National Maternity Reform
How are the Government’s reforms being implemented?
Legislation is in draft form
Although the maternity reforms were announced in May 2009, there is a lot of work to be done to implement the government’s Budget commitments.
Legislation to enact the reforms is still before the federal Parliament. The House of Representatives has passed the 3 midwifery relevant Bills in September 2009.
The Bills are currently before the Senate. It is expected that a vote will be taken on them in early 2010.
In late October 2009 the Health Minister announced an amendment to her own Bills, to require eligible midwives to have “collaborative arrangements” in place with one or more medical practitioner. The College has been in detailed discussions with the government about this proposed amendment and how it might be implemented.
In late November, the Senate resolved to refer the Bills to its Community Affairs Committee to consider the implications of the Government’s amendment to the Bills. Click here for information about the Senate Inquiry, including terms of reference and submissions from ACM and other stakeholders.
Who is being consulted about these reforms?
The Department of Health and Ageing has created a number of stakeholder groups to advise it on the details of policy being developed to implement the maternity reforms. The College is represented on all relevant groups.
Maternity Services Advisory Group
The Maternity Services Advisory Group (MSAG) is the main stakeholder forum in the implementation process for the national reforms. The Australian College of Midwives was invited to nominate two representatives to this group. Dr Barbara Vernon (Executive Officer) and Professor Sally Tracy are the ACM representatives on this group.
As the name suggests, MSAG is an advisory group not a decision making group. It’s role is to discuss the full range of issues involved in implementing the government’s reform and provide professional and technical advice as needed. The Department then formulates policies which it puts to the Minister for her decision.
In addition to MSAG there are three technical working groups discussing specific areas of work.
Medicare Eligibility for Midwives
The eligibility technical working group is advising on the criteria that might be applied to determine which midwives should be granted a Medicare provider number. These criteria are likely to require certain experience, education and skills, in accordance with the terms of the legislation before Parliament. Decisions about eligibility are yet to be made by the government. These decisions will be important in determining how accessible midwifery care is to Australian women.
The definition of the “eligible” midwife has been of keen interest to existing private practice midwives. It is likely that the new Nursing and Midwifery Board of Australia will have a role in administering applications for Medicare provider status from midwives, and maintaining the endorsement register of eligible midwives.
ACM’s representative on this group is our national President, Associate Professor Jenny Gamble (President ACM). ACM has been arguing for eligibility criteria to recognise that Medicare funded care will not alter the normal scope of practice of a midwife, and therefore that a qualified and registered midwife, competent across the full scope of midwifery practice should be eligible. We have also encouraged the government to consider using the College’s Midwifery Practice Review program as a suitable mechanism to identify midwives who have a commitment to reflective practice.
Medical Benefits Schedule Design
The MBS working group is advising on suitable items and arrangements under the Medical Benefits Schedule (MBS) to reimburse women for the costs of midwifery care. Medicare will pay set fees for a range of midwifery services. The financial value of these fees will influence the viability of private midwifery practice. It seems likely that midwives will be allowed to (and may need to) charge co-payments for their visits with women.
This group is also working on “collaborative” arrangements and how this requirement will be demonstrated by midwives.
ACM’s representative on this group is our national President, Associate Professor Jenny Gamble (President ACM). ACM has been advising on aspects of the care to be provided under MBS, how the items might best be structured, and what levels of rebate would be needed to make private Medicare funded practice viable for a midwife.
Pharmaceutical Benefits Scheme
This technical working group advises on midwives access to a set drug formulary which will be subsidised under the Pharmaceutical Benefits Scheme (PBS). Cathy Styles is the ACM representative on this group.. State drugs and poisons legislation will need to be amended to give midwives legal rights to prescribe the drugs which will be subsidised under the PBS.
ACM has been advising on the formulary of relevant drugs and encouraging the Commonwealth to provide advice on this formulary to state and territory governments to make any legislative changes at state level consistent.
Collaboration – National Health and Medical Research Council
One area of work has been contracted by DoHA to the National Health and Medical Research Council (NHMRC). This is the essential work of developing guidance for how maternity caregivers should work together. NHMRC has assembled a project reference group, including clinicians and consumers, to advice on this work. Professor Sally Tracy and Associate Professor Hannah Dahlen are the ACM representatives on this reference group.
What do the reforms mean for midwives?
How do I become “eligible” to access Medicare?
This question is yet to be answered and work is being undertaken within the technical working groups to define an eligible midwife and advise on the processes that the midwife must undertake.
We know already from the legislation, that an eligible midwife will need to have one or more of the following characteristics – a certain level of experience, certain educational qualifications and potentially be credentialed in some way.
The ACM has put forward a position paper which outlines what we think should be the criteria.
When will these options be available to me?
The first package available to midwives will be access to the government supported indemnity package. This is expected to be available for access prior to the commencement of the national regulation scheme in July 2010.
The process for accessing indemnity insurance has not yet been determined, although we do know from the draft legislation that all midwives will be required to meet “eligibility” criteria in order to access indemnity insurance.
Access to Medicare will commence on 1 November 2010.
Access to the PBS is expected to be possible by November 2010, although the ability of midwives to access rebates under the PBS will be dependent on changes to state based legislation (Drugs and Poisons Acts) which will give midwives the ability to prescribe drugs.
What will these reforms mean for the way that I practice?
Under these reforms it is hoped that midwives will have an opportunity to work in private practice. Midwives ability to work in private practice will depend on details of the implementation process, including legislation determining the collaborative arrangements.
Midwives may be able to offer a range of services in private practice including antenatal and postnatal care in the community and intrapartum care in hospitals. It is envisaged that midwives might work in a variety of models, including in solo private practice, group midwifery practice or in group practice with other health professionals. Some midwives may wish to work as employees of private medical practices.
What will the reforms mean for women?
At this point it is difficult to see the immediate gains without further information from the federal government about the implementation. The policies and arrangements put in place by state and territory governments will also be important.
There are many factors that may limit the implementation of these reforms.
The limitations of Medicare
Many obstacles are built into Australia’s complex health funding system. The reforms are based in the Medicare system, which is a system of social insurance which refunds users/patients/consumers for their costs when buying private health care services. This is separate from the public hospital system, which provides free acute care inside state-funded hospitals. An issue for implementation is that Medicare won’t pay rebates for services provided to a person admitted to a hospital as a public patient.
Private practice midwives providing private care
The above difficulties impact on private midwifery care, predominantly for hospital care.
• Intrapartum care from a midwife in private practice will only be Medicare funded if the woman is admitted to a hospital as a private patient.
• The woman’s medical backup care may also need to be Medicare funded. This means doctors working for a public hospital won’t be able to provide backup, and arrangements may need to be made with private doctors for medical care.
• Models that already exist whereby a private patient of a VMO Obstetrician can receive care from public hospital midwives may be able to be reversed – private client of a midwife receives medical care from a public hospital doctor – but such arrangements are not yet in place or familiar to health professionals or administrators.
• The woman’s hospital costs must be privately funded, either through health insurance or out-of-pocket.
These various factors means that hospital birth with a private midwife, funded by Medicare, may be difficult to achieve, except when that midwife is working in a close partnership with a private obstetrician, and the woman has private health insurance.
It also appears unlikely that this model would support many women in rural areas. In these areas obstetric care is often provided by GP obstetricians who rarely provide intrapartum care under Medicare (according to our limited data from Qld and some other localities). It is also unlikely that this model will improve/increase access to continuity of care for the women who are most vulnerable and arguably in most need of this type of continuity of care:
• Aboriginal and Islander women, especially those in remote communities.
• Young women.
• Women from culturally and linguistically diverse backgrounds.
• Women with additional health needs including those who have a physical disability, lived mental health experience, substance abuse, domestic violence issues or socially isolated women.
The potential for private/non-state-run birth centres, including Aboriginal-controlled services, to function under this model is currently unclear.
Hybrid models in the public system
A model which ACM has begun to explore which may provide increased access to midwifery care for the women listed above is a hybrid contract-plus-employment model in the public system. In this (not yet existing) model, midwives would have contractual arrangements with the hospital to provide antenatal and postnatal care as private providers under Medicare, and provide intrapartum care as employees in a public hospital to women who are admitted as public patients.
The motivation is developing these models is providing free access to midwifery care for women. It is a very different model of private midwifery care to that which currently exists. This model also requires supportive State Governments, public hospitals and health managers and will require significant discussion at a state level.
Will women have the ability to choose homebirth with a private midwife?
Homebirth with a private midwife remains a difficult prospect.
The new national registration scheme will require all midwives to have professional indemnity insurance for all aspects of their practice from 1 July 2010. It remains impossible to buy insurance for midwifery care for labour and birth in Australia.
On the 4th of September Nicola Roxon made an announcement that the Australian Health Minister’s Council had agreed there would be an exemption for midwives from the new requirement to hold Professional Indemnity Insurance (PII) when providing homebirth care, for a period of up to two years. The exemption announcement was a remarkable development, indicating how effective the consumer driven campaign in support of homebirth was. However the exemption does not mean business as usual for midwives or women wishing to access their services.
What does the indemnity exemption mean?
It has recently been clarified that the exemption applies only to intrapartum (labour and birth) care at home. Midwives will still require insurance for their antenatal and postnatal care. The College is investigating possible sources of such insurance on the private insurance market. Preliminary advice is encouraging that insurance for pregnancy and postnatal care will become available through the ACM in 2010.
In the event that such insurance is not forthcoming, private midwives wishing to continue to care for women planning homebirth will need to apply for exemption and seek access to the Commonwealth’s insurance scheme for insurance to cover her for antenatal and postnatal care in any setting, and intrapartum care in hospital, subject to certain conditions.
Woman choosing to birth at home will not have the benefit of an insured caregiver with professional indemnity insurance and will not have their labour and birth funded under Medicare. However it appears that Medicare funding for antenatal and postnatal care will not be conditional on place of birth. This could make homebirth with a midwife in private practice significantly more affordable for women.
The obvious goal is for homebirth to be a choice like any other place of birth. Homebirth care should be funded, and covered by professional indemnity insurance, as hospital care is. The Minister, however, has decided not to deliver this support at this stage.
The way forward
What the national maternity reforms finally look like is anybody’s guess right now. ACM is continuing to actively influence the implementation of these reforms to ensure they are good for women and good for midwives. Your membership is critical to supporting us to do this. If you care about these issues, give a membership gift voucher to a friend, or encourage a friend to join. ACM needs every midwife in Australia to become a member of the College to give us strength in influencing policy makers.