BILL ANALYSIS                                                                                                                                                                                                    Ó






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          |SENATE RULES COMMITTEE            |                        SB 407|
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                                    THIRD READING


          Bill No:  SB 407
          Author:   Morrell (R)
          Amended:  4/21/15  
          Vote:     21  

           SENATE HEALTH COMMITTEE:  9-0, 4/15/15
           AYES:  Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,  
            Pan, Roth, Wolk

           SENATE APPROPRIATIONS COMMITTEE:  7-0, 5/11/15
           AYES:  Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen

           SUBJECT:   Comprehensive Perinatal Services Program:  licensed  
                     midwives


          SOURCE:    Author


          DIGEST:  This bill expands the definition of "comprehensive  
          perinatal provider" as used in the Comprehensive Perinatal  
          Services Program (CPSP) to include a licensed midwife.   
          Authorizes a health care provider to employ or contract with  
          licensed midwives for the purpose of providing comprehensive  
          perinatal services in the CPSP.


          ANALYSIS:


          Existing law:
          
          1)Establishes the Medi-Cal program, which is administered by the  








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            Department of Health Care Services (DHCS), under which  
            qualified low-income individuals receive health care services,  
            including comprehensive perinatal services. Comprehensive  
            perinatal services are a Medi-Cal benefit, as provided through  
            an agreement with a CPSP designated health care provider  
            meeting the standards developed by the Department of Public  
            Health (DPH), and subject to utilization controls.

          2)Requires, to the extent that federal financial participation  
            is available, that midwifery services provided by a licensed  
            midwife are covered under the Medi-Cal program. 

          3)Establishes the CPSP, administered by DPH, to maintain, to the  
            extent resources are available, a permanent, statewide  
            community-based comprehensive perinatal system to provide care  
            and services to low-income pregnant women and their infants  
            who are considered underserved in terms of comprehensive  
            perinatal care. 

          4)Defines, for purposes of the CPSP, a "comprehensive perinatal  
            provider" to mean any general practice physician, family  
            practice physician, obstetrician-gynecologist, pediatrician,  
            certified nurse midwife, a group, any of whose members is one  
            of the above-named physicians, or any preferred provider  
            organization or clinic enrolled in the Medi-Cal program and  
            CPSP certified. 

          5)Authorizes, for the purpose of providing comprehensive  
            perinatal services, a health care provider to employ or  
            contract specified practitioners, including physicians,  
            certified nurse midwives, nurses, nurse practitioners,  
            physician assistants, social workers, health and childbirth  
            educations and registered dieticians.
          
          This bill:

          1)Expands the definition of "comprehensive perinatal provider"  
            as used in the CPSP to include a licensed midwife, thereby  
            allowing a licensed midwife to receive reimbursement for CPSP  
            services.  

          2)Authorizes a health care provider to employ or contract with  
            licensed midwives for the purpose of providing comprehensive  
            perinatal services in the CPSP. 







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          3)Prohibits this bill from being construed to revise or expand  
            the scope of practice of licensed midwives.

          4)Requires DHCS to commence, no later than March 1, 2016, the  
            revision of existing regulations, in accordance with the  
            Administrative Procedure Act, as it determines necessary for  
            the implementation of this bill.
          





          Comments:


          1)Author's statement.  According to the author, licensed  
            midwives provide comprehensive childbirth, prenatal health,  
            and breastfeeding education to their patients. Studies have  
            shown that women who receive these services during pregnancy  
            have healthier pregnancies and less complicated births. This  
            bill expands health care access by adding licensed midwives to  
            the list of Medi-Cal-eligible comprehensive perinatal services  
            providers. Expectant mothers of all income levels should have  
            options when it comes to deciding where and how they bring  
            their children into the world. The current non-inclusion of  
            licensed midwives from the list of eligible Medi-Cal providers  
            limits these choices for low-income individuals. This bill  
            would expand the choices available to low-income, pregnant  
            women. Increasing the number of comprehensive perinatal  
            Medi-Cal providers alleviates wait times and access issues  
            within the overall perinatal health delivery system, allowing  
            women to receive timely and personalized care. Authorizing  
            licensed midwives as Medi-Cal providers of comprehensive  
            perinatal services will help all low-income women, even if  
            they do not choose a licensed midwife as their provider.  
            Lastly, authorizing licensed midwives as comprehensive  
            perinatal services providers will save the state resources. A  
            home birth or "birth center" birth with a licensed midwife can  
            save the state up to 80 percent when compared to the cost of a  
            hospital birth. Increasing access to licensed midwives drives  
            down the cost in the state health care system while also  
            ensuring safe, quality care for pregnancy and childbirth.







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          2)CPSP.  Under CPSP, Medi-Cal-eligible women receive  
            comprehensive services, including prenatal care, health  
            education, nutrition services, and psychosocial support for up  
            to 60 days after delivery of their infants. Local health  
            department staff offer technical assistance and consultation  
            to potential and approved providers in the implementation of  
            CPSP program standards. The Maternal Child and Adolescent  
            Health Program in DPH develops standards and policies,  
            provides technical assistance and consultation to the local  
            health perinatal services coordinators, and maintains an  
            ongoing program of training for all CPSP practitioners  
            throughout the state.


            CPSP provides reimbursement for some services that Medi-Cal  
            does not provide reimbursement for, including early entry into  
            care, vitamins, case coordination, a 10th antepartum visit,  
            and support services. The goals of the CPSP program are to  
            decrease and maintain the decreased level of perinatal,  
            maternal and infant mortality and morbidity and to support  
            methods of providing comprehensive prenatal care that prevent  
            prematurity and the incidence of low birth weight infants.


          3)Licensed midwives.  Licensed midwives are licensed by the  
            Medical Board of California and practice under the Midwifery  
            Practice Act, which specifies the requirements for licensure  
            and the scope of practice for a licensed midwife. There are  
            332 licensed midwives in California as of December 31, 2014.  
            Existing law defines the practice of midwifery as the  
            furthering or undertaking by any licensed midwife to assist a  
            woman in childbirth as long as progress meets criteria  
            accepted as normal. AB 1308 (Bonilla, Chapter 665, Statutes of  
            2013) made significant amendments to various Business and  
            Professions Code sections governing the practice of midwifery  
            in California. 


            Licensed midwives can practice without physician supervision,  
            and their scope of practice allows them to attend cases of  
            normal pregnancy and childbirth (as defined), and provide  
            prenatal, intrapartum, and postpartum care, including  







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            family-planning care, for the mother, and immediate care for  
            the newborn. A licensed midwife is authorized to directly  
            obtain supplies and devices, obtain and administer drugs and  
            diagnostic tests, order testing, and receive reports that are  
            necessary to his or her practice of midwifery and consistent  
            with his or her scope of practice. The scope of practice of  
            midwifery does not include the assisting of childbirth by any  
            artificial, forcible, or mechanical means, and licensed  
            midwives are not authorized to practice medicine, perform  
            surgery or perform abortions.


            Licensed midwives are a different licensure category than  
            certified nurse midwives (certified nurse midwives are  
            included as CPSP providers under current law). Certified nurse  
            midwives are licensed and regulated by the Board of Registered  
            Nursing and practice under physician supervision. A certified  
            nurse-midwife, under the supervision of a physician, is  
            allowed to attend cases of normal childbirth and to provide  
            prenatal, intrapartum, and postpartum care, including  
            family-planning care, for the mother, and immediate care for  
            the newborn. As of March 1, 2015, there were 1,316 certified  
            nurse midwives in California.


          


          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   No

          According to the Senate Appropriations Committee, one-time  
          costs, less than $50,000, to revise existing regulations and  
          develop a state plan amendment to allow licensed midwives to  
          provide services in the CPSP, under Medi-Cal (General Fund and  
          federal funds).

          According to the Senate Appropriations Committee, no significant  
          impact to the utilization of services in the Medi-Cal managed  
          care program is anticipated. Under current law and practice, the  
          services that are authorized under the Comprehensive Perinatal  
          Services Program are required benefits for Medi-Cal managed care  
          beneficiaries. Because those beneficiaries already have access  
          to those services through managed care, it is not likely that  







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          adding an additional authorized provider will increased the  
          utilization of those services. (For example, if a licensed  
          midwife who is seeing a pregnant woman in Medi-Cal managed care  
          wished to order a covered service, that midwife could simply  
          work with another eligible practitioner to order the services.)

          According to the Senate Appropriations Committee, unknown  
          potential increase in costs to provide services in the  
          fee-for-service Medi-Cal system (local funds and federal funds).  
          Under current practice, Medi-Cal beneficiaries in  
          fee-for-service can receive Comprehensive Perinatal Services  
          Program services from their health care provider. In the  
          fee-for-service system, those costs are paid for with local  
          funds and federal matching funds. The state does not provide  
          General Fund support for those costs. It is possible that there  
          could be an increase in the utilization of services under this  
          bill, to the extent that Medi-Cal beneficiaries are being  
          provided care by a licensed midwife and it is not easy for that  
          provider to get another authorized provider to order the  
          specified services. The extent to which the fact that licensed  
          midwives are not eligible to provide the specified services is  
          actually a barrier to women getting those services in not known,  
          so it is difficult to estimate whether there would actually be  
          an increase is service utilization. The bill does not create a  
          new program or mandate a higher level of service (the legal test  
          for whether a state mandate is reimbursable). Therefore, it is  
          not likely that the state would be required to reimburse  
          counties for any increased costs under the bill, even if  
          utilization of services does increase.


          SUPPORT:   (Verified5/12/15)


          American Nurses Association California
          California Association of Midwives
          California Black Health Network
          California Families for Access to Midwives
          California Nurse-Midwives Association
          Capital OB/GYN, Inc.
          Central California Alliance for Health
          Improving Birth, Inc.
          Monterey County Board of Supervisors
          Wellspace Health







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          Two individuals



          OPPOSITION:   (Verified5/12/15)




          American College of Obstetricians and Gynecologists Region IV


          ARGUMENTS IN SUPPORT: The California Association of Midwives  
          (CAW) writes that licensed midwives work in various health care  
          settings and have specialized training in attending births in  
          out-of-hospital settings, such as California's licensed  
          alternative birth centers. CAW argues the passage of this bill  
          will allow more California mothers to receive care in these  
          safe, specialized settings as there is increasing consumer  
          demand for prenatal care with midwives in birth centers. CAW  
          states this bill will allow LMs to help fill the shortage of  
          maternity care providers who take Medi-Cal and CPSP as many  
          rural and medically underserved communities have no health care  
          provider who accepts CPSP, while licensed midwives are waiting  
          to fill that gap. CAW concludes that pregnant women who receive  
          prenatal care with licensed midwives have reduced rates of  
          costly pregnancy complications such as prematurity and cesarean  
          section, which could lead to significant cost savings for the  
          state.
          
          The California Nurse-Midwives Association writes in support that  
          this bill will increase the number of maternity care providers  
          who accept Medi-Cal. According to a recent report, California  
          ranks second lowest in percentage of physicians currently  
          accepting new Medi-Cal patients, at a rate of 54 percent.  
          California's underserved deserve better health care access.  
          Increasing CPSP providers will make it easier for women to  
          receive quality prenatal care early in their pregnancy resulting  
          in better health outcomes for themselves and their babies, at a  
          lower cost to the taxpayers.
          


          ARGUMENTS IN OPPOSITION:     The American College of  







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          Obstetricians and Gynecologists Region IV (ACOG) writes it is  
          opposed unless amended to this bill, arguing they do not believe  
          the licensed midwives have the qualifications to be the lead  
          "comprehensive perinatal provider" under CPSP. ACOG writes that  
          it recognize the licensed midwives have a barrier to providing  
          care through licensed midwife-owned alternative birth centers,  
          that of the requirement to be a CPSP provider. ACOG writes they  
          believe licensed midwives' problem with regard to the  
          alternative birth centers could be remedied by adding them as  
          practitioners (which this bill does) as the alternative birth  
          center licensing law requires that licensed midwives be a  
          provider of comprehensive services, but not the lead  
          comprehensive perinatal provider. ACOG indicates it would remove  
          its opposition to deleting licensed midwives from the definition  
          of a "comprehensive perinatal provider."

          Prepared by:Jonas Austin / SFA / (916) 651-1520
          5/13/15 19:07:58


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