Next Tuesday (April 20th), the Oregon Public Employees Benefits Board (PEBB) will discuss and, hopefully, restore its members’ access to licensed direct-entry midwives (LDMs). PEBB Members for Maternity Care Choice (members) will be there to continue months-long efforts to have PEBB direct Providence Health Plans to properly process claims for LDM reimbursement. The coalition’s online petition, with more than 470 signatures, enjoys broad-based, statewide support among PEBB members. Both the Oregon State University and the University of Oregon Presidents support restoring access to LDMs.
For background read my first and second posts. Click here for a guide to midwifery credentials and terms in Oregon.
Pregnant women caught up in PEBB’s procedural gaffe
In 2009, PEBB announced it would self-insure with Providence as the plan administrator. Many PEBB members planning or desiring coverage for LDMs asked for and received repeated assurances of uninterrupted access. PEBB members using LDMs are a proactive group. For more than a decade under PEBB BlueCross BlueShield, members enjoyed access to LDM-attended homebirth. In most of the state, LDMs are the only maternity care providers offering homebirth services. Because insurance coverage for this option is not the norm, members favoring this choice were motivated to double- and triple-check PEBB’s assurances of “no change” as it announced plans to self-insure. PEBB Q&A sessions, email exchanges and close readings of the draft 2010 handbook in September indicated LDMs would, indeed, continue to be covered as an out-of-network option at 70% reimbursement.
During the fall 2009 open enrollment, many members planning for or around current pregnancies made decisions regarding flexible savings accounts predicated on LDM access. By the end of 2009, as some members prepared to submit claims to Providence, they were told this benefit choice was excluded and claims would be rejected.
Members were referred to the 2010 handbook issued in January that excludes the services of direct entry and lay midwives. This language was not included in the draft handbook. Then in January 2010, members received PEBB’s newsletter with the following “fast fact:”
- Direct-entry midwives are not listed as providers.
Clearly, PEBB staff and Providence believe the 2010 handbook and newsletter bar coverage for LDMs. This is incorrect – neither the exclusion nor the “fast fact” pertain to licensed direct-entry midwives. LDMs fully meet current definitions of practitioner and provider in the PEBB handbook and PEBB-Providence contract. In other words, PEBB staff and Providence employees are misinterpreting these governing documents and, as a result, erroneously rejecting legitimate claims. An explanation for this about-face has yet to be provided, although as of its last meeting PEBB directed staff to provide one in writing.
PEBB documents cover LDMs
The terms “qualified practitioner” and “qualified provider” are used in the 2010 handbook and in the PEBB-Providence contract. LDMs meet the definitions in each document.
Starting with the 2010 handbook definition on page 76:
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.
The Oregon Health Licensing Agency licenses LDMs. Within their scope of practice, LDMs provide prenatal, intrapartum (birth) and postpartum care. They are trained to screen for and identify risk factors falling outside their scope of practice. When necessary, they advise and help transition women into medical care.
On page 43, the PEBB handbook limits coverage for homebirth services to those provided by qualified providers. Because LDMs meet the above definition of “qualified practitioner,” they should also 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.
Finally, LDMs meet the definition of provider in the PEBB-Providence contract on page 37:
“Provider means a health care practitioner or facility that is validly licensed by the appropriate state agency to diagnose or treat health care conditions and is providing services within the scope of that license.”
PEBB should process claims and increase transparency
PEBB, not Providence, determines what is and what is not covered and at what level. During the transition to self-insure, PEBB and Providence employees may have been unfamiliar with the LDM choice in maternity 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 directed Providence to restore coverage.
Restoring coverage for LDMs is no different. It requires that PEBB see the issue for what it is – a procedural gaffe. Accordingly, it should direct Providence to correctly interpret governing documents and process LDM claims. This can be done at the April 20th meeting.
PEBB should take the additional step of increasing transparency within governing documents by specifically naming LDMs as qualified practitioners who are qualified providers.
LDM access is a win-win scenario
Ensuring proper processing of claims and tightening language will align PEBB with its governing Vision and Key Components by prioritizing transparency, cost effectiveness, evidence-based care rooted in informed choice and excellent outcomes. Subject-area expert Dr. Melissa Cheyney speaks to this:
“There’s a common misconception in the U.S. that the hospital is the safest place to give birth,” she said. “This is certainly true for higher risk women. But for low-risk women there are now 33 studies that demonstrate that with a trained care provider, when a complication arises, and the home birth is planned, that home birth is as safe as or safer than the hospital. It also results in enormous cost savings, lower rates of intervention, higher rates of psychosocial outcomes that are considered positive like prolonged breastfeeding and high satisfaction rates for the mother. So these women are actually practicing evidence-based maternity care.”
In other words, LDM-assisted homebirth is a maternity model of care predicated on health and wellbeing, the very essence of preventive care that PEBB is striving to encourage among all members.
Correcting course is also a financial win-win scenario for PEBB and its members. Women and families opting for homebirth with an 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.
Regardless of the reason for selecting LDM-assisted homebirth, women who choose this option avoid the routine use of intervention and cesarean surgery to manage low-risk, normal labor. If PEBB fails to remove bureaucratic barriers, women unable to pay out of pocket will be forced into the hospital. Hospitals are struggling and mostly failing to acknowledge and correct practices fueling the nation’s cesarean epidemic and astonishingly poor track record for supporting women and babies to breastfeed. Withholding LDM-care from those who prefer it is a losing proposition for women, families and PEBB.