The Affordable Care A ct & Birth Centers

1. The Affordable Care Act & Birth Centers Jill Alliman, DNP, CNMLegislative Committee ChairAmerican Association of Birth Centers

2. A brief history of birth centers in the US • 1975- Maternity Center Association in NYC • 1981-Cooperative Birth Center Network (14 centers) • 1982 APHA published Guidelines for Regulating and Licensing Birth Centers • 1983-Organization became NACC • 1989-National Birth Center study published in NEJM • 2005-NACC became AABC • 2010-Medicaid Birth Center Reimbursement Act passed • 2014- 270 birth centers

3. What is the status of birth center birth in the US? • 270 known birth centers in US • 15,577 births in 2012 • 0.3% of all US births • 42% increase in past 5 years (MacDorman et. al, 2014)

4. All OOH births in 2012 in US • 53,635 births / 3,952,841 • 1.36% of all US births • 35,184 at home and 15,577 in birth centers • Up from 1.26% in 2011 • Most increase among non-Hispanic white women-rate of 2.05% of all births (MacDorman, 2014)

5. Birth Center Midwifery Providers • 61% CPMs or LMs • 52% CNMs • (AABC Medicaid Survey of Birth Centers 2009)

6. Birth center outcomes of care Low cesarean rates & improved outcomes Cost savings Increased client satisfaction (Rooks, 1989;Stapleton, 2013)

7. US spends more -- but our mothers and babies have higher risk of dying • US is 46th in maternal mortality (2 X higher than 31 other nations) • US is 27th in infant mortality (6.1 deaths per 1000 live births)(WHO, 2012) • Huge racial disparities make some at much higher risk • Medicaid pays for 48% of US births

8. Triple Aim Innovative approaches should meet the Triple Aim of CMS Better Care Better Health Lower Costs Birth Center Care meets the Triple Aim and is a model for improving maternity care.

9. Birth Centers by State

10. States where CPMs are legally authorized to practice Map courtesy of The Big Push for Midwives – pushformidwives.org

11. 82% of States Have Regulationsfor Licensing Birth Centers

12. AABC definition of Birth Center A home-like setting where care providers, usually midwives, provide family-centered care to healthy pregnant women.

13. AABC definition of Birth Center • Most are separate from hospitals • A few are inside hospitals and must meet standards for independence and be separate from L & D unit AABC definition of Birth Center

14. Definition of Birth Center in Federal Law • USC § 1396(l)(3) (A) The term “freestanding birth center services” means services furnished to an individual at a freestanding birth center (as defined in subparagraph (B)) at such center. • (B) The term “freestanding birth center” means a health facility— • (i) that is not a hospital; • (ii) where childbirth is planned to occur away from the pregnant woman’s residence; • (iii) that is licensed or otherwise approved by the State

15. Definition of a birth center, cont. • (iii) continued • To provide prenatal, labor and delivery or postpartum care and other ambulatory services that are included in the plan; and • (iv) that complies with such other requirements relating to the health and safety of • individuals furnished services by the facility as the State shall establish. [42 U.S.C. § 1396(l)(3) (A), (B), & ( C)]

16. Birth Center Medicaid Reimbursement Act • Introduced by Sen Boxer (R co-sponsor Sen. Corker) • AABC version did include both the facility and all licensed birth attendants • CBO cost estimate—would save Medicaid $$$$ • Amended by Sen Cantwell to add more language about types of birth attendants • Added to ACA Bill • Passed in 2010 as Section 2301 of ACA

17. Original language of Bill-Attendant • The term ’licensed birth attendant’ means an individual who is licensed registered by the State involved to provide health care at childbirth and who provides such care within the scope of practice under which the individual is legally authorized to perform such care under State law (or the State regulatory mechanism provided by State law), regardless of whether the individual is under the supervision of, or associated with, a physician or other health care provider. Nothing in this subparagraph shall be construed as changing State law requirements applicable to a licensed birth attendant.".

18. Mandated Services under Medicaid • Section 1905 of SSA lists services that Medicaid (“Medical Assistance”) must cover • “The term ‘medical assistance’ means payment of part or all of the cost of the following care and services or the care and services themselves, or both” • Freestanding Birth Centers added as paragraph 28 to the list of mandated covered services as part of the cross referencing of this bill

19. Harkin Amendment to the ACA • Applies to commercial/private insurance plans • Provider non-discrimination—states that plans cannot discriminate against non-physician providers • Not any willing provider • Cannot discriminate against a whole class of providers (e.g. birth centers)

20. Implementation Steps • States must submit a State Plan Amendment (SPA) stating they will cover birth centers and their birth attendants--at least 26states have completed this step • All the states that license or recognize birth centers are mandated to pay for the facility services and the professional service fees for midwives who attend births in those birth centers • AABC position—CMS needs to issue Rules and Regulations so states will comply correctly • Rules needs to state that Medicaid MCO’s must comply with Medicaid mandate

21. Reimbursement levels and MCOs—the next hurdles for birth center access Florida—implementation of facility services payment very slow. FABC’s worked to increase budget for the line item that covers birth centers. TX—Medicaid reimbursement too low for most centers to accept Medicaid Mediciad Managed Care Organizations won’t contract with birth centers in some places—need CMS Rules

22. Bottom Line . . . With the ACA If you are a licensed provider, working in a licensed or otherwise recognized by the state birth center: • Medicaid is mandated to pay your facility service fees and professional services of the birth attendant • Commercial plans don’t have to contract with every birth center, but should offer access to consumers for birth centers in their coverage area

23. AABC Actions • Submitted comments to FTC on barriers to practice for freestanding birth centers, and for the providers who practice in them • Submitted comments to CMS/IRS/Department of Labor on the need to properly enforce the Harkin Amendment • Continue to pressure CMS to issue Rules and Regulations so the Medicaid reimbursement mandate will be appropriately implemented by all states.

24. How Can You Get Involved? • If you are not receiving Medicaid reimbursement for birth center facility and birth attendant fees, then contact us: • jillalliman@birthcenters.org • Fennell.k.s@gmail.com • Or call the AABC office at: • 215-234-8068 info@birthcenters.org

25. References MacDorman, MF, Mathews, TJ, & DeClerq, E. (2014) Trends in out-of-hospital births in the United States, 1990-2012, NCHS Data Brief No 144, Hyattsville, MD: National center for Health Statistics. Rooks, J. P., Weatherby, N. L., Ernst, E. K. M., Stapleton, S., Rosen, D., & Rosenfield, A. (1989). Outcomes of care in birth centers. The national birth center study. New England Journal of Medicine, 321(26), 1804-1811. Stapleton, S., Osborne, C., & Illuzzi, J. (2013). Outcomes of care in birth centers: Demonstration of a durable model. Journal of Midwifery and Women's Health, 58(1),3-14. doi: 10.1111/jmwh.12003/full