From Value-Based Care to Whole-Person Care

Licensed nurses and medical assistants spend 6.1 hours per physician per week entering information into the medical record for no reason other than external quality reporting. Network and provider contracting teams did not intend that. They wrote it, one reasonable measure at a time.

By RaeAnn, Founder and Chief Executive Officer, HLTHWORKS

What the contract asks for today

Strip the language out of most value-based and at-risk agreements and four objectives remain. Lower inpatient admissions. Lower emergency utilization. Recapture risk adjustment codes. Close Star and HEDIS gaps.

Each is defensible. Together they produce a list of demands passed through to the medical group, and most groups cannot ingest the volume. Action requests arrive faster than anyone can work them. Alerts accumulate in the electronic health record until the practice stops reading them.

What the physician does with the time is the part worth sitting with. Minutes that should address the care need in front of them go instead to documenting chronic conditions the patient already has, and to recommending screenings that may or may not change that patient’s outcome. The visit is reshaped around the contract rather than around the person.

That is not a failure of execution. It is the design working as written.

What it costs on the other side of the table

Weill Cornell and the Medical Group Management Association measured the burden in 2016. Practices spent 15.1 hours per physician per week on external quality measures, or 785 hours per physician per year, at roughly forty thousand dollars per physician and 15.4 billion dollars across four specialties.

Two findings inside that number matter more than the headline.

The physician is not carrying it. Of the 15.1 hours, the physician accounts for 2.6 and the staff account for 12.5. Licensed nurses and medical assistants alone spend 6.1 hours per physician per week entering information into the medical record for no purpose other than external reporting. The nurses and medical assistants absorbing value-based care are the ones nobody negotiates with.

And the practices did not think it was worth it. Eighty-one percent reported spending significantly more time on quality measures than three years earlier, and nearly three-quarters of groups reported that the measures were not clinically relevant.

That data is a decade old. Nothing since has reduced the number of measures directed at a practice.

Nurses and medical assistants are absorbing value-based care. They are the ones nobody negotiates with.

Artificial intelligence is not solving this

The reasonable hope is that ambient documentation tools absorb the burden. The evidence says they are helping, modestly, with a different problem.

A study of 1,800 clinicians across five academic medical centers between 2023 and 2025 found that ambient scribes saved about sixteen minutes of documentation time per eight hours of patient care. A separate study of 263 clinicians across six health systems found burnout falling from 51.9 percent to 38.8 percent after thirty days of use. Both are real gains and worth having.

Neither touches this. An ambient scribe documents the encounter. It does not close a care gap, reconcile a payer file, chase a risk adjustment code, or work an alert queue. And it does not help the nurse or the medical assistant, who carry five-sixths of the work and were never the intended user.

Sixteen minutes per eight hours against 15.1 hours per week is not a solution. It is a rounding adjustment.

And the list is often wrong

Health plans do not count a closed measure quickly. Published plan guidance to providers commonly states that gap closure through claims appears thirty to forty-five days after service, and that supplemental data submitted from the medical record reflects sixty to ninety days after it is sent. Plans reconcile quarterly, which suits the plan’s reporting and not the physician.

In the interval, the screening that was performed, the lab that resulted, and the prescription that was filled all continue to show as open. The practice is asked, repeatedly, to close what it already closed. Staff then cross-reference payer files against their own record to strip the false positives, and every payer sends a different file in a different format on a different schedule.

The staleness is structural. Where a plan runs claims on a thirty-day cycle and reconciles quarterly, the file is out of date on the day it is generated. A physician who has learned the list is frequently wrong stops trusting it, which is a reasonable response to a tool that has repeatedly been incorrect.

And almost no plan sets a ceiling on how many open items it pushes. The volume that reaches the practice is whatever the algorithm produces, and nobody in the plan is accountable for that number because nobody is asked to state it.

Why adding rarely works

Nineteen years ago RAND explained the mechanism that has repeated through every subsequent wave. Disease management programs encourage patients to follow up with their physicians but do not integrate with those practices, and without integration they add another layer to an already fragmented system. If the layer does not save cost, it may increase waste.

A vendor is contracted, a population is stratified, outreach begins, and the physician seeing the patient learns about none of it. The member receives messages from four organizations that do not know about each other and responds to one.

That was 2007, and it describes 2026. Business Group on Health surveyed 121 employers covering 11.6 million lives for its 2026 Employer Health Care Strategy Survey. Fifty-one percent are changing or issuing requests for proposal for health and well-being vendors, and forty-one percent are doing the same with pharmacy benefit managers, against a projected median trend of nine percent. The organization stated the reasoning plainly: employers must take a hard look at benefit offerings and eliminate those that do not deliver value.

The buyers have run the experiment long enough to price it.

Excellent at process. Last at health.

The Commonwealth Fund compared ten high-income countries across seventy performance measures in its 2024 Mirror, Mirror report. The United States ranked last overall, last on access, last on affordability, last on equity, and last on outcomes. Americans live the shortest lives and have the most avoidable deaths of the ten, with life expectancy more than four years below the group average. The report calls the United States the only clear outlier and describes it as in a class by itself in the underperformance of its health care sector.

Now the finding that should reframe this entire discussion. On care process, the United States is among the top performers. Care process is prevention, safety, coordination, patient engagement, and sensitivity to patient preferences. It is, almost exactly, the list of things our quality measures measure.

The Commonwealth Fund noted this as particularly interesting and suggested that value-based reimbursement models may be contributing to that strong care process performance, while observing that it does not translate into improved health outcomes.

Read that plainly. We built an apparatus to measure and reward process, the apparatus works, we are near the top of the world at process, and we are dead last at health. The 785 hours are not being wasted in the sense of producing nothing. They are producing exactly what we asked for, and what we asked for is not health.

We are near the top of the world at process and last at health. The measures are working. They are measuring the wrong thing.

The regulator has already said this

None of the above is a novel complaint, and it is worth being fair about that.

In February of 2023, six CMS leaders published a perspective in the New England Journal of Medicine proposing a Universal Foundation of quality measures. They wrote plainly that the agency administers roughly twenty quality programs, that the lack of alignment across them creates confusion and undue burden on clinicians and health plans, and that there is genuine tension between measuring everything important and reducing measure proliferation. The stated goal was more parsimonious measure sets, aligned across programs, moving over time toward outcome and patient-reported measures. Preliminary adult and pediatric sets were released, with add-ons contemplated for maternal, hospital, specialty, post-acute, and long-term care.

The CMS National Quality Strategy then set a success target: implement the Universal Foundation across all CMS quality and value-based programs, across the care journey, by 2026.

That year is now. And the practice experience described in this article has not changed in the way the target implies it should have. There is a straightforward reason, and it is the reason this article is addressed to contracting teams rather than to regulators. CMS can align the twenty programs it operates. It has no authority to align what a commercial payer writes into a private agreement.

So as federal measure sets converge, the remaining fragmentation increasingly sits in commercial and delegated contracts. That is not a policy problem anymore. It is a contracting problem, and it belongs to the people reading this.

The direction has since gone further. In May of 2025 the CMS Innovation Center published a new strategic direction built on three pillars: promoting evidence-based prevention, empowering people to achieve their health goals, and driving choice and competition. Read those against the argument in this article and they are the same argument. Prevention over activity. The person inside the arrangement rather than outside it.

One line in that strategy deserves particular attention from anyone drafting a measure schedule. Among the Medicare Advantage model features the agency said it might test are changes to quality measures that better align with promoting health. That is the regulator stating, in its own words, that the current measures do not.

Two other signals matter operationally. The Innovation Center has said it will require all models to carry downside financial risk and require providers to assume some of it, which raises the cost of a badly constructed measure schedule rather than lowering it. And the previous target of placing every Medicare beneficiary in an accountable care relationship by 2030 has not been carried forward. Breadth of participation is no longer the objective. Performance is.

What we should be building instead

The goal is not a better list. It is a shorter one, pointed at the whole person.

A contract should move from twenty or more competing demands to a single health and outcome aligned path, organized by life stage, that supports clinical and mental wellness together rather than treating behavioral health as a separate program with its own vendor and its own file. It should track and reward health and health outcomes, not the completion of administrative tasks that stand in for them.

It should also put the patient inside the arrangement. Today accountability runs between two parties. The plan holds the practice to a schedule, the practice absorbs it, and the person whose health is the subject of the entire exercise is never shown the scoreboard. They receive outreach calls from vendors they did not select and a benefit design that makes maintenance and prevention merely covered rather than genuinely easy to reach.

Shared accountability means three parties, each with something they owe. The plan owes a shared view, a clean file, a stated limit, and funding for coordination. The practice owes action on what the shared view surfaces. The patient owes engagement that the benefit design has actually made possible. Where accountability runs in one direction, which is how nearly every contract currently reads, the other two parties will optimize around it.

This is a smaller change than it sounds. It does not require a new payment model, new technology, or a pilot. It requires a shorter schedule, a cleaner file, a stated limit, and a benefit design that agrees with the measure schedule instead of contradicting it.

Six rules for a simpler schedule

ONE. EIGHT TO TEN MEASURES, MATCHED TO THE PANEL.

Not thirty. A pediatric practice does not need cancer screening and a geriatric panel does not need lead screening. Select from the life stages the panel actually contains. The appendix organizes thirty-one measures for exactly this purpose, and no single contract should carry all of them.

TWO. COUNT THE CLOSE WHEN IT HAPPENS, NOT WHEN THE PLAN CATCHES UP.

Commit contractually to an ingestion interval, accept the practice’s medical record as evidence of closure, and suppress the alert on receipt rather than at quarterly reconciliation. A physician who has learned to ignore the list will keep ignoring it after it is fixed.

THREE. SET A CEILING ON OPEN ITEMS PER PHYSICIAN.

State the number in the contract. If the alert system generates more, the plan prioritizes and sends the top of the list rather than all of it. No plan currently offers this, and every practice has wanted it.

FOUR. AT LEAST TWO MEASURES THAT SIGNAL A TURN.

Most schedules consist entirely of measures confirming something was completed. A schedule with no alert measures cannot support a watch list, which means the arrangement can only report performance after the year in which it could have been changed.

FIVE. ALIGN THE SPECIFICATION, NOT JUST THE CONCEPT.

Two payers measuring diabetes control differently create two workflows. Where a national specification exists, use it unmodified, and where a measure appears in the CMS Universal Foundation, adopt that version rather than a house variant. Custom specifications are the largest avoidable contributor to those 12.5 staff hours, and they are the one form of burden a single contracting team can remove unilaterally.

SIX. ONE LINE THAT FUNDS THE COORDINATION.

A per-member-per-month payment for orchestration, not contingent on shared savings and not tied to a program. It funds the shared view and the connective work between parties, and its absence is why the layers stay parallel.

The limit worth naming

There is a hard constraint on rule four. Nearly every measure available today is retrospective, asking whether something happened by the end of a measurement year. That is a compliance architecture, not a watch list.

A watch list needs leading indicators. Rate of change in blood pressure rather than a threshold in December. A first missed refill rather than an adherence ratio at year end. A decline in gait speed rather than a fall that already happened. Almost none of that exists as a standardized, contractible measure, which is the honest reason organizations keep buying programs instead. It is easier to procure a vendor than to specify a measure nobody has written.

One signal is worth noting for anyone drafting now. Care for Older Adults, Functional Status Assessment returns to the Medicare Advantage Star Ratings for 2027 as a new measure. The program is moving toward function as a rated outcome, and contracts written this year should meet that direction rather than lag it.

The shift that has to happen

Article 05 defined HealthSpan as measured function and capacity across a whole life. Article 06 argued that whole-person care is the only framing that matches how people get sick and stay well. Neither argument reaches a patient except through a contract.

The purpose here is larger than a shorter measure schedule, and it is worth stating directly. As an industry we have to move from administrative jumping jacks and regulatory metrics to a shared focus on healthspan, and that shift has to happen in four places at once. In provider contracting, so the practice is asked for the right things. In benefit design, so the member can reach them. In care management, so the work is coordinated rather than layered. And in regulation, so the measures that plans are rated on describe health rather than activity. Changing one without the others produces what we have now, which is a system that performs process beautifully and produces health poorly.

Strategy documents are written by people who do not draft contracts, and contracts are drafted by people rarely asked what the strategy requires. The gap between them is where whole-person care has been dying for twenty years, quietly, in measure schedules nobody reads end to end.

Contracts are also the most editable document in healthcare. What is missing is not permission or capability. It is someone counting what the current schedule asks a practice to carry, and asking whether that list would produce health if every item on it were achieved. In most organizations it would not, and any contracting team can establish that in a week with its own files.

APPENDIX

A Shared HealthSpan Measure Set

Every measure below is currently specified and reported. Nothing here is invented. Sources are the 2026 Medicaid and CHIP Child and Adult Core Sets and the 2027 Medicare Advantage Star Ratings measure list. Each measure is classified by the work it does: it drives wellness, maintains it, or raises an alert that something in the HealthSpan trajectory requires attention.

This is a selection pool, not a contract schedule. Choose eight to ten matched to the panel the agreement covers, including at least two classified as Alert. Nothing here is invented. Sources are the 2026 Medicaid and CHIP Child and Adult Core Sets and the 2027 Medicare Advantage Star Ratings measure list.

Abbreviations. CCS indicates the Child Core Set, ACS the Adult Core Set, and Stars the Medicare Advantage Star Ratings.

BIRTHSPAN | BIRTH THROUGH AGE FIVE

MEASURE	SOURCE	FUNCTION	WHY IT BELONGS
Well-Child Visits in the First 30 Months (W30)	CCS	Drive	The contact points at which everything else in this phase is detected. Absence is itself the first alert.
Developmental Screening in the First Three Years (DEV)	CCS	Alert	The earliest reliable signal of a trajectory that diverges, and the phase where intervention returns the most.
Lead Screening in Children (LSC)	CCS	Alert	An environmental exposure with irreversible developmental consequence. Detection is the entire intervention.
Weight Assessment and Counseling for Nutrition and Physical Activity (WCC)	CCS	Drive	Establishes the nutrition and activity trajectory that determines chronic onset thirty years later.
Childhood Immunization Status (CIS)	CCS	Maintain	Population protection. Voluntary for 2026 Core Set reporting but retained here as clinically foundational.
Topical Fluoride for Children (TFL)	CCS	Drive	Oral disease is the most common chronic condition of childhood and the most preventable.
Live Births Weighing Less Than 2,500 Grams (LBW)	CCS	Alert	A whole-life risk marker set before the first well-child visit occurs.

DEVELOPMENTSPAN | AGES SIX THROUGH TWENTY

MEASURE	SOURCE	FUNCTION	WHY IT BELONGS
Child and Adolescent Well-Care Visits (WCV)	CCS	Drive	The only routine touchpoint in a phase where most divergence is behavioral rather than clinical.
Screening for Depression and Follow-Up, Ages 12 to 17 (CDF-CH)	CCS	Alert	Adolescent onset predicts adult course. The follow-up requirement is what distinguishes this from a checkbox.
Follow-Up After ED Visit for Mental Illness, Ages 6 to 17 (FUM-CH)	CCS	Alert	An emergency visit is the loudest signal a system receives and the one most often unanswered.
Follow-Up After ED Visit for Substance Use, Ages 13 to 17 (FUA-CH)	CCS	Alert	Same logic, and the phase in which the trajectory is still most reversible.
Follow-Up Care for Children Prescribed ADHD Medication (ADD)	CCS	Maintain	Tests whether prescribing is accompanied by management. A prescription without follow-up is an unmanaged risk.
Asthma Medication Ratio, Ages 5 to 18 (AMR-CH)	CCS	Alert	A ratio that shifts toward rescue medication is a leading indicator, not a retrospective one.
Metabolic Monitoring for Children on Antipsychotics (APM)	CCS	Alert	Iatrogenic metabolic risk introduced in adolescence and carried for life.
Sealant Receipt on Permanent First Molars (SFM)	CCS	Drive	A single intervention with decades of effect, delivered in a narrow window.

VITALSPAN | AGES TWENTY-ONE THROUGH SIXTY-FOUR

MEASURE	SOURCE	FUNCTION	WHY IT BELONGS
Controlling High Blood Pressure (CBP)	ACS	Maintain	The single highest-yield modifiable input to later-life function.
Glycemic Status Assessment for Patients with Diabetes (GSD)	ACS	Maintain	Determines whether the chronic phase is managed or merely diagnosed.
Breast, Cervical, and Colorectal Cancer Screening (BCS, CCS, COL)	ACS	Drive	Stage at detection is the outcome. Colorectal is respecified for 2027 with an expanded age band.
Screening for Depression and Follow-Up, Age 18 and Older (CDF-AD)	ACS	Alert	The most common untreated condition in the phase and a multiplier on every chronic condition beside it.
Initiation and Engagement of Substance Use Disorder Treatment (IET)	ACS	Alert	Measures whether identification led to treatment, which is where the pathway usually breaks.
Adult Immunization Status (AIS)	ACS	Maintain	Composite protection that carries directly into the next phase.
Prenatal and Postpartum Care (PPC)	ACS	Drive	Two HealthSpans are determined in this window rather than one.
Prevention Quality Indicators 01, 05, 08, 15	ACS	Alert	Admissions that should not have happened. The clearest available evidence that maintenance failed upstream.

PRESERVATIONSPAN | AGE SIXTY-FIVE AND ABOVE

MEASURE	SOURCE	FUNCTION	WHY IT BELONGS
Care for Older Adults, Functional Status Assessment (COA-FS)	Stars	Alert	Returns to Star Ratings for 2027 as a new measure. Function is the substance of HealthSpan and this is the closest rated proxy.
Reducing the Risk of Falling	Stars	Alert	Falls are the pivot event between independence and decline, and the risk is assessable before the event.
Transitions of Care	Stars	Maintain	The interval in which most avoidable harm and most avoidable cost occur together.
Medication Reconciliation Post-Discharge	Stars	Alert	The specific mechanism by which a transition failure becomes a readmission.
Plan All-Cause Readmissions	Stars	Alert	The outcome that confirms the transition was not managed.
Medication Adherence, diabetes, hypertension, and cholesterol	Stars	Maintain	Three of the few measures where a first missed refill is observable in near real time.
Polypharmacy, Multiple Anticholinergic Medications (Poly-ACH)	Stars	Alert	New for 2027. Directly implicated in cognitive decline and fall risk.
Concurrent Use of Opioids and Benzodiazepines (COB)	Stars	Alert	New for 2027. A prescribing pattern with acute mortality risk.

A NOTE ON ACCURACY

Measure sets change annually. The 2027 Medicare Advantage and Part D final rule, published April 6, 2026 and effective June 1, 2026, removes eleven measures beginning with the 2027 Star Ratings, including Care for Older Adults, Pain Assessment. Several Core Set measures moved between mandatory and voluntary reporting for 2026. Confirm every measure against the current CMS Core Set measure lists and the 2027 Advance Notice measure table before writing any of this into a contract.

Also in The Standard

Article 05. HealthSpan. The framework this measure set is organized against.

Article 06. Whole-Person Care. Why the framing matches how people actually get sick and stay well.

Resource. A Shared HealthSpan Measure Set, available as a standalone reference at hlthworks.com.

HLTHWORKS transforms Medicare Advantage, Commercial, and Medicaid health plans, driving efficiency in the business of health, impact in the value and quality of care delivery, and simplicity in the patient journey.