BY KELLY PRICE

Is a third children's hospital in Orlando too much of a good thing?

The Orlando area is already home to two fully-accredited children's hospitals: Florida Children's Hospital and the Arnold Palmer Hospital for Children.

Florida Children's Hospital is one of seven Orlando hospitals that make up Florida Hospital, which is owned and operated by Adventist Health System as part of the worldwide organization of the Seventh-day Adventist Church.

With the opening of the Winnie Palmer Hospital for Women and Babies last year, the Arnold Palmer Hospital for Children became a fully-accredited children's hospital under the umbrella of the Orlando Regional Healthcare system, which includes the Orlando Regional Medical Center, the only Level 1 trauma center in Central Florida.

Supporters of the two established hospitals believe that a third full-service children's hospital facility would be an unnecessary duplication of services, would escalate costs and would exacerbate a staffing situation that is already strained for subspecialty physicians and experienced nurses.

According to the National Association of Children's Hospitals and Related Institutions (NACHRI), only three markets that are comparable in size to Orlando (pediatric population of 100,000-250,000) have more than one pediatric hospital serving the community.

The Nemours Institute argues that a new full-service, top-tier facility children's hospital would greatly benefit the community, and recently announced plans to site the proposed facility in the Lake Nona area, about 14 miles southeast of the city.

The Nemours Institute is a 70-year-old organization founded and funded by a bequest from the estate of Alfred I. DuPont, who established a trust specifically for the care and well-being of children in Delaware and Florida. The Nemours Foundation is the primary beneficiary of the Alfred I. DuPont Testamentary Trust, which has assets of $4 billion. Nemours is one of the nation's largest health systems devoted to pediatric patient care, teaching, and research. It operates the Alfred I. DuPont Hospital for Children in Wilmington, Del., as well as major children's multi-specialty centers in Delaware, Florida, Pennsylvania and New Jersey. Nemours is the academic partner of Thomas Jefferson University and Jefferson Medical College.

Nemours has twice applied to the Florida Agency for Health Care Administration (AHCA) for a certificate of need (CON) to build a full-service children's hospital in Orlando. Both applications were denied in 2006 because the state felt Nemours had failed to demonstrate a need for another children's hospital in the Orlando area. AHCA also cited some architectural problems with Nemours' proposed site near the Mall at Millenia.

Nemours filed another letter of intent with AHCA in February and is in the process of preparing a third proposal for a CON, due April 18. At the same time, institute leaders are appealing the rejection of their first application and also considering appealing their second application.

Karen Breakell, spokesperson for Nemours, said "there is significant expense, approaching $50,000, for each application along with the necessary support material, but we're determined because we know this need is critical."

Dr. Ross Morgan, a pediatric surgeon who has practiced at both the Nemours Clinic in Orlando and Arnold Palmer Hospital, argues that an additional children's facility in the area is not critical, necessary or even wise. He points out that statistical projections and marketing plans made by Arnold Palmer Hospital have shown the number of existing or planned beds will be sufficient for the needs of pediatric patients in the community for the next 20 years. Duplicating services and facilities unnecessarily would drive up costs.

He also predicted the addition of another hospital would be a deterrent to attracting subspecialty physicians who might be interested in training or practicing in the area. Staffing at the current hospitals is already stressed, both for skilled nurses and physicians, and filling pediatric subspecialty positions could turn into a bidding war. Getting physicians to practice medicine in Florida is always challenging because of the state's skyrocketing malpractice premiums, he said.

Morgan points out that when Nemours first came to Orlando in 1990, they often said "they had no interest in being innkeepers." They planned to offer multi-specialty outpatient services in their clinic for children from all over the state. He felt that the synergy between the Arnold Palmer Hospital, which delivers inpatient services, and Nemours, with a multi-specialty outpatient clinic facility, showed great promise, and he is disappointed that this structure proved unworkable between the two groups.

Many of the physicians who joined Nemours when it first opened have resigned and returned to practice at Arnold Palmer Hospital. In the Nemours system, physicians are salaried employees and the system handles scheduling, appointments, insurance filing and malpractice premiums.

Dr. David Moser, a pediatric ENT surgeon who has worked in both systems and is now at the Nemours Clinic, said, "They relieve physicians of all the 'widget' parts of a medical practice."

According to Morgan, Nemours cut physician salaries and made unfulfilled promises to physicians who joined their staff. Morgan feels there are a number of needs for pediatric patients that aren't being met in Orlando at this time and that there is an opportunity for Nemours "to make a significant contribution" by offering services in the fields of pediatric transplant, inpatient orthopedic rehab, childhood obesity, mental health, research and education.

Morgan compares the idea of duplicating a well-planned and administered inpatient hospital by building another one nearby to the idea of adding another airport in a city that is well served. "Why do you need another one?" he asks.

Breakell says population growth speaks to the issue: the pediatric population in the Orlando area is the fourth most populated in the state and will grow to the third largest in the next 20 to 30 years, reflecting the fact that "families are moving to the area at the rate of 1,200 a day," she said. Additionally, Orlando's central location makes it ideal for access by patients in other parts of the state who are seeking a medical second opinion.

Breakell points out that the recent decision on the part of Nemours to position the proposed hospital in the Lake Nona area gives it a unique opportunity to be a part of a world class "medical city" destined for this area. In March, the Veterans Administration announced plans to build a new, long-awaited Veteran's Hospital at Lake Nona as part of a half-billion dollar medical complex. The State of Florida has chosen to site the new University of Central Florida Medical School at Lake Nona, and the largest-ever economic incentive package from the community has caused the Burnham Institute for Medical Research, an internationally recognized nonprofit life sciences research laboratory, to commit to build its East Coast branch within this "medical city."

In denying Nemours' requests to build an 87-bed, $246 million children's hospital, AHCA said that an additional hospital would aggravate staffing shortages in the area, compromise the ability to maintain innovative programs and/or quality standards, create operational inefficiencies and duplicate services. The new application of intent that Nemours filed in February 2007 said its plans now called for as many as 120 acute care beds and two neonatal intensive care units with up to 25 beds with a capital investment of $300 million, a significant upward revision of the denied plan. Nemours plans for a new hospital to include services for pediatric specialties such as pediatric rheumatology, allergies/immunology and dermatology, which do not exist at current area hospitals.

Nemours is not asking for any state or local incentives and will build the hospital at no cost to the community.

Breakell cites statistics from a study by the Milken Institute of California that show the proposed pediatric specialty hospital of this size would have a favorable economic benefit for the community and could result in 5,000 jobs during the construction phase and 2,500 permanent jobs when it opens, and it should bring about an increase in Orlando's lower-than-average wages, while increasing efficiency and quality of care. The economic impact report was sponsored by Nemours.

In declining the application for CON, the state pointed out that the Alfred I. DuPont Children's Hospital operated by Nemours in Wilmington, Del., is not considered to be in the top tier of children's hospitals in the United States. In the last month, that hospital has been named by Child Magazine to its list of top children's hospitals, ranking it at 34th in the country. DuPont Children's has never been listed on the U. S. News & World Report list of top children's hospitals, ranked by board-certified pediatricians and considered to be a more prestigious list. With the addition of the Winnie Palmer Hospital for Women and Babies, the Arnold Palmer Hospital will be eligible to be considered for this list for the first time this year.