Legislature(2005 - 2006)CAPITOL 106
03/31/2005 03:00 PM House HEALTH, EDUCATION & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| HB225 | |
| HB53 | |
| HB111 | |
| HB220 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 225 | TELECONFERENCED | |
| += | HB 53 | TELECONFERENCED | |
| *+ | HB 111 | TELECONFERENCED | |
| *+ | HB 220 | TELECONFERENCED | |
| *+ | HB 14 | TELECONFERENCED | |
HB 111-MEDICAID COVERAGE FOR BIRTHING CENTERS CHAIR WILSON announced that the next order of business would be HOUSE BILL NO. 111, "An Act adding birthing centers to the list of health facilities eligible for payment of medical assistance for needy persons." 3:38:26 PM REPRESENTATIVE HARRY CRAWFORD, Alaska State Legislature, as sponsor, explained that HB 111 would give uninsured women the same choice as insured women to have their babies at a birthing center, attended by a midwife. He pointed out that presently Medicaid pays for hospital births and doctors; the bill would allow Medicaid to pay for births at birthing centers as well. He commented that the bill would save Medicaid money because doctors and hospitals cost more than birthing centers. 3:41:30 PM CHAIR WILSON asked whether the department estimated any savings from this. She noted that there was a zero fiscal note. REPRESENTATIVE CRAWFORD replied that the state has no experience to draw on and thus can't estimate any savings. However, a study in California showed a 22 percent savings rate. 3:42:39 PM BARBARA NORTON, Certified Nurse Midwife (CNM); Part Owner, Geneva Woods Birth Center, clarified that Medicaid pays for midwife services, but does not pay the facility fee. She said: We really need to encourage the use of midwives in this state. The State of Florida passed a bill several years ago to say that by 2005, they wanted 25 percent of their births attended by midwives because there was significant cost savings. And I believe that they have instituted that. ... Approximately 14- 15 percent of births in this state are attended by midwives. And just to compare a Cesarean section rate: ... the Cesarean section rate right now at Providence Hospital is 33 percent and growing because doctors as refusing to do a vaginal birth for someone who's had a Cesarean section once. So now all of those women are becoming repeat Cesarean sections at twice the cost to Medicaid. Midwives have a Cesarean section rate in this state of between 3-10 percent, and physicians average probably 20-50 percent, depending upon which physician you're talking about. So preventing that first Cesarean section is a huge savings. And using midwives is a very significant way to prevent that first Cesarean section. MS. NORTON continued, "The other issue is just offering families choice: we're not bringing high risk people to the birthing center; we're only bringing low-risk people to the birthing center." MARIBETH GARDNER, Family Nurse Practitioner; Nurse Midwife, testified in support of Medicaid reimbursing birthing facilities. She stated that she has attended births at home, at birth centers, and in hospitals. She commented that births attended in nationally certified birth centers or birth centers that meet the National Association of Childbirthing Centers (NACC) are a nice alternative for low-risk women. JACK NIELSON, Executive Director, Rate Review, Office of the Commissioner, Department of Health and Social Services (DHSS), stated that he works for the DHSS Medicaid program. He said that DHSS is neutral on the bill, but would like to raise a few points. He said: The bill as it's written now adds birthing centers to the list of facilities whose Medicaid payment rates are required by statute to be established based on reasonable costs incurred by the facility. But ... the way it's written right now doesn't really add birthing centers as a Medicaid service authorized by state law to be offered in the Alaska Medicaid program. The list of authorized services is in AS 47.07.030. Adding the birthing centers to the list of authorized services in [AS 47.07.030] would make legislative intent absolutely clear and possibly assist the department in dealing with getting this type of service approved by the federal government as a Medicaid service so we can get the federal government to share in the cost. MR. NIELSON continued: There is a question whether birthing centers are an allowable Medicaid service that the federal government will participate in financially. A few states have obtained federal participation in the past but the federal criteria really aren't clear. And recently it's become more and more difficult to gain federal approval for provider types that are not specifically defined in federal statutes and regulations. The department would, of course, make every effort to gain federal approval. However, if we were not successful, payments to birthing centers would be state general fund only payments rather than payments matched by the federal Medicaid program. ... [In 2006] that match is going to be around 50 percent. The type of federal approval that we're able to gain could also somewhat drive the methodology for calculating payment rates that we would end up using for birthing centers. So, until we have a written approval from the federal agency, we won't know for sure what they would have to say about that. In 2004 there were close to 10,000 births in Alaska; approximately 50 percent of those were Medicaid. Overall in the state, ... historically about 3 percent of births are in birthing centers. ... In some areas where there are birthing centers, the birthing center rates are much higher. ... Just looking at the statewide statistic though, we'd be looking at maybe 150 or so Medicaid births per year in birthing centers if this provider type were adopted by Medicaid. MR. NIELSON continued: Some of the factors to consider in estimating costs and savings on adding this new provider type: on the savings side, we did find a study that was done in California ... where paying for these facility fees for birthing centers instead of hospitals resulted in a 22 percent savings overall in facility fees, and overall to the ... California Medicaid program, it basically resulted in a 7 percent savings, if you include doctor fees versus midwife fees.... So there are studies out there that show some savings along those lines. Certainly the facilities would have a lower cost; the space, the staff, the supplies, would be lower cost. As was mentioned earlier, fewer C- sections would likely happen using the birthing centers. Probably less epidural anesthesia would be used, and so all of these things are sort of on the savings side of the equation. MR. NIELSON continued: On the cost side of the equation we have things like: we would have to change our Medicaid management information system; that costs about $130,000 to put a new provider type in. We could have some births now that are happening at home that would move to the birthing center; we would have increased costs there. In the case where we have hospital transfers, we may end up paying both the birthing center and the hospital for those situations, and Medicaid would likely have to pay transportation costs between the two.... Hospital costs, of course, are different by different area of the state. There is always the potential of a slight chance of a bad outcome where the patient isn't in the hospital while they're giving birth and so they're not right on site if something bad were to happen. In the hospital study, the birthing centers that were studied were part of a large health network, either owned by an organization that had a hospital and various levels of care within it, or ... the hospital is a member of a network with a firmly established referral process.... This regulation would require the department to set the rates for the birthing centers based on actual birthing center costs. We don't know for sure what those costs are at this point; we would have to find out and set the rates accordingly. But that's sort of an unknown at this point. Presumably it would be less than a hospital cost, but we just don't know how much. ... The federal government may have a say in the type of reimbursement system we use. The federal government may not participate, although we would work certainly very hard to try to make sure that happened. ... Alaska Medicaid babies may be more at risk than the California study; you know, we've got a lot of rural communities.... CHAIR WILSON inquired as to the number of birthing centers in the state. MR. NIELSON replied that there are eight. In further response to Chair Wilson, Mr. Nielson specified that most of the birthing centers are located around population centers. Upon further questioning, Mr. Nielson said that there are at least three states for which birthing centers are covered by Medicaid. CHAIR WILSON surmised that if there are at least a few other states, the federal government would probably cover Alaska as well. 3:57:34 PM REPRESENTATIVE CRAWFORD expressed his willingness to address any problems or concerns with the bill through amendments. 3:59:32 PM TORA GERRICK, Part Owner, Midwives Birth Center, commented, "Without this bill we're definitely sending a negative message to our working class and underinsured people in Alaska. I think that we're telling them where they have to have their babies, and frankly, I think it's a subtle form of discrimination, economic discrimination at best." She highlighted that her facility participates in the community in a variety of ways, including the YWCA Early Breast and Cervical Cancer Screening program that offers early cancer screening for low income women in Alaska. She also highlighted that, to the best of her knowledge, all of the birth centers in Alaska are owned by Alaskan women. Therefore, by supporting this bill, the [state] would also be supporting locally owned businesses, and would keep Medicaid monies in the state. In response to an earlier statement by Mr. Neilson, she clarified that women who can't afford the birth center facility fees aren't necessarily choosing home births. In fact, she said she has seen them go to the hospital instead. She also reiterated that the birth centers only offer services to low-risk women, and so high-risk women would already be birthing in hospitals. 4:02:33 PM REPRESENTATIVE CISSNA commented that there is no one on Prince of Wales Island to deliver babies, and therefore the women there have to travel to Ketchikan about two weeks prior to their due date to deliver. She asked if those costs wouldn't be cut as well if there were birthing centers in rural areas. CHAIR WILSON replied that she wasn't sure that Medicaid covered those costs. She noted that no babies are delivered in Wrangell anymore due to insurance costs. 4:04:27 PM KITTY ERNST commented that she is not an Alaskan, but is in the state for a meeting being conducted on women's health by the local chapter of the American College of Nurse Midwives. She stated: [House Bill 111] speaks primarily to a cost savings of only $40,000 for 100 births in the birth center, which ... it is alleged could easily be offset by one birth center with serious complications. This sort of infers that serious complications don't occur in hospitals, and they do, and they also have added costs when serious complications occur. Cesarean sections ... result from a serious complication. Neonatal intensive care units result from serious complications. Both of these complications, for example, are far less ... in a birthing center, because you're dealing with a low-risk population. But it is significant that in a national birth center study, the Cesarean rate was 4 percent among 17,000 birth center women. I think that represents a significant cost savings. When we look at the fact that the Cesarean section rate in this country in 2003 has climbed to an all-time high of 28 percent and much higher in certain locales. And the prognosticators are telling us it's going to be 50 percent by 2010. And that's attributed to ... elective Cesarean sections, which means it does not have to be a medical indication to have this major surgery, and secondly, the virtual national shutdown of any place to have a VBAC, which is a vaginal birth after Cesarean section. And both ... the American College of Obstetricians and Gynecologists and the American College of Nurse Midwives have strongly stated that the solution to the problem is to reduce the number of primary Caesarian sections. And that is exactly what the birth centers do. ... MS. ERNST continued: I really urge you not to take a short sighted look in your decision on whether or not to reimburse birth centers because my 30 year experience in working to establish and demonstrate and evaluate this innovation in the delivery of health care ... is that we need a lot more evidence before we shut these places down. And if you don't pay a facility for its services, it's going to shut down. ... All the other things are also important, such as giving choice to Medicaid mothers. ... We have the experience ... that the time and education and intensive care given by midwives in birthing centers empower these women to take control of their lives. MS. ERNST shared a few anecdotes regarding empowerment of women at birth centers. She concluded by saying that birth centers are safe and there is a 97 percent satisfaction rate among the women who use birth centers. 4:13:22 PM KAYE KANNE, CDM, Executive Director, Juneau Family Birth Center, pointed out that she recently calculated that on average a hospital facility fee is about $2,500 more than a birth center facility fee, not counting any additional services. She also noted that in 2004, an estimated 186 women on Denali KidCare have had babies at Alaskan birth centers. She said that an additional 85 women were not able to pay the facility fee. She calculated that the state paid over $200,000 additional for those 85 women to go to the hospital instead of the birth center. Noting that the hospital in Juneau has a Cesarean section rate of 40 percent while the local birth center has an eight percent rate, she commented that many of those 85 women probably ended up having Cesarean section, which cost the state tens of thousands of additional dollars. MS. KANNE stated that even if the federal government did not support this, the cost to the state of paying 100 percent of the birth center facility fees is still less than paying 50 percent of the hospital facility fees. In response to Representative Cissna's earlier question, she replied that many women from rural areas come to Juneau to deliver their babies, and if they have Denali KidCare coverage, this will pay for the travel and lodging expenses, whether the women have their babies at the birth center or at the hospital. However, if there is a hospital in the rural area, Denali KidCare will cover the mother at that hospital, but not cover her to travel to Juneau to deliver her baby. MS. KANNE replied to an earlier remark by Mr. Nielson: I have never seen anybody have a home birth and then go to a birth center birth; once they've had a home birth, they're always going to have a home birth. What I do see is women who choose to have a hospital birth because they can't afford the facility fee. One thing we do at a nonprofit birth center is we donate that facility fee if people cannot afford to pay, or we offer them a sliding scale. And it does make it hard for our ... nonprofit birth center to pay the bills. And I think it is really important to support our birth centers and to keep our doors open; we do need to be on an even playing field with the hospitals as far as getting reimbursement from Medicaid. CHAIR WILSON remarked that she assumes that midwives' charges are less than the doctors' charges. MS. KANNE replied, "Midwives charges are less than a physicians', and Medicaid pays midwives at a lower rate than they pay physicians. ... We do get paid by Medicaid, but probably we get ... 60 percent of what physicians get." 4:19:44 PM CHAIR WILSON closed public testimony. 4:19:52 PM REPRESENTATIVE SEATON moved to adopt Conceptual Amendment 1, which would make the provisions of Section 1 contingent upon approval of matching funding from the federal Medicaid. There being no objection, Conceptual Amendment 1 was adopted. 4:20:22 PM REPRESENTATIVE KOHRING commented that he thinks it is good to encourage people to attend birthing centers, however, he stated, "From a philosophical standpoint, I just am concerned about the fact that we're encouraging use of Medicaid monies for what you had described as not a sickness...." He questioned the wisdom of using Medicaid dollars when "if they're young, capable of producing children and they're healthy, they ought to figure out a way to pay their own bills." He said, "I think that perhaps we ought to go the other direction and not encourage Medicaid payments either in these kind of facilities or in hospital situations, and perhaps that will be an incentive for women to go to these kind of facilities." He continued, "My point is that maybe we ought to discourage the use of Medicaid monies and not encourage the use of Medicaid monies." 4:22:47 PM REPRESENTATIVE CRAWFORD clarified that this bill is not to encourage more people to use Medicaid, but to allow those people who are already on Medicaid to use a lower cost facility. 4:23:21 PM REPRESENTATIVE SEATON moved to report HB 111, as amended, out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, CSHB 111(HES) was reported from the House Health, Education and Social Services Standing Committee.
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