Home-birth law fails to deliver

By CRAIG IDLEBROOK

Contributing writer

 

DANBY, Vt.
It was supposed to be a watershed moment for home-birth midwives like Heather Whitley.

Last year, Vermont legislators responded to a grassroots campaign to bring home births more into the mainstream medical system, passing a bill that requires private health insurers to cover deliveries by certified professional midwives.

Babies delivered at home currently account for only 3 percent of births in Vermont. But that percentage, the highest in the nation, has been rising in recent years as more women try to avoid what they see as unnecessary medical interventions, such as Cesarean-section deliveries, that have become common in hospital births.

In the past, Vermont women who wanted to give birth at home often could not get private insurance companies to pay for professional midwifery services. If they wanted a midwife, they had to pay out of pocket.

Whitley hoped the new law would clear the way for more women from Rutland and Bennington counties to come to her practice, Sego Lily Midwifery.

“I was very optimistic and excited,” Whitley said.

But she and many midwives across the state soon found that, despite the new law, Blue Cross Blue Shield Vermont, the state’s largest private insurer, was refusing to reimburse for most home births.

Since the new law took effect in October, more than two dozen women have complained to the Vermont Public Interest Research Group, an advocacy group that had pushed for the law, saying Blue Cross wasn’t complying.

Some national insurance companies like Cigna did start paying for home-birth midwives, and Vermont’s Medicaid system has covered home births for years.

But Whitely pointed out that Blue Cross Blue Shield is the insurance provider for the biggest employers in the region. Because of the company’s policy, she lost clients who couldn’t afford to pay for her services without insurance.

Other clients, she said, had to jump through administrative hoops. One client opted instead for a hospital birth, while another dropped her coverage and applied for Medicaid so she could get a home birth covered.

Across the state, advocates say, women went ahead and gave birth at home, then argued in vain with Blue Cross Blue Shield Vermont to get their midwife care covered after the fact.

“There’s nothing worse than a woman in the postpartum period … to have to be battling with her insurance company over the paperwork,” Whitley said.

Differing standards?

In late January, after weeks of intense negotiations among health-care advocates, Blue Cross Blue Shield volunteered legislative language it said would allow insurance companies to include certified professional midwives in their HMO networks without requiring the midwives to carry malpractice insurance.

But until the Legislature actually passes that language, the company is refusing to cover home births.

Home-birth advocates said they were pleased that the company has tentatively agreed to a legislative fix. But they still are bewildered by the way the original legislation, which was supposed to mandate coverage for home births, didn’t accomplish that in reality.

Before last year’s law passed, insurance companies had been providing coverage for some home births, including those attended by certified nurse midwives, who have nursing credentials and official connections to hospitals. Insurers also covered the services of midwives who had other medical degrees, like naturopathic doctors, said Cassandra Gekas, a health care advocate at the Vermont Public Interest Research Group.

People like Gekas pushed for last year’s law because many insurance companies had balked at reimbursing for home births attended by certified professional midwives, who lack medical degrees although they go through standardized training and receive certification from a national midwife organization.

Last year’s insurance law, which also mandated greater oversight for professional midwives, was designed to erase that distinction so that both groups of midwives could get paid by insurance companies, Gekas said.

Some health care advocates pushed for the law because they believe home births reduce the risk of unnecessary medical interventions at hospitals. But the bill faced stiff opposition from the Vermont Medical Society, which claimed home births are more risky than hospital births.

After the bill passed, Gekas said she hadn’t expected that there’d be any serious problem carrying out the new policy.

“The intent of the law was very clear,” she said.

But a debate quickly erupted over how insurance companies should implement the new law.

Malpractice coverage at issue

Blue Cross Blue Shield Vermont at first argued that the law allowed insurance companies to refuse to cover home births unless the attending midwives had a written agreement with a practicing physician. Home-birth advocates cried foul, saying a similar law wound up virtually banning midwife-attended home births in neighboring New York until it was repealed in 2010.

Blue Cross backed off from this initial interpretation, but it then argued that it couldn’t include home-birth midwives in its network unless the midwives carried malpractice insurance. Blue Cross requires all its network providers to carry malpractice coverage, from chiropractors to ophthalmologists, said Kevin Goddard, a spokesman for the insurer.

Insurance companies are required by the state to maintain quality control, and one important way to do that is to require malpractice insurance, Goddard said.

“What we didn’t want to do is make an exception in our guidelines,” he said.

Gekas said she understands the dilemma the insurance company faced, but she said home-birth midwives just don’t do enough business to be able to afford malpractice insurance. Nor do they receive the same level of reimbursement that doctors receive for births, she said.

Whitley, for example, estimated the cost of malpractice insurance would consume about 30 percent of her income before taxes.

Gekas pointed out to state regulators that Vermont allows insurance companies to reimburse for medical services outside of their network coverage if those services aren’t available otherwise in a geographic area. For example, if a foot surgeon is not in an insurance company’s network but is the only foot surgeon available in a wide area, the state’s regulations require an insurance company to reimburse for the surgeon’s services.

Gekas argued that under this standard, home births would be covered even if not in a network.

But the state Department of Banking, Insurance, Securities and Health Care Administration ruled against this interpretation, saying home-birth midwives provide the same service as obstetricians, with the location of the services delivered being the only difference between the two groups of providers.

This was a surprise to home-birth advocates, who had been arguing for years that the state should view the two professions as equals, only to be told the opposite.

Although a tentative compromise has now been reached, not everyone may be happy with it.

Gekas said the legislative fix now being proposed would provide cover for insurance companies whose other providers would rebel if the insurance company made such an exception independently.

But Madeleine Morgan, the deputy executive vice president of the Vermont Medical Society, said Blue Cross Blue Shield had not contacted her organization about the proposed legislative changes. She said she’s concerned such an exception would create an unlevel playing field.

“We think it’s important that everybody be held to a standard of quality of care,” Morgan said.

Despite this objection, Gekas said she is confident the new rules can pass before the legislative session ends in April. She hopes to have the changes included in what are called “housekeeping” bills, those aimed at fixing legislative language rather than making new laws.