An analysis of insurance claims from more than 350 commercial carriers found that plastic and maxillofacial surgeons billed out-of-network more frequently than any other type of specialist in an inpatient setting.

This article was first published on Monday, May 6, 2019 in Kaiser Health News.

By Michelle Andrews

Bob Ensor didn't see the boom swinging violently toward him as he cleaned a sailboat in dry dock on a spring day two years ago. But he heard the crack as it hit him in the face.

He was transported by ambulance to an in-network hospital near his home in Middletown, N.J., where initial X-rays showed his nose was broken as were several bones of his left eye socket. The emergency physician summoned the on-call plastic surgeon, who admitted him to the hospital and scheduled him for surgery the next day.

Shortly before surgery, the doctor introduced Ensor to a second plastic surgeon who would assist in the 90-minute procedure. Entering through Ensor's nose, the physicians realigned his facial bones, temporarily sewing Ensor's left eye shut so that the lids would stay in place as the bones knitted back together.

Six weeks later, as Ensor, then 65, continued to make an uneventful recovery, a collection agency called to inquire how he and his wife planned to pay the $71,729 bill for the assistant surgeon. Ensor's company health plan had denied payment because the surgeon wasn't part of its contracted physician network.

There was more bad news. Ensor received notice that the health plan wouldn't cover the $95,885 charged by the first plastic surgeon either because he also was out-of-network.

"The hospital knew these doctors were out-of-network and didn't bother to tell us," said his wife, Linda Ensor, noting they faced more than $167,000 in charges. "We were panicked."

Riverview Medical Center in Red Bank, N.J., where Ensor was treated, said that it "empathizes with patients who are trying to navigate the complexity of the healthcare billing system" and that transparency in billing has not always been optimal for emergency department patients

As surprise out-of-network billing becomes a politically charged issue, Americans want the federal government to take action. In an April survey, more than three-quarters of consumers said the government should protect them from such bills, according to the Kaiser Family Foundation's monthly health tracking poll. (KHN is an editorially independent program of the foundation.)

An analysis of insurance claims from more than 350 commercial carriers found that plastic and maxillofacial surgeons billed out-of-network more frequently than any other type of specialist in an inpatient setting. Examining hospital admissions in 2016, researchers at Johns Hopkins Bloomberg School of Public Health found that plastic and maxillofacial surgeons billed their services out-of-network 23% of the time, more than any of the other 50 specialties analyzed.

That leaves patients like Ensor, whose care requires plastic or maxillofacial surgery, extremely vulnerable. It also catches patients off guard: When a parent brings in a child with a cut and a triage nurse asks if they'd prefer a plastic surgeon, many reflexively answer "yes" not understanding whether there is an actual need nor anticipating the charges.

According to one survey of emergency department directors at more than 440 hospitals, 81% reported they had inadequate plastic surgery coverage, a higher percentage than reported shortages of any other type of surgical specialty.

The reasons these specialists are such frequent out-of-network billers are fairly straightforward.

Many plastic surgeons don't participate in health plans because they have flexibility other physicians may not have — their practices often focus on elective cosmetic procedures like nose reshaping and breast augmentation that patients pay for on their own.

Also, general surgeons and heart surgeons generally want to maintain good relations with the hospitals — and be on call for the ER— since the ER is a source of patient referrals and their patients often require inpatient care. In contrast, plastic surgeons often operate at outpatient centers.

"Fortunately for some plastic surgeons with alternative revenue streams, they don't need to participate with insurance companies," said Dr. Gregory Greco, the board vice president for health policy and advocacy of the American Society of Plastic Surgeons, who has a solo practice in New Jersey and Manhattan. Greco participates in the employee plans at the institutions where he has hospital privileges, but he doesn't accept other insurance plans.

The society did not respond to a request for information regarding the percentage of plastic surgeons who participate in insurance networks.

That can spell trouble in emergency care. Under the federal Emergency Medical Treatment and Labor Act (EMTALA), hospital emergency departments are required to screen and stabilize any patient who walks through the door, whether or not they can afford to pay. Hospitals often rely on a roster of on-call specialists to treat emergency patients, but studies show many specialists are reluctant to be on call, and low rates of insurance reimbursements may play a role in those decisions.

Data from a New York state program to arbitrate surprise medical bills — a 2015 state law holds patients harmless for such charges — highlights the scope of the problem with plastic surgery coverage.

Emergency care involving out-of-network plastic surgery services was by far the most common type of bill reviewed, according to figures from the state Department of Financial Services. By late 2018, there had been 543 decisions regarding such bills, compared with 335 for emergency physician care and 263 for orthopedists.

In New York, the surprise billing law has discouraged plastic surgeons from charging extremely high fees for out-of-network work, said Dr. Andrew Kleinman, a plastic surgeon in suburban New York City who is a former president of the Medical Society of the State of New York. Under the program, which uses a process called "baseball arbitration," the insurer and provider each submits a proposed dollar amount and the arbitrator picks one.

"Baseball arbitration gives the physician an incentive not to bill an outrageous rate because they're going to lose," Kleinman said. If a doctor charges $20,000 for services provided, but the insurer offers $500, "the insurer will win every time," he said.

More than two dozen states have passed laws that address surprise bills to some extent — although they do not protect the many patients covered by plans regulated by national rules. Congress is debating measures that would address surprise bills at the national level.

In the meantime, patients remain vulnerable. Dr. Meghan Candee was visiting family in Riverhead, N.Y., last summer when her daughter, who was 4 at the time, fell against a wooden bench and got a small cut underneath her left eyebrow. Candee, a pediatric neurologist in Salt Lake City, took her to the emergency department nearby, where she opted for a plastic surgeon, who put in a single stitch, without any sedation.

Candee paid the $100 copayment for the emergency department visit and took the stitch out herself five days later.

A few weeks later, Candee's insurer sent a $25,175 check to pass on to the out-of-network plastic surgeon, who had charged that amount for his work.

Assuming there was an error, Candee called the plastic surgeon's billing office but was told the amount was correct. Even though she wasn't herself on the hook, Candee was "outraged."

"This is why people have issues with physicians, and they think most of us are out there trying to get money," she said.

In New York, the average out-of-network charge at a hospital or other setting for an injury like Candee's daughter's — a simple repair of a superficial wound on the face that is 2.5 centimeters or less in length — is $438.01, according to FAIR Health, a national, independent nonprofit organization that collects and manages an extensive database of insurance claims. In the Great Neck/Port Washington area of Long Island, the area with the highest charges for that repair nationwide, the average charge is $1,067.25.

Patients should know that a plastic surgeon may not be covered in-network and is not necessary in many cases. "It's not uncommon for a family to say they would like a plastic surgeon," said Dr. William Jaquis, president-elect of the American College of Emergency Physicians. "But, in the vast majority of cases, a well-trained emergency physician can do most of the repairs." A plastic surgeon makes sense when there's extensive, deep-tissue damage and the skin is not cleanly torn, especially on the face, he said. A dog bite or an eye socket injury like Ensor's is a classic example.

Luckily for the Ensors, the sailing club stepped in to take up his case with the out-of-network plastic surgeons. Since sailing club members were required to volunteer on work projects to keep membership costs in check, the club's insurer agreed to cover the accident as a workers' compensation case. It paid 100% of the outstanding bill.

Michelle Andrews: andrews.khn@gmail.com, @mandrews110

Most downgraded homes had payroll records that showed no RN hours at all for four days or more. The remainder failed to submit payroll records or sent data that couldn't be verified.

This article was first published  on Friday, May 3, 2019, in Kaiser Health News.

By Jordan Rau and Elizabeth Lucas

The federal government accelerated its crackdown on nursing homes that go days without a registered nurse by downgrading the rankings of a tenth of the nation's homes on Medicare's consumer website, new records show.

In its update in April to Nursing Home Compare, the Centers for Medicare & Medicaid Services gave its lowest star rating for staffing — one star on its five-star scale — to 1,638 homes.

Most were downgraded because their payroll records reported no registered-nurse hours at all for four days or more, while the remainder failed to submit their payroll records or sent data that couldn't be verified through an audit.

"Once you're past four days [without registered nursing], it's probably beyond calling in sick," said David Grabowski, a health policy professor at Harvard Medical School. "It's probably a systemic problem."

It was a tougher standard than Medicare had previously applied, when it demoted nursing homes with seven or more days without a registered nurse.

"Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes," the agency announced in March. "CMS found that as staffing levels increase, quality increases."

The latest batch of payroll records, released in April, shows that even more nursing homes fell short of Medicare's requirement that a registered nurse be on-site at least eight hours every day. Over the final three months of 2018, 2,633 of the nation's 15,563 nursing homes reported that for four or more days, registered nurses worked fewer than eight hours, according to a Kaiser Health News analysis. Those facilities did not meet Medicare's requirement even after counting nurses whose jobs are primarily administrative.

CMS has been alarmed at the frequency of understaffing of registered nurses — the most highly trained category of nurses in a home — since the government last year began requiring homes to submit payroll records to verify staffing levels. Before that, Nursing Home Compare relied on two-week snapshots nursing homes reported to health inspectors when they visited — a method officials worried was too easy to manipulate. The records show staffing on weekends is often particularly anemic.

CMS' demotion of ratings on staffing is not as severe as it might seem, however. More than half of those homes were given a higher rating than one star for their overall assessment after CMS weighed inspection results and the facilities' own measurement of residents' health improvements.

That overall rating is the one that garners the most attention on Nursing Home Compare and that some hospitals use when recommending where discharged patients might go. Of the 1,638 demoted nursing homes, 277 were rated as average in overall quality (three stars), 175 received four stars, and 48 received the top rating of five stars.

Still, CMS' overall changes to how the government assigns stars drew protests from nursing home groups. The American Healthcare Association, a trade group for nursing homes, calculated that 36% of homes saw a drop in their ratings while 15% received improved ratings.

"By moving the scoring 'goal posts' for two components of the Five-Star system," the association wrote, "CMS will cause more than 30 percent of nursing centers nationwide to lose one or more stars overnight — even though nothing changed in staffing levels and in quality of care, which is still being practiced and delivered every day."

The association said in an email that the payroll records might exaggerate the absence of staff through unintentional omissions that homes make when submitting the data or because of problems on the government's end. The association said it had raised concerns that salaried nurses face obstacles in recording time they worked above 40 hours a week. Also, the association added, homes must deduct a half-hour for every eight-hour shift for a meal break, even if the nurse worked through it.

"Some of our member nursing homes have told us that their data is not showing up correctly on Nursing Home Compare, making it appear that they do not have the nurses and other staff that they in fact do have on duty," LeadingAge, an association of nonprofit medical providers including nursing homes, said last year.

Kaiser Health News has updated its interactive nursing home staffing tool with the latest data. You can use the tool to see the rating Medicare assigns to each facility for its registered nurse staffing and overall staffing levels. The tool also shows KHN-calculated ratios of patients to direct-care nurses and aides on the best- and worst-staffed days.

Jordan Rau: jrau@kff.org, @JordanRau

Elizabeth Lucas: elucas@kff.org, @eklucas

For decades, the American medical establishment has known how to manage diabetes. Yet across the country, surgeons still perform tens of thousands of diabetic amputations each year.

This article first appeared on Wednesday, May 1, 2019 in Kaiser Health News.

By Anna Gorman

LOS ANGELES — On his regular rounds at the University of Southern California's Keck Hospital, Dr. David Armstrong lives a brutal injustice of American healthcare.

Each week, dozens of patients with diabetes come to him with deep wounds, severe infections and poor circulation — debilitating complications of a disease that has spiraled out of control. He works to save their limbs, but sometimes Armstrong and his team must resort to amputation to save the patient, a painful and life-altering measure he knows is nearly always preventable.

For decades now, the American medical establishment has known how to manage diabetes. Even as the number of people living with the illness continues to climb — today, estimated at more than 30 million nationwide — the prognosis for those with access to good health care has become far less dire. With the right medication, diet and lifestyle changes, patients can learn to manage their diabetes and lead robust lives.

Yet across the country, surgeons still perform tens of thousands of diabetic amputations each year. It's a drastic procedure that stands as a powerful example of the consequences of being poor, uninsured and cut off from a routine system of quality health care.

"Amputations are an unnecessary consequence of this devastating disease," said Armstrong, professor of surgery at Keck School of Medicine of USC. "It's an epidemic within an epidemic. And it's a problem that's totally ignored."

In California, where doctors performed more than 82,000 diabetic amputations from 2011 to 2017, people who were black or Latino were more than twice as likely as non-Hispanic whites to undergo amputations related to diabetes, a Kaiser Health News analysis found.

The pattern is not unique to California. Across the country, studies have shown that diabetic amputations vary significantly not just by race and ethnicity but also by income and geography. Diabetic patients living in communities that rank in the nation's bottom quartile by income were nearly 39% more likely to undergo major amputations compared with people living in the highest-income communities, according to one 2015 study.

A 2014 study by UCLA researchers found that people with diabetes in poorer neighborhoods in Los Angeles County were twice as likely to have a foot or leg amputated than those in wealthier areas. The difference was more than tenfold in some parts of the county.

Amputations are considered a "mega-disparity" and dwarf nearly every other health disparity by race and ethnicity, said Dr. Dean Schillinger, a medical professor at the University of California-San Francisco. To begin with, people who are black or Latino are more at risk of diabetes than other groups — a disparity often attributed to socioeconomic factors such as higher rates of poverty and lower levels of education. They also may live in environments with less access to healthy food or places to exercise.

Then, among those with the disease, blacks and Latinos often get diagnosed after the disease has taken hold and have more complications, such as amputations. "If you go into low-income African American neighborhoods, it is a war zone," said Schillinger, former chief of the Diabetes Prevention and Control Program at the California Department of Public Health. "You see people wheeling themselves around in wheelchairs."

Part of the outrage for researchers is that medical science has made so much headway in diabetes treatment. Nationwide, fewer than 5 adults out of every 1,000 with diabetes get amputations.

But for those who do, the consequences are profound. More than half of amputations in California from 2011 to 2017 occurred among people ages 45 to 64, according to the KHN analysis, meaning many people are left disabled and dependent on others for care during their prime working years.

From Mother To Son

Jackson Moss leaned back on his couch and raised his right leg. His wife, Bernadette, sprayed antiseptic on a gaping wound on the sole of his foot before dabbing it with Vaseline and rewrapping it with gauze.

A stocky man who used to deliver poultry, Moss, 47, said he had to stop working after his left leg was amputated below the knee about 10 years ago. Later, he lost part of his right foot. With Bernadette's help, he is trying to save the rest of it.

"If I didn't have my wife, I don't know where I'd be," said Moss, who wears a prosthesis on his left leg and uses a wheelchair. "I can't get around good like I used to."

Moss, who lives in Compton, embodies many of the characteristics of people most likely to get diabetic amputations. He is African American with a relatively low family income: about $30,000 a year from his Social Security disability check and his wife's job with the county mental health department.

Moss has not always received regular medical care. His mother, who also had a leg amputated from diabetes, would take him to the doctor when he was a boy. But he stopped going as an adult. He didn't have insurance during much of his 20s and 30s. Medical care just wasn't a priority, he said, until about 25 years ago when his blood sugar shot up so high he passed out at home.

After he was diagnosed with Type 2 diabetes, he started seeing a physician more often. He tried to avoid sugar, as his doctor recommended, but bad habits die hard. "It takes a lot to eat right," he said, "and it costs more."

One day, about 10 years ago, he bumped his toe on the bed. He thought little of it until he developed an infected wound. A fever sent him to the hospital, where his lower leg was removed. A few years later, with his diabetes still poorly controlled, he lost the toes on his other foot.

In recent years, Moss and his wife said, health providers have sometimes ignored their concerns. They recalled trips to the emergency room when they had to convince doctors his fever came from a diabetes-related infection. "They wouldn't take my word," he said. The couple did not see it as discrimination, more like dismissiveness.

Now, Moss goes to a clinic run by Martin Luther King, Jr. Community Hospital, which serves a large Latino and black population in South Los Angeles. On a recent visit, his doctor asked if he was staying off the foot with the wound. "I just get up when I have to go to the restroom and to get in and out of the bed," Moss responded.

Moss hopes someday he will be able to do more — get back to taking his grandsons to Chuck E. Cheese or playing dominoes with friends.

"I just sit here all day long," he said.

'The Most Shameful Metric'

Amputations typically start with poorly controlled diabetes, a disease characterized by excess sugar in the blood. Untreated, it can lead to serious complications such as kidney failure and blindness.

People with diabetes often have reduced sensation in their feet, as well as poor circulation. As many as one-third of people with the most common form — Type 2 — develop foot ulcers or a break in the skin that can become infected.

Amputations occur after those infections rage out of control and enter the bloodstream or seep deeper into the tissue. People with diabetes often have a condition that makes it harder for blood to circulate and wounds to heal.

The circumstances that give rise to amputations are complex and often intertwined: Patients may avoid doctors because their family and friends do, or clinics are too far away. Some may delay medical visits because they don't trust doctors or have limited insurance. Even when they seek treatment, some find it difficult to take medication as directed, adhere to dietary restrictions or stay off an infected foot.

Californians with diabetes who have a regular place to go for health care other than the emergency room are less likely to get amputations, according to an analysis conducted for Kaiser Health News by the UCLA Center for Health Policy Research. If they have a plan to control their diabetes, they also have less chance of amputation.

The analysis shows that many amputations could be avoided with better access to care and better disease management, said Ninez Ponce, director of the center.

"It's the most shameful metric we have on quality of care," Ponce said. "It is a health equity issue. We are a very rich state. We shouldn't be seeing these diabetic amputations."

An amputation often leads to a cascade of setbacks: more infections, more amputations, decreased mobility, social isolation. Research shows as many as three-quarters of people with diabetes who have had lower-limb amputations die within five years.

The health system bears surprisingly large costs for what remains a relatively uncommon problem. A single lower-limb amputation can cost more than $100,000. By far, government programs — Medicaid and Medicare — pay for the most amputations.

Experts say the best bet is to intervene well before they become necessary. People with diabetes are "very much in need of the simplest, basic, cost-effective, easy-to-implement treatments," said Dr. Philip Goodney, director of the Center for the Evaluation of Surgical Care at Dartmouth.

Along with basic measures to control diabetes, regular foot exams are key. The Centers for Disease Control and Prevention estimates somewhere between 11% and 28% of people with diabetes get the recommended podiatric care, a yearly foot exam to check for loss of sensation and blood flow. Under federal rules governing Medicaid, the government program for low-income Americans, such care is optional and not covered by every state.

California includes it as an optional benefit, limiting access to such care. An analysis by UCLA researchers estimated that the use of preventive podiatric services saved the Medi-Cal system — California's version of Medicaid — up to $97 million in 2014, based on avoided hospital admissions and amputations, and that savings could be much greater if more patients had access.

Fighting For Jesse

Jesse Guerrero is 12, but already knows what diabetes — and amputations — can do to a family. He has seen how life changed since his mom, Patricia Zamora, had her first surgery. She had to stop working as a group home supervisor. They were evicted and eventually moved into his grandmother's house in Pomona.

Now, they stay home a lot more than they used to. "I want her to get better so we can finally go places," Jesse said.

First diagnosed with gestational diabetes, Zamora, 49, eventually was diagnosed with conventional Type 2. Though her mother has diabetes, she said, she didn't understand the risks.

Her serious troubles started in 2014, when she stubbed her big toe and it turned black and purple. When she finally went to an ER, doctors said it had to be amputated. The next year, after another stumble and another infection, doctors removed the remaining toes on her right foot.

Now, she is fighting a third wound and risks losing the limb below her knee. She uses a scooter and wears a boot to keep the pressure off.

Many days, she wants to give up.

"But I can't," she said. "I have Jesse."

His health is also a concern. Though only in middle school, Jesse is overweight, putting him at greater risk for Type 2 diabetes. She recently took away his PlayStation and signed him up for flag football so he would be more active.

Jesse, too, is scared.

"I don't want to get my foot cut off," he said. "I'd rather have a full life than a short one."

The Gift Of Pain

As hospitals have seen the impacts — and cost — of amputations, some have made efforts to reduce them. Some, like Keck Hospital, have started limb preservation centers, which use cross-disciplinary teams and technology to treat wounds and help patients improve disease management.

Even with a team of specialists, however, saving a limb often depends on patients coming in early rather than waiting until their foot has become dangerously infected. But because their sensation is dulled, they often don't appreciate the danger.

"How do you get someone to come in if they don't have pain?" Armstrong said. "They need the gift of pain."

One of Armstrong's patients, Cirilo Delgado, has a wound on his heel that could cost him his lower leg. He already lost a toe.

Delgado, 41, knew diabetes ran in his family. His father, 68, has diabetes. His mother, who had diabetes and kidney failure, died at 67. His diabetic sister died at 35 of a heart attack, a possible complication of diabetes.

"I saw them die young," he said. "I don't want to be the next one."

Like Moss, Delgado didn't always have insurance. And he didn't seek care for his diabetes until the symptoms got dire.

Delgado used to work at a dry cleaning shop but had to stop because he doesn't have the balance he once did. His blood pressure fluctuates dangerously, and he needs dialysis three times a week for kidney failure. He has moved in with his father, a truck driver who stopped working to help care for him.

In November, doctors used a skin flap from his leg to try to heal his latest wound. He's praying he doesn't get another.

"I know there's a prosthesis," he said, "but it's not the same as a limb."

METHODOLOGY BOX:

Kaiser Health News analyzed 2011-17 data from California's Office of Statewide Health Planning and Development (OSHPD) on diabetes patients discharged after lower-limb amputations. OSPHD grouped the amputations into these racial and ethnic categories: white, black, Hispanic and other; and these age groups: under 45, 45-64, 65 and over. To compare amputation rates across groups, KHN calculated crude rates using California population data for each year from the U.S. Census Bureau, and calculated the final age-adjusted rate for each racial/ethnic group using U.S. 2010 population distribution as weights.

California Healthline ethnic media editor Ngoc Nguyen and Kaiser Health News data editor Elizabeth Lucas contributed to this report.

Anna Gorman: agorman@kff.org, @AnnaGorman

Dignity Health, like other Catholic chains, is bound by ethical and religious directives from the United States Conference of Catholic Bishops.

This article was first published on Monday, April 29,2019 in Kaiser Health News.

By Jenny Gold

SAN FRANCISCO — As Catholic healthcare systems across the country expand, the University of California's flagship San Francisco hospital has become the latest arena for an emotional debate: Should the famously progressive medical center increase its treatment space by joining forces with a Catholic-run system that restricts care according to religious doctrine?

At issue is a proposal that UCSF Medical Center affiliate with Dignity Health, a massive Catholic healthcare system that, like other Catholic chains, is bound by ethical and religious directives from the United States Conference of Catholic Bishops.

Among other prohibitions on services, Dignity hospitals ban abortions unless the mother's life is at risk, in vitro fertilization and physician-assisted death.

Twenty-four of Dignity's 39 hospitals prohibit contraception services and gender-confirming care for transgender people, such as hormone therapy and surgical procedures.

The affiliation would not keep UCSF from performing such procedures at its own medical center and outpatient clinics, and both entities would remain independent. UC doctors with practicing privileges at Dignity would be free to discuss all treatment options and could refer patients to other facilities when necessary.

But they would have to abide by Dignity's care restrictions while practicing at Dignity hospitals.

For opponents of the plan, the issue boils down to a clear-cut principle: How can a public hospital that has been a leader in women's healthcare and medical services for the gay and transgender community partner with a private system that not only denies such services but also casts them as immoral?

"It feels really concerning to me that our university that has been a fierce advocate for women's health and LGBTQ health would be affiliating with a corporation that doesn't support those values and restricts care," said Dr. Jody Steinauer, who directs UCSF's Bixby Center for Global Reproductive Health.

The two systems already have a relationship among several departments, including neurology, cardiology and adolescent psychology. This new affiliation would formalize the collaboration at Dignity's four Bay Area hospitals and could expand services to departments including cancer care and cardiology, which would be staffed by UCSF physicians.

The proposal has sharply split faculty and medical staff at UCSF, who are airing their differences in impassioned letters and heated public forums. Participants on both sides include national figures renowned in their specialty fields.

Supporters of a closer alliance with Dignity say it's an easy way to add capacity to a public healthcare system that is strapped for bed space and turning away more than 800 patients a year. They also note that Dignity is California's largest private provider for patients with Medi-Cal, the state-federal insurance program for the poor.

"So much healthcare is being delivered in this country by faith-based organizations. For us to not participate with them seems like a missed opportunity," Mark Laret, president and CEO of UCSF Health, told a December meeting of the UC Board of Regents, which must decide the issue.

The agreement could include a new labor and delivery unit based at Dignity's St. Francis Memorial Hospital, which would be staffed by non-UCSF obstetricians. That would let Dignity absorb more patients with low-risk pregnancies, leaving UCSF time and space to deal with more complex cases, said Dr. Dana Gossett, a UCSF obstetrician-gynecologist who has been part of the negotiations with Dignity.

"I feel a little like women's health has been portrayed as a casualty of this negotiating," said Gossett. "But as someone who works in labor and delivery and is in the trenches every day, I see it differently. I see the damages our capacity problems have on women right now because we haven't expanded our capacity enough to meet the need."

Of particular concern to opponents of the affiliation are two recent lawsuits against Dignity filed by the American Civil Liberties Union. In one case, a woman was denied a tubal ligation following a cesarean section delivery at a Dignity facility in Redding, Calif. In another, a transgender man was denied a hysterectomy after a Dignity facility in Sacramento learned the procedure was part of his plan to align his gender identity and body.

In March, Steinauer, the head of the Bixby Center, joined more than 1,500 UCSF faculty members, residents, students and alumni in signing a letter opposing the affiliation. "Our affiliation with [Dignity] not only compromises the safety and quality of our patient care, but also threatens the integrity of our reputation as a provider of evidence-based care in an inclusive environment free of bias and discrimination," they wrote.

UCSF is hardly the first public hospital to wrestle with the question of Catholic health care.

Catholic hospital systems now oversee 1 in 6 acute care hospital beds in the U.S., according to MergerWatch, a nonprofit group that tracks hospital consolidation. And the number of hospitals that are Catholic-owned or -affiliated increased by 22% from 2001 to 2016.

Earlier this year, Dignity Health joined forces with another system called Catholic Health Initiatives in a merger approved by both the California Department of Justice and the Vatican. The resulting $29 billion system, CommonSpirit Health, has 119 acute care hospitals and is now the largest nonprofit hospital system in the country, according to MergerWatch.

As health systems across the country scramble to merge and affiliate to gain market share, Catholic health systems have become an appealing partner for some secular hospitals, even when values diverge. In a highly consolidated region like Northern California, partnership options are limited.

The University of Michigan is affiliated with two Catholic systems: Trinity Health and Ascension. The University of Washington affiliated with the Catholic nonprofit PeaceHealth in 2013.

Entanglements between secular and Catholic hospitals have presented problems, said Lois Uttley, who runs MergerWatch. During a trial affiliation between secular Sierra Vista Regional Health Center and the Catholic Carondelet Health Network, both in Arizona, obstetricians initially were told they could perform tubal ligations, only to be told later they needed to stop. The partnership was dissolved.

The UCSF administration said a formal affiliation is necessary to expand services and increase revenue. Dignity is already an important part of UCSF's Canopy Health, a network of doctors and hospitals that can earn bonuses for delivering medical care more efficiently under a program created by the Affordable Care Act. Canopy Health aims to provide care for upwards of 200,000 patients within a few years.

The details of the arrangement are being worked out, but under discussion is the possibility that UCSF will get a financial stake in the affiliated Dignity hospitals, according to UCSF administrators.

The arrangement would provide "a revenue flow to support some of our money-losing programs," UCSF's Laret told the UC Regents this month. "There really is not a good alternative from our standpoint," he added. "If we have to disengage from our partnership with Dignity, forget UCSF, I think that it's catastrophic for the health care delivery system in San Francisco."

Dignity, meanwhile, would benefit from the inflow of patients at hospitals that often operate under capacity.

UCSF has promised workarounds to avoid potential conflicts where Dignity's hospitals prohibit services. Patients would be informed upfront about which services are not provided at Dignity facilities, for example, so they could choose to go to their preferred hospital. No UCSF staff would be asked to provide obstetric or reproductive services at Catholic facilities. And if patients at a Dignity hospital needed a prohibited service, they could be transferred to UCSF.

In an emailed statement, Dr. Todd Strumwasser, a Dignity Health senior vice president, wrote that "physicians practicing at Dignity Health hospitals may discuss all treatment options with patients" and "facilitate access" to another site when a Dignity hospital does not provide a certain service. "In a situation in which a pregnant woman's life is in danger, life-saving procedures that may result in termination of the pregnancy will be performed."

Such policies, however, are subject to changes by the bishops who set the rules at Catholic hospitals, said Lori Freedman, a UCSF professor who studies reproductive health care at Catholic hospitals.

"We don't know what the future really looks like," Freedman said. "Sometimes workarounds don't stick around."

Jenny Gold: jgold@kff.org, @JennyAGold