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169 Midwives Outnumber the State's 154 Practicing Obstetrician Gynecologists in Model State for Midwifery

By by Haley Wachdorf - New Mexico Business Weekly

A new agreement between the New Mexico Human Services Department, managed care organizations and the state's midwives means that midwives will once again be paid for delivering babies for Medicaid-eligible women outside of hospitals without holding medical malpractice insurance.

To those unfamiliar with midwives, that may seem inconsequential, but consider this: New Mexico's 169 midwives outnumber the state's 154 practicing obstetrician gynecologists, and in 15 counties there are no practicing OB-GYNs, meaning that women in those counties are often relying on general practice doctors or midwives for prenatal care.

Midwives have been facing increasing difficulty in getting paid for treatment of Medicaid-eligible women since 1997, when New Mexico's Medicaid program was privatized and began to be operated by the state's managed care organizations. The state requires the MCOs that contract for Medicaid services to have medical malpractice insurance, and MCOs in turn require the same of all providers who treat their Medicaid patients. Today, those MCOs are Molina Health Care, Lovelace Community Health Plan and Presbyterian Salud!.

But midwives, like other providers, saw their malpractice insurance premiums increase steadily over the years -- including an increase by as much as 60 percent in 2004. The Northern New Mexico Midwifery Center in Taos reported in 2005 that it was paying $72,000 each year for its malpractice insurance, 36 percent of the three-midwife practice's income. Over time, fewer and fewer companies were willing to grant policies to midwives, not because their practices generate a high number of claims, but because they are not profitable customers for insurance companies according to Roberta Moore, maternal health program manager for the New Mexico Department of Health.

The effect for the businesses of midwives in New Mexico was significant. Moore says that Medicaid-eligible women make up 65 percent of the practices of certified nurse midwives, who deliver babies both in homes and in hospitals, and a high percentage of the practices of direct-entry midwives, whose practices deal exclusively with home birth. Moore says that at least one midwifery practice in Roswell went out of business in part because they could not afford the insurance, and therefore could not treat Medicaid patients.

Under the new Birthing Options Program, Larry Heyeck, deputy director of the medical assistance division of HSD, says Medicaid-eligible women who elect to use the services of a midwife for their birth will sign a form stating that they are aware that the midwife does not have malpractice insurance. In order to be a Medicaid provider, a midwife must provide documentation that they are unable to procure medical malpractice insurance and that they do not have a history of past malpractice claims against them. By signing the form, patients are waiving their rights to pursue legal action against the state, the MCO managing their Medicaid care, or the midwife.

It's not a guarantee that no one will ever sue -- in today's society, that's almost impossible to prevent. But it does give the managed care organizations some protection and still allows women to choose to receive midwife care at home, which is a covered benefit of Medicaid.

From the perspective of managed care organizations, it's an acceptable solution, albeit an unusual one according to Steve DeSaulniers, Medicaid director for Lovelace's Medicaid product.

"This alleviates a bit of our liability, but it doesn't take it all away," he says. "But on the other hand, most women who work with midwives are very interested in their health and the health of their child, and typically, they aren't going to engage in any high risk behaviors. So in that way, this is a good population to work with."

In rural areas, it is important for women to have the option of seeing a midwife, according to Dr. Ann Wehr, president and CEO of Molina Health Care.

"Because of the state's size, many rural and frontier moms prefer to have their babies at home," Wehr says. "While we continue to urge those with risk factors or complications to deliver in a hospital setting, this program will allow any mom who decides to enroll to have her baby at home despite her attending midwife's lack of insurance coverage."

Midwife Hilary Schlinger, owner of Sage Femme Midwifery in Albuquerque, she says she is glad to see that a compromise has been found.

"Midwives do want to serve women who are on Medicaid," she says. "It's not about the Medicaid money. My commitment as a midwife has always been towards serving women. I didn't get into midwifery because I thought I was going to get rich. It's because I believe that how we are brought into the world makes a difference."