Sunday, February 26, 2012

Arranging collaboration

Each time a Medicare-authorised midwife agrees to work with a woman in providing midwifery services we have to navigate the sometimes-challenging terrain of collaborative arrangements'.

Without a collaborative arrangement that meets the requirements set down in the National Health (Collaborative arrangements for midwives) Determination 2010, the midwife is not permitted to offer a Medicare rebate for services. The degree of ease or difficulty experienced in reaching tick in the collaboration box varies from woman to woman. In last week's blog post I listed some of the situations that midwives have faced in attempting to arrange collaboration, ranging from simple and workable, to outright obstruction by a medical practitioner.

A midwife who has recently obtained her Medicare provider number, and who is setting up private practice for the first time, has decided to focus on postnatal midwifery services, rather than primary midwifery care that spans the prenatal, labour and birth, and postnatal episode of care for individual women. The midwife contacted the Medicare office, and reported:
"they [Medicare] don't need collaboration, all they want just referral from a doctor."

"the doctor can be a GP who does not have the diploma of obstetrics."

"also called the two insurance companies, who confirmed, no need for a collaborative agreement for postnatal, only referral from a doctor which could be a GP who initially made the booking in."

This apparently conflicting advice highlights the need for a serious review of the government's Maternity Reform package and the associated bureaucratic processes. There is no differentiation made in the legislation between prenatal or postnatal midwifery services; they all come under the same set of requirements. It is ludicrous for the Medicare office to tell a midwife that "You don't need collaboration, only a referral from a doctor." The referral letter IS the collaboration arrangement, according to Section 5 (1) (b) of the Determination.

Midwives who seek to meet the Medicare-related requirements take the relevant legislative instruments into consideration in preparing a care plan for each woman. Using a highlighter, here is a summary of two new laws which impact on midwifery services:

For each episode of care, the midwife needs to consider:
1. National Health (Collaborative arrangements for Midwives) Determination 2010 [NH(CM)] 
2. Health Insurance (Midwife and Nurse Practitioner) Determination 2010 [HI(MNP)]

Specified Medical Practitioner for this episode of care: _____________________________________

Collaborative agreement or arrangement under Section 5 NH(CM): ______________________

5 Collaborative arrangements — general
(1) For the definition of authorised midwife in subsection 84 (1) of the Act, each of the following is a kind of collaborative arrangement for an eligible midwife:
(a) the midwife is employed or engaged by 1 or more obstetric specified medical practitioners, or by an entity that employs or engages 1 or more obstetric specified medical practitioners;
(b) a patient is referred, in writing, to the midwife for midwifery treatment by a specified medical practitioner;
(c) an agreement mentioned in section 6 for the midwife;
(d) an arrangement mentioned in section 7 for the midwife.
If the collaborative arrangement is (d) above [Section 7 midwife’s written records] 

(1) (a) the (specified) named medical practitioner(nmp): _________________________ 
(b) Midwife has told the patient of collaborative arrangement with nmp: 
(c) acknowledgement by nmp: 
(d) plans for consultation, referral, and transfer of care to nmp: 
(2) (a) record of any consultation or other communication with nmp: 
(b) record of any referral to nmp: 
(c) record of any transfer of care to nmp: 
(d) acknowledgment of receipt by nmp/hospital of booking: 
(e) acknowledgment of receipt by nmp/hospital of maternity care plan: 
(f) record of imaging& pathology results to nmp: 
(g) discharge summary to nmp and usual general practitioner

• Practice arrangement [HI(MNP) 4(2)(a)] for midwife with primary booking in this care plan: partner / employee / [other] ___________
• Other midwife who provides relief services or locum [HI(MNP) 4(2)(b/c)]:
• Requirement [HI(MNP) 6] for collaborative arrangement has been met:
• Requirement [HI(MNP) 7(1)(a)] service has been met:
• Requirement [HI(MNP) 7(1)(b)] (not employed) has been met:
• Labour and delivery [HI(MNP) 8] requirements (1) to (4) have been met if applicable:

In addition, a midwife who intends to attend a woman for birth in the home is required to have the woman sign an agreement, in which the woman acknowledges that she understands that there is no professional indemnity insurance for home birth, and that midwives are exempt until 30 June 2013 from having insurance for homebirth.

These are just a few examples of the new and complicated terrain that privately practising midwives in Australia must navigate.  In time midwives will face audits and investigations, and will be held accountable for the way we practice.  Midwives who wish to discuss practice in more detail with their peers are invited to join Australian Private Midwives Association (APMA), and contribute to APMA yahoo! group email discussions.

Wednesday, February 22, 2012

Assessing progress with Medicare

Let's review and assess private practice midwives and Medicare!

In the past year midwives who have the 'eligible' notation against their name on the Midwives Register have been able, in theory at least, to facilitate Medicare rebates to women in their care. The common process is that the receipt issued by the midwife contains the midwife's Medicare Provider Number, the name and address of the practice as it is registered with Medicare, and the Medicare Item number(s) for services provided.  The woman/client receives rebate of the scheduled fee plus any addition rebate under the Extended Medicare Safety Net scheme.

The Health Insurance (Midwife and Nurse Practitioner) Determination 2011 - F2011L02162 is the legislation that gives detailed description of the Items and the current level of the scheduled fee for midwifery services, from which rebate is calculated.

Australian Private Midwives' Association (APMA) has asked members to provide information about how they are traveling in the new 'Medicare eligibility' terrain. Understandably, much of the response has focused on the requirements of the new legislation for a collaborative agreement or arrangement with a named, specified obstetric medical practitioner - all of which is defined and directed in the law. The midwife is required to demonstrate and record suitable collaboration in order for Medicare rebates to be available to the woman, but there is no linked requirement, or even encouragement, for any doctor to reciprocate when collaboration is requested.

Some midwives are situated in communities where doctors and even public hospitals are willing to enter collaborative arrangements with private midwives. The midwives are getting on with the job of being with woman; the women are receiving expert midwifery care from their own midwives through the continuum, as promised by the Health Minister when the maternity reform package was announced, and receiving significant Medicare rebates for the midwifery services.

However, midwives practising privately in other communities, such as densely populated big cities, or covering rural towns and villages, face multiple challenges each time they attempt to comply with the collaboration law. Here are a few quotes from midwives' responses.

[The collaboration requirements are]
"absolutely unreasonable. We are qualified competent midwives who should not be held to ransom by our medical colleagues. It is mainly unworkable and my clients are having to travel all over the place to get an agreement and they pay a new patient fee and then are told ‘oh no I’m not doing that now’ even though the doctor signed an agreement with another client the week before. It’s not fair on the doctor either as they often don’t understand they are not required to do anything and if there are any deviations from normal then we consult directly with the [backup] hospital. Doctors often say there’s no point to this because we’re doing the same thing and doubling up and it’s not required for a healthy uncomplicated pregnant women. I say "I KNOW, but can you just sign anyway" because it’s just a formality and a requirement until we get the legislation changed!!"
[The collaboration requirements]
"should not have such and emphasis on the midwife being subservient to the doctor. It should also provide an incentive for a doctor to want to collaborate with us!"
[The collaboration requirements]
"are not necessary - we had the same system of referral and transfer here before Medicare and it worked fine but it was not formalised. Now it takes extra time and the doctor has the power to veto - this is not acceptable."

Collaboration can be a relatively simple matter.  A letter of referral (one of the processes by which collaboration is demonstrated) from a doctor Melbourne, who had not previously met this woman, wrote to the midwife:
"Thanks for caring for <M>  for the antenatal and postnatal period of her pregnancy.  She is well.  I am happy to provide collaborative care."   
On the other hand, an obstetrician, who is a senior consultant at a public maternity hospital has said:
"I am not comfortable with this model of care (ie private midwife).  If <M> wants a private midwife she will need to make a booking at [public] hospital, and have all her care under that system.  Any additional care she wants from a private midwife will be at her own cost.  I will not sign a collaborative arrangement."
The midwife, and the woman, must return to the drawing board, seeking a way to meet the collaboration requirements.

Readers are welcome to make their own assessment of progress in the midwife-Medicare labour.
Midwives assess progress (of this labour) externally, and the external features that can be noted include the fact that some women are claiming rebate on midwives' fees.  The amount of this rebate could be up to $1000 per woman/episode of care.

Midwives also assess progress internally, and the internal signs of the Medicare labour are not good.  The efforts made by some obstetricians to isolate and exclude private midwifery, blocking what little financial assistance the woman is entitled to, will lead to distress and obstruction.  The people who will suffer most are the mother and her baby.

Thankyou for your comments.

Friday, February 3, 2012

membership in APMA

The APMA committee are checking our membership database, and sending a reminder message to those whose membership has lapsed due to unpaid subscription fees.

This is a good opportunity to invite other midwives who are practising privately in Australia to consider taking out membership, and joining other colleagues in our effort to improve maternity care through access to private midwifery.

For more information about APMA, please click here, and fill out the membership inquiry message.

Of course – should you feel able or willing to make a donation to APMA to assist us further to meet the goals of APMA it would be greatly appreciated.

The fee for renewal of membership is $50.00 annually. Please make payment by direct deposit/electronic transfer into the APMA account, and include your name in the message.

The APMA bank account is: BSB: 067-105 Account #: 10344192

If you are no longer practising as an independent midwife, and would like to continue as a ‘supporter’ of APMA, please let me know [], and that will be recorded on our database.

The APMA committee are also in the process of preparing a Statement of Purpose. Some of the points noted at a recent brainstorming session are:
  • To represent midwives who practise privately – across the full scope of practice, not just Medicare-eligible midwives, not just homebirth midwives 
  • To support and care for members in a non-judgmental way, with flexibility to respond to different people and situations 
  • To respond to issues related to private practice midwives 
  • To present the needs of private practice midwives to the regulatory authority – eg to ensure that midwives’ peers are used as experts in investigations and hearings 
  • To lobby in the political sphere, in response to current issues 
  • To share information with members and the wider community 

Members and other readers are welcome to contribute your ideas and suggestions to the development of a Statement of Purpose.

Joy Johnston
(Vice President, and blogger)