The Business of Midwifery
As a new midwife, you know all about the business of midwifery...but do you know about the business of midwifery?
#1: Midwives are independent contractors...
Most Ontario midwives work for themselves, as independent contractors, within midwifery practice groups. These midwives are not:
- Hospital employees
- Employees of the provincial health-care system
- Practice group employees (or employees of any kind)
A small but growing number of midwives work as employees in health-care settings other than midwifery practice groups. The College of Midwives of Ontario requires that new registrants (NRs) work in established practice groups so NRs are not eligible for employee model work for at least one year. In at least their first jobs, all Ontario midwives are independent contractors.
#2: ...As in, they hold a contract
Most midwives (except for a handful of solo midwives in rural communities) work in practice groups. Each midwife has a contract with that practice group. The practice group, in turn, has a contract with the local Transfer Payment Agency (TPA). This is the template contract that the AOM negotiates with the Ministry of Health (MOH), the one that sets out the skills, effort, responsibilities, working conditions and compensation structure for midwives.
The job of the TPA (which may be a local hospital, community health centre or other local organization) is to support and flow funding to the practice group. The TPA has a contract with the Ontario Midwifery Program (OMP), the branch of the MOH that manages midwifery in Ontario. It is the Ministry that determines where midwives can work, and the establishes the number of clients that the profession cares for on an annual basis.
|Midwife →||has a contract with →||Midwifery Practice Group|
|Midwifery Practice Group →||has a contract with →||Transfer Payment Agency|
|Transfer Payment Agency →||has a contract with →||Ontario Midwifery Program (at the MOH)|
#3: They get paid through these contracts
Once a month, midwifery practices submit invoices to TPAs, reflecting the work done by the midwives. This includes billable courses of care and caseload variables (approved non-clinical services e.g. special populations).
The funding agreement between practice groups and TPAs outlines how midwives will get paid, what they get paid for, and what is expected of the practice group. The AOM negotiates template agreements with the Ministry, but each practice signs it with their TPA.
Funding flows in the same way. The Ministry pays the TPAs, who pay the practice group, who in turn pay individual midwives.
|Ontario Midwifery Program (MOH) →||flows funding to →||Transfer Payment Agency|
|Transfer Payment Agency →||flows funding to →||Midwifery Practice Group|
|Midwifery Practice Group →||
flows funding (compensation) to →
#4: There's an annual budgeting process...
Because midwifery is a managed program, there is an annual budget process MPGs must engage in to establish their budgets for the upcoming year. Practice groups write budgets based on the projected number of clients their midwives will care for in the upcoming year, as well as any furniture, equipment, renovation costs, new registrant positions or other expenses that they foresee.
Practices submit these budget proposals to TPAs at the end of January every year. TPAs review each MPG's budget and submits the total requested courses of care and other costs to the OMP, creating a regional budget for all midwifery services.
Until that budget is approved, MPGs can assume they will receive a "base caseload," or the same funding that they received the previous year.
The OMP approves TPA budgets, and advises them of the decision. TPAs then decide on individual practice budgets, based on what was requested from MPGs and actually budgeted by the OMP.
#5: ...Where clinics project how much care they will provide (& be paid for)
Midwives do not bill in a fee for service model; rather they bill on the basis of an entire course of care provided, from the time a client enters into care through to discharge at 6 weeks postpartum. A BCC is a billable course of care--one lump sum that a midwife gets paid for providing this care. Each clinic's annual budget carves out a set amount of funding for the volume of BCCs a practice group projects they will undertake.
In addition to billing for clinical care provided to clients, practices can also bill for work up to pre-approved amounts for caseload variables. These CVs are intended to compensate practices for not taking a client into care because they have had to do other work. CVs are available for specific work that takes midwives away from their clinical work. This includes work with identified client populations and specific hospital or OHT activities.
For rural and remote practice groups, there is also a supplement paid per course of care.
There is an operational fee associated with each BCC that is diverted to the operations of the practice group. The operational fee is used to cover things like rent, salaries of receptionists, book keepers, accountants, cleaning staff, and disposable supplies for home births and clinic appointments such as sterile gloves, drugs, syringes etc. Other expenses, like travel and insurance premiums, are also paid.
Practice groups can expense the purchase of non-disposable equipment with funding from the Ministry based on a dollar amount per midwife in a practice. The practice is responsible to figure out which equipment is needed most in the year.
There is also separate funding for equipment for new registrants. Each midwife, as an independent contractor owns her/his own equipment. Practices can apply for grants for capital costs to do renovations for their clinic spaces.
#6: Midwives get benefits associated with each BCC
The Ontario Midwifery Program pays an additional 20% of your total BCCs to be used for benefits. This gets forwarded to the practice group but then immediately gets sent on to the AOMBT (Association of Ontario Midwives Benefits Trust) so you would not see this money in any of your pay cheques.
It is important to remember that this is included in your taxable income each year from the perspective of CRA. When figuring out how much money you make and trying to anticipate how much tax you will pay, you need to add your BCC amounts and your benefits amounts.
Because the benefits amounts are based on your BCCs, they will vary from month to month.
Your benefits include:
1. Health and group benefits for midwives, spouse/partner, and dependents: Prescriptions, paramedical services, dental services
2. Life insurance, critical illness, short-term disability, and long-term disability
3. Self-funded Leave plan (optional) and GRSPs
4. Parental leaves (covered by an annual grant from the MOH)
#7: OK, just tell me how much I'm going to get paid!
While all practices have the same Funding Agreement (login required), signed with a Transfer Payment Agency (TPA) and negotiated between the AOM and the Ontario government, each practice implements the agreement differently. This will impact how much compensation you receive and when. As a result, there is no short explanation of how midwives are paid and the only way to get answers to these questions is to discuss them with the practice that you are considering. Prior to starting work at the practice, you should ask for a contract which describes the payment agreement. The terms may either be spelled out in the contract or in practice policies appended to the contract.
The NR Compensation (login required) page describes some of the things you should know about and questions to answer these questions. Other AOM pages describe the system of midwifery funding, the philosophy behind that system, and the funding agreement.