Maternity Rules Raise Questions on Care, Cost

Until July, most mothers and their infants were sent home from Greater Baltimore Medical Center in less than 24 hours after routine deliveries because insurers balked at paying for longer stays.

But since Maryland began requiring insurers to pay for at least 48 hours of hospitalization, new mothers have overwhelmingly taken advantage of it--and the hospital has had to double the size of its maternity ward. Meanwhile, fewer babies are being readmitted for complications.

Nurses, relieved that they no longer had to console tearful mothers who didn’t want to leave the hospital, hung a banner reading: “We Survived 24-Hour Stays.”

Arguably the nation has too. Congress is poised to make the 48-hour maternity stay the law of the land, reversing a trend that had driven maternity stays to as little as six or eight hours.

Congress is expected to approve the new maternity rules this week. President Clinton, a supporter of the legislation, is expected to sign it, and it would go into effect in January 1998. (The bill also mandates a minimum 96-hour hospital stay for caesarean-section births.)

The bill--which allows mothers the option of leaving the hospital earlier than 48 hours if they and their doctors see fit--poses a host of new issues for patients, the health care industry, insurers and employers. Foremost, it seems certain to drive up medical costs for health insurers, who will pass those costs on to employers, who will eventually pass it on to workers, employee-benefits experts say.

But others say the new law could be a catalyst for innovations in health care, prompting hospitals and insurers to develop less-costly alternatives to hospitalization for mothers and newborns. For example, hospitals might choose to build nearby outpatient maternity centers where mothers and babies could be transferred after one or two days to be monitored by nurses.

In any case, if Maryland--the first state to pass such legislation--is any guide, the new law will be much appreciated by new mothers. More than 80% of Greater Baltimore Medical Center’s mothers are opting to take advantage of the second day, and other Baltimore hospitals report similar experiences.

“So many of our patients were leaving in 18 hours or less, and we ended up with a lot of tears,” said Lisa Boyce-Gates, manager of maternal services at the hospital in an affluent section of north Baltimore. “It was a nightmare for hospital staff because so many of our mothers didn’t feel confident, physically or emotionally, to go home. They felt like they were hamsters and you were running them out the door on a wheel.”

The increasingly widespread practice of sending healthy mothers and infants home in less than 24 hours--derisively dubbed “drive-through deliveries” by critics, who say it endangers patients’ health--was intended to attack rising health care costs.

Such arguments won the day in 28 states during the past year, but not in California, where 48-hour-stay legislation died in the Legislature this summer after intense opposition from health insurers.

The insurers argued that the issue was overblown. They said there was scant evidence that earlier discharges posed greater medical risks to mothers and newborns or that lots of women were clamoring to stay longer in the hospital. They also insisted that doctors, not insurers, were determining how soon mothers would be discharged.

“Patterns of care shouldn’t change because, even today, [maternity-discharge] decisions are made on a case-by-case basis,” said Richard I. Smith, vice president for the American Assn. of Health Plans, a trade group.

But Victor Khouzami, a Baltimore obstetrician, said Greater Baltimore Medical Center has “already seen a decline in hospital readmission rates for babies” due to jaundice and other health risks. Some hospital officials in New Jersey, the second state to enact a 48-hour-stay law, also report a decline in readmissions.

For now, the Maryland law has provided a boon for some Baltimore hospitals, allowing them to fill empty beds or open wards previously taken out of service.

The longer stays are giving nurses more time to instruct mothers in infant care and to monitor babies for medical problems that often do not appear in the first 24 hours.

“We don’t have to rush the nursing staff to provide baby-care and breast-feeding instruction to the mothers,” Khouzami said.

Some health care experts, however, say the longer maternity stays may prove a mixed blessing.

“From the hospital’s point of view, [the 48-hour-stay] law represents additional revenue,” said Robert Kowal, Greater Baltimore Medical Center’s chief executive. “[But] as a societal issue, it represents additional health care costs.”

One estimate by health care consultant Watson Wyatt Worldwide found that the federal law would affect roughly 60% of all insured maternity admissions in the West.

Lengthening maternity stays to 48 hours from 24 hours for normal vaginal deliveries would raise bills by 18%, according to the study, based on 1993 data.

In California--where upward of 80% of the privately insured population is enrolled in managed-care plans, which have been among the most insistent on shorter maternity stays--the cost figures would likely go even higher, benefits experts say.

And hospital officials are concerned that insurers will use their marketplace clout to push the cost burden down to them. “Some of the insurers are already looking into creative ways to lessen their loss for the second day,” Kowal said.

Jim Lott, a spokesman for the Healthcare Assn. of Southern California, which represents hospitals, notes that the proposed federal law doesn’t specify the amount that insurers must pay hospitals for additional maternity days.

“Insurance companies can still leverage the oversupply in the market and say, ‘We’ll pay you $600 a day for a two-day stay,’ ” Lott said, adding that that would not be enough to cover the cost.

Ultimately, however, the extra cost is borne by employees.