Another important change: Medicaid now reimburses for the services of any provider who practices in a state-licensed, free-standing birth center as long as that provider is practicing within the state’s scope of practice laws and regulations. That means that if a state allows doulas or lay midwives to provide childbirth care in free-standing birth centers, the federal and state Medicaid programs will pay for this care. This policy is consistent with “any willing provider” rules found elsewhere in Medicaid.
There are 215 birth centers in the United States, with more in development. The number of birth centers has increased more than 20% over the past 5 years; they are regulated in 41 states.4
ACOG’s Guidelines for Perinatal Care asserts: “The hospital, including a birthing center within a hospital complex, or free-standing birthing centers that meet the standards of the Accreditation Association of Birth Centers, provide the safest setting for labor, delivery, and the postpartum period.”5
Reimbursements for nonphysicians are increasing
Beginning in 2011, the Medicare program began reimbursing CNMs, the most highly trained midwives, at 100% of the physician payment rate for obstetric services. Until 2011, CNMs were paid at 65% of the physician’s rate for the same billed services.
In addition, from 2011 through 2015, CNMs whose primary care services account for at least 60% of their Medicare-allowed charges will receive Medicare bonus payments of 10%, reflecting Congress’ concern that our nation faces a serious shortage of primary care providers.
Another important provision goes into effect in 2014: All health plans offered in a state insurance exchange must accept and pay any provider recognized under state law for services covered by that plan. CPMs, some of whom are among the least highly trained providers, are licensed to provide maternity care in 24 states. This provision may put pressure on health insurers to pay for maternity care provided by CPMs, regardless of their training and certification, even if the insurer doesn’t contract with these providers.
“Even a normal pregnancy can become high-risk”
In 2008, the Massachusetts legislature debated expanding childbirth care to encompass less highly trained providers. ACOG President Kenneth L. Noller, MD, MS, cautioned them about the move, saying: “Even a normal pregnancy can become high-risk with little or no warning, and serious, sometimes life-threatening complications may arise for the woman and her fetus.”
He noted that shoulder dystocia occurs in one in every 200 births and listed the frequency of other complications:
- prolapsed umbilical cord: 1 in every 200 births
- life-threatening maternal hemorrhage: 1 in 250
- eclamptic seizures: 1 in 500
- uterine inversion: 1 in 700
- Apgar score of 0–3 at 5 minutes: 1 in 100 to 200.
Three years later, ACOG President Richard A. Waldman, MD, and American College of Nurse Midwives (ACNM) President Holly Powell Kennedy, CNM, PhD, wrote: “Collaborative practice [is] the provision of health care by an interdisciplinary team of professionals who collaborate to accomplish a common goal, and is associated with increased efficiency, improved clinical outcomes, and enhanced provider satisfaction.”5
These messages demonstrate the importance of careful use of collaboration to manage risk and maintain the highest standards of patient care. The questions for ObGyns who are considering collaborative practice:
- What is careful use?
- How do you collaborate carefully, without increasing the risks faced by your patients and your practice?
- How do you make collaboration a success?
- ACOG has taken on these questions and offers sound practical advice.
ACOG recommends high standards and clear practice agreements
ObGyns have a long history of collaboration with our nurse-midwife colleagues—possibly one of the strongest collaborative traditions in medicine. ACOG supports the practice and licensure of trained midwives credentialed by the ACNM. CNMs are well-educated, highly trained, and well-integrated into the health-care system.
In addition to the ACNM standards, ACOG supports the “global standards for midwifery education” established by the International Confederation of Midwives (ICM) in 2010:
- The minimum entry level of students is completion of secondary education
- The minimum length of a direct-entry midwifery education program is 3 years
- The minimum length of a post-nursing/health-care provider program is 18 months
- Standards are congruent with current core ICM documents and position statements.
ACOG strongly encourages that in no case should the professional standards of any maternity provider be less than the standards established or accepted by ACOG or the ACNM.
Effective collaboration depends on clear practice agreements between physicians and CNMs, consistent use of shared practice guidelines, and malpractice insurance coverage of all parties. A collaborative agreement that clearly spells out the mechanism for consultation, collaboration, and referral is essential to assure the best care.