Saturday, June 01, 2013

Midwives and Medicare

For the past 2+ years I have been able to give clients Medicare rebates for antenatal and postnatal midwifery services.  I am looking forward to having a prescriber number in the near future.  This is part of the government's reform measure, More Choice for Women - Expanding Medicare Support for Midwives, introduced in November 2010.

The basic requirement that I must fulfill before a client can claim a Medicare rebate is that there is a collaborative arrangement in place: a letter or statement, signed by a suitable doctor.  As I have no 'agreement' to meet this need, I must seek out an arrangement for each woman.

There are a couple of doctors who have 'collaborated' with me on more than one occasion.  Most of the time it's a one-off.  Most of my clients live within a 1-hour drive radius of my home.  That's a huge metropolitan area, and some out in nearby towns.  In that area there are thousands of doctors.  Very few have met me.  Some have refused to collaborate, saying that they would thereby be liable for anything I did.

Several months ago a woman who has had three previous uncomplicated births in hospital contacted me.  She wants to have her next baby at home.  I explained Medicare and collaboration, and emailed a letter describing the need for a collaborative arrangement with a doctor, to her.  She took the letter to her local doctor.  In her own words, 



I am just writing to advise you of the trouble that I am having getting a GP to write a referral to your services.
After contracting you to get a letter for the referring doctor, I went to my local GP for confirmation of my pregnancy. They were happy to send me for tests and ultrasounds but when I explained that I didn't want to birth my fourth child in a hospital, but rather have midwifery care and plan a homebirth I was met with an almost hostile response. This GP who had seen me throughout 2 of my previous pregnancys pointed out that he would not write me a referral due to the use of the word "collaborative" . He failed to understand where his duty of care ended and the midwife's began. I tried to explain that I didn't need to see him throughout the pregnancy and that I only needed initial blood tests and this letter but he would not listen. He continued to explain that he would not put his reputation on the line for the sake of my Medicare rebate!
Feeling disheartened I searched for a doctor who had a similar outlook on the way birth should be. I felt positive that this woman would give me the referral I needed.
This time the doctor endorsed homebirth, was happy for me to see a private midwife and ordered the appropriate tests to be sent to my chosen care provider but once more would not write the letter. When I asked for an explanation once again there was talk of scaremongering from insurance companies who had advised her that if she wrote this letter and something went wrong at the birth, even if she was 200ks away she would be liable.
I find it extremely frustrating and disheartening that in order to get the birth that is right for me and my family, I am being financially penalised because my doctors of choice don't fully understand what is required of them.


With this woman's permission, I forwarded her letter to the Health Minister, Hon Tan Plibersek, MP.  The letter I have received from the Minister's office, in reply, gives me hope that the wrinkles may be ironed out.

Excerpts from the Minister's letter, dated 27 May 2013:

The More Choice for Women - Expanding Medicare Support for Midwives, introduced on 1 November 2010, expanded the Medicare arrangements to include midwifery care.  This was in recognition that women should have a range of birthing options available to them and be supported in their choice of practitioner.

Recognising midwives as primary maternity care providers under Medicare was also intended to assist in improving service delivery by enabling better use of the existing workforce ...
 ...
Since the measure was introduced, midwives have reported ongoing difficulties with establishing collaborative arrangements with individual medical practitioners.  This has hindered their ability to provide services under Medicare.

In recognition of this, at the Standing Committee on Health (SCoH) meeting of 10 August 2012, the Minister for Health ... agreed to vary the legislation on collaborative arrangements, to enable agreements between midwives and hospitals and health services.

The Department is currently in discussion with the medical, midwifery  and consumer groups to discuss the detail of the proposed changes.

The Minister recognises that the lack of hospital clinical privileging and admitting and practice rights is a fundamental issue for midwives.  This prevents privately practising eligible midwives from working to their full scope of practice, undermines continuity of care and reduces choice for women.  

As such, the Minister has asked Health Ministers to finalise consistent approaches to credentialing for midwives in public hospitals in line with States' and Territories' commitments under the Maternity Services Plan.

The Minister is committed to supporting increased participation by eligible midwives in the Medicare arrangements and to the proposed changes to the collaborative arrangement requirements that would facilitate this.

Thankyou for raising this important issue.  I trust this information is of assistance to you.
Yours sincerely
[&c]

My comment:
A letter like this to an ordinary inquirer like me does not give any new information.  However, I feel encouraged by the tone of the latter part of the letter.

Specifically:
  • that midwives need practising rights in public hospitals 
  • that the Minister has put pressure on the State and Territory Health Ministers, to get a move on 
  • that public hospitals will be expected to support collaborative arrangements with midwives
  • that the Minister is committed to this reform measure.
Readers may also share critical thought about the More Choice for Women ... reform measure, such as:
  •  the inequity of signed collaborative arrangements, in that the midwife is required to obtain the arrangement, but no doctor is obliged to agree or to sign anything.  The loser, of course, is the woman.  AND the midwife looks pretty useless.
  • the lengthy delays (such as since SCoH in August 2012) in making even the promised changes to the Collaboration Determination
  • the obstruction by public hospitals throughout the country, with the exception of a few in S-E Qld, to any progress on practising rights for midwives
  • with the above point in mind, surely it's unlikely that these hospitals will agree to collaborate with midwives, even after the legislation has been varied as promised 
  • and finally, with an election, and probably a change of government in September, will we see ongoing support for More Choice for Women - Expanding Medicare Support for Midwives?

Your comments are welcome

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