I will respond to sections of Maria's post in quotation marks.

Marsha Walker, RN, IBCLC
Weston, MA


Surely we all support the idea that every mother/baby dyad should receive
good lactation support and have it paid for by her insurance company.
 However, we also must recognize that if insurance companies are planning
to pay a third of what we would charge, then these are the only things that
could possibly happen, and none of them are good for mother/baby dyads:

"Aetna's reimbursement rates will depend on your geographical location.
Reimbursement for a one hour visit could range from $93 to $123 depending
on where you live. You are under no obligation to accept Aetna members for
lactation care and services. If they cannot afford to pay you they will
either find someone else who will take their insurance or formula feed
their infant. Many IBCLCs will choose to not only continue accepting
fee-for-service clients but also add Aetna mothers to their practice. This
helps close the disparity gap between mothers who can afford to pay and
those who cannot."

1.  Mothers will start choosing to get help from IBCLC's who accept the low
payments from insurance, and the only IBCLC's who will be able to afford to
practice will be those who are doing it as a sort of charity work (in other
words, they are relying on a husband's/partner's  income), and since in
2012 in NY we live in a world where women actually expect to get paid for
their work and many need to feed their families, the rest of the IBCLC's
will get other jobs and move on to other careers.  There will not be good
help readily available for mothers and babies.

" You are making a rather broad assumption that only IBCLCs of poor quality
will accept insurance reimbursement. There is no evidence that this will
come to pass. You assume that all of your clients will be paying by
insurance which again is an assumption that is not necessarily true. Many
very good IBCLCs will continue their fee-for-service clients as well as add
insurance clients. The two can co-exist in the same practice."

2.  The good IBCLC's will continue to charge their rates out of network,
but they will have less business and fewer people will be helped.  These
good IBCLC's may or may not go out of business.  There will not be good
help readily available for mothers and babies.

" I fail to see any logic in this statement. How do you define "good
IBCLCs?" Only those who work in New York? How on earth would any IBCLC go
out of business if their colleagues decide to accept insurance
reimbursement? The mothers who need insurance to see an IBCLC would
certainly not be seeing one who did not accept insurance."

3.  At least some of the IBCLC's who are in network will be of a category
that unfortunately might be described as "you get what you pay for."  These
IBCLC's certainly will not be able to afford $1500 scales, and weighed
feeds will not be done when appropriate.  They will not be able to afford
paperless charting, and especially with all of the new ins. co. paperwork,
record keeping will suffer.  They will not be able to afford conferences
and continuing education.  We have all, unfortunately, seen situations
where IBCLC's did not do a weighed feed when it should have been done.  I
have heard too many stories of LC's not examining the mother's breasts or
the baby and therefore missing important things.  Who on this list HASN'T
identified TT and made a referral and thereby saved a breastfeeding
relationship when the mother had seen an LC or sometimes multiple LC's
before?  At the very least, the LC's working for the reduced rates are
going to have a real incentive to reduce the time they spend with mothers,
because they will NEED to see three times as many dyads.   Mothers and
babies will fail at breastfeeding because of lack of good help.  I heard
from a mother today who was given formula by IBCLC's at a Massachusetts
hospital.  Free formula while her baby was gaining 2 ounces a day on her
own milk.  The sad part is that they talked her into using some of it.
 "Feed the baby is the first rule," they said.  I guess they didn't
understand that breastfeeding is feeding.  Bad help is worse than no help!!

" It seems you are equating poor lactation care with insurance
reimbursement. Do you have any evidence that lousy IBCLCs will be the only
ones accepting insurance payment? How do you figure out who is a lousy
IBCLC? The above paragraph has nothing to do with insurance reimbursement.
How do you know that IBCLCs who accept insurance will not be able to afford
a scale or will not know when to weigh a baby? These assumptions are not
really grounded in any evidence that this will be true."

As a policy matter, we should do what dentists have done, that is, stay out
of network until insurance companies pay what we deserve.
Of course we all feel bad for mothers and babies who need help, but, as set
forth above, we are not helping anyone by allowing ourselves to be taken
advantage of by insurance companies.  Rather, we are derailing our
profession and putting ourselves out of business--then where will mothers
get good help??  It is short-sighted to think that we can save the world by
devaluing our time!  Please do not be fooled when insurance companies throw
out the argument about mothers not being able to afford help.

" You have the option of not accepting insurance reimbursement. However,
Aetna and other insurers are offering the opportunity for IBCLCs to be
reimbursed for their services through insurance payments. If this is not
enough money for you then you are certainly not obligated to join any
insurance network. There is no pressure being placed on you to accept
insurance. However, as I have said before, many IBCLCs can combine
insurance and fee-for service in the same IBCLC practice. This allows
mothers who cannot afford to pay for your services to still obtain them."

First, YES, this is a very real issue, but that means that the insurance
companies should cover it!!  By working for reduced rates, we are in effect
serving as insurance for the mothers!  This is not our cost or burden to
bear!  We need to be paid for our work.  Like many of the members of this
list, I do believe strongly in the importance of volunteer work, but we
need to a) choose when and where to volunteer and for whom, and that should
not mean volunteering for an insurance company, and b) value our work and
not think that everything we do should be on a volunteer basis, because
that thinking does not benefit mothers and babies or society in the end.

"How do you come to the conclusion that accepting insurance is volunteer
work? Much of the rest of the US health care system uses insurance
reimbursement. This places IBCLCs on the same team and at the same table as
the rest of health care providers. You do not have to accept insurance
payments. But please do not accuse any other IBCLC of volunteering, not
being paid for their work, or not valuing the work that they do."

Second, there are many mothers who can afford help and expect to pay for
it, but will end up choosing the free option if they are not aware that
they might be getting better service if they actually paid for it.  I do
believe that it should be covered for all mothers, but not at the proposed
rates.  Further, it does not make sense for us to be providing services at
ridiculously low rates when the homes we are visiting are of friends with
our same level of education and who would NOT discount their professional
time for us and would NOT want to be treated like charity cases.

" Where is the evidence that says mothers will receive better care if they
pay out of pocket for it? I have seen no data saying that only poor quality
IBCLCs will accept insurance and that only good IBCLCs will refuse to do
so."

Interestingly, I was reading on a website for promoting breastfeeding in
pediatricians' offices that a pediatrician can bill a visit re lactation as
a regular visit!  Now, the amount a physician would receive for a 15 minute
visit (which visit would not give the mother the thorough lactation help
that she needed) would be more than an IBCLC would make at a 2 hour home
visit that included an hour of travel round-trip!  Why are we not asking
the insurance company's to be paid the same rate per each 15 minutes that a
pediatrician makes???!!!!!  We have MORE expertise than a pediatrician in
this area, it only makes sense that we should be paid at least what they
are currently paying physicians for this same service, because at least we
will be able to provide good lactation help for that same pay!
This is a second career for me.  I served as general counsel to a large
medical research foundation, so I obviously did not change professions to
get richer; I chose this profession because I am committed to helping
mothers and babies.  But I am not willing or able to be steam-rolled by
insurance companies.

"IBCLCs are not physician providers and will not be reimbursed at the same
rate as a physician."

If I may be of any help in the negotiating process, please let me know.
I know I am really preaching to the choir on this list, and I so appreciate
all of the people who have been working so hard to achieve a reimbursement
status for IBCLC's.  It is really now or never for establishing rates.  As
any lawyer or business person will tell you, there is NO negotiating UP.
 We really need to take all costs into account, and the experience that we
have is unique and we should be paid for it.  At the current proposed
rates, it is not worth it for us to get into our cars and risk being hit by
an uninsured motorist.  Our families would lose our  services and our
income, all while we were out practically volunteering for Aetna.  And
there wouldn't even be any worker's comp to cover anything.  And has anyone
on this list been able to get worthwhile disability insurance?  We
certainly could not even afford that insurance (many thousand of dollars
each year)  at Aetna's rates.
Is anyone paying for childcare while making home visits.  If we are working
at rates so low that we couldn't even pay for good childcare, let's think
what message we are sending about the value--or lack thereof--of our
profession.    We are not helping women and children by preventing women
with children whom they need to support from even working in our profession.
How can we help to make sure that the rates are fair and reasonable?  What
specific actions can we all take today to let the insurance companies know
that good lactation help cannot be made available for the rates they are
talking about.
Perhaps these numbers were somehow derived from a hospital LC's salary.
 And we all know that hospital LC's are underpaid.  Part of that is because
women want to help women and so we have worked for less than we deserve.
 But it is a terrible cycle.  The ones who really benefit are not the
mothers and the babies but the people who are truly making money at the
hospitals.  …. As far as salary formulas go, a law firm hiring an
attorney looks to make six times the attorney's salary.  That's right, six
times, and then 1/6 of it goes to the attorney.  Arguably, reimbursement
for an IBCLC in PP should be making six times what an LC at a hospital is
making.  Perhaps the number should be even higher because the equation is
figured by calculating what is needed to make up for overhead, expenses,
continuing education, equipment and supplies, health insurance expenses,
disability insurance, etc.
I welcome all thoughts on how we can best address this situation.

"You are welcome to negotiate with any insurer that you want. IBCLCs have
been complaining for many years about the lack of insurance reimbursement
for their services. Many mothers have not been able to secure the services
of an IBCLC because it was not covered by their insurance. Now that they
can, it is hoped that many IBCLCs will accept mothers with insurance so
that they too can receive the care that they need in order to continue
breastfeeding."

             ***********************************************

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