St. Louis — Inside the greater than 600 Catholic hospitals across the country, not a single nun might be found occupying a chief executive suite, in accordance with the Catholic Health Association.
Nuns founded and led those hospitals in a mission to treat sick and poor people, but some were also shrewd business leaders. Sister Irene Kraus, a former chief executive of Daughters of Charity National Health System, was famous for coining the phrase “no margin, no mission.” It means hospitals must succeed — generating enough revenue to exceed expenses — to satisfy their original mission.
The Catholic Church still governs the care that might be delivered to tens of millions in those hospitals annually, using religious directives to ban abortions and limit contraceptives, in vitro fertilization, and medical aid in dying.
But over time, that give attention to margins led the hospitals to rework into behemoths that operate for-profit subsidiaries and pay their executives tens of millions, in accordance with hospital tax filings. These institutions, a few of that are for-profit firms, now look more like other megacorporations than just like the charities for the destitute of yesteryear.
The absence of nuns in the highest roles raises the query, said M. Therese Lysaught, a Catholic moral theologist and professor at Loyola University Chicago: “What does it mean to be a Catholic hospital when the enterprise has been so deeply commodified?”
The St. Louis area serves because the de facto capital of Catholic hospital systems. Three of the most important are headquartered here, together with the Catholic hospital lobbying arm. Catholicism is deeply rooted within the region’s culture. During Pope John Paul II’s only U.S. stop in 1999, he led Mass in a packed stadium of greater than 100,000 people.
For 1 / 4 century, Sister Mary Jean Ryan led SSM Health, one among those giant systems centered on St. Louis. Now retired, the 86-year-old said she was one among the last nuns within the nation to steer a Catholic hospital system.
Ryan grew up Catholic in Wisconsin and joined a convent while in nursing school within the Nineteen Sixties, surprising her family. She admired the nuns she worked alongside and felt they were living out a better purpose.
“They were very impressive,” she said. “Not that I necessarily liked all of them.”
Indeed, the nuns running hospitals defied the simplistic image often ascribed to them, wrote John Fialka in his book “Sisters: Catholic Nuns and the Making of America.”
“Their contributions to American culture usually are not small,” he wrote. “Ambitious women who had the abilities and the stamina to construct and run large institutions found the convent to be the primary and, for a very long time, the one outlet for his or her talents.”
This was definitely true for Ryan, who climbed the ranks, working her way from nurse to chief executive of SSM Health, which today has hospitals in Illinois, Missouri, Oklahoma and Wisconsin.
The system was founded greater than a century ago when five German nuns arrived in St. Louis with $5. Smallpox swept through the town and the Sisters of St. Mary walked the streets offering free care to the sick.
Their early foray grew into one among the most important Catholic health systems within the country, with annual revenue exceeding $10 billion, in accordance with its 2023 audited financial report. SSM Health treats patients in 23 hospitals and co-owns a for-profit pharmacy profit manager, Navitus, that coordinates prescriptions for 14 million people.
But Ryan, like many nuns in leadership roles in recent a long time, found herself confronted with an existential crisis. As fewer women became nuns, she needed to make sure the system’s future without them.
When Ron Levy, who’s Jewish, began at SSM as an administrator, he declined to steer a prayer in a gathering, Ryan recounted in her book, “On Becoming Exceptional.”
“Ron, I’m not asking you to be Catholic,” she recalled telling him. “And I do know you have only been here two weeks. So, should you’d prefer to make it three, I suggest you be prepared to hope the subsequent time you are asked.”
Levy went on to serve SSM for greater than 30 years — praying from then on, Ryan wrote.
In Catholic hospitals, meetings are still more likely to start with a prayer. Crucifixes often adorn buildings and patient rooms. Mission statements on the partitions of SSM facilities remind patients: “We reveal the healing presence of God.”
Above all else, the Catholic faith calls on its hospitals to treat everyone no matter race, religion or ability to pay, said Diarmuid Rooney, a vp of the Catholic Health Association. No nuns run the trade group’s member hospitals, in accordance with the lobbying group. But the mission that compelled the nuns is “what compels us now,” Rooney said. “It’s not only words on a wall.”
The Catholic Health Association evaluates the hospitals every three years on whether or not they’re living as much as Catholic teachings. It assesses them across seven areas, including how they act as an extension of the church and look after poor and vulnerable patients.
“We’re not counting on hearsay that the Catholic identity is alive and well in our facilities and hospitals,” Rooney said. “We can actually see on a scale where they’re at.”
The association doesn’t share the outcomes with the general public.
At SSM Health, “our Catholic identity is deeply and structurally ingrained” even with no nun on the helm, spokesperson Patrick Kampert said. The system reports to 2 boards. One functions as a typical business board of directors while the opposite ensures the system abides by the foundations of the Catholic Church. The church requires the vast majority of that nine-member board to be Catholic. Three nuns currently serve on it; one is the chair.
Separately, SSM is also required to file an annual report with the Vatican detailing the ways, Kampert said, “we deepen our Catholic identity and further the healing ministry of Jesus.” SSM declined to supply copies of those reports.
From a business perspective, though, it’s hard to differentiate a Catholic hospital system like SSM from a secular one, said Ruth Hollenbeck, a former Anthem insurance executive who retired in 2018 after negotiating Missouri hospital contracts. In the contracts, she said, the difference amounted to a single paragraph stating that Catholic hospitals would not do anything contrary to the church’s directives.
To retain tax-exempt status under Internal Revenue Service rules, all nonprofit hospitals must provide a “profit” to their communities corresponding to free or reduced-price look after patients with low incomes. But the IRS provides a broad definition of what constitutes a community profit, which supplies hospitals wide latitude to justify not needing to pay taxes.
On average, the nation’s nonprofit hospitals reported that 15.5% of their total annual expenses were for community advantages in 2020, the most recent figure available from the American Hospital Association.
SSM Health, including all of its subsidiaries, spent proportionately far lower than the association’s average for individual hospitals, allocating roughly the identical share of its annual expenses to community efforts over three years: 5.1% in 2020, 4.5% in 2021, and 4.9% in 2022, in accordance with a KFF Health News evaluation of its most up-to-date publicly available IRS filings and audited financial statements.
A separate evaluation from the Lown Institute think tank placed five Catholic systems — including the St. Louis region’s Ascension — on its list of the 10 health systems with the most important “justifiable share” deficits, which suggests receiving more in tax breaks than what they spent on the community. And Lown said three St. Louis-area Catholic health systems — Ascension, SSM Health and Mercy — had justifiable share deficits of $614 million, $235 million, and $92 million, respectively, within the 2021 fiscal 12 months.
Ascension, Mercy, and SSM disputed Lown’s methodology, arguing it doesn’t keep in mind the gap between the payments they receive for Medicaid patients and the price of delivering their care. The IRS filings do.
But, Kampert said, lots of the advantages SSM provides aren’t reflected in its IRS filings either. The forms reflect “very simplistic calculations” and don’t accurately represent the health system’s true impact on the community, he said.
Today, SSM Health is led by longtime business executive Laura Kaiser. Her compensation in 2022 totaled $8.4 million, including deferred payments, in accordance with its IRS filing. Kampert defended the quantity as needed “to retain and attract essentially the most qualified” candidate.
By contrast, SSM never paid Ryan a salary, giving as an alternative an annual contribution to her convent. “I didn’t join the convent to earn money,” Ryan said.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one among the core operating programs at KFF — the independent source for health policy research, polling and journalism.
