Over the last few years, the cost of health care has increased at a rate higher than inflation. Everyone who pays for health care has become concerned. Consequently, how to provide health care for a reasonable cost is the challenge of the 1980s.
Health planners have proposed several ways to contain health costs. Diagnostic-related groups (DRGs), usual and customary reimbursement (UCR), health maintenance organizations (HMOs), home health care, voucher systems, and changing the tax deductions allowed for health care expenditures have all been suggested as possible ways of controlling costs.
Some nursing leaders have strongly promoted increasing competition between medical providers as another significant cost control measure as long as the provider group is expanded, by legislation where necessary, to include nurse-practitioners, nurse-anesthetists, and nurse-midwives. Because midwifery has the longest history and the most documentation, they point to studies that show that nurse-midwives provide care which is as good as physician care but costs less, as justification for expanding the medical provider pool.1–3
Nurse-practitioners and nurse-midwives are said to charge less because their sharply focused educational programs are much shorter and less expensive than medical school and residency, their malpractice premiums are minimal, and their annual incomes range from $20-35,000 whereas physicians earn over $50-150,000/year. Because of these factors, many nurse-practitioners and nurse-midwives charge a fixed percentage of the fee charged by physicians for the same service.4
However, as we market ourselves to consumers and third-party payers, we should remember that cost-effective does not necessarily mean cheaper. It means that the service paid for was worth the cost. The following discussion will focus on whether CNM care should and can always cost less than physician care. As we argue our cost-effectiveness, we should continue to prove that midwives are worth what we cost without underselling ourselves.
How to price our care is difficult. Maybe we should charge less than physicians because we do not have as many years of education as physicians do, even though some of that education is irrelevant to the task, and because we do have to collaborate with and/or refer some patients to our physician backups. On the other hand, when we provide prenatal and delivery care to a normal population, we are providing approximately the same service that doctors provide. Are we afraid that if we cost the same as physicians, consumers will not choose us? If third-party payers want to reimburse CNMs less than physicians for the same services, are they not justified if we ourselves have set the example by charging a substantially lower fee than physicians in our community? Do we expect reimbursement for who we are or what we do?
The “who we are” has apparently led to an undervaluation of a CNM's worth. An earlier editorial5 focused on a similar topic, but it is worth briefly discussing it again.
Traditionally, the major pathway to professional midwifery has been through the ranks of nursing. As one of the female helping professions, nursing, like social work and teaching, has historically commanded low salaries. And because nurse-midwives are considered by many to be simply expanded-role nurses, salaries have remained in line. In fact, many nurse-midwives with master's degrees who are on-call and work up to 60 hr/week receive only a slightly larger salary than RNs who have less educational preparation and who work simply a straight 8-hr shift.
Midwifery should be evaluated as a medical profession on a par with medicine and dentistry, as it is in France. When we become midwives, we assume daily a life and death responsibility for mothers and babies that is certainly greater than the risks assumed by the average dermatologist. But that weighty assumption of risk is not calculated into our respective earning power or the esteem of our respective professions because the dermatologist is a doctor and we are only nurses.
I doubt whether many of us find midwifery an easy way to make a living, no matter how much we love it. The hours we work are disruptive and exhausting, the daily politics start to wear one down, and the life and death responsibility is sometimes overwhelming. The cost of midwifery burn-out to the profession and to the public is difficult to calculate, but each of us certainly knows midwives who, by choice, no longer practice clinical midwifery or who have gone on to other careers in more socially rewarding fields like medicine, law, or business.
Some of the business arrangements under which nurse-midwives must practice also contribute to the difficult question of our cost. One midwifery service, for example, turns over 50% of the fees collected on every client to their consulting obstetricians regardless of whether the physician ever sees the patient. There are CNMs who are employees in physician practices who annually bring in five times their salary in patient fees to the practice's coffers. There are those birth centers that restrict nurse-midwives' salaries to keep the cost of the birth center lower than comparable hospital care.
In the past, the cost of malpractice insurance and the cost of defensive medicine were not significant factors for CNMs, but they may become more influential soon. The American College of Obstetricians and Gynecologists recently released a study that showed that the rising cost of malpractice insurance and an increase in the use of precautionary measures to guard against malpractice suits have increased the cost of ob/gyn services.6 Although our rates for malpractice insurance still are drastically lower than those paid by physicians, this year's 500% increase in ACNM professional liability insurance (from $38-$225/year) must be calculated into the fees we charge for our services. And our rates for malpractice insurance undoubtedly will increase again over the next couple of years.
As our profession grows, our malpractice risk is also likely to grow. CNMs may find that the precautionary measures many physicians now use routinely like continuous fetal heart monitoring, intravenous fluids, and ultrasound may be forced upon us as customary practice by the courts and the institutions with which we are affiliated. These procedures would all add to the cost of the health care we provide.
We need to show that there are less costly midwifery alternatives to some of the defensive medical practices that are becoming so prevalent today. Some of these include counting fetal movements before resorting to nonstress tests; observing clients even earlier in pregnancy to evaluate gestational age instead of relying on routine ultrasound; prescribing castor oil and breast stimulation to induce labor instead of depending on intravenous pitocin; providing intensive nutritional counseling instead of intensive care for low birth weight babies; preparing women physically and emotionally for labor to reduce the reliance on anesthesia; promoting highly immune breastfed infants instead of formula-fed babies who are more susceptible to respiratory and intestinal illnesses; striving towards 90% vaginal births instead of 25% cesareans; providing safe out-of-hospital births as a viable option instead of routine hospitalization for all normal pregnancies; preparing families for early discharge instead of requiring a routine three-day hospital stay.
Midwifery's selling point has been its commitment to noninterventionist family-centered birth.7 We undoubtedly are more expert when it comes to normal pregnancy than the average obstetrician who has been trained in an American tertiary care center. Several studies attest that we do commendably well with higher-risk populations as well.2
As we set about proving our cost-effectiveness, I hope it is not done at too great a personal and financial cost to CNMs. CNMs should earn salaries commensurate with their education, hours worked, and weighty responsibilities. We should share with each other our experiences in setting up equitable business arrangements to encourage job satisfaction and remaining in the profession. We must endeavor to keep our malpractice costs as low as possible by keeping our patients adequately informed and involved in their own care.
Nurse-midwives are cost-effective because we can show improved neonatal and maternal outcomes with fewer operative procedures and medical interventions, because we provide safe births in less expensive out-of-hospital settings or for fewer hospital days, and because we can show that emotional support and education about nutrition, exercise, breastfeeding, and self-care are worthwhile. Cost-effective should mean that both the consumer and the nurse-midwife are satisfied with the health care offered.