BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | SB 407| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- 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 SB 407 Page 2 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. SB 407 Page 3 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. SB 407 Page 4 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 SB 407 Page 5 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 SB 407 Page 6 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 SB 407 Page 7 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 SB 407 Page 8 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 **** END ****