Religious, secular hospital mergers pose challenges for ethics committees

Committees can take the lead in creating harmony

As the market for providing health care gets increasingly competitive, "merger mania" is continuing to sweep the nation. More and more community hospitals are becoming part of larger health systems to take advantage of economies of scale and consolidation of services.

While this may be good for the bottom line, many communities are finding the consequences devastating when the merging organizations don’t take steps to develop a common mission before finalizing their agreement.

"My view about hospital mergers is that it is a merger at the level of the business, but it is also a blending of cultures," says Stephen E. Lammers, a published expert on medical ethics and religious issues and a professor of religion at Lafayette College in Easton, PA. He also is a consulting humanist for a local hospital, Lehigh Valley Hospital Center, where he serves as a member of the center’s institutional review board and ethics committee.

"You may have a religiously affiliated hospital and one that is not. Or it could be a not-for-profit hospital or public hospital and a for-profit system that are merging. Or you may just have two different hospitals, each with a different pace and way of doing things. The important thing for ethics committees to realize is that they are part of a distinct hospital culture, and first they need to consider several issues of how their hospital approaches things and how the other hospital approaches the same issues," explains Lammers.

Complicating matters further, the last five years have seen an increase in the number of mergers between religiously affiliated hospitals — particularly larger, not-for-profit Catholic health systems — and secular hospitals. Accord ing to statistics from the St. Louis-based Catholic Health Associa tion of the United States, there were 16 mergers or affiliations between Catholic hospitals and non-Catholic facilities in 1994. There were 35 such arrangements in 1998.

Dilemmas go beyond culture clash

The growing frequency of these types of mergers pose problems beyond just a culture clash, notes Ann Pasley-Stuart, SPHR. Pasley-Stuart is president of Pasley-Stuart HR Consultants, a professional human resources consulting firm specializing in retaining workers, change management, and conflict resolution.

"There are a lot of issues to consider," she explains. "One is that very often services are going to be limited. The classic case is a for-profit system taking over a not-for-profit; it is highly likely that charitable services will be changed, curtailed, or even eliminated."

Many religious charitable hospitals were founded with a mission to care for the entire community, including providing services to the poor, Stuart notes. A shift to a system that is profit-driven can be stressful for the staff, even leading to large numbers of resignations, if staff feel the hospital no longer meets its mission.

In addition, Catholic hospitals must adhere to a set of rules, established by the National Conference of Bishops, which is known as the Ethical and Religious Directives for Health Care. These rules govern which services may or may not be provided at Catholic facilities, with the issues of physician-assisted suicide, abortion, contraception, and reproductive health services receiving the most public attention. (For additional information on the debate, see story, p. 128.)

The merging hospital may be asked to come under the directives in order to affiliate with the sectarian hospital.

"In the case of the Catholic and other religious organizations, the A-word always comes up," Stuart continues. "Will the hospital provide abortion services? What about employee benefit programs? Will these services be covered by health insurance? What about coverage of birth control or sterilization procedures?"

Committee plays a leading role

Hospital ethics committees need to be prepared to play a leading role in facilitating or guiding a merger that its administrators believe should happen, say Stuart and Lammers.

"The classic role of the ethics committee is to educate themselves and then educate others about a particular issue, and that should hold true in this case," Lammers notes.

There are two key areas where "the rubber meets the road" in these mergers, and they should be examined by the committee with an eye toward developing policy for the new organization that both of the original hospitals can live with.

"One is the issue of commitments to charity care and medical education that might be subject to change," says Lammers. "The second would be, as in the example of the Catholic hospital, issues around abortion or reproduction or other services that might be subject to change."

Examine your internal culture’

The committee also should be prepared to examine its internal "culture" to determine the institution’s core values, goals, and approach to providing medical care and then compare these core characteristics to those of the other organization.

"Examine the differences in mission and philosophy," he advises. "That involves more than reading mission statements. It involves asking yourselves, What do they do in areas that we think are important?’ and What do they not do in areas that we think are important?’ etc. That way you can at least lay out the issues for the people on your side."

For the process to work effectively, both experts agree, the committee must be focused on organizational as well as clinical ethics.

"There should already be an organizational or human resources person or component in the ethics committee," says Stuart. "You should have the person in charge of the people at the organization on the committee, and most do, but not all. This is an excellent opportunity for the ethics committee to really shine." (For additional information on developing a mission statement, see p. 132.)

Strong commitment’ required

In the best-case situations that Stuart has witnessed, the committee incorporated staff and community focus groups into its discussions to determine the impact of the merger and head off problems.

"The ones that have worked well are those that had a strong commitment for the merger to succeed. Both organizations were committed to excellence and just redefined excellence in terms of the newly merged organization," she relates. "The transitions were handled very well, and it was expensive to do it correctly, but well worth it. If your staff leaves, it is going to be more expensive."

Committee can spot problems

In addition to helping a merger succeed, the ethics committee might be able to foresee irresolvable differences in policy, values, and culture that would make a joint agreement unworkable, adds Lammers.

"The committee is going to have to be very proactive and insert themselves into this process," Lammers advises. "The committees totally focused on clinical ethics are not well-situated to do this. Committees that have started to move into the realm of organizational ethics are more prepared. It is more natural for them to know about the situation and be asked about it because the staff and administration would be aware that there would be ethical issues involved."