Dear all:

Back in my public health days, often the determination of costs for
services was based on analyses of "willingness to pay".  This could vary
widely from culture to culture.  Sometimes free services were found to not
be as valued by the target population as services that charged a nominal
fee.

I think it is important to realize that running groups are not always
necessarily free - there are the costs of the facility - rental fees,
utilities, etc, and the salary costs of the person running the group.

When I worked at Elizabeth Seton before it closed, they took a fair number
of Medicaid clients.  These clients were covered for as many lactation
consultant visits as needed.  Our "Mommy and Me" groups and
our "Breastfeeding Support Groups" were on a suggested donation basis which
worked quite well.  Suggested donations were $5 - $10 and we generally
covered the salary  costs.  Women who didn't contribute often just forgot
to bring money along.  There didn't seem to be any correlation between
income and donations.

In fact, I have noticed the same phenomenon with my private clients -
income does not seem to bear any relationship to their perception of the
fee.  For those without insurance or on Medicaid, I always tell them what
my fees are, what Elizabeth Seton used to get from Medicaid when I had a
mechanism for Medicaid billing and then ask them to pay what they feel
comfortable paying.  The range that they have decided to pay is $60-$100.

Here in Manhattan, I actually have discovered that there is a small
subsegment of my medicaid clients who are middle class, but opt to use
medicaid for insurance - living in gorgeous huge apartments that they
probably bought at a very low price and renovated themselves.  Sort of
gives me pause when we write our checks for our health insurance which is
higher than our rent because both my husband and I are self-employed and we
live in a rent stabilized dilapidated pre WWI building.

Now that the educators from Elizabeth Seton have joined Realbirth, there is
more of an incentive to make sure it works financially - so our fees for
groups are $10.  I haven't heard any complaints.

So, from my experience, both the suggested donation basis and the flat
nominal fee work well. Perhaps a flat fee with a sliding scale for
extremely destitute clients would work as well and help out the truly
destitute clients.

Best, Susan Burger

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