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Medicaid and State Regulation of Nurse-Midwives: The Challenge of Data Retrieval Andrea Sonenberg Policy Politics Nursing Practice 2010 11: 253 DOI: 10.1177/1527154411398137 The online version of this article can be found at: http://ppn.sagepub.com/content/11/4/253

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Articles

Medicaid and State Regulation of Nurse-Midwives: The Challenge of Data Retrieval

Policy, Politics, & Nursing Practice 11(4) 253–259 © The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/1527154411398137 http://ppn.sagepub.com

Andrea Sonenberg, DNSc, NP, CNM1

Abstract This article discusses one of four findings of a larger descriptive correlational health policy study, the purpose of which was to investigate relationships among state regulation of nurse-midwifery practice, utilization of certified nurse-midwives (CNM) for Medicaid funded prenatal care, and maternal newborn outcomes. The larger study showed that use of accurate data about CNM practice and subsequent health care outcomes creates a challenge for researchers because of the paucity of data related to services provided by CNMs. Barriers to adequate data collection related to CNM services, specifically those funded by Medicaid, preclude legitimate conclusions about subsequent health care policy. Methods of workforce data collection need to be addressed by health care and health policy groups to facilitate further investigation of the relationships among state regulation of CNM practice, utilization of CNMs for Medicaid-funded prenatal care and maternal newborn outcomes as they affect access to care for vulnerable populations. Keywords certified nurse-midwife, state legislation, advanced practice nurses, research methodology, Medicaid, women’s health, practice regulation.

This article discusses findings derived from a larger study exploring the relationships among regulation of certified nursemidwives (CNMs), Medicaid reimbursement policies, and birth outcomes across the United States (Sonenberg, 2007), a short summary of which is also presented. The study goal was to describe how these factors might be associated with achievement (or non achievement) of key Healthy People 2010 goals, early access to prenatal care (PNC), and improved neonatal outcomes. The identification of state regulatory policies that potentially contribute to impeding access to care and optimal health outcomes of vulnerable populations of mothers and newborns is essential to effective health care policy reform. The study results in their entirety are to be submitted for separate publication. This discussion focuses on one finding in particular: how serious limitations in the retrieval of data related to CNM practice and financing presented obstacles to understanding the issues and drawing valid conclusions, despite demonstration of significant correlations. This methodological limitation may indeed be a contributing factor to a scarcity of more recent evidence available in nurse-midwifery related literature searches. In light of the valuable contribution CNMs make as primary care providers of women (American College of Nurse-Midwives [ACNM], 2010), as well as women’s reproductive health care providers, understanding the influences on CNM practice regulation and its potential affect on maternal

fetal health outcomes is imperative, especially now on the dawn of perhaps the most significant health care policy reform in decades. The issue of adequate workforce data collection related to services provided by advanced practice registered nurses (APRNs) should be addressed not only by the nursemidwifery and nursing community but also by other stake holders in the field of public health and health care policy.

Background A key Healthy People 2010 goal is to have 90% of pregnant women in the United States registered for prenatal care by the end of the first trimester. Pregnant women have been identified as a particularly vulnerable population (U.S. Department of Health and Human Services, 2000). In a landmark report by the Institute of Medicine (IOM; 1985), inadequate prenatal care (PNC) has been linked to poor pregnancy and birth outcomes. Other seminal studies also report that absent or limited PNC is 1

Pace University, Pleasantville, NY

Corresponding Author: Andrea Sonenberg, DNSc, NP, CNM, Assistant Professor, Pace University, Lienhard School of Nursing, 861 Bedford Road, LH311, Pleasantville, NY 10570 Email: [email protected]


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a risk factor associated with poor newborn outcomes of premature birth and low-birth weight (Carroli et al., 2001; Chen, Wen, Yang, & Walker, 2007; Friedman, Heneghan, & Rosenthal, 2009; IOM, 1985; Raatikainen, Heiskanen, & Heinonen, 2007; Taylor, Alexander, & Hepworth, 2005; Vintzileos, Ananth, Smulian, Scorza, & Knuppel, 2002). Studies indicate that providing expanded health insurance coverage through Medicaid results in enhanced access to prenatal care for pregnant women and potentially improved maternal infant outcomes (Baldwin et al., 1998; Howell, 2001). Access to adequate PNC may be limited in health care provider shortage areas, particularly in rural and inner city areas (Hartley, 2003; National Center for Workforce Analysis, 2004). It was first posited in a landmark article by Safriet (1992) that APRNs are a viable and valuable source of health care in primary care provider shortage areas. Close to two decades later, the expanded role of APRNs in providing primary care continues to be recommended by many(Callaghan, 2008; Fairman, Rowe, Hassmiller, & Shalala, 2010; IOM, 2010). The CNM is one type of APRN who specializes in the primary care of women throughout the lifespan (ACNM, 1997; Chapman, Wides, & Spetz, 2010; DeSandre, 2000; IOM, 2010). During their reproductive years, low-risk women may receive holistic, individualized care from CNMs for family planning, preconception planning, and throughout the pregnancy, including the labor, birth, and postpartum periods (Varney, Kriebs, & Gegor, 2003). There is a long history of research supporting the quality, cost-effectiveness, and recipients of CNM care, which is sufficient evidence to support the recommendation of the utilization of CNMs, without need for replication (Summers, 2007). These seminal studies continue to provide the most recent evidence of the value of nurse-midwifery care to vulnerable populations. Among these research findings, it has been demonstrated that CNMs provide a greater percentage of care to non-White, non insured, and Medicaid recipients (Declercq, 2009; Declercq et al., 2001; Grumbach, Hart, Mertz, Coffman, & Palazzo, 2003; Paine et al., 2000; Paine, Scupholme, DeJoseph, & Strobino, 1993), resulting in improved pregnancy and birth outcomes to low-risk women as well as being of lower cost as compared to physicians (Biro, Waldenstrom, Brown, & Pannifex, 2000; Davidson, 2002; MacDorman & Singh, 1998; Page, McCourt, Beake, Vail, & Hewison, 1999; Rana, Rajopadhyaya, Bajracharya, Karmacharya, & Osrin, 2003;. Rosenblatt et al., 1997; Tucker et al., 1996; Turnbull et al., 1996; Visintainer, Umann, Horgan, Verma, & Tejani, 2000). The World Health Organization recognizes midwives as integral to healthy maternal infant outcomes and recommends that Member States include midwives in all facets of striving to improve maternal infant outcomes, from health care service delivery to involvement in health policy initiatives (WHO, 2002). After extensive study, both the Public Citizens Research Group and The Pew Health Professions Commission, in its landmark report, Charting a Course for the 21st

Century: The Future of Midwifery, recommended that midwifery services be integrated into the continuum of care for women and be incorporated into every health care system (Dower, Miller, O’Neil, & the Taskforce on Midwifery, 1999; Gabay, & Wolfe, 1995; Paine, Dower, & O’Neil, 1999). Section 1905 (a)(17) of Title XIX of the Social Security Act mandates that State Medicaid programs offer midwifery services as one of the basic services provided for its categorically needy patients (Centers for Medicare and Medicaid Services, 2005a; Slager, 2007). Since the Medicaid program is both federally and state funded, while managed by the state, this mandate is implemented individually by each state. Furthermore, each state varies in its regulation of CNM practice, by virtue of the regulatory body that develops the guidelines for practice (Declercq, Paine, Simmes, & DeJoseph, 1998; Howe & Lowe, 2007; MacDorman & Singh, 1998; National Center for Workforce Analysis, 2004; Reed & Roberts, 2000). Paine et al. (1993) explored the relationship between professional practice regulation and overall utilization of CNMs. State regulation of practice in this study was measured by the Regulatory Rating Scale, which was developed solely for the purpose of the study and allocated a score in each of six categories: Regulatory Board Membership, Admitting Privileges by Law, Prescriptive Authority, Malpractice, Insurance Reimbursement, and Birth Center/Medicaid Coverage (Paine et al., 1993). To date, no study has investigated the relationship between the CNM Professional Practice Index Score (National Center for Workforce Analysis, 2004) as an indicator of state regulation of practice, and the proportion of the specific service of PNC delivered by CNMs to the sample of the population that is comprised of Medicaid enrollees. If one exists, it may demonstrate that restrictive state practice regulation of CNMs results in reduced access to care and potentially poorer health outcomes for a vulnerable population of mothers and newborns. Such a finding would have great implications for health policy reform; one means to improving access to care for vulnerable populations would be to focus on “reducing restrictions that . . . constrain advanced practice nurses, especially nurse practitioners and certified nurse-midwives” (Safriet, 1992, p. 417), including those restrictions related to regulations on payment (Chapman et al., 2010).

The Original Study The purpose of the study State Regulation of Practice and the Utilization of Nurse-Midwives for Medicaid-Funded Prenatal Care (Sonenberg, 2007), on which this article is based, was to identify the influencing factors in the utilization of certified nurse-midwives (CNMs) for Medicaid-funded prenatal care (PNC) to provide a focus for health policy research and reform, the ultimate goal of which would be to improve access to care and health outcomes of mothers and newborns. The study was


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Sonenberg undertaken to achieve four aims specifically. These were to describe 1. any association between a state’s CNM Professional Practice Index Score[PPIS] and the proportion of Medicaid-funded services delivered by CNMs in each of the 50 states of the United States; 2. any association between a state’s CNM PPIS and the proportion of Medicaid-funded prenatal care delivered by CNMs in exemplar states representing the extremes on the PPIS; 3. the category of regulation of practice (legal status, reimbursement policies, or prescriptive privileges) within the index that has the greatest association with the proportion of Medicaid-funded services delivered by CNMs; and 4. the factors within the most influential category that had the greatest association with the proportion of Medicaid-funded services delivered by CNMs. This health policy study was a descriptive correlational design utilizing multiple secondary data sets. The sources and data, from 2002-2003, were Kaiser Family Foundation (total Medicaid births, 1st trimester PNC, neonatality data); U.S. Census Bureau (poverty data) ; Centers for Medicare and Medicaid Services (total Medicaid claims, total CNM Medicaid claims); National Center for Vital Statistics (total CNM attended births); Quality Resource Systems, Inc.(total number of CNMs in each state); and The National Center for Health Workforce Analysis (CNM Professional Practice Index Score[PPIS], as a measure of regulation of CNM practice). The CNM PPIS is an additive scale, the purpose of which is to define the scope of professional practice of CNMs in each state. The score index has a total possible score of 100 and is comprised of a set of indices in three categories (legal status, reimbursement, and prescriptive authority). A variation of the scale has also been used to define the scope of practice of nurse practitioners and physician assistants (National Center for Health Workforce Analysis, 2004). In this study, the relationships between the independent variables, CNM services and maternal/newborn health outcomes, and the dependent variable, regulation of CNM practice, were investigated. Several relationships were demonstrated, including statistically significant correlations between CNM PPIS and each of the following outcome variables: Proportion CNM births, Low Birth Weight Rate, Premature Birth Rate, Neonatal Mortality Rate, Percentage Below Poverty Level, Proportion Minority. The second step in the analysis was, for each of these associations, to further investigate the relationships between each CNM PPIS category (legal status, reimbursement, and prescriptive authority) and the outcome variables. The final step was to determine the contributory factor of each category that had the most influence on each of the significant relationships.

There were several limitations that impeded achieving this study’s proposed aims, highlighting important policy issues. Information about the scope of practice of CNMs was readily available in the report of the National Center for Health Workforce Analysis (2004) and summarized in its Nurse-Midwife Scope Index report (National Center for Workforce Analysis, 2004); however, key information about Medicaid-funded PNC delivered by CNMs was difficult, and in many cases impossible, to locate. Centers for Medicare and Medicaid Services (CMS) DataMart set (CMS, DataMart, 2005b) is a database of all Medicaid-funded services provided, categorized by a variety of variable codes, including Service Type and Service Provider. Although data related to PNC as a Service Type is maintained, it was impossible to nest the data to determine what proportion of this particular Service Type was supplied by which Service Provider (e.g., CNM). States had either not collected this statistic separately from Medicaid claims in general or had not reported it separately. A fundamental contributing factor to the paucity in data available for this study is that there is no requirement that states collect and/or submit to CMS data for all variable codes included in the set. In the absence of a national data source about payment for specific providers of PNC, attempts at individual informal telephone and email inquiries were made to state departments of health, only two of which, those of Washington and Massachusetts, were able to provide the statistics under study. Washington State officials reported utilizing a database called The First Steps Database, which links vital statistics related to the pregnancy, birth, postpartum, and neonatal periods; Medicaid claims; and eligibility data via a variety of forms submitted by providers (Cawthon, 1996). Massachusetts officials reported having a system by which birth data are linked to Medicaid claims through a form called the Hospital Worksheet for Birth Certificates (Massachusetts Department of Public Health, 2002). While national statistics are available on births certified as attended by CNMs this too might be misleading. The number of total CNM births is larger than Medicaid-funded CNM births. In addition, the total number of CNM births is potentially further skewed because in some institutions, births attended by CNMs may be billed under a physician name and, in some cases, the billing provider may sign the birth certificate rather than the birth attendant. This billing and documentation practice leads to an underestimation of total births attended by CNMs (Diers, 2007).

Discussion The four key findings of the original study are (a) there is a paucity of data related to individual and specific Medicaidfunded services provided by certified nurse-midwives (CNMs); (b) states with the fewest barriers to practice have the greatest proportion of CNM births; (c) states with the most restrictive practice regulation also have the highest proportion of


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vulnerable populations (minority and populations in poverty) and higher percents of adverse perinatal outcomes (low birth weight, premature birth, and neonatal mortality); and (d) states with the greatest autonomy in three areas, professionalism (legal status), business practices (reimbursement), and clinical practice (prescriptive authority), may have the greatest access to care for vulnerable populations. For future understanding of CNM practice, regulatory and payment policy, and birth outcomes, access to data is of primary concern because without adequate and accurate information, analyses and conclusions will not be accurate. There are two key areas related to expanding the database of retrievable information that is lacking and needs to be addressed, that is, data about CNMs as distinct from other nurses and advanced practice registered nurses (APRNs), and data about payment for CNM services both prenatally and at time of delivery. One issue is to identify an organizational body responsible for collecting data on CNMs. Several organizations that collect data related to the health care professions do not differentiate CNMs or APRNs from other registered nurses. The agenda of the American College of Nurse-Midwives (ACNM) Division of Research, as the official national association for the profession, includes the item “develop a systematic approach to collecting clinical practice data across the membership” (American College of Nurse-Midwives [ACNM], Division of Research, 2005). One of the limitations of this source of data is that it only reflects the practice of members of ACNM, thus potentially underestimating the contribution of all CNMs. For example, in 2008, the total number of CNMs in the United States was 7,529(ACNM, State Fact Sheets, 2010b), but the total number of ACNM members was 5,847 (ACNM, 2008 Annual Report, 2010a). When ACNM surveys its members, the results are not necessarily representative of all CNMs but biased toward members of a professional association; for example in 2008 the ACNM membership represented 78% of all midwives, which, although an impressive membership in a professional organization, is not an accurate statistical representation when researching outcomes of practice of the professional group as a whole. The focus of investigation in clinical practice and outcomes should be broadened from the membership to the whole profession in order to better reflect the total contribution of CNMs rather than that of the subgroup of the ACNM membership. The issue of data collection is paramount to future research related to the practice of nurse-midwifery. An organizational commitment to work collaboratively with government agencies to collect this data for the profession as a whole (Diers, 2007; Kennedy, Schuiling, & Murphy, 2007) would greatly enhance our understanding of the nature of nursing practice and outcomes, thus informing areas for policy reform. Two fundamental problems exist with the compilation of data by several national resources: CNM and other APRNs are not distinguished from registered nurses (RN) as a broader group and data related to services provided are not generally collected.

Through several of its health care surveys, The National Center for Health Statistics (2005b) collects data related to physician ambulatory care and the care delivered by nonphysician providers (National Center for Health Statistics, 2005a); however, it does not always differentiate CNMs from other APRNs, or APRNs in general from all RNs (Morgan, Strand, Østbye, & Albanese, 2007). The Henry J. Kaiser Family Foundation collects data related to the total number and state distribution of RNs, nurse practitioners (NP), and physician assistants, but does not collect data related to any APNs except NPs and also does not collect data related to services provided by any nonphysician providers (Henry J. Kaiser Foundation, 2005). The U.S. Department of Labor has a registry of various health professions, for example, obstetricians/gynecologists separate from other physicians/surgeons, physician assistants, respiratory therapists, and social workers. In the case of RNs, again, the data are collected in total, without distinguishing between APRNs and other RNs or the specific services provided (U.S. Department of Labor, 2005). This collective labeling of RNs, without recognition of the various levels of practice or subspecialties, complicates the surveillance of practice, quality of care, and outcomes of CNMs on a state and national level. Perhaps the new model on Licensure, Accreditation, Certification, and Education (LACE) can assist in remedying the dilemma of nomenclature for APRNs (Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, & Education, 2008). The second major area related to data collection that should be addressed pertains to information sought when Medicaidfunded services are provided by various providers. Diers (2007) identified many shortcomings of hospital data sources (clinical and administrative) and claims data as they relate to the integrity of CNM services data. The focus of the summary is primarily on documentation of birth and birth attendant. The U.S. Standard Certificate of Live Birth (National Center for Health Statistics, 1991) forms currently identifies gestational age at initiation of prenatal care, number of prenatal visits, attendant at birth, and payer source at birth; however, prenatal care provider type is not a field that is included. Documenting PNC provider type is important for the purposes of investigating differences in outcomes of care delivered by various provider types, as many health outcomes, specifically low birth weight and premature labor, are most greatly influenced by factors occurring prior to the birth itself. Descriptive case studies of the procedures utilized by Massachusetts and Washington would be a logical starting point for this area of policy research. With advancing technologies and electronic submission of insurance claims, research in informatics should address the process of simultaneous data collection of ICD-9 code with payer source and provider type. This will allow for the study of relationships between PNC provider and outcomes, both practice and clinical. Feasibility studies in the area of collection of Medicaid data are essential to further policy and practice research related to CNM care of vulnerable populations.


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Conclusion and Recommendations

Funding

Despite the limitations of this study in determining the relationship between Nurse-midwife (CNM) Professional Practice Index Score (PPIS) and the utilization of CNMs for Medicaidfunded prenatal care (PNC) specifically, study findings have established that although a direct causal association cannot be concluded, there continues to be a relationship between state regulation of practice and the utilization of overall Medicaid services provided by CNMs. For that reason, it is logical to conclude that since PNC is a subtype of all Medicaid services, a relationship might exist between these two variables as well. At the dawn of this historic new era of health reform, the potentially invaluable role of APRNs to the expansion of access to care to the previously uninsured cannot be underestimated. The CNM is one of the four APRN roles described in the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, & Education (National Council of State Boards of Nursing, 2008) and cited as essential APRN role by the IOM in their recent report on The Future of Nursing (2010). The consensus model recommends a national framework for regulating APRNs. For the feasibility and validity of future studies related to regulation of practice as it relates to its potential impact on access to care and health outcomes, the APRN Consensus Workgroup and National Council of State Boards of Nursing APRN Advisory Committee, of which the ACNM is a member, along with the IOM, need to continue their collaborative work and address the limitations of data collection related to APRNs, including CNMs. As a multidisciplinary group, these stake holders, among others, need to recommend to the agencies and organizations that collect data related to workforce distribution and services to distinguish between RNs and each category of APRN. Furthermore, these stake holders, as a collaborative task force, need to urge the Center for Medicare and Medicaid (CMS) to mandate that states collect and report data related to services of specific provider types, so as to facilitate services and outcomes research under that payer system. Both Washington and Massachusetts currently follow feasible processes, which could be replicated in other states. A final recommendation, specific to prenatal care, is that The U.S. Standard Certificate of Live Birth (National Center for Health Statistics, 1991) form should be revised to include a field for prenatal care provider type. Any evidence used as a basis for health care reform must include health care delivery models that are collaborative and multidisciplinary. This evidence cannot be ascertained without adequate sources of data related to services and outcomes of a variety of health care providers. An essential component of health care reform ought to include a revision of the current processes of health workforce data collection. This revision would create a more comprehensive and accurate database as one potential source of evidence on which to base future health policy reforms.

The author(s) received no financial support for the research and/or authorship of this article.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the authorship and/or publication of this article.

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Bio Andrea Sonenberg, DNSc, NP, CNM, is assistant professor, Lienhard School of Nursing, Pace University, in Pleasantville, NY.
