Abstract
Introduction
Improving breastfeeding
For a payer of healthcare benefits, one of the three or four major cost areas is maternity and newborn care, and in Medicaid it is the highest cost area. Maternity and newborn care and outcomes are also one of the areas we all consider absolutely critical in the healthcare system. To meet the needs of the payers of healthcare benefits, both employers and the government, maternity support services are provided commonly within the health management and health insurance industries, including OptumHealth.
Support for breastfeeding with mothers
The maternity management programs within OptumHealth are managed with clinical staff that is experienced in maternity care—both obstetrical experienced nurses, many of whom also have neonatal experience, and Board-certified obstetricians/gynecologists, including a maternal–fetal medicine specialist. In addition, one of the nurse directors within operations is a Past President of International Lactation Consultant Association and works to increase staff knowledge regarding breastfeeding issues and improve education of the consumer. During the assessment of pregnant consumers, breastfeeding is always discussed and encouraged. The consumer is educated on breastfeeding and the benefits of breastfeeding.
OptumHealth is attentive to World Health Organization guidelines regarding marketing of breastmilk substitutes and does not promote formula or give out samples, coupons, or advertising of infant formula.
OptumHealth does perform high-risk obstetrical case management on a significant number of Medicaid members. For members who may be eligible, OptumHealth refers the consumer to the Women, Infants, and Children (WIC) Program, which is dedicated to “health of low-income women, infants, and children up to age 5 who are at nutrition risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care.” 4 As was clearly presented at the Third Annual Summit on Breastfeeding, WIC promotes breastfeeding and works with low-income families to facilitate and encourage breastfeeding among the clients it serves.
Breast pump coverage does vary significantly even in the Medicaid population. Breast pump coverage by each state may be and generally is different. OptumHealth will work with the consumer to obtain a breast pump to meet her needs and when necessary refers her to resources in the community, when that is the best option—such as referrals to WIC.
Breastfeeding—working with physicians and hospitals
As part of the high-risk obstetrical case management and the neonatal case management, the clinical staff of the healthcare company will interact with the clinical staff at the hospital or doctor's office, including with the physicians. Although opportunities for improving care and outcomes may be present anywhere, neonatologists and neonatal staff generally have a good knowledge of the benefits of breastfeeding and why it is important to support and encourage the mothers in breastfeeding. Involvement of a lactation consultant is still critical.
There is an opportunity to improve care for the breastfeeding mothers among obstetricians. Obstetrician interactions with neonatologists or pediatricians taking care of the baby are extremely variable and many times may be infrequent or limited. Obstetricians may not know the difficulties encountered with the baby or see the advantages to breastfeeding over formula feeding—they are not taking care of the baby and do not typically receive updates on the baby.
The obstetricians generally will recommend breastfeeding to their mothers and will know the basic advantages of breastfeeding for mother and baby. Knowledge of more detailed advantages of breastfeeding or comparison to formula feeding may be an opportunity for an obstetrician to improve their ability to encourage breastfeeding in their patients. In addition, training in lactation support for the mother is not part of the standard training for obstetricians.
Specific advantages of breastfeeding versus use of formula are many. Some of the specific advantages of exclusive breastfeeding include:
• Diarrhea—reported up to 53% reduction. This is a common reason a child may be brought to the pediatrician and/or the emergency room/urgent care for evaluation.
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• Hospitalizations for lower respiratory tract infections in the first year of life—reported up to 72% reduction (odds ratio=0.28). This is another very common illness in infants in the first year of life (R. Lawrence. Human Milk and Protection from Infection. Oral presentation given at the 2011 Tennessee Initiative for Perinatal Quality Care [TIPQC] Annual Meeting). • Late-onset sepsis in very low birth weight infants—73% reduction (odds ratio=0.27)
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• Necrotizing enterocolitis in premature infants—83% reduction
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• Reduction in sudden infant death syndrome (R. Lawrence. Human Milk and Protection from Infection. Oral presentation given at the 2011 TIPQC Annual Meeting).
Participation in Collaboratives
Various healthcare companies will participate in collaboratives to improve the care and outcomes to its members, including OptumHealth. Currently, OptumHealth is participating on or working with collaboratives in four states: Ohio, Illinois, Tennessee, and Texas. As an active participant, OptumHealth will share best practices among the collaboratives where this is possible, in an attempt to improve care across many markets.
One of the best practices that has been shared with other collaboratives is from the Collaborative in Tennessee, the TIPQC. The mission of TIPQC is “to improve health outcomes for mothers and infants in Tennessee by engaging key stakeholders in a perinatal quality collaborative that will identify opportunities to optimize birth outcomes and implement data-driven provider- and community-based performance improvement initiatives.” 8 One of the ongoing projects of TIPQC is “Human Milk for the NICU [Neonatal Intensive Care Unit] Infant,” initiated in March 2009. The project manager is Ramasubbareddy Dhanireddy, M.D. When the project started, from data in the most recent year 2008, less than 20% of very low birth weight infants in Tennessee were discharged from the NICU feeding with human breast milk. Dr. Reddy and his project team were able to increase the rate of human breast milk usage from less than 20% to greater than 75% using evidence-based practices incorporated into this project's tool kit. This information was shared with the Ohio Collaborative.
OptumHealth also reaches out to key specialty societies, such as the American Congress of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, on an ongoing basis to discuss current issues or possible areas of opportunity to improve care and outcomes—such as increasing the use of 17α-hydroxyprogesterone or reduction in <39-week elective admissions for delivery.
Payers as Players
One of the key questions from the Academy of Breastfeeding Medicine (ABM) and the participants at the Third Annual Summit on Breastfeeding was “How can we increase coverage and support for breastfeeding support for the patients?” Critical to addressing this question is to understand “Who is the ‘Payer’?” In healthcare the “Payer” is the entity that purchases the health benefits. The purchaser of the health benefits determine which benefits they want to cover. The insurance company's role is to tell that Payer how much those benefits will cost—that is, what is the premium required to cover the cost of those benefits that the payer has decided to cover or is considering if it wants to cover in the companies health benefit plan.
For the fully insured business of an insurance company, the insurance company is taking the risks if the cost of the benefits is more than anticipated and the Payer has a fixed premium, regardless of the cost associated. Fully insured business may be as low as 20% of total business for a healthcare company.
The majority of business for a major insurance company is self-funded, where the company (or government) paying for the health benefits takes its own risk and therefore the company (or government) will benefit if the cost of medical care is lower than anticipated. The payers frequently write their own health benefit language and have the insurance company administer for a fixed fee.
If we want to increase the coverage for breastfeeding support for the patients, we have to make the business case to the Payer—what is the cost for the benefit and will having that benefit save money for the Payer or be an expense, and if an expense, how much? We strongly believe supporting and increasing breastfeeding among mothers will reduce overall costs. We, as clinicians, have not made the business case to the Payer.
Another, perhaps obvious, barrier to coverage directly related to human breastmilk is that food is not considered a covered benefit for health benefits, typically. Even enteral feeds are generally not a covered benefit. This will need to be considered when one makes the business case for the Payer.
From the information presented by the speakers at this Third Annual Summit on Breastfeeding, a strong business case can be developed that would address the financial needs and concerns of the Payer. The benefits presented with the reduction in the occurrence of several high-impact adverse outcomes indicate there would be an associated reduction in dollar costs. Developing an effective business case and improving on it via presentations to several major Payers is a challenge both to the ABM leadership and to us all.
Footnotes
Disclosure Statement
M.H. is a Senior National Medical Director with OptumHealth, which provides health management services directly to health plans, insurance companies, and employers and for Medicare- and Medicaid-managed care plans. OptumHealth is one of the business segments within Optum. Optum serves the entire health system, including nearly 250,000 health professionals and physician practices, 6,200 hospitals and facilities, more than 270 state and federal government agencies, over 2,000 health plans, two of every five FORTUNE 500 employers, more than 400 global life sciences companies, and one in every five U.S. consumers.