Thursday, April 17, 2014

indemnity insurance: who benefits?

It's a simple question.  Who benefits from indemnity insurance?

We're all familiar with insurance: home and contents insurance, vehicle and third party property insurance, health insurance, travel insurance ...  Some are mandatory; some are not.  

Narrowing the field a little ...
... to mandatory indemnity insurance for midwives as regulated health professionals.  Who benefits from that?

The obvious answer is that the consumer - the mother+baby who receive professional care from the midwife - are potential beneficiaries.  When/if a mother or her baby experience adverse outcomes that may have been avoided under professional care that may have been done differently, that mother or baby are able to sue the midwife for the loss they claim to have suffered.

An eye for an eye!

The matter is placed in the hands of lawyers.
If the midwife has indemnity insurance, the insurer advises and supports the midwife.  The insurance policy may have exemptions and limits that are taken into consideration.
Sometimes a settlement is reached without going to court.  Money is paid to the person who suffered loss, and that's the end of it.
Or the case is scheduled to be heard in the appropriate law court.
If the court agrees that the midwife was culpable, an order is made that a sum of money be paid to the person who suffered loss in the care of the midwife.
Who benefits?
The person who was harmed.

The complication is the availability/affordability of indemnity insurance.  This is a global problem.  No-where in the world is there an indemnity insurance product for individual midwives that provides assurance of sufficient funds to pay out for the life-long health needs of a baby who is severely disabled by hypoxia at the time of birth. 

It's not a new problem.  I have been attending births without indemnity insurance since it became unavailable in 2001.   I (and others in this country) have been permitted to continue practising without insurance for births, while our government agencies attempt to solve the problem.  Midwives in oz are at present exempt from having indemnity insurance for privately attended homebirth, because it's not available. This exemption will be reviewed by June 2015.

Australia's national regulatory board published a research report on professional indemnity insurance for midwives in December 2013.

The UK Department of Health has rejected a proposal by Independent Midwives UK, concluding that government funding of midwives' insurance will not give patients protection (DoH News story 6 March 2014).

German midwives and mothers have been holding huge public rallies - see hebammenblog and scroll down to 13 March (and use translation if, like me, you don't understand German)

It does seem to me that privately practising/independent midwives will 'die out' as soon as the laws mandating indemnity insurance are applied. Because the stakes are so high in childbirth, insurance becomes too expensive except through large corporations (hospitals) or medical defence schemes which cost more than some midwives earn.

I am considering this threat to private midwifery practice from as many perspectives as I can.  Readers may consider my concerns to be tainted by self-interest, because I practise midwifery privately.  But, as I am close to retirement from attending births, I see myself as a commentator who knows the terrain well.

From a professional perspective, the cost of indemnity insurance demands consideration.  Midwives who are taking a full caseload (40+ births per year as primary carer, as well as other midwifery services) are paying between approximately $2,000 to $7,500 annually.  Neither of the policies on offer covers homebirth; the more expensive policy covers birth attendance in a public hospital at which the midwife has been credentialed and awarded clinical privileges.  The number of women planning homebirth with a privately practising midwife is small - less than 0.5% of the birthing population.  Midwives who take too many bookings burn out quickly, and women lose faith with their private one-to-one midwife if she is not available to attend their births. 

That's the top end of the scale. 

Midwives who have a very small caseload; perhaps only a few bookings for primary care per year, are also required to have indemnity insurance, and the minimal cost is approximately $2,000.  Those midwives, possibly living in rural towns or properties, may work part time as employees in the local hospital, and see their small 'private practice' as an expensive hobby.   

From a professional business perspective, there is clearly a point at which the cost of private practice outweighs any perceived benefit.   

As fees for indemnity insurance increase, and the cost is passed on to the client, some midwives will not be able to earn enough to afford meaningful PII, unless they charge high fees that make their services unaffordable to the majority of women.

It's a self-defeating cycle.

costs progressively rise - 
midwives burn out or fail to attract enough business to continue offering their professional services - 
reduced access to private midwifery services for women

However, the bigger issue (imho) is the myth that mandatory indemnity insurance is somehow in the public interest, when the vast majority of cases of cerebral palsy, for example, cannot be linked to an action or omission by any professional care provider (hospital or home), and there's no claim on anyone's insurance.

From a social perspective, does our society think that midwives should be free to provide services privately (independently) to women, in a way that is affordable and accessible? 

Or the other side of the same coin, that women should be free to engage a midwife privately? 

Most women in our society like to be able to control who provides other personal, intimate services such as hair cutting, or beauty services for removal of unwanted hair, so why would they not want to have a say in who attends them for the most intimate of professional services?

But most women in our society have no idea of the scope of a midwife's practice, or indeed of their own birth-right: to give birth safely and triumphantly under amazing natural forces.
The midwife's ability to protect, promote and support normal birth is limited by the professional/regulatory control: a state's duty to protect the public through the regulation of the profession.

The UK government article that I referenced above suggests that midwives should be able to form 'social enterprise' businesses that purchase insurance for members. To me (I do enjoy the one-to-one relationship between me and the woman for whom I provide primary maternity care) this sounds like layers of unhelpful nanny state control that provides only a mirage of safety.

The indemnity insurance situation for midwives in Germany is different from that in Australia or UK.  A German midwife informed me that "Our "independent" midwives do not practice "privately" or "outside" the system.  Here their service are still covered by national healthcare and their "extinction date" has just been pushed back another year as the insurers will offer indemnity insurance for another year to come (with another raise of 20% and limited for another 12 months and the sum covered cut down to half of what it covered before…)

Back to the initial question:
Who benefits? 

  • when a midwife's indemnity insurance does not cover what midwives do?
  • when the increasing costs of providing midwifery services prevents some midwives from offering their professional services, thereby reducing access of women in the community to midwives?
  • when the increasing pressures associated with providing midwifery services lead to burn-out and break-down and unsustainable commitments being made
  • when the increasing costs of providing midwifery services leads to business models that focus on risk management and the bottom line $$ rather than the woman-midwife partnership?

Who benefits?
  • Not the consumer/client/woman+baby
  • Not the midwife
  • Not the community
someone else!

Dear reader, today I have only touched on these matters.  What solutions can we propose?
In the present climate I see reports of cases before the coroner that are likely to have had good outcomes if they had been managed differently.  I read reports of midwives taking extreme positions on management of women with known risk. 

I have phone calls from women who think they would like homebirth because they don't like hospital.   

The solution is not to be found in ever-tightening rules being imposed on midwives.

The solution is not to be found in governments throwing money at the insurance industry.

One aspect of the solution, as I understand birth, must be that a midwife can arrange to provide care for women in hospital as well as home.  

I would like to see the 'villagemidwife' concept available in any town or community where a midwife chooses to work in a professional capacity, providing primary maternity care for individual women.  The setting for births in this midwife's practice must be determined by the woman's and baby's needs at the time of birth.

A society that provides regulation of midwifery must also ensure the ability of the midwife to practise midwifery.  That is the only way to protect the public.  A society that makes midwifery unaffordable, inaccessible, or restricted to homebirth, is depriving its mothers and babies of one of the most basic health promotion services that human existence has ever known.

1 comment:

Denise Hynd said...

IN New Zealand midwives who are self employed like our German sisters work with in the system including to attain Professional Indemnity Insurance (PII)! The midwives who choose to contract with New Zealand women for continuity of carer or as their Lead Maternity Carers (LMC) such that the government pays them for their services have 2 steps to attain PII. LMC midwives pay levies to the national Accident Compensation Commission each year depending on the nuber of women they have attended in the year! Plus LMC midwives pay a higher membership to the NZCoM. Evidence of the latter along with their Annual Practicing Certificate has to be presented each year to the hospitals where they seek and are given admission rights. Australia could go down this path if Bill Shorten forms a government and re-introduces the National Injury Insurance Scheme the Productivity Commission wanted introduced along with the National Disability Support Scheme doing the Gillard governments term!