Despite a new law that requires insurance companies to cover home births, Peggy Cohen, a certified professional midwife in Burlington, has had to turned away patients whose insurance will not cover the service.
That’s because Cohen has not entered an agreement with a licensed physician which would enable her to qualify for coverage by Blue Cross Blue Shield of Vermont. Even though midwives go through a certification process through the North American Registry of Midwives to become professionals, including a minimum of 1,350 clinical contact hours, they must collaborate with a doctor for their services to fall under the company’s coverage.
“For some reason, insurance companies feel like they’re in the position that they need to screen providers,” Cohen said. “They’re basically validating only conventionally trained providers.”
Cohen is one of a handful of midwives who found insurance companies were not covering their services, even after legislation went into effect in October. She said she expects similar issues with other insurance providers.
Act 35, the law that requires insurance companies to cover midwife services, allows insurance companies to require an agreement between midwives and physicians before their services are covered.
Blue Cross Blue Shield of Vermont, for example, requires licensed midwives to enter into an arrangement with a physician approved by the insurance company and to have malpractice insurance.
Cohen said the requirement for a formal agreement with an obstetrician and the cost of malpractice insurance, which runs upwards of $15,000 a year, created too many barriers for her to become an approved provider.
Without insurance coverage, the out-of-pocket cost for some patients was too much, Cohen said, and some transferred to a different provider. Patients, in most cases, have to decide whether to foot the bill or switch to a provider who is covered by their insurance.
In Vermont, as in the rest of the country, most women give birth in a hospital. According to a 2010 study by the U.S. Department of Health and Human Services, 97.6 percent of Vermont women gave birth in a hospital. Those figures, which represent 2005-2006 data, show Vermont has a higher rate of out-of-hospital births than most states. More than half of these babies were delivered by midwives, according to the study.
Vermont Department of Health numbers for 2010 show that in 2010 of the 5,775 total births, 128 were at home. Of those, 90 were attended by a licensed midwife. A total of 5,640 were hospital births, according to the Health Department.
Home births attended by licensed midwives are already covered by the state’s health insurance program for low-income Vermonters. Eleven other states provide Medicaid reimbursement for licensed certified professional midwives who practice in out-of-hospital settings.
In May, Vermont joined a number of other states with a mandate that covers midwifery. Prior to the law, private insurance would not reimburse patients for the service.
Jen Quavelin of Burlington went through multiple rounds of appeals with her insurance company before the new law went into effect. Because her midwife’s services were not covered, her family had to pay around $4,000 out of pocket to cover prenatal care and the birth itself. She said she went ahead with a home birth because it seemed like a better option than having a baby in the hospital, despite the extra costs.
“I feel more comfortable with a home birth rather than a birth in the hospital,” Quavelin said.
She said it seemed really inappropriate to have an insurance company essentially dictate which type of provider she could have for her pregnancy.
Home birth advocates have championed a study by the State of Washington that shows the state saved nearly a half million dollars every two years since it required insurance companies to cover home births, which are less expensive than hospital births.
Blue Cross Blue Shield of Vermont’s credentialing requirements for midwives are consistent with the current law and help to protect patients, according to Kevin Goddard, vice president of external affairs and sales for Blue Cross Blue Shield of Vermont. Malpractice insurance can protect patients who are injured by a medical provider’s negligence by compensating them financially.
Midwives either cannot or are reluctant to obtain the requisite malpractice insurance, Goddard said.
Goddard said the insurance company is working with midwives and the Department of Banking, Insurance, Securities, and Health Care Administration to reconcile the conflict.
“We’re trying to see what we can do to be supportive of this and how we can protect our members through malpractice insurance,” Goddard said.
Mary Lawlor, a certified professional midwife in Vermont and New Hampshire and president of the National Association of Certified Professional Midwives, confirmed that negotiations between midwives and insurance companies in Vermont are ongoing. The disagreement is over the interpretation of what insurance companies have to cover.
Cassandra Gekas, a health care advocate for the Vermont Public Interest Research Group, said insurers’ refusal to pay for midwives runs afoul of the Legislature’s intent to cover the service.
“We know this is a service that increasing numbers of Vermont families want,” Gekas said. “They want to give birth at home in a place where they feel comfortable. We have licensed providers who can provide that service. The Legislature last year passed a law to end the discriminatory practice and make sure that families with private insurance can have their home births.”
Gekas lobbied for the bill last year against opposition from the Vermont Medical Society and insurance companies.
The medical society opposed the coverage mandate based on the inherent risks to patients. A study in the American Journal of Obstetrics and Gynecology shows an increase of three times the rate of infant mortality in home births over those at hospitals.