The AAP affirmed in their 2012 and 2022 “Breastfeeding and the Use of Human Milk” policy statements that infants should be exclusively breast fed for the first 6 months of life; however, MOM sometimes is unavailable or not available in sufficient quantity to meet an infant’s nutritional needs [
7,
8]. For this reason, PDHM and HMB-HMF are commonly used to support adequate growth in VLBW infants. Unfortunately, the cost of PDHM and human milk–based products is a major issue for most hospitals exploring EHMD implementation. Currently, only California, Connecticut, Illinois, Kansas, Kentucky, Louisiana, Missouri, New Jersey, New York, Ohio, Oregon, Pennsylvania, Texas, and Utah, and Washington, DC, have laws that require Medicaid programs to reimburse PDHM costs [
30]. In addition, Florida, Maine, Massachusetts, Nevada, Oklahoma, South Carolina, and Virginia have had bills in recent legislative sessions that will mandate coverage for PDHM, if passed. Tricare (U.S. Defense Health Agency, Falls Church, VA) health insurance for United States military personnel and their dependents covers banked PDHM for certain medical conditions. The neonatology community must support ongoing and future efforts to require insurance companies and Medicaid to reimburse hospitals for the use of this “medicine” in our most vulnerable patients.
Advocacy efforts must also include education of lawmakers and regulatory authorities on the short- and long-term benefits of an EHMD for VLBW infants, particularly the cost savings realized by preventing comorbidities of preterm birth [
30].
Real-world experience
Unfortunately, it is the experts’ experiences that EHMD adoption is hindered by the reality that its implementation is a complex process. Practical lessons learned over time that may facilitate EHMD implementation include building a case for starting an EHMD program, the importance of standardized feeding protocols, building an EHMD team, identifying which outcomes to monitor, and the need for advocacy in the neonatology community.
Each institution has its own decision-making process for determining whether to implement a new therapy. Institutions also vary in terms of the availability of reimbursement for EHMD products, need for new staff to implement an EHMD, financial/insurance status of patients, and existing comorbidity burden. If comorbidity rates are already low, that may affect the ability to make a compelling argument for EHMD funding. When developing a proposal for an EHMD program, the implementation team must educate the hospital administration on the benefits of an EHMD beyond reductions in comorbidities, including improved growth, shorter LOS, and better long-term outcomes. It should be emphasized that the cost of an EHMD—approximately $12,500 for a 90-day NICU hospitalization—represents only a fraction of the usual cost of care for a VLBW infant [
11]. Cost-savings data from other institutions and cost-avoidance projections based on internal data can also enhance funding proposals.
Involving a finance representative and other key stakeholders (e.g., dieticians, nurses, and lactation consultants) in internal discussions may further increase understanding of the clinical and economic rationale for an EHMD and build internal advocacy for implementation. Funding barriers may be easier to overcome in the small number of states that allow Medicaid reimbursement for PDHM and HMB-HMF. Convincing the hospital administration to forego yearly re-justification of EHMD costs would also save time and increase program efficiency.