Correspondence
Effects of a Law against Early Postpartum Discharge
N Engl J Med 2003; 348:1602-1603April 17, 2003
- Article
To the Editor:
Madden and coworkers (Dec. 19 issue)1 provide data suggesting that mandating an increased length of stay for maternity care has had a limited effect on public health in terms of health outcomes in newborns. However, it is also important to recognize that society has clearly valued this change from the standpoint of the provision of more rest for new mothers and greater assurance that parents will be more confident at discharge as they assume child-care functions. It is important to recognize that this societal benefit carries costs.
Although the authors present data indicating that expenditures by a health maintenance organization (HMO) were minimally affected by this change in policy, the costs incurred by the hospitals providing the service are more important than the expenditures of the HMO. It is clear, on the basis of data from my own institution, that the overall costs of maternity care, including associated longer lengths of stay, have substantially increased during the time frame of this study, whereas the margins or “profits” — particularly from low-risk deliveries — have declined substantially. For an institution like my own, such margins are needed to offset the poorly reimbursed and increasing costs of high-risk maternity care. Although one might argue that my hospital should have negotiated better coverage of costs from commercial HMOs, unfortunately, a substantial percentage of our care involves patients covered by Medicaid, whose payments have languished for more than a decade. In short, although they are of some benefit to society, such unfunded mandates, at least in Massachusetts, may have a negative effect on many hospital systems that are already in financial crisis.
1 ReferencesRonald T. Burkman, M.D.
Baystate Medical Center, Springfield, MA 01199
rtb@bhs.org 1
Madden JM ,Soumerai SB ,Lieu TA ,Mandl KD ,Zhang F ,Ross-Degnan D . Effects of a law against early postpartum discharge on newborn follow-up, adverse events, and HMO expenditures. N Engl J Med 2002;347:2031-2038
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To the Editor:
Madden et al. present evidence that a law against early postpartum discharge had little effect on HMO expenditures and adverse events. The decision by the HMO to look only at cost effectiveness and safety — with any psychosocial factors ignored — is the reason that HMOs have become so unpopular. The irony is that the decision itself had its own unintended consequences of causing desperation in hundreds of women and requiring the passage of the law.
Joseph M. Heyman, M.D.
24 Morrill Pl., Amesbury, MA 01913
jh@massmed.org Author/Editor Response
Dr. Burkman suggests that hospitals may have been financially harmed by laws requiring a minimum maternity stay. Ideally, policy decisions in this area should be supported by complete analyses of costs from the societal perspective as well as from the narrower perspective of each group affected, including patients, clinicians, hospitals, and insurers. Our cost analysis was constrained by the data available to us from the billing systems of one insurer. We would welcome rigorous studies of the economic effect on hospitals of changes in the length of stay, which are practically nonexistent in the literature.
Both Dr. Burkman and Dr. Heyman raise the issue of mothers' readiness for discharge. We share their concern about the well-being of mothers. However, it would be difficult to calculate the full spectrum of psychosocial effects attributable to changes in the timing of discharge and the intensification of outpatient and home-based services. The lack of attention to maternal readiness in our article is due to the absence of relevant retrospective measures. Unpublished analyses of available measures such as postpartum mental health–related diagnoses and services show no evidence of changes related to policy. Our data do suggest, however, that the frequency of screening for depression in pregnant women increased substantially after implementation of the reduced-stay program.
Our coauthor Dr. Mandl and his colleagues previously evaluated the same reduced-stay program at Harvard Vanguard Medical Associates and Harvard Pilgrim Health Care by investigating the experiences of mothers who delivered at the largest contracting hospital.1 Using postdischarge telephone surveys of women who delivered in early 1995, when no other insurer had an early-discharge program, they found no differences in the sense of maternal competence, depressive symptoms, or satisfaction with care among women with stays of different lengths. A simultaneous survey of members of Harvard Vanguard Medical Associates and Harvard Pilgrim Health Care who delivered at other contracting hospitals showed no differences in overall satisfaction between mothers with shorter stays and those with longer stays. These two assessments preceded the extensive negative publicity concerning shorter stays, which supporters of the program believe shaped public opinion. It is also worth noting that there were steady increases in the rate of voluntary early discharge before the implementation of the reduced-stay program.
No HMO in the competitive insurance market in eastern Massachusetts can afford to ignore customer satisfaction. Meanwhile, managing ever-limited resources for an enrollee population requires difficult choices, and cost effectiveness and safety must be fundamental criteria for the ethical allocation of resources.
1 ReferencesJeanne M. Madden, Ph.D.
Dennis Ross-Degnan, Sc.D.
Stephen B. Soumerai, Sc.D.
Harvard Medical School, Boston, MA 02115
drossdeg@hms.harvard. edu 1
Mandl KD ,Brennan TA ,Wise PH ,Tronick EZ ,Homer CJ . Maternal and infant health: effects of moderate reductions in postpartum length of stay. Arch Pediatr Adolesc Med 1997;151:915-921
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