State Regulation of Practice and the Utilization of Nurse Midwives for Medicaid Funded Prenatal Care Andrea Sonenberg, NP, CNM, DNSc Assistant Professor Lienhard School of Nursing Pace University Pleasantville, New York, USA
Purpose To determine what association, if any, existed between state regulation of nurse-midwife (CNM) professional practice and the proportion of Medicaid funded prenatal care (PNC) delivered by CNM s. If such an association was found: to identify which factors related to regulation of practice had the greatest association with the Medicaid utilization of CNM s for PNC delivery. 2
Background One of the leading health indicators in Healthy People 2010 is early access to PNC. The goal is to have 90% of pregnant women in the US registered for PNC by the end of the first trimester. (Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, 2005). 3
Background Pregnant women have been identified as a particularly vulnerable population at risk. (Centers for Disease Control and Prevention, 2005; Gabbe, Niebyl, and Simpson, 2002; Institute of Medicine, 1985; Lasker, Coyle, & Ortynsky, 2005; Rosenberg et al. 2005; Varney, 2004). Risk Factors for Low Birth Weight & Prematurity -- Demographic -- Psychosocial -- Past Medical & Obstetric History -- Complications of Pregnancy Racial disparities in all reproductive health outcomes. (Anachebe & Sutton, 200, Freeman, 2005; Lasker, Coyle, Ortynsky, 2005; Lu and Halton, 2003; National Center for Vital Statistics, 2005 ) 4
Background Nurse - Midwifery Care To vulnerable populations Quality & Cost-effectiveness State Regulation of Practice-Midwifery Practice Acts Determined by and specific to each state Determine: licensure, scope of practice, collaborative relationships, provide/restrict prescriptive authority Impact Access to care Recommendations World Health Organization, 2002 Title XIX of the Social Security Act Institute of Medicine,1985 and 2001 Public Citizens Research Group, 1995 The Pew Commission, 1999 5
Aday s Framework for Classifying Topics and Issues in Health Services Research (Aday, 1998) 6
Aims To describe: Any association between a state s CNM Professional Practice Index Score and the proportion of Medicaid funded services delivered by CNM's in each of the fifty states of the United States. Any association between a state s CNM Professional Practice Index Score and the proportion of Medicaid funded PNC delivered by CNM's in exemplar states representing the extremes on the Professional Practice Index. The category of regulation of practice (legal status, reimbursement, or prescriptive authority) within the index that has the greatest association with the proportion of Medicaid funded services delivered by CNM's. Which of the factors within the most influential category has the greatest association with the proportion of Medicaid funded services delivered by CNM's 7
Design Health policy study Descriptive Correlational design utilizing multiple secondary data sets Population & Sample Unit of measure: the state. Sample: the fifty states of the United States of America. Variables Independent variable: State regulation of CNM practice as measured by the Professional Scope of Practice Index Score (National Center for Health Workforce Analysis, 2002). Primary Dependent variable: Utilization of CNM's for Medicaid funded PNC, reflected in The proportion of Medicaid funded services delivered by CNM's The proportion of Medicaid funded PNC delivered by CNM's 8
All Outcome Variables Total # of CNM s Total births Total CNM births Proportion CNM births Total Medicaid claims Total CNM Medicaid claims Proportion of CNM Medicaid claims % 1 st Trimester PNC Low Birth Weight rate Premature Birth rate Neonatal Mortality Rate Proportion Minority % Poverty 9
Secondary Data Sources Kaiser Family Foundation Total Medicaid births 1 st Trimester PNC Neonatality data US Census Bureau Poverty Data Centers for Medicare and Medicaid Total Medicaid Claims Total CNM Medicaid Claims National Center for Vital Statistics Total CNM Births The National Center for Health Workforce Analysis CNM Professional Practice Index Score Quality Resource Systems, Inc. Total # CNM s in each state 10
State Regulation of Practice of CNM's The National Center for Health Workforce Analysis (2002) Professional Practice Index is an additive scale (total score=100) comprised of a set of indices in 3 categories. to define the scope of professional practice of CNM s in each state. Categories of Professional Practice Index: Legal status (Optimal Score=35) Reimbursement (Optimal Score=35) Prescriptive authority (Optimal Score=30) 11
Proportion of Total Medicaid Funded Services by CNM's CMS Data Mart dataset (Centers for Medicare and Medicaid, 2005) Data submitted by the states Variable Code: Service Type Midwife Variable Code: Plan Type Prenatal Care Only submitted by Alabama 12
Proportion of Medicaid Funded Prenatal Care by CNM's States on both ends of the spectrum of Professional Practice Index Scores (PPI) PPI Score<50 (Most Restrictive): Alabama, Georgia, Illinois, Nebraska, and South Carolina PPI Score>85 (Least Restrictive): Alaska, Connecticut, Maine, New Mexico, New York, Oregon, Rhode Island, Utah, and Washington 13
Descriptive Data: 50 States Data Analysis Scatter Plots: PPI Score and Outcome Variables Correlations: variables showing linearity with Scope Score Spearman rho correlation with p<0.05 analyzed by category Categories with Spearman rho correlation p<0.05 analyzed category components Compared Group means of States at extremes of PPI scale for outcome variables 14
Results & Analysis Scatter Plots with Linear Fits - PPI Score and Proportion CNM births % 1 st Trimester PNC Low Birth Weight Rate Premature Birth Rate Neonatal Mortality Rate % < Poverty Level Proportion Minority Correlations with p<0.05 PPI Score and Proportion CNM births Low Birth Weight Rate Premature Birth Rate Neonatal Mortality Rate % <Poverty Level Proportion Minority 15
Most Contributory Categories for Relationship of Professional Practice Index Score with Outcome Variables Outcome Variable Prop CNM Births Category w/ Most Influence Reimbursement Premature Birth Rate Neonatal Mortality Rate Low Birth Weight Rate Legal Status Legal Status Rx Authority % Poverty Rx Authority Proportion Minority Rx Authority
Extreme Group Comparisons Outcome Variable Most Restrictive CNM States [Mean] PPIS<50 Least Restrictive CNM States [Mean] PPIS>85 PPI Score 41.4 88.8 -Legal Status 18.4 28.1 -Reimbursement 13.6 34.4 -Rx Authority 9.4 26.2 Prop CNM Births 0.06 0.13 Premature Birth Rate 13.72 10.82 Prop Minority 30.40 25.89 %Poverty 13.34 11.91
PPI Score Category Components for Two Extreme Groups of States Category Component Max. Score Most Restrictive CNM States [Mean] Least Restrictive CNM States [Mean] Legal Status Regulatory Body 3 0.2 1.9 Relationship w/ MD 3 1.8 2.7 Autonomous Practice 5 0.0 5.0 Reimburse. 3 rd Party/HMO 15 0 15 Direct Access 5 0 5 Rx Authority Own DEA 3 0.6 3.0 Extent of Authority 16 2.8 16 Authority Through 4 1.2 2.9
In Summary: The key findings A paucity of data related to CNM services States w/ fewest barriers to practice greatest proportion of CNM births States w/ most restrictive practice regulation highest proportion of vulnerable populations and highest rates of adverse perinatal outcomes States with the greatest CNM autonomy may have the greatest access to care for vulnerable populations. 19
Strengths & Limitations Strengths Supports discoveries of past research Identifies that barriers to CNM practice through restrictive state regulations continue to impact the utilization of CNM s for care to vulnerable populations, and thus realized access to care. Limitations Methodology Data Collection Medicaid funded PNC Total CNM births Medicaid Claims Measurement Professional Practice Index Rates of low birth weight and premature births Not just Medicaid population, include births to the uninsured 20
Future Research on CNMs Developing and including CNM care and quality metrics in national data sets Improving methodologies on cross-national CNM roles and outcomes with all types of pregnancies high and low risk Studying the impact of least-restrictive CNM state practice acts and their link to neonatal and maternal outcomes. For example, do states with laws that allow CNMs to practice within their full educational and certified scope have greater access to perinatal care and improved outcomes than states with more restrictive state practice acts? For example, do states with laws that allow CNMs to practice within their full educational and certified scope have greater access to perinatal care and improved outcomes than states with more restrictive state practice acts? 21
Consensus Model on APRN Regulation (2008) A 4 year long consensus-building with dozens of stakeholders including Educators, certifying bodies, 50 state boards of nursing and educational accrediting agencies Creates a national framework for regulating advanced practice nurses, including CNMs. Recommends that: Boards of Nursing [or Midwifery] shall be solely responsible for regulating all advanced practice nurses [CNMs] [CNMs] must be licensed as independent practitioners with no regulatory requirement for collaboration, direction or supervision. (National Council of State Boards of Nursing, 2008. https://www.ncsbn.org/170.htm) 22
Health Policy Implications No central data source for CNM practice patterns, cost, or outcomes CNMs could play a large role in expanding access to care for vulnerable populations if state practice acts were consistently less restrictive in all 3 categories of regulation: Legal status, Reimbursement Prescriptive authority States must move to modernize and reduce restrictions on CNM practice acts by utilizing: Evidenced-Based regulations The Consensus Model for APRN Regulation as the national framework 23
Conclusion There is a paucity of data on specific Medicaid funded services provided by nurse-midwives. A relationship still exists between states with restrictive CNM practice regulation and: decreased services provided by CNM s greater proportions of vulnerable populations increased rates of adverse perinatal outcomes Future research and policy reform should focus on decreasing barriers to practice and increasing utilization of CNM's & access to care for vulnerable populations of pregnant women. 24