Progress report: 2 years

It has been two years since the federal government's maternity reforms became effective, with the political spin of  “Providing More Choice in Maternity Care – Access to Medicare and PBS for Midwives”, stating that "... in light of current evidence and consumer preference, there is a case to expand the range of models of maternity care." (for more detail click here)

Yes, 
consumer preference was very clear: thousands of submissions to inquiries, many from ordinary mums and dads and grandparents, many of whom had never previously made any attempt at political action.
But,
consumer preference in this instance was overwhelmingly in favour of the option of homebirth attended privately by a midwife.
And,
since current evidence supports planned homebirth, with access to suitable obstetric hospital services when required, as being at least as safe as hospital birth for most women, I fail to understand the action of the government in summarily excluding homebirth from any Medicare benefit.
(Many have made plausible suggestions about a paternalistic, nanny-state, socialist policy that seeks to provide a one-size-fits-all plan for maternity care.  'Informed decision making' has become a one of those hollow phrases that are used because they sound so fine.)


The package of maternity reform focused on professional indemnity insurance, Medicare, and PBS (pharmaceutical benefits scheme) for midwives, with provisions for midwives to attend our clients privately for birth in hospitals.  Looking at each of these elements:

• Midwives are now covered by professional indemnity insurance (PII) for all antenatal or postnatal services, and for intrapartum services provided in (just a few) hospitals.  Midwives attending homebirth have been granted an exemption from PII until June 2015.  The obvious problem with this arrangement is that if PII is a rational and reasonable product, cover for intrapartum care would be essential.  But, since noone in the insurance industry has been able to come up with an affordable insurance product for midwives, the exemption has been put forward as a stop-gap measure. (more here)  Perhaps the implementation of the government's National Disability Insurance Scheme will ease pressure on the insurance market, and bring some relief to this stalemate.  Independent midwives in the UK at present face loss of their ability to practise because PII has become mandatory.  This is definitely not in the public interest, and is an example of regulation of a profession being delegated to the insurance industry.
• Medicare provider numbers are being used by an estimated 150-200 midwives nationally.  The provision of Medicare rebates for women who receive part of or all their maternity care from privately practising midwives should lead to a reduced reliance on maternity hospitals, which are in may places overstretched, overbooked, and under-staffed.  Yet, midwives who have asked hospitals to refer women to them for shared antenatal care, or for primary care with a plan for hospital birth, have (almost uniformly) received negative responses.   Victorian midwives in private practice continue to experience roadblocks to implementing the promised reforms. 
• The PBS provisions of the reform package are yet to be fully implemented.  We know of one midwife in Victoria who has been endorsed by the Board for prescribing.  Other midwives will be applying now, having completed the Flinders University's Graduate Certificate in Midwifery (pharmacology and diagnostics).  The Victorian legislative changes have recently been gazetted (click here), enabling authorised midwives to become prescribers. 

The hospitals where intrapartum care is (or soon will be) provided by private midwives are Toowoomba, Gold Coast, and Ipswich, in Queensland.  The model has been established with My Midwives. 

Collaboration, the core requirement for Medicare funding to be accessed by the woman, continues to present huge challenges to midwives.  Most midwives who practise privately have women coming to them from many different communities.  These women see different doctors, and it is not possible for the midwife to have met or worked with most of these people.  Some doctors are ready and happy to refer women to midwives for private care; some refuse outright; and some go to extraordinary lengths to cover themselves, in case something goes wrong.  One doctor sent a letter by registered mail to the private midwife and the pregnant woman, informing them that she (the doctor) opposed home birth under any circumstances.  No evidence was given for this position.  In the discharge letter to the GP, the midwife wrote:

... I acknowledge receipt of your letter in which you stated that you do not endorse homebirths.  I would like to direct you to the Cochrane (2012) review of planned hospital versus planned home birth, in which the authors state “Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications.” 

Hospital visiting access has been the dream of some privately practising midwives.  There are many practical reasons why they would like to offer hospital birthing to their clients, the obvious one being that this is where most Australian women intend to give birth.  Homebirth can be seen as unusual, and not well understood.  

At present an investigation is being undertaken by the ACCC into specific cases of anti-competitive behaviour by obstetricians or hospitals, blocking access to midwives.  Any midwives who have documentary evidence that they believe would contribute to this inquiry may contact me by email, and I will give you the names and contact details for the case officers who are heading up this investigation. [Joy Johnston joy@aitex.com.au ]

Is there a way ahead?  Is there a light at the end of this next tunnel?

Midwifery is a legitimate option for women seeking maternity care.

Midwives are able to offer basic maternity services, regardless of where that birth is planned.

Fellow midwives, I encourage you to reconsider the way we provide midwifery care for mainstream women who intend to give birth in a hospital.  In the past we, the 'good girls', have entered shared care arrangements where possible, and provided private midwifery services in addition to the services provided by public hospitals, accompanied these women to hospital in labour, and done all in our power to protect, promote and support wellness, within the constraints of the system that would prefer us not to be involved.  

The new midwifery led primary maternity care model will be woman-centred, and community based.  The hospital will be excluded from the model until the time comes to use the hospital, whether that is during labour, or before or after birth.  Since independent midwives have been excluded from hospital collaboration, we have no choice but to act autonomously within the community, at the same time as collaborating with the specified medical practitioner for that woman, and providing a written handover to the hospital when hospital care is required.  

Women who choose this model of care may be classified as 'planned homebirth', when in fact they did not plan homebirth.  That doesn't matter - it's not about the setting, or the statistics.  The main goal of this proposal is that women are able to access midwifery primary care from a known and trusted midwife: 'more choice' from 'expanded models' of maternity care.

This post contains the opinions of the writer, which are not necessarily shared by all members of MIPP.

Your comments are welcome.

An update on midwife prescribing

Midwives who have achieved eligibility for Medicare (MBS) under the Commonwealth Government's National Maternity Service Plan (2010) are also preparing to extend our practices to include prescribing, and participation in the Pharmaceutical Benefits Scheme (PBS).  Midwives with PBS authorisation will be able to prescribe, supply, and administer scheduled medicines. 

Historically, midwives attending homebirth have obtained the few medicines we need in private midwifery practice through a doctor's prescription.  The midwife has administered these drugs without a legislated process.  Oxytocics for the management of post partum haemorrhage by intramuscular injection have been prescribed by doctors for women in our care, and purchased (in boxes of 5 ampoules) from local pharmacies.  The midwife assesses the woman's condition, and administers the drug on her/his own authority.  The management of the third stage pf labour is basic to midwifery, and it is in the public interest that all midwives maintain their competency in the use of oxytocics: that this is not restricted to those who have PBS authorisation. 

A number of Victorian midwives are enrolled in the 6-month Pharmacology course at Flinders University in Adelaide, which is the only such accredited course for midwives seeking PBS authorisation.  We know of a couple of midwives who have completed courses in pharmacology which have been accepted by the regulatory authority (AHPRA) as equivalent. 

Each state and territory have already either undertaken, or are in the process of making, the necessary legislative changes to authorise registered midwives to prescribe under the PBS.  

The Victorian Health Department has appointed the 3CentresCollaboration to consult with stakeholder groups, and to prepare a draft list of Schedule 2, 3, 4 and 8 medicines for prescribing by midwives in Victoria.  The work has advanced to the final checking of the list before it is approved in the law.  The stakeholder groups and experts who have been invited to review the list include relevant midwifery and obstetric colleges, unions and professional organisations, employers of midwives, consumer groups with a remit or interest in midwifery, maternity services or associated services as well education providers (ie midwifery pharmacology course providers). 

The scope of prescribing is limited to medicines appropriate for midwifery practice across pregnancy, labour, birth and post natal care (including neonates up to six weeks).  Midwives who will use their PBS endorsement include those providing private antenatal and postnatal care in a variety of settings and intrapartum care as a private midwifery provider to a private client either at home, or (when midwives are able to have clinical privileges/visiting access) within a health service. 

[MiPP has submitted a response to the draft documents.]
 
Your comments are welcome.

Questions and Answers - Medicare-eligible midwife starting up private practice

Hello dear reader,
I am preparing a series of posts on general questions asked by women and midwives about private midwifery practice. If you have questions, please add them in the comments section, or send me an email joy@aitex.com.au

In preparing questions and (attempting) answers, please note that questions on clinical conditions can only be addressed in a general way, and cannot replace the face-to-face discussion and decision-making between a woman and her midwife or other care provider.  Also readers are welcome to provide additional information or discussion via the 'comments' section, or to write guest posts.

Frequently asked questions can be grouped, and colour-coded to help organise:

1. about midwives who have (or plan to obtain) Medicare provider numbers
2. about planned homebirth
3. about planned hospital birth
4. about vaginal birth after caesarean surgery (VBAC)
5. about women who have certain 'risk' factors
6. about ...

Today's question, to get the ball rolling, is:

Q. I wish to practise as an eligible midwife providing antenatal education and postnatal care.  How do I go about getting started?

A.  The short answer is that there is a great deal of scope for Medicare participating midwives to offer private midwifery services, including antenatal care and postnatal care.

When commencing private practice, a midwife is advised to find an experienced mentor, who is willing to support the midwife's entry into private practice. You may avoid a few headaches!



The longer answer ...

Women who receive midwifery care from a chosen midwife in private practice who is Medicare-eligible, and who has fulfilled the requirements such as collaborative arrangements and indemnity insurance (these have been written about previously on this blog. Use the search function if you want to check out previous posts) will receive rebate on the midwife's fees for services that have a Medicare item number.  The amounts of rebate are set out in legislative tables that are available for anyone interested.


The following brief summary is quoted from the government's ComLaw website.

Health Insurance (Midwife and Nurse Practitioner) Determination 2011 - F2011L02162

Schedule 1 Midwifery services and fees

Part 1 Midwifery services and fees

Part 1 of Schedule 1 of the Determination sets out the relevant general midwifery services, assigns applicable item numbers, item descriptors and fees for the services. These items enable the payment of Medicare benefits to patients of participating midwives for antenatal, birthing and postnatal care: ·

• an initial antenatal attendance of at least 40 minutes duration (item 82100); · 
• a short antenatal attendance of up to 40 minutes duration (item 82105); · 
• a long antenatal attendance of more than 40 minutes duration (item 82110); · 
• development of a maternity care plan for a pregnant woman, where the pregnancy has progressed beyond 20 weeks (item 82115); · 
• management of a confinement for up to 12 hours (item 82120); · 
• management of a confinement in excess of 12 hours, where care of the patient is transferred from one midwife to a second midwife (item 82125); · 
• short postnatal attendance of up to 40 minutes duration (item 82130); · 
• long postnatal attendance of at least 40 minutes duration (item 82135); and · 
• six week postnatal attendance (item 82140), after which the woman would see her general practitioner. 

Antenatal and postnatal services may be provided in a range of settings including in consulting rooms, community clinics and the woman’s home. Medicare benefits for the management of labour and delivery are only payable where the service is provided to an admitted patient of a hospital, including a hospital birthing centre.

Please note that there is no Medicare item number for antenatal education.  However, midwives provide education for each woman in their care, relating the science and art of midwifery to that woman's personal situation, and guiding the woman in her preparation for birth and mothering.

A midwife who intends to provide Medicare-rebated prenatal (items 82100, 82105, 82110, 82115) and postnatal services (items 82130, 82135, 82140) is able to charge a fee, or bulk bill.  The amount of rebate the woman receives will depend on her status with the Extended Medicare Safety Net (EMSN) capping system.

For example, if the midwife's charge for a 1-hour postnatal visit (Item 82135) in the woman's home is $120, the scheduled fee for that item is $75.05, and the EMSN (if applicable) is $20.65

The rebate a woman who has passed the Safety Net threshold is $75.05+$20.65=$95.70.
Out-of-pocket expenses for that consultation are $24.30.

On the other hand, if the midwife chooses to do so, she may 'Bulk Bill' for that item.  The midwife receives the 'Benefit 85%' (of the scheduled fee) payment of $65.60 into her nominated bank account, from the public purse.  The midwife may consider the ease of bulk billing, and the opportunity to provide a greater number of postnatal visits without increased cost to the woman, to outweigh the lesser unit payment.

Midwives participating in Medicare are able to obtain portable EFTPOS machines from their bank, which enable easy and quick credit card payments (swipe the credit card), Medicare rebates into the client's debit card account, and bulk bill payments (swipe the Medicare card). 


Where to go for more information:
Midwives Australia
has a wealth of information and links at its website. Midwives Australia is a not-for-profit organisation supporting midwives through these changes with practical hands on initiatives, programs and resources.

Your comments are very welcome.
Please note that any opinions expressed in this blog are the opinions of the writer, Joy Johnston, and may not necessarily be shared by other members of MiPP.

the reshaping of private midwifery practice

Private midwifery practice is undergoing real changes, as midwives who have Medicare provider numbers are able to offer certain midwifery services for which women will receive substantial Medicare rebates. 

There is scheduled fee for each item, from which rebates are calculated [variation in amount payable depends on a person's safety net]. For example: