STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
SOUTH MIAMI HOSPITAL, INC., )
)
Petitioner, )
)
vs. )
)
DEPARTMENT OF HEALTH AND )
REHABILITATIVE SERVICES, and ) CASE NO. 91-5723 SOUTH DADE HEALTH CARE GROUP, )
LTD., d/b/a DEERING HOSPITAL, ) f/k/a CORAL REEF HOSPITAL, )
)
Respondents, )
and )
) DR. JOHN T. MACDONALD FOUNDATION, ) d/b/a DOCTORS' HOSPITAL OF CORAL ) GABLES, and BAPTIST HOSPITAL OF ) MIAMI, INC., )
)
Intervenors. )
)
RECOMMENDED ORDER
Pursuant to notice, a formal hearing was conducted in this case at Tallahassee, Florida, beginning on June 11, 1992, before Michael M. Parrish, a duly designated Hearing Officer of the Division of Administrative Hearings.
Appearances for the parties at the hearing were as follows:
APPEARANCES
For Doctors' Hospital: W. David Watkins, Esquire
Oertel, Hoffman, Fernandez & Cole, P.A.
2700 Blairstone Road, Suite C Post Office Box 6507 Tallahassee, Florida 32314-6507
For Baptist Hospital: Jay Adams, Esquire
Jay Adams, P.A.
418 East Virginia Street Tallahassee, Florida 32301
For South Miami Hospital: Jean Laramore, Esquire
7007 McBride Pointe
Tallahassee, Florida 32312
For AHCA: Lesley Mendelson, Esquire Senior Attorney
Agency for Health Care Administration
2727 Mahan Drive
Tallahassee, Florida 32308
For Deering Hospital: Robert D. Newell, Jr., Esquire
Newell & Stahl, P.A.
817 North Gadsden Street Tallahassee, Florida 32303
STATEMENT OF THE ISSUES
The basic issue in this case is whether Deering Hospital's application for a certificate of need to operate an inpatient cardiac catheterization program should be granted or denied.
PRELIMINARY STATEMENT
South Dade Health Care Group, Ltd., d/b/a Deering Hospital (hereinafter, "Deering") applied to the Department of Health and Rehabilitative Services ("DHRS") for a certificate of need to initiate inpatient cardiac catheterization services. 1/ This file was assigned CON No. 6664. DHRS made an initial agency determination to approve the application and a petition for formal administrative hearing to contest that decision was filed by South Miami Hospital, Inc. ("South Miami"). That proceeding was assigned Case No. 91-5723 at the Division of Administrative Hearings. Petitions to Intervene were filed on behalf of the Dr. John T. MacDonald Foundation d/b/a Doctor's Hospital of Coral Gables ("Doctor's") and Baptist Hospital of Miami, Inc. ("Baptist"), and those petitions were granted. Petitions challenging the validity of Rule 10-5.032, Florida Administrative Code, in all of its configurations, were filed at various times by South Miami, Doctor's and Baptist. Those rule challenge petitions were assigned Case Numbers 91-6390R; 92-3435RX; 92-3442RX and 92-3511RX. The rule challenge petitions were consolidated with the certificate of need proceeding for the formal hearing in all five cases. Pursuant to an order by the hearing officer, and upon due notice to all parties, the final hearing in the five consolidated cases was conducted on June 11, 1992, through June 25, 1992.
During the course of the final hearing all parties presented testimony and offered exhibits. 2/
Thereafter, on July 27, 1992, the transcript of the final hearing was filed with the hearing officer. The deadline for the submission of the parties proposed recommended orders and proposed final orders was extended to September 21, 1992. Timely proposed recommended orders containing proposed findings of fact and proposed conclusions of law were filed on behalf of all parties. The parties' proposals have been carefully considered during the preparation of this Recommended Order. Specific rulings on all proposed findings of fact submitted by all parties are contained in the appendix hereto.
FINDINGS OF FACT
Deering Hospital, formerly known as Coral Reef Hospital, is located at 9333 Southwest 152nd Street, Miami, Florida, in HRS District 11, Dade County. Deering Hospital has a total of 260 beds: 170 medical/surgical, 54 adult psychiatric, 16 adolescent and child psychiatric and 20 substance abuse beds. It is an acute care hospital.
Deering's primary geographic service area is north to the town of Kendall, west to the Everglades, east to Biscayne Bay and south to 232nd Street. The secondary service area is south to the Florida Keys. Deering's primary service is defined by 62 percent of its admissions, its secondary service area by 17 percent, and all other areas, including North Monroe County, comprise 21 percent of all its admissions.
Competitors in Deering's primary and secondary service areas include Kendall Regional Medical Center, Baptist Hospital, South Miami Hospital, and South Miami-Homestead Hospital, which was previously called James Archer Smith Hospital. These hospitals have shared a service area as long as they all have existed. South Miami-Homestead Hospital does not have a cardiac catheterization laboratory. Deering is within 30 minutes travel time of three full service cardiac catheterization programs located in facilities with open heart surgery, including two of the challengers to its application.
On June 18, 1990 South Dade Health Care Group, Ltd., was formed in order to acquire Coral Reef Hospital. South Dade Health Care Group, Ltd., at the time of the application was and is currently licensed by HRS to operate Deering Hospital. Columbia Hospital Corporation of South Dade ("Columbia') is the general partner of South Dade Health Care Group, Ltd. Columbia, acting on behalf of South Dade Health Care Group, Ltd., acquired Coral Reef on September 26, 1990. Coral Reef changed its name to Deering Hospital on April 2, 1991. Deering's CON application in this batch cycle was submitted on March 25, 1991.
The June 18, 1990, audited balance sheet for South Dade Health Care Group, Inc., was prepared for a development stage enterprise and is an audit of costs to start up the hospital after the acquisition by Columbia. The December 31, 1990, audit covers a 97 day period from September 26, 1990, (date of acquisition) to December 31, 1990, and included development and organizational costs. Since the applicant/entity/licensee did not exist before June 18, 1990, and the hospital was not acquired by that entity before September 26, 1992, there are no other financial statements that could have been prepared before the Deering application was submitted on March 25, 1991.
South Dade Health Care, Group, Ltd., submitted a timely and valid letter of intent and a timely application for Certificate of Need ("CON") 6664 to provide in the July 1993 planning horizon inpatient cardiac catheterization services at Deering Hospital. South Dade Health Care Group, Ltd., and Columbia have authorized Deering Hospital's participation in this case.
The capital projects list in the application is complete.
When Deering was purchased by Columbia in 1990, Deering had a special procedure room that was apparently equipped and had the capacity to provide diagnostic coronary catheterizations as well as peripheral (i.e., the extremities) vascular diagnostic and therapeutic procedures. Although outpatient catheterizations had been performed in the special procedure room in the past, none were being done when Columbia acquired the hospital in September 1990.
In late 1990, following evaluation of the equipment, Deering recruited an experienced CCRN cardiac catheterization laboratory nurse, hired a qualified CV tech, and began offering outpatient cardiac catheterization services. The decision to begin outpatient cardiac catheterization services was based in part
on the idea that there would be no capital costs since the equipment to perform the procedures already existed.
In December of 1990, the existing outpatient cardiac catheterization laboratory did about nine procedures and experienced some equipment failures. As a result of the equipment failures, Deering temporarily stopped doing outpatient cardiac catheterization, but was able to continue doing special procedures (vascular and arterial catheterizations, not coronary) in the room.
After exploring various possibilities, Deering entered into a lease to obtain new equipment for its existing outpatient cardiac catheterization laboratory and signed a renewal lease to continue the lease of the equipment that was already in the outpatient laboratory.
In January of 1992 the hospital resumed doing outpatient cardiac catheterization procedures and ten outpatient cardiac catheterizations have been performed in the room since January 31, 1992.
From 1985 through April of 1991 the Deering outpatient cardiac catheterization program has done a total of twenty-nine outpatient procedures. The lab was closed temporarily to outpatient cardiac catheterization procedures from March 1991 through January 1992 in order to bring in new equipment. The hospital has been diligent and persistent, from the date Deering was acquired by Columbia to the present, in its efforts to maintain and enhance its outpatient cardiac catheterization program.
Currently, however, if a Deering inpatient needs a cardiac catheterization, that patient must be taken past an active outpatient catheterization laboratory at Deering, only to be transferred to another hospital with an inpatient cardiac catheterization certificate of need.
In health planning, it is generally desirable to use existing facilities and equipment to do additional procedures. By its application in this case, Deering proposes to use its existing outpatient cardiac catheterization laboratory to perform inpatient cardiac catheterization.
For calendar year 1991, about 50 cardiac catheterization inpatients were transferred from Deering to other hospitals. Patients requiring inpatient cardiac catheterization or open heart are transferred from Deering to South Miami Hospital, Baptist Hospital, or Kendall Regional Medical Center.
At Deering the spatial relationships between the existing outpatient cardiac catheterization laboratory and related services such as telemetry and intensive care appear to be adequate.
Deering has 16 telemetry beds and they can be easily increased if needed. An uncomplicated inpatient cardiac catheterization typically results in one day in telemetry. Deering has ample capacity for over 300 additional telemetry patient days.
At Deering the intensive care unit and the coronary care unit are collectively referred to as the critical care service (CCS). Deering has 14 CCS beds where a patient can be directly connected to a cardiovascular monitor allowing monitoring of any clinical changes. The current CCS average daily census is ten (10).
Deering's application is not by or on behalf of an HMO. No evidence was presented to show that HMO's in District 11 have unmet cardiac catheterization needs or that Deering's application would fulfill any needs of HMO's. To the contrary, HMO's have a tendency to prefer cardiac catheterization services at facilities with open heart surgery.
Typically an uncomplicated diagnostic cardiac catheterization does not require a CCS stay. Even if 50 percent of Deering's cardiac catheterization inpatients required CCS during their stay, Deering has the capacity to accommodate the 150 additional CCS patients annually.
The physical space which comprises the existing outpatient cardiac catheterization laboratory is clinically adequate in its current configuration to facilitate communication during the procedure and time savings. The dark room, computer room and procedure room are all adjunct. There are no medical or clinical reasons why the space is not adequate.
According to the medical director, who has extensive experience at other hospitals and who has performed outpatient cardiac catheterizations in Deering's procedure room, Deering's procedure room is more than adequate for performing inpatient cardiac catheterization.
If the inpatient certificate of need is granted, the procedure room where outpatient catheterizations are currently performed will continue to be a mixed used room, i.e., peripheral angioplasties and coronary catheterizations will be scheduled in the same room.
Deering Hospital is JCAHO accredited. It received a three year accreditation in 1991. The laboratory currently used for outpatient procedures was surveyed by JCAHO as a special procedure room. Deering has never been cited in any JCAHO or HRS licensure survey for any inadequacy in life, safety, or fire codes in the outpatient cardiac catheterization special procedure room.
Deering currently has all of the equipment, staff and ancillary services described in, and required by, the applicable rule.
Deering has two physicians on staff that serve and are compensated as co-directors of the existing outpatient cardiac catheterization laboratory. Dr. Palomo is co-medical director of the existing outpatient cardiac catheterization program and will be co-medical director of the inpatient program if the program is approved.
Dr. Palomo is Board certified in internal medicine and Board certified in cardiovascular diseases. He was previously an assistant professor of medicine at the University of Miami and ran the cardiac catheterization lab at the Veteran's hospital in Miami. Last year Dr. Palomo performed 300 cardiac catheterizations in the Miami area. Dr. Palomo has cardiology staff privileges at six Miami hospitals, including two of the challengers to this application, Baptist Hospital and South Miami Hospital. He lives ten minutes from Deering Hospital and his office is located eight minutes from Deering.
There is no industry standard for credentialing cardiac catheterization laboratory nurses, but it is generally agreed that all cardiac catheterization personnel should be ACLS trained. All Deering nurses who are cross-trained for the cardiac catheterization laboratory are ACLS certified. Deering has also cross-trained an ECHOvascular technician into the scrub roll in the laboratory. All current cardiac catheterization laboratory staff and all
cross-trained cardiac catheterization laboratory staff are already full time Deering employees.
Current staff can accommodate the projected volume of inpatient cardiac catheterizations and the current rate of peripheral and outpatient catheterizations. If awarded the service, Deering would be able to implement the service the day of the award. The current staff is adequate regardless of whether they are performing an inpatient, outpatient, or peripheral procedure.
The staffing of the inpatient lab would be the same as the current outpatient laboratory; i.e., a physician, RN and a CVT. There would not be any need to add staff if the number of procedures increased between 300 and 1,000 annually. Accordingly, Deering does not intend to recruit additional professional personnel from the local market.
The capacity of Deering's existing laboratory, when used for inpatient cardiac catheterization procedures, can conservatively be calculated as follows:
1 hour from arrival at the procedure room to departure from the procedure room, times an 8 hour day, times a 5 day week, times 52 weeks a year equals 2,080 case theoretical capacity. One-half that theoretical capacity is four cases a day or 1,040 cases a year. A cardiac catheterization laboratory can typically do between 1,000 and 1,500 cases per year. Four cases per day (1,040 cases per year) is a reasonable number to express the capacity of Deering's existing laboratory to accommodate inpatient procedures with current space, equipment and staff. The existing inpatient cardiac catheterization laboratories in District
11 have similar capacities. With additional staffing, Deering or any of the existing laboratories might have even greater capacities.
If granted inpatient cardiac catheterization services, Deering would not do coronary angioplasties because it does not have open heart surgery in the same facility.
Deering maintains transfer agreements with other facilities for services that Deering does not provide. Deering has developed an adequate protocol outlining how an open heart or angioplasty backup patient would be transferred.
Deering has established medically appropriate criteria for granting and maintaining privileges in its outpatient cardiac catheterization laboratory that would be suitable for the proposed inpatient cardiac catheterization program.
Deering has developed adequate and appropriate forms to manage its patient care in the outpatient program which would be suitable for the inpatient program.
Deering has developed clinically adequate and appropriate protocols for temporary pacemaking, recording hemodynamic data, and insuring the emergency availability of staff in the cardiac catheterization laboratory.
Deering has a policy and procedures statement to orient new employees to the cardiac catheterization laboratory.
Generally, there is no alternative to cardiac catheterization when catheterization is medically indicated. However, there are alternatives to Deering's application, such as allowing existing providers to achieve efficient levels of utilization.
Deering is not proposing joint, shared, or cooperative health care services.
Deering is not proposing to provide services for research or teaching purposes.
Deering does not propose to provide a substantial portion of its services to individuals not residing in the service district. Indeed, inpatient cardiac catheterization services are readily available in adjoining service areas.
Deering is not proposing any new construction in its application.
Deering is not proposing to add nursing home beds.
No service reductions will occur as a result of this proposal.
Financial feasibility of a project means the project can be accomplished within the financial resources of the overall institution. Short- term financial feasibility means the applicant can cover the start-up project costs. Long-term financial feasibility means the project will generate a surplus of operating revenue over operating expenses within two years.
The proposed project would most likely be financially feasible in the short and long-term, even though (for reasons addressed below) it is unlikely to achieve the results projected in the pro formas. This is because Deering is already operating an outpatient cardiac catheterization laboratory and would have very little additional expense if it began performing inpatient cardiac catheterizations using the existing staff and the existing equipment.
If the project were to be approved, the hospital as a whole would probably have a positive cash flow in the first and second year, because with a mere four or five inpatient procedures it would recover the additional costs associated with converting the existing outpatient lab to an inpatient lab.
A contribution margin is the difference between the variable expenses and variable revenues on a per unit basis or in the aggregate. For additional inpatient cardiac catheterization services on a per case basis, Deering projects a positive contribution margin of $2,500 per procedure. This is similar to the contribution margins of other hospitals performing inpatient cardiac catheterizations in Deering's service area.
Break-even analysis determines how many procedures must be done before incremental fixed costs are covered. Since incremental fixed costs are $10,000, after only 4 or 5 inpatient procedures the service would break-even.
For a number of reasons mentioned below, it is very unlikely that Deering would be able to achieve its projected utilization levels. Specifically, it is unlikely that Deering would be able to achieve a utilization level of 300 admissions per year by the end of its second year of operation. The analysis on which Deering bases its much higher utilization projections appears to be flawed in several respects and is also contrary to reasonable expectations based on the average historical performance of diagnostic-only cardiac catheterization programs in District 11.
In an effort to demonstrate that Deering would perform in excess of
300 procedures per year, Deering's health planning expert, undertook the following analysis:
The number of MDC-5 (circulatory diagnoses) at Deering in 1990 was approximately 750.
It was assumed, from data in the Winslow report and the Dade County actual data that one third of the MDC-5 admissions would receive a cardiac catheterization.
Multiplying 750 times one third results in 250 admissions at Deering who would receive
a catheterization, or approximately 20 per month.
Because some people would refuse to have a catheterization, or would undergo it at another facility, it was assumed that 17 patients per month, or approximately 195 per year, would be cathed at Deering in the first year of operations.
It was assumed that the growth at Deering between year one and year two of operations at Deering would be equal to the projected growth in catheterizations in Dade County between July, 1989 and January, 1994.
It was assumed that all of the cases projected above would be inpatients.
Based on this analysis, it was projected that Deering would be able to do in excess of 300 cases per year starting in its second year of operations. The greater weight of the evidence indicates that this methodology suffers from a number of flaws.
The "one third" factor applied in step 2, above, is erroneous and was incorrectly applied even if correct. The Winslow paper provides no support for the proposition that one third of all MDC-5 admissions will require catheterization. The actual statistic from Dade County is that all inpatient catheterizations, including those done in anticipation of open heart surgery and for angioplasty, constitute 21 percent of the number of MDC-5 admissions. Of the catheterizations done in Dade County, 9 percent (1,382 catheterizations out of a total of 16,155) were performed in conjunction with open heart surgery and
16 percent (2,700 of 16,155) were angioplasties. Because Deering will be unable to do either open heart surgery or angioplasty, a full 25 percent of the catheterization case load is unavailable there. Applying the 21 percent factor (percent of actual inpatient catheterizations to MDC-5 admissions) would result in 158 potential catheterizations. Dropping out 25 percent of those (the percent requiring open heart surgery and angioplasty) results in 118 potential cases. Using then the 85 percent figure (to reflect those who refuse to be catheterized or must go elsewhere because of managed care agreements, etc.) leaves approximately 100 inpatient cases in the first year, or roughly half of what Deering projects.
There is no persuasive support for the idea advanced by Deering that its growth between year one and year two of operations would be the same rate of growth that all Dade County providers experienced between 1989 and 1994. To the contrary, such an experience is most unlikely. First, the projected rate of growth assumes that Dade County's use rate will continue at the same rate. This is optimistic. Second, it assumes that Deering will reflect the growth in the
number of cardiac catheterizations in Dade County even though it is only providing diagnostic catheterizations (i.e. no angioplasties or catheterizations during open heart surgery). Finally, it assumes that Deering's rate in providing cardiac catheterizations will be the same as four and one half years experience in Dade County. If the actual annual rate of increase in Dade County were applied to Deering's own projected first year utilization, it would still only be likely to do 230 cases in the second year.
The actual number of patients transferred from Deering for inpatient catheterizations plus its actual number of outpatient procedures provides a more accurate guide to the number of cases Deering could be expected to do. Based upon these figures, Deering might be expected to do between 70 and 150 cases the first year and less than 200 the second.
One assumption made by Deering to support its utilization projections was that there would be a growth in the utilization of cardiovascular services at Deering. The historical use pattern at Deering fails to reveal any trend that would suggest such an increase. According to data reported to the HCCCB, there was an overall decline in the number of intensive care days at Deering between 1985 and 1991. Similarly, emergency room visits have also declined during the same period. Emergency room admissions account for 60 percent of all admissions to Deering. As a result, the total number of patient days at Deering has declined from 47,089 in 1985 to 40,975 in 1991. Thus, although Deering is projecting a large increase in utilization to project satisfactory utilization of its proposed laboratory, the historical record does not support that record.
According to Deering, indicators of cardiac volume include the following services: EKGs; echocardiograms; holter monitors; treadmills; pulmonary function tests; thallium exams; and, coagulation studies. According to data presented by Deering, none of those "cardiac volume indicators" showed an increase in utilization between 1988 and 1990.
In its financial analysis, Deering assumed that all of the 195 procedures in the first year and all 360 in the second year would be inpatient procedures. In Dade County for the 12 months ending September 30, 1991, 39 percent of all catheterizations were done on an outpatient basis (6,240 outpatient procedures out of 16,165 total cases). That percentage would be even higher at facilities that are unable to provide open heart surgery. (For example, currently 80 percent of the cardiac catheterization procedures at Doctors' Hospital are outpatient procedures.) In all of Florida approximately
50 percent of all cardiac catheterizations are inpatient. The trend in Dade County, in Florida, and nationally is that the number, and percentage, of outpatient procedures is increasing. The significance of this fact as it relates to Deering's financial projections is that Deering did not make any adjustment in its utilization projections to account for outpatient utilization and projected the pro formas by assuming that income associated with each case would be the income associated with a full inpatient admission. Thus, the pro forma projections are overstated to the extent that the projected procedures will actually be performed on an outpatient basis. At least 35 percent of Deering's procedures are likely to be on an outpatient basis with the trend indicating that outpatient utilization will actually be much higher.
In projecting the average length of stay to be attributed to each inpatient catheterization at Deering, it was assumed that it would be the same length of stay as the District 11 average. The District 11 average includes the average inpatient stay associated with open heart surgery, which is much longer than for a routine diagnostic catheterization. Thus, Deering has overstated its
projected average length of stay. In addition, the average length of stay for inpatient catheterizations has been dropping. This compounds the extent to which the number of inpatient days associated with catheterizations has been overstated in Deering's pro formas.
One assumption in Deering's financial analysis is that patient days at Deering would increase at the same rate as the population increase in Dade County. This assumption finds no support in the evidence presented at hearing. In fact, it was demonstrated that the actual number of patient days have been declining at Deering since 1985. In 1985, Deering has 47,089 patient days; in 1991 it had 40,975 patient days, a drop of 13 percent. This drop occurred even though Dade County has had continuous steady growth. The financial assumption that Deering's inpatient days will grow at the same rate as the population as a whole is found to be unsupported.
One reality check of Deering's projection that it will perform in excess of 300 procedures in its second year of operations is to measure its proposed "capture rate" against that of the other hospitals it will be competing against. In 1990 there were a total of 491 cardiac catheterizations performed on patients who reside in Deering's primary service area. Of these, Baptist, which is a full service provider, was able to capture only 203 cases, or 41 percent. If Deering, with one catheterization lab which is also used to do peripheral procedures, were to capture 300 procedures from its primary service area, this would represent in excess of 60 percent of the procedures from that area, or one and one half times better than Baptist is able to do with a full service catheterization facility, three dedicated catheterization laboratories, four full catheterization teams, and angioplasty and open heart capabilities. It is most unlikely that Deering can achieve such a projection.
Deering proposes to provide a diagnostic-only program. Of the 13 cardiac catheterization programs in Dade County, nine are traditional and four are diagnostic-only. The diagnostic-only laboratories in District 11 have historically operated at significantly lower volumes than the laboratories in facilities with open heart surgery. During calendar year 1991 the four diagnostic-only providers performed the following number of procedures:
Doctors' Hospital | 301 |
Humana Hospital-Biscayne | 55 |
Palmetto General Hospital | 432 |
Parkway Regional Med. Center | 262 |
TOTAL | 1050 |
The total of 1050 procedures constitutes an average of 262.5 procedures for each of the four existing providers. If this pool of 1050 procedures were to be divided five ways to accommodate a new provider, there would be an average of
210 procedures per diagnostic-only provider. It would require an increase of almost 50 percent in the number of procedures being done by diagnostic-only laboratories for five such laboratories to be performing an average of 300 procedures per year. This is yet another reason for which it is most unlikely that Deering would achieve the utilization levels it projects.
There appears to have been little physician acceptance of the outpatient catheterization laboratory at Deering. From 1985 through the date of hearing, Deering only performed 29 cardiac catheterizations. Dr. Palomo is the medical director of the Deering cardiac catheterization laboratory. One of his duties as medical director is "promoting" the laboratory. In 1992, through June 16, Dr. Palomo performed only two or three cardiac catheterizations at Deering;
in calendar year 1991, he did four to six cardiac catheterizations at Deering. Dr. Palomo does approximately 300 catheterizations per year. It is unlikely that Deering will perform over 300 catheterization cases per year when its own medical director is doing less than 2 percent of his cases there.
South Miami is an acute care hospital located in Dade County. South Miami has a open cardiac catheterization program which means any physician within the community can apply for privileges, and, if granted, perform cardiac catheterizations at South Miami. Until recently, it was a closed program.
Baptist is a large, full service acute care hospital located in South Miami, Dade County, District 11. Baptist provides a full array of cardiac services at its Miami Vascular Institute. These include cardiac catheterization, open heart surgery, and angioplasty. Baptist is within the primary service area of Deering. It is approximately eight minutes drive from Deering. Deering currently transfers its cases needing inpatient catheterizations to other hospitals, including Baptist.
If Deering were to be approved, and if it were able to perform 360 cases in its second year of operations as it projects, it would most likely be performing something in the neighborhood of 150 cases that otherwise would have been done at Baptist. 3/ This was calculated as follows:
There were a total of 491 catheteriza- tions performed in 1990 on patients residing in Deering's primary service area.
Of those 491 cases, Baptist performed the catheterizations for 203 patients.
If Deering were to perform 360 inpatient catheterizations in its second year of operations, it is projected that Baptist would lose cases in the same relation as its current market penetration, i.e. 41 percent. This equates to 149 cases.
This methodology presents a reasonable projection of the number of cases that Baptist would be likely to lose if Deering's application for inpatient cardiac catheterization were approved and Deering were able to achieve its projected utilization levels.
Baptist has a contribution margin of approximately $2,560 per cardiac catheterization. This figure is the average revenue per case less the variable costs per case. Using the methodology described above, it is projected that the net annual loss at Baptist, if Deering were approved, would be in the neighborhood of $380,000.00. If Deering were to achieve its projected utilization levels, it is likely that it would also be performing a substantial number of cases that otherwise would have gone to South Miami Hospital or one of the other nearby existing providers.
Doctors' Hospital is a 255-bed acute care hospital located in Coral Gables, Dade County, Florida. Doctors' has had a cardiac catheterization program since December of 1986, and is authorized to perform diagnostic catheterization on both inpatients and outpatients. With its current staffing compliment, the Doctors' cardiac catheterization laboratory could comfortably perform four catheterizations per day or between 800 and 900 per year. Doctors' performs cardiac catheterization on all patients regardless of ability to pay.
Since 1988, the Doctors' cardiac catheterization laboratory has experienced declining utilization. The following chart represents the utilization of Doctors' cardiac catheterization laboratory since 1988:
TOTAL INPATIENT AND CALENDAR YEAR OUTPATIENT CARDIAC CATHS
1988 | 484 |
1989 | 400 |
1990 | 380 |
1991 | 295 |
1992 | 240 (estimated) |
The Doctors' inpatient cardiac catheterization program is at a crossroads. The current volume is well below the minimum quality threshold which is acceptable for cardiac catheterization laboratories.
In its early years of operation, the Doctors' cardiac catheterization laboratory generated a profit. Such is no longer the case.
Several factors have resulted in the declining utilization of Doctors' cardiac catheterization laboratory. One of the factors is that more of the existing laboratories have become open staff versus closed staff. Doctors' laboratory has always had an open staff policy. At the time that Doctors' established its cardiac catheterization laboratory, it was one of only two that had an open staff policy. Another factor in the decline of utilization at Doctors' has been a shift from inpatient to outpatient cardiac catheterization. Therefore, the opening of outpatient-only cardiac catheterization laboratories, including the one at Deering, has resulted in a reduction in the number of outpatient cardiac catheterization procedures done at Doctors'.
Doctors' does not offer angioplasty or open heart surgery. Doctors' diagnostic-only cardiac catheterization capability has contributed to its declining utilization since Doctors' is unable to compete with full service hospitals for cardiac catheterization patients that require the services of a full service hospital.
Another factor which has resulted in the decline in utilization at the Doctors' cardiac catheterization laboratory is a change in HMO service patterns to facilities that can provide full-service cardiology services, including cardiac catheterization, angioplasty, and open heart surgery.
The primary reason Doctors' Hospital catheterization laboratory is now losing money is its decrease in utilization. As utilization of a cardiac catheterization laboratory declines, the per unit cost of providing a catheterization increases.
Based upon the current market share of inpatient cardiac catheterization patients in District 11, and assuming Deering would be able to achieve its projected year two utilization of 360 new inpatient cardiac catheterization patients, a small number of those patients probably would have otherwise gone to Doctors' Hospital.
Because of the declining utilization at the Doctors' cardiac catheterization laboratory, and the fact that its program is not co-located with open heart surgery, the loss of even a small number of patients may be
significant to the future viability of the cardiac catheterization program at Doctors' Hospital.
If the Deering inpatient program were to be approved, both the Deering and Doctors' programs would likely be low volume programs operating at utilization levels well below the minimum for maintaining quality standards and well below the minimum for economic efficiency.
There are 13 providers of inpatient cardiac catheterization services in Dade County which operate a total of 24 catheterization laboratories. These providers are geographically well dispersed in the population centers of the county. The existing inpatient cardiac catheterization providers in District 11 are available, provide high quality care, are appropriate, and are accessible.
In District 11 there is an ample excess capacity to provide additional inpatient cardiac catheterizations at existing facilities. The existing catheterization laboratories are not producing sufficient numbers of cases to be operating efficiently. The practical capacity of a typical catheterization laboratory is somewhere between 1,000 and 1,500 cases per year. Given that there are 24 existing catheterization laboratories and four more expected to come on line soon, the existing providers are operating at approximately half of their capacity. These programs have not reached a level of optimal efficiency in terms of operations. Optimal efficiency for health planning purposes should be measured at a level of approximately 80 or 85 percent of capacity. The economic efficiency of the existing providers of inpatient cardiac catheterization would be enhanced if new entries into the market were precluded until existing providers were operating at approximately 80 or 85 percent of their practical capacity.
It is well accepted in health planning that a catheterization laboratory must perform at least 300 cases per year in order to maintain proficiency and quality. There appears to be a relative correlation between the number of cases performed in a laboratory and the skill of the staff.
In District 11, HMO's and PPO's have shifted their service patterns to facilities that can provide full cardiac services including angioplasty and open heart surgery. The shift in use patterns has had a significant effect on cardiac catheterization laboratories unable to provide angioplasty and open heart surgery. This effect would likely be felt at Deering Hospital if its inpatient lab were approved and supports the conclusion that Deering, as a provider of diagnostic catheterizations only, would be unlikely to achieve its utilization projections.
Cardiac catheterization services are highly competitive in District
As such, the approval of Deering's application will have little beneficial improvement by way of increased competition. Additionally, the trend in District
11 is for third party payers to contract for the provision of cardiac services at full service providers. As such, Deering would be unable to effectively compete with the nine full service providers of which three, Baptist, South Miami, and Kendall, are in Deering's primary service area.
There is no evidence that any patient has had, or is likely to have, problems accessing inpatient catheterization services if this proposal is not approved. The geographic access standard contained in the applicable rule is met by the existing providers. Additionally, none of the programs or doctors have been unable to schedule catheterizations because of heavy utilization at any District 11 catheterization provider. Accordingly, patients are not likely
to experience any difficulty in accessing inpatient cardiac catheterization services if Deering's application is denied.
Currently and historically, cardiac catheterization has been regulated by HRS as an inpatient institutional health service, not a tertiary service.
On February 8, 1991, HRS published official notice of the need for one more inpatient cardiac catheterization program in District 11 for the 1993 planning horizon, calculated in accordance with the methodology in the applicable rule. The fixed need pool in this case was never challenged by Petitioners.
The projected number of procedures by population in the planning horizon using the methodology in Joint Exhibit 1 and actual data collected by HRS show that there are enough procedures in the marketplace for Deering to perform 300 in the second year of operation and for the protestants in this case to maintain their annual current volumes. However, major portions of that rule- based methodology have been found to be invalid in the Final Order issued this same day in the related rule challenge cases.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter of and the parties to this proceeding. Sec. 120.57(1), Fla. Stat.
Section 381.705, Florida Statutes (1991), contains the applicable statutory review criteria for certificate of need applications. 4/ This section reads as follows, in pertinent part:
381.705 Review criteria.-
The department shall determine the reviewability of applications and shall review applications for certificate-of-need determinations for health care facilities
and services, hospices, and health maintenance organizations in context with the following criteria:
The need for the health care facilities and hospices being proposed in relation to the applicable district plan and state health plan, except in emergency circumstances which pose
a threat to the public health.
The availability, quality of care, efficiency, appropriateness, accessibility, extent of utilization, and adequacy of like and existing health care services and hospices in the service district of the applicant.
The ability of the applicant to provide quality of care and the applicant's record of providing quality of care.
The availability and adequacy of other health care facilities and services and hospices in the service district of the applicant, such as outpatient care and ambulatory or home care services, which may serve as alternatives for the health care facilities and services to be provided by the applicant.
Probable economies and improvements in service that may be derived from operation of
joint, cooperative, or shared health care resources.
The need in the service district of the applicant for special equipment and services which are not reasonably and economically accessible in adjoining areas.
The need for research and educational facilities, including, but not limited to, institutional training programs and community training programs for health care practitioners and for doctors of osteopathy and medicine at the student, internship, and residency training levels.
The availability of resources, including health manpower, management personnel, and funds for capital and operating expenditures, for project accomplishment and operation; the effects the project will have on clinical
needs of health professional training programs in the service district; the extent to which the services will be accessible to schools for health professions in the service district for
training purposes if such services are available in a limited number of facilities; the availability of alternative uses of such resources for the provision of other health services; and the extent to which the proposed services will be accessible to all residents
of the service district.
The immediate and long-term financial feasibility of the proposal.
The special needs and circumstances of health maintenance organizations.
The needs and circumstances of those entities which provide a substantial portion of their services or resources, or both, to individuals not residing in the service district in which the entities are located or in adjacent service districts. Such
entities may include medical and other health professions, schools, multidisciplinary clinics, and specialty services such as
open-heart surgery, radiation therapy, and renal transplantation.
The probable impact of the proposed project on the costs of providing health services
proposed by the applicant, upon consideration of factors including, but not limited to, the effects of competition on the supply of health services being proposed and the improvements or innovations in the financing and delivery of health services which foster competition and service to promote quality assurance and cost-effectiveness.
The costs and methods of the proposed construction, including the costs and methods
of energy provision and the availability of alternative, less costly, or more effective methods of construction.
The applicant's past and proposed provision of health care services to Medicaid patients and the medically indigent.
In cases of capital expenditure proposals for the provision of new health services to inpatients, the department shall also reference each of the following in its findings of fact:
That less costly, more efficient, or more appropriate alternatives to such inpatient services are not available and the development of such alternatives has been studied and
found not practicable.
That existing inpatient facilities providing inpatient services similar to those proposed are being used in an appropriate and efficient manner.
In the case of new construction, that alternatives to new construction, for example, modernization or sharing arrangements, have been considered and have been implemented to the maximum extent practicable.
That patients will experience serious problems in obtaining inpatient care of the type proposed, in the absence of the proposed new service.
In the case of a proposal for the addition of beds for the provision of skilled nursing
or intermediate care services, that the addition will be consistent with the plans of other agencies of the state responsible for the provision and financing of long-term care, including home health services.
The applicable rule provisions appear at Rule 10-5.032, Florida Administrative Code. Although there have been circumstances under which the courts have concluded otherwise, in de novo proceedings such as this the rule in effect at the time of the final decision is normally the version of the rule that should be applied. Accordingly, the application in this case should be considered in light of the provisions of the current version of Rule 10-5.032, Florida Administrative Code. In this regard it should be noted that by separate Final order issued this same day, it has been concluded that certain portions of the current version of Rule 10-5.032, Florida Administrative Code, are invalid exercises of delegated legislative authority. The invalid portions of the subject rule have not been applied in the consideration of the pending application.
AHCA is the single state agency responsible for issuance of certificates of need. No license may be issued to a health care facility in Florida for a certificate of need regulated service before the facility has obtained a certificate of need. Section 381.704(1),(2), Fla. Stat. (1991).
A certificate of need is a license within the meaning of Section 120.52(9), Florida Statutes (1991). The applicants have the burden of proving entitlement to a license. Florida Department of Transportation v. J.W.C.
Company. Inc., 396 So.2d 778, 787 (Fla. 1st DCA 1981). The award of a certificate of need must be based on a balanced consideration of all statutory and rule criteria. Department of Health and Rehabilitative Services v. Johnson & Johnson Home Health Care Inc., 447 So.2d 361, 363 (Fla. 1st DCA 1984).
As existing providers of adult inpatient cardiac catheterization services in District 11, South Miami Hospital, Doctors' Hospital, and Baptist Hospital have standing to bring this proceeding pursuant to Section 381.709(5)(b), Florida Statutes.
The weight to be given to each criteria is not fixed but varies depending upon the facts of each case. Northridge General Hospital v. NME Hospitals, 478 So.2d 1138, 1139 (Fla. 1st DCA 1985); Collier Medical Center Inc.
v. Department of Health and Rehabilitative Services, 462 So.2d 83, 84 (Fla. 1st DCA 1985).
An inpatient cardiac catheterization is an institutional health service of the type requiring certificate of need review pursuant to Section 381.706(1)(h), Florida Statutes (1991), since the projected annual operating costs of the project typically exceed $500,000.
Petitioners have suggested that the existing special procedure room and equipment at Deering are not adequate to support inpatient cardiac catheterization services. The greater weight of the evidence is to the effect that the existing space and equipment are adequate for inpatient cardiac catheterization services because they have already been shown to be adequate for outpatient cardiac catheterization services and there are no significant medical differences in the performance of the two classes of procedures.
Sunk costs are not relevant to determine the cost of Deering's new service. Venice Hospital v. Department of Health and Rehabilitative Services,
14 F.A.L.R. 1220, 1230, 1231 (HRS 1990). The cost of the outpatient laboratory space, equipment, and personnel at Deering are sunk costs.
Evidence relating to the new outpatient cardiac catheterization laboratory equipment was not an impermissible update. Rather, it is evidence of a change in circumstances that results directly from maintaining an existing outpatient service that uses equipment identical to that used for inpatient service.
HRS must make certificate of need determinations for health care services in the context for those criteria in Section 381.705(1), Florida Statutes (1991), which are relevant to the type of service sought to be approved.
Petitioners' failed to challenge the fixed need pool rule published in this case. Accordingly, Petitioners have effectively and practically waived their entitlement to question the numerical need determination applied in this case. See, Health Ouest v. Department of Health and Rehabilitative Services, 11
F.A.L.R. 5427, 5439 (HRS 1989); National Healthcorp v. Department of Health and Rehabilitative Services, 11 F.A.L.R. 4314, 4315 (HRS 1989).
The State Health Plan contains four preferences that pertain to certificate of need applications for cardiac catheterization programs. While such preferences can be very material to determining the relative merits of two or more competing applicants, where, as here, there is only one applicant, the
preferences are, for all practical purposes, irrelevant to the issue of whether a CON should be granted or denied.
Taking as a given that numeric need exists for Deering's proposed cardiac catheterization program under the HRS rule formula, that is only the starting point for determining whether the certificate of need should be granted. In St. Mary's Hospital, Inc. v. Department of Health and Rehabilitative Services et al., 14 FALR 2210 (Final Order May 5, 1992) HRS issued a Final Order denying a certificate of need for an inpatient cardiac catheterization laboratory which it had preliminarily approved, notwithstanding the existence of numeric need pursuant to its fixed need pool projection. In St. Mary's, the Department adopted the Hearing Officer's conclusion that the inpatient cardiac catheterization program proposed by Good Samaritan Hospital would be unable to achieve the number of admissions projected in its application. Thus, although numeric need, as calculated pursuant to the HRS numeric need formula, demonstrated a numeric need for the proposed program, the Hearing Officer nonetheless recommended denial of the Good Samaritan project. Specifically, the Hearing Officer found, at page 2220:
32. Seventy-nine (79) to eighty-two (82) patients were transferred from Good Samaritan to other facilities for cardiac catheterization procedures in 1990. Good Samaritan correctly points out that transfers are costly and disruptive for the patients. As of October 15, 1991, Good Samaritan had 53 cardiac transfers, or annualized approximately 70 patients were expected to be transferred in 1991 to other hospitals for cardiac catheterization procedures. Good Samaritan, based on the experience of St. Mary's, will not be able to retain all of these patients for inpatient cardiac catheterization services. The assumptions that Good Samaritan would have 115, not 70 transfers in 1991, and that with a cardiac catheterization laboratory, all the transfers would remain at Good Samaritan are the bases for Good Samaritan's projected utilization, and are rejected.
Additionally, with respect to the relationship between cardiac catheterization laboratory volume, patient safety, and financial feasibility, the Hearing Officer concluded:
Good Samaritan has not demonstrated that it can capture enough catheterization admissions to safely operate its program from its current cardiac inpatient service area, from its transfers of patients to other facilities, and from the out-migration of county residents.
The failure to show sufficient utilization undermines the pro forma by not providing support for the basic underlying assumptions. Therefore, Good Samaritan has failed to demonstrate the financial feasibility of its proposal.
Id. at 2224
Like the inpatient cardiac catheterization laboratory proposed by Good Samaritan, the Deering proposal would not be colocated with an open heart surgery program. Also, both the Deering and Good Samaritan proposals are located in close proximity to other programs which are currently under-utilized. Finally, like Good Samaritan, Deering has predicated its ability to achieve its utilization projections based in part upon the number of inpatients being transferred to other facilities to receive cardiac catheterization. The only significant difference in this respect is that Good Samaritan documented approximately 70 inpatient transfers annually to other hospitals for cardiac catheterization (as opposed to the 50 documented by Deering) but was nevertheless found by the Department to be unable to achieve its utilization projections, thereby necessitating the denial of the application.
In Sarasota County Public Hospital Board d/b/a Memorial Hospital, Sarasota v. Department of Health and Rehabilitative Services, 11 FALR 6248 (HRS 1989), a case in which there was shown to be numeric need for an additional open heart surgery program, the Hearing Officer found, at page 6281:
However, approval of a CON cannot result from the application of the Department's numeric need methodology in a vacuum. This is just one of the criteria that must be weighed and considered, and is no more important than any of the other criteria. There is a place for reality in the CON process Therefore,
while a determination of numeric need may serve as a basis to initiate a review of this application, all criteria enumerated in Section 381.705(1) (2), Florida Statutes, must be balanced in arriving at a recommendation on
CON 5715.
In the above case, HRS found there to be numeric need for an additional open heart program. In spite of this finding, the Hearing Officer, by examining the distribution of existing and approved programs and the procedures performed at each, found that the applicant would not reach an acceptable level of service within the allotted time frame.
In a later open heart surgery CON proceeding, Humana of Florida, Inc. d/b/a Humana Hospital Lucerne v. Department of Health and Rehabilitative Services, 12 FALR 823 (HRS 1990), the Hearing Officer made the following finding of fact:
Additional open heart surgery programs are not needed in District 7. The . . . real potential that existing programs will suffer substantial financial losses, the real risk that declining volume at existing programs will lead to poorer quality of care or that the new programs will fail to achieve their hoped for volume, are not outweighed by enhanced convenience to patients, their families and physicians.
Id. at 826, 843. The finding gave rise to the following conclusion of law:
On balance, the situation in District 7 is similar to that in District 8, where recently HRS, after formal hearing, adopted a recommended order of denial of an additional open heart surgery program, even where it had initially approved the application and its need formula suggested numeric need.
Similarly, in St. Joseph Hospital of Port Charlotte, Florida, Inc. v. Department of Health and Rehabilitative Services, 11 FALR 4567 (HRS 1989), the Hearing Officer determined:
It is concluded that Petitioner's proposal fails to meet the requisite criteria of Sections 381.705(1) and (2), Florida Statutes, as well as Rule 10-5.011(l)(b), Florida Administrative Code. Balanced consideration of the statutory and rule criteria leads to the conclusion that Petitioner's application should be denied. In view of Petitioner's failure to meet other criteria unrelated to
a showing of need, this conclusion is applicable regardless of whether numeric or other need
for the proposed cardiac catheterization laboratory exists.
Id. at 4574.
In at least one case, numeric need has been viewed as merely an indicator as to which party or parties have the burden of proof in a certificate of need administrative hearing. In Balsam v. Department of Health and Rehabilitative Services, 486 So.2d 1341 (Fla. 1st DCA 1986), a case involving a certificate of need for psychiatric beds, the court explained the parties' roles in instances where the HRS formula showed no need for beds:
The bed-need formula is part of a rule having general statewide application and should be viewed merely as the beginning point for determining need. The formula is so broad in scope that it cannot be treated as taking into consideration all the peculiar conditions found in a particular area sought to be served by the applicant. While the bed-need formula shifts the burden from HRS to the applicant to
show a need where none is shown by calculations under the formula, HRS should not simply stand on these calculations and abandon its responsibility to consider and weigh the other criteria.
Id. at 1349.
The existence (or non-existence) of numeric need is but one of the factors to be considered in determining whether a certificate of need application should be awarded. In the instant case, a balanced consideration of
all statutory and rule criteria requires denial of the Deering proposal. Taking formula numeric need as a given, no other indicators of need appear to be present. Further, Deering's ability to achieve its projected volumes in its first two years of operation is highly unlikely. Historically, a relatively small number of patients have been transferred from Deering to other facilities for the purpose of receiving a cardiac catheterization. Neither population growth nor increasing market share can be realistically expected to generate the
195 cases projected for year one and 360 cases projected for year two.
Even if Deering were to be able to achieve its projected utilization levels, such levels would be achieved at the expense of the existing cardiac catheterization laboratories. The expense to the existing providers would not be just a dollars and cents expense. Further reductions in utilization levels at some of the existing providers could begin to raise concerns as to quality of care because there is a positive correlation between cardiac catheterization laboratory volume and the proficiency of the physicians and staff performing the catheterizations. For example, since the Doctors' cardiac catheterization laboratory is now performing a marginal volume of cases, any further loss of patients poses the risk of reducing the proficiency of the laboratory staff, in addition to the efficiency and cost-effectiveness of the laboratory.
In view of the circumstances of the existing providers of impatient cardiac catheterization in District 11, the Deering proposal is inconsistent with the concerns addressed by Section 381.705(1)(b), Florida Statutes. This is because the existing providers are providing appropriate, accessible, available, quality care, and at the same time the existing providers are under-utilized and are operating well below their optimum efficiency levels.
In view of the fact that Deering's proposed program is unlikely to achieve an annual program volume of 300 admissions by the second year, the proposal fails to meet the mandatory requirements of Rule 10-5.032(8)(b), Florida Administrative Code. The cited rule provision is a mandatory requirement 5/ and is a standard that addresses quality of care considerations. The ability of a proposed provider to provide quality care is cast into doubt if it cannot be shown that the proposed service is likely to achieve the utilization level required by the rule. Failure to meet the requirements of Rule 10- 5.032(8)(b), Florida Administrative Code, also causes the instant proposal to be inconsistent with the quality of care concerns addressed by Section 381.705(1)(c), Florida Statutes.
In its proposed recommended order, Deering argues that the review criteria at Section 381.705(2)(a) through (e), Florida Statutes, are not applicable because Deering's application is not a "capital expenditure proposal." Although the matter is not entirely free from doubt, in view of the definition of the term "capital expenditure" at Section 381.702, Florida Statutes, and in view of the unique financial considerations in a project of this nature, it appears that the instant project is subject to the review criteria in Section 381.705(2)(a) through (e), Florida Statutes. 6/
The Deering proposal fails to satisfy the requirements of Section 381.705(2)(a), Florida Statutes, because there is a more appropriate alternative to the services it proposes. The more appropriate alternative is to allow the existing providers to increase their economic efficiency by precluding new entries into the market until a substantial number of the existing providers have utilization levels at or near their optimum efficiency levels.
The Deering proposal fails to satisfy the requirements of Section 381.705(2)(b), Florida Statutes, because the existing inpatient cardiac catheterization laboratories are not being used in an efficient manner. All of the existing laboratories are operating at utilization levels well below the level of optimum economic efficiency. Some of the existing laboratories are operating at such low levels of utilization as to cause concern about their future ability to maintain proficiency and quality.
The Deering proposal fails to satisfy the requirements of Section 381.705(2)(d), Florida Statutes, because there is an abundance of unused capacity in the existing laboratories and there is no evidence that patients will experience serious problems in obtaining the proposed services in the absence of the Deering proposal.
Notwithstanding the numeric formula determination of need, for the reasons described above, the application in this case should be denied. The failure of the applicant to show compliance with the requirements of the mandatory requirements of Rule 10- 5.032(8)(b), Florida Administrative Code, raises quality of care concerns which cannot be overcome by compliance with other rule criteria. Denial is made more compelling by the absence of evidence of any real need for an additional provider and by the fact that the proposal is inconsistent with all of the applicable criteria at Section 381.705(2), Florida Statutes.
In all probability the proposal in this case would be beneficial to Deering's financial bottom line; if implemented it would probably generate more revenue than expenses. But that benefit to Deering would be a detriment to the District-wide health care delivery system because it would unnecessarily duplicate existing services that are not being used efficiently.
All other statutory and rule criteria not discussed above are either not applicable to the Deering proposal or appear to be adequately addressed by the Deering proposal. 7/
On the basis of all of the foregoing, it is RECOMMENDED that a Final Order be issued in this case denying the subject certificate of need application.
DONE AND ENTERED this 1st day of April, 1994, at Tallahassee, Leon County, Florida.
MICHAEL M. PARRISH, Hearing Officer Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-1550 904/488-9675
Filed with the Clerk of the Division of Administrative Hearings this 1st day of April, 1994.
ENDNOTES
1/ Since the submission of the certificate of need application which generated this proceeding and the related rule challenge cases, the administration of the certificate of need program has been reassigned from the Department of Health and Rehabilitative Services to the Agency for Health Care Administration ("AHCA"). DHRS took a number of the actions related to the handling of the certificate of need application in this case AHCA assumed its successor role.
For convenience, and hopefully to minimize confusion, throughout this order both agencies will be referred to as AHCA or as "the agency."
2/ Witness lists and exhibit lists are contained in the voluminous transcript of the final hearing.
3/ Another analysis of the potential impact on Baptist Hospital predicted a different, but similar result.
4/ Since the application in this case was filed, the statutory review criteria have been transferred to Chapter 408, Florida Statutes (1993). In view of the fact that all of the parties' proposed recommended orders are written in terms of the 1991 version of the statutes, it appeared to be more convenient to do the same in this Recommended Order. The ultimate result is the same under either version of the statute.
5/ The subject rule provision reads: "Applicants shall demonstrate that they will be able to reach an annual program volume of 300 admissions within 2 years after the program becomes operational." The word "shall" in a statute or rule normally has a mandatory connotation. See Neal v. Bryant, 149 So.2d 529 (Fla. 1962); Humhosco, Inc. v. Dept. of Health and Rehabilitative Services, 561 So.2d 388, 391 (Fla. 1st DCA 1990).
6/ In this regard it is noteworthy that Deering devoted the better part of three pages of its application to a discussion of the criteria at Section 381.705(2)(a) through (e), Florida Statutes. See pages 26-28 of the application. Those criteria are also specifically addressed in the State Agency Action Report at pages 13 and 14.
7/ In view of the dispositive nature of the insufficiencies in the Deering proposal, it does not seem to serve a useful purpose to discuss in any detail the various criteria which are adequately addressed by the proposal.
APPENDIX
The following are the specific rulings on all proposed findings of fact submitted by all parties.
Findings submitted by South Miami Hospital:
The paragraph numbers referred to immediately below are to the paragraphs that appear under the caption "Supplemental Findings Of Fact" at pages 43-49 of South Miami Hospital's proposed final and recommended order. Other findings of fact proposed by South Miami Hospital are addressed in the related Final Order.
Paragraph 1: Accepted in substance.
Paragraphs 2, 3, 4, 5, 6, and 7: Rejected as subordinate and unnecessary details.
Paragraphs 8 and 9: Rejected as statements of party positions and not proposed findings of fact.
Paragraphs 10, 11, and 12: Rejected as constituting argument or proposed conclusions of law, rather than proposed findings of fact.
Paragraphs 13, 14, and 15: Accepted in substance.
Paragraphs 16, 17, and 18: Rejected as irrelevant or as subordinate and unnecessary details.
Paragraph 19: Rejected as being more nearly hyperbole than proposed findings of fact.
Paragraph 20: Accepted in substance.
Findings submitted by Baptist Hospital and Doctors' Hospital:
Paragraphs 1 through 11: These paragraphs all relate to the issues in the related rule challenge proceedings and are addressed in the Final Order in those cases.
Paragraph 12: Rejected as primarily argument or conclusions of law, rather than proposed findings of fact.
Paragraph 13: Accepted in substance.
Paragraphs 14, 15, 16, 17, and 18: Rejected as irrelevant or as subordinate and unnecessary details. Where, as here, there is only one applicant, preferences in the State Health Plan are of little use in determining whether a CON should be granted.
Paragraphs 19 and 20: Accepted in substance.
Paragraph 21: Rejected as constituting description of issues, rather than proposed findings of fact.
Paragraphs 22, 23, 24, and 25: Rejected as subordinate and unnecessary details or as irrelevant.
Paragraph 26: Rejected as contrary to other persuasive evidence. Paragraph 27: Rejected as subordinate and unnecessary details.
Paragraph 28: Rejected as contrary to other persuasive evidence.
Paragraphs 29, 30, and 31: Rejected as contrary to other persuasive evidence and as irrelevant in light of other evidence.
Paragraphs 32 and 33: Rejected as subordinate and unnecessary details. Paragraphs 34, 35, 36, 37, and 38: Accepted in substance.
Paragraph 39: Rejected as subordinate and unnecessary details. Paragraphs 40, 41, 42, 43, 44, 45, and 46: Accepted in substance.
Paragraphs 47, 48, and 49: Rejected as irrelevant.
Paragraphs 50, 51, 52, and 53: Accepted in substance.
Paragraph 54: Rejected as in part irrelevant and as in part contrary to the greater weight of the evidence.
Paragraph 55: Rejected as repetitious.
Paragraph 56: Rejected as too broad and vague or as argument. Paragraphs 57 and 58: Accepted in substance.
Paragraph 59: First two sentences accepted. The remainder is rejected as an argument or opinion that does necessarily apply to the specific circumstances of this case.
Paragraphs 60, 61, 62, and 63: Accepted in substance.
Paragraphs 64, 65, 66, 67, 68, 69, and 70: Rejected as subordinate and unnecessary details.
Paragraphs 71 and 72: Accepted in substance.
Paragraph 73: Rejected as combination of subordinate and unnecessary details and argument.
Paragraphs 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, and 84: Accepted in substance.
Paragraph 85: Rejected as combination of subordinate and unnecessary details and argument.
Paragraphs 86 and 87: Accepted in substance. Paragraphs 88 and 89: Rejected as repetitious. Paragraph 90: Accepted in substance.
Paragraph 91: Rejected as subordinate, unnecessary, and repetitious. Paragraph 92: Rejected as irrelevant.
Paragraphs 93, 94, 95, and 96: Accepted in substance.
Paragraphs 97, 98, 99, and 100: Rejected as subordinate and unnecessary details.
Paragraphs 101, 102, 103, 104, 105, 106, and 107: Accepted in substance with some subordinate and unnecessary details omitted.
Paragraph 108: Rejected as irrelevant.
Paragraph 109: Rejected as constituting a conclusion of law, rather than a finding of fact.
Paragraph 110: Accepted in substance.
Paragraph 111: Rejected as consisting primarily of subordinate and unnecessary details.
Paragraph 112: First four sentences rejected as consisting primarily of argument. The remainder is accepted in substance.
Paragraphs 113, 114, 115, and 116: Accepted in substance.
Findings submitted by Deering Hospital and AHCA:
Paragraphs 1, 2, 3, 4, 5, 6, 7, and 8: Accepted in substance with some subordinate and unnecessary details omitted.
Paragraphs 9 and 10: Rejected as subordinate and unnecessary details or as irrelevant.
Paragraph 11: Accepted in substance.
Paragraph 12: Rejected as subordinate and unnecessary details.
Paragraph 13: Rejected as subordinate and unnecessary details and also as an incomplete description.
Paragraph 14: Accepted that many inpatient and outpatient procedures are essentially the same, but other details are omitted as unnecessary.
Paragraph 15: First six sentences rejected as subordinate and unnecessary details. The remainder is accepted in substance.
Paragraphs 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 28: Rejected as subordinate and unnecessary details or as irrelevant.
Paragraphs 29, 30, 31, 32, 33, 34, and 35: Accepted in substance. Paragraph 36: Rejected as subordinate and unnecessary details.
Paragraph 37: First sentence accepted. The second sentence is rejected as constituting a conclusion of law, rather than a proposed finding of fact.
Paragraph 39: Rejected as constituting an inseparable amalgamation of facts and conclusions that are not all warranted by the evidence of record. A broader view of the evidence supports a conclusion that there is no real need.
Paragraph 40: Rejected as discussion of the parties' arguments and counter-arguments, rather than proposed findings of fact.
Paragraph 41: First two sentences accepted in substance. Last sentence rejected as constituting an oversimplification.
Paragraphs 42 and 43: Rejected as subordinate and unnecessary details or as irrelevant.
Paragraph 44: First sentence rejected as statement of position. Second sentence rejected as subordinate and unnecessary details; broader findings have been made regarding the utilization histories of existing providers.
Paragraph 45: Accepted.
Paragraphs 46 and 47: Rejected as subordinate and unnecessary details. Paragraphs 48 and 49: Accepted in substance.
Paragraph 50: First sentence accepted in substance. For reasons discussed in the related Final Order, the second sentence is rejected as not warranted by the evidence.
Paragraph 51: Accepted in substance.
Paragraphs 52, 53, 54, and 55: Rejected because the greater weight of the persuasive evidence is to the effect that Deering's projections in this regard were flawed.
Paragraph 56: Rejected as contrary to the greater weight of the persuasive evidence.
Paragraph 57: First two sentences accepted in substance. Last sentence rejected as completely correct; the referenced information should be considered, but be considered in light of other relevant facts.
Paragraph 58: Accepted, but for reasons discussed in the related Final Order, the methodology is flawed.
Paragraph 59: Rejected as subordinate and unnecessary details.
Paragraph 60: Rejected as subordinate and unnecessary details or as irrelevant because this data does not shed any useful light on the operation of Deering's cardiac catheterization program.
Paragraphs 61 and 62: Rejected as subordinate and unnecessary details.
Paragraph 63: Rejected as subordinate and unnecessary details most of which are of only marginal relevance to the issues in this case because they do not directly address the issue of future utilization of inpatient cardiac catheterization at Deering.
Paragraphs 64, 65, 66, and 67: Rejected as subordinate and unnecessary details or as irrelevant.
Paragraphs 68, 69, 70, 71, and 72: Accepted in substance.
Paragraphs 73 and 74: Rejected as subordinate and unnecessary details. Paragraphs 75, 76, and 77: Accepted in substance.
Paragraphs 78 and 79: Rejected as subordinate and unnecessary details. Paragraphs 80 and 81: Accepted in substance.
Paragraphs 82, 83, and 84: Rejected as subordinate and unnecessary details.
Paragraphs 85, 86, and 87: Accepted in substance.
Paragraphs 88, 89, 90, 91, and 92: Rejected as subordinate and unnecessary details.
Paragraphs 93 and 94: Accepted in substance.
Paragraphs 95, 96, and 97: Rejected as subordinate and unnecessary details.
Paragraphs 98, 99, and 100: Accepted in substance.
Paragraphs 101, 102, and 103: Rejected as subordinate and unnecessary details.
Paragraph 104: Accepted.
Paragraphs 105, 106, and 107: Rejected as subordinate and unnecessary details.
Paragraphs 108, 109, 110, 111, and 112: Accepted in substance.
Paragraphs 113, 114, 115, 116, 117, and 118: Rejected as subordinate and unnecessary details.
Paragraphs 119, 120, 121, 122: Accepted in substance.
Paragraphs 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135,
136, 137, 138, 139, 140, 141, 142, 143, and 144: Rejected as subordinate and unnecessary details.
Paragraph 145: Accepted in substance.
Paragraph 146: Rejected as subordinate and unnecessary details. Paragraphs 147 and 148: Accepted in substance.
Paragraph 149: First sentence rejected as argument; second sentence rejected as repetitious.
Paragraphs 150 and 151: Accepted in substance.
Paragraphs 152, 153, 154, 155, and 156: Rejected as subordinate and unnecessary details.
Paragraph 157: Rejected as constituting a conclusion of law, rather than a finding of fact.
COPIES FURNISHED:
W. David Watkins, Esquire Oertel, Hoffman, Fernandez & Cole, P.A.
2700 Blairstone Road, Suite C Post Office Box 6507 Tallahassee, Florida 32314-6507
Jay Adams, Esquire Jay Adams, P.A.
418 East Virginia Street Tallahassee, Florida 32301
Jean Laramore, Esquire 7007 McBride Pointe
Tallahassee, Florida 32312
Lesley Mendelson, Esquire Senior Attorney
Agency for Health Care Administration 2727 Mahan Drive
Tallahassee, Florida 32308
Robert D. Newell, Jr., Esquire Newell & Stahl, P.A.
817 North Gadsden Street Tallahassee, Florida 32303
Douglas M. Cook, Director
Agency for Health Care Administration 2727 Mahan Drive
Tallahassee, Florida 32308
Harold D. Lewis, Esquire General Counsel
The Atrium, Suite 301
325 John Knox Road Tallahassee, Florida 32303
Sam Power, Agency Clerk
Agency for Health Care Administration The Atrium, Suite 301
325 John Knox Road Tallahassee, Florida 32303
NOTICE OF RIGHT TO SUBMIT EXCEPTIONS
All parties have the right to submit written exceptions to this Recommended Order. All agencies allow each party at least 10 days in which to submit
written exceptions. Some agencies allow a larger period within which to submit written exceptions. You should contact the agency that will issue the final order in this case concerning agency rules on the deadline for filing exceptions to this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the final order in this case.
=================================================================
AGENCY FINAL ORDER
=================================================================
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
SOUTH MIAMI HOSPITAL, INC.,
Petitioner, CASE NO: 91-5723 CON NO: 6664
vs. RENDITION NO: AHCA-94-84-FOF-CON
STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION AND SOUTH DADE HEALTH CARE GROUP, LTD. d/b/a DEERING HOSPITAL,
Respondents,
and
DR. JOHN T. MACDONALD FOUNDATION d/b/a DOCTORS HOSPITAL OF CORAL GABLES AND BAPTIST HOSPITAL OF MIAMI, INC,
Intervenors.
/
FINAL ORDER
This cause came on before me for the purpose of issuing a final agency order. The Hearing Officer assigned by the Division of Administrative Hearings (DOAH) in the above-styled case submitted a Recommended Order to the Agency for Health Care Administration (AHCA). The Recommended Order entered April 1, 1994, by Hearing Officer Michael M. Parrish is incorporated by reference.
RULING ON EXCEPTIONS FILED BY AHCA AND DEERING
Counsel for the agency excepts to the conclusion in paragraph 90 that the need rule in effect at the time of the hearing should be used instead of the rule in effect at the time of the initial review. The exception is granted; the need rule under which the application was initially reviewed is applicable through this Section 120.57 proceeding. Section 59C-1.008(2), Florida Administrative Code; Central Florida Regional Hospital vs. Department of Health and Rehabilitative Services, 582 So2d 1193 (Fla. 5th DCA 1991), review denied 592 So2d 679 (Fla. 1991).
Counsel for the agency and Deering maintain that the Hearing Officer did not consider all applicable review criteria and made a single criteria, excess capacity of existing providers, outcome determinative. I disagree with counsel. The Recommended Order speaks for itself, but some highlights are:
Deering is very unlikely to achieve the utilization level it projects. See paragraphs 51 through 63, 73 through ?5, and 83.
The utilization level which Deering is likely to achieve is well below the minimum for maintaining quality of care standards. See paragraphs 78 and 81.
The utilization level which Deering is likely to achieve is well below the minimum for economic efficiency. See paragraphs 78 and 80.
Approval of the Deering proposal would not enhance competition because existing providers are well dispersed throughout the district, there is ample excess capacity, and there are no access problems. See paragraphs 79, 80, 73, and 84.
Existing programs could be harmed by approval of a program at Deering. See paragraph 65, 67, 69, 77, and 110.
Deering does not have an open heart surgery program which is perceived as a liability by managed care networks. See paragraphs 20, 82, and 83.
The only support for finding a need for the Deering proposal is the numerical projection under the rule formula.
The Hearing Officer's Recommended Order is a well reasoned and in-depth analysis of the facts and the review criteria. The exceptions are denied.
FINDINGS OF FACT
The agency hereby adopts and incorporates by reference the findings of fact set forth in the Recommended Order.
CONCLUSIONS OF LAW
The agency hereby adopts and incorporates by reference the conclusions of law set forth in the Recommended Order except paragraph 90 is adopted as modified by the ruling on the exceptions.
Based upon the foregoing, it is
ADJUDGED, that the application of South Dade Health Care Group, Limited, d/b/a Deering Hospital for Certificate of Need 6664 be DENIED.
DONE and ORDERED this 6th day of June, 1994, in Tallahassee, Florida.
Douglas M. Cook, Director Agency for Health Care
Administration
A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS
SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED.
Copies furnished to:
W. David Watkins, Esquire
OERTEL, HOFFMAN, FERNANDEZ & COLE, P. A.
Post Office Box 6507 Tallahassee, FL 32314-6507
Jay Adams, Esquire
418 East Virginia Street Tallahassee, FL 32301
Michael M. Parrish Hearing Officer The DeSoto Building
1230 Apalachee Parkway
Tallahassee, FL 32399-1550
Jean Laramore, Esquire 7007 McBride Pointe
Tallahassee, FL 32312
Lesley Mendelson, Esquire Senior Attorney, Agency for Health Care Administration
325 John Knox Road
Atrium Building, Suite 301 Tallahassee, FL 32303-4131
Robert D. Newell, Jr., Esquire NEWELL & STAHL, P. A.
817 North Gadsden Street Tallahassee, FL 32303-6313
Elizabeth Dudek (AHCA/CON) Alberta Granger (AHCA/CON) Elfie Stamm (AHCA/CON)
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to the above named addresses by U.S. Mail this 7th day of June, 1994.
R. S. Power, Agency Clerk State of Florida, Agency for
Health Care Administration
325 John Knox Road
The Atrium Building, Suite 301 Tallahassee, FL 32303
(904)922-3808
| Issue Date | Proceedings |
|---|---|
| Jun. 07, 1994 | Final Order filed. |
| Apr. 01, 1994 | Recommended Order sent out. CASE CLOSED. Hearing held June 11, 1993. |
| Apr. 01, 1994 | Case No/s 91-5723, 91-6390R, 92-3435RX, 93-3442RX, 92-3511RX: unconsolidated. |
| Feb. 25, 1994 | (AHCA) Request for Official Recognition of Supplemental Authority w/attached Final Order filed. |
| Sep. 28, 1992 | Letter to MMP from J. Laramore; Corrected Pages 27, 40, 44 & 49 of Proposed Recommended Order filed. |
| Sep. 24, 1992 | (one computer disk) Joint Proposed Order filed. (From L. Mendelson) |
| Sep. 24, 1992 | (Respondents) Joint Proposed Order (one computer disk) w/cover ltr filed. |
| Sep. 24, 1992 | Letter to MMP from Jean Laramore (re: one day Extension of Time to file PRO) filed. |
| Sep. 22, 1992 | South Miami Hospital Inc. d/b/a South Miami Hospital Proposed Final and Recommended Order w/cover ltr filed. |
| Sep. 21, 1992 | Joint Final Order Proposed By The Agency for Health Care Administration and South Dade Health Care Group, LTD, d/b/a Coral Reef Hospital w/Exhibits A&B filed. |
| Sep. 21, 1992 | Agency for Health Care Administration and South Dade Health Care Group, LTD., d/b/a Coral Reef Hospital`s Joint Proposed Recommended Order filed. |
| Sep. 21, 1992 | Proposed Findings of Fact and Conclusions of Law Submitted by Dr. John T. MacDonald Foundation D/B/A Doctor`s Hospital of Coral Gables and Baptist Hospital of Miami, Inc.; Dr. John T. MacDonald Foundation d/b/a Doctors` Hospital of Coral Gables and Baptis |
| Sep. 02, 1992 | Letter to MMP from D. Watkins (re: Extension of time to file Proposed Recommended Order) filed. |
| Aug. 19, 1992 | (ltr form) Request for Extension of Time filed. (From Jay Adams) |
| Jul. 30, 1992 | Memorandum sent out. (Counsel of Record: PRO & Proposed Final Orders due 8/26/92) |
| Jul. 27, 1992 | Transcript (17 Volumes) filed. |
| Jun. 25, 1992 | CASE STATUS: Hearing Held. |
| Jun. 15, 1992 | South Miami Hospital Inc. d/b/a South Miami Hospital Unilateral Prehearing Statement filed. |
| Jun. 15, 1992 | Unilateral Prehearing Stipulation w/Witness List filed. (From W. David Watkins) |
| Jun. 15, 1992 | Baptist's Prehearing Statement filed. |
| Jun. 12, 1992 | Cases Consolidated Per Hearing Officer Instructions. (Consolidated cases are: 91-5723, 92-3435RX, 92-3442RX & 92-3511RX). |
| Jun. 12, 1992 | South Dade`s Response to Prehearing Order filed. |
| Jun. 12, 1992 | (DHRS) Unilateral Prehearing Stipulation filed. (From Lesley Mendelson) |
| Jun. 11, 1992 | Order Extending Time sent out. (Prehearing Stipulation due 6/15/92) |
| Jun. 11, 1992 | Motion to Stay Entry of Final and or Recommended Order in the above Proceeding filed. |
| Jun. 11, 1992 | Petition for Determination of Invalidity of Rule 10-5.032 and Motion to Consolidate filed. |
| Jun. 11, 1992 | South Miami Hospital Response to "DHRS" Motion to Dismiss; Motion to Establish Order of Consolidated Cases w/Exhibit-A & Attachment-B; Motion to Stay Entry of Final and or Recommended Order in the Above Proceeding w/Exhibit filed. |
| Jun. 11, 1992 | (Respondent) Notice of Appearance As Co-Counsel filed. |
| Jun. 11, 1992 | Deering`s Supplemental Response to Baptist`s Request for Production of Documents filed. |
| Jun. 11, 1992 | Corrected Page-4 w/cover ltr filed. (From Gina J. Gilcher) |
| Jun. 10, 1992 | Deering`s Response to Baptist`s Request for Production of Documents filed. |
| Jun. 10, 1992 | (Petitioner) Response to Motion to Dismiss filed. |
| Jun. 09, 1992 | (Respondent) Notice of Hearing filed. |
| Jun. 09, 1992 | (Dr. J. T. Macdonald Foundation) Notice of Hearing (Motion hearing set for 6/12/92) filed. |
| Jun. 04, 1992 | Notice of Taking Deposition Duces Tecum; Notice of Taking Deposition filed. (From Jay Adams) |
| Jun. 01, 1992 | Unanimous Motion for Extension of Time to File Prehearing Stipulation filed. |
| May 29, 1992 | 90-5124(Respondent) Motion to Dismiss w/Exhibit-A filed. |
| May 27, 1992 | (Dr. John T. MacDonald Foundation) Notice of Taking Deposition; Notice of Taking Deposition Duces Tecum filed. |
| May 26, 1992 | (Respondent) Notice of Taking Deposition Duces Tecum filed. |
| May 19, 1992 | Notice of Taking Deposition Duces Tecum filed. (From W. David Watkins) |
| May 07, 1992 | (Baptist Hospital of Miami, Inc.) Request for Production of Documents filed. |
| Apr. 27, 1992 | (Petitioner/Intervenor) Notice of Cancellation of Deposition filed. |
| Apr. 24, 1992 | Order Denying Motion In Limine sent out. (Motion denied) |
| Apr. 24, 1992 | Order Denying Motion for Protective Order sent out. (Motion for Protective Order denied) |
| Apr. 23, 1992 | (DHRS) Reply to Joint Response w/Exhibit-A filed. |
| Apr. 20, 1992 | (Baptist Hospital of Miami) Notice of Filing; Petition for Declaratory Statement filed. |
| Apr. 20, 1992 | (Baptist Hospital of Miami) Notice of Service of Answers to Interrogatories filed. |
| Apr. 16, 1992 | (Dr John T. Macdonald Foundation) Amended Notice of Taking Depositions Duces Tecum filed. |
| Apr. 16, 1992 | (Motion for Protective Order w/Exhibits A-C filed. (From Gerald M. Cohen) |
| Apr. 10, 1992 | Joint Response to Motion in Limine Filed by the Department of Health and Rehabilitative Services filed. |
| Apr. 10, 1992 | Request for Entry Upon Land; Notice of Taking Depositions Duces Tecum filed. (From W. David Watkins) |
| Apr. 01, 1992 | (J. Macdonald Foundation) Notice of Cancelling Depositions filed. |
| Mar. 31, 1992 | Motion for Extension of Time to File Response to Motion in Limine filed. |
| Mar. 31, 1992 | Notice of Assignment and Order Extending Time sent out.(Motion granted and time for responding to that Motion is extended to 5:00pm on 4-10-92) |
| Mar. 31, 1992 | Order Granting Continuance and Rescheduling Hearing sent out. (hearing rescheduled for 6-15-92; 10:00am, and 9:00am each day after; Tallahassee) |
| Mar. 27, 1992 | (Intervenor/Petitioner) Motion for Extension of Time to Respond to Motion in Limine filed. |
| Mar. 27, 1992 | (Respondent) Motion for Continuance of Final Hearing filed. |
| Mar. 26, 1992 | (Petitioner) Notice of Taking Deposition Duces Tecum filed. |
| Mar. 20, 1992 | (Respondent/Intervenor) Notice of Service of Answers to Interrogatories filed. |
| Mar. 19, 1992 | HRS's Request for Judicial Recognition filed. |
| Mar. 19, 1992 | (DHRS) Motion in Limine filed. (From Lesley Mendelson) |
| Feb. 26, 1992 | Order Granting Motion in Opposition to Request for Entry Upon Land sent out. |
| Feb. 14, 1992 | (Baptist Hospital of Miami, Inc.) Request for Production of Documents; Notice of Service of Interrogatories filed. (From Jay Adams) |
| Feb. 12, 1992 | Notice of Service of Interrogatories filed. (From Gerald M. Cohen) |
| Jan. 24, 1992 | (Respondent) Motion in Opposition to Request for Entry Upon Land filed. |
| Jan. 24, 1992 | (Petitioner) Notice of Service of Answers to First Interrogatories to South Miami Hospital, Numbers 15, 16 filed. |
| Jan. 22, 1992 | (Baptist Hospital of Miami Inc) Notice of Service of Request for Production of Documents filed. |
| Jan. 21, 1992 | Response to First Request for Production of Documents to South Miami Hospital, Inc. filed. |
| Jan. 16, 1992 | (Petitioner) Response to First Request for Production of Documents to Doctor John T. MacDonald Foundation d/b/a Doctors` Hospital of Coral Gables filed. |
| Jan. 16, 1992 | (Intervenor) Request for Entry Upon Land filed. |
| Dec. 10, 1991 | Order Granting Intervention (for Baptist Hospital of Miami, Inc) sent out. |
| Dec. 02, 1991 | Notice of Service of Answers to First Interrogatories to John T. MacDonald Foundation d/b/a Doctors` Hospital of Coral Gables filed. |
| Nov. 27, 1991 | Notice of Service of Answers to First Interrogatories to South Miami Hospital, Inc., d/b/a South Miami Hospital filed. |
| Nov. 26, 1991 | Order Granting Intervention sent out. (for South Dade Health Care Group, Ltd. d/b/a Deering Hospital f/k/a Coral Reef Hospital, in case no. 91-6390R). |
| Nov. 25, 1991 | (Baptist Hospital of Miami, Inc.) Petition to Intervene filed. |
| Nov. 08, 1991 | CC Letter to W. David Watkins from Gerald M. Cohen (re: ltr dated October 31, 1991 regarding Extension) filed. |
| Nov. 04, 1991 | Order Granting Intervention sent out. (for South Miami Hospital, Inc. d/b/a South Miami Hospital, in case no. 91-6390R). |
| Nov. 04, 1991 | (South Dade Health Care Group, Inc. d/b/a) Petition to Intervene filed. |
| Nov. 04, 1991 | CC Letter to Gerald M. Cohen from W. David Watkins (re: telephone conversation October 31, 1991) filed. |
| Oct. 31, 1991 | Dr. John T. MacDonald Foundation d/b/a Doctors' Hospital of Carol Gables First Request for Production of Documents to South Dade Health Care Group, LTD. d/b/a Deering Hospital f/k/a Carol Reef Hospital; Noticeof Service of First S et of Interrogatories re |
| Oct. 23, 1991 | Order Granting Consolidation sent out. 91-5723 & 91-6390 consolidated. |
| Oct. 15, 1991 | Notice of Service of Interrogatories filed. (From Gerald Cohen) |
| Oct. 11, 1991 | (Dr. John T. MacDonald Foundation d/b/a) Motion to Consolidate (with DOAH Case No. 91-6390R) filed. |
| Oct. 01, 1991 | Notice of Hearing sent out. (hearing set for April 21 - May 1, 1992;10:00am; Tallahassee) |
| Sep. 30, 1991 | Respondent, South Dade Health Care Group, Ltd`s Supplemental Response to Pre-Hearing Order; Petitioner`s Proposed Findings of Facts and Conclusion of Law; Intervenor, Tom Quinn Company, Inc.`s Proposed Findings of Facts and Conclusion of Law; Respondents |
| Sep. 26, 1991 | South Miami Hospital Response to Prehearing Order filed. |
| Sep. 20, 1991 | Order Granting Intervention (for Dr. John T. MacDonald Foundation d/b/a Doctors Hospital of Coral Gables) sent out. |
| Sep. 11, 1991 | Prehearing Order sent out. |
| Sep. 11, 1991 | Notice of Appearance filed. (From Gerald M. Cohen) |
| Sep. 09, 1991 | Notification card sent out. |
| Sep. 06, 1991 | (Dr. John T. MacDonald Foundation) Petition to Intervene filed. (From W. David Watkins) |
| Sep. 05, 1991 | Notice; Petition for Administrative Hearing filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Jun. 06, 1994 | Agency Final Order | |
| Apr. 01, 1994 | Recommended Order | Application for Certificate Of Need for inpatient card cath in Dade County denied for lack of need and for failure to comply with Rule 10-5.032(8)(b), FAC. |
