At her children's store, Playdate, in West Asheville, Francesca Santi speaks about her soon-to-be second child. Santi delivered her first child at WNC Birth Center two years ago and was planning on delivering her newest child there until she learned they would be closing before her due date. (Photo by Christian Green / Carolina Public Press)

This story was originally published by Carolina Public Press.

Melissa Fehling’s second child is due Aug. 3. 

She delivered her first child, River, at the WNC Birth Center in Asheville two years ago, and she said she was looking forward to a similar experience there. 

But on June 19, she received an email from the center, announcing an indefinite closure on July 20, just two weeks before her due date. 

Fehling, 34, was at home with her son when she read the email. 

“I just kept rereading it,” Fehling said. “My brain could not understand what the email was saying. It could not comprehend what was going on.”

Nearby in West Asheville, Francesca Santi, another pregnant mother, received news of the center’s closure. 

“I saw the email, and as I started reading through, I just got this pit in my stomach,” Santi said. “I could just feel the news coming and then when I saw it … it sucked. I felt awful.” 

The closure of the birthing center marks the latest in a series of challenges for expectant mothers in Western North Carolina. Reimbursement issues and provider regulations limit choices for pregnant mothers.

Impossible Math

The closure was a last resort after all other options were exhausted, said Nancy Koerber, executive director for the birth center.  

“We just couldn’t make it work,” Koerber said. “We’ve really done everything we can. …. We’re 16 women trying to buck an entire system, and it is very, very difficult.” 

Although the WNC Birth Center increased its number of deliveries each year for its five years of existence, the center was never able to make the numbers work for financial sustainability.

The struggle came, in large part, because insurers and Medicaid reimburse birth centers at lower rates than hospitals, even when they deliver the exact same service. Koerber estimated her birth center was reimbursed, on average, less than half of hospital reimbursement. 

“Compared patient to patient, someone who had an uncomplicated birth here versus a hospital, we are reimbursed half of what a hospital would be for the same resources utilized for that patient,” Koerber said. 

Health care facilities like birth centers and hospitals bill for three broad categories when they deliver a baby: a physician fee for prenatal care and the actual work of delivering the baby; a facility fee to cover the infrastructure needed to deliver the baby; and a third fee that pays for care given to the baby after birth. 

Nearly half of patients at the WNC Birth Center paid through Medicaid, consistent with statewide and national averages. 

For physician fees, the WNC Birth Center earned $1,627 from Medicaid per delivery. The funds covered not just the hours worked by midwives at the time of delivery, but also the seven-13 prenatal consultations that occur over the nine months leading up to birth. 

For each delivery, Medicaid paid the center $1,587 in facility fees.

Together, in addition to some smaller fees, Koerber said that the birth center earned $3,712 per birth. 

But on average, Koerber estimated the birth center paid about $6,000 in materials and labor to deliver that baby, meaning that the facility incurred a net loss of over $2,000 for every baby delivered to a mother on Medicaid.

Private insurers generally pay higher rates than Medicaid, but even then, Koerber said, the payments were not enough to sustain the center. 

For comparison, Medicaid generally pays a hospital somewhere between $8,000 and $11,000 for a routine vaginal delivery. 

Koerber said this discrepancy was primarily due to hospitals receiving reimbursement as inpatient services, while health insurers view the birth center currently as an outpatient facility.

Birth centers receive reimbursement at rates similar to hospitals for physician fees, but hospitals receive much higher payments for facility fees, based on the assumption that inpatient services typically cost more to build and maintain than outpatient clinics. 

But birth centers, Koerber said, don’t really fit into the inpatient/outpatient dichotomy. 

“We’re not a fully inpatient facility, but we’re also not just a walk-in clinic,” Koerber said. “With our infrastructure and staffing, we’re somewhere in between.”

Koerber said the “in-betweenness” of birth centers in the current reimbursement model has prompted discussion of a third alternative category. To date, no such category exists, so birth centers are reimbursed at rates that make it difficult to stay afloat. 

“People recognize the problem, but like anything in a system, it just moves so slowly,” Koerber said. “The problem is that, by moving this slowly, they may be actually eradicating a good solution that’s already sitting here right now. That’s the biggest fear.” 

Supervisory Requirements Influence Midwives

When WNC Birth Center closed, it became the fifth North Carolina birth center to do so since 2018, according to Koerber. 

Only two stand-alone independent birth centers remain in the state, one in Chapel Hill and one in Statesville.

While finances are a major barrier to birth center success, it is not the only one, according to Ami Goldstein, president of the North Carolina Affiliate of the American College of Nurse-Midwives. 

Goldstein said the issue of full-practice authority, another barrier for midwives, could be solved more immediately than complicated health insurance reimbursement schedules. 

Midwifery was formalized in North Carolina with the passage of the Midwifery Practice Act in 1983, which established certified nurse-midwives, or CNMs, as a class of advanced practice registered nurses, or APRNs. 

Like all APRNs in North Carolina, certified nurse-midwives are required by law to practice under the supervision of a licensed physician. In the 1990s, several states such as Oregon, Montana and New Mexico, began to pass legislation to grant full-practice authority to APRNs and end supervision requirements. 

Currently, at least 28 states plus the District of Columbia give full-practice authority to APRNs either immediately after completing their education or after some designated period of supervision under a physician.

Within the U.S., North Carolina is one of the most restrictive states when it comes to midwifery. 

Studies find the midwife model can lead to better maternal outcomes, including fewer cesarean section deliveries. 

Goldstein said full-practice authority legislation is important for all APRNs in the state but is particularly impactful for maternal care in North Carolina because states with fewer restrictions are more attractive to the workforce.

“That makes it an access problem,” Goldstein said. “There are people in the western part of the state who can’t open a practice to provide care to people who really need it because they can’t find anybody who will provide the supervision.”

Full-practice authority also carries a financial benefit. 

North Carolina ARPN regulations require that all midwives have a physician sign on to serve as their supervisor. In many cases, independent practices have to pay that provider, even though the supervision requirements mandate that they meet with a supervising physician only once every six months

“If no physician is willing to sponsor you, you can’t open a midwifery practice,” she said. “If a physician sponsoring you suddenly dies or retires, you can’t touch another patient from that moment on until you find someone else.”

A Legislative Dispute

A coalition of legislators and advocacy groups already tried to address the full-practice authority issue with legislation in 2015-16 but was unsuccessful. 

The bills were heavily opposed by physicians and pro-doctor lobbying groups, who said full-practice authority for advanced practice registered nurses could result in lower-quality care and diminished safety. 

Goldstein disputes their arguments. “There’s just no strong evidence to support that idea,” she said. 

None of the states that have granted full-practice authority over the past two decades have reimposed restrictions, and several studies show that APRNs who are acting independently and within the scope of their training deliver care as well as physicians. 

An updated version of the SAVE Act has been introduced in both the N.C. House and Senate with broad and bipartisan support. More than 70 representatives signed on as sponsors to the bill in the House, and 25 senators are listed as sponsors. 

Though the bills would likely pass if brought to a vote, given the many sponsors, they currently sit in committees, where they died in previous sessions. 

Sen. Jim Burgin, R-Harnett, a primary co-sponsor on the Senate bill, said he hoped the measures make it to the floor for a vote this time around, but that will ultimately depend on broader political negotiations in the General Assembly. 

“We have bills that are over there,” Burgin said of the process.

“They have bills that are over on our side, and there is this trading that goes back and forth. Plus, we have the added aspect of having budget negotiations going on and the horse-trading that goes on in the budget. So, this bill will be something that gets included in all of that negotiation.”

Physicians who do not oppose full-practice authority for certified nurse-midwives may oppose the act because they oppose full-practice authority for other providers such as nurse practitioners and other APRNs, Koerber said. 

Koerber is open to legislation more narrowly tailored to just granting full-practice authority to CNMs if that would be more likely to pass, but other organizations such as the North Carolina Affiliate of the American College of Nurse-Midwives disagree, saying that APRNs are stronger together in their fight for full-practice authority. 

As the legislative battle continues, the concerns are immediate for expectant mothers in Western North Carolina. 

“We just lost what I feel is a very important option for prenatal and maternal care in our area,” said Savannah Talley, who gave birth at the WNC Birth Center just months before it closed. 

“I am so heartbroken for the women in this area, for the women who are in the middle of their pregnancy now and for women in the future who now have one less option.” 

Though the center is now closed, Koerber did say that she has hope it won’t be permanent. She is currently in talks with potential partners, whom she declined to name, who hope to be able to bring the center back. 

“After we announced we were closing, there was a huge outpouring of grief in the community,” Koerber said. “People have seen the resources we provide, and our results have been recognized. We can’t live on false hope …, but I feel like the community deserves for us to explore every single option and leave no stone unturned.”

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