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Family physician Jonathan Bushman discusses his article, “The hidden moral injury behind value-based health care.” He shares the story of a young physician who was told to remove her most complex patients from her panel to protect the health system’s performance metrics. Jonathan uses this powerful example to explain moral injury: a deep, ethical wound that is fundamentally different from burnout. The conversation exposes how value-based payment models, even in not-for-profit systems, can incentivize data manipulation and force doctors to choose between their patients’ well-being and their employer’s bottom line. He argues that this crisis of integrity is a primary reason many physicians are leaving employed positions for independent models like direct primary care (DPC), where they can answer directly to their patients instead of a spreadsheet. His core message is an urgent call to confront the reality that when “value” becomes code for “profitable,” the entire system’s moral compass is at risk.

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Transcript

Kevin Pho: All right. Welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Jonathan Bushman. He’s a family physician. Today’s KevinMD article is “The hidden moral injury behind value-based health care.” Jonathan, welcome to the show.

Jonathan Bushman: Thank you. Thanks for having me.

Kevin Pho: All right, so just tell us a little bit about your story, and then let’s jump right into your KevinMD article.

Jonathan Bushman: Sure. Absolutely. So this was a tough one. I had a colleague reach out to me who wanted to speak about her experiences. She’s two years out of residency, and she’s basically feeling a lot of feels in practice and trying to figure out her path. She prepared her life for this, and she’s going in and out of practice with her patients and loving the aspect of taking care of them. But she gets outside of the exam room and keeps getting told to do different things.

One of the things that just hit her on a different level, that she was just really wrestling with, was this idea that because of the value-based payment model that they’re under, a few of her patients who happen to have higher A1Cs were representing some bad data in her profile. The idea, which was given to her by a mid-level manager, was, “Perhaps you could just—we can just take those people off your panel, but increase your data, make your data look better, and you’ll be able to keep the biggest part of your payment through this value-based contract.”

And she was like, “No, there’s no way. You’ve got to be kidding, right? We’re not doing that. That’s unethical.” And she was very, very adamant. “That’s unethical. I’m not doing it.” And they said, “Well, OK.” They kind of let it go at the moment, and a few weeks later, she’s going through her panel. Patients now were listed as having no primary care provider. Of course, she throws a fit, and the first thing that was said was, “Well, they still can see you. We just don’t assign them to you so that you don’t get the bad credit for their A1Cs.”

And she’s sitting here going, “How does this make sense? How can—I don’t understand how they can do this.” And then I told her I’m in direct primary care. I’ve been in direct primary care for six and a half years. This is some of the stuff I ran away from, but I remember specifically, about ten years ago in a medical group meeting, with probably 50 physicians in the room, they described what value-based care was and these models that were coming out for payment and the enhanced payment if you could get the quality metrics. This was all kind of new to us at the time. I remember raising my hand in that meeting and I said, “How long before the smartest people in this room figure out how to get rid of the sickest patients?” Not that I was in support of that, just saying it is completely evident to me that’s exactly what’s going to happen here. And they said, “No, no, no, no. That’ll never happen.”

And then sure enough, you start seeing more and more of the pay tied to those metrics. And this really is the basis of that moral injury that we all talk about in burnout. The more you speak up about it, the more you become, quote-unquote, the problem in terms of the system. It’s just show up and shut up, right?

Kevin Pho: So for this physician fresh out of residency, you’re taught to take care of those sick patients, but in a way, you’re being told by people who focus on analytics that sometimes having that sicker panel isn’t necessarily beneficial in that value-based care model. For those who don’t understand why, who aren’t versed in the specifics of value-based care, why is it that having those sicker patients adversely skews the economics?

Jonathan Bushman: Yeah, so for the providers—and by the way, I’m not saying value-based care is all bad because there are a lot of really, really good things that it’s brought. But to say it’s “value-based care” is a really, really broad term. We don’t really know what that means until we look at the basis of the contract and the details. But if part of my compensation is tied to what you do, whether that’s through compliance or just you take good care of yourself and you meet these quality metrics, whether it’s your blood sugars or screening exams, et cetera, that relationship that we have with patients is first and foremost. And when we tie a portion of their outcomes or a portion of their choice and autonomy in their own care, now a third party has entered into that relationship and said, “This looks different. It feels different.”

I remember this specifically happening to me about eight years ago with a lady that had a very similar situation. She comes in, she doesn’t want any screening exams, she’s diabetic and really doesn’t want to take care of a whole lot. And you know what? As much as I loved her, I didn’t push her. I basically said, “Listen, I get it, but I will never get rid of you as a patient because you need me. I need to be here for you.” But something that really bothered me in that moment was that I looked at her differently—differently than I had the two years prior to that part of my contract being changed.

And that’s really, as I described in the article, that’s the moral injury. When we start looking at patients as transactional, as part of my metrics, part of these measurements that are tied back to my compensation versus just, “You are who you are. I’m going to respect that. I’m going to give you my everything. I’m going to always promote your health, but at the end of the day, you get to choose how you live.” Right? That’s autonomy. My job is to make sure that I provide the education, the tools, and the things that you need, whether that’s medications, referrals, et cetera. We are doing what we can to put the needs in front of the patient, and the patient gets to choose how they do that. But yeah, when we tie the payment to it, we’re really opening up this potential for looking at the patient differently.

Kevin Pho: And in your article, you make that distinction between moral injury and burnout. This example that we’re talking about, how quantifying patients and being incentivized to meet metrics, that’s a specific example of moral injury, right?

Jonathan Bushman: Exactly. Exactly. And I think people misuse the term burnout a lot. Burnout can happen everywhere. It does happen everywhere. But burnout really is just emotional exhaustion, right? Moral injury is different. And I think physicians get mislabeled as being burned out when honestly, they’re morally injured. When that happens, and I think this physician is going through this dilemma herself, she’s early in her career, still paying off debt, under contract, trying to figure out how to go forward with this.

She can’t ignore it. She can’t unsee it. She can’t unfeel it. Where does she go with this? And that’s the dilemma. It’s a moral dilemma for her. It’s like, “I almost have to participate in this, but I don’t feel right about it. Or I can just get out, but there’s going to be a huge cost for me to get out of that system.” And that’s the dilemma for them.

And that hurts. Moral injury truly is where you know that what you’re doing doesn’t align with your values. And that’s exactly where she’s at. In fact, she’s loving the rest of her career. She’s busy, she’s enjoying so many parts of it. But when you start to not believe in the system that’s been built around the relationships you’re building with patients, that’s hard to show up to.

Kevin Pho: Yeah, and there’s a certain amount of irony as well because this physician worked for a quote-unquote not-for-profit system. But being so focused on the financial incentives, it’s a little bit counterintuitive.

Jonathan Bushman: It really is. And it’s not unique to this system. It’s not unique to a lot of systems. And I think there have been quite a few writings. There have been great articles and books. I know Marty Makary’s book, The Price We Pay, highlighted this with nonprofit health systems—that sometimes they were actually the worst actors in the system. And the whole basis for a nonprofit organization is to benefit the community or to have specific beneficiaries. When patients get looked at as benefactors rather than the beneficiaries of health care, we have a problem.

Kevin Pho: So the whole point of value-based care is that we wanted to get away from that fee-for-service system where the more we do and the more patients that we see, the more the hospital will get paid. Now, in your opinion, by sharing this story, where do you think we went wrong when it came to implementing value-based care?

Jonathan Bushman: So, yeah, and a great little overview of value-based care. Of course, I mentioned I do direct primary care. That’s 100 percent capitation, 100 percent prospective upfront payment, right? Where fee-for-service is retrospective payment, all based on the code and the service. Value-based care is everything in between. You can have this little partial capitation, 10 percent capitation and 90 percent value-based. You could have 90 percent fee-for-service and 10 percent value-based. That’s why I say “value-based” is not real descriptive. We don’t really know what that means. If you’ve seen one value-based contract, you’ve seen one value-based contract.

The problem behind the system here is that the health system is working with bigger players, bigger payers. And these bigger payers are saying, “We want to know that the money being spent in your system is yielding outcomes,” and somebody has to come up with these measures. The trouble is the money flows from that entity through the health system, which then has contracts with its employed providers, and those contracts have different incentives.

So, in the case of this physician, a mid-level manager is trying to do their job, right? “Hey, I’m just trying to help you out. I’m trying to help you get a full paycheck. I’m trying to help you get that bonus.” But in essence, they’re really working for the system because the system’s under contract with some larger payer, and the physician is none the wiser. “I don’t know who these payers are. I don’t know if they’re insured or uninsured.” In many cases, they’re told not to care about that. But at the system level, those incentives have come from the top down, and sometimes even good intentions at the top level, by the time they get down to the exam room level, have been lost. And it affects those relationships that we all get into medicine for, the ones with patients.

Kevin Pho: Now, when confronted with that moral injury where those financial incentives interfered with your motivation for being a physician, you obviously chose to go in one direction, doing a direct primary care practice. What kind of advice did you give to that physician who shared that story with you? What did you tell her?

Jonathan Bushman: Well, in full disclosure, that’s kind of why they’re reaching out. It’s like, “Tell me why you went into this model. Did you go through the same things?” And she had a pretty good idea that I had, and she wanted to know the stories, like, what was this? I went back to that same meeting. I had this thought 10 years ago. This isn’t new; it’s new to you. You’re really experiencing this for the first time, and this almost this betrayal of everything you believed in about what you were getting into and that you’ve devoted the last decade of your life to get in the position to help people.

You’ve worked so hard to get there, and you’ve been taught to think independently and critically. And now you show up in your job and you’re told, “Don’t think about that. We’ll take care of that for you. We’ve got you covered.” It’s like, that hurts. That really hurts.

So the advice I gave to her was, “Listen, you did dedicate your life. You’re the one who made the sacrifices to get to the place where you have opportunities. And while you can continue to do what you’re doing, and I’m sure you can find the silver lining in everything and make a great career of it, perhaps you listen to your heart and you say, ‘Hey, what is it going to take for me to get closer to my patients?'” It doesn’t mean I’m anti this or anti that, but what do I have to do to be absolutely pro-patient? And I think in her case, she’s really leaning in that direction, saying, “You know what? If I could align the incentives directly with my patients like you have in this model, it just seems very attractive.” It’s very attractive from the emotional sense of care.

Kevin Pho: Now you’ve been doing direct primary care for a little while. Has it been the panacea that you expected? Has it been everything that you hoped it would be in terms of bypassing that moral injury that traditional health care systems place on physicians?

Jonathan Bushman: For me personally, absolutely. Do we still deal with a troubled system in many ways? Absolutely, we do. It’s kind of funny, I have a lot of colleagues that have gone into direct care that were really running away. They’re running away from the system as we know it. And then there are some that have run toward patients. I kind of feel like my experience was a little bit of both. I was ready to get away from what I was experiencing, but I was so ready to be closer to my patients, to not have those barriers, to have more time with them, and better relationships.

But I’ll tell you, there are a lot of good things I didn’t anticipate about direct primary care, like the feeling of being abused by patients. You get called after hours, people try to get free advice, or they stop you in the grocery store, all these things. And a lot of my colleagues, if they’re not at work, you don’t find them out in public. They don’t want to be in public; they don’t want to go to the grocery store. I love the grocery store. That’s where I get to see my patients being normal human beings, just shopping with their families. I love it. And if they have a medical question for me, because they’re members of the practice, that is not abuse, that is just absolute service. It doesn’t bother me at all. I never expected that. I was a little worried that with this unlimited access, they were just going to run over me, and that has not been the case. Not at all.

I’ve gotten to know them at a deeper level. They’ve gotten to know me at a deeper level. So you call this a panacea. I’ve never thought of it that way, but in many ways, it has become that. One of my teenagers asked me randomly a while back, we were driving down the road and she goes, “Dad, do you feel like you’re the very best doctor in town?” And I was like, “Whoa, hang on a second. Number one, no, I’d never think of myself that way.” I was curious why she was asking, but I kind of sat with that for a little bit and I said, “I’m the very best doctor I could be. I now can say that I’m the best doctor I’ve ever been.” And whether that compares to someone else or how it compares to someone else, I’m not really concerned. But I’m where I need to be. I’m doing what I need to do, and there’s nothing more gratifying than that for me.

Kevin Pho: We’re talking to Jonathan Bushman. He’s a family physician. Today’s KevinMD article is “The hidden moral injury behind value-based health care.” Jonathan, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Jonathan Bushman: Absolutely. I think for patients, recognize that there’s a human being behind the interaction with you as well. Physicians, in many cases, are feeling some pressures that are outside of the relationship you have with them. They may seem rushed, they may seem short, they may even seem like they’re a little pushy. Perhaps the relationship that you once had with them has degraded over time. And I want you just to consider that these are real human beings probably dealing with a whole lot more than what you see at a surface level. So show them some grace as we show our patients grace.

Know that there are questions you can ask them. There’s nothing more important and nothing I’m more grateful for than when patients walk in the room and stop before I can even start the visit and say, “Hey doc, how are you doing? How’s your family? What have you been doing recently?” I never used to get that. Relationally, we’re there now. But looking back, I think about where I came from and where I’m at now. And that would be my message to patients: take the time to ask your physician how they’re doing because they really are human beings that are feeling a lot of things. It may be distracting from your visit, but they care to be known as well.

For clinicians, I feel you. I’ve been there. I really, really hurt when I listen to physicians that have gone through what my colleague went through recently because I understand the feeling of that betrayal, that poll, the frustration, and the questions that it leads to. Know that you’re not alone. Also know that there are various different fixes, there are various different opportunities, and you did get into this career to make a difference in people’s lives. And if you’re in a current place where you don’t feel like you’re at your best and practicing your best, look for it. Create it. It exists, and you can go after a model of medicine that really is completely satisfying and fulfilling.

Kevin Pho: Jonathan, thank you so much for sharing your story and insight, and thanks again for coming on the show.

Jonathan Bushman: Absolutely. I appreciate you having me.