Breastfeeding Medicine

Physicians blogging about breastfeeding

Breastfeeding Promotion and the Accountable Care Organization

with 5 comments

Health care is not only becoming unaffordable to the average American family; it is also becoming unaffordable to the Government of the United States.   As Medicare and Medicaid spending spiral farther and farther out of control, the federal deficit will inevitably reach the breaking point.   The cost of medical care will continue to rise with increasing provision of services, each one of which demands its own separate fee.  

The health care reform package proposes to solve this problem, at least in part, by changing the reimbursement paradigm: why not replace the volume-driven, fee-for-service model with a performance-driven model based on accountability of care? If the medical care system shifts its focus from numbers of patients treated to quality of care provided, the cost of care may return to sustainable levels.   The emphasis will shift from treatment of disease to disease prevention and health maintenance, an orientation which will hopefully save the health care system millions of dollars every year.  

One strategy for linking reimbursement to performance is the Accountable Care Organization (ACO).   The ACO involves a partnership of primary care physicians, specialists, and a hospital (or hospitals) serving a given community in a manner that ensures cost containment and achievement of defined standards of high-quality performance.   The Medicare savings realized from this approach will be shared with the ACO participants.   Because the principle objective will be maintaining health rather than treating disease, the physicians most likely to benefit from the ACO will be primary care practitioners.

For primary care, breastfeeding support constitutes the quintessential health maintenance and disease prevention intervention.   Billions of dollars could potentially be at stake.   Traditionally, medical practitioners may have eschewed breastfeeding support interventions because they tend to be labor intensive, which as a general rule are poorly reimbursed.   There is now an opportunity to turn this situation around entirely.   If breastfeeding-related metrics can be included in performance standards upon which Medicare bonuses are based, there could quite conceivably be a very substantial financial incentive for physicians to become far more actively involved in breastfeeding support in their respective practices.   The nature of primary care could be radically altered in a short period of time, and in a very favorable manner.

Our task now is to keep the importance of breastfeeding support front and center in the thinking of our policy makers.   We need to educate the leaders of our professional health societies and the Centers for Medicare and Medicaid Services (CMS) that breastfeeding must not be overlooked if we truly wish to reduce the cost of medical care and safeguard the health of American citizens in the years ahead.

Jerry Calnen, MD, is a pediatrician and is president of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by gcalnen

May 19, 2010 at 6:22 am

Posted in In the news, policy

5 Responses

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  1. Dear Dr. Calnen,
    It has occurred to me that no doctor feels “responsible” for my breastfeeding outcomes–for if, how long, and how exclusively I nurse my children (I have three). Not my ob/gyn, whose practice merely asked my intentions, and not my pediatrician, whom I see primarily after that critical experience in the hospital has passed. My understanding is that, while some data is gathered at my well-child check-ups (“Are you breastfeeding? How often does the baby nurse?”), it does not capture many specifics, and is not fed into a database or linked to my physicians. Do you think it would be possible, or desirable, to gather a standardized set of data–all the assistants at my pediatricians are walking around with laptops these days–and make it available to physicians, so that they could see a profile of their patients’ feeding practices? If physicians could see what their patients were doing, and if that were bundled into a score, would they be more motivated to improve that score, particularly when given concrete ways to do so by their professional organization? Could patients, eventually, have access to their physicians’ “scores” to help them decide which doctors to see? I do not work in the medical field and I don’t know whether these things might seem a burden or intrusive. To me it seems that some transparency, and patient access to a basic description of the data, might be helpful.
    Jenny Robinson

    Jennifer Robinson

    May 19, 2010 at 9:28 pm

    • Dear Ms. Robinson:
      You’ve asked a lot of great questions, and the ability to answer them may well have a tremendous impact on the quality of medical care delivered in the emerging age of value-based medical financing. Recently passed federal legislation calling for reimbursement based on performance touches on three domains of practice development: 1) Meaningful use of electronic health records (EHR), 2) the medical home, and 3) the accountable care organization. All three of these domains involve incorporation of performance metrics. The metrics should certainly include those related to the medical management of breastfeeding. But the domain of practice development most relevant to your comments is the first of these, the institution of meaningful use of EHR.
      The Centers for Medicare and Medicaid Management (CMS) requires that meaningful users meet the following criteria to qualify for HITECH incentive payments (
      1. Improve quality, safety, efficiency, care coordination, population and public health,
      2. Reduce health disparities,
      3. Engage patients and their families, and
      4. Ensure adequate privacy and security protections for personal health information.
      The boldfaced bullets are particularly pertinent to the concerns you have raised. Breastfeeding is a cornerstone to the provision of optimal health care, and this should be reflected in the first of the listed items. The public health implications are also substantial. Epidemiological studies of national breastfeeding trends conducted by the CDC, the FDA, and other organizations could be greatly improved and expanded if the needed data were to be made more readily accessible by EHR. Physicians would also be given a financial incentive under Meaningful Use to collaborate in the collection and reporting of such data.
      Specific objectives developed by CMS to achieve this goal include maintenance of a problem list, including relevant diagnostic code numbers; the reporting of ambulatory quality measures to CMS or to the States; the implementation of clinical support rules relevant to specialty or high clinical priority; and the exchange of key clinical information among providers of care. Medical management of breastfeeding by meaningful users could potentially be very positively impacted by the implementation of these objectives.
      Your suggestion of making medical care more transparent by providing patients with information about how well their physicians are supporting breastfeeding is anticipated in the third bullet above. Transparency can be promoted by reporting compliance with performance standards to CMS and the States, and by requiring meaningful users to provide an electronic copy of the medical record to patients on request. Together, these two objectives can lead to greater physician accountability in the area of breastfeeding support, if the appropriate metrics are put in place.
      So what we need to do is to engage whatever organizations of which we may be members to push for inclusion of breastfeeding support among the performance metrics currently under consideration. Health professionals can contact their respective societies. Parents can approach a variety of breastfeeding support organizations, such as La Leche League or the United States Breastfeeding Committee, or even such women’s organizations as the General Federation of Women’s Clubs. Each one of us can contact his or her congressional representative. It is imperative that policy makers, professional health societies, Medicare, and private insurers understand the central importance of breastfeeding before we go too far down the road to quality-driven medical care financing.

      Jerry Calnen, MD

      May 20, 2010 at 10:43 am

      • Sorry about the delay…I wanted to thank you for this thorough response! It is very helpful.

        Jennifer Robinson

        June 2, 2010 at 9:35 pm

  2. Jenny has a very good idea! I, like Jenny, don’t know if this will unnecessarily burden the medical staff, but I have found, when looking for a pediatrician, breastfeeding rates among their patients are not available. Or, for that matter, any other information to show how supportive they are of breastfeeding. Unless, of course, they have a website and specifically state their feelings towards breastfeeding. Which is rare.

    I know that doctors (as a whole) can be held accountable if a woman chooses not to breastfeed, but, in my experience, if women are told something by their, or their child’s, physician, they usually do that to some extent. Inadvertently, a physician with a high number or “score” of breastfeeding/breastfed patients, may reveal they are more supportive of breastfeeding.

    Now, the only ways that I would see this becoming a problem is of course, the burden on the staff and physicians. Also, statistically (at least in my area) lower income women are less likely to breastfeed. (I provide my services to WIC and see this all the time). Therefore, these women are more likely to be enrolled in the Medicaid program and the physicians who accept Medicaid may have lower scores. Or would this help those physicians to actually be more proactive with breastfeeding for these patients?

    Anyway, great idea Jenny. Whether it would be possible or fair, I don’t know. But I, for one, would like to know a physician’s position about breastfeeding before picking one. (Hence, the reason I still drive 40 miles one way, since moving, to my children’s pediatrician for fear of getting one that doesn’t support my parenting beliefs.)

    Thank you,
    Nicole Hedge

    Nicole Hedge

    May 20, 2010 at 9:40 am

    • *edit my second paragraph*
      I know that doctors (as a whole) can NOT be held accountable if a woman chooses not to breastfeed…

      Nicole Hedge

      May 24, 2010 at 7:53 pm

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