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A thought-provoking podcast exploring the future of maternal healthcare through the lens of innovation and human connection. Hosted by Jennifer Sargent, each episode features conversations with leaders, providers, and changemakers who are working to improve access to care, enhance personalized support, and bridge gaps in maternal health. Listeners will gain valuable insights into the real-world solutions and care models shaping the future for expecting parents and families.
Dr. Michael Udwin:
This is often where the system breaks down after the pregnancy. How do we connect that pregnancy back up to primary care? Often, you got a lot going on. You've had a baby you're trying to deal with recovering from the delivery as well as managing your family, and now you're asked to go follow up with the doctor. So how do we make that care accessible, convenient, affordable, and to your word longitudinal so that that care transcends the pregnancy, whether it be behavioral health, mental health, as well as endocrine or other conditions that are going along as well?
Jennifer Sargent:
Welcome to Maternity Reimagined, a podcast exploring the future of maternal healthcare through the lens of innovation and human connection. I'm Jennifer Sargent. In each episode I'll be speaking with healthcare leaders, providers, and change makers who are working to transform how we support expecting parents and families. From hybrid care models and emerging technologies to policy shifts and real world solutions we'll uncover insights that are shaping a more connected, accessible future for maternal care. Whether you're a healthcare leader, provider, or just passionate about advancing maternal health, this podcast is for you. Join me as we reimagine what maternal healthcare can and should be.
Today on Maternity Reimagined, I'm thrilled to be joined by Dr. Michael Udwin. Dr. Udwin is a mission-driven physician executive and nationally respected leader in clinical transformation. As medical director at Care First Blue Cross Blue Shield and a long-time OB-GYN, he brings decades of experience aligning physicians, payers and systems around one shared goal, delivering high-value patient-centered care. Whether it's designing accountable care models, advancing population health strategies, or rethinking how we engage providers and maternal health outcomes, Dr. Udwin has helped organizations across the country transform care from the inside out. Michael, welcome.
Dr. Michael Udwin:
Thank you. Nice to be here.
Jennifer Sargent:
I'm so looking forward to the conversation.
Dr. Michael Udwin:
Me too. It's a great topic.
Jennifer Sargent:
Good. Well, I thought maybe we'd start a little higher level and talk about some of the broader system dynamics as it relates to maternal care. You've led transformation efforts across health systems and payer-provider partnerships, so you've sort of seen a lot of the broad landscape. When it comes to maternity care specifically, what are the core clinical delivery models that you feel like need to evolve?
Dr. Michael Udwin:
It's a great question, I might almost reframe it. I'm not even sure it's a matter of evolving, but perhaps it's blending. Different types of models are out there. We think about doula care that is very much at the center for the patient. We think of midwifery support during delivery as well. We think about a team model care, you still don't want to give up some of the expertise and the high-tech care that's there. So I feel like all the building blocks are there, but it's the way we put them together that's going to make a difference in terms of transforming or evolving the care as we move forward.
Jennifer Sargent:
That's great. And maybe related to that, as you think about putting those building blocks together, where do you feel like the breakdowns happen between what patients need and what's being delivered today? I mean, maybe it's a little bit of that team-based model, but maybe share some thoughts there.
Dr. Michael Udwin:
I think it comes down to one word and that's communication, and that works both ways. It's communication to making sure patients and members feel heard and respected. It's also communication from the provider lens, making sure that the instructions, the advice, the counseling that they're providing to patients is heard and respected and hopefully bring those two together. Now, there's an interesting dichotomy because from a high-level perspective, hospitals, health systems, entities are very much driven on reducing variation in care. We want to have everyone coming through in a standardized process because that's how systems usually function best is standardization as opposed to the opposite, which is very patient-focused, which is trying to customize all outcomes, all behaviors toward meeting the needs of the patient. So you don't want to sacrifice one for the other, but again, it comes back to that first question, which is how do we bring the crux of what you're asking communication together to make sure it's understood, received, and communicated effectively, to use the word in the definition.
Jennifer Sargent:
I love that focus on communication and at Pacify we have a big focus on relationship-based care between our lactation consultants and doulas and the member. But I think that also we need to think about the relationship between the providers and the care teams. And one of the things we focused on is how do we get doulas to develop better relationships with providers and have that bidirectional communication and relationship building? And I think the team sort of needs to start as we also fix the communication between the patient or member and the care team.
Dr. Michael Udwin:
Yes, I a hundred percent agree. I love doulas and I know doulas come in different varieties. There's of course doulas who deliver babies or some who coach on the front end, there's some who coach on the back end, some who do both. So I think some of the problem as much as I'm an advocate for doulas is they're doing their job, they're advocating for their patients, but implied in the word advocacy means that you're fighting against something, you're pushing back against something. So I don't want to change anything they're doing, but I'd like to come up with a new word that describes the relationship they have between the member and the provider community because I think it's more than just the OB, him or herself, it's the overall community with which that doula is working. So sometimes it's the nurses in the hospital, it's the administrators in the hospital as well as the nurses and folks in the office as well that we need to find a better way to make sure that their role is understood within the community.
Jennifer Sargent:
I really like that perspective, and I think we use the word advocacy a lot and it's an important part of what we're trying to provide for our members, but I agree with you. Sometimes that word can be a little loaded and maybe we can think of a new word and maybe our listeners who are listening today can put some suggestions in the comments and we can come up with a better word to describe that service that doulas provide, but in the continuum and the spirit of building relationships across the care team.
Dr. Michael Udwin:
Yeah, agreed. I don't want to change anything about what they're doing. I just want to rebrand it. I want to change the words.
Jennifer Sargent:
Yeah, I think that's fair. Shifting gears a little bit, let's talk about value-based care. I think value-based care, that word is thrown around a lot in healthcare and can mean a lot of different things. I always describe it as a continuum of potentially just looking at outcomes and metrics and tying financials to that all the way through to bundle payments, full risk and kind of in between. But when you think about value-based care for you and how Care First is thinking about working within value-based care model with your providers for maternity, what does that look like for you? What are you focused on?
Dr. Michael Udwin:
I would say it comes down, I'm going to lean on the quadruple aim a little bit in terms of we look at are we having care that's affordable, that's appropriate cost-wise, and thereby not just affordable but accessible? I think those two work hand in hand. Is their quality? And quality can be defined differently. It'd be defined by C-sections if you want to. It could be defined by NICU or neonatal intensive care use. It could be defined by the timeliness with getting appointments. We think about experience, the member experience as fits into that as well. And the final element of that quadruple aim is the provider satisfaction. In other words, if the docs aren't happy with the model or with the team they're working with, of course that's going to translate not just into the care providing, but the way that care is experienced. So I really believe value can be centered from a lot of different prisms, but if all four of those pillars aren't looked at collectively and holistically, it's not going to achieve quote "the value," air quotes there, that we're looking for.
Jennifer Sargent:
Yeah, I think that's a really great way to look at it. I think oftentimes we get too focused on either just the financial or just the quality metrics and miss the bigger picture around experience for both the patient member and the provider, all of the key stakeholders, extremely important.
Dr. Michael Udwin:
It is, especially I think now more than ever, I think patients coming back to the point earlier do feel frustrated and don't feel like they're heard. And of course there's burnout within the clinical community, not just the docs, the nurses, all the folks involved in the healthcare system I think are feeling a little bit of that strain and burnout that we have to be sensitive to. I want them to feel like they're empowered and part of a collective good.
Jennifer Sargent:
Great. We'll come back to talking a little bit more about how you're thinking about helping and empowering providers, but before we do that, you've worked extensively in population health and risk adjustment. How do you think about maternity care as a part of a broader population health strategy?
Dr. Michael Udwin:
I think historically, and it's a fair assumption, there's always been this thought that maternity brings in members to hospitals, and that may or may not be true. There's some debate about that, but I think any way you think of it, they certainly are a bellwether. So as maternity works or doesn't work within a community, it's probably a good function of how overall population worked within the system. So maternity is a great way to bring the patients, their families, their children now into the overall system of health and preventive health as well.
And it works both ways. If you have a community that has a high diabetes rate, well that's going to complicate maternity. By the same token, if you have a complicated pregnancy and it's not followed up as an outpatient once the pregnancy is over, that's going to complicate preventive care as well. And there's no reason to think that if there's problems with the overall health of the mom, it's going to impact the father, the children, grandparents, grandchildren. The rest of the family is probably suffering in a global perspective from a lot of the elements that are impacting that pregnancy as well.
Jennifer Sargent:
Yeah, I think that's a really great way to think about how you can use a pregnancy episode if you will, as a way to engage more broadly with a patient. Maybe let's take a minute and talk about how systems can shift from fragmented episodic model of maternity care. So just looking at the maternity sort of journey all the way from say, preconception through to postpartum and transitioning into early childhood for the child and the new parent. And we're thinking about that as we look at our partnership with Progeny on the fertility side and our new partnership with Seven Starling on the behavioral health side. How can we help connect members into services, not just between when they're pregnant and when they deliver, but the pre and post? How do you think about that and how do you think systems can shift and who do you think needs to be at the table to make that shift happen?
Dr. Michael Udwin:
You need a large table because there's a lot of different stakeholders to have that conversation. I think before you could begin that conversation, you have to understand the community itself, the population itself. And so we haven't talked yet about health equity and the disparities in outcomes across populations that's impacted not just maternity care, but care overall. So as we think about bringing folks to the table, we want to make sure that we have folks who can address impact and actually have a unique perspective to their own community. So if there are disparities in rates of C-section, if there are disparities in rates of diabetes or disparities in rates of vaccination, whatever you want to look at, that has to be included in how we think about the care from just not the paternity episode but longitudinally.
So folks typically don't just have diabetes during the pregnancy. It can complicate the pre-pregnancy and post-pregnancy state. Depression as well. Pregnancy often exacerbates a lot of those conditions, but they exist outside that norm. So I think the key to what you're asking, which is a great question, is how do we bolt on the non-pregnant and the pregnancy care? So often that begins with pre-pregnancy counseling, family planning well in advance of the pregnancy, making sure that we would use in medical term to tune them up before they get pregnant so they have a low blood sugar counts and appropriate blood sugar counts while they're pregnant.
This is often where the system breaks down after the pregnancy. How do we connect that pregnancy back up to primary care? Often you got a lot going on. You've had a baby, you're trying to deal with recovering from the delivery as well as managing your family, and now you're asked to go follow up with the doctor. So how do we make that care accessible, convenient, affordable, and to your word, longitudinal so that that care transcends the pregnancy, whether it be behavioral health, mental health, as well as endocrine or other conditions that are going along as well?
Jennifer Sargent:
I agree. We need a big table. We need to pull up some chairs. I think oftentimes we miss one key constituent at that table, and that's the member or patient themselves that is actually experiencing the things that well-intended people are trying to solve that maybe haven't experienced directly. Are you all doing anything around really how to represent the voice of the member or the patient in the maternal journey?
Dr. Michael Udwin:
Yes, we are, but frankly, there's always more we can do. We are in the process now of setting up a portal so that members can provide feedback on what their experience was in a safe environment. It's not going to come back to the member that we've done so, but will enable us to better understand beyond just the typical surveys that are done to give us a very high level perspective of how the members experiencing care, but more personal. We want to know what's working, what's not working. Did they feel respected? Did they feel heard? What resonated, what didn't resonate? Not they want to beat the providers over the head, but we want to be able to make sure that providers understand.
They really do have, I think often believe, the best intentions at heart, and it's the way that maybe their unintended actions are being perceived that needs to change often. And some of this is just a gentle coaching. I bet you didn't realize that the way you stood rather than were seated when you're meeting and greeting the patient has an impact. So it's often the little things that can have a profound impact on how one feels heard, coming back to our communication discussion.
Jennifer Sargent:
I love that and looking forward to hearing about what insights you're gleaning from getting that member feedback.
Dr. Michael Udwin:
Yeah, we are too.
Jennifer Sargent:
Let's shift a bit to thinking about the providers, the OB-GYNs and the advanced practitioners and how you're engaging with them. What's your take on how those providers are being engaged or not in these broader value-based or population health strategy conversations?
Dr. Michael Udwin:
We do our best to include as many of the clinicians and the folks who are delivering the care. And yes, sometimes as doctors, sometimes nurses, sometimes MAs. I think the more representation we have at the table, to your point, makes a big difference. We also want to, as we think about value-based care more broadly, how can the community and community resources contribute as well? How can technology support that journey, whether it be at the doctor's office, but other more global and holistic approaches we can provide that can essentially fuel that communication that we know is so desperately needed. So we think about getting as many folks involved. When we think about value-based care, we talked about that quadruple aim. We want to make sure if we're developing a model that incents the outcomes we're looking for, including high-quality, improved experience, reducing burnout, and is cost-effective, that we have within that model, things are within the doctor's control.
Some things they can't control, some things they can control, they can control hopefully making it convenient and accessible for patients to follow up on a very regular basis, not just during the pregnancy but afterwards, but making sure they're accessible on the front end. We also want to make sure that the providers often have very good intentions, know where to refer so they can refer to high-value specialists, refer to high-value facilities. Because that makes a difference, not just in the quality of the care that's provided, but in the overall cost and the experience by the member themselves. So we want to bring it all together and make sure that model is holistic, includes folks like doulas as best we can, midwifery support if we can. Whatever we think can really provide a more team-based structure. I think most folks would agree that team-based structure seems to provide the best way of providing that care.
Jennifer Sargent:
That's great. Obviously in order for these types of models to work and create change, we need to have engagement or adoption by the providers. And as we mentioned, providers have a lot on their plates. They're very busy experiencing burnout. What from your experience does it take to actually engage clinicians and get them excited and adopting transformation work like you described?
Dr. Michael Udwin:
I honestly don't think it's that hard. Providers are in medicine because they want to do the right thing. They want to do right by their patients. I also went back to the IHI. We want to engage in the provider's quality initiatives. Providers really want to provide the best level of care, and it's up to us to make it easy to do so. It often begins by understanding they're curious and competitive. Folks want to know, they truly believe, and frankly, a lot of times it is they're providing a high level of care, but they want to know how they compare their care to others. So providing data to providers, understanding how they compare as a peer group to others often goes a long way. And then they can look at that. They understand, "You know what? Maybe we're not risk adjusting properly. I do take care of, my colleague takes care of sicker patients, so it's understandable they may have a higher complication rate or more challenges in the office than I might have otherwise."
So as you do that and as you engage them, I also want to be sensitive to two things. One, most importantly for most providers, we think about quality, often we think about it from looking at charts and graphs. For providers, when you're with a patient, it's extremely personal. You really believe that you're providing high level of care and to be told that it's not as good as someone else, it's easy to become defensive. So I want to make sure the providers understand that you're providing great care. This is how we can go even further. We also want to make it easy to do the right thing. We talked earlier about systems, make sure we have systems that make it easy to do the right thing.
And we want to award and reward and recognize the small changes. We don't need to boil the ocean, right? I want to create some small changes, making it easy for patients to come in the office. Having a bundle during labor and delivery that makes it easy to provide safe care in the operating room or even in the labor and delivery room. And finally, as we engage those providers, I want to be sensitive to their time. You talked earlier about burnout. I want to meet on their schedule. If it's in the morning because they start patients at 8:00 and they want to start any quality meetings at 7:00, I'm all for it. If it's early in the evening, that's fine too. If they have families in the evening, the last thing I want to do is have a meeting when it competes with family time, we'll do it lunchtime. So I want to be very sensitive to taking it the least amount of time I need to providers to gather insight, but still making sure we've included their perspective in anything we do moving forward.
Jennifer Sargent:
Maybe let's unpack a couple things you said in a little bit more detail. First, the easy part. And we are also very focused on how do we just make it really easy for providers to refer members to us for doula services so they don't have to take an extra step. But as you have worked across the systems and worked with different provider groups, what are some example, small, large, medium of practice level redesigns or just changes that have been made to make some of these things easier?
Dr. Michael Udwin:
So some things are really easy, some things are not as easy to do. I think some things, I'm going to start first in the hospital, order sets have been around forever, but bundling postpartum follow-up, which often most folks would benefit from lactation support as well as behavioral support. And if they've had a complicated pregnancy, close follow up afterwards. So why can't we bundle all those together and make them easy to access lactation, behavioral health resources, and postpartum? It's for blood pressure, if it's for sugar levels related to a complicated pregnancy, make it easy to do.
I think also in the office, making it easy to see the right patients in the right order. I think there's a lot of work going on now with stratifying low and high risk patients in the office setting. So if there is a physician assistant or someone else in the office, you can see and spend more time with patients who maybe are less complicated or a little more time, let's do that. If we have super complex patients and they need specialized care, let's make sure the docs are available to treat those. So being thoughtful in who sees patients and how much time is assigned to folks as are going through the system.
And finally, routine screening. We do it for diabetes, high blood pressure, a lot of viral conditions during pregnancy. Behavioral health is just as important. So doing a screening test and then making follow-up super easy is the key. So there's always been this concern that if I screen for depression, I won't know where to send them. So we need to make it easy to follow up once you've found someone, and most folks, if you ask, they'll tell you. If you create a safe environment, they'll tell you how they're feeling, and then make it easy to refer those patients out. So those are just simple things.
I know there's other work around the country going with virtual visits, which I think is super cool. If you send them home with a Doppler machine and a blood pressure cuff, do virtual visits. I think the Mayo Clinic has done some really interesting work. Kaiser does work in that space as well, which I think can go a long way, again, to meeting patients where they are. So we want to be innovative, we want to be thoughtful in how we introduce technology and make it again, patient centered.
Jennifer Sargent:
Yeah, I think that's great. And I think we look at virtual care as very appropriate in certain settings, especially if you think about the postpartum setting, new mom, new baby, not maybe wanting to leave the home and virtual care for certain things can play a really compelling role in that member journey, for sure.
Dr. Michael Udwin:
Yep, totally agree.
Jennifer Sargent:
Let's shift gears a little bit and talk about reimbursement strategies. I'm going to start a little high level, and you touched on a few things related to reimbursement, bundle payments, et cetera. How else are you thinking about reimbursement strategies across maternal care, especially as you think about potentially adding in additional care team members like doulas, et cetera, across that continuum?
Dr. Michael Udwin:
Yeah, no, it's great. I do believe that reimbursement strategies have to be part of the equation. Balanced, of course, we talked about before, we don't want to sacrifice quality. We don't want to sacrifice experience, and I don't want to sacrifice provider burnout in the process as well. So I want to be very thoughtful to all those. We often talk about we want to lower the C-section rate because a C-section rate is high, but I want to be thoughtful in the way we do it. Sometimes there are very good reasons why there are C-sections. Sometimes there are C-sections that are avoidable. Sometimes it's a patient preference. I want to be thoughtful. And often it's not a matter of looking so much at the actual number of C-sections, but the safety and the processes behind those C-sections. So thinking about our C-sections done safely, is there a pause before a C-section?
Some organizations now have instituted a second opinion for any C-section to make sure is this the right thing for this patient? So I want to make sure C-sections are done on folks who truly need them, but if there's a chance to avoid without compromising safety or patient preference C-sections, we want to go there and support those efforts as well. Something that comes down to transparency, I think the more transparent we are in providing C-section rates, especially first time term C-sections, that goes a long way in the process.
But I also want to look at other elements that are impacting care as well. We talked about behavioral health screening. Can we incent behavioral health screening? We talked before about social drivers, health a little bit and health equity. Can we incent screening for that and referrals for that as well? Because we know that plays an important part in overall care and access and outcomes as we think about it. And you alluded to it earlier incenting not just the doctors, but other folks at the table. We talked about the doulas, midwives, folks within the community who are supporting that care. We want to make sure they have a seat at your table you mentioned earlier, and they share in the incentivizations that we've offered there as well.
Jennifer Sargent:
That's great. Let's talk a little bit about Medicaid. Obviously they are major player in the maternal care landscape in the US and are oftentimes a leading driver and things like doula reimbursement and other things in which then sort of cause a groundswell for change across the country. But maybe share some thoughts about innovative ways that Medicaid or MCOs managed care organizations can better work within Medicaid and align incentives to improve outcomes in maternal health.
Dr. Michael Udwin:
Oh, it's such a great question because you're right. I think 40% of all deliveries are done within Medicaid, so has a very high prevalence rate, and you look at it nationally across the country. Some things are ahead of the curve line. I think Medicaid in many parts of the country has introduced CenteringPregnancy, which is group prenatal care. Love the concept, not just because it's often a way of building collaboration among the patients who are there and in building lifelong friends. I've heard lifelong friends developing from their CenteringPregnancy courses and classes as well, but also doula support too.
I think doulas often came out of a lot of the Medicaid markets, and that's been terrific. I would be remiss if I didn't talk about there are challenges with the reimbursement for doula care that often makes it very challenging, we were a doula event last week, just to sustain it. They're there for the long haul for that pregnancy. If it's a six-hour labor or a two-day labor, that doula is with that member, and so we need to find a better way to compensate and align the incentives for doula care as well as we think about it.
Often, we talk about the 80% of one's health and wellbeing occurs outside the walls of the doctor's office. That applies to a lot of the social drivers of health and the barriers to care as we think about it and in lieu of services do play a role in the Medicaid market as well. So if we can make meals available to members, not just when they're pregnant, but you talked about earlier postpartum, that's probably when you need those meals as well, if not more than you needed during the pregnancy. Transportation we've talked about. One of the things we don't talk about as much about, but we should have is health literacy as well. It comes back to the conversation we're having about communication that making sure that members are heard and we're speaking a language that's resonating with our members. So I think there's a lot that Medicaid can do to highlight the importance of health equity and unconscious bias training as well as the other in lieu of services we talked about around social drivers of health in addition to just cool programs like CenteringPregnancy.
Jennifer Sargent:
Yeah, I love that, and I think a big focus on how we just get members engaged with better community services can be so critical. We talked about health equity and oftentimes members, yes, they're pregnant and they're thinking about that pregnancy, but they're also thinking about and focused on and concerned other areas in their life, which can then just add more stress to that pregnancy. So I think anything we can do in partnerships as we pull the chairs up to the table to think about how we address those needs more broadly can be hugely impactful.
Dr. Michael Udwin:
Yes, a hundred percent agree. I think also the more we can connect the pediatrics to the OB. Often, and OB is as guilty as any field, we hand the baby off and that's it, right? We're done. In some parts of the country, the OB does a circumcision in other parts of the country, it's not even done by the OB, so there's almost a dismissal of the pediatric end. I think the more we can do to connect those pieces in our value-based care models of incenting care that doesn't involve the NICU or neonatal care, but also looking more globally as we think about the overall population health of how well children thrive and how much we can link that back to overall maternity care as well.
Jennifer Sargent:
Yeah, I think that's great. We have talked a lot today about opportunities for improvement, which I love, and things that could get better. Let's end with one final question. What gives you hope right now about the future of maternal health?
Dr. Michael Udwin:
I would go far beyond hope, I'm optimistic. I'm nearly certain, if not certain, that there is a bright future ahead. It's because there is such visibility on the topic. There are such motivated people all aligned on the same goals. We want healthy families, and that begins with maternity care. So I'm extremely optimistic about where we are. The OBs that I talk to, they're extremely engaged. The doulas, the midwives, all the stakeholders we alluded to earlier, they often mentioned, just you bring it out of nowhere that they are optimistic about the future themselves. So I think it's our job to create a framework, to create an infrastructure that recognizes everybody's sincere commitment to do the right thing.
Jennifer Sargent:
Well, I share your optimism. Dr. Udwin, thank you so much for joining us today and having the conversation, and thank you for everything that you are doing to try to reimagine maternity and drive a better experience.
Dr. Michael Udwin:
Thank you. It's been my pleasure.
Jennifer Sargent:
Thank you for listening to Maternity Reimagined. I'm your host, Jennifer Sargent. If today's conversation resonated with you, please subscribe and listen wherever you get your podcasts. And be sure to share this episode with those who, like us, are passionate about reshaping the future of maternal health. Until next time, as we continue to build bridges and transform maternal care together.