- Email: [email protected]
Legislative exchange
On December 18, 1980, the Oversight and Investigations Subcommittee of the Energy and Commerce Committee of the U.S. House of Representatives devoted an entire hearing to the topic of restraint of nurse-midwifery practice and of consumers’ right to choose among safe maternity care options. In a hearing room crowded with nurse-midwives, press, and interested observers, Congressman Albert Gore (D-TN) heard testimony and asked probing questions of the four panels of witnesses. Congressman Gore was joined by Congresswoman Barbara Mikulski (D-MD), the author of the recently enacted nurse-midwifery Medicaid reimbursement bill. The hearing grew out of the problems experienced by two CNMs, Susan Sizemore and Victoria Henderson, in Nashville. The CNMs began a private practice in May 1980 with Dr. Darrell Martin as their collaborating physician. They began applying for privileges at the hospitals at which Dr. Martin also had privileges and were subsequently turned down for different reasons by each hospital. In the course of filing their applications and meeting the rejections, they wrote to Congressman Gore explaining their dilemma. He became interested in their problem and in the difficulties faced by nursemidwives across the country and I decided to hold investigatory hearings. The five-hour hearing included testimony from twelve witnesses: Sally Tom, C.N.M., for the American College of Nurse-Midwives
Journal of Nurse-Midwifery Copyright
Q 1981 by the American
l
Judy Norsigian, for the National Women’s Health Network Susan Sizemore, C. N. M., and Darrell Martin, M.D., for Nurse-Midwifery Associates of Nashville, TN Lonnie Holtzman Morris, C.N.M., for Childbirth Center of Englewood, NJ Ruth Lubic, C.N.M., for Maternity Center Association of New York City Marion McCartney, C.N.M., for Maternity Center of Bethesda, MD C. Arden Miller, M.D., for the University of North Carolina Judith Rooks, partment of Services Warren Pearse, can College Gynecologists
M.D., for the Ameriof Obstetricians and
Rosanna Lenker, C.N.M., for the Nurses’ Association of the American College of Obstetricians and Gynecologists. Selected quotations from the hearing follow. Copies of the entire transcript can be obtained by writing to Subcommittee on Oversight and Investigations, Energy and Commerce Committee, Room 2323 Rayburn House Office Building, Washington D.C. 20515, or by calling (202) 2254441. Thanks to Sally Tom for proving information on the hearing to the Legislative Exchange. Congressman
Gore:
Most recently, Congress has expressed its concern in the areas both of quality and of cost of health care in this country. That debate has considered
Vol. 26, No. 3, May/June
College
C.N.M., for the DeHealth and Human
of Nurse-Midwives
the role of competition in the health care delivery system, as a means not only to provide relief from the staggering cost of health care, but also to improve the quality of that care. Maternal and child health care, I believe, presents us with an excellent opportunity to explore the nature of the competition and ways which it might be strengthened where it is restrained. We will hear from all sides of this debate-from nurse-midwives as well as the professional organization representing the obstetricians and gynecologists in the United States. Congresswoman
Mikulski:
As we worked for passage of my nurse-midwife legislation, we always emphasized its profound national policy implications. By opening the reimbursement system for health care, we enable consumers to make a true choice among types of service based on their own needs, preference and values; and at the same time we allow for the real possibility of controlling health care costs, not by denying needed services, but by making available a wider range of cost effective services. Sally Tom: Despite the demand for nursemidwives by consumers, state governments and Federal agencies, despite the record of improved health for mothers and babies, despite cost effectiveness, and despite the widespread employment of nurse-midwives throughout the country, resistance to nurse-midwifery practice is strong and seems to be gathering strength. The GAO report mentioned three forms of obstacles to practice which
61
1981 0091.2182/81/030061+3$02
50
are of concern in these hearings today: physician resistance to nurse-midwifery practice, restrictive state licensing, and third-party reimbursement practices. . . . Resistance comes from many sources: individual physicians, professional organizations, such as medical societies, hospital departments of obstetrics, public bodies such as state boards of health and state medical practice boards, insurance companies, and occasionally, nursing. The form which the resistance takes vanes as well. It includes refusal to provide medical back-up, refusal of permission or privileges for use of hospital facilities, placement of unjustifiable restrictions on nurse-midwifery practice or settings, refusal of thirdparty payors to reimburse nursemidwives, harassment of physicians who support nurse-midwifery practice, requests for unreasonable payments for liability insurance and misrepresentation of the nature of nursemidwifery practice to the public. . . . Nurse-midwives have always practiced and will continue to practice in collaboration with physicians; that relationship will not change. What has begun to change, however, is the monetary relationship between the nurse-midwife and her collaborating physician. Nurse-midwives are now not always employees of physicians. In some cases the nurse-midwife has joined the practice of her physician partners. In other cases, nursemidwives are employing physicians to provide them with consultation and referral services. Nurse-midwives are increasingly eligible for direct third-party reimbursement. Many private insurance companies, including Connecticut General, Travelers, Aetna, and all union insurance programs, will reimburse nursemidwives in all states. New Mexico, Utah, and Maryland have adjusted their insurance codes to include direct reimbursement to nurse-midwives. CHAMPUS reimburses nurse-midwives and Congress recently passed legislation which mandates reimbursement for nurse-midwifery services to Medicaid clients. All of these changes mean that a nurse-midwife may become economically independent of her physician or hospital back-up services. Her professional interde-
62
pendence with physicians pitals remains.
nism for securing privileges for midwives and to protect the rights of consumers. I believe that consumers need to join forces to educate other consumers concerning the safe, legal, and more economical services they are being denied and use this information to exert pressure on physicians, hospitals, and lawmakers. I believe that the American College of Obstetrics and Gynecology has an obligation to its members and to the people they serve to enforce printed statements concerning family-centered maternity care as well as hospital access for midwives. If they are unwilling or unable to do this, then I believe it is the obligation of this committee, as well as state legislature, to force hospitals to grant access to licensed health-care providers.
and hos-
Judy Norsigian: In all the examples we will be hearing today there is the potential for both protracted struggle and protracted litigation. The situation in New Jersey, where consumers and nurse-midwives found themselves at odds with the New Jersey Board of Medical Examiners, should not be repeated. Many of us urge the American College of Obstetricians and Gynecologists to do its utmost to influence the attitudes and behavior of obstetricians now opposed to the expansion of nurse-midwifey practice. Nurse-midwives, consumers, and physicians can spend the next few years locked in struggle, or we can spend them productively improving the quality and acceptability of options for childbearing women and their families. I hope that we all choose wisely. Susan
Ruth Lubic:
Sizemore:
We still provide midwifery services to the disadvantaged poor at Metropolitan Nashville General Hospital and we will continue to do so. Apparently, it is quite acceptable to the medical community of Nashville for poor women to receive our services. In fact they are the only ones who indeed have a choice. Self-paying or non-Medicaid third-party paying clients do not have thii choice-they must be delivered by an obstetrician if choosing any one of a number of hospitals for delivey. Darrell Martin: In the fall of 1980, I realized that I needed to place my family before the practice. The pressure was overwhelming. Without any overt physician support, lack of malpractice insurance, statements by physicians that they would ruin me, lack of referrals, silent treatments at meetings, removal of favorable policies and procedures, and fear of physical as well as further emotional harm, I felt that I was unable to function effectively as a husband and father, let alone physician to my patients. For these reasons I have elected to relocate to South Carolina. In conclusion, what can each of us do to help consumers have a choice in health care? Personally, I believe that I must consider legal action as a mecha-
Journal of Nurse-Midwifery
Blue Cross/Blue Shield of Greater New York Findings-a fiscal audit for the years 1976-1977 reported in January 1979 by Blue Cross/Blue Shield of Greater New York sets forth the information that charges for Childbearing Center care are 37.6% of inhospital care, barring complications. The audit report also noted that the cost to BCBSGNY for families delivered at the Center is 66.1% of the cost to the plan had the same family gone to a hospital setting, also barring complications. Subject to annual review of our service, BCBSGNY has reimbursed to families our full charges (currently $l,OOO.OO). Charges are based upon projected costs at full operation and represent the figure necessay for the CbC to be completely selfsupporting. (BCBSGNY in 1979 extended the review period to three years.) The Medicaid Program-it is interesting to compare CbC charges of $1000 with Medicaid reimbursement for in-hospital normal maternity care, as shown in the attachment. In a representative group of hospitals, Medicaid is currently paying from $1649.53 to $2230.04 for normal maternity care with a total three-day hospital stay, or approximately $700 to $1200 more than MCA charges. For a total fourday stay, the surplus over MCA’s charges varies from approximately $1000 to $1750. As can be seen, the
l
Vol. 26, No. 3, May/June
1981
out-of-hospital concept promises the Medicaid program marked savings, even at full reimbursement for charges of $1000 such as the CbCs. (MCA is currently appealing an assigned rate of $885 for total care.) Warren
Pearse:
Under no circumstances should a nurse-midwife engage in independent practice. In 1971, in the “Joint Statement on Maternity Care,” the ACOG, NAACOG, and ACNM agreed that “the health-care team organized to provide maternity care will be directed by a qualified obstetrician -gynecologist.” That statement was subsequently clarified and expanded in 1975 with a supplementary statement which required a written agreement among members of the health-care team clearly specifying consultation and referral policies and standing orders, and final responsibility for direction of care to be accepted by the obstetrician gynecologist. The ACOG continues to support and endorse the reasoning represented in the statements quoted to this point. The ACOG cannot accept a recent draft statement by the ACNM that describes nurse-midwifey practice as “the independent management of care” of essentially normal newborns and women. * * li February 4, 1981 was “Women’s Rights Day” in Congress and ACNM was there. Sally Tom, ACNM’s Government Liaison, testified before the Health Subcommittee of the House Energy and Commerce Committee. The hearing included testimony from three different panels: Occupational Health, Abortion Rights, and Women as Health Care Providers. Women’s Rights Day was organized by a coalition of women’s organizations to demonstrate to the new Congress that progress is still needed on many issues of concern to women. sr Ir Ir
Journal of Nurse-Midwifery
l
The New Jersey Board of Medical Examiners’ regulations of nursemidwifery practice became effective on January 9, 1981. However, the state’s Attorney General agreed to stay the effective date of the controversial Section 9.3.~. until Februay 20 to allow the NJ CNMs and the Board time for further negotiations. The CNMs are endeavoring to add a statement regarding collaborative management to the list of demographic and medical conditions which make a woman ineligible for CNM care. The section of the regulations requiring physician presence when a CNM provides family-planning care is in effect. Facilities which do not employ a full-time physician may request a Board waiver; however; whether the Board will approve any facilities under this waiver is not known. The plight of the NJ CNMs received favorable publicity in the area media. The Sunday New York Times (New Jersey Section) included a two-part article on the struggle with the Board of Medical Examiners on December 14 and December 21, 1980. Local television coverage included a half-hour program with Lonnie Holtzman Morris, C. N.M., and Dan Columbo M.D. on New York City’s PBS Station WNET (Channel 13) on January 27, 1981. Dr. Columbo is the president-elect of the New Jersey Obstetrical Society. * * * An attempt to increase penalties against lay-midwifery and to augment the powers of the State Medical Board was defeated by one vote in November 1980 in the Ohio House of Representatives. Current Ohio law licenses CNMs by the Board of Medical Examiners and prohibits the practice of lay-midwifery. Represen-
Vol. 26, No. 3, May/June
1981
tative Clare Ball of Athens, Ohio plans to introduce new legislation to legitimize the practice of laymidwifery in Ohio. * * * As of November 1, 1980 the Food and Drug Administration requires that the labeling of prescription drugs which are systematically absorbed must include categorization of level of risk to a fetus. The information must be included in the “Precautions” section of package inserts. The categories are: A: Studies in women indicate no risk to a fetus in the first trimester. B: No studies in women, but animal studies have not demonstrated fetal risk. C: Teratogenic or embryocidal effect demonstrated in animals, but no studies available in women. Drug should be used only if potential benefit justifies the potential risk in the fetus. D: Positive evidence of human fetal risk, but the benefit from use in the woman may be acceptable despite the risk (i.e., lifethreatening disease for which safer drugs are not available. ) X: Positive evidence of human fetal risk outweighs any possible benefit to the woman. The extended deadline for ratification of the Equal Rights Amendment is June 30, 1982, only one year away. I urge CNMs in the key unratified states of Florida, North Carolina, Illinois, Missouri, and Virginia to mobilize to help pass the amendment in their states. Other unratified states are Alabama, Arizona, Arkansas, Georgia, Louisiana, Mississippi, Nevada, Oklahoma, South Carolina, and Utah. CNMs in other states can help by donating money to ERAmerica or the NOW-ERA Fund.
63
Journal of Nurse-Midwifery Copyright
Q 1981 by the American
l
Judy Norsigian, for the National Women’s Health Network Susan Sizemore, C. N. M., and Darrell Martin, M.D., for Nurse-Midwifery Associates of Nashville, TN Lonnie Holtzman Morris, C.N.M., for Childbirth Center of Englewood, NJ Ruth Lubic, C.N.M., for Maternity Center Association of New York City Marion McCartney, C.N.M., for Maternity Center of Bethesda, MD C. Arden Miller, M.D., for the University of North Carolina Judith Rooks, partment of Services Warren Pearse, can College Gynecologists
M.D., for the Ameriof Obstetricians and
Rosanna Lenker, C.N.M., for the Nurses’ Association of the American College of Obstetricians and Gynecologists. Selected quotations from the hearing follow. Copies of the entire transcript can be obtained by writing to Subcommittee on Oversight and Investigations, Energy and Commerce Committee, Room 2323 Rayburn House Office Building, Washington D.C. 20515, or by calling (202) 2254441. Thanks to Sally Tom for proving information on the hearing to the Legislative Exchange. Congressman
Gore:
Most recently, Congress has expressed its concern in the areas both of quality and of cost of health care in this country. That debate has considered
Vol. 26, No. 3, May/June
College
C.N.M., for the DeHealth and Human
of Nurse-Midwives
the role of competition in the health care delivery system, as a means not only to provide relief from the staggering cost of health care, but also to improve the quality of that care. Maternal and child health care, I believe, presents us with an excellent opportunity to explore the nature of the competition and ways which it might be strengthened where it is restrained. We will hear from all sides of this debate-from nurse-midwives as well as the professional organization representing the obstetricians and gynecologists in the United States. Congresswoman
Mikulski:
As we worked for passage of my nurse-midwife legislation, we always emphasized its profound national policy implications. By opening the reimbursement system for health care, we enable consumers to make a true choice among types of service based on their own needs, preference and values; and at the same time we allow for the real possibility of controlling health care costs, not by denying needed services, but by making available a wider range of cost effective services. Sally Tom: Despite the demand for nursemidwives by consumers, state governments and Federal agencies, despite the record of improved health for mothers and babies, despite cost effectiveness, and despite the widespread employment of nurse-midwives throughout the country, resistance to nurse-midwifery practice is strong and seems to be gathering strength. The GAO report mentioned three forms of obstacles to practice which
61
1981 0091.2182/81/030061+3$02
50
are of concern in these hearings today: physician resistance to nurse-midwifery practice, restrictive state licensing, and third-party reimbursement practices. . . . Resistance comes from many sources: individual physicians, professional organizations, such as medical societies, hospital departments of obstetrics, public bodies such as state boards of health and state medical practice boards, insurance companies, and occasionally, nursing. The form which the resistance takes vanes as well. It includes refusal to provide medical back-up, refusal of permission or privileges for use of hospital facilities, placement of unjustifiable restrictions on nurse-midwifery practice or settings, refusal of thirdparty payors to reimburse nursemidwives, harassment of physicians who support nurse-midwifery practice, requests for unreasonable payments for liability insurance and misrepresentation of the nature of nursemidwifery practice to the public. . . . Nurse-midwives have always practiced and will continue to practice in collaboration with physicians; that relationship will not change. What has begun to change, however, is the monetary relationship between the nurse-midwife and her collaborating physician. Nurse-midwives are now not always employees of physicians. In some cases the nurse-midwife has joined the practice of her physician partners. In other cases, nursemidwives are employing physicians to provide them with consultation and referral services. Nurse-midwives are increasingly eligible for direct third-party reimbursement. Many private insurance companies, including Connecticut General, Travelers, Aetna, and all union insurance programs, will reimburse nursemidwives in all states. New Mexico, Utah, and Maryland have adjusted their insurance codes to include direct reimbursement to nurse-midwives. CHAMPUS reimburses nurse-midwives and Congress recently passed legislation which mandates reimbursement for nurse-midwifery services to Medicaid clients. All of these changes mean that a nurse-midwife may become economically independent of her physician or hospital back-up services. Her professional interde-
62
pendence with physicians pitals remains.
nism for securing privileges for midwives and to protect the rights of consumers. I believe that consumers need to join forces to educate other consumers concerning the safe, legal, and more economical services they are being denied and use this information to exert pressure on physicians, hospitals, and lawmakers. I believe that the American College of Obstetrics and Gynecology has an obligation to its members and to the people they serve to enforce printed statements concerning family-centered maternity care as well as hospital access for midwives. If they are unwilling or unable to do this, then I believe it is the obligation of this committee, as well as state legislature, to force hospitals to grant access to licensed health-care providers.
and hos-
Judy Norsigian: In all the examples we will be hearing today there is the potential for both protracted struggle and protracted litigation. The situation in New Jersey, where consumers and nurse-midwives found themselves at odds with the New Jersey Board of Medical Examiners, should not be repeated. Many of us urge the American College of Obstetricians and Gynecologists to do its utmost to influence the attitudes and behavior of obstetricians now opposed to the expansion of nurse-midwifey practice. Nurse-midwives, consumers, and physicians can spend the next few years locked in struggle, or we can spend them productively improving the quality and acceptability of options for childbearing women and their families. I hope that we all choose wisely. Susan
Ruth Lubic:
Sizemore:
We still provide midwifery services to the disadvantaged poor at Metropolitan Nashville General Hospital and we will continue to do so. Apparently, it is quite acceptable to the medical community of Nashville for poor women to receive our services. In fact they are the only ones who indeed have a choice. Self-paying or non-Medicaid third-party paying clients do not have thii choice-they must be delivered by an obstetrician if choosing any one of a number of hospitals for delivey. Darrell Martin: In the fall of 1980, I realized that I needed to place my family before the practice. The pressure was overwhelming. Without any overt physician support, lack of malpractice insurance, statements by physicians that they would ruin me, lack of referrals, silent treatments at meetings, removal of favorable policies and procedures, and fear of physical as well as further emotional harm, I felt that I was unable to function effectively as a husband and father, let alone physician to my patients. For these reasons I have elected to relocate to South Carolina. In conclusion, what can each of us do to help consumers have a choice in health care? Personally, I believe that I must consider legal action as a mecha-
Journal of Nurse-Midwifery
Blue Cross/Blue Shield of Greater New York Findings-a fiscal audit for the years 1976-1977 reported in January 1979 by Blue Cross/Blue Shield of Greater New York sets forth the information that charges for Childbearing Center care are 37.6% of inhospital care, barring complications. The audit report also noted that the cost to BCBSGNY for families delivered at the Center is 66.1% of the cost to the plan had the same family gone to a hospital setting, also barring complications. Subject to annual review of our service, BCBSGNY has reimbursed to families our full charges (currently $l,OOO.OO). Charges are based upon projected costs at full operation and represent the figure necessay for the CbC to be completely selfsupporting. (BCBSGNY in 1979 extended the review period to three years.) The Medicaid Program-it is interesting to compare CbC charges of $1000 with Medicaid reimbursement for in-hospital normal maternity care, as shown in the attachment. In a representative group of hospitals, Medicaid is currently paying from $1649.53 to $2230.04 for normal maternity care with a total three-day hospital stay, or approximately $700 to $1200 more than MCA charges. For a total fourday stay, the surplus over MCA’s charges varies from approximately $1000 to $1750. As can be seen, the
l
Vol. 26, No. 3, May/June
1981
out-of-hospital concept promises the Medicaid program marked savings, even at full reimbursement for charges of $1000 such as the CbCs. (MCA is currently appealing an assigned rate of $885 for total care.) Warren
Pearse:
Under no circumstances should a nurse-midwife engage in independent practice. In 1971, in the “Joint Statement on Maternity Care,” the ACOG, NAACOG, and ACNM agreed that “the health-care team organized to provide maternity care will be directed by a qualified obstetrician -gynecologist.” That statement was subsequently clarified and expanded in 1975 with a supplementary statement which required a written agreement among members of the health-care team clearly specifying consultation and referral policies and standing orders, and final responsibility for direction of care to be accepted by the obstetrician gynecologist. The ACOG continues to support and endorse the reasoning represented in the statements quoted to this point. The ACOG cannot accept a recent draft statement by the ACNM that describes nurse-midwifey practice as “the independent management of care” of essentially normal newborns and women. * * li February 4, 1981 was “Women’s Rights Day” in Congress and ACNM was there. Sally Tom, ACNM’s Government Liaison, testified before the Health Subcommittee of the House Energy and Commerce Committee. The hearing included testimony from three different panels: Occupational Health, Abortion Rights, and Women as Health Care Providers. Women’s Rights Day was organized by a coalition of women’s organizations to demonstrate to the new Congress that progress is still needed on many issues of concern to women. sr Ir Ir
Journal of Nurse-Midwifery
l
The New Jersey Board of Medical Examiners’ regulations of nursemidwifery practice became effective on January 9, 1981. However, the state’s Attorney General agreed to stay the effective date of the controversial Section 9.3.~. until Februay 20 to allow the NJ CNMs and the Board time for further negotiations. The CNMs are endeavoring to add a statement regarding collaborative management to the list of demographic and medical conditions which make a woman ineligible for CNM care. The section of the regulations requiring physician presence when a CNM provides family-planning care is in effect. Facilities which do not employ a full-time physician may request a Board waiver; however; whether the Board will approve any facilities under this waiver is not known. The plight of the NJ CNMs received favorable publicity in the area media. The Sunday New York Times (New Jersey Section) included a two-part article on the struggle with the Board of Medical Examiners on December 14 and December 21, 1980. Local television coverage included a half-hour program with Lonnie Holtzman Morris, C. N.M., and Dan Columbo M.D. on New York City’s PBS Station WNET (Channel 13) on January 27, 1981. Dr. Columbo is the president-elect of the New Jersey Obstetrical Society. * * * An attempt to increase penalties against lay-midwifery and to augment the powers of the State Medical Board was defeated by one vote in November 1980 in the Ohio House of Representatives. Current Ohio law licenses CNMs by the Board of Medical Examiners and prohibits the practice of lay-midwifery. Represen-
Vol. 26, No. 3, May/June
1981
tative Clare Ball of Athens, Ohio plans to introduce new legislation to legitimize the practice of laymidwifery in Ohio. * * * As of November 1, 1980 the Food and Drug Administration requires that the labeling of prescription drugs which are systematically absorbed must include categorization of level of risk to a fetus. The information must be included in the “Precautions” section of package inserts. The categories are: A: Studies in women indicate no risk to a fetus in the first trimester. B: No studies in women, but animal studies have not demonstrated fetal risk. C: Teratogenic or embryocidal effect demonstrated in animals, but no studies available in women. Drug should be used only if potential benefit justifies the potential risk in the fetus. D: Positive evidence of human fetal risk, but the benefit from use in the woman may be acceptable despite the risk (i.e., lifethreatening disease for which safer drugs are not available. ) X: Positive evidence of human fetal risk outweighs any possible benefit to the woman. The extended deadline for ratification of the Equal Rights Amendment is June 30, 1982, only one year away. I urge CNMs in the key unratified states of Florida, North Carolina, Illinois, Missouri, and Virginia to mobilize to help pass the amendment in their states. Other unratified states are Alabama, Arizona, Arkansas, Georgia, Louisiana, Mississippi, Nevada, Oklahoma, South Carolina, and Utah. CNMs in other states can help by donating money to ERAmerica or the NOW-ERA Fund.
63