On another blog, there is a discussion about why midwives charge so much... how can they possibly justify the $2500 they charge for a birth. (In my practice and location, the average is more like $4000.) The implication is that midwives make far more than a doctor does for a birth - with barely a whiff of the education.
Reading the comments, women have defended the cost mostly with speaking about the time a midwife spends with her clients... how midwives drive all over hell and tarnation... how long prenatals are... things like that.
Because I am not commenting on that blog, I thought I would share what exactly one gets for the $4000 when they come to me and my practice. Time is but a small part of the entire picture. Some things, of course, overlap with physicians... other things, however, do not come out of a physician's direct pay from a client. They do directly come out of the money paid to a midwife.
- a clean and well-maintained office
- a receptionist that answers the phones
- linens provided by a professional service
- medications including pitocin, methergine, Vitamin K, erythromycin, antibiotics, IV equipment and fluids, syringes, needles, suture equipment, clamps, instruments, doppler, nitrazine paper, urine dip sticks, toilet paper, bottled water, drapes, speculums, gel, bandaids, cotton balls, oxygen... you get the picture. Anything that goes in or on a client is provided by me - the midwife.
- Electricity to keep the office cool/warm year 'round
- Costs of making and maintaining charts including paper, copy machines, toner, etc.
- Office supplies that assist in client care including pens, pencils, appointment books, highlighters, notepads, etc.
- cost of pager and cell phone
- Gas to drive the 60,000 miles a year to tend to women around the county and beyond
- Tires, oil, insurance and upkeep of the vehicle I drive that carries the $10,000 worth of equipment I own and use for births
- Food to eat on the road going to and from client's homes
- CEUs, on-going education and learning via the Internet, journals, midwifery magazines, etc.
- Conferences where to obtain said education and CEUs
- $500 to an assistant at the birth
I'm sure I am missing a slew of things a midwife provides that comes out of the midwifery fee, but reading what I wrote above, I think it offers a pretty good idea of what is spent to maintain a midwifery practice. Most midwives don't have out-of-home offices, but it still costs money to maintain an in-home office.
Moving to the time issues, it's important to note that midwives do everything from beginning to end and inbetween. We take blood pressures, do phlebotomy, client education, schedule appointments, do follow-up phone calls, chat with the lab, chats with radiologists, email with each of my clients (I have at least 6 emails a day with clients alone - not to mention the emails with my apprentice, other midwives and other professionals - all with regards to my current practice), make charts, copy papers, pull and re-file charts - ALL of those things physicians simply do not do because they have a staff that does those menial things for them. The cost of hiring staff to do these things and to maintain an office are spread between as many doctors as are in the practice... in my area, averaging about 6-12 docs. In my world, it is the midwife's sole responsibility, so we do it - but it does take time.
A prenatal visit is about 60 minutes long. Home visits (at 37 weeks, one day postpartum, three days postpartum [where the Newborn Screen is completed] and sometimes two weeks postpartum) are at least 2 hours long. I average 13 prenatal visits with clients, then the home visit, the two postpartum visits and two more postpartum office visits before formal care ends.
I answer all my own phone calls. There is no one to take call for me. I answer at least 2 middle of the night calls every single night. I can't imagine any physician tolerating such intimacy.
Many midwives do not have malpractice insurance to spend money on (it isn't an option for many of us), but some states require it so add that to the mix, too. Doctors, of course, have exhorbitant malpractice insurance bills, but more and more docs are going bare (without insurance) to compensate for having to contend with the cost and liability of carrying malpractice insurance.
The median salary for an obstetrician-gynecologist is $220,000. A midwife taking 4 clients a month for 10 months out of the year - taking in $2000 a birth (unlikely!!!) - would make $80,000. HARDLY $220,000 a year. How anyone could say midwives make more than physicians is beyond me. One quiet site on the web states many OB-GYNs make $200 AN HOUR. Yeah, midwives certainly make more than that, don't they? snort
I've worked in an OB-GYN group's office. It isn't unusual to see upwards of 30 patients a day - per doc. 70 births a month - PER OB. 30 GYN surgeries.
The busiest midwives I have ever known to be paid saw about 6-7 births a month. The average in my world is 4 births a month - and hardly anyone gets 4 births month after month after month.
All we really need to do is look at what midwives and doctors drive. That alone answers the question of who makes more money.
Should doctors make more money than a midwife? Of course! Hell, their education is infinitely more dramatic and their skills far more complex than a midwife's basic knowledge of normal birth. But that wasn't the issue. The issue was why do midwives charge so much?
As a midwife, monitrice or doula I have been paid in full probably a dozen times in 23+ years and over 850 births. I have traded services (web design/upkeep, moving my household goods, housecleaning, etc.) and have received beautiful gifts of organic vegetables for a summer, pieces of art, fruit from the orchard and other similar benefits of being able to barter. Never in my life can I imagine a doctor remotely entertaining the idea of trading services for babysitting. A car, maybe. But fruit from the migrant camp? Not so much.
One of my standard lines is to not allow price determine where you have your baby or who your care provider is. There is always a way to work out having a homebirth if money is an issue. I have women paying $20 a month more than three years after their babies were born. (Most women who set up payments actually quit paying anything once the baby arrives. Priorities change. And it isn't too likely that a midwife is going to hire a strong-arm service to force the client into paying. I believe women will pay if they can. If they can't, I will be paid in some other way - not always monetarily.)
It is also important to note that I do bill insurance companies and am paid fairly well that way. We bill globally unless a woman transfers care and delivers in the hospital or with another midwife, then we bill appointment by appointment.
Because I own the practice, I ask the client for their deductible and their co-pays, due before 37 weeks. We bill globally once the baby is 6-weeks old.
When midwives do not want to just take the deductible and co-pays, but instead choose to have the money up front from the client and then bill insurance globally, the law states that the client will be reimbursed up to the amount they have paid. Any extra would go to the practice. That has, by the way, never happened.
We use a billing specialist and the rate of return on insurance billing increased 30% over when the apprentice midwives were doing it themselves. (It was the first thing I dumped when I bought the practice - no billing crap for me!)
Many midwives charge the client and then will give them an itemized list of services received so the client can bill their own insurance and handle the headache themselves.
Sometimes, I don't know what would be easier on my nerves. Insurance issues are certainly just as frustrating for docs as they are for midwives.
A complex topic... much more complex than the other blog makes it sound. It's good for me to put it down on paper, though. A great piece of information if a client ever asks, "Where does all that money go to?"
Let me show you.