It sounds like a crime begging for action: The penny-pinching insurance industry is saving money by forcing mothers and their newborns out of the hospital so fast that both are exposed to serious, possibly life-threatening complications.

It's hard to find evidence that this problem — known by the negative nickname "drive-through deliveries" — is widespread. But anecdotal testimony abounds. Obstetricians and pediatricians say more and more insurers expect discharge of mother and baby within 24 hours of delivery. Mothers tell of having to go home from the hospital when they still have not recovered from giving birth, and before receiving important education in caring for a newborn. Their babies have been subjected to the risk of jaundice and dehydration. Everyone seems to know someone who knows someone who has been affected.

For their part, insurance industry representatives insist they have not pushed mothers and babies out too early. If they did anything medically improper, insurers say, they would face lawsuits costing far more than any savings. But the issue has resonated so much with the public, and consequently with its elected representatives, that the normally clout-heavy insurance industry and its business allies have waved a white flag of surrender. It became impossible to overcome images of new mothers being sent home by ruthless insurers, says Larry Barry, president of the Illinois Life Insurance Council, which represents most of the major health insurers doing business in the state. "We were getting beat up for something that we're not doing, which is nuts. We don't like the government getting into how long length of stay should be, but we were just getting killed."

Illinois officials are almost certain to curb the practice of early discharges this spring; the idea has become so popular that two state representatives engaged in an unusually public floor fight over who deserved the most credit for the mea-

Length of stay for all births:1987-1994

Source: Illinois Health Care Cost Containment Council. Data includes caesarian and vaginal births.

Illinois Issues May 1996 ¦ 27

sure. The example of intense public interest overcoming powerful forces to fuel legislative action is something that worries the insurance industry.

If such interest can spur governmental action on "drive-through deliveries," similar interest might encourage lawmakers to intervene in other cost-cutting efforts of managed care insurance plans. When the idea of curbing early maternity discharges was proposed last fall, Jeff Mays, vice president of human resources at the Illinois State Chamber of Commerce, decried "the frontal assault this legislation launches on managed care."

Managed care plans, commonly in the form of health maintenance organizations, or HMOs, limit participants' ability to get whatever care they need from whatever doctor or hospital they want. Unlike a traditional fee-for-service program, a managed care plan gives patients' primary care doctors, known as gatekeepers, the power to determine care, including whether the patients will see specialists.

By controlling access to expensive and unnecessary tests and additional doctors, the industry argues, managed care plans can save money without sacrificing quality. In theory, a doctor with an incentive to keep a patient healthy will provide more cost-effective preventive care.

Robert K. Burger, executive director of the Illinois Association of HMOs, says everyone benefits because managed care provides high-quality health care at lower cost. And, because they save money, managed care plans are spreading. The programs are most prevalent in the Chicago area and in midsized downstate cities such as Rockford and Champaign. Those regions have the critical mass of patients, providers and facilities that allow managed care to work.

Yet Dr. Bernard J. Turnock, who heads the community health sciences department at the University of Illinois at Chicago, says many people don't like managed care because it involves an outside force placing limits on their choices.

Enrollment of Illinoisans in health maintenance organizations as of December 31 of the year listed.
1990	1,536,485
1991	1,571,650
1992	1,672,490
1993	1,649,974
1994	1,746,918
1995	1,957,457
Source: Illinois Department of Insurance

"The public in general has kind of an idyllic view of medical care, where we almost all have immediate access to some sort of Dr. Welby figure who will tie us into the most sophisticated, up-to-date technologies that will save our lives," says Turnock. "Now we've come to a point that we can't afford to have that and the controls are being put on, and it threatens our sense of what's safe and secure."

When Turnock was state health director he championed preventive efforts in which society uses its resources to prevent problems rather than spending more money to cure illnesses after health problems have developed. He says the theory behind managed care is good. But he says it is most likely to work in areas where managed care has been in place a long time, rather than such places as Illinois, where new players are trying to win business by charging low prices.

Meanwhile, doctors are among the plans' loudest critics. They argue that managed care programs save money and increase profits by unreasonably restricting their patients' access to care. "You have to look at ways to save money," says Dr. Raymond Hoffmann, a Rockford surgeon and president of the Illinois State Medical Society. "We think that managed care and some of these issues do save money and are noble. We are just concerned that we don't push so hard that we push the quality out of the system."

Dr. Ronald Ruecker, who serves on the medical society's board, agrees. The Decatur internist, who specializes in gastroenterology, says a doctor's main goal is healthy patients. Managed care firms, he says, may not oppose that, but their main consideration "may be the balance sheet."

In fact, American Medical Association affiliates have been lobbying for restrictions on managed care programs all over the country. Illinois' medical society has dubbed its version the "Patient Rights Act." The accompanying public relations campaign emphasizes such issues as patients' ability to choose their own doctors and concerns about quality of care. The doctors especially dislike having to justify their actions to insurance company medical departments. And their proposed legislation would give them much more power in their dealings with insurers.

Representatives of the insurance industry and other business interests want to preserve their ability to implement policies they think will help them control health care costs. The state chamber's Mays refers to the medical society's proposal as the "Doctor Protection Act" because, he says, it would strip away almost all insurers' abilities to control costs.

Politics, not substance, may determine the outcome of proposals to change managed care. Republican leadership kept the medical society's bill stuck in each chamber's rules committee, which avoided an election-year fight between two of the party's staunchest political and financial backers. But the high stakes that accompany legislation affecting the insurance industry has stalled less sweeping measures.

For example, state Rep. Rosemary Mulligan, a Republican from suburban Des Plaines, wants to require managed care plans to guarantee to women reimbursement for one gynecological checkup each year, or the option of choosing an obstetrician-gynecologist as her primary care doctor. Yet Barry, who represents the health insurance industry, says such legislation is unnecessary because insurance companies already do what Mulligan wants. She counters that insurers would not oppose her proposal so forcefully if they already followed this policy.

Without the kind of public interest

28 ¦ May 1996 Illinois Issues

that surrounded the "drive-through delivery" idea, Mulligan says, her proposal could not survive the insurance industry's intense lobbying.

People on all sides of the health care debate — from physicians to insurers to consumers — predict that both broad and narrow managed care questions will appear on the legislative agenda even after the baby delivery issue is long forgotten.

"I haven't heard anyone suggest that the battle is over," says Burger of the HMO association. "The medical society is a respected and powerful body, and I would not anticipate that this legislation is going away."

Turnock thinks the most important thing government can do is to make sure consumers who use medical services and the businesses that pay for them get quality information that allows them to evaluate whether particular providers have good results. He says that would allow the marketplace to work better.

"Managed care is here to stay. How can you be against managed care? Do we want unmanaged care?" he asks. "The question is who is going to be managed. To what extent will government allow the private sector to totally control and manage health care as a commodity?"

Managed care, he says, "will ensure both better care for people, and more effective use of our resources than totally unmanaged fee-for-service types of arrangements. But it will require some significant adaptations from both consumers and providers to act more responsibly, to treat health as a social good rather than a commodity."

Indeed, many lawmakers report growing numbers of constituent complaints about managed care. But it seems clear that without the widespread public interest generated by "drive-through deliveries," they cannot move forward with legislation limiting health insurance. In the long run, it appears the public holds the power to prescribe treatment for the industry's ailments.

Anthony Man is the Statehouse bureau chief for the four Lee Enterprises Inc. newspapers with readers in Illinois.

Regulations on hospital stays for moms and their new babies Lawmakers want mothers and babies to get more time in the hospital after birth. Pending legislation would specify a 48-hour stay in the hospital for a normal, vaginal delivery, and 96 hours of hospitalization following a Caesarean section. There are no guarantees, however. The key decisions are left with the doctor, not the patient. Just how much the 48/96 hour guidelines would increase hospital stays is unclear. The Illinois Health Care Cost Containment Council reports the average length of hospitalization for mothers was two days in 1994, down from 2.2 days the year before. Its database is not broken down to reflect differences in mothers' stays for vaginal births and caesareans. The council reports that vaginal birth newborns spent an average of 1.6 days in the hospital in 1994, and C-section newborns were in the hospital for 3.5 days. Also, state law can regulate only the 30 percent to 40 percent of insured Illinoisans who are covered by traditional insurance plans, not the majority, who are covered by employer self-insurance programs. Most companies are self-insured even though their benefit programs may be managed by insurance companies. The legislation would apply to self-insured state and local government programs and probably the Medicaid health program for the poor. Despite the conditions, David Harris, a vice president of the Illinois Hospital and Health Systems Association, predicts the legislation will lengthen hospital stays for mothers and babies. He says the legislation probably will make it easier for doctors to keep patients in the hospital longer because they will not have to spend so much time and energy justifying their actions to the insurers. Hospital association, insurance industry and cost containment council figures show an extra day of hospitalization can cost from $800 to $1,500. There were 189,000 babies born to Illinois residents in 1994, but many of those deliveries had hospital stays longer than the new minimums. The cost containment council reports about 71,000 women were discharged in one day. If each of them stayed for one more day at $900, that would cost $64 million. Some medical authorities say the extra day is worthwhile. The Illinois chapter of the American Academy of Pediatrics says there is "substantial risk of injury" from jaundice and dehydration with early discharges because those conditions may not be detected in the first 48 hours of life. The insurance industry argues it never has sent people home too quickly. Lobbyists say their companies consistently have paid for care as long as it was medically necessary. Often, they say, women who are discharged early may feel it would have been better to stay in the hospital for what may be worthy — but not medically necessary — reasons. In one of the few scientific studies of the issue, a Dartmouth University researcher examined 15,000 New Hampshire births in 1993. Dr. Judith E. Frank found that babies discharged at less than two days had a 50 percent greater chance of readmission and a 70 percent greater chance of an emergency room visit than those discharged at two or more days after birth. But she also found that the increased cost from readmissions was more than offset by the cost savings from earlier discharges. She reported that the cost of rehospitalization of infants whose risk was attributable to early discharge was less than 1 percent of the charges for an additional day of hospitalization. Anthony Man

Illinois Issues May 1996 ¦ 29