New law for midwives in New Mexico unfair to Ob/Gyns

[MacGyver]

http://thewelltimedperiod.blogspot.com/2007/03/it-doesnt-pay-to-be-obgyn.html


1) New law says that midwives can get Medicaid reimbursement WITHOUT malpractice insurance coverage.

2) Existing law mandates that ob/gyns must have malpractice coverage.

Midwives performing home births typically do not carry malpractice insurance. When that insurance is available, the cost is prohibitive, but few insurance companies are willing to write policies covering home births at any cost. It's not that there have been a large number of expensive claims, said Roberta Moore, maternal health program manager for the New Mexico Department of Health. Insurers simply don't see this market as profitable.

This doesnt make any sense. If lawsuits are low for midwives, and they are taking premiums from all the midwives, that translates into profits. How can it be non-profitable if there are very low numbers of lawsuits against them?

For the record, New Mexico is a very physician-hostile state. First they gave psychologists the right to script drugs, and recently they have started talking about letting optometrists do eye surgery.

Probably wont be long before that fool Bill Richards lets the midwives do c-sections.

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[bubblegumbezoar]

Yep. I completely agree that NM is a physician hostile state. I would add that the state in general is in danger of not having adequate number of ob/gyns as the residency program there had two interns leave last year and this year, they seem to have upset quite a few people with the match from what I've heard.

 

[Bernalillo]

Granted, NM is a strange state and wierd stuff happens here all the time. But please don't take this as a relflection on our Ob-Gyn residency program. I'm a MS IV here and will soon be starting internship at UNM. Our department is great. People left for personal reasons and switched to other specialties, I really don't think it has to do with the program. We have a lot of midwives, they too are great.

I've got to say the psychologists and opthomologists getting increased rights (prescribing and surgical) is scarry. I don't think the opthomologists have gotten anywhere yet. This Midwife law is new to me. Some may argue that our state is WAY underserved and it would be great to at least have some health-provider attending births that can't be staffed by OBs. I suspect that after a few people have bad experiences with home births, this law may change.

Our malpractice environment is actually pretty friendly, especially when you look at our costs compared to other states. I don't see this as a "physician-hostile state" at all. Unless all you care about is money, money, money, which some OBs obviously do. But most of our patients are just grateful for care.

 

[saiyagirl]

Granted, NM is a strange state and wierd stuff happens here all the time. But please don't take this as a relflection on our Ob-Gyn residency program. I'm a MS IV here and will soon be starting internship at UNM. Our department is great. People left for personal reasons and switched to other specialties, I really don't think it has to do with the program. We have a lot of midwives, they too are great.

I've got to say the psychologists and opthomologists getting increased rights (prescribing and surgical) is scarry. I don't think the opthomologists have gotten anywhere yet. This Midwife law is new to me. Some may argue that our state is WAY underserved and it would be great to at least have some health-provider attending births that can't be staffed by OBs. I suspect that after a few people have bad experiences with home births, this law may change.

Our malpractice environment is actually pretty friendly, especially when you look at our costs compared to other states. I don't see this as a "physician-hostile state" at all. Unless all you care about is money, money, money, which some OBs obviously do. But most of our patients are just grateful for care.

I'm pretty sure you meant optometrists, right? Ophthalmologists are MD's. Optometrists are not.

And his name is Bill Richardson.

 

[3dtp]

Yep. I completely agree that NM is a physician hostile state. I would add that the state in general is in danger of not having adequate number of ob/gyns as the residency program there had two interns leave last year and this year, they seem to have upset quite a few people with the match from what I've heard.

I beg to differ. I loved NM during my time there. And I think their residency program was well run and a fun program to be at. All programs have some problems and these problems will fluctuate from year to year. I was very happy with the program and the people. I did leave the program to take a radiation oncology position, and it was, in retrospect a very good opportunity for me. Making the decision to leave UNM was extremely difficult and I very nearly cancelled my rad-onc spot at the last minute.

NM is not a wealthy state. In part because of its geography, and in part because of its demographics. Salaries are a tad lower than LA or NYC.

 

[hilseb]

It's the opposite in Florida. Midwives are required to carry malpractice insurance, and OBs can go bare.

 

[bubblegumbezoar]

I still think that this legislation is very hostile. NM is a very underserved state in which people live up to 50-75 miles from another neighbor in some cases. For such an undererved state, it is ludicrous to pass legislation allowing midwives to practice with this new legislation.

In terms of the ob/gyn program at UNM, I have heard from many people that the residents are overly involved in the selection process of residents. There is one theory stating that people in any field will pick those just like themselves, and this seems to be going strong at UNM's program. I would like to think that with as much education and training as it requires to get to being an MD that a program would be open to inviting in those applicants who are in some way different than the current residents (i.e. academically different, politically different, etc). Because without letting new life into any field, the field becomes stagnant. This issue is not specific to UNM's ob/gyn, but needs to be looked at closely to help academic departments grow.

 

[Doula-2-OB]

Midwives performing home births typically do not carry malpractice insurance. When that insurance is available, the cost is prohibitive, but few insurance companies are willing to write policies covering home births at any cost. It's not that there have been a large number of expensive claims, said Roberta Moore, maternal health program manager for the New Mexico Department of Health. Insurers simply don't see this market as profitable.

I am wondering about this specifically- did they check with all of the homebirth midwives in the state to see who had insurance and who does not? In my state (WA) there are very few midwives that I am aware of (and granted, I haven't polled them, but in my line of work/network, we know a lot that providers don't even know we know.. lol) who are practicing bareback. I mean, I think I know of ONE and she rarely even takes clients, and she's definitely considered outside of the mainstream. Midwives here are working very hard to not be edged out by the state and being as 'legal' as possible is definitely the norm. The midwives I know personally, and have worked with, are definitely insured (yes we've discussed it!) and wouldn't consider being otherwise unless it came down to their ability to practice at all. Right now they're not able to attend known breech, VBAC or twins. Some will do it knowing that they are not covered, rather than send mom to a cesarean birth (if that is the case), but it is not the 'routine' for the midwives here. I wonder how the climate differs in NM. It does seem odd to me that any insurance carrier would support a provider who did not have insurance, and I can't say that I agree with it either. Where is the quality control mechanism? I highly doubt that anyone is looking at physicians and trying to screw them, but I have to wonder where the common sense is in this....

 

[ohbee gin]

Right now they're not able to attend known breech, VBAC or twins. Some will do it knowing that they are not covered, rather than send mom to a cesarean birth (if that is the case)

Yikes. Why not just send their patients to an OB who does VBAC or is comfortable with twin vaginal deliveries? By performing procedures that could potentially need the support of an OR, when safer alternatives exist, seems unfair to the mother and unethical to the practice.

 

[Doula-2-OB]

Oh don't misunderstand -- most midwives do refer their clients who are breech/VBAC etc. I would say the large majority do. The percentage that would take on those clients is very small, in my world, and I've been very connected to the birth world here for the last 6 years.

Yikes. Why not just send their patients to an OB who does VBAC or is comfortable with twin vaginal deliveries? By performing procedures that could potentially need the support of an OR, when safer alternatives exist, seems unfair to the mother and unethical to the practice.

The real trick is finding someone. Most women who are going to midwives for their care for a vaginal twin or VBAC or whatever are doing it because there are no docs who will take them. Vaginal breech.... hah! It's basically extinct.

Women are desperate to be heard. They don't want to be cut open. They don't want cesareans. The medical profession isn't listening, and even when the docs are sympathetic and want to help, their own hands are tied. It's terrible for everyone.

How is the VBAC situation where you practice? I'm near Seattle and it's pretty difficult for most women out here to find the option for VBAC without huge restrictions, and most docs who will do VBAC require the woman give birth (how crazy is that statement... require a woman to give birth lol) by 40 weeks before he starts talking repeat cesarean. So if a woman can find the option to VBAC, she's under restriction for weight gain and length of pregnancy and what type of monitoring she's 'allowed' to decline, whether she can use water for pain therapy, etc. Women are willing to go through it all becuase a vaginal birth means that much. It's very frustrating, and we tend to be more 'progressive' than other areas too! VERY frustrating.

 

[BinkyBear]

I am in a medium sized town in Oklahoma. Our hospital does not "do" VBAC, breech vaginal deliveries, or vaginal twin deliveries at all. It is not that the physicians are not willing to let a patient try, but the hospitals insurance will not cover it.
To attempt a VBAC a patient needs to drive to one of the teaching hospitals. The teaching hospitals are at least an hour and a half away each. And even there they are very "conservative" about it.
I will admit that I think that it is so unfair to the patient because it takes away their choice in the matter. But, at this point there is not a while lot that anyone can do about it.

 

[pruritis_ani]

Unfair to the patient?

If patients will insist on litigation for every bad outcome, as well as insist on having these cases tried with juries that understand nothing about medicine, than these are the consequences.

I am all for patient autonomy. However, defensive medicine is a reality in our world today. And, no, it is not the fault of the MDs or the insurance companies. It is the fault of the litigous nature of patients and the attorney's that represent them.

So, if you want your doctor to be able to provide the care that you want, support tort reform and malpractice reform. If you want to sue, be prepared to have little choice in your care.

 

[Faebinder]

Unfair to the patient?

If patients will insist on litigation for every bad outcome, as well as insist on having these cases tried with juries that understand nothing about medicine, than these are the consequences.

I am all for patient autonomy. However, defensive medicine is a reality in our world today. And, no, it is not the fault of the MDs or the insurance companies. It is the fault of the litigous nature of patients and the attorney's that represent them.

So, if you want your doctor to be able to provide the care that you want, support tort reform and malpractice reform. If you want to sue, be prepared to have little choice in your care.

Words of wisdom from those battling in the trenches.

 

[BinkyBear]

I understand what you are saying, and people do seem to be very sue happy (I'm still "fresh faced" and maybe my perspective will change over the years). But I do think that with something as important as the birth of a child the patient should have at least a little bit of a say in the process. I understand (and I haven't been burned yet) that it is more of a CYA type thing, but I was just giving my perspective.

 

[pruritis_ani]

I understand what you are saying, and people do seem to be very sue happy (I'm still "fresh faced" and maybe my perspective will change over the years). But I do think that with something as important as the birth of a child the patient should have at least a little bit of a say in the process. I understand (and I haven't been burned yet) that it is more of a CYA type thing, but I was just giving my perspective.

The patient should have more say in the process, just as I shouldn't have to consider how my management will appear in the event of a poor outcome if the patient specifically asked me to manage the pregnancy this way. Remember, a patient that asks you to VBAC can still sue you when something bad happens as a result of the VBAC she asked you for!

In medicine, physicians are punished be legal action for poor outcomes. So, my practice is biased toward avoiding poor outcomes, even if the chance is relatively remote.

Patients should have the right to decide how they want to have a baby. But, the problem is that they do not seem willing or able to accept the risk of poor outcomes, and they can and do cry to the malpractice lawyer if they have one. Even after being informed of risks. Even after appearing to understand these risks.

Don't get me wrong, malpractice exists, and there should be something in place to compensate victims of it. The problem is that very few people outside of medicine understand the difference between poor outcomes and malpractice, and the attorneys like it that way.

So, until something is done, my hands are essentially tied. I will not offer something that has a slightly increased chance of a poor outcome (ie, uterine rupture after VBAC) unless I am in an ideal practice situation (in house anesthesia coverage, ability to be in the OR in 2 minutes).

Patients should pay attention to this debate. If you want choices, you cannot be sue happy. I would LOVE to be able to do everything every patient wants, and I would if I knew that I would't be the one paying for it. If this sort of care is important to patients, get proactive with the malpractice crisis. If you want to sue us all of the time, then be prepared for us to protect ourselves.

 

[pruritis_ani]

BTW, just had my second uterine rupture with a VBAC attempt. Not to mention the last elective repeat I did revealed an occult rupture, and this was an elective procedure prior to labor. The statistics sure sound safe for VBACs, but let me tell you, it doesn't take many ruptures before you gain some serious respect toward them. Without an anesthesiologist about 30 seconds away, and the ability to deliver these kids within minutes, we would have had some bad, bad outcomes. I cannot imagine what would happen if you had to drive to the hospital after you ruptured, or if you had to wait for the OB or anesthesiologist to get there. Well, I can imagine it, but I don't want to.

After a couple ruptures, I can promise you that I would NEVER recommend a VBAC to my wife, or to a family member. More power to those that want them, but it seems like a foolish risk to take. I truly doubt that I will offer them in my practice, as my goal is to avoid disasters.

 

[BinkyBear]

I understand that. Like I said, I am sure a few months or years from now my perspective will change. It is just a matter of time. But at this moment in time that is how I feel about it.
I understand that we have to go in with the mindset that the freak occurrence is the norm. All that I am saying is that for patients sake I wish that it was different, but unless I go into politics (never!) I am not really in a position to change it. All that I can do is tell patients "no" and send them to another hospital. It's tragic, that's all.