WV Health Care Authority
ADDITION/RENOVATION/REPLACEMENT BEDS
CON STANDARDS MEETING
SONIA CHAMBERS: Okay. Why don't we go ahead and get started. I'm Sonia Chambers of the West Virginia
Health Care Authority and with me present here today. I have Sam Kapourales
board member of the Health Care Authority and is Marylyn on the phone>
MARYLYN
WHITE: I'm on the phone.
WHITE:
Isn't it
though.
SONIA CHAMBERS: What
I'd like to do is … I think most of the folks here have been to at least one of
these meetings, so I might not have to go through the whole why are we here and
what are we doing part. Basically to be
in agreement with the legislature, we are having meetings around the various
services that are covered by CON to let folks have their say whether they
should continue to be covered or not. So
that's the purpose of today's meeting as well as the other ones that we're
having. What we usually do is identify
ourselves here in the room. Let the
folks on the phone identify themselves, then Dayle or Tim—I notice Tim has his
highlighted. Tim today is going to
briefly go through the standards and then we will open it up for comments and
discussion. Also let me remind everybody
that we are recording these conversations.
The transcript will be available on our website. We would also invite folks to submit written
comments if you would like within the—we'd ask that you'd do those within 30
days, and as this is being recording if you would please identify yourself before
you make your comments, so that we can accurately attribute those comments to
you, and with that why don't we see who we have on the phone other than Marylyn
White. Anybody?
MARYLYN WHITE: I'm
all by myself, huh?
SONIA CHAMBERS: You're
all by yourself. Okay. Then we'll go around the room here. Why don't we start down this side?
DAYLE STEPP: Dayle
Stepp, CON Director.
TIM ADKINS: Tim
Adkins, CON Department.
SHEILA KELLY: Sheila
Kelly, CON Department.
NORA MCQUAIN: Nora
McQuain, Bureau for Medical Services.
KELLY JOHNSON:
Kelly Johnson, Bureau for Medical Services.
MARIANNE KAPINOS: Marianne
Kapinos, General Counsel, Health Care Authority.
CINDY DELLINGER: Cindy
Dellinger , Health Care Authority.
KAY MYERS: Kay
Myers, Health Care Authority.
ED HAMILTON: Ed
Hamilton,
JESSE KLINE: Jesse Kline, Consumer Advocate office.
MARTHA MORRIS: Martha
Morris, Consumer Advocate office.
SHAWN MCDANIEL: Shawn
JIM THOMAS: Jim
Thomas, Attorney for Jackson Kelly.
LINDSAY DARLING: Lindsay
Darling, Attorney for Jackson Kelly.
SONIA CHAMBERS: I
would also invite you all who are in the peanut gallery to come up and sit at
the table if you would like to, especially if you're gonna make comments. You might come up and get a little closer to
the microphone.
RAYMONA KINNEBERG: You
want David and I to identify ourselves.
SONIA CHAMBERS: Oh, yeah, sorry.
RAYMONA KINNEBERG: Raymona
Kinneberg for Bill Crouch and Associates.
DAVID JARRETT: David Jarrett, CAMC.
SONIA CHAMBERS: All
right, Tim.
TIM ADKINS: Okay. We had two sets of standards that we
will be discussing. The first one is the
addition of acute care beds, the lead methodology states that the authority
will not approve application for
additional acute care beds if the resulting number of - - acute care beds for
the hospital is equal to or exceeds 160% of the average daily census for
licensed acute care beds for the last 12 months period. It also says that the authority may grant an
exception to the 160% average daily census if the applicant has experienced
significant fluctuation and it's occupancy levels and A if the applicant is the
sole hospital in a county or, B, the applicant has exceeded an 85% acute care
occupancy level for two consecutive months during the past 12 months. It also says that in determining the average
daily census the hospital may adjust for observation equivalent days and swing
bed days. Under quality it states that
the applicant poses to add acute care beds to an existing facility must
demonstrate compliance with applicable licensing and certification
requirements. The applicant must
document the ability to recruit and employ any additional professional
personnel required to staff the additional beds for approval. The proposal must involve the provision of
space and related equipment for ancillary and support services, shown to be
appropriate for the projected patient load to the hospital. The applicant must also demonstrate that the
physical layout for the new beds is conducive to efficient staffing. Under continual care the applicant must
demonstrate that the proposal under construction is the less costly or most
appropriate alternative to provide. The
applicant must demonstrate that it has in place an effective utilization QA,
pure review and discharged planning.
Under calls, the applicant must demonstrate financial feasibility. The applicant must also demonstrate that the
capital related cost of the project are consistent to the authorities right
setting methodology in effect as of the date of application. Under costs also the applicant must submit
reliable probative and substantial evidence to demonstrate that the proposed
square footage cost—construction costs per square foot and costs for equipment
for all nursing units, ancillary services, and support services directly
effected by the proposal are appropriate and reasonable. Under B there are about ten other issues,
areas that needs to be discussed dealing with the physical layout, dealing with
–
SONIA CHAMBERS: We'll
just skip over that.
TIM ADKINS: Accessibility the proposal should not
adversely affect continued liability of an existing hospital or health care
services that served as population of at least 10,000, not having 30 minutes
access to another hospital or critical access hospital. Under alternatives, communities or entities
considering the addition of new acute care beds to serve a population that's
not presently accessible with a 30 minute driving time, shall first consider
less costly alternatives to the construction of the new facility or of the
space then there's also other areas that need to be addressed. Also in the addition of acute care beds there
are—there's a section that deals with specialized acute care that have
particular issues that need to be addressed.
The applicant—a hospital may change its bed complements within it's
approved licensed beds among specialized units for services that are currently
offered by the hospital and which do not cost the addition of new institutional
health services and areas that we're talking about pediatric tertiary,
pediatric care, NICU, OB critical care, - - , and long-term care.
SONIA CHAMBERS: All
from acute care.
TIM ADKINS: All
from acute care.
SONIA CHAMBERS: Okay.
TIM ADKINS: Excuse
me. Renovation and replacement of acute
care facilities and really the main difference is in the need of methodology
that's still similar, but some things have to be addressed. And renovation replacement of a acute care
facilities the authority will consider for approval proposals for renovations
or replacement of hospital beds if the
applicant submits reliable probative and substantial evidence that the project
is necessary and there are three areas that they must show that's
necessary. The services provided by the
applicant requires space or the facility requires replacement or renovation to
meet minimum requirements documented by written from appropriate crediting. There
are sufficient operating problems that can most effectively be corrected by the
proposed replacement. The replacement or
renovation is being proposed to correct deficiencies that place the facilities
patients or employees' health or safety at significant risk. And then under lead methodology again, the
authority will not approve any renovation or replacement dealing again with
160% average daily. An applicant must
removed acute care beds from it's licensed to meet the 160% requirement. If a removal of acute care beds from the
hospital's license would cause a breech of a covenant in a bond instrument or
other dead instrument to which the applicant is a party the removal of beds
from services may be used to meet the requirement of these standards. That applicant may grant an exception here
again if the applicant is the sole applicant in—the hospital's a sole hospital
in a county, if the applicant has exceeded 85% level, and critical access
hospitals are not subject to the requirements of section three. The remainder of the requirements are
basically the same as in addition.
SONIA CHAMBERS: Okay. Thank you very much. Okay.
Comments? Start over on this side
of the room. Come on up.
FEMALE VOICE: Do
you want comments or are you asking for question about—yes, do you believe that
both the addition of acute care beds - - will placate—
SONIA CHAMBERS: Okay.
David.
DAVID JARRETT: Yes,
we - - .
SONIA CHAMBERS: Even though it's a royal pain for you? All right.
- - .
FEMALE VOICE: With
the West Virginia Hospital Association my position this support continued a
review of specialty beds, - - beds, - - .
SONIA CHAMBERS:
Jim?
JIM THOMAS: I have no comment.
SONIA CHAMBERS: I
presume you don't either. Okay. Ed?
ED HAMILTON: Well,
we support the CON standards, perhaps not in their current form.
SONIA CHAMBERS: Okay.
ED HAMILTON: With
a slight modification.
SONIA CHAMBERS: Okay.
The question is whether the addition of acute care beds or the
renovation or replacement of acute care facilities and services should remain
reviewable?
ED HAMILTON: Yes, definitely.
SONIA CHAMBERS: Nora. You too Martha? Sorry.
I say that wrong all the time.
Okay. Anybody else who wishes to
just speak on that part? That was quick. Well, actually while we are here why
don't—are there—is anybody prepared to discuss particular portions of the
standards whether they should be visited.
Ed, I think you alluded to that in your comments.
ED HAMILTON: Well,
this is Ed Hamilton, Blue Cross Blue Shield.
One of the questions we have is when you looked at the uniform financial
reports and you see the occupancy.
ED HAMILTON: One
of the questions that we have that we've been pondering on an ongoing basis and
this is Ed Hamilton with Mountain State Blue Cross Blue Shield. When you look at the uniform financial
reports and you see occupancy rates they're following and I think that's
probably a function of increased technology,
services, moving to out-patient settings and in some instances to away from the
inpatient provider completely, but is there a methodology for dealing with the
elimination of excess capacity and who's responsible for doing that?
SONIA CHAMBERS: And actually it would be interesting to see
because I have—we don’t have our annual report for the legislature yet. That we deliver in December or January. I know that there has been—this is Sonia
Chambers, by the way. I know there has
been a—there is a very—a real discrepancy between licensed beds and setup and
staff beds, and those show up in those occupancy rates because for a long time
I think facilities were very reticent to get rid of any licensed beds and held
onto those. When we redid the standards in '02, we tried to set this—set the
standards to such that we would get a little more closer that licensed beds and
setup and staff beds that there would be more of a meaningful
relationship. Those numbers would be a
bit more—bit closer. So that any time a
facility came in for renovation or replacement they would have to get those
beds off of their license those access beds, the ones that were above that
160%--160% percentage and the purpose for that was to get those beds out of the
system. At the same time we then there
were a number of facilities that were concerned that they might get rid of
those beds. They would come off their
license, but then they might get a new service, get a new physician and that in
the past there was almost no way for them to put new beds, so we tried to make
that a more streamlined process, but if you were really bumping up against that
occupancy weight, you could get new beds and it wouldn't be impossible to do
so, so that is what we short of telling everybody if you don't—if you're not
using the beds get them off your license.
We tried to—we have been trying to do that through this process and I
think a lot of those beds have indeed come off of hospital licenses, so the
numbers—the number is getting a little closer.
I think that—so—
ED HAMILTON: And
I'm not—this is Ed Hamilton again. I'm
not really sure that it represents what we would call a real cost issue.
SONIA CHAMBERS: Right.
ED HAMILTON: 'Cause
obviously there's nobody in the bed you don't staff the bed.
SONIA CHAMBERS: Right.
ED HAMILTON: All
you're doing is maybe heating the building; don't even have to have the lights
on so to speak.
SONIA CHAMBERS: But I don't think—I don't think the
facilities. I don't think that's an
issue. I think those beds they just
don't exist. They aren't anywhere. They're—it's a fictitious number. It really doesn't mean anything, and the
difficulty on the uniform financial reports and our annual report is that we
don’t ask facilities to report to us their setup and staff bed number, which is
more of a real and meaningful number, than their licensed bed number. Again through the revisions of these
standards we were trying to get those numbers a little closer to each other, so
that they would make more sense. So that
is one thing that we have tried to do.
Anybody else want to add anything to that? The one other thing that I would say though
is we've looked at these occupancy rates and just heard from facilities. I think there is a—I think you will see differing—I
think you'd see a wide variation of occupancy rates.
ED HAMILTON: Is
that because the calculations?
SONIA CHAMBERS: No, I don’t think you did before. I think the tertiary facilities more and more
probably have pretty high occupancy rates particular in their critical care
units because they have been coming to us asking for more beds. I think some of the smaller facilities
probably have much lower occupancy rates.
And some of that I think is a function of the kind of care that's being
delivered and the way care is being delivered.
I think also part of that is the fact that large tertiary centers have
come in for more renovation and replacement projects and so have therefore had
to get those beds off the—those excess beds off their licenses. I think just anecdotally, we are seeing more
and more of the tertiary facilities are more often particularly in their
specialized or their high acuity beds are full and are sometimes closed to
diversion. Whereas I don’t think that's
the case with some of the smaller facilities that are predominantly have
regular medical surgical beds. I know
Dave does that sound reasonable accurate?
DAVID JARRETT: That's
very accurate. We've experienced a huge
need I believe in our CON for the 24 ICU that you guys have built in a
year. We have experienced 550 to 600 and
some requests for ICU beds, patients to come in and we had to turn away—we just
didn't have a bed for them and that was a six month period. We have the specials and you're outlying
facilities don't and they rely on us.
That's what we're there for. So
yeah, we have experienced a huge need for—
SONIA CHAMBERS: And
I think more and more care is either out-patient or it's high acuity. It seems to me that care is either on one of
those two ends of the spectrum.
ED HAMILTON: Yeah.
RAYMONA KINNEBERG: This
is Raymona Kinneberg; I just want to agree with what Sonia said. I've done a number of - - applications and
addressing the renovations and replacement standards a number of hospitals have
had to reduce beds and I think any hospital that's had a renovation project in
the last five years has had to reduce their beds for that 160%.
DAVID JARRETT: This
is David Jarrett with CAMC. We just gave
up 80, and we just got a new license last month. We turned in 89 to bring two ICU units on.
SONIA CHAMBERS: Right
I know WVU has had to give up a number of beds.
United did with their - - replacement, so there are a number of
facilities that have been having to do that, and again we decided that one of
the ways to do that because it wasn't an immediate cost issue was just to do it
through the CON process as people come in for renovation and replacements.
RAYMONA KINNEBERG: And
this is Raymona again. I think the other
thing is I think the time is right. Those
beds that aren't setup and staffed don't exist.
It's not that you're leaving the building unheated, they just aren't
there.
SONIA CHAMBERS: I had the very same question, Ed, when we went
through these in '02.
ED HAMILTON: Yeah.
SONIA CHAMBERS: You know one of the things that we have had
some discussion about and I'd be interested to know what other folks here think
is whether we ought to continue to have separate certificate of need standards
that if a hospital wants to change a its bed compliment within it's license,
like if a hospital wants to have more ICU beds, wants to convert some of them,
wants to have obstetrical beds, wants to do different things, whether that
facility ought to have to come in for CON.
Or whether we care.
RAYMONA KINNEBERG: This is Raymona. Those changes within the acute care beds
right now are handled as determination of reviewability, and the only reason
for doing that is so licensing knows that it's okay with that Health Care
Authority. It is a pretty simple
process. If you wanted to change that,
the only thing you'd have to do is tell OPHLAC that hospital isn't increasing
the number of beds and is staying within the kind of beds that they don't need
a decision from you 'cause that's the only reason they go through that process
is to get more of a change.
DAYLE STEPP: This
is Dayle. That's basically the only
reasons what we do that is so OPHLAC has something in their hand that says the
CLDs come through us and we've said it's not subject to any review or they've
gone through CON review.
RAYMONA KINNEBERG: That's
something that can be done between OPHLAC and the Health Care Authority.
ED HAMILTON: This
is Ed Hamilton with Mountain State Blue Cross Blue Shield. How often would a change like that approach
the threshold of $2 million in expense?
RAYMONA KINNEBERG: Right. Usually there's not enough money.
ED HAMILTON: That's what I was thinking too.
DAVID JARRETT: This
is David Jarrett, CAMC. I’m not sure we
have enough equipment to a typical acute care med surgery that upgraded to an
ICU would tip the $2 million. It just
doesn't seem like there would be that much and in what we recently added to - -
select specialty or specialty select was have to spend that much money.
RAYMONA KINNEBERG: This
is Raymona again. Again I think most of
those changes have been either for the critical care units or SYKE between
acute care or SYKE. Those are the two
that I'd see.
SONIA CHAMBERS: One
of the other I think things we've been looking at or discussing is the
threshold or the number in here for NICU beds and whether that ought to be
changed or not. I think they're—we have
heard from a number of the tertiary facilities those that have NICU that their
NICU are full, that they are having to divert out of state and that they need
to have some more flexibility. I think
on the flip side of that we've had some discussions with—well, with PEIA who is
more for whom it is costly to pay for an in state NICU bed than an out of state
NICU bed, but I think there's been some concern expressed on the part of
Medicaid that more NICU beds may mean more costs to Medicaid. That and since Medicaid is really the primary
payer Medicaid has a little concern about that.
MARIANNE KAPINOS: This
is Marianne Kapinos. We've also had for
the presence of the - - beds number 2 for some hospital.
RAYMONA KINNEBERG: This
is Raymona Kinneberg. That has to do
with renovations in particular.
MARIANNE KAPINOS: Right.
RAYMONA KINNEBERG: I
don’t think people in general are looking at really the problem you got. You got a lower threshold for
MALE VOICE: This is - - .
We operate Woman and Children's Hospital. When you look at the services offered
there. When you look at OB, you'll
notice some remarkable fluctuations service and when babies are born and what
basis we—if you look at it over the time—if you look at pediatric services,
it's just the way the ops hit and the flu season and different things and the
way they are just bombarded with patients at certain times, and certain times
they are less than half full. It's just
so darn hard to target how many beds they should have or anything, but we
don't—I mean right now if I had to come in for a project tot Woman and
Children's I would have to give up beds and I would think I would be giving up
beds that during another crunch time part of the year I would need. That we would have to turn children away if I
gave up those beds to renovate my NICU that we desperately need for beds, and
it's just very tough. It's a tough
service to look at and pin how many beds you should have.
SONIA CHAMBERS: Nora,
did you want to say something?
NORA:
Yes, this is Nora
with CMS. I heard you had requests of
additional NICU beds.
SONIA CHAMBERS: Yes.
NORA:
Recently.
SONIA CHAMBERS: Cabell
Huntington came and asked us about that and we had some discussions.
ED HAMILTON: WVU.
SONIA CHAMBERS: And
WVU did. We granted the increase to WVU
of NICU beds, and Cabell Huntington, too.
WVU was last year. Cabell was
this year. Anybody else?
MARYLYN WHITE: Sonia,
this is Marylyn, do we know the occupancy rate of the ICU and CCU beds, not the
NICU, but just the adult ICU and CCU beds?
Do we have any way of getting that information to get a grasp on are they
ICU or—
DAYLE STEPP: This is Dayle. I think if we look at the cost reports, we
have days and discharges on that.
MARYLYN WHITE: Uh-huh.
DAYLE STEPP: The
departments I think we can do a calculation to arrive at that.
MARYLYN WHITE: I
think it would be something if we're gonna make any changes or modifications,
thinking about does a hospital necessarily need to come through CON if they
want to, let's say, add five more as one of those beds. I think we ought to establish is there a need
because I have a feeling there might be, and we don't want them to go out of
state just because we won't let them have a bed.
RAYMONA KINNEBERG: This
is Raymona. Marylyn so far that hasn't been
an issue because of the 160% requirement. People that need ICU beds are simply
able to convert Med surg beds and I'm not aware of a situation where that's not
a problem. In addition, if they're over
160% and so they don't want to convert to med surg bed, they need to add. I'm not—the way the standard is currently
written that hasn't been a problem either.
MARYLYN WHITE: Okay. That's good.
MALE VOICE:
The only thing stopping us at the moment is space to locate a new unit. That and getting a CON approved.
SONIA CHAMBERS: All
right. Anything else? All right.
Appreciate everybody's time. The
next meeting is Wednesday and it is imaging.
1:00 to 3:00; correct? For
imaging. All right. You never know. All right.
Thanks, Marylyn.
MARYLYN WHITE: Uh-huh. Bye, bye.