EP511: The Tension When Clinical Teams Take On Risk for Policymakers and Others Looking to Rustle Up Future Perverse Incentives, With Dr. Siva and Monica Lypson, MD, MHPE
Episode Description
In this episode, Dr. Monica Lypson and Dr. Ahilan Sivaganesan join the conversation to dissect the complexities of value-based payment models and the "perverse incentives" that often follow. By examining the parallels between Medicare Advantage upcoding and sliding-scale bundled payments, Dr. Lypson and Dr. Sivaganesan provide a masterclass on the systemic friction between financial risk and clinical equity.
Key Discussion Themes
- The Upcoding/Downcoding Tug-of-War: An analysis of how Medicare Advantage plans and health systems navigate risk adjustment, and why current models often incentivize "grading your own homework."
- The TDABC Solution: Dr. Sivaganesan explains why physicians cannot truly manage risk without Time-Driven Activity-Based Costing (TDABC) to identify condition-specific costs.
- Selection Bias in Care: A deep dive into the "cherry picking" (selecting low-risk patients) and "lemon dropping" (avoiding high-risk patients) dilemmas that threaten healthcare's moral compass.
- Equity vs. Efficiency: Dr. Lypson explores how value-based care can either bridge the gap for underserved populations or inadvertently widen disparities through structural barriers.
- The Path Forward: Why "whole-person health"—including non-clinical factors like housing—is the ultimate cost-saver, and the necessity of neutral, third-party risk scoring.
=== LINKS ===
🔗 Show Notes with all mentioned links:
https://cc-lnk.com/EP511
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00:00 Introduction to this episode.
01:53 Upcoding problems: a previously unpublished clip from EP505 with Dr. Siva.
05:22 What is the minimum requirement for physicians to go at risk?
07:22 How sliding scale bundle payments can reduce risk for physicians.
10:43 The question covered in the upcoming episode.
13:19 Is value-based care good for underserved communities?
15:01 "If you create perverse incentives, you actually might make known healthcare disparities worse … to meet the demand's value." —Dr. Lypson
16:18 "There actually might be systematic and structural ways that the healthcare system might say … we're not interested in taking care of you." —Dr. Lypson
16:51 "The incentive to have a good outcome is not there; the incentive to have another visit is there." —Dr. Lypson
17:15 EP485 with Cristin Dickerson, MD.
17:49 "The only indictment I have on the fee-for-service system is that it's gotten us to where we are right now." —Dr. Lypson
18:41 "If you don't have any connection in that system, even the provider trying to … provide a good outcome might be disconnected because the system is not in place to … connect the dots." —Dr. Lypson
19:15 EP436, EP491, and SUMS9 with Elizabeth Mitchell.
19:28 What are the must-haves for a value-based system that create the patient outcomes we need?
19:51 What is a whole health model?
22:00 EP462 (Scott Conard, MD), EP319 (Grace Terrell, MD), EP431 (Kenny Cole, MD), EP409 (Larry Bauer, MSW, MEd), and EP495 (Mick Connors, MD).
22:23 LinkedIn post by Mark Weber.
25:05 EP484 with Dave Chase.
25:31 Why we need to fix the structural issues if we want to fix health.
26:00 Why a patient's bias is the one we want in the room.
27:36 Stacey's conclusion on this week's episode.
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