Expanded Support for Midwifery Services a Win-Win in Health Reform


Yesterday we provided a broad-brush overview of the implications for women of the health reform bill signed into law yesterday by President Obama.

At the time, it was not yet clear which elements of the original House bill favorable to expansion of midwifery services provided by certified nurse-midwives had survived and been incorporated into the Senate bill ultimately passed by the House this weekend.

As an update to our original article–and because midwifery services have been a long-neglected and in fact marginalized aspect of health care for women–here is an overview of how the bill addresses midwifery provided by certified nurse-midwives and expands the conditions under which nurse-midwives may provide broader health care services.

The American College of Nurse-Midwives underscores that certified nurse-midwives (CNMs) and Certified Midwives (CMs) provide health care services to women of all ages and stand to play a vital role in increasing access to quality, affordable primary care, gynecology, family planning, and maternity care services. Toward this end, the bill does the following:

Expands services:

  • Equitable reimbursement of midwives under Medicare. The bill establishes reimbursement for CNMs at 100 percent of the Part B fee schedule as of January 2011, equivalent to physicians.  “Inadequate reimbursement for midwifery services has been a significant barrier to women’s access to the valuable services of CNMs and certified midwives (CMs),” stated ACNM President Melissa Avery, CNM, PhD, FACNM, FAAN. “This legislation not only improves Medicare for women, but will encourage Medicaid plans and third-party payers to adopt equitable reimbursement policies for midwifery services.”

According to ACNM:

Equitable reimbursement will enhance the viability of midwifery practices as well as increase the incentive for hospital and physician practices to employ CNMs and CMs. In addition, CNM- and CM-attended births—which occur primarily in hospitals, but also in birth centers and private residences—are associated with high-quality outcomes and fewer cesarean sections. The US cesarean section rate has reached an all-time high of nearly 1 in 3 births; cesarean section has been identified as an overused maternity care intervention by the National Priorities Partnership, an influential multi-stakeholder coalition working to identify top priorities for improving the quality and affordability of health care in the US.

  • Coverage for freestanding birth center services. Provides for coverage of services provided by free-standing birth centers under Medicaid.
  • Expands options for nurse-midwives in home health care.  The bill clarifies that the face-to-face encounter required prior to certification for home health services may be performed by a physician, nurse practitioner, clinical nurse specialist, certified nurse-midwife, or physician assistant.
  • Maternal, Infant, and Early Childhood Home Visiting Programs. Provides funding to States, tribes, and territories to develop and implement one or more evidence-based Maternal, Infant, and Early Childhood Visitation models. Model options would be targeted at reducing infant and maternal mortality and its related causes by producing improvements in prenatal, maternal, and newborn health, child health and development, parenting skills, school readiness, juvenile delinquency, and family economic self-sufficiency.  This is particularly critical for low-income women.
  • Support, Education, and Research for Postpartum Depression. Provides support services to women suffering from postpartum depression and psychosis and also helps educate mothers and their families about these conditions. Provides support for research into the causes, diagnoses, and treatments for postpartum depression and psychosis.
  • Women’s Preventive Health Services. Eliminates cost sharing for women’s preventive health services.
  • Patient Protections. Requires that a plan enrollee be allowed to select their primary care provider, or pediatrician in the case of a child, from any available participating primary care provider. Precludes the need for prior authorization or increased cost-sharing for emergency services, whether provided by in-network or out-of-network providers. Plans are precluded from requiring authorization or referral by the plan for a female patient who seeks coverage for obstetrical or gynecological care.

Taken together, these provisions greatly expand both the range of options available for care and the degree of choice individuals can exercise in choosing primary care-givers without facing undue barriers and approvals from insurance companies.

Expands the pool of primary caregivers

The health reform bill also helps to strengthen the pool of primary caregivers in a variety of ways, including through expanded support for the education and training of nurses and nurse-midwives.

  • Advanced Nursing Education Grants. Strengthens language for accredited nurse-midwifery programs to receive advanced nurse education grants in Title VIII of the Public Health Service Act.
  • Nurse Education, Practice, and Retention grants. Awards grants to nursing schools to strengthen nurse education and training programs and to improve nurse retention.
  • Expands the pool of nurses through education grants.  A nursing Loan Repayment and Scholarship Program will provide for additional faculty at nursing schools as eligible individuals for loan repayment and scholarship programs and establishes a Nurse Faculty Loan Program for nurses with outstanding debt who pursue careers in nurse education. Nurses agree to teach at an accredited school of nursing for at least 4 years within a 6-year period.
  • Nursing Student Loan Program. Increases loan amounts and updates the years for nursing schools to establish and maintain student loan funds.
  • Graduate Nurse Education Demonstration Program. This provision directs the Secretary to establish a demonstration program to increase advanced practice nurse education training under Medicare and authorizes $50 million to be appropriated from the Medicare Hospital Insurance Trust Fund for each of the fiscal years 2012 through 2015 for such purpose.

In short, states ACNM, this is a critical step toward eliminating health disparities and improving health care access for the millions of women who are currently uninsured.

In addition to equitable reimbursement for midwives, the bill recognizes freestanding birth centers under Medicaid, improves access to women’s preventive health services, ensures direct access to the obstetrician/gynecologist or CNM/CM of their choice, takes significant steps to address the health care workforce needs of the nation, ends gender discrimination and exclusion based on pre-existing conditions, and begins the effort to reduce the rate of increase for medical malpractice insurance through state-focused initiatives.

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  • courtroom-mama

    Thanks for this breakdown, Jodi. I’m glad to hear that access to midwifery care is now officially a matter of national concern; I’m particularly happy about the recognition of birth centers under Medicaid, as there is a definite socioeconomic gap in access to the whole-woman prenatal care that the midwifery model provides.

    Now I hope we can stop this nonsense of legislators trying to make CPMs illegal!

  • smjesq

    Thanks, Jodi, also for highlighting the health care reform provision that guarantees access to freestanding birth centers for all pregnant Medicaid recipients.  As counsel for the American Association of Birth Centers, I would like to thank everyone who helped us secure access on this basis.  Now, Medicaid recipients who are pregnant will have the same right to go to a midwife-owned or -staffed birth center for prenatal and childbirth services as to obstetricians and hospitals, which were already guaranteed Medicaid services.  At present only about 20 states include birth centers under their Medicaid plans, but within a short time, every state will have to do so — regardless of whether the birth center is owned or staffed by CNMs, CMs, or CPMs — so long as the midwife is licensed and works in a birth center, Medicaid will cover the birth center fee.

    And we are hopeful that, as CMS develops the rules over the next few months, it will implement payment for the professional fees of CPMs and other licensed midwives.

    Now, as Courtroom Mama commented, the struggle moves back to the state legislatures.  We need to convince the rest of the states to start licensing certified professional midwives, so that all women can have access to midwives, home birth, and birth centers, and so women who qualify for Medicaid will have these services covered by their state Medicaidi plan. 

    Please, everyone who read this — join your state Friends of Midwives group and get active in the campaign to license CPMs!  That’s how we influence legislators — through consumers making phone calls, sending emails, going to their state capitols, to let their state representatives, senators, and governors know that women and their families want access to licensed midwives NOW.  Twenty-seven states down, and twenty-three, plus DC and PR, to go!  Come work with the Big Push by joining your state Friends of Midwives group.

    And check out http://www.thebigpushformidwives.org and http://www.birthcenters.org

    online and on facebook

    Thanks again, Susan