Health care reform, bright futures, and the community lactation center

Perhaps a little belatedly, an epiphany has dawned upon policy makers in the field of health care financing: it makes far more sense to prevent disease than to treat it. For one thing, the outcome of even the most successful treatment interventions may still be far less than optimal. A child may be successfully cured of bacterial meningitis, for example, but be left with severe cognitive impairment, profound sensorineural hearing loss, or intractable seizures.

For another, an ounce of prevention is indeed worth a pound of cure. A child who sustains an epidural hematoma can be saved with prompt diagnosis and treatment. The outcome is far better than it was only a few decades ago, when imaging and surgical techniques were primitive in comparison to what is available today. Such intervention, however, is quite costly. There are the costs associated with CT scanning, surgical evacuation, ICU care, medication, and rehabilitation. On the other hand, how much does a bicycle helmet cost?

The Patient Protection and Affordable Care Act is largely based on the very sound belief that preventive care can save the health care system enough money to help ensure its solvency. It is for this reason that the Act requires that all preventive care measures listed in the publication, Bright Futures, be covered by public and private insurance plans without additional out-of-pocket expenses accruing to the health care consumer.

So what does Bright Futures¹ say about breastfeeding?

A systematic review suggests that physician counseling can be effective as one part of a larger intervention to increase breastfeeding rates. ² The USPSTF found fair evidence that programs that combine breastfeeding education with behaviorally oriented counseling are associated with increased rates of breastfeeding initiation and its continuation for up to 3 months, although effects beyond 3 months are uncertain. Effective programs generally involved at least 1 extended session, followed structured protocols, and included practical, behavioral skills training and problem solving, in addition to didactic instruction.³

Section 2713 of the Patient Protection and Affordable Care Act (“Coverage of Preventive Health Services”) can provide health care providers with the financial backing they need to create neighborhood lactation consultation centers. Physician counseling would constitute an integral part of such a center, but it would only be one part (“the larger intervention”). The clear implication is that medical practices would have to work in collaboration with community resources to promote and support breastfeeding, a classic application of the “medical home” concept. The lactation center would involve medical supervision (and, when necessary, intervention), along with breastfeeding education and counseling.

Before the Patient Protection and Affordable Care Act, insurance coverage would typically be available only if a provider was treating a diagnosable problem: mastitis, poor weight gain, or jaundice, for example. This system of reimbursement not only severely restricted coverage of services, but also succeeded only in contributing to the medicalization of breastfeeding support. Hopefully, with the passage of the Patient Protection and Affordable Care Act, coverage should be available to assist breastfeeding dyads before any serious problems develop.

The community lactation center concept dovetails well with other innovations in value-based health care financing. For example, in order to qualify as an Accountable Care Organization, a medical group must develop programs that ensure delivery of a high quality of care while at the same time saving health care dollars. A lactation center would effectively meet both of those requirements. Computerized data generated from the clinical operations of a lactation center could contribute to improved quality of patient care, thereby assisting providers in their efforts to qualify as “meaningful users” of electronic health records. Finally, CMS-backed medical homes would have similar financial incentives for creating community lactation centers.

The development of the concept of a community-based lactation center will require the close collaboration of a substantial number of private and public sector organizations dedicated to breastfeeding promotion and support. No other organization is more ideally positioned to accept this challenge than the United States Breastfeeding Committee.

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

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

1. Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics, page 243.
2. Dyson L, McCormick F, Renfrew M. Interventions for promoting the initiation of breastfeeding. Cochrane Database Syst Rev. 2005;(2)CD001688.
3. US Preventive Services Task Force. Behavioral interventions to Promote Breastfeeding: Recommendations and Rationale. Rockville, MD: Agency for Healthcare Research and Quality; 2003.