Tuesday, March 30, 2010
Chair, ACNM Government Affairs Committee
Tuesday, March 23, was a big day for many Americans when the President signed major health care reform legislation into law. But Tuesday was an even BIGGER day for midwives. Under this new law, after 19 years of hard work, certified nurse-midwives (CNMs) will be equitably reimbursed for their services under Medicare beginning January 1, 2011.
It would seem like receiving our current rate—65% of what physicians receive from Medicare—wouldn’t be that much of a hardship on a day-to-day basis for most midwives, as we don’t care for many women covered by Medicare. But receiving 100% is a very important change because Medicare often serves as the gold standard of reimbursement rates. For example, I just learned last week that Aetna is reducing its reimbursement rate in Washington State (and many other states) for nurse practitioners, physician assistants, and certified nurse-midwives to 85% of what physicians receive starting June 1. It’s not a coincidence that they did not apply these new rates to certified nurse anesthetists, as they currently receive 100% under Medicare. Other insurers who have a discrepancy in rates include Blue Cross Blue Shield and Regence, and I am sure there are many others. There are also 22 states where Medicaid currently reimburses CNMs less than 100% for their services. What’s their reasoning? That’s the interesting part—they don’t have to give one.
When we midwifery advocates lobbied on this bill, we explained to legislators that a pap smear is a pap smear is a pap smear. Meaning—it doesn’t matter what the letters are after your name; as long as you are qualified and licensed to perform it, you should be equitably reimbursed. But for CNMs, this took a lot of education, phone calls, e-mails, letters, trips to DC, and downright begging to convince legislators to understand. I have been lobbying on this bill since 2001, and there were many midwives that came before me who are celebrating just as loudly as me. So, here’s a toast to us little people who have finally won one in the battle against the giants. Watch out, private insurers and Medicaid states. The new gold standard rate for CNMs is 100%.
Editor’s note: If you have been involved in gaining support for equitable reimbursement for CNMs at any point in time—by contacting your members of Congress, visiting Capitol Hill, or working to mobilize support—help ACNM thank and celebrate you by sending your name, picture, and a sentence or two about your involvement to firstname.lastname@example.org. And, while you’re at it, leave a comment on this post!
From left to right: ACNM Executive Director Lorrie Kline Kaplan; Midwives-PAC President Katy Dawley, CNM, PhD, FACNM; Representative Jim McDermott (D-WA); ACNM Government Affairs Committee Chair Heather Bradford, CNM, ARNP; ACNM President Melissa Avery, CNM, PhD, FACNM, FAAN.
Senator Al Franken and Brielle Stoyke, CNM
Thursday, March 18, 2010
Once about every four years, ACNM hosts its Annual Meeting in DC. Why DC? We need your voice. On Tuesday, June 15, we hope hundreds of midwives will storm Capitol Hill to meet with their legislators (two senators and one US representative) and discuss issues vital to the sustainability and growth of midwifery. This is one of the most important personal contributions you can make to your profession. Not convinced? Here are my top 10 reasons why you should lobby on Capitol Hill in pumps and pearls or shirt and tie instead of spending the afternoon touring the White House in shorts and a T-shirt.
1. Only you can tell the story of midwifery. Our lobbyist can talk about our issues until he is blue in the face, but only you can share the stories of your clients and the barriers you face in caring for them.
2. You don’t have to worry about what to say or do because we have all the answers. Set your mind at ease by attending the one-hour Lobby Day Prep session the morning of Lobby Day and then hop on the ACNM-provided buses to the Capitol. We’ll also provide maps to get you home.
3. There is power in numbers. Every constituent that attends sends a stronger message to our members of Congress.
4. You will feel empowered after this experience. This is the third time I have helped organize Lobby Day, and it’s probably my most favorite part of the job.
5. Meet with your legislators and their staff in a more casual setting at the Capitol Hill Reception immediately following Lobby Day. Tickets sell fast, so buy one when you register for the Annual Meeting.
6. Show your children and practice partners the importance of political action. What better civics lesson can you teach your child?
7. Meet other midwives from your home state. All midwives from each state go together to meet with their two senators. Midwives from different congressional districts then divide into small groups and meet with their House representatives.
8. Have a picture taken of you and your member of Congress to hang in your office or home. All legislators are happy to do this.
9. Earn two contact hours. Simply lobby and complete a lobbying evaluation form afterward.
10. Every woman deserves a midwife. Even if you’re not a fan of your elected official, there are some things we can all agree on, including access to midwifery care.
June 15 seems like a long way off, but the time to plan is now:
Tuesday, March 16, 2010
A curious thing happened last month in Ventura County, CA. St. John’s Pleasant Valley Hospital in Camarillo decided that midwives can no longer practice at their facility. Midwives have been practicing at St. John’s for the past 30 years. Evidently, the pediatrics and obstetrics committees along with the board of directors made the decision for “safety reasons.” Midwives were not included in the discussion.
One would assume this was related to bad outcomes; however, no peer review on the midwives’ quality of care occurred prior to the decision. In fact, the letter notifying staff midwives, three days prior to their effective dismissal, said that the loss of hospital privileges was not a reflection upon the care provided. The letter also stated that there was no allowance for a hearing or review.
The odd part of this whole situation is the board and committees’ reasoning. They say that because the hospital does not have a neonatal intensive care unit (NICU), it is unsafe for midwives to attend birth on the premises. However, physicians continue to deliver babies at St. John’s Pleasant Valley, including cesarean births, which statistically have more risk for a newborn to be admitted to NICU. Officials at the hospital have been mute, except to insist that this new policy is all about patient safety without further explanation. They declined to respond when asked to release statistics of babies admitted to NICU whose birth was attended by midwives as opposed to those attended by physicians.
In general, midwives care for women who are at low risk for complications. Numerous studies, including a recent Cochrane Review, testify to the high quality and safety of midwifery care. In fact, research indicates that midwifery care may reduce the risk of neonatal morbidity and mortality and therefore the need for NICU admission. Birth Action Coalition, is spearheading a campaign to force the hospital to rescind this unjust and unsubstantiated policy. If you live in the area, please join them at their next rally Friday, March 19, 11am to 1pm.
Thursday, March 11, 2010
This past week the NIH held a 3-day Consensus Conference examining the current situation in maternity care regarding vaginal births after cesarean (VBACs), which have diminished considerably in number over the past 10 to 15 years. I was able to attend, and urge everyone to read the consensus preliminary report. In addition, many news outlets have picked up the story, including The New York Times.
Midwifery was well represented at the conference. Midwife and ACNM President Melissa Avery was in attendance, as was ACNM Executive Director Lorrie Kaplan. Tina Johnson, ACNM director of Professional Practice and Health Policy, spoke eloquently to the NIH assembled panel during the Q and A session. Certified nurse-midwives (CNMs) Mary Barger and Judith Rooks also raised important issues for the panel to consider. CNMs Cathy Emeis and Mona T. Lydon-Rochelle were featured speakers who presented VBAC data to the panel. Most impressive was Tekoa King, midwife extraordinaire and deputy editor of the Journal of Midwifery & Women’s Health, who was one of the NIH panelists.
I felt that the conference was quite good, and the meeting was as close to “fair and balanced” as it could get, which is not always the case with these NIH conferences. The bottom line is that the panel believes VBACs need to be offered to women as a part of informed consent, and that the opportunities for VBACs need to return to where they were in the mid-90s before ACOG and other groups began cautioning women about this method of birth. Much more research needs to be done regarding outcomes, and as pointed out by several speakers, any change in policy will require some form of tort reform in order to remove fears of litigation from those practitioners involved in VBAC care. But all in all, this NIH statement is hopefully the start of reversing the trend away from VBACs.
Nice work, all you midwifery and birth advocates in attendance!
Hear more from Dr. McCool at the ACNM 55th Annual Meeting & Exposition.
Tuesday, March 9, 2010
I spent the good part of today glued to the live webcast of the National Institutes of Health Consensus Develop Conference on Vaginal Birth After Cesarean (VBAC). The agenda was packed with expert testimony on the findings of a systematic review of 35 studies involving over 660,000 women with prior cesareans, prepared by the Agency for Healthcare Research and Quality.
So many important findings were presented that I would not begin to do them justice if I summarized them here. What amazed me as much as the incredibly enlightening science, though, was the remarkable involvement of consumers and consumer advocates, many of whom are very savvy users of social networking tools such as blogs, Facebook, and Twitter.
And another interesting thing happened: the NIH Panel acknowledged the bloggers. Gina from The Feminist Breeder posted this picture of a slide from their introduction…
…right around the time that I was tweeting this:
They are right: there is an active blog community on the internet. And we’ve been “actively blogging” about VBAC for several weeks now. The blogging effort was coordinated, too. The International Cesarean Awareness Network pulled together an amazing collection of links to posts all over the internet on the topic of “VBAC as a Vital Option.”
This all got me wondering: have the NIH panelists been reading our blogs? And should they?
The panelists are supposed to be independent and objective (as we have seen, this is rarely if ever the case). But does independence equate with impartiality? And do the rules of impartiality that govern, say, juries in courts of law (eg, don’t google the case!), pertain to independent scientific panels?
Surely they’ve read somewhat if not extensively in the the scientific literature on VBAC. After all, the NIH would want to choose panelists who would be able to effectively do their job: coming to consensus on VBAC, and doing so requires some familiarity with the research and clinical issues. All of those testifying have affirmed that the available literature for nearly every important aspect of VBAC decision-making is “thin,” “scarce,” or “limited” and that major areas for future research include emotional and mental health outcomes, quality of life, long-term health, and impact on mother-infant bonding and breastfeeding. So if the scientific evidence cannot provide answers, what about asking women themselves? Especially those of us who are eagerly sharing our perspectives and personal stories on blogs and Twitter?
I’m interested to hear others’ thoughts on the role (if any) of consumer advocates, connected via social media, on the scientific panels like the NIH meeting.
I have to end it there to take part in a Blog Talk Radio Show with The Feminist Breeder and Debra Bingham, the president-elect of Lamaze International and the Executive Director of the California Maternal Quality Care Collaborative. Tune in!
Thursday, March 4, 2010
In Washington State, we are working on legislation related to an access to care issue. The legislation would authorize pharmacists to fill prescriptions written by advanced registered nurse practitioners (ARNPs) in other states or in certain provinces of Canada. What does this have to do with midwifery? In Washington, certified nurse-midwives (CNMs) are licensed as ARNPs. The legislation would help CNMs in border states too, as the language considers those midwives to be ARNPs.
Current law authorizes pharmacists to accept prescriptions from physicians, osteopaths, dentists, podiatrists, and veterinarians licensed in any state or in a province of Canada that shares a common border with the state of Washington; however, ARNPs are not included. This can be problematic for women choosing an ARNP or CNM as her primary care provider. Most people need prescriptions filled locally so they have easy access to refills and consultation with their pharmacists. In our argument to legislators, we have shared that CNMs and ARNPs in our bordering states, Idaho and Oregon, have the same independent scope of practice and full authority to write prescriptions. The good news is the bill has passed unanimously in our state Senate and is moving forward through the House of Representatives.
Unfortunately, the language of the bill does not extend to prescriptions written by ARNPs across the country. Currently, only two other states (Kentucky and Texas) have limits on accepting prescriptions from ARNPs licensed in other states. In these states, pharmacists will not accept schedule II prescriptions for which their state’s ARNPs are not authorized to write. It is less clear which states have limits on accepting prescriptions written by CNMs licensed in other states. I received varying responses in an informal poll on the ACNM eMidwife clinical practice discussion group. There are some limitations with pharmacy laws in Texas and Kansas, both requiring a physician name on all prescriptions. However, with the use of a DEA or NPI number (which are essentially national license numbers), many states accept out-of-state prescriptions written by a CNM. Of the 15 or so responses I received, these states include Massachusetts, New Hampshire, New York, New Jersey, Virginia, Georgia, Mississippi, Arkansas, Missouri, and Alabama. Obviously, this is not a conclusive list, but it seems that the law needs to change in Washington State with hopes of others following suit.
Is anyone else advocating for or working on midwifery legislation in their state similar to this?
Tuesday, March 2, 2010
Many of you already know about the upcoming NIH Consensus Development Conference on Vaginal Birth After Cesarean (VBAC): New Insights, March 8-10, at the NIH Campus in Bethesda, Maryland. Many midwifery advocates, including me, have had a bad taste in our mouths about NIH conferences on cesarean sections based on the 2006 NIH “State-of-the Science” conference on Cesarean Delivery on Maternal Request. The people who did the review of the literature and prepared the background paper for the 2006 conference on elective cesareans seemed, in my humble opinion, to be biased and made ridiculous decisions about what evidence should be considered during the conference. They concluded that “no information exists,” thus asserting that no one knows anything about the relative risks of attempting to have your first baby vaginally compared to having an elective cesarean.
However, I’d like to draw your attention to the March 2010 conference tagline “New Insights.” I’m taking this as a hint that NIH is aware of the damage caused by unnecessary cesareans and would like to encourage more women to try trial of labor after cesarean (TOLAC). We don’t know if there will be a midwife on the panel that will have the final say on the report resulting from this conference. The identity of panel members will not be revealed until the conference opens. Nevertheless, there are lots of reasons to be optimistic about this conference.
- Mona T. Lydon-Rochelle, CNM, PhD, MPH, will present an important paper on the short-term benefits and harms to the mother of attempting a TOLAC versus having an elective repeat cesarean delivery and factors that influence maternal outcomes.
- Lucky Jain, MD, MBA will do a presentation on the short-term benefits and harms to the baby of its mother’s attempt to have a VBAC versus having an elective repeat cesarean delivery, and factors that influence short-term outcomes for the baby should be very good. Every pregnant woman who is faced with making this decision should know the information he will present.
- Emmanuel Bujold, MD, FRCSC, will explore differences between the American Congress of Obstetricians and Gynecologists’ (ACOG’s) VBAC guidelines compared to those of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and probably those of the OBGYN organizations of other countries.
- I expect that a paper by David Birnbach, MD, MPH, will be important, too. People need to know that there is a shortage of OB anesthesiologists and nurse anesthetists to provide epidurals. This is also relevant to the new ACNM Position Statement on Nitrous Oxide Analgesia During Labor.
- Howard Minkoff, MD, will present a paper on the “Immediately Available Physician Standard,” which should be very interesting and important.
- Ditto for a paper by Miriam Kuppermann, PhD, MPH, on understanding risk, patient and provider preferences, and obstetric decision making; a paper by Anne Drapkin Lyerly, MD, on the medical ethics of VBACs; and a medical reporter’s paper on mother’s stories.
Overall, this should be a very good and important conference. Please don’t be discouraged from registering and participating because you were so discouraged about the 2006 NIH conference on elective cesareans. Midwifery advocates need to be there in force, especially articulate midwives who are knowledgeable about issues related to VBAC and problems related to lack of access to TOLACs. This is an important issue for midwives, and we need to make NIH and the entire maternity care community see that we are actively engaged with the scientific and professional issues surrounding VBACs.