Abstract
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ACOs are “networks of physicians or physicians, hospitals and other providers that take both clinical and financial responsibility for the care of patients.” 1 The specific providers enrolled in a maternal–infant–young child ACO would include practices in obstetrics, pediatrics, family medicine, and at least one hospital providing maternity services. Such an ACO could provide the coordination and continuity of care required for the management of breastfeeding, as well as a variety of relational issues impacting both mother and child, such as maternal depression, and family socioeconomic issues such as substance abuse, homelessness, food insecurity, and poverty.
With respect to breastfeeding management, a core lactation team within the ACO consisting of a medical director, lactation consultants, peer counselors, and an administrative staff would be responsible for the entire continuum of care, including prenatal, maternity, and postnatal care. This team would constitute the “captain of the ship” whose responsibility would be to follow the breastfeeding family from the earliest prenatal visit until breastfeeding is terminated or upon the arrival of the infant's first birthday, whichever comes first. The care of the dyad would thus be consistent and seamless, involving the same team throughout the entire cycle of care. Close and ongoing communication with, and collaboration between, the core lactation team and the medical providers will ensure that all members involved in the care of the family will have access to the medical information necessary to make informed decisions.
Unlike ACO's serving adult populations, the pediatric ACO serves a population of mostly healthy individuals. The adult ACO, therefore, focuses primarily on management of chronic diseases, whereas the pediatric ACO focuses on optimizing health: “When caring for children, wellness and prevention programs… become vitally important. By investing in these strategies early in life, healthcare organizations may also help to reduce some of the disease burden in their communities… as these patients grow into adulthood.” 2 As a “wellness and prevention program,” breastfeeding management is just as vital to maternal and childhood health as nutrition, immunizations, safety, or mental health.
Cost savings could be realized by reimbursement of services on an “episode of care” basis, 3 the episode defined as the time of the first prenatal visit until the first birthday of the infant or the termination of breastfeeding. Such a compensation model, as well as “bundled payments,” would help to keep down the cost inherent in a “fee for service” model and would meet the expectations on the part of third party payers that providers assume a measure of financial risk. In addition, bundled payments would give the lactation center some flexibility in determining what additional services a dyad may require that might not otherwise be covered in a fee-for-service arrangement. 4
Financial incentives would be provided to the ACO for meeting certain breastfeeding benchmarks, thus helping to ensure quality of care. Disincentives may also be utilized to prevent such “sentinel events” 5 as hypernatremic dehydration and starvation jaundice.
To be sustainable, any effort to overcome the fragmentation of care in breastfeeding management must also overcome the fragmentation involved in reimbursement of services. An ACO is designed to meet just such an exigency.