Network Adequacy and Midwifery Care

Essential Health Benefits Required Coverage for Most Plans

What is in the law? Ambulatory Patient Services Prescription Drugs

Emergency Services Rehabilitative and Habilitative Services and Devices

Hospitalization Laboratory Services

Maternity and Newborn Care Preventive and Wellness Services and Chronic Disease Management

Mental health and Substance use Disorder Services, including Behavioral Health Treatment

Pediatric Services, including Oral and Vision Care (pediatric oral services may be provided by stand-alone plan)

See Section 1302 of the ACA, available at: http://housedocs.house.gov/energycommerce/ppacacon.pdf

Percent of Births Attended by Certified Nurse-Midwives (CNMs) and Certified Midwives (CMs) - 2012

MT

7.72%

WY

5.71%

ID

7.28%

WA

9.26%

OR

16.17%

NV

3.08% UT

8.59% CA

8.45%

AZ

6.50%

ND

5.56%

SD

6.50%

NE

6.10%

CO

11.70%

NM

27.02%

TX

3.12%

OK

3.82%

KS

4.40%

AR

0.63%

LA

2.84%

MO

3.09%

IA

7.13%

MN

10.43% WI

8.80%

IL

5.94%

IN

6.16%

KY

5.79%

TN 5.06%

MS

2.12%

AL

1.59% GA

15.40%

FL

10.53%

SC

4.39%

NC

12.49%

VA

6.19%

WV

12.81%

OH

7.25%

MI

6.43%

NY

10.01%

PA

10.56%

MD 8.33%

DE 6.17%

NJ 6.90%

CT 10.66%

RI 11.44%

MA 13.51%

ME

18.57% VT 20.70%

NH 18.46%

AK

14.56%

HI 9.87%

4.51% – 6.49% of births

6.50% - 8.89% of births

12.00% - 28.00% of births

Source: CDC Vital Stats, Births - Available at: http://www.cdc.gov/nchs/data_access/vitalstats/vitalstats_births.htm

8.90% - 11.99% of births

0% – 4.50% of births

DC 9.40%*

CNMs/CMs are major providers of maternity and newborn care.

What do Midwives Do Differently? Normal Physiologic Birth

What is Normal Physiologic Birth?

Source: Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA and NACPM. Available on-line at: http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000002179/Physioloigical%20Birth%20Consensus%20Statement-%20FINAL%20May%2018%202012%20FINAL.pdf

Spontaneous onset and progression of

labor

Biological and psychological conditions that promote

effective labor

Vaginal birth of the infant and placenta

Results in physiologic blood loss

Skin-to-skin contact between mother and

infant post partum

Supports early initiation of breastfeeding

Disruptions of Normal Physiologic Birth

• .

Source: Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA and NACPM. Available on-line at: http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000002179/Physioloigical%20Birth%20Consensus%20Statement-%20FINAL%20May%2018%202012%20FINAL.pdf

Induction or augmentation

of labor

An unsupportive environment (bright

lights, cold room, lack of privacy, multiple providers, lack of

supportive companions)

Time constraints, including those driven by institutional policy

and/or staffing

Nutritional

deprivation,

e.g., food and drink

Opiates, regional analgesia, or general

anesthesia

Episiotomy

Operative vaginal (vacuum, forceps) or abdominal (cesarean)

birth

Immediate cord clamping

Separation of

mother and infant

Any situation in

which the mother

feels threatened or unsupported

Practices that Support Normal Physiologic Birth

Source: Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA and NACPM. Available on-line at: http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000002179/Physioloigical%20Birth%20Consensus%20Statement-%20FINAL%20May%2018%202012%20FINAL.pdf

Access to midwifery care

Time for shared decision making, freedom from

coercion

No inductions or augmentations without

an evidence-based indication

Encouragement of food and drink during labor as the

woman desires

Freedom of movement in labor and choice of birth

position

Intermittent auscultation of heart tones unless

electronic monitoring is indicated

Providers skilled in non-pharmacologic methods of

coping with pain

Care that supports woman’s comfort, dignity,

and privacy

Respect for woman’s

cultural needs

Midwifery Results - ACNM’s 2013 Benchmarking Data

Metric Reported Average

Performance

Total Rate of Vaginal Birth 87.2%

Rate of Spontaneous Vaginal Birth 83.3%

Primary Cesarean Rate 9.2%

Repeat Cesarean Rate 3.6%

Intact Perineum Rate 49.4%

Episiotomy Rate 3.1%

Preterm Birth Rate (<37 weeks) 3.2%

Rate of Low Birthweight Infant (<2500 grams) 4.4%

Rate of NICU Admissions 4.1%

Breastfeeding Initiation Rate (exclusive breastmilk for first 48 hours of life) 85.3%

Breastfeeding Continuation Rate (any breastmilk at 6 weeks postpartum) 87.3%

Data drawn from 232 practices, representing the work of 979 midwives on a total of 97,158 births occurring in 44 states.

Midwifery’s High Value Results Women’s Health Issues • A systematic review comparing CNM-led care to physician-led care concluded that “Care by

CNMs has been shown to be safe and effective.” 2013 Cochrane Review • Midwifery-led care leads to lower rates of regional analgesia, episiotomy, instrumental birth,

preterm birth and fetal loss, higher rates of maternal satisfaction. “Similarly there was a trend towards a cost-savings effect for midwife-led continuity of care compared to other care models.”

Washington State Department of Social and Health Services • Among low risk women, midwifery led hospital birth resulted in savings of 7% over hospital

births attended by other types of providers. Urban Institute • A midwife-led birth center in Washington DC saved the Medicaid program an average or $1,163

per birth. British Medical Journal • Hospital midwifery units led to savings of 11.6% over physician led units. Australian Health Review • A midwifery led model of care “resulted in cost savings.”

The midwifery model of care is substantively different than a medicalized model of care that emphasizes interventions in the normal physiologic processes of birth. Coverage for the one model of care is not equivalent to coverage for the other.

ACNM Survey of Health Plans • ACNM contacted 232 of the 277 insurance plans

offering coverage through the marketplace. • We were able to survey 85, from 33 different

states. • We inquired regarding inclusion of CNMs/CMs in

provider networks and coverage of their services. • Full survey results are available at:

http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000004394/EnsuringAccesstoHighValueProviders.pdf

ACNM Survey Results Do you contract with certified nurse-midwives as network providers for your plans? (N=87)

75%

19%

6%

Yes

No

Sometimes

Nearly one-fifth of insurers surveyed refuse to include CNMs in their provider networks.

ACNM Survey Results Do you cover primary care services provided by certified nurse-midwives? (N=59)

ACNM’s definition of the practice of midwifery includes the provision of primary care services. This definition is incorporated into the legal definition of scope of practice by many states.

69%

17%

14%

Yes

No

Sometimes

ACNM Survey Results Do you impose any restrictions on what certified nurse-midwives can do, beyond those imposed by state scope of practice laws and regulations? (N=56)

The Public Health Service Act prohibits insurers from discriminating against providers acting within the scope of their license as defined by state laws and regulations.

14%

86%

Yes

No

ACNM Survey Results Do you cover services of certified nurse-midwives provided in birth centers? (N=54)

Birth centers are licensed in 41 states and the District of Columbia, yet nearly one-quarter of plans do not cover CNM services in that setting.

72%

24%

4%

Yes

No

Sometimes

ACNM Survey Results Do you cover home birth services offered by certified nurse-midwives? (N=36)

In 2012, there were more than 35,000 home births in the U.S.

36%

56%

8%

Yes

No

Sometimes

ACNM Survey Results Do you contract with birth centers to cover their services? (N=70)

A recent study concluded that a birth center in Washington DC saved the Medicaid program in that city $1,163 per birth.

49%

47%

4%

Yes

No

Sometimes

Provider Discrimination is Illegal “A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.” Section 2706(a), Public Health Service Act

Conclusions • ACNM’s survey demonstrates that many plans are systematically

discriminating against CNMs/CMs purely on the basis of licensure. • This behavior is explicitly prohibited by Section 2706(a) of the Public Health

Service Act. • State insurance commissioners have a duty to see that insurers comply with

the provisions of Section 2706(a) of the Public Health Service Act. • State insurance commissioners should closely examine plan networks to

determine whether they are including CNMs/CMs and should inquire as to whether plans are providing coverage for all services CNMs/CMs are allowed to render under applicable state scope of practice requirements.

• Plans that include CNMs/CMs in their networks will save money because the midwifery model of care involves the use of fewer interventions.