For Maryland's hospital directors, it was just one regulation too many.
They had sat still this year when a Prince George's County hospital became embroiled with a regulatory agency over the question of how far a toilet should be from a renovation site.
And for years, all the state's hospital administrators were faced with the virtually impossible task of ensuring that the water temperatures in patients' rooms was kept at exactly 110 degrees Fahrenheit, since the state requires that it cannot drop below that and the federal government decrees that it must not exceed the same 110 degrees.
But when the state of Maryland promulgated a new requirement, asking hospitals to fill out a new Medicaid form, it was too much. Last week, 34 Maryland hospitals, all members of the Maryland hospital association, filed a court challenge to the latest requirement.
Just two weeks earlier the association issued a voluminous report criticizing what they called the confusion caused by the 108 state, federal and local agencies that regulate the state's hospitals.
The overall result of these agencies' work, the association claims in its report, is to produce a morass of sometimes contradictory, redundant or imprecise rules that hospitals are hard put to follow. Typical of the problems, association members say, are the examples cited above, one by the report and one by a Baltimore hospital administrator.
Steven Summer, vice president of the association, said that the latest form which hospitals are being asked to process duplicates information provided in other forms to other agencies. "It is a case in point" of the kind of duplication criticized in the report, he said.
An official of the state agency that drew up the new form said it is needed so the state, under a new computerized system, can scrutinize Medicaid billings before the bills are paid to prevent fraud or abuse. Charles Putnam, director of the Medical Assistance Policy Administration, said the information now provided on similar forms is available only after the bills are paid.
Summer said the hospitals do not argue with the state's need for the information, but have proposed another less expensive method for the state to receive it. He added that Maryland hospitals will have to spend about $1.3 million annually to comply with the regulation.
Putnam, however, argued that there is "no way to get the information before the bills are paid if you use the hospitals' proposed system."
This argument will probably be settled in an Anne Arundel County Circuit Court, where the suit was filed. But the hospital association, which represents 65 hospitals, raised the larger issue of regulation in its special report.
The report said that many of the 108 agencies regulating Maryland hospitals hold sway over the same areas.
Twelve different bodies, for instance, regulate the area of waste disposal. One of these, the Maryland Water Resources Administration, requires hospitals to put waste matter through a special steaming process to purify it. A second state agency, the Division of Licensure and Certification, prohibits use of this specal process and requires something different, according to the report.
The report also stated that "the greatest regulatory concern is directed at administrative services," rather than at the quality of patient care.
The state's Health Services Cost Review Commission, which is currently conducting a similar study, estimated that hospitals in Maryland spend about $19 million annually complying with regulations that require inspections, the completion of forms, reports or questionnaires and the creation of committees, according to Graham Atkinson, head of research and development for the commission.
The hospital association, in its report, stated that "rational hospital regulation is in the public interest," but that regulation "has proliferated to the point where it generates duplication, conflict and unnecessary cost."
The Prince George's General Hospital and Medical Center official who pointed out the disagreement between the hospital and an agency over placement of a toilet said that dispute centered on the interpretation of a regulation requiring that the toilet be within a "reasonable distance" from the renovation site. The official, Lance Shields, assistant to the administrator, said one major problem is that regulations are broadly stated and open to various interpretations by different agencies.
James McCaslin, associate administrator of Maryland General Hospital in Baltimore, said that "satisfying one agency sometimes draws dissatisfaction from another."
"It's like playing in a sports arena, where the umpire behind first base is using different rules than the umpire behind second."
The hospital association has called on the Maryland General Assembly to examine the existing system before adding any new regulations.
The Cost Review Commission, which regulates hospital rates, has called on for a "moratorium" on creating new agencies or expanding the authority of existing ones. It is also asking other regulatory agencies to join the commission in seeking review by the General Assembly to determine whether some functions should be abolished.