Tuesday, July 18, 2006


"Complete Health Care HMO. May I help you?"

"Yes, I'd like to order a hospital grade electric breast pump for a patient."

"I'm sorry, we don't cover those."

"But you're required to cover them...."

The above is a template of a common conversation I and several of our NICU nurses have had with various Medicaid HMO's in our state. Most of my patients have some type of Medicaid, and it is usually with a Medicaid HMO. (The state pays the HMO a monthly fee per person enrolled, and the HMO pays for that person's health care. The less the HMO pays out, the more profit it makes.) These Medicaid HMO's are required to cover hospital grade electric breast pumps, because straight Medicaid covers them and Medicaid HMO's by law have to cover everything straight Medicaid does, but getting them to provide them is like pulling teeth. I'm not sure if it's so hard just because many of the HMO employees are incompetent, or because the HMO wants to make it difficult, hoping people will give up, which they sometimes do, so they won't have to pay for the pump.

Most people reading this know that breast milk is the best food for an infant, but perhaps not all of you realize that it is even more important for a very premature baby. Necrotizing enterocolitis (NEC) - think of it as sort of a lethal infection of a baby's intestine, although it's a little more complicated than that - is a dreaded killer of premies. Babies who are fed breastmilk are less likely to get NEC. Also, a study in this month's Pediatrics reminds us that premies fed breast milk have higher intelligence scores when tested at age 18 months - the equivalent of about 5 I.Q. points higher. The advantages of breast milk are so great that when a tiny premie is born, I ask the mother to pump her breasts for milk for her baby even if she wasn't planning to breastfeed. Most of them do it, but it doesn't always last.

Which is where the hospital grade electric breast pump comes in. The easier it is for a woman to pump - and I'm told the hospital grade electric pumps are vastly superior to hand held pumps - the easier it is for her to maintain her milk supply. So when a Medicaid HMO makes it hard for us to get a good breast pump, as they almost invariably do, sometimes successfully, they are decreasing a baby's chance of survival, as well as decreasing his or her chance of an optimal I.Q. I'm not exaggerating. When HMO's make it hard to get a good breast pump through either planned or unplanned incompetence, they are toying with manslaughter.

There are many forms of health care insurance coverage, such as HMO's, fee for service, and single payor plans. Each has its advantages and disdvantages. But as long as a company's profit is enlarged by denying health care or health care equipment, as is the case with HMO's, needed care will sometimes be denied.

P.S. Check out the new pediatric grand rounds.


Blogger Jamie said...

Oh, this makes my head hurt. Cost of pump rental vs. cost of NEC treatment -- do the math, HMO guys.

12:14 PM  
Anonymous Dianne said...

I'm not sure if it's so hard just because many of the HMO employees are incompetent, or because the HMO wants to make it difficult, hoping people will give up,

At a guess, the answer is probably "yes". HMOs probably hire people who will work cheap and treat them like crap, meaning that they are likely not the best and the brightest to start with and have little motivation to give their best to their job. But the HMOs probably also make the rules such that it is very difficult to get them to pay for any benefits. I don't know but wouldn't be suprised to find that employees are told to always deny coverage for anything the first time the request is made. Give me a nice government bureaucracy any day: government bureaucrats could care less most of the time but they're rarely actively blocking you.

12:40 PM  
Blogger stockingup99 said...

Thanks, NeoHero for covering a topic close to my heart. I was a lactivist, before it had that name.

Have you thought about the formula industry doing some active sabotage in this case? I always try to see where a formula rep may have been there first.

A formula rep visited my ex-chucrh and gave them 'free safer formula' to provide to mothers who brought breastmilk to the church nursery. I was asked to dump my "bottle of hazardous bodily fluid and refill it with free safer formula". Very effective, a shamed based message followed by free poison, from a source of spiritual guidance.

Since formula is made by Ross, I might guess that they strong armed somewhere. Look for the conspiracy.

Or it could be as simple as those reps think formula is good enough, and breastfeeding is an extra that medcaid recipients do not deserve. Most people view BFing as an extra, not a normal.

Breast is Normal. If you know of any Nurse Ins or Nurse Out I can post them to my yahoo group, nurseoutmichigan. I've helped promote a couple local nurse ins already. Did you see me on the six o'clock news for the Victoria Secret Nationwide Nurse In.

How 'bout those weight charts? In 1998 I had to fight to not supplement. The fleas were concerned because she was a 20% and settling gently. They didn't even believe me when I said their charts were for formula fed babies, and someone has to be at 20% anyways. There were formula ads on the chart itself.

Just picked a new flea, in 2005 a Doctor had to confirm online that I had a real CDC weight chart for breastfed babies, and didn't just make it up. He was about to give me a feed him more lecture, but on my chart, my baby was at 50%.

Oh, and I just love the recent ER visit where the doctor stitching my son was concerned he might not be getting enough calcium because he was still breastfeeding at 18 months. I told her my (new)pediatrician was not concerned.

I have been barraged with wean him, and what they really mean is cow milk in a bottle. My baby weaned himself from the bottle at 11 months, but continues to nurse. He eats real food, and drinks water anytime he likes, we keep it available.

I know, long comment, back to your topic. I showed a few examples of why breast is considered extra, and not needed, to illustrate how the denial of decent pumps is part of the bigger formula conspiracy.

Boycott Nestle, they are killing babies in third world contries by giving free formula in the hospital, so moms don't start nursing. Then after the two huge free cans run out, moms can't afford enough powder, and the water isn't safe. Babies die of disintery.

1:23 PM  
Blogger Jamie said...

ND, does your NICU ever work with milk banks to obtain donor milk?

3:58 PM  
Blogger Flea said...

...they are toying with manslaughter

Listen, I agree with you about breast milk, man, but I hope you keep rhetoric like that in the blogosphere! You're never gonna convince opponents by going way over the top.



4:20 PM  
Blogger Ex Utero said...

Flea is right.

It's not manslaughter. It's bedside rationing. Only it's not the doctors that are making the decision, it's HMOs. I see it all the time too.

Here's another place where Flea could come in handy beause he seems to have lawyers crawling all over his site. We need a lawyer to take this on and file a class action suit. Someone who gives a damn not because of the money, but because it's the right the thing to do.

Nice Post NeoDoc!

5:33 PM  
Blogger Emma B. said...

WIC has a hospital-grade breast pump loan program, and they also have lactation consultants and peer support. Any Medicaid recipient is automatically qualified for WIC, and the WIC food package would likely be helpful for her as well.

I think the details vary from state to state, so you might want to check with your own state's WIC office for specifics.

5:46 PM  
Blogger WendyLou said...

My so-called family friendly state, Utah, no longer covers pumps for mothers of NICU babies as part of Medicaid. Following that, the health insurance companies stopped covering the pumps as well.

I am about to appeal the claim denying reimbursement for my pump while my baby was in the NICU.

Mom's on WIC can get them free. Thankfully, I could afford to pay out of pocket to rent mine, only because DH had just received a large bonus. I worry about the middle income moms, too much for WIC, but can't afford the rental.

While in the NICU, I saw one mom struggle with hand pumps. She quit pumping when her little one was a week old. She was where I was, too rich to qualify for WIC, too poor to rent one herself. (When she called to say she was quitting, she had a less than breast feeding friendly nurse, but that's another story.)

I will also add, the NICU my baby was in is "Pumping friendly" not breast feeding friendly. No one breast fed in there, only pumping. One mom with a full term baby breast fed, but her baby was also given formula. He was only in the NICU for bili-lights. Even babies bottle feeding with no problems were not allowed to breast feed until a few days before they left.

Side comment- Are Nicu's really Hippa compliant? I could tell you what was going on with all the other babies, by just listening. I tried no to, but my job is to observe, and it is hard to turn that off. It is also boring to stare at a sleeping baby, so I would over hear what is happening with everyone else.

6:04 PM  
Blogger Jamie said...

I don't think "toying with manslaughter" is way over the top. Lucas and Cole found that human milk makes an enormous difference in the incidence of NEC. The abstract says, "Among babies born at more than 30 weeks' gestation confirmed necrotising enterocolitis was rare in those whose diet included breast milk; it was 20 times more common in those fed formula only." That's quite an odds ratio. (That reference is old (1990), but Dr. Phillip Gordon just pointed out that the incidence and mortality figures for NEC have been mostly unchanged for 50 years.)

Despite the misperception that breastfeeding depends mostly on a mother's determination, there are important physiological limits faced by lactating women. As a woman moves from lactogenesis II to galactopoiesis, she's in a sensitive window, calibrating her future milk production. Some women are able to bounce right back from a slow start, but some women will never be able to meet their babies' needs without early frequent milk removal.

A hospital-grade pump makes a real difference. It's very tough to bring in a full milk supply with a Pump In Style. It's even tougher if it's your neighbor's secondhand Pump In Style, since the motor is designed with a 200-hour life and diminished milk output is an early sign of equipment failure (the manufacturer's equipment, not the mother's equipment). It's pretty much impossible, except in the case of serious overproducers, to do it with a cheapo battery-powered pump from CVS.

A good pump is an inexpensive item that saves babies' lives. Schanler et al. found that infants fed human milk were discharged an average of 15 days earlier than infants fed formula. Maybe, ND, someone who deals with insurance headaches at your hospital could send a copy of that article to the CFO of the HMO in question. Maybe that would get the word out that denying payment for breastpump rental is irresponsible fiscally as well as morally.

[climbs down from soapbox]

10:35 PM  
Blogger Am said...

Way to go, this post is wonderful, Doc! I wish all doctors had this same attitude about breastfeeding.

10:37 PM  
Blogger Jamie said...

Oops, bad link.

Schanler, et al. -- full text

10:42 PM  
Anonymous Anonymous said...

as a brit who is covered by the NHS i don't really understad the complexities of health insurance. what happens to people on benefits as their only income, what level of health care are they entitled to? do u know of a website that exlpains this?

5:47 AM  
Blogger Trax said...

Go Get up NeoDoc!!

10:01 AM  
Anonymous Anonymous said...

I pumped, and my baby still ended up getting NEC. His gut eventually perforated, and even though I didn't know if he would ever be able to take breastmilk, I continued to pump during his long recovery. Stress from the gravity of the situation caused a huge decline in milk production (down to only 10ml at a session), and I was physically and emotionally suffering due to frustration and lack of rest and sleep. I wanted to be at my son's bedside helping him to recover but instead I was stuck in the lactation room trying to squeeze out 10ml of milk. Finally, my son's neo told me to stop pumping and take care of myself because if my son would ever be able to take the pumped milk, I had enough of my milk frozen in the NICU freezer to help him build up some immunities.

The lactation consultant hounded me to get the milk out of her freezer if we weren't going to actively attempt to use it. Finally, the neo tried giving my son some of the saved breastmilk, but his gut couldn't tolerate it. To make the lactation consultant happy, I took in a cooler to take all of that milk home because she said that it would be good for up to a year. As it turned out, the day didn't go as planned, and I had to remain at the hospital all day due to a complication with my son. When I arrived home, all of the frozen milk had thawed in the cooler from being in my car all day.

As I poured that hard-earned milk down the drain, I think I cried more fluid in those tears than I did pumping the milk all 10mls at a time.

Pumping was okay before he developed NEC, but afterward, pumping was traumatic.

11:09 AM  
Anonymous Amanda said...

Utah Valley Regional Medical Center in Provo, Utah (a *very* pro-breastfeeding NICU) has a grant (I don't know from where) that gives them the resources to give all NICU babies donor milk. One of the best things is that we don't have to beg the insurance companies to pay for it.

12:20 PM  
Anonymous M said...

It must be written somewhere that the Medicaid HMO must cover whatever the regular state Medicaid covers. Perhaps it's on the state Medicaid website. Or on the website for the state insurance commissioner.
What I'm getting at is that there must be a state agency that regulates the Medicaid HMO insurer; the insurer can't just come into a state, set up shop and cover whatever they want. If you (or whoever in your dept. handles insurance matters) could find this out, and go from there, it would be easier to deal with the HMO, and counter their misinformation with real information gotten from a state agency.

The people who answer the HMO tollfree lines are either poorly trained or trained to obfuscate. Probably both.

Another source of concrete information is the written contract that a Medicaid HMO member has with the insurer. That document should state what is covered, and what isn't. But the member has to ask for this; a doctor can't usually.

Or the Medicaid HMO insurer, on their own website, may state their medical policies. I believe that providers can usually access these.

8:18 PM  
Blogger neonataldoc said...

Thanks to all for the comments and suggestions. I don't think that "toying with manslaughter" is over the top, but I do kep that rhetoric on the blogosphere. Breast milk, in some babies, can be the difference between life and death. I'm sure ex utero will back me up on this.

We don't have human milk banks in my area; there's some data to suggest that banked human milk is no better than formula. Stockingup99, Nestle drives me crazy too. Anonymous 11:09, I'm sorry to hear about your baby's NEC and the loss of that precious breast milk.

Anonymous 5:47, in the U.S. government covered care is either Medicare (for the elderly) or Medicaid (for the poor.) Maybe you could google them.

9:32 PM  
Anonymous Anonymous said...

Our state has a Medicaid HMO that is operated by a Catholic organization. As such, certain procedures and prescriptions are not covered by the HMO. However, since Family Planning is such an important part of the Medicaid program, once we get the rejection from the HMO, we can file the claim to the state Medicaid office for payment. Just wondering if there might be similar issues at play with your fun HMO.

4:12 PM  
Anonymous nancy said...

Oh but Dianne, as a 20 year veteran health professional with a Master's Degree in Health Care Policy, I have to warn you about giving the pass to gov't bureaucracies who don't 'actively block you". Do not be naive. Revenue is revenue. Budgets are budgets--and because they bring an unmatched knack for being wasteful in their layers of red-tape, which costs us dearly, they are just as motivated to "block someone" from payment, sometimes more so.

11:36 AM  
Anonymous nancy said...

and BTW, Neodoc, would you point me in the right direction to find in writing the legalities around medicaid HMO's being required to cover what straight medicaid covers. I write appeals for pt's and can't find that fact on any reputable sites, CMS or otherwise. Thanks in advance!

11:42 AM  
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11:44 PM  

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