What OB Providers Need to Know About Value-Based Care: An Interview with Dr. David Lagrew at Providence St. Joseph Health

Dr. David Lagrew is the Executive Medical Director of Women’s Services with Providence, St. Joseph Health. In his current role, he develops the Ministry's Centers of Excellence and regional Clinical Institute of Women's Health, while aligning efforts with the Providence Health System's Women's initiatives. Wildflower recently interviewed Dr. Lagrew to gain his insights on how providers can effectively engage in value-based care. 

There has been a great deal of discussion about value-based care within the OB setting, but where are we on the adoption curve?

We are in the infancy of value-based models for OB care. There have been a few trials and a lot of interest, but it’s been difficult to apply existing models to it. It’s a lot easier to construct a bundle knee replacement compared to a delivery package, especially since a lot of the costs have to do with the baby’s health and outcomes.

Across the country, we haven’t specifically solved for how to do it, but we have the interest, the motivation, a lot of the tools, many of the necessary resources. We just need to tie it all together. At Providence, some of the best quality improvement work we’ve done is within the OB setting. We’ve had positive experiences with C-section rates and hypertension, among other metrics. 
 

What is needed to drive broader adoption of value-based care?

We are so accustomed to paying by volume. We have incented and rewarded physicians based on widgets.  We have entire armies of people negotiating contracts for widgets. We use the widget mentality to influence behavior. So, when you start talking about taking all that away and say you’re just going to issue a set amount of compensation for each pregnancy, that is completely at odds with the existing infrastructure.

There’s currently no incentive to move away from the current system, not for providers and not for payers. They both actually benefit financially from rising healthcare costs. To be clear, I don’t think physicians overtly make decisions for financial gain, but the incentives are there. 

The pressure to change will have to come from the outside, from the government and from those who are ultimately responsible for healthcare costs, i.e. employers. And from environmental factors, such as the pending physician shortage. At Providence, we have a lot of OBs aging out and retiring in the next five years. We are far from unique. Physician shortages mean we have to be more efficient with the care being delivered. 

Physicians, nurses and other providers want to be a part of high-quality care. They will rally around quality. This is also a chance for physicians to have a better lifestyle as well. That’s the other reason I think you’ll see physicians accept this shift. 

There are many things we must do differently as we move toward value-based care. Could you provide an example of a specific challenge we should be solving?   

We should consider solutions that help us more effectively risk screen women, specifically expectant moms, to identify health concerns and tailor support based on their needs. This will have a far greater impact than some of the broad-based changes we talk about, which typically are things we try to do anyway as clinicians. We generally don’t have the vision and proactive assessment of risk we need to properly care for women. That needs to change. 

As an example, consider a woman who is diabetic and trying to become pregnant. The time she needs intervention is before she’s pregnant. Birth defects linked to diabetes occur before a woman even knows she is expecting. Our best chance to help this patient get healthy and avoid a premature birth and other complications is not when she first presents in our office. It’s much earlier than that. Our current system doesn’t allow for this type of proactive care. We need to be able to engage patients sooner, conduct risk screenings and apply timely interventions. This will lead to improved outcomes. 

Your organization has been very effective at leveraging digital health solutions to improve your approach to value-based care. What’s next on your technology priority list?

We’re still completing our digital infrastructure. Part of the current work effort is to migrate all of our hospitals onto a single EHR. Once we complete this integration, providers and patients will have a totally different experience. Another priority for us is getting better at incorporating clinical data and experience into our approaches. Historically, healthcare has been myopically focused on administrative data. There are more than 61,000 reimbursement codes. There’s even a code for falling out of an airplane. But this data is superficial. We may have codes to note that Mrs. Smith had preeclampsia and blood pressure problems. But there are no metrics here. We need an expanded clinical data set to see the actual story behind Mrs. Smith and her experience. Without this data, you can’t track your care processes, measure their effectiveness and refine to make them better. You can’t achieve cyclical quality improvement.

Do you think value-based care will have a positive impact on health equity?

None of us should feel comfortable with where we are as it relates to health equity. It’s a terrible reality. It’s also a quality metric that can be included in value-based design. It’s something you can measure, something you should measure. I don’t think anyone is really debating the need for greater equity, but we need to be better at developing solutions and applying them.

If clinicians aren’t forced to make widgets, maybe we’ll see more social workers engaged or deliveries of fresh veggies to the inner city. If we take resources away from unnecessary care and deploy them in other non-traditional activities that don’t have a reimbursement code, we can do what’s right for each patient.

What should providers keep in mind when considering a transition to value-based care?

You better know where the data is coming from, how it’s collected and what tools you have at your disposal. You need to incorporate people into your practice who know how to work with data. You need a good EHR, good analytics and other tools. It’s the only way you can move forward confidently.

Providers also need to really understand how quality and costs are being measured and what their role is. They need to know who sets the measures for quality and who determines outcomes and payment. It’s important to know how much of a voice the provider will have in the process. If you are a provider, and you find you are not at the table to help make these decisions, I’d advise you to find a different partner who will save you a seat at a different table. This requires collaboration, and if the provider isn’t being included in the process, it isn’t going to work. 

Any parting words on what we can expect from value-based care moving forward?

It is going to take a broad coalition, and a good sense of humor. It’s a complex process with so many permutations. If you think you can plan for all scenarios, you are out of your mind. I don’t think this journey will be easy. People who say, “we’ll just do it,” are underestimating the task. It can be done. Absolutely. But again, it isn’t an easy road ahead. 

For more insights from this interview series, as well as additional tools and best practices to accelerate your journey in virtual and value-based care, please visit www..valuebasedobcare.com.