Legislature(2013 - 2014)BARNES 124
04/15/2014 03:15 PM House LABOR & COMMERCE
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SB 156-DIRECT-ENTRY MIDWIVES 3:26:01 PM CHAIR OLSON announced that the first order of business would be SENATE BILL NO. 156, "An Act relating to direct-entry midwives." 3:26:06 PM HEATHER SHATTUCK, Staff, Senator Pete Kelly, Alaska State Legislature, stated the concept for SB 156 was brought to the sponsor by the Midwives Association of Alaska. The statutes pertaining to the practice of midwifery were put into place in 1992 but have not been updated since. Placing specific practices of a profession in statute stymies growth and management of the profession. These initial required practices were placed into statute prior to a functioning board of certified direct-entry midwives MS. SHATTUCK said the Board of Certified Direct-Entry Midwives (BCDM) has tried to establish and develop a comprehensive regulatory framework through practice regulations and guidelines crafted to ensure public safety and professional discipline. However, the outdated statute cements certain obsolete practice requirements in place and can only be updated by an act of the legislature. This bill will update the statutes and place the certified direct-entry midwives into regulation rather than statute. The proposed changes in the bill will also ensure greater public safety in the field of midwifery. This enables the Board to oversee the profession more effectively and incorporate current nationally-recognized best practices. This type of authority is granted to most professional boards in order to develop and maintain professional practice standards. The public safety provisions are addressed in a few ways. The midwives association requested a higher threshold of training in order for a licensed certified direct-entry midwife (CDM) to act as a supervisor to an apprentice midwife. In addition to the requirement to be licensed and practicing for two years, the bill further requires a licensed CDM to attend 50 or more births as a primary or assistant midwife in order to supervise an apprentice direct-entry midwife. The proposed changes to the threshold will ensure a greater level of expertise prior to providing supervision. The also would help ensure greater public safety in the field of midwifery. 3:28:28 PM MS. SHATTUCK related that under SB 156 well-baby care will also be covered under the scope of CDM practice for up to four weeks after birth. This helps to ensure that the delivering midwife can properly follow up with both mother and baby, and it helps ensure the baby will thrive while midwives can maintain an ongoing relationship with the patient. Additionally, some required tests for newborns are performed after the current seven-day set-off in statute. This has put midwives in the situation of providing services without being reimbursed, where applicable, by Medicaid. MS. SHATTUCK said that SB 156 also repeals the cultural midwives exemption, requiring all CDMs in the state to be licensed and under the disciplinary regulation of the BCDM. Currently, an individual whose cultural traditions have included, for at least two generations, the attendance of midwives at birth, and has assisted in at least 10 births does not fall under regulation of the board. As noted in a letter in members' packets from the Division of Corporations, Business, and Professional Licensing (DCBPL), state licensing exemptions exist for employees of tribal health programs. She discussed the exemption with the Alaska Native Tribal Health Consortium (ANTHC) and the organization agreed with the provision being removed. 3:29:44 PM MS. SHATTUCK offered her belief that midwives provide a good option for women with low-risk pregnancy in Alaska. She pointed out that these services represent a lower financial impact on Medicaid eligible patients under Denali Kid Care. She emphasized the sponsor's intent to make the BCDM as effective and efficient as possible in the oversight of this field. 3:30:14 PM REPRESENTATIVE JOSEPHSON asked whether the expansion of the practice for the first four weeks after birth is the period in which babies would receive inoculations. MS. SHATTUCK acknowledged that is her understanding. She referred to last year's bill [SB 87] by Senator Micciche that required newborn testing. Currently, midwives can only receive reimbursement from Medicaid for services provided up to seven days for newborns, but some testing is provided after two weeks. She deferred to midwives available to testify. 3:31:08 PM MS. SHATTUCK provided a section-by-section analysis of the bill. Section 1 would provide conforming language to remove an exemption that Section 6 repeals relating to cultural traditions exclusions. Section 2 would clarify the board's authority to adopt regulations necessary for establishing practice requirements and guidelines. Section 3 would add the requirement for a licensed CDM to attend 50 or more births as a primary or assistant midwife in order to supervise an apprentice midwife. Section 4 would update the required practices and directs the board to adopt regulations regarding the practice of direct-entry midwifery. Section 5 would update the definition of the "practice of midwifery" and includes well baby care through the age of four weeks and preventative measures for the infant. Section 6 would repeal the cultural traditions exclusion allowing a person to practice midwifery for compensation without meeting the education and practice requirements for practicing midwifery. 3:32:18 PM CHERYL CORRICK, Certified Direct-Entry Midwife and Chair of BCDM, stated that she is a certified direct-entry midwife (CDM) in Alaska and a certified professional midwife with the National Association of Registered Midwives. She has over 20 years of experience in the field of midwifery and has worked at a birth center in a group practice in Fairbanks. Additionally, she currently serves as the chair of the Board of Certified Direct- Entry Midwives (BCDM). She explained that SB 156 would increase the requirements for CDMs by requiring the experience of 50 births as the primary or assisting midwife in addition to the current requirement of two years of experience. This would require preceptors with experience closer to the national standards. This bill would also remove the cultural midwife exemption that allows an individual who meets the definition to practice as a midwife and receive compensation with the only required training to have assisted another cultural midwife with 10 births. This level of training is extremely inadequate and is simply not safe for our mothers and babies. The practices have been in statute for over 20 years during which time health care practices have greatly changed. She said she has served on the BCDM for six years, during which time the board's goal has been to support legislation to remove the required practices from statute and allow the board to update and revise regulations to maintain current state and national standards of care. On February 21, 2014 the BCDM unanimously voted to support SB 156 and the companion bill, HB 311, and sent a letter of support [in members' packets]. She urged members to support SB 156. 3:34:28 PM REPRESENTATIVE JOSEPHSON wondered how CDM's would ensure that newborns receive vaccinations if they cannot administer them. MS. CORRICK responded that the initial vaccine would be for Hepatitis B, which is given at the hospital or by their pediatrician at one month visit. Other vaccines are given at two months, and midwives do not administer the vaccinations; however, they are required by regulation to recommend that parents and newborns see a physician within the first seven days of life. 3:35:48 PM REPRESENTATIVE JOSEPHSON asked whether any historic problems have arisen since 1992 in terms of the certified direct-midwife practice or if things have gone relatively smoothly in the past 22 years. MS. CORRICK offered her belief that they have gone relatively smoothly, although midwifery has had occasional problems as all professions experience. She reported that the latest data set from the U.S. Centers for Disease Control and Prevention (CDC) actually shows that Alaska has the highest rate of "out of hospital" births and the lowest rate of [Caesarean sections]. 3:36:47 PM SUSAN TERWILLIGER, Certified Direct-Entry Midwife (CDM); President, Midwives Association of Alaska (MAA), stated she is also a certified professional midwife with the national registry of midwives and the president of Midwives Association of Alaska (MAA). She reported that she has been in practice for 17 years in Texas and for the past 9 years in Alaska with a small home birth practice. She related that the MAA supports SB 156. She urged members to support the bill so the standards for midwives can be updated. Initially, the CDMs did not have a board, but the BCDM has been in place for a number of years, and doctors, CDMs, public members serve on the board. 3:38:39 PM CHAIR OLSON, after first determining no one else wished to testify, closed public testimony on SB 156. 3:38:52 PM REPRESENTATIVE CHENAULT referred to page , lines 3-4, Section 5, to the well-baby care of infant and preventative measures. He asked who pays for this. MS. SHATTUCK answered that infant care up to four weeks is covered by Denali Kid Care. She related her understanding that it would move the scope from the pediatrician to the midwives. Otherwise, private insurance would cover it, she said. 3:40:53 PM REPRESENTATIVE CHENAULT asked whether [CDMs] currently provide this service or would it be an increased workload for the midwives. MS. SHATTUCK suggested that this provision was requested with respect to children covered by Denali Kid Care. She explained that the midwives are currently providing the care but are not eligible for reimbursement. REPRESENTATIVE CHENAULT related his understanding that this language would allow [CDMs] to be reimbursed. He asked what happens if the child cannot qualify for Denali Kid Care. 3:41:30 PM MS. CORRICK answered that Denali Kid Care and Medicare have typically covered midwifery services through six or eight weeks but last year after conducting a massive audit decided not to cover CDMS since the care was not in their scope of practice. The CDMs argued for coverage, which was extended until January 2014; however, currently the Denali Kid Care doesn't cover CDM care beyond seven days [after birth]. Part of the problem results because CDMs are required to provide services by regulation for the [phenylketonuria] PKU screening. The second screening is traditionally done between two and three weeks. Thus, midwives must provide the care per regulation but are not reimbursed. This language would allow the midwives to be reimbursed. In response to an earlier question, she said if Medicaid or Denali Kid Care did not cover the care, it would be covered by the parents through private insurance, just as they receive coverage for their pediatricians. 3:42:55 PM REPRESENTATIVE CHENAULT understood this language would extend coverage that has not been allowed since January 2014 for services beyond seven days. MS. CORRICK answered that is correct. She added that prior to January 2014, midwives did receive reimbursement for providing these services. REPRESENTATIVE CHENAULT noted a lack of a fiscal note, and although this is not a new charge since Denali Kid Care previously picked up the costs, but he anticipated an increase. 3:44:04 PM REPRESENTATIVE HERRON moved to report SB 156 out of committee with individual recommendations and the accompanying fiscal note. There being no objection, SB 156 was reported from the House Labor and Commerce Standing Committee.