An Age of 'Drive-thru Deliveries'

July 11, 1995|By ELLEN GOODMAN

BOSTON — Boston. -- The phrase is just a little too cute. ''Drive-thru deliveries''? Not even the most parsimonious health insurer has actually told a mother to keep her car running outside the delivery room for a postpartum getaway.

But you get the idea. Suddenly, we are confronted with a fast-food approach to birthing. Mothers don't dally at the hospital anymore. They don't even have time to digest. They're supposed to get what they came for -- a baby -- and get out.

Remember all those years when women tried to get the medical establishment to stop treating childbirth like an illness? Remember the pressure to make delivery less institutional and more homey? Well, be careful what you wish for.

In the 1990s, the postpartum world isn't just like home, it is home. Mothers and babies are routinely discharged in a day. Sometimes they're ejected 12 or even six hours after delivery.

This is not because the insurers took a women's health movement seminar. It's because of financial pressures. The new managers of care may not yet have limited the number of contractions on your health plan, but they've determined how many hospital hours you're permitted.

The managed care of mothers is not all that different from the managed care of any other patients. In the new world of cost-cutting medicine, any treatment short of a triple-bypass is a candidate for an outpatient procedure. People are being discharged with -- I use the term deliberately -- abandon.

But with four million deliveries a year, birth is the most common reason for hospitalization and the most widely shared experience. With the growing testimony about dramatic and sometimes dangerous results of early discharge, this is the procedure that's finally rung the national alarm bell.

There is alarm about the small but serious number of problems in newborns discharged too early. Problems of jaundice, dehydration, even death. There's alarm as well about the mothers dismissed before they felt physically or emotionally ready to deal with their children at home. There's the loudest

alarm at the sense that neither patients nor doctors -- but rather HMOs and insurers -- are making medical decisions.

For every story about a newborn who developed severe problems, for every mother without enough time to heal or learn how to breast-feed, there's a tale of a doctor under pressure to cut costs or be ''de-selected'' from some insurer's list of providers. One threatened obstetrician in New Jersey even called herself ''an indentured servant.''

For these reasons, ''drive-thru'' patients and stressed-out doctors have jointly turned to the legislature for help. Maryland and New Jersey have now both passed bills that require insurers to pay for a hospital stay of at least 48 hours after a routine delivery. Similar bills have been introduced in California and Massachusetts.

On June 27, a bill was also introduced in the U.S. Senate that would make 48 hours the standard for a routine delivery and 96 hours for a Caesarean. Shorter stays would be permitted as long as the doctor and mother agreed and home health care was provided.

Generally, it's a bad idea to legislate medical treatment. We don't want politicians deciding that everyone's entitled to an X-ray or to a certain medication for a disease. Medicine changes too fast. Health problems are too diverse for mass prescription.

Even in childbirth, there are a lot of women who regard the hospital as unhealthy and want to get out as quickly as possible. There are some who prefer to give birth at home.

At $1,000 or so a day, the hospital's a pretty expensive place to use for recuperating or for learning how to bathe a newborn. The option of a home health visit is a good one if it exists and works properly.

But it's clear that we need some legislation to keep medical decisions in the hands of patients and doctors. That's not just true in the managed maternity ward but in the whole new health care world.

Robert Blendon of Harvard's School of Public Health says that we are witnessing the emergence of new medical consumer protection laws. There's an alliance between the consumer -- the patient -- and the physician. Both want medicine to be practiced according to the highest professional standards, not according to the industry's bottom line.

In the end we don't just want to protect the number of hospital hours. We want to make sure that the quality and quantity of treatment is determined by medical judgment.

What better place to begin than at birth? On the highway to drive-thru deliveries, we're finally laying down some speed bumps.

Ellen Goodman is a Boston Globe columnist.

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