Dear all:

The discussion here is reminding me of the Brazil trip.  I and many other international nutrition experts were once "invited" to a trip to Brazil by the government of Brazil and a major pharmaceutical company.  The purpose was to develop policy for Brazil.  Our report was supposed to inform the Brazilian government.  All expenses were paid. We worked really hard in our working groups to understand the problems and make the best recommendations we could come up with.  We thought this was a great opportunity to bring an evidence base to the problems of micronutrient malnutrition.  Of course there were cynics about the fact that this was sponsored by the pharmaceutical industry. And I was not so naive as to suppose that there would not be some influence.  But I was naive to the extent of the influence they wielded. The pharmaceutical company threw out the report in its entirely and inserted their own report and used our names.  Since that experience, I have noticed that experts can retaliate and remove their names from documents and it has forever taught me that you really should look gift horses in the mouth. 

Now,  here is the issue.  We have an opportunity.  Insurance companies will be forced, by law, to cover certain services.  This is an unprecedented opportunity in that IF we band together we have some leverage.  It may not be much leverage, but it is some leverage.  In order to use this leverage we cannot be REACTIVE -- which would be to gratefully accept crumbs just because we are offered crumb that would leave us feable and malnourished, when we need a full and nourishing meal to remain healthy and thrive.  That is operating from a position of weakness.

Liz Kruger did NOT use this approach when she pushed through the Breastfeeding Bill of Rights.  She gets my "Wow she has OVARIES of TITANIUM" award.  I'd put her ovaries of titanium against BOTH presidential candidates.  The approach she used which I have seen DOES work in politics is log rolling.  She didn't mess around.  She wanted us to ask for the sky -- reach for the unattainable -- ask for as much or more than you could get.  Then, we you "concede" by taking less than your reach for the sky -- the "opponent" feels like they made a good deal.

Now, what is utterly disappointing in the discussions on Lactnet are the attacks on the fine women of New York City who work very hard, volunteer for our professional organization not just for a few years but some for DECADES, do LOTS of probono work, and stay in the trenches.  They may be "Lightweights" because they can't often afford to take the time off from their income earning activities to attend ILCA conferences, they may provide what some consider to be "concierge services" in the eyes of some which includes endless follow up via phone and email (which is INCLUDED in what some consider to be outrageous fees even though it barely pays the rent), they may be falsely accused of "causing women to formula feed" because they cannot see every single woman who needs help but if they can't see someone they refer to other lactation consultants who can see them but truthfully I've never known any mother who can't afford a visit to be turned away with no help, and they may be falsely accused of not being "dues paying members" but I can assure you that our members very often cough up the money to be ILCA members as well. I include these women in my "Wow they have ovaries of Titanium" award because they continue to persevere despite all the obstacles.  Just because many of my New York private practice colleagues have expressed concern doesn't mean these women are wimps or are criticizing the AMOUNT of work anyone else does.  At no point have I personally made that complaint nor have I heard any of my colleagues make that complaint.  I have complained about making unfair ASSUMPTIONS about the rates charged by private practice IBCLCs and I stand by that complaint.

Similarly, what is utterly disappointing in the discussions on Lactnet is justifying providing LESS care for mothers and babies.    Since when have we lost our mission to provide the BEST care for mothers and babies?  ALL mothers and babies?  Why would we not want the BEST possible assessments?   And seriously, why would we assume that breastfeeding problems are suddenly going to miraculously become less complex and the solutions less complicated if more woman have health insurance coverage?  If the problems are that easy then really why couldn't any number of other breastfeeding counselors, their own families or other health care practitioners handle the situation?  In New York City we are planning on RECRUITING doulas to our cause by working WITH doulas.  I'd be happy if the doulas did develop the skills to handle easy busy problems within the context of the mothers home because doulas spend far MORE time with mothers than the 2-3 hours that New York lactation consultants spend or the 1 hour that others spend.  So having doulas on our side can enhance the effectiveness of our recommendations because someone is there offering continuing support.

Moving back to Liz Kruger, what I propose is adopting her log rolling technique.  We should be OUTLINING the full meal, starting with mothers and babies -- what will keep their breastfeeding relationship well nourished and thriving -- not the crumbs that might keep them from outright starvation.  Similarly -- if you are in an airplane which necessitates the use of oxygen, the adult needs to put the oxygen mask on first because the adult might pass out before getting the mask on the child and both will die.  So, we need to nourish the lactation consultant as well. We should be OUTLINING the full meal that will also nourish the lactation consultant -- providing an adequate income so she can a) afford her rent, b) afford health insurance, c) put aside some money for retirement, and d) have a residual for continuing education.   Then we MUST ALSO ask for desert.  We can jettison desert and make Aetna feel good.

Then we should look toward the various models that can be put together to meet those needs.  For instance, not every mother really needs a home visit, but as Judy and outlined some mothers have sensitive situations that require PRIVACY, other mothers have mobility issues where they canNOT leave their home.  Desert would be having home visits available to all women.  My sister had a normal vaginal delivery and her insurance COVERED the home visit.  The visit from the nurse prevented my mother and my brother in law from sticking a bottle of sugar water in my niece's mouth.  So even for uncomplicated deliveries with no serious problems, the home visit can prevent unnecessary risk from unnecessary use of formula.  The nourishing meal would be keeping the home visit for those women who we feel really need it and can't get those services in a group or office setting.  

Then I do think we need to leave room for more services for complex and complicated cases.   Aren't we the professionals who have the experience and skills to handle these cases?  And don't you really think that peer support and counselors can handle the easy breezy stuff?  I think we absolutely need to outline what constitutes the types of cases that need more time to resolve.  For instance, the number visits allowed by insurance companies for someone who is suicidal is different from the number of visits allowed for someone who is experiencing temporary job insecurity.  We need to define the number of hours required for certain conditions.  If you have a client who requires pumping -- you absolutely should spend the time to watch the pumping, demonstrate massage techniques and observe the mother applying those techniques and lay out a plan for mom to not go stark raving bonkers while pumping.  If you have a baby that requires supplementing and you need to track progress you absolutely should be able to spend the time to do a test weighing.  If you have a mother who has insufficient glandular tissue you canNOT really help her process that problem in a group setting.  You either MUST do a home visit, have her stay after the group and discuss it with in private or less desirably discuss it with phone follow up.  Phone follow up is not nearly as good because it is NOT face to face.  We should outline which services fall into the complex and complicated, how long it takes to accomplish these services and describe the value of providing these services.  

I agree with others on hiring a lawyer knowledgeable in health insurance negotiations to be key.  I think it is utterly naive to assume that Aetna is going to miraculously provide us with what we need.  I don't think it is wise to just sit back and passively let them tell us what they are going to cover and then REACTIVELY try to better our position after its too late. I think it is better to go in PREPARED. With a smile, we can present a whole array of options and questions and outlines and ideas for how we can save them money.

And everyone should know that Aetna is NOTORIOUS in New York State among other health care providers for their low reimbursement rates.  They have had to raise their rates when they couldn't get sufficient providers to be on their panels. This may be one potential point of negotiation.

Sincerely, 
Susan E. Burger

PS.  Light weights can win out over heavy weights using technique.  I learned this by a happy accident in jiu jitsu.  I'm a newbie and abysmal, but merely by chance I managed to end up in side-control when "rolling" with one of the men.  He outwieghed by two or three times.  By that happy accident of ending up in side-control I had him pinned to the floor, he was completely unable to move.  Seriously.  He had to tap out and give up. 

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