* Providence Health & Services, Appellant V. Department Of Health, Respondent

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9HK I'11 -T-
IN THE COURT OF APPEALS OF THE STATE OF WASHINGTON
PROVIDENCE HEALTH & SERVICES -
WASHINGTON, d/b/a PROVIDENCE
REGIONAL MEDICAL CENTER
EVERETT, and d/b/a PROVIDENCE
SACRED HEART MEDICAL CENTER;
and SWEDISH HEALTH SERVICES, d/b/a
SWEDISH MEDICAL CENTER/FIRST
HILL,
Appellants,
v.
DEPARTMENT OF HEALTH OF THE
STATE OF WASHINGTON,
Respondent,
UNIVERSITY OF WASHINGTON
MEDICAL CENTER,
Intervenor.
No. 73454-7-
DIVISION ONE
PUBLISHED OPINION
FILED: July 5, 2016
Appelwick, J. — UWMC applied for a certificate of need to add 79 acute
care beds to its Seattle facility. 	The traditional numeric methodology did not
demonstrate 	need. 	However, 	the 	Department's 	certificate of 	need 	program
approved the 	application. 	The 	HLJ upheld 	this approval, 	reasoning that an
alternative methodology, Criterion 2, showed a need for additional beds. 	This
 	 	 	 	 	 	 	 	 	 	 	 	 	

No. 73454-7-1/2
appeal challenges the review officer's subsequent decision that it was proper to
utilize Criterion 2 and that it was properly applied. 	We affirm.
BACKGROUND
The State Health Planning and Resources Development Act, chapter 70.38
RCW, regulates the number of healthcare providers in the market. 	Univ. of Wash.
Med. Ctr. v. Dep't of Health, 164 Wn.2d 95, 99, 187 P.3d 243 (2008). 	Under this
statutory scheme, providers may open certain healthcare facilities and programs
only when the Washington State Department of Health (Department) issues a
certificate of need (CN). 	]d. at 99-100. 	The CN program is intended to promote
accessible health services while controlling costs. 	RCW 70.38.015.
When considering a CN application, the Department analyzes the need for
the proposed project, the financial feasibility of the project, structure and process
of care, and cost containment. 	WAC 246-310-210 (need); WAC 246-310-220
(financial feasibility); WAC 246-310-230 (structure and process of care); WAC 246-
310-240 (cost containment).
FACTS
The University of Washington Medical Center (UWMC) is a tertiary and
quaternary care1 hospital located in Seattle. 	It is also the teaching hospital for the
University of Washington (UW) School of Medicine. 	UWMC is part of the UW
Medicine health system. 	This system also includes Harborview Medical Center,
Northwest Hospital & Medical Center, Valley Medical Center, the UW School of
1 "Tertiary care" is a level of medical care available only in larger medical
institutions, involving specialized techniques and equipment. "Quaternary care" is
an advanced level of tertiary care.
 	 	 	 	 	 	 	 	 	 	 	 	 	

No. 73454-7-1/3
Medicine, 	UW 	Physicians, 	UW 	Neighborhood 	Clinics, 	and 	Airlift Northwest.
UWMC is currently licensed for 450 beds, 360 of which are used for acute care.
In 2005, UWMC began planning to build a new patient care tower. The UW
Board of Regents approved the Montlake Tower in 2007, and construction was
complete in 2012. 	The last three stories of the eight story tower were shelled in
for future expansion, but unfinished.
In November 2012, UWMC applied for a CN to add 79 additional acute care
beds 	in the Montlake Tower. 	Its original estimated capital expenditure was
$70,771,363. 	This amount was estimated to be the cost of completing the three
floors that had already been shelled in for future expansion.
Over 	the 	next 	year, 	the 	Department 	thoroughly 	assessed 	UWMC's
application. 	It requested supplemental information from UWMC. 	It held a public
hearing 	on 	UWMC's 	application. 	And, it collected 	written statements from
interested parties.
Robert Russell was the CN program analyst leading the evaluation. Russell
applied 	the 	numeric 	methodology 	that 	the 	Department 	traditionally 	uses 	to
calculate need for acute care beds. This methodology revealed that there was not
enough projected need in the planning area to support UWMC's request for 79
additional beds. 	Because need is an integral CN requirement, Russell drafted an
evaluation that denied UWMC's CN application.
Then, Bart Eggen, executive director of the office that manages the CN
program, reviewed Russell's draft evaluation. 	Eggen did not look at UWMC's CN
application. 	He did not review UWMC's responses to the Department's requests
 	 	 	 	 	 	 	 	 	 	 	 	 	

No. 73454-7-1/4
for supplemental information. 	He did not review any of the public comments
submitted in connection with UWMC's application. 	He did not review the financial
analyst's memo to Russell concerning the costs of UWMC's proposed project.
Instead, after reviewing only Russell's draft evaluation, Eggen ordered Russell to
rewrite the evaluation, find that the need requirement was met, and grant UWMC
the CN.
Russell complied. He revised the draft evaluation to conclude that while the
numeric methodology did not show enough need to justify UWMC's project, the
methodology inaccurately allocated bed need in the planning area. The evaluation
did 	not cite 	other approaches to calculate bed 	need. 	Yet, 	due to 	Eggen's
instructions, the Department found that UWMC's project met all of the CN criteria,
including need. 	The Department issued the CN to UWMC.
Several of UWMC's competitors—Providence Health and Services, doing
business as Providence Sacred Heart Medical Center and Providence Regional
Medical Center Everett, and Swedish Health Services, doing business as Swedish
Medical 	Center/First 	Hill 	(collectively 	"Providence")—opposed 	UWMC's
application during the public comment period. 	In its written statements opposing
the 	CN, 	Providence 	urged 	the 	Department 	to 	correctly 	apply 	the 	numeric
methodology and find that UWMC's project did not satisfy the need requirement.
Then, after the Department departed from this methodology in order to award the
CN to UWMC, Providence again insisted that the Department should follow its own
rules. 	It requested an adjudicative hearing to contest the CN. After requesting the
hearing, Providence deposed Russell and Eggen. 	These depositions informed
 	 	 	 	 	 	 	 	 	 	 	 	 	

No. 73454-7-1/5
Providence of the Department's initial review of UWMC's application and Eggen's
direction to grant the CN.2
The adjudicative hearing was held in June 2014 before Health Law Judge
Frank Lockhart. Both UWMC, as intervenor, and Providence called witnesses and
presented exhibits. The HLJ used "Criterion 2" of the hospital bed need forecasting
method contained in the Washington "State Health Plan" to determine that there
was a need for the additional beds. 	See former RCW 70.38.919 (1989), repealed
by Laws of 2007, ch. 259, § 67. 	He did so rather than relying on the traditional
numeric methodology that is also found in the State Health Plan. 	The numeric
methodology provides a formula 	to calculate bed 	need in the planning area,
whereas Criterion 2 looks at whether other circumstances—such as accessibility
to underserved groups, expansion of programs with better results, and promotion
of training programs—indicate a need for additional beds. 	The HLJ relied on
Criterion 2 because he believed that the numeric methodology did not accurately
capture the need for additional acute care beds. The HLJ concluded that UWMC's
project satisfied all of the CN requirements. 	On September 12, 2014, the HLJ
entered findings of fact, conclusions of law, and an initial order approving UWMC's
CN to add 79 acute care beds.
2 The 	discovery of Eggen's 	role in the 	Department's evaluation 	likely
energized an otherwise routine competitor dispute over bed allocation.
 	 	 	 	 	 	 	 	 	 	 	 	 	

No. 73454-7-1/6
Providence sought administrative review of the 	HLJ's initial order. 	On
January 26, 2015, the review officer adopted the findings of fact and conclusions
of law from the initial order. 	And, the review officer entered a final order that
affirmed the initial order.
Providence filed a petition for judicial review in King County Superior Court.
The parties jointly requested an order certifying the petition for judicial review to
this court. 	The trial court certified the matter to this court. 	The parties jointly filed
a motion for discretionary review to this court. This court granted the motion.
DISCUSSION
The Washington Administrative 	Procedure Act (WAPA), 	chapter 34.05
RCW, governs this court's review of administrative actions. 	King County Pub.
Hosp. Dist. No. 2 v. Dep't of Health, 178 Wn.2d 363, 371-72, 309 P.3d 416 (2013);
RCW 34.05.570. We sit in the same position as the superior court, applying WAPA
to the record before the agency. 	DaVita, Inc. v. Dep't of Health, 137 Wn. App. 174,
180, 151 P.3d 1095 (2007). The agency decision is presumed to be correct, and
the challenger bears the burden of proof. 	RCW 34.05.570(1 )(a); Overlake Hosp.
Ass'n v. Dep't of Health, 170 Wn.2d 43, 49-50, 239 P.3d 1095 (2010).
Under WAPA, this court may grant relief only in limited circumstances.
DaVita, 137 Wn. App. at 181. We may grant relief when the agency followed an
unlawful procedure, erroneously interpreted or applied the law, or entered an order
that is not supported by substantial evidence. 	RCW 34.95.570(3)(c), (d), (e). We
review an agency's factual findings to determine whether they are supported by
substantial evidence sufficient to persuade a fair-minded person of the stated
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No. 73454-7-1/7
premise. 	DaVita, 137 Wn. App. at 181. This court overturns the agency's factual
findings only if they are clearly erroneous, meaning that the entire record leaves
us with the firm and definite conviction that a mistake was made. 	Univ. of Wash.
Med. Ctr., 164 Wn.2d at 102. 	Under the error of law standard, this court may
substitute its interpretation of the law for that of the agency, but the agency's
interpretation is accorded substantial deference, particularly where the agency has
special knowledge and expertise. 	Id. 	This court may also grant relief from an
agency order that is arbitrary and capricious, meaning that it is the result of willful
and unreasoning disregard of the facts and circumstances. 	RCW 34.05.570(3)(i);
Overlake, 170 Wn.2d at 50.
Although 	Providence articulates strong 	concern 	over the 	Department's
evaluation of UWMC's application, we do not review Eggen's or Russell's actions
directly. 	Their decisions received an adjudicative hearing before the HLJ. 	And,
when the HLJ affirmed the decision of the Department, a 	review officer then
reviewed the matter and entered a final order upholding the CN. 	We review the
correctness of this final administrative decision. 	DaVita, 137 Wn. App. at 181
(noting that this court reviews the Department's final order pertaining to a CN
application).
I. 	Utilization of Criterion 2 to Determine Need
Providence 	argues 	that 	the 	HLJ's 	reliance 	on 	Criterion 	2 	was 	an
unprecedented departure from the Department's consistent use of the numeric
methodology. 	Providence asserts that the regulatory scheme does not allow the
Department to use Criterion 2 to assess bed need. 	And, it contends that the
 	 	 	 	 	 	 	 	 	 	 	 	 	

No. 73454-7-1/8
Department disclosed 	its 	reliance 	on 	Criterion 	2 	too 	late for 	Providence 	to
participate meaningfully in the public comment process. 	As a result, Providence
argues that the decision to use Criterion 2 of the State Health Plan to assess need
for 	UWMC's 	proposal 	was 	an 	error 	of 	law, 	arbitrary 	and 	capricious, 	and
unsupported by substantial evidence.3
Criterion 2 of the State Health Plan states,
2. 	CRITERION: Need for Multiple Criteria
Hospital bed 	need forecasts are only one aspect of planning
hospital 	services 	for 	specific 	groups 	of 	people. 	Bed 	need
forecasts by themselves should not be the only criterion used to
decide whether a specific group of people or a specific institution
should develop additional beds, services, or facilities. Even where
the total bed supply serving a group of people or a planning area
is adequate, it may be appropriate to allow an individual institution
to expand.
STANDARDS:
b. Under certain conditions, institutions may be allowed to expand
even though the bed need forecasts indicate that there are
underutilized facilities in the area. The conditions might include
the following:
• 	the proposed development would significantly improve the
accessibility or acceptability of services for underserved
groups; or
• 	the 	proposed 	development 	would 	allow 	expansion 	or
maintenance of an institution which 	has staff who have
greater training or skill, 	or which has a wider range of
important services, or whose programs have evidence of
better 	results 	than 	do 	neighboring 	and 	comparable
institutions; or
3 Providence assigns error to findings of fact 1.6, 1.7,1.11, and 1.12, which
contain the HLJ's Criterion 2 analysis.
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No. 73454-7-1/9
• 	the 	proposed 	development would allow expansion 	of a
crowded 	institution 	which 	has 	good 	cost, 	efficiency, 	or
productivity measures of its performance while underutilized
services 	are 	located 	in 	neighboring 	and 	comparable
institutions with higher costs, less efficient operations or
lower productivity.
In such cases, the benefits of expansion are judged to outweigh
the potential costs of possible additional surplus.
Neither RCW 70.38.115 nor WAC 246-310-210 provide an exclusive, finite
approach 	for 	determining 	a 	population's 	need 	for 	hospital 	beds. 	RCW
70.38.115(2) provides only that the Department must consider "[t]he need that the
population served or to be served by such services has for such services." And,
WAC 246-310-210 lists several factors on which a determination of need shall be
based. The first factor is whether "[t]he population served or to be served has need
for the project and other services and facilities of the type proposed are not or will
not be sufficiently available or accessible to meet that need."4 	WAC 246-310-
210(1).
The Department has traditionally relied on a 12 step numeric methodology
contained in the State Health Plan to calculate the need for hospital beds. The 12
step methodology provides a formula for forecasting the aggregate need for
hospital beds in a particular planning area. 	Its steps are separated into three
elements: develop trend information on hospital utilization, calculate baseline non-
psychiatric bed need forecasts, and determine total baseline hospital bed need
4 This lack of definite standards for determining acute care bed needs
stands in contrast to several other situations in which a facility must apply for a CN.
For example, WAC 246-310-284 provides a concrete methodology to determine
need for kidney dialysis stations, WAC 246-310-290(7) states the steps used to
project the need for hospice services, and WAC 246-310-360 contains guidelines
for calculating need for nursing home beds.
 	 	 	 	 	 	 	 	 	 	 	 	 	

No. 73454-7-1/10
forecasts.5 	The State Health Plan remained effective until June 30, 1990. 	See
former RCW 70.38.919 (1989) (Laws of 1989, 	1st Ex. Sess., ch. 	9, § 610),
repealed by Laws of 2007, ch. 259, § 67. 	But, the Department continues to use
this methodology.
Providence argues that the Department's consistent use of the numeric
methodology 	means 	that 	the 	Department 	may 	not 	use 	other 	standards 	to
determine bed need. 	To support this contention, Providence relies on language
from the Department's prior administrative decisions.6 	In In re Certificate of Need
Decision 	on 	Providence 	Sacred 	Heart Medical 	Center & Children's 	Hospital
Proposal to Add 152 Acute Care Beds to Spokane County, No. M2009-1141 at 14-
15 (Dep't of Health Aug. 9, 2011) ("Sacred Heart"), the Department explained that
it relies on the numeric methodology because there is no statutory or regulatory
process to calculate bed need. 	It recognized that both the CN program and
applicants have used this methodology, and "[t]he predictability afforded by the
consistent use of the State Health Plan methodology argues for its continued use."
Id. at 15. 	But, it also noted, "This does not prohibit an applicant from submitting
an alternative approach to show need exists." 	Id. 	The Department used similar
language in In re the Certificate of Need Decision on Valley Medical Center's.
Auburn Regional Medical Center's, and Multicare Health System's Application for
5The numeric methodology uses population and healthcare use statistics
on the statewide, health service area, and planning area level. The planning area
involved here is the North King Planning area, which is comprised of select zip
codes within King County.
6 Although we are not bound by these decisions, we examine them to the
extent they demonstrate the Department's prior bed need analyses.
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No. 73454-7-1/11
Acute Care Beds in Southwest King County, No. M2011-253 (Dep't of Health Feb.
13, 	2012) ("Valley"). 	The Valley decision 	also 	recognized 	the value 	in the
consistent application 	of the methodology. 	Id. at 	14. 	But, 	the 	Department
acknowledged 	that, 	"[a]ny 	bed 	need 	methodology 	used 	should 	provide 	a
predictable, transparent, and consistent process for applicants." 	Id. at 14 n.8. 	It
clarified, 	"An 	applicant 	should 	know 	what 	is 	required 	to 	apply 	for 	a 	CN
(transparency of process), how the program will apply the process (predictability
of the process), and whether the program follows the process (consistency with
the past process)." 	Id.
Neither of these cases requires that the Department apply only the 12 step
methodology. 	Although the Department recognized the value of consistency and
predictability, 	in 	both decisions it acknowledged the fact there may be other
approaches to determine bed need. 	In Sacred Heart, the Department explicitly
stated that applicants may submit alternative methods to show need. 	No. M2009-
1141 	at 	15. 	And, 	Valley 	emphasized 	the 	importance 	of 	consistency 	and
transparency in the CN review process—not that the 12 step methodology is the
only means of determining bed need. 	No. M2011-253 at 14 n.8. 	Moreover, in
neither case did the applicant request the Department to apply Criterion 2.
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No. 73454-7-1/12
The recognition that there may be other methods of determining bed need
is consistent with the statutory and regulatory scheme. 	WAC 246-310-200(2)(b),
which outlines the criteria for a Department's review of a CN application, allows
the Department to consider
(i) 	Nationally 	recognized 	standards 	from 	professional
organizations;
(ii) 	Standards developed 	by professional 	organizations 	in
Washington state;
(iii) 	Federal 	[Mjedicare 	and 	Medicaid 	certification
requirements;
(iv) State licensing requirements;
(v) Applicable 	standards 	developed 	by 	other 	individuals,
groups, 	or organizations with recognized 	expertise 	related to a
proposed undertaking; and
(vi) The written findings and recommendations of individuals,
groups, 	or organizations with recognized 	expertise 	related 	to a
proposed undertaking, with whom the department consults during
the review of an application.
And, RCW 70.38.115(5) recognizes that "[criteria adopted for review in
accordance with subsection (2) of this section may vary according to the purpose
for which the particular review is being conducted or the type of health service
reviewed."
Utilizing standards other than the numeric methodology is not inconsistent
with the Department's previous CN evaluations. 	The Department has previously
acknowledged,7 "The methodology is 	a 	flexible 	tool, 	capable 	of delivering
meaningful results for a variety of applications, dependent upon variables such as
referral patterns, age-specific needs for services, and the preferences of the users
of hospital services, among others." 	Sacred Heart CN Evaluation at 8. 	In its
7The record contained a copy of the Department's evaluation of the CN in
Sacred Heart (Sacred Heart CN Evaluation).
12
 	 	 	 	 	 	 	 	 	 	 	 	 	

No. 73454-7-1/13
evaluation of Sacred Heart's proposal to add 152 acute care beds, the Department
concluded that the methodology did not show a need for additional beds until well
beyond the projection period. 	Id. at 16. 	But, the Department did not end its
analysis there—it looked to whether there was evidence supporting Sacred Heart's
claims of overcrowding, increased population growth within the community, and
long waits before patients could be admitted. 	Id. 	Because it found that Sacred
Heart had not demonstrated that there were no other facilities available to meet
the need, and because the methodology did not indicate need, the Department
found that the need criterion was not met. 	Id at 17. 	Similarly, on reconsideration
of Kennewick General Hospital's (KGH) application (KGH RCN) to add 34 beds,
30 of which would be acute care beds, the Department assessed external and
internal factors affecting the need for additional beds at KGH, in addition to the
numeric methodology. 	KGH RCN at 15. 	The Department concluded that even
though the methodology did not show need for additional beds in the planning area
until 	past the 	projection year, 	"patient utilization 	trends 	support a 	need 	for
additional bed capacity at KGH, regardless of the number of beds already available
in the planning area." 	Id
Given 	the 	Department's 	previous 	history 	of 	relying 	on 	the 	numeric
methodology but recognizing its limitations, we conclude that the Department's use
of Criterion 2 here was not unprecedented, as Providence claims.
Providence contends that Criterion 2 of the State Health Plan is not a
"standard" that WAC 246-310-200 allows the Department to consider. 	Instead,
Providence characterizes Criterion 2 as legally ineffectual language from the State
13
 	 	 	 	 	 	 	 	 	 	 	 	 	

No. 73454-7-1/14
Health Plan, which has been defunct for 25 years. 	But, if the fact that the State
Health Plan no longer has any legal authority means that Criterion 2 is not a
standard, then the 12 step methodology should not be considered a valid standard
either. 	The methodology has not been enacted into law; rather, the Department
has previously cited with approval to the State Health Plan when applying it. 	See
Sacred Heart, No. M2009-1141 at 14; Valley, No. M2009-1141 at 14-15.
Criterion 2 recognizes that the numeric based methodology is not always
the most effective means of evaluating bed need. 	It provides an alternative
process through which the 	Department may assess bed 	need. 	Although the
Department has not previously used Criterion 2, that alone does not preclude the
Department from referring to it. 	Criterion 2 satisfies the language of WAC 246-
310-200, as it is an applicable standard developed by a group with expertise in the
field. 	And, by offering an alternative method of evaluating bed need, Criterion 2 is
also 	in line with the 	purpose 	of the 	State 	Health 	Planning 	and 	Resources
Development Act, which is to promote accessibility of health services. 	RCW
70.38.015.
Providence contends that even if Criterion 2 is a 	proper standard, the
Department was required to disclose the standard before it evaluated UWMC's
application. 	It cites to WAC 246-310-200(2)(c) in support of this proposition. That
regulation provides,
At the 	request of an 	applicant, the department shall identify the
criteria 	and 	standards 	it will 	use 	prior 	to 	the 	submission 	and
screening of a certificate of need application. ... 	In the absence of
an applicant's request under this subsection, the department shall
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No. 73454-7-1/15
identify the criteria and standards it will use during the screening of
a certificate of need application.
WAC 246-310-200(2)(c).
Providence argues that it was not able to contribute meaningfully in the
public comment process because the Department did not disclose that it would
rely on Criterion 2. 	But, Providence had 	notice from the beginning 	that the
Department 	might 	consider factors 	other than 	the 	numeric 	methodology 	to
determine need. 	In its CN application, UWMC analyzed need using both the
numeric methodology and Criterion 2. In the application, UWMC asserted that the
numeric methodology understates the need for acute care beds. 	Accordingly,
UWMC encouraged the Department to look at Criterion 2 as an alternative need
analysis. 	UWMC also referred to Criterion 2 in response to the Department's
request for supplemental information. 	Therefore, Providence had notice that the
Department might consider Criterion 2 in evaluating UWMC's application.
The public comment period was 	not the only opportunity to challenge
Criterion 2. When the Department issued its decision, Providence had no trouble
determining that the numeric methodology would not support the decision. Given
that UWMC had sought reliance on Criterion 2, Providence reasonably should
have anticipated that was the basis for the Department's decision. Providence had
an opportunity for discovery and for a hearing. 	It does not identify how it was
unable to adequately challenge the use of the Criterion 2 methodology.
We conclude that it was not legal error to use Criterion 2 as a standard to
assess bed need. 	And, findings of fact 1.6, 1.7, 1.11, and 1.12 relating to WAC
246-310-220 are not clearly erroneous.
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No. 73454-7-1/16
II. 	Application of Criterion 2
Providence asserts that, even applying Criterion 2, the record does not
support a finding of need for UWMC's project. 	It argues that the record does not
contain the comparative data that Criterion 2 requires on factors such as greater
training and skill, a wider range of important services, and programs with evidence
of better results. 	And, Providence contends that the findings of fact concerning
Criterion 2 are arbitrary and capricious and unsupported by substantial evidence.
The HLJ found that all three of the Criterion 2 standards were met in this
case: UWMC's project would improve the accessibility of services for underserved
groups; allow expansion of an institution with a wider range of services, programs
with better results, and staff with greater training or skill; and facilitate expansion
of a crowded institution with good cost, efficiency, or productivity. 	In support of
this, the HLJ made several factual findings: 89 percent of UWMC's patient days
come from outside the 	North 	King 	planning area; 	UWMC 	provides a 	higher
percentage of care for tertiary and quaternary areas including cardiology, high risk
pregnancy, oncology, and organ transplants than other providers in the state; 10
percent of UWMC's patient days come from persons who live outside the state;
the 	population 	in 	the 	Washington, Wyoming, 	Alaska, 	Montana, 	and 	Idaho
(WWAMI) region is projected to grow 11 percent over the next decade; UWMC is
at maximum effective capacity; many patients with complex medical needs in
Washington and the WWAMI region will not have other treatment options available;
UWMC provides the highest percentage of inpatient care to Medicaid recipients
out of any King County hospital except its affiliated hospital, Harborview; and
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No. 73454-7-1/17
UWMC also provides training to physicians as the WWAMI region's only teaching
hospital.8
Here, there is evidence in the record supporting the finding that UWMC's
project would improve the accessibility of services for underserved groups. 	The
evidence shows that, 	compared to other hospitals in the 	North 	King County
planning area, UWMC provides an above average percentage of charity care,
meaning care to patients with little to no ability to pay for health care. 	In 2011, the
UW Medicine system provided more than $300 million in uncompensated care.
During that time frame, UWMC provided 23 percent of its care to Medicaid patients,
and 7.5 percent to self-pay patients. 	This was at the high end of the range for
providers in King County. 	There is also evidence in the record that many of the
patients who are transferred to UWMC from other hospitals for complex care are
uninsured or receiving Medicaid—including patients that are transferred from
Providence's hospitals.
The record also supports the finding that UWMC's project would allow the
expansion or maintenance of an institution with staff possessing greater training or
skill, or a wider range of important services, or programs with evidence of better
results than 	neighboring and comparable institutions. 	The record shows that
UWMC has received numerous awards recognizing the quality of its acute care
services. 	Since the U.S. News & World Report began ranking hospitals in 1990,
UWMC has made its honor roll. And, in the latest rankings UWMC was ranked the
number one hospital in Washington. 	UWMC's organ transplant programs have
8 Finding of fact 1.8.
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No. 73454-7-1/18
been nationally recognized. 	In 2010, UWMC received two silver awards from the
Health Resources and Services Administration for outstanding transplant care in
its kidney and liver transplant programs. 	It also received a bronze award for its
kidney/pancreas transplant program. 	In 2012, UWMC received bronze awards for
its 	heart, 	kidney, 	and 	liver transplant 	programs. 	UWMC's 	organ 	transplant
programs 	have 	also 	been 	recognized 	by 	the 	Blue 	Cross 	and 	Blue 	Shield
Association. 	In 2013, UWMC was awarded a Blue Distinction for its positive
outcomes in lung, liver, and pancreas/kidney transplant programs.
There is also evidence showing that UWMC serves complex patients from
across the WWAMI region, not just within the planning area. 	Its cardiac surgery
service 	has 	the 	highest 	volume of heart 	transplant 	and 	mechanical 	assist
procedures in the state. 	In 2012, UWMC performed 20 heart transplants, placed
58 left ventricular assist devices and seven total artificial hearts, and put one
patient on extracorporeal life support. Ofthe most recent 99 patients, 12.1 percent
were 	from out-of-state. 	At the 	UWMC 	Regional 	Heart 	Center, 	which treats
complex cardiac patients, about half of the patients reside outside of King County,
and 7 or 8 percent reside out-of-state.
UWMC is also the training hospital for the only allopathic medical school in
the WWAMI region. 	There are 1,318 residents and fellows in training at UWMC.
The school's accreditation depends on its students handling a minimum volume of
cases. 	In many instances, these cases must occur at a single clinical site. And,
the UW School of Medicine is nationally recognized for its research—the greater
university is ranked the top public research institution in the country. 	Evidence
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No. 73454-7-1/19
supports the finding that additional beds would help UWMC train new physicians
and meet its research goals, which would benefit the wider WWAMI region.
The record further shows that neighboring and comparable institutions do
not provide the same level of care as UWMC. 	The other hospitals within the
planning area are either specialized, like Seattle Cancer Care Alliance, which is
limited only to oncology, or general community based hospitals, like Swedish's
Ballard 	hospital or Northwest Hospital. 	These 	hospitals are not capable of
providing the complex care that UWMC provides. 	And, there is evidence that
UWMC 	treats 	a 	higher percentage 	of patients 	in 	select 	quaternary 	areas,
particularly cardiology, oncology, and organ transplants, than other providers in
the state. Although Providence argues that UWMC has inaccurately represented
its 	share of complex 	cases,9 	it 	conceded 	in 	public 	comments 	and at the
adjudicative hearing that UWMC's total share of complex cases is higher than
other providers, and that UWMC provides more organ transplants and oncology
care than other providers in the state.
And, 	the evidence shows that UWMC 	is currently 	operating 	near its
maximum effective capacity. 	During 2011, the average midnight occupancy rate10
for UWMC's acute care beds was 78 percent. The Department generally treats a
9 	Providence 	has 	continually 	argued 	that 	UWMC's 	data 	analysis
misrepresents the percentage of its patients who receive complex care that is
unavailable at other hospitals. It has contended that UWMC's comparison ofcases
and services is a "cherry-picked" group of complex cases, inflating 	UWMC's
relative market share ofthese particularly complex cases. Providence asserts that
when analyzing a complete group of complex cases in the state, UWMC's total
share of the complex cases is only slightly higher than other providers.
10 Midnight is the lowest census point of the day. 	The average midnight
occupancy rate is also called the average daily census (ADC).
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No. 73454-7-1/20
75 percent occupancy rate as the ideal point for the efficient provision of services—
an occupancy rate above 75 percent begins to compromise access to health care
and often justifies additional beds. 	When looking at only UWMC's ICU beds, the
occupancy rate in 2012 was 84 percent for one unit and 92 percent for the other.
These high occupancy rates have resulted in UWMC having to turn away
patients. 	The director of the UW Medicine Transfer Center testified that in 2011,
UWMC had to deny transfers to around seven percent of patients because it had
no available acute care beds. During the public comment period, numerous health
care providers in the WWAMI region submitted letters explaining that patients who
have needed to be transferred to the UWMC have been delayed in receiving
treatment. 	And, they expressed concern that without additional acute care beds,
UWMC would deny transfers to patients in need of specialized care.
And, the population UWMC serves—the WWAMI region—is expected to
grow by over eleven percent in the next decade. Within that same population and
time frame, the age range of 65 and over, a group that receives a disproportionate
amount of acute inpatient hospital care, is projected to grow 36 percent.
It is not enough for Providence to show that there is some credible evidence
to the contrary of the HLJ's findings. 	Univ. of Wash. Med. Ctr., 164 Wn.2d at 102.
Instead, Providence must show that those findings were clearly erroneous—that
the entire record leaves this court with the definite and firm conviction that the HLJ
made a mistake. 	\± 	We conclude that there is substantial evidence supporting
findings offact 1.8,1.13,1.14, and 1.15, which found that UWMC established need
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No. 73454-7-1/21
under WAC 	246-310-210. 	Therefore, 	we 	hold 	that the 	HLJ 	did 	not err in
determining that UWMC met the need requirement.
III. 	Building Costs
Providence argues that UWMC's project fails the financial feasibility and
cost containment criteria, because UWMC omitted $34 million in building costs
from the application. 	It argues that, because these costs were not included in
UWMC's application, the Department has not analyzed the true costs of UWMC's
project. 	As a result, Providence claims that the HLJ's decision that the financial
feasibility and cost containment criteria were met is legally erroneous.
Both the financial feasibility and 	cost containment criteria touch 	on a
project's costs. WAC 246-310-220 lists three criteria on which a determination of
financial feasibility shall be based: (1) whether the immediate and long range
capital and operating costs can be met, (2) the cost of the project, including
construction costs, will probably not result in an unreasonable impact on the cost
of health services, and (3) the project can be appropriately financed. 	WAC 246-
310-240 also lists three criteria on which a determination of cost containment shall
be based: (1) superior alternatives, in terms of cost, efficiency, or effectiveness,
are not available or practicable,11 (2) if a project involves construction, the costs,
scope, and method of construction are reasonable and the project will not have an
unreasonable impact on the costs to the public of providing health services, and
(3) the project will involve appropriate improvements in the delivery of health
services.
11 See section V, infra.
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No. 73454-7-1/22
In its CN application, UWMC stated that its estimated capital expenditure
for the project was $70,771,363. 	It broke down its expenses into construction
costs, fixed 	and 	moveable equipment, 	architect fees, 	consulting fees, 	taxes,
financing, and CN fees. 	In reviewing the financial feasibility of the project, the
Department relied on its own experience and expertise to determine if UWMC's
pro forma income statements reasonably project that the proposal would meet its
immediate and long range capital and operating costs by the end of the third year
of operation. 	It noted that this project is part of a larger construction project, as the
physical shell for the 	proposed beds was already constructed as part of the
Montlake Tower project. 	After analyzing the cost of this project in relation to
UWMC's assets, the Department concluded that the project would not adversely
affect UWMC's financial health. 	The Department also concluded that the cost of
the project would probably not result in an unreasonable impact on health care
costs. And, it concluded that the project was appropriately financed. With regards
to cost containment, 	the 	Department determined that 	based 	on 	its financial
feasibility analysis, the criteria were met.
After the adjudicative hearing, the HLJ found that UWMC met the financial
feasibility requirements, even though it did not include the $34 million that itspent
to build the shell for the current project.12 	Responding to Providence's argument
that this expense should have been included in the construction costs, the HLJ
noted that UWMC was forthcoming about the relationship between the Montlake
12 This decision is reflected in findings of fact 1.3,1.4,1.17,1.18,1.19,1.20,
1.21, and 1.22.
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No. 73454-7-1/23
Tower project and 	the 	current project. 	He 	found 	that 	UWMC disclosed 	or
referenced the cost of the shell on three different occasions. First, in 2008, UWMC
filed a request for a determination of non-reviewability with the Department in
which it disclosed the cost of the shell. 	Second, in 2010, UWMC applied for a CN
requesting approval for an expanded neonatal service, in which it included the
expenses associated with the entire Montlake Tower project, including the shell.
UWMC did not finance the shell—it paid for the shell in full using cash from
UWMC's reserves. 	The shelled space then became an asset of UWMC, and its
ownership has not diminished UWMC's ability to pay the capital and operating
costs of the project. And, in UWMC's application for the CN at issue here, it stated
that the physical shell for the proposed beds was already constructed as part of
the Montlake Tower project. UWMC later clarified in response to the Department's
questions, that it had already provided all of the expenses for the Montlake Tower
project in the 2010 CN application.
From this, the HLJ concluded that it was not unreasonable for UWMC to
assume that it did not have to include the shell costs in its capital expenditure
budget for this project. 	Further, the HLJ pointed out that the crux of the financial
feasibility requirement is the reasonableness of the financing, and including the
shell costs in the capital expenditure costs would not have made the project
unreasonably expensive.
Providence asserts that UWMC was legally required to include the shell
costs, and the 	HLJ's contrary decision is legally erroneous. 	It cites to RCW
70.38.025(2) and WAC 246-310-010(10), both of which define capital expenditure.
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No. 73454-7-1/24
Both definitions provide that a capital expenditure is an expenditure "which, under
generally 	accepted 	accounting 	principles, 	is 	not 	properly 	chargeable 	as 	an
expense 	of operation 	or maintenance." 	RCW 70.38.025(2); 	WAC 	246-310-
010(10). 	Providence claims that this definition indisputably establishes that all
construction costs must be included in an applicant's capital expenditure estimate,
and therefore UWMC's estimated capital expenditure was legally inaccurate. 	But,
the shell was already paid for. No new construction of the shell was contemplated.
No financing for shell construction was needed; no debt repayment was identified.
Therefore, no negative impacts of construction costs or financing of the shell
existed nor needed to be evaluated under WAC 246-310-220 and 240.
We conclude that findings of fact 1.17, 1.18, 1.19, 1.20, 1.21, 1.22, 1.30,
1.31, and 1.32 are not clearly erroneous. Therefore, the conclusion that UWMC's
application satisfied the financial feasibility and cost containment criteria was not
legally erroneous or arbitrary and capricious.
IV. 	Superior Alternatives
Providence also argues that UWMC has not met the superior alternative
prong of the cost containment requirement. 	Providence alleges that a superior
alternative to this project would be to transfer less complex services from UWMC
to its affiliated hospital, Northwest.
As discussed above, WAC 246-310-240 contains three criteria that must be
assessed to determine whether a proposed project will foster cost containment.
One of these factors is if "[superior alternatives, in terms of cost, efficiency, or
effectiveness, are not available or practicable." WAC 246-310-240(1).
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No. 73454-7-1/25
But, the record supports the finding that Providence's proposed superior
alternative would not be feasible. 	UWMC has already transferred less complex
service lines to Northwest, including hip and knee replacement surgeries, hernia
surgery, midwifery, and its multiple sclerosis center. 	And, 	UWMC considered
shifting additional acute inpatient programs to Northwest as an alternative to the
current proposal. 	But, it determined that this alternative would require significant
investments—it would require the duplication of expensive equipment, as well as
the need for additional staff with the specialized training and knowledge base of its
UWMC staff. 	UWMC reasoned that because its staff largely support the entire
hospital, rather than a single unit, transferring patient lines to Northwest would not
eliminate staff or equipment from UWMC.
Northwest's director, Cynthia Hecker, testified that as a community-based
facility, Northwest delivers secondary and low end tertiary care. 	As such, she
explained that 	Northwest does 	not have the staffing expertise or equipment
necessary to provide the high end care available at UWMC.
In arguing 	that 	shifting 	services 	to 	Northwest 	would 	be 	a 	superior
alternative, 	Providence 	relies 	on 	a 	comparison 	of 	DRGs13 	to 	suggest 	that
Northwest provides "virtually all of the services offered by UWMC." 	Providence
points to the testimony of its expert, Dr. Frank Fox, who explained that he looked
at the DRGs that occurred at both UWMC and 	Northwest and compared the
lengths of stay for those DRGs. He concluded that when the DRGs and the lengths
13 DRGs are Diagnostic Related Groups, which is a common system of
labeling hospital cases.
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No. 73454-7-1/26
of stay were the same, the care delivery in terms of resource consumption would
be roughly the same. 	Dr. Fox's data showed that 91.5 percent of the DRG cases
he analyzed are also observed at Northwest.
But, Providence did not produce any evidence to show that Northwest has
the staff or equipment necessary to duplicate additional inpatient lines. 	Nor did it
show that Northwest has the capacity to accommodate the transfer of additional
patient lines. Hecker testified that Northwest currently has a 60 percent occupancy
rate during any given 24 hour period, but it usually reaches 100 percent occupied
during the middle of the week when patients come in for and recover from elective
procedures. 	Jody Carona, 	the 	principal 	with 	Health 	Facilities 	Planning 	&
Development, testified that if Northwest were to meet its target occupancy rate, its
available ADC would be 15.8. She explained that this is the only room for growth
available at Northwest. 	Yet, UWMC would have to relocate patient services lines
amounting to an ADC of 50 by 2015-2016 in order to avoid the need for the
proposed bed expansion. 	Thus, Northwest currently does not have the ability to
take on additional patient lines from UWMC such that would make it the superior
alternative here.
From this evidence, we hold that finding of fact 1.29, which found that
UWMC satisfied the superior alternative requirement, was not clearly erroneous.
V. 	Structure and Process of Care
Providence argues that UWMC has not met the structure and process of
care requirement, because it has not shown that its project will not result in an
unwarranted fragmentation ofservices. Providence asserts that, without a finding
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No. 73454-7-1/27
of numeric need for additional beds, UWMC's project cannot meet the requirement
that its project will not result in fragmentation of services. And, it contends that the
HLJ's finding 1.25, that UWMC's project would not create a surplus of the type of
beds that the beds will be used for, is unsupported by the record.14
WAC 246-310-230 sets out criteria for determining that a project fosters an
acceptable or improved quality of health care. 	These criteria include that "[t]he
proposed project will promote continuity in the provision of health care, not result
in an unwarranted fragmentation of services, and have an appropriate relationship
to the service area's existing health care system." WAC 246-310-230(4).
But, as discussed above, UWMC presented evidence that its tertiary and
quaternary services are not available at other hospitals in the planning area.15
Northwest Hospital does not have the equipment or staff to provide this level of
care. 	Swedish's Ballard facility is also a community-based hospital that does not
provide tertiary services. This evidence suggests that adding 79 acute care beds
at UWMC would 	promote the continuity of health care, 	rather than result in
fragmentation 	of services. 	Instead of duplicating 	services that are already
available in the planning area, UWMC's project will fill an existing need.
Therefore, Providence has not shown that the HLJ erred in finding that
UWMC's project will not cause an unwarranted fragmentation of services. 	We
conclude that findings of fact 1.25 and 1.26 are not clearly erroneous.
14 Providence also challenges finding of fact 1.26, which determined that
UWMC's 	project satisfies WAC 246-310-330's structure and process of care
requirement.
15 See section III, supra.
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No. 73454-7-1/28
VI. 	2012 CHARS Data
Providence also asserts that the HLJ erroneously decided to exclude 2012
CHARS (Comprehensive Hospital Abstract Reporting System) data, the most
current data available. And, Providence contends that it was materially prejudiced
by this decision.
The HLJ decided that he would not consider 2012 CHARS data. 	But, he
did not exclude the UWMC's annualized 2012 projections, instead deciding to treat
them 	as 	having 	the same 	inherent flaws 	as 	any 	projection 	has. 	The 	HLJ
determined that new data that comes in after the public comment period, too late
for the parties to incorporate it into the application, or too late for the Department
to integrate 	it into its evaluation should generally be excluded 	from 	the 	CN
decision.
The review officer concluded that the HLJ's decision to exclude this data
was supported by law and by the facts of this case. 	And, the review officer noted
that while the 2012 CHARS data would have been more correct than the 2012
projections, it was not so different as to suggest a different outcome.
This court reviews the health law judge's evidentiary rulings for an abuse of
discretion. 	Univ. of Wash. Med. Ctr., 164 Wn.2d at 104. 	The HLJ has discretion
to decide to admit or not admit evidence that came into existence after the public
comment period had closed. 	Id
Here, the public comment period closed on May 15, 2013. Afterward, both
UWMC and Providence submitted rebuttals to the public comments. 	The last
round of rebuttals were due on July 11, 2013. 	UWMC did not receive the 2012
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No. 73454-7-1/29
CHARS data until July 10, 2013. 	As such, this data was not available until after
the close of the public comment period. 	Neither UWMC nor Providence included
the 2012 CHARS data in any of their materials submitted to the Department. And,
the Department did 	not 	utilize the 2012 CHARS data in evaluating 	UWMC's
application. 	Based on 	these facts, 	the HLJ did 	not abuse his discretion by
excluding 2012 CHARS data from his review.
Providence claims that the HLJ's decisions regarding 2012 CHARS data
were prejudicial, because UWMC was permitted to use annualized 2012 data,
which Providence would have been able to rebut if the HLJ admitted the 2012
CHARS data. 	However, the HLJ specifically stated that he was taking UWMC's
annualized 	2012 	data 	as 	argumentative, 	rather 	than 	factual. 	He 	assured
Providence that he would filter out information that is simply argument, and that he
would view the projections as "less reliable." 	There is no evidence that the HLJ
gave these projections more weight than was appropriate. 	Instead, the HLJ relied
on 	the 2011 	CHARS data and 	Providence's own 	concessions in making 	his
findings on the most hotly contested issue, bed need. 	Providence has not shown
that the annualized 2012 data affected the HLJ's decision.
We affirm.
WE CONCUR:
OlMa, 	, 	Qlj^UaVcISLl* 	,
29