BILL ANALYSIS Ó
SB 407
Page 1
Date of Hearing: June 23, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB
407 (Morrell) - As Amended June 17, 2015
SENATE VOTE: 36-0
SUBJECT: Comprehensive Perinatal Services Program: licensed
midwives.
SUMMARY: Expands the definition of a comprehensive perinatal
provider, as used in the Comprehensive Perinatal Services
Program (CPSP) for the purposes of reimbursement for Medi-Cal
services, to include a licensed midwife, and authorizes a health
care provider to employ or contract with a licensed midwife, as
specified. Clarifies that this bill is not intended to expand
or revise the scope of practice of licensed midwives.
EXISTING LAW:
1)Establishes the Medi-Cal Program under the direction of the
Department of Health Care Services (DHCS) to provide
qualifying individuals health care and a uniform schedule of
benefits, including comprehensive perinatal services.
2)Requires midwifery services provided by a licensed midwife to
be covered under the Medi-Cal program, to the extent that
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federal financial participation is available.
3)Establishes the CPSP under the direction of the Department of
Public Health (DPH).
4)For the purposes of reimbursement for Medi-Cal services,
defines a comprehensive perinatal provider as any general
practice physician, family practice physician,
obstetrician-gynecologist, pediatrician, certified nurse
midwife (CNM), a physician group, as specified, or any
preferred provider organization or clinic enrolled in the
Medi-Cal program and certified pursuant to the standards of
existing law.
5)Requires comprehensive perinatal providers to schedule visits
with appropriate providers and ensure the provision of
specified services.
6)Authorizes a health care provider to employ or contract with
specified medical practitioners for the purpose of providing
comprehensive perinatal services, including physicians, CNMs,
nurses, nurse practitioners, physician assistants, social
workers, health and childbirth educators, and registered
dietiticians.
FISCAL EFFECT: 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
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(General Fund (GF) and federal funds).
No significant impact to the utilization of services in Medi-Cal
managed care (MCMC) is anticipated. Under current law and
practice, the services that are authorized under the CPSP 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 adding an
additional authorized provider will increase the utilization of
those services. (For example, if a licensed midwife who is
seeing a pregnant woman in MCMC wished to order a covered
service, that midwife could simply work with another eligible
practitioner to order the services.)
Unknown potential increase in costs to provide services in
fee-for-service (FFS) Medi-Cal (local funds and federal funds).
Under current practice, Medi-Cal beneficiaries in FFS can
receive CPSP services from their healthcare provider. In FFS,
those costs are paid for with local funds and federal matching
funds. The state does not provide GF 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. This 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.
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COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, studies have
shown that women who receive comprehensive childbirth,
pre-natal health, and breastfeeding education services during
pregnancy have healthier pregnancies and less complicated
births. The author contends that expectant mothers of all
income levels should have options when deciding where and how
their child is brought into the world, however existing law
limits these choices for low-income individuals by the
exclusion of licensed midwives on the list of eligible
Medi-Cal providers for these services. The author states that
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. The author also
contends that the authorization of licensed midwives as
comprehensive perinatal service providers will save the state
financial resources. The author maintains births at home or
at birth centers with licensed midwives can save the state up
to 80% when compared to the cost of a birth in a hospital.
The author concludes that this bill will expand health care
access and choices to low-income, pregnant women, and drive
down the cost in the state health care system, while also
ensuring safe, quality care for pregnancy and childbirth.
2)BACKGROUND.
a) CPSP. The CPSP, under the direction of DPH, provides a
wide range of services to pregnant Medi-Cal beneficiaries,
from conception through 60 days postpartum. Beneficiaries
receive enhanced nutrition, psychosocial, and health
education services, in addition to standard obstetric
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services under the program. The goals of the CPSP are to:
decrease the incidence of premature births; improve
pregnancy outcomes; give every baby a health start in life;
and, lower health care costs by preventing catastrophic
illness in infants and children. According to DPH, there
are over 1,500 Medi-Cal providers approved to for the CPSP,
in both FFS and MCMC. The CPSP is administered by Federal
Title V Maternal and Child Health block grant funds,
Federal Title XIX Medicaid funds, and the Maternal, Child,
and Adolescent Health program.
b) Midwifery. 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 of the birth meets criteria accepted as normal.
Licensed midwives are authorized to attend cases of normal
pregnancy and childbirth, as defined by existing law, and
provide prenatal, intrapartum, and postpartum care,
including family-planning care, for the mother, and
immediate care for the newborn. Midwives are not
authorized to practice medicine or perform surgery, and are
not authorized to assist childbirths by any artificial,
forcible, or mechanical means. Licensed midwives are
authorized to directly obtain supplies and devices, obtain
and administer drugs and diagnostic tests, order testing,
and receive reports that are necessary to the practice of
midwifery and consistent with his or her scope of practice.
As of December 31, 2014, there were 332 licensed midwives
in California.
CNMs are a different designation of the midwifery
profession, licensed by the California Board of Registered
Nursing. CNMs are registered nurses who acquired
additional training in the field of obstetrics and are
certified by the American College of Nurse Midwives. These
professionals commonly work in hospitals and birthing
centers that are licensed by the state. CNMs have an
independent scope of practice and work in collaboration and
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consultation with physicians, depending on the medical
needs of the individual woman or infant and the practice
setting. Existing law requires nurse-midwifery care to be
performed under the supervision of a licensed physician and
surgeon, but supervision does not require physical presence
of the physician. All complications are referred to a
physician immediately and CNMs provide emergency care until
physician assistance can be obtained. As of March 1, 2015,
there were 1,136 CNMs in California.
3)SUPPORT. The California Association of Midwives, the sponsor
of this bill, states there is an increasing demand for
prenatal care with midwives in birth centers, and that this
bill will allow more California mothers to receive care in
safe, specialized settings. The sponsor contends many rural
and medically underserved communities have no health care
providers who accept CPSP, and licensed midwives are ready to
fill this gap.
Supporters of this bill state allowing licensed midwives to
offer comprehensive perinatal services lowers state health
care costs, and makes quality prenatal health care possible
for a larger portion of the state's low-income pregnant women
and their infants. Supporters also contend that by increasing
the number of maternity care providers who accept Medi-Cal,
this bill will help rural communities, where families on
Medi-Cal have limited options for maternity care. Supporters
state this bill 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 state taxpayers.
4)OPPOSITION. The American Congress of Obstetricians and
Gynecologists, District IX (California) is opposed unless
amended to a prior version of this bill, stating that licensed
midwives do not have the qualifications to be a lead CPSP;
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however the organization has no opposition to adding licensed
midwives as a provider of comprehensive perinatal services.
The opposition writes it would remove its opposition if the
language only added licensed midwives as a provider of
services in subsection (e) of this bill's provisions, and
deleted the right to lead from subsection (a).
5)RELATED LEGISLATION.
a) AB 1306 (Burke) removes the physician supervision
requirement for CNMs allowing them to manage a full range
of primary health services, perform peripartum care,
provide emergency care when a physician is not present and
perform and repair episiotomies in all practice settings.
AB 1306 is currently pending referral at the Senate Desk.
b) SB 408 (Morrell) establishes minimum training
requirements and duties that may be performed by a midwife
assistant. SB 408 is currently in the Assembly Business
and Professions Committee.
6)PREVIOUS LEGISLATION.
a) AB 1308 (Bonilla), Chapter 665, Statutes of 2013,
authorizes a midwife to directly obtain supplies and
devices, obtain and administer drugs and diagnostic tests,
order testing and receive reports that are necessary to
his/her practice of midwifery and consistent with his/her
scope of practice; expands the disclosures required to be
made by a midwife to a prospective client to include the
specific procedures that warrant consultation with a
physician and surgeon; and, makes other correcting and
conforming changes.
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b) SB 614 (Figueroa), Chapter 614, Statutes of 2005,
expands the scope of practice for CNMs to include
furnishing or ordering Schedule II controlled substances
outside a hospital, as specified.
7)DOUBLE REFFERAL. This bill has been doubled referred. Upon
successful passage of this Committee, this bill will be
referred to the Assembly Business and Professions Committee.
REGISTERED SUPPORT / OPPOSITION:
Support
California Association of Midwives (sponsor)
Association of California Healthcare Districts
California Black Health Network
California Families for Access to Midwives
Capital OB/GYN, Inc. (prior version)
Central California Alliance for Health (prior version)
Monterey County Board of Supervisors (prior version)
Planned Parenthood Affiliates of California
Santa Cruz County
WellSpace Health (prior version)
Two individuals
Opposition
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American Congress of Obstetricians and Gynecologists (prior
version)
Analysis Prepared by:An-Chi Tsou / HEALTH / (916)
319-2097