Affordable Health Care Begins with IBCLCs:

Affordable Health Care Begins with IBCLCs: Access to Lactation Support as a Cost-Effective Preventive Health Measure Lactation Consultant in Private Practice March 2015 1 Judy Gutowski, BA, IBCLC, RLC jlgutowski@comcast.net 724-331-6607 Email for updated bibliography Chair: US Lactation Consultant Association Licensure and Reimbursement Committee www.uslca.org IBCLC Licensure/Reimbursement Medicaid Group https://www.facebook.com/groups/111712392311033/ Maternal & Child Health Prevention Primary - taking action to prevent disease from happening; breastfeeding and breastfeeding promotion Secondary - earliest possible identification of potential problems, before symptoms occur, in order to readily treat or manage adverse results; breastfeeding education and preventive counseling Tertiary - stopping progression of the existing condition, reducing the severity, limiting complications, and aiding recovery; clinical lactation care for problems National Public Health Partnership, 2006; Current Nursing 2012; LibraryIndex.com, n.d.; The Open University OpenLearn Site, 2013 1

Preventive Intervention Measurement Cost-Benefit Analysis net cost savings in money Cost Effectiveness unit of health outcome such as lives saved, disease avoided Cost Utility/Quality Adjusted Life Years - length and quality of life saved during the remaining life years generated by the health care intervention Successfully Breastfed Infants Cost-Benefit Analysis : $13 billion could be saved annually $5909 per infant indirect costs and premature death, based on 2007 dollars $1000/child < health care costs per year direct costs Otitis, NEC, LRTI, At Derm, T1D, SIDS, Leukemia Cost Effectiveness: 900 infant deaths could be prevented annually. Cost Utility/Quality Adjusted Life Year (QALY) : Skilled breastfeeding support in Neonatal Unit resulted in 0.009-0.251 QALY) per infant and was cheaper 66 (~$108 USD) to 586 (~$966 USD) per infant across the birthweight subpopulation. Bartick & Reinhold, 2010: Renfrew et al, 2009) Successful Breastfeeding Mothers Cost Benefit Analysis: Reduces Maternal health care costs $18.625 billion $9715 per woman based on 2011 dollars Cost Effectiveness: 4981 cases breast cancer 58,847 cases hypertension 13,946 myocardial infarction 4,396 fewer premature deaths Bartick, Steube, Bimla-Schwarz, Luongo, Reinhold & Foster, 2013 2

EFFECTS ON INFANT Infection Diarrhea Haemophilus Influenza Meningitis in Preterm Infants Necrotizing Enterocolitis Otitis Media Pneumococcal Disease Respiratory Infections (general) Respiratory Syncytical Virus Sepsis in Preterm Infants Urinary Tract Infections Childhood Illnesses Autoimmune Thyroid Disease Undescended Testicle Gastroesophageal Reflex General Morbidity Immunologic Development Infant Survival & SIDS Inguinal Hernia Pyloric Stenosis Toddler Health Wheezing Allergies Allergies, Asthma & Eczema Development and Intelligence Cognitive Development Gastrointestinal & Immune Dev Hormones IQ Psychomotor and Social Dev Thymus development Visual acuity Physiologic Response During Feedings Long Term Effects Appendicitis Bone mass Cancer Cardiovascular Disease, Cholesterol Celiac Disease Dental Health Diabetes Mellitus Helicobacter pylori infection Haemophilus Influenzae Meningitis Inflammatory Bowel (Crohn's & Colitis) Juvenile Rheumatoid Arthritis Multiple Sclerosis Obesity Parent-child relationships Tonsillitis Transplant recipients Vaccine Response MATERNAL EFFECTS A. Cancer Breast Cancer Endometrial Cancer Esophageal Cancer Ovarian Cancer Thyroid Cancer Uterine Cancer B. Emotional Health C. Fertility D. Insulin Requirements E. Osteoporosis F. Postpartum Weight Loss G. Urinary Tract Infections SOCIETAL EFFECTS A. Child Abuse B. Child Spacing C. Environment D. Financial Cost to Government and Families Food Expense Medical Expenses E. Vaccine Effectiveness Policies Recognize Breastfeeding as Primary Health Care Prevention United States Preventive Services Task Force recommends interventions during pregnancy and after birth to promote and support breastfeeding Institute of Medicine Consensus Report Clinical Preventive Services for Women: Closing the Gaps US DHHS National Prevention Strategy US Surgeon General Call to Action to Support Breastfeeding 8 A National Health Priority Healthy People 2020 Increase incidence and duration, workplace support, recommended care in birth facilities, decrease formula use in first 2 days CDC Breastfeeding Report Card, Maternity Practices in Infant Nutrition and Care Survey, Guide to Strategies to Support Breastfeeding: Strategies to Prevent Obesity and Other Chronic Diseases White House Task Force on Childhood Obesity Report to the President USDA WIC Food Packages HRSA Office of Women s Health Business Case for Breastfeeding 9 3

Patient Protection & Affordable Care Act Section 2713: Coverage of Preventive Health Services Requires Private Insurers to cover Comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment. In conjunction with each birth. Optional for state Medicaid to cover Health Authority Policy Support for Breastfeeding Joint Commission Perinatal Core Measures NICHQ Best Fed Beginnings Bright Futures, an initiative of the Maternal and Child Health Bureau / AAP adopted United States Preventive Services Task Force breastfeeding recommendations 11 4. Every infant should have an evaluation within 3 to 5 days of birth and within 48 to 72 hours after discharge from the hospital to include evaluation for feeding and jaundice. Breastfeeding infants should receive formal breastfeeding evaluation, and their mothers should receive encouragement and instruction, as recommended in the 2012 AAP statement Breastfeeding and the Use of Human Milk (http://pediatrics.aappublications.org/content/129/3/e827.full). Newborn infants discharged less than 48 hours after delivery must be examined within 48 hours of discharge, per the 2010 AAP statement Hospital Stay for Healthy Term Newborns (http://pediatrics.aappublications.org/content/125/2/405.full). 4

Breastfeeding rates in different settings globally are related to key socio-cultural factors: societal norms public policy availability of appropriate care and support, both professional and lay Evidence of Need for Breastfeeding Support: Duration Rates PA and US Breastfeeding Rates Compared to Healthy People 2020 Goals 90% 80% 70% 82% 77% 74% 70% Goal Any Breastfeeding Exclusive Breastfeeding 60% 60% 61% PA PRAMS 50% 40% 51% 46% 43% 30% 32% 34% 26% 20% 17% 10% 0% Initiation 1 month 2 months 3 Months 6 Months 12 Months 14 Inadequate Breastfeeding Assistance in Primary Care When Most Needed 15 5

When breastfed babies come along in a health care system created when bottle feeding was the norm, things have to change. 17 years for practice change!!! Compared to prenatal care investment, we need postpartum care that takes the 4th Trimester as seriously. (Steube) Current level of hospital services do not meet the need Post-discharge breastfeeding support is insufficient Healthcare System Flaw Systematic reviews -nurses, nutritionist, pharmacists and physicians do not possess core knowledge and skills needed to provide breastfeeding support and services to women Health care professionals breastfeeding knowledge impacts the quality of breastfeeding services for women and breastfeeding outcomes Audrey Perry, DNP Capstone - 2013 6

WIC does not provide this service ~ 71% WIC participants are on Medicaid Medicaid providers refer patients to WIC for lactation support WIC rarely provides clinical care from IBCLCs 38% of surveyed agencies had an IBCLC on staff They may or may not provide clinical services WIC employs peer counselors receive training in basic support expressly trained to refer to IBCLCs Imagine if formula companies made their products as difficult to access as it is for mothers to locate and to pay for breastfeeding support. Breastfeeding Support must be Included as Standard of Care Indicidualized, Face-to-face support is most effective Mothers don t seek assistance!! Support only offered if women seek help unlikely to be effective Women need predictable, scheduled, ongoing visits Telephone support less helpful 7

Timeliness is essential - difficult breastfeeding is grueling, and if support is not initiated immediately, the ability to breastfeed can be lost within days or hours. Ellie at birth, 33 wk gestation 11 months still breastfeeding At Birth In-Patient 79% of Mothers nationally choose breastfeeding 92% of first-time mothers have early feeding problems & low confidence 71% of in-patient care requires IBCLCs even when regular staff is well-trained After Discharge 51% have unresolved problems on day 7 60% weaned before meeting their breastfeeding goals problems are nearly universal in 1 st time mothers causes formula use and reduced duration and exclusivity 8

Mothers Need Empathy, experience & educational tools Solutions that work in specific situation, setting, circumstances & bring behavior change. IBCLC Clinical Competencies require these skills Mothers fear providers won t understand their circumstances, particularly when they reject feeding recommendations and feel powerless to breastfeed exclusively. IBCLCs are ESSENTIAL Allied Healthcare Providers Provide clinical care Lactation assessment & intervention, 60 minutes+ Particular need in first month of breastfeeding 9

Access to IBCLC Services Improves Breastfeeding Incidence and Duration Impact of IBCLC care in hospital & post-discharge is poorly documented with nonhospital based services left unquantified. In part due to differences in study methods and design definitions of breastfeeding type of intervention many mixed education, support, materials phone, face-to-face providers outcomes of interventions target populations Common theme -support by professionals trained in lactation, offering individualized & offered long-term care were successful 28 Morris & Gutowski Supplements before 1 mo 47% No IBCLC 41% IBCLC Greater odds of Exclusive Bf 4-6 mo compared to 0 mo = 1.75 Greater odds of Exclusive Bf 4-6 mo compared to 1-2 mo = 1.83 Any Bf 1 yr 14% 26% 2.15 odd ratio No LC Contact but LC available 3.14 USLCA Recommends #1 -State licensure of IBCLCs Recognition and credentialing of the International Board Certified Lactation Consultant (IBCLC) as the preferred provider of lactation care and services for private and Medicaid insurance plans Third party reimbursement of skilled breastfeeding support provided by the IBCLC Delineation of IBCLC-provided lactation services as distinct from other healthcare services in the medical system 30 10

1 State Passed Licensure, 35 States Licensure Underway States with Bills Introduced Georgia - http://www.legis.ga.gov/legislation/en- US/display/20152016/HB/649 Massachusetts - https://legiscan.com/ma/bill/s1183/2015 Minnesota - https://www.revisor.mn.gov/bills/bill.php?b=senate &f=sf932&ssn=0&y=2015 New Jersey -revising New York revising Texas - http://www.capitol.state.tx.us/tlodocs/84r/billtext/ pdf/hb03976i.pdf#navpanes=0 Include support for lactation as an essential medical service Ample evidence of the need for support from IBCLCs has not yet translated, to comprehensive availability of their care. Need 8.6 IBCLCs per 1000 live births U.S. has 3.35 IBCLCs per 1000 live births 11

Mother/Consumer What level of support will identify moms at risk and triage them to the appropriate level of care, without medicalizing normal breastfeeding? (Steube) Aunt and niece breastfed Mother/Consumer How does she find the right products? How does she find the right services when she has a breastfeeding problem? Where is protection from fraudulent claims on products & services? Consumer Confusion in the Market Place International Board Certified Lactation Consultant Community Breastfeeding Educator Early Breastfeeding Care Specialist / Doula Breastfeeding Training Certified Lactation Counselor WIC Peer Counselor Certified Lactation Educator La Leche League Leader Certified Breastfeeding Specialist Certified Lactation Specialist Certified Lactation Counselor Breastfeeding Counselor Breastfeeding Educator Lactation Educator Counselor Lactation Care Specialist 12

Certification? Registry? Licensure? Professional Certification = Voluntary process IBCLC Non-governmental entity grants a timelimited recognition and use of a credential Verifies an individual has met predetermined and standardized criteria Vehicle used to differentiate among its members Using standards Developed through a consensus driven process Based on legal and psychometric requirements Durely (2005) Registry = RLC Governmental agency grants a time-limited status on a registry Determined by specified knowledge-based requirements (e.g., experience, education, examinations) Authorizes individuals to practice, similar to licensure For IBCLCs: Louisiana RLC designation Durley (2005) 13

Licensure Mandatory process State governmental agency grants timelimited permission to an individual to engage in a given occupation IBCLC verifies achievement of predetermined and standardized criteria 40 Purposes - Identification Mechanism to be known by the public, employers, policy makers and insurers Links IBCLC to a meaningful process of examination Accredited as legally defensible Delineates entry level standards and continuing competence Professional credibility, aligns with other regulated health professionals 41 What s in it for You Licensure FAQ from USLCA Credibility with colleagues and healthcare administration Increased IBCLC staffing?? Means to reimbursement Billing independently for outpatient Minimal Cost (one visit fee??) 14

Challenges Must pass legislation 50 times Requires support of legislator(s) States don t want new boards or registries Government does not want to spend money on regulation Public perception of regulation as ineffective or corrupt Creating a new board is cost prohibitive for small numbers of IBCLCs 43 Purposes Public Protection Insures competence and ethics in the profession Differentiates IBCLCs from other breastfeeding support providers Assures consumers that professionals have met standards of practice Ensure that consumers have access to care 44 Legislation Elements Mandatory licensure - required to practice Titles or initials protected Defined clinical lactation services Define licensure qualification - IBCLC or equivalent Education, clinical practice hours, exam Additional exam or IBCLC (recommended) IBCLC Scope of Practice /Code of Conduct Continuing Education Additional clearance- criminal, child abuse 45 15

Legislation Elements Create a Board or find an Existing board to administer IBCLC Some states have allied health Wisconsin may have a Licensure Dept rather than boards Created Board has 5-9 members Limited terms IBCLC, public, other HCPs Rules within bill or separately defined Proof of qualifications Renewal time and Non-renewal Legislation Elements Exemptions State reciprocity State disciplinary measures Complaint processes/ hearings Suspensions, civil and/ or criminal penalty Fines or misdemeanor for unlicensed practice Other state requirements Public notices RI Exemptions Nothing in the Act or these Regulations shall be construed to prevent qualified members of other professions or other occupations or volunteers from performing functions consistent with the accepted standards of their respective professions; provided, however, that they do not hold themselves out to the public by any title or description stating or implying that they are lactation consultants licensed to practice clinical lactation care and services in Rhode Island. 16

GA Exemptions Nothing in this article shall be construed to affect or prevent: (1) Persons licensed to practice the professions of dentistry, medicine, osteopathy, chiropractic, nursing, physician assistant, or dietetics from engaging in the practice of lactation care and services when incidental to the practice of their profession, except such persons shall not use the title 'licensed lactation consultant' or 'licensed L.C.'; (2) Doulas and prenatal and childbirth educators from performing nonclinical education functions consistent with the accepted standards of their respective occupations, except such persons shall not use the title 'licensed lactation consultant' or 'licensed L.C.' or designate themselves by any other term or title which implies that such person has the clinical skills and abilities associated with licensure as a lactation consultant; (3) The practice of lactation care and services by students, interns, or persons preparing for the practice of lactation care and services under the qualified supervision of a licensed lactation consultant or any licensed professional listed in paragraph (1) of this Code 160 section; (4) Employees of the United States government or any bureau, division, or agency thereof from engaging in the practice of lactation care and services within the discharge of the employee's official duties so long as such employees are performing their duties within the recognized confines of a federal installation regardless of whether jurisdiction is solely federal or concurrent; (5) Employees of a department, agency, or division of state, county, or local government from engaging in the practice of lactation care and services within the discharge of official duties, including, but not limited to, peer counselors working within the Special Supplemental Nutrition Program for Women, Infants, and Children; (6) Individual volunteers providing lactation care and services provided: (A) Such persons shall not use the title 'licensed lactation consultant' or 'licensed L.C., or state that they are licensed to practice lactation care or designate themselves by any other term or title which implies that such persons have the clinical skills and abilities associated with licensure; 17

(B) Their volunteer service is performed without fee or other form of compensation, monetary or otherwise, from the individuals or groups served; and (C) The individual volunteer receives no form of compensation, monetary or otherwise, except for administrative expenses such as mileage; (7) A nonresident IBCLC from practicing lactation care and services in this state for five days without licensure or up to 30 days with licensure from another state if the requirements for licensure in such other state are substantially equal to the requirements contained in this article; or (8) Other health care related professionals from seeking licensure for their professions." Many procedures and systems must be in place for IBCLCs to be considered for coverage as lactation service providers. Education of Stakeholders Tool Developed for Educating 3rd Edition Now Available! 53 Medicaid Dilemma Medicaid covers approximately ~50% of US births Federal requirement of state licensure of Medicaid providers Issue Brief 2010 no mention of IBCLC New final rule language applicable Licensed provider can refer to unlicensed provider for care Requires CMS approved of amended State Plan 54 18

Thoughts About the Money?? PA example If 69% breastfeed x Medicaid mothers (1,805,151 is 48% U.S. Births) = 1,245,554 according to HP2010 goals, savings in reduced health care costs only $1000/child Estimated cost for provision of 6 IBCLC visits $600/ child + Quality breast pump $150/child = $750 $1,245,554,00 ($934,165,500) Net Reduction in Health Care Costs $311,388,500 Creation of IBCLC Licensure Boards in first year?????? U.S. Annual savings to Medicaid U.S. Medicaid Spending 2012 $415,154,234,831 $5,000,000 $306,388,500 7.38% Savings Private Insurers and Insurance Exchanges Insurers must be educated about the IBCLC May choose to credential IBCLCs without an additional license This must be done with each insurer Aetna is the first insurer to credential IBCLCs July 2012 Council for Affordable Quality Healthcare Universal Credentialing DataSource Difficult to navigate process without a license number Coding and Fees must be negotiated 56 Developing Insurer Models for Coverage Medicaid New York requires another license Oklahoma requires another license Oregon -?? Rhode Island not happening Private Insurers Aetna Blue Cross Blue Shield Nebraska National Business Group on Health 57 19

Why Should We Become Advocates? While breastfeeding may not seem the right choice for every parent, it is the best choice for every baby. Spangler,(2005) Advocacy Required At least now everyone knows benefits of breastfeeding? Must educate with all stakeholders, especially IBCLCs many misunderstandings about licensure and reimbursement Other Health Care Professionals think we are encroaching on their Scope Public, Legislators, Insurers 59 Who is Target Audience? Legislators / Current political climate Medical professionals Public health employees Private Insurance - Medicaid Health policy makers Other breastfeeding support providers Public 20

Homework Find out how licensure works in your state It may be hard to do! Research related legislation Maternal and child health Breastfeeding in public, workplace Obesity, nutrition Know your Department on Health and Medicaid roles Contact sponsors of this type of legislation Call to Action: Open Doors Grass roots advocacy Recruit legislative sponsors Letter writing (email) Distributing materials Public speaking Testifying at hearings 21

Face to Face Meetings REMEMBER You are the expert! Be Prepared Don t go alone when you attend meetings or speak Dress professionally Small folder of 1-2 documents to leave behind Prepare to discuss the political and fiscal climate and health issues such as obesity and breast cancer Meet with both Democrats and Republicans, men and women USLCA Documents for Meetings Containing Healthcare Costs 3 rd edition KNOW THE CONTENT OF THIS BOOKLET Containing Healthcare Costs Flyer Who s Who in Lactation: An Inventory of Breastfeeding Support: From Confusion to Clarity Lice Create one for Wisconsin 22

Sunrise Evaluation Fully describe the extent to which members of the general public are advocating or opposing the legislation. Provide the number of Pennsylvania practitioners in each organization, which advocates or opposes the legislation. Is the membership within the occupation or profession to be regulated generally united in support of a need for licensure? Document any threat to public health, safety or general well being that would result from the unregulated practice of the occupation or profession that is subject to proposed regulation. Face to Face Meetings Understand why licensure of the IBCLC is important For protection of the public To insure access to care for all mothers To reduce disparities in breastfeeding care To stand as a valued member of the health care team To contribute to lower healthcare costs Tell a brief personal story Know what you want and go for it! 23

Stand up for you Breastfeeding! Talk about the issue Tell your stories Connect us with people who can help Questions?? 24