Market Share of US Catholic Hospitals and Associated Geographic Network Access to Reproductive Health Services

IMPORTANCE Access to reproductive health services is a public health goal. It is unknown how geographic and health plan network availability of Catholic and non-Catholic hospitals may be associated with access to reproductive health services in the United States. OBJECTIVE To characterize the market share of Catholic hospitals in the United States, both overall and within Marketplace health insurance plans’ hospital networks. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of US counties used data on hospitals’ Catholic affiliation and discharges, hospital networks in Marketplace health insurance plans, and US Census population data to construct a national, county-level data set. The Catholic hospital market share overall in each county and in Marketplace plans’ hospital networks in each county were calculated. The study examined whether the Catholic hospital market share was different within Marketplace networks compared with the counties they served. Data analysis was conducted in May and June 2018. MAIN OUTCOMES AND MEASURES The overall Catholic hospital market share was calculated on the basis of the share of discharges in Catholic hospitals in a county compared with all hospital discharges. Overall market share was categorized as minimal ( 2%), low (>2% to 20%), high (>20% to 70%), or dominant (>70%). The Catholic hospital market share in Marketplace networks was calculated as the share of Catholic hospital discharges in each Marketplace network. RESULTS The sample included 4450 hospitals in 3101 counties. Overall, 26.1% of US counties had minimal Catholic hospital market share, 38.6% had low Catholic hospital market share, and 35.3% had high or dominant Catholic hospital market share; 38.7% of US reproductive-aged women resided in counties with high or dominant Catholic hospital market share. Among counties with Catholic hospital market share greater than 2%, the distribution of the median Marketplace network’s Catholic hospital market share (median [interquartile range], 4.6% [0%-24.3%]) was lower than overall Catholic hospital market share (median [interquartile range], 18.5% [8.1%-36.5%]). The median Marketplace hospital network had a lower Catholic hospital market share than the county overall in 68.0% of US counties with Catholic hospital market share greater than 2%. CONCLUSIONS AND RELEVANCE In this national study, 35.3% of counties had high or dominant Catholic hospital market share serving an estimated 38.7% of US women of reproductive age. Marketplace health insurance plans’ hospital networks included a lower share of Catholic hospitals than the counties they serve. JAMA Network Open. 2020;3(1):e1920053. doi:10.1001/jamanetworkopen.2019.20053 Key Points Question Is access to reproductive health services in the United States associated with the market share of Catholic hospitals? Findings In this cross-sectional study of all US counties, 35.3% of US counties, where 38.7% of US women of reproductive age live, have a high Catholic hospital market share. Hospital networks in Marketplace health insurance plans included a lower share of Catholic hospitals than the overall county share. Meaning Restricted access to reproductive health services associated with high Catholic hospital market share is common in US counties, but health insurance plans’ hospital networks do not exacerbate this issue. + Invited Commentary Author affiliations and article information are listed at the end of this article. Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2020;3(1):e1920053. doi:10.1001/jamanetworkopen.2019.20053 (Reprinted) January 29, 2020 1/12 Downloaded From: https://jamanetwork.com/ by a Non-Human Traffic (NHT) User on 05/30/2021


Introduction
Access to safe and effective reproductive health services is widely recognized as a public health policy goal. 1 The Patient Protection and Affordable Care Act contained several provisions to expand access to reproductive health services. These included expanding insurance coverage to an estimated 20 million people, requiring insurers to cover maternity care, and requiring insurers to cover the full range of US Food and Drug Administration-approved contraceptive methods without patient cost-sharing. [2][3][4] Rigorous empirical work suggests that these provisions have contributed to better access to contraceptive care and may have improved pregnancy-related outcomes. [5][6][7][8] A critical barrier to access to reproductive health services may be directives from religious health care organizations. [9][10][11][12] In particular, Catholic hospital systems follow a religious directive that prohibits the provision of contraception, infertility treatments, sterilization for contraceptive purposes, and induced abortion. 13 If prospective patients were both aware of these restrictions and had unimpeded access to health systems offering the care restricted by Catholic hospital systems, the ultimate impact on health would be limited. However, a recent survey 14 exploring the issue of awareness found that 37% of women whose primary hospital system was Catholic were unaware of that fact. This study explores factors that may impede health system access.
Geographic availability of health care systems is a significant determinant of access to care. 15,16 We posit that there are 2 ways that the geography of available Catholic and non-Catholic hospital systems might be associated with access to reproductive health care services. The first way is based on the concentration of the supply of Catholic hospital systems. In geographic areas where Catholic hospital systems dominate the market, these systems are difficult to avoid. In areas where they have no presence, Catholic hospital restrictions do not play a role at all. Given this supply, health insurance can play a strong role in driving demand via hospital networks-that is, the set of hospitals available to enrollees in a given health plan. A health plan's hospital network essentially constrains the choice of hospitals among beneficiaries to those hospitals that are in the plan's network. Thus, both the concentration of Catholic hospitals in a geographic area and the degree to which health plan hospital networks disproportionately exclude or include Catholic hospitals work together to affect the probability that women receive care in a Catholic hospital that does not provide many reproductive health services.
In this study, we sought to determine how access to reproductive health services might be shaped by the availability of Catholic and non-Catholic hospitals in the United States. First, we measured the market share of Catholic hospitals in each county according to the percentage of discharges from Catholic hospitals among county residents. Second, we measured how access to reproductive health services might be altered by health plans' in-network hospitals on the basis of Marketplace insurance plans' hospital networks. The Marketplaces were created by the Patient Protection and Affordable Care Act to provide health insurance coverage to nonelderly, nondisabled adults who do not have affordable offers of health insurance via an employer and do not qualify for Medicaid. In 2016, 6.8 million women enrolled in Marketplace plans. 17 Given that the Marketplaces primarily insure nonelderly adults, they are an important source of insurance coverage for women of reproductive age. Marketplace plans' networks tend to be narrow. 18 They may, thus, direct women away from or toward hospitals providing reproductive health services by covering a disproportionate share of Catholic or non-Catholic hospitals. The Marketplaces also are of particular interest because Marketplace insurers' networks have received little regulatory scrutiny since their launch in 2014. As such, they provide a clear picture of how insurers without regulatory oversight may promote or decrease access to reproductive health services. We tested differences in counties' Catholic hospital market shares overall and in their Marketplace insurance plans' networks to assess whether Marketplace plans provide greater access to reproductive health services compared with the counties they serve. Finally, we quantified the share of counties in which Marketplace plans' networks provided greater access to reproductive health services compared with counties they serve.

Measures Catholic Hospital Market Share Overall
We measured Catholic hospitals' overall market share in each county. To do so, we first identified Catholic and non-Catholic hospitals using the AHA data. From the count of discharges for each hospital-zip code dyad provided by the MedPAR data, we first excluded hospitals that are more than 50 miles from the zip code's geographic center and that have less than 0.5% of the zip code's discharges. Catholic hospital market share at the zip code level is simply the share of discharges from Catholic hospitals among residents of the zip code. Next, we aggregated Catholic hospital market shares from the zip code to the county level using a weighted average of hospital market shares among zip codes in each county. The zip codes were weighted by their female population aged 15 to 44 years (ie, reproductive-aged women) as identified in the 5-year 2016 American Community Survey. The zip codes crossing county lines were assigned to the county where most of their population resided. We grouped counties by their level of Catholic hospital market share: minimal (Յ2%), low (>2% to Յ20%), high (>20% to Յ70%), and dominant (>70%).

Catholic Hospital Market Share in Marketplace Networks
We then measured, for each Marketplace health insurance network in each county where a plan using that network is sold, the Catholic hospitals' market share among the in-network hospitals.
Because the number of Marketplace plan networks per county ranged from 1 to 19, with a mean of approximately 4, this measure was estimated for 12 838 network-county dyads in the continental United States. We identified hospitals' participation in networks with Vericred data. 21 Because the Vericred data define hospitals using National Provider Identifiers and a single hospital can be assigned multiple National Provider Identifiers, we consolidated National Provider Identifiers sharing the same AHA identifier. 24

Results
The sample included 4450 hospitals in 3101 counties. Figure 1         to select a Marketplace network that is less Catholic than the county overall. However, it also is possible for women to select a Marketplace network with greater than 80% Catholic hospital market share in 440 counties (19.3%). This occurs primarily in counties with higher Catholic hospital market share, which often have at least 1 Marketplace hospital network dominated by Catholic hospitals.

Discussion
In US counties, the median Catholic hospital market share was 18.5%, but there was large variation that includes 993 counties with high market shares (>20% to Յ70%) and 101 counties with dominant market shares (>70%). Although the mean Catholic hospital market share was 18.4%, 35.3% of counties have market shares greater than 20%. These counties at the high and dominant level, which are the counties at greater risk of reduced access to reproductive health services, were home to 38.7% of US women of reproductive age. These findings suggest that Catholic hospital reproductive health policies are associated with access to reproductive health services for a substantial fraction of women who may require these services.
We also found that the Catholic hospital market shares in Marketplace health insurance networks were lower than the counties they served. These findings suggest wide geographic variability in terms of whether the Catholic hospital market share might pose a barrier to obtaining reproductive health care. This is concerning given that the United States consistently ranks poorly compared with other wealthy nations on measures of women's reproductive health and has an unacceptably high rate of maternal mortality. 25 An estimated 10% of US women have unmet needs for family planning services, although these unmet needs are substantially greater for socially disadvantaged groups. 26 Little research has examined the implications of the Catholic health care system market share on health outcomes, although 1 study 27 found that hospital affiliation with a Catholic health care system reduced tubal ligation rates by 30%.
Other studies [28][29][30] investigating the effects of structural changes on the health care system suggest that reduced access to reproductive health services may be adversely associated with health outcomes. For example, prior work has found that hospital obstetric unit closures in rural areas are associated with increased risk of preterm birth 29 and that restricting access to Planned Parenthood clinics is associated with a decrease in contraceptive use and a concurrent increase in maternal mortality. 29,30 Concerns about restricted access to reproductive health services could be mitigated if patients were able to accurately choose hospitals whose services meet their needs and values. 31  State-based health insurance Marketplaces were created under the Affordable Care Act to improve health insurance coverage and access to care for nonelderly adults, and policy makers explicitly mandated that insurance cover both maternity and contraceptive services. 35 However, currently there are no oversight standards with respect to realized access to reproductive services. 36 There is a high amount of heterogeneity by geography with little association with population characteristics. Hospital network adequacy standards exist and could be helpful for network-related limited access, 37 but they currently do not consider whether hospitals are Catholic. Adding this metric to network adequacy standards could be one policy option to monitor access to reproductive services in the Marketplaces.

Strengths and Limitations
Major strengths of this study include nationally representative data and our ability to quantify how health insurance networks are associated with the market share of Catholic hospitals faced by patients. This study also has limitations. First, the use of Marketplace network data precluded us from generalizing our findings about Catholic hospital market share to other insurance networks, such as Medicaid managed care plans. This is an important limitation given that state Medicaid programs are the largest single payer for health care for nonelderly women. Medicaid managed care networks also may have charitable objectives in line with Catholic hospitals, which may mean that Medicaid networks are relatively more Catholic than their Marketplace counterparts. We note that the overall estimates of Catholic hospital market share are national in scope. Second, we are unable to measure whether Catholic hospitals provide systems whereby patients could be referred for reproductive health services elsewhere. Even a referral system for reproductive health services would likely still pose a barrier to care for many patients, however. Third, our study examined the market share of Catholic hospitals, as opposed to the market share of Catholic health care systems. Therefore, these findings are informative to understand geographic variability in access to reproductive health services occurring in inpatient settings or hospital-owned outpatient clinics, but do not necessarily generalize to access to outpatient services.

Conclusions
This is the first study, to our knowledge, to provide national estimates of Catholic hospital market share in the United States. We found that 35.3% of US counties, where 38.7% of US women of reproductive age live, had a high Catholic hospital market share. Marketplace health insurance networks tend to include a lower share of Catholic hospitals than the overall county share, suggesting that Marketplace networks are protective of access to reproductive health services. The geographic variation in availability of Catholic and non-Catholic hospital systems is an important factor for consideration in the study of reproductive health outcomes in the United States.