5. Conclusions and Policy Implications
A. Strategies for Managing the Affiliation Process Between Catholic and Non-Catholic Health Care Organizations
In response to marketplace changes, a growing number of religious and non-sectarian hospitals and health systems are affiliating and finding ways to accommodate differences in ethical and religious values. Affiliations may include a wide range of adaptive alternatives, all of which are assumed to have the potential to increase an organization's chances for survival and to improve performance.
Currently, Catholic hospitals are the most numerous religiously sponsored health care organizations in the United States and account for about 10% of U.S. acute-care hospitals. Catholic hospitals and health systems were involved in about 18% of the nation's hospital affiliations between 1990 and 1996. Affiliations between Catholic and non-Catholic health care organizations are growing in number and as a proportion of all affiliations involving Catholic institutions. Nearly 80% of affiliations involving a Catholic hospital or health system between 1990 and 1996 were between Catholic and non-Catholic partners. In most instances, the non-Catholic partner was a not-for-profit entity.
Formal models for affiliations between Catholic and non-Catholic partners are quite varied and include mergers, acquisitions, consolidations, joint ventures, and long-term lease agreements. Furthermore, the agreements reached to accommodate different ethical and religious values or commitments to specific services vary widely. In some instances, these agreements result in a loss of Catholic identity, and some formerly Catholic institutions continue to follow the Directives after affiliations, while others do not. Various arrangements for making reproductive health services available have been devised. In four case studies of different types of affiliations between Catholic and non-Catholic partners, the project found that regardless of the affiliation type, both market forces and value-based concerns were apparent in decision-making processes. Although the partners in each case were driven by market changes to consider strategic affiliations to ensure organizational survival or competitiveness, their business decisions were impacted by their ethical and religious traditions, as well as by the historical and community contexts of earlier affiliation attempts.
Similarities in the strategies for managing the affiliation process were observed in the case studies, and several factors associated with the successful negotiation of an affiliation were identified, regardless of the partnership model selected. Key among these was identifying a strategy, early in the affiliation process, to address the partners' different ethical and religious values and the impact of these values on the provision of controversial services. Although reproductive health services (particularly abortion) figured prominently in the value-based concerns raised in all four cases, concerns about social justice and responsible stewardship also were evident. Other factors characterizing successfully negotiated affiliations included: identifying strategies to obtain necessary approvals from the Department of Justice and the Catholic Church; developing a plan for managing the operational consolidation and cultural changes required to support integration, including human resources issues related to workforce reduction; developing strategies to promote active physician involvement, as well as development of physicians' administrative skills, during the affiliation process; and actively involving the community by soliciting input and providing information throughout the affiliation process.
B. Issues Regarding Reproductive Health Services in Affiliations
Although value-based concerns about reproductive health services were apparent in the affiliation process in all four case studies, few changes in the availability of reproductive health services occurred as a consequence of these affiliations. Abortion (for purposes other than to save the life of the woman) was the only service for which there was evidence of a negative effect on availability. Obstetrical services were expanded and improved in two of the cases following affiliations, due to infusions of capital and the ability to realize economies of scale. Availability of family planning, sterilization, and infertility services generally were unchanged as a result of affiliations.
Abortion was the most contentious service considered during affiliation negotiations, and hospital-based abortion services (except to save the life of the woman) were discontinued in two of the cases as a consequence of affiliation. In one case, the abortion policy decision was made by a vote of the newly established governing board of a consolidated medical center, and in one case by pre-affiliation agreement between a Catholic system and a district hospital engaging in a joint venture. In both cases, abortion referrals were provided post-affiliation. In the two cases in which abortion availability was unchanged as a result of the affiliation, abortion continued to be available at the non-Catholic facility under certain conditions and continued to be proscribed at the former Catholic facility. (In both cases, the Catholic partner became a non-sectarian provider, although, in one case, the Directives continued to be followed at the former Catholic facility.) As described earlier, cases involving more complex financial arrangements to distance a Catholic partner from abortion provision by another partner to an affiliation have been reported in the media but were not observed in our case studies.
The geographic separation of services by campus to avoid potential conflicts over provision of controversial services also was observed for gynecological care. In case B, all outpatient surgeries were consolidated on the former Catholic campus following the merger, with the exception of ambulatory gynecological surgery, which was consolidated on the non-Catholic campus. Informants explained that although it would have been more efficient and logistically easier to provide gynecological procedures with other types of surgery, the decision to keep them separate was made to accommodate the continued compliance of the former Catholic facility with the Directives while meeting women's needs for proscribed reproductive care (such as sterilization procedures). In other cases, geographic separation of services by campus was driven by financial and quality considerations. This was observed for different types of medical and surgical services, including obstetrical care. For example, the decision in case A to continue not providing obstetrical care on the former Catholic campus and the decision in case C to consolidate pregnancy-related services on one campus were made because of volume issues and to realize economies of scale.
The four case studies, together with public information about other instances of affiliations between Catholic and non-Catholic health care organizations, show that specific reproductive health services are impacted differently by affiliations. Most notably:
- Hospital-based surgical abortions (other than to save the life of the woman) are often curtailed after affiliations, although in some cases they may continue to be provided by the non-Catholic partner. Prohibitions against abortion referrals typically are not observed, and in some instances, policies ensuring referrals have been adopted.
- The provision of obstetrical services is often threatened in financially struggling hospitals. Declining patient volume has both financial and quality implications, particularly for high-risk obstetrical care, and may result in discontinuing these services. Affiliations therefore may strengthen and, in some cases, expand obstetrical care to the community as a result of capital infusion and economies of scale.
- Explicit policies that prohibit providers from counseling their patients about family planning options and from prescribing contraceptives within their medical practices typically are not observed at religious hospitals, either pre- or post-affiliation. Because organizations are not likely to invade the privacy of the physician-patient relationship to enforce their positions about fertility-control services, provision of contraception generally is not impacted by affiliations involving Catholic and non-Catholic parties.
- Provision of emergency contraception does not appear to emerge as an important issue during affiliations because emergency contraception is permissible at Catholic facilities when conception has not occurred and because victims of sexual assault often are referred to local or regional rape crisis centers.
- Sterilization services involve procedures that typically are performed on an inpatient or outpatient basis on a hospital's campus. These services may become more widely available after an affiliation if the Directives no longer apply, or curtailed if the Directives are followed. However, because sterilizations may be provided under the principles of cooperation (see Glossary, Appendix A), models for preserving these services often are observed.
- Infertility services generally are provided by large, tertiary care centers and not by small or mid-size hospitals. These services tend to be preserved post-affiliation, based on the principles of cooperation. Instances in which the non-Catholic hospital providing the services assumes Catholic identity, however, may be an exception.
Determinants of availability of reproductive health services following affiliations between Catholic and non-Catholic health care organizations are complex and vary by case. The project found no simple correspondence between the type of affiliation and these outcomes. Factors affecting how decisions regarding the availability of services were made include, for example, the range of services provided by the partnering organizations prior to the affiliation, the history of prior affiliation attempts, the relative financial strength of the Catholic partner, the level of community involvement during the affiliation process, and community traditions, particularly with regard to women's reproductive rights.
C. Lessons Learned and Implications for Policy
Affiliations between Catholic and non-Catholic health care providers have generated concern among community groups and policymakers. Both reproductive rights and anti-abortion advocacy groups have influenced the fate of affiliations in some instances. In addition to their potential impact on reproductive health care and other proscribed services, however, affiliations between Catholic and non-Catholic providers also may impact on the community by preserving local health care institutions and services, training opportunities, and jobs. This study has described four cases of successfully negotiated affiliations in which community impact was generally positive and in which the overall impact on availability of various reproductive health services was generally neutral, although there was some enhancement in the case of obstetrical services and some curtailment of hospital-based surgical abortion services.
Government has an interest in ensuring individuals' access to basic health services, particularly among the most vulnerable members of the community who may not have the options to seek care elsewhere if facilities close or if needed services are not available. Boozang (1996) argues that sectarian health care providers may benefit the community sufficiently to justify "negotiated accommodation" between religious principles and the state's interest in ensuring patient access to health care. Creative affiliation arrangements have the potential both to facilitate the survival of sectarian health care providers and to ensure that members of sociodemographically diverse communities have access to services that might be regarded as controversial within some religious traditions. The goal of these arrangements is to balance the needs of sectarian providers while ensuring access to care without adding to the burdens of those seeking services.
With regard to availability of reproductive health services, particularly abortion services, an important concern is protecting women in need of these services from undue hardship or risk to physical or mental health as a consequence of complex organizational arrangements for service provision. For example, as a result of some arrangements, women may be required to travel long distances for care, to make additional visits, to delay care, to pay more for out-of-plan services, or to seek specific services from providers unknown to, or not coordinated with, their primary care providers.
In addition, the case studies demonstrated the importance of ensuring that community members are informed of the policies and practices of affiliating health care providers. Although the partners to observed affiliations devoted substantial time and resources to informing the community and soliciting its input to the affiliation process, it is not known whether this occurs in most instances of affiliations or how well community members understand the arrangements that are made with regard to controversial services. An important role for policymakers is to ensure that the community receives full disclosure of the impact of affiliations on availability of such services.
In summary, assessments of the impact of affiliations between Catholic and non-Catholic health care providers for the health care of the community should consider a range of possible outcomes. Community and advocacy groups play an important role in directing public attention to issues of concern in local communities and in focusing attention on the need for impact assessments prior to, during, and after affiliations. Policymakers at the state and local levels, furthermore, frequently play an important role in ensuring that community members have access to needed health care services and that health care providers adhere to standards of care and meet the needs of pluralistic communities. All stakeholders, however, need to be sensitive to the range of possible costs and benefits to a community when religious and non-religious health care providers affiliate.
