On March 16, PEBB Members for Maternity Care Choice attended the PEBB Board meeting to request reinstatement of coverage for homebirth maternity care with Oregon licensed direct-entry midwives (LDMs). Despite multiple assurances of uninterrupted access to this choice in benefit, LDMs were excluded from coverage in the 2010 Statewide Plan. The Statewide Plan is one of PEBB’s three healthcare plans; it serves nearly 80% of PEBB members. Most PEBB members learned of the exclusion through a January newsletter.
Before the meeting, the coalition issued a press release. Thirteen coalition members (photos), with newborns and toddlers in tow, attended. A petition with more than 350 signatures from OUS and state government employees was presented. Seven OUS employees made public comments in support of restoring LDM coverage to the Board. Among them were three pregnant women, a representative of the OSU President’s Commission on the Status of Women and Dr. Melissa Cheyney, an LDM and OSU anthropologist whose research focuses on out-of-hospital maternity care. Additional information is available on the coalition’s Wiki page including a letter of support from the OSU Reproductive Health Lab. PEBB archive video should also be available. The United Academics of the University of Oregon published a summary.
Based on public comments, the PEBB Board made LDM coverage an agenda item for its next meeting. In the interim, the Board directed PEBB senior administrators to draft a report explaining why and how the loss in maternity care choice occurred. The Board also requested a briefing on the research about homebirth with LDMs. Dr. Cheyney offered her expertise.
In 2009, PEBB announced plans to become more cost-effective through self-insuring. Providence Health Plans won the contract to administer the plan. By self-insuring, PEBB assumes its own risks with the goal of lowering costs. As a self-insurer, PEBB determines what is or is not covered and at what rate. This is explained in a September 2009 Q&A document:
The Board has made no changes to the current design of the healthcare plans. It is the Board, not the insurance company or administrator, that determines what is covered and at what level in the healthcare plans.
For the past ten years, PEBB members have received out-of-network coverage at a rate of 70% for homebirth with a LDM. The Oregon Board of Direct Entry Midwifery professionally licenses LDMs.
In almost all of Oregon, direct-entry midwives are the only maternity care providers offering homebirth services. Of these practitioners, those who are licensed by the state were eligible for insurance reimbursement by Regence BCBS.
Following the announcement to self-insure, many Coalition members asked for and received repeated assurances that LDMs would remain a covered choice. UO and OSU employees detail the extensive reassurances provided at Benefits Q&A sessions and via follow-up phone conversations here. In light of PEBB statements, members anticipated continued coverage under the new 2010 Statewide Plan.
After open enrollment, during which decisions regarding healthcare plans and flexible savings accounts were made, members communicating with Providence learned PEBB would reject LDM claims. No exclusion appeared in the draft 2010 PEBB Handbook. An explanation has thus far been unavailable.
After much back-and-forth, PEBB responded with a transition of care plan to continue LDM-coverage for pregnant women already in their third trimester on January 1, 2010. Last week, PEBB extended the transition period approximately six months. Coalition members appreciate the accommodation but remain committed to ongoing LDM access for themselves and others in the future.
PEBB Handbook supports coverage for LDMs
The LDM exclusion mentioned in the PEBB January newsletter and by PEBB and Providence employees is inconsistent with the 2010 PEBB Handbook.
On page 76, PEBB defines a qualified practitioner to be inclusive of LDMs:
Qualified Practitioner means a physician, women’s health care provider, nurse practitioner, certified nurse midwife, clinical social worker, physician assistant, psychologist, dentist, podiatrist, acupuncturist, naturopath, chiropractor, audiologist, Christian Science practitioner, or other practitioner who is professionally licensed by the appropriate governmental agency to diagnose or treat an injury or illness and who provides Covered Services within the scope of that license.
On page 43, PEBB limits coverage for homebirth services to those provided by qualified providers. Because LDMs meet the above definition of “qualified practitioner” they should be viewed as a “qualified provider” of homebirth services.
Exclusions that apply to Reproductive Services:
- All Services related to sexual disorders or dysfunctions regardless of gender, including all Services related to a sex-change operation, including evaluation, surgery and follow-up Services;
- Condoms and other over-the-counter birth control products; and
- Home births and all related Services, except Services provided by a Qualified Provider.
What should be done?
During the 2010 transition to self-insurance, it seems likely PEBB and Providence employees were unaware of and unfamiliar with the LDM choice in maternity care benefit. There have been other oversights and they are being resolved. Upon learning of unintended changes in coverage for breast pumps or of a failure to recognize naturopaths as a type of primary care physician, PEBB has direct Providence to restore coverage. Restoring coverage for LDMS is no different.
PEBB must honor its commitment not to change benefits by reinstating coverage for LDMs. Explicitly naming LDMs as a type of provider would increase transparency for everyone involved. Correcting course in this way will align PEBB more tightly with its governing Vision and Key Components prioritizing transparency, cost effectiveness and evidence-based care rooted in informed choice.
Correcting course is a win-win scenario for PEBB and its members. Women and families opting for homebirth with a LDM will generate significantly reduced claims. Roughly speaking, LDM maternity care runs approximately $3,000, meaning PEBB reimburses $2100. Hospital-based maternity care including uncomplicated birth costs approximately $16,000. In the case of planned cesarean section, insurers regularly pay more than $20,000. Coalition members project annual savings for PEBB ranging between $265,000 and $560,000.
PEBB, as a self-insured healthcare provider, should welcome lower claims as they leave resources in the reserves. Perhaps in the future, PEBB Board members will see homebirth with LDMs as a model of the excellent and cost-effective care that it looks to provide throughout the plan.