Bigger and Bigger THE GROWTH OF CATHOLICH HEALTH SYSTEMS H H Bigger and Bigger THE GROWTH OF CATHOLIC HEALTH SYSTEMS By Tess Solomon, MPH Lois Uttley, MPP Patty HasBrouck, MBA and Yoolim Jung, MPH Graphic Design by Brucie Rosch COMMUNITY CATALYST 2020 This publication was made possible through generous support from the Tara Health Foundation Acknowledgements The authors wish to express their deep provided helpful comments and suggestions, appreciation for the support of the Tara especially Lori Freedman, Ph.D, of the Health Foundation for research and analysis University of California San Francisco, carried out for this publication. We especially Debra Stulberg, M.D., of the University of benefitted from the insights of Tara Health Chicago; Phyllida Burlingame of the ACLU Founder and President Ruth Shaber, M.D.; of Northern California; and Amy Zarin, a and Elise Belusa, Director of Programs and consultant with Community Catalyst’s Operations. We also wish to thank colleagues Women’s Health Program. who reviewed drafts of this publication and About Community Catalyst Community Catalyst is a national, non-profit consumer advocacy organization founded in 1998 with the belief that affordable quality health care should be accessible to everyone. We work in partnership with national, state and local organizations, policymakers and philanthropic foundations to ensure consumer interests are represented wherever important decisions about health and the health system are made: in communities, statehouses and on Capitol Hill. For more information, visit www.communitycatalyst.org. Follow us on Twitter @HealthPolicyHub. Table of Contents Introduction _________________________________________________________________________________________________ 1 Executive Summary _____________________________________________________________________________________ 3 Key Findings of 2020 Study __________________________________________________________________________ 6 Key Finding 1: Big Catholic health systems gain reach and influence ____________________________ 6 Key Finding 2: Number of Catholic hospitals increases, while others decline __________________ 13 Key Finding 3: More communities have only a Catholic hospital _________________________________ 15 Key Finding 4: Catholic hospitals provide less Medicaid and charity care ______________________ 18 Key Finding 5: Catholic hospitals receive public funds, but have religious restrictions _______ 19 Key Finding 6: Catholic hospital partnerships with other providers are non-transparent _____ 21 Conclusion and Recommendations _____________________________________________________________ 25 Appendix A: Methodology __________________________________________________________________________ 28 Appendix B: Catholic Hospitals by State ____________________________________________________ 29 Appendix C: List of Catholic Sole Community Hospitals _____________________________ 30 Endnotes ___________________________________________________________________________________________________ 31 Introduction For nearly 20 years, staff of the Definitions: As in our previous publications, MergerWatch Project – now part of the this report focuses on short-term acute Women’s Health Program of Community care hospitals, sometimes referred to as Catalyst – have been tracking the growth of general hospitals. Patients are most likely to Catholic hospitals and health systems that encounter Catholic religious restrictions at use religious directives to restrict medical care. these hospitals. Not included in this group This report is the fourth in a series that began of facilities are specialty hospitals, such as in 20021 and continued in 20132 and 20163. rehabilitation, chemical dependency treatment, This new report provides a 2020 update on psychiatric or orthopedic hospitals. Critical the growth of Catholic health systems and the access hospitals have been excluded from spread of religious restrictions on care. our counts and analysis because those that are non-Catholic sometimes have affiliations Catholic hospitals operate under Ethical and with Catholic hospitals solely for the purpose 4 Religious Directives (ERDs) that are issued of transferring patients for more advanced and enforced by the U.S. Conference of types of care. Such affiliations do not appear Catholic Bishops. The directives explicitly to impose Catholic restrictions on the critical prohibit the provision of key reproductive access hospital. This report does, however, health services, including contraception, provide for the first time a count of all types 5 sterilization, abortion and infertility services. of hospitals operated by large Catholic health The ERDs have also been interpreted to systems — as well as the numbers of urgent curtail the provision of LGBTQ-inclusive care centers, ambulatory surgery centers and 6 care, such as gender-affirming care, and physician practices they own or operate — in prohibit patients from exercising death with order to fully depict the expanding size of dignity options in states where that choice is these systems. legal.7 Our previous reports documented the spread of these restrictive religious policies Methodology: For our 2020 analysis, we through mergers of Catholic and non-Catholic utilized hospital and health system data hospitals and began to examine the creation from Definitive Healthcare, which draws of large regional and national Catholic health from hospital cost reports filed with the systems. We also examined existing public federal Centers for Medicare and Medicaid policies that permit these hospitals to receive Services (CMS), proprietary research on government funding while using religious health systems and from the annual American doctrine to restrict care. Hospital Association (AHA) survey. Hospitals THE GROWTH OF CATHOLIC HEALTH SYSTEMS 1 We categorized hospitals as Catholic Because control of many if they met two or more of the following criteria: membership in the Catholic Health hospitals has changed Association, participation in a Catholic hands over the last two health system, Catholic affiliation stated in public materials (such as a hospital website), decades, there are now inclusion in local diocese lists or having been founded by Catholic entities. We also hospitals following the developed a discreet category of “Catholic- Catholic ERDs in all of the affiliated” for hospitals within a Catholic health system that do not meet at least two of the ownership categories. criteria. Using this methodology, we identified 544 Catholic hospitals and 33 Catholic- self-identify their type of ownership or control affiliated hospitals. Both “Catholic” and as being one of these categories: government, “Catholic-affiliated” have religious restrictions non-profit church, non-profit other or for- on care, although the “Catholic-affiliated” profit. Because control of many hospitals has hospitals may not strictly follow all of the changed hands over the last two decades, ERDs. Catholic and non-Catholic hospitals there are now hospitals following the Catholic are entering into increasingly complex and ERDs in all of the ownership categories. For non-transparent partnerships that make example, historically-Catholic hospitals that the comprehensive application of the ERDs were purchased by for-profit systems may still difficult for both consumers and advocates be following the Catholic ERDs as a condition to determine. In the findings that follow, the of the sale. Non-Catholic non-profit hospitals Catholic and Catholic-affiliated hospitals are that have merged with Catholic facilities grouped together and referred to as Catholic are often required to adopt all or some of because all have restricted at least some the ERDs. Public hospitals that are being services due to the partnership with a Catholic managed by Catholic health systems may hospital or system. See further details in the have agreed to eliminate any services that Methodology section in Appendix A. conflict with the ERDs. 2 BIGGER AND BIGGER Executive Summary In 2020, a new round of hospital data • # 2 CommonSpirit Health, which analysis has documented nearly two decades was formed in 2019 by Dignity Health of growth by Catholic health systems. Through and Catholic Health Initiatives (CHI) to mergers, acquisitions, business partnerships create the nation’s largest non-profit and expansion into new types of care, these mega system, with 114 short-term systems are extending the reach of Catholic acute care hospitals. health restrictions across the country. • # 4 Ascension Health, which has grown from 36 short-term acute 1. Catholic health systems are growing care hospitals in 2001 to 80 in 2020 and exerting greater influence as they through a string of acquisitions rather control more hospitals and physician than mergers with other Catholic practices, while expanding into the systems, a path to growth differing growing sectors of urgent care, retail from its Catholic peers. health clinics and ambulatory surgery. • # 6 Trinity Health, which is the result • The 10 largest Catholic health systems of the 2013 merger of Catholic Health have grown and strengthened through East and Trinity Health. mergers and acquisitions, and now • # 7 Providence St. Joseph control significantly more short-term Health, which is a result of the 2016 acute care hospitals than they did two combination of Providence Heath & decades ago. These 10 systems own Services and St. Joseph Health. or control 394 short-term acute care hospitals, a 50 percent increase since • Nearly all