Shorter hospital stays: How short is too short?
Sacramento Business Journal - by Stephanie Mckinnon Mcdade / Correspondent
As managed care enters adolescence, growing pains have kicked in. And one area where the kicking has been most noticeable is in shorter hospital stays.
Shorter stays for new mothers and infants -- so-called "drive-by deliveries" -- have been hugely controversial, as have shorter stays after mastectomies. But thousands of other procedures now involve less hospitalization than they used to.
The average length of stay in Sacramento area hospitals in 1995 was 4.19 days -- a 20 percent drop from 1991, when the average was 5.25 days, state records say.
"The primary drive to find more efficient ways to deliver healthcare is definitely motivated by restricted dollars for healthcare," says Dr. Rolland Lowe, president-elect of the California Medical Association. "We have looked at shortening stays in the hospital, which is the most costly part of healthcare."
In California, 13 million people -- one-third of the population, and a higher percentage in Sacramento -- are covered by health maintenance organizations. HMOs have helped curtail medical inflation in several ways.
One way has been with preventive medicine. Primary care physicians catch disorders before they become emergencies. And when a hospital procedure is required, the patient is taught what's involved and often gets preoperative therapy to strengthen the body for recovery.
But the real change agent is money -- less of it. In the old fee-for-service medicine, hospital profit came from patients who were hospitalized. Now, hospitals can lose money if their average length of stay is not controlled.
Control has come in several ways. New technologies and procedures involve quicker recovery time, from bypass surgery to hip replacement. Hospitals also have formed partnerships with doctors to share financial risk, so that physicians are careful about what they order. And hospitals have changed the way they operate.
A self-defeating cycle? HMOs move patients who are recovering away from the hospital and into less-costly alternatives, such as home healthcare, sub-acute facilities or simple clinic follow-up.
"The hospital is not the end-all and be-all that it was 20 years ago," says Daniel Doore, central area chief executive officer for Sutter/CHS, pointing to a growth in outside services. "Home care has grown, medical equipment supplies are up, urgent-care clinics have grown. The whole network of services have grown over the last five years."
In 1994, there were 1,059 licensed home health agencies in the state; they made 14.3 million visits to 620,000 patients. Some of the revenue going to home health, however, once went to hospitals. And ultimately, Doore worries that the effort could be self-defeating.
"There's been a 2 percent to 4 percent reduction in premiums, so we're operating with less revenue" he says. "Our margins are thinner, which means we have less money to invest in the future technology that helps decrease length of stay.
"With shorter lengths of stay there will be twice as many hospital beds as we need in the year 2000." As a result, Sutter is merging two of its area hospitals.
Despite the financial pain, few providers say it's affected quality of care.
"The key when looking at length of stay is to know what's available before and after surgery, and to reduce variances in procedure," says Barbara Crawford, quality outcomes leader for Kaiser Permanente in Sacramento. "We get better at providing care because we get better at being consistent with that care."
Crawford helps set Kaiser's "clinical paths," or care guidelines. A group of doctors, nurses and managers examine a "homogeneous group" of patients for a procedure. The guidelines they set begin with education, followed by a specific procedure, placement after surgery and follow-up care.
"When we look at designing a clinical path, we don't look at the money saved," she says. "If you reduce variances you will reduce costs by standardizing the costs."
One size fits all: Some physicians believe such standardization can be irresponsible, that doctors aren't involved enough and that inadequate checks are made to ensure that each patient fits into the "homogeneous" patient base, or is being discharged to a strong support system.
Quick discharges for new mothers and infants have triggered debate in government. Congress has mandated that insurance companies start paying for 48 hours of hospital stay, beginning next Jan. 1. Currently, many HMOs pay for only 24 hours, even when physicians recommend a longer stay.
Mastectomy stays draw similar fire.
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