1. Introduction
A. Background and Context
The purpose of this project is to examine the affiliation process between Catholic and non-Catholic health care providers and to assess the outcomes of affiliations for the availability of reproductive health services in the community. In the changing health care environment, there are increasing market pressures on hospitals-pitals and other health care organizations to form affiliations of various kinds. Often these organizations have different value orientations that may affect both the type of affiliation formed and the range of services made available to sociodemographically diverse communities. Catholic-sponsored hospitals have been increasingly involved in formal affiliations in recent years, and because Catholic values proscribe or constrain provision of certain reproductive services, some of these affiliations have attracted the attention of the media and advocacy groups concerned about the public's access to these services. Because women are the major consumers of reproductive health services, women's groups have been particularly concerned about these affiliations. This project considers how affiliation agreements are reached between Catholic and other health care organizations, the role of reproductive health services in forming these agreements, and the impact of these affiliations on the availability of reproductive health services in communities.
Catholic hospitals comprise the largest component of religiously sponsored health care organizations in the United States. In 1995, there were approximately 600 Catholic hospitals (about 10% of all U.S. acute-care hospitals), accounting for approximately 14% of all acute-care hospital beds (Japsen 1995a). The 1995
American Hospital Association Guide reports 62 Catholic multihospital systems with 487 hospitals operating over 112,000 beds; these hospitals comprised 83% of all hospitals in church-related systems, 34% of all hospitals in not-for-profit systems, and 17% of all system hospitals nationwide. The largest non-Catholic religious systems include Adventist and Baptist systems.
Catholic health care facilities in the United States are guided by the
Ethical and Religious Directives for Catholic Health Care Services (hereinafter referred to as the
Directives), which were approved by the National Conference of Catholic Bishops (NCCB) in 1971 and revised in 1994 (NCCB 1995). The
Directives address the social responsibility of Catholic health care services; the pastoral and spiritual responsibility of Catholic health care; the nature of the professional-patient relationship; issues in care for the beginning of life; issues in care for the dying; forming new partnerships with health care organizations and providers; and principles governing cooperation with activities considered to be morally wrong. With regard to reproductive health services, the
Directives proscribe abortion (see Glossary,
Appendix A) and "direct sterilization...when its sole immediate effect is to prevent conception" (NCCB 1995:20). The
Directives also state that "Catholic health institutions may not promote or condone contraceptive practices" (NCCB 1995:20). In addition to these proscriptions, the
Directives state that "a Catholic health care institution should provide prenatal, obstetric, and postnatal services for mothers and their children in a manner consonant with its mission" (NCCB 1995:19).
Regarding affiliations, the
Directives recognize that new partnerships with non-Catholic health care organizations provide both opportunities and challenges. On the one hand, Catholic institutions that partner with non-Catholic organizations have opportunities to continue to implement religious and ethical teachings; on the other hand, these partnerships may involve Catholic institutions in activities judged morally wrong and may pose challenges to the viability of the Catholic mission in health care. Because of the risk of scandal (see Glossary, Appendix A) when partnerships are formed between Catholic and non-Catholic providers, the
Directives suggest that "increased collaboration among Catholic-sponsored health care institutions is essential and should be sought before other forms of partnerships" (NCCB 1995:26).
Directive #69 states that "when a Catholic health care institution is participating in a partnership that may be involved in activities judged morally wrong by the Church, the Catholic institution should limit its involvement in accord with the moral principles governing cooperation" (NCCB 1995:27). The
Directives contain an appendix outlining the principles of cooperation, which are theological tools to assist individuals in reasoning about the circumstances under which one may justifiably be involved in activities that are considered to be morally wrong. (See Glossary,
Appendix A.) According to the National Coalition on Catholic Health Care Ministry, the principle of material cooperation "reflects the fact that in order to accomplish good, some cooperation with wrongdoing may at times be unavoidable" (NCCHCM 1995:15). The principle might be invoked, for example, to justify a Catholic health care institution's partnership with a provider offering services, other than abortion, that are proscribed by the church.
Issues related to the provision of reproductive health services are not the only threats to Catholic identity that may surface in affiliation attempts between Catholic and non-Catholic health care organizations. Also problematic from the perspective of Catholic values regarding the dignity of the human person is end-of-life decision making and the debate surrounding euthanasia. In addition, and on the basis of its mission to advance social justice, in 1995, the Catholic Health Association banned for-profit hospitals from membership, thereby discouraging affiliations between Catholic and for-profit health care organizations (Japsen 1995b). Issues related to reproductive health services therefore are part of a larger context of Catholic health care organizations' strategic attempts to reconcile religious values and mission with affiliations to enhance viability and organ-izational survival.
Advocacy groups have been active in bringing to public attention some recent cases in which the provision of certain fertility-control services was threatened by attempted or actual affiliations between religiously controlled and non-sectarian hospitals. One issue of concern to advocacy groups is that consumers may not be aware either of the implications of proposed affiliations for service delivery or of the post-affiliation policies of the parties with respect to fertility-control services. In addition, the most vulnerable consumers - those who are uninsured, low-income, or do not have a personal physician - may have the fewest options for accessing these services at alternative sites. Accordingly, advocacy groups have sought to provide information to inform the public as well as to intervene in specific cases.
For example, Catholics for a Free Choice, based in Washington, D.C., published an overview of 57 affiliations between Catholic and non-Catholic hospitals in the early 1990s, based on information obtained from the Lexis/Nexis database (Catholics for a Free Choice 1995). It also published results of a 1995 survey of 800 women ages 18 to 50, in which 28% of Catholic women and 26% of non-Catholic women answered "yes" to the question, "Would belonging to a Catholic health plan mean that your access to medical procedures is restricted in any way?" and 31% answered that they did not know. In response to the question, "If your hospital merged with a Catholic hospital, do you think the services you receive should be restricted by the dictates of Catholic teachings?" 86% of women answered "no" (EDK Associates 1995).
The Reproductive Freedom Project of the American Civil Liberties Union, a national project that defends and advances reproductive rights, published a report on hospital mergers to alert activist communities and to highlight successful strategies that have been used to protect access to reproductive health services (ACLU 1995). The report cited three cases of proposed mergers and acquisitions between non-sectarian and Catholic hospitals in which state civil liberties groups participated in efforts to block the affiliations due to concerns about potential loss of reproductive health services.
Mergerwatch, a project of Family Planning Advocates, Inc., of New York State, which works closely with the Center for Reproductive Law and Policy in New York City, provides statewide monitoring of hospital mergers involving Catholic institutions, a resource clearinghouse, an activists' guide and technical assistance, statewide action alerts, policy analysis, and lobbying (Family Planning Advocates 1996). Family Planning Advocates was party to a lawsuit filed to challenge state approval of a merger between a Catholic and a non-sectarian hospital to form a new Catholic system in Troy, New York; following the merger, family planning services and vasectomies were discontinued at the formerly non-Catholic hospital. The lawsuit was settled in 1996 when the system agreed to provide referral information and followup to patients seeking these services.
Thus affiliations between Catholic and non-Catholic health care organizations and public attention to issues pertaining to reproductive health services in these affiliations provide the context of this project.
B. Research Questions and Definitions
The project addresses the following questions:
- What is the extent of affiliations involving Catholic health care organizations and what are the major types of affiliations?
- What are the key issues in the affiliation process, including motivating factors and operational challenges, as well as strategies to address these concerns?
- What role, if any, do issues involving reproductive health services play in the affiliation process between Catholic and non-Catholic health care organizations?
- What is the impact of affiliations between Catholic and non-Catholic health care organizations on the community, especially with regard to availability of reproductive health services?
- What are some approaches used by the partners in these affiliations to make specific reproductive health services available to the communities served?
For purposes of this project, "reproductive health services" is defined broadly to include pregnancy-related care (e.g. preconception care, prenatal care, prenatal genetic screening, obstetrics, alternative birthing services), services to curtail or enhance fertility (e.g. contraceptives, male and female sterilization, abortion, and infertility diagnosis and treatment), and routine gynecological care including screening and treatment for sexually transmitted diseases and for cancers of the female reproductive system (Delbanco and Smith 1995). This broad definition provides a basis for examining the impact of affiliations on both controversial and non-controversial reproductive health services. It also provides a basis for considering an organization's provision of comprehensive health care for women.
For purposes of this study, "affiliations" are defined as formal arrangements involving a hospital and another hospital or health system, including joint ventures, mergers, acquisitions, consolidations, and long-term lease arrangements (see Glossary, Appendix A.) The project focuses on affiliations involving Catholic and non-Catholic partners, because these are the affiliations in which potential conflicts between Catholic religious values and the values and practices of non-Catholic providers may arise.
C. Methods
The project uses both quantitative and qualitative methods. (See
Appendix B for a detailed description of these methods.) To address the research question on the extent and types of affiliations involving Catholic health care organizations, a statistical profile was compiled of formal affiliations occurring between 1990 and 1996. Because there is no central repository of such information for the health care industry, data were obtained from several sources. It is important to note, however, that these data reflect only those affiliations that were publicly announced and reported by the organizations providing the source data. In addition, the data do not reflect attempted affiliations that failed or completed affiliations that subsequently dissolved (e.g. "demergers").
To address the other research questions, a multiple case study design was used. The case study method was appropriate because detailed information about the affiliation process and decisions with regard to provision of reproductive health services could not be obtained except from on-site, confidential interviews with participants. Four cases of affiliations involving Catholic and non-Catholic health care organizations between 1994 and 1996 were selected for study based on criteria developed from the statistical profile and information obtained from public sources and knowledgeable informants. (See
Appendix B.) It is important to note that these cases do not necessarily represent all affiliations between Catholic and non-Catholic providers during this time period. Rather, the cases are intended as illustrative models of successfully negotiated affiliations and of possible solutions to issues involving availability of reproductive health services in communities.
D. Organization of the Report
The remainder of this report is organized into four sections. Section II presents national findings on the numbers and types of affiliations involving Catholic health care organizations between 1990 and 1996, including information from public sources on alternative outcomes with regard to provision of reproductive health services. Section III presents findings from the four case studies with respect to the affiliation process, including factors motivating the affiliations; the role of reproductive health services in the affiliation process; factors in successfully negotiated affiliations; and post-affiliation challenges. (The case study reports are presented in
Appendix C.)
Section 4 presents findings from the case studies with respect to the outcomes of the affiliations, including overall community impact; availability of specific reproductive health services (obstetrical, contraception, sterilization, infertility, and abortion services); and emerging issues involving non-surgical abortion, benefits packages, and comprehensive women's health services.
Section 5 presents the study conclusions, lessons learned, and implications for policy.
