Washington -- Still distant, but coming into view is a big, troublesome question in health-care politics: How much economizing in medical service will the public tolerate?
Will it tolerate six-hour hospital stays for mothers and newborns in uncomplicated births -- sometimes referred to as "drive through delivery?" And, with spending on Medicare patients heavily concentrated on what turns out to be the last year of life, are economies to be sought in care of the very sick elderly -- or shunned?
Disappointments and irritations have become increasingly evident as managed-care and other cost-cutting systems spread through the medical economy. But this is just the beginning of thrift in the American health-care system, which remains lavishly expensive by the standards of other industrialized nations.
The worrisome presence of the cost-vs.-care trade-off in health care is evident in the advertising of managed-care systems. Aware of bad word-of-mouth reports about accessibility and duration of care, the promoters emphasize in their ads that it's a problem, sure enough. But we're different, they proclaim.
Qualms if not rebellion are already evident among doctors, who find that medical judgments increasingly must yield to the economy demands of the insurers who pay the bills. Just recently, for example, the American College of Obstetricians and Gynecologists strongly deplored the trend toward shorter and shorter hospital stays for mothers and newborns. How much they've shrunk will come as a surprise to those unacquainted with the new brevity in post-partum care.
From 1970 to 1992, the median hospital stay following routine birth declined from 3.9 to 2.1 days, according to the Centers for Disease Control. But now, the obs and gyns report, insurers commonly set a limit of "up to only 24 hours," and the insurers are talking about 12 hours and even considering 6-hour stays, according to the doctors.
In the latest election for the presidency of the American Psychiatric Association, one of the candidates campaigned against managed care, contending that its limitations on services are often incompatible with the needs of patients. With that as his main issue, he won.
The question of how much is enough is one of the most puzzling and controversial in health care. While attacking the short-stay edicts of the insurers, the American College of Obstetricians and Gynecologists concedes that "there is relatively little scientific data on the ideal length of hospital stay for delivery."
Unanimity on these problems is generally confined to agreeing that knowledge is in short supply. Beyond that, the doctors and the managers tend to fall out. The medical side of the argument laments the subordination of medical judgment to financial motives, while the managers complain that the American health-care system maintains too many hospitals, beds, physicians and nurses for the population it serves. High-quality care, say the managers, is possible at far lower cost, even for very sick elderly patients.
The only solution to this conflict is through careful studies of what works and doesn't work in health care -- such as on the murky issue of the best length of hospital stay following birth. But a political irony of the moment is that the budget ax is slated to fall on the government agency that organizes and finances such studies, the Agency for Health Care Policy and Research.
In one respect the studies are expensive, since they usually involve the long-term, careful tracking of patients to assess the effect of different treatments. Though the results are extremely useful for doctors, it's difficult to make money from this kind of research, which is why Washington is the main source of finance.
But the research really is cheap in the grand scheme of things. With America's annual health-care spending now around the $1 trillion mark, a carefully researched conclusion on the best treatments easily can save more than the agency budget of $162 million. In recent years, for example, its studies have shed light on the best treatments for low back pain, post-stroke rehabilitation, ulcers, depression and management of cancer pain -- all big-ticket items in health care.
The quest for medical economy and the demands for quality care are naturally in conflict. And the conflict is bound to intensify as new treatments and techniques are developed, the population ages and the budget cutters demand greater thrift.
Which is why "drive through delivery" may be coming to childbirth.
Daniel S. Greenberg is a syndicated columnist specializing in the politics of science and health.