Erika Lanasa entered the hospital at 3 p.m. and delivered her son, Anthony, at 7:37. Less than 24 hours later, at 2:30 p.m., she checked out in accordance with the new rules of her insurance company, Blue Cross and Blue Shield of Maryland.
Nurses barraged Mrs. Lanasa with information about how to care for her new baby during her short stay last February at the Greater Baltimore Medical Center. But the 28-year-old Baltimore housewife and her husband were too exhausted to absorb it and wound up calling the hospital for help nearly as soon as they arrived home.
"We are promoting this health stuff, but we don't give the moms the chance to learn how to feed the babies," said Mrs. Lanasa, who founded a peer support group for new mothers as a result of her experience. "A lot of women are feeling dead-tired, and having to remember how to care for a circumcision is difficult.
"Nowadays, there is nobody around," she added. "Most women are in a single home by themselves all day."
Mrs. Lanasa is one of an increasing number of new mothers in Maryland being forced out of hospitals 24 hours after a normal delivery by Blue Cross and other payers looking for ways to reduce medical costs. (For a Caesarean section, major abdominal surgery, the stay is down to 72 hours.) And medical officials say 24 hours in a hospital is too short a time to teach mothers -- especially teen-agers -- how to breast-feed and adequately care for their newborns.
"I really wasn't prepared to function," said Beth Stein, 27, a personnel administrator for Mars Supermarkets in Harford County. She came home groggy June 7, three days after delivering her son, Brady. "I couldn't bend over. I couldn't sleep. It was terrible."
Hospital stays have dropped steadily for five years, but the 24-hour policy for routine maternity cases took Greater Baltimore Medical Center by surprise beginning six months ago. That is when the state's largest insurer joined some health maintenance organizations in insisting that doctors cite medical necessity before allowing mothers to stay longer. Until then, Blue Shield had covered 48 hours.
Blue Cross officials said when they changed their reimbursement rates a year ago they looked to state guidelines for a now-defunct medical assistance program for poor pregnant women not covered by federal programs.
But the administrator of Medicaid programs in Maryland said Friday that the state guidelines were never applied to poor women, who are covered under federal programs. Under federal guidelines, a "medically necessary" stay for a new mother can last three days before regulators question any payments.
"The likelihood that any woman would deliver under the state medical program is remote at best," said Lawrence R. Payne, director of the medical care compliance administration in the Maryland Department of Health and Mental Hygiene. "The argument is specious."
Friday, Blue Cross officials said they also consulted several studies, including one by a Michigan consulting firm, of trends in hospital stays in the western United States in arriving at the 24-hour norm. Blue Cross also claimed that it is one of the last insurers to move to a shorter stay.
Caught off guard, Greater Baltimore Medical Center and other hospitals are scrambling to make major changes in the way they care for mother and baby to ensure the health of both. And health care professionals are concerned about the effects of shorter stays.
"I think it is criminal," said Dr. Karin Blakemore, obstetrician and assistant professor at the Johns Hopkins University. "I am not sure in terms of long-term benefits that this is where we want to start with mother-child relationships. There is no time to teach them anything."
Beyond making it difficult for new mothers to learn how to give a screaming baby a bath, she and a half-dozen top pediatricians at area hospitals say, early discharges don't give the mothers time to learn how to breast-feed or what the signs of jaundice are.
"Some of these kids are coming back with very high levels of bilirubin," said Dr. Steven Amato, chair of pediatrics at GBMC. "Parents are coming back saying, 'Gosh, my child looks like a pumpkin.' "
Although some insurers routinely attempt to provide the same education at home through visiting nurses that hospitals now offer for an additional $300 to $500 a day, the system has its flaws.
At the University of Maryland, doctors say they are gravely concerned about the impact of the new policies on socially at-risk teen-agers with low levels of education. In many such instances, they said, the follow-up home visit that takes the place of the extra day in some insurance programs is useless because many teen mothers don't return to the address they use on admission papers.