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01:53 Upcoding problems: a previously unpublished clip from EP505 with Dr.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.