"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.