FOR A DECADE, California, the national laboratory for the health insurance experiment called managed care, has pioneered radical reductions in length of stay for hospitalized patients. But news that California-style lengths of stay are moving east has provoked a major rebellion against insurers' freedom to dictate patients' medical fates.
In New Jersey, Maryland, Massachusetts, New York, New Hampshire and even on Capitol Hill, a coalition of health-care activists, patients, doctors and nurses has used the quintessential women's health issue, childbirth, to mount the first successful legislative challenges to insurers' ability to summarily eject patients from the hospital "quicker and sicker."
Their actions are spawning a national protest that promises to move beyond maternity stays to challenge the managed care credo that shortening hospital stays is the best way to cut health care costs.
Horror stories abound about "drive-through delivery" or "OB express." In a practice that has been condemned by the American College of Obstetrics and Gynecology, the American Society of Pediatrics and the American Medical Association, insurers now whisk mothers and babies out of the hospital only 24 hours after normal vaginal deliveries (in California, the time can be as little as six hours) and three days after a Cesarean section.
The Maryland and New Jersey legislatures have passed bills that would allow women to stay in the hospital for 48 hours after a normal vaginal delivery, 96 hours after a C-section. The New Jersey bill enacts an almost revolutionary provision that gives patients a voice in determining how long they can stay in the hospital. Sens. Nancy Kassebaum, R-Kan., and Bill Bradley, D-N.J., have introduced similar federal legislation.
These laws followed complaints about the human costs of an increasingly profit-driven system. Researchers at the University of California, San Francisco, reported that between 1972 and 1991, only one case of advanced jaundice in a newborn had been recorded in the 23 hospitals they surveyed. Five severe cases were reported at just one of those hospitals between 1992 and 1994. Jaundice is a common condition in infants and can be easily treated if caught quickly. However, infants who leave the hospital too soon may not yet show symptoms. Similarly, doctors say that shortened stays make it impossible for them to test for several common genetic metabolic diseases. Babies must have 24 hours of milk feedings if blood tests are to detect such disorders.
Dozens of doctors told how insurance companies use economic blackmail to force them to discharge unstable patients. "One of the very large HMOs in this area came to my office with two graphs," said New Jersey obstetrician Holly Roberts. "They told me they were pleased that my C-section rate was below the median but very unhappy that my length of stay rate was above the median. They said that if I didn't get patients out sooner, they would have to eliminate me from being able to . . . care for patients in this HMO."
Insurance and HMO executives argue that mothers and babies do better by staying in the hospital no more than 24 hours. Hospitals, they insist, are breeding grounds for infections and human error. While hospitals can be dangerous -- and are definitely unpleasant places to be -- they are nonetheless indispensable for women who are either sick or exhausted after childbirth and in need of expert monitoring and evaluation.
Women can no longer count on being cared for by their own mothers, grandmothers or even friends when they return home. For the exhausted woman who has had a 30-hour labor, who may not be able to walk because she has suffered a tear from her vagina to her rectum or who has two or three other kids to care for at home, the hospital is the only source of respite and assistance. It is also the only place where doctors and nurses can evaluate medical problems and intervene to prevent serious harm. This is true not only for maternity patients but also for anyone who has undergone serious medical treatment.
With little evidence that overall costs are reduced, managed care has elevated short hospital stays to a quasi-religious principle. But length of stay should be determined by the needs of patients, not by those of insurers and employers. If patients are in stable condition, if they have safe, reliable and expert care-giving in the home and community, then -- and only then -- should they be discharged.
Suzzanne Gordon, who has covered trends in hospital care, is writing a book about nursing. She wrote this for the Los Angeles Times.