THE VIRGINIAN-PILOT
Copyright (c) 1996, Landmark Communications, Inc.
DATE: Saturday, January 13, 1996 TAG: 9601130304
SECTION: LOCAL PAGE: B1 EDITION: FINAL
SOURCE: BY DEBRA GORDON, STAFF WRITER
LENGTH: Long : 165 lines
A Virginia legislator has joined a growing legislative movement against insurance-company policies that send mothers and newborns home from the hospital 24 hours after delivery.
Del. Clifton A. ``Chip'' Woodrum, D-Roanoke, this week introduced a bill that would require insurance companies to pay for a 48-hour hospital stay after a vaginal delivery, and a 96-hour stay after a Caesarean, if the physician or mother requests it.
Four states - North Carolina, Maryland, New Jersey and Massachusetts - have passed similar bills. Comparable measures are pending in at least 10 other states and at the federal level.
Woodrum said he became interested in the issue last year after reading several articles about problems around the country resulting from early discharge of mothers and their babies. Several obstetricians also brought it to his attention, said an aide.
``I just felt this was something that needed legislative attention,'' Woodrum said.
The controversy over 24-hour discharges has grown as more and more people have joined HMOs, which regulate medical procedures more closely than traditional insurers.
Most HMOs require women who have had uncomplicated vaginal deliveries to leave the hospital one day after delivery. Those who had Caesareans are usually granted a two- or three-day stay. Most policies were implemented four or five years ago.
Critics say these policies lead to ``drive-by deliveries,'' placing newborns at risk and disrupting the physician/patient relationship by pressuring doctors to release mothers early.
``I think the insurance companies have gone to this 24-hour discharge with absolutely no evidence to show that it was proper medical care to do that,'' said local obstetrician Willette L. LeHew. LeHew chairs the Virginia chapter of the American College of Obstetricians and Gynecologists and helped draft Woodrum's bill.
The early discharge policies don't allow enough time for mother and baby to be observed by nursing staff and doctors, LeHew said. Probably 80 percent of his patients are well enough to go home within 24 hours, he said, but ``we need the option to let them stay longer if they need to.''
The region's largest HMO provider, Sentara Health System, said most of its mothers would go home within 24 hours voluntarily, even if they had the option of staying longer. Sentara implemented a short-stay policy several years ago after its data showed the average length of stay for uncomplicated vaginal deliveries was 1.2 days, said Sharon Metz, vice president.
``If the mother wants to stay for 48 hours and the doctor feels it's necessary for her health and well-being, we'll authorize it,'' Metz said.
Other HMOs in the region, including Healthkeepers, owned by Trigon, and MDIPA, owned by Mid-Atlantic Medical Services, said they too, try to be flexible with their members.
``From our perspective, we don't see the need for the legislation because we think we're doing a good job in how we're managing deliveries now,'' said Cindy Henegar, MAMSI's senior director of utilization management.
``Baloney,'' LeHew said when told of the insurers' claim of flexibility. He noted that physicians are often ``totally harassed'' by insurance companies if they want their patients to stay longer than 24 hours.
Norfolk obstetrician Theresa Whibley said she is not aware of any flexibility in the short-stay policies for anything other than fairly severe medical complications. Even if the baby is having problems, and the mother is ready to be discharged, she said, the mother cannot stay.
Last year, several major medical associations jumped into the short-stay fray. In May, ACOG urged that no more short-stay policies be implemented until their safety was established.
In June, the American Medical Association adopted a policy saying that the time of discharge should be determined by the physician ``and not by economic considerations.''
In October, the American Academy of Pediatrics issued its policy statement condemning insurance companies' ``arbitrary newborn discharge policies.''
At the same time, the AAP set minimum criteria (see related story) that should be met before newborns are discharged. It's doubtful, the AAP said, that most mothers and their babies will meet these criteria in less than 48 hours. The guidelines include having the infant urinate and have at least one bowel movement, and providing detailed education to the mother on such things as breastfeeding, bathing and proper infant safety.
``There are clearly some babies who, from a medical standpoint, seem like they're OK to go home, but perhaps the mothers are not ready for the volume of items that they're required to do in taking care of the baby,'' said Robert Fink, a Hampton Roads pediatrician who is the AAP's local spokesman.
Since the advent of early discharge policies, doctors throughout the country have reported an increasing number of babies with jaundice, a condition in which the infant is unable to excrete bilirubin, a yellow pigment that builds up in their blood and skin. Left untreated, jaundice can lead to brain damage or even death. A longer stay, say pediatricians, would help detect jaundice problems.
Other problems that can result from early discharge, Fink said, include dehydration from inadequate breastfeeding and problems with bonding between mother and baby.
Medical professionals say some of these problems could be avoided if insurance companies automatically sent a home health nurse to visit every mother and baby who have been discharged early. But not all do, Whibley said.
Some plans, like Sentara and Trigon's HMOs, said they provide home health nurses when the physician requests them.
But physicians are loathe to request too many services that may negatively affect their medical and financial ``profile'' with an insurer, Whibley said, which shows how much it costs to provide care for their patients.
Even if the Virginia legislation passed, she said, she fears doctors would still hesitate to keep their patients an extra day unless there were specific medical reasons for it. ``The insurance companies keep track of our lengths of stay, and they evaluate them when they contract with us,'' she said.
Whibley and other physicians are not optimistic about the legislation's chances in the General Assembly. ``The insurance lobby in Virginia is very, very powerful,'' Whibley said.
The bill has been sent to the House Committee on Corporations, Insurance and Banking. MEMO: RECOMMENDATIONS
The American Academy of Pediatrics recommends that the following
conditions be met before newborns are discharged. The AAP said it is
unlikely that criteria will be fulfilled in less than 48 hours. Further,
the academy said, the timing of discharge of the newborn from the
hospital should be ``the decision of the physician caring for the baby,
not by arbitrary policy established by third-party payers.''
The criteria include:
Uncomplicated pregnancy, delivery and recovery for both mother and
baby.
Vaginal delivery.
The baby is a single newborn born between the 38th and 42nd weeks of
pregnancy, and is an appropriate weight.
The baby's vital signs are normal and stable for the 12 hours
preceding discharge.
The baby has urinated and passed at least one stool.
The baby has completed at least two successful feedings, with
documentation that the baby is able to coordinate sucking, swallowing
and breathing while feeding.
There are no abnormalities that require continued hospitalization.
There is no evidence of excessive bleeding at the circumcision site
for at least two hours.
There is no evidence of significant jaundice in the first 24 hours of
life.
The mother's knowledge, ability and confidence to provide adequate
care for her baby are documented by the fact that she has received
training sessions regarding:
Breast-feeding or bottle-feeding. The breast-feeding mother should be
assessed by trained staff regarding nursing position, latch-on,
swallowing and mother's knowledge of urine and stool frequency.
Cord, skin and infant genital care.
Ability to recognize signs of illness and common infant problems,
particularly jaundice.
Proper infant safety (for example, proper use of a car seat and
positioning for sleeping).
Family members or other support persons familiar with newborn care
and knowledgeable about lactation and the signs of jaundice and
dehydration are available to the mother and the baby for the first days
after discharge.
Screening tests are performed in accordance with state regulations.
Initial hepatitis B vaccine is administered or a scheduled
appointment for its administration has been made within the first week
of life.
A physician-directed source of continuing medical care for both the
mother and the baby is identified, and an appointment for the baby to be
examined within 48 hours has been made.
Family, environmental and social risk factors should be assessed,
including parental substance abuse, income, lack of social support,
history of domestic violence and age of mother.
KEYWORDS: BIRTHS GENERAL ASSEMBLY MEDICAL CARE PREGNANCY by CNB