Early-Release Policy at HMOs Draws Fire : Health care: Kaiser decision to send some mothers and newborns home after eight hours raises the debate to a new level.


In a striking example of cost-cutting efforts in medicine, Kaiser Permanente, the giant health maintenance organization, has begun sending mothers and newborns home as early as eight hours after delivery at one of its Los Angeles medical centers.

Hospital stays for mothers and their babies have been getting shorter nationwide since the 1970s, and many hospitals now discharge within 24 hours women who have had routine vaginal births. But the movement has drawn a growing chorus of criticism from doctors, nurses and lawmakers, who contend that early discharge may pose health risks to mothers and babies.

Assemblywoman Liz Figueroa (D-Fremont) said Thursday that she will sponsor legislation that would ban certain early-discharge practices. She said the bill will be modeled on legislation enacted in Maryland last month that requires insurers to provide at least two days of hospital maternity care. New Jersey is considering similar legislation.

Figueroa said that "there's no room for putting profits before the concerns of a healthy society." She noted that many insurers, not just Kaiser, limit hospital stays.

Insurers contend that early discharges sharply cut the cost of delivery, which enables them to expand other services and reduce members' premiums. Kaiser and several other insurers said their studies found no evidence that early discharges pose health risks.

Kaiser's pilot program, begun in April at its Sunset Boulevard medical center, raises the debate to a new level.

If Kaiser adopts the program throughout its vast system--and if other insurers follow its lead--there could be significant repercussions in the way deliveries are handled in the country. Kaiser has 4 million members in California and about 6 million nationwide.

A Kaiser official said the eight-hour discharge program is not a blanket policy and that decisions are made by physicians on a case-by-case basis. The policy applies only to women who have normal vaginal deliveries without complications, and only if the mother and baby are both healthy.

"What we hope to learn is whether this is a reasonable alternative-treatment plan for normal pregnancies," said neonatologist David Wirtschafter, regional coordinator of perinatal services for Kaiser.

Wirtschafter said other Kaiser hospitals in California generally send mothers with normal deliveries home in 18 to 24 hours.

The new policy has been controversial among the medical staff at Kaiser's Sunset facility and has prompted complaints from patients, according to one nurse there who asked not to be named.

The nurse said Kaiser has tried to create a "safety net" by requiring nurses to make phone calls to mothers discharged early to give them advice and answer questions. "We have not had any re-admissions of babies at this point, but what we don't know is how this has impacted breast-feeding, because mothers and babies are going home without having latched on to one another," she said.

According to an internal Kaiser memorandum dated March 31, a copy of which was obtained by The Times, Kaiser-Sunset administrators said one of the benefits of the eight-hour discharge would be to "reduce our overhead costs to remain competitive in a fluid marketplace and thus retain our jobs and attract more patients." The memo also cited less need for routine monitoring of patients and "reduced education responsibilities for hospital-based nurses."

It also cited benefits for patients, including: "childbirth is a natural event, and an early homecoming is a celebration of such; bonding with an infant is an intimate pleasure which can best be pursued in the privacy of one's own home."

At Los Angeles County-USC Medical Center, which serves mainly indigent patients, mothers and newborns are discharged as early as 12 to 24 hours, said Dr. Richard Paul, an obstetrician-gynecologist at the USC School of Medicine. But, he noted, those patients are required to return with the baby within 24 hours to check for any medical problems.

Joanne Steffan, vice president for health services at Cigna Healthcare of Southern California, said the insurer discharges mothers and newborns within 12 to 24 hours for normal deliveries and 48 hours after Cesarean sections.

She said Cigna has seen no significant number of hospital re-admissions for mothers or babies who encountered problems after going home.

But a recent study by a Dartmouth University researcher found a 50% higher rate of hospital re-admissions for babies who were discharged within 48 hours.

Critics decry the move toward earlier discharges as "drive-through" childbirth and say the practice puts mothers and children at great risk.

Calling the trend "an uninformed experiment," the American College of Obstetricians and Gynecologists last month called for a moratorium on shorter hospital stays until data could demonstrate the safety of early discharges.

Dr. James Heaps, an obstetrician-gynecologist at UCLA Medical Center, said many women need time to recuperate from childbirth and to get some training in breast-feeding before going home.

"The vast majority of babies do not suckle normally at first, and it is incredibly frustrating to the mother," he said. "With the hospital nursing staff, the moms get a lot of support."

Moreover, Heaps and other doctors said most common neonatal problems, such as jaundice or dehydration, can take one or two days to develop and would not be noticed by hospital staff members during the first eight to 12 hours.

Other critics of Kaiser's policy noted that the HMO began its pilot project at the Sunset facility, which has a large proportion of lower-income, Latino patients.

"We're concerned that Kaiser is targeting a much more vulnerable population . . . that has a high population of low-income women and children," said Susan Berke Fogel, staff attorney at the California Womens Law Center.

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