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The future of a proposed alternative birth center in Elizabethtown now is in the hands of the state.
An attorney for the Visitation Birth & Family Wellness Center argued opponents have not submitted evidence worthy of overcoming the presumption of need set by the Cabinet for Health & Family Services while counsel for Hardin Memorial Health, Flaget Memorial Hospital in Bardstown and Twin Lakes Regional Medical Center in Leitchfield said the center is not needed, its business model is faulty and its utilization projections are inflated.
The two sides lobbied the state one final time through written closing statements, which were issued Tuesday by the cabinet to The News-Enterprise through an open records request.
Proponents say presumption of need remains intact
J. Guthrie True, attorney for the center, argued the facility’s presumption of need can only be overcome by “clear and convincing evidence” but the three health care providers failed to do so in attacking potential safety hazards for mothers and babies, referring to the notion as a “nonstarter.” He argued the real “attack” was levied at the center’s utilization projections and financial model.
The center intends to serve a 24-county service area with roughly 100 births in the first year and 200 births by year two. It expects to attract between 75 and 90 percent of all home births in the service area and around half of its clients from Jefferson County.
“If the VBC is so unlikely to meet its utilization and financial projections, then why would two of the state’s largest health care conglomerates — Baptist Healthcare System and KentuckyOne Health — go to the expense and trouble of mounting the level of opposition offered to this application?” True said in the closing statements. “The answer is simple: they know the facility and the providers are safe, they know the demand for the service exists, and they know the VBC will be a financial success.”
True argued the center will create a safe birthing environment without proximity to HMH. State law allows for creation of freestanding birth centers without requiring them to be near a hospital, he argued.
The center, he said, will perform frequent risk assessments to ensure mothers are fit to give birth at the facility and will make decisions in cooperation with registered nurses and other medical professionals. The center’s medical staff will receive up-to-date training on resuscitation procedures, he said.
True argued evidence has shown the majority of hospital transfers from birth centers are not emergencies, giving physicians ample time to evaluate a mother’s health.
The opposing hospitals have said they have space for additional patients, but True said under-utilization of obstetric services is irrelevant because the three hospitals do not offer the same services the center has proposed. HMH uses midwives and attempts to follow a patient’s birth plan, but True argued the service does not equate to a freestanding birth center.
The center’s proposed service area is reliable and reasonable, he said, because it was based on the distance patients drive for obstetric services in counties surrounding Hardin County.
“Patients will travel further distances to receive a service they desire or require, and they will certainly travel to receive a desired or required service that is not available closer to home,” True said.
The use of home births in utilization projections, he argued, is reasonable because, in both cases, mothers have shown desire to seek an alternative out-of-hospital experience and no other birth centers exist in Kentucky to glean data from. Because the center has faith in its projections, it is confident its financial model is sound, he said.
Mary Carol Akers, a certified nurse midwife who filed the application for the center, said she would forgo an annual salary in the first two years to protect the center’s solvency. True said this savings should produce revenue by year two.
Opponents say flawed plan indicates lack of need
Mathew Klein and Ellen Houston, representing HMH and Twin Lakes, and Michael Baker, representing Flaget, said the plan only can be feasible if three things occur: the home birth rate in the region increases by 40 percent; the usage rate exceeds 1 percent, more than triple the national average of .3 percent; and it attracts 75 to 90 percent of home births in its service area.
“If even one of these fail, the applicant’s need model fails and the proposed center will fail,” they said.
The statewide home birth rate of 1.24 percent projected by Roger Cochran, a Florida-based consultant who developed the center’s model, is not rooted in reality but was taken from a snapshot of data between 2004 and 2009, they said.
“If you assume a 40-percent increase every five years as Dr. Cochran did, then 100 percent of all births in Kentucky will essentially be in the home by 2070,” they said.
They argued home births have increased while birth center births decreased and still constitute the bulk of out-of-hospital births, outpacing birth center births at a greater than two-to-one ratio. Jefferson County is below the 2009 statewide home birth rate of .9 percent, with only 45 home births reported that year, they said.
The group of attorneys refuted the notion the center could attract more than three times the national average of birth center births, saying states with the highest usage rates are large rural centers with few densely populated areas. Should the projections hold, they said, Kentucky would be propelled near the top nationally in birth center usage, which is unlikely when looking at bordering states Indiana and Tennessee. Both have established birth centers but neither has cracked .6 percent in usage rates, they argued.
Using the national rate of .3 percent as an indicator of births, the numbers fall from 200 in year two to around 52, according to the closing statement. Because the center did not account for Medicaid patients, who will not be accepted, they argued the number of births would plummet further. Should demand be reduced to this level, it would devastate the center’s budget and make it unprofitable, they argued. Proponents of the center have said the national usage rate is skewed because it includes states with no birth centers.
The opposition also targeted Akers’ choice for medical director and consulting obstetrician, claiming she has failed to seek collaborations and support from obstetricians and pediatricians in Hardin County. Akers has tapped Dr. Mark DeMuth as her medical director and Lexington obstetrician James O’Neill as its consultant. DeMuth, they said, has no real background in obstetrics while O’Neill is not part of the local community and is incapable of gaining admitting privileges at HMH without relocating.
A responsible birth center, they said, must have partnerships with qualified physicians to meet licensure requirements but also provide the proper oversight.
“A birthing center without these checks and balances is definitely not needed,” they said.
No timeline given on certificate of need decision
The state may need some time to sort this one out.
Beth Fisher, a spokeswoman for the Cabinet for Health and Family Services, said no timeline has been released or deadline placed on a decision regarding the Visitation Birth & Family Wellness Center.
During a four-day hearing, both sides waived the deadline on a decision, giving Hearing Officer Kris M. Carlton more time to review the case.
Certificates of need take priority, and Carlton said she will try to render a decision as soon as possible.
Because there are no existing birth centers in the state, the decision may take longer, Fisher said.