Written and presented throughout 2013

• Since this presentation there has been an addition in the determination to include a fifth collaborative arrangement – basically credentialing.

Dr Belinda Maier• Midwifery Advisor QH 2009 – 2013

• Maier.Belinda@yahoo.com.au

Nursing and Midwifery Office Queensland

Dr Belinda Maier, NMOQ

• Eligible Midwives/col laborat ive arrangement s• Prerequi s i te s• Credent ia l ing of e l ig ible midwives for hosp i tal acce s s• Acce s s l icense agreement• Collaborat ive arrangement• Regulatory requirements of the Elig ible Midwife :• Eligible midwive s: co s t bene f i t s for publ ic hosp i tal s• Eligible midwive s: qual i ty and safe ty

ELIGIBILITY:ELIGIBILITY:

• The only requirement for midwives The only requirement for midwives applying for a Medicare provider number applying for a Medicare provider number is to be an “eligible midwife”. This is is to be an “eligible midwife”. This is achieved by a notation on a midwife’s achieved by a notation on a midwife’s registration by the Australian Health registration by the Australian Health Practitioners Registration Authority Practitioners Registration Authority (AHPRA). (AHPRA).

What is a collaborative What is a collaborative arrangement?arrangement?

• A collaborative arrangement is an arrangement between A collaborative arrangement is an arrangement between an eligible midwife/eligible nurse practitioner with a an eligible midwife/eligible nurse practitioner with a medical practitioner that must provide for:medical practitioner that must provide for:

• consultation with a specified medical practitioner;consultation with a specified medical practitioner;• referral of a patient to a specified medical practitioner; referral of a patient to a specified medical practitioner;

and and • transfer of the patient’s care to a specified medical transfer of the patient’s care to a specified medical

practitioner,practitioner,• as clinically relevant, to ensure safe, high quality health as clinically relevant, to ensure safe, high quality health

care.care.

MisconceptionsSupervisory roleLegally responsible for the actions of the midwifeSupport homebirthExtra workExtra on callRealityProfessionalismCollegialityHealthy women and babiesTimely and appropriate access to medical careEffective and timely use of resources

Credentialing of eligible midwives for hospital access

• Establishment of a midwife credentialing subcommittee of existing hospital credentialing committee

• Process follows standard credentialing template used for medical officers.

Access license agreement• Sets conditions for access and use of

hospital facilities;• Follows standard format for VMOs;• Model documents used by Toowoomba

and Gold Coast hospitals have sign-off by hospital and professional indemnity insurer solicitors

• Should include “collaborative arrangement”.

Collaborative arrangement

Requirement of midwives, in order for women to receive MBS rebates.

There are 4 options which the midwife may have that constitute a collaborative arrangement as set out in National Law:

•Employment arrangement;•Referral from doctor; •Signed agreement with hospital and/or obstetrician; and•Midwife’s written records of collaboration.

Regulatory requirements of the Eligible Midwife:

• Safety and Quality Framework within which sits the requirement that Midwives use the Australian College of Midwives Guidelines for Consultation and referral. The use of these guidelines is also a Directive of Queensland Health.

Overview of care• Antenatal care• All women self select model of care and therefore access to care is "all risk"

on entry;• Private, MBS-rebatable care (including pathology and diagnostics) provided

in community; and

• Consultation, referral and transfer to medical care as per ACM guidelines (plus any additional requirements in local agreement).

• Labour and birth care• Woman is admitted to hospital as private patient under private midwife; or• Admitted as public patient and midwife is employed to provide continuity;

and• Consultation and referral to obstetricians for complexities as per ACM

guidelines (plus any additional requirements in local agreement)• Postnatal care• Private, MBS-rebatable care following discharge to 6 weeks; and• Early discharge possible with private home visiting. Consultation and referral

to other health professionals as per ACM guidelines (plus any additional requirements in local agreement)

Eligible midwives: cost benefits for public hospitals

Collaborating with eligible midwives potentially yields

significant clinical and financial benefits to public hospitals

providing maternity services.

Antenatal care• Private, MBS-rebatable, antenatal

midwifery care at no cost to public hospital;

• Eligible midwives’ referrals to named specialists are accepted by Medicare and enable billing to Medicare by hospitals for antenatal medical care; and

• Pathology and diagnostics are billed to Medicare by midwife or hospital.

Labour and birth care: normal birth• Medicare rebate for woman: MBS item 82120: labour

and birth care by eligible midwife who has provided antenatal care: scheduled fee: $739, MBS rebate: $554;

• Midwife may charge above scheduled fee, e.g. approx. $2000;

• Private health insurers pay full gap or proportion of gap;• Insurer or woman pays hospital bed fee of approx

$320/day;• Hospital paid under state ABF for normal birth

DRG: O60C VAGINAL DEL SINGLE UNCOMPL = 0.8518 WAU (WAU = $4,808) = $4095.45 (this includes postnatal care while admitted); and

• After transition to national ABF, DRG payment for O60C private patient will be discounted to 83% of public payment $4095.45 = $3399.22.

Postnatal careWoman receives private postnatal care at home and/or community clinic at no cost to hospital, enabling early discharge.

Financial benefits to hospital - examples• Hospitals benefit financially if any proportion of care is

provided by eligible midwives.• Private patient, normal birth with eligible midwife as private self

employed midwife • $4095 (ABF) + $320 (private bed charge) = $4415 for short stay use

of room, no medical costs, minor associated costs and no postnatal care costs. Significant additional MBS bulk billing income to hospital for medical care is also possible (e.g. obstetric consult, anaesthetic attendance, paediatric attendance).

• Private antenatal and postnatal care, public intrapartum care with midwife (fractional employment model), normal birth

• $4095 (ABF) - $369 (8hrs x $46/hr public caseload midwife NO2.1) = $3726, short stay use of room, some core midwifery care, no medical costs and no postnatal care costs.

• Private antenatal and postnatal care, private intrapartum care (bed fee waived), normal birth

• $4095 (ABF), short stay use of room, minor associated costs, no medical costs and no postnatal care costs. Significant additional MBS bulk billing income to hospital for medical care.

Eligible midwives: quality and safetyRegulated requirements• AHPRA registration requirements for all midwives• AHPRA registration standard for eligible midwives:• Current general registration as a midwife with no restrictions on

practice;• 3 years full-time experience;• Current competence across the full scope of midwifery practice;• Professional review process endorsed by the NMBA (such as the

Australian College of Midwives Midwifery Practice Review);• Additional 20 hours of CPD requirements annually;• Completion of a prescribing course within time limit; and• Insurance covering full scope of practice (Commonwealth-

subsidised insurer – MIGA – is the only insurer for intrapartum care in hospital).

Insurer’s requirements (Commonwealth-subsidised PI insurance)

• Collaborative arrangement or communication of care plan with hospital (template specified);

• Annual completion of comprehensive risk management training program; and

• Notification of events (template specified).

Private practice requirements

• Public liability insurance;

• Work cover;

• Occupational Health and Safety requirements;

• Public Health regulations; and

• Significant business and financial requirements.

Hospital licence requirements• Antenatal care• Agreement with hospital specifies consultation and

referral pathways, sharing of clinical information, including use of pregnancy health record (not enforceable with GPs);

• Australian College of Midwives National Midwifery Guidelines for Consultation and Referral;

• “Care coordinator” or care manager role for women with complex obstetric needs, with medical specialist in lead carer role;

• Case review meetings fortnightly with medical staff;• Fortnightly governance meetings with midwifery

managers or clinicians; and• Hospital requirements for professional development.

• Labour and birth care in hospital• Successful completion of hospital credentialing;• License agreement specifies access conditions;• Hospital protocols, work place instructions, procedures

and guidelines;• Intrapartum records shared with hospital; and • Australian College of Midwives National Guidelines for

Consultation and Referral.• Postnatal care (in community)• Australian College of Midwives National Midwifery

Guidelines for Consultation and Referral; and• Care summary shared with GP.

Eligible midwives – how to implement visiting access to public hospitals: A Guide for Hospital and Health Services

Eligibility Medicare 19(2) exemption – revenue for public employed

midwives to attract Medicare rebates