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

The midwife

I have been enjoying the BBC series 'Call the Midwife', which has been shown on Australian ABC TV.  This week we will see the fifth and final episode in the series.

(If you go to You Tube you can apparently download and watch the full first series.)

Since I began writing my stories in the mid 1990s, in The Midwife's Journal,  I have hoped that I am setting down on the record something of the essence of midwifery, within the context of ordinary life, so that it is available to future generations of midwives, and anyone else who is interested.  The discipline of writing down the stories as they happen must have been similar for the writer, Jennifer Worth, who journaled her experiences in London in the 1950s.

Last week I wrote about women's rights in childbearing.  This is a very important topic, but is likely to lead to a skewed view of birth, unless there is an equal emphasis put on the midwife.  The partnership of midwife and woman, working in harmony with sensitive natural physiological processes, is precious, but easily disrupted.

Just as without a strong healthy mother the baby is unlikely to thrive; without a strong, confident, and capable midwife, the woman is unlikely to progress safely along the pathway to birth: a mystery journey each time.

Today's world offers women a potentially overwhelming burden of knowledge about aspects of birth, without preparing a woman for the real job, which includes giving birth and nurturing their young.  Women are bombarded with an array of mainstream and alternative treatments, for their bodies, their minds, their relationships ...
By the way, I am referring to the woman, because only the woman can give birth.

A woman (or couple) may attend childbirth education classes at a hospital, independent childbirth education, exercise classes on balls, exercise classes in a yoga studio, exercise classes in the local swimming pool, and video sessions with commentaries by consumers, professionals, and lay activists to name a few.  They may follow pregnancy-birth related social media groups and forums.  She may see her primary maternity care provider for basic check-ups, as well as a naturopath and homeopath and acupuncturist and chiro or osteo or any number of other therapists and healers, each of whom offer to have some part of her body in tip-top shape for the big event, but none of whom can offer what the midwife does.

I said it's a potentially overwhelming burden of knowledge about aspects of birth.  I rarely see women coming to birth with calm confidence in the wonderful processes that our minds can not fully grasp no matter how hard we try.  I see a father anxiously coaching the woman who is carrying his child, telling he how to move or what to relax.  I wonder where he obtained this knowledge.  I hear recorded voices of unknown strangers who guide visualisation of climbing a mountain or a flower opening.

One mother who gave birth about a week ago had confidence.  I have been with her for several of her babies.  She is a beautiful, gentle woman who invests herself fully in her family, and avoids the public gaze.  Her preparation for birth included good food, adequate rest, and work about her home.

As the labour became strong this mother withdrew from her children, knowing that they were all in bed and quiet.  I rested on the couch.  Then she invited me into her bedroom: "it won't be long now," she told me.

Quietly and steadily she guided her baby down and out.  There was a cry as the little one's head passed over the perineal threshold - the older children said they heard it.  Shortly afterwards there was another cry, as the newborn took air into her lungs and made that amazing transition from placental to lung circulation.  The third stage proceeded without the need for any medical intervention, and there was minimal blood loss.  When I visited this mother she was sitting outside in the gentle spring sunshine.  I saw a well mother, with a well baby at her breast. 


In telling this story I have not mentioned the buzz word of the day: collaboration.  Those in authority today will insist that collaboration is the key to safe maternity care.

Yes, there was a collaborative arrangement in place, a letter of referral from a suitably qualified doctor, enabling this mother to claim some Medicare rebate on my fees.  The birth plan was, as is usually the case in primary maternity care for planned homebirth, to proceed under normal physiological conditions, working in harmony with the natural processes, unless complications were to arise. We planned to go to the nearest suitable public maternity hospital without delay for urgent obstetric concerns, or to refer to a local doctor for non-urgent medical indications.  This is basic midwifery.  The baby is born safely; the mother recovers quickly; all without medical (or midwifery) intervention.


Thankyou for your comments.

a career in private midwifery?

... continuing thoughts on this topic from the MIPP blog.

with Sue and baby Benjamin - photo taken by Amy, used with permission

Today I want to focus on questions that arise for midwives and midwifery students who are considering a career in private midwifery practice. If you want to practise privately, independent of the mainstream maternity hospitals (public or private) which provide employment for the great majority of midwives in this country, you need to find a sustainable way to work.

Most midwives who practise privately in this country rely for 'business' almost exclusively on individual women who seek the one-to-one midwife who will work with them when they labour and give birth.  Midwives in private practice have caseload bookings, with individual women, usually across the spectrum of pre-, intra-, and postnatal services.

Most births at which the woman's chosen midwife is the primary/leading professional in attendance - the one who takes responsibility for the conduct of the birth and ensuring the wellbeing of mother and child in that acute episode of care - are in the woman's own home. There are midwives with clinical privileges in hospitals in the South-Eastern corner of Queensland (Toowoomba, Ipswich, Brisbane, Gold Coast), and Sydney. I don't have the details, but can follow up if anyone wants to know more.

What does a private midwifery practice look like, from a business perspective?

We need to consider the practice (the acts and being of midwifery) separately from the business (structure and financial aspects).

The midwife's practice can be 'solo' (working as the only professional midwife booked by a woman for the episode of care) or in arrangements where two or more midwives work together to provide the primary care for each woman who is booked with them. This is often described as a 'group practice'.

The private midwife's business arrangements for earning a living can be a simple 'fee for service' in which the woman/client pays that midwife directly, or the fee may be paid to an employer/company which in turn remunerates the midwife for the work she undertakes. The employer in the latter instance could be a midwifery group practice, or another business such as a group of obstetricians. The midwife may or may not be a partner in the practice.  Whatever the arrangement, laws applying to tax, employment and superannuation must be complied with.

My system for management of payments is that any money that is transacted, whether by cash, credit card, cheque, or electronic transfer, and whether by the woman or by Medicare (bulk billing) is immediately recorded by hand in a small 'Cash Receipt' book with carbon copies.  This automatically generates a number for the receipt, as all the pages are numbered, and I add a prefix which refers to the number on the outside of the booklet - at present the prefix is 17.  The top page is placed in the client's file, and the carbon page stays in the receipt book.  The receipt number and information will be entered into my Quickbooks accounting system when I get to it.  This is the basis for my income tax, and quarterly BAS returns.  Midwifery services do not generate the goods and services tax (GST), but the GST charged on purchases by the midwife in carrying out her business can be claimed from the ATO.

Most of my midwifery practice is 'solo', with some bookings made in which I practise with another midwife.  Recently I have enjoyed working with my colleague and friend, Jan Ireland from MAMA, in providing midwifery services for a woman who was booked with Jan.  I will describe this case from the perspective of the new Medicare arrangements, as it demonstrates how midwives are able to work together within the collaborative arrangement and maternity care plan set up by the midwife who has made the primary booking.

In this case, from the Medicare perspective, the second midwife is able to act as a reliving midwife or locum for the primary midwife.  The locum is described in legislation
Health Insurance (Midwife and Nurse Practitioner) Determination 2011, Health Insurance Act 1973,

Part 4 Interpretation

(1) In this Part: collaborative arrangement, for a participating midwife’s patient, means a collaborative arrangement mentioned in regulation 2C of the Health Insurance Regulations 1975. delivery includes episiotomy and repair of tears.

(2) For this Part, a participating midwife is a member of a practice that provides a patient’s antenatal care if the midwife:

(a) participates (whether as a partner, employee or otherwise) in the provision of professional services as part of the practice; or

(b) provides relief services to the practice; or

(c) provides professional services as part of the practice as a locum.

The arrangement by which I have provided (b)'relief services to the practice' or (c) 'professional services as part of the practice as a locum' is under (a) 'otherwise', since I am neither partner nor employee of MAMA.



Midwives who are beginning private practice, and who have Medicare eligibility, may consider the 'relief/locum' model, either as partner, employee, or otherwise, as a means of getting started.  



I commenced this post with a question, 'a career in private midwifery?'.  I believe there is a great potential for midwives to aspire to extending their midwifery practice when they step out of hospital employment into private practice.  However there are also significant risks, which all would do well to consider. 

Midwives who practise privately in a community are able to support each other, with relief/locum services, on one hand, while on the other they may be competitors for business.  Being able to accept and work constructively with this dynamic is a key to sustainability in private midwifery practice, not just for the individual midwife, but also for the community served by midwives over generations.

Midwives with Medicare 2

During this past week there has been an increse in activity in preparation for the advent of the medicare-midwife next Monday 1 November.

Midwives seem to be positioning themselves in two main camps: pragmatism, making the best of the situation, on one hand, and resistance to what is seen as removing the midwife's right to autonomy in practice as well as threatening the woman's right to informed consent. Much of the disagreement centres around legislation requiring a collaborative agreement between a midwife and a named doctor in order for the midwife to be able to access Medicare funding, and visiting access in hospitals for intrapartum care.

The Australian Private Midwives Association (APMA) position statement on Collaborative arrangements [click here] opposes the Determination, contending that:

"Private practice midwifery will become known as the model whereby midwives are working in private medical practices, with little regard for those self employed midwives who currently provide true midwifery care at this current time."

A recent meeting between the Health Minister Nicola Roxon and four independent candidates who stood in extremely marginal seats in this year's federal election, and maternity activist Justine Caines, has given rise to an interesting report published anonymously at the APMA blog. The writer indicates that

"It is possible that the Gillard Government is contravening its responsibilities under the Convention of the Elimination of all forms of Discrimination Against Women (CEDAW)."... and

"The political cost has been high with Minister Roxon embarrassed by poor advice."

 The Australian College of Midwives (ACM) has promoted the pragmatist position, with statements such as:

"The College maintains the view that while this Determination is a poor piece of legislation we need to continue working with the Minister’s Office and the Department of Health and Ageing to provide evidence that will support the Minister in making any necessary changes. The College is dedicated to ensuring that midwives and women are not disadvantaged by this legislation." (e-Bulletin 29/10/2010)

 Leaders in ACM have encouraged members to accept the Determination, indicating a fear that the whole maternity reform process could be derailed if there were to be a motion to disallow the Determination, and that motion were passed.  The reforms that enable midwives to claim Medicare funding, and have limited prescribing rights, and the right to order basic tests and investigations are seen as being of great value to the profession as a whole, while the potential disadvantage that comes with a return to medical supervision of a midwife's practice, sold under the guise of team work/collaboration, is seen as an acceptable trade off.

Midwives continue to work through these issues.

I hope to be able to keep readers informed of progress.

Midwives with Medicare

sisters Anna and Jenni, and their beautiful babies

Today I have checked through the application form that midwives are required to complete in order to obtain a Medicare provider number.

I would love to be able to say to my clients that from 1 November they will be able to claim Medicare rebates on my fees. However, as I do not yet have a doctor who will meet the legal requirements of the Midwives Collaborative Arrangements Determination I cannot proceed with any such application.

If you want to check the full detail of the Medicare fee schedule, go to the Federal Register of Legislative Instruments F2010L02640. [I can't find the link, but I have the document saved as a .pdf]

Here are a few examples of the Medicare fee schedule for a participating midwife's services:
Item 82100
Initial antenatal professional attendance by a participating midwife,
lasting at least 40 minutes, including all of the following:
(a) taking a detailed patient history;
(b) performing a comprehensive examination;
(c) performing a risk assessment;
(d) based on the risk assessment — arranging referral or transfer of the patient’s care to an obstetrician;
(e) requesting pathology and diagnostic imaging services, when necessary;
(f) discussing with the patient the collaborative arrangements for her maternity care and recording the arrangements in the midwife’s written records in accordance with section 2E of the Health Insurance Regulations 1975
Payable only once for any pregnancy
$51.35

Item 82120
Management of confinement for up to 12 hours, including delivery (if undertaken), if:
(a) the patient is an admitted patient of a hospital; and
(b) the attendance is by a participating midwife who:
(i) provided the patient’s antenatal care; or
(ii) is a member of a practice that provided the patient’s antenatal care
(Includes all attendances related to the confinement by the participating midwife)
Payable once only for any pregnancy (H)
$724.75

Item 82130
Short postnatal professional attendance by a participating midwife, lasting up to 40 minutes, within 6 weeks after delivery
$51.35


Clearly it would be in the intersts of both the woman and the midwife for this funding to be accessible. Midwives practising in homebirth would at least be able to give their clients the benefit of rebates for prenatal and post natal visits. Once midwives have visiting access at public hospitals (this is still theoretical), women who choose to have their own midwife attend them at a hospital would be able to claim a substantial rebate for the fee.


As I have considered how I could possibly comply with these requirements, without giving up my integrity as a midwife, the only pathway I can see is if I can obtain a collaborative arrangement with a public hospital. In effect, that's the way I have collaborated with the medical profession for many years. My clients have homebirth backup bookings at (usually) the Women's, Monash Clayton, or Box Hill. If medical referral is needed at any time through the episode of care, the medical team on duty at the time accepts the referral.

I will keep readers informed as we progress down this pathway.
A quick calculation of the fees payable by Medicare for:

• an uncomplicated hospital birth (1 midwife) $1504.65
• antenatal and postnatal care for planned home birth $779.90

[These amounts are calculated assuming that the mother has 3 long and 2 short prenatal checks; and two long and 3 short postnatal checks.  Other once only consultations as described in the legislation.]