Tuesday, January 17, 2012

Medicare and midwives

[The following post is written by Joy Johnston, who is a member of APMA. Any opinions expressed are those of the writer, and are not necessarily shared by the organisation.]

It is useful for midwives to consider an opinion piece in the MJA, What is wrong with Medicare?, by Tony D Webber (MJA 2012; 196 (1): 18-19), and a linked article on The Conversation, 17 January 2012, Look beyond the hype to see what’s really wrong with Medicare.

The writers of these two articles have strong credentials.
Dr Webber states that he was
"Director of Professional Services Review (a role established to protect the integrity of Medicare and the Pharmaceutical Benefits Scheme) for over 6 years, ..."
and that
"From the beginning, there were inadequate safeguards in a scheme based on the honour system. In no other area of public expenditure where recipients have significant control has so little attention been paid to audit."
The author of the second article, Jim Gillespie, is Deputy Director, Menzies Centre for Health Policy & Senior Lecturer in Health Policy at University of Sydney.

Midwives and maternity activists who have been lobbying government for many years, remember the clear statement by then Labor Health Minister Dr Carmen Lawrence that Medicare will NEVER be available to midwives. It's now history that Kevin Rudd, with Health Minister Julia Gillard, have introduced Medicare for eligible midwives, and that every day midwives are giving our clients receipts that entitle them to rebates, or using EFTPOS machines to bulk bill for some services. Surely this is good, for midwives and our clients.

We midwives would do well to hear the concerns of these two well-informed writers.
The serious claims made by Dr Webber are to do with rorts and inefficiencies estimating that "2–3 billion dollars are spent inappropriately each year." An example quoted is that "After the Safety Net was introduced, a small group of obstetricians raised their fees for antenatal care from around $3000 to nearly $10,000."

In his useful analysis of a complex situation, Dr Gillespie states:
"But the Medicare system wasn’t designed to encourage continuity of care. Instead, it uses fee-for-service to fragment care into short episodes. A major criticism of the current system is that it doesn’t provide optimal care because it’s episodic and as a result, it may be creating incentives for abuse of the system as doctors’ incomes are generated by multiplying episodes of care."

Continuity of care, and of carer, are key principles valued within midwifery standards, codes, and models of care.   Evidence and logic support systems that link a pregnant-birthing woman to a known midwife who provides the primary level of maternity care.  Most women like to know and trust their hair-dresser!  How much more significant is it that those who have the intention to approach childbirth as a physiological event (rather than a medical procedure) would like to know and trust our midwife!

Maternity care offered the health system an excellent opportunity to reform funding to protect continuity of care, based on the total basic package of care for each woman in pregnancy and birth. Normal pregnancy is one potential *item* that is very definable - there is no such thing as chronic pregnancy! Complications are also definable - Medicare items already exist for such medical services.  Once labour starts a baby has to be born, and the modes of transfer from the womb to the outside world are limited. Postnatal services are, similarly, containable.

However, by applying the standard Medicare model of fragmented items to Medicare funding for midwifery services, the same weaknesses that are so obvious in medically-managed Medicare have been carried across to midwifery-Medicare.   Medicare does not have any limitation or expectation as to the number of claims made on certain midwifery items, for example, prenatal and postnatal consultations.  A midwife can provide as many postnatal consultations in the first 6 weeks of the baby's life, and Medicare will rebate the amount calculated on the scheduled fee, plus the extended safety net.  If a midwife provided 42 postnatal visits for a woman, and received the Bulk Bill rebate of $65.50 for each consultation, a total of $2,751 would be paid from the public purse to that midwife.  Would that be considered over-servicing?  Perhaps - it's an unlikely scenario.  If that daily consultation with a particularly needy mother and her baby kept them well, and out of hospital, surely the health money would be well spent, and the midwife should be congratulated.  But isn't that taking continuity of care to an extreme?  Would the midwife be rorting the Medicare system?  Do we need more rules, more stringent 'safeguards', to define what would be reasonable, or will (most) midwives do the right thing - whatever that is?

In giving this example I have touched on an area of change for private midwives.  In the past, before private midwives had Medicare provider numbers, the client paid the midwife's fee for each visit, or the midwife did extra visits without charging.  Now, Medicare-participating midwives who are able to comply with the collaboration rules can provide much more affordable care.  Women who are experiencing difficulties in the early postnatal period, even after discharge from hospital, are now able to engage a private midwife the whose fees are mostly rebated by Medicare.  A woman who had a private obstetrician for pregnancy and birth, for whom Medicare rebated several thousand dollars, is now able to be rebated by Medicare for a midwife's care.

In this post I have not attempted to justify or explain the new Medicare-funded private midwifery, which has been in operation since November 2010.  I consider that although the system we have is flawed, midwives are seeking to work within the system, and the benefit is a greater degree of financial equity for women who employ midwives for professional care.


Anonymous said...

Thanks for this posting Joy. I agree with your commentary that there are real benefits to women in the availability of MBS rebates for midwifery care, but that the fee-for-service model doesn't drive continuity.
Some submissions to the Commonwealth's Review of Maternity Services (including Maternity Coalition's) proposed funding episodes of care in order to support continuity. I suspect the Government's decision stick with fee-for-service was an act of reasonable caution. The Commonwealth has however been discussing the possibility of funding episodes of care thru Medicare, which could at some time be used in midwifery.
New Zealand funds episodes, with payments for trimesters 1+2, trimester 3, labour and birth, and postnatal. It's worth noting that this only totals approx NZ$2000 per pregnancy, birth and postnatal episode.
I think there is likely to be a time when amendment of MBS funding for midwifery should be considered, but that will probably be after bigger problems are solved - such as collaborative arrangements and the eligible midwife/public hospital interface.

Joy Johnston said...

Good to hear from you Bruce.
As you have mentioned the NZ situation, I think one of the main differences between NZ funding and Medicare is that the NZ midwives and GPs are not entitled to charge a fee on top of the standard payment. The same amount is paid for the same service, regardless of whether the service was provided by a midwife or a doctor.
Thanks for your comment.