Getting Insurance to Pay for Midwives - NYTimes.com

Medical doctors deliver more than 85 percent of American babies, and the overwhelming majority of births in the United States take place in hospital labor and delivery wards. But in many European countries, midwives attend to most pregnancies, often in clinics, resulting in maternity charges that are a fraction of those in the United States.

At a time when the United States is looking for ways to rein in its runaway medical spending, a surprising glitch is preventing American women from choosing the low-cost option: Many insurance plans do not have midwives in their provider networks, or do not cover midwife care at all.

Dozens of readers expressed their frustration on this topic in response to a New York Times article on the high costs of maternity care in the United States, ?American Way of Birth, Costliest in the World.? One said that her insurer at first refused to pay for her midwife delivery as an ?unauthorized service,? though it later relented after she fought back. Another, in Kansas City, said that her insurer, UnitedHealthcare, had no birth centers in its local network. Another, in New York, relayed that her ?comprehensive medical insurance? wouldn?t cover her childbirth at a birthing center at all, and she noted: ?If I had used a medical doctor, medications and had a C-section with a hospital stay of one week, my coverage would have been 100 percent.?

Susan Pisano, vice president for communications at America?s Health Insurance Plans, a trade group, said that care for midwife services varied widely among plans, adding: ?If this is a feature that is important to you, you have to ask before you enroll.?

Thirty-three states require private insurers to cover nurse-midwife services, according to the American College of Nurse-Midwives. But access to coverage is often further limited in practice by whether midwives can get privileges to treat patients at local hospitals, whether freestanding birthing clinics are permitted and local medical custom, Ms. Pisano said.

?It?s really complicated, because the restrictions on midwife practice are such that they most often end up working for a hospital or an obstetrician,? helping out with prenatal visits and deliveries, said Eugene Declercq, a professor at the Boston University School of Public Health.

In that case, when midwives serve as ?physician extenders,? their presence may not be cost-saving but add to the nation?s maternity bills, since their services will be charged as an additional physician visit. And they will follow the practice patterns of the doctor, he said.

One of the reasons midwife care saves money is that midwives generally order fewer tests and their patients are less likely to end up having Caesarean deliveries, studies have shown.

In the United States, the use of midwives varies hugely by state and region; they can deliver babies at a birthing center, in hospitals or in homes. They generally need physician back-up in case a pregnancy has complications they cannot handle. There are few midwife births in the South and Texas, while the rate is above 15 percent in Oregon and New Mexico. In Britain and Denmark, more than two-thirds of all births are attended by a midwife.

Today, even where it is available, some employers may specifically exclude midwife care from their list of covered benefits; insurers may make little effort to include midwives in their networks, since they tend to focus on negotiations with large physician groups.

That is likely to change. The Affordable Care Act added birth centers and midwife care as mandatory Medicaid services, for example. Many health experts are recommending an expanded use of birthing centers as a cost-saving measure as well as in response to women?s demand.

Jeffrey Singerman, administrator of the obstetrics and gynecology department at St Luke?s-Roosevelt Hospital Center, which runs the only in-hospital birthing center in Manhattan, said that the hospital?s birthing center was in-network for 99 percent of local insurance plans, and so the facility fee would be covered. But he added that the nurse-midwife?s fee might or might not be covered depending on whether she was in a particular insurance network.

In Portland, Ore., where midwife births are relatively popular, the Providence Maternal Care Clinic, with 10 midwives, participates with all local insurers, although it still has to occasionally argue against denials for midwife care. Its pregnancy package for its midwife service from the first visit to the six-week checkup after delivery is $6,800, though that does not include the fee for the hospital; it is developing a cheaper package.

Source: http://well.blogs.nytimes.com/2013/07/03/getting-insurance-to-pay-for-midwives/

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