Help end incompetent midwifery care in Oregon

Obama care is coming to Oregon and it’s bad news for homebirth midwives.

Big changes are coming with the implementation of President Obama’s Affordable Care Act, and some local midwives are worried that low-income clients from the Oregon Health Plan (OHP) will be lost in the shuffle. OHP services in Lane County have historically been provided through Lane Independent Practice Association and LaneCare, but beginning Nov. 1, those services will be provided by Trillium, Lane County’s new coordinated care organization (CCO).

“We have been covered by the OHP open card, historically, and the open card is going to be going away,” Erin Lusk of Sacred Waters Birthing Center says. “As of now, we’re not included as providers with the new coordinated care organization in the area.”

Since most insurance companies do not pay for undereducated, undertrained homebirth midwives (as opposed to certified nurse midwives), Oregon homebirth midwives have been encouraging their clients to file (fraudulent?) claims in order that to get reimbursement for themselves.

Here’s how it works:

Oregon Health plan essentially has two types of care plans.

Managed Care and Open Card. Managed care contracts with health care agencies to provide members with care in a specified manner. Licensed Midwives in Oregon are not contracted on Managed care contracts and thus are not able to bill for services for clients with this type of insurance.

Open Card is an option primarily created for a)those areas in Oregon (certain counties) that do not have access to Managed Care providers b) Native Americans, and can also be accessed to all people desiring birth with a Licensed Midwife regardless of location in the state of Oregon. Open card is the one way a Licensed Midwife can bill for homebirth costs.

As a Client desiring to obtain Open Card you must wait to apply after 29 weeks of pregnancy. Applying for Oregon Health Plan before 29 weeks will result in denial of Open Card care and often result in being placed on a Managed Care program, which will make it even more difficult if not impossible to change to an Open Card

It is very important when applying for Open Card at 29 weeks or after that you have the appropriate pregnancy verification from a Licensed Midwife stating you are receiving your care from them and plan to birth with them. This will help tremendously in being placed on Open Card. (emphasis in original)

If I understand the Oregon regulations correctly, Open Card is reserved for women who cannot or do not start prenatal care at the beginning of pregnancy. Since it is often extremely difficult to find a provider in the second of third trimester, homebirth midwives were allowed as a last ditch option. Therefore, Oregon homebirth midwives advised their clients NOT to register for insurance at the beginning of pregnancy, but specifically to wait until it was too late to find a real provider.

With the advent of the new health care legislation, Oregon, like all states, has reorganized its public healthcare system to create a CCO (Coordinated Care Organization). Now all providers (even those who provide care as a last resort) must meet the same standards to qualify as providers in the CCO.

The option to trick the State of Oregon into paying homebirth midwives is about to disappear, because all Oregon healthcare providers, including homebirth midwives, will be required to meet the same standards, and one of those standards is having malpractice insurance. Malpractice insurance primarily benefits patients by giving them legal recourse to economic compensation in the event of malpractice. Homebirth midwives don’t carry malpractice insurance because it is expensive.

Oregon homebirth midwives are desperate to retain the ability to get reimbursed for providing care, but they have no intention of meeting the same standards as every other provider. They are fighting back with a marketing campaign, that, as usual, highlights their mendacity.

I have taken the liberty of amending one of their posters to more accurately reflect what is happening.

The first thing to not is that midwifery care in Oregon is NOT in danger. Women will have the same access to certified nurse midwives as they have always had. The only people affected are homebirth midwives who, in many cases, have no formal training in midwifery, and have appallingly high rates of perinatal mortality.

Second, the changes do NOT make it impossible for homebirth midwives to join CCO’s; they are NOT excluding homebirth midwives from CCO’s. Homebirth midwives simply have to follow the SAME rules as all other providers. Homebirth midwives don’t want to follow these rules because it will cut into their profits. Of course malpractice cuts in to the profits of any provider so many would be tempted to go without it. Oregon mandates malpractice insurance as a protection for patients.

Third, homebirth midwives think they can get around the requirements by getting their clients to protest on their behalf. As far as I can determine, they have no intention of ever complying with the same requirements that apply to everyone else.

Oregon homebirth midwives are caught in a bind. They want to be reimbursed like professionals, but they don’t want to meet the standards of professionals. In other words, they want the benefits without any of the burdens.

This may be how Oregon solves the problem of grossly incompetent homebirth midwives who have astronomically high mortality rates: stop paying them until they meet the same standards required of everyone else.

  • Sadlady

    Thought I’d update: I had my sweet baby girl last Friday in another state under the care of an older male ob. Far cry from my oregon cpm. I thought the 3rd would be easier but baby did not tolerate or even recognize labor. Her heartrate dropped to the lower seventies and upper sixties at times when I tried to get her position lower with gravity (sitting up). They had me recline and gave me oxygen to get her HR back up. I had an epidural at 5 cm because I only got a cm in 3 hours, and I know relaxing helped me dilate last time. There was mo pitocin because of the heart rate issue. He got an ultrasound to see if she was breech, no. Then I was at 10 and she was almost out in one push but the doctor told me to stop pushing because she had a double nuchal cord! (I am told stopping pushing hurts real bad without the episode) he did not seem worried, told me it would be fine (even though I was a double nuchal cord as a baby and I did not breathe for a whole minute and needed revived, my mother told me) so he unlooped her, then one more push she was out, and purple but breathing. So yeah not to thrilled with double nuchal at homebirth. So because of the VA not funding a potential disaster and this website convincing me to agree/come to grips with the reality Baby girl is home safe, and back to birthweight!

    • Sadlady

      Corrections: no pitocin, and epidural not episode

    • MLE

      Congratulations! So glad to hear that!

  • Sadlady

    Got my VA letter authorizing any OB of my choice to be paid by the VA for my care. It does specify OB. That’s OK. I will be receiveing a new letter authorizing out of state care since my new husband just landed a new job in another state and suddenly we have to move. I got out of my midwife care scot free since I am now moving and did not bring up OHP or VA anymore to her. I will pick up my record on our last appointment. :)

    • Young CC Prof

      OK, I’m glad to hear you got through the bureaucratic mess, and that your husband has a job, but sorry you now have to move so late in pregnancy!

  • Sadlady

    OK I finally made the call to let her go. It was an answering machine. I knew when I was 27w that it wouldn’t work out, but had to look for care so I had someplace to go before calling, and Friday was a holiday. I’m 29w now. I hope that we go by the date I last saw her and couldn’t keep going and not today. A lot of CPMs have a 28 week policy…(for payment in full)But I think hers was 34, I can’t remember there was no carbon copy. Just being on the list of patients for a week while fully knowing I had to let her go shouldn’t count IMO. I already paid the deposit, which cost my big girls their ballet lessons over the summer! I think that’s fair. Now I get to wait 5 weeks for my next appointment. :( With a VA general practitioner to refer me to maternity care. I’m already measuring large for dates. I’m thinking of simultaneously pursuing OHP (like going to my hospital of choice) and just seeing what they can do with my OHP coverage, not even using my VA benefits, just the normal state stuff that everyone else does. The VA is awesome though because they send you home with a state of the art, high caliber double electric breast pump. Which is great because my second baby had failure to thrive (Which I did not recognize for 11 weeks because she grew into the next size of clothes, due to being tall, not fat, and I was exhausted I was feeding her every 2 hours, with a bad latch). SO I would really like VA care so that I won’t have to supplement again. I’m not sure. Would the VA ask why did I go somewhere else when they were working on it? Im just super frazzled.

    • Young CC Prof

      Call OHP and see what happens. Worst case, go back to VA.

      And no, nobody needs this stress third trimester!

  • Sadlady

    The VA scheduled my appointment for 4 weeks before I’m due…as a primary intake. Meaning they will then refer me to an ob. So…yeah Idk if they will be fast enough. Call my cpm what you will…at least she was avaliable. They said I’ll probably deliver in Portland. An hour and a half away in good traffic. If I last that long with my 3rd. I thought I was making the right choice. I let my wallet decide. It’s hard to let my heart be in it with these result.

    • Young CC Prof

      No, that doesn’t sound fast enough. 2 months for primary intake? Is that standard operating procedure for pregnancies? Even if you were in the first trimester, that would be seriously substandard care. I mean, if you called at 6 weeks, you’d be getting intake at 14, which is already too late for precise dating or triple screen. This is outrageous that the VA can’t provide minimally adequate care for pregnant women.

      Is there any way for you to continue getting blood pressure and urine checks? Those are important not just for the baby but for you as well.

      And of course, if anything seems wrong, if you feel sick or the baby isn’t moving or you think labor might be starting, go to the ER.

      • Sadlady

        The local pharmacy has those test strips for the urine…and the blood pressure cuff test machine. And the VA pays er. And I can get my file with the ultrasound and everything. If you Google the news about women vet care…the wait times are bad.

        • Sadlady

          Oh I forgot I have ohp too…how does it work if I try with them and I got the ball rolling with the VA already? They can’t blame me if they are slow…hmm.

          • Young CC Prof

            I have no idea how VA and ohp interact, I don’t even live in Oregon. But the ohp folks probably know. Call them tomorrow and find out!

          • Sadlady

            Ohp is then same thing as nationalized medicine. But for our state.

  • Sadlady

    Update I’ve been wait listed with the VA. So I will have to part ways with my cpm just on the hope of being seen on time by a medical professional. I guess I’ll printout the VA rules and highlighter pen the type of midwifery they do not cover when I tell her why. VA had a notorious wait time of 80 days to be seen so Idk if I will be expedited for having a due date. I might be seen a week before the due date if I’m.just treated as average. If the baby comes before that…VA covers er.

    • Mishimoo

      Glad you’re getting into the hospital, it really is so much safer. Hope everything goes well and that you have a lovely, healthy baby.

      • Sadlady

        We will see when I get that appointment!

  • Doula for Women

    Right, So don’t select a CPM, they are not experienced enough (because back in the day no one knew how to deliver babies without four walls, fetal monitoring, and an epidermal handy). And don’t hire an OB, because they only want your money and you are on THEIR TIME, unless you are a high risk pregnancy you do not a Provider with 25 years of experience and this and that under their belt, do your research. Not all OB’s and Midwifes (credentials or not) are good providers, but not all are bad. The provider is not birthing the baby, YOU are. Home births are beautiful IF you can do (if you cannot do not feel bad, not everyone can) and hospital births can be just as rewarding, as long as you have a provider that is looking out for the best interest of the baby, you, and of course respects your birthing plan.

  • sadlady

    OK but there is a contradiction in what insurance allows with this. The insurer will say, OK you can have a midwife but she has to be a CNM (yay) but then a state law (it varies, but NY I know bans it) will say CNMs are not allowed to leave a hospital setting. So you have to choose between paying out of pocket for a CPM or get your CNM covered and go where you don’t want to and have people step in when your labor takes too long. (Too long for who? The facility? The doctor have some place to be, or the actual baby? Its never been made clear to me when I’m told its taking too long)

    • Mer

      Too long for you and for the baby. Labor is hard on baby, they basically have to hold their breath with each contraction and the longer it takes the higher your risk of a postpartum hemorrhage. Those are just two reasons for concern about labor taking too long, there are more.

  • Sadlady

    I need some advice…I actually like my midwife, but I found out that my ohp and also the VA won’t pay her. I did my budget and I cannot afford to pay any more than the nonrefundable deposit I already paid. So I don’t know how to break up, and is really awful that I have to do it because it’s for no other reason than money. I really don’t want to do ob birth again because they make me hurt myself laying down, but I guess have to…also is there any way I can find an ob who accepts my refusal to lay down if it hurts.it’s just for their convenience to see if I’m at 10cm… So is my contract iron clad and I have to go into debt to have this baby at 28 weeks, or can I break up, as much as it hurts? What do I say, how do I make the switch?

    • Sadlady

      I wanted to add that the midwife is cpm ldm and it is a financial agreement. I thought between ohp and the VA her services would be covered. They aren’t. I’ve seen her 5 times!!!

      • Young CC Prof

        I have no idea how contract law in Oregon works, but I really doubt she could, say, sue you, if you just walked away.

        Some of the hospitals in Oregon are very friendly to natural childbirth. Take a look around. You might have to be checked at a few points during the labor, but really, how long does the exam take? A couple minutes?

        If she’s done blood tests or anything, ask for the records.

        • Sadlady

          Thank you for a fast response. I’m hovering all over the net for answers. She has done a urine test each time. My weight and a diabetes test (2 hours post lunch one since I hate the sugar drink). Also an ultrasound was done. I think ohp covered that. Or maybe my midwife did thinking ohp would…not sure I haven’t gotta bill for it! I had to go to a separate place for that. :-( I just didn’t need these changes so late in the game. The worst part is the VA said they’d call Friday to schedule an appointment and they didn’t. They have to confirm the pregnancy then outsource me to an authorized practitioner. Since VA is mostly for men and women are a marginal percentage of vets. I have to act like I never had anyone at all help me I guess…maybe I’ll ask if my midwife is on the list but I seriously doubt it. The 2012 document I read said no cpm or direct entry. Couldn’t find a newer VA document on it.

          • Young CC Prof

            There’s no reason to lie to your new provider. Get the ultrasound record from the ultrasound clinic, it’ll be very useful. Actually, you could call the VA and ask if your ultrasound would count as proof of pregnancy!

            This late in the pregnancy, I don’t want you out of care any longer than can possibly be avoided. I know how stressful it is dealing with all this paperwork and hunting around finding a new provider and all, but right now, this is job #1, protecting yourself and your child by accessing care.

          • sadlady

            Thanks. I’m way ahead of time on finding a new person. I’m not due for another appt for 2 weeks, so I won’t be missing any appointment time frames. And I didn’t mean lie I meant that for the part where they ask if you prefer an an object or midwife, maybe I can put her name down to see if she is on the list. (it won’t be if the 2012 document is still accurate because by midwife they mean cnm) it’s worth a shot for continuity of care. Worst case scenario I will pick a cnm and I think she won’t make me lay supine unless medically necessary. Can’t do anything on a Suns but for now I’m looking up etiquette about politely letting someone go!

          • sadlady

            That was supposed to say ob not object lol. I have predictive text on my cell.

          • Doula for Women

            You can go to whatever provider you are covered by, and give them your birthing plan. Get a Doula, they can definitely help you through this and the birth. they are a professional birthing coach. I am a Doula and I help countless women decide how they want their birth. I provide no clinical advice, that is not my scope, I support the mother and partner and am an advocate for the mother, You can tell the provider, Midwife or OB what position you want to be in for when you give labor, and the Doula knows a dozen different birthing positions as well as pain coping methods. look into it, they usually range $300-$1,400, depending on their income sliding scale.

          • Trixie

            You might find it informative to poke around on this site more and read about the education levels of CPMs and the death outcomes of CPMs before you consider staying with one.

          • sadlady

            I am reading a lot on this website so that I can better wrap my mind around what I’m going to have to do. I don’t think it would be good for my “birth experience” to be a reluctant hater. I’d like to see some things I can agree with.I do know I don’t want a repeat of last time. But that is just for me. My babies had no adverse effects of there institutionalized delivery. Just me, lol. I was going this route for me since I found my body apt after 2. I never would have had my first at home, too new, narrower hips etc.

          • Trixie

            Doesn’t really matter if you’ve got a proven pelvis; a myriad of things can and do go wrong in a moment that a CPM has no training or ability to deal with. Look up Dr. Amy’s post on the death rates in Oregon as written about by Judith Rooks. Even though you’re low risk, just having a birth with a CPM raises your chances of your baby dying by at least 3 times. Your baby’s risk of permanent brain damage is about 18 times higher at home than in a hospital. Only you can decide if that’s worth an experience.
            FWIW, I had an unmedicated hospital VBAC with CNMs, and it was great, no one asked me to be on my back until I chose that position out of comfort. It was the best of both worlds, really.

          • Sadlady

            Cool, thanks. Yeah cnm would be an improvement in my last doctors.

          • Trixie

            In a place like Oregon, unless you become high risk, there’s no reason you can’t have an incredibly positive, “natural” birth in a hospital with CNMs that will also be covered by insurance.

        • AmyP

          Yeah–if she sued, I be very tempted to respond that she falsely presented herself as a qualified medical practitioner. Which is what she did.

    • Trixie

      It’s pretty awful that this fraud took your nonrefundable deposit knowing full well that her services wouldn’t be covered and you probably couldn’t afford it. She tricked you and manipulated you.
      I’m sure there are some great CNM options out there. I think YCCP’s advice is good.

    • Maria

      Do you mind if I ask what part of Oregon you are in? You can be vague, but I have heard that some of the hospitals in Portland and Eugene are very, very friendly to those seeking unmedicated births. Lots of free range for walking during labor, tubs for labor (and even a few with birth tubs, but I am not a huge fan of those), intermittent monitoring unless indicated otherwise, and absolutely you would have the choice to find the most comfortable position in which to push. I am sorry your experience with an OB before was not good, but working with a CNM or even a different OB in a different hospital may make all the difference for you.

      As for “breaking up” with your current CPM, she will understand if she is a professional. If she takes it personally and gives you a hard time about it, that is a red flag as to the quality of care you have been or would have received from her. My OB was on maternity leave for the first half of my last pregnancy and I saw another one who I liked. But I LOVE my OB and when she came back I very happily saw her for my last two appointments before I went into labor (early). I had no qualms at all about hurting the other OBs feelings. She is a professional and she knew I had a long history with my original OB.

  • Alicia Anderson

    A. homebirth midwives are required to be properly trained in order to deliver babies, that’s how they register births.
    B. Just because you have M.D. at the end of your name doesn’t give you the right to insult others….at alll!!
    C. I birthed at home, I have a healthy nearly-two year old. Guess what else? I’m going with the same midwife! In fact, hospitals scare me more than the unknown of homebirth.
    D. Babies die in the hospital, are given needless antibiotics and medications in the hospital, so your argument isn’t valid.
    *This is coming from a mama that did a homebirth and prefers to birth at home. I have no medical licensing, I just go off of common sense and life experience. I don’t appreciate the disrespect from this “Ob”. We don’t even know id she has a license!

    • Stacy48918

      A. No they are not. The United States is the only industrialized nation in the world that has 2 classes of midwives. CNMs are highly educated and trained medical professionals. CPMs, DEMs, lay midwives, etc are only required to have a high school diploma, attend 25-50 births and can train through distance learning. They are not medically qualified to attend hospital births in the US like CNMs are, nor could they deliver home births in any other industrialized nation (Netherlands, Canada, UK for example). Which is your midwife? A CPM or a CNM? If a CPM, ask her one day why she decided not to have proper medical training and become a CNM.
      B. Even if they killed a baby?
      C. You’re allowed to be scared. Just don’t pretend it’s safer. Study after study after study has shown that choosing to give birth outside of a hospital increases your baby’s risk of dying at least 2-8 times.
      D. PRETERM babies die in the hospital, babies with DEFECTS die in the hospital, babies of DRUG ADDICTS die in the hospital. Full term, healthy babies with no risk factors or complications DO NOT DIE IN THE HOSPITAL. Her argument is absolutely valid considering healthy full term babies die at home birth all the time.
      Dr. Amy may not currently have a license (umm…she’s not practicing medicine so why should she?) but she has years of education, training and teaching to her CV. You have no medical training, “common sense and life experience” and I’m sure plenty of birth blogs and “The Business of Being Born.”
      You have no idea what you are talking about.

      Have a home birth if you want to. But you are risking your child’s life to do it.

    • Bombshellrisa

      You go off your life experience of one birth?

  • SkepticalofOBs

    Thank you for pointing out what continuously gets left out of “Dr.” Amy’s diatribes.

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  • Cusenza

    Dr. Tuteur, I was wondering where I might find the information on perinatal deaths and homebirth midwives. Could you point me in the right direction?

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