EP322: Cherry Picking, Lemon Dropping, and Other Learnings for Value-Based Care Models, With Monica Lypson, MD, MHPE

Imagine if innovators in other businesses operated in the way that some health care status quo doomsayers finger wag. So much for failing fast, iterating, and folding learnings into something that might work better. I don’t like to see screeds that seem to advocate an approach of “try it a few times at a minimum half-heartedly, fail, and then just quit, because obviously anything worth doing should be that easy.”

Pieces fell into place with me as I was speaking to Monica Lypson, MD, MHPE. Dr. Lypson is an expert in a bunch of things, but one of them is thinking about next-generation primary care and health equity and what that might look like in value-based care (VBC) metrics. I asked her if because of some of the negative potential perverse incentives to these patient populations whether we should throw out the VBC baby with the bathwater. Her response was succinct and amounted to, “And go back to what? FFS? Because that’s worked out so well?”

All this being said, there are big issues with value-based care right now that we really need to take a hard look at and think critically about. But that critical thinking, to be considered innovative and productive, really should inform creative thinking: What do we learn and do better next time?

Cherry picking and lemon dropping is a very real potential problem with value-based care. To find out what that means, you’ll have to listen to the interview. Another issue is who gets to decide what the measures and standards are. Who determined what is high-value and low-value care? And is that determination relevant to all communities and all care settings? Then ferreting out from there the potential loopholes for people to game the system because, despite all the virtue signaling that goes on around here, it is amazing sometimes the raw ingenuity exhibited when it comes to gaming the system.

Dr. Lypson brought up some points that I have not heard so succinctly before. One of them is that a national framework is pretty necessary here to enable local initiatives. You can’t have a local program, for example, help the homeless get homes when, on a national level, dollars are siloed into firewalled buckets. So, trying to take health care dollars and apply them to housing takes two years and an act of Congress—because it literally takes two years and an act of Congress, or at least someone with more time and authority than a local care team.

For more insight into this topic, listen to also the upcoming interview with Mai Pham as well as Nicole Bradberry and Kelly Conroy. Also, the recent interview with Dr. Rich Klasco (EP321), Jeff Hogan (EP309), and Dr. Mark Fendrick (EP308).

This is a huge, complicated topic that will take everyone sitting at the table thinking creatively to solve, incrementally, one step forward at a time. Monica Lypson, MD, MHPE, is currently vice dean for education at Columbia University Vagelos College of Physicians and Surgeons. She has practiced in a number of primary care settings, including the Department of Veterans Affairs. MHPE stands for Master of Health Professions Education, by the way.

You can connect with Dr. Lypson on LinkedIn.  

Monica L. Lypson, MD, MHPE, FACP, serves as a professor, vice-chair of medicine, division director of general internal medicine at The George Washington University School of Medical and Health Sciences. She will join Columbia University’s Vagelos College of Physicians and Surgeons as vice dean for medical education on June 1, 2021. Her work focuses on innovations and improvements in health professions education and assessment, health equity, workforce diversity, faculty development, medical care delivery, and provider communication skills. Dr. Lypson most recently served as director for medical and dental education for the Veterans Health Administration, where she oversaw undergraduate and graduate medical education across the nation within the Department of Veterans Affairs.

04:08 Is value-based care good for underserved communities?
05:09 “If you create perverse incentives, you actually might make known health care disparities worse … to meet the demands’ value.”
06:29 “There actually might be systematic and structural ways that the health care system might say … we’re not interested in taking care of you.”
07:12 “The incentive to have a good outcome is not there; the incentive to have another visit is there.”
08:33 “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.”
08:55 “The only indictment I have on the fee-for-service system is that it’s gotten us to where we are right now.”
09:30 What are the must-haves for a value-based system that creates the patient outcomes we need?
09:58 What is a whole health model?
10:43 EP319 with Grace Terrell, MD.
11:08 EP312 with Douglas Eby, MD, MPH, CPE.
16:25 “We want to move money around with the accountability of the patient outcome. We want to be responsible stewards of that dollar.”
17:14 What does it mean to keep an equity framework?
20:48 Do we know the impact of independent physicians closing their offices?
25:20 What do we need to be mindful of when constructing a value-based system of care?
27:52 “The large health care system needs their community partners at the table.”

You can connect with Dr. Lypson on LinkedIn.