The Tennessee Health Facilities Commission voted 7–1 Wednesday to deny a certificate of need for a proposed outpatient cardiovascular center in Cookeville. Commissioners raised concerns about patient safety, staffing and whether the effects of duplicating services would benefit patients.

The proposed TN Heart Cardiovascular Surgery Center would have been located at 999 S. Willow Ave. Its estimated cost was $11,835,798. The facility would have performed selected outpatient cardiac catheterization and electrophysiology procedures, including cardiac ablations and the implantation of cardiac rhythm devices.

The Stern Cardiovascular Center would have owned the facility, with Atria Health supporting its development and operation. TN Heart physicians advocated for the project. Cookeville Regional Medical Center opposed it.

“This proposed center is the same model and same services offered at a recently approved cardiovascular surgery center in Memphis,” Lauren Gaffney, an attorney representing the applicant, said in her opening statement. “All numbers show the need for this project.”

The application said the center would improve access to care in its proposed four-county service area: Cumberland, Putnam, Overton and White counties. Cookeville Regional and Cumberland Medical Center in Crossville are the two hospitals in that area with cardiac catheterization labs.

Disagreement over access

TN Heart argued that patients experience delays scheduling outpatient procedures, including diagnostic cardiac catheterizations, pacemaker implants and cardiac ablations.

“Transitioning safe and appropriate outpatients procedures to an ambulatory surgical treatment center (ASTC) would alleviate current capacity constraints at CRMC and ensure that patients receive care in a setting that aligns with their clinical needs,” the application states.

TN Heart cited hospital-reported data in calculating that existing catheterization labs were operating above state capacity standards. CRMC disputed those calculations, saying some previously reported figures had been miscoded. TN Heart questioned the revised numbers, and the disagreement prompted extensive discussion during the hearing. Commission staff said the available data had limitations.

The application also pointed to projected population growth and an increasing number of older residents in the service area. It argued that an outpatient facility could offer an appropriate setting for selected patients who do not need hospital-based care.

TN Heart cited lower Medicare reimbursement for certain procedures at ambulatory surgical centers as a potential source of savings. Those estimates vary by procedure and do not establish what every patient would pay.

CRMC disputed the need for another facility and emphasized the hospital’s ability to respond immediately if a complication occurs during a heart procedure.

“Nearly 10 years ago, my mother underwent a cath and had to go into emergency surgery when they found a blocked artery,” Colton Smith told commissioners. “She was in the hospital, so the transition was quick. She would not be here today if that had happened in an outpatient setting.”

TN Heart said the proposed facility would treat patients selected for appropriate outpatient procedures and would have protocols for transferring a patient to a hospital if necessary.

Staffing questions

The proposed center projected 13.6 full-time-equivalent positions in its first full year, including 10.6 in direct patient care and three in other positions.

Commissioners questioned how the center would recruit specialized employees and what effect it could have on staffing at CRMC.

“It’s hard to recruit cardiologists and people to run the EP labs,” said Travis Swearingen, an attorney representing CRMC. “They are highly skilled positions and hard to find.”

TN Heart representatives said they would recruit locally and from outside the area.

Years of disagreement

TN Heart said CRMC had denied requests for additional lab space and equipment upgrades dating to 2018. It also said the number of recovery beds available for its cardiac procedure patients had been reduced from 15 to 12.

CRMC described investments it has made in its cardiac program. Swearingen said the hospital has spent millions of dollars over the past five years to meet the region’s health care needs, including renovations to its catheterization labs.

“The ASTC proposed by TN Heart will be less than three miles from CRMC and would impact the quality of the cardiac program at CRMC by unnecessarily diluting volumes and fragmenting care in a manner which could potentially harm patients,” Swearingen said.

Before the vote, commission staff told members they could approve all or part of the application. Commissioner Katie Evans moved to deny it, citing insufficient proof that the project would provide care meeting appropriate quality standards and that the effects of competition or duplicated services would be positive overall for consumers.

Seven commissioners voted for the motion to deny. Commissioner Tim Evans cast the sole vote against it. Dr. Steven Flatt, a retired physician from Putnam County, recused himself.

“While we are disappointed in the outcome, our goal is always to find ways to serve our patients better and will continue to do so,” said Debbie Hayes, CEO of TN Heart.

“Cookeville Regional Medical Center has been and will continue to be partners with our Tennessee Heart team in providing the cardiac care that patients deserve,” said Buffy Key, CRMC CEO.

TN Heart physicians retain privileges to perform procedures at CRMC, according to Hannah Davis, the hospital’s vice president of marketing and communications.

7–1
 The Tennessee Health Facilities Commission’s vote to deny the certificate of need. Tim Evans was the sole vote against denial. Dr. Steven Flatt recused himself.

$11,835,798
 Estimated cost of the proposed TN Heart Cardiovascular Surgery Center.

4 counties
 The proposed service area: Cumberland, Putnam, Overton and White.

2 hospitals
 Cookeville Regional Medical Center and Cumberland Medical Center have cardiac catheterization labs in the proposed service area.

13.6
 Full-time-equivalent positions the applicant projected for the center’s first full year, including 10.6 in direct patient care.

999 S. Willow Ave.
 The proposed Cookeville location.

Source: TN Heart certificate of need application and Sept. 23 Tennessee Health Facilities Commission hearing.

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