The 48-Hour Fix

A new law keeps moms and newborns in the hospital longer--but they still may be getting shorted on care.

It's quite the rage these days to be mad at health care insurers, particularly those offering managed care. Health horror stories about patient dumping, "drive-through" procedures, and denial of emergency care abound in the news media. Politicians have gotten a lot of mileage from publicly lambasting health plans for putting profits above quality care.

One of the most compelling such tales concerns so-called drive-through deliveries: heartless insurers kicking mothers and their newborn infants out of hospitals, sometimes only a few hours after birth. Mothers being treated like so much cattle made for great sound bites. President Clinton himself condemned the practice and called for a law to force the nasty health plans to be nicer. And so we got the Newborns' and Mothers' Health Protection Act of 1996, which took effect at the beginning of 1998.

Some insurers have indeed shown poor judgment, but that's not the end of the story. Nor did the legislated solution make everything right. In fact, some health care providers say the law, offered as a panacea, is really just an ill-fitting band-aid. The law may actually endanger those it's supposed to protect by stunting the growth of a new health care market niche. With the strong Democratic showing in the recent elections, some form of a "patient bill of rights" is again a legislative possibility, so it's especially important to examine carefully the effects of government intrusion into health care.

Contrary to popular myth, shorter hospital stays after birth stemmed from the desires of families, rather than from a cost-cutting frenzy by insurers. According to the American Academy of Pediatrics, the movement toward shorter stays began in the 1980s, when people were looking for something between home birth and the full hospital delivery experience. This development accompanied an overall growth in the home health care industry, as consumers increasingly opted to get treatment outside of the hospital when possible. Not surprisingly, health plans liked the idea of shorter postpartum stays, which could save a bundle on expensive hospital bed days.

But the movement to recuperate from birth at home left a gap: Mothers still needed follow-up care. Nurses and traditional home health care companies recognized this emerging health care need and moved quickly to fill it.

By the early 1990s, a fast-growing maternal home health care niche had formed. Companies like Healthy Homecomings in St. Louis, founded by two former maternity ward nurses and later sold to a larger health care company, capitalized on the trend by offering home nursing visits to new mothers. The companies marketed their services to insurers by telling them it was fine to send mothers home early as long as they followed up with some sort of home health care.

It seemed not only workable but an ideal solution. Coupling shorter hospital stays with home visits by nurses allows mothers to recuperate in the familiar surroundings of home (to say nothing of the improvement at mealtimes). A home health nurse can better assess the progress of mother and child in their natural habitat. Nurses can make sure breast-feeding is working out OK. (New mothers don't automatically know what to do, and often nurses have to instruct them on how to feed their hungry babies.) More important, nurses can catch problems that could send a baby to the emergency room. Conditions like sepsis or jaundice--one of the bigger concerns for newborns because it signifies a liver problem--often do not show up until after 48 hours.

Best of all for health plans, shorter postpartum stays followed by an in-home checkup save money. A day in the hospital can cost thousands of dollars. A home nursing visit, by contrast, comes with a price tag of no more than a few hundred dollars.

Despite what seemed an obvious money-saving formula, maternal home care providers say it wasn't easy to convince health care payers to add a home visit to the care package. So mothers continued to go home earlier and earlier, but often with no follow-up care until the next pediatrician visit.

Unfortunately for this new business niche, there are always some who will take a good idea to its illogical extreme. Some managed care companies and health plans abbreviated post-birth time in the hospital so much that people started getting upset. The public was appalled by the stories of women sent home dazed and sore with a baby only a few hours old.

The reaction reached its highest pitch in 1996, whipped up by politicians quick to jump behind a popular issue with an appealing name. Several states adopted legislation setting mandatory hospital stays. By the end of the year, the Newborns' and Mothers' Health Protection Act was law. It prohibits insurers from forcing new mothers to leave the hospital before 48 hours after a normal birth, 96 hours in the case of a Cesarean section.

While regulating health care--which depends on a variety of factors, many having nothing to do with money--is often tricky, the solution to "drive-through deliveries" must have seemed crystal clear: Keep new moms in the hospital for two days--one day to sleep, the other to get ready to leave. Problem solved.

But according to Lenore Williams, co-founder of Professional Nurse Associates, a Cleveland company specializing in maternal home care, the problems were far from solved for health care workers fighting to persuade insurers of the preventive value of postpartum home care. In fact, the new legislation has made it tougher for them to convince health plans that such care is important, even though, on average, it takes only one low-cost home visit to determine if the baby is off to a good start. Suddenly, all a health plan had to do to be a good guy was to let moms stay in the hospital for two days after delivery. "They think, `We've met the letter of the law and we don't have to do anything now,'" Williams says.

No one has been able to state with certainty the ideal time that a new mother should stay in the hospital; each delivery is different. But even 48 hours is likely too short a time if it's not followed up, Williams says. Some of the health insurers she works with recognize that and have continued to provide outpatient home care for mothers and their newborns.

It works, too, Williams says. She recalls a recent day she had two postpartum home visits. In both cases, she found the babies in dire need, nearly requiring blood transfusions. In fact, if a nurse had not visited the babies, that's very likely what would have happened later--costly emergency room visits for a couple of very sick babies.

Study after study abstracted in the American Medical Association's database supports Williams' assertion: Shorter hospital stays don't necessarily hurt the future health of newborns, provided they get follow-up outpatient care. Further, the American Academy of Pediatrics stated in 1995 that "discharge of a newborn from the hospital should be the decision of the physician caring for the baby, not by arbitrary policy established by third-party payers." But what might make medical sense doesn't always translate into a simple, public-pleasing solution that can be enforced by another regulation. Simply mandating that mothers be kept in the hospital for a certain amount of time impedes the evolution of health care, which allows people to be treated in alternative ways and places. Granted, that evolution will sometimes beget a monstrosity, and the public will want it dead. But as with all evolution, the road to stronger systems has some jarring bumps.

For now, the road ahead appears to lead instead to more regulation. With the supposed success of the "drive-through delivery" legislation, we can look forward to blanket rules covering more health care "problems." Next target for our caring lawmakers: "drive-through mastectomies."