STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
COLUMBIA HOSPITAL CORPORATION OF ) SOUTH BROWARD, d/b/a WESTSIDE )
REGIONAL MEDICAL CENTER, )
)
Petitioner, )
)
vs. ) CASE NOS. 94-1020
) 94-1021
AGENCY FOR HEALTH CARE )
ADMINISTRATION, )
)
Respondent, )
and )
)
AMISUB (North Ridge Hospital), ) INC., d/b/a NORTH RIDGE MEDICAL ) CENTER; HOLY CROSS HOSPITAL, )
INC., SOUTH BROWARD HOSPITAL ) DISTRICT d/b/a MEMORIAL HOSPITAL; ) and FLORIDA MEDICAL CENTER, LTD., )
)
Intervenors. )
)
RECOMMENDED ORDER
THIS CAUSE came on for formal hearing before Suzanne F. Hood, Hearing Officer with the Division of Administrative Hearings, commencing on May 15, 1995, and concluding on June 19, 1995, in Tallahassee, Florida.
APPEARANCES
For Petitioner: Stephen A. Ecenia, Esquire
Thomas W. Konrad, Esquire
R. David Prescott, Esquire Rutledge, Ecenia, Underwood,
Purnell and Hoffman, P.A.
215 South Monroe Street, Suite 420 Tallahassee, Florida 32301 (Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center)
For Respondent: Samuel Dean Bunton, Esquire
John F. Gilroy, Esquire
Agency for Health Care Administration 2727 Mahan Drive, Third Floor Tallahassee, Florida 32308
(Agency for Health Care Administration)
For Intervenors: R. Terry Rigsby, Esquire
Geoffrey D. Smith, Esquire Wendy A. Delvecchio, Esquire Blank, Rigsby, Meenan, P.A.
204 South Monroe Street Tallahassee, Florida 32301
(South Broward Hospital District d/b/a Memorial Hospital, and Florida Medical Center)
William B. Wiley, Esquire Darrell White, Esquire Charles A. Stampelos, Esquire
McFarlain, Wiley, Cassedy and Jones
215 South Monroe Street, Suite 600 Tallahassee, Florida 32301
(Holy Cross Hospital, Inc.)
Michael J. Cherniga, Esquire David C. Ashburn, Esquire Greenberg, Traurig, Hoffman,
Lipoff, Rosen and Quentel, P.A.
101 East College Avenue Tallahassee, Florida 32301 (AMISUB (North Ridge Hospital),
Inc. d/b/a North Ridge Medical Center) ISSUE
The issue is whether Petitioner Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center, should be granted a Certificate of Need to establish an adult open heart surgery program.
PRELIMINARY STATEMENT
On August 6, 1993, the Agency for Health Care Administration (AHCA or Agency) published a Notice of Adult Open Heart Surgery Program Fixed Need Pool in the Florida Administrative Weekly, Vol. 19, No. 31. The Agency projected need for one additional adult open heart surgery (OHS) program in District X for the January 1996 planning horizon. District X consists entirely of Broward County, Florida.
Five hospitals in Broward County, including Petitioner Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center (Westside), timely filed Letters of Intent and submitted Certificate of Need (CON) applications seeking to establish an adult OHS program at their respective facilities. The Agency assigned CON Action No. 7455 to Westside's CON application.
On January 21, 1994, AHCA published in the Florida Administrative Weekly, Vol. 20, No. 3, notice of its intent to preliminarily deny all CON applications for an adult OHS program in District X. Four of the five applicants timely filed petitions to challenge AHCA's decision, including Cleveland Clinic Florida Hospital d/b/a Cleveland Clinic Hospital (Cleveland Clinic) (DOAH Case No. 94- 1019), Westside (DOAH Case No. 94-1020), North Broward Hospital District d/b/a North Broward Medical Center (NBMC) (DOAH Case No. 94-1022), and Plantation General Hospital, L.P. (DOAH Case No. 94-1023).
AMISUB (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center (North Ridge), Holy Cross Hospital, Inc. (Holy Cross), South Broward Hospital District d/b/a Memorial Hospital (SBDH or Memorial), and Florida Medical Center, Ltd. (DOAH Case No. 94-1021) (FMC) timely filed petitions to intervene in the proceedings. All were granted intervenor status, in opposition to Westside's CON application, subject to providing proof of standing at the final hearing.
Prior to the hearing, Plantation General Hospital, L.P., and Cleveland Clinic, dismissed their petitions for formal administrative hearing and withdrew their respective CON applications from consideration. Accordingly, the files in DOAH Case Nos. 94-1019 and 94-1023 were closed.
NBMC filed a Petition for Administrative Determination of Agency Policy Statement Not Promulgated by Rule and Motion to Consolidate (DOAH Case No. 95- 1465RU) on April 20, 1995. Before the hearing concluded, NBMC filed a motion to dismiss DOAH Case No. 95-1465RU, resulting in its severance and the closure of that file. On May 8, 1995, the parties filed a Joint Prehearing Stipulation, agreeing that the CON review criteria and standards applicable in this proceeding are set forth in Sections 408.035(1), 408.035(2), 408.037, and 408.039, Florida Statutes, and Rules 59C-1.008, 59C-1.030, 59C-1.033, Florida Administrative Code. The parties further stipulated that each of these statutory and rule criteria and standards remains at issue with the following exceptions:
As to Section 408.035(1)(c), Florida Statutes, the parties stipulated to both NBMC's and
Westside's past record of providing quality of care.
As to Rule 59C-1.033, Florida Administrative Code, the parties stipulated to NBMC's and Westside's ability to offer those services described in this subsection. The parties
did not stipulate as to the appropriateness
of the level of staffing, volume of procedures necessary to provide quality care, nor the availability of personnel which may be required to effectuate these services at either NBMC or Westside.
At the final hearing, the parties presented testimony from the following witnesses, tendered and accepted as experts in the areas/fields noted: (1) Westside--David Bussone (Hospital Administration), Robert L. Newman (Health Care Finance and Hospital Administration), Murry Drescher, M.D. (Cardiology), Malcolm
J. Dorman, M.D. (Cardiovascular Surgery), Charlene J. Welker, R.N. (Critical Care Nursing, Open Heart Surgery Administration, Deborah Kolb (Health Planning and Health Finance), James A Cruickshank (Health Care Finance, and Hospital Administration), David L. Alexander (Architecture), Scott Hopes (Health Care Planning, Health Care Finance, and Epidemiology), Ann Laseter, R.N. (Hospital Staffing); (2) NBMC--Will Trower (Hospital Administration), Jim Freund (Respiratory Therapy, Administration of Cardiopulmonary Services), Jeffrey Dennis, M.D. (Clinical and Invasive Cardiology), Eleanor Hundley (Social Services), Richard Jeffcote (Accounting, Health Care Finance), Barry Solomon (Health Care Administration), Jan Fisher (Hospital Administration and Operations), Kathleen LaFrance, R.N. (Nursing and Nursing Administration), Jerome H. Modell, M.D. (No Tender Offered), Armand Edward Balsano (Health Planning), James A. Alexander, M.D. (Cardiovascular Medicine and Surgery), Raymond P. Hamilton Fishe, Ph.D. (Statistics, Economics and Finance); (3)
Memorial--Elton Scott, Ph.D. (Health Care Planning and Health Care Economics), Miles Price (Architecture), Marty O'Neill, R.N. (Critical Care Nursing and Open Heart Surgery Program Administration); (4) AHCA--Elizabeth Dudek (Health Care Planning and CON Review Process); (5) North Ridge--Mark Richardson (Health Planning), Rick Knapp (Health Care Finance, Accounting, and Financial Feasibility); (6) FMC--Patricia Greenberg (Health Care Planning and Financial Feasibility), Chris Lloyd (Hospital Administration and Health Care Finance), Elizabeth A. Dunlevy, R.N. (Critical Care Nursing and Nursing Administration).
Westside exhibits 1-12, 13 (response to question number five on the last page), 14-27, 30-33, 35-48, 50-65 were received into evidence along with the depositions of Patricia Greenberg (WS48), Juan Vallerino (WS58), Richard Simonet (WS59), and Rachel Seifert (WS60). NBMC's exhibits 1-35, 37-44, 46, and 48 were received into evidence together with the depositions of Merlin Redfern (NB40), Joseph Cascone, M.D. (NB41), Eleanor Lawrence (NB42), and Stephen M. Shapiro (NB46). Holy Cross' exhibits 1 and 2, consisting of the deposition of Richard
Baehr, expert in Health Planning and Health Care Finance, and Deborah Nichelson, expert in Nursing, were received into evidence. Also received into evidence were AHCA's exhibit 1, North Ridge's exhibits 1-13, Memorial's exhibits 1-18, and FMC's exhibits 1-14.
The transcripts of the hearing were filed on July 14, 1995. All parties except NBMC filed their proposed recommended orders on September 25, 1995. On October 2, 1995, NBMC dismissed its petition for formal hearing and withdrew its CON application from consideration. The file in DOAH Case No. 94-1022 was closed.
FINDINGS OF FACT
The Applicant
Westside is a 204-bed hospital located in west central Broward County, which is accredited by the Joint Commission for Accreditation of Healthcare Organizations. It offers a broad spectrum of services including pediatrics, obstetrics, oncology and cardiac services. Westside operates a free-standing outpatient surgery center and two home health agencies providing approximately 110,000 visits per year. However, Westside currently does not provide services in mental health, subacute or skilled nursing, rehabilitation or neonatal intensive care. Westside does not offer any "tertiary" health care services.
Westside is wholly owned by a non-publicly traded corporation, and is an indirect subsidiary of its ultimate parent corporation, Columbia/HCA Healthcare Corporation (Columbia), which is a publicly traded corporation on the New York Stock Exchange. Columbia began operations in 1987. It has grown into the largest proprietary health care company in the world, operating approximately 315 hospitals. Columbia's south Florida division encompasses hospitals in Dade, Broward and Palm Beach counties.
Within Broward County, Columbia operates Westside, University Hospital, Pompano Beach Medical Center, Plantation General Hospital, Pembroke Pines Hospital and HCA Northwest Regional Medical Center. With the exception of Northwest Regional Medical Center, all of these hospitals have cardiac catheterization (cath) programs. None of them offer OHS or comprehensive medical rehabilitation.
Columbia attempts to operate its Broward County hospitals as a single system or network, as if its hospitals were one 1200-bed hospital with multiple
sites, in order to avoid duplicative services and overhead. Management services provided by Columbia to its individual hospitals include data processing services, capital financing, national purchasing agreements, and reimbursement support. However, Columbia has not yet achieved common credentialing of physicians among its hospitals in Broward County.
Westside timely filed its Letter of Intent with AHCA on August 23, 1993. Contemporaneously, Westside filed a licensure application requesting a transfer of ownership of the Westside facility from Galen of Florida, Inc. to Columbia Hospital Corporation of South Broward (CHCSB) which was a wholly owned subsidiary of CHC Holdings, Inc., another indirect subsidiary of Columbia. Westside properly published its public notice September 6-13, 1993. It timely filed its initial CON application on September 22, 1993. CHCSB became the owner of the Westside facility on November 5, 1993. Westside timely filed its omission response on November 8, 1993.
Approximately three years ago, Westside established its inpatient cardiac cath program. In 1994, Westside performed 532 caths representing an increase of 140 procedures from the previous year.
Westside is not a disproportionate share provider. Historically, Westside has provided approximately two percent of its total acute patient days for Medicaid clients. Of all the Broward County hospitals, Westside's record indicates that it provides the lowest number of patient days to the medically indigent.
Westside proposes to establish an adult OHS program for a total project cost of $1.8 million. The project includes renovation of two operating rooms on the ground level of its facility, located across the corridor from its existing cardiac cath lab. Westside also proposes renovations on the third floor of its facility to provide four beds dedicated to a cardiovascular intensive care unit (CVICU) and three beds dedicated to a progressive care unit (PCU). Westside's existing intensive care unit (ICU) is located on the second floor.
Existing OHS Providers
There are five providers currently offering OHS programs in District X: Memorial, FMC, North Ridge, Holy Cross, and North Broward Hospital District d/b/a Broward General Medical Center (Broward General).
Memorial is a 646-bed tertiary center, licensed and operated by the South Broward Hospital District, a public agency that provides health care services to residents in District X without regard of ability to pay. Memorial is a full service public hospital, offering inpatient cardiac cath, adult OHS, neurosurgery, oncology, inpatient and outpatient psychiatric services, drug rehabilitation, medical/surgical services, and comprehensive medical rehabilitation. The Joe DiMaggio Children's Hospital, with Level II and III neonatal ICUs, a pediatric ICU, and a cystic fibrosis center, is located in Memorial's main facility. Additionally, the facility contains three adult ICUs, a dedicated eight-bed CVICU, and a medical ICU with twenty-four beds that has the ability to increase to thirty beds during the busy winter season.
Memorial is a disproportionate share provider of Medicaid-reimbursed services. From May of 1992 to May of 1994, Medicaid represented 13.27 percent of Memorial's total revenues. During that same period, Memorial's average deduction from revenues for charity care amounted to 8.83 percent.
FMC is a 459-bed acute care hospital offering medical/surgical services, psychiatric services, cardiac cath, adult OHS, oncology, orthopedics, wound care and an infertility program. Three of FMC's operating rooms are dedicated to OHS. It has three cardiac cath labs, a forty-bed ICU including a ten-bed CVICU, and 70 telemetry or step-down beds. FMC is owned by OrNda, a chain of 48 hospitals, four of which are located in south Florida. Prior to its purchase by OrNda in 1993, FMC was owned by a limited partnership which included physicians on its medical staff. Within the past year, OrNda has considered entering a joint venture with physicians for the operation of the hospital. FMC has consistently been one of the largest volume OHS providers in Broward County.
North Ridge is a 395-bed general acute care hospital offering an adult OHS program. North Ridge is part of the Tenet proprietary hospital chain in south Florida. It operates the most successful OHS program in District X. During the most recent year, North Ridge again exceeded all other OHS providers' volumes performing more than 900 surgeries.
Holy Cross is a 597-bed, not-for-profit, acute care hospital offering a full array of cardiology services, including but not limited to, an adult OHS program, angioplasty, and cardiac cath. From July 1, 1993, through June 30, 1994, Holy Cross performed 451 OHS procedures: 248 cases on Broward County residents (55 percent), 162 cases from District IX (36 percent), four cases from District XI (9 percent), and 37 cases on other residents (8 percent).
Broward General is licensed and operated by the North Broward Hospital District, a public agency that provides medical care to residents in District X without regard for ability to pay. Broward General initiated its adult OHS program approximately ten years ago. However, Broward General did not perform more than the benchmark number of 350 adult OHS cases until 1992. The number of procedures it performed decreased from 551 in 1993, to 463 in 1994.
Holy Cross, Memorial, and Broward General participate in the Community Health Network, an accountable health partnership (AHP) which consists of seven area hospitals. North Ridge and FMC participate in Affiliated Health Providers, an AHP made up of eight hospitals.
Need In Relation To State And District Health Plans -- Section 408.035(1)(a), Florida Statutes.
State Health Plan
The State Health Plan provides for six preferences to be used in evaluating CON applications for OHS programs.
Westside meets the first State Health Plan preference which favors applicants establishing programs in counties with a population in excess of 100,000 or more where the percentage of elderly residents is higher than the statewide average.
Westside does not meet the second State Health Plan preference which favors applicants demonstrating an ability to perform 350 adult procedures annually within three years of establishing a new program. Quality of care of an OHS program is directly related to the volume of procedures performed. AHCA expects OHS facilities to perform a minimum of 350 adult procedures on an annual basis.
Westside's application claimed that its OHS service area would be District X as a whole and, based on an analysis of hospital-wide inpatient discharges for each of the Columbia hospitals in Broward County, projected that it would perform 175 OHS procedures in year one, 250 in year two, and 360 in year three. Westside attempted to support these projections at hearing by presenting an analysis of the zip codes constituting its historical MDC-5 and cardiac cath service areas using updated use rate and population data. This supplemental analysis projected that Westside would perform 175 OHS procedures in year one, 250 in year two, and 350 in year three.
These projections are premised on Westside's ability to capture an increasing percentage of the market share for each of the first three years.
There is no persuasive evidence that approval of the Westside program would drive any existing provider below 350 cases.
Westside expects its OHS service area to encompass the entire district because of Columbia's multiple hospital presence in Broward County. If granted a CON, Westside could draw patients from throughout the district and affect, to a degree, all open heart providers.
Westside's assumption that it would attract patients from throughout the district to some degree is consistent with the experiences of existing providers. Although FMC's primary service area is western Broward County, it receives managed care patients from all areas of the county, and its OHS competition consists of all Broward County OHS providers. Similarly, Memorial, whose primary service area is southern Broward County, attracts approximately
170 OHS cases from a zip code in the northeast part of the county.
Plantation General Hospital, which originally was a competing applicant, and Northwest Regional have become part of the Broward Columbia system since Westside filed its application. However, negotiations are currently underway which would place one of Columbia's Broward facilities, Pembroke Pines, under the control of the South Broward Hospital District.
Established physician referral patterns in Broward County are unique. As a general rule, physicians do not refer patients past the nearest existing OHS providers. Physicians in District X tend to limit their practices to the east or west side of the county with a main highway corridor as the dividing line. Common credentialing of physicians among the Broward Columbia facilities, if and when it occurs, will not overcome this barrier.
Other than its intent to utilize the Broward Columbia network and to aggressively compete for managed care business, Westside has not described any special or unique attributes of its proposal or facility which would affect a redirection of patients or alteration of existing physician referral patterns. Westside's argument that the Broward Columbia network will ensure the success of its program is not persuasive due to the lack of success the Columbia hospitals have had in this regard in Dade County.
Between 1989 and 1992, the District X, adult OHS use rate (procedures per 1000 population age 15 years and over) grew from 2.16 cases per one thousand adult population to 2.91 case per one thousand adult population, at an average annual rate of increase of 10.5 percent. AHCA projected Broward County adult population growth of about two percent annually between 1992 and 1997. With a constant use rate of 2.9 cases per one thousand adult population, the result would be 297 more OHS cases in 1997 than in 1992. Under this constant use rate
scenario, meeting its projected case volumes of 175 in 1995, 250 in 1996, and
350 in 1997, would require Westside to achieve District X annual OHS market shares of 5.3 percent, 7.5 percent, and 10.3 percent, respectively.
Alternatively, if the use rate increases at 5.25 percent annually (one-half its 1989 to 1992 annual rate of increase), and assuming no population growth, the result would be an additional 912 District X OHS cases by 1997.
If the use rate increases at 5.25 percent annually (one-half its 1989 to 1992 rate of increase), and the population increases as AHCA projected, there would be 1,291 more cases in 1997 than in 1992. Under this scenario, Westside's projected annual case volumes would require it to achieve market shares of only
4.6 percent, 6.1 percent, and 8.0 percent, respectively.
Under any of these scenarios, Westside's market share would be lower than that of each existing OHS provider. However, Westside's application appears to project market share by setting a goal of obtaining at least 350 cases in three years and then determining the level of market share required to achieve that target.
More recent data and the greater weight of the evidence indicates that the district-wide OHS use rate has declined and remains flat at a level lower than 2.9 cases per one thousand adult population. In fact, the district-wide use rate was 2.68 cases per one thousand adult population in 1993 and 2.83 cases per one thousand adult population in 1994.
In projecting future adult OHS volumes in Broward County, it is reasonable and instructive to review not only use rates in Broward County but also adult OHS use rates relative to the state of Florida and the entire United States.
Nationally, the number of adult OHS cases being provided per year is flattening and, as a result, utilization rates are declining.
Between calendar years 1992 and 1994, Florida's adult OHS use rate has also declined. One-third of the existing programs state-wide are not meeting the 350 procedure target established by AHCA.
Declining adult OHS use rates in Broward County, the state of Florida as a whole, and the United States as a whole indicate that a declining use rate should be employed in forecasting adult OHS volumes.
Westside's application identified its primary and secondary service areas by zip code. Its secondary service area incorporated the zip codes representing the service areas for each of the four then existing Columbia hospitals in Broward County. These zip codes accounted for 66 percent of all hospital-wide discharges in the Broward Columbia system in 1992.
Westside's primary service area consisted of thirteen zip codes which generated 80.4 percent of its overall discharges. Based on population data available in 1993, Westside's application projected that the population in this service area would increase by 33,784 by 1998, representing 27.4 percent of the total projected Broward County population growth.
Even though an OHS service area is defined by rule as the entire district, Westside's opponents contend that a more reasonable definition of a facility's OHS service area is the area from which it derives its MDC-5
patients, for all cardiac related services, or its historical cardiac cath service area.
As with any hospital service, the fewer competitors, the higher the market share, so that the district-wide OHS market share of all the open heart providers is 150 percent - 250 percent greater than their district MDC-5 market shares.
Columbia's Broward facilities had a market share of approximately 25 percent of the MDC-5 category (all cardiac related diagnosis) for District X from July of 1993 to June of 1994. Westside's market share of District X's MDC-5 category was 6.5 percent during that period. Westside's market share of 6.5 percent of District X resident MDC-5 cases is greater than North Ridge's 5.8 percent district-wide MDC-5 market share. However, these statistics alone do not mean that there is a need for another OHS program in Broward County or that Westside can achieve its projected OHS volumes.
Westside presented evidence at hearing which analyzed its historical cath service area in response to anticipated criticism by adverse parties that historical cath service areas should be considered in evaluating the reasonableness of Westside's utilization projections, as opposed to the Broward Columbia network's service area. Using updated population and use rate data, this statistical evidence appears to support Westside's original volume projections at first blush.
Westside's hospital-wide discharge service area is virtually identical to its inpatient cath service area. The zip codes constituting Westside's historical cath and MDC-5 service areas are subsets of the service area presented in the application.
At Westside, four zip codes constitute 50 percent of the inpatient cardiac cath (DRGs 124-125) case volume, and an additional seven zip codes account for a total of 75 percent of the cath volume for the 12 months ending June, 1994.
The service area from which Westside derives 75 percent of its cardiac caths had approximately 275,000 residents in 1994, and is projected to grow to about 300,000 in 1998. The service area comprising 50 percent of Westside's cath patient origin is projected to grow at a rate of 1.5 percent per year, while the area comprising 75 percent of cath patient origin is projected to grow at two percent per year. The remainder of District X is projected to increase at a rate of 1.4 percent annually, and the total District X adult population annual growth rate is predicted to be 1.6 percent.
From 1994-1998, Westside's historical service area is now projected to grow by 22,337 adults which is lower than projected in Westside's application. Westside's cath service area also includes a growing elderly population which is expected to increase by 4,878 from 1994-1998. However, the over 65 age group in Broward County is actually decreasing as a percentage of the total population.
A decreasing percentage of elderly in Broward County is significant because OHS is very age dependent. The vast majority of OHS cases are performed on patients from their early 60s through their mid to late 70s. The adult OHS use rate actually declines relative to the population in the late 70s and older. Therefore, a shift toward a smaller percentage of elderly will cause a decline in the adult OHS use rate throughout the district.
For the twelve months ending June, 1994 there were 253 OHS cases from the four zip codes constituting 50 percent of Westside's cath volume, and 350 cases from the additional seven zip codes constituting 75 percent of the cath volume, for a total of 603 OHS cases generated from Westside's historical cath service area. Westside would require a market share of 10.9 percent of the OHS cases performed in the district in 1998 to achieve its projected volume based on updated population and utilization statistics. However, evidence that Westside will be able to achieve this projected market share is contrary to more persuasive evidence relating to actual market dynamics.
There are twelve Broward County providers of adult cardiac cath services with a total of nineteen cardiac cath labs. Additionally, University Hospital and Cleveland Clinic Hospital have received CON approval for the initiation of these services. There are twelve Dade County hospitals which currently offer cardiac cath services. Each of these existing cardiac cath providers is underutilized.
The total number of cardiac caths in Broward County increased from 9,598 in 1990, to 14,849 in 1994. The average annual increase in the number of procedures per provider was 17.7 percent from 1990 to 1991. From 1993 to 1994, this percentage of increase fell to 7.6 percent. The number of district-wide cardiac cath procedures continues to grow but at a declining rate.
It is reasonable to assume that a cardiac cath lab would be appropriately utilized if it performed approximately 1,500 adult cardiac caths annually. With 1,500 procedures per lab in Broward County, the county-wide volume is barely over 50 percent of its capacity. It is highly probable that future utilization for cardiac cath will flatten out.
Between Broward and Dade counties, there were six programs performing fewer than 500 adult cardiac caths in 1994. Existing OHS facilities are experiencing most of the growth in cardiac cath.
Westside claims that its cath market share of 9.5 percent corroborates its projected OHS volume. There is a correlation between cath volume and achievable OHS volume. Westside has the highest cath volumes of any provider in the District without OHS. Westside's cath volume increased from fewer than 400 when the application was filed, to over 530 in 1994. While Westside now has 9.5 percent of the district cath volume, the Broward Columbia network has over 20 percent of the district cath volume. Historical cath lab data does not reflect the referral patterns that would exist at Westside following start-up of OHS because, without OHS backup, physicians do not refer patients to Westside for cath who are at risk or require angioplasty.
Cath volume, and thus cath market share, typically increase with a provider's initiation of an OHS program. Nevertheless, a facility performing a substantial number of cardiac caths does not necessarily guarantee that it will perform at least 350 adult OHS procedures. For example, Kendall Regional Medical Center in Dade County, a Columbia facility, has had an OHS program for at least five years. In 1990, it performed 563 cardiac caths and angioplasties and 135 OHS procedures. In 1994, Kendall Regional Medical Center performed 965 cardiac cath procedures and angioplasties and only 204 adult OHS procedures.
Moreover, the ratio of cardiac caths to OHS procedures is increasing, which means a facility currently needs to perform more cardiac caths on average, in order to perform one OHS procedure than it did three to five years ago.
Conversely, the ratio of OHS cases to cardiac cath cases in District X for providers of OHS is declining. In 1992, 24 percent of cardiac caths resulted in OHS. In 1994, only 21 percent of cardiac caths resulted in OHS.
In Dade County, the ratio of OHS to cardiac caths is significantly lower, i.e., 16 percent for 1994. Dade County has higher managed care penetration than does Broward County. Due to the increasing penetration of managed care in Broward County, the current ratio of OHS to cardiac caths in Dade County is a more reliable indicator than Broward County's ratio of 21 percent in terms of what Broward County will be like through 1998.
Conservatively assuming, however, that Westside's 1993- 94 cath market share in each of its service area zip codes would remain unchanged, and that the 1993-94 OHS use rate for each zip code would remain constant, then Westside still could not perform its projected volume of 175 OHS cases in its first year of operations.
Historical data indicates that it is reasonable to assume that no more than one-fourth of all persons receiving a cardiac cath will require OHS.
Since Westside's cardiac cath lab is currently experiencing volumes in the mid-500 range, it is reasonable to assume that Westside's cardiac cath lab would generate no more than 125-130 open heart surgeries in its first year of service.
Existing volumes of referrals of patients from Westside's cardiac cath lab demonstrate that Westside cannot reasonably expect to achieve its projected adult OHS volumes.
Information supplied by Westside for the first nine months of 1994, indicated that only 61 persons were referred from Westside's cardiac cath lab to another facility for adult OHS. However, this does not mean that each of those persons actually had OHS after evaluation by a surgeon.
Even a straight annualization of the volume of 61 persons referred from Westside's cardiac cath lab to another facility for OHS (which is likely an overstatement due to the fact that peak volumes are experienced during the first three months of the year) yields only slightly more than 80 cases.
The volume of persons recently referred from Westside's cardiac cath lab is far below that which Westside's own health planning witness has endorsed as being indicative of an ability to support a projected volume of 200 adult open heart surgeries per year.
As part of a planning commission in another state, Westside's health planning witness endorsed a requirement that an applicant be required to generate 180 adult open heart surgeries in its cardiac cath lab to support the reasonableness of a projection that it could perform a minimum of 200 adult open heart surgeries per year.
It therefore logically follows that a lesser number of referrals for adult OHS from a cardiac cath lab could not support a projection of 350 or more adult open heart surgeries per year as projected by Westside.
Westside was criticized in the State Agency Action Report (SAAR) for not providing experiential data to support its volume projections and for not specifying the number of potential OHS admissions which went to another hospital
because Westside was unable to perform OHS. However, Westside provided the number of coronary artery bypass grafts (CABG) and percutaneous transluminal coronary angioplasty (PTCA) cases it referred from its cath lab. It is impossible for anyone to determine where those cases ultimately went, whether they actually had surgery, or the number of physicians who referred patients directly to a hospital for surgery. In fact, the SAAR acknowledges that about
40 percent of referrals for CABG surgery within District X come directly from a physician's office.
However, the suggestion that Westside's volume projections are reasonable since in excess of 40 percent of OHS referrals come directly from physicians misapprehends the manner in which patients access adult OHS services.
Whether a person requires OHS is determined through the performance of a cardiac cath. Whether the patient is then transferred to another facility under a physician order or a hospital-to-hospital transfer is irrelevant since the cardiac cath lab information captures both sets of information. In any event, Westside has presented no persuasive evidence describing how it would redirect existing physician referral patterns.
Testimony and exhibits presented by Westside relative to its volume projections do not provide persuasive evidence that it will in fact meet those goals. The district-wide growth of the target population for cardiac cath is expected to be only two percent. The use rate for OHS is either declining or at best flat. Expected growth in the number of OHS cases is only twelve cases per year in the zip codes accounting for 75 percent of Westside's cardiac cath service area from 1996 to 1998. Westside predicts an increase of only nine additional adult OHS cases from 1994 to 1998 for the zip codes accounting for 50 percent of Westside's cardiac cath volume. These facts undermine confidence in Westside's third year volume projections.
One-third of the total OHS cases in Broward County are a result of the in-migration of patients from adjoining districts. In District IX, Columbia hospital has recently acquired a facility with an OHS program which will aggressively market its existing service. AHCA recently entered a final order granting a CON for another new OHS provider in District IX which is expected to become operational before Westside can implement its proposed program in the instant case. These two events will adversely impact the in-migration of patients and Westside's ability to achieve its target volume of 350 by capturing
10 percent of the total market in Broward County.
Additionally, five of the eight adult OHS providers in Dade County are operating well under the target number of 350 cases and have not performed that number since 1990. In 1994, the other three Dade County OHS providers included Baptist Hospital of Miami with 393 procedures, Miami Heart with 551 procedures and Mt. Sinai Medical Center with 1,053 procedures.
Columbia operates three OHS programs in Dade County, two of which have not achieved a volume of 350 cases and are currently experiencing adult OHS volumes in the low 200s. Therefore, Westside's argument that the Broward Columbia network will guarantee success of the proposed project is not persuasive.
It is in the public's best interest to avoid the proliferation of adult OHS providers as evidenced by the current Dade County situation.
Westside presented contradictory themes in its application related to access in an attempt to justify approval of its application.
First, Westside argued that approval of its application is necessary to address access issues for persons located in the western part of the county which is Westside's traditional hospital service area.
However, at least 80 percent of Westside's projected managed care adult OHS cases will be Medicare managed care patients. A relatively small number of Westside's cases will consist of patients between the ages of 45 and
Westside's projected payer mix distribution is not consistent with an intent to serve the western portion of Broward County which has a younger population than the remainder of the county.
Despite its arguments pertaining to a need for a new OHS program in the western portion of Broward County, Westside's volume projections were based on a methodology which contemplated that it would derive cases from all areas throughout Broward County. As noted above, an OHS program at Westside, even if supported by referrals from the Broward Columbia system, would serve the whole district to a limited degree. However, Westside's presentation of contradictory reasons for approval of its CON detracts from the credibility of either argument.
Even though Westside's cath service area generated 603 OHS cases between July of 1993 and June of 1994, the weight of the evidence indicates that Westside can not generate sufficient cases from its historical cath service area to reach its volume projections within three years.
Westside has not met the third State Health Plan preference which favors applicants who will improve access to OHS who are currently migrating out of the district. In District X, out-migration accounts for only 10 percent of the OHS cases whereas one-third of the cases are the result of in-migration. There is no evidence that the small percentage of cases migrating out of Broward County do so because of geographic or financial access problems.
There are five OHS providers in Broward County, three in Palm Beach County (District IX), and eight in Dade County (District XI). Thus, there are sixteen, plus one approved, adult OHS programs within two hours of the subject population. Broward County residents can easily drive to existing OHS providers within a reasonable time frame.
Westside has not met the fourth State Health Plan preference which favors applicants with a history of providing a disproportionate share of charity care and Medicaid patient days, and gives priority to applicants proposing to provide services to all without regard for ability to pay. Westside is not a disproportionate share provider. Westside's historical financial write-off for Medicaid, representing the difference between charges and reimbursement, does not provide persuasive evidence that Westside satisfies this preference. Likewise, Westside did not provide a separate accounting of its charity care. Instead, Westside claims its charity care is folded into bad
debt revenue. Westside has not clearly documented its claim that it is striving to become a disproportionate share provider for the Medicaid program.
The fifth State Health Plan preference has not been met by Westside. This preference favors the applicant offering OHS services with the least expense while maintaining high quality of care standards. Larger hospitals can usually accommodate the required physical plant specifications with lower capital expenditures.
Westside's size, at 204 beds, is adequate to support OHS as evidenced by a number of quality OHS programs around the country in similar sized hospitals. There is no documented correlation between hospital size and success of an OHS program.
North Ridge has the highest volume OHS program in the district yet maintains the lowest average daily census (ADC) for acute care beds of all OHS providers. Moreover, the Cleveland Clinic in Fort Lauderdale with 153 beds was recently preliminarily approved by AHCA for OHS.
Westside may have the resources to develop a quality program but its application does not present a cost-effective proposal.
Westside's proposed renovations are inadequate to accommodate its projected volume of 350 OHS cases in the third year or the anticipated number of cardiac cath if the project is as successful as Westside predicts.
The fifth State Health Plan preference also considers an applicant's ability to maintain high quality of care standards. Westside responded to this preference in its application by designating Cheryl Homer, R.N., as the only named member of the core of its OHS team. Ms. Homer formerly held the position of Assistant Nursing Supervisor/Staff Development Coordinator of the Cardiac Surgical ICU at Shands Hospital for the University of Florida. Westside claimed that its OHS team, like Ms. Homer, would be experienced in both the surgical and post-operative care of patients to ensure quality of care. Testimony at the final hearing established that Ms. Homer is no longer employed at Westside.
The sixth State Health Plan preference favors applicants who perform PTCA, streptokinase, or other innovative techniques as alternatives to surgery for low risk patients. The applicant must include protocols for the selection of surgery patients or alternative non-surgical therapeutic cardiac procedures.
Westside's application included protocols for the selection of patients for OHS. It also included quality assessment and improvement plans that address the clinical plan of care, and continuum of care through diagnostic, nuclear lab, ultrasound, cardiac rehabilitation and patient education. Westside elected not to include protocols for PTCA, streptokinase or acetokinase to document its plan for using non-invasive innovative techniques. Instead, it makes the bare assertion that it has these capabilities.
Additionally, the record indicates that Westside should expect to perform on average 1.1 PTCA procedures for every OHS procedure. Westside only projected .50 PTCA procedures for every OHS procedure in year one and .75 in year two. Westside's failure to project a volume of PTCA procedures equal to the national average, which exceeds 1.0 for every OHS procedure, indicates that it does not intend to maximize the use of innovative techniques.
District X Local Health Plan
The District X Local Health Plan sets forth two preferences which are applicable to proposed adult OHS programs.
The first preference favors OHS applicants who document their willingness to make services available to all segments of the service area population regardless of ability to pay.
Westside's application stated its willingness to make OHS services available to all segments of the population without regard to ability to pay. Westside conditioned its CON approval on the provision of at least two percent of its cases to Medicaid patients but limits this condition to the first two years of operation. It currently provides a Medicaid obstetrical program and provides free transportation to Medicaid patients as well as other patients.
Westside's commitment to provide OHS services to Medicaid patients is higher than the percentage currently being provided by FMC and Holy Cross which is approximately one to two percent.
Medicaid patients do not utilize OHS services at a very high rate. There is no access problem for indigent or Medicaid patients in need of OHS services in Broward County. In fact, the most recent data indicates that there was minimal Medicaid out- migration for OHS during the twelve months ending March 1994. It is impossible to document the reason for out-migration for any patient category. Except for the limitation of two years, Westside's commitment to serve Medicaid patients is consistent with the demand in the service area.
Westside also conditioned its CON on not exceeding the net revenue per case projected in its application for its managed care payers in the first two years of operation. Westside presented testimony that it would not charge more than its projected net revenue per case for managed care payers on a global fee basis. A global fee includes not only the hospital fees, but also the fees of the surgeon, the radiologist, anesthesiologist, and other specialists who are involved in the care of those patients. However, Westside did not provide persuasive evidence that it could negotiate all of its managed care contracts on a global fee basis so as to "guarantee" rates.
The Agency questioned Westside's proposal to hold net revenues per case to a fixed rate of reimbursement due to its historical charge increases for non-OHS services. A fixed net revenue or payment is more relevant than historical charges because Medicare, Medicaid and managed care payers all reimburse at rates significantly less than actual charges. However, charges are an important consideration for OHS patients with traditional insurance plans or no insurance.
Westside's willingness to serve all segments of the population regardless of ability to pay is also doubtful because physician investors in Columbia hospitals will admit a greater percentage of their indigent and Medicaid patients to not-for- profit as opposed to Columbia facilities. Evidence to the contrary is not persuasive.
Additionally, Westside has not adequately documented its willingness to meet the requirements of this preference because it failed to specify its commitment for provision of services to charity care for the medically indigent.
The second preference of the local health plan addresses existing OHS providers who propose to establish cardiac cath services. This preference is not applicable to the application at issue here.
Other Factors Relating To Need
Published numeric need represents the starting point for determining whether an additional OHS program is needed. In this case, AHCA calculated and published a need for one additional adult OHS program in District X. Except for a rule restricting approval to only one OHS program at a time, the agency's numeric need methodology indicated that Broward County needed 4.3 new OHS programs.
The Agency will not normally approve a new OHS program if it would reduce the twelve-month total at an existing provider below 350 cases. For years Broward General consistently performed low volumes of OHS resulting in no published need for another facility under AHCA's rule methodology. Though Broward General now exceeds the 350 threshold, its OHS volume decreased from 551 in 1993, to 463 in 1994.
The weight of the evidence indicates that an additional OHS program in District X at Westside will not cause the volume of any existing provider to fall below 350. Nevertheless, AHCA's decision to deny all applicants despite the presence of a positive fixed need pool is justified.
A positive fixed need pool is just one factor among many to be assessed in determining whether there is a need for a new OHS program. Published need alone does not warrant approval here where Westside, on balance, has failed to demonstrate compliance with statutory and rule criteria.
AHCA has given preliminary approval of a CON application for an adult OHS program in District X in a subsequent batching cycle based on a later planning horizon. That application, which was filed six months after the instant application, is still pending in administrative litigation. Regardless of that preliminary approval, Westside has not proven that a need exist in District X for an additional OHS program.
The weight of the evidence here indicates that there is no need for an additional OHS program in District X where there are no problems with capacity of existing providers, geographic accessibility or financial availability. Westside's proposed project will not improve services currently offered in the district. On the other hand, a new OHS program at Westside will have significant adverse impact on existing providers.
The fixed need pool (based in part on data for the twelve months ending March of 1993) forecasts a growth of approximately 200 cases over a three-year period or about 70 cases per year. Since the calculation of the fixed need pool, the actual use rate for adult OHS has declined and flattened out. The most credible evidence, based on more current data, projects fewer cases for the twelve months ending July 1997 than for the twelve months ending January 1996 (3,211 for the later period versus 3,254 for the earlier period).
Between 1990 and 1994, every OHS provider in Broward County experienced some growth. This growth was due in part to the increase in population which is currently at one to two percent per year. However, because of minimal projected growth in numbers of OHS cases, an additional provider cannot achieve 350 cases per year without substantial redirection of cases from existing providers.
A new provider would still have a shortfall of 150 cases in the third year of operation if it were to capture all of the OHS growth originally
projected (approximately 200 cases over a three year period). This is especially true because of the recent approval of a new OHS program in District IX (Martin Memorial) which accounts for a significant number of cases migrating into District X.
There are no limitations on the capacity of existing OHS programs to accommodate reasonably foreseeable adult OHS volumes. The existing programs can increase their volumes without triggering the need for additional operating rooms, cath labs, and critical care beds. There is no persuasive evidence of significant delays in the provision of angioplasty or other related cardiac services due to the lack of available OHS operating rooms for emergency purposes.
Westside argues that North Ridge exceeded an average of 100 percent capacity in its critical care beds in 1992. However, this argument is flawed because it assumes that North Ridge has only 26 critical care beds when in fact, North Ridge has the ability to operate 44 critical care beds.
The existing providers are operating efficiently and in an appropriate manner. Moreover, greater capacity is being created as lengths of stay in critical care units decrease.
Existing OHS providers are sufficiently geographically accessible to Broward County residents. Westside's assertion that maldistribution of OHS services in the western portion of District X justifies the need for its proposed project is without merit. To the contrary, existing providers are appropriately located in areas with dense concentrations of the elderly population which has the highest use rate for OHS.
One of the zip codes with the highest density of residents over the age of 60 is located directly north of FMC in central Broward County. Holy Cross and North Ridge serve areas in northeastern Broward County with a high density of elderly. Memorial serves the southeast and southwest area of the county which has a high density of elderly residents. In contrast, Westside's service area does not include a high percentage of elderly population. Instead, it has the lowest percentage of elderly population and the lowest median age in the county.
There are no financial access barriers to OHS services in District X. Approximately two-thirds of all adult OHS is covered by Medicare. Additionally, District X has two tax supported hospital systems with a mission to care for all patients regardless of their ability to pay. Out-migration is minimal.
Between July of 1993 and June of 1994, approximately 72, or three percent of total OHS cases were performed on Broward County Medicaid patients with only 18 out-migrations to Dade County. During that same period, 88 OHS cases were performed on Broward County indigent or self-pay charity care patients, seven of which left the district. There is no record evidence that these patients left District X for OHS because of economic access problems.
The existing providers' charges for adult OHS are reasonable and do not limit financial access to those services in the district.
There is no problem with the quality of existing OHS services which would justify the approval of an additional program in District X. On the other hand, record evidence indicates that approval of an additional OHS program in Broward County could adversely impact the quality of care currently available.
The Medicare program presently uses the diagnostic related grouping (DRG) reimbursement system to pay health care providers. The expected future trend is for Medicare patients to participate in plans sponsored by health maintenance organizations (HMOs). Medicare HMOs are likely to cause the volume of OHS to decrease as they search for alternatives to expensive surgery as the most cost efficient way to treat and/or prevent cardiac related illness.
Quality of care is at risk when the volume of an OHS facility falls below 350. There is a direct relationship between the number of procedures being performed and mortality, to wit: the more procedures, the lower the mortality rate. Approval of an additional OHS program in Broward County will only exacerbate the risk of decreased volumes and quality of care.
South Florida hospitals historically have had difficulty finding and keeping qualified staff for OHS teams. A new program in District X will cause a substantial increase on the drain of qualified personnel in the existing OHS programs thereby affecting the quality of care.
There is no evidence that denial of Westside's application will limit the development, competition in, or growth in managed care in District X. Managed care competition can be enhanced by increasing the number and strength of managed care entities in the district. It is not dependent upon the addition of an adult OHS provider in Broward County.
Managed care plans are increasingly assuming control of the delivery of health care which historically was controlled by health care providers. Because the relevant competition among managed care plans is for covered lives and premium dollars, the addition of an adult OHS provider in District X is not even relevant to managed care competition.
Westside and the Columbia network are not unduly disadvantaged in negotiating managed care contracts because no Columbia Hospital in District X offers OHS services. Columbia generally does not enter into universal managed care agreements on behalf of all of its hospitals. Rather, each Columbia facility contracts individually with managed care payers. Furthermore, Westside is free to contract or network with an existing OHS provider for OHS services in Broward County or with one of Columbia's four existing open heart facilities in the adjoining districts.
Currently, Westside has more than 30 managed care contracts. Managed care constitutes approximately 50 percent to 60 percent of its service volume. Thus, with its current range of services, Westside is able to actively compete for managed care business. Westside and the other Broward Columbia facilities anticipate entering into additional managed care contracts during the current fiscal year.
There are currently at least thirty-eight active AHPs offered in Broward County all of which include provider networks including hospitals and physicians. Therefore, the approval of an additional adult OHS program in Broward County is not necessary to establish managed care linkages for the further development of managed care.
Dade County and Broward County are the most competitive managed care marketplaces in Florida. However, despite the extensive penetration of managed care in these counties, the managed care market is still immature in terms of the reimbursement mechanisms employed by managed care entities.
Currently, most managed care entities provide reimbursement to hospitals on a discount off-charges basis. Consequently, the risk relative to utilization of services remains with the insurance company or payer, rather than the hospital or health care providers.
In more mature managed care markets in other parts of the United States, e.g. California, managed care entities reimburse hospitals on the basis of "capitation."
Under a capitation system, the managed care company provides hospitals with a set amount of funds to take care of all of the health care needs of a given group of patients. Reimbursement on the basis of capitation shifts the risk relative to the utilization of health care services to the hospital.
Consequently, capitation tends to reduce utilization of services in markets where that form of reimbursement is more pervasive.
For example, in California, OHS utilization rates have been 20 percent to 30 percent lower than those experienced in Broward County.
The Broward County marketplace is progressing toward a higher level of managed care penetration.
Additionally, as time passes, more managed care entities in the Broward County area will provide services on a capitation basis.
As managed care penetrates a marketplace, it effectively drives down profitability of existing providers on a per unit basis. The development of managed care causes significant contraction in volumes across the broad spectrum of health care services. It will especially impact existing OHS programs because the government is providing incentives for elderly Medicare patients to shift to managed care plans.
Managed care entities thrive by imposing continuing reimbursement reductions and limitations. Consequently, cost efficiencies and profit margins are becoming of even greater concern to existing OHS providers. To address these concerns, it is necessary for each existing OHS program to be able to provide a larger number of procedures annually thereby reducing fixed cost per case to ensure the financial viability of their programs.
At the same time, the increased use by managed care entities of capitation as a basis for reimbursement of services will result in decreased utilization of adult OHS services, making it even more difficult in the future for existing adult OHS programs to maintain sufficiently high volumes.
Over time managed care will cause significant readjustments in terms of OHS referrals and trends. To reduce overall program costs, HMOs will not hesitate to send patients for a tertiary service like OHS to an existing facility which is relatively close to where they live though not located at the nearest health care provider.
As discussed above, Westside has not demonstrated that there is any need for its proposed OHS program or that there is any exceptional or special circumstances which justify a new OHS program.
The Availability, Quality Of Care, Efficiency, Appropriateness, Accessibility, Extent Of Utilization, And Adequacy Of Like And Existing Health Care Services In The Service District: Section 408.035(1)(b), Florida Statutes.
There was no evidence presented that persons in need of OHS services are not able to access those services in District X. With the exception of FMC, all five OHS providers in the district are located on the eastern side of the county. There is little movement of patients and physicians between the eastern and western portions of Broward County. Nevertheless, there is no lack of availability of OHS services based on either geographic or financial grounds.
Westside's patients are typically transferred to FMC for OHS and elective angioplasty. Though not ideal, these transfers do not cause significant problems for OHS patients.
There is no persuasive evidence that physicians in District X have experienced delays in scheduling OHS at existing providers in urgent and emergency cases. There have been no significant problems resulting from delays in scheduling elective OHS and angioplasty procedures at FMC.
When a hospital is on diversion status, its emergency room notifies the emergency medical system that patients should not be brought to the hospital. There is no credible evidence that reported diversion at FMC has been directly related to problems with capacity in critical care areas.
Each of the existing providers of OHS services is providing good quality of care.
Although Westside's CON application failed to assert that any of the existing providers of OHS services was delivering poor quality of care, Westside sought to introduce evidence to link the mortality statistics at FMC and Memorial to the quality of care provided at those facilities. However, such evidence is accorded no weight in light of the expert testimony and exhibits which cast significant doubt on the analysis provided by Westside.
Westside's exhibits regarding mortality rates at FMC and Memorial showed that the overall mortality rates were adjusted statistically based on two criteria -- age mix and DRG mix. According to the analysis provided by Westside, the mortality rates at FMC and Memorial ranged from 30-50 percent higher than the other OHS providers in Broward County. The greater weight of the evidence showed that this analysis was inadequate. A more appropriate method of analysis would require the use of a multi-variant statistical model that considered the typical risk characteristics of patients seeking OHS in order to establish expected mortality rates. The more credible analysis, appropriately adjusted for risk characteristics, showed that Memorial's mortality rate was two percent -- the lowest of all open heart providers in Dade and Broward counties. The uncontroverted evidence also showed that in 1994, FMC's rate was 4.55 percent. For the period May 1994 through April 1995, FMC's mortality rate had declined to 3.5 percent.
Westside's own witness spoke to the quality of care offered at FMC. Murry Drescher, M.D., Director of Westside's cardiac cath lab, testified that FMC is an excellent provider of cardiovascular services and that he would not practice at FMC if it were not. Robert Kersh, M.D., Director of Plantation General Hospital's cardiac cath lab, agreed that the quality of care at FMC is very good.
The Ability Of The Applicant To Provide Quality Of Care And The Applicant's Record Of Providing Quality Of Care: Section 408.035(1)(c), Florida Statutes.
The parties stipulated to Westside's past record of providing quality of care and its ability to offer the services described in Rule 59C-1.033, Florida Administrative Code. The applicant, like the existing providers in District X, is accredited by the Joint Commission on Accreditation of Healthcare Organizations.
Westside has documented its plan to implement quality assurance processes, utilizing peer review activities, departmental specific and multi- disciplinary teams, medical staff and outside experts. It has designed quality improvement processes which could be used to develop a new OHS program.
The quality of the employees, the quality of the medical staff and the availability of technology at Westside are not at issue here. Miami Heart Institute, a Dade County Columbia facility, will provide additional support in implementing the Westside program. However, these are not the only factors which must be considered in evaluating Westside's ability to provide quality of care in a new OHS program.
A reliable indicator of an applicant's ability to deliver quality of care in its proposed OHS program is its ability to achieve 350 procedures during the third year of operation. Westside has not demonstrated that it can capture
10 percent of District X's market in order to achieve this goal.
One-third of the market that Westside hopes to capture is dependent upon patients migrating into Broward County from adjoining districts. In order to achieve its projected market share, a substantial number of patients migrating into District X would have to bypass existing providers who are closer to the borders of the adjoining districts. It is unlikely that this will happen because FMC, located in central Broward County and approximately four miles from Westside, typically attracts only about 5 percent of its total patients from outside Broward County. Patients from outside Broward County account for approximately one percent of FMC's adult OHS cases.
Existing providers in northern Broward County rely heavily on in- migration from District IX. Recent developments in District IX are likely to have an impact on future in-migration for OHS services. First, Columbia has purchased an existing provider of OHS services in District IX which will mitigate patient movement patterns into District X. Second, AHCA recently approved a new OHS program that will be operational before any proposed program in this case, if approved, will become operational. As a result, in- migration from District IX to Broward County should decrease significantly. Existing providers in District X could face a substantial loss of volume, even without the approval of a new program in the District.
Westside's physical plant cannot support 350 OHS cases by the third year. The evidence showed that, based on FMC's experience in the market, Westside should anticipate that its cath lab would perform on average 1.1 PTCA procedures for each open heart, and 4.1 cardiac cath per open heart procedure, or an overall average of 5.2 procedures in the cath lab for every OHS projected. Based on Westside's projected volume of OHS cases of 175 in year one, 250 in year two, and 360 in year three, the evidence suggests that in year one, Westside should perform 906 cath procedures (including PTCA). In year two, Westside should perform approximately 1,295 cath procedures. In year three, it
is estimated that Westside will have to perform 1,864 cath procedures to support the projected volume.
Assuming that a single cath lab has the capacity to perform approximately 1,500 procedures annually according to national planning guidelines, Westside's single cardiac cath lab would fall short of its capacity to deliver the volume of OHS cases in its third year. National ratios of caths to OHS procedures and the ratios experienced at other Columbia facilities, indicate that Westside will reach capacity in its cardiac cath lab much earlier in the second year.
Westside's CON application does not address the issue of adding another cardiac cath lab, nor does it address the construction and equipment costs to implement a second cath lab.
An additional problem with Westside's physical capacity to implement this project concerns its existing and proposed critical care or intensive care beds. The evidence demonstrates that Westside's proposed CVICU will be bottlenecked at just 250 open heart procedures, which is projected to occur during its second year. Westside's proposed CVICU is undersized to support the capacity it projects from open heart procedures and PTCA's.
Westside's CON application did not state an average length of stay (ALOS) in its CVICU, but record evidence shows that Westside projects a four-day stay in CVICU, a three-day stay in the PCU, and, on average, a five-day stay in medical/surgical beds.
Westside failed to include any projected length of stay for PTCA procedures. Generally, a patient will spend one day in the CVICU after PTCA.
Westside's proposed four-bed CVICU achieves 87 percent occupancy during its second year, and will achieve 100 percent occupancy before the end of the second year. During its third year, with a projected case load of thirty procedures per month, the occupancy will be 126 percent.
Westside expects to place its overflow patients from the CVICU and PCU into its existing ICU, located one floor below the proposed CVICU. However, evidence showed that this is not an acceptable alternative, as the average occupancy in Westside's existing ICU is already at 91 percent, with four months of the year showing 100 percent occupancy and only five months below 90 percent occupancy. In contrast, the occupancies in the critical care units at the existing open heart providers in Broward County range from 63 percent at FMC to
86 percent at North Ridge, which demonstrates that there is overall capacity at these existing providers to accommodate additional critical care patients.
Westside recognized the need to establish a separate, dedicated ICU for cardiovascular surgery patients to ensure that staff will have the expertise necessary to render the best quality of care possible in a new program. Placing overflow patients from the CVICU into Westside's ICU also raises concerns about whether the ICU staff would have the necessary expertise to care for these patients.
It is also clear that Westside has not projected a sufficient number of staff positions to adequately support its proposed OHS program. The additional manpower requirements for the proposed project's first year are listed in Table 11. Westside projects additional staffing in the areas of patient care and the OHS surgery unit, as well as pharmacy, cardiac
rehabilitation and the cardiac cath lab. The greater weight of the evidence showed that Westside's staffing projections for patient care and the surgery unit were not reasonable. In addition, there are several key staff positions which are not listed that are material and should have been included.
The evidence shows that Westside based its Table 11 staffing projections on staffing ratios, and not staffing patterns. A staffing pattern is a method of providing maximum nursing coverage. Nursing administrators use staffing patterns after first considering the appropriate staffing ratio. In other words, the first step in establishing a staffing pattern is to determine the staffing ratio. Westside's testimony that a more modern approach to determining full-time equivalents (FTEs) is to use staffing patterns instead of staffing ratios is not persuasive.
Westside's projected 9.6 FTEs for patient care addresses only the care provided in the CVICU and PCU areas, and does not address nursing care for the five days of nursing care that the OHS patient will require in the general medical/surgical floor of the hospital prior to release.
The appropriate staffing ratio considers that the patient will receive twenty-four hours of nursing care on the first day (1:1 ratio); on days two through four, the patient remains in the CVICU and receives twelve hours of nursing care (1:2 ratio); on days five through seven in the PCU, the patient receives eight hours of nursing care (1:3 ratio); and on days eight through twelve, the patient receives six hours of nursing care (1:4 ratio), which is the normal medical/surgical staffing ratio.
Westside's 9.6 FTEs for patient care does not include any additional FTEs for vacation or sick leave coverage. A more appropriate FTE staffing for nursing care would be from eleven to twelve FTEs. Westside submitted a CON application in a subsequent batching cycle showing 10.7 FTEs for patient care.
As for the surgery unit, the greater weight of the evidence also shows that Westside's projected staffing is not reasonable. Using Miami Heart Institute as an example, the OHS team at a minimum should consist of: a cardiovascular surgeon as the primary surgeon, and another cardiovascular surgeon to assist; one or two residents (or other staff surgeons) who are involved to either assist in the opening of the procedure, and in the harvesting of the vein; a nurse to assist in the procedure; a circulating professional who could be a registered nurse (RN) or a tech; the anesthesiologist; and a perfusionist. As a start-up program, Westside would not be expected to use a lesser number of individuals.
At a minimum, Westside would also be expected to employ two teams of two employees each -- an RN and one other person who is either an RN or tech -- for OHS procedures. Westside's Table 11 shows only two FTE's for RN's in the surgery unit, which basically constitutes one team. There is no provision on Table 11 for surgical techs, or a recovery room RN. Regardless of whether Westside's application contained an typographical error listing 1.0 FTEs for a secretary instead of a scrub tech, Westside's manpower projections for its surgical team are inadequate.
The evidence showed that Westside's application should have provided for a total of six individuals in the OHS unit with sufficient flexibility for emergencies, sick days, and vacations.
Westside's 1.0 FTE for a secretary in the surgical unit is not reasonable. This basically provides coverage for a forty hour work week, five days per week. It does not indicate any coverage for nights and weekends. A
2.8 FTE for the surgical secretary is a more appropriate number, and provides coverage for the day and evening shifts for seven days. Westside included a 2.8 FTE for the surgical secretary position in its subsequent CON application to establish an OHS program.
Westside's CON application provides that respiratory therapists will operate the intra-aortic balloon pump and ventilators (respirators), yet there is no provision for that staff position on the manpower list.
Westside attempted to show that its existing surgical unit secretary and respiratory therapists could handle any additional cases that resulted from the OHS program. There was no evidence that Westside currently has idle personnel in these positions. Therefore, this argument is not persuasive.
Table 11 requests that the applicant compute the staffing FTE's required to perform particular functions related to the proposed project, and to then indicate what portion, if any, of the job is to be covered by existing and/or new employees. Westside did not indicate what portion, if any, of the FTEs would be covered by existing secretary or respiratory therapy positions. The greater weight of the evidence demonstrates that Westside's staffing projections for patient care and the surgery unit are not reasonable.
Westside has not demonstrated that it has the ability to achieve 350 open heart surgery procedures in its third year of operation. However, even if Westside's volume projections were reasonable, Westside failed to show that its proposed project will have the physical capacity to handle the expected patient flow, or that its project will be adequately staffed. Westside has not demonstrated its ability to provide quality of care in its proposed OHS program.
The Availability And Adequacy Of Other Health Care Facilities And Services In The District Which May Serve As Alternatives For The Services To Be Provided By The Applicant: Section 408.035(1)(d), Florida Statutes.
This criterion is not applicable to a CON application to establish an OHS program. Each of the experts agreed that where OHS is needed, there is no suitable alternative health care service option.
Probable Economies And Improvements In Service That May Be Derived From Operation Of Joint, Cooperative, Or Shared Health Care Resources -Section 408.035(1)(e), Florida Statutes.
Westside does not propose the operation of a joint, cooperative or shared program with any other health care entity. Westside contends that its application is consistent with this criteria because it proposes the sharing of certain resources with Miami Heart Institute in Dade County, and because it will benefit from the "Columbia purchasing system." However, the testimony showed that the involvement of Miami Heart Institute will be limited to initial staff training and possible assistance in selecting Westside's staff cardiovascular surgeon.
Likewise, the ability to take advantage of Columbia's group purchasing system does not equate to a sharing of resources as envisioned by the criterion. Westside has not demonstrated compliance with this criterion.
The Need In The Service District For Special Equipment And Services Which Are Not Reasonably And Economically Accessible In Adjoining Areas: Section 408.035(1)(f), Florida Statutes.
This criteria addresses situations where a need cannot be met in an adjoining area. Competent substantial evidence indicates that there are more than ample adult OHS programs to the south, in Dade County, and to the north, in Palm Beach County.
The Need For Research And Educational Facilities Health Care Practitioners, And Doctors Of Osteopathy And Medicine At the Student, Internship, And Residency Training Levels: Section 408.035(1)(g), Florida Statutes.
There is no evidence of a demonstrated need for educational facilities in District X. Westside asserts in its application that it maintains good relationships with certain educational facilities in the areas of nursing, cardiology, physical therapy, pharmacy, and dietary. However, Westside did not detail its relationship with the listed educational institutions, and it did not specify what, if any, training programs are in place at the student, internship, or residency level for any of the specified disciplines.
Westside does not participate in any significant educational or training programs, and has not indicated that it will institute such programs if its proposed project is approved.
The Availability Of Resources And Funds For Project Accomplishment And Operation; The Effects The Project Will Have On Needs Of Health Professional Training Programs In The District; Section 408.035(1)(h), Florida Statutes.
Westside has the financial resources to commit to the proposed OHS program. It also has sufficient management personnel for project accomplishment. However, as discussed above, Westside's proposal does not allow for adequate manpower to staff its new program.
Additionally, there is a limited available pool of qualified individuals to staff another OHS program in District X. Approval of Westside's proposed project will cause a "ripple effect" on salaries and wages because all OHS providers will be competing for that limited pool of individuals. The overall effect would be to drive up salaries in the district, either to attract or retain qualified individuals.
Westside has not demonstrated that its proposed project will be accessible for training and educational purposes after Miami Heart conducts the initial classroom and clinical training of staff.
The Immediate And Long-Term Financial Feasibility Of The Proposal - Section 408.035(1)(i), Florida Statues.
The immediate financial feasibility of a proposed project is satisfied by showing that the applicant has adequate financial resources to fund the capital costs of the project, and the financial ability to fund any short- term operating losses. Westside presented credible evidence to demonstrate the immediate financial feasibility of its proposed project.
Long-term financial feasibility is satisfied by demonstrating that projected revenues can be attained in light of the projected utilization of the proposed service and the ALOS. A proposed project is deemed to be financially
feasible in the long-term if that project would break even by the end of its second year of operation. Westside has not demonstrated that it can achieve its projected revenues and has therefore failed to demonstrate long-term financial feasibility.
Westside projected its utilization by payer class on Table 7 of its application. Because a larger percentage of elderly utilize OHS services, Westside projected for its first year that its open heart procedures would consist of 26.3 percent Medicare and 55.2 percent managed care (including a high but unspecified percentage of Medicare managed care). These percentages are consistent with historical experience and industry trends at the time Westside filed its application.
Westside's Table 7, Utilization by Class of Pay, did not specify indigent as a class separate from self-pay. Instead Westside included a footnote indicating that self-pay, with a projected utilization rate of 2.8 percent, included indigent care. Westside relies on the assumptions allegedly supporting its pro forma to assert that projected charity care represents two percent of gross revenue. This information is insufficient to distinguish the projected utilization of charity care patients from the projected utilization of self-pay patients which may include persons who make partial payments, who have the financial means to pay but refuse to do so, or who do not have the means to pay but do not qualify as indigent under state and federal guidelines.
Westside claims that it did not separate charity care from self-pay on Table 7 because the amount of clerical work required to do so did not outweigh the benefit of performing that clerical function. Westside asserts that charity and/or indigent care is also reflected under bad debt expense on the OHS pro forma. However, under the OHS pro forma, Westside separated charity care from "Other Deductions" (write-offs for commercial payers and private-pay payers that may pay some portion of their bill) as separate deductions from gross charges and listed bad debt as an expense.
Westside projected that it can achieve a volume of 250 open heart cases in its second year of operation. As indicated above, Westside's volume projection is dependent on its ability to capture an increasing percentage of the market share in District X. Westside assumes that it will draw 5 percent of the total OHS market for District X during year one, and 7.5 percent of the market in year two. However, approximately 33 percent of that existing market is a result of in-migration from adjoining districts, particularly District IX. Credible evidence suggests that the level of in-migration from adjoining districts will decrease.
Analysis of the demographics of the target population in Westside's service area and the district as a whole, as well as the projected increase in the target population within these areas, shows that OHS growth in the service area is virtually flat or declining; district-wide, the growth of the target population for cardiac cath is expected to be only two percent. In sum, the more credible evidence shows that the expected growth in the number of cases in Westside's service area is twelve cases per year, which shows that Westside will not be able to achieve its projected volume.
Westside's CON application failed to state a precise ALOS. Instead, Westside included a statement that its ALOS would be one day less than the district average but did not state the district average. Westside's application
did include an ALOS for each relevant DRG. Westside correctly predicted at the time it filed its application that new clinical protocols would reduce the ALOS over time.
A reasonable ALOS per patient is twelve days. It is clear that Westside based its financial projections on four days in the CVICU, three days in the PCU, and five days in a general medical/surgical bed.
At the final hearing, Westside attempted to revise its projected ALOS, offering that the average time spent in the CVICU would be two days instead of four, with a twelve-day overall length of stay. Reductions in length of stay would have a positive impact on Westside's projected revenues because Medicaid, representing approximately two percent of Westside's OHS payers, reimburses on a per diem basis, with the overwhelming majority of payers reimbursing on a flat fee basis. Nevertheless, Westside's proposed project is not financially feasible in the long-term based on projected volumes and utilization which cannot be achieved regardless of whether the ALOS is four or two days in the CVICU.
Gross charges are not as significant now as in previous years due to the growth in managed care and because Medicare reimburses for adult OHS services and angioplasties irrespective of gross charges. Even so, it is important to examine gross charges for two reasons. First, reimbursement calculated upon gross charges is still the basis of payment for a material number of OHS procedures. Second, the Health Care Board (HCB) is charged with the duty to collect hospital information and regulate hospitals' gross charges. The HCB has the ability to impose fines and penalties when a hospital exceeds certain established gross charge targets.
One cannot determine Westside's average charges without dividing gross charges by total cases. Westside claims it used the average 1992 charge by DRG for existing OHS providers, inflated forward by 3 percent, to project its charges. These projected charges are consistent with the requirement in Rule 59C-1.033(6), Florida Administrative Code, that charges be comparable to those established by similar institutions in the service area.
However, Westside's projected charges do not reflect its historical charge increases for non-OHS service. More importantly, Westside's projected charges are understated based upon an analysis comparing the historical charges of Westside with two of its sister hospitals currently providing OHS services. Under that analysis, Westside has understated its charges by $29,000 compared to the charges of Lucerne Medical Center in Orange County, and by $26,000 compared to the charges of Miami Heart in Dade County.
It is true that Lucerne and Miami Heart are located in different geographic markets with different competitive forces. It is also true that if Westside's charges are significantly greater than those of its competitors in Broward County, it will be forced to discount its charges to a greater degree in order to be competitive for managed care contracts. However, higher charges would enhance Westside's financial feasibility to the detriment of about 12 percent of the payers (insurance and private pay) reimbursing on the basis of charges or a discount off-charges. Westside's understatement of its projected gross charges casts serious doubt on the reasonableness of its entire pro forma.
Because few payers reimburse at full charges, a meaningful analysis of financial feasibility involves a comparison of projected net revenues and operating expenses associated with the new program. Westside projected its net
operating revenues for year one at $3,809,000 and $5,343,000 in year two. It projected that it would incur $3,612,000 in expenses in year one and $5,024,000 in expenses in year two. Westside calculates its after tax net income at
$120,000 in year one and $195,000 in year two. However, the greater weight of the evidence indicates that Westside has overstated the profitability of the proposed project.
First, Westside failed to deduct from the bottom line in its pro forma the profit margin it currently enjoys with respect to patients it now transfers to other facilities for adult OHS services which it would not transfer for such services if its application were approved.
Next, Westside failed to account for the expense of additional management and supervisory personnel which is necessary for the new program.
Furthermore, the staffing projections contained in Table 11 are unreasonable. Not only did Westside underestimate the number of FTEs required for the new program but it also failed to include some necessary staff positions. As a result of Westside's underestimation of its staffing requirements in the areas of patient care and surgery unit, its first year pro forma projections understate the projected gross staffing expenditures by approximately $420,000. Westside's second year pro forma indicates that the salary, wage and benefit expense per case is $4,484. In Westside's subsequent application, filed six months later, Westside's second year pro forma shows that the salary, wage and benefit expense per case is $5,213. This difference cannot be explained by the passage of time.
Additionally, comparing Westside's instant application to its application filed six months later reveals that Westside has significantly understated: (1) supplies and other expenses by approximately $2,600 per case; and (2) marginal costs by $3,300 per case.
Westside's pro forma projections also failed to include other expense adjustments that significantly impact its projections. Westside's historical experience shows that it failed to include or understated its two percent corporate management fee ($100,000); bad debt expense ($260,000); and overhead ($750,000). Based on actual historical data provided to AHCA, Westside's net income would be $4.9 million, expenses would total $6.3 million (instead of the
$5.024 million in the pro forma), and the net loss to Westside totals $1.4 million.
Despite Westside's contention that managed care will be one of the linchpins of its OHS program, it has failed to demonstrate a cost structure that gives rise to managed care profitability. Specifically, Westside projects that its marginal costs per managed care case will be $20,547 but that its net revenue per case will be only $19,308.
Westside did not present credible evidence that its proposed OHS program was financially feasible in the long term.
The Special Needs Of Health Maintenance Organizations - Section 408.035(1)(j), Florida Statutes
AHCA has consistently interpreted this provision as applicable only where a CON application is submitted by or directly on behalf of a HMO. However, AHCA's expert testified at hearing that an applicant does not have to be an HMO to satisfy this criteria.
Westside's main concern is not to serve the needs of managed care providers by establishing an open heart program in the Columbia Broward network. Instead, it desires to enhance its negotiating leverage with managed care providers. This is not the kind of goal that satisfies this criteria.
The Columbia network is the only network in Broward County without OHS. Transporting managed care patients to a Columbia hospital with OHS in Dade County is a viable option though not particularly helpful to Westside when negotiating managed care contracts. However, there is no persuasive evidence that managed care patients will have to travel out of the district if Westside's application is not approved. Managed care companies usually carve out OHS services when negotiating contracts so that their subscribers can receive those services close to home rather than be transported to a remote facility. It is not necessary for Westside to have a "one-stop shop" in order for it compete in the managed care market.
The Needs And Circumstances Of Those Entities Which Provide A Substantial Portion Of Their Services Or Resources, Or Both, To Individuals Not Residing In The District: Section 408.035(1)(k), Florida Statutes.
Westside does not provide a substantial portion of its services to individuals residing outside of Broward County, and its application is therefore not consistent with this provision.
The Probable Impact Of The Proposed Project On The Costs Of Providing Health Services Proposed By The Applicant: Section 408.035(1)(l), Florida Statutes.
Some impact on existing providers is always expected with the introduction of a new program which creates a new option and redirects patient flow to some degree. Such impact, unless it is significant, should not discourage approval of an additional OHS program. AHCA's need methodology anticipates that the average number of surgeries performed by each existing provider will decline to some degree when an additional OHS program is approved. AHCA's rules do not protect existing providers from ever suffering adverse impact.
Higher volumes generally equate to better quality of care and lower fixed cost per unit of service. A loss of 50 to 100 cases from one of the existing providers in the instant case will affect cost- efficiency to a meaningful degree.
Although the addition of new OHS program at Westside will not result in the volumes of any existing provider falling below 350, the impact of a new program is still an important consideration.
There is no persuasive evidence that Westside will be able to achieve its projected market share by the third year. Westside cannot meet its goals by capturing just the OHS growth market. If Westside's program is as successful as it projects, all Broward County providers would be significantly impacted, especially FMC and Memorial.
Westside asserts that its proposed program is needed in order to promote competition with FMC in the western and central portion of Broward County. However, the testimony established that the adverse impact on some or all of the existing providers in the district outweighs any benefit that is alleged to result if Westside's proposed program is approved. Westside
acknowledged that there is competition among the providers of OHS in Broward County for managed care contracts. The competition for managed care contracts in Broward County as a whole is intense.
The evidence clearly establishes that the majority of Westside patients in need of angioplasty and/or OHS services are referred to FMC. Between FMC and Westside, there is a significant overlap in physicians and medical staff. It is estimated that there is approximately 60-70 percent commonality between physicians on staff at FMC and those on staff at Westside.
Westside also proposes to compete with Memorial for angioplasties and OHS services. There is significant physician overlap between Memorial and Westside.
The existence of physician investors in the Columbia hospitals in Broward County would have an adverse impact on physician referrals to both Memorial and FMC if Westside's application is approved. In Broward County, Broward Healthcare Systems, Inc. (BHSI) is the umbrella entity which owns or is the general partner of all of the Columbia facilities. Interests in BHSI were sold to physicians, and the physicians are realizing a handsome return on their investments.
Westside expects physician investors to refer a significant portion of their projected volume to Westside through a "network feeder system" comprised of the other Broward Columbia hospitals. Credible evidence indicates that where physicians have a financial incentive to utilize or refrain from utilizing services, on average, the utilization of services increases or decreases accordingly. The influence of physician investors on staff at Broward Columbia facilities will not be sufficient to ensure that Westside would achieve its projected volumes. However, an additional OHS program at Westside would adversely impact the number of OHS cases that the Columbia physician investors are now referring to FMC and Memorial.
Westside's proposed project would likely take away between twenty- five and fifty cases a year from Memorial. Irrespective of the financial incentives of Columbia physician investors, a minimum of 15 percent (27 cases) of all patients originating in the zip codes constituting Westside's primary service area would be lost to Westside.
Memorial would lose revenues of approximately $40,000 per case, totaling in excess of one million dollars in gross revenues if Memorial lost just the minimum of twenty-five to twenty-seven cases. There would not be a corresponding reduction in expenses, however, as a portion of the expenses are fixed -- that is, they occur regardless of any reduction in the number of cases. If net revenues, projected to be approximately 40-50 percent of gross revenues, amount to $500,000, and fixed expenditures account for approximately 60 percent of net revenues, Memorial would lose, at a minimum, approximately $300,000.
The projected losses to Memorial, as a disproportionate share provider, have a dual impact. First, the hospital is not generating profits to provide services to Medicaid and indigent patients in the district. Second, the hospital must cover the fixed expenditures that remain, either by raising charges to their paying patient base, or by increasing taxes to the residents of the South Broward Hospital District.
The projected losses to Memorial focus solely on the OHS cases. The approval of Westside's proposed project would also have an additional financial impact on their cardiac cath admissions, including invasive cardiology and angioplasties, amounting to millions of dollars in revenues.
An additional component of financial impact concerns the likelihood that Columbia's physician investors will refer a substantial percentage of their Medicaid and charity cases to Memorial, while directing their paying patients to Westside. Credible evidence shows that this selective admission by physicians results in a higher cost to competing hospitals and a lack of services to Medicaid and charity care patients at Columbia hospitals because the physicians do not admit them to Columbia's hospitals. The loss of paying patients due to physician investor referrals will result in an increase in the charges to paying patients at Memorial, or ultimately lead to a tax increase to residents of the South Broward Hospital District in order to provide Medicaid and charity care.
Westside projects that its proposed project will have the greatest financial impact on FMC. Based on District X's historic cardiac cath service areas, Westside anticipates that it will draw approximately 40 percent of its open heart cases from FMC. In its third year of operation, Westside expects that 140 cases would be drawn from FMC. Westside's projections show that FMC's loss in gross revenues would total in excess of $7.6 million; its net operating revenue losses would exceed $3 million. Westside further alleged that a corresponding reduction in expenses of $3.3 million, would zero out FMC's loss in net revenues.
However, FMC established that the financial impact of Westside's proposed project will not, as Westside projects, zero out. There is a strong overlap in the service areas of FMC and Westside, and a significant overlap in physicians. Additionally, 50 percent of FMC's open heart volume comes from the service area that generates 75 percent of Westside's cardiac caths. Furthermore, the evidence showed that the anticipated rate of growth in the target population within this service area is small -- only twelve additional cases are expected. The greater weight of the evidence showed that Westside would likely draw close to 75 percent of its volume from FMC, a significant impact to FMC's program.
The approval of Westside's proposed project will also result in the dilution of FMC's total cardiac program. The evidence showed that Westside will draw approximately 22 percent of FMC's entire cardiac program, including OHS procedures, cardiac caths and PTCA's. The gross revenues lost from the entire program will amount to approximately $13 million. With a corresponding decrease in expenses, the net loss to FMC will exceed $2 million each year.
Evidence that FMC has rejected patients for elective OHS due to the lack of ability to pay or because they were indigent or Medicaid eligible is not credible. FMC may have required cash payments from self-pay patients with the ability to pay before it would accept them for elective OHS. However, the greater weight of the evidence is that FMC is accessible to all segments of the population for elective, urgent and emergency OHS regardless of the ability to pay.
The projected loss of volume in OHS cases, and corresponding losses in cardiac cath and angioplasty procedures, will have an effect on salaries and wages at FMC and Memorial. The evidence demonstrated that there are a limited number of qualified individuals to staff OHS programs, and competition for these individuals is strong.
North Ridge could reasonably expect to lose at least between 42 and
57 adult OHS cases if Westside establishes a new program and achieves its projected third year volume.
Loss of 50 adult OHS cases would result in a pre-tax loss to North Ridge of approximately $650,000. Similarly, a new OHS program at Westside will cause a loss of angioplasties resulting in a pre-tax loss to North Ridge of approximately $260,000. In sum, the adverse financial impact upon North Ridge as a result of the approval of Westside's application would exceed $900,000.
It is appropriate to assess the financial impact on North Ridge in terms of pre-tax dollars since those amounts constitute the amounts North Ridge's management would need to generate to make up for the money lost as a result of the approval of Westside's application.
The Costs And Methods Of The Proposed Construction And The Availability Of Alternative, Less Costly, Or More Effective Methods Of Construction: Section 408.035(1)(m), Florida Statutes.
Westside's proposed project entails the renovation of two operating rooms located on the ground floor directly across from the existing cardiac cath lab, the renovation of a storage area for a cardiac rehabilitation unit on the ground floor, and the renovation of patient rooms on the third floor of the facility into a four-bed CVICU, a three-bed PCU, and a waiting area. The proposed renovations will not result in a change in the number of hospital beds.
The mechanical and fire safety aspects of Westside, and its emergency power capacity are well within acceptable standards. The hospital is 100 percent sprinkled. The pumps and medical gas systems are also up to date. All areas to be renovated meet the Florida Access For Handicapped Act where applicable.
Westside's primary and backup operating rooms are appropriately sized for OHS. An existing surgical waiting room on the ground floor is available to family and friends of OHS patients.
The elevator which will transport patients from the operating room to the CVICU is large enough to accommodate all appropriate personnel and equipment. The transport time of one minute and fifteen seconds, with the elevator ride requiring roughly 20 seconds, is reasonable and safe.
Westside's CVICU is not large enough to accommodate its projected volumes. Westside does have a fourteen-bed ICU unit, an eight-bed ICU overflow area, and a cardiac observation unit which is capable of monitoring intensive care patients. Other hospitals, with established OHS programs, such as North Ridge and Tampa General, occasionally use "overflow" ICU beds at peak times of utilization. However, it is unacceptable for a new program like Westside to initiate its program knowing that it will have to routinely use its "overflow" ICU beds to achieve its projected volumes.
Westside will also have a capacity problem in its PCU unit. It is true that Westside currently has about forty-five telemetry beds on the third floor, ten of which are on the same wing as the proposed PCU. However, the extra telemetry beds nearest the PCU will not be monitored by staff dedicated to the OHS program. Instead existing staff will monitor them and provide secretarial support from the central nurses' station located at the intersection of the third floor wings.
A PCU consisting of telemetry beds is not subject to ICU standards. Under AHCA rules, a PCU is treated like any other patient room. However, the PCU of a new OHS program should at least be large enough to handle its projected
volumes without depending on additional telemetry beds which will not be monitored by staff dedicated to serve the OHS program.
The schematic drawings and renovation descriptions in Westside's application show project size, scope, services involved, and relationship of spaces for CON review purposes. They also show that the proposed project is inadequate for an OHS program in several respects.
The proposed CVICU and PCU will require substantial further modification in both cost, design and square footage to conform with the requirements of Rule 59A-3.081, Florida Administrative Code. These modifications will require an additional $125,000 expenditure.
The design of Westside's proposed CVICU and PCU does not focus on the patient, but instead appears designed to meet the minimum requirements for such a project. For example, the proposed PCU places male and female patients in the same renovated patient room with a single bathroom. Hospitals do not usually mix genders in patient rooms. In fact, there is no evidence that any hospital has ever allowed the mixing of sexes in patient rooms.
Westside's CVICU and PCU are designed to employ cubicle curtains which afford minimal privacy to the patient, even when drawn completely around the patient's bed area. Cubical curtains meet the minimum rule requirements but they are far from ideal in a CVICU and PCU. This is especially true where both genders are placed in the same room.
The CVICU's patient bed area is not adequately sized to accommodate necessary equipment for the recovering OHS patient, and, more importantly, does not appear to allow sufficient space to administer treatment to patients.
Additional aspects related to the physical design and construction of Westside's proposed projects are included in the discussion of administrative rule requirements below.
The Applicant's Past And Proposed Provision Of Health Care Services To Medicaid Patients And The Medically Indigent: Section 408.035(1)(n), Florida Statutes.
Westside showed that its commitment to provide 2.3 percent Medicaid services is comparable to the level of Medicaid services provided by the existing OHS programs in District X; however, Westside limited its Medicaid commitment to the first two years of operation. Westside did not commit to providing any specific percentage of care to the medically indigent or charity care.
The Applicant's Past And Proposed Provision Of Services Which Promote A Continuum Of Care In A Multilevel Health Care System: Section 408.035(1)(o), Florida Statutes.
Westside does not believe that this statutory criteria is applicable in this case. The criteria examines whether the applicant has historically provided a continuum of care which includes, but is not limited to, nursing care and home health care. Westside did not include any information to document that such a continuum of care exists, or is planned for its OHS patients.
Whether Less Costly, More Efficient, Or More Appropriate Alternatives To The Proposed Inpatient Services Are Available: Section 408.035(2)(a), Florida Statutes.
There are no alternatives for OHS when a patient requires that service. A patient at Westside needing OHS must be transported to a facility with an OHS program.
For any tertiary service there will be some interruption in the continuity of care when a patient is transferred to a hospital where the primary physician lacks privileges. Interruption in the continuity of care between doctors and OHS patients in Broward County is not a significant problem.
Alternatives to OHS such as angioplasty, arthrectomy and implantation of stents are high risk procedures, requiring OHS backup. They are only appropriate on younger patients with less complex cardiovascular illness. Eventually the patients utilizing these procedures will require OHS as cardiovascular disease worsens. The original predictions that these alternatives to OHS would curb the utilization of OHS never occurred.
Westside can continue to transfer its patients to existing OHS providers in the district. FMC is located in central Broward County just four miles from Westside. Westside could also transfer its OHS patients to a sister hospital in Dade County that provides OHS services.
Whether The Existing Facilities Providing Similar Inpatient Services Are Being Used In An Appropriate And Efficient Manner -- Section 408.035(2)(b), Florida Statutes.
The evidence demonstrated that the existing OHS providers in District X are each operating efficiently and appropriately. There is no persuasive evidence that any provider is suffering from over-utilization, or that any patient has been unable to access OHS services when such services were deemed necessary. To the contrary, there is unanimity among the experts from all parties to this proceeding that there is no problem with geographic or financial access to existing providers.
There have been no delays in scheduling emergency OHS procedures. At times elective open heart surgeries and angioplasties may have to be rescheduled to a later time in the day to accommodate emergency or urgent cases. However, the greater weight of the evidence showed that there is no capacity problem at FMC, or any other existing provider in District X.
In The Case Of New Construction, That Alternatives To New Construction Have Been Considered And have Been Implemented To The Maximum Extent Practicable: Section 408.035(2)(c), Florida Statutes.
Westside proposes the renovation of its existing facility, rather than new construction. To the extent that such renovations are an alternative to new construction, Westside's application complies with this criteria. However, as indicated above, and in the discussion of administrative rule requirements below, the renovations to Westside's existing facility are not adequate to support its proposed project.
That Patients Will Experience Serious Problems In Obtaining Inpatient Care Of The Type Proposed, In The Absence of the Proposed New Service: Section 408.035(2)(d), Florida Statutes.
Westside did not present evidence showing that any patient has experienced any problem or adverse outcome due to the lack of an additional OHS
provider in District X, or that any patient will experience a problem, serious or otherwise, if its proposed OHS project is not approved. Westside failed to show that the existing OHS providers in District X were not available or accessible to all residents of Broward County.
The testimony of Westside's witnesses regarding the risk of transferring patients for OHS services is inconsistent; therefore, it is accorded little weight. On the one hand, Westside presented evidence that transfers of its patients to existing OHS providers are disruptive and not in the best interest of the patients. Westside presented other evidence indicating that much of its proposed volume would consist of transfers from the Columbia "network feeder system." Westside's own witness conceded that patients transferring from other Columbia facilities to Westside would encounter the same risks as any other transfer.
The greater weight of the evidence also showed that when a patient is transferred, there is no continuity of care issue because the transferred patient's physician usually provides treatment at the other facility.
Neither Westside nor its staff physicians have encountered any problems in overall patient care and the overall outcomes of open heart cases due to the transfer of patients to any existing provider of OHS services in Broward County.
Miami Heart Institute, located in Dade County, handles all of the indigent cases for Martin County, and routinely arranges for the transfer of at least 100 patients from facilities in Martin County to Dade County.
OHS is a tertiary service, defined by statute and administrative rule as a health care service that, by its nature, should be provided in a limited number of facilities to assure that the highest quality of patient care is provided and that the facilities maximize their utilization. Designation of certain health care services as tertiary services envisions the necessity of transferring patients to those limited number of facilities offering the service, Otherwise, the volumes of the tertiary facilities would be diluted, affecting the quality of care provided to the patient.
Whether The Addition Of Skilled Nursing Beds Is Consistent With The Plans Of Other State Agencies Responsible For The Provision And Financing Of Long- term Care, Including Home Health Services -- 408.035(2)(e), Florida Statutes
Although apparently not stipulated to by the parties, this statutory criterion applies to the establishment of skilled nursing units or intermediate care services, and is not applicable to the CON applications at issue in this proceeding.
Intervenor Standing: Section 408.039(5)(b), Florida Statutes
Pursuant to the Hearing Officer's Orders granting party status to North Ridge, Holy Cross, Memorial and FMC, the Intervenors were required to provide proof of standing at the final hearing.
Westside intends that, if approved, its proposed OHS program will have a "proportionate" impact on each of the existing providers in District X. Westside will draw its volume, projected to be 10 percent of the total cases in District X, from a weighted percentage of each providers' historic market share. The greatest impact would be felt by FMC, where Westside expects to draw
approximately 40 percent of its projected volume. The next greatest impact would be felt by Memorial and Broward General Hospital.
Memorial, FMC, Holy Cross and North Ridge each demonstrated that their existing OHS programs will be substantially affected if Westside's proposed project is approved.
Approval of a OHS program at Westside will also have an adverse effect on the cost of labor at existing OHS providers. The evidence demonstrated that there are a limited number of qualified individuals to staff OHS programs, and competition for these individuals is strong.
CON Application Content and Procedures: Section 408.037, Florida Statutes, and Rule 59C-1.008, Florida Administrative Code.
The evidence presented at the final hearing demonstrates that Columbia Hospital Corporation of South Broward complied with the statutory and rule requirements which mandate complete disclosure of all capital projects, including health facility acquisitions, applied for, pending, approved or underway at the time of its application for the certificate of need at issue in this case.
Columbia Hospital Corporation of South Broward was incorporated in the spring of 1993. It was owned by CHC Holdings, Inc., a subsidiary of a corporation now known as Columbia/HCA Healthcare Corporation and formerly known as Columbia Healthcare Corporation.
In the Summer of 1993, Chos Acquisition Corp., a subsidiary of Columbia/HCA Healthcare Corporation, acquired or merged with Galen Healthcare, Inc. Galen Healthcare, Inc. survived the merger as a subsidiary of the company now known as Columbia/HCA Healthcare Corporation. Galen Healthcare, Inc. owned Galen of Florida, Inc. Galen of Florida, Inc., owned the Westside facility.
Also in the Summer of 1993, Columbia Hospital Corporation of South Broward was identified, by its ultimate parent corporation, Columbia/HCA Healthcare Corporation, as the appropriate entity to become the licensed owner of the Westside facility.
On August 23, 1993, Columbia Hospital Corporation of South Broward filed its letter of intent properly disclosing the pending transfer of the Westside facility. That same day, Columbia Hospital Corporation of South Broward filed an application for change in ownership of Westside facility.
When Westside's application was submitted in September of 1993, Galen of Florida, Inc. still owned Westside Regional Medical Center. Columbia Hospital Corporation of South Broward, had not begun operations and had only nominal assets. The original application does not contain a Schedule 2 for the disclosure of capital projects and expenditures.
The audited financial statement submitted with Westside's application indicated that Columbia Hospital Corporation of South Broward had only $122 in total assets as of October 1993.
Through a series of intra-company transactions on November 5, 1993, Galen of Florida, Inc. transferred the assets of the Westside facility to Columbia Hospital Corporation of South Florida.
The omissions response deadline was November 8, 1993. The transfer of the assets of the Westside facility from Galen of Florida, Inc. to Columbia Hospital Corporation of South Broward had already taken place at that time.
There was no "acquisition" of the Westside facility by Columbia Hospital Corporation of South Broward in the usual understanding of the term.
The transfer of the Westside facility to Columbia Hospital Corporation of South Broward did not involve the assumption of long term debt or liability to pay a parent corporation or any other entity for those assets. The only liabilities incurred by Columbia Hospital Corporation of South Broward were current operating liabilities in the normal course of business, such as payroll. Except for those few capital projects listed on Columbia Hospital Corporation of South Broward's Schedule 2 in Attachment R of its omissions response, all liabilities incurred as a result of the ownership change were "properly chargeable as an expense of operation."
The Westside facility had a substantial book value at the time of the transfer. After the transaction, Westside's audited financial statements showed assets of $51.8 million. The audited financial statements submitted with the application do not reflect any such assets, nor were they required to do so.
No long term debts were incurred as a result of the transfer of ownership of Westside. Therefore there was no need to disclose the transaction on the capital projects list.
Criteria Used In Evaluation Of CON Applications: Rule 59C-1.030, Florida Administrative Code
AHCA's rules set forth additional criteria to be used in evaluating CON applications which focus on whether there is a need for the proposed service in the population to be served, and whether the proposed project is accessible to those in need of the service. The evidence showed that there is no unmet need in District X for OHS services, and that the target population Westside proposes to serve is adequately served by the existing providers of OHS services. Furthermore, the evidence showed that the two percent anticipated growth in the target population will generate a minimal number of additional cases in the district, which can be easily accommodated by any of the five existing providers.
This rule also examines the extent to which an applicant provides services to Medicare, Medicaid, and medically indigent patients. The evidence showed that Westside, at best, provided minimal services to Medicaid patients, and it did not demonstrate any level of service to the medically indigent. Westside's application does not comply with these additional review criteria.
Open Heart Surgery Program: Rule 59C-1.033, Florida Administrative Code
Rule 59C-1.033, Florida Administrative Code, sets forth standards and requirements for the establishment of an adult OHS program. Prior to the final hearing, the parties stipulated to Westside's ability to offer those services described in Rule 59C-1.033(3), Florida Administrative Code. The parties did not stipulate that Westside's CON application included the appropriate level of staffing for any of their proposed services, that Westside would achieve the volume of procedures necessary to provide quality care, or that qualified personnel needed to effectuate these services at Westside would be available.
The same facts which demonstrate that Westside cannot deliver quality of care due to its inability to achieve projected volumes, its unreasonable staffing projections, and its significant underestimation of projected expenditures, also show that Westside's proposed project fails to comply with the administrative rule criteria regarding service quality.
Hospital Physical Plant Requirements For Intensive Care Units: Rule 59A-3.081, Florida Administrative Code
This rule sets forth physical plant requirements for hospitals, and specifically addresses requirements for ICUs and the additional requirements for CVICUs.
OHS is traumatizing to all body organs and muscle groups. A patient arriving in the CVICU after OHS typically has been lying on the hard surface of the operating room table for up to five hours. The patient has been under anesthesia, and is breathing with the assistance of a ventilator (respirator). The patient arriving in the CVICU is accompanied by the physician, and three to four nurses, and usually is connected to the ventilator, monitors, and IV pumps. It is not unusual to also see a patient arrive with an intra-aortic balloon pump. The patient requires close observation for the first twenty-four hours.
The testimony clearly established that Westside's proposed CVICU is not adequately designed to accommodate the patient and the necessary equipment that will be placed in the patient bed area following OHS. The proposed CVICU minimally complies with AHCA's rules governing ICUs. The greater weight of the evidence established that a substantial increase in cost of this project is necessary in order to bring the design into compliance with these rules.
Subsection (4)(b) of the rule requires that the location of the ICU be arranged to eliminate the need for through traffic. Westside plans to locate its proposed CVICU on the third floor, at the northern end of an existing medical/surgical patient wing. The plan does not provide a way to control traffic through the unit either by mechanical or supervisory means.
The proposed location is adjacent to an existing stairwell and elevator. Westside's application indicates that the elevator will be dedicated for operating room patients. However, if all operating room patients utilize this elevator to reach their rooms on the third floor, then the proposed CVICU is also a throughway for operating room patients whose rooms are on the third floor but not in the CVICU.
Furthermore, it was shown that the Life Safety Code requires that the stairs be accessible to anyone on that third floor. The unit could be closed off from general through traffic from the central nursing station with the use of double egress doors, however no such doors were described or shown in the design of Westside's proposed unit.
Subsection (4)(c) of the rule requires that the nurses' station be located so that nurses have visual control of each patient from common spaces. The configuration of the proposed CVICU places the nurses' station in the center of the four-bed unit, with two patient beds placed side-by-side against the north wall, and two patient beds placed side-by-side against the south wall. Westside proposes to use cubicle curtains to separate each patient's bed area. The cubicle curtains, suspended from tracks on the ceiling, are intended to be drawn around each patient bed to provide the patient with privacy. In order to maintain patient privacy, the cubicle curtains will have to be drawn around the
patient bed at all times. If the curtains are drawn, it is not possible for the nurses in the unit to have visual control of each patient from the common places in the unit.
Subsection (4)(e) of the rule requires that each bed in the unit be provided with one outside window, measuring a minimum of 10 square feet. Westside's plan call for six of these windows located along the eastern wall with the head of the patient beds along the north and south wall. If the cubicle curtains are drawn for patient privacy, no window in the unit will be enclosed within the cubicle curtains. Thus, in order to have visual access to the outside through the windows located along the eastern wall, the cubicle curtains must be opened.
Subsection (4)(g) of the rule requires that multiple bed spaces using cubicle curtain separators have a minimum net usable area of 100 square feet per bed. Westside's proposed CVICU facility has approximately 800 total square feet. The evidence shows that the area enclosed by each cubicle curtain measures approximately 8 1/2 feet by 8 1/2 feet -- only 64 square feet per cubical area. Westside meets the minimum requirements for this subsection of the rule. However, it was shown that the area contained within the cubicle curtain, when drawn about the patient, is not appropriately sized to locate the equipment that each OHS patient is likely to require post surgery.
Typically, a patient placed in CVICU after OHS would have a cardiac monitor, IV pumps to deliver medications, and a ventilator. A patient might also require the use of an intra-aortic balloon pump, and a CVVH or portable dialysis machine.
Of significant concern is that there is not adequate space surrounding the patient in the event of a crisis. In that event, a number of staff members will be called to the patient's bedside. The design of Westside's CVICU does not allow sufficient space for those persons to move in and administer care to the patient. Under those circumstances, it will not be possible to push other patients out of the way, as they will be connected to various machines, as well as well as the necessary gasses located at the head of the bed.
The design of Westside's proposed CVICU places a toilet and sink beside the head of each patient bed. These would be enclosed by the cubicle curtain when drawn around the bed. In the event of a crisis which requires immediate access to the patient, it will not be possible to move the toilet and sink out of the way. Even without a crisis, the presence of an exposed toilet in the patient area enclosed by a cubicle curtain raises concerns about patient dignity and privacy.
It was also shown that the proposed patient area within the proposed CVICU is not adequate to include a patient chair or lounger, which is considered a necessary part of the patient's recovery. After OHS, the patient is encouraged to get up and move in order to ensure that the patient is being adequately perfused. Unless the lounger is located in the immediate patient area, the patient is unable to move from the bed and remain connected to all of the tubes and other equipment.
In order to provide appropriate patient areas within the proposed CVICU, the unit would require at least as much additional square footage as is contained in the two patient rooms adjacent to it.
Subsection (4)(j) of the Rule requires that at least one private room or cubicle must be provided in each ICU for patients requiring isolation or separation. Westside's proposed CVICU does not contain any isolation room or cubicle. There are other isolation rooms in Westside's facility: four rooms on the second floor, and monitored isolation rooms elsewhere on the third floor. However, none of these isolation rooms meet the requirements of the rule as they are not contained within the CVICU itself.
Subsection (4)(o)(1) of the rule requires that a soiled workroom be located within each ICU. Westside's plan to use a third floor soiled workroom, located some 70-80 feet away from the nurses' station in the CVICU, and well outside of the proposed unit, does not comply with the requirements of this rule. The location of the proposed soiled workroom is not reasonable because it is not readily accessible from the CVICU. The evidence clearly shows that in order to access the soiled workroom, staff will necessarily have to leave the confines of the CVICU, and the patients residing there. The requirement that the soiled workroom be located in the CVICU is critical for purposes of storing bio-hazardous waste, soiled linens, and red bag materials generated by the patients.
Subsection (4)(o)(3) of the rule requires that the unit contain a clean linen closet or clean linen alcove. The proposed unit will be served by a "clean linen cart" to be located in front of the nurses' station on the outside wall of the unit, under the windows. Examination of Westside's floor plans shows that the proposed location is not an alcove, but is instead along the exterior wall of the unit and at the foot of a patient bed.
Subsection (4)(o)(10) of the rule calls for a visitor waiting room to be immediately available within each ICU. Under this rule, the waiting room may be shared by more than one ICU if direct access to the waiting room is available from each intensive care suite. Westside's proposed CVICU is the only ICU located on the third floor of Westside's facility. There is, therefore, no other ICU that is proposed to share the CVICU waiting room.
Westside's CVICU waiting room will be located across the corridor from the proposed CVICU, and adjacent to the proposed PCU. The configuration of the visitor's room shows only one toilet, and does not comply with the requirement that two toilets for visitor use be available within 75 feet of the waiting room.
Westside's proposed PCU raises significant concerns about patient privacy and dignity. The design of the PCU also mixes males and females in the same room, and the cubicle curtains do little to shield patients from seeing and hearing what is going on with other patients, and from being heard and seen by the other patients in the room. All patients in the PCU will share the use of a bathroom, including one toilet and shower.
The rule also provides two additional special requirements for CVICUs. The first additional special requirement is that each cardiac patient shall have a private room or enclosure for acoustical and visual privacy. The evidence showed that Westside's proposed unit does not have private rooms, but instead places four beds in one large room with cubicle curtains. The cubicle curtains provide an enclosure for visual privacy but they do not provide acoustical privacy. The cubicle curtains also prevent visual control of the patient as required by 59A-3.081(4)(c), Florida Administrative Code.
The second additional special requirement is that each cardiac patient shall have access to a toilet directly from the room or cubicle. Westside's schematics show a toilet and sink located beside each bed. However, as indicated above, the cubicle curtain provides the only visual and acoustical privacy afforded to a patient who is able to use the toilet.
On balance, the design of Westside's proposed CVICU and PCU facilities do not comply with the applicable regulations, and bringing the plans into compliance would significantly increase the square footage and costs, requiring denial of its CON application.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter and parties to these proceedings pursuant to Sections 120.57(1) and 408.039(5)(b), Florida Statutes.
The record contains competent substantial evidence that Memorial, FMC, North Ridge and Holy Cross have standing to intervene in this proceeding.
Westside bears the burden of proving by a preponderance of the evidence that it is entitled to a CON to establish an OHS program in District X. Boca Raton Artificial Kidney Center, Inc. v. Department of Health and Rehabilitative Services, 475 So. 2d 260 (Fla. 1st DCA 1985); Humana, Inc. v. Department of Health and Rehabilitative Services, 469 So. 2d 889 (Fla. 1st DCA 1985). The award of a CON must be based on a balanced consideration of all applicable statutory and rule criteria. Department of HRS v. Johnson and Johnson Home Health Care, Inc., 447 So. 2d 361 (Fla. 1st DCA 1984).
Pursuant to Section 408.035(1)(a), Florida Statutes, an applicant must demonstrate need for the proposed facility in relation to the applicable state and district health plans.
AHCA's projection of a numeric need for one additional adult OHS program in District X is the starting point for determining whether Westside is entitled to a CON. South Miami Hospital, Inc. v. Agency for Health Care Administration, 16 F.A.L.R. 2733 (AHCA 1994). A showing of need under the agency's need methodology establishes a rebuttable presumption of need. Balsam
v. Department of Health and Rehabilitative Services, 486 So. 2d 1341, 1349 (Fla. 1st DCA 1986). In this case, Westside's opponents have presented sufficient evidence to rebut the presumption.
The second State Health Plan preference favors applicants who can perform 350 adult procedures annually within three years of establishing a new program.
Throughout the final hearing, Westside's opponents objected to certain evidence and testimony relative to Westside's utilizations projections on grounds that it constituted an impermissible amendment to Westside's CON application. Rule 59C-1.010(2)(b), Florida Administrative Code, provides that "[s]ubsequent to an application being deemed complete by the Agency, no further application information or amendment will be accepted by the Agency." Generally, the rule precludes consideration of substantial changes to a completed application except upon a change of circumstances beyond the applicant's control. Manor Care, Inc. v. Department of Health and Rehabilitative Services, 558 So. 2d 26, 28-29 (Fla. 1st DCA 1989).
In Charter Medical-Orange County, Inc. v. DHRS, (DOAH Case No. 87- 4748), Appendix 2, the Hearing Officer states:
The word "control" probably is intended as a "knew or reasonably should have known" standard. If the applicant reasonably should have known about the information and should have provided the Department with the information as a part
of its original application, then the new information cannot be considered during the formal administrative hearing.
An applicant may introduce "updated current planning information at a formal hearing." Health Care & Retirement Corp. v. HRS, 516 So. 2d 292, 295, (Fla. 1st DCA 1987).
"To the extent that evidence explains or elaborates on assertions made in an application, and the evidence does not change the nature and scope of the proposal, such evidence does not constitute an impermissible amendment."
NME Hospitals, Inc. v. Department of Health and Rehabilitative Services, 14 F.A.L.R. 1882, 1883-1884 (HRS 1992).
The exhibit and testimony in question is contained within the testimony of Dr. Kolb, Westside's expert on health planning and health finance, and Westside's Exhibit 12. This evidence analyzes patient origin for Westside's historical inpatient MDC-5 and cardiac cath service areas by zip code using updated use rate and population data.
It is undisputed that Westside's application does not address or analyze existing services in terms of MDC-5 or cardiac cath patient origin. Instead, Westside's application relied on population projections for the county as a whole and based its volume projections on a district-wide service area. However, the zip codes constituting Westside's historical MDC-5 and cath service areas are subsets of the hospital-wide discharge service area for all Broward Columbia Facilities as presented in the application.
The analysis that Westside used to project volumes in its application was appropriate because Rule 59C-1.033(2)(b), Florida Administrative Code, provides that "[t]he adult open heart surgery program service area is the district." In light of this rule, it is not reasonable to expect an applicant to know that its application should analyze its proposed OHS service area and base its utilization projections on its historical inpatient MDC-5 or cardiac cath service areas which are geographically smaller than the whole district.
It also was appropriate for Westside to provide data on its MDC-5 or cardiac cath service area at hearing in an attempt to explain or elaborate on the information originally submitted and as anticipatory rebuttal to the criticism of opposing parties. Moreover, the information provided at hearing did not change the nature and scope of Westside's proposed facility because it did not significantly alter the original utilization projections.
In the instant case, there is no competing applicant entitled to comparative review. The intervenors have not shown that they were prejudiced by surprise at the formal hearing by the presentation of the analysis in question.
The information contained in Westside Exhibit 12 and Dr. Kolb's testimony relating thereto was not an impermissible amendment to the original
application. However, the evidence supporting Westside's utilization projections, in the application and presented at trial, is contrary to more persuasive evidence indicating that Westside could not achieve its projected volumes and market shares in the first three years of operation
The greater weight of the evidence indicates that Westside's proposed OHS program will not reach its volume projections for many reasons, including, but not limited to: (1) OHS use rates in Broward County are flat and/or declining due to increasing penetration of the market by managed care companies;
(2) The percentage of elderly in the district is actually decreasing as a percentage of the total population; (3) Columbia has not been successful in achieving its targeted volumes in Dade County; (4) In-migration of OHS patients to District X from District IX will substantially decrease as another new program OHS in District IX becomes operational; (5) Westside's single cath lab and proposed CVICU and PCU, as currently designed, are physically inadequate to support the needed volumes; (6) Westside has not provided persuasive evidence that its proposed program will cause significant changes in existing physician referral patterns.
Additionally, there is no need for a new OHS facility in District X based on problems with geographic or financial access. Westside has not adequately documented its willingness to make OHS services available to all segments of the population regardless of ability to pay. On balance, Westside has not demonstrated that its proposal will meet needs identified in the state and local health plans, as required by Section 408.035(1)(a), Florida Statutes.
Westside has not presented persuasive evidence that existing providers have experienced capacity constraints or problems providing quality of care to their patients. To the contrary, competent substantial evidence indicates that the existing providers are being used in an appropriate and efficient manner as required by Sections 408.035(1)(b) and 408.035(2)(b), Florida Statutes.
Westside's ability to provide quality of care in a new OHS program is undermined by the same evidence showing that it cannot achieve its utilizations projections including, but not limited to, limitations associated with a single cath lab, the physical design of the proposed unit and inadequate manpower projections. Accordingly, Westside has not met the requirements of Section 408.035(1)(c), Florida Statutes.
Section 408.035(l)(i), Florida Statutes, requires an applicant to demonstrate the immediate and long-term financial feasibility of the new program. Westside has not demonstrated that it can achieve its projected revenues and has therefore failed to carry its burden relative to long-term financial feasibility.
Approval of Westside's CON will have a significant impact on the ability of existing providers to offer quality services while maintaining cost effective programs contrary to Section 408.035(1)(l), Florida Statutes. A new program in District X is not needed to foster competition.
Westside's proposed renovations are inadequate to support its projected volumes. The most credible evidence indicates that Westside's cath lab cannot accommodate the increased numbers of cardiac cath procedures necessary to achieve its projected volume. Further, the physical design of the proposed CVICU and PCU, including the facilities for patient care will be bottlenecked at 250 procedures. The design of these areas raise significant
concerns about patient privacy and dignity. Substantial revisions to the plans and budget would be required for compliance with rule 59A-3.081, Florida Administrative Code.
Section 408.035(1)(n), Florida Statutes, requires consideration of the applicant's past and proposed provision of health care services to Medicaid patients and the medically indigent. Historically, Westside has provided approximately two percent of its total acute patient days for Medicaid clients. Of all the Broward county hospitals, Westside's record indicates that it provides the lowest number of patient days to the medically indigent. Westside proposes to commit 2.3 percent of its OHS volume to Medicaid patients but limits this commitment to two years. It did not commit to providing any specific percentage of care to the medically indigent or charity care.
Citing Section 408.035(2)(d), Westside claims that patients in the western portion of District X will experience problems with geographic accessibility if its CON is not approved. However, Westside presented no persuasive evidence that OHS patients have experienced any problems or adverse outcomes due to the lack of an additional OHS provider in District X.
The greater weight of the evidence demonstrates that there is no need for another open heart provider in District X. More importantly, Westside has failed to demonstrate compliance with statutory and rule criteria as set forth above.
Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that AHCA enter a Final Order denying Westside's application for CON Action No. 7455.
DONE AND ENTERED this 31st day of January, 1996, in Tallahassee, Leon County, Florida.
SUZANNE HOOD, HEARING OFFICER
Hearing Officer
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-1550
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 31st day of January 1996.
APPENDIX TO RECOMMENDED ORDER CASE NOS. 94-1020 AND 94-1021
To comply with the requirements of Section 120.59(2), Florida Statutes, the following rulings are made on the parties' proposed findings of fact:
Westside's Proposed Findings of Fact
1-5. Accepted in part and rejected in part as set forth in Findings of Fact (FOF) 1-8.
6-11. Accepted in relevant part in FOF 9-16.
12-14. Accepted in relevant part in FOF 102-104.
Accepted in part in FOF 106. Reject implication that pending approval of OHS CON in subsequent batching cycle is evidence of need for new OHS program in District X.
First sentence rejected; not supported by persuasive competent substantial evidence (PCSE). Second sentence accepted in FOF 103.
Accept first sentence as restated in FOF 109. Third sentence rejected; see FOF 32. Fourth sentence accepted as restated in FOF 45. Last two sentences rejected; see FOF 46-47.
Accepted; see FOF 103 and 212; see also FOF 111.
Accepted in FOF 18.
Accepted in FOF 19.
Accepted in part but reject last sentence. A program with a single surgeon and one OHS team would either have to forego vacations and sick leave or shut the shut the surgery unit down to provide these benefits.
Accepted in FOF 23 and 104.
23-25. Accepted in part and rejected in part in FOF 28-31. 26-28. Accepted in FOF 23-24 and 37-39.
Accepted in FOF 41.
Accepted as restated in FOF 42.
31-33. Accepted in FOF 43-45.
Irrelevant; relates to NBMC.
Accepted as restated in FOF 46.
Irrelevant; relates to NBMC.
Accepted as restated in FOF 48.
Accepted as restated in FOF 53.
First sentence accepted in FOF 54 but reject second sentence as not supported by PCSE; see FOF 58.
Accepted in part; see FOF 25 and 53. Reject that cath volume supports projected market share; see FOF 54-66.
Irrelevant as related to NBMC; otherwise rejected because no PCSE.
Accepted; see FOF 53 and 62.
Accepted; see FOF 67; see also 67-68.
Rejected; no PCSE; see FOF 70-73.
Accepted as restated in FOF 40 and 41; rejected in part as argumentative. MDC-5 and cath market share are not the only market dynamics which must be considered.
46-47. Accept that some local doctors and other Broward Columbia facilities would support new program to limited degree; otherwise rejected; see FOF 46-79.
48-49. Irrelevant; relates to NBMC.
Rejected; see FOF 80-81.
Accepted in part and rejected in part; see FOF 82. 52-53. Accepted in part and rejected in part; see FOF 83-
88.
54. Accepted in part and rejected in part; see FOF 89-
91
55-65. Accepted in part and rejected in part; see FOF 92- 101; see also FOF 228. Specifically reject any attempt to revise limitations on commitment to Medicaid patients.
Not a FOF.
Rejected; see FOF 75-78.
First two sentences rejected; see FOF 32-36 and
103. Last sentence accepted but based on outdated data.
Accept next to last sentence; see FOF 102-105. Rejected otherwise as not supported by PCSE.
70-72. Rejected; see FOF 111-113.
73-85. Accepted in part and rejected in part; but conclusions regarding transfers, delays in scheduling, capacity of existing OHS programs, diversion, quality of care, and mortality rates rejected as contrary to more persuasive evidence; see FOF 142-148, 249-260.
86-105. Accepted in part and rejected in part; see FOF 149-
176. Specifically reject claim that cath lab is capable of supporting an OHS program with volumes of 350 or more cases; contrary to more persuasive evidence; see FOF 155-157. Extent of Dr. Dorman's and Miami Heart's involvement with new program is ambiguous; greater weight of evidence indicates that actual commitment is limited to start-up phase; see FOF 151 and 178.
106-110. Accepted in part and rejected in part; conclusions rejected; see FOF 177 re Section 408.035(1)(d), Florida Statutes; see FOF 248-251 re Section 408.035(2)(a), Florida Statutes; also see 75-78, 141-148, 209-210, and 256.
Reject conclusions; see FOF 178-179 re Section 408.035(1)(e), Florida Statutes as to economies from shared health resources; see FOF 252-253 re Section 408.035(2)(b) as to appropriate and efficient use of existing OHS programs; see FOF 254 re Section 408.035(2)(c), Florida Statutes, as to modernization or sharing arrangement as alternatives to new construction; see also FOF 155- 176, 233-245, and 283-305 as to new construction.
Accepted in FOF 180.
Accepted in FOF 181-182.
114-129. Accepted in part and rejected in part; conclusions rejected; see FOF 183-185; see also FOF 149-176, 233- 245, and 283-305.
130. Irrelevant; relates to NBMC.
131-149. Accepted in part and rejected in part. Conclusions rejected as contrary to more persuasive evidence; see FOF 186-207.
150-157. Accepted in part and rejected in part. No PCSE that any OHS patients will have to outmigrate if new program not approved; see FOF 208-210.
158. Accepted in FOF 211.
159-168. Accepted in part and rejected in part; conclusions rejected in FOF 212-232. See also FOF 104-110. No
PCSE to support: second sentence in proposed FOF 160, 161, 162; proposed FOF 163; first sentence in proposed FOF 166, first and third and fourth sentence in proposed FOF 168; proposed FOF 168.
169. Irrelevant; relates to NBMC.
170-195. Accepted in part and rejected in part; conclusions rejected in FOF 233-245, 254, 283-305.
Specifically reject as contrary to more persuasive evidence: proposed FOF 172, first two sentences and statement revisual control of patients in proposed FOF 175, last sentence in proposed FOF 176, last two sentences in proposed FOF 177, proposed FOF
178-182, first sentence in proposed FOF 183, implication in proposed FOF 184- 187 that PCU has adequate capacity, proposed FOF 188 irrelevant as it relates to NBMC, proposed FOF 191, proposed FOF
193 irrelevant as it relates to NBMC.
Conclusions relating to Sections 408.035(1)(n) and 408.035(2)(d), Florida Statutes, rejected in FOF 246, 255-260. See also FOF 92-101.
Accepted in FOF 247.
Memorial's Proposed Findings of Fact 1-4. Accepted in FOF 1-8.
5-6. Irrelevant; relates to NBMC.
7-12. Accepted in FOF 9-16.
13. Accepted. See Preliminary Statement.
14-15. Accepted in FOF 17-18.
16-19. Accepted in FOF 19-79.
Accepted in FOF 80-81.
Accepted in FOF 82.
22-23. Accepted in FOF 83-88.
24. Accepted in FOF 89-91.
25-26. Accepted in part, rejected in part, in FOF 92-101.
27-31. Accepted in FOF 102-140.
32-36. Accepted in FOF 141-148.
37-52. Accepted in FOF 149-176.
53. Accepted in FOF 177.
54-55. Accepted in FOF 178-179.
Conclusion accepted in FOF 180.
Accepted in FOF 181-182.
58-59. Accepted in FOF 183-185.
60-67. Accepted in FOF 186-207.
Accepted in FOF 208-210.
Accepted in FOF 211.
70-80. Accepted in FOF 212-232.
81-83. Accepted in FOF 233-245.
Accepted in FOF 246.
Accepted in FOF 247.
Accepted in substance in FOF 248-251.
87-88. Accepted in FOF 252-253.
89. Accepted in FOF 254.
90-94. Accepted in substance in FOF 255-260.
95. Accepted in FOF 261.
96-103. Accepted in substance in FOF 262-265.
Rejected in FOF 266-278.
Accepted in FOF 279-280. 106-107. Accepted in FOF 281-282. 108-127. Accepted in FOF 283-305.
North Ridge's Proposed Finding of Fact
Accepted in FOF 9 and 13.
Accepted as related to Westside; irrelevant as to NBMC; see Preliminary Statement.
Irrelevant as to NBMC.
Accepted. See Preliminary Statement.
5-17. Irrelevant as related to NBMC.
18-25. | Accepted in substance in FOF 102-140. | ||
26. | Accepted in FOF 111. | ||
27-31. | Accepted in FOF 113-114 and 116. | ||
32. | Accepted as restated in FOF 143 and 253. | ||
33-34. | Accepted in FOF 112, 143, and 253. | ||
35. | Accepted in FOF 113. | ||
36. | Accepted as restated in 112, 143, and 253. | ||
37-38. | Irrelevant as relates to NBMC. | ||
39. | Accepted in FOF 116. | ||
40-47. | Irrelevant as relates to NBMC. | ||
48-49. | Accepted in FOF 118-119. | ||
50-61. | Accepted in FOF 25, 123-140. | ||
62. | Irrelevant as relates to NBMC. | ||
63-75. | Accepted in FOF 127-140. | ||
76-77. | Irrelevant as relates to NBMC. | ||
78-79. | Accepted in FOF 72-74. | ||
80-82. | Irrelevant as relates to NBMC. | ||
83-87. | Accepted in FOF 33-36. | ||
88. | Irrelevant as relates to NBMC. | ||
89-91. | Accepted in FOF 46-47. | ||
92-93. | Accepted as restated in FOF 70. | ||
94. | Irrelevant as related to NBMC. | ||
95. | Rejected, no PCSE. | ||
96-100. | Accepted in FOF 75-78. | ||
101-103. 104-106. | Accept in part and reject in part; see FOF 27, and 69. Accepted in substance in FOF 31. | 24, | 26- |
107-108. | Accepted in FOF 27. | ||
109-121. | Accepted in FOF 58-69. | ||
122-125. | Conclusions accepted in FOF 1, 4, 26, and 210. | ||
126-131. | Accepted; see Conclusions of Law. | ||
132. | Accepted in FOF 31. | ||
133-141. | Irrelevant as relates to NBMC. | ||
142-143. | Accepted in FOF 73. | ||
144-147. | Accepted in substance; see FOF 212-232. | ||
148-164. | Irrelevant as relates to NBMC. | ||
165-169. | Accepted in FOF 212-232. | ||
170-172. | Accepted in FOF 196. | ||
173. | Irrelevant as relates to NBMC. | ||
174-175. | Accepted in 196 and 198. | ||
176-178. | Irrelevant as relates to NBMC. | ||
179-182. | Accepted in FOF 198 and 199. | ||
183-216. | Irrelevant as relates to NBMC. | ||
217-229. | Accepted in FOF 210-207. | ||
Holy Cross's Proposed Findings of Fact
Irrelevant as relates to NBMC.
Accepted in FOF 1.
3-4. Accepted in substance; see FOF 260, last sentence irrelevant as relates to NBMC.
5-7. Accepted in substance; see FOF 102-140.
8-12. Accepted as subordinate to FOF 102-140; Irrelevant as relates to NBMC in proposed FOF 8 and 9.
13. Accepted in substance in FOF 102-140.
14-17. Accepted in or subordinate to FOF 9-16 and 102-140.
Irrelevant as it relates to NBMC.
Accepted in substance in FOF 81.
Irrelevant as relates to NBMC.
Accepted in or subordinate to FOF 14, 71 and 191. 22-35. Accepted in substance and relevant part in FOF 34-
35, 49-57, and 72-74. Irrelevant as relates to NBMC: last sentence in proposed FOF 24, next to last sentence in proposed FOF 27, next to last sentence in proposed FOF 29, first sentence in proposed FOF 33, next to last sentence in proposed FOF 34, all but first sentence in proposed FOF 35.
36-41. Accepted in substance as to relevant part in FOF 57, 120, 123-140.
42-47. Accepted in substance as to relevant part in FOF 80- 82, 92-100, and 113-119. Proposed FOF 45-47
irrelevant as relates to NBMC.
48-56. Accepted in substance and/or as subordinate to FOF 84-88, 119-122, 128-139, 141-176.
57-59. Irrelevant as relates to NBMC.
60-61. Accepted in substance and/or as subordinate to FOF 154, 212-232.
62-66. Irrelevant as relates to NBMC; last sentence in proposed FOF 66 accepted in FOF 15.
67-83. Accepted in substance but irrelevant as relates to NBMC. FMC's Proposed Findings of Facts
1-19. Accepted in substance but irrelevant as relates to NBMC.
COPIES FURNISHED:
Stephen A. Ecenia, Esquire Thomas W. Konrad, Esquire
R. David Prescott, Esquire Rutledge, Ecenia, Underwood,
Purnell and Hoffman, P.A.
215 South Monroe Street, Suite 420 Tallahassee, Florida 32301
Samuel Dean Bunton, Esquire John F. Gilroy, Esquire
Agency for Health Care Administration 2727 Mahan Drive, Building 3
Tallahassee, Florida 32308
R. Terry Rigsby, Esquire Geoffrey D. Smith, Esquire Wendy A. Delvecchio, Esquire Blank, Rigsby, Meenan, P.A.
204 South Monroe Street Tallahassee, Florida 32301
William B. Wiley, Esquire Darrell White, Esquire Charles A. Stampelos, Esquire
McFarlain, Wiley, Cassedy and Jones
215 South Monroe Street, Suite 600 Tallahassee, Florida 32301
Michael Cherniga, Esquire David C. Ashburn, Esquire Greenberg, Taurig, Hoffman,
Lipoff, Rosen and Quentel, P.A.
101 East College Avenue Tallahassee, Florida 32301
R. Sam Power, Agency Clerk
Agency for Health Care Administration Fort Knox Building 3, Suite 3431
2727 Mahan Drive
Tallahassee, Florida 32308-5403
Douglas M. Cook, Director
Agency for Health Care Administration 2727 Mahan Drive
Tallahassee, Florida 32308-5403
Jerome W. Hoffman, General Counsel Agency for Health Care Administration 2727 Mahan Drive
Tallahassee, Florida 32308-5403
NOTICE OF RIGHT TO SUBMIT EXCEPTION
All parties have the right to submit written exceptions to this recommended order. All agencies allow each party at least ten days in which to submit written exceptions. Some agencies all a larger period within which to submit written exceptions. You should contact the agency that will issue the final order in this case concerning agency rules on the deadline for filing exceptions to this recommended order. Any exceptions to this recommended order should be filed with the agency that will issue the final order in this case.
================================================================= AGENCY FINAL ORDER
=================================================================
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
COLUMBIA HOSPITAL CORPORATION OF SOUTH BROWARD d/b/a WESTSIDE
REGIONAL MEDICAL CENTER, et al.,
Petitioners,
Respondents.
/
FINAL ORDER
A Recommended Order was entered in this case on January 31, 1996. On February 19,1996, Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center, withdrew its application for CON 7455, which was the subject of this proceeding.
Upon consideration of the withdrawal of the application, CON 7455 is denied and the agency's file is CLOSED.
DONE and ORDERED this 6th day of March, 1996, in Tallahassee, Florida.
Douglas M. Cook, Director Agency for Health Care
Administration
A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED.
Copies furnished to:
Stephen A. Ecenia, Esquire
R. David Prescott, Esquire Rutledge, Ecenia, Underwood, Purnell & Hoffman, P. A.
215 South Monroe Street, #420 Post Office Box 551
Tallahassee, Florida 32302-0551
John Gilroy, Esquire
Senior Attorney, Agency for Health Care Administration 2727 Mahan Drive
Fort Knox Bldg. 3, Suite 3431
Tallahassee, Florida 32308-5403
R. Terry Rigsby, Esquire Blank, Rigsby & Meenan, P. A.
204 South Monroe Street Tallahassee, Florida 32301
Michael J. Cherniga Esquire Greenberg, Traurig, Hoffman, Lipoff, Rosen & Ouentel, P. A.
101 East College Avenue Post Office Drawer 1838 Tallahassee, Florida 32301
Darrell White, Esquire
McFarlain, Wiley, Cassedy & Jones, P. A.
215 South Monroe Street, Suite 600 Tallahassee, Florida 32301
Suzanne F. Hood Hearing Officer
The DeSoto Building 1230 Apalachee Parkway
Tallahassee, Florida 32399-1550 Elizabeth Dudek (AHCA/CON) Alberta Granger (AHCA/CON)
Elfie Stamm (AHCA/CON)
CERTIFICATE OF SERVICE
HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to the above named addresses by U. S. Mail this 6th day of March, 1996
R. S. Power, Agency Clerk State of Florida, Agency for Health Care Administration 2727 Mahan Drive
Fort Knox 3, Suite 3431
Tallahassee, Florida 32308-5403
(904)922-3808
| Issue Date | Proceedings |
|---|---|
| Mar. 07, 1996 | Final Order filed. |
| Jan. 31, 1996 | Recommended Order sent out. CASE CLOSED. Hearing held 05/15/95 thru 06/19/95. |
| Oct. 26, 1995 | Order Denying Joint Motion to Permit Supplementation of Proposed Findings of Fact And Conclusions of Law sent out. (motion denied) |
| Oct. 09, 1995 | Disk (containing Holy Cross Proposed Recommended Order, tagged) filed. |
| Oct. 09, 1995 | Westside's Response to Motion to Permit Supplementation of Proposed Findings of Fact and Conclusions of Law filed. |
| Oct. 03, 1995 | Joint Motion to Permit Supplementation of Proposed Findings of Fact, Conclusions of Law filed. |
| Oct. 03, 1995 | Disk (containing Proposed findings of fact of AMISUB, HO has disk); Cover Letter filed. |
| Oct. 02, 1995 | (North Broward Hospital) Notice of Voluntary Dismissal filed. |
| Oct. 02, 1995 | SBHD & FMC Disk (Proposed Recommended Order and Memorandum of Law/HO has disk) filed. |
| Sep. 25, 1995 | Westside's Legal Brief In Support of Its Proposed Recommended Order filed. |
| Sep. 25, 1995 | Florida Medical Center, LTD.'s Proposed Recommended Order; South Broward Hospital District d/b/a Memorial Hospital's Proposed Recommended Order (for HO signature); Cover Letter filed. |
| Sep. 25, 1995 | Proposed Recommended Order of Holy Cross Hospital, Inc.; Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Proposed Recommended Order filed. |
| Sep. 25, 1995 | South Broward Hospital District d/b/a Memorial Hospital`s and Florida Medical Center, LTD.`s Joint Memorandum of Law filed. |
| Sep. 25, 1995 | Amisub (North Ridge Hospital), Inc.'s Proposed Findings of Fact, Conclusions of Law filed. |
| Sep. 12, 1995 | Order Granting Motion for Extension of Time to File Proposed findings of Fact and Conclusions of Law sent out. |
| Sep. 11, 1995 | North Ridge Medical Center's Motion for Extension of Time to File Proposed Findings of Fact, Conclusions of Law filed. |
| Sep. 06, 1995 | Order Granting Motion for Extension of Pages And Proposed Recommended Orders sent out. (motion granted) |
| Sep. 05, 1995 | (North Broward) Motion for Extension of Pages And Proposed Recommended Order filed. |
| Aug. 11, 1995 | Order Granting Extension of Time to File Proposed Recommended Orders sent out. (proposed recommended orders will be due 9/15/95) |
| Aug. 09, 1995 | Joint Motion for Extension of Time to File Proposed Recommended Orders filed. |
| Jul. 20, 1995 | Notice of Appearance And Substitution of Counsel (from John Gilroy) filed. |
| Jul. 14, 1995 | Volume 32 thur 36 Transcript w/cover letter filed. |
| Jul. 12, 1995 | (Susan Horovitz Maurer) Notice of Change of Address filed. |
| Jul. 10, 1995 | (Volumes 14 thur 31) Final Evidentiary Hearing ; Disks Transcript filed. |
| Jun. 22, 1995 | Master Index ; (Volume 1 thur 13) Transcript; (3) Disk filed. |
| Jun. 19, 1995 | North Broward Hospital District`s Memorandum of Law Re: Impermissible Amendment to CON Applications filed. |
| Jun. 08, 1995 | Petitioner, North Broward Hospital District's Motion to Sever Consolidation and Voluntary Dismissal of Amended Petition for Administrative Determination of Agency Policy Statement Not Promulgated By Rule And Motion to Consolidate filed. |
| May 26, 1995 | Letter to SFH from R. Terry Rigsby (RE: scheduling difficulties) filed. |
| May 26, 1995 | Letter to SFH from Seann Frazier (RE: availability of day for testimony) filed. |
| May 25, 1995 | Letter to HO from Michael J. Cherniga Re: Hearing schedule for May 31st. filed. |
| May 17, 1995 | North Broward Hospital District d/b/a North Broward Medical Center's Notice of Withdrawal of Motion to Strike Exhibits From Holy Cross Hospital, Inc. Exhibit List filed. |
| May 15, 1995 | CASE STATUS: Hearing Held. |
| May 12, 1995 | (Susan Horovitz Maurer) Notice of Filing Original Affidavit of Service; Return of Service; Subpoena Ad Testificandum filed. |
| May 12, 1995 | Error & Omissions Response for Adult Open Heart Surgical Service Application at North Broward Medical Center Pompano, Beach Florida CON #7456 LOI #H9308108 Volume II of II filed. |
| May 12, 1995 | North Broward Medical Center's Motion to Strike Exhibits of Holy Cross Hospital, Inc.; Letter to HO from Seann M. Frazier Re: North BrowardMedical Center's CON Application Number 7456; Certificate of Need Application for Adult Ope n Heart Surgical Servi |
| May 11, 1995 | (Stephen A. Ecenia) Notice of Withdrawal of Production Requests; Letter to Stephen Ecenia from Geoffrey D. Smith Re: Confirming the status of outstanding discovery matters filed. |
| May 11, 1995 | Petitioner, North Broward Hospital District's Motion to Strike AHCA Witness filed. |
| May 11, 1995 | Order sent out. (motions are moot) |
| May 10, 1995 | Holy Cross Hospital, Inc.'s Amended Witness and Exhibit List filed. |
| May 10, 1995 | Agency for Health Care Administration's Response in Support of Motions for Protective Order Filed by Florida Medical Center and South Broward Hospital District; Notice of Voluntary Dismissal filed. |
| May 10, 1995 | Letter to HO from David C. Ashburn Re: Exhibits that were not enclosed with the Motion filed. |
| May 09, 1995 | Letter to HO from Geoffrey D. Smith Re: Outstanding Discovery Mattersfiled. |
| May 09, 1995 | (David C. Ashburn) Motion in Limine or in the Alternative Motion to Compel Production of Documents filed. |
| May 09, 1995 | Letter to HO from Stephen A. Ecenia Re: Copy of Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's certificate of need application number 7455 filed. |
| May 09, 1995 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Witness List w/cover letter; Agency for Health CareAdministration's Response in Support of Motions for Protective Order Filed by Florida Medic al Center and South Br |
| May 09, 1995 | Order Granting Motion to Compel Subject to Protective Order sent out. (ruling on motions) |
| May 09, 1995 | Order Denying North Broward Hospital District's Motion to Compel And Amisub (North Ridge Hospital), Inc.'s Motion for Protective Order sentout. (motions are moot) |
| May 08, 1995 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Exhibit List; Columbia Hospital Corporation of South Broward d/b/a Westside regional Medical Center's Exhibit List; Holy Cross Hospital, Inc.'s Witness and Exhibit L |
| May 08, 1995 | Petitioner, North Broward Hospital District's Compliance With Order of Prehearing Instructions; Petitioner's Exhibit List; North Broward Hospital District, d/b/a North Broward Medical Center's Witness List; Agency for Health Care Administration Statemen |
| May 08, 1995 | (Joint) Prehearing Stipulation; AMISUB (North Ridge Hospital), Inc.'sWitness List; AMISUB (North Ridge Hospital), Inc.'s Exhibit List; Florida Medical Center, LTD. Witnesses; Florida Medical Center, LTD. Exhibits; South Broward Ho spital District d/b/a |
| May 08, 1995 | Petitioner, North Broward Hospital District's Motion for Hearing on Petitioner's Motion to Strike Witnesses of Petitioner, Plantation General Hospital, L.P. filed. |
| May 05, 1995 | North Broward Hospital District d/ba/a North Broward Medical Center'sResponse to AMISUB (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center's Second Request for Production of Documents filed. |
| May 05, 1995 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Response in Opposition to Florida Medical Center, LTD.'s and South Broward Hospital District d/b/a Memorial Hospital's Petitions to Intervene and Motion for More Def |
| May 05, 1995 | Florida Medical Center, LTD.'s And South Broward Hospital District d/b/a Memorial Hospital's Motion for Protective Order filed. |
| May 05, 1995 | Letter to SFH from S. Ecenia (RE: response to request for suggested languange) filed. |
| May 04, 1995 | Letter to HO from David C. Ashburn Re: North Broward Hospital District's Motion to Compel and AMISUB (North RIdge Hospital) Motion for Protective Order is moot filed. |
| May 04, 1995 | Holy Cross Hospital, Inc.'s Petition to Intervene filed. |
| May 03, 1995 | Holy Cross Hospital, Inc.'s Witness and Exhibit List filed. |
| May 02, 1995 | North Broward Hospital District's Motion to Compel filed. |
| May 01, 1995 | Letter to HO from Seann M. Frazier Re: Motion for Summary RecommendedOrder seeking the dismissal of the North Broward Hospital District's CON Application; AMISUB (North Ridge Hospital), Inc.'s Motion for Summary Recommended Order Against the North Brow |
| Apr. 28, 1995 | (David C. Ashburn) Motion for Protective Order filed. |
| Apr. 27, 1995 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Response to Florida Medical Center, LTD. and South Broward Hospital District's Motion to Compel Against Westside; Notice of Taking Deposition Duces Tecum; (2) Notice |
| Apr. 27, 1995 | Letter to HO from Thomas W. Konrad Re: Copy of Columbia HOspital Corporation of South Browrd d/b/a Westside Regional Medical Center's Memorandum of Law in Opposition of North Broward Hospital District's Summary Recommended Order against Westside w/attac |
| Apr. 26, 1995 | Petitioner, North Broward Hospital District's Motion to Strike Witnesses of Petitioner, Plantation General Hospital, L.P.; Re-Notice of Taking Deposition w/cover letter filed. |
| Apr. 25, 1995 | Florida Medical Center's Petition to Intervene; South Broward Hospital District d/b/a Memorial Hospital's Petition to Intervene; Notice of Hearing filed. |
| Apr. 25, 1995 | Transcript (copy tagged) filed. |
| Apr. 25, 1995 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's And The Agency for Health Care Administration's Joint Response In Opposition to North Broward Hospital District d/b/a North Broward Medical Center's Motion for Summa |
| Apr. 25, 1995 | North Broward Hospital District d/b/a North Broward Medical Center's Memorandum of Law In Support of Motion for Summary Recommended Order of Dismissal of Columbia Hospital Corporation of South Broward, Inc. d/b/a Westside Regional Medical Center filed. |
| Apr. 25, 1995 | North Broward Hospital District d/b/a North Broward Medical Center's Motion for Summary Recommended Order of Dismissal of Westside RegionalMedical Center; Cover Letter filed. |
| Apr. 25, 1995 | Letter to HO from David C. Ashburn Re: Copy attached of AMISUB (NorthRidge Hospital), Inc.'s Motion for Summary Recommended Order Against the North Broward Hospital District and for Official Recognition filed. |
| Apr. 20, 1995 | (North Broward) Notice of Filing Original Affidavit of Service; Affidavit of Service; Subpoena Duces Tecum (from S. Maurer) filed. |
| Apr. 20, 1995 | (Susan Horovitz Maurer) Amended Petition for Administrative Determination of Agency Policy Statement not Promulgated by Rule and Motion to Consolidate filed. |
| Apr. 20, 1995 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Motion to Compel Interrogatory Answers and DocumentProduction from Florida Medical Center, LTD. and South Broward Hospital District and Reques t for Oral Argument re |
| Apr. 19, 1995 | Florida Medical Center's Motion to Compel Against Columbia Hospital Corporation of South Broward Inc., d/b/a Westside Regional Medical Center; South Broward Hospital District's Motion to Compel Against Columbia Hospital Corporation of South Broward d/b/ |
| Apr. 17, 1995 | Florida Medical Center's Second Interrogatories to Plantation GeneralHospital L.P.; Plantation's Responses to FMC's Second Request for Production filed. |
| Apr. 17, 1995 | Order Granting Consolidation And Notice of Hearing sent out. (Consolidated cases are: 94-1020, 94-1021, 94-1022, 94-1023, 94-1465RU; hearing will be held May 15, 1995 thru June 16, 1995; 10:00am; Talla) |
| Apr. 17, 1995 | Case No/s 94-1020, 94-1021, 94-1022, 94-1023: unconsolidated. |
| Apr. 17, 1995 | (R. Terry Rigsby) Notice of Taking Deposition Duces Tecum filed. |
| Apr. 17, 1995 | (R. Terry Rigsby) Notice of Taking Deposition Duces Tecum filed. |
| Apr. 14, 1995 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Response to Florida Medical Center's Second Requestfor Production; Columbia Hospital Corporation of South Browar d/b/a Westside Regional Medic al Center's Notice of |
| Apr. 13, 1995 | (Susan Horovitz Maurer) Notice of Taking Deposition filed. |
| Apr. 13, 1995 | (Susan Horovitz Maurer) Notice of Taking Deposition filed. |
| Apr. 12, 1995 | AMISUB (North Ridge Hospital), Inc.'s Response to North Broward Hospital District's Request for Production of Documents; AMISUB (North Ridge Hospital), Inc. Response to North Broward Hospital District's Request for Admissions filed. |
| Apr. 12, 1995 | (Susan Horovitz Maurer) Re-Notice of Taking Deposition (Duces Tecum*)filed. |
| Apr. 11, 1995 | Order sent out. (petitioner's request denied) |
| Apr. 10, 1995 | (Susan Horovitz Maurer) (6) Notice of Taking Deposition filed. |
| Apr. 10, 1995 | Florida Medical Center Inc's response to Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Centr's second request for production of documents filed. |
| Apr. 07, 1995 | (Michael J. Cherniga) Response to Westside's Motion to Compel AgainstAMISUB filed. |
| Apr. 05, 1995 | Holy Cross Hospital, Inc.'s Response in Opposition to North Broward Hospital District's Second Motion to Amend Hearing Location filed. |
| Apr. 04, 1995 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's and the Agency for Health Care Administration's Joint Response in Opposition to North Broward Hospital District d/b/a North Broward Medical Center's Second Renewed M |
| Apr. 03, 1995 | (Susan Horovitz Maurer) (4) Notice of Taking Deposition filed. |
| Mar. 31, 1995 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Motion to Compel Against AMISUB (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center (5) Notice of Taking Deposition filed. |
| Mar. 30, 1995 | (FMC) Notice of Holding Depositions In Abeyance filed. |
| Mar. 29, 1995 | (Gregory D. Smith) Amended Notice of Taking Deposition Duces Tecum filed. |
| Mar. 29, 1995 | (North Broward Hospital) Renewed Motion to Amend Hearing Location filed. |
| Mar. 27, 1995 | (Petitioner) Notice of Filing; Deposition of Elmo Elrod filed. |
| Mar. 21, 1995 | Florida Medical Center's Response to Motion for Protective Order of Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center filed. |
| Mar. 20, 1995 | Petitioner's Second Set of Interrogatories to Plantation General Hospital filed. |
| Mar. 20, 1995 | North Broward Hospital District d/b/a North Broward Medical Center's Request for Admissions to AMISUB (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center filed. |
| Mar. 20, 1995 | North Broward Hospital District d/b/a North Broward Medical Center's Request for Production of Documents to AMISUB (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center's filed. |
| Mar. 17, 1995 | Holy Cross Hospital, Inc.'s Response to North Broward Hospital District's Motion in Limine filed. |
| Mar. 15, 1995 | Florida Medical Center, LTD.'s Second Request for Production to Planation General Hospital, L.P.; Florida Medical Center's Notice of Service of Second Interrogatories to Plantation General Hospital, L.P.; Florida Medical Center's Second Request for Prod |
| Mar. 15, 1995 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Motion for Protective Order filed. |
| Mar. 15, 1995 | Florida Medical Center's Notice of Service of Second Interrogatories to Westside filed. |
| Mar. 14, 1995 | Order Granting Motion to Expedite Response to North Broward Hospital District d/b/a North Broward Medical Center's Motion In Limine And Scheduling Hearing On Motion sent out. (telephonic hearing set for 3/17/95; 2:00pm) |
| Mar. 13, 1995 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Response to North Broward Hospital District d/b/a North Broward Medical Center's Request to Expedite Responses to its Motion in Limine filed. |
| Mar. 13, 1995 | North Broward Hospital District d/b/a North Broward Medical Center Motion in Limine with Regard to Disclosure of HMO and PPO Contractual Provisions filed. |
| Mar. 10, 1995 | Columbia Hospital Corporationof South Broward d/b/a Westside RegionalMedical Center's Second Request for Production of Documents to Florida Medical Center; Columbia Hospital Corporation of South Broward d/b/aWestside Regional Med ical Center's First Re |
| Mar. 09, 1995 | (R. Terry Rigsby) Notice of Taking Depositions filed. |
| Feb. 22, 1995 | Amisub (North Ridge Hospital), Inc.'s Preliminary Witness List filed. |
| Feb. 22, 1995 | AMISUB (North Ridge Hospital), Inc.'s Preliminary Witness List filed. |
| Feb. 20, 1995 | Florida Medical Center, LTD.'s Amended Preliminary Witness List; South Broward Hospital District's Preliminary Witness List filed. |
| Feb. 17, 1995 | Notice of Service of Second Set of Interrogs. to Plantation General Hospital filed. |
| Feb. 17, 1995 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Revised Preliminary Witness List filed. |
| Feb. 15, 1995 | Transcript filed. |
| Jan. 11, 1995 | North Broward Hospital District d/b/a North Broward Medical Center's Response to Florida Medical Center's First Request for Production of Documents; North Broward Hospital District d/b/a North Broward Medical Center's Notice of Serving Answers to Florid |
| Dec. 29, 1994 | Order sent out. (motion denied) |
| Dec. 20, 1994 | (Plantation General Hospital, L.P.) Notice of Appearance and Substitution of Counsel filed. |
| Dec. 19, 1994 | (Petitioner North Broward Hospital District d/b/a North Broward Medical Center) Memorandum Of Law Regarding Lack Of Authority To Enter A Summary Recommended Order filed. |
| Dec. 16, 1994 | Revised Notice of Taking Deposition Duces Tecum filed. |
| Dec. 15, 1994 | (Stephen A. Ecenia) Columbia Hospital Corporatioh Of South Borward d/b/a Westside Regional Medical Center's Response To AMISUB (North RidgeHospital), Inc. d/b/a North Ridge Medical Center's Second Request For Production filed. |
| Dec. 15, 1994 | (Stephen A. Ecenia) Columbia Hospital Corporation Of South Broward d/b/a Westside Regional Medical Center's Notice Of Service Of Answers ToAMISUB (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center's First Interrogatorie s filed. |
| Dec. 13, 1994 | (D. Ashburn) Notice of Taking Deposition Duces Tecum filed. |
| Dec. 12, 1994 | Agency For Health Care Administration's And North Broward Hospital District d/b/a North Broward Medical Center's Joint Statement Of Position Regarding Amisub (North Ridge), Inc.'s Motion For Summary Recommended Order filed. |
| Dec. 12, 1994 | Order Granting Continuance and Rescheduling Hearing sent out. (hearing rescheduled for May 15, 1995 through June 16, 1995; 10:00am; Talla) |
| Dec. 09, 1994 | Notice of Motion Hearing sent out. (motion hearing set for 12/21/94;10:00am; Talla) |
| Dec. 07, 1994 | (Plantation General) Notice of Hearing; Motion for Contuniance filed. |
| Dec. 07, 1994 | Notice of Hearing (set for 12-19-94; 10:00a; Talla) filed. |
| Dec. 01, 1994 | Notice of Taking Deposition Duces Tecum (from D. Ashburn) filed. |
| Nov. 23, 1994 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Response to Amisub (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center's First Request for Production of Documents filed. |
| Nov. 23, 1994 | (Holy Cross) Notice of Taking Deposition Duces Tecum filed. |
| Nov. 23, 1994 | North Broward Hospital District d/b/a North Broward Medical Center's Response to Amisub (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center's First Request for Production of Documents filed. |
| Nov. 23, 1994 | North Broward Hospital District d/b/a North Broward Medical Center's Notice of Serving Answers to Amisub (North Ridge Hospital), Inc. d/b/aNorth Ridge Regional Medical Center's First Set of Interrogatories; North Broward Hospital District d/b/a North B |
| Nov. 22, 1994 | Holy Cross Hospital, Inc.'s Amended Preliminary Witness List filed. |
| Nov. 22, 1994 | Order sent out. (renewed motion to amend hearing location id denied) |
| Nov. 22, 1994 | Order sent out. (request for consolidation denied) |
| Nov. 21, 1994 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Preliminary Witness List filed. |
| Nov. 17, 1994 | North Broward Hospital District d/b/a North Broward Medical Center's Preliminary Witness List filed. |
| Nov. 17, 1994 | (Petitioner) Notice of Taking Deposition (Telephone Noticeed 11/15/94) filed. |
| Nov. 17, 1994 | Reply By AMISUB (North Ridge Hospital), Inc. to Responses to Motion to Consolidate filed. |
| Nov. 16, 1994 | Second Request for Production of Documents By Amisub (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center to North Broward Hospital District filed. |
| Nov. 16, 1994 | Second Request for Production of Documents By Amisub (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center to Columbia Hospital Corporation of South Broward, Inc. d/b/a Westside; Second Request for Production of Documents By Amisub (North Ridge |
| Nov. 16, 1994 | Florida Medical Center, LTD.'s Request for Copies of Documents Obtained By Amisub, Inc. d/b/a North Ridge Medical Center From North BrowardHospital District filed. |
| Nov. 15, 1994 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's And The Agency for Health Care Administration's Joint Response In Opposition to North Broward Hospital District d/b/a North Broward Medical Center's Renewed Motion t |
| Nov. 14, 1994 | (Petitioner) Notice of Hearing filed. |
| Nov. 14, 1994 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Response to South Broward Hospital District d/b/a Memorial Hospital's First Request for Production of Documents filed. |
| Nov. 14, 1994 | Columbia Hospital Corporation of South Broward d/b/a Westside RgionalMedical Center's Notice of Service of Answers to South Broward Hospital District d/b/a Memorial Hospital's First Interrogatories filed. |
| Nov. 10, 1994 | Notice of Hearing (Petitioner) filed. |
| Nov. 10, 1994 | North Broward Hospital District d/b/a North Broward Medical Center's Response to notice of supplementary authority for AMISUB (North Ridge Hospital), Inc.'s Motion for Summary Recommended Order filed. |
| Nov. 09, 1994 | South Broward Hospital District, d/b/a Memorial Hospital And Florida Medical Center's Response to Motion to Consolidate filed. |
| Nov. 09, 1994 | Colunmbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Response In Opposition to Amisub (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center's Motion to Consolidate filed. |
| Nov. 09, 1994 | North Broward Hospital District d/b/a North Broward Medical Center's Response to North Ridge's Motion to Consolidate (w/94-4800) filed. |
| Nov. 09, 1994 | Intervenor's' Resonse to Petitioner's Renewed Motion to Amend HearingLocation filed. |
| Nov. 09, 1994 | AHCA's Preliminary Witness List filed. |
| Nov. 09, 1994 | Florida Medical Center, LTD.'s Notice of Service of First Set of Interrogatories to North Broward Hospital District d/b/a North Broward Medical Center; Florida Medical Center, LTD.'s First Request for Production to North Broward Hospital District d/b/a |
| Nov. 07, 1994 | Petitioner's Renewed Motion to Amend Hearing Location filed. |
| Nov. 07, 1994 | (Respondent) Response to North Ridge Medical Center's Motion to Consolidate filed. |
| Nov. 07, 1994 | Holy Cross Hospital, Inc.'s Preliminary Witness List filed. |
| Nov. 07, 1994 | Plantation General Hospital's Preliminary Witness List filed. |
| Nov. 07, 1994 | Florida Medical Center, LTD.'s Preleminary Witness List; South Broward Hospital District's Preliminary Witness List filed. |
| Nov. 01, 1994 | Notice of Supplementary Authority for AMISUB (North Ridge Hospital), Inc.'s Moiton for Summary Recommended Order filed. |
| Oct. 31, 1994 | Notice of Filing North Ridge Medical Center's Motion to Consolidate And Request for Oral Argument (with DOAH Case No/s. 94-4800, 94-4801, 94-4802, 94-4803, 94-4804, 94-4805, 94-4806, 94-1020 thru 94-1023) filed. |
| Oct. 31, 1994 | (AMISUB) Request for Oral Argument On North Ridge Medical Center's Motion to Consolidate filed. |
| Oct. 28, 1994 | North Ridge Medical Center's Motion to Consolidate (with DOAH Case No/s. 94-1020, 94-1021, 94-1022, 94-1023, 94-4800, 94-4801, 94-4802, 94-4803, 94-4804, 94-4805, 94-4806) filed. |
| Oct. 26, 1994 | (Amisub) Reply to North Broward Hospital District's Response to Amisub (North Ridge Hospital), Inc.'s Motion for Summary Recommended Order of Dismissal; Cover Letter filed. |
| Oct. 24, 1994 | Florida Medical Center's Response to North Broward Hospital District's Motion to Compel Better Responses to Request for Production of Documents; Florida Medical Center's Response to North Broward Hospital District's Motion to Compel Responses to Second |
| Oct. 21, 1994 | Holy Cross Hospital, Inc.'s Response to North Broward Hospital District d/b/a North Broward Medical Center's First Request for Production of Documents filed. |
| Oct. 20, 1994 | Holy Cross Hospital, Inc.'s Response to North Broward Hospital District d/b/a North Broward Medical Center's Second Request for Production of Documents filed. |
| Oct. 20, 1994 | North Ridge Medical Center's Objections to Westside First Set of Interrogatories; North Ridge Medical Center's Response to Westside Regional Medical Center's First Request for Production of Documents filed. |
| Oct. 20, 1994 | Holy Cross Hospital, Inc.'s Notice of Support of Amisub (North Ridge Hospital), Inc's Motion for Summary Recommended Order Against the North Broward Hospital District And for Official Recognition filed. |
| Oct. 20, 1994 | Notice of Service of Holy Cross Hospital, Inc.'s Answers to Petitioner, North Broward Hospital District's First Set Interrogatories; Petitioner's First Interrogatories to Holy Cross Hospital, Inc. filed. |
| Oct. 18, 1994 | Notice of Non-Party Production (from S. Horovitz); Subpoena Duces Tecum filed. |
| Oct. 18, 1994 | North Broward Hospital District d/b/a North Broward Medical Center's Motion to Compel Better Responses to Request for Production of Documents filed. |
| Oct. 18, 1994 | North Broward Hospital District d/b/a North Broward Medical Center Response to Amisub (North Ridge, Inc. d/b/a North Ridge Medical Center'smotion for summary Recommended Order of Dismissal filed. |
| Oct. 17, 1994 | South Broward Hospital District's Response to Westside's First Request for Production of Documents; South Broward Hospital District d/b/a Memorial Hospital's Notice of Servicing Answers to Columbia Hospital Corporation of South Broward d/b/a Westside Re |
| Oct. 17, 1994 | Florida Medical Center, LTD.'s Notice of Serving Answers to Westside Regional Medical Center's Interrogatories; Florida Medical Center's Response to Westside's First Request for Production of Documents filed. |
| Oct. 14, 1994 | (Petitioner) 2/Notice of Taking Deposition (Previous Notice Given ViaTelephone) filed. |
| Oct. 14, 1994 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Notice of Service of Answers to Florida Medical Center's First Interrogatories filed. |
| Oct. 14, 1994 | Colunbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Response to Florida Medical Center's First Request for Production filed. |
| Oct. 13, 1994 | North Broward Hospital District d/b/a North Broward Medical Center's Motion to Compel Responses to Second Request for Production of Documents filed. |
| Oct. 12, 1994 | Amisub (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center's First Request for Production of Documents to Plantation General Hospital, L.P.; Amisub (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center's Notice of Service of Interrogat |
| Oct. 12, 1994 | Amisub (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center's First Request for Production of Documents to Columbia Hospital Corporation of South Broward; Amisub (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center's Notice of Service |
| Oct. 12, 1994 | (Amisub) (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center's First Request for Production of Documents to North Broward Hospital District; Amisub (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center's Notice of Service of First Set |
| Oct. 12, 1994 | (Petitioner) Notice of Taking Deposition Duces Tecum filed. |
| Oct. 07, 1994 | South Boreward Hopsital Hospital District d/b/a Memorial Hospital's First Request for PRoduction to Plantation General Hospital, L. P. filed. |
| Oct. 07, 1994 | South Broward Hospital District d/b/a Memorial Hospital's Notice of Service of First Set of Interrogatories to Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center; South Broward Hospital District d/b/a Memorial Hospital |
| Oct. 07, 1994 | South Broward Hospital District d/b/a Memorial Hospital's First Request for Production to Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center filed. |
| Oct. 06, 1994 | AMISUB (North Ridge Hospital), Inc.'s Motion for Summary Recommended Order Against The North Broward Hospital District And for Official Recognition filed. |
| Oct. 03, 1994 | (Petitioner) Request for Copies Obtained by Production Pursuant to Florida Rules of Civil Procedure 1.351(b) and Florida Administrative Code Rule 60Q-2.019 filed. |
| Sep. 30, 1994 | North Broeard Hospital District d/b/a North Broward Medical center's Notice of Serving Answers to Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's First Set of Interrogatories and First Request for Production w/(T |
| Sep. 23, 1994 | Order sent out. (motion for summary recommended order denied) |
| Sep. 23, 1994 | Holy Cross Hospital, Inc.'s Notice of Service of First Interrogatories to Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center; Holy Cross Hospital, Inc.'s First Request for Production of Documents to Columbia Hospital C |
| Sep. 22, 1994 | Notice of Taking Deposition filed. (From Susan Horovitz Maurer) |
| Sep. 22, 1994 | Columbia Hospital Corporation of South Broeard d/b/a Westside REgional Medical Center's Notice of Service of First Interrogatories to Holy Cross Hospital, Inc. filed. |
| Sep. 22, 1994 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's First Request for Production of Documents to Amisub(North Ridge Hospital), Inc. d/b/a North Ridge Medical Center filed. |
| Sep. 22, 1994 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Notice of Service of First interrogatories to Ammisub (North Ridge Hospital), Inc. d/b/a North Ridge Medical Center filed. |
| Sep. 22, 1994 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's First Request for Production of Documents to Holy Cross Hospital, Inc. filed. |
| Sep. 21, 1994 | Columbia Hospital Corporation of South Broward d/b/a Westside Regional Medical Center's Memorandum of Law in Opposition of North Broward Hospital District d/b/a North Broward Medical Center's filed. |
| Sep. 20, 1994 | Notice of Taking Deposition Duces Tecum filed. (From Susan Horovitz) |
| Sep. 20, 1994 | North Broward Hospital District d/b/a North Broward Medical Center Motion to Compel Plantation General Responses to the First Set of Interrogatories; North Broward MOtion to Compel Plantation General Reponse to First Request for Production of Documents |
| Sep. 19, 1994 | Notice of Service of Production of Documents; Response to Motion to Compel; Notice of Service of Answers to Interrogatories filed. (From Jay Adams) |
| Sep. 19, 1994 | Amended Notice of Hearing filed. (From Stephen A. Ecenia) |
| Sep. 16, 1994 | (Columbia Hospital Corp) Notice of Hearing filed. |
| Sep. 13, 1994 | (Columbia Hospital Corp of South Broward) Amended Notice of Taking Deposition Duces Tecum filed. |
| Sep. 13, 1994 | Order of Consolidation sent out. (Consolidated cases are: 94-1020, 94-1021, 94-1022, 94-1023) |
| Sep. 13, 1994 | Case No/s 94-1019, 94-1020, 94-1021, 94-1022, 94-1023: unconsolidated. |
| Mar. 11, 1994 | Prehearing Order and Order of Consolidation sent out. (Consolidated cases are: 94-1019, 94-1020, 94-1021, 94-1022, 94-1023) |
| Mar. 09, 1994 | Notification card sent out. |
| Mar. 07, 1994 | (joint) Notice of Appearance and Substitution of Counsel filed. |
| Feb. 25, 1994 | Notice of Related Petitions (94-1019 through 94-1023); Notice; Westside Petition for Formal Administrative Hearing filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Mar. 06, 1996 | Agency Final Order | Request for CON was withdrawn after the Recommended Order was issued. |
| Jan. 31, 1996 | Recommended Order | Petitioner did not prove that there was a need for another open heart surgery program in District X. Petitioner's proposal did not meet statutory and rule criteria. |
