The Unintended Consequence of Value-Based Care

Value-based care is no longer a policy experiment. It’s becoming the foundation of American healthcare, with nearly half of hospitals now participating in value-based arrangements.The model saw 25% growth in provider participation last year alone. The core idea remains sound: reward clinicians for patient outcomes, not service volume, making healthcare accountable for results.

But as value-based care expands across the system, we’re discovering a critical flaw in how we’ve implemented it. We mandated that clinicians measure patient outcomes without building the infrastructure to actually do so. We required documentation of progress without providing tools, and layered measurement requirements on top of an already overwhelming administrative burden. The result has left clinicians drowning in the mechanics of measurement when they should be focused on treatment.

The irony is devastating. Value-based care is growing precisely because we want to improve patient outcomes. We believed measurement would drive better care. Instead, we’ve created a system where clinicians have less time with patients, at a time when this model is becoming the standard for how healthcare operates.

The Wrong Problem Keeps Getting Solved

When I founded Twofold, I believed the primary burden of documentation was transcription. Clinicians were typing endless notes instead of seeing patients. If we automated note-taking, they would have more time for care. It was a correct diagnosis of the wrong problem.

The transcription burden is real. Our AI scribe saves clinicians 30 – 45 minutes daily. They are also reporting lower burnout rates and more patient time. While that matters, our recent survey shows clinicians who are using these tools are still drowning.

Why? Because the real crisis is measurement. Here’s a typical example: A therapist administers the PHQ-9 depression scale for high-risk patients. Then they may assign homework and track whether patients complete it. They are also monitoring whether symptom scores are improving. If you’re a primary care physician, you’re also tracking blood pressure logs, A1C trends, medication adherence, and lifestyle modifications. All of this must be documented, logged appropriately, and analyzed.

This is clinically necessary work. Evidence-based care depends on systematic measurements, and many value-based care contracts include outcome and quality reporting requirements. That leaves clinicians stuck in spreadsheets and disconnected patient portals, manually tracking data that should be automated.

In our recent survey, 107 clinicians (24 percent) specifically flagged standardized outcome measures as particularly burdensome. These are people already using AI documentation tools, so we know the transcription problem is being addressed. The measurement problem remains unsolved.

The Practice Size Reversal

Here is what troubles me most. Solo practitioners struggle with progress tracking at 35.8 percent. But in medium-sized practices with 10 to 49 clinicians, that number jumps to 47.5 percent. Insurance concerns drop from 16.8 percent to 2.5 percent.

Larger practices figured out how to delegate insurance work to billing staff, but they cannot delegate clinical measurement. As professionals, we know progress tracking requires judgment and is specific to each patient. The problem compounds as patient volume increases.

This means practices with the most resources are actually struggling more with progress tracking than solo practitioners. That reversal reveals something critical. Throwing more people at the problem won’t solve the challenge. What will fix the problem are better technology-based systems.

How Policy Outpaced Infrastructure

Administrative tasks already consumed 50 percent of physician time before value-based care expanded. Then the Centers for Medicare and Medicaid Innovation set a goal of transitioning 100 percent of Medicare beneficiaries to value-based arrangements by 2030. States followed, and commercial payers jumped in.

Nobody asked whether clinicians had tools to track outcomes at scale, or whether they would assess what would happen if you mandated measurement without building infrastructure. The   documentation burden wasn’t measured before creating new requirements.

We designed a policy that says: “You must measure whether your patients are getting better. Here are the consequences if you do not.” Then we gave clinicians spreadsheets and patient portals that do not talk to each other, and made their life-saving jobs more difficult.

When clinicians can reduce typing through AI tools, they gain time. Yet that time is immediately consumed by outcome tracking because the measurement infrastructure isn’t in place. It is like giving someone a faster car on a road with no destination. The result is clinicians spending less time in the room with patients and more time in the evenings documenting and measuring progress instead of being with their families. It is the very burnout we were trying to prevent.

What Actually Needs to Change

AI documentation tools like ours remove one layer of burden, gaining back valuable time. But it reveals the deeper crisis. When clinicians have more time, they do not use it to have a better work-life balance, see more patients, or earn more money. They use it to track whether their patients are actually improving.

Technology companies keep automating the surface layer while missing the real crisis. We built better transcription when clinicians needed better measurement. 

Reducing documentation time is part of the answer. The clinicians I speak with are not resisting value-based care because they oppose accountability. They are drowning in the mechanics of measurement and want tools that help them understand whether their treatments are working.

That means giving them access to tools that reduce the documentation burden and systems that make outcome tracking a natural byproduct of clinical work, not a separate administrative task consuming their evenings.

If we want value-based care to actually work, we need to make measurement work for clinicians. Otherwise, we have succeeded only in creating a healthcare system that is excellent at measuring failure while preventing success.