She works for a not-for-profit health system, but nothing about what she described to me felt charitable. A young physician, just a few years into her career, she’s already facing a choice that no doctor should ever have to make: protect her patients or protect the metrics that determine her employer’s paycheck.

The heart of the problem

This physician works under a value-based payment model. On paper, it sounds great: Pay doctors for better outcomes instead of more visits. In reality, these contracts often encourage data manipulation and cherry-picking patients to hit performance targets.

She told me about a meeting with a mid-level manager who reviewed her quality metrics and suggested she “remove” certain high-risk patients from her panel. These were patients with complex needs—the ones she cared most about. She refused.

Weeks later, those very patients were removed anyway. On paper, they were marked as “no PCP” (no primary care provider). In reality, they lost the doctor who refused to give up on them.

Her confusion runs deeper because she works for a not-for-profit health system—an organization that, in theory, exists to serve the most vulnerable. “Why would they do this for financial gain?” she asked. It’s a question I couldn’t answer without pointing out the obvious: Even nonprofits have bottom lines, and value-based contracts pay out better when the numbers look clean.

Moral injury is not burnout.

She’s early in her career, and while she loves most of her work, this betrayal of her ethics has shaken her. She’s left wondering: Is this what my career will look like for the next 20 years? Can I stay in a system that punishes me for doing the right thing?

This is moral injury. It’s not just being tired or burned out. It’s the deep wound that forms when a physician is forced to act against their values or watch the system do it for them. And because doctors are often well-paid, speaking out about this can sound like complaining. But moral injury isn’t about money—it’s about integrity.

This is why so many primary care physicians are leaving employed positions for independent models like direct primary care (DPC). We’re not anti-hospital or anti-insurance—we’re pro-patient. In DPC, I answer directly to my patients, not a payer or a spreadsheet. It’s not about maximizing metrics. It’s about restoring the relationships that make medicine meaningful.

When you see physicians in your community move to DPC, know this: They’re not walking away from medicine. They’re walking toward a version of it that hasn’t betrayed its own purpose.

Health care is full of good people with strong ethics. But the financial structures around them—yes, even in “not-for-profit” systems—are distorting the mission. Value-based care isn’t inherently bad, but when “value” becomes code for “profitable,” patients lose.

It’s time to confront this. Physicians need safe spaces to speak out, and health systems need to remember that no quality metric is worth the cost of eroding a doctor’s moral compass. If we want better care, we must stop forcing good doctors to choose between their patients and their paychecks.

Jonathan Bushman is a board-certified family physician, health benefits advisor, and passionate advocate for reimagining health care delivery. As the founder of Primed Healthcare, a physician-owned benefits agency, Dr. Bushman helps employers and employees navigate a transparent, trust-based approach to health care. He brings deep expertise in direct primary care and employer-sponsored health plans, focusing on solutions that align physician-led care with cost-effective strategies. Dr. Bushman serves as a fractional chief medical officer and continues to drive innovation in health plan design. Through his leadership at Reliant Direct Primary Care and thought leadership shared via LinkedIn, he works to empower organizations with health care solutions built on meaningful care rather than bureaucracy.