STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
FLORIDA HEALTH SCIENCES CENTER, INC., d/b/a TAMPA GENERAL HOSPITAL, Petitioner, vs. AGENCY FOR HEALTH CARE ADMINISTRATION, Respondent, and SUN CITY HOSPITAL, INC., d/b/a SOUTH BAY HOSPITAL, Intervenor. ST. JOSEPH'S HOSPITAL, INC., d/b/a ST. JOSEPH'S HOSPITAL, Petitioner, vs. AGENCY FOR HEALTH CARE ADMINISTRATION AND SUN CITY HOSPITAL, INC., d/b/a SOUTH BAY HOSPITAL, Respondents.
| ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) | Case No. 08-0614CON Case No. 08-0615CON |
SUN CITY HOSPITAL, INC., d/b/a SOUTH BAY HOSPITAL, Petitioner, vs. AGENCY FOR HEALTH CARE ADMINISTRATION AND ST. JOSEPH'S HOSPITAL, INC., d/b/a ST. JOSEPH'S HOSPITAL, Respondents.
| ) ) ) ) ) ) ) ) ) ) ) ) ) ) | Case No. 08-1205CON |
RECOMMENDED ORDER
Pursuant to notice, the Division of Administrative Hearings, by its designated Administrative Law Judge, Charles A. Stampelos, held the final hearing in the above-styled cases on December 6 through 10 and 13 through 17, 2010, and January 5, 6, and 12, 2011, in Tallahassee, Florida.
APPEARANCES
For Florida Health Sciences Center, Inc., d/b/a Tampa General Hospital:
Jeffrey L. Frehn, Esquire Radey, Thomas, Yon & Clark, P.A.
301 South Bronough Street, Suite 200 Tallahassee, Florida 32301
For St. Joseph's Hospital, Inc.:
Karen A. Putnal, Esquire Robert A. Weiss, Esquire
Parker, Hudson, Rainer & Dobbs, LLP The Perkins House, Suite 200
North Gadsden Street Tallahassee, Florida 32301
For Agency for Health Care Administration:
Lorraine M. Novak, Esquire Warren J. Bird, Esquire
Agency for Health Care Administration Fort Knox Building III, Mail Stop 3 2727 Mahan Drive, Suite 3431
Tallahassee, Florida 32308
For Sun City Hospital, Inc., d/b/a South Bay Hospital: Stephen A. Ecenia, Esquire
Richard M. Ellis, Esquire Rutledge, Ecenia & Purnell, P.A.
South Monroe Street, Suite 202 Tallahassee, Florida 32301
STATEMENT OF THE ISSUE
Whether Certificate of Need (CON) Application No. 9992, filed by Sun City Hospital, Inc., d/b/a South Bay Hospital to establish a 112-bed replacement hospital in Riverview, Hillsborough County, Florida, satisfies, on balance, the applicable statutory and rule review criteria for approval.
PRELIMINARY STATEMENT
Background
In the August 2007 batching cycle for hospital beds and facilities, Sun City Hospital, Inc., d/b/a South Bay Hospital (South Bay or SB) and St. Joseph's Hospital, Inc., d/b/a
St. Joseph's Hospital (St. Joseph's Hospital or SJH) filed CON Applications No. 9992 and 9993, respectively, with the Agency for Health Care Administration (Agency or AHCA).
South Bay proposes to replace and relocate its existing 112-bed acute care hospital to Big Bend Road, in Riverview,
Hillsborough County, Florida, AHCA acute care planning subdistrict 6-1 (subdistrict 6-1).
St. Joseph's Hospital proposed the establishment of a 90-bed satellite acute care hospital across the street from SB's proposed location through the transfer of 90 beds from its existing hospital in Tampa.
In the December 28, 2007, edition of the Florida Administrative Weekly, Vol. 33, No. 52, AHCA gave notice of its intent to approve SB's application (CON No. 9992) and deny SJH's application (CON No. 9993).
Florida Health Sciences Center, Inc., d/b/a Tampa General Hospital (Tampa General or TG) filed a petition for formal administrative hearing to challenge SB's preliminary approval. St. Joseph's Hospital filed a petition to challenge the preliminary denial of its application. South Bay filed an "approved applicant" petition for hearing of the two co-batched applications pursuant to Florida Administrative Code
Rule 59C-1.012(2)(a). The three petitions were referred to the Division of Administrative Hearings (DOAH) and were assigned Case Nos. 08-0614CON, 08-0615CON, and 08-1205CON, respectively.
In the meantime, in a different administrative proceeding involving the February 2005 batching cycle, by Final Order dated August 15, 2008, AHCA granted SJH's CON Application No. 9833.
Like CON Application No. 9993, SJH proposed a 90-bed satellite acute care hospital through the transfer of 90 beds from its
existing hospital in Tampa. St. Joseph's Hosp., Inc. v. Agency for Health Care Admin., Case No. 05-2754CON (Fla. DOAH May 13, 2008; Fla. AHCA Aug. 15, 2008), aff'd, Sun City Hosp., Inc. v. Agency for Health Care Admin., 18 So. 3d 1042 (Fla. 1st DCA 2009). (The approved hospital is expected to be built off Big Bend Road.)
Tampa General, South Bay, and Brandon Regional Hospital, which were parties to the administrative litigation as existing health care facilities opposed to SJH's proposal, appealed the Final Order that approved CON No. 9833 in Case No. 05-2754CON. Id.
These consolidated cases, which had been in abeyance pending the outcome of the appeal, were returned to the hearing docket and scheduled for final hearing to take place in November 2010.
The hearing was subsequently continued and rescheduled to take place on December 6 through 10 and 13 through 17, 2010.
On August 13, 2010, SB moved to dismiss SJH's petition in Case No. 08-0615CON. On August 20, 2010, SJH filed a response in opposition, which was treated as a motion to amend its petition. After a response was filed, the motion to amend the petition was granted to clarify that SJH's amended petition was subject to proof of standing at hearing. St. Joseph's Hospital filed its amended petition on September 17, 2010, and thereafter participated as an existing health care facility, subject to proof of its standing.
Joint Pre-Hearing Stipulation
On December 6, 2010, the parties filed a Joint Pre-hearing Stipulation. The parties stipulated that the CON review criteria in section 408.035, Florida Statutes (2007), apply to SB's application, given its filing in the August 2007 comparative review cycle. Ch. 2008-29, § 5, Laws of Fla.
The parties stipulated that the following statutory rule criteria are at issue in this proceeding: section 408.035(1) through (3), (5) through (7), and (9). Section 408.035(10) does not apply.
Regarding section 408.035(4), the parties stipulated that SB's Schedule 2 is complete, and that the completeness of the Schedule 2 did not require proof at hearing. The short-term and long-term financial feasibility of SB's proposal is in dispute. The parties further stipulated that SB's Schedule 6A is reasonable as it relates to the staffing for the replacement hospital and that SB has the ability to recruit and train the staff identified on Schedule 6A.
Tampa General and SJH contend that Schedule 6A is not reasonable concerning staffing for the freestanding Emergency Department (ED) and outpatient services to be housed in the existing SB facility following the establishment of the replacement hospital. Conversely, SB and the Agency contend that staffing for these items is not an issue to be addressed within the scope of this proceeding. St. Joseph's Hospital and TG also
dispute whether SB has funds available for capital expenses and for project accomplishment.
Regarding section 408.035(8), the parties stipulated that SB's costs and methods of the proposed construction of the replacement hospital are reasonable, including the costs and methods of energy provision. The parties disagree as to the availability of alternative, less costly, or more effective methods of construction. Notwithstanding this stipulation, SJH and TG contend that SB should renovate and expand its existing facility at its existing location, rather than replace and relocate its hospital.
The parties further stipulated that the architectural drawings submitted with SB's application are reasonable and satisfy applicable code requirements. This stipulation, however, did not preclude SJH and TG from offering testimony as to the conceptual design of the replacement hospital.
The parties stipulated that SB's letter of intent and CON application were timely filed; that the Agency properly noticed its preliminary intent to approve SB's CON application and its denial of CON Application No. 9993 filed by SJH; that TG and SJH timely filed petitions challenging the Agency's preliminary decision; and that SB timely filed a petition requesting an administrative hearing regarding the merits of the two co-batched applications.
St. Joseph's Hospital's CON application for a satellite hospital is not at issue. The standing of SJH and TG to contest the award of a CON to SB is at issue in this proceeding.
Witnesses and Exhibits
At the hearing, SB presented the testimony of the following witnesses: Sharon Roush, CEO of South Bay Hospital, an expert in hospital administration; A. Ghassan Ksaibati, M.D., an expert in emergency medicine; Armand Balsano, an expert in health planning and health care finance; Jeffrey N. Gregg, Bureau Chief of AHCA's CON Unit, an expert in health planning (who also testified on behalf of AHCA); Jack Daniel Miller, president of HCA's West Florida Division and an expert in hospital administration; Darryl Weiner, an expert in health care finance; and Charles Siconolfi, an expert in health care architecture. South Bay's Exhibits (SB Ex.) 1A through 29, 31 through 39, and 41 through 50 were admitted in evidence.
St. Joseph's Hospital presented the testimony of the following witnesses: Joseph P. LaBarbera, M.D., an expert in internal medicine and geriatrics; Janet Wilbur, R.N., an expert in home health care services, administration, and nursing;
Mark M. Richardson, an expert in health care planning; Ed Barnes, president of the Sun City Center Community Association; Harold Crow, M.D., an expert in family practice medicine; Anne Cross; Eileen Peco, president of Federation of Kings Point; Dolores Berens; Janet Wilson; David T. Travis, former chief of the
Hillsborough County Fire Rescue Department and an expert in emergency rescue services; Isaac Mallah, CEO of St. Joseph's Healthcare Center, Inc., and an expert in health care administration; Anne Finlon, an expert in health care finance; Stephen J. Henry, P.E., an expert in traffic engineering; and Barry L. Oliver, AIA, an expert in health care facility architecture and design and hospital construction contract administration. St. Joseph's Hospital's Exhibits (SJH Ex.) 1, 2, 4, 5 through 11, 13 through 17, 19 through 21, 26A, and 30 through 35 were admitted in evidence. Exhibits 32, 32A, and 33 were received over SB's motion in limine as to the deposition testimony and exhibits of Gary Maier and Stephen Dailey, with ruling reserved as to the weight to be accorded those exhibits.
Tampa General presented the testimony of Ronald A. Hytoff, CEO of Tampa General and an expert in hospital administration; Steve L. Short, executive vice-president and CFO of Tampa General and an expert in health care finance; and Thomas Davidson, an expert in health care planning and finance. Tampa General's Exhibits (TG Ex.) 1 through 3, 5 through 16, 19, and 21 were admitted in evidence.
The Agency's Exhibits 1 and 2, which appear as SB's Exhibits
11 and 12, were admitted in evidence.
The Transcript (T), volumes 1 through 14, of the final hearing was filed at DOAH on January 25, 2011.
After receiving unopposed extensions of time, SB and AHCA filed a joint proposed recommended order and a memorandum of law on March 21, 2011. St. Joseph's Hospital and Tampa General also filed separate proposed recommended orders on March 21, 2011. On April 15, 2011, SJH and TG filed separate responsive memoranda of law. All post-hearing submissions have been considered.
FINDINGS OF FACT
The Parties A. South Bay
South Bay is a 112-bed general acute care hospital located at 4016 Sun City Center Boulevard, Sun City Center, Florida. It has served south Hillsborough County from that location since its original construction in 1982.
South Bay is a wholly-owned for-profit subsidiary of Hospital Corporation of America, Inc. (HCA), a for-profit corporation.
South Bay's service area includes the immediate vicinity of Sun City Center, the communities of Ruskin and Wimauma (to the west and east of Sun City Center, respectively), and the communities of Riverview, Gibsonton, and Apollo Beach to the north. See FOF 68-72.
South Bay is located on the western edge of Sun City Center.
The Sun City Center area is comprised of the age- restricted communities of Sun City Center, Kings Point, Freedom
Plaza, and numerous nearby senior living complexes, assisted- living facilities, and nursing homes. This area geographically comprises the developed area along the north side of State Road (SR) 674 between I–75 and U.S. Highway 301, north to 19th Avenue and south to the Little Manatee River.
South Bay predominantly serves the residents of the Sun City Center area. In 2009, Sun City Center residents comprised approximately 57% of all discharges from SB. South Bay had approximately 72% market share in Sun City Center zip code 33573. (Approximately 32% of all market service area discharges came from zip code 33573.)
South Bay provides educational programs at the hospital that are well–attended by community residents.
South Bay provides comprehensive acute care services typical of a small to mid-sized community hospital, including emergency services, surgery, diagnostic imaging, non-invasive cardiology services, and endoscopy. It does not provide diagnostic or therapeutic cardiac catheterization or open-heart surgery.
Patients requiring interventional cardiology services or open-heart surgery are taken directly by Hillsborough County Fire Rescue or other transport to a hospital providing those services, such as Brandon Regional Hospital (Brandon) or SJH, or are transferred from SB to one of those hospitals.
South Bay has received a number of specialty accreditations, which include accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), specialty accreditation as an advanced primary stroke center, and specialty accreditation by the Society for Chest Pain. South Bay has also received recognition for its quality of care and, in particular, for surgical infection prevention and outstanding services relating to heart attack, heart failure, and pneumonia.
South Bay's 112 licensed beds comprise 104 general medical-surgical beds and eight Intensive Care Unit (ICU) beds. Of the general medical-surgical beds, 64 are in semi-private rooms, where two patient beds are situated side-by-side, separated by a curtain. Forty-eight are in private rooms. Semi- private rooms present challenges in terms of infection control and patient privacy, and are no longer the standard of care in hospital design and construction.
Over the years, SB has upgraded its hospital physical plant to accommodate new medical technology, including an MRI suite and state-of-the-art telemetry equipment. South Bay is implementing automated dispensing cabinets on patient floors for storage of medications and an electronic medication administration record system that provides an extra safety measure for dispensing medications. Since 2009, SB has implemented numerous programmatic initiatives that have improved the quality of care.
South Bay is converting one wing of the hospital to an orthopedic unit.
In 2001, South Bay completed a major expansion of its ED and support spaces, but has not added new beds. Patients presenting to the ED have received high quality of care and timely care. Since 2009, SB has improved its systems of care and triage of patients in the ED to improve patient flow and reduce ED wait times.
Overall, South Bay has a reputation of providing high- quality care in a timely manner, notwithstanding problems with its physical plant and location.
South Bay's utilization has been high historically. From 2006 to 2009, SB's average occupancy has been 79.5%, 80.3%, 77.2%, and 77.7%, respectively. Its number of patient discharges also increased in that time, from 6,190 in 2006 to 6,540 in 2009, at an average annual rate increase of 1.9%. (From late November until May, the seasonal months, utilization is very high, sometimes at 100% or greater.)
Despite its relatively high utilization, SB has also had marginal financial results historically. It lost money in 2005 and 2007, with operating losses of $644,259 in 2005 and
$1,151,496 in 2007 and bottom-line net losses of $447,957 (2005) and $698,305 (2007). The hospital had a significantly better year in 2009, with an operating gain of $3,365,113 and a bottom- line net profit of $2,144,292. However, this was achieved
largely due to a reduction in bad debt from $11,927,320 in 2008 to $7,772,889 in 2009, an event the hospital does not expect to repeat, and a coincidence of high surgical volume. Its 2010 financial results were lagging behind those of 2009 at the time of the hearing. South Bay's 2009 results amount to an aberration, and it is likely that 2010 would be considerably less profitable.
South Bay's marginal financial performance is due, in part, to its disproportionate share of Medicare patients and a disproportionate percentage of Medicare reimbursement in its payor mix. Medicare reimburses hospitals at a significantly lower rate than managed care payors.
As noted, SB is organizationally a part of HCA's West Florida Division, and is one of two HCA-affiliated hospitals in Hillsborough County; Brandon is the other. (There are approximately 16 hospitals in this division.)
Brandon has been able to add beds over the past several years, and its services include interventional cardiology and open-heart surgery. However, SB and Brandon combined still have fewer licensed beds than either St. Joseph's Hospital or Tampa General Hospital, and fewer than the BayCare Health System- affiliated hospitals in Hillsborough in total.
South Bay's existing physical plant is undersized and outdated. See discussion below. Whether it has a meaningful opportunity for expansion and renovation at its 17.5-acre site is
a question for this proceeding to resolve. South Bay proposes the replacement and relocation of its facility to the community of Riverview.
In 2005, SB planned to establish an 80-bed satellite hospital in Riverview, on a parcel owned by HCA and located on the north side of Big Bend Road between I-75 and U.S.
Highway 301. SB filed CON Application No. 9834 in the February 2005 batching cycle. The application was preliminarily denied by AHCA, and SB initially contested AHCA's determination.
South Bay pursued the satellite hospital CON at that time because of limited availability of intercompany financing from HCA. By the time of the August 2007 batching cycle, intercompany financing had improved, allowing SB to pursue the bigger project of replacing and relocating the hospital.
South Bay dismissed its petition for formal administrative hearing, allowing AHCA's preliminary denial of CON Application No. 9834 to become final, and filed CON Application No. 9992 to establish a replacement hospital facility on Big Bend Road in Riverview.
St. Joseph's Hospital
St. Joseph's Hospital was founded by the Franciscan Sisters of Allegany, New York, as a small hospital in a converted house in downtown Tampa in 1934. In 1967, SJH opened its existing main hospital facility on Martin Luther King Avenue in Tampa, Florida.
St. Joseph's Hospital, Inc., a not-for-profit entity, is the licensee of St. Joseph's Hospital, an acute care hospital located at 3001 West Martin Luther King, Jr., Boulevard, Tampa, Florida.
As a not-for-profit organization, SJH's mission is to improve the health care of the community by providing high- quality compassionate care.
St. Joseph's Hospital, Inc., is a Medicaid disproportionate share provider and provided $145 million in charity and uncompensated care in 2009.
St. Joseph's Hospital, Inc., is licensed to operate approximately 883 beds, including acute care beds; Level II and Level III neonatal intensive care unit (NICU) beds; and adult and child-adolescent psychiatric beds. The majority of beds are
semi-private. Services include Level II and pediatric trauma services, angioplasty, and open-heart surgery.
These beds and services are distributed among SJH's main campus; St. Joseph's Women's Hospital; St. Joseph's Hospital North, a newer satellite hospital in north Tampa; and
St. Joseph's Children's Hospital. Except for St. Joseph's Hospital North, these facilities are land-locked. Nevertheless, SJH has continued to invest in its physical plant and to upgrade its medical technology and equipment.
In February 2010, SJH opened St. Joseph's Hospital North, a state-of-the-art, 76-bed satellite hospital in Lutz,
north Hillsborough County, at a cost of approximately $225 million. This facility is approximately 14 miles away from the main campus.
This followed the award of CON No. 9610 to SJH for the establishment of St. Joseph's Hospital North, which was unsuccessfully opposed by University Community Hospital and Tampa General Hospital, two existing hospital providers in Tampa. Univ. Cmty. Hosp., Inc., d/b/a Univ. Cmty. Hosp. v. Agency for Health Care Admin., Case Nos. 03-0337CON and 03-0338CON.
St. Joseph's Hospital North operates under the same license and under common management.
St. Joseph's Hospital, Inc., is also the holder of CON No. 9833 for the establishment of a 90-bed state-of-the-art satellite hospital on Big Bend Road, Riverview, Hillsborough County. These all private beds include general medical-surgical beds, an ICU, and a 10-bed obstetrical unit. On October 21, 2009, the Agency revised CON No. 9833 with a termination date of October 21, 2012.
This project was unsuccessfully opposed by TG, SB, and Brandon. St. Joseph's Hosp., Inc. v. Agency for Health Care Admin., Case No. 05-2754CON, supra. St. Joseph's Hospital anticipates construction beginning in October 2012 and opening the satellite hospital, to be known as St. Joseph's Hospital South, in early 2015. This hospital will be operating under
SJH's existing license and Medicare and Medicaid provider numbers and will in all respects be an integral component of SJH.
The implementation of St. Joseph's Hospital South is underway. SJH has contracted with consultants, engineers, architects, and contractors and has funded the first phase of the project with $6 million, a portion of which has been spent.
The application for CON No. 9833 refers to "evidence- based design" and the construction of a state-of-the-art facility. (The design of St. Joseph's Hospital North also uses "evidence-based design.")
St. Joseph's Hospital South will have all private rooms, general surgery operating rooms as well as endoscopy, and a 10-bed obstetrics unit. Although CON No. 9833 is for a project involving 228,810 square feet of new construction, SJH intends to build a much larger facility, approximately 400,000 square feet on approximately 70 acres.
St. Joseph's Hospital Main's physical plant is 43 years old. The majority of the patient rooms are semi–private and about 35% of patients admitted at this hospital received private rooms. Notwithstanding the age of its physical plant and its semi–private bed configuration, SJH has a reputation of providing high quality of care and is a strong competitor in its market.
St. Joseph's Hospital, Inc., has two facility expansions currently in progress at its main location in Tampa: a new five-story building that will house SJH neonatal intensive
care unit, obstetrical, and gynecology services; and a separate, two-story addition with 52 private patient rooms. Of the 52 private patient rooms, 26 will be dedicated to patients recovering from orthopedic surgery, and will be large enough to allow physical therapy to be done in the patient room itself.
The other 26 rooms will be new medical-surgical ICU beds at the hospital.
At the same time that SJH expands its main location, it is pursuing a strategic plan whereby the main location is the "hub" of its system, with community hospitals and health facilities located in outlying communities.
As proposed in CON Application No. 9610, St. Joseph's Hospital North was to be 240,000 square feet in size. Following the award of CON No. 9610, SJH requested that AHCA modify the CON to provide for construction of a larger facility. In its modification request, SJH requested to establish a large, state- of-the-art facility with all private patient rooms, and the desirability of private patient rooms as a matter of infection control and patient preference. AHCA granted the modification.
St. Joseph's Hospital, Inc., thereafter planned to construct St. Joseph's Hospital North to be four stories in height. The plan was opposed. St. Joseph's Hospital, Inc., offered to construct a three-story building, large enough horizontally to accommodate the CON square footage modification. The offer was accepted.
St. Joseph's Hospital, Inc., markets St. Joseph's Hospital North as "The Hospital of the Future, Today." The hospital was constructed using "evidence-based design" to maximize operational efficiencies and enhance the healing process of its residents –- recognizing, among other things, the role of the patient's family and friends. The facility's patient care units are all state-of-the-art and include, for example, obstetrical suites in which a visiting family member can spend the night. A spacious, sunlit atrium and a "healing garden" are also provided. The hospital's dining facility is frequented by community residents.
In addition, SJH owns a physician group practice under HealthPoint Medical Group, a subsidiary of St. Joseph's Health Care Center, Inc. The group practice has approximately 19 different office locations, including several within the service area for the proposed hospital. The group includes approximately
106 physicians. However, most of the office locations are in Tampa, and the group does not have an office in Riverview, although there are plans to expand locations to include the Big Bend Road site.
St. Joseph's Hospital, Inc., anticipates having to establish a new medical staff for St. Joseph's Hospital South, and will build a medical office building at the site for the purpose of attracting physicians. It further anticipates that
some number of physicians on SB's existing medical staff will apply for privileges at St. Joseph's Hospital South.
St. Joseph's Hospital, Inc., is the market leader among Hillsborough County hospitals and is currently doing well financially, as it has historically. For 2010, St. Joseph's Hospital Main's operating income was approximately $78 million.
Organizationally, SJH has a parent organization,
St. Joseph's Health Care Center, Inc., and is one of eight hospitals in the greater Tampa Bay area affiliated with BayCare. On behalf of its member hospitals, BayCare arranges financing for capital projects, provides support for various administrative functions, and negotiates managed care contracts that cover its members as a group.
St. Joseph's Hospital characterizes fees paid for BayCare services as an allocation of expenses rather than a management fee for its services. In 2009, SJH paid BayCare approximately $42 million for services.
St. Joseph's Hospital is one of three BayCare affiliates in Hillsborough County. The other two are
St. Joseph's Hospital North and South Florida Baptist Hospital, a community hospital in Plant City. St. Joseph's Hospital South would be the fourth BayCare hospital in the county.
Tampa General
The Hillsborough County Hospital Authority, a public body appointed by the county, operated Tampa General Hospital
until 1997. In that year, TG was leased to Florida Health Sciences Center, Inc., a non-profit corporation and the current hospital licensee.
Tampa General is a 1,018-bed acute care hospital located at 2 Columbia Drive, Davis Island, Tampa, Florida. In addition to trauma surgery services, TG provides tertiary services, such as angioplasty, open-heart surgery, and organ transplantation. Tampa General operates the only burn center in the area.
A rehabilitation hospital is connected to the main hospital, but there are plans to relocate this facility. Tampa General owns a medical office building.
Tampa General is JCAHO accredited and has received numerous honors. Tampa General provides high-quality of care.
Approximately half of the beds at TG are private rooms.
Tampa General's service area for non-tertiary services includes all of Hillsborough County.
Tampa General is also the teaching hospital for the University of South Florida's College of Medicine. As a statutory teaching hospital, TG has 550 residents and funds over
300 postgraduate physicians in training.
Tampa General is the predominant provider of services to Medicaid recipients and the medically indigent of Hillsborough County. It is considered the only safety-net hospital in Hillsborough County. (A safety net hospital provides a
disproportionate amount of care to indigent and underinsured patients in comparison to other hospitals.)
A high volume of indigent (Medicaid and charity) patients are discharged from TG. In 2009, the costs TG incurred treating indigent patients exceeded reimbursement by $56.5 million. Approximately 33% of Tampa General's patients are Medicare patients and 25% commercial.
Tampa General has grown in the past 10 years. It added
31 licensed acute care beds in 2004 and 82 more since SB's application was filed in 2007. In addition, the Bayshore Pavilion, a $300-million project, was recently completed. The project enlarged TG's ED, and added a new cardiovascular unit, a new neurosciences and trauma center, a new OB-GYN floor, and a new gastrointestinal unit.
Facility improvements are generally ongoing. Tampa General's capital budget for 2011 is approximately $100 million.
In 2010, TG's operating margin was approximately $43 million and a small operating margin in 2011.
AHCA
AHCA is the state agency that administers the CON law. Jeff Gregg testified that during his tenure, AHCA has never preliminarily denied a replacement hospital CON application or required consideration of alternatives to a replacement hospital. Mr. Gregg opined that the lack of alternatives or options is a
relevant consideration when reviewing a replacement hospital CON application. T 468.
The Agency's State Agency Action Report (SAAR) provides reasons for preliminarily approving SB's CON application. During the hearing, Mr. Gregg testified, in part, that the primary reasons for preliminary approval were issues related to quality of care "because the facility represents itself as being unable to expand or adapt significantly to the rapidly changing world of acute care. This is consistent with what [he has] heard about other replacement hospitals." T 413.
Mr. Gregg also noted that SB focused on improving access "[a]nd as the years go by, it is reasonable to expect that the population outside of Sun City Center, the immediate Sun City Center area, will steadily increase and improve access for more people, and that's particularly true because this application includes both a freestanding emergency department and a shuttle service for the people in the immediate area. And that was intended to address their concerns based upon the fact that they have had this facility very conveniently located for them in the past at a time when there was little development in the general south Hillsborough area. But the applicant wants to position itself for the expected growth in the future, and we think has made an excellent effort to accommodate the immediate interests of Sun City Center residents with their promises to do the emergency, freestanding emergency department and the shuttle
service so that the people will continue to have very comfortable access to the hospital." T 413-14.
Mr. Gregg reiterated "that the improvements in quality outweigh any concerns that [the Agency] should have about the replacement and relocation of this facility; that if this facility were to be forced to remain where it is, over time it would be reasonable to expect that quality would diminish."
T 435.
For AHCA, replacement hospital applications receive the same level of scrutiny as any other acute care hospital applications. T 439-40.
South Bay's existing facility and site
South Bay is located on the north side of SR 674, an east-west thoroughfare in south Hillsborough County. The area around the hospital is "built out" with predominantly residential development.
Sun City Center, an age-restricted (55 and older) retirement community, is located directly across SR 674 from the hospital as well as on the north side of SR 674 to the east of the hospital. Other residential development is immediately to the west of the hospital on the north side of SR 674. See
FOF 3-6.
Sun City Center is flanked by two north-south arterial roadways, I-75 to the west and U.S. Highway 301 to the east, both of which intersect with SR 674.
The community of Ruskin is situated generally around the intersection of SR 674 and U.S. 41, west of I-75.
The community of Wimauma is situated along SR 674 just east of U.S. Highway 301.
South Bay is located in a three-story building that is well–maintained and in relatively good repair. The facility is well laid out in terms of design as a community hospital.
Patients and staff at SB are satisfied with the quality of care and scope of acute care services provided at the hospital. Notwithstanding current space limitations, and problems in the ICU, see FOF 77-82, patients receive a high quality of care.
One of the stated reasons for replacement is with respect to SB's request to have all private patient rooms in order to be more competitive with St. Joseph's Hospital South.
South Bay's inpatient rooms are located within the original construction. The hospital is approximately 115,800 square feet, or a little over 1,000 square feet per inpatient bed. By comparison, small to mid-sized community hospitals built today are commonly 2,400 square feet per inpatient bed on average. All of SB's patient care units are undersized by today's standards, with the exception of the ED.
ICU patients, often not ambulatory, require a higher level of care than other hospital patients. The ICU at SB is not adequate to meet the level of care required by the ICU patient.
SB's ICU comprises eight rooms with one bed apiece. Eight beds are not enough. As Dr. Ksaibati put it at hearing: "Right now we have eight and we are always short . . .
double . . . the number of beds, that's at least [the] minimum [t]hat I expect we are going to have if we go to a new facility." T 198-99 (emphasis added).
The shortage of beds is not the only problem. The size of SB's ICU rooms is too small. (Problems with the ICU have existed at least since 2006.)
Inadequate size prohibits separate, adjoining bathrooms. For patients able to leave their beds, therefore, portable bathroom equipment in the ICU room is required.
Inadequate size, the presence of furniture, and the presence of equipment in the ICU room creates serious quality of care issues. When an EKG is conducted, the nurse cannot be present in the room. Otherwise, there would be no space for the EKG equipment. It is difficult to intubate a patient and, at times, "extremely dangerous." T 170. A major concern is when a life-threatening problem occurs that requires emergency treatment at the ICU patient's bedside. For example, when a cardiac arrest "code" is called, furniture and the portable bathroom equipment must be removed before emergency cardiac staff and equipment necessary to restore the function of the patient's heart can reach the patient for the commencement of treatment.
Comparison to ICU rooms at other facilities underscores the inadequate size of SB's ICU rooms. Many of the ICU rooms at Brandon are much larger -- more than twice the size of SB's ICU rooms.
Support spaces are inadequate in most areas, resulting in corridors (at times) being used for inappropriate storage. In addition, the hospital's general storage is inadequate, resulting in movable equipment being stored in mechanical and electrical rooms.
Of the medical-surgical beds at SB, 48 are private and
64 are semi-private. The current standard in hospital design is for acute care hospitals to have private rooms exclusively.
Private patient rooms are superior to semi-private rooms for infection control and patient well-being in general. The patient is spared the disruption and occasional unpleasantness that accompanies sharing a patient room –- for example, another patient's persistent cough or inability to use the toilet (many of SB's semi-private rooms have bedside commodes). Private rooms are generally recognized as promoting quality of care.
South Bay's site is approximately 17.5 acres, bordered on all sides by parcels not owned by either SB or by HCA- affiliated entities. The facility is set back from SR 674 by a visitor parking lot. Proceeding clockwise around the facility from the visitor parking lot, there is a small service road on
the western edge of the site; two large, adjacent ponds for stormwater retention; the rear parking lot for ED visitors and patients; and another small service road which connects the east side of the site to SR 674, and which is used by ambulances to access the ED. Dedicated parking for SB's employees is absent.
A medical office building (MOB), which is not owned by SB, is located to the north of the ED parking lot. The MOB houses SB's Human Resources Department as well as medical offices. Most of SB's specialty physicians have either full or part-time offices in close proximity to SB.
Employee parking is not available in the MOB parking lot. Some of SB's employees park in a hospital-owned parking lot to the north of the MOB, and then walk around the MOB to enter the hospital. South Bay's CEO and management employees park on a strip of a gravel lot, which is rented from the Methodist church to the northeast of the hospital's site.
In 2007, as part of the CON application to relocate, SB commissioned a site and facility assessment (SFA) of the hospital. The SFA was prepared for the purpose of supporting SB's replacement hospital application and has not been updated since its preparation in 2007. The architects or engineers who prepared the SFA were not asked to evaluate proposed options for expansion or upgrade of SB on-site. However, the SFA concludes that the SB site has been built out to its maximum capacity.
On the other hand, the SFA concluded that the existing building systems at SB met codes and standards in force when constructed and are in adequate condition and have the capacity to meet the current needs of the hospital. The report also stated that if SB wanted to substantially expand its physical plant to accommodate future growth, upgrades to some of the existing building systems likely would be required.
Notwithstanding these reports and relative costs, expansion of SB at its existing site is not realistic or cost- effective as compared to a replacement hospital. Vertical expansion is complicated by two factors. First, the hospital's original construction in 1982 was done under the former Southern Standard Building Code, which did not contain the "wind-loading" requirements of the present-day Florida Building Code. Any vertical expansion of SB would not only require the new construction to meet current wind-loading requirements, but would also require the original construction to be retrofitted to meet current wind-loading requirements (assuming this was even possible as a structural matter). Second, if vertical expansion were to meet current standards for hospital square footage, the new floor or floors would "overhang" the smaller existing construction, complicating utility connections from the lower floor as well as the placement of structural columns to support the additional load. The alternative (assuming feasibility due to current wind-loading requirements) would be to vertically
stack patient care units identical to SB's existing patient care units, thereby perpetuating its undersized and outdated design.
Vertical expansion at SB has not been proposed by the Gould Turner Group (Gould Turner), which did a Master Facility Plan for SB in May 2010, but included a new patient bed tower, or by HBE Corporation (HBE).
Horizontal expansion of SB is no less complicated. The hospital would more than double in size to meet the modern-day standard of 2,400 square feet per bed, and its site is too small for such expansion. It is apparent that such expansion would displace the visitor parking lot if located to the south of the existing building, and likely have to extend into SR 674 itself.
South Bay's architectural consultant expert witness substantiated that replacing SB is justified as an architectural matter, and that the facility cannot be brought up to present-day standards at its existing location. According to Mr. Siconolfi, the overall building at SB is approximately half of the total size that would normally be in place for a new hospital meeting modern codes and industry standards. The more modest expansions offered by Gould Turner and HBE are still problematic, if feasible at all. Moreover, with either proposal, SB would ultimately remain on its existing 17.5-acre site, with few opportunities to expand further.
Gould Turner's study was requested by SB's CEO in May 2010, to determine whether and to what extent SB would be able to
expand on-site. (Gould Turner was involved with SB's recent ED expansion project area.)
The resulting Master Facility Plan essentially proposes building a new patient tower in SB's existing visitor parking lot, to the left and right of the existing main entrance to SB. This would require construction of a new visitor parking lot in whatever space remained in between the new construction and
SR 674. The Master Facility Plan contains no discussion of the new impervious area that would be added to the site and the consequential requirement of additional stormwater capacity, assuming the site can even accommodate additional stormwater capacity.
This study also included a new 12-bed ICU and the existing ICU would be renovated into private patient rooms. For example, "[t]he second floor would be all telemetry beds while the third floor would be a combination of medical/surgical, PCU, and telemetry beds."
In Gould Turner's drawings, the construction itself would be to the left and to the right of the hospital's existing main entrance. Two scenarios are proposed: in the first, the hospital's existing semi-private rooms would become private rooms and, with the new construction, the hospital would have 114 licensed beds (including two new beds), all private; in the second, some of the hospital's existing semi-private rooms would become private rooms and, with the new construction, the hospital
would have 146 licensed beds (adding 34 beds), of which 32 would be semi-private.
South Bay did not consider Gould Turner's alternative further or request additional, more detailed drawings or analysis, and instead determined to pursue the replacement hospital project, in part, because it was better not to "piecemeal" the hospital together.
Mr. Miller, who is responsible for strategic decisions regarding SB, was aware of, but did not review the Master Facility Plan and believes that it is not economically feasible to expand the hospital.
St. Joseph's Hospital presented testimony of an architect representing the hospital design/build firm of HBE, to evaluate SB's current condition, to provide options for expansion and upgrading on-site, and to provide a professional cost estimate for the expansion.
Mr. Oliver personally inspected SB's site and facility in October 2010 and reviewed numerous reports regarding the facility and other documents. Mr. Oliver performed an analysis of SB's existing physical plant and land surrounding the hospital.
HBE's analysis concluded that SB has the option to expand and upgrade on-site, including the construction of a modern surgical suite, a modern 10-bed ICU, additional elevators, and expansion and upgrading of the ancillary support spaces
identified by SB as less than ideal. HBE's proposal involves the addition of 50,000 square feet of space to the hospital through the construction of a three-story patient tower at the south side of the hospital.
The additional square footage included in the HBE proposal would allow the hospital to convert to an all-private bed configuration with either 126 private beds by building out both second and third floors of a new patient tower, or to 126 private beds if the hospital chose to "shell in" the third floor for future expansion. Under the HBE proposal, SB would have the option to increase its licensed bed capacity 158 beds by completing the second and third floors of the new patient tower (all private rooms) while maintaining the mix of semi-private and private patient rooms in the existing bed tower.
The HBE proposal also provides for a phased renovation of the interior of SB to allow for an expanded post-anesthesia care unit, expanded laboratory, pharmacy, endoscopy, women's center, prep/hold/recovery areas, central sterile supply and distribution, expanded dining, and a new covered lobby entrance to the left side of the hospital. Phasing of the expansion would permit the hospital to remain in operation during expansion and renovation with minimal disruption. During construction the north entrance of the hospital would provide access through the waiting rooms that are currently part of the 2001 renovated area
of the hospital with direct access to the circulation patterns of the hospital.
The HBE proposal also provides for the addition of parking to bring the number of parking spaces on-site to 400.
The HBE proposal includes additional stormwater retention/detention areas that could serve as attractive water features and, similar to the earlier civil engineering reports obtained by SB, proposes the construction of a parking garage at the rear of the facility should additional parking be needed in the future.
However, HBE essentially proposes the alternative already rejected by SB: construction of a new patient tower in front of the existing hospital. Similar to Gould Turner, HBE proposes new construction to the left and right of the hospital's existing lobby entrance and the other changes described above.
HBE's proposal recognizes the need for additional stormwater retention: the stand of trees that sets off the existing visitor parking lot from SR 674 would be uprooted; in their place, a retention pond would be constructed. Approval of the Southwest Florida Water Management District (SWFWMD) would be required for the proposal to be feasible. Assuming the SWFWMD approved the proposal, the retention pond would have to be enclosed by a fence. This would then be the "face" of the hospital to the public on SR 674.
HBE's proposal poses significant problems. The first floor of the three-story component would be flush against the exterior wall of the hospital's administrative offices, where the CEO and others currently have windows with a vista of the front parking lot and SR 674. Since the three-story component would be constructed first in the "phased" construction, and since the hospital's administration has no other place to work in the existing facility, the CEO and other management team would have to work off-site until the new administrative offices (to the left of the existing hospital lobby entrance) were constructed. The existing main entrance to the hospital, which faces SR 674, would be relocated to the west side of the hospital once construction was completed in its entirety. In the interim, patients and visitors would have to enter the facility from the rear, as the existing main entrance would be inaccessible. This would be for a period of months, if not longer.
For the second and third floors, HBE's proposal poses two scenarios. Under the first, SB would build the 24 general medical-surgical beds on the tower's second floor, but leave the third floor as "shelled" space. This would leave SB with a total of 106 licensed beds, six fewer than it has at present. Further, since HBE's proposal involves a second ICU at SB, 18 of the 106 beds are ICU beds, leaving 88 general medical-surgical beds.
By comparison, SB currently has 104 general medical- surgical beds, meaning that it loses 16 general medical-surgical
beds under HBE's first scenario. In the second scenario, SB would build 24 general medical-surgical beds on the third floor as well, and would have a total of 126 licensed beds. Since 18 of those beds would be ICU beds, SB would have 108 general medical-surgical beds, or only four more than it has at present. Further, the proposal does not make SB appreciably bigger.
The second and third floors in HBE's proposal are designed in "elongated" fashion such that several rooms may be obscured from the nursing station's line of sight by a new elevator, which is undesirable as a matter of patient safety and security. Further, construction of the second and third floors would be against the existing second and third floors above the lobby entrance's east side. This would require 12 existing private patient rooms to be taken out of service due to loss of their vista windows. At the same time, the new second and third floors would be parallel to, but set back from, existing semi- private patient rooms and their vista windows along the southeast side of the hospital. This means that patients and visitors in the existing semi-private patient rooms and patients and visitors in the new private patient rooms on the north side of the new construction may be looking into each other's rooms.
HBE's proposal also involves reorganization and renovation of SB's existing facility, and the demolition and disruption that goes with it. To accommodate patient circulation within the existing facility from the ED (at the north side of
the hospital) to the new patient tower (at the south side of the hospital), two new corridors are proposed to be routed through and displace the existing departments of Data Processing and Medical Records. Thus, until the new administrative office space would be constructed, Data Processing and Medical Records (along with the management team) would have to be relocated off-site.
Once the new first floor of the three-story component is completed, the hospital's four ORs and six PACU beds will be relocated there. In the existing vacated surgical space, HBE proposes to relocate SB's existing cardiology unit, thus requiring the vacated surgical space to be completely reconfigured (building a nursing station and support spaces that do not currently exist in that location). In the space vacated by the existing cardiology unit, HBE proposed expanding the hospital's clinical laboratory, meaning extensive demolition and reconfiguration in that area. The pharmacy is proposed to be relocated to where the existing PACU is located, requiring the building of a new pharmacy with a secure area for controlled substances, cabinets for other medications, and the like. The vacated existing pharmacy is in turn proposed to be dedicated to general storage, which involves still more construction and demolition, tearing out the old pharmacy to make the space suitable for general storage.
HBE's proposal is described as a "substantial upgrade" of SB, but it was stated that a substantial upgrade could
likewise be achieved by replacing the facility outright. This is SB's preference, which is not unreasonable.
There have been documented problems with other hospital expansions, including patient infection due to construction dust.
South Bay's proposal
South Bay proposes to establish a 112-bed replacement hospital on a 39-acre parcel (acquired in 2005) located in the Riverview community, on the north side of Big Bend Road between I-75 and U.S. Highway 301. The hospital is designed to include
32 observation beds built to acute care occupancy standards, to be available for conversion to licensed acute care beds should the need arise. The original total project cost of $215,641,934, calculated when the application was filed in October 2007 has been revised to $192,967,399. The decrease in total project cost is largely due to the decrease in construction costs since 2007. The parties stipulated that SB's estimated construction costs are reasonable.
The remainder of the project budget is likewise reasonable. The budgeted number for land, $9,400,000, is more than SB needs: the 39-acre parcel is held in its behalf by HCA Services of Florida, Inc., and was acquired in March 2005 for
$7,823,100. An environmental study has been done, and the site has no environmental development issues.
The original site preparation budgeted number of $5 million has been increased to $7 million to allow for possible impact fees, based on HCA's experience with similar projects. Building costs, other than construction cost, flow from the construction cost number as a matter of percentages and are reasonable.
The equipment costs are reasonable. Construction period interest as revised from the original project budget is approximately $4 million less, commensurate with the revised project cost. Other smaller numbers in the budget, such as contingencies and start-up costs, were calculated in the usual and accepted manner for estimated project costs and are reasonable.
South Bay's proposed service area (PSA) comprises six zip codes (33573 (Sun City Center), 33570 (Ruskin), 33569 (Riverview), 33598 (Wimauma), 33572 (Apollo Beach), and 33534 (Gibsonton)) in South Hillsborough County. These six zip codes accounted for 92.2% of SB's discharges in 2006. The first three zip codes, which include Riverview (33569), accounted for 76.1% of the discharges.
Following the filing of the application in 2007, the
U.S. Postal Service subdivided the former zip code 33569 into three zip codes: 33569, 33578, and 33579. (The proposed service area consists of eight zip codes.)
The same geographic area comprises the three Riverview zip codes taken together as the former zip code 33569. In 2009, the three Riverview zip codes combined accounted for approximately 504 to 511/514 of SB's discharges, with 589 discharges in 2006 from the zip code 33569. Of SB's total discharges in 2009, approximately 8 to 9% originated from these three zip codes.
In 2009, approximately 7,398 out of 14,424 market/service-area discharges, or approximately 51% of the total market discharges came from the three southern zip codes, 33573 (Sun City Center), 33570 (Ruskin), and 33598 (Wimauma). Also, approximately 81% of SB's discharges in 2009 originated from the same three zip codes. (The discharge numbers for SB for 2009 presented by St. Joseph's Hospital and SB are similar. See SB Ex. 9 at 11 and SJH Ex. 4 at 8-9. See also TG Ex. 4 at 3-4.)
In 2009, SB and Brandon had an approximate 68% market share for the eight zip codes. See FOF 152-54 and 162-65 for additional demographic data.
St. Joseph's Hospital had an approximate 5% market share within the service area and using 2009-2010 data, TG had approximately 6% market share in zip code 33573 and an overall market share in the three Riverview zip codes of approximately 19% and a market share of approximately 23% in zip code 33579.
South Bay's application projects 37,292 patient days in year 1; 39,581 patient days in year 2; and 41,563 patient days
in year 3 for the proposed replacement hospital. The projection was based on the January 2007 population for the service area as reflected in the application, and what was then a projected population growth rate of 20.8% for the five-year period 2007 to 2012. These projections were updated for the purposes of hearing. See FOF 246-7.
The application also noted a downturn in the housing market, which began in 2007 and has continued since then. The application projected a five-year (2007-2012) change of 20.8% for the original five zip codes.
At hearing, SB introduced updated utilization projections for 2010-2015, which show the service area population growing at 15.3% for that five-year period.
South Bay's revised utilization projections for 2015- 2017 (projected years 1-3 of the replacement hospital) are 28,168 patient days in year 1; 28,569 patient days in year 2; and 29,582 patient days in year 3. The lesser utilization as compared with SB's original projections is partly due to slowed population growth, but predominantly due to SB's assumption that St. Joseph's Hospital will build its proposed satellite hospital in Riverview, and that SB will accordingly lose 20% of its market share. The revised utilization projections are conservative, reasonable, and achievable.
With the relocation, SB will be more proximate to the entirety of its service area, and will be toward the center of
population growth in south Hillsborough County. In addition, it will have a more viable and more sustainable hospital operation even with the reduced market share. Its financial projections reflect a better payor mix and profitability in the proposed location despite the projection of fewer patient days.
Conversely, if SB remains in Sun City Center, it is subject to material operating losses even if its lost market share in that location is the same 20%, as compared to the 30 to 40% it estimates that it would lose in competition with St. Joseph's Hospital South.
South Bay's medical staff and employees support the replacement facility, notwithstanding that their satisfaction with SB is very high. The proposal is also supported by various business organizations, including the Riverview Chamber of Commerce and Ruskin Chamber of Commerce.
However, many of the residents of Sun City Center who testified opposed relocation of SB. See FOF 210-11.
South Bay will accept several preconditions on approval of its CON application: (1) the location of SB on Big Bend Road in Riverview; (2) combined Medicaid and charity care equal to 7.0% of gross revenues; and (3) operating a free- standing ED at the Sun City location and providing a shuttle service between the Sun City location and the new hospital campus ("for patients and visitors"). SB Ex. 46, Schedule C.
In its SAAR, the Agency preliminarily approved the application including the following:
This approval includes, as a component of the proposal: the operation of a freestanding emergency department on a 24-hour, seven-day per week basis at the current Sun City location, the provision of extended hours shuttle service between the existing Sun City Center and the new campuses to transport patients and visitors between the facilities to locations; and the offering of primary care and diagnostic testing at the Sun City Center location. These components are required services to be provided by the replacement hospital as approved by the Agency.
Mr. Gregg explained that the requirement for transport of patients and visitors was included based on his understanding of the concerns of the Sun City Center community for emergency as well as routine access to hospital services.
Notwithstanding the Agency statement that the foregoing elements are required, the Agency did not condition approval on the described elements. See SB Ex. 12 at 39 and 67. Instead, the Agency only required SB, as a condition of approval, to provide a minimum of 7.0% of the hospital's patient days to Medicaid and charity care patients. (As noted above, SB's proposed condition says 7.0% of gross revenues.)
Because conditions on approval of the CON are generally subject to modification, there would be no legal mechanism for monitoring or enforcement of the aspects of the project not made a condition of approval.
If the Agency approves SB's CON application, the Agency should condition any approval based on the conditions referenced above, which SB set forth in its CON application. SB Ex. 12 at 39 and 67. See also T 450 ("[The Agency] can take any statement made in the application and turn that into a condition," although conditions may be modified.1
St. Joseph's Hospital and Tampa General are critical of SB's offer of a freestanding ED and proposed shuttle transportation services. Other than agreeing to condition its CON application by offering these services, SB has not evaluated the manner in which these services would be offered. South Bay envisions that the shuttle service (provided without charge) would be more for visitors than it would be for patients and for outpatients or patients that are ambulatory and able to ride by shuttle. Other patients would be expected to be transported by EMS or other medical transport.
As of the date of hearing, Hillsborough County does not have a protocol to address the transport of patients to a freestanding ED.
South Bay contacted Hillsborough County Fire Rescue prior to filing its CON application and was advised that they would support SB's establishment of a satellite hospital on Big Bend Road, but did not support the closure and relocation of SB, even with a freestanding ED left behind. See FOF 195-207.
At hearing, SB representatives stated that SB would not be closed if the project is denied.
Compliance with applicable statutory and rule criteria
Section 408.035(1): The need for the health care facilities and health services being proposed
The need for SB itself and at its current location is not an issue in this case. That need was demonstrated years ago, when SB was initially approved. For the Agency, consideration of a replacement hospital application "diminishes the concept of need in [the Agency's] weighing and balancing of criteria in this case."
There is no express language in the CON law, as amended, which indicates that CON review of a replacement hospital application does not require consideration of other statutory review criteria, including "need," unless otherwise stipulated.
Replacement hospital applicants, like SB, may advocate the need for replacement rather than expansion or renovation of the existing hospital, but a showing of "need" is still required. Nevertheless, institution-specific factors may be relevant when "need" is considered.
The determination of "need" for SB's relocation involves an analysis of whether the relocation of the hospital as proposed will enhance access or quality of care, and whether the relocation may result in changes in the health care delivery
system that may adversely impact the community, as well as options SB may have for expansion or upgrading on-site.
In this case, the overall "need" for the project is resolved, in part, by considering, in conjunction with weighing and balancing other statutory criteria, including quality of care, whether the institution-specific needs of SB to replace the existing hospital are more reasonable than other alternatives, including renovation and whether, if replacement is recommended, the residents of the service area, including the Sun City Center area, will retain reasonable access to general acute care hospital services. The overall need for the project has not been proven. See COL 360-70 for ultimate conclusions of law regarding the need for this project.
Section 408.035(2): The availability, quality of care, accessibility, and extent of utilization of existing health care facilities and health services in the service district of the applicant
The "service district" in this case is acute care subdistrict 6-1, Hillsborough County. See Fla. Admin. Code R. 59C-2.100.
The acute care hospital services SB proposes to relocate to Big Bend Road are available to residents of SB's service area. Except as otherwise noted herein with respect to constraints at SB, there are no capacity constraints limiting access to acute care hospital services in the subdistrict.
The availability of acute care services for residents of the service area, and specifically the Riverview area, will increase with the opening of St. Joseph's Hospital South.
All existing providers serving the service area provide high quality of care.
Within the service district as a whole, SB proposes to relocate the existing hospital approximately 5.7 linear miles north of its current location and approximately 7.7 miles using
I-75, one exit north. South Bay would remain in south Hillsborough County, as well as the southernmost existing health care facility in Hillsborough County, along with St. Joseph's Hospital South when it is constructed.
The eight zip codes of SB's proposed service area occupy a large area of south Hillsborough County south of Tampa (to the northwest) and Brandon (to the northeast). Included are the communities of Gibsonton, Riverview, Apollo Beach, Ruskin, Sun City Center, and Wimauma. The service area is still growing despite the housing downturn, with a forecast of 15.3% growth for the five-year period 2010 to 2015. The service area's population is projected to be 168,344 in 2015, increasing from 145,986 in 2010.
The service area is currently served primarily by SB, which is the only existing provider in the service area, and Brandon. For non-tertiary, non-specialty discharges from the service area in 2009, SB had approximately 40% market share,
including market share in the three Riverview zip codes of approximately 10% (33569), 6% (33578), and 16% (33579). Brandon had approximately 28% of the market in the service area, and a market share in the three Riverview zip codes of approximately 58% (33569), 46% (33578), and 40% (33579). Thus, SB and Brandon
have approximately a 61% market share in the Riverview zip codes and approximately a 68% market share service area-wide.
The persuasive evidence indicates that Riverview is the center of present and future population in the service area. It is the fastest-growing part of the service area overall and the fastest-growing part of the service area for patients age 65 and over. Of the projected 168,334 residents in 2015, the three Riverview zip codes account for 80,779 or nearly half the total population.
With its proposed relocation to Riverview, SB will be situated in the most populous and fastest-growing part of south Hillsborough County. At the same time, it will be between seven and eight minutes farther away from Sun City Center.
In conjunction with St. Joseph's Hospital South when constructed, SB's proposed relocation will enhance the availability and accessibility of existing health care facilities and health services in south Hillsborough County, especially for the Riverview-area residents. However, it is likely that access will be reduced for the elderly residents of the Sun City Center area needing general acute care hospital services.
St. Joseph's Hospital and Tampa General contend that:
(1) it would be problematic to locate two hospitals in close proximity in Riverview (those being St. Joseph's Hospital South and the relocated SB hospital) and (2) SB's relocation would deprive Sun City Center's elderly of reasonable access to hospital services.
St. Joseph's Hospital seems to agree that the utilization projections for SB's replacement hospital are reasonable. Also, St. Joseph's Hospital expects St. Joseph's Hospital South to reach its utilization as projected in CON Application No. 9833, notwithstanding the decline in population growth and the proposed establishment of SB's proposed replacement hospital, although the achievement of projected utilization may be extended.
There are examples of Florida hospitals operating successfully in close proximity. The evidence at hearing included examples where existing unaffiliated acute care hospitals in Florida operate within three miles of each another; in two of those, the two hospitals are less than one-half mile apart. These hospitals have been in operation for years. However, some or all of the examples preceded CON review. There are also demographic differences and other unique factors in the service areas in the five examples that could explain the close proximity of the hospitals. Also, in three of the five examples,
at least one of the hospitals had an operating loss and most appeared underutilized.
One such example, however, is pertinent in this case: Tallahassee Memorial Hospital and Capital Regional Medical Center (CRMC) in Tallahassee, which are approximately six minutes apart by car. CRMC was formerly Tallahassee Community Hospital (TCH), a struggling, older facility with a majority of semi-private patient rooms, similar to South Bay. Sharon Roush, SB's current CEO, became CEO at TCH in 1999. As she explained at hearing, HCA was able to successfully replace the facility outright on the same parcel of land. TCH was renamed CRMC and re-opened as a state-of-the-art hospital facility with all private rooms. The transformation improved the hospital's quality of care and its attractiveness to patients, better enabling it to compete with Tallahassee Memorial Hospital.
St. Joseph's Hospital and Tampa General also contend that SB's relocation would deprive Sun City Center's elderly of reasonable access to hospital services.
When the application was filed in 2007, Sun City Center residents in zip code 33573 accounted for approximately 52% of all acute care discharges to SB and SB had a 69% market share. By 2009, Sun City Center residents accounted for approximately 57% of all SB discharges and SB had approximately 72% market share.
Approximately half of the age 65-plus residents in the service area reside within the Sun City Center area. This was true in 2010 and will continue to be true in 2015. The projected percentage of the total population in the Sun City Center zip code over 65 for 2009-2010 is approximately 87%. This percentage is expected to grow to approximately 91% by 2015. Sun City Center also has a high percentage of residents who are over the age of 75.
Demand for acute care hospital services is largely driven by the age of the population. The age 65-plus population utilizes acute-care hospital services at a rate that is approximately two to three times that of the age 64 and younger population.
South Bay plans to relocate its hospital from the Sun City Center zip code 33573 much closer to an area (Riverview covering three zip codes) that has a less elderly population.
Elderly patients are known to have more transportation difficulties than other segments of the population, particularly with respect to night driving and congested traffic in busy areas.
Appropriate transportation services for individuals who are transportation disadvantaged typically require door-to- door pickup, but may vary from community to community.
At the time of preliminary approval of SB's proposed relocation, the Agency was not provided and did not take into
consideration data reflecting the percentage of persons in Sun City Center area who are aged 65 or older or aged 75 and older. The Agency was not provided data reflecting the number of residents within the Sun City Center area who reside in nursing homes or assisted living facilities.
In general, the 2010 median household incomes and median home values for the residents of Sun City Center, Ruskin, and Gibsonton are materially less than the income and home values for the residents from the other service areas.
Freedom Village is located near Sun City Center and within walking distance to SB. Freedom Village is comprises a nursing home, assisted living, and senior independent living facilities, and includes approximately 120 skilled nursing facility beds, 90 assisted living beds, and 30 Alzheimer's beds. Freedom Village is home to approximately 1,500 people.
There are additional skilled nursing and assisted living facilities within one to two miles of SB comprising approximately an additional 400 to 500 skilled nursing facility beds and approximately 1,500 to 2,000 residents in assistant or independent living facilities.
Residents in skilled nursing facilities and assisted living facilities generally require a substantial level of acute- care services on an ongoing basis. Many patients 65 and older requiring admission to an acute-care facility have complex
medical conditions and co-morbidities such that immediate access to inpatient acute care services is of prime importance.
Area patients and caregivers travel to SB via a golf cart to access outpatient health care services and to obtain post-discharge follow-up care. Although there are some crossing
points along SR 674, golf carts are not allowed on SR 674 itself, and the majority of Sun City Center residents who utilize SB in its existing location do not arrive by golf cart -– rather, they travel by automobile.
The Sun City Center area has a long–established culture of volunteerism. Residents of Sun City Center provide a substantial number of man-hours of volunteer services to community organizations, including SB.
Among the many services provided by community volunteers is the Sun City Center Emergency Squad, an emergency medical transport service that operates three ambulances and provides EMT and basic life support transport services in Sun City Center 24-hours a day, seven days a week. The Emergency Squad provides emergency services free of charge, but charges patients for transport which is deemed a non-emergency. Most patients transported by the Emergency Squad are taken to the SB ED.
It is customary for specialists to locate their offices adjacent to an acute-care hospital. Most of the specialty physicians on the medical staff of SB have full-time or
part-time offices adjacent to SB. The location of physician offices adjacent to the hospital facilitates access to care by patients in the provision of care on a timely basis by physicians.
The relocation of SB may result in the relocation of physician offices currently operating adjacent to SB in Sun City Center, which may cause additional access problems for local residents.
In 2009, the SB ED had approximately 22,000 patient visits. Approximately 25% of the patients that visit the South Bay ED are admitted for inpatient care.
South Bay recently expanded its ED to accommodate approximately 34,000 patient visits annually. The average age of patients who visit the South Bay ED is approximately 70.
Patients who travel by ambulance may or may not experience undue transportation difficulties as a result of the proposed relocation of SB; however, patients also arrive at the South Bay ED by private transportation. But, most patients are transported to the ED by automobile or emergency transport.
In October 2010, the Board of Directors of the Sun City Center Association adopted a resolution on behalf of its 11,000 members opposing the closure of SB. The Board of Directors and membership of Federation of Kings Point passed a similar resolution on behalf of its members.
Residents of the Sun City Center area currently enjoy easy access to SB in part because the roadways are low-volume, low-speed, accessible residential streets.
SR 674 is the only east-west roadway connecting residents of the Sun City Center area to I-75 and U.S. Highway 301. The section of SR 674 between I-75 and U.S.
Highway 301 is a four-lane divided roadway with a speed limit of 40-45 mph.
To access Big Bend Road from the Sun City Center area, residents travel east on SR 674 then north on U.S. Highway 301 or west on SR 674 then north on I-75.
U.S. Highway 301 is a two-lane undivided roadway from SR 674 north to Balm Road, with a speed limit of 55 mph and a number of driveways and intersections accessing the roadway. (Two lanes from Balm Road South, then widened to six lanes from Balm Road North.)
U.S. Highway 301 is a busy and congested roadway, and there is a significant backup of traffic turning left from U.S. Highway 301 onto Big Bend Road. A portion of U.S. Highway 301 is being widened to six lanes, from Balm Road to Big Bend Road. The widening of this portion of U.S. Highway 301 is not likely to alleviate the backup of traffic at Big Bend Road.
I-75 is the only other north-south alternative for residents of the Sun City Center area seeking access to Big Bend Road. I-75 is a busy four-lane interstate with a 70 mph speed
limit. The exchange on I-75 and Big Bend Road is problematic not only because of traffic volume, but also because of the unusual design of the interchange, which offloads all traffic on the south side of Big Bend Road, rather than divide traffic to the north and south as is typically done in freeway design. The design of the interchange at I-75 in Big Bend Road creates additional backup and delays for traffic seeking to exit onto Big Bend Road.
St. Joseph's Hospital commissioned a travel (drive) time study that compared travel times to SB's existing location and to its proposed location from three intersections within Sun City Center. This showed an increase of between seven and eight minutes' average travel time to get to the proposed location as compared to the existing location of SB. The study corroborated SB's travel time analysis, included in its CON application, which shows four minutes to get to SB from the "centroid" of zip code 33573 (Sun City Center) and 11 minutes to get to SB's proposed location from that centroid, or a difference of seven minutes.
The St. Joseph's Hospital travel time study also sets forth the average travel times from the three Sun City Center intersections to Big Bend Road and Simmons Loop, as follows:
Intersection Using I-75 Using U.S. 301
South Pebble Beach Blvd. and Weatherford Drive | 12 | min. | 17 | secs. | 14 | min. | 19 | secs. |
Kings Blvd. and Manchester Woods Drive | 15 | min. | 44 | secs. | 20 | min. | 39 | secs. |
North Pebble Beach Blvd. and Ft. Dusquesna Drive | 13 | min. | 15 | secs. | 15 | min. | 41 | secs. |
The average travel time from Wimauma (Center Street and Delia Street) to Big Bend Road and Simmons Loop was 15 minutes and 16 seconds using I-75 and 13 minutes and 52 seconds using U.S. Highway 301, an increase of more than six minutes to the proposed site. The average travel time from Ruskin (7th Street and 4th Avenue SW) to Big Bend Road and Simmons Loop was
15 minutes and 22 seconds using U.S. 41 and 14 minutes and 15 seconds using I-75, an increase of more than five minutes to the proposed site.
Currently, the average travel time from Sun City Center to Big Bend Road using U.S. Highway 301 is approximately
to 16 minutes. The average travel time to Big Bend Road via
I-75 assuming travel with the flow of traffic is approximately 13 minutes. The incremental increase in travel time to the proposed site for SB for residents of the Sun City Center area, assuming travel with the flow of traffic, ranges from nine to 11 minutes. For residents who currently access SB in approximately five to 10 minutes, travel time to Big Bend Road is approximately 15 to 20 minutes.
As the area develops, traffic is likely to continue to increase. There are no funded roadway improvements beyond the current widening of U.S. Highway 301 north of Balm Road.
Most of the roadways serving Sun City Center, Ruskin, and Wimauma have a county-adopted Level of Service (LOS) of "D." LOS designations range from "A" to "F", with "F" considered gridlock. Currently, Big Bend Road from Simmons Loop Road (the approximate location of SB's propose replacement hospital) to
I-75 is at LOS "F" with an average travel speed of less than
mph.
Based on a conservative analysis of the projected growth in traffic volume, SR 674 east of U.S. Highway 301 is projected to degrade from LOS "C" to "F" by 2015. By 2020, several additional links on SR 674 will have degraded to LOS "F." The LOS of I-75 is expected to drop to "D" in the entirety of Big Bend Road between U.S. Highway 301 and I-75 is projected to degrade to LOS "F" by 2020.
The Hillsborough County Fire Rescue Department (Rescue Department) opposes the relocation of SB to Big Bend Road. The Rescue Department supports SB's establishment of a satellite hospital on Big Bend Road, but does not support the closure of SB in Sun City Center.
The Rescue Department anticipates that the relocation of SB will result in a reduction in access to emergency services
for patients and increased incident response times for the Rescue Department.
The Rescue Department would support a freestanding ED should SB relocate.
David Travis, formerly (until February 2010) the rescue division chief of the Rescue Department, testified against SB's proposal. The basis of his opposition is his concern that relocating the hospital from Sun City Center to Riverview would tend to increase response times for rescue units operating out of the Sun City Center Fire Station. The term response time refers to the time from dispatch of the rescue unit to its arrival on the scene for a given call.
Mr. Travis noted that rescue units responding from the Sun City Center Fire Station would make a longer drive (perhaps seven to eight minutes) to the new location in Riverview to the extent that hospital services are needed, and during the time of transportation would necessarily be unavailable to respond to another call. However, Mr. Travis had not specifically quantified increases in response times for Sun City Center's rescue units in the event that SB relocates.
Further, SB is not the sole destination for the Rescue Department's Sun City Center rescue units. While a majority of the patients were transported to SB, out of the total patient transports from the greater Sun City Center area in 2009,
approximately one-third went to other hospitals other than SB, including St. Joseph's Hospital, Tampa General, and Brandon.
The Rescue Department is the only advanced life support (ALS) ground transport service in the unincorporated areas of Hillsborough County responding to 911 calls.
The ALS vehicles provide at least one certified paramedic on the vehicle, cardiac monitors, IV medications, advanced air way equipment, and other services.
The Rescue Department has two rescue units in south Hillsborough County - Station 17 in Ruskin and Station 28 in Sun City Center. (Station 22 is in Wimauma, but does not have a rescue unit.) Stations 17 and 28 run the majority of their calls in and around the Sun City Center area, with the majority of transports to the South Bay ED. The Rescue Department had 3,643 transports from the Sun City Center area in 2009, with 54.5% transports to SB.
If SB is relocated to Big Bend Road, the rescue units for Stations 17 and 28 are likely to experience longer out-of- service intervals and may not be as readily available for responding to calls in their primary service area.
The Rescue Department seeks to place an individual on the scene within approximately seven minutes, 90% of the time (an ALS personnel goal) in the Sun City Center area. Relocation of SB out of Sun City Center may make it difficult for the Rescue
Department to meet this response time, notwithstanding the proximity of I-75.
A rapid response time is critical to providing quality
care.
The establishment of a freestanding ED in Sun City
Center would not completely alleviate the Rescue Department's concerns, including a subset of patients who may need to be transported to a general acute care facility.
There are other licensed emergency medical service providers in Hillsborough County, with at least one basic life support EMS provider in Sun City Center.
The shuttle service proposed by SB may not alleviate the transportation difficulties experienced by the patients and caregivers of Sun City Center. Also, SB has not provided a plan for the scope or method of the provisional shuttle services.
Six residents of Sun City Center testified against SB's proposed relocation to Riverview, including Ed Barnes, president of the Sun City Center Community Association.
Mr. Barnes and two other Sun City Center residents (including Donald Schings, president of the Handicapped Club, Sun City Center) spoke in favor of St. Joseph's Hospital's proposed hospital in Riverview at a public land-use meeting in July 2010, thus demonstrating their willingness to travel to Riverview for hospital services.
Mr. Barnes supported St. Joseph's Hospital's proposal for a hospital in Riverview since its inception in 2005, when St. Joseph's Hospital filed CON Application No. 9833 and thought that St. Joseph's Hospital South would serve the Sun City Center area.
There are no public transportation services per se available within the Sun City Center area. Volunteer transportation services are provided. In part, the door-to-door services are provided under the auspices of the Samaritan Services, a non-profit organization supported by donations and staffed by Sun City Center volunteers. It is in doubt whether these services would continue if SB is relocated.
There is a volunteer emergency squad using a few vehicles that responds to emergency calls within the Sun City Center area, with SB as the most frequent destination.
Approval of SB's project will not necessarily enhance financial access to acute care services. The relocation of SB is more likely than not to create some access barriers for low- income residents of the service area. The relocation would also be farther away from communities such as Ruskin and Wimauma as there are no buses or other forms of public transportation available in Ruskin, Sun City Center, or Wimauma.
However, it appears that the Sun City Center residents would travel not only to Riverview, but north of Riverview for hospital services following SB's relocation, notwithstanding the
fact that Sun City Center residents are transportation- disadvantaged.
The Hillsborough County Board of County Commissioners recently amended the Comprehensive Land-Use Plan and adopted the Greater Sun City Center Community Plan, which, in part, lists the retention of an acute care hospital in the Sun City Center area as the highest health care planning priority.
For Sun City Center residents who may not want to drive to SB's new location, SB will provide a shuttle bus, which can convey both non-emergency patients and visitors. South Bay has made the provision of the shuttle bus a condition of its CON.
As noted herein, the CON's other conditions are the establishment of the replacement hospital at the site in Riverview; combined Medicaid and charity care in the amount of 7.0% of gross revenues; and maintaining a freestanding ED at SB. SB Ex. 46, Schedule C.
Section 408.035(3): The ability of the applicant to provide quality of care and the applicant's record of providing quality of care
South Bay has a record of providing high quality of care at its existing hospital. It is accredited by JCAHO, and also accredited as a primary stroke center and chest pain center. In the first quarter of 2010, SB scored well on "core measures" used by the Centers for Medicare and Medicaid Services (CMS) as an indicator of the quality of patient safety. South Bay
received recognition for its infection control programs and successfully implemented numerous other quality initiatives.
Patient satisfaction is high at SB.
AHCA's view of the need for a replacement hospital is not limited according to whether or not the existing hospital meets broad quality indicators, such as JCAHO accreditation. Rather, AHCA recognizes the degree to which quality would be improved by the proposed replacement hospital -– and largely on that basis has consistently approved CON applications for replacement hospitals since at least 1991. See FOF 64-66.
South Bay would have a greater ability to provide quality of care in its proposed replacement hospital. Private patient rooms are superior in terms of infection control and the patient's general well-being. The conceptual design for the hospital, included in the CON application, is the same evidence- based design that HCA used for Methodist Stone Oak Hospital, an award-winning, state-of-the-art hospital in San Antonio, Texas.
Some rooms at SB are small, but SB staff and physicians are able, for the most part, to function appropriately and provide high quality of care notwithstanding. (The ICU is the exception, although it was said that patients receive quality of care in the ICU. See FOF 77-82.) Most of the rooms in the ED "are good size."
Some residents are willing to give up a private room in order to have better access of care and the convenience of care to family members at SB's existing facility.
By comparison, the alternative suggested by
St. Joseph's Hospital does not use evidence-based design and involves gutting and rearranging roughly one-third of SB's existing interior; depends upon erecting a new patient tower that would require parking and stormwater capacity that SB currently does not have; requires SB's administration to relocate off-site during an indeterminate construction period; and involves estimated project costs that its witnesses did not disclose the basis of, claiming that the information was proprietary.
South Bay's physicians are likely to apply for privileges at St. Joseph's Hospital South. Moreover, if SB remains at its current site, it is reasonable to expect that some number of those physicians would do less business at SB or leave the medical staff. Many of SB's physicians have their primary medical offices in Brandon, or otherwise north of Sun City Center.
Further, many of the specialists at SB are also on staff at Brandon. St. Joseph's Hospital South would be more convenient for those physicians, in addition to having the allure of a new, state-of-the-art hospital.
South Bay is struggling with its nursing vacancy rate, which was 12.3% for 2010 at the time of the hearing and had
increased from 9.9% in 2009. The jump in nursing vacancies in 2010 substantially returned the hospital to its 2008 rate, which was 12.4%.
As with its physicians, SB's nurses generally do not reside in the Sun City Center area giving its age restrictions as a retirement community; instead, they live further north in south Hillsborough County. In October 2007 when the application was filed, SB had approximately 105 employees who lived in Riverview.
It is reasonable to expect that SB's nurses will be attracted to St. Joseph's Hospital South, a new, state-of-the-art hospital closer to where they live. Thus, if it is denied the opportunity to replace and relocate its hospital, SB could also expect to lose nursing staff to St. Joseph's Hospital South, increasing its nursing vacancy rate.
Section 408.035(4): The availability of resources, including health personnel, management personnel, and funds for capital and operating expenditures, for project accomplishment and operation
The parties stipulated that Schedule 2 of SB's CON application was complete and required no proof at hearing.
South Bay will not have to recruit nursing or physician staff for its proposed replacement hospital. Its existing medical and nursing staff would not change, and would effectively "travel" with the hospital to its new location. Conversely, the replacement hospital should enhance SB's ability to recruit specialty physicians, which is currently a challenge for SB in its existing facility.
The parties stipulated to the reasonableness of SB's proposed staffing for the replacement hospital as set out in Schedule 6A, but SJH and TG contend that the staffing schedule should also include full-time equivalent positions (FTEs) for the freestanding ED that SB proposes to maintain at its existing hospital. This contention is addressed in the Conclusions of Law, concerning application completeness under section 408.037, at COL 356-57.
South Bay has sufficient funds for capital and operating expenditures for project accomplishment and operation. The project cost will be underwritten by HCA, which has adequate cash flow and credit opportunities. It is reasonable that SB's project will be adequately funded if the CON is approved.
Section 408.035(5): The extent to which the proposed services will enhance access to health care for residents of the service district
The specific area that SB primarily serves, and would continue to serve, is the service area in south Hillsborough County as identified in its application and exhibits.
The discussion in section IV.B., supra, is applicable to this criterion and incorporated herein.
With its proposed relocation to Riverview, SB will be situated in the most populous and fastest-growing part of south Hillsborough County; will be available to serve Sun City Center, Ruskin, and Wimauma; and will be between seven and eight minutes farther away from Sun City Center than it is at present.
However, while the relocated facility will be available to the elderly residents of the Sun City Center area, access for these future patients will be reduced from current levels given the increase in transportation time, whether it be by emergency vehicle or otherwise.
Section 408.035(6): The immediate and long-term financial feasibility of the proposal
Immediate or "short-term" financial feasibility is the ability of the applicant to secure the funds necessary to capitalize and operate the proposed project.
The project cost for SB's proposed replacement hospital is approximately $200 million.
The costs associated with the establishment and operation of the freestanding ED and other services were not included in the application, but for the reasons stated herein, were not required to be projected in SB's CON application.
South Bay demonstrated the short-term financial feasibility of the proposal. The estimated project cost has declined since the filing of the application in 2007, meaning that SB will require less capital than originally forecast.
While Mr. Miller stated that he does not have authority to bind HCA to a $200 million capital project, HCA has indicated that it will provide full financing for the project, and that it will go forward with the project if awarded the CON.
Long-term financial feasibility refers to the ability of a proposed project to generate a profit in a reasonable period
of time. AHCA has previously approved hospital proposals that showed a net profit in the third year of pro forma operation or later. See generally Cent. Fla. Reg. Hosp., Inc. v. Agency for Health Care Admin. & Oviedo HMA, Inc., Case No. 05-0296CON (Fla. DOAH Aug. 23, 2006; Fla. AHCA Jan. 1, 2007), aff'd, 973 So. 2d
1127 (Fla. 1st DCA 2008).
To be conservative, SB's projections, updated for purposes of hearing, take into account the slower population growth in south Hillsborough County since the application was originally filed. South Bay also assumed that St. Joseph's Hospital South will be built and operational by 2015. The net effect, as accounted for in the updated projections, is that SB's replacement hospital will have 28,168 patient days in year 1 (2015); 28,569 patient days in year 2 (2016); and 29,582 patient days in year 3 (2017). That patient volume is reasonable and achievable.
With the updated utilization forecast, SB projects a net profit for the replacement hospital of $711,610 in 2015;
$960,693 in 2016; and $1,658,757 in 2017. The financial forecast was done, using revenue and expense projections appropriately based upon SB's own most recent (2009) financial data.
Adjustments made were to the payor mix and the degree of outpatient services, each of which would change due to the relocation to Riverview.
The revenue projections for the replacement hospital were tested for reasonableness against existing hospitals in SB's peer group, using actual financial data as reported to AHCA.
St. Joseph's Hospital opposed SB's financial projections.
St. Joseph's Hospital's expert did not take issue with SB's forecasted market growth. Rather, it was suggested that there was insufficient market growth to support the future patient utilization projections for St. Joseph's Hospital South and SB at its new location and, as a result, they would have a difficult time achieving their volume forecasts and/or they would need to draw patients from other hospitals, such as Brandon, in order to meet utilization projections.
St. Joseph's Hospital's expert criticized the increase in SB's projected revenues in its proposed new location as compared to its revenues in its existing location. However, it appears that SB's payor mix is projected to change in the new location, with a greater percentage of commercial managed care, thus generating the greater revenue.
South Bay's projected revenue in the commercial indemnity insurance classification was also criticized because SB's projected commercial indemnity revenues were materially overstated. That criticism was based upon the commercial indemnity insurance revenues of St. Joseph's Hospital and Tampa General, which were used as a basis to "adjust" SB's projected
revenue downward. St. Joseph's Hospital and Tampa General's fiscal-year 2009 commercial indemnity net revenue was divided by their inpatient days, added an inflation factor, and then multiplied the result by SB's year 1 (2015) inpatient days to recast SB's projected commercial indemnity net revenue. The contention is effectively that SB's commercial indemnity net revenue would be the same as that of St. Joseph's Hospital and Tampa General.
There is no similarity between the three hospitals in the commercial indemnity classification. The majority of SJH's and TG's commercial indemnity net revenue comes from inpatients rather than outpatient cases; whereas the majority of SB's commercial indemnity net revenue comes from outpatient cases rather than inpatients. This may explain why SB's total commercial indemnity net revenue is higher than SJH or TG, when divided by inpatient days. The application of the lower
St. Joseph's Hospital-Tampa General per-patient-day number to project SB's experience does not appear justified.
It is likely that SB's project will be financially feasible in the short and long-term.
Section 408.035(7): The extent to which the proposal will foster competition that promotes quality and cost-effectiveness
South Bay and Brandon are the dominant providers of health care services in SB's service area. This dominance is likely to be eroded once St. Joseph's Hospital South is
operational in and around 2015 (on Big Bend Road) if SB's relocation project is not approved.
The proposed relocation of SB's facility will not change the geography of SB's service area. However, it will change SB's draw of patients from within the zip codes in the service area. The relocation of SB is expected to increase SB's market share in the three northern Riverview zip codes. This increase can be expected to come at the expense of other providers in the market, including TG and SJH, and St. Joseph's Hospital South when operational.
The potential impact to St. Joseph's Hospital may be approximately $1.6 million based on the projected redirection of patients from St. Joseph's Hospital Main to St. Joseph's Hospital South, population growth in the area, and the relocation of SB. Economic impacts to TG are of record. Tampa General estimates a material impact of $6.4 million if relocation is approved.
Notwithstanding, addressing "provider-based competition," AHCA in its SAAR noted:
Considering the current location is effectively built out at 112 beds (according to the applicant), this project will allow the applicant to increase its bed size as needed along with the growth in population (the applicant's schedules begin with 144 beds in year one of the project). This will shield the applicant from a loss in market share caused by capacity issues and allow the applicant and its affiliates the opportunity to maintain and/or increase its dominant market share.
SB Ex. 12 at 55.
AHCA's observation that replacement and relocation of SB "will shield the applicant from a loss in market share caused by capacity issues" has taken on a new dimension since the issuance of the SAAR. At that time, St. Joseph's Hospital did not have final approval of CON No. 9833 for the establishment of St. Joseph's Hospital South. It is likely that St. Joseph's Hospital South will be operational on Big Bend Road, and as a result, SB, at its existing location, will experience a diminished market share, especially from the Riverview zip codes.
In 2015 (when St. Joseph's Hospital proposes to open St. Joseph's Hospital South), SB projects losing $2,669,335 if SB remains in Sun City Center with a 20% loss in market share. The losses are projected to increase to $3,434,113 in 2016 and
$4,255,573 in 2017. It follows that the losses would be commensurately more severe at the 30% to 40% loss of market share that SB expects if it remains in Sun City Center.
St. Joseph's Hospital criticized SB's projections for its existing hospital if it remains in Sun City Center with a 20% loss in market share; however, the criticism was not persuasively proven. It was assumed that SB's expenses would decrease commensurately with its projected fewer patient days, thus enabling it to turn a profit in calendar year 2015 despite substantially reduced patient service revenue. However, it was also stated that expenses such as hospital administration, pharmacy administration, and nursing administration, which the
analysis assumed to be variable, in fact have a substantial "fixed" component that does not vary regardless of patient census. South Bay would not, therefore, pay roughly $5 million less in "Administration and Overhead" expenses in 2015 as calculated. To the contrary, its expenses for "Administration and Overhead" would most likely remain substantially the same, as calculated by Mr. Weiner, and would have to be paid, notwithstanding SB's reduced revenue.
The only expenses that were recognized as fixed by SJH's expert, and held constant, were SB's calendar year 2009 depreciation ($3,410,001) and short-term interest ($762,738), shown in the exhibit as $4,172,739 both in 2009 and 2015. Other expenses in SJH's analysis are fixed, but were inappropriately assumed to be variable: for example, "Rent, Insurance, Other," which is shown as $1,865,839 in 2009, appears to decrease to
$1,462,059 in 2015. The justification offered at hearing, that such expenses can be re-negotiated by a hospital in the middle of a binding contract, is not reasonable.
St. Joseph's Hospital's expert opined that SB's estimate of a 30 to 40% loss of market share (if SB remained in Sun City Center concurrent with the operation of St. Joseph's Hospital South) was "much higher than it should be," asserting that the loss would not be that great even if all of SB's Riverview discharges went to St. Joseph's Hospital South.
(Mr. Richardson believes the "10 to 20 percent level is likely
reasonable," although he opines that a 5 to 10% impact will likely occur.) However, this criticism assumes that a majority of the patients that currently choose SB would remain at SB at its existing location.
The record reflects that Sun City Center area residents actively supported the establishment of St. Joseph's Hospital South, thus suggesting that they might use the new facility. Further, SB's physicians are likely to join the medical staff of St. Joseph's Hospital South to facilitate that utilization or to potentially lose their patients to physicians with admitting privileges at St. Joseph's Hospital South.
Tampa General's expert also asserted that SB would remain profitable if it remained in its current location, notwithstanding the establishment of St. Joseph's Hospital South. It was contended that SB's net operating revenues per adjusted patient day increased at an annual rate of 5.3% from 2005 to 2009, whereas the average annual increase from 2009 to 2017 in SB's existing hospital projections amounts to 1.8%. On that basis, he opined that SB should be profitable in 2017 at its existing location, notwithstanding a loss in market share to
St. Joseph's Hospital South. However, the 5.3% average annual increase from 2005 to 2009 is not necessarily predictive of SB's future performance, and the evidence indicated the opposite.
Tampa General's expert did not examine SB's performance year-by-year from 2005 to 2009, but rather compared
2005 and 2009 data to calculate the 5.3% average annual increase over the five-year period. This analysis overlooks the hospital's uneven performance during that time, which included operating losses (and overall net losses) in 2005 and 2007.
Further, the evidence showed that the biggest increase in SB's net revenue during that five-year period took place from 2008 to 2009, and was largely due to a significant decrease in bad debt in 2009. SB Ex. 16 at 64. (Bad debt is accounted for as a deduction from gross revenue: thus, the greater the amount of bad debt, the less net revenue all else being equal; the lesser the amount of bad debt, the greater the amount of net revenue all else being equal.) The evidence further showed that the 2009 reduction in bad debt and the hospital's profitability that year, is unlikely to be repeated.
Overall, approval of the project is more likely to increase competition in the service area between the three health care providers/systems. Denial of the project is more likely to have a negative effect on competition in the service area, although it will continue to make general acute care services available and accessible to the Sun City Center area elderly (and family and volunteer support). Approval of the project is likely to improve the quality of care and cost-effectiveness of the services provided by SB, but will reduce access for the elderly residents of the Sun City Center area needing general acute care hospital services who will be required to be transported by
emergency vehicle or otherwise to one of the two Big Bend Road hospitals, unless needed services, such as open heart surgery, are only available elsewhere. For example, if a patient presents to SB needing balloon angioplasty or open heart surgery, the patient is transferred to an appropriate facility such as Brandon.
The presence of an ED on the current SB site may alleviate the reduction in access somewhat for some acute care services, although the precise nature and extent of the proposed services were not explained with precision.
If its application is denied, SB expects to remain operational so long as it remains financially viable.
Section 408.035(8): 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 parties stipulated that the costs and methods of the proposed construction, including the costs and methods of energy provision, were reasonable.
St. Joseph's Hospital and Tampa General did not stipulate concerning the availability of alternative, less costly, or more effective methods of construction, and take the position that SB should renovate and expand its existing facility rather than replace and relocate the facility.
Whether section 408.035(8) requires consideration (weighing and balancing with other statutory criteria) of potential renovation costs as alternatives to relocation was
hotly debated in this case. For the reasons stated herein, it is determined that this subsection, in conjunction with other statutory criteria, requires consideration of potential renovation versus replacement of an existing facility.
St. Joseph's Hospital offered expert opinion that SB could expand and upgrade its existing facility for approximately
$25 million. These projected costs include site work; site utilities; all construction, architectural, and engineering services; chiller; air handlers; interior design; retention basins; and required movable equipment. This cost is substantially less than the approximate $200 million cost of the proposed relocation.
It was proven that there are alternatives to replacing SB. There is testimony that if SB were to undertake renovation and expansion as proposed by SJH, such upgrades would improve SB's competitive and financial position. But, the alternatives proposed by SJH and TG are disfavored by SB and are determined, on this record, not to be reasonable based on the institutional- specific needs of SB.
Section 408.035(9): The applicant's past and proposed provision of health care services to Medicaid patients and the medically indigent
Approval of SB's application will not significantly enhance access to Medicaid, charity, or underserved population groups.
South Bay currently provides approximately 4% of its patient days to Medicaid beneficiaries and about 1% to charity care.
South Bay's historic provision of services to Medicaid patients and the medically indigent is reasonable in view of its location in Sun City Center, which results in a disproportionate share of Medicare in its current payor mix. South Bay also does not offer obstetrics, a service which accounts for a significant degree of Medicaid patient days. South Bay proposes to provide 7% of its "gross patient revenue" to Medicaid and charity patients as part of its relocation. South Bay's proposed service percentage is reasonable.
Section 408.035(10): The applicant's designation as a Gold Seal Program nursing facility pursuant to s. 400.235, when the applicant is requesting additional nursing home beds at that facility
The parties stipulated that this criterion is not applicable.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties to and the subject matter of this proceeding pursuant to sections 120.569, 120.57(1), and 408.039(5), Florida Statutes.
An administrative hearing involving disputed issues of material fact is a de novo proceeding in which the administrative law judge independently evaluates the evidence presented. Fla. Dep't of Transp. v. J.W.C. Co., 396 So. 2d 778, 787 (Fla. 1st DCA
1981); § 120.57(1), Fla. Stat. The Agency's preliminary decision on a CON application, including its findings in the SAAR, is not entitled to a presumption of correctness. Id.
A CON applicant has the burden of demonstrating that its application should be granted. Boca Raton Artificial Kidney Ctr., Inc. v. Dep't of Health & Rehabilitative Servs., 475 So. 2d
260 (Fla. 1st DCA 1985).
The award of a CON must be based on a balanced consideration of all applicable statutory and rule criteria. Balsam v. Dep't of Health & Rehabilitative Servs., 486 So. 2d 1341 (Fla. 1st DCA 1986).
"[T]he appropriate weight to be given to each individual criterion is not fixed, but rather must vary on a case-by-case basis, depending upon the facts of each case." Collier Med. Ctr., Inc. v. State, Dep't of Health & Rehabilitative Servs., 462 So. 2d 83, 84 (Fla. 1st DCA 1985)(citation omitted). See also Lawnwood Med. Ctr., Inc. v. Agency for Health Care Admin., 678 So. 2d 421, 426 (Fla. 1st DCA 1996)("Perhaps in a proper case AHCA might attribute greater weight to certain of the review criteria than that attributed by the hearing officer."); Morton F. Plant Hosp. Ass'n, Inc. v. State, Dep't of Health & Rehabilitative Servs., 491 So. 2d 586 (Fla. 1st DCA 1986)(the hearing officer and AHCA afforded more weight to one criterion over other criteria in denying a CON application).
South Bay's application states that need for the replacement facility is based on the following: (1) Facility conditions, including capacity limitations; (2) site constraints at the existing location; (3) current utilization; (4) service area demographic trends; (5) potential market growth; and
(6) SB's and HCA's commitment to the community. A. Statutory review criteria
In general; joint stipulations
The parties stipulated that the CON review criteria in section 408.035, Florida Statutes (2007) apply to SB's application, given its filing in the August 2007 comparative review cycle. Ch. 2008-29, § 5, Laws of Fla.
The parties stipulated that the following statutory and rule criteria are at issue in this proceeding: section 408.035(1) through (3), (5) through (7), and (9). Section 408.035(10) does not apply. See supra at 6-8 for additional stipulations.
Recent history of section 408.035 and related CON statutes
The parties have different interpretations of the applicability of and weight to be given to the statutory review criteria. South Bay and the Agency contend that whether SB should renovate, rather than replace its existing facility, is not at issue in this proceeding. St. Joseph's Hospital and TG assert that the reasonableness of renovations to the existing facility must be compared to the cost of replacement and weighed
and balanced with other considerations set forth in the applicable statutory criteria.
Historically, "[certificate of need] law was designed to provide for community health needs in a responsible and cost effective manner without unnecessary duplication of health services." Home Health Prof'l Servs., Inc. v. Dep't of Health & Rehabilitative Servs., 463 So. 2d 345, 347 (Fla. 1st DCA 1985)(citation omitted). The term "unnecessary duplication of services" has been restated for many years in CON orders.
In Baptist Medical Center of Clay Inc. v. Agency for Health Care Administration, Case Nos. 06-0555CON, 06-0563CON, and 06-0843CON (Fla. DOAH Dec. 3, 2007; AHCA May 30, 2008, at 11), aff'd, 12 So. 3d 756 (Fla. 1st DCA 2009), the Agency rejected the notion that "unnecessary duplication of existing resources or services is used in CON terminology as a synonym for no need." The Agency referred to two CON cases in which the administrative law judge discussed "unnecessary duplication under the criteria found in 408.035(1)(e) and 408.035(2)(a), (b), and (d), respectively," and stated that "[t]hese provisions were deleted by the legislature in 2000 as 'obsolete.'" The Agency assumed these criteria were still applicable and concluded that "it is within the ALJ's authority to weigh and balance the criteria when evaluating CON applications." Id. (citation omitted).
Generally, health care planning should not be done on an institution-specific basis. See Amisub, (North Ridge Hosp.),
Inc. v. Agency for Health Care Admin., Case Nos. 94-1012, 94- 1016, 94-1017, and 94-1018 (Fla. DOAH Mar. 17, 1995, at COL 145;
Fla. AHCA June 9, 1995); St. Joseph's Hosp. v. Dep't of Health & Rehabilitative Servs., Case No. 86-1542 (Fla. DOAH Sept. 8, 1987, at COL 67; Fla. DHRS Dec. 15, 1987), aff'd, 536 So. 2d 346 (Fla.
1st DCA 1988); Morton F. Plant Hosp. Ass'n, Inc. v. Dep't of Health & Rehabilitative Servs., Case Nos. 83-1275, 84-0296, and 84-0699 (Fla. DOAH Mar. 27, 1985; DHRS Oct. 4, 1985)("The purpose
of the Certificate of Need law is not only to eliminate unnecessary duplication of health services, but also to rationally examine alternative methods of achieving health goals, 'and to aid in their achievement through the most effective means possible within the limits of available resources.' Section 381.493(2), Florida Statutes." RO at COL 39), aff'd, 491 So. 2d
586 (Fla. 1st DCA 1986).
In 1990, the Department of Health and Rehabilitative Services (HRS), now AHCA, proposed the adoption of several rules, including a rule (proposed rule 10-5.004(2)(g)) dealing with projects subject to expedited review-capital expenditure projects. This proposed rule and others were valid, whereas other proposed were invalid. Venice Hosp., Inc. v. State of Fla., Dep't of Health & Rehabilitative Servs., Case Nos. 90- 2383RP, et seq., 1990 Fla. Div. Adm. Hear. LEXIS 6982 (Fla. DOAH Oct. 10, 1990), vol. dismissed, 1D90-3553 (Fla. 1st DCA Mar. 13, 1991).
As noted in the Final Order, "[s]ome of the more common capital expenditures include expansion of emergency departments or emergency rooms and renovation or expansion of other patient care areas. An application to relocate a hospital is also considered a capital expenditure." Venice Hosp. Inc., FO at FOF 29. Also instructive is the discussion of the circumstances when an existing health care facility might apply for a replacement facility at that time and HRS' review of the replacement facility applications. Id. at FOF 30-31.
At that time, competitors did not have standing to challenge the proposed capital expenditure of $1 million or more filed on behalf of a health care facility, including an application for a replacement facility. Id. at FOF 32. See also HCA Health Servs. of Fla., Inc. v. Dep't of Health & Rehabilitative Servs., 599 So. 2d 211, 212-13 (Fla. 1st DCA 1992). At that time, the court stated that "[f]or purposes of the CON review process, capital expenditure is defined in pertinent part as an expenditure which exceeds the minimum as specified in section 381.706(1)(c) for "activities essential to acquisition, improvement, expansion, or replacement of the plant and equipment." § 381.702(1), Fla. Stat. (1989). The term "replacement" is not defined by statute. It is clear in this case that West Volusia seeks to close Fish Memorial and open a new facility, although with the same number beds, on property it
owns several miles distant from the city of the Deland." Id. at 212.
In HCA Health Servs. of Fla., Inc., HCA asserted that HRS' determination to approve West Volusia's CON substantially and adversely affected HCA because the CON would allow West Volusia to establish a new hospital with a substantially different service area. Ultimately, HCA wanted the opportunity to submit a competing proposal via the statutory review cycle.
The court recognized "HCA's concern that it will not have an opportunity to challenge HRS' determination that West Volusia's new hospital is merely a capital expenditure in the form of a replacement hospital. This, however, is a matter to be addressed to the legislature." Id. at 213. The matter was addressed in 1997.
In 1997, the Legislature adopted Committee Substitute for Senate Bill No. 238, which appears as chapter 97-270, Laws of Florida.
Among other amendments, the Legislature amended section 408.035(2)(c) to require the Agency to consider alternatives to replacement construction in evaluating capital expenditure proposals for new inpatient health services. The Agency was required to reference the following in its findings of fact in cases of capital expenditure proposals for the provision of new health services to inpatients: "(c) In the case of new construction or replacement construction, that alternatives to
the new construction, for example, modernization or sharing arrangements, have been considered and have been implemented to the maximum extent practicable." Ch. 97-270, § 2, Laws of Fla. (emphasis in original).
Section 408.036(1)(b), titled "projects subject to review" for "all health-care-related projects," was also amended to require regulation of replacement facilities relocated from an existing site as follows: "(b) The new construction or establishment of additional health care facilities, including a replacement health care facility when the proposed project site is not located on the same site as the existing health care facility." Id. at § 3. (emphasis in original). The
"(h) [r]eplacement of a health care facility when the proposed project site is located in the same district and within a 1-mile radius of the replaced health care facility" was added as a project subject to expedited review under section 408.036(2)(h). Id.
Section 408.036(1)(c), pertaining to capital expenditures, was deleted. Id. at § 3.
Section 408.039(5)(b) was also amended, deleting language denying standing to initiate or intervene in an administrative hearing relating to CON review of a capital expenditure by deleting the following language: "In administrative proceedings challenging the issuance or denial of a certificate of need . . . . Existing health care facilities
may initiate or intervene in an administrative hearing . . . provided that existing health care providers, other than the applicant, have no standing or right to initiate or intervene in an administrative hearing involving a health care project which is subject to certificate of need review solely on the basis of s. 408.036(1)(c). . . ." Id. at § 5.
These changes afforded existing health care providers the opportunity to challenge CON applications proposing replacement facilities, including hospitals, because replacement hospital projects were made subject to regular CON review and no longer subject to expedited review as a capital expenditure. (This was the potential legislative change discussed in HCA Health Servs. of Fla., Inc., supra.)
The following exemption under section 408.036(3)(b) was amended as follows: "(b)(f)For any expenditure to replace or renovate any part of a licensed health care nursing facility, provided that the number of licensed beds will not increase and, in the case of a replacement facility, the project site is the same as the facility being replaced." Id. Ch. 97-270, § 3, Laws of Fla. See also § 14 regarding the prospective applicability of the 1997 amendments.
In 2000, the Legislature adopted Committee Substitute for House Bill No. 2339, which appears as chapter 2000-256, Laws of Florida. The Legislature proposed "a significant reduction and clarification of the review criteria used to evaluate a CON
and remove other obsolete provisions." See House of Representatives as further revised by the Committee on Health Care Licensing & Regulation Final Analysis, CS/HB 2339, storage name: h2339s1z.hcl, June 12, 2000, at 34 and 39; see also Baptist Med. Ctr. of Clay Inc. v. Agency for Health Care Admin., Case Nos. 06-0555CON, 06-0563CON, and 06-0843CON (Fla. DOAH
Dec. 3, 2007; AHCA May 30, 2008, at 11)(referring to HB 2339 and
2000 changes).
Other changes were made to the review criteria in section 408.035. Ch. 2000-256, § 6, Laws of Fla. For example, section 408.035(1)(d), Florida Statutes (1999), pertaining to "[t]he availability and adequacy of other health care facilities and health services in the service district of the
applicant. . . ." was deleted. See also changes to
§ 408.035(1)(b), Fla. Stat. (1999). Id.
Section 408.035(1)(l) was also amended with all but the first sentence remaining, i.e., "The extent to which the proposal will foster competition that promotes quality and cost- effectiveness." Ch. 2000-256, § 6, Laws of Fla. See also
§ 408.035(8), Fla. Stat. (2007).
Prior to being deleted in 2000, section 408.035(2)(c), Florida Statutes (1999) stated: "In cases of capital expenditure proposals for the provision of new health services to inpatients, the agency shall also reference each of the following in its finding of fact: . . . (c) In the case of new construction or
replacement construction, that alternatives to the construction, for example, modernization or sharing arrangements, have been considered and have been implemented to the maximum extent practicable." Section 408.035(2)(a)-(e), Florida Statutes (1999), was deleted. Ch. 2000-256, § 6, Laws of Fla.
South Bay and the Agency argue that when in 2000 paragraph (2)(c) was deleted, CON review of a replacement facility no longer required consideration of alternatives to replacement, including renovation of an existing facility.
Except for renumbering the paragraph in 2000, section 408.035(10), formerly paragraph (1)(m), provided that "[t]he 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" and was not amended and remains as an applicable statutory criterion. See § 408.035(8), Fla. Stat. (2007). (HCA, infra, and Morton Plant, infra, at pages 93-95 suggest this criterion requires consideration of renovation construction as an alternative when considering a replacement hospital CON application.)
There were also several changes to section 408.036(1), Florida Statutes (1999).
But, section 408.036(1)(b) remained the same requiring CON review for "[t]he new construction or establishment of additional health care facilities, including a replacement health
care facility when the proposed project site is not located on the same site as the existing health care facility." Ch. 2000- 256, § 7, Laws of Fla.
Section 408.036(2)(h), which pertains to projects subject to expedited review, was re-lettered to paragraph (e), and continued to provide for expedited review of a "[r]eplacement of a health care facility when the proposed project site is located in the same district and within a 1-mile radius of the replaced health care facility." Id.
Section 408.036(3) was amended to provide for an exemption from CON review "[f]or replacement of any expenditure to replace or renovate any part of a licensed health care facility on the same site, provided that the number of licensed beds in each licensed bed category will not increase and, in the case of a replacement facility, the project site is the same as the facility being replaced. Id. (emphasis in original).
In 2004, the Legislature adopted House Bill No. 329, which appears as chapter 2004-383, Laws of Florida. The Legislature again made several changes to the CON review criteria in section 408.035 and also amended section 408.036(1)(b), Florida Statutes (2003), projects subject to review, as follows: "The new construction or establishment of additional health care facilities, including a replacement health care facility when the proposed project site is not located on the same site as or
within 1 mile of the existing health care facility, if the number of beds in each licensed bed category will not increase."
Ch. 2004-283, § 6, Laws of Fla. (emphasis in original).
Section 408.036(2)(e), Florida Statutes (2003), providing for expedited review of "[r]eplacement of a health care facility when the proposed project site is located in the same district and within a 1-mile radius of the replaced health care facility," was repealed. Id.
The CON statutory review criteria in section 408.035 remained unchanged following the 2004 amendments through 2007. See § 408.035(1)-(10), Fla. Stat. (2007).
As of 2007 and applicable in this case, "[u]nless exempt under subsection (3), all health-care-related projects, as described in paragraphs (a)-(g), are subject to review and must file an application for a certificate of need with the agency. The agency is exclusively responsible for determining whether a health-care-related project is subject to review under ss. 408.031-408.045." § 408.036(1), Fla. Stat. (2007).
Relevant here, section 408.036(1)(b), Florida Statutes (2007), provides for review for "[t]he new construction or establishment of additional health care facilities, including a replacement health care facility when the proposed project site is not located on the same site as or within 1 mile of the existing health care facility, if the number of beds in each licensed bed category will not increase." A replacement health
care facility includes a replacement hospital. § 408.032(8), Fla. Stat. (2007).
The Legislature, in amending the CON law in 1997, 2000, and 2004, did not expressly exempt replacement facility applications (proposed to be located more than 1 mile of the existing facility) from the statutory review criteria nor limit consideration of the criteria.
Relevant case law pertaining to replacement health care facilities
On April 15, 2011, the parties provided the undersigned with copies of cited cases, which were filed at DOAH. Two cases have particular relevancy in this case because they involve CON review of replacement hospital applications filed in September 2001 and April 2002, respectively, after the 1997 and 2000 amendments noted above. HCA Health Servs. of Fla., Inc., d/b/a Oak Hill Hosp. v. Agency for Health Care Admin., Case No. 02-0454CON (Fla. DOAH Dec. 24, 2002; Fla. AHCA Feb. 19, 2002)(HCA); Morton Plant Hosp. Ass'n, Inc., d/b/a North Bay Hosp. v. Agency for Health Care Admin., Case Nos. 02-3232CON-3237CON and 02-3515CON (Fla. DOAH Mar. 19, 2004; Fla. AHCA May 14, 2004)(Morton Plant).
In HCA, in September 2001, the applicant, Hernando HMA, Inc., d/b/a Brooksville Regional Hospital, requested approval to replace and relocate its existing 91-bed hospital in Hernando County. Relevant considerations included "whether the transfer is needed and is more cost-efficient than renovation or
expansion of the existing facility, and whether the proposal is financially feasible. See also sections 408.035(1), (4), (8),
(9), and (10), Florida Statutes (2001)." HCA, RO at FOF 23; see also HCA, RO at FOF 37-50. (Section 408.035(10) provided for consideration of "[t]he costs and methods of proposed construction . . ." and was re-numbered, but appears in the 2007 statutes in the same manner as section 408.035(8).)
Deficiencies were discussed, although none of the deficiencies was found to affect the hospital's ability to provide excellent care. HCA, RO at FOF 42. Nevertheless, it was found that "[c]onsidering the deficiencies in the current structure which can only be corrected by closing the hospital completely and rebuilding it on site, taking five to six times as long as construction of a new facility, renovation of the existing structure is not a viable alternative." Id. RO at
FOF 48. See also HCA RO at COL 81. It was also determined that the hospital would be more competitive if it relocated and replaced the facility. Id. RO at COL 82. There was a favorable recommendation, which was adopted by the Agency.
In Morton Plant, there was extensive discussion in the Recommended Order pertaining to the merits of replacing or renovating the existing (applicant) hospitals. Morton Plant, RO at FOF 26-53 and 98-102, and COL 113-119. (The applications were filed in April 2002.)
Ultimately, it was recommended that Community Hospital's proposal be approved (and not North Bay's proposal), in part, because "Community Hospital's existing facility is in bad condition and needs to be replaced. North Bay's facility placement does not. It is not a prudent use of resources for Community Hospital to be replaced or renovated on its current site." Id. RO at COL 115. It was further concluded that "many of Community Hospital's deficiencies cannot reasonably be corrected onsite. Renovation or replacement on-site is impractical and not cost-effective. Its only cost-efficient alternative is relocation and construction of a new hospital." Id. RO at COL 117. The Recommended Order was adopted by the Agency.
South Bay and the Agency assert that SB's application to relocate should be approved, in part, because the Agency has "consistently granted" applications for replacement hospitals.
While it appears that the Agency has historically favored replacement hospitals, even when replacement locates competitors closer, these actions do not necessarily mean that replacement hospitals undergo less scrutiny under the CON review criteria, especially in light of determinations made in HCA and Morton Plant. See also FOF 67.
The determination of the merits of each CON application, including a replacement hospital, must be based on the unique facts and circumstances of each case and must involve
weighing and balancing of the applicable statutory and rule review criteria. Collier Med. Ctr., Inc., supra.
Based upon the foregoing, it is appropriate to consider (weigh and balance) among other applicable statutory criteria, whether renovation of the existing SB facility is more efficient and appropriate than replacement.
Section 408.035(1)
As noted herein, the Agency's review of replacement facilities has changed over time. Prior to 1997, these applications were reviewed on an expedited basis without the intervention of existing health care providers. Comparative review of competing replacement applications was not authorized. Institution-specific factors were considered. As noted in Venice Hosp. Inc., FO at FOF 30 and 31:
Under extreme circumstances of pervasive physical plant deficiencies, coupled with a lack of practical renovation options to overcome plant deficiencies, an existing health care facility might apply for a replacement facility. Only when such replacement facility would (1) involve no new beds or changed bed use (e.g., from general acute care to comprehensive medical rehabilitation beds), (2) involve no substantial change in services, and (3) involve no substantial change in service area would HRS consider such an application to be solely reviewable as a capital expenditure and thus entitled expedited review under the proposed rule.
HRS reviews replacement facility applications by carefully assessing the applicant's claims of pervasive physical plant problems. HRS sends a team of experts, including architects, to the existing
facilities to independently judge whether the physical plant is in such a condition as would warrant replacement and whether renovations could serve as a practical alternative from a physical standpoint. HRS also performs an economic assessment to compare the alternatives of replacement versus renovation in order to determine the most cost-effective alternative. Replacement facility applications typically involve a determination not of whether dollars will be spent, but rather, how they are best spent-- by replacement or by renovation. As such, HRS helps to contain health care costs without participation by competitors in these institution-specific decisions.
The CON review landscape changed in 1997 and thereafter as noted above.
Given the development of CON review of replacement facilities over time, consideration of the "need" for a proposed replacement facility, here a general acute hospital, is different than assessing the need for a new general acute care hospital.
South Bay is an existing health care provider in the subdistrict and the overall "need" for the hospital was demonstrated when the hospital was first licensed. South Bay would continue as an existing hospital provider in the subdistrict if the replacement hospital is approved.
Beginning with the 1997 amendments to the CON law, in cases of capital expenditure proposals for the provision of new health services to inpatients, the Agency was required to reference several criteria in its findings of fact, including the following: "In the case of new construction or replacement construction, that alternatives to the new construction, for
example, modernization or sharing arrangements, have been considered and have been implemented to the maximum extent practicable." See Ch. 97-270, § 2, Laws. of Fla. (emphasis in original); § 408.035(2)(c), Fla. Stat. (1997). See also Suncoast Nursing Home, Ltd. v. Agency for Health Care Admin., Case No. 96- 2418 (Fla. DOAH June 4, 1007, at COL 53; AHCA Nov. 6, 1997)(a
pre-1997 CON application and consideration of this unamended criterion to a proposed 97-bed replacement nursing home). This statutory provision was repealed by chapter 2000-256, section 6, Laws of Florida.
Section 408.035(1)(m), Florida Statues (1996), remained the same, to wit: "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," but, by stipulation of the parties, was not considered in Suncoast Nursing Home, Ltd., RO at FOF 18. See Ch. 97-270, § 2, Laws of Fla.
There is no express language in the CON law, as amended, which indicates that CON review of a replacement hospital application does not require consideration of the statutory review criteria, including "need," unless otherwise stipulated. Replacement hospital applicants, like SB, may advocate the need for replacement rather than expansion or renovation of the existing hospital, but some showing of "need"
is still required. Nevertheless, institution-specific factors may also be relevant when "need" is considered.
South Bay's experts acknowledge that the determination of "need" for SB's relocation involves an analysis of whether the relocation of the hospital as proposed will enhance access or quality of care, and whether the relocation may result in changes in the health care delivery system that may adversely impact the community, as well as options SB may have for expansion or upgrading on-site.
In this case, the "need" for the project is resolved, in part, by considering, in conjunction with weighing and balancing other statutory criteria, whether the institution- specific needs of SB to replace the existing hospital are more reasonable than other alternatives, including renovation and whether, if replacement is recommended, the residents of the service area, including Sun City Center, will retain reasonable access to general acute care hospital services.
It has been stated that "[n]ot every city, town or hamlet can or should have its own hospital." Columbia Hosp. Corp. of South Broward v. Agency for Health Care Admin., Case Nos. 01-2891CON and 01-2892CON (Fla. DOAH July 3, 2002, at FOF 62; Fla. AHCA Sept. 30, 2002)(application to establish a new 100- bed hospital in Broward County), aff'd, 883 So. 2d 283 (Fla. 1st DCA 2004); see also Manatee Memorial Hosp., L.P. v. Agency for Health Care Admin., Case Nos. 04-2723CON, 04-3027CON, and 04-
3147CON (Fla. DOAH Dec. 1, 2005, at FOF 104; AHCA Apr. 11,
2006)(application to establish a new acute care hospital in Sarasota County)("A community's desire for a new hospital does not mean there is a 'need' for a new hospital. Under the CON program, the determination of need for a new hospital must be based upon sound health planning principles, not the desires of a particular local government or its citizens.")(cited in Osceolasc, LLC, d/b/a St. Cloud Reg'l Med. Ctr. v. Agency for Health Care Admin. and Osceola Reg'l Hosp., Inc., d/b/a Osceola Reg'l Med. Ctr., Case No. 08-612CON (Fla. DOAH Dec. 31, 2008, at COL 275; Fla. AHCA March 3, 2009)).
In the context of recommending approving of
St. Joseph's Hospital's satellite hospital and based on prior Agency precedent, it was said that "[w]ith regard to access to emergency services, however, AHCA does consider patient convenience." St. Joseph's Hosp., Inc., d/b/a St. Joseph's Hosp. v. Agency for Health Care Admin., Case No. 05-2754CON (Fla. DOAH May 13, 2008, at FOF 43; Fla. AHCA Aug. 15, 2008, at 7-8), aff'd,
18 So. 3d 1042 (Fla. 1st DCA 2009).
The Agency does not have a travel time standard rule with respect to access to acute care services. See generally Wellington Reg. Med. Ctr., Inc., d/b/a Wellington Reg. Med. Ctr., v. Agency for Health Care Admin., Case Nos. 05-2352CON,
05-2594CON, and 05-2753CON (Fla. DOAH Apr. 5, 2007, at FOF 110 and 354-58; Fla. AHCA Aug. 9, 2007, at 27, 34-35), aff'd, 5 So.
3d 26 (Fla. 4th DCA 2009). (On the same day, the court affirmed the two companion cases arising from this administrative proceeding. Wellington Reg. Med. Ctr., Inc. v. Agency for Health Care Admin., 4 So. 3d 21 (Fla. 4th DCA 2009) and JFK Med. Ctr.
Ltd. P'ship, v. Agency for Health Care Admin., 4 So. 3d 1245 (Fla. 4th DCA 2009).)
In HCA, supra, it was found that "[t]he acute care travel time goal is to have most residents able to reach [general acute care hospital services] within 30 minutes." HCA, RO at FOF 33.
On this record, it appears that a travel time of 15 to
30 minutes for residents to general acute care hospital services is reasonable, although patients and families generally do not want to travel 15 to 30 minutes to receive general acute care hospital services. However, this travel time will be met if SB's project is approved.
Overall, as ultimately concluded herein, need for the replacement hospital has not been proven.
Section 408.035(2)
This section has been referred to as the "'catch-all criteria,' which includes consideration of the impact of approving a new hospital on an existing hospital in the same service district." Baptist Med. Ctr. of Clay Inc., RO at FOF
316. Currently, general acute care hospital services are available and accessible to residents of the proposed service
area and the subdistrict. The quality of care is high and the area provider hospitals are appropriately utilized, although SB is heavily utilized during the seasonal months.
South Bay's service area will not change as a result of the proposed relocation, although its payor mix will change. The application demonstrates that SB is currently the closest hospital to the "centroid" of each of the six service area zip codes in terms of travel time, and will continue to be the closest hospital to each of the service area zip codes in its new location in Riverview; although, when operational, St. Joseph's Hospital South will share this proximity. South Bay (at its new location) (and Brandon, St. Joseph's Hospital, and TG) will continue to be available and accessible to residents in all zip codes of SB's service area, including Sun City Center. But, access for the elderly residents of the Sun City Center area will be reduced.
Section 408.035(3)
Despite shortcomings described herein, including the condition of the ICU, see FOF 77-82, which affects quality of care, SB provides high quality of care in its existing facility. However, its continued high quality of care is at risk in the event SB loses patients, physicians, and nurses to St. Joseph's Hospital South once operational.
South Bay demonstrated that it has the ability to provide high quality of care in its proposed replacement
hospital. The replacement hospital should enable an increase in quality of care, patient safety, and patient satisfaction for those who use the new facility. However, it is not unreasonable to expect the elderly from the Sun City Center area to express dissatisfaction with having to travel to the new location, although they may have a choice of hospitals, depending on the referral source and mode of transport, for example.
Section 408.035(4)
South Bay demonstrated availability of resources for project accomplishment and operation, including health personnel and funding.
Section 408.035(5)
While SB's overall service area will not change, it will be situated closer to the center of population in its service area with the proposed location in Riverview. SB's proposal is likely to provide an alternative (to St. Joseph's Hospital South) for general acute care hospital services for the Riverview residents of the service area, but reduce access for the elderly residents of the Sun City Center area.
Section 408.035(6)
South Bay demonstrated both the immediate or short- term and long-term financial feasibility of the proposal. Section 408.035(7)
Generally, SB's proposal is likely to foster competition among the three health care delivery systems
currently serving the service area. See generally Baptist Med. Ctr. of Clay Inc., FO at 12-13 for the Agency's interpretation of this criterion.
The alternative of compelling SB to remain in place does not promote the institutional needs of SB such that its quality or cost-effectiveness will be improved. Approval of SB's replacement hospital is likely to improve the quality of care and cost-effectiveness of services offered by SB by affording the subdistrict and service area users the choice, subject to referral patterns and emergency transport, of two (South Bay and St. Joseph's Hospital South) state-of-the-art general acute care hospitals that would be equally accessible to resident's within the service area.
Conversely, approval of the project is also likely to reduce access for the elderly residing in the Sun City Center area to general acute care hospital services and increase associated costs, such as emergency transport to Big Bend Road. Section 408.035(8)
Section 408.035(8) requires consideration of "[t]he costs and methods of the proposed construction, including the costs and methods of energy provision and the availability of alternative, less costly, or more efficient methods of construction." Included in this criterion is a comparison of the merits of renovation of the existing facility versus replacement.
Morton Plant Hosp. Ass'n, Inc., d/b/a North Bay Hosp. v. Agency for Health Care Admin., supra.
There is persuasive evidence that SB can renovate its existing facility at a cost far less than the cost to replace the facility. However, renovation is not a reasonable alternative for SB.
Section 408.035(9)
South Bay's historic provision of services to Medicaid patients and the medically indigent is reasonable in view of its location in Sun City Center, and the disproportionate share of Medicare in its current payor mix. South Bay's proposed provision of services to Medicaid and the medically indigent is reasonable.
Section 408.037
Section 408.037 addresses application completeness and requires a detailed financial projection, among other items. South Bay's application is complete and was appropriately deemed complete by AHCA. St. Joseph's Hospital and TG take issue with the application's completeness, asserting that the staffing and related costs of the proposed freestanding ED should have been included in the application. However, a freestanding ED does not itself require a CON, and so is technically not part of the proposal for which projected staffing, revenues, and expenses must be shown. Patients presenting to a freestanding ED are not
admitted and cannot be kept overnight. Patients requiring admission would be transferred to a hospital.
As a logistical matter, SB should have no difficulty operating the freestanding ED, which is supported by, for example, Dr. Ksaibati. Hillsborough County Fire Rescue has indicated that it would support the freestanding ED's operation. Further, freestanding or "off-site" EDs are not new to Florida -- to the contrary, there are already six in the state, including one operated by BayCare (Morton Plant Hospital's freestanding ED in Largo). South Bay should be able to staff its proposed freestanding ED using EmCare, the same emergency medicine physician group which currently staffs the hospital's dedicated ED.
Adverse impact
Consideration of adverse impact on St. Joseph's Hospital and Tampa General is relevant for standing purposes. It is also a relevant factor to consider under section 408.035(2), which includes consideration of the impact of approving a new hospital, here a replacement hospital, on an existing hospital in the same service district. Baptist Med. Ctr. of Clay, Inc. v. Agency for Health Care Admin. and Orange Park Med. Ctr., Inc., d/b/a Orange Park Med. Ctr., supra.
St. Joseph's and Tampa General have demonstrated that their respective hospital's will be impacted sufficient to
establish standing in this proceeding pursuant to section 408.039(5)(c).
Ultimate Conclusions of Law and Recommendation
This is a difficult case to resolve both factually and legally.
All of the relevant statutory criteria have been considered. In weighing and balancing these criteria, the two critical, countervailing interests are the need of the elderly patient population of the Sun City Center area for continued nearby access to general, non-tertiary, acute care hospital services at the present SB location versus the institutional needs of SB to replace its existing facility and move to Big Bend Road, within close proximity to the anticipated and operational St. Joseph's Hospital South.
To this end, the stated and proven need for these services at the current location is weighed and balanced with the proven and stated institutional needs of SB to replace its existing facility, to achieve a more competitive atmosphere in which to provide its general acute care services, and to provide better quality of care to its patients.
Typically, general acute care services should be available within 15 to 30 minutes. This is a general health care planning concept, not a statutory or rule standard. But, it provides some reasonable parameters. Also, patient populations are not necessarily guaranteed neighborhood general acute care
hospital services as the health care delivery system does not generally have such resources.
The elderly, like other potentially disadvantaged groups, have special needs. They are not as agile as they once were and not always able to cope with change. Transportation to and from health care services presents difficulties. These difficulties may be accentuated when emergencies (requiring emergency health care services) arise, notwithstanding the availability of ambulance and other emergency transport. Patient visitation, often helpful during the recovery process, may be restricted.
South Bay has been and continues to be an excellent corporate citizen and has been part of the Sun City Center community for approximately 30 years. South Bay's commitment to the area is well-documented.
Approving SB's application will enhance competition, especially among SB and Brandon, St. Joseph's Hospital South and related entities, and TG. Relocation would negate the likely negative financial impact to SB due to expected loss of market share in the Riverview area. Problems with the ICU and issues related to the use of private versus semi-private patient rooms would disappear, and the overall inadequacy of support spaces, storage, and parking would be alleviated with a new facility. The quality of care at SB will get better, even though it is currently high at the present location.
But, approval will reduce access for the elderly residents of the Sun City Center area for general acute care, non-tertiary hospital services. Approval will result in the duplication of these services in the service area by placing two facilities virtually across the street on Big Bend Road.
"Matters that are susceptible of ordinary methods of proof, such as determining the credibility of witnesses or the weight to accord evidence, are factual matters to be considered by the hearing officer. On the other hand, matters infused with overriding policy considerations are left to agency discretion." Baptist Hosp., Inc. v. State, Dep't of Health & Rehabilitative Servs., 500 So. 2d 620, 623 (Fla. 1st DCA 1986)(citations omitted). See also Pillsbury v. State, Dep't of Health & Rehabilitative Servs., 744 So. 2d 1040 (Fla. 1st DCA 1999); McDonald v. Dep't of Banking & Fin., 346 So. 2d 569, 579 (Fla. 1st DCA 1977).
In a general sense, whether there is a need for this project is susceptible to ordinary methods of proof. But, the issue is infused with health care policy considerations in light of the statutory and rule criteria. Osceolasc, LLC, d/b/a
St. Cloud Reg'l Med. Ctr., RO at COL 273 (citing Baptist Hosp., Inc.).
While it is concluded that reasonable minds may differ especially with respect to policy considerations, it is ultimately recommended that SB's CON application for a
replacement general acute care hospital be denied based in large measure on the expected reduction of access to general acute care hospital services for a definable elderly population and the duplication and maldistribution of similar services within close proximity.
Based on the foregoing Findings of Fact and Conclusions of Law, it is
RECOMMENDED that a final order be entered denying CON Application No. 9992.
DONE AND ENTERED this 8th day of August, 2011, in Tallahassee, Leon County, Florida.
S
CHARLES A. STAMPELOS
Administrative Law Judge
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-3060
(850) 488-9675
Fax Filing (850) 921-6847 www.doah.state.fl.us
Filed with the Clerk of the Division of Administrative Hearings this 8th day of August, 2011.
ENDNOTE
1/ "[T]here is established law that supports the Agency's ability to impose conditions on a CON application that were not explicitly agreed to by the applicant in its CON application.
See Peterson Health Care v. AHCA, 19 FALR 3861 (AHCA 1997); and Beverly et. al v. AHCA et. al, 17 FALR 3569, 3570 (AHCA 1995)."
St. Joseph's Hosp., Inc., d/b/a St. Joseph's Hosp. v. Agency for Health Care Admin., Case No. 05-2754CON (Fla. DOAH May 13, 2008;
Fla. AHCA Aug. 15, 2008, FO at 9), aff'd, 18 So. 3d 1042 (Fla.
1st DCA 2009).
COPIES FURNISHED:
Stephen A. Ecenia, Esquire Rutledge, Ecenia & Purnell, P.A.
119 South Monroe Street, Suite 202 Post Office Box 551
Tallahassee, Florida 32302-0551
Karen A. Putnal, Esquire
Parker, Hudson, Rainer & Dobbs, LLP The Perkins House, Suite 200
118 North Gadsden Street Tallahassee, Florida 32301
Jeffrey L. Frehn, Esquire
Radey, Thomas, Yon & Clark, P.A.
301 South Bronough Street, Suite 200 Tallahassee, Florida 32301
Lorraine M. Novak, Esquire
Agency for Health Care Administration Fort Knox Building III, Mail Stop 3 2727 Mahan Drive, Suite 3431
Tallahassee, Florida 32308
Richard J. Shoop, Agency Clerk Agency for Healthcare Administration 2727 Mahan Drive, Mail Stop 3
Tallahassee, Florida 32308
Justin Senior, General Counsel Agency for Healthcare Administration 2727 Mahan Drive, Mail Stop 3
Tallahassee, Florida 32308
Elizabeth Dudek, Secretary
Agency for Healthcare Administration 2727 Mahan Drive, Mail Stop 3
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 | Document | Summary |
|---|---|---|
| Dec. 03, 2011 | Agency Final Order | |
| Aug. 08, 2011 | Recommended Order | The applicant for a replacement hospital did not prove that, on balance, it met the applicable statutory criteria for approval of its CON application. |
