What is Value-based Health Care?
Understanding Trends in Childbirth
Just as there are trends in any other area of life as we evolve in humanity, there are trends in childbirth and parenting as well. Some assume that since childbirth is a “natural process,” it is the same today as it always has. I mean how much could really change? Don’t babies come out the same way they always have? Well…yes…and no.
Just as clothing has evolved from fig leaves to funky leggings, and people were once convinced the world was flat, opinions and trends regarding procreation shift as well. There was a time when there was no such thing as childbirth classes; can you imagine? GASP!!
Trends in childbirth have included swatting babies’ bottoms to make them cry upon birth, medical professionals recommending treatments later proven to cause deformities in children as well as cancer and other tragedies, women clamoring for pain relief options later found to promote inhumane and unethical treatment of patients, and the movement to include fathers in delivery rooms and label them as coaches in decades past.
More recently we’ve seen trends that have made a way for informed consent and refusal, awareness and demand for evidence-based medical care, promotion of the golden hour after birth to increase skin-to-skin contact for maternal-infant bonding and breastfeeding, the elimination of infant nurseries and increase of rooming-in, and now: value-based health care promoting shared decision-making.
What is Value-based Health Care?
A recent Huffington Post article explains, “Value-based models change incentives to focus on value by rewarding better outcomes and lower spending. Historically, most medical treatment services are paid/reimbursed in a fee-for-service (FFS) environment,” which “promotes the use of more tests, procedures, and treatments, some which may not be supported by evidence-based medicine” .
In contrast to the fee-for-service model, value-based models typically include six elements: shared savings, bundles, shared risk, and global capitation. What this means is that health-care providers will be compensated based on overall outcomes and cost savings, as well as patient experience (new term for patient satisfaction), rather than based on how many procedures and how expensive those procedures are. While it may be bad news bears for provider’s pocket books in the short term, this model is far superior in terms of community health and the long-term goal of bringing healthcare costs down to reasonable rates. In Crossing the Quality Chasm, a report from 2001, the Institute of Medicine advocated reforming health care practices in order to promote healthcare that is safe, effective, patient-centered, timely, efficient and equitable,” Of the ten steps lined out in the report to implement these core values, many include shared decision-making as an integral value.
Current Conflicts for Value-based Care
Many would be shocked to find that a value-based healthcare initiative is not a new idea. As early as 1975, we have seen initiatives moving in this direction. “In that year, Harvard Professor of Medicine Dr. Howard Hiatt famously encouraged physicians to collaborate with other experts and the public to protect the medical commons” . Many others followed in Hiatt’s footsteps in suggesting more effective, collaborative care and lowering costs. We also have heaps of research to suggest the benefits of this, as well as voices of patients who WANT this kind of care. So, since it’s clearly beneficial and wanted, is that what we’re currently experiencing? Not so much.
In their article “Shared Decision Making to Improve Care and Reduce Costs,” authors Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. share:
“The gap between the way many patients wish healthcare decisions could be made and the way these decisions are actually made is tremendous. According to a 2014 survey conducted by the Altarum Institute, nearly all patients expect to be in control of medical decisions. Only 7% of adult, nonelderly patients wanted their physicians to be in the lead role.2 Despite this clear preference, the same survey found that the vast majority of patients let the doctor take charge of care decisions nonetheless.
“For many health situations in which there's not one clearly superior course of treatment, shared decision-making can ensure that medical care better aligns with patients' preferences and values. One way to implement this approach is by using patient decision aids — written materials, videos, or interactive electronic presentations designed to inform patients and their families about care options; each option's outcomes, including benefits and possible side effects; the health care team's skills; and costs. Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with patients' values” 
What about Maternity Care?
If we segment out maternity care, the findings really aren’t much different from those in the greater scope of healthcare. The Listening to Mothers III survey authors summarized their findings by explaining,
“Our maternity care system is failing to provide care that many mothers told us they want and that is in the best interest of themselves and their babies. Moreover, this unnecessarily costly style of care places a considerable burden on governments, employers, and families who pay the bills for this major sector of the health care system. The Institute of Medicine’s landmark Crossing the Quality Chasm report exposed the gulf between where our health care system is and where it should be with respect to safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
“Survey results point to the need for mothers themselves to become more engaged and activated and take an increased role in the challenging yet crucial responsibility to become informed, understand their maternity rights, and make wise decisions about matters that impact the health and well-being of themselves and their babies. Mothers need skills and tools to be able to take these steps forward, including improved knowledge about quality maternity care, high-quality decision aids, critical appraisal skills, and help in navigating the maternity care system .
The authors of the Listening to Mothers survey emphasize the necessary role of mothers themselves to enact change to improve their experiences, and I believe this will create a ripple effect throughout the rest of the system. Wouldn’t that be fascinating? Instead of maternity care being the last to see improvement as it has throughout history, what if it could be the area of healthcare that BIRTHS evolution (pun intended)?
Promoting Shared Decision-making in Maternity Care
What would shared decision-making look like within prenatal care, childbirth and postpartum care? As mentioned above, the use of patient decision aids such as written materials, videos and presentations that inform families of their options is integral to the collaborative relationship between parents and care providers, as well as improving patient experience and decreasing fear and unnecessary costs! How amazing is it that such a simple tool can create such vast improvements? So, how do we do that?
Since it’s inception, the Your Birth Experience™ Childbirth Education Curriculum was designed to address all of these needs. Very early on in my doula career, I observed that mothers and their families had an immense amount of fear regarding childbirth, which I could substantially attribute to their lack of knowledge surrounding the process of childbirth and their options. Many birthing people I encountered were ill informed or misinformed about their rights and options in birth. Additionally, the bulk of their understanding of the process of childbirth itself was informed by popular culture, television and horror stories from their social circles.
I found that when individuals understood the most basic principals of physiological birth, as well as accurate, evidence-based information about protocols and interventions, their anxiety plummeted and their confidence soared. Then, when equipped with collaborative communication tools to work WITH their chosen care providers, they seemed to have much more positive experiences overall! Now that I’m sharing this information beyond my own personal clients, there are doulas and childbirth educators across the United States, in Canada and even Japan bringing it to numerous communities. The Your Birth Experience™ Parent Guide and childbirth classes offered by YBE Instructors help parents achieve satisfying birth experiences by empowering them with accurate information and accessible tools for shared decision-making.
How to Achieve Shared Decision-making
The key to shared decision-making lies in the first word: shared. Like the authors of the Listening to Mothers survey shared, improvements in maternity care are going to depend on the birthing persons and their families taking the initiative to gather information and advocate for themselves in communication with care providers. My experience and research has revealed some very simple and effective tools that accomplish this goal:
- Guided Visualization – Visualizing one’s ideal experience helps identify underlying desires and feelings about the birth experience that can guide the individual in seeking appropriate care. It has the added benefit of reducing fear and anxiety and improving everything from optimism to blood pressure, sleep and stress!
- Creating a Birth Vision Statement – Many childbirth classes and books encourage parents to focus on what options and interventions they want, leading them down one of two paths, either a “natural” birth experience or a “medicalized” one. This can set up parents for disappointment when unexpected circumstances arise, as they almost always do due to the unpredictable nature of birth. When parents focus on the feelings and accomplishments they desire, they find there are many more that two paths to a positive experience.
- Understanding Basic Personality Traits and Needs – People don’t know what they don’t know, whether that’s the facts of birth or what decisions will feel right for them in the birthing space. I’ve found that our personalities, or the way we are all pre-wired, can give us clues as to what kind of comfort measures, settings, communication strategies, and birthing options will be most conducive to aiding parents in feeling ownership and promoting the 5 aspects of control. These are agency, personal security, connectedness, respect and knowledge.
- Understanding Personal Bias – Everyone has knowledge and experience that informs the way they make decisions about themselves, especially when it comes to making medical decisions. Kim James and Laurie Levy developed the Groopman and Hartzband Spectrum tool based on the book Your Medical Mind that helps parents uncover the kind of options and interventions that typically are the best fit for them. When parents know this information about themselves and can work with a care provider that supports the individual’s values, real and perceived outcomes are often improved.
- Understanding the Birth Process and Options – With the wealth of information available about choices in childbirth, including books, classes and a sea of opinionated blog posts, parents are often overwhelmed and may not have the energy to sift through the information. Or, they may look for quick answers and unintentionally absorb incorrect ones. Providing parents with concise, comprehensive, accurate and unbiased information is crucial to promoting informed consent and refusal.
The Your Birth Experience™ curriculum incorporates all of these into a concise and accessible class model or self-paced process so parents can get the information and inspiration they need to feel empowered and take action to achieve the kind of birth experience that will feel most satisfying to them.
Women’s Role in Change
As many movements have taught us, women have the power to make the shifts necessary to improve maternity care. While policy makers have historically been slow to make changes and improvements, we have seen over and over that when women are powerful change agents. If you don’t believe me, watch the documentary She’s Beautiful When She’s Angry and get schooled on the Women’s Rights Movement. In fact, the history of women’s rights dates back to July 13, 1848 when Elizabeth Cady Stanton and her friends organized a convention they titled “A convention to discuss the social, civil, and religious condition and rights of woman”  We can thank those heroines and the ones that came after them for the right to vote, pivotal steps forward in the Civil Rights Movement, birth control advancements, evidence-based medicine, sex education, sexual discrimination and harassment legislation and SO much more.
If you are not convinced that we are in the midst of another wave of women leading social progress globally, start your research by reading Rucha Chitnis' article How Women-Led Movements are Redefining Power, from California to Nepal in Yes! Magazine. In her article from March of 2016, she states, "Around the world, women’s movements have long recognized the wisdom of that thought, which emphasizes the way social movements benefit by recognizing the intersections between different forms of oppression" . If you ask me, restricting patient's rights and ability to participate in the decisions that shape their healthcare IS oppression. She goes on to say, "Women’s movements are also bringing to the forefront that which is alarmingly invisible: women’s paid and unpaid labor as caregivers, farmers, domestic workers, natural resource managers, and human rights defenders," and in here in the United States the Women's March on May 8th and the March for Moms in Washington will take place this coming Sunday on Mother's Day, May 14 2017!
The vision statement for the Women's March states, "In solidarity with our families, friends, neighbors, coworkers and communities, we collectively stand for dignity, justice and freedom in the face of attacks on our health care, our identities and our lives. When one community is harmed, all of our communities are harmed. We are all part of one movement, and we pledge allegiance to the survival and liberation of all people" . Anyone else find it interesting that none of this is in the mainstream media? Well, whether you realize it or not, it's happening, and guess what. You get to decide whether or not you're going to join the revolution!
Shared Decision Making as a Path to Progress
So, you say you want a revolution, eh? Well, if shared decision-making is seen by researchers and leading experts in this field as the path to progress, I say we focus on THAT as our goal! I could have told you this long before seeing any formal research studies. As I have learned from the families I’ve worked with as a birth doula and childbirth educator, all outcomes improve when parents work WITH their care providers to chart the most satisfying course of action. When patients listen to and respect care providers’ opinions, take them into consideration while voicing their own concerns and desires, and feel informed and encouraged to make decisions that seem right to them, everyone benefits!
Why am I bringing this up? Because I believe right now, at this moment in history, we are on the verge of the next wave of the Women’s Rights Movement, which will be the catalyst for transforming healthcare on a broader scale. Ultimately, I’m predicting that VALUES-based care, meaning patients and providers working together to meet goals based on the intrinsic values of each unique individual and family unit, will be the key that brings the greater goal of Value-based Care to fruition.
written by: Missy David, BS, CD(DONA), CYBET, CLC, HCHD
- Sanicola, L. (2017, February 02). What is Value-Based Care? Retrieved May 09, 2017, from http://www.huffingtonpost.com/entry/what-is-value-based-care_us_58939f9de4b02bbb1816b892
- Richardson, W. C., Berwick, D. M., Bisgard, J. C., Bristow, L. R., Buck, C. R., Cassel, C. K., . . . Warden, G. L. (2001). Crossing the Quality Chasm. Institute of Medicine. doi:10.17226/10027
- Moriates, C., Arora, V., & Shah, N. (2015). Understanding Value-Based Healthcare. McGraw-Hill.
- Lee, E. O., M.A., & Emanuel, E. J., M.D., Ph.D. (n.d.). Shared Decision Making to Improve Care and Reduce Costs — NEJM. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp1209500#t=article
- Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to MothersSM III: Pregnancy and Birth. New York: Childbirth Connection, May 2013.
- National Women's History Project, History of the Women’s Rights Movement. Retrieved from http://www.nwhp.org/resources/womens-rights-movement/history-of-the-womens-rights-movement/
- Chitnis, R. (2016, September 08). How Women-Led Movements Are Redefining Power, From California to Nepal. Retrieved from http://www.yesmagazine.org/people-power/how-women-led-movements-are-redefining-power-from-california-to-nepal-20160308
- 10 Days / 100 Days Campaign: Pledge of Liberation. (n.d.). Retrieved from https://www.womensmarch.com/