"In the decade before these laws, postpartum hospital stays were getting shorter and shorter, possibly because more people were covered by managed-care organizations that were trying to cut costs," said Dr. William H. Dow, assistant professor of health policy and administration at the UNC School of Public Health. "Women were leaving hospitals less than 24 hours after vaginal deliveries.
"Starting in 1995, negative press reports began featuring so-called 'drive-through deliveries,' including stories about children who had died or had other bad outcomes maybe as a result," Dow said. "State and federal governments began debating length-of-stay mandates in response to these news reports and pressure from women's advocates." In 1995, Maryland became the first of many states to regulate the length of hospital stays after birth. In 1998, a similar federal law took effect that filled gaps in state drive-through delivery regulation efforts. Those laws generally required that most health insurance plans pay for at least a 48-hour stay after vaginal delivery and a 96-hour stay following cesarean delivery.
A report on the impacts of the laws appears in the current issue of the Journal of Health Economics. Besides Dow, study collaborators include Dr. Zhimei Liu, a former doctoral student at UNC now with Zynx Inc. in Los Angeles, a private health research group; and Dr. Edward C. Norton and Dean M. Morris, associate professor and clinical associate professor, respectively, of health policy and administration.
Using a national hospital discharge database and focusing on 18 states and a million hospital records, the researchers sought to determine if the state and federal laws had any impact on hospital discharge practices over time.
"We found that the laws increased both length of stays and hospital charges, but the size of the effect wasn't as large as those estimated in previously reported case studies," Dow said. "We also found that the effects varied according to how the laws were worded and that the effects partially spilled over to Medicaid patients whose births were not covered by the laws." On average, before the legislation was passed, 55 percent of privately insured women spent one night or less following normal births, he said. Afterward, on average, 39 percent of such women spent that little time in the hospital. The change was significant.
"We cannot say yet whether the longer stays contributed to better health outcomes for women since we were not able to measure that yet," Dow said. "We suspect that if there are any health benefits that those benefits are small."
A second major finding was that the effects varied from state to state, he said.
"In Maryland, for example, very little changed once the first law was passed in 1995 in terms of length-of-stay patterns," Dow said. "After a stricter law passed in 1996, however, that led to a very sharp decline in drive-through deliveries."
A key difference was that Maryland's 1995 law allowed exceptions to be made if physicians felt that early discharge would not harm either the mother or the child. State legislators changed the law so mothers had the final say about remaining in the hospital if they wanted to, and insurance companies had to pay for the extra time. On average, the longer stays boosted hospital charges by about $200.
"Whether that is cost-effective we don't know, but previous studies have shown that longer stays certainly seemed to make the new mothers happier," he said. Answers to such questions are important for considering whether to retain or re-word the existing laws and also for debating if the laws should be extended to cover Medicaid patients as well, Dow said.
The UNC School of Public Health's Program on Health Outcomes supported the research.
Note: Dow can be reached at 919-966-7384.
School of Public Health Contact: Lisa Katz, 919-966-7467
News Services Contact: David Williamson, 919-962-8596
Journal
Journal of Health Economics