COLUMN ONE : When the Church and Medicine Clash : More hospitals are merging with Catholic facilities to survive. Vital care is preserved, but some patients lose access to family planning or options for the terminally ill.

By SHARI ROAN

Feb. 2, 1995 12 AM PT

TIMES HEALTH WRITER

With the next closest hospital 26 miles down a mountain road, patients with all kinds of needs are welcomed at Sierra Nevada Memorial Hospital in tiny Grass Valley, tucked into the Sierra foothills.

But some townspeople fear that if the community-owned Nevada Memorial affiliates with the larger, Catholic Mercy Healthcare Sacramento, as is planned, services long provided there may be disallowed by the strict doctrine governing Catholic health care institutions.

Some worry that women who want tubal ligations or even family planning advice will be turned away, and that the old or dying may lose the option to terminate treatment when the end of life is near.

Mercy officials as well as Nevada Memorial’s board of directors--which will cast a preliminary vote on the proposal Feb. 10--insist that services would not change and that the hospital would remain non-Catholic.

Nevertheless, many Grass Valley residents remain concerned, and the once-private negotiations have exploded into a debate reflecting the philosophical and economic impact of the growing prominence of Catholic hospitals in a health care market that is enmeshed in rapid change.

Faced with uncertain financial futures caused by escalating costs, private, independent hospitals in many communities must merge and consolidate to survive.

The Catholic Church is the largest private health care provider nationwide, accounting for about 16% of hospital services. Because of their size and resources, Catholic facilities are able to buy and affiliate with many smaller hospitals that need such support to stay open. In Grass Valley, for example, Nevada Memorial solicited Mercy as a partner.

However, some consumer health groups say the expansion of Catholic health care institutions threatens the medical needs of women and men whose views lie outside the church’s conservative doctrine.

They say that although Catholic hospitals provide a valuable economic boost in assuming struggling facilities, they may eliminate important choices for many patients.

Under the “Ethical and Religious Directives for Catholic Health Care Services,” revised by the U.S. Conference of Catholic Bishops in December, Catholic hospitals may not offer contraceptive counseling, sterilization and abortion. They also may not offer artificial insemination, in vitro fertilization and other treatments for infertility. And they are limited as to what action can be taken when a patient is dying, such as the use of pain medication if it may hasten death.

About half a dozen partnerships between Catholic and non-Catholic hospitals have occurred in California in the past two years, said Bud Lee, executive director of the California Assn. of Catholic Hospitals. An estimated three dozen agreements have been reached nationwide.

In some cases, the ethical directives are imposed. In others, the non-Catholic hospital is not required to adapt to Catholic doctrine.

“The church is not trying to impose its will on others,” Lee said. “What the Catholic Church and its ministries want to do is maintain a level of service to the community that it deserves. It’s not to take anything away from anyone.”

But instances in which a non-Catholic hospital became Catholic have generated criticism when the hospital is the sole provider of medical services in an area.

“The (Nevada Memorial) case is the beginning of public awareness on services for women in Catholic hospitals,” said Susan Fogel, an attorney with the California Women’s Law Center. “The issue is coming to a head because there is no other access to care for women” in Nevada County, which is in northeastern California.

This is not the first case of its kind.

With a steady stream of purchases, the Sacred Heart Health System organization of Eugene, Ore., has acquired almost 70% of the hospitals in Lane County, Ore., as well as a number of outpatient clinics and physicians’ networks. It denies patients such services as artificial insemination and sterilization unless “medically necessary.”

Partnerships between Catholic and non-Catholic hospitals have also raised community ire in Sacramento, Oakland, Davenport, Iowa; Springfield, Ohio, and Portland, Me.

Other mergers have been accomplished without discernible community response.

In June, when St. Joseph Hospital in Orange announced an agreement to purchase the privately owned, 240-bed Mission Hospital Regional Medical Center in Mission Viejo, there was little mention by hospital officials about the repercussions of Mission’s conversion to a Catholic hospital. The hospital, which retained its name, no longer provides abortion, sterilization or in vitro fertilization.

In cases where a hospital is purchased or merged with a Catholic facility, the ethical directives usually are applied to the new facility. However, in other arrangements--particularly when hospitals simply “affiliate” to share some resources but retain their identities--the church has accommodated its partner’s practice of providing some services, such as sterilizations and in vitro fertilization. Nevada Memorial is seeking this type of affiliation with Mercy. Moreover, in six mergers between 1989 and 1994, non-Catholic hospitals resulted, according to the Catholic Health Assn.

“It usually works to the satisfaction of both parties,” Lee said. “We have seen some pioneering efforts on how Catholic and non-Catholic institutions can come together.”

In affiliating with non-Catholic hospitals, Lee said, the church’s aim is to provide quality health care to a community that may be in danger of losing services because of economic hardship.

Hospital mergers generally are seen as a necessary trend in the era of rising health care costs and emphasis on economic reform. The partnerships allow hospitals to consolidate services and share revenue and resources, Lee said.

But the increasing influence of Catholic health care is troubling to some--even those within the Catholic Church.

The nation’s bishops have expressed their own unease at Catholic and non-Catholic health care coalitions, noting that even loose affiliations could result in confusion over the church’s teachings.

At the bishops’ conference last December, leaders noted that while the acquisitions are generally good for the church and individual communities, potential problems exist. Said the bishops: “The risk of scandal cannot be underestimated when partnerships are not built upon common values and moral principals.”

“This is a major trend with major policy implications,” said Frances Kissling, president of the Washington-based Catholics for a Free Choice. “In order to preserve revenue, hospitals and other health care institutions have to merge, acquire, grow and develop into these integrated networks. The Catholic health care institutions face the same pressures.”

But Kissling said she fears that some communities, especially in isolated or rural areas, may not realize that when its hospital is purchased by the church, the Catholic ethical directives require that some services be halted.

According to research conducted by Catholics For a Free Choice, many of the mergers and affiliations have resulted in limits on sterilization, contraceptives counseling, safe sex counseling, treatment of rape victims and infertility treatments. In a few cases, such as Mercy Healthcare Sacramento’s merger with Methodist Hospital in Sacramento, hospitals that were performing abortions have stopped as part of the affiliation.

But how the ethical directives-- a list of 70 specific rules issued by the bishops--are applied to non-Catholic institutions varies with each case and often depends on the hospital’s board, bishops and dioceses involved, Lee said.

“I think that a lot of people mistakenly believe that the restraints the Catholic institutions operate under preclude them from having mutually beneficial partnerships. That’s not so,” he said. “Let’s just say that miracles do happen.”

Full implementation of the ethical directives usually only applies to situations in which the non-Catholic hospital converts to a Catholic facility.

“A lot of it depends on the legal structure,” said Corrine Bayley, senior vice president of mission and values for St. Joseph Hospital. “In an affiliation, a non-Catholic hospital remains a non-Catholic hospital, but it is in some way connected to the system. In our case, St. Joseph purchased Mission, so Mission now has the same (ethical) requirements as St. Joseph. So they had to change as to what they can do.”

Similarly, when Providence Hospital and Merritt Peralta Medical Center merged in Oakland in 1992, Merritt stopped providing abortions and other reproductive services despite community outcry.

However, in Springfield, Ohio, a merger agreement between Community Hospital and Mercy Medical Center ended sterilizations but allowed Community Hospital to open a building on site for birth control services.

The impact on a community from such mergers often depends on whether patients have other places where they can seek services, Bayley noted.

“There are some obstetricians and their patients who will not be going (to Mission) now. And that is somewhat of a hardship. But there are any number of other hospitals a woman can go to (in South Orange County),” she said.

But, Kissling says she objects to a certain evasiveness, on the part of hospital and church officials, surrounding many mergers. She said she supports the community groups in Nevada County who are asking to be included in the negotiations. Often, communities don’t realize the impact of a merger until it is too late.

“This is a truth-in-advertising question and an informed-consent question,” Kissling said. “People should be told what services will be available, especially in situations where the hospital is the sole provider of services in the region.”

This was of particular concern on a rainy night last week, when the town hall meeting on the proposed affiliation drew 400 people to the high school theater. “It was one of the largest community meetings ever,” said Nanci G. Clinch, a local attorney and opponent of the affiliation. “People had a lot of questions. The community has a right to full disclosure (about which services will be offered) and discussion prior to a vote.”

Abortions have never been available at Nevada Memorial, but most other reproductive services are. Ninety-six tubal ligations were performed there last year. And other decisions, such as life-sustaining treatment at the end of life--an important issue in this largely retirement community--were left up to individuals and their doctors as long as no laws were violated.

“I am really worried about having personal choices in contraception,” said Marsha Bartholomay, a single mother who lives in the nearby town of Rough And Ready. “If the hospital stopped doing it, family planning services would be nonexistent in this area. You would have to go to (about 50 miles) Sacramento for it. For me, that would be an extreme hardship. We use MediCal, so our options are already limited.”

Some Nevada County residents are worried that the church might tighten its control of the hospital over time, despite reassurances that nothing will change, said Dr. Marian Gallaher, a retired physician and USC professor who lives in nearby Nevada City, Calif.

“Our hospital is saying, ‘Don’t worry about it, the directives won’t apply to us.’ Our concern is that four years later, the hospital is enacting changes because of pressure from the (church). If we are to be excluded from the Catholic directives, then we are hoping to get the exclusions in writing,” said Gallaher, president of the Nevada County branch of the American Assn. of University Women, which co-sponsored the town hall.

Nevada Memorial, seeking a way to remain solvent and competitive, sought partnership proposals from larger institutions two years ago, said Daren Correll, public relations manager for the 120-bed hospital.

“We are not going to have religious artifacts on the walls. The way we practice medicine here would not change,” he said. “The board will not agree to anything that is not in the best interest of the community.”

Executives of Catholic health care facilities are sensitive to the concerns of a community, added Cindy Holst, a spokeswoman for Mercy Healthcare Sacramento.

Under an approach called the Community Sponsorship Model, hospitals that affiliate with Mercy are not asked to absorb the ethical directives “verbatim,” she said, but are asked to follow “common values” that include such general concepts as preserving a patient’s dignity and confidentiality. However, the “common values” approach does call for a “belief in the sanctity of life from the moment of conception until death,” she added.

“The two areas in which the hospital would be in a position--from a policy standpoint--of not to providing services would be abortion and euthanasia.”

Sometimes the differences in secular and Catholic philosophies cannot be reconciled. In one proposed merger involving three hospitals in Portland, Me., virtually all hospital care in the city would have been subject to the ethical directives.

The deal fell through when the two non-Catholic hospital boards balked at honoring the directives and church leaders refused to compromise.

Nevertheless, the impetus for hospitals to consolidate remains strong. After rebuffing the Catholic hospital, the other two are continuing their own merger negotiations with each other.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

Medical Mergers

Hospitals nationwide are merging and consolidating in order to save money. But some controversy has emerged over affilations between Catholic and non-Catholic institutions. In one such merger, St. Joseph Health System in Orange purchased Mission Hospital Regional Medical Center last June. In becoming a Catholic hospital, Mission acquired several community outreach programs, including a chaplaincy department, but was required to stop providing a range of other medical services.

MISSION HOSPITAL REGIONAL MEDICAL CENTER

Where: Mission Viejo

Care: General acute

Beds: 240

Previous owner: Mission Viejo Medical Development Company

Services eliminated from Mission as a result of purchase:

* Contraceptives counseling

* Sterilizations

* Assisted reproductive treatments, including in vitro fertilization

* Abortions

ST. JOSEPH HOSPITAL

Where: Orange