Suburban Hospital in Bethesda should get state approval for a new open-heart surgery program, according to a recommendation yesterday by Larry Ginsburg, a member of the Maryland Health Care Commission, who conducted hearings on the issue.

Three other hospitals have applied, and the full commission will vote next month on which of the four will get the program. The others - Holy Cross Hospital in Silver Spring, Shady Grove Adventist Hospital in Rockville and Southern Maryland Hospital Center in Clinton - will get another chance to make pitches for their programs before the decision is made.

The Ginsburg recommendation brings closer to conclusion a process begun by the commission more than two years ago. The commission limits the number of hospitals that can perform open-heart surgery because such programs are expensive to set up and operate and because research has found that high-volume programs tend to have better results. Periodically, the commission reviews its health plan to determine whether more programs are needed.

Each time, there's a debate between the "haves" and "have-nots" - hospitals that have programs saying they can meet future needs, and hospitals that don't have programs saying patients need more.

"All the haves are going to say, 'No way'; all the have-nots are going to say, 'Yes,' " said Michael J. Chiaramonte, executive vice president at Southern Maryland Hospital Center.

Mike Hall, manager of media and community relations at Holy Cross, said his hospital could provide the best access to under-served populations.

Chiaramonte said his hospital is best positioned to serve 900,000 Marylanders south of the Capital Beltway.

Robert Jepsen, a spokesman for the Adventist Health System, said Shady Grove is best positioned to serve the rapidly growing population in upper Montgomery and Frederick County.

Beyond community needs, open-heart programs have business value to the hospital. "Is it lucrative? Sure," said Hall. "It's one of the few things in health care that is."

In this cycle, several Baltimore-area hospitals also were seeking open-heart programs, but the commission decided that another Maryland program was needed only in the Washington suburbs.

After the decision to select one new program, Ginsburg conducted seven days of public hearings and received thousands of pages of documents from the hospitals.

Ginsburg wrote that Suburban would have the least impact on existing programs and that a proposed research and program involving National Institutes of Health and Johns Hopkins Medicine would "attract both medical and surgical specialists of the highest caliber."

In the past, after the commission has voted, decisions have generally been subject to court challenges from hospitals whose requests aren't approved.

MedStar Health, which owns three hospitals with open-heart programs, has gone to court this time, arguing that the commission shouldn't have allowed a new program at all. MedStar lost in Howard County Circuit Court and has appealed. The Maryland Court of Appeals is scheduled to hear arguments in the case next month.