CHI Franciscan-Virginia Mason merger stirs worry over religious-based limits to care
The proposed medical merger of Seattle-based Virginia Mason and Tacoma-based CHI Franciscan has raised concerns over how patients will get help with reproductive health or end-of-life decisions.
While plans call for Virginia Mason to continue to operate as a non-Catholic health system, the two health systems will align operations, which means navigating the Ethical and Religious Directives for Catholic Health Care Services followed by CHI Franciscan.
The directives come from the U.S. Conference of Catholic Bishops to govern Catholic health facilities. The directives put an emphasis on care that is “supportive” of life. That means some legal health services in Washington are either not offered or restricted if they are contrary to Catholic teachings.
Services feared at risk with the merger plans include some reproductive health services (including abortion) outside of the Catholic directives, gender confirmation surgery and physician-assisted death for terminally ill patients.
“Prior affiliations between CHI Franciscan and secular health systems have resulted in hospitals and clinics refusing to provide pregnancy terminations — even, in some cases, when a patient is suffering a miscarriage,” read a July joint statement from the ACLU of Washington and other patient and medical advocacy groups.
As interest and concern has grown about the merger, first announced July 16, the two health systems wrote an open letter to the community, distributed as advertising to area newspapers, including The News Tribune.
The letter was signed by CHI Franciscan CEO Ketul Patel and Virginia Mason CEO Gary Kaplan.
Some services, the letter noted, would be affected, as the systems acknowledged early after their initial announcement.
According to the letter: “While there are still many details to determine, it’s important to us to be transparent about what we do know. Should we reach a final agreement, certain services related to reproductive health and physician-assisted death would no longer be provided at Virginia Mason. This would affect only a fraction of a percent of the 12,000 patient encounters our systems provide each day.”
It added, “These services would continue to be accessible in the settings they are already typically delivered, which are outpatient treatment centers mostly outside of the Virginia Mason health system. All other palliative and end-of-life care will continue to be provided across the health system, and Virginia Mason and CHI Franciscan would continue to adhere to each patient’s wish as expressed in advance directives, including any Do-Not-Resuscitate orders.”
The letter also stated, “Care would not change for LGBTQ patients and all of the services currently provided at Virginia Mason are also currently provided at CHI Franciscan.”
Critics maintain that the transformation of Virginia Mason to align practices is too high a price to pay in reduction of care to patients.
Advocates of both reproductive and end-of-life medical care say the services affected by the changes will inevitably have a bigger ripple effect on both providers and patients involved than what has been presented in public statements and recent advertising.
That’s important, they add, as the percentage of hospital beds under Catholic hospital control rises in the state to among the highest in the nation.
Reproductive health services
NARAL Pro-Choice Washington and the ACLU were among groups issuing a rebuke of the plans in a combined public statement issued July 21.
“Virginia Mason’s plans jeopardize access to reproductive and end-of-life care, subordinating patients’ health care needs to religious doctrine,” said Leah Rutman, Health Care and Liberty Counsel for the ACLU of Washington in the statement.
“Even worse, this is not the first move of this kind, nor is it likely to be the last.”
The health systems reject that argument, pointing to a 2013 analysis by the Healthcare Research Group comparing access to reproductive and end-of-life services among both secular and religious health care organizations in Washington state.
That study, commissioned by the Washington Office of Financial Management, said in its executive summary: “Our findings suggest that communities predominately served by religious hospitals do not appear to be experiencing barriers to care.”
But that was 2013, and in 2020, advocates offer arguments they say show just the opposite.
Morgan Steele Dykeman wrote about her story in 2019 in an essay. It described her experience as a patient to terminate what was later determined to be an ectopic pregnancy, in which the fertilized egg implants outside the uterus.
She described receiving delayed care after an initial denial of service at a Seattle Catholic medical site she declined to name.
“Because I wasn’t keeping the pregnancy, (the doctor) couldn’t send me to the obstetrics department for tests. She couldn’t even give me a list of local abortion providers,” she wrote in the essay.
She told The News Tribune in a recent interview, the rise in Catholic control of hospitals “In my experience, and in the experience of many others throughout the state who are afraid to come forward, has resulted in not just a decreased quality of care, but also an incredibly limiting limited spectrum of options for care, and that’s for women seeking reproductive health options, or assistance, even with something as benign as miscarriage treatment to queer folks seeking gender affirming care, a Catholic hospital is not a friendly place for all Washingtonians, and that can have dire health consequences.”
She has worked with advocacy groups to help spread the message.
“I wanted to pull the curtain back on the situation in our state. When I moved to Washington, I thought it was a blue Mecca in Seattle, of all places I was going to be able to find progressive health care options … options that would be respectful of my choices and my autonomy.”
Instead, she said she faced “the shock and betrayal I felt when that wasn’t the case.”
She described news of the merger as “incredibly worrying.”
Now living in the Bellingham area, she says she’s “terrified of going to PeaceHealth,” another Catholic health system, “because of what happened to me at the Seattle Catholic hospital.”
Rutman, in an interview in August with The News Tribune, said, “We are strongly advocating for are very clear policies when it comes to miscarriage and ectopic pregnancies that make it clear that irrespective of religious doctrine, providers are allowed to treat patients in those situations.
“You don’t want a provider to say, ‘Well this is an absolute emergency situation.’ You want them to say, ‘This is standard of care.’ We should be able to take patients in this situation, because we’ve put their lives, their health at risk by not treating them.”
An online FAQ at innovativecareahead.org, a website the systems created to answer questions and offer updates about the merger, notes: “Virginia Mason would ensure it does not cause CHI Franciscan to come out of compliance with the Ethical and Religious Directives (ERDs), and a very small number of services related to reproductive health and physician-assisted deaths would no longer be provided at Virginia Mason.”
The two health networks defend their plans and future care offered, as stated in their joint community letter.
“Let us be clear: if a patient seeks services either organization does not provide, then we would provide information about other providers. As we do today, clinicians in the state of Washington are required by law to provide information about all treatments, including elective pregnancy termination and physician-assisted death.
“In addition, in cases where the mother’s life is at risk, procedures to treat a serious health condition of the mother are permitted when they cannot be safely postponed.
“Any claim that CHI Franciscan or the combined organization won’t provide this care is simply false.”
Under CHI Franciscan’s overall policy posted online: “It is the policy of CHI Franciscan that all services rendered in our facilities shall be supportive of life. At no time may direct actions to terminate life be performed or permitted.”
Under the posted policy it offers links of what’s allowed at each facility.
End of life care
Washington’s Death with Dignity Act, approved by voters in 2008, went into effect in 2009.
The act, as described by the state Department of Health, “allows terminally ill adults seeking to end their life to request lethal doses of medication from medical and osteopathic physicians. These terminally ill patients must be Washington residents who have less than six months to live.”
When enacted, Washington became the second state to allow for it, after Oregon.
Two doctors told The News Tribune that finding a physician providing such a service can be made more complicated by whether or not the doctor works for a Catholic health system.
Berit Madsen is a radiation oncologist who formerly worked as medical director at the Seattle Cancer Care Alliance-Peninsula Center, serving Kitsap County.
Now semi-retired, she recently spoke with The News Tribune in a phone interview from her home.
Madsen noted that in her experience of working alongside medical oncologists employed by CHI Franciscan, doctors could theoretically talk about Death with Dignity but they could not participate in any way if their contract was through a Catholic health system.
She said it meant “those doctors weren’t allowed to prescribe the medications, so they would send their patients to providers who were not limited by being part of the Catholic system.”
“I was getting referrals of patients that I otherwise had never met, had never referred because I was one of the few doctors in the area who was willing to, you know, to write these prescriptions and help with this. So I would see a patient who was dying, sometimes very, very sick,” Madsen said. “I would meet them for the first time, you know, to consult with them, to make sure that they met the criteria. And then go through all the paperwork with them and their families — a very difficult conversation.”
While admittedly these conversations can always be part of a doctor’s job, she noted, it’s still “you taking on a big emotional burden.
“I think it’s kind of unfair to patients and their families that they’re scrambling at the end of their life … to get this process underway, which can be kind of complicated. So there are doctors that have been taking care of them for their entire illness, all of a sudden … to send them out of their system to somebody else.”
She later wrote in an email: “When physicians are barred from Death with Dignity, they may not present DWD as an option for their terminal patients as part of informed consent. It has been my experience that many patients do not realize that DWD is allowed in Washington.
“When oncologists counsel their terminal patients, all options should be presented including palliative treatment, supportive care such as Hospice and Death with Dignity. The options are not necessarily exclusive …”
Wayne Dodge, a retired primary care physician who worked in the Kaiser Group Health network, said that tug-of-war between treatment and directives looms in the background for many doctors.
“The law currently would not allow CHI Franciscan to forbid that oncologist from discussing what your options are,” Dodge said. “But neither does it require that they mention that option.
“As a volunteer physician with End of Life, Washington, I certainly have dealt with cases where I am seeing patients for the first time, whose home care team was unable to provide that type of care. So it happens. One third of the clients who contact End of Life Washington, one out of three, need us to help them find a provider who’s willing to provide this service, because their home care team, either cannot or will not.”
He added that while he understood doctors making independent decisions, that was different than mandates from above.
“This is rupturing the primary relationships that you build as a patient with your home team care system. Around death. You’re going, ‘I would be willing to do it but I cannot do it because I’m forbidden to by my employer.’”
Dodge’s own practice brought the issue front and center to him and drives his passion about the topic today, and warns of slipping back to what times were like before this level of care was codified.
“I started and ran the HIV programs at Group Health from the ‘80s, so I was dealing a lot with the end-of-life issues, starting with that point, and … we were dealing with a lot of death. And a lot of death that at that point was basically inevitable, and I had no legal options other than the best palliative care that I knew. Even though people were saying, ‘I know I’m dead. And I’d like to not go through the remainder of this, please.’”
He paused, overwhelmed by the memories of that time.
“End of Life Washington continues to try to be bringing support to practitioners who are willing and interested in providing this service. But again, it’s a small volunteer organization. And so, at times it feels like an uphill battle.”
The health systems, in a statement to The News Tribune, responded:
“The relationship between our patients and their providers is private and we expect our physicians to continue to exercise their professional judgment to discuss all treatment options. If a patient seeks services we do not provide, then we would provide information about other providers.”
Responding to business concerns
Health networks have seen a flurry of medical mergers or affiliations as the industry becomes made up of fewer independent health groups and more combined systems to pool resources and build finances.
Catholic Health Initiatives combined with Dignity Health to form CommonSpirit Health in 2019. At that time, the alignment included CHI Franciscan’s health system among more than 700 care sites and 142 hospitals, as well as virtual care services, home health services and living communities in 21 states.
CommonSpirit executives at the time predicted cost-savings in its supply chain and contracts and physician practice management of related services.
Those elements have become even more critical amid the coronavirus pandemic, monetary loss from reduced services to focus on COVID-19 and the subsequent supply-chain issues to maintain adequate PPE for its health-care workers.
After CHI Franciscan/Virginia Mason merger, the two health systems would operate 12 hospitals and more than 250 care sites statewide. That would include same-day surgery centers, Benaroya Research Institute at Virginia Mason, Bailey-Boushay House and the Virginia Mason Institute, according to the announcement in July.
At the Catholic Health Assembly in 2019 in Dallas, CEOs, including those with CommonSpirit, maintained that the mergers were good for expanding care to the poor.
They also identified potential barriers to mergers, including pushback from communities when it came to changes in services.
Financial concerns loom large, Dodge noted.
“So, we talk about the medical system. We do not have a system. We have a patchwork quilt. And as Group Health found out, we could no longer be a reasonable player,” Dodge remarked, recalling his days with Group Health before it merged with Kaiser.
“We had to go together with Kaiser to survive. Virginia Mason is at the same existential thing. … They have to associate with a larger group. And the big fish in the sea who are willing to do this are currently the Catholic systems.”
A 2016 MergerWatch report about the growth of Catholic hospitals and health systems noted that Washington had the third-highest percentage of hospital beds operating under Catholic directives, behind Alaska and Iowa. At that time, about 41 percent of acute care hospital beds in the state were in hospitals operating under Catholic restrictions.
Kaiser Health News, in an article about the proposed merger in early August, noted that if the merger goes through, “the only hospital in each of four cities in the state — Bellingham, Centralia, Walla Walla and Yakima — will be a Catholic hospital.”
“Washington state is a growing epicenter of religious-secular health system affiliations,” the ACLU’s Rutman noted in the July joint statement. “In 2010, 26 percent of the state’s hospital beds were in religious or religiously affiliated health systems. With this merger, that number would rise to above 50 percent.”
The move to a merger comes after several years of working together, CHI Franciscan CEO Ketul Patel told The News Tribune in July.
“In 2017, we signed a strategic alliance and clinical affiliation. And during this time, we’ve had great success,” he said.
The two worked toward creating an OB unit at Virginia Mason Medical Center in Seattle, he added.
“We’ve had a long history of a partnership in radiation oncology. And so this is just a culmination of that.”
CHI Franciscan and Virginia Mason, in their community letter in August, concluded that without the merger, access to care across the board would suffer.
“The financial resources required to invest in high-quality care, cutting-edge technology, and world-class facilities have grown exponentially, making it increasingly difficult for systems like Virginia Mason to remain independent,” read the health systems’ letter to the community. “Failing to pursue a partnership with CHI Franciscan would result in reduced care options for patients in our communities.”
Patel told The News Tribune at the start of the process: “We have a lot of work to do before we do become one organization.
“In the next few months, we’re going to be spending a lot of time building a strategic plan for what we’re calling the health system of the future.”
This story was originally published September 15, 2020 at 5:30 AM.
