Health system shifts will bring ministry new ethical issues, says lecturer

April 1, 2011

Goal will be to translate Catholic mission in reformed delivery system

Reform will have a profound impact on how health care is delivered, and ministry ethicists must be able to keep pace with the changes.

That was the thrust of a webinar presented last month by Fr. Tom Kopfensteiner, senior vice president of mission for Englewood, Colo.-based Catholic Health Initiatives. During the CHA-hosted session — "Delivering Health Care Into the Future: A New Health Care Paradigm Needs Different Ethical Thinking" — Fr. Kopfensteiner described how the health care landscape is changing, identified potential challenges that could arise and explained the ethical and moral principles that may require increased attention by ministry health systems and facilities.

Fr. Kopfensteiner said he believes "that our tradition has enough tools in the toolbox to be able to navigate the ethical dilemmas and rough waters that we might be facing in the future. But that is still an open question."

As the Patient Protection and Affordable Care Act rolls out, the health care delivery system is undergoing a transformation,

Fr. Kopfensteiner said. The focus is shifting to reducing waste and redundancy, improving care quality, increasing cost effectiveness and reducing the rate of growth in costs incurred by government payers.

Although the law will extend insurance coverage to millions and advances the belief that health care is a basic good, it was financially, not morally driven, he said. And, because poor, undocumented immigrants cannot receive insurance subsidies established in the law, it does not accomplish a preferential option for the poor that is part of the ethical fabric of Catholic health care, he said.

Hospital and health system administrators are fundamentally changing their organizations' infrastructures to align with the focus areas set out in the law. Many are, or will be, consolidating with other providers to create larger systems, cutting services and staff to increase efficiency, employing physicians directly and investing in information technology.

"The delivery system will look very different from today," Fr. Kopfensteiner said.

Mergers and consolidations
The mergers and consolidations will require extensive ethical reflection, particularly when it comes to Catholic facilities merging with other-than-Catholic ones,

Fr. Kopfensteiner said. The players will have to examine how well their missions align, to what extent the charitable work of the Catholic providers will be maintained, and whether safety net services can be preserved. Catholic organizations must be able to continue to adhere to the Ethical and Religious Directives for Catholic Health Care Services post-merger.

He said the ethical considerations related to the ERDs go well beyond high-profile questions on women's services. For instance, Catholic facilities merging with non-Catholic ones need to determine whether they will require strict adherence to the ERDs by all merger partners; or, in the alternative, if they will agree on policies that will ensure none of the partners will fall out of compliance with the directives. This is a nuanced, but important distinction, Fr. Kopfensteiner said.

He said that adhering to a too-strict definition of Catholic purity in partnerships can be a problem, as can watering down the ministry's traditions too much. "The issue for me today," he said, "is how do we apply the principle of material cooperation, which is the most difficult principle in our moral tradition to apply correctly, in a context that is different ecclesially?" For the church, material cooperation happens when a person or organization participates in circumstances that are needed for an act to be committed, so that the act could not occur without the participation. The church says it is morally impermissible to materially cooperate in evil actions. 

Service cuts
Ministry providers may face mounting financial pressure to cut services should government reimbursement decline or end. Fr. Kopfensteiner said, for instance, that if a state discontinues Medicaid reimbursements for some of the health services undocumented immigrants receive and other providers stop serving this population, their uninsured immigrant patients would be expected to seek care at Catholic facilities. The burden for unreimbursed care would fall disproportionately on ministry facilities, he said.

Fr. Kopfensteiner said it will be important for ethicists to highlight the ministry's ethical obligation to serve undocumented immigrants and care for the marginalized, despite the financial challenges of providing those services. 

Workforce reductions
With consolidations and service cuts, employee layoffs at health systems and facilities likely will become necessary.

Fr. Kopfensteiner said that health care facilities often are among the largest employers in their communities. If they have layoffs, their regional economy can suffer. Therefore, he said, ethicists will need to concern themselves not only with ensuring that workers are treated right when laid off — with fair compensation for instance. They also will need to consider the community impact of downsizings.

In the midst of this, many ministries will need to continue to wrestle with the related question of labor unions representing their employees. Catholic social teaching has a pro-union bias, but many ministry facilities have struggled with this bias in practice, Fr. Kopfensteiner noted. 

Employed physicians
Another challenge will have to do with the fact that more health systems and facilities are employing physicians rather than contracting with them.

For ethicists, it will be important to bring up questions about how well these physicians are being formed in the traditions of Catholic health care. They also will need to raise the issue of disproportionately high physician pay, as compared to the pay of other associates. The ethicists will need to apply Catholic principles of workplace justice and the bias toward a living wage to address this question, Fr. Kopfensteiner said. 

IT investments
Fr. Kopfensteiner predicted that extraordinary investments in information technology will shift investments away from facilities, equipment, staff and programs.

And, he said, as ministry providers invest in technological tools to increase efficiency, such as telemedicine, more care will be delivered at a distance. "And … what does all of this technology do to our sense of an encounter?" The hands-on application of care is a key part of the Catholic health mission, and the concept of a face-to-face "encounter" is part of Catholic theological tradition. As ministry clinicians begin to treat more people without touching them directly, for instance using data transmitted from home health monitoring devices, ethicists will need to ensure that the heart of the ministry is preserved, the presenter said.

 

Copyright © 2011 by the Catholic Health Association of the United States
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