Presentation on theme: "The Affordable Care Act & Birth Centers"— Presentation transcript:
1The Affordable Care Act & Birth Centers Jill Alliman, DNP, CNM Legislative Committee Chair American Association of Birth Centers
2A brief history of birth centers in the US 1975- Maternity Center Association in NYC1981-Cooperative Birth Center Network (14 centers)1982 APHA published Guidelines for Regulating and Licensing Birth Centers1983-Organization became NACC1989-National Birth Center study published in NEJM2005-NACC became AABC2010-Medicaid Birth Center Reimbursement Act passedbirth centers
3What is the status of birth center birth in the US? 270 known birth centers in US15,577 births in 20120.3% of all US births42% increase in past 5 years(MacDorman et. al, 2014)
4All OOH births in 2012 in US 53,635 births / 3,952,841 1.36% of all US births35,184 at home and 15,577 in birth centersUp from 1.26% in 2011Most increase among non-Hispanic white women-rate of 2.05% of all births(MacDorman, 2014)
5Birth Center Midwifery Providers 61% CPMs or LMs52% CNMsMidwifery Providers61% CPMs or LMs52% CNMsA growing number of birth centers have BOTH CPMs and CNMs. Of AABC member birth centers:Member Centers: Midwifery Providers19% CNM & CPM together28% CPMs53% CNMsSource: AABC Medicaid Survey of Birth Centers 2009Source: AABC Member Database 2014(AABC Medicaid Survey of Birth Centers 2009)
6Birth center outcomes of care Low cesarean rates & improved outcomes Cost savings Increased client satisfaction (Rooks, 1989;Stapleton, 2013)
7US spends more -- but our mothers and babies have higher risk of dying US is 46th in maternal mortality (2 X higher than 31 other nations)US is 27th in infant mortality (6.1 deaths per live births)(WHO, 2012)Huge racial disparities make some at much higher riskMedicaid pays for 48% of US birthsAlthough the US health care system spends more on maternity care, we are not improving the health of mothers and babies. In fact, our global standing continues to drop!How do these statistics tie in with birth centers?
8Triple AimInnovative approaches should meet the Triple Aim of CMS Better Care Better Health Lower Costs Birth Center Care meets the Triple Aim and is a model for improving maternity care.Read slide,Our maternity care system needs a lot of changes, But birth centers can be part of that solution if barriers to our practice are addressed and removed.
9Birth Centers by StateDo you notice a pattern here? There are 5 states that have 142 of the 270 birth centers in the US. These are the states that have regulations with the fewest barriers for birth center operations.These states do not necessarily have the best Medicaid reimbursement of birth centers. But they do all have licensure for CPMs.
10States where CPMs are legally authorized to practice Where are CPMs legally authorized to practice? Where aren’t they? Where are families fighting Big Medicine for legal access to CPMs?CPMs are legally authorized to practice in 28 states (EMERALD GREEN states above)26 States that regulate CPMs (Law Enacted / Rules in Some States)2 States Legalized CPMs by Statute (Law Enacted)CPMs are not legally authorized to practice in 22 states14 states have active CPM legislation (LIME GREEN states above)3 states (and the District of Columbia) are planning CPM legislation (MUSTARD YELLOW states above)5 states (and 2 territories) are organizing their CPM advocacy efforts (PLUM PURPLE states above)- See more at:Map courtesy of The Big Push for Midwives – pushformidwives.org
1182% of States Have Regulations for Licensing Birth Centers Of the states with no regulations, North Carolina is the only state that has regulations that allow Medicaid reimbursement of birth centers
12AABC definition of Birth Center A home-like setting where care providers, usually midwives, provide family-centered care to healthy pregnant women.
13AABC definition of Birth Center AABC definition of Birth Center Most are separate from hospitalsA few are inside hospitals and must meet standards for independence and be separate from L & D unitAABC definition of Birth Center
14Definition of Birth Center in Federal Law USC § 1396(l)(3) (A) The term “freestanding birth center services” means services furnished to an individual at a freestanding birth center (as defined in subparagraph (B)) at such center.(B) The term “freestanding birth center” means a health facility—(i) that is not a hospital;(ii) where childbirth is planned to occur away from the pregnant woman’s residence;(iii) that is licensed or otherwise approved by the StateFederal language is important in that it sets a definition that can be used in other places in law and sets a standard for consistency.An example is the Maternity Provider shortage act, that includes birth centers as sites where if maternity provider shortages exist, midwives can be recruited and placed. It references this definition of the freestanding birth center.
15Definition of a birth center, cont. (iii) continuedTo provide prenatal, labor and delivery or postpartum care and other ambulatory services that are included in the plan; and(iv) that complies with such other requirements relating to the health and safety ofindividuals furnished services by the facility as the State shall establish [42 U.S.C. § 1396(l)(3) (A), (B), & ( C)]Again, this definition gives the states the authority too establish requirements for licensed facilities in that state.
16Birth Center Medicaid Reimbursement Act Introduced by Sen Boxer (R co-sponsor Sen. Corker)AABC version did include both the facility and all licensed birth attendantsCBO cost estimate—would save Medicaid $$$$Amended by Sen Cantwell to add more language about types of birth attendantsAdded to ACA BillPassed in 2010 as Section 2301 of ACAI will take just a few moments to go over the history of this bill and how it evolved and passed through Committees until it was added to the ACA
17Original language of Bill-Attendant The term ’licensed birth attendant’ means an individual who is licensed registered by the State involved to provide health care at childbirth and who provides such care within the scope of practice under which the individual is legally authorized to perform such care under State law (or the State regulatory mechanism provided by State law), regardless of whether the individual is under the supervision of, or associated with, a physician or other health care provider. Nothing in this subparagraph shall be construed as changing State law requirements applicable to a licensed birth attendant.".Original language by AABC did include both the facility and the attendant
18Mandated Services under Medicaid Section 1905 of SSA lists services that Medicaid (“Medical Assistance”) must cover“The term ‘medical assistance’ means payment of part or all of the cost of the following care and services or the care and services themselves, or both”Freestanding Birth Centers added as paragraph 28 to the list of mandated covered services as part of the cross referencing of this billWhen writing a bill—it must connect to all relevant sections and amend them as necessary.So, this section shows that birth center reimbursement is clearly a mandate because birth centers are added under the list of covered services.The list of mandated covered services for Medicaid includes such other things as in-patient hospital services, out-patient hospital services, labs, prescriptions, hospice, and now—Freestanding birth centers!!In the past when new services are mandated, Rules have been issued by CMS, but not as of yet for the birth centers. Rules are still needed.
19Harkin Amendment to the ACA Applies to commercial/private insurance plansProvider non-discrimination—states that plans cannot discriminate against non-physician providersNot any willing providerCannot discriminate against a whole class of providers (e.g. birth centers)The Harkin Amendment is a totally separate section of the ACA, Section 2706.It was added so non-physician providers would have a better chance of being included in all new health plans that would be created as a result of the law. Some of the provider associations- (chiropractors, nurse anesthetists, optometrists, ACNM, and AABC, continue to work to make sure this amendment is enforced.Senate just recently let the CMS know they are not happy with the way this law is NOT being implemented or enforced.
20Implementation StepsStates must submit a State Plan Amendment (SPA) stating they will cover birth centers and their birth attendants--at least 26 states have completed this stepAll the states that license or recognize birth centers are mandated to pay for the facility services and the professional service fees for midwives who attend births in those birth centersAABC position—CMS needs to issue Rules and Regulations so states will comply correctlyRules needs to state that Medicaid MCO’s must comply with Medicaid mandateRead summarize
21Reimbursement levels and MCOs—the next hurdles for birth center access Florida—implementation of facility services payment very slow. FABC’s worked to increase budget for the line item that covers birth centers. TX—Medicaid reimbursement too low for most centers to accept Medicaid Mediciad Managed Care Organizations won’t contract with birth centers in some places—need CMS Rules
22Bottom Line . . . With the ACA If you are a licensed provider, working in a licensed or otherwise recognized by the state birth center:Medicaid is mandated to pay your facility service fees and professional services of the birth attendantCommercial plans don’t have to contract with every birth center, but should offer access to consumers for birth centers in their coverage area
23AABC ActionsSubmitted comments to FTC on barriers to practice for freestanding birth centers, and for the providers who practice in themSubmitted comments to CMS/IRS/Department of Labor on the need to properly enforce the Harkin AmendmentContinue to pressure CMS to issue Rules and Regulations so the Medicaid reimbursement mandate will be appropriately implemented by all states.The FTC comments and Harkin comments written by AABC contain a wealth of information and are available on the birthcenters.org website
24How Can You Get Involved? If you are not receiving Medicaid reimbursement for birth center facility and birth attendant fees, then contact us:Or call the AABC office at:Join AABC if you are not yet a member. We can do so much more if we all work together!
25ReferencesMacDorman, MF, Mathews, TJ, & DeClerq, E. (2014) Trends in out-of-hospital births in the United States, , NCHS Data Brief No 144, Hyattsville, MD: National center for Health Statistics.Rooks, J. P., Weatherby, N. L., Ernst, E. K. M., Stapleton, S., Rosen, D., & Rosenfield, A. (1989). Outcomes of care in birth centers. The national birth center study. New England Journal of Medicine, 321(26),Stapleton, S., Osborne, C., & Illuzzi, J. (2013). Outcomes of care in birth centers: Demonstration of a durable model. Journal of Midwifery and Women's Health, 58(1), doi: /jmwh.12003/full