Maternity stakeholder information sessions

Kia ora koutou, ko Kass Jane tōku ingoa, Principal Clinical Advisor in the Maternity team at the Ministry of Health. I’m a registered midwife and I maintain a small lead maternity care caseload.

And tēnā koutou katoa, ko Bridget Kerkin tōku ingoa. I am a Senior Advisor in the Maternity team and I am also a registered midwife.

It is our pleasure, in this video, to provide a brief overview of the changes to the Primary Maternity Services Notice. We’d like to share with you what these changes will mean for those claiming for community maternity services.

We have a slideshow to summarise the changes to the Notice and through this discussion we will do our best to address the most “frequently asked questions”.

I’d like to start by explaining why we refer to the Notice as the Notice and not Section 88.

The actual title of this document is the Primary Maternity Services Notice pursuant to Section 88 of the New Zealand Public Health and Disability Act 2000. Section 88 is literally a brief description in this legislative document which explains that it is possible to hold contracts for the provision of services relevant to the Act. And the Primary Maternity Services Notice is just one of many notices pursuant to this Act. Therefore, we refer to the document under discussion today as “the Notice”.

The Notice is your contract for service if you are an authorised provider for community maternity services.

Like any contract for services, the Notice contains high level information, definitions of all sorts, as well as detailed descriptions of the services to be provided for the fee paid. Also like any contract, the Notice contains audit provisions, reporting provisions, and claiming information.

The Notice is set out in the following way:

Part A contains high-level information about the service specification. It sets out the process for making amendments to the fees and to the service specifications and payment rules. It is these processes we followed when making the changes that have resulted in the 2021 Notice.

Part B contains the definitions and interpretations pertaining to the service specification. The changes contained in this part are updates to definitions used throughout the Notice. One example of significance is the changed definition of the term ‘vaginal birth after caesarean’.

Part C contains the general requirements for primary maternity services. The main changes in this part of the Notice are to clause CA7. This clause pertains to lapsing of authorisations to claim under the Notice. The period of time before your authorisation would be lapsed, has now been extended to 18 months. It was previously 12 months. Clause CB1 has been amended to include the requirements of the Children’s Act 2014.

Part D and its subparts set out the specific requirements for each primary maternity service. Part D has been subject to significant change as it is in this part of the notice that new services are introduced, some services amended, and other services are exited. We will go into more detail about Part D and give you some examples as we progress through this video.

In mid-July 2020 Julie Anne Genter, who was Associate Minister of Health at the time, announced an additional $21.25 million was to be added to the Primary Maternity Services Notice lead maternity carer, or LMC, modules. She specified that $15.25 million was to be spent on provision of care for women with complex care requirements during their maternity experience. The remaining $6 million was allocated to the care of women living in rural regions.

These changes to the funding allocation in the Notice also provided an opportunity to make some administrative changes while the document was open. This allowed the changes to the definitions that we referred to earlier, for example. We commenced the consultation process for the proposed changes to the Notice in September 2020 and consultation continued for the maximum period specified – 10 weeks.

During the consultation period the Ministry received a phenomenal amount of feedback about the proposed changes and also many suggestions about what maternity services might look in the future.

Part D contains the service specifications and payment rules for each service. It is divided into the three subparts you see here:

• DA – Lead maternity care services
• DB – Primary maternity single services
• DC – Primary maternity ultrasound services

The term ‘non-LMC’ has been retired and we have reverted to referring to those services provided by authorised providers other than the LMC as ‘primary maternity single services’. One reason for avoiding the use of ‘non-LMC’ is that some of the PMSS can now also be claimed by a woman’s LMC.

Here is an example of a service specification, and the associated payment rules. The service specification sets out the services to be provided under this module. The payment rules outline the minimum requirements to be eligible for payment. They also set out any exclusions. We have chosen the third trimester care module to share here because this is an existing module which has just been updated for the 2021 Notice. Of note in the third trimester care module, you will find that there is now a requirement for 1 in-person consultation. Previously there was no minimum requirement for visits in any module of care, except the postnatal period. It is valuable for us to capture information about the number of visits LMCs are providing, but additionally the number of visits is now relevant to a new module we have introduced – the Additional Care Supplement (we’ll give you more information on that later!). You will also find that the dates for the trimesters are now clearly defined in weeks and days. This eliminates the unusual “no pay” zone that was present at the beginning of this module in the 2007 Notice.

It was necessary to add some new modules into the Notice to pay for services where new funding was allocated for provision of care to women in rural regions and those with additional needs during their maternity care experience. It was also necessary to amend the module structure to fund LMCs for services provided at registration and in the first trimester of pregnancy, the aim of which is to remunerate services closer to the time of service delivery and support more women to receive timely care in line with best practice.

Here you’ll see a list of what is new in the 2021 Notice. We consulted on most of these modules, though some have been developed as a result of feedback from the consultation process, and in subsequent collaboration with the relevant professional bodies.

The First and second trimester module has been split into a First trimester care and a Second trimester care module.

The Labour and birth (exceptional circumstances) module has been rescoped and we have introduced a new Planned caesarean section fee.

Rural practice and travel supplements and Additional care supplements have been created which we’ll talk about in some detail in a moment.

A Second trimester pregnancy loss module has been added which provides payment for services provided to women experiencing a pregnancy loss between 14 weeks and 0 days and 19 weeks and 6 days.

And there is now a Missed birth – rural module which remunerates LMCs providing care to women in rural regions when a woman is unexpectedly unable to birth locally and the LMC is unable to travel with the woman to attend the birth.

In the Draft Notice for consultation and the Discussion Document, we proposed introducing an LMC Additional Travel module that would fund travel on a per kilometre basis over a specified minimum threshold per trip of 15kms. We also proposed that the scope of payments would expand from funding only postnatal travel in the 2007 Notice to include antenatal travel.

Feedback during the consultation process clearly told us that tracking travel in this way was not going to work for the majority of LMCs. This was one of the areas in which we went back to the drawing board and significantly adapted the proposed approach.  As a result, we have developed the Rural Practice and Travel Supplements.

These new modules are available for claiming by LMCs for the provision of care to women who are not able to easily access services due to distance, in particular but not limited to, women living in rural areas.

StatsNZ have retired the 1993 rural codes that are supplied in the 2007 Notice. They now have an updated 2018 version, using slightly different terminology. The StatsNZ urban accessibility classifications (UAC) are supplied in a different format and are not available in a handy document as previously, but they are very thorough and, in the majority of cases, adequately represent the urban/rural spread of our population.

An LMC can submit a RPaTS claim with every trimester, the labour & birth, or postnatal claim that they make, whether the woman lives rurally or not. We have retained a sliding scale of payment, meaning that those women living in remote or very remote locations attract a higher fee than those living in major, large or medium urban areas.

In the Draft Notice for consultation, and the accompanying Discussion Document, the introduction of ‘additional visits’ modules in the antenatal period, was proposed, much like the Additional postnatal visits module in the 2007 Notice.

Again, feedback during the consultation period clearly indicated that this proposed approach of additional visits would not adequately remunerate all aspects of the additional care provided by LMCs.

And so… back to the drawing board we went and we have developed the Additional Care Supplements in consultation with the relevant professional organisations.

These new modules are available for claiming by LMCs for the provision of any additional care required by a woman due to their social or clinical complexity, and also for care provided to women belonging to groups over-represented in the most concerning statistics.

These supplements incorporate the ‘additional visits’ notion as one of many considerations in the assessment of complexity.

They can be claimed at the end of the third trimester, when the labour and birth is claimed and at the end of the postnatal module of care.

As we mentioned earlier, while the Notice was open, we took advantage of the opportunity to make some administrative changes and to rescope services in line with best practice.

The Registration module has been rescoped to become the First assessment, registration and care planning module and we have introduced a payment for this service.

The Home birth supplies and support module has been rescoped to reflect planning and supplies, as we pay for the support aspect via the Second midwife support module.

The Labour and birth (exceptional circumstances) module is now just about truly exceptional circumstances.

The rescoped Postnatal ACS replaces the Additional postnatal visits module from the 2007 Notice.

The Postnatal rural practice and travel supplement replaces the Rural travel modules from the 2007 Notice.

The Non-LMC First trimester care (with or without miscarriage, threatened miscarriage or termination of pregnancy) is now two new modules: First trimester single service and First trimester pregnancy loss.

Three modules from the 2007 Notice (Urgent in hours pregnancy care, Urgent out of hours pregnancy care and Urgent postnatal care) have been combined in to one new module: Urgent single service.

A Transfer support module replaces part of the 2007 Notice LMC labour and birth (rural support) and Non-LMC labour and birth (rural support) modules. This can now be claimed by any practitioner who accompanies a woman or baby in an air or road ambulance during the antenatal, labour and birth, or postnatal period.

The new Rural support module replaces the 2007 Notice LMC labour and birth (rural support) and Non-LMC labour and birth (rural support) modules.

It is intended that the changes to the Notice will clarify what maternity providers are eligible to claim for and simplify claiming processes significantly. However, we acknowledge everyone will need time to adjust to these new modules. What we want to let you know is that, post-implementation, the Ministry will be monitoring claiming patterns closely. This is to ensure that claims under this new Notice are appropriate, that claiming patterns meet expected volumes, and that our expected volumes are accurate. Claim volume prediction is in important part of fee setting and it has been challenging to predict some volumes in the revamp of this Notice, particularly in relation to the ACS. It is important to ensure that the expected volumes are accurate and that LMCs are, therefore, being remunerated appropriately. If unexpected patterns of claiming become obvious, we may need to adjust the associated payments.

It has been a pleasure to share this information with you in this short video. Please read the Guide to the Notice and accompanying relevant documents on the Ministry of Health website to supplement your understanding of the structure of the Notice, the service specifications and payment rules and claiming process.

You can contact the Maternity Team with questions specifically about the Notice on:

maternitynotice2021@health.govt.nz