State-Imposed Obstacles to Medicaid Payment Shutters Two Birth Centers

With a couple exceptions, the state’s CCOs continue to shut out birth centers from their networks while women who want Medicaid to pay for their services must clear a lengthy and discouraging process. The Oregon Health Authority stayed mum when asked for an explanation.

Two Oregon birth centers will close in the coming weeks, reducing the options for women who want to deliver their babies outside hospitals.

The owners of Trillium Waterbirth Center in Medford and Home Sweet Home Birth Center in Lincoln City both have had a very difficult time getting paid for their services from the Oregon Health Plan, which pays for more than half of all Oregon births, with an even larger share of babies in rural areas.

Both birth centers had been unable contract with coordinated care organizations and relied instead on persuading women on the Oregon Health Plan to leave their CCO for childbirth and apply for the Medicaid “open card” through a cumbersome process. The birth centers did also offset their Medicaid patients with what little private insurance they could bill.

Augustine Colebrook, the midwife-proprietor of Trillium Waterbirth, said a state functionary at the Oregon Health Authority had required her and other midwives to submit extensive paperwork before getting compensated, a process that sometimes took the bulk of a pregnancy. If a woman was declined, or ended up delivering in a hospital, Trillium would receive nothing for its prenatal services. Additionally, she said the state had recently stopped compensating midwives who assist the primary midwife at a delivery.

Oregon Health Authority spokeswoman Stephanie Tripp did not respond to questions about the health authority’s approval process.

“Birth centers provide a very viable natural alternative for families that don’t want a home birth, and don’t want to have a hospital birth,” Colebrook said.

Only pregnancies that are deemed to be low-risk are appropriate for out-of-hospital births, but Colebrook said 91 percent of her patients delivered at her birth center. When problems arise such as a breech birth, presence of genital herpes or some other illness that could affect the infant’s health, or a history of caesarean deliveries, the woman must deliver her baby in the hospital.

Colebrook also runs a birth center in Grants Pass, which despite its smaller size in a smaller town, will remain open, largely because of a hostile relationship she has with Providence Medford Hospital, which might not accept her patients if a transfer was needed. She said she had no problems with other area hospitals.

Cynthia Luxford is closing her Lincoln City birth center that opened 10 years ago and “retiring” as a midwife after 29 years because her business could no longer absorb the loss of business from the Oregon Health Plan. Before the CCO experiment was launched, she would deliver 45 babies a year, but that number has fallen to less than 20. The closure leaves the Central Coast without a birth center.

“I wouldn’t have to retire if I was able to practice with autonomy,” Luxford told The Lund Report. “It’s very cumbersome to get anybody with an open card.”

Colebrook mentioned a third birth center in Eugene that was reportedly set to close, but when reached for comment, an employee said the facility would remain open.

The subject of birth centers has been avoided by the CCOs, but a common complaint has been that birth centers typically do not carry malpractice insurance as obstetricians and hospitals do.

Dean Andretta of Willamette Valley Community Health, the Salem CCO, wouldn’t comment on birth centers specifically but noted that Willamette Valley does offer the services of nurse midwives who are affiliated with Silverton Hospital and Willamette Health Partners. Nurse midwives are nurse practitioners who specialize in childbirth and typically deliver at hospitals, while birth centers are more likely to employ professionals licensed as direct-entry midwives.

Colebrook explained that malpractice insurance was cost prohibitive, routinely exceeding a midwife’s annual salary. Private insurance reimbursed her for services without such a requirement. She argued that since nearly all CCOs are owned and controlled by hospitals and physician groups, they have an economic incentive to prevent women from going outside their facilities or choosing direct-entry midwives for childbirth. “They don’t want to lose revenue to the birth centers,” she said. Hospitals, on the other hand, typically complain that Medicaid payments don’t cover their costs.

The decision by CCOs to balk at contracting with freestanding birth centers is not limited to Oregon. Lesley Rathbun, the president of the American Association of Birth Centers, wrote U.S. Health & Human Services Secretary Sylvia Burwell in July, accusing managed care organizations in Oregon and four other states of violating the Affordable Care Act by preventing women from utilizing a covered service like birth centers.

There is at least one freestanding birth center in Oregon that has successfully contracted with a CCO -- Growing Family Birth Center in Lebanon -- which has had a contract with Intercommunity Health serving Linn, Benton and Lincoln counties.

“It’s been really good for our women,” said Debbie Cowart, a midwife and the owner of Growing Family.

Cowart said Intercommunity approved her facility after she presented them with studies that showed birth centers were cost-effective and safe for low risk births from the Apple Health Medicaid system in Washington as well as from Providence Health & Services. After a gap in coverage, the Providence study led to the insurer covering birth centers for the Public Employees Benefit Board -- the health plan for state employees -- after PEBB switched from Regence BlueCross BlueShield, which had provided the option.

Cowart added that a birth center in Salem had also been able to get reimbursed by the Salem CCO,  Willamette Valley, through a nurse midwife who delivered babies there.

Silke Akerson, the legislative liaison for the Oregon Midwifery Council, said another direct-entry midwife who duals as a naturopathic physician has also broken into the Jackson Care Connect network, which is managed by CareOregon.

Akerson said many medical executives are just not familiar with the direct-entry midwifery profession and the birth center option, despite their effective use in Washington. “It definitely feels like midwives might be compatible with reducing costs,” Akerson said.

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Comments

CCO's are a monster created by former Governor Kitzhaber and his medical colleagues as a way of consoidating power in the hands of a few -- eliminating choice of providers for the poorest of our community all in the name of saving money. The Lund Report has very clear demonstrated how much money the CCO's are extracting by denying procedures and needed care while filling the administrators and CCO's coffers.

Nurse Midwives have proven they are safe affordable care providers. I spent time in labor and delivery for 6 months with both Nurse Midwives and Physicians. Their styles are very different. When they share the same work areas they learn from each other and women have a choice and care is improved. Women love their nurse midwives. We had a Nurse Midwive in Klamath Falls in the past with 4,000 deliveries.What the CCOs are doing is eliminating women's choice and marginalizing starving out their providers whom they selected and adore.

This is a very clear to me sexual descrimination. It is led by men who in their massaginist wisdom know what is best for women. We have a female Governor, head of the Oregon Health Authority and Medicaid Commissioner. You three women have the power to stop the total elimination of birth centers and nurse midwifery in our state. Women should always be equal partners and should be listened to and given choices over the medical care they choose, not spoon fed a bitter pill by the bean counters in CCO,s. This is America not Syria.

Stop these sexist bastards and pull nurse midwives into the process so their patients will have choice and access to the same care as patients who choose physicians as their providers. These are mothers and babies that deserve the best that we as a state can provide! 

Michael Sheets