The Role of Certified Nurse-Midwives and Certified Midwives in Ensuring Women’s Access to Skilled...

The Role of Certified Nurse-Midwives and Certified Midwives in Ensuring Women’s

Access to Skilled Maternity Care

November 2015Jesse S. Bushman

Director, Advocacy and Government AffairsAmerican College of Nurse-Midwives

Presentation Purpose

• Describe current trends in the maternity care workforce

• Describe the role of CNMs/CMs in addressing maternity care provider shortages

• Put forward specific proposals to address barriers to educating more CNMs/CMs

Defining Terms – CNMs, CMs and CPMsUnless specifically noted, this presentation focuses on the practice of Certified Nurse-Midwives (CNMs) and Certified Midwives (CMs). • CNMs are educated in two disciplines: midwifery and nursing. They earn graduate degrees,

complete a midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME), and pass a national certification examination administered by the American Midwifery Certification Board (AMCB) to receive the professional designation of CNM. CMs are educated in the discipline of midwifery. They earn graduate degrees, meet health and science education requirements, complete a midwifery education program accredited by ACME, and pass the same national certification examination as CNMs to receive the professional designation of CM. There are approximately 11,300 CNMs and CMs in the US and 95% of the births they attend occur in hospitals.

• Certified Professional Midwives (CPMs) may come through one of several educational routes, though they are largely educated through a non-accredited apprenticeship model. There are approximately 1,800 CPMs in the US and 83% of the births they attend occur in an out of hospital setting.

Patient Needs

Projected Numbers of Women, 2015-2060

20142016

20182020

20222024

20262028

20302032

20342036

20382040

20422044

20462048

20502052

20542056

20582060

50,000,000

70,000,000

90,000,000

110,000,000

130,000,000

150,000,000

170,000,000

190,000,000

Age 15+

Age 15-49

Nearly 44 million more women (12 million of childbearing age) will need care in 2060.

Sources in Notes View.

Projected Births in the United States – 2014-206020

14

2016

2018

2020

2022

2024

2026

2028

2030

2032

2034

2036

2038

2040

2042

2044

2046

2048

2050

2052

2054

2056

2058

2060

3,000,000

3,200,000

3,400,000

3,600,000

3,800,000

4,000,000

4,200,000

4,400,000

4,600,000

4,800,000

5,000,000

The Census Bureau estimates a 14% increase in the number of births per year by the end of this timeframe.


Pregnancy and Newborn Care Hospital Discharges Together Far Outnumber Discharges for any Other Major Diagnostic Category

Infectious & Parasitic Diseases

Mental

Kidney & Urinary Tract

Nervous System

Digestive System

Musculoskeletal System & Conn Tissue

Respiratory System

Newborns & Other Neonates

Pregnancy, Childbirth

Circulatory System

0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 5,000,000

1,428,045

1,428,060

1,671,380

2,192,941

3,242,725

3,251,134

3,549,166

3,933,511

4,160,286

4,796,175

Number of Discharges


Workforce Demographics

Maternity Care Providers per 10,000 Women Age 15-49 Years20

00

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

OB/GYNs CNMs/CMs Total

Prov

ider

s pe

r 10,

000

Wom

en

• Many providers are not clinically active.• As the population ages, a larger portion of clinician time will

be taken up rendering primary care to older women.


Maternity Care Providers per 10,000 Women Age 15+ Years20

00

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

OB/GYNs CNMs/CMs Total

Prov

ider

s pe

r 10,

000

Wom

en The ratio has not changed appreciably in 16 years.


First-Year OB/GYN Residents and Newly Certified CNMs/CMs, 1979 - 2014

1979 1987 1993 1998 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 20140

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

1st Year OB/GYN Residents Newly Certified CNMs/CMs

• The number of medical graduates entering OB/GYN residencies has remained relatively flat for three decades.

• New CNMs/CMs have been increasing recently.


Distribution of OB/GYNs by Age

<35 Yrs 35-44 Yrs 45-54 Yrs 55-64 Yrs 65+ Yrs0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

5.20

%

16.6

0%

26.9

0% 31.2

0%

20.1

0%24.7

0% 29.8

0%

25.3

0%

11.8

0% 3.40

%

Males FemalesAge

• More than 15,000 OB/GYNs will likely retire in the next decade, outpacing the rate of new OB/GYNs entering the profession by 20%.

• In 2013, 82.6% of first year OB/GYN residents and interns were women.

• Over time, the OB/GYN profession will become predominantly female.


Multiple Studies Show Female Physicians Work Fewer Hours than Male Physicians

A 2006 AAMC survey found that among physicians who had the option to work part time, 34% of female physicians did so, while only 7% of male physicians did.

Age

Aver

age

Hou

rs W

orke

d pe

r Wee

k, 2

005-

2007


Average Age at which ACOG Fellows Stop Practicing Obstetrics

1992 1996 1999 2003 2006 200925

30

35

40

45

50

55

50.2

48.4

51.2 51 51.7

51.9

39.5

39.2 40

.8 42 43.1

43.8

MalesFemales

Year of Study

Age

(yea

rs)


An Increasing Percent of OB/GYNs are Subspecializing

Obstetrics/Gynecology

Maternal-Fetal

Medicine

Reproductive Endocrinology and Infertility

Gynecologic Oncology

Female Pelvic Medicine and

Reconstructive Surgery

In 2000 7% of OB/GYN residents entered a subspecialty fellowship. In 2012, 19.5% subspecialized. Many OB/GYN subspecialists do not typically attend births.


Bottom Line: Serious Challenges

Static entries into OB/GYN residencies

and increasing subspecialization

Changes in providerdemographics

Increasing patientneeds

Seriouschallenges withensuring skilled

attendants at birth

Using a measure of demand that takes into account population, prevalence and incidence of conditions and disease, as well as rates of insurance coverage, available supply of providers and utilization of care, ACOG has projected a shortage of between 15,723 – 21,723 OB/GYNs by 2050.


Workforce MaldistributionCompounding the Problem

Obstetrician/Gynecologists per 100,000 PopulationData Current as of 2011

Out of 3,142 U.S. Counties, 1,459 (46%) have no OB/GYN.

0

0.1 – 29.9

30.0 +

OB/GYNs per 100,000

ACOG estimates that in 2011, there were 9.5 million people living in a county without a single OB/GYN.


Certified Nurse-Midwives per 100,000 PopulationData Current as of 2011

Out of 3,142 U.S. Counties, 1,758 (56%) have no CNM.

0

0.1 – 4.9

5.0 +

CNMs per 100,000


CNMs and OB/GYNs per 100,000 PopulationData Current as of 2011

Out of 3,142 U.S. Counties, 1,263 (40%) have no CNM or OB.

0

0.1 – 29.9

30.0 +

CNMs & OB/GYNs per 100,000


Patient Population vs.

Workforce Structure

Pregnancy and Risk Stratification

Higher Risk

Pregnancies

Low-Moderate Risk

Pregnancies

There is no uniformly utilized definition of a high risk pregnancy.

• CDC estimates that in 2013, 83% of first time mothers were at low risk for a cesarean birth.1

• The NIH lists several high risk factors affecting 2-10% of pregnancies.2

• More than half of pregnant women in the US are overweight or obese, which increases their risk.3

It is reasonable to assume that the majority of women are low-moderate risk.


Ideal Maternity Care Workforce Structure

Higher Risk

Pregnancies

Low-ModerateRisk

Pregnancies

ProvidersTrained to

Treat Higher Risk

Providers Trained to Care for Women with Low-

Moderate Risk

Ideally, the workforce structure reflects the makeup of the patient population

Current Maternity Care Providers in the US

OB/GYNs

• Medical degree & specialized residency

• Skilled in specialized surgical techniques and primary care

• Trained to attend low, moderate and high risk births and address complications and co-morbidities

• 99.9% of births they attend occur in hospitals.

CNMs/CMs

• Masters Degree• Skilled in fostering

innate, hormonally driven processes of normal physiologic birth for women with low-moderate risk

• Provide primary care to women throughout the lifecycle

• 94.6% of the births they attend occur in hospitals.

CPMs

• Most complete a non-accredited apprenticeship model of education

• Skilled in fostering innate, hormonally driven processes of normal physiologic birth for women of low risk

• Do NOT provide primary care

• 16.9% of births they attend occur in hospitals

Both physicians and midwives are essential to an appropriately structured maternity care workforce.

CNMs/CMs are Appropriate Providers for Low-Moderate Risk Pregnancy

• The Lancet - 2014“Provision of accessible quality midwifery services that are responsive to women’s needs and wants should be part of the design of health-care service delivery and should inform policies related to the composition, development, and distribution of the health workforce in all countries.”

• Cochrane Reviews – 2013 and 2009“The review concludes that most women should be offered midwife-led continuity models of care, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.”

• Women’s Health Issues - 2012“Based on this systematic review, there is moderate to high evidence that CNMs rely less on technology during labor and delivery than do physicians and achieve similar or better outcomes.”


Note that these studies look at midwives meeting standards of the International Confederation of Midwives. CNMs/CMs meet or exceed such standards. It is not clear at this point whether or how many CPMs in the US meet such standards.

Inter-Professional Collaboration – The Ideal

Lower

RiskPatients

ModerateRisk

Patients

HigherRisk

Patients

Midwife-LedCare

Physician-LedCare

Jointly-LedCare

“Ob-gyns and CNMs/CMs are experts in their respective fields of practice and are educated, trained, and licensed, independent providers who may collaborate with each other based on the needs of their patients. Quality of care is enhanced by collegial relationships characterized by mutual respect and trust, as well as professional responsibility and accountability.” Joint Statement of Practice Relations Between Obstetrician/Gynecologists and Certified Nurse-Midwives/Certified Midwives


Current US Maternal Care Workforce Structure

Providers Trained to Treat Higher Risk

(43,732 OB/GYN Fellows/Jr. Fellows*)

Providers trained to care for women with normal

Pregnancies (11,113 CNMs/

CMs and 1,800

CPMs*)

The US maternity care workforce is upside down relative to patient needs.

Higher Risk

Pregnancies(1,500,000 births*)

NormalPregnancies

(2.4 million births**)

Sources in Notes View

How We Got Upside Down:Public Investment in Developing the Maternity Care Workforce

Series1$0

$2,000,000,000

$4,000,000,000

$6,000,000,000

$8,000,000,000

$10,000,000,000

$12,000,000,000

$14,000,000,000

$15,

000,

000,

000

$283

,000

,000

$224

,000

,000

$50,

000,

000

Graduate Medical EducationNational Health Service CorpsNursing Workforce Development (Title VIII of the PHSA)Graduate Nursing Education Demonstration

2014 Expenditures

• Medicare policies say nothing with regard to whether CNMs/CMs can be paid for supervising medical interns, residents or student midwives.

• Teaching physicians are reimbursed for services of medical interns/residents under their supervision.

• While there may be midwives in teaching hospitals who are willing to precept CNM/CM students, these hospitals have a powerful economic incentive to favor education of OB/GYN residents.


How We Got Upside Down:Public Investment in Developing the Maternity Care Workforce

OB/GYN Res-idents

CNN/CM Students

0

1,000

2,000

3,000

4,000

5,000

6,000

1,3582,395

3,6704

Not supported Through GME or GNESupported through GNE or GME

2014

• Medicare GME funds approximately 73% of medical residents. Others may be funded through Medicaid, the VA or commercial GME.

Total GME spending amounts to approximately $127,000 per year for every resident in the U.S.Spending on each OB/GYN resident is reportedly $100,000/year

• The GNE demonstration funded approximately 0.17% of CNM/CM students (available in only one educational program)

Total GNE spending on CNM/CM preceptor sites is approximately $25 per year for every CNM/CM student in the U.S.

Sources and methods in Notes View.

How We Got Upside Down:The National Health Service Corps

Series10

500

1,000

1,500

2,000

2,500

3,0002,

405 2,

873

157

130

51 40

Physicians Working Off a Multi-Year Commitment for Past AwardNPs/PAs/CNMs Working off Multi-Year Commitment for Past AwardOB/GYNs Working Off a Multi-Year Commitment for Past AwardCNMs Working off Multi-Year Commitment for Past AwardOB/GYN Recipients - 2014CNM Recipients - 2014

Indi

vidu

al R

ecip

ient

s NHSC Funding goes to individuals in the form of scholarships or loan repayment, it does not reward clinical preceptors.


Maternal Care Workforce Structure in Several Developed Countries:Midwives per Obstetrician

UK

Australia

Belgium

Finland

France

Denmark

Sweden

Germany

Japan

Netherla

nds

Austria

Korea

Portugal

Italy

Greece

Spain

Luxembourg

Singapore

Canada US0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

19.4

9

15.6

7

9.67

6.54

4.52

4.39

3.94

3.83

3.23

2.57

2.54

1.94

1.57

1.21

1.06

1.00

0.87

0.83

0.40

0.32

• Other developed countries have structured their maternity care workforce to match the needs of their population.

• The midwife-to-obstetrician ratio in the US is one-eighth the median among this group.

Sources listed in Notes View.

Maximizing Midwifery: What is Possible

Finland Iceland Sweden Denmark France US0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

78%

77%

75%

72%

72%

9%Percent of Births Attended by Midwives

Maternal mortality per 100,000 live births (2013)


Infant mortality -probability of dying by age 1 per 1,000 live births (2012)

4 4 4 5 9 28

2 2 2 3 3 6

Reasonable Expansion of Midwifery in the US Context

Alaska

New Mexico

Vermont

New Hampsh

ire

Orego

n0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

30.7

%

26.3

%

22.3

%

20.8

%

19.8

%

Percent of Births Attended by CNMs/CMs/CPMs

• Among the five states with the highest percentage of CNM/CM/CPM attended births in 2013 the average was 24%.

• Nationwide, in 2013, CNMs/CMs/CPMs attended 8.9% of all births.

• If CNMs/CM/CPMs had attended 24% of all 2013 births, they would have attended 594,300 additional births.

• Expansion of midwifery across the country to reflect what is already occurring in these five states would greatly alleviate current pressures on the OB/GYN workforce.

• Such expansion in the US is a reasonable goal.


Physician Time as an Economic Asset

Educating OB/GYNs entails enormous public and personal investment

Using OB/GYNs to attend most normal births underutilizes the economic value of their full skillset and results in a less than optimal return on their personal investment and that of the public

Physician Time as an Economic Asset

When OB/GYNs focus on higher risk mothers, they more fully utilize their skillset, maximizing the return on personal and public investment in their education.

MGMA studies show physician groups that use nurse practitioners are more economically healthy and physicians experience higher compensation because they focus on providing services that only they can render.


Cost and Length of Education: CNMs/CMs as an Answer to the Maternity Care Provider Shortage

OB/GYNs CNMs/CMs0

1

2

3

4

5

6

7

8

4

2

4

0

Years to Complete Education

Medical School or Midwifery SchoolResidency

Medical School CNM/CM Educa-tion

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$131

,556

$53,

505

2081

38

Total Cost of Education

Public Institution Private Institution


Educating midwives is comparatively rapid and economical.

• 13 of the 39 midwifery education programs offer a 2-year MS or the option of a 3-year DNP program.

• Many midwifery programs require 1-year of experience as an RN prior to acceptance into the program.

Average of Public and Private Institution Costs

Note that physicians will likely incur additional expenses during their residency.

Precepting Students: The Most Significant Challenge to Creating More CNMs/CMs

• Precepting students reduces the instructor’s revenue generation and/or increases work hours.

• CNM/CM education programs consistently report that obtaining sufficient preceptors is the primary barrier to educating more CNMs/CMs.


• Preceptors are CNMs/CMs who oversee students and help them experience the hands on, specialized caregiving associated with the midwifery model.

• A large percentage of preceptors are active community clinicians, rather than faculty who work in an educational institution and dedicate their time solely to instruction.

Precepting Students: The Most Significant Challenge to Creating More CNMs/CMs

Series10%

10%20%30%40%50%60%70%80%90%

100%62

%

38%

Most CNM/CM PreceptorsAre Unpaid

Unpaid Midwifery PreceptorsPaid Midwifery Preceptors

• The GNE demonstration is reimbursing CNM preceptors with $15,000/year per student.

• CNM/CM students need precepting during approximately 80% of their two year program.

• Based on GNE expenditures, $24,000 is an appropriate amount needed to precept a student throughout their entire education.


Funding for Maternity Care Workforce Development

What would the public get for an investment of $10 million in developing the maternity care workforce?

GME or precepting costs per practitioner to complete their residency or education

Number of practitioners that could be supported with $10 million

Average number of births attended annually by a single practitioner

Additional births that could be attended annually by the additional skilled practitioners educated as a result of the $10 million investment

Physicians $400,000 25 122* 3,050

CNMs/CMs $24,000 417 70** 29,190

Sources and methods in Notes View.

Supporting Midwifery Education: The ROI

Sources and methodology in Notes View.

Savings from Reduced Rates of Cesarean Birth

Rate of cesarean birth among low-risk women.*

2015 costs for using this provider type to attend 70 low-risk women.**

Medicaid portion of these costs

Commercial portion of these costs

Physicians 14.66% $1,113,884 $309,636 $804,248

CNMs/CMs 8.49% $1,081,191 $300,931 $780,260

• One year ROI for the average Medicaid program is $8,705. During that same period, commercial payers would save $23,988. These savings would accrue from reductions in cesarean births alone.

• Further savings from the midwifery model would accrue based on other aspects of their practice (e.g., reduced use of epidurals).

What Can be Done to Increase the Supply of CNMs/CMs?

Potential Solutions

• Identify Shortage Areas• Funding for the NHSC• Graduate Nurse Education Program• Tax credits for preceptors• Payment for supervised services• Revisions to medical school OB rotations

Getting More Data: H.R. 1209/S. 628“Improving Access to Maternity Care Act of 2015”

• HRSA to designate maternity care health professional shortage areas – locations or populations without sufficient full scope maternity care providers or hospitals or birth center labor and delivery units.

• NHSC scholarships and loans could be available to maternity care providers who agree to work in these new shortage areas.

Potential Solutions: Helping Midwifery Students

Series1$0

$100,000,000

$200,000,000

$300,000,000

$400,000,000

$500,000,000

$600,000,000

$700,000,000

$800,000,000

$900,000,000 $

287,

370,

000

$81

0,00

0,00

0

National Health Service Corps Expen-ditures

FY 2015 AppropriationFY 2016 Presidential Budget

• HRSA’s proposed FY 2016 budget would increase the NHSC field strength by 6,664.

• NHSC helps students afford their education, but does not address the challenges with obtaining more preceptor sites.


Potential Solutions:The Graduate Nurse Education Demonstration

$200 Million given to 5 hospitals over 4 years

Hospitals partner with schools of nursing and community clinical sites…

…to provide clinical education for more advanced practice nurses.


Potential Solutions:Georgia Preceptor Tax Incentive Program

480 hours of precepting to qualify.

Certain medical, NP and PA students.

Each 160 Hours.

$1,000 Tax Deduction.

Maximum deduction = $10,000


Potential Solutions: Reimbursing Midwife Educators

Medicare pays teaching physicians for the services of the interns/residents that they are educating.

CNMs/CMs frequently provide educational oversight to medical interns/residents and student midwives. There is no Medicare policy ensuring payment for services overseen by CNMs/CMs.

Hospitals are discouraged from fostering inter-professional education or supporting midwifery education.

Legislation is needed to ensure that when CNMs/CMs oversee services performed by medical interns/residents or student midwives they can be paid for those services, just as teaching physicians are currently paid.


Changes to Medical Education

• Have medical students get exposure to obstetrics through mechanisms other than direct patient care allowing student midwives that opportunity instead.

• Modifying OB/GYN residency requirements for those who plan to subspecialize in areas that do not involve attending births so that student midwives can have those clinical experiences instead.

Appendix

Data from Risk Adjusted Comparative Studies in the US: % of Cesarean Births

Study 1 -

1992

Study 2 -

1993

Study 3 -

1993

Study 4 -

1994

Study 4 -

1994*

Study 4 -

1994*

Study 5 -

1995

Study 6 -

1997

Study 7 -

2002

Study 7 -

2002*

Study 8 -

2003

Study 9 -

2006*

Study 9 -

2006

Study 10 -

2013

Study 11 -

2015

0%

5%

10%

15%

20%

25%

30%

0.40

%

12.3

0%

4.00

% 12.8

8%

18.0

7%

6.67

%

19.3

0%

13.6

0%

25.8

0%

13.7

0%

19.1

0%

15.6

0%

34.0

0%

16.6

0%

7.93

%

2.14

%

9.75

%

2.00

%

8.51

% 12.7

3%

1.93

%

13.0

0%

8.80

%

15.9

0%

8.40

%

10.7

0%

5.60

%

13.0

0%

12.4

0%

2.44

%

Physician Attended Births Midwife Attended Births

Sources and methods listed in “Notes” view.* Study 4 included overall cesarean rates, as well as C/S for primiparas and multiparas cesarean. * Study 7 included overall cesarean rate and primary cesarean rate.* Study 9 included overall cesarean rate and primary cesarean rate.

Among studies reporting study population and incidence figures, there were 2,435 cesareans among 19,241 births attended by physicians (12.66%) and 304 of 3,746 births attended by Midwives (8.12%). Among all studies the averages of the respective rates are 14.66% and 8.49%

Among the 234 midwifery practices reporting on 97,158 births in ACNM’s 2013 benchmarking data, the median rate of cesarean birth was 11.8%

Average Total Charges and Payments for Maternal and Newborn Care in the U.S. - 2010

Commercial - Vaginal

Commercial - Cesarean

Medicaid - Vaginal

Medicaid - Cesarean

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$32,

093

$51,

125

$29,

800

$50,

373

$18,

329 $2

7,86

6

$9,1

31

$13,

590

Charges Allowed Amount

Inflating these figures by the Medicare Economic Index (MEI) yields an estimate that in 2015 dollars commercial insurers are incurring costs of $18,961 for vaginal births and $28,826 for cesarean births, while Medicaid programs are paying $9,446 and $14,058 respectively.


The Role of Certified Nurse-Midwives and Certified Midwives in Ensuring Women’s Access to Skilled...

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