The Board of Tristers of the Health Manning Amoriation of Norther Olio (HANWO), on Ortolar 21, 1974. by a 15-5 vole, comended that the proposed project of Sandusky Memorial Hempt to add 24 medical-surgical beds, be disapproved.

Dr. Kenneth Krakoff, President of the Roard of Trustees, stated that the dinjitoval was not intended as an attack, on Sandusky Memorial Betal or on Samhusky, Ohio. It was taken because Sandusky, Ohio is presently badly over-bedded, with a supply of unused acute care beds nisting at Providence and Good Samaritan Hospitalx No capital rapemliber is reiptired to use these facilities, just a cooperative spirit. The drei-nes by the IPANWO's Board was to bring about further local consideration of the problem and to encourage sharing of facilities and services, as well as, promote better utilisation of these already built and available services

People who are concerned about the rising, costs of health care must male that the solution to these proldems are often in our own back yards. l'emple of Erie County do not have to look far to determine some of these factors in rising health care costs

The HPANWO is not taking a position which is to be regarded as attacking the osteopathic inedical profession or hospital. We recognize that many persons have exhibited a choter for care by ostropathic physicious, and we believe this care is of the highest quality. It is our opinion that dus care, can and should, where the situation indicates, be provided in any hospital in the community, as it is in other areas of Ohio and the Nation. The HFANWO realizes that Sandusky Menorial Nomit: A is in need of modernization and has supported that component of the plan

The Ohio Department of Health, itself, has said that there is a marjas of hoejais inds in die County now. HilANWO', in exipstion has mealed that esteopathic physicians may apply for hospital privile at Good Samaritan Hospital. A letter is on file at the IANWO office to dial effect. All general hospital facilities ought to be made to osteopathic physicians and the atmosphere ought to be one in which they feel comfortable.

The future of the matter appears to be that osteopaths and M.D.' and to some extent, the hospital, would rauier fight than switch. The HPANWO does not feel that such an attitude is mature, reasonable, nor in the best interests of the health of the people of Erie County and the Sandrisks area In the event agreement cannot be achieved, it is the responsibility of the comminuty to resolve this issue of what to do with the overlapping of beds.

On October 25, 1974, Dr. John Casuman iraed the following letter Ar. G. L Mylander, President of Sandusky Memorial Hospital Corporation:

The combined negative finding and positive recommendation is a result of our intention to clearly inheate the DPA's determination to support both the applicalde planning documents and the planning proerm while at the same time recognizing the severe spatial problems at Sandusky Memorial Hospital and the fact that several unique factors are operating in the comminaty which seem to preclude implementation of optimal janning entera at this time.

Please obser- that the DPA does not expect this decision to serve as the impetus the continued isolated planning by arra hormtals Instead, it is hope the events of the past several inonths have visildy dlustrated that community wide planning is a necessity, if healta care services are to be provided in an atinosphere that promotes quality yet fosters cost

Inasmuch as Section 100.106(c) of the Regulations provides the applicant with antunity for a fair hearing in the case of an adverse finding or 1 endation. I wish to advise you that a request for an appeal of 1. on to the Puldic Health Council must be received by the Di hin thirty (30) days of your receipt of this letter. The details or hearing proces, can be found in the Project Sponsor Guideline al forwarded to you earlier.

Please be advierd that I have charged my staff and the Health Manning Association of Northwest Ulo to follow in the future the degree to which the joint responsibility of arcawide planning and corndination of services and facilities is being achieved.

46-585 - 79 47

It has been my understanding aid that of the other volunteers and staff of the liealth Manning Aworiation of Northwest Ohio that there were very explicit requirements, both under this law and policies of the Department of Health, Education and Welfare, concernung comprebensive health plannoir, alwut the maintenance of high standards of health care and effective cost cuntrol measures. Consistent with this understanding, the prople of this myncy have undertaken several very exhaustive reviews and have taken and maintained some positions which were, at læst, unpleasant and, in some cases, damagire to personal and Inisiness telationships. Those of us who have been involved in these endeavors, have accepted thin as part of the price that must be paid in order to accomplish the planning for health to which we have all been committed.

The position which we took in this instance was arrived at after a series of very complete and difficult hearings. The denial of this application, as I hope you are aware, was based upon the conviction that if the community of Sandusky felt that Sandusky Memorial Hospital needed the additional beds it was incumbent upon that community to ⚫decirle and plan for consolidation of services and/or closure of beds that are not being utilized in the other area hospitals so as to represent no net increase in bed capacity in the area. The remodeling of the hospital was not an iwie; and as a matter of fact, it was muggested to the hospital that they might submit another application that encompassed the remodeling without the additional beda.

It is obvious that your position of not approving the application, but of not denying reimbursement, is de facto approval of the project. This being the case, you have not only denied support to this agency, Laut have very effectively subverted the entire thrust and meaning of comprehensive health planning. Had this situation arisen in an area that had not been labeled by the Insurance Commissioner of Ohio, in agrement with our data, as the most over-bedded county in the State, there might conceivably be some justification for it. But in the present circumstance, I can conceive of no valid reason for this art other than a concession to political pressure. The merits of this particular case were very clear under the requirements of the law; Department of Ilealu, Education and Welfare and Ohio regulations; and, indeed, common

This is the story of disagreement and ennflirt. It is viewed by mouse Northwest Ohio vermin Samlunk v Memorial Hospital of Toledo erama Sandusky. The farts are clear that this derisio wendel premet Sambe-Le Minorial Hospital to proceed, if supported by the Secretary of IEN and by Dr. Calmanı

The IIPANWO will continue to vigorously appear this progurt. because it feels that the counnanuty of Sandusky, its traders citizens, doctors and patients, should recome the need to work together in a cooperative spirit and for better health care and contred of health care rikk

The IIPANWO has never stated that we wish to prevent Sazalky Memorial Hospital from expansion, since we do trugure their needs as a unique institutum serving people of Northwest Ohio, W'r du, horart, state that some me of or adjusted use of existing services med fariators should be made before additional hospital beds are constructed in thr community. The III'ANWO does mupport the need for modernization and upgrading of the Sandusky Memorial Hospital's ancillary sTURE

The HPANWO) has not created the policy that we will not promit expansion of ustropathic hospital facilities, nor have we adopted a policy of forceful merger of M.D.'s and D.O.%. We do feel that all hospitals are provided and paid for by the community and that walk increasing expenses in health care, it is our responsibility to encumtræe a sharing consolidation to promote optimal use of these raprimer facilities Osteopathic hospitals will be approved for expation and enlargement in the future, depending on the demonstrated need and cooperative efforts shown.

What's the next step as we are it? The IIPANWO forks that the time hospitals in Sandusky, with medical staff, Board and civic leadership, should begin immediate discussions on cooperative effort in areas including emergency medical services. One emergency roum fuüv staffed and equipped would be superior to thee. Discussions an obstetrical services and pediatric services should be taking place to determine if a plan of consolidation can be achieved.

Medical staffing should be discussed and a climate of comperation should exist between M.D.'s and D.O.'s. The HPANWO believes that the leadership exists in the Sandusky area to do just that and we pledze aur assistance to that end.

The issue of what to do with remaining unused leds in Sandusky remains a serious one, which should also be cooperatively addPACE. This is not the time for planning by pressure group. It is the time for statesmanship, cooperation, and in the spirit of the season, a little real luvc

NOTE: This project is one of the first in Ohio, under P.L. 92603, which requires the 11PANWO's review, the State Health, Department's review and the Secretary of HEW's review, for health facility projets costing in excess of $100,000; which charges the number of linda, or substantially changes the services in a hospital. This project was approved by the Erie County Health Hansung Commeñ nd the Areawide Facilities and Services Committee of the IIPANWO, The Board of the PANWO is the final decision-making authority in Northwest Ohin on such projects, and it recomiended disapproval.

This article is presented to inform the readers of the Newsletter concerning this issue. We will be glad to print reactions to this article by perans wishing to commacht. All comuients erusi le nord and we vi exercise the right to choose those most representative of various pomte of view. The IIPANWO wishes to make it clear that its policy for a kd moratorium on hospitals in Northwest Ohio is still in effect and wei continue, in spite of this decision by Dr. Cashman and/or the Secretary of NEW.

OCTOBER 26, 1978

SPECIAL ISSUE

The Certificate of Need Council of the State of Iowa in a dramatic vote approved on October 26th the Des Moines General application for cardiovascular surgery. The 3-1 vote for approval came after a meeting of almost SIX hours of the CON Council and 1122 Review Committee. Strong opposition to approval of the project was presented by the Health Systems Agency representative and by the Chairman of the 1122 Committee. Des Moines General, however, argued that the CON law requires that providers (physicians and hospitals) and patients be given a freedom of choice between osteopathic services and allopathic services. The Hospital pointed out throughout its presentation that this is a basic right recognized and established by the Legislature and that this principle impacted on their consideration of the total project.

Mr. Kingsbury, in his comments, stated that this provision does not relieve Des Moines General from CON review nor does it mean that DMGH does not have to meet review standards. It does, however, mean that the committees must look at that issue as it relates to and perhaps modifies the other criteria for a certificate. In this particular case, for example, DMGH had established an osteopathic, unmet need that was going to be served. In addition, however, the Hospital had to demonstrate its ability to meet other CON criteria, such as financial feasibility and quality of the program. Des Moines General also made a strong case that its program could be implemented for an extremely low dollar amount ($80,000) and that its program would be cost-effective. The Hospital projects that it will serve 200-240 patients by three years after implementation. The Hospital also demonstrated that its program would not adversely affect the quality of care or financial feasibility of other existing programs,

APPROVAL WAS

A TEAM EFFORT

Throughout the process of planning for and seeking approval for the CV surgery program, the effort was one of a team approach. A substantial number of people from DMGH were involved in virtually all phases of the program. The "team approach" began with the Corporate Board and Board of Trustees making decisions and determining direction for the program. The Trustees also appointed a task force to look at the feasibility of developing the program, and that group met for several months early in 1978. A second administrative group was assembled in May and has worked for the past several months to work through the planning process. That group has had between 17-20 physicians and administrative people providing input and assistance.

From an administrative point of view, the team approach occurred with Mr. Kingsbury primarily handling the health planning process and presentations. Mr. Tate coordinating the preparation of the hospital for the actual operation of the program, and Mr. Lintjer providing the substantial research and written material necessary in seeking approval. In a similar manner, the legal counsel that has been involved in the CV issue has included several different people. Primary leadership in the legal area has come from Mr. George LaMarca of the Williams, Hart, Lavorato & Kirtley law firm. In addition to assistance from the attorneys and staff at Mr. LaMarca's firm, other assistance was provided by John Connolly III and Bernard Connolly, Jr. of the Connolly, O'Malley, Lillis & Hansen 1.rm (the Hospital's general counsel). Finally, Mr. Dick Thornton from the Stewart,

In addition to the osteopathic philosophy, the Hospital pointed out that its philosophy and approach is different in that it is incorporating its program into existing services and programs of the Hospital. This philosophy is opposed to the philosophies of some CV surgery programs of creating totally separate and new facilities and services exclusively for the CV surgery effort. This approach is financially advantageous and also has the benefit of strengthening many areas of the institution. DRAMATIC DECISION The decision came in a manner that could not have been more dramatic had it been directed by Hollywood! After the long and intense meeting, the discussion came to a close with an impassioned plea by an HSA Board member to deny the project. The 1122 Committee Chairman then asked for his group to make a motion regarding the application. Several minutes passed with no one making a motion or saying a word. The Chairman again asked for a motion and indicated he could wait a long time for such a motion. Again, several minutes passed with no motion and no discussion. Finally, one Board member raised several additional questions, received answers from Mr. Kingsbury and then made a motion for denial of the project. The motion was seconded and unanimously passed. That decision was and is unimportant in that it only gives approval for reimbursement for the equipment costs of the project (which are relatively minor). However, it seemed to present a bad omen for the critical decision of the CON group.

The Chairman of the CON Council, Mr. Wendell Benson, then called for his group to make a motion. Without hesitation, but in an extremely soft voice, Mrs. Frances Colston made a simple and direct motion for approval of the DMGH application for CV surgery. Although it sounds overly dramatic, the quietness of Mrs. Colston's voice and the drama of the I situation had virtually everyone in the room leaning forward on the edge of their seats. The motion was immediately seconded by Mrs. Constance Cissack of Clinton and a roll call vote was demanded.

The first voter, Mrs. Colston, voted YES; the second member voted NO; the third individual, Mrs. Cissack, voted YES and the final vote was to be cast by Mr. Benson, the Chairman. The possibility of a tie vote alone was surprising, and it was then apparent that would be the worst that would occur. In a loud and certain vote Mr. Benson indicated "The Chair votes YES."!!!!

The impact of that moment cannot be described but the group as a whole literally let out a sigh of relief. The sigh was one of frustration on the few who opposed our project and one of relief and joy of the many in the room who came to support Des Moines Genal. Again, although it sounds dramatic, it was a moment that few of those in the audience will forget.

POSSIBLE APPEAL After a short recess, the Health Systems Agency representative indicated that the HSA would appeal the decision. It was unclear at that time

and unclear at the time of this writing whether the HSA Board had authorized such an appeal or whether the individual speaking has the authority to make such a decision. It is also unclear what the grounds of such an appeal will be.

In relation to appeal, Mr. Kingsbury has indicated that "The CON decision is what counts. We now have a certificate to perform cardiovascular surgery." Mr. Kingsbury went on, "I question what grounds the HSA will appeal this decision on and whether the HSA even has standing to make such an appeal. I am also encouraged by the fact that the burden of proof is now on them and, finally, I am very confident in the strength of the record we have created in gaining the CON approval." Mr. Kingsbury also indicated he anticipates DMGH will proceed with plans for implementing the surgery and will work with the State in defending any appeal that might come along.

Perhaps most impressive was the substantial number of people who were involved in the actual presentation at formal planning meetings. Mr. Kingsbury indicated that at the final CON meeting there were 19 people who provided testimony or comments in person and a substantial number of others who provided written letters of support or information. Mr. Kingsbury, Dr. Dakovich, Dr. Loerke, Dr. LeMar, Dr. K. Brown, Mr. LaMarca and Mr. Thornton all provided a part of the detailed presentation. Each covered a particular area with Mr. Kingsbury coordinating the overall presentation and providing the concluding summary.

Dr. Burt Routman made comments from the perspective of the General Practitioner who is involved in referring potential cases. He, along with Doctors LeMar and Brown and other physicians, provided the perspective of freedom of choice of physicians to elect osteopathic -medical care. As further physician support, Dr. David McClain (President-Elect of the lowa Osteopathic Society) invited physicians from throughout the state to attend the meeting and represent their particular part of lowa. Dr. Julius Abramsohn, Dr. Dan Toriello, Dr. Patrick Frankl, Dr. Roger Rademacher, Dr. Ray Avera, Dr. G. Earl Jurgensen, Dr. John Campbell and Dr. David Wilson attended the CON meeting in that capacity. Each made a short presentation in support of the project and in support of the osteopathic profession and principles being presented by Des Moines General. A very effective letter was read from an osteopathic patient who will require cardiovascular surgery. indicating his preference for having such surgery done by an osteopathic physician. In addition, Phil Pletcher, Ph.D., made a personal presentation regarding his recently-completed open heart surgery. Dr. Pletcher also pointed out his right to choose between osteopathic and allopathic medicine and surgery. Finally, numerous letters of support were received from physicians throughout lowa in support of the project and the philosophy and approach being taken. Substantial use was also made of a survey of osteopathic physicans in lowa and their feelings regarding the project. An important letter was also received from Dr. Leonard Azneer, President of COMS, in support of the program and explaining its importance to the educational goal of COMS and DMGH. Supportive letters were also provided by Mr. Dwight Reigert of Davenport Osteopathic Hospital and Mr.Darrell Vondrak of Manning General Hospital.

D. Kurt Brown, D.O., Cardiovascular Surgeon
APPROVAL PROCESS:
LONG AND HARD

The approval process for the cardiovascular surgery project was one that was extremely long and difficult. It perhaps is an excellent example of a need for a new perspective between the scope of a project (that is, the

cost) and the need for an extensive approval process. A process that costs more to go through to gain approval than the cost of actual implementation of a project has to raise questions regarding the value and appropriateness of such a review project. Nevertheless, the health planning process is one that has been developed over many years of trial and error and consideration. It is one that is developed with the best of motives and with the community interest at heart. In the final analyis, perhaps the best summary of what occurred is that cardiovascular surgery became a symbol of what some planners saw as their obligation to restrict. The perception of some on the planning agencies was that cardiovascular surgery is extremely unique from all other kinds of surgery and is extremely expensive to implement. The planners have also struggled with a concept that says that one consolidated unit is better than two smaller units and that competition does not work in the health care field. In the review of DMGH's cardiovascular project, planners also had concern for the "precedent" they would establish by making a positive decision. In the end, however, the CON Council looked beyond these concerns and, apparently, addressed the facts as presented, and applied the law as they understood its simple, straightforward reading.

Whatever the causes, the process of developing the cardiovascular program and seeking its approval was perhaps the single most major project taken on by DMGH for the past twelve months.

The process began perhaps in the early 1970's when DMGH made a commitment to assist in the training of a D.O. cardiovascular surgeon. The commitment for a specific program at Des Moines General was formalized in September 1977 when the Corporate Board of DMGH resolved to do whatever necessary to initiate a cardiovascular program. Since that time presentations have been made at six different formal planning meetings to almost 100 different individuals over a span of more than two months. The formal meetings have lasted a total of almost 20 hours, and preparation for those meetings have undoubtedly been many times that amount. Numerous informal meetings were held with the staffs of the various agencies and countless individual meetings with people involved in some aspect of the project. The planning and preparation meetings within DMGH were beyond count but must have been well over 50. Mr. Kingsbury reported that the two CV groups met over 20 times and estimated that, considering the value of the participants' time, those meetings alone cost over $20,000.