Horrific car crashes, stabbings and gushing gunshot wounds are relatively few in Clay County.
The suburban county produced 290 trauma patients in 2008 - about one-sixth the number of cases in Duval County, its gritty neighbor to the north. Yet here, where the allure is an escape from the grim realities of the inner city, the largest hospital operator in the country wants to open a trauma center.
Plopping trauma centers in out-of-the-way places like Orange Park seems to be HCA's game plan in Florida. This year, five hospitals operated by the Nashville, Tenn.-based company have sought state health officials' approval to open trauma centers.
The requests have puzzled HCA's peers. Why, they wonder, is a for-profit company getting so deeply involved in an endeavor so historically unprofitable?
After all, many trauma patients, particularly victims of violent crime, are uninsured or have inadequate insurance. Trauma centers tend to bleed millions of dollars a year in unpaid bills; in many cases, they need government help to survive. Florida's 22 centers collectively lose about $100 million a year.
"Now that we see this large number of new applications, we're kind of dumbfounded, and we're concerned a little bit about the viability" of the existing trauma centers in those areas, said Tony Carvalho of the Safety Net Hospital Alliance of Florida, whose membership includes several state trauma centers.
Complicating matters is HCA's track record. In 2000, the company admitted to submitting inflated bills to Medicare, which it used to foot its marketing and advertising costs and to dish out kickbacks to physicians for patient referrals. In the end, HCA was forced to pay back $1.7 billion.
The controversy has found its way back into the headlines as a major issue in the campaign for the Republican gubernatorial nomination in Florida. Rick Scott ran the company at the time, but was never personally implicated. Nonetheless, his main opponent, Attorney General Bill McCollum, has hammered him on the issue.
Joseph Tepas, chief of pediatric surgery at Shands Jacksonville, which operates Northeast Florida's only trauma center, said HCA's trauma application for Orange Park Medical Center puts him in an "ethical and moral conundrum."
On the one hand, he said, it would be hypocritical of him to oppose a new trauma center after advocating for more trauma resources for so many years. Tepas has co-authored numerous assessments that have called for more trauma centers in Florida and more stable funding.
On the other hand, the new center, with its plum location, might damage the bottom line at Shands.
"There's clearly a need for new trauma centers," Tepas said. "But if certain trauma centers are barely making the fiscal levels they're achieving, they might say, 'We can't afford to lose the patients we're having.' "
'A NEW CONCERN'
The Times-Union tried contacting HCA spokesman Ed Fishbough several times for an interview about the company's trauma applications, but he referred questions to the individual hospitals behind the requests. When asked whether the hospitals had independently made the requests, Fishbough replied by e-mail that "HCA's longstanding operations strategy has included a decentralized market model."
The arrival of so many aspiring trauma centers, particularly from hospitals with the same parent company, is unprecedented in recent memory in Florida.
"It's a new concern," Carvalho said. "The safety nets have never been concerned about too many trauma centers."
As recently as the 1980s, dozens of trauma centers dotted the Sunshine State's health care landscape. In Jacksonville alone, there were eight units, Tepas said.
But several phenomena combined to chase most away: increasing costs, low reimbursement for care, greater frequency of malpractice suits and difficulty in attracting and maintaining the necessary stable of specialists.
IT'S ALL ABOUT LOCATION
Contrary to popular belief, trauma centers can make money, said Casey Nolan, a health care consultant with Navagant Consulting in Washington.
"The keys to success in health care are the same as they are in real estate - location, location, location," he said.
Hospital executives should choose a suburban location, where the patient mix is expected to favor those with health insurance. And the center shouldn't be too far away from an interstate to ensure an influx of patients covered by personal-injury plans through their car insurance.
HCA has followed this plan to a T, Nolan said.
In addition to Orange Park, HCA hospitals have proposed trauma centers in Fort Walton Beach, a laid-back tourist destination in the Panhandle; Bradenton, a retirement community in Southwest Florida; Hudson, which bills itself as a "jewel in the rough" that is greater Tampa; and Miami.
The combined population of the first four cities is about 94,000 - about a tenth of the size of Duval County.
Miami stands out from the other hospitals for its size, but even there the application has drawn fierce criticism. Officials with Jackson Health System and the University of Miami, who run Miami-Dade County's lone trauma center, have said the HCA hospital's unit would destroy their finances, according to The Miami Herald.
The state's review process, however, doesn't take into account a new trauma center's potential fiscal impact on existing centers. They must follow a strict list of equipment, staffing and procedural guidelines and amass at least 500 trauma patients in their first year, said Susan McDevitt, head of the Florida Department of Health's office of trauma.
NO CHALLENGE YET
The Orange Park Medical Center application, for its part, has drawn no formal challenges. It has applied to be a Level II trauma center, the designation for hospitals that aren't affiliated with a medical school.
CEO Tom Pentz has asked the state for an 18-month extension on the center's provisional review period to give him time to hire staff members and complete a $40 million expansion. The project is expected to add two heart catheterization labs, two open-heart operating rooms, expand the intensive-care unit's capacity and enlarge the emergency room.
It is scheduled to begin operating under provisional status on Oct. 1, 2011.
Leonardo Alonso, the medical director of Orange Park's emergency department, said the trauma designation, if approved, would further improve the 202-bed hospital's standing in the community.
"It used to be a Humana hospital and HCA/Columbia," he said. "It has a bad reputation among some people in the community. But it seems to be making a turnaround. People who haven't been here in years say, 'Wow.' "