Nurse-midwives push for more Medicare pay

Washington -- The American College of Nurse-Midwives has launched a lobbying effort aimed at bringing midwives' Medicare pay closer to that of physicians and convincing Congress that it needs to take a hard look at how many cesarean sections doctors are performing.

The two-pronged initiative has already resulted in some action. Lawmakers in the House and Senate have announced plans to reintroduce legislation that would address the Medicare payment issue.

Most nonphysician health professionals, such as nurse practitioners, clinical nurse specialists and physician assistants, are paid at 85% of the Medicare physician fee schedule. Since certified nurse-midwives joined the Medicare ranks in 1988, they have received 65% of what physicians earn for the same services. The legislation would bring CNMs' pay up to 95% to account for the higher liability insurance rates they typically face, compared with other nonphysicians, according to bill sponsors.

The current funding situation makes it difficult for nurse-midwives to treat patients from the pool of roughly 3 million women of childbearing age who are Medicare-eligible because of disabilities, as well as elderly women who require gynecological care, said Marion McCartney, CNM, the director of professional services for the ACNM.

"Most physicians think Medicare reimbursement is very low, and when you only get 65% of Medicare reimbursement, it's really difficult to make ends meet," she said.

The move would have a negligible effect on physician pay because relatively few Part B reimbursements flow to nurse-midwives, said Patrick Cooney, the chief lobbyist for the group. Medicare would offset the change by adjusting the conversion factor in the physician fee schedule in a way that would be virtually unnoticeable to doctors, he said.

"We're talking about less than a million dollars over 10 years, which is budget dust," Cooney said. The bigger effect likely would occur in the private sector, where insurers often look to Medicare when setting rates.

The American College of Obstetricians and Gynecologists has not taken a position on the federal legislation but generally supports the ACNM's push for more Medicare equity. Many OBs believe that certified nurse-midwives should be paid at least as much as other nonphysicians in the program, said Richard Henderson, MD, an obstetrician-gynecologist in Wilmington, Del., and an ACOG officer.

Doctors are less supportive of another provision in the bill that would expand the scope of practice for nonphysicians by allowing certified midwives to bill Medicare in states where they are permitted to practice. CMs take the same accrediting courses as CNMs but are not registered nurses and cannot receive Medicare money.

Serious patient safety concerns may arise if such a move encourages non-nurse midwives to take on more patients with disabilities, said Janette H. Strathy, MD, an ob-gyn in St. Louis Park, Minn. Some of these CNs administer home births without having a professional relationship with a practicing physician.

"Medicare beneficiaries tend to have higher-risk pregnancies because they often have related medical issues," Dr. Strathy said.

As Congress looks into certified nurse-midwives' Medicare payment, it must also examine why the rate of cesarean sections is so high, the ACNM says.

Too many C-sections?

More than 27% of births in the United States in 2003 were achieved via C-section, a rise of about 6% from the year before, a report from the National Center for Health Statistics shows. Experts attribute much of the increase to a significant decline in the rate of women who undergo vaginal births after previous cesareans.

"ACNM feels strongly that the cesarean rate is heading in the wrong direction," said Katherine Camacho Carr, CNM, PhD, president of the American College of Nurse-Midwives. Government oversight hearings would help spur needed research on the C-section issue, the group states.

But the ob-gyn community is equally concerned about the potential patient safety concerns associated with more surgeries and does not need lawmakers to step in, Dr. Strathy said. ACOG and other physician groups are already promoting research and public discourse on the issues of medical liability, patient choice and practice culture that are at the heart of the matter.