STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
MEMORIAL MEDICAL CENTER OF )
JACKSONVILLE INC., d/b/a )
MEMORIAL MEDICAL CENTER, )
)
Petitioner, )
)
vs. ) Case No. 85-1518
)
DEPARTMENT OF HEALTH AND )
REHABILITATIVE SERVICES )
and THE BEACHES HOSPITAL, )
)
Respondents. )
)
RECOMMENDED ORDER
Final hearing was held in the above-styled case before Mary Clark, Hearing Officer, on October 21-23, 1985 in Jacksonville, Florida. The parties were represented as follows:
APPEARANCES
For Petitioner Medical Christopher C. Hazelip, Esquire Memorial Medical Michael J. Dewberry, Esquire Center, Inc. 1300 Gulf Life Drive
"Memorial": Jacksonville, Florida 32207
For Respondent John F. Gilroy, Esquire Department of Health Assistant General Counsel and Rehabilitative Department of HRS Services "HRS": 1323 Winewood Boulevard
Building One, Suite 407 Tallahassee, Florida 32301
For Respondent Thomas A. Sheehan, III, Esquire The Beaches Hospital 625 North Flagler Drive "Beaches": 9th Floor, Barnett Centre
Post Office Box 3888
West Palm Beach, Florida 33402
ISSUES AND PROCEDURAL MATTERS
This proceeding arose from proposed action by HRS to approve an application for Certificate of Need filed by Beaches. While the application included relocation of the existing facility, the only portion objected to by Memorial was the proposed addition of outpatient obstetrical services in the form of a birthing center. A similar objection was made by St. Lukes Hospital Association in Division of Administrative Hearings case #85-1515. Both cases were consolidated until St. Lukes was dismissed for lack of standing. (See Final Order dated November 21, 1985 in case number 85-1515.
Upon commencement of the hearing the Hearing Officer clarified for the record that Beaches' Motion for Joinder of Party was granted, and Beaches participated at the hearing, as it had in all pre-hearing matters, as a co-respondent with HRS.
Beaches offered evidence in support of its application through three witnesses and seven exhibits; Memorial contested the additional services through the testimony of five witnesses and six exhibits. HRS presented a single witness and no exhibits.
All post-hearing submissions by the parties have been fully considered. Those include a brief by Memorial, written closing argument by Beaches and Proposed Recommended Orders by all three parties. Specific rulings on proposed findings of fact are found in Appendix A, attached to and incorporated in this Recommended Order.
FINDINGS OF FACT
The Parties
The Beaches is a public hospital supported by taxes through a special hospital taxing district, most recently authorized by Chapter 82-291, Laws of Florida, and by a 1982 voters' referendum. The hospital currently includes 82 acute care beds and is located in Jacksonville Beach within subdistrict
3 of HRS District IV. The hospital is managed under a contract with Hospital Corporation of America. In its application for CON #3526, Beaches proposes to move its facility to a nearby location and to add obstetrical services on an outpatient basis through a connected birthing center. No additional beds are intended. (Beaches Exhibit #1, Application for CON) The birthing center, consisting of approximately 2700 square feet, includes its own entrance through a family waiting room, a nurses station, reception area, examination room, staff lounge and toilet, office, utility room and janitor's supply closet. The two
birthing rooms each have their own adjacent kitchenette and toilet/bathroom. The birthing center is intended to accommodate admission, delivery and discharge of the mother and baby, generally within a 24-hour period. (T.25)
Memorial is a 353-bed acute care hospital also located in subdistrict 3, District IV. It currently provides obstetrical services through its 32-bed obstetrical wing.(T.213, Beaches Exhibit #7, p.51)
HRS completed its State Agency Action Report on the Beaches application in February 1985, and concluded that the project should be approved in its entirety. (Memorial Exhibit #4)
The State and Local Health Plans
The 1985 State Health Plan acknowledges that the demand for highly accessible health care facilities has increased. (p.23) It recognizes an increase in the number of birthing centers and conjectures that in the future ". . . birthing centers may become a major provider of obstetrical services . . . and that . . . hospitals may be relegated to the role of a support institution equipped to handle emergencies, problem cases and overly cautious individuals." (p.27) Birthing centers are an alternative to hospitals for normal pregnancies but are not a substitute in high risk situations. (p.31) One goal of the state plan is the reduction of infant mortality. (p.16)
HRS District IV includes Duval, Nassau, Baker, Clay, St. Johns, Flagler and Volusia counties. Subdistrict 3 consists of southeastern Duval County and all of St. Johns County.
The 1984 District IV local health plan projects a shortage of 54 obstetric beds in 1988, 16 of which are identified in subdistrict 3. The plan further states, however, that unopened beds (51 in subdistrict 3) could be utilized to ease obstetrical bed shortages. (p.50) In keeping with the rapid growth of population in the area and increase in number of deliveries, the 1985 local health plan forecasts a shortage of 22 obstetrical beds in 1989 in subdistrict 3 with 51 beds still identified as unopened and unclassified by service. (p.84) Because of a surplus of acute care beds in subdistrict 3, the plan recommends that no CONs be approved which would increase bed capacity in the subdistrict through 1989. Obstetrical beds are a sub-set of acute care beds.
Two factors would suggest a downward adjustment in the shortages projected in subdistrict 3: approval of 11 obstetrical beds for Baptist Hospital (also in subdistrict 3), and the
methodology of allocating patient days to subdistrict 3 when St. Lukes relocated there from subdistrict 1 and dropped its obstetrical services. Memorial contends that the allocation method is in error since Methodist Hospital in subdistrict 1 opened an obstetrical unit (presumably inducing obstetrics patients who formerly would have gone to St. Lukes to stay in the subdistrict),and St. Lukes no longer provides the service. While it is simple to apply the first factor by subtracting the 11 approved beds, precise application of the second factor is impossible. Conceptually one could agree with Memorial that an allocation of 38% of St. Lukes former obstetric patient days to subdistrict 3 is excessive. However, no evidence was produced for an alternative allocation and Memorial made no effort to have the local health council adjust its allocation.
Memorial also urges that the need for obstetrical beds in subdistrict 3 is overstated since the 75% occupancy standard has not been met. However, the 1985 district health plan shows a current average occupancy rate of 70.3% with the lowest figure from Flagler hospital, located in St. Johns County at the southern end of the subdistrict. The plan suggests that when there are more than one widely separated hospital service areas within a single subdistrict (as St. Augustine and south Duval in subdistrict 3), the State should make an exception to the District health plan when it is reasonable and logical to do so. (p.92) In fact, Herbert Straughn, HRS Medical Facilities Consultant, testified that the level of occupancy of existing beds is not the only consideration or driving force in determining need for additional beds. (T-p.347-348)
Existing Like Facilities and Other Alternatives to Proposed Service
The Beaches outpatient birthing center is a unique service in the Jacksonville area, and possibly throughout the State. Other hospitals maintain birthing rooms, with a homelike atmosphere and accessibility to family members, but those rooms are utilized virtually exclusively for obstetrical inpatients. Freestanding birthing centers also exist, although no evidence established how many exist in the Jacksonville area.
Three hospitals in subdistrict 3 offer inpatient obstetrical services: Baptist, with 27 beds: Flagler with 8 beds; and Memorial, with 32 beds. (Beaches Exhibit #7, p.51) Flagler's occupancy rate in 1984 was only 52.3% but its distance from the Beaches area militates against its being a viable alternative. In 1984 the other two hospitals operated at 75.8% (Baptist) and 70.2% (Memorial) (Beaches Exhibit #7, p.85) The limited evidence of occupancy rates in 1985 suggests that for both hospitals the occupancy rates were at, or above, the 75%
level. While hospitals maintaining obstetrical beds often have the capacity, in the event of over-flow, to convert other acute care beds on a temporary or permanent basis, this conversion would not provide the service sought by women who prefer the birthing center experience. The 1985 State Health Plan cites unnamed and undated surveys which indicate that 11% of expectant mothers would prefer a freestanding birthing center to hospital delivery and conjectures that this figure is likely to increase as attitudes change. (p.32) Even though the Beaches project is not a "freestanding" center, it is more similar to that facility than a hospital obstetrics unit, since it is outpatient-oriented.
Quality of Care
The American College of Gynecologists classifies three levels of care. Level I is routine normal care to women and infants. It is targeted for low-risk patients but must be capable of handling certain emergency procedures such as resuscitation of infants. Level II is care to women and newborns who have more risks involved. Level II facilities exercise some independent judgment as to what degree they can manage a patient who is having problems. Level III provides the highest level of care and is considered to be capable of handling the most complicated high risk cases and the fullest range of services. (T.242) In the Jacksonville area, only University Hospital is classified as providing Level III services. It provides back-up and a transportation team to the other hospitals in the area. (T.242) The Beaches proposed birthing center would be classified as a Level I facility. It intends to establish a transfer relationship with appropriate facilities to insure the back-up medical care for the problems which occur. (T.35)
In addition to the transfer arrangements, Beaches will have a screening program to insure that at an early stage the high risk cases will be referred to Level II and III facilities. The screening program will be developed in detail once physicians are recruited, so as to insure their input in the guidelines. Other quality of care mechanisms to be used by the center include standard accreditation and licensure, peer review programs, the hiring of trained nursing staff and continuous updated training programs for staff. (T. 34-36)
The objection to the quality of care expressed by neonatolgist expert, Dr Chiu, was generally directed to any further Level I services in a metropolitan area. He was not familiar with the specifics of the Beaches' proposal. (T-25l)
Freestanding birthing centers are now licensed by the state. The State Health Plan provides: "With birth centers now covered by licensure in Florida, the issue of quality care which
is most often raised by established physicians and hospitals with obstetrical departments has been recognized and handled by the Legislature." (p.32) From a design standpoint the Beaches center would meet state requirements for both freestanding centers and birthing rooms in a hospital. (T 91-9 )
Staffing
The parties have stipulated that physicians representing the only three obstetrician groups practicing in the projected service area do not support the addition of obstetrical services to the applicant's proposed relocation facility. (Stipulation, filed 10/18/85) This fact does not, however, suggest that recruitment will be impossible or even difficult. Beaches has not commenced recruitment as it intends to wait to insure that the project will be approved. It does not plan to require its obstetricians to limit their practice to the Beaches. (T.47)
For the birthing center, the Beaches will hire six registered nurses trained in labor and delivery as well as infant resuscitation, CPR and advanced cardiac life support. (T. 31, 36)
For both its doctors and nurses, the Beaches will utilize the recruiting services of its management corporation, Hospital Corporation of America. (T.31, 33)
The Beaches long term plan suggests that if Jacksonville area OB/GYNs cannot be interested in using its outpatient services then consideration should not be given to offering obstetrics in the new facility since another inpatient obstetrics program would be duplicative and costly. (Beaches Exhibit 1, Long Term Plan, p.39) That provision does not imply that recruitment would be difficult or that recruitment should be limited to existing physician groups. The context of that provision in the plan indicates a concern that the obstetrical services be outpatient, and if doctors are not interested, the services should be abandoned rather than modified to inpatient services.
Physical and Economic Accessibility
Improved access is one of the considerations given in the State Agency Action Report which found the CON should be granted. The Beaches Hospital is the only hospital in Duval County directly on the Atlantic Coast. The beach coast is separated from Memorial Hospital by a waterway served by a drawbridge. (Memorial Exhibit #4, p.5,7)
Memoria1 maintains the closest obstetrical services to the beach. Aside from the waterway impediment addressed above, the beaches area is approximately 20 minutes from Memorial during non-peak traffic hours. (T.57-58)
As Beaches is a tax-supported hospital, its services_ would be provided to all eligible patients regardless of ability to pay. Most obstetrical services to indigents in the Jacksonville area are currently provided by University Hospital. University Hospital, is approximately 30 miles from the beaches. (T.37,38,77) University Hospital had an obstetrical occupancy rate for 1984 of 114.2%. (Beaches Exhibit #7, p.85)
About 75% of all deliveries are low risk and suitable for Level I births. (T.28) While indigent mothers tend to be more high risk, they are not all high risk and those in the beaches area who are medically eligible for the birthing center would benefit from the prenatal classes at the hospital and the geographical proximity.
Capital Costs and Financial Feasibility
The proposed birthing center will have an initial start up cost of approximately $320,000: $77,000.00 for equipment and around $245,000.00 for construction costs. (T 36,92) The parties have stipulated that funds for start up costs are available to the applicant. (Stipulation, filed 10/18/85) These costs are reasonable. (T. 92)
Annual operating costs will amount to approximately
$200,000.00 to $230,000.00. (Beaches Exhibit #5)
Beaches projects an excess of revenue over expense for each year ranging from approximately $18,000.00 in 1987 (first year of operation) to approximately $110,000.00 in 1989. (Beaches Exhibit #5) However, these projections are based upon an assumption of 336 births the first year and 480 births the third year. The demand for alternatives to traditional
obstetrical services in the beaches area is unknown and extremely difficult to predict. (Beaches Exhibit 1, Long Range Plan, p.40)
Beaches methodology for calculating its proposed utilization rate is inconsistent: its application states that the projected figures are based on 10% and 12% of births expected in the beaches area for the first and second years of operation. (Beaches Exhibit #1, p.108); in testimony the methodology was described as applying the Beaches' market share of approximately 30% to the total anticipated number of Level I deliveries in the primary service area. (T. 30,107,117) The methodology in the application is not explicated; the "market share" methodology is explained in the testimony of Bart Hove and Theresa Dupree,
Beaches hospital administrator and comptroller, respectively. As conjectural as it is, the loose "market share" methodology is accepted as reasonable. It assumes, first, that not all births in the area are suitable for Level I delivery. After that it picks up only that percentage of the market which the Beaches now enjoys. It also takes into consideration lower costs, improved access and a unique service concept which has not yet been marketed in the Jacksonville area. Both changing attitudes toward outpatient services in general and the interest generated by marketing the service are factors likely to positively affect utilization. (T.80-81,230-231,187-188)
While financial losses caused by a service can lead to an increase in patient charges, it is unlikely that Beaches would raise other charges if the center were losing money. (T.134) Beaches does not currently subsidize any service which is losing money with revenue from a different service. (T.135) To HRS, the advantage of these services to the community override the potential loss of money in the services. (T. 376 )
Impact on Competition
Just as utilization of the new service is difficult to predict, so also is its impact on existing facilities providing similar services. Memorial presented an exhibit intended to demonstrate the financial impact of the proposed birthing center. (Memorial Exhibit #2) However, the exhibit is flawed as it does not consider an increase in deliveries as population increases. (T.182) It allocates deliveries at the Beaches from a 3-zipcode area, as opposed to the larger area (5 zipcodes, plus Mayport) utilized by the Beaches. (T.105) The exhibit also addresses gross revenue loss, rather than net loss. (T.180-181) Given the small number of deliveries anticipated by Beaches (336-480) in comparison to Memorial's much higher volume, 2300 deliveries in 1984 (T.269) and Memorial's excess revenues in 1984 of $3.5 million (T.186), the economic impact on Memorial would be minimal.
Memorial prides itself on its women's health care (T.214) It also enjoys the highest charges for a normal delivery, based on Hospital Cost Containment Board reports, of any hospital in the District: $505.00 for the baby, and
$1,592.00 for the mother. (Memorial Exhibit #2) Given these 1984 figures, which are likely to increase, in comparison with Beaches 1987 projected fee of $857.00 for each birth, obstetrical health care consumers would save $416,640.00 in the first year of the Beaches center's operation, if the Beaches projected utilization rate of 336 for the first year is correct. While the services are clearly different (inpatient vs. outpatient deliveries), to the administrator of Memorial, Mark Mrozek, "A
birth is a birth." (T 217) Memorial does not now encourage outpatient births and does not maintain a set fee schedule for such. However, if Memorial finds the market demands a type of services, it will begin providing them, with presumably a cost significantly below its inpatient rate. (T.217,274-275,413) In such manner competition would be enhanced by the establishment of the proposed birthing center.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction in this proceeding pursuant to Section 120.57(1), Florida Statutes and Section 381.494(8)(e), Florida Statutes.
As part of an application to move a facility with its attendant capital expenditure the proposed birthing center requires a certificate of need pursuant to Section 381.494(1)(c), Florida Statutes. Aside from the larger project to move the facility, the addition of obstetrical services would require a certificate of need as a substantial change in health services pursuant to Section 381.494(1)(g), Florida Statutes.
Review of the application to establish a birthing center is subject to the criteria found in Section 381.494(6)(c), Florida Statutes and implementing rules at 10-5.11(1) through (12), Florida Administrative Code. While criteria for determining need for acute care beds may be some guidance in determining the need for a service, the criteria are not controlling since no additional beds are required for this outpatient obstetrical project. By stipulation, the parties have agreed that the criteria in subsections 381.494(6)(c)5, 6 and 7 are not applicable. The remaining criteria are addressed in the following general categories in accordance with the evidence presented at the hearing:
The state and local health plans and long range plans of the facility. (Section 381.494(6)(c)1., Florida Statutes and Rule 10.511(1) and (2), Florida Administrative Code.) The proposal is consistent with the need identified in the state and local health plans. The state plan recognizes a growing need and demand for alternatives to inpatient hospital care; the local plan identifies a specific need for additional obstetrical beds in subdistrict 3. That need for beds translates into a need for services in the limited geographical locations. Those services are proposed here in a manner which will avoid the addition of beds in a district already experiencing a surplus of acute care beds. The project is also consistent with the facility's Long Range Planning Study which recommends that the obstetrical services be provided only through an outpatient program. If the program cannot be staffed due to lack of physician support, the
plan, by inference, recommends abandonment of the project rather than its modification to provide inpatient services. The applicant adequately demonstrated that nonsupport by the existing three obstetrical groups does not portend nonsupport from any potential practitioner at the birthing center.
Existing facilities and services. (Section 381.494(6)(c)2. and 4., Florida Statutes and Rule 10-5.11(4) and (6), Florida Administrative Code.) No other facility like the one proposed exists in the area and perhaps in the state. Freestanding birthing centers exist but no evidence was produced to indicate how many of those facilities are found in the service area, their utilization or how they would be impacted by the proposed hospital-based outpatient facility. Obstetrical services are being provided by several existing hospitals but outpatient deliveries at those facilities are not encouraged either through marketing or even the maintenance of a standard fee schedule. Those facilities which would likely be impacted by the new center are operating at appropriate levels and, given the projected increase in population and the relatively small number of deliveries projected at the Beaches in relation to the total deliveries in the area, the impact would be minimal. When that impact is weighed against the advantages of the availability of a new type of service, the demand for which has been demonstrated in other areas of the country, the need and desirability of the new service becomes obvious.
Quality of care. (Section 381.494(6)(c)3., Florida Statutes.) The proposed center will meet a range of accreditation standards and will meet or exceed the state's requirements imposed on freestanding birthing centers. As the State Health Plan provides, the legislature by regulating such centers has resolved the quality of care issue. Opposition to the project, based on quality of care issues has been directed to the adequacy of Level I obstetrical services generally and not to the adequacy of the specific project. In addition, no evidence was addressed to show that the existing Level I providers in the area are actually jeopardizing their patients or are falling short of professional standards.
Staffing. (Section 381.494(6)(c)8., Florida Statutes, and Rule 10-5.11(7), Florida Administrative code.) Dispute with regard to this criteria centered on the lack of support by existing obstetrical groups in the area. The applicant adequately demonstrated that such a lack of support does not necessarily translate into failure to find physicians to practice obstetrics at the facility later. Since no recruitment efforts have commenced, it is premature to predict an unfavorable outcome. It is sufficient to conclude that the applicant's evidence demonstrates a greater likelihood of success. No
suggestion was made that nurses could not be hired, rather the issue focused on the quality of that staff. Again, the applicant has produced sufficient evidence of training opportunities to sustain its burden in this regard.
Accessibility. (Section 381.494(6) (c)8., Florida Statutes, and Rule 10-5.11, Florida Administrative Code.) It was established that the proposed services would be available to all residents of the area who would be medically eligible to participate. Indigents in the beaches area will be served and the closer geographical proximity will induce them to obtain the prenatal instruction to be offered at the new facility. The fact that indigent mothers have a higher percentage in the high risk category does not rebut the distinct advantage of having a facility available in the beaches community to serve those who are not high risk.
Capital Costs and Financial Feasibility. (Section 381.494(6)(c)8., 9 and 13, Florida Statutes, and Rule 10-5.11(5) and (12), Florida Administrative Code.) No evidence was adduced to rebut the Beaches testimony showing that the construction costs, initial equipment costs and annual operating expenses are reasonable. The primary emphasis was on discrediting the "market share" approach in predicting the revenue to be generated by the project. Certainly any prediction of utilization of a unique first-of-its-kind service is bound to be speculative, but the projections made by Beaches Administrator and Comptroller had some rational basis and the projections by Memorial were no more rational. The birthing center project, isolated from the larger project described in the application, is relatively small-scale. The capital expenditure falls well below the cap provided in Section 381.494(1)(c) and the annual operating costs are below the threshhold provided in the definition of "institutional health service" at Section 381.494(3)(m), Florida Statutes.
While neither of those cited provisions relate directly to this
project, they do reflect legislative acknowledgment that economically small-scale projects are less likely to impact the health services planning process or to affect available resources.
Effect on Competition. (Section 381.494(6)(c)12., and Florida Statutes, and Rule 10-5.11(4) and (12)(b), Florida Administrative Code.)
Section 381.493(2), Florida Statutes provides:
. . . "It is intended that strengthening of competitive forces in the health services industry be encouraged." This project unquestionably will stimulate competition.
Its lower cost for delivery and marketing of the new service will encourage other facilities to lower costs and consider the provision of similar services. The willingness of Beaches to take the initial risk of introducing the new service will cushion the way for other facilities to experiment with this or other forms of less- intensive, lower cost health services.
Whether the project ultimately succeeds or fails, the Jacksonville area health care community will be enriched by the information that is generated both on the economics of a hospital-based outpatient birthing center and the quality of care that such a facility can actually provide. The value of such an experience weighs heavily in favor of approval of the project.
The remaining criteria relating to special needs and circumstances of health maintenance organizations (Section 381.494(6)(c)10., Florida Statutes) and the needs and circumstances of entities serving individuals outside the service district (Section 381.494(6)(c)11., Florida Statutes) are not deemed relevant to the proposed application. Little, if any, evidence was produced at hearing to address those criteria.
The applicant has met its burden of showing that in light of the applicable statutory and regulatory criteria, its certification of need should be issued.
Based upon the foregoing, it is recommended that Certificate of Need No. 3526 be approved.
DONE AND ORDERED this 22nd day of January 1986 in Tallahassee, Leon County, Florida.
MARY W. CLARK, Hearing Officer Division of Administrative Hearings The Oakland Building
2009 Apalachee Parkway
Tallahassee, Florida 32399
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 22nd day of January 1986.
COPIES FURNISHED:
David Pingree Secretary
Department of Health and Rehabilitative Services
1323 Winewood Blvd.
Tallahassee, Florida 32301
Steve Huss General Counsel
Department of Health and Rehabilitative Services
1323 Winewood Blvd.
Tallahassee, Florida 32301
Christopher C. Hazelip, Esquire Michael J. Dewberry, Esquire 1300 Gulf Life Drive Jacksonville, Florida 32207
John F. Gilroy, Esquire Assistant General Counsel Department of Health and
Rehabilitative Services 1323 Winewood Blvd.
Tallahassee, Florida 32301
Thomas A. Sheehan, III, Esquire 625 North Flagler Drive
9th Floor Barnett Centre Post Office Box 3888
West Palm Beach, Florida 33402
APPENDIX
The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties to this case.
Rulings on Proposed Findings of Fact Submitted by Memorial
Adopted in the preamble and paragraph 1.
Adopted in substance in paragraph 3.
Adopted in substance in paragraph 2.
Adopted in the preamble.
Adopted in paragraphs 2, 5 and 10.
Adopted in the preamble.
Adopted in paragraphs 7, 8 and 10, except the final sentence regarding reduction of occupancy rates which is not supported by competent substantial evidence.
Adopted in paragraph 6.
Adopted in paragraphs 6, 7 and 8.
Adopted in part in paragraph 18. The final sentence regarding the long term plan's failure to identify need is rejected as being immaterial and a misstatement of the facts. Population projections are included in the plan, with a conclusion that obstetrical care "could be a viable service in the Beach area zip codes." (long term plan, p.39)
Adopted in paragraphs 23 and 24.
Rejected as contrary to the weight of the evidence.
Rejected as contrary to the weight of the evidence.
Rejected as unsupported by competent substantial evidence. The statement of no support by Jacksonville physicians is far broader than the parties' stipulation.
Rejected as a misstatement of the plan. See paragraph 18.
Adopted in part in paragraphs 11 and 21.
Rejected as unnecessary.
Rejected as immaterial.
Rejected as being unsupported by competent, substantial evidence.
Stricken by consent of the parties. See Beaches Motion to Strike, dated December 30, 1985 and Response by Memorial dated January 2, 1986.
Rejected as unnecessary and, as to the final sentence, unsupported by competent substantial evidence.
Partially adopted in paragraph 25. The market share approach is, however, accepted as reasonable.
Adopted in paragraph 22.
Adopted in part in paragraph 10. The fact relating to interest of Jacksonville area women is unsupported by competent substantial evidence.
Rejected as contrary to the weight of the evidence. See paragraphs 25 and 26.
Adopted in paragraph 26.
Rejected as unnecessary.
Rejected as unnecessary.
Rejected as unnecessary. The statement regarding availability of sufficient delivery services is rejected as contrary to the weight of the evidence.
Rejected as contrary to the weight of the evidence and unnecessary. The speculative nature of the financial impact on Memorial is addressed in paragraph 27.
Addressed in paragraph 22, but rejected in substance.
Adopted in paragraph 11.
Rulings on Proposed Findings of Fact Submitted by Beaches
Adopted in preamble and paragraph 1.
Adopted in substance in paragraph 1.
Adopted in paragraphs 1 and 12.
Adopted in paragraphs 16 and 23.
Rejected as unnecessary.
Adopted in substance in paragraphs 6 and 7.
Adopted by implication in paragraph 27.
Adopted in paragraph 4.
Adopted in substance in paragraphs 7 and 8.
Adopted in paragraph 10.
Adopted in substance in paragraph 10.
Rejected as unnecessary and confusing.
Adopted in paragraph 27.
Adopted in substance in paragraph 27.
Adopted in substance in paragraphs 27 and 28.
Adopted in substance in paragraphs 27 and 28.
Adopted in paragraph 16.
Adopted in part in paragraph 17. The fact of Memorial's experience is unnecessary.
Adopted in substance in paragraph 15. The facts regarding the Tallahassee experience are irrelevant.
Addressed in conclusion of law, paragraph 7.I
Adopted in paragraph 12.
Adopted in substance in paragraph 13.
& Rejected as being cumulative, however, the quality of
care mechanisms are addressed in paragraphs 11 and 12.
Adopted in substance in paragraph 14.
The classification of Beaches proposed facility is addressed in paragraph 11. The remainder of the paragraph is unnecessary.
Addressed in conclusions of law, paragraph 6.
Adopted in paragraph 23.
Adopted in paragraph 23.
Rejected as unnecessary.
Adopted in paragraph 25.
Rejected as unnecessary.
Adopted in part (as to the State Health Plan) in paragraph
4. The remainder is unnecessary.
Adopted in paragraph 26.
Rejected as unnecessary.
Adopted in paragraphs 19 and 20.
Adopted in paragraph 21.
Rejected as unnecessary.
Rejected as unnecessary.
Adopted in paragraph 28, except that the savings to consumers has been recomputed for a total of $416,640, rather than $441.168.00 (not a significant difference).
Adopted in substance in paragraph 28.
The State Health Plan is addressed in paragraph 4. Most of this proposed finding is rejected as cumulative and unnecessary.
Adopted in substance in paragraph 6.
The long term plan was addressed in paragraph 18 and the proposed finding is adopted in substance in that paragraph.
Adopted in substance in paragraph 18.
Rulings on Proposed Findings of Fact Submitted by HRS
Paragraph 1 adopts the Proposed Findings of Beaches. See preceding rulings on those proposed findings.
Adopted in paragraph 1.
Adopted in paragraph 6.
| Issue Date | Proceedings |
|---|---|
| Jan. 22, 1986 | Recommended Order (hearing held , 2013). CASE CLOSED. |
| Issue Date | Document | Summary |
|---|---|---|
| Jan. 22, 1986 | Recommended Order | Freestanding birthing center requires a Certificate of Need which provides reasonable alternative to existing services and will stimulate competition. |
