Collaborative Arrangements and Referral Refusal
Privately Practicing Midwives (PPMs) are currently required to enter into a collaborative arrangement with a medical professional or health service in order to access Medicare rebates for the care they provide their clients. Medicare rebates are only available for the antenatal and postnatal components of care. This mandated requirement came about after the National Maternity Services reform in 2010 and has been problematic from the start.
Homebirth Australia believes that this collaborative arrangement requirement adds to a PPMs already enormous workload and is a huge barrier in women accessing their preferred model of care, adding unnecessary emotional and financial stress . It unfairly targets PPMs and women who chose homebirth, particularly those in regional and remote areas.
The Australian College of Midwives (ACM) have outlined their concerns with collaborative arrangements in this statement on their website. In our 2022 Homebirth Australia conference panel discussion titled 'Collaborative Care: Working Together for the Best Outcomes', ACM spokesperson Kellie Wilton stated that "when the government legislation mandates collaboration, that it is suggestive of an ongoing priority and support for medical models and not for the expansion of midwives to provide primary healthcare." The recording of this session is available to view for free on our Vimeo channel and is recommended viewing for anyone wanting to know more about this issue. It should be noted that the Royal Australian College of GPs (RACGP) were invited to take part in this panel discussion, but they declined our invitation.
The National Guidance on Collaborative Maternity Care identifies 9 Principals, which focus on providing woman-centred care, enabling women to choose care based on best evidence, enabling women to make informed decisions, as well as establishing professional trust between health professionals. These principals sound great in theory, but in reality, collaborative arrangements undermine a PPMs autonomy and limit a woman's choice to access their preferred model of care.
Referral Refusal
For a lot of women who choose homebirth in Australia, the requirement for collaborative arragements means they need to get a referral from a GP to their PPM in order to access the much-needed Medicare rebate for the antenatal and postpartum components of their care.
Referral refusal has been an issue in the homebirth community for many years, as outlined in this report by Homebirth NSW in 2018.
In the last few years, reports of GPs refusing to write referrals to women for maternity care with a PPM have increased significantly, with a noticeable shift in reasoning leaning towards fear of liability, although we believe that existing bias for medicalised models and unfounded fears of homebirth safety still play a large role in this.
HBA has received reports of midwives losing existing collaborative arrangements with GPs due to the increased fear of litigation, which has been exacerbated by insurance companies openly advising their clients against referring to PPMs. This is despite the fact that the RACGP guidelines for referral clearly state that "Third parties, such as insurers, should not be actively involved in any decision-making process regarding patient referrals."
HBA have been made aware of posts among private GP groups on Facebook where this information has been shared followed by derogatory comments about PPMs, which has had a knock-on effect and led to more GPs refusing to write referrals to PPMs.
There appears to be a misunderstanding by GPs about what actually constitutes a collaborative arrangement. Based on feedback given to our PPM members by their local GPs, they believe that by writing a referral to a PPM that they are entering into a collaborative arrangement and accepting responsibility for any adverse outcomes or future liability.
A referral to a PPM and entering into a collaborative arrangement with a PPM are two very different things. By writing a referral to a PPM, a GP is not automatically entering into a collaborative arrangement. The referral is purely so that the woman can obtain Medicare rebates for the antenatal and postnatal care provided by their PPM.
In the RACGP referral guidelines it outlines:
'The Medical Board of Australia’s code of conduct sets out three principles for good referrals between medical professions. It suggests that you should:
When a GP refers a woman on to the care of another specialist, they are still responsible for their care but the referral guidelines clearly state that by referring you are sharing responsibility for patient care which falls outside of your scope of practice. Referrals to PPMs should be treated just like any other referral to a health professional.
Fears about liability imply that they believe homebirth in unsafe, despite the research indicating otherwise. At a recent ACM panel discussion on insurance for PPMs, a spokesperson from MIGA communicated that claims against PPMs are very low in number.
HBA has spoken to GPs who have established professional relationships with PPMs in their area. Many have admitted that initially their views on homebirth were fear-based, but that by working with PPMs and having read research on the safety of homebirth, they have changed their views and are now supportive of homebirth as a safe choice for most Australian women. We fear that the spreading of false information among GPs is only limiting their ability to enter into a conversation with women about homebirth with an open mind.
Women have reported being "lectured'" by their GP about the dangers of homebirth and encouraged to re-think their choice to birth at home. This condescending behaviour is not in the spirit of providing woman centred care and only leads to break-down of the GPs established relationship with their clients, forcing them to seek a referral elsewhere. One of the most frequently asked questions in online homebirth groups is for recommendations for GPs who will write a referral to a PPM.
Feedback we have received from PPMs in relation to collaborative arrangements and referrals from GPs include:
We believe that the false information being given to GPs by their insurers is extremely detrimental and should be addressed immediately. The Department of Health, RACGP and RANZCOG have a responsibility to correct this misconception and provide accurate information.to GPs and we call on them to do so. HBA will continue to engage with the ACM and RACGP on behalf of our members about potential education opportunities for GPs to help provide accurate information about homebirth and the referral process.
Homebirth Australia is taking part in the Department of Health's review into collaborative arrangements, which is being facilitated by a third party. HBA have engaged with PPMs via our newsletter and social media and we've communicated their concerns during the interview process.
We encourage all PPMs who are affected by collaborative arrangements to complete the survey here: https://ipsmc.qualtrics.com/jfe/form/SV_3atMyAS9KIpyGLs
14th June 2022
Homebirth Australia believes that this collaborative arrangement requirement adds to a PPMs already enormous workload and is a huge barrier in women accessing their preferred model of care, adding unnecessary emotional and financial stress . It unfairly targets PPMs and women who chose homebirth, particularly those in regional and remote areas.
The Australian College of Midwives (ACM) have outlined their concerns with collaborative arrangements in this statement on their website. In our 2022 Homebirth Australia conference panel discussion titled 'Collaborative Care: Working Together for the Best Outcomes', ACM spokesperson Kellie Wilton stated that "when the government legislation mandates collaboration, that it is suggestive of an ongoing priority and support for medical models and not for the expansion of midwives to provide primary healthcare." The recording of this session is available to view for free on our Vimeo channel and is recommended viewing for anyone wanting to know more about this issue. It should be noted that the Royal Australian College of GPs (RACGP) were invited to take part in this panel discussion, but they declined our invitation.
The National Guidance on Collaborative Maternity Care identifies 9 Principals, which focus on providing woman-centred care, enabling women to choose care based on best evidence, enabling women to make informed decisions, as well as establishing professional trust between health professionals. These principals sound great in theory, but in reality, collaborative arrangements undermine a PPMs autonomy and limit a woman's choice to access their preferred model of care.
Referral Refusal
For a lot of women who choose homebirth in Australia, the requirement for collaborative arragements means they need to get a referral from a GP to their PPM in order to access the much-needed Medicare rebate for the antenatal and postpartum components of their care.
Referral refusal has been an issue in the homebirth community for many years, as outlined in this report by Homebirth NSW in 2018.
In the last few years, reports of GPs refusing to write referrals to women for maternity care with a PPM have increased significantly, with a noticeable shift in reasoning leaning towards fear of liability, although we believe that existing bias for medicalised models and unfounded fears of homebirth safety still play a large role in this.
HBA has received reports of midwives losing existing collaborative arrangements with GPs due to the increased fear of litigation, which has been exacerbated by insurance companies openly advising their clients against referring to PPMs. This is despite the fact that the RACGP guidelines for referral clearly state that "Third parties, such as insurers, should not be actively involved in any decision-making process regarding patient referrals."
HBA have been made aware of posts among private GP groups on Facebook where this information has been shared followed by derogatory comments about PPMs, which has had a knock-on effect and led to more GPs refusing to write referrals to PPMs.
There appears to be a misunderstanding by GPs about what actually constitutes a collaborative arrangement. Based on feedback given to our PPM members by their local GPs, they believe that by writing a referral to a PPM that they are entering into a collaborative arrangement and accepting responsibility for any adverse outcomes or future liability.
A referral to a PPM and entering into a collaborative arrangement with a PPM are two very different things. By writing a referral to a PPM, a GP is not automatically entering into a collaborative arrangement. The referral is purely so that the woman can obtain Medicare rebates for the antenatal and postnatal care provided by their PPM.
In the RACGP referral guidelines it outlines:
'The Medical Board of Australia’s code of conduct sets out three principles for good referrals between medical professions. It suggests that you should:
- take reasonable steps to ensure the specialist to whom you refer is the appropriate person (i.e. they have the appropriate qualifications, experience, knowledge and skills)
- understand that you remain responsible for the overall management of the patient and your decision to delegate
- communicate sufficient information to the specialist in order to enable them to assess, diagnose, treat and/or manage the patient.
When a GP refers a woman on to the care of another specialist, they are still responsible for their care but the referral guidelines clearly state that by referring you are sharing responsibility for patient care which falls outside of your scope of practice. Referrals to PPMs should be treated just like any other referral to a health professional.
Fears about liability imply that they believe homebirth in unsafe, despite the research indicating otherwise. At a recent ACM panel discussion on insurance for PPMs, a spokesperson from MIGA communicated that claims against PPMs are very low in number.
HBA has spoken to GPs who have established professional relationships with PPMs in their area. Many have admitted that initially their views on homebirth were fear-based, but that by working with PPMs and having read research on the safety of homebirth, they have changed their views and are now supportive of homebirth as a safe choice for most Australian women. We fear that the spreading of false information among GPs is only limiting their ability to enter into a conversation with women about homebirth with an open mind.
Women have reported being "lectured'" by their GP about the dangers of homebirth and encouraged to re-think their choice to birth at home. This condescending behaviour is not in the spirit of providing woman centred care and only leads to break-down of the GPs established relationship with their clients, forcing them to seek a referral elsewhere. One of the most frequently asked questions in online homebirth groups is for recommendations for GPs who will write a referral to a PPM.
Feedback we have received from PPMs in relation to collaborative arrangements and referrals from GPs include:
- "I recently commenced in private practice, providing antenatal and postnatal care only. To this day I have been unsuccessful in gaining a collaborative agreement."
- "This requirement very much feels like it takes away from our autonomy as Midwives. We have worked very hard to become endorsed and we are more than capable of providing care to women without having GP's or OB's as the gatekeepers to our care. We are the only health professionals that are required to collaborate in this way."
- "this collaborative requirement does not seem to be in the best interest of the women or the Midwives who are affected by it"
- "it is incredibly hard to gain collaboration. I provide antenatal and postnatal care and have been rejected by every single doctor I’ve approached, except for one who I currently have collaboration with. As far as I know, he is the only doctor in the state willing to form a collaborative agreement with PPMs so we all use him."
- "By far the biggest stressor in my practice as a PPM is collaboration and maintaining this into the future"
- "Many PPMs in my area have expressed interest gaining collaboration and admitting rights at our tertiary hospitals to give women more options yet this has been declined, stating that ‘they do not collaborate with PPMs as they already have a continuity service that meets the needs of their community’. They’re referring to MGP which while we are lucky to have, is vastly different to the care we can provide as PPMs"
- "I have been in practice as a home birth midwife for two years now and still struggling to get collaboration for each family as well as admitting rights being applied for nearly two years ago at my local hospital with no progress…."
We believe that the false information being given to GPs by their insurers is extremely detrimental and should be addressed immediately. The Department of Health, RACGP and RANZCOG have a responsibility to correct this misconception and provide accurate information.to GPs and we call on them to do so. HBA will continue to engage with the ACM and RACGP on behalf of our members about potential education opportunities for GPs to help provide accurate information about homebirth and the referral process.
Homebirth Australia is taking part in the Department of Health's review into collaborative arrangements, which is being facilitated by a third party. HBA have engaged with PPMs via our newsletter and social media and we've communicated their concerns during the interview process.
We encourage all PPMs who are affected by collaborative arrangements to complete the survey here: https://ipsmc.qualtrics.com/jfe/form/SV_3atMyAS9KIpyGLs
14th June 2022
UPDATE
On the 10th of May 2023, the Australian College of Midwives sent an email to their members stating that the requirement for collaborative arrangements has been removed by the Federal Government. You can read the statement here.
This is great news! However, as it requires a legislative change, it will need to go through Parliament which might take a few months. For women who are pregnant now, they may still need to get a GP referral to access the Medicare rebates. We will keep you updated with any changes as we hear them.
This is great news! However, as it requires a legislative change, it will need to go through Parliament which might take a few months. For women who are pregnant now, they may still need to get a GP referral to access the Medicare rebates. We will keep you updated with any changes as we hear them.
