Religious rules continue to roil deals between religious and secular hospitals

Earlier this year, CEO Chris Thomas and the board at Community Hospital in Grand Junction, Colo., were deep in merger talks with Centura Health, a 17-hospital system that’s a partnership between Catholic Health Initiatives and Adventist Health System.

But some community residents and board members of the 60-bed hospital raised objections to Community coming under the Catholic Church’s Ethical and Religious Directives for Catholic Health Care Services, or ERDs, forbidding services such as abortion, contraception, tubal ligation and gender transition surgery, along with physician aid in dying, which is legal in Colorado. Those rules already govern the western Colorado town’s dominant hospital, St. Mary’s Medical Center.

That set off a string of events that complicated Community Hospital’s quest to find a partner, and they’re not alone. Hospital leaders across the country are facing these types of quandaries as Catholic and non-Catholic healthcare systems increasingly consider merging or partnering to gain scale and survive in the rapidly consolidating healthcare market.

At Community Hospital, leaders next opted to join with Centura’s Adventist arm, which imposes less-restrictive religious rules on healthcare services than CHI does. Then, however, board members learned that Adventist rules required replacing Thomas with a CEO who is a member of the Seventh-day Adventist Church, which they didn’t want to do.

Due to these worries over religious directives, Community’s leaders broke off negotiations with Centura in March, deciding to remain independent. Centura declined to comment.

“There was quite a bit of concern about how having a religious affiliation would dictate healthcare,” said Thomas, who dealt with Catholic care restrictions while previously working as an administrator at CHI and Avera hospitals. “Our decision to stay independent was extremely well-received by the community.”

Two months later, UCSF Health similarly ended long-running negotiations to expand its partnership with Catholic-affiliated Dignity Health. UCSF leaders cited widespread protests from physicians, students, staff and community members that Dignity’s Catholic rules would limit services to women, LGBTQ patients, and those seeking physician aid in dying, which is allowed in California.

Nevertheless, some are pushing ahead with deals between Catholic and secular hospitals and between Catholic and other faith-based hospitals.

“We want to bring population health to the entire region, and we’ll do that more effectively working together than doing it on our own,” said Kevin Klockenga, regional CEO for St. Joseph Health system in Northern California, which has signed an affiliation deal with Adventist Health.

That’s despite revisions in the ERDs approved last year by the U.S. Conference of Catholic Bishops imposing tighter scrutiny over deals with non-Catholic providers. Those revisions were intended to ensure Catholic healthcare organizations aren’t collaborating in what the church considers “intrinsically immoral” actions such as contraception, abortion, assisted suicide and sterilization.

Yet deal architects are finding innovative ways to structure the partnerships that slip through the obstacles erected by the bishops and opponents of religious restrictions on healthcare.

In April, Adventist and St. Joseph reached an agreement to combine nine hospitals in six largely rural Northern California counties. The proposed joint operating company would allow Adventist and St. Joseph to retain their own religious identity and rules at each of their hospitals.

Advocacy groups are challenging the partnership on the grounds that it could expand religious restrictions on care. A decision by the California attorney general’s office on whether to approve the deal is due by Sept. 30.

In January, Dartmouth- Hitchcock Health signed an agreement to combine with Catholic-led GraniteOne Health in New Hampshire. The deal would keep Dartmouth-Hitchcock facilities free from Catholic rules while requiring their physicians to follow those rules when practicing at GraniteOne’s Catholic Medical Center facilities. The two systems hope to finalize the agreement in September and win regulatory and diocese approval by next year.

Previously, a proposed merger between Dartmouth-Hitchcock and Catholic Medical Center was blocked in 2009 due to concerns over whether secular or religious rules would prevail.

In March, Women’s and Children’s Hospital in Lafayette, La., merged with Our Lady of Lourdes Regional Medical Center, and started operating under the Catholic ERDs.

System leaders exploring such partnerships often face daunting challenges.

On one side, physicians, nurses and advocacy groups are pushing to protect patient and provider choice as Catholic health systems become the dominant or sole providers in many markets.

They fear a growing number of patients have no convenient alternative to a Catholic provider, since nearly 1 in 6 U.S. hospital beds now are in Catholic facilities, according to the Catholic Health Association. Catholic hospitals are designated as sole community providers in 46 markets, according to Merger Watch, which tracks Catholic healthcare deals. And Catholic providers make up a large part of health plan networks in a number of markets, including Chicago and Denver.

These advocacy groups previously challenged the merger of CHI and Dignity Health, which included 15 historically non-Catholic hospitals. But that deal ultimately was approved by the California attorney general and was completed last year, forming CommonSpirit Health.

The secular forces are intensifying their efforts as part of a broader political fight against measures by the Trump administration and Republican-led states to restrict access to abortion and contraception and let healthcare workers refuse to provide certain services on religious or moral grounds.

They cite research showing that most Catholic facilities do not explicitly inform patients about care restrictions at Catholic hospitals and that many patients aren’t aware of them. In addition, physicians, particularly OB-GYNs, often struggle to arrange workarounds to get patients care they need, such as fudging a medical condition to justify inserting an IUD.

OB-GYNs practicing in Catholic hospitals say they have to seek permission from religious authorities to end pregnancies in cases of miscarriage or premature rupture of membranes, or to perform tubal ligations as part of cesarean deliveries. Such decisions may vary sharply depending on the Catholic ethics official who is on duty at the time, and policies can change when a new bishop or archbishop is appointed.

“You really don’t know what you can or can’t do,” said Dr. Eliza Buyers, a Denver OB-GYN who practiced for eight years at a Catholic hospital in that city. “There are things we were doing, then we couldn’t do them, like doing a tubal at the time of a C-section. That felt very restrictive and wrong.”

That uncertainty is illustrated by Oliver Knight’s case. He said he was prepped to undergo a hysterectomy in August 2017 at St. Joseph Hospital in Eureka, Calif., as part of his treatment for gender dysphoria. But his OB-GYN surgeon came in minutes before the scheduled start of the procedure and told him the hospital wouldn’t allow it because Knight is transgender.

Knight said he went into a panic attack and was given a sedative, then was immediately discharged. He has sued St. Joseph for violation of his civil rights and infliction of emotional distress.

“Everything was cleared and I had no idea there was any issue with me being transgender,” Knight said. “We shouldn’t be refused care just because of who we are.”

In its response to Knight’s lawsuit, St. Joseph said it has a constitutional right to refuse to perform procedures barred by Catholic religious doctrine.

Advocacy groups say UCSF’s recent retreat from its expanded partnership with Dignity due to concerns about religious rules has given their side new momentum in the fight.

“Particularly in light of what’s happening with attacks on reproductive healthcare and LGBTQ folks, people are saying we have to protect bias-free medicine,” said Phyllida Burlingame, reproductive justice and gender equity director for the American Civil Liberties Union of Northern California. “There is much more understanding about the risk posed by hospitals making decisions based on religion rather than health needs.”

On the other side, Catholic authorities tout their heightened fidelity to the religious rules. The bishops’ revised ERDs state that in collaborations with non-Catholic organizations, everything the Catholic organization controls by acquisition, governance or management “must be operated in full accord with the moral teaching of the Catholic Church.” Additional language bars the establishment of an independent entity to “oversee, manage, or perform immoral procedures.”

The Catholic Health Association declined to comment for this article.

Dr. Joseph Pepe, CEO of GraniteOne Health and of the Catholic Medical Center, said CMC performs thorough audits to make sure the hospital abides by the ERDs. “Our Catholicity has strengthened over the last seven years to the point where I believe we are the most conservative Catholic hospital in New England,” he boasted.

Even so, he and other hospital leaders involved in the proposed partnerships in New Hampshire and Northern California stress that those deals are structured to preserve the governing autonomy and philosophical positions of both the Catholic and non-Catholic organizations.

The combination between Dartmouth-Hitchcock and GraniteOne would establish two corporate co-members—Dartmouth Hitchcock Health GraniteOne and the Catholic Medical Center Health System. The latter would continue to be controlled by the bishop of the Manchester, N.H., diocese. The bishop would have the power to ratify or veto any decisions by the system’s board relating to CMC, particularly regarding adherence to the ERDs.

The partnership between Adventist Health and St. Joseph would set up a joint operating company, with each partner retaining management and control over its own facilities. Neither would be allowed to cause the other to violate its religious rules. The agreement would establish a process for resolving any religious conflicts over care. If no resolution were reached, either party could dissolve the joint operating company.

The Catholic partners in these proposed deals hope the way they’ve structured the agreements will convince Catholic religious authorities that they don’t violate the ERDs. They stress that the Catholic organization will maintain the religious care rules within its walls, and won’t control or profit from prohibited services provided by the partner organization.

John Haas, president of the National Catholic Bioethics Center, said the proposed agreement in Northern California appears carefully designed to avoid any kind of oversight or financing by St. Joseph of services provided in Adventist facilities that violate Catholic rules, thus avoiding “immoral cooperation with illicit activities.”

Pepe said his organization learned from the failed merger with Dartmouth-Hitchcock a decade ago to build in ironclad protections for continued adherence to Catholic rules.

“There will be clear prohibitions preventing other hospitals and corporate members from requiring Catholic Medical Center to do anything not consistent with the ERDs,” he said. “It’s structured in a way where our Catholicity will remain ad infinitum.”

For their part, the non-Catholic partners are striving to show secular advocacy groups that the deals will preserve access to women’s reproductive and other services prohibited under Catholic rules.

“We permit contraception, sterilization, in vitro fertilization, and we are LGBTQ-friendly,” said Jill Kinney, administrative director for communications at Adventist Health’s Northern California region. “We remain with our policies, they remain with theirs, and nothing would change.”

Dr. Joanne Conroy, Dartmouth-Hitchcock’s CEO, emphasized that patients in the new system, particularly obstetrics patients, will be fully informed about what services they can receive in what facilities, and will be given a choice in advance of where they want to go. Dartmouth-Hitchcock physicians and residents already practice at the Catholic Medical Center and know how to navigate the different care rules, she added.

“They do a really good job of identifying what patients’ views and desires are ahead of time,” Conroy said. “For those with a real affinity for Catholic healthcare, they make sure they deliver their OB care at Catholic Medical Center. For those who want something not covered there, we direct those patients to other facilities.”

But neither Catholic nor secular advocates are convinced, though the Catholic bishops in both locations have allowed the negotiations to go forward.

“The system board would approve budgets, and that puts Dartmouth-Hitchcock, an abortion provider, in control of the finances of Catholic Medical Center,” said Jason Hennessey, president of New Hampshire Right to Life. “As it stands now, we’re dead-set against this combination, which is not aligned with Catholic doctrine.”

The ACLU’s Burlingame was just as skeptical, pointing to the tough language in the Catholic ERDs on partnerships with non-Catholic providers.

“When they say they’ll allow Adventist to provide the same level of services as before, that seems in fundamental conflict with the new ERDs,” she said. “It’s essential these questions be asked and answered in a substantial way before the California attorney general moves forward with approving this deal.”

St. Joseph’s Klockenga insisted that the Catholic side wouldn’t control any of the joint operating company assets on the Adventist side, leaving Adventist’s care policies untouched. “The management of the JOC will be JOC employees, not employees of any Catholic organization,” he said.

He noted that other organizations that want to affiliate with the new St. Joseph-Adventist system could choose between joining the Catholic or Adventist side, as with Centura in Colorado. In addition, he said physicians in St. Joseph facilities, while forbidden to provide certain services, are free to refer patients to Adventist or other facilities where they can get those services.

Burlingame noted, however, that the ERDs specifically bar administrators or employees of Catholic institutions from making referrals for “immoral procedures.”

Another limitation is that Adventist Health, like St. Joseph, does not offer gender transition surgery or participate in physician aid in dying, according to Adventist’s Kinney.

The Seventh-day Adventist Church officially describes gender dysphoria as “an expression of the damaging effects of sin” and “strongly cautions transgender people against sex reassignment surgery and against marriage,” the ACLU noted in a recent letter to the California attorney general’s office challenging the Adventist-St. Joseph deal.

Adventist Health’s Kinney said her system does not discriminate based on sexuality or gender identity but that its hospitals are not equipped to provider gender confirmation treatment.

Back in Grand Junction, Community Hospital’s Thomas pointed to a new development that he believes confirms the wisdom of his organization’s choice to keep the hospital secular.

Physicians at the town’s largest independent OB-GYN group just applied for privileges at Community because officials at nearby St. Mary’s Medical Center recently said they will no longer permit tubal ligations as part of C-sections for women who don’t wish to bear any more children, Thomas said. St. Mary’s declined to confirm or deny this.

“That’s certainly disappointing for patients who need to deliver at St. Mary’s,” said Dr. Kara Danner, an OB-GYN employed by Community who was informed by St. Mary’s about the new enforcement of the Catholic rule against sterilization. “It doesn’t seem like the right thing to do to make women who have to have a C-section go through two separate surgeries when it could be done together.”

Thomas said all the OB-GYN physicians in town now have privileges at his hospital, which has boosted its finances. “The board is feeling pretty good about the decision to make sure there are options in town,” he said.