05 | Unintended Consequences: Hospital Consolidations and Women’s Health (Part 2 – The Provider Perspective)

In the backdrop, Illinois Governor J.B. Pritzker signed the Reproductive Health Act in July of this year.  The Act eliminates nearly all restrictions on contraception, sterilization and abortion in the state, and ushered in a law that supports reproductive health care as a “fundamental right”.  Yet, as reported in the Crain’s Chicago Business July 2019 article “Why Illinois’ newly recognized ‘fundamental right’ is getting harder to exercise”, the new law, and the acquisition of regional hospitals by Catholic systems are at odds with one another.  Catholic hospitals operate under a set of rules known as Ethical & Religious Directives for Catholic Health Care Services, or ERDs, which were developed by the U.S. Conference of Catholic Bishops.

ERDs largely restrict access to and the provision of care for contraception, fertility treatment, sterilization and abortion. For women covered by Illinois Medicaid managed care plans in Cook County, this creates a significant barrier to comprehensive reproductive health care access, as the County’s plans are heavily dependent on contractual referral relationships with hospitals newly merged with Catholic hospital systems.  

In this episode, I’m talking with Janine Hill, President of Soar Strategies, Inc., former Executive Director of EverThrive Illinois (a statewide coalition for maternal and child health), lecturer in public health at UIC School of Public Health and non-profit management at Northwestern University, and PhD candidate in community health with a focus on maternal health outcomes.

Janine’s expertise in public health policy, health systems and maternal and child health research brings a unique perspective to this new challenge in Illinois, as the health outcomes for women and their children is largely dependent on broad access to comprehensive reproductive health care services. 

Soar Strategies is a consulting and coaching firm committed to helping leaders and groups in the social good and corporate sectors to share their strengths, create goals, and achieve their professional as well as personal goals through a collaborative process.

We are passionate about teams and individuals. We believe that our diversity in experiences, knowledge, and thoughts are our best qualities, and our goal is to help your special gifts shine at work, school, and home by creating brave spaces for coaching interactions, as well as consulting engagements.

We believe that change is a collaborative process that must be guided by goals. We seek to continuously collaborate with organizations, individuals, and teams to facilitate crucial conversations that lead to transformation.

For more on the article “Why Illinois’ newly recognized ‘fundamental right’ is getting harder to exercise”

Reflecting on your research and work, what impact would this have on Maternal and Child health outcomes at the population level?

So, I think this is an important topic, and I think that Illinois really is an outlier in the number of hospital beds we have in our state that are Catholic-owned. So 14.5% of US hospitals are Catholic-owned, as you can see from the research from Dr. Stulberg, it’s even more pronounced in our state, and that does have implications for population health outcomes. So, If I’m a woman going to a facility that is now allowed through ERDs to give me a tubal ligation or IUD or even talk about those types of family planning services, then a couple of things can happen.

Let me back up. One of the most important things that we think about when we have reduced access to family planning methods, which is really what we’re talking about is an increase in unintended pregnancies. So about 5% of women of reproductive age in any given year have an unintended pregnancy, and about half of pregnancies are unintended. So we can logically assume that if we have reduced access to family planning and contraception, we’re going to have increased numbers of unintended pregnancies, and many of those will end in either abortion or in births, right? So, let’s follow that flow-chart.

So if the mom is not able to get family planning services, she gets pregnant, she delivers, the research shows that there are adverse implications for both mom and baby. They include mental health challenges for mom, they include challenges in mother/child bonding when the baby is born, they include things like not getting prenatal care in the first trimester, which is recommended, and increased adverse outcomes like low birth weight and preterm birth. We know that the literature shows us very clearly that, when we have access to family planning, we have less unintended pregnancies, and we have a reduced likelihood of those adverse outcomes like low birth weight, preterm births, [difficulty with] mother/child bonding, etc.

Then, let’s follow the other side of that equation, right? Let’s say that, somehow I was able to get an abortion, we know there’s a very clear link to reduced access to family planning, and increased number and incidence of abortions. So moms may wait later to get an abortion, and that’s a more involved medical procedure. They may, unfortunately, try to access unsafe abortion facilities and practices, and then have a number of medical complications due to that.

So I really do think that there are very clear policy recommendations we can make in this instance, and I think we have to think about what these mergers and acquisitions [mean] in our state and the implications of those at the population and individual levels. This article talks about a woman that’s not able to access family planning services. We know that people who are lower-income, who are Medicaid-eligible, who are in more rural surroundings who are not in the Cook County or Chicagoland area; we know that these women are more likely to be challenged by having one catholic hospital in their network.

In your opinion, how are health care systems impacted by this “consolidation effect”? Specifically, what happens to family planning services across systems of care (i.e., Medicaid managed care, hospital-based care, and primary care)?

I think a couple of things, and maybe I’ll start with the research because that’s where I live. We’d not done a lot of research on the impact of training and [practicing medicine] at a Catholic-based institution earlier, but with these mergers and acquisitions, there are some researchers who are starting to ask those types of questions. There was a 2017 study, published in the Journal of General Medical Education. This was a qualitative study that actually interviewed 31 graduates from seven (7) Catholic residencies between June of 2014 and February of 2015.

What the clinicians reported [were] gaps in reproductive health training that they had to access elective training on their own to get that type of information. And after graduation, they were pretty dissatisfied with their training on family planning. They felt they had delayed competencies in this area, and rightfully so, they thought they had a lack of ability to perform various family planning procedures. They all mentioned that they thought that Catholic programs should improve family planning training by providing routine, opt-out, family planning training opportunities.

So you see this thought at the systems-level and at the provider-level, that the impact of being trained at a Catholic institution, that [providers] reported that is was quite negative in terms of their perceptions of their [own] competencies around family planning. So I do think we have to think about collaborations and what is meant by in-network and out-of-network. If I’m a woman in a rural part of our state, and I have one hospital in-network, and it happens to be a Catholic-owned hospital, is there a way that I could have (for example) access to family planning services in another hospital that would be for the auspices my payment and my managed care plan, be considered in-network for those types of services. It feels to me very unfair to have one hospital that has already stated through the ERDs that they are not able or willing to do certain types of procedures. Yet, as we know, we just passed the reproductive health act. We have decided that each person has a fundamental right to make decisions about reproductive health care, and that includes contraception, abortion and maternity care. A fundamental right is classified as one that the government cannot interfere with, except in certain narrow situations.

So it feels like, if I’m on Medicaid or another type of managed care plan, and I don’t have this access in-network, that feels like interference to me, and so I think we need to think about what that means at the systems-level and systems-level changes that we can provide for these women.

What are the implications for health care equity? Specifically, who is most impacted by this change in the health care delivery system in Illinois?

So, I think we have a lot of different types of data converging here. If I told you the groups that were more likely to have unintended pregnancies, you could overlay the same demographics with the groups that have less access to health care or [within] some of these Catholic-owned institutions. What do I mean by that? We talked about the rural piece, which I think is really important. Really,really important. The other pieces which we have talked about a little bit are, women that are low-income, right? We’ve talked about Medicaid-eligible women a lot in this segment. I would also put women who also have plans that would be considered catastrophic coverage, and don’t have a lot of health care coverage. I would put them in a similar bucket here, because the in-network and out-of-network are pretty tight and there are very clear, large financial implications for selecting a provider that’s out of network. So I would say low-income women, either in Medicaid or other, private, managed care plan. I would say rural women; definitely there are implications for health care equity.

What we haven’t mentioned, but I want to mention here, is that one of the groups that also have high rates of unintended pregnancies are women of color, and in particular, Black women. I know in the article we’re discussing, that was a Black woman. So I think it’s important to think about the converging of those types of demographics on health care equity. It’s going to be the same crew that would have challenges getting family planning anyway. It would be the same crew that would have increased, unintended pregnancies anyway. If we know that from the get-go, and we know that from the research and the data, shouldn’t we be most focused on that population if we really want to see an impact on the reduction of unintended pregnancies? Shouldn’t we be thinking about what can we do for women who may be inside one Catholic-owned, in-network hospital or provider, and what we can do to expand the delivery system and expand their options?

What might be policy-level options to reduce or eliminate the resulting disparity?

That’s a great question, and I have been thinking about this. If I’m the head of the Department of Healthcare and Family Services, or head of the Medicaid Division, what can I do to think about how to address this issue? In some ways, again, I think the wind is in our sails with the passage of the Reproductive Health Act. We have a great opportunity here. The state has said that we have a fundamental right to make decisions about when and where to have children, and when to choose to not have a child.

If we’ve said that, if we’ve passed this public act, then I do think we have a responsibility. I think I should say that first. Some of that might be around the guidance that the Medicaid Division gives to managed care organizations, and this is where I think advocacy could be useful, too – to think about what in-network and out-of-network mean, particularly for family planning and contraceptive services. I honestly think that there should be a statute that says that, if my network is a Catholic-owned institution or hospital, then I should have another option that is a non-Catholic-owned institution to be classified as in-network for me to get my family planning and reproductive health care services. Period.

We could talk about other, less impactful efforts, but I really think we need to think about the classification of in-network and out-of-network, and I should have another option. Because what the ERDs say is that, obviously there should be timely referrals if I’ve decided that I cannot, by virtue of my employer, provide a tubal ligation, or insert an IUD, then I’m supposed to [receive] a timely referral someplace else, right? But timely referral [is something] I almost want to put in quotes, right? If I’m in a rural situation or if it just gets lost in the shuffle, timely ends up not being so timely, and when you’re pregnant, every week matters. And so I don’t think we need to be doing that in the midst of it; like I go and I can’t get an IUD, that plan needs to be set from the very get go. I think there needs to be educated on this also for consumers to understand that, you are enrolled in a plan that actually has as its in-network hospital, a Catholic-based institution. Here’s what they can do, here’s what they can’t do. We actually will give you another period of time if family planning and contraceptive services are important so you can choose another plan, and to choose another in-network hospital.

I bet that if we had a focus group of reproductive aged women in Catholic-based institutions and we asked them: “do you understand that, in your plan, [which is] under an ERD, you cannot get x,y and z at your hospital”. I bet most of them would not know that right now, and they won’t know that until they get into a situation, which I think is unfortunate. So, one – I think we need to do a better job of education on the front-end about health plans and, two – I think we really need to reevaluate what in-network means, and having an in-network option that’s non-Catholic owned for women of reproductive age.