Attack the Profit Motive, Not Case-by-Case Horror

Eight-hour hospital stays for women who have just given birth. Outpatient mastectomies for breast cancer. In the new world of managed health care, focused like a laser on the bottom line, patients are being thrown out of hospitals “quicker and sicker,” as nurses put it, or not being admitted at all.

In the high-visibility, emotionally compelling cases such as maternity stays, an uproar resulted. State legislatures reacted with bills mandating that HMOs and other insurers pay for 48-hour stays after vaginal deliveries and five days after caesarean sections. And now state legislators and members of Congress are proposing that insurers pay for two-day stays for mastectomies.

This kind of procedure-by-procedure approach to legislating appropriate hospital stays ultimately can’t work. Reducing the use of hospitals is the central cost-cutting, profit-boosting mechanism of the managed care industry. Lengths of stay are being cut dramatically for just about every serious medical illness and surgical procedure.

Reacting only to high-sympathy cases like mastectomy and childbirth obscures the breadth of the problem. Is it any less heart-wrenching to ask a 75-year-old woman with crippling arthritis to care for her 79-year-old husband, recovering from heart surgery, than to ask a 45-year-old man to care for his wife hours after an outpatient mastectomy?

Paradoxically, even successful passage of piecemeal legislation could make the general problem of de-hospitalization worse by giving the public and lawmakers the impression that the problem is being dealt with, while most patients remain unprotected. Additionally, there are thousands of medical diagnoses and procedures; it is simply impossible to legislate each of them. Decisions about when a patient should be hospitalized or when it is safe to send her home can be made only when a range of factors--including the patient’s condition, level of pain and other symptoms and the situation at home--is considered.

Consider a recent case that occurred in New York state.

A woman, 23, pregnant for the first time, began to have severe nausea and vomiting in her 12th week. She became dangerously dehydrated, but her HMO physician refused to admit her to the hospital for intravenous fluids. Instead, he insisted that IV fluids be administered at home. The exhausted, dehydrated woman was cared for by her father, who was recovering from a life-threatening illness, a mother who had just had a hip replacement operation and a husband whose own mother was having a bone marrow transplant in another city. Despite the family’s best efforts, her worsening dehydration resulted in a kidney stone, for which, finally, she was admitted to the hospital.

Ignoring the family’s situation yet again, the woman’s HMO sent her home quickly, with an even more sophisticated intravenous line that the family was charged to maintain.

How could legislation be designed to protect this woman? Would lawmakers mandate hospitalization for intractable nausea and vomiting during pregnancy? Would there be a minimum length of stay for kidney stones?

Disease-of-the-day laws are only an illusion of protection. Instead, reluctant legislators will have to tackle the far bigger issue of the appropriate role of profit in health care. Investor-owned managed care plans routinely take 20% to 30% of premium dollars off the top for profit and administration. Nonprofits have a better record in this regard, but ruthless competition for employer contracts and doctor “bonuses” for cost-cutting are blurring the distinction. Hospitals, which used to be almost exclusively not-for-profit institutions, are being taken over by large corporate chains.

Corporate entities have redefined the mission of health care. Their primary concern is not to meet the needs of their patients and communities but to fulfill their legal mandate to maximize return to investors. Cutting costs and boosting profits are the first considerations and it’s unarguably profitable to deprive patients of services.

Competition for the lowest price and consolidation in the health-care industry are making things worse. Without a wide umbrella of protection from our elected representatives, any one of us could find ourselves out in the rain with our portable IV lines.