STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
COLUMBIA HOSPITAL CORPORATION ) OF SOUTH BROWARD d/b/a WESTSIDE ) REGIONAL MEDICAL CENTER, )
)
Petitioner, )
)
vs. ) CASE NO. 94-4801
)
AGENCY FOR HEALTH CARE ) ADMINISTRATION and CLEVELAND ) CLINIC FLORIDA HOSPITAL )
)
Respondents, )
and )
)
HOLY CROSS HOSPITAL, INC., )
)
Intervenor. )
) HOLY CROSS HOSPITAL, INC., )
)
Petitioner, )
)
vs. ) CASE NO. 94-4802
)
AGENCY FOR HEALTH CARE ) ADMINISTRATION and CLEVELAND ) CLINIC FLORIDA HOSPITAL )
)
Respondents. )
) FMC HOSPITAL, LTD. d/b/a )
FLORIDA MEDICAL CENTER, )
)
Petitioner, )
)
vs. ) CASE NO. 94-4803
)
AGENCY FOR HEALTH CARE ) ADMINISTRATION, and CLEVELAND ) CLINIC FLORIDA HOSPITAL, )
)
Respondents. )
) NORTH BROWARD HOSPITAL d/b/a ) NORTH BROWARD MEDICAL CENTER, )
)
Petitioner, )
)
vs. ) CASE NO. 94-4804
)
AGENCY FOR HEALTH CARE )
ADMINISTRATION and CLEVELAND ) CLINIC FLORIDA HOSPITAL )
)
Respondents, )
)
HOLY CROSS HOSPITAL, INC., )
)
Intervenor. )
) SOUTH BROWARD HOSPITAL DISTRICT ) d/b/a MEMORIAL HOSPITAL, )
)
Petitioner, )
)
vs. ) CASE NO. 94-4806
)
AGENCY FOR HEALTH CARE ) ADMINISTRATION and CLEVELAND ) CLINIC FLORIDA HOSPITAL )
)
Respondents. )
) CLEVELAND CLINIC FLORIDA ) HOSPITAL d/b/a CLEVELAND CLINIC )
HOSPITAL, a not for profit )
corporation, )
)
Petitioner, )
vs. ) CASE NO. 94-5076
)
AGENCY FOR HEALTH CARE )
ADMINISTRATION; COLUMBIA ) CORPORATION OF SOUTH BROWARD, ) d/b/a WESTSIDE REGIONAL MEDICAL ) CENTER; and the NORTH BROWARD ) HOSPITAL DISTRICT, d/b/a NORTH ) BROWARD MEDICAL CENTER, )
)
Respondents. )
)
RECOMMENDED ORDER
This case was heard by Eleanor M. Hunter, Hearing Officer 1/ , for the Division of Administrative Hearings, on February 12-15, 20-23, 26-March 1, March 4-8, 1996, in Tallahassee, Florida.
APPEARANCES
For Petitioner, Stephen A. Ecenia, Attorney Columbia R. David Prescott, Attorney
Hospital Thomas Kourad, Attorney Corporation of Rutledge, Ecenia, Underwood and South Broward Purnell, P.A.
d/b/a Westside Barnett Bank Building, Suite 420 Regional Medical Post Office Box 551
Center: Tallahassee, Florida 32302-0551
For Petitioner, Robert A. Weiss, Attorney Cleveland Clinic Armando L. Bassarrate, Attorney Florida Hospital Karen A, Putnal, Attorney
d/b/a Cleveland Parker, Hudson, Rainer and Dobbs Clinic Hospital: The Perkins House, Suite 200
118 North Gadsden Street Tallahassee, Florida 32301
For Petitioner, Seann M. Frazier, Attorney North Broward Panza, Maurer, Maynard and Neel
Hospital 3600 North Federal Highway, Third Floor District d/b/a Fort Lauderdale, Florida 33308
North Broward Medical Center:
For Petitioner, William B. Wiley, Attorney Holy Cross Charles A. Stampelos, Attorney
Hospital, Inc.: McFarlain, Wiley, Cassedy and Jones, P.A.
600 First Florida Bank Street Tallahassee, Florida 32301
For Petitioner, R. Terry Rigsby, Attorney South Broward Blank, Rigsby and Meenan Hospital 204 South Monroe Street District d/b/a Tallahassee, Florida 32301 Memorial
Hospital, and FMC Hospital, Ltd., d/b/a Florida Medical Hospital:
For Respondent, Lesley Mendelson, Senior Attorney Agency For Agency For Health Care Administration Health Care 2727 Mahan Drive
Administration: Fort Knox Building 3, Suite 3431
Tallahassee, Florida 32308-5403
STATEMENT OF THE ISSUE
Whether the application of Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center or that of Cleveland Clinic Florida Hospital d/b/a Cleveland Clinic Hospital should be approved to meet the fixed numeric need for one additional adult open heart surgery program in Broward County, Florida.
PRELIMINARY STATEMENT
Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center ("Westside") and Cleveland Clinic Florida Hospital ("CCFH") are competing applicants for a certificate of need ("CON") to establish an additional adult open heart surgery program in Broward County, Florida. The Agency For Health Care Administration ("AHCA") is the state agency which administers the CON program in Florida. After reviewing the applications, AHCA preliminarily approved that of the CCFH and preliminarily denied that of Westside. The North Broward Hospital District ("NBHD"), Holy Cross Hospital, Inc. ("Holy Cross"), the South Broward Hospital District d/b/a Memorial Regional Hospital ("Memorial Regional"), and FMC Hospital, Ltd., d/b/a Florida Medical Center ("FMC") operate four of the five existing OHS programs in Broward County.
At the final hearing, CCFH presented the testimony of Carl Gill, M.D., expert in cardiovascular surgery; Delos M. Cosgrove, M.D., expert in cardiovascular surgery; William Michener, M.D., expert in graduate medical education; Gayle Whitman, R.N., expert in post surgical open heart nursing and post surgical open heart nursing administration; Donna Zabell, R.N., expert in open heart surgical nursing and administration of surgical components of a cardiothoracic surgery program; Margaret McRae, R.N., expert in nursing and nursing administration; David Owen, expert in health care architecture; Thomas Davidson, expert in health care finance; and Ronald T. Luke, Ph.D., J.D., expert in health planning. CCFH's exhibits 1-10, 12-15, 19-22, 24-31, 33, 35-36, an
were received in evidence.
Westside presented the testimony of David Bussone, expert in hospital administration; Malcolm Dorman, M.D., expert in cardiovascular surgery; Charlene Welker, R.N., expert in critical care nursing and open heart surgery program administration; Murry Drescher, M.D., expert in cardiology; Robert Kersh, M.D., expert in cardiology; Judith Horowitz, expert in health care planning and health care finance; Deborah S. Kolb, Ph.D., expert in health care planning; David Alexander, expert in hospital architecture; Curt Hatch, expert in health care network development; and James A. Criuckshank, expert in health care finance and hospital administration. Westside's exhibits 1-27 were received in evidence.
FMC presented the testimony of Christopher R. Lloyd, expert in hospital administration; Elizabeth Ann Dunlevy, R.N., expert in critical care nursing and nursing administration; and Patricia Greenberg, expert in health care planning and health care finance. FMC's exhibits 1-27, and 29-31 were received in evidence.
Memorial Regional presented the testimony of Martha O'Neill, R.N., expert in critical care nursing and open heart surgery program administration; and Elton Scott, Ph.D., expert in health care economics, health care finance, and health care planning; and Miles A. Price, expert in architecture. Memorial's exhibits 1-4 were received in evidence.
NBHD presented the testimony of Ruth Eldridge, R.N., expert in cardiac nursing and hospital administration, and Timothy Menton, expert in health care finance. NBHD's exhibits 1, 2, 4- 13 were received in evidence.
Holy Cross presented the testimony of Richard A. Baehr, expert in health care planning and finance. Holy Cross' exhibits 1-9 were received in evidence.
AHCA presented the testimony of Elizabeth Dudek, expert in health planning.
AHCA's exhibits 1 - 4 were received in evidence.
The final volumes of the transcript of the hearing were filed on May 15, 1996. On July 1, 1996, citing the length of the transcript (nearly 5,000 pages), counsel for Westside filed a Motion To Extend The Time To File Proposed Recommended Order (by one week) and To Exceed Page Limit (from 40 to 50 pages). The Motion was opposed in a response, filed on July 2, 1996, by counsel for CCFH. On July 3, 1996, an Order was entered granting the motion to extend both the time for filing and the number of pages (from 40 to 50) of proposed recommended orders. Proposed recommended orders were filed on July 22, 1996.
Westside, in addition to the proposed recommended order of 48 pages, also filed a Legal Brief In Support Of Its Proposed Recommended Order of 15 pages. On July 24, 1996, CCFH moved to strike the brief as an unauthorized submission exceeding 50 pages (when combined with the proposed recommended order)
On August 7, 1996, CCFH moved to strike the SBHD's legal brief or, alternatively, the last three pages as exceeding the 50 page limit, when combined with SBHD's proposed recommended order, and a similar motion to strike FMC's 15-page brief. On August 16, 1996, SBHD and FMC filed a Joint Response To Motions To Strike and Joint Motion For Attorney Fees, to which CCFH responded on August 28, 1996.
Based on the provisions of Rule 60Q-2.031, Florida Administrative Code, all motions to strike and the motion for attorney fees are denied.
FINDINGS OF FACT
The Agency For Health Care Administration ("AHCA") is the state agency which administers the health care certificate of need ("CON") program in Florida. AHCA published a need for one additional adult open heart surgery program, for the July 1996 planning horizon, in District 10, Broward County, in the Florida Administrative Weekly, Volume 20, Number 5 (February 4, 1994).
Existing Providers
Broward County is the only county in District 10. Immediately to the north, District 9 encompasses Indian River, Okeechobee, St. Lucie, Martin, and Palm Beach Counties. South of Broward County, District 11 includes Dade and Monroe Counties. West of Broward County is District 8 which includes, among others, Collier County. Subsection 408.032(5), Florida Statutes.
There are five existing OHS providers in Broward County, three in Palm Beach County, and eight in Dade County. In adjoining District 9, a new OHS program has been approved for Martin or St. Lucie County. In District 8, a new program has been approved for Collier County. Of 3,268 OHS in District 10 in the year ending September 30, 1995, approximately 915 OHS or 28 percent were
performed at North Ridge, 750 or 22.7 percent at FMC, 18.8 percent or 622 at Memorial Hospital, 16 percent or 551 at Broward General, and 14.6 percent or 483 at Holy Cross.
The largest OHS volume projections, assuming the highest and a constant use rate, are 3,434 in 1997, 3,485 in 1998, 3,536 in 1999, and 3,589 in 2000, or an increase of 286 OHS cases from the year ending June 30, 1995 to the year 2000. By AHCA rule, OHS backup services are required when angioplasties are performed. In Broward County, the ratio of angioplasties to OHS is approximately one-to-one. Given that ratio, up to 300 additional angioplasties will be performed in 2000. In addition, the ratio of OHS to cardiac catheterizations ("caths") is a few percentage points higher than four-to-one in South Florida, or a projected increase of 1200 to 1500 cardiac caths.
On average, each OHS operating room has the physical capacity to accommodate an average of two OHS a day, or ten for 50 weeks of the year, or approximately 500 a year. In each cardiac cath laboratory, the capacity is 1500 procedures a year based on recommended national guidelines.
North Ridge Medical Center (North Ridge)
North Ridge is a 395-bed, Tenet-owned for-profit hospital, with the largest OHS volume and the lowest average lengths of stay for OHS in Broward County. North Ridge is the closest provider to Palm Beach County, which is in AHCA District 9 and is immediately north of Broward County. North Ridge attracts significant numbers of OHS patients from District 9, particularly from the areas of Boca Raton and Delray. In 1994, District 9 residents comprised over 50 percent of the OHS patients at North Ridge.
Holy Cross Hospital (Holy Cross)
Holy Cross Hospital is a 587-bed not-for-profit hospital with 9 Level II NICU (neonatal intensive care unit) beds, and 43 comprehensive medical rehabilitation (CMR) beds. Holy Cross is also located in northern Broward County.
Holy Cross operates 2 cardiac cath labs. At Holy Cross, two operating rooms, and a third room for angioplasty backup and other emergencies (of a total
18 operating room suites), 10 of 32 YUCCA rooms, and 24 of 100 telemetry (monitored beds) are used to provide OHS services. In 1994, 412 OHS procedures were performed at Holy Cross, 36 percent on residents of District 9 (particularly from Martin and St. Lucie Counties). The volume from District 9 is reasonably expected to decrease with the initiation of a new OHS program in either Martin or St. Lucie County.
Florida Medical Center
FMC is a 450-bed hospital, located on 50 acres (30 of which are developed), surrounded by a retirement community in central, western Broward County. FMC is accredited by the JCAHO. FMC offers psychiatric and CMR services. FMC does not have obstetrics or pediatric services.
FMC is owned by Ornda Health Corporation, a for-profit corporation, which also owns Golden Glades Hospital and Parkway Regional Medical Center in Dade County, both approximately three miles from the Broward County border, and Coral Gables Hospital in southern Dade County.
FMC has 40 ICU beds (10 in a separate cardiovascular intensive care unit, or CVICU), an additional 70 telemetry beds, 3 cardiac cath labs, and 9 operating rooms (2 dedicated to OHS and a third used as a standby room for angioplasties) Approximately, 2200 cardiac caths, 800 angioplasties, and 700 OHS were performed at FMC in 1995. FMC's 3 cardiac cath labs operate weekdays from approximately 8:00 A.M. to 4:00 P.M. One lab usually operates later during the winter months ("the season") to accommodate scheduled procedures which have been delayed or "bumped" due to emergencies. The 10 CVICU beds at FMC were fully occupied on 20 days during the month of December 1995.
In contrast to the in-migration experience by North Ridge and Holy Cross, 98 percent of FMC's cases come from Broward County, and 80 percent from its immediate service area.
North Broward Hospital District (Broward General)
The North Broward Hospital District ("NBHD") is a tax-supported not- for-profit special district created by the Florida Legislature, governed by a Board of Directors appointed by the Governor. NBHD has residency programs established with the University of Florida and Nova Southeastern College of Osteopathic Medicine. NBHD operates four acute care hospitals and covers an area which includes approximately two-thirds of the residents of Broward County. One NBHD hospital, North Broward Medical Center, was initially an applicant in this batch, subsequently voluntarily dismissing its petition for review of the preliminary denial of its application. Broward General, another NBHD hospital, is an existing OHS provider, and is located in central, eastern Broward County.
With 744 licensed beds, Broward General is the largest hospital in the County, and a major tertiary care center, with all the tertiary services except pediatric cardiac surgery and organ transplantation. The 744 beds are divided into 593 for acute care, 36 in a Level II NICU, 27 in a Level III NICU, 68 for adult psychiatry, and 20 for skilled nursing. The NBHD also operates public health clinics in the district, from which referrals for inpatient care are made to Broward General or the other NBHD acute care hospitals. Broward General is a Level II adult and pediatric trauma center and a regional perinatal intensive care provider. With Congressional grant funding, Broward General also serves "Ryan White patients" (HIV positive).
Broward General has 2 dedicated operating rooms for OHS, with a third backup room for angioplasties, 10 CVICU beds, (operating at 80 to 90 percent occupancy), and 50 PCU beds. Broward General has the capacity to accommodate 700 OHS in its current physical spaces. At Broward General, 551 OHS cases, 688 angioplasties, and 1500 caths were performed in 1995. Although the OHS program has been in existence since the 1970's, Broward General failed to reach 350 OHS cases until 1992. In 1994, District 9 residents constituted 23 percent of the OHS patients at Broward General.
South Broward Hospital District (Memorial Regional)
The South Broward Hospital District is a tax supported district which covers approximately one-third of the residents of Broward County and operates 3 hospitals, including Memorial Regional.
Memorial Regional is a 646-bed tertiary center, with adult open heart surgery, and a Level II trauma center. Memorial is located in southern Broward County between Interstate 95 and the Florida Turnpike. It is a disproportionate share provider of Medicaid reimbursed services.
Memorial Regional has 2 dedicated OHS operating rooms on the second floor of the hospital. An 8-bed heart surgery unit on the sixth floor of the hospital is used as a CVICU. Memorial has three adult intensive care units, a 22-bed step down unit for OHS patients, and a 48-bed telemetry unit. At Memorial Regional, approximately 575 OHS were performed in 1995. Approximately
87 percent of Memorial Regional's OHS patients are Broward County residents.
The Applicants
In response to the published need, AHCA received applications from the Cleveland Clinic Florida Hospital (CCFH) and Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center ("Westside"), Columbia Hospital Corporation of South Broward d/b/a Plantation General Hospital, L.P., and the North Broward Hospital District d/b/a North Broward Medical Center.
Only CCFH and Westside remain applicants in this proceeding, following voluntary withdrawals by the other two hospitals.
Cleveland Clinic Florida Hospital (CCFH)
CCFH is a 153-bed licensed hospital at which Cleveland Clinic - Fort Lauderdale, Florida (CC-Florida) physicians admit and treat inpatients. In December 1994, CCFH `initiated outpatient cardiac cath, followed in May or June 1995 with inpatient cardiac cath. Other non-invasive cardiology services, available at CCFH, include steptokinase and other thrombolytic (clot dissolving) drug therapies, stress testing, and echocardiology. CCFH operates approximately
133 of the 153 licensed beds, including 24 in a telemetry unit, 12 in an intermediate unit (with hard wire heart monitoring) and 8 in an ICU. In 1995, the average occupancy of CCFH was just under 50 percent. CCFH is not a disproportionate share provider.
The sole corporate member of CC-Florida and CCFH is the Cleveland Clinic Foundation in Ohio (CC-Ohio). CCFH pays management fees to CC-Ohio and to CC-Florida. In 1995, the management fees were $2.5 million to CC-Ohio foundation and $2.1 million to CC-Florida.
CC-Ohio is a not-for-profit multi-specialty, integrated health care organization, which employs the personnel, including physicians, who operate an inpatient hospital and outpatient clinic in Cleveland, Ohio. CC-Ohio was established in 1921 by three doctors seeking to continue practicing in a cooperative and collegiate fashion, as they had done in a World War I mobile army surgical hospital.
Approximately 600 salaried physicians and 600 residents are currently on the staff of the CC-Ohio, and the staff receives national and international referrals of patients. CC-Ohio provides outpatient and inpatient services on a unified medical campus. It is a major cardiac care and educational facility, with both open heart surgery ("OHS") and heart transplantation programs. CC- Ohio is affiliated with the Cleveland Clinic Education Foundation, and is accredited by the American Council of Graduate Medical Education. Cardiovascular services are provided in approximately 300 of a total of 1200 beds at CC-Ohio. In 1995, 3645 open heart surgeries ("OHS") were performed at the CC-Ohio, 2,000 more cases than the second largest cardiovascular center in the United States. In 1995, the closed staff of 8 cardiovascular surgeons each
performed from 400-450 procedures, in 11 dedicated surgical suites. At CC-Ohio,
55 of a total of 125 ICU beds and 72 of a total of 224 telemetry beds are dedicated to the care of cardiac surgery patients.
CC-Ohio doctors pioneered in performing cardiac caths in the 1950's, coronary bypass graft surgery in the 1960's, reducing the need for blood transfusions during OHS, and in the use of the mammary artery rather than the saphous vein for grafts. Recent innovations include valve repairs rather than replacements, a specialty of Dr. Delos M. Cosgrove, one of the cardiovascular surgeons on staff. Other advances at CC-Ohio include the use of smaller incisions resulting in less invasive OHS and transplants of muscles from the back to the heart. In partnership with an equipment manufacturer, CC-Ohio standardized modules containing the equipment needed for each different kind of OHS.
CC-Florida is also a not-for-profit foundation, which employs salaried staff physicians to practice in a multi- specialty clinic which was established in 1987, by Dr. Carl Gill and 23 physicians from CC-Ohio. Now 100 board- certified physicians are on the CC-Florida staff. The clinic is located at 3000 West Cypress Creek Road. Two additional 50,000 square foot clinics are planned, one each for Southern Palm Beach and Collier Counties.
CCFH, the acute care hospital, is approximately 10 miles from the CC- Florida clinic, on U.S. Highway AlA in a high rise condominium residential area, located on a 3 acre site on a strip of land between the intracoastal waterway and the Atlantic Ocean. The highway is heavily travelled and congested, making it extremely inconvenient for the vast majority of CCFH's south Florida patients. As a result of the location, patients were evacuated during Hurricanes Andrew and Erin, and transferred to Florida Medical Center without difficulty, at a cost of approximately $72,000 for the rental of ambulances (not including lost revenue) . A total of 42 patients were relocated, 3 to the ICU,
9 to telemetry (heart monitoring) beds, and 30 to medical/surgical beds by ground transportation. CCFH has no helicopter landing pad.
The building owned by CCFH was built in 1972, operated as North Beach Hospital, and purchased by CCFH in 1990. The medical staff includes community physicians who are not employees of CC-Florida, but are "grandfathered" for having previously practiced at North Beach Hospital. As the "grandfathered" physicians admissions to CCFH have declined, CC-Florida physicians admissions of patients to CCFH have increased. CCFH filed a CON application to build an $80 million replacement facility, so that it could locate its clinic adjacent to the new hospital. The co-location of the facilities would allow CC-Florida to operate on a unified medical campus, consistent with the CC-Ohio model. In addition, CCFH would have the additional space needed to expand graduate medical education programs. The replacement facility was not listed as a planned CCFH expense because the facility would be constructed and owned by Tenet, the parent company of North Ridge, and operated by CCFH. The existing facility has no space for expansion.
CCFH is the applicant for CON 7687 to operate an adult OHS program, following the protocols and with training by the staff from CC-Ohio. The OHS program and related services will be provided on the second floor of the existing hospital, which is the current location of a recently renovated surgical suite. If approved for an OHS program, CCFH staff will train for approximately two weeks at the CC-Ohio. To allow staff to have hands-on experience in patient care, CC-Ohio expects the staff to receive Ohio licenses. Follow-up training by CC-Ohio staff at CCFH will also be provided.
CCFH will renovate second floor space for a 22-bed semiprivate telemetry unit and a 6-bed cardiovascular intensive care unit ("CVICU"). The CVICU beds will be arranged in a "L" shaped configuration, separated by walls into rooms of approximately 13 by 15 feet each, with glass walls and doors at the end facing the nurses' station to allow visual monitoring of the patients.
Prior to the start of inpatient caths at CCFH, in June 1995, inpatient cath patients were transferred to Holy Cross or, more frequently, Broward General. At CCFH, caths are performed in a single cath lab, which is also located on the second floor.
Dr. Carl Gill and Dr. David E. Lammermeir are the CC-Florida cardiovascular surgeons who currently provide OHS services at Broward General and would perform OHS at CCFH, if approved. Despite serving an older, more acutely ill population, the CC-Florida surgeons have achieved excellent results. If the CCFH CON is approved, they expect to move 90 percent of their OHS cases to the CCFH. The two Board-Certified CC-Florida cardiovascular surgeons began practicing OHS in Florida in 1989 with approximately 30 OHS, followed with about
80 in 1990, and 120 in 1991. They performed a total of 147 OHS in 1992, 215 in 1993, 200 in 1994, and 205 in 1995. Most of their referrals come from four cardiologists on the staff of the CC-Florida.
CCFH commits to hold charges at the pro forma levels during the period projected in the pro formas, and to provide free OHS to 13 (year 1) and 14 (year
2) uninsured patients, not qualified for public assistance, until the year 2000. CCFH is not a disproportionate share provider.
Cleveland Clinic Florida Hospital Plan "CCFHP" is a preferred provider organization with a total number of 3500 covered lives. Dr. Gill performed OHS on 20-25 members of the health plan in 1995. The budgeted CCFHP number for OHS is 100 in 1996. Currently, CCFHP may be experiencing "adverse selection", by attracting a disproportionate number of enrollees at risk for needing OHS. The rate of OHS for CCFHP enrollees is twice that expected in the general population, while the volume is below that projected.
CCFH is located approximately 1 1/2 to 2 miles from Holy Cross, 3 to 4 miles from North Ridge, 6 to 7 miles from Broward General, 8 miles form FMC, and 11-12 miles from Memorial Regional.
Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center ("Westside")
Westside is a 204-bed medical/surgical community hospital located in Plantation, in western Broward County. Westside's services include obstetrics, pediatrics, oncology, orthopedics, outpatient surgery, and home health agencies. Westside is JCAHO accredited.
Westside is owned by Columbia Hospital Corporation of South Broward, a subsidiary of Columbia/HCA Hospital Corporation ("Columbia"), a for-profit organization of 350 hospitals, 60 of those in Florida. Columbia owns six and operates five hospitals in Broward County. One Columbia-owned hospital, Pembroke Pines, is leased to the South Broward County Hospital District. The other four Columbia Hospitals in Broward County are Northwest Regional Hospital, University Medical Center, Pompano Beach Medical Center, and Plantation General Hospital. Columbia has filed an application to move Pompano Beach Hospital to western Broward County, near the site at which CCFH applied to build a replacement facility. Columbia has initiated the organization of the Broward
Physician Alliance, a closed physician network hoping to attract 400 primary care doctors and specialists to establish an integrated health care delivery organization with the Columbia hospitals.
Westside is the applicant for CON 7686 to establish an adult OHS program. Two ground floor operating rooms, located across the corridor from the cardiac cath lab, will be designated as the main and backup OHS suites. Two private and one semi- private room on the third floor will be converted to a 4- bed CVICU, with two beds on each end of the room, separated by privacy curtains. Each CVICU patient area is approximately 8 1/2 by 9 feet. One semiprivate and one private room on the third floor will also be converted to a 3-bed Progressive Care Unit ("PCU"). A storage room on the ground floor will be converted to a cardiac rehabilitation unit. Westside also has a 14-bed ICU on the second floor.
Westside proposed three conditions for the issuance of CON 7686: (1) ensuring that at least two percent of its open-heart cases are Medicaid during the first two years of operations, (2) ensuring that a percentage of its open heart cases are for charity care patients (i.e., those meeting federal poverty guidelines) during the first three years of operation, and that an amount equal to $160,000 in the first year, $280,000 in the second year, and $353,000 in the third year is placed in a restricted fund at the beginning of each year for this purpose, and (3) not exceeding the net revenue per case projected in the first two years for managed care payors. In the first year of operation, the commitment equates to the provision of OHS services to 3 charity and 5 Medicaid patients, and in the second year, 5 charity and 7 Medicaid patients.
Approximately 20 cardiologists, and 8 cardiovascular surgeons are on the staff at Westside, although Westside has not identified which surgeons will participate in its OHS program. Westside's existing cardiac services include electrophysiology, nuclear cardiology, electrocardiology, echocardiography, and stress testing. Inpatient and outpatient cardiac cath services were initiated at Westside in 1990. At Westside, 530 cardiac caths were performed in 1994, and
455 in 1995. In the CON application, Westside projected that it would perform 694 cardiac caths in 1995. The 1994 to 1995 decline is attributed to the opening, in the fall of 1994, of an inpatient cardiac cath lab at another Columbia facility, University Hospital, and to the preferences of managed care companies and physicians for having cardiac caths performed at hospitals with OHS backup services. Westside's cardiac cath lab is physically located on the ground floor of the hospital directly across the corridor from the surgery suites. Westside's objectives of initiating diagnostic electrocardiogram ("EKG") within 5 minutes of a chest pain patient's arrival and the start of thrombolytic drug therapy, if needed, within 30 minutes, have been exceeded 90 percent of the time.
Westside is located approximately 3 to 4 miles from FMC, 7 miles from Broward General, 8 to 9 miles from Memorial Regional, 9 miles from North Ridge, and 9 to 10 miles from Holy Cross.
CON Review Criteria
Subsection 408.035(1)(a) - The need for the health care facilities and services and hospices being proposed in relation to the applicable district plan and state health plan. Local Health Plan Priority
The District 10 health plan gives priority to an applicant proposing to initiate cardiac cath or cardiac surgery who documents a willingness to serve patients regardless of their ability to pay. Westside proposes to condition its CON on the provision of 2 percent Medicaid for the first two years of operation, and on placing $160,000 in year one, $280,000 in year two and $353,000 in year three in a restricted fund for charity care. The commitment is consistent with Westside's provision of 2.4 percent Medicaid patient days in 1993, which increased to 5.9 percent in 1995.
CCFH commits to provide free OHS to 13 patients in year one, 14 in year two, and 16 in year three. CCFH also commits to providing 21, 24, and 27 free angioplasties in each of the three years, respectively. Of 804 cardiac care patients at CCFH, as determined by a January 1996 market share report, 2 were Medicaid and 32 were reported in a combined self pay/charity category, which generated revenue roughly equivalent to the commercial HMO category. CCFH's inpatient cardiac cath CON was also conditioned on the provision of 80 free caths a year, 36 inpatient and 44 outpatient. From June 1995, when inpatient caths began, until October 1995, CCFH performed 12 charity care caths, or a shortfall of 34 cases below its CON commitment.
Of the two applicants, Westside better documents the reliability of its limited commitment to Medicaid and charity care.
The only other District 10 local health plan priority, for applicants establishing cardiac cath labs at facilities with existing OHS capabilities, is inapplicable.
State Health Plan Preferences
The preferences in the 1993 applicable state health plan are applicable to this review. Preference one is given to applicants establishing new OHS programs in larger counties in which the percentage of persons over age
65 is higher than the statewide average and the total population exceeds 100,000. Both applicants propose to locate facilities in Broward County, which had a projected population close to 1.4 million in January 1996, with 20.2 percent of that population age 65 and over. This compares favorably, in terms of the preference, to the statewide average of 18.8 percent of the total state population over 65 years of age. Although Westside claimed, in its application, that the percentage of people over 65 residing in its service district was higher than the county average, that was shown to be incorrect.
Preference two is given to applicants clearly demonstrating the ability to perform more than 350 adult OHS procedures within three years of initiating the program.
In the CON application, CCFH projected achieving OHS volumes of 298 in 1996, 343 in 1997, and 382 in 1998. At hearing, CCFH's expert conceded that the OHS program was unlikely to meet those projections. CCFH extended the projections, using more recent experiences, to 335 in 1998, 372 in 1999, and 410 in 2000, which are now projected to be the first three years of the program.
The projections are based on the expected growth in the volume of OHS performed by Dr. Gill and Dr. Lammermeir, increasing enrollees in the CCFHP, attracting Florida residents currently receiving OHS at CC-Ohio, attracting uninsured patients, attracting patients from the current Broward County in-migration, and reversing out-migration.
Dr. Gill and Dr. Lammermeir performed 215 OHS in 1993, 200 in 1994, and 220 OHS in 1995, 75 of the latter were managed care and had to be performed at Broward General, leaving a patient base of 145. By contrast, the CON application projected a patient base of 172 in 1995. Assuming that CC-Florida's cardiovascular surgeons experience a three-to-one ratio of cardiac caths to OHS, although the County ratio is four-to-one, then its cardiac cath volumes are inadequate to support its projected OHS utilization. CCFH projected performing a total of 600 caths in 1995, as compared to the actual total of 484 caths. The projected number of cardiac caths is not sufficient to support the projected OHS volumes, and, rather than increasing, the volume of OHS performed by cardiovascular surgeons appears to have become static.
CCFHP has not met projections in the original CON application, having started in 1995 with 23 enrollees who received OHS, rather than beginning in 1994 with 19 and achieving a volume of 37 OHS on enrollees in year two. The financial viability of CCFHP is also reasonably questioned, because of its having failed to break-even in the first three years of operations.
Some CC-Ohio OHS patients from Florida are reasonably expected to have altered patterns of out-migration to Ohio, choosing instead a CC-Florida cardiovascular surgeon. Approximately 50 Florida residents a year have OHS in Cleveland, and CCFH assumed that half those will opt to stay at a program offered at CCFH. CCFH failed to support that assumption having provided no information on the CC-Ohio Florida patients' districts of origin, or the extent to which CC-Florida cardiovascular surgeons have not already captured some of the out-migration.
CCFH's projection also is based on services to uninsured patients. That projection is not supported by the limited information available to compare its cardiac cath CON projections to its performance, or the proportions of uninsured in its total cardiac care patients. CCFH is reasonably expected to have difficulty attracting uninsured patients given the availability of services provided by the NBHD and the SBHD at seven tax-supported hospitals in the County. See, Finding of Fact 43.
CCFH expects to capture some Broward County in-migration, particularly from Districts 8 and 9. In fact, CCFH contracts with a transportation service for patients in the Naples area, in District 8. New OHS programs in both Districts 8 and 9 are reasonably expected to decrease their residents demand for services in District 10. CCFH physicians already attract more than 13 percent of OHS patients from beyond Districts 8, 9, 10 and 11, with only 50 to 55 percent of OHS performed on Broward County residents. Due to the excellence of its surgeons and its reputation as an affiliate of CC-Ohio, it is reasonable to conclude that CC-Florida has already captured a significant segment of the in- migration and reversed some Broward County out-migration, except that based on managed care contracts and patient proximity to Dade County. CCFH reported that
15 percent of 1994 discharges came from other Florida Counties, other states, and foreign counties, which reflects its operation as a referral facility. In general, CCFH failed to demonstrate that moving its OHS program from Broward General to CCFH will increase its share of in-migration or further reduce out- migration of patients, or otherwise be able to achieve the 350 minimum within three years.
In a CON application filed six months prior to the one at issue in this proceeding, Westside projected performing 175OHS cases in year one, and 250 in year two. In this CON application, Westside projected OHS case volumes of
204 in 1996, 305 in 1997, and 357 in 1998. At hearing, Westside's projections
were 204 in 1997, 306 in 1998, and 361 in 1999, assuming a use rate of 2.30 procedures for every 1000 adults, with 18 percent market share in the 13 zip codes in Westside's service area and with 22 additional OHS cases from outside the area.
Westside's ratio of 2.3 per 1000 is the provider use rate for Broward County, which includes in-migration from other districts. However, in-migration provides additional cases for OHS providers which border neighboring districts, but is not evenly distributed among all Broward providers. In the northern part of the county, Holy Cross and North Ridge draw more patients from adjoining District 9. In the south, Dade draws approximately 300 cases from contiguous areas, nearly half of those from border zip codes in the Hollywood area. The closest provider to Westside, FMC experiences little in-migration. Therefore, the adult resident use rate (which excludes in- migration) without out- migration, or 1.9 per 1000, is more reliable in projecting the volume of OHS cases at Westside.
At FMC, which shares overlapping cardiologists and an overlapping service area with Westside, the ratio of cardiac caths to OHS is four-to-one. Although Westside has what AHCA's expert described as a mature inpatient cardiac cath program, 240 cardiac caths were performed in 1993, 530 in 1994, and 455 in 1994. Westside had projected performing 564 total caths (inpatient and outpatient) in 1994, and 694 in 1995. The 1994 to 1995 decline was attributed to the opening of an inpatient cath lab at another Columbia facility, University Hospital, and to the preference of managed care companies and some physicians for cardiac cath labs which have OHS backup services. In Dade County, Columbia operates two OHS programs which are below the 350 threshold. The most reasonable projections are that Westside will achieve approximately 164 to 175 cases in year one, 247 to 250 in year 2, and up to 284 in year 3.
Neither CCFH nor Westside supported their projections to clearly demonstrate compliance with preference two of the state health plan.
State health plan preference three is given to applicants who will improve access to open heart surgery for persons who are currently seeking the service outside the district, to improve accessibility and reduce travel time. CCFH does not meet the preference because much of that reversal of out-migration already occurs in the CC-Florida physicians' practices at Broward General. Westside is also unlikely to have an impact on out-migration due to its location in a service area in central Broward County.
Preference four is given to an applicant with a history of providing a disproportionate share of charity care and Medicaid patient days, and who provide services to persons regardless of their ability to pay. CCFH and Westside are not disproportionate share charity or Medicaid providers and do not meet the preference.
Preference five is given to an applicant that can offer a service at the least expense with high quality of care standards. The preference specifically notes that the physical plant of larger facilities is more likely to meet the preference, by accommodating the required operating and recovery rooms at lower capital expenditures than smaller facilities. Westside and CCFH are small community hospitals, which currently offer no tertiary services. Westside is obviously a larger hospital than CCFH, comparing 153 to 204 beds, and proposes lower capital expenditures. Westside also has more patient days, approximately 60 percent higher average daily census, with more Medicare, more MDC-5 (cardiac care) patients, and a more active emergency room. Although the
correlation of these factors to OHS cases is questionable, considering the fact that the largest number of OHS in the county were performed, in 1994 to 1995, at the OHS provider with lowest average daily census, North Ridge. In general, however, the larger hospital can have a lower cost per adjusted admission adjusted for case mix, which favors Westside. CCFH is approximately $200 per admission more expensive than any of the existing OHS providers and approximately $750 more than West side.
Westside contends that the real cost of the CCFH OHS project is approximately $5 million, not $2.9 million (as shown on Schedule 1), and should include the surgical renovation project which is underway at CCFH. CCFH notes in its application that CON Action Number 7472 was approved and "is currently in the process of being implemented. When construction is complete, CCFH will have adequate operating rooms, pump room space, and recovery room space to accommodate the open heart program." Westside's expert, however, was unable to distinguish the portions of the surgery project related specifically to OHS as opposed to general surgery.
Westside's total project cost of $1.8 is reasonable. If Westside achieves the volume of 350 OHS, its physical facilities will be inadequate for the cardiac cath and angioplasties expected based on FMC's ratios of four-to-one for OHS to cardiac caths and one-to-one for OHS to angioplasties. National guidelines suggest 1500 procedures for each cardiac cath laboratory.
The plans submitted with a CON application are block drawings designed to show the size, scope, and cost of the project. Although Westside notes that the plans submitted were more detailed than required, the general location of various functions is established. Westside's expert architect conceded that the proposal to have surgery suites on the ground floor and CVICU on the third floor is not the most desirable arrangement, even if connected by a dedicated elevator. The claim that Westside's elevator would be dedicated was not supported by the explanation of any alternative route for other surgery patients. Those patients have to be moved from the ground floor surgery area to the 14-bed ICU located on the second floor, directly below the proposed CVICU and PCU. The CVICU proposed by Westside also has inadequate space, inadequate windows, and exposed toilets within patient cubicles. If the CVICU and PCU are full, or to avoid having different genders in the PCU which has one bathroom, patients will be placed in monitored rooms on the third floor or in a 14-bed ICU on the second floor. Although proposed to serve as the overflow area, the ICU is full on average for four months each year. The additional monitored beds generally do not have comparable coverage by nursing staff dedicated to the care of OHS patients. In general, the physical plant and proposed locations of various components of the OHS program are sufficiently inadequate at Westside to adversely affect quality of care and to raise doubt that subsequent, more detailed construction plans can comply with AHCA licensure requirements.
CCFH contends that its nursing units are organized to provide state- of-the-art care to patients in a compact, efficiently used spaces. However, in a subsequent CON application filed by CCFH in which it sough to replace and relocate its hospital facility at a cost in excess of $80 million, CCFH claimed "monumental barriers in using its present facility" that was "designed for delivery of health care in a different era," which is "crowded" and one of the most inefficient providers in Broward County. CCFH is unable to conduct research, education, training, and residency programs at its facility. The replacement application notes the inefficiency which results from physicians traveling back and forth between the hospital and the clinic, which also undermines the ability to replicate the CC-Ohio model.
Neither Westside nor CCFH is entitled to be favored under preference five.
Preference six, for applicants, performing streptokinase, P.T.C.A., and other innovative alternatives to surgery is met by the applicants to the extent allowed by Florida law. Both propose to perform those additional procedures which require open heart surgery backup, if their OHS programs are established.
Subsection 408.035(1)(b) - 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.
All residents of Broward County currently have access to OHS services. There is no geographic access problem in the district. In fact, Broward County OHS programs serve more non- residents than Broward residents served outside the district, although that net in-migration is expected to decrease due to the approval of new OHS programs in either Martin or St. Lucie Counties, and in Collier County. Existing OHS programs are geographically well dispersed throughout the county, with Holy Cross and North Ridge in the north, FMC and Broward General in the center, west and east, respectively, and Memorial Regional in the south (between 1-95 and the Florida Turnpike). AHCA has classified OHS as a tertiary health service which, because of the complexity and cost of service, should be limited to and concentrated in a limited number of hospitals to assure quality, availability, and cost-effectiveness. Every Broward County resident is within 2 hours average travel time of an OHS provider, which exceeds the geographic accessibility standard set by AHCA rule.
There is evidence that financial access is also not a problem in Broward County, due to the unique coverage of the county by the two tax- supported health care districts.
There is no evidence of programmatic access enhancements from the applicants proposals. None of the procedures performed at Westside or by Dr. Gill and Dr. Lammermeir will differ from those performed by other cardiovascular surgeons in Broward County.
There was evidence of past inefficiencies at Broward General Hospital. Subsequently, in 1995 and continuing into 1996, the NBHD has substantially reduced the number of administrators, frozen salaries for senior management, aggressively negotiated supply contracts with major vendors, and reduced inventory.
Subsection 408.035(1)(c) - The ability of the applicant to provide quality of care and the applicant's record of providing quality of care.
Both applicants have a record of providing an excellent quality of care and are JCAHO accredited. Westside can use its affiliation with Miami Heart Institute and other Columbia OHS providers, as CCFH can with CC-Ohio to assist in establishing their OHS programs. Their ability to provide a high
quality of care in an OHS program is, nevertheless, adversely affected by physical plant constraints and the inability to demonstrate compliance with the preference for achieving 350 OHS cases within three years.
Florida Administrative Code Rule 59C-1.033, expresses AHCA's intent not normally to approve an applicant which does not meet the applicable statutory criteria and the criteria in the rule. The rule includes additional criteria which, in part, assure quality of care, as well as accessibility, including the range of OHS and related supporting services, hours of operation, and staffing levels.
CCFH has two cardiovascular surgeons and Westside has the ability, with the help of Columbia, to recruit cardiovascular surgeons who will perform the range of surgeries required by the rule. Both offer inpatient cardiac cath, and other supporting services and departments, as required by the rule.
The rule also requires OHS programs to operate 8 hours a day, 5 days a week, and to be capable of rapid mobilization within a maximum period of 2 hours, 24 hours a day, 7 days a week. CCFH's plan to have its OHS program "closed" to surgeons other than Dr. Gill and Dr. Lammermeir, will assure that only well-qualified CC-Florida cardiovascular surgeons staff its program. CCFH failed to demonstrate that the hours of operation can be as required by the rule with these two surgeons, one of whom has regular commitments in Ohio. Due to personal and professional commitments, including management responsibilities at CC-Ohio, one of the cardiovascular surgeons testified that each one of them will be unavailable from 30 to 45 days a year. CCFH proposed that a surgeon from CC- Ohio might be used if the two CC-Florida surgeons are unavailable. The rule requires a minimum of two cardiovascular surgeons on staff. As a practical matter, the rule also requires both to be at the hospital to operate an OHS program and an angioplasty program efficiently, during the hours required in the rules. One board-certified or board-eligible cardiovascular surgeon is required for the OHS team, one is required to provide backup for angioplasties, and one of these must also be on call at all times.
Subsection 408.035(1)(d) - 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.
There is no evidence of alternatives to inpatient OHS services, therefore the criterion is inapplicable.
Subsection 408.035(1)(e) - Probable economies and improvements in service that may be derived from operation of joint, cooperative, or share health care resources.
Although the affiliation with large health care groups may allow both applicants to take advantage of economics of scale in training, consultative, and purchasing agreements, neither is proposing to operate a joint, cooperative, or shared health care program.
Subsection 408.035(1)(f) - The need in the service district of the applicant for special equipment and services which are not reasonably and economically accessible in adjoining areas.
CC-Florida's OHS patients experience average lengths of stay consistent with those experienced in Broward County, not the longer stays which characterize a facility doing more difficult procedures, like CC-Ohio. There are no services proposed at CCFH or Westside which are not provided or approved at OHS programs in Districts 8, 9 and 11. There are three OHS programs in Palm Beach County and another one approved for District 9. J.F. Kennedy Hospital in Atlantis, in Palm Beach County, District 9, and Miami Heart Institute in Dade County, District 11, are Columbia-owned OHS providers which are located within 2 hours drive time of Westside. Five of the eight Dade County OHS providers operate below the 350 threshold, and two of the five are Columbia facilities. Three Columbia hospitals in Dade County accounted for approximately 1000 OHS cases in 1995. Over half of these OHS were performed at Miami Heart Institute, leaving volumes in the low 200s at the other two programs, Cedars and Kendall.
Subsection 408.035(1)(g) - 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.
Westside did not propose to meet any need for research or training programs, although it currently has established relationships with high schools, vocational schools, and community and four year colleges.
CCFH offers internal medicine and colorectal surgery residency programs. In addition, CCFH provides graduate medical education programs for family practice residents. Approximately 50 residents rotated, for one or two months each, through CCFH or CC-Florida in 1994 and 1995.
In the replacement CON application, CCFH acknowledges that it has 792 square feet per bed in contrast to both current community hospital averages of 1,000 to 1,200 square feet per bed, and teaching and research facility averages of 1,400 to 1,500 square feet per bed.
In general, CCFH's expert in graduate medical education testified there are a sufficient number of cardiovascular surgeons and cardiovascular surgeon training programs in the United States. Florida, however, ranks forty- first of the fifty states in providing graduate medical educational opportunities. That ranking is unlikely to be altered by the approval of the CCFH OHS CON, because there is no space for additional students or residents at CCFH.
Subsection 408.035(1)(h) - 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 need for clinical training programs for health professionals is considered under Subsection 408.035(1)(g). The extent to which the proposed services will be accessible to residents of the district is considered under the local and state health plans, under Subsection 408.035(1)(n), and Rule 59C- 1.033.
Both CCFH and Westside have the funds necessary to establish the proposed OHS programs.
The staffing proposed by CCFH is adequate to provide postoperative care to the projected volume of 343 OHS patients and 157 PTCA patients in the second year of operation for projected average lengths of stay of 10.9 and 2.7 days, respectively.
Westside's proposed OHS staffing for nurses in the CVICU and PCU is inadequate. FMC's expert demonstrated that 12 (not the proposed 10.7) registered nurse full time equivalent positions are needed. Although there was testimony that Westside would use the existing staff of laboratory technicians and respiratory therapists to meet the needs of OHS patients, Westside failed to account for their time on the staffing tables in the application. One reasonable expert opinion is that Westside underestimated staff costs, salaries and benefits, by over $500,000.
Subsection 408.035(1)(j) - The special needs and circumstances of health maintenance organizations.
Based on AHCA's interpretation, an applicant favored under this subsection must be a health maintenance organization (HMO), which CCFH and Westside are not.
Subsection 408.035(1)(k) - 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 district. 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.
CCFH serves more patients from outside the district and adjoining districts than will Westside, is affiliated with a multidisciplinary clinic, and
proposes to provide OHS services. CCFH, by functioning as a referral facility with 15 percent of its cases coming from beyond Broward County and adjacent districts, better meets the statutory criterion than Westside.
Subsection 408.035(1)(1) - 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.
CCFH's OHS program will reduce volumes of OHS cases at Broward General to 346, 348, and 350 in the first three years of CCFH's operations. On Broward General's open staff, between 10 and 15 cardiovascular surgeons are credentialed to perform OHS. Approximately 40 percent of all OHS at Broward General are performed by CC-Florida cardiovascular surgeons, with 90 percent of those under their direct control. Broward General receives a contribution margin to its fixed costs (derived by subtracting variable costs from total revenue) of
$1,686,000 from the CC- Florida OHS cases it is projected to lose to CCFH. In addition to OHS, CC-Florida physicians provided other cardiac services at Broward General with an estimated total contribution margin (for OHS and other cardiac services) of $2.4 to $2.9 million. Any financial detriment to Broward General diminishes its ability to provide Medicaid and charity care, which it already provides at a disproportionately greater level than any other OHS provider in the District. The establishment of an OHS program at CCFH will also substantially adversely affect Broward General in terms of quality of care, by reducing volumes below the minimum set by the state.
Westside projected that from 40 to 60 percent of its OHS cases will come from FMC, 16 percent from Broward General, and the remainder from the other OHS providers in Broward County.
Westside also projected that 30 percent of its cases would come from a Humana HMO contract. At the time the projection was made Humana OHS cases were performed at Broward General, many of those by CC-Florida physicians. Subsequently, that contract was awarded to FMC, resulting, in part, in the decline in CC-Florida's patient base. With the added Humana cases, FMC reasonably expects to lose approximately 215 cases to Westside. FMC would remain over the 350 minimum, but would suffer a substantial adverse financial loss, in excess of $1.5 million, as a result of the approval of an OHS program at Westside.
If an OHS program is approved at CCFH, FMC reasonably expects to lose approximately 60 OHS cases, or between $.s million to $1 million in adverse financial impact, but will retain volume substantially above the 350 minimum at approximately 650 cases.
Holy Cross, regardless of the approval of OHS at Westside or CCFH, expects to lose from 125 to 150 OHS cases to a new District 9 provider. If CCFH's OHS application is approved, Holy Cross reasonably expects to lose another 60 to 80 cases each year during the first three years of the program. If Westside's CON is approved, then Holy Cross reasonably expects to lose 9,
15, and 17 cases, respectively, in each of the first three-years. The projected cumulative financial loss to Holy Cross is $2.8 million if CCFH is approved, and
$.5 million if Westside is approved. Combining the cases lost to a new District
9 provider with Holy Cross' estimate that it will lose 58 cases in year one, 68 in year two, and 76 in year three to a program at CCFH, Holy Cross reasonably expects for its OHS volume to fall below 350 if the CCFH OHS program is approved.
Memorial Regional reasonably expects to lose in the range of 35 to 55 cases in each of the first three years of an OHS program at Westside, and from
18 to 23 cases over the same period if an OHS program is approved at CCFH.
Subsection 408.035(1)(m) - 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.
There is no evidence of less costly or more effective methods of construction at CCFH or Westside which could alleviate physical plant inadequacies of their facilities or proposals, respectively.
Section 408.035(1)(n) - The applicant's past and proposed provision of health care services to Medicaid patients and the medically indigent.
In the year ending 1993, CCFH provided 2.6 percent Medicaid and 1.0 percent charity care and, in 1994, 2.5 percent Medicaid and 1.8 percent charity care. For the same periods of time, Westside provided 2.9 percent Medicaid and
.32 percent charity, and 3.8 percent Medicaid and .4 percent charity care. CC- Florida cardiovascular surgeons performed OHS on two Medicaid patients in 1993 and one in 1995. Existing OHS providers range from lows (from 9/92 to 8/93) of
.48 percent of Medicaid and .7 percent of charity at North Ridge, 4.32 and .21 at FMC, 6 percent and .79 percent at Holy Cross, to highs of 12 percent and 9 percent at Memorial Regional, and 22 percent and 7 percent at Broward General. The history of providing Medicaid and charity care at CCFH and Westside is below that of other private, non-tax supported facilities, except North Ridge.
CCFH proposed to provide 13 free OHS in year one and 14 in year two, until the year 2000. By comparison, Westside proposed to provide the equivalent of care for 3 charity and 5 Medicaid patients in the first year, and 7 Medicaid and 5 charity cases in year two, and $353,000 in a restricted fund for charity care in the third year.
CCFH's commitment is not reliable based on the actual performance of its cardiovascular surgeons, and the comparison of its projections and experiences in providing free inpatient cardiac caths. See, Finding of Fact 43. Westside's commitment is consistent with its experience and reliable, although lower than that of CCFH, and limited to two years for Medicaid and three years for charity care.
Section 408.035(1)(o) - The applicant's past and proposed provision of services which promote a continuum of care in a multilevel health care system, which may include, but is
not limited to, acute care, skilled nursing care, home health care, and assisted living facilities.
Although one applicant operates a clinic and the other has two home health agencies, neither demonstrated that the OHS services will be offered in a manner which promotes a continuum of care in a multilevel health care system.
Section 408.035(2) - 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 facts:
(b) That existing inpatient facilities providing inpatient services similar to those proposed are being used in an appropriate and efficient manner.
(d) That patients will experience serious problems in obtaining inpatient care of the type proposed, in the absence of the proposed new service.
Subsection (a), related to alternatives to inpatient care is discussed below. Subsections (c), related to new construction, and (e), related to long- term care, are inapplicable. Subsection (b) is applicable and considered under subsection 408.035(1)(b), supra.
CCFH's two cardiovascular surgeons experience no difficulty scheduling patients for OHS at Broward General. Similarly, Westside's cardiovascular surgeons are able to transfer patients to FMC, within an overlapping service area, for OHS, despite the fact that its ICU reaches capacity during the season. Approximately 90 percent of OHS are elective, scheduled procedures.
There was no showing that OHS patients will experience any problems in obtaining OHS services in the absence of the establishment of an additional program.
Subsection 408.035(1)(i) - The immediate and long-term financial feasibility of the proposal.
Both CCFH and Westside demonstrated that their proposals are financially feasible in the immediate or short- term.
Westside overstated the volume of OHS cases (based on the use rate) and understated staffing needs, both of which adversely affect the long-term financial feasibility of its project. CCFH also overestimated the volume of OHS cases by failing to clearly support the reasonableness of the various components of its projections.
CCFH expects a contribution margin per OHS case in the range of
$3,400 to $3,700. In order to cover fixed and variable costs, CCFH estimates that it must perform 251 of the projected increase of 286 new OHS cases in Broward County by the year 2000. CCFH is not reasonably expected to achieve projected volumes See, Findings of Fact 48-53. CCFH also underestimated the proportion of Medicare patients and overestimated the commercial insurance patients within its payor mix, as compared to total patients and to cardiac care
(MDC-5) patients. Medicare reimburses at a fixed rate which is lower than most commercial insurance full coverage plans.
Assuming only that Westside failed to include approximately $500,000 in salaries and benefits, then the profit projected in the second year, in excess of $200,000, would become a loss of over $200,000 from operations.
Losses would continue in the third year at approximately $100,000 for that year.
CCFH and Westside are also at risk for not reaching projected utilization because of their relatively small size and low volume of cardiac caths. Neither CCFH or Westside supported its utilization assumptions and, therefore, neither demonstrated that its proposal is financially feasible in the long-term.
Subsection 408.035(2)(a) - That less costly, more efficient, or more appropriate alternatives to a new OHS program are not available or not practicable (or the need for an additional OHS provider).
AHCA's expert was not aware of any facts to suggest that OHS providers in Broward County are unavailable, inefficient, inappropriate, inaccessible, overutilized or delivering unsatisfactory quality of care. Therefore, absent "not normal" circumstances which have not been shown, need must be demonstrated in relation to the statutory and rule criteria.
The numeric need methodology indicates a numeric need for four additional OHS providers. Using the district's facility use rate for the 12 months ending September 30, 1993, or 2.8 procedures for every 1000 adults (the population age 15 and over) and the projected population for January 1996 of
1.15 million, AHCA calculated the expected OHS procedures for July 1996 to equal 3,198. Dividing that total by 350, the minimum number of procedures required at each facility, AHCA calculated a total numeric need for the district of 9.137 providers, which minus the 5 existing providers, results in a difference of
4.137. AHCA has a rule allowing the publication of the need of only one additional OHS program in a district at a time. Before AHCA publishes need, however, the rule also requires an arithmetic showing that all OHS programs can maintain, with a new provider, at least 350 procedures. That requirement was demonstrated by dividing 3,198 projected procedures by 350, which demonstrates that six district programs can average 533 OHS procedures.
The highest projected increase in the volume of OHS is 286 additional cases by the year 2,000. Approximately 500 OHS cases can be performed in each of the 11 OHS operating rooms in the districts every year, meaning that, in terms of physical capacity, over 5,000 total, or nearly 2,000 additional OHS cases can be accommodated at the existing providers. Using 1,500 cardiac caths as full capacity, cardiac caths labs also have excess capacity. At the five OHS providers, cath lab utilization ranges between 61 to 81 percent of capacity.
Non-OHS provider cath labs utilizations ranges from 9 to 37 percent of capacity. The existing providers also have the capacity to accommodate more patients in their critical care units, in which 1994-1995 occupancy ranged from lows of 62 percent at FMC and 69 percent at Holy Cross, to highs of 73 percent at Broward General and Memorial, and 86 percent at North Ridge.
CONS are not required to add cardiac cath labs or to add operating rooms dedicated to OHS services. In effect, the applicants assert that existing providers may expand capacity to bar new competitors from the market, therefore,
capacity should not be emphasized over other CON criteria. In this case, however, excess capacity demonstrates that patients will not go unserved if the applicants fail to qualify under the other statutory and rule criteria. In addition, national trends indicate OHS rates increasing more slowly than the rates of alternative new forms of angioplasties.
On balance, considering criteria which distinguish between the two, Westside's application presented limited, but more credible Medicaid and charity care projections than CCFH. Westside is also a larger, more active facility, in which proposed renovations are less costly. Westside's proposal is inadequate in terms of physical design with space constraints which make it impossible to comply with licensure requirements or to provide quality care. With inadequate support for its utilization projections, Westside failed to demonstrate that its volume of OHS and staffing will assure quality of care or its long-term financial feasibility. Apart from the numeric calculation, no need for Westside's program was demonstrated in terms of CON statutory and rule criteria. A program at Westside would adversely affect revenues derived from OHS programs at FMC and Memorial Regional.
On balance, CCFH's application demonstrated that CCFH would function more like a referral facility, serving more patients from beyond adjacent areas. But, as with Westside, no need was demonstrated in terms of other CON statutory and review criteria. While CCFH proposed to be an excellent teaching and research facility, no need for that type of facility was demonstrated, and CCFH could not meet that need given its admitted physical plant constraints. In addition, or because they are not needed, CCFH, like Westside, failed to support its utilization projections and the long-term financial feasibility of its proposed OHS program. The approval of a program at CCFH will substantially adversely affect the quality of care and revenues generated from existing OHS programs at Broward General and Holy Cross.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties to and subject matter of this proceeding. Subsections 408.039(5) and 120.57(1), Florida Statutes.
The four existing providers of OHS services in AHCA District 10, who are parties to this proceeding, have standing to challenge the preliminary agency action. FMC and Memorial Regional operate established programs which will be substantially adversely affected financially by the approval of a new OHS program at Westside. Broward General and Holy Cross operate existing OHS programs which will be substantially adversely affected, in terms of quality of care and financially, by the approval of a program at CCFH.
Each applicant has the burden of proving that its proposal meets, on balance, the statutory and rule criteria for the issuance of a CON. Boca Raton Artificial Kidney Center v. Department of Health and Rehabilitative Services, 475 So.2d 260 (Fla. 1st DCA 1985)
AHCA's published a need for an additional OHS program in District 10 is a starting point, but only one factor in considering whether a need exists for a new program. South Miami Hospital, Inc. v. Agency For Health Care Administration, DOAH Case No. 91-5723 (AHCA 1994)
Both applicants have the funds required to initiate their proposals, but both have failed to support their utilization projections and, therefore, to
establish the long- term financial feasibility of their proposals. Subsection 408.035(1)(h) and (i). Both applicants have failed to demonstrate the ability to assure a quality OHS program by reaching 350 OHS cases within three years, the threshold set by AHCA. Subsection 408.035(1)(c). CCFH has also failed to demonstrate that its two cardiovascular surgeons, given other personal and professional responsibilities, can operate an OHS and angioplasty program as required by AHCA rules. Rules 59C- 1.033 and 59C-1.032, Florida Administrative Code.
Reviewing the local and state health plan preferences, both applicants meet the preferences for proposing to locate in Broward County and for proposing to perform innovative alternatives to OHS. Neither applicant meets the preferences for achieving 350 OHS in three years, for reversing out- migration, for disproportionate share providers, or for physical plants adequate to accommodate OHS, although Westside is larger and has the lower capital expenditure. In general, there is no showing of need in relation to the local and state health plans. The plan preferences demonstrate, in general, the inadequacies of the proposals. Subsection 408.035(1)(a).
Need for an OHS program at CCFH and Westside is also not demonstrated by other statutory review criteria. There is substantial evidence, from every health planning expert who testified, that the existing providers are accessible, available, provide excellent quality of care, are appropriately utilized, adequate, and efficient. Subsection 408.035(1)(b).
The applicants do not propose joint, shared or cooperative programs. Subsection 408.035(1)(e).
Neither applicant is a health maintenance organization. Subsection 408.035(1)(j)
CCFH serves more patients from beyond the district or adjacent districts than Westside. Subsection 408.035(1)(k)
While CCFH seeks to expand opportunities for graduate medical education, it is unable to do so in its current location due to a lack of space. As a result, there is nothing in the CCFH proposal to distinguish it as meeting a need for medical research and education. Subsection 408.035 (1)(g).
Westside's proposal adversely affects quality assurance and cost effectiveness at FMC and Memorial Regional, although less than the adverse effect of CCFH on Holy Cross and Broward General. Subsection 408.035(1)(1).
The costs and methods of construction are inadequate to establish adequate physical facilities for an OHS program at either Westside or CCFH. Subsection 408.035(1)(m).
Neither applicants' past or proposed Medicaid or charity care is sufficient to distinguish it, although Westside's proposed commitment is more reliable than that of CCFH. Subsection 408.035(1)n).
Neither applicant proposed to provide OHS in a multilevel health care system in a manner which promotes a continuum of care. Subsection 408.035(1)(n).
There is substantial evidence that the less costly, more efficient, more appropriate plan is to serve additional OHS and angioplasty patients at the
existing OHS providers. Approval of either CON application will result in a costly, unnecessary duplication of services. Subsection 408.035(2)(a), (b) and (d).
Given the statutory and rule criteria, it is impossible to recommend approval of either application.
Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the applications of Columbia Hospital Corporation of South
Broward d/b/a Westside Regional Medical Center for CON 7686, and Cleveland Clinic Florida Hospital for CON 7687 be denied.
DONE AND ENTERED this 2nd day of December, 1996 in Tallahassee, Leon County, Florida.
ELEANOR M. HUNTER
Administrative Law Judge
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-3060
(904) 488-9675 SUNCOM 278-9675
Fax Filing (904) 921-6847
Filed with the Clerk of the Division of Administrative Hearings this 2nd day of December, 1996.
ENDNOTE
1/ Subsequently, title was changed to Administrative Law Judge, pursuant to legislation effective on October 1, 1996.
COPIES FURNISHED:
Lesley Mendelson, Senior Attorney Agency for Health Care Administration 2727 Mahan Drive
Fort Knox Building 3, Suite 3431
Tallahassee, Florida 32308-5403
Jonathan L. Rue, Esquire 1500 Marquis, Two Tower
285 Peachtree Avenue Northeast Atlanta, Georgia 30303
Robert A. Weiss, Esquire John M. Knight, Esquire Karen A. Putnal, Esquire
Parker, Hudson, Rainer and Dobbs The Perkins House, Suite 200
118 North Gadsden Street Tallahassee, Florida 32301
Stephen A. Ecenia, Esquire Rutledge, Ecenia,
Underwood and Purnell, P.A. Barnett Bank Building, Suite 420 Post Office Box 551
Tallahassee, Florida 32302-0551
Darrell White, Esquire William B. Wiley, Esquire Charles A. Stampelos, Esquire 600 First Florida Bank Tower
215 South Monroe Street Tallahassee, Florida 32301
R. Terry Rigsby, Esquire Blank, Rigsby and Meenan
204 South Monroe Street Tallahassee, Florida 32301
Susan Horovitz Maurer, Esquire Panza, Maurer, Maynard and Neel
3600 North Federal Highway, Third Floor Ft. Lauderdale, Florida 33308
R. S. Power, Agency Clerk
Agency for Health Care Administration 2727 Mahan Drive
Fort Knox Building 3, Suite 3431
Tallahassee, Florida 32308-5403
Jerome W. Hoffman, General Counsel Agency For Health Care Administration 2727 Mahan Drive
Fort Knox Building 3, Suite 3431
Tallahassee, Florida 32308-5403
NOTICE OF RIGHT TO SUBMIT EXCEPTIONS
All parties have the right to submit written exceptions within 15 days from the date of this recommended order. Any exceptions to this recommended order should be filed with the agency that will issue the final order in this case.
| Issue Date | Proceedings |
|---|---|
| Mar. 18, 1997 | (AHCA) Final Order filed. |
| Dec. 02, 1996 | Recommended Order sent out. CASE CLOSED. Hearing held February 12-15, 20-23, 26-March 1, March 4-8, 1996. |
| Aug. 28, 1996 | Cleveland Clinic`s Reply to Memorial`s and Florida Medical Center`s Responses to Motions to Strike and Response to its Motion for Attorneys Fees filed. |
| Aug. 16, 1996 | South Broward Hospital District d/b/a Memorial Regional Hospital's and FMC Hospital, LTD.'s Joint Response to Motions to Strike, and Joint Motion for Attorney Fees filed. |
| Aug. 07, 1996 | (Cleveland Clinic) Motion to Strike FMC`s Legal Brief As Unauthorized Submission; (Cleveland Clinic) Motion to Strike South Broward Hospital District`s Legal Brief As Unauthorized Submission filed. |
| Aug. 06, 1996 | Cleveland Clinic's Response to Westside's Objection to Motion to Strike (filed via facsimile). |
| Aug. 02, 1996 | Whiteside's Response to Cleveland Clinic's Motion to Strike Westside's Legal Brief as Unauthorized Submission filed. |
| Jul. 24, 1996 | (Cleveland Clinic Florida Hospital) Motion to Strike Westside`s Legal Brief as Unauthorized Submission filed. |
| Jul. 24, 1996 | Memorandum to A. Ziade from D. Ketchum (re: clarification of receipt for PRO) sent out. |
| Jul. 23, 1996 | Letter to HO from R. Rigsby Re: Replacing page 18 of FMC's Proposed Recommended Order filed. |
| Jul. 23, 1996 | North Broward Hospital District d/b/a North Broward Medical Center's Proposed Recommended Order filed. |
| Jul. 22, 1996 | South Broward Hospital District d/b/a Memorial Hospital's and FMC Hospital, LTD.'s Joint Memorandum of Law filed. |
| Jul. 22, 1996 | Proposed Recommended Order of the Agency for Health Care Administration filed. |
| Jul. 22, 1996 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center`s Proposed Recommended Order; Closing Argument of Holy Cross Hospital, Inc.; Proposed Recommended Order of Holy Cross Hospital, Inc. filed. |
| Jul. 22, 1996 | FMC Hospital, LTD. d/b/a Florida Medical Center's Proposed Recommended Order; South Broward Hospital District d/b/a Memorial Regional Hospital's Proposed Recommended Order; Cleveland Clinic Florida Hospital's Proposed Recommended Order; Westside's Legal |
| Jul. 22, 1996 | North Broward Hospital District d/b/a North Broward Medical Center's Proposed Recommended Order; Cover letter from A. Ziade filed. |
| Jul. 05, 1996 | Order Granting Motion for Extension of Time to File Proposed Recommended Orders and to Exceed Page Limit and Canceling Telephonic Hearing sent out. |
| Jul. 03, 1996 | (Columbia Hospital) Supplemental Memorandum in Support of Motion for Extension of Time to File Proposed Recommended Orders and to Exceed Page Limit and Notice of Telephonic Hearing filed. |
| Jul. 02, 1996 | Cleveland Clinic Florida Hospital's Response to Columbia Hospital Corporation of South Broward, d/b/a Westside Regional Medical Center's Motion for Extension of Time to File Proposed Recommended Orders and to Exceed Page Limit filed. |
| Jul. 02, 1996 | (Columbia Hospital) Notice of Cancellation of Telephonic Hearing filed. |
| Jul. 01, 1996 | (Petitioner) Motion for Extension of Time to File Proposed Recommended Orders And to Exceed Page Limit And Notice of Telephonic Hearing filed. |
| May 15, 1996 | Notice of Filing; (Volumes 26-34) DOAH Court Reporter Final Hearing Transcript filed. |
| May 10, 1996 | Notice of Filing; DOAH Court Reporter Final Hearing Transcripts (Volumes 14 thru 25, tagged) filed. |
| May 07, 1996 | Notice of Filing; (11-13 of 34) DOAH Court Reporter Final Hearing Transcript filed. |
| Apr. 30, 1996 | Notice of Filing; DOAH Court Reporter Final Hearing Transcripts (volumes 4 thru 10, tagged) filed. |
| Apr. 16, 1996 | Notice of Filing; (3 Volumes) DOAH Court Reporter Final Hearing Transcript filed. |
| Mar. 25, 1996 | North Broward Hospital District`s Memorandum in Opposition to Filing of Deposition of Scott Hopes and Response to Cleveland Clinic Florida Hospital`s Memorandum in Opposition to Motion to Reopen Expert Witness Deposition filed. |
| Mar. 19, 1996 | (Cleveland Clinic) Notice of Telephonic Hearing filed. |
| Mar. 07, 1996 | (Cleveland Clinic Florida Hospital) Memorandum in Opposition to Motion to Reopen Expert Witness Deposition filed. |
| Feb. 27, 1996 | DOAH Court Reporter Transcript (Excerpt of Proceedings, tagged) filed. |
| Feb. 21, 1996 | Transcripts (Volumes 9, 10, tagged) filed. |
| Feb. 09, 1996 | (Joint) Prehearing Stipulation filed. |
| Feb. 09, 1996 | Order Granting Motion to Substitute Party sent out. (FMC Hospital, Ltd. for Florida Medical Center, Ltd., DOAH Case #94-4803) |
| Feb. 09, 1996 | Order Granting CCFH's Unopposed Motion to Further Amend Prehearing Order sent out. |
| Feb. 08, 1996 | Holy Cross Hospital, Inc.'s Witness And Exhibit List filed. |
| Feb. 07, 1996 | (Robert A. Weiss) Amended Notice of Taking Telephonic Deposition Duces Tecum filed. |
| Feb. 02, 1996 | (Robert A. Weiss, Jonathan L. Rue, Armando L. Basarrate) Cleveland Clinic Florida Hospital's Notice of Appearance of Additional Counsel of Record filed. |
| Feb. 02, 1996 | (Cleveland Clinic) Notice of Taking Deposition Duces Tecum; Cleveland Clinic Florida Hospital`s Notice of Appearance of Additional Counsel of Record (Robert Weiss) filed. |
| Feb. 01, 1996 | CCFH's Unopposed Motion to Further Amend Prehearing Order; Notice of Taking Depositions Duces Tecum filed. |
| Jan. 31, 1996 | (Karen A. Putnal) Amended Notice of Taking Telephonic Deposition Duces Tecum; Notice of Taking Telephonic Deposition Duces Tecum; (3) Notice of Taking Deposition Duces Tecum; (Thomas W. Konrad) Re-Notice of Taking Deposition filed. |
| Jan. 30, 1996 | Order Closing File sent out. (file no. 94-4800, closed; Consolidated cases are: 94-4801, 94-4802, 94-4803, 94-4804, 94-4806, 94-5076) |
| Jan. 30, 1996 | Case No/s 94-4800, 94-4801, 94-4802, 94-1803, 94-4804, 94-4806, 94-5076: unconsolidated. |
| Sep. 19, 1994 | Amended Prehearing Order and Order of Consolidation sent out. (Consolidated cases are: 94-4800, 94-4801, 94-4802, 94-4803, 94-4804, 94-4805, 94-4806, 94-5076; parties shall file their prehearing stipulation no later than 15 days prior to date set for |
| Sep. 19, 1994 | Case No/s 94-4800, 94-4801, 94-4802, 94-4803, 94-4804, 94-4805, 94-4806, 94-5076: unconsolidated. |
| Sep. 07, 1994 | Prehearing Order and Order of Consolidation sent out. (Consolidated cases are: 94-4800 through 94-4806) |
| Sep. 01, 1994 | Notification card sent out. |
| Aug. 30, 1994 | Notice Of Related Petitions (94-4800, 94-4801, 94-4802, 94-4803, 94-4804, 94-4805, 94-4806); Notice; Petition for Formal Administrative Hearing filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Mar. 17, 1997 | Agency Final Order | |
| Dec. 02, 1996 | Recommended Order | No need for additional adult open heart surgery in Broward County based on statute and rules despite numeric need. |
