Questions Unasked at Recent Louisville Forum on Hospital Mergers

Last Wednesday, Dec 14, I appeared on a Louisville Forum panel with two other individuals with serious concerns about the proposed acquisition: Ms. Beverly Glascock, a nurse and attorney; and Dr. Ken Zegart, a prominent Ob/Gyn physician.  It turned out to be a spirited affair.  The house was packed with UofL supporters.  There was not much time for many of the questions submitted in writing from the audience.  I was disappointed in the spectrum of questions asked.  I had prepared a list of questions that I hoped would be asked of the supporters, and in fairness, a list of questions I half-expected would be asked of us.

How would you answer these questions?  I will take a stab at them one-by-one in subsequent entries in this Policy Blog.  If you indicate a favorite, I will tackle that one first.  I numbered the questions in each section for that purpose although they are not in any particular order.  Look also at the many questions I posed in the first major entry in this Hospital Acquisition Series.  What questions would you have asked?  Ask them here!  Perhaps the acquisition proponents will respond respond as well.  Read on to see the questions.

Questions for Merger Advocates:

1.  In 2008, the Dean of the School of Medicine, Dr. Edward Halperin, admonished his graduating class, “not to accept even the smallest of gifts” that might bias your judgment.  “When people offer you a gift that is intended to persuade, remember that the dictionary definition of that is a bribe.  Turn it down.”   Given that the $200 million being offered to the University Health Sciences Center is not targeted to patient care, is this gift then a bribe?  Given that the University has refused to reveal any meaningful details of the proposed uses of the money, how is the public to decide?

2.  Dr. Taylor, you have been quoted as saying that agreeing to honor the Catholic directives was a business decision, and that this compromise was a “very small one.”  After hearing the impassioned and almost universal criticism from outside the University, do you still contend, whether public or not, that trading away the secular nature of the University’s Hospital is a small thing?  [The audience at the Louisville Forum groaned when Dr. Taylor repeated his comment that this was a “business decision.”]

3.  Norton Hospital and the University of Kentucky have formed a partnership to attack the same priorities that you have. In fact their stated goals are nearly identical.  They did not have to merge to do so. Why do you?

4.  The University of Louisville Board of Trustees, without public discussion, authorized President Ramsey to approve and sign “any and all documents, including an academic affiliation agreement, lease, sponsorship agreement and any other agreements needed to implement the proposed merged academic teaching hospital.”  The Board of the University of Louisville Hospital is heavily loaded with individuals closely associated with the University.  President Ramsey and the University’s spokesman have been at the forefront of public pronouncements.  How can you in good conscience continue to assert that this is not a University of Louisville project?

5.  On June 19, a Courier-Journal editorial asked where the headquarters of the new organization would be located.  “No merger hospital in which UofL is a partner can possibly be located anywhere other than Louisville.  It should not even be a point for negotiation.”  Where will the headquarters of the new organization be located?  If you promise us Louisville, how can we know you won’t pull a Rick Scott on us and move the headquarters elsewhere?

6.  Isn’t it true that this proposed business deal is more about competition with Norton Healthcare and the University of Kentucky?  Or for that matter, about making a drug company out of the University of Louisville?  Convince us that your platitudes about improving health care, lowering cost, and increasing access are more than that?

7.  University Hospital originally indicated it would follow the Catholic  health system directives.  Now you claim, out of respect, to agree by contract with some or perhaps even or all of the ethical and religious directives.  Why is this not a distinction without a difference?   Why did you change your position?  The local archbishop has been clear he will approve the arrangement only if the participants agree to follow all the directives?  How can you possibly ask the Governor, the Bishop, and the public to agree to your plans without disclosing what you have agreed to?  [Some, but not all of the documents were released the day ot the Forum debate.]

8.  Louisville’s Archbishop Kurtz has unequivocally stated that he could not foresee a situation in which University or Jewish hospitals would operate under Catholic ownership without also following the formal ethical and religious directives for Catholic Health Care Services.  One must admire the man for his candor.  What part of “unequivocally” does the University of Louisville not understand?  Should this merger advance and survive the inevitable lawsuits, the University and its hospital will have to deal with such inflexibility forever.  President Ramsey and university leaders, how can you possibly ask us to accept this deal?

9.  Why should the University of Louisville Hospital, and ultimately the taxpayer, become liable for the $400 million of the long term debt of Jewish Hospital?  UofL Hospital is not approaching bankruptcy but Jewish Hospital is.  Surely UofL could have extracted a better deal from CHI.  Why didn’t it?  If UofL wants to buy Jewish Hospital, why not do so outright?

10.  The interpretations of the bishops that guides implementing the Ethical and Religious Directives require that the Bishop or his delegate sit on the hospital’s ethics committee and that regardless of the decision of the committee, the Bishop’s opinion is final.  Will University of Louisville Hospital follow these requirements or ignore them?  Will it be mandated that that a priest or nun sit on its ethics committee?  Will a Catholic Priest chair any interdenominational chaplains committee as is required by Catholic Health Systems?

11.  Freedman and colleagues studied miscarriage management in Catholic -Owned Hospitals. The study concluded that in “some Catholic-owned hospitals, the private patient–physician relationship, patient safety, and patient comfort are compromised by religious mandates that require physicians to act contrary to the current standard of care in miscarriage management.”  Given the lack of clarity and consistency in your responses on this matter, how can you possibly continue to withhold from the public, or the church for that matter, the specific agreements you are willing to make in allowing this takeover of our most critical community hospital?

12.  The City of Louisville Website and its Department of Public Health and Safety direct individuals wanting help with family planning and contraceptives to go to the University Ob/GYN Foundation in the Ambulatory Care Building of the University of Louisville Hospital.  Are you going to ask the city to take down that webpage?

13.  Last July, Mayor Fischer said regarding the lack of details in a proposed merger plan, “this issue will not go away from the city’s perspective until these issues are addressed with some concrete action plans and the citizens are happy that the service level is there.”  “If we’re having this same conversation a month from now, that’ll be a problem.”  Why are we having this same conversation in December?

14.  Merger talking points stressed that out of respect, the religious identities of two of the hospitals will remain intact.  Why does not the secular identity of University of Louisville Hospital remain intact?  Why does not respect go both ways?  [I asked this question myself at the Forum.  It was not answered.]

15.  How can the University of Louisville School of Medicine affiliate with an institution in such a major way that prohibits the use of condoms to prevent the spread of HIV infection and AIDS, and uses pseudo-science and disinformation to discredit the effectiveness of this fundamental public health principle.  Are not magical thinking, inerrancy, and discrimination antithetical to the clinical and scientific practice of medicine?  How do you justify this to your students and trainees, indeed to yourselves?

16.  Much has been made about the University’s plans to ship women to Baptist Hospital for procedures you will refuse to do at University Hospital, and then as a magnanimous gesture, pay for those services.  Will you do the same for all the women in the rural counties served by the small hospitals with which you will be merging that deny these vulnerable women these essential and basic services?  Those women have no such face-saving workaround available to them?  If not, how can you possibly justify this merger with the claim that you are increasing access to health care?  Indeed, as a partner, you facilitate a deliberate strategy of limiting basic health care for women for religious reasons that may not be their own.

17.  Baptist Hospital provides very little indigent care.  Why should not Baptist provide medical care to the transported patients for free?  Let University Hospital keep its $15 million for other uses.  In fact, Baptist should be pleased to provide reproductive and family planning care for free to all the women living in the catchment ares of the partner hospitals who request  this essential but denied care.  Would you support such a proposal?

18.  According to Federal statistics, St. Joseph Hospital provides less than half the average amount of indigent care provided by other hospitals in Kentucky. University of Louisville Hospital and Jewish & St. Mary’s (mostly St. Mary’s)  provide among the highest amounts of indigent care.  Why should not University and Jewish Hospital acquire St. Joseph’s Hospital on their own terms, and show St. Joseph’s Health Care System how providing indigent care is really done?  [I provided this data at the Forum.  The proponents were not pleased.]

19.  Will CHI pay any malpractice defense and judgements against physicians who are sued for failure to apply the standard of medical care in their institutions that was refused?

20.  Isn’t it true that virtually none of the money that CHI says it will give to Kentucky hospitals, the University of Louisville, or our Community Jewish Foundation is given as charity by their parent religious institution?  Is the funding not skimmed off the profits of the other hospitals they own or manage.  Why will not the same thing happen in Louisville?   Is this a acquisition bubble waiting to burst?  Given that public taxpayer dollars and insurance premiums are financing these Catholic hospitals, how can you justify refusing to provide services needed and expected by the public?

21.  Why abandon the Computerized medical record that University Hospital already payed for and obtained federal incentives to do so?  Why give CHI the ability to scrutinize what we are doing here, or use Louisville patient data for other purposes?  Is it because the electronic physician ordering module does not have a slot for birth control pills?

22.  Will you agree today to put off the merger until an independent task force can study the merger agreements to determine what are the financial repercussions to the Commonwealth and the ramifications to health care services?

23.  Dr. James Taylor has said that University of Louisville Hospital is “doing fine, thank you.” On the other hand, Jewish Hospital and St. Mary’s is struggling, and the word bankruptcy is being heard in the community.  Why then is University of Louisville Hospital being given the same paltry 15% control in the new proposed system as is Jewish & St. Mary’s, compared to the 70% by CHI.  Is this not the definition of acquisition?

24.  What is the percentage or the amount of money that will be going into the CHI Mission and Ministry Fund?

25.  If your grandchild had a life threatening disease, and the best, if not the only treatment was embryonic stem cell, would you deny her that treatment since it is forbidden by ERDs?  Why is UofL giving back its hard fought right to do fetal stem-cell research and use its results in its hospitals?

26.  Exactly how is the infused money form CHI to be spent, what profits do they expect, why is CHI so interested in failing institutions, what is their ROI, how much do they expect from local and state government after merger, how much more money will they be paid after the Affordable Care Act is enacted and more indigent will have insurance.

27.  How does the faculty of the University of Louisville feel about this acquisition?  [See the subsequent Policy Blog posting for the answer to this question.]

Questions that might have been asked of the “Concerned” side:

1.  Why are you so against this merger?  Only a very few patients and treatments will be affected.

2.  If this merger does not go through, University of Louisville Hospital and Jewish Hospital may go bankrupt and have to close.  Have you no heart?

3.  The new accountable care act is forcing hospitals to change the way they do business.  Why are you standing in their way?  The information technology changes alone are going to make it harder for them to provide indigent care.

4.  The Atty. Gen. has ruled most recently that University of Louisville Hospital is private.  What right do you have to interfere?

5.  Jewish Hospital is too big to fail.  The Louisville business community has pegged its future to the healthcare related businesses.  We will lose jobs if this merger does not go through. Are you against jobs?

6.  Kentucky needs more doctors.  The merger partners have promised to place more doctors throughout the state.  Isn’t this important enough to allow this merger to go forward?

7.  If no one at University Hospital can have their tubes tied, it is not discrimination to send someone somewhere else to get that procedure. Don’t’ you agree?

8.  Why are you bashing religion?

9.  Is this merger going to affect your patients?

10.  Has does this merger affect recruiting doctors for your practice.

11.  What are the changes that you as a physician will have to make in order to accommodate the ERD restrictions?  And what are your colleagues worried about?

Peter Hasselbacher, MD