In Health Care, We Cannot Have It All : Reform: Demands for every new procedure may cost us old ones like longer hospital stays for newborns and their moms.
At a large HMO hospital in Los Angeles, a woman is given several medications and undergoes artificial insemination. She succeeds in conceiving, and her prenatal care and labor and delivery go smoothly. She has four ultrasounds during her pregnancy--two very early to confirm that she has a viable pregnancy, then the later ones to “to be sure everything looks OK.” She arrives at the hospital in labor, and throughout her labor the baby’s heart rate is monitored electronically. She has an “internal pressure monitor” to measure and record the exact strength of her contractions. The delivery goes well. As part of a new protocol, which has been widely reported in the press, the woman and her baby are sent home from the hospital eight hours after delivery. Two days later she returns, her child severely dehydrated and having seizures.
In recent months, a number of health care payers (HMO’s and insurance companies) have adopted policies that pay for hospital stays of only 12 hours following a normal delivery and only two days following a cesarean section.
Changes in health care practices should not be instituted haphazardly or at the discretion of an insurance company or HMO. Everyone seems to agree that changes such as these early discharges must be tested so that problems with newborns or their mothers are not missed. It’s hard to argue with this sentiment. Yet there is more going on than first meets the eye in this debate. Let’s look closely at the above scenario once again: Artificial insemination was in use for years before any randomized trials were done. Some of the medications this woman took have never been shown to increase the chance that she would conceive. No one tested the need for electronic fetal heart rate monitoring in labor before it was put into widespread use; even now, there is scholarly debate over whether enough evidence exists to continue using these monitors the way we do. There is not one well-designed study to show that measuring contractions with an “internal pressure monitor,” even with all its precision, results in better outcomes or fewer injuries to mother or baby than simply feeling contractions with a hand on the mother’s belly.
Yet all these changes were readily adopted and have becomling to accept “progress” that bypasses scientific methods of testing when we feel there is the chance to get something extra or new because of it. The moment we hear that something will be taken away from us, however, we demand testing and rigorous proof.
Perhaps human nature forces us into this situation. But this attitude has lead us to the brink of bankruptcy as we pour on the technological advances and then refuse to yield when someone tries to eliminate a popular practice.
Discharging women and their babies so early may be wrongheaded and dangerous, but this is a problem we have created for ourselves. There is too much money being spent on new practices to retain all the old practices without paying a price, and that price is ever-higher costs.
Shocked at the speed with which mothers and babies are now being discharged, physicians, patients and a variety of advocacy groups have united to decry these early discharges. The state of Maryland now mandates that all insurers pay for a longer hospitalization (48 hours after vaginal delivery and 96 hours after cesarean). California legislators have proposed similar limits.
These pieces of legislation are admirable in one way. They are an attempt to maintain a minimum standard of health care for a vulnerable population, but they ignore the root of the problem: If health care providers did not feel compelled to provide new, expensive services (like infertility treatments or ultrasounds or electronic fetal monitoring), more money would be available for longer postpartum hospitalization, or for spending more time educating patients in the office.
HMOs are wrong to discharge women and babies so soon after delivery without testing the practice first. But it is just as wrong to begin providing routine ultrasound examinations for every pregnant woman when the largest study ever done on this subject says they will not provide better care or result in a healthier baby. If we can agree that to avoid bankrupting an already overtaxed medical system we will not institute or eliminate practices without some semblance of supportive scientific evidence, the health of our nation, physical and financial, can only be improved.
