4. The Outcomes of Affiliations in the case studies
A. Community Impact of Affiliations
Hospitals are key institutions in communities, providing needed services to consumers, training for health care providers, and employment opportunities. Religiously sponsored hospitals often have long traditions of serving specific community populations, providing training and employment opportunities to members of religious communities, and serving the poor. Affiliations that alter the religious identification of hospitals or the configuration of the local health care system may have both positive and negative impacts on the local community.
In the four case studies, key informants consistently described the affiliations as having had an overall positive impact on the local community. In cases A and C, community surveys conducted post-affiliation showed support for the hospitals' collaborative efforts. Similarly, community support was evident in case D, where district residents voted, in advance, in favor of the joint venture. Positive outcomes of the affiliations that were reported in all cases included avoiding the closure of facilities, service improvements, cost reductions, and expansion of community-based health programs.
In three of the cases, one of the partnering hospitals had been threatened, prior to the affiliation, with possible closure due to reductions in inpatient revenues and to operating inefficiencies. In an effort to reduce their deficits, the two Catholic hospitals in cases A and B and the district hospital in case D had begun closing clinical departments and laying off employees. The closure of these facilities would have seriously limited the availability of inpatient and emergency care in the hospitals' service areas, especially in case A (where the Catholic hospital was the only provider of inpatient services in a mid-size town) and in case D (where the district facility was the only hospital in that portion of the county). The affiliations therefore were regarded as having ensured the survival of the hospitals as well as the continued availability of services to the communities.
Service improvements related to better service coordination or renovations of physical space were noted in all case studies. In case A, badly needed renovations to the former Catholic facility were completed following the affiliation; the communication system was replaced; and a new patient transportation service was initiated between the hospital's two campuses. Enhanced service coordination was observed in case B, and improvements in ambulatory surgery and obstetrical facilities were evident in case C. Finally, a plan for capital improvements for a number of hospital units was approved in case D.
An important goal of affiliations in general is containing costs. Case C, the earliest affiliation among the four cases, had documented over $50 million in savings during the past two years as a result of service consolidation, workforce reduction, and attaining operating efficiencies. The other cases, which were relatively new affiliations, also expected savings of varying magnitudes. Hospital executives hoped that lower costs would translate into smaller increases in rates and therefore improved financial accessibility of services. They also contended that lower operating expenses would free up resources that could be used for service expansion as well as for supporting community-based health projects.
Support for community-based programs has expanded following affiliations in all of the cases but has been driven by different factors. Case B distinguished itself in terms of its responsiveness to community needs, as reflected in the strategic plan of the newly formed system and in the initiatives that the system had implemented. Among other goals, the strategic plan focused on community health improvement and the expansion of primary care services. Accordingly, a new position for a vice-president for community health was created during the merger, and an assessment of system services based on the objectives of Healthy People 2000 (a national initiative to improve the public's health) was completed. Outreach to underprivileged populations was accomplished through clinical services in underserved areas and education programs. The system also is promoting development of school-based clinics and has funded community programs (e.g.parenting skills programs, a dental clinic, translator services).
Support of community health projects had increased in the other cases as well. In case A, lifting the restrictions on the provision of fertility-control services at the former Catholic hospital allowed the facility to initiate community education programs in contraception. Post-consolidation savings allowed case C's newly formed medical center to provide a grant to the local community health center to construct a new facility. The medical center also expanded its breast cancer education program for low-income community women. Finally, as part of case D's joint venture agreement, the Catholic system gave the district several million dollars that, together with the tax revenue generated, will be used by the district hospital to fund community health projects. At present, the hospital is funding projects in the areas of women's health and cardiovascular health.
The four sites varied in the extent to which they conducted community needs assessments: cases A and B were more active in this area than cases C and D. The non-Catholic hospital in case A, for example, conducted extensive market research on a regular basis to guide its decision-making processes and used such research tools as community surveys, focus groups, and one-to-one meetings with physicians. Similarly, case B's system evaluated community needs through surveys and focus groups, meetings with community-based organizations, and collaboration with the state health department to identify service gaps and prioritize needs.
Two problematic areas were identified in the case studies: diminished consumer choice and workforce reductions. Consumer choice of hospitals could be construed as having been diminished due to the loss of religious identity of a hospital or to discontinuation or consolidation of some services in affiliating facilities. Informants in all four case studies, however, emphasized that consumer options would have been more seriously constrained in the absence of the affiliation, especially if a facility were forced to close.
With regard to workforce reductions, downsizing occurred in all four cases and was described as one of the major challenges that the partners faced in operationalizing the affiliations. The numbers of both clinical and administrative staff members were typically reduced, leading to resentment and low employee morale. Our informants believed, however, that workforce reduction was not a negative outcome of affiliations. On the contrary, they stressed that affiliations prevented hospital closures, which would have meant more displaced workers, and they pointed out that lay-offs had already begun at the financially struggling hospitals prior to the affiliations.
On balance, informants in all case studies reported that they view the affiliations as beneficial to their communities.
B. Availability of Reproductive Health Services Pre- and Post-Affiliation
Figure 2 summarizes the findings with regard to availability of reproductive health services in the case study sites, pre- and post-affiliation. With respect to reproductive health services broadly defined, these case studies provide evidence that affiliations between a Catholic and non-Catholic provider affect specific services differently and that the outcomes are determined by multiple factors, as described in the previous chapter. Among the services studied, obstetrical services were most likely to be enhanced as a result of affiliations, and abortion services were most likely to be curtailed.
The following sections present the context within which these services were examined and the findings for each type of reproductive health service in the case studies.
Obstetrical Care
Prenatal, obstetrical, and postnatal services are supported by Catholic religious values and may, indeed, be central to the mission of many Catholic health care institutions. Prenatal genetic screening, however, may be controversial. According to the
Directives, "prenatal diagnosis is not permitted when undertaken with the intention of aborting an unborn child with a serious defect" and "genetic counseling may be provided in order to promote responsible parenthood and to prepare for the proper treatment and care of children with genetic defects" (NCCB 1995:20). Nevertheless, some Catholic hospitals, especially those in financial difficulty, do not provide obstetrical services. Declining patient volume is a problem in some communities, and this has both financial and quality implications for hospitals. Financially, it is more difficult to support obstetrical services when patient volume declines or when patient payer mix changes so that uninsured or underinsured women increase as a proportion of patients. Declining volume also has quality implications, particularly for high-risk obstetrical cases, since providers treat fewer cases and skills or teams may not be maintained. Affiliations therefore may provide both economies of scale and training opportunities in obstetrical care within a community.
The provision of prenatal and obstetrical services was improved in two of the case study sites as a consequence of affiliations. In case C, the partnering hospitals had both provided obstetrical services prior to affiliation; consolidation of the two hospitals therefore provided an opportunity for economies of scale and increased efficiency in obstetrical care. The affiliation also provided infusion of capital to improve obstetrical services. Following consolidation, obstetrics (including prenatal care and childbirth classes) was moved to one campus, where an expanded labor and delivery floor was under construction at the time of the site visit. The birthing unit also was being renovated and expanded in case D.
In two of the case studies (A and B), obstetrical services had not been provided at the Catholic hospitals prior to the affiliations, due to declining patient volume, and continued not to be provided after the affiliations. It is possible however, that the affiliations may have facilitated access to these services at the non-Catholic partner's campus for patients in the formerly Catholic hospital's service area and for clinicians. Also, at case B, strategic plans for a birth center had been developed by the women's health line leadership and had been distributed to senior executives for review. (At case C, a proposal for a birth center, that would have included nurse-miwifery services, was rejected when the obstetricians objected.)
Prenatal genetic screening and counseling were available to patients in all four cases, either on the same campus at which obstetrical services were provided or by referral within the community to specialized providers. These services were not affected by the affiliations.
Family Planning Services
According to the
Directives, "Catholic health institutions may not promote or condone contraceptive practices, but should provide, for married couples and the medical staff who counsel them, instruction both about the Church's teaching on responsible parenthood and in methods of natural family planning" (NCCB 1995:20). Emergency contraception for victims of rape is permitted if there is no evidence that conception has already occurred, and it is recommended that sexually assaulted women "be advised of the ethical restrictions that prevent Catholic hospitals from using abortifacient procedures" (NCCB 1995:16,31).
Among the reversible forms of contraception used by U.S. women ages 25 to 44 in 1990, methods requiring a physician prescription accounted for the majority of users, and oral contraceptives were the most frequently used method (Peterson 1995). The majority of users of reversible contraception obtain their methods from private physicians or managed care organizations, and about one-third attend family planning clinics. Family planning clinics are a particularly important source of contraceptive services for adolescent, minority, uninsured, and low-income women who do not have access to private physicians. Most family planning clinics are operated by public health departments, Planned Parenthood, or other agencies; in 1992-1993, an estimated 6% of family planning clinics were sponsored by hospitals (Henshaw and Torres 1994).
In general, family planning services (including the provision of counseling and contraceptive services) were not substantially affected in the case study sites as a consequence of affiliations. With regard to contraception, administrators and providers interviewed in all of the case study sites reported that this was a matter left to the discretion of the individual physician within the context of the physician-patient relationship. No policies were reported that interfered with physicians' ability to prescribe contraception within their medical practices, either before or after affiliations.
None of the sites (regardless of religious affiliation) operated family planning clinics either before or after affiliations. Only one of the sites (case B) showed evidence of active involvement with community-based organizations to promote family planning services. Case A had begun a program in community education for family planning in the former Catholic hospital's service area after the
Directives ceased to apply on that campus.
Availability of services, including emergency contraception, for rape victims was in evidence in all four cases. In cases B and C, these services were provided on-site; in cases A and D, the services were provided by referral to a local rape crisis center.
Sterilization
According to the
Directives, "direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution when its sole immediate effect is to prevent conception." In 1987, 93% of tubal sterilizations were performed in hospitals, either as inpatient procedures or in outpatient surgery centers (Schwartz et al. 1989). Advocacy groups have raised questions about the costs, inconvenience, and risks to health that might be incurred if women cannot obtain postpartum tubal ligations in a Catholic hospital and must seek this service elsewhere. Data from the 1993 National Hospital Discharge Survey reveal that church-owned hospitals provided significantly fewer postpartum sterilizations than other types of hospitals (Clarke and Taffel 1995).
Availability of male and female sterilizations (vasectomies and tubal ligations, respectively) was not affected by affiliations in three cases (B,C, and D) and was expanded in case A, where the procedures became available at the former Catholic campus following its acquisition. Following the merger in case B, the non-Catholic campus continued to provide sterilizations, while the formerly Catholic campus continued to follow the
Directives and did not provide them. In case C, both hospitals provided sterilizations both pre- and post-consolidation. In case D, provision of sterilization continued at the district hospital following its joint venture with the Catholic system. In all cases where sterilizations were provided, postpartum sterilization was available.
Infertility Services
Infertility services include both diagnosis and treatment of fertility problems in men and women. The
Directives include a number of statements and restrictions on techniques of assisted reproduction. Therapies for infertility are permitted for married couples only if the therapies do not interfere with the "unitive and procreative meanings of sexual intercourse and do not involve the destruction of human embryos" (NCCB 1995:18). Both heterologous fertilization (using gametes from at least one donor other than the spouses) and homologous fertilization (using gametes of the spouses) are proscribed. Artificial fertilization (including artificial insemination) is proscribed because it is "extra-corporeal" and "separates procreation from the marital act in its unitive significance" (NCCB 1995:19).
The use of infertility services nationwide is measured in the National Survey of Family Growth. Between 1988 and 1995, the percentage of women of reproductive age who had ever used some kind of infertility service increased from 12% (6.8 million women) to 15% (9.3 million women) (Abma et al. 1997). The most frequently reported services were advice on becoming pregnant and infertility tests on the male or female partner; among specialized services, the most frequently reported was ovulation-inducing drug treatment. Infertility services are used disproportionately by college-educated, high-income, white, married women, who are most likely to be able to afford the service of medical specialists. The number of infertility clinics has been estimated at over 300 nationwide (Laurence and Weinhouse 1994).
In general, the case studies provided no evidence that availability of infertility services changed as a result of affiliations. In two cases (A and B), the non-Catholic partner continued to provide infertility diagnosis and treatment. In case D, the district hospital continued to provide basic infertility services and to refer to a local specialty group for advanced treatments. In case C, the services continued not to be offered at either campus. Case C had considered providing infertility services and had investigated community needs and resources. Analyses revealed that community demand for these services was low and that infertility specialists were not available locally. Consequently, clients requesting these services were referred to the academic medical center fifty miles away. The case studies indicate that advanced infertility services, similar to other high-technology services, are typically provided by large, tertiary care centers and not by small community hospitals.
Abortion
The
Directives define abortion as "the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus" and state that abortion is never permitted in Catholic health care institutions "even based upon the principle of material cooperation" (NCCB 1995:19). ("Material cooperation" is defined in the Glossary, Appendix A.) However, treatments for a seriously ill pregnant woman that "cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child" are permitted (NCCB 1995:19-20). Catholic providers are expected to offer care to women "who have suffered from the trauma of abortion" (NCCB 1995:19).
Declining access to abortion services nationwide has been identified as a major problem by abortion rights advocates, and affiliations between religiously-sponsored and non-sectarian hospitals have been cited as one factor in this decline (Chavkin 1996). Although hospitals provide only a small proportion of abortions, they provide important services for women needing late-term abortions and treatment of abortion complications, and they provide training in abortion procedures for residents in obstetrics-gynecology. Nationally, the trend is for surgical abortions to be provided in non-hospital settings and as outpatient procedures. In 1992, only 7% of abortions were performed in hospitals, 89% were performed in clinic settings, and 4% were performed in physicians' offices. Only 16% of short-term general hospitals provided abortion services in 1992 (down from 19% in 1988), and 51% of hospitals providing abortions performed fewer than 30. Only 11% of hospital abortions were performed on an inpatient basis (Henshaw and Van Vort 1994).
The case studies provided evidence that abortion was the most contentious reproductive health issue raised during the affiliation process and that it was the service most likely to be curtailed as a result of affiliations. In cases C and D, abortions (except to save the life of the woman) were discontinued as a matter of policy in non-Catholic hospitals that had provided both elective and medically indicated abortions prior to the affiliations. In both of these cases, administrators and clinicians reported that the hospitals had performed only a small number of abortions prior to affiliation, so that the new policy did not constitute major change. Abortion referrals were available in cases C and D. In case D, abortion counseling, direct referrals to local abortion providers, and transportation were provided, and clinicians did not perceive that there was an access problem for women seeking abortions. In case C, however, a potential access problem was observed: the nearest abortion provider was fifty miles away and not accessible by public transportation, and it was reported that some providers in local community-based health centers were unwilling to treat women with post-abortion complications. A needs assessment had not been conducted in the local community.
In contrast, no change in abortion policy occurred in cases A or B as a result of affiliations. Abortions continued to be proscribed at the former Catholic hospitals (although they now operate as non-sectarian providers). Abortion continued not to be performed at the non-Catholic hospital in case A except to save the woman's life and the woman cannot access care elsewhere in the community (a rare combination of circumstances). In case B, second-trimester abortions continued to be provided at the non-Catholic hospital for life or health of the woman or for fetal anomalies.
The abortion policies observed in the case studies had been formulated with regard to surgical abortions. Only one case study site had directly addressed the provision of non-surgical abortions. In case D, the Catholic health system recently had approved a CME course on the uses of RU486 that will be provided at the district hospital and had indicated that it could not invade the privacy of the physician-patient relationship to enforce its position on abortion.
C. Emerging Issues
Three emerging issues were identified as potentially important ones for the future availability of reproductive health services within the case study sites. These pertained to the provision of non-surgical abortions; provision of comprehensive benefits within health insurance plans; and developing service lines or programs in women's health.
Non-surgical Abortions
Chemically-induced abortions are expected to increase for early-term abortions with the availability of methotrexate and, eventually, mifepristone (RU486). Because these medical methods may be administered within the privacy of physicians' offices, they are expected to increase the availability of abortions for women who identify a need for termination early in pregnancy (Castle and Coeytaux 1994). These methods will not, however, eliminate the need for surgical abortions in cases of more advanced gestational age or in the event of unsuccessful medical abortions.
With the exception of case D, as noted above, the case study sites had not yet addressed the implications of the availability of non-surgical methods of abortion for their providers and services. Some informants reported that they saw this as a non-issue, since medical abortions could be provided within the privacy of the physician-patient relationship according to the model established for contraceptive services. Others, however, drew no distinction between medical and surgical abortions and assumed that current policies proscribing surgical abortions (except to save the life of the woman) would apply equally to both types of abortion procedures. In at least one case, informants disagreed in their perceptions of how non-surgical abortions would be handled, suggesting that conflict would eventually surface and perhaps become matters to be considered by the governing board.
Benefits Packages
Health insurance plans and purchasers increasingly define core benefits packages as including a wide range of reproductive health services, including fertility-control services such as contraception, sterilization, and abortion. Health care providers that do not offer the required range of services are not likely to be competitive in the managed care marketplace.
There was little evidence in the case study interviews that the issue of core benefits had been fully considered, particularly with respect to abortion services. Certainly there was little indication that the issue had arisen at the level of governing boards. In all likelihood, the pressure to offer core benefits will increase the need for affiliating institutions to develop mechanisms to ensure the availability of covered services.
Women's Health Care
The case study sites varied in the degree to which they had conceptualized women's health services and taken steps to develop service lines or comprehensive programs to provide women's health care. The changing normative climate in women's health nationally has drawn attention to the fact that women's health encompasses more than reproductive health, and that reproductive services are a key component of comprehensive women's health care and should be integrated with other services. Hospitals and health care systems that provide a range of reproductive health services are better positioned than those providing no or limited reproductive services to offer comprehensive health care to women.
Nationally, there has been a trend toward hospital-sponsored women's health centers of various kinds: in the 1994 American Hospital Association annual survey, 32% of U.S. hospitals reported having some type of women's health center, up from 19% in 1990. The 1994 National Survey of Women's Health Centers, conducted at Johns Hopkins University with support from The Commonwealth Fund, identified multiple types of hospital-sponsored centers. These included comprehensive primary care centers, reproductive health centers, birth or childbearing centers, breast care centers, and others providing either highly specialized clinical services or mainly information and referral services (Weisman, Curbow, and Khoury 1995). Hospital-sponsored women's health centers tend to be market-oriented and to seek to tap local women's needs for both clinical and non-clinical services (for example, education and support groups). A defining feature of the hospital-sponsored comprehensive primary care centers is the integration of reproductive and non-reproductive services to provide comprehensive, coordinated care to women through the lifespan.
Three of the four case study sites (A, B, and D) were developing women's health programs based on community needs assessments and/or regional considerations. Since two of the case study affiliations involved a Catholic hospital that did not provide obstetrical services, it is possible that the affiliations enhanced access to more comprehensive care among women in the former Catholic hospitals' services areas. In case A, plans for establishing women's resource centers (to provide education, information, and referral services) at the hospital's ambulatory care sites and main campus were being developed. In case B, a new women's service line that integrates reproductive and midlife services emerged as one of seven major products following the affiliation. And in case D, development of a women's service line by the Catholic system's regional division was underway. Case C had not identified women's health as a priority area and had no immediate plans to do so, although some clinicians and administrators reported that they would like to see the medical center become more proactive in women's health and to expand the conception of women's health care beyond maternity or other specific reproductive services.
