She is employed by a not-for-profit health organization, yet nothing about her account felt generous. A young doctor, just starting in her early career, she’s already confronted with a decision no physician should ever face: safeguard her patients or uphold the metrics that influence her employer’s revenue.

The core of the issue

This doctor operates within a value-based compensation framework. At first glance, it appears beneficial: Compensate doctors for improved outcomes instead of increased visits. However, in practice, these agreements frequently incentivize data manipulation and selective patient treatment to achieve performance benchmarks.

She recounted a discussion with a mid-level supervisor who assessed her quality data and proposed she “eliminate” certain high-risk patients from her roster. These were individuals with intricate needs—the ones she prioritized most. She declined.

Weeks later, those same patients were removed regardless. On paper, they were labeled as “no PCP” (no primary care provider). In reality, they lost the doctor who was unwilling to abandon them.

Her bewilderment goes deeper since she is part of a not-for-profit health system—an entity that, in principle, is meant to assist the most needy. “Why would they do this for financial interests?” she inquired. It’s a query I couldn’t address without highlighting the clear truth: Even nonprofits have financial targets, and value-based agreements yield better payouts when the data appears pristine.

Moral injury differs from burnout.

She is still early in her career, and while she enjoys most aspects of her job, this betrayal of her ethics has unsettled her. She’s left contemplating: Is this what my career will entail for the next 20 years? Can I remain in a system that penalizes me for making the right choices?

This represents moral injury. It transcends mere fatigue or burnout. It’s the profound hurt that occurs when a physician is compelled to act against their principles or observe the system doing so on their behalf. And because doctors are often fairly compensated, raising concerns about this can come across as grievances. But moral injury isn’t related to finances—it’s about maintaining integrity.

This is why numerous primary care doctors are transitioning from employed roles to independent models like direct primary care (DPC). We’re not hostile toward hospitals or insurance—we’re focused on patients. In DPC, I am accountable directly to my patients, not to a payer or a metric. It’s not centered on optimizing metrics. It’s about rebuilding the connections that give healthcare its significance.

When you notice physicians in your community shifting to DPC, understand this: They’re not departing from medicine. They’re moving toward a form of it that hasn’t compromised its inherent purpose.

Healthcare is filled with dedicated individuals who uphold strong ethics. However, the financial frameworks surrounding them—yes, even within “not-for-profit” systems—are skewing the mission. Value-based care isn’t inherently detrimental, but when “value” turns into a synonym for “profit,” patients suffer.

It’s time to address this. Doctors require safe environments to voice their concerns, and health systems need to recognize that no quality metric is worth the sacrifice of a physician’s ethical standards. If we desire improved care, we must cease compelling good doctors to choose between their patients and their salaries.

Jonathan Bushman is a board-certified family physician, health benefits advisor, and a fervent proponent of reimagining healthcare delivery. As the founder of Primed Healthcare, a physician-owned benefits agency, Dr. Bushman aids employers and employees in navigating a clear, trust-based approach to healthcare. He possesses extensive knowledge in direct primary care and employer-sponsored health plans, concentrating on solutions that harmonize physician-led care with cost-effective strategies. Dr. Bushman acts as a fractional chief medical officer and continues to foster innovation in health plan design. Through his leadership at Reliant Direct Primary Care and insights shared via LinkedIn, he strives to empower organizations with healthcare solutions founded on meaningful care rather than bureaucracy.