September 12, 2012

Holy family planning

A look at how Catholic restrictions on reproductive health care are impacting KentuckyOne Health facilities, including some of Louisville’s largest OB/GYN providers

The threat of increased restrictions on women’s reproductive health care services appeared to subside late last year when Gov. Steve Beshear nixed the proposed merger of the city’s hospital giants with University Hospital, a move that would have prohibited the public institution from dispensing contraceptives and performing tubal ligations under Catholic directives.

But recent developments surrounding the less-publicized merger that happened a week later — between Jewish Hospital & St. Mary’s HealthCare and St. Joseph Health System, giving Denver-based Catholic Health Initiatives majority ownership of the new KentuckyOne Health — reveal there is still grounds for concern.

On Aug. 24, The Courier-Journal reported that the physicians of Highlands Family Medicine — now part of KentuckyOne — were departing because they could not in good conscience follow the Catholic health directives that limited the contraceptive services they provide.

Following the January merger, the family practice, located at Mid City Mall, was prohibited from prescribing birth control pills, administering birth control shots, or placing intrauterine devices (IUDs) if the sole purpose was to prevent pregnancy, as opposed to regulating menstruation or some other medical reason. They also claimed to be pressured to discuss “natural family planning” with patients.

Though Highlands Family Medicine is the only known practice to have left KentuckyOne over these issues, questions remain about how the Catholic directives have affected other KentuckyOne facilities and their physicians, one of whom tells LEO she’s been encouraged to list reasons other than birth control when prescribing contraceptives, a falsification of medical records she considers “ethically wrong.”

Of particular concern is how the doctors within Jewish Hospital’s far-reaching OB/GYN collective, Premier Gynecology and Obstetrics, are responding to these Catholic directives that limit women’s reproductive health care options.

In September of 2011, Jewish Hospital formed Premier Gynecology and Obstetrics (PGO), a network of five local OB/GYN practices that includes 25 doctors and some of the city’s largest providers, such as Total Woman and Partners in Women’s Health.

In a Business First story heralding its creation last fall, Jewish/St. Mary’s Vice President Jim Parobek declared: “Women are the decision-makers when it comes to health care.”

Given PGO is now under the umbrella of KentuckyOne and beholden to the directives from Catholic Health Initiatives, LEO Weekly asked KentuckyOne spokeswoman Barbara Mackovic what guidelines are placed on OB/GYNs and their staff at these facilities.

In a statement, Mackovic said they continue to provide a “full” and “wide” range of family planning and reproductive health services. She added that while the PGO facilities are not Catholic, they “have agreed to not perform a very limited number of procedures that would cause our Catholic facility partners to fall out of compliance with the (Ethical and Religious Directives).”

LEO Weekly followed up with some basic questions: What specific procedures are physicians and staff prohibited from performing? Are doctors required to discuss “natural family planning” with patients? Are they prohibited from prescribing contraceptives for the sole purpose of birth control? Can practitioners still administer birth control shots and place non-hormonal IUDs? What about performing tubal ligations? Finally, we asked if any written guidelines pertaining to the above had been issued.

Mackovic declined to answer any of these questions.

LEO attempted to ask several OB/GYN’s who work for PGO about the specifics of these guidelines, including their medical director, Dr. Robert Zoller, and the executive director of Jewish/St. Mary’s Women’s Services, Dr. Kim Alumbaugh (who is married to Dr. Dan Varga, chief clinical officer of KentuckyOne). Every doctor either did not respond or referred us to Mackovic.

LEO also called Total Woman and was told by a receptionist that placement of non-hormonal IUDs — the sole purpose of which is to prevent pregnancy — is no longer available for patients. She could not say why this is the case.

Dr. Elena Salerno, a longtime partner at the independent OB/GYN practice All Women, says her office was in negotiations to join the providers that eventually made up PGO but pulled out soon after Jewish Hospital entered the picture.

Salerno says All Women decided against it mostly because it did not make financial sense for their practice. But there was also the consideration that Jewish — soon to have Catholic Health Initiatives as its majority owner once the merger was approved — could place staff and even contracted physicians under strict Catholic directives.

“They assured us that (CHI) would not do anything, but we knew that was not an option,” Salerno says. “It was written all over the paper that the bishop said they would follow (the Ethical and Religious Directives), there was no question. I’m Catholic, and I know how things work.”

Though Salerno says entering a large partnership like PGO would have its advantages, it’s not worth losing the ability to practice medicine the way they see fit.

“We wish to give patients the best care we can, and that’s what it’s all about,” Salerno says. “So to be restricted by a religious or political belief that is not mine, I did not feel like that was the right choice.”

Dr. Rebecca Terry, an OB/GYN at Louisville’s only other independent practice, Women First, agrees that the freedom of doctors to give women the best care possible is vital to their field of medicine.

“The great thing is, we have that independence,” Terry says. “We can do tubal ligations, we can offer every means of contraception. We just really want to take care of women and give them the most optimal care that they can have.”

Norton Healthcare has 41 individual OB/GYN providers and has no religious directives. Spokesman Tom Johnson tells LEO “that’s not something that defines how Norton Healthcare operates.”

But are doctors at KentuckyOne facilities adhering to the new guidelines — whatever those may be — and is KentuckyOne management attempting to enforce them?

One family practitioner who provides OB/GYN services at a Jewish facility (though not under the PGO) tells LEO that’s not the case.

“I am doing nothing different, but I do feel the pressure,” says the physician, speaking on the condition of anonymity. “There have been comments where they encourage us to write on charts that we discuss natural family planning and that we prescribe birth control for reasons besides birth control.”

The doctor says she does not discuss natural family planning with each patient, viewing this as a woefully ineffective birth control method. And despite the pressure to conform to many of the vague, unwritten guidelines, she says she will not falsify medical documents.

“To me it is just ethically wrong to write in a chart a diagnosis that is not correct in order to give someone birth control,” she says. “It’s not mandated, but the vibe I have gotten since the merger is to do that sort of thing.”

While the situation is far from ideal, she plans to continue practicing with KentuckyOne for now, that is unless they begin to crack down on Catholic directives.

“At this point they aren’t changing what I have to do, which is why I’m still here,” she says, adding, “The church should not be mandating these things.”

When asked if any KentuckyOne executives or administrators have told doctors or staff they can ignore Catholic guidelines and continue practicing as they have, Mackovic replied, “No senior leader has given permission to ignore the guidelines that we have communicated to our physicians.”

Dr. Lori Freedman, a medical sociologist at the University of California, San Francisco, who researches the growing conflict between physicians and Catholic-owned hospitals around the country, says such physicians often find “workarounds,” meeting patients’ needs while not following the letter of their guidelines.

“I’ve seen some doctors fighting back, but I think it’s much more common that people discover workarounds, finding that the hospital looks the other way if certain things happen,” Freedman says.

The number of primary care physicians and specialists employed by hospitals has doubled and quadrupled over the last decade, respectively, while one in six hospitals in America is Catholic-owned.

“The thing that’s really concerning for Americans is just how much this control is coming from this outside institutional force, and that they’re able to deny women options, information, referrals and actual care based on these ‘conscience rights,’” Freedman says. “And it’s really the institution’s conscience that is being protected here, not the physicians, and not the patients.”

Dr. Terry of Women First says doctors who find themselves forced to abide by guidelines they disagree with face an ethical dilemma: Do you skirt the rules or make a defiant stand like the physicians at Highlands Family Medicine?

“I admire the people that left, and I have sympathy for the people that haven’t,” Terry says. “Because that would be a hard way to provide care every day. It’s like going back in time, and it doesn’t do women any favors.”

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