Sunday, June 20, 2010

Insurance for homebirth midwives

With only 10 days left before legislation requiring midwives to have indemnity insurance for all our private practice excluding homebirth, we midwives want to know what insurance product is available, what it will cost, and how it will impact on the service we provide for women and babies in our care.

I am taking care to update readers in a factual way, although when you have read to the end of this post you may be less than confident in knowing the way forward. What you read here is the opinion of the writer, with links to the information provided by the insurance companies. This information may change from time to time as the sites are updated.

A previous post on this blog has information about the two products on offer, and links to their sites.

Updating the situation:
The VERO Mediprotect insurance provides indemnity only for prenatal and postnatal midwifery services. It has an excess of $2,500 with each and every claim.

The MIGA insurance, which covers prenatal, birth in hospital, and postnatal care claims to be "the sole provider under a new Government supported Scheme to provide Professional Indemnity Insurance to privately practising midwives" (from the MIGA website), now linked to the front page of the College of Midwives.

A News Flash from MIGA (18 June) states that "Over the next few days we will be updating the policy and other information on our website to reflect the changes which essentially relate to the collaborative requirements and employment."

A third avenue by which midwives have investigated obtaining insurance that meets the new legislative requirements is through membership in the nurses and midwives union, ANF. In several States (Vic, Qld and WA), all ANF members, EXCEPT independent midwives, have a professional indemnity insurance cover of $10 Million, with legal representation and support thrown in. The curious fact is that this policy is sourced from VERO. Members have pointed this fact to the ANF professional, legal, and industrial departments and written emails and letters reminding ANF that now homebirth is exempt, surely the risk to the organisation is minimal, and no greater than the 'risk' any other member's private practice engenders. ANF must have private practice nurses working in high risk nursing such as diabetes, wound care, and probably many other fields, and these members are indemnified. To date, ANF Victorian Branch has consistently rejected members' attempts to engage on this matter, responding with rather dismissive letters that contain obvious inaccurate information, while ANF Qld and ANF WA branches have given some members a positive response - that their membership insurance will meet the requirements of the new legislation, EXCLUDING homebirth.

I have written about this publicly because midwives who are members of ANF expect their union to apply its principles of fairness and support for workers to them as well as our colleagues who are employed. ANF has in the past decade hidden behind the belief that midwives in private practice, and homebirth, are high risk and cannot be insured. With the exclusion of homebirth, ANF now has the opportunity to stand up for members who are midwives. This matter is now being referred to the federal ANF level.

Back to the two insurance options, VERO-Mediprotect and MIGA.

Advice from Paul Currall, Director, Medical Indemnity Section at the federal Department of Health (dated 15 June 2010) is that:
"Professional indemnity insurance is a registration requirement, .... The obligation is on the midwife to have appropriate insurance arrangements in force, and midwives will need to consider whether the Mediprotect policy is appropriate for them. As it is a registration requirement, if it becomes an issue then it will be the Nursing and Midwifery Board which is the relevant body."

[Note that the complete contents of the email that this advice appeared in are copied below for those who are interested.]

In conclusion, here are some of the apparent differences between the two insurance products currently on offer (as I understand the situation. If I have missed anything please let me know).

  • the less expensive option
  • excess of $2,500 with each and every claim

My opinion: this insurance product appears to meet the requirements at present for midwives in private practice, covering prenatal and postnatal care, and excluding homebirth.  A woman in the care of a midwife who is skilled in basic midwifery as primary carer is extremely unlikely to experience incidents which would lead to claims on such an insurance policy. When a woman in our care is transferred to hospital, the midwife who accompanies her has no practising rights in the hospital.

  • the more expensive option
  • offers medico-legal support
  • requires risk management at the instigation of the insurer
  • no excess
  • Option A provides cover for midwives eligible for MBS/PBS and hospital birth
  • Option B is similar in cost to VERO-Mediprotect, BUT is available only "if providing no Intrapartum Care at all in your private practice"*

My opinion: this product will be useful when midwives practising privately are able to attend their clients to give birth in hospital, limit their practice to hospital birth, and when the clients are able to claim Medicare rebates (due to commence November 2010). * Since the raison d'etre for the midwife as primary carer is continuity of care, enabling the development of trust and reciprocity between the woman and her known midwife, what's the point of providing NO intrapartum care? [sigh! They just don't get it, do they?]

The MIGA insurance appears to usher midwives into a new era of defacto regulation by in insurance company that exists to make money for its shareholders. In essence, as far as MBS/PBS eligible midwives are concerned, the NMBA becomes a rubber stamp committee.

NOTE: The views expressed in this post are that of the author only and are not intended to be advice. Individual midwives should of course make their own investigations before determining which insurance product is most suitable for their practice.

Question from the College of Midwives to the Medical Indemnity section of the Health Department:
"Is it the case that a midwife wishing to apply for an MBS provider number will need to purchase the MIGA policy? That’s what I’ve been presuming, because I know that the provider number will not discriminate between a midwife doing pregnancy care only and one doing everything, so presumably they have to be insured to do everything?

"The answer to this question will as you would no doubt anticipate be of particular interest to the HB midwives, who are weighing up now whether to take up the MBS option or to simply practice under the exemption with the Vero policy."

Response to the above question, from Paul Currall (dated 15 June 2010):
"Professional indemnity insurance is a registration requirement, not a separate requirement for MBS/PBS access. The obligation is on the midwife to have appropriate insurance arrangements in force, and midwives will need to consider whether the Mediprotect policy is appropriate for them. As it is a registration requirement, if it becomes an issue then it will be the Nursing and Midwifery Board which is the relevant body.

"A midwife wishing to apply for an MBS provider number must meet the NMBA's requirements for registration as an eligible midwife. These are the same requirements that a midwife needs to meet in order to be eligible for the MIGA insurance policy.

"If the midwife meets the NMBA requirements for registration as an eligible midwife, then she/he can apply to Medicare Australia for a provider number to gain access to MBS rebateable services. In the case of a midwife who has insurance cover for ante and post natal services only (and provides intrapartum services for homebirth), access to MBS funds will only be available with respect to clinically relevant ante and post natal midwifery services.

"If a midwife is an eligible midwife for the purposes of the National Health Act 1953 and is approved to prescribe medicines in the state and territory in which she/ he will be practising, the midwife can apply for approval as an authorised midwife, a PBS prescriber, and be allocated a prescriber number."


Joy Johnston said...

A question that comes to mind is "what insurance does a private midwife need when she intends to accompany the woman to hospital for birth?"

In my practice some women come to me as their primary care provider, without having made up their minds as to whether they want to give birth at home or hospital. I encourage this thinking, and have based my guidance on the Albany midwifery group practice in London (I think they have been shut down now unfortunately). The woman comes to her midwife for prenatal checks, and organises blood tests and any other medical investigations with her local doctor, and we make a hospital booking. After establishment of labour the midwife works with the woman at home. The woman decides if she wants to go to hospital, with her midwife, or if she wants to continue labouring at home.

My understanding is that the MIGA insurance is only appropriate for midwives who have clinical privileges/practising rights in the hospital. MIGA has a policy that covered antenatal-postnatal only, but Option B is available only "if providing no Intrapartum Care at all in your private practice"

I understand that a midwife who has purchased an insurance that covers birth in hospital may intend to use that fact in negotiating access to the hospital.

Midwives in private practice need to systematically write to the public hospitals, and ask for visiting access so that the process can be got started.

In the mean time when we go to hospital with a client we will not need insurance, because it's effectively a homebirth transfer. I can't see that there is any acknowledgment in the insurance policies of the option for 'planned hospital birth with private midwife in attendance'.

Joy Johnston said...

make that last sentence: 'planned hospital birth with private midwife WHO MAY NOT BE ACKNOWLEDGED AS A MIDWIFE BY THE HOSPITAL, BUT WHO THE WOMAN HAS CHOSEN TO PROVIDE EXPERT MIDWIFERY CARE in attendance'.