Health workforce changes are being implemented in

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1 State Regulation, Payment Policies, And Nurse-Midwife Services Despite recent progress, barriers continue to keep this group of providers from improving access to care for the nation s vulnerable populations. by Eugene R. Declercq, Lisa L. Paine, Diana R. Simmes, and Jeanne F. DeJoseph HEALTH ABSTRACT: State regulatory and reimbursement policies continue to exert a strong influence on health workforce policy. Surveys conducted in and for the purpose of examining the impact of state regulation on the supply and practice of certified nurse-midwives (CNMs) showed that the single best predictor of the distribution and practice activities of CNMs was the degree to which state policies facilitated or restricted CNM practice. Health workforce changes are being implemented in the public and private sectors throughout the United States in an attempt to address continuing concerns about access to care. Expanded use of nurse-midwives has been proposed as one part of the solution to the problem of access to care for women. The research described here examines the impact of state regulatory structures on the workforce distribution of nurse-midwives. The establishment of nurse-midwifery as a profession in the s stemmed in part from the use of state regulatory structures to eliminate midwifery as an independent profession at the turn of the century. 2 Advocates of occupational regulation of any profession tout the benefits of state licensure and oversight with emphasis in the health professions on protection from incompetent providers. However, the process also typically serves to protect the profession from competition, particularly if the given professionals have achieved self-regulation. In the case of health care, physician control of state medical regulatory boards has helped to insulate physicians Eugene Declercq is associate professor and associate chair, Maternal and Child Health Department, Boston University School of Public Health. Lisa Paine is associate professor and chair of the department. Diana Simmes is a research associate, Center for Child Health Outcomes, Children s Hospital and Health Center, in San Diego. Jeanne DeJoseph is associate professor and codirector, Nurse-Midwifery Education Program, College of Nursing, University of California, San Francisco. H E A L T H A F F A I R S ~ V o l u m e, N u m b e r 2 The People-to-People Health Foundation, Inc.

2 H E A L T H W O R K F O R C E from potential competitors. 4 The maternity care workforce. The persistence of barriers to health services for women and children has been of particular concern to health policy analysts, despite a targeted broadening of Medicaid benefits and the passage of national legislation to improve access to health insurance for children. With many traditional private insurance plans limiting preventive care for women, infants, and children, and more than twenty million women of childbearing age and children living in communities with a shortage of health care providers and clinics, these barriers extend beyond the 4. percent of children (2. percent of poor children) without health insurance. One proposed solution has been to increase the number of health care providers whose major focus is on delivery of primary care services and expand the use of nonphysician providers, such as nurse practitioners (NPs), physician assistants (PAs), and certified nurse-midwives (CNMs). CNMs hold particular promise in easing the problems of access for women, newborns, and families with children. In CNMs working in a variety of health care settings attended. percent (2,) of all U.S. births, more than double the number of births they attended a decade earlier. These advances aside, barriers to nurse-midwifery practice remain. While barriers such as physician supervision and restricted licensing and prescriptive authority are comparable to those faced by other midlevel practitioners and advanced practice nurses, some are more specific to CNMs (for example, access to physician consultation in freestanding birth centers and at home births). A study of barriers to nurse-midwifery care concluded that there was a lack of information about such care among the public in general and policymakers in particular; it recommended further research designed to document CNMs contributions to the care of vulnerable populations and measure the impact of nurse-midwifery care on health care costs. These concerns led to a Robert Wood Johnson Foundation (RWJF) sponsored study, which found that CNMs make a major contribution to the care of vulnerable populations. Study Methods One goal of the vulnerable populations research was to gather information on the regulation of CNM practice, explore the nature of barriers faced by CNMs, and measure the subsequent impact of such barriers on the distribution and practice of nurse-midwives as well as women s access to CNM services. The RWJF study included a regulatory survey conducted in 2, which we replicated in. The authors built on prior research to develop a weighted scale that DATAWATCH H E A L T H A F F A I R S ~ M a r c h / A p r i l

3 2 HEALTH was more sensitive to the practice environments of CNMs and used two time periods to examine the impact of regulatory changes over time. Equally important was the use of a dependent variable measuring patient contacts, not available in prior research. A pilot study was completed in 2 to develop and refine a self-administered survey instrument to assess state regulation of CNMs. In June 2 surveys were sent to nurse-midwives identified by the American College of Nurse-Midwives (ACNM) as state legislative liaisons and, therefore, most knowledgeable about regulation in their respective states. Follow-up telephone interviews were conducted with these midwives and others. Five areas related to midwifery regulation were explored: membership on the state regulatory board that oversees nurse-midwifery practice, prescriptive authority, reimbursement by Medicaid and private insurance companies, hospital admitting privileges, and reimbursement policies for freestanding birth centers. 2 The regulatory data were coded, and scales were created that allowed for rating of states as to how supportive their regulatory climate was for nurse-midwives. To maintain consistency with the vulnerable populations study, the 2 survey focused on the status of regulations in, whereas the survey assessed contemporary regulations. The followup study used a similar methodology. Other sources of data on state regulation included information routinely gathered by the ACNM as well as data concerning advanced nursing practice. Individual ratings of a state s regulatory environment and reimbursement system for CNMs were developed from the individual variables. The regulatory scale was designed to address the following questions: How much direct or indirect input did CNMs have to the board that licensed them and regulated their practice? Could CNMs write their own prescriptions? If so, for which medications and under what circumstances? The reimbursement system scale was designed to address the following questions: Were state mandates consistent with federal mandates for Medicaid and private insurance reimbursements for CNMs? If so, which services could CNMs directly bill for, and what was the level of reimbursement compared with physician reimbursement levels? Individual items were weighted and combined into an overall ordinal ranking of states. 4 Study Results Regulatory board input. Most nurse-midwives in both survey years were regulated by a state board of registration in nursing, yet in CNMs in only eight states had a designated place on the board. (In other states CNMs may serve as the nurse practitioner H E A L T H A F F A I R S ~ V o l u m e, N u m b e r 2

4 H E A L T H W O R K F O R C E representative.) New York and Utah were the only states in which CNMs constituted a majority of the board; in most states there was not even a formal route to providing input. The overall pattern of regulatory board involvement changed little between and. Interviews in both surveys suggested that the content of CNM education and certification did not necessarily coincide with the nursing boards definition of CNM scope of practice. In some cases, the nursing board supported limitation of practice for CNMs. For example, in a national survey of CNMs, a lack of support from fellow nurses was cited by. percent of CNMs as a barrier to practice. The Pew Health Professions Commission report also cited tensions within nursing as problematic. The CNM advisory boards existed on paper in some states but had not actually met or had any input to regulatory boards, leading to the committee s being subject to elimination via sunset provisions in at least one state (Arkansas). This lack of control of their own regulatory boards is in sharp contrast to the traditional physician dominance on the boards that regulate medical practice. When new laws or regulations affecting nurse-midwifery practice are proposed in states without advisory boards, CNMs may be invited to present testimony at hearings, but the likelihood that CNM legislative liaisons and their colleagues would be made aware of regulatory changes would be dependent upon the initiative of the unpaid state legislative liaison. CNMs in some states hired lobbyists directly or joined with others (typically other nonphysician clinicians) to do so. The most commonly cited forms of input were letters to the regulatory board, testimony at hearings, and coalition formation, particularly with other advanced practice nurses. Prescriptive authority. A 2 national survey of CNMs found that the most frequently cited barrier to practice was limited prescriptive authority, with percent of the respondents citing it as a problem. In CNMs in forty-one states had some form of prescriptive authority but typically were limited to specifically identified uncontrolled substances; additional provisions require a physician s cosignature, so that practical independent prescriptive authority for CNMs existed in only twenty-five states. Also, in almost half of the forty-one states in which CNMs had prescriptive authority, CNMs had to complete extra training to receive it. Reimbursement. Federally mandated Medicaid reimbursement was available in all states, but there was considerable variance in services covered and levels of reimbursement. One of the major changes noted between the and surveys was the expansion of CNM services reimbursed by Medicaid. In thirty-five states covered at least all maternity services (some also covered care out- DATAWATCH H E A L T H A F F A I R S ~ M a r c h / A p r i l

5 side the maternity cycle), whereas in these services were covered in forty-six states. Levels of reimbursement varied widely. Twenty-eight states reimbursed at percent of physicians fees for comparable services, while others reimbursed at rates as low as percent for the same service. In thirty-one states mandated that private insurers cover some CNM services; however, the exact meaning of those mandates varied. In only fifteen states were CNMs reimbursed by private insurers for all maternity services. Another complication in the case of reimbursement by Medicaid or private insurers was the issue of whether or not CNMs could bill directly for their services, or if their work could be reimbursed only in their role as a salaried employee of a physician or an institution. For example, in Mississippi reimbursement is mandated only if the CNM works under the supervision of a physician who must sign and submit the claim form on behalf of the CNM. Conversely, a law in Washington State mandated that insurers permit direct access to CNMs (among other women s health care providers) without requiring a referral. 4 HEALTH Support For CNMs In The States An overall scale was developed based on the weighting of the factors described above. The scores reflect the status of laws and regulations as they existed in fall and fall. The state scores were divided according to whether or not they addressed regulatory (board membership and prescription authority) or reimbursement issues (Medicaid and private insurers). The resulting total scores (Exhibit ) were used to create an ordinal ranking of states on the degree of support for CNM practice, which was used in the statistical analyses discussed below. For descriptive purposes, state scores were also rated as low (less than ), medium ( 2), or high (more than 2) support. A high score (that is, a score greater than ) did not necessarily imply a barrier-free state environment for CNMs. In each survey only two states achieved such a score: New York and Utah in and New York and New Hampshire in. New York s high support score was maintained from to when a drop in its reimbursement score was more than matched by an increase in regulatory support. Changes between and. In general, there was marginal improvement in the overall scores from to, with more than half of the states changing categories. Three states scores shifted from low to high (Iowa, West Virginia, and Wisconsin); two shifted from high to low (Idaho and Kansas); and the remainder that changed shifted only one category (for example, low to medium or medium to high). The changes were not concentrated in either the H E A L T H A F F A I R S ~ V o l u m e, N u m b e r 2

6 H E A L T H W O R K F O R C E EXHIBIT State Regulatory Reimbursement Scores, And Region Regulatory Reimbursement Total Rating Regulatory Reimbursement Total Rating New England Maine New Hampshire Vermont Massachusetts Rhode Island Connecticut Middle Atlantic New York New Jersey Pennsylvania East North Central Ohio Indiana Illinois Michigan Wisconsin West North Central Minnesota Iowa Missouri North Dakota South Dakota Nebraska Kansas South Atlantic Delaware Maryland District of Columbia Virginia West Virginia North Carolina South Carolina Georgia Florida East South Central Kentucky Tennessee Alabama Mississippi West South Central Arkansas Louisiana Oklahoma Texas Mountain Montana Idaho Wyoming Colorado New Mexico Arizona Utah Nevada H E A L T H A F F A I R S ~ M a r c h / A p r i l

7 EXHIBIT State Regulatory Reimbursement Scores, And (cont.) Region Regulatory Reimbursement Total Rating Regulatory Reimbursement Total Rating Pacific Washington Oregon California Alaska Hawaii Mean Median SOURCE: Authors calculations. a Not applicable a a a a HEALTH regulatory or reimbursement categories. Many states expanded prescriptive authority and broadened their insurance coverage for nurse-midwives. In the case of insurance coverage, the expansion may not have been targeted solely at CNMs but rather as part of any-willing-provider provisions requiring insurers to extend coverage to NPs and PAs as well as to CNMs. Regional pattern. Examination of the data in Exhibit reveals a regional pattern of regulatory support for nurse-midwifery practice in. There was evident clustering, with states having systems with the highest support scores located largely in the Northeast and West. Southern and lower midwestern states generally received scores that reflected lower support. The degree to which this pattern suggests that states are consciously adopting systems comparable to those of neighboring states is unclear. State characteristics. Factors often cited as influencing state health policy, resources, and need were measured. Their relationship to state support scores and CNM activity (as measured by the proportion of all births attended) was determined (Exhibit 2). Of the six state demographic characteristics, five state health system measures, and three health outcomes measures, state support scores were clearly related only to four variables: median family income, physicians per capita, nurses per capita, and hospital costs. State support score and CNM distribution. We found a very high correlation between the support score and the corresponding distribution of CNMs in each year (. [p.] in and. [p.] in ). Likewise, the support scores were strongly related to the proportion of CNM-attended births in (. [p.]). CNM-attended births were not related to the majority of standard state measures, with the exception of physicians per capita, hospital costs, and, not surprisingly, the distribution of CNMs. The correlation seen in Exhibit 2 between the distribution of H E A L T H A F F A I R S ~ V o l u m e, N u m b e r 2

8 H E A L T H W O R K F O R C E EXHIBIT 2 Correlation Between CNM Support Score, Proportion Of Births Attended By CNMs, And Key State Variables, State characteristic a CNM support score Percent CNM-attended births Demographic Population density () Percent urban () Median family income Percent below poverty level Percent births to unmarried mothers Percent population nonwhite Health system Percent of population uninsured Health expenditures per capita Physicians per capita () Nurses per capita () Hospital costs per day Outcomes measures Infant mortality rate Neonatal mortality rate Percent low birthweight Related variables CNMs per female population ages 44 () CNMs per female population ages 44 () CNM support score CNM support score CNMs in and the corresponding support score is more dramatically shown in Exhibit. An average of more than three times as many CNMs resided in states with high rather than low support scores. The same relationship existed with the data (not shown). Likewise, in states with high support scores, CNMs attended almost three times as many births and had more than twice as many patient contacts. Given that CNMs are more likely to serve populations at greater risk for poor outcomes and access, the significance of their increased presence and activity in states with more supportive environments should not be underestimated. Discussion.4..4* *.*.*.*.2.* *..4*... There is growing evidence that CNMs provide a means by which access to maternal and infant health services can be extended and costs cut at the same time. 2 However, the likelihood that such an option can be exercised may rest largely on individual state regulatory structures. Our analysis reveals a strong relationship between.*.*..4*.*.*.* b SOURCE: Authors calculations. NOTES: CNM is certified nurse-midwife. Correlation was determined using a Spearman Rank correlation coefficient. a All data are for unless otherwise noted. b Not applicable. * p. H E A L T H A F F A I R S ~ M a r c h / A p r i l

9 E X HIBIT Relationship Between Regulatory Support And CNM Practice CNM/population Percent CNM births CNM visits/population SOURCE: Authors calculations. NOTES: CNM is certified nurse-midwife. CNM/population is the number of CNMs in per, female population ages 44 ( rating). Percent CNM births is the proportion of all births in state attended by CNMs ( rating). CNM visits/population is the number of visits to CNMs per, female population ages 44 ( rating). HEALTH state laws and workforce size, with a much larger proportion of CNMs located in states with supportive regulatory and reimbursement environments. Interestingly, there may be a delay in the impact of a state s environment on the distribution of CNMs. The support scores were more highly correlated with the distribution of CNMs (. [p.]) than was either score with the distribution in the corresponding year. The differences in the correlations are not large, however, and the decision of a nurse-midwife to locate in a state may be determined by factors other than the work environment. In addition, the direction of the causality is not always clear; the presence of a larger number of CNMs in a state may create the critical mass needed to influence a state s regulatory climate. Overall, however, the single best predictor of the distribution of CNMs and the level of their activity was the regulatory and reimbursement system within which they worked. This relationship was also more subtle than it initially seemed. For example, in most states CNMs were regulated by a state nursing board, and advisory boards of CNMs existed in a number of cases. However, the state boards of nursing were often not seen as supportive, and the advisory boards existed mostly on paper. Conversely, CNMs in some states resorted to the use of informal mechanisms to deal with barriers to hospital admitting and prescription writing constraints. Nonetheless, the degree to which a state s formal environment facilitates or restricts CNM practice establishes clear parameters within which these informal arrangements operate. The dilemma faced by CNMs is a common one for nonphysician H E A L T H A F F A I R S ~ V o l u m e, N u m b e r 2

10 H E A L T H W O R K F O R C E practitioners: Those drawn to nurse-midwifery are primarily interested in providing direct services to mothers and children and are not very active in the state politics of nurse-midwifery. 22 This is particularly true in states where only a handful of CNMs practice; respondents in those states cited a sense of isolation and a lack of resources to challenge the status quo. The ACNM has begun to address these problems through legislative conferences, newsletters, and the addition to their national staff of a second policy analyst who will focus on state issues. However, the resources available for this effort are but a fraction of those used by other health professionals in support of their practices, and the urgency of federal policy issues with regard to CNM practice, such as recent federal health care workforce projections, may delay ACNM efforts geared toward state regulatory reform. 2 The case of nurse-midwives illustrates the potential for states to reconcile the need to increase access while reducing costs. While regulatory control is likely to remain a state function, leveling the playing field for CNMs in terms of federal reimbursement could affect women s ability to gain access to nurse-midwifery services. The authors gratefully acknowledge the financial support of the Robert Wood Johnson Foundation (Grant no. 4) and the ACNM Foundation, Inc. Acknowledgment is also given to the American College of Nurse-Midwives for use of ACNMgenerated data for research purposes. Preparation of this paper was supported in part by Grant no. MCJ-2 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, U.S. Department of Health and Human Services. DATAWATCH NOTES. Pew Health Professions Commission, Critical Challenges: Revitalizing the Health Profession s for the Twenty-first Century (San Francisco: UCSF Center for the Health Professions, ). 2. J.B. Litoff, American Midwives, to the Present (Westport, Conn.: Greenwood Press, ); and E.R. Declercq, The Trials of Hanna Porn, American Journal of Public Health ( June 4): L. Benham, The Demand for Occupational Licensure, in Occupational Licensure and Regulation, ed. S. Rottenberg (Washington: AEI Press, ). 4. B.J. Safriet, Health Care Dollars and Regulatory Sense: The Role of Advanced Practice Nursing, Yale Journal on Regulation (Summer 2): S. Flint and R. Benson, A Private Health Insurance Coverage of Maternity and Infant Care, in A Pound of Prevention: The Case for Universal Maternity Care in the U.S., ed. J. Kotch et al. (Washington: American Public Health Association, 2); J. Liu et al., The Health of America s Children, 2 (Washington: Children s Defense Fund, 2); and R. Bennefield, Health Insurance Coverage:, Current Population Reports, P- (September ).. P.O. Kohler, Specialists/Primary Care Professionals: Striking a Balance, Inquiry (Fall 4): 2 2; S. Foreman, Managing the Physician Workforce: Hands Off, the Market Is Working, Health Affairs (Summer ): ; H E A L T H A F F A I R S ~ M a r c h / A p r i l

11 HEALTH R.A. Cooper and S.J. Stoflet, Trends in the Education and Practice of Alternative Medicine Clinicians, Health Affairs (Fall ): 22 2; and K. Kelly, Nurse Practitioner Challenges to the Orthodox Structure of Health Care Delivery: Regulation and Restraints on Trade, American Journal of Law and Medicine (January ): 22.. National Center for Health Statistics, Advance Report of Final Natality Statistics,, Monthly Vital Statistics Report 4, no. (Supplement) (Hyattsville, Md.: U.S. Public Health Service, ); and S. Clarke, J. Martin, and S. Taffel, Trends and Characteristics of Births Attended by Midwives, Statistica l Bulletin (January March ):.. Annual Update of How Each State Stands on Legislative Issues Affecting Advanced Practice Nursing Practice, Nurse Practitione r (January ): 4; and J. Haas and J. Rooks, National Survey of Factors Contributing to and Hindering the Successful Practice of Nurse-Midwifery: Summary of the ACNM Foundation Study, Journal of Nurse-Midwifery (): Haas and Rooks, National Survey.. L. Paine et al., Nurse-Midwifery Care to Vulnerable Populations in the United States: The Final Report (Washington: American College of Nurse-Midwives, ).. See E. Sekscenski et al., State Practice Environments and the Supply of Physician Assistants, Nurse Practitioners, and Certified Nurse-Midwives, New England Journal of Medicine ( November 4): Data on malpractice issues and admitting privileges also were collected in the original survey but were not used in the overall scale.. American College of Nurse-Midwives, Nurse-Midwifery Today: A Handbook of State Legislation, (Washington: ACNM, ); Physician Payment Review Commission, Annual Report to Congress, (Washington: PPRC, ), chap. ; and C. Hoffman, Medicaid Payment for Nonphysician Practitioners: An Access Issue, Health Affairs (Fall 4): For an appendix of the weighting values assigned to each item, write to Eugene R. Declercq, Maternal and Child Health Department, Boston University School of Public Health, Albany Street, Boston, Massachusetts 2.. DHHS, A Survey of Nurse-Midwives, Pub no. OEI-4--2 (Washington: DHHS, Office of Inspector General, 2), A-.. Pew, Critical Challenges, 4.. DHHS, A Survey of Nurse-Midwives,.. ACNM, Nurse-Midwifery Today.. Ibid.. The measurement of patient contacts was developed as part of the larger study of CNM practice. For a complete explanation of the development of this measure, see PPRC, Annual Report to Congress, ; and Hoffman, Medicaid Payment for Nonphysician Practitioners. 2. R.A. Rosenblatt et al., Interspecialty Differences in Obstetric Care of - Risk Women, American Journal of Public Health (): 44 ; and D. Oakley et al., Comparisons of Outcomes of Maternity Care by Obstetricians and Certified Nurse-Midwives, Obstetrics and Gynecology (November ): T. Gesse, Political Participation Behaviors of Nurse-Midwives, Journal of Nurse-Midwifery (May/June ): J. Sharfstein and S. Sharfstein, Campaign Contributions from the American Medical Political Action Committee to Members of Congress, New England Journal of Medicine ( January 4): 2 ; and K. Carr and K. Fennell, Primary Care Workforce Projections: Implications for CNMs, Quickening (November/ December ):,,. H E A L T H A F F A I R S ~ V o l u m e, N u m b e r 2