IMAGE CREDIT: ANNA TODD
GP referral refusal position statement
Latest Updates
This Health Legislation Amendment for ‘Removal of Requirement for a Collaborative Arrangement’ Bill introduced into Parliament by Assistant Minister for Health and Aged Care the Hon. Ged Kearney MP in March, passed through the Senate 17 May 2024. This will come into effect from 1 November 2024 and ends the decade long barrier to direct access to Medicare rebates for care provided by Endorsed Midwives and Nurse Practitioners.
Importance/Problem/History
Privately Practising Midwives (PPMs) are currently required (until November 2024) to obtain a referral from a GP, health service or Obstetrician in order to provide Medicare rebatable antenatal and postnatal care to women. Unfortunately, this collaboration is often one-way, whereby the GP/OB is required to provide referral but doesn’t necessarily follow up or form a relationship with the midwife they have referred to. Around Australia, women are continuously being refused referrals to a Privately Practising Midwife (PPM) by their General Practitioner (GP), sometimes with the reason given being that their practice policy dictates they are unable to refer. This is despite their right to informed, woman-centred antenatal, intrapartum and postnatal care.
Given the knowledge that midwifery-led continuity of care improves outcomes for both mothers and babies (Sandall et al., 2016), and that birth at home leads to no differences in maternal or neonatal mortality yet significantly better maternal morbidity (Homer et al., 2019; Hutton et al., 2019; Scarf et al., 2018; Davies-Tuck, 2018), care with a PPM should not only be a valid option in Australia but should also be supported by our other healthcare providers.
Australia’s PPMs are some of the most qualified pregnancy, birth and postpartum specialists available, having undertaken a Bachelor’s degree, having had to practice a minimum of 3 years within the hospital system and undertaking continual professional development activities in order to register and go into private practice, as well as being regularly audited while practicing. To suggest that a GP who has minimal antenatal, birth and postnatal experience should have to refer to a specialist is insulting to the midwifery profession as a whole.
Furthermore, we have observed that when GPs do refuse referral to the women they are caring for these women either go elsewhere for referral, reducing the continuity of care they would usually have with their chosen GP, are out of pocket for expenses incurred without Medicare rebate, or choose to go through their pregnancy alone, without any medical care; all of these options reduce the safety for women and babies.
In budget announcements of 2023, it was declared that mandated collaboration requirements for endorsed midwives would be removed. There was initial celebrating, but with caution, as midwives and the community was uncertain about how this impact insurance, with the concern that the insurance provider for privately practicing midwives' antenatal and postnatal insurance product (MIGA) would then declare that a GP referral would remain necessary as a condition of the midwives' insurance. It remains uncertain whether this will be an issue or not, but the legislation has now passed the Senate as of May 2024, with the requirement for referral no longer needed to access Medicare rebates as of November 2024.
Our aims
We aim to push against the requirement for PPMs to collaborate with other healthcare providers in order to provide Medicare rebatable care. We aim to ensure that PPMs can provide Medicare rebatable antenatal, birth and postnatal care to women without first seeking referral from a GP, OB or healthcare service, maintaining safety for women and babies and providing midwives with the respect their profession deserves.
How will we do this?
We have lobbied against mandatory collaborative agreements, raise these issues with the Australian Health Practitioners Regulation Agency (AHPRA) and keep these collaborative agreements in mind when sitting in on policy and legislative changes, such as those currently being considered within changing the Medicare funding for intrapartum care to include homebirths. We will continue to call out GP practices who do have policies against referring to PPMs, and will continue to follow the insurance trail to determine whether insurers have suggested they are unable to provide insurance to GPs who refer to PPMs.
We completed a research project to determine the various effects of GP referral refusal on women and presented this at the Homebirth Australia Conference in 2019, and continue to share this information with organisations including Maternity Choices Australia and Homebirth Australia. We also made this information readily available and shareable via our website, and will continue to share the information widely.
Where are we now?
Mandated collaboration has officially been scrapped with legislation having been passed in the Senate (May 2024). We will continue to monitor the issue in the case that insurance providers deem referrals still necessary for midwives to provide antenatal and postnatal care in order to remain insured. For now, as of November 2024, women will not require a GP or other health service referral to access Medicare rebates for antenatal and postnatal care from a Privately Practicing Midwife.
We will continue to advocate for Medicare rebates for intrapartum care by a PPM, which we hope will be available following the PII insurance solution (please see Professional Indemnity Insurance under "Campaigns" for more information).
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