SFhbdler
Shmw
Rls’ng, CNM, M.S. ond Robert J. Houde. Sh.
Ms. RMng Professor
is currently an Asr!stmt of Nursing
and Gy~wcvhgy
and Obstetrks
at the Untuemtty crj
Mimes&t. the
She ia also the Director G$ Chilabzaring Childrearing
Ceiller.
Mr. Hmde is Assistant to the Dew forf?“wcial Mutters “t Yale Llnlvers. tiy School of He also sewa 01 (I Consultant to the Childbearing
Nmtng.
Childrelmting Center. 6
n the f&l of 1972, the first nursemfdwife awas employed at the Urdversic of to develop both a” e&czdonal and a service prograt”. i)iscussionr with the Chair. ma” of the Deparfment of Obstefrks and Gynecology lndkatod a wflllng“BB to support the orggsnkationof the nurse-midwifery service as a dip aete unit wlthin the overall structure of the Health Sciences. Tfw related Health Science components are School of Medklne, School of NwoI”g and fJtw&ty Hc@tals, aU re. potting to the offke of the University Vice Resident for He&h kiancees Philosophically the nurse-mid. wifety service was “wrt like the Schwl of Nursing whkh edueatlon. ally was pfonwflng a cuukulum focused on health and growth. It was also expanding on Its own missIon statement which called for increased resmitme”t and use of “une-practitloners, and demonstration of the independent nursing role Thts.waain concert with the overall won statement of the Unlversily whkh read in part,
I
“u IS lmperauvethat rpoc!aland I”. creasedomphaslrsholddb+ give” to resescha”ddeve!qmw”tof Innova,. ive SyltlrnS for dellwring opnmu”l healthcare. The Uneerslty HospHah and other he&h scb”ce clink pro. grams should provide the facilitks and resowcs~~ throughwhkh exer,,pby m&k of he&h care pro(pamr can be testedand the dellveryof corn. prehenwe healthcaresw.wes canbe used as a teacht”na laboratoruand demonshatlon model for 6 the hedthprofeslonr”
Minnesota
ProfessIonally. the sewke was closely tied wtth the Depmtment of Obstetrkz and Gynecolqy through academic and service appointments, and also through approved medical protocolr signed by the Ch!ef of Ob. stefrks. Although no direct responsibllfty to “utsiing servke adminktra. tion was OutlIned, nursing appantmenis were &&ted and frequent contact was maintained with the clinical Director of Obstetrics. Ractlcally, the servke was part of the University Hospuds system and
JOURNAL OF NURSE-MIDWIFERY
l
vol. XXII, NC+.2. Summw1977
Its out~patknt
department.
Hospital
administration viewed this consumermiented SewIce as one response to wowina discontent on the hart of the comm&y to a seemin& removed bureaucratic stucture. The hospital. too. was seeking methods of outreach. Because of this multi-unit assockBon. the office of the Vice Resident of Health Sciences became a crucial contact point. That office occasionally helped with netlotiations but. m&e i~potiantly, g&e invaluable perspective on the total picture of the Health Sciences including plans for expansioicn. lnltiation of the Service he Hrst nurse-midwifery care was provided by a nurse.mld. wife working closely with the Chief of Obstetrics. They saw his caseload to&her - alternating on visits - and shortly, a group of women specifically opting for nurse-
T
three month contract. One of his most important functions was to prepare the materials and outline the *tmtegy for approaching Blue Crass/ Blue Shield, the largest payee in Minnesota Having facts and programs well m hand is crwal to subseque.lt suctees in dealing with tnsurance companies; and he spent much trne establishins the base on which our case would be made. The document that was dweloped for their use included: 1. Purpose and scope of project 2. Description of services 3. Description of expanded role of nurse care-givers including medical back-up system 4 Lega! status of nursing practice in the state
7. Clarification of que511on of “double billing” (nursemidlulfe and phvsicianl
s-
We have not been programmed to demand fees. . . -9 The negotiations began in the Spring of 1973: and by Fall, a Blues executive sympathetic to the cause of nursemidwifery had managed to get a favorable ruling from the Blues for nurse-midwifery as an experimental program. It has been our experience that the initiei approach to insurance companies, welfare and a&al ageoties. and other pwate and public purchasers of health care should be made at the highest possible cotpotate level. Instrumental in developing our contacts with Minnesota Blues was the hospital director who sat on the board of directors of both Blue Cross and Blue Shield. Support of the medical community (in out case the University tkparhnent of Obstettics and Gynecology) is also most
midwife attendance at delivery had selected themsolves. Within a few months, it was clear that a separate caseload was most appropriate; and ten months after the first nurse-mldwllery care was wen, the obstetricians indicated that they no longer felt comfort&e billing for nurse. midwife setvIces. Slncc these con~utnere were private patients at the University, it was clear that a separate billing system needed to be implemented. As the serutce continued to expand as a separate unit, It was felt that outside ~nwltetion would be beneftcial. Mr. R. Houde, a financial experf well acquafnted with admini. stratfve systems and also familiar with nursemfdwlves, was employed on a vol.
XXII, No. 2. Summer 1977
lelpful. It is also easier to neg.&ate myment intuauy on a “trial= basis of iix months subject to contiuatian lfter review. Choke of “target:ompeny i* crucial. It is always easier to sell other companies aoragencks If you can refer to anothw (prefer&y IIrger) company abeady making payments to you. hce direct billing wm indeed an actualltv, several decfsfons had to be made: 1. Who would do the tlillinq? 2. How much would u e charge? 3. Whet kind of folkw-uo would we have for delinquent fills?’ 4. How would we conduct the ap. preach to other public and private health care purchasers? 5. Would we compro.nisx OUTsyr tern if a patticukr company refused to reimburse for muse-midwifery care? The Childbearing Childre.. ‘ng Center at that time had no secretarial services so the logical billing site was in the ObGyn office. Separate bilk with appropdato letterhead were desigwd and all bilk were to be spedally nagged to facilitate data analvsis. An account was owned to handle the income; an fR< number was obtained. This billins clerk hen& ed all of our transact& and kept careful records of income. No bit were sent until after deliveryr but many couples instttuted their own time payment plan - often starting prior to delivery. We were sensitive to the paten!id competition with the University ob s!etricians and felt we should charge an amount similar to. but sli~htlu ka than. their fees. The ow.alif& ~a5 arbitrarily designated as onehatf for prenatal care and the postparmm visit and onehalf for l&x and delivery. Thk determinatfian was essential in the instances of caesarian section when the attending obstetdin did bill for his mofessional fee. Technically, n nursemidwifery fee for cae during labor would also be legitimate: but we elected not to fwther stress these couples by demanding ad&-
kmMwdwmPee
7,
liondpeynw.nt.Wehavenowr~xon. sidvced the4 ksoe and am&y drageaetmQbtnwse.n~dwlfer+e, v&h eny additklnd medk4l pn,fes. meI bilk b&g vkwd as conarlt-
antfees,
-+hereis no qoes&n that ~foUow.up o” d&“qwnt bills is a headecbe People move, have financial d&r*Crr. pwzmsi3nete . emi yet pw IYWW& evokes such h&ship on those with the most diffkndty to cay, i a thr pena” above me&i&d ellsi_ bibty hat not insured. A dassk exwnpie io a cvupfe where the wife har wax” waking to put her husband throughbwschoolNow heir,u*set. Ung up e pm&% rhe ir due to deli”. a; and they have no ~“avance. Some might say they did soma poor planning but their sitoation $ very red as they sit in your oflke beggtng for fl”iacid co”s#eratlo”. hv3de”*ly. a definite hazard to billing is becoming personally involved in the system. We have not been proqrammed to demand fees since mod of us in nowing have been salaried. A “ice ba’ante 1s to enmurage regular time paymenr for those who need each ,I plan. A!wJ, we occ&“dly wrote off ell n-m of our professional bill for extenuaUna circwn*ces. h is our s”qgehon?hat any budgeting should allour approdm?l*ely 15% for nonpa!meat and a” additional 358 for 5lO’JJ pQymen*. As bilk to other I”!ura”ce ca”iers came through. the nurse-midw+fe Initidly s@ml them before sendtng them on to the company with a smell packet of information ~egar+g “urwnidwifely caw so”wh”os, several conk&~ bet’ueen the conwny and oar blling offke were m& before the can%x wes comfort. able with direct reimbwmont. It was pmbably ~ne~vit&e that we event&y encwotwed II company tha! refosedto pay. SIrwe we did not wad ate couples TV have to pay for pmfemdonalcare that technkally was covered by t;~d pIen> we had the OWPJI Chbf of ObGyn rig” the claim aa admin@tre*ord the Deoert“lent. That seenled to “Q II r&o”-
s
at&? colnfxo”lbe w It “Im dea thd hewasPotaikdlng*oanycR”kd !twdvem.mt with the pdbnt, end It saH&edtheleltelofthelewwlth*he inwencecompmy. ProgresofthcSyatem n July 1975, the Chi!dtwlng Childrearing Center became an offkial out.rezch pmgrmn of Unlvprdty Hospltelr The ho#tel I
agreed to eellvy nurse.midwife podtloos with the Centa but b&ted that our proferriond bliloq would result In double pawent by ow conwunon for name-midv&y coca The ho@tat, of course, had to raise fees to cover the c&s of its profegional nurse-tidwiveg At the tlnw, the advantegesto horpltd fl”e”cid support were many, and th case for fea&& ity of thkd party prment to numzs had been made A total of approxt. mately 21 i”s”re”ce conlpanks, five county medical assistance,and state medical a&sta”ce had reimbursed us directly by the time we agreed to stop our billing. The hospitd added out pmfe&onel cost to the total fInaxial package charged the consumtr but identified it aa e sqmrate Ben) i) the payees. It qlso pkked up the tots4rewnslbilihr for billing E&W It alreaoy wes proc&ng the h&tel bULThh was acceptable to the Con. ter primarily because of lack of sup portive sta3 to do the Wiling. There IB no qoeetkln that bavlng the hosoitd do the biting has led to decreased p,~rsonallzatlo”. Many conwrners !ndkated to us that they appreciated being abk to pay for a servke thal they vduod Reoumably tha feeling is dsaeaed il total pay men* goes into the “big system: Son;? inarmncr comoankr have dw al a lnefere&e for a dir,. tind ~~rofealond MU. BlUlna and fol. low-lip on wynlents ere very *i”w consruming~3ivttie$ conently, it is to our hnefit to Utiii hospital services; but eventuslly we hope to reclaim billingactkiiior. The Chiidbearlng ChildrearIng Center hw: recently moved into a wmn, homey how for all of ib od. patient xtliw2s. All fiwmn~ coI’11.
hinted
b done there This etmorphere helps to rehfmce for the cons+“s. the type of c(ce ehe b buyI”‘& F@dng In a”-* the consumer coming to os gets about 245how of ~emionef nwse.mldwi[~r~y cae. At $15.00 per hoor thb c~>sb over $500.00 and that doean’, lndode all of the suouort oemonnd co”“e&d with that.&. & cotrent charge Is about on&df of that. There. pre&ely, stends the cold r&y. Do you chags whet It costs and definitely limit clientele? Do you forever rely on subddy? Do you &ilnur to pm-tide some modkd care. but reduce anwnitk~ and shorten fength of vLsik?Do you compromw the type eae you we”* to ddlvar? The newest emvice tmt we are adding et the Center b the provEJon of wllwoman care to wane” who have delIvered with us. The determi. nation of chewa for thb care has been done most carefully, taking into co”5ldemtio” cosl of: pwferionel tlnw, b&c maintenance of the Center, support pemm”wJ. and IOUtine laboratory tests. Separete cost stmctwes were developed for corn. ple4e wellwoma” che&, Institution of family planning method only, nvlslts, pn?glwley conflrmatlon. we are conftdent that ow chages are both reasonableand also re&tk for our costs. These ere soma of the crucial qU&iO”S f&“g m ,” +,I,, “ew ere Of wofsssio”dMn. As Cathrvn Welch has said, “we have echi&ed a plnneck of profeniond es well as p&l. cd eophi&ation and M a result we and our clknts will gal” full to ‘the eystem.’ “* Our hope b that the kktd of health exe that n-s dellver will come to be valued and reimbused rnopedy y3 a~ to acknoviiedge its importance and to support the de&ions of ate consumers who are ok&g soch cwz.
sek,g
of
JOURNAL OF NURSE-MIDWIFERY
l
Vol. x)(11,No. 2, Summr 1977
Shmw
Rls’ng, CNM, M.S. ond Robert J. Houde. Sh.
Ms. RMng Professor
is currently an Asr!stmt of Nursing
and Gy~wcvhgy
and Obstetrks
at the Untuemtty crj
Mimes&t. the
She ia also the Director G$ Chilabzaring Childrearing
Ceiller.
Mr. Hmde is Assistant to the Dew forf?“wcial Mutters “t Yale Llnlvers. tiy School of He also sewa 01 (I Consultant to the Childbearing
Nmtng.
Childrelmting Center. 6
n the f&l of 1972, the first nursemfdwife awas employed at the Urdversic of to develop both a” e&czdonal and a service prograt”. i)iscussionr with the Chair. ma” of the Deparfment of Obstefrks and Gynecology lndkatod a wflllng“BB to support the orggsnkationof the nurse-midwifery service as a dip aete unit wlthin the overall structure of the Health Sciences. Tfw related Health Science components are School of Medklne, School of NwoI”g and fJtw&ty Hc@tals, aU re. potting to the offke of the University Vice Resident for He&h kiancees Philosophically the nurse-mid. wifety service was “wrt like the Schwl of Nursing whkh edueatlon. ally was pfonwflng a cuukulum focused on health and growth. It was also expanding on Its own missIon statement which called for increased resmitme”t and use of “une-practitloners, and demonstration of the independent nursing role Thts.waain concert with the overall won statement of the Unlversily whkh read in part,
I
“u IS lmperauvethat rpoc!aland I”. creasedomphaslrsholddb+ give” to resescha”ddeve!qmw”tof Innova,. ive SyltlrnS for dellwring opnmu”l healthcare. The Uneerslty HospHah and other he&h scb”ce clink pro. grams should provide the facilitks and resowcs~~ throughwhkh exer,,pby m&k of he&h care pro(pamr can be testedand the dellveryof corn. prehenwe healthcaresw.wes canbe used as a teacht”na laboratoruand demonshatlon model for 6 the hedthprofeslonr”
Minnesota
ProfessIonally. the sewke was closely tied wtth the Depmtment of Obstetrkz and Gynecolqy through academic and service appointments, and also through approved medical protocolr signed by the Ch!ef of Ob. stefrks. Although no direct responsibllfty to “utsiing servke adminktra. tion was OutlIned, nursing appantmenis were &&ted and frequent contact was maintained with the clinical Director of Obstetrics. Ractlcally, the servke was part of the University Hospuds system and
JOURNAL OF NURSE-MIDWIFERY
l
vol. XXII, NC+.2. Summw1977
Its out~patknt
department.
Hospital
administration viewed this consumermiented SewIce as one response to wowina discontent on the hart of the comm&y to a seemin& removed bureaucratic stucture. The hospital. too. was seeking methods of outreach. Because of this multi-unit assockBon. the office of the Vice Resident of Health Sciences became a crucial contact point. That office occasionally helped with netlotiations but. m&e i~potiantly, g&e invaluable perspective on the total picture of the Health Sciences including plans for expansioicn. lnltiation of the Service he Hrst nurse-midwifery care was provided by a nurse.mld. wife working closely with the Chief of Obstetrics. They saw his caseload to&her - alternating on visits - and shortly, a group of women specifically opting for nurse-
T
three month contract. One of his most important functions was to prepare the materials and outline the *tmtegy for approaching Blue Crass/ Blue Shield, the largest payee in Minnesota Having facts and programs well m hand is crwal to subseque.lt suctees in dealing with tnsurance companies; and he spent much trne establishins the base on which our case would be made. The document that was dweloped for their use included: 1. Purpose and scope of project 2. Description of services 3. Description of expanded role of nurse care-givers including medical back-up system 4 Lega! status of nursing practice in the state
7. Clarification of que511on of “double billing” (nursemidlulfe and phvsicianl
s-
We have not been programmed to demand fees. . . -9 The negotiations began in the Spring of 1973: and by Fall, a Blues executive sympathetic to the cause of nursemidwifery had managed to get a favorable ruling from the Blues for nurse-midwifery as an experimental program. It has been our experience that the initiei approach to insurance companies, welfare and a&al ageoties. and other pwate and public purchasers of health care should be made at the highest possible cotpotate level. Instrumental in developing our contacts with Minnesota Blues was the hospital director who sat on the board of directors of both Blue Cross and Blue Shield. Support of the medical community (in out case the University tkparhnent of Obstettics and Gynecology) is also most
midwife attendance at delivery had selected themsolves. Within a few months, it was clear that a separate caseload was most appropriate; and ten months after the first nurse-mldwllery care was wen, the obstetricians indicated that they no longer felt comfort&e billing for nurse. midwife setvIces. Slncc these con~utnere were private patients at the University, it was clear that a separate billing system needed to be implemented. As the serutce continued to expand as a separate unit, It was felt that outside ~nwltetion would be beneftcial. Mr. R. Houde, a financial experf well acquafnted with admini. stratfve systems and also familiar with nursemfdwlves, was employed on a vol.
XXII, No. 2. Summer 1977
lelpful. It is also easier to neg.&ate myment intuauy on a “trial= basis of iix months subject to contiuatian lfter review. Choke of “target:ompeny i* crucial. It is always easier to sell other companies aoragencks If you can refer to anothw (prefer&y IIrger) company abeady making payments to you. hce direct billing wm indeed an actualltv, several decfsfons had to be made: 1. Who would do the tlillinq? 2. How much would u e charge? 3. Whet kind of folkw-uo would we have for delinquent fills?’ 4. How would we conduct the ap. preach to other public and private health care purchasers? 5. Would we compro.nisx OUTsyr tern if a patticukr company refused to reimburse for muse-midwifery care? The Childbearing Childre.. ‘ng Center at that time had no secretarial services so the logical billing site was in the ObGyn office. Separate bilk with appropdato letterhead were desigwd and all bilk were to be spedally nagged to facilitate data analvsis. An account was owned to handle the income; an fR< number was obtained. This billins clerk hen& ed all of our transact& and kept careful records of income. No bit were sent until after deliveryr but many couples instttuted their own time payment plan - often starting prior to delivery. We were sensitive to the paten!id competition with the University ob s!etricians and felt we should charge an amount similar to. but sli~htlu ka than. their fees. The ow.alif& ~a5 arbitrarily designated as onehatf for prenatal care and the postparmm visit and onehalf for l&x and delivery. Thk determinatfian was essential in the instances of caesarian section when the attending obstetdin did bill for his mofessional fee. Technically, n nursemidwifery fee for cae during labor would also be legitimate: but we elected not to fwther stress these couples by demanding ad&-
kmMwdwmPee
7,
liondpeynw.nt.Wehavenowr~xon. sidvced the4 ksoe and am&y drageaetmQbtnwse.n~dwlfer+e, v&h eny additklnd medk4l pn,fes. meI bilk b&g vkwd as conarlt-
antfees,
-+hereis no qoes&n that ~foUow.up o” d&“qwnt bills is a headecbe People move, have financial d&r*Crr. pwzmsi3nete . emi yet pw IYWW& evokes such h&ship on those with the most diffkndty to cay, i a thr pena” above me&i&d ellsi_ bibty hat not insured. A dassk exwnpie io a cvupfe where the wife har wax” waking to put her husband throughbwschoolNow heir,u*set. Ung up e pm&% rhe ir due to deli”. a; and they have no ~“avance. Some might say they did soma poor planning but their sitoation $ very red as they sit in your oflke beggtng for fl”iacid co”s#eratlo”. hv3de”*ly. a definite hazard to billing is becoming personally involved in the system. We have not been proqrammed to demand fees since mod of us in nowing have been salaried. A “ice ba’ante 1s to enmurage regular time paymenr for those who need each ,I plan. A!wJ, we occ&“dly wrote off ell n-m of our professional bill for extenuaUna circwn*ces. h is our s”qgehon?hat any budgeting should allour approdm?l*ely 15% for nonpa!meat and a” additional 358 for 5lO’JJ pQymen*. As bilk to other I”!ura”ce ca”iers came through. the nurse-midw+fe Initidly s@ml them before sendtng them on to the company with a smell packet of information ~egar+g “urwnidwifely caw so”wh”os, several conk&~ bet’ueen the conwny and oar blling offke were m& before the can%x wes comfort. able with direct reimbwmont. It was pmbably ~ne~vit&e that we event&y encwotwed II company tha! refosedto pay. SIrwe we did not wad ate couples TV have to pay for pmfemdonalcare that technkally was covered by t;~d pIen> we had the OWPJI Chbf of ObGyn rig” the claim aa admin@tre*ord the Deoert“lent. That seenled to “Q II r&o”-
s
at&? colnfxo”lbe w It “Im dea thd hewasPotaikdlng*oanycR”kd !twdvem.mt with the pdbnt, end It saH&edtheleltelofthelewwlth*he inwencecompmy. ProgresofthcSyatem n July 1975, the Chi!dtwlng Childrearing Center became an offkial out.rezch pmgrmn of Unlvprdty Hospltelr The ho#tel I
agreed to eellvy nurse.midwife podtloos with the Centa but b&ted that our proferriond bliloq would result In double pawent by ow conwunon for name-midv&y coca The ho@tat, of course, had to raise fees to cover the c&s of its profegional nurse-tidwiveg At the tlnw, the advantegesto horpltd fl”e”cid support were many, and th case for fea&& ity of thkd party prment to numzs had been made A total of approxt. mately 21 i”s”re”ce conlpanks, five county medical assistance,and state medical a&sta”ce had reimbursed us directly by the time we agreed to stop our billing. The hospitd added out pmfe&onel cost to the total fInaxial package charged the consumtr but identified it aa e sqmrate Ben) i) the payees. It qlso pkked up the tots4rewnslbilihr for billing E&W It alreaoy wes proc&ng the h&tel bULThh was acceptable to the Con. ter primarily because of lack of sup portive sta3 to do the Wiling. There IB no qoeetkln that bavlng the hosoitd do the biting has led to decreased p,~rsonallzatlo”. Many conwrners !ndkated to us that they appreciated being abk to pay for a servke thal they vduod Reoumably tha feeling is dsaeaed il total pay men* goes into the “big system: Son;? inarmncr comoankr have dw al a lnefere&e for a dir,. tind ~~rofealond MU. BlUlna and fol. low-lip on wynlents ere very *i”w consruming~3ivttie$ conently, it is to our hnefit to Utiii hospital services; but eventuslly we hope to reclaim billingactkiiior. The Chiidbearlng ChildrearIng Center hw: recently moved into a wmn, homey how for all of ib od. patient xtliw2s. All fiwmn~ coI’11.
hinted
b done there This etmorphere helps to rehfmce for the cons+“s. the type of c(ce ehe b buyI”‘& F@dng In a”-* the consumer coming to os gets about 245how of ~emionef nwse.mldwi[~r~y cae. At $15.00 per hoor thb c~>sb over $500.00 and that doean’, lndode all of the suouort oemonnd co”“e&d with that.&. & cotrent charge Is about on&df of that. There. pre&ely, stends the cold r&y. Do you chags whet It costs and definitely limit clientele? Do you forever rely on subddy? Do you &ilnur to pm-tide some modkd care. but reduce anwnitk~ and shorten fength of vLsik?Do you compromw the type eae you we”* to ddlvar? The newest emvice tmt we are adding et the Center b the provEJon of wllwoman care to wane” who have delIvered with us. The determi. nation of chewa for thb care has been done most carefully, taking into co”5ldemtio” cosl of: pwferionel tlnw, b&c maintenance of the Center, support pemm”wJ. and IOUtine laboratory tests. Separete cost stmctwes were developed for corn. ple4e wellwoma” che&, Institution of family planning method only, nvlslts, pn?glwley conflrmatlon. we are conftdent that ow chages are both reasonableand also re&tk for our costs. These ere soma of the crucial qU&iO”S f&“g m ,” +,I,, “ew ere Of wofsssio”dMn. As Cathrvn Welch has said, “we have echi&ed a plnneck of profeniond es well as p&l. cd eophi&ation and M a result we and our clknts will gal” full to ‘the eystem.’ “* Our hope b that the kktd of health exe that n-s dellver will come to be valued and reimbused rnopedy y3 a~ to acknoviiedge its importance and to support the de&ions of ate consumers who are ok&g soch cwz.
sek,g
of
JOURNAL OF NURSE-MIDWIFERY
l
Vol. x)(11,No. 2, Summr 1977
