United States Lactation Consultant Association: Supporting Breastfeeding for Better Health Outcomes

1. United States Lactation Consultant AssociationPursuing The Surgeon General's Call to Action to Support Breastfeeding

2. Who We Are and What is Our Goal?

3. IBCLC Professionals • 27 year old profession • Stand alone or added to existing profession • 12,969 IBCLCs in the United States • Work in a variety of clinical, governmental, and research areas

4. Professional Standards for IBCLCs • Clinical Competencies for IBCLC Practice • Code of Conduct for IBCLCs • Documentation Guidelines • IBLCE Disciplinary Procedures • Scope of Practice • Standards of Practice • Available at • http://www.iblce.org/resources

5. IBCLC Qualifications • 500-1000 clinical experience hours • 90 hours of didactic education • 8 college level health science courses • 6 health related continuing education courses • Pass an independent, criterion-referenced exam • Must recertify every 5 years by continuing education or exam

6. If 90% of US families could comply with medical recommendations to breastfeed exclusively for 6 months, the United States would save $13 billion per year and prevent an excess 911 deaths, nearly all of which would be in infants ($10.5 billion and 741 deaths at 80% compliance).

7. Breastfeeding is Primary Health Care Prevention • Institute of Medicine Consensus Report Clinical Preventive Services for Women: Closing the Gaps • US DHHS National Prevention Strategy • United States Preventive Services Task Force recommends “interventions during pregnancy and after birth to promote and support breastfeeding”

8. A National Health Priority • Healthy People 2020 • CDC Breastfeeding Report Cardand Maternity Practices in Infant Nutrition and Care Survey • White House Task Force on Childhood Obesity Report to the President • USDA WIC Food Packages • IRS “breast pumps and other nursing supplies could qualify for tax breaks” • HRSA Office of Women’s Health Business Case for Breastfeeding • Affordable Care Act

9. Policy Support for Breastfeeding • Joint Commission Perinatal Core Measures • NICHQ Best Fed Beginnings • Bright Futures, an initiative of the Maternal and Child Health Bureau / AAP adopted United States Preventive Services Task Force breastfeeding recommendations

10. 77% of Mothers Choose to Breastfeed • “The vast majority of first-time mothers have early breastfeeding problems coupled with low confidence.” • “They do not receive adequate assistance in the primary care setting resulting in early formula use and reducing breastfeeding duration and exclusivity.”

11. Low Duration Rates: Evidence of Need for Breastfeeding Support mothers goal

12. Access to IBCLC Services Can Improve Breastfeeding Incidence and Duration “International Board Certified Lactation Consultants (IBCLCs) are the only health care professionals certified in lactation care. They have specific clinical expertise and training in the clinical management of complex problems with lactation.” Surgeon General CTA 2011

13. USLCA Recommended Staffing Ratios • 1.9 FTE per 1000 births for Level III hospitals • 1.6 FTE per 1000 births for Level II hospitals • 1.3 FTE per 1000 births for Level I hospitals Multiply the FTEs calculated times the percentage of breastfeeding mothers in that facility Comprehensive lactation services require additional calculations 1 IBCLC FTE per 235 infant transfers-in per year should be added to the total number of FTEs Adopted by AWHONN 2010

14. Limited Access to Care • Professional Support Needed: 8.6 IBCLCs per 1,000 live births, SGCTA (2011) • Best measure currently available • Includes IBCLCs in all settings • Available 2.67 IBCLCs per 1000 live births

15. Inadequate Breastfeeding Assistance in Primary Care Where It Is Most Needed

16. 2011 Survey on the Recognition of IBCLCs by Third Party Payers • Survey sent through IBLCE to all IBCLCs in the United States via email • Response rate: 29% (n=2637) or 1 out of 4 IBCLCs in the United States (in 2011) • Research Question: • What are IBCLCs currently doing to facilitate their clients being reimbursed for lactation consult services? And how well is it working?

17. 2011 IBCLC Demographics Based on Survey Responses • 87 % were non-Hispanic White • 1.6 % were non-Hispanic Black • 67 % were 40-59 years old • 41 % had been certified for <5 years • 41% had been certified for 6-15 years • Average pay per hour $36.77 / hour SD $14.95 • Half worked part-time or per diem • One third receive differential pay for their IBCLC Certification

18. Work Site of Survey Respondents

19. What is your official title in your current position?

20. What reimbursement strategy do you or your facility use for third party reimbursement?

21. Submission Rate & Recognition Rate

22. Submission & Recognition by Work Site, Job Classification, and Reimbursement Strategy

23. Summary of Survey Results • IBCLCs don’t know about reimbursement practices • 57% recognition and 41% submission • 1/3 of IBCLC consults are not communicated to insurance • IBCLC consults are inconsistently recognized by insurance • Private community clinics are most likely to submit insurance claims and receive recognition • IBCLCs in positions that recognize their IBCLC status are more likely to submit claims to insurance companies than IBCLCs working as nurses • Another medical license on the billing form is more likely to be recognized by insurance companies than IBCLC credentials

24. Other Health Care Providers have Limited Ability to Support Breastfeeding • Includes all disciplines • Insufficient formal training in lactation • Qualified to make preliminary assessments and treat routine problems • Physicians feel uncomfortable/ inadequately prepared to support breastfeeding • Requires long term, time intensive strategies prohibited by health resource constraints10 11 12 13 14 15

25. The Solution: USLCA Recommends • Recognition of the IBCLC certification as the preferred provider of lactation care and services • Delineation of IBCLC-provided lactation services as distinct from other health care services in the medical system • “Credentialing of IBCLCs” in order to standardize proven qualifications, identify sound practice strategies, and maintain appropriate oversight • Reimbursement of skilled breastfeeding support provided by the IBCLC

26. Advocacy Required • At least now everyone knows benefits of breastfeeding • Must educate with all stakeholders, especially • IBCLCs – many misunderstandings about licensure and reimbursement • Other Health Care Professionals – think we are encroaching on their Scope • Public, Legislators, Insurers

27. History of Licensure Efforts • Documented efforts since 1997, Texas • ILCA Taskforce in 2005-06 • Texas and Massachusetts Bills • USLCA Committee 2006 • Licensure Toolkit Published in 2007 • New Committee formed August 2009 • Affordable Care Act 2010 – preventive health • Efforts reinforced by SGCTA 2011

28. Action 9. Provide education and training in breastfeeding for all health professionals who care for women and children. • Improve the breastfeeding content in undergraduate and graduate education and training for health professionals. • Establish and incorporate minimum requirements for competency in lactation care into health professional credentialing, licensing, and certification processes. • Increase opportunities for continuing education on the management of lactation to ensure the maintenance of minimum competencies and skills.

29. Action 11. Ensure access to services provided by International Board Certified Lactation Consultants. • Include support for lactation as an essential medical service for pregnant women, breastfeeding mothers, and children. • Standard coverage for IBCLCs as “covered providers” • Provide reimbursement for IBCLCs independent of their having other professional certification or licensure. • Alternatively, developing state licensureof lactation consultants • Work to increase the number of racial and ethnic minority IBCLCs to better mirror the U.S. population.

30. Licensure • Certificate? • Certification? • Registry? • Licensure?

31. Certificate Holder - One who completes a professional certificate program • Training program on a topic • Not as defensible to use for regulatory purposes as compared to a professional certification • May become quickly outdated • 3 types of certificate programs • knowledge-based certificate • generic, narrow scope of specialized knowledge used in performing duties • issued after passing an assessment instrument • curriculum-based certificate • completes a course(s) and passes assessment instrument • content may not be completely representative of professional practice • certificate of attendance or participation • no knowledge assessment or demonstration of competence

32. Certificant holder of a Professional Certification (IBCLC) • Independent assessment of knowledge or skills • “Credentialing agency” does not provide training • Voluntary, Non-governmental process • Time-limited recognition and use of credential • Must meet predetermined criteria developed through a consensus driven process to be eligible based on legal and psychometric requirements

33. Certificant = IBCLC • Must pass a “high stakes” psychometric exam • Allow individuals to perform professional duties • End of course examinations not valid a substitute • Criteria that distinguish a professional credentialing (certification, licensure or registration) examinationfrom an end-of-course examination • Professional role delineation / job analysis conducted and periodically validated • Demonstration of how the examination is linked to a defined body of knowledge, based on role delineation / job analysis • Demonstration of reliability and validity of the examination, based on psychometrically accepted statistical methods, is provided • Minimum passing score developed using psychometrically accepted statistical methods

34. Lactation Care Specialist Community Breastfeeding Educator Early Breastfeeding Care Specialist / Doula Breastfeeding Training Certified Lactation Counselor WIC Peer Counselor Certified Lactation Educator La Leche League Leader Certified Breastfeeding Specialist Certified Lactation Specialist Counselor Breastfeeding Counselor Breastfeeding Educator Lactation Educator Counselor Confusion with Non-IBCLC Breastfeeding Support Providers

35. Registry = RLC • Assures a highly qualified, objective, recognized third party (the credentialing body) has examined this person and found them to meet defined, published, psychometrically sound, and legally defensible standards • Governmental agency grants a time-limited status on a registry • Determined by specified knowledge-based requirements (e.g., experience, education, examinations) • Authorizes individuals to practice, similar to licensure • For IBCLCs: Louisiana RLC designation

36. Licensure • Mandatory process • State governmental agency grants time-limited permission to an individual to engage in a given occupation • IBCLC verifies achievement of predetermined and standardized criteria

37. Requires a license to use the title Unlicensed IBCLCs may not use the title, although they may practice Identifies LC as a professional if linked to meaningful credentialing i.e. IBCLC Relative to the scope of practice Like MDs, RNs Unlicensed individuals cannot practice Unlicensed individuals cannot use the title Title Protection Practice Protection

38. Purposes - Identification • Mechanism to be known by the public, employers, policy makers and insurers • Links IBCLC to a meaningful process of examination • Accredited as legally defensible • Delineates entry level standards and continuing competence • Professional credibility, aligns with other regulated health professionals

39. Purposes – Public Protection • Insures competence and ethics in the profession • Differentiates IBCLCs from other breastfeeding support providers • Assures consumers that professionals have met standards of practice • Ensure that consumers have access to care

40. Challenges • Must be carried out in 50 states • Requires support of legislator(s) • States don’t want new boards or registries • Government does not want to spend money on regulation • Public perception of regulation as ineffective or corrupt • Creating a new board is cost prohibitive

41. Advocacy: Lobbyist – Scott Harshman • Licensure Legislation • Draft of model bill completed • Lessons learned document complete • Licensure FAQs for IBCLCs • Licensure Summary for Physicians

42. Model Legislation • Finding an existing board to house IBCLC • Licensure tied to IBCLC credential • No additional exam • Required to practice • Exemptions: other qualified professionals and volunteers may still support lactation • State discipline may still be enforced • Fines for unlicensed practice • Plans for state reciprocity

43. Leading Efforts: Massachusetts Pennsylvania Georgia North Carolina New York Indiana Hawaii Florida Initial Discussions: Connecticut Virginia Washington Rhode Island Arizona Kansas Utah States Currently in Pursuit of Licensure

44. Reimbursement

45. Purpose of Reimbursement • Lactation consultant services as part of preventative healthcare strategies • Encourage breastfeeding as preventive health behavior • Ensure equitable access to care • Reduce overall healthcare costs for families, employers and third party payers • Ensure breastfeeding is preserved unless true medical contraindications exist

46. Many procedures and systems must be in place for IBCLCs to be considered for coverage as lactation service providers. • Education of Stakeholders • Tool Developed for Educating • public • insurers • public health • legislators • policy makers • 2nd Edition July 2012

47. Systems and Procedures are Needed for IBCLCs to be Reimbursed • National Provider Identifier (NPI) • Occupational Listing • Informing • State Medicaid Directors • Federal Administrators • Comments to Innovations Center and state projects • Apply for Coding • Informing State Insurance Commissioners • Needed: Actuarial Analysis

48. Hogan Lovells US LLPColumbia Square555 Thirteenth Street, NWWashington, DC 20004 • Erin Hertzog • Lindsey Murtagh • Craig Smith • David Robbins

49. Progress Report • Taxonomy Code Approved • National Provider Identifier Number • Necessary to bill for services • RN LC exists • Non-RN new effective April 2011

50. US Department of Labor Occupational Analysis • 1106 Occupations listed for 2009 • Many kinds of nurses • Nothing for lactation or breastfeeding in database • Completed and submitted an occupational analysis • Assigned a code as “health educator” • Appealing this designation