What I have been surprised by in this discussion are the dismissive comments on the part of some of those involved with USLCA. In fact, every time this issue comes up, our legitimate questions are treated with this kind of disregard. 


This is not a brave new world we are discussing. The experiences of practitioners who have worked similarly to us are instructive. Homeopaths, naturopaths and nutritionists come to mind. For each, an intake appt is generally about 2 hours. Many insurance companies claim to cover the services, but look at the numbers who actually participate. Is this because they dont care that people cannot afford their care? In my 25 years of using such services, that has not been my experience. The reality, though is that they simply cannot afford to take insurance. They spend far too much time with their patients to accept insurance reimbursement for less than half that time. 


I want to address several of the issues raised in the threads here. 


Marsha wrote (in response to Susan):

"No one says that you have to give up
charging a fee for your services that you set. This does however impact
mothers who cannot afford to pay out of pocket to see private IBCLCs in
Manhattan. This creates a disparity and lack of access to IBCLCs in the
mothers who cannot afford to pay you. If these mothers cannot obtain the
level of care that they need they will simply wean babies onto formula."
I cannot imagine another profession in which providers are guilted into making the choice to risk the well-being of their own families like this. It strikes me as an interesting feminist conundrum. As a single mother with no medical insurance, I am the last person to be insensitive as to the costs of health care. But, I am not impressed with such an argument. We should be advocating for both the needs of mothers/babies and our own families, not our clients over our families. 
How many articles have been published about HCPs who are torn between paying their bills and spending enough time with their patients? We have seen it in every health care profession, so why would we clamor to join their ranks?

"IBCLCs can continue to see fee for service clients as well as accept
insurance reimbursement. The two can be done together."
If all insurance companies are mandated to provide this coverage, who is going to expect to pay out of pocket? 
Susan noted:
"In Manhattan I know of no IBCLC who is making tons of money and many very
competent IBCLCs who are struggling to make an adequate income when they
are relying predominantly on their income as an IBCLC.  The average rate
for a home visit is $250 per VISIT and a visit usually lasts between 90
minutes and 3 hours for most IBCLCs I know.  Transporation time is about
1-2 hours for each and every client seen."

Marsha responded:
"$250 is a lot of money for many mothers to have to pay for lactation
services. Some IBCLCs can and will continue to see mothers who pay upfront
as well as mothers with insurance coverage. What happens to the mothers who
cannot afford the $250? With insurance coverage, at least they then have an
opportunity to receive the same type of care that more wealthy clients
enjoy."

So, we are to be told that we are overcharging now? Yes, it may be a lot for some mothers who pay, but it is not a lot to earn for an avg 3.5 hours of time in a city with such a high cost of living. I just paid a therapist in NYC $200 for 45 minutes to see my daughter. She sits in her office and sees a lot more clients in one day than an LC could manage, given the time constraints. She does take insurance (after we met the deductible), but her co-pay of $50 is as much as USLCA is suggesting an IBCLC should reasonably earn for a visit (given that visits take approx two hours and not one).


There is a very misleading dialogue going on here that really disturbs me. The implication is that mothers will be adequately supported in one hour visits. A potentially valid argument I have been offered is that if women can be reimbursed, they won't delay getting care and their problems will be less complex. I would like to see the proof in this before we are tied down to this reimbursement structure. I am not buying it, bc the causes for breastfeeding problems are not going away: medicalized birth, including excessive numbers of induced/premature births, an impossible family non-leave public policy and a bottle-feeding culture to name a few. 


This response from Marsha to Susan really confounds me:


Susan:
On another discussion forum Judy mentioned that Aetna will reimburse at less than half of what an IBCLC in Manhattan would make and that the time of a visit is considered to be 60 minutes.  Personally, I do not see how anyone can competently and thoroughly assess an mother baby infant in a mere 60 minutes, let alone including transportation time.

Marsha:
"Many of us have certainly had to learn how to provide care in short time periods. You do not have to give up charging $250 to fee for service clients. You can also see Aetna patients who have no other manner of securing IBCLC services."



Who exactly are the "fee for service" clients supposed to be when insurance providers are all mandated to cover these services? And the comment that "Many of us have certainly had to learn how to provide care in short time periods"  is stunning to me. So, is the implication that the more efficient LCs will do just fine? Is the implication that we will somehow weed out the less efficient time-wasters? Isn't that how other HCPs have been treated? I am just boggled by the idea that we should give up the very foundation of what makes us good at what we do. Again, no new territory here--I am sure every other profession that has had to streamline patient care tried to hold onto excellent care as well--until they were compelled to " learn how to provide care in short time periods.". 



Susan:
If Aetna manages to get IBCLCs to be on their provider panels it is likely
to be those who practice infrequently.  I know some hospital IBCLCs who
dabble in seeing clients on the side who might be able to afford putting
themselves on a provider panel.  While there are some terrific hospital
IBCLCs who practice privately, I also have had to follow up after SOME
hospital IBCLCs who really have minimal experience with older babies and do
not even provide insurance forms, care plans or receipts.  So, what I think
will happen is that those who dabble to augment their income in the
hospital and those who dabble because this is a hobby and not a profession
will be the ones who can afford to be on the provider panels.  They will
then outcompete those who really rely on the IBCLC as a profession and for
our income. The quality of care will also drop.

Marsha:
" I fail to see any relevance in this paragraph. You are making pretty
gross assumptions that have certainly not been shown anywhere to be true.
Based on the number of interested high power LCs that attended the
licensure and reimbursement special interest group at the ILCA conference,
I would have to disagree with your conclusions."



Can I repeat this again so that I can take it in? 


"Based on the number of interested high power LCs that attended the licensure and reimbursement special interest group at the ILCA conference,..."


So, are these "high-powered IBCLCs" supposed to know what is best for the rest of us....I would have to think..low-powered IBCLCs? Frankly, I think this sentence speaks volumes about what I have always said about ILCA--they have never listened to their membership. 





In addition, in response to comments by Judy Gotkowski:


Judy, you state that travel cannot be included in reimbursement, but there are certainly covered care providers who do home visits, such as VNA. Are you suggesting they are only paid for their time in the patient's homes?

Further, Judy wrote:


"The  IBCLCs will be providing "preventive counseling"..." 
and Judy L replies:
~~~ See now perhaps we are getting somewhere. I read "preventative  
counseling" as a pro-active session designed to provide information and some  basic 
problem-solving strategies. That does sound like something that would take  
less time and require simpler documentation. What I do, and what many 
IBCLCs do  is more like "crisis intervention" and feels a lot like trying to stop 
a train  that has gone in completely the wrong direction  or derailed  
completely,  for dyads for whom many things have not been prevented from  going 
off track, even sometimes have gone horribly wrong.  Many dyads are  
"crashing or have crashed" . This is very time-consuming and ultra-detailed  
consulting. I don't know any other health professional who goes to the home of  
the affected family and spends that kind of time and energy, which is then 
also  followed by intense and regular phone and/or email contact after the  
consultation ( the vast majority of which asks for no further fee despite many  
extra hours). The phrase "preventative counseling" seems to  have little to 
do with how most private practice IBCLCs work. "
Exactly. Although, frankly, my preventive care visit with moms also takes 2-3 hours, bc it takes that long to help them come to understand the physiologic norm, and what it is they are really trying to preserve during and after birth. 
Once, after a I told a mom my fee for the intake is $175, she asked if I could do an intake half as long for half the fee. Looks like she was seeing into the future of our profession. 
Judy: 
"In surveys of IBCLCs distributed in 2008 by USLCA, and distributed in 2011 by IBLCE, the majority of respondents indicated that their wages were between $25 and $39 per hour. The example of fees for services associated with the maximum preventive counseling 60 minute visit yielded reimbursement amounts between $93 and $123 among 4 states that were checked in the east, central and western parts of the US. Assuming 1-2 hours of consult time and the additional administrative and documentation time of 1 hour these fees seem within the range of usual income for IBCLCs an will be an increase for many. :"


I agree with Susan--this assessment is invalid if it merges the hourly rate of hospital/clinic-based IBCLCs and PP-IBCLCs, who pay our own medical insurance, education expenses, travel, and retirement. If we have an office (I had my own office in CT for years), we have that overhead as well. We also have no job security, unlike employed IBCLCs. There is simply no comparison. As always, the IBCLCs who provide the bulk of care to breastfeeding families beyond the first few days are all but shut-out. 

Judy:
"It is our hope that more IBCLCs will be able to gain enough clients to support opening private practice offices or will have more opportunities to be employed in clinics or physician practices since this coverage is available. Additionally, we are in the process of working on the option for lactation visits to be done electronically for locations that are remote or distant from any IBCLC providers for Aetna. While I know it is not ideal, if a mother and baby can be visualized via Skype and the lactation consultant can demonstrate techniques with a doll model this may help many mothers and IBCLCs to connect. ":

I had a private practice office. All of my intake appts took about 2 hours. An office does not mean I get to provide half the needed care. Now I work 90% by Skype. My intakes are still approx 2 hours and I am not interested in being paid $50 an hour for that time, which of course takes no account of all the time it takes to do paperwork or answer emails before and after the consult.  I don't need to work harder in my life, really, I assure you I don't. 

Jennifer Tow, IBCLC, CT, USA & Paris 




 

 

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