United States
Lactation Consultant Association
Pursuing The Surgeon General's Call to
Action to Support Breastfeeding
1
Who We Are and What is Our Goal?
2
IBCLC Professionals
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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
3
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
IBCLC Qualifications
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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
5
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).
6
Breastfeeding is Primary
Health Care Prevention
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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”
7
A National Health Priority
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Healthy People 2020
CDC Breastfeeding Report Card and 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
8
Policy Support for Breastfeeding
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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
9
77% of Mothers Choose to Breastfeed
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“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.”
10
Low Duration Rates: Evidence of Need
for Breastfeeding Support
UNITED STATES BREASTFEEDING RATES AS COMPARED TO
HEALTHY PEOPLE 2020 GOALS
90%
80%
82%
75%
US Population
70%
60%
African American
61%
mothers goal
54%
46%
44%
50%
34%
40%
27%
30%
HP2020 Goal
20%
35%
26%
24%
12%
15%
10%
0%
Initiation
6 months Any
12 Months Any
3 months exclusive 6 months exclusive
11
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
Setting
Effect of IBCLCs on staff
WIC
More mothers initiate
breastfeeding
Primary
Care
Promote a longer duration of
breastfeeding
NICU
Breastfeeding rates 50% compared
to 36% without an IBCLC
Hospitals
2.28 times increase in the odds of
breastfeeding at discharge
Medicaid
mothers
with IBCLC
contact in
hospitals
4.13 times increase in the odds of
breastfeeding at discharge
12
USLCA Recommended Staffing Ratios
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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
13
Limited Access to Care

Professional Support Needed:
8.6 IBCLCs per 1,000 live
births, SGCTA (2011)
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Best measure currently
available
Includes IBCLCs in all settings
Available 2.67 IBCLCs per
1000 live births
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Inadequate Breastfeeding Assistance in
Primary Care Where It Is Most Needed
15
2011 Survey on the Recognition of
IBCLCs by Third Party Payers
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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:
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What are IBCLCs currently doing to facilitate their
clients being reimbursed for lactation consult
services? And how well is it working?
16
2011 IBCLC Demographics Based on
Survey Responses
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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
17
Work Site of Survey Respondents
18
What is your official title in your current
position?
19
What reimbursement strategy do you
or your facility use for third party
reimbursement?
20
Submission Rate & Recognition Rate
Submission Rate
Recognition Rate
High (> 4 out of 5 times)
14.8%
3.7%
Moderate (2-4 out of 5 times)
3.3%
3.7%
Low (< 1 out of 5 times)
41.3%
35.4%
Don’t know
40.6%
57.2%
21
Submission & Recognition by Work Site, Job
Classification, and Reimbursement Strategy
Inpatient Hospital
Outpatient Hospital
Private Community
Non-Profit Community
Self-Employed
APN/CPM/MD/PA/RD
RN & IBCLC
RN Only
IBCLC Only
Management
Other
IBCLC Certificate
Infrastructure
Other Medical License
No Billing Submitted
IBCLC & Infrastructure
Other
Submission Rates
High
Low
18%
77%
43%
48%
63%
26%
12%
91%
19%
77%
45%
50%
29%
65%
20%
76%
25%
68%
5%
42%
6%
92%
-------------------------
Recognition Rates
High
Low
3%
92%
17%
64%
32%
37%
4%
95%
6%
89%
20%
63%
11%
79%
4%
92%
9%
81%
3%
40%
2%
84%
21%
67%
5%
87%
30%
45%
--100%
20%
32%
10%
82%
22
Summary of Survey Results
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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
23
Other Health Care Providers have Limited
Ability to Support Breastfeeding
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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
10 11 12 13 14
prohibited
by
health
resource
constraints
15
24
The Solution: USLCA Recommends
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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
25
Advocacy Required
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At least now everyone knows benefits of
breastfeeding
Must educate with all stakeholders, especially
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IBCLCs – many misunderstandings about licensure
and reimbursement
Other Health Care Professionals – think we are
encroaching on their Scope
Public, Legislators, Insurers
26
History of Licensure Efforts
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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
27
Action 9. Provide education and training
in breastfeeding for all
health professionals who care for
women and children.
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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.
Action 11. Ensure access to services
provided by International Board
Certified Lactation Consultants.
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Include support for lactation as an essential medical service for
pregnant women, breastfeeding mothers, and children.
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Provide reimbursement for IBCLCs independent of their having
other professional certification or licensure.
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Standard coverage for IBCLCs as “covered providers”
Alternatively, developing state licensure of lactation consultants
Work to increase the number of racial and ethnic minority
IBCLCs to better mirror the U.S. population.
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Licensure
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Certificate?
Certification?
Registry?
Licensure?
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Certificate Holder - One who completes
a professional certificate program
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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
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curriculum-based certificate
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generic, narrow scope of specialized knowledge used in performing
duties
issued after passing an assessment instrument
completes a course(s) and passes assessment instrument
content may not be completely representative of professional practice
certificate of attendance or participation
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no knowledge assessment or demonstration of competence
Certificant holder of a
Professional Certification (IBCLC)
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Independent assessment of knowledge or skills
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“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
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Certificant = IBCLC
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Must pass a “high stakes” psychometric exam
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Allow individuals to perform professional duties
End of course examinations not valid a substitute
Criteria that distinguish a professional credentialing
(certification, licensure or registration) examination
from an end-of-course examination
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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
Confusion with Non-IBCLC Breastfeeding
Support Providers
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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
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Certified Breastfeeding
Specialist
Certified Lactation
Specialist Counselor
Breastfeeding
Counselor
Breastfeeding Educator
Lactation Educator
Counselor
34
Registry = RLC
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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
35
Licensure
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Mandatory process
State governmental agency grants timelimited permission to an individual to engage
in a given occupation
IBCLC verifies achievement of predetermined
and standardized criteria
36
Title Protection
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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
Practice Protection
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Relative to the scope of
practice
Like MDs, RNs
Unlicensed individuals
cannot practice
Unlicensed individuals
cannot use the title
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Purposes - Identification
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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
38
Purposes – Public Protection
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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
39
Challenges
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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
40
Advocacy: Lobbyist – Scott Harshman
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Licensure Legislation
 Draft of model bill
completed
 Lessons learned
document complete
 Licensure FAQs for
IBCLCs
 Licensure Summary
for Physicians
41
Model Legislation
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Finding an existing board to house IBCLC
Licensure tied to IBCLC credential
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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
42
States Currently in Pursuit of Licensure
Leading Efforts:
 Massachusetts
 Pennsylvania
 Georgia
 North Carolina
 New York
 Indiana
 Hawaii
 Florida
Initial Discussions:
 Connecticut
 Virginia
 Washington
 Rhode Island
 Arizona
 Kansas
 Utah
43
Reimbursement
44
Purpose of Reimbursement
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Lactation consultant services as part of
preventative healthcare strategies
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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
45
Many procedures and systems must be in
place for IBCLCs to be considered for
coverage as lactation service providers.
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Education of Stakeholders
Tool Developed for Educating
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public
insurers
public health
legislators
policy makers
2nd Edition July 2012
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Systems and Procedures are Needed for
IBCLCs to be Reimbursed
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National Provider Identifier (NPI)
Occupational Listing
Informing
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State Medicaid Directors
Federal Administrators
Comments to Innovations Center and state projects
Apply for Coding
Informing State Insurance Commissioners
Needed: Actuarial Analysis
47
Hogan Lovells US LLP
Columbia Square
555 Thirteenth Street, NW
Washington, DC 20004
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Erin Hertzog
Lindsey Murtagh
Craig Smith
David Robbins
48
Progress Report
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Individuals
or
Groups
Taxonomy Code
Approved
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National Provider
Identifier Number
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Necessary to bill for
services
RN LC exists
Non-RN new
effective
April 2011
Nursing
Service
Providers
Registered
Nurse
Other
Service
Providers
Lactation
Consultant
Non-RN
174N0000X
Lactation
Consultant
163WL0100X
49
US Department of Labor Occupational
Analysis
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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
50
Coding for Lactation Services
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Currently there are no codes in the American Medical
Association or the Healthcare Common Procedure Coding
System specific to lactation care and services
USLCA has requested a code be designated to include face-toface services:
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maternal, infant, birth and feeding comprehensive history
physical examination that includes:
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maternal nipple and breast
infant oral anatomy
infant suck assessment
feeding observation
problem assessment
management plan and patient education.
The code describes a 15-minute increment because certified
lactation consultants may, in some instances, provide an initial brief
visitation lasting roughly 15 minutes, although individualized
lactation consultant services generally last roughly 1-2 hours.
51
Advocacy for Inclusion of
Lactation Services from IBCLCs
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Essential Health Benefits
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USLCA advocated for lactation services to be included under
the category of:
“Preventive and wellness services and
chronic disease management”
Medicaid Directors
Title V Funding Public Comments
WIC Public Comments
Innovations Model
State by State
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250 Insurers, top 5 in each state
as opportunities present
52
Developing Insurer Models for Coverage
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Medicaid Redesign
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Insurance Exchange
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New York
Georgia
North Carolina
Florida
Private Insurers
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Aetna
Blue Cross Blue Shield Federal Employee Plan
53
Medicaid and the Dilemma
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Medicaid covers approximately 41% of the births which
occur in the US each year
The federal requirement regarding state licensure of
Medicaid providers arises from language in section 1905
of the Social Security Act. Federal regulations define terms
1905: 42 C.F.R. 440.60 (medical or other remedial care
furnished by licensed practitioners); and 42 C.F.R. 440.90
(clinic services). As the provision regarding "other
diagnostic, screening, preventive, and rehabilitative
services" was added to section 1905 by ACA, there is not
yet a regulation on point.
Issue Brief 2010 no mention of IBCLC
The IBCLC without a license cannot provide services
54
Current State Medicaid Coverage of
Lactation Services

State Medicaid Coverage of Perinatal Services:
Kaiser Family Foundation Report, Usha (2009)
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39 States offer individual lactation counseling
22/50 States Breastfeeding Education Services
14/50 USLCA Survey States Lactation
Consultation
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Only 1 Medicaid provider in Rhode Island authorizes
the IBCLC as a provider
Oklahoma requires nurse or dietician with license
55
Patient Protection and
Affordable Care Act (ACA)
Section 2713: “Coverage of Preventive Health
Services”
• Requires coverage:
“Comprehensive lactation support and
counseling, by a trained provider during
pregnancy and/or in the postpartum period,
and costs for renting breastfeeding
equipment. In conjunction with each birth.”

56
ACA - Early Prevention Screening Diagnosis
and Treatment (EPSDT)
State Medicaid programs are required to cover
under their benefit “any service which [they]
are permitted to cover under Medicaid that is
necessary to treat or ameliorate a defect,
physical and mental illness, or a condition
identified by a screen . . . regardless of
whether the service or item is included in [the
state’s] Medicaid state plan.” States will be
required to provide coverage for primary
care preventions to promote breastfeeding
under its EPSDT benefit category as of 2013.
57
ACA - Medicaid “benchmark plans,”

These “essential health benefits” are defined to
include “preventive and wellness services.” While the
term “preventive and wellness services” is not
defined by the statute, the Institute of Medicine
(IOM) recently issued guidelines with respect to
preventive services for women for purposes of the
“essential health benefits.” These recommendations,
which have been endorsed by the U.S. Department of
Health and Human Services, recommend coverage
for “lactation counseling and equipment to help
women who choose to breastfeed do so
successfully.”
58
Private Insurers and Insurance Exchanges
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May choose to “credential” IBCLCs without an
additional license
This must be done with each individual
insurer
Insurers must be educated about the IBCLC
Council for Affordable Quality Healthcare
Universal Credentialing DataSource
Coding and Fees must be negotiated
59
Ongoing Research and Communication

Compiling supportive research for need and
effectiveness of IBCLC in healthcare setting

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>50 references
Web links provided for all research
Webpage on USLCA site
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Includes a link to recruit volunteers
Includes informative articles from eNews
Includes publications
60
Questions
61
Contact Us
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Laurie A Beck RN, MSN, IBCLC, RLC
laurie.beck@dchstx.org
Marsha Walker, RN, BSN, IBCLC, RLC
marshalact@gmail.com
Judith L. Gutowski, BA, IBCLC, RLC Email:
jlgutowski@comcast.net
Ellen Chetwynd, RN BSN IBCLC, RLC, MPH
ellenchetwynd@gmail.com
United States Lactation Consultant Association
WWW.USLCA.ORG
2501 Aerial Center Parkway, Suite 103
Morrisville, NC 27560 USA
Phone: 919-861-4543
Email: Info@uslca.org
62