As value-based care continues its nationwide expansion, healthcare leaders are confronting an uncomfortable paradox: systems designed to improve outcomes may be eroding the very clinical time and therapeutic presence they depend on.
New survey data from Twofold Health highlights a growing disconnect between policy goals and day-to-day clinical reality. Among 446 mental health and primary care clinicians surveyed, more than one-third say documentation and patient progress tracking—not insurance—is their single biggest challenge. The finding signals a deeper structural problem as accountability expectations accelerate without equivalent investment in clinical infrastructure.
“The surprise is really a signal,” says Gal Steinberg, CEO of Twofold Health. “Clinicians have found ways to offload some insurance work to staff, but progress tracking is still treated like an add-on that lives in scattered portals, spreadsheets, and extra clicks.”
Progress Tracking Surpasses Insurance as the Top Pain Point
According to the survey, 36 percent of clinicians cite documentation and progress tracking as their most significant challenge, more than double the 15.5 percent who point to insurance-related issues. In an industry where reimbursement friction typically dominates conversations, the magnitude of the gap stands out.
Tracking patient progress has become “the price of admission” in value-based arrangements, Steinberg says, but without the operational scaffolding to support it. “Outcome documentation has become the price of admission, without equivalent investment in the day-to-day infrastructure to make it easy,” he explains.
Nowhere is this tension more evident than in mental healthcare. Measurement-based care is widely recognized as clinically valuable, particularly for tracking symptom improvement and treatment effectiveness over time. But when collection, scoring, interpretation, and documentation are disconnected from clinical workflows, those benefits give way to administrative drag.
“Especially in mental health,” Steinberg says, “measurement-based care is clinically valuable, but it can degrade into administrative work when collection, scoring, interpretation, and documentation are not integrated into the workflow.”
When Value-Based Care Meets Outdated Measurement Infrastructure
The intent behind value-based care, rewarding outcomes rather than volume, is broadly supported across the healthcare industry. Yet translating that philosophy into workable clinical processes has proven far more difficult.
“The goals of value-based care are reasonable,” Steinberg says. “Rewarding outcomes, not volume, makes total sense. It is the execution that falls short.”
He points to a widening gap between measurement expectations and the systems clinicians rely on to meet them. Standardized assessments, between-session task tracking, longitudinal progress documentation, and payer-specific reporting requirements are expanding rapidly, often without alignment across programs.
“In practice,” Steinberg says, “clinicians are asked to collect standardized measures, track between-session tasks, document change over time, and report it in formats that vary across payers and programs, often with duplicative or misaligned definitions.”
At the same time, federal policy is pushing more providers into accountable care models. CMS and the broader market are actively scaling participation toward 2030, raising the stakes for accurate, timely reporting, particularly for small and mid-sized practices that lack enterprise analytics teams.
The Hidden Cost of After-Hours Documentation
For many clinicians, the cumulative burden of progress tracking doesn’t end when the workday does. Survey respondents report spending two or more hours each night completing documentation that often feels disconnected from patient care.
“When documentation spills into nights, the first casualty is cognitive bandwidth,” Steinberg says. “Clinicians enter sessions already thinking about what they need to capture, which can subtly reduce therapeutic presence and listening quality, even for highly skilled providers.”
Research consistently shows that clinicians now spend more time on EHR and desk work than in direct face-to-face care, often adding one to two hours of “pajama time” after hours. Over time, this pattern fuels burnout and attrition.
“Long-term, this accelerates burnout,” Steinberg says. “Chronic ‘pajama time’ is closely tied to stress, lower job satisfaction, and attrition. The burden directly competes with the core clinical work.”
Clinicians feel the tradeoff acutely. As one therapist summarized in the survey: “I spend more time on administration than monitoring the patient.”
Measurement Isn’t the Problem—Implementation Is
Despite the frustration, most clinicians are not rejecting measurement-based care itself. Standardized outcomes and between-session work are widely seen as clinically useful when implemented well.
“Most clinicians don’t object to measurement in principle,” Steinberg says. “Standardized outcomes and between-session work can strengthen care when they are lightweight, clinically meaningful, and easy to act on.”
The breakdown, he explains, lies in manual processes and fragmented tools. Research on measurement-based care consistently identifies workflow, time burden, and tooling, not clinical skepticism, as the primary barriers to adoption.
“The practical fix is less about removing measures and more about making them flow,” Steinberg says. “We need patient-friendly collection, automatic scoring, trend visibility, and one-click documentation that closes the loop in the note and treatment plan.”
Without that integration, measurement becomes compliance work rather than clinical insight.
Why Medium-Sized Practices Feel the Pain Most
The survey reveals a pronounced spike in frustration among medium-sized practices. Nearly half of clinicians in organizations with 10 to 49 providers cite progress tracking as their top operational challenge.
“That pattern makes sense operationally,” Steinberg says. “They have enough scale to feel the pain, but they usually lack the enterprise infrastructure of very large organizations.”
Unlike solo practitioners, these practices manage higher patient volumes and greater variability. Unlike large health systems, they lack dedicated analytics teams, custom integrations, and formal measurement programs. Some administrative work can be delegated, but clinical measurement resists easy offloading.
“Clinical measurement cannot be fully offloaded because it requires context and judgment,” Steinberg says. “That creates a bottleneck that grows with volume.”
AI Scribes as a Signal, Not a Solution
One of the clearest signals of strain in the system is the rapid adoption of AI scribes. While often framed as productivity tools, Steinberg sees their popularity as a symptom of deeper structural imbalance.
“The adoption of AI scribes is a market signal that the system has been running on ‘documentation debt,’” he says. “Clinicians are buying back time simply to do the care they were trained to do—listen, think, and respond.”
For healthcare leaders, he argues, the takeaway should extend beyond faster note-taking. The reclaimed time must not be consumed by disconnected measurement tasks.
“It’s an opportunity to digitize the measurement layer,” Steinberg says. “Many of our users come for faster documentation, but the consistent follow-on request is help with progress tracking and outcomes workflows, so the regained time doesn’t get swallowed by disconnected measurement tasks.”
How Documentation Overload Worsens Access to Care
Patients experience the consequences of documentation overload indirectly, but profoundly. Long waitlists, shorter sessions, and rushed encounters are increasingly common in mental healthcare, even as demand continues to rise.
“Documentation overload definitely reduces access,” Steinberg says. “It shrinks capacity, increases turnover, and encourages shorter, more rushed visits to keep up with downstream work.”
Large portions of clinicians’ workdays are consumed by EHR tasks and after-hours documentation, leaving fewer appointment slots and accelerating burnout-driven attrition. Patients feel the effects without seeing the administrative root cause.
“When progress tracking is manual and fragmented, the hidden work expands, and access quietly deteriorates,” Steinberg says.
What Needs to Change for Value-Based Care to Work
Looking ahead, Steinberg emphasizes that value-based care has not failed because outcomes measurement is misguided, but because clinicians were asked to shoulder data responsibilities without adequate systems.
“Value-based care didn’t fail because outcomes measurement is wrong,” he says. “It stumbled because we asked clinicians to become data teams without giving them data systems.”
He identifies three changes that could rapidly reduce friction:
Measure alignment and simplification. Fewer measures, clearer definitions, less duplicative reporting, and greater reliance on patient-reported or passively captured data.
Interoperability that actually reduces work. Automated data exchange and streamlined prior authorization workflows. CMS’s Interoperability and Prior Authorization Final Rule is “directionally important,” Steinberg says, because it explicitly targets burden reduction.
Funding measurement infrastructure. If outcomes tracking is required, policy must also fund the tools and integrations needed, particularly for small and mid-sized practices, to comply without sacrificing clinical time.
As accountable care participation continues to scale toward 2030, the stakes are rising. Whether value-based care ultimately improves outcomes may depend less on policy intent, and more on whether the industry finally modernizes the measurement plumbing beneath it.
For more information, visit trytwofold.com.
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Daniel Casciato is a seasoned healthcare writer, publisher, and product reviewer with two decades of experience. He founded Healthcare Business Today to deliver timely insights on healthcare trends, technology, and innovation. His bylines have appeared in outlets such as Cleveland Clinic’s Health Essentials, MedEsthetics Magazine, EMS World, Pittsburgh Business Times, Post-Gazette, Providence Journal, Western PA Healthcare News, and he has written for clients like the American Heart Association, Google Earth, and Southwest Airlines. Through Healthcare Business Today, Daniel continues to inform and inspire professionals across the healthcare landscape.
