Thursday, August 12, 2010

Collaborative arrangements for midwives

photo: Mizz with Josh
Readers who have been following the political developments in the world of midwifery will know that the Australian government has signed into law a requirement for midwives to have 'collaborative arrangements' in order to entitle their clients to claim Medicare rebates on their charges. Midwives may become eligible for Medicare provider numbers after 1 November this year, if all goes to plan.

Midwives have known since early in the maternity reform process that the Health Minister is committed to collaborative arrangements. Midwives and childbirth advocates have repeatedly lobbied the Health Minister and her bureaucrats about the fact that the requirement for collaborative arrangements for midwives, without any matching requirement that doctors should engage in such arrangements, was an effective veto of private midwifery practice. There is no incentive, no reason why any doctor would consider signing a collaborative arrangement with a midwife in private practice, who is, in a small way, competing with the doctor for business.

Press releases and discussion about the Gillard government's action in progressing the small piece of legislation, 'National Health (Collaborative arrangements for midwives) Determination 2010' under subsection 84(1) of the National Helath Act 1953 can be reviewed at recent posts to the MiPP blog.

My intention in commenting here on this matter is to work through a scenario that I, and a woman who sought my services, would encounter if we tried to comply with the requirement for collaborative arrangements as laid down in this piece of legislation.

Section 7 requires that (1) an eligible midwife must record the following for a patient in the midwife's written records:
(a) the name of at least 1 specified medical practitioner who is, or will be, collaborating with the midwife in the patient's care (a named medical practitioner);
(b) that the midwife has told the patient that the midwife will be providing midwifery services to the patient in collaboration with 1 or more specified medical practitioners in accordance with this section;
(c) acknowledgment by a named medical practitioner that the practitioner will be collaborating in the patient's care;
(d) plans for the circumstances in which the midwife will do any of the following:
(i) consult with an obstetric specified medical practitioner
(ii) refer the patient to a specified medical practitioner;
(iii) transfer the patient's care to an obstetric specified medical practitioner.

Under this section, the woman who is my 'patient' requires a named medical practitioner (a) of whom the woman has been informed (b), and who agrees in writing to be the collaborating doctor (c).

I don't know where to start looking for this doctor (or doctors). My clients at present come from as far away as Epping in the North, Point Cook in the S-W, and the Yarra Ranges in the East - from 20-50K in each direction. I do not know the local doctors. Most of my clients are healthy women who take good care of their bodies and their families, and who don't have much need for doctors.

I have no idea how the named medical practitioner of this section is going to make him/herself available 24/7. Midwives take small caseloads so that we can respond at any time, day or night. Critical decision making in maternity care, particularly when the midwife is committed to protecting, promoting and supporting the natural physiological processes, is not something that happens in office hours. Most doctors have work hours; many medical practices are closed out of hours. Is this doctor going to give me his/her private contact details, and engage with the midwife at any time, under this collaborative arrangement?

I can only imagine how the insurance company of the named medical practitioner of this section will respond to any potential claims. The indemnity issue alone will probably be off-putting enough for even those most supportive of midwifery practice.

The requrement (d), plans for consultation and referral and transfer of care are not a problem at present. A midwife, by definition, arranges medical referral when and if required.


The legislation continues:
(2) The midwife must also record the following in the midwife's written records:
(a) any consultations or other communications ...
(b) any referral ...
(c) any transfer ...
(d) when the midwife gives a copy of the hospital booking letter for the patient to the named medical practitioner - acknowledgment [signed -received]
(e) when the midwife gives a copy of the patient's maternity care plan to the named medical practitioner - acknowledgment [signed - received]
(f) if the midwife requests diagnostic imaging &c for the patient - when the midwife gives the results to the named medical practitioner - acknowledgment [signed - received]
(g) that the midwife has given a discharge summary to the named medical practitioner and the GP - acknowledgment [signed - received]


Reading this section makes me wonder how I would be able to comply with all the complexities of this system.  I don't have a secretary sitting at a desk and organising my letters and paperwork. I wonder if this doctor is going to be happy with faxes, or with results sent by mail from the pathology lab?

My conclusion is that the future looks unpromising for midwives who are hoping to set up Medicare - supported practices.



In the Radio National's Life Matters program today, midwife Liz Wilkes and obstetrician Ted Weaver spoke on "collaborative arrangements".

For those who'd like to hear the online audio, download the podcast, or make comment, the website is:
http://www.abc.net.au/rn/lifematters/

Liz spoke well. Ted Weaver has his head in the sand. He reckons doctors haven’t been asked if they would sign a collaborative arrangement so that a midwife’s clients can access Medicare. He suggested obstetricians will agree to increase their clinical load without being paid – he used the term altruism!

Midwives are regulated practitioners in our own right.  Yet the Medicare reforms put us not only at the mercy of the medical profession, but also asking for their generosity.  There is really no sense, from a doctor's point of view, in supporting someone in competition for business.

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