November 2015 Jesse S Bushman Director Advocacy and Government Affairs American College of NurseMidwives Presentation Purpose Describe current trends in the maternity care workforce Describe the role of CNMsCMs in addressing maternity care provider shortages ID: 529785
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Slide1
The Role of Certified Nurse-Midwives and Certified Midwives in Ensuring Women’s Access to Skilled Maternity Care
November 2015
Jesse S. Bushman
Director, Advocacy and Government Affairs
American College of Nurse-MidwivesSlide2
Presentation Purpose
Describe current trends in the maternity care workforce
Describe the role of CNMs/CMs in addressing maternity care provider shortages
Put forward specific proposals to address barriers to educating more CNMs/CMsSlide3
Defining Terms – CNMs, CMs and CPMs
Unless specifically noted, this presentation focuses on the practice of Certified Nurse-Midwives (CNMs) and Certified Midwives (CMs).
CNMs are educated in two disciplines: midwifery and nursing. They earn graduate degrees, complete a midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME), and pass a national certification examination administered by the American Midwifery Certification Board (AMCB) to receive the professional designation of CNM. CMs are educated in the discipline of midwifery. They earn graduate degrees, meet health and science education requirements, complete a midwifery education program accredited by ACME, and pass the same national certification examination as CNMs to receive the professional designation of CM.
There are approximately 11,300 CNMs and CMs in the US and 95% of the births they attend occur in hospitals.
Certified Professional Midwives (CPMs) may come through one of several educational routes, though they are largely educated through a non-accredited apprenticeship model. There are approximately 1,800 CPMs in the US and 83% of the births they attend occur in an out of hospital setting.Slide4
Patient NeedsSlide5
Projected Numbers of Women, 2015-2060
Nearly 44 million more women (12 million of childbearing age) will need care in 2060.
Sources in Notes View.Slide6
Projected Births in the United States – 2014-2060
The Census Bureau estimates a 14% increase in the number of births per year by the end of this timeframe.
Sources in Notes View.Slide7
Pregnancy and Newborn Care Hospital Discharges Together Far Outnumber Discharges fo
r any Other Major Diagnostic Category
Sources in Notes View.Slide8
Workforce DemographicsSlide9
Maternity Care Providers per 10,000 Women Age 15-49 Years
Many providers are not clinically active.
As the population ages, a larger portion of clinician time will be taken up rendering primary care to older women.
Sources in Notes View.Slide10
Maternity Care Providers per 10,000 Women Age 15+ Years
The ratio has not changed appreciably in 16 years.
Sources in Notes View.Slide11
First-Year OB/GYN Residents and Newly Certified CNMs/CMs, 1979 - 2014
The number of medical graduates entering OB/GYN residencies has remained relatively flat for three decades.
New CNMs/CMs have been increasing recently.
Sources in Notes View.Slide12
Distribution of OB/GYNs by Age
More than 15,000 OB/GYNs will likely retire in the next decade, outpacing the rate of new OB/GYNs entering the profession by 20%.
In 2013, 82.6% of first year OB/GYN residents and interns were women.
Over time, the OB/GYN profession will become predominantly female.
Sources in Notes View.Slide13
Multiple Studies Show Female Physicians Work Fewer Hours than Male Physicians
A 2006 AAMC survey found that among physicians who had the option to work part time, 34% of female physicians did so, while only 7% of male physicians did.
Age
Average Hours Worked per Week, 2005-2007
Sources in Notes View.Slide14
Average Age at which ACOG Fellows Stop Practicing Obstetrics
Sources in Notes View.Slide15
An Increasing Percent of OB/GYNs are Subspecializing
In 2000 7% of OB/GYN residents entered a subspecialty fellowship. In 2012, 19.5% subspecialized. Many OB/GYN subspecialists do not typically attend births.
Sources in Notes View.Slide16
Bottom Line: Serious Challenges
Static entries into
OB/GYN residencies
a
nd increasing
subspecialization
Changes in provider
d
emographics
Increasing patient
n
eeds
Serious
c
hallenges with
e
nsuring skilled
attendants
at birth
Using a measure of demand that takes into account population, prevalence and incidence of conditions and disease, as well as rates of insurance coverage, available supply of providers and utilization of care, ACOG has projected a shortage of between 15,723 – 21,723 OB/GYNs by 2050.
Sources in Notes View.Slide17
Workforce MaldistributionCompounding the ProblemSlide18
Obstetrician/Gynecologists per 100,000 Population
Data Current as of 2011
Out of 3,142 U.S. Counties, 1,459 (46%) have no OB/GYN.
0
0.1 – 29.9
30.0 +
OB/GYNs per 100,000
ACOG estimates that in 2011, there were 9.5 million people living in a county without a single OB/GYN.
Sources in Notes View.Slide19
Certified Nurse-Midwives per 100,000 Population
Data Current as of 2011
Out of 3,142 U.S. Counties, 1,758 (56%) have no CNM.
0
0.1 – 4.9
5.0 +
CNMs per 100,000
Sources in Notes View.Slide20
CNMs and OB/GYNs per 100,000 Population
Data Current as of 2011
Out of 3,142 U.S. Counties, 1,263 (40%) have no CNM or OB.
0
0.1 – 29.9
30.0 +
CNMs & OB/GYNs
per 100,000
Sources in Notes View.Slide21
Patient Population vs.
Workforce StructureSlide22
Pregnancy and Risk Stratification
There is no uniformly utilized definition of a high risk pregnancy.
CDC estimates that in 2013, 83% of first time mothers were at low risk for a cesarean birth.
1
The NIH lists several high risk factors affecting 2-10% of pregnancies.
2
More
than
half
of pregnant women in the US are overweight or obese, which increases their risk.3
It is reasonable to assume that the majority of women are
low-moderate risk.
Sources in Notes View.Slide23
Ideal Maternity Care Workforce Structure
Ideally, the workforce structure reflects the makeup of the patient populationSlide24
Current Maternity Care Providers in the US
Both physicians and midwives are essential to an appropriately structured maternity care workforce.Slide25
CNMs/CMs are Appropriate Providers for Low-Moderate Risk Pregnancy
The Lancet
- 2014
“Provision
of accessible quality midwifery services that are responsive to women’s needs and wants should be part of the design of health-care service delivery and should inform policies related to the composition, development, and distribution of the health workforce in all
countries.”
Cochrane Reviews
–
2013 and 2009
“The review concludes that most women should be offered midwife-led continuity models of care, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.”Women’s Health Issues - 2012“Based on this systematic review, there is moderate to high evidence that CNMs rely less on technology during labor and delivery than do physicians and achieve similar or better outcomes.”
Sources in Notes View.
Note that these studies look at midwives meeting standards of the International Confederation of Midwives.
CNMs/CMs meet or exceed such standards. It
is not clear at this point whether or how many CPMs in the US meet such standards.Slide26
Inter-Professional Collaboration – The Ideal
Lower
Risk
Patients
Moderate
Risk
Patients
Higher
Risk
Patients
Midwife-Led
Care
Physician-Led
Care
Jointly-Led
Care
“Ob
-gyns and CNMs/CMs are experts in their respective fields of practice and are educated, trained, and licensed, independent providers who may collaborate with each other based on the needs of their patients. Quality of care is enhanced by collegial relationships characterized by mutual respect and trust, as well as professional responsibility and
accountability.”
Joint
Statement of Practice Relations Between Obstetrician/Gynecologists and Certified Nurse-Midwives/Certified
Midwives
Sources in Notes View.Slide27
Current US Maternal Care Workforce Structure
Providers Trained to
Treat Higher Risk
(43,732 OB/GYN
Fellows/Jr. Fellows*)
Providers trained to care
f
or women with normal
Pregnancies (11,113
CNMs/
CMs and
1,800
CPMs*)
The US maternity care workforce is upside down relative to patient needs.
Sources in Notes ViewSlide28
How We Got Upside Down:Public Investment in Developing the Maternity Care Workforce
Medicare policies say nothing with regard to whether CNMs/CMs can be paid for supervising
medical interns, residents or student midwives
.
Teaching physicians are reimbursed for services of medical interns/residents under their supervision.
While there may be midwives in teaching hospitals who are willing to precept CNM/CM students, these hospitals have a powerful economic incentive to favor education of OB/GYN residents.
Sources in Notes View.Slide29
How We Got Upside Down:Public Investment in Developing the Maternity Care Workforce
Medicare GME funds approximately 73% of medical residents. Others may be funded through Medicaid, the VA or commercial GME.
Total GME spending amounts to approximately $127,000 per year for every resident in the U.S.
Spending on each OB/GYN resident is reportedly $100,000/year
The GNE demonstration funded approximately 0.17% of
CNM/CM students
(available in only one educational program)
Total GNE spending on
CNM/CM preceptor
sites is approximately $25 per year for every
CNM/CM student
in the U.S.
Sources and methods in Notes View.Slide30
How We Got Upside Down:The National Health Service Corps
NHSC Funding goes to individuals in the form of scholarships or loan repayment, it does not reward clinical preceptors.
Sources in Notes View.Slide31
Maternal Care Workforce Structure in Several Developed Countries:
Midwives per Obstetrician
Other developed countries have structured their
maternity
care workforce to match the needs of their population.
The
midwife-to-obstetrician ratio in the US is one-eighth the median among this group
.
Sources listed in Notes View.Slide32
Maximizing Midwifery: What is Possible
Maternal mortality per 100,000 live births (2013)
Sources in Notes View.
Infant mortality -probability of dying by age 1 per 1,000 live births (2012)
4 4 4 5 9 28
2
2 2 3 3 6 Slide33
Reasonable Expansion of Midwifery in the US Context
Among the five states with the highest percentage of CNM/CM/CPM attended births in 2013 the average was 24%.
Nationwide, in 2013, CNMs/CMs/CPMs attended 8.9% of all births.
If CNMs/CM/CPMs had attended 24% of all 2013 births, they would have attended 594,300 additional births.
Expansion of midwifery across the country to reflect what is already occurring in these five states would greatly alleviate current pressures on the OB/GYN workforce.
Such expansion in the US is a reasonable goal.
Sources in Notes View.Slide34
Physician Time as an Economic Asset
Educating OB/GYNs entails enormous public and personal investment
Using OB/GYNs to attend most normal births underutilizes the economic value of their full skillset and results in a less than optimal return on their personal investment and that of the publicSlide35
Physician Time as an Economic Asset
When OB/GYNs focus on higher risk mothers, they more fully utilize their skillset, maximizing the return on
personal and public investment in their education.
MGMA studies show
physician
groups that use
nurse practitioners are
more economically healthy
and
physicians
experience higher compensation
because they
focus
on providing services that only they
can render.
Sources in Notes View.Slide36
Cost and Length of Education: CNMs/CMs as an Answer to the Maternity Care Provider Shortage
Sources in Notes View.
Educating midwives is comparatively rapid and economical.
13 of the 39 midwifery education programs offer a 2-year MS or the option of a 3-year DNP program.
Many midwifery programs require 1-year of experience as an RN prior to acceptance into the program.
Average of Public and Private Institution Costs
Note that physicians will likely incur additional expenses during their residency.Slide37
Precepting Students: The Most Significant Challenge to Creating More CNMs/CMs
Precepting students reduces the instructor’s
revenue generation and
/or increases work hours.
CNM/CM education
programs consistently report that obtaining sufficient preceptors is the primary barrier to educating more
CNMs/CMs.
Sources in Notes View.
Preceptors are CNMs/CMs who oversee students and help them experience the hands on, specialized caregiving associated with the midwifery model.
A large percentage of preceptors are active community clinicians, rather than faculty who work in an educational institution and dedicate their time solely to instruction.Slide38
Precepting Students: The Most Significant Challenge to Creating More CNMs/CMs
The GNE demonstration is reimbursing
CNM preceptors
with $15,000/year per student.
CNM/CM students
need precepting during approximately 80% of their two year program
.
Based on GNE expenditures, $24,000 is an appropriate amount needed to precept a student throughout their entire education.
Sources in Notes View.Slide39
Funding for Maternity Care Workforce
Development
What would the public get for an investment of $10 million in developing the maternity care workforce?
GME or precepting costs per practitioner to complete their residency
or education
Number
of practitioners that
could be s
upported with $10
million
Average number
of births attended annually by a single practitioner
Additional
births that could be attended annually by the additional skilled practitioners educated as a result of the $10 million investment
Physicians
$400,000
25
122*
3,050
CNMs/CMs
$24,000
417
70**
29,190
Sources and methods in Notes View.Slide40
Supporting Midwifery Education: The ROI
Sources and methodology in Notes View.
Savings from Reduced Rates of Cesarean Birth
Rate
of cesarean birth among low-risk women.*
2015 costs for using this provider type to attend 70 low-risk women.**
Medicaid portion of these costs
Commercial portion of these costs
Physicians
14.66%
$1,113,884
$309,636
$804,248
CNMs/CMs
8.49%
$1,081,191
$300,931
$780,260
One year ROI for the average Medicaid program is $8,705. During that same period, commercial payers would save $23,988.
These savings would accrue from reductions in cesarean births alone
.
Further savings from the midwifery model would accrue based on other aspects of their practice (e.g., reduced use of epidurals). Slide41
What Can be Done to Increase the Supply of CNMs/CMs?Slide42
Potential Solutions
Identify Shortage Areas
Funding for the NHSC
Graduate Nurse Education Program
Tax credits for preceptors
Payment for supervised services
Revisions to medical school OB rotationsSlide43
Getting More Data: H.R. 1209/S. 628“Improving Access to Maternity Care Act of 2015”
HRSA to designate maternity care health professional shortage areas – locations or populations without sufficient full scope maternity care providers or hospitals or birth center labor and delivery units.
NHSC scholarships and loans could be available to maternity care providers who agree to work in these new shortage areas.Slide44
Potential Solutions: Helping Midwifery Students
HRSA’s proposed FY 2016 budget would increase the NHSC field strength by 6,664.
NHSC helps students afford their education, but does not address the challenges with obtaining more preceptor sites.
Sources in Notes View.Slide45
Potential Solutions:The Graduate Nurse Education Demonstration
$200
Million given
to 5 hospitals over 4 years
Hospitals partner with schools of nursing and community clinical sites…
…to provide clinical education for more advanced practice nurses.
Sources in Notes View.Slide46
Potential Solutions:
Georgia Preceptor Tax Incentive Program
480 hours of precepting to qualify.
Certain medical, NP and PA students.
Each 160 Hours.
$1,000 Tax Deduction.
Maximum deduction = $10,000
Sources in Notes View.Slide47
Potential Solutions:
Reimbursing Midwife Educators
Medicare pays teaching physicians for the services of the interns/residents that they are educating.
CNMs/CMs frequently provide
educational oversight
to medical interns/residents and student midwives. There is no Medicare policy ensuring payment for services overseen by CNMs/CMs.
Hospitals are discouraged from fostering
inter-professional
education or supporting midwifery education.
Legislation is needed to ensure that when CNMs/CMs oversee services performed by medical interns/residents or student midwives they can be paid for those services, just as teaching physicians are currently paid.
Sources in Notes View.Slide48
Changes to Medical Education
Have medical students get exposure to obstetrics through mechanisms other than direct patient care allowing student midwives that opportunity instead.
Modifying OB/GYN residency requirements for those who plan to subspecialize in areas that do not involve attending births so that student midwives can have those clinical experiences instead.Slide49
AppendixSlide50
Data from Risk Adjusted Comparative Studies in
the US: %
of Cesarean
Births
Sources and methods listed in “Notes” view.
* Study 4 included overall cesarean rates, as well as C/S for
primiparas
and multiparas cesarean.
* Study 7 included overall cesarean rate and primary cesarean rate.
* Study 9 included overall cesarean rate and primary cesarean rate.
Among studies reporting study population and incidence figures, there were 2,435 cesareans among 19,241 births attended by physicians (12.66%) and 304 of 3,746 births attended by Midwives (8.12%). Among all studies the averages of the respective rates are 14.66% and 8.49%
Among the 234 midwifery practices reporting on 97,158 births in ACNM’s 2013 benchmarking data, the median rate of cesarean birth was 11.8% Slide51
Average Total Charges and Payments for
Maternal and Newborn Care in the U.S. - 2010
Inflating these figures by the Medicare Economic Index (MEI) yields an estimate that in 2015 dollars commercial insurers are incurring costs of $18,961 for vaginal births and $28,826 for cesarean births, while Medicaid programs are paying $9,446 and $14,058 respectively.
Sources in Notes View.