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Understanding Your Practice Environment: Making an Informed Decision About Where to Work
Cara Kinzelman, PhD, Manager, State Government Affairs
Jesse Bushman, Director, Advocacy and Government Affairs
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Where are Your Colleagues?
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Where CNMs and CMs Practice Data Current as of February 2014
MT
WY
ID
WA
OR
NV UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN 206
MS AL
46
GA
FL
SC
NC
VA WV
OH
MI
NY
PA 426
MD: 306
DE: 30
NJ: 305 CT: 200
RI: 67
MA: 431
ME
VT: 76
NH: 103
AK HI
DC: 37
Under 100 Licensed CNMs
101-250 Licensed CNMs
250-500 Licensed CNMs
Over 500 Licensed CNMs
83
34
50
44
92
80
49
94
40
86
43
42
31
17
58
28
62
15
190
150
120
196
136
199
348
441
443
315
262
373
358
314
411
258
362
1,026
635
973
126
Source: American Midwifery Certification Board
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Number and Density of CNMs/CMs by State Data Current as of February 2014
MT
43
WY
15
ID
44
WA
362
OR
314
NV
31 UT
136 CA
1,026
AZ
190
ND
17
SD
28
NE
42
CO
348
NM
196
TX
411
OK
58
KS
80
AR
34
LA
49
MO
86
IA
92
MN
262 WI
199
IL
443
IN
150
KY
120
TN 206
MS
40
AL
46 GA
441
FL
635
SC
126
NC
373
VA
258
WV
62
OH
358
MI
315
NY
973
PA
426
MD 306
DE 30
NJ 305
CT 200
RI 67
MA 431
ME
94 VT 76
NH 103
AK
83
HI 50
2.54 – 3.11
3.18 – 3.47
5.56 – 12.16
Source: Number of CNMs/CMs per state provided to ACNM by the American Midwifery Certification Board (AMCB). Population figures from US Census, rounded to nearest 1,000.
3.94 – 5.40
0.96 – 2.33
DC 37
Midwives per 100,000
Population
Number of CNMs/CMs shown in each state. Density indicated by color.
There were a total of 10,866 CNMs/CMs as of 2/11/14.
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Number of ACNM Members Per State Data Current as of February 2014; Membership Density Noted in Parentheses
MT
WY
ID
WA
OR
NV UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN: 150
(73%)
MS AL GA
FL
SC
NC: 233 (63%)
VA
WV: 46 (74%)
OH
MI
NY
PA
MD: 195 (64%)
DE: 26 (87%)
NJ: 189 (62%)
CT: 153 (77%)
RI: 46 (69%)
MA: 254 (59%)
ME: 79 (84%)
VT: 54 (71%)
NH: 72 (70%)
AK HI
DC: 40 (108%)
Under 100 ACNM Members
100-200 ACNM Members
201-300 ACNM Members
Over 300 ACNM Members
27 (59%)
67 (81%)
15 (44%)
28 (56%)
36 (82%)
69 (75%)
60 (75%) 72 (60%)
23 (47%)
21 (53%)
58 (67%)
28 (65%)
33 (79%)
24 (77%)
13 (76%)
43 (74%) 80 (63%)
23 (82%)
132 (69%)
101 (67%)
123 (63%)
100 (74%)
180 (70%)
136 (69%)
231 (66%)
283 (64%)
294 (66%)
248 (79%)
201 (77%)
227 (63%)
204 (65%)
297 (70%)
268 (65%)
258 (71%)
15 (71%)
519 (51%)
351 (55%)
585 (60%)
Source: American College of Nurse-Midwives and American Midwifery Certification Board
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Number of Midwifery Education Programs by State Data Current as of June 2014
MT
WY
ID
WA
2
OR
1
NV
UT
1
CA
3
AZ
ND
SD
NE
CO
1
NM
1
TX
2
OK
KS
1
AR
LA
MO
IA
MN
1 WI
1
IL
1
IN
1
KY
1
TN - 1
MS AL GA
1
FL
1
SC
NC
1
VA
1
WV
OH
3
MI
2
NY
4
PA
2
MD
DE
NJ - 1 CT -1
RI
MA - 1
ME
VT
NH
AK HI
DC-1
Source: ACNM, see: http://www.midwife.org/Education-Programs-Directory
2 Programs
0 Programs
1 Program
3 Programs
4 Programs
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The Prevalence of Midwifery
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Number of Births Per State in 2012
MT
WY
ID
WA
OR
NV UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VA
WV: 20,827
OH
MI
NY
PA
MD: 72,883
DE: 11,023
NJ: 104,230
CT: 36,539
RI: 10,926 MA: 72,439
ME
VT: 6,009
NH: 12,352
AK HI
DC: 9,399
25,001 – 50,000 Births
50,001 – 100,000 Births
100,001 – 200,000 Births
Over 200,001 Births
58,448
11,187
38,347
18,980
22,963
38,702
40,341
12,798
38,669
12,118
25,942 34,911
27,068
10,106
45,067
12,104
7,572
86,441
65,187
83,227
55,758
62,642
68,772
75,446
52,751 57,155
80,371
51,465
87,463
67,295
130,280
159,160
113,091
119,831
138,483
142,514
103,013 503,755
213,148
240,916
382,727
0 – 25,000 Births
Source: Births: Final Data for 2012, National Vital Statistics Report, available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_09.pdf
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Births Attended by CNMs/CMs and “Other” Midwives – 2000-2012
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
400,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
29
7,9
02
30
5,6
06
30
7,5
27
31
0,3
42
30
8,1
13
30
6,3
77
31
7,1
68
31
6,8
11
31
7,6
26
31
3,5
16
31
2,1
29
30
9,5
14
31
3,8
46
16
,63
7
16
,79
2
17
,70
8
17
,81
1
17
,78
6
18
,71
7
19
,17
9
23
,94
3
20
,71
2
21
,78
7
23
,50
0
26
,01
1
28
,34
3
CNMs/CMs Other Midwives
Source: CDC Vital Stats, Births - Available at: http://www.cdc.gov/nchs/data_access/vitalstats/vitalstats_births.htm , also National Vital Statistics Reports, vol. 62, no. 9, Births: Final Data for 2012, December 30, 2013. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_09.pdf
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Percent of Births Attended by CNMs/CMs - 2012
MT
7.72%
WY
5.71%
ID
7.28%
WA
9.26%
OR
16.17%
NV
3.08% UT
8.59% CA
8.45%
AZ
6.50%
ND
5.56%
SD
6.50%
NE
6.10%
CO
11.70%
NM
27.02%
TX
3.12%
OK
3.82%
KS
4.40%
AR
0.63%
LA
2.84%
MO
3.09%
IA
7.13%
MN
10.43% WI
8.80%
IL
5.94%
IN
6.16%
KY
5.79%
TN 5.06%
MS
2.12%
AL
1.59% GA
15.40%
FL
10.53%
SC
4.39%
NC
12.49%
VA
6.19%
WV
12.81%
OH
7.25%
MI
6.43%
NY
10.01%
PA
10.56%
MD 8.33%
DE 6.17%
NJ 6.90%
CT 10.66%
RI 11.44%
MA 13.51%
ME
18.57% VT 20.70%
NH 18.46%
AK
14.56%
HI 9.87%
4.51% – 6.49% of births
6.50% - 8.89% of births
12.00% - 28.00% of births
Source: CDC Vital Stats, Births - Available at: http://www.cdc.gov/nchs/data_access/vitalstats/vitalstats_births.htm
8.90% - 11.99% of births
0% – 4.50% of births
DC 9.40%*
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CNM/CM Attended Births by Location - 2012
Source: CDC Vital Stats, Births - Available at: http://www.cdc.gov/nchs/data_access/vitalstats/vitalstats_births.htm Note these data are from states where this level of specificity is provided on the birth certificate. The data are not available for 551,247 of 3,952,841 births occurring in 2012.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hospital Birth Center Home Other Clinic/Office
94.76%
2.58% 2.56% 0.06% 0.04%
The vast majority of CNM/CM attended births occur in a hospital.
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Percent of Births Attended by “Other” Midwives - 2012
MT
2.51%
WY
0.58%
ID
2.87%
WA
3.15%
OR
2.15%
NV
0.59% UT
2.07% CA
0.43%
AZ
0.90%
ND
0.66%
SD
N/A
NE
0.00%
CO
1.79%
NM
1.62%
TX
0.67%
OK
0.39%
KS
0.74%
AR
0.68%
LA
0.15%
MO
1.11%
IA
0.56%
MN
0.34% WI
0.34%
IL
0.08%
IN
0.49%
KY
0.44%
TN 0.47%
MS
0.18%
AL
0.05% GA
0.05%
FL
1.21%
SC
1.07%
NC
0.11%
VA
0.59%
WV
0.18%
OH
0.65%
MI
0.44%
NY
0.01%
PA
1.50%
MD 0.48%
DE 0.38%
NJ 0.18%
CT 0.18%
RI 0.11%
MA 1.56%
ME
1.37% VT 1.80%
NH 1.24%
AK
14.26%
HI 0.83%
0.21% – 0.49% of births
0.50% - 0.89% of births
2.00% - 15.00% of births
Source: CDC Vital Stats, Births - Available at: http://www.cdc.gov/nchs/data_access/vitalstats/vitalstats_births.htm
0.90% - 1.99% of births
0% – 0.20% of births
DC 0.00%*
Data Not Available
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“Other” Midwife Attended Births by Location - 2012
Source: CDC Vital Stats, Births - Available at: http://www.cdc.gov/nchs/data_access/vitalstats/vitalstats_births.htm Note these data are from states where this level of specificity is provided on the birth certificate. The data are not available for 551,247 of 3,952,841 births occurring in 2012.
0%
10%
20%
30%
40%
50%
60%
Hospital Birth Center Home Other Clinic/Office
16.30%
24.59%
57.15%
0.23% 1.72%
“Other” midwives practice predominantly out of hospital.
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Number of Accredited Birth Centers Per State Accreditation by Commission for the Accreditation of Birth Centers (CABC)
Data Current as of June 2014; Does Not Include Pending Accreditations
MT
WY
ID
WA
OR
NV
UT CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN: 2
MS AL
GA
FL
SC
NC
VA WV
1
OH
MI
NY
PA
MD: 2
DE: 1
NJ CT: 1
RI
MA: 1
ME
VT
NH
AK HI
DC: 1
Under 5 Birth Centers
5-9 Birth Centers
No Accredited Centers
4
2
2
3
1 1
1
2
1
1
2
1
1 1
1
4
1
1
1
1
6
9
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Total Number of Birth Centers per State (Accredited and Non-Accredited) Accreditation by Commission for the Accreditation of Birth Centers (CABC) Data Current as of February 2014; Does Not Include Pending Accreditations
MT
WY
ID
WA
OR
NV UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN: 4
MS AL
GA
FL
SC
NC
VA
WV: 1
OH
MI
NY
PA
MD: 2
DE: 1
NJ CT: 2
RI
MA: 2
ME
VT
NH: 4
AK HI
DC: 1
Under 5 Birth Centers
5-9 Birth Centers
10 or More Birth Centers
No Birth Centers
9
5
3
6
6 3
4
7
7
1
2
1
3 8
15
5
2
1
1
6
62
24
1
2
29
1
1
3
1
2
1
1
10
14
Source: American Association of Birth Centers
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Rates of Cesarean Delivery Vary Dramatically Across the U.S. Percent of Births by Cesarean - 2012
MT
31.18%
WY
29.17%
ID
24.91%
WA
28.96%
OR
28.30%
NV
33.85% UT
22.60%
CA
33.22%
AZ
27.22%
ND
28.53%
SD
25.37%
NE
34.98%
CO
25.93%
NM
23.92%
TX
35.34%
OK
33.78%
KS
30.17%
AR
34.86%
LA
40.23%
MO
31.81%
IA
30.84%
MN
26.96% WI
26.34%
IL
31.93%
IN
30.75%
KY
36.24%
TN
33.84%
MS
38.13%
AL
35.47%
GA
33.82%
FL
38.13%
SC
35.42%
NC
30.61%
VA
34.27%
WV
35.88%
OH
30.91%
MI
32.61%
NY
34.27%
PA
31.53%
MD 34.97%
DE 33.08%
NJ 38.74%
CT 34.76%
RI 31.59%
MA 31.72%
ME
30.47% VT 27.09%
NH 30.80%
AK
23.37%
HI
25.10%
22.00% – 27.99%
28.00% - 30.99%
31.00% - 33.49%
33.50% - 34.99%
Source: CDC Vital Stats – Births, available online at: http://www.cdc.gov/nchs/data_access/vitalstats/VitalStats_Births.htm
35.00% - 41.00%
DC 33.57%
The cesarean rate is a window into local practice patterns.
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Laws and Regulations Affecting Midwifery
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Regulatory Structure for Certified Nurse-Midwives and Certified Midwives
Data Current as of June 2014
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VA WV
OH
MI
NY
PA
MD
DE
NJ
CT RI
MA
ME
VT
NH
AK HI
DC
Supervision Required
Written Collaborative Agreement
Written Collaborative Agreement --- Rx Only
Independent Practice
Source: ACNM analysis of state laws and regulations.
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Medical Staff Provisions for Certified Nurse-Midwives in Law and Rule
Data Current as of January 2014
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VA WV
OH
MI
NY
PA
MD
DE
NJ
CT RI
MA
ME
VT
NH
AK HI
DC
Membership is Denied Note: Could be Implicit or Explicit Denial
Membership is Allowed Note: Could be Implicit or Explicit Allowance
Source: ACNM analysis of state laws and regulations.
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Clinical Privileging Provisions for Certified Nurse-Midwives (CNM®) in Law and Rule
Data Current as of 2013
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VA WV
OH
MI
NY
PA
MD
DE
NJ
CT
RI
MA
ME
VT
NH
AK HI
DC
Clinical Privileges Granted in Law or Rule (31)
Clinical Privileges are Implied (19)
Clinical Privileges are not Granted (0)
Clinical Privileges are not Granted (Implied) (1)
Source: ACNM analysis of state laws and regulations.
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Clinical Privileging Provisions for Certified Midwives (CM®) in Law and Rule
Data Current as of 2013
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VA WV
OH
MI
NY
PA
MD
DE
NJ
CT RI
MA
ME
VT
NH
AK HI
DC
Clinical Privileges Granted in Law or Rule (4)
Clinical Privileges are Implied (1)
Clinical Privileges are not Granted (0)
Clinical Privileges are not Granted (Implied) (0)
CM® Credential is not Recognized (46)
Source: ACNM analysis of state laws and regulations.
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Which States License/Regulate Birth Centers
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VA WV
OH
MI
NY
PA
MD
DE
NJ
CT RI
MA
ME
VT
NH
AK HI
DC
No Regulation
Under Other Regulations
Birth Center Specific Regulations
Medicaid coverage for birth center services is only available if the state regulates or licenses them.
Source: American Association of Birth Centers. They note that these data are somewhat out of date. See: http://www.birthcenters.org/open-a-birth-center/birth-center-regulations
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Medicaid: Your Most Important Payer
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Percentage of Births Covered by Medicaid - 2010
MT
WY
ID
WA
OR
NV UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN: 51.3%
MS AL GA
FL
SC
NC
VA
WV: 51.82%
OH
MI NY
PA
MD: 25.93%
DE: No data available
NJ: 28.1%
CT: 31.43%
RI: 46.05%
MA: 26.75%
ME
VT: 46.61%
NH: 29.87%
AK HI
DC: 67.91%
Under 25% of Births
25-50% of Births
51-70% of Births
24.04%
47.60%
36.82%
48.82%
41.9%
38.59%
46.59%
40.46%
32.54% 43.59%
45.28%
49.83%
42.25%
35.04%
31.14% 44.05%
45.75%
28.54%
38.22%
44.88%
32.67%
49.98%
35.98%
47.63%
30.64%
29.75%
38.79%
49.51%
52.52%
55.63%
53.29% 67.13%
52.04%
69.02%
63.04%
53.36%
64.69%
53.78%
63.95%
35.35%
Source: Markus, et. al., “Medicaid Covered Births, 2008 to 2010, in the Context of the Implementation of Health Reform,” Women’s Health Issues, vol. 23, issue 5, e273-e280. Available at: http://www.whijournal.com/article/PIIS1049386713000558/fulltext#tbl1 These figures represent 2010 births. * Note that Delaware data for 2010 were not available, so map represents 2009 data.
CNM services are a required Medicaid benefit.
Medicaid is likely the largest single payer of CNM services.
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Income Eligibility Levels for Pregnant Women to Obtain Medicaid Coverage As a Percent of the Federal Poverty Level, Data Current as of April 1, 2014
MT
162%
WY
159%
ID
138%
WA
198%
OR
190%
NV
165% UT
144% CA
213%
AZ
161%
ND
152%
SD
138%
NE
199%
CO
200%
NM
225%
TX
203%
OK
138%
KS
171%
AR
214%
LA
138%
MO
201%
IA
380%
MN
283% WI
306%
IL
213%
IN
213%
KY
200%
TN 200%
MS
199%
AL
146% GA
225%
FL
196%
SC
199%
NC
201%
VA
148%
WV
163%
OH
205%
MI
200%
NY
223%
PA
220%
MD 264%
DE 217%
NJ 199%
CT 263%
RI 195%
MA 205%
ME
214% VT 213%
NH 201%
AK
205%
HI 196%
138%-199% of Federal Poverty (23 states)
250% or More of Federal Poverty (6 states, including DC)
200%-249% of Federal Poverty (22 states)
DC 324%
Source: Kaiser Family Foundation analysis of CMS data, available at: http://kff.org/medicaid/state-indicator/medicaid-and-chip-income-eligibility-limits-for-pregnant-women-at-application-as-of-april-1-2014/
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Percent of Births Attended by CNMs Covered by Medicaid - 2012
MT
45.19%
WY
N/A
ID
42.01%
WA
32.14%
OR
44.24%
NV
28.01% UT
33.02% CA
29.77%
AZ
N/A
ND
25.41%
SD
38.16%
NE
34.67%
CO
43.01%
NM
67.57%
TX
43.97%
OK
48.66%
KS
36.21%
AR
N/A
LA
72.89%
MO
50.87%
IA
35.80%
MN
33.46% WI
47.80%
IL
57.00%
IN
51.33%
KY
50.45%
TN 44.83%
MS
N/A
AL
N/A GA
43.30%
FL
58.18%
SC
46.67%
NC
41.26%
VA
N/A
WV
N/A
OH
50.12%
MI
50.80%
NY
56.84%
PA
30.45%
MD 41.94%
DE N/A
NJ N/A
CT N/A
RI N/A
MA 36.13%
ME
N/A VT 42.52%
NH 33.95%
AK
N/A
HI N/A
33.95% - 41.26%
41.94% - 44.24%
50.80% - 72.89%
44.83% - 50.45%
25% - 33.46%
DC N/A
Source: CDC Vital Stats – Births - http://www.cdc.gov/nchs/data_access/vitalstats/VitalStats_Births.htm Note, data is available for physicians for 38 states and for CNMs/CMs for 36 states. Results reflect only situations where payer was reported on the birth certificate.
Data Unavailable
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Percent of Births Covered by Medicaid by Provider Type - 2012
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
44
.18
%
43
.58
%
Physician CNM
Nationwide, physicians and CNMs see essentially the same proportion of Medicaid patients.
Source: CDC Vital Stats – Births - http://www.cdc.gov/nchs/data_access/vitalstats/VitalStats_Births.htm Note, data is available for physicians for 38 states and for CNMs/CMs for 36 states. Results reflect only situations where payer was reported on the birth certificate.
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Source: CDC Vital Stats – Births - http://www.cdc.gov/nchs/data_access/vitalstats/VitalStats_Births.htm Note, data is available for physicians for 38 states and for CNMs/CMs for 36 states. Results reflect only situations where payer was reported on the birth certificate.
Medicaid Attended Births, by Provider Type – 2012 States where CNMs do More States where Physicians do More
State Percent CNM Percent Physician State Percent CNM Percent Physician
Colorado 43.01% 34.23% California 29.77% 48.31%
Florida 58.18% 50.57% Georgia 43.30% 48.42%
Idaho 42.01% 40.31% Iowa 35.80% 39.33%
Illinois 57.00% 47.72% Nevada 28.01% 39.17%
Indiana 51.33% 45.06% North Carolina 41.26% 46.01%
Kansas 36.21% 33.25% North Dakota 25.41% 28.09%
Kentucky 50.45% 43.25% Oklahoma 48.66% 56.41%
Louisiana 72.89% 65.71% Oregon 44.24% 45.56%
Maryland 41.94% 31.28% Pennsylvania 30.45% 34.32%
Massachusetts 36.13% 28.55% South Carolina 46.67% 52.45%
Michigan 50.80% 43.48% Tennessee 44.83% 53.85%
Minnesota 33.46% 20.52% Texas 43.97% 46.70% Missouri 50.87% 44.24% Vermont 42.52% 48.13%
Montana 45.19% 35.17% Washington 32.14% 39.87%
Nebraska 34.67% 31.38%
New Hampshire 33.95% 30.00%
New Mexico 67.57% 55.53%
New York 56.84% 44.60%
Ohio 50.12% 39.62%
South Dakota 38.16% 33.38%
Utah 33.02% 28.17%
Wisconsin 47.80% 38.02%
Not all states birth certificates report payer type, so not all are listed here.
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Medicaid Fee-for-Service Payments for Obstetric Services as a Percent of Medicare Payments - 2012
MT
105%
WY
174%
ID
82%
WA
107%
OR
104%
NV
80% UT
74% CA
54%
AZ
92%
ND
124%
SD
84%
NE
101%
CO
68%
NM
100%
TX
68%
OK
97%
KS
73%
AR
74%
LA
73%
MO
57%
IA
86%
MN
66% WI
93%
IL
86%
IN
78%
KY
97%
TN N/A
MS
90%
AL
101% GA
81%
FL
90%
SC
139%
NC
72%
VA
91%
WV
108%
OH
65%
MI
61%
NY
80%
PA
115%
MD 89%
DE 94%
NJ 37%
CT 123%
RI 39%
MA 97%
ME
100% VT 82%
NH 61%
AK
114%
HI 66%
60-79%
80-99%
Source: Kaiser Family Foundation Medicaid to Medicare Fee Index, available at: http://kff.org/medicaid/state-indicator/medicaid-to-medicare-fee-index/
100-120%
37-59%%
DC 80%
>121%
Nationally, fee-for-service Medicaid payments for obstetric services are equivalent to 78% of Medicare payments.
Data Unavailable
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Medicaid Fee-for-Service Payments to CNMs as a Percent of Payment to Physicians
Data Current as of June 2014
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL
IN
KY
TN: 90%
MS AL
GA
FL
SC
NC
VA WV
OH
MI
NY
PA
MD
DE
NJ: 70%
CT: 90%
RI
MA
ME
VT
NH
AK HI
DC: 100%
Under 80% Reimbursement
80-89% Reimbursement
90-99% Reimbursement
100% Reimbursement
80%
85%
80%
80%
85%
85%
80%
88%
85%
90%
90%
90%
97%
92%
75%
75%
75% 75%
75%
Source: ACNM analysis of state law, regulation and payment policy. MN pays 90% in most sites. MA pays 85%, depending on certain criteria.
Medicare pays CNMs at 100% of Physician rates.
Medicaid is generally the lowest payer out there and frequently pays CNMs/CMs less than physicians.
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Percent of Adults with Medicaid Covered Under a Comprehensive Managed Care Plan – FY 2011
MT
0%
WY
0%
ID
0%
WA
68.8%
OR
80.2%
NV
71.6% UT
0.1% CA
24.6%
AZ
83.1%
ND
0.1%
SD
0%
NE
49.4%
CO
11.7%
NM
67.1%
TX
35.0%
OK
0%
KS
67.8%
AR
<0.05%
LA
0%
MO
49.0%
IA
0%
MN
70.2% WI
89.7%
IL
6.7%
IN
89.8%
KY
19.4%
TN - N/A
MS
0.2%
AL
<0.05% GA
85.1%
FL
69.8%
SC
52.7%
NC
0%
VA
64.6%
WV
76.9%
OH
92.7%
MI
70.5%
NY
74.0%
PA
60.5%
MD 64.7%
DE 84.9%
NJ 54.9%
CT 57.2%
RI 79.1%
MA 61.1%*
ME
N/A VT N/A
NH 0%
AK
0%
HI 95.0%
<0.05% -48.9%%
49.0%-65.9%%
Source: Medicaid and CHIP Access and Payment Commission, MACSTATS, June 2014, available at: http://www.macpac.gov/macstats
66.0%-79.9%
0%
DC 91.9%
Managed Care Organizations are free to contract with providers using different rates than fee-for-service.
80.0-95%
48.0% of adults covered by Medicaid in 2011 were covered under a comprehensive managed care plan.
Data Unavailable
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Medicare’s Physician Fee Schedule: How you Get Paid
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Medicare’s Physician Fee Schedule – A Brief Overview
Work RVUs
Work GPCI
Practice Expense
RVUs
Malpractice RVUs
Malpractice GPCI
Conversion Factor
Payment
Total Adjusted RVUs
Practice Expense
GPCI
For an excellent plain language discussion of the Medicare physician payment methodology, see the Payment Basics document by MedPAC, available at: http://www.medpac.gov/documents/MedPAC_Payment_Basics_13_Physician.pdf Source: http://www.ananursespace.org/blogsmain/blogviewer/?BlogKey=b9e87d7e-57a1-4c93-b9b9-e48874a2be0c&ssopc=1
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Relative Value Units (RVUs)
Physician Work
• Time
• Effort
• Skill
• Stress
Practice Expense
• Office Space
• Supplies
• Equipment
• Administrative Staff
• Clinical Staff
Malpractice
• Malpractice Premiums
RVUs represent the relative effort and expense involved in a given procedure.
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Geographic Cost Indices (GPCIs)
GPCIs adjust payments based on regional expense variations.
Physician Work GPCI
• Relative wage difference for each locality compared to the national average.
Practice Expense
GPCI
• Measures variation in employee wages, purchased services, rent, equipment, supplies and miscellaneous expenses
Malpractice
GPCI
• Measures variation in cost of malpractice Premiums for $1 million to $3 million mature claims made policies.
There are 89 physician fee schedule localities. Which localities are your commercial payers using to calculate their rates?
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The Conversion Factor (CF)
The CF is a dollar figure, updated each year. If actual expenditures exceed an established target, then the CF is lowered the next year to make up for the difference. In 2014, the CF is $35.8228.
$0
.00
$1
.10
$3
.60
$7
.10
$9
.70
$7
.90
$7
.70
$6
.60
$2
.10
($4
.80
)
($1
1.6
0)
($1
5.9
0)
($1
8.6
0)
($1
9.8
0)
($1
7.8
0)
($1
4.9
0)
($6
.60
)
($25.00)
($20.00)
($15.00)
($10.00)
($5.00)
$0.00
$5.00
$10.00
$15.00
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
In B
illio
ns
of
Do
llars
Cumulative Difference Between Target and Actual Expenditures
Source: http://cms.hhs.gov/Medicare/Medicare-Fee-for-Service-Payment/SustainableGRatesConFact/Downloads/sgr2014f.pdf
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Additional Modification to Physician Payments
Program Does it Affect Medicare Payments to
CNMs?
Physician Quality Reporting System (PQRS) Yes (note as well that the PVBP is built on PQRS reporting)
Physician Value Based Payment Program (PVBP)
May apply to payments beginning January 1, 2017
EHR Meaningful Use No
Health Professionals Shortage Area bonus payment
No
Primary Care Incentive Payment No
Payment Reduction for Non-Participatory Status
No
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Medicare Physician Payments in the Future
Accountable Care Organizations (ACOs)
• A single organization that takes responsibility for the quality and cost of care for a specified population.
Bundled Payment Arrangements
• A single lump sum, non-varying payment for a defined episode of care.
Value Based Purchasing
• Rewarding high performance relative to specified quality and cost measures.
All of these approaches are likely to benefit midwifery!
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Enrolling with Payers
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Getting Your Numbers
National Provider Identifier (NPI)
• Standardized number used on all claims, remittance notices, etc.
• Used by all other providers, payers and claims processing clearinghouses.
• Must obtain an NPI before obtaining a Medicare PTAN.
• https://nppes.cms.hhs.gov/NPPES/Welcome.do
Medicare Provider Transactions Access Number (PTAN)
• Allows you to participate in Medicare and bill for services provided to Medicare beneficiaries.
• Obtained through the Provider Enrollment, Chain and Ownership System (PECOS).
• https://pecos.cms.hhs.gov/pecos/login.do
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Documenting and Coding
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Learning to Document and Code is CRITICAL!
Learn what services you can provide.
Learn what CPT codes correspond to those services.
Learn to document what you have done.
If you are not documenting and coding as completely and accurately
as possible, you are likely:
• Losing money
• Unable to prove your value to your group or hospital
• Opening yourself up to allegations of fraud/waste/abuse.
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The Bottom Line: Payment and Salary
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Average Total Charges and Payments for Maternal and Newborn Care in the U.S. - 2010
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
Commercial -Vaginal
Commercial -Cesarean
Medicaid -Vaginal
Medicaid -Cesarean
$3
2,0
93
$5
1,1
25
$2
9,8
00
$5
0,3
73
$1
8,3
29
$2
7,8
66
$9
,13
1
$1
3,5
90
Charges
Allowed Amount
Source: “The Cost of Having a Baby in the United States,” Truven Health Analytics Marketscan® Study, January 2013. Costs and charges associated with newborn care include those incurred through the first three months of life.
Payments for cesarean births are approximately 50% higher than payments for vaginal births.
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Source of Payments for Maternal and Newborn Care in the U.S. - 2010
$0
$5,000
$10,000
$15,000
$20,000
$25,000
Commercial -Vaginal
Commercial -Cesarean
Medicaid - Vaginal Medicaid -Cesarean
$1
5,9
31
$2
4,9
49
$9
,00
2
$1
3,3
27
$2
,24
4
$2
,66
9
$1
53
$2
67
Primary Payer
Out-of-Pocket
Secondary Payer
Primary payer pays 87% of costs for vaginal birth and 90% of costs for cesarean birth.
Source: “The Cost of Having a Baby in the United States,” Truven Health Analytics Marketscan® Study, January 2013. Costs and charges associated with newborn care include those incurred through the first three months of life.
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Average CNM and CM Salary Per State Data Current as of May 2013; Based on Bureau of Labor Statistics and ACNM Data
MT
WY
ID
WA
OR
NV UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN: $70,890
MS AL GA
FL
SC
NC
VA
WV: $76,500
OH
MI NY
PA
MD: $96,300
DE: $65,720
NJ: $99,540 CT: $86,130
RI: $83,450
MA: $107,710
ME
VT: $94,370
NH: $108,360
AK HI
DC: $81,560
$50,000 - $74,000 Annually
$75,000 - $99,000 Annually
$100,000 or More Annually
$103,980
$113,070
$116,420
$103,460
$111,480
$92,930
$87,620
$92,710
$95,850
$91,880
$86,560
$79,960
$82,720
$88,020
$92,460
$83,300
$82,620
$80,860
$80,150
$93,580
$96,780
$92,460
$65,790
Note: Salary data followed by an * indicates NP data due to limited CNM-specific data.
$88,320 * $95,890
*
$94,220 *
$82,010
$82,990
$61,960
$81,550 *
$89,020 *
$88,130 *
$107,220 $92,070
*
$88,060 *
$94,720 *
$92,130 * $81,180
$103,980
$93,220
Source: Bureau of Labor Statistics, available at: http://www.bls.gov/oes/current/oes291161.htm Due to limited midwifery salary data, NP data was substituted for some states as a rough estimate. In general, NP salaries tend to be slightly higher than CNM salaries.
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CNM Salary as a Percent of OB Salary Data Current as of May 2013; Based on Bureau of Labor Statistics and ACNM Data
MT
36%
WY
35%
ID
50%
WA
46%
OR
33%
NV
N/A UT
38% CA
58%
AZ
45%
ND
45%
SD
36%
NE
40%
CO
50%
NM
48%
TX
41%
OK
25%
KS
34%
AR
38%
LA
38%
MO
36%
IA
34%
MN
53% WI
60%
IL
46%
IN
33%
KY
36%
TN 35%
MS
40%
AL
37% GA
42%
FL
40%
SC
39%
NC
43%
VA
31%
WV
40%
OH
42%
MI
42%
NY
50%
PA
44%
MD 47%
DE 27%
NJ 44%
CT 41%
RI 51%
MA 51%
ME
44% VT 50%
NH 45%
AK
42%
HI 48%
36% - 45%
46% - 55%
Source: Bureau of Labor Statistics, available at: http://www.bls.gov/oes/current/oes291161.htm Due to limited midwifery salary data, NP data was substituted for some states as a rough estimate. In general, NP salaries tend to be slightly higher than CNM salaries.
56% - 60%
25% - 35%
DC 45%
Data Unavailable
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Q&A