A plan to bundle maternity care so midwives and GPs could be funded to manage pregnancy and birth in private hospitals is just a way to maximise insurance profits, says a leading obstetrician.
With out-of-pocket costs of private hospital births driving women away from delivering their babies in private hospitals, Private Healthcare Australia — the peak body for Australia’s biggest health insurers – has floated a new solution.
PHA’s modelling document has calculated that a bundled maternity care proposal could slash the cost of pregnancy care and birth in the private system by almost 30%.
The draft proposal suggests a lead practitioner (obstetrician, GP, or midwife) would coordinate care and negotiate a single, up-front price for the mother.
The PHA hopes it could encourage thousands of women to use their private health insurance and give birth in a private hospital.
According to PHA CEO Dr Rachel David, the bundled care model is an opportunity to help sustain private obstetrics in this country, “which is currently evaporating in front of our eyes due to the high out-of-pocket costs doctors are charging for managing the pregnancy in the community that can exceed $6500 in some cities”.
“The model creates a comprehensive care package that spans the entire pregnancy journey instead of just the hospital stay, which is all health funds are legally allowed to pay at present,” she said.
“By allowing health funds to contribute towards out-of-hospital costs when part of a bundled package, it removes the artificial boundaries that have historically contributed to expenses, like scans, pathology and an anaesthetist, should one be required for the delivery,” she said.
PHA said this model of care is used in many countries around the world safely and effectively.
“Our model promotes team-based care with the continuity of a lead practitioner, which provides accountability and quality. Where a midwife is leading that care, they would need arrangements with obstetricians and other doctors to ensure any contingencies are covered within the private hospital where the mother is admitted,” said the PHA model.
The president of the National Association of Specialist Obstetricians and Gynaecologists, Dr Gino Pecoraro, told TMR’s sister publication Health Services Daily that he doesn’t think the plan will work, however.
“We’ve discussed bundling before. It doesn’t work. It’s a waste of time. It’s just a way for private health insurers to maximise their profits,” he said.
He said one concern he has is if a woman needed an obstetrician in the middle of the night.
“No obstetrician in Australia would sign up to that. Why would you when you’re going to get all the medico-legal responsibility? All you’re doing is opening yourself up to litigation,” he said.
PHA’s model has become public after new findings were published in the British Journal of Obstetrics and Gynaecology that revealed the stillbirth and neonatal death rate of Australian public hospital deliveries is double that of newborn fatalities in the private system.
The study analysed matched outcomes and costs for more than 362,000 births in Australia over four years to December 2019.
They found the standard public model had an extra:
- 778 stillbirths or neonatal deaths (0.9% versus 0.4%);
- 2301 neonatal intensive care admissions (3.5% versus 1.3%);
- 3273 women with more severe vaginal tears (2.5% versus 0.7%);
- 10,627 women with postpartum haemorrhage or excessive bleeding (9.6% versus 3.8%);
- $5929 cost per pregnancy ($28,645 versus $22,757) including costs to all payers when compared to the private obstetric-led model.
“The earth-shattering thing is that it would be cheaper for the federal government to give every pregnant woman a quantum of money and say, ‘go get the best maternity care you can get – if you go into the private sector, it will save $6000 per baby delivered,’” Dr Pecoraro said.
However, Hannah Dahlen, professor of midwifery from Western Sydney University, and Jenny Gamble, professor of midwifery at Monash University, wrote in The Conversation that the BJOG data doesn’t tell the entire story.
“A major problem with doing research with big data sets is they do not contain the many medical and social complexities that inform health outcomes. These complexities are much more prevalent in the public system and impact on health outcomes,” they wrote.
They highlighted how only diabetes and blood pressure problems were included in medical complications controlled for in this paper.
“But there are others that impact on outcomes. There was no controlling for drug and alcohol use, mental health, refugee status and many more significant factors impacting health outcomes for mothers and babies,” they wrote.
They also said while the authors tried to match the data, it didn’t have data on artificial reproductive technology, body mass index and smoking, for example, which could all impact outcomes.
They also highlighted that the study grouped multiple models of public hospital care into one group (which includes fragmented models and care and continuity of care where a woman sees a small number of providers) and compared them to private obstetric care.
“Women favour continuity of care and they and their babies experience better outcomes in these models, especially under midwifery continuity of care.
“However, continuity of midwifery care can be difficult to access, despite calls to expand this model worldwide,” they wrote.
Dr Pecoraro agreed that continuity of care is most important, but sometimes even women in the midwifery care model don’t receive it.
“We also know that in 50%, one out of every two patients, that go to a midwifery continuity of care model will need an obstetrician to deliver the baby. So it’s the next best thing, but it’s pretty, average,” he said.
What it shows is that something needs to change.
“Continuing to do what we’re doing now is simply nonsensical. It is expensive, it is causing loss of life, and it is harming women,” he said.
“What we need to do is to go back to having proper teams where every woman is seen by an obstetrician, a midwife, with input from paediatricians and anaesthetists during their healthcare journey in our public hospitals. So that way, something happens, and she needs intervention with a specialist, she will have met that person before,” Dr Pecoraro continued.
In a statement, RANZCOG agreed that women in Australia deserve more.
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“A framework that limits practitioners’ ability to provide care will ultimately lead to fewer options for women, especially those facing high-risk pregnancies or those who prioritise continuity of care with an obstetrician,” they said.
“Models of care should be determined by evidence for safety and quality and should take women’s choices into consideration – they should not be dictated by insurance companies who are likely to prioritise profit.”
The AMA agreed.
“The AMA is consulting with members on a range of reform options for maternity care, but any changes to private maternity funding should be backed by robust economic modelling, preferably conducted by an independent private health system authority,” AMA president Dr Danielle McMullen said.
“As a starting point, MBS and health fund medical item numbers for all specialties relevant to maternity care must be urgently corrected to reverse the funding shortfall caused by the Medicare freeze and years of inadequate indexation,” she continued.
With rising costs, worsening outcomes, and dwindling access, Australia’s maternity care model can’t afford to stand still. However, it shouldn’t be a debate about midwives versus obstetricians. Dr Pecoraro said both have an important role in positive pregnancy, birth and postpartum outcomes.
“I can’t work without midwives. Midwives can’t work without me. We’ve got a very good relationship in the hospitals that I work at, because we understand and respect each other.
“Women have a right to be seen by both obstetricians and midwives,” he concluded.
