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Donald A. Brennan, president and CEO of the Daughters of Charity National Health System (DCNHS), St. Louis, foresees a strong role for Catholic healthcare in serving people better as healthcare in the United States continues to move into managed care. He shared his views in a recent interview with Health Progress.

"Managed care today is often managed access," said Brennan. "It has not lived up to its promise." But anyone who thinks managed care will eventually disappear is wrong, he said. Rather than working toward managed care's demise, Catholic healthcare can continue to emphasize the potential of managed care: to assure that the right care is delivered by the right people at the right time and in the right setting, and at a fair and reasonable price.

"We need a much more humane public policy, and Catholic healthcare must be effective in its advocacy. This means bringing ideas to the table, arguing for systemic change," he insisted.

Support for Healthcare Infrastructure
Brennan believes managed care can pose a threat to basic public health. "As care providers in managed care arrangements increasingly assume responsibility only for the health of defined populations, will we also be committed to general public health efforts?" he asked. "We need to address broad public health issues such as violence and lack of housing."

Cooperation among healthcare organizations, managed care providers, and other insurers is essential, according to Brennan. "All the players in the health system must understand that they will be harmed if the healthcare infrastructure becomes weaker," he said. "The entire private sector, along with government, has to be committed to supporting public health infrastructure and research. All of us benefit by a healthy community, and we have to work together."

But differences in the obligations of not-for-profit and investor-owned organizations can hinder cooperation. "Investor-owned organizations have an obligation to return a reasonable amount to investors. In Catholic healthcare, our obligation is to provide return to the community. When organizations have lots of resources, they might be able to do both. But when resources are restricted, an investor-owned organization's primary obligation to investors is unambiguous."

Acute/Long-Term Care Barriers
In addition to public health, persons with chronic medical conditions constitute a major challenge for healthcare today, Brennan said. He believes there are "artificial lines" between acute and long-term care. "We need to get away from thinking about acute and long-term care as distinct. We must change the way care is organized and delivered so that the focus of our activities is on individuals and their needs." Brennan said the reimbursement system reinforces the fragmentation of care, and advocacy efforts must focus on changing the way care is paid for.

Catholic health ministry can make the necessary arguments for breaking down the distinctions between systems of care, according to Brennan. "Healthcare systems, especially, can contribute. With their ability to gather data, focus on outcomes, and look at different ways to deliver care, they can continue to develop the capacity to truly integrate care."

Forming Partnerships
As more affiliations become necessary and appropriate for healthcare organizations that want to create continuums of care, "the future for DCNHS is more partnerships," Brennan said. "In many situations some DRGs [patients with certain diagnoses] can and should be admitted directly to a long-term care facility," he noted.

Forming partnerships can be difficult, Brennan said. Even when organizations have compatible missions, cultural differences can interfere. And parties must recognize that the arrangement will have a profound impact on governance, management, and sponsorship, he cautioned.

A source of tension for Catholic healthcare is affiliating with non-Catholic partners, but in many areas the lack of a significant Catholic presence and other factors make it necessary. Brennan believes in partnerships, however. He advises, "Pick your friends carefully, but pick them you must."

In picking partners, "it's important to be unambiguous about your mission," Brennan said. Other advice:

• "Determine if your values are really compatible or whether the words are merely trappings."
• "It's as wrong to structure for failure — by not taking time to do things right — as it is to not partner at all."
• "Most meaningful partnerships go through a stormy period; don't try to short-circuit it. When you're undergoing significant change, the most hopeful times are at the beginning and the end. In the middle, things look impossible."

Creating a Flexible Culture
Organizations must be flexible in this era of new partnerships, Brennan insisted. They must be less bureaucratic and more tolerant of risk. "There will be less emphasis on hierarchy and more on what a person contributes. In changing organizations, job titles will be less important because they will no longer clearly indicate what an employee actually does. The ability to cooperate with others within and outside the organization will be increasingly important."

Organizing for Strength
Brennan sees a clear trend to consolidation in Catholic health ministry at both the local and national levels. "Sponsors who are geographically dispersed in several regions and are trying to assure that they have a meaningful presence in healthcare must ask themselves, Do we concentrate our sponsorship in a larger system where we can influence the whole or in multiple local or regional arrangements?" he said.

But Brennan sees no single, right model. "For the next few years we will see a continuing pluralism of models, regional and national. Increased local concentration is likely as we have fewer payers. There will be cosponsorship at the local level, some with non-Catholic organizations."

A New Model of Sponsorship
When the Daughters of Charity National Health System adopted a new vision in 1996, the system knew it had to answer the question, What is the right structure to carry out our vision (see "Daughters of Charity Health Vision Statement" at the end of this article)? The answer was greater unity within the system. Working together, sponsor representatives, staff leaders, and board members crafted a new model of sponsorship, explained Brennan. In fall 1997, the system shifted from region-by-region provincial ownership and governance to a unified model in which the Daughters of Charity provincial councils together sponsor the entire system. The regional level of governance is eliminated.

With the system's new two-level governance model, regional boards' responsibilities are reallocated between the DCNHS national board and the local boards. "The structure strengthens local health ministries, allows more effective use of financial and human resources, and enables faster decision making. The more unified system now has a stronger advocacy voice," said Brennan.

The structure facilitates the partnerships DCNHS committed to in its vision statement and prepares the system for the future. Brennan explained, "We are taking better advantage of the synergies that exist within a system by using our national strengths to add value to our local ministries. For example, the national system disseminates systemwide findings on best clinical practices. We are better able to carry on a tradition of 170 years of service to communities while acting effectively in a marketplace that calls for innovation and responsiveness."

Ethical Challenges in a "Bright" Future
Brennan predicts a "challenging but bright future" for the Catholic health ministry. "We face formidable challenges in clinical, social justice, and business ethics. For example, how should we allocate scarce resources or handle the unnecessary duplication of services?"

Society responds to the values of Catholic healthcare, according to Brennan. "People have a fundamental concern for others and for the communities in which they live. They embrace what we stand for. I am optimistic that the Catholic health ministry will remain strong and will continue to speak for a more humane and just society and a better healthcare system."

Judy Cassidy is editor, Health Progress.

Our vision is a strong, vibrant Catholic health ministry in the United States in the 21st century. We are committed to partnering with those with whom we share compatible values, including other sponsors, physicians, and associates. We believe the laity are partners in sharing responsibility for the health ministry.

Our vision demands transformation and calls us to:

• Advocate for a humane and just society, with special concern for those persons who are poor and vulnerable.
• Emphasize a culture that embraces learning, diversity, collaboration and the well-being of our associates.
• Strengthen the development of religious and lay leaders.
• Commit ourselves to all aspects of health — community health, personal health, disease management and spirituality.
• Achieve a full continuum of care — a balance of home, community, ambulatory and inpatient services — to meet preventive, acute, and chronic needs.
• Foster growth to strengthen the ministry through partnerships, acquisitions, and diversification.
• Invest in change by demonstrating the value of innovation.