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

MIDWIFERY SERVICES [HI(MNP)] 

• 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.