Legislature(1999 - 2000)

02/08/1999 03:15 PM L&C

Audio Topic
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
txt
                                                                                                                                
HB 10 - EXTEND CERTIFIED DIRECT-ENTRY MIDWIVES BD                                                                               
                                                                                                                                
Number 0049                                                                                                                     
                                                                                                                                
CHAIRMAN ROKEBERG announced the committee had before it HB 10, "An                                                              
Act extending the termination date of the Board of Certified                                                                    
Direct-Entry Midwives; and providing for an effective date."                                                                    
                                                                                                                                
Number 0064                                                                                                                     
                                                                                                                                
REPRESENTATIVE BILL HUDSON, Alaska State Legislature, came forward                                                              
to present HB 10 as the legislation's sponsor.  He thanked the                                                                  
chairman for his welcome, noting the references to his previous                                                                 
service on the House Labor and Commerce Standing Committee.                                                                     
Representative Hudson stated that HB 10 would extend the operation                                                              
of the Board of Certified Direct-Entry Midwives (CDMs) for another                                                              
four years to June 30, 2003.  He indicated board members and                                                                    
midwives were present to answer questions.  Representative Hudson                                                               
commented that Alaska was among the forerunners in the worldwide                                                                
movement to establish a midwifery model of care as an alternative                                                               
choice to the medical model, as noted in the sponsor statement,                                                                 
and, since the board was in its final year, he indicated some                                                                   
legislation must pass this session if the board was to continue.                                                                
He noted they appreciated the timely hearing of the legislation.                                                                
Representative Hudson indicated he would be happy to try to answer                                                              
any questions before stepping back to allow others to testify on                                                                
the good works of the Board of Certified Direct-Entry Midwives and                                                              
to answer questions.                                                                                                            
                                                                                                                                
CHAIRMAN ROKEBERG asked Representative Hudson about the decision to                                                             
use the year 2003, rather than 2004, as was recommended in the                                                                  
audit report done by the Division of Legislative Audit [audit                                                                   
control number: 08-1454-9; January 9, 1998].                                                                                    
                                                                                                                                
Number 0267                                                                                                                     
                                                                                                                                
REPRESENTATIVE HUDSON indicated the same bill had been introduced                                                               
the previous session, originating on the Senate side and he thought                                                             
the 2003 date had come from discussion that year with the prime                                                                 
sponsor of the previous Senate bill, and Kaye Kanne and some of the                                                             
others, in order to avoid contention.  In answer to Chairman                                                                    
Rokeberg's follow-up question, Representative Hudson confirmed that                                                             
previous bill had not made it to "conference."                                                                                  
                                                                                                                                
CHAIRMAN ROKEBERG noted the committee would proceed to further                                                                  
testimony and indicated the 2003 issue might be addressed later.                                                                
                                                                                                                                
Number 0379                                                                                                                     
                                                                                                                                
MARILYN HOLMES, Public Member and Secretary, Board of Certified                                                                 
Direct-Entry Midwives; Member, Citizens for Midwifery, came forward                                                             
to testify in support of HB 10.  Ms. Holmes stated Citizens for                                                                 
Midwifery was a national grassroots organization which promoted                                                                 
midwifery in general.  She commented the organization promoted the                                                              
midwifery model of care:  medical midwives as well as direct-entry                                                              
midwives.  Ms. Holmes referred to the past legislative session's HB
459 which provided Medicaid funding to certified direct-entry                                                                   
midwives.  Ms. Holmes indicated the reason the board had not been                                                               
extended the previous year was because of some confusion around the                                                             
comparatively high licensing fees for certified direct-entry                                                                    
midwives.  She indicated the fees were high because there were                                                                  
currently very few certified direct-entry midwives in Alaska, but                                                               
because they were becoming licensed their numbers would increase as                                                             
time went on.  She added that it was to the state's advantage to                                                                
regulate and license midwives in order to have control over safety                                                              
issues and the other items governed by licensure.  Ms. Holmes said                                                              
the previous year's sunset bill had gotten somewhat "hung-up" on                                                                
that issue of Medicaid funding.  She noted the Medicaid funding had                                                             
gone through and was now available for direct-entry midwives; it                                                                
should now just be a matter of course to extend the board because                                                               
if there were midwives practicing and receiving third-party                                                                     
reimbursement, they should be regulated.                                                                                        
                                                                                                                                
REPRESENTATIVE CISSNA confirmed with Ms. Holmes that the receipt of                                                             
Medicaid funding did not change the higher licensing fees.                                                                      
                                                                                                                                
Number 0551                                                                                                                     
                                                                                                                                
MS. HOLMES indicated the receipt of funding did not change the fees                                                             
but it did mitigate them, noting that there was now another market                                                              
for the services so there would be an expansion of the profession                                                               
into that area.  She indicated the licensing fees would decrease as                                                             
the number of midwives increased.  Ms. Holmes additionally                                                                      
indicated the board's costs would decrease because increased                                                                    
regulation of midwives would reduce the number of people operating                                                              
outside of the system, lowering the board's costs associated with                                                               
investigations.  She said the more regulation and more state                                                                    
control over the body of midwives, the less cost to the state.  Ms.                                                             
Holmes added that the state actually made money on midwifery                                                                    
through Medicaid dollars, explaining that a midwifery birth cost                                                                
approximately 57 percent of a medical birth.  Therefore, the same                                                               
mother on Medicaid receiving care would be paying less and the                                                                  
state would be paying less.  Ms. Holmes added that the babies were                                                              
healthy, with few problems, so follow-up costs were lower.                                                                      
Additionally, she said these babies were breast-fed most of the                                                                 
time, which made for healthier babies, so there were lower costs                                                                
down the line.                                                                                                                  
                                                                                                                                
REPRESENTATIVE SANDERS asked if the Medicaid payment was a lump sum                                                             
to the state or if it was per each birth.                                                                                       
                                                                                                                                
Number 0700                                                                                                                     
                                                                                                                                
MS. HOLMES replied it was per each birth.  She commented there were                                                             
4,500 pregnant women in the state.  In response to Representative                                                               
Sanders' further question about how the state would save money, Ms.                                                             
Holmes indicated the state matched funds to the Medicaid dollars                                                                
received from the federal government.                                                                                           
                                                                                                                                
CHAIRMAN ROKEBERG clarified that there were "two different baskets                                                              
of money, so to speak," and there was no connection between                                                                     
licensing fees and state savings.  He said he appreciated Ms.                                                                   
Holmes' point of view that Medicaid costs to the state were reduced                                                             
by using direct-entry midwives' services, but he indicated there                                                                
was no resulting monetary benefit to the board.                                                                                 
                                                                                                                                
Number 0763                                                                                                                     
                                                                                                                                
REPRESENTATIVE HALCRO asked how many licensed certified                                                                         
direct-entry midwives there were as of January 1999.                                                                            
                                                                                                                                
MS. HOLMES said she thought the number was 19.                                                                                  
                                                                                                                                
AN UNIDENTIFIED SPEAKER noted the number was 14.                                                                                
                                                                                                                                
Number 0777                                                                                                                     
                                                                                                                                
REPRESENTATIVE HALCRO referred to the auditor comments section of                                                               
the audit report, noting the comments seemed a bit dated because                                                                
they spoke of a July 1997 letter.  He indicated the comments spoke                                                              
of the high licensing fees as a barrier to entry into the                                                                       
profession and asked Ms. Holmes if she thought having Medicaid                                                                  
reimbursement would help draw more people into the program.                                                                     
Representative Halcro commented the audit report noted 15 licensed                                                              
CDMs, so apparently one had been lost.                                                                                          
                                                                                                                                
MS. HOLMES said she was unsure about the count of 14.                                                                           
                                                                                                                                
Number 0825                                                                                                                     
                                                                                                                                
CATHERINE REARDON, Director, Division of Occupational Licensing,                                                                
Department of Commerce and Economic Development, stated she would                                                               
call to confirm that information, at the chairman's request.                                                                    
                                                                                                                                
Number 0833                                                                                                                     
                                                                                                                                
MS. HOLMES replied, in response to Representative Halcro's                                                                      
question, that the licensed midwives were happy to pay their fees                                                               
and willing to carry that cost.  She said she thought it had been                                                               
conjecture on the part of the auditor that the high fees were a                                                                 
possible deterrent to the profession's growth.  Ms. Holmes                                                                      
commented they had created a procedures guide in the last year                                                                  
which clearly spelled out the fee structure.  She indicated she                                                                 
thought this had not deterred anyone; in many ways it had made it                                                               
clearer.  She said people were trying to apply all the time.  Ms.                                                               
Holmes said she thought it was difficult to become licensed in                                                                  
Alaska because of the many requirements, including tests and a                                                                  
large number of births.  She indicated she thought the level of                                                                 
difficulty was appropriate.  Ms. Holmes noted, however, the money                                                               
was only part of it, and now that they had the Medicaid                                                                         
reimbursement there would be more money to go around.                                                                           
                                                                                                                                
REPRESENTATIVE MURKOWSKI asked if Ms. Holmes could tell her how                                                                 
many pregnant women would use a midwife's services as opposed to                                                                
the services of a regular physician.  She commented on information                                                              
in the bill packet stating that 95 percent would use a physician                                                                
and four percent would use a midwife.                                                                                           
                                                                                                                                
Number 0932                                                                                                                     
                                                                                                                                
MS. HOLMES replied that there were 4,500 pregnant women in Alaska                                                               
eligible for Medicaid, noting those were just the Medicaid births.                                                              
She indicated she thought midwifery births accounted for about five                                                             
percent of all births, both in Alaska and nationally, and the                                                                   
numbers were increasing.  Ms. Holmes referred to materials in the                                                               
bill packet pointing out that the countries with the lowest                                                                     
incident of infant mortality used midwives for 70 percent of                                                                    
births, without a physician in attendance.  She emphasized this was                                                             
the model that was the safest and was having the best effect in the                                                             
world, indicating the United States was twenty-second on the list                                                               
in terms of birth outcomes.  Ms. Holmes noted the United States                                                                 
might use a medical model for 95 percent of its births but it was                                                               
twenty-second when it came to safety.                                                                                           
                                                                                                                                
Number 0997                                                                                                                     
                                                                                                                                
REPRESENTATIVE CISSNA said she had some questions about the                                                                     
apparent high number of unlicensed individuals.  She confirmed from                                                             
Ms. Holmes that unlicensed midwives had to go through enough births                                                             
in order to qualify for licensure and this was part of the reason                                                               
for having apprentices.                                                                                                         
                                                                                                                                
Number 1054                                                                                                                     
                                                                                                                                
PAM WEAVER, Chair, Board of Certified Direct-Entry Midwives; Board                                                              
Member, North American Registry of Midwives (NARM), testified next                                                              
via teleconference from Anchorage in support of HB 10.  She                                                                     
indicated she was a practicing licensed certified direct-entry                                                                  
midwife in Anchorage.  She noted the North American Registry of                                                                 
Midwives was the national certification board; she said she also                                                                
served as liaison to state legislators and policymakers.  Ms.                                                                   
Weaver indicated she had spoken with the Division of Medical                                                                    
Assistance, Department of Health and Social Services, for some                                                                  
updated facts and figures that morning.  She stated approximately                                                               
45 percent of Alaskan pregnant women were currently eligible for                                                                
Medicaid, and her understanding was that another approximately 800                                                              
pregnant women were expected to become eligible as of April 1                                                                   
because the federal poverty guidelines were changing.  Ms. Weaver                                                               
noted Ms. Holmes had mentioned 4,500, but she indicated she had                                                                 
heard the number 10,000 from Nancy Weller's office [Nancy Weller,                                                               
Medical Assistance Administrator, Division Medical Assistance,                                                                  
Department of Health and Social Services] that morning.  Ms. Weaver                                                             
indicated this figure made approximately 50 percent of the market                                                               
accessible to midwives, which she said was "going to change the                                                                 
face of direct-entry midwifery and out-of-hospital births here in                                                               
Alaska."  On that note Ms. Weaver said she highly recommended the                                                               
extension of the board as a regulatory process:  keeping the                                                                    
oversight, guiding the issues and public safety, the "minimal"                                                                  
competency of practitioners, et cetera.                                                                                         
                                                                                                                                
CHAIRMAN ROKEBERG asked if Ms. Weaver could clarify the difference                                                              
between the legislation's 2003 extension date and the legislative                                                               
audit's recommendation.                                                                                                         
                                                                                                                                
Number 1211                                                                                                                     
                                                                                                                                
MS. WEAVER stated she knew the auditors had recommended a six-year                                                              
board extension because the auditors had given them "high marks                                                                 
(indisc.) as a board," and said she also understood, from                                                                       
conversations with legislators, that it was rare or nonexistent for                                                             
board to be extended past the normal four years.  Commenting that                                                               
she hadn't been involved the discussions regarding the 2003 date,                                                               
Ms. Weaver said she assumed it was a happy medium.                                                                              
                                                                                                                                
CHAIRMAN ROKEBERG noted Ms. Reardon's return and requested her                                                                  
clarification on the previously-mentioned number of licensees.                                                                  
                                                                                                                                
Number 1256                                                                                                                     
                                                                                                                                
CATHERINE REARDON, Director, Division of Occupational Licensing,                                                                
Department of Commerce and Economic Development, stated her                                                                     
division provided the staff assistance to the Board of Certified                                                                
Direct-Entry Midwives.  Ms. Reardon said there were currently 14                                                                
licensed midwives and 6 licensed apprentices.  She said the                                                                     
expiration and renewal date had been December 31, 1998, and it was                                                              
not unusual to see one or two people choose not to renew but,                                                                   
generally, that loss was regained as new people came in during the                                                              
two-year period.  Ms. Reardon commented that perhaps one or two of                                                              
the apprentices would move up.  She confirmed for the chairman that                                                             
the biennial cycle ran January 1, 1999, to 2000.                                                                                
                                                                                                                                
Number 1305                                                                                                                     
                                                                                                                                
CHAIRMAN ROKEBERG asked if there were any further questions for Ms.                                                             
Weaver.                                                                                                                         
                                                                                                                                
REPRESENTATIVE MURKOWSKI observed there was a discrepancy between                                                               
the number of licensed midwives, 14, and the number of                                                                          
Medicaid-eligible women.  She asked what efforts were being made to                                                             
recruit and train more [midwives].                                                                                              
                                                                                                                                
Number 1344                                                                                                                     
                                                                                                                                
MS. WEAVER responded that all of those women were not necessarily                                                               
going to choose, or be eligible for, direct-entry midwifery care,                                                               
noting that CDMs could only attend low-risk women through their                                                                 
pregnancies and childbirth.  Ms. Weaver indicated the majority of                                                               
those women would choose or fall into the conventional medical                                                                  
model of care.  Ms. Weaver stated the majority of that eligible 50                                                              
percent of pregnant women would choose physicians or in-hospital                                                                
care with certified nurse midwives.  She indicated, however, the                                                                
small fraction certified direct-entry midwives would receive of                                                                 
those Alaskan Medicaid-eligible women was a great deal more than                                                                
the current zero amount.                                                                                                        
                                                                                                                                
REPRESENTATIVE MURKOWSKI asked again if there were efforts being                                                                
made to recruit and train additional midwives, noting these efforts                                                             
would probably not be through the licensing board.                                                                              
                                                                                                                                
Number 1403                                                                                                                     
                                                                                                                                
MS. WEAVER answered in the affirmative.  She indicated there were                                                               
education and advocacy efforts in place and advancing, commenting,                                                              
"Getting the word out about midwifery model of care specifically,                                                               
out-of-hospital births, safety issues, and all of those things that                                                             
you can imagine would be of concern to policymakers and the                                                                     
public."                                                                                                                        
                                                                                                                                
CHAIRMAN ROKEBERG mentioned the July 7, 1997, letter from Ms.                                                                   
Reardon in the audit which contained eight suggestions for                                                                      
cost-containment on the board to lower the rather high biennial                                                                 
licensing fees caused by the relatively small number of licensees.                                                              
He asked Ms. Weaver if the board had considered the suggestions and                                                             
if anything had come of those recommendations.                                                                                  
                                                                                                                                
Number 1464                                                                                                                     
                                                                                                                                
MS. WEAVER said, speaking as a member of the association, that they                                                             
had definitely considered the suggestions.  She said the board had                                                              
also discussed the suggestions and she herself had spoken with Ms.                                                              
Reardon at fair length about them.  Ms. Weaver indicated none of                                                                
the points satisfied the association enough for the association to                                                              
advocate moving towards the suggestions.  She noted Ms. Reardon's                                                               
presence at the meeting and said their discussion was more                                                                      
regarding the fiscal matters if the board was or was not extended                                                               
as a result of those eight points.  Ms. Weaver added it was her                                                                 
recollection that there would not be an appreciable decrease in the                                                             
licensure fees should the board not be extended.                                                                                
                                                                                                                                
CHAIRMAN ROKEBERG said he had been struck by the recommendation to                                                              
lower the board size from the current five members.  He commented                                                               
it seemed the board had a pretty good cross-section:  a mandated                                                                
nurse midwife, a physician in the area, two midwives [certified                                                                 
direct-entry midwives], and a public member.  He asked if going to                                                              
three members would hurt the board's ability "to have proper                                                                    
oversight and input into the activities of the board."                                                                          
                                                                                                                                
Number 1569                                                                                                                     
                                                                                                                                
MS. WEAVER replied she personally thought that was a possibility.                                                               
She said she was not sure if that change could ever be successfully                                                             
proposed, indicating legislators in 1992 when the statute was                                                                   
enacted were strongly in favor of the board's current composition.                                                              
Ms. Weaver noted she personally wouldn't mind seeing it reduced,                                                                
commenting on the situation of members from one profession                                                                      
governing members of another profession.                                                                                        
                                                                                                                                
CHAIRMAN ROKEBERG noted it was the committee's purview to make sure                                                             
the regulatory structure was in place and working effectively.  He                                                              
asked to what degree they relied on the department for their                                                                    
licensing and examinations.                                                                                                     
                                                                                                                                
Number 1628                                                                                                                     
                                                                                                                                
MS. WEAVER indicated their licensing examiner accepted and screened                                                             
applications initially before forwarding the applications to the                                                                
board for review.  She stated, "He also (indisc.) with the national                                                             
testing agency for test dates for those applicants who are ready to                                                             
test."  Ms. Weaver indicated the licensing examiner additionally                                                                
arranged for proctors and performed the staff duties of that                                                                    
nature.  She confirmed for the chairman that they used the national                                                             
standardized examination.  She added that the national                                                                          
certification board she belonged to [NARM] had developed this                                                                   
examination.                                                                                                                    
                                                                                                                                
CHAIRMAN ROKEBERG confirmed there were no more questions for Ms.                                                                
Weaver.                                                                                                                         
                                                                                                                                
Number 1698                                                                                                                     
                                                                                                                                
KAYE KANNE, Midwives Association of Alaska; Member, Board of                                                                    
Certified Direct-Entry Midwives, came forward to testify in support                                                             
of HB 10.  Ms. Kanne stated she was a practicing certified                                                                      
direct-entry midwife in Juneau, noting she had been practicing here                                                             
for 15 years and the previous April they had opened a freestanding,                                                             
nonprofit birth center in Juneau.  She invited the committee                                                                    
members to visit the birth center.  Ms. Kanne addressed some of the                                                             
questions which had arisen.  She stated that they did 10 percent of                                                             
the births in Juneau and sometimes more.  At the birth center there                                                             
was another certified direct-entry midwife and herself, and three                                                               
students.  Ms. Kanne indicated the 10 percent figure was based on                                                               
500 births a year in Juneau, although sometimes there were fewer                                                                
than 500 births, of which the midwives were doing at least 50.  She                                                             
stated she was really proud of the certified direct-entry midwives                                                              
in Alaska and their accomplishments, noting she had served on the                                                               
board since its inception in 1992 and had worked very hard to get                                                               
the board into place.  She said she felt they really had                                                                        
accomplished a lot in that time:  written the regulations, defined                                                              
the scope of practice, and defined the required course of study for                                                             
apprentices.  She noted the statistics for midwives in Alaska had                                                               
been very good.  Ms. Kanne said she thought the midwives as a group                                                             
were doing very well.  They continued to provide quality care for                                                               
low-risk women who chose that option.  She noted that option was                                                                
low-cost in addition to being safe, indicating it was available for                                                             
people without insurance or for those who didn't qualify for                                                                    
Medicaid.  She clarified for Representative Sanders that there were                                                             
two midwives in Juneau and they did all the births together as a                                                                
team.                                                                                                                           
                                                                                                                                
REPRESENTATIVE SANDERS asked what their capacity was, wondering                                                                 
whether they could do one birth a week and be adequate.                                                                         
                                                                                                                                
Number 1807                                                                                                                     
                                                                                                                                
MS. KANNE replied that sometimes they did three or four births a                                                                
week, noting the births tended to come in bunches, with sometimes                                                               
four in one week and none in the next.  She said they could                                                                     
probably do twice that and still be functioning very well,                                                                      
mentioning they had three students who worked very hard also.  Ms.                                                              
Kanne noted she thought their maximum capacity, doing it well,                                                                  
would be ten births a month as a group, two midwives together.  She                                                             
said they were actually recruiting for a third midwife.  Ms. Kanne                                                              
referred to the figure of six that had been given for licensed                                                                  
apprentices.  Ms. Kanne stated there were many more apprentices                                                                 
than that in the state of Alaska; she knew because she had three                                                                
apprentices who were not licensed with the state at that point.                                                                 
Ms. Kanne said, "There is a loophole in the law that says that you                                                              
don't have to be a licensed apprentice until ... maybe the last two                                                             
years of their apprenticeship and they'll get ... their                                                                         
certification and then go into -- and I have a waiting list of four                                                             
people who want to be midwives -- so there's definitely a lot of                                                                
women out there that do want to be certified direct-entry midwives                                                              
and are working towards that goal."  She stated the cost of the                                                                 
license was not a deterrent to the midwives; they would like it to                                                              
be lower but were willing to pay because they thought having the                                                                
board was very important.  Ms. Kanne noted the apprenticeship for                                                               
certified direct-entry midwives was less expensive than going to                                                                
medical school or becoming a certified nurse midwife, for example.                                                              
She said the apprentices didn't have student loans that needed to                                                               
be repaid once they began practicing, indicating the licensing fee                                                              
could just be considered part of the education cost.                                                                            
                                                                                                                                
REPRESENTATIVE MURKOWSKI noted Ms. Kanne mentioned she had both                                                                 
licensed and unlicensed apprentices.  Representative Murkowski                                                                  
asked what the difference was for a licensed apprentice versus a                                                                
non-licensed apprentice in their responsibilities and what they                                                                 
could do.                                                                                                                       
                                                                                                                                
Number 1893                                                                                                                     
                                                                                                                                
MS. KANNE clarified that apprentices were not licensed:  it was                                                                 
just a certificate which said the person could be an apprentice.                                                                
She noted all apprentices had to have direct in-room supervision                                                                
from a certified direct-entry midwife.                                                                                          
                                                                                                                                
CHAIRMAN ROKEBERG asked Ms. Kanne to explain how her care would                                                                 
compare to that of an "OB/GYN" [physician specializing in                                                                       
obstetrics and gynecology] in terms of post and prenatal care, and                                                              
the entire services she brought to a birth.                                                                                     
                                                                                                                                
Number 1935                                                                                                                     
                                                                                                                                
MS. KANNE indicated that was a very long explanation.  She stated                                                               
that, first of all, they spent a lot more time with women.  For a                                                               
normal prenatal visit, midwives would spend an hour with a woman                                                                
instead of ten minutes or whatever.  The midwives spent a lot more                                                              
time on nutrition, on the woman's overall health.  She indicated                                                                
they checked on how the woman was feeling and on areas she might                                                                
want to know more about.  Regarding postpartum, the midwives spent                                                              
the entire labor with the woman, rather than coming in just at the                                                              
end and delivering the baby.  They also stayed with the woman after                                                             
the birth.  After the birth the midwives visited the woman every                                                                
day for three days; they saw the woman at one, two, three, four and                                                             
six weeks after the birth.  At each one of those visits they did                                                                
well-baby checks, and checked the mother for everything:  how she                                                               
was doing physically and emotionally, how was breastfeeding going,                                                              
how was her life in general.  Ms. Kanne said they had new mother                                                                
breastfeeding support groups and brought in speakers every week on                                                              
subjects like infant massage, breastfeeding and bonding, and                                                                    
vaccinations.  She noted most midwives did the same thing she did.                                                              
She commented that there was more of a continuity of care with the                                                              
women the midwives saw; there was a relationship that developed.                                                                
                                                                                                                                
CHAIRMAN ROKEBERG indicated he would like Ms. Kanne to give the                                                                 
committee an estimate of the cost for her services to one patient                                                               
versus the cost for a typical medical birth.                                                                                    
                                                                                                                                
Number 1991                                                                                                                     
                                                                                                                                
MS. KANNE replied that the charge for all of their care was $2,800                                                              
with an additional $800 if the patient had her baby at the birth                                                                
center.  She noted those figures did not include lab or ultrasound.                                                             
Ms. Kanne said the physicians' fees in Juneau were comparable to                                                                
the midwives' fees; the hospital itself made most births cost well                                                              
over $5,000, and if the women had medications, epidurals,                                                                       
interventions, the cost could be close to $10,000.                                                                              
                                                                                                                                
CHAIRMAN ROKEBERG commented, "So it's a facility that you provide                                                               
as much as the services, and then there's a shift in the philosophy                                                             
of services and time too, is that correct?"                                                                                     
                                                                                                                                
MS. KANNE agreed, noting they did home births as well as birth                                                                  
center births.                                                                                                                  
                                                                                                                                
CHAIRMAN ROKEBERG asked how it worked in terms of their training                                                                
with that major issue:  when they thought there was an anomaly and                                                              
referred to a physician.  He questioned how their training gave                                                                 
them the ability to alert themselves to the fact they needed                                                                    
additional medical expertise.                                                                                                   
                                                                                                                                
Number 2038                                                                                                                     
                                                                                                                                
MS. KANNE stated that when they needed to refer was spelled out                                                                 
very clearly in their regulations and scope of practice.  She                                                                   
added, however, that there was also the intuition all midwives had                                                              
that a particular birth just wasn't going very well.  Ms. Kanne                                                                 
commented her transport rate was about 10 percent.  She indicated                                                               
this was mostly first-time mothers and the labor was taking too                                                                 
long - either the membranes had been ruptured too long or the                                                                   
contractions were just too painful, they were not progressing, and                                                              
the woman might need an epidural.  She said if there was an                                                                     
immediate complication which had to be dealt with at that moment,                                                               
for example, a postpartum hemorrhage or a baby that needed to be                                                                
resuscitated, the midwives were trained to deal with that and then                                                              
transport.                                                                                                                      
                                                                                                                                
CHAIRMAN ROKEBERG noted there had been two pieces of legislation                                                                
passed to assist midwives in terms of insurance coverage mandates                                                               
and the previously-mentioned Medicaid coverage.  He indicated that                                                              
had gone into effect the previous year.  Chairman Rokeberg asked                                                                
how much increase they had seen in their business, particularly                                                                 
from the Medicaid eligibility aspects.                                                                                          
                                                                                                                                
Number 2081                                                                                                                     
                                                                                                                                
MS. KANNE replied the Medicaid [reimbursement] would begin February                                                             
12; the regulations had taken that long to be completed and signed                                                              
into law.  Ms. Kanne said they had continued to take Medicaid                                                                   
clients in the meantime and written them off as part of the                                                                     
nonprofit birth center, noting they hadn't turned anyone away.                                                                  
                                                                                                                                
CHAIRMAN ROKEBERG commented on the excellent lesson this provided                                                               
for the newer committee members regarding the effective date of                                                                 
legislation and the time it took to implement regulations before                                                                
there was actual practical effect of passing legislation.                                                                       
                                                                                                                                
Number 2116                                                                                                                     
                                                                                                                                
REPRESENTATIVE SANDERS commented on an article about midwives in                                                                
that morning's Anchorage Daily News.  He highly recommended it to                                                               
everyone, indicating it was approximately 20 pieces of Eskimo                                                                   
advice from the times before Western physicians.                                                                                
                                                                                                                                
Number 2147                                                                                                                     
                                                                                                                                
REPRESENTATIVE MURKOWSKI asked Ms. Kanne to describe the                                                                        
professional relationship between the physicians in Juneau and the                                                              
midwives.  She asked if the physicians viewed the midwives as a                                                                 
professional threat because the midwives were taking some of their                                                              
patients, or if the physicians had accepted the obvious benefits                                                                
that came from midwifery.                                                                                                       
                                                                                                                                
Number 2165                                                                                                                     
                                                                                                                                
MS. KANNE responded she thought it depended on the individual                                                                   
doctor.  She said she would say in Juneau she had always had a good                                                             
relationship with the physicians.  Ms. Kanne indicated she felt                                                                 
there was some healthy fiscal competition, but she thought the                                                                  
relationship was very healthy for the most part.  Ms. Kanne stated                                                              
the midwives were autonomous practitioners, they did not require                                                                
physician backup.  In other words, they did not have to have an                                                                 
official relationship with a physician.  She said she thought that                                                              
made the physicians feel more comfortable because the physicians                                                                
did not have to say officially that they backed the midwives up, so                                                             
they then did back them up in reality.  Ms. Kanne said the                                                                      
physicians were there for the midwives, the midwives could call                                                                 
them at any time.                                                                                                               
                                                                                                                                
CHAIRMAN ROKEBERG noted that the committee had received written                                                                 
testimony as well from Ms. Kanne.  He invited Ms. Reardon forward                                                               
again.                                                                                                                          
                                                                                                                                
Number 2208                                                                                                                     
                                                                                                                                
CATHERINE REARDON, Director, Division of Occupational Licensing,                                                                
Department of Commerce and Economic Development, came forward again                                                             
to testify.  She stated the department strongly supported the                                                                   
legislation and the continuation of the Board of Certified                                                                      
Direct-Entry Midwives.  Ms. Reardon clarified that her previously-                                                              
referred-to memorandum in the audit was her list of all of the                                                                  
possible steps she could think of for somewhat lower licensing                                                                  
fees; it was not a list of recommended actions.  Ms. Reardon noted                                                              
most of the items on the list would have some significant negative                                                              
effects.  She indicated one of those items had been eliminating the                                                             
board and having the department regulate the profession directly,                                                               
which meant she and her staff would be writing the regulations and,                                                             
more importantly, without the necessary knowledge determining                                                                   
whether someone had practiced competently as a midwife.  Ms.                                                                    
Reardon indicated her division would probably end up having to hire                                                             
experts to review files and such, and that these costs might be                                                                 
more than the cost of the board.  She said, therefore, they found                                                               
having a board very useful, especially in a profession like this.                                                               
Ms. Reardon mentioned one of the other items which related to the                                                               
current five-member board size of one nurse midwife, one                                                                        
obstetrician, two certified direct-entry midwives, and one public                                                               
member.  She indicated one of the possible downsides from reducing                                                              
the board to three members was the possibility that one of the                                                                  
members would have a conflict of interest related to a disciplinary                                                             
procedure and would be unable to vote.                                                                                          
                                                                                                                                
MS. REARDON stated she knew it had been important to both the                                                                   
nursing and medical professions to be able to be involved in the                                                                
discussions and decisions involving direct-entry midwifery.  She                                                                
said this was because midwifery was relatively new in terms of a                                                                
state-licensed function.  Ms. Reardon indicated she thought having                                                              
some representation from those other professions was part of the                                                                
compromises that permitted the creation of the board.  She noted                                                                
she thought there might be some concerns if they were to disrupt                                                                
the consensus that had developed.  Ms. Reardon stated she                                                                       
personally thought having the option of certified direct-entry                                                                  
midwifery was very valuable to Alaskan women and she would not want                                                             
to see it disappear.  She said she thought they did need both the                                                               
medical model and the certified direct-entry midwife model, noting                                                              
CDMs handled the low-risk cases.  Ms. Reardon indicated she thought                                                             
they might hear from the nurse midwives and the physicians noting                                                               
some of the difference in cost was because the more expensive cases                                                             
would go to the medical model.  She commented she thought that was                                                              
appropriate and only made sense.  Ms. Reardon encouraged the                                                                    
committee to pass the legislation, stating she would be happy to                                                                
answer any questions.                                                                                                           
                                                                                                                                
Number 2366                                                                                                                     
                                                                                                                                
REPRESENTATIVE BRICE confirmed from Ms. Reardon that the certified                                                              
direct-entry midwives paid for the administration of their board                                                                
100 percent.                                                                                                                    
                                                                                                                                
REPRESENTATIVE CISSNA asked about the distribution of the midwives                                                              
throughout the state.  She asked how many of the licensed CDMs were                                                             
located in the Bush, and if there were unlicensed apprentices in                                                                
the Bush who did not have access to a licensed midwife.                                                                         
Representative Cissna mentioned the high cost of bringing people in                                                             
from the Bush, and just the problems there were with childbirth and                                                             
the possibilities in the Bush.                                                                                                  
                                                                                                                                
Number 2406                                                                                                                     
                                                                                                                                
MS. REARDON replied she did not believe very many, if any, of their                                                             
licensed midwives were actually in a village, and she said that                                                                 
perhaps some of the midwives that had testified could give the most                                                             
feedback about the reasons for that.  Ms. Reardon noted part of it                                                              
was that they were talking about a licensed profession which had                                                                
only developed since 1993.  She stated there was an exemption in                                                                
the law for practice of midwifery that was part of a person's                                                                   
cultural inheritance and she indicated she thought that was likely                                                              
intended initially to cover probably Native midwives in villages.                                                               
Ms. Reardon further indicated the exemption's wording had created                                                               
some problems because people from many backgrounds and distances                                                                
from that cultural tradition could perhaps legally claim coverage                                                               
under the exemption, although that may not have been the                                                                        
exemption's intent.  However, she said she thought for that reason                                                              
there very well might be Native midwives in villages who were                                                                   
legally exempt and who were practicing.  Ms. Reardon stated she                                                                 
would be happy to provide the committee with a list of addresses                                                                
for the 14 midwives the division had.  She commented she suspected                                                              
there were two midwives in Juneau because Ms. Kanne had been active                                                             
in reaching out to the community and in the training of other                                                                   
midwives.                                                                                                                       
                                                                                                                                
Number 2474                                                                                                                     
                                                                                                                                
CHAIRMAN ROKEBERG confirmed there was no one else who wished to                                                                 
testify on HB 10 and stated the public hearing was closed.                                                                      
                                                                                                                                
Number 2485                                                                                                                     
                                                                                                                                
REPRESENTATIVE BRICE made a motion to move HB 10 out of committee                                                               
with individual recommendations and the accompanying zero fiscal                                                                
note.  There being no objections, HB 10 moved out of the House                                                                  
Labor and Commerce Standing Committee.                                                                                          

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