Maryland was hailed as the first to put its foot down against health insurers when it passed a law last spring to guarantee new mothers and babies a 48-hour hospital stay. But when the law goes into effect Sunday, women delivering babies in Maryland can expect to spend less time, not more, in the hospital.
A giant, but little-publicized, loophole in the new law makes it likely that most women who have routine vaginal births will be discharged from the hospital after only one night's stay. The law's fine print permits doctors to discharge new mothers and babies after 24 hours if insurers offer a post-partum visit from a home care nurse. Most insurance companies are expected to opt for the home care nurse instead of paying for mothers to
spend a second night in the hospital.
In fact, large insurers such as Blue Cross and Blue Shield of Maryland have begun denying an extra night's stay to women who deliver babies late in the day -- after 4 p.m. and up to 11:59 p.m. And hospitals are beginning to crack down on their own grace periods, which allow patients to stay six to 18 hours past the 24-hour cutoff.
Finally, to the shock of doctors, nurses, and new mothers, Blue Cross is refusing to pay for more than two days in the hospital for women who have scheduled Caesarean section deliveries. The typical stay has been three days.
"It's unbelieveable," said Victor A. Khouzami, chief of obstetrics at the Greater Baltimore Medical Center, which delivers 5,300 babies annually.
C-section mothers are being sent home before they are eating regular food, he said, and most have to return to the doctor's office to have surgical staples or clips removed.
He and other doctors are troubled by the continued erosion in post-partum hospital stays. The trend comes at a time when women think they are about to get a bonus day because of the fanfare surrounding the new law, which was billed in the media and by some politicians as a bold step .
But the new law gives insurance companies -- not new mothers -- the choice of 24-hour or 48-hour hospital stays for routine deliveries. Insurers are unlikely to choose the extra day in the hospital, which costs $1,000 to $2,000 compared with as little as $67 for a home care nurse. But the exception to the 48-hour stay is catching women by surprise.
Last week, Cathy Shapiro, nine months pregnant with her first child, received a letter from her insurer telling her she is entitled to a free home visit from a nurse after delivery. On page three of the letter, she learned the insurer will pay for only one night in the hospital if her delivery is routine.
Shocked, she called the attorney general's office and the insurance commissioner to report the company, thinking she was being denied her 48-hour stay under the new law.
Mrs. Shapiro, 36, who runs her own public relations firm in Baltimore, said she was misled by the publicity about the new law.
"Nowhere did I see that it wasn't 48 hours," she said, adding that people even called it the "48-hour" bill. "Myself and everybody else I know is under the impression we got a 48-hour stay."
Confusion all over the state
Confusion among women about to deliver is being reported by doctors all over the state. They attribute it to vague or mistaken media reports about the new law, some of them linking the Maryland law with a more liberal "48-hour" law in New Jersey. The New Jersey law allows the mother to choose between a longer hospital stay and early discharge followed by medical care at home.
Both the Maryland and New Jersey laws were inspired by public outrage over new mothers' being pushed out of hospitals so quickly and newborns being discharged before they can be properly tested for problems that can lead to mental retardation. In some cases, newborns have been brought back to the hospital suffering from dehydration, jaundice or other illnesses.
Plenty of women want to leave the hospital early, and some doctors say the germs in hospitals are good reason to send healthy babies home as soon as possible. But doctors also say that some women, particularly first-time mothers who undergo long labors, need more time to recover than insurers are allowing.
In Maryland, all but a few hundred of 25,032 mothers who had normal deliveries in the year that ended March 30 stayed in the hospital more than 24 hours, according to the Maryland Hospital Association.
But in the coming months mothers like Jane Bourgeois, who delivered a son in a routine vaginal birth at 10 a.m. last week, can expect to be discharged shortly after 10 a.m. the next day -- instead of at 1 p.m. or 5 p.m. or even 7 p.m. as they are now.
'I would have cried'
"I would have cried if I had to leave early," said Mrs. Bourgeois, who delivered at Greater Baltimore Medical Center. "This is my second child. If this was my first, I would be really nervous."
About 80 percent of the pregnant women in Claire M. Weitz's practice come in thinking the new law will give them an extra day in the hospital, Dr. Weitz said.
"These women actually believe they have the say, and they don't," said Dr. Weitz, who is chief of high-risk deliveries at GBMC.
The change in Blue Cross coverage for scheduled C-sections is catching almost everyone off guard: doctors, nurses and new mothers. Last week, at least two mothers ended up fighting with the insurer from their hospital beds after learning their stays would be cut short.
Nurses coming in for the afternoon shift at GBMC watched in shock last week when Sharon Curtis was wheeled out to a waiting car less than 48 hours after a scheduled C-section. "Where are you going?" they asked, unaware of the new policies.
Mrs. Curtis was furious. Her newborn son, Patrick, had just emerged from intensive care, and she was being monitored RTC because of her diabetes.
"I personally think insurance companies are getting too big for their britches," Mrs. Curtis said as she watched her 2-year-old, Brian, hold his brother for the first time.
Can't afford more, insurers say
But insurers say they can't afford to pay for a mother to rest in the hospital.
"The mom may be tired, but the hospital is not the place you stay in," said Dr. Robert Sheff, president of Blue Cross managed care plans. "We don't see medical insurance as being custodial care."
Dr. Sheff said cutbacks in grace periods for afternoon and evening deliveries and the new, shorter stay for routine Caesarean sections were introduced to hospitals a year ago and are now being enforced.
He added that emergency C-sections generally get a longer stay because the surgery follows hours of exhaustive labor that makes recovery more difficult.
A 48-hour stay for scheduled C-sections was pioneered in Maryland by Mid Atlantic Medical Services Inc., whose managed care products include MD IPA and Optimum Choice. Scheduled C-sections carry less risk to the mother, and usually are planned for morning to give mothers more time to recover. But some larger companies, including Aetna and Cigna, have no plans to shorten the C-section stay.
"Three days seems appropriate," said Dennis McIntyre, medical director of Aetna Health Plan's MidAtlantic regional office. "There's lots of waste in the medical system, but people who manage medical expenses need to understand there's a point where it can no longer be squeezed."
Often little choice
Though doctors are responsible for discharging patients, the policies of insurers often give them little choice about the length of hospital stays after routine deliveries.
Steven M. Berlin, president of the Obstetrics-Gynecological Society of Maryland, said doctors fear they will be dropped from insurers' programs if they approve extra time for women who are exhausted and need care, but who are not in medical danger.
The new law was intended more to protect babies, who were being sent home before the hospital could spot health problems or properly perform an important blood test for newborns. The test, a metabolic screening commonly known as PKU, can't be done until the baby has been feeding for at least 24 hours.
"The whole thrust of the legislation was to ensure that a mother and baby had a proper follow-up care," said Del. Ann Marie Doory, Democrat of Baltimore City, the law's prime sponsor.
But she called "unfortunate" the cutbacks in grace periods and C-section stays. The New Jersey law, she pointed out, has a minimum 96-hour hospital stay for C-section deliveries. "That may be our next bill," she said.