New Mexico obstetricians are crying foul over an agreement forged by the state's human services department, several managed care organizations, and the state's midwives that will allow for Medicaid reimbursement for home births yet not require the midwives to carry liability insurance.
New Mexico has unusual parity in its numbers of midwives and obstetricians. According to the state Department of Health, there are 55 licensed midwives and 144 certified nurse-midwives in the state, a total of 199. According to the American College of Obstetricians and Gynecologists, there are 146 ACOG members (plus 51 junior fellows) in the state. In 1997, the New Mexico Medicaid program was privatized, and it's now run by managed care organizations (MCOs). The state requires that MCOs carry medical malpractice insurance, and MCOs in turn require the same of all their providers.
Midwives performing home births typically do not carry malpractice insurance. When that insurance is available, the cost is prohibitive, but few insurance companies are willing to write policies covering home births at any cost. It's not that there have been a large number of expensive claims, said Roberta Moore, maternal health program manager for the New Mexico Department of Health. Insurers simply don't see this market as profitable.
The new agreement provides for reimbursement of midwives provided that Medicaid-eligible women who choose to use their services acknowledge that they are aware of the midwife's lack of insurance and formally waive their rights to pursue legal again action against the state, the MCOs, or the midwife. The relatively small number of obstetricians in New Mexico and the state's rural character helped proponents of the agreement argue that it offers women in underserved remote areas access to care that they ordinarily would not have.
Dr. Sharon T. Phelan, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, doesn't buy this argument. In an interview, she noted that family physicians frequently perform births in rural areas of New Mexico where there are no obstetricians, so these areas are not really underserved. Those family physicians have mandatory malpractice insurance.
In addition, the agreement does not limit Medicaid reimbursement to midwives in rural areas. An Albuquerque-based midwife would receive reimbursement, even though there are many obstetricians in that city, Dr. Phelan pointed out.
Furthermore, there is a fundamental unfairness in allowing midwives to go without malpractice insurance while receiving about the same fee as an obstetrician does for a birth, Dr. Phelan said.
“When you're getting paid $1,200 for 9 months of care and a delivery, there are places where docs are having to deliver a hundred babies just to meet their malpractice [insurance premiums],” Dr. Phelan said, noting that with premiums of approximately $80,000 annually, New Mexico obstetricians are getting somewhat of a bargain, compared with colleagues in other parts of the country. New Mexico authorities basically treated the malpractice insurance problem “with an aspirin, which is to say [that midwives] are an exception to the rule and they don't have to carry insurance and they could still get paid. But they did not deal with the underlying problem,” which is the malpractice insurance crisis.
And she noted that when a home birth starts going wrong, mother and baby would be transferred to a hospital. Supposing the infant or the mother dies or the child has an ongoing deficit, “who's going to be sued?” Dr. Phelan asked. “It's the doctor who inherited a problem that was already in development, because he or she is the one with the malpractice insurance. We're the ones with the deep pockets, so we're the ones who are going to get dragged to court and have to spend days in depositions and in court going through all that emotional stuff on our own.”
The Midwives Alliance of North America (MANA), one of the two national midwifery associations (the other is the American College of Nurse-Midwives), said that it's true that midwives aren't sued very often, but the reasons are unclear. According to Diane Holzer, MANA's president and a licensed midwife, part of the reason may be that patients are more satisfied with their care or that midwives are able to develop more of a personal connection with their clients.
She noted that even in the nine states in which Medicaid reimbursement for home births technically is permitted, many midwives cannot actually receive reimbursement. California, for example, allows for Medi-Cal reimbursement of home births only if the licensed midwife is being supervised by a physician. But according to Ms. Holzer, not a single physician in California is willing to supervise midwives.