Submission to Medicare Benefits Schedule Review Taskforce. Public Consultation Paper

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1 Ph: Submission to Medicare Benefits Schedule Review Taskforce Public Consultation Paper 9 November 2015 Liz Wilkes CEO Jenny Gamble Chair and Director 1

2 About Midwifery Maternity Provider Organisation Australia The Midwifery and Maternity Provider Organisation Australia (MMPOA) is a not for profit organisation established to support and promote continuity of midwifery care in the public and private sector. We also provide information to childbearing women about maternity care options. MMPOA was incorporated in February 2015 and aims to meet the Commonwealth government objectives as outlined in the National Maternity Services Plan. Our organisation connects with upward of 5000 maternity consumers annually through the broad membership base of our member organisation - Maternity Choices Australia - and through our strong relationship with the Pregnancy, Babies and Children's Expo. We run a "Meet the Midwife" area at the annual expos in Perth, Brisbane, Sydney, Adelaide and Melbourne and provide six education sessions per expo. Additionally we work with midwives working in continuity of care models in the public and private sector, including those with a Medicare provider number. Our engagement and support for this group of midwives includes education, mentoring, data collection, consulting services and business support. MMPOA s vision is Transforming Maternity Care: Midwifery continuity of care for every woman by Our purpose is to support the ongoing improvement in health outcomes for women and families that result from continuity of midwifery care from a known midwife. MMPOA provides unbiased evidence-based expertise and experience about the design, implementation and evaluation of maternity care. Our communication strategy with stakeholders includes direct communication with every eligible midwife in Australia enabling us to engage effectively with eligible midwives in our own right and on behalf of, or in conjunction with, the Commonwealth. Similarly to many professional and consumer organisations, we strongly support a universal funding model for all Australians, such as Medicare, and advocate for universal access to primary maternity care. Our view is that maternity care needs to be a focus of the current review of Medicare because maternity care is universally applicable every person is born and most women and their partners have at least one baby. We are concerned that primary maternity care has been neglected and poorly served at a state and national level and across sectors and that this MBS review provides an opportunity to address the oversights and problems. Evidence for changing models of maternity care 2

3 There is overwhelming evidence that women provided with continuity of midwifery care have better outcomes than in medical models (Sandall et al., 2015). Importantly, continuity of midwifery care did not show poorer outcomes on any variable compared with other models of care. This model is also less expensive than traditional fragmented models of care (Beake et al., 2001; O Brien, 2010; Toohill et al., 2012; Tracey & Hartz, 2005; Tracy et al., 2013). The cost savings and cost effectiveness of continuity of midwifery care has been consistently demonstrated for well over a decade and in different countries. This evidence of improved outcomes and cost benefit is reflected in national maternity policy through the National Maternity Services Plan (Department of Health, 2011). Furthermore, consumers have consistently sought improved access to continuity of care and this finding has been captured in every maternity services review (regional, state and national) since the review of maternity services in NSW in 1988 (Shearman, 1989). Despite the quality of the scientific evidence, the positive financial drivers, national policy, consumer and midwifery profession demand, scaling up access to continuity of midwifery care has been very slow and hesitant. As a result very few women and their families in Australia have access to this value-based - rather than the traditional activity based - model of maternity care. The pressing need for a primary care framework and relational care offered through continuity of midwifery care grows. Many current major impacts on women in pregnancy including mental health concerns, domestic violence, perinatal mental health, smoking, other drug use and obesity require a primary health approach integrated within their maternity care. Women may also require specialist services including specialist medical care, but the predominant need for all women is to have an ongoing relationship with their midwife (Sandall et al., 2015, Teakle, 2014). The genesis of many chronic diseases is in the perinatal period and therefore the opportunity to impact on the health of the whole community in the long term is also profound. MMPOA has a strong view that models where there is clear evidence supporting better outcomes and which are demonstrated to be cost effective should be the focus of the MBS review. Midwifery continuity of care is one such model. Challenges in funding maternity care Maternity care is funded by the Commonwealth in many ways; through the MBS, through funding to state hospitals and through the private health insurance rebate. Consumers of maternity care have long demanded change. The National Maternity Services Plan (Department of Health, 2011) provides a plan for reorientation, however much of this plan has not been fulfilled. Difficulties with the MBS have prevented significant uptake of the plan nationally. Therefore this provides another strong rationale to focus significantly on maternity care in the MBS review. 3

4 Challenges of the current MBS review The current MBS review process has not been set up to support widespread reorientation of the MBS in the maternity care area. The taskforce and working parties remain strongly medically focused. There is a limited opportunity for consumer input and, at this point, there appears to be no involvement for maternity consumers that have a representative role through nomination by a consumer organisation. An approach which tinkers at the edges without examining some of the fundamental issues, such as medical dominance of the health funding landscape, reinforces that there is a significant challenge which the reform may be avoiding addressing. Reform of the health system is overdue with a need to reorientate a medically dominated illness system to encourage a health focused wellness system. This requires far greater change, particularly in maternity care, than currently appears to be proposed. To create a significant change, disruptive thinking is required and MMPOA believes that maternity care could and should lead this change. MMPOA s submission will focus on specific components of the consultation paper provided by the Taskforce. The areas of focus are: Examples where the MBS seems to be failing to support delivery of best value healthcare, o Which services funded through the MBS represent low-value patient care (including for safety or clinical efficacy concerns) and should be looked at as part of the Review as a priority? o Which services funded through the MBS represent high-value patient care and appear to be under-utilised? Recommended improvements to the surrounding rules, processes and systems that support the MBS. Examples where the MBS seems to be failing to support delivery of best value healthcare The area of maternity care funding is complex and there may be elements that are outside the remit of the MBS review which will be addressed in the white paper regarding the relationship between the Commonwealth and the states for funding health. Maternity care is an area where primary health care intersects with acute services almost without fail (i.e. most women birth their baby in hospital) and as such the impact of MBS on maternity care must be examined. There is no equity in terms of similar work attracting the same payments for midwives and medical practitioners. There is 4

5 little analysis of the cost: benefit ratio for many areas of health and this is particularly apparent with areas such as bedside ultrasound. Despite the strong body of evidence around the benefits of continuity of midwifery care, little has been done to shift funding patterns to support these models either through the state funded system or within the MBS. There are three main issues to be addressed in this MBS review. 1) Enhanced use of midwives to provide more women with primary maternity care. MMPOA strongly supports a shift in the MBS funding model to support midwives providing continuity of care through pregnancy, birth in hospital and the postnatal period. In MMPOAs view there should be a shift to a primary model of maternity care where midwives, and to some extent GPs, are the main providers of universally accessible primary pregnancy care funded by Medicare. There should be move away from pregnancy care provision in the public hospital system. Implementation of this model would need appropriate focus on funding and workforce strategies but would be supported through Federal/state reform and potentially other reforms in the primary health space. Women would see a midwife or GP throughout pregnancy unless they required consultation, referral or transfer of care to obstetric specialist care which would attract a fee for service item numbers. Where women choose, rather than need, to seek private obstetric care they would be able to make this choice supported by private health insurance. 2) Bundling antenatal and postnatal items to promoting continuity of care MMPOA views bundling of antenatal and postnatal items as a strategy to provide better incentives for provision of primary maternity care and continuity of care. Mechanisms to ensure compliance with minimum standards of care and requirements around safe provision of care would be built in to the item descriptors. This model of care funds a more appropriate mix of health care provision: right provider, right level of care at the right time; focused on consumer needs rather than promoting one single model the biomedical model over any others. MMPOA sees that a mixed funding model which allows for pre-payment and payment based on an entire episode of care (e.g. a trimester of pregnancy), blended with access to fee for service models (i.e. for discrete obstetric consultations where required), would better serve consumer needs with client-led funding and the payment following the woman. Our view is that this would allow for more appropriate health measures and would promote well-being in pregnancy. 5

6 3) Fair recompense for Medicare-funded midwives A fairness test needs to be applied to the type of care provided. Currently eligible midwives providing 12 hours of direct client care have a scheduled fee for that service that is almost identical for the scheduled fee for obstetric care in normal birth. Obstetric care for normal birth generally consists of very small periods of attendance over the woman s labour, at times consisting of as little as 10 minutes of care. Antenatal visits with a midwife are generally 1 hour long. The scheduled fee for a long antenatal visit is $ MMPOA feels that items should be more equitable and time-based. Midwives with visiting rights to hospital are required (as part of their access agreement) to attend inter-professional team meetings (e.g. audit) and be part of clinical governance in the hospitals where they have visiting access. This needs to be funded through some mechanism. Similarly, recompense is required for clinical teaching of students and preceptoring new graduates and midwives transitioning to Medicare-funded practice (e.g. pre-eligible midwives) if workforce sustainability is to be addressed. Recommended improvements to the surrounding rules, processes and systems that support the MBS. While the MBS provides for some midwives to have access to Medicare, the rules and processes around this are restrictive and the actual funding model within the MBS does not support the continuity element of this model. The current rules and measures surrounding midwives access to the MBS have created barriers to women using midwifery care from Medicare-funded midwives. There are three stand-out problems with the Medicare rules: 1) Collaborative arrangements used to restrict midwives access to hospitals Collaborative arrangements are inappropriately used to block midwives gaining visiting access to hospital in most Australian states/ territories (except Queensland). Collaborative arrangements are a legislated requirement for midwives participating in the MBS, however there is no concurrent onus on the collaborating partner to participate. This places women in a completely untenable position as accessing participating midwives is reliant on an obstetrician being prepared to accept working collaboratively. This is unnecessary and both administratively and clinically burdensome. A recommended alternative is to remove this requirement and to indicate that midwives must be able to indicate pathways for clinical referral e.g. booking women to hospital for their intrapartum care. 6

7 2) Salaried midwives need to be able to use Medicare Salaried midwives working in public employed continuity of midwifery care models are prevented from using Medicare to improve access for women these models. This area of potential reform sits within the current COAG arrangements. Salaried midwives could provide access for women to continuity of midwifery care models with a process which enables salaried midwives to have rights to private practice in public employed models of care, not just those restricted to hospitals with a 19.2 exemption. 3) Requiring three-years of fulltime equivalent practice post-registration before being able to obtain a Medicare provider number restricts Medicare-funded midwives from being able to grow the workforce of Medicare eligible midwives and to meet demand for services. This timeframe (3 years) was arbitrarily determined and is an anomaly. It should be changed to be consistent with the requirement for medicine. Midwives who have less than three years experience but are working in private practices with accredited midwives need a pathway to access a provisional Medicare rebate, potentially for a limited number of items. Summary of recommendations to the MBS Review Taskforce 1. Enhance access for midwives and GP s as primary care provider to MBS to promote primary maternity care 2. Review descriptors of obstetric items to reduce use of high cost, low value services such as bedside ultrasound 3. Bundle antenatal and postnatal items to promote continuity of care 4. Fairly compensate Medicare-funded midwives 5. Remove the collaborative arrangements requirements and replace with pathways to acute obstetric care where required 6. Provide a mechanism for salaried midwives to access rights to private practice and potential Medicare rebates for work in public employed continuity of midwifery care models. The current restriction to enable this to only occur those hospitals with a 19.2 exemption needs to be removed. 7. Remove the requirement 3 years post-registration requirement for access to a Medicare provider number and replace with a system to allow midwives to work toward a provider number in a practice with other Medicare provider midwives. 7

8 References Beake S, McCourt C, Page L. (2001). Evaluation of one-to-one midwifery: second cohort study. London: The Hammersmith Hospitals NHS Trust and Thames Valley University, ( Department of Health, (2011). National Maternity Service Plan. Australian Government, Canberra. O Brien, B., Harvey, S., Sommerfeldt, S., et al. (2010). Comparison of costs and associated outcomes between women choosing newly integrated autonomous midwifery care and matched controls A pilot study. JOGC ;32(7): Sandall, J., Soltani, H., Gates, S., Shennan, A., Devane, D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD DOI: / CD pub4. Shearman, R.P. (1989). Final Report of the Ministerial Taskforce on Obstetric Services in NSW. Maternity Services in NSW, Department of Health. Teakle, B., (2014). Primary Maternity Care Reform: Consumer Action Pack. Accessed: Toohill, J., Turkstra, E., Gamble, J., & Scuffham, P. (2012). A non-randomised trial investigating the cost-effectiveness of Midwifery Group Practice compared with standard maternity care arrangements in one Australian hospital. Midwifery. doi: /j.midw Tracey, S., Hartz, D. (2005). North Sydney Central Coast Area Health Service. Quality review of the Ryde Midwifery Caseload Practice. Tracy, S., Hartz, D., Tracy, M., Allen, J., Forti, A., et al. (2013). Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. The Lancet 382 (9906), Wilkes, E., Gamble, J., Adam, G. and Creedy, D. (2015). Reforming maternity services in Australia: Outcomes of a private midwifery practice. Midwifery. http;//dx.doi.org/ /j.miw/

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