Dear all:

What I find particularly disturbing about the proposed 1 hour visit for $100 is the lack of imagination about different models for providing care.  Again, I feel Marsha has made some assumptions about private practice IBCLCs that I find disconcerting. Really I am stinging over the completely unfair and unprofessional comment about how we private practice IBCLCs might CAUSE women to formula feed by DENYING women our services.  We have the right to earn a decent living and we have the right to advocate for a decent living.  

The issue here is not about governmental versus nongovernmental, the issue is about big institutions and individual women owned businesses.  Hospitals have governmental subsidies.  In the United States they must treat patience who cannot afford to pay for their services and who may be using hospitals for conditions that could very well be treated in community health centers if the United States had place value on preventive care.  Because the United States does not value preventive care, our tax dollars go for much more expensive treatments in hospitals at later stages of disease progression than should be the case.  Salaries in hospitals are completely inappropriate as a guide for services provided by individual providers.  This is because the economies of scale are entirely different.  Individual practitioners must pay higher rates for social security, higher rates for health insurance (since we don't have the clout to negotiate more reasonable rates), higher rates for financial services to develop a retirement account (because we don't have a specialized team to work on this) and we have to either pay for or develop our own forms and expend time trying to persuade insurance companies to honor the contract with their clients to pay them for the services they thought would be covered.  This is a much more time intensive proposition when you are a solo practitioner than when you are a salaried employee in a large institution.  

Now -- the notion that we in private practice are not working hard to ensure access to our services because we want adequate compensation is a slap in the face.  Furthermore the model of someone coming to your office for a neat and tidy one hour visit shows a lack of imagination and a lack of understanding of many different models of care that could be developed.

The reason why most IBCLCs in Manhattan do not have an office is that renting space is prohibitive.  My husband's small office (which can fit exactly three women) costs over $20,000 a year.  I haven't yet met an IBCLC in Manhattan who has been able to develop an office only model.

Many of us do offer two different models of group services.  One is a take off on the peer support model where women come and chat and the IBCLC facilitates. This is a great model for some types of problems.  Another model is the clinical support model where the IBCLC works with the mothers in the group to problem solve.  This model sometimes includes full assessment of intake and growth and sometimes does not.  Many IBCLCs can cover the cost of the facility with this type of group or find community centers where they don't have to pay a rental fee.

The one variation on this model, which I have to say took me a long time to develop the skills to do and I'm still improving is adding in the paperwork -- including tips and suggestions in a written form for mothers.  This is best done with group sizes of 4-8.  I have done it with group sizes up to 12-15 but it is quite exhausting and not ideal.  The advantage over this is that you can follow mothers over time and get a much fuller picture of the dyad. I undercharge for this group because I charge the same for providing a fuller assessment and WRITTEN tips as do others who never provide and individualized written tips.  I consider this my community service group, but I may rethink this model and charge more. 

Many of us charge a toke $5 for Medicaid or WIC clients for attendance at groups.

The other model is the small registration only clinic.  There are two of us who are currently using this model. I do full paperwork and individualized care plans that are every bit as detailed as what I provide on a home visit.  I advertise this as a 2 hour group.  Not once have I been able to kick them out before 3 hours because of the varied feeding rhythms of their babies.    It is far more intensive than trying to do a visit with a single mother. 

I have been toying with an old model that my mentors used which was a rolling entry clinic.  They used to bounce back and forth between two rooms and even 12 years ago they were charging $100 a visit for attending the rolling clinic.  When I have a weekend when there are too many women for my small group (I can only handle 3 at a time) I have used a staggered approach where they come 1 hour later than each other.  To really make this work and cover all my costs, I would need to charge more than $100, but it would be viable to come closer to the $100.   This is the type of model that SHOULD be discussed with insurance companies.  Many women who are mobile could get care and lactation consultants could make a reasonable income.

As for basing rates for home visits on salaries at hospitals and what occurs in hospitals -- I will need to go see Dr. Linda Dahl for a jaw adjustment -- she's going to need to tighten up the muscles so that I can close my jaw.  There ARE women who legitimately canNOT make it into an office.  There are not many of these. And I do think that for some women, the home visit is a luxury.  But is is definitely not for others.  The more APPROPRIATE model would be investigating how the Visiting Nurse Services of New York handles their insurance reimbursements.  I just checked the salaries and they are in a range that many private practice IBCLCs would die for -- close to $70,000 a year (with benefits and less social security and no business costs).  I am sure that the Visiting Nurse Services are not reimbursed at a rate of $100 per visit if they can offer salaries in that range.  A legitimate medical need for a home visit NEEDS to be treated entirely differently than an office visit and insurance companies should be educated about this.  If members of my own profession cannot understand this distinction -- I welcome them to join me when I do home visits to mothers who really need the home visit and see if they can finish a visit and meet a mother's needs in less time than I can.

Sincerely,

Susan E. Burger, MHS, PhD, IBCLC

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