Pooh & Value Based Care: Part Two

The Tao of Presence—and the Trouble with Tigger’s Bounce

“Wisdom, Happiness, and Courage are not waiting somewhere out beyond sight at the end of a straight line; they’re part of a continuous cycle that begins right here.” — Benjamin Hoff, The Tao of Pooh

Pooh doesn’t chase status. He’s not building a portfolio, earning RVUs, or checking his inbox before breakfast. He notices the wind, the hum of the forest, the silence when someone’s missing. Instead of rushing to the next thing, he lingers. This isn’t just charm—it’s a challenge. What if our care models did the same?

Value-based care, in its ideal form, seeks to reconcile its lofty intentions with the realities of implementation. It aspires to reward presence, prevention, and person-centered care—but often struggles to maintain that ethos amid the metrics and mandates that shape practice. what happens when that vision becomes a compliance checklist? When metrics meant to support care begin to displace it?

Here’s the philosophical risk: when we try to measure compassion, do we risk replacing it with performance?

Enter The Compliance Trap—the double documentation trap. In theory, value-based care was meant to reduce waste and improve care. But to go after "quality," providers often find themselves documenting not once, but twice—once in the electronic health record, and again in Excel spreadsheets or dashboards to prove they met the metrics. It's a duplication that drains time and attention—two things that should belong to patients, not paperwork. In chasing metrics, we risk competing with the very quality we aim to prove.

And it gets worse when it comes to our sickest patients. There is a phenomenon in which well-meaning value-based frameworks inadvertently penalize providers for taking on the sickest patients. If success is measured by improved outcomes, what happens when a patient can’t or won’t comply with care plans—perhaps because of life circumstances, trauma, or systemic barriers?

This is especially troubling in light of what we now understand about social determinants of health—the conditions in which people are born, grow, live, work, and age. These factors, like housing instability, food insecurity, and systemic inequality, influence up to 80% of a person's health outcomes. Yet providers are often held accountable for improving outcomes they can't fully control.

The result? A model that may de-incentivize care for those who need it most—not out of malice, but out of math. When patients are seen as a risk to a scorecard, we lose the plot.

“Tiggers don’t like to hold still!” — Tigger

Tigger is the perfect picture of movement without direction. He bounces. He disrupts. He means well, but rarely pauses. Healthcare too has a Tigger problem: it celebrates motion, even when what’s needed is stillness. Providers are asked to bounce from room to room, task to task. But what if the most important thing isn’t the bounce—it’s the moment after?

“It is hard to be brave,” said Piglet, “when you're only a Very Small Animal.”

Piglet reminds us that care takes courage—especially in a system where human needs don’t always fit the form. Where chronic illness, trauma, or social complexity make the “ideal patient” unrecognizable.

But patients aren’t quality scores. They are people. And care must follow suit. Yet we also must recognize that tracking some aspects of care is what allows us to continue doing the work—because if the lights go out, no one gets seen. Documentation isn’t just red tape; it’s tied to reimbursement. That means capturing key metrics isn’t optional—it’s how we keep clinics open and services available.

So how do we reconcile these needs? One answer lies in embracing what can be measured while staying honest about what can’t. There are real signals—like those in Compassionomics—that show how compassion moves the needle. But there are also quiet moments, relational investments, and human trust that defy clean categorization. And that’s okay. Because a system built on care must leave room for both the measurable and the meaningful.

Compassionomics offers some hope. Its authors found that brief moments of true presence measurably improve outcomes—reduced pain, anxiety, and even healthcare costs. Compassion isn’t a soft extra; it’s a vital sign—one that should influence not only how care is delivered, but how it’s reimbursed. These findings demonstrate that some of the most humane aspects of medicine can be measured—brief encounters of genuine connection can move the needle on tangible health outcomes.

But even with that promise, some things resist quantification. Time spent listening or earning trust doesn’t always show up cleanly on a dashboard. And maybe that’s okay. Not because those moments don’t matter, but because their value might transcend simple metrics. If we believe compassion matters, we need to build systems that support it—not just measure it.

So what can we do?

First, we need to acknowledge a deeper structural tension: many providers, even in value-based environments, find themselves tracking metrics not once but twice. In the electronic medical record, and then again—in Excel spreadsheets, shared trackers, or separate dashboards—to satisfy oversight or incentive programs. We said this twice…. it is a huge part of healthcare delivery today. It's a duplication that drains time and divides attention. It's not why most of us got into healthcare. And yet, here we are—trying to care while also trying to prove we care. This disconnect is enormous, and it explains why your provider might seem distracted: they’re often documenting care while simultaneously tracking care in a parallel system designed to prove their value.

Next, we must keep asking the hard questions. Can value-based care truly be for everyone, or just those easiest to care for? Can we reward providers for showing up, not just for fixing? Can we train for virtue, not just compliance?

We don’t need to abandon measurement. But we do need to hold space for the parts of care that aren’t yet captured—and may never be. That’s not a weakness of the system. It’s a reminder that some of the best things in medicine are slow, steady, and deeply human.