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Superior Court Filing 4AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services The answer is no. ASMC does not dispute that orthopedic ambulatory surgical services are available either in a hospital or freestanding ASC setting in HPA-3. Metro Atlanta has hundreds of orthopedic surgeons however few if any serve the prospective professional athlete patients that actively seek care from Dr. Andrews and his surgeon colleagues. For example, Dr. Andrews in his own estimate has performed about 4,000 UCL or "Tommy John" procedures. Few if any of his current and former professional and amateur athlete patients actively sought receiving this surgery at an Atlanta hospital or freestanding ASC or existing orthopedic group practice. These athletes actively bypass Atlanta orthopedic surgical providers because only a handful of orthopedic surgeons have successfully and consistently performed this procedure. Dr. Andrews for example revolutionized this procedure, by incorporating a different technique as described in this excerpt from an ESPN article from 2013: This is somewhere around Andrews' 4,000th Tommy John operation. (Thedoctor himself has lost track of the number.) The procedure involves harvesting a tendon from elsewhere in the body and using it as a graft. The graft is nestled into the remains of the damaged ligament, and the two are rolled up together,the cells of the tendon transmogrifying over time into the cells of a new UCL. No orthopedist other than its inventor, Dr. Frank Jobe himself, is as closely aligned with the Tommy John procedure as Andrews, mostly because of sheer volume. He has become its most practiced practitioner. But he has also made two important modifications to the original Jobe method. First, he moved the funny bone. The funny bone isn't a bone at all but a nerve (called the ulnar nerve) that runs from the vertebrae of the upper spine to the pinky finger, and that turns out to be white and thick and almost shocking in its nonorganic resemblance to an iPhone cord. It also runs straight across the UCL. In all Tommy Johns, the surgeon must move this nerve out of the way so he can engage unimpeded in the main surgical action. But instead of putting it back in its natural position, Andrews essentially leaves it where it is when he's finished. Thus, according to Andrews, the repositioned nerve makes it less likely these patients will aggravate their elbows--or have the pleasure of feeling that weird funny-bone-bonk sensation again. Second, to access the damaged elbow ligament,Andrews doesn't detach the muscle mass in the forearm that blocks it. Rather, he figured out how to get at the ligament by sticking his instruments underneath the muscle. The resulting procedure is less invasive." Source: ESPN On line Article titled"The doctor will save you now,"dated September 27,2013; page 9. (A copy is attached hereto as part of supplemental Appendix N-8) The amateur and professional athletes and other patients prefer(patient choice) treatment by Dr. Andrews and his colleagues (orthopedic and sports medicine physicians and Fellowes trained at the Andrews Institute in Pensacola and Birmingham, AL) will experience improved quality of care and geographical access by having this procedure available at the ASMC SS-ASC, particularly since no one in Atlanta is as experienced in performing this unique procedure than Dr. Andrews. A list of organizations to be associated with ASCM is attached hereto as part of supplemental Appendix N-8. They include the NFL, NHL, MLB, CFL, NBA, WNBA, WWE, MLS, USTA, US Youth Soccer,and numerous others. Secondly, ASCM's ASC's 4 ORs will be 624 square feet in size, so that not only can each OR accommodate the surgical team and various anesthesia, surgical instrumentation/equipment, monitors, etc., each is capable of accommodating surgical fellows in training. Dr. Andrews has a fellowship program for orthopedic surgeons and primary care physicians. Again,the surgery center will be orthopedic only. Thirdly, it is doubtful that any of the existing HOPD and freestanding ASCs incorporate an "observation" corridor in their respective Surgical Suite. The purpose of this observational corridor is to allow for parents, significant others and spouses to observe and actually communicate with the surgical suite staff during the procedure. For younger patients this often help alleviate their apprehensiveness about their procedure when their parents are just on the outside the OR watching from the observation window. The ASMC ASC will provide a site for continuing research and education of orthopedic sports medicine fellows through the Atlanta Sports Medicine Center—Research and Education Institute to be house on the ASCM campus; it is doubtful that any exiting HPA-3 ASC is s world class training facility for orthopedic surgeons perfecting their sports medicine skills. Thus, the proposed orthopedic ASC is a valuable source of patient quality care related research and State of Georgia:Certificate of Need Application Page 38.4 Form CON 100 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services training not commonly if at all, available in any similar existing ambulatory surgery service. An article abouDr. Andrews work to prevent youth injuries is attached as part of Appendix N-12. (Noted Surgeon Dr. James Andrews wants your young athlete to stay healthy by playing less, www.cleveland .com) HOPD's do not include on-site integrated dedicated ambulatory surgery facilities with comprehensive sports rehabilitation and performance training facilities. For this noaoon, none of the existing HOPDs in HPA-3 are comparable or similar to ASMC ASC, Secondly, none of these HOPD'scurrently orprospectively are the finotchoice of professional athletes in need of orthopedic ambulatory surgical semices. they commonly bypass HPA-3 andGeorgiaHOPDs, electing to go to the Andrews Institute ASC in Pensacola or seek similar surgical services in other states. Metro Atlanta has extensive hospital-basej and freestanding ambulatory orthopedic surgical r*nouumn, however, none incorporate all of the professional tmining, patient pre, intra and post-operative sports medicine services at a single site such as the proposed ASMC campus. For this reason, ASMC SS-ASC is unique and distinct physically,operationally, and in terms of a significant proportion of its prospective patient population (professional athletes)from these HOPD and freestanding ASCs in HPA-3. ASMC's campus includes facilities and a well-documented pre and post-operative physical and sports injury therapy program which has proven to be integral to surgical success. Prior to surgmry, many patients benefit from a pre surgical therapy assessment and exercise followed by post-operative immersion in a rehabilitation and recovery program within days of their procedure, Provision of a full-range of post-operative naoovery, rehabilitation andperformancetrainingisnotcurrentlyavailableatonelocationatanyHOPDorfreestandingASCinHPA-3. An enhanced site plan is attached as supplemental Appendix 1-4. It is doubtful that any HPA-3 ASC or HOPD ambulatory surgery service has comparable and extensive direct referral relationships with professional sports franchises, professional trainers and medical staffs of these franchises as does the Andrews Institute. These professional athletes, many who live in Georgia, bypass Georgia services and commute out-of-state for their orthopedic sports injury medical care; a definitive indication that the Andrews Institute ASC is unique and that existing H[)PD and freestanding ASCs do not provide a comparable range of medical, nurgiuoi, nahebi|itytion, training, research and educational services as proposed on the campus of the ASMC. Thus, there is a definitive population that this project, in particular the ASMC SS-ASC will remedy an existing atypical quality(provision of Tommy John surgery for example)cost and geographic access barrier(eliminate personal costs associated with out-of-state tnave|, a particular hardship for Georgians who cannot afford the costs of travel to Pensacola)to a comprehensive integrated orthopedic and sports medicine facility that includes a broad range of services not limited to orthopedic ambulatory surgery samice, sports medicine tnoinin0, research and education facility; and rehabilitation and performance training not currently available in HPA-3 or anywhere else in Georgia. ASMC SS-ASC will remedy an atypical cost,quality and geographical access barrier for a defined population. Additional support letters describe the experience of Georgia amateur high school and college athletes and their families who at great expense elected to go to the Andrews Institute ASC because their children did not have favorable orthopedic surgical outcomes here in Metro Atlanta, but did so under Dr. Andrews' care (supplement to Appendix M). These letters indicate in these particular cases, that Andrews Institute ASC is a destination facility because it is not only perceived to provide quality patient care it is oftentimes improves upon former orthopedic care rendered by other providers. The letters of support demonstrate that a need exists to improve availability, and access to quality and geographically accessible broad spectrum orthopedic sports medicine services in 8eorgio, thereby reducing the need for Georgians to travel out-of-state for such services. Andrews Institute achieves success in patient care and outcomes because it offers a well-integrated and seamless provision of pre, intra and post-operative rehabilitative services crucial to favorable patient outcomes. Patients are not referred to unrelated therapy and rehabilitation oemiceo, often miles from the hospital or ASC. A common theme in the letters of support from former patients is that they were unsuccessful in obtaining comparable quality of care in State of Georgia:Ceitificate of Need Application Page 38.5FormCON100 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services Georgia; and that their patient experience at the Andrews Institute was more favorable and they experienced a better outcome than previous orthopedic surgery performed in Georgia. None of these existing facilities in metro-Atlanta presently compare to the broad range of prospective sports medicine services that ASMC will have on-site in a single location. The many letters of support are direct indicators that Georgians have elected to leave the state because of actual experience or perception that Andrews Institute ASC is a better quality of care alternative,even though it entails significant personal sacrifice and travel related costs. Not all amateur athletes have access to financial resources to afford the travel costs to make the trip to Pensacola, so they do not have access to this level of care. Appendix M contains around 150 support letters, many of which are from professional and amateur athletes, coaches, trainers, sports agents, etc. One letter, from Paul Kinzer, MLBPA Certified Agent mentioned how it was inconvenient for an injured professional baseball client to travel to Pensacola. Another letter from Karen L. Colen, states how difficult it was for her daughter to travel to Pensacola from the Atlanta area to receive ACL surgery then return and receive physical therapy services from Gina Lee, PT. She explained how difficult it was for her daughter to tolerate the pain of travel that if ASMC was here it would have relieved much of that hardship. Diana Colen, the daughter wrote her own support letter, saying how she consulted with two Georgian orthopedic surgeons, who each recommended a different repair procedure and decided to use Dr.Andrews'different approach to her procedure. She further explained the difficulty she encountered in maintaining her post-op rehabilitation, having to drive one hour one way 4 times per week to receive physical therapy services from Gina Lee at her Lawrenceville. Ms. Lee has a long standing professional referral relationship with Dr. Andrews and provides physical therapy rehabilitation services to many of his Metro Atlanta athletes and patients. Recently, John Smoltz thanked Dr. Andrews when he was inducted into the Baseball Hall of Fame and Mr. Smoltz also provided letters of support for the project. (A copy of Mr. Smoltz's Hall of Fame speech is attached as part of Appendix N-12 and his letters of support are part of Appendix M) Peter Moylan, another of Dr. Andrews patients,was recently activated with the major league Braves and pitched again at the age of 36. (See, Peter Moylan ready for call-up in comeback, Albany Herald, August 15, 2015, a copy is attached as part of included in Appendix N-12) There are similar "testimonial" letters from Haley Worthy, Chuck and Regina Rosenblum, and their son Justin additional support letters). A common refrain is that their experience in receiving orthopedic surgery and rehabilitation services from and through Dr. Andrews exceeded what they had experienced in Georgia. These families obviously expended the time and financial resources to access alternative orthopedic ambulatory surgery at the Andrews Institute in Pensacola, FL. They each point to their local experience as not being as favorable and not comparable in terms of quality of care. For families of amateur high school and college athletes who cannot afford the cost of out of state travel and extended hotel stays in Pensacola, the ASMC SS-ASC will remedy this cost and geographical access barrier to high quality orthopedic ambulatory surgical services. As noted, ASMC SS-ASC's prospective patient population is comprised of people who prefer receiving orthopedic surgery in a facility with an excellent patient outcome reputation and access to surgeons,therapists, and support staffwithextensiveexpertiseandexperienceinthetreatmentofsportsrelatedinjuries. ASMC has a unique patient referral network around the US and the world, most of these patient referrals are direct and therefore would not be treated at any local HOPD or freestanding ASC in HPA-3. Many of the Georgians who travel to Pensacola receive primary medical and even orthopedic diagnoses and rehabilitative services locally, but either because of pastproblemswiththeirpriorsurgeryorrecommendationsfromtheirlocalphysician, coaches and trainers, they are referred to the Andrews Institute ASC. Clearly, it would be difficult for many HPA-3 amateur high school and collegeathletestoaffordthecostoftravelandrelatedovernightexpensesfortheirfamiliestogotoPensacola, so they are dependent on receiving localized orthopedic and related rehabilitative care. ASMC's indigent and charity care program will help some of these athletes who cannot afford the cost of their orthopedic surgery and rehabilitation; and because of ASMC's SS-ASCs location it will definitely improve and remedy a geographic and cost barrier particularly for those who cannot afford the personal expense to travel and stay for extended period in Pensacola. For these reasons, ASMC SS-ASC will remedy an atypical access barrier to quality, cost and geographically accessible orthopedic ambulatory surgical services specifically targeting a unique population of professional andamateurathletesinGeorgia,the US and from other nations.ASMC SS-ASC will be a primary source of Tommy John surgery, which is limited to only a handful of capable surgeons nationally, with Dr. Andrews performing more than any other orthopedic surgeon. Provision of this particular procedure will in fact remedy an atypical quality and State of Georgia:Certificate of Need Application Page 38.6 Form CON 100 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services geographical access barrier to this procedure since currently athletes bypass Georgia HOPDs and ASCs to obtain this procedure at the Andrews Institute in Pensacola. Pensacola simply does not provide the improve geographical accessibility of Atlanta's closer geographic proximity and direct flight access to major population centers, colleges and professional sports franchises. Not to mention Metro Atlanta's population of hundreds current and former (retired) professional, amateur high school and college athletes, and recreational athletes that are former and current patients of the Andrews Institute in Pensacola. ASMC will provide the following programs: A) HIGH SCHOOL OUTREACH PROGRAMS Provide High Schools With Athletic Trainers Provide High School Physicals For Every Sport Provide Saturday Moring Clinics For Injured Football Players Provide Education For Coaches,Athletes And Trainers,Coaches Clinics Provide Medical Services For Uninsured High School Athletes Provide Instructional Lessons And Camps For High School Athletes Provide Sports Performance Training For High School Athletes Provide Mentorship Programs By Professional Athletes To High School Athletes B) HOST SITE FOR NFL PROGRAMS Play 60(Program To Encourage 60 Minutes Of Physical Activity A Day) Fuel Up To Play 60(Program To Encourage And Educate Youth On Healthy Food Choices To Be Able To Be Active For 60 Minutes A Day) NFL Concussion Center(Pian To Develop A Concussion Center That Will Be A Center For Nfl Players Once They Have Been Diagnosed With A Concussion)The Trust-(Nfl Organization That Provides A Transition Plan For Former Players.We Plan To Be A Partner With NFL To Provide Those Services For Medical, Career, Nutrition, Continuing Education,And Entrepreneurial Services) C) HOST SITE FOR MLB PROGRAMS Pitch Smart(Program To Help Young Pitchers Reduce Arm Injuries By Providing Comprehensive Resources For Safe Pitching Practices) Play Ball-(Hosts Educational Resources On Health And Safety For Coaches, Umpires, Parents,And Players) One Baseball-(Program To Allow All Youth The Opportunity To Play Baseball No Matter What Economical Status Inspire Baseball-(Program To Keep Youth Interested In Baseball Programs) D) HOST SITE FOR OTHER PROGRAMS- Stop(Sports Trauma And Overuse Prevention)-Program Raises Awareness And Provides Education On Injury Prevention,Smart And Safe Play To Extend A Child's Carrer, Improve Teamwork, Reduce Obesity Rates, And Create A Lifelong Love Of Exercises And Healthy Lifestyle)Program To Provide Sports Medicine Care To Wounded Warriors,Allow Them To Interact And Train With College And Professional Athletes(Eagle Fund is the program in Florida and a similar program will be based at the ASCM campus) Wounded Warrior(Provide Medical Care And Resources For Wounded Military Men And Women) Folds Of Honor(Programs For The Families Of Military Members) Kids Serve Too(Program For Kids Of Military Families-Provide Educational Services In Sports Medicine, Sports Camps, Life Changing Experiences At Our Faciity With Professional Athletes)Safe Kids Usa(Program To Protect Kids From Unintentional Injuries-Provide Education On Prevention Of Sports Injuries) State of Georgia:Certificate of Need Application Page 38.7 Form CON 100 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services Team Holyfield Foundation(Evander Holyfield)-Program To Influence Others On Faith,Family, And Foundation To Succeed In Sports And Life Special Olympics(Program For Individuals With Disabilities-Provide Camps And Host Site For Special Olympics Events) Make A Wish Foundation(Provide A Child The Opportunity To Fulfill A Wish With A Professional Athlete At Our Facility) Boys And Girls Club(Provide Sports Camps And Mentorship Programs With The Youth Involved) Big Brothers, Big Sisters(Provide Mentorship Programs With Professional Athletes And Staff At Asmc,Llc.) Community Providers Programs(Provide Programs For Training,Fitness,And Health For Local Policemen And Firefighters) Outreach Educational Programs(Educational Sports Medicine Programs For General Managers, Managers, Coaches,Agents,Scouts,Medical Doctors,Trainers,Physical Therapists,Strength Coaches,Occupational Therapists) ASCM Indigent and Charity Commitment ASMC's SS-ASC is making a 5% indigent and charity care commitment; only a few HPA-3 ASCs currently have a similar commitment level. The table on the next page lists HPA-3 freestanding MS-ASCs, Single-Specialty ASCs, and "LNR ASCs." The second column titled "Percent" is each facility's CON related indigent and charity care commitment. Only one MS-ASC (Northside/Alpharetta Surgery Center) has a 6% commitment; approval of this project was in-part based on its higher commitment level and the lack of comparable commitments and provision of uncompensated indigent and charity care by similar ASCs in HPA-3. Only 9 of HPA-3's total of 16 MS-ASCs actually have CON indigent and charity care commitments. OHP in its approval evaluation of the Northside/Alpharetta MS-ASC found pursuant to the exception rule that lack of such a commitment and provisions of low amounts of uncompensated indigent and charity care by existing multi and single specialty CON approved ASCs supported a finding of an atypical financial access barrier. Continued on next page State of Georgia:Certificate of Need Application Page 38.8 Form CON 100 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services Freestanding ASC Indigent/Charity Care CommitmentsPercentSubtypeCountyFacilityName1' 0 lib Muth-Specialty Fulton NorthsideJAlpharelta Surgery Center20133Singe-Specialty Henry PairrUare Center of Georgia3' 0.02 Nol Applicable Fayette Soulhern Pain Institute,P L.4 CF-0.3 IVIulti=Specially Cherokee -Advanced-Surgery Center Ut Lieorge5' I1133 Celled-Purpose Fulton Atlanta tye Surgery Center at Ormi westb' 0.03 Lorded Purpose Deka) Girt!Valley Clinic0.03 Il/Tulti--Specialty Uayton Spivey Station-Surgery Centerb00.3--Lirreled Purpose Fulton tenter For Reconstructive Surgery9' 0 03 Multi-Specialty DeKalb Northlake Surgical Center100.03 Multi-Specialty 1-orSyth Northw oodg-Surgery Center,LLC11U.0.3-Multi-Speciatty Cobb Marietta Surgical Center11003191ulti=Specially Cobb hast-VVest--Surgery Center130113Linrrled-PurpOse Fulton Atlanta Center tOr Reconstructive-Foot and Ank140.03 Muth-Specialty Fulton Childreffs Mealthcare of Atlanta Surgery,Mench150.03 Limited Purpose Fulton Tenter for Pain Management(the Emory Clinic)16' 0.03 Crated-Purpose Fulton Rosw elltenter tor-Foot and Ankle Surgery1/' U U3 Multi-Specialty DeKalb brory Orthopaedic and Spine I-Mysiatry Uiltpati15' 0,03 Lrrded Purpose 1-uRon Milton Fiall-Surgery Center190.03 Limrtedikarpose Dayton Clayton Cataract ancFLaSer Surgery Center20ULMSingle-Specialty Rockdale interventional Spine and Pain Management Arrty21LT.U5"Single-Specialty Fulton Atlanta Aesthebt Surgery Center210.03 LNKASC. ULKALB "Northlake bioscopy CenterU.0.3- 'I!'ASC. telkab DeKall,Lerfter for Foot arid Ankle Surgery,LLC1403,13 ENR A-St COBB Foot-Surgerylenter, me25' 0.03 ENHASC ULSALB 'Atlanta thdoscopy Center,LW.lb IluS chili ASC. UF_KALE3 uekatti Endoscopy Center110.11.3 LNKASC l'.1-1ERUPLI=E North Lieorge Endoscopy Center,Inc2511.03 CFR AST. rFULTOR -brory Aesthetic Center291.1.11.3-1-NK ASL 3CiVVINNET i -Northsidel-odU&Ankle UutpatSti0.113 Llkitt AUL 1-UL MN -Lerner For-Plastic surgery31U.0(37ENK ASC liEW-Fti, Georgia Upthalmologets,LIG32LE-U3 LA-S1, LUATTON -Antulatory Laser&Surgery Ur33U.LISDNHASC FULTON Northside surgery Center,Inc.34 0.03 LNKASC. FULTON -Specialty Surgery Center,Inc.35 0.03 LNRASC HL ION -Surgical-Suite, [Fie 313' LT-03 [NH SC FULTON -Resurgens Surgical Center310332 [NH ASL. FULTON Atlanta AesthetiC andlietonstructive Surgery35UlmL-NRASt CLAYTON -al.tridoscopy Center39' 0.03 LNK ASL; CLAY ION Clayton outpatient burg Ur40' Il.0.3 [NHASC FUL.ION -Rodengue SurgFcenter,Inc.41 0.01-1-lei ASC COM LAHJKLAA PA1N SPINt LEN!tHi,CLL.;41- 0.02 LNKASC DCIUGLAs -L.111iTS-URUERY CIN I EK.343' 11132 LNK AbC NtVV IUN -ISFTill-A-SG A 1-LOVING ION,LLL44' 0.02 LNKASC FAULLArvu U-11.01SUKUERY Whitt("245' 0.02 LNKASC FULTON "Windward Surgery Center LLC4b' 0.01 LNK ASC.. 1-UL I UN -Bucichead Mobs Surgical Center,LLC - 41 0.01'LNK ASL. ULICAL13 Gastro Specialists Endoscopy Center,CLL.45 0.02 L NH AbC FENKY Georgia Fein Management Center,LLC49C.02 LNK ASC COBB GA Urology,PA Cobb Ambulatory Surgery Len505IJU.Cri-L-NHA-SC COBB FIrinace-Ckillopaedics Surgery Center-Austell,51 0,02'MKASC FUL1UN 'L.xV1SU Rosw eh,FG.51 0.04 LNKA-SL. FullOn NASA Surgery tenter,LLC53' 0.03 LNHASC Fulton Dennis Surgery Center,INC540.01 [MASI- Fulton Georgia Endoscopy Center,LLC55' 0.111 LNK ASC. Rockdale Southern Cross Surgery Center,LLC5430A.12 LNKASC 13w mnett jt'w inner-Surgery Center,LLC510.02 [NRS[, Cherokee -bastrointeslinal Diagnostic bricio Vvogdstock,Ltbe0.02 LNKASC theroe -Pinnace Ortho burg Ur-Woodstock LLL j59' CHM LPIR ASC.' Fulton Peachtree UrthOpaedic Surgery Center at Pereba01)2 LNK AbC Cherokee "Northwest 1:141 Surgery Centerbi1102-L-IWA-SC Forsyth North Atlanta Eye Surgery CenterdiULULNKASC. Henry 171inirnally Invasive NeuroSpine&Pain Institute1330.01 LNKASC 1-unon Atlanta Orthopaedic-Surgery Centerb40.01 LNKASC. Cobb Reiner Ambulatory Surgical Center,CLL. ,b5 0.02 [NH ASC Fulton 1SHVIASC at-Marron!bb' 0.02 LNK ASC DeKalb Fanola Endoscopy Center620.02 LNKASC Futon Atlanta General and BanaTric Surgery CenterbIT0.02 LKIKASC. 13w inneR -AdvanCed Urology Surgery Centerb90.04 LNH AbC Fulton Feachtree bluckhead Surgery CenterLT13.01 LNK AM. Douglas center tor spine Intervention AbC 1Source:2014 FSASC.Database. State ofGeorgia:Certificate of Need Application Page 38.9FormCON100 AMENDED Response to CON Rules 111-2-2-A0 for Ambulatory Surgery Services ASMC SS-ASC INDIGENT AND CHARITY CARE PROGRAM OVERVIEW,the process to provide direct unfettered access to ASMC SS-ASC's indigent and charity care program: ASMC SS-ASC will have a web site portal that will allow any prospective patient to apply on-line for consideration to receive uncompensated indigent and charity care. Financially indigent and charity patients who are medically qualified for orthopedic ambulatory surgical services will have all of their professional, diagnostic and surgery charges waived. High school coaches and trainers will be able to assist their student athletes without personal computers,to access the ASMC web site. ASMC SS-ASC main phone can be used by a prospective indigent or charity patient (not limited to just amateur athletes)to inquire about accessing the indigent and charity program.ASMC SS-ASC will have a financial counselor to handle all uncompensated indigent and charity care patients. Patients who qualify for this program will receive the following benefits: a) Such residents will receive coordinated medical, diagnostic, ambulatory surgery, and rehabilitation services at little or no cost. b) ASMC SS-ASC will waive the facility fee and professional fee component charges for medically and financially indigent patients. c) All of ASMC SS-ASC participating physicians and surgeons will waive entirely or only charge a nominal fee for patients in the program,for pre and post-surgery office visits. d) ASMC waive or charge a nominal fee based on a sliding scale fee schedule for laboratory, and conventional and advanced diagnostic imaging services. Georgia high school athletic program directors and coaches will be supplied a specific username and password to access the ASMC website to schedule appointments for uninsured financially indigent and charitable students who are unable to obtain similar services locally.The web site will allow a prospective patient to fill-out the necessary pre- admission forms and request for fee waiver, while scheduling an appointment to see an ASMC physician. High school student requires surgery based on local physician recommendation and diagnoses will be pre-scheduled for all related services when they are commuting well beyond a reasonable travel distance and time so to avoid a need to schedule multiple visits when possible. Dr. Andrews has been at the forefront of education of youth sports coaches and player such as the Pitch Smart program in connection Major League Baseball. Dr. Andrews book, Any Given Monday, Sports Injuries and How to Prevent Them for Athletes, Parents and Coaches — Based on My Life in Sports Medicine, New York, Simon & Schuster, Inc. 2014, is a leading treatise on educating all who participate in sports at any level. The Pitch Smart Program is explained by Dr. Andrews and other MLB personnel at m.mlb.com/pitchsmart. A copy of the FAQ prepared by Dr. Andrews is attached hereto part of Appendix N-12. Dr. Andrews also contributes to Stop Sports Injuries which can be found at www.stopsportsinjuries.orq. A copy of the material relating to baseball injuries is attached here as Appendix N-13. Likewise, American Sports Medicine Institute provides information related to the Pitch Smart program on its website, www.asmi.arq. A copy of some of the materials is attached here also is included as part of Appendix N-12. The Wounded Warriors project started by Dr.Andrews in Florida is a good example of the type of program to be established in Georgia and will offer veterans an opportunity to participate in rehab programs. A list of programs to be hosted at the ASCM campus is identified above. The Atlanta Sports Medicine Research and Institute Center will play a significant role in education and research for prevention,treatment and rehabilitation of sports related injuries. A summary of the Institute's function is attached as Appendix N-14.. c) Each applicant shall have a hospital affiliation agreement and/or the medical director must have admitting privileges and other acceptable documented arrangements to insure the necessary backup for State of Georgia:Certificate of Need Application Page 38.10 Form CON 100 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services medical complications. The applicant must document the capability to transfer a patient immediately to a hospital with adequate emergency room services. RESPONSE: See Appendix N-1,a copy of a hospital affiliation and transfer agreement. d)An applicant shall submit written policies and procedures regarding discharge planning. These policies should include, where appropriate, designation of responsible personnel, participation by the patient, family, guardian or significant other, documentation of any follow-up services provided and evaluation of their effectiveness. RESPONSE: Appendix N-2 is a copy of draft Discharge Policies and Procedures. e) An applicant shall provide evidence of a credentialing process that provides that surgical procedures will be performed only by licensed physicians who have been granted privileges to perform these procedures by the organization's governing body. RESPONSE: Appendix N-3 is a copy of draft Physician Credential Application form. f) An applicant shall assure that an anesthesiologist, a physician qualified to administer anesthesia, an oral surgeon, or a nurse anesthetist trained and currently certified in emergency resuscitation procedures is present on the premises at all times a surgical patient is present. RESPONSE: Appendix N-4, Anesthesia services verification. A letter from the proposed anesthesia provider is attached verifying its commitment to stay on the premises at all times a surgical patient is present. (See, supplemental to Appendix N-4) g)An applicant shall submit evidence that qualified personnel will be available to insure a quality service to meet licensure, certification and/or accreditation requirements. RESPONSE: Appendix N-5, a draft Personnel Recruitment and Retention Plan and copy of a partial Dr. Andrews Curriculum Vitae(original is 168 pages, first 19 pages supplied).We have also enclosed Dr.Andrews new Georgia license. h)An applicant shall submit a policy and plan for reviewing patient care, including a stated set of criteria for identifying those patients to be reviewed and a mechanism for evaluating the patient review process. RESPONSE: Appendix N-6 draft peer review policies and procedures. i) An applicant shall submit written policies and procedures for utilization review consistent with state federal and accreditation standards. This review shall include review of the medical necessity for the service, quality ofpatient care,and rates of utilization. State of Georgia:Certificate of Need Application Page 38.11 Form CON 100 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services RESPONSE: Appendix N-7 draft utilization review policy and procedures. j) An applicant shall provide a written statement of its intent to comply with all appropriate licensure requirements and operational procedures required by the Office of Regulatory Services of the Georgia Department of Human Resources. RESPONSE: ASMC, LLC intends and will comply with this regulation.Acknowledgement of said intent to comply is evidenced by applicant's authorized representative's signature on page 39 of this CON application form. ASMC, LLC hereby commits to abide by and comply with applicable CON Rules and Regulations, and to additionally upon completion of the proposed Surgery Center, it will ensure that the Center satisfies any and all applicable licensing Rules and Regulations enforced and administered by the Healthcare Facility Regulation Division, Georgia Department of Community Health. k) An applicant for a new ambulatory surgery service shall provide a statement for the intent to meet, within 12 months of obtaining state licensure, the appropriate accreditation requirements of the Joint Commission for Accreditation of Healthcare Organizations jJCAHO), the Accreditation Association for Ambulatory Health Care (AAAHC), the American Association for Accreditation of Ambulatory surgery Facilities,Inc.(ASF)and/or other appropriate accrediting agency. RESPONSE: ASMC, LLC simultaneously or as soon as possible following receipt of an Ambulatory Surgery Treatment Center license pursuant to HFR Rules 11-8-4, SCL will apply for"deemed status" Medicare Certification and Accreditation inspection. Within 12 months of receiving a ASTC license permit, ASMC, LLC will apply for accreditation from one of the three(3) national accreditation organizations. I) An applicant for an expanded ambulatory surgery service shall provide documentation that they fully meet the appropriate accreditation requirements of the Joint Commission for Accreditation of Healthcare Organizations(JCAHO), the Accreditation Association for Ambulatory Health Care(AAAHC), the American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (ASF) and/or other appropriate accrediting agency. RESPONSE: Not Applicable.Not an expansion project. m) An applicant shall provide documentation that charges are reasonable compared to other similar surgery services serving the same planning area. RESPONSE: Table B are projected average charges for 10 procedures that will occur at ASMC, LLC Surgery Center which are all orthopedic. Table B:ASMC,LLC Surgery Center Projected Gross Average Charges State of Georgia:Certificate of Need Application Page 38.12 Form CON 100 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services ASMC PROJECTED AVERAGE CHARGES HCPCS Procedure Description Year I Year 2 Year 3 Year 4 Year 5 1 13030 Low back disk surgery 11,307 $11,476 $11,649 $11,823 $12,001 2 822551 ACDF-Neck spine fuse&remov bel c2-Level 1 $20,440 $20,747 $21,058 $21,374 $21,694 3' 2310 Epidural Injection CervicaVTboracic 1,680 $ 1,705 $ 1,730 $ 1,756 $ 1,783 4'1;2311 Epidural Injection Lumbar/Sacral 1,680 $ 1,705 $ 1,730 $ 1,756 $ 1.783 5 14721 Carpal tunnel surgery 3,459 $ 3,511 $ 3,563 $ 3,617 $ 3,671 6'29824 Shoulder arthroscopy/surgery 11,946 $12,125 $12,307 $ 12,491 $12,679 7'29827 Arthroscopy rotator cuff repr 11,946 $12,125 $12,307 $ 12,491 $ 12,679 8'23412 Repair rotator cuff chronic 10,344 $10,499 .$ 10,657 $10,817 $ 10,979 9'29807 Shoulder arthroscopy/surgery 11,946 $12,125 $12,307 $12,491 $ 12,679 10'29881 Knee arthroscopy/surgery 6,452 $ 6,549 $ 6,647 $ 6,747 $ 6,848 The only similar available charge data is from 2013 and is not comparable because the above are projected charges beginning in 2013. Secondly, not all HPA-3 SS-ASCs report all of these 10 procedures, therefore it is difficult to offer a reasonable and fair comparison. What we do know is that ASMC, LLC will receive the same reimbursements as other HPA ASCs under Medicare and Medicaid payment policies and guidelines; and that it will negotiate fair and equitable reimbursement contracts with Third Party payers. Self-pay patients will not be charged full price,"typically eligible for a 40%discount of posted or scheduled charges. n)An applicant shall foster an environment that assures access to services to individual's unable to pay and regardless ofpayment source or circumstances by the following: 1. providing evidence of written administrative policies and directives related to the provision of services on a nondiscriminatory basis; 2.providing a written commitment that unreimbursed services for indigent and charity patients in the service will be offered at a standard which meets or exceeds three percent of annual gross revenues for the service after Medicare and Medicaid contractual adjustments and bad debt have been deducted;and 3. providing documentation of the demonstrated performance of the applicant, and any facility in Georgia owned or operated by the applicant or the applicant's parent organization, of providing services to individuals unable to pay based on the past record of service to Medicare, Medicaid, and indigent and charity patients,including the level of unreimbursed indigent and charity care. RESPONSE: 1. Appendix J-1 and J-2, copies of a draft Admissions, Non-Discrimination and Indigent and Charity Care Policies. 2. ASMC, LLC Surgery Center is also making a 5% in annual adjusted gross revenues (gross revenues minus Bad Debt, Medicare and Medicaid adjustments)towards provision of uncompensated indigent and charity care. ASCM will provide services to any high school athlete that cannot pay for care for a sports injury. ASMC will develop numerous programs for the community as identified in the materials attached. o) An applicant for art ambulatory surgery service shall document an agreement to provide Department requested information and statistical data related to the operation and provision of ambulatory surgery and to report that data to the Department in the time frame and format requested by the Department. This information shall include, but not be limited to, any changes in number of ambulatory surgery operating rooms that may occur as a result of service expansion. RESPONSE: State of Georgia:Certificate of Need Application Page 38.13 Form CON 100 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services ASMC, LLC hereby agrees to provide the Department any and all requested information and statistical data related to the operation and provision of ambulatory surgery and to report that data to the Department in the time frame and format requested by the Department.The reported information shall include but not be limited to, any changes in the number of ambulatory surgery operating rooms that may occur as a result of service expansion. State ofGeorgia:Certificate of Need Application Page 38.14 Form CON 100 APPENDIX M LETTERS OF SUPPORT Name Organization Title 1. John H. Eaves, Ph.D. Fulton County Board of Chairman Commissioners 2. CJ Leggett Georgia Institute of GA Tech Football Player- Technology Red Shirt Due to Injury 3. David Belle Isle City of Alpharetta Mayor 4. Rusty Paul Sandy Springs Mayor 5. Sharon Cooper House of Representatives GA State Representative, District 43; Chairman, House Health and Human Services Committee 6. Senator John Albers GA State Senate Senator, District 56 7. Cody Worthy Georgia Institute of GA Tech Baseball Player Technology 8. Lester M. Archambeau National Football League PAD Director Players Association 9. John Smoltz Major League Baseball Professional Player- Retired 10. Jeremy Loflice Composing Motion Inc.Biomechanical Pitching Consultant 11. Andrew Young United Nations United States Ambassador to the United Nations and Former Mayor of Atlanta 12. Mary Rose Taylor N/A N/A 13. Vicki R. Palmer Coca-Cola Enterprises Retired EVP 14. Takehisa Ohashi Valuable Selection Co President LTD.,Japan 15. Justin Niefer Innergy Sport/EvoShield Co Founder 16. Bill Clark Louisville Slugger President 17.Lee Hanson The Hanson Group President 18.Ralph Lombardo Avadim Technologies,Inc. Senior Vice President of Sales 19.Doak Ostergard University ofNebraska Athletic Performance Research Coordinator 20. Kirk Maxwell North Point Community Church 21. Charles Peyton Day Days Inn/ROAM 22. Matt Capps Major League Baseball Professional Player 1 f i BOARD OF COMMISSIONERS OF FULTON COUNTY FULTON COUNTY GOVERNMENT CENTER 141 PRYOR STREET,SW ATLANTA,GEORGIA30303 JOHN H.EAVES TELEPHONE:(404)730-8206 FAX(404)730-4754 CHAIRMAN M4-7.7"..... Ewa:john.eaves®Mtoncountyga.gov E" s f Ir. .- i MEMMN MINIUM June 15,2015 Ms.Rachel King Director,Division ofHealth Planning Georgia Department of Community Health 2 Peachtree Street,NW Atlanta,GA 30303 Dear Ms.King, Thank you for your service to the State of Georgia and the Department of Community Health. I am writing this note in support ofthe Atlanta Sports Medicine Center(ASMC) Certificate ofNeed application for the newly proposed outpatient surgery center to be located in Alpharetta,GA.The ASMC surgery center will be part of a comprehensive sports medicine center being designed and developed in association with Dr.James Andrews,world renowned orthopedic surgeon and sports injury,rehabilitation expert. Fulton County shares the excitement ofthis new multi-million dollar investment covering 170,000 square feet of space on a 32 acre campus.Buildings will include physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging,sports performance center,specialty sports academies,athletic fields and a Foundation for research and education. The ASMC surgery center is the complete solution to an athlete's medical needs.It would attract medical practitioners of superior caliber to work at the facility. Additionally,the success ofthe Atlanta Sports Medicine Center will make it a destination location for treatment,education and research in the field of sports medicine. Please feel free to call my office with any questions or to further discuss. Thank you for your consideration. iI d ' gards, g . H.Eaves,Ph.D. I an,Fulton County Board of Commissioners CJ Leggett One Crazy Turn My name is Cl Leggett and I am writing this letter on behalf of Dr.James Andrews and his efforts to establish a facility here in Georgia. I have played sports all my life and I have been blessed with athletic ability. I have played many sports but in 9`h grade I decided to concentrate primarily on football.My senior year in high school I was the leading rusher in 6AAAAAA ball in the State of Georgia. I received several offers from D1 schools to play football in college and I choose Georgia Tech to play the running back position. My life took a dramatic turn on the last day and the last play of the 2015 spring practice at Georgia Tech. In just seconds I tore my ACL. I went immediately from starting running back to out for the season. I knew that I was in for a long tough battle. I lay there thinking the first few nights"Why Me". I have been working hard for months, relentlessly dedicating myself and I have waited my whole life for an opportunity like this. It was bitter,tough news for me to handle, but after the tears and prayer I concluded that God must be preparing me for something bigger and better. In life we have a number of bumps in the road and often face adversity. The strength of your faith and personal resolve are the necessary ingredients needed to see you through. I am determined to do whatever it takes to get back on the field and be better than ever. When adversity hits your support system has to be strong and you must also be mentally strong within yourself. I am fortunate enough to have loving parents in my life who mean the world to me. They have always supported me no matter what it was that I wanted to do. They have attended every one of my football games and athletic events since elementary school.They have consistently emphasized the importance of academic development and quality education. My parents have always been available, loving, caring,and supportive. When this injury occurred it was no different. I along with my family met with the team doctor at Emory.We were given the devastating news,informed that my season was over and the prognosis for my recovery.The disappointment was overwhelming and I cried. Once my father got the news he immediatelycalled all of his orthopedic colleagues and personal friends in an effort to collect information on what was the best approach for repair and who was the best surgeon on the world to perform the repair. He called NFLPA representative Lester Archambeau, NFL HALL of Fame running backs Emmit Smith,Jerome Bettis and close friend Hall of Fame Defensive End Chris Doleman. He asked all of these sources who they would recommend for someone with my injury.They all emphatically recommended Dr.Jim Andrews. Each of these individuals placed personal calls to Dr.Andrews and his staff on my behalf.Their collective efforts resulted in my being able to get an immediate appointment with the best orthopedic knee surgeon in the world. I was immediately ecstatic when I heard the news. I knew that I was in good hands. I took the time to research Dr.Andrew's amazing track record. He has operated on countless superstars such as Adrian Peterson,Jamal Charles, Lindsey Vonn and Todd Gurley and a number of others. He has proven from his work that people don't just comeback,they excel when they return and often come back even better than before, such as Adrian Peterson for example. Adrian Peterson didn't just comeback, he had one of his most explosive seasons of his career,coming just eight yards short of Eric Dickerson's NFL single season rushing record. I was instantly put at ease and knew I was going to have a chance to comeback better than ever. I informed my home team physician and coach that I would be having my surgery at the Andrews Institute in Pensacola,Florida.The surgery went flawless. I am three months out of surgery and I'm way ahead of schedule to the thanks of God,Gina Lee and Dr.James Andrews. I am recovering great and my knee is coming back faster than I ever thought As a result of my dad being a physician with access to the orthopedic medical community to gain access to the latest knowledge and approaches surrounding repair of ACL injuries I was fortunate enough to have Dr.Andrews operate on me and give me the best opportunity for returning at full speed to a game I love. I realize that all kids or players don't have access to my family's financial resources,network of friends and in depth access into the medical community that gives them the knowledge to determine who indeed is the best physician in the world for a particular medical problem. In this case ACL injury. I am grateful and extremely fortunate. I am writing this letter in support of the Andrews Institute moving to Atlanta because I want all young athletes to have access to information and treatment strategies and surgical techniques that could directly affect their ability to reengage into their lifelong athletic dream. The choice of physician,surgical approach and recovery protocols are critical components in this process.Additionally,Dr.Andrews's dedication to develop a more comprehensive institute that focuses on bringing worldwide attention to overuse injuries and injury prevention would have global implications for young athletes. As great as Dr.Andrews is if given the choice I would much rather have had the knowledge of how to prevent an ACL injury than the task of recovering from one. I am so grateful and feel so blessed that I want to help create pathways for those without my resources or family network of contacts to still experience the access, surgical and preventive wonders that Dr.Andrews has to offer.His experience,volume of cases, technical expertise and compassion are incomparable and a gift to this world. I am so thankful 1 could personally benefit from his greatness as a human and surgeon!Atlanta,Georgia could become the center of the orthopedic world with Andrews here. Sincerely, C.1 Leggett CITYO/c A LP HAR ETTA 2 PARK PLAZA ALPHARETTA,GA 30009 PHONE: 678.297.6000 GEORGIA WWW.ALPHARETTA.GA.US June 18, 2015 Rachel King Director, Division of Health Planning. Georgia Department of Community Health 2 Peachtree Street, NW Atlanta, GA 30303 . Ms. King, First, thank you for your service to Georgia and the Department of Community Health. I am writing this note in support of the Atlanta Sports Medicine Center (ASMC) Certificate of Need application for the newly proposed outpatient surgery center to be located in Alpharetta, GA. The ASMC surgery center will be part of an innovative and comprehensive sports medicine center being designed and developed in association with Dr. James Andrews, world renowned orthopedic surgeon and sports medicine expert. We here in the City of Alpharetta share the excitement of this new multi-million dollar investment covering over 150,000 square feet of space and located on a 32 acre campus. Buildings will include physician's offices, surgery, rehabilitation and physical therapy, MAYOR diagnostic imaging, sports performance center, specialty sports DAVID BELLE ISLE academies, athletic fields and a Foundation for research and COUNCIL MEMBERS education. D.C.AIKEN MICHAEL CROSS The ASMC surgery center is the complete solution to an athlete's JIMGILVIN medical needs. It would attract medicalpractitioners of superior MIKE KENNEDY P DONALD F.MITCHELL caliber to work at the facility. CHRIS OWENS CITY ADMINISTRATOR ROBERT.REGUS Additionally, the success of the Atlanta Sports Medicine Center will make it a destination location for treatment, education and research in the field of sports medicine. Thank you for your consideration as my office is in full support of ASMC CON request. Sincerely, David Belle Isle, Mayor EDF-GE\,u yf _ y/ 1776 Cause of Representatives SHARON COOPER MAJORITY CAUCUS CHAIRMAN-EMERITUS REPRESENTATIVE DISTRICT 43 STATE CAPITOL ROOM 436 1234 POWERS FERRY ROAD ATLANTA,GA 30334 STANDING COMMITTEES: SUITE 104 404)656-5069 HEALTH&HUMAN SERVICES,CHAIRMAN MARIETTA;GEORGIA 30067 404)651-5829(FAX) JUDICIARY-NON-CIVIL 770)956-8357(0) REGULATED INDUSTRIES 770)951-2841(H) RULES 770)952-8688(FAX) EMAIL:Sharon.cooper@house.ga_gov June 15,2015 Ms.Rachel King,Director Division ofHealth Planning Georgia Department ofCommunity Health 2 Peachtree Street,NW Atlanta,GA 30303 Dear Ms.King, I am writing this letter in support of the Atlanta Sports Medicine Center(ASMC)Certificate of Need application for the newly proposed outpatient surgery center to be located here in Georgia. The ASMC surgery center will be part of a comprehensive sports medicine center being designed and developed in association with world renowned orthopedic surgeon and sports injury expert Dr.James Andrews. The ASMC surgery center is a new multi-million dollar investment covering 170,000 square feet located on a 32 acre campus. Buildings will include physician's offices,surgery,rehabilitation and physical therapy, diagnostic imaging,sports performance center,specialty sports academies,athletic fields and a Foundation for research and education. Additionally,with Georgia constructing new National Football League and Major League Baseball stadiums,the success of the Atlanta Sports Medicine Center will make Georgia a destination location for treatment,education and research in the field of sports medicine. Thank you for your consideration ofthis request and please feel free to call my Capitol office with any questions you may have. 1 believe this type of facility will make for better health care outcomes for Georgia citizens and am wholeheartedly in support oftheir request for a CON. Sincerely, 007,AM drgie. Sharon Cooper Georgia State Representative,District 43 Chairman,House Health and Human Services Committee SC/dls Capitol Office COMMITTEES: Room 110 State Capitol State&Local Governmental Operations,Chairman Atlanta,Georgia 30334 Public Safety,Vice Chairman 404)463-8055 Finance,Secretary 4,••'°•° ,p°.ti Appropriations,Member District Office waY .?1p MARTOC,Member 1076 Canton Street it` f`.!,}w :=1'; Lower Level E,;"u ""yg Chief Deputy Whip Roswell,GA 30075 VP- I Z4, Jo C: john@senatoralbers.com www.senatoralbers.com 1776 Senator John Albers District 56 Monday,June 8,2015 Ms.Rachel King Director Division of Health Planning Georgia Department of Community Health 2 Peachtree Street,NW Atlanta,Georgia 30303 Ms.King, I am writing this letter in support ofapproval for Certificate of Need application for the Atlanta Sports Medicine Center(ASMC). The ASMC surgery center will be part ofa state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world-renowned orthopedic sports surgeon.The Alpharetta,Georgia development will be a multi-faceted 170,000 square foot facility located on a 32 acre campus to include office buildings for physician's offices,surgery rehabilitation and physical therapy, diagnostic imaging,sports performance center,including various specialty sport academies,athletic fields and a Foundation for research and education. I respectfully request your support for the ASMC application in helping to bring this unique first class facility to North Fulton County.I truly believe that with new top tier National Football League and Major League Baseball stadiums currently under construction,Atlanta Sports Medicine Center could emerge as a hub for the world's best athletes and a complete solution to all oftheir medical needs. This is a wonderful investment in North Fulton and a huge economic development opportunity for the State ofGeorgia. Thank you for your consideration and please call my Senate office with any questions. Sincerely, d.14442._ Senator,56 District Rachel King 7/31/2015 Director Division of Health Planning Department of Community Health 2 Peachtree Street 5th Floor Atlanta,GA 30303 Dear Ms. King, I am writing to express.my support for the ASMC, LLC Certificate cif Need application for a planned outpatient surgery center in Alpharetta,GA. I played basketball and baseball in high school and was able to commit to Georgia Tech. My senior year in high school I tore the UCL ligament in my pitching arm. I thought my chances of playing in college were gone. Dr. Lourie contacted Dr. Andrews; I went in the next week for my surgery and it was a fantastic experience. What makes the Andrews Institute such a wonderful place is the whole atmosphere of positive and professional people doing a job they love. Every step of the process was organized.with very little wait time. Each person took the time to explain exactly what was wrong,the surgery,and what needed to be done after the surgery. I felt that I was as important as any professional athlete there. My mother was able to watch most of the surgery. She had a person from Andrew's office stand there with her and answer any questions. The facility was well kept and easy to move around in. The rehab center was well run, doing everything from fitting me with a brace to my first post-op exercises. I was given a very detailed rehab program. There were two other guys who were having the same surgery the same day I was,one going to college and one going into Major League baseball. As we went from x-ray,to Dr. Andrew's office,to the surgery center,we became friends. Our parents sat together and shared information,checking on each other and how surgery went. We exchanged phone numbers afterwards. The set-up there does not isolate you,but instead offers support in so many ways. You feel relaxed and happy to be there. I did therapy back in the Atlanta area with Gina Lee,who trained at the Andrews Institute. Matt Capps,a professional baseball player and friend told me that Gina was the person I needed to go see. Even though I lived in Douglasville,we drove to see her in Lawrenceville for all my physical therapy. She is a driving force behind the new facility. Gina is great! She worked with me from April 2014-August 2014. Gina is a genius with physical therapy in the clinic and in the swimming pool. She makes the whole experience of physical therapy a positive one. The college guy that had surgery the same day I did was at PT in Griffin. He suffered through lots of pain,setbacks, had to get scar tissue surgically removed. I had no setbacks,no pain,no scar tissue problems,and my coaches at GT were quite pleased with my progress. If Gina is behind the project,it will be done well and with the same caring attitude she brings to her patients. I respectfully request your support for the ASMC,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. Cody Worthy 7/31/2015 Georgia Tech Baseball Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street 5th Floor Atlanta,GA 30303 Dear Ms.IGng, I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgery centerin Alpharetta,GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building for physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional sports and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support for the ASMC,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. LC,Skt. A, Aravv.,4_644.. irr PrintName 7/4 gnature Dite Team/University/Association affiliation / Dear Ms.King, I first want to say that Dr.Andrews has had a huge impact on my career,to the point of extending the longevity by several years.During my career as a major league pitcher,I traveled to Birmingham,Alabama,over 25 times to see him at his facility.So,it is with the knowledge of personal experience that I write this letter,stating the importance ofwhat Dr.Andrews can do for the athletes and patients whom he sees,and what the facility would mean for area teams.So many great athletes make their home in Georgia,but currently travel to Dr.Andrews'Alabama facility to get his expert help.It would be a shame ifDr.Andrews and his clinic are denied here in Georgia the opportunity to help so many people. I can honestly say I would have never accomplished what I did in the great game of baseball,nor have any chance ofinduction to the National Baseball Hall of Fame,without Dr.Andrew's expertise.Dr.Andrews and his staff have provided so much for so many athletes that I cannot think ofanother institution which has done more or whom I would more recommend to have a strong presence in Atlanta. I am asking you to please consider the opportunities which the residents ofthis state will have with Dr.Andrews facility here in Atlanta. Th. - - y. Jo 9. A.Smoltz 10 Foxhollow Run Alpharetta,GA 30004 Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street 5th Floor Atlanta,GA 30303 Dear Ms.King, I am writing to express my support for the ASMC, LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. I am very excited about the opportunity to have a state-of-the-art comprehensive sports medicine. center at the disposal for kids and parents in my community to be able to utilize. The center is being developed in association with Dr.James Andrews,world-renowned orthopedic sports surgeon. I had the pleasure of working for Dr.Andrews for 7 years as a biomechanist in the biomechanics laboratory located at his non-profit facility,the American Sports Medicine Institute(ASMI),in Birmingham, Alabama. While at ASMI,we worked relentlessly to identify why there was an up and coming epidemic"of baseball related pitching injuries. Children as young as 12 years old were coming into Dr. Andrews'clinic with baseball related injuries that were normally associated with 20-30 year olds. Many of the kids and young adults were travelling from the Atlanta and surrounding suburbs to Birmingham to have an established doctor like Dr.Andrews treat their injuries because there were no doctors in Atlanta with the expertise in the throwers shoulder and/or elbow. ASMC will have a collective group of doctors with high levels of experience with the throwers shoulder and/or elbow,so the throwing athletes in the region will now be coming into Atlanta to be evaluated,treated,and repaired. They will also have the fortune of staying after their surgical intervention for first class physical therapists that will be on campus also. I have a great interest in the Biomechanics laboratory section of ASMC,as I know the massive athletic population surrounding the Atlanta area can not only be able to utilize the strengths of a lab for injury prevention and performance enhancement in many sports,but also will give me,as an epidemiological researcher,an opportunity to have a vast amount of biomechanical data to analyze so we can inform the public on better,more efficient,and healthier ways to move in sports. Another avenue that will be explored in the biomechanics lab is the introduction of the first professional baseball draft combine. Most every other major sport has some sort of combine or pre draft workout facility where the professional organizations can view the prospective player and get valuable info and statistics. This idea has never been introduced in the sport of professional baseball,partly because of the logistics of getting everyone into the same place,at the same time;and having the appropriate staff to pull it off. ASMC will be tailor made to host this type of event,especially with the staff that is being collectively pulled together to take part in the center. This model could also be introduced globally as an avenue to thoroughly evaluate baseball talent for MLB organizations. I am a former Division I baseball pitcher whose career was cut short due to baseball pitching related injuries and eventually surgery. I chose my college degree direction and therefore work related profession in life to help create for others the opportunities I never achieved by learning more about my physical and mental shortcomings. I grew up in the suburbs of Atlanta and was introduced to the profession"of travel baseball at a young age. Neither my parents, nor I were informed enough on the rigors that year round travel baseball would take on my adolescent body and how I would be negatively affected by something that meant so much to us at the time. I envision being able to use the data and the high volume of clients who use the facility to give direction to the baseball community around Atlanta and around the country on all aspects of baseball movement to keep them performing at their highest level,while staying injury free. After leaving ASMI,I started a company called Composing Motion Incorporated(CMI). CMI was designed to help Major League Baseball organizations to determine how likely the pitchers within each respective organization were to become injured based on pitching mechanics. I have since followed my passion into youth baseball to help curb the incidence of youth baseball injuries. When I began CMI 8 years ago,I was the only person in the country trained for pitching biomechanics that was working with Major League Baseball teams. Nobody else in the Atlanta area,let alone the Southeast United States does what I do for baseball pitchers. I have found a unique niche and the trickle down effect from MLB into youth baseball is fascinating for me. This training center gives me the opportunity to have an enormous impact on the future of youth and amateur baseball in Atlanta and the surrounding areas. Also,as of right now,I have high-level athletes from the Atlanta area that travel up to me in Athens,GA to train with me sometimes twice a week. Some are college and some are professional baseball pitchers. I have a network of doctors in Atlanta that will also refer me their highest-level pitchers whom they have performed surgery on,so I can perform rehab throwing with them to give them the best opportunity to return to their respective teams. Having this facility in Atlanta,will allow them to take greater advantage of any service that I can provide on a more consistent basis without the logistics of getting to and from Athens without getting caught in Atlanta traffic. Lastly,I would like to use this facility as an avenue to place talented athletes ofall sports involved into college. With the high volume of athletes coming through the center,we could gather all necessary demographic and athletic data. This would make it easier for college coaches and professional scouts to view the full profiles of their prospective players and make a more informed decision on how each athlete may fit into each respective college or professional organization. ,Having this service available will no doubt bring athletes from all over the country to Atlanta for extended periods of time to train and receive the best available patient/player care around. Please try to envision the hub of sporting excellence that ASMC will become,especially with a unique doctor like Dr.Andrews backing the project. The meetings I have had with the people involved in bringing this vision to life have been nothing short of heart pounding. We have the opportunity to be the first sport medicine center of this magnitude with all the necessary branches in place on the same campus. The goal ofthis center is to have an impact on the youth community that will last throughout the playing careers of each athlete that comes through the doors. We can change the atmosphere of youth sports,and thus high school,college,and professional sports,to be one where the athletes and coaches are better informed about their sports. This direction of thinking and acting will help to keep athletes healthier and more knowledgeable than they have ever had the opportunity to be. I respectfully request your support for the ASMC,!LC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. Print Name Signature Date Team/University/Association affiliation Rachel.King Director Division of Health Planning Department of Community Health 2 Peachtree Street 5`h Floor Atlanta,GA 30303 Dear Ms.King, I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building for physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional sports and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support for the ASMC,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. kid-17 -123 c r ;I 4-31/2::› Pri t Namej I Si •-tore Date Team/University/Association affiliation Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street 5`h Floor Atlanta,GA 30303 Dear Ms.King, I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgerycenter In Aipharetta,GA. The ASIVIC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building for physician's officessurgery,rehabilitation and physical therapy.diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and locacommunities will benefit greatly from this center both In terms of providing care and treatment of patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional sports and this facility will become adestination location for treatment,education and research inthe fi*|dcf sports medicine. I respectfully request your support for the ASMC,UC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. q 77? yr Print Name 6 . Date 67( x44- ' ^ ~~~^ i Team/University/Association c'«' 1.101111111111.11111111 Rachel long Director Division of Health Planning Department of Community Health 2 Peachtree Street 5°'Floor Atlanta,GA 30303 Dear Ms.King, I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr.lames Andrews,world renowned orthopedic sports surgeon_ The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building for physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, sports performance center,induding various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in term of Investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional sports and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request yoursupport for the ASMC,LIC applica:'ori in helping bringing this unique facility focused on providing first dass comprehensive services: t PL1 6 Prin Name Signature Date gek ig VP CfjcA --(Pk a4 -iesp-t Team/University/Association affiliation S3iiGs GEORGIA Tuesday,June 16,2015 Ms. Rachel King Director Division of Health Planning Georgia Department of Community Health 2 Peachtree Street,NW Atlanta,Georgia 30303 Ms. King, I am writing this letter in support of Atlanta Sports Medicine Center (ASMC) request for a Certificate ofNeed. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with world renowned orthopedic sports surgeon Dr. James Andrews. The North Fulton development will be a multi-faceted 170,000 square foot facility located on a 32 acre campus to include office buildings for physician's offices, surgery rehabilitation and physical therapy; diagnostic imaging, sports performance center, including various specialty sport academies,athletic fields and a Foundation for research and education. I respectfully request your support for the ASMC CON application to help bring this unique first class facility to North Fulton County. I truly believe that with new top tier National Football League and Major League Baseball stadiums currently under construction, Atlanta Sports Medicine Center could emerge as a hub for the world's best athletes and a complete solution to all of their medical needs. This is a wonderful investment in North Fulton County and a huge economic development opportunity for the State of Georgia. Thank you for your consideration and feel free to call my office with any questions. 6 4-1----') 141?------ Rusty Paul Mayor of Sandy Springs 7840 Roswell Road,Building 500 • Sandy Springs,Georgia 30350 • 770.730.5600 • 770.206.1420 fax • SandySpringsGAgov Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street 5th Floor Atlanta,GA 30303 Dear Ms.King, I am writing to express my support for the ASMC,EEC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building for physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional sports and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support for the ASMC,ELC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. wfll5.A OJ)74 5 Print Name 1"1 -.7‘\, Signature J Date sFe T VA Lti S "teen-'A) 6 C01-41A0 Team/University/Associatio( affiliation Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street 5th Floor Atlanta,GA 30303 Dear Ms.King, I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building for physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional sports and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support for the ASMC,LIC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. 41-57-7A/ ll,c C J Print Name ffi::::.--1/14-la Signatu P Daie MerlSf.C4-0 rti Et/ 15',-41/e-id Team/Univi fsiWAssociation affiliation Rachel King Director Division of Health Planning Department of Coinrriunil.y Health 2 Peachtree Street S"'Floor Atlanta,GA 30303 Dear Mr:.King, I am writing to express my support for the ASML,I 1 C Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part of a state-of the art comprehensive spot is medicine center being developed in association with D_lames Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building for physihaan's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, sports performance center,Including various specialty sport academies and athletic fields,and a Foundation for research and education. The Stale of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional sporbs anti this facility will become a destination location tortreatment,education and research in the field of sports medicine. I respectfully request your supportfor the ASML,I IC application in helping bringing this unique facility focused nn providing first class comprehensive servicers to Georgia. 4/7 C747 k Print Name 4,7, 77/ Signatti e Date Y( -rn- boys vi/f( U (K. Tears/University/Association affiliation Rachel King Director Division of Health Planning Department:of Community I Icalth 7 Peachtree Street th Floor Atlanta,GA 30303 Dear Ms_King, I am writing to express my support for the ASML,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA, The ASMC:surgery center will be part of a state,ofthe-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon_ The project will be a multi-faceted 1/0,000 square font facility located on a 32 acre campus and include office building for physician's offices,surgery,rehabilitation arid physical therapy,diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia arid local communities will benefit greatlyfrom this center both in terms of providing cure and treatment of patients as well as economic development interm of investrnent and jobs creation and attract athletes nationally and internationally to this center of excellence_Atlanta has long been recognised as a major sports center for both amateur,collegiate and professional spor Is and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support.for the ASMC,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. Pi Ird.Name V Sigr-allure tate 77e-j i earn/thiiversityJAss!lo4ciation affiliation / Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street Sd'Floor Atlanta,GA 30303 Dear Ms. King, I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building forphysician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports tenter for both amateur,collegiate and professional sports and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support for the ASMC,LLC application in helping bringing this unique facility focused on providingfirst class comprehensive services to Georgia. frefsh 444266lb Print Nam Signature Date fd d` 0e1M 4y/ i Vic, Team/University/Association affiliation Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street Sth floor Atlanta,GA 30303 Dear Ms_King, I ant writing to express my support for the ASML,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be par l of a stare-of-the-art comprehensive sports medicine center being developed in association with Dr.lames Andrews,wmId renowned orthopedic sports surgeon. The project,will be a multi faceted 1/0,000 squarefoot facility located on a 32 acre campus and include office building kw physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, sports per fur mance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center hot:h in terms of providing care and treatment of patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally in ibis center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional spur Ls and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your supper I.for the ASML'.,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. t'rint Name c6-zf- lJ Signature Date M.` t-T< Adult 4.4711 , r= . C Team/University/Association affiliation +, 4 I'iG(/'Sl D by -CVA Rachel King Director Division of I Icalth Planning Department of Community Health 2 Peachtree Street 5`h Floor Atlanta,GA 30313 Dear Ms.King, I am writing to express my support for the ASML,LI.0 Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with 1)r.James Andrews,world renowned orthopedic sports surgeon. I he project will be a multi-faceted 170,000 square foot facility located on:.r 32 acre campus and include office building for physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State,of Georgia and local communities will benefit greatly from this center both in terms of providing care and treaunenl of patients:as well as economic development in ter rn of investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional sports and this,facility will become a destination location fortreatment,education arid research in the field of sports medicine. I respectfully request your support for the ASMC,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. x_X /i"r/fkr'./t'- Print Name f t. 2(— z.e Date 1197ri /A/% (I>rYl wu../Z/ C'ap..t't/ ,--/(1242/1- I f{/24 /L- I earn/University/Association affiliai.ion Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street 5`tfloor Atlanta,GA 30303 Dear Ms.King, I ani writing to express my support for the ASMt:,i_t_C":Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will he part ofa state-of-the-art corrmprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 1./0,000<.yuare font,facility located on a 32 acre campus and include office building for physician's oftires,surgery,rehabilitation and physical therapy,diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a f=oundation for research and education. The State of Georgia and local communities will benefit greatly froth this center both in Lerrn::of providing care and treatment of patients as well as economic development interm of investment and jobs creation and attract athletes nationally and ini.erriatinnallyto this center of excellence.Atlanta has long been recognized as a major spot is center for both amateur,collegiate and professional sports and this facility will become a destination location for treatment,education and research in the field of sports medicine. I r espectfully request your support for the ASMC,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. L hk4Icl _P 4PalPrintMarne 11-1I r' Signature Date L QI .Jv Team/Univers" y/Associati"naffiliation Moldovan, Victor L. From: Gina Lee<ginalee4@yahoo.com> Sent: Sunday,August 09,2015 12.37 PM To: Moldovan,Victor L. Cc: Jerry Brown Subject: Fwd: Letter Ms. King, I would like to thank you for taking the time to review this application as well as read my letter. I am extremely humbled to have the ear and attention of the state of Georgia and being an Atlanta native I am ecstatic to have a small part in this project. As a young man at Alexander High School in Douglasville I lettered in 4 sports (Baseball, Basketball, Football, and Cross Country) and was fortunate to make it through my 4 years of high school sports without any major injuries, aside from a few broken bones. I was then blessed to be drafted by the Pittsburgh Pirates and make it through the minor leagues and my first couple of years in the Big Leagues healthy. It was about 6 weeks into my third year in Pittsburgh I suffered my first significant injury to my shoulder. Fortunately for me this time i was able to only miss a couple of months time and rehab myself back to 100% or as close to 100% as possible. After returning and getting through the 2008 season I was able to successfully pitch healthy for almost 4 years until another shoulder injury stopped me in my tracks, this time needing surgery to repair. June 4, 2013 is the day I had my shoulder fixed just outside of Philadelphia. From June 5th, the day I flew back home to Ga, on I have been on my journey to recovery driving to 5 different places all over Georgia to work on my shoulder/body/craft to get back to where I once was. I even put over 35,000 miles on my truck in less than a year going to and from different facilities, not including the out of state trips I made to see my surgeon and as well as other doctors on the recommendation of my agents and teams. As an athlete I am more than happy to drive and fly whenever and wherever it may be to get my mind and body into the best possible place and shape to perform, it is my job. Ms. King as a father I am writing asking for your help in making this journey better and more successful for the next generation of athletes not only in Georgia but all across the country and even the world. With what this complex is going to be I have no doubts that athletes from all over the world will more than willingly come and stay to give their recovery the best possible chance for success. With doctors, rehab therapist, strength & conditioning, massage therapy and a baseball facility where I could do all my throwing and be around the sport it would of been an easy decision for me as to where I would have been for all of my recovery process. Athletes will have the opportunity to come to a sports medicine facility that truly has the potential to be the best in the world and pioneer a new 1 way of treating the weekend warrior all the way to our next olympians right here in Georgia. Again I thank you for your consideration and will close by saying that for those individuals playing sports, especially those lucky enough to play professionally and as long as I have we know it is a matter of when and not if they will need some kind of help and they will go somewhere, why not here? Matt Capps 2 APPENDIX N-11 DRIVEN: Dr. James Andrews, Sports Surgeon coming to FOX Sports South driven-drfames-andrews-sports-surgeon-coming-to-fox-sports-south I FOX Sports Page 1 of 3 DRIVEN: Dr. James Andrews, Sports Surgeon coming to FOX Sports South FOX SPORTS SOUTH STAFF FS South NOV 19,2013 AT 12:08P ET ATLANTA--FOX Sports South will debut DRIVEN:Dr.James Andrews,Sports Surgeon,this Saturday,November 23 at 7 p.m.ET,following the ACC college football game between Boston College and Maryland. From the state-of-the-art Andrews Institute for Orthopaedics&Sports Medicine in Gulf Breeze,Florida, and Andrews Sports Medicine and Orthopaedic Center in Birmingham,Alabama,to the sidelines ofthe University of Alabama and Auburn University football games,DRIVEN takes viewers into the world of this legendary physician. The preeminent name in the field ofsports medicine,Dr.Andrews is credited with saving and extending the careers of innumerable athletes. FOX Sports South sits down with some of Dr.Andrews'most famous patients,including Jack Nicklaus,Tom Glavine,Roger Clemens,David Wells,Adrian Peterson and John Smoltz to talk about the"career saver's"impact on their lives. Excerpts from DRIVEN:Dr.James Andrews,Sports Surgeon Jack Nicklaus: "When you're going about what you do,you don't think about injury.But if I have injury,my mind immediately goes to,`Where's Jim[Dr.Andrews]?What do you think Jim would say? What do you think Jim will do?I need to call him." Tom Glavine: "Is there really something about Dr.Andrews that makes him betterthan everybody else? The answer is yes,there is." http://www.foxsports.com/south/story/driven-drfames-andrews-sports-surgeon-coming-to-... 8/25/2015 driven-dr-james-andrews-sports-surgeon-coming-to-fox-sports-south I FOX Sports Page 2 of 3 John Smoltz: "When I hear Dr.Andrews'name,there is a smile that runs across my face,because I know how much I was able to pitch after my surgeries." David Wells:"I had one ofthe greatest sports surgeons in sports history,if not the greatest,and then threw a perfect game and he[Dr.Andrews]was right there with me." Ronnie Brown:"When I tore my ACL in 2007,it was a no brainer where I was going. And ever since then he[Dr.Andrews]has kept in contact with me.He just does that." Dr.James Andrews:"I never understood loo percent where I am or how I got here.I was fortunate early on in my career to have signature athletes to help jump start my career." DRIVEN:Dr.James Andrews,Sports Surgeon—Air Dates Debut:.FSSO 11/23 @ 7:oo p.m.ET(after ACC football game) Re-air:.FSSO 11/25 @ 9:00 p.m.ET FSSO 11/27 @ 6:3o p.m.ET FSSO 11/3o @ 3:00 p.m.ET FSSO 12/7 @ 6:00 p.m.ET DRIVEN,a FOX Sports South EMMY Award-winning original programming series presented by Cadillac,provides viewers with inspiring stories of dedication,accomplishments and success in sports by taking a deeper look at those individuals and organizations with the innate drive to rise up and set unprecedented paths. The FOX Sports regional networks serving the Southeast—FOX Sports South,FOX Sports Tennessee,FOX Sports Carolinas and SportSouth—collectively reach more 13 million cable and satellite households in seven states across the Southeast. They are the television home oftheAtlanta Braves,Atlanta Dream,Atlanta Hawks,Carolina Hurricanes,Charlotte Bobcats,Memphis Grizzlies, Nashville Predators,Cincinnati Reds,Indiana Pacers,New Orleans Pelicans,and St.Louis Cardinals, as well as the Atlantic Coast Conference,Conference USA,Southeastern Conference,and Big 12 Conference,and offer expanded coverage ofthe University ofKentucky, University ofSouth Carolina and University ofTennessee. Combined,thefour networks produce more than 800 live local events and televise more than 1400 live local events each year.For more information,please visit FOXSportsSouth.com,FOXSportsTennessee.com,and FOXSportsCarolinas.com. http://www.foxsports.comisouth/story/driven-drfames-andrews-sports-surgeon-coming-to-... 8/25/2015 driven-drfames-andrews-sports-surgeon-coming-to-fox-sports-south I FOX Sports Page 3 of 3 Ynn unt to add a comment onFoxSports.com,subject to Facebook's Terms of Useand Privacy Policy.Your Facebook na + M iarmation you make public on Facebook and comment will appear on FoxSports.com,and may be used on Fox Sports'other media platforms.Any questions? 0 Comments Sort by Top Add a comment... Facebook Comments Plugin http://www.foxsports.com/south/story/driven-drfames-andrews-sports-surgeon-coming-to-... 8/25/2015 APPENDIX N-12 Orthopedic Surgery Center matters regarding Dr. Andrews Peter Moylan ready for call-up in comeback Albany Herald Page 1 of 2 Peter Moylan ready for call-up in comeback Former Atlanta Braves reliever working his way back from second Tommy John surgery Want daily summaries and Breaking News alerts? Saturday duSust 15 2015 By Carroll RogersWalton Ccpynott2015 AlbanyNerato CHARLOTTE,N.C.(TNS)—Amid the upheaval in the Atlanta Braves organization this season and the transaction turnstile that has been the roster,there lurks a familiar feel-good story from down under. You know Peter Moylan,his arm angle,his Australian heritage.He's been down on the farm this season, working his way back from a second Tommy John surgery,and by all accounts in Triple-A Gwinnett,it's going well. My arm feels great,'Moylan said recently before a game against the Charlotte Knights.°Back feels great. The ball is coming out great I couldn't even dream to feel as good as I do,especially after,I mean,when you qy 4i add it all up,it's like'C'mon.'" Moylan,36,hasn't pitched for the Braves since 2012.By his estimation,he hasn't pitched effectively in the Gwinnett Braves pitcherPeterMoylan ishoping to get big leagues since 2010.He had back surgery in May 2011.He's had a torn rotator cuff.Then the second called up soon to pathagain withthe Atlanta Braves. Tommy John in six years last spring. The former relewxis progressing wellafterhaving a secondTommy Hohnsurgery(special Photo) "When you look at itthat way,(2010)is a long time ago,°Moylan said."There's a lot more critics that have reared their ugly head in the last fiveyears.I hear all the time that'I'm done,'but I don't think I'm anywhere near done" With the way he's pitching now,Gwinnett manager Brian Snitker and pitching coach Marty Reed are hopeful that a September call-up is coming. We're all pulling for him toget another shot,'Reed said."He's done everything you could ask of him here.The encouraging thing for me is the last month or so I've seen his velocity jump up a little bit.Atthe beginning ofthe yearhe was mostly 88,89(mph),sitting right in that area,and he'd pop a 90, 91 here and there on a good night.All of a sudden you go"wow,'you look at a 91.Now he's sitting 90,91 and he's popping a 93 here and there. And he's done a great job.We'd love to see him get another shot.In my own mind,I believe he will.' The Braves signed Moylan in March to serve as a minor league player-coach during his comeback,but things have progressed so well,he dropped the coaching'part ofthe title soon after spring training. That was probably me being an absolute pain..too,'Moylan said,imitating his daily plea to Braves coaches.-I feel good.I feel good.I feel good.I feel good.I feel good.I feel good.'So yeah it's worked out well.I'm where I want to be.In Gwinnett,I'm 15 minutes from my house. If it happens that I get called up to Atlanta,I'm still half an hour from my house.And it'swith the team that I really wish I hadn't have left,to be honest.' Moylan spent 2013 withthe Dodgers and last spring signed with the Astrosjust before he tore his ulnar collateral ligament in spring training for a secondtime.It was a week after his good friend Kris Medlen tore his UCL for the second time in Braves camp.Moylan had just taken Medlen out for dinner in Orlando,Fla.,to give him the'this isn't the end"pep talk,when he had to call Medlen and tell him he'd blown out,too. Their operations with Dr.James Andrews were two weeks apart They spent their rehabstogether.Moylan and Medlen worked out last year with trainer Gina Lee ofGwinnett SportsRehab,concentrating theirefforts in pool work,doing full body workouts with less stress on their joints. Moylan lost 41 pounds in the process,down to 211,and is now up to about 220 It'soverused,but,I'm literally in the best shape of my life,'said theclean shaven Moylan,while finishing up a post-batting practice snack of yogurt and granola. When he signed with the Braves in March,they encouraged him to slow his rehab process.So instead of throwing 45-pitch bullpens using all his pitches, he went back to 30 pitches,all fastballs,and slowly built back up.He's had no setbacks—"touch wood"as he said,for luck—and he feels strong. Pitching in Gwinnett since June has allowed Moylan to stay on a regular program,usually pitching every other night.It's given him the freedom to figure out he needs to play catch,even on off days,or he gets out of whack mechanically. Moylan is 2-0 with a 3.00 ERA in 26 appearances for Gwinnett,with nine walks and 23 strikeouts in 27 innings.Since giving up four runs in an outing shortly after the All-Star break,when he figured out he should have been playing catch every day,he has made nine consecutive scoreless appearances. Medlen is five appearances into his return to the majors,pitching in relief for the Kansas City Royals.He gave up four runs in 3 113 innings his first time out and hasn't been scored on in his past four outings,over seven innings.He and Moylan talk at least once a week. When and if the opportunity comes(for me),he'll be as pumped as I am,I'm sure,"Moylan said Asfor Moylan? I'vethought about it,'he said."It's one of those things where obviously it's going to be meaningful,but it's going to be personally more meaningful because I know what I've had to go through.' http://dev.albanyherald.com/news/2015/aug/15/peter-moylan-ready-for-call-up-in-comeba.." 8/24/2015 Peter Moylan ready for call-up in comeback Albany Herald Page 2 of 2 0 Comments Sort by Oldest Add a comment.. Facebook Comments PWgm Sponsored From Around the Web y Cheated on for Controversial 4 Stages to a Heart Tr'zits Car Fight DiabetesS Being"Too Old" "Genus Drug" Attack Are Youat nsurance Agents rmod Amputation See Her Revenge Used by Rich Risk% Dont Want You to by Doing This Transformation People Know http://dev.albanyherald.com/news/2015/aug/15/peter-moylan-ready-for-call-up-in-comeba... 8/24/2015 1 SPITCH MART TOMMY JOHN FAQSMART 11+3!1 1.What is Tommy John surgery? Tommy John surgery is a reconstruction of the ulnar collateral ligament(UCL)of the elbow.A tendon from elsewhere in the body is used to repair a torn or ruptured UCL. It was first performed by Dr.Frank Jobe in 1974 on Tommy John,a pitcher for the Los Angeles Dodgers. 2. Does an athlete require an actual elbow injury to undergo the surgery? Yes.51%of high school athletes incorrectly believe that Tommy John surgery should be performed on players with an elbow injury to enhance performance.However,the only approved medical reason for Tommy John surgery is a torn or ruptured ulnar collateral ligament.The procedure should not be performed in the absence of an injury. 3.How many pitchers undergo Tommy John surgery per year? Historically,15-20 Major League pitchers have undergone Tommy John surgery per year but over the past three years that number has increased to 25-30.A 2012-2013 survey of active players found that 25%of Major League pitchers and 15%of Minor League pitchers had undergone Tommy John surgery at some point in their careers. 4.Are pitchers having the surgery at a younger age? While accurate numbers are difficult to find for the Minor Leagues and amateur levels, anecdotal evidence strongly supports the notion that younger pitchers are undergoing the procedure at an unprecedented rate.Records from the American Sports Medicine Institute show that the number of Tommy John surgeries performed on youth pitchers at their facility have more than doubled since 2000. 5.What factors influence the likelihood of an arm injury? There are a number of factors that contribute to the likelihood of having Tommy John surgery or another arm injury.The single most important factor is daily,weekly and annual overuse. Other factors include lack of rest,pitching while fatigued,poor mechanics,playing catcher when not pitching and playing on multiple teams at the same time.There are also certain behaviors which may increase your likelihood of an arm injury,including throwing curveballs and sliders,pitching multiple days in a row and throwing at maximum effort. 6.How often are pitchers able to return to play baseball after Tommy John surgery? Overall,Tommy John surgery has a high rate of return to play,particularly relative to other common procedures for pitchers.Most studies have concluded that 70-80%of pitchers return to their previous level of competition following surgery assuming that they follow rehab protocols.However,the rate and time of return to play vary according to the individual and there are many other issues that may complicate the success rate of the surgery. 7.How long does it take to return to competitive throwing following surgery? The average pitcher returns to game action 12-16 months following surgery but that time varies greatly by individual.In a recent study by Romeo et al.,Major League pitchers returned in as little as 11 months and as many as 30 months.The player's return also depends on when the surgery is performed in the context of the baseball season as well as the severity of the injury.Players,parents and coaches should remember that each injury is unique and has its own timeline for recovery. 8.Does Tommy John surgery improve performance? 35%of parents incorrectly believe that overall pitching performance would be enhanced following surgery.While there are notable instances of players improving following surgery, the most optimistic expectation for a pitcher undergoing Tommy John surgery is that the procedure allows the player to return to his previous level of performance.In fact,two recent studies have shown that players returning from Tommy john surgery tend to follow the typical aging pattern for players without surgery. 9.Does Tommy John surgery improve pitching speed? No. 53%of college athletes incorrectly believe that pitching speed would improve following Tommy John surgery.Similar to overall performance,players do not throw harder after Tommy John surgery than they did before the procedure.Most doctors have concluded that in cases where pitchers who have thrown harder post-surgery,it was predominantly due to the quality of their rehabilitation and improved strength and conditioning. 10.How often do pitchers suffer another arm injury after having Tommy John surgery? A subsequent arm injury is common among pitchers who have had Tommy John surgery. More than half of Major League pitchers who underwent Tommy John surgery from 1999 to 2011 went on the Disabled List with an arm injury after returning from surgery.Another recent study from the American Sports Medicine Institute(ASMI)concluded that 19%of Tommy John patients will have a subsequent elbow surgery and 25%will have shoulder surgery. 11.Can someone have Tommy John surgery twice? Yes.2-4%of pitchers undergo a second Tommy John surgery,often called a UCL revision. There have been fewer studies of players with revisions,but those have shown that these pitchers also are able to return to play at a high rate,though often in a reduced role. 12.Would lowering or eliminating the mound reduce the stress on the elbow and reduce the number of UCL injuries? It's unclear.Most studies have concluded that there is little difference in stress between pitching on the mound and throwing from flat ground but other studies have shown significant differences.Overall,amount of pitching, pitching mechanics and rest have been shown to be much more important factors than mound height. 13.Are players who throw harder more susceptible to UCL injuries? There is evidence that players who throw harder are more susceptible to UCL injuries, ostensibly because the increased velocity correlates with force in the elbow.Many studies have shown that players who throw harder are more likely to spend time on the Disabled List or miss time due to surgery.Pitchers who throw harder should be especially cognizant of the recommendations on pitch counts,rest and fatigue. The relationship between velocity and injury is complicated.Increased velocity is also associated with improved performance such that players with higher velocity have longer careers and also perform better.Therefore,it would be unrealistic to recommend that pitchers simply not throw as hard.However,varying speeds might improve a pitcher's effectiveness and conceivably also reduce injury risk. 14.Does long-toss reduce the number of arm injuries? White there are many advocates on both sides of this issue,it is important for the player not to exceed the distance at which he feels comfortable and which does not change his biomechanics.One recent study concluded an appropriate long-toss distance is typically 120 feet for college pitchers,but certain pitchers may be capable of throwing from longer distances while still maintain proper biomechanics and throwing the ball on a relatively horizontal trajectory. 2014 MLB Advanced Media,LP.Ali rights reserved. American Sports Medicine Institute I Home Page 1 of 2 T S:: hhschtisite: I J To Improve the understanding,prevention,and treatment arch sports-related injuries through research and education American Sports Medicine institute Welcome to the American Sports Medicine Institute' Major League Baseball and USA Baseball launch Pitch Smart website with input from ASMI. Click here to learn more U1 PITCH SMART W. PITCH SMART. A series of practical,age-appropriate guidelines to help parents.players and coaches avoid overuse injuries and foster J long,healthy careers foryouth pitchers. t • t. J 4;4it EXPLORE as Q 114i+r t ir_• FTr-, r I, • 4' Click here to view ASMI's position statement for youth baseball pitchers. Click here to view ASMI's position statement for Tommy John injuries in baseball pitchers. Upcoming Events 34th Annual Injuries in Baseball Course January 29-31,2016 Westin South Coast Plaza Costa Mesa,CA http://www.asmi.org/ 8/24/2015 American Sports Medicine Institute I Home Page 2 of 2 June Weekly Conference Schedule available here. Now available in book stores: Any Given Monday:Sports Injuries and ASMI Injuries In Baseball Conference How toPrevent Them Dr.James Andrews essential new book on sports injuries. Y/1 1 a N heClickhere for more information. A See the latest article from Anthony Scillia,Kyle Aune,John American, Medicine Institute XA , Andrachuk,Lyle Cain,Jeff Dugas,Glenn Fleisig,and James Sgoru y ( Andrews via RehabWehii ars.comReturntoPlayAfterChondroplastyoftheKneeinNational Football League Athletes. 2015 Injuries in Baseball Course Now AvailableAmJSportsMed2015Mar;43(3):663-8. Amesscan Sports Medeine Institute f 2660 10th Avenue South,Suite 505 I B rmmgham,Alabama 35205 205)918-0000 info0tasmi.orq 2012 http://www.asmi.org/ 8/24/2015 Hall of Fame Ceremony:John Smoltz's Speech Transcript I Online Gambling News Page 1 of 11 Online Gambling News Rouletters.com Hall of Fame Ceremony: John Smoltz's Speech Transcript Posted on July 28,201why Thomas derlan John Smoltz pitchedfrom 1988 to 2009,all but the 2009 season with the Atlanta Braves.He made the All-Star team eight times,and won a World Series with the Braves in 1995.He is the only pitcher in major league history to have over 200 wins and 100 saves in a career.Below is his Hall of Fame introduction speech: tk411, Wow.Hope you're ready for a wild ride'cause 4 **I'm going to warm you up for Pedro1Kse ;f r and Randy, and you never know what's going jra a t to bei ; coming. b_w t syr #4,'. ate ^„ This is truly t A I a treat.I 0! want to talk r ; about four significant phone calls in my life. The first was getting drafted by the Detroit Tigers,a dream that a hometown kid would have. http://news.rouletters.com/hall-of-fame-ceremony john-smoltzs-speech-transcript-0002957... 8/24/2015 Hall ofFame Ceremony:John Smoltz's Speech TranscriptI Online Gambling News Page 2 of 11 The second one was not the best of phone calls.It was getting traded by the Detroit Tigers to the Atlanta Braves,the worst team in all ofbaseball at the time. The third was very significant,and I will touch on it later.It was a call from Tommy John,encouraging me to continue with my career at the age of 34. The fourth call is not something I ever dreamed about.I don't know,I can't speak for the rest of Hall of Famers,but on January 6,when I got the call letting me know that I had been inducted into the Hall of Fame, words and emotions could not describe. The phone rang.I wasjust thankful that Greg Maddux had not put up an ultimate prank in letting me know that this was not for real.Thankfully they told me quickly that I had made it. I truly want to thank the Hall of Fame,Jane Forbes Clark,and Jeff IdeIson,for what they've done and preserved the character ofthis great Hall.For Brad Horn,Whitney,all the people behind the scenes making this like the perfect wedding,orchestrating it to the fullest.And of course the Baseball Writers ofAmerica, your votes obviously got me to this point.I cannot thank you enough. To Randy,Pedro and Craig,I will never forget this class.It is a class that I have had the utmost respect for each and every one of them. Of course,Craig,I've competed the most against. It's hard to believe that I never competed against Randy Johnson.I can't say that I'm sorry.But I don't think we ever hooked up.I had a seat in the bullpen when he pitched his perfect game as I was the closer for the Braves.Actually half-heartedly started to warm up in the ninth,it was a 2-0 game,knowing full well I didn't think I was going to get in that game.But at 6'10",he was truly the freak that mastered the game in a way that no other could. In a weird way with Pedro Martinez being on the opposite end the spectrum,me in the middle at 6'3",it shows why baseball is a game of all sizes and shapes and why truly it is America's pastime. Craig is a teammate that you always wanted and a guy you never wanted to play against.And Pedro,you got me in a lot of trouble facing you in my career.You were the most dominant pitcher I'd ever seen.It was Bugs Bunny.In today's world it was basically Nintendo or any kind of game you watch,that's the kind of stuff you had. I got fined$100 for check swinging,hurting my wrist against you.Thanks a lot. Well,I'm going to try to do it backwards.I'm going to do the tough part first.I never thought I'd ever read a speech,but for the sake of time,I'm going to do. http://news.rouletters.com/hall-offame-ceremonyjohn-smoltzs-speech-transcript-0002957... 8/24/2015 Hall of Fame Ceremony: John Smoltz's Speech Transcript Online Gambling News Page 3 of 11 I want you to know the best way to describe my career is unique.I can't think of another word.It's unique in every way.I have fingerprints all over my career by those who touched me and impacted me and helped me along the way.It's a huge army that got me from Lansing,Michigan,to where I am today.I'm not going to touch on all of them.I'm going to do that in a personal way.There's too many people to thank.I know I'll forget somebody.But I will take care ofyou on the back end,I promise.But I will be talking about some who made it possible to reach this dream. To my wife Kathryn,the hardest thing to do is when we met six years ago transition from a baseball career to retirement.As Craig mentioned,this life is a great life but a cruel life,a tough one.You made that transition so seamless,I can't even thank you enough.You took a blended family and you made them seem like your own.You love my kids as if they were your own.You saw me at my worst,trying to make a comeback with the Boston Red Sox after major shoulder surgery.I truly could not have made it without you. Everything you did for this event,it's not possible.I'm letting you know right now there's too many moving parts.I love you so much.You're where my place ofcomfort and peace really is.I look forward to the future as a retired-well,broadcaster for the MLB Network as we transition our career. To my kids,Andrew,Rachel,Carly and Kelly,I can't tell you what it's like for the journey of a major league player,you sacrificed so much.I love you very much.You adjusted and adapted to the challenges in our life. It wasn't the perfect road.You knew it wouldn't be.I always tried to give you the best of what I had.I can't wait to see what God has for every one of you as you pursue your passions.Be unique,they are your own.I can't wait to see the families that you are able to raise,as well. To Sara Kathryn and Ashley,my two stepdaughters,can't imagine what you were thinking when your mom and I got married and you were starting a whole newjourney.Your willingness to adapt with the twists and turns and your ability to just go with the flow,it seems like we've been meant to be together our whole lives. I can't tell you how much I love you guys. To my mom and dad,this is where the story gets interesting,you did so much for me to get me to this point. You didn't know much about sports or baseball.You pretty much knew what you knew,and that was playing the accordion because that's how you met.You were accordion teachers and I thank you for the opportunity to start me on my quest to be the next Lawrence Welk at the age of four.I played till the age of seven.Then I hit you with the ultimate whopper of all whoppers.At the age of seven I said,I know what I want to be in life,and I'm going to be a Major League baseball player. He loved me enough to give me room to go after my dream.You didn't discourage me from leaving the accordion for Major League Baseball.You just told me to have a backup dream,and I did that as well. Even though it was a gas station attendant at the time,I thought that was pretty cool. http://news.rouletters.com/hall-of-fame-ceremonyjohn-smoltzs-speech-transcript-0002957... 8/24/2015 Hall of Fame Ceremony: John Smoltz's Speech Transcript I Online Gambling News Page 4 of 11 I cannot imagine the odds and what you felt when I told you I was going to play Major League Baseball. These things might have caused you to sway me in a different direction.You not only allowed me to pursue this newfound passion of mine,you went on a journey to find opportunities for me to play this great game of baseball.You served as a great example for me and all future parents,that when a kid has a dream,no matter how outrageous or outlandish it might be,giving them the chance to pursue that is the greatest thing in life.You put aside what you knew and what you thought would fall in the family Iine of tradition of great accordion players,I can't thank you enough. I'm proud of the way I grew up,the heritage in which we grew up.The polka music on the eight-track tapes, I enjoyed it all.You taught me so much to not be afraid of who I am,to learn,to laugh,to cry,you gave me the characteristics and morals by which I live by today.I'm so thankful.Dad,you taught me my competitiveness,your unwillingness to let me win at the age of four and five was relentless,but I thought it was great because I returned the favor when I got a chance to. You taught me to honor God first,family second,school third,and sports fourth.You put the priorities where they needed to be,and you stood by them.I thank you for that. To my brother and sister,I can't thank you enough for sacrificing your summers.Thankfully we didn't grow up in Florida or warm weather where you fall prey to playing every day or all year.Two months in Michigan is long enough.But you sacrificed enough for me.One year apart,close-knit family,following my 21-year career,you were there at every turn,when I needed you the most. My extended family is my biggest army in the world and I can't thank them enough because of everything we did.We were close-knit and we had a blast.Yes,it always involved playing the accordion and dancing. One thing I never did do was dance,but I played_the accordion.I can't thank you enough for the love you had and I can't possibly repay you all. To my extended family,to my in-laws for jumping on this ride,not knowing exactly what you're going to get, this is a cool ending so far in the midst of my journey. My baseball journey began outside our home in Lansing,Michigan.I have a unique story.I already told you about the accordion.I had a wild imagination. Before I go any further,Jeff Foxworthy,I'm not going to tell any corny jokes.Relax,I can see you tense up as we speak. I started with a rubber ball and a brick wall.For those who know me,this won't come as a surprise.The GM, the manager,the pitching coach,the grounds crew,the play-by-play,you name it,in my mind I did it.I would stand outside that wall in a generous strike zone and pitch the greatest games ever known to mankind.I'm a self-taught baseball player,Tiger fanatic growing up.I would watch someone and http://news.rouletters.com/hall-of-fame-ceremonyjohn-smoltzs-speech-transcript-0002957... 8/24/2015 Hall ofFame Ceremony: John Smoltz's Speech Transcript Online Gambling News Page 5 of 11 immediately emulate them outdoors.Thankfully didn't have the technology that exists today that kind of distracts our attention to get outside and do that which we love. I'm also happy to say that in all those big games that I pitched in my life,I won them all.I truly believe if the moment were to get there,I would be a little kid on the mound relishing in the fact that I get to do this cause I've already done it in my mind so many different times. Growing up in Lansing was incredible.It's where my baseball career kind of took off.My best friend Chuck Cascarilla,we did everything together.We thought of games,we went outside,we were constantly doing whatever it took.For a lot ofyou in the stands that might not know what it is,we played a lot of strike-out, pickup baseball,games that I'll never forget. Aside from my family and Chuck,a guy that I call my second dad,I owe great gratitude to,could not make it today,at home in Lansing,Michigan,hopefully watching,Carl Wagner,dedicated over 50 years of his baseball life teaching and honoring kids.Over 50 years he provided the opportunity for kids to go out and play the great game of baseball.He taught me to never be complacent,never think you arrived,because there's always somebody working harder to take your job and be better than you are. Two other significant people from Lansing,Javier Cavazos dedicates his life to teaching youth all over Lansing,and he has been a big influence on me putting me in situations.He may be one of the few people that as a coach will understand Pedro Martinez,because he told me in a game in Brooklyn,New York,where I gave up four two-run homers in an inning,I'm not afraid to fail and I learned from some of the greatest failure moments in my life. In Brooklyn,New York,they were all yelling at me in Spanish.He came out.He said,You want to know what they said? You might as well tell me as you're taking me out. He said,They were yelling to get Ben-Gay for your neck because every time you threw a pitch you'd turn around because it was over the fence. Thank you,Javier,for your humility as well as your ability to teach kids. For Phil Odium,my high school basketball coach,I had the two greatest years of my life.I loved every minute of my life where I grew up,where it ends and where it's going.You gave me the keys to lead a basketball or baseball team that I would take later and pursue that in my big league quest,to be the best baseball player,but the best teammate I possibly can be. http://news.rouletters.com/hall-of-fame-ceremonyjohn-smoltzs-speech-transcript-0002957... 8/24/2015 Hall of Fame Ceremony: John Smoltz's Speech Transcript I Online Gambling News Page 6 of 11 To start with the drafts,I have to thank the Tigers for drafting me in the 22nd round.I think I'm the latest round draft pick to be in the Hall of Fame.If it were not the scouts,the backbone ofour game,for seeing what I had,the motor that was ticking inside the 6'3",180-pound skinny kid,this would all not be possible. Drafted by my hometown team was a dream come true,as I said.I had a unique situation where I got drafted,the last day before you go to college.Imagine getting drafted and going to the team you idolized and staying with them for 35 days in the big leagues.Instead of going to rookie ball,I went to the big club, got a chance to see what the heroes were doing in their locker room,in their home. I got to say this:As odd and as in awe as I was of these guys,I remember sitting in the locker room at Tiger Stadium,a fish out of water,scared to death a Hall of Famer in my mind,a guy I will never forget in making the first impression in my pro career,came up to me and said,Hi,I'm Alan Trammell.Anything I can do for you,don't hesitate to ask.This house is your house. I will never forget.I thank you,Alan Trammell,for teaching me what a professional baseball player is all about. It was as if he introduced and gave me a baton and said,Now,pay this forward every chance you can because this game has a chance to impact a lot of people.And I have done that to the best of my ability thanks to Alan Trammell's imprint in my life,just that five-to 20-second time of his day took to welcome a newcomer to the game. I also want to thank a good friend of mine,Bruce Fields,taking me into an instructional league.Right after big leagues I went right into instructional league and I worked 6'3",185,went into a home of veterans.They helped and nurtured me for the big leagues,thanks to his wife Julie,they put 20 pounds on me,which I desperately needed. Now the most infamous trade in Atlanta Braves history.I can't spend enough time talking about this gentleman. I will hear about it later from the fellow Hall of Famers that I respect,but Bobby Cox is every single thing to me on why I stand up here today. He was the general manager that took the chance and made the trade and got me over to Atlanta.And,yes, sir,they were the worst team in baseball at the time.It was the most devastating time of my life.But I realized I would have an opportunity to pitch in an organization that desperately needed pitching. I used to only think of that trade as myself and what it did for me.Tom Glavine reminded me that that trade opened up a spot for him in the big leagues and he never looked back.I'm glad that two-for-one worked out. Bobby became my manager.He's the reason I stayed in the organization for 20 years.I would rather go nowhere else.As I said,time does not permit me to tell you what an incredible manager,the history I was http://news.rouletters.com/hall-of-fame-ceremonyjohn-smoltzs-speech-transcript-0002957... 8/24/2015 Hall of Fame Ceremony: John Smoltz's Speech Transcript I Online Gambling News Page 7 of 11 able to watch. He empowered people,he gave you confidence when you didn't have it.He was a tremendous leader.I owe a great amount of my career to this man. Because of the faith that he had in me,it was the reason I was able to make the transition from starter to closer,then start back to starter.He believed in everything I did.He knew my personality.He allowed me to play golf,which always puts a smile on my face.It's the reason that the three of us were able to play as long as we did. The starting rotation will be talked about for the rest of time and maybe always compared to things.But to do something and make it come full circle,to talk about the two greatest teammates,the two greatest pitchers that got inducted,I was watching them actually rip me a new one,enjoying every second of it.I thought we would go back in time and just do this for a second. Glav,Maddux,back when I had hair,we had the time of our lives.It's the only time,Greg,you're not going to be able to talk about my bald head.What I want to talk about is the time we had playing golf and pitching. What you don't know about Greg and Tom is you know that all the statistics got him here and they got him here in the Hall of Fame.But they did things behind the scenes for me that I will never,ever forget.When I lost my change-up,they were there helping me to find it.When I lost my golf book,which was the prize of what I had,because I was the golf concierge,they looked tirelessly and helped me find it.Recently I lost 20 pounds,and they helped me find it.Thank you,guys. I cannot say enough about them.As time permits,obviously you know how much we have been together. Tommy for 15 years,Greg for 10.To Chipper Jones,soon to be inducted in the Hall of Fame,another one of the Atlanta Braves. I'm not going to say anything about him because he'll have the mic last.Would somebody please steal his Twitter account. Thanks to all the trainers that worked so hard.I'm a medical miracle that stands before you today.I spent more time in the training room.I can't thank them for their patience.I know I drove them crazy.Dave Pursley,Jeff Porter,and Jim Lovell,everybody else that had a hand in my career.I can't thank you all enough.Like I said,I hope one day to be able to give you something special. To Chris Verna and Peter Hughes,you were invaluable in my career and crucial for the day-to-day what it took to get to the mound. To all the doctors in Atlanta,I spent a lot of time counseling with you and seeing how it was going to be possible to throw another pitch.One doctor I spent the most time with and the most passionate doctor,as Tommy said and even Greg,Dr.Joe Chandler,there's no possible way I could have done this without you.I can't thank you enough.You are everything I could ask for in your profession. http://news.rouletters.com/hall-of-fame-ceremonyjohn-smoltzs-speech-transcript-0002457... 8/24/2015 Hall of Fame Ceremony: John Smoltz's Speech Transcript I Online Gambling News Page 8 of 11 You watched the medical miracle keep existing.We had many times at your house,in your office,and I can't thank you enough for the time you spent with me.It's invaluable. To all the pitching coaches I had,roving pitching coaches in Detroit,John Hiller and Ralph Treuel,bearing with the wild stallion.Thank you to Bruce Dal Canton,my first pitching coach.Then Roger McDowell,of course. My first encounter of Leo Mazzone is when I came over from the Detroit Tigers in a trade.He helped simplify my mechanics and my ability to pitch.With the throwing program we were able to use over the last 15 years of my career is the reason we stayed healthy.Thank you,Leo,for your patience and your diligence in seeing something through and making it work. To my good friend Greg Olson who is here today.We hit it off right away on the field and off.His upbeat attitude helped me get through so many of my tough games.I'll never forget him jumping in my arms against the Astros,the first time we were able to get to the playoffs.He jumped in my arms,I never anticipated after nine innings,he was pretty heavy,but at that time he felt pretty light. We got a chance to do it again after Game 7 after an unbelievable game of Steve Avery 1-0 in Pittsburgh. Jumped into my arms again,and we were on to the World Series.This all happening after a 2-11 first start, and then Bobby's patience and faith and a 12-2 second half allowed this all to be possible. We never planned it,but however we were working on a Trifecta in Game 7 against Jack Morris.We were one run away from that happening.It didn't happen.My idol growing up Jack Morris ruined that incredible opportunity to have three times you jumping in my arms. Thank you,011ie,for all we did and all we did in our friendship,all the catchers I had.I was not an easy person to catch.I can't thank them enough for their willingness to get me through a game. To Brian McCann,now with the New York Yankees,it truly was a privilege to teach him what I Iearned from a lot of the other catchers in our game. To all my teammates,I can't name you all,I thank you for what we had,an incredible run.My goal in life was to be the best teammate that I possibly could be.That meant caring for you on and off the field,being there doing my best to be prepared,laughing,joking,golfing,whatever it took.l cared about each and every one of them.That was our family away from our family and we spent a lot of time and good times together. A special thanks to the great centerfielder I've ever seen in Andruw Jones.Andruw Jones caught more fly balls that I threw than probably anybody else.He was truly a pleasure to be playing behind. http://news.rouletters.com/hall-of-fame-ceremony john-smoltzs-speech-transcript-0002957... 8/24/2015 Hall of Fame Ceremony:John Smoltz's Speech Transcript I Online Gambling News Page 9 of 11 To the Atlanta Braves organization,to wear this great uniform and represent the great state of Georgia,I never took one day for granted.Wearing this uniform,I played every game as if it was my last.The Braves uniform became such a platform for not only your foundation,but my later foundation I formed and the charities we were able to touch.I can't wait to represent these organizations in the future as now representing the greatest team behind me in the Hall of Fame. A special thank you to the Boston Red Sox for taking a chance on a broken-down guy recovering from a shoulder surgery.I can't thank you enough for this experience,giving me an opportunity.Although I did not do very well,I am so sorry for that.But giving me that opportunity,you showed me what another organization's view is like and the rich history you had. To the St.Louis Cardinals,I will never thank you for giving me that chance after being released by the Boston Red Sox,and deservedly so by the way,for giving me an opportunity to end my career in what was an improbable and unbelievable playoff season.For Tony La Russa,I can't thank you enough for making me feel like one of your own,trusting me with the ball in some of the big moments. I will never forget these two organizations because I would retire after wearing the Cardinals uniform in 2009. Last but not least,I want to steal a little bit of what Craig Biggio said in my speech,I want to thank the clubhouse guys.They are the heart and soul of our team.They are the heart and soul of everyjunk we bring to them.I watch these kids grow up from kids to adults to now having families.It started with Casey Stevenson,Chris Van Zant,Ben Acree to name a few. Bill,for all the things you did away from the game.The game consumes you and you need things to be in the proper order,in the right way.I can't thank you enough.John Schuerholz,Terry McGuirk,the whole Braves organization,you treated me as the family I now have in Atlanta and will forever live there,Lord willing. John Holland and Fred Stone in spring training,I had so much fun with the guys behind the scenes because they never get enough time to be noticed or even know that they're there.Sometimes get treated in a way that doesn't represent what the game is. Before I hand it over to the next inductee,I'd be remiss if I did not talk about Tommy John.I've been given an opportunity as one of the only players,the only one right now to be inducted into the Hall of Fame,with Tommy John surgery.It's an epidemic,something affecting our game.It's something I thought would cost me my career.Thanks to Dr.James Andrews and all those before him,performing the surgery with such precision has caused it to be almost a false read like a Band-Aid you put on your arm. http://news.rouletters.com/hall-of-fame-ceremonyjohn-smoltzs-speech-transcript-0002957... 8/24/2015 Hall of Fame Ceremony: John Smoltz's Speech Transcript I Online Gambling News Page 10 of 11 I want to encourage the families and parents that are out there to understand that this is not normal to have a surgery at 14 and 15 years old.You have a time.Baseball is not a year-round sport.You have an opportunity to be athletic and play other sports. Don't let the institutions that are out there running before you guaranteeing scholarship dollars and signing bonuses that this is the way.We have such great dynamic arms in our game that it's a shame that we're having one,two,three Tommy John recipients.I want to encourage you if nothing else,know that your children's desire and passion to play baseball is something they can do without a competitive pitch.Every throw a kid makes today is a competitive pitch.They don't go outside,they don't throw enough.They're competing and maxing out too hard too early.That's why we're having these problems.Please,take care of those great future arms. To Tommy John,I can't thank you enough for the phone call,whether you were coerced or not.The phone call at the age of 34 years old meant the world to me.Emotionally I'd given up.I thought that no one would wait for a pitcher of my age on the last year of my contract.Thank you for encouraging me.That was a pivotal part of my career to push through what I thought might be a career-ending. At 34,and 14 post-season years and 200 post-season innings is one of the reasons that I thought Tommy John,besides genetics,had happened to me.Because of Dr.Andrews and the team that had been before him,I had confidence that the surgery would work and the rest would write its story. Last but not least,or close to last but not least,I want to thank Mike Nixon,Scott Runyun for taking our family up here in a plane.That was an absolute gift.As you can see,my family is huge.It takes an army. Thank you for your generosity. Being inducted into the Hall of Fame is one of the greatest honors that I could have here on earth.However, I know there's another one coming.The ultimate Hall of Fame.I want to thank God for the talent He has given ine and the support system that I have. I would not be the man I am today if it were not for a couple people who sowed seeds into my life,telling me about Christ and telling me to take a deeper look into my faith.Jose Alvarez,Marty Clary,Sid Bream,Terry Pendleton,the list could go on.They took the time,not to care so much about my talent,but the heart and the man I would become. Jackie and Ken Kendall,Mike and Kellie McCoy,Walt and Patty Wiley,and last Tim Cash and Barb,these are the people through the toughest times of my life,the intimacy of knowing what life has challenged you with, they've been in my every corner.They've allowed me to know that I have more to Iive for thanjust the http://news.rouletters.com/hall-of-fame-ceremonyjohn-smoltzs-speech-transcript-0002957... 8/24/2015 Hall of Fame Ceremony: John Smoltz's Speech Transcript I Online Gambling News Page 11 of 11 uniform I was wearing.They gave me the greatest gift,to find my salvation in Christ.I can't thank you enough for caring enough to invest your time and heart in me. I have a unique group of men that meet every Thursday in JR's.Jeff Foxworthy and the likes of so many men who have,through those days,taught me the impact I can make just beyond wearing a uniform. I'm so humbled to be a member of the National Baseball Hall ofFame,I'm honored by so many of my family members.To be here in Cooperstown is not something I ever dreamt.I know along the way I forgot some people,but in my baseball career,I've been around two men that I would entrust my children with,I would leave my children with,who have represented me in baseball with the first class and degree in it that I always wanted my parents to be proud of. Myles Shoda and Lonnie Cooper,I cannot thank you enough for taking care of my needs away from the game and my intentions,yours.It's so vital. To the guys who introduced me in transition to broadcasting.Thank you for taking the time for taking a simple-minded,no vocabulary,accordion-playing player into transition to baseball.Thank you to the MLB Network.It started with TBS.I can't think of another home I'd rather be and take the abuse when 1 get back from a great organization like the MLB Network.Think I covered it all. I am thankful,honored and blessed.Thank you very,very much. Posted in Sport shooks 0 2015 Online Gambling News Powered by WordPress&]hemegraphy http://news.rouletters.com/hall-of-fame-ceremonyjohn-smoltzs-speech-transcript-0002957... 8/24/2015 Noted surgeon Dr. James Andrews wants your young athlete to stay healthy by playing le... Page 1 of 10 Menu Set weather Subscnbe Sign In Search 14 Noted surgeon Dr. James Andrews wants your coto young athlete to stay healthy by playing less s" :,. J.,- tts- L A x ems l-s L a S x per, ....46...„. l 4 yV7r Notedsurgeon Dr.James Andrewswantstoconvinceparentsthatpushing theirChildrenintoyear-roundsports can be dangerous to theyoungsters'headn(Photo byAPfile) KrTheny Dennis Menotoff. e Plato Dealer PP=M Followon Twitter on February27,2013 at5:00AM,updatedFebruary 27,2013 at1.14 PM CLEVELAND,Ohio--JamesAndrews has seen enough. Enough ofcoaches who mean well and try hard,but who really don'tknow what they need toknow. Enough of parentswho think their son ordaughter isthe next superstar athleteand must bepushed and pushed and pushed. Enough ofyoungsterswho are forced to visit him and his colleagues around the nation. Andrews has become soalarmed that he isissuing written and verbal warnings to anyone willing to read or listen.Why should the public care what Andrewsthinks? Because when the"Dr."isplacedin front ofhis name,he becomesaworld-renowned orthopedicsurgeon. Andrews,who haspracticed medicine fornearly 4oyears,is most famous for hisability to put professional athletes back together.These athletes--notably,a who's who of quarterbacks--have signed contracts fora combined total well north of$t billion after hissurgeries.In 201o,Andrewswas the only doctor to be named among thetop 40 most powerful people in the NFL by Sports Illustrated. Andrews'specialties are knees,elbows and shoulders.One of his recent patientswas Washington Redskins quarterbackRobert Griffin III,who needed theanteriorcruciate ligament and lateral collateral ligament repaired in his right knee. http://www.cleveland.com/dman/index.ssf/2013/02/noted_surgeon_drjames_andrews.html 8/25/2015 Noted surgeon Dr.James Andrews wants your young athlete to stay healthy by playing le... Page 2 of 10 Thework on athletes,while important,isu't the reason Andrews collaborated withDon Yaeger,a former associate editor at Sports Illustrated,to write,"Any Given Monday: Sports Injuries and How to Prevent Them,forAthletes,Parents and Coaches--Based on My Lifein Sports Medicine."He felt compelled to write thebook,then talkabout it, out offear for theyounger generation. I started seeing a sharp increase in youth sports injuries,particularly baseball, beginningaround 2000,"Andrews told ThePlain Dealer in a telephone interview."I started tracking and researching,and what we've seen is a five-to sevenfold increase in injuryrates inyouth sports across the board.I'm trying to help these kids,given the Reads epidemic of injuries that we're seeing.That's sort ofm_v mission:to keep them on the playing field and out ofthe operating room. I hate to see the kids that we used to not see get hurt....Now they'recoming inwith adult,mature-type sports injuries.it's a real mess.Maybe this bookwill help make a dent." PD:What is thecrux ofthe we"fuu as mission? 1 want parents and coaches torealize the implications of putting a 12 or 13-year-old through the type ofathletic work done by a25-year- old,"says Dr.James Andrews J.A.:The deal is,as sports APfie physicians,we've allbeen amiss foryears worryingabout putting people back together TheDr.lames Andrews file and fixingthings and new techniques.But we'velargely Born:1942. ignoredthereal problem: prevention ofinjuries. Children:Six. Everybody now agrees thatthe Education:Louisiana State time is rightto keep thesekids standout pole vaulter);LSU School from getting hurt so often. ofMedicine;Tulane(residency). That's been mymission for so Mentor:Dr.Jack C.Hughston. to 12 years,andit's really come Offices:Andrews Sports Medicine to the forefront that last three to Orthopaedic Center in fouryears,when I helped start a Birmingham,Ala.,and Andrews prevention program with the Institute for Orthopaedics&Sports sports-medicine society that we Medicine in GulfBreeze,Fla. callthe STOP program:Sports Former and current patients: Trauma and Overuse RogerClemens,Albert Pujols, Prevention(in youth sports). CharlesBarkley,Scottie Pippen, Kerri Strug,Jack Nicklaus,Troy All proceeds fromthe book aregoing to Aikman,Drew Brees,BrettFavre, the STOPprogram.It's not an"I"thing, Bo Jackson,Emmitt Smith,Terrell not afinancial thing,forme.It's a Owens,Matthew Stafford,Sam passion. Bradford,Peyton Manning,Eli Manning,Trent Richardson,Robert PD:Why thespike in youth injuries? Griffin III,Adrian Peterson,Marcus J.A.:Multiple factors,but two stand out:Lattimore and a member ofthe specialization and what we call Saudi royal family(tom ACL). professionalism. Dennis Manoloff Specialization leads to playing the sport year-round.That means not only an Related stories increasein riskfactors fortraumatic injuries but a sky-high increase in overuse ' Andrews debunks sports myths injuries.Almost half ofsports injuries in adolescents stem from overuse. Professionalism is taking these kids at a young age and trying to work them as ifthey are pro athletes,in terms oftraining andyear-round activity.Some cando it,like Tiger Woods.Hewas treated like a professionalgolferwhen hewas4,5,6 years old.But you've got to realize that Tiger Woods is a special case.A lot of these kids don't have the ability towithstand that typeoftraining and that type ofparental/coach pressure. http://www.cleveland.com/dman/index.ssf/2013/02/noted_surgeon_dr_james_andrews.html 8/25/2015 Noted surgeon Dr.James Andrews wants your young athlete to stay healthy by playing le... Page 3 of 10 Now parents are hiring ex-pro baseball players as hitting and pitching instructors when their kid is 12.They're thinking,'What's more is better,'and they'reending up getting the kids hurt. PD:Is money at the root oftheproblem--e.g.,the pursuitofcollege scholarships or pro contracts? J.A.:The almighty dollar has a lot to do with it,yes.Some parents are putting a football orbaseball in theirkids'hands when they're 3 years old,and it's notjust for a fun little photograph.Parents are projecting 10,12 years.Don't get mewrong,I'm for sports.I Redmt love sports.Iwant these kids to reach their full potential,and ifthe potential is a college scholarship,great.Ifit's a pro career,great.But to think they're all going to be professional athletes is misguided.The odds against it are sovery,very high.Even the ones who get college scholarships comprise a much smaller percentage than parents think. PD:Canparents beput in a no winposition as well? J-A-:Yes,tothis extent:The systems out there in youth sports,particularly travel ball, have been important financial resourcesfor the people who run them.Parents spend a fortune keeping their kids in a SportsInsider:Dennis Manoloff talks about Dr. year-round sport,with travel JamesAndrewsinterview and everythingelse.What's On today'sepisode ofSports Insider,cleveland.com's Glenn Moore speakswithThePlam Dealers DennisManobflabout his interview happening is,the tail iswagging wdh Dr James Andrews the dog.The systems are calling theshots:Ifyour son or daughter doesn't play my sport year-round,he orshe can'tplay for me.Never mind that your kid is12--I need year-round dedication. Parents need to understand thatwe've got to correct thesystem.Unfortunately,it's easier said than done.It's a bigproblem.And itbecomes a socioeconomic problem if they keep getting hurtin high school. PD:The best advice you would gineparents ofayoung athlete? J.A.:The first thing I would tell them is,their kid needs at least two months offeach year to recover from a specific sport.Preferably,three to four months.Example:youth baseball.For at least two months,preferably three to four months,they don't need todo any kind ofoverhead throwing,anykind ofoverhead sport,and let the body recover in order to avoid overusesituations.That's why we're seeing so manyTommyJohn procedures,which is an adult operation designed forprofessionals.In my practice now, 3o to 43 percent ofthe ones I'm doing are on high-schoolers,even downto ages 12 or 13.They're already coming in with tornligaments. Give them time offto recover.Please.Give them time to recover. I said in thebook,I want parentsand coaches to realize the implications ofputting a 12- or 13-year-old through thetype ofathletic work done bya 25-year-old.Parents and coaches,though they mean well,need to understand what the long-term effects of overuse can be. PD:What are yourthoughts on youngsters throwing curveballs? J.A.:Throwinga curveball has a neuromuscular-control dynamic.In other words,it takesa lot ofnatural ability at a youngage to throw that pitch.It'sa complicated pitch. Ifyou throw it with good mechanics,it doesn'thave any greater force onyour shoulder than throwing other pitches,butyou've got to throw it correctly.It'smisleading to say it's OK to throw the curve-tall with good mechanics because the rub is,most kids don't http://www.cleveland.com/dman/index.ssf/2013/02/noted_surgeon_dr_james_andrews.html 8/25/2015 Noted surgeon Dr. James Andrews wants your young athlete to stay healthy by playing le... Page 4 of 10 throw itwith good mechanics.My rule ofthumb is,don't throw thecurveball until you can shave,until yourbone structure has matured and you have the neuromuscular control to be able to throw the pitch properly. PD:Whatadvice would you give pitchers,ingeneral? JA:r.Use proper mechanics.The No.1 problem in any specific sport is improper mechanics. 2.Don't playyear-round. Rede? 3.Avoid the radar gun at ayoung age.Don't try to overthrow.A lot ofkids are 13 years old andchecking the radar gun.That's going to get you in trouble.The radar gun makes you want tothrow harder than you are capable of throwing. 4.Bevery careful withshowcases.I call them"show-off'cases because kids go there Saturday afterthrowing the football on Friday.Theyjump on a mound and overthrow because scouts are there.The next thing you know,the shoulderor elbowgets injured. HBO's Real Sports on Dr.JamesAndrews(Part II here) PD:How manypro athletes have you operated on in your career? J.A.:I'vehad people ask me that,and I don'tliketo answer with numbersbecause it might sound like I'm braggingor self-promoting.So I don't go into a specific number. Chuckle)What I like to sayis,"Too many to count and not enough toquit." PD:Whatpercentage ofyour totaloperations are done onpro athletes? JA:About 20 percent.Now I'm getting to where I'm operating on the sons of ballplayers I had. PD:Have you stoppedto think about themoney inplayercontractsfor which you've been responsible by extending careers? JA:(Chuckle)No.Seeing these guys getback to doing what they dobest,that'swhere I derive the enjoyment.I don't worry about how much money they might make in the future.I wishthem all the best,but it's nerve-rackingjust the same.Every play.In the NFCChampionship Game a few years ago,theVikings played theSaints.Brett Favre and Drew Brees were twoofmy patients.I was pulling for Drew on offense,then Brett on offense,so I couldn't lose.ButI was nervous. PD:It is easy toforget how many surgeriesyou do on nonstars. JA:A hugejoy for me comes from operating on kids inhigh schools near where I live, kids who were injured and didn't have insurance.We've had a policy through theyears that,ifyou gethurt playing high school football in my area,we'll do the bestwe can to help.(Andrews has offices in Alabama and Florida_) http://www.cleveland.com/dman/index.ssf/2013/02/noted surgeon_dr_james_andrews.html 8/25/2015 Noted surgeon Dr.James Andrews wants your young athlete to stay healthy by playing le... Page 5 of 10 To seethese kids comebackand get a scholarship,or even a pro contract,isa thrill.I once had a high school basketball playerin Mississippiwhom nobody world fix.The coaches brought him to me.Well,he eventually signed au NBA contract and has had several contracts and made tens ofmillions of dollars.He came back to see mewith anotherinjury.I toldhim,"This time I'm going to charge you." You'd besurprised inour part of thecountry how many kids get hurt.We've had kids playing in rural areas,great athletes who gethurtbut neverwere able to get the proper medical attention. Reddt PD:The most complexsurgery you've everdone? J.A.:Marcus Lattimore,runningback from South Carolina--his leg.Drew Brees' shoulder.I'llsay this about Drew:It's amazing that he's been able to come back and throw afootball,let alone play at the level he does. PD:What goes throughyour mindwhen players such asAdrian Peterson,whose knee youfixed,come back to rushfor2,000 yards in one season? J.A.:I don't want to take creditfor things like that.Ifyou operate on the right athletes, the high-levelathletes,they will make you look pretty goodas a physician.Ifyou don't have athletes whoare motivated,who areso driven to come back,it won'tmatter.And the people who get the players after thesurgeries--they're the ones who deserve the most credit.The physical therapy and rehab people.My time with them is a couple hours,then I become a cheerleader. As an example,the people who rehabbed Adrianwere incredible.The combination of Adrian's motivation,hisGod-given abilityand the help be got post-surgery gave you what you saw on the field in 2012. PD:Which is the morecomplicatedsurgery,tornACL or Tommy John? J.A.:Even though they involve different parts ofthe body,they are similarsurgeries. I've called Tommy John theACLof theelbow.Throwing a baseball at 90miles an hour with a reconstructed elbow is equallyas impressive as a running back comingbackfrom an ACL tear. PD:Have you ever neededto tell an athlete after surgery that itdoesn't look good? J.A.:My rule is,the glass is halffull,nothalfempty.One ofthe things you don't dois wake up an athlete in the recovery room and say,"That's the worst injury I've ever seen, and you're not going to make it back."You've got to be positive.I told Drew[Breen]:"I could do youroperation loo timesand probablycouldn't do it as well as I did it today. You are going to get through this,and you will be betterthan ever.Now go to work." At the sametime,you have to berealistic.When you get to a certain point where you knowthey're not goingto be able to make it,you let themdown slowly.You don't tell them right away.You graduallywork it in.Asyou get toknow them better,you gradually let them know there is life afterfootball. PD:Because ofyour resume,doyoufeelpressure to deliverevery time? J.A.:Yes,I feel pressure.A lot ofit.Butthe bulkof thepressure is what all ofusfeel in this profession.There is extra pressure because people come tome who'vebad multiple surgeries.All ofa sudden,you are inundated with people who have bad failed surgeries. They cometo you andexpect you to put thembacktogether again.So the pressure mounts,believe me. All ofusinsports medicine operate in a fishbowl.Ifthere's a failure,it's all over the place.But you can'tbe perfectwith everything you do.You dothe bestyou can. Unfortunately,the onlyresults I ever really remember are the bad ones.Those are the onesyou need to study in ordertofigure out what you can dobetter. PD:You have knownBrowns running back TrentRichardson since his high school daysin Florida. http://www.cleveland.com/dman/index.ssf/2013/02/noted_surgeon_dr_j ames_andrews.html 8/25/2015 Noted surgeon Dr.James Andrews wants your young athlete to stay healthy by playing le... Page 6 of 10 J.A.:He's a specialindividual,asyou all in Cleveland knowby now.He played with broken ribs this past season.Imagine playing with broken ribs.That's how tough be is. He's a heck of a running back. PD:Richardson hashad surgeries on both ankles andtwo on the left knee.Is he injuryprone? J.A.:No,no,no,no.The injuries haven't been serious.He delivers a blow.That'swhat he does.lie delivers more damage than anybody delivers to him.Justwatch him play. PD:Will he have a long,productiveNFL career? Reddt J.A.:I'm biased,ofcourse,but,yes,absolutely.He can overcome almost anything.He has a great mental attitude,he can recover quickly and he's a survivor.That's the key to Trent:He's a survivor.The Cleveland Browns have a wonderful player who hasn'teven scratched thesurface. Twitter:@dmansworldpd Reddt RelatedStories t ' P t pitched his fanny off:Josh Tomlinbrushes I 1 ' asideinjury- riddledpast.home runballs Ten tips for high schoolsports parents:Tim Warsinskey's Takerevisited photos) 14 comments Sign in Post comment as... Newest Oldest Faiza Khan Jul 30,2015 Joseph Heller never particularly informs us the first 21 grabs m his popularWWII novel Catch-22 butthat22one is absolutely afantastic.While not Informing usthe other21 grabs,he also actually forgets to put them to be able_I have lengthy suggestedthat ifwe at least realized the factsand the transaction of the un-named first21 grabs,we would be much better able to actually comprehendcatch-22 httpjlbrandingimportarfce.beep.coml Like Reply FromtheArchive frewest i Oldest Steve D Mar1,2013 Decent article and it almost pushed themessage across.I'm not sure why you deviated fromthe message of injuries in youngathleteswith the last 15 orso questions about pro athletes(thefirst 9 were on point), http://www.cleveland.com/dman/index.ssf/2013/02/noted surgeon_drjames_andrews.html 8/25/2015 APPENDIX N-13 STOP SPORTS INJURIES MATERIALS Baseball Injuries I Baseball Injury Prevention& Treatment Page 1 of 3 Get OurNewsletter Search STOP Sports Injuries Fan.Us in Follow Us Home Sports Injury Prevention Resources Media About Find a Specialist Support Us Events Store Slog Sports Injury Prevention Preventing Baseball Injuries Sports Specific Resources EMIR i Injures in young athletes are on the rise.but elbow and shoulderinjunes in children are onthe Athletes'Resources verge of becoming an epidemic Thousands of children are seen each year complaining of elbow Coaches'Resources or shoulder pan Damage or tear to the ulcer collateral ligament(UCL)is the most common injury suffered and is often causec by pitchers throwing too much.This ligament is the main stabilizer of Healthcare Providers'Resources the elbowfor the motions of pitching When it becomesdamaged,it can be difficult to repair and rehabilitate Parents'Resources Download tris PDF Send this PDF to a F.ed Quick Links Issue Specific Resources How is anelbow or shoulder injury diagnosed? How can overuse baseball injuries be prevented? ACL Injury Prevention How is an overuse elbow or shoulder injury treated References and 4'idhional Resources Concussion Contributing Experts Conditioning Tips Female Athlete Triad HeatIllness HOW IS AN ELBOW OR SHOULDER INJURY DIAGNOSED? Knee Injury Prevention Ifa young athlete is throwing toohard.too much too early.and without rest a serious elbow or shoulder injury may be onOveruseInjurythehorizon.if theathlete complains of elbow or shoulder panthe day after throwing,or movement of thejoint is painful or Sports Nutrition restricted compared to the opposite side,see aphysician familiar withyouth sports injunes immediately Strength Training Tips Back to top HOW CAN OVERUSE BASEBALL INJURIES BE PREVENTED? Overuse injuries—especially those related to the UCL Maximum Pitch Counts and shoulder—are preventable.Some tips to keepyou Age Pitches/Game 7-8 50 in the gamethroughout your life include: 9-10 75 11-12 85 Warm up properly by stretching,running,and easy. 13-16 95 gradual throwing 17-18 105 Become an Advocate Rotate playing other posthons besides pitcher Concentrate on age-appropriate pitching Source LittleLeague Baseball for Sports Safety Adhere to pitch count guidelines such as those There isa by Little League Baseball(See tables)Rest Periods Required epidemic of Avoid pitching on multiple teamswith overlapping Ages 14and Ages15-16 Required eof seasons under Rest Pitches preventable youth •Don'tpitch with elbow or shoulder pain '1 thepain 66+ 76+ 4 calendardays sports injuries that *$'7 persists,seea doctor 51-65 61-75 3 calendar days are dismantling Don't pitch on consecutive days 36-50 46-60 2 calendar days 21-35 31-45 I calendar day kids athletic hopes. Don'tplay year-round 1-20 1-30 None Take the pledge to spread the Never use a radar gun Communicate regularly about how your arm;s feeling Source Little League Baseball worn about sports safety. and ifthereis pain Develop skillsthatare age appropriate Age Recommended for Various Pitches Emphasize control accuracy,and good mechanics Pitch Age Master rise tastball fast and the change-up second. Fastball 8t2 before considering breaking pitches Slider 16±2 Speak with a sports medicine professional or athletic Change-up 10±3 trainer ifyou have any concerns about baseball injuries Forkbali 16±2 or baseballinjury prevention strategies Curveball 14±2 http://www.stopsportsinjuries.org/baseball-injury-prevention.aspx 8/24/2015 Baseball Injuries I Baseball Injury Prevention& Treatment Page 2 of 3 Knucklebait 15±3 Screwball 17±2 Source:From work by James R Andrews MD and Glenn S Fleisrg,PhD Back to top HOW 1S AN OVERUSE ELBOW OR SHOULDER INJURY TREATED? The most obvious treatmentfor overuse is rest especially from the activity that created the injury Ice is also used to reduce soreness and utftamnatron Ibuprofen can be takes;to help with any pain It symptoms persist,itis critical that a physician he contacted,especially if there isa lack of toll-joint motion.An examinationand radiographs should be done An MRI scan may also be helpful Usually a simple"rest cure'approach will not to enough,because even though it allows symptoms to subside,it also creates loss of muscle bulk.tone,flexibility.and endurance.Once pain is gone and full motion ispresent.a throwing rehabilitation program can start. Under some circumstances.surgery may be necessary to correct aproblem Overuse and stress related problems can affect growing partsof bone,notpint the soh tissue(muscles,tendons.ano ligaments).If thecondition is not treated it could cause deformity ofthe limband permanent disability.The athleteshould return to play onlywhen clearance is granted by a health care professional. Back to top REFERENCES AND ADDITIONAL RESOURCES References Prevention and Emergency Management of Youth Baseball and SoftballInjuries American Orthopaedic Society for Sports Medicine.2005, Little League Baseball www.ldheleague orgtAssetsfold_assetsrredralpitchcount_faq_08.Pdt American Spats Medicine Institute.wvwvasmi org Professional Baseball Athletic Trainers Society•enmv.pbats coat Back to top CONTRIBUTING EXPERTS The following expert consultants contributed to the tip sheet: MaryLloyd Ireland.MD James R.Andrews,MD Glenn S.Flersig,PhD Sports Tips provide general rJormatron only and are not a substitute foryour own good judgement or consultation with a physician To order multiple copies of thisfact sheet or learn more about sports injury preventron please vise www STOPSpertslrvunes org Back to top ion=I Sports ogu•y Provo;tai:Resev es I Vein r,i.:r:ai t i-cr a Sie_arc: S_peon'Js:uv.ns:S'.z t tt x i!nor, Q Fapeoeok xcet http://www.stopsportsinjuries.org/baseball-injury-prevention.aspx 8/24/2015 Baseball Injuries I Baseball Injury Prevention&Treatment Page 3 of 3 6300 North River Road.Suite 500 • Rosemont,IL 60018 • Phone:1-847-655-8660 • www STOPSportslnjunes org http://www.stopsportsinjuries.org/baseball-injury-prevention.aspx 8/24/2015 APPENDIX N-14 ASMC INSTITUTE SUMMARY ATLANTA SPORTS MEDICINE CENTER - RESEARCH AND EDUCATION INSTITUTE ASMC INSTITUTE") PURPOSE ASMC INSTITUTE WILL BE A NON-PROFIT FOUNDATION ESTABLISHED TO PROVIDE PROGRAMS FOCUSED ON PREVENTION, TREATMENT AND REHABILITATION OF SPORTS RELATED INJURIES AS WELL AS EDUCATIONAL PROGRAMS. PROGRAMS FELLOWSHIP TRAINING 1) Sports Medicine Orthopaedic Surgery Fellowship ASCM Institute will provide advanced training in orthopaedic and musculoskeletal surgical techniques, rehabilitation and education. Training will include emphasis on Biomechanics Research to incorporate in treatment and prevention of injuries. The program will participate in on-going development of a data base to track outcomes and epidemiology for use in diagnosis, treatment and rehab that will be shared nationally and internationally within the sports medicine profession. Fellows will participate in Collaborative Research Programs with affiliated Hospitals, Medical Schools and Residency Programs. They will participate in Biomechanics Studies with emphasis in improving knowledge of the impact on athletes from a biology and mechanics assessment utilizing state-of-the-art Biomechanics Lab on site. Fellows will follow patients through rehabilitation and performance training during their recovery interfacing with physical therapists and trainers as part of the patient continuum of care process to full recovery. The program will provide extensive training and experience treating a wide range of clinical encounters that will develop surgical skills, diagnostic knowledge and medical management of patients under the direct supervision of an elite medical staff led by Dr. James Andrews. Fellows will participate in clinical trials for new pharmaceutical treatment, medical devices and prevention and assessment technology. The Institute will host weekly conferences including nationally and internationally recognized experts in the field of sports medicine. They will provide sports assessment examinations and work with therapists and trainers on protocols for treatment as well as performance enhancement. Fellows will also participate in providing educational programs for the community as well and medical students and residents. 2) Non-Surgical Sports Medicine Fellowship Program ASCM Institute will provide training for Non-Orthopaedic Surgeons, Internal Medicine and Family Medicine Fellows. This program will develop expertise focusing on Total Care for patients of all age and skill levels who may sustain or develop musculoskeletal injuries or conditions related to physical activity. The purpose of this program is to provide the "generalist" in-depth training in both prevention and treatment of injuries through rehabilitation. The focus is on a growing number of patients who are actively involved in sports and wellness activities, including military personnel. The goal is to develop a greater knowledge of current treatment philosophies and an increased understanding of anatomical mechanics and techniques utilized in rehabilitation. These Fellows will also participate in Research, Clinical Trials, Biomechanics Studies and community education programs. EDUCATION PROGRAMS The ASMC Institute will conduct multiple training programs on a continuous basis providing Continuing Medical Education for Physicians, Physical Therapists, Trainers and other medical professionals through a broad panel of seminars monthly. In addition, the Institute will provide webinar conferences sharing best practices, outcome based data and current treatment strategies on a weekly basis available to medical professionals.The Institute will also provide seminars for Coaches and program administrators at the Youth through Secondary Schools and Colleges on prevention and training techniques. BIOMECHANICS LAB The ASMC Institute will include a Biomechanics Lab managed by a world-class staff of professionals to conduct Biomechanics Studies on athletes with a primary focus on prevention of injuries. In addition, these studies will be instrumental in development of protocols for both rehab and performance training following treatment for injury by patients. The advancements in technology available now and in development will increase significantly and become an integral part of training for athletes of all ages in the future. ASMC Institute will be at the forefront of these programs in developing protocols for training, prevention of injury and recovery working closely with the ASMC Medical Staff. CLINICAL TRIALS, RESEARCH AND TESTING The Medical Staff, including Fellows, along with, Research Specialists, Physical Therapists, Trainers and Technical Personnel will participate in multiple IRG clinical trials on an on-going basis. These studies will include pharmacology, surgical devices, surgical implants as well as genetics. They will incorporate a multi-disciplinary approach following outcomes for patients through treatment and recovery to normal activity levels. RESEARCH/RESOURCE LIBRARY The Library will be a major component of the facility and be available to medical professionals to access in treatment and management of patients. The LIBRARY will be available to medical professionals, therapists and trainers to access for their use and contain Publications, Clinical Trial Studies & Outcomes and Preventative Practices to Sports Related Injuries. CADAEVER LAB The Lab will be included to conduct studies on joint structures and function as well as repair techniques, replacement devices and materials testing. CLASSROOMS The Institute will have classrooms located on site to meetings and conferences and will include wireless connectivity with for educational purposes throughout the campus including surgical suites. GA R&R-GAC-Rule ]1}-2-2-.40. Specific Review Considerations for Ambulatory Sur... Page 1 of 6 Ga. Comp. R. 06Regs. r. 111-2-2-./&0 Specific Review Considerations for Ambulatory Surgery Services Georgia Administrative Code Department 111. Rules of Department of community health Chapter 111-2. HEALTH PLANNING Subject 111-2-2. CERTIFICATE OF NEED Current through August 14, 2015 Rule 111~2~2~,40, Specific Review Consider |tions for Ambulatory Surgery Services 1) Applicability. For Certificate of Need purposes, an Ambulatory Surgery Service is considered a new institutional health service if it is to be offered in an ambulatory surgery facility (ASF) or in a diagnostic, treatment, or rehabilitation center (DTRC). a) If the ambulatory surgery service is or will be provided as "part of a hospital", the hospital's provision of such service is not subject to Certificate of Need (CON) review under this rule. For purposes of this rule, the following are always considered to be part of a hospital": a) if the service is located within a hospital; or, b) if the service is located in a building on the hospital's primary campus and that building, or relevant portion thereof, is included within the hospital's permit issued by the State's licensing agency, subject to determination by the Department. The Department also will make a determination of reviewability on a case-by-case basis in other situations involving hospitals. b) The entity that develops any ambulatory surgery service shall be the applicant. c) A single specialty ambulatory surgery service will be issued a single spedaityCDN. A new CON will be required to become a multispecialty service. d) These Rules do not apply to adult open-heart surgery, adult cardiac catheterization, pediatric cardiac catheterization, pediatric open-heart surgery, and obstetrica/ services because these services are covered under other CON Rules. If an ambulatory surgery service, which is part of a hospital, expands the number of ambulatory surgery operating rooms and the capital expenditure exceeds the CON threshold, the project will be reviewed under these Rules 111-2'2'.40. If an ambulatory surgery service, which is part of a hospital, involves a capital expenditure, which exceeds the CON threshold and does not increase the number of Copyright © 2015 Lawriter LLC - All rights reserved.' Email Us I 844-838-0769 I Live Chat AUG 76 15 i i:3744 bUp://roles.aoo.Qu.gov/GA^[Yl1]-2'2-.40 8/25/2015 Dir; iarrianivrr or Georgia Certificate of Need 041k Additional Information DATESTAMP 3-ENTER the Project Number and County below for the project for which you are supplying additional information.Use the Format YYYY-###.RL.. J PIED PROJECT NUMBER fit:elJG 1 2 of Georgia 2irnng015 GA 2015 - 017 uf Department oi Commw"Ly 11,,,a!th COUNTY: Alpharetta Signed Original and 1 Copy This Box for Division ofHealth PlanningUselt30--- Name of Applicant: ASMC, L.L.C.d/b/a Atlanta Sports Medicine Center General Information: 1. This Additional Information form is a required document that must be submitted by an Applicant wishing to supply additional information. Additional information is information and data submitted in response to a direct request from the Department at the 60-day meeting or information submitted consistent with the scope, physical location, costs, charges, and owners identified in the original application. 2. Please review this form before attempting to complete and submit the information requested. 3. This form must be typewritten or completed and printed in this MS Word format. Handwritten responses must not be submitted and will not be accepted. 4. All form fields must be completed. If a field is not applicable,so indicate. 5. Attach you additional information to this form. 6. This form and the attached additional information must be submitted to the Department no later than the 75th day of the review cycle. Applicants must submit a signed original and one(1)copy of this form and any and all attached documentation. 7. The signed original Additional Information form and the single copy must be submitted on loose leaf, one-sided 8 1/2 by 11-inch paper only. The copy and the original should be rubber banded to separate the copy from the original. The signed original must not be hole punched nor stapled or otherwise bound. The single copy must be three-hole-punched but must not be stapled or otherwise bound. 8. Faxed copies of documents and information are not official and must be followed-up with the original documents by the mandated deadline for inclusion in a project master file. RIG ;12115 2:20-PF, State of Georgia:Certificate of Need Additional Information Form CON 104 Page 1 Revised June 2010 2779 SECTION A. IDENTIFYING INFORMATION 1. Please identify the Applicant. APPLICANT Applicant Legal Name: ASMC, L.L.C. d/b/a(if applicable): Atlanta Sports Medicine Center Address: c/of Andrews Institute 1040 Gulf Breeze Parkway City: Gulf Breeze State: FL Zip:32561 County:Okaloosaka Main Business Phone:850-916-8700 2. Please identify the person to whom the Department may address questions regarding this Additional Information. CONTACT PERSON Name: Kenneth N. Hancock Title or Position: Manager Address: c/of Andrews Institute 1040 Gulf Breeze Parkway City: Gulf Breeze State: FL Zip:32561 Phone:615.301.8142 Fax: E-mail Address: khancock@meridiansurg.com 3. Additional Information. Attach 8-1/2 by 11-inch sheets providing the information and data in response to the direct request from the Department at a 60 day meeting or at any other time prior to the 75th day,or other information consistent with the scope, physical location, costs,charges,and owners identified in the original application. Is the attached information in response to the 60-day meeting? ®Yes No If the information is not in response to the 60-day meeting, please explain. State of Georgia:Certificate of Need Additional Information Form CON 104 Pae 2 Revised June 2010 27/80 4. Applicant Certification. By signing below, a) I hereby certify that the contained statements and all attachments hereto are true and complete to the best of my knowledge and belief and that t possess the authority to submit this form and bind the Applicant to promises made herein; b) I further understand that if issued a Certificate of Need, the Applicant is bound to any representations that have been made within this form and any and all documentation attached hereto;and c) I certify that the Applicant wilt accept a condition or conditions on the award of a Certificate of Need based upon any representation of intent contained herein. APPLICANT CERTIFICATION Signature f Authorized Signatory(BLUE INK ONLY): Nam . Kenneth N.Hancock Title: Manager Date: Ir. /0. /r Submit to:Division of Health Planning Department of Community Health 2 Peachtree Street, NW-5`"Floor Atlanta, GA 30303 State of Georgia:Certificate of Need Additional Information e1FormCON104272fRevisedJune2010 McGuireWoods LIP Promenade 1230 Peachtree Street N.E. Suite 2100 Atlanta,GA 30309-3534 Tel 404.443.5500 Fax 404.443.5599 www.mcguirewoods.com victor I.moldo708 McGUIREWOODS vmoldovan@Fax:404.443s.com 5777Direct:404.443.5708 Fax:404.443.S777 August 12, 2015 VIA HAND DELIVERY Karesha Berkeley Laing Department of Community Health Division of Health Planning 2 Peachtree Street 5th Floor Atlanta, GA 30303 Re: ASMC, LLC, Project No. 2015-017 Dear Ms. Laing: We are submitting additional information for your review in connection with the above stated application and in response to your comments at the 60 day meeting. The items included are as follows: Single Specialty Orthopedic Surgery Center: The Application has been revised where necessary to reflect that ASCM, LLC ("ASCM") seeks a Certificate of Need ("CON") for single specialty orthopedic ambulatory surgery center, not a multi-specialty center. In order to be certain we have made the change in all places, we have replacement pages where appropriate. Address Correction: We have corrected the address in Section 1, Question 2 and Question 17. Please find enclosed replacement pages 1 and 8. Lobbyist Disclosure Information We have enclosed replacement page 6 to reflect information regarding ASMC's lobbyist. Atlanta I Austin I Baltimore I Brussels I Charlotte I Charlottesville I Chicago I Dallas I Houston 4 Jacksonville{London Los Angeles-Century City I Los Angeles-Downtown I New York I Norfolk f Pittsburgh I Raleigh I Richmond{Tysons Corner I Washington,D.C.I Wilmington 2782 August 12, 2015 Page 2 Need and Existing Alternatives: The Application includes revised pages for Question 18, 19, 20 and 21 and the service specific rules to address the need for the project and existing alternatives. In addition, we have added additional letters of support and further explained the unique nature of the project and why it should be approved. (Rules 111-2-2.09(1)(b) and (1)(c) and 111- 2-2-.40(3)(a) and (b)) The project will offer services for sports injuries that are either not available or difficult to access in Georgia, not just HPA-3. In fact, many Georgia residents (including professional athletes and college and high school students) leave the state to go to Dr. Andrews for surgery. Financial Feasibility: We have edited the form on page 13 for Capitol Cost Estimates to make clear that the project is 20, 000 square feet new construction. (Rule 111-2-2-.09(1)(d)) The amounts identified therein for the shell and common areas are the pro rata share of the costs for the new building. The Equipment Budget in Appendix G is accurate and contains the list of equipment. The redactions do not identify any additional equipment. The "Pro Forma" on page 15 of the application contains only surgery center patients. The patients for the other services on the campus are not counted in the total. To be clear, all of the materials related to the financial projections include only surgery center patients. The projected patient origin for ASCM is addressed on pages 11-11.4 of the enclosed submission. Effects on Payors: The top ten procedures are identified and are all orthopedic. (Rule 111-2-2-.09(1)(e)) Construction Methods and Costs: A revised letter from the architect to include architecture and engineering fees is included as replacement for Appendix I-1. (Rule 111-2-2-.09(1)(f)) Financial Accessibility: The Application uses the same definition for indigent care qualifications throughout the materials (i.e. 125% of the federal poverty guideline). (Rule 111-2-2-.09(1)(g)) Qualified Anesthesia Personnel: A letter from the anesthesia provider is included which states that it will comply with all rules including having qualified personnel at the center until all patients are discharged. 2783 August 12, 2015 Page 3 Rule 111-2-2-.40(3)(f)) Also, enclosed is a resume of one of the Georgia licensed physicians. The materials are included as supplemental to Appendix N-4. Qualified Support Personnel: Dr. Andrews' new Georgia license is enclosed. (Rule 111-2-2-.40(3)(g)) (Appendix N-7) Top Ten Procedure Charges: The top ten charges are all orthopedic and are included. (Rule 111-2-2-.40(3)(n)) Other Issues We have included additional letters of support to be included in Appendix M. We have included a more detailed site plan to show the uses of the building in the project to be part of Appendix 1-4. We have included set of articles about Dr. Andrews regarding the unique nature of his practice. (Appendix N-8) We have also included as part of Appendix N-9 a summary of the overall project and an economic impact report of the project. We have raised some technical legal issues for the record out of a abundance of caution and to preserve them for later argument if necessary. (Appendix N-10) Please let me know if you have any questions. Very truly yrs, Vict$r L. Moldovan 2784 REPLACEMENT PAGES 9-14 2785 18. Provide a detailed description of the proposed project including a listing of the departments (e.g. ED, ICU), services, (e.g. Home Health, Cardiac Cath), and equipment(e.g. MRI, PET,Cath)involved. c2- NOTE: If your description exceeds this blocked space, attach additional 8-%by 11-inch pages, number the first sheet Page 9.1, the second Page 9.2 and so on. Do not alter the main page numbers of this application. Once printed, insert your additional pages 9.1, etc. behind this Page 9. ASMC, LLC is planning an athletic training, rehabilitation and single-specialty orthopedic ambulatory surgery center complex on about 30 acres of land.ASMC will be designed, equipped and staffed to provide comprehensive training, rehabilitation, medical and surgical services to amateur and professional athletes from across the United States. The proposed ASMC Orthopedic Single Specialty Ambulatory Surgery Center("SS-ASC')will cost an estimated$10.5 million for pre-development related costs, construction,furnish and equip with state of the art diagnostic and surgical equipment(see Appendix G-4, equipment budget).This single story facility will have approximately 20,000 gross square feet of space.This ASC will have 4 general operating rooms and two minor procedure rooms with the necessary staff support, patient preparation, recovery and discharge areas consistent with state, federal requirements and accreditation guidelines. ASMC anticipates that approximately 40%of the projected ASC patients will originate from out-of-state and other countries. The remaining patients will originate from throughout Georgia, not just Health Planning Area Three("HPA-3"). The SS-ASC facility will be staffed by some of the finest orthopedic surgeons in the country, including Dr.James Andrews. The proposed SS-ASC is unlike any similar existing HPA-3 Hospital Outpatient Department surgical service("HOPD")or freestanding SS-ASC because its patients will originate from mainly other regions of Georgia and out-of-state. Additionally, this SS-ASC will improve geographical access to a particular type of orthopedic procedureperformednationallybyonlyafewsurgeonslikeDr.Andrews, this procedure is a Tommy John or UCL surgical procedure and many athletes from Georgia, around the nation and other countries have receivedit, but not here in Georgia. Dr. Andrews has performed thousands of Tommy John procedures at his facility in Pensacola, FL., and in Birmingham. ASMC anticipates that professional and amateur athletes, from various professional sports leagues such as the NFL, Major League Baseball, NBA, National Soccer League, etc.;and college and high school athletes will find it more convenient to access ASMC's SS-ASC than traveling to Pensacola, FL., because Atlanta has direct flight routes to and from Atlanta's Hartsfield-Jackson International Airport. ASMC will also provide medical, surgical and rehabilitation services to Georgia high school athletes who do not have the financial resources to cover the cost of their medical, surgical and rehabilitation treatment services. Response continued on page 9.1 State of Georgia:Certificate of Need Application Section 2 Form CON 100 Page 9 Revised July 2008 2786 ASMC, LLC-Continued Response To CON Application Item 18,Page 9 The proposed Atlanta Sports Medicine Center Single-Specialty Ambulatory Surgery Center("SS-ASC')will offer a range of medical, surgical and rehabilitation services comparable to the Andrews Institute Orthopedic Sports Medicine, located at 1040 Gulf Breeze Parkway, in the City of Gulf Breeze, FL. However, ASMC will include a sports training facility with playing and recreational fields for athletic training, rehabilitation and recovery. The ASMC will be a comprehensive center of excellence for athletic performance, medical, diagnostic, surgical, and physical rehabilitation servicesNothing comparable currently exists in Georgia. Atlanta represents an excellent location for ASMC because it has Atlanta Hartsfield-Jackson Airport and private non-commercial airports providing direct airline and private plane access from all parts of the United States and internationally. The proposed site is will have athletic training facilities and outdoor fields dedicated to provision of a comprehensive range of services so that prospective clients and patients can receive all of their care, rchobi|itaUon, and athletic training at one rather than multiple sites.The sites proximity to local hotels and other amenities and close proximity to Buukhead. Mid-Town and Downtown Atlanta make it an accessible site from anywhere in Georgia and for out-of-state clients of Dr. Andrews and his colleagues. ASMC will create fellowship affiliations with Medical Schools and Physical Therapy Rehabilitation training programs. It will also provide uncompensated diagnostic, surgical and therapeutic services to Georgia high school athletic programs whose athletes do not have adequate health insurance and lack family financial resources to cover the cost of their care if they are injured on the playing field. To facilitate high school player access, ASMC will create a"log-in"at its web site that will provide direct access to high school athletic programs by which they can apply for assistance through the ASMC's foundation. ASMC will at a minimum, provide: Credentialed physicians, specialty nurses, rehabilitation therapists, physician assistants, athletic trainers, and pain management specialists dedicated to restoring function to the fullest extent possible Highly trained experts in sports science, neumo|ogy, pain medioine, orthopedica, orthopedic surgery, sports physical thorapy, human perfnmnanne, strength and conditioning and sport nutrition to help athletes in prevent injury, recover from injury and improve performance to reach their personal athletic goals. Comprehensive orthopedic, sports medicine, spine and rehabilitation centers under a single roof. Technologically advanced diagnostic and stress testing equipment. Same day appointments for injured athletes. Human performance labs to help athletes reach peak performance, Concussion management using computerized neuropsychological testing. Non operative management of arthritis and back pain. ASMC SS-ASC will provide the latest in both surgical and nonsurgical treatments and rehabilitative therapies from physical to occupational (hand)therapies. Surgical interventions employ minimally invasive endoscopic and arthroscopic procedures for the best outcome and most rapid recovery. The center will utilize the latest in limb preservation and joint reconstruction procedures shown to dramatically improve outcomes, allowing patients/athletes to recover and achieve often improved performance. ASMC will be a new state-of-the-art facility that offers comprehensive world-class sports medicine care. Clinical services include consultations for diagnosing, treating and rehabilitating musculoskeletal injuries, as well as imaging evaluations. ASMC will offer athletes performance training programs dedicated to serving the needs of all patients by offering the latest in sports medicine technology, treatment options,and performance training equipment. Multiple cardiovascular training npdono--tneadmiUs, elliptical trainers, recumbent bicycle, rowing ergometer, upper body ergometer. Interactive stationary bicycles, with video screens for interactive play. State of Georga:Cerlificate of Need Application Section 2 Form CON 1no Page 9.1 Revised July aoua 2787 ASMC, LLC-Continued Response To CON Application Item 18, Page 9 Indoor climbing unit,with a rotating rock wall climbing system for core strength, endurance, and stability training. Simulator reaction trainer,with 46-inch high-definition screen.This high-intensity virtual reality exercise system is designed to challenge coordination, balance, body movement,and speed,with immediate feedback. Computerized training system with real-time feedback and performance analysis to measure and develop speed, agility, balance, reaction time,vertical jump, and power. Suspension training system. Designed to challenge the strength and stability of any athlete. Vertimax®Training system increases the explosive power of all major muscle groups in the legs to improve the vertical jump and acceleration/deceleration capabilities. Shuttle MVP®strengthening unit provides intense lower extremity training and conditioning, with reduced joint stress for low-impact plyometrics and strength training. Dumbbells and Smith squat rack with Olympic weight system. Motion analysis system,with force plate for running and throwing assessment. The proximity of surgical and medical clinics with rehabilitation facilities and comprehensive orthopaedic and prosthetic services underscores the center's multidisciplinary approach to sports medicine and allows patients to have all their needs met under one roof. ASMC will offer: Electrical stimulation Biofeedback Computerized strength testing and training Store for braces,training aids and rehabilitation accessories OVERVIEW OF EXISTING ANDREWS INSTITUTE FOR ORTHOPEDIC AND SPORTS MEDICINE AND BACKGROUND INFORMATION ABOUT DR. JAMES ANDREWS: Dr. James Andrews is internationally known and recognized for his scientific and clinical research contributions in knee, shoulder and elbow injuries, as well as his skill as an orthopaedic surgeon. Dr.Andrews is a founding partner and medical director for the Andrews Institute in Gulf Breeze, Florida. In addition, he is a founding member of the American Sports Medicine Institute(ASMI). Dr.Andrews has been the mentor for more than 250 orthopaedic/sports medicine fellows and more than 45 primary care sports medicine fellows. Involved in education and research in sports medicine and orthopaedic surgery, he has made major presentations on every continent, and has authored numerous scientific articles and books. Dr.Andrews is a member of the American Board of Orthopaedic Surgery and the American Academy of Orthopaedic Surgeons. He has served on the Board of Directors of the American Orthopaedic Society of Sports Medicine, and served as Secretary of that Board from May 2004 to May 2005. He has served on the' Board of Directors of the Arthroscopy Association of North America and the International Knee Society. He is Clinical Professor of Orthopaedic Surgery at the University of Alabama Birmingham Medical School,the University of Virginia School of Medicine, the University of Kentucky Medical Center,and the University of South Carolina Medical School. He has been awarded a Doctor of Laws Degree from Livingston University, Doctor of Science Degree from Troy State University and a Doctor of Science Degree from Louisiana State University. Dr.Andrews serves as Co—Medical Director for Intercollegiate Sports at Auburn University. He is Senior Orthopaedic Consultant for Intercollegiate Athletics at the University of Alabama. He is the orthopaedic consultant for the athletic teams of Troy University, University of West Alabama,Tuskegee University and Grambling University. State of Georgia:Certificate of Need Application Section 2 Form CON 100 Page 9.2 Revised July 2008 2788 ASMC,LLC-Continued Response To CON Application Item 18, Page 9 Dr.Andrews serves as Co—Medical Director for Intercollegiate Sports at Auburn University. 1-le is Senior Orthopaedic Consultant for Intercollegiate Athletics at the University of Alabama. He is the orthopaedic consultant for the athletic teams of Troy University, University of West Alabama, Tuskegee University and Grambling University. DR.ANDREWS'AFFILIATIONS,ASSOCIATIONS &HONORS Senior Orthopaedic Consultant for the Washington Redskins Professional Football team. Medical Director for the Tampa Bay Devil Rays Professional Baseball Team. Co—Medical Director for Intercollegiate Sports at Auburn University. Senior Orthopaedic Consultant for Intercollegiate Athletics at the University of Alabama. Orthopaedic consultant for the athletic teams of Troy University, University of West Alabama, Tuskegee University and Grambling University. Team physician for the Birmingham Barons Double A Professional Baseball Team,an affiliate of the Chicago White Sox. Co—Medical Director of the Ladies Professional Golf Association. Member of the Sports Medicine Committee of the United States Olympic Committee. Former committee member of the NCAA Competitive Safeguards in Medical Aspects of Sports Committee. Current member of the Medical and Safety Advisory Committee of USA Baseball. National Medical Director of Benchmark Medical, Inc. Board of Directors member for FastHealth Corporation. Board of Directors member for Robins Morton Construction Company. Board of Trustees member for Troy University. Alabama Sports Hall of Fame inductee and was named recipient of the Alabama Sports Hall of Fame 1992 Distinguished Sportsman Award. Louisiana State University(LSU)Alumni Hall of Distinction. Inducted 1996. The Andrews Institute Ambulatory Surgery Center is a specialized facility, and was designed from the ground up to be optimal for outpatient procedures. Our eight operating rooms have complete digital equipment including the latest state-of-the-art technology utilizing high definition camera and video systems. This equipment allows your physician the ability to view the most finite detail as it relates to your procedure. Our surgery center utilizes innovative anesthesia and pain management techniques to make surgery a more pleasant experience. The anesthesiology department is a leader in this field and conducts numerous training seminars around the globe in addition to participating in research and training initiatives. This expertise allows the patients to have a more comfortable procedure and recovery. At the Andrews Institutes Hand Center,we understand that even the smallest hand injuries require expert medical attention. Our center is led by a team of caring,experienced orthopaedic physicians with specialized training in the management and care of simple and complex hand,wrist, forearm, elbow and upper extremity injuries and conditions including: Trauma Tendonitis Arthritis Dupuytren's Disease State of Georgia:Certificate of Need Application Section 2 Form CON 100 Page 9.3 Revised July 2008 2789 ASMC,LLC -Continued Response To CON Application Item 18, Page 9 DeQuervain's Tendonitis Cubital Tunnel Disease Trigger Finger Ganglion Cysts Nerve Compressions such as carpal tunnel syndrome Sports injuries including fractures and dislocations Our goal is to provide rapid and accurate initial evaluation and leading-edge treatment methods to minimize short-and long-term effects on the hand and upper limb. Our team offers cost-effective surgical and non- surgical treatment options for patients of all ages including on-site occupational therapy. ORTHOPAEDIC FOOT&ANKLE CENTER The Andrews Institute Orthopaedic Foot&Ankle Center is dedicated to keeping you on your feet. Ignoring foot or ankle pain is like driving your car on flat tires. Even minor pain can be a sign of a more serious problem that, if left untreated,could lead to bigger complications. The foot consists of 26 bones,-33 joints, 107 ligaments and 19 muscles. Each day, these complex structures support us in taking an average of 8,000 to 10,000 steps.Throughout a lifetime,that adds up to about 115,000 miles—more than four trips around the world! It's easy to see how 75 percent of Americans experience some type of foot or ankle problem in their lifetime. As the Pensacola area's only Orthopaedic Foot&Ankle Center, our team of board-certified, fellowship- trained physicians provide innovative and cost-effective surgical and non-surgical treatment options for foot and ankle pain. Our mission is to provide the best medical care through orthopaedics and sports medicine and to improve patient care through research and education, emphasizing injury prevention. ORTHOPAEDIC TRAUMA&FRACTURE CARE ORTHOPAEDIC TRAUMA Our physician team is comprised of four doctors who specialize in this health care area. They provide 24-hour coverage at Baptist Hospital,a state-approved level II trauma center, and Gulf Breeze Hospital emergency department. The largest orthopaedic trauma physician team in the area, Baptist Health Care and the Andrews Institute have made an investment to best care for those in our community and anyone who visits for treatment. Using innovative technology and a team approach for each individual situation, our doctors diagnose and treat patients to prevent or reduce permanent disability—even in some of the most severe and complex cases.Treating everything from hip and pelvic fractures to polytraumatic injuries(multiple traumatic injuries)and major open fractures/dislocations,Andrews Institute physicians are authorities in the use of tissue-saving surgical techniques in an ER setting. FRACTURE CARE Whether you have a broken arm or a broken hip, our team can care for you best. Andrews Institute doctors provide surgical follow-up and other orthopaedic services at the Andrews Institute in Gulf Breeze and Baptist Medical Towers in Pensacola. Physicians accept new patient appointments for: Simple and complex fractures Post-traumatic joint replacement Pelvic fractures Deformity State of Georgia:Certificate of Need Application Section 2 Form CON 100 Page 9-4 Revised July 2008 2790 ASMC,LLC-Continued Response To CON Application Item 18,Page 9 Fragility fracture care ANDREWS INSTITUTE SPINE CENTER The Andrews Institute Spine Center provides a comprehensive, interdisciplinary and integrated team approach for the evaluation and management of disorders of the spine. Our center focuses on the conservative treatment of spine disorders afflicting both the athlete and non—athlete. Our treatment strategies strive to return the individual to their highest functional level possible. Conservative approaches are our primary focus, utilizing rehabilitative programs designed by our physical therapists and physiatrists. Our Spine Center also has a team of pain management physicians dedicated to treating acute or chronic pain, along with a prescribed rehabilitative program. When surgery is contemplated,we have a team of neurosurgeons and orthopaedic surgeons available for consultation. Our surgeons have been trained in the newest emerging surgical techniques that focus on minimally invasive spine surgery to promote the best outcomes. Our physicians are on the leading edge— developing new surgical techniques through ongoing clinical research and by taking on difficult cases. Our patients suffer much less pain and_are often back to their normal activities within a few days to weeks. No other medical center in Northwest Florida utilizes a multidisciplinary approach by including physicians from the fields of orthopaedic surgeons, neurosurgeons and physiatrists who work with occupational therapists, physical therapists and other rehabilitation specialists to provide individualized plans of care and recovery. Our state-of-the art spine center offers minimally and maximally invasive surgeries and leading—edge technologies such as the 0-arm®imaging system, and has the expertise to help return you to work and play at your pre—injury level. Whether physical therapy, microsurgery or complex reconstructive surgery is needed, the diverse and acclaimed staff ofthe Andrews Institute stands ready to alleviate your pain... and return you to full form. FRAGILITY FRACTURE CARE PROGRAM Fragility fractures can dramatically change the quality of life for patients and their families due to a loss of independence, significant disability and even death. To help patients gain back their quality of life following a fragility fracture,the Andrews Institute for Orthopaedics&Sports Medicine established the Fragility Fracture Care program.Our dedicated team provides a customized, comprehensive post-fracture health care plan and serves as primary advocates to ensure that appropriate action is taken to provide proper follow-up fragility fracture care, and almost just as important, reduce the risk of future fractures. According to the National Osteoporosis Foundation,a fragility fracture is any fall from a standing height or less resulting in a fracture. Such fractures occur most commonly in the hip, spine(vertebral)and wrist(distal radius). Normally, our bones should be able to sustain a fall from this height, without a fracture, unless there is some underlying cause to suspect a bone disorder, such as osteoporosis or osteopenia that weakens our bone structure. Fragility fractures are fairly common and affect up to one-half of women and one-third of men older than the age of 50 and most often are associated with low bone density. During the next 20 years, an estimated 450 million people will celebrate their 65th birthday,which makes a large percentage of our population susceptible to fragility fractures. State of Georgia:Certificate of Need Application Section 2 Form CON 100 Page 9.5 Revised July 2008 2791 ASMC,LLC-Continued Response To CON Application Item 18, Page 9 Pain, suffering and health care costs can be enormous for all fracture patients, particularly those with hip fractures. Some studies have shown that patients with fragility fractures have a higher mortality rate than for most cancers. However, proper fragility fracture patient care, including follow-up treatment, can reduce the risk of future fractures by up to 50 percent. Follow-up care typically includes evaluation with appropriate labs and scans, as well as treatment specifically tailored to each patient's needs. Working closely with the patient's family physician and family members ensures the best possible outcome for the patient. ANDREWS INSTITUTE REHABILITATION Andrews Institute Rehabilitation provides the most comprehensive range of rehabilitation and physical medicine services available in Northwest Florida and Southern Alabama,with several locations across the region. We are committed to providing effective, high—quality,customer—friendly services at each of our locations. Our staff is composed of licensed and certified professionals who have the training, experience and skills necessary to provide specialized services that meet our patient's individual needs. Our therapists implement a progressive,_specialized approach to injury treatment that combines patient education, individualized exercise, manual therapy, aquatic therapy and a full range of modalities.We work closely with your physician resulting in a more efficient and effective recovery process. PHYSICAL MEDICINE&REHABILITATION Recovering from an illness, injury, physical impairment or disability can be a difficult journey, one that starts with an appropriate diagnosis and requires a multitude of resources,and a specialized treatment plan. The goal of physical medicine and rehabilitation (PM&R)specialists at the Andrews Institute is to enhance and restore functional ability and quality of life for all of our patients. Our comprehensive team specializes in diagnosing and providing non-surgical solutions to treat nerve, muscle and bone conditions that affect a person's mobility. Our physiatrists(PM&R specialists)treat patients who suffer from a broad spectrum of injuries, conditions and illnesses from shoulder and knee pain, arthritis and tendonitis to spinal cord injuries and nerve entrapments. Our physiatrists also treat serious disorders of the musculoskeletal system that result in severe physical limitations such as those of wounded military,amputees and patients injured in car accidents. Physiatrists treat patients with conservative methods such as physical therapy, medication, injections,and bracing. At the Andrews Institute we recognize that every patient is an individual with unique, personal goals and make it a priority to work closely with physical therapists, interventional pain medicine physicians and scientists to tailor a treatment plan specific to each patient. Our physiatrists also communicate with each patient's primary care physician to develop a treatment plan for the whole person, not just the problem area. We also understand that personal interaction and attention are an important part of the healing process and that patients and their family members are an integral part of the healthcare team.That's why we work hard to keep our patients informed and explain the rehabilitative process and the expected results every step of the way. Our staff is dedicated to effective PM&R therapies and is committed to delivering the best possible patient care.Working together, Andrews Institute PM&R specialists help patients return to their highest possible levels of independent functioning. ANDREWS INSTITUTE TOTAL JOINT CENTER Today, Americans are enjoying longer, more active lives than during any time in history. As we grow older and our bodies begin to change, many individuals experience painful problems with their joints.Whether State of Georgia:Certificate of Need Application Section 2 Form CON 100 Page 9.6 Revised July 2008 2792 ASMC,LLC -Continued Response To CON Application Item 18, Page 9 caused by arthritis, injury,disease or daily wear and tear,joint pain and stiffness can become so severe that performing even the simplest daily activities can be difficult. If you are considering the benefits of hip,knee or shoulder surgery,contact us.After thoroughly evaluating your condition, specialists prepare your custom care plan to help you feel ready for your procedure both mentally and physically. Your doctor will support you throughout your experience by continuously monitoring your progress before and after your surgery. Depending on your individual needs, our highly- trained surgeons will explain how you can benefit through traditional procedures or the latest minimally invasive techniques—which can result in faster recovery, less bleeding,decreased post-operative pain and reduced scarring. Many patients who undergo joint replacement experience pain-free basic movement of joints and return to a more fulfilling lifestyle. The proposed SS-ASC will also include comparable orthopedic related medical, surgical and therapeutic services on-site. State of Georgia:Certificate of Need Application Section 2 Form CON 100 Page 9.7 Revised July 2008 2793 Section 3: General Review Considerations All Certificate of Need applications are evaluated to determine their compliance with the general review considerations contained in Rule 111-2-2-.09. Please document how the proposed project conforms with the following general review considerations. Rule 111-2-2-.09(1)(a): Consistency with State Health Plan The proposed new institutional health services are reasonably consistent with the relevant genera!goals and objectives of the State Health Plan. 19. Explain how the project is consistent with the State Health Plan or why it does not apply. Also explain how the application is consistent with the Applicant's own long range plans. NOTE: If your explanation exceeds this blocked space, attach additional 8-%by 11-inch pages, number the first sheet Page 10.1, the second Page 10.2 and so on. Do not alter the main page numbers of this application. Once printed, insert your additional pages 10.1, etc. behind this Page 10. The 1998 Ambulatory Surgery Services Component Plan ('ASSCP") goals and objectives are stated in bold type with a specific response shown below. 1.ASSCP Goal: To ensure that Georgia citizens have access to cost-effective,efficient,and quality ambulatory surgery services. The proposed ASMC SS-ASC will be a national center of excellence that will provide access to cost- effective, efficient and quality ambulatory surgery and ancillary post-op multi-faceted comprehensive medical, surgical and rehabilitation services by accomplishing the following objectives: 1. The SS-ASC will offer direct referral relationships with Georgia high school athletic departments that are interested to provide uncompensated diagnostic, ambulatory surgical, and physical therapy and rehabilitation services to eligible high school students from across the state. 2. SS-ASC projects that 40%of total patient admissions will originate from out-of-state, and other countries this is based on current patient origin experience at the Andrews Institute ASC in Gulf Breeze, Florida. The Gulf Breeze ASC draws 30%to 35%of orthopedic cases originate from out-of- state. A higher proportion of out-of-state patients are projected at the Alpharetta SS-ASC because its location is more accessible than Gulf Breeze which lacks a commercial airline hub,whereas Atlanta has Hartsfield-Jackson a hub for direct domestic and international air traffic; and several small airports for private air travel.Atlanta provides improved geographic access for patients traveling from other states and countries. 3. Patients typically are 17 to 35 years old; many are amateur and professional athletes from a broad range of sports. US and international professional athletes are expected to comprise at least 12%of the projected SS-ASC patient population; high school athletes from Georgia and contiguous states about 15%;another 20%will be college athletes. Thusly an estimated 47%of the patients will be amateur and professional athletes.The balance of the remaining patients will consist of adults, many of whom will be current and former patients who actively seek-out Dr. James Andrews and his fellows for ongoing orthopedic medical, surgical and rehabilitation services. 4. A critical component to SS-ASC is its focus on a full range of medical and rehabilitation therapeutic and sports training services.ASMC will have indoor and outdoor training facilities for indoor sportssuchasbutnotlimitedbasketball; and outdoor facilities for competitive track and field,tennis, baseball,football and soccer rehabilitation and training. Injured and recovering athletes will receive medical, surgical, rehabilitative and sports training at one rather than multiple locations. 5. The prospective payer mix will be 70%Third Party, 10%Self Pay, 10% Medicare, 5%Medicaid.A projected 5%of patients are indigent and charity care. Responses continued on page 10.1 State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 10 Revised July 2008 2794 ASMC, LLC-Continued Response To CON Application Item 19,Page 10 2.ASSCP Goal:Improve access to cost effective, quality ambulatory surgery services by authorizing these services in sufficient numbers and in locations compatible with needs. The proposed SS-ASC will improve geographical access to cost-effective high quality ambulatory surgical services because of Atlanta's improved geographical proximity to more of the U.S. and Atlanta Hartsfield- Jackson International Airport hub,which provides direct commercial flight access from all major US and many international airports. Georgia residents will benefit from access to a comprehensive outpatient medical, surgical, rehabilitation and training facilities; particularly injured high school athletes who do not have adequate health insurance or cannot afford the cost of their medical, surgical and rehabilitation services, ASMC will have a program to assist these high school students. 3.ASSCP Goal:Encourage continuity of ambulatory surgery services within communities. The proposed SS-ASC will be one component of a multi-faceted comprehensive medical,surgical, rehabilitation and training complex. Patients will receive a full range of the required medical and surgical sub- specialty care by board certified experienced physicians. Patients will receive coordinated treatment planning, pre and post-operatively; and those requiring post-op rehabilitation will receive it on-site, inclusive of critical sports-training to reduce the risk of re-injury. The objective is to ensure patients receive the highest quality surgical care services, but also whatever rehabilitation services they require post-operatively. This proposed SS-ASC, like it's sister facility in Gulf Breeze will have distinct specialized ancillary medical and therapeutic clinics(see pages 9.1 to 9.6 for summary description of various specialty clinics). 4.ASSCP Goal:Ensure quality and patient safety through compliance with appropriate standards and guidelines. The proposed SS-ASC will be operated using proprietary patient safety and quality of care guidelines that exceed industry standards. It will also fully comply with State ASTC licensing, Medicare ASC certification and national accreditation requirements. 5. ASSCP Goal: Foster an environment, which assures access to services to individual's unable to pay and regardless to payment source or circumstance. ASMC is making an indigent and charity commitment to provide uncompensated surgical and post-op on-site rehabilitation services to injured Georgia high school athletes and others who are uninsured and financially indigent. The ASMC SS-ASC is making a commitment to provide 5%of annual adjusted gross revenues in uncompensated indigent and charity care. 6.ASSCP Goal:Assess availability,quality and effectiveness of services being provided through Agency information and statistical data. ASMC SS-ASC will participate in Georgia's Department of Community Health, Healthcare Regulation Division, Office of Health Planning data collection surveys; such as but not limited to the"Division of Health Planning Annual Freestanding Ambulatory Surgery Center Survey,"and"Indigent and Charity Care Survey." State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 10.1 Revised July 2008 2795 ASMC,LLC -Continued Response To CON Application Item 19, Page 10 Consistency with Long Range Planning: This project is consistent with legal applicant's long range planning objective to develop a comprehensive sports medicine and training complex in Georgia. ASMC has determined that the proposed site will provide improved geographical access to prospective amateur andprofessional athletes originating from outside of Georgia and the US. Particularly patients who are seeking Tommy John surgery, a procedure generally not currently available at the success rates attained by the Andrews Institute in Pensacola. Thusly, ASMC's SS- ASC will provide a specific procedure not currently available in Georgia. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 10.2 Revised July 2008 2796 Rule 111-2-2-.09(1)(b): Need The population residing in the area served, or to be served, by the new institutional health service has a need for such services. 20. Please explain the need for your particular project or service. For services for which a need methodology exists in the State Health Plan, please use the said methodology. In submitting information to explain the need for your project, please also use the following guidelines: For any population projections,the official projections of the Office of Planning and Budget should be utilized; Include maps that clearly define both the primary and secondary service areas and identify all other providers of the proposed service that lie within the primary and secondary service area on such maps; Describe the relationship of the site to public transportation routes, if any, and.to any highway or major road developments in the area. Describe the accessibility of the proposed site to patients/clients, visitors, and employees;and For services that already have documented utilization rates, include such historical utilization data, and projections for future utilization. NOTE: Ifyour explanation exceeds this blocked space, attach additional 8-%by 11-inch pages, number the first sheet Page 11.1, the second Page 11.2 and so on. Do not alter the main page numbers of this application. Once printed, insert your additional pages 11.1, etc. behind this Page 11. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that supports the need for your project into APPENDIX E. All documents such as tables, charts, and maps that support your need analysis and that are able to be inserted or created in MS Word format should be inserted following this page according to instructions in the note above. The prospective ASMC SS-ASC patients will originate from across the state, with an estimated 40% originating from out-of-state. Expect about 32% most likely may originate in HPA-3 because it is the most populous planning area; and 28%from other Georgia HPAs(expect mostly North Georgia counties; HPAs 1 to 7). Place of Origin of Patients 1 HPA-3 32% 2 Other Georgia HPAs 28% 3 Alabama 5% 4 Florida 3% 5 South and North Carolina 4% 6 Tennessee 6% 7 Other States 22% 9 Total: 100% The applicable CON "need methodology" reflects projected ambulatory surgery service utilization and demand strictly based on a rate of use within a planning area. Secondly, all HPA-3 exiting ASCs and hospital ambulatory surgery programs have low out-of-state patient admissions, with most patients originating within HPA-3. Whereas, this proposed SS-ASC has a high proportion of out-of-state patients means that this facility serves a different patient population not included in CON rule 111-2-2-.40(3) (a) 1, the need methodology. The projected patient origin is based in-part on actual orthopaedic patient origin at Andrews institute ASC in Gulf Breeze for the years 2012 to 2014. About 20% of all patients originated from states other than Florida; 70% of all cases were orthopedic, and of these patients, about 30% originated out-of-state. The anticipated patient origin experience at the proposed ASMC SS-ASC will be different because its location in North Metro-Atlanta is more accessible than Gulf Breeze. Response continued on page 11.1. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 11 Revised July 2008 2797 ASMC,LLC-Continued Response To CON Application Item 20, Page 11 1. ASMC's proposed SS-ASC will improve geographical access to cost-effective high quality ambulatory surgical services because of Atlanta's improved geographical proximity to more of the U.S. and Atlanta Hartsfield-Jackson International Airport hub,which provides direct commercial flight access from all major US and many international airports. Georgia residents will benefit from access to a comprehensive outpatient medical, surgical, rehabilitation and training facilities; particularly injured high school athletes who do not have adequate health insurance or cannot afford the cost of their medical, surgical and rehabilitation services,ASMC will have a program to assist these high school students. 2. ASMC will be a multi-faceted comprehensive medical, surgical, rehabilitation and training complex. Patients will receive a full range of the required medical and surgical sub-specialty care by board certified experienced orthopedic surgeons. Patients will receive coordinated treatment planning, pre and post- operatively; and those requiring post-op rehabilitation will receive it on-site, inclusive of critical sports- training to reduce the risk of re-injury. The objective is to ensure patients receive the highest quality surgical care services, but also whatever rehabilitation services they require post-operatively.The SS- ASC, like the Gulf Breeze SS-ASC,will have distinct specialized medical/surgical clinics(see pages 9.1 to 9.6 for summary description of various specialty clinics). 3. The ASMC SS-ASC will have a CON commitment to provide uncompensated indigent and charity care for surgical and post-op on-site rehabilitation services to injured Georgia high school athletes and other patients. This commitment is 5%of annual adjusted gross revenues in uncompensated indigent and charity care. 4. Patient origin data for HPA-3 existing SS-ASCs and hospitals shows that none of the ASCs serve as high a proportion of out-of-state and statewide patients as will ASCMC SS-ASC. Table 20.1 shows HPA-3 SS- ASC "out-of-state"patient origin data,only one SS-ASC reported that 9%of their patients originated from out-of-state and it reported a very low volume of total patients.Appendix E-1 contains the source data set for the summary in Table 20.1. These 15 ASCs combined only admitted 2%of theirpatients from out- of-state. In almost every instance, 70%or more of their patients originate in HPA-3. Table 20.1: HPA-3 SS-ASC Out-of-State Patient Origin Out of State %Out of MS-ASC County Patients Pats. State 1 Northside Dunwoody Surg.Center DeKalb 241 22 9.13% 2 Emory Clinic ASC DeKalb 5,352 253 4.73% 3 Ftrirneter Surgery Center Fulton 3,580 119 3.32% 4 t7rary Orth.&Spine Physiatry Out.Surg.Cntr. DeKalb 2,433 75 3.08% 5 Gw innett Center for Outpatient Surgery Gw innett 2,248 48 2.14% 6 Atlanta Outpatient Surgery Center Fulton 7,186 116 1.61% 7 Northside Alpharetta Surgery Center Fulton 1,128 14 1.24% 8 Northw odds Surgery Center Forsyth 597 5 0.84% 9 Marietta Surgery Center Cobb 4,532 35 0.77% 10 Northlake Surgery Center DeKalb 2,235 12 0.54% 11 East West Surgery Center Cobb 2,008 10 0.50% 12 Advanced Surgery Center Cherokee 1140.00% 13 Spivey Station Surgery Center Clayton 1,623 -0.00% 14 Atl.Outpat.Feachtr'Dunwoody ASC Fulton 240 -0.00% 15 FiedmontWest ASC Fulton 1,924 0.00% Total: 35,441 709 2.00% Source:2013 FS-ASC Survey Database;2012 FO data used for consistency 5. Hospitals also reported very few out-of-state ambulatory surgery cases.Table 20.2 is a summary showing HPA-3 hospital out-of-state experience.The HPA-3 combined hospital out-of-state ambulatory surgery patient origin was only 1.7%. Only Emory University reported 18%out-of-state origin. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 11.1 Revised July 2008 2798 ASMC,LLC-Continued Response To CON Application item 20, Page 11 Table 20.2: HPA-3 Hospital Out-of-State Patient Origin Out of Total Amb. %Out of State Surg.Pats. State 1 Emory Univ.Hosp. 633 3,512 18.0% 2 Emory Orth.&Spine Hsp. 30 346 87% 3 Northside HospitaL 759 19,080 4.0% 4 Emory Mdtow n 202 6,991 2.9% 5 Wellstar Windy Hill Hosp. 65 2,316 2.8% 6 St.Joseph's Atl.Hosp. 122 4,354 2.8% 7 Piedmont Hospital 248 11,759 2.1% 8 Nside Hosp.Forsyth 60 5,258 1.1% 9 Welistar Cobb Hosp. 78 7,217 1.1% 10 Atl.Med.Cntr. 34 3,180 1 1% 11 Wellstar Kennestone Hosp. 144 13,630 1.1% 12 Emory Johns Creek Hsp. 65 6,669 1.0% 13 Eastside Med.Cntr. 44 . 4,519 1.0% 14 Gw innett M.C.Duluth 61 7,029 0.9% 15 DeKalb Med.Cntr. 71 8,219 0.9% 16 Gw innett Med.Cntr. 86 11,008 0.8% 17 North Fulton Reg.Hsp. 45 5,821 0.8% 18 l'side Hosp.Cherokee 27 4,394 0.6% 19 Grady Mem Hosp. 18 3,031 0.6% 20 Southern Reg.M C. 29 5,717 0.5% 21 Wellstar Douglas Hosp. 14 3,016 0.5% 22 DeKalb Med.Cntr.Hillandale 12 2,970 0.4% 23 South Fulton Hosp.10 3,016 0.3% 24 Rockdale Hospital 15 4,927 0.3% 25 Piedmont Henry Hosp. 15 5,183 0.3% 26 Wellstar Paulding Hosp. 4 1,463 0.3% 27 Piedmont Fayette Hosp. 30 12,462 0.2% 28 Newton Med.Cntr.11 4,880 0.2% Total: 2,932 171,967 1.7% Source:2013 AHQ Survey database,ant).Surg.Patient origin 2012. 6. The patient origin data in Tables 20.1 and 20.2 indicate that existing sources of ambulatory surgical services in HPA-3 do not serve a comparable proportion of out-of-state patients. For this reason,ASMC SS-ASC will serve a different patient population. SERVICE AREA POPULATION PROJECTIONS Table 20.3 on the next page shows the population projections for HPA-3 and state. Table 20.4 are US Census population projections for the Southern U.S., an area expected to account for many not afl ASMC SS- A SC out-of-state patients. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 11.2 Revised July 2008 2799 ASMC,LLC-Continued Response To CON Application Item 20, Page 11 Table 20.3: HPA-3 Population Projections HPA-3 and State Total Population,2015 and 2020 HPA 3 2015 2020 Net Change %Change 1 Cherokee 264,285 309,150 44,865 17% 2 Clayton 290,965 304,633 13,668 5% 3 Cobb 779,807 845,458 65,651 8% 4 DeKalb 819,193 885,607 66,414 8% 5 Douglas 159,765 186,427 26,662 17% 6 Fayette 132,165 153,081 20,916 16% 7 Forsyth 221,128 264,630 43,502 20% 8 Fulton 1,114,788 1,192,726 77,938 7% 9 Gwinnett 910,677 1,006,914 96,237 11% 10 Henry 247,235 293,903 46,668 19% 11 Newton 129,789 157,414 27,625 21% 12 Paulding 169,702 200,653 30,951 18% 13 Rockdale 97,728 109,019 11,291 12% Total:P' 5,337,227 P' 5,909,615 572,388 11% State 11,076,619 12,189,252 1,112,633 10% HPA%of State Total: 48% 48% 51% Source:04/11 OPS Resident Population projections Table 20.4: US Census Southern Region Population Projections Region,division,and Projections Projections state July 1,2015 July 1,2020 Net Change %Change South 120,440,208 127,570,819 7,130,611 6% South Atlantic 64,019,354 68,442,026 4,422,672 7% Delaw are 927,400 963,209 35,809 4% Maryland 6,208,392 6,497,626 289,234 5% District of Columbia 506,323 480,540 25,783) 5% Virginia 8,466,864 8,917,395 450,531 5% West Virginia 1,822,758 1,801,112 21,646) 1% North Carolina 10,010,770 10,709,289 698,519 7% South Carolina 4,642,137 4,822,577 180,440 4% Georgia 10,230,578 10,843,753 613,175 6% Florida 21,204,132 23,406,525 2,202,393 10% East South Central 18,530,725 18,978,828 448,103 2% Kentucky 4,351,188 4,424,431 73,243 2% Tennessee 6,502,017 6,780,670 278,653 4% Alabama 4,663,111 4,728,915 65,804 1% Mississippi 3,014,409 3,044,812 30,403 1% U.S.Census Bureau,Population Division,Interim State Population Projections,2005. Internet Release Date:April21,2005 The population projections show overall growth in the Southern US states;that HPA-3 contains 48%of Georgia's total population and is projected to experience 51%of the state's projected growth is expected in HPA-3. The major population centers in each of the Southern States other than Georgia shown in Table 20.4 are generally within a 2 hour flight from Atlanta. Professional and amateur athletes from contiguous states of Alabama, Florida,Tennessee, South and North Carolina have less than a 2 hour flight time from Birmingham, Northern;from Asheville, Memphis, Nashville, TN; Raleigh, NC and Columbia SC.These states have a combined total resident population of almost 26 million residents(excluding Florida,which has the largest population at 21 plus million residents). Within a 2 hour flight time are multiple major Division 1 college athletic programs(SEC and ACC teams, plus other mid major divisions), six NFL football teams, 5 NBA teams, plus professional baseball, and soccer State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 11.3 Revised July 2008 2800 ASMC, LLC-Continued Response To CON Application Item 20, Page 11 teams.Atlanta provides excellent proximity to these programs and their athletes. As mentioned earlier, ASMC will offer via an on-line portal, Georgia High School Association member high schools an online process to provide their uninsured orthopedic injured athletes'uncompensated indigent or charity care. The ASMC SS-ASC will attract patients from primarily outside HPA-3, a significant proportion will be professional and amateur athletes, former professional athletes, originating across the US and from other countries. Thusly, this proposed SS-ASC will serve a distinct orthopedic patient population substantially different than existing HOPD and freestanding HPA-3 ambulatory surgery services. SERVICE AREA MAPS SHOWING SIMILAR EXISTING AMBULATORY SURGERY SERVICES A single map of the proposed service area and existing similar freestanding SS-ASCs and hospitals is inconsequential given that ASMC SS-ASC patients are expected to originate from much of Georgia other than HPA-3 and out-of-state. Exiting similar facilities is not necessarily relevant because ASMC will have marginal service overlap with similar existing HPA-3 and other Georgia SS-ASCs and hospitals.ASMC patients are expected to potentially originate from over 60 counties;for example in 2014 the Andrews Institute in Gulf Breeze admitted patients from 180 of 1,469 zip codes in Florida; and over a 1,500 zip codes in other states. A map of HPA-3 and existing hospitals and three maps showing the 14 adult SS-ASCs are in Appendix E-2. Appendix E-3 shows the southern states comprising the primary and secondary service areas. Georgia and Alabama are PSA states; and Florida,Tennessee, South& North Carolina, Mississippi,Arkansas, Louisiana, Virginia,West Virginia, and Kentucky comprise the secondary service area and several of the"other states." Patients from other states are expected to originate from most states in the US and Virgin Islands.The Gulf Breeze ASC admitted patients from over 30 states in 2014. SITE ACCESS The proposed site is in close proximity to MARTA rail and bus service in North Fulton County. Site is also accessible by private automobile and taxi service from Atlanta Hartsfield-Jackson International Airport. Site is accessible off Georgia Highway 400. PROJECTED PATIENT ORIGIN AND UTILIZATION Table 20.5 is the ASMC SS-ASC projected patient origin by HPA and by state.A more discrete breakdown by potential"county of origin"would be highly speculative at best, these projections are based on actual 3-year patient origin by zip code analysis for the Gulf Breeze Andrews Institute Ambulatory Surgery Center. The proposed SS-ASC location in North Metro-Atlanta is expected to attract more orthopedic out-of-state patients because it provides improved travel distance and time from most southern,central, mid-west,west and northern states than Gulf Breeze. Other States and international patients are included under"Other." Table 20.5: Projected Patient Origin ASMC MS-ASC Projected Patient Origin Anticipated GA HPA and 'Ye of Patients by Year: 2017 2018 2019 2020 2021 Other Staes of Origin Place of Origin Patients: 2,395 3,799 3,989 4,188 4,398 1 HPA-3 32% 766 1,216 1,276 1,340 1,407 2 Other Georgia HPAs 28% 671 1,064 1,117 1,173 1,231 3 Alabama 5% 120 190 199 209 220 4 Florida 3% 72 114 120 126 132 5 South and North Carolina 4% 96 152 160 168 176 6 Tennessee 6% 144 228 239 251 264 7 Other 22% 527 836 878 921 968 8 Total: 100% 2,395 3,799 3,989 4,188 4,398 State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 11.4 Revised July 2008 2801 Rule 111-2-2-.09(1)(c): Existing Alternatives Existing alternatives for providing services in the service area the same as the new institutional health service proposed are neither currently available, implemented, similarly utilized, nor capable of providing a less costly alternative, or no Certificate of Need to provide such alternative services has been issued by the Department and is currently valid. 21. Identify existing health care facilities and services and those approved for development in the service or planning area. Describe how your service differs in terms of population served from the existing and approved services. Describe how the proposed project will enhance service delivery in the service or planning area. Also, explain the internal organizational alternatives that the Applicant considered. NOTE: If your explanation exceeds this blocked space, attach additional 8-%by 11-inch pages, number the first sheet Page 12.1, the second Page 12.2 and so on. Do not alter the main page numbers of this application. Once printed, insert your additional pages 12.1, etc. behind this Page 12. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis of existing alternatives into APPENDIX F. All documents such as tables, charts, and maps that you wish to use to analyze the existing alternatives and that are able to be inserted or created in MS Word format should be inserted following this page according to instructions in the note above. None of the hospital outpatient department ambulatory surgery services("HOPD") nor freestanding single and multi-specialty ASCs in HPA-3 are the same or are reasonable alternatives to the proposed ASMC SS-ASC for the following reasons: 1. ASMC SS-ASC will serve primarily athletes and patients who routinely receive primarily orthopedic medical, surgical and rehabilitation treatment and care by Dr. Andrews and his associates at the Andrews Institute in Gulf Breeze, Florida. 2. There are no similar comprehensive sports medicine campuses in Georgia that include multi- specialty clinical, surgical, diagnostic, rehabilitation and training facilities specifically for amateur and professional athletes. The complex will include facilities for training, including a gym, outdoor training facilities and expert certified and accredited personal trainers and therapists. 3. Many of the prospective SS-ASC patients will receive post-operative recovery, rehabilitation and training on-site. 4. An estimated 40%of the projected patients will originate from out-of-state;whereas HPA-3 HOPD or SS-ASC report that 2% or less of their outpatient surgery patient cases are from other states. ASMC SS-ASC will serve a younger age cohort of patients. For this reason, none of the existing HOPD and freestanding single and multi-specialty ASCs are the same as this proposed SS-ASC. 5. The projected in-state patients are anticipated to primarily originate from North Georgia, and secondarily from other counties in Central and South Georgia because of ASMC's prospective affiliations with statewide high schools and existing referral patterns from Georgia to the Andrews Institute. For example, in 2014, the Andrews Institute ASC admitted 75 patients from Georgia who originated from 27 total counties, of which 3 counties in HPA-1; 8 in HPA-3; 4 in HPA-4; 1 in HPA- 5; 1 in HPA-6; 1 in HPA-7; 2 in HPA-8; 2 in HPA-10; 2 in HPA-11; 1 in HPA-12; and 2 in NPA-13. The proposed ASMC SS-ASC will offer a range of services not available at the Gulf Breeze facility that are expressly targeted to serve amateur and professional athletes. 6. ASMC will provide a unique regional resource for sports medicine services; it will also have affiliations with medical schools, exercise and rehabilitation therapy training programs to provide on-site residency training. State of Georgia:Certificate of Need Application Section 3 Forin CON 100 Page 12 Revised July 2008 2802 Rule 111-2-2-.09(1)(d): Financial Feasibility The project can be adequately financed and is, in the immediate and long-term, financially feasible. 22.Provide project cost estimates for the following categories. Enter in whole dollar amounts except Cost/Sq.Ft. PROJECT COST ESTIMATES Type of Cost Amount Sq.Ft. Cost/Sq.Ft. COSTS APPLICABLE TO FILING FEE Construction 1) New Facility Costs 3,926,800 20,000 196. 2) Expansion Costs(pro rata of building exterior) 3,326,200 20,000 166.31 3) Renovation Costs 4) Architectural and Engineering Fees 196,340 5) Subtotal Construction 7,449,340 -4— Add Lines 1 through 4 Equipment Attach Purchase Orders or 6) Fixed Equipment(not in construction contract) Quotes for All Major Medical 7)Moveable Equipment 4,245,065 Equipment at APPENDIX G. 8)Subtotal Equipment I 4,245,065 4 Add Lines 6 through 7 Other 9)Contingency 200,000 10) Legal and Administrative Fees 45,000 11)Interim Financing 12) Underwriting Costs 13) Building and Fire Code Compliance 14)Other: 15)Subtotal Other 245,000 4 Add Lines 9 through 14 16)TOTAL COST APPLICABLE TO FILING FEE 11,939,405 4--- Add Lines 5, 8 and 15 COSTS EXCLUDED FROM FILING FEE NOTE: 17) Site Acquisition Cost(2 plus acres) 500,000 Enter the Amount of Line 16 18) Predevelopment Costs on the Cover Page at Item 2 of the Submission Table. a)Preparation of Site b) Development and Preparation of CON Application 14,000 19)Subtotal Predevelopment 514,000 Add Lines 18a and 18b 20) Escrow for Debt Service 21)TOTAL COST EXCLUDED FROM FILING FEE 514,000 4— Add Lines 17, 19, and 20 22)GRAND TOTAL ESTIMATED PROJECT COST 12,453,405 4-- Add Lines 16 and 21 NOTE: Use the amount ofLine 22 for all responses throughout this application except for calculating the filing fee. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 13 Revised July 2008 2803 23. Indicate the anticipated sources of funds for the proposed capital expenditures if any. Specify the amountreceivedfromeachsource. Round to whole dollar amounts. Attach documentation indicating the current availability of grants, private contributions, and unrestricted reserves, if any, at Appendix G. Fund Sources If you enter debt financing oouoeo, provide the following inSourceAmountAPPENDIXG: 1. Contingency letters ofDEBTcommitmentfromabank or other reputable lending1) Revenue Certificates institution(s)indicating its interest in financing the project2) General Obligation Bonds if a Certificate of Need is issued to the Applicant that 3) Commercial Loans 12,500,000 states the ontidpaVodterms, including the interest rate, 4) Government Loans frequency of payments,total amount to be borrowed,and EQUITY the duration of the financial obligation. 5) Grants 2. Amortizationxuheduhy including the interest,6) Private Contributions(Philanthropy) principal,depreciation and amortization by year. 7) Public Campaign 8) Unrestricted Reserves on Hand(Cash) 9) Other(please specify): Investor Equity 10)TOTAL ESTIMATED FUNDS 12,453,405 4---- Add Lines I through 9 clr NOTE: The amount of Line 10 should equal the amount of Line 22 of Question 22 above! 24. Does the Applicant undergo annual financial audits? FlYES • NO If YES 4 Attach the most recent financial audit at APPENDIX G. If NO 3 Please provide Balance Sheete, Bank Gbabyments, Tax Rmturne, or other financial statements verifying income. Attach this documentation in APPENDIX G. Appendix G-1,ASCM, LLC 2014 Financial Statements (new entity without financial activity). Appendix G-2,Verification of Project Fimamcimg' State of Geor ;a:Certificate of Need Application Section 3FormCON1nvpage14 Revised July 2008 2804 REPLACEMENT PAGES 1 AND 8 2805 Section 1: General Identifying Information 1. Enter the following information for the person or entity that will offer or develop the new institutional health service. If applicable, this information should correspond with the information submitted to the Department of Human Resources as the "Name of the Governing Body." The contact person should be a person directly affiliated with the Applicant and not a consultant or attorney. APPLICANT Applicant Legal Name: ASCM, LLC d/b/a(if applicable): Atlanta Sports Medicine Center Address: c/o Andrews Institute City: Gulf Breeze Parkway State: FL Zip: 32561 County: Santa Rosa Main Business Phone: 850-916-8700 Parent Organization: CONTACT PERSON Name: Victor Moldovan Title or Position: Legal Counsel Phone:404-443-5708 Fax: 404-443-5771 E-mail Address: vmoldovan@mcguirewoods.com 2. Is the name of the facility or proposed facility different than the Applicant's legal name? ®YES NO If YES 4 Enter the facility information below. If applicable, this information should correspond to the"Name of Facility" maintained by the Department of Human Resources. If NO 4 Continue to the next question. FACILITY Facility Name:Atlanta Sports Medicine Center Facility Address: Intersection of Morris Road and Old Milton Parkway City:Alpharetta State: Georgia Zip: 30004 County: Fulton Phone: 404-443-5708 3. If the facility is currently existing, is it currently licensed or permitted by the Department of Human Resources? YES 1 NO 0 Not Applicable If YES 4 Attach a copy of any and all licenses and permits at APPENDIX B. If NO 4 Continue to the next question. If Not Applicable 4 Check one of the following: Not Currently Existing(Proposed Only) 0 No License or Permit Required State of Georgia:Certificate of Need Application Section 1 Form CON 100 Page 1 Revised July 2008 2806 16. Check the most appropriate category(ies)for this project. Check all that apply. PROJECT CATEGORY Construction Service Change El New Facility 0 New Service Expansion of Existing Facility Expansion of Service Renovation of Existing Facility Expansion or Acquisition of Service Area Replacement of Existing Facility 0 Consolidation of Service Relocation of Facility Procurement of Medical Equipment Other Purchase Lease Donation(fair market value must be used) 17. Please provide the following site information for the facility and services identified in this application._ Check the appropriate box to indicate the current status of the site acquisition. ' Attach the appropriate documents that provide for the Applicant's entitlement to the site at APPENDIX D. NOTE: If an unsigned lease is attached, include a letter documenting both parties' commitment to participate in the lease once the CON is approved, if applicable. PROJECT SITE INFORMATION Street Address: Intersection of Morris Road and Old Milton Parkway City: Alpharetta County: Fulton Zip: 30004 Number of Acres: Status of Site Acquisition Purchased(attach deed) Leased(attach lease) Under Option(attach option agreement) Under Contract(attach contract or bill of sale) Other; please specify: Zoning Is the site appropriately zoned to permit its use for the purpose stated within the application? ® YES NO If NO-3 Describe what steps have been taken to obtain the correct zoning and the anticipated date of re-zoning: Encumbrances Are there any encumbrances that may interfere with the use of the site,such as mortgages, liens, D YES assessments,easements,rights-of-way,building restrictions,or flood plains? NO State of Georgia:Certificate of Need Application Section 2 Form CON 100 Page 8 Revised July 2008 2807 REPLACEMENT PAGE 6 2808 AUTHORIZED REPRESENTATIVE Name: Firm: Address: City: State: Zip: Phone:Fax: Email: NOTE: This authorization will remain in effect for this application until written notice oftermination is sent to the Department of Community Health that references the specific CON application number. Any such termination must identify a new authorized representative. Also, if the authorized representative's contact information changes at any time, the Applicant must immediately notify the Department of Community Health of any such change. 13. Does the Applicant have any lobbyist employed, retained,or affiliated with the Applicant directly or through its contact person or authorized representative? DYES NO If YES 4 Please complete the information in the table below for each lobbyist employed, retained, or affiliated with the Applicant. Be sure to check the box indicating that the Lobbyist has been registered with the State Ethics Commission. Executive Order 10.01.03.01 and Rule 111-1-2- 03(2) require such registration. If NO Continue to the next question. LOBBYIST DISCLOSURE STATEMENT Affiliation with Registered with Name of Lobbyist Applicant State Ethics Commission? Brad Alexander Employed Yes Other Affiliation 0 No Employed Yes Other Affiliation No Employed Yes Other Affiliation No Employed 0 Yes Other Affiliation No Employed Yes Other Affiliation 0 No 0 Employed Yes El Other Affiliation 0 No El Employed Yes Other Affiliation 0 No Employed Yes Other Affiliation No State of Georgia:Certificate of Need Application Section 1 Form CON 100 Page 6 Revised July 2008 2809 REPLACEMENT PAGES 31-35 2810 Rule 111-2-2-.09(1)(h): Relationship to Health Care Delivery System The proposed new institutional health service has a positive relationshipexistingtothehealth care deliverysystemmtheuon/earea. 36. In the space provided below, exp|ain how the proposed new institutional health service will complement existing semiueo, provide services for which there is a target popu\atkon, provide an alternative to existing oom/ues, or provide services for which there is an unmet need. You may wish to list referral arrangements and working relationships with other providers. NOTE: If your explanation exceeds this blocked space, attach additional 8-X by 11-inch pages, number the first sheet Page 31.1, the second Page 31.2 and so on. Do not alter the main page numbers of this application. Once printed, insert your additional pages 31.1, etc. behind this Page 31. Et, Attach any dooumenbadon, such as magazine ort\c|as, research popam, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis of the relationship of your project to the health care delivery system into APPENDIX K. All documents such as tables, ohads, and maps that you wish to use to analyze the relationship with the health care delivery system and that are able to be inserted or created in MS Word format should be inserted following this page according to instructions in the note above. The ASMC, LLC SS-ASC will have a positive relationship to the existing healthcare delivery market in HPA-3 and most of Georgia and Southern U.S. It will be a premier center of excellence in sports medicine; it will attract patients from all over the US and it will provide unparalleled comprehensive medico|, diagnoadc, uuqgioo|, comprehensive rehabilitation and training services on one campus. The letters of support illustrate the comprehensive support the project has from patients and other individuals from all of over the country. The ASC will offer state of the art comprehensive sports medicine from a pioneer in the field. The target population is much broader than the local community where the ASC will be based. The proposed SS-ASC will be part of a large development project that will house a not-for-profit foundation that will attract physicians and other professionals from all over the country for research and educational events. The training facility will be used by athletes from all over the country and the world, a destination complex where they will not only receive orthopedic medical and surgical treatment, but injury prevention training, bio-mechanical testing and trainingmedical and rehabilitation services to hasten recovery or improve performance. Slate of Georgia:Certificate of Need Application Section Form CON 1oo Page 31 Revised July 2008 2811 Rule 111-2-2-.09(1)(i): Efficient Utilization The proposed new institutional health service encourages more efficient utilization of the health care facility proposing such service. 37. State how your proposed project will enhance delivery of the services within your facility. Do not exceed the space provided for your response. n Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis of the effect your project on utilization into APPENDIX L. Not Applicable, proposed new dedicated orthopedic single specialty ASC. Rule 111-2-2-.09(1)(j): Non-Resident Services The proposed new institutional health service provides, or would provide, a substantial portion of ifs services to individuals not residing in its defined service area or the adjacent service area. 38. State how your proposed project provides or will provide a substantial portion of the proposed services to individuals not residing in the defined service area or the adjacent service area. Limit your response to the space provided. If this consideration is not applicable, so state. Attach any documentation, such as magazine articles, research papers, or any other document thatcannotbereproducedorcreatedinMSWordformatandthatyouwishtousetodemonstratehowyour project conforms to this rule into APPENDIX L. ASMC, LLC anticipates that 40% of admissions will originate from other states and countries; and 28% from other Georgia Counties not part-of HPA-3. Thusly this SS-ASC will serve a substantial portion of patients not residing in a defined service area or adjacent service area. These projections are based on historical annualized patient origin (orthopedic surgery patients) experience at the Andrews Institute affiliated ASC in Pensacola, FL. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 32 Revised July 2008 2812 Rule 111-2-2-.09(1)(k): Research Projects The proposed new institutional health service conducts biomedical or behavioral research projects or a new service development, which is designed to meet a national,regional, or statewide need. 39. State how your proposed project includes research projects or develops new services that will meet a national, regional,or statewide need. Limit your response to the space provided. If not applicable,so state. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you wish to use to demonstrate how your project conforms with this rule on research projects into APPENDIX L. ASMC, LLC's sports medicine complex and the SSASC will include orthopedic and primary care physician sports medicine fellowship training programs; including clinical research and trials; and sponsorship and conducting of on-site educational programs in orthopedic and sports medicine for sports trainers and physical therapists. Rule 111-2-2-.09(1)(l): Assistance to Health Professional Programs The proposed new institutional health service meets the clinical needs of health professional programs which request assistance. 40. State how your proposed project will meet the clinical needs of health professional programs,which request assistance. Limit your response to the space provided. if not applicable, so state. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis of how your project addresses the needs of health professional programs into APPENDIX L. ASMC, LLC intends to offer on-site clinical training experience to local RN, Surgical Technologists, and sports medicine and related medical/surgical physician and therapist schools. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 33 Revised July 2008 2813 Rule 111-2-2-.09(1)(m): Improvements and Innovation The proposed new institutional health service fosters improvements or innovations in the financing or delivery of health services, promotes health care quality assurance or cost effectiveness, or fosters competition that is shown to result in lower patient costs without a loss in the quality of care. 41. State how your proposed project fosters improvements or innovations in the financing or delivery of health services, promotes health care quality assurance or cost effectiveness, or fosters competition. Limit your response to the space provided. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize to demonstrate your projects compliance with this rule consideration into APPENDIX L. ASMC SS-ASC will foster lower costs and reimbursements for outpatient surgical services; it will provide quality healthcare outpatient surgical services facilities consistent with national accreditation standards. ASMC SS-ASC will foster improvement and quality in the delivery of ambulatory surgery services specifically targeting amateur and professional athletes. Rule 111-2-2-.09(1)(n): Needs of HMOs The proposed new institutional health service fosters the special needs and circumstances of health maintenance organizations. 42. State how your proposed project fosters the special needs of HMOs. Limit your response to the space provided. If not applicable, so state. In. Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis of the effect of your project on the needs of HMOs into APPENDIX L. Not Applicable. The proposed SS-ASC will not foster the special needs and circumstances of health maintenance organizations. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 34 Revised July 2008 2814 Rule 111-2-2-.09(1)(o): Minimum Quality Standards The proposed new institutional health service meets the department's minimum quality Standards, including, but not limited to, standards relating to accreditation, volumes, quality improvements, assurance practices, and utilization review procedures. _ 43. State how your proposed new institutional health service meets the department's minimum quality standards. Limit your response to the space provided. If not applicable, so state. Ci Attach any documentation, such as magazine articles, research papers, or any other document that cannot be reproduced or created in MS Word format and that you utilize in your analysis into APPENDIX L. ASMC, LLC will satisfy applicable State "Ambulatory Surgery Treatment Center" licensing and Medicare ASC Certification participation rules, regulations and standards. Appendix L is an example draft Quality Improvement Policy and Procedure manual. ASMC, LLC will adopt and implement formal quality improvement; utilization review; peer review; and other required policies and procedures. Examples of applicable policies and procedures are provided in Appendix N. Rule 111-2-2-.09(1)(p): Necessary Resources The proposed new institutional health service can obtain the necessary resources, including health care management personnel. 44. State how your proposed new institutional health service meets the department's requirement to be able to obtain the necessary resources. Limit your response to the space provided. If not applicable,so state. Attach any documentation, such as magazine articles, research papers, or any other document thatcannotbereproducedorcreatedinMSWordformatandthatyouutilizeinyouranalysisintoAPPENDIXL. ASMC, LLC has professional medical and administrative staff through the Andrews Institute, to plan, develop and implement the proposed SS-ASC including recruitment, training and retention of professional and support staff. State of Georgia:Certificate of Need Application Section 3 Form CON 100 Page 35 Revised July 2008 2815 RESPONSES TO SERVICE SPECIFIC RULES 2816 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services 111-2-2-.40 Specific Review Considerations for Ambulatory Surgery Services. 3)Standards. a) The need for an ambulatory surgery service shall be determined through application of a numerical need method and an assessment of the aggregate utilization rate of existing services. 1. The numerical need for a ambulatory surgery service shall be determined by a demographic formula which includes the number of ambulatory surgery services cases in a planning area. The following need calculation applies to each planning area: i) determine the projected ambulatory surgery services patients for the horizon year by multiplying the planning area ambulatory surgery patients' rate by the total Resident population for the planning area for the horizon year; ii) determine the number of operating rooms needed by dividing the number ofprojected ambulatory surgery services patients (step i) by the capacity per operating room. Capacity per operating room per year is 1000 patients. (This is based on 250 operating room days per year(50 weeks x 5 days/weeks)x 5 patients per room per day x80% utilization.); iii) determine the existing and approved inventory of ambulatory surgery operating roomsbyadding: i) The pro-rata portion of hospital shared inpatient/ambulatory surgery operating rooms devoted to ambulatory surgery services. This portion is determined as follows: ambulatory surgery patients x 90 min.) ambulatory surgery patients x 90 min)+(inpatient patients x 145 min.))x # shared rooms II)#of hospital dedicated ambulatory surgery operating rooms;and Ill)#of freestanding ambulatory surgery operating rooms. iv) determine the projected net surplus or deficit for ambulatory surgery services by subtracting the total ambulatory surgery operating rooms needed (step iii) from the inventory of existing and approved ambulatory surgery services operating rooms in the planning area. 2. Prior to approval of a new or expanded ambulatory surgery service in any planning area, the aggregate utilization rate of all existing and approved ambulatory surgery service in that planning area shall equal or exceed 80 percent during the most recent year;and 3. A proposed multi-specialty ambulatory surgery service shall have a minimum of three operating rooms and a limited purpose ambulatory surgery service shall have a minimum of two operating rooms. RESPONSE: The "2018 Ambulatory Surgical Services Need Projection by HPA" updated 3/28/14 indicates a surplus of ambulatory surgery operating rooms (ORs) in the planning region (HPA-3), and the aggregate utilization rate is 57%, which is less than threshold 80% rate. However, the methodology for determining need does not include the complete universe of patients that ASMC, LLC ("ASMC")will serve. The need methodology requires calculation of need based solely on a HPA's projected population, there is no independent factor or calculation to adjust for out- of-state and patient origin from other HPAs. State of Georgia:Certificate of Need Application Page 38.1 Form CON 100 2817 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services ASMC projects that 40% of it single specialty orthopedic ASC will originate from states and countries other than Georgia,and that 28%will originate from other HPA's in Georgia; or 68%will not be HPA-3 residents. Table A shows the projected ASMC origin of patients. These projections are based on Andrews Institute historical patient origin data and consideration of ASMC's location in Metro Atlanta will greatly enhance access by out-of- state patients of Dr. Andrews and his colleagues. The Andrews Institute in Gulf Breeze is accessible by private automobile and for out-of-state patients by commercial or private aircraft. Pensacola airport offers few direct flights from most states of origin by Andrews Institute patients, thereby requiring connecting flights at other airports, such as Atlanta Hartsfield-Jackson International. Eliminating the connecting routes will improve access. Secondly, Andrews Institute does not offer the range of athletic training and rehabilitation services that will be available at ASMC(see outline summary description of these services and comparable clinical services offered at the Andrews Institute, beginning on page 9.1). Table A: Projected ASMC SS-ASC Patient Place of Origin ASMC MS-ASC Projected Patient Origin Anticipated GA HPA and %of Patients by Year: 2017 2018 2019 2020 2021 Other Staes of Origin Place of Origin Patients: 2,395 3,799 3,989 4,188 4,398 1 l-PA-3 32% 766 1,216 1,276 1,340 1,407 2 Other Georgia FFAs 28% 671 1,064 1,117 1,173 1,231 3 Alabama 5% 120 190 199 209 220 4 Florida 3% 72 114 120 126 132 5 South and North Carolina 4% 96 152 160 168 176 6 Tennessee 6% 144 228 239 251 264 7 Other States 22% 527 836 878 921 968 8 Total: 100%2,395 3,799 3,989 4,188 4,398 These patient origin projections though rudimentary are based on Dr. Andrew's and his colleague's years of actual experience in treating many athletes from over every state and US territory. Many amateur and professional sports teams have expressed support for a complex and campus like the proposed ASMC, particularly if it is located in a metropolitan area with a hub airport and enough private airports to convenient access for professional athletes. Metro Atlanta is home to many professional baseball, football, and basketball athletes who reside in Metro Atlanta during their off-season, and many retired professional athletes in the area. Many are current and former patients of Dr.Andrews who are very supportive of having a campus like ASMC that provides them with a full range of clinical, diagnostic,surgical, rehabilitation and recovery, and strength training facilities at one rather than multiple locations. The Atlanta Business Chronicle reported that almost 750 former NFL players live in Georgia. (See, "Why hundreds of former NFL players call Georgia home",Atlanta Business Chronicle, July 3, 2015: a copy is attached hereto)) ASMC ASC is not a typical HOPD or freestanding ASC, it will serve predominantly non-HPA-3 patients; it will serve as another source of comprehensive medical and therapeutic care for Georgia high school athletes who do not have adequate health insurance or ability to pay for such services. Though ASMC is anticipating a significant number of patients originating in HPA-3, the projections anticipate that all will be patients served by doctors' affiliated with ASMC, rather than a competing orthopaedic or sports medicine practice. They are patients who are referred directly by a physician not a HOPD, for the express purpose of receiving outpatient surgical services and related recovery, rehabilitation and sports training at ASMC. The projected number of patients originating from a HPA-3 county is equivalent to one OR in terms of annual utilization, which represents one-half of one percent of the projected number of outpatient cases by the planning horizon year 2019 (1,276/253,502 the projected 2019 total outpatient surgery patients). Therefore, ASMC's impact on potential demand of similar existing services is negligible assuming that if given the opportunity that projected ASMC patients would even consider using HOPDs and existing freestanding ASCs, it is doubtful that most would except for uninsured financially indigent patients who may not have access to other options. ASMC ASC qualifies for special status and exemption from this service specific need methodology because the need methodology is restricted only to projected HPA-3's population prospective ambulatory surgery demand. To the contrary,ASMC will serve 68%of its patients from out-of-state and counties not in HPA-3. State of Georgia:Certificate of Need Application Page 38.2 Form CON 100 2818 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services b) The Department may allow an exception to the need standard referenced in(3)(a), in order to remedy an atypical barrier to ambulatory surgery services based on cost, quality, financial access, or geographic accessibility. An applicant seeking such an exception shall have the burden of proving to the Department that the cost, quality, financial access, or geographic accessibility of current services, or some combination thereof, result in a barrier to services that should typically be available to citizens in the planning area and/or the communities under review. In approving an applicant through the exception process, the Department shall document the bases for granting the exception and the barrier or barriers that the successful applicant would be expected to remedy. RESPONSE: The exception rule requires that the applicant... "Prove to the Department that the cost, quality, financial access, or geographic accessibility of current services, or some combination thereof, results in a barrier to services that should typically be available to citizens in the planning area and/or the communities under review." Specifically, pursuant to Surgery Ctr., LLC v. Hughston Surgical Inst., LLC, 293 Ga.App. 879(2008). ASMC, LLC does not believe the applicable need methodology applies and therefore nor does the exception rule because ASMC's proposed SS-ASC is not limited to serving"citizens in the planning area and/or communities under review," ASMC will serve mainly patients originating out-of-state, other countries and other communities in Georgia, not just communities in HPA-3. If the need rules apply the ASC meets the exception for a barrier to access based on geography,finances,and quality. In sum, Dr. Andrews' services to patients for sports related injuries are unique in the medical world and he will offer those at ASMC. He does more"Tommie John" surgeries in the country and has been covered extensively by the press for it. The service is generally not available in Georgia and is performed very infrequently, particularly for college and professional athletes. Dr. Andrews will offer it along with other procedures at ASCM. The list of notable athletes treated by Dr. Andrews is long.We have attached some articles about him to this response which identify some of these athletes. The fact is that patients are required to travel out of state to see him now. In addition, as explained in this application, ASCM will offer services to Georgia high school athletes, including"Tommie John" if they cannot pay for it as part of its commitment to provide indigent and charity care. ASMC contends that nothing comparable in terms of population to be served, is currently available in HPA-3 or inGeorgia. That it will serve a unique patient population composed mainly of amateur and professional athletes from across the US and other countries; and that ASMC unlike similar sports medicine facilities,will provide a full range of medical, diagnostic, rehabilitation, and sports training services and facilities on its campus. A list of professional athletes who left the state for treatment is attached as part of supplemental materials for Appendix N-8, most of whom were treated by Dr.Andrews. Dr. Andrews and his colleagues have through historical experience treating athletes and persons experiencing sports, recreational and work related physical injuries have determined that there is a definitive need for this type of campus and that they have established national and regional referral relationships to meet projected patient origin. The following information is provided relative to the HSI Appellate Court ruling, although ASMC SS-ASC will admit patients originating from primarily outside HPA-3 and the state of Georgia. HSI Appellate Court first Criterion/Consideration:Are existing HOPD and freestanding ASCs available to the patient population to be served? The answer is no. ASMC does not dispute that orthopedic ambulatory surgical services are available either in a hospital or freestanding ASC setting in HPA-3. Metro Atlanta has hundreds of orthopedic surgeons however few if any serve the prospective professional athlete patients that actively seek care from Dr. Andrews and his surgeoncolleagues. For example, Dr. Andrews in his own estimate has performed about 4,000 UCL or "Tommy John" procedures. Few if any of his current and former professional and amateur athlete patients actively sought receiving this surgery at an Atlanta hospital or freestanding ASC or existing orthopedic group practice. These athletes actively State of Georgia:Certificate of Need Application Page 38.3 Form CON 100 2819 AMENDED Response to CON Rules 111-2-2-A0 for Ambulatory Surgery Services bypass Atlanta orthopedic surgical providers because only a handful of orthopedic surgeons have successfully and consistently performed this procedure. Dr. Andrews for example revolutionized this procedure, by incorporating a different technique as described in this excerpt from an ESPN article from 2013: This is somewhere around Andrews' 4,000th Tommy John operation. (The doctor himself has lost track of the number.) The procedure involves harvesting a tendon from elsewhere in the body and using it as a graft. The graft is nestled into the remains of the damaged ligament, and the two are rolled up together,the cells of the tendon transmogrifying over time into the cells of a new UCL. No orthopedist other than its inventor, Dr. Frank Jobe himself, is as closely aligned with the Tommy John procedure as Andrews, mostly because of sheer volume. He has become its most practiced practitioner. But he has also made two important modifications to the original Jobe method. First, he moved the funny bone. The funny bone isn't a bone at all but a nerve (called the ulnar nerve) that runs from the vertebrae of the upper spine to the pinky finger, and that turns out to be white and thick and almost shocking in its nonorganic resemblance to an iPhone cord. It also runs straight across the UCL. In all Tommy Johns, the surgeon must move this nerve out of the way so he can engage unimpeded in the main surgical action. But instead of putting it back in its natural position, Andrews essentially leaves it where it is when he's finished. Thus, according to Andrews, the repositioned nerve makes it less likely these patients will aggravate their elbows—or have the pleasure of feeling that weird funny-bone-bonk sensation again. Second, to access the damaged elbow ligament, Andrews doesn't detach the muscle mass in the forearm that blocks it. Rather, he figured out how to get at the ligament by sticking his instruments underneath the muscle. The resulting procedure is less invasive." Source: ESPN On line Article titled "The doctor will save you now," dated September 27, 2013; page 9. (A copy is attached hereto as part of supplemental Appendix N-8) The amateur and professional athletes and other patients prefer (patient choice) treatment by Dr. Andrews and his colleagues (orthopedic and sports medicine physicians and Fellowes trained at the Andrews Institute in Pensacola and Birmingham, AL) will experience improved quality of care and geographical access by having this procedure available at the ASMC SS-ASC, particularly since no one in Atlanta is as experienced in performing this unique procedure than Dr. Andrews. A list of organizations to be associated with ASCM is attached hereto as part of supplemental Appendix N-8. They include the NFL, NHL, MLB, CFL, NBA, WNBA, WWE, MLS, USTA, US Youht Soccer, and numerous others. Secondly, ASCM's ASC's 4 ORs will be 624 square feet in size, so that not only can each OR accommodate the surgical team and various anesthesia, surgical instrumentation/equipment, monitors, etc., each is capable of accommodating surgical fellows in training. Dr. Andrews has a fellowship program for orthopedic surgeons and primary care physicians. Thirdly, it is doubtful that any of the existing HOPD and freestanding ASCs incorporate an "observation" corridor in their respective Surgical Suite. The purpose of this observational corridor is to allow for parents, significant others and spouses to observe and actually communicate with the surgical suite staff during the procedure. For youngerpatientsthisoftenhelpalleviatetheirapprehensivenessabouttheirprocedurewhentheirparentsarejustonthe outside the OR watching from the observation window. The ASMC ASC will provide a site for continuing research and education of orthopedic sports medicine fellows; it is doubtful that any exiting HPA-3 ASC is s world class training facility for orthopedic surgeons perfecting their sports medicine skills. Thusly the ASC is a valuable source of patient quality care related research and training not commonly if at all, available in any similar existing ambulatory surgery service. HOPD's do not include on-site integrated dedicated ambulatory surgery facilities with comprehensive sports rehabilitation and performance training facilities. For this reason, none of the existing HOPDs in HPA-3 arecomparableorsimilartoASMCASC. Secondly, none of these HOPD's currently or prospectively are the first choiceofprofessionalathletesinneedoforthopedicambulatorysurgicalservices, they commonly bypass HPA-3 and State of Georgia:Certificate of Need Application Page 38.4 Form CON 100 2820 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services Georgia HOPDs, electing to go to the Andrews Institute ASC in Pensacola or seek similar surgical services in other states. Metro Atlanta has extensive hospital-based and freestanding ambulatory orthopedic surgical resources, however, none incorporate all of the professional training, patient pre, intra and post-operative sports medicine services at a single site such as the proposed ASMC campus. For this reason, ASMC SS-ASC is unique and distinct physically, operationally, and in terms of a significant proportion of its prospective patient population(professional athletes)from these HOPD and freestanding ASCs in HPA-3. ASMC's campus includes facilities and a well-documented pre and post-operative physical and sports injury therapy program which has proven to be integral to surgical success. Prior to surgery, many patients benefit from a pre surgical therapy assessment and exercise followed by post-operative immersion in a rehabilitation and recovery program within days of their procedure. Provision of a full-range of post-operative recovery, rehabilitation and performance training is not currently available at one location at any HOPD or freestanding ASC in HPA-3. An enhanced site plan is attached as supplemental Appendix 1-4. It is doubtful that any HPA-3 ASC or HOPD ambulatory surgery service has comparable and extensive direct referral relationships with professional sports franchises, professional trainers and medical staffs of these franchises as does the Andrews Institute. These professional athletes, many who live in Georgia, bypass Georgia services and commute out-of-state for their orthopedic sports injury medical care; a definitive indication that the Andrews Institute ASC is unique and that existing HOPD and freestanding ASCs do not provide a comparable range of medical, surgical, rehabilitation,training, research and educational services as proposed on the campus of the ASMC. Thus, there is a definitive population that this project, in particular the ASMC SS-ASC will remedy an existing atypical quality (provision of Tommy John surgery) cost and geographic access barrier(eliminate personal costs associated with out-of-state travel, a particular hardship for Georgians who cannot afford the costs of travel to Pensacola)to a comprehensive integrated orthopedic and sports medicine facility that includes a broad range of services not limited to orthopedic ambulatory surgery service, sports medicine training, research and education facility; and rehabilitation and performance training not currently available in HPA-3 or anywhere else in Georgia. ASMC SS-ASC will remedy an atypical cost,quality and geographical access barrier for a defined population. Additional support letters describe the experience of Georgia amateur high school and college athletes and their families who at great expense elected to go to the Andrews Institute ASC because their children did not have favorable orthopedic surgical outcomes here in Metro Atlanta, but did so under Dr. Andrews' care (supplement to Appendix M). These letters indicate in these particular cases, that Andrews Institute ASC is a destination facility because it is not only perceived to provide quality patient care it is oftentimes improves upon former orthopedic care rendered by other providers.The letters of support demonstrate that a need exists to improve availability, and accesstoqualityandgeographicallyaccessiblebroadspectrumorthopedicsportsmedicineservicesinGeorgia, thereby reducing the need for Georgians to travel out-of-state for such services. Andrews Institute achieves success in patient care and outcomes because it offers a well-integrated and seamless provision of pre, intra and post-operative rehabilitative services crucial to favorable patient outcomes. Patients are not referred to unrelated therapy and rehabilitation services, often miles from the hospital or ASC. A common theme in the letters of support from former patients is that they were unsuccessful in obtaining comparable quality of care inGeorgia; and that their patient experience at the Andrews Institute was more favorable and they experienced a better outcome than previous orthopedic surgery performed in Georgia. None of these existing facilities in metro-Atlanta presently compare to the broad range of prospective sports medicineservicesthatASMCwillhaveon-site in a single location. The many letters of support are direct indicators that Georgians have elected to leave the state because of actual experience or perception that Andrews Institute ASC is a better quality of care alternative, even though it entails significant personal sacrifice and travel related costs. Not allamateurathleteshaveaccesstofinancialresourcestoaffordthetravelcoststomakethetriptoPensacola, so they do not have access to this level of care. State of Georgia:Certificate of Need Application Page 38.5 Form CON 100 2821 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services Appendix M contains around 112 support letters, many of which are from professional and amateur athletes, coaches, trainers, sports agents, etc. One letter, from Paul Kinzer, MLBPA Certified Agent mentioned how it was inconvenient for an injured professional baseball client to travel to Pensacola. Another letter from Karen L. Colen, states how difficult it was for her daughter to travel to Pensacola from the Atlanta area to receive ACL surgery then return and receive physical therapy services from Gina Lee, PT. She explained how difficult it was for her daughter totoleratethepainoftravelthatifASMCwashereitwouldhaverelievedmuchofthathardship. Diana Colen, the daughter wrote her own support letter, saying how she consulted with two Georgian orthopedic surgeons,who each recommended a different repair procedure and decided to use Dr. Andrews' different approach to her procedure. She further explained the difficulty she encountered in maintaining her post-op rehabilitation, having to drive one hour one way 4 times per week to receive physical therapy services from Gina Lee at her Lawrenceville. Ms. Lee has a long standing professional referral relationship with Dr. Andrews and provides physical therapy rehabilitation services to many of his Metro Atlanta athletes and patients. There are similar "testimonial" letters from Haley Worthy, Chuck and Regina Rosenblum, and their son Justin additional support letters). A common refrain is that their experience in receiving orthopedic surgery and rehabilitation services from and through Dr. Andrews exceeded what they had experienced in Georgia. These families obviously expended the time and financial resources to access alternative orthopedic ambulatory surgery at the Andrews Institute in Pensacola, FL. They each point to their local experience as not being as favorable and not comparable in terms of quality of care. For families of amateur high school and college athletes who cannot afford the cost of out of state travel and extended hotel stays in Pensacola, the ASMC SS-ASC will remedy this cost and geographical access barrier to high quality orthopedic ambulatory surgical services. As noted, ASMC SS-ASC's prospective patient population is comprised of people who prefer receiving orthopedic surgery in a facility with an excellent patient outcome reputation and access to surgeons, therapists, and support staff with extensive expertise and experience in the treatment of sports related injuries. ASMC has a unique patient referral network around the US and the world, most of these patient referrals are direct and therefore would not be treated at any local HOPD or freestanding ASC in HPA-3. Many of the Georgians who travel to Pensacola receive primary medical and even orthopedic diagnoses and rehabilitative services locally, but either because of past problems with their prior surgery or recommendations from their local physician, coaches and trainers, they are referred to the Andrews Institute ASC. Clearly, it would be difficult for many HPA-3 amateur high school and college athletes to afford the cost of travel and related overnight expenses for their families to go to Pensacola, so they are dependent on receiving localized orthopedic and related rehabilitative care. ASMC's indigent and charity care program will help some of these athletes who cannot afford the cost of their orthopedic surgery and rehabilitation;and because of ASMC's SS-ASCs location it will definitely improve and remedy a geographic and cost barrier particularly for those who cannot afford the personal expense to travel and stay for extended period in Pensacola. For these reasons, ASMC SS-ASC will remedy an atypical access barrier to quality, cost and geographically accessible orthopedic ambulatory surgical services specifically targeting-a unique population of professional andamateurathletesinGeorgia, the US and from other nations.ASMC SS-ASC will be a primary source of Tommy John surgery, which is limited to only a handful of capable surgeons nationally, with Dr. Andrews performing more than any other orthopedic surgeon. Provision of this particular procedure will in fact remedy an atypical quality andgeographicalaccessbarriertothisproceduresincecurrentlyathletesbypassGeorgiaHOPDsandASCstoobtain this procedure at the Andrews Institute in Pensacola. Pensacola simply does not provide the improve geographical accessibility of Atlanta's closer geographic_proximityanddirectflightaccesstomajorpopulationcenters, colleges and professional sports franchises. Not to mention Metro Atlanta's population of hundreds current and former (retired) professional, amateur high school and college athletes, and recreational athletes that are former and current patients of the Andrews Institute in Pensacola. ASMC will provide the following programs: A) HIGH SCHOOL OUTREACH PROGRAMS Provide High Schools With Athletic Trainers Provide High School Physicals For Every Sport State of Georgia:Certificate of Need Application Page 38.6 Form CON 100 2822 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services Provide Saturday Moring Clinics For Injured Football Players Provide Education For Coaches,Athletes And Trainers, Coaches Clinics Provide Medical Services For Uninsured High School Athletes Provide Instructional Lessons And Camps For High School Athletes Provide Sports Performance Training For High School Athletes Provide Mentorship Programs By Professional Athletes To High School Athletes B) HOST SITE FOR NFL PROGRAMS Play 60(Program To Encourage 60 Minutes Of Physical Activity A Day) Fuel Up To Play 60(Program To Encourage And Educate Youth On Healthy Food Choices To Be Able To Be Active For 60 Minutes A Day) NFL Concussion Center(Plan To Develop A Concussion Center That Will Be A Center For Nfl Players Once They Have Been Diagnosed With A Concussion) The Trust-(Nfl Organization That Provides A Transition Plan For Former Players. We Plan To Be A Partner With NFL To Provide Those Services For Medical, Career, Nutrition, Continuing Education,And Entrepreneurial Services) C) HOST SITE FOR MLB PROGRAMS Pitch Smart(Program To Help Young Pitchers Reduce Arm Injuries By Providing Comprehensive Resources For Safe Pitching Practices) Play Ball-(Hosts Educational Resources On Health And Safety For Coaches, Umpires, Parents,And Players) One Baseball-(Program To Allow All Youth The Opportunity To Play Baseball No Matter What Economical Status Inspire Baseball-(Program To Keep Youth Interested In Baseball Programs) D) HOST SITE FOR OTHER PROGRAMS- Stop(Sports Trauma And Overuse Prevention)-Program Raises Awareness And Provides Education On Injury Prevention,Smart And Safe Play To Extend A Child's Carver, Improve Teamwork, Reduce Obesity Rates,And Create A Lifelong Love Of Exercises And Healthy Lifestyle)Eagle Fund(Program To Provide Sports Medicine Care To Wounded Warriors,Allow Them To Interact And Train With College And Professional Athletes) Wounded Warrior(Provide Medical Care And Resources For Wounded Military Men And Women) Folds Of Honor(Programs For The Families Of Military Members) Kids Serve Too(Program For Kids Of Military Families-Provide Educational Services In Sports Medicine, Sports Camps, Life Changing Experiences At Our Faciity With Professional Athletes)Safe Kids Usa(Program To Protect Kids From Unintentional Injuries-Provide Education On Prevention Of Sports Injuries) Team Holyfield Foundation(Evander Holyfield)-Program To Influence Others On Faith,Family, And Foundation To Succeed In Sports And Life Special Olympics(Program For Individuals With Disabilities-Provide Camps And Host Site For Special Olympics Events) Make A Wish Foundation(Provide A Child The Opportunity To Fulfill A Wish With A Professional Athlete At Our Facility)Boys And Girls Club(Provide Sports Camps And Mentorship Programs With The Youth Involved) Big Brothers, Big Sisters(Provide Mentorship Programs With Professional Athletes And Staff At Asmc,LIc.) Community Providers Programs(Provide Programs For Training,Fitness,And Health For Local Policemen And Firefighters) Outreach Educational Programs(Educational Sports Medicine Programs For General Managers, Managers, Coaches,Agents,Scouts,Medical Doctors,Trainers,Physical Therapists,Strength Coaches, Occupational Therapists) ASCM Indigent and Charity Commitment State of Georgia:Certificate of Need Application Page 38.7 Form CON 100 2823 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services ASMC's SS-ASC is making a 5% indigent and charity care commitment; only a few HPA-3 ASCs currently have a similar commitment level. The table on the next page lists HPA-3 freestanding MS-ASCs, Single-Specialty ASCs, and "LNR ASCs." The second column titled "Percent" is each facility's CON related indigent and charity care commitment. Only one MS-ASC (Northside/Alpharetta Surgery Center) has a 6% commitment; approval of this project was in-part based on its higher commitment level and the lack of comparable commitments and provision of uncompensated indigent and charity care by similar ASCs in HPA-3. Only 9 of HPA-3's total of 16 MS-ASCs actually have CON indigent and charity care commitments. OHP in its approval evaluation of the Northside/Alpharetta MS-ASC found pursuant to the exception rule that lack of such a commitment and provisions of low amounts of uncompensated indigent and charity care by existing multi and single specialty CON approved ASCs supported a finding of an atypical financial access barrier. Continued on next page State of Georgia:Certificate of Need Application Page 38.8 Form CON 100 2824 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services Freestanding ASC Indigent/Charity Care CommitmentsiPercentSubtypeCounty acuity Name1U.Ub Mull-Specialty Fulton Northside/Aipharetta Surgery center20.133 Single;Specialty 1-enry Pain-Gare Center 01 Georgia3 -13112 Not Applicable Fayette Southern Pain Ins-tRute,-'U40.03Mulb-Specialty Cherokee Advanced-Surgery Center L/1 Georgia50.03 Limited-Hirpose 1-ulton Atlanta Eye Surgery Center at Omni West611.03-Irmited1Airpose DeRat Ull Valley Clinic0.03 Multi-Specialty Clayton Spivey Station Surgery CenterisU. l_imited-Flirpose 1-ulton Tenter For Reconstructive Surgery9' U. RI-Specialty DeKalb 1%rl1-lake burgicalCenter 1U 003 -Ili-Specialty 1-orsyth Northw oods Surgery Center,LLC11U.03 Multi-Specialty Cobb Marietta Surgical Center12U.U3 Multi-Specialty Cobb East-West Surgery Center13IT. 11: itiuted- Ftirpose Fulton Atlanta Center tor Reconstructive Foot and Ankt4" 11.0.3 Multi-Specialty Fulton Children's Healthcare Ot Atlanta Surgery,Mendi15a-1) ed Purpose FultOn Center tor Pain Management(the tmory Clinic)16' . riled Purpose 1-ulton liosw ellCenter for Fool and Ankle Surgery110.0 ' TO-Specialty DeKalb Emory Orthopaedic and Spine physiatry UutpatiitsU.U.3 irnited-PurpoSe 1-ulton Wilton HaR-Surgery Center19U.0 imAed-Purpose Clayton Uayton Cataract and Laser Surgery Center2U0.U3 Single-bpecialty Rockdale Interventional Spine and Pain Management Arr6 11 0, ' ingle-Specialty 1-ulton Atlanta Aesthetic Surgery CenterzzU.OJ NRASL. DEKALB Northlake Enoscopy Center230.11.3 LNKAbl, Miceli) UeKalb Center tor Foot and Ankle Surgery,LL240.0 LNKASC COBB 1-Oa-Surgery Center, the25CLUJLIV-tASL: LJEKALb Atlanta tndOscopy Center,Ltd.26 0.0 NRAbt, UtICALH -Mkalb EndoscOpy Center2/ 0.11 NHASC CHEROKEE "l'iorth Georgia Endoscopy Center,IncAi0.1.1 LNR-ASC FDL ION Embry Aesthetic Center290.03 NRAUL. GWINNET i "Northside I-call-Ankle Outpat 31) U.0 NK ASC FDL I LR4 Center For Plastic Surgery31U.Ub/ LNK Abe NEWIUN Georgia Opthaimologists,LLC32' 11.0 NRASC CLAY ION 'Ambulatory Laser&Surgery(Ar330.03 LM-ASC FUL ION Northside Surgery Center,Inc.34 0.03-ELNK ASC FLILION 'Specialty Surgery Center,tic.35 U.1.13ILNK ASC FIJIION Surgical-Suite, toe 36' 0.03 11/K ASC. FUL I ON Resurgens Surgical Center 31 0.02 LNK ASC. 1-ULI ON Atlanta AestheliC and Reconstructive SurgerViASLiaNKASCCLAYTONG-.I.- EndoscOpy Center39U. NK ASC Cl/NY-TON I-Cla, yton Outpatient burg Ur40 (./.. NR ASC. 1-ULION ''RoderiQue Surgi-center,Inc. 41 0114LNKASe COBB GEORGIA PATN-SFINE(_.1 I ER,LIC 42 U. NK ASC DOUGLAS L.-WI SURGERY GEN I tK 343U.U2 LNK ASL: NEWION ISFMASUA I LXJVINGIVN,LLC 44 CLU1 LNKA SC 1-,ACLUING GM SURGERY CENTER z 45 U.UZ LNKASC 1-ULION vVindw ard-burgery Center LLL:4b 0.U2 LNK ASC.: 1-UL ION Buck/lead Mons Surgical Center,LW 4/ II. 1 NKASC., UtKALB LGastro Specialists Endoscopy Center,LW 49 0.02 LNK ASU I-ItNKY Georgia Pain Management Center,LLL. _ 49 0.02 LNKAbC COBB GA Urology,PA Cobb Ambulatory Surgery Caen50CT.01-LNRA-SC. COBB Pinnacle Orthopaedics Surgery Center-Austell,51 0T-02-LNK ASC FOL ION L-1-11/ISL.Rosw ell,EC 51 ITINFLNKAbC Fulton NASA-Surgery Center,(IC53U.U.1-LNR-ASC Pullen Dennis Surgery Center,INC540.0/LNK AbL. Fulton tDeorgia-Endoscopy Center,LW55C1.02 NK ASC. Rockdale 'Southern Cross-Surgery Center,LW56' 0.02 LNK Abe 3w innett Gw Innen Surgery Center,LLC5! 0.01-LNli ASC Cherokee -GastrointestinallAagnostic Endo Woodstock,LI. 515 0.02--LNRASC Cherokee ' 'Pinnacle Ortho Surg Ur-Woodstock LLC A59 (LUZ INK Abu Fuiton Peachtree Orthopaedic Surgery Center at Perim bU 0.112 INK Ast, 4-Lnerokee Northwest1ENI Surgery Centerbl (I.1J2 LNK ASL. Forsyth North Atlanta Eye Surgery Centerb2U.UZILNRASL; Henry Minimally Invasive Ileurespine&Pain-hstitute - bJ U.U2ILNK AsL, Fulton Atlanta Orthopaedic Surgery Center b4 LTUZ-LNK AbL. Cobb Fiemer Ambulatory Surgical Center,LLCb5U.02-LNR Abl. Futon bFIVTASL,at Pedrront bb' 0.02 LNK AbC Uelkaits Panola Endoscopy Center b/ 0.02 LNK Abl, 1-uRon Atlanta General and bariatric Surgery-Centerbl:S 0.1.11 LNK Abl, Liw Innen Advanced Urology Surgery Centerb9U.U4 LNK ASL i-ulton Peachtree buckhead Surgery CenterU13.1.12 LNK ASC Titiuglas -Center Tor Spine Intervention AbC'I Source:2014 FSASC-liatabase. State of Georgia:Certificate of Need Application Page 38.9FormCON100 2825 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services ASMC SS-ASC INDIGENT AND CHARITY CARE PROGRAM OVERVIEW,the process to provide direct unfettered access to ASMC SS-ASC's indigent and charity care program: ASMC SS-ASC will have a web site portal that will allow any prospective patient to apply on-line for consideration to receive uncompensated indigent and charity care. Financially indigent and charity patients who are medically qualified for orthopedic ambulatory surgical services will have all of their professional, diagnostic and surgery charges waived. High school coaches and trainers will be able to assist their student athletes without personal computers, to access the ASMC web site. ASMC SS-ASC main phone can be used by a prospective indigent or charity patient (not limited to just amateur athletes)to inquire about accessing the indigent and charity program. ASMC SS-ASC will have a financial counselor to handle all uncompensated indigent and charity care patients. Patients who qualify for this program will receive the following benefits: a) Such residents will receive coordinated medical, diagnostic, ambulatory surgery, and rehabilitation services at little or no cost. b) ASMC SS-ASC will waive the facility fee and professional fee component charges for medically and financially indigent patients. c) All of ASMC SS-ASC participating physicians and surgeons will waive entirely or only charge a nominal fee for patients in the program,for pre and post-surgery office visits. d) ASMC waive or charge a nominal fee based on a sliding scale fee schedule for laboratory,and conventional and advanced diagnostic imaging services. Georgia high school athletic program directors and coaches will be supplied a specific username and password to access the ASMC website to schedule appointments for uninsured financially indigent and charitable students who are unable to obtain similar services locally.The web site will allow a prospective patient to fill-out the necessary pre- admission forms and request for fee waiver, while scheduling an appointment to see an ASMC physician. High school student requires surgery based on local physician recommendation and diagnoses will be pre-scheduled for all related services when they are commuting well beyond a reasonable travel distance and time so to avoid a need to schedule multiple visits when possible. c) Each applicant shall have a hospital affiliation agreement and/or the medical director must have admitting privileges and other acceptable documented arrangements to insure the necessary backup for medical complications. The applicant must document the capability to transfer a patient immediately to a hospital with adequate emergency room services. RESPONSE: See Appendix N-1, a copy of a hospital affiliation and transfer agreement. d)An applicant shall submit written policies andprocedures regarding discharge planning. These policies should include, where appropriate, designation of responsible personnel, participation by the patient, family, guardian or significant other, documentation of any follow-up services provided and evaluation of their effectiveness. RESPONSE: Appendix N-2 is a copy of draft Discharge Policies and Procedures. State of Georgia:Certificate of Need Application Page 38.10 Form CON 100 2826 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services e) An applicant shall provide evidence of a credentialing process that provides that surgical procedures will be performed only by licensed physicians who have been granted privileges to perform these procedures by the organization's governing body. RESPONSE: Appendix N-3 is a copy of draft Physician Credential Application form. f) An applicant shall assure that an anesthesiologist, a physician qualified to administer anesthesia, an oral surgeon, or a nurse anesthetist trained and currently certified in emergency resuscitation procedures is present on the premises at all times a surgical patient is present. RESPONSE: Appendix N-4, Anesthesia services verification. A letter from the proposed anesthesia provider is attached verifying its commitment to stay on the premises at all times a surgical patient is present. (See, supplemental to Appendix N-4) g)An applicant shall submit evidence that qualified personnel will be available to insure a quality service to meet licensure, certification and/or accreditation requirements. RESPONSE: Appendix N-5, a draft Personnel Recruitment and Retention Plan and copy of a partial Dr. Andrews Curriculum Vitae(original is 168 pages, first 19 pages supplied).We have also enclosed Dr. Andrews new Georgia license. h)An applicant shall submit a policy and plan for reviewing patient care, including a stated set of criteria for identifying those patients to be reviewed and a mechanism for evaluating the patient review process. RESPONSE: Appendix N-6 draft peer review policies and procedures. i) An applicant shall submit written policies and procedures for utilization review consistent with state federal and accreditation standards. This review shall include review of the medical necessity for the service, quality of patient care,and rates of utilization. RESPONSE: Appendix N-7 draft utilization review policy and procedures. j) An applicant shall provide a written statement of its intent to comply with all appropriate licensurerequirementsandoperationalproceduresrequiredbytheOfficeofRegulatoryServicesoftheGeorgia Department of Human Resources. RESPONSE: ASMC, LLC intends and will comply with this regulation.Acknowledgement of said intent to comply is evidenced by applicant's authorized representative's signature on page 39 of this CON application form. ASMC, LLC hereby commits to abide by and comply with applicable CON Rules and Regulations, and to additionally upon completionoftheproposedSurgeryCenter, it will ensure that the Center satisfies any and all applicable licensing Rules andRegulationsenforcedandadministeredbytheHealthcareFacilityRegulationDivision, Georgia Department of Community Health. State of Georgia:Certificate of Need Application Page 38.11 Form CON 100 2827 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services k) An applicant for a new ambulatory surgery service shall provide a statement for the intent to meet, within 12 months of obtaining state licensure, the appropriate accreditation requirements of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), the Accreditation Association for Ambulatory Health Care (AAAHC), the American Association for Accreditation of Ambulatory surgery Facilities, Inc.(ASF)and/or other appropriate accrediting agency. RESPONSE: ASMC, LLC simultaneously or as soon as possible following receipt of an Ambulatory Surgery Treatment Center license pursuant to HFR Rules 11-8-4, SCL will apply for"deemed status" Medicare Certification and Accreditation inspection. Within 12 months of receiving a ASTC license permit, ASMC, LLC will apply for accreditation from one of the three(3)national accreditation organizations. I)An applicant for an expanded ambulatory surgery service shall provide documentation that they fully meet the appropriate accreditation requirements of the Joint Commission for Accreditation of Healthcare Organizations(JCAHO), the Accreditation Association for Ambulatory Health Care(AAAHC), the American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (ASF) and/or other appropriate accrediting agency. RESPONSE: Not Applicable. Not an expansion project. m) An applicant shall provide documentation that charges are reasonable compared to other similar surgery services serving the same planning area: RESPONSE: Table B are projected average charges for 10 procedures that will occur at ASMC, LLC Surgery Center. Table B:ASMC,LLC Surgery Center Projected Gross Average Charges ASMC PROJECTEDAVERAGE CHARGES HCPCS Procedure Description Year 1 Year 2 Year 3 Year 4 Year 5 1' 3030 Low back disk surgery 11,307 $11,476 $11,649 $11,823 $ 12,001 2'12551 ACDF-Neck spine fuse&remov bel c2-Level 1 $20,440 $20,747 $21,058 $21,374 $21,694 3'f;2310 Epidural Injection CervicavThoracic 1,680 $ 1,705 $ 1,730 $ 1,756 $ 1,783 4%2311 Epidural Injection Lumbar/Sacral 1,680 $ 1,705 $ 1,730 $ 1,756 $ 1,783 5't4721 Carpal tunnel surgery 3,459 $ 3,511 $ 3,563 $ 3,617 $ 3,671 6'19824 Shoulder arthroscopy/surgery 11,946 $ 12,125 $12,307 $ 12,491 $ 12,679 7'19827 Arthroscopy rotator cuff repr 11,946 $ 12,125 $ 12,307 $ 12,491 $ 12,679 8'13412 Repair rotator cuff chronic 10,344 $ 10,499 $ 10,657 $10,817 $ 10,979 9'19807 Shoulder arthroscopy/surgery 11,946 $12,125 $12,307 $12,491 $ 12,679 10'19881 Knee arthroscopy/surgery 6,452 $ 6,549 $ 6,647 $ 6,747 $ 6,848 The only similar available charge data is from 2013 and is not comparable because the above are projectedchargesbeginningin2013. Secondly, not all HPA-3 SS-ASCs report all of these 10 procedures, therefore it isdifficulttoofferareasonableandfaircomparison. What we do know is that ASMC, LLC will receive the same reimbursements as other HPA ASCs under Medicare and Medicaid payment policies and guidelines; and that it will negotiate fair and equitable reimbursement contracts with Third Party payers. Self-pay patients will not be charged full price,"typically eligible for a 40%discount of posted or scheduled charges. n)An applicant shall foster an environment that assures access to services to individual's unable to pay and regardless of payment source or circumstances by the following: State of Georgia:Certificate of Need Application Page 38.12 Form CON 100 2828 AMENDED Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services 1. providing evidence of written administrative policies and directives related to the provision of services on a nondiscriminatory basis; 2.providing a written commitment that unreimbursed services for indigent and charity patients in the service will be offered at a standard which meets or exceeds three percent of annual gross revenues for the service after Medicare and Medicaid contractual adjustments and bad debt have been deducted;and 3. providing documentation of the demonstrated performance of the applicant, and any facility in Georgia owned or operated by the applicant or the applicant's parent organization, of providing services to individuals unable to pay based on the past record of service to Medicare, Medicaid, and indigent and charity patients,including the level of unreimbursed indigent and charity care. RESPONSE: 1. Appendix J-1 and J-2, copies of a draft Admissions, Non-Discrimination and Indigent and Charity Care Policies. 2. ASMC, LLC Surgery Center is also making a 5% in annual adjusted gross revenues (gross revenues minus Bad Debt, Medicare and Medicaid adjustments)towards provision of uncompensated indigent and charity care. ASCM will provide services to any high school athlete that cannot pay for care for a sports injury. ASMC will develop numerous programs for the community as identified in the materials attached. o) An applicant for an ambulatory surgery service shall document an agreement to provide Department requested information and statistical data related to the operation and provision of ambulatory surgery and to report that data to the Department in the time frame and format requested by the Department. This information shall include, but not be limited to, any changes in number of ambulatory surgery operating rooms that may occur as a result ofservice expansion. RESPONSE: ASMC, LLC hereby agrees to provide the Department any and all requested information and statistical data related to the operation and provision of ambulatory surgery and to report that data to the Department in the time frame and format requested by the Department. The reported information shall include but not be limited to, any changes in the number of ambulatory surgery operating rooms that may occur as a result of service expansion. State of Georgia:Certificate of Need Application Page 38.13 Form CON 100 2829 APPENDIX I-1 2830 DAV I S STOKES. COLLABORATIVE,P.C. A • R • C - H - I • T - E • C • T • S May 22,2015 DIVISION OF HEALTH PLANNING Georgia Department ofCommunity Health 2 Peachtree Street,NW,5th Floor Atlanta,GA 30303 Subject: ASMC Alpharetta,Georgia The estimated construction cost for the shell building is$3,326,200.00 and is based on 20,000 square feet at a construction cost of$166.31 per square foot. The estimated construction cost for the tenant improvements ofthe ambulatory surgery center is 3,926,800.00 and is based on 20,000 square feet at a construction cost of$196.34 per square foot. The total estimated construction cost for both shell and ambulatory surgery center is 7,253,000.00 based on$362.65 per square foot. The Architectural and Engineering fees will be 196,300.00. Sincerely, dr Willie O.Stokes GA Architectural Registration No: 06490 7121 Crossroads Blvd. Brentwood,TN 37027 Phone 615.726.0010 Fax 615.726.2090 2831 APPENDIX N-4 2832 Paradigm Anesthesia,^=^" v,,P.C.v ^ 1040 Gulf Breeze Parkway Suite 100 Gulf Breeze, FL 32561 August 8, 2015 Gina Lee, Manager ASCM, LLC Dear Ms. Lee: As per your request, I am following up on our discussion regarding our provision of anesthesia services ASCM. LLC's ambulatory surgery center ("ASC") to be located in A|phanatta. Georgia subject to the ASC obtaining a Certificate of Need and a mutually acceptable contractual arrangement. As you know, Dr. Billy Thomas and Dr. StephenAnderson (GA license 72507) are currently licensed in Georgia and we would add other Georgia physicians and CNRAs as necessary. We understand that the provision of anesthesia services requires our providers to comply with applicable laws and regulations. VVe understand that under the rules requires that the ASC must assure that an anasthenio|ogimt, a physician qualified to administer anesMhooio, an oral uuqJenn, or a nurse anesthetist trained and currently certified in emergency resuscitation procedures is present onthepremisesatalltimesasurgicalpatientispresent. (Rule 111-3'2-.40(3)C0). if the ASC obtains a CON and we execute a mutually acceptable contract we will abide all rules for the ASC including assuring that an anestheska/o0iot, a physician qualified to administer mnmsdhenie, an oral surgeon, or a nurse anesthetist trained and currently certified in emergency resuscitation procedures is present on the premises at all times a surgical patient is present. I look forward to working with you. Very truly Gregory Pmx // Hickman, M.D. Anesthesia 2833 396 NIEADOWIIROOK DRIV1. ATLANTA, Glit)ItG1A 30342 PHONE 178-731-9081 • E-MAIL STEl'llliN7192@YA110O.COM STEPHEN MILLEDGE ANDERSON EDUCA'T'ION June 1999—May 2003 University of Georgia BS/Biology Athens,Georgia August 2004—May 2008 Medical College of Georgia MD Augusta,Georgia July 2008—June 2009 Emory University Urology Resident Atlanta,Georgia July 2009—June 2013 Georgia Regents University Anesthesia Resident Augusta,Georgia Chief Resident(2012-2013) August 2013—July 2014 Andrews Institute for Sports Medicine RegionalAnesthesia Fellow Gulf Breeze,Florida PROFESSIONAL EXPERIENCE June 2003—June 2004 Congressman Jack Kingston Legislative Assistant Washington,D.C. 2014—present Northside Anesthesiology Consultants Associate Physician Admua,Georgia II ONORARY/PROI=ESSI ON AL MEMBERSHIPS American Society of Anesthesiologists (2009-current) Georgia Society of Anesthesiologists (2009-current) Phi Kappa Phi Honor Society (2003) American Medical Association (2009—current) Presidential Scholar (2003) College Republicans (1999-2003,2004-2008) Campus Chair(2005-2006) 2834 VOLUNTEER EXPERIENCE June 2002—July 2003 Congressman Jack Kingston Intern Washington,D.0 May 2000—June 2000 Habitat for Humanity Volunteer Athens,Georgia AWARDS Foundation for Anesthesia Education and Research (FAER) Scholarship Winner 2011 Resident Educator of the Year Georgia Regents Univerrity—Department o/Anesthesio/ojy 2011 PRESENTATIONS AND PUBLICATIONS Cannon C,KangJ,Anderson S,Dalton ML,Wang Z. Rapamycin inhibitsfree radical-induced y/otoxici)in vascularendothelialce//s. Presentation at the Southeastern Surgical Congress. Lake Buena Vista,FL.2006 Brown JA,Anderson SM. Laparoscopic?Fina/tumor cyoab/alion: assessment offeasibility and oulrrmes in 55th Annual James C.Kimbrough Urological Seminar,San Diego,CA. 2008. Brown JA,Anderson SM. Laparo.topicrenal Mirror cryoablation: assessmentoffeasibi/ivyandouhnmes in a low volumepractice. 72t's annual SESAUA meeting,San Diego,CA. 2008. Anderson SM,Brown JA.Laparoscopic Cryoablation ofRerra/Tumors:Assessment ofLearning Curve and Outcomes in a Low Volume Practice Current Urology. 2010;4:81-84 JM Angell,SM Anderson,B Kapp,C Ritenour and MM Issa Remote Monitoring and Supervision in Integrated Hndournlogy.Smiles: ;1 Study of Patients'Perception and Acceptance 28th World Congress on Endourology and S\XVF,Chicago IL.2010 M M Issa,JM Angell,SM Anderson,B Kapp,C Ritenour Remote Monitoring and Supervision in Integrated Endourology Suites: A Study ofPatients'Perception and Acceptance The 4th Annual American Urological Association Vit Urologist's Forum,Washington DC.2011 SM Anderson,B Kapp,Til Abd,D Saint-Elie,JM Angell,NJ Thompson,CWM Ritenour and M M Issa.Remote Monitoring and Supervision in Integrated Endourrology Suites:A Study ofPatients' Perception andAcceptance Journal of Endourology.2012 Aug 20. Anderson,S.,Hong,T.,Patel,V.,Castresana,M. A Challengingcase Report: Ventilatory Management ofan Unexpected Intraoperative Bronchiallrluy in the Non-Operative Lung During Re-Da Ivor Lewis Procedure. 2012 IARS Annual Meeting. 2835 APPENDIX N-7 2836 i,ar;.6• LaSharn Hughes,MBA,Executive Director Print date:4/13/2015 ID#58329-11 7,-,,;•;.,.• Georgia Composite Medical Board Prof#1104 2 Peachtree St.,NW.,36th Floor Lic#15530 Atlanta Georgia 30303 Batch date 4nW2015 Need to update your address,order a wall certificate,complete your ti- uk , 61physicianprofile,or renew your A:license?Scan this code with your tablet 1 JAMES RHEUBEN ANDREWS to go directly to the login page. CY '1040 GULF BREEZE PARKWAY SUITE 203 GULF BREEZE,FL 32561 Official Georgia Composite Medical Board License Card Your new Georgia Composite Medical Board license card is attached below. Please review it immediately for accuracy to ensure your name,address,and expiration date are correct. If there are any errors or corrections needed,notify the Board within 30 days of the print date(above)and a new card will be mailed to you. If there are any changes or corrections needed after 30 days, a$25 lee is required for duplicate card.Duplicates can be ordered online or by mail. You-are-require-d-byla7litb-keep-your address current with the Board. If you change your address,please notify the Board. You can change your address at http://tinyurl.coin/tvledicalBoardLogin,or scan the code on this page with your smartphone or tablet. PLEASE NOTE YOUR EXPIRATION DATE.YOU MAY NOT PRACTICE AFTER YOUR LICENSE HAS EXPIRED. The Board offers a frameable certificate of your Georgia Medical Board license.You can order these wall certificates online by logging in at httpi/tinyurl.com/MedicaiBoardLogin,using the same user ID. Each physician certificate is$50; each non-physician certificate is$25. Please allow up to 6 weeks for delivery,as your certificate will be signed personally by the Board Chairman at the monthly Board meetings.1 GEORGIA PROFESSIONAL HEALTH PROGRAM NEEDS YOUR HELP!GA PHP is the nonprofit 501c(3)foundation that administers the Georgia Composite Medical Board's wellness program.GA PHP provides initial triage,treatment referral,and long-term monitoring services for health care professionals with addictive disorders,enabling many of these professionals to return to the practice of medicine with reasonable skill and safety.GA PHP receives no state funding,so it charges its participants fees to meet its operating expenses. In many cases,the professionals who participate are already financially strapped,so the program's success also depends on the financial support of donors willing to fund this important activity.To learn how you can make a tax-deductible donation to support GA PHP's partnership with the Board, go to www.gaphp.org,or call 1-855-MY-GAPHP. 4ti'..,_,...;... STATE OF GEORGIA - STATE OF GEORGIA GEORGIA COMPOSITE MEDICAL BOARD 1 GEORGIA.COMPOSITE MEDICAL BOARD PIPISiCIAN 2 IF LOST Ott STOLEN,IMMEDIATELY c LICENSE NO: 15530 ob, CALL 404-650913 JAMESIFIEUBEN ANDREWS WWW;MEDICALIIOARD,GEORGIA,GOVo c VALID ONLY IFSIGNED BY LICENSEE1040GULFBREEZEPARKWAY SUITE 203 g GULF.BREEZE,FL 32561 C EXPIRATION DATE: 5/31/2017 IDA". SIGNATURE 2837 i I APPENDIX M 2838 LETTERS OF SUPPORT Name Organization Title 1. Kerry Meier National Football League Professional Player-Retired 2. Dr. Cl Leggett N/A Physician/Son is GA Tech Football Player-Red Shirt Due to Injury 3. Paul Kinzer Repl Baseball MLB Agent 4. Blair Johnson Major League Baseball Professional Player- Retired 5. Terry Williams Vortex Sports & Sports Agent Entertainment 6. Diana Colen The College of Charleston Tennis Player 7. Haley Worthy Kennesaw State University Soccer Player 8. Justin Rosenblum N/A Student 9. Chuck and Regina N/A Parents of Patient Justin Rosenblum Rosenblum 10.Michael Palmer Major League Football Professional Player- Retired 11. Rodney Bullard Chick-fil-A-Foundation Executive Director 12. Jeff Chandley Atlanta Athletic Club Director of Tennis 13. Susan Clay N/A Life Coach 14. Mike Berenger Rapid Sports Performance Owner/Personal Trainer 15. Andrew Taylor Taylor&Mathis President 16.Milt Miller GA High School Coach Retired 2839 Hello.My name is Kerry Meier.I was blessed with the qualities to play the sport of football at the highest level for a few years.In the 2010 N.F.L.draft,the Atlanta Falcons selected me to play wide receiver for their organization. For an entire long time,I relentlessly pushed and challenged myselfto be the best 1 could at the sport of football.The game required an ample amount of my physical and mental tools that were all tested through the years both collegiately and professionally.At the professional level,I ran into a string of injuries that required surgery and extensive medical rehabilitation. In 2010,my rookie year,during a preseason game I tore the anterior cruciate ligament in my right knee. Re-constructive surgery was required to allow me to pursue my passions again in the sport.After researching and evaluating doctors throughout the country,I elected to travel to Florida for surgery with Dr.James Andrews. Seeking the best medical help was my only interest and I received that upon surgery.Post-surgery,I elected to conduct my rehabilitation back in Atlanta,at my home with the Falcons.I felt it was in my best interest to be near the confines of my own home and my job.After a grueling five-hour car ride back to Atlanta,I began my rehabilitation a few days later.Due to irritation,inflammation,and the limited time ofrecovery post-surgery,I was unable to fly because of the physical state ofmy knee.Throughout the rehabilitation process,multiple trips were also required to see Dr.Andrews at facilities in Florida and Alabama.The inconvenience left many miles on my car and missed time at work. In 2012,after a healthy year ofplaying with the Falcons,I ran into another medical injury.A few pines into the 2013 season,I injured both of my adductor muscles.The medical imaging and evaluations proved that re-constructive surgery was required.1 sought help in Boston,Massachusetts which required two separate trips to complete surgery. Again,the surgery was a success and after proven rehabilitation success with the Falcons medical staff on my knee,I elected to work with them again,It was great being able to complete my rehabilitation near my home and to have the convenience of working with the Falcons staff but I still made two separate trips to Boston for physical check-ups and evaluations.Those trips proved to be more of a hassle than anything but were required as part of being medically cleared to begin playing again Since I've put my football career to a close,I've been able to reflect upon the sport of football and my time playing it.The physical aspect offootball is,was,and will always be present.The physicality can create for a multitude of present and future problems.Due to some recent extensive mind/body evaluations to past N.F.L. players,physical and mental problems arc being discovered.Now more than ever,the importance ofplayer safety in all sports is at an all-time high.Proper medical attention,both current and future,is of the essence.In my time playing in Atlanta,the inconveniences after my surgeries proved to become problems,The service of having the doctor who performed my surgery and a physical therapy team together,under one roof would have been such an advantage.I have always felt a facility that housed elite doctors,a medical staff,first class equipment,and an environment that suited ail ages would have been a luxury during my rehabilitation.Atlanta is a great city for a facility of such.The professional teams,importance of sports and fitness,not to mention the prime location of it in the south create for an appealing facility.In life,we aim to find convenience and efficiency in our daily lives.This would create convenience and opportunity for people to make their lives better in a multitude of ways. Best, Kerry L.Meier 2840 Dr. Christopher J.W.B. Leggett Dear Ms. King: I am writing this letter on behalf of my wife Denise and my entire family in support of Dr. James Andrews bringing his world renowned reputation and impeccable surgical expertise to the State of Georgia. His quest to build a world class comprehensive surgical and educational center, physiologic and structurally based performance institute coupled with an injury prevention educational focus for young athletes and life preservation emphasis for older retired athletes is unmatched anywhere in the world. Our son who is currently a running back for Georgia Tech, has played sports most of his life since the age of four. He has played baseball, golf, basketball and football. After much contemplation he finally choose football as his primary sport. He excelled in every way; we loved to see him play and would look forward to Friday night lights for high school football. As a parent who just happens to be a physician at times it was hard to watch knowing that with each hit, there could be a catastrophic injury. In April of 2015 on the last day of Spring practice, after winning the starting position as running back, we received the dreaded call from CJ's coach that he had been injured. A parent's worst nightmare. He was scheduled for an MRI the next day with the team doctor at Emory Orthopedics. After review of the MRI it was determined that CJ had a torn ACL. Having experienced the same injury myself I understood the importance of engaging the most experienced surgeon with a full understanding of the pros and cons of each surgical repair approach. I also was aware of the lifelong joint mobility limiting consequences of a suboptimal surgical result coupled with improper rehabilitation and post physical therapy. After learning of the quadriceps tendon repair choice as the approach recommended by the Georgia Tech team physician we immediately swung into an information mode gathering. We set up a meeting with the team doctor to learn the specifics and rationale for this approach to CJ's surgery. Our research revealed that there was not an established substantial database on the durability and long term prognosis with the usage of quadriceps tendon repair for ACL injuries which is what the Emory doctor was proposing. It was at this time we chose to seek a second opinion. My residency training was at Johns-Hopkins Hospital so I made inquiries to several sports medicine orthopedic surgeons well versed in ACL injuries. Each expert I contacted without exception said that patella tendon surgery was the surgical approach of choice and that this repair would give our son the best opportunity for complete recovery that would allow him to resume competing at the highest level. We also have been fortunate to have as friends several professional athletes who have experienced sports injuries and sought out the best surgeons for their repair and recovery. Simply stated, every orthopedic physician contacted and every player called unequivocally recommended Dr. Andrews to do CJ's surgery. After much prayer, research and deliberation we took our son to Dr. Andrews in Pensacola Florida. This was no easy decision for our family. I had to weigh the inherent backlash from the team physician and his staff against our son along with the risks of complications, infection and being away from home against the apparent ease of allowing the team physician to operate on our son. We chose Andrews. From the minute we set foot on the campus we were amazed at the professionalism and caring that was demonstrated by staff and Dr. Andrews himself. We immediately felt at home and confident in our decision. Thanks be to God the surgery was flawless. CJ's recovery and rehab has been nothing short of spectacular to date. He has been following the meticulously outlined rehab protocol of Dr. Andrews and Dr. Andrews' physical therapist Gina Lee. 2841 Dr. Christopher J.W.B. Leggett Throughout my training I have always been taught and trained to be my patients' best opportunity for a good outcome. In those instances where you're not the best it then becomes your duty to make sure you direct your patient to the physician who is the best. In this situation with our son all indicators pointed to Dr. Andrews as being the superior choice for his repair. As a father getting him to Dr. Andrews became my highest priority to insure the best possible outcome. I fully realize that my network of colleagues, friends and financial resources permitted me to create access for our son to the highly sought after expertise of Dr. Andrews. We all feel extremely blessed. I recognize that many local athletes and some of my son's teammates would have had to settle for the team physician recommended therapy because of lack of access or knowledge about what is the best repair. I now want others to have the access to the best that our son experienced. Local opposition to Dr. Andrews establishing an institute in Atlanta centers on fear of competition, shift in economic revenue and a loss of patients. All of these elements have nothing to do with what's best for patients. None of the opposition is related to Andrews lack of talent, poor outcomes or blemished track record. The Andrews Institute of Atlanta is a phenomenal idea that gives Georgia an opportunity to land the world's most prolific and well regarded sports medicine orthopedic surgeon. It instantly creates and establishes Atlanta as the international mecca of sports medicine. The planet's greatest athletes will seek injury prevention advice, training and surgical repair here. The local amateur and student athletes will be able to have access to the best sports medicine mind of our era. History will acknowledge Dr. Andrews as one of the pioneers of our era and legends of sports medicine surgery. The rich high profile athlete will continue to flock to him wherever he is located. We have an opportunity to engage his expertise and knowledge in the twilight of his career to educate the masses, help increase awareness of how to prevent overuse injuries, utilize physiologic information to enhance proper development and performance all while providing access to the highest level of surgical expertise when needed. As for the Leggett family whether, our son ever reaches the elite level of performance that we know he is capable of we can rest assured that we along with Dr. Jim Andrews gave him the best opportunity to achieve that goal, for that we are forever and extremely grateful. I hope Atlanta will be smart enough to land this gem! 2842 7/t 4 1 1, U.',/s.!-IilAi_i., i August 5,2015 To Whom It May Concern: I am a Major League Baseball Agent and have been representing athletes for over 19 years. Throughout those years we have had our athletes go to Los Angeles, Birmingham,and Pensacola for surgery. I think having a surgery and rehab facility together on the East Coast would be a tremendous benefit. Atlanta,being a hub for travel nationally and internationally is very valuable. With Dr.Andrews involved you would draw interest from athletes around the world. I personally represent players from 11 different countries. Our Company,Rep 1, represents 53 NFL football players and this would also be an asset for them. IfI can he of any assistance,feel free to contact me at 770-94.9-7397. Sincerely, Paul Kinzer R fi a== E3 A Sf BA i_.l. F"r$c:E /7..) .-.,.. PAX ; j0--W•.:'- , 2843 Dear Rachel King, I'm writing this letter in hopes of giving you an understanding into why having a Baseball Academy tied into a medical facility is the future. I want to start off by giving you a little background and the hardships I faced when playing professional baseball for 8 years. I was your above average guy playing for elite teams growing up. I always had an emphasis on working hard,whether that was in the weight room,or out on the field. I was not known for having an overpowering fastball for much of my youth but I did have great mechanics,thanks in part to the wonderful instructors I had growing up and the encouragement from my family. It was around my junior year in high school that my body began to fill out and all of a sudden I was a top prospect in the nation throwing upwards around 96 mph. What began as an aspiration to play Division I baseball now suddenly became a dream of being drafted and playing in the Major Leagues. I did end up signing with the Pittsburgh Pirates with the 42"d pick in the 2002 Major League Baseball Amateur Draft. Unfortunately most of my playing days were spent in the training room post surgery. The training room is a very lonely place. You don't have fans cheering you on,and you constantly doubt yourself. I always thought I had done everything in my power to perform at an elite level but there was one thing I was not doing,arm care maintenance. The training staff stressed the importance but I thought I would stick to what got me there. Very naïve,but to that point I had not been introduced or had even heard of preventative maintenance. What shocks me even to this day is that there is still no plan in place for our young athletes. The sports academy industry has a bad name for itself because it has the stigma of putting the good of the academy first. My plan is to change that stigma. I plan to utilize every partnership with the facility and create an academy that puts the youth athlete's health first. My goal with the academy is not only to provide world class instruction in an environment that promotes growth,but to also introduce at a young age a preventative maintenance program that gives kids an understanding of how important arm care maintenance is along with mechanics and strength. That's where I want the physicians on site to come in. I want to strategically align the academy with the local physicians to develop an age specific arm care program to protect our next generation. Right now there is an epidemic of youth sports related injuries that is astronomically higher than anything that was going on around the time I was playing. This needs to be addressed and we will do everything in our power to bring awareness within our facility. The simple fact is that there is no other Academy in the nation to my understanding that is going to provide this type of service. What I would have given to be able to have a facility of this nature growing up could have been a game changer for me. Knowing what I do now and the plethora of knowledge I gained throughout my playing career combined with the passion of the people that 2844 surround this project, excites me for the next generation of athletes not only in the Metro Atlanta area but also around the world for the game of baseball. Our ultimate goal is to change the way the game of baseball is taught. Not to just put money in our wallets,but to put our energy where it matters,the youth. My aspirations are for giving back to the next generation ofbaseball players. I do want to give a little insight into what its like to come back from an injury/surgery and what a difference having a facility like the one proposed would mean to an athlete. After having surgery you are given a plan of action. The average person would have to communicate this to secondary resources such as physical therapists and make a trip to multiple locations just to receive quality care. This facility positions itself to give a one-stop shop not only for professional athletes,but amateur ones as well. This could be a valuable resource not only to athletes from Atlanta but Internationally. just to think you could map out your whole rehabilitation process, from start to finish within the confines ofone complex. Athletes can have their surgery performed by prestigious doctors while following post surgery care in the other secondary services provided by the facility. Everything from gaining your strength back while rehabilitating your injury to working out in one of the featured academies truly has no measured value. Sincerely, Blair Johnson 2845 A.wxty rt, August 5,2015 Ms.Rachel King,Director Division of Health Planning Dept.of Community Health 2 Peachtree Street,5th Floor Atlanta,Ga 30303 RE: Andrews Medical Facility Ms.King: I am writing you to express my support of the proposed medical facility of Dr.James Andrews. As a sports agent we send all of our athletes to Dr.Andrews'facility in Pensacola,Florida when surgery is needed and when certain rehabilitation is required. With NFL players,when there are orthopedic injuries,the team doctor evaluates and makes the diagnosis for any injury. Under the NFL Players Association collective bargaining agreement,the player is entitled to a second medical opinion and I will tell you that probably 90%seek Dr.Andrews'opinion since he is the leading expert on sports injuries. If you ever look at ESPN programs on player injuries they always interview Dr.Andrews as he is the one doing the surgery on any high level athletes. The great thing about Dr.Andrews is that not only does he heal the high profile athlete but he sees all patients if he can help them. I will tell you that any facility in Atlanta would be an asset to the community and it would bring more business to the Atlanta area. We are going to send our athletes to Dr.Andrews in Pensacola regardless,but it sure would be a lot nicer to send them to Atlanta since it is closer and the air travel to Atlanta is so much easier. We will definitely be sending our clients to any Atlanta Facility of Dr.Andrews. If there is no facility,we wilt continue sending them to Pensacola. With this facility,you will bring more professionals(medical and athletes)to the Atlanta area. This facility will bring new jobs and provide medical graduates in Georgia the opportunity to remain in Georgia with their skills. Thank you for the opportunity to address this issue and if you have any questions please don't hesitate to call. Sincerely, Terry Williams www.vortex-se.com 1.888.451.3800 COLUMB1AOFFICE l 1931 Bull Street I Columbia,SC 29201 PO Box 68 t Columbia,SC 292112 803.254.3330 1803.256.3253 FAX 2846 Page 1 o[2 Subj: LettersupportoYfn,newfaoi\hy Date: 8/B2O151O:42:37PKA. Ea ernDaylight Time From: o§V« corn To: CC: nyyoIldr @D wt. shceb0§agLcorn Rachel King DirectorDivimionofHoaKhPbnning Department of Community Health 2 Peachtree Street 5th Floor Atlanta,GA 30303 Mrs.DeorK)ng. I am writing to urge you to approve the ASMC surgery center that will be part of the state-of-the-art comprehensive sports medicine center being developed in association with Dr. James Andrews. I have personal experience with Dr.Andrews because he is the one who performed my ACL reconstructive surgeI will be attending The College of Charleston on a full Dl tennis scholarship starting ri August. I first started playing tennis at the age of four and knew that it was my passion. I am originally from Atlanta, Georgia and have lived here my whole life. At the age o 13, I decided that I wanted to take my tennis to the next level so my family and I moved to Hilton Head, South Carolina in hopes that I would get the training that I needed to become a nationally ranked player. My goal was always to play college tennis but I could never find a facility that offered both physical fitness training and intense tennis training. In October of junior year in high school, I decided thaI needed to move back to Atlanta to get more intense training so I could reach my goal. In May of my junior year, I was offered a scholarship to The College of Charleston to start in early January which meant I would have to graduate high school a semester early. However, 1 was not able to start early because I tore my ACL in September of my senior year. My parents and I chose to go out of the state of Georgia to go to Dr.Andrews in Pensacola for surgery for several reasons. First, he is a world renowned orthopedic sports physician who has extensive experience treating both professional and amateur athletes. Secondly, the two orthopedic surgeons I saw in the state of Georgia both recommended surgeries that would either use the hamstring tendon or the quad as\hegraft. Dr.Andmwswan\od to use the patella tendon and since he is a world renowned physician I trusted his opinion the most. After my surgery my family and I decided to stay in Pensacola for two weeks so I could be under Dr. Andrews supervision to make sure I was on the correct path for a full recoveryThe environment was incredible down there, everyone was very supportive and caring. It was amazing to look around and see other athletes working out and knowing that I would soon be up and movingaround like them. Dr. Andrews suggested going to Gina Lee for rehab once I got home from being in Pensacola. He said that even though she was an hour in Lawrenceville, Georgia the drive would be worth it because I would be working with the best therapist so I would be on the right path to make a full recovery. After my first day working with Gina I knew that I had made the right decision to work with her. I drove up to Lawrenceville four times a week to do rehab,two days being in the clinic and two days would be driving to a different facility to do aquatic training. I have had the best rehabexperiencebecauseIhavebeenabletoworkwithprofessionalbaseballandfootballplayers.They helped mget through every step of this rehab process because they taught me that it is possible togetthroughayearlongrecoveryandcomebackstrongerphysicallyandmentallythanIwasbefore my injuryHowever,this process would have been a lot easier if Gina's facility was not an hour away because I have put so many miles on my car and have spent thousands of dollars on gas: not to 2847 Tuesday,August 04,2U\5 /\Ol.: Shccbj Page 2 oft mention how tiring it is to drive at two hours a day.With this new facility it would allow anyone in my position to have the amazing experience that I have had but without the long drives. I respectfully request your support for the ASMC, LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia Diana Colen Tuesday,August 04.2015 AOL: Shcehj 2848 Rachel King • 7/31/2015 Director Division of Health Planning Department of Community Health 2 Peachtree Street 5th Floor Atlanta,GA 30303 I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. Dear Ms.King, My name is Haley Worthy and I am in the recovery portion of my third surgery.My first two experiences with operations were fine,but nothing compared to my visit at the Andrews Institute.I committed to play soccer at Kennesaw State University in January and it was by far one of my proudest moments. Unfortunately, I tore my ACL,MCL and Meniscus on May 23'during a soccer game and I was beyond devastated. Before my mom even called my dad,she called Gina Lee,the physical therapist at Gwinnett Sports Rehab who is a driving force behind this project. I went to her when I had hip surgery and my brother also went to her when he had to have elbow surgery last year.She recommended a knee specialist at Emory and we were not satisfied by the service whatsoever.The doctor told us what he thought might be wrong with my knee and scheduled an MRI for me,only after saying rude remarks targeted at Dr.Andrews himself.The MRI would have cost us around 1800 dollars and there was no way we could pay for that,especially with a possible upcoming surgery,so we had to reschedule elsewhere. I was just kind of left hanging after that,not sure what was wrong or what I needed to be doing to stabilize my knee and prevent further injury.We finally went back and he showed us the MRI,and expectantly,I had torn three ligaments/cartilage.I was absolutely devastated,discouraged and not sure if I wanted to pursue my college career after all. My mom called Gina right after and she told me to come in the clinic that next Monday to start"prehab"to help regain my motion and strength before I underwent surgery.That month of therapy,both in the clinic and the aquatic center,was so beneficial and I had gained some confidence going into this major knee surgery.My family took into consideration many surgeons in the Atlanta area,but the reviews were nowhere near those of Dr.Andrews.A girl on my travel soccer team tore her ACL in eighth grade and had her surgery done at OrthoAtlanta,only to come back at the six month mark and retear it the first day back at training.By this time the answer was clear,we had decided that we would go to see Dr.Andrews because he is one of the best surgeons in the world and his facility is outstanding.We arrived at Andrews Institute,a nine hour drive from Douglasville,Georgia to Pensacola,and I immediately felt comfortable and cared about.I went in for my pre operation appointment and I had many doctors come in to tell me what exactly was wrong with my knee and how they were going to fix it,all before Dr.Andrews even came to see me.There was a boy there who played on my brother's baseball team who needed elbow surgery and I found it very helpful to have someone to talk to and undergo this journey with.When Dr.Andrews came to see me I knew a few things right off the bat. He was obviously very experienced on knee surgeries,he was passionate 2849 about his job and I could sense that he genuinely felt sorry for what had happened to me and that he was going to have to perform surgery to fix it. He then told me that he was leaving for the Fourth of July weekend and that he would like to operate on my knee later that afternoon so I would have time to recover and it would also allow him to see me before we parted ways. I was sent from his observing room down to physical therapy,where I was fitted for a brace and given my first exercises,and then to the surgical waiting room to fill out paperwork and get prepared for surgery.I underwent surgery that afternoon,a day earlier than expected,and it went perfectly. Everyone that worked there was genuine and they always made sure I was as comfortable as possible. I had no pain that night and I returned the next morning for my first rehab session with the trainer there. I returned home and had a good amount of pain for the first couple of weeks, but I returned to therapy with Gina only five days post operation. She pushes me,encourages me and is always the positive driving force behind me,and I couldn't think of a better person to help run the new Andrews Institute in Alpharetta. Recovering beside professional and collegiate athletes at the Andrews Institute and at Gwinnett Sports Rehab with Gina has given me confidence and a self-assurance that I can get through this minor setback and make a major comeback. I respectfully request your support for the ASMC,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. Haley Worthy 2850 Dear Ms. King, My name is Justin Rosenblum and I am writing to you on behalfofthe new Andrews facility. Playing sports since I was very young. I have sustained my fair share of sports related injuries."Tearing my ACL when I was only 13 years old, I have had a lot ofexperience with surgeries and physical therapy. When I first tore my ACL,we didn't know of any well-known orthopedic doctors around the area. So wejust had to use one that was close to home and sounded credible.Aller using that doctor for my surgery and doing physical therapy for a year, I went out for my high school's football spring practice. Within not even 30 minutes ofpractice, I had re-torn my same ACI.. I then went back to the same doctor for surgery. I was not even 15 years old and I had already had two major knee surgeries. I decided to not play any sports for the next three years because I was so seared of injuring my knee again.Going into my senior year I decided to play football again. Making it through the season I earned a scholarship and got to play in college, but, I only made it half way through my freshman year before tearing the same ACE again. My family and I were very frustrated and upset and did not want to go back to the same doctor. We decided to fly down to Pensacola, Florida to use Dr. Andrews because we knew he was,if not the best,one of the best orthopedic doctors in the country. Being that this was my third knee surgery, I had some experience so I knew what this surgery and physical therapy consisted of. After getting surgery from Dr.Andrews and doing physical therapy at his clinic, and now currently doing therapy with one of Andrews Clinic top recommended physical therapists, I can now compare my two experiences.Getting my surgery at Andrews Clinic was night and day compared to when I had my two surgeries by my doctor in Atlanta.The whole time we were at Andrews Clinic it was a first class experience. When I was doing therapy there for a week. I was next to two current NFL players the whole time doing the same exact things I was doing.This was comforting to me knowing that I was getting the same treatment as such high profile athletes. Even though I had both my knees operated on at the same time by Dr. Andrews, it was still a lot less painful recovery than the other two surgeries where my doctor only repaired one knee_t am recovering a lot better,stronger,and faster this time around. I would go anywhere to use Dr. Andrews if I ever needed orthopedic surgery again,as would most pro athletes because they know he is the best. I really think the Atlanta area would benefit with such an amazing facility and team coming here. Dr. Andrews and his team has given me the opportunity to continue being active and living my life to the fullest,and I know he can do the same to many others. Sincerely, ju ett Rrr Cum* Justin Rosenblum 2851 7/30/2015 To Ms.King, Our son Justin is 19 years old.He has had 3 knee surgeries.The third surgery was done this year by Dr. Andrews in Pensacola,Florida.Dr.Andrews is such an incredible surgeon,we would have gone anywhere to have had him do Justin's procedure. Justin had surgery on both knees with Dr.Andrews and has had a lot less pain than he has had with his previous surgeries.He is recovering faster and stronger than in the past. Dr.Andrews is willing to open a surgery center here in The Atlanta area.Our community would benefit tremendously by him being here.Not only is Dr.Andrews an amazing surgeon,he is also a very genuine and caring man.We have never seen such a surgeon with such tremendous bed side manner.This man has one of the most impressive reputations around.Not only would his patients benefit from him being here,but Atlanta Georgia would benefit as well.People from around the world would come to see him. Dr.Andrews has such a way with people no matter what their status is.He treats everyone with such great compassion and respect. Our family has been through 5 knee surgeries.We know the difference when it comes to the right orthopedic care and physical therapy.We believe that Dr.Andrews and his staff give people a better chance of living a normal life after their orthopedic surgery and therapy. Sincerely, Ccuci/6)44.ktaguy& RhjLl2t/ kC' 729Cu44/ Chuck and Regina Rosenblum 2852 Ms King, My name is Michael Palmer,and I am a retired NFL tight end. I played S seasons,including 3 with the Atlanta Falcons and 2 with the Pittsburgh Stealers. Being a local kid from Gwinnelt County and having played for the Falcons, I have spent the majority of my life in or around the city of Atlanta and definitely the state of Georgia.When I decided to retire this past January,I knew I needed to have elbow and ankle surgery.As soon as I began discussing this with my agent,Terry Williams, he immediately told me that we would he heading to Pensacola because that's where the best orthopedic doctors are located. Like I have stated before, I grew up in Georgia. I played professionally in Georgia. I,as well as Terry, knew I was not going have my surgeries done in the state of Georgia. There is nothing in Georgia that comes close to comparing to the incredible facility in Pensacola as well as the doctors there.This comprehensive facility that we are trying to bring to Alpharetta will not only be better than the one in Pensacola, but will also bring all of the very best doctors.I've been a competitor my entire life, and because of that, I have always pushed my body to the brink. Frankly, there have been no doctors in this state that are experienced enough or whom I trust enough to ever handle any of my orthopedic needs.Unfortunately,I'm not alone in that thinking either. I have many former teammates who are still playing and fully agree with me. Due to reasons that aren't relevant to this letter,they feel uncomfortable writing a letter to you while they are still playing. However, I can tell you that not only did I put miles on my car to drive all the way to Florida,but so have many of my friends and teammates.Once again,my teammates wanted the best doctors at the best facility,and that was not located in Georgia. One of the hot topics in sports today is concussions.A good friend of mine who is still playing in the NFL spent 3 days this past offseason in Utah at a facility that specializes in concussions. lie has 4 kids,and it was paramount to him to make sure his brain was in great condition.After he received his report,which contained good news,he was excited to get back to football to continue making a living for his family.After listening to his testimony about this experience,I am currently in the process of setting up an appointment to fly out there and go through the same experience. flow awesome would it be to have something similar to this right here in Atlanta for athletes of all ages to be able to use,and also,for their parents to be able to see tangibly how their sons and daughters brains are doing after a concussion.Once again,there is nothing in the state of Georgia that offers this experience,and we want to change that. Lastly,one of my favorite things about this new comprehensive facility is that no child will he turned away due to lack of insurance.My family hit some rough financial times when I was in high school,and I was never sure when I had insurance.That's a scary thing for any person much less a high school athlete playing a sport where you are bound to get hurt. It would have put my parents and myself at ease knowing that I would still be taken care of even without insurance. I don't believe any of us can truly see the incredible impact that this new comprehensive facility wit!have not only on the state of Georgia,but the entireUnitedstatesandworld. Professional athletes need a place that they trust to takerareoftheirbodies.Kids need a place that they trust to take care of their bodies. 2853 Parents need a place that they can trust to take care of their kids,with or without Insurance.The team that is being assembled with this facility is ready to make an impact on the state of Georgia and change lives for the better. Sincerely, fhaei.}? Mi l Palmer 2864 Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street 5'`^Floor Atlanta,GA 30303 Dear Ms. King, I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrewsworld renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building for physician's offices,surgery, rehabilitation and physical therapy,diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional sports and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support for the ASMC,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. J ''p~L.~ Print Name y_ e Signature Date Tea nun/veouy/*ssooationaffiUatkzn Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street 5th Floor Atlanta,GA 30303 Dear Ms.King, I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building for physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional sports and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support for the ASMC,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. 6-'r G C k y__„ 7 PO Signat .Pdip Date i r,, ii Ani, L e IG (11t4b Team/University/Association affiliation 2856 Moldovan, Victor L. From: Gina Lee<ginalee4@yahoo.com> Sent: Tuesday,August 11,2015 5:39 PM To: Moldovan,Victor L. Cc: Jerry Brown Subject: Fwd: Letter of Support Dear Ms King, I'm writing this letter in support of the Atlanta sports medicine facility. I am sure that the information and statistics surrounding the job opportunities and amount of money exc.,that a facility such as this one,can and will bring in and offer to the city and its residents is amazing and has been addressed in other letters. So, I am writing this letter in support ofthe life enhancing and life changing services at this facility will offer to the wounded athletes and their families. I have had the pleasure of working with the founder and organizer,Gina Lee,for a number of years now and have been very impressed with her vision and fortitude in seeing this facility become a reality. After many years of working with Dr Andrews and helping take injured athletes through the rehabilitation process after surgery she has seen,the type and quality of care that is necessary to return these athletes to their sport,both healthy, and fit to rejoin their teams. A feat that at times, is nothing short of amazing. It is because of her respect for Dr.Andrews and her concern for the health and recovery ofthese athletes that she has developed and championed this vision of a facility to cover all facets of the care,education and recovery of all athletes. And I can't think of any two people,working as a team,who are better suited to take on this project. As a life coach, I have had the opportunity to work with people in the entertainment and athletic professions and I have seen first hand,the effects a major injury has on their self image and self esteem. If not dealt with,it could lead to doubt and fear and eventually be the very thing that takes them away from what they love the most. Gina has envisioned a facility that will not only care for the "injuries",but also offering them counseling,education on how to prevent future injuries,digital monitoring to map the progression of their healing,and including her exclusive aquatic therapy protocols,while making space for both of Baseball and Football camp facility. This facility is to also include a Concussion injury and Research Center as well as Youth Prevention education outreach programs. I do realize that there are many hospitals in the Atlanta area that will be more than happy to attempt to stop this facility from becoming a reality, and I'm sure that they can and will argue that it is a direct competition to their facilities.But, I know that although they each offer similar Surgical and Rehabilitation treatments,there are none that can,do,and will offer such complex and comprehensive treatment of the injured athlete as will this facility. 1 2857 It is because of this combination of care and Rehab of both the injury and the athlete,that this facility can,and I have no doubt will,be the first to open their doors in the Atlanta area, as a top quality world-renowned,comprehensive care facility for the injured athlete.And I do hope that you will see your way to joining them in making this vision a reality. Thank you for your time, Susan Clay No matter how dark the night,the day will break. 2 2858 Moldovan, Victor L. From: Gina Lee<ginalee4@yahoo.com> Sent: Tuesday,August 11, 2015 5:42 PM To: Moldovan,Victor L. Cc: Jerry Brown Subject: Fwd: support letter Ms King, Thank you for your time in reviewing my letter today. I've been a small business owner for the past 13 year and specialize in athletic performance training(strength&conditioning/speed training&injury prevention training). We work with youth athletes 11 yrs of age to athletes at the professional level. My initial vision for my business was to model ourselves after some of the best performance and injury prevention training methods that exist and deliver superior customer service to our clients. I'm proud to say that my company name, Rapid Sports Performance, has become a trusted brand in the Atlanta baseball market. I believe this is largely due to a balanced blend of relationships building customer service,and a passion for delivering excellent training that progresses year to year. Our reputation has given us the opportunity to work with over 50 professional baseball players, hundreds of collegiate level players,and each year a few hundred athletes at the middle&high school level. As you are aware, playing sports also means dealing with injuries. Having trained as many athletes as we have over the years also resulting in having worked with our fair share of athletes that get injured during the season or have completed rehab and need to get back to"playing shape". In order to make the "return to sport"training effective, it is important for the trainer to interact with the athlete's physical therapist so that everyone is"on the same page"with training needs,intensity&frequency. Having interactions with many of Atlanta's orthopedic groups and physical therapy clinics, I really got to learn and understand the landscape when it comes to how an athletes moves through the system(from surgery to getting back on the field of play). It's very unfortunate,but what I find is that in order for athletes to get high quality care,athletes are having to travel all around the metro Atlanta area and depending on what type of surgery is involved,it may even mean having to go out of state. The athletic population including coaches,parents,&athletes are becoming aware that not all doctors, therapists or trainers are created equal(no matter how sports oriented they say they are). Specialization is extremely important along with a quality reputation,and in my experience,in order to receive the level of quality most look for, athletes are willing to travel to make it happen. This project that is under review,would be a huge asset to Atlanta as a whole. A center of excellence where athletes would be cared for in a team environment from start to finish,is a concept that only most dream about. I've listened to CEO's and Directors speaking of such a concept in Atlanta for over 5 years now,but it's still yet to come together. The research,education,and the high level services offered will raise the bar and will only force other sports medicine groups to become better at their craft. In my opinion,the Atlanta sports medicine population as a whole will elevate their game and athletes from all over the metro Atlanta area will benefit from this. I'm extremely passionate about helping youth athletics and providing the best possible service for them. Having Dr Andrews in the Atlanta areas,along with a team of specialized therapists and trainers is what athletes deserve. My dream is to be part of such team. With the number of athletes in the United States alone,a facility of this magnitude will not only better serve the athlete,but will help raise the standard within the sports medicine world. I appreciate your time and consideration,Mike Berenger 1 2859 245 TownPark Drive,Suite 575 Kennesaw,GA 30144 July 8,2015 Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street 5th Floor Atlanta,GA 30303 Dear Ms.King, I am writing to express my support for the ASMC,JLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part ofa state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building for physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional sports and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support for the ASMC,LLC application in helping to bring this unique facility focused on providing first class comprehensive services to Georgia. Sincerely, Andrew Ms- yior President 2860 Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street St°Floor Atlanta,GA 30303 Dear Ms.King, i am writing to express my support for the ASMC,tic Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part ofa state-of-the-art comprehensive sports medicine center being developed in association with Dr.lames Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building for physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, sports performance center,including various specialty sport academies and athleticfields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatmentof patients as well as economic development in term ofinvestment and jobs creation and attract athletes nationally and internationally to this center ofexcellence.Atlanta has long been recognized as a major sports centerfor both amateur,collegiate and professional sports and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support for the ASMC,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. Print Name ZINS J Signatur Ava,0 J;' ? ( Q- Team(University/Assjciation affiliation fdeipit 2861 APPENDIX I-4 2862 1STFLOOR GMOGVIVU'l”ASC 20,000 SFRAPIDSPORTSMAGNMSTICS20,000 SFUNPEJtARMOURor..." ,•• PRES THERAPY 10,000SF PHARMACY TAROSP ACIVATICSICNN** sPoirrs pyrei UFECOACH • - -Mr FLOOR/3RD FLOOR1-..;.:.---.--,."••7 -.: ...___- ;-',.. . ....„--,,-1:,.. -TRIUMVIR IIIINANCEMENT . .„,,,c*i' -. . • 4.. „,, '.. 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SPORTS TECHNOLOGY 0 •*, „•,•7., 4t,. . 1\ .SPORTSEQUIPMENTEtrLABORATORY Y/ 41D ' 4 *. ..--., t‘-- T- ci) --- ,.... ---., ,.,,,, • le 0 ............ 1- -___--_- ,------ 001Y --------_---- 1.- --------- -----'___------ ool!ll------- visSTOKES ASMC 1101611. 111•CA•6 ALPHARETTA,GEORGIA SITE PLAN 2863 APPENDIX N-8 2864 ORGANIZATIONS TO BE ASSOCIATED WITH AT ASMC,LLC.: NFL(NATIONAL FOOTBALL LEAGUE) NHL(NATIONAL HOCKEY LEAGUE) MLB(MAJOR LEAGUE BASEBALL) CFL(CANADIAN FOOTBALL LEAGUE) NBA(NATIONAL BASKETBALL LEAGUE) WNBA(WOMEN'S BASKETBALL LEAGUE) WWE(WORLD WRESTLING FEDERATION) MLS(MAJOR LEAGUE SOCCER) OLYMPIC SPORTS AND COMMITTEE PGA(PROFESSIONAL GOLF ASSOSIATION) LPGA(LADIES PROFESSIONAL GOLF ASSOCIATION) USGA(UNITED STATES GOLF ASSOCIATION) USA FIELD HOCKEY MLB PLAYERS UNION NFL PLAYERS UNION NHL PLAYERS UNION NBA PLAYERS UNION USA BASEBALL ASSOCIATION INTERNATIONAL BASEBALL ASSOCIATION WORLD BASEBALL CLASSIC NATIONAL PITCHING ASSOCIATION MLB ALUMNI ASSOCIATION 2865 NFL ALUMNI ASSOCIATION NBA ALUMNI ASSOCIATION NHL ALUMNI ASSOCIATION US LACROSSE PERFECT GAME GEORGIA HIGH SCHOOL DUGOUT CLUB EAST COBB BASEBALL AMERICAN RUNNING ASSOCIATION METRO ATLANTA YOUTH LACROSSE ASSOCIATION ATLANTA BOX LACROSSE ASSOCIATION NCA(NATIONAL CHEERLEADER ASSOCIATION) NDA(NATIONAL DANCE ASSOCIATION) AAHPERD(AMERICAN ALLIANCE FOR HEALTH,PHYSICAL ED,RECREATION,AND DANCE NFHCA(NATIONAL FIELD HOCKEY COACHES ASSOCIATION) USTA(UNITED STATES TENNIS ASSOCIATION) AJGA(AMERICAN JUNIOR GOLF ASSOCIATION) USSA(US SKI AND SNOWBOARD ASSOCIATON) US YOUTH SOCCER NSA(NATIONAL SOFTBALL ASSOCIATION) USFA-(UNITED STATES FASTPITCH ASSOCIATION) USSSA(UNITED STATES SPECIALTY SPORTS ASSOCIATION) USA SOFTBALL USA BASEBALL FASA(FASTPITCH AMERICA SOFTBALL ASSOCIATION) 2866 SOFTBALL PLAYERS ASSOCIATION USA SWIMMING AMATEUR SWIMMING ASSOCIATION ATA(AMERICAN TENNIS ASSOCIATION) USA VOLLEYBALL USA WRESTLING BASEBALL FACTORY GEORGIA HIGH SCHOOL ATHLETIC ASSOCIATION NATA(NATIONAL ATHLETIC TRAINERS ASSOCIATION) SPORTS PHYSICAL THERAPY SECTION OF APTA APTA(AMERICAN PHYSICAL THERAPY ASSOCIATION) AAOS(AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS AMERICAN MEDICA(.SOCIETY OF SPORTS MEDICINE PFATS(PROFESSIONAL FOOTBALL ATHLETIC TRAINERS SOCIETY) PHATS(PROFESSIONAL HOCKEY ATHLETIC TRAINERS SOCIETY) PBATS(PROFESSIONAL BASEBALL ATHLETIC TRAINERS SOCIETY) NBATA(NATIONAL BASKETBALL ATHLETIC TRAINERS ASSOCIATION) THE AMERICAN ORTHOPAEDIC SOCIETY ASMI(AMERICAN SORTS MEDICINE INSTITUTE) AMERICAN COLLEGE OF SPORTS MEDICINE AMERICAN MEDIC*ASSOCIATION AMERICAN SHOULDER AND ELBOW SURGEONS ARTHRITS FOUNDATION OF GEORGIA GEORGIA MEDICAL ASSOCIATION 2867 Hundreds of ex-NFL players call Georgia home-Atlanta Business Chronicle Page 1 of 3 From the Atlanta Business Chronicle http://www.biziournals.com/atlanta/print-edition/2015J07/03/hundreds-of- ex-nfl-olavers-call-georgia-home.html Why hundreds of former NFL players call Georgia home SUBSCRIBER CONTENT: Jul 3, 2015, 6:00am EDT Phil W. Hudson Staff Writer- Atlanta Business Chronicle Email I Twitter Linkedln Facebook While the Atlanta Falcons are the only National Football League team that calls Georgia home, nearly 750 former professional football players representing all 32 NFL teams have also set up camp in the Peach State— making Georgia home to more former NFL players per capita than any other state. Many players settle down in Atlanta because they played in one of the region's powerhouse college conferences and wanted to live in a large city like Atlanta after their playing days came to an end. Some notable former NFL players that call Georgia home include: Shannon Sharpe (Broncos and Ravens), Herschel Walker (Cowboys, Vikings, Eagles and Giants), Jamal Anderson Falcons), Bill Fralic (Falcons and Lions), Chris Doleman (Vikings, Falcons and 49ers), Matt Stinchcomb (Raiders and Buccaneers) and Lucius Sanford (Bills and Browns). See Also The 100 Most Influential Atlantans of 2014 (SLIDESHOW) What's the most popular NFL iersey in Georgia? Depends on your gender Washington sees push to stop NFL"Patriotism for.Profit" practices Another is Fran Tarkenton, the legendary quarterback for The University of Georgia, a Pro Football Hall of Famer and CEO of the Tarkenton Cos. and Tarkenton.org. Tarkenton was born in Virginia but moved to Athens, Ga., when he was 10 years old. Scramblin' Fran"was drafted by the Minnesota Vikings in the third round of the 1961 NFL Draft and was traded to the New York Giants in 1967. Then, in 1972 he was traded back to Minnesota for three players plus first- and second-round draft choices. http://www.bizj ournals.com/atlanta/print-edition/2015107/03/hundreds-of-ex-nfl-players-ca... 7/3:!xB015 Hundreds of ex-NFL players call Georgia home-Atlanta Business Chronicle Page 2 of 3 After his football career came to an end, Tarkenton worked as a salesman in Minneapolis, but decided to move to Atlanta and make it home for two reasons: it's a good business town and the weather. I stayed two years in Minneapolis and that's where my future could have been very bright in business, but I moved down here because I couldn't stand the winters up there," he said. I worked in the off-season down here [Atlanta) for The Coca-Cola Co. and learned a lot, but I made a decision that I didn't want to work for a big company. I wanted to work for myself and Atlanta is a wonderful city to do just that" Georgia Rep. Dewey McClain, D-Lawrenceville, who is originally from Oklahoma and played college football at East Central State University, signed with the Atlanta Falcons as a free agent, and played for the team as a linebacker from 1976 until 1980. He then played for the United States Football League's Oakland Invaders and Oklahoma Outlaws, before making Atlanta his home. When I retired from the USFL in 1985, I stayed in Georgia mainly because of the weather," McClain said. "I love the weather. My kids went to The University of Georgia. I spent 21 years in Oklahoma and have now spent 41 years in Georgia, so I guess I can say I'm a Georgian." McClain is a founding member and past president of the Atlanta Chapter of the National Football League Players Association and current member of the board of directors of the players association. He attributes Georgia's high number of former NFL players to the state's nice weather, golf courses and the opportunities the state offers former players. There are hundreds of celebrity golf tournaments in Georgia every year because Georgia is home to so many great charities,"McClain said. "Aside from contributing to the community, we (former football players) know we wouldn't get the opportunity to play these courses if it was not for our celebrity status, so that's another reason why so many former NFL players live here." Another NFL player who has earned celebrity status is Atlanta native Jamal Lewis. He was drafted by the Baltimore Ravens fifth overall in the 2000 NFL Draft and helped the team win Super Bowl )OOCV during his rookie season. Lewis is the NFL's No. 3 all-time single season rusher, edging out Barry Sanders but trailing Eric Dickerson and Adrian Peterson. Lewis said he made Atlanta home because of its business climate. There are more business opportunities and Atlanta is growing,"Lewis said. "A lot of my resources are here and when I was done playing in 2009-2010, I saw where the city was going and liked its entrepreneurial spirit." Lewis is senior vice president of business development for the exhibit company Metro Exhibits and co-founder and president of the software company Think Jineus. He said Atlanta's diverse business scene is one of the reasons he stayed. http://www.bizj ournals.com/atlanta/print-edition/2015/07/03/hundreds-of-ex-nfl-players-ca... 7/280015 Hundreds of ex-NFL players call Georgia home-Atlanta Business Chronicle Page 3 of3 Atlanta is one of the top trade show cities in the nation and with the technology growth in the city, it's a natural fit for me to stay in Atlanta because so many VC firms and tech companies are moving here from the West." Lewis added that, for former NFL players and other former professional athletes, Atlanta is a great city to continue to network. There are a ton of athletes that move to Atlanta because of the weather and being able to fly anywhere in the world because of Hartsfield[-Jackson Atlanta International] Airport," he said. "It's great city for athletes to expand their business networks. Another former Falcon who calls Atlanta home is Buddy Curry, who was born in North Carolina, grew up in Virginia, and played football for the University of North Carolina. He was a second-round pick in the 1980 NFL draft by the Falcons, selected as the 1980 NFL Defensive Rookie of the Year and was an All-Pro selection in 1980 and 1982. When I finished playing for the Falcons in 1987, I moved my family back up to North Carolina and had a career in business,"Curry said. "We moved back down to Atlanta in 2001 because there was a business opportunity. Atlanta offers an abundance of business and entrepreneurial opportunities that I wanted to take advantage of. In addition to that, the school system, especially the one in Gwinnett County where my kids go to Buford, is a good school system." In 2002, Curry founded Kids & Pros, a non-profit youth sports organization,with the help of his former Falcons teammate, Bobby Butler. Living in Atlanta allows me to connect with people I played with,"Curry said. "Now, with what I do with Kids & Pros, it's great to be here because there are so many NFL players to choose from and we have a core group of guys that help us with our camps and clinics. I couldn't imagine a better place to live for my business and family." Phil W. Hudson is a finance, music and sports reporter. Click here to follow him on Twitter and here to follow him on Facebook. http://www.bizjournals.com/atlanta/print-edition/2015/07/03/hundreds-of-ex-nfl-players-ca... 7/2072015 Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street 5th Floor Atlanta,GA 30303 Dear Ms.King, Let me begin by giving you a brief history of myself. I am in year 21 of high school teaching and coaching in the state of Georgia. Over my 21 years of being a part of high school athletics,I have seen many young men and women have their high school and collegiate career be put on hold do to surgeries due to injuries that occurred while participating or training for their particular sport. These times can be very stressful for the athletes,parents and even the coaches. So many questions go through the parent and athletes minds leading up to surgery. Questions like is surgery the best option,is the best doctor for the procedure,and how long will the recovery process take. These doubts and concerns are very common among parents Who little understanding of the medical field and the doctors in their specific fields. I do know that Dr.James Andrews is a name that is well known across our country and even parents with tittle knowledge in the field of orthopedic surgery our aware of the trust our professional athletes have in Dr.lames Andrews. I am writing to express my support for the ASMC, LLC Certificate of Need application for a planned outpatient surgery center in Aipharetta,GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office building for physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging,sports performance center, including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally to this center of excellence.Atlanta has long been recognized as a major sports center for both amateur,collegiate and professional sports and this facility will become a destination location for treatment, education and research in the field of sports medicine. I respectfully request your support for the ASMC, LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. Tim Barron m- Si#natun, Date Heard County High School Head Football Coach d wips;gn 00111 Rew Explaining Dr. James Andrews, the brand By Eric Sollenberger0q,)ESollenberger on Sep 15,2013, 10:04a 2 i""4-. ..-,..rE-:.. . Irk,- , Nk\ s8,4, -- T.,,, • s.:,10,%-`- _..,0 - , . 11:- ,',- --., tf s L..... t.rret .:. '-'`'' ' —4 1.A 144:,-; e i e , 1 4-, --y,„ „,,r, ,-,,,,t„'-,:inir:,...... • v 44.40.404:*-10' 1.-, .,,,,,,,ki :dr_ , ii, i . ,. IiID1.1)17.:-.. , A 1,4, Afr c, / iits41,1 : D E w1L., I N.i ,., 11/4, -4,„ 41L',„)....:-,,,? 4,0‘,_ . t ,'' . .1,,V/1.-.4.. ..,. uJ ,,,,,iN I \,. 4... -.,,, #4•., l'..,- ' 7' .," w.: -, vi !r 1. * ,,,,.....:- .,,ri-...,•!,:,,,,v.A:1 Ie. _ 74. f ..5. ' - . -., '• N.J44,;-,7,e,th, .:..,..,_ e."1 img src="https://cdnl.vox- cdn.cotn/thumbor/41fe5qfTgAKUidg7dzpX88s1IDY=/11x0:339x219/730x487/cdnO.vox- cdn.com/uploads/chorusimage/image/19419167/thjames.O.jpg" alt=""/> Dr. James Andrews is only doctor whose name appears as frequently on ESPN's bottom line as the stars that he treats. How did he get there, and more importantly, does he take walk-ins? LlTweetShare on Twitter(9)0ShareShare on Facebook(21)0PinPinterest2 Comments Team physicians used to be in every professional training room in America. These doctors were beholden to the head coaches and owners in leagues that minimized the control a player might have over the direction ofhis own career. Rarely, ifever, was there a call for a second opinion. NFL Week 2 injury report 2872 A i 'I lit' . w K I.v. ( it r 3 f4 f% s r . 16 r i fit` k t , s ; I / fes. {J{W stn. .. 1. i t4 yy,ye ppy dr. t 0140. It: - 0., ,...-.,7__ 1 r Wet'RdS9 ACa'"lv .. r fi 4.w yf Y.N si '.y..1T^'.. .n. .,,,,..,-kW v t Larry Fitzgerald is questionable for Week 2, Vick Ballard was placed on injured reserve,plus other injury news likely to impact this week's games. In 1985,a young pitcher named Roger Clemens was starting to second-guess the team's diagnosis of a shoulder injury that was causing him a lot ofpain and knocking a few miles per hour offof his fastball.Despite reassurances from the club that he could pitch through it, Clemens'agent sent him down to see Dr. James Andrews,an accomplished doctor specializing in minimally invasive arthroscopic surgery. Scoping was just beginning to catch on and Dr. Andrews was at the forefront of the movement.He diagnosed Clemens with a tear ofthe labrum and performed the surgery himself.Eight months later Clemens was striking out 20 players in a game. Clemens repaid him tenfold by becoming a walking business card for Andrews'practice. Word of mouth started to build. Andrews gained a reputation as a player's doctor who they could trust for an athlete-centric diagnosis instead of a team physician. Stars like Bo Jackson,Michael Jordan,Jack Nicklaus,John Smoltz, Brett Favre and Adrian Peterson have all sung his praises in the 28 years since Clemens. James Andrews,MDTm the brand is a product of mistrust in team doctors and trainers as much as anything else. 2873 Approximately 40%of his surgery clients are high-level athletes. He operates on the most unique parts of the most unique athletes in the world. These are people whose shoulders, knees, ankles and elbows allow them to run faster,jump higher, throw harder and make more money playing sports than any human that has ever lived at any point in the history of the world. I dislocated-my shoulder playing rec-league kickball and I wanted him to take a look. More accurately, I wanted to find out if he would even visit with me or give me the time of day. The answer was yes, if I could wait. The biggest name in sports medicine would be available to perform my shoulder surgery, but the earliest he could schedule an examination was November. Mark Sanchez gets to cut to the front of the line like it's a prom picture. If you have good insurance, it's not even that costly to have him personally reattach your labrum that you frayed diving head-first into third base while drunk.According to my carrier, my surgery would max out at a$500 copay and an MRI would be an additional $250. I'm not saying the stakes are as high as Drew Brees'$100 million contract,but ifwe win another championship we get elevated into the "social"division which appears higher-up on the standings portion of the league website. It's not like we're talking chump change. Am I going to travel to Birmingham in November for an appointment and next-day surgery? Probably not. Repairing a mild torn labrum can be done just as effectively by most competent orthopedic surgeons specializing in sports medicine. But now that the surgery has become commonplace, why do athletes still make the trip across the country to see him?Does James Andrews have the Midas touch?Is he really head and shoulders above the rest?Granted,the consequences of my injury are absolutely nothing compared to someone who makes a living in professional sports,but I was curious about the name. Did he have better equipment or steadier hands? I spoke with one orthopedic surgeon who practiced alongside Andrews. The former colleague had great things to say about him,but acknowledged that the media coverage is unprecedented for a doctor, with the implication being that any other specialist is now second-rate to Andrews. It's as much a PR move for a team to send their star player to Jim as it is a medical move. You won't find a case of an athlete with a reported injury being sent to Andrews without the doctor's name specifically being mentioned to the journalists covering it. The Chris Mortensens and Ed Werders of the world have in turn begun to use Dr. Andrews'name in their reports as a red flag for a potentially serious injury, which serves to further the brand Dr.James AndrewsTM Exhibit 1-A is Dan Snyder and the Washington Redskins. Snyder's the type of guy who would buy Jimi Hendrix's white Stratocaster if he wanted to teach himself his wife's favorite song for their anniversary. It's no surprise Snyder has Andrews evaluating high ankle sprains on Sundays. He would take his cat to get neutered at the Andrews Institute. Sending an athlete to Dr. Andrews does two things ifyou're an owner: It gives you a selling point to free agents that you care about your athletes. It gives athletes peace of mind when they're hurt that they're dealing with a competent physician who has a history of thinking about the player first ... and the team second. The landscape in sports has changed quite a bit since 1985. Ownership has come around to providing their most valuable players with top-tier medical service. 2874 I have no experience in any type ofmedical field beyond reading a lot about sports medicine and having my shoulder recently examined by a former colleague of Dr.Andrews. As far as I know, he's a leader in the community with a great reputation,a trusted commodity and a brand name that professional athletes and GMs are drawn to. Going to him for common surgeries might be overkill, but when you're an executive in a league that revolves around branding and protecting The Shield,a wall full of degrees from Johns Hopkins means less than Dr. James AndrewsTM 2875 Dr. James Andrews: The Athletes' Surgeon By Bleacher Report,Analyst Apr 18,2009 Share Tweet Next ARTICLE » Use your 4-- (arrow)keys to browse more stories Photo by Jim Mclsaac/Getty Images) 1.8K Reads 2 COMMENTS You crouch behind the quarterback, waiting for the snap. He calls for the ball and turns and hands it to you, it presses into your hands and you run forward into the pile of players and you go down, someone lands on your leg, someone on your knee,the pain is terrible,will it ever stop? 2876 You lie on the field,the rest of the players get up,but you stay on the ground,your team's trainers run out onto the field and soon, you find yourselfriding off of the field on a cart and your replacement comes running onto the field. In your mind,you know that something is wrong, although you don't know what. Your knee feels horrible,Iike some one is pounding on it with a sledgehammer. Will you ever be able to play again? Many NFL players,as well as other athletes,turn to Dr. James Andrews, an orthopedic surgery in Alabama,when they suffer injuries on and off of the field. Andrew has operated on such notables as Peyton and Eli Manning(above), Reggie Bush,Drew Brees, Barry Zito,Roger Clemens,Andy Pettitte, Michael Jordan, Shaquille O'Neal,Allen Iverson,and just this week, Andrew performed surgery on New Orleans Saints'wide receiver Lance Moore after Moore injured his left shoulder while lifting weights. Andrews was an athlete himself,the Louisiana native won an SEC conference championship in polevaulting at LSU in his college days. In 1996,Andrews, along with Larry Lemak,his partner, opened Alabama Sports Medicine and Orthopedic Center in Birmingham,where he practiced until 2005,when he moved to St. Vincents Hospital and formed Andrews Sports Medicine and Orthopedic Center. It is said that every athletic trainer,physical therapist, strength-and-conditioning coach in the land seems to have Andrews'cell phone number. Many athletes have had success even after suffering horrible injuries. Take Drew Brees,the quarterback for the New Orleans Saints. While still with the San Diego Chargers,Brees was trying to prove that he,even though he was short, could be the quarterback ofthe future for the Chargers. He was hit on the goal line on New Years Day in 2005 in a game against the Denver Broncos and fumbled the ball. As he dove to recover the fumble,other players who were also going for the ball,landed on Brees'right shoulder. With the drafting of Phillip Rivers,Brees was done with the Chargers and after having his shoulder fixed by Andrews, signed the next year with the New Orleans Saints. Brees then preceded to lead the Black and Gold to the NFC Championship game. Since opening the 2006 preseason for the Saints against the Tennessee Titans,Brees has never missed a game— regular season or preseason. In fact, Brees was a candidate for the NFL's MVP award in 2008 after becoming only the second player to throw for over 5,000 yards in one season,finishing only 16 yards behind Dan Marino's single season yardage record. 2877 Instead, Peyton Maiming,another of Dr. Andrews'patients,captured the award. It has been said that Dr. Andrews belongs in the Major League Baseball Hall of Fame because of his contributions to the sport,but it hasn't happened yet. As long as he can, Dr. Andrews will sit in Birmingham,Alabama, and quietly put athletes back together,one surgery at a time. Notable Patients Treated By Dr.James Andrews(courtesy of ESPN) Football players Bo Jackson: shoulder, 1984;hip, 1992 Doug Williams: knee, 1988 Bruce Smith:knees, 1990 and 1991 Troy Aikman:elbow and shoulder, 1991 Michael Irvin: shoulder, 1994 Emmitt Smith: shoulder, 1994 Trent Green: knee, 1999 and 2001 Chad Pennington: shoulder,2005 (twice) Deuce McAllister: knee,2005 Daunte Culpepper: knee,2005 and 2006 Takeo Spikes: achilles tendon,2005 Donovin Darius: ACL,2005; shoulder,2006 Drew Brees: shoulder,2006 Byron Leftwich: ankle,2006 Donovan McNabb: knee,2006 Matt Hasselbeck: shoulder,2007 Joey Porter: knee,2007 Kenny Irons:knee,2007 Isaiah Kacyvenski: knee,2007 D.J. Shockley:knee,2007 Baseball players Roger Clemens: 1985, shoulder, 1985 David Wells: 1985,elbow, 1985 Jimmy Key: elbow, 1988; shoulder, I994, 1995 Jose Rijo: elbow, 1995; five more elbow ops, 1996-2003 Steve Karsay: elbow, 1995; shoulder,2003 Kerry Wood: elbow, 1999 John Smoltz: elbow,2000 and 2003 Carl Pavano: elbow,2001 and 2006 Jon Lieber: elbow,2002 A.J.Burnett : elbow,2003 Andy Pettitte: elbow,2004 Gary Sheffield: shoulder,2004 Jim Thome: elbow,2005 2878 Mark Prior: shoulder, 2007 Anibal Sanchez: shoulder, 2007 Freddie Garcia: shoulder, 2007 Chris Ray: elbow,2007 Basketball players Charles Barkley: shoulder, 1990 Michael Jordan: shoulder(therapy,not surgery), 1994 Penny Hardaway: knee, 1996 Randy Livingston: knee, 1996 Scottie Pippen: elbow,2001 Allen Iverson: elbow,2001 Aaron McKie: shoulder,2001 Chris Webber:knee,2003 Shaun Livingston: knee,2007 Golfers Jack Nicklaus: knee, 1984 Jerry Pate: shoulders, 1985, 1986,2003,2006 Mark McCumber: shoulder, 1996 2879 ESPN.com - The doctor will save you now Page 1 of 10 l r1[PRINT] ESPN.com: ESPN Print without images] Tuesday,September 17, 2013 Updated:September 27, 1:02 PM ET The doctor will save you now By Scott Eden ESPN The Magazine This story appears in ESPN The Magazine's Sept. 30 Franchise Issue. Subscribe today! THE DOCTOR OPENS the door to Exam Room 2. Perched on the table is an 18-year-old male, flanked by nervous-looking parents. He wears shorts and a T-shirt and has a mop of tussled strawberry blond hair. He was once a phenom,albeit a local one. At 14,his fastballs went 80 miles an hour. Then one day, during a practice session just before the start of his freshman season in high school,he felt a bad twinge," "just kind ofa pop," and he hasn't taken the mound since.Now,he tells the doctor,he wants to try out for the baseball team at the college he'll attend in the fall,his goal a scholarship and then who knows. So he has traveled here with his parents,to the clinic of the celebrated orthopedist,to see if the doctor can heal whatever it is that ails that doubtful right shoulder--to see if the doctor can save his dream,which is why they all come to see Dr. James Andrews. "I don't want to let it go," the boy says. As Andrews likes to do whenever a mother is in the room,he addresses her. "Here's the big question for y'all,Mama," he says. "Ifhe decides he's just gonna go to skoo and be an engineer or whatever,you don't necessarily have to operate on this.Professional players we see when they're retirin',with even worse shoulders than his--we don't operate on'em." The doctor's distinctive Louisiana drawl has compelled at least one patient ofNorthern origin to nickname him Foghorn --as in Foghorn Leghorn,the Looney Tunes rooster. Over the decades,though, his accent has proved a highly useful clinical tool. Slow and informal,it soothes the frayed nerves of his patients. It carries along on its easeful waves the reliability and trustfulness of the old country doc ofAmericanlore. You close your eyes when you hear that drawl,you see the Norman Rockwell pictures. It distracts the listener from the core, uncomfortable truth--that when an athlete is listening to Dr. James Andrews,he's listening to his best last chance. THE DOCTOR OPENS the door to Exam Room 5. "Hey,Big Man! Whatchyou been doin'?" This is Charles Morgan, 32 years old, a 285-pound mixed martial artist from the outskirts ofNew Orleans. His triceps protrude like handles.He has a trapezius muscle that bulges from his shoulders like a linebacker's neck roll. He has come to see Andrews for the elbow he mangled during a bout last year(which he won). He didn't get it fixed then and still fought in a championship match just two days before(which he also won). "Two titles in six months with one arm,"he brags. The doctor again opens the door to Exam Room 2 -- another pitcher, 29,an eight-year veteran of the major leagues complaining of soreness in his throwing shoulder.The doctor sits down in a chair and crosses his legs,presenting for inspection a pair of tasseled cordovan alligator-skin loafers. A meticulous dresser,he wears today a glen plaid blazer in baby blue and a 2880 http://espn.go.com/espn/print?id=9669812 8/10/2015 ESPN.com -The doctor will save you now Page 2 of I 0 canary yellow necktie with little yachts on it. His hair is I white and soft-looking. He peers at the pitcher through F steel-rimmed spectacles. "Lemme tell you,the last thing a Avow you wanna do--in your category and your age group-- i is have your shoulder operated on," the doctor says. XSeeingyouforthefirsttime,a red flag goes up,but itfl I1$541 dudn't wave yet. Know what I mean?" He recommends 4 an injection of cortisone and 10 days of rest. fit_ Here at the Andrews Institute in Pensacola,Fla., Mondays are clinic days. It's late April,a month after " .- Vit, .. MLB's Opening Day,and that means a steady influx of 1'"‘e16. shoulders and elbows wounded by the repetitive hurling Neve dwson pick up the pheonmeaxim from his mentor: ofbaseballs.Today,no fewer than three pitchers present with damage to the ulnar collateral Iigaments in their elbows--the so-called Tommy John ligament,or UCL -- for which Andrews has become one of the world's two or three most-sought-after menders. Other sports are represented as well.A petite female Israeli high jumper with a torn ACL.A journeyman golfpro in his early 40s with early-onset arthritis ofthe shoulder.An Olympic-medalist-grade javelin thrower, female,who has come to America from across the Atlantic because,she says,the European orthopedic infrastructure remains short on throwing-injury expertise. She has torn her Tommy John. On Mondays,as on all days,it is hard to keep up with the doctor. He moves from room to room in elaborate,unpredictable patterns. He pops into one,talks to a patient for a bit,emerges,thinks,pops into another,disappears to field a call on his cellphone,comes back and stands quietly in a corner,thinking.He does a lot of thinking,and at such times he hates to be disturbed. "When I walk out of a room," he complains later, "I'm trying to figure out what's wrong with this patient--I'm trying to figure out: What should I do?--and people just destroy your whole thought process." Surgical fellows in coats and ties strive to stay by his side. Presently,Andrews is nowhere to be seen. One of the fellows looks around,then says: "To be honest with you,he disappears. Eighty percent of our energy is just trying to keep up with him."Then from somewhere offstage, Foghorn bellows, presumably into his iPhone: "Hey man! He's got a partial ligament injury that probably hasn't quite declared itself yet. Here's what we're gon'do..." Andrews'days,and often his nights,are punctuated by such calls. The contact list on his iPhone has surpassed 3,000 names,among them athletes,agents,trainers,other orthopedists,coaches, GMs, owners. Within a six-month span this year,the list of damaged and diminished players who trekked to one of Andrews'two clinics--the newer facility in Pensacola,the older and more established in Birmingham,Ala. --included Redskins QB Robert Griffin III;MLB pitchers Matt Harvey, Sean Burnett, Jonny Venters,Jake Westbrook and Joel Hanrahan,along with second baseman Scott Sizemore and slugging wunderkind Bryce Harper;NBA draftee Nerlens Noel, Celtics point guard Rajon Rondo and Pacers forward Danny Granger; and dozens of other athletes undisclosed by their agents or teams. When his phone rings, it is part of Andrews'ethic that he never doesn't pick up. Later this very week,Andrews will celebrate his 71st birthday.He has reached his fifth decade as a practicing physician. Since age 30,he has averaged perhaps 1,000 surgeries a year. A typical orthopedist will do 400.He has trained some 350 fellows,who have gone on to populate all levels ofthe sports medical establishment. He's the originator of a movement that has attempted to stem a widespread rise in overuse injuries among youth athletes. He has treated not only athletic royalty but actual royalty: For many years he served as chief orthopedist to the House of Saud. 2881 http://espn.go.com/espn/print?id=9669812 8/10/2015 ESPN.com -The doctor will save you now Page 3 of 10 All that toiling has made Andrews rich,with the Citation III in the hangar and the Ferrari 599 in the garage and the custom-made mahogany Hacker-Craft on the lift by the dock of his waterside Pensacola manse. But the long hours have taken their toll. Seven years ago,a heart attack almost killed him,and many who know him attribute that event at least partially to overwork.As a consequence,he has in fact slowed down.He sees probably half as many patients now as he did just before the heart attack and performs half the number of surgeries(down from 1,200 a year at his peak,he says). He is fully aware that he has reached "the twilight of my orthopedic career."And yet,and yet...he can't quite bringhimselftohanguphisinstruments.Not yet. OUTSIDE OF THE TV doctors Oz f..- and Gupta, A - r and maybe L.:: :4 - .,.,,t, t,.. ,- ,,,,,,, ,, 4., i...e 44 1thelatedi1 VSurgeon r. i ... , ,..-- General C. IR 1 - • 1111 E Koop, not I, k i i L.ItLii 1 ' ' V-7 ii:many Ai-f,i A, :k1 \1. , 1 - physicians z-za,, 4- , . ,....7„.. 4, I A rrihavebecome11--. - t t. • -, , , - - ,, household I1, t 441 'A. \t,1 'A.-1,,,, 4 I`names. If James 14 lif4' i !I,',00", 'it •Andrews d hasn't,he's 1/4 l'it '1 1:117.4 4 4`4' x:w. too come close. Andrews saves careers,but who will tell him when it's time to hang up the scalpel? His fame has been propelled,in part,by the rise of omnipresent sports media--along with the corresponding expansion of interest among fans in the ruptured anterior cruciate ligaments,dislocated patellas and medial meniscus tears oftheir sporting heroes. And,of course,there have been Andrews' many famous reconstructive triumphs across eras:the Roger Clemens shoulder,the John Smoltz elbow, the Drew Brees shoulder,the Adrian Peterson knee.But the fact remains that possibly dozens of U.S. orthopedic surgeons are as capable as Andrews of knitting up these sorts of injuries and sending healed players back out into the arena--and dozens, in fact, do. So how is it that Andrews has achieved status as the nation's pre-eminent savior of athletic careers? It might have something to do with the arc of his biography,which is as American as Twain. The humble origins: born in New Orleans,raised in rural Louisiana,in a hamlet called Homer. The grandfather with the grade-school education who became a cotton planter and also a kind of communal medicine man. The World War II veteran father who was a two-way college football lineman,the progenitor ofthe boy's other loves:baseball,football,basketball,track.The extreme dexterity that allowed him to become,at Louisiana State,the pole vault champion of the SEC(1963). The medical degree from LSU;the residency at Tulane;the apprenticeship under the master,Dr.Jack Hughston,of Columbus, Ga. Hughston,who died in 2004,is considered a father ofthe orthopedic subspecialty of sports medicine. For him,Andrews was more than a prized student;he was Hughston's"fair-haired child," as the elder 2882 http://espn.go.comkspn/print?id=9669812 8/10/2015 ESPN.com -The doctor will save you now Page 4 of 10 physician once called his protégé. Says Andrews, "He was like a father to me." Eventually the teacher made the student his partner. It was from Hughston,a bow-tie-wearing stickler of the old school,that Andrews learned to never not pick up the phone. At that time, in the 1960s and '70s,sports medicine was largely preoccupied with the traumas of football,which meant knees;Hughston was a knee specialist. Andrews became one too,but he also gravitated to the overuse injuries of baseball and golf,in which repeated movements wear down bodies over time,producing physical damage less obvious than the gridiron's weekly carnage.He had found his niche. He invited the players on the local minor league Columbus Astros to present with their problems at his office,the better to increase his pool of subjects and his knowledge. When the team ran into financial distress and faced a move to another city,Andrews bought the team with a colleague just so he could continue seeing pitchers and studying their injuries. (They paid$40,000 and sold it 10 years later for$1 million,Andrews says. "One of the best investments I ever made.")Several years later, when he struck out on his own and opened a clinic in Birmingham,he built a biometrics lab to film the throwing motions of pitchers and plumb the data for insights.The studies that eventually arose out of the lab helped popularize the pitch count. But it was the arthroscope,the fiber-optic device used to examine the interior of a joint--invented in Japan in 1919,popularized in the U.S. in the early 1970s--that made Andrews' career.It also helped drive him and Hughston apart. Inexplicable as it may seem today,Hughston renounced the technology, preferring traditional open surgery. At first,Andrews had to use the instrument virtually behind Hughston's back and had to learn how to work it from other surgeons, chiefly from Dr.Lanny Johnson, one of arthroscopy's pioneers, who developed many of the tools that ultimately transformed the scope from a simple visual device into a surgical one. For Andrews,all this turned out to be a piece of good fortune. Once arthroscopy showed a few initial successes,patients in droves began demanding the doctors who were the best and most experienced at using it. Among the first(if not the first)to scope an elbow,Andrews turned himself into one of those doctors. They say of great athletes that they make their own luck,and maybe so it goes with Andrews. "I can't take credit for lotta things; I've just been there at the right time,right place," he likes to say.False modesty,perhaps. But there is evidence:In early 1984,the team doctor of the Detroit Tigers, impressed by a speech Andrews gave at an orthopedic conference,asked the young surgeon to look at their shortstop, Alan Trammell,afflicted by tendinitis in the shoulder, once the season had concluded. The Tigers went on to win the World Series,Trammell was named MVP, and instead of going to Disney World,the new superstar went to see James Andrews.Also in the early '80s,Andrews examined a teenage multisport phenom from Bessemer,Ala.,and later became his personal orthopedist. When Bo Jackson tore up his hip less than a decade later,Andrews only assisted on the surgery,but the mediacarnivalsurroundingJackson's rehab(which Andrews'right-hand man,physical therapist Kevin Wilk, oversaw)served to amplify Andrews'reputation. In the summer of 1985, a second-year pitcher presented in Columbus complaining of severe shoulder pain. According to the pitcher,team doctors in Boston couldn't figure out what was wrong,so off to Andrews he went.A shoulder scope revealed that a fingernail-size piece of cartilage had loosened and was catching in the shoulder joint. With his arthroscopic instruments,Andrews shaved off the nub.ThenextApril, free of pain,Roger Clemens would strike out 20 Mariners in nine innings at Fenway, setting a major league record.By season's end,he would win the first of his seven Cy Youngs. Soon enough,players who came back from Andrews'treatments told still other players about this Southern doc with the drawl and the magic scope.The media caught wind.More injured players wanted to come. And as the success stories accumulated,he at some point became known as the world's foremost savior ofathletic careers. "He got to a stature where even his failures became successes," says 2883 http://espn.go.com/espn/print?id=9669812 8/10/2015 ESPN.com-The doctor will save you now Page 5 of 10 Dr. Champ Baker Jr.,who practiced with Andrews at the Hughston Clinic. "Ifplayers couldn't get back, they'd say,'Even Andrews couldn't fix me."' THERE ARE THOSE--rival orthopedists among them--who suggest that Andrews'outsize reputation stems to some degree from a talent for self-promotion.There are those who believe that Wilk, Andrews' longtime rehabilitation expert,has played a far larger role in Andrews' success than is appreciated outside the walls of the doctor's clinics.There are those who believe that Andrews has people who alert the media whenever a big-name patient presents at his clinics. (Lanier Johnson, executive director of Andrews'Birmingham clinic,who has also served as the doctor's PR man for more than 20 years,vehemently denies this. "I can assure you we have never ever called up the media to say, Hey, so-and-so has come to the office.")There are even those who question whether Andrews' brand has grown so large as to become a cult ofpersonality;those who wonder if it is,in fact,a good thing for a doctor to be the driving force behind the news cycle of Robert Griffin III. Jim Andrews has worked hard; I respect him. But he kind ofhas a PR machine," says the team physician for one NFL franchise. There are also those who would note that,for a man as famed as Andrews,criticism comes with the territory. "Sports medicine is a very competitive world," says Walt Lowe,a prominent Houston orthopedist. "I will tell you there's a lot ofjealousy in the sports medicine world,and there's a lot of jealousy surrounding Jimmy.Another surgeon once asked me,'Don't you mind being in Jimmy Andrews' shadow?'My reply was: 'What better place is there to be?When the time comes for him to retire or wind down,I just hope I'm one of the guys who has the ability to rise out of that shadow."' WHEN ANDREWS OPENS the door to Exam Room 4,he encounters a distressing sight.The patient is a repeat customer. For Andrews,repeat customers represent a form of defeat.Perhaps because of this- or perhaps in an effort to drown the doubt inside his head --Andrews enters the room with a burst of bravado. "This kid here's a survivor! See how big he is?Reminds me ofRoger Clemens,the way he's built. A young Roger Clemens." The survivor is a 24-year-old minor league pitcher.He wears black athletic shorts and a white T-shirt, both emblazoned,a little cruelly it turns out,with the batter-silhouette logo of Major League Baseball. Almost exactly three years ago,during his junior season in college,he came to Andrews,who clamped six anchors to his glenoid bone, sewed them to his labrum--the band of cartilage that rims the shoulder socket like the rubber seal on a Mason jar--and pulled the loose labrum tight to the socket: SLAP repair Superior Labrum,Anterior and Posterior).The surgery seemed to work. After college,he signed as a free agent with his hometown Orioles and pitched well enough in rookie ball in the Gulf Coast League last year that he was about to be promoted to the IronBirds of Aberdeen,Md. But then,two weeks before this visit,disaster struck. During an extended spring training game against the Twins,he took the mound for an inning of work. He wound up for his third pitch,he reached his release point,he released.In the exam room now,he describes the feeling as an explosion. "It felt like somebody shot me in the back of the shoulder."Not long after,the Orioles released him. He's covered in Pensacola by 2884 http://espn.go.com/espn/print?id=9669812 8/10/2015 ESPN.com -The doctor will save you now Page 6 of 10 workers'compensation. t. The previous two weeks have been "frustrating," the fk '' pitcher says. "You want to know what's going on so bad. You want to know if you can come back;you want to know if you're finished." a' r t The pitcher has come to Pensacola with his mother-- late middle age,steel-gray hair, large eyeglasses,vowel- heavy rt Baltimore accent.Andrews refers to her alternately as Mother and Mama. She sits in the examination room and notes that the week before his The way Andrews positions the elbow's ulnar nervelatestinjury,her son faced Orioles second baseman and --here,of a 28-year-old pitcher--is one of his former All-Star Brian Roberts. "Popped him up!" she signature moves during UCL surgery. says. "That's probably gonna be his claim to fame! Popped up Brian Roberts."Then she laughs awkwardly,and a little too loudly. Andrews performs a series of palpations and oblique rotations of the pitcher's malfunctioning limb. He rechecks the MRI.He tells the pitcher it looks as though he's retorn his labrum. "Something acute hashappened,"he says,and the only way to find out what is to scope his shoulder. The dialogue in the exam room then circles,at varying distances.around a central decision: Should the pitcher have this surgery?And if he does,what are the chances he'll be able to continue to strive for the majors?Should he attempt another comeback or finally just find another line of work? Don't ever go into anything saying,'Well,I'm not gonna ever play baseball again,'"Andrews says. "I understand where you're coming from,with as much as you've been through... " But realistically,a second scope is ... " Is hard," says Andrews, finishing the pitcher's sentence. "It's hard to get back into baseball. Because now you've been released,and teams are gonna hear about all this history of yours. What you might have to do is go play independent ball and maybe get picked up again--as long as you get your velocityback." Yeah,that's the thing," Mama says. Anyway.That's where y'all are." A lot of ifs," the survivor says. WHEN ANDREWS IS asked to give public talks,they often take the form ofmotivational speeches. He likes, for example,to discuss the keys to success,a word that gets refracted through the lens of his accent,emerging as"sussess." And if Andrews were to rank his keys to sussess--which of course he has--No. 1 would be "positivity." He has even quantified the concept.As he said in his outgoing speech as president of the American Orthopaedic Society for Sports Medicine in 2010, "Positive thoughts should have a 5-to-1 ratio,and preferably a 10-to-1 ratio,over negative thoughts." 2885 http://espn.go.com/espn/print?id=9669812 8/10/2015 ESPN.com - The doctor will save you now Page 7 of 10 And yet Andrews also likes to say: "The only results you ever remember are your bad ones. That's what you dwell on." And as long as there are such negative outcomes,Andrews will have what he calls his worry list. "This patient, that patient -- the ones who are struggling to recover." The list haunts him. Early on Monday mornings, the list will present itself to his mind and he will wake up suddenly, the various and distressful complaints of the players on the list crowding out all other thoughts. He will spend the rest of the day trying to reach "this patient" and "that patient" on the phone. Andrews, of course,will not reveal the names ofthe patients cloaked by the pronouns "this" and that." (A high-profile example might be former Cubs pitcher Mark Prior, who had his shoulder operated on by Andrews in 2007 but who never regained top-level form.)He will not go into detail on his most challenging cases. And he positively bristles when asked: Have you ever had an outcome that you feel put your reputation in jeopardy?There will be a long pause. He will stare at the questioner. He will say: "Not really. Not a good question. That's a negative question. So I don't answer those kinda questions." He will then, in a way, answer the question: "You know,everybody has to go back and mend fences. If you have a patient that you didn't get the operation done quite as well as you wanted to,then you gotta really shower'em with kindness and attention to try to get'em through it. Because there is room for error, and they can still recover. You have to work harder with rehab and spend a lotta time with'em, when you hadn't quite been able to fix'em as good as you want. And maybe it's not possible to fix'em as good as you want. Everybody's got to face failyahs during their career. You can't be scared of failyahs. Because that's what you build your whole career on,being able to get through the failyahs. ifyou think all you're gonna have are sussesses in medicine? Surely you are going to be disappointed." According to a search of the available public records since Andrews began his private practice,he has been named in only one malpractice lawsuit, a 1999 case by pitcher Jack McDowell against numerous doctors and hospitals, later dismissed. Given the prolific nature of Andrews'practice,it's a rather extraordinary fact. Still, a patient struggling to recover has a tendency to put Andrews, in his words, down in the dumps." But he has a remedy. He makes sure to ask each patient,post-op,to text him photos of the healing wounds, the improving ranges of motion. He searches now through the photos stored on his iPhone. It takes him several minutes to find the right one. When he does,he holds it up for view. It shows American decathlete Trey Hardee in the moments after he crossed the finish line in the 1,500 meters,the last event of his silver medal performance in the 2012 London Olympics. In the photo, Hardee is holding up his arm for the camera and, more specifically, for Andrews. Visible there on his forearm is the scar from the surgery the doctor performed nearly a year earlier--a Tommy John repair, crucial forjavelin tossing. Whenever Andrews is feeling low,he looks at this photo and is cheered. ON SURGERY DAYS --every Tuesday and Thursday,his game days--Andrews likes to tuck the trouser legs of his aquamarine scrubs into a pair of white shin-high Wellingtons. His masked attendants await him wordlessly,the lights blazing down. Just after he enters the operating room,a nurse stands behind Andrews and helps him into his long-sleeved outer-layer smock, like the valet of a duke. Andrews has prepared for this performance by sitting silently by himself in another room, thinking, visualizing, gathering himself into the zone.Now he sits down on a stool before his patient: a 19-year- old pitching prospect drafted a year earlier by the Blue Jays. One of Andrews' surgical fellows has already dissected the forearm. As is typical, Andrews arrives to execute only the toughest,most integral portion of the procedure before he moves on to the next OR to do the same. (He will perform eight surgeries on this day.) 2886 http://espn.go.com/espn/print?id=9669812 8/10/2015 ESPN.com - The doctor will save you now Page 8 of 10 This is somewhere around Andrews'4,000th Tommy John operation. (The doctor himself has lost track of the number.)The procedure involves harvesting a tendon from elsewhere in the body and using it as a graft. The graft is nestled into the remains ofthe damaged ligament, and the two are rolled up together, the cells of the tendon transmogrifying over time into the cells of a new UCL. No orthopedist other than its inventor, Dr. Frank Jobe himself, is as closely aligned with the Tommy John procedure as Andrews,mostly because of sheer volume. He has become its most practiced practitioner. But he has also made two important modifications to the original Jobe method. First,he moved the funny bone. The funny bone isn't a bone at all but a nerve (called the ulnar nerve) that runs from the vertebrae of the upper spine to the pinky finger, and that turns out to be white and thick and almost shocking in its nonorganic resemblance to an iPhone cord. It also runs straight across the UCL. In all Tommy Johns, the surgeon must move this nerve out of the way so he can engage unimpeded in the main surgical action. But instead of putting it back in its natural position, Andrews essentially leaves it where it is when he's finished. Thus, according to Andrews,the repositioned nerve makes it less likely these patients will aggravate their elbows--or have the pleasure of feeling that weird funny-bone-bonk sensation again. Second, to access the damaged elbow ligament,Andrews doesn't detach the muscle mass in the forearm that blocks it. Rather, he figured out how to get at the ligament by sticking his instruments underneath the muscle. The resulting procedure is less invasive. In Andrews' hand now is an instrument that looks something like an awl but is actually called a curette. With it, he is boring tunnels into the bones that make up the elbow joint: the ulna and the humerus. He pushes hard with the curette-- disconcertingly hard. He leans into it. At one point, Andrews grunts. Through these tunnels he next begins to weave the graft tendon, a white strand of fibrous ribbon 16 or so centimeters long. From a distance, it could be a huge albino earthworm. Guide sutures attached to the tendon help Andrews pull its length through the tunnels. The sutures'threads gather in loose spider- webbing bunches at each end of the bone tunnels. The interior workings of the elbow are intricate.The surgery is essentially in miniature, and as Andrews sews his complex interlacings,needle holders in one hand, forceps in the other,his eyeglasses down at the tip of his nose, performing it seems akin to building boats inside bottles. As with certain highly specialized artistic or athletic acts--philharmonic- grade first violin, Cirque du Soleil—scale acrobatics--watching it makes one wonder how anyone could ever summon enough will across enough time to acquire the skill necessary to achieve mastery over the act. AT THE ANDREWS Institute in Pensacola,the operating rooms have windows. Four of them,each the size of storefronts, surround a central observation area. Family members are invited here for the money portion of each surgery,or when big decisions need to be made. Like now. Into the room comes Mama. Her son -- the survivor,the repeat customer,the young Roger Clemens-- is being scoped by the master. A cranelike device holds her unconscious son's right arm into the air at about a 60-degree angle, demonstrating his impressive wingspan. By the time Mama sits down on the bar stool in front of the window,Andrews has had a sufficient look around inside. His voice booms through the intercom. Better take his biceps off!" It emerges over the next few moments that what Andrews is referring to is the Curt Schilling procedure - the still-uncommon, still-controversial operation by which the biceps brachii muscle is snipped from its natural moorings at the shoulder socket, lifted out,then reattached to the arm bone farther down. It is typically used on aging civilians suffering from wear and tear to their biceps tendon,the tissue that connects the muscle to the cartilaginous rim of the shoulder socket--the labrum. Far less typically, it has been used on pitchers with stubborn labral tears,a la Schilling in 2008. The idea is that by relieving 2887 http://espn.go.com/espn/print?id=9669812 8/10/2015 ESPN.com - The doctor will save you now Page 9 of 10 the labrum of the weight of the biceps muscle, the labrum will be better able to heal. All of this remains contentious, more than a little experimental. But if all else has failed -- if, as with Mama's son, the pain returns after a previous labrum surgery -- it may be the only option, other than retiring from baseball. At least that's the current thinking of Dr.James Andrews,who is now standing in the operating room over Mama's unconscious son. He says to Mama through the intercom now: "If he wants to throw again, it would be better to take his biceps off, sew it into the bone down here. So it'll quit pullin'on all-a-this." Mama leans in toward the window. She needs to make a decision. She puts her face closer to the intercom's speaker: "Do the biceps. Do the biceps." ONE OF THE reasons Andrews was driven to leave the Hughston Clinic and start his own practice was that Hughston, like some medical Lear,refused to name a successor as he grew old and approached retirement age. Hughston did not like even to broach the notion that his career was coming to an end.When Andrews gave Hughston a hunting shotgun for his birthday one year, "he got mad at me!" Andrews says now with bemusement. The older physician took the gift as a kind of mischievous hint: You'll need this thing, old man,for all that quail hunting you'll be enjoying when you soon retire for good. Hughston also couldn't bring himself to cede much decision-making power to his young partners.I think I finally realized that Dr. Hughston wudn't ready to let me go to the next level," Andrews says now. "He wanted to control everything himself-- which was his privilege. He deserved it. But sooner or later, it's sorta like when you let an eagle fly, y'know?" In 1986 he set up his own shop 140 miles from Columbus in Birmingham,partly on the basis of the city's proximity to the major schools of the SEC. That also meant relocating his second wife,Jenelle, and his five children, ranging in age from newborn to 18. Hughston considered the move a betrayal -- "It was a devastation to him," says one former Hughston employee--and held it against his protégé for most ofthe rest of his life. Andrews has never quite gotten over it either. One of his keenest regrets, he says, is never having fully reconciled with his mentor. "1 guess both of us were too hardheaded to do it." The year Andrews opened his Birmingham clinic, Hughston turned 69. Andrews himself has now surpassed that mark by two years. Long ago, he promised himself he would do all he could to avoid treating his own retirement as Hughston did: hemming, delaying, avoiding,hawing. He once toldJohnson, "Don't ever let happen to me what happened to Dr. Hughston." He even went so far as to essentially bequeath his Birmingham practice in 2008 to two ofhis own young protégé partners: Dr. Lyle Cain and Dr. Jeff Dugas. But letting go, as Andrews has learned,is easier delayed than done. Consider the Sunday morning in January 2006, as he was looking into the mirror and tying his necktie, getting ready for church, when the infarction hit. In cardiologic circles, the event is known as "the widow maker." Mortality rates are upward of 90 percent.As it happened,though, a fortuitous series of events kept Mrs. Andrews from being made a widow--in particular,when Andrews arrived by ambulance at the hospital that Sunday, one of the state's best heart surgeons was by chance right there in the cath lab, basically scrubbed in and ready to go. "Probably more people have walked on the moon than have survived a left main occlusion," says Dr. John Richardson Jr., a Birmingham cardiologist who two months later would perform Andrews' quadruple bypass.Now consider that not long after the heart attack, still in the ICU, Andrews was somehow able to smuggle his cellphone into that strict no- cellphone zone and was fielding patient calls until Richardson,almost forcibly,had to take the device from him. Then consider that three days after the attack, Richardson opened the door of Andrews' hospital room to find the orthopedist standing on his bed -- the Foley catheter still up inside his bladder, his split gown failing to conceal all of his pale backside--as he examined from above the worn-out shoulder of aging Astros slugger Jeff Bagwell. 2888 http://espn.go.com/espn/print?id=9669812 8/10/2015 ESPN.com - The doctor will save you now Page 10 of 10 It's hard to retire," Andrews says. "I can understand Dr. Hughston now, not wantin' to give it up." IT IS LATE on a Friday afternoon, and Andrews is sitting in the VIP waiting room of his Birmingham clinic, inscribing copies of his recently released book,Any Given Monday, which details what he believes will be his most lasting professional Iegacy: his efforts to curtail overuse injuries in children who play sports. Stacks rise from a table, awaiting Andrews'Hancock, and as he works through them, he grows cryptic on the subject of his eventual withdrawal from the arena. "People always want to know: When you gonna retire?' Basically my thought process is you should never tell anybody when you're gon' retire. I may be planning on retirement next week, but I wouldn't tell you that." His eyes rise from the book he's signing. "I'm not, though,"he says. The consensus among his friends and colleagues is that Andrews will work right up to the bitter end. AsRichardsonsays, "I think if he could die right there in that operating room,that's what he'd want to do." Andrews himself doesn't quite put it like that. Instead,he enjoys deflecting questions about the end of his career with a riddle. "Another thing people always ask me: 'How many operations have you done?' And the answer to that is, more than I can count, but not enough to quit." How many would be enough to quit? "Who knows. I mean, when you start losing your technical drive and your ability in the operating room,you don't need somebody else to come tell you, 'Hey, it's time for you to quit.'That's what happens with a lotta doctors. Everybody around'em knows it's time for them to quit, but the doctor dudn't know. But the doctor should know. Athletes have a hard time figurin'that out too. I never met an athlete who didn't want two more years." Andrews finishes signing the last book when his phone rings. "Oh Lord, I ruined my day seein'that X- ray," he says into the phone. The person on the other end is a trainer for a major league club of perpetual hard luck. The subject of their conversation is a pitching prospect in the team's farm system who underwent Tommy John surgery more than a year ago. While the pitcher was throwing in a recent game, a piece of bone in his repaired elbow came loose. Andrews explains to the trainer that this is an exceedingly rare occurrence but that it does happen from time to time, "about 1 in 400 cases." The condition is serious. The pitcher will likely require another operation. The pitcher's career is likely at risk. Andrews leans over and rubs his forehead as if already recalibrating his worry list. "Tell him I'm just distraught about it," he says. "But I don't know what else to do, other than fix it." Follow The Mag on Twitter (ci)LSPNino ) and like us on l+acebook. 2889 http://espn.go.com/espn/print?id=9669812 8/10/2015 ESPN.com -Dr.James Andrews still works on the cutting edge Page 1 of 13 11ral PRINT] ESPN.com: ESPN Print without images]I >rI , Monday,September 17, 2007 Updated:September 20,6:53 PM ET Dr. James Andrews still works on the cutting edge By John Helyar E5PN.com BIRMINGHAM,Ala. --Dr.James Andrews placed the arthroscope in anesthetized Drew Brees,then looked up to view his shredded shoulder on the monitor. Oh,my goodness," Andrews said in his Louisiana twang to his assisting surgeons. "How are we goin'to fix all this?' When he saw it happen,he knew it was bad. Andrews,a huge sports fan,was watching Denver play San Diego on New Year's Eve 2005 when Brees,then with the Chargers,fumbled on the goal line,then dove for the ball.As he extended his arm,a ton or so of football players landed on Brees'exposed right shoulder. As TV viewers winced watching Brees leave the field,his right arm grotesquely extended,Andrews instead diagnosed:subluxation erecti. That's the clinical term for a dislocation that occurs when the arm is extended upward.The arm pops out of the bottom of the shoulder joint,causing a particularly horrific separation. Five days later,in his operating room in Birmingham,Andrews surveyed the damage. The worst was the labrum,a ring of tissue surrounding the end of the shoulder blade -- it had a 360-degree tear.The undersurface of Brees'rotator cuff was also a disaster. What's worse,this complex repair job required the medical equivalent of r a two-minute drill.The surgery had to be completed within two hours or ::0-4'? tissue would begin swelling. a..ti.-.r- Andrews didn't think about the patient's name or contract. He focused on how to implant a series of anchors in Brees' shoulder. Working with his i F k R ,-full set of arthroscopic tools, checking a monitor above the operating rtable,quarterbacking his team of surgeons,Andrews implanted 12 of those anchors,which reattach torn tissue to bone. That was the the most -'7-73:-='-------„,; i lr-`' . anchors he had ever used in an operation,and when it was over--when they'd beaten the two-hour clock and sewn up the shoulder--Andrews l';'-'::-."', i, and his assistants walked out ofthe operating room and did what people t do here in the Bible Belt. They prayed. When Brees came back to lead the New Orleans Saints to the NFC Championship Game a year later,it wasn't just a matter of divine Dr.James Andrews performs intervention. It happened because an all-world surgeon was in the zone elbow surgery at St.Vincent's in Birmingham,Ala.Andrews hasthedayofhissurgery.After that operation,Andrews told the done 40,000 surgeries,mostly on quarterback's agent,Tom Condon, "I did it about as well as it can be knees,shoulders and elbows. done.” 2890 http://espn.go.com/espnlprint?id=3024046 8/10/2015 ESPN.com- Dr. James Andrews still works on the cutting edge Page 2 of 13 Says Condon, who has known Andrews for decades: "That's the only time I've ever heard Doc come close to bragging." A great surgeon is like a great athlete--with extraordinary physical skills,exceptional powers of concentration, an ability to work through adversity and embrace,not shrink from, a challenge.All of that describes James Rheuben Andrews, 65,who has been patching up athletes for nearly as long as Joe Paterno has been coaching Penn State and is still at the top of his game. Hordes of top-tier athletes-- among them Troy Aikman, a r" C » vCharlesBarkley,Roger Clemens, Allen Iverson,Bo Jackson,Michael Jordan, Jack Nicklaus,Emmitt Smith, at* John Smoltz and Doug Williams --have made their way to his practices in the Deep South,where he happened to - land in the early 1970s at the dawn of modern sports medicine. And with a diagnosis of season-ending surgery or the prospect of rehab instead,he is at once Grim s . Reaper and medical Good Housekeeping Seal of Approval. Andrews' numbers are as awesome as his celebrity Andrews averages 30 surgeries a week,and many of patients. He's logged 40,000 lifetime surgeries,mostly on those involve athletes. knees, shoulders and elbows. They're not all on superstars,of course. Pro and college athletes compose 20 to 25 percent of his practice.But the man has done 2,500 Tommy John surgeries alone,with a 90 percent success rate.That's to say nothing about the number of influential opinions he has rendered--just last week on Eli Manning's shoulder when Andrews concurred with New York Giants physicians that the quarterback could play. And if you thought Trevor Hoffman has a lot of career saves,think of how many careers Andrews has saved. Of Roger Clemens' 354 wins,95 percent came after Andrews scoped his shoulder in 1985. In 2000,John Smoltz thought a throbbing elbow might end his career.Andrews performed Tommy John surgery that year,and Smoltz set a National League saves record(55)two seasons later. Yet the big numbers and the big names tell only part ofthe Jim Andrews story--maybe not even the best part. He has been at the forefront of a 30-year revolution that has transformed sports medicine. Andrews has been on the cutting edge of new surgical technologies and rehab techniques that enable players to play longer and recover from injuries faster. Hall of Fame Talk Will Carroll, an author of"Baseball Prospectus," writes that Dr.James Andrews belongs in the Baseball Hall of Fame for his contributions to the sport. And he's had a profound influence in other ways,too. His nonprofit American Sports Medicine Institute ASMI)has produced some ofthe field's most influential research.An ASMI study on teen pitchers correlated a combination of their overthrowing in games and their overlong competitive seasons with increased arm surgeries. Andrews then lobbied Little League for pitch-count limits,which it adopted this year.(Eleven and I2-year-olds must quit at 85 pitches and take three days off before next pitching.) 2891 http://espn.go.com/espn/print?id=3024046 8/10/2015 ESPN.com-Dr. James Andrews still works on the cutting edge Page 3 of 13 ASMI also puts six aspiring sports orthopedists,called "Andrews Fellows,"through a rigorous apprenticeship each year under the master. More than 200 fellows are now practicing on their own, though they remain very much in Andrews' orbit. Andrews isn't the only elite sports orthopedist,of course.The Kerlan-Jobe Orthopaedic Clinic --its co- founder Frank Jobe invented Tommy John surgery--has a stable of name-brand surgeons in Los Angeles.The Steadman Hawkins Clinic is renowned for knee surgeries--and is located conveniently close to skiing mishaps,in Vail, Colo. There are others,too. The modest Andrews would demur, in fact, that he's merely part of a generation of sports orthopedists who combined to vault that specialty far forward. But Andrews'ubiquity and energy set him apart. He is the alpha doc at the center of a sports-medicine network that extends well beyond doctors.Every athletic trainer,physical therapist, strength-and-conditioning coach in the land seems to have Andrews' cell phone number. And he seems to take their every call,on a 24/7 basis.His wife,Jenelle,has something in common with Brees. She's a saint. At first blush, Andrews seems less a roaring dynamo than an unremarkable Rotarian.His salt-and-pepper hair has gone mostly to salt.His waistline barely holds its own against his fondness for hot dogs and other non-lean food products. But he climbs into scrubs,pulls on a pair of green surgical boots and is instantly in his element.The years drop away. The man's strides lengthen,and colleagues 30 years his junior straggle along hospital corridors in his wake.His pace accelerates in the operating room,where he requires nurses to have his tools ready two steps ahead ofhim.He handles those tools so deftly as to be an extension of himself. Yet the man tosses out accolades to his support staff like he tosses out surgical gloves.Invoking an aphorism that sounds straight out of coach-speak,Andrews says, "'We'makes'I' stronger." Andrews'unwillingness to be a remote super-surgeon and his unfailing habit of spreading the credit around has helped spawn a culture of multidisciplinary teamwork in this field. "He is a great integrator of people and ideas," says Dr. Lanny Johnson,who pioneered arthroscopic surgery in the 1970s and mentored the young Andrews. "I like to say Jimmy saw my ideas and applied money to them." Talk about money and multidiscipline ... take a gander at Rii,1 the new$50 million Andrews Institute.The 140,000- square-foot complex opened in May in Gulf Breeze,Fla. ` _ r r It is at once a surgical clinic,a medical-research facility, x a biomechanics lab,an education clearinghouse and a training center for elite athletes. Although Andrews remains based in Birmingham,he spends Fridays at the 4` r institute.i The place is the ultimate testament to the power of Andrews as a brand and, says the doctor, "It's the pinnacle of my career." Andrews examines baseball player Ryan Kochen's shoulder at Andrews'facility in Birmingham,Ala. It's also something else. The Andrews Institute culminates its namesake's comeback from a period as painful in its own way as anything his patients have endured.Andrews'practice has weathered a series of crises since 2003,when corporate partner HealthSouth was battered by an accounting fraud scandal. Andrews had to find new backers and new 2892 http://espn.go.com/espn/print?id=3024046 8/10/2015 ESPN.com - Dr. James Andrews still works on the cutting edge Page 4 of 13 quarters. He has worked out of cramped, temporary facilities since 2005. Andrews had a heart attack in 2006 and split with his partner of 21 years, Dr. Lawrence Lemak, earlier this year. Now he's emerging from the storms, more energized than battered,more driven than ever. He is still doing a volume business-- 10 surgeries on NFL and MLB players in the past six weeks-- and he is still driven by his keen identification with athletes. A big part of his success lies with his extraordinary ability to communicate with them,whether it's explaining their anatomy or giving them pep talks. I tell 'em,'Never give up your career, even though you may be injured,' he says. "'Never give up your hopes and your dreams, because until you fulfill 'em,you'll always be wondering and wishing what you might have done if you'd kept going.' Andrews implores so strongly and relates so closely because his athletic career was cut short,though not by injury. His father got lung cancer and died during Andrews' sophomore year at LSU. He was a collegiate champion pole vaulter, but he gave that up to accelerate his studies and graduate from LSU after three years. He wanted to get a jump on med school, and earn doctor money to support his family. Practicing sports medicine allowed him to combine the love of sports he got from his father,who coached football and track teams in Andrews'home town of Homer, La.,and the aptitude for medicine he got from his grandfather, who was an unofficial, unlicensed healer in a rural part of the state with few doctors. I think I was born to be a physician," he says. Few doctors were drawn to sports medicine in the early 1970s,when Andrews got his start. Sports wasn't a big business, and there weren't big bucks in this subspecialty. Sports orthopedics was mostly the province of physicians who liked hanging around athletes. Team doctors were mostly buddies of owners and inclined to do their bidding on treating injuries. That irked a firebrand young baseball agent named Randy Hendricks, who thought his clients deserved better and who pushed hard for second opinions. It was a radical notion then, and it was a brave doctor who'd provide independent ones and risk offending the lords of baseball. Hendricks discovered there was a young sports orthopedist in Columbus, Ga.,who would do so. He began taking his injured clients there. What made Jim remarkable was that he'd provide [an opinion] and he'd call it as he saw it," Hendricks says. "Teams would get unhappy because we went to Jim, but he was our link to a state-of-the-art doctor." That's how Andrews came to examine a scared-to-death kid named Roger Clemens in 1985. Then a second-year pitcher for the Boston Red Sox, Clemens would get shoulder pains and lose velocity after three or four innings. Local doctors couldn't diagnose anything, so his agent recommended seeing Andrews. Clemens was amazed, not just at how quickly Andrews put his finger on the physical problem -- a torn labrum -- but at how quickly he reduced his mental stress. 2893 http://espn.go.com/espn/print?id=3024046 8/10/2015 ESPN.com-I)r.James Andrews still works on the cutting edge Page 5 of 13 We hit it off," Clemens says. "His approach made me extremely comfortable. He gave me a CliffsNotes version of a course about the a= 11 shoulder and how the big muscles and small muscles related." I Andrews both cleared up Clemens'problem with a then-novel arthroscopic surgery and lectured him on preventing recurrences. f. He gave me a stern father talk about doing shoulder exercises," Clemens v,, recalled. K The regimen Andrews prescribed,with 3-to 5-pound weights,has been a ' major contributor to Clemens'longevity -- as, of course,was the operation. Eight months after it, Clemens set a major league record by r, ,` 4 R istrikingout20SeattleMariners. t k He and Andrews have remained close since. The Rocket has been a huge '' t`'' referral source. He has returned for periodic checkups on his arm and to . . _.„ have his delivery analyzed at ASMI's biomechanics lab. He has not only Roger Clemens poses in 2986 with endured on the mound but followed Andrews into his field. Last year,in a bats commemorating his 20 strikeout game against the Seattle conjunction with a Houston hospital,he opened the Roger Clemens Mariners on April 29.He wouldn't Institute for Sports Medicine&Human Performance. have done it without Andrews. Andrews is so tight with patients that some become regular houseguests.Two-sport star Bo Jackson spent so much time at the home of Andrews,with whom he'd been close since shoulder surgery at Auburn,he was practically a surrogate son. When Jackson suffered hip dysplasia as a Los Angeles Raiders running back in 1991,he participated in the discussion about what to do to come to terms with his injury. He and Andrews studied surgical options,the risks,the artificial-hip brands,the works. Andrews only assisted in the hip replacement operation-- a White Sox team physician took the lead--but het - • '' t t 4411'0'thoroughly prepared Jackson for it,right down to getting him relaxed the day before. They grilled steaks,then 0' caught a Chicago Bulls game. P Dr. Andrews isn't going to B.S.you and tell you t r something is all right when it isn't,"Jackson says. "And when he treats you,he takes care of you as ifyou were his own kid." t'r f Some orthopedists privately sniped that hip replacement "' i ° for Jackson,then 29,wasn't appropriate for such a young aus. r patient. 1. se— v+ 1# Jim took heat for that operation; a lot ofpeople thought hehe was grandstanding," says Tim Kremchek,an Andrews Fellow at the time. "But they weren't taking into account After Bo Jackson hurt his hip--on this play--he how well he knew Bo--what made him tick and why participated in the discussion with Andrews about what to do.The process helped Jackson come to that was the right approach." terms with the injury. The surgery provided sports fans one more dramatic Jacksonian moment--a home run in his first at-bat back with the White Sox in 1993.But Jackson was reduced to a part-time player and retired after the 2894 http://espn.go.com/espn/print?id=3024046 8/10/2015 ESPN.com-Dr. James Andrews still works on the cutting edge Page 6 of 13 1994 season. Andrews couldn't regain the magic for Jose Rijo, either. He performed six elbow surgeries on the one-time star pitcher,starting in 1995,but Rijo never successfully came back. Kremchek,now a prominent sports orthopedist in Cincinnati, closely modeled his own practice on Andrews' axioms.Example 1: You don'tjust operate on patients;you listen to them, read them, motivate them. Example 2: You don'tjust need to know tendons;you need to know and love sports. It certainly takes passion to satisfy another Andrews axiom: 24/7 availability. In 1991,Andrews worked the Sugar Bowl in New Orleans one night,hopped a flight over to Dallas to operate on Troy Aikman's shoulder and elbow early the next morning, then flew back to Birmingham for his regularly scheduled surgeries the rest of the day.He couldn't take time off if he tried. He was hunting quail in south Alabama once when Emmitt Smith showed up to have him look at his bum shoulder.He was planning to take a Memorial Day weekend off once when Jerry Jones called to say he had to fly over and fix Michael Irvin's shoulder right now. How else would Irvin be ready to go by training camp time? Andrews did it. Tom Condon,the NFL's top player agent,wouldn't use anyone else for second opinions. "Jim's not awed or starstruck with players," Condon says. "The players see him as a peer." When a player's--maybe a franchise's-- future hinges on a doctor's decisions and incisions,you don't want awed and starstruck. But Andrews acknowledges being intimidated a time or two earlier in his career. I remember having Jack Nicklaus draped out in the operating room," he says. "I looked down at his knee and said,'My goodness,I've got Jack Nicklaus on the table.' And 1 thought,'Have I got the right knee?'" But then he caught himself and went about his business. Notable Patients Dr. James Andrews'patient list reads like a cross-sport hall of fame. He's a rundown of some of the most notable athletes who have been treated by Andrews: Football players Bo Jackson: shoulder, 1984;hip, 1992 Doug Williams: knee, 1988 Bruce Smith:knees, 1990 and 1991 Troy Aikman: elbow and shoulder, 1991 Michael Irvin: shoulder, 1994 Emmitt Smith: shoulder, 1994 Trent Green: knee, 1999 and 2001 Chad Pennington: shoulder,2005 (twice) Deuce McAllister:knee,2005 Daunte Culpepper:knee,2005 and 2006 Takeo Spikes: achilles tendon,2005 Donovin Darius: ACL,2005; shoulder, 2006 Drew Brees: shoulder,2006 Byron Leftwich: ankle,2006 Donovan McNabb:knee,2006 Matt Hasselbeck: shoulder,2007 2895 http://espn.go.com/espn/print?id=3024046 8/10/2015 ESPN.com-Dr. James Andrews still works on the cutting edge Page 7 of 13 Joey Porter: knee, 2007 Kenny Irons: knee,2007 Isaiah Kacyvenski:knee, 2007 D.J. Shockley: knee,2007 Baseball players Roger Clemens: 1985, shoulder, 1985 David Wells: 1985,elbow, 1985 Jimmy Key: elbow, 1988; shoulder, 1994, 1995 Jose Rijo: elbow, 1995;five more elbow ops, 1996-2003 Steve Karsay: elbow, 1995; shoulder, 2003 Kerry Wood:elbow, 1999 John Smoltz: elbow,2000 and 2003 Carl Pavano: elbow,2001 and 2006 Jon Lieber: elbow,2002 A.J.Burnett :elbow,2003 Andy Pettitte:elbow,2004 Gary Sheffield: shoulder,2004 Jim Thome: elbow,2005 Mark Prior: shoulder,2007 Anibal Sanchez: shoulder, 2007 Freddie Garcia: shoulder,2007 Chris Ray:elbow, 2007 Basketball players Charles Barkley: shoulder, 1990 Michael Jordan: shoulder(therapy,not surgery), 1994 Penny Hardaway: knee, 1996 Randy Livingston: knee, 1996 Scottie Pippen:elbow,2001 Allen Iverson:elbow,2001 Aaron McKie: shoulder,2001 Chris Webber:knee,2003 Shaun Livingston:knee, 2007 Golfers Jack Nicklaus:knee, 1984 Jerry Pate:shoulders, 1985, 1986, 2003, 2006 Mark McCumber: shoulder, 1996 To Andrews,the key is to not do something extra special because of who the patient is, "because then you mess up. You treat them with your routine." Dealing with athletes does require a special bedside manner,Andrews says. You don't sit there and give them miles and miles of lingo," he says. "They want the straight facts,and they want you to be positive. An athlete doesn't go into a game saying,'Well,we may not be able to winthisone.'They want their doctor to go into it like an athlete,too: 'We're going to get this fixed,and we're going to get you back on the road so you can play your sport again.' 2896 http://espn.go.com/espn/print?id=3024046 8/10/2015 ESPN.com -Dr. James Andrews still works on the cutting edge Page 8 of 13 One reason Andrews communicates so well with athletes: He was a good one himself.He was the Southeastern Conference's pole vault champ as an LSU undergrad,clearing 15-feet 1-1/2 inches in the pre-fiberglass age when the world record was just scraping 16 feet. "I got a high out of clearing that bar," he says. "I still dream about clearing the bar.I've always regretted losing that last year of eligibility. That's why I can relate to athletes about their careers." LSU will honor Andrews,in conjunction with the SEC's 75th anniversary celebration,by naming him one of its six most distinguished student-athlete alums. As an older and richer man,his sport became sailing. He raced a 50-foot racing sloop called Abracadabra that won championships on the elite Southern Ocean Racing Conference circuit in the mid-'90s.A costly, futile run at the America's Cup in 2000 eventually sent him into hiatus,but he admits the sport is still in his blood. "I like the solitude," he says, "and I like to compete." To Andrews,his principal job benefit is being part of the raw emotion and passion of sports--getting athletes from their broken-down low points back to their competitive highs. He felt goose bumps when Jimmy Key,whom he somehow kept pitching through a series of shoulder and elbow operations,won the deciding games of the 1992 and 1996 World Series,with the Blue Jays and Yankees,respectively. He derives that psychic income not just by patching up the stars but by taking care of athletes from Nowheresville.Part of the deal he negotiated with HealthSouth was that an athlete from anywhere in Alabama--anybody--would be treated by his clinic,health insurance be damned. I wanted to be sure ifsomebody got hurt playing football, HealthSouth would take care of him," Andrews says. "We probably had the greatest athletes of anywhere in the country but the poorest sports-medicine care.Especially in the rural areas,you had great athletes who got hurt and didn't get fixed.It wasn't fair." Because of his attention to the local patient base,Andrews has attained a deified status in his adoptive state ofAlabama: He's a team doctor for Alabama and Auburn.(His official titles: senior orthopedic consultant and co-medical director,respectively.)His rooting interests lie firmly with Auburn,with whom he has long been affiliated,and he takes sides(with the exception of the Auburn-Alabama game) when"covering" football games. He'll pace the sidelines like a cat," says Dr. John Richardson,who has covered Auburn games with Andrews."When they screw up,he'll yell, 'What the hell are they doing?' When he's mad at the officials, he'll throw down his hat and scream, 'That's the sorriest call I ever saw!"' Andrews has been affiliated with the Tigers since he was a medical cub because his mentor,Dr.Jack Hughston, was Auburn's longtime team physician. Based in Columbus,Ga.,he was one of the few prominent sports orthopedists in the 1960s and 1970s. Andrews read a treatise by him about knee injuries while a second-year resident at Tulane University Medical Center,then called to see whether he could come over and watch him operate. Sure, Hughston said.He was so impressed with Andrews during the visit that he invited 2897 http://espn.go.com/espn/print?id=3024046 8/10/2015 ESPN.com-Dr. James Andrews still works on the cutting edge Page 9 of 13 him to do his third-year residency at his clinic. Andrews did,and ultimately joined the Hughston Clinicin1973.1973. Many of Andrews'guiding principles were originally Hughston axioms--most prominently availability.Among other things,Hughston operated on Saturdays to provide prompt relief for players suffering 71injuriesonFridaynights. Andrews became zealously,ubiquitously available, even in the most obscure corners of the Deep South.R.T. Floyd, athletic trainer at West Alabama State University,When he isn't in surgery,Andrews can probably berecallsAndrewsmakingeveningflightstoremotefoundmakingphonecalls. Livingston to examine football players for three or four hours.Floyd, in turn,once drove some injured players four hours to Columbus,where Andrews examined them in his living room at 11 p.m. He put up the ones requiring surgery in guest rooms. Hughston believed physicians had to keep learning and keep up with the field. One of his signature sayings: "If you're green,you're growing.If you're ripe,you're next to rotten." Andrews adopted that as one of his favorite aphorisms. Every six weeks,he'd fly in the clinic's plane to Lansing,Mich.,to learn about a new technique called arthroscopic surgery. Lanny Johnson,an inventor of some of its key tools,practiced there.Andrews,on a stepladder in the operating room,watchedJohnson. Andrews also organized sports-medicine conferences to share and grow the slim body of knowledge in that field.For instance,he started a multiday,multidiscipline "Injuries In Baseball" course that marked its 25th anniversary this year. By the 1980s,he was making quite a name for himself. He operated on Jack Nicklaus'knee and Bo Jackson's shoulder in 1984. He saw his MLB patient load spike after the shot in the arm he gave Clemens' career in 1985. But jealousy stirred at the Hughston Clinic as the protégé's renown began to rival that ofthe mentor. Some partners looked askance at Andrews'embrace of arthroscopy.(Many surgeons,including Hughston,believed it inferior to traditional "open" surgery.) Some grumbled about peripatetic Andrews' heavy use of the practice's plane. By the mid-1980s,with the mentor in his late 60s and the protégé in his mid-40s,Andrews should have been the logical successor to lead the practice.But some colleagues didn't want him in that role and Hughston wouldn't commit to him. Andrews once got his nerve up to ask, straight-out,who'd be the next leader and got no answer. When a hospital in Birmingham recruited Andrews to start a sports-medicine center in 1986,he agreed. Andrews' father-son relationship with Hughston was blown like a ruptured ACL.The two remained distant until Hughston's death in 2004. The vision of Andrews and his partner,Lawrence Lemak,for a super-practice was thwarted at first. The hospital didn't have the resources to fulfill its recruiting pitch. Then they met Richard Scrushy,who 2898 http://espn.go.com/espn/print?id=3024046 8/10/2015 ESPN.com-Dr. James Andrews still works on the cutting edge Page 10 of 13 headed a chain of health care clinics called HealthSouth.He developed his own vision ofaffiliating with the high-profile sports surgeon and thereby vastly raising his obscure company's profile. Scrushy bought the hospital and built Andrews his dream clinic. The centerpiece of Alabama Sports Medicine and Orthopaedic Clinic(ASMOC)was a suite of four operating rooms,with an area in the middle of them from which surgeries could be observed. (An Andrews Fellow also could watch on closed-circuit TV in a theater downstairs.)HealthSouth also funded a big chunk of the budget for ASMI, the nonprofit research and education arm. Andrews recruited other sports-medicine all-stars,including Bill Clancy,a knee specialist who developed an innovative approach to ACL surgery, and Kevin Wilk, one of the nation's foremost athletic rehab specialists,who ran ASMOC's physical therapy department. It all worked beautifully and synergistically until 2003,when Scrushy and other top executives were charged with inflating HealthSouth's earnings by$2.7 billion over a six-year period. Scrushy was acquitted in 2005 (15 other former executives pleaded guilty to stock fraud), but was forced out as CEO. The new management had a new agenda: retrenching and trying to save the crippled company.That meant selling wow. ' _ some hospitals,including the one housing ASMOC. fir. k"• , Andrews had nothing to do with the fraud. ("It was an accounting fraud," says a spokesman for U.S.Attorney Alice Martin in Birmingham. "It had nothing to do with a" I ;r..`. doctors." But the scandal left him and his partners out on the street. In 2005,the practice landed at St. Vincent's in 1: Birmingham,but without the magnificent operating suites and closed-circuit TV. Physical therapists had one-third Kevin Wilk,chief of Andrews'rehab center, as much room as at HeaIthSouth. The operating quarters examines Peden Rucker six weeks after shoulder were cramped.The practice had to downsize, letting its surgery.Rucker plans to pitch again next year for the University of South Carolina Aiken.hand and spine surgeons g0. Andrews also had to scramble to save ASMI,the nonprofit arm. HealthSouth had contributed an annual average of$431,000 from 2000 to 2003 --and that also was gone. Other sources of funding would have to be tapped--medical vendors,Andrews Fellows alumni and others--to fill that gap. Andrews'partner,Larry Lemak,usually handled money matters. While Andrews was solely focused on medicine,Lemak had a head for business.He had a host of things going on the side,in real estate, medical and sports enterprises,and managed the financial aspects of the HealthSouth relationship. When ASMOC was uncoupled from that company, however,the partnership began to fray. For one thing, Lemak appeared less concerned with saving ASMI than with launching his own nonprofit institute,called The National Center for Sports Safety. While Andrews was losing sleep, feeling responsible for all the ASMOC and ASMI employees,Lemak seemed increasingly active in his outside ventures. Some members ofthe practice were steamed at Lemak, 2899 http://espn.go.com/espn/print?id=3024046 8/10/2015 ESPN.com -Dr.James Andrews still works on the cutting edge Page 11 of 13 but not Andrews.At least,not in any way he would acknowledge. He hates and avoids conflict. A disgusted m `{ y Clancy,the topknee specialist,left in 2004. Y p aE !MO'_: , I was disenchanted with all the politics," says Clancy, a... ' " * , i who disagreed with Lemak's philosophy and who was Elor,—"i .° g}'`' " -• 1 frustrated by Andrews'reluctance to confront the partner. :az' . r He [Andrews]takes the punches like a punching bag." .- a , `. ElEALTHSOLITH The issue that surfaced underlying tensions was J"` Andrews wanted to make sure that if any player in succession. Andrews was totally taken with two of his Alabama got hurt,he could visit HealthSouth for fellows in the late 1990s: Drs. Lyle Cain and Jeffrey treatment. Dugas. He asked them to stay after their year was up and join the practice.He would reach age 60 in 2002 and wanted to start grooming successors. But when Lemak's son, David,joined the practice in 2005,his father pushed for him to be get the same kind of ` 1 succession-track status as Cain and Dugas.It was more I , ,._'4 agony for a practice already roiled by HealthSouth. i ` 1.1\,,1 - 0,,, _ . stf Instead of dealing with those issues, i ii ,r-r Andrews burrowed e t 1 ,j even more deeply into tendons and labrums and his r A-` whirlwind of demands. To worried friends and family,he r , r . : was takingon too much.Duringfootball season,he was i t e4f tt flying to Washington Redskins games each Sunday,on s. top ofhis usual swirl of Saturday college games. He was ,/ .-ti , helping out his friend Joe Gibbs,who,upon his 2004 Andrews(center)with two of his proteges, Drs.Jeff return to the NFL sideline,wanted Andrews to be the Dugas(left)and Lyle Cain. team's orthopedic consultant. The guy couldn't say "no," couldn't turn offhis cell phone. "I was riding with him once,and he was on the cell phone,as usual," says fellow Birmingham physician John Richardson. "The way he was talking,I thought it was a big shot from the NFL or something. It turned out to be a locker room attendant at the club he used to belong to in Columbus. He had Jim's number,too,and Jim had time for him." In January 2006,his heart surgeon saw the results. He helped save Andrews'life after a major heartattack. On a Sunday morning at home,after returning from a Redskins playoff game,Andrews found himself gasping for breath,then being rushed by ambulance to St.Vincent's.A team of cardiologists was on hand after completing a rare Sunday procedure. They were soon joined by Richardson,who says speed saved Andrews from a form of heart attack that's almost always fatal. As it was,Andrews soon was examining patients from his bed in the ICU.The Astros'Jeff Bagwell showed up for an appointment to check his bum shoulder,not knowing about Andrews'heart attack. Andrews insisted on seeing him. Same with Brees,whose shoulder he had repaired the previous week and who had stayed in Birmingham for rehab. Even after being sacked by a heart attack,Andrews seemed more interested in the quarterback's condition than his own. Nonetheless,it was sobering and galvanizing for Andrews.He couldn't let this end up like the Hughston Clinic succession mess. "I sat with him in the ICU the day of the heart attack and he was very 2900 http://espn.go.com/espn/print?id=3024046 8/10/2015 ESPN.com -Dr.James Andrews still works on the cutting edge Page 12 of 13 introspective," says Dugas,his protege. "I think it made him think about refocusing on the things that were most important,like his legacy and his succession plan." Andrews and Lemak announced the split in February 2007,with both parties downplaying hostilities. Lemak,though,declined to be interviewed for this story. This is very amicable;they remain very good friends," says Gene Hallman, executive director of a Lemak side venture,the Alabama Sports Foundation. "This came about because of Dr. Lemak's desire to have a separate practice with his son." Nonetheless,they're in an awkward phase. The divorce has gone through,and Andrews'clinic now goes by Andrews Sports Medicine and Orthopaedic Center. But his practice and Lemak's are still temporarily under the same roof at St. Vincent's. There is otherwise a sense of relief and renewal. St. Vincent's is constructing a Musculoskeletal Institute, which will house the Andrews practice. After its completion next summer,Andrews can expand his clinic,adding back specialists who had to be dropped in 2005. Clancy is set to return this fall. Andrews flies to the Florida panhandle on Fridays to work out of the institute bearing his name--then heads out for a spin on his boat,moored a few hundred yards away. Jenelle Andrews admits she has failed miserably to get her husband to decelerate. She got him a new recliner for Father's Day,but doubts he'll take the hint--except when he's watching former and future patients on TV. Andrews might not possess a lower gear. He appears locked in overdrive, still pushing himself and everyone in his vast sphere of influence--to advance the state of the art in sports medicine. That's sure what it sounded like in his speech at his "Injuries In Baseball"course this past January in Birmingham.Titled "What I have learned about the shoulder in the past 30 years," it could have been a paean to himself.Instead, it was a call to arms. For all the advances of the past three decades,he told the 400 attendees, 14bn 4 there were still injuries that seemed to defy repair. ASe I.VV:1111.Do we have the answer to labral tears?" he asked. "No,a large percentage of these still don't heal. I think we have a long way to go." For all the improvements in technology, he cautioned,there also has qr.) been a downside.It has given too many surgeons itchy scalpel fingers. If you want an excuse to operate on a baseball pitcher's throwing shoulder," he said, "just do an MRI." For all they know about healing athletes today,versus the dark ages of the 1970s,there is still much to do. If you're still talking about what you did yesterday,you're not doing much today," he says. "Even today,in the twilight ofmy career,I'm still learning."Andrews,at age 65, is still driven 2901 http://espn.go.com/espn/print?id=3024046 8/10/2015 ESPN.com-Dr. James Andrews still works on the cutting edge Page 13 of 13 John Helyar is a senior writerfor ESPN.com and ESPN The Magazine. to advance the state of the art in sports medicine. Hepreviously covered the business ofsportsfor The Wall Street Journal and Fortune magazine and is the author of"Lords ofthe Realm: The Real History ofBaseball." 2902 http://espn.go.com/espn/print?id=3024046 8/10/2015 ESPN.com -The doctor is in Page 1 of 2 1111111114.111111111111116111111111[ PRINT] ESPN.com: ESPN Print without images] Tuesday, December 4, 2012 Updated: December 5, 1:09 PM ET The doctor is in By Chris Jones ESPN The Magazine V This story r= appears in ESPN The r a vMagazine's t#Dec. 10 5 yyInterviewt issue. 4 (} u.:ZS i2 x Subscribe i lam fi,•r 7e e Is DR.JAMES ANDREWS 440'4 is watching 1 r+: \\ ,+R`+ t the weekend's Jfjj} t football highlights l and nearly Biolo ics,or stem cells,is somethingAndrews is experimenting with--ver every one y quietly. features a patient of his, a man whose career has been saved by his hands.He's rattling off the names in his Southern drawl as they appear on his screen,the grand sum oftheir repaired parts: Drew Brees, Alex Smith, Matthew Stafford ... The 70-year-old Andrews has taken their broken shoulders and made them capable ofmagic again. He won't reveal the exact number of surgeries he's performed because he fears it will sound like bragging. "Let's just say too many to count and not enough to quit." He turns his attention back to his TV. "There's Manning. I've seen him too." Which Manning?"Both of'em," Andrews says. In his decades of practice,he's seen hundreds of athletes overcome injuries that would have finished them not long ago. Knee dislocations,patellar tendon ruptures,ligament and rotator cuff tears--he has mastered each ofthese former impossibilities,bringing dead arms and legs back to life. But Andrews still sees damage that even he can't repair. It's one of the reasons he often still works seven days a week: Enemies remain. He has spearheaded prevention programs for young athletes{visit StopSportsInjuries.org to find out more),but he knows that hurt will always bel partof the game, He calls one injury in particular"the nemesis." It cripples football players especially,dooming them to pain and early retirement. When the articular cartilage in their battered knees wears away,when Andrews hears that telltale grind of bone on bone,he knows the fight is over. "We can patch it,but we can't fix it," he says,and he sounds almost wistful,the way a cop might admire a really good thief. 2903 http://espn.go.com/espn/print?id=8681969 8/10/2015 ESPN.com-The doctor is in Page 2 of2 For the past three years,however,Andrews has been experimenting with a new strategy. "Stem cells," he says. "What we call biologics. They're on their way,and that will be a transformational event." Very quietly-- "We don't advertise it," Andrews says, "and we don't want to sensationalize it" --he and his colleagues at clinics in Birmingham,Ala., and Gulf Breeze,Fla.,have been performing stem cell injections on professional athletes. He won't name names,but Andrews has mostly employed stem cells in the deteriorated knees of football players, and virtually all of them have reported significant decreases in pain and inflammation. "It's early," he says, "but the results have been remarkable." Stem cells are unique in that they can become any other type of cell,including that elusive articular cartilage.They are the universal part. Embryonic stem cells--what most people think of when they think of stem cells--are set with religious and political traps,but adults carry stem cells too. Andrews mines them from the marrow in the patient's pelvic bone and then injects them directly into the damaged joint. That's the only stem cell procedure the FDA presently allows--the self-donation of unaltered adult stem cells. "We're neophytes,"Andrews says. But this is the first step. Other countries, such as South Korea,Japan and Germany,have far more advanced programs in stem cell therapy. (Peyton Manninti reportedly had his neck treated in Europe.)Andrews agrees with the FDA that more research is needed,but he doesn't like seeing his prize patients going overseas. "We have to do the work here," he says.He's been trying to arrange clinical trials,but those require two things in short supply: money and patients willing to take the risk,not because the procedure is dangerous but becausesomepatientswillreceivestemcellsandothersaplacebo. Athletes aren't interested in saline.Time is never on the side of the suffering. That's the other reason Andrews still works seven days a week.He had long predicted that stem cell therapies would be routine by now.Today he hopes that another decade might be enough and that he will still be working whenever his prediction finally comes true.Along with his urgency,his optimism is the most essential part of his practice. Andrews dreams constantly ofmarvels,of hearts grown fresh in labs,of Tommy John surgeries sidelining players for weeks rather than months. It's easier to believe in miracles,of course,when you see them throwing perfect spirals on your TV,Brees and Smith and Stafford,each one a bridge between a past that couldn't be saved and a future that always could be. Follow The Mag on Twitter(,ESPN:nag)and like us on Facebook. 2904 http://espn.go.com/espn/print?id=8681969 8/10/2015 Listing of Georgia Athletes Operated on Out of State Adam Brandenburg John Foster Adam Wainwright John Smoltz Allen Iverson Jonny Venters Blaine Boyer Justin Rosenblum Blake Wood Kelly Johnson Brandon Beachy Kris Benson Brian Jordan Kris Medlin Brice Butler Kyle Davies C J Leggett Lee Hyde Calvin Johnson Joey Devine Cam Newton John Foster Charlie Whitehurst John Smoltz Cody Worthy Jonny Venters Derrick Morgan Justin Rosenblum Diana Colen Kelly Johnson Eddie Perez Kris Benson Effrem Hill Kris Medlin Eric O'Flarety Kyle Davies Eric Weems Lee Hyde Fernando Velasco Joey Devine Frank Hermann _John Foster Greg Maddux John Smoltz Haley Worthy Rafael Furcal Herschel Walker Theo Ratliff Horacio Ramerie Todd Gurley Jamaal Anderson Tom Glavine Jamin Elliott Zach Mettenberg Jiar Jurrjens Zack Wheeler Joey Devine 2905 APPENDIX N-9 2906 Georgia !, orf i r Tech `i fi© e r r= r.' Atlanta Sports Medicine Center- Economic Impact Analysis The Atlanta Sports Medicine Center is a State-of-the-Art comprehensive healthcare facility being developed in association world renowned sports orthopedic surgeon James R. Andrews, M.D. on a thirty-two acre campus in Alpharetta at the intersection of Old Milton Road and Georgia Highway 400. The project will be a multi-faceted two hundred twenty five thousand (225,000) square foot facility combining a medical office building for physician's practices, an ambulatory surgery center, a rehabilitation and physical therapy, diagnostic imaging, sports performance center and various sports academies including athletic fields as well as a research and education foundation. The Enterprise Innovation Institute (El') at Georgia Tech was asked to conduct a high-level economic impact analysis of both the construction and operation of the facility. Based on information provided by the developer, it is estimated that total capital expenditures will be in excess of $100 million. Once fixtures, furniture, and equipment are removed, the remaining construction budget is $81.5 million. That amount of spending on medical facility-related construction in Georgia would directly support 430 full and part-time jobs in the state with income of nearly $24 million including benefits. The resulting indirect and induced impacts from company and employee spending would generate another 484 full and part-time jobs in the state. (Table 1 below has the complete economic impact results on the State of Georgia from the construction spending.) In addition, the construction of the Table 1:Atlanta Sports Medicine-Construction Impact project will generate more than$4.5 million in new state and local tax Employment Income Output revenue — the bulk of which willDirectImpact43023.8M $81.5M Indirect Impact 240 come from additional sales taxes.p 13.2M $38.6M Induced Impact 244 10.5M $31.4M Total Impact 914 47.5M $151.5M While these economic impacts are impressive, they are temporary and Multiplier 2.13 2.00 1.86 only last during the construction of the project. The more lasting economic impact will come from the operation of the facility. It is estimated that full, revenue-stable operation will be realized in year 5 of the project. At that time,the facility will employ 308 full and part- time jobs (or 275 full-time equivalents) with a payroll of just over $25 million. These jobs include doctors and staff, physical therapists, as well as professional research and foundation staff and staff to run the sports academies. Combined, it is estimated that these will generate more than $50 million in economic activity. Given the regional nature of this facility, patients/clients will be attracted from all over the southeast region meaning that a large portion of this economic activity will be new to the state Enterprise Innovation Institute innovate.gatech.edu A Unit ofthe University System ofGeorgia An Equal Employment Opportunity Institute 2907 and should generate more than 350 new full and part-time jobs in the state through indirect and induced spending. (Table 2 below has the complete economic impact results on the State of Georgia from the operation of the Atlanta Sports Medicine Center.) In addition, the operation of the Table 2:Atlanta Sports Medicine-Operation Impact Atlanta Sports Medicine Center will generate more than $3.4 million in Employment Income Output taxes annually for state and localDirectImpact30825.3M $53.6M governments—the bulk of which comeIndirectImpact1597.4M $20.3M Induced Impact 219 9.2M $27.6M from new sales taxes ($1.2M), Total Impact 680 41.9M $101.5M property taxes ($1M), and personal income taxes($750K). Multiplier 2.21 1.66 1.89 The terms "direct," "indirect," "induced," "income," and "output" as used in this report are defined below. Direct Impact - The initial economic activity that results from changes in production or expenditures by producers and/or consumers. Indirect Impact - The economic activity that results from local industries buying goods and services from other local industries. This cycle of spending continues until all the money leaks out from the regional economy. Induced Impact - The economic activity that results from the spending of employees' labor income. This cycle of household spending continues until all the money leaks out from the regional economy. Income - All forms of employment income, including employee compensation and proprietor income. Employee compensation is the total payroll cost of the employee paid by the employer including wages and salary, all benefits (health, retirement, etc.) and employer-paid payroll taxes(social security,unemployment,etc.). Proprietor income consists of payments received by self-employed individuals and unincorporated business owners, and includes the capital consumption allowance Output - Final value of industry production. For manufacturing companies, output is sales plus/minus changes in inventory. For service sectors, output is equal to sales. For retail and wholesale trade companies,output equals gross margin,NOT gross sales. 2908 ATLANTA SPORTS MEDICINE CENTER THE ATLANTA SPORTS MEDICINE CENTER IS DESIGNED TO BE A WORLD CLASS SPORTS MEDICINE CENTER THAT WILL PROVIDE STATE OF THE ART HEALTH CARE SERVICES RELATED TO SPORTS MEDICINE. AN ALL-INCLUSIVE CONTINUUM OF CARE WILL BE PROVIDED AT ASMC FOR ATHLETES OF ALL AGES AT ALL LEVELS TO OBTAIN THE BEST CARE. UNDER THE LEADERSHIP AND REPUTATION OF INTERNATIONALLY RENOWNED ORTHOPAEDIC SPORTS MEDICINE SURGEON DR. JAMES ANDREWS, ASMC WILL PROVIDE A SPECTRUM OF SERVICES IN ORDER FOR PATIENTS TO QUICKLY AND ACCURATELY ADDRESS THEIR ORTHOPAEDIC NEEDS. THE UNIQUE DEVELOPMENT OF THE ENTIRE CAMPUS AND EXPERT STAFF WILL ALLOW FOR EFFICIENCY AND ONE OF A KIND SPORTS MEDICINE SERVICE FOR ALL ATHLETES ON AN INTERNATIONAL LEVEL. OFFICE SPACE: KINETIQ- KINETIQ IS A GLOBAL INNOVATION EDUCATION ENTERPRISE THAT BRINGS BASIC AND NEXT STEP KNOWLEDGE IN THE FIELD OF SPORTS MEDICINE, WELLNESS, AND PERFORMANCE ART TO PLACES AROUND THE WORLD AND EVEN THOSE AREAS THAT HAVE NO READILY ACCESS TO IT. THEY PROVIDE HIGHLY INTERACTIVE SOLUTIONS THAT COMBINE PERSONAL GROWTH, PHILANTRHROPY,TECHNOLOGY, AND SERVICE-ORIENTED LEADERSHIP. THE MISSION IS TO CHANGE THE WORLD BY CHANGING HOW THE WORLD WORKS WITH EACH OTHER WITH EDUCATION AS THE DRIVING FORCE TO MAKE IT HAPPEN. THE GOAL IS TO PROVIDE SPORTS MEDICINE EDUCATION BY EXPERTS THAT CHAMPION THE KNOWLEDGE TO PEOPLE IN COUNTRIES ALL OVER THE WORLD AND FREE BORDERS OR HIERARCHY WHEN IT INVOLVES ACCESS TO BOTH BASIC AND ADVANCED KNOWLEDGE IN SPORTS MEDICINE, WELLNESS,AND PERFORMANCE ART. KONNECT XL-KONNECT XL IS AN EXTERNSHIP-INTERNSHIP EXPERIENCE WHERE EXPERTS WORK TOGETHER WITH CLIENTS IN ORDER FOR A TRULY GLOBAL LEARNING EXCHANGE TO OCCUR.IT IS REAL TIME COMMUNICATION, STRATEGY FORMING, AND CULTURAL EXCHANGE APPLICABLE IN THE REAL WORLD SITUATIONS LEARNED IN A EDUCATIONAL ON THE SPOT MENTORSHIP PROGRAM FOR SPORTS MEDICINE AND WELLNESS. KINETIQKONSULT-KINETIQKONSULT IS A SERVICE PROVIDED BY EXPERTS FROM AROUND THE GLOBE IN THE WORLD OF SPORTS MEDICINE,WELLNESS, AND PERFORMANCE ART. THE EXPERTS ASSIST IN SPORTS REHABILITATION DESIGN, SPORTS SCIENCE SYSTEMS, INTEGRATED WELLNESS EDUCATION PLATFORMS,AND CLINICAL CONCIERGE. 2909 BEKINETIQ FOUNDATION-BEKINETIQ FOUNDATION IS DEDICATED TO CREATING A COMMUNITY OF EXPERTS,TEACHERS,STUDENTS, AND MENTORS. THE FOUNDATION CREATES KNOWLEDGE SHARING BETWEEN PRACTITIONERS IN THE FIELDS OF SPORTS MEDICINE, FITNESS, WELLNESS, AND NUTRITION, WITH ON FIELD AND OFF FIELD EXPEREINCES THAT DEMONSTRATE GRATITUDE, LIVING LIFE TO THE FULLEST, AND CHANGING THE WORLD. THE GOAL IS TO PROVIDE A PLATFORM FOR SPORTS MEDICINE EXPERTS THROUGHOUT THE WORLD TO GIVE THEM OPPORTUNITIES TO GIVE BACK THROUGH KNOWLEDGE SHARING AND ACTS OF KINDNESS ON A GLOBAL LEVEL. KONNECT-KONNECT IS A CLASS THAT OFFERS INFORMATION, INSPIRATION, AND TRANSFORMATION, GIVEN TO THE FUTURE GENERATIONS OF ATHLETES, THEIR PARENTS, COACHES AND TEACHERS AT HIGH SCHOOLS AND COLLEGES FOR THEM TO HAVE A BETTER UNDERSTANDING OF THE PATHS OF THOSE WHO HAVE COME BEFORE THEM, AND TO LEARN FROM PROFESSIONAL ATHLETES AND ELITE SPORTS MEDICINE PROFESSIONALS. SPORTS TECHNOLOGY CENTER-A STATE OF THE ART SPORTS SCIENCE TECHNOLOGY CENTER WILL PROVIDE AN INCUBATOR/ACCELERATOR FOR START UPS IN THE WORLD OF SPORTS PERFORMANCE TECHNOLOGY. THIS CENTER WILL ASPIRE TO BE THE INNOVATION, INCUBATION, AND ACCELERATION HUB OF EVERYTHING SPORTS MEDICINE AND PERFORMANCE RELATED IN THE WORLD. SPORTS SCIENCE LABORATORY-THE WORLD OF SPORTS IS CHANGING. PERFORMANCE ON THE FIELD, THE PITCH, THE COURT CAN NOW BE CAPTURED, ANALYZED, AND RE-APPLIED TO ATHLETES IN ORDER FOR THEM TO IMPROVE ON ALMOST EVERY ASPECT OF THEIR GAME. THE GOAL OF THE SPORTS SCIENCE LABORATORY IS TO SERVE AS A CENTRAL LOCATION FOR THE UNDERSTANDING AND APPLICATION OF ALL CURRENT AND FUTURE TECHNOLOGIES DEVELOPED INSIDE AS WELL AS OUTSIDE OF THE START UP INCUBATOR AND TESTED ON A REAL POPULATION OF ELITE ATHLETES AT ASMC. INCUBATOR/ACCELERATOR/START-UPS-WITHOUT INNOVATION, THERE IS NO GROWTH IN ANY INDUSTRY. BY CREATING A SPACE WHERE THOSE INNOVATIVE MINDS WILL HAVE THE CHANCE TO THRIVE BY BEING SURROUNDED BY THEIR OWN PEERS IN THE WORLD OF SPORTS, THE DISCOVERIES FOR SPORTS TECHNOLOGY COULD BE LIMITLESS. THE GOAL OF THIS TECHNOLOGY INCUBATOR IS TO PROVIDE AN OFFICE SPACE FOR EVERY SPORTS, FITNESS, WELLNESS, NUTRITION EXPERT WHO MIGHT ALSO BE AN ENGINEER, AN ENTREPRENEUR, A CREATIVE MIND. BY HAVING THESE EXPERTS FROM ALL OVER THE WORLD COME TO ASMC,LLC AND INCUBATING THEM TO SOLIDIFY THEIR IDEAS, AND ALLOWING THEM TO ACCELERATE BY DEVELOPING PRODUCTS THERE IS NO DOUBT THAT MANY BILLION DOLLAR COMPANIES WILL TRACE THEIR ROOTS BACK TO ASMC SPORTS TECHNOLOGY CENTER. 2910 MOTUS -MOTUS GLOBAL IS A HUMAN PERFORMANCE SOFTWARE COMPANY FOCUSED ON SPORTS INJURY PREVENTION AND ANALYSIS. THEY FOCUS ON USING TECHNOLOGY FOR ALL BODY PARTS SO ATHLETES CAN SEE IF THEIR SWING IS CHANGING FROM PITCH TO PITCH AND TRACK THE MOTION OF PITCHERS TO COLLECT AND ANALYZE KEY METRICS RELATING TO PITCHING MECHANICS. THEIR PRODUCTS COLLECT 3 DIMENSIONAL MOTION DATA RELATING TO EVERY THROW TO CALCULATE WORKLOADS ON THE ARM, AND RECOMMENDS DAILY THROW LIMITS TO HELP MAINTAIN ARM HEALTH AND PREVENT INJURIES.THIS TECHNOLOGY IS ABLE TO MEASURE THE FORCE ON THE UCL AND POTENTIALLY ASSIST IN DECREASING TOMMY JOHN SURGERIES. EVOSHIELD-EVOSHIELD IS A COMPANY THAT SPECIALIZES IN PERFORMANCE DRIVEN SPORTS PROTECTION WITH MULTI-SPORT APPLICATIONS.THIS COMPANY WAS FOUNDED BY ATHLETES TO PROVIDE CUSTOM FIT IMPACT-DISPERSING PROTECTION WEAR. THE DRIVING FORCE BEHIND THEIR COMPANY IS TO ASSIST IN PREVENTION OF INJURY AND ALLOW ATHLETES TO STAY ON THE FIELD INJURY-FREE BY USING THEIR PRODUCTS. COMPOSING MOTION INC.-COMPOSING MOTION IS A BASEBALL BIOMETRICS ANALYSIS COMPANY. THE COMPANY OWNER IS A PROFESSIONAL BIOMECHANICAL PITCHING CONSULTANT FOR NUMEROUS MAJOR LEAGUE BASEBALL ORGANIZATIONS. HE ANALYZES PITCHING MECHANICS FOR MAJOR AND MINOR LEAGUE PITCHERS, AS WELL AS PROSPECTIVE AMATEUR PITCHERS WHO WILL BE PARTICIPATING IN THE MAJOR LEAGUE AMATEUR BASEBALL DRAFT EACH YEAR. THIS ANALYSIS ASSIST PITCHERS IN IMPROVING THEIR MECHANICS FOR OPTIMUM RESULTS AND INJURY PREVENTION. INNERGY SPORT-AVADIM TECHNOLOGIES INC.-INNERGY SPORT, A DIVISION OF AVADIM TECHNOLOGIES INC. IS A LIFE SCIENCES COMPANY COMMITTED TO MAKING A DIFFERENCE BY BRINGING HIGHLY DIFFERENTIATED TECHNOLOGIES INTO HEALTH AND ATHLETIC ARENAS. IT IS A TOPICAL TECHNOLOGY AND WAS DEVELOPED WITH THE ATHLETE IN MIND TO OPTIMIZE ENDURANCE AND PERFORMANCE LEVELS.THIS PRODUCT NORMALIZES THE ATHLETE'S INTEGUMENTARY SYSTEM, THUS INCREASES MUSCLE PERFORMANCE, DECREASING MUSCLE PERFORMANCE, DECREASING MUSCLE RECOVERY TIME, AND PROVIDES IMMEDIATE CRAMP RELIEF. THE INNERGY PRODUCT LINE IS BEING UTILIZED AND EVALUATED BY PROFESSIONAL, UNIVERSTITY, AND HIGH SCHOOL ATHLETIC TEAMS THROUGHOUT THE UNITED STATES. 2911 BASEBALL ACADEMY-THE BASEBALL ACADEMY WILL PROVIDE INDOOR AND OUTDOOR FACILITIES INCLUDING BATTING CAGES,PITCHING MOUNDS, WORKOUT SPACE, AND FULL SIZE OUTDOOR BASEBALL FIELD. BASEBALL ATHLETES OF ALL AGES WILL HAVE ACCESS TO WORLD CLASS INSTRUCTIONAL LESSIONS, CAMPS, AND CLINICS TAUGHT BY CURRENT AND FORMER PROFESSIONAL BASEBALL PLAYERS, CURRENT AND FORMER PROFESSIONAL BASEBALL COACHES, AND CURRENT AND FORMER COLLEGE COACHES TO ENSURE THE BEST MECHANICS AND TECHNIQUES NEEDED TO SUCCEED IN BASEBALL ARE BEING TAUGHT. THE FOUNDATION OF THE PRINICALS ENFORCED AT THE ACADEMY WILL FOCUS ON THE GUIDELINES AND PREVENTION OF INJURY PROTOCOLS DEVELOPED BY WORLD RENOWNED ORTHOPEDIC SURGEON, DR JAMES ANDREWS. A GOAL OF THIS ACADEMY WILL BE TO PROVIDE EXCELLENT EDUCATIONAL OPPORTUNITIES FOR ATHLETES, COACHES, PARENTS, TRAINERS, AND OTHERS INVOLVED WITH BASEBALL ACTIVITIES. FOOTBALL ACADEMY-THE FOOTBALL ACADEMY WILL BE OPERATED BY CURRENT AND FORMER PROFESSIONAL NFL FOOTBALL PLAYERS. THEY WILL UTILIZE THE NATIONS TOP COACHING STAFF INCLUDING CURRENT AND FORMER NFL/CFL PLAYERS AND COACHES AND HIGHLY SKILLED COLLEGE COACHES. THEY WILL OFFER CUSTOMIZED FOOTBALL TRAINING, POSITION SPECIFIC INSTRUCTION AND DRILLS, SKILLS TRAINING, CAMPS, AND CLINICS TO ATHLETES OF ALL AGES AND LEVELS. SPORTS PERFORMANCE AND NUTRITION-THE SPORTS PERFORMANCE CENTER WILL BE A GLOBAL LEADER FOR INTEGRATED PERFORMANCE TRAINING AND NUTRITION FOR ATHLETES OF ALL AGES. THE STAFF WILL BE EXPERTS THAT HAVE TRAINED ELITE ATHLETES ALL OVER THE WORLD. THE TRAINERS WILL DESIGN AND DELIVER HEALTH AND PERFORMANCE GAME PLANS THAT GUIDE PROFESSIONAL ATHLETES, OLYMPIC ATHLETES, YOUTH ATHLETES, THE MILITARY, AND RECREATIONAL ATHLETES TO ACHIEVE THE HIGHEST LEVEL OF SUCCESS. THE FOCUS OF THIS TRAINING WILL BE TO ALLOW THE INDIVIDUAL TO EXCEL AT THE HIGHEST LEVEL OF STRENGTH, MOVEMENT PATTERNS, POWER, NUTRITION AND ENDURANCE TO MEET THEIR MAXIMUM POTENTIAL AND GOALS. ALL TRAINING WILL BE RESEARCH AND SCIENTIFIC BASED TO ACHIEVE THE HIGHEST LEVEL OF HUMAN PERFORMANCE. 2912 MEDICAL BUILDING: PHYSICIAN OFFICES:THE PHYSICIAN OFFICES WILL INCLUDE PHYSICIANS THATSPECIALIZE IN ORTHOPAEDICS, PHYSIATRY,SPORTS MEDICINE,PRIMARY CARE, AND REHABILITATION TO HELP PATIENTS ACHIEVE THE HIGHEST QUALITY OUTCOME AND RETURN TO ACTIVITIES. THEY WILL BE UNDER THE DIRECTION OF RENOWNED SPORTS MEDICINE ORTHOPAEDIC SURGEON, DR. JAMES ANDREWS. MAJORITY OF THE PHYSICIANS WILL BE FELLOWSHIP TRAINED UNDER DR.ANDREWS AND OTHER WORLD KNOWN SPORTS MEDICINE SURGEONS. EACH PHYSICIAN WILL BE EXPERTS IN PREVENTING, DIAGNOSING, AND TREATING MUSULOSKELETAL INJURIES AND CONDITIONS RELATED TO ATHLETES AND PHYSICALLY ACTIVE INDIVIDUALS OF ALL AGES. THEY WILL SPECIALIZE IN LEADING EDGE TECHNOLOGY AND ADVANCED TREATMENT OPTIONS FOR EVERY NEUROMUSCULAR DISORDER. THEY WILL HAVE THE LEVEL OF EXPERTISE TO DEVELOP TAILORED SURGICAL AND NON-SURGICAL PLANS FOR EACH INDIVIDUAL PATIENT.THE PHYSICIANS WILL PROVIDE CARE THAT ATTRACTS ATHLETES OF ALL AGES FROM AROUND THE WORLD TO SEEK OUT ASMC. DIAGNOSTIC IMAGING AND MRI: IMAGING NEEDS AT ASMC WILL BE FOCUSED ON THE MOST ADVANCED TECHNOLOGIES FOR DIAGNOSIS OF MUSCULOSKELETAL PATHOLOGIES. THE MRI AND IMAGING WILL BE LOCATED IN THE MEDICAL OFFICE BUILDING FOR EFFICIENCY AND CONVENIENT TESTING.A COMPLETE, ACCURATE DIAGNOSIS WILL BE ABLE TO BE REACHED IN A SINGLE DAY FOR MUSCULOSKELETAL INJURIES WHICH ALLOWS FOR FAST TURNAROUND SERVICE FOR ALL PATIENTS. PHYSICIANS WILL ALSO BE ABLE TO ACCESS THEIR PATIENTS' IMAGES ON COMPUTERS IMMEDIATELY AFTER THEY ARE TAKEN. AMBULATORY SURGERY CENTER-THE SURGERY CENTER WILL BE EQUIPPED WITH THE STATE-OF-THE-ART EQUIPMENT AND INSTRUMENTATION, LEADING-EDGE TECHNOLOGY AND UNIQUE PATIENT AMENITIES. EACH OPERATING ROOM WILL HAVE COMPLETE DIGITAL EQUIPMENT UTILIZING HIGH DEFINITION CAMERAS AND VIDEO SYSTEMS. THE EQUIPMENT WILL ALLOW THE PHYSICIAN TO VIEW THE MOST FINITE DETAIL AS IT RELATES TO THE PROCEDURE TO ENSURE THE BEST POSSIBLE OUTCOMES. PHARMACY-THE PHARMACY WILL PROVIDE EFFICIENCY FOR PATIENTS AND THEIR FAMILIES WHILE ATTENDING ASMC.THE PHARMACIST WILL HAVE SERVERAL CERTIFICATIONS AND BE AN EXPERT IN COMPOUNDING. THIS WILL MEET THE UNIQUE NEEDS OF AN INDIVIDUAL PATIENT WHEN COMMERICALLY AVAILABLE DURGS DO NOT MEET THEIR NEEDS. 2913 PHYSICAL THERAPY AND REHABILITATION-THE PHYSICAL THERAPY AND REHABILITATION CENTER WILL PROVIDE EFFECTIVE, HIGH QUALITY, SPECIALIZED SERVICES FOR ALL PATIENTS. THE STAFF WILL INCLUDE LICENSED AND CERTIFIED PROFESSIONALS WHO HAVE TRAINING ,EXPERIENCE, AND SKILLS NECESSARY TO PROVIDE SERVICES THAT MEET EVERY INDIVIDUAL NEED. THE STAFF WILL IMPLEMENT A PROGRESSIVE, SPECIALIZED APPROACH TO INJURY TREATMENT THAT COMBINES PATIENT EDUCATION, INDIVIDUALIZED EXERCISE, MANUAL THERAPY, DRY NEEDLING, MYOFASCIAL RELEASE, MASSAGE, CUPPING, KINESIO- TAPPING,AND AQUATIC THERAPY.ALL STAFF WILL HAVE EXPERTISE IN TREATING YOUTH, HIGH SCHOOL,COLLEGE, AND PROFESSIONAL ATHLETES. AQUATIXELITE-AQUATIXELITE WILL BE A PART OF THE PHYSICAL THERAPY CENTER. IT IS AN AQUATIC REHAB PROGRAM DESIGNED FOR ATHLETES AT ALL LEVELS. AQUATIXELITE UTILIZES AN INJURY FREE ENVIRONMENT FOR HIGH-INTENSITY TRAINING AND REHAB. BY UTILIZING THE PROPERTIES OF WATER,THIS PROGRAM ACCELERATES ATHLETES' ABILITIES THROUGH PROVEN PROTOCOLS THAT INTEGRATE SPECIALIZED AQUATIC EQUIPMENT, GIVING WORLD-CLASS COMPETITORS THE ULTIMATE EDGE DURING REHAB AND CONDITIONING. THIS AQUATICS PROGRAM INTEGRATES PHYSICAL AND PSYCHOLOGICAL TRAINING TO ELIMINATE ANY FEARS OR HESITATION IN RETURNING TO A SPORT AFTER AN INJURY. IT ALSO OPTIMIZES LEVELS OF STRENGTH, NEUROMUSCULAR CONTROL, POWER, FLEXIBILITY, AND ENDURANCE DURING AN ATHLETES REHAB AND TRAINING. THE ATHLETE WILL IMPROVE THEIR SPEED, AGILITY, QUICKNESS,AND REACTION TIME TO BE ABLE TO ACHIEVE THEIR PEAK PERFORMANCE. THIS PROGRAM IS NOT CURRENTLY PROVIDED ANY WHERE IN THE WORLD AND WILL ALSO OFFER EDUCATIONAL OPPORTUNITIES TO TRAIN STAFF FROM COLLEGE AND PROFESSIONAL ATHLETIC PROGRAMS. SPORTS PSYCHOLOGIST/LIFE COACH-THE SPORTS PSYCHOLOGIST AND LIFE COACH WILL PROVIDE VALUABLE MENTAL SKILLS PROGRAMS WITH SOLUTIONS FOR ALL ATHLETES IN ALL SPORTS.THEY WILL PROVIDE INDIVIDUAL MENTAL SKILLS COACHING TO PREPARE ATHLETES TO DO WHAT THEY NEED TO DO WITHOUT HAVING TO THINK ABOUT IT AND DOING IT WHEN IT COUNTS ON A CONSISTENT BASIS.THE GOALS IS FOR EACH ATHLETE TO KNOW WHO THEY ARE, KNOW WHAT THEY WANT, AND KNOW WHAT TO DO WHEN THEY DO NOT GET IT. THEY WILL ALSO PROVIDE PROGRAMS TO ALLOW ATHLETES TO CONTINUE DEVELOPMENT IN THEIR SPORTS WHILE REHABILITATING PHYSICAL INJURIES AND TO BOLSTER THE MENTAL SKILLS OF THE ATHLETE DURING A TIME WHEN MANY LOSE THEIR IDENTITIES, THEIR CONFIDENCE, AND SOMETIMES THEIR WILLINGNESS TO CONTINUE TO PURSUE THEIR DREAMS. THEY WILL ALSO ASSIST RETIRING AND FORMER ATHLETES IDENTIFY NEW GOALS AND PASSIONS, UNDERSTAND 2914 HOW TO APPLY THE LIFE LESSONS THEY HAVE LEARNED PLAYING THE GAME IN THEIR NEW CAREERS,AND FIND CHALLENGES AND HAPPINESS IN THEIR NEXT CAREERS. RESEARCH AND EDUCATION CENTER-THE ANDREWS RESEARCH AND EDUCATION CENTER AND FOUNDATION IS A NON-PROFIT CENTER ESTABLISHED TO ADVANCE THE SCIENCE OF ORTHOPAEDIC CARE AND SPORTS MEDICINE TO EDUCATE NOT ONLY THE PROFESSIONAL COMMUNITY BUT ALSO THE GENERAL PUBLIC ON ISSUES THAT AFFECT THEIR DAILY HEALTH AND WELL-BEING. PREVENTION OF YOUTH SPORTS INJURIES AND MUSCULOSKELETAL MEDICINE PROGRAMS TO PREVENT AND TREAT INJURIES ARE A PRIMARY FOCUS AT THIS CENTER. THE RESEARCH AND EDUCATION INITIATIVES PROVIDE PROGRAMS THAT GENERATE NEW TECHNIQUES, TECHNOLOGY, AND METHODOLOGIES THAT ARE IMPLEMENTED IN DIRECT PATIENT CARE AND WILL IMPROVE SPORTS MEDICINE AROUND THE WORLD.THE FOUNDATION ALSO PROVIDES A FELLOWSHIP TRAINING PROGRAM UNDER THE WORLD RENOWNED ORTHOPAEDIC SURGEON, DR.JAMES ANDREWS.A PRIMARY CARE SPORTS MEDICINE TRAINING PROGRAM IS ALSO OFFERED TO PHYSICIANS WITH AN INTEREST IN SPORTS CARE. THE CENTER WILL ALSO PROVIDE A BIOMECHANICS LAB FOR THE THROWING ATHLETE FOR RESEARCH DATA, ANALYSIS,AND TO IMPROVE OUTCOMES. A CADAVER LAB WITH ALSO BE INCLUDED FOR EDUCATIONAL AND TEACHING PURPOSES. ALL THESE QUALITIES ARE UNIQUE TO A SPORTS MEDICINE FACILTY DUE TO THE VISION AND ACCOMPLISHMENTS OF DR.JAMES ANDREWS. CONCUSSION CENTER-THE CONCUSSION CENTER WILL OFFER A TEAM OF EXPERTS THAT USE EVIDENCED-BASED RESEARCH TO ASSESS, MANAGE, AND TREAT CONCUSSIONS IN PEOPLE OF ALL AGES AND ALL LEVELS OF ATHLETES. SPECIALIZED EXAMS AND TESTS WILL BE PROVIDED TO ALL ATHLETES AT THE CONCUSSION CENTER. THE STAFF WILL BE TRAINED TO TREAT VESTIBULAR, BALANCE, AND EYE MOVEMENT PROBLEMS THAT MAY OCCUR WITH CONCUSSIONS. THE CENTER WILL ALSO HAVE THE KNOWLEDGE TO PRESCRIBE ACADEMIC ACCOMMODATIONS TO ATHLETES AFTER A CONCUSSION. THEY WILL BE DETERMINED TO EDUCATE TEACHERS, COACHES, AND PARENTS ON CORRECT TREATMENT FOR AN ATHLETE THAT HAS BEEN DIAGNOSED WITH A CONCUSSION TO ALLOW FOR PROPER HEALING AND RECOVERY. SPORTS CARDIOLOGY CENTER-THE SPORTS CARDIOLOGY CENTER WILL PROVIDE ATHLETES WITH ESTABLISHED CARDIOVASCULAR DISEASE OR THOSE AT RISK WITH A COMPREHENSIVE INDIVIDUAL AND SPORT SPECIFIC CARDIOVASCULAR ASSESSMENT AND PATIENT CENTERED COUNSELING ON LIFESTYLE, PREVENTION, NUTRITION, AND TRAINING. PROGRAMS WILL BE DEVELOPED BY AN EXPERT CARDIOLOGIST FOR ATHLETES THAT WANT TO CONTINUE THEIR SPORT AND FORMER ATHLETES THAT WANT TO LIVE A HEALTHIER LIFESTYLE AFTER SPORTS. 2915 2916 APPENDIX N-10 2917 LEGAL OBJECTIONS ASCM, LLC herby notifies DCH of following legal objections to the process and the certificate of need law for the record. 1. The CON law as drafted and as applied violates the anti-monopoly clause of the Georgia constitution. Ga. Const. Art.3, §6, 11V; 2. The CON law as drafted and applied violates the Privileges and Immunities Clause of the Georgia Constitution. Ga. Const. Art. VI, § 1, 11 VII; 3. The CON law as drafted and as applied violates the Due Process Clause of the Ga. Const. Art. I, § 1, ¶VII; 4.The CON law as drafted and as applied violates the Fifth and Fourteenth Amendments of the U.S. Constitution because it violates ASCM LLC's rights to be free from irrational government restrictions and is a taking of ASCM LLC's property rights. 5. The CON law as drafted and as applied violates the Dormant Commerce clause of the U. S. Constitution under Article 1, Section 8, Clause 3 by interfering with access to healthcare by out of state residents and the provision of healthcare services by new out of state providers. 2918 McGuireWoods LLP Promenade 1230 Peachtree Street N.E. Suite 2100 Atlanta,GA 30309-3534 Tel 404.443.5500 Fax 404.443.5599 www.mcguirewoods.com yvictorLmoldovan ACVUIREWLJIJVS vmoldovan@mcguirewoods.com Direct:404.443.5708 'V! Fax:404.443.5777 September 1, 2015 Hand-Delivery Karesha Berkeley Laing Department of Community Health Division of Health Planning 2 Peachtree Street 5th Floor Atlanta, GA 30303 Re: ASMC, LLC, Project No. 2015-017 Dear Ms. Laing: Attached please find a letter of support from Michael Busch, M.D., Sports Director of the Sports Medicine Program and Pediatric Orthopaedic Surgeon at Children's Healthcare of Atlanta. Please let me know if you have any questions. 1f Very truly yours, Victor L. Moldovan SEP 012015 ORIGINAL yS4 7 1. : Atlanta I Austin I Baltimore I Brussels I Charlotte I Charlottesville I Chicago I Dallas I Houston I Jacksonville I LondonLosAngeles—Century City I Los Angeles-Downtown I New York I Norfolk I Pittsburgh I Raleigh I Richmond I Tysons Corner I Washington,D.C.I Wilmington 2919 Vt . Children's Georgia Orthopaedics of Pediatric Atlanta Subspecialists of c.,hdcrc' l....i_o August 27.2015 fi Rachel King Director,Division of Health Planning Department of Community Health 2 Peachtree Street,5't`Floor Atlanta.GA 30363 Dear Ms.King. 1 aro writing to express my support :'or the ASMC. LLC Certili.:ate of Need application Cor a planned outpatient surgery center in Alpharetta.GA. The ASN1C surgery center will be part of a slate-of-the-an comprehensive sports medicine center being developed in association with Dr lames Andrews, world renowned orthopaedic sports surgeon who I have known fair years. The project will include an office building for physician's offices, surgery, rehabilitation and physical therapy, diagnostic imaging, sports 1$4l ito:kt performance center, including various specialty sport academies and athletic fields. and a a., .,;,"sits ,",,;, Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care: and treatment or patients as well as economic development in term of investment and jobs creation and attract athletes nationally and internationally to this center of excellence. Atlanta has long been rccotnized as a major sports center for both amateur. collegiate and professional sports and this facility is :mended to become a destination location for treatment. education and research in the field of sports medicine. We hope to attract IS.n;Hndn,',tie•_:, titin] t{ , patients from the entire Southeast.not just from the Atlanta MSA. r' : >'• : , My practice is focused in pediatric orthopaedic sports medicine. 1 perform oxer 500 sports related surgical procedures annually,primarily at Children's}Healthcare of Atlanta. 14'e intend to be tmole•ed with this venture and promote e'.,en, further the specialty of pediatric and a n:,•,v„ adolescent sports medicine. I'm interested in supporting the comprehensive model being considered with this project including: the ability to properly educate and condition my patients prior to surgery, a world class surgical facility to perform surgery and the ability to rehabilitate 41: • my patients post-surgery all in one convenient location. I have referred patients to Dr.Andrews for consultation and surgery for specific sports injuries and will continue in the future. Having Dr.Andrews and this facility in Atlanta will remove a barrier to access for their treatment. I respectfully request your support for the ASMC, LLC application in helping bringing this unique facility focused on previdin_ first class comprehensive services to Georgia Sincerely. Akikalt Michael Busch.M.D. Sports Director Sports Medicine Program Pediatric Orthopaedic Surgeon Children's Healthcare of Atlanta 2920 n>Plc no, r,., tnh/')CC tenni Rachel King Director Division of Health Planning Department of Community Health 2 Peachtree Street RECEIVED 5th Floor Atlanta,GA 30303 D ORIGINAL AUG 0 6 2015 Oof ^:itt PlanningOfficeF.,u 8 Dear Ms.King, Georgia Department of Commun,ty Heaith I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. I am very excited about the opportunity to have a state-of-the-art comprehensive sports medicine center at the disposal for kids and parents in my community to be able to utilize. The center is being developed in association with Dr.James Andrews,world-renowned orthopedic sports surgeon. I had the pleasure of working for Dr.Andrews for 7 years as a biomechanist in the biomechanics laboratory located at his non-profit facility,the American Sports Medicine Institute(ASMI),in Birmingham, Alabama. While at ASMI,we worked relentlessly to identify why there was an up and coming epidemic"of baseball related pitching injuries. Children as young as 12 years old were coming into Dr. Andrews'clinic with baseball related injuries that were normally associated with 20-30 year olds. Many of the kids and young adults were travelling from the Atlanta and surrounding suburbs to Birmingham to have an established doctor like Dr.Andrews treat their injuries because there were no doctors in Atlanta with the expertise in the throwers shoulder and/or elbow. ASMC will have a collective group of doctors with high levels of experience with the throwers shoulder and/or elbow,so the throwing athletes in the region will now be coming into Atlanta to be evaluated,treated,and repaired. They will also have the fortune of staying after their surgical intervention for first class physical therapists that will be on campus also. I have a great interest in the Biomechanics laboratory section of ASMC,as I know the massive athletic population surrounding the Atlanta area can not only be able to utilize the strengths of a lab for injury prevention and performance enhancement in many sports, but also will give me,as an epidemiological researcher,an opportunity to have a vast amount of biomechanical data to analyze so we can inform the public on better,more efficient,and healthier ways to move in sports. Another avenue that will be explored in the biomechanics lab is the introduction of the first professional baseball draft combine. Most every other major sport has some sort of combine or pre draft workout facility where the professional organizations can view the prospective player and get valuable info and statistics. This idea has never been introduced in the sport of professional baseball,partly because of the logistics of getting everyone into the same place,at the same time;and having the appropriate staff to pull it off. ASMC will be tailor made to host this type of event,especially with the staff that is being collectively pulled together to take part in the center. This model could also be introduced globally as an avenue to thoroughly evaluate baseball talent for MLB organizations. 71511:55 2921 I am a former Division I baseball pitcher whose career was cut short due to baseball pitching related injuries and eventually surgery. I chose my college degree direction and therefore work related profession in life to help create for others the opportunities I never achieved by learning more about my physical and mental shortcomings. I grew up in the suburbs of Atlanta and was introduced to the profession"of travel baseball at a young age. Neither my parents,nor I were informed enough on the rigors that year round travel baseball would take on my adolescent body and how I would be negatively affected by something that meant so much to us at the time. !envision being able to use the data and the high volume of clients who use the facility to give direction to the baseball community around Atlanta and around the country on all aspects of baseball movement to keep them performing at their highest level,while staying injury free. After leaving ASMI,I started a company called Composing Motion Incorporated(CMI). CMI was designed to help Major League Baseball organizations to determine how likely the pitchers within each respective organization were to become injured based on pitching mechanics. I have since followed my passion into youth baseball to help curb the incidence of youth baseball injuries. When I began CMI 8 years ago,I was the only person in the country trained for pitching biomechanics that was working with Major League Baseball teams. Nobody else in the Atlanta area,let alone the Southeast United States does what I do for baseball pitchers. !have found a unique niche and the trickle down effect from MLB into youth baseball is fascinating for me. This training center gives me the opportunity to have an enormous impact on the future of youth and amateur baseball in Atlanta and the surrounding areas. Also,as of right now,I have high-level athletes from the Atlanta area that travel up to me in Athens,GA to train with me sometimes twice a week. Some are college and some are professional baseball pitchers. I have a network of doctors in Atlanta that will also refer me their highest-level pitchers whom they have performed surgery on,so I can perform rehab throwing with them to give them the best opportunity to return to their respective teams. Having this facility in Atlanta,will allow them to take greater advantage of any service that I can provide on a more consistent basis without the logistics of getting to and from Athens without getting caught in Atlanta traffic. Lastly,{would like to use this facility as an avenue to place talented athletes of all sports involved into college. With the high volume of athletes coming through the center,we could gather all necessary demographic and athletic data. This would make it easier for college coaches and professional scouts to view the full profiles of their prospective players and make a more informed decision on how each athlete may fit into each respective college or professional organization. Having this service available will no doubt bring athletes from all over the country to Atlanta for extended periods of time to train and receive the best available patient/player care around. Please try to envision the hub of sporting excellence that ASMC will become,especially with a unique doctor like Dr.Andrews backing the project. The meetings I have had with the people involved in bringing this vision to life have been nothing short of heart pounding. We have the opportunity to be the first sport medicine center of this magnitude with all the necessary branches in place on the same campus. The goal of this center is to have an impact on the youth community that will last throughout the playing careers of each athlete that comes through the doors. We can change the atmosphere of youth sports,and thus high school,college,and professional sports,to be one where the athletes and coaches are better informed about their sports. This direction of thinking and acting will help to keep 2922 athletes healthier and more knowledgeable than they have ever had the opportunity to be. I respectfully request your support for the ASMC,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. Ee04 F11(.6 Print Nam- AKV" Si:• •ture Date 6NlebS/MG, 1140-rind 146.. Team/University/Association affiliation 5 1i:560. 2923 ll We:4/PSPORTS & ENTERTAINMENT, INC.' 1RIGIioL August 5,2015 Ms. Rachel King,Director Division of Health Planning Dept.of Community Health 2 Peachtree Street,5th Floor RECEIVED Atlanta,Ga 30303 AUG 0 7 2015 RE: Andrews Medical Facility Office of Hoath P!anr.,ng eorgia Department of Community Health Ms.King: I am writing you to express my support of the proposed medical facility of Dr.James Andrews. As a sports agent we send all of our athletes to Dr.Andrews'facility in Pensacola, Florida when surgery is needed and when certain rehabilitation is required. With NFL players,when there are orthopedic injuries,the team doctor evaluates and makes the diagnosis for any injury. Under the NFL Players Association collective bargaining agreement,the player is entitled to a second medical opinion and I will tell you that probably 90%seek Dr.Andrews'opinion since he is the leading expert on sports injuries. If you ever look at ESPN programs on player injuries they always interview Dr.Andrews as he is the one doing the surgery on any high level athletes. The great thing about Dr.Andrews is that not only does he heal the high profile athlete but he sees all patients if he can help them. I will tell you that any facility in Atlanta would be an asset to the community and it would bring more business to the Atlanta area. We are going to send our athletes to Dr.Andrews in Pensacola regardless,but it sure would be a lot nicer to send them to Atlanta since it is closer and the air travel to Atlanta is so much easier. We will definitely be sending our clients to any Atlanta Facility of Dr.Andrews. If there is no facility,we will continue sending them to Pensacola. With this facility,you will bring more professionals(medical and athletes)to the Atlanta area. This facility will bring new jobs and provide medical graduates in Georgia the opportunity to remain in Georgia with their skills. Thank you for the opportunity to address this issue and if you have any questions please don't hesitate to call. Sincerely, Terry Williams www.vortex-se.com 1.888.451.3800 COLUMBIAOFFICE 1 1931 Bull Street I Columbia,SC 29201 2924 PO Box 68 I Columbia,SC 29202 803.254.3330 1803.256.3253 FAX fA 1OR&MATHIS 245 TownPark Drive,Suite 575 Real Estate Development,Management andLeasing Kennesaw,Georgia 30144 770-795-1330 / Fax 770-420-1372 July 7,2015 enIGINAL Rachel King Director RECEIVED Division of Health Planning Department of Community Health JUL 0 9 2015 2 Peachtree Street 5th Floor Office of Health Planning Atlanta, GA 30303 Georgia Department of Community Health Dear Ms.King, I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta, GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include office buildings for physician's offices, surgery,rehabilitation and physical therapy, diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in terms of investment and jobs creation and attract athletes nationally and internationally to this center of excellence. Atlanta has long been recognized as a major sports center for both amateur, collegiate and professional sports,and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support for the ASMC,LLC application in helping to bring this unique facility focused on providing first class comprehensive services to Georgia. Sincerely, Andrew Taylor President 1715 11t45 t Atlanta • Jacksonville • Miami • Orlando •Tampa 2925 qt.t SAYHpiuNÔs 2-o/ GEORGIA Tuesday,June 16,2015 Ms. Rachel King RECEIVED Director JUN 2 2 2015DivisionofHealthPlanning Georgia Department of Community Health Office of Health Piannin 2 Peachtree Street,NW Georgra Department ofCommunity Health Atlanta, Georgia 30303 Ms. King, I am writing this letter in support of Atlanta Sports Medicine Center (ASMC) request for a Certificate ofNeed. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with world renowned orthopedic sports surgeon Dr. James Andrews. The North Fulton development will be a multi-faceted 170,000 square foot facility located on a 32 acre campus to include office buildings for physician's offices, surgery rehabilitation and physical therapy, diagnostic imaging, sports performance center, including various specialty sport academies,athletic fields and a Foundation for research and education. I respectfully request your support for the ASMC CON application to help bring this unique first class facility to North Fulton County. I truly believe that with new top tier National Football League and Major League Baseball stadiums currently under construction, Atlanta Sports Medicine Center could emerge as a hub for the world's best athletes and a complete solution to all of their medical needs. This is a wonderful investment in North Fulton County and a huge economic development opportunity for the State of Georgia. Thank you for your consideration and feel free to call my office with any questions. Rusty Paul Mayor of Sandy Springs 7840 Roswell Road,Building 500 • Sandy Springs,Georgia 30350 • 770.730.5600 • 770.206.1420 fax • SandySp } GA.gov Jack Nicklaus May 28,2015 Dear Ms.King: Ej ' #ut:'Aiii I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr. James Andrews, world renowned orthopaedic sports surgeon. The project will be a multi-faceted 170,000 square foot facility located on a 32 acre campus and include an office building for physician's offices,surgery,rehabilitation and physical therapy, diagnostic imaging, sports performance center,including various specialty sport academies and athletic fields,and a Foundation for research and education. The State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment ofpatients as well as economic development in term ofinvestment and jobs creation and attract athletes nationally and internationally to this center of excellence. Atlanta has long been recognized as a major sports center for amateur,collegiate and professional sports and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support for the ASMC,LLC application in helping bringing this unique facility focused on providing first class comprehensive services to Georgia. Sincerely ti,,. k-14-----.. Ms.Rachel King JUN 0 4 20i5 Director Division of Health Planning Department of Community Health 2 Peachtree Street 5th Floor Atlanta, GA 30303 11780 U S.Highway#1,Suite 500,North Palm Beach,Florida 33408 THOMAS G. COUSINS 3445 PEACHTREE ROAD,SUITE 175 ATLANTA,GEORGIA 30326 404/233-4339 D ORIGINAL May 27,2015 Rachel King,Director Division of Health Planning Department of Community Health 2 Peachtree Street,5t'Floor JUN 0 2 2015 Atlanta,GA 30303 Dear Ms.King: I am writing to express my support for the ASMC,LLC Certificate of Need application for a planned outpatient surgery center in Alpharetta,GA. The ASMC surgery center will be part of a state-of-the-art comprehensive sports medicine center being developed in association with Dr.James Andrews,world renowned orthopedic sports surgeon. The project will be a multi-faceted 170,000 square foot campus located on a 32 acre campus and include office buildings for physician's offices,surgery,rehabilitation and physical therapy,diagnostic imaging, and a sports performance center will include various specialty sport academies and a Foundation for research and education. I have personal experience with Dr.Andrews,and I believe that the State of Georgia and local communities will benefit greatly from this center both in terms of providing care and treatment of patients as well as economic development in terms of investment and job creation. This center of excellence will attract athletes nationally and internationally. Atlanta has long been recognized as a major sports center for amateur,collegiate and professional sports,and this facility will become a destination location for treatment,education and research in the field of sports medicine. I respectfully request your support for the ASMC,LLC application in helping to bring this unique facility focused on providing first class comprehensive services to Georgia. Sincerely, N nGEORGIA DEPARTMENT OF COMMUNITY HEALTH VASTER FILE Nathan Deal,Governor Clyde L. Reese III,Esq.,Commissioner 2 Peachtree Street, NW I Atlanta, GA 30303-3159 I 404-656-4507 I www.dch.georgia.gov CERTIFICATE OF NEED GA2015-017 ASMC,LLC D/B/A ATLANTA SPORTS MEDICINE CENTER OPPOSITION MEETING AUGUST 27,2015 2:00 P.M. AGENDA Introduction Rule 1112-2-.08(1)(4)4: Any party who is opposed to an application, or to an application(s) submitted during a batching cycle must submit a notice ofopposition, on the form provided by the Department, no later than the sixtieth (60th) day of the batching review cycle. The notice must contain the information specified by the form. The notice of opposition form submission shall also include one signed original of the written vendor lobbyist certification required by 111-2-2-.03(2). The notice of opposition must not contain the substantive arguments against a particular application. II. PURPOSE Rule 111-2-2-X8(1)(04: Those parties who are opposed to an application will be given an opportunity to meet with the Department at a time and place specified by the Department after a review of the opposition notices. The opposition meeting provided for by O.C.G.A. if 31-6-43(h), shall be held no earlier than the ninetieth(90th)day of the batching review cycle. The applicants) shall be entitled to attend the opposition meeting. The opposition parties shall bring to the opposition meeting substantive written comments and arguments regarding the nature of their opposition to the particular project. The opposition parties must provide an original and one copy of the substantive opposition comments to the Department at the meeting, and also provide one copy ofthe substantive opposition comments to the applicant at the opposition meeting. The applicant(s) will not be allowed to speak in rebuttal of the opposition remarks at the opposition meeting. The Department shall make no formal substantive comments regarding the review of the application(s) at the opposition meeting. In order for an opposing party to have standing to appeal an adverse decision pursuant to O.C.G.A. §31-6-44, such party must attend and participate in an opposition meeting. III. Project Description ASMC, LLC d/b/a Atlanta Sports Medicine Center has requested a Certificate of Need for the development of a single-specialty ambulatory surgery center ("ASC") in Alpharetta, Fulton County, Health Information Technology I Healthcare Facility Regulation I Medical Assistance Plans I State Health Benefit Plan Equal Opportunity Employer 2929 rk' GEORGIA DEPARTMENT UOF COMMUNITY HEALTH Georgia. The proposed ASC will specialize in orthopedic surgery and consist of four operating rooms, two procedure rooms and the necessary staff support, patient preparation, recovery and discharge areas. The proposed ASC will be developed as part of an athletic complex, which will be equipped to provide comprehensive training, rehabilitation and medical services to amateur and professional athletes. The total estimated cost of the project is $12,453,405. The applicant is making a five percent(5%)service specific indigent and charity care commitment with the proposed project. IV. Opposition Presentation(s) Northside Hospital, Inc. d/b/a Northside/Alpharetta Surgery Center Northside Hospital,Inc. d/b/a Northside Hospital-Atlanta Northside Hospital,Inc. d/b/a Northside Hospital-Cherokee Northside Hospital,Inc.d/b/a Northside Hospital-Forsyth Emory University d/b/a Emory University Orthopaedics and Spine Hospital Emory Ambulatory Surgery Center at Dunwoody, LLC The Emory Clinic.d/b/a Emory Orthopedic and Spine Physiatry Outpatient Surgery Center EHCA Johns Creek, LLC d/b/a Emory Johns Creek Hospital Saint Joseph's Hospital of Atlanta, Inc. d/b/a Emory Saint Joseph's Hospital Atlanta Surgery Center, LTD d/b/a Atlanta Outpatient Surgery Center Marietta Outpatient Surgery, LTD d/b/a Marietta Surgical Center Piedmont Hospital,Inc. d/b/a Piedmont Atlanta Hospital Piedmont West Ambulatory Surgery Center, LLC North Fulton Medical Center,Inc.d/b/a North Fulton Hospital Oral presentations are not to exceed fifteen(15)minutes. V. Deadlines 120-Day Decision Date:September 26, 2015 Amendments/Response to Opposition Deadline: September 16, 2015 (110th day ofreview) Health Information Technology I Healthcare Facility Regulation I Medical Assistance Plans I State Health Benefit Plan Equal Opportunity Employer 2930 nGEORGIA DEPARTMENT OF COMMUNITY HEALTH Nathan Deal,Governor Clyde L.Reese III,Esq.,Commissioner 2 Peachtree Street, NW I Atlanta, GA 30303-3159 I 404-656-4507 1 www.dch.georgia.gov CERTIFICATE OF NEED GA2015-017 ASMC,LLC D/B/A ATLANTA SPORTS MEDICINE CENTER OPPOSITION MEETING AUGUST 27,2015 2:00 P.M. ATTENDANCE SHEET PLEASE SIGN YOUR NAME BELOW TO INDICATE YOUR ATTENDANCE. THANK YOU. NAME DEPARTMENT/ORGANIZATION it ; /1 M'\. 1 f t t\ v,- ;11) imYA 1 P. ttgccou Thoyvukcit jovii, paq (oh vd444- AimiA_ Fdietkv, A jesr‘all /117d vkc.„4„ j.611,1_, h' ` ( d ( O}i , M e W 62 1,-- 9,41 IS vo„,,,k1 A)2A.dsv-i: 0e_fit- Health Information Technology f Healthcare Facility Regulation I Medical Assistance Plans I State Health Benefit Plan Equal Opportunity Employer 2931 rGEORGIA DEPARTMENT F OF COMMUNITY HEALTH 1 Nathan Deal,Governor Clyde L.Reese Ill,Esq.,Commissioner 2 Peachtree Street, NW I Atlanta,GA 30303-3159 I 404-656-4507 I www.dch.georgia.gov CERTIFICATE OF NEED GA2015-017 ASMC,LLC D/B/A ATLANTA SPORTS MEDICINE CENTER OPPOSITION MEETING AUGUST 27,2015 2:00 P.M. ATTENDANCE SHEET PLEASE SIGN YOUR NAME BELOW TO INDICATE YOUR ATTENDANCE. THANK YOU. NAME DEPARTMENT/ORGANIZATION 1.: i A-\\, Z-- SIT _ LIHht-t- ce gr.'A*, I-ec.., .,p4 PJo 4-1--s,cot h( a3e,4., U Best-cU Klu -vrS,x kAosk JC Ol1',Gur & .\,.r-r„. , t A - k Nosyk\ Ae=.2 ID C qn.A.acev,<Atiy 604- AJC!-1 IP' 1)C_Al Health Information Technology I Healthcare Facility Regulation I Medical Assistance Plans I State Health Benefit Plan Equal Opportunity Employer 2932 le EMORY Office of the General Counsel Representing Emory University and Emory Healthcare August 27, 2015 Rachel L. King,J.D. Executive Director, Office of Health Planning Department of Community Health k1== > 2 Peachtree St,NW, 5th Floor Atlanta, GA 30303 Re: Project No. GA 2015-17 ASMC, LLC d/b/a Atlanta Sports Medicine Dear Ms. King: The attached Statement of Opposition is submitted pursuant to Department Rule 111-2-2- 07(1)(h)(1)on behalf of the listed Emory entities in connection with the above-described application for a Certificate of Need to develop a single specialty orthopedic surgery center. Should you have any questions or require additional information,please contact me. Thank you for your attention to this matter. Sincerely, C- ) w f"r, :, Jeffrey B r Associ e Ger1ral Counsel AUG 2 7 2015 Emory University 71`,1,!.-,.: !;;;;I:-, AHP 27115 21:1 riPti Emory University Tel 404.727.6011 101 Administration Building Fax 404.712.5522 Atlanta,GA 30322 2933Anequalopportunity,affirmative action university Project No. GA 2015-017—ASMC,LLC d/b/a Atlanta Sports Medicine Center Statement of opposition on behalf of: The Emory Clinic,Inc. d/b/a Emory Orthopedic and Spine Physiatry Outpatient Surgery Center Saint Joseph's Hospital of Atlanta, Inc. d/b/a Emory Saint Josephs' Hospital Emory University d/b/a Emory University Orthopaedics and Spine Hospital EHCA Johns Creek,LLC d/b/a Emory Johns Creek Hospital Emory Ambulatory Surgery Center at Dunwoody LLC d/b/a Emory Ambulatory Surgery Center collectively referred to as "Emory") Emory submits this Statement of Opposition pursuant to O.C.G.A. §31-6-43 and Department of Community Health("DCH", or the"Department") Rule 111-2-2-.07(1)(h)(1)to the application for a Certificate ofNeed ("CON")filed by ASMC, LLC d/b/a Atlanta Sports Medicine Center ASMC") seeking approval to develop a single specialty orthopedic ambulatory surgery service in Alpharetta, Fulton County,Georgia. The Emory entities listed above have previously submitted notices of their opposition as required by the above cited regulations. Emory strongly asserts that the ASMC application is not consistent with applicable DCH rules under which it must be reviewed, most importantly Rule 111-2-2-.40 Service Specific Considerations for Ambulatory Surgery Services(the"ASC Rule"). ASMC's contention that this service specific rule does not apply should be rejected by the Department, and correct application of the need formula and exception criteria based on the guidelines established by Georgia courts and Department precedent mandate that this application be denied. The ASC Rule should be applied: The ASC Rule contains a need formula that calculates the projected demand for ambulatory surgery services by the population of the defined service area and the capability of the existing ambulatory surgery services to meet that demand. The ASMC proposed location is in the northern part of the metro Atlanta area, which is designated as Health Planning Area 3 ("HPA 3"). The current computation of the need formula projects a surplus of 73 ambulatory surgery operating rooms in HPA 3. The need methodology also assesses whether the existing 1 2934 ambulatory surgery services are being effectively utilized at an aggregate level of 80%or higher; the current aggregate utilization rate is 57%. ASMC argues that this need methodology is not relevant because it projects to draw its surgical patients from outside HPA-3,with 40%estimated to come from outside Georgia,and 28% estimated to come from Georgia outside HPA-3, hence the ASC Rule is not applicable. This argument fails for several reasons: There is no precedent in the application of the CON Rules to ignore a service specific rule under these circumstances—the Rule is the Rule. ASMC may be suggesting that its application is analogous to the destination cancer hospital analysis, but that position is without merit because destination cancer hospitals were created under a statutory exception. Emory further notes that there have been issues for DCH with enforcing compliance of the one existing destination cancer hospital with its statutory requirement to maintain a cap on the percentage of patients from Georgia admitted. Moreover, in this instance, ifthis ASC were to be developed,there would be no authority available to the Department to require ASMC to maintain patient origin consistent with its"estimated projections" in the application. Emory, as will be discussed below, further submits that there is insufficient basis presented in the application to credibly support the projected patient origin. Hence the ASC Rule is to be applied, and the need methodology is nowhere near met. ASMC is left to try to demonstrate consistency of its application with the exception criteria in the ASC Rule. ASMC cannot show that its application will remedy an atypical barrier based on cost, quality,financial access,or geographic accessibility: The ASC Rule states that the Department in its application of the Rule may allow an exception to the need methodology where the applicant demonstrates that its proposal will "remedy an atypical barrier to ambulatory surgery services based on cost,quality, financial access, or geographic accessibility." The standard that an applicant must meet in this regard has evolved from a decision of the Georgia Court of Appeals in the Hughston matter,which involved an application for an ambulatory surgery center in Columbus. The Hughston test sets out a three pronged approach under which an applicant must show: The proposed services are not available in the service area; There is a population that is unserved; and The proposed project will remedy the problem. 2 2935 ASMC suggests that its proposal "meets the exception for a barrier to access based on geography, finances and quality." Its main argument in support is that Dr. Andrews"does more Tommie John"(sic) surgeries in the country and has been covered extensively by the press for it." Emory submits that the appropriate analysis here should not focus on Dr. Andrews's reputation or experience in connection with performing this surgical procedure on professional and other athletes. While Dr. Andrews reputation is widely known in professional athletic circles,that he does not currently operate in Georgia in no way establishes the existence of a barrier to necessary care under the Hughston test. There is no statistical evidence that Georgians do not have access to Dr. Andrews at his Gulf Breeze,FL facility—Dr. Andrews performed the Tommy John procedure on only 11 Georgia residents at the Florida facility in 2014. Dr. Andrews performed 97%of the Tommy John surgeries at the GulfBreeze facility in 2014. Dr. Andrews is in the twilight of his career and it does not appear that there has been an effort to develop other surgeons to perform the complex Tommy John procedures. This almost complete reliance on Dr. Andrews with no obvious heir apparent begs the question of will the ASMC be a center for Tommy John procedures once Dr. Andrews is no longer practicing. Dr. Andrews at 73 is,by his own acknowledgment,nearing the end of his operating career. In an ESPN article2 submitted with ASMC's Additional Information filing, Dr. Andrews admits he has reached the twilight of his career. But the long hours have taken their toll. Seven years ago, a heart attack almost killed him, and many who know him attribute that event at least partially to overwork As a consequence, he has in fact slowed down. He sees probably half as manypatients now as he didjust before the heart attack andperforms half the number ofsurgeries (downfrom 1,200 a year at his peak, he says). He isfully aware that he has reached "the twilight ofmy orthopedic career." The Tommy John procedure has come under scrutiny in recent years. The number of Tommy John procedures has been steadily increasing. Dr. Andrews characterized the increased A patient-level database is available from the Florida Agency for Healthcare Administration for ambulatory surgery facilities at http://www.tloridahealthfinder.gov/Researchers/OrderData/order-data.aspx. This database contains approximately almost 100 data elements for each patient seen at a facility(data dictionary detailing data elements is attached). The analyses presented are based on the database of CY 14 discharges from Andrews Institute ASC-#14960631 2"The Doctor Will Save You Now",http:i/espn.go.comiespn/story,' /id/9669812/celebrated-orthopedist-iames- andrews-treats-robert-griffin-iii-bryce-harper-espn-mgazine 3 2936 incidence of Tommy John surgeries as an epidemic3 and he has co-developed an app that is trying to stem the tide ofthese devastating injuries"4 In addition,there is significant controversy about the advisability of anyone other than a professional athlete having the Tommy John procedure. At his recent induction into the Baseball Hall of Fame, John Smoltz warned against Tommy John surgery for teens.5 A recent study found that 15-to 19-year-olds accounted for 57 percent of the Tommy John surgeries that occurred between 2007 and 2011. Young adults between 20 and 24 accounted for another 22 percent.6 Another study found that"51 percent of high school athletes believed the surgery should be performed in the absence of injury with the sole intention to improve performance". Furthermore,the analysis of need for a new orthopedic surgery center under the Hughston test as to whether a barrier to access has been demonstrated cannot be limited to one procedure projected to constitute a small percentage of the total surgeries to be performed—a recent study8 found that between 2007 and 2011, a total of 790 patients (average of 158 per year)underwent Tommy John surgery in the U.S. ASMC does not represent,nor could it, that the other orthopedic procedures projected to be performed are not currently performed by numerous qualified providers as quality facilities in the service area. Neither are the additional non-surgical services proposed to be offered by ASMC unique, and are readily available at Emory and multiple other sports medicine oriented programs in the area. If the development of the sports complex focusing on post-surgical and training is Dr. Andrews's priority,he can do so without CON approval. Nor do ASMC's representations regarding its intent to develop surgical and related training programs,or its proposed outreach programs, demonstrate any unavailability of services. In addition to other programs in the area, Emory provides: An ACGME accredited orthopedic sports medicine training program–2 sports fellows per year A Primary Care- Sports Medicine Fellowship An Athletic Trainer Residency Program (6 AT's per year) 3 Tommy John surgery now'an epidemic',USA TODAY,April 11,2014 http://www.usatoday.com/story/sports/mlb/2014/04/l 1/tommy-john-elbow-surgery-strasburg-parker- corbin/7583413/ http://espn.go.com/mlb/story/_/id/11002986/drfames-andrews-app-aiming-limit-tommyjohn-surgeries http://www.forbes.com/sites#/sites/bobcook/20I5/07/26/in-hall-of-fame-speech:john-smoltz-warns-against- tommyjohn-surgery-for-teens/ 6 http://consumer.healthday.com/kids-health-information-23/adolescents-and-teen-health-news-719/teens- increasingly-likely-to-have-tommy-john-surgery-study-70 1292.html http://www.sportsmed.org/uploadedFiles/Content2/Media/Press_Room/Press_Releases/Specialty_Day_2010/ Tommy%20JohnL%20press%2orelease.pdf B"Trends in Medial Ulnar Collateral Ligament Reconstruction in the United States",The American Journal of Sports Medicine,July 2015,http://ajs.sagepub.comlcontent/43/7/1770 4 2937 Other Orthopedic Fellowships(Spine-5 per year,Tumor– 1 per year,Joint Replacement 2 per year,Pediatrics– 1 per year) ASMC goes on to suggest,under a geographic access argument,that there is a barrier to Dr. Andrews' services because airport service to his Gulf Breeze facility is inferior to getting to Alpharetta by air. First,Emory asserts that the Department is not in the position to apply the Hughston test to a multi-state service area to ascertain whether a geographic barrier to any service is present. Second, accepting this argument would support locating any desired service in Atlanta with its busy airport to improve geographic accessibility. Third, it is questionable whether flying into Hartsfield Jackson and then driving to Alpharetta during most hours of the day is in fact easier than getting to the Gulf Breeze facility,which is 10 miles(20 minutes)from the Pensacola airport compared to 38 miles (55 minutes)from the Atlanta airport in non-rush hour traffic. Finally, it is virtually impossible to navigate the trip from the Atlanta airport to the proposed Alpharetta site by mass transit. In addition,there is ample cause to doubt the veracity of ASMC's overall patient origin projection. Even a statistic as simple as the number of Georgia residents treated cannot be trusted. The application indicates that 75 patients were from Georgia;however,data submitted by the center to the indicates only 58 Georgians were treated—an overstatement by ASMC of almost 30%. ASMC alleges that 40%of its patients will be from out of state and indicates that "These projections are based on historical annualizedpatient origin (orthopedic surgerypatients) experience at the Andrews Institute affiliation ASC in Pensacola, FL." An analysis of CY14 data for Andrews Institute ASC in Gulf Breeze9 does not support these numbers and indicates that only 22%of orthopedic cases originated out-of-state. In addition,it is important to note that Gulf Breeze is only 20 miles by road from the Florida/Alabama border, while the proposed ASMC site in Alpharetta is approximately 75 miles by road from the Georgia border. Applying the 75 mile radius to the CY14 Gulf Breeze facility orthopedic data indicates that 8% of its patients resided in Alabama but within 75 miles of the Gulf Breeze facility. Thus the percentage of the GulfBreeze patientsfrom out-of-state minus Alabama residents within 75 miles (the same distance that the Georgia site is from the Georgia border) equates to only 14%. This is much lower than the 40% ofout-of-state patients that ASMC isprojecting in its CON application. ASMC indicates that"Georgia and Alabama are PSA states". The commonly accepted definition of Primary Service Area(PSA)is the geographic area from which 75%of patients are 9 Database from Florida Center for Health Information and Policy Analysis containing patient-level information for CY14 discharges from ANDREWS INSTITUTE ASC-#14960631 5 2938 residents. This suggests that 15%of patients will come from Alabama since 60%are projected to come from Georgia. Therefore, over one-third of the 40% from out-of-state will be coming from.Alabama. This suggests that the ASMC geographic draw is substantially narrower than the map in Appendix E, which shows a service area with a radius of approximately 550 miles around Atlanta encompassing parts of 18 states. In addition, the ASMC application indicates that 22%of its patients will come from outside Georgia and contiguous states. The Gulf Breeze experience is that only 7% came from outside Florida and contiguous states. Furthermore, The Emory Clinic's Executive Park ASC,with highly developed expertise and a strong reputation in the sports medicine related procedures, including treatment ofprofessional athletes, draws less than 5%of its patients from outside Georgia. It is also interesting to note that two of the top ten procedures that ASMC indicates will be performed in the Georgia facility are epidural injections. It is unlikely that patients will come from out of state for these procedures. Another example from the CON application that casts doubt on ASMC's assertion that it has a huge geographic draw is its admission that while 28%of its patients will come from Georgia HPAs, it expects those patients to mostly come from North Georgia counties(HPAs 1 —7). The distance from Alpharetta to farthest point in the HPAs referenced is only 180 miles. Thus they do not believe that many Georgia residents are likely to travel more than 3 hours for the services offered. The basis for the volume projections is unclear other than the statement that "Dr. Andrews and his colleagues have through historical experience treating athletes andpersons experiencing sports, recreational and work relatedphysical injuries have determined that there is a definitive needfor this type ofcampus and that they have established national and regional referral relationships to meet projectedpatient origin. " ASMC projects a volume of 2,395 in Year 1 and 3,799 in Year 2. Curiously,even though when it revised the application to seek approval as a single specialty orthopedic ASC rather than a multi-specialty facility as originally requested, and consequently reduced its stated array of specialty procedures/physicians from seven to two,ASMC did not revise its volume projections. In comparison,the CY14 volume in the 4 ORs at the Emory Orthopedic Outpatient Surgery Center was approximately 2,600. These procedures were perfoiined by 13 physicians. ASMC's statement that"[Titre projections anticipate that all will be patients served by doctorsaffiliated with ASMC, rather than a competing orthopedic or sports medicine practice." implies that ASMC will recruit physicians new to the area. It is difficult to imagine that physicians new to the market could generate almost as many surgeries as a long-established practice in Year 1 of being in the market. Even more unbelievable that in the Year 2 ASMC will perform 146%ofthe volume at an established orthopedic only ASC. 6 2939 A comparison was performed between the procedures performed at Emory facilities and those performed at the Gulf Breeze facility. Only two procedurestll were performed at the Florida facility and not at the Emory facilities. One was the Tommy John procedures discussed in detail earlier. The other one (CPT Codes 29848 –an arthroscopic wrist procedure)was only performed 57 times at the Florida facility in CY14 (fewer than 5 times a month). Emory accordingly asserts that it is clear that the absence of a single purpose orthopedic ASC in which Dr. Andrews performs Tommy John procedures does not demonstrate that orthopedic surgical services are not available in the service area due to a quality or geographic access barrier as required under the first prong of the Hughston test,nor that there is a population that is unserved per the second prong of the Hughston test. Addressing the ASMC suggestion that its facility would improve financial accessibility to sports related orthopedic surgical procedures, Emory submits that ASMC's arguments are misleading for the following reasons: ASMC is being disingenuous with regard to its Indigent and Charity Care Program targeting to high school athletes. ASMC's statement that it"will also provide uncompensated diagnostic, surgical and therapeutic services to Georgia high school athletic programs whose athletes do not have adequate health insurance" is an empty promise. High schools in Georgia require parents to sign a form stating that they have purchased either the necessary school insurance or possess a family insurance plan that covers athletic injury. In addition, in Georgia, high school student-athletes are covered for life-altering injuries sustained in sports by a$5 million catastrophic insurance policy. The state's governing bodies for athletics—the Georgia High School Association(GHSA)and Georgia Independent School Association (G1SA)—purchase the policy'°. ASMC-is also being disingenuous with its information about charges. ASMC's list of projected charges for the top ten procedures is misleading. It is showing the charge for individual CPT codes; however, only half of the GulfBreeze patients with one of the 10 listed codes in the table had only one procedure. Therefore,the average charge per patient is significantly higher than shown on the table. As an example, 96%of patients at the Gulf Breeze facility with a primary CPT code of 29827 had more than one procedure and 65%had at least 4 procedures. Therefore, the average total charge for those patients was $25,79411, not the$11,946 shown in the CON. i11 With volumes greater than 36 10 http://news.shepherd.org/catastrophic-care-coverage-for-high-school-athletes Il Database from Florida Center for Health Information and Policy Analysis containing patient-level information for CY14 discharges from ANDREWS INSTITIJ 1 h ASC-#14960631 7 2940 In addition, the unrealistically low projected charges based on actuals in Floridal`)are close to or higher than the average charge for many of the procedures at Emory facilities. As an example the average charge for patients with 29827 as the primary procedure was only $9,650 at Emory's Ortho ASC—lower than the single procedure charge shown in the CON and 37% of the average charge per patient at GulfBreeze. CY14 Avg Charge per Florida Database for Patients with CON Year 1 Actual Charge as Average Charge at Code CPT Code Listed as Primary Charge in CON %of CON Charge Emory Facilities 29827 25,794 11,946 216% 9,650 29824 20,898 11,946 175% 8,120 29807 20,063 11,946 168% 8,049 63030 20,290 11,307 179% N/A 23412 13,193 10,344 128%11,032 29881 9,169 6,452 142% 5,333 64721 I2,358 3,459 357% 5,198 62311 2,340 1,680 139% 1,994 62310 2,340 1,680 139% 2,000 22551 N/A N/A N/A N/A Note:Pink shading highlights instances where the average charge perpatient at Emory's Ortho ASC is less than the average charge perprocedure projected for the Alpharetta ASC. Since ASMC cannot demonstrate that the first two prongs of the Hughston test are met, analysis of the third prong is moot. Development of the ASMC facility would not remedy any barriers by providing necessary, otherwise unavailable surgical care;rather, it would undercut the Department's health planning goals of developing only those services determined to be needed by Georgia's population and promoting efficient utilization of existing services. Several of the General Considerations (Rule 111-2-2-.09) are not met: ASMC's application, as amended and modified by additional information, does not demonstrate consistency with the applicable General Considerations: Rule 111-2-2-.09(1)(a)–the proposed project is not reasonably consistent with the stated goals of the Ambulatory Surgery Services Component of the State Health Plan ("Component Plan"). The Component Plan addresses the need for ASC services by planning area in Georgia,and does not embrace the development of ASC services to serve an out of state population, or to provide services on a statewide basis,as ASMC proposes. The Component Plan does embody the customary CON goals of encouraging effective utilization of existing ASC services,which ASMC's project would adversely impact. Further, based on the factors set out above,the ASMC proposal is not consistent with the Component Plan goals and guidelines in that it does not demonstrate any barriers to access to ASC services based on cost,quality, financial or geographic access, and that at best the ASMC facility would be redundant to the existing quality sports medicine programs in HPA 3. 8 2941 Rule 1 l-2-2-.09(1)(b)—ASMC's application does not demonstrate that its project is needed in the defined planning area, or in Georgia for that matter,based on any accepted health planning methodology. Nor does it meet the criteria that has been set out by Georgia Courts and developed by the Department to apply the exception in the ASC rules. Rule 111-2-2-.09(1)(c)—As discussed above, there are multiple alternative facilities offering outpatient orthopedic surgical procedures in HPA 3,which ASMC cannot dispute or contest. Moreover, there are multiple alternative facilities offering the orthopedic procedures most often related to sports oriented injuries that ASMC projects to offer, with the exception of the Tommy John surgery,which is not frequently performed in HPA 3 or in Georgia,or in the US for that matter. As documented above, the Tommy John procedure is,or should be, an elective procedure performed on a minute percentage of elite athletes. There is no documentation in the ASMC application that these athletes cannot access his Gulf Breeze facility;rather, it is asserted only that Alpharetta would be more convenient. To the extent that ASMC is positing that its facility should be developed in order to make the Tommy John procedure available to a broad spectrum of Georgia athletes,particularly high school athletes, the medical necessity and appropriateness of that position are in serious dispute. Rule 11 I-2-2-.09(1)(e)—As noted above, contrary to ASMC's representation otherwise, ASMC's proposed charges do not appear to be credible,based on the experience at its Gulf Breeze facility. Rule 111-2-2-.09(1)(h)—Emory submits that the ASMC proposal will not have a positive relationship with the existing health care delivery system if developed. As asserted above, ASMC's projection regarding out of state and non-HPA 3 residents who would utilize the ASC is not supported in the application,nor is it supportable,hence to achieve its projected volumes the ASC would have to take patients residing in HPA 3 that currently have ready access to existing, quality outpatient orthopedic surgery services. ASMC would also in all likelihood look to hire local surgeons, who currently operate at existing facilities. Further, it is important to note that the local surgeons hired away by ASMC would not be employed for the purpose of performing Tommy John procedures, as ASMC avers that that procedure is not currently available in HPA 3 or Georgia. Emory notes that the Orthopedic and Spine Physiatry Outpatient Surgery Center at Executive Park focuses heavily on sports related orthopedic procedures,and that the volume of orthopedic surgeries at Emory Ambulatory Surgery Center at Dunwoody is growing as that ASC moves into its second year of operation under Emory. Emory's orthopedic and spine surgeons also perform sports related outpatient orthopedic procedures at Emory University Orthopaedic and Spine Hospital. The outpatient orthopedic programs at Emory Saint Joseph's Hospital and Emory Johns Creek Hospital are growing as well. 9 2942 Each of these facilities would be negatively impacted by the proposed ASMC project, with the most adverse impact falling on the Executive Park and Dunwoody ASCs. Collectively these facilities performed orthopedic surgical procedures on 2,521 patients from HPA 3 in 2014. Given the strong likelihood that, for the reasons advanced above, ASMC's proposed facility would draw significantly more patients than projected from HPA 3 ifdeveloped, the resulting adverse impact on the Emory and other ASCs and hospital based services would not result in a positive impact on the existing delivery system for outpatient orthopedic procedures. Rule 111-2-2-.09(1)(i)—ASMC projects that 40%of its patients would come from outside Georgia, and 28%of its Georgia patients would come from outside HPA 3. For the reasons stated above,Emory disputes the accuracy of these projections because they are not supported in fact nor are they are not based on any credible health planning methodology. Emory further submits that even if ASMC's projections were believable,they do not justify award of an exception under the ASC rule since no access barriers have been demonstrated to be present. If projecting to serve out of state/planning area patients consistent with this General Consideration is somehow interpreted to warrant ignoring the ASC rule and the balance of the General Considerations, Emory points out that this Rule Ill-2-2-.09(1(i)does not entail any enforcement mechanism against the approved applicant which the Department can utilize if the out of state/planning area projections prove to have been misrepresented. Rule 111-2-2-.09(1)(1)—Emory reiterates that it offers the extensive array of training programs for physicians and affiliated professionals in the orthopedic space described above, and that ASMC's proposal does not offer any programs not already available in the service area in this regard. ASMC has not documented the requisite site entitlement Rule 111-2-2-.06(5)(b)6. requires the applicant to document entitlement to its proposed site in order for its application to be deemed complete. ASMC presented two documents: a Draft Lease Agreement between landlord Atlanta Sports Medicine Center, LLC and itself as tenant for a Suite in a building planned, but not yet constructed on land not yet owned by the putative landlord; and an Agreement of Purchase and Sale of the property between the current owner and Atlanta Sports Medicine Center, LLC. While the Agreement of Purchase and Sale has been executed, it does not appear to have been performed, and there is no requirement that Atlanta Sports Medicine Center LLC acquire the property, even if the CON is awarded. Since ASMC lacks the legal capability to require Atlanta Sports Medicine Center LLC to either perform under the Agreement of Purchase and Sale, or execute the Draft Lease Agreement, Emory submits that it has not documented site entitlement in accordance with the Department's historical application of this requirement,and the application should not have been deemed complete,nor can it be approved. 10 2943 Conclusion Based on the foregoing,Emory asserts that ASMC's application does not demonstrate consistency with the applicable Department considerations, and should be denied. 11 2944 The American Journal of Sports Medicine http://ajs.sagepub.com/ Trends in Medial Ulnar Collateral Ligament Reconstruction in the United States: A Retrospective Review of a Large Private-Payer Database From 2007 to 2011 Brandon J. Erickson, Benedict U. Nwachukwu, Sam Rosas,William W. Schairer, Frank M. McCormick, Bernard R. Bach, Jr, Charles A. Bush-Joseph and Anthony A. Romeo Am J Sports Med 2015 43: 1770 DOI: 10.1177/0363546515580304 The online version of this article can be found at: http:/lajs.sagepub.com/content/43/7/1770 Published by: SAGE http://www.sagepublications.com On behalf of: American Orthopaedic Society for Sports Medicine jci AOSSM Additional services and information for The American Journal ofSports Medicine can be found at: Email Alerts:http://ajs.sagepub.com/cgifalerts Subscriptions:http://ajs.sagepub.comisubscriptions Reprints:http://www.sagepub.comljoumalsReprints.nav Permissions:http://www.sagepub.com/joumalsPermissions.nav Version of Record-Jun 30, 2015 What is This? Downloaded fromajs.sagepue.00mat EMORYUNIVon My15,2015 2945 Trends in Medial Ulnar Collateral Ligament Reconstruction in the United States A Retrospective Review of a Large Private-Payer Database From 2007 to 2011 Brandon J. Erickson,*t MD, Benedict U. Nwachukwu,* MD, MBA, Sam Rosas,§ BS, William W. Schairer,t MD, Frank M. McCormick,§ MD, Bernard R. Bach Jr,t MD, Charles A. Bush-Joseph,t MD, and Anthony A. Romeo,t MD Investigation performed at Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago Illinois, USA Background:Overuse injuries to the elbow in the throwing athlete are common.Ulnar collateral ligament reconstruction(UCLR), commonly known as Tommy John surgery,is performed on both recreational and high-level athletes.There is no current literature regarding the incidence and demographic distribution of this surgical procedure in relation to patient age, location within the Unites States, and sex. Purpose: To determine the current demographic distribution of UCLR within the US population included in the PearlDiver database. Study Design: Descriptive epidemiology study. Methods:A retrospective analysis of the PearlDiver supercomputer database,a private-payer database,was performed to iden- tify UCLR procedures performed between 2007 and 2011.The Current Procedural Terminology(CPT)code 24346(reconstruction of the ulnar collateral ligament of the elbow with the use of a tendinous graft)was used. Results:Between 2007 and 2011,a total of 790 patients underwent UCLR.The average(±SD)annual incidence was 3.96±0.38 per 100,000 patients for the overall population but was 22 -±- 3.4 for patients aged 15 to 19 years.The overall average annual growth was 4.2%.There were 695 males and 95 females.The 15-to 19-year-old patients accounted for significantly more pro- cedures than any other age group(56.8%;P<.001),followed by 20-to 24-year-olds(22.2%).The incidence of UCLR in the 15-to 19-year-old group increased at an average rate of 9.12% per year(P= .009). Significantly more UCLR procedures were per- formed in the southern United States than in any other region (P < .001). The number of procedures significantly increased over time(P= .039). Conclusion:According to this database of a privately insured population, UCLR was performed significantly more in patients aged 15 to 19 than any other age group.The average annual incidence of UCLR per 100,000 people for patients aged 15 to 19 was 22±3.4.Further,this database showed that the number of UCLR procedures is increasing over time.Further work should address risk reduction efforts in this at-risk population. Keywords:ulnar collateral ligament(UCL)reconstruction; elbow;Tommy John;epidemiology;pitcher;incidence;United States Over the past 15 years, ulnar collateral ligament recon- a significant increase in the number of UCLR procedures struction(UCLR)of the elbow has become a common pro- performed on Major League Baseball (MLB) pitchers, cedure among both adolescent and elite-level athletes3'18 with only 1 surgery performed in 1986 and 32 performed First described by Jobe et al in 1986,1°UCLR has allowed in 2012 in MLB 5'14 athletes,most commonly pitchers,to return to sport,and to Although most media andliterature regarding UCLR sur- do so at a high level, after what was once thought to be round MLB and elite-level pitchers, this cohort of players a career-ending injury 4'5'10 Recent evidence has shown makes up a very small percentage ofthe overall patient pop- ulation undergoing these procedures. National Collegiate Athletic Association(NCAA)research has shown that only 1 The American Journal of Sports Medicine,Vol.43,No.7 in 200(0.5%)high school baseball players will play MLB.is DOI:10.1177/0363546515580304 Thus,high school and college-aged pitchers must be analyzed 2015 The Author(s) to determine whether UCLR in these players is increasing at 1770 Downloaded Loin ajs.sagepub.comatEMORY UNN on JW,15.2015 2946 Vol.43,No. 7,2015 Trends in UCLR in the US 1771 the same rate as for MLB pitchers.Azar et al2 reviewed the Distributions over US region and quarter ofthe year were cohort of patients who underwent UCLR performed by Dr compared with an equal grouped frequency distribution, James .Andrews and noted that in 1988-1994, only 8% (7 while age groups were compared with the proportion of the total)of the patients who underwent UCLR were high school US population as reported in the 2011 US Census estimates. athletes,and in 1995-2003,13%(77 total)ofthe patients who A chi-square goodness-of-fit test was used to calculate differ- underwent UCLR were high school athletes.ences in UCLR procedure utilization,while Poisson regres- The purposes of this study were to determine(1)the inti- sion was used to calculate annual trends in the number of dence of UCLR reported in a private-payer database of UCLR procedures. Statistical significance was determined patients in the United States, (2) the rate of increase of with a P value less than .05. Statistical analyses were per- UCLR in these patients,(3)the age distribution of patients formed using State(version 12.1;StataCorp). in this database undergoing UCLR in 2007-2011, (4) the regions ofthe United States in which UCLR procedures cap- tured in this database are performed,and(5)the quarterly RESULTS distribution of the performance of UCLR in this database. The authors hypothesize that in this US database popula- In the period 2007 2011, 790 patients in this database tion, there will be a significant increase in the number of underwent UCLR (Table 1). Of these patients, 695 were UCLR procedures performed over time,the most common male (88%) and 95 were female (12%), a ratio of 7.3:1. age group to undergo UCLR will be teenagers,the majority The majority of the UCLR procedures were performed in ofUCLR procedures willbe performed in the second quarter patients aged 15-19 years (56.8%;P < .001), followed by of the year, and the majority of UCLR procedures will be 20-to 24-year-olds(22.2%)(Figure 1).More UCLR proce performed in the southern region ofthe United States. dares (53%) were performed in the South than in the West, Midwest, and Northeast regions (P < .001). The annual calendar quarterly distribution for UCLR is shown METHODS in Figure 2,with most surgeries performed in the second quarter (April-June) (P < .001). Of all UCLR procedures performed during 2007-2011, 58% were performed in an A retrospective review of the PearlDiver database was con- ducted to capture UCLR procedures performed in 2007- outpatient hospital setting,40%were performed at surgi- cal center, and 3%were performed in the inpatient hospi- 2011.Data from 2012 and 2013 werenot available.The Pearl- tel setting.Diver database is a publicly available national database that The number of UCLR procedures significantly increased is compliant with the Health Insurance Portability and Accountability Act (HIPAA). The database uses supercom over time (P = .039) (Table 1) and showed an average of technologyto collate individual 4.2%annual growth rate from 2007 to 2011.Furthermore, puter patient records in the 15-to 19-year-old group,in which the most surgeriesassociatedwithCurrentProceduralTerminology(CPT)and were performed, the overall number of UCLR proceduresInternationalClassificationofDiseases, Ninth Revision performed significantly increased over time,with an annualICD-9)codes related to orthopaedic procedures. This study growth of 9.84% (P = .005). The overall average (+SD) selected patients with the CPT code 24346,which is defined annual incidence ofUCLR per 100,000 people was 3.96 ± as reconstruction ofthe ulnar collateral ligament ofthe elbow 0.38, while the average annual incidence of UCLR per with the use of a tendinous graft,to query the database. 100,000 people for patients aged 15-19 was 22 ± 3.4.This The primary data points that were extracted included incidence ofUCLR in the 15-to 19-year-old group also sig- patient age at the time ofsurgery(broken down into the fol- nificantly increased over time at an average rate of 9.12%lowing age groups: 10-14,15-19,20-24,25 29,30 34,35-39, per year(P=.009)(Figure 3).Hence,both the overall num- 40-44,45-49,50-54,and 55-59 years),year ofsurgery,quer- ber and the incidence of UCLR in 15-to 19-year-olds signif- ter ofthe year during which surgery was performed,patient icantly increased over time in the years 2007-2011.sex,location ofsurgery(outpatient hospital,inpatient hospi- tal, surgical center), and geographic region of the United States(divided into Northeast,South,West,and Midwest) DISCUSSION in which surgery was performed. The number of patients in the specific age groups previously listed, as well as the UCLR has become a common procedure in both elite MLB overall number of patients in the database for each year of pitchers and high school athletes2'5 The incidence of 2007-2011, was recorded and used as the "population at UCLR in elite pitchers has been previously reported as risk"to determine the incidence. steadily increasing over the past 10 years.5'14 The incidence Address correspondence to Brandon J.Erickson,MD,Midwest Orthopaedics at Rush,Rush University Medical Center,1611 W Harrison Street,Suite 300,Chicago,IL 60611,USA(e-mail:berickso.24@gmail.com). Midwest Orthopaedics at Rush,Rush University Medical Center,Chicago,Illinois,USA. Hospital for Special Surgery,New York,New York,USA. Holy Cross Hospital Orthopaedic Institute,Fort Lauderdale,Florida, USA. Presented at the 41st annual meeting of the AOSSM,Orlando,Florida,July 2015. One or more of the authors has declared the following potential conflict of interest or source of funding:B.B.has received research funds from ArthrexInc,CONMED Linvatec,DJ Orthopaedics,Ossur,Smith&Nephew,and Tornier.A.A.R.is a consultant for,has received research/speaking fees from,and has received royalties from Arthrex;and has received research support from Arthrex and Smith&Nephew. Dow,oadedfromejs aagepub.00 nalEMORYUNIVon.kly 15.2015 2947 1772 Erickson et al The American Journal ofSports Medicine TABLE 1 Number of UCLR Patients per Year and per Age Group,Overall Population at Risk,and Incidence per 100,000 People' 2007 2008 2009 2010 2011 Age No.of Pop at No.of Pop at No.of Pop at No.of Pop at No.of Pop at Group,y UCLR Risk Incidence UCLR Risk Incidence UCLR Risk Incidence UCLR Risk Incidence UCLR Risk Incidence 10-14 6 365,636 1.64 6 374,076 L6 10 370,928 2.7 2 373,042 0.54 4 384,239 1.04 15-19 79 403,156 19.6 73 409,866 17.8 88 406,958 21.6 103 402,853 25.6 106 419,323 25.3 20-24 39 304,108 12.8 31 305,587 10.1 35 293,982 11.9 37 286,080 12.9 34 338,525 10 25-29 5 406,058 1.23 4 409,821 0.98 4 394,821 1.01 3 378,301 0.79 10 389,174 2.6 30-34 3 497,671 0.6 2 502,214 0.4 4 494,571 0.81 5 487,977 1.02 0 498,631 0 35-39 4 607,937 0.66 4 614,152 0.65 1 595,551 0.17 7 578,713 1.21 2 574,335 0.35 40-44 2 670,629 0.3 5 668,875 0.75 6 647,605 0.93 1 648,725 0.15 3 672,665 0.44 45-49 5 755,212 0.66 3 766,061 0.39 6 744,725 0.81 3 742,912 0.4 5 748,462 0.67 Pop,population;UCLR,ulnar collateral ligament reconstruction. m25 - 27 a0m 0 20 A c 25- Q oa o g 23 15 c a c`21 u am10; M n4*.....4.%""...../ 7 19 c a05c 17 a' 0 T 15 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 2007 2008 2009 2010 2011 Age,y Year Figure 1. Overall average incidence of ulnar collateral liga- Figure 3. Annual incidence of ulnar collateral ligament ment reconstruction by age of patients in the PeariDiver reconstruction in patients aged 15-19 in the PearlDiver data- database in 2007-2011. base in the years 2007-2011. 250 procedures performed in the United States over the time studied,the most common age group of patients undergoing 200 11 UCLR were late teenagers (specifically aged 15-19 years old),the majority of surgeries were performed in the second 150 quarter of the year, and the majorityof UCLR procedures o 1 Y 100 were performed in the southern region ofthe United States. Z so III . p It has been wellestablished tht the number of MLB pitchers hohohave undergone UCLR has been increasing o 111 since the 1980s to 2012 and has continued to increase in 2013 and 2014.5°14 While Azar et al2 found an increase in 01 02 03 04 the percentage (from 8%to 13%) and number (from 7 to Yearly Quarter 77)ofhigh school athletes who underwent UCLR,the over- all US population has not been studied.The data from this Figure 2. Yearly quarter distribution of ulnar collateral liga- PearlDiver database have shown that the number ofUCLR ment reconstruction of patients in the PearlDiver database procedures performed each year is significantly increasing in 2007-2011.at an average of 4.2% per year in the overall population and 9.84%in patients aged 15-19_This statistic is impor- tant,as the majority of these players who are undergoing of this procedure in the general population is not well UCLR are in the 15-to 19-year age group(Figures 1 and understood. The purposes of this study were to determine 3).The current study found an overall average incidence the incidence of UCLR in the United States, the rate of per 100,000 patients of 3.96 ± 0.38, with the number of growth ofUCLR in the United States,and the age distribu- patients in the overall database remaining relatively con- tion of UCLR in the United States in the years 2007-2011. stant over the time period analyzed.However,the average The authors' hypotheses were confirmed, in that there annual incidence ofUCLR per 100,000 people for patients was a significant increase in the number of UCLR aged 15-19 was 22 ± 3.4(Figure 3). This is a staggering Downloadedfrom alesagepub.ccmatEMORY UNIV onJuly 15,2015 2948 Vol. 43,No. 7,2015 Trends in UCLR in the US 1773 statistic and may be due,in part,to the public perception children are finishing school,and it may be that parents did surrounding UCLR.While this overall incidence ofUCLR not want their children to miss time at school for surgery. of 3.96 per 100,000 patients has not surpassed the overall This is reflected in the data from this study, which show incidence of anterior cruciate ligament reconstruction that more patients underwent UCLR between April and ACLR)(recent population studies from the United States June than in any other quarter of the year,indicating that have shown an annual incidence of 43.5 per 100,000 per- the majority of injuries occur during the season and, more son-years),further population studies are needed to deter- importantly,at the beginning of the season.This finding is mine how close UCLR has come to surpassing ACLR in the important for injury prevention,because it shows that the 15-to 19-year-old group9.15.19 majority of resources should be dedicated to ensuring ath- Cain et a13 reviewed 1281 patients who underwent letes transition well from off-season to in-season, as this is UCLR in 1988-2006 performed by Dr James Andrews. In the time when most sporting injuries occur (transitioning the latter years of their study, 2003-2006, more than 700 from little activity to peak activity).In addition,the majority UCLR procedures wereperformed,the majority in patients ofUCLR procedures were performed in the Southern United older than 18 years.Similarly,Osbahr et al17 reviewed 313 States.This is likely multifactorial.First,studies have shown patients who underwent UCLR at 10-year follow up and that pitchers who come from warm climates are more likely reported an average age of 22.L Again, these patients to undergo UCLR than those from cold climates,leading to underwent UCLR in the early 2000s.However, our study a higher number of UCLR procedures performed in the found that in the specific patient population evaluated South.6 Furthermore,Dr Andrews,who performs a high vol- for this paper,the majority of UCLR procedures were per- ume of UCLR-s,practices in the South.3.17 formed in patients between 15 and 19 years of age.As the time period for the Cain and the Osbahr studies was early Limitations 2000s and the years of this study were 2007-2011,this may represent a shift in the age at which UCLR is performed as The limitations of this study include the use of a private- more and more patients attempt to have the surgery done payer database that does not include the entire population earlier in their careers.3.17 This paradigm shift should be of the United States.This adds a degree ofsampling bias to further evaluated. the results as some athletes may not have been included in In 2012, Ahmad and colleagues' issued a survey that this sample if they did not have access to private-payer was completed by 189 baseball players (both high school insurance.Furthermore,the patients included in the data- and college),31 baseball parents,and 15 baseball coaches base may have been privileged, with pressure to perform to assess public perception of UCLR.The goal of the ques- consistently at high levels—hence the high number of tionnaire was to measure the surveyed participants'per- UCLR procedures. Patients' parents may also have been ception of UCLR as it related to indications, risks, able to afford the cost associated with this procedure, recovery time,operative technique,and benefits.Interest- including medical and rehabilitation expenses, ensuring ingly,51%of high school athletes,26%of college athletes, that money was not an issue for surgery.This study used 30%of coaches,and 37%of parents thought UCLR should the CPT code 24346 only. This may have missed some be performed as a prophylactic procedure on healthy patients who were erroneously coded with various other patients to enhance performance.Unfortunately,although CPT codes such as 24345(repair of the UCL), although it UCLR can restore some pitchers to their preoperative level is our belief that UCLR should routinely be coded as of function,it has not been shown to improve performance 24346. Furthermore, if the 24345 code was used, the pitch velocity, accuracy, etc).5.12,14 Furthermore, 28% of search may have found duplicate patients if the surgeons players,31%of coaches, and 25%of parents did not think coded for both 24346 and 24345 in the same patient, that the number of pitches thrown by a pitcher was a risk thereby falsely elevating the results. It is also possible factor for sustaining an ulnar collateral ligament (UCL) that when the coders entered the CPT codes into the data- injury, and 44% of parents, 24% of players, and 20% of base, the numbers were entered incorrectly, thereby coaches believed that the average return to sport time increasing or decreasing the actual numbers. The activity was less than 9 months.' The number of pitches a player levels of the patients undergoing UCLR, as well as their throws in a given period of time has been shown to be sport played, level of sport, nonoperative treatment regi- a risk factor for UCL injury, and the average return to men,and revision status,were not known to this review. sport time has not been clearly defined but is generally However, the strengths include the number of patients considered to be over 1 year.5.7.13.14.2o analyzed through this database, the data points that UCLR was most frequently performed during the second were available,and the ability to determine the incidence quarter ofthe year(April-June)(Figure 2).As baseball is typ- and increase ofUCLR over time. ically played from February to October,pitchers are throwing competitively during these months of the year.While there are geographic areas where baseball is a year-round sport, CONCLUSION the majority of players are in the off-season from October to February.8 Unlike some injured athletes, a pitcher who According to the privately insured database used in this requires UCLR would have a hard time waiting until the study,UCLR was performed significantly more in patients end ofthe season(quarter 4)and so often undergoes surgery aged 15-19 years than any other age group. The average at the time ofinjury 3.4•'1 Also,this is the time ofyear when annual incidence ofUCLR per 100,000 people for patients Downloadedfrom aja.sagepubmmatEMORYUN!VonJuly15.2015 2949 1774 Erickson et al The American Journal of Sports Medicine aged 15-19 was 22 ± 3.4. Further, in this database, the 10. Jobe FW,Stark H,Lombardo SJ.Reconstruction of the ulnar collet- number of UCLR procedures is increasing over time.Fur- eral ligament in athletes. J Bone Joint Surg Am. 1986;68(8):1158- ther work should address risk reduction efforts in this at- 1163. risk population. 11. Jones KJ,Dines JS,Rebolledo BJ,et at.Operative management of ulnar collateral ligament insufficiency in adolescent athletes.Am J Sports Med.2014;42(1)117-121. 12. Keller RA,Steffes MJ,Zhuo D,Bey MJ,Moutzouros V.The effects of REFERENCES medial ulnar collateral ligament reconstruction on Major League pitch- ing performance.J Shoulder Elbow Surg.2014;23(11):1591-1598. i. Ahmad CS,Grantham WJ,Greiwe RM.Public perceptions of Tommy 13. Kerut EK,Kerut DG,Fleisig GS,Andrews JR.Prevention of arm injury John surgery.Phys Sportsmed.2012;40(2):64-72. in youth baseball pitchers.JLa State Med Soc.2008;160(2):95-98. 2. Azar FM,Andrews JR,Wilk KE,Groh D.Operative treatment of ulnar 14. Makhni EC, Lee RW, Morrow ZS, Gualtieri AP, Gorroochurn P, collateral ligament injuries of the elbow in athletes.Am J Sports Med. Ahmad CS. Performance, return to competition, and reinjury after 2000;28(1):16-23. Tommy John Surgery in Major League Baseball pitchers:a review 3. Cain EL Jr,Andrews JR,Dugas JR,et al.Outcome of ulnar collateral of 147 cases.Am JSports Med.2014;42(6):1323-1332. ligament reconstruction of the elbow in 1281 athletes:results in 743 15. Mall NA,Chalmers PN,Moric M,et al.Incidence and trends of ante- athletes with minimum 2-year follow-up. Am J Sports Med. dor cruciate ligament reconstruction in the United States. Am J 2010;38(12):2426-2434. Sports Med.2014;42(10):2363-2370. 4. Dines JS,ElAttrache NS,Conway JE,Smith W,Ahmad CS.Clinical 16. NCAA Estimated probability of competing in athletics beyond the outcomes of the DANE TJ technique totreat ulnar collateral ligament high school interscholastic level. https://www.ncaa.org/sites/ insufficiency ofthe elbow.Am JSports Med.2007;35(12):2039-2044. defaultiles/Probability-of-going-pro-methodology_Update2013.pdf. 5. Erickson BJ,GuptaAK,HarrisJD,et al.Rate ofreturn to pitchingand Updated September 24,2013. performance after Tommy John Surgery in Major League Baseball 17. Osbahr DC, Cain EL Jr, Raines BT, Fortenbaugh D, Dugas JR, Pitchers.Am J Sports Med.2014;42(3):536-543. Andrews JR. Long-term outcomes after ulnar collateral ligament 6. Erickson BJ, Harris JD,Tetreault M, Bush-Joseph C, Cohen MS, reconstruction in competitive baseball players:minimum 10-year fol- Romeo AA. Is Tommy John surgery performed more frequently in low-up.Am J Sports Med.2014;42(6):1333-1342. Major League Baseball pitchers from warm weather areas?Orthop 18. Petty DH,Andrews JR,Fleisig GS,Cain EL.Ulnar collateral ligament J Sports Med.2014;2(10):2325967114553916. reconstruction in high school baseball players:clinical results and 7. Fleisig GS,Andrews JR.Prevention of elbow injuries in youth base- injury risk factors.Am J Sports Med.2004;32(5):1158-1164. ball pitchers.Sports Health.2012;4(5):419-424. 19. Thur CK, Edgren G,Jansson KA, Wretenberg P. Epidemiology of 8. Friscia BA,Hammitt RR,McGuire BA,Hertel JN,Ingersoll CD.Ante- adult ankle fractures in Sweden between 1987 and 2004:a popula- rior shoulder laxity is not correlated with medial elbow laxity in high tion-based study of 91,410 Swedish inpatients. Acta Orthop. school baseball players.J Sport Rehabil.2008;17(2):106-118.2012;83(3):276-281. 9.Granan LP,Bahr R,Steindai K,Fumes 0,Engebretsen L Development 20. Yang J,Mann BJ,Guettler JH,et al. Risk-prone pitching activities of a national cruciate ligament surgery registry.the Norwegian National and injuries in youth baseball:findings from a national sample.Am Knee Ligament Registry.Am J Sports Med.2008;36(2):308-315.J Sports Med.2014;42(6):1456-1463. For reprints and permission queries,please visit SAGE's Web site at httpi/www.sagepub.com/journalsPermissions.nav Downloaded from ajs.sagepuStomarEMORY UNNonJoe15,2015 2950 The American Orthopaedic Society for Sports 11ledicine News Releasewww.5 ort,,,.da. EMBARGOED FOR RELEASE UNTIL FEBRUARY 19,2011 Misguided Public Perception on What Tommy John Surgery Can Do for Pitching Performance Apparent in New Study SAN DIEGO,CA–Despite known risks and outcomes ofthe common elbow procedure known as Tommy John surgery,parents,coaches and players still have incorrect assumptions regarding player performance,say researchers presenting theirstudy at the American Orthopaedic Society for Sports Medicine's Specialty Day in San Diego,CA(February 19th). Despite the recognized risk of pitch type and amount of pitches,nearly a third ofthose we surveyed did not believe pitch counts were a risk factor for injury.Even more disturbing was that fact that a quarter of players and coaches thought that a pitcher's performance could be enhanced by having a Tommy John surgery,"said lead author of the study,Christopher S.Ahmad,MD of Columbia University's,Center for Shoulder,Elbow and Sports Medicine. During the spring of2010,researchers surveyed 189 players,15 coaches and 31 parents through either one-on- one intIe sew.s or a mail-in questionnaire,An alarming_5lpercent of high school athletes believed surgery should __-{Formatted:Highlight be perfo4med in the absence ofinjurywith the sole intention to improve performance.Thirty-one percent of coaches,28 percent ofplayers and 25 percent of parents did not relate pitch type with injury risk. Furthermore, 31 percent of coaches did not believe that the number of pitches thrownwas a risk factor for injury to the elbow. ligament.A substantial percentage also believed that control and velocity of pitches would be improved by having a Tommy John Surgery performed.The study also determined that individuals from each group underestimated the time required to return to competition at nine months.(Typical return-to-play is a year). In addition,identification of the surgical details of repairing the ulnar collateral ligament(UCL)and rehabilitation needs were poor among all the groups surveyed. Recent studies suggest an alarming rise in UCL injuries in young players,with the implementation of breaking pitches at an early age,fatigue,overuse,showcases and single sport specialization being the key aspects of injury rate increases.While this is the first studyto analyze public misperceptions related to elbow UCL injury, several other organizations are working to increase the awareness of overuse injuries and help prevent injuries, including the STOP Sports Injuries campaign and USA Baseball.Our research supports their efforts and we advocate with them to correct these publicmisperceptions,"said Ahmad. The American Orthopaedic Society for Sports Medicine(AOSSM)is a world leader in sports medicine education, research,communication and fellowship,and includes national and international orthopaedic sports medicine professionals.The Society works closely with many other sports medicine specialists,including athletic trainers, physical therapists,family physicians,and others to improve the identification,prevention,treatment,and rehabilitation of sports injuries.The STOP Sports Injuries campaign was initiated by the American Orthopaedic Societyfor Sports Medicine(AOSSM)andincludes a comprehensive public outreach program focused on the importance ofyouth sports safety—specifically relating to overuse and trauma injuries.Visit the website at www.STOPSportslnjuries.org For more information,please contact AOSSM Director of Communications Lisa Weisenberger at847/292-4900,or e-mail her at lisatf0aossm.orq.You can also visit the AOSSM newsroom at www.sportsmed.org. 2951 fulton County Schools Where Students Come First Athlete I Parent Handbook for GHSA Sanctioned Interscholastic Athletic Activities 2013 -2014 TABLE OF CONTENTS for Athlete!Parent Handbook for GHSA Sanctioned Interscholastic Athletic Activities GHSAMember Schools ofFulton County Schools 1 Table of Contents 2 GHSA Sports Seasonal Calendar 3 National and School District Testing Dates and Conflicts 4 Fulton County Testing Calendar 5 Statement ofPhilosophy 6 Objectives 6 Governances 6 Fulton County Board ofEducation(FCBOE)6 GeorgiaHigh School Association(GHSA) 6 The Georgia High School Association(GHSA)Regions 6 National Federation ofHigh Schools(NFHS) 6 Requirements forParticipation 7 Pre-Participation Physical Examination 7 Parent Consent for Athletic Participation and Transportation 7 Emergency Medical Authorization 7 Student/Parent Concussion Awareness Form 7 Student Insurance 7 Introductions 7 To the Parent/Guardian 7 Sportsmanship 8 Grievances and Complaints 8 To the Student-Athlete 9 Conditioning and Try Outs I Dead Week 9 Participation is aprivilege 9 Athlete Playing Time 9 Varsity Teams 9 Student-Athletic Codes ofConduct 10-I I BasicInterscholastic ParticipationPolicies 12-13 Student-Athlete Scholastic Eligibility[www.ghsa.net] 13-26 Appendix 27 Off-Season and Summer Training Tips 27 Concussions in Sports 27-28 Q&A forMRSA 28 Skin Lesions• 29-30 Weather Conditions and Athletics 31-36 Fulton County Guidelines on Recruiting/Undue Influence 37 Fulton County Board Policies 37 Forms Release ofLiability for Bus Transportation/Designated Driver 38 StudentParticipation Application (required) 39 Verification ofInsurance (required) 40 Pre-participation Physical Evaluation(required) 41-43 Pre-Participation Physical Evaluation Clearance Form 44-45 Student/Parent Concussion Form 46 Receipt Acknowledgement for Athlete/Parent Handbook for GHSA Sports 47 This handbook is designed as minimum standards for the Fulton County Board of Education schools that are members of and participate in Georgia High School Association Interscholastic Athletic sanctioned athletic events. Participating schools may increase the standards for participation but are required to submit to the Fulton County Schools Director ofAthletics and to print/distribute to parents/guardians and students any addenda for each section that exceeds the minimum standards set in this handbook 2 2953 FULTON COUNTY SCHOOL SYSTEM DEPARTMENT OF ATHLETICS VERFICATION OF INSURANCE COVERAGE Effective for School Year 2013-2014 I havewaived the medical/health insurance coverage that has been approved by the Fulton County School System and offered to my child, Date of Birth: Name of Child) The medical/health insurance that I am using for my child for the current school year at is provided by and School Name) Name ofInsurance Company) the insurance policy number is This insurance policy Insurance Policy Number) is in-effect from: to Date) Date) Attach a copy ofMedical/Health Insurance Certificate to this form to verify information listed above.Thank you. The above medicaUhealth insurance coverage provides for the following interscholastic athletics activities: 1. 2. 3. - 4. We/I understand that per The Georgia High School Association a Pre-participation Physical evaluation must be performed by a physician to medically screen each student who participates in the interscholastic athletic programs ofthe Fulton County School District.We/I understand that a basic medical screening(the required physical exam)is general in nature and limited in scope and does not indicate or assure me/us that my/our child is completely free from impairments.IfUwe wish for a more detailed physical exam to be performed upon my/our child then it is my/our responsibility to arrange and to pay for such an exam.If this more detailed exam is performed;it is my/our responsibility to notify the Fulton County School District,and ifs appropriate employees, of any potential medical problems uncovered by any physical exam given to my/our child other than the general physical required by the school system for athletic participation.I agree to fully waive any and all claims ofwhatever nature,fully and finally,now and forever,for my/our child,for myself,my estate, my heirs, my administrators,my executors,my assignees,my agents,my successors, and for all members of my family, and to indemnify, release, defend, exonerate, discharge and hold harmless all current,former and future members of the School Board ofthe Fulton County Board ofEducation,all current,former and future employees ofthe Fulton County Board of Education,their schools,their trustees,officers,Board of Education, agents,coaches, athletic trainers,physicians,volunteers,and any other practitioner of the healing arts(an"Indemnified Party")from any and all liability,personal or property damages,claims,causes of action or demands brought against the Fulton County School District or indemnified party arising out of any injuries to my/our child or to his or her property or losses of any kind which may result from or in connection with his or her participation in any activity related to the interscholastic athletic programs provided by the Fulton County School District. My signature below attests that I have read,understood and concur with the information on this form,and that I give consent for my child to participate in the athletic programs as stated above. ALLPARENTS/GUARDIANS/MUST SIGN BELOW AND DATE Signature ofparent/guardian: Date: Signature of parent/guardian: Date: Signature of student Date: PRIOR TO PARTICIPATION IN ANY CONDITIONING, TRYOUT, PRACTICE SESSION, OR PLAY IN ANY INTERSCHOLASTIC ATHLETIC ACTIVITY,THE STUDENTATHLETE MUST SUBMIT THIS FORM FOR PARTICIPATION IN INTERSCHOLASTIC ATHLETICS TO THE COACH OF THE ACTIVITY. FAILURE TO SUBMIT THIS FORM WILL DELAY THE ELIGIBILITY OF THE STUDENT-ATHLETE TO JOIN 1HP TEAM 40 2954 http://consumer.healthday.com/kids-health-information-23/adolescents-and-teen-health-news- 719/teens-increasingly-likely-to-have-tommyjohn-surgery-study-701292.htm1 11•11•Ime MEM! More Teen Athletes Undergoing Tommy John Elbow Surgery: Study 1:L_1' By Dennis Thompson 1IealthDay Reporter TUESDAY, July 14, 2015 (HealthDay News) -- Most Tommy John surgeries to fix elbows torn in sports-related injuries are being performed on teenagers, especially baseball pitchers, and the numbers are rising every year, a new study reports. v7`- Tommy John surgery fixes a torn ulnar collateral ligament, or UCL, The UCL is located on the inside of the elbow and connects the bone of the upper arm to a bone in the forearm. Teens between ages 15 and 19 accounted for nearly 60 percent of all Tommy John surgeries performed in the United States between 2007 and 2011, the study said. Kids these days are playing sports year-round, and often specializing in a single sport to improve their chances of getting a scholarship or making the big leagues, said lead author Dr. Brandon Erickson, an orthopedic surgery resident at Rush University Medical Center in Chicago. The more pitches kids throw and the faster they throw seems to put them at increased risk for elbow injury," Erickson said. "Kids are throwing harder and more often than they had in previous years, and it puts additional stress on their arm," The study findings were to be presented this week at the American Orthopaedic Society for Sports Medicine's annual meeting in Orlando, Fla. Findings presented at meetings are generally considered preliminary until published in a peer-reviewed journal. Injuries that require Tommy John surgeries often occur in baseball players, especially pitchers, according to the American Academy of Orthopaedic Surgeons (AADS). In fact, the surgery is named after major league pitcher Tommy John, who was the first professional baseball player to have the surgery, in 1974. In the procedure, surgeons replace the injured UCL with a tendon taken from the player's own body, usually either the forearm or the knee. To get some idea how often Tommy John surgery is performed, the researchers reviewed medical records from a private insurance database. They found that 15-to 19-year-olds accounted for 57 percent of the 790 Tommy John surgeries that occurred between 2007 and 2011. Young adults between 20 and 24 accounted for another 22 percent of Tommy John surgeries performed. 2955 1 The 15-to-19 age group experienced an average 9 percent increase per year in the number of Tommy John surgeries, more than double the annual overall growth rate of 4 percent for all ages, the researchers found. What is worrisome is even within a five-year span you can see the incidence of the surgery has gone up," said Dr. Ban-y Boden, a sports medicine specialist at The Orthopaedic Center in Rockville, Md. Sports medicine experts chalked up this increase to overuse. A lot of these younger players are being pushed to perform at a younger age, and in some areas of the country they are playing year-round," Boden said.. "There's a lot of competition out there, and a lot of people who want to make it to the top.They are pushing their bodies to the limit." It used to be that athletic teens played different sports depending on the season, rotating from baseball to basketball to football to soccer, said Dr. David Geier, an orthopecic surgeon and sports medicine specialist in Charleston, S.C. That rotation protected young athletes from injuries caused by repetitively stressing any single part of their body year-round, Geier said. Tommy John surgery has been hailed for its ability to return major league pitchers to play. Four out of five pitchers in the major leagues who undergo Tommy John surgery eventually return to pitch as well as they had prior to surgery, according to a study presented at last year's meeting of the AAOS. But an elbow tear that requires Tommy John surgery will keep a kid out of play for at least a year, and there's no guarantee that they'll ever return to the sport, Geier said. About 15 to 20 percent of players never return to the same level of performance, and even if you do get back you generally have to go through a year of physical therapy and rehabilitation," he said. "It's a lot of work to get back to that point, and there's a chance you won't make it." Erickson, Geier and Boden all agree that preventing elbow ligament tears is much better than relying on Tommy John surgery to repair the damage. Parents and coaches need to monitor players' pitch counts to make sure they aren't throwing the ball too often, Baden said. Even better, parents and coaches should be encouraged to hold a child out of play for at least three months every year, Geier said. You can play sports, but play something that doesn't stress the elbow and shoulder, like soccer or track," he said. Players also need to be taught proper body mechanics, and encouraged not to pitch through pain or fatigue, Geier said. The key is that young pitchers really want to avoid ever having this injury," he said. 'This is one that's much better to prevent than to treat." 2956 2 http://www.forbes.com/sites/bobcook/2015/07/26/in-hall-of-fame-speechjohn-smoltz-warns- against-tommyjohn-surgery-for-teens/ Forbes 2FRF[1Sur jut=42oi;es32,v 5,434,3.-+.: In Hall of Fame Speech, John Smoltz Warns Against Tommy John Surgery For Teens LongtimeAtlanta Bravespitcher John Smoltz onJuly 26 was inducted into the BaseballHallofFameand broke LeonardoME newground—hesthefirst pitchertoundergo TommyJohnsurgerytomake itto hissport's hallowed groundVirtuosoTommyJohnhadafinecareerafterrecoveringfrombeingthefirstMajorLeagueBaseballpitcher,in I9i4,to I undergo whatisformallyknown as elbowulnarcollateralligament reconstructionsurgery,buthe'snotaHall of Web-based EHR,CCI Famer.Smoltz's careerisdefinedbyTommyJohnsurgery:hewas astellarstarterbefore hissurgery,missed Certified Free needs ars Bob Cook the a000 season ashe recovered,andcamebathes astellarreliefpitcher.@ J W 1:.:C5. InhisHall of Fainespeech,Scholtzwantedparentsand teensto makesure theydidn'tgetthewrongmessage 11111/rm+ •Rs fromhiscareer—thatTommy Johnsurgery canmakeyou astronger,betterpitcher,USAToday's FortheWin sr f i A featurewas oneofmany whoposted Smoltz'svideo andspeech transcript: ea RRl Lv); tt`Beforelhand it overtonestinductee,rd beremissifrelidnottalkaboutTommy-John.Psebeen,61' anopportunityas oneoftheonlyplayers,the only one rightnow,to beinductedintothe HallofFameccithTonnnyJohnSurgeryIfsan epidemic.Ifssomethingthat isaffectingourgame.It'ssomethingthatIthoughtWouldcostmemycareer,butthauksto 1)r.JamesAndrewsandall thosebeforehim,pecformingthe surgerynithsuchprecisionhascauseditto bealmostaf- read,like a band-aidyouputonyomarm. Iwantto encouragethefamiliesandparentsthatareouttherethatthisisnotnormal tohave asurgeryat Li andz5 years old.Thatyou havetime,thatbaseballisnotay-ear-r ndsportThatyvuhavean.opportumiyto beathleticandplayother sports.Don'tletthe institutions thatare outtheremimingbeforeyouguaranteeingscholarship dollars andsigning bonuses thatthisisisthe way—. Iwantto encourageyou,ifnothingelse,knorthat}mnrchcldren'spassionanddesiretophay-baseball issomethingthat theycandawithoutacompetitive pitch.Ewnythrowakid makestodavisacompetitive pitch.Theydon'tgooutside,they don'thavefun,tbeydont throwenough—butthecrecompeting andmasing outtoohard,too early,and that'swhywe're having theseproblems.Please,take careofthosegreat futureamts.' When Smoltzsays'theseproblems,'he'stalking aboutthe rapidincreasein the numberof2%ILBpitchers undergoingTommyJohn surgery,andatyoungages.Afterall,Johnwas 31whenhehadhissurgery,and Smoltzwas 34.Recentlya studyns.releasedsaying themajority ofTommy John surgeries are performed on 1540-19-year-oldpatients,which ishappening because ofa combination ofincorrectpitchingmechanicsand overwork,especially asyoungpitchers increacirtglythrow year-roundin ayouth sportsenvironment inwhich single-sport speciailzationhappens atyonngerages.Smoltz,by theway,was amultisport athlete(he wasgoing to walkon to playbasketballat Michigan Statehad he electedtoplaybaseballthere instead ofsigningwiththe Detroit Tigers outofhighschool)whose parents stayed wellmakebackgroundduringhissportsyouth(they weremusicians). 2957 1 http://www.usatoday.com/story/sports/m1b/2014/04/11/tommyjohn-elbow-surgery-strasburg- parker-corbin/7583413/ Tommy John surgery now 'an epidemic' Jorge LOrtiz,USA TODAY Sports 1 E 7tc' :' 'Y f393 Mt116 in 7 f1 2", It•.+,nuld be easy to assemble an Alt-Starstair of pitchers who have excelled afterTommy John younisurgery,aces such as Main Mi wright.Francisco Ltiano and Stephen Strasburgoho returned torn pica roe caws=ak urn elbow reconstruction as goodas ever,and earned zcn;xspers tens of millions of dollars thanks to their new ulnar collateral ligaments. Yet the once-revolutionary surgery has bec on so commonplace-and suscessful- that finding ananswerfora rash in pitchers undergoing the procedure proves elusive Pitchers arethrowing harderthan ever-and on a year-round bass at a younger age- both ofwhit hcan add stress to a very delicate ligament And oddly,the alureof the cure-and some ofthe myths it has engendered—may be pertly to blamefor the spike inthe surgery's incidence. PADRE:Tc17iry Johr suery ce it t.iirr-rasters it seems like every year I'mdoing more and more,so from rrj standpoint it's an epidemic"said James Andrews.the noted orthopedic surgeon who has become the go-to doctor for major leaguers with elbow problems. tTampa Bay Rays left-hander Matt Moore opts forTommy John elbowsurgery as expected,he will be the 13th major league pitcher to have the ligament-replacement operation since spring training.That's only six fewerthan all oflast season,and three underthe annual average from 2CM-2011.according toan industry-commissioned study. The Allarta Braves were hittwice lastmonth when they lost Kris Medlen and Brandon Beechyto torn elbowligaments,wiping outtwo-fifths oftheir rotation.Thisweek, Braves reliever CorrGearrin t onrinned he will need theoperation as well. In addition,promising pitchers likeArizona Diamondbacks All-Star Patrick Corbin, OaklandAthletics aceJarrpd Parker.Pittsburgh Pirates prospect JamesonTailon and Detroit Tigers reliever Bruce Rondan also respired thesurgery inrecentweeks. Andrews said he recently tried to convince two high-level pits hers with ligament tears to consider the more conservative option at rest and rehabilitation. PADRE:EltsbL ry::or't apolo;i e fcr joirir 'r'erke-es There's so mea h information•about how good the procedure is that playersdon't want to wait,"Andrews said.`They want it done.So ifs astruggle.Thae's always roomfor conservative treatment" There's strong evidence in favor of surgery.though:2958 y Surgery not foolproof Surgery notfoolproof Astudy published in December in The American Journal ofSports Medicine showed an 83%rate of returnto the rnajars among 179 pitchers who had theoperation,and a 57_2%rate of return to pitching in the pros.Only fee pitchers inthe sample failed to make it back. t nd while theMica!rexurnfromTommy John surgery.takes ayear,an ursuc cessful rehabmay wind up costing a pitcher nearly two seasons,depending on its length and when the injury occurs.. Moore spent more than a month on the disabled list with elbow soreness late last season,then had to leave Monday's game inthe frfth inning when pain flared upagain. Moore was examined by Andreas on Wednesdayy,and he and the Rays are weighing which coarse ofaction to take regarding his torn ulrar colateral ligament. it needs to be looked at a little tit more deeply because it's not a slam duck surgery right now, Rays manager Joe tvtaddon told reportersWedrres!fay. GALLERY PLAYERS UNDERGOING TOMMYJOHN SURGERY ilk *0 . i . • 11, 33 .0% i f S PHOTOS y. 4y.- t A. , I,may* x' :. e, iii- di} Speaking of players who have faced Tommy John surgery in general,not Moore specifically,Andrews said elements such as the significance aid location ofthetear the players attitude,contract status and the time ofthe season when theyget hurt usually factor into the decision of how to address the injury. Andres and Stan Conte;vice president of medical services for the Los Arneles Dodgrrs.agree some misconceptions about the procedure rrigfrt be contributing to its increase. 2959 2 Far one,its notfool-proof. General managers,coaches,agents,even players think its an automatic to get-we11 if youjust go ahead and fix it"Andrews said.'The`}don't realize the complications associated with the surgery.There's no injury that can't be made worse with surgery." There is also the notion that pitchers throw harder after having the operation- Andre s has had parents bring in healthy teenagers hoping the surgery will add vebcity to their fastballs-when in reality it is the strength gained through rehab that rrrey c attributeto any uptick in mph. There are some myths aboutTommy John surgery that(may prompt}people toget the surgery."Conte said.'Have you everser a pitcherwho is not proud of his Tommy John surgery se ar7 I)RE:Pira:re p r 's rortro'eers.l Conte is the lead irwestigator in a study that began in 2012 and surveyed all the major and nnor-leaguers to :an;inetheirhistoryofinjuriesandtheprevMengeofplayers- mostiy pitcher-who had urxtergcne the Tammy John procedure. Conte said from DD-11 the average number of thesesrrgeries among major leaguers falljust short d 16,then the figure skyrocketed too record 3£in M12 before droppng to 19 in 2013. Of course,this yearwe're delnitaly ahead ofschedule,"Conte sae.'When you look al Tommy Johns from 2002-2013.mast ofthem occarred inJue,not in April and May. This has definitely been one of the strongest starts,forwhatever reason." Figuring outwhy elbows blow out-thisyear,perhaps,more than ever-is aquestion that has vexed an industry in which pitchers we as much assets as theyare athletes. A different species Glenn Fleis ig,researchdirector forthe American Sports Medicine Institute in Birmingham,Ala.,is working with Conte oath study and is an ex pert On the tionrechanics d pits ping. Fleisig has examined UCL injuries for more than a decade and,lie his collaborators, expected their numbers to de~tease with better knowledge of their c at&e's and of proper mec hanic s.That hasn't been the case. Sports medicine,Fleisig noted,aims to help athletes perform.at their best while also avciding injuries. Sometimes those goals work in unison;kr the past decade,they can cor#lict. Through science and medicine(plus training and nutrition),we've enabled more pitchers to maximize their potential,"Fleisig said.Ifyou look at any tearris major and minor league rosters,they have more guys bringing it at mph than 10years ago or 23 years ago.Butthat has carne at the cost of the ligaments andtendons. mss we've oplimted yourability to have strong muscles and the ability to use the muscles atthe rig httimewith proper mechanics,the ligamerks and tendons have not been improved as mux h as the muscles.- Th uscles.` That's bec ruse ligaments and tendons don't getas healthy a supply of blood as the muscles,a physiological fact no amount oftraining ortendercarewil I alter. 2960 3 Thais because ligannnts and tendons dont get as healthy asupply d blood as the muscles,a physiological fact no amount oftraining ortendercarewill alter And those on the field confirmthat themodern pitcher-whileenjoying a era of dominance afteryears of hitting theatrics-is an entirely different spm ies. Velocities are way up,"says Boston Red Sox catcherA.J.Pier ynski,a 17-year veteran_"More guys are throwing cutters, more guys throwing sliders.Something has bgive.Unfortunatety,it seems likethe elbow,which sucks:" More not always better' Pierrynsld alsoc anothertrend that has alanredthose who work in sports medicine.Kids.he says,are kind cf born and bred to be pitchers tom 5 years old,6 years old.and throw so much.It stinks." Indeed,the proliferation oftravel ball-starting several years before the 12-year-olds we sea on a national stage atthe little League'.brld Series-makes baseball a year- round proposition at an early age.Whk pitch counts and innings limits create short- termsafeg- uards horttermsaiwguarlsagainstoveruse:years of spmialization taketheir bit We=thematically,statistical,scientifically have proven that the kids who play baseball yea-round are threetimes more likely to end up on astrgery table by their th birthday that those who don't.'says Fleisig,citing a 10-year study targeting teenagers who pito h more than 100 innings in a calendar year. We leve in a day ofspecialization where kids love one sport and their parents love supporting them,and there are baseball centers and travelingteams,so instead d playing various sports and having periods d activity and inactivity,kids ere having this unnatural cycle of playing baseball allthe time,and that statistically seriously increases their chances ofgetting hurt.More is not always barter." Andrews says the-real proderr?'begins in younger age groups,whe nolohers suffer near injuries"playing year-round baseball,playing in two leagues at the sametine, overthrowing,watching the radar gin,trying to increase their veiociEy beyond the development ofthat ligamert." This year's crop of big league victims definitely skews young.Soo of the 13-if Moore is included-are 25 seyounger,and Parker,5,has undergone his second surgery. That reality has led some clubs to stockpile arms as the best safeguard against the likelihood some pitchers will break down. The:The AtshingtortNationals,forexample,had stir ha surplus of starting candidates during spring training,they couki afford tolet go of veteran Chris Young—picked up by the Seattle Mariners—and reeve Ross Detwiler to the bullpen. Then again,three members of the'Ahshington rotation—Stephen Strasburg,Jordan Jmmersann and Taylor Jordan—have had Tommy John surgery. The fact of the matter is,this is an unnatural attevery time they throw the baseball,so you worry about R. Everybody worries about it,"manager MattWilliams said.'They go out there and compete on a regular basis,throwthat ball 100 limes in agame.There's wearand tear- And little guarantee the ulnar collateral ligament holds up. I don't knowifthere's really a scientific reason,"says Shawn KeIey,currently the iankr rInc>=ranti ate,timcTommi_Inknattruivnr'ntharthan none*areregthnn 2961 4 mmane aTE ldwar5 OTT` TT-yTr=a1r?,5-1s rerirr=ll IM_rrspe-Ps5. itiesar_vaay up."Says E stortR•.c_cox.atfar A_.J. r rTlir.Ski, 1 ysar lerar. 'Mor__i:ys ars t}.rower.y ci re TS,more_E;vs trowind slimsera.Eorrieth ir;to to,Tye.Urforlurasty.:,scams is:e ire eib+i9,h.,l:-r au:.+.s.` More notalways.better' Pieiyrali also Blies another ther.d that tea alarril:_i these c work it spoor=s mesicire.Kids. he-says."are kira•,f borr.aro brad be pitoPers from cyears ole, years old,arr•,trrow so mL .li siirks" lrc=a _theprofif•=raforoftrsverball-a?artir_severai:tear5beforette7-Year-c4 s we see or a rai oral stage at is_hire Lea ti_•1tiori Seri-_-5-rtlak_a basebsii a year- roi rd proposiror at ar early ace..Valle pitch:ours ard irrit_a llini.a aea short- S=rm a ate:Lar:s acairs overt se,}tears of sp__ial: lfor take.their if. We ri7Atsm.micaliy,sta5sacaily. s_i=rlifital}y have prover fret ie kits who play baseball year-roLr_•^are tr rae times more likely to era bp or a sL reery table by their Z41birthday thattrosewt Iter:t"says Reis4,€tIraat_sy rsiLcytar_tiry sra_erswho pitt more liar t irrirds ira ealardaryear. Ws.14-7.ir a day of spedaa.lb_aeor where kids love ore-spost arse it-pants lov aL pportirc tem,ar•i tier=are baseball carters erd irveiirs teams,so instead of playirL varioLs spa :rind Payr;periods ofactkey of ir>aeti itj. kid s are hal/117g this LrratLraleyeleofplay irgbaseba:llall ff_tints,ar- 1rats1•at1italtys=riaLslfirer_ases reireta roesffaetirg, Tort.More is r•Dtalways Leis:' Andrews says Its"real problem'b:errs ir.yourger age groups.Vie rpKerere sLff_r iror irj&ries"playiry yea-ro1rd baseball,playirg ir;.'Fo!segues alike sameJim=. ooertkre',irm,watch ird Ike radar di.r,tryira to ir:rease tsir iei it bayor,o Ike velopmneri of that ligament Tr is yearss crop ofbid l=athe widima c_firit_t skein}Sole!3.Six ofIke i'!.-if Moore to include;.-are F.ars yoLroer.and Parker,2E,kaaa i:roer or_kis secoro surgery. That reality las L_some Cisbatit stockg&arms asstkebeat safeduaari'£a;alrsi Its likelitcoci some pizkers will break dowr.. The N-atorafs,forexamp}_,tad saek.a surplus ofstorlir.;candid cLrirgsprint;lairit•s.they caul:afr r to let goofv-erar.Chris Young-picl 2Lpby Its fea"nle Marir_rs--ara move Ross Dewilerto t_bLli per. Thar,.ayair,tree memberscd4tt_Washirolr.rr r aticr-2epker.;=trasburg,Jor ar Zimmermarrar•e iayorJarrd=n-t-avekadTommy JohnsLr_ryt. The fact ofthe matter is,this is an Lrr atLral adtevery time*el*row•the baseball, so you worry about i;. Elerybo:y worries aboLT rt. mar.a;sr Mali'Williams saki."Theyhey go OLTtker_aro comate or a reoslar basis,t-row that ball i.:(i tins;ir'a game.The res wear ars.lear.'- Arc Erb oLa.rart http://news.shepherd.org/catastrophic-care-coverage-for-high-school-athletes i in !tsar aiR Wheel n !b 1 ATLANTA JAY-'D.2e13 Catastrophic Care Coverage for High School Athletes Experts urge parents to determine coverage available from schools before kids play sports. virt r fl; 11111114i1771 r. t After ntakir;the catch,ArqLeviot s Crare bazar"fi_htir_'for yards it a high school J:r football game rear Marta in.23=7.Toe , his lir_charge.. It was a rormal'c.ii,frart aro back,JLs1 a fr_akial a:ater1,'says the yo.rg mar whogoes by"0..--1 was face gena:and about to start pariekir:about rot being,able try breathe. I warted to turn over teems_1 was eatirg a lr+1 of diol. Q ecLkir t move.He had sustained a F-to-'?.spiral cord ir-Ary aro was paralyzed from the chest Caren. As he b_;-an r_h-abilitatior.at Shepherd center,Barbara erase,the grardnrolher who years earlier ad-opted 0 and his four younger:aiblir:gs.was it•a daze. he diir I krow who wo..lc pay the medical bills that cotid total miliiors of collar. Mary medical irsurar.e plars have a$2 ;1OJ Emit,are much like homecarers are rarely irsured against flood carnage to homes i,-rl_ss they have flood ir•smraree,those meeal plans often.ort provide aiacuat_coverace for catastrophic injuries like 0s. Barbara's ar'awer?ire. "deo gid. h'ycj school student-athletes are covered for life-altering injuries smstair=3 ir sports by a S5 milia catastrophic irsLrar.ce policy_The stales governing bodies for athletics—the Georgia High School Aas€i,.iatior.;3H`A)arra.Georgia_1r-depend-est School Association{3ISAI—purchase the poky from MLti.al of Omaha. Cranes high school,South 3wir_rett, is it the GHSA. 1 didn't kror,that !:roil 1 i tt.-Gairrelt}coach(Jahr.Smal;;came to the hospitalart told me.'Barbara recalls. At that time, I ditirl rale_what it meant' The 3HSA polity helps . r- w 1,with disability berefits,college itiiier,are:assistant who accealparz?s him to class,a power whl:hair,an adapted var are more e_Lipmerl pica cLsto:ial home Care. It is orb./a partial berefit list. Former Shepherd Center palt=rt Ardt.evious'Q' vrar_arc his grandmother.Barbara Crane,of metro Marta, are iharkful that Crs high,achsal carried catastrophic injury irscrar_e,which has covered mary of the medal xperaes y has tad sirce be sLataire•_a spiral cord injury ir a school football game ir 2iD7. Every high.school atueert-altlate ire^Georgia must have medical iraamine to play,but few.if cry, medical or st:pplemertal plars cover experses likeya.Are ssonte states cc rot require schools to purchase cataalr*ph . coverage. In Illrois,estimates sL;eesl that 5 p_rceri of the states atLder.i-all'leles have catastrophic insurance through, their schools. Ir-iivi:Cal catastrophic policies for yoirg people are rare ir.the Unite:Stales. A bill before the Illir:'is House of Representatives that=Lid have marcatec catastrophic coverage of S7.5 miiiior.or 1:5 year for athletes at=very high school failed to pass it fall EE42.A similar bill is before the Illinois gate this year. 2963 Senate tris year. Utah offi:ia s nay begin chaheirs E.per SIVI=!t-a:r cin -fray a rya i Cata5irripViC coverage premiums pr_mpic by racer:claims. i he al=rraiWe nay b a rise ir game ticket prei,__a. Msarwrile it a=eon's.,the HE s poky is funs+ by a poriOr f arrLai cuss irargirg from S345 to paki by each of more tier member schcala.High Sc-Pols seek to wady that stu:ert-aitite.3 rave medisal irs rair:e throu;h parents or CLar.iars,or Ihat trey buy a supper-aerial plan, before they Lian participate it sports at school. t few pererts seek tc t.rderslar: ,Cc r ira.rarcc•_cVera;s li"ilits, nor co trey real,.'•.+these pears may hes helpful for a broken ankle or a kree irjr:ry, but are rot laic& 1D cover a catastrophic spiral r:oro or brair irjLry. Marys patents rave ro ica if there is-a'statswice,school sysl m-ws•or ever a school spealfie Catastroprie irsuraree par ir pla._toao that. Why?They ccrf ask.Wrc ihirks a catastrophic irjury will ever hapoe-r t.them? Here are some experts' suggestions for parents of aspiring school athletes: Determine the breadth and depth ofyour primary insurance coverageanddor supplemental policy. Health irsi.rar.accoverage vane.;•.'.rarlalisax(iyr from family to family, says Boon Eoz_1ri ht,vice president of BEST Irsurarce+_rotes,wrier has harsh;the SHEA,aatastrcpr poky for 23 year.It is importart to be aware of ire bereftts,e_x€h.si ens a.rd limits'antic:your policy. Man?yr Taylor,a Shepherd ;terter pest-aait=case rnaray=r for spiral cord irj;..fy, says:1 spend a lot of time explairirg to clients. Yes,you,rave Blue Cross, but that ccccs rot maxr•you bought Ire whole pie. trey'tray rave a piece_A lot of people dor 1 realize-they car.call customer service and elsevas treir benefits Talk to a school official about insurance coverage available through the school.Find out if they cover ambulance service,emergency room care,outpatient care and,most importantly,whether the school provides catastrophic coverage. Ask the school exactly what Ire policy covers,'say; HeCi Jr,circ:iorof workers Comperaatior.at Shepherd eerier.`How mint r_kabiii alior.is intlhLea?What about;Crab;_medic-al ecu prnert(such as wheelchairs, etc.;.?What are the limits?Parents reed to krcrr whether there is a poky that cover;catastrophe injury:- Taylor njury sTrayloradd;:'Trete are rot a let of:paraoral;policies thal provide catastrophic coverage.Ratability/Or is usually expear3 to be short term for irjuries such as a broker limb or joint replacem_ri, but rot irjuri=s th-al recuire a S?::.s=.wheelchair. Realize thatfootball is not the only sport in which serious injuries occur. Brain and spinal cord injuries can result from many types of sports. Mutual of Cmaha vice presidert of special risk Se-oil Harsor says the cornpar:y has seer claims for every spar!. For eitarnpl_,at tine University of 3corg . baseball player J.oi'rat'ar-Taylor,a former Shepherd Center patient. su;;tair=.a C-5 to r,spiral a-ori injury it a 21Y-,dam=it wrier re collided with another player in the£SLTf i:3. Fortunately for John-attar, USA has a suppl_in_rtal policy that paic the bulk of the medical expenses incurred before the NCAs catastrophic policy kicked in. says Clause notion, serbr associate athletic cirertor al USA. Hanson.rotes that a oxtail roprie plan may be tre oriy;safeyuare to suffktiently care for a catastrophically irjtr_d your perstr arc avert firarcial nir. O.Crane is a Case it point.Though he has seer a rease:'furciior ir hi;arms, re must still use an expensive power wheelchair,Whet his policy„over.It also pays his ILitior..As a jit.ior at Ssor is Gairrett Coll, e s1u_yig political s i=rce with a minor it criminology, he warts loan-arc;law school.after graduatior.Also, le plays billiarc;-and lirkers around in a•.3arale music studio at a horns doralea to tie family. I took what I red arc raver gave up.'C'says."Keep strNtrj. I'm a eompe-ll-tor.' Barbara.-a cisa.bd former meat packer, has three gr;ndchi irer..in cubes lirtiluding ore or a basketball scholarship;and two in IV. school. Life is rot easy, but her family is+hang by with help from Ire paople cf luiiie. 3a.,and catastrophic cars irsurarce. 1 can really feel for people who dor I have insurance Tike Arcuiviee5 has,"are says.'We try to do wral we car, are wave beer biassed as far a; help." Written by Marr Winke!john Phorograpphy by Gary Meek About Shepherd Center 1 2964 2 http://espn.go.com/m1b/stor_y/ /id/11002986/drfames-andrews-app-aiming-limit-tommy-john- surgeries Andrews, Wilk create pitching app a f.1s,sa tr r 5K S:Dt:r;547,rcet si`3po,4 Pwlis Nctedorthopedic surgeonDr.Jar mAndrewshasperformedDT,r,=„OMToirmrj- John surgeries onthe elbowsofbav_hal.players.Dr.$esinEl'il Irissleit ima physicaltherapistcolleague.,has overseenthe rehabilitation ofmany ofthese Inathletes-followingthe procedure, rofafterleo-Mussing aniucreasing number ofthroen seekirgToisei Jahnsurgeryatprogressively primer Bees,AndrewsandIt&are tWrI trgingtnstemthetideafthese devastatinginjuriesatthe youthlevel Ihrteamingup todexelopanJOS application deed to educate players;parents and coaches onhow to prevent throning injuries. The app,ThrowLikea Pro,wilbe mres raleased inthe caningswk;,When wrsct,o.ra re C_-•-,ti- _._ - aaarl?hl'.ittvillfeaturefour main elects,allcentered around scialiific dataandinput from Onesectionincludesrecouz*nd =torpitcbrasfromthe American Spot. SK Medicine Institute;Bich as avoidingthroning to thetargeteraradargun and Rafe hutearl focienthroning,withproper mechanics. The appalso inchidee apreseason preparation guideandpregamewarm-up routine,including-video instructionof annus throwingexercises from Var..In additiontoseommendingspecificminden,Wilkoffers tips to avoidcome= 411) mndakes. Perhaps oneof#hemostpractical sections ofthe app is thepitchcounter and rest calculator.l3urpitchmintercanbeusedto trackliewmanypitches are thrownduringa€ameand throattheseason. F-1115 Basedon theplays age,Throw Like aProcreate;spec cguidelines with = rC' regards to numbersofpitches.The ScFwe rrrc'-3.lassru"w rr c? ttheb4 problem ratcalma foroutlines appropriate niguktawcy RonY:4Afrtrl:dh SGrrs rest prior toresuming pitching. M'adlctraIca'st¢'sIr-t::":cr_nnTcr!rrg ionicUr.'Is1.a:stcrsstn.cro:GI=s»i% a• ralm:s:rxr Q::•!dS hc4,':ad Wilac said thegoal oftheappisto reduceshoulderandelbowinjuries in youth baseballplayerwhile trnalianeonsly ivper, Hopefullythiswill help themtoplayatpeakperformance withoutiajory,"Wilk saki;"so they canpirssnetheirbaseball aspirations inahealthymanner." Andrews ernisbnstheapp asa.means ofbroadly educatingplayers alongwith 1,i Iz tii-6I-a r i_}tliairfauolies auud clau tohelppreventcrvp-_raseiajnriesinzv FF44l sthrowers. Fmreallyexcited,"Andrews said."roarthefirsttime,kidsand parents everpsi•,erevsfilhaveaccesstotheinformation androwthat wehopewill patan mitathisepidemic.' 2965 1 THE STRATEGY HOUSE 71 Vickery Street Roswell,Georgia 30075 Telephone 770-394-8465 Facsimile 770-394-5470 www.thestrategyhouse.net August 27,2015 Hand-delivered Karesha Berkeley Laing Senior Health Systems Analyst Healthcare Facility Regulation Georgia Department of Community Health AUG 2 7 2015 2 Peachtree Street, NW Fifth Floor Atlanta,GA 30303-3159 RE: Joint Opposition to ASMC,LLC d/b/a Atlanta Sports Medicine Center's CON GA 2015- 017 Dear Ms.Laing: On behalf of Marietta Outpatient Surgery Center, LTD d/b/a Marietta Surgical Center and Atlanta Surgery Center, LTD d/b/a Atlanta Outpatient Surgery Center, I am enclosing two copies of their joint opposition to ASMC, LLC d/b/a Atlanta Sports Medicine Center's CON application (GA 2015-017),which seeks to develop a freestanding ambulatory surgery center in Alpharetta Georgia(HPA 3). Thank you for your consideration of this information. cere 09- 11‘*--- Dani l M. Beall Attachments 2966 Joint Opposition to HPA 3 Ambulatory Surgical Services ASMC,LLC d/b/a Atlanta Sports Medicine Center Project No.GA.2015-017 RF:CFVr: ORIGINAL AUG 2 7 2015 By Competing Healthcare Facilities: Marietta Outpatient Surgery,LTD d/b/a Marietta Surgical Center Atlanta Surgery Center,LTD d/b/a Atlanta Outpatient Surgery Center August 27,2015 AUG 77719 571:1, 2967 Opposition to Project No.GA 2015-017 August 27,2015 ASMC, LLC d/b/a Atlanta Sports Medicine Center Page 1 Marietta Outpatient Surgery, LTD d/b/a Marietta Surgical Center ("MSC") and Atlanta Surgery Center, LTD d/b/a Atlanta Outpatient Surgery Center ("AOSC") previously identified themselves as competing health care facilities that would be aggrieved if the Department were to approve ASMC, LLC d/b/a Atlanta Sports Medicine Center CASMC') CON application for a freestanding ambulatory surgery center("ASC") in Aipharetta (Fulton County)Georgia. Background MSC is a freestanding multi-specialty ambulatory surgery center that is located in Marietta Georgia(Cobb Cmunty), which is in HPA 3. MSC operates six operating rooms. In addition, MSC operates two endoscopy rooms. During 2014. MSC accounted for 3,879 ambulatory surgery patients in its six operating rooms and operated at 57 percent of maximum uh|ization, which is below the Department's targeted utilization. In 2014. MSC drew patients from 57 Georgia counties as well as patients from Alabama, Florida, North Carolina and South Carolina and Tennessee. Approximately 90 percent of its patients reside in HPA 3 counties. MSC's services are easily accessible to indigent/charity patients and other underserved populations. In 2014, MSC provided o1.201.499 in uncompensated care to 239 indigent/charity patients,which accounted for 3,7 percent of its AGR. AOSC is a freestanding multi-specialty ambulatory surgery center that is located in Atlanta Georgia Fulton County),which is in HPA 3, AOSC operates seven operating rooms. In addition,AOSC operates three minor procedure rooms. During 2014,AOSC accounted for 6,788 ambulatory surgery patients in its seven operating rooms and operated at 78 percent of maximum ud|izsdion, which is below the Department's targeted utilization. In 2014, AOSC drew patients from 73 Georgia counties as well as patients from Alabama, Florida and other states. Approximately 86 percent of its patients reside in reside in HPA 3 counties. Although AOSC does not have an indigent/charity care commitment, it does provide limited services to patients without the financial means to pay. On June 1, 2015. ASMC filed a CON application to construct a 20,000 square foot, frmeotandin0, multi- specialty ambulatory surgery center on 30+acres at the intersection of Morris Road and Old Morris Road ulti- opeoiahyombu|ahurysurgmryuentoron30+acresattheinhensectionofyNnninRoadand8|dyNorrisRoad Old Milton Parkway), which is located in HPA 3. The proposed ASC includes four operating rooms, two minor procedure rooms and 19 recovery beds and is estimated to cost$12,543,405. The applicant filed the application pursuant to Rule 111-2-2-.40(3)(b), requesting an exception to the need standard in order to remedy an atypical barrier to ambulatory surgery services based on financial ocneos, geographic access and quality barriers to ambulatory surgery services. 8pecifioaUy, the applicant states that it will serve a unique patient population composed mainly of amateur and professional athletes from across the D.S. and that unlike similar sports medicine facilities it will provide a full range of medical, diagnostic, rehabilitation and sports training services and facilities on its campus. 2968 Opposition to ProjecNo.GA2O15-017 g ust 27 2015A8MC. LLC d xaAdan Gpo Medicine 2 On August 12, 2015, ASMC filed an Additional Information submission and "revised' its application to reflect a request for a single specialty orthopedic ambulatory surgery center, not a multi-specialty center. Essentially,all other aspects of its application remained the same. MSC and AOSC each filed a timely Notice of Opposition to ASMC's applications on July 24,2015. Opposition Summary ASMC's application should be withdrawn - ASMC's change from a multi-specialty ambulatory surgery center to a single-specialty orthopedic ambulatory surgery center is a material change in its proposed project and requires that ASMC withdraw its current application and submit a new application. There is no need for ASMC's ASC puoieu± HPA 3 has a surplus of ambulatory surgery rooms that are underutilized. Based on the Department's 2019 Ambulatory Surgical Services Need Projection, HPA 3 has a projected surplus of 73 operating rooms and existing HPA 3 providers are operating at only 57% utilization. Despite population growth of almost 400,000 residents,the number of ambulatory surgery patients in HPA 3 declined from 265,429 to 253,502 in five years 2010 to 2014). In combination with the growing population and declining ambulatory surgical voiummo, the rate of ambulatory surgery patients declined from 54.88 outpatients per 1.000 to 48.47 outpatients per 1,000 during this five-year period. In mddition, during this period, the projected surplus of ambulatory surgery rooms increased from 33 rooms to 73 rooms as the aggregate utilization of HPA 3 providers dropped from 64 percent to 57 percent. ASMC has not demonstrated that there exists an atypical barrier to ambulatory surgical services. Service area residents have excellent access to high quality ambulatory orthopedic surgery facilities through existing hospital-based services and freestanding services. Professional and amateur athletes, the primary population that ASMC is proposing to serve,do not face barriers to ambulatory orthopedic surgery services. Simi|ody, non-athletes do not face barriers to ambulatory orthopedic surgery services_ Ambulatory orthopedic surgery facilities, including those that serve professional and amateur athletes are readily available in the metro Atlanta area. Furthermore, nationally recognized orthopedic surgeons with specialties in sports medicine, many of whom are fellowship-trained in sports medicine, practice in Atlanta. In addition, ASMC has provided no documentation that that low innome, uninsured and underinsured residents have a financial barrier to accessing these ambulatory orthopedic surgery services. In sum, ASMC's project does not meet the"Hughston"criteria for establishing an atypical barrier. 2969 Opposition to Project No.GA 2015-017 August 27,2015 ASMC, LLC d/b/a Atlanta Sports Medicine Center Page 3 Other area hospitals and freestanding ambulatory surgery centers are more appropriate alternatives to this project. ASMC has failed to address the abundance of appropriate alternatives to its proposal including the other 31 hospitals and 33 freestanding multispecialty and orthopedic-only ambulatory surgery centers' located in HPA 3. These ambulatory surgery providers have historically provided high quality orthopedic/sports medicine surgical services to patients throughout Georgia and other states, including professional and amateur athletes. In addition, these providers account for significant amounts of uncompensated care to indigent/charity patients and they are underutilized. Moreover, these existing alternatives have the capacity to treat many more patients, including the types of patients that ASMC is proposing to serve in its orthopedic ambulatory surgery center. ASMC has not demonstrated that its volume projections are reasonable, which puts the financial viability of its project in question. ASMC offers no objective analysis of how it will achieve its volume projections, relying solely on the experience of the Andrews Institute for Orthopaedics & Sports Medicine in Gulf Breeze, Florida, which is a materially different facility than ASMC's proposed orthopedic-only ambulatory surgery center. Other than Dr. James Andrews,ASMC has not demonstrated that it has the surgeon support necessary to attain its volume projections. ASMC has neglected to provide any need analysis or financial analysis of key and essential components of its overall sports medicine "center" concept. Essential to ASMC's vision of a sports medicine center are numerous non-surgical services and facilities, which ASMC argues makes its project unique in Georgia. However, the applicant excludes these essential services and facilities from its application, which raises the question of the need and financial viability of the"entire"project. Review Considerations Rule 111-2-2-.07: Review Procedures ASMC's Additional Information submission, which it filed with the Department on August 12, 2015, the 72nd day of the review, informed the Department that it had revised its application to reflect that it now was seeking a CON for a "single specialty orthopedic ambulatory surgery center, not a multi-specialty center." It is MSC's opinion that this"revision"reflects a total change in the scope of the project and that the Department should consider the application withdrawn and ASMC should be required to submit a new Includes both CON-approved and LRN-approved centers 2970 Opposition to Project No. GA 2015-017 August 27,2015 ASMC, LLC d/b/a Atlanta Sports Medicine Center Page 4 application for a single specialty orthopedic ambulatory surgery center. ASMC's original intent to develop a multi-specialty center is a misrepresentation of its"revised"plan and contradicts the Department's intent to allow non-material changes in the scope of services. Rule 111-2-2-.09(1)(b)and 111-2-2-.40(3)(a): Need Based on the Department's 2019 Ambulatory Surgical Services Need Projection, there is no need for additional ambulatory surgery operating rooms in HPA 3. Based on future population growth,the analysis indicates that there is a projected surplus of 73 operating rooms in NPA 3. Despite the Department's projections of a surplus of operating rooms in HPA 3 over the past five years, from 2010 to 2014, the number of ambulatory surgery operating rooms in HPA 3 actually increased by 6.6 percent from 332 to 354. This increase occurred despite a decline in ambulatory surgery patients,which showed a decline of 4.5 percent. Meanwhile,the operating room aggregate utilization in HPA 3 decreased from 64% in 2010 to its current utilization rate of 57%, which is significantly lower than the 80% aggregate utilization required to justify the need for additional ambulatory surgery operating rooms. Please see the following exhibit. Exhibit 1 HPA 3 Historical Ambulatory Surgery Utilization 2010 2011 2012 2013 2014 %Change Population 4,836,660 4,930,461 5,025,250 5,125,114 5,230,014 8.1% Outpatients 265,429 266,142 262,011 261,992 253,502 4.5% Rate per 1000 54.88 53.98 52.14 51.12 48.47 11.7% OR Inventory 332 339 354 356 354 6.6% Surplus 33 39 58 60 73 121.2% Utilization 64.0%63.0%59.0%59.0%57.0%10.9% Source:Department ofCommunity Health Currently, HPA 3 has 354 ambulatory surgery rooms in its inventory. Based on maximum possible utilization (1,250 patients per room), these 354 operating rooms have the capacity to treat 442,400 ambulatory surgery patients (354 x 1,250). Only 253,502 ambulatory surgery patients were actually treated,which means that there was sufficient capacity to treat an additional 188,998 ambulatory surgery patients in these existing rooms (442,400 - 253,502). Even based on the Department's targeted utilization of 1,000 patients per operating room, the 354 surplus operating rooms had significant unused capacity and could treat an additional 100,498 ambulatory surgery patients. Please see the following exhibit. 2971 Opposition to Project NoCA2O15'01Tun 2015 ASMC, 27, Page 5 Exhibit 2 HPA 3 Unused Ambulatory Surgery Room Capacity 2010 2011 2012 2013 2014 Capacity t 100% utilization 415.000 423.750 442.500 445.008 442.500 Outpatients 265.429 266.142 262.011 361.992 253.502 Unused Capacity 149.571 157.608 180.489 183.008 188,998 Capacity©80%utilization 332.000 330.000 354'000 356.000 354.000 Outpatients 265.429 266.142 262.011 261.902 253.502-7 Unused Capacity 66.571 72.858 91,989 94.008 100,498 8pecifion|ly, MSC and AOSC are operating at a low utilization and have capacity for additional volume including orthopedic patients. Over the past five years, MSC has seen its volume decline by almost 40 percent from 6,301 patients in 2010 to just 3,879 patients in 3014. With this decline in patient volume, its utilization has had a concomitant decline from 84 percent of capacity to 51.7 percent of capacity. Please see the following: Exhibit 3 Marietta Surgery Center Utilization Trend 2010 2011 2012 3013 2014 %Change Operating Rooms 6 6 6 6 6 0.U%- Capacity(1.25Opatients per OR) 7,500 7.500- 7.500 7.500 7.500 0.0% Outpatients 6.301 5.600 4,532 4,255 3,879 Utilization 84.0%84.O96 7479& 60.4% 56.7% 51.7% Source:Freestanding Ambulatory Surgery Center Survey AOSC has seen its volume decline slightly from 6.850 patients in 2010 to 6,788 patients in 3014. However, of the past year, AOSC saw its volume decline by almost 10 percent from 7,525 patients to 6,788 patients. Cunently, the facility is operating at 77.6 percent of uU|izabon, which is below the Departments optimal capacity target of 80 percent. Please see the following: 2972 Opposition to Project No. GA 2015-017 August 27,2015 ASMC,LLC d/b/a Atlanta Sports Medicine Center Page 6 Exhibit 4 Atlanta Outpatient Surgery Center Utilization Trend 2010 2011 2012 2013 2014 %Change Operating Rooms 7 7 7 7 7 0.0% Capacity(1,250 patients per OR) 8,750 8,750 8,750 8,750 8,750 0.0% Outpatients 6,850 6,341 7,193 7,525 6,788 0.9% Utilization 78.3% 72.5% 82.2% 86.0% 77.6% 0.9% Source:Freestanding Ambulatory Surgery Center Survey In summary,there is not a need in HPA 3 for additional ambulatory surgery rooms. As evidenced by the utilization of HPA 3 ambulatory surgery providers, at the Department's targeted utilization of 1,000 patients per operating room,there is enough unused operating room capacity to accommodate more than 100,000 additional ambulatory surgery patients. The approval of ASMC's CON application will simply duplicate existing resources and add unneeded operating rooms in a planning area that has seen declining ambulatory surgery volumes, low utilization rates and increasing unused ambulatory surgery operating room capacity. . Rule 111-2-2-.40(3)(b): Exception to Need - ASMC takes the indefensible position that because it is proposing to serve a population that is not limited to serving "citizens in the planning area and/or communities under review,"the Department's need methodology and exception rules do not apply to its application. ASMC's position is wrong. The CON General Rule Considerations anticipate that some providers and services may serve a broad geographic area and gives consideration to these broader geographic service areas. Rule 111-2-2-.09(1)(j): Non-Resident Services, specifically addresses this issue,stating: The proposed new institutional health service provides, or would provide, a substantial portion of its services to individuals not residing in its defined service area or the adjacent service area. Just because an applicant proposes to serve a broad geographic area, does not exempt the applicant from the Department's need methodology and exception rules. If this were the case, as ASMC argues, the Department would have written a specific CON-exemption for these types of projects, under Rule 111-2-2-.03: Exemptions from Review, which it did not, or would have written specific review standards under 111-2-2-.40: Specific Considerations for Ambulatory Surgery Services such as those written for Destination Cancer Hospitals,which it did not. 2973 Opposition to Project No.GA 2015-017 August 27, 2015ASMC, LLC d/b/a Atlanta Sports Medicine Center Page 7 It is obvious that ASMC's application is bound for review under the Department's need methodology for Ambulatory Surgical Services. It is undisputable that based on the Department's most recent numeric need methodology there is no need for additional ambulatory surgery operating rooms in HPA 3 as ASMC is proposing. Therefore, the Department can approve ASMC's application only if the proposed project meets the exception rules for Ambulatory Surgery Services. The exceptions to the need standard for Ambulatory Surgery Services are clear, The Department may allow an exception to the need standard in (3)(a), in order to remedy an atypical barrier to ambulatory surgery services based on cost, quality, financial access, or geographical accessibility. An applicant seeking such an exception shall have the burden of proving to the Department that the cost, quality, financial access, or geographical accessibility of current services, or some combination thereof, result in a barrier to services that should typically be available to citizens in the planning area and or/the communities under review. In approving an applicant through the exception process, the Department shall document the bases for granting the exception and the barrier or barriers that the successful applicant would be expected to remedy. Trying to have it both ways,ASMC states that"(i)f the need rules apply the ASC meets the exception for a barrier to access based on geography, finances, and quality." ASMC bases its atypical geographic barrier argument on the fact that Dr. James Andrews performs "Tommy John" surgeries and that this procedure is"generally not available in Georgia." ASMC bases its atypical financial barrier argument on its willingness to offer services to Georgia high school athletes if they are unable to pay. Finally,ASMC bases its quality argument largely on anecdotal letters from Dr. Andrews' patients, who commend Dr. Andrews and his facility for producing a positive outcome. ASMC's arguments, including its supportive documentation, are not sufficient to demonstrate that there is an atypical barrier to orthopedic ambulatory surgery services and, therefore, meet the exception to need for ambulatory surgery services. The simple fact is that there are no barriers to orthopedic ambulatory surgery services in HPA 3. The criteria for meeting this exception, commonly referred to as the "Hughston Criteria," are well documented and accepted. To demonstrate that a project remedies an atypical barrier, it must meet each of the following criteria: 1. The services proposed are not sufficiently available in the area. 2. There is a specific population in need of such services_ 3. The proposed project will remedy the barriers that exist among the specific populations. 2974 Opposition to Project No.GA 2015-017 August 27, 2015ASMC, LLC d/b/a Atlanta Sports Medicine Center Page 8 ASMC fails to demonstrate that there is an atypical barrier to orthopedic ambulatory surgery services and that the proposed project meets each of these criteria. ASMC attempts to position its application as a request for an "athletic training, rehabilitation and single- specialty orthopedic ambulatory surgery complex...designed to provide comprehensive training, rehabilitation, medical and surgical services to amateur and professional athletes from across the United States" [Emphasis added]. As further presented in its application, this complex, which would encompass 30+acres,would include: one-story, 19,020 square foot Baseball Academy two-story, 52,883 square foot Sports Performance Center three-story, 92,481 square foot Medical Office Building, which includes the 20,000 square foot ASC future two-story, 55,816 square foot Medical Office Building In reality, ASMC's CON request is not for a 32+ acre athletic training, rehabilitation and ambulatory surgery "complex". Its application is only for a 20,000 square foot orthopedic-only, freestanding ambulatory surgery center, with four operating rooms and two minor procedure rooms. In fact, ASMC offers no documentation that there is a need for its larger"complex",that there is adequate financing for it or that the "complex" is financially feasible. ASMC proposed "complex" is purely speculative and there are no assurances that ASMC will develop it or if it even has the resources to develop it. Orthopedic ambulatory surgery services are readily available in the service area. ASMC's proposal does not meet the first prong of the Hughston criteria that services proposed are not sufficiently available in the area. In fact, orthopedic ambulatory surgical services are readily available in the service area. ASMC actually states in its submissions that, ASMC does not dispute that orthopedic ambulatory surgical services are available either in a hospital orfreestanding ASC setting in HPA-3. Source:Page 36.3,ASMC's Amended Response to CON Rules 111-2-2-.40 for Ambulatory Surgery Services ASMC also states that the Metro Atlanta area also has "hundreds" of orthopedic surgeons, although it tries to make the case that"few if any serve the prospective professional athletes that actively seek care from Dr. Andrews and his surgeon." There is no dispute that Dr. Andrews has a stellar and national reputation and attracts patients from throughout the United States. Nonetheless, nationally recognized 2975 Opposition to ProjecNoGA 2015-017 August 27, 2015 ASMC, LLC d/bla Atlanta Sports Medicine Center Page 9 orthopedic surgeons currently practice in Atlanta that not only serve professional athletes but also serve amateur athletes from all levels. Included in this list of nationally recognized physicians are: o Spero G. Karas, MD, sports medicine specialist and orthopedic surgeon, oversees orthopedic and medical care for all Falcons' players and its coaches. Karas serves as an associate professor of Orthopedics at Emory University. Dr. Karas also serves as the orthopedic surgeon for Georgia Tech baseball and consulting team physician for Georgia Tech, Emory University, Oglethorpe University, and Georgia Perimeter College athletics. Dr. Karas belongs to numerous prestigious medical o,gmnizationm, including the NFL Physicians Society, the American Shoulder and Elbow Gungeonu, American Academy of Orthopaedic Surgery, Arthroscopy Association of North America, American Orthopaedic Society for Sports Medicine, and American Orthopaedic Association. Michael P. Bernot, MD is a member of Peachtree Orthopaedic Clinic and is the Head Team Orthopaedist for the Atlanta Hawks basketball team. Dr. Bernot has extensive experience in Sports Medicine. He has served as Team Orthopaedist for the World Championship Figure Skating Competition, Team Orthopaedist for the Cincinnati Cyclones hockey team, Assistant Team Orthopaedist for the Cincinnati Bengals football team and Miami University Varsity Athletics. He was the Venue Director for the Olympic Basketball and Gymnastics venues during the 1996 Gunnme, Olympic Games. Dr. Bernot also serves as Team Orthopaedist for the Lovett School in Atlanta. Xavier Duralde, MD, a member of Peachtree Orthopaedic C|inic, has served as an orthopedic surgeon to the Atlanta Braves since 1998, becoming the Lead Orthopaedist in 2006. Dr. Duralde has been named as one of the top orthopedic surgeons in Atlanta for six straight years: 2010. 2011, 2012, 2013, 2O14and 2O15. Becker's Orthopaedic, Spine and Pain Management Review also named him as one of the top 66 Outstanding Shoulder Surgeons. Dr. Duralde is Board Certified by the American Board of Orthopaedic Surgery and serves as associate adjunct professor at the Emory University School of Medicine. He is a member of the American Shoulder and Elbow Surgeons Society, Association of Bone and Joint Surgaonw, American Orthopaedic Association arid the Major League Baseball Physicians Association. John Xerogeanes, MD, is Pnzfeosnr. Department of Orthopaedic Surgery at the Emory Sports Medicine Center and Chief of Sports Medicine. Dr. Xerogeanes is Head Orthopaedist and Team Physician for Georgia Tech, Emory University, and the Atlanta Dream of heVVNBA. US News &World Report has recognized Dr. Xerogeanes as one of its Top Doctors 2976 Opposition to Project No.GA 2015-017 August 27, 2015 ASMC, LLC d/b/a Atlanta Sports Medicine Center Page 10 with a special distinction listing him among the top 1% in the nation in his specialty. Press Ganey has consistently ranked Dr. Xerogeanes among the top health care providers within Emory Healthcare in Patient Satisfaction° by patient polling. Along with recreational athletes, his patients range from past Presidents of the United States to Academy Award winning actresses to professional and Olympic athletes. He is one of only two Emory School of Medicine faculty members to be nominated and elected to the Alpha Omega Alpha, a national medical honor society founded in 1902. In its application,ASMC tries to distinguish Dr.Andrews's accomplishments with"Tommy John"surgery. Contrary to ASMC's assertion, "Tommy John"surgery is available in Georgia. Orthopedic surgeons that perform Ulnar Collateral Ligament ("UCL") Reconstruction or"Tommy John"surgery are readily available in the Atlanta area including,but not limited to,the following surgeons: Orthopedic surgeons at The Emory Clinic including Dr. Kyle Hammond, Dr. Scott Maughon who received his Sports Medicine fellowship at American Sports Medicine Institute in Birmingham,AL under Dr. James Andrews, Dr. Spero Karas,and Dr. Mathew Pombo. Peachtree Orthopaedic Clinic surgeon Christopher A. Potts, MD, who also received his Sports Medicine fellowship at American Sports Medicine Institute in Birmingham, AL under Dr. James Andrews. Peachtree Orthopaedic Clinic surgeon Timothy Griffin, MD, who also serves as team physician for the Gwinnett Braves and serves as the Atlanta affiliate team physician for the New York Mets. Amy E. Borrow, MD, an orthopedic surgeon at the Longstreet Clinic in Gainesville/Buford, who received her fellowship from the American Sports Medicine Institute in Birmingham Alabama under the direction of Dr. James Andrews. Dr. Borrow is one of the team physicians for the Dacula High School, North Gwinnett High School, Lanier High School and the Lanier Soccer Association and was one of the team physicians for the Georgia Force. Robert M. Titelman, MD, an orthopedic surgeon with Resurgeons,who completed a fellowship in shoulder and elbow surgery from the University of Washington and a fellowship in elbow surgery from the Mayo Clinic. ASMC, which only highlights the work of Dr. Andrews, cannot ensure the availability of Dr. Andrews for patients requiring surgery. Dr. Andrews, who turns 73 in September, by his own admission, has cut his 2977 Opposition to Project No.GA 2015-017 August 27,2015 ASMC, LLC d/b/a Atlanta Sports Medicine Center Page 11 practice in half.2 Please see Attachment A. Not only does Dr. Andrews perform surgery in his Gulf Breeze Institute, but he also remains active with the Andrews Sports Medicine and Orthopaedic Center in Birmingham where the Center prominently portrays him on its website. Over his career, Dr.Andrews has affiliated with the Hughston Clinic(Columbus Georgia), HealthSouth(Birmingham Alabama), St.Vincent's Health System (Birmingham Alabama) and Baptist Healthcare (Gulf Breeze Florida). At best, Dr. Andrews'participation in ASMC's proposed project will be limited and sporadic. Additionally, ASMC argues that there is a need for its project to improve geographic access for Georgians. As presented above, Georgians have access to quality orthopedic ambulatory surgery facilities and orthopedic/sports medicine surgeons with first-class credentials and national reputations. Even if ASMC's argument was valid, which it is not, the approval of this project does not improve geographic access for the 40 percent of its proposed patients who reside outside the state and must travel to Atlanta. For athletes living outside Georgia, especially those living in Alabama and Florida, Dr. Andrews' centers in Birmingham (Andrews Sports Medicine and Orthopaedic Center) and Gulf Breeze Andrews Institute for Orthopaedics&Sports Medicine)may be more convenient than traveling to Atlanta. Moreover, for patients that live outside the Metro Atlanta area, ASMC's project does not improve access to the broader range of ASMC's sports medicine services, i.e. physical rehabilitation and pain management, which typically patients will utilized on a regularly scheduled basis, sometimes daily or weekly. Athletes living outside Metro Atlanta, especially those living outside Georgia, will simply not be able to travel for daily or weekly therapy sessions. ASMC's contention that it will be the only "comprehensive", "integrated" orthopedic/sports medicine facility in the area is not factual. There are many orthopedic/sports medicine providers offering a comprehensive array of sports medicine services,some of the largest and most comprehensive are: Emory Healthcare Sports Medicine Center3, which includes 13 physicians, an orthopedic-only ambulatory surgery center, a full range of diagnostic imaging including a 3T MRI Scanner, Emory Orthopedic and Spine Hospital, a specialty orthhopaedic hospital, and five comprehensive physical therapy locations. Current and former team and organization affiliations include: Atlanta Falcons Oglethorpe University Atlanta Dream Robert Morris College USA Track and Field Spellman College 2"An interview with Dr.James Andrews,the man who's operated on all your favorite athletes",Vox.com, 7/13/2014. 3Source: Emory Healthcare website 2978 Opposition to Project NoGA 2015-017 August 27, 2015 ASMC. LLC d/b/aAtlanta Sports Medicine CentePage 12 Atlanta DeKalb International UNC at Chapel Hill Olympic Training Center University of Pittsburgh Philadelphia Union(MLS) Widener University Pittsburgh Steelers Berkmar High School Pittsburgh Penguins Chattahoochee High School Pittsburgh Ballet Decatur High School Agnes Scott College Interboro High School Duquesne University Johns Creek High School Emory University Lakeside High School Georgia Perimeter College St. Pius X High School Georgia Tech Peachtree Orthopaedic Clinic ("POC") Sports Medicine's includes nine physicians. POC also offers two orthopedic-only ambulatory surgery oonVo,w, imaging services and physical/hand therapy. Current and former team and organization affiliations include: Atlanta Braves Emory University Atlanta Hawks Georgia State University Atlanta Glory Georgia Tech Atlanta Silverbacks soccer team New York University Atlanta Ballet Miami University Gwinnett Braves Moms Brown College United States Ski Team University of Michigan Chicago Bulls University of Washington Chicago White Sox Holy Innocent's Episcopal School Cincinnati Cyclones Marist School Cincinnati Bengals The Lovett School Denver Broncos The Westminster Schools New York Mets,Walton High School World Championship Figure Skating Whitefield Academy Competition TopHat Soccer Club Agnes Scott College Source: Peachtree Orthopaedic Clinic website 2979 Opposition tnPn eu No GA2016'017 August 27,2015 ASMC, LLC dlbla Atlanta Sports Medicine Center Page 13 Resurgeons Orthopaedics Sports Medicines identifies 41 physicians on its staff as well as additional specialty centers for foot & mnkle, hand, joint and spine. Resurgeons also offers orthopedic-only ambulatory surgery centers in six locations, imaging services, rehabilitation services,orthotic services and urgent orthopedic care. Current and former team and organization affiliations include: Atlanta Knights lvin Alley Dance Theater New York Boston Bruins Georgia Tech Chicago Bears Mississippi Valley State Delta Devils Chicago Cubs Washington Huskies Chicago Blackhawks University of Pennsylvania Houston Astros Alatoona High School Houston Texans Campbell High School New England Patriots Central Forsyth High School New York Mets Creekview High School Philadelphia Flyers McEachern High School Phi|ade|phiaPhU/iea North Paulding High School Philadelphia Sixers Sequoyah High Schoo ATP Tour South Cobb High School U.S.Amateur Boxing Association Stars Mill High School Georgia Ballet River Ridge High School dhoAtlantotsorthopedio practice includes 15 fellowship-trained sports medicine specialists and eight additional physicians who specialize in sports medicine. OrthoAtlanta offers two orthopedic- onlyou,Qeryuenbeno. dtagnostioimagingoen/ican. indudingk8N| semicem. nmhebi|ibtiveoenvicao. orthopedic urgent care services and orthotic services. Cunantly. OrthoAtlanta physicians have team and organization affiliations with: Atlanta Gladiators Love Joy High School Atlanta Silverbacks Luella High School Chick-fil-a Bowl Milton High School Clayton State College and University Mundys Mill High School Georgia State University North Fulton Christian Academy Resurgeons Orthopaedics website Gource:OrthoAtlanta website 2980 Opposition to Project No.GA 2015-017 August 27,2015 ASMC, LLC d/b/a Atlanta Sports Medicine Center Page 14 Alpharetta High School Our Lady of Mercy High School Brookwood High School Stockbridge High School Chattahoochee High School Whitefield High School Dutchtown High School Whitewater High School Henry County High School Woodward Academy Eagles Landing High School Gwinnett Gymnastics Jonesboro High School Lightning Soccer Loganville High School North Atlanta Soccer Association Pinnacle Orthopaedics' Sports Medicine includes six fellowship-trained sports medicine specialists and five additional surgeons who specialize in sports medicine. Pinnacle offers two orthopedic-only surgery centers, diagnostic imaging services, including MRI services, full-service rehabilitative care and a non-profit research institute. Currently, Pinnacle physicians have team and organization affiliations with: Chattahoochee Technical College Mount Paran Christian School Kennesaw State University North Cobb High School Harrison High School Walker High School Kennesaw Mountain High School Cobb Atlanta Volleyball Lassiter High School VolleyballOne ASMC offers no documentation that there is a specific population in need of the services that it is proposing that cannot access those services. ASMC fails to meet the second prong of the Hughston criteria that there is a specific population in need of such services. The specific population that ASMC most often mentions in support of its proposed project is professional athletes. These athletes have the financial resources and means to travel to any orthopedic surgeon in the United States for care. In fact, many professional athletes now choose to travel to Atlanta for their orthopedic surgery procedures. Although recent applicants for new Ambulatory Surgery Services have typically requested an exception to need based on atypical financial barriers, ASMC fails to present any evidence that financially indigent patients do not have reasonable access to orthopedic ambulatory surgery services. Current hospital- based ambulatory surgery centers as well as freestanding ambulatory surgery centers provide a significant amount of indigent and charity care. During 2013 data from the Hospital Financial Survey, HPA 3 hospitals with surgery programs provided over $840 million in uncompensated indigent/charity care to ambulatory patients, many of whom were ambulatory surgery patients. In addition, freestanding Source: Pinnacle Orthopaedics website 2981 Opposition to Project No. GA 2015-017 August 27,2015 ASMC,LLC d/b/a Atlanta Sports Medicine Center Page 15 and orthopedic-only ambulatory surgery centers8 in HPA 3 provided over $9 million in uncompensated indigent/charity care in 2014. Please see Attachment B. ASMC's project cannot remedy an access problem that does not exist.ASMC has not demonstrated that high quality, cost-effective orthopedic ambulatory surgery services are not available in the service area or that there is a specific population in need of orthopedic ambulatory surgery services that cannot access those services. Having failed to meet the first two prongs of the Hughston criteria, ASMC also fails to meet the third prong that the proposed project will remedy the barriers that exist among the specific populations. Because it has failed to demonstrate that an atypical barrier exists to orthopedic ambulatory surgery services, its project cannot remedy a nonexistent barrier. ASMC's letters of support do not document an atypical barrier -ASMC has present approximately 130 letters of support for its project. Overwhelmingly, the letters are the same form letter or slight variations of the same form letter. None of the letters describe an atypically barrier to orthopedic ambulatory surgery services of any kind - geographical, quality or financial. In addition, only four physicians have offered support for the project and no physician committed to performing surgery at the proposed ambulatory surgery facility. To conclude, ASMC has failed to document that there are geographic, quality or financial barriers to orthopedic ambulatory surgery services. Orthopedic ambulatory surgery services are readily available in the Metro Atlanta area and HPA 3, a point,which ASMC concedes. In addition, a number of high quality providers, including physicians that are nationally acclaimed sports medicine surgeons, practice in the Metro Atlanta and serve both professional and amateur athletes. ASMC also fails to demonstrate that a patient's financial status is a barrier to receiving orthopedic ambulatory surgery services. Therefore, ASMC's project fails all three prongs of the Hughston criteria. Rule 111-2-2-.09(1)(c): Existing Alternatives-As previously documented,there are numerous alternatives to ASMC's project that are more economical and are already providing high quality and financially accessible orthopedic/sports medicine ambulatory surgery services within the service area. Without regard to the fact that there are multiple alternatives to ASMC's proposal, the applicant glosses over these other providers as legitimate alternatives to its project. In addition to the many hospital-based ambulatory surgery programs that are alternatives to this project, several existing freestanding, multi-specialty ambulatory surgery programs and CON and LNR-single specialty ambulatory surgery centers are alternatives for ASMC's proposed project. There are 17 6 Includes both CON-approved and LRN-approved centers 2982 Opposition to Project No.GA 2015-017 August 27, 2015 ASMC, LLC d/b/a Atlanta Sports Medicine Center Page 16 freestanding CON-approved ambulatory surgery centers operating in HPA 3. Sixteen of these facilities are multi-specialty ambulatory surgery centers and one is a limited purpuue, orthopedic ambulatory surgery center. As previously pointed out, these ambulatory surgery centers provide a significant amount of uncornpensated care to indigent and charity patients. These providers also have excess capacity, operating at just 51 percent of maximum utilization. Also, HPA 3 has 16 LNR-single specialty, orthopedic ambulatory surgery centers that account for 46 orthopedic surgery rooms and are operating at 67 percent of maximum utilization. Please see Attachment C. Included in these 17 CON-approved freestanding ambulatory surgery programs are MSC and AOSC. As multi-specialty ambulatory surgery nenhem, orthopedic surgeons frequently utilize these facilities. Annually, MSC and AOSC list orthopedic procedures among their top 10 surgical procedures. MSC's and AOSC's patient origin include a significant number of patients from the HPA 3. HPA 3 service area residents accounted for almost 90 percent of MSC's 2014 volume or 3.449 ambulatory surgery patients and 86 percent of AOSC's 2014 volume or 5,538 patients. Please see the following exhibit: Exhibit 5 MSC and AOSC Patients from HPA 3 Counties MSC AOSC Counties Patients %of Total Patients %of Total Cherokee 696 17.9%289 , 7.5% Clayton 25 0.6Y6 209 5.4% Cobb 2.029 52.3% 1,014 26.196 DeKalb 41 1.1%587 15.1% Douglas 94 2.4%194 5.0% Fayette 5 0.1%103 2.7% Forsyth 5 0.1%192 4.9% Fulton 182 4.7% 1.910 49.2% Gwinnett 31 , 0.8%85 25.4% 6 0.2%184 4.7% Newton 2 0.1% 57 1_5% Paulding 329 8.5% 69 1.8% Rockdale 4 0.1% ,45 1.2°4 Subtotal 3,449 88.9% 5.838 86.0% Total 3.879 100.0% 6,788 100.0% Source:2014 Acnbiiatory Surgery Center Survey Currently, MSC includes six operating rooms, which it operates at only 51.7 percent of maximum utilization and it has capacity to accommodate more patients, including orthopedic patients. In addition, 2983 Opposition to Project No.GA 2015-017 August 27, 2015 ASMC, LLC dibla Atlanta Sports Medicine Center Page 17 its services are available to all patients regardless of ability to pay. In 2014, MSC provided $1,201,499 in uncompensated care (3.7 percent of AGR) to 239 indigent/charity patients. AOSC includes seven operating rooms. It has seen its volume decline slightly from 6,850 patients in 2010 to 6,788 patients in 2014. Hcwveve,, over the past year, AOSC saw its volume decline by almost 10 percent from 7.529 patients to 6,788 patients. Cunently, the facility is operating at 77.6 percent of utilization,which is below the Departments optimal capacity target of 80 percent. Although AOSC does not have an indigenticharity care commitment, it does provide limited services to patients without the financial means to pay. ASMC's failure to recognize the many other legitimate alternatives to its pnojeo, speaks to its attempt to ignore these pmvides, hoping that the Department will not recognize and address these better alternatives to ASMC's proposal in its decision. Not only are there existing providers that are easily accessible to the service area nuoidentn, these providers have significant unused capacity in their ambulatory surgery facilities to serve additional orthopedic/sports medicine patients and they have a history of serving indigent and charity patients. ASMC's proposal is an unnecessary and expensive duplication of existing services. Rule 111'2'2`09(1)(d>: Financial Feasibility — ASMC's financial performance is dependent upon performing surgeries on 2,395 outpatients in its first year and 3,799 outpatients in its second year. There is no objective analysis of how ASMC will achieve these volume projections. The only explanation provided by ASMC for its projected volumes is, 'Theme projections are based on Andrews Institute historical patient origin, data and consideration of ASMC's location in Metro Atlanta..." ASMC offers no analysis that takes into consideration generally accepted volume projection vohabknm, such as demographic characteristics of the popu|mtion, the health status of the popu|adon, service use pattwmn, standards and trends, financial and geographic accessibility, and market economics, including market share assumptions. Amajor flaw inASMC's financia|feasibility iothe absence nfany financial analysis urconsideration ofthe other major components of ASMC's proposed complex. As presented by ASMC, a key aspect of its project and one that differentiates it from other sports medicine providers in the Metro Atlanta area are the other related facilities and services that it plans to provide including: 30+acre site with playing and recreation fields for athletic training one-story, 19.020 square foot Baseball Academy two-story, 52,883 square foot Sports Performance Center three-story,92,481 square foot Medical Office Building,which includes a 20,000 square foot ASC future two-story, 55,816 square foot Medical Office Building 2984 Opposition to Project NoGA 2015-017 August 27, 2015 ASMC, LLC dlbla Atlanta Sports Medicine Center Page 18 As presented in its CON submission, 'The ASMC will be a comprehensive center of excellence for athletic perfonnmnoe, medical diaQnomtic, surgical and physical rehabilitation services. Nothing comparable exists in Georgia." (CON, page 9.1) Essentially, ASMC is arguing that although orthopedic- onlyembu|mtorysunQorycentemwxistintheK8etno;d|antaoroeandothmrpmrtsofth*state.thenoisnc*a comprehensive sports medicine center that provides the playing and recreation fields, Baseball Academy, Sports Medicine Center and Medical Office Buildings that ASMC is proposing. However, as important as these non-surgical services and facilities apparently are to its overall vision and success of ASMC (ASMC refers to these as"critical"components)the applicant offers no financial analysis of the entire project. Of the 220,200 square feet of facilities that ASMC is proposing in its center, ASMC restricts its CON application to the orthopedic-only ambulatory surgery center, which accounts for less than 10 percent of the entire complex. Although ASMC argues that the other 90+ percent is the differentiating factor between its project and existing sports medicine providers in Georgia, it provides no documentation that there is a need for the other 90+ percent, that it has the financial means to fund the other 90+percent, or that, npeogionm|ly, the other 90+ percent will be financially viable. In comparison, the Andrews Institute for Orthopaedic & Sports YNmdioine, to which the applicant frequently compares its pnojmct, is a 140.000 square foot complex with an estimated cost of$50 million.9 ASMC has only accounted for$12.5 million in its CON application with no assurances that the funds required to complete the entire complex are available. ASMC has also failed to show that it can fund the entire cost of the site, which based on the Agreement of Purchase and Sale (Appendix D of the application) includes approximately 32 acres at a cost of$8 million. ASMC includes only$500,000 in Site Acquisition costs in its Project Cost Estimate and Fund Sources. ASMC does not account for the remaining $7.5 million in funding needed to acquire the site. Based on ASMC's Balance 8heet, which it presented in Appendix G of its application, with total assets of only$350,000, it does not have the financial resources to fund the remaining components of the project itself. Because the non-ambulatory surgical components are so fundamental to the essence of the pnoject. ASMC failure to include them in the CON project is a significant flaw that demands the Department's denial of the project. Rule 111'2'2-.09(1)(q) and 111'2'2`40(3)(1k Financial Accessibility. ASMC has not presented any information or data to support its argument that there iso need for its orthopedic ambulatory surgery center due to an atypical financial barrier. ASMC has not identified a specific population of patients that experience barriers in obtaining orthopedic ambulatory surgery services because of limited financial resources. All available information supports that ambulatory surgery facilities are available to financially r.JmmneoAndnswootU|worksontheouM/ngedge'. ESPN.com. 9/2020U7.ASK4CAddbkznm| Information submission 2985 Opposition to Project No.GA 2015-017 August27.201S ASMC, LLC d/b/a Atlanta Sports Medicine Center Page 19 indigent patients. As previously diwcunoed, area hospital-based ambulatory surgery programs as well as freestanding ambulatory surgery programs serve indigent/charity patients. In summary, there is no atypical financial barrier to orthopedic ambulatory surgery services since there are now multiple facilities providing these services that are readily available and accessible to indigent/charity patients. ASMC has failed to show that"a particular group of patients" need orthopedic ambulatory surgery services and it has failed to demonstrate how the construction of a new orthopedic ambulatory surgery center inAipharetta (Futton County)will significantly improve, much less remedy, an access problem that it has failed to identify. Rule 111-2-2-.09(1)(h): PQsitive Relationship to Health Care Delivery System - ASMC'S project will tt have a positive relationship to the health care delivery system. It will duplicate services already offered and similarly udi|izod, including services now accessed by indigent and charity patients. Existing providers in the service area have underutilized facilities and excess capacity to treat additional patients. Specifically, MSC and AOSC,which serve a significant number of residents from HPA 3, have additional operating room capacity. MSC has also seen a significant decline in patients over the past five years. From 2010 to 2014, its volume of patients decreased by 38% from 6.301 patients to 3.879 patients or from 1.O50.2patients per room toG46.5patients per room. Utilization of MSC's operating rooms declined from a high of 84% in 2010 to just 51.7 percent in 2014. AOSC has also seen a decline in its utilization, especially in the past year, when the number of surgical patients declined by 10 percent. Curront|y. AOSC is operating below the Departments targeted utilization rate of 80 percent. Please see the following exhibits: Exhibit 6 Marietta Surgery Center Utilization Trend 2010 2011 2012 2013 2014 %Change Operating Rooms 6 6 6 6 6 0,096 Capacity(1.250patients per OR) 7,500 7.500 7,500 7.500 7.500 0.0% Outpatients 6,301 5.800 4,532 4,255 3.078 ' -38.4% Utilization 84.09k 74.7% 60.4% 56.7% 51.7%38.5Y6 Source:Freestanding Ambulatory Surgery Center Survey Exhibit 7 Atlanta Outpatient Surgery Center Utilization Trend 2986 Opposition to Project No.GA 2015-017 August 27, 2015 ASMC, LLC d/b/a Atlanta Sports Medicine Center Page 20 2010 2011 2012 2013 2014 %Change Operating Rooms 7 7 7 7 7 0.0% Capacity(1,250 patients per OR) 8,750 8,750 8,750 8,750 8,750 0.0% Outpatients 6,850 6,341 7,193 7,525 6,788 0.9% Utilization 78.3% 72.5% 82.2% 86.0% 77.6% 0.9% Source:Freestanding Ambulatory Surgery Center Survey Contrary to ASMC's project having a positive relationship to the health care delivery system,the approval of the project will have an adverse impact on existing providers, including MSC and AOSC. MSC and AOSC, as well as many others, serve the residents of the HPA 3 and other residents throughout the state and from neighboring states. ASMC's project can only be feasible if it is able to capture a significant number of incremental patients from existing providers. For all these reasons, MSC urges the Department to DENY this CON application request by ASMC.for its proposed orthopedic-only ambulatory surgery center in Fulton County. 2987 Attachment A An Interview with Dr.James Andrews,the Man Who's Operated on All Your Favorite Athletes Vox.com 2988 An interview with Dr.James Andrews,the man who's operated on all you... http://www.vox.eom/2014f6/13/5803496Jan-interview-with-drfames-an... VOX An interview with Dr. James Andrews, the man who's operated on all your favorite athletes Updated by Joseph Strorrrbcrq onJune 13,2014,7:00a.m.ET VIr )josephstrornbeyi josephei o.eeorn Thr AndrewsInsbtuta. Dr.James Andrews is America's sports surgeon to the stars. When a top athlete gets seriously injured,the odds are overwhelmingly good that he or she will make the pilgrimage to Andrews'Pensacola office.The list of players Andrews has treated(http://soorts.espn.go.com/espn/news/story?id=3024046) includes Michael Jordan,Tom Brady,Adrian Peterson,Albert Pujols,Robert Griffin Ill, Jack Nicklaus,and many,many more. Andrews'remarkable popularity among top-tier athletes stems from his 1985 WHEN A Top ATHLETE arthroscopic surgery of a young pitcher 2989 I of9 8/21/2015 11:20 AM An interview with Dr.James Andrews,the man who's operated on all you... http://www.vox.com/2014/6/13/5803496/an-interview-with-drfames-an... named Roger Clemens.Clemens,who G E TS INJURED, THE would would go on to be a seven-time Cy ODDS ARE Young winner,credited Andrews with EWIHEL A/1 NGLY saving his career—and began spreading the gospel of Andrews to any athlete who GOOD HE CR SHE GOES would listen.Those players began heading TO ANDREWSS South—initially to his practice in Birmingham,Alabama,and now to his new office in Pensacola—in droves. But Andrews also founded and runs the American Sports Medicine Institute( http://www.asmi.org/)—a nonprofit that conducts research on sports injuries,and recently released an influential position statement(http://www.asmi.org research.php?page=research&section=TJpositionstatement)on the factors driving the recent rise in torn elbow ligaments(http://www.npr.org/2014/06 08/320061096/tommy_johns-e Ibow-has-made-him-the-hottest-name-in- baseball)among major league pitchers that require Tommy John surgery( http://en.wikipedia.orgiwiki/Tommy John surgery),a procedure for which Andrews is well known.And in addition to pro athletes,Andrews treats thousands of college, high school,and little league athletes annually,as well as ordinary seniors who've fallen and broken a hip. I recently spoke with Andrews about his remarkable career,how teams spin injuries, and the alarming rise in Tommy John surgeries. HIGHLIGHTS( FULL INTERVIEW JAVASCRIPT:V010(0):) JAVASCRIPT:VOID(0):) On his success I never consider myself anything more than an ordinary orthopedic surgeon that's interested in sports.The two things that have made me successful are accessibility and communication. When an athlete calls,I just pick up the phone,and say'come on down:They've all f./UST PICK UP THE PHONE AND got my number. SAY'COME ON DOWN' I had a professional basketball player from Belgium call me today,he tore his knee 2990 2 of 9 8/21/2015 11:20 AM An interview with Dr.James Andrews,the man who's operated on all you... http://www.vox.com/2414/6/13/5803496/an-interview-with-drfames-an... up,and I said'come on Monday,we'll take care of you.'You have to do that,that's accessibility.It all starts from answering the telephone.You can't always do that,but if you don't get people in in a timely fashion,you have a lot of fences you've got to mend." On a day in the life of Dr.James Andrews t I ' i t k i m vipt-- a.+.. n?Andrews S,stitJ:eIn P''I1Su40t1 Fkevia,Andrews Institute(httn:f/www.theendrewslnstitute,com/Exaerience/PhotoGellery R/Contentimages/PhotoGanerv/ai ext nitmt.ing) My day is not as complicated as you might think.I do about half the number of surgeries I did three to four years ago.When I moved down to Pensacola,I designed my practice to be more reasonable in my older age,in terms of how many cases I can do a week.I cut my practice in half. But in cutting it in half,it actually became more complicated:I gave up a lot of the easier things I used to do,and now I do more hard things.I'm doing mostly athletes, rather than the older population—I've got other people doing that now.That athletic world is very difficult." On the difficulties in treating athletes With college athletes,it becomes more complicated because you've got the school,the athletic trainer,the team physician,the coaches,the school insurance to worry about.A lot of those kids think they're automatically going to be professional athletes,but they don't understand only about one percent will be. 2991 3 of 9 8/21/2015 11:20 AM An interview with Dr.James Andrews,the man who's operated on all you.. l4/6/Y3/5 With professionals,it gets even more complicated,because you've still got the patient and the mother to worry about—I don't care how old they are—but also the agents,the team doctor,the trainer,the physical therapist,the coach,management. And the most difficult,nowadays,is the press.The press has no idea about HIPAA laws—about violating confidentiality.And if you don't handle it properly,they'll just say whatever they want to say.So itjust gets more complicated asyou go up the ladder?' On whether there are ever tensions between him and team doctors Well,theuarnph okyna|wuyshanth Ona|aeyNowi|o en*baon hepmt mnt and the team physician didn't,then I take precedence.But if the team physician is taking care of an injured athlete,and he doesn't want to play him yetbut another doctor says he can,that doesn't mean a thing in the world.Or if I operate on him, and the team physician says he can play and I say he can't,he's my responsibility. But if the team physician operated and I'm just providing the second opinion,then he has the final say." On the most remarkable comeback he's ever seen INN s. 00 DreworeosRonald war,moxClen,Images One case I do have permission to talk about is Drew Brees,who had the most remarkable comeback that I've ever treated. All expectations were that he had a career-ending shoulder injury.But he had such a 2992 4of9 8/21/201511:20AM An interview with Dr.James Andrews,the man who's operated on all you... http:l/www.vox.com/201416/13/5803496/an-interview-with-drjames-an... good work ethic,and he so well taken care of by physical therapist Kevin Wilk,in Birmingham,who worked with him for a solid four months,that some way,some how,he got well.But I have to give him and the therapist all the credit,not me.He was an unbelievable comeback.And he's still playing." On his failures Usually,the only results I remember are the bad ones.I just think on the players who don't have that kind of comeback.I saw a pro baseball player today who I've operated on three times—once on his shoulder,twice on his elbow.And he still has not been able to come back and play.Those are the ones you remember. I wake up at 6 a.m.on Monday morning,after the weekend,and start thinking about the patients having trouble.I call it my'worry list"' On teams'PR spin about injuries y FI i _ ,l•II•; rT s . „ V,lir a c r.M 'h.z, f' yam fit 4 ,,. Q. r . a. i Win. '. `yMt' a r 1 4 s ire tacker-urn/Getty trneges Teams,in general,will put out as little information about an injury as they can get away with.They may call something a knee sprain,when it's a complex injury of the knee ligaments.And a lot of times,the press wants a diagnosis immediately,and you just don't know. And the press is always going to report something,from the bits and pieces they do get.And I'm not criticizing it,because that's their job," 2993 5 of9 8/21/2015 11:20 AM An interview with Dr.James Andrews,the man who's operated on ail you... http://www.vox.com/2014/6/13/5803496/an-interview-with-drfames-an... On the next big thing in sports medicine The big revelation over the last 40 years was the arthroscope.We've been looking for another one ever since. I predict the next one will be so-called biologics":stem cell therapy( THE RIG THING RIGHT NOW THATPEOPLE ARE WORKINGhtto://www.nature.com/mtdournal/v20/n9 ) IS STEM CELL THERAPY' full/mt2012172a,html),gene therapy,tissue engineering.At some point in time we'll be able to make a piece of ligament,a graft,through tissue engineering,and take it off the shelf from a sterile container and put it in a knee. The big thing right now that people are working on is stem cell therapy.It's still experimental,but has a lot of potential.We're working on it here at the Andrews Institute.It's going to take a lot of clinical research,and trials,to figure out how exactly to use it:where,when,concentrations.But it's coming." On the epidemic of Tommy John surgeries i iVsli r It\ rK 4 I a' 4'x x1.x S Atiftr_ z"1 rose re'r ndez.the M.arm Marhos nacho,-sidOtnetrwith torn ethow irgarrrentVetrequired Ton my john surger-.M,tte€hrmanntCetty O,Inges I think the biggest thing is overuse,especially during childhood.If you look at the major league pitchers that I'm seeing,if you study their history,you'll find that they had injuries duringtheir youth.They may have forgotten about it—I had one in here 2994 6 of9 8/21/2015 11:20 AM An interview with Dr.James Andrews,the man who's operated all you._ http://www.vox.com/20l4/6/l3/5ames-an— last week,we could tell from the now,X-ray,and said,"Oh,|remember i was 12 I missed a month of baseball with a sore elbow."About 50 percent have some pre-existing minor injury from overuse that was ignored. The biggest faoto atanya a nou\is THE BIGGESTfatue.{fthey're ayingvvithfat ue— AG,.. CJeOUP /S (--A7/GVfeitherfromtoomanypitchesinagame,or too many innings in a season,or from pitching year-round competitive baseball—you have 600 percent increased chance that you'll injure your shoulder or elbow So the recognition of fatigue is extremely important.If you're a major league pitching coach,you're probably good at recognizing it.But it gets harder and harder to spot as you go down in the youth levels.Some coaches mean well,but they don't recognize fatigue when it's obvious.There's a lot being done at the youth level that needs to be under better control.So we need a better education process.We've had a tenfold increase in injuries in youth baseball since 2000.Something has to be done about it." On whether youth football can ever be safe 71 ,,e...,,.- 1.1 eir, i ris fr ei, ,.,Vi I " •1).., 1 4 ii 0 p}t,Igo",wThe Def° /«mv/4£ewImages Football has the highest rate of serious injuries of any sport.The safest sport,for 2995 7 o 9 8/21/201511:20AM An interview with Dr.James Andrewsthe man who's operated on all you... l4/6//]88U349dhan'inte~ie~-,bh-d,j^mev-an— youn8kids.isQoUL For me,l think the lessons learned in football still outweigh the injury risk.But I'm a football guy,and I may be too biased. But there are ways we've got to make football safer.The first is pre-participation exams,and ruling out kids that shouldn't be playing.Another thing is having physiological age groups:two kids can both be 12 years old,but if they've matured at different rates,that's a huge mismatch.We have weight limits sometimes,but those don't always work.You've got to match up similar bodies,and that doesn't happen. We've also got to have athletic trainers in all FOOTBALL HAS THE HIGHESThighschools,and everywhere youth football RATE OF SERIOUS INJURIES OFisbeingplayed.The trainers are there to ANY SPORT recognize injuries when they first happen, even if they're minor,to prevent them from becoming major injuries.Right now,that doesn't happen.Some schools have them, but not all.Some states mandate it,but don't provide any funds for it.That's a joke. The other thing is that we need more education on injury prevention,during games and practice.This includes parameters for practicing in the heat.But if you don't have an athletic trainer,the head coach can't do it—they might not know how.So we need all state high school athletic associations to have rules on when they can practice,how often,etc. We need better emergency action plans for high schools.What you do,who you call. There should be defibrillators—like we're providing through a foundation that I'm head out—at all high schools.There needs to be a dedicated ambulance at every high school football game.Often,they have to pay for them to come,and it's expensive as hell,so the ambulance is there at the start of the game,but if they get a call to go somewhere else,they just leave.So a kid gets hurt,and he can die on the field because he has no ambulance to get him to the hospital. So there are all these problems.And for a nation that's as sophisticated and educated and advanced as we are,those things should be automatic.But they're not.^ Read thmul/iutemiew(javascript:void(0);) 2996 8o[9 8/21/2015 11:20 AM Attachment B Profile of HPA 3 Hospital-based Ambulatory Surgery Programs and HPA 3 Freestanding Multi-specialty and Orthopedic Ambulatory Surgery Centers Uncompensated Indigent and Charity Care 2997 I Profile of HPA 3 Hospital-based Ambulatory Surgery Programs Uncompensated Indigent and Charity Care 2998 2013 Outpatient Indigent and Charity Care Hospital Indigent Care Charity Care Total Cherokee Northside Hospital Cherokee 30,421,306 15,652,508 $46,073,814 Clayton Southern Regional Medical Center 6,392,657 2,799,811 $9,192,468 Cobb Emory-Adventist Hospital 536,443 13,583,307 $14,119,750 WellStar Cobb Hospital 50,680,669 5,380,618 $56,061,287 WellStar Kennestone Hospital 68,537,517 9,285,753 $77,823,270 WellStar Windy Hill Hospital 1,083,669 216,416 $1,300,085 DeKalb Children's Healthcare of Atlanta at Egleston 10,902,858 492,430 $11,395,288 DeKalb Medical Center 6,593,650 0 $6,593,650 DeKalb Medical Center at Hillandale 6,511,770 0 $6,511,770 Emory University Hospital 6,748,023 14,750,799 $21,498,822 Emory University Orthopaedics&Spine Hospital 27,980 167,402 195,382 Douglas WellStar Douglas Hospital 21,633,041 2,536,283 $24,169,324 Fayette Piedmont Fayette Hospital 3,608,264 12,054,456 $15,662,720 Forsyth Northside Hospital Forsyth 30,654,673 18,390,448 $49,045,121 Fulton Atlanta Medical Center 8,840,581 0 $8,840,581 Children's Healthcare of Atlanta at Scottish Rite $13,542,559 823,571 $14,366,130 Emory Johns Creek Hospital 1,741,195 3,036,092 $4,777,287 Emory University Hospital Midtown 11,396,095 22,712,243 $34,108,338 Grady Memorial Hospital 161,868,493 23,089,634 $184,958,127 North Fulton Regional Hospital 3,153,012 6,793,189 $9,946,201 Northside Hospital 51,490,404 29,682,800 $81,173,204 Piedmont Hospital 4,389,477 14,790,727 $19,180,204 Saint Joseph's Hospital of Atlanta 7,830,055 6,305,128 $14,135,183 Gwinnett Eastside Medical Center 16,516,987 2,609,037 $19,126,024 Gwinnett Medical Center 23,999,246 22,944,120 $46,943,366 Gwinnett Medical Center-Duluth 8,128,608 8,724,230 $16,852,838 Henry Piedmont Henry Hospital,Inc 4,788,604 8,303,747 $13,092,351 Newton Newton Medical Center 9,560,646 4,737,267 $14,297,913 Paulding WellStar Paulding Hospital 14,927,209 1,776,488 $16,703,697 Rockdale Rockdale Medical Center 2,389,032 783,408 $3,172,440 Total 588,894,723 $252,421,912 $841,316,635 Source:Hospital Financial Survey 2999 HPA 3 Freestanding Multi-specialty and Orthopedic Ambulatory Surgery Centers Uncompensated Indigent and Charity Care 3000 Freestanding Ambulatory Surgery Centers'Indigent/Charity Care Indigent/Charity Care CON-Ambulatory Surgery Centers Limited Purpose-Orthopedic Emory Ambulatory Surgery Center at Dunwoody 1,212 Mum-Specialty Advanced Surgery Center Of Georgia 52.202 Atlanta Advanced Surgery Center(Atlanta Outpatient Peachteree-Dunwoody Center) 0 Atlanta Outpatient Surgery Center 52,369 Children's Healthcare of Atlanta Surgery,Meridian Mark 1,244,011 East-West Surgery Center 190.318 Emory Clinic Ambulatory Surgery Center 884.257 Emory Orthopaedic and Spine Physiatry Outpatient Surgery Center 119,608 Gwinnett Center for Outpatient Surgery 0 Marietta Surgical Center 1.201.489 Northlake Surgical Center 890.396 Northside/Alpharetta Surgery Center 1.553.997 Northside/Dunwoody Surgical Center N/A Northwoods Surgery Center, LLC 230`537 Perimeter Surgery Center of Atlanta N/A Piedmont West Ambulatory Surgery Center 5.068 Southlake Ambulatory Surgery Center,LLP(Spivey Station Surgery Center) 96.191 Subtotal 8.835.661 LNR'OrthqpedicAmbuiatnry Surgery Centers Academy Orthopedics,LIc 0 Atlanta Sports Medicine Surgery Center 0 Georgia Surgical Ctr On Peachtree 39,382 Hand&Upper Extremity Surg Ctr Of Ga, LLC 19.812 Lawrenceville Surgery Center 23,923 Northwest Ga Orthopaedic Sc 121,303 Orthopaedic South Surgical Center 132.510 Peachtree Orthopaedic Surgery Center at Perimeter,LLC 497,356 Peachtree Orthopaedic Surgery Center at Piedmont 14.650 Perimeter Outpatient Surg Associates, Inc 0 Pinnacle Ortho Surg Ctr-Woodstock LLC 281.576 Pinnacle Orthopaedics Surgery Center-Austell, LLC 268.707 Resurgens Surgical Center 889,066 RoUeriqunSungi-nenmor. Inc. 49,411 Roswell Surgery Center, L./.o. 67,855 Southern Orthopaedic GungCtr[fFayetteville, Un 0 Subtotal 2,405,551 Grand Total 9,041,212 3001 Attachment C Utilization of HPA 3 CON Freestanding Multi-specialty and Orthopedic-only ASCs Utilization of HPA 3 LNR Freestanding Orthopedic-only ASCs 3002 Utilization of HPA 3 CON Freestanding Multi-specialty and Orthopedic-only ASCs 3003 2014 CON-approved Multi-specialty and Orthopedic-Only Ambulatory Surgery Centers County Name Type Operating Room Patients Forsyth Northwoods Surgery Center,LLC Multi-Specialty 3 1,791 Cherokee Advanced Surgery Center Of Georgia Multi-Speciatty 3 765 Clayton Southlake Ambulatory Surgery Center,LLP Mufti-Specialty 3 1,627 Cobb East-West Surgery Center Multi-Specialty 3 1,156 Cobb Marietta Surgical Center Multi-Specialty 6 3,879 DeKalb Emory Ambulatory Surgery Center at Dunwoody Limited Purpose-Orthopaedics 3 242 DeKalb Emory Clinic Ambulatory Surgery Center Multi-Specialty 6 5,293 DeKalb Emory Orthopaedic and Spine Physiatry Outpatient Surgery Center Multi-Specialty 4 2,439 DeKalb Northlake Surgical Center Multi-Specialty 3 2,347 DeKalb Northside/Dunwoody Surgical Center Multi-Specialty 3 243 Fulton Atlanta Advanced Surgery Center Multi-Specialty 6 1,070 Fulton Atlanta Outpatient Surgery Center Multi-Specialty 7 6,788 Fulton Children's Healthcare of Atlanta Surgery,Meridian Mark Multi-Specialty 8 9,967 Fulton Northside/Alpharetta Surgery Center Multi-Specialty 3 1,424 Fulton Perimeter Surgery Center of Atlanta Multi-Specialty 5 3,580 Fulton Piedmont West Ambulatory Surgery Center Multi-Specialty 4 1,559 Gwinnett Gwinnett Center for Outpatient Surgery Multi-Specialty 3 2,160Total7346,330 Total Capacity @ 1,250 patients per Room 91,250 Utilization Percentage 50.8% Source:Freestanding Ambulatory SurgeryCenter Survey 3004 i 1 Utilization of HPA 3 LNR Freestanding Orthopedic-only ASCs 3005 2014 LNR Orthopedic-Only Ambulatory Surgery Centers County Name Aft-dation Operating Rooms PatientsForsythAcademyOthopedics,LLC Academy Orthopedics 1 915 Fulton Atlanta Sports Medicine Surgery Center Atlanta Sports Medicine&OrthopedicCenter 3 382FultonGeorgiaSurgicalCenteronPeachtreeGeorgiaHand,Surgery&Elbow 2 1,354FultonHand&Upper Extremity Surgery Center of GA Hand&Upper Extremity Center of Georgia 2 1260FayetteSouthernOrthopaedicSurgeryCenterofFayettevilleOrthoAtlanta31,305 Fulton Peachtree Orthopaedic Surgery Center at Perimeter Peachtree Orthopaedic Clinic 2 3,533FultonPeachtreeOrthopaedicSurgeryCenteratPiedmontPeachtreeOrthopaedicClinic43,704 Fulton Perimeter Outpatient Surgical Associates Perimeter Orthaepedics 2 335CherokeePinnacleOrthopaedicSurgeryCenter-Woodstock Pinnacle Orthopaedics 3 3,098 Cobb Pinnacle Orthopaedic Surgery Center-Austell Pinnacle Orthopaedics 3 2,617GwinnettLawrencevilleSurgicalCenterResurgeons33236 Cobb Northwest Georgia Orthopedic Surgery Center Resurgeons 4 4,696ClaytonOrthopaedicSouthSurgicalCenterResurgeons33,349FultonResurgeonsSurgicalCenterResurgeons54,416FultonRoswellSurgeryCenterResurgeons44,117FultonRoderiqueSurgi-center Roderique Center for Hand&Upper Extremity Surgery 2 232Total4638,549 Total Capacity @ 1250 patients per Room 57,500UtilizationPercentage67.0% Source:Freestanding Ambulatory Surgery Center Survey 1 Xt C.:C-) IV3 tc3si i--s a LI 3006 RFC F: '11=:: NORTHSIDE HOSPITAL,INC. d/b/a NORTHSIDE HOSPITAL AUG 2 7 2015 d/b/a NORTHSIDE HOSPITAL CHEROKEE d/b/a NORTHSIDE HOSPITAL FORSYTH 1,1:,:1,,,,:,,,i,;, d/b/a NORTHSIDE/ALPHARETTA SURGERY CENTER D riG11:,'li JOINT OPPOSITION TO ASMC,LLC d/b/a Atlanta Sports Medicine Center's PROPOSED ESTABLISHMENT OF AN AMBULATORY SURGERY CENTER PROJECT NO. GA 2015-017 Northside Hospital, Inc. d/b/a Northside Hospital ("NHA"),Northside Hospital Cherokee NHC"), Northside Hospital Forsyth ("NHF"), and Northside/Alpharetta Surgery Center NASC") (collectively, "Northside") is opposed to the above-referenced certificate of need CON") application filed June 1, 2015 by ASMC, LLC d/b/a Atlanta Sports Medicine Center ASMC") seeking authorization for the establishment of a new single-specialty orthopedic ambulatory surgery center ("ASC") with four (4) operating rooms ("ORs") and two (2) procedure rooms in Alpharetta, Fulton County, Georgia in Health Planning Area 3 (the Project"). Northside is an existing provider of outpatient surgical services at NHA, an acute care hospital located in Fulton County, NHC, an acute care hospital located in Cherokee County, NHF, an acute care hospital located in Forsyth County, and NASC, an ASC with three (3) ORs located in Fulton County less than ' mile from the proposed Project site. In 2014,NHA, NHC, NHF, and NASC collectively provided outpatient surgery to 29,911 patients (20,288; 3,385; 4,814; and 1,424 patients,respectively).Northside will be aggrieved should ASMC's application be approved. A. INTRODUCTION ASMC is proposing to develop a$12,453,405,four OR orthopedic ASC in Fulton County when, by its own admission, there is a surplus of 73 ambulatory operating rooms in Health Planning Area 3 ("HPA 3"). In addition, many HPA 3 ORs are underutilized, resulting in an aggregate utilization rate of only 57%. Faced with the significant surplus of underutilized operating rooms, ASMC first seeks to be excused from complying with the statutory review considerations and Department of Community Health ("DCH" or the "Department") service-specific review considerations for ASCs based on the projected (largely out-of-state)patient origin for the Project. Yet, as detailed below, ASMC cannot circumvent the specific review considerations for ASCs,DCH Rule 111-2- 2-.40 et. seg. (the "ASC Rule"), or applicable general review considerations. While the State Health Planning Development Act ("Act") exempts certain types of projects (e.g., destination cancer hospitals) from complying with the need, existing alternatives, positive impact and other statutory general review considerations based on projected patient origin, O.C.G.A. 31-6-42(b.1), NIG 77'15 •3IFFI1 3007 the legislature has not afforded similar special treatment to ASCs. Likewise, while certain Department service-specific regulations contain need exceptions in circumstances involving existing facilities with high out-of-state utilization (e.g., comprehensive inpatient rehabilitation, long term acute care, and megavoltage radiation therapy), no similar regulatory exception is contained in the ASC Rule. See, e.g., Rules 111-2-2-.35(3)(c)(2); 1I 1-2-2-.36(3)(c); and 111-2- 2-.42(3)(b)3. Thus, ASMC's requested "special status and exemption from this service specific need methodology", Application at amended page 38.2, is contrary to the statutory and regulatory framework established by the General Assembly and the Department. Alternatively, ASMC contends that HPA 3 residents face atypical barriers to care based on "geography, finances and quality." Yet, ASMC fails to document any such barriers to care and completely disregards precedent establishing the standards required to comply with the exception to the need methodology. The ASMC Application is not unique in its approach to the barrier to care exception. As illustrated by each of the form support letters, all of the alleged barriers are premised entirely on the reputation of"Dr. James Andrews, world renowned orthopedic sports surgeon," which is even referred to in supporting articles as a trademarked "brand" that "appears as frequently on ESPN's bottom line as the stars that he treats." Application at Appendix N-8. ASMC boldly recognizes that "metro Atlanta has hundreds of orthopedic surgeons" and that orthopedic ambulatory surgery services are readily available throughout the planning region. Id. at Amended page 38.3.1 ASMC asks that all of these alternatives be ignored, not because of poor quality, lack of financial accessibility, or distance, but simply because some "amateur and professional athletes and other patients prefer(patient choice)treatment by Dr.Andrews and his colleagues(orthopedic and sports medicine Fellows trained at the Andrews Institute in Pensacola and Birmingham, AL)." Id at 38.4 (emphasis added). Thus, the Application seeks a more convenient location to serve "the prospective professional athlete patients that actively seek care from Dr. Andrews and his surgeon colleagues." Id. at 38.3. ASMC further claims that its campus will be "unique and distinct physically and operationally" with a focus on fellowship training,technology, and ancillary services/resources. Id. at 38.4-38.5. While Dr. Andrews' reputation is beyond reproach, the reputation of a single (73-year- old) orthopedic surgeon, and the desire of ASMC (and its affiliates)to develop an ASC campus associated with Dr. Andrews" for training and other purposes is insufficient to demonstrate an atypical barrier to care under the ASC Rule. Indeed, a virtually identical project filed by an affiliate of the Hughston Clinic, P.C.2 to develop a single specialty orthopedic ambulatory surgery center to bring"enhancements and improvements"in the delivery of ambulatory surgery services was denied at all administrative levels of review and, ultimately, by the Georgia Court of Appeals for"failure to identify any patient population that was not presently receiving quality I See also Id. at 38.5("Metro Atlanta has extensive hospital-based and freestanding ambulatory orthopedic surgical resources")(emphasis added). 2 Ironically, Dr. Andrews trained under"the master, Dr. Jack Hughston, of Columbus, Ga", the founder of the Hughston Clinic and the`father ofthe orthopedic subspecialty ofsports medicine." Application at Appendix N-8 This doctor will save you now)(emphasis added). 2 3008 services." The Surgery Center, LLC v. Hughston Surgical Institute, LLC, 293 Ga. App. 879 2008). The "world-wide reputation" of the Hughston Clinic "in quality orthopedic care, research, training, and education", July 7, 2006 Review Board Decision, In re: Hughston Surgical Institute, LLC, at 3, was not sufficient to meet the rigid exception criteria of the ASC Rule. The current ASMC Project suffers from the same flaws. The Application suffers from additional flaws as well, including notable omissions, misstatements, and inconsistencies, which call into question the credibility of the Project and its stated goals. For example, ASMC complains that college and professional athletes should not have to incur the expense to travel to from Georgia to contiguous states (Pensacola, Florida and Birmingham, Alabama), yet asserts that the Georgia Project will easily draw patients from midwest, midatlantic and southern us" (Application at Appendix E) and even projects that 22% of the Project's patients will originate from areas of the United States that are not contiguous to Georgia. Application at 11. If Virginia residents are expected to drive (or fly by private jet) to Atlanta, it is certainly not unduly costly and burdensome for Atlanta residents to drive 2 hours or fly by private jet)to Birmingham. Unlike Hughston Surgical, the Application also focuses entirely on the reputation of Dr. Andrews, a single physician, who already practices in two other states. Yet, Dr. Andrews will not be managing the Project. Rather, ASMC, LLC will be managed by its Managing Member,3 Meridian Surgical Partners-Georgia, LLC, a Delaware for-profit entity that manages 10 ASCs nationwide, which notably do not include the Andrews Institute Surgery Center, the Andrews Hand Center, or other facilities associated with Dr. Andrews. Neither Dr. Andrews nor any of his (unnamed) "colleagues" from the Andrews Institute will serve as the medical director of the Project. Rather, a Piedmont physician (Joseph Wilkes) who has not trained under Dr. Andrews and who is affiliated with the OrthoAtlanta Orthopaedic and Sports Medicine surgery centers)is the only physician identified as "available" to perform medical director duties. Application at Appendix N. Notably,only three physicians support the project and,of these, only one(Thomas Myers) trained under Dr. Andrews. Of course, this physician is already operating in the metro Atlanta through the Atlanta Outpatient Surgery Center. Dr. Andrews' involvement in the Project is also questionable given that (1) none of the submitted policies and procedures for the Project originates from the Andrews Institute (see Section F below) and (2) "the" surgery that is the sole basis for the quality exception for the Project,Tommy John Surgery, is misspelled"Tommie John"surgery throughout the Application. E.g., amended page 38.3. In truth,this surgery, like all of the other surgeries to be offered by the Project, already is available at numerous providers in metropolitan Atlanta, including Emory Healthcare sites,Northside Hospital sites, and Northeast Georgia. As the articles included in the 3 Notably, Meridian Surgical Partners — Georgia, LLC reserves all rights to manage and control ASMC, which includes"complete right and power to control all management functions and decisions of the business and affairs of the Company." See Application, Appendix C, Operating Agreement of ASMC, LLC at Section 9.1 and 15.3. Meridian Surgical Partners,LLC,not the Andrews Institute,also is responsible for the funding ofthe project.See Ici at Appendix G.2 and G.4. 3 3009 Application point out, the fact that professional and college teams nationwide have their players bypass available quality providers to be treated by Dr. Andrews (not his "colleagues") for Tommy John and other surgeries "is as much a PR move for a team...as it is a medical move." Application at Appendix N-8 (Explaining Dr. James Andrews, the brand). For these reasons and the additional reasons detailed below, Northside respectfully submits that the Application should be denied. The ASMC Project fails to comply with numerous service-specific rules and statutory general considerations. In seeming recognition of the weakness of its Project, ASMC's Additional Information preserves" frivolous constitutional challenges to the Act. Such challenges, while not appropriate for consideration at this time, illustrate ASMC's complete disregard for well- established laws, regulations, and precedent designed to avoid the unnecessary duplication of services. B. THE PROJECT MUST COMPLY WITH EACH OF THE SERVICE-SPECIFIC REVIEW CONSIDERATIONS AS WELL AS THE GENERAL REVIEW CONSIDERATIONS In its original CON application and August 12, 2015 additional information("Additional Information"), ASMC repeatedly contends that the Project is exempt from review under the service-specific review considerations for ASCs (especially the need methodology) because ASMC projects that most of its prospective patient population will originate from outside HPA 3 including 40% from out of state). Yet, the Department is not authorized to afford the Project such special treatment. The ASC Rule establishes a need methodology and other review considerations that,with only one exception not applicable here,4 apply to all CON applications to develop new or expanded ambulatory surgery services. DCH Rule 111-2-2-.40. Nothing in the language of the rule would excuse the Project from complying with each of the review considerations, and the Department must strictly apply the ASC Rule as written. See O.C.G.A. § 50-13-9.1(h)(4)( the Department may not grant any variance or waiver of a Department rule); See also Dogwood Square Nursing Center, Inc. v. State Health Planning Agency, 255 Ga. 694,696(1986)(declaring the rule is the rule" in connection with a finding that the review board acted beyond its powers in deeming part of the planning agency rule inapplicable in a matter to which it applied by its express terms). Thus, the Department cannot ignore the need methodology, deem it inapplicable to a matter to which it applies by its express terms, or expand the limited exceptions to the need standard established by Rule 111-2-2-.40(3)(b). 4 The sole exception applies only under very limited circumstances to hospital-based ambulatory surgery services. Otherwise,each"ambulatory surgery service",regardless ofwhether s single-specialty ASC or multi-specialty ASC, is subject to the standards established by DCH Rule 111-2-2-.40. The only difference is that a "single specialty ambulatory surgery service will be issued a single specialty CON",thus requiring a new CON to become a multi- specialty service.Rule 111-2-2-.40(1)(c). 4 3010 Notably, different service-specific rules expressly allow exceptions to numeric need standards in circumstances where an existing provider demonstrates historically high levels of out-of-state utilization. See, e.g., Rules 111-2-2-.35(3)(c)(2)(comprehensive inpatient physical rehabilitation); 111-2-2-.36(3)(c)(long term care hospitals); and 111-2-2-.42(3)(b)3(non-special megavoltage radiation therapy services). As the Department has not adopted a similar regulatory alternative need analysis for ASCs with high out-of-state utilization, ASMC's proposed patient origin is irrelevant. Moreover, in those few instances where the Department's rules permit an alternative analysis for high out-of-state utilization, the exception is premised on documented actual out-of-state utilization of existing providers, not theoretical,projected high out-of-state utilization ofproposed facilities. C. ASMC FAILED TO DEMONSTRATE A NEED FOR ITS PROJECT (DCH RULES 111-2-2- 40(3)(A),111-2-2-.40(3)(B),&111-2-2-.09(1)(B)) 1. Outpatient Surgery is Readily Available at Existing Surgical Services Pursuant to the need methodology prescribed by the ASC rule (DCII Rule 111-2-2-.40) and the March 31, 2015 CON Batching Review Cycle Notification for Ambulatory Surgery Centers, there is no need for additional outpatient operating rooms in HPA 3. The need methodology projects there will be a surplus of 73 outpatient operating rooms in the planning region in 2019 at 28 hospitals and 21 ASCs5. Moreover, the 354 existing HPA 3 operating rooms were only 57% utilized in the aggregate in the most recent survey year. Given this substantial surplus of largely underutilized operating rooms in HPA 3, there is no calculated numeric need for the Project. Notably, the need projection does not take into account the large number of single- specialty operating rooms available in HPA 3 that were established without CONs. In HPA 3, there are 18 orthopedic LNR ASCs, 3 hand surgery LNR ASCs, and 23 pain LNR ASCs available to serve ASMC's target patient population. 2. ASMC Failed to Document Barriers to Care Based on Quality, Geographic Accessibility,or Cost/Financial Accessibility As an alternative to its request for an exemption from the ASC service-specific considerations, ASMC requests an exception to the ASC-specific need methodology based on alleged atypical barriers to care in the proposed service area,including"geography,finances, and quality". Application at 38.3. However, ASMC failed to demonstrate any barrier to care in the service area, much less an "atypical barrier" to care as required under the Department's rules. Indeed, the Application 5 In its Application, ASMC lists only 15 HPA 3 ASC's. According to recently reported data, there are 21 CON- approved ASCs. ASMC's analysis fails to account for Atlanta Center for Reconstructive Foot and Ankle Surgery, Interventional Spine and Pain Management Ambulatory Surgical Center, Pain Care Center of Georgia, Roswell Center for Foot and Ankle Surgery,Southlake Ambulatory Surgery Center,LLP,and the Surgery Center of Atlanta. 5 3011 and Additional Information disregard well-established standards for documenting atypical barriers to care. As recognized by the Court of Appeals in The Surgery Center, LLC v. Hughston Surgical Institute, LLC, 293 Ga. App. 879, 881-882 (2008), the need exception requires an applicant seeking the exception to prove that "the cost, quality, financial access, or geographic accessibility of current services, or some combination thereof, result in a barrier to services that should typically be available to citizens in the planning area and/or the communities under review." (Emphasis in original). Thus, under the Hughston Surgical criteria, ASMC has the burden of showing that "orthopedic ambulatory surgical services of a sufficiently high quality was not available in the area, that a particular group of patients needed such care, and that the proposed project would reach this population."Id. at 881-882(emphasis added). a. ASMC's Barrier Arguments Erroneously Focus on only a Fraction of the Expansive Proposed Service Area Under the Hughston Surgical criteria, ASMC must demonstrate that individuals from its proposed service area cannot obtain typically available services in the area "because they are restricted, prevented or impeded from doing so". July 7, 2006 State Health Planning Review Board Decision in re: Hughston Surgical Institute, LLC, Project No. 2005-038 ("Hughston Review Board Decision")at 16. It failed to do so. As an initial matter, ASMC's barrier arguments should be evaluated in light of the incredibly broad proposed service area for the Project, which extends well beyond HPA 3. According to its own projections, less than 1/3 of the Project's patients (32%) are expected to reside in HPA 3. Notably, the Project maintains that more patients (40%) are expected to reside outside of Georgia,including internationally. Despite the Project's purported statewide/international reach, ASMC's barrier arguments narrowly focus only on HPA 3. The Application,thus,is plagued with internal inconsistencies. Regardless, the Project must be denied. ASMC failed to document any barriers to care based on quality, geographic access, financial accessibility, or cost in the service area as a whole or HPA 3. b. ASMC Failed to Document Any Quality Barriers to Care As noted above,under the Hughston Surgical criteria,ASMC has the burden of showing that "orthopedic ambulatory surgical services of a sufficiently high quality was not available in the area,that a particular group of patients needed such care,and that the proposed project would reach this population."Hughston Surgical Institute,293 Ga. App. at 881-882(emphasis added). Here, as in Hughston,the applicant has not identified any patient population that"was not presently receiving quality [orthopedic} services." Id. at 881. ASMC failed to present any documentation that the numerous existing hospital-based and freestanding existing providers (in HPA 3, Georgia, or elsewhere in the service area)are offering suboptimal quality care. 6 3012 Instead, as in Hughston, ASMC effectively is arguing that its Project would offer enhancements and improvements achieved in the delivery and outcome of orthopaedic surgical interventions." Id. Specifically, ASMC's quality arguments are premised entirely on Dr. Andrew's success in developing a worldwide reputation in quality orthopedic care, and pledge to bring a"unique"campus to the service area. Rather than demonstrate that service area patients are restricted or impeded from obtaining quality orthopedic services, ASMC proposes to establish a more convenient location for athletes (regardless of where they reside) who prefer one surgeon's services over other orthopedic surgeons practicing in the area and who otherwise would travel to Pensacola to receive treatment from Dr. Andrews. This evidence is woefully inadequate to show that there is an atypical quality barrier to orthopedic surgery service in HPA 3 or Georgia. In fact, virtually identical "special level of quality" arguments were rejected by the Department, an administrative hearing officer, the Review Board, and the Court of Appeals in Hughston Surgical. The Hughston Surgical Institute, which was comprised of physicians with a world-wide reputation in quality orthopedic care, research, training and education", sought to develop an ASC with "unique" characteristics, including its equipment, research, and training, that allegedly would have offered a"higher level of care". Hughston Review Board Decision at 3, 4, and 8. Such proposed quality "enhancements" fail to demonstrate an "atypical barrier to care."Id. Other applications premised on the reputation of the applicant, likewise, have failed. For example, the Department found that Emory Johns Creek Hospital's proposal to "enhance care" by offering "unique clinical research and cutting-edge" services associated with the Emory Winship Cancer Institute at a new radiation therapy center was insufficient to comply with the quality barrier to care exception. The Department specifically found that the quality of the unique services proposed to be offered by the applicant, while "commendable", failed to demonstrate that there is a "demonstrable service quality issue" at existing providers. See December 18,2009 Department Decision,Project No. GA 2009-055,at 7. ASMC presented no data or other information to demonstrate that orthopedic surgical outcomes for existing ambulatory surgery services is deficient or that orthopedic surgeons practicing in existing HPA 3 or other Georgia surgical facilities provide suboptimal care. At most, the Application and certain letters of support suggest that Dr. Andrews may utilize different techniques for performing the same surgery than another surgeon. ASMC presented no clinical research studies, peer reviewed journal articles, comparative outcome studies, or any other verifiable data to demonstrate the superiority of any particular technique utilized by Dr. Andrews over another technique. For example, while one patient indicates that she chose Dr. Andrews over two Georgia surgeons because he proposed to use the patella tendon as opposed to a hamstring or quad tendon)to reconstruct her ACL,there is no evidence that one method offers higher quality outcomes over the other. ASMC provided no data concerning Dr. Andrews's success rates with his technique versus the approach proposed by the two Georgia surgeons. Moreover, this patient example merely illustrates a professional difference of opinion between three surgeons, which is only a minuscule fraction of available orthopedic surgeons in Georgia and HPA 3. Indeed, the concept of obtaining a "second opinion" for any surgical 7 3013 procedure is not novel,unique,or atypical as it is not uncommon for different physicians to offer different treatment plans for the same condition. Similarly, ASMC's suggestion that patients who currently obtain surgery in Florida face- a quality barrier to care because they receive post-surgery rehabilitation in a different location is misguided. In each of these cases, the patient chose to travel to obtain surgery in a different state. The patient received necessary care. If ASMC desires to establish an outpatient rehabilitation center in Georgia,it may do so without CON review and approval. The suggestion that a patient must receive surgery and post-surgery rehabilitation in a single site is disingenuous. ASMC presented no evidence to support the suggestion that a patient will have improved quality outcomes simply by receiving physical therapy in the same setting as surgery. It is not atypical for a patient to receive postsurgical therapy in a different setting. Incongruously, the Project proposes to serve a high volume of patients (40% of total patients) from outside Georgia who presumably would obtain post-surgical rehabilitation closer to home even if the Project offered on-site physical therapy. Currently Georgia residents who receive surgery at Dr. Andrews' Pensacola facility are able to obtain post-surgery rehabilitation from a local therapist, Gina Lee, who works directly with Dr. Andrews. There is no evidence that this arrangement leads to negative outcomes. c. ASMC Failed to Document Any Geographic Access Barriers To Care ASMC admits,as it must,that there are other orthopedic and related surgical providers in HPA 3. There are 28 hospitals, 21 CON-approved ASCs, and 24 orthopedic-related single specialty LNR ASCs in HPA 3 alone. While many of these existing providers(including NASC) are located in close proximity to the proposed Project site, ASMC asks that all of these alternatives be disregarded because Dr. Andrews does not practice at any of these Georgia locations.6 ASMC further falsely asserts that no Georgia orthopedic surgeons perform a relatively uncommon ulnar collateral ligament reconstructive surgery commonly referred to as Tommy John surgery"(or"UCL reconstruction")in HPA 3. ASMC asserts that athletes should not be required to travel to Pensacola to receive care from Dr. Andrews or his affiliates. Yet, as previously mentioned,there is nothing atypical about athletes traveling to obtain care from Dr. Andrews or from any other physician they elect to patronize for that matter. No athlete or any other person is required to travel to obtain care from Dr. Andrews. Contrary to ASMC's contentions, every procedure proposed to be offered by the Project is available locally. ASMC's statements that it "will provide a specific procedure not currently available in Georgia," Application at amended page 10.2, is based solely on the erroneous assertion that "[`Tommie John' surgery] is generally not available in Georgia." Application at 6 Neither the Application nor supplemental filings disclose how often Dr. Andrews would provide surgery at the Project,which is a critical omission given Dr.Andrews'competing practices in Birmingham and Pensacola. 8 3014 38.3.7 In reality, multiple current providers in HPA 3 perform Tommy John surgery, including, but not limited to: Dr.Douglas H. Murray(Peachtree Orthopaedic Clinic/Northside Hospital) Dr. Bronier L. Costas and Joshua A. Ratner (the Hand and Upper Extremity Center of Georgia,PC/Northside Hospital) Drs. Kyle Hammond, Claudius Jarrett, Spero Karas, T. Scott Maughon, Gary McGillivary, and Mathew Pombo (Emory Orthopedics and Spine Center, Emory University Hospital,Emory Johns Creek Hospital) Dr.Amy Borrow(The Longstreet Clinic,P.C./Northeast Georgia Medical Center) Dr. Robert M. Titelman(Resurgens Orthopedics,P.C./St. Joseph's Hospital of Atlanta) Thus, no patient is restricted from obtaining medically necessary Tommy John surgery from surgeons practicing in HPA 3 or Georgia. Moreover, as Northside and other HPA 3 providers employ open medical staff models,nothing would prohibit Dr. Andrews or his"colleagues"from obtaining privileges at an existing Georgia facility to provide Tommy John surgery. Even if Dr. Andrews were uniquely qualified to perform Tommy John surgery, ASMC failed to demonstrate that any HPA 3 patient is impeded from obtaining such surgery. ASMC concedes that Tommy John surgery"is performed very infrequently,"Application at 38.3,which is not surprising as the procedure is most often performed to repair noncontact elbow injuries in baseball pitchers. In a recent article, Dr. Andrews disclosed that the Andrews Institute performs only about 120-130 Tommy John procedures annually despite Dr. Andrews' reputation in the field and the Andrews Institute's national and international patient base. See "Prevention of Elbow Injuries in Youth Baseball Players", Sports Health, Vol 4, No. 5, p. 420. In these circumstances,(1)few,if any, Georgia athletes will need Tommy John Surgery,8 and(2) it is not a surgery that typically would be available in every Georgia community. Indeed,ASMC's letters of support indicate that athletes regularly travel to obtain Tommy John Surgery and other services from Dr. Andrews. Paul Kizner, a Major League Baseball agent, for example, writes that he sends athletes "to Los Angeles, Birmingham, and Pensacola for surgery". Similarly, Terry Williams, also a sports agent, indicates "we send all of our athletes to Dr. Andrew's facility in Pensacola,Florida when surgery is needed". ASMC failed to submit even a single letter documenting a patient from HPA 3 who failed to receive needed ambulatory surgical care due to geographic considerations.9 In fact, every one ASMC did not attempt to demonstrate that any procedure other than Tommy John Surgery is not available in HPA 3 or Georgia. 8 ASMC admits that only 75 Georgia patients were treated at the Andrews Institute in Gulf Breeze last year for all types of surgery. No volume of Tommy John surgeries on Georgia residents was provided. 9 Notably, although there are numerous letters of support in the record,all but a small handful are duplicative form letters generally stating that the proposed project would be good for the community. Almost all ofthese letters are footnote continued on nextpage) 9 3015 of the support letters demonstrates that athletes and others are willing to travel to obtain care from Dr. Andrews in Pensacola: Myparents and I chose to go out ofthe state ofGeorgia to go to Dr. Andrews in Pensacola. . . ." Diana Colen, amateur high school and college tennis player We chose Andrews." Dr. Christopher J.W.B. Leggett, parent of amateur athlete Thus, no patient providing a letter of support went untreated because they opted to receive care from Dr. Andrews. Instead of demonstrating patients who fail to receive or are restricted from receiving needed ambulatory surgical care due to an actual barrier, ASMC documents patients who obtained needed care,but who elected to bypass existing providers and travel to Pensacola because of the reputation and name recognition of Dr. Andrews. Thus,rather than remedying actual barriers to care, the Project is designed to be more convenient to a select group of patients,as illustrated by the following letter: We are going to send our athletes to Dr. Andrews in Pensacola regardless, but it sure would be a lot nicer to send them to Atlanta since it is closer and the air travel to Atlanta is so much easier." Terry Williams, sports agent for professional athletes Establishing a more convenient location for mostly affluent professional and amateur baseball pitchers who elect to receive a rare surgery from a renowned physician is not warranted under Hughston Surgical. ASMC also misrepresents the proximity of services offered by surgeons affiliated with Dr. Andrews. Throughout the Application and Additional Information, ASMC suggests that Pensacola, Florida is the closest location for Georgia residents to obtain care from Dr. Andrews and his protégés. ASMC fails to disclose that ten orthopedic providers from the Andrews Sports Medicine and Orthopedic Center practice at St. Vincent's Health System in Birmingham, Alabama. In fact, one of these ten physicians, Dr. Benton Allen Emblom, M.D., advertises that he performs Tommy John Surgery. As Birmingham is a mere 150 miles from Atlanta approximately two hours driving time and even closer by private jet), athletes in HPA 3 (and from individuals residing outside HPA 3 and even Georgia. A few others provide information that is wholly irrelevant to an analysis of barriers to care or whether the Project is needed(e.g.,a letter that talks about a baseball academy that may be connected to Dr.Andrews'other plans for the Alpharetta site,but is not directly related to the proposed Project). Only 5 or 6 letters provide any specific examples ofpatients who even required ambulatory surgery,and some of those are duplicative. 10 3016 many other parts of Georgia) have the option to travel to Birmingham rather than Pensacola if they choose to be treated by physicians affiliated with the Andrews Institute. Finally, ASMC's geographic access arguments (for HPA 3) are inconsistent with its proposed service area, which assumes that high volumes of patients will elect to travel across state lines and from other countries to obtain orthopedic services from Dr. Andrews and his colleagues. Indeed, ASMC's support letters illustrate that travel is not an impediment to care: A]thletes are willing to travel to make it happen." Mike Berenger,athletic performance trainer Thus, if travel from other planning areas, states, or countries for the services of a single physician constitutes a barrier to care, then the proposed Project is not designed to remedy any such barriers. ASMC projects that 68%of its patients will travel from outside metro Atlanta to obtain care at the Project. Accordingly, the majority of patients projected to receive surgery at the Project will be required to travel. d. ASMC Failed to Document Cost or FinancialAccessibility Barriers to Care ASMC failed to identify a specific patient population in the proposed service area or HPA 3 that could not obtain orthopedic services because of cost or a financial barrier. Indeed, the request for a financial access barrier exception is somewhat amusing as the target patient population consists largely of affluent professional athletes. In fact, according to ASMC, the Project location was chosen because of the many"private non-commercial airports"available for landing private jets "from all parts of the United States and internationally". Application at amended page 9.1. In arguing that patients who elect to travel to Pensacola encounter unwanted costs, ASMC misconstrues the cost and financial accessibility barrier criteria. Specifically, ASMC does not argue that athletes face a financial barrier to receiving orthopedic surgery services in HPA 3, only that it would be cheaper and more convenient for them to receive Dr. Andrews' services in Atlanta rather than Pensacola. This fact alone does not represent either an atypical cost or financial accessibility barrier to care. While ASMC also states that it would offer a financial access program for "low income high school athletes" in Georgia who suffer sports injuries and would qualify for charity care, it fails to demonstrate a need for such a program to remedy an existing barrier to care. ASMC presented no data regarding the volume of low income high school athletes who suffer sports injuries in HPA 3 (or Georgia) who require orthopedic surgery. Likewise, ASMC presented no evidence that any low income high school athletes failed to receive needed orthopedic outpatient surgery because of their financial status. In such circumstances,ASMC failed to carry its burden 11 3017 to document a specific patient population that encounters financial accessibility barriers to care.10 ASMC's commitment to provide 5% of the adjusted gross revenues ("AGR") of the Project for the benefit of indigent and charity care patients does not establish a barrier to care. See Hughston Review Board Decision at 12, 17(Finding that a"laudatory promise"to provide an indigent charity care commitment above the minimum required in the CON application "does not establish a barrier to care"). Like the failed Hughston Surgical applicant, ASMC provided no evidence of any population in the planning service area "who could not receive indigent care." Id. ("No barrier is shown by this pledge, however, as nobody was identified as needing care above the three percent required for a CON application.") ASMC conveniently ignores that multiple existing providers of surgical services in HPA 3 (whether or not CON-approved) provide high levels of indigent and charity care, including 5 CON-approved ASCs, 9 orthopedics-related LNR ASCs, and 24 hospitals that met or exceeded 5%ofAGR in indigent and charity care during the most recent survey period. In these circumstances,ASMC failed to document any financial or cost barrier to care. D. THERE ARE EXISTING ALTERNATIVES TO ASMC's PROJECT (DCH RULE 111-2-2- 09(1)(c)) As provided in Section C above, many other hospital-based surgical services and freestanding ASCs in HPA 3 (and Georgia) are existing alternatives to the proposed statewide Project. Additionally, given that the Project seeks to improve convenience for patients seeking Dr. Andrews' services, it would be a less costly alternative for Dr. Andrews and/or his colleagues to join the medical staff of an ambulatory surgery center or hospital in the metropolitan Atlanta area and offer those services locally than to expend millions of dollars to build a dedicated ambulatory surgery center. That appears to be the model employed by Dr. Andrews' colleagues in Birmingham with St.Vincent's. Alternatively, Dr. Andrew's group practice could develop a single-specialty ambulatory surgery center that complies with the CON exemption criteria established under O.C.G.A. 31-6- 47(a)(18). E. THE PROJECT HAS NOT BEEN DEMONSTRATED TO BE FINANCIALLY FEASIBLE (DCH RULE 111-2-2-.09(1)(D)) ASMC failed to demonstrate that its Project will be financially feasible. Specifically,the Project's utilization projections lack foundation. 10 As noted in Section F below, ASMC's pledge to develop a financial access program is not credible as ASMC failed to submit even basic financial access policies required by the Department's rules. 12 3018 In its Application,ASMC originally sought to develop a multi-specialty surgery center in which only approximately 70% of its patients would receive orthopedic-related surgery. Application at 11. In its Additional Information, however, ASMC narrowed the scope of the Project to the development of a single specialty ASC offering only orthopedic surgery. Despite this significant amendment to the scope of services to be offered by the Project, ASMC failed to adjust the original projected case volume and revenue estimates for the Project: In its original Application, ASMC proposed to serve only approximately 1,677 and 2,659 orthopedics-related patients in 2017 and 2018, respectively (i.e., 70% of its annual case volume). ASMC now projects that 2,395 and 3,799 orthopedic cases will be treated in 2017 and 2018,respectively(100%of its annual case volume). ASMC failed to justify the significant increase in projected orthopedic cases (718 additional orthopedic-related cases in year 1 and 1,140 additional orthopedic-related cases in year 2). F. THE PROJECT HAS NOT BEEN DEMONSTRATED TO BE FINANCIALLY ACCESSIBLE DCH RULES 111-2-2-.09(1)(G); 111-2-2-.40(3)(N)) The documentation submitted by ASMC in Appendix J fails to demonstrate that ASMC will be financially accessible. Indeed,the documentation in the Application indicates a disregard for financial accessibility considerations. Apparently ASMC does not have any of the required policies and procedures to ensure financial accessibility. Rather than reflecting the business practices that will be employed by ASMC to ensure financial accessibility,the policies and documentation submitted by ASMC are nothing but a meaningless collection of non-specific, often conflicting policies seemingly gathered by ASMC's consultant from prior clients: The "ASMC Draft Patient Payment Policy" clearly was appropriated from the Surgery Center of Loganville, LLC,which is referenced throughout the policy; The "Patient Eligibility Application Form" likewise was appropriated from the Pain Care Center of Georgia,which is referenced on the form; The "ASMC Draft Ambulatory Surgery Center Indigent and Charity Care Policy", despite its heading,clearly represents the policy of a hospital not an ASC. The policy repeatedly refers to "inpatient care"(see, e.g.,page 5), "hospital personnel" (see, e.g., page 3), and "Hill Burton care" (see, e.g., page 3). Such references unmistakably reference hospital services,not an ASC; and The "Medical Staff Bylaws" unquestionably are outdated. They refer to "HCFA guidelines"even though HCFA has not been the name of the government agency now known as CMS for almost 15 years. 13 3019 Because ASMC failed to submit valid financial access policies, the Project cannot be deemed to be financially accessible. G. ASMC's PROJECT WILL NOT HAVE A POSITIVE RELATIONSHIP WITH THE EXISTING HEALTH CARE DELIVERY SYSTEM(DCH RULE 111-2-2-.09(1)(H)) Because ASMC's project is not tied to any community or objective need standard and would represent a duplication of existing resources, including the orthopedic-related services offered at Northside and a myriad of other providers in HPA 3 and Georgia, the Project will not have a positive impact on the existing health care delivery system. Additionally, ASMC's arguments that it will not impact existing providers are false. ASMC's contention that the"target population is much broader than the local community where the ASC will be based"ignores the hundreds of patients ASMC would necessarily have to draw from existing providers to meet its utilization projections. In years 1 and 2, respectively,ASMC projects that it will serve 1,437 and 2,280 Georgia patients. Application at 11.4, Table 20.5. Yet, ASMC admits that only 75 Georgia patients were treated at the Andrews Institute in Gulf Breeze last year. Consequently, in the first two years of operation more than 3,500 Georgia patients will be treated at ASMC who would otherwise have received care at existing providers. In other words, between 95-97% of the Project's patients from Georgia will need to be captured from existing providers. While ASMC's Application contends that the Project is aimed at a special population that is not treated locally in Georgia, the Application reveals that ASMC intends to target patients other than elite athletes. In fact,only 47%of patients are expected to be comprised of amateur or professional athletes. Application at 10. The remaining 53% ofpatients are comprised of a non- athlete patient base. For example, the Andrews Institute Total Joint Center as described in the Application at 9.6-9.7, is aimed at providing joint replacement surgery to the elderly: "as we grow older and our bodies begin to change, many individuals experience painful problems with their joints". Without question, despite its attempts to portray otherwise,ASMC will need to compete directly with and attract patients from existing area providers. Given the significant available capacity at existing area operating rooms, the Project will significantly duplicate existing services. H. ASMC FAILED TO DOCUMENT APPROPRIATE ARRANGEMENTS FOR MEDICAL COMPLICATIONS(DCH RULE 111-2-2-.40(3)(c)) The ASC Rule requires an applicant "to insure the necessary backup for medical complications" by demonstrating that (1) it has an affiliation agreement and/or (2) its medical director has "admitting privileges and other acceptable documented arrangements". This documentation must ensure that the facility has the capability to transfer patients immediately. ASMC has presented no documentation that would ensure immediate transfer of patients in emergency situations. 14 3020 ASMC presented no hospital affiliation or transfer agreement demonstrating that a local hospital is willing to accept emergency transfer of patients from ASMC. Instead,in Appendix N, ASMC submitted a letter from Joseph S. Wilkes, MD, who is on staff at Piedmont Hospital in Atlanta. Nothing in the Application identifies Dr. Wilkes as the Medical Director for ASMC. Instead, Dr. Wilkes claims in his letter that he "will be available to perform the duties as a Medical Director." It is unlikely that Dr. Wilkes, who is a member of OrthoAtlanta, which has two of its own single-specialty orthopedic ambulatory surgery centers, would be selected to be the Medical Director for this competing facility. Even if Dr. Wilkes, in fact, were selected to be the Medical Director, his staff privileges at Piedmont Hospital do not"insure the necessary backup" for transferring patients immediately. An ambulance transferring a critical patient from ASMC to Piedmont Hospital in Atlanta would bypass 9 closer hospitals and travel 30-40 minutes even in the few non-congested periods ofthe day before a patient could receive emergency medical treatment. Clearly, this proposal is unacceptable and fails to comply with the requirements of Rule 111-2-2-.40(3)(c). I. ASMC FAILED TO DEMONSTRATE THE REQUIRED ANESTHESIA COVERAGE (DCH RULE 111-2-2-.40(3)(F)) As the sole documentation to support its allegations that it will be in a position to provide anesthesia coverage as required by Rule 111-2-2-.40(3)(f), ASMC submitted a letter from Paradigm Anesthesia, PC, which currently operates exclusively in Gulf Breeze, Florida at the Andrews Institute. See Appendix N-4. In the letter,the President of Paradigm indicates that two of its physicians, Dr. Billy Thomas and Dr. Stephen Anderson are Georgia licensed. This documentation does not comport with the regulatory requirements. First, the letter is outdated. Dr. Anderson recently left Paradigm Anesthesia to join Northside Anesthesiology Consultants. ASMC failed to provide any evidence that Dr. Anderson is willing or legally entitled under his current employment arrangement to cover the proposed Project. Regardless,ASMC fails to demonstrate how anesthesia coverage can be provided by two or fewer) anesthesiologists practicing in Gulf Breeze, Florida, more than 350 miles away from the Project site in Alpharetta, Georgia. Paradigm Anesthesia presented no commitment from Dr. Thomas,who is or was a fellow at the Andrews Institute,to permanently relocate to Alpharetta. J. ASMC's "LEGAL OBJECTIONS" TO THE CON PROCESS AND CERTIFICATE OF NEED LAW HAVE No RELEVANCE AND CANNOT BE CONSIDERED BY THE DEPARTMENT While ASMC claims that Georgia's CON law violates several clauses of the Georgia and U.S. Constitutions(Appendix N-10), such arguments are baseless. The Department must adhere to the CON laws,and is not authorized to determine the constitutionality of such laws. 15 3021 K. THE PROJECT IS NOT CONSISTENT WITH THE STATE HEALTH PLAN(DCH RULE 111-2- 2-.09(1)(A)) Because the Project fails to meet the general review considerations outlined above and fails to satisfy many of the specific review considerations for ASCs, it contravenes the goals and objectives of the State Health Plan. As demonstrated above, ASMC's Project fails to comply with the general and service specific review criteria. Accordingly,Northside respectfully requests the Project be denied. Thank you for your attention to this matter. Very truly yours, Kathlynn Butler Polvino At n r-=713— r.tnza 16 3022 Opposition to ASMC,L.L.C.d/b/a Atlanta Sports Medicine Center Develop a New Freestanding Single Specialty Ambulatory Surgery Center Project No.GA.2015-017 By Competing Healthcare Facilities: D ORIGINAL Piedmont Hospital,Inc.d/b/a Piedmont Atlanta Hospital Piedmont West Ambulatory Surgery Center,LLC Morris,Manning&Martin,LLP RE siali , Robert C.Threlkeld,Esq. AUG 2 7 2015 Anthony J.Cestaro,Esq. Dunbar Consulting,LLC Davis Dunbar AUG77'15 1'=7R August 27,2015 3023 Opposition Summary The Project fails to satisfy the requirements of the Service-Specific Rule for Ambulatory Surgical Services with respect to need and utilization, among others. There is no basis by which to grant ASMC "special status" exempting it from the Service-Specific Rule, as ASMC requests. ASMC has not satisfied the Hughston Criteria to qualify for an atypical barrier exception to the need requirements under the Service-Specific Rule. The Project fails to satisfy the requirements of the General Review Considerations to demonstrate need, among others, and there are numerous existing alternatives present. ASMC's constitutional objections are premature. 3024 The Project fails to satisfy the Service-Specific Rule. There is no need for the Project. Specific need formula specified in Department Rule 111-2-2-.40(3)(a}1 Using that formula, Department's need projections indicate a surplus of 73 operating rooms in HPA 3. Need formula is cut and dry 3 3025 2019 Ambulatory Surgical Services Need Projection by HPA 2014 Resident 2014 Total Rate per1,000 2019 Resident 2019 Projected Rooms 2014 Room Rooms HPA Population' Outpatients• Population Population' Patients Needed' lnyerdorv° Needed° 1 788,161 38,779 49.20 868,038 42,709 43 56 13 I3 5230,014r253,502 48.47 5,790,222 280,656 2761 354 733 I 5 g60,329 28643 I 1.l2 035 32,206 32 44 72 6 556,242 43.087 77.46 595.174 46,103 46 66 20 7 484,451 46,398 95 77 517609 49,602 50 73 23 8 388,840 28,615 73.59 413,128 30,402 30 43 13 9 155,017 5.945 38.35 163,505 6,271 6 12 6 10 615,378 58,065 94.36 674,347 63,629 64 74 10 11 392,794 29.044 73.94 414,979 30,684 31 45 14 12 267,288 15,905 59.51 265.640 16.997 17 26 9 13 379,581 28.042 73.88 413,470 _ 30,546 31 49 18 9mteslde 10.867,050 625,781 57.58 11,957,641 686,329 688 911 223 Ambulatory Surgery Center Operating Room Aggregate UUUzation Final Need Outcome Rats by HPA. Rooms X 1,250 tote HPA Utilisation HPA Tata'ORe Pa/lents Outpatients'HPA FinalAssessment 1 56 70,000 38,779 55% 1 No Rooms Needed 2 36 45,000 26.206 56% 3 354 442.500 253,502 57% 3 No Rooms Needed 4 33 41,250 23.552 57% 5 44 55,000 28,643 52% 5 No Rooms Needed 6 66 82,500 43.087 52% 6 No Rooms Needed 7 73 91,250 46,398 51% 7 NoRooms Needed 8 43 53,750 28,615 53% 8 No Rooms Needed 9 12 15,000 5.945 40% 9 No Rooms Needed 10 74 92,500 58,065 63% 10 No Rooms Needed 11 45 56,250 29.044 52% 11 No Rooms Needed 12 26 32,500 15,905 49% 12 NoRooms Needed 13 49 61,250 28,042 46% 13 No Rooms Needed Siatewlde 911 1,138,750 625,783 55% Ogles are Sources: 2014and2010 ResidentPopulation based onOPB Praleetions,4/11 Release 1Oulpat.nts calcailatedusing damfrom2014 AnremiHospital Oueatbnnaiee end2014 AnnualFreestanding Ane Song CO Sumo"from CON=Braisedlrseetan6lg ambuWuysorgenycenters.Prioryeardata usedWire2013datawas notyet available. Assumes 1,000patientcapacityperoperatingroom:250aperamngroomdays peryear(50 weeks/yearx5days/week)x 5patientsperroamperday060%ufltratbn.See Rub 111-2-2A0(3Xe)1(9Trough 111-2-2-A0(3)(a)t(N). Inventory based ondemsubmitted in Annual Hospital Cueslbnnaies andAnnus,Freestanding Amb SorgCOSurveys.Anychangesit room numbers authodmdbyCON approval orbyothermeansv4tehoccurred afterOnedose ofOrssurveyperiodare cubo reO •redinthe inventory.See Rub 111-2-2-.40(2X0. r 1.250patients perOR represents Ike mmdmum possible ualzatbn pertheComponent Ran. Aggregatemasaeon rate must meetorexceed60%pursuant to Rule 111-2-2-A0(3Xe)2. Originally Calculated: 9262014 Updeted:3272015 4 Prepared by Health Planning Dem Resources end Analysis Section,Healthcare Facility Regulation Division Need Protected byHPA Page 1 at 2 3026 The Project fails to satisfy the Service-Specific Rule. The Department should deny ASMC's requests for exception. ASMC states that it "qualifies for special status and exemption from this service- specific need methodology" and requests such "special status" and "exemption." Additional Information, p. 38.2) In the alternative, ASMC asserts that an atypical barrier exists and requests an exception under Department Rule 111-2-2-.40(3)(b) for an atypical barrier. 3027 The Project fails to satisfy the Service-Specific Rule. There is no authority permitting "special status and exemption" to be granted to ASMC. Department incorporated exception into Service-Specific Rule for atypical barrier. Department has discretion to grant an exception to the service-specific need methodology due to an atypical barrier on cost, quality, financial access or geographic accessibility. Department's regulations do not allow for "special status" or any other exception other than those specifically enumerated in the Service-Specific Rule. Georgia law specifically prohibits a waiver or variance from any rule or regulation promulgated or adopted by the Department of Community Health. — O.C.G.A. § 50-13-9.1(h)(3) A government agency is bound by its own regulations. 5 3028 The Project fails to satisfy the Service-Specific Rule. There is no basis to grant an atypical barrier exception because the Hughston Criteria are not satisfied. ASMC has burden to demonstrate, with specificity,the Hughston Criteria are satisfied: i) that orthopedic surgical services of a sufficiently high quality are not available in the service area, ii)that a particular group of patients need such care, and iii)that the Project would reach the population and remedy the atypical barrier. The exception argument by its very nature must be appropriately developed and supported so that the Department may render a decision that is consistent with established precedence and able to withstand scrutiny." (Project 2013-031 Decision, p. 8) ASMC has failed to meet its burden. 7 3029 The Project fails to satisfy the Service-Specific Rule. Hughston Criterion No. 1 is not satisfied. ASMC admits orthopedic surgical services readily available in HPA 3. ASMC admits that metro Atlanta has "hundreds of orthopedic surgeons." Additional Information, p. 38.3) ASMC admits that metro Atlanta has "extensive hospital-based and freestanding ambulatory orthopedic surgical resources." (Additional Information, p. 38.5) 8 3030 The Project fails to satisfy the Service-Specific Rule. Hughston Criterion No. 1 is not satisfied. Numerous hospital systems offer comprehensive orthopedic surgical services in HPA 3 (e.g. Piedmont Healthcare, Emory Healthcare, Northside Hospital System). Tommy John" procedures are available in HPA 3. 5"Tommy John" procedures were performed at Piedmont Atlanta alone in 2014. CY 2014 Hospital Total Piedmont Hospital-Atlanta,GA 5 Newton Medical Center-Covington,GA 2 Gwinnett Medical Center-Duluth-Duluth,GA 1 Total 8 Source: Georgia Hospital Association database,2014 Note:'Tommy John'procedures defined as CPT codes 24346 and 24345. Note:Data does not include any'Tommy John"procedures performed at freestanding ASCs. a 3031 RustingRUldeaofUrtlwpefe SonnySeniors in=ASCU/ling wNm30Mgrs 08dmProposedAd4nu SpanMeddeGager DR* Roll.Newt SirenAfar. CR4 aP %MRes I NathCmcemOrogenCava 11975Mar's RudSur 160 AplmeIa 30005 RI The Project fails to satisfy the 3Mita,lialNergers Centerlk2365061MdkoFutuna,Sune 100 A 4Roswell.FeeFagAndAdkSager,L 636013gperHembreeRoad, cSv200 Roswell 30076 301 Service—Specific Rule. SfNucRoma Pc 129511udr¢ .ARoSaoA-101 tad 30076 31 6 Nati. Foot Gurria.LLC 1285 HembreeRudSia2040 Rame1 300'16 3.15 7Nalbde Far R Antic<knpt 3915 iidcanbBilgeRud Nam®x 30092 811 8Natus..Amwoody SurgeryCan. 4553 No.9m0w.fudRavd.ole60-C Atlanta 30338 1014 9P.aolf Amhatn SurgeryCIaa,lk 800MawVraonH01899,Srve 100 Alarm 30328 1105 IOPaine.SvpayConn OfAlba 1140 Hannon.DoBollingF,Sle6100 Adana 30328 1/25 II RewagmSappy Cune,I.k 5671 Pee.AtreeAmwadyR4&dc800 Adm. 30342 1201 Hughston Criterion No. 1 is not satisfied. 12 PerimeterWharton, RecemSurg Foot Atoentes. Inc 2673 l0S.. rce0PM6. R4r800 Manta 30342 1202 13 A4eleCr-RemmactreeFang ArdkSeg lk 218SellySprpxPau Adams 30728 1211 145gmwamnSegieal Cain 1100Johns.Foe,RoadSate200 SandySanas 30342 1214 15 NeoSager/Cmm,lk 110014...FerryRoad,Svc180 Mame 30342 1214 16A0meOagemn SappyCana 5730Caen..One,Suiten300AM400 Alma 30328 12.19 17 Hod&UpperEaremay SegC.Of(ia,lyefuel 9940John..Fort'RoadSueMO Agan 30342 12.19 18 Metro.NateMons Srpn Caner,The 5730Glen.ec pose.Sac 110 AN.. 30328 12.19 There are 49 existing providers pSattrical5lIleOfAd8aCe SMendien mdSae340 Ss;P Uu ltd...I% 25eeS 21 AcademyOrlvpedk.,/k 3187.0-MtCapRud Govan! 30040 1226 of orthopedic surgery services in S u Rd.5=37 25Peachtree Rd..Se12.37ekASCsettingthatarelocatedS* oilySagereCookagCir Peachtree 42wnark 1237 15.57 within 20 miles of the proposed n n.k 00 A 29Lwnaeo.tSop.)Co. 758OId\aaueRoad,Sate 125 Lweuevr 30045 1634 Atlanta Sports Medicine site. Nad keStogie.Center 21491 550Wanxw1Rd Tucker 16.7 31 Na4001.0'm(04.9aa8cSurgeryCaner 2500SVidy HfRudSnt218 Manua 30067 16.78 32FoolNewsyCmlm,lls 2320Weedy IMRM,Sec 105 Mucro 30067 16.82 33EmmyOrlapadc0 paomSageryCape 59Emcawe Part.511 Mac AIM. 50329 17.12 14MmklaSepcalCega 780Canton Ru4 Sue 100 Marotta 3060 17.29 35MuemE.Sagery 895Canter RookBldg2004Sea300 Maxilla 30060 17.29 36Rana ArimlmaySerpi.IC:ma,LIc 211Clnip.Ante Menem 30060 17.45 It should be noted that the list 3 e Cott.Lk 65Vann 790ChurchStreetArc530 M 331755 39AdvancedSurgeryCmerOfCo 270Bwpel Rud Cemw 30114 1775 at right does not include Center.Inc 5 5 AthrttoAda.. 30327• 7 18,15 42Wes 06,PAabuhn SepvelCent.Lk 11611kwelcMSRands3)0 Atlanta 31327 1817 hospital-based ASCs.93Atlanta Sagry SapnCam 3161 NowellMdRoad...300 Adam 70427 IgI7 49Fandrhp SogeryCron NAS Fnddup Ru45me]110 Rafael 30518 1892 45Sam.Medrol Amocmtr 1874PodmaRd.Ne,SaleNBFE Alava 30324 18.92 46NanaChic AmlrbvnySc 13650CM.Ru4 N I_06008820) Alkna 303=1 1937 47Peachtree(kda ScAsPd..m 77CoferRoot..2000 Allan 30109 1947 48(tragiStagedCaOnPeachtree 2.1 Peachtree Rand Sone 100 Ago. 30309 1915 49Gwimen Cede/For Oapmu Sago).2131 FanninDrive Soak& 30078 199 muaampxwM•c...am.ieb®wo.rmelwrbva.....x.ar,sro++eeaen. 10 3032 The Project fails to satisfy the Service-Specific Rule. Hughston Criterion No. 1 is not satisfied. Hughston Criterion No. 1 is NOT satisfied because orthopedic surgical services, including the "Tommy John" procedure, are readily available in HPA 3. II 3033 The Project fails to satisfy the Service-Specific Rule. Hughston Criterion No. 2 is not satisfied. ASMC fails to identify particular group in need of proposed services. ASMC does not quantify the "athletes" it asserts it will serve. ASMC does not provide any data indicating that patients are failing to access orthopedic surgical services. 12 3034 i The Project fails to satisfy the Service-Specific Rule. Hughston Criterion No. 2 is not satisfied. CY 2014 Cases by Diagnosis Category Andrews Institute Ambulatory SurgeryCenter; GulfBreeze,Florida Percent Commutative ICD-9 Diagnosis Category Cases ofTotal Percent The Andrews Institute ASC in Gulf diseases ofthe musculoskeletal system and connectivetissue 3,131 54.6% 546% diseases ofthe sense organs 994 17.3% 71.9% Breeze, Florida is one of the injury andpoisoning 829 14.5% 86.4% applicant's existingfacilities diseases ofdie nervoussystem 447 7.8% 94.2% pp diseases ofthe respiratory system 66 1.2% 95.3% offering similar services as the diseases ofthe circulatory system 54 0.9% 96.3% proposed Project. diseases ofthe digestive system 46 0.8% 97.1% neoplasms 41 0.7% 97.8% external causes ofinjury and supplemental classification 38 0.7% 98.5% diseases ofthe skin and subcutaneous tissue 31 0.5% 99.0% The vast majority of the existing endocrine,mAritiaoalandmetabolicdiseases,and innmmitydisorders 16 0.3% 99.3% congenital nalies 14 0.2% 99.5% diseases oftheAndrewsInstituteASCcasesareofthegenitourinarysystem 14 0.2% 99.8% orthopedic in nature. symptoms,signs,and ildefned cams 10 0.2% 99.9% infectious andparasitic diseases 3 0.1% 100.0% Total 5,734 100.0% Source:Flon&CY 2014 Ambulator,&tatnse,Florida Agency forHealth CareAdministration 13 3035 The Project fails to satisfy the Service-Specific Rule. Hughston Criterion No. 2 is not satisfied. The Andrews Institute ASC in GulfBreeze,Florida is an existing ASC of the Applicant which offers CY 2014 Cases by Age Cohort similar services as the Project. (Please note that Andrews Institute Ambulatory Surgery Center, GulfBreeze,FloridatherearealsofacilitiesinBirmingham,Alabama.) While a significant percentage of patients (34%) Percent Cummulative were younger than 44 years of age, a much larger proportion(approximately 66%)were over the age Age Cohort Cases ofTotal Percent of45. 0-17 400 7.0% 7.0% This indicates that the Florida facility functions as 18-44 1,559 27.2% 34.2% a general orthopedic surgery center,and the Project 45-64 2,227 38.8% 73.0% will function similarly.65+ 1,548 27.0% 100.0% In the CON for the Georgia project,the applicant Total 5,734 100.0% highlights the fact that the ASC will cater to athletes similar to the Florida facility;however, it Source: Florida CY 2014 Ambulatory database,Florida Agency for Health Care Administration is clear from the Florida experience that the majority of cases will come from an older population, which indicates a more general orthopedic population. 3036 The Project fails to satisfy the Service-Specific Rule. Hughston Criterion No. 2 is not satisfied. Hughston Criterion No. 2 is NOT satisfied because ASMC has not identified a particular group in need of the proposed services. 3037 The Project fails to satisfy the Service-Specific Rule. Hughston Criterion No. 3 is not satisfied. ASMC does not provide evidence showing that the Project will reach the population and remedy the alleged atypical barrier. Tommy John" procedure is not an atypical barrier. Tommy John" procedure is available in metro Atlanta. Tommy John" procedure only accounted for 2.4%of procedures at ASMC's Florida facility. CY 2014'Tommy John'Cases as a Percent drill Cases Andrews Institute Ambulatory Surgery Center, GulfBreeze,Florida Percent Commutative Tommy John"procedure is classified as CPT CPT Code/Procedure Cases ofTotal Percent codes: 24346-reconstruction medial collateral ligament,elbow,with tendon graft 136 2.4% 2.4% 24345-repair medial collateral ligament, elbow, Other cases 5,598 97.6% 97.6% with onn local cistruction24346-rrecon or medial collateral ligament,elbow,with tendongraft All Cases 5,734 100.0% Somce:Florida CY 2014Ambidatory database.Florida Agency for Health Care Administration Appropriate inquiry is access to the specialty(i.e.orthopedic surgery),not any one particular procedure or any one particular physician. Ic 3038 The Project fails to satisfy the Service-Specific Rule. Hughston Criterion No. 3 is not satisfied. Andrews Institute Patient Distribution by ZIP Florida,Alabama and Georgia Patients Only NORTHCAROLINA TENNESSEE Very few patients from SOUTH CAROLINA. Cdum6ta• Georgia went to ASMC's Florida facility. rho. Only about 1% of the Florida facility's GEORGIA patients originated ALABAMA • - '' MISSISSIPPI 9a^0V from Georgia in 2014. ladcson CY 2014 Ambulatory Aea Database,Florida Agency for Health Care Administration) i'r 1N;• - Tanahaeree Loi s mem FLORIDA rrn AndrewsInst ute C, j frGatnesvle I 17 3039 The Project fails to satisfythe Service-Specific Rule. Hughston Criterion No. 3 is not satisfied. CY 2014 Cases by Payor Andrews Institute Ambulatory Surgery Center, GulfBreeze,Florida Percent Cummulative 2014 payor mix for ASMC's Payor Cases ofTotal Percent Florida facility was heavily Commercial 3,242 56.5% 56.5% Medicare 1,386 24.2%weighted to Commercial 80.7% patients. Other Fed 593 10.3% 91.1% Worker's Comp 389 6.8% 97.8% Less than 1% of cases were Self-Pay64 1.1% 99.0% Medicaid.Mediciad 49 0.9% 99.8% Other 11 0.2% 100.0% Total 5,734 100.0% Source: Florida CY2014 Ambulatory database,Florida Agency for Health Care Administration IF 3040 The Project fails to satisfy the Service-Specific Rule. Hughston Criterion No. 3 is not satisfied. ASMC misrepresents current HPA 3 providers'indigent and charity care commitments.(Additional Information p.38.9) All CON-ASCs on this chart have a least a 3%indigent/charity care commitment. ASMC's analogy of its 5% indigent/charity care commitment to Northside Alpharetta Project (Project 2010-021) is misleading. Project 2010-021 involved comprehensive Financial Access Surgery Program("FASP")to remedy atypical barrier,but no such solution is being proposed here. Northside Alpharetta is opposing the Project. Northside Alpharetta is less than a mile from the Project's proposed site. ASMC states it will provide services to"any high school athlete that cannot pay for a sports injury"(Additional Infomration, p.38.13)but this statement and any relevant criteria are absent from ASMC's indigent/charity care policies in Appendix J. ASMC's proposed location is in the affluent suburbs north of Atlanta and 36 miles away from Hartsfield-Jackson Airport. ASMC asserts that proximity to the airport is important for low-income patients who travel, but ASMC has chosen not to locate the Project in the less affluent area south of Atlanta and closerto Hartsfield-Jackson Airport. 3041 The Project fails to satisfy the Service-Specific Rule. Hughston Criterion No. 3 is not satisfied. Hughston Criterion No. 3 is NOT satisfied because ASMC has not demonstrated that it will reach the specific population and remedy an alleged atypical barrier. 3042 The Project fails to satisfy the Service-Specific Rule. The utilization threshold has not been met. Department Rule 111-2-2-.40(3)(a)2 requires that the aggregate utilization for ASCs be at least 80%. Department's projections indicate aggregate utilization for HPA 3 is only 57%. 21 3043 2019 Ambulatory Surgical Services Need Projection by HPA 2014 Resident 2014 Total Rate per 1,680 2019 Resident 2019 Projected Rooms 2014 Room Rooms HPA Population' Outpatients° population Population' Patients' Needed' Inventory. Needed° 1 788.161 38,779 49.20 868,038 42-709 43 56 13 2 514,617 26,206 50.92 587,174 29.901 30 36 6 3 5,230,014 253,502 48.47 5,790,222 280.656 281 354 73 4 534,338 23,552 44.08 604,020 26.623 27 33 6 5 560,329 28,643 5112 630,035 32,206 32 44 12 6 556,242 43.087 77 46 595,174 46.103 46 86 20 7'484.451 46.398 95.77 517,909 49,602 50 73 23 8 388,840 28.615 73.59 413,128 30.402 30 43 13 9 155,017 5,945 38.35 163,505 6.271 6 12 6 10 615,378 58,065 9436 674,347 63,629 64 74 10 11 392,794 29,044 73 94 414,979 30,684 31 45 14 12 267,288 15,905 59.51 285.640 16,997 17 26 9 13 379,581 28,042 73.88 413,470 30,546 31 49 18 Statewide 10.667,050 625.783 57.59 11.957.841 686.328 688 911 223 Ambulatory Surgery Center Operating RoomAggregate Utilization FinalNeed Outcome Rata byHPA• Rooms X 1,250 Tata HPA Umlaation NPA Total ORni Patients Outpatients'X HPA Final Assessment I 56 70,000 38,779 55% 1 No RoomsNeeded I 2 No RoomsNeeded 3 354 442.500 253,502 57% I 3 No RoomsNeeded 4 No RoomsNeeded 5 44 55,000 28,643 52% 5 No RoomsNeeded 6 66 82,500 43,067 52% 6 No RoomsNeeded 7 73 91,250 46,398 51% 7 No Room Needed 8 43 53,750 28,615 53% 8 No RoomsNeeded 9 12 15.000 5,945 40% 9 NO RoomsNeeded 10 74 92,500 58,065 63% 10 No RoomsNeeded 11 45 56,250 29,044 52% 11 No RoomsNeeded 12 26 32,508 15,905 49% 12 No RoomsNeeded 13 49 61,250 28,042 46% 13 No RoomsNeeded atelewide 911 1,138.750 825.783 55% otos and Sources- 2014 and 2019Resident Population based on OP5 Projections,4111 Release 2 Outpatients calculated using dotsfrom2014Annual HospitalQuestionnaires and 2014AnnualFreestandingAmb SorgCbSurveysfromCON authorized freestanding ambulatory surgery carters.Pnoryeardata usedvhere2013 dalewas notyetavailable. a Asamea 1.000 Pa6ant capeclyPeropardingroom:250operatingroom daysperyear(50weelayeara 5dayshwek)0 5 patientsparootttperdaya66%091860100.See Rule 111-2-2-_40(38»1(0through 111-2-2-.40(3)1a)1(N)- Inventorybasedon data manned bh AnnualHespial Qteetlenrubesand Annual FreestandingAmb Sure CoSurveys.AnyMenges laman01000°m euftotimd by CON approval or byothermeans whits occurredalterthe dose Maresurvey parkin are alsoretestedIn asinventory.Sea Rub 111-2-2-.40(280. s 1.250patientsperOR representsthe maximumpossible um.a5onperMe Component Plat. Agpegeteuliatiwt rate mummeatorexceed80%pursuantto Role111-2-2-40(3)0)2. Originally Calculated. 9262014 Updated:3272015t2 Prepared by.HeatResourcesPlanningDale endAnalysis Section,Healthcare Facility Regulation Division Need Projectedby HPA,Page1 or 2 3044 The Project fails to satisfy the General Review Considerations. There is no need. CY 2014 Patient Origin by State Andrews Institute Ambulatory Surgery Center; GulfBreeze,Florida Again, experience of the Percent Cummulative Florida facility actually State Cases ofTotal Percent suggests local patient FL 4,539 79.2%79.2% origins, as facility is near AL 742 12.9%92.1% the Florida-Alabama GA 60 1.0%93.1% border. LA 42 0.7%93.9% Only 1% of Florida facilityTX 33 0.6%94.5% residents originate from MS 29 0.5%95.0% Georgia. Other states 289 5.0% 100.0% Total 5,734 100.0% Source: Florida CY 2014 Ambulatory database,Florida Agency for Health Care Administration73 3045 Andrews Institute Patient Distribution by ZIP Florida,Alabama and Georgia Patients Only ARKANS- NORTH CAROLINA" TENNESSEE MENPNIS HudsvilE: - SOUTHC'AROt 4A ' GEORGIA ALABAMA • " bus t MISSISSIPPI - Mormlomery r r *Judson rib et -•••a. •: arT 10 •t Tallahassee LOL LEGEND FLORIDA stir r tpGainesviON 24 3046 The Project fails to satisfy the General Review Considerations. There is no need. ASMC admits that its patient origin projections are "rudimentary!' (Additional Information, p. 11.4) ASMC does not break down patients by county of origin because ASMC states same "would be speculative at best!' (Additional Information, p. 11.4) Even if ASMC were to serve many out-of-state patients, it must still show need for patient population,which ASMC fails to do. ASMC's use of projected growth for the entire populations of 10 different states is unreasonable and not directly related to the application. On their face,ASMC's utilization projections show less than 50%utilization in Year 1. ASMC's patient utilization projections are not supported by an explanation, reasoning, data,or evidence. ASMC has not provided any need projection anywhere in the application, has not provided any evidence of a barrier to access, and has not provided any other evidence of need.zs 3047 The Project fails to satisfy the General Review Considerations. There are numerous existing alternatives. Department Rule 111-2-2-.09(1)(c) requires consideration of facilities and services similar to the proposed service. The Department's need projections indicate that there is the capacity for at least 100,498 ASC visits in HPA 3 generally. There are a myriad of orthopedic surgery providers in HPA 3. Many orthopedic surgery providers in HPA3 have excess capacity. 26 3048 Existing Providers ofOrthopedic Surgery Services in an ASC Setting Within 20 Miles ofASMC Location Note:Excludes Hospital-Based ASCs and Hospitals Ll1.P— ARICKEIkS DAWSON BANKS CHE; HALL BARTOW JACKSON iiweai 20 Mile Radius BARROW rS: tM LEGEND PAULDING Cscanr bmgilYON(Mee Ptibletori She SS WALTON DOUGLAS e ; e e wime 0o y DEKALB NR6CKDALE. 27egrow.wer Peden 3049 Examples ofFreestanding ASCs that Offer Orthopedic Surgery and Have Excess Capcity within 20 Miles of the Proposed Atlanta Sports Medicine Center Utilization Facility Name ORs Patients Percent Windward Surgery Center Lie 2 543 21.7% Roswell Ctr For Foot And Ankle Surgery,Lk 2 379 15.2% Northside Foot&Ankle Outpat 1 372 29.8% Northside/Dunwoody Surgery Center 1 130 10.4% Resurgens Surgery Center,Lk 5 4,416 70.7% Perimeter Outpatient Surg Associates,Inc 2 335 13.4% Southeastern Surgical Center 2 1,529 61.2% Nasa Surgery Center,Lk: 2 1,245 49.8% Atlanta Outpatient Surgery Center 7 6,788 77.6% Hand&Upper Extremity Surg Cu Of Ga,Lk(The) 2 1,260 50.4% Surgical Suite,The 3 713 19.0% Academy Orthopedics,I.lc 1 915 73.2^/ Atlanta Outpatient Peachtree Dunwoody 7 6,788 77.6% Specialty Surgery Center,Inc. 1 470 37.6% Gwinnett Surgery Center,Lk 2 1,163 46.5% Buckhead Molls Surgical Center,Lk 3 854 22.8% Northlake Surgical Center 3 2,347 62.6% Foot Surgery Center,The 1 80 6.4% Emory Orthopaedic Outpatient Surgery Center 4 2,604 52.1% Marietta Surgical Center 6 3,879 51.7% Cobb Foot And Leg Surgical Center,Lk 2 271 10.8% Advanced Surgery Center Of Ga 3 809 21.6% Atlanta Sports Medicine Surgery Center(2013) 3 382 10.2% Atlanta Orthopaedic Surgery Center(a) 1 931 74.5% Peachtree Ortho Sc At Piedmont 4 3,704 74.1% Georgia Surgical Ctr On Peachtree 2 1,354 54.2% Gwinnett Surgery Center 2 1,163 46.5% Source.Gcorgta Map2Care vchsito;includes only providers oforthopedic services andexcludeshospital-based ASCs. 2014 Freestanding Ambulatory Surgery Center 3050 The Project fails to satisfy the General Review Considerations. There are numerous existing alternatives. Piedmont Atlanta has 10 dedicated outpatient rooms, which serviced 5196 patients in 2014. This means that these ORs alone can accommodate over 4,200 additional patients and still remain within the 80%occupancy threshold. The excess capacity is tremendous if all HPA 3 freestanding ASC ORs offering orthopedic services are considered in addition to all hospitals' dedicated and shared ORs. Where there exists significant and unused capacity, Department Rule 111-2- 2-.09(1)(c) requires that strong justification be present under other criteria to approve the Project: no such justification exists. The Project represents an unnecessary duplication of services. AnG 27> 5 29 3051 Opposition to ASMC,L.L.C.d/b/a Atlanta Sports Medicine Center Develop a New Freestanding Single Specialty Ambulatory Surgery Center Project No.GA.2015-017 RECEIVEDE ORIGINAL AUG 2 7 2015 By Competing Healthcare Facilities: Piedmont Hospital,Inc.d/b/a Piedmont Atlanta Hospital Piedmont West Ambulatory Surgery Center,LLC Morris,Manning&Martin,LLP Robert C.Threlkeld,Esq. Anthony J.Cestaro,Esq. Dunbar Consulting,LLC Davis Dunbar August 27,2015 i-ih 77'F _:97PN 9602942v4 3052 Piedmont Hospital, Inc. d/b/a Piedmont Atlanta Hospital ("Piedmont Atlanta") and Piedmont West Ambulatory Surgery Center, LLC ("Piedmont West") previously identified themselves as competing health care facilities that would be aggrieved ifthe Department were to approve ASMC, L.L.C. d/b/a Atlanta Sports Medicine Center's ("ASMC") CON application to develop a new freestanding single specialty (orthopedic) ambulatory surgery center in Fulton County(the"Project"). I. Background Piedmont Atlanta is a general acute care hospital that is located in Atlanta, Georgia Fulton County),with approximately 481 set up and staffed beds. Piedmont Atlanta is located in HPA 3.1 In 2014, Piedmont Atlanta had over 295,000 non-emergency outpatient visits, including over 11,500 outpatient surgeries. Piedmont Atlanta's service area for outpatient surgical services includes,without limitation,Cherokee,Clayton,Cobb,DeKalb,Fulton,Fayette, Gwinnett, Henry Counties,2 which together accounted for approximately 80% of Piedmont Atlanta's total outpatient surgery patient origins in 2014. Piedmont Atlanta treated 3796 outpatient surgical patients from Fulton County alone in 2014.3 Piedmont West is a freestanding multispecialty ambulatory surgery center located in Atlanta,Georgia(Fulton County). Piedmont West is also located in HPA 3. In 2014,Piedmont West had over 4200 outpatient surgeries. Piedmont West's service area includes, without limitation, Cobb, DeKalb, and Fulton Counties,4 which together accounted for approximately 69%of Piedmont West's total patient origins in 2014. Piedmont West treated 682 patients from Fulton County alone in 2014.5 The Department does not use the 12 State Service Delivery Regions("SSDRs")when analyzing an ambulatory surgical service. Instead,the Department usesthe 13 Health Planning Areas("HPAs"). 2 All ofthese counties arc located in HPA 3. Piedmont Atlanta's 2014 AHQ can be accessed at http://www.georgiahealthdata.info/CCSS/AHOPDF2014.php?uid=HOSP617. AHQ data for all hospitals can generally be accessed at http-J/gamap2care.info/Home.html or via the Department's databases at https://dch.georgia.gov/health-planning-databases. All of these counties are located in HPA 3. 5Piedmont West's 2014 AHQ can be accessed at http://www.georgiahealthdata.info/CCSS/FASCPDF2014.php?uid=ASC039. Free-standing ASC survey data for all such providers can generally be accessed at http://gamap2care.info/Home.html or via the Department's databases at https://dch.georgia.gov/health-planning-databases. Piedmont Opposition to Project 2015-017 Page 1 3053 On June 01, 2015, ASMC submitted a CON application to develop a new freestanding multispecialty ambulatory surgery center in Fulton County,6 Project No. 2015-017 (the Project"). On August 12, 2015,ASMC submitted additional information in response to the 60- Day Meeting. This additional information seeks to change the Project from a multispecialty ambulatory surgery center to a single specialty ambulatory surgery center,even though no formal amendment was filed by ASMC. The Project, as changed by the Additional Information, includes approximately 20,000 square feet of space, including without limitation 4 general operating rooms and two minor procedure rooms. Total costs are estimated to be $12,453,405. Piedmont Atlanta and Piedmont West (collectively, "Piedmont") timely filed their Notices of Opposition on July 23, 2015, and hereby jointly submit this written Opposition, and accompanying PowerPoint presentation,as part ofthe 90-Day Opposition Meeting. II. Opposition Summary The following summarizes Piedmont's opposition to the Project: The Project fails to satisfy the Service-Specific Rule for Ambulatory Surgical Services requirements for need and utilization,among others. There is no basis by which to grant ASMC "special status" exempting it from the Service-Specific Rule,as ASMC requests. ASMC has not satisfied the Hughston Criteria to qualify for an atypical barrier exception to the need requirements under the Service-Specific Rule. The Project fails to satisfy the General Review Considerations requirements to demonstrate need,among others,and there are numerous existing alternatives present. ASMC's constitutional objections are premature. Ill. The Project fails to satisfy the Service-Specific Rule. The burden is on the applicant, ASMC, to produce information and evidence satisfying the applicable criteria, including the Service-Specific Rule and the General Review Considerations. Department Rule 111-2-2-.09(1). The Project completely fails to satisfy fundamental requirements under the Service-Specific Rule for Ambulatory Surgical Services(the Service-Specific Rule"). In particular, (A) there is no need for the project; (B) the utilization 6 The Project is to be located at the intersection of Morris Road and Old Morris Road in Alpharetta,GA,with a Milton Parkway street address. Additional Information,p.1. Piedmont Opposition to Project 2015-017 Page 2 3054