State hospital oversight inadequate for era of hospital consolidation, closures

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Women and their doctors in Sierra Vista, AZ, had no say when their only hospital joined a Catholic health system in 2010 and adopted religious restrictions on reproductive health care. Tubal ligations were banned and a woman suffering a miscarriage was sent 80 miles away to the nearest non-religious hospital for help ending her doomed pregnancy, the treatment necessary for her to avoid infection. It took over a year of community protests to convince the board of Sierra Vista Regional Health Center to end its ill-advised affiliation with the Carondelet Health Network.

Unfortunately, people in Arizona and many other states across the nation are being left unprotected as a wave of hospital consolidation is changing the health care landscape in their communities.  Hospital mergers and acquisitions jumped from 66 in 2010 to 112 in 2015, an increased pace that is continuing in 2016.  Regional and national health systems – like the Carondelet Network’s parent system, Ascension Health – are growing larger. The top 25 systems in the nation now control nearly one third of all acute care hospital beds in this country, giving them increased financial and political power.  Many financially-struggling hospitals are either joining these large systems or closing – 60 rural hospitals have shut their doors since 2010. 

Who is watching out for the needs of health care consumers affected by all this hospital consolidation? A new national survey by MergerWatch concludes that state oversight of hospital consolidation is woefully inadequate to protect community access to needed health services. State Certificate of Need (CON) programs were enacted during an earlier era of hospital expansion, with the primary purpose of guarding against overbuilding, duplication of services and resulting excessive health care costs.  Some states (such as Arizona) have abandoned CON review entirely, as part of a general trend toward de-regulation, leaving consumers unprotected from hospital “merger mania.” In most of the 35 states that still do have CON programs, the review guidelines and process have not been updated to address the current trend of hospital consolidation, downsizing and closing. 

Learn more about how hospital consolidation is changing the health care landscape by joining a MergerWatch webinar on June 15 from 3 to 4:15 p.m. Eastern. You can register for this webinar here.

MergerWatch staff studied the elements of each state’s CON law and implementing regulations to determine its suitability for the current market condition of consolidation.  The MergerWatch study found, for example, that only 10 states require CON review when a hospital is going to close or if a service would be discontinued.  Hospitals routinely close or downsize as a result of transactions involving two or more hospitals.  Sometimes one of the hospitals will be transformed into a different type of facility, such as a substance abuse treatment center. Or, as was the case in Sierra Vista, AZ, reproductive health services may be eliminated when a secular hospital joins a religiously-governed health system. 

This study also found that:

• Only eight states require CON review when a proposed hospital transaction is structured as an affiliation or something other than a merger or acquisition, even though it could mean a new entity would be in control of the hospital.
• Just nine states require consumer representation on the CON reviewing body.
• Only four states mandate that the reviewing body consider written testimony from the public.

MergerWatch research gave each state’s program a grade, ranging from F for those states with no CON process up to A- or A for the six states with relatively strong (although still imperfect) hospital oversight policies. How did your state rate? You can check out the state grades and read the entire MergerWatch report on its survey findings, When Hospitals Merge: Updating State Oversight to Protect Access to Care.

What can state and local health advocates do to help ensure consumer voices are heard and community health needs considered when hospital transactions are proposed? MergerWatch staff have identified model CON policies that would allow for state oversight of a wider range of proposed hospital transactions, such as affiliations, and in circumstances when control of a hospital board is to be shifted to another entity, such as a health system. Review would be required for proposed hospital closings and when services would be discontinued at one or more of the partnering hospitals, including reproductive health services. CON review boards would be required to include consumers and consumer advocates, and have limits on the number of members who are hospital industry insiders.

Under these model policies, CON review would include an examination of community health needs, as documented in an existing or new needs assessment or state health planning document, and an assessment of how services meeting those needs would be affected by the proposed transaction. There would be much more transparency to the public about the review process and any transactions being reviewed, as well engagement of affected consumers through such mechanisms as public hearings and submission of written comments.

How can a robust CON program make a difference? Rhode Island’s CON program, one of the strongest in the nation, ensured that consumer voices were heard and community health needs considered as state officials reviewed a proposal to close the obstetrics unit at Memorial Hospital in Pawtucket, RI, which was acquired by the Care New England system in 2013. Care New England said it would send pregnant women to two of the system’s other nearby hospitals. The state Department of Health was required to issue a “reversal” of Certificate of Need and held three public hearings in the Pawtucket area, during which local women and midwives voiced concerns about loss of the hospital’s “mother-friendly” birthing center. Although the DOH ultimately approved the shut-down, citing the hospital’s “unsustainable” financial situation, it imposed several what it termed “patient-focused conditions.” For example, Care New England was required to submit a plan to “replicate Memorial Hospital’s unique alternative birthing experience” at another of the system’s hospitals and ensure low-income women would have transportation to this alternative location.
 
Learn more about model CON policies and some action steps advocates can take in their states by joining a MergerWatch webinar on June 15 from 3 to 4:15 p.m. Eastern. You can register for this webinar here.

Public Hearings Held in California for Catholic Health System Merger

This week, health care consumers throughout California have the opportunity to attend public hearings to voice their concerns about the proposed merger between two large Catholic health systems, St. Joseph Health System based in CA and Providence Health and Services, a WA based system. This merger will impact hospitals from each system across  seven states, but in many of those states there is no formalized government oversight of hospital mergers, and thus no way to be certain that health care access will be maintained or that prices will be kept in check.

California’s unique Attorney General review process allows for these public hearings which will be held right in the communities where the hospitals are located so that people who may be impacted can attend.

The ability for health care consumers to voice concerns about the impact of hospital mergers is not available in many places. Hospitals can merge, close, or reduce certain services without anyone looking out for the communities that rely on those services.

MergerWatch conducted a national study (to be released at the end of this month) that outlines the limits of state oversight, specifically in the form of Certificate of Need (CON) of hospital transactions across the country. Only 33 states have oversight of hospital mergers in the form of Certificate of Need, but even these states do not have the robust policies necessary to protect access to necessary health care. Community input in the form of public hearings when hospital merge is just one type of policy that is severely lacking in many places. In many states the CON policies that exist do not even require oversight of certain types of transactions that can greatly reduce access to healthcare, such as the closure of a hospital service line, or the consolidation of two hospitals that will move one service line many miles away.

The forthcoming MergerWatch report will detail this lack of oversight around the country so that health care advocates can learn how to get engaged and push for more robust Certificate of Need policies that can be used to preserve access to health care in their state.  Please check back soon for the release of this report! 

Grave Consequences for Women’s Health from Bishops’ 'Fortnight for Freedom'

In 2010, a woman who had been 15-weeks pregnant with twins arrived at the Sierra Vista Memorial Medical Center’s emergency department after miscarrying one of the twins at home. The remaining fetus had a heartbeat. The doctor who examined her recommended that the pregnancy be terminated, given the risks, including severe hemorrhaging and infection.

The physician later recalled, “The patient and her husband were, of course, upset by the situation, but decided to proceed with the treatment.” The physician and staff then began routine preparations to complete the miscarriage. That’s when a hospital administrator intervened.

The Sierra Vista hospital had recently started a trial affiliation with a Catholic health system. That meant the hospital had to adhere to the Ethical and Religious Directives for Catholic Health Care Services (ERDs), which prohibit many reproductive health services. A hospital administrator ordered the physician to transfer the patient to avoid violating the (ERDs). The patient was sent by ambulance to the nearest non-Catholic hospital, which was 80 miles away, and after a dangerous hour and a half drive, she finally received the care she needed.

Fortnight For Freedom (June 21 – July 4^th) is a  campaign by the United States Conference of Catholic Bishops to, among other things, maintain the Bishops’ ability to impose Catholic restrictions on health care needed by everyone in a community. The result will be more stories like the one in Sierra Vista, where a Catholic hospital can refuse to provide medically-sound health care to women facing devastating pregnancy related emergencies. Religious “freedom” for Catholic hospitals means we will see more stories like that of Tamesha Means in Michigan. A Catholic Hospital refused to treat her miscarriage, sending her away bleeding and in pain twice with no information about the health care options available to her until she eventually began to deliver in the waiting room.

 

The insistence of the US Conference of Catholic Bishops on their right to religious freedom means women needing reproductive health care are placed in danger.

Because of the Bishops’ Directives, women seeking care at Catholic hospitals aren’t able to receive comprehensive reproductive healthcare. They’re denied contraceptives, tubal ligations, and emergency care for ectopic pregnancies and miscarriages.

There are grave consequences for women when the Bishops are allowed to impose their religious beliefs on the health care of an entire community.

We join the Coalition for Liberty and Justice and the Catholics for Choice in raising awareness about the real-life impact of Bishops’ campaign to elevate their right to religious freedom over the medical needs of women.

by Christianna Silva

Prime Healthcare backs out of deal with Daughter's of Charity in CA

Prime Healthcare, a for-profit health care network with hospitals across the country backed out of purchasing six financially struggling Roman Catholic Hospitals in California’s Central Valley. MergerWatch had been keeping an eye on this purchase in the hopes that it would lead to a return of reproductive and LGBTQ health services to the communities where those hospitals are located. The six hospitals being purchased are operated by the Daughters of Charity Health System and are required to follow the Ethical and Religious Directives for Catholic Health Care (ERDs) which limit the provision of reproductive health services like abortion, elective sterilization and contraception.

California law has a review mechanism that allows the state Attorney General to oversee hospital sales and mergers in order to ensure that the community’s needs are met and patients’ best interests are served. California’s Attorney General Kamala Harris had approved the deal but with stringent conditions on Prime to provide necessary health services for the next ten years. These included beginning to provide comprehensive reproductive health care without restrictions, preserving acute care and emergency services, providing charity care and not discriminating against lesbian, gay, or transgender patients.

As Michael Hiltzik explained in the LA Times, “Prime's business model has been based on cutting medical services except for those that turn a profit or are required by law. There's nothing wrong with that strategy, except when these practices leave residents in medically underserved communities with nowhere else to go for services they need. That's why public officials must make sure those communities aren't shortchanged.” But when faced with the requirement that the hospitals fulfill these conditions and provide necessary emergency and primary care to an economically disadvantaged and underserved region, Prime backed out of the deal.

While it remains to be seen what will happen to the struggling Daughters of Charity Health System and whether reproductive health services can be provided there,  it seems clear that California’s AG review process is doing its job to keep consumers protected from disadvantageous hospital mergers and acquisitions.

MergerWatch Weighs in on New York State Medicaid Redesign

As New York State begins to implement an ambitious Medicaid redesign program known as the Delivery System Reform Incentive Payment (DSRIP) program, MergerWatch is keeping an eye on how new health care partnerships that are being formed  could  affect the ability of low-income women to get needed reproductive health care services. The New York State Department of Health (NYS DOH) is currently reviewing applications for the creation of new collaborative provider networks that will implement DSRIP, known as Performing Provider Systems (PPSs), which will bring together hospitals, clinics, community-based organizations and individual health care practitioners.  The stated goal of creating these PPS entities as part of DSRIP is to deliver better quality care at a lower cost. PPS members can share financial rewards for achieving this goal.

We believe that to be successful, New York’s PPSs must engage women and women’s health organizations on an ongoing basis, so as to identify potential barriers to care and address any such  barriers promptly. MergerWatch staff examined the PPS applications to see how women’s health figures into these new networks. We looked to see how patients would be informed about having their care coordinated by these new systems, and whether better quality reproductive health care could be undermined by either cost control measures or the spread of religious restrictions from Catholic hospitals to other providers within a PPS.  On February 15^th, we took the opportunity to submit comments in advance of the PPS application review and to urge the NYS DOH to make comprehensive reproductive health care a priority in the Medicaid redesign project. See our comments here.

Our comments highlighted the importance of addressing women’s health for New York State’s DSRIP program to achieve the “Triple Aim” (improving the health of a population, enhancing the experience and outcomes of the patient, and reducing the per capita cost of care). Two-thirds of all adult Medicaid beneficiaries are women, and nearly three-quarters of them fall within the reproductive (18-44) age group. For many women of reproductive age, the point of entry into the health care system is their women’s health or family planning provider.  According to the Guttmacher Institute, 6 in 10 women view their gynecological provider as their primary care provider, and for 4 in 10 women gynecological services are their only point of medical contact. In order to maximize the benefits of DSRIP, the New York State Department of Health should require all PPSs to prioritize reproductive health care as a fundamental focus of overall health service provision.

We welcomed the opportunity to submit comments on the PPS applications to help ensure that women’s voices and needs are accounted for in the DSRIP process, and we look forward to ongoing involvement and engagement in this process at both the community and statewide levels.