Can it work?

A community battle over religion-based directives on issues such as reproductive rights and end-of-life care could determine whether two New Hampshire providers are allowed to proceed with a controversial affiliation agreement.

In February, Catholic Medical Center in Manchester, N.H., entered into an affiliation agreement with Dartmouth-Hitchcock Health, a holding company affiliated with 369-bed Dartmouth-Hitchcock Medical Center, Lebanon, N.H. Through the agreement, physicians with the Dartmouth-Hitchcock Clinic would provide difficult-to-access specialty and surgical care to patients at 223-bed Catholic Medical Center and its clinical facilities. Officials at both systems say the arrangement would bring much-needed medical services to the Manchester community.

“It will bring pediatrics and more primary care and hard-to-find subspecialties that we've had trouble recruiting,” said Catholic Medical Center President and CEO Alyson Pitman Giles.

When the affiliation will take effect is uncertain, with the last in a series of public forums yet to take place. New Hampshire's attorney general's office is beginning to review the proposed transaction as is the Diocese of Manchester.

Not all residents are supporting the proposed affiliation. Opponents of the agreement argue that the relationship would compromise the missions of both providers.

“This isn't a review of whether either institution provides good care; it's a concern that the academic goals and Catholic directives aren't compatible,” said Kary Jencks, spokeswoman for the New Hampshire division of Planned Parenthood of Northern New England, one of the groups critical of the proposal.

According to a draft of the proposed affiliation, the agreement would set up two holding companies, the chief of which would be controlled by Dartmouth-Hitchcock. That board would review and approve all decisions regarding joint operations under the affiliation agreement, said Thomas Colacchio, president of the Dartmouth-Hitchcock Clinic, whose physician services will be leased under the deal. “CMC and Dartmouth-Hitchcock will maintain their boards and financials,” Colacchio said. “What the system board has responsibility for is accepting the recommendations” that the provider members make in terms of finances and services related to the affiliation.

But critics say the arrangement essentially asks doctors and the two institutions to toe an unclear line created to honor the Roman Catholic Church's ethical and religious directives while also allowing Dartmouth-Hitchcock physicians who practice at the Catholic provider's facilities to continue providing those services.

Under the professional services agreement, Catholic Medical Center would only lease Dartmouth-Hitchcock physician services that are in keeping with the church's ethical and religious directives. That means abortions, birth-control services and certain advance-care directives would not be provided as Catholic Medical Center services. But the doctors would still be free to offer the services under the Dartmouth-Hitchcock banner.

“The physicians there do not perform abortions and don't want to,” Giles said in reference to Dartmouth Clinic. “Now they do provide tubal sterilization, and that is about 2% of what they do. So, we won't commingle any of the financials, management or governance of those services.” Giles also noted that the agreement would give the Diocese of Manchester substantial power to block certain activity at Catholic Medical Center or dissolve the partnership if the two providers reach an ethical standoff.

Currently, the two providers are working on a system that would call for Dartmouth-Hitchcock doctors to bill payers under Dartmouth-Hitchcock's provider number for services that fall outside of the Catholic provider's ethical and religious directive. Giles said that the two organizations have yet to work out how they would bill separately, for example, when a patient comes in for a single office visit that includes both Church-approved and -unapproved healthcare services. “The church does not want patients to believe that they now approve of birth control and sterilization,” Giles said. “I can't tell you exactly how it will work for something like a vasectomy, but we will work that out.”

Such uncertainty about how the affiliation will allow both providers to continue operating in keeping with their own sometimes competing ethical directives has brought together an unusual alliance of individuals and organizations in opposition of the proposed affiliation. In addition to Planned Parenthood, the New Hampshire Right to Life committee is also challenging the proposed affiliation.

“I think it's not a viable agreement,” said Barbara Hagan, former head of New Hampshire Right to Life. “I think there are other places in the U.S. where Catholic bishops have refused to buy into” affiliations with secular providers.

To be certain, other providers are struggling with similar quandaries. In October, Denver-based Exempla Healthcare's secular co-sponsor, Community First Foundation, agreed to turn over complete operational control of the provider, which owns two hospitals and manages a third, to its other co-sponsor, the Roman Catholic Sisters of Charity of Leavenworth Health System (Oct. 19, p. 16). The agreement followed a dispute over services provided by two secular Exempla hospitals.

This is also not the first time that Catholic Medical Center has waged such a fight. A 1994 merger with Elliot Hospital, Manchester, was dissolved in 2001 in part because of the organizations' different ethical views.

Giles said that the current proposed affiliation is not a repeat of the previous merger, and says she hopes opponents will see value in the two organizations coming together to provide a broader range of healthcare services. “What they don't realize is healthcare is about to go through a revolution, and we need to partner with academic medical centers and other providers to deliver world-class services.”

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