We're not going to take it anymore.
The mantra is increasingly popular among community groups and physicians in the consolidation-happy world of healthcare.
Whether it's over lost services, lost jobs, a hospital closure or physician issues, people are rising up-and speaking out-against some of this merger mania.
There's much to be concerned about.
Last year, healthcare mergers and acquisitions hit a record high with 1,183 transactions recorded, an increase of 19% from 1996 (Feb. 2, p. 24).
For hospitals alone, 181 deals were signed in 1997, compared with 169 in 1996 and 133 in 1995, according to an annual report from New Canaan, Conn.-based Irving Levin Associates.
Fueling some of the backlash is the intense public scrutiny hospital mergers and acquisitions are getting from some women's rights groups and family planning advocates. They are concerned about a loss of women's reproductive services in some deals between Roman Catholic and non-Catholic hospitals.
This summer, the National Women's Law Center in Washington published a guide giving local communities advice about using antitrust laws to fight mergers that threaten these services.
Another group has published a guide to help mobilize communities to preserve services for women: Albany, N.Y.-based MergerWatch, which monitors healthcare deals nationwide for their effect on women's services.
"We are not anti-merger," says Lois Uttley, director of MergerWatch. "We fully recognize that in today's challenging healthcare environment, hospitals do need to find ways to collaborate. What we oppose is the enforcement of restrictive rules at secular hospitals and the resulting loss of services."
Also adding to the reaction is a growing public sentiment that healthcare is just another business.
"People are less willing to allow high-sounding rhetoric from hospitals to go unchallenged," says James Blumstein, a law professor and director of the public policy program of the Health Policy Center of Vanderbilt University, Nashville. "People care about medical care, and they care about the symbolism of their hospital in many communities."
Another factor seems to be the growing attention of national media to healthcare business catastrophes.
People see national stories about fraud investigations, providers going bust and hospitals shutting down. Then, they hear talk about a deal involving their local hospital.
"It's logical for the paranoia to become rampant," says Dan Zismer, national practice leader for health system consulting at Towers Perrin in Minneapolis.
When deals involve not-for-profit and community hospitals, some backlash is almost inevitable.
"Invariably a merger doesn't help every constituent group, and the group it doesn't help (is) going to try to stop it," says Stuart Altman, professor of national health policy at Brandeis University in Massachusetts and former chairman of the Medicare Prospective Payment Assessment Commission.
While mergers of for-profit hospitals are outside public control, communities have a vested interest in their not-for-profit facilities, Altman says.
"In the not-for-profit world there's a good chance that the community will be able to override and undo (a deal)," Altman says. "The community has power . . . because it ultimately gave the charter."
To try to understand some of this backlash, MODERN HEALTHCARE looked at four deals that encountered, or are encountering, some opposition:
A proposed merger between Genesee Memorial and St. Jerome hospitals in Batavia, N.Y., which has sparked community concern over tubal ligations.
Optima Healthcare's plan to consolidate acute-care services at a single hospital in Manchester, N.H.
A proposed merger in Miami between Baptist Health Systems of South Florida and Mercy Hospital that aroused physician anger.
A situation involving the closure of Winsted (Conn.) Memorial Hospital. This one has come to a happy conclusion. Community activists acquired the shuttered hospital building and reopened it as an outpatient facility and urgent-care center.
Opposition in N.Y. Earlier this year, residents of Genesee County in upstate New York had a defining moment regarding the future of their two local hospitals.
When they called 70-bed Genesee Memorial Hospital, an operator might answer "Genesee Mercy North Street," and if they called 96-bed St. Jerome Hospital, they might hear "Genesee Mercy Bank Street."
It was an awakening for some in the community and a rallying point for others who already had joined to protest the terms of a proposed merger between the two hospitals.
"That was the point at which the community sat up and took notice," says Martha Munson, co-chair of a local activist group. "It somehow made real for them that something significant was happening to their hospitals."
Genesee Memorial and St. Jerome have proposed merging to create Genesee Mercy Healthcare, with ownership split 50-50 between the private not-for-profit group that now runs Genesee Memorial and Catholic Health System of Western New York in Buffalo, which sponsors St. Jerome, says Paul Battaglia, chairman of the new parent board. Battaglia came from the board of Genesee Memorial.
What community members are upset about is an agreement by Genesee Memorial to follow Roman Catholic rules when it comes to which medical procedures will be allowed.
At Genesee Memorial that means no more tubal ligations for women. Sterilizations are not allowed under the Catholic ethical and religious directives governing healthcare facilities. Abortions aren't performed at Genesee Memorial.
Community activists, such as Munson, say that subjecting the entire community to rules of the Catholic church isn't right.
"I think it's extraordinarily unfair; I think it's outrageous," she says. "If people have accepted a particular spiritual discipline, they should do that. They can't expect the rest of the world to do that."
Munson is co-leader of the local group People Against Lost Services. The group was formed in January and since then has held public meetings, organized picketing and circulated petitions decrying the subjugation of Genesee Memorial, a secular hospital, to religious rules.
Munson says her group wants the hospitals to revise their deal to allow tubal ligations.
"We do not oppose a merger," she says. "We understand managed care . . . something needs to happen."
But Battaglia says Genesee Memorial, an independent hospital, had no choice but to abide by the Catholic rules if it hoped to merge with St. Jerome.
"If we don't put these two hospitals together, my fear was this: Genesee Memorial Hospital would eventually die a slow death," says Battaglia, a local accountant. Under the proposed merger, Genesee Memorial would remain an acute-care facility, while St. Jerome would become a post-acute facility handling rehabilitation and other long-term care.
Battaglia says the hospitals-the only two in Genesee County-filed their pre-merger documents with the Federal Trade Commission late last year. They assume the deal was cleared because they never received any comments or questions.
Certificate-of-need applications for the merger of the hospitals also have been filed with the state Department of Health. Battaglia expects the state to consider them later this year.
Battaglia says sacrificing the fewer than two dozen tubal ligations done annually after women gave birth by Caesarean section was a trade-off that had to be made.
"We are trying to serve the greater good of the community as much as possible," he says.
Munson says estimates are that another 60 to 70 tubal ligations are done as elective procedures annually.
In its certificate-of-need applications to the state, the not-for-profit group that now owns Genesee Memorial has proposed building a new $1.5 million outpatient center where women can go for tubal ligations. The group hopes the proposed facility will alleviate some community concerns.
However, those women who want the procedure following a Caesarean section will have to be referred-before they give birth-to other hospitals outside Genesee County. Transportation will be made available for them, Battaglia says.
Battaglia recognizes the tension the proposed merger has caused in this county of just more than 61,000 people.
"There are some people who I would like to call my friends who don't like the idea of the merger, and it has made it uncomfortable for us," he says. "I feel terrible about that."
But in the end, Battaglia says, people will believe the hospitals did the right thing.
Becoming one in N.H. Community opposition often sprouts as merged hospitals start to trim services. Sometimes that resentment grows so strong it threatens to unravel the hospital marriage, especially in cases of not-for-profit hospitals in which the public has a stronger say. Take Optima Healthcare, a three-hospital health system that is New Hampshire's largest. Based in the Manchester suburb of Bedford, Optima was created through the 1994 merger of 242-bed Catholic Medical Center and 238-bed Elliot Hospital.
Last year, Optima added 150-bed St. Joseph Health Center in nearby Nashua, N.H.
Separated by the Merrimack River, religious tradition and social class, CMC and Elliot are the only two private, acute-care facilities in Manchester. But according to Optima's cost-saving blueprint for the future, eventually there would be only one facility.
Over vocal objections from Catholic activists, local politicians and staff physicians, as well as a new community organization, Optima said in 1995 that it would expand Elliot Hospital and move all acute care, including emergency care, there from CMC. The goal: Turn CMC into an outpatient, psychiatric and rehabilitation facility and make Elliot the acute-care crown jewel.
Optima management "figured they would have a Taj Mahal at Elliot Hospital-that it was going to be Massachusetts General North," says Andre Martel, founder and chairman of the Community Action Group to Save Catholic Medical Center, which has spearheaded grass-roots opposition to Optima's plan.
Martel's group was instrumental in putting Optima's transformation of CMC on the ballot in 1997. By a 2-to-1 margin, Manchester voters approved a nonbinding measure last November that called for both hospitals to stay open as full-service, acute-care facilities.
The vote against Optima marked a turning point. Prompted by the electoral message and a subsequent plea by several state legislators, New Hampshire Attorney General Philip McLaughlin launched an investigation of the Optima merger last December.
This March, he issued a report that concluded Optima's actions during the merger and ongoing consolidation had broken state laws by flouting the charitable missions of CMC and Elliot hospitals.
That stunning finding validated what many local residents, especially Martel, had been saying about Optima all along.
Martel, 51, a former manager at computermaker Digital Equipment Corp., was disabled in a near-fatal car accident almost a dozen years ago. Blocking Optima from gutting CMC has become his life's work.
For Martel the fight has been trying. At times, he says, "I felt like John the Baptist in the desert."
At a low ebb last fall, before the referendum on consolidation, Optima made Martel the focus of critical advertisements during a television blitz. Happily, he says, those ads boomeranged and actually increased donations fourfold to Save CMC.
Through it all, a sense of history has helped Martel stick to his guns.
He has not forgotten that his kin going back several generations, and their working-class neighbors, went door-to-door and down the aisles of their churches collecting money to build the two neighborhood Catholic hospitals that merged to form CMC in 1974.
After Optima began dismantling CMC, Martel says, "I felt like it was my turn to get involved and right the wrong."
In response to the attorney general's report, Optima is reviewing its CMC-Elliot merger and consolidation plans with two new special boards of directors designed to reflect the pre-merger governance of the hospitals.
In the first major casualty of the community backlash, Wentworth-Douglass Hospital in Dover, N.H., pulled out of a year-old affiliation with Optima in July. Preoccupied with its problems in Manchester, Optima was unable to make headway on the goals of the alliance, Wentworth-Douglass officials said. Optima agreed to dissolve the agreement.
This fall, the special Optima hospital boards are set to decide on how or whether to continue the merger and consolidation strategy. McLaughlin is also expected to weigh in.
Ultimately, a probate court may decide Optima's fate. A court-ordered reversal of the merger or a requirement to revive CMC's acute-care mission is a possible outcome.
In any event, Martel isn't slowing down. Optima's history of foot-dragging in regard to community concerns and its continuing unwillingness to renounce consolidation, he says, keep him on guard.
"People are even more adamant today than they were six months or a year ago because Optima is still in denial," he says. "People are so angry at Optima, they just want it to disappear."
Angry docs in Miami. Miami physician Pepi Granat can remember a time when women went to back-alley clinics to get abortions.
So any move to restrict the availability of abortions is something she can't accept.
"Women who do need an abortion and want an abortion should be able to get one," says Granat, who practices at Baptist Health System's 397-bed South Miami (Fla.) Hospital.
That's why Granat was among a cadre of doctors, community members and activists-including a Miami-Dade County commissioner-to protest a move by Baptist Health to restrict abortions at its four hospitals, allowing the procedure only to save the mother's life.
In July that protest derailed a proposed merger-more than two years in the making-between Baptist and nearby 365-bed Mercy Hospital, a Roman Catholic facility.
Hit with a swell of criticism over its policy, the board of Baptist Health agreed in May to temper its stance and allow abortions to continue at one of its hospitals, South Miami.
That concession killed its proposed merger with Mercy because Catholic church directives prohibit abortions, except in cases where a mother's life is in jeopardy.
"It was very disappointing to see them cave in to their medical staff," says Sister Elizabeth Anne Worley, chairwoman of Mercy's board.
But Baptist Health staff physician Fleur Sack says killing the long-discussed merger with Mercy wasn't what the doctors wanted.
What they opposed was Baptist Health's original move to halt abortions. When Sack joined the Baptist Health staff 16 years ago, she says, there was no prohibition on abortions. "All of a sudden there was a change."
Of Baptist's four hospitals, only two performed abortions: South Miami and its flagship, 392-bed Baptist Hospital. In the past year, 35 abortions were done systemwide, says a Baptist Health spokeswoman.
Worley says from the beginning, Baptist agreed to halt abortions at all its hospitals-except when a mother's life is in jeopardy-to make the merger with Mercy happen.
But she says it was Baptist Health's decision in May to implement the policy in June before the merger was completed.
Mercy, she says, didn't force them.
Baptist Health's board had first approved a policy restricting abortions last year, but it was never implemented because of physician opposition.
Baptist Health tried to address the issue of abortion services. It had proposed "carving out" of its system an outpatient surgery center near South Miami Hospital so that the procedures could be moved there. Once divested, the surgery center would have been a separate corporate organization from Baptist Health and not part of the system Mercy would join.
Worley says the deal with Mercy would not have denied access to abortion services because the procedure is available at other facilities in the Miami area.
"I was astounded at some members of the community as to how they would be so adamant for abortion," Worley says. "It's an experience I don't really want to go through again. I didn't think people could fight so hard to take the life of a baby."
To Granat, Baptist Health overstepped its bounds when it decided to ban abortions at its hospitals.
"A patient's decision is between herself and her physician, and the administration of a hospital has no business in those decisions," she says.
Fighting back in Conn. Winsted, Conn., is no ordinary community.
But then again, its favorite son-consumer activist Ralph Nader-is no ordinary citizen.
So when the only hospital in Nader's hometown landed in bankruptcy court last year, people did as Naderites do: They fought back.
Community leaders formed a not-for-profit foundation, bought Winsted Memorial Hospital's buildings out of bankruptcy with $200,000 of debt and lined up local providers as partners in a new venture to preserve local healthcare services.
In April the hospital sprang to life, a pared-back, painstakingly planned version of its former self.
The new operation, called Winsted Health Center, houses a 16-hour-a-day emergency room and a variety of outpatient services, from radiology to cardiac rehabilitation. Ambulatory surgery will be performed beginning in October. A second building houses primary-care physician practices.
"Our approach to this was not to try to re-create a small-town hospital but to create a charitable organization in a smaller town that worked with other hospitals to secure (necessary health services)," says Fred Hyde, M.D., a director at the health center.
The foundation lined up two eager partners. Charlotte Hungerford Hospital in Torrington, Conn., agreed to run Winsted Health Center's emergency room, staff outpatient services, provide emergency transportation and offer health and wellness programs. Saint Francis Hospital and Medical Center in Hartford, Conn., completely renovated one building for physician office space. Together, they invested more than $2 million in renovations and equipment.
Under a joint venture agreement, the two hospitals are equal financial partners in Winsted Health Center's radiology and laboratory, run by Charlotte Hungerford, and physical therapy services, managed by Saint Francis. Profits on those services are intended to offset losses on the emergency room.
So far, the foundation has paid off $160,000 of the $200,000 debt. It's working on finding financing for building improvements and for a permanent endowment.
The effort came not long after the community failed to save its hemorrhaging hospital. The 72-bed, acute-care provider was losing $250,000 a month when the board voted in August 1996 to close its doors. Eventually the facility went into bankruptcy.
In July the new center had total patient visits of 1,103, up from 336 in April. The center is expected to generate annual revenues of $2.3 million, but it will be at least a year before the operation breaks even. No estimates were available on current losses.
For making good on a bad situation, foundation leaders claim victory.
But the battle isn't over. Plans are under way for a subacute-care facility. Down the line they would like to see a childbirth center, a walk-in urgent-care center, a magnetic resonance imaging service and pediatric outreach services.
And the people's verdict? Overwhelming support, says John Capobianco, vice president of outpatient services. "We started doing patient-satisfaction surveys the day we opened," he says. "In practically every survey, people take the time to say `thank you' or `nice job.' "
With Scott Hensley
and Karen Pallarito