You are a midwife with three years of experience in a federally qualified health center practice that delivers in a private hospital. You love your work, your patients, and your growing confidence in your clinical skills. You’ve noticed lately however, that as the hospital tries to grow its own practice, the atmosphere has become a little tense. Midwives in your practice are being criticized for being “too crunchy” and told they need to consult for types of care that you’ve always done independently.
Then one day you walk onto labor and delivery for your shift and are abruptly informed that you no longer have privileges. You go to the medical staff office and are told that a decision to revoke your privileges was made last night after a hospital obstetrician and nurse wrote you up for allowing your patient to eat a banana while in early labor. You say that this is ridiculous and you want to have a chance to defend yourself. You are told that, since you are allied health and not active medical staff, you have no recourse and just need to empty your locker and leave. The balloon payment on your mortgage is due in two weeks.
Can this really happen? The answer is that, yes, in the majority of hospitals in the U.S. this can happen. Midwives all over the country have experienced situations like this, but in May 2018 the members at the ACNM annual meeting voted to pursue Congressional legislation to amend federal statute to require that midwives have the same type of privileges in hospitals as physicians.
Please stay tuned for the next installment in this new series on hospital privileging for midwives and what you can do to help make equal privileging a reality. Meanwhile, here is a list of terms that every midwife seeking hospital privileges should know:
What are Clinical Privileges?
• Clinical privileges are the permissions granted to provide clinical care in a hospital. They arewhat a provider needs to get in the door and take care of patients.
• Clinical privileges outline what midwives and other providers are allowed to do. They are determined by state law and by the delineation of privileges that the hospital makes where it lists the things a provider is allowed to do (i.e., your “scope”). For instance, a midwife would not have privileges to do a cardiac catheterization, but would have privileges to attend births.
Note: Ohio at one point had a law that required that CNMs be given clinical privileges but prohibited them from having admitting privileges.
There are categories of privileges, including:
Active Medical Staff Privileges:
• The active medical staff are the providers in charge of clinical care in a hospital.
• They admit and discharge patients, but they also vote (on committees and also as members of the entire medical staff) on policies affecting care.
• They serve on a variety of committees (e.g., the Medical Executive Committee or the Credentialing Committee or the Bylaws Committee) and can lead those committees and be officers of the medical staff.
• They have the right to due process if any issue arises with their privileges. For instance, if someone accuses them of rendering care that is not up to standard, they have a right to be notified and to have a hearing and to defend themselves.
Allied Health Medical Staff:
• Are providers who have clinical privileges of some sort but who may or may not admit their own patients under their own name.
• They are not guaranteed the same rights (like due process) as the active medical staff and do not exert the same control (like through committees and overall med staff votes) over policies that affect care.
• Many midwives have allied health privileges.
• Several states still require that midwives practice under a physician’s supervision as part of their license. This is the ultimate in control over the ability to practice.
• A midwife whose supervising physician dies, quits OB, moves or gets mad because s/he talks back to them can lose the ability to practice overnight.
• Several states further restrict the ability to practice by limiting the number of providers a physician can supervise or the distance the physician can be from the perfectly-capable providers they supervise.
• Note also that most supervising physicians never actually see the patients whose care they are theoretically supervising.
Furthermore, except in D.C., Oregon and New Mexico, under current law a hospital can institute supervisory requirements at will in their bylaws, regardless of what the law allows.
• According to the Joint Commission, which is the private entity that administers the Conditions of Participation, a provider under supervision cannot admit patients.
• The Conditions of Participation (CoPs) are the federal regulations that determine what hospitals have to do to get paid by Medicare and Medicaid.
• The Conditions of Participation are based on and authorized by the Social Security Act.
• A number of states don’t require actual supervision, but do require a collaborative agreement with a physician in order to practice.
• You can think of this as “supervision-lite” because it has almost the same effect as supervision except that the provider at least has the potential to be able to admit patients according to Joint Commission guidelines.
Licensed Independent Practitioner (LIP):
• LIPs are able, under the law and their hospital bylaws, to practice independently. It’s how the Joint Commission categorizes providers who are allowed to admit.
• So a midwife practicing under supervision cannot be an LIP. (Neither can a PA because they by definition practice under supervision.)
• Midwives want to have LIP status in all hospitals.
• The ACNM midwifery privileging bill will make this possible, as will statutory and regulatory changes in states that require supervision.