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.


Anonymous said...

collaboration (kəˌlæbəˈreɪʃən)

— n (often foll by on, with, etc )
1. the act of working with another or others on a joint project
2. something created by working jointly with another or others
3. the act of cooperating as a traitor, esp with an enemy occupying one's own country

Which witch said...

Of course this was all predictable. Now we have the situation where women are able to have a baby at home without any help at all if they choose. They can choose to give birth on the roadside travelling up to 200 kms to the nearest hospital in remote areas. They can choose a carer without the experience of a qualified and emergency skilled midwife. Who asks a modest payment compared with the $6000 + for which they must pay private insurance in order to claim or they can choose public hospital care and be challenged to try and avoid all of the myriad of tests and threats of intervention and operative birth. Or they can choose a lay midwife or doula birth attendant.This is what many women are doing. Cash is exchanged wiht no rebate. If anything goes wrong then the lay/and sometimes the registered midwife will have her name splattered all over the news. The difference is that babies can die in hospital and no one is held accountable except perhaps by themeans of an internal review by peers. This same hospital doctor can work in private practice and charge enormous fees with probable equal private insurance rebates for the woman. This doctor can have a hospital regime controlled midwife conducting the labour of the doctor's private woman/patient who may be the only person assisting at the birth. This hospital midwife receives no bonus (extra money) for the privlege. The doctor does not even have to check the midwife's credentials and the woman is not consulted nor does she have any say about whether this midwife is suitable or she may not even meet her until she enters hospital. There is no need for a doctor to reveal his CV or record on interventions and episiotomies or infection heamorrhage or even pass a check on her/his surgery skills. Especially if he intends to have a high caeaarian birth rate. How do we know she/he is competent to conduct a birth? But an elgible qualified registered midwife cannot work in private practice with a woman without passing a checklist from a doctor i.e. if the Medicare rebate is to be received for the midwives more than competent and care. The midwife becomes known to you and your family. When did an obstetrician meet your family in your home - how many times does that happen? The woman has the power to refuse this system but the midwife may be suspended as has already happened, from practice if the woman chooses not go to the hospital for checks. When a doctor makes mistakes we do not hear about it even maternal deaths statistics do not appear for about 3 years causes and where and who it happened with are not revealed. Does any woman ask for a quality control check on a doctor she is atending? I do.

All questions will go unanswered I can guarantee - I am not allowed to comment on the Conversation site only a doctor can tick the box. How fair is that?

Joy Johnston said...

You are right, Anonymous. The third meaning of the word 'collaboration' is troubling to many midwives.
Without trying to speak for others, I believe that those midwives who have sought to comply with the collaboration requirements of the Medicare package are doing so with the best of intentions, with the wellbeing and safety of mother and baby paramount in our minds.

Joy Johnston said...

Thankyou Which Witch for your comments.

You said:
"All questions will go unanswered I can guarantee - I am not allowed to comment on the Conversation site only a doctor can tick the box. How fair is that?"

There are many aspects of the maternity reform package that independent midwives and women who employ us privately would like to see changed. The requirements for a doctor to agree, or to sign something that provides access to public money is a good example. You ask 'how fair is that', and the clear answer is 'it's not!'

I would encourage you to do what midwives have done throughout history - found a way to protect the wellbeing of the mother and her baby, and to promote health, within the society in which they work.