Effecting Change in Your State at the Legislative and Policy Level2015 AABC Birth InstituteOctober 4, 2015 – Scottsdale, AZ

Abigail Lanin Eaves, CNM, MSN Melanie Yanke, CNM, MSNDar a Luz Birth & Health CenterAABC Legislative Panel Presentation

State Licensure in New Mexico

New Mexico: What’s the Issue?

• New Mexico has not had birth center facility licensure since the 1960s (Maternity Homes)

• Not illegal to operate a birth center without a license

• NMDOH initially stated we could only be licensed as a “special hospital” if we wanted to be licensed

New Mexico: What’s the Issue?

• Once ACA requirements were known, DOH stated they would add birth centers to existing outpatient regulations (August 2011)

– It would lump us in with ambulatory surgical centers, diagnostic treatment facilities, etc.

– Many regulations are similar to hospitals: room size, corridors, etc.

– Did not want to give birth centers their own special regulations within the existing regulations, just fitting the square peg into the round hole

– AIA “Facility Guidelines Institute” and 200 ft2 for birth rooms (not including bathroom)

New Mexico: How Did We Solve (or attempt to solve) the Issue?

• We argued that there was no evidence to support AIA/FGI

• 200 ft2 non-negotiable for birth room size- STALEMATE

• We created BIRTH ROOM ENVIRONMENT SURVEY to show birth room size did not affect safety of birth/birth outcomes (complete 6/1/14)

– Survey sent electronically to 252 birth centers

– 118 responded (47%)

– Total births in past year (when survey was sent): 12,619

– 265 total birth rooms: 24% 100-199 ft2, 35% 200-299 ft2, 24% 300-399 ft2

– Very few emergency transfers

New Mexico: How Did We Solve (or attempt to solve) the Issue?

• By fall 2014, still no real movement/commitment from DOH

• Hired lobbyist, secured House Representative to carry the bill

• Nov 2014: met with Secretary of Health, DOH and Medicaid

– Secretary stated she WOULD support legislation and encouraged us to do so in order to add birth centers to list of licensed facilities

– Secretary mandated that DOH would create birth center specific regulations with our help and would be done within the next 60 days

• HB 84 introduced in the 2015 legislative session– Rep Trujillo (D) and Rep Harper (R) -> Excellent bipartisan

support

– Senator Rodriguez (D) introduced bill simultaneously in the Senate (SB 176)

• HB84 passed through both House committees, house floor with unanimous “Do Pass”

• SB176 passed through both Senate committees with unanimous “Do Pass”, with amendment added in first committee (SB stopped here)

New Mexico: What Went Well? Not So Well?

• HB84 came over to the Senate, passed same committees that SB176 had been through, unanimous “Do Pass”

• HB84 came to the Senate floor where pro-life Senator (R) wanted to add abortion clinics -> massive freak-out (day before session ended)

• Rep Harper told him to let that go, support this bill for midwives and babies being born, passed Senate floor with unanimous “Do Pass”

• HB84 signed by Governor Martinez on March 20, 2015, two hours before the deadline

• Finished working with DOH in March working on regulations/language

New Mexico: What Went Well? Not So Well?

New Mexico: What Did We Expect to Happen?

• We expected the bill to pass without drama: WRONG

• We expected the regulation process to be timely: WRONG

• We expected that DOH would remember/write down/make note of things that we already discussed/agreed upon: WRONG

• We expected to have a license application July 1, 2015 (per Secretary of State, DOH and HB84): WRONG

• We expected to have to fight for many things in the regulations (birth room size, janitor’s closet, etc.): WRONG

New Mexico: What Actually Happened?

• Passed and made law a House Bill with excellent bipartisan and client support!

• Excellent representation on both sides: CNMs, LMs, DOH, Medicaid, legal, lobbyist, Young Women United

• Everyone was willing to listen to each other and hear each other out- true collaboration

• Excellent preparation on our part- having articles and evidence including ALL other state regulations

New Mexico: What Actually Happened?

• The work with DOH went slower than anticipated

– Long meetings, very collaborative though

– Pushed back ~6 months

– Open lines of communication

• Regulations got stuck in legal at DOH for 3-4 months

• No communication at all (except when we checked in)

• Hearing set for October 20th

• Rules then in promulgation for 30 days

• Application for licensure should be available by the end of the year

• Tedious site visit…

• Must work with Medicaid to set facility payment at a decent rate

• Get private and Medicaid payers to add birth centers as licensable facilities with competitive reimbursement

New Mexico: Next Steps…

Dar a Luz Birth & Health Center

Improving Medicaid Reimbursement for Birth Centers in MarylandAnn Sober, RN, BSNSpecial Beginnings Birth and Women’s CenterAABC Legislative Panel Presentation

Maryland: What is the Issue?

Expenses• Accounting

• Pharmaceuticals (non-reimbursable

• Legal Fees

• Medical Supplies (non-reimbursable)

• Cleaning

• Electricity

• Telephone

• Maintenance/Repairs

• Laundry and Linens

• Office & Administrative

• Medical Waste Removal

• Trash

• Contracted Services

• Advertising

• Educational material

• Interest Expense

• Bank Charges

• Licenses and Permits

• Property Taxes

Maryland: What is the Issue?

Expenses• Medical Malpractice Insurance

• Employee Health Insurance

• Property Liability Insurance

• Workman’s Compensation

• Dues and Subscriptions

• Accreditation/ Licensure

• Training

• Postage

• Rent/Mortgage

• Depreciation Expense

• Infant Services

• Transport to Hospital (Transfers)

• Medical Director (required by Maryland State Law – not billable as a professional fee)

• Pension Expenses*

• Payroll Expenses*

• Payroll Taxes*

• * professional fees insufficient to cover this expense

Maryland: Working on the Issue

• Networking

• Who should you talk to?

• How should you make contact?

Maryland: Working on the Issue

• Be prepared for your meetings

• Be ready to support your position with hard facts

• Prepare a budget explaining why additional funds are needed to provide the service

• Explain why the birth center provides cost effective care

Removing Physician Supervision and Integrating Licensed Midwives into Medicaid in CaliforniaSarah Davis, CPM, LM, IBCLCBirth RootsAABC Legislative Panel Presentation

California Licensed Midwife Bills

• AB 1308 in 2013 – Many issues including removal of Physician supervision

• SB 407 in 2015 – Inclusion in enhanced Medi-Cal (California’s Medicaid) service

• SB 408 in 2015 – Creates Midwife Assistant role

California: Organizations and Consultants• California Association of Midwives

• California Families for Access to Midwives

• Pro Bono lobbyists in 2013Paul Hastings Law Firm

• Consultant, 2013 and 2015Katie Prown – Prown & Associates

• Social media, 2013 and 2015Jeanette McCullough – Birthswell

• Legal Counsel, 2015Susan Jenkins, JD

California: Our Strategy

• Build and leverage consumer base

• Hands on lobbying

• Focus on access and equity

• Invest in our political education

Overcoming the Certificateof Need in KentuckyMary Carol Akers, CNM, PhD, FACNMEducation for Childbirth and ParentingAABC Legislative Panel Presentation

Kentucky: Certificate of Need

• Intent of Certificate of Need (CON)

• Cost of CON

• Reality

Kentucky: CON Cost

• Lawyer starting February 6, 2012

• Experts– CON Experts

– Building Experts

– Midwifery Experts

– Birth Center Experts

Kentucky: CON Process

• Application – Found Lawyer, experts, contracts, architect

– Application fills a 3” 3-ring binder

• Hearings – February 20 and 21, March 13 and 26, 2013

• “Affected Parties” – Hardin Memorial Hospital, Twin Lakes Regional Medical Center and Flaget Hospital

• Depositions – prior to hearings

• Testimony – 4 days of the hearings

• Heard by an administrative law judge

Kentucky: CON Findings

• Conclusions of Law: (August 1, 2013)– Affected parties have refuted need

– In accordance with KRS 216B.096 (4), if the facility or service for which a capital expenditure is proposed is not found to be required, the certificate of need cannot be approved

– The proposed capital expenditure of $852,590 relates to the lease of a building and its equipment

– Application denied

Kentucky: Appeal Process

• Going to court again October 29, 2014

• Findings:– Final order reversed February 23, 2015

• Hospitals are not affected parties• Licensure requirements should not be considered in

“certificate of need”

Kentucky: Appealing the Appeal

• So, of course, the hospitals are appealing the findings of the appellate judge

• This sets up the place in which we find ourselves now

Questions??

Activism is something that no one can fake. You get angry. You cry. But you never throw in your towel, because that anger is what is propelling you to further action.Leymah GboweeNobel Peace Laureate and Oxfam Ambassador