11 Jul 2023

We need a new health services delivery system. ASAP!!

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Today, I listened to an episode of Kimberly Seals Allers’ podcast, Birthright. https://birthrightpodcast.com/podcast/season-2-episode-10-finding-joy-for-black-birth-workers-black-doulas-speak-out/

In it, Black doulas from across the country describe a situation that I experienced myself just this morning, in a TennCareConnect webinar about Tennessee medicaid’s new reimbursement process for lactation counselors and consultants.

Both the podcast and the webinar reminded me of 1989, when Philadelphia’s only maternity hospital (The John C Franklin Maternity Hospital, formerly known as Booth Maternity Hospital) where I worked closed because there was no profit in normal birth. This hospital was run by midwives; maternity care there was based on a midwifery model. At the time, midwives were reimbursed at 60% of what an OB/GYN was paid; and the midwives gave far better care. This care was individualized and given by people who loved what they were doing, who believed that most birth was normal and needed nothing but encouragement and support for the birthing person and their family. A hospital that everyone loved, where nurses would stay long after their shift was done because it was such fun to hang out in a community of women, where people came from all over the country to have their babies, where foreign trained midwives could work in a program that would enable them to practice in the US, that paradise died from economic starvation.

Both the doulas I heard today in the podcast and the state administrators who spoke in the webinar described a model whereby the provider (i.e. doulas, lactation counselors and consultants) would have to register with the state medical assistance agency, and then apply to each Managed Care Organization individually. In Tennessee, this means 4 long applications, all different, with none of the time spent filling them reimbursed, and all requiring extensive documentation. What this means in reality is that going through these processes, and then submitting a claim (on a complex billing form that requires knowledge of diagnostic and current procedural terminology  codes) that  takes lord knows how long to complete, and that is discouraging and impersonal, also lacks any guarantee of success, Claims can be delayed or denied; an appeals process is just as intricate and tedious as filing the original claim.

Back in the 1990s, an insurance biller spoke at a professional association meeting. She told us of the practice of tossing claims; each insurance company had its own procedure for “losing” every 5th or 7th claim. The company counted on the consumer giving up, because resubmitting a claim was too arduous a process. She said that this was standard practice.

One MCO in Tennessee reimburses a lactation consultant  $45 for one hour of care in a client’s home. Reimbursements from MCOs and state Medicaid organizations are notoriously low and unreliable, with one doula in the podcast saying she’d submitted 4 claims and was reimbursed for only 1. And that reimbursement could be 6 months after the claim was filed.   No way can a dedicated and skilled provider live joyously by doing so much work for so little return.

The cry has been for decades that  the US needs more doulas, lactation counselors and consultants, and midwives. That’s what communities both need and want; to have the intimate aspects of maternity care tended to by folks who look like their clients, who have an appreciation of relationship, and who know their scope of practice so that the few high-risk folks are referred to more highly skilled providers.

After decades of activism and political involvement, the healthcare services delivery system responds in a way that looks good. “See, only 5 states in the country offer medicaid reimbursement for lactation care. Tennessee will be the 6th,”  The response sounds exciting and wonderful, but is neither efficient nor practical, nor respectful. Administrators will now boast of offering services, but “people just don’t want to do the work” when the real issue that that dedicated health workers are burned out and discouraged by the bureaucracy, and tired of wages too small for joyful living.  This also means that folks of all colors who live in poverty, Black and Brown and Indigenous folks, folks on the LGTBQIA+ spectrum and immigrants continue to be denied necessary care, care that evidence has been proven over and over again to be effective and fiscally prudent.

When the Franklin Maternity Hospital closed due to lack of financial support, it was the first of many to close in Philadelphia over the next decades. Between 1997 and 2009, 13 of a total of 19 maternity wards in Philadelphia closed. I always remember an administrator from the Medical College of Pennsylvania being quoted in the local paper as their maternity unit was the second to close; he said something like, “Birth is not productive.”  (Are you kidding me?)  But in our capitalistic society, what he meant is that there is no money in birth. Hospitals make money when babies go to NICU, and when labor is induced using all the expensive bells and whistles, leading to a cesarean section. Capitalism views healthy, normal birth as a financial  burden.

Is this the reason that reimbursement for helping babies be born healthy, and helping them to breastfeed, is so paltry?

I have watched over the past half century shift from maintain wellness to maintaining profit. Healthcare costs are topics of media concern but little is done to reduce them.  I have seen people being kicked out of a rehabilitation hospital before they recovered because their insurance benefits ran out, and been grateful (and sad at the inequity) that my husband’s insurance covered a bill of $333,000.

I have talked to physicians and administrators alike about breastfeeding lowering the chance of someone getting diabetes. In 2017, the American Diabetes Association estimated that diabetes cost the US an estimated $327 Billion a year. The disconnect between what the health says and what it does all makes sense when one realizes that folks are getting rich from that $327 billion, while the $55 billion/year commercial milk formula industry influences policy and distributes its product (while receiving rebates from the US government) freely, particularly in the WIC program. (Gabrielle Palmer writes about this at length in her classic work, The Politics of Breastfeeding, 3rd Ed. Pinter & Martin 2009.)

Our challenge now is to deal with this broken health care system. Do we scrap it and start over? Do we go back to community healthcare centers and accept bartering as a new medium of exchange? Do we save up our pennies and move to another country that care about the health of its citizens?

What do you think?


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