For Midwives, Getting Into Health Reform May Not Be the Answer

I write this blog entry as homebirth midwives from all over the United States are heading to California to the annual conference of the Midwives Alliance of North America (MANA). I have many friends that will be at the MANA conference, and I wish I could join them, since it is always a fun time. I believe that this blog entry becomes a talking point at the conference. First, a little background: In the United States there are two types of midwives; nurse midwives, and non-nurse midwives generally referred to as direct entry. (I am aware that there are a few other classifications, but I'm trying to keep this as simple as possible). Nurse midwives generally deliver in hospitals and are called Certified Nurse Midwives and direct-entry midwives generally deliver out-of-hospital. and are rapidly embracing a designation known as "Certified Professional Midwife." Many CPM's (Certified Professional Midwives) attend the MANA conference. While nurse-midwives are legal in all states and are a mandated service under Medicare and Medicaid, the CPM’s do not enjoy the same status. The CPM's are working very hard to be included in the federal health care reform legislation working its way through Congress. The importance the CPM's are placing on getting into health care reform cannot be underestimated, for if they fail, they could conceivably find it impossible to attract new patients (clients). Many believe that being excluded from healthcare reform will doom the profession. I hope I can word. my next point, very carefully so as not to be misunderstood by my friends at the conference. Assuming the CPM is successful in getting into health care reform, what will they do differently so as not to allow legislative success to become their albatross?? I'm sure many of you are scratching your head, asking, “What is Alan talking about??” Let me give you a little Florida midwifery history. First of all, in Florida, direct entry midwives are called “Licensed Midwives” and are automatically qualified as CPMs (although they are NOT required to become CPM's). In 1992, Florida Gov. Lawton Chiles signed a law giving Florida the best direct entry midwifery legislation in the United States. The governor may have been America's most powerful midwife advocate, after his daughter was aided by a midwife during her birth. Basically, the Florida law coupled with the Governor’s and his daughter’s ongoing support gave Florida Licensed Midwives everything could have asked for. They got licensure, midwifery schools, a requirement for insurance companies to pay Licensed Midwives, they could be autonomous (work without supervision of a physician), they can receive Medicaid reimbursement and if there were any regulatory hoops, the Governor's daughter held a seat on the Florida Council of License Midwifery, which meant that every Dept. of Health employee worked for her father. This combination was considered the Royal-Flush of midwifery legislation! In fact, when the governor signed the 1992 law, he said that in 10 years, the Licensed Midwives will handle 50% of the births in the State of Florida. So what were the results? The number of licensed midwives increased from 30 to 300 between 1975 and 1990, the number of licensed birth centers from none to 20, and the percentage of births attended by midwives (10 percent) was one of the highest rates in the nation. Remember, this is before the governor signed the best direct entry midwifery legislation in the country. In the year 2007, 98.9% of the resident births occurred in hospitals; .6%, in freestanding birth centers; .4% were home births; and .1% happened either en route to a delivery facility or in some other location. Medical doctors attended 83% of the births; osteopathic physicians delivered 5% of the babies; 10.8% were delivered by certified nurse midwives; 0.6%, by licensed midwives; and 0.6%, by some other person As of August 2008, there were more than 540 certified nurse midwives (CNM) with active Florida Advanced Registered Nurse Practitioner licenses. Approximately 293 locations in Florida have certified nurse-midwives providing comprehensive maternity care and/or well-woman care services. In 2007, CNMs attended 25,861 births, or 11% of Florida births for that year (Florida CHARTS). Since 1988, CNMs are able to write prescriptions under a joint practice protocol signed by the certified nurse midwife and the physician. During the most recent reporting period, there were 34 licensed non-nurse midwives practicing - 18 working in individual practice and 16 in a 12 multi-practice setting. Of the 1,126 clients who gave birth under the care of a licensed, non-nurse midwife, 328 gave birth at home and 798 gave birth in a birth center. Medicaid was the payer for 471 of these women. (Click Here Tao Read the Florida Dept of Health Report citing the above stats) Recapping: in 2008 there were 34 licensed non-nurse (CPM type) midwives practicing, delivering less than 1% of the babies in the State of Florida So, I again repeat the question, if the CPM's get everything they want nationally, what will they do differently so as not to repeat any mistakes that were made post-Florida legislation? I wish the MANA midwives, a fun, wonderful and productive conference. Alan

If People Are Dying Now, Why Are We Waiting until 2012?

As congressional Democrats meet behind closed doors to hammer out a health care reform bill, I keep wondering why the media is not asking a key question. On every talk show, we keep hearing that we must do healthcare reform NOW because people are dying everyday. Yet, if we passed a bill tomorrow, the provisions requiring insurance companies to cover pre-existing conditions and accept everyone regardless of health won't kick in until 2012. So the question to be asked is: If we have to pass this bill immediately, why are we NOT covering the most vulnerable Americans, immediately?” Of course, among the most vulnerable Americans are pregnant women. They need coverage, so they know that their at prenatal care and birth will be paid for. Why is this not being covered immediately? Can you imagine calling the fire department and being told that fire trucks will arrive in three years? Why is the media not asking the most simple of questions? In fact, if we can cover every baby born immediately, that would cut down the number obstetrical lawsuits from parents that have no choice but to sue the obstetrician, midwives, and hospital so that they can get medical care for their uninsured baby for any birth injury. What is the rationale for waiting until 2012, to cover babies? I know this blog post is not one of the more sexy ones I've written, and that is because this one is so simple. If Passing a Bill Today Is Crucial Because Americans Are Dying, Then Let's Pass a Bill That Is Effective Today, . So No More Americans Die!! Alan

What Does My GPS and Electronic Medical Records Have in Common?

I love my GPS! I can travel all over, and not have to look at a map. I am comfortable that `Maggie" my Magellan GPS knows how to get me there and will lead me in the right direction. Maggie increases safety by letting me know if there is a left or right turn coming up before the signs tell me. She also allows me not to think!! I have an excellent sense of direction, however, since Maggie and I have become an item, I don't pay attention to where I'm going, so therefore I can never find the place again, without Maggie's assistance. Four years ago, Lenox Hill Hospital in New York, adopted an electronic medical records system in their L&D unit called “Peribirth.” This system is used by 34 hospitals nationwide and checks 6500 best practices and protocols and alerts nurses and physicians when there may be a possible error. Click here to read full article from Nurse.com As it has been my standard, I am not taking a position for or against this system, just asking some questions. I have no doubt that “Peribirth.” has caught errors and saved lives. Yet, I keep thinking about my “Maggie.” I know I don't have to think as much! I know if I continuously use Maggie, my sense of direction will begin to wither. Sometimes, Maggie is wrong , and I ignore her and follow my gut. I have been driving for over 35 years and have only been relying on Maggie for a year. What will happen in another three or four years? Will my gut tell me that Maggie is wrong and will I listen to my gut or will I do as Maggie says? Regardless, whether Maggie's right or wrong, the end result is a loss of a little bit of TIME. Maybe I go 5 or 10 miles out of my way before I realize she's wrong and get back on the right path. What about the doctors, nurses and midwives? Do you really believe that if they continue to rely on improved technology to catch errors, they will be able to listen to their gut when it tells them something's wrong? What about the new obstetricians, will they ever develop a gut feel? Will they deliver by the numbers and if they don't develop a gut feel, is that a bad thing? Alan

If This Is a Birth Blog, Why so Much Health Reform?

I hear this question a lot from people that read my blog. The answer is rather simple, but tells all. I write this blog to attract people that don't read birth blogs! I of course welcome and want all the so-called "birth people" and I know that at the early stages the “birth people” are the only people reading this. However, there are many wonderful birth blogs to rile the blood of any birth advocate. This may be the only blog that people that are involved in birth, but are not considered part of the "birth world." may actually read. In other words, if VBAC is your issue, there are blogs that deal with VABC everyday. If homebirth is your issue, go to Dr. Amy. If natural birth or unassisted birth is your issue, tere are multiple places you can go to. However, if you are among the vast majority (over 90%) of obstetricians, nurses, pediatricians, hospital administrators, etc. I doubt you have ever been on a birth blog, nor have you ever been to a birth conference. Birth is a tiny part (approximately 2%) of healthcare spending. I know that labor is the greatest reason for hospital admissions, but that has more to do with coding the actual number of people having babies. In fact, there are approximately 4.5 million births in the United States and 85 million hospital admissions. The claim of single greatest admission is overemphasized because there are multiple ways of coding chest pains but only one way to code labor. Birth care cannot be performed in a vacuum. Doctors midwives and hospitals do not get paid enough to deliver babies. Any talk of reducing their reimbursements reduces the number of doctors and hospitals and midwives who wish to continue delivering babies I will tell you the secret that everyone knows but no one is will say: “Many decisions in birth are made for financial reasons." Although everyone knows this, they can't admit to it. Just like the Congress has to deal with the budgetary effects of the healthcare reform bill, birth care providers are constrained by the reimbursement of the insurance company. A scheduled C-section takes 15 minutes in the middle of a workday. Whereas a "normal" birth can take hours at 2 AM on Sunday morning, you the obstetrician would be paid the same. Health care reform is about money and the medical system. How the money is distributed and/or allocated will have a major effect on birth practices. That is why this blog focuses on financial issues, because that effects ALL birth issues. Alan

Fathers to Be, Do You Take Them for Granted?

Once a week I blog about the Controversies in Childbirth Conference. Today is the day. Imagine in the labor room, a person who is not a patient and is not even a relative. This person is a guest of your patient. This person may have even come to a few prenatal visits with your patient; you don't even know this person's name. When you deliver the baby, this person’s status has changed. This person now has the right to make demands. This person has the right to file a lawsuit against you even if you're patient says no. This person is" "the baby's father." Birth care providers such as obstetricians, nurses, midwives, doulas, childbirth educators, even administrators believe that they are treating the father of the baby GREAT, but how do they really know? The patient gets the survey, not the father. The patient (baby’s mother) goes back for six weeks of follow-up visits, but not the father. The patient has a total support system, from hospital follow-up to mothers and mothers-in-law's, but not the father. Patrick Houser, the author of: "The Fathers to Be Handbook" will present a half day workshop on Thursday, September 18th, where he will go over what fathers encounter, how they feel, what the perception is, what they want and how you, the birth care professional can benefit by accommodating them. Did you know that the greatest single variable for the success of pregnancy, birth and breast-feeding is the father? You will learn that when fathers are supportive women have a better chance of remaining low risk . Further, when fathers to be (and fathers postpartum) are treated well, the risk of a lawsuit is substantially diminished. Often the father is the instigator in a med-mal suit, sometimes in conflict with the mother's wishes. This workshop will have a definitive impact on your bottom line, as well as reducing obstacles in your practice. Go to www.birthconference.org to register for the conference and workshop. Have a great weekend. Alan

How Much Will My Insurance Pay?

The problem with health insurance reform is does not appear to reform the practice that makes the entire system “NUTS!!” Imagine going into restaurant and having a wonderful meal. When the check comes, you tell the owner that he will submit his bill to your restaurant paying service. Somewhere between two and six months, your restaurant paying service will send the restaurant a check for 80% of what they feel the meal was worth. NUTS???? That’s how insurance operates. The government and insurance companies buy in volume and negotiate. That is a key part of their cost containment. However, this buffer between the customer and care provider takes away from the customer’s (patient’s) ability to negotiate because they don't know how much the bill is. Then they are not told how much the insurance company will pay. For health-care reform, to be successful, the f secret negotiations must stop, unless the procedure is covered 100%. 80% -- 20% or 50% -- 50% or co-pays or out-of-pocket maximums makes no sense when the real numbers are hidden. More importantly, providers cannot run a business without knowing in advance, how much they get paid for the services they perform. If you really want healthcare reform, we need to look at this current insurance practice and realize that secret contracts make the patient/client, a bystander in their own healthcare. Alan. Early bird discount for Controversies in Childbirth Conference expires Saturday www.birthconference.org

Do Hospitals Know How to Market to Pregnant Women?

As many of you know, I do consulting with a company called "Business of Birth". I try to help birth care providers and facilities get their marketing message heard by the 20 to 40 year old females that are; The pregnancy target market. Hospitals are places for old sick people, and they do a great job marketing to these , old sick people. Pregnant women are not old, and they are rarely sick. So, it would make sense that the same message that would be targeted to older people would fall on deaf ears in the pregnancy population. Yet, when I talked to hospitals, or even hospital birth centers about simple marketing techniques such as: "A separate website for the maternity unit,." they are reluctant to tery something new. Ohio Valley General Hospital, just announced that they are closing L.&D. by the end of the year. Ohio Valley is in the Pittsburgh, PA region. In 2006 Ohio Valley spent millions of dollars opening new maternity unit trying to grow to 800 births a year from 300 births a year. They were unable to accomplish this, and have raised the white flag of surrender. Click Here to Read Article in the Pittsburgh Post-Gazette I have no personal knowledge of the steps that Ohio Valley took to try to grow the maternity unit. I am willing to guess that they did not reach out to the birth advocates, the birth bloggers, the birth movie people (Business of Being Born, Orgasmic Birth, etc.) to try to do anything really different. This is another example of one of my pet peeves. Hospital executives pay scant attention to what happens in the maternity unit. Then, when it is time to close the maternity unit, the hospital CEO gets up and explains why the maternity unit had to close. My question is? "Why do CEOs wait until they announce the closure of the maternity unit before they get involved in operation of the maternity unit?" Alan