Abstract
TRICARE uses the military services' healthcare structure as the primary healthcare delivery system. This is referred to as the “direct care sector” and includes 59 military hospitals and 364 health clinics. This system is complemented by civilian care, referred to as the “private care sector.” This care is arranged for by TRICARE regional contractors both within the continental United States and overseas. There are over 380,000 TRICARE-recognized providers and 60,000 retail pharmacies within the private care sector.
It is important to note that TRICARE is not an insurance program as most Americans think of them; it is an entitlement program, authorized in statute. All of the benefits are defined by the law and detailed in the Code of Federal Regulations, with specifics explained in the TRICARE policy manual. So, unlike a commercial insurance company that provides benefits based on what is requested by the companies they serve and can modify the benefits by updating their policies, changes to TRICARE benefits require either a statutory or regulatory change. Additionally, when Congress passes laws that affect the insurance industry, they do not affect TRICARE unless the laws that govern TRICARE specifically are changed as well.
The MHS and TRICARE, in provision of care to all beneficiaries, together focus on the Quadruple Aim: Assuring readiness, improving population health, enhancing the patient experience, and responsibly managing cost. This concept mirrors the Institute for Healthcare Improvement's Triple Aim initiative with the additional emphasis on assuring the readiness of our troops.
TRICARE supports breastfeeding within the MHS population in various ways. In terms of policies, TRICARE provides coverage for hospital-grade electric breast pumps for mothers whose infants were born prematurely (prior to 36 weeks) while the infant is in the hospital in the immediate postpartum period. With a physician's order, in some cases, they may also be covered after these premature infants are discharged from the hospital. Breastfeeding guidance and counseling are covered when provided as part of the well-child care program and are provided by the attending pediatrician, family physician, pediatric nurse practitioner, or certified physician assistant. At this point in time, lactation consultants are not TRICARE-authorized providers, and TRICARE does not reimburse for their services.
Another way that TRICARE is supporting breastfeeding is by its promotion and support as one of the key preventive measures identified in the fight against childhood obesity. In August 2010, the Department of Defense formed a Childhood Obesity Working Group in response to the report released by the White House Childhood Obesity Task Force, “Solving the Problem of Childhood Obesity in a Generation.” 1 One of the tasks of the Working Group's MHS subcommittee was to develop an MHS-wide policy on the management and prevention of childhood obesity. The policy developed by the subcommittee, which is currently in formal coordination, places an emphasis on breastfeeding as a specific activity that can help prevent childhood obesity and, additionally, directs the Surgeons General of the military services to promote and support breastfeeding in military hospitals and clinics. The regional contractors that maintain the MHS private care sector are also encouraged to recruit and retain hospitals and providers who support breastfeeding.
The hospitals in the MHS follow many of the Ten Steps to Successful Breastfeeding outlined in the joint World Health Organization/UNICEF statement and used by the Baby-Friendly Hospital Initiative, 2 but there are two that have gone on to become Baby-Friendly designated, one each in the Army and Navy. Additional hospitals are in various stages of the designation process as well. Of the U.S. hospitals that are currently designated as Baby-Friendly, approximately 27% are hospitals that are part of the networks established by TRICARE's regional contractors.
Maternal/child health and perinatal issues have been recognized as a priority by senior leaders within the MHS. As such, an MHS Perinatal Advisory Group has been established that has tri-service representation from pediatrics and obstetrics as well as representatives from the Department of Defense's population health, quality assurance, and other relevant divisions. Methods to help improve breastfeeding support and to increase breastfeeding rates are regularly addressed by the group. In an effort to standardize practices across the MHS, the group is in the very early stages of drafting a statement emphasizing the activities that hospitals and clinics should do to promote and support breastfeeding. It will emphasize the Ten Steps to Successful Breastfeeding and the importance of prohibiting the provision of free formula or formula marketing materials to breastfeeding mothers. The Navy currently has a Perinatal Advisory Group in place, and the other services are considering forming them as a way to disseminate information down from the MHS group and to address perinatal issues specific to their hospitals and providers.
The importance of breastfeeding education is emphasized in the Veterans Administration/Department of Defense's Clinical Practice Guidelines for the Management of Pregnancy. 3 Because between 50% and 90% of mothers decide how they will feed their babies either before conceiving or very early in pregnancy, it is very important to begin breastfeeding education as early as possible once you know a woman is pregnant or trying to conceive. The guide specifies that breastfeeding education should be provided at every visit. In particular, it should be provided to all women at the first prenatal visit and should continue throughout all prenatal visits for women who express a desire to breastfeed or are undecided. In order to provide the best opportunity for education, when addressing breastfeeding at the first visit, it notes that the question asked should be, “What do you know about breastfeeding?” rather than “Do you plan on breast or bottle feeding?” This will allow even those women who at that stage plan on bottle feeding to become more educated on the benefits and importance of breastfeeding to their child's health. An additional point made in the Guidelines is that not only should the mother be educated, but the family and significant others should be included in breastfeeding education. By including those people who are important in the mother's life early on, this helps build an ongoing support network for the mother that will be in place during her pregnancy and after she gives birth. Having the support of the baby's father and others in the mother's life can be very important to successful breastfeeding.
TRICARE participates in some innovative partnerships to educate its pregnant beneficiaries on pregnancy, breastfeeding, and infant care topics. The Parent Review is a program that provides weekly e-mails to expectant and new parents from week 7 through week 40 of pregnancy and up until the child turns 3 years old. There is a breastfeeding module as part of the program that has three components: Research-based information, links to resources, and advice and encouragement from other moms. These educational e-mails are sent directly to the mother's personal e-mail, and enrollment is done at military obstetric or pediatric clinics where she or her child is being seen. Right now this program is available to patients at 30 military hospitals, and, in addition to the pregnancy and pediatric information, the e-mails also contain information specific to their hospital.
Another program that is being evaluated for use with our pregnant beneficiaries is text4baby, a program of the National Healthy Mothers, Healthy Babies Coalition (www.text4baby.org/). This service supports pregnant and new mothers by providing accurate, text-length health information and resources directly to their cell phones. It allows them to sign up directly by texting “BABY” or “BEBE” to 511411 and then entering their due date or their baby's birthday to register. The Department of Defense is investigating the possibility of working with the program to make sure the messages that TRICARE beneficiaries receive are relevant to their care in military hospitals.
Besides the work being done directly within the MHS, there are other programs within the Department of Defense that help promote breastfeeding. Military Community and Family Policy has purview over the Department of Defense child development centers located on military installations. They currently have a revised Department of Defense Instruction for Child Development Programs that is in the approval process. It incorporates standards from the new “Preventing Childhood Obesity in Early Care and Education Programs,” 4 which was developed by the American Academy of Pediatrics, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care and Early Education. These standards require that child care centers encourage support and facilitation of providing breastmilk to children. They should support mothers who want to nurse onsite during the day and promote the Academy of Breastfeeding Medicine's guidelines for breastmilk use and storage, which are also endorsed on the Centers for Disease Control and Prevention's website.
Additionally, all Department of Defense child development centers, which serve over 200,000 military children, have adopted Michelle Obama's “Let's Move” Child Care program (www.healthykidshealthyfuture.org). This program stresses addressing healthy behaviors in five areas—physical activity, screen time, food, beverages, and infant feeding—and provides a checklist for child care centers to follow. In the infant feeding section, it emphasizes that for mothers who want to continue breastfeeding, centers should provide their milk to their infants and welcome them to breastfeed during the child care day. All new parents should be supported in their infant feeding decisions.
In order to track the effectiveness of the MHS clinical perinatal programs, the new Joint Commission perinatal measures are being followed for all MHS hospitals. Certain measures that TRICARE tracks, deemed most important, are reported quarterly up to senior leadership, which includes the Deputy Director of TRICARE and the Service Surgeons General. Of the perinatal measures, the rate of exclusive breastfeeding on hospital discharge after delivery was chosen as one of the measures to be reported to senior leadership. For the most recent quarter, the average rate of exclusive breastfeeding on discharge across the MHS was 56%, which exceeds the national average by 16%. The service rates also exceeded the national average by 10–22%, although there was a wide range of rates across the MHS hospitals, from less than 20% to above 90%.
The Affordable Care Act does not cover mothers in the military, and thus the military services are not required to guarantee breastfeeding mothers adequate time to pump or a clean place to pump. The military services do have policies in place that encourage installation commands to provide these benefits, but they are not mandatory, and implementation is dependent on circumstances present on each installation, as well as on level of command support. Each military service is tasked with helping its supervisors learn how to best accommodate breastfeeding mothers in their own specific situations, which may be more difficult than those typically found in the civilian world.
The MHS and TRICARE have recognized the importance of increasing breastfeeding rates in military families, but there is still a lot of room for improvement. Continuing work, through the TRICARE Perinatal Advisory Group, on a breastfeeding statement that encourages MHS hospitals to adopt the Ten Steps to Successful Breastfeeding 2 and to ban the provision of free formula and formula marketing products to breastfeeding mothers would help standardize care throughout the MHS. Additionally, the reporting of The Joint Commission's exclusive breastfeeding measure to senior leadership within TRICARE and the military services will ensure that there is an emphasis on supporting breastfeeding and improving breastfeeding rates in TRICARE beneficiaries. TRICARE and the MHS continue to work on finding ways to support breastfeeding opportunities in military families.
Footnotes
Disclosure Statement
No competing financial interests exist.