SOURCE: American College of Nurse-Midwives (ACNM)

October 03, 2014 18:18 ET

New Survey Examines Coverage of Midwifery Care Through Marketplace Plans

American College of Nurse-Midwives Says Insurers, Policy Makers Have Significant Opportunity to Increase Access to High-Value Maternity, Newborn Care

SILVER SPRING, MD--(Marketwired - October 03, 2014) - A new survey by the American College of Nurse-Midwives (ACNM) of health insurers offering coverage through the health insurance marketplaces created under the Affordable Care Act (ACA) found that many plans are not fully utilizing the high value care offered by certified nurse-midwives (CNMs) and certified midwives (CMs). The results also indicate that policymakers need to do more to ensure plans take advantage of the cost-effective services and high quality outcomes associated with midwifery care. 

Summaries of benefits describing plans available through the marketplaces do not describe the extent to which midwifery services are covered by marketplace plans. Using a methodology developed by the National Nursing Centers Consortium (NNCC), ACNM conducted its own survey between March and July 2014 to address this lack of clarity. 

Collectively, CNMs and CMs attend approximately 8% of all US births, though the number varies widely by state. In several states, CNMs and CMs attend 10 to 20% of births. In New Mexico, CNMs attend more than 27%. CNMs are legally recognized in all 50 states and the District of Columbia. CMs are legally recognized in 5 states. 

ACNM was able to survey 85 of the 277 marketplace insurers or 30.7%, located in 33 different states. While not every plan was able to respond to every question, ACNM found that 20% of responding plans do not contract with CNMs and 60% do not contract with CMs. Forty-seven percent of plans do not contract with birth centers, facilities for birth that are largely run by midwives. 

"Certified nurse-midwives and certified midwives are proven providers of high value care. While most insurers have recognized this fact, it is a concern that a significant number have not yet taken advantage of the savings available under the midwifery model, which emphasizes physiologic birth and individualized, evidence-based care," said ACNM President Ginger Breedlove, CNM, PhD, APRN, FACNM. "This is a loss to both the plans and their enrollees. As major providers of maternity and newborn care, a required benefit category for marketplace plans, midwives should be included in all plans' provider networks."

The scope of practice for CNMs and CMs, defined by ACNM and incorporated into many state laws and regulations, includes primary care, gynecologic, and family planning services. The survey found, however, that 17% of plans do not cover primary care services provided by CNMs and that 14% restrict what CNMs can do beyond what is permitted under state laws or regulations. 

"Inadequate inclusion of CNMs/CMs in provider networks limits choices available to women and reduces the value of the plans available to them," Breedlove said. "At a time when the nation is facing a significant shortfall of primary care providers and where many areas of our country have limited or no access to maternity care providers, this is a shortsighted approach. We encourage insurers to re-examine their practices and work with midwives to improve the value of the products they offer."

Half of the surveyed plans pay CNMs at a rate lower than they pay physicians when they perform the same service. "When a health insurer inequitably reimburses midwives, it can discourage them from participating in the plan's provider network, making their services less accessible to women enrolled in that plan," Breedlove said. "Congress recognized this fact in 2010 when it modified federal law to require Medicare, the nation's largest payer, to reimburse CNMs at the same rate as physicians." 

The ACA contained a provision prohibiting insurers from discriminating against providers who render care in accordance with their state scope of practice requirements. 

"This survey clearly demonstrates that many plans are excluding midwives from their networks, or paying them at reduced rates for services they are legally allowed to perform, solely because of the type of license they hold," Breedlove said. "While we do not know why plans have made these decisions, we do know that policymakers have a responsibility to enforce provisions of law that prohibit provider discrimination and to put in place requirements that encourage the inclusion of high value providers in plan networks."

"Whereas obstetricians are experts in providing care to women with high-risk pregnancies, midwives are experts in caring for women with low-risk pregnancies and meeting the everyday health care needs of women throughout the lifecycle. There is a critical need for both obstetricians and for midwives, and both should be reimbursed equitably for their services," she added. 

Reputable studies over decades published in multiple Cochrane reviews, the Journal of Midwifery & Women's Health, Women's Health Issues, The Lancet, the British Medical Journal, and the Australian Health Review, among others, have demonstrated the value of midwifery care both in terms of outcomes and cost savings. 

According to Breedlove, "Most insurers have recognized the proven value of midwifery care and have taken appropriate steps to include them in their networks and cover their services, but there is real room for improvement. To the extent plans not currently contracting with midwives bring their practices in line with the majority, they will be able to offer their beneficiaries better service and better respond to the desires of hundreds of thousands of women to have access to the unique model of care offered by midwives."

Full survey results are available on ACNM's website. An executive summary can be found here. Questions about the survey can be directed to Jesse Bushman, ACNM's Director of Advocacy and Government Affairs, at or 240-485-1843.

The American College of Nurse-Midwives (ACNM) is the professional association that represents certified nurse-midwives (CNMs) and certified midwives (CMs) in the United States. ACNM promotes excellence in midwifery education, clinical practice, and research. With roots dating to 1929, our members are primary care providers for women throughout the lifespan, with a special emphasis on pregnancy, childbirth, and gynecologic and reproductive health. ACNM provides research, administers and promotes continuing education programs, establishes clinical practice standards, and creates liaisons with state and federal agencies and members of Congress to increase the visibility and recognition of midwifery care.

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