BILL ANALYSIS Ó
SB 407
Page 1
Date of Hearing: June 30, 2015
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Susan Bonilla, Chair
SB 407(Morrell) - As Amended June 17, 2015
SENATE VOTE: 36-0
NOTE: This bill is double-referred, having been previously heard
by the Assembly Health Committee on June 23, 2015, and approved
by a 17-0 vote.
SUBJECT: Comprehensive Perinatal Services Program: licensed
midwives.
SUMMARY: Authorizes licensed midwives to provide services under
the Comprehensive Perinatal Services Program.
EXISTING LAW:
1)Establishes the Licensed Midwifery Practice Act of 1993 (Act),
which provides for the licensure of midwives by the Medical
Board of California (MBC). (Business and Professions Code
(BPC) Section 2505 et seq.)
2)Provides that the license to practice midwifery authorizes the
holder to attend cases of normal pregnancy and childbirth and
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to provide prenatal, intrapartum, and postpartum care,
including family-planning care, for the mother, and immediate
care for the newborn. (BPC Section 2507(a))
3)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, as specified. (BPC Section 2507(b))
4)Establishes the Medi-Cal program, which is administered by the
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 State Department of
Public Health (DPH), and subject to utilization controls.
(Welfare and Institutions Code (WIC) Section 14000 et seq.,
14132(u))
5)Requires, to the extent that federal financial participation
is available, and, subject to utilization controls, that
midwifery services provided by a licensed midwife are covered
under the Medi-Cal program. (WIC Section 14132.39)
6)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.
7)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
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of the above-named physicians, or any preferred provider
organization or clinic enrolled in the Medi-Cal program and
CPSP certified.
8)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:
9)Expands the definition of "comprehensive perinatal provider"
as used in the CPSP to include a licensed midwife.
10)Authorizes a health care provider to employ or contract with
licensed midwives for the purpose of providing comprehensive
perinatal services in the CPSP.
11)Provides that its provisions shall not be construed to revise
or expand the scope of practice of licensed midwives, as
specified.
12)Requires the Department of Health Care Services 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.
13)Makes conforming changes.
FISCAL EFFECT: According to the Senate Appropriations Committee
Analysis dated May 11, 2015:
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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 Comprehensive
Perinatal Services Program, under Medi-Cal (General Fund and
federal funds).
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 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.)
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
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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.
COMMENTS:
Purpose. This bill is sponsored by the California Association
of Midwives . According to the author, "Licensed midwives
provide comprehensive childbirth, prenatal health, and
breastfeeding education to their clients. 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?.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% when compared to the cost of a hospital birth.
Increasing access to licensed midwives drives down the cost in
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the state health care system while also ensuring safe, quality
care for pregnancy and childbirth."
Comprehensive Perinatal Services Program (CPSP). According to
the DPH, the CPSP provides a wide range of culturally competent
services to Medi-Cal pregnant women, from conception through 60
days postpartum. In addition to standard obstetric services,
women receive enhanced services in the areas of nutrition,
psychosocial and health education. The Legislature enacted CPSP
in 1984 in response to findings from the OB Access Project,
which found that a comprehensive approach reduced both low birth
weight rates and health care costs in women and infants. CPSP
became a Medi-Cal benefit in 1987. Medi-Cal providers who
provide services to pregnant women may apply to become a CPSP
provider. Medi-Cal Managed Health Care Plans are required to
provide access to CPSP-comparable services for pregnant Medi-Cal
eligible recipients. The goals of the CPSP are to decrease
perinatal, maternal and infant mortality and morbidity and
support methods of providing comprehensive prenatal care that
prevent prematurity and the incidence of low birth weight
infants. According to DPH, being a CPSP provider leads to
better patient outcomes and offers higher reimbursement because
it covers support services that Medi-Cal does not cover, and
more staffing flexibility.
Under CPSP, the provider is required to ensure the provision of
the following services either through the provider's own service
or through subcontracts or referrals to other providers: 1) a
psychosocial assessment and when appropriate, referrals to
counseling; 2) nutrition assessments and when appropriate,
referral to counseling on food supplement programs, vitamins,
and breast-feeding; and 3) health, childbirth, and parenting
education. For example, some of the reimbursable services
include: early entry into care, vitamins, case coordination, a
10th antepartum visit, and support services.
Currently, the following health care practitioners can become a
CPSP provider if they have an active National Provider
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Identifier Number and are an active Medi-Cal provider in good
standing with Medi-Cal and their licensing board: 1) physicians
and surgeons, including general practitioners, family practice
physicians, pediatricians, or obstetrician-gynecologists; 2)
Certified Nurse Midwives (CNMs); 3) physician medical groups; 4)
clinics; and 5) preferred provider organizations. All CPSP
providers and the following CPSP practitioners may deliver CPSP
services under the supervision of a physician and surgeon and as
permitted by the scope of practice, if licensed: 1) registered
nurses; 2) nurse practitioners; 3) physician assistants; 4)
social workers; 5) health and childbirth educators; and 7)
registered dieticians.
According to the DPH, over 1,500 Medi-Cal providers are approved
as CPSP providers, in both the fee-for-service and managed care
systems. Local health department staff offer technical
assistance and consultation to potential and approved providers
in the implementation of CPSP program standards. The Maternal,
Child & Adolescent Health Program develops standards and
policies; provides technical assistance and consultation to the
local health perinatal services coordinators; and, maintains an
ongoing training program for CPSP practitioners.
Licensing Midwives. A "licensed midwife" is an individual who
has been issued a license to practice midwifery by the MBC. The
practice of midwifery authorizes the licensee to attend cases of
normal pregnancy and childbirth, and to provide prenatal,
intrapartum, and postpartum care, including family-planning
care, for the mother, and immediate care for the newborn without
physician supervision. AB 1308 (Bonilla), Chapter 665, Statutes
of 2013, made numerous changes to the Act, and removed the
statutory requirement for a licensed midwife to practice under
the supervision of a physician and surgeon and instead specified
that a midwife may assist in normal pregnancy and birth. A
licensed midwife is also 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
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her practice of midwifery and consistent with his or her scope
of practice.
Licensed midwives, who have achieved the required educational
and clinical experience in midwifery (including completing a
three-year postsecondary education program in an accredited
midwifery school approved by the MBC) or met the challenge
requirements (obtaining credit by examination for previous
education and clinical experience -this option is no longer
available as of January 1, 2015), must pass the North American
Registry of Midwives' (NARM) comprehensive examination. After
successful completion of this examination, prospective
applicants are designated as a "certified professional midwife"
and are eligible to submit an application for California
midwifery licensure.
The profession of midwifery also has another designation, that
of "certified nurse-midwife" (CNM). CNMs are licensed by the
Board of Registered Nursing and are registered nurses who
acquired additional training in the field of obstetrics and are
certified by the American College of Nurse Midwives (ACNM).
CNMs usually work in hospitals and birthing centers that also
are licensed by the state. The nurse-midwifery certificate
authorizes the CNM to provide prenatal, intrapartum, and
postpartum care, including interconception care and family
planning, under physician supervision - however, physical
presence is not required. The nurse-midwifery certificate also
authorizes the CNM to attend cases of normal childbirth on his
or her own responsibility, as well as immediate care for the
newborn.
Prior Related Legislation. AB 1308 (Bonilla) Chapter 665,
Statutes of 2013, removed the statutory requirement for a
licensed midwife to practice under the supervision of a
physician and surgeon who has current practice or training in
obstetrics, and instead specified that a midwife may assist in
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normal pregnancy and birth, and for pregnancies that are not
considered normal, the midwife must refer the client to a
physician and surgeon for an examination. AB 1308 also
authorized 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 or her practice of
midwifery and consistent with his or her scope of practice, and
expanded 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.
SB 1638 (Figueroa), Chapter 536, Statutes of 2006,required the
MBC to create and appoint the Midwifery Advisory Council, and
required licensed midwives to make annual reports to the Office
of Statewide Health Planning and Development containing
specified information regarding the births the midwife assisted
in delivering during the prior year.
SB 1950 (Figueroa), Chapter 1085, Statutes of 2002, required the
MBC to adopt regulations by July 1, 2003, defining the
appropriate standard of care and level of supervision required
for the practice of midwifery.
ARGUMENTS IN SUPPORT:
According to the Association of California Health Care
Districts , "Studies have shown that women who receive care from
those practicing midwifery have healthier pregnancies and less
complicated births. Allowing licensed midwives to offer
comprehensive perinatal services makes quality prenatal
healthcare possible for a larger portion of the state's
low-income pregnant women and their infants?This approach to
expanding Medi-Cal eligible service providers will also aid in
decreasing health care costs. Offering the option for pregnant
women to receive care from a midwife in a home birth or birth
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center environment will save the state the comparatively high
hospital birth costs. Increasing access to quality licensed
midwives is beneficial not only for families who choose a
midwife, but also for the state health care system as a whole."
According to the Santa Cruz County Board of Supervisors ,"[This
bill] will increase the number of maternity care providers who
accept Medi-Cal. This is especially important in rural
communities where families on Medi-Cal have limited options for
maternity care. 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 taxpayers."
ARGUMENTS IN OPPOSITION:
According to the American Congress of Obstetricians and
Gynecologists, District IX , "We do not believe the Licensed
Midwives have the qualifications to be the lead CPSP
Providers?.Education and training of Licensed Midwives has been
inconsistent through the years and until AB 1308, that
inconsistency included apprentice trained midwives. The
apprentice trained already licensed midwives were grandmothered
in. Their backgrounds are very different from Certified Nurse
Midwives. In the future that may change but historically the
training and education has varied widely. If the problem they
are trying to address is to be able to have licensed LM-owned
birth centers, we do believe their problem could be remedied by
adding them as practitioners?.Under Alternative Birth Center
licensing law?, all that is required is that they are a provider
of comprehensive services.?We have no opposition to adding
Licensed Midwives as a provider of services?versus the
coordinator of all levels of services as a CPSP Provider?."
POLICY ISSUE
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AB 1308 (Bonilla), Chapter 665, Statutes of 2013, made numerous
changes to the Act, and removed the statutory requirement for a
licensed midwife to practice under the supervision of a
physician and surgeon who has current practice or training in
obstetrics, and instead specified that a midwife may assist in
normal pregnancy and birth. For pregnancies that are not
considered normal, the midwife must refer the client to a
physician and surgeon for an examination. Under existing law, a
pregnancy is not normal if there is: 1) any "preexisting
maternal disease or condition likely to affect the pregnancy";
or 2) if there is "significant disease arising from the
pregnancy." AB 1308 directed the MBC to adopt regulations
further specifying those conditions, and those regulations are
still pending. Because these regulations have not yet been
finalized, it may be beneficial to delay the operative date of
the provision that would authorize a licensed midwife to serve
as a CPSP provider, rather than a practitioner, until those
regulations have been adopted.
AMENDMENTS
On page 2, line 8, strike the following: licensed midwife
On page 4, add subdivision (l) as follows: (l) Notwithstanding
subdivision (a), on the effective date of the regulations
adopted by the Medical Board of California pursuant to Section
2507 of the Business and Professions Code, a licensed midwife
shall be eligible to serve as a comprehensive perinatal
provider.
REGISTERED SUPPORT:
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California Association of Midwives (sponsor)
Association of California Healthcare Districts
California Black Health Network
Central California Alliance for Health
California Nurse-Midwives Association
Monterey County Board of Supervisors
Santa Cruz County Board of Supervisors
Wellspace Health
Associate Professor of Department of Obstetrics & Gynecology, UC
Davis School of Medicine
President, Capitol OB/GYN, Inc.
REGISTERED OPPOSITION:
American Congress of Obstetricians and Gynecologists, District
IX
Analysis Prepared by:Eunie Linden / B. & P. / (916)
319-3301