The Collaborative Surgery Center Certificate of Need Application Development of Ambulatory Surgery Center Docket Number GMCB-008-21con July 30, 2021 Collaborative Surgery Center submits this Certificate of Need Application (the “Application”) to the Green Mountain Care Board (“GMCB”) in accordance with 18 V.S.A. § 9434(a)(1), (6) and GMCB Rule 4.302(1). The Application requests a Certificate of Need (“CON”) to open a multi-specialty ambulatory surgical center called the Collaborative Surgery Center in Colchester, Vermont (the “Project”). The Collaborative Surgery Center Certificate of Need Application Development of Ambulatory Surgery Center Docket Number GMCB-008-21con July 30, 2021 Collaborative Surgery Center submits this Certificate of Need Application (the “Application”) to the Green Mountain Care Board (“GMCB”) in accordance with 18 V.S.A. § 9434(a)(1), (6) and GMCB Rule 4.302(1). The Application requests a Certificate of Need (“CON”) to open a multi-specialty ambulatory surgical center called the Collaborative Surgery Center in Colchester, Vermont (the “Project”). P a g e | 1 TABLE OF CONTENTS TABLE OF CONTENTS.............................................................................................................................................. 2 EXECUTIVE SUMMARY ........................................................................................................................................... 3 I. PROJECT NARRATIVE .................................................................................................................................... 5 A. AMBULATORY SURGERY CENTERS (ASCS) – A BRIEF OVERVIEW ............................................................................... 5 1. ASC Regulation ..................................................................................................................................... 5 B. WHY VERMONT NEEDS COLLABORATIVE SURGERY CENTER (CSC) ............................................................................. 7 1. ASCs Reduce Costs ................................................................................................................................ 8 2. CSC Will Help Alleviate Existing Shortage of Outpatient Surgery Capacity in Chittenden County ........... 11 3. Vermont Lags Far Behind Nationwide Trend Toward Increased ASC Outpatient Surgery Capacity ........ 13 4. CSC Will Help Vermont Attract and Retain Physicians .......................................................................... 17 5. ASCs Have High Levels of Patient Satisfaction ..................................................................................... 18 6. CSC Will Aid Advancement of Health Care Reform Efforts .................................................................... 20 C. COLLABORATIVE SURGERY CENTER FUNDAMENTALS ............................................................................................. 21 D. APPLICANT’S IDENTIFICATION, ORGANIZATION AND OWNERSHIP ............................................................................. 23 E. CHARITABLE FOUNDATION ............................................................................................................................. 24 F. FACILITY LOCATION ...................................................................................................................................... 25 G. FACILITY DESIGN, LEASE PROVISIONS AND PROJECT COST ...................................................................................... 27 H. STAFFING .................................................................................................................................................. 29 I. SCOPE OF SERVICES ...................................................................................................................................... 29 J. CHARGE STRUCTURES AND PATIENT SAVINGS ..................................................................................................... 31 K. UTILIZATION, REVENUES AND PROFITABILITY ...................................................................................................... 34 L. STAFFING POLICIES AND PROCEDURES .............................................................................................................. 35 II. CONSISTENCY WITH THE HRAP CON STANDARDS ....................................................................................... 37 III. CONSISTENCY WITH 18 V.S.A. § 9437 .......................................................................................................... 62 IV. CONCLUSION .............................................................................................................................................. 77 V. INDEX OF TABLES REQUIRED BY THE GREEN MOUNTAIN CARE BOARD ...................................................... 78 VI. INDEX OF EXHIBITS ..................................................................................................................................... 79 VII. INDEX OF SELECTED CITATIONS .................................................................................................................. 80 P a g e | 2 EXECUTIVE SUMMARY The Collaborative Surgery Center (CSC) files this Certificate of Need Application to construct a multi-specialty ambulatory surgery center (ASC) in Colchester, VT (the “Project”). CSC will consist of four operating suites and associated ancillary rooms totaling approximately 9,016 square feet. The Project is estimated to cost $2.4 million to renovate the existing building for use as a surgery center. Total Project costs including lease payments over 10 years, medical equipment purchases, and other soft costs are estimated to be $11.9 million. The women led CSC and its associated charitable foundation, the Collaborative Community Foundation (CCF), will offer significant benefits to Vermonters and Vermont’s health care system. A lack of operating room availability has impeded access to quality surgical care in this region for some time and the 2020 closure of Fanny Allen’s five operating rooms and two procedure rooms has made the problem more acute. There is a backlog of surgical cases and long wait times for patients, causing negative consequences in terms of patient health and satisfaction. The CSC will quickly and cost-effectively add surgical capacity to the region as it will utilize existing infrastructure and efficient design, reducing redundancy and cost. As the need for additional operating capacity is critical, and since the CSC can be up-and-running quickly, the CSC is requesting expedited review of this application. The Project will: • Improve patient access to necessary surgical procedures and help to alleviate longer than desired and harmful wait times. Affordable surgical capacity is particularly needed for orthopedic, ENT, urology, and dental procedures. The CSC will help to address this by including these surgical specialties as core procedures. • Reduce the cost of outpatient surgery for Vermonters to roughly half of what the same service would cost if performed at a hospital. Additionally, CSC’s prices will be transparent so patients will know the cost of their surgery ahead of time, easing stress and possibly prompting pursuance of needed care that might otherwise be delayed due to concerns about unknown costs. • Quickly and cost effectively deliver additional surgical capacity to Chittenden County without unnecessary duplication. The CSC will be housed in an already constructed building that will allow the project to be completed within 12 to 18 months. It will cost $2.4 million to fit up to ASC specification, an efficient figure relative to health care capital expenditures statewide and nationwide. • Be managed by women. Women still have strides to make in gaining equal access to opportunities and equivalent pay scales as men nationally and in Vermont. CSC will help to expand such opportunities. • Expand high quality, affordable surgical options to help meet the needs of Chittenden County’s growing and aging population and help respond to a massive industry shift toward more care being delivered in an outpatient setting vs in a hospital. As P a g e | 3 Chittenden County’s population ages, the need for surgical procedures grows, as does the need for outpatient surgical space. Vermont’s health care system must adapt to provide this care in a timely and cost-efficient manner. • Drive meaningful improvements in Vermont’s health care delivery system more broadly by distributing 50 percent of CSC’s profits to its associated Collaborative Community Foundation to support primary care, mental health and child counseling services, or other needed community services. • Offer a convenient, safe, and high-quality care option that is highly valued by patients and physicians. ASCs have high patient and provider satisfaction scores and can help recruit much needed specialty surgeons to Vermont. • Help move Vermont to be more in line with other states regarding adoption of ASCs as a high value health care option. Vermont is currently ranked 50th out of 50 states for the number of ASCs available to serve Medicare beneficiaries on a per capita basis. Vermont’s extreme outlier status leaves Vermonters with limited access to local lower cost alternatives to hospital-based outpatient surgery. • Aid advancement of state health care reform efforts around price transparency and payment reform, and encouragement of competition in the health care sector as outlined in President Biden’s July 9, 2021, Executive Order.1 The Executive