After a year and a half in private practice, working with families from all walks of life, I recently surprised myself with an observation I made. I am stunned nearly on the daily by the observations of the families I work with. “This is pain without sorrow, I will be fine”…pronounced about 4 minutes prior to crowning by a first-time mom. “I am made a mother in the most unexpected and welcome ways” confided a mom who had adopted after years of trying to conceive, only to find herself pregnant 3 weeks after the adoption was finalized. Well on and on it goes, I could quote my clients until I’m the old granny midwife I recently promised a young girl I would be so that I could be with her when she has her babies…but my realization came when focused on the one part of the Out of Hospital Birthing World rarely discussed: The Money.
We are paid the smallest percentage per office visit and birth relative to hospital-based care imaginable. Even if the insurance companies paid us what we bill, we would still be saving them millions per year for the care of low-risk women and babies. But they don’t—they pinch, they squeeze, they delay, they deny, deny again, fight, lose papers, call with demands, don’t answer call-backs unless you manage to navigate dozens of voice prompts while the moon is aligned just-so (and when the moon is aligned just-so I don’t have time to be on the phone pushing buttons, I’m watching women become mothers!) I’ve filled out credentialing forms three times for more than two companies. They still can’t find them. I completed paper work for one company in May of 2013 and was approved as a provider in June of 2014 (woot, woot!). And yes, I pay a biller who has been trying to tag-team these people with me in the name of access to healthcare for women who want it when they want it where they want it and how they want it. Which I fully support! In fact, this idea of “access to care” has been termed a basic right by the big politicos.
Of course women have recognized that birthing is steeped in human rights issues, the story of feminism in our country, and right to self determination for centuries. I love the women called Shifra and Puah in the bible, not just because they were midwives, but because they exhibit one of the earliest acts of women engaging in civil disobedience in the name of doing what is right, in the name of preservation of life.
Not only do I wake up every day happy to go to work and to do what I do, I seem to keep paying the lease to the clinic on time. In the beginning I had some help from family to get me going—but now I’ve paid them back and keep writing checks every month to pay the rent. I can still hear my grandmother singing to my son while she bounced him on her knee, “All around the mulberry bush, the monkey chased the weasel. The monkey thought ‘twas all in fun, POP! Goes the weasel. A penny for a spool of thread, a penny for a needle. That’s the way the money goes, POP! Goes the weasel” Of course I had enjoyed that song when I was little, but it was only hearing her sing it then to my son, at a time when money was stretched tight in our family, that I began to understand the lyrics. And again over the past months I’ve felt we’ve had a little of what I’ll dub “Mulberry Bush Economics” at play in our practice. And while I thought I was alone, running like a mad-woman round and round, turns out I am not so alone after all and I’m not chasing anything.
The women who come into our care have always been offered the option of payment plans to cover the large deductibles, lack of insurance, or non-covered services. A high percentage of families choose this option. We simply have them fill out a piece of paper to let us know when they plan to make payments and ask them to let us know if that plan changes at all. Seeing so many small checks instead of a few big ones made me wonder, how on earth do I keep paying the lease? And that’s where I made this most amazing observation. Women have their babies. They start making payments when it works for their family, often times stretching quite a ways out into their first year. And that means that each mother is supporting other mothers as they gestate and birth. And then those mothers support the next group that comes along. And now we’ve got a thriving economic system which keeps the doors open and provides opportunities for women to access care who would not be able to afford it otherwise. It is a dizzying wonderful marvel.
In my practice I realized very quickly that the healthcare system is ineffective and uninterested in promoting optimal health for all women and families. It is short-sighted and lacks motivation to invest in the health of communities. It is layered and designed to funnel money to companies who work really hard to take money from families and keep money from providers and the institutions trying to serve them. Instead of waiting around for permission to participate in the usual way, we built ourselves a little boardwalk straight across the swamp and invited other providers and community service organizations to join us.
And just like that women who had no prenatal care had slow-paced individualized care with births in the location of their choice. It’s not perfect, there are places we have to jump over broken planks and times we don’t quite reach the women on the other side in the way I hoped we would. But I am delighted with it. I look forward to expanding it. And I am thrilled that the economics have followed the practice and we all get to dance around the mulberry bush, though no longer chasing that illusive monkey. We simply join hands and celebrate the results of creating community through this deeply spiritual, visceral, and financially remarkable system of ours.