadmap to more consistent and sustainable use of VBCs