HAGERSTOWN - When hospital construction projects are sent to state health planners for review, they're usually accompanied by letters of support from local elected officials.
The opposite was the case, however, for Washington County Hospital in Hagerstown, which plans to build a replacement facility just outside the current city limits. Far from forwarding warm endorsements on city letterhead, the Hagerstown government, which objected to the cost and location of the new hospital, jumped in to challenge the project.
The challenge by a hometown government appears to be unprecedented. It has kept Washington County Hospital tied up for two years - uncontested cases usually win clearance in a matter of months - and has led to changes in the project and the hospital's financing plans.
The protracted battle comes as the Maryland Health Care Commission has a task force studying its process for reviewing "certificates of need," or CONs, for major hospital projects, nursing homes and expensive high-end health services. The panel is considering how to streamline or modify the CON rules - or even eliminate CONs altogether, as some states have done.
The Hagerstown fight, or at least that phase of it, could end today, when the Maryland Health Care Commission votes on the Washington County proposal. In contested cases, the commission designates one of its members to review the proposal in detail, and the reviewer, Robert E. Nicolay, has recommended commission approval. The full commission usually goes along with the reviewer, and the city has agreed not to challenge the health planning review further.
Under pressure from the city's challenge, the hospital dropped a plan to add 30 beds and it is now seeking 267 beds, four less than the current licensed capacity. And state regulators approved only a 4.7 percent increase in hospital rates to finance the project, compared with 13.1 percent initially sought by the hospital.
"It was dramatic, confrontational, but we saved our residents that much money," said William M. Breichner, who led the fight as mayor until he was defeated for re-election last month.
"At this stage of the process with the state and the city, I don't want to sound negative," said James P. Hamill, president and chief executive of the hospital and its parent, Washington County Health System. "But we could have started last March, for $165 million."
Now, with inflation in construction costs, he said, the price tag for the smaller project is up to $235 million. And, Hamill said, the hospital estimates that each day of further delay costs the hospital about $15,000 more. He believes that rapid growth in the county population eventually will confirm that the now-dropped 30 additional beds are needed.
Even if the commission approves the project this week, the hospital has hurdles to clear, as it attempts to settle issues of zoning approval, water and sewer connections and road improvements with the Washington County and Hagerstown city governments.
One opponent, J. Michael Nye, who lives near the proposed site of the new hospital, promises a lengthy appeal if the hospital wins zoning approval from the county. "At a very minimum, this issue is not going to be resolved for three, and maybe five, years," he said.
In addition to the size and financing questions raised by the city, Nye and other neighbors have complained that the new hospital, which would be located on a campus with a medical office complex, would inappropriately bring ambulances, helicopters and more traffic into a suburban residential neighborhood.
But Ed Lough, president of the Hagerstown-Washington County Chamber of Commerce and one of three co-chairmen of Community Healthcare Coalition, a group that supports the hospital plans, said he is optimistic that state approval of the project will be the catalyst for solving the remaining issues. "Once the CON is issued, it's important for elected officials to get things done, to figure out ways to make this work," Lough said.
Even the project's opponents agree that the hospital needs replacement or extensive renovation. The existing hospital consists of seven interconnected buildings, built between 1935 and 1991. The emergency department, designed for 45,000 annual visits, expects about 70,000 this year - and has beds in its hallways to handle the patient load. Some of its patient rooms don't meet current code standards and have been converted to offices.
The new hospital would include a nursery that could handle newborns with problems such as low birth weight. (Such cases now usually go to Baltimore, Hamill said.) Beyond that, the services the hospital offers wouldn't change, Hamill said, but the hospital would be larger, more modern and more efficient.
Hamill said the location the hospital chose for the new facility, at the existing Robinwood Medical Center, would be best because the hospital already owns the land and it would be convenient for patients and staff to be located next to the mall-like complex where about 70 physicians already have offices. According to letters of support written to the health care commission by leaders of the medical staff, a poll of doctors found that 90 percent of those who responded supported the Robinwood site.
Like Washington County Hospital, many other Maryland hospitals are seeking additions, renovations and replacement sections to convert semiprivate rooms to private ones - more popular among consumers and better for infection control - and to create space for new technology and allow privacy and family participation in patient care.
Statewide, the Health Care Commission expects to have reviewed $2.7 billion worth of capital projects in the three years ending in 2005, compared with $734 million approved from 2000 to 2002.
The commission aims to help control health costs by ensuring that major capital projects are needed and that plans are cost-effective. Sometimes projects are challenged by competing hospitals, and CareFirst BlueCross BlueShield sometimes becomes involved by questioning projects it believes will drive up costs needlessly. CareFirst joined the city in challenging the Washington County case but is satisfied by the changes in size and financing, said Bruce Edwards, the insurer's senior vice president for provider network management.
The health planners can remember only one instance before the Washington County project when a local government intervened in a review - and that wasn't the government where the hospital in question was located.
Upper Chesapeake Health System proposed in 1996 closing a hospital in Fallston and opening a replacement in Bel Air. The government of Havre de Grace entered the proceedings to protect the hospital there, Harford Memorial. During the course of the review, Havre de Grace became satisfied that its hospital wasn't threatened, and it withdrew from the case, according to Pamela Barclay, the commission's deputy director for health resources.
Lewis C. Metzner, a member of the Hagerstown City Council, said city officials realized that "ultimately, we'd never be able to stop the hospital from getting a certificate of need. But [a challenge to the CON] was the only way to get them to the negotiating table," to talk about location, cost, roads and sewers.
The hospital became the most hotly argued issue in the city election last month. Richard Trump, a Republican who favored the Robinwood location, defeated Breichner. But five council candidates running on a Republican slate with Trump lost, and critics such as Metzner were returned to the council.
Now, Trump said, he will work to help solve the zoning and water-sewer issues. "We're not obstructionist," he said. "We're facilitators."