Tamesha Means was 18 weeks pregnant in 2010 when her water broke. The Michigan woman visited a nearby Catholic hospital twice, and was sent home, each time in severe pain, according to a lawsuit filed by the ACLU in December of last year. Doctors at the hospital, directed by Catholic guidelines that forbid abortion, did not tell her that her fetus had virtually no chance of survival or that the safest treatment was to terminate the pregnancy, which was the case, according to the suit. On her third trip to the hospital, after she’d begun to show signs of an infection, the hospital was preparing to send her home again when she miscarried.
While Means’ experience happened in Michigan, women’s health advocates worry that in the wake of an unprecedented number of affiliations in Seattle, this sort of scenario could just as easily happen here—at a hospital or clinic where patients have no idea that Catholic beliefs are steering their health care options.
Across the country, as the health care industry buckles under rising costs, many hospitals are partnering with one another in the hope that scale will help them survive and control costs. In some cases, that means Catholic health care organizations are acquiring secular hospitals or entering into affiliations and collaborations with non-Catholic organizations. And it just so happens that in Washington state, where Catholic health care organizations are in good financial shape, they are taking on a larger share of the system, more than in many other states. This includes recent alliances between UW Medicine and PeaceHealth; Swedish Health Services and Providence Health & Services; and Highline Medical Center and Franciscan Health System.
Sheila Reynertson, advocacy coordinator at MergerWatch, which tracks hospital mergers, called the rapid expansion of Catholic-sponsored or -affiliated health care systems in our state an anomaly. A MergerWatch/ACLU study found that in 2011, one in nine acute-care hospital beds across the country had a Catholic affiliation. At the same time in Washington state, 28 percent of acute-care hospital beds were Catholic. That study is based on the most recent information released by Medicare. But the Washington chapter of the ACLU has been closely tracking activity in Washington since then and reports that once all announced agreements are finalized, around 50 percent of all hospital beds in the state could be affiliated with a Catholic organization.
At the heart of the matter for patients like Tamesha Means is a document called the “Ethical and Religious Directives for Catholic Health Care Services,” which guides Catholic providers. Written by the United States Council of Catholic Bishops in 2009, the directives forbid doctors at Catholic hospitals from prescribing contraceptives for the sole purpose of family planning; performing tubal ligations and vasectomies; terminating pregnancies in any scenario except if the mother’s life is in danger; and assisting terminally ill patients seeking to terminate their lives under Washington’s Death with Dignity law.
People should be aware “that the person who decides about your health care may not be your doctor, it may be [a] bishop,” says Janet Chung, a lawyer with Legal Voice, a nonprofit organization specializing in advancing the legal rights of women and girls in the Pacific Northwest.
But what specific health care organizations will and will not do isn’t cut and dried. Hospitals in Washington have made many different types of arrangements (see sidebar below). Take the one between Highline Medical Center, with a hospital and clinics in south Seattle, and the much-larger Franciscan Health System. When that merger was completed last year, Highline CEO Mark Benedum said, “Our alliance with a high-caliber organization like Franciscan brings incredible strength to our ability to achieve our mission and meet the needs of the communities that we serve.” When it was reported that Highline agreed to follow the
Catholic directives, some wondered if this mission had been sidelined.
When we asked Franciscan’s spokesperson Scott Thompson if women visiting Highline know their doctors can’t prescribe contraceptives for family planning purposes, he asked why we thought they couldn’t do so. We pointed to Franciscan’s website, which says that it and its eight hospitals, including Highline, follow the Catholic directives. “Part of the ethical directives also states that we honor the sacredness of the relationship between doctor and patient,” Thompson said. “We don’t inquire as to why” a doctor prescribes contraceptives. He added that Highline “remains a secular institution.”
Thompson’s answers reveal a gray area in these mergers and illustrate the potential for confusion. “Part of the problem is the uncertainty for people who work [at Catholic-affiliated hospitals] and the patients who go there,” said Legal Voice’s Chung. “It has a chilling effect on the conversations that physicians and staff feel they can have because they aren’t sure what they can provide.”
In 2013, when the University of Washington announced its “strategic collaboration” with PeaceHealth, a Catholic health care organization that operates nine hospitals in the region, it specified that the agreement allowed UW to continue to offer its full range of services. But for at least one doctor on the staff, there’s still a measure of uncertainty. “I have concerns,” says Sarah Prager, associate professor in obstetrics and gynecology and the director of the family planning division at UW Medicine. “I have certainly been reassured that this is a different situation, because it’s not a merger, it’s an affiliation, which apparently has different connotations that aren’t entirely clear to me.”
UW Medicine vice president for medical affairs Tina Mankowski said the contract between the organizations explicitly states that their agreement will not change the range of services that UW Medicine offers, including reproductive health and end-of-life services.
But this is an evolving situation and one reason doctors like Prager are concerned is that even with hospitals that have reassured their doctors and patients that secular policies will prevail, similar arrangements have resulted in a diminution of patient services. For instance, when the Seattle-based secular Swedish Health Services merged with the larger Catholic Providence Health and Services, Swedish patients were assured they wouldn’t see any difference in how they access care.
Providence and Swedish initially called their 2012 agreement an affiliation and said that Providence would keep its Catholic identity while Swedish would remain a nonreligious organization. However, a week after the announcement, Swedish issued a press release stating that after the effective date of the new relationship, it would quit performing elective abortions, in a move a Swedish spokesperson told The Seattle Times was an act of “respect for the affiliation.”
“Following clinical best practice, elective pregnancy terminations are now performed in outpatient settings where specialized resources fully support patients and their families seeking these services,” Swedish spokesperson Clay Holtzman said. While “outpatient” usually refers to a procedure that doesn’t require a patient to spend the night in the hospital, Holtzman clarified that he meant settings that would include Planned Parenthood.
There were also concerns when, in February 2012, Swedish eliminated its hospice service, citing three years of operating losses. Some merger watchers were concerned this might limit terminally ill patient's access to assistance under Washington's Death with Dignity law. Swedish healthcare providers have always been allowed to talk to patients about Death with Dignity and provide referrals but not administer lethal medications at Swedish facilities. When its hospice service was in place, nurses could also be present when patients self-administered these medications.
Critics of the merger are concerned that Swedish's post-merger decision to eliminate its hospice service sharply reduces access to Death with Dignity services for patients because at-home hospice is where it is most often used. Holtzman said the decision to shut down the hospice service was not because of the affiliation with Providence. Current Swedish policy requires that while its practitioners provide patients who request it with information about all the rights and options available to them for their end-of-life decisions and provide referrals, it will not dispense medications under the law nor is the self-administering of life-ending medications permitted at Swedish facilities.
Even where hospitals have clearly described the services they won’t offer, patients may not fully understand the implications, UW’s Prager says. “You might have a patient who says they would never have an elective abortion and then gets pregnant and has a problem pregnancy,” she says. It can be difficult to know where a Catholic hospital draws the line between elective and emergency situations. We asked Swedish to define elective abortion and also if a doctor there could do a selective reduction in the case of multiple embryos or perform an abortion in the case of a fetus having a serious genetic condition.
“Elective abortions are just that, elective,” Holtzman said. “In the instances of nonelective abortions, it is up to our physicians, in full collaboration with patients and family members, to make the right medical decisions on behalf of every Swedish ob patient.” At Swedish, “when it comes to complex and high-risk pregnancies and emergent medical situations, Swedish clinicians are empowered, at all times, to exercise their best medical judgment on behalf of patients,” he said.
A scenario that played out in Bellingham also has set advocacy groups on guard. In early 2012, after PeaceHealth took over St. Joseph Medical Center in Bellingham, Seattle’s Archbishop J. Peter Sartain instructed the hospital to stop processing lab work for Mt. Baker Planned Parenthood, according to the organization’s executive director Linda McCarthy. Her clinic relies on St. Joseph for a few types of tests, including a series of blood tests drawn 24 hours apart to rule out ectopic pregnancy, she said.
Ultimately, her team pressured PeaceHealth and the testing arrangement continued, according to McCarthy. PeaceHealth did not reply to repeated requests for comment.
Beyond incidents like these, opponents of these mergers also raise larger questions about whether institutions that receive public money can limit services for religious reasons, and some advocacy groups are focused on passing regulations that compel hospitals to be clear about exactly what services they will and will not offer.
Recently, Washington’s Department of Health instituted new rules that require hospitals to post online their policies on reproductive and end-of-life care, among other services. So, in principle, patients like Tamesha Means wouldn’t have to learn the hard way.
Mergers and Acquisitions
Recent expansion of Catholic-affiliated health care in Washington state
February 2012: Swedish Health Services, which operates five hospitals, two medical centers and a network of clinics in the greater Seattle area, signs an affiliation agreement with Providence Health & Services, a Catholic health care organization with 27 hospitals and medical centers in five states. Swedish says it remains a nonreligious organization, but has stopped performing elective abortions and providing Death with Dignity care since the agreement.
April 2013: Franciscan Health System (which includes eight Seattle-area hospitals, as well as a network of primary- and specialty-care clinics in King, Pierce and Kitsap counties) acquires Burien-based Highline Medical Center, a 154-bed acute-care hospital with more than 20 clinics, from West Seattle to Vashon Island. Highline has agreed to follow the Catholic directives.
April 2013: PeaceHealth breaks off negotiations with Catholic Health Initiatives to form an integrated regional health system in the Pacific Northwest. Founded by the Sisters of St. Joseph of Peace and based in Clark County, not-for-profit PeaceHealth operates 10 hospitals and physician groups in Alaska, Washington and Oregon. Colorado-based Catholic Health Initiatives is a much larger “faith-based” system operating in 18 states and comprises 89 hospitals.
September 2013: Taxpayer-supported UW Medicine (which operates UW, Harborview, Northwest Hospital and Valley medical centers, Neighborhood Clinics, UW Physicians, UW School of Medicine and Airlift Northwest) finalizes a strategic collaboration with PeaceHealth. According to the announcement, the organizations remain legally separate and independent with no change in services.
February 2014: Pacific Medical Centers, which has nine locations and 150 health care providers in the greater Seattle area, announces a “secular affiliation” with Providence Health & Services. PacMed says it won’t comply with the Catholic directives and will continue to prescribe contraceptives and perform sterilization. Historically, PacMed hasn’t performed elective pregnancy terminations or administered lethal medications for Death with Dignity, and that won’t change.
*The information about Swedish was updated from the original and continues to evolve. As we we made these edits, Providence was making changes to its Death with Dignity policy.