Radiation vibe | Goodall Hospital execs talk about their surprising decision to partner with former rivals on a controversial York County cancer center

For more than two years, two competing hospital groups have waged an emotional and often nasty fight over the right to build a cancer care center in southern Maine. Besides arguments over the two groups' qualifications to operate the proposed $6 million radiation therapy center, the debate featured accusations of bias within the state Department of Human Services and patients' suspicions of a conspiracy to drive local community hospitals out of business.

Given that contentious history, it was especially surprising when H.D. Goodall Hospital in Sanford ˆ— previously a partner with York Hospital and New Hampshire-based Wentworth-Douglass Hospital in a bid to build the facility ˆ— announced in early August that it was teaming up with former rivals Maine Medical Center and Southern Maine Medical Center, which were awarded the contract to build the facility in 2003. (That contract has been held up through a series of appeals ever since). Under the new partnership, Goodall, MMC and SMMC plan to move the facility to Sanford, rather than its previously approved location in Wells.

The competition began in 2001, when both hospital groups applied for a certificate of need to build and operate the York County cancer center. The fight heated up in February 2003 when DHS awarded the project to the MMC/SMMC partnership, despite overwhelming support among Wells residents for the team lead by nearby York Hospital. At the time, then-DHS Commissioner Kevin Concannon said he based his decision on the hospitals' qualifications, not popular opinion. York, Goodall and Wentworth-Douglass immediately appealed that decision with DHS, which upheld the CON award in April 2003.

At that point, Goodall Hospital dropped out of the fight. In May 2003, York Hospital and Wentworth-Douglass appealed the state's ruling in Maine Superior Court, which also upheld DHS' decision in 2004. The hospitals then took their case to the Maine Supreme Judicial Court, which is expected to hear it this month.

In the meantime, Goodall, MMC and SMMC moved on, forming a new plan that will move the cancer center from Wells to a 10-acre site in Sanford owned by Goodall, which the hospital says offers a more centralized location in York County, less potential traffic congestion and about $350,000 in savings due to easier site preparation work. The collaborative hopes to have the facility completed by January 2006.

To learn more about Goodall's decision to join with former rivals, and to gain insight into why the process has been so contentious, Mainebiz spoke with Dale Shaw, Goodall's treasurer, and Dee Hopper, vice president of patient care. The two are acting as the hospital's interim presidents following the July resignation of former president Peter Booth.

Goodall's decision to join with MMC and SMMC surprised people familiar with the cancer center project. Why did you make the decision to join with your former competitors?
Shaw: We started out in a collaborative with folks located in York County and its surroundings. In the course of [the certificate of need] process, it became pretty clear that having an out-of-state partner was going to be an impediment to getting the CON. So, when the CON was awarded to the Maine Med/Southern Maine collaborative, we went through the first appeal process with our team, but then decided it made sense not to appeal this further in order to get on with getting the cancer care center built and patient care delivered.

We kind of sat on the sidelines as that process has played out on appeals, and [during that time] began a discussion with the medical centers about how we might participate in that [group's plan]. And lo and behold, as they started looking at it, Sanford became what looked like a better location. That combination of events made it make sense for us to join and get on with developing the radiation center and getting patient care out there.

Hopper: We actually backed out of the prior agreement as of April 2003.

Can you elaborate on why you thought having the out-of-state partner would be a disadvantage in the CON process?
Shaw: I get the impression that the state of Maine, through its regulatory body, the Department of Human Services Certificate of Need [Program], doesn't like having partners that it can't regulate involved with projects. And unfortunately, Wentworth-Douglass is located in New Hampshire, even though they are accredited in cancer care and have done radiation therapy for years. The state can't reach across the border and regulate them. Now, the project itself would have been in Maine. However, a lot of the expertise around radiation therapy would have come from Wentworth-Douglass.

But you still decided to appeal the initial decision, then declined to join the subsequent lawsuits. Why did you stop pursuing your case after one appeal?
Shaw: From my perspective, it was important to make sure all of the due process that needs to occur had occurred, and that's what we were looking for. The York Hospital/Wentworth-Douglass/Goodall submission was done almost three months before the Maine Med/Southern Maine Med proposal, so there was a lot of concern about whether everyone got the same equal footing [because of that time gap]. And [DHS] went through the [appeal] process, looked it over and said, "Yes, this is the way the rules read, we're going to go from there."

At that point, both from a management perspective and a board perspective, we decided that, okay, we've had our opportunity here, we've lost, we're going to go on. Our other two partners felt there was still merit to pursuing [the appeal], and they still are pursuing it. There's a Maine Supreme [Judicial] Court hearing on Sept. 20 on that appeal, and out of that will come some finality, I think.

Hopper: It was very clear, also, that we just wanted to get the project moving and get the care for our patients, rather than delaying the project.

One news report on the new partnership and plan to move the center to Sanford said that Maine Medical Center had been looking for a "backup plan" for its Wells site anyway. Who first approached whom about Goodall Hospital joining the team?
Shaw: Actually, they were looking for alternative sites before they approached us. They'd done some demographic studies trying to figure out where the center of this service area is. And the center of this service area sits about at the end of [the Sanford Regional Airport] runway. From what I understand, because our board president is heavily involved with this, as they started looking for land here in Sanford, we had a conversation with them about what was going on and started looking at land with them. As we were helping them we started saying, "Gee, maybe we'd be interested in this."

What do you think Goodall Hospital brings to the partnership that wasn't there before?
Hopper: We are accredited by the American College of Surgeons [as are Maine Medical Center and Southern Maine Medical Center], so we bring a certain amount of expertise, as well as the land.
Shaw: We're bringing a volume of patients in here, too. Maine Med is bringing expertise to the table, but they aren't bringing much in the way of a service area ˆ— because the service area they are coming to is shared by York Hospital, Southern Maine Medical Center, Goodall and certainly Wentworth-Douglass. So patient volume is important.

I also think it truly becomes a whole lot more of a collaborative effort. If after all of the appeals it's decided that the CON stays where it is, and if York Hospital joined [with us], I think that would be an advantage even further. I fully expect that York will wait for all of the appeals before they make a decision like that, and then they'll do what is rational for them to do at that point.

The idea of former rivals collaborating on this project is still hard to believe, because this seemed like such a nasty fight at times. What made the process so emotional?
Hopper: I think it was the threat of competition.

Shaw: Yes. What made this CON different from the start is that there have been very few competitive CONs in the state. More typically what happens is a hospital designs an idea for its service area, presents that as a CON and very seldom is there competition.

It was testier than the typical process, and I guess it does say a little bit about competition. In the end, we're all in the business of providing health care, but at the same time, it is a business, and each of us has to look at how we're going to serve the people in our service area and how we retain the people in our service area.

I think that's the crux of this and, in the end, the patients will get served. Did we bat this around too much? I don't know. I don't know if more of this [type of fight] is going to occur or not.

I was curious about that. Hospital expansion plans are under a lot of scrutiny at the state level, and this debate could raise questions about how to handle the certificate of need process. Do you think the process needs any changes to prevent a situation like this from arising again?

Shaw: The balance you're asking about here is between regulation and governmental oversight and more of a free-market approach. The CON is kind of a blend of those two. I have a real bias, and it's difficult to get beyond it. I don't necessarily think someone sitting in a centralized government office doling out where new services should be is the best answer.

So I don't think the CON process is a terribly bad process. One of the things that's clear in the CON process is that you have the right of appeal, and that appeal is going to delay the opening of this center by just about two years. That's the part of the process we have to figure out how to do better.

I must admit that due process is important, but perhaps we need to go to some kind of panel hearings and that's it, not [unlike] malpractice panel hearings, which use a panel that's made up of some medical people and some legal experts. The CON [also] could have a panel of folks ˆ— it could include some hospital people, it could include some vendors even, to understand how technology could be dispersed.

Going through the process wasn't bad. That fact that it was competitive wasn't bad ˆ— I think it may actually be a positive in the state to have more of that. But the ongoing appeals are an arduous process.

Hospitals don't like to talk about certain services being profit centers, but I've read that radiation treatment can be a valuable business. Was the financial importance of cancer treatment also a factor in this competition?
Shaw: There's not much question, if you looked at either of our CONs, that the radiation therapy center is expected to generate more income than expenses. Now, almost all of that [profit], if not all of it, ends up being returned to the community in one way or another in [other] services.

For example, Goodall may do the housekeeping services for the [cancer center] because we're here. Well, we would charge for our costs for doing that housekeeping service, so some fees would come back to Goodall Hospital. Another component of [the plan] is to have each of the hospitals do oncology education ˆ— how to do prevention and wellness training around oncology. So there would be funds flowing from this radiation center that allow that to happen.

So from a pure economic perspective, I don't think any of the members of either collaborative were going to get a large profit out of this. I don't think that was driving [the competition], as much as maintaining your patient base.

With all the controversy, it's hard to remember why this facility is necessary in the first place. What's the advantage of building a dedicated radiation therapy center?
Hopper: [A cancer center] is a very costly investment, and we certainly don't need three radiation therapy centers in southern Maine where there are three independent hospitals. One would really be appropriate to have for this area and the number of patients we serve here.

It's really important that these patients don't have to travel far. We actually have patients that refuse to go to Scarborough or Dover [N.H.] for radiation therapy ˆ— it's too far to travel. So on the one hand you want to provide access; on the other hand, it doesn't make sense for each hospital to have its own radiation therapy center. Having a centralized, functioning, self-sustaining center makes a lot of sense.

You said you left your original partnership in 2003. But what happens if the Maine Supreme Court overturns this ruling and awards the project to the original partnership? Will you join them again?

Shaw: We'll have to see how that plays out. With at least a brief conversation we've had with Jud Knox, [president of] York Hospital, he indicated he'd be willing to consider us rejoining them. But we're in a new partnership, and that's the partnership we're supporting. That will be a really tough decision if it goes that way ˆ— a really tough decision.

It will be a tough decision for all of us because, ultimately, the York County hospitals have to collaborate on this. Whether it's the York collaborative or the Southern Maine/Maine Med collaborative that ends up with [the center] after all the appeals, we all have to work together. I would hope that if it's reversed we might be able to be an intermediary and still bring the [five] hospitals together to do it.

Hopper: But even if they were to prevail at this hearing, what does that mean? Does [the decision] get sent back to the CON process to start all over again, or does it flip the decision? I think those are all unknowns that we can't judge at this time. It's kind of wait and see. I just feel very strongly that I'd like to see us move on and provide the service to the patients. It's such a need, and to keep delaying it ˆ— it's frustrating.

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