Contributor: Roadmap to the Quadruple Aim—A Framework for Minimizing Physician Burnout During the Transition to Value-Based Care

As provider and payer organizations pursue the Quadruple Aim, it is important that they take into account not just the contracting but also the transformation in staffing, clinical workflows, and culture as these organizations evolve.

Value-Based Payments as a Tool to Improve Patient Care

As we move toward an increasingly value-based ecosystem, careful implementation of clinical and administrative operating models may lessen physician burnout. Value-based care (VBC) aligns financial incentives with clinical outcomes, which can motivate physicians to alter their practice patterns to achieve better care for the individual, better care for the population, and lower cost for all. VBC also emphasizes integrated care by addressing a patient’s medical, mental, behavioral, and social needs. Value-based payment (VBP) is a key tool to help transition our health care system from one based on volume to one based on quality. However, this change has the potential to either worsen or improve physician burnout depending on its execution.

Burden of Physician Burnout

Physician burnout is a long-standing challenge that has been fueled by the COVID-19 pandemic. In a cross-sectional survey in late 2020, 24.3% of physicians reported high intent of leaving their jobs within the next 2 years.1 Further, there was a 25% increase in burnout from the end of 2020 to the end of 2021.2 Burnout among health care workers has harmful consequences for patient outcomes, patient safety, and staffing shortages, and is even associated with worse physician physical and mental health.3-8 Burnout also exacts a heavy financial toll on the US economy by driving $2.6 billion to $6.3 billion of annual burnout-related turnover costs, which is approximately as much as 0.02% of the country’s entire gross domestic product.9 A 2022 physician survey identified several drivers of burnout to include too many bureaucratic tasks, lack of autonomy, and insufficient compensation. In the transitions toward VBC, there is a risk of potentiating some of these drivers but also an opportunity to improve on them.

Finding a Path Toward VBC Without Increasing Burnout

In pursuit of the Quadruple Aim, we can use this opportunity to combat the burnout pandemic. The concept of the Quadruple Aim was first born in 2014 in work by Thomas Bodenheimer and Christine Sinsky.10 However, it wasn't until a 2022 report by Surgeon General Vivek Murthy that this concern was highlighted nationally.11 The report informs infrastructure design of care delivery in the American transition to VBC. For example, 70% of all beneficiaries of Humana, 1 of the 3 largest Medicare Advantage health insurers in the United States, are aligned to a VBC primary care provider.12,13 The evolution toward VBC may serve as a powerful opportunity to implement scaled change that can reduce levels of burnout for physicians through design around financial incentives. Bringing focus to burnout during this crucial period will support the intelligent design of programs to prevent it.

To support the health care leaders who design VBC, we humbly offer a framework that can be used to evaluate provider organizations on how the interaction between payment contracts and physician financial incentives is protective towards or precipitative of burnout. Our hope is that as organizations move toward more integrated population-based payments, this framework might serve as the beginning of a roadmap in designing a path towards more value-based reimbursement models.

Developing a Framework at the Intersection of Physician Payment and Organization Reimbursement Structures

The Health Care Plan Learning and Action Network (HCP-LAN) refined a payment framework from CMS to better describe the spectrum of reimbursement models in American health care organizations. The LAN framework can be crosswalked with a spectrum of financial incentives for individual physicians.

The primary levers for physician financial incentive structures include the presence or lack thereof of a bonus, whether the bonus is quality based or volume based, time until bonus is paid out, and lastly alignment with shareholders (Table 1). Notably, these structures are not comprehensive and may in fact be combined in some organizations.

Table 1. Descriptions of Physician Incentive Structures

Table 1. Descriptions of Physician Incentive Structures

With increasing adoption and exploration of different value-based contracting strategies, it is vital to understand how different combinations of VBP and physician financial incentives are related to physician burnout as our health care system advances toward the Quadruple Aim. This analysis strives to approximate physician burnout relative to individual physician payment incentives and practice-level reimbursement structures by subjectively integrating the Maslach Burnout Index and Mini-Z 2.0 (both of which are well established tools for measuring burnout in physicians) with our clinical and operational experience (Table 2). These factors contributing to burnout include work overload, lack of control, insufficient rewards, breakdown of community, sense of fairness, and conflicting values.14 This analysis assumes that organizational and physician payment structures are transparent and that physician bonus structure is sufficient to motivate behavior, combat burnout, and be meaningful relative to base salary.

Table 2. Analysis of Burnout Risk Based on Combinations of VBP Contracting and Physician Incentive Models

Table 2. Analysis of Burnout Risk Based on Combinations of VBP Contracting and Physician Incentive Models

Key Insights on How to Minimize Physician Burnout During the Transition to VBC (Table 2)

First off, models that combine either Category 3 or 4 with physician payment strategies that are salary only or include volume-based incentives (Model A, B, C) may be more associated with burnout. We believe this may be driven by the conflict in values and incentives when a health care system is reimbursed for “value” whereas physicians are reimbursed for volume.

Conversely, there are several combinations of individual payment and organizational reimbursement that may protect against burnout. Strategies that combine Category 1 or 2 with volume-based physician payment models (Models B and C) may be protective towards burnout. When the system is incentivized to maximize throughput and services offered and its physician workforce is similarly incentivized, it may result in “work overload”; however, the principle of “fairness” is presumably intact because physicians will be compensated appropriately for the increased volume of care they deliver. This comes at the expense of physicians potentially feeling dissatisfied with the quality of care that they provide to their patients. To combat this concern, there should be systems in place to ensure that there are still specific quality measures that must be met by both the health care system and its physicians to ensure that the patient population they serve is receiving high-quality care.

Another protective combination includes the presence of Category 4 payment models with physician incentive structures oriented around quality outcomes (Models D and E). When both a health care organization and its physicians have aligned financial incentive towards quality, we believe that the ensuing clinical workflows and operational models that may be developed would be complementary to physician incentives and thus be protective against burnout.

Similarly, Category 4 and fee-for-service (FFS) models that are combined with physician incentive structures including partner dividends may be protective towards burnout because it directly aligns shareholder value with physician incentives, although Category 4 models would more likely lead to better outcomes for patients than FFS models.

While Table 2 can serve as a helpful guide, one major limitation of this matrix is that provider organizations seldom have a single contract type with a single payer. Therefore, making use of this matrix in the real world may require a combinatorial approach to interpreting the myriad contract types between a provider organization and its respective payers and the different individual provider incentive structures within a provider organization. When a health care system has multiple contracts with multiple payers across different LAN categories then physicians may experience increased levels of burnout because working in a system with a mix of FFS and VBC models creates a fundamental discordance in incentives. There may be an opportunity to apply artificial intelligence to the complex mix of physician incentives and organizational contracts within a provider organization to offer recommendations for simplification of reimbursement schemes that move toward VBC based on the matrix in Table 2.

Another limitation of this framework is that it is heavily influenced by the personal experiences of the authors and the matrix has not been empirically validated. Further investigation is needed to understand the exact relationship between physician compensation strategy and provider organization contract types.

Recommendations and Next Steps:

In our collective effort toward achieving the Quadruple Aim, we believe moving toward Category 4 models will be vital. However, if this is done without paying attention to individual provider incentive structures, the transition to VBC may exacerbate burnout and further deplete our physician workforce.

We believe that Table 2 may serve as a roadmap for how Category 1, 2, or 3 organizations can transition to more progressive VBP models while still ensuring they are supporting their physicians. For example, a health care organization may decide to pursue more integrated population level reimbursement contracts with payers (Category 4) but is currently oriented around fee for service-based contracts (Category 1). Understanding that this transition is unlikely to happen overnight, they may utilize Category 3 or 4 reimbursement strategies as intermediates to integrated population health plans. To ensure they are in alignment with the Quadruple Aim, they may design their transition toward VBC by tracking along the green cells in Table 2 to identify what combinations of reimbursement strategy and physician financial incentivization structure may serve as stepping stones en route to Category 4 models. Once these organizations have established themselves in 4B models with an aligned physician financial incentive structure, the next step would be to investigate the important VBC metrics that one must consider to build a thriving health care delivery organization that delivers the highest quality care to their patients and shifts the cost curve of health care nationally.

VBC is much more than a financial model; it is also a clinical operating model. As provider and payer organizations follow this roadmap to the Quadruple Aim, it is important that they take into account not just the contracting but also the transformation in staffing, clinical workflows, and culture as these organizations evolve.


1. Rotenstein LS, Brown R, Sinsky C, Linzer M. The association of work overload with burnout and intent to leave the job across the healthcare workforce during COVID-19. J Gen Intern Med. 2023;38(8):1920-1927. doi:10.1007/s11606-023-08153-z

2. Shanafelt TD, West CP, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. Mayo Clin Proc. 2022;97(12):2248-2258. doi:10.1016/j.mayocp.2022.09.002

3. Trockel MT, Menon NK, Rowe SG, et al. Assessment of physician sleep and wellness, burnout, and clinically significant medical errors. JAMA Netw Open. 2020;3(12):e2028111. doi:10.1001/jamanetworkopen.2020.28111

4. Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care-associated infection. Am J Infect Control. 2012;40(6):486-490. doi:10.1016/j.ajic.2012.02.029

5. Dyrbye LN, Major-Elechi B, Thapa P, et al. Characterization of nonphysician health care workers' burnout and subsequent changes in work effort. JAMA Netw Open. 2021;4(8):e2121435. doi:10.1001/jamanetworkopen.2021.21435

6. Garcia CL, Abreu LC, Ramos JLS, et al. Influence of burnout on patient safety: systematic review and meta-analysis. Medicina (Kaunas). 2019;55(9):553. doi:10.3390/medicina55090553

7. West CP, Tan AD, Shanafelt TD. Association of resident fatigue and distress with occupational blood and body fluid exposures and motor vehicle incidents. Mayo Clin Proc. 2012;87(12):1138-1144. doi:10.1016/j.mayocp.2012.07.021

8. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62. doi:10.1001/archsurg.2010.292

9. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170(11):784-790. doi:10.7326/M18-1422

10. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576. doi:10.1370/afm.1713

11. Murthy V. Addressing Health Worker Burnout: The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce. U.S. Public Health Service, HHS; 2022. Accessed April 15, 2024.

12. Value-based care report 2023. Humana. 2023. Accessed April 15, 2024.

13. AMA identifies market leaders in health insurance. News release. American Medical Association. December 12, 2023. Accessed April 15, 2024.

14. Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016;15(2):103-111. doi:10.1002/wps.20311

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