US government REMOVES exclusive breastfeeding as a hospital quality metric!

In a victory for both babies and mothers, the Centers for Medicare and Medicaid Services (CMS) has REMOVED exclusive breastfeeding rate as a hospital quality metric!

Specifically, the government removed PC-05.

What is PC-05?

PC-05 assesses the rate of newborns exclusively fed breast milk during the newborn’s entire hospitalization.

As I’ve written in the past, this purported quality metric has been the cause of a great deal of infant and maternal suffering. It is almost certainly the proximate cause of the epidemic in newborn hypernatremic dehydration.

How did a quality measure designed to improve infant health end up harming infants? The answer can be found in data science: Goodhart’s Law.

When a measure becomes a target, it ceases to be a good measure.

Campbell’s Law, a corollary of Goodhart’s Law, is equally instructive:

The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor.

When hospitals are incentivized to maximize rates of exclusive breastfeeding at discharge, they ignore dehydration, hypoglycemia (low blood sugar) and jaundice because treating them would involve formula and that would reduce the rate of exclusive breastfeeding.

When hospitals are incentivized to maximize rates of exclusive breastfeeding at discharge, they make formula hard to get: they restrict access to it, lock it up and force women to sign odious, shaming “consent forms” to get it.

When hospitals are incentivized to maximize rates of exclusive breastfeeding at discharge they make sure that hospital personnel will not have to endure the anguished cries of starving infants by closing well baby nurses and leaving babies in mother’s rooms around the clock. And should nurses break down because of simple human compassion and offer formula, they are excoriated by official policy.

Is it any wonder then that exclusive breastfeeding has become the leading risk factor for hospital readmission, responsible for literally tens of thousands of newborn hospital readmissions each year? By setting the wrong target, PC-05 incentivized poor, even deadly, care.

Interestingly, the stated reason for removing the exclusive breastfeeding quality metric is maternal health.

According to a recent announcement (page 1659):

In the FY 2022 IPPS/LTCH PPS proposed rule (86 FR 255801) we proposed to remove PC-05 beginning with the CY 2024 reporting period/FY 2026 payment determination under removal Factor 5—the availability of a measure that is more strongly associated with desired patient outcomes for the particular topic

… We believe that the Maternal Morbidity structural measure is more strongly aligned with our current focus on maternal health than the PC-05 eCQM. The Maternal Morbidity structural measure focuses on determining hospital participation in a Statewide or national Perinatal QI Collaborative and implementation of patient safety practices or bundles within that QI initiative, which includes breastfeeding, while PC-05 targets only breastfeeding, a less holistic area of maternal health.

Like all changes to CMS rules, this was open to public comment and the comments are addressed.

A few commenters did not support our proposal to remove PC-05, because the Maternal Morbidity structural measure does not specifically focus on breastfeeding, and therefore, is not a true replacement of PC-05. A few commenters did not support our proposal to remove PC-05 because of their concern that removing it would result in less focus on and investment in supporting breastfeeding in hospitals…

The response:

…[W]e note that the Maternal Morbidity structural measure does address breastfeeding. It focuses on determining hospital participation in a State or national Perinatal QI Collaborative and implementation of patient safety practices or bundles within that QI initiative, which includes breastfeeding, whereas PC–05 targets only breastfeeding, a less holistic area of maternal health.

In other words, hospitals WILL continue to support breastfeeding but exclusive breastfeeding rates will no longer be used as a quality metric to evaluate and compensate hospitals. The pressure on hospitals — and therefore new mothers — to value exclusive breastfeeding above infant needs and maternal desires is dramatically reduced.

Hallelujah!

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