Journal Issue: Low Birth Weight Volume 5 Number 1 Spring 1995
The aggregate effect of these changes in manpower, facilities, technology diffusion, financing, competition, and health care organization has been a cessation or even reversal of the general trend toward regionalization. This deregionalization has been noted in several studies. The National Perinatal Information Center studied six regions using in-depth interviews with hospital executives, neonatologists, and obstetricians. While there was great variation from region to region, most agreed there was a general deterioration in perinatal regionalization, that competition had replaced cooperation, and that traditional levels of care were blurring as all facilities escalated the level of care provided. These trends also occurred in many community hospitals where the volume of patients was inadequate to maintain professional skills or provide a cost-effective revenue base.71 Another study of the Hartford region identified similar concerns, centered on the balance between competition and cooperation. It noted the potential for dispersing the NICU population into smaller competing NICUs versus a single unresponsive monopoly on regionalized services.72 Similar concerns have been voiced by others who have called for negotiated cooperation agreements in place of traditional regionalization schemes.73 Interestingly, deregionalization following National Health Service reforms in the United Kingdom has also produced adverse effects on perinatal care.74 These issues provoked the Committee on Perinatal Health to reconvene to formulate an agenda for regionalization in the 1990s and beyond.75 They recommended improvements in health education, prenatal care, system organization, access to inpatient and specialty services, documentation and evaluation, and adequate financing of perinatal care.
The reality of perinatal regionalization is that market forces are forcing hospital closures, consolidations, and mergers. Patients are increasingly channeled by payer-provider negotiations rather than historical regional designations. However, the long-term outcome may not be bad. Consolidated obstetric services are inherently safer and more efficient. Regionalized perinatal care is also inherently cost effective, utilizing graded levels of care according to need. The development of highly integrated vertical networks that eliminate redundant services may actually strengthen the regionalization of perinatal care. This level of integration, however, may not be achieved in many regions, and even where it is, the transition may cause serious dislocations for perinatal care.