This article, titled “Reducing the value/burden ratio: a key to high performance in value-based care“, is authored by Patrick Runnels and Peter J. Pronovost. It was published in BMJ Quality & Safety in 2025, appearing online first on October 16, 2024.
The authors address significant defects in healthcare value in high-income countries, noting that one in ten patients experiences harm and nearly 13% of health expenditures are spent managing this harm. They highlight that half of patients with chronic diseases are not on recommended therapy, leading to avoidable hospitalizations and emergency department visits, all while healthcare costs rise as a percentage of GDP.
Central to the article is the concept of the value/burden ratio, which the authors introduce as an urgent priority for improving healthcare performance. They propose incorporating this ratio into the value equation as: Value = Quality / [Financial Cost + Human Cost (Excess Time + Reduced Job Satisfaction)]. The article argues that while policymakers, health plans, and health systems strive to improve value, they often inadvertently increase the burden on physicians. This burden is defined as the “multitude of inputs that impact two broad variables—excess time and reduced job satisfaction—contributing to human cost”. It encompasses various factors such as the time required for high-quality care, the number of clicks to complete tasks, clumsy new technologies, increased documentation, negative emotions from rapid change, competing incentives, and perceived loss of autonomy. This increased burden not only leads to physician burnout and demoralization but also diminishes the capacity to deliver high-value care. The authors explicitly connect this to “administrative harm,” a concept describing negative consequences of administrative decisions on patients, providers, and organizations.
The authors explain that physicians face an “efficiency-thoroughness trade-off,” where meeting an increasing number of quality metrics across their entire patient population either requires decreasing time per patient or increasing total work hours. For example, a recent analysis suggested that primary care physicians would need 27 hours in a 24-hour day to manage every metric and close every gap in care. This paradox is a symptom of how healthcare systems are built and how healthcare culture is perpetuated. They identify the challenge of reducing burden as an adaptive challenge, which is complex and requires more than simple technical expertise to solve, often encountering “cultural lock-in”—an inability to change despite clear threats.
To address this, the article proposes a path forward with three key steps for leaders:
- Designate burden reduction as a distinct strategic initiative at the system level and track it using data like provider experience and EMR utilization metrics.
- Acknowledge the suffering and discomfort in the current system, providing a hopeful future vision that links better patient outcomes with a good quality of life for clinicians, leveraging affiliative and visionary leadership styles.
- Build deliberate space for teams to identify burdens and innovate solutions. This involves seeing innovation as necessary work and using a structured approach to identify what tasks can be stopped, automated, assigned to less costly roles, outsourced, or must remain “sacred” with clinicians. The authors advocate for a human-centered design approach to create the best experience for all users.
The article provides examples from their own system, such as efforts to eliminate CLABSI infections in ICUs, where initial checklist additions overwhelmed clinicians. Instead of pushing compliance, leaders paused, challenging the team to reorganize workflows to accommodate new items without increasing burden. Another example details how their primary care physicians, despite achieving shared savings, experienced rising job dissatisfaction. By gathering these physicians to define and share their burdens, leaders validated their experiences and discovered numerous “microexperiments” already underway to reduce individual burden. These initiatives aim to reduce clinician time outside of scheduled work and maximize joy in their work.
The authors note that integrating burden reduction into system-level strategic initiatives is a nascent effort, with no clear benchmarks yet established for an ideal value/burden ratio. However, considering burnout as a proxy, the current burden on physicians is deemed too high. They conclude that proactively addressing this adaptive challenge is strategically necessary for future performance and is “an act of love”.
Reference: Runnels, P., & Pronovost, P. J. (2025). Reducing the value/burden ratio: a key to high performance in value-based care. BMJ Quality & Safety, 34, 133–136. https://doi.org/10.1136/bmjqs-2024-017591
