STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
BETHESDA HEALTHCARE SYSTEM, INC., ) d/b/a BETHESDA MEMORIAL HOSPITAL, )
)
Petitioner, )
)
vs. ) Case No. 00-0461CON
)
AGENCY FOR HEALTH CARE )
ADMINISTRATION, )
)
Respondent, )
)
and )
)
COLUMBIA/JFK MEDICAL CENTER )
LIMITED PARTNERSHIP, d/b/a JFK ) MEDICAL CENTER and TENET HEALTHSYSTEM ) HOSPITALS, INC., d/b/a DELRAY MEDICAL ) CENTER, )
)
Intervenors. )
)
BOCA RATON COMMUNITY HOSPITAL, INC., )
)
Petitioner, )
)
vs. ) Case No. 00-0462CON
)
AGENCY FOR HEALTH CARE )
ADMINISTRATION; GOOD SAMARITAN ) HOSPITAL, INC., d/b/a GOOD SAMARITAN ) HOSPITAL; MARTIN MEMORIAL MEDICAL ) CENTER, INC., d/b/a MARTIN MEMORIAL ) MEDICAL CENTER; and BETHESDA )
HEALTHCARE SYSTEM, INC., d/b/a )
BETHESDA MEMORIAL HOSPITAL, )
)
Respondents, )
)
and )
)
COLUMBIA/JFK MEDICAL CENTER )
LIMITED PARTNERSHIP, d/b/a JFK ) MEDICAL CENTER and TENET HEALTHSYSTEM ) HOSPITALS, INC., d/b/a DELRAY MEDICAL ) CENTER, )
)
Intervenors. )
)
MARTIN MEMORIAL MEDICAL CENTER, INC., ) d/b/a MARTIN MEMORIAL MEDICAL CENTER, )
)
Petitioner, )
)
vs. ) Case No. 00-0463CON
)
AGENCY FOR HEALTH CARE )
ADMINISTRATION, )
)
Respondent, )
)
and )
)
PALM BEACH GARDENS COMMUNITY )
HOSPITAL, INC., d/b/a PALM )
BEACH GARDENS MEDICAL CENTER; ) LAWNWOOD MEDICAL CENTER, INC., d/b/a ) LAWNWOOD REGIONAL MEDICAL CENTER; ) and COLUMBIA/JFK MEDICAL CENTER ) LIMITED PARTNERSHIP, d/b/a JFK )
MEDICAL CENTER, )
)
Intervenors. )
)
RECOMMENDED ORDER
Pursuant to notice, the Division of Administrative Hearings, by its designated Administrative Law Judge, Eleanor M. Hunter, held a final hearing in the above-styled case on December 3-7,
10-14, 17-21, 2001; January 7-11, 14-18, 22-23, 28-29, and
February 7-8, 2002, in Tallahassee, Florida.
APPEARANCES
For Petitioner Bethesda Healthcare System, Inc., d/b/a Bethesda Memorial Hospital:
W. David Watkins, Esquire
R. L. Caleen, Jr., Esquire Watkins & Caleen, P.A.
1725 Mahan Drive, Suite 201
Tallahassee, Florida 32317-5828 For Petitioner Boca Raton Community Hospital, Inc.:
H. Darrell White, Esquire William B. Wiley, Esquire McFarlain & Cassedy, P.A.
305 South Gadsden Street Post Office Box 2174
Tallahassee, Florida 32316-2174 and
Seann M. Frazier, Esquire Michael J. Cherniga, Esquire Greenberg Traurig, P.A.
101 East College Avenue Tallahassee, Florida 32302
For Petitioner Martin Memorial Medical Center, Inc., d/b/a Martin Memorial Medical Center:
Paul H. Amundsen, Esquire Amundsen, Moore & Torpy, P.A.
502 East Park Avenue Post Office Box 1759
Tallahassee, Florida 32302 and
Robert D. Newell, Jr., Esquire Law Firm of Newell & Terry, P.A. 817 North Gadsden Street Tallahassee, Florida 32303-6313
For Respondent Agency for Health Care Administration:
John F. Gilroy, III, Esquire
Agency for Health Care Administration Fort Knox Building 3, Suite 3431
2727 Mahan Drive
Tallahassee, Florida 32308-5403 and
Gerald L. Pickett, Esquire
Agency for Health Care Administration
525 Mirror Lake Drive, North Sebring Building, Suite 310K St. Petersburg, Florida 33701
For Intervenor Tenet Healthsystem Hospitals, Inc., d/b/a Delray Medical Center and Palm Beach Gardens Medical Center, Inc., d/b/a Palm Beach Gardens Medical Center:
C. Gary Williams, Esquire Michael J. Glazer, Esquire Ausley & McMullen
227 South Calhoun Street Post Office Box 391 Tallahassee, Florida 32302
For Intervenor Columbia/JFK Medical Center Limited Partnership, d/b/a JFK Medical Center:
Stephen A. Ecenia, Esquire David R. Prescott, Esquire
Rutledge, Ecenia, Purnell & Hoffman, P.A.
215 South Monroe Street, Suite 420 Tallahassee, Florida 32302-0551
STATEMENT OF THE ISSUES
Whether the adult open heart surgery rule in effect at the time the certificate of need (CON) applications were filed, and until January 24, 2002, or the rule as amended on that date is applicable to this case.
Which, if any, of the applications filed by Martin Memorial Medical Center, Inc. (Martin Memorial); Bethesda Healthcare System, Inc., d/b/a Bethesda Memorial Hospital (Bethesda); and Boca Raton Community Hospital, Inc. (BRCH) meet the requirements for a CON to establish an adult open heart surgery program in Agency for Health Care Administration (AHCA) Health Planning District 9, for Okeechobee, Indian River,
St. Lucie, Martin, and Palm Beach Counties, Florida.
PRELIMINARY STATEMENT
In September 1999, Martin Memorial, Bethesda, BRCH, Good Samaritan Hospital, Inc., d/b/a Good Samaritan Hospital (Good Samaritan) and Indian River Memorial Hospital (IRMH), each filed an application for a CON to establish an additional adult open heart surgery program in AHCA District 9. AHCA, on December 30, 1999, published in Volume 25, Number 52, Florida Administrative Weekly, its intent to deny all of the applications. On
January 19 and 20, 2000, the five hospital applicants timely filed petitions for formal administrative proceedings contesting AHCA's decisions.
On January 28, 2000, the cases were referred to the Division of Administrative Hearings (DOAH) by AHCA, with a notice that the petitions were all related. On February 1, 2000, Petitions to Intervene were filed by Columbia/JFK Medical Center Limited Partnership, d/b/a JFK Medical Center (JFK), in opposition to the
Bethesda, BRCH, and Martin Memorial applications; by Tenet Healthsystem Hospitals, Inc., d/b/a Delray Medical Center (Delray) in opposition to the BRCH application; by Palm Beach Gardens Community Hospital, Inc., d/b/a Palm Beach Gardens Medical Center (PBGMC) in opposition to the Good Samaritan application; and by PBGMC and Lawnwood Medical Center, Inc., d/b/a, Lawnwood Regional Medical Center (Lawnwood), both in opposition to Martin Memorial's application. The Petitions to Intervene, filed on February 1, 2000, on behalf of Lawnwood, in DOAH Case No. 00-0463CON; on behalf of PBGMC, in DOAH Case Nos. 00-0460CON and 00-0463CON; on behalf of Delray in DOAH Case No. 00-0462CON; and on behalf of JFK in DOAH Case Nos. 00-0461CON and 00-0462CON, were granted on March 3, 2000. On March 3, 2000, the Petition to Intervene, filed on February 1, 2000, on behalf of Delray in DOAH Case No. 00-0461CON, to which Bethesda filed a Response/Answer to Petition to Intervene, on February 9, 2000, was granted subject to proof of standing at the hearing. The Petition to Intervene in DOAH Case No. 00-0463CON, filed on October 2, 2001, on behalf of JFK in opposition to the Martin Memorial application, was granted on October 23, 2001.
In response to an Initial Order of February 1, 2000, and at the request of the parties, the cases were consolidated and set for hearing, initially, from September 12 through October 20, 2000. Based on motions for continuances filed first on behalf of
IRMH, then BRCH, and finally Martin Memorial, the hearing was postponed three times due to pending legislation or to await the conclusion of a case in which proposed amendments to the OHS rule were challenged. After the rule challenge case was heard, from September 10 through 14, 2001, a fourth motion for a continuance, filed on behalf of Bethesda on September 24, 2001, was denied, and the hearing remained scheduled for November 26, 2001, through January 25, 2002.
As a result of a Notice of Voluntary Dismissal taken by Good Samaritan on June 29, 2000, DOAH Case No. 00-0460CON was closed and a final order entered on July 20, 2000. On October 11, 2001, IRMH filed a Notice of Voluntary Dismissal and that case, DOAH Case No. 00-0459CON, was also unconsolidated, closed and remanded to AHCA, which entered a final order dismissing IRMH’s petition, on December 20, 2001.
On October 23, 2001, AHCA filed a Notice of Change of Agency Position, abandoning its proposed denial of all of the applications and, instead, favoring the approval of the applications filed by BRCH and Martin Memorial. As a result of a conflict in the schedules of some counsel in the case, affecting only the first two days of the scheduled hearing, the start of the case was delayed until December 3, 2001.
At the start of the hearing, on December 3, 2001, Martin Memorial's Request for Official Recognition of the Final Order in
the case finding the proposed amendments to the open heart surgery rule not invalid was granted. See Martin Memorial Exhibit No. 68, Bethesda Health Care System, Inc. v. AHCA (DOAH Case No. 01-2665RP, Nov. 15, 2001). The parties agreed to brief, in their proposed recommended orders, the issue of whether the rule in existence during the CON review process and at the time the hearing commenced, or the rule as amended on January 24, 2002, during the hearing, is applicable to this case.
At the final hearing, Martin Memorial presented the testimony of Joseph Ferrara, expert in emergency medical services in Florida and paramedics; Nancy Dgetluck, expert in biostatistics, public health, and hospital quality management; Sandra Genday Whitfield, expert in nursing and emergency department management in an acute care hospital; Karen Cooper Keane, expert in cardiac catheterization management and radiologic technology; Richmond M. Harman, expert in health care administration and health care finance; Thomas P. Wharton, Jr., M.D., expert in cardiology, including interventional cardiology; Judith Horowitz, expert in health care planning and health care finance; William D. Spotnitz, M.D., expert in thoracic and cardiac surgery; Marvin Dewar, M.D., J.D., expert in medicine; Laura MacLafferty; and Robert Beiseigel, expert in health care finance. Martin Memorial's Exhibits numbered 1-30, 32-34, designated sections of 35 and 36, 39-44, 50, 51, 56-60, 62, 63,
75, and 80-85 were received in evidence. Official recognition was taken of Martin Memorial's Exhibits numbered 68, 69, and 70.
Bethesda presented the testimony Robert D. Hill, expert in hospital administration; Robert B. Taylor, Jr., expert in health care finance; Ernestine M. Ziacik, R.N., expert in nursing administration; Lynne Beattie, R.N., expert in critical care unit nursing and administration; Mary McClory, expert in health care quality management, including continuous quality improvement and performance improvement; Tom Hicks, expert in medical equipment planning; Gary Spring, expert in health care architecture; and Peggy Miller Cella, expert in health care planning. Bethesda's Exhibits numbered 1-19, 25-40, 41 (as limited), 43, 45-47, 50,
51(f), 51(h), 51(i), 51(j), 55-73, and 75, 81, 83-85, and 87
(designated portions) were received into evidence.
BRCH presented the testimony of Randolph J. Pierce, the Chief Executive Officer of BRCH; Ronald Assaff, the Chairman of the Board of BRCH; Thomas Bartzokis, M.D., expert in cardiology, including interventional cardiology; Richard Greenwald, M.D., expert in medicine and hospital medical administration;
Dianne Goatley, expert in hospital human resources administration; Armand Balsano, expert in health care finance and health care financial feasibility analysis; Daniel Weiss, M.D., expert in cardiology and cardiac electrophysiology; Mark B. Saltzman, M.D., expert in cardiology, including interventional
cardiology; George Miceli, M.D., expert in emergency medicine and hospital emergency department management; Douglas A. Farber, expert in health care space planning; Rick D. Knapp, expert in health care finance; Monica G. Noether, Ph.D., expert in health care economics; and Thomas Davidson, expert in health care planning. BRCH’s Exhibits numbered 1-26, 28-35 (except pages 54-
, 36-38, and 40-43 were received in evidence.
AHCA presented the testimony of Jeffery N. Gregg, Chief of the Bureau of Health Facility Regulation and expert in health care planning. AHCA’s Exhibits numbered 1, 3, and 4 were received in evidence.
Tenet (Delray and PBGMC) presented the testimony of
Jose Luis Rodriguez, P.E., expert in transportation engineering; Eric David Peterson, M.D., M.P.H., expert in cardiology; Mitchell S. Feldman, expert in health care facility administration; David Katzin, M.D., expert in cardiology and hospital quality assurance; Kim Streit, expert in survey methodology; Maria Dulaney, R.N., expert in nursing and nursing administration; Karen Grimley, R.N., expert in nursing and nursing administration; William Gieseke, M.D., expert in cardiovascular and thoracic surgery; Julie Hilsenbeck, A.R.N.P., expert in nursing and nursing administration; and
Daniel Sullivan, expert in health care planning and health care finance. Tenet's Exhibits numbered 1-6, 8-11, 13-40, 42-52, 54-
57, 58(A-C), (E), (L), (N), (O), 59, 60, 63, 64(A-W), 64X, 64Y,
64Z, 64(AA-CC), and 65-72 were received in evidence. Tenet Exhibit 12 is also received in evidence.
JFK and Lawnwood presented the testimony of Terence Peter Downing, M.D., expert in cardiothoracic surgery; Jay Midwall, M.D., expert in interventional cardiology; Phillip Robinson, expert in hospital administration; Darryl Weiner, expert in health care finance; Michael L. Schwartz, expert in health planning; and Richard Baehr, expert in health care finance, health care planning, and health care policy. JFK’s and Lawnwood’s Exhibits numbered 1 and 3-20 were received into evidence.
The transcript of the final hearing was filed on April 1, 2002. On May 6, 2002, Delray filed a Motion to Reopen the Record Based Upon Newly-Discovered Evidence and to Schedule an Evidentiary Hearing. On May 13, 2002, Bethesda filed a Response in Support of the Motion to Re-Open the Record, Martin Memorial filed a Memorandum of Law in Opposition to the Motion, and BRCH filed a Response in Opposition to the Motion and Request for Attorney's Fees. Delray filed a Reply to BRCH's and Martin Memorial's Response in Opposition, on May 16, 2002, and a Supplement to its Motion to Reopen the Record, on May 21, 2002.
Martin Memorial filed a Memorandum of Law in Opposition to the
Supplement on May 23, 2002. An Order Denying Motion to Reopen the Record was issued on May 24, 2002.
On June 3, 2002, BRCH filed a Renewed Motion for Attorney's Fees and Tenant filed a letter on the same issue. An Order Denying the Motion for Attorney's Fees was issued on June 10, 2002.
On May 14, 2002, JFK and Lawnwood filed a Motion for Extension of Time to File Proposed Recommended Orders and Request for Expedited Ruling, which was considered during a telephone conference on May 17, 2002. The parties agreed to an extension of time to June 28, 2002, to file proposed recommended orders, and agreed not to request any further extensions due to an attorney's or law firm's workload. The parties filed proposed recommended orders on June 28, 2002. In addition, Tenet submitted a Memorandum of Law in Support of Proposed Recommended Order filed on behalf of Delray Medical Center and Palm Beach Gardens Medical Center. Because BRCH filed a proposed recommended order exceeding by five pages the sixty-page maximum length established at the close of the hearing, Tenet filed a motion to strike it in its entirety. In its response to the motion to strike, BRCH noted that Tenet had filed the twenty-page memorandum of law in addition to its proposed recommended order. BRCH also submitted an identical proposed recommended order, which after computer reformatting, was sixty pages in length.
The Motion to Strike is denied. On October 7, 2002, Martin Memorial filed a Notice of Supplemental Authority citing the First District Court of Appeal's dismissal of the appeal in Hernando HMA, Inc. v. HCA Health Services of Florida, Inc., Case No. 00-3216CON, et al. (R.O. Oct. 4, 2001, F.O. Jan. 24, 2002),
and its per curiam affirmance of University Medical Center v.
AHCA, DOAH Case No. 00-0481CON, et al. (R.O. Mar. 30, 2001, F.O. Oct. 17, 2001).
FINDINGS OF FACT
The Agency for Health Care Administration (AHCA) is the agency which administers the certificate of need (CON) program for health care facilities and programs in Florida. It is also the designated state health planning agency. See Subsection 408.034(1), Florida Statutes.
For health planning purposes, AHCA District 9 includes Indian River, Okeechobee, St. Lucie, Martin, and Palm Beach Counties. See Subsection 408.032(5), Florida Statutes.
AHCA published a fixed need pool of zero for additional open heart surgery programs in District 9, for the January 2002, planning horizon. The mathematical need formula in the rule, using the use rate for open heart surgery procedures in the district as applied to the projected population growth, indicated a gross numeric need for 7.9 programs in District 9. After rounding off the decimal and subtracting four, for the number of
existing District 9 open heart surgery programs, the formula showed a numerical need for four additional ones. The need number defaulted to zero, however, because one of the existing programs, at Lawnwood Medical Center, Inc., d/b/a Lawnwood Regional Medical Center (Lawnwood), had not reached the required minimum of 350 surgeries a year, or 29 cases a month for 12 months prior to the quarter in which need was published. Having initiated services in March 1999, the Lawnwood program had not been operational for 12 months at the time the applications were filed in October 1999.
The other existing providers of adult open heart services in District 9, in addition to Lawnwood, are Palm Beach Gardens Community Hospital, Inc., d/b/a Palm Beach Gardens Medical Center (PBGMC); Columbia/JFK Medical Center Limited Partnership, d/b/a JFK Medical Center (JFK); and Tenet Healthsystem Hospitals, Inc., d/b/a Delray Medical Center (Delray). All are intervening parties to this proceeding. In the Pre-Hearing Stipulation, the parties agreed that the Intervenors have standing to participate in this proceeding.
Despite the publication of zero numeric need, five hospitals in District 9 applied for CONs to establish new adult open heart programs asserting need based on not normal circumstances. Three of those applications are at issue in this case: CON Number 9249 filed by Martin Memorial Medical Center,
Inc. (Martin Memorial); CON Number 9250 by Bethesda Healthcare System, Inc., d/b/a Bethesda Memorial Hospital (Bethesda); and CON Number 9248 by Boca Raton Community Hospital, Inc. (BRCH).
AHCA initially reviewed and denied all of the applications. After changing its position before the final hearing, AHCA supports the approval of the applications filed by
Martin Memorial and BRCH.
Martin Memorial
Martin Memorial, the only hospital in Martin County, and the only party/applicant not located in Palm Beach County, operates two facilities, a total of 336 beds, on two separate campuses under a single license. The larger hospital, in Stuart, has 236 beds and is located approximately 20 miles south of Lawnwood and 30 miles north of PBGMC. Martin Memorial owns and maintains, at the hospital, its own ambulance service used exclusively for hospital-to-hospital transfers. The drive from Martin Memorial to Lawnwood averages 38 minutes. The drive time to PBGMC averages 48 minutes. By helicopter, it takes 11 or
12 minutes to get from Martin Memorial to PBGMC. The remaining
100 Martin Memorial Hospital beds are located on its southern campus, approximately six miles south of the Stuart facility.
Martin Memorial is a private not-for-profit hospital, established in 1939. The parent corporation also operates an
ambulatory care center, physician group, billing and collection company, and a foundation.
Martin Memorial is applying to operate an open heart program at its Stuart location, where it currently offers cardiology, hematology, nephrology, pulmonary, infectious disease, pathology, blood bank, anesthesiology, diagnostic nuclear medicine, and intensive care services.
Martin Memorial has a 25-bed telemetry unit, a 14-bed medical intensive care unit, a nine-bed surgical intensive care unit, and a 22-bed progressive care unit, with an identically equipped 16-bed overflow unit used only for high seasonal occupancy, from approximately December to April.
If its CON is approved, Martin Memorial will dedicate four surgical intensive care unit beds and six progressive care beds for post-open heart surgery patients. Martin Memorial agreed to condition its CON on the provision of 2.4% of the project's gross revenues for charity care and 2% for Medicaid. The total estimated project cost is $6.5 million. Martin Memorial intends to affiliate with the University of Florida and its teaching facility, Shands Hospital, to assist in establishing the program and training staff. The cardiovascular surgeon is expected to be a full-time faculty member who will live and work in Martin County.
Although initially opposed, AHCA now supports Martin Memorial’s application primarily because (1) it has the largest cardiac catheterization (cath) program at any hospital in this state which does not also provide open heart services; (2) it has a medium size and growing Medicare population, which constitutes the age group most likely to require open heart surgery and related services; (3) Martin County residents now must receive open heart and related services at hospitals outside Martin County, primarily in areas ranging from Palm Beach County south to Dade County; (4) emergency heart attack patients who present at Martin Memorial-Stuart could receive primary angioplasties without transfer; and (5) it is a not-for-profit hospital, while all of the existing open heart providers in the District are for- profit corporate subsidiaries. Of the applicants, Martin Memorial is also located the greatest distance from the existing providers.
Bethesda Memorial
Bethesda has 362 licensed beds located in Boynton Beach. JFK is nine miles north or an average drive of 18 minutes from Bethesda. Delray is nine miles south or an average drive of
17 minutes from Bethesda.
Established in February 1959, Bethesda is a not-for- profit subsidiary of Bethesda Health Care Systems, Inc., which also operates some for-profit subsidiaries, including Bethesda
Medical/Surgical Specialists, Bethesda Management Services, and Bethesda Comprehensive Cancer Institute. Bethesda is a disproportionate share provider of Medicaid and Medicare services.
The services currently available at Bethesda include obstetrics, Level II and III neonatal intensive care, cardiology, orthopedics, pediatrics, neurological and stroke care, peripheral vascular surgery, wound care, pulmonary and infectious disease care. Bethesda recently eliminated a 20-bed unit for adult psychiatric services, and a 20-bed skilled nursing unit.
Currently, at Bethesda, the sickest patients are placed in a 10-bed critical care unit. The hospital also operates a 12- bed surgical intensive care unit, an eight-bed medical intensive care unit, and 30 and 25-bed telemetry units. Bethesda was planning to open a 20-bed extension to the telemetry unit, all in private rooms, in January 2002.
If an open heart surgery program is established, Bethesda, will add an eight-bed cardiovascular intensive care unit to care post-operatively for the patients. Bethesda offered to condition its CON on the provision of 3% of total open heart surgeries to Medicaid and 3% of total open heart surgeries to indigent patients. Bethesda's estimated total project cost is
$4 million, $1.7 million for equipment, and $2.24 for construction. Bethesda will receive assistance from Orlando
Regional Medical Center in training personnel and developing protocols for an open heart program. At Orlando Regional, a statutory teaching hospital, the number of open heart cases ranges from 1,300 to 1,600 a year. Bethesda has a contract with a physicians' group to provide a board-certified cardiovascular surgeon to serve as medical director for the open heart program.
AHCA’s position is that the Bethesda application is "approvable" but, of the Palm Beach County applicants, less desirable than that of BRCH. By contrast, Bethesda's experts emphasized (1) the absence of any overlap with the Lawnwood market; (2) the greater need for a new program, based on the volume of cases, in Palm Beach County than elsewhere in the District; (3) the size, growth, and age of the population within Bethesda's market area, and (4) the ability of Bethesda to enhance access for underserved groups, particularly Medicaid patients.
Boca Raton Community Hospital
BRCH is licensed for 394 beds. Located in southern Palm Beach County, close to the Broward County line, BRCH is from eight to nine miles south of Delray and approximately 15 miles north of North Ridge Medical Center (North Ridge), in adjacent Broward County. On average, the drive from BRCH to Delray takes
20 minutes. The drive from BRCH to North Ridge takes about 25 minutes.
Founded in the late 1960's, BRCH operates as a not-for- profit corporation.
BRCH has a staff of 750 physicians and 1,600 employees.
Services at BRCH include cardiology, a 10-bed Level II neonatal intensive care unit, hematology, nephrology, pulmonology, radiology, nuclear medicine, and neurology.
If approved and issued a CON for adult open heart surgery, BRCH will build a new facility for the program, including two new cath labs, an electrophysiology lab and 12 intensive care beds. In the CON, the estimated construction cost was $16.5 million and the estimated equipment cost was $2.7 million of the $20 million estimated for the total project. BRCH agreed to having conditions on its CON (1) to provide 5% of open heart cases in year two to uninsured patients, (2) to establish an outreach program to increase the utilization of open heart services among the uninsured, and (3) to relinquish the CON if it fails to perform at least 350 open heart surgery procedures a year in any two consecutive years after the end of the second year of operations.
AHCA determined that it should change its initial position opposing the approval of the BRCH application to one of approval because of (1) the large Medicare population in the service area; (2) the volume of emergency room heart attack patients; (3) the district out-migration for services primarily
to North Ridge; (4) the large, well-developed interventional cardiology program; and (5) the not-for-profit organizational structure. When AHCA decided to support the approval of the BRCH application, it did so, in part, based on erroneous data. The cath lab volume was assumed to be approximately 1,800 caths a year, as compared to the actual volume of 667 caths for the year ending March 2001. Having considered the corrected data, AHCA’s expert described BRCH’s application as significantly less compelling, but still preferable to that of Bethesda. BRCH is the largest hospital in number of beds in Florida which does not have an open heart surgery program.
AHCA also responded favorably to identified "cultural" access issues, described as underservice to demographic groups, based on race, gender, and class. BRCH presented a plan to equip a mobile unit to provide diagnostic screenings and primary care in underserved areas.
Pre-Hearing Stipulations
The parties stipulated that all of the applications met the statutory requirements concerning the application content and filing procedures of Sections 408.037 and 408.039, Florida Statutes (1999), and Rule 59C-1.033, Florida Administrative Code.
Martin Memorial, Bethesda, and BRCH have a history of providing quality care. See Subsection 408.035(1)(c), Florida Statutes (1999).
There are no existing outpatient, ambulatory or home care services which can be used as alternatives to inpatient adult open heart and angioplasty services. See Subsection 408.035(1)(d), Florida Statutes (1999).
Martin Memorial and Bethesda have sufficient available funds for capital and operating expenses required for their proposed open heart surgery programs. See Subsection 408.035(1)(h), Florida Statutes (1999).
Martin Memorial complied with the requirements related to costs and methods of construction, and equipment for the proposed project. Except for the contention that it omitted
$1,687,180 in fixed equipment costs and that the proposed construction project is excessively large and expensive, the parties stipulated that BRCH reasonably estimated construction and equipment costs, including costs and methods of energy provision. See Subsection 408.035(1)(m), Florida Statutes (1999).
The parties agreed that Subsections 408.035(1)(p), and 408.035(2)(e), Florida Statutes, related to nursing home beds, are not at issue at in this proceeding.
If Bethesda, BRCH, and Martin Memorial can recruit the necessary, competent nursing and surgical staff, they will meet the requirements of Rule 59C-1.033(3), (4)(b), (4)(c), and (5)(c), Florida Administrative Code.
Adult open heart surgery services are currently available to District 9 residents within the two-hour travel standard of Rule 59C-1.033(4)(a), Florida Administrative Code.
Bethesda, BRCH, and Martin Memorial are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), assuring quality as required by Rule 59C-1.033(5)(a), Florida Administrative Code.
The parties agreed that if Bethesda, BRCH, and Martin Memorial can recruit the necessary nursing and surgical personnel, their programs would meet the requirements of Rule 59C-1.033(4)(b), (4)(c), (5)(b), and (5)(c), Florida Administrative Code, except that JFK and Lawnwood did not agree that the applicants satisfied the requirements related to cardiovascular surgeons.
Martin Memorial will be able to obtain perfusionist services, as required by Rule 59C-1.033(5)(b)5, Florida Administrative Code.
Bethesda and BRCH projected reasonable staffing patterns, in their CON schedules 6A, given projected census levels, although the ability to recruit staff and adequacy of projected salaries are at issue.
The rule criteria related to pediatric open heart surgery are not applicable to this proceeding.
Disputed Statutory and Rule Criteria
The following statutory criteria and applicable in this case: Subsections 408.035(1)(a), (b), (c) - for comparison; (e), (f), (g), (h) - related to funding for BRCH, and related to staff recruitment and salaries; (i), (j), (k), (l), (m) - for Bethesda, and related to the size, scope, and fixed equipment cost for BRCH, (n), and (o); and Subsections 408.035(2)(a), (b), (c), and (d), Florida Statutes. The criteria in Rules 59C-1.030, and of Rule 59C-1.033(5)(b) - related to staffing, except as stipulated
- are at issue. The parties have also raised the issue of whether AHCA is consistent in applying its agency rules related to open heart cases.
The District 9 health plan contains two preferences for open heart applicant hospitals, the first for hospitals with established cardiac cath programs, the second for applicants with a documented commitment to serve patients regardless of their ability to pay or county of residence.
All of the applicants have established diagnostic cardiac cath programs and related cardiology services. During the cardiac cath procedure, a catheter is inserted into a cardiac chamber to diagnose heart disease. During a therapeutic cardiac cath procedure, or angioplasty, the catheter with a balloon-tip is inserted into a coronary artery and inflated to open blockages. The latter requires open heart surgery back-up in
case a vessel is ruptured and thus, an open heart surgery certificate of need.
Martin Memorial operates the largest cardiac cath program at a hospital in Florida which does not also offer open heart surgery. At Martin Memorial, 1,885 inpatient and outpatient caths were performed in 1999, 1,770 in 2000, and 1,286 in the first nine months of 2001. Cardiac caths are only performed at the Stuart facility.
Non-invasive cardiology services began in the 1970's at Martin Memorial. A CON to establish the first cardiac cath lab was issued in 1989, and a second, CON-exempt cath lab opened in 1998. Martin Memorial also offers pacemaker implants and peripheral angioplasties to eliminate clots in other areas of the body, for example, in the legs, electrocardiography, echocardiography, stress tests, and cardiac rehabilitation. Neither electrophysiology studies nor defibrillator implants are performed at Martin Memorial.
Martin Memorial has an open staff of cardiologists, meaning that its cath lab is available for use by any of the invasive cardiologists on staff. The facilities include two cardiac cath procedure rooms, a control room for the laboratory, a five-bed holding room and a two-bay inpatient recovery area.
Bethesda also has an established cardiac cath program with an open staff. Seventeen cathing physicians were listed on
the Bethesda roster for the month of March 2001. Of those, five were also the only cardiologists allowed to perform caths at the closed lab at JFK. Some of these cardiologists are permitted to perform emergency angioplasties at Bethesda. Bethesda has, at least, two cardiovascular surgeons on staff. From 1995 to 1998, the volume of cardiac caths at Bethesda increased over 60%, from
133 to 213. For the 12 months ending August 31, 2000, Bethesda cardiologists performed 428 caths. For the 12 months ending September 30, 2001, the cath volume was 506 cases.
Currently, cath procedures at Bethesda are performed in one lab with recently upgraded digital equipment. As part of the planned expansion of the hospital, the existing lab will be relocated and a second one added. Permanent pacemakers are implanted at Bethesda, but internal cardioverter defibrillator procedures, electrophysiology, and table studies are not performed.
Cardiac cath services, at BRCH, started in 1987. Two cath labs with state-of-the-art digital equipment are used. In the 12 months ending March 31, 2001, there were 667 inpatient and outpatient caths performed at BRCH.
Currently, cardiac services at BRCH are the largest source of admissions, approximately 20% of total admissions. The available services include echocardiography, tilt table studies, electrocardiography, stress tests, cardiac wellness and
rehabilitation programs, electrophysiology studies, and internal cardioverter defibrillator implants. Each year, one or two "rescue" or salvage angioplasties are performed in extreme, life- threatening circumstances at BRCH. Forty-nine cardiologists are on the closed "invitation-only" medical staff at BRCH, 47 are board-certified and approximately half are invasive cardiologists. The staff also includes seven electrophysiologists, five of whom are board-certified, and seven thoracic surgeons, five of whom perform open heart surgeries at other hospitals. For the first two years of operating an open heart program, BRCH intends to have a closed program, by virtue of an exclusive contract with a single group of cardiovascular surgeons.
Subsection 408.035(1)(a) - district health plan preference for serving patients regardless of county of residence or ability to pay; and Subsection 408.035 (1)(n) - history of and proposed services to Medicaid and indigent patients
Martin Memorial, Bethesda, and BRCH will serve patients regardless of residence and, they contend, will enhance access for Medicaid, indigent, charity and/or self-pay patients. Each applicant has offered to care for patients in some of these categories as a condition for CON approval.
The proposed conditions, are, for Martin Memorial, 2.4% of total project revenues for charity and 2% of admissions for Medicaid patients.
Martin Memorial provides a number of services without charge, including follow-up education to former inpatients to assist them in managing diseases such as asthma, diabetes, congestive heart failure and chronic obstructive pulmonary disease. Obstetric care includes one free home visit by a nurse/midwife to check the health of newborns and mothers.
Office space is provided for a free clinic for the "working poor" of Martin County, which receives approximately 10,000 annual visits from a patient base of about 2,000 patients. Over
$100,000 a year is provided for an indigent pharmacy program. Combining the outreach services with other charitable contributions, including charity care, Martin Memorial valued "community benefits" at $24 million in 1998, $30.5 million in 2000.
When Martin Memorial received an inpatient cardiac cath CON, it agreed to provide a minimum of 2.5% of total cardiac caths to Medicaid patients and 3% to charity care. Due to changes in state regulation, Medicaid and charity care for cardiac caths no longer needs to be reported to the state. That data, representing as it does, the base of patients from which open heart cases will come, is useful in evaluating Martin Memorial's projections. In 1999, seven-tenths of one percent of the patients in Martin Memorial's cath lab were Medicaid and four-tenths of one percent were indigent. In 2000, seven-tenths
of one percent were Medicaid and two-tenths of one percent were indigent. Martin's cath lab data indicates that its projected open heart levels of Medicaid and indigent care are not attainable.
Bethesda offered a commitment to provide 3% of total open heart cases for Medicaid patients and 3% to indigent patients annually.
Historically, Bethesda has cared for a relatively large number of Medicaid, minority, and indigent patients. It is recognized as a disproportionate share provider of Medicaid care under the Florida program and of Medicare under the Federal program. The Palm Beach County Health Department provides approximately $1 million a year to Bethesda for charity care. As a percentage of gross revenue, Bethesda provided 8.8% Medicaid and 3.46% charity care in 1999. Approximately 54% of the charity care is attributable to obstetrics and pediatric services.
Bethesda's younger patient base and the number of adult open heart Medicaid cases from Bethesda's service area, 2.4% or 7 cases in the year ending September 2000, raise the issue of its ability to generate sufficient cases to meet the proposed commitment. In 1995, 20 of the 36 total resident Medicaid open heart surgeries were performed at the three providers in District 9, Delray, JFK, and PBGMC. In 1999, when Lawnwood began open heart care, the Medicaid volume at the District providers
increased to 51 of the 64 total Medicaid resident cases. In 2000, the four programs treated a net number of 56 of 60 resident Medicaid cases.
A program at Bethesda also could reasonably be expected to increase the number of Medicaid and charity cases performed in the District, in volume and by reversing outmigration, but the patients must come from a base of patients with cardiac diagnoses. For the year ending September 2000, in Bethesda's service area, 4.9% of cardiac patients were Medicaid and charity patients combined, 1.6% Medicaid and 3.3% charity. Assuming that the same proportions could be maintained for open heart surgeries, Bethesda cannot achieve 3% Medicaid and, although unlikely, has a chance of reaching 3% charity only in the best case scenario.
If approved, BRCH commits to providing 5% of total OHS in the second year to uninsured patients and to establish an outreach program to increase utilization by uninsured patients.
BRCH has, over the past three and a half years, established outreach programs, which include having nurses and social workers in schools, providing free physical examinations to children who do not have primary care doctors, and performing echocardiograms for high school athletes, equipping police and fire rescue units with portable defibrillators, and operating mobile units for mammography screenings and vans to transport
patients to and from their homes for hospital care. A free dental screening program is operated in conjunction with Nova Southeastern University. BRCH also operates a family medical center approximately seven miles west of the hospital.
Recently, the Foundation for BRCH purchased, for $1.8 million, a large bus to equip as a mobile clinic. The mobile diagnostic unit is intended to reach uninsured patients to provide primary care and ultimately open heart surgery care to those who might not otherwise be screened, diagnosed and referred. No information was available and no decisions had been made about the staff and equipment, or service areas for use of the van. Because of the lack of more specific plans, it is impossible to determine whether the outreach effort has any reasonable prospects for success in meeting any unmet need.
For the years ending June 1996, 1997, and 1998, BRCH provided six-tenths of one percent, and five-tenths of one percent of gross revenues for charity care. In 2000, BRCH provided one-half of one percent for charity care and, in 2001, twenty-seventh hundreds of a percent. The historical levels do not support the proposed commitment of 5% of open heart surgeries for uninsured patients in the second year of the program. Although worded to apply only to the second year, BRCH's President and CEO testified concerning the condition without limiting it to the second year. In Boca Raton Community
Hospital, Inc.'s Proposed Recommended Order (Reformatted), filed on July 5, 2002, the condition is described as follows:
49. As conditions of CON approval, Boca will, beginning in the second year of operation of the program and continuing thereafter, provide a minimum of five percent each year of OHS cases to uninsured patients, and establish an outreach program to locate and provide OHS and cardiology services to uninsured patients in Palm Beach County. (Boca Ex. 3 at Schedule C; Pierce, 1899). Boca reasonably decided to focus on the needs of the uninsured, rather than Medicaid patients, because of the low volume of Medicaid patients who require OHS services. (Pierce, 1902).
At BRCH, Medicaid and Medicaid health maintenance organization (HMO) care as a percent of total ranged from 1.3% to 1.4% from 1996 through 1998. BRCH projected serving 1.2% to 1.3% open heart Medicaid cases, or four patients in the first year and 1.5% to 1.6%, or seven Medicaid patients in the second year. The projections are consistent with its history although BRCH offered no Medicaid condition.
Bethesda and BRCH also claimed not normal circumstances exist in District 9 due to the disparity in open heart care for uninsured and Medicaid patients as compared to the insured.
For uninsured residents of Palm Beach County during the twelve months ending June 30, 2000, the use rate was 4.7 per 1000, as compared to 21.8 per 1,000 for insured open heart patients. For angioplasty patients, the insured use rate was
38.2, but the uninsured rate was only 8.9. Assuming that the use rates should not be so different, the discrepancy in access for the uninsured is significant and unfortunate but was not shown to be a not normal circumstance in the health care delivery system. The applicants' proposals, unlikely as they are to meet even the proposed conditions, are inadequate to increase access materially for the uninsured.
Comparisons of the level of Medicaid provided statewide to that provided in District 9 without consideration of other factors, including age and income levels, were not useful in analyzing access. Assertions that any discrepancy in care for potential Medicaid open heart patients constitutes a not normal circumstance are not substantiated by this evidence.
Subsection 408.035(1)(b) and (2)(b) - availability, quality of care, efficiency, appropriateness, accessibility, extent of utilization and adequacy of like and existing facilities in District Nine
In 2006, the population in District 9 is projected to reach 1.2 million people, of which approximately 992,378 will reside in Palm Beach County, 119,573 in Martin County, 181,406 in St. Lucie County, 106,790 in Indian River County, and 31,140 in Okeechobee County. In District 9, throughout Florida, and in the United States, heart disease is the leading cause of death. In 2000, heart disease was the cause in 522 of 1,560 total deaths in
Martin County, and 4,337 of 12,795 total deaths in Palm Beach County.
From 1995 to 2000, the number of Florida residents having open heart surgeries increased 15.1%. During the same period of time, the number of District 9 resident cases, regardless of where the surgeries were performed, increased from 3,119, to 3,938, an increase of 755 OHS cases, or 24%. Palm Beach County residents represented 427 of the 755 increase, and 2,633 of the total of 3,938 resident cases. The distribution of the remaining 1,305 District resident cases by county was as follows: 597 from St. Lucie, 339 from Martin, 269 from Indian River, and 100 from Okeechobee County.
More recent data, however, indicates trends towards a leveling off or even decline in the number, but an increase in the complexity of open heart procedures. Some experts describe open heart volumes having reached a "plateau" in the United States, in Florida, and in District 9. Last year, the number of open heart surgeries in the United States declined 22%. The statewide volume of cases was 32,199 in 1996, 33,507 in 1997, 34,013 in 1998, and 32,097 in 1999.
At District 9 hospitals, open heart volumes were 1,670 in 1994, 1,841 in 1995, 2,152 in 1996, 2,407 in 1997, 2,527 in 1998, 2,656 in 1999, and 2,650 in 2000.
Cardiac Catheterizations and Angioplasties
The major reason given for the stable and declining open heart volume is the increase in the utilization of angioplasty, or therapeutic cardiac cathing, an alternative which costs less and is less invasive. Angioplasty procedures increased from 1995-2000, by over 2,500 cases for District 9 residents, and over 2,600 cases in District 9 hospitals, from 2,104 cases in 1995, to 4,714 in 2000.
Among the procedures generally referred to as angioplasties are percutaneous transluminal angioplasty (PTCA) or balloon angioplasty, percutaneous transluminal coronary rotational atherectomy (PTCRA), and the insertion of scaffolding- like devices, called stents, to prevent re-occlusion of coronary arteries.
In Florida, diagnostic cardiac caths may be performed at facilities which do not have angioplasty and open heart surgery programs, but angioplasties must be performed, except in rare emergency circumstances, only at hospitals which are licensed to provide open heart services, in case back-up surgery is needed.
Lawnwood Regional
Lawnwood is located in Fort Pierce, in St. Lucie County, which is second to Palm Beach County in population and in District 9 resident open heart cases. Lawnwood is owned by a
subsidiary of HCA, the Hospital Corporation of America, formerly known as Columbia. HCA is a for-profit, investor-owned corporation which owns and operates approximately 200 hospitals in the United States.
A $17 million addition at Lawnwood, designed for the open heart program, includes two dedicated operating rooms and a 12-bed intensive care unit. The Lawnwood program has a full-time staff of two surgeons and one additional surgeon who divides his time between Lawnwood and PBGMC.
Lawnwood, having opened its program early in 1999, is not considered a mature program. In addition, Lawnwood has had some difficulties with accreditation and disputes with cardiologists. Lawnwood reported one open heart case in the first quarter of 1999, and 143 or 144 for the year. In calendar year 2000, between 330 to 340 open heart surgeries were performed at Lawnwood. In calendar year 2001, the volume was between 333 and 336 cases. Depending on the source of the data, the volume at Lawnwood was reported to be as high as 364 for the twelve months ending September 30, 2000; in a range from 336 to 396 for the twelve months ending March 31, 2001; and up to 412 for the twelve months ending July 2001. The variances result from seasonal patient utilization, and from AHCA’s use, for the fixed need pool, of the most current available data which it receives from the various local health councils. That data is submitted
on handwritten or typed forms which are not uniform across districts. Subsequently, the hospitals provide electronic data tapes directly to AHCA, which if properly decoded, should provide more accurate statistics. While there may be variances either way, in this case, the lower volumes for Lawnwood were derived from the more reliable electronic tapes. Based on that data and the testimony of the cardiac surgeon who is the director of the program at Lawnwood, the annual volume of open heart surgeries was approximately 330 in 2000, and 348 in 2001. The new rule, adopted on January 24, 2002, reduces the minimum number required for existing programs to 300 a year, or 25 adult operations a month.
The number of angioplasties performed at Lawnwood increased from 465 in 1999, to 845 in 2000.
Palm Beach Gardens Medical Center
South of the four relatively small northern counties in District 9, PBGMC has 204 beds located in northern Palm Beach County. It is a subsidiary of Tenet Healthsystem Hospitals (Tenet). Adult open heart surgery has been available at PBGMC since 1983. The surgeries are typically performed in two or three of the 11 operating rooms, although five are equipped to handle open heart cases. PBGMC has 94 telemetry beds, and 32 intensive care beds, eight designated for cardiovascular intensive care patients. PBGMC has four cardiac cath labs and
separate electrophysiology labs. The medical staff of approximately 400 physicians includes about 200 cardiologists, 24 invasive cardiologists and seven cardiac surgeons.
The number of open heart cases at PBGMC was 700 in 1994, 801 in 1995, 913 in 1996, 1,028 in 1997, 1,045 in 1998, 1,124 in 1999, 940 in 2000, and 871 in 2001.
The number of angioplasties increased from 552 in 1994, to 1,019 in 1997, to 1,431 in 2000.
JFK
JFK, which has 387 beds, is located roughly in the center of Palm Beach County, in the City of Lake Worth. Like Lawnwood, JFK is an HCA's subsidiary, having been purchased by that corporation in 1995.
Open heart services and cardiac cath services began simultaneously at JFK in 1987. JFK has three open heart operating rooms. JFK, after a major expansion, has a separate entrance to its three cardiac cath laboratories, a dedicated electrophysiology suite, for treatment of arrhythmias, and 17- patient holding area. JFK provides all cardiac services, except heart transplants. The average age of patients at JFK is 74 years old.
The medical staff of 504 board-certified or board- eligible physicians includes 25 cardiologists, five invasive cardiologists, two electrophysiologists, and three cardiac
surgeons. JFK has recently accepted applications from but not yet extended privileges to three additional cardiovascular surgeons.
Volumes of open heart cases at JFK were, with some variances depending on the data source, approximately 428 in 1994, 434 in 1995, 630 in 1996, 674 in 1997, 711 in 1998, 613 in 1999, 621 in 2000, and 610 in 2001.
The number of angioplasties ranged from 709 in 1994, to 1,152 in 1997, to 1,281 in 2000.
Delray
Delray, with 343 beds, in Delray Beach, is the trauma center for southern Palm Beach County. Open heart care began at Delray in 1986. The surgeries are currently performed in three of ten, but soon to be a total of twelve operating rooms with shelled-in spaces set aside for two more. Patients recover in a 15-bed surgical intensive care unit. The Delray medical staff of over 600 physicians has close to 60 cardiologists, including 15 invasive cardiologists and six cardiovascular surgeons. Delray has three cath lab rooms and seven bays for holding patients pre- and post-procedure.
For the years 1994 through 2001, open heart volumes at Delray were 542, 606, 609, 705, 771, 758, 759, and 738, respectively.
During the same period of time, the annual number of angioplasty procedures increased from 591 in 1994, to 810 in 1997, to 929 in 2000.
The existing CON-planned and approved programs in the District are well distributed geographically and allocated appropriately based on population. Considering the declining utilization, the like and existing open heart surgery programs are available and accessible.
Subsection 408.035(1)(f) - services that are not reasonably and economically accessible in adjoining areas
Over 30% of District 9 resident open heart cases are performed in other districts, the vast majority at North Ridge in District 10 (Broward County). The district outmigration for a service when excessive or difficult can indicate access or quality concerns and constitute a not normal circumstance for approval of a new program. In this case, with adequate available services in District 9 and its close proximity, the outmigration to North Ridge, which is 15 miles or 25 minutes from BRCH is not a not normal circumstance. There is also substantial overlap in the medical staff at both hospitals which allows continuity of care for patients despite transfers. The argument that families, particularly an older spouse, will necessarily have to drive farther to visit the patient is rejected, since that depends on
where in the district the person resides not on the distances between hospitals.
North Ridge has 391 licensed beds, with 260 to 270 acute care beds in use. At North Ridge, cardiovascular surgeons usually use three OHS operating rooms, although a fourth is also available. Open heart patients recover in a six-bed cardiovascular intensive care unit.
The reported volumes of open hearts at North Ridge have been from 1994 through 2001, respectively, 864, 935, 893, 826, 882, 890, 905, and 795. The total number of open heart cases in District 10 has been declining since 1998.
The volume of angioplasties at North Ridge increased from 793 in 1994, to 829 in 1997, to 1,155 in 2000, consistent with a rising District 10 use rate from 2.95 to 3.66 over the same period of time.
The staff at North Ridge includes 107 cardiologists, 27 interventional cardiologists, and 17 cardiovascular surgeons, many of whom also regularly perform open heart surgeries at Holy Cross, which is approximately a mile south of North Ridge in Fort Lauderdale. At Holy Cross, which also has established referral networks from District 9, open heart volumes declined from a high of 753 in 1998 to 693 in 2000.
All of the open heart services proposed by the applicants are reasonably available in adjoining areas, in
Districts 10 and 11 to the south and in the other districts to the north.
Subsection 408.035(1)(c) - comparisons of quality; and Subsection 408.035(1)(e) - joint, cooperative or shared resources; and Subsection 408.035(1)(g), (h), and (k) - need for research, educational and training programs or facilities for medical and health care professionals; and Subsection 408.035(1)(h) and
Rule 59C-1.033 - recruitment, training and salaries for staff
The parties stipulated that the applicants have a history of providing quality care.
Martin Memorial was accredited with commendation by the JCAHO in 1997, which is now called accreditation without Type I Recommendations. That was followed, in July 2001, with a score of 93 on survey items with some follow-up improvements required related to patient assessment and nutrition.
Martin Memorial offers internships, and residencies for training non-physician medical personnel from Barry University, Indian River Community College, and Florida Atlantic University. The cancer center at Martin Memorial is affiliated with the Moffitt Center. Despite the absence of an open heart program, Martin Memorial has participated in clinical trials of cardiac drugs.
The Shands Healthcare System of nine affiliated hospitals, including two research and teaching hospitals, is the model for the relationship proposed with Martin Memorial. The partnerships are intended to upgrade the care available in
community hospitals and to establish, for complex cases, referral networks for the Shands teaching hospitals. Shands has already satisfied itself that Martin Memorial meets its due diligence test for the quality of its existing program and philosophical compatibility. If Martin Memorial's CON is approved, Shands will assist in training staff for the program. Initially, the program will have one cardiovascular surgeon, a University of Florida medical school faculty member, in Martin County. When that surgeon is ill or on vacation, others from the University of Florida will be available. The logistics of the plan raises questions about the adequacy of coverage to meet the 24-hour requirements of Rule 59C-1.033, Florida Administrative Code.
In the JCAHO survey process, Bethesda received a score of 97, as a result of its survey in June 2000, and was accredited for the maximum allowable time, three years.
Personnel for a Bethesda program can be appropriately trained at Orlando Regional, a statutory teaching hospital with a high volume open heart program.
In June 2000, BRCH received a JCAHO score of 96.
BRCH maintains a scholarship program for new nurses making a two-year commitment, and an on-site educational department with a preceptorship for training operating room and emergency room nurses. Nursing students from Florida Atlantic University (FAU), which is located across Glades Road from BRCH,
rotate at BRCH. FAU is in the process of establishing a medical school.
There is a severe shortage of nurses in the United States, in Florida, and in District 9. All of the hospitals in District 9 have resorted to highly competitive and innovative recruitment and retention strategies, including international recruiting, signing bonuses, child care and, of course, rising salaries and benefits. The demand is greater and shortages more severe in highly specialized areas, such as critical care, telemetry and open heart surgery nursing.
The average age of nurses has also increased to 46 or
47 years old, while enrollment in nursing schools and the number of nursing school professors have declined. All of the applicants concede that recruiting and retaining nurses for new open heart program will be a challenge. The likely results are a loss of experienced nurses from existing programs, an increase in total health care costs, an increase in vacancies, and, at least temporarily a decline in the quality of experienced nursing care in existing open heart programs.
At this time, there is no evidence that declining open heart utilization will eventually alleviate the shortage of experienced nurses. It has, so far, only eased the need to resort as frequently to other extreme and expensive alternatives,
including pay overtime, contracting with private agencies, and bringing in traveling nurses.
Subsection 408.035(1)(m) - size, scope and fixed equipment cost at BRCH; Subsection 408.035(2)(c) - alternatives to new construction; and Subsection 408.035(1) (h) - funding for BRCH
BRCH plans to construct a 74,000 square-foot cardiac care facility, which will include two open heart operating rooms and two cardiac cath labs, an electrophysiology lab, 12 cardiovascular intensive care beds, and 18 cardiac cath lab bays. Only 18,568 square feet are attributable to the open heart operating rooms and cardiovascular intensive care unit which compares favorably with Bethesda's estimate of 17,759 square feet for the same functions. It is not possible, therefore, to conclude that the size of the BRCH project is excessive as compared to that proposed by Bethesda.
BRCH underestimated the cost for fixed equipment for the open heart project by approximately $1.6 million. That omission resulted in understated estimates of depreciation by approximately $275,000.
The total project cost for BRCH is approximately $2.2 million when almost $2 million in omitted equipment costs is added to the original estimate of $20 million. All pending capital projects, as shown on Schedule 2 of the BRCH application, total $54 million. With combined cash and investments of $160 million, the BRCH foundation has sufficient funds for the
hospital's projects. Although BRCH earned profits of
$6.6 million and $7.3 million in 1998 and 1999, respectively, the hospital lost $30 million from operations due to billing and collection errors in 2000. BRCH has a donor who has stated a willingness to donate $20 million for the cardiac care center.
BRCH has the funds necessary to build the facility. With Medicare capital cost reimbursement completely phased out, there is insufficient evidence of a direct impact on health care costs based on this proposed capital expenditure.
Subsection 408.035(1)(i) - short and long term financial feasibility
Martin Memorial initially projected that its program would perform 360 open heart surgeries in year one and 405 in year two. As a result of changes in the use rate, Martin Memorial lowered its second year projection to 375 surgeries while increasing staffing levels. Even if projected open heart surgery revenues of $264,000 in the second year decline in proportion to expected lower utilization, estimated angioplasty revenues of $468,000, are sufficient to make up the deficit and to keep the combined program financially feasible in the short and long term.
Bethesda projected volumes of 165 open heart surgeries in the first year and 270 in the second year. Assuming Bethesda's revenues are 90% of the district average, the combined
net profit for open heart and angioplasty services is reasonably expected to be approximately $750,000 in the second year operations. The project is profitable, therefore, financially feasible in the short and long term.
BRCH's expert projected volumes of 308 open heart surgeries and 289 angioplasties in the first year, and 451 open heart surgeries and 422 angioplasties in the second year. If utilization projections are correct, then BRCH will receive incremental net income of $1.6 million from the open heart surgery program and $825,000 from the angioplasty services. Factoring in claims that the Medicare case weight was overstated and depreciation underestimated, the BRCH project is, nevertheless, financially feasible for the short and long term.
Typically, any open heart surgery program that can reach volumes in the range of 200 to 250 cases, will be financially feasible. The establishment of an open heart program also has a "halo effect," for the hospital, attracting more patients to the cardiac cath labs and other related cardiology services. Open heart surgery and angioplasty tend to be profitable, generating revenue which hospitals use to offset losses from other services.
Subsection 408.035(1)(j) - needs of HMOs
All of the applicants will enter into contracts with, but none is a health maintenance organization.
Subsection 408.035(1)(l) - probable impact of fostering competition to promote quality assurance and cost-effectiveness
Hospitals with higher volumes of open heart surgeries and angioplasties usually have higher quality as measured by lower mortality rates and fewer complications.
The open heart surgery rule, in effect at the time the applications were filed, established a minimum volume of 350 annual admissions for existing providers. In the rule as amended on January 24, 2002, the minimum volume for existing programs was reduced to 300. The divisor in the formula for determining need, which represents the average size of a program in the district, was 350 prior to amendment and 500 subsequently.
The minimum and average volumes in the rule set, in effect, the protected range for existing programs, not the optimal size, or "cut point" at which outcomes are worse below and better above.
According to the American College of Cardiology and American Heart Association (ACC/AHA) the evidence is clear that outcomes are better if an individual performs at least 75 procedures at a high volume center with more than 400 cases. The ACC/AHA guidelines indicate, although more controversial and less clearly established, that acceptable outcomes may be achieved if the individual operator performs at least 75 procedures in centers with volumes from 200 to 400 cases. Because the
relationship between higher volumes and better outcomes is continuous and linear, and because research showing the benefits of primary angioplasty with or without open heart surgery back-up is preliminary and limited, the position of the ACC/AHA is, in summary, as follows:
The proliferation of small angioplasty or small surgical programs to support such angioplasty programs is strongly discouraged.
(Journal of the American College of Cardiology, Vol. 37, no. 8 June 15, 2001, pp. 2239xvii (Tenet Exhibit 5))
An open heart program at Martin Memorial will redirect cases that would otherwise have gone to Lawnwood, PBGMC, and JFK.
The proposed Martin Memorial Service area overlaps that of Lawnwood in southern St. Lucie County, an area which generates one quarter of the open heart cases at Lawnwood. Lawnwood is reasonably expected to lose 56 open heart cases a year with total volume going down below 300, resulting in loss of
$1.8 million, or 20% of its total revenues. Lawnwood would have unacceptably low volumes threatening the quality of the open heart program.
PBGMC, as a result of a new program at Martin Memorial, will lose approximately 170 and 180 open heart cases annually and an equal number of angioplasties reducing its open heart volume to approximately 700 a year. The financial loss would range from $4 to $5 million a year, as compared to total
net income which was between $20 and $30 million a year for past three years. PBGMC would not suffer an adverse impact sufficient to threaten either the quality or the financial feasibility of the open heart program or total hospital operations.
JFK, which currently receives most of the angioplasty referrals from Martin Memorial, is expected to lose from 25 to 30 open heart cases, and 65 to 70 angioplasties each year during the first two years of a Martin Memorial program. The estimated financial loss to JFK is $1.7 million, a significant detriment when compared to $2.8 million in net income from operations in calendar year 2000.
Approval of open heart program at Bethesda will adversely affect case volumes at JFK and Delray.
Bethesda projected that, in its first year, 75% of its cases would have gone to Delray and 25% to JFK, and that by the third year, the split would be even at 50% from Delray and 50% from JFK. JFK, depending on the approach to the impact analysis, will lose from 40 to 60 open heart cases in the first year, from
90 to 110 in the second year, and from 115 to 170 in the third year of a program at Bethesda. The volumes of lost angioplasties is expected to be slightly higher. The resulting combined open heart and angioplasty financial loss is $6.6 million, far greater than the significant detriment expected from a Martin Memorial program alone. The annual volume of open heart cases at JFK
would be approximately 400 to 500, assuming flat not continued declining utilization.
If Bethesda offered the service, Delray's open heart volumes would decline by 124 cases in the first year and by 248 cases in the third year of operations, decreasing total volume to
500 or 600 annual surgeries. Delray had a net income from operations of approximately $24.7 million in 2000, which would indicate that neither quality nor financial stability would be significantly adversely affected.
If an open heart program is approved for BRCH, the volumes of cases at Delray and North Ridge will decline.
Delray would be expected to lose 163 open heart cases and 235 in years one and two, respectively, and equal numbers of caths and angioplasties, resulting in annual open heart cases reduced from the low 700s to approximately 500 cases. Delray's pre-tax revenue was $39 million in 2001. In terms of quality and financial stability, Delray can withstand the adverse impact of a new program at BRCH.
North Ridge would lose approximately 124 open heart cases in year one and 178 in year two, and similar numbers of caths, reducing open heart volumes from the upper 700s to approximately 600 annual cases. North Ridge's pre-tax income was
$21 million for the year ending May 31, 2001. It appears that
North Ridge could, even with the adverse impact of BRCH, maintain a quality, financially viable open heart program.
Subsection 408.035(l) - probable impact on costs
The applicants, all not-for-profit corporations, contend that the fact that District 9 has only for-profit open heart hospitals affects charges and is a not normal circumstance for the approval of one or more not-for-profit. District 9 is the only district in Florida in which all open heart providers are for-profit corporations.
Statewide, not-for-profit open heart hospitals charge 31% less than for-profit.
Martin Memorial's CON proposal includes a charge structure below that at existing programs.
Bethesda's planned charges are 10% less than the District 9 average for open heart and angioplasty services.
BRCH is the applicant which is most likely to increase competition in District 9, based on the Herfindahl-Hirschman Index (HHI). The HHI's measurement of competition in a market used by economists frequently to analyze anti-trust issues.
Charges are not a factor in up to 75% of open heart/angioplasty cases reimbursed by payors, such as Medicare, at set flat rates. In approximately 10% of cases, including complex "outlier" cases exceeding the range for flat
rate reimbursement and for other payors on a percent-of-charges
basis, charges are not irrelevant. But, the evidence to demonstrate lower charges were applicable to patients of the same severity was questionable.
Subsection 408.035(1)(o) - continuum of care
There is insufficient evidence the any applicant is preferable based on its ability to promote a continuum of care in a multilevel system.
Subsection 408.035(2)(a) - alternatives to inpatient services
There are no alternatives to inpatient services for open heart surgery and angioplasty patients.
Subsection 408.035(2)(d) - patients who will experience serious problems in the absence of the proposed
new service
The applicants and AHCA determined that new open heart surgery programs are needed mainly to provide emergency or "primary" angioplasty to patients suffering heart attacks (acute myocardial infections). Primary angioplasty is an alternative to "clot busting" medications, or thrombolytics, and to open heart surgery. Performed on an emergency basis, the three different treatments are used to restore blood flow before heart muscle dies. Because "time is muscle," patients benefit only if treated within a relatively short time after the onset of symptoms. The goal is 90 minutes from door-to-balloon for angioplasty. The decision to treat a patient with a particular therapy is based on a number of factors assessed during triage. Paramedics in
consultation with ER doctors at the receiving hospital frequently begin triage and administering medications and oxygen in ambulances equipped with sophisticated diagnostic equipment.
As the statistical data demonstrates, angioplasty, whether scheduled or emergency, is increasingly becoming the preferred therapy. Some studies have shown improved outcomes, higher survival rates and fewer complications, from primary angioplasty as compared to thrombolytics. Comparisons have not been made over extended periods of time, and the apparent benefits of angioplasty have not been duplicated in community hospitals as compared to clinical trials in high volume research centers.
Estimates of the number of people who could benefit from the availability of angioplasty services at the applicants vary based on the number of elderly in the service area, the number of non-traumatic chest pain ER visits, delays in transfers of emergency patients, and the number of patients being transferred to existing providers for angioplasties or open heart surgeries.
Martin Memorial selected five patients as examples of those who could be served in an open heart program at Martin Memorial. The anecdotal evidence of transfer "delays" is insufficient to demonstrate bed unavailability or capacity constraints.
Martin Memorial-Stuart and Martin Memorial South transferred 240 heart attack patients to open heart surgery hospitals. Only 18 of the emergency heart attack patients who presented at the Martin Memorial ER were transferred from the ER. Approximately ten patients a year are so unstable that an intra- aortic balloon pump is required during transfer.
Martin Memorial presented evidence of delays of two hours or more in transfers of 84 patients from its cath labs to open heart surgery hospitals. The transfer records, created for subsequent certificate of need litigation, were of questionable probative value. The case studies were inadequate to establish whether "delays" were reasonable or not. Factors such as physician consultation time, time to stabilize a patient for transfer and the assumed travel time seem to have been included in the time periods.
Bethesda transferred 270 patients for cardiac care from October 1999 through September 2000. Thirty patients were transferred, from November 2000 to July 2001, for angioplasties or open heart surgery after having cardiac caths at Bethesda.
Bethesda failed to establish that transfers were delayed due to capacity problems at existing hospitals because emergency patients were not classified separately, and the causes of the time lapses were not identified.
Of the applicants, BRCH has the busiest ER, with 50,000 to 52,000 annual visits compared to approximately 48,000 at the two Martin Memorial locations combined. BRCH admitted 439 heart attack patients through its ER during the year ending
June 30, 2000. The majority of patients are treated with thrombolytics at BRCH. BRCH transfers approximately one emergency heart attack patient a week on average, or from 30 to
50 a year, for interventional cardiac procedures.
BRCH's presentation of evidence of delays in transfers was flawed. The data was collected and used only for litigation, and was incomplete. Some patient records were lost and others were deleted due to inaccurate data.
Of the applicants, BRCH is located in an area with the largest percentage of the population age 65 and older, approximately 35%, as compared to 24% in Martin Memorial's service area.
Agency Consistency
Martin Memorial, through expert witness testimony, compared its situation to that of Brandon, a hospital in AHCA District 6, which was issued an open heart surgery CON in 2001. The expert noted that Martin Memorial and Brandon are both in five county health planning districts, and that they are 19 and from 15 to 17 miles, respectively, from the nearest open heart provider. Three of the counties in District 6 have open heart
programs, including Hillsborough County where Brandon is located, as compared to two District 9 counties, St. Lucie and Palm Beach, but not Martin. The Martin Memorial primary service area projected population is 238,861 for 2004, 24.1% aged 65 and older. The Brandon service area population projection is 309,000 for 2004, with 10.5% aged 65 and older. Brandon has 255 beds, Martin Memorial-Stuart has 236. Brandon had 53,000 emergency room visits, and Martin Memorial, at both locations, had 48,503 in 1999. Before defaulting to zero, the numerical formula yielded a need for 3.27 additional open heart programs in District 6 as compared to 3.9 in District 9. Other specific comparisons favorable to Martin Memorial included the number of heart attack patients presenting at its ER, cath lab volumes, patient transfers for open heart and angioplasty procedures.
Among others, there are several significant distinguishing facts in Florida Health Sciences Center, Inc. v. Agency for Health Care Administration, Case No. 00-0481CON, (R.O. Mar. 30, 3001, F.O. Oct. 17, 2001) aff'd per curiam sub nom, University Community Hospital v. Agency for Health Care Administration, Case No. 1DO1-3592, et al. (Fla. 1st DCA
Sept. 19, 2002), the Brandon case. In that case, the two existing providers performing fewer than 350 cases a year, Blake Medical Center, and Manatee Memorial Hospital, both in Manatee County, were mature programs located 40 miles from Brandon with
no service area overlap. By contrast, Lawnwood which is not a mature program and, therefore, has not reached its potential volume, is 20 miles from Martin Memorial, and has an overlapping service area. Martin Memorial's ER volume and the number of transfers from its ERs are the combined experience from two locations. The more accurate comparison is 27,000 ER visits at Martin Memorial-Stuart to 53,000 at Brandon. Emergency heart attack patients presenting at Martin Memorial South would continue to require transfers for primary angioplasty. Finally, the decision in Brandon was based, in large part, on transportation difficulties, inadequate interfacility ambulances and traffic congestion, which are not factors in District 9.
Factually, the case of Halifax Hospital Medical Center, d/b/a Halifax Medical Center v. Agency for Health Care
Administration, et al., Case No. 95-0742 (AHCA Jan. 14, 1997) is also distinguishable. The applicant could have no effect on the low volume providers located 80 miles to the north. That was one not normal circumstance. Need existed because of another not normal circumstance, i.e., capacity constraints at the only other provider in the same primary service area.
In Oak Hill Hospital v. AHCA, Case No. 00-3216CON (R.O. Oct. 4, 2001, F.O. Jan. 22, 2002), appeal dismissed sub nom
Hernando HMA, Inc. v. HCA Services of Florida, Inc., Case No. 1DO2-854 (Fla. 1st DCA June 6, 2002), the two approved applicants
were in separate counties which constituted entirely separate health care markets. Neither applicant would adversely affect the low volume providers.
After the Administrative Law Judge recommended approval of the Citrus County applicant, AHCA, engaging in what appears to be a comparative review of the two remaining applicants from Hernando County, approved a second applicant from the same district at the same time. Some facts are similar to those in this case: The average drive time between hospitals was
30 minutes; transfers and admissions procedures required additional time; there was a recognition of increasing preferences for reperfusion of heart muscle using primary angioplasty; patients and families experience stress and anxiety as a result of transfers. Institution-specific issues included the transfer of 600 cardiac patients by ambulance from Oak Hill, the size of the cardiology and cardiac cath programs (1,641 caths in 1999), the larger elderly population in the service area, and the hospital's size.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties to and the subject matter of these proceedings. Sections 120.569, 120.57(1), and 408.039(5), Florida Statutes.
All of the parties to this proceeding have standing.
An applicant for a certificate of need has the burden of demonstrating that its application should be granted. Boca
Raton Artificial Kidney Center v. Department of Health and Rehabilitative Services, 475 So. 2d 260 (Fla. 1st DCA 1985). The award of a Certificate of Need must be based on a balanced consideration of all statutory and rule criteria. Department of
Health and Rehabilitative Services v. Johnson and Johnson Home Healthcare, Inc., 447 So. 2d 261 (Fla. 1st DCA 1984); Balsam v. Department of Health and Rehabilitative Services, 486 So. 2d 1341 (Fla. 1st DCA 1988). The weight to be given each criterion is not fixed but depends on the facts and circumstances of each case. Collier Medical Center, Inc. v. Department of Health and Rehabilitative Services, 462 So. 2d 83 (Fla. 1st DCA 1985).
Because the fixed numeric need is zero, each applicant must demonstrate not normal circumstances for approval. See Rule 59C-1.033(7)(a), Florida Administrative Code; Halifax Hospital Medical Center v. Agency for Health Care Administration, etc., Case No. 95-0742CON (R.O. Sept. 9, 1996, F.O. Jan. 15, 1997), aff'd, 698 So. 2d 841 (Fla. 1st DCA 1997).
An invalidated rule has been held inoperative as to CON applications already filed or in process. Agency for Health Care Administration v. Mount Sinai Medical Center, 690 So. 2d 689 (Fla. 1st DCA 1997). In general, Florida follows the general rule that a change in a licensure statute during the pendency of
an application is operative as to that application. Lavernia v. Department of Professional Regulation, 616 So. 2d 53 (Fla. 1st DCA 1993), rev. denied, 624 So. 2d 267 (Fla. 1993). That position is inconsistent with rules and decisions intended to assure the fairness of the CON review process. Rule 59C- 1.010(3)(b), Florida Administrative Code, provides that:
The agency shall deem the application complete or withdrawn within 7 calendar days of the receipt of the requested information. Subsequent to an application being deemed complete by the agency, no further application information or amendment will be accepted by the agency.
The imposition of new criteria without allowing an amendment places an applicant in the untenable position of not being allowed to offer proof that its proposal meets the criteria. See Manor Care v. Department of Health and Rehabilitative Services,
558 So. 2d 26 (Fla. 1st DCA 1989). In addition, after June 1999, Subsection 120.54(1)(f), Florida Statutes, as amended, prohibits agencies from adopting retroactive rules unless expressly authorized by statute. For these reasons, the open heart surgery rule in existence at the time the applications were filed is applicable.
Open heart surgery is defined as a tertiary service by rule. Transfers are inherent to the classification system. A "tertiary health service" is defined in Section 408.032(17), Florida Statutes, as follows:
health service, which, due to its high level of intensity, complexity, specialized or limited applicability, and cost, should be limited to, and concentrated in, a limited number of hospitals to ensure the quality, availability, and cost-effectiveness of such service.
There is no evidence of not normal circumstances related to programmatic or geographic access limitations. District 9 open heart surgery hospitals are well distributed, having all been approved pursuant to the CON process.
There is evidence of unequal access to open heart and angioplasty services for uninsured people, but insufficient evidence of the causes to determine that to be a not normal circumstance. There is insufficient and/or vague evidence that any applicant can or will improve access for the uninsured.
There is insufficient anecdotal evidence of transfer delays, of the causes, or to establish adverse outcomes as a result. See Naples Community Hospital v. Agency for Health Care Administration, et al., Case No. 92-1510CON (R.O. Mar. 19, 1993;
F.O. June 6, 1993).
There is insufficient evidence that any benefits from primary angioplasty, shown in randomized trials in high volume research centers are long term or can be duplicated at the applicant hospitals. The risk to the quality of care at existing programs as a result of exacerbating declining district surgical volumes, in the absence of need or not normal circumstances,
outweighs the benefits of on-site angioplasty under current ACC/AHA guidelines. During a challenge to recent amendments to the open heart surgery rule, AHCA maintained and defended their consistency with the tertiary classification and the provision for approval under normal circumstances of only one new program in a district at a time. Bethesda Healthcare System, Inc. v.
Agency for Health Care Administration, et al., Case No. 01-2665RP (DOAH Nov. 15, 2001), aff'd, (Fla. 1st DCA Nov. 1, 2002). When
there is adequate scientific evidence to the contrary, AHCA will presumably undertake appropriate rulemaking. See Cleveland
Clinic Florida Hospital v. Agency for Health Care Administration, 679 So. 2d 1237 (Fla. 1st DCA 1996).
Martin Memorial's application best meets the district health plan preference for having the largest established cardiac cath program. It would also improve geographical access but to the detriment of Lawnwood. Of the hospitals in Palm Beach County, i.e., BRCH and Bethesda, neither will adversely affect Lawnwood, but BRCH is the larger hospital, with higher cardiac cath volumes, busier ER, and greater number of transfers of cardiac patients.
All of the applicants have cardiac cath programs and treat residents of any county, regardless of ability to pay, as required by Subsection 408.035(1)(a), Florida Statutes (1999).
Based on its history of service to Medicaid and indigents, Bethesda established itself as the provider likely to serve more Medicaid and indigent patients, in conformity with Subsection 408.035(1)(n), Florida Statutes (1999) and Rule 59C- 1.030, Florida Administrative Code.
Lawnwood's, but not PBGMC's, ability to maintain the volume of cases needed to assure quality will be substantially adversely affected by a new open heart program at Martin Memorial. JFK will be materially adversely affected financially by the establishment of an open heart/angioplasty program at Martin Memorial. Martin Memorial, therefore, should not be approved under the criterion of Subsection 408.035(1)(l), Florida Statutes (1999).
Approval of BRCH's open heart CON will adversely affect Delray and North Ridge, but not enough to affect the quality of care of open heart and angioplasty services or the financial profitability of hospitals. BRCH's application could be approved consistent with Subsection 408.035(1)(l), Florida Statutes (1999).
Approval of a program at Bethesda will significantly adversely affect JFK financially, but not Delray. Bethesda should not be approved under the criterion in Subsection 408.035(1)(l), Florida Statutes (1999).
All of the applicant's proposals can be adequately funded and are financially feasible in the short and long term, as required in Subsections 408.035(1)(h) and (i), Florida Statutes (1999).
The proposals to lower charges do not support a conclusion that patients of the same severity will be charged less, as result of competition as required by Subsection 408.035(1)(l), Florida Statutes (1999).
The existing providers in District 9 and adjacent districts are available, accessible, efficient and, with the exception of Lawnwood, have declining utilization. No need for an additional program is demonstrated under Subsections 408.035(1)(b), (1)(f), (2)(b), and (2)(d), Florida Statutes (1999).
The existing providers will be adversely affected by competition for nurses which would increase health care costs, contrary to Subsection 408.035(1)(h), Florida Statutes (1999).
For the reasons stated in the Findings of Fact or based on the prehearing stipulation, the applicants' proposals are not materially distinguishable based on the criteria in Subsections 408.035(1)(c), (d), (e), (g), (j), (k), (m), (o), (p), and (2)(a), (c) and (e), and in Rule 59C-1.033, Florida Administrative Code, except Subsection (5)(b), as related to cardiovascular surgeon coverage at Martin Memorial.
Institution-specific criteria alone have not constituted not normal circumstances in the past. West Florida
Regional Medical Center, Inc. v. Agency for Health Care Administration, Case No. 93-4886 (R.O. Nov. 18, 1994, F.O. Apr 18, 1995), relying on St. Anthony's Hospital v. HRS, etc.,
Case No. 88-0637, 11 FALR 2193, (AHCA Mar. 31, 1989). Except for
aggravating the nursing shortage, BRCH is arguably the least harmful of the three applicants. But even a comparison to the institution-specific factors in Oak Hill does not support approval of BRCH. In Oak Hill, approximately 600 emergency cardiac patients a year were transferred, compared to 30 to 50 a year at BRCH. Oak Hill's cath volume was over 1,600, but BRCH's is between 600 and 700 a year.
If, nevertheless, BRCH is approved, the conditions it offered should be accepted. The provision of 5% of open heart care to uninsured could assist in alleviating the inequity in access. Relinquishment of the CON if it fails to perform 350 open heart surgeries a year in any two consecutive years would mitigate against the risk that BRCH would become a mature low volume provider suppressing future numeric need.
On balance, there is no need for the establishment of a new District 9 open heart surgery/angioplasty program based on the statutory and rule criteria (or under medical guidelines),
particularly in light of the potentially harmful consequences which are likely to result.
RECOMMENDATION
Based on the foregoing Findings of Fact and Conclusions of Law, it is
RECOMMENDED that the Agency for Health Care Administration enter a final order denying Certificate of Need Application Number 9248 filed by BRCH, Certificate of Need Application Number 9249 filed by Martin Memorial, and Certificate of Need Application Number 9250 filed by Bethesda.
DONE AND ENTERED this 11th day of November, 2002, in Tallahassee, Leon County, Florida.
S
ELEANOR M. HUNTER
Administrative Law Judge
Division of Administrative Hearings The DeSoto Building
1230 Apalachee Parkway
Tallahassee, Florida 32399-3060
(850) 488-9675 SUNCOM 278-9675
Fax Filing (850) 921-6847 www.doah.state.fl.us
Filed with the Clerk of the Division of Administrative Hearings this 11th day of November, 2002.
COPIES FURNISHED:
Lealand McCharen, Agency Clerk Agency for Health Care Administration Fort Knox Building 3, Suite 3431
2727 Mahan Drive
Tallahassee, Florida 32308-5403
Valda Clark Christian, General Counsel Agency for Health Care Administration Fort Knox Building 3, Suite 3431
2727 Mahan Drive
Tallahassee, Florida 32308-5403
Gerald L. Pickett, Esquire
Agency for Health Care Administration
525 Mirror Lake Drive, North Sebring Building, Suite 310K St. Petersburg, Florida 33701
Lori C. Desnick, Esquire
Agency for Health Care Administration Fort Knox Building 3, Suite 3431
2727 Mahan Drive
Tallahassee, Florida 32308-5403
Stephen A. Ecenia, Esquire David Prescott, Esquire
Rutledge, Ecenia, Purnell & Hoffman, P.A.
215 South Monroe Street, Suite 420 Post Office Box 551
Tallahassee, Florida 32302-0551
W. David Watkins, Esquire
R. L. Caleen, Jr., Esquire Watkins & Caleen, P.A. 1725 Mahan Drive, Suite 201 Post Office Box 15828
Tallahassee, Florida 32317-5828
H. Darrell White, Esquire William B. Wiley, Esquire McFarlain & Cassedy, P.A.
305 South Gadsden Street Post Office Box 2174
Tallahassee, Florida 32316-2174
Paul H. Amundsen, Esquire Amundsen, Moore & Torpy, P.A.
502 East Park Avenue Post Office Box 1759
Tallahassee, Florida 32302
Robert D. Newell, Jr., Esquire Law Firm of Newell & Terry, P.A. 817 North Gadsden Street Tallahassee, Florida 32303-6313
C. Gary Williams, Esquire Michael J. Glazer, Esquire Ausley & McMullen
227 South Calhoun Street Post Office Box 391 Tallahassee, Florida 32302
Seann M. Frazier, Esquire Michael J. Cherniga, Esquire Greenberg Traurig, P.A.
101 East College Avenue Tallahassee, Florida 32302
NOTICE OF RIGHT TO SUBMIT EXCEPTIONS
All parties have the right to submit written exceptions within 15 days from the date of this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the Final Order in this case.
| Issue Date | Proceedings |
|---|---|
| Jul. 30, 2003 | Final Order filed. |
| Nov. 21, 2002 | Recommended Order issued (hearing held December 3-7, 10-14, and 17-21, 2001; January 7-11, 14-18, 22-23, and 28-29, and February 7-8, 2002 ) CASE CLOSED. |
| Nov. 21, 2002 | Recommended Order cover letter identifying hearing record referred to the Agency sent out. |
| Oct. 07, 2002 | Martin Memorial Medical Center, Inc`s Notice of Supplemental Authority filed. |
| Jul. 05, 2002 | Boca Raton Community Hospital, Inc.`s Proposed Recommended Order (reformatted) filed. |
| Jul. 05, 2002 | Boca Raton Community Hospital, Inc.`s Response to Motion to Strike Proposed Recommended Order filed. |
| Jul. 03, 2002 | Delray Medical Center`s and Palm Beach Gardens Medical Center`s Motion to Strike Boca Raton Community Hospital, Inc.`s Proposed Recommended Order filed. |
| Jul. 01, 2002 | Letter to Judge Hunter from R. Newell enclosing a diskette of a proposed recommended order filed. |
| Jun. 28, 2002 | Notice of Appearance and Substitution of Counsel (filed by L. Dresnick via facsimile). |
| Jun. 28, 2002 | Bethasda Healthcare System, Inc.`s Proposed Recommended Order filed. |
| Jun. 28, 2002 | Martin Memorial Medical Center, Inc.`s Proposed Recommended Order filed. |
| Jun. 28, 2002 | Agency for Health Care Administration`s Proposed Recommended Order (filed via facsimile). |
| Jun. 28, 2002 | Lawnwood Regional Medical Center`s and JFK Medical Center`s Joint Proposed Recommended Order filed. |
| Jun. 28, 2002 | Notice of Appearance and Substitution of Counsel (filed by L. Desnick via facsimile). |
| Jun. 28, 2002 | Menmorandum of Law in Support of Proposed Recommended Order Filed on Behalf of Delray Medical Center and Palm Beach Gardens Medical Center filed. |
| Jun. 28, 2002 | Proposed Recommended Order by Delray Medical Center and Palm Beach Gardens Medical Center filed. |
| Jun. 28, 2002 | Boca Raton Community Hospital, Inc.`s Proposed Recommended Order filed. |
| Jun. 10, 2002 | Order Denying Motion for Attorney`s Fees issued. |
| Jun. 03, 2002 | Letter to Judge Hunter from M Glazer, regarding motion to reopen as it relates to attorney fees filed. |
| Jun. 03, 2002 | Boca Raton Community Hospital, Inc.`s Renewed Motion for Attorney`s Fees and Response to Delray Medical Center`s Supplement to its Motion to Reopen the Record filed. |
| May 24, 2002 | Order Denying Motion to Reopen the Record issued. |
| May 23, 2002 | Martin Memorial Medical Center, Inc`s Memorandum of Law in Opposition to Tenant Healthsystem Hospitals, Inc.`s Suplement to its Motion to Reopen the Record filed. |
| May 21, 2002 | Tenet Healthsystem Hospitals, Inc. D/B/A Delray Medical Center`s Supplement to its Motion to Reopen the Record filed. |
| May 20, 2002 | Order Extending The Time to File Proposed Recommended Orders issued. (parties shall file proposed recommended orders by June 28, 2002) |
| May 16, 2002 | Notice of Telephonic Hearing filed by Intervenors. |
| May 16, 2002 | Tenet Healthsytem Hospitals, Inc. D/B/A Delray Medical Center`s Reply to Boca Raton`s and Martin Memorial`s Response in Opposition to Tenet`s Motion to Reopen the Record filed. |
| May 14, 2002 | Motion for Extension of Time to File Proposed Recommended Orders and Request for Expedited Ruling filed by Intervenors. |
| May 13, 2002 | Bethesda Healthcare System, Inc. d/b/a Bethasde Memorial Hospital`s Response in Support of Motion to Reopen the Record Based upon Newly-Discovered Evidence and to Schedule an Evidentiary Hearing (filed via facsimile). |
| May 13, 2002 | Martin Memorial Medical Center, Inc.`s Memorandum of Law in Opposition to Tenet Health System Hospitals, Inc.`s Motion to Reopen the Record filed. |
| May 13, 2002 | Baxo Raton`s Response in Opoposition to Tenet`s Motion to Re-open the Record, and Request for Attorney`s Fees filed. |
| May 09, 2002 | Order issued. (proposed recommended orders are due as scheduled) |
| May 06, 2002 | tenent Healthsystem Hospitals, Inc. D/B/A Delray Medical Center`s Motion to Reopen the Record Based upon Newly-Discovered Evidence and to Schedule an Evidentiary Hearing filed. |
| Apr. 30, 2002 | Notice of Change of Address filed by H White. |
| Apr. 01, 2002 | Transcripts (Volumes I through LIII) filed. |
| Jan. 04, 2002 | Cross Notice of Taking Deposition Duces Tecum, M. Schwartz filed. |
| Dec. 31, 2001 | Notice of Taking Deposition Duces Tecum, M. Schwartz filed. |
| Dec. 31, 2001 | Cross-Notice of Taking Deposition Duces Tecum (filed via facsimile). |
| Dec. 31, 2001 | Notice of Taking Deposition Duces Tecum, M. Schwartz filed. |
| Dec. 28, 2001 | Cross-Notice of Taking Deposition Duces Tecum, M. Schwartz (filed via facsimile). |
| Dec. 20, 2001 | Martin Memorial Medical Center, Inc.`s Notice of Cancellation of Deposition, S. Hopes filed. |
| Dec. 17, 2001 | Cross Notice of Taking Deposition Duces Tecum, S. Hopes (filed via facsimile). |
| Dec. 14, 2001 | Cross Notice of Taking Deposition, S. Hopes (filed via facsimile). |
| Dec. 14, 2001 | Martin Memorial Medical Center, Inc.`s Amended Notice of Taking Deposition Duces Tecum (Amended as to Date and Time Only) filed by S. Hopes. |
| Dec. 13, 2001 | Cross Notice of Taking Deposition, S. Hopes (filed via facsimile). |
| Dec. 13, 2001 | Martin Memorial Medical Center, Inc.`s Notice of Taking Deposition Duces Tecum, S. Hopes filed. |
| Dec. 04, 2001 | Response to Boca Raton Community Hospita;, Inc.`s Motion in Limine filed by Intervenor. |
| Dec. 03, 2001 | CASE STATUS: Hearing Held; see case file for applicable time frames. |
| Nov. 29, 2001 | (Joint) Pre-hearing Stipulation filed. |
| Nov. 28, 2001 | Notice of Cancellation of Deposition, S. Millstein filed. |
| Nov. 28, 2001 | AHCA`s Witness and Exhibit List (filed via facsimile). |
| Nov. 28, 2001 | Boca Raton Community Hospital, Inc.`s Motion in Limine (filed via facsimile). |
| Nov. 27, 2001 | Order Amending Pre-Hearing Order issued. |
| Nov. 27, 2001 | Notice of Taking Deposition, S. Milstein filed. |
| Nov. 26, 2001 | Re-Notice of Taking Deposition, S. Hopes (filed via facsimile). |
| Nov. 26, 2001 | Delray and PBGMC Response to Motion for Official Recognition filed. |
| Nov. 26, 2001 | Cross Notice of Taking Telephonic Deposition Duces Tecum, J. Styperek (filed via facsimile). |
| Nov. 26, 2001 | Cross Notice of Taking Deposition Duces Tecum, M. Weston (filed via facsimile). |
| Nov. 21, 2001 | Martin Memorial Medical Center, Inc.`s Request for Official Recognition filed. |
| Nov. 21, 2001 | Third Motion to Amend Prehearing Order (filed by Boca Raton Community Hospital via facsimile). |
| Nov. 21, 2001 | Cross Notice of Taking Deposition Duces Tecum, J. Styperek filed. |
| Nov. 21, 2001 | Notice of Taking Depositions Duces Tecum, M. Weston filed. |
| Nov. 21, 2001 | Notice of Taking Telephonic Deposition Duces Tecum, R. Brady filed. |
| Nov. 21, 2001 | Martin Memorial Medical Center, Inc.`s Amended Cross Notice of Taking Deposition, S. Hopes filed. |
| Nov. 21, 2001 | Notice of Taking Deposition, J. Rosser filed. |
| Nov. 21, 2001 | Amended Notice of Taking Deposition, Duces Tecum, S. Hopes (filed via facsimile). |
| Nov. 20, 2001 | Cross Notice of Taking Deposition (P. Cella) filed. |
| Nov. 20, 2001 | Cross Notice of Taking Deposition Duces Tecum, P. Cella filed. |
| Nov. 20, 2001 | Notice of Taking Telephonic Deposition Duces Tecum, J, Styperek filed. |
| Nov. 20, 2001 | Notice of Taking Deposition Duces Tecum, R. Asaf, D. Weiss filed. |
| Nov. 20, 2001 | Martin Memorial Medical Center, Inc.`s Cross Notice of Taking Deposition, S. Hopes filed. |
| Nov. 20, 2001 | Amended Notice of Taking Deposition Duces Tecum, R. Greene filed. |
| Nov. 20, 2001 | Notice of Taking Deposition Duces Tecum, S. Hopes filed. |
| Nov. 19, 2001 | Notice of Supplement to Witness List (filed by Petitioner via facsimile). |
| Nov. 19, 2001 | Notice of Intention to Use Summaries at Final Hearing (filed by Petitioner via facsimile). |
| Nov. 19, 2001 | Delray Medical Center`s Response to Boca Raton Community Hospital`s Request for Admissions filed. |
| Nov. 19, 2001 | Cross Notice of Taking Deposition Duces Tecum, R. Greene filed. |
| Nov. 19, 2001 | Cross Notice of Taking Deposition Duces Tecum, J. Rusin, R. Decerbo, P. Mercer filed. |
| Nov. 19, 2001 | Cross Notice of Taking Depositions Duces Tecum, E. Peterson filed. |
| Nov. 13, 2001 | Cross-Notice of Taking Deposition Duces Tecum 2 filed. |
| Nov. 13, 2001 | Martin Memorial Medical Center, Inc.`s Notice of Taking Deposition Duces Tecum filed. |
| Nov. 13, 2001 | Cross Notice of Taking Deposition Duces Tecum, R. Taylor, T. Hunter, P. Barlow, B. Eisenberger, M. Dutily filed. |
| Nov. 13, 2001 | Notice of Taking Deposition Duces Tecum, R. Greene, J. Rusin, R. Decerbo, P. Mercer filed. |
| Nov. 09, 2001 | Cross Notice of Taking Telephonic Deposition Duces Tecum (A. Lopman and J. Pierson) filed. |
| Nov. 09, 2001 | Notice of Taking Depositions Duces Tecum, R. Baehr, D. Weiner, D. Sullivan, C. Holloway filed. |
| Nov. 09, 2001 | Cross Notice of Taking Telephonic Deposition, Duces Tecum, A. Lopman, J. Pierson filed. |
| Nov. 09, 2001 | Notice of Taking Depositions Duces Tecum R. Taylor, T. Hunter, P. Barlow, B. Eisenberger, M. Dutily filed. |
| Nov. 05, 2001 | Cross Notice of Amended Notice ofTaking Deposition Duces Tecum (J. Gregg and E. Dudek) filed. |
| Nov. 05, 2001 | Cross Notice of Taking Deposition Duces Tecum, M Saltzman, R. Breenwald, T. Bartzokis filed. |
| Nov. 05, 2001 | Cross Notice of Taking Telephonic Depositions Duces Tecum filed. |
| Nov. 05, 2001 | Cross Notice of Taking Deposition Duces Tecum filed. |
| Nov. 05, 2001 | Cross Notice of Amended Notice of Taking Deposition Duces Tecum filed. |
| Nov. 02, 2001 | Cross-Notice of Taking Deposition Duces Tecum (T. Davidson, R. Brady and R. Knapp) filed. |
| Nov. 02, 2001 | Cross-Notice of Taking Deposition Duces Tecum (J. Gregg and E. Dudek) filed. |
| Nov. 02, 2001 | JFK Medical Center`s Responses to Martin Memorial Medical Center`s Request for Prodcution of Documents filed. |
| Nov. 02, 2001 | JFK Medical Center`s Answers to Martin Memorial`s First Set of Interrogatories filed. |
| Nov. 02, 2001 | JFK Medical Center`s Notice of Service of Answers to Martin Memorial Medical Center, Inc.`s First Set of Interrogatories filed. |
| Nov. 02, 2001 | Cross-Notice of Taking Deposition Duces Tecum J. Gregg filed. |
| Nov. 02, 2001 | Notice of Taking Telephonic Deposition Duces Tecum, A. Lopman, J. Pierson filed. |
| Nov. 02, 2001 | Amended Notice of Taking Deposition Duces Tecum, J. Gregg filed. |
| Nov. 02, 2001 | Notice of Taking Deposition, M. Saltzman, R. Greenwald, T. Bartzokis filed. |
| Nov. 01, 2001 | Lawnwood Regional Medical Center`s Supplement to Preliminary Witness List filed. |
| Nov. 01, 2001 | Notice of Taking Depositions Duces Tecum T. Davidsonfiled. |
| Nov. 01, 2001 | Cross Notice of Taking Depositions P. Cella, A. Balsano filed. |
| Nov. 01, 2001 | Delray Medical Center`s Response to Bethesda Healthcare System, Inc.`s Third Request for Production of Documents filed. |
| Oct. 31, 2001 | Order Granting Continuance and Re-scheduling Hearing issued (hearing set for December 3 through 7, 10 through 14, 17 through 20, 2001, January 7 through 11, 14 through 18, 22, and 23, 2002; 9:00 a.m.; Tallahassee, FL). |
| Oct. 30, 2001 | JFK Medical Center`s Objections to Cross Notice of Taking Deposition Duces Tecum filed. |
| Oct. 30, 2001 | Notice of Taking Deposition Duces Tecum A. Balsano filed. |
| Oct. 29, 2001 | Cross-Notice of Taking Deposition Duces Tecum (filed via facsimile). |
| Oct. 29, 2001 | JFK Medical Center`s Objections to Amended Notice of Taking Deposition Duces Tecum filed. |
| Oct. 29, 2001 | Lawnwood Regional Medical Center`s Objections to Amended Notice of Taking Deposition Duces Tecum filed. |
| Oct. 29, 2001 | Notice of Taking Deposition Duces Tecum (3) filed. |
| Oct. 29, 2001 | Notice of Taking Telephonic Deposition Duces Tecum filed. |
| Oct. 29, 2001 | Amended Notice of Taking Deposition Duces Tecum filed. |
| Oct. 29, 2001 | Boca Raton Community Hospital, Inc.`s Motion to Compel third Request for Production of Documents to TenetHealthsystem Hospitals, Inc. d/b/a Delray Medical Center filed. |
| Oct. 29, 2001 | Palm Beach Gardens Medical Center`s Notice of Service of Answers to Martin Memorial Medical Center`s First Interrogatories filed. |
| Oct. 29, 2001 | Palm Beach Gardens Medical Center`s Response to Martin Memorial Medical Center`s Request for Production of Documents filed. |
| Oct. 26, 2001 | Notice of Taking Deposition, Duces Tecum J. Hilsenbeck filed. |
| Oct. 26, 2001 | Answers to Bethesda Healthcare System, Inc.`s Renewed First Set of Interrogatories to Martin Memorial Medical Center, Inc. filed. |
| Oct. 26, 2001 | Martin Memorial Medical Center, Inc.`s Responses and General Objections to Bethesda Healthcare System, Inc.`s Second Request for Production of Documents to Martin Memorial Medical Center, Inc. filed. |
| Oct. 26, 2001 | Martin Memorial Medical Center, Inc.`s Notice of Service of Interrogatory Answers and Objections to Bethesda Healthcare System Inc.`s Renewed First Interrogatories filed. |
| Oct. 24, 2001 | Martin Memorial Medical Center, Inc.`s Motion to Reschedule Final Hearing filed. |
| Oct. 24, 2001 | Amended Cross Notice of Taking Depositions Duces Tecum (filed via facsimile). |
| Oct. 24, 2001 | Order Granting Continuance and Re-scheduling Hearing issued (hearing set for November 28 through 30, December 3 through 7, 10 through 14, 17 through 20, 2001, January 7 through 11, 14 through 18, 22, and 23, 2002; 9:00 a.m.; Tallahassee, FL). |
| Oct. 23, 2001 | Order Granting Intervention issued (Columbia/JFK Medical Center Limited Partnership, d/b/a JFK Medical Center). |
| Oct. 23, 2001 | Bethesda Healthcare System, Inc.`s Response to Martin Memorial Medical Center`s Request for Production (filed via facsimile). |
| Oct. 23, 2001 | Notice of Service of Bethesda Healthcare System, Inc`s Response to Martin Memorial Medical center`s First Set of Interrogatories (filed via facsimile). |
| Oct. 23, 2001 | Notice of Appearance ad Co-Counsel (filed by G. Pickett via facsimile). |
| Oct. 23, 2001 | Supplemental Motion to Reschedule Final Hearing filed by C. Williams |
| Oct. 23, 2001 | Notice of Change of Agency Position (filed by Respondent via facsimile). |
| Oct. 23, 2001 | Notice of Change of Agency Position (filed by Respondent via facsimile). |
| Oct. 23, 2001 | Cross Notice of Taking Depositions Duces Tecum (filed via facsimile). |
| Oct. 23, 2001 | Notice of Change of Agency Position (filed by Respondent via facsimile). |
| Oct. 22, 2001 | Cross Notice of Taking Depositions Duces Tecum (filed via facsimile). |
| Oct. 22, 2001 | Cross Notice of Taking Depositions Duces Tecum filed. |
| Oct. 22, 2001 | Boca Raton Community Hospital, Inc.`s, Response in Oppostion to Motion to Reschedule filed. |
| Oct. 22, 2001 | Martin Memorial Medical Center, Inc.`s Second Amended Preliminary Witness List filed. |
| Oct. 22, 2001 | Notice of Taking Deposition Duces Tecum, K. Keane, Dr. Helfman, S. Whitfield, E Hengtgen/P. Roderick, Dr. Gardner filed. |
| Oct. 22, 2001 | Amended Notice of Taking Telephonic Deposition Duces Tecum, C. Heinemann (amended to include time) filed. |
| Oct. 22, 2001 | Cross Notice of Taking Deposition, P. Roderick filed. |
| Oct. 22, 2001 | Cross Notice of Taking Telephonic Depositions Duces Tecum, Dr. Spotnitz, Dr. Dewar filed. |
| Oct. 22, 2001 | Martin Memorial Medical Center, Inc., Notice of Taking Deposition filed. |
| Oct. 22, 2001 | Amended Notice of Taking Telephonic Deposition Duces Tecum, Dr. Spotnitz, Dr. Dewar filed. |
| Oct. 22, 2001 | Notice of Taking Telephonic Deposition Duces Tecum, C. Heinemann filed. |
| Oct. 22, 2001 | Notice of Change of Agency Position (filed by Respondent via facsimile). |
| Oct. 19, 2001 | Notice of Taking Telephonic Deposition Duces Tecum filed by C. G. Williams. |
| Oct. 19, 2001 | Petitioner, Bethesda Healthcare System, Inc.`s Motion for Protective Order (filed via facsimile). |
| Oct. 19, 2001 | Boca Raton Community Hospital Inc.`s First Request for Admissions to Tenet Healthsystem Hospitals, Inc., d/b/a Delray Medical Center filed. |
| Oct. 19, 2001 | Motion to Reschedule (filed by Tenet HealthSystem Hospitals, Inc. via facsimile). |
| Oct. 18, 2001 | Amended Notice of Taking Deposition Duces Tecum as to Schedule A Only, G. Lynn filed. |
| Oct. 17, 2001 | Subpoena Duces Tecum, G. Lynn filed. |
| Oct. 17, 2001 | Notice of Taking Deposition Duces Tecum, G. Lynn filed. |
| Oct. 17, 2001 | Notice of Taking Deposition Duces Tecum, J. Gregg, K. Rivera, J. McLemore filed. |
| Oct. 17, 2001 | Notice of Cancellation of Depositions filed by Petitioners. |
| Oct. 17, 2001 | Amended Notice of Taking Deposition Duces Tecum (To Reflect Witness Changes on October 25th Only), M. Feldman, J. Newman, R. Blais, E. Szymcyzk, W. Gieseke, L. Cillo,M. Kamireddy, S. Baine, M. Dulaney (filed via facsimile). |
| Oct. 17, 2001 | Lawnwood Medical Center, Inc.`s Answers to Martin Memorial`s First Set of Interrogatories filed. |
| Oct. 17, 2001 | Lawnwood Medical Center`s Responses to Martin memorial Medical Center`s Request for Production of Documents filed. |
| Oct. 17, 2001 | Lawnwood Regional Medical Center, Inc.`s Notice of Service of Answers to Martin memorial medical Center, Inc.`s First Set of Interrogatories filed. |
| Oct. 15, 2001 | Cross Notice of Taking Depositions, Duces Tecum (filed via facsimile). |
| Oct. 15, 2001 | Notice of Taking Depositions, Duces Tecum, G. Spring, T. Hicks, T. Hunter, L. Beattie, R. Hill, M. McClory, G. Lynn, E. Ziacik (filed via facsimile). |
| Oct. 15, 2001 | Notice of Taking Depositions, Duces Tecum, M. Feldman, R. DeCerbo, J. Newman, R. Blais, W. Gieseke, L. Cillo, M. Kamireddy, S. Raine, M. Dulaney (filed via facsimile). |
| Oct. 11, 2001 | Palm Beach Gardens Medical Center`s Amended Preliminary Witness List filed. |
| Oct. 11, 2001 | Delray Medical Center`s Amended Preliminary Witness List filed. |
| Oct. 11, 2001 | Notice of Voluntary Dismissal (filed Petitioner via facsimile). |
| Oct. 09, 2001 | Notice of Taking Depositions Duces Tecum, T. Wharton filed. |
| Oct. 09, 2001 | Notice of Taking Depositions Duces Tecum filed. |
| Oct. 05, 2001 | cross Notice of Taking Depositions, N. Dgetluck, W. Grabowski, E. Belizar, F. Newstead, T. Corbin, K. Ripper, E. Hengtgen, J. Bradley, H. Helfman filed. |
| Oct. 05, 2001 | Notice of Service of Bethesda Healthcare System, Inc.`s Response to Delray Medical Center`s Second Set of Interrogatories filed. |
| Oct. 05, 2001 | Bethesda Healthcare System, Inc.`s Response to Delray Medical Center`s Third Request for Production of Documents filed. |
| Oct. 03, 2001 | Order Denying Motion for Continuance issued. |
| Oct. 03, 2001 | Martin Memorial Medical Center, Inc.`s Request for Production of Documents to Columbia/JFK Medical Center limited Partnership filed. |
| Oct. 03, 2001 | Notice of Service of Martin Memorial medical Center, Inc.`s First Set of Interrogatories to Columbia/JFK Medical Center Limited Partnership filed. |
| Oct. 03, 2001 | Bethesda Healthcare System, Inc.`s Third Request for Production of Documents to Tenet Healthsystem Hospital`s, Inc. d/b/a Delray medical Center filed. |
| Oct. 02, 2001 | Petition to Intervene filed by Columbia/JFK Medical Center Limited Partnership. |
| Oct. 02, 2001 | Martin Memorial Medical Center, Inc.`s Response to Palm Beach Garden Medical Center`s Third Request for Production of Documents filed. |
| Oct. 02, 2001 | Martin Memorial Medical Center, Inc.`s Notice of Service of Interrogatory Answers and Objections to Palm Beach Garden Medical Center`s Second Interrogatories filed. |
| Oct. 01, 2001 | AHCA`s Response to Bethesda`s Motion for Continuance (filed via facsimile). |
| Sep. 28, 2001 | Statement of Position (filed by Boca Raton Community Hospital via facsimile). |
| Sep. 27, 2001 | Delray Medical Center`s Response to the Request for Production of Documents From Boca Raton Community Hospital filed. |
| Sep. 27, 2001 | Notice of Taking Depositions Duces Tecum, C. Lynn and I. Gelb filed. |
| Sep. 26, 2001 | Indian River Memorial Hospital`s Response to Bethesda`s Motion for Continuance filed. |
| Sep. 25, 2001 | Second Order Amending Pre-Hearing Order issued. |
| Sep. 24, 2001 | Cross Notice of Taking Depositions Duces Tecum filed. |
| Sep. 24, 2001 | Bethesda healthcare System, inc.`s Motion for Continuance (filed via facsimile). |
| Sep. 21, 2001 | Notice of Appearance (filed by Boca Raton Community Hospital via facsimile). |
| Sep. 20, 2001 | Cross Notice of Taking Depositions Duces Tecum, D. Farber, F. Frederick, J. Mills, R. Caldwell, G. Futral, M. Noether (filed via facsimile). |
| Sep. 20, 2001 | Indian River Memorial Hospital`s Preliminary Witness List filed. |
| Sep. 20, 2001 | Delray Medical Center`s Preliminary Witness List (filed via facsimile). |
| Sep. 20, 2001 | Palm Beach Gardens Medical Center`s Preliminary Witness List (filed via facsimile). |
| Sep. 19, 2001 | Boca Raton Community Hospital Inc.`s Response to Delray Medical Center`s Third Request for Production of Documents filed. |
| Sep. 19, 2001 | Notice of Service of Answers to Delray Medical Center`s Second Set of Interrogatories to Boca Raton Community Hospital, Inc. filed. |
| Sep. 19, 2001 | Boca Raton Community Hospital Inc.`s Preliminary Witness List filed. |
| Sep. 19, 2001 | Martin Memorial Medical Center, Inc.`s Amended Preliminary Witness List filed. |
| Sep. 19, 2001 | Letter to Judge Hunter from R.D. Prescott concerning filing a Rsponse to Second Motion to Amend Prehearing Order, and inadvertently failing to attach Exhibit A filed. |
| Sep. 19, 2001 | Notice of Taking Depositions Duces Tecum, D. Farber, F. Frederick, J. Mills, R. Cadwell, G. Futral, and M. Noether filed. |
| Sep. 19, 2001 | Delray Medical Center`s Notice of Service of Answers to Boca Raton Community Hospital, Inc.`s Second Interrogatories filed. |
| Sep. 18, 2001 | Response to Second Motion to Amend Prehearing Order filed by Intervenors. |
| Sep. 17, 2001 | Bethesda Healthcare System, Inc.`s Second Request for Production of Documents to Martin Memorial Medical Center, Inc. (filed via facsimile). |
| Sep. 17, 2001 | Second Motion to Amend Prehearing Order (filed by Boca Raton Community Hospital, Inc. via facsimile). |
| Sep. 17, 2001 | Notice of Service of Bethesda Healthcare System, inc.`s Renewed First Set of Interrogatories to Martin Memorial Medical Center, Inc. (filed via facsimile). |
| Sep. 17, 2001 | Martin Memorial Medical Center, Inc.`s Request for Production of Documents to Palm Beach Gardens Community Hospital, Inc. filed. |
| Sep. 17, 2001 | Notice of Service of Martin Memorial Medical Center, Inc.`s First Set of Interrogatories to Palm Beach Gardens Community Hospital, Inc. filed. |
| Sep. 17, 2001 | Martin Memorial Medical Center, Inc.`s Request for Production of Documents to Bethesda Healthcare System, Inc. filed. |
| Sep. 17, 2001 | Notice of Service of Martin Memorial Medical Center, Inc.`s First Set of Interrogatories to Bethesda Healthcare System, Inc. filed. |
| Sep. 17, 2001 | Martin Memorial Medical Center, Inc.`s Request for Production of Documents to Lawnwood Medical Center, Inc. filed. |
| Sep. 17, 2001 | Notice of Service of Martin Memorial Medical Center, Inc.`s First Set of Interrogatories to Lawnwood Medical Center, Inc. filed. |
| Sep. 12, 2001 | Delray Medical Center`s Response to Boca Raton Community Hospital, Inc.`s Request for Production of Documents filed. |
| Sep. 07, 2001 | Notice of Appearance as Co-Counsel (filed by Martin Memorial Medical Center. Inc. via facsimile). |
| Aug. 30, 2001 | Notice of Appearance and Substition of Counsel (filed by Respondent via facsimile). |
| Aug. 28, 2001 | Boca Raton Community Hospital, Inc.`s Third Request for Production of Documents to Tenet Healthsystem Hospitals, Inc. d/b/a Delray Medical Center filed. |
| Aug. 20, 2001 | Boca Raton Community Hospital, Inc.`s Notice of Service of Second Interrogatories to Tenet Healthsystem Hospitals, Inc., d/b/a Delray Medical Center filed. |
| Aug. 17, 2001 | Delray Medical Center`s Third Request for Production of Documents to Boca Raton Community Hospital, Inc. filed. |
| Aug. 17, 2001 | Delray Medical Center`s Third Request for Production of Documents to Bethesda Healthcare System, Inc. filed. |
| Aug. 17, 2001 | Palm Beach Garden Medical Center`s Third Request for Production of Documents to Martin Memorial Medical Center, Inc. filed. |
| Aug. 17, 2001 | Palm Beach Gardens Medical Center`s Notice of Service of It`s Second Interrogatories to Martin Memorial Medical Center, Inc. filed. |
| Aug. 17, 2001 | Delray Medical Center`s Notice of Service of It`s Second Interrogatories to Boca Raton Community Hospital, Inc. filed. |
| Aug. 17, 2001 | Delray Medical Center`s Notice of Service of It`s Second Interrogatories to Bethesda Healthcare System, Inc. filed. |
| Aug. 07, 2001 | Notice of Change of Address filed by R. Rigsby |
| Jul. 02, 2001 | Martin Memorial Medical Center, Inc.`s Response to Lawnwood`s Second Request for Production filed. |
| Mar. 28, 2001 | Boca Raton Community Hospital, Inc.`s Withdrawal of its Second Request for Production of Documents to Tenet Healthsystem Hospitals, Inc., d/b/a Delray Medical Center filed. |
| Mar. 28, 2001 | Notice of Withdrawal of Bethesda Healthcare System, Inc.`s Second Request for Production of Documents to Tenet Healthsystem Hospital`s, Inc., d/b/a Delray Medical Center (filed via facsimile). |
| Mar. 27, 2001 | Palm Beach Garden Medical Center`s Withdrawal of Its Second Request for Production of Documents to Martin Memorial Medical Center, Inc. filed. |
| Mar. 27, 2001 | Delray Medical Center`s Withdrawal of Its Second Reqeust for Production of Documents to Boca Raton Community Hospital, Inc. filed. |
| Mar. 27, 2001 | Delray Medical Center`s Withdrawal of Its Second Request for Production of Documents to Bethesda Healthcare System, Inc. filed. |
| Mar. 26, 2001 | Order Granting Continuance and Re-scheduling Hearing issued (hearing set for November 26 through 30, December 3 through 7, 10 through 14, 17 through 21, 2001, January 7 through 11, 14 through 18 and 22 through 25, 2002; 9:00 a.m.; Tallahassee, FL). |
| Mar. 20, 2001 | Response to Motion for Continuance filed by C. Gary Williams and M.J. Glazer. |
| Mar. 20, 2001 | Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center and Lawnwood Medical Center, Inc. d/b/a Lawnwood Regional Medical Center`s Response to Martin Memorial Medical Center, Inc.`s Motion for Continuance filed. |
| Mar. 15, 2001 | Martin Memorial Medical Center, Inc.`s Motion for Continuance filed. |
| Mar. 07, 2001 | Bethesda Healthcare System, Inc.`s Second Request for Production of Documents to Tenet Healthsystem Hospital`s, Inc., d/b/a Delray Medical Center filed. |
| Mar. 05, 2001 | Boca Raton Community Hospital, Inc.`s Second Request for Production of Documents to Tenet Healthsystem Hospitals, Inc., d/b/a Delray Medical Center filed. |
| Mar. 02, 2001 | Delray Medical Center`s Second Request for Production of Documents to Boca Raton Community Hospital, Inc. filed. |
| Mar. 02, 2001 | Palm Beach Garden Medical Center`s Second Request for Production of Documents to Martin Memorial Medical Center, Inc. filed. |
| Mar. 02, 2001 | Delray Medical Center`s Second Request for Production of Documents to Bethesda Healthcare System, Inc. filed. |
| Sep. 27, 2000 | Notice of Filing (Proposed Rule Development) filed. |
| Sep. 25, 2000 | Order Granting Continuance and Re-Scheduling Hearing issued (hearing set for July 9 through August 31, 2001, 9:00 a.m., Tallahassee). |
| Sep. 21, 2000 | Notice of Cancelling Deposition Duces Tecum filed. |
| Sep. 21, 2000 | Notice of Cancelling Deposition Duces Tecum filed. |
| Sep. 19, 2000 | Response to Boca Raton Community Hospital Ins.`c Motion to Continue Final Hearing filed. |
| Sep. 15, 2000 | Boca Raton Community Hospital Inc.`s Motion to Continue Final Hearing filed. |
| Sep. 15, 2000 | Notice of Telephonic Hearing filed by H. White. |
| Sep. 15, 2000 | (M. Glazer) Notice of Taking Depositions Duces Tecum filed. |
| Aug. 21, 2000 | Bethesda Healthcare System, Inc.`s Response to Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center`s Second Request for Production of Documents filed. |
| Jul. 21, 2000 | Martin Memorial Medical Center, Inc.`s Response to Lawnwood Medical Center, Inc.`s First Request for Production of Documents filed. |
| Jul. 21, 2000 | Martin Memorial Medical Center, Inc.`s Notice of Service of Interrogatory Answers and General objections to Lawnwood Medical Center, Inc. filed. |
| Jul. 18, 2000 | Boca Raton Community Hospital Inc.`s Response to Delray Medical Center`s First Request for Admissions filed. |
| Jul. 17, 2000 | Bethesda Healthcare System, Inc.`s Response to Delray Medical Center`s First Request for Admissions filed. |
| Jul. 17, 2000 | Martin Memorial Medical Center, Inc.`s Response to Palm Beach Gardens Medical Center`s First Request for Admissions filed. |
| Jul. 14, 2000 | Amended Order Granting Continuance and Re-Scheduling Hearing Order sent out. (hearing set for January 8 through 11, 2001; January 16 through 19; 2001; January 22 through 26, 2001; January 29 through February 2; 2001; February 5 through February 8, 2001; F |
| Jul. 14, 2000 | Delray Medical Center`s Response to Boca Raton Community Hospital, Inc.`s First Request for Production of Documents filed. |
| Jul. 11, 2000 | Lawnwood Medical Center, Inc. d/b/a Lawnwood Regional Medical Center and Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center`s Notice of Cancelling Cross-Notice of Taking Deposition Duces Tecum filed. |
| Jul. 10, 2000 | Bethesda Healthcare Systems, Inc.`s Notice of Postponement of Deposition Duces Tecum filed. |
| Jul. 07, 2000 | Order Granting Continuance and Re-scheduling Hearing sent out. (hearing set for January 8 through 11, 2001; January 16 through 19, 2001; January 22 through 26, 2001; January 29 through February 2, 2001; February 26 through March 2, 2001 1/8/01) |
| Jul. 07, 2000 | Notice of Cancelling Deposition Duces Tecum filed. |
| Jul. 06, 2000 | Notice of Service of Bethesda Healthcare System, Inc.`s Responses to JFK Medical Center`s First Interrogatories filed. |
| Jul. 06, 2000 | Bethesda Healthcare System, Inc.`s Response to Columbia/JFK Medical Center Limited Partnership d/b/a/ JFK Medical Center`s First Request for Production of Documents filed. |
| Jul. 03, 2000 | Notice of Taking Deposition Duces Tecum (Judy Horowitz) filed. |
| Jul. 03, 2000 | Notice of Taking Deposition Duces Tecum (Peggy Cella) filed. |
| Jun. 30, 2000 | Order Closing File (CLOSING DOAH Case No. 00-0460 ONLY) issued. |
| Jun. 30, 2000 | Notice of Telephonic Hearing filed. |
| Jun. 30, 2000 | Bethesda Healthcare System`s Response Opposing Indian River memorial Hospital`s Motion to Continue Final Hearing filed. |
| Jun. 30, 2000 | Bethesda Healthcare System`s Notice of Withdrawing its Pending Motion in Limine filed. |
| Jun. 30, 2000 | Response of Columbia/JFK Medical Center Limited Partnership and Lawnwood Medical Center, Inc. to Indian River Memorial Hospital, Inc.`s Motion to Continue Final Hearing filed. |
| Jun. 30, 2000 | Lawnwood Medical Center, Inc. d/b/a Lawnwood Regional Medical Center and Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center`s Cross Notice of Taking Deposition Duces Tecum filed. |
| Jun. 30, 2000 | Palm Beach Gardens Community Hospital`s Response to Indian River Memorial Hospital`s Motion to Continue Final Hearing filed. |
| Jun. 30, 2000 | Delray Medical Center`s Response to Indian River Memorial Hospital`s Motion to Continue Final Hearing filed. |
| Jun. 29, 2000 | Notice of Voluntary Dismissal (Good Samaritan Hospital) filed. |
| Jun. 29, 2000 | Martin Memorial Medical Center, Inc.`s Memorandum in Support of Indian River Memorial Hospital, Inc.`s Motion for Continuance and Request for Telephonic Hearing filed. |
| Jun. 29, 2000 | Martin Memorial Medical Center, Inc.`s Petition to Intervene filed. |
| Jun. 28, 2000 | Martin Memorial Medical Center, Inc.`s Notice of Service of Interrogatory Answers and General Objections to Palm Beach Gardens filed. |
| Jun. 28, 2000 | Bethesda Healthcare System, Inc.`s Notice of Taking Deposition Duces Tecum-M. Jernigan filed. |
| Jun. 28, 2000 | Bethesda Healthcare System, Inc.`s Reply to Good Samaritan`s Response in Opposition to Bethesda`s Motion for Limine filed. |
| Jun. 28, 2000 | Martin Memorial Medical Center, Inc.`s Response to Palm Beach Garden Medical Center`s First Request for Production of Documents filed. |
| Jun. 27, 2000 | Petition to Determine Invalidity of Existing Rules filed. |
| Jun. 27, 2000 | Indian River Memorial Hospital, Inc`s Motion to Continue Final Hearing filed. |
| Jun. 26, 2000 | Bethesda Healthcare System, Inc.`s Motion and Memorandum of Law to Compel Good Samaritan Hospital`s Responses to Bethesda`s Discovery Request filed. |
| Jun. 23, 2000 | Boca Raton Community Hospital Inc.`s Amended Preliminary Witness List filed. |
| Jun. 23, 2000 | Columbia/JFK Medical Center Limited Partnership d/b/a/ JFK Medical Center`s Second Request for Production of Documents to Bethesda Healthcare System, Inc. filed. |
| Jun. 22, 2000 | Lawnwood Medical Center, Inc. d/b/a Lawnwood Regional Medical Center`s Second Request for Production of Documents to Indian River Memorial Hospital, Inc. filed. |
| Jun. 22, 2000 | Lawnwood Medical Center, Inc. d/b/a Lawnwood Regional Medical Center`s Second Request for Production of Documents to Martin Memorial Medical Center, Inc. filed. |
| Jun. 22, 2000 | Indian River Memorial Hospital`s Supplemental Preliminary Witness List filed. |
| Jun. 22, 2000 | Motion to Compel (filed by Palm Beach Gardens Community Hospital via facsimile) filed. |
| Jun. 21, 2000 | Supplement to Motion for Leave to Withdraw as Counsel for Good Samaritan Hospital, Inc. filed. |
| Jun. 21, 2000 | Motion for Leave to Withdraw as Counsel of Record for Good Samaritan Hospital, Inc. filed. |
| Jun. 19, 2000 | Lawnwood Medical Center, Inc. d/b/a Lawnwood Regional Medical Center`s Preliminary Witness List filed. |
| Jun. 19, 2000 | Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center`s Preliminary Witness List filed. |
| Jun. 19, 2000 | Indian River Memorial Hospital`s Preliminary Witness List filed. |
| Jun. 19, 2000 | Boca Raton Community Hospital Inc.`s Preliminary Witness List filed. |
| Jun. 19, 2000 | Good Samaritan`s Response in Opposition to Bethesda Motion in Limine filed. |
| Jun. 19, 2000 | Good Samaritan Preliminary Witness List filed. |
| Jun. 19, 2000 | Delray Medical Center`s Preliminary Witness List filed. |
| Jun. 19, 2000 | Palm Beach Gardens Medical Center`s Preliminary Witness List filed. |
| Jun. 19, 2000 | Martin Memorial Medical Center, Inc.`s, Preliminary Witness List filed. |
| Jun. 19, 2000 | Bethesda Healthcare System, Inc.`s Preliminary Witness List filed. |
| Jun. 19, 2000 | Indian River Memorial Hospital`s Preliminary Witness List filed. |
| Jun. 16, 2000 | Palm Beach Gardens Medical Center`s First Request for Admissions to Martin Memorial Medical Center, Inc. filed. |
| Jun. 16, 2000 | Palm Beach Gardens Medical Center`s First Request for Admissions to Good Samaritan Hospital, Inc. filed. |
| Jun. 16, 2000 | Delray Medical Center`s First Request for Admissions to Bethesda Healthcare System, Inc. filed. |
| Jun. 16, 2000 | Delray Medical Center`s First Request for Admissions to Boca Raton Community Hospital, Inc. filed. |
| Jun. 14, 2000 | Good Samaritan Written Responses and Legal Objections to the Written Discovery Request of Palm Beach Gardens filed. |
| Jun. 14, 2000 | Bethesda Healthcare System, Inc.`s Response to Boca Raton Community Hospital, Inc.`s First Request for Production of Documents filed. |
| Jun. 14, 2000 | Bethesda Healthcare System, Inc.`s Response to Boca Raton Community Hospital, Inc.`s First Request for Admissions filed. |
| Jun. 14, 2000 | Notice of Service of Bethesda Healthcare System, Inc.`s Responses to Boca Raton Community Hospital, Inc.`s First Set of Interrogatories filed. |
| Jun. 13, 2000 | Indian River Memorial Hospital`s Preliminary Witness List filed. |
| Jun. 12, 2000 | Bethesda Healthcare System, Inc.`s Response to Delray Medical Center`s First Request for Production of Documents filed. |
| Jun. 12, 2000 | Notice of Service of Bethesda Healthcare System, Inc.`s Responses to Delray Medical Center`s First Interrogatories filed. |
| Jun. 12, 2000 | Notice of Service of Answers to Delray Medical Center`s First Set of Interrogatories to Boca Raton Community Hospital, Inc. filed. |
| Jun. 07, 2000 | Order sent out. (unopposed motion for extension of time to file response to Bethesda`s motion in limine is granted, good Samaritan hospital shall file response to Bethesda`s motion in limine by June 19, 2000) |
| Jun. 06, 2000 | Boca Raton Community Hospital, Inc.`s First Request for Production of Documents to Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center filed. |
| Jun. 06, 2000 | Boca Raton Community Hospital, Inc.`s Notice of Service of First Interrogatories to Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center filed. |
| Jun. 02, 2000 | Unopposed Motion for Extension of Time to File Response to Bethesda`s Motion in Limine filed. |
| Jun. 02, 2000 | Boca Raton Community Hospital, Inc.`s Notice of Service of First Interrogatories to Tenet Healthsystem Hospitals, Inc., d/b/a Delray Medical Center filed. |
| Jun. 02, 2000 | Boca Raton Community Hospital, Inc.`s First Request for Production of Documents to Tenet Healthsystem Hospitals, Inc. d/b/a Delray Medical Center filed. |
| Jun. 01, 2000 | Order Amending Pre-Hearing Order sent out. |
| Jun. 01, 2000 | Bethesda Healthcare System, Inc.`s Motion in Limine and Memorandum of Law to Exclude Evidence by Good Samaritan Hospital, Inc., Regarding Therapeutic Cardiac Catheterization filed. |
| Jun. 01, 2000 | Indian River Memorial Hospital, Inc.`s First Request for Production of Documents to Lawnwood Medical Center, Inc. d/b/a Lawnwood Regional Medical Center filed. |
| Jun. 01, 2000 | Notice of Service of Indian River Memorial Hospital, Inc.`s First Set of Interrogatories to Lawnwood Medical Center, Inc. d/b/a Lawnwood Regional Medical Center filed. |
| May 26, 2000 | Lawnwood Medical Center, Inc. d/b/a Lawnwood Regional Medical Center`s First Request for Production of Documents to Martin Memorial Medical Center, Inc. filed. |
| May 26, 2000 | Lawnwood Medical Center, Inc. d/b/a Lawnwood Regional Medical Center`s Notice of Service of First Set of Interrogatories to Martin Memorial Medical Center, Inc. filed. |
| May 26, 2000 | Lawnwood Medical Center, Inc. d/b/a Lawnwood Regional Medical Center`s First Request for Production of Documents to Indian River Memorial Hospital, Inc. filed. |
| May 26, 2000 | Lawnwood Medical Center, Inc. d/b/a Lawnwood Regional Medical Center`s Notice of Service of First Set of Interrogatories to Indian River Memorial Hospital, Inc. filed. |
| May 26, 2000 | Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center`s First Request for Production of Document to Boca Raton Community Hospital, Inc. filed. |
| May 26, 2000 | Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center`s Notice of Service of First Set of Interrogatories to Boca Raton Community Hospital, Inc. filed. |
| May 26, 2000 | Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center`s First Request for Production of Documents to Good Samaritan Hospital, Inc. filed. |
| May 26, 2000 | Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center`s Notice of Service of First Set of Interrogatories to Good Samaritan Hospital, Inc. filed. |
| May 26, 2000 | Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center`s First Request for Production of Documents to Bethesda Healthcare System, Inc. filed. |
| May 26, 2000 | Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center`s Notice of Service of First Set of Interrogatories to Bethesda Healthcare System, Inc. filed. |
| May 18, 2000 | Notice of Change of Address filed. |
| May 15, 2000 | Good Samaritan`s Response to Motion to Amend Pre-Hearing Order filed. |
| May 12, 2000 | Delray Medical Center`s First Request for Production of Documents to Bethesda Healthcare System, Inc. filed. |
| May 12, 2000 | Delray Medical Center`s Notice of Service of Its First Interrogatories to Bethesda Healthcare System, Inc. filed. |
| May 12, 2000 | Delray Medical Center`s First Request for Production of Documents to Boca Raton Community Hospital, Inc. filed. |
| May 12, 2000 | Delray Medical Center`s Notice of Service of Its First Interrogatories to Boca Raton Community Hospital, Inc. filed. |
| May 12, 2000 | Palm Beach gardens Medical Center`s First Request for Production of Documents to Indian River Memorial Hospital, Inc. filed. |
| May 12, 2000 | Palm Beach Gardens Medical Center`s Notice of Service of Its First Interrogatories to Indian River Memorial Hospital, Inc. filed. |
| May 12, 2000 | Palm Beach Gardens Medical Center`s First Request for Production of Documents to Good Samaritan Hospital, Inc. filed. |
| May 12, 2000 | Palm Beach Gardens Medical Center`s Notice of Service of Its First Interrogatories to Good Samaritan Hospital, Inc. filed. |
| May 12, 2000 | Palm Beach Garden Medical Center`s First Request for Production of Documents to Martin Memorial Medical Center filed. |
| May 12, 2000 | Palm Beach Gardens Medical Center`s Notice of Service of Its First Interrogatories to Martin Memorial Medical Center, Inc. filed. |
| May 11, 2000 | Notice of Service of Bethesda Healthcare System, Inc.`s Responses to Indian River Memorial Hospital, Inc.`s First Set of Interrogatories filed. |
| May 11, 2000 | Bethesda Healthcare System, Inc.`s Responses to Indian River Hospital, Inc.`s First Set of Interrogatories filed. |
| May 11, 2000 | Bethesda Healthcare System, Inc.`s Response to Indian River Memorial Hospital, Inc.`s First Request for Admissions filed. |
| May 08, 2000 | Indian River Memorial Hospital, Inc.`s Response to Bethesda Healthcare System, Inc.`s First Request for Production of Documents filed. |
| May 08, 2000 | Notice of Service of Indian River Memorial Hospital, Inc.`s Answers to First Interrogatories From Bethesda Healthcare System, Inc. filed. |
| May 08, 2000 | Indian River Memorial Hospital, Inc.`s Response to Bethesda Healthcare System, Inc.`s First Request for Admissions filed. |
| May 03, 2000 | (W. Watkins) Motion to Amend Pre-Hearing Order filed. |
| Apr. 24, 2000 | Martin Memorial Medical Center, Inc.`s Responses to Bethesda Healthcare System, Inc.`s Request for Production of Documents filed. |
| Apr. 24, 2000 | Martin Memorial Medical Center, Inc.`s Responses to Bethesda Healthcare System, Inc.`s Request for Admissions filed. |
| Apr. 24, 2000 | Martin Memorial Medical Center, Inc.`s Notice of Service of Interrogatory Answers and Objections to Bethesda Healthcare System, Inc. filed. |
| Apr. 24, 2000 | (H. White) Notice of Service of Answers to Bethesda Healthcare System, Inc.`s First Set of Interrogatories to Boca Raton Community Hospital, Inc. filed. |
| Apr. 24, 2000 | Boca Raton Community Hospital Inc.`s Response to Bethesda Healthcare System, Inc.`s First Request for Admissions filed. |
| Apr. 24, 2000 | Boca Raton Community Hospital Inc.`s Response to Bethesda Healthcare System, Inc`s First Request for Production of Documents filed. |
| Apr. 17, 2000 | JFK Medical Center`s Responses to Bethesda Memorial Hospital`s First Request for Production of Documents filed. |
| Apr. 17, 2000 | JFK Medical Center`s Responses to Bethesda Memorial Hospital`s Request for Admissions filed. |
| Apr. 17, 2000 | JFK Medical Center`s Answers to Bethesda Memorial Hospital`s First Set of Interrogatories filed. |
| Apr. 13, 2000 | Boca Raton Community Hospital Inc.`s First Request for Production of Documents to Bethesda Healthcare System, Inc. filed. |
| Apr. 13, 2000 | Boca Raton Community Hospital Inc.`s First Request for Admissions to Bethesda Healthcare System, Inc. filed. |
| Apr. 13, 2000 | Notice of Service of Boca Raton Community Hospital Inc.`s First Interrogatories to Bethesda Healthcare System, Inc. filed. |
| Apr. 11, 2000 | Good Samaritan`s Response to Bethesda`s First Set of Interrogatories filed. |
| Apr. 11, 2000 | UCH`s Reply to Brandon`s Response to UCH`s Motion to Compel filed. |
| Apr. 11, 2000 | Good Samaritan`s Response to Bethesda`s First Request for Production of Documents filed. |
| Apr. 11, 2000 | Good Samaritan`s Response to Request for Admissions by Bethesda filed. |
| Apr. 07, 2000 | Delray Medical Center`s Response to Bethesda Healthcare System, Inc.`s First Request for Admissions filed. |
| Apr. 07, 2000 | Delray Medical Center`s Response to Bethesda Healthcare System, Inc.`s First Request for Production of Documents filed. |
| Apr. 07, 2000 | Delray Medical Center`s Notice of Service of Answers to Bethesda Healthcare System, Inc.`s First Interrogatories filed. |
| Mar. 14, 2000 | Indian River Memorial Hospital, Inc.`s First Request for Production of Documents to Bethesda Healthcare System, Inc. filed. |
| Mar. 14, 2000 | Notice of Service of Indian River Memorial Hospital, Inc.`s First Interrogatories to Bethesda Healthcare System, Inc. filed. |
| Mar. 10, 2000 | Bethesda Healthcare System, Inc.`s Request for Admissions to Good Samaritan Hospital, Inc. filed. |
| Mar. 10, 2000 | Notice of Service of Bethesda Healthcare System, Inc`s First Set of Interrogatories to Good Samaritan Hospital, Inc. filed. |
| Mar. 10, 2000 | Bethesda Healthcare System, Inc`s First Request for Production of Documents to Good Samaritan Hospital, Inc. filed. |
| Mar. 10, 2000 | Notice of Service of Bethesda Healthcare System, Inc`s First Set of Interrogatories to Boca Raton Community Hospital, Inc. filed. |
| Mar. 10, 2000 | Bethesda Healthcare System, Inc`s First Request for Production of Documents to Boca Raton Community, Inc. filed. |
| Mar. 10, 2000 | Bethesda Healthcare System, Inc.`s Request for Admissions to Boca Raton Community Hospital, Inc. filed. |
| Mar. 10, 2000 | Bethesda Healthcare System, Inc`s First Request for Production of Documents to Indian River Memorial Hospital, Inc. filed. |
| Mar. 10, 2000 | Bethesda Healthcare System, Inc.`s Request for Admissions to Indian River Memorial Hospital, Inc. filed. |
| Mar. 10, 2000 | Notice of Service of Bethesda Healthcare System, Inc`s First Set of Interrogatories to Indian River Memorial Hospital, Inc. filed. |
| Mar. 10, 2000 | Bethesda Healthcare System, Inc.`s Request for Admissions to Martin Memorial Medical Center, Inc. filed. |
| Mar. 10, 2000 | Bethesda Healthcare System, Inc`s First Request for Production of Documents to Martin Memorial Medical Center, Inc. filed. |
| Mar. 10, 2000 | Notice of Service of Bethesda Healthcare System, Inc`s First Set of Interrogatories to Martin Memorial Medical Center, Inc. filed. |
| Mar. 08, 2000 | Notice of Service of Bethesda Healthcare System, Inc.`s First set of Interrogatories to Tenet Healthsystem Hospitals, Inc. d/b/a Delray Medical Center filed. |
| Mar. 08, 2000 | Bethesda Healthcare System, Inc.`s First Request for Admissions to Tenet Healthsystem Hospitals, Inc. d/b/a Delray Medical Center filed. |
| Mar. 08, 2000 | Bethesda Healthcare System, Inc.`s First Request for Production of Documents to Tenet Healthsystem Hospitals, Inc. d/b/a Delray Medical Center filed. |
| Mar. 08, 2000 | Notice of Service of Bethesda Healthcare System, Inc.`s First Set of Interrogatories to Columbia JFK Medical Center Limited Partnership d/b/a JFK Medical Center filed. |
| Mar. 08, 2000 | Bethesda Healthcare System, Inc.`s First Request for Admissions to Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center filed. |
| Mar. 08, 2000 | Bethesda Healthcare System, Inc.`s First Request for Production of Documents to Columbia/JFK Medical Center Limited Partnership d/b/a JFK Medical Center filed. |
| Mar. 03, 2000 | Order Granting Intervention issued. (Lawnwood Medical Center) |
| Mar. 03, 2000 | Order Granting Intervention issued. (Tenet Healthsystem) |
| Mar. 03, 2000 | Order Granting Intervention sent out. (Palm Beach Gardens Community Hospital) |
| Mar. 03, 2000 | Notice of Hearing sent out. (hearing set for September 12 through 27, 2000 and October 2 through November 10, 2000 (excluding October 19 and 20, 2000) 9:00 a.m; Tallahassee) 9/12/00) |
| Mar. 03, 2000 | Order of Pre-hearing Instructions sent out. |
| Mar. 03, 2000 | Order of Consolidation sent out. (Consolidated cases are: 00-000459, 00-000460, 00-000461, 00-000462, 00-000463) |
| Feb. 09, 2000 | Joint Response to Initial Orders and Motion for Consolidation (Cases requested to be consolidated: 00-459, 00-460, 00-461, 00-462, 00-463) filed. |
| Feb. 01, 2000 | Petition to Intervene (Columbia/JFK Medical Center) filed. |
| Feb. 01, 2000 | (Tenet Healthsystem Hospitals, Inc. d/b/a Delray Medical Center) Petition to Intervene filed. |
| Feb. 01, 2000 | Initial Order issued. |
| Jan. 28, 2000 | Notice of Related Petitions filed. |
| Jan. 28, 2000 | Petition for Formal Administrative Hearing filed. |
| Jan. 28, 2000 | Notice filed. |
| Jan. 28, 2000 | Notice of Related Petitions (00-0459, 00-0460, 00-0461, 00-0462, 00-0463) filed. |
| Issue Date | Document | Summary |
|---|---|---|
| Jul. 29, 2003 | Agency Final Order | |
| Nov. 21, 2002 | Recommended Order | With four existing open heart programs all CON-approved, well dispersed geographically, declining in case volumes, and a new program at approximately 350 cases, no need established for another open heart provider in AHCA District 9. |
