Prime HealthCare Services-Kansas City, LLC v. State, Dep't of Health & Senior Servs., WD84723

CourtCourt of Appeal of Missouri (US)
Writing for the CourtKaren King Mitchell, Judge.
Docket NumberWD84723
Decision Date02 August 2022



No. WD84723

Court of Appeals of Missouri, Western District, First Division

August 2, 2022

Appeal from the Circuit Court of Cole County, Missouri The Honorable Jon E. Beetem, Judge.

Before: Janet Sutton, Presiding Judge, and Alok Ahuja and Karen King Mitchell, Judges.

Karen King Mitchell, Judge.

Prime Healthcare Services-Kansas City, LLC, d/b/a St. Joseph Medical Center (St. Joseph), appeals the judgment declaring 19 C.S.R. § 30-40.430(1)(M) (the 15-mile rule) valid.[1] St. Joseph


raises three points on appeal.[2] First, St. Joseph challenges, as against the weight of the evidence, the trial court's finding that the 15-mile rule is not arbitrary and capricious under § 536.014,[3]arguing that the evidence did not support a 15-mile geographical restriction on designation of level III trauma centers but, instead, supported a needs-based assessment of trauma center designation that incorporates travel times. For its second and third points, St. Joseph claims the trial court erred in finding that the 15-mile rule is not barred by article III, § 40(28) of the Missouri Constitution because there is no rational basis supporting imposition of a 15-mile geographical restriction on level III trauma centers. Finding no error, we affirm.


On April 11, 2018, St. Joseph, a licensed hospital, applied to the Missouri Department of Health and Senior Services for designation as a level III trauma center.[4] By letter dated May 10, 2018, the Department denied St. Joseph's application because St. Joseph "is located approximately 8.9 miles from St. Luke's Hospital of Kansas City (currently a Missouri level I trauma center) and approximately 9.4 miles from Research Medical Center (currently a Missouri level I trauma center)." Thus, the Department concluded that granting St. Joseph's application would violate the 15-mile rule.

On June 11, 2018, St. Joseph filed a complaint with the Missouri Administrative Hearing Commission (AHC) challenging the denial of St. Joseph's application and the validity of the 15-mile rule. The Department filed a motion for summary decision, which the AHC granted on January 29, 2019, affirming the Department's denial of St. Joseph's application based on the


15-mile rule but noting that the AHC lacks authority to declare regulations invalid or unconstitutional, issues which the AHC found St. Joseph had preserved for judicial review.

St. Joseph then filed a petition and an amended petition for declaratory judgment, judicial review, and injunctive relief. As relevant to the three points raised on appeal, the amended petition claimed that the 15-mile rule violated chapter 536 because the rule was "in conflict with state law, and/or is so arbitrary and capricious as to be unreasonably burdensome upon persons affected." St. Joseph also sought a declaration that the 15-mile rule is a special law prohibited by article III, § 40(28) of the Missouri Constitution.

A bench trial was held on February 11, 2021. Following admission of stipulated exhibits and opening statements, St. Joseph rested and moved for a directed verdict; the motion was denied. Two witnesses testified for the Department. Nicole Gamm, manager of the Time Critical Diagnosis Unit within the Department's Bureau of Emergency Medical Services, testified that Missouri hospitals may voluntarily apply for designation as time-critical diagnosis centers for trauma. There are three levels of designation with level I being the highest. Level I centers have the most resources and specialists. Level II centers are similar to level I centers, but are not required to have specialists for burns, limb reattachment, and pelvic and spine care. According to Gamm, level III centers "have very limited capacity, very limited resources, and basically [are] referral center[s], they usually work with a level I or II hospital to get the patient a rapid transport to one of those higher centers of care that have the specialists to take care of those patients."

Gamm testified that trauma requires multidisciplinary specialty care because different parts of the body may be injured and diagnosing the injuries is time critical. "[M]inutes matter with these patients," and the purpose of Missouri's system of designated trauma centers is to "get the right patient to the right place [in] the right amount of time." Gamm was not employed by the


Department when the 15-mile rule was promulgated and, thus, she could not speak to why the Department chose that distance.[5] But Gamm explained that Missouri's trauma center regulations are based on guidance from the American College of Surgeons (ACS).[6] The 15-mile rule allows patients who are "critical" to get "definitive care" in a reasonable amount of time. For example, level III trauma centers are not required to have a general trauma surgeon or an anesthesiologist on site at all times or have a fully staffed and available operating room, meaning a patient who is taken to a level III center may have to wait for lifesaving care.[7] And, if the patient needs to be transferred to a level I or II center to receive care, the delay in treatment caused by the transfer could increase the likelihood of a negative outcome. "People are hurt when they are delayed by going to an inappropriate center that does not have the capability and capacity to treat a severely injured patient."

Jeffrey Coughenour, a trauma surgeon at the University of Missouri/Columbia, testified that unrestricted expansion of trauma centers results in increased costs and dilution of patient volume which decreases the patient care experience of individual centers. He cited "a fairly sizable amount of surgical literature" describing a direct correlation between a trauma center's patient volume and experience and the quality and efficiency of care that center provides. "It is fairly widely accepted that a mature trauma system will decrease the risk of death anywhere from 15 to 20 percent." Dr. Coughenour believes 15 miles "is probably the best reasonable answer for avoiding multiple centers . . . be[ing] stacked up close to each other but still providing a more


uniform coverage for that particular area." He also explained that the ACS adopted a needs-based assessment tool for trauma center designation in 2015, but that tool has not been widely validated: Missouri is "still trying to work our way through how [the needs-based assessment tool] can be used."

In its judgment and order dated July 12, 2021, the trial court concluded that the 15-mile rule is "not so arbitrary and capricious as to be unreasonably burdensome on persons affected." The court found that professional opinion and surgical literature "support patients going to trauma centers with the volume and experience to handle [those] trauma patients," and the 15-mile rule is a reasonable limitation to avoid "the unrestricted expansion of trauma centers in Missouri that [would] dilute the overall patient volume and decrease the experience of any one particular center." The court concluded,

The Department has implemented this fifteen (15) mile restriction on level III trauma centers in order to ensure severely injured trauma patients are sent to trauma centers (level I and II) which can provide definitive care in order to ensure the best outcome for the patients. Level I and II trauma centers provide the subspecialties, staffing and resources to fully care for severely injured trauma patients thus reducing the morbidity and mortality of trauma patients, without requiring transfer to a higher level of care. Trauma patients get timely and medically appropriate care when they are sent to the higher levels of trauma centers (levels I and II) instead of the level III trauma center that is within fifteen (15) miles of the level I and II trauma centers.

The court also found that the Department offered evidence showing that the reasons for adopting the 15-mile rule have remained consistent since the rule was promulgated in 1998.[8] As for St. Joseph, the court concluded that the hospital "provided no evidence to dispute the [Department's] evidence that restricting level III trauma centers from being within 15 miles of


level I or II centers promotes state[-]of[-]the[-]art emergency medical services in the interest of public health, safety and welfare." As to St. Joseph's constitutional challenge, the court questioned whether state regulations are subject to the Missouri Constitution's article III, § 40(28) prohibition on special laws, but the court nevertheless considered the merits of St. Joseph's argument and concluded that the 15-mile rule is constitutional because it has a rational basis. St. Joseph appeals.

Standard of Review

"On review of a court-tried case, an appellate court will affirm the circuit court's judgment unless there is no substantial evidence to support it, it is against the weight of the evidence, or it erroneously declares or applies the law." Wilson v. Trusley, 624 S.W.3d 385, 396 (Mo. App. W.D. 2021) (quoting Ivie v. Smith, 439 S.W.3d 189, 198-99 (Mo. banc 2014)). We review questions of statutory, regulatory, and constitutional interpretation de novo. Reuter v. Hickman, 563 S.W.3d 816, 819 (Mo. App. W.D. 2018); In re E.R.V.A., 637 S.W.3d 100, 106 (Mo. App. W.D. 2021).


St. Joseph raises three points on appeal. In its first point, St. Joseph challenges, as against the weight of the evidence, the trial court's finding that the 15-mile rule is not arbitrary and capricious under § 536.014(3). St. Joseph's second and third points challenge the trial court's conclusion that the 15-mile rule is not barred by article III, § 40(28), of the Missouri Constitution.[9]We address each point in turn.


A. St. Joseph failed to prove that...

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