Adventist Health v. Health Care

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Adventist Health Care Inc. v. Maryland Health Care Commission, No. 73, September Term, 20 05. Opin ion by Bell. ADMINISTRATIVE LAW - DEFERENCE When an adm inistrativ e reg ulati on is amb iguo us, in orde r to re solv e tha t amb iguity, deference is appropriately given to the interpretation of that regulation by the administrativ e agency pro mulgating it. IN THE COURT OF APPEALS OF MARYLAND No. 73 September Term, 2005 _______________________________________ ADVENTIST HEALTH CARE INC. v. MARYLAND HEALTH CARE COM MISS ION, et al. ______________________________________ Bell, C.J. Raker Wilner Cathell Harrell Battaglia Greene, JJ. Opinion by Bell, C.J. _______________________________________ Filed: April 12, 2006 The Maryland Health Care Commission ( Commission ), one of the appellees herein, is required by Md. Code (1982, 2005 Replacement Volume), § 19-118 of the Health-General Article,1 at least every 5 years, to adopt a State health plan ( SHP ), § (a) (1), that shall include [t]he methodologies, standards, and criteria for certificate of need review . . . . § 19118 (a) (2) (i). Mo reover, the C ommissio n is charged with developing standards and policies consistent with the S HP that re late to the Certificate of Need ( CON ) process. § 19-118 (d) (1).2 These standa rds, inter alia, [s]ha ll addres s the av ailability, ac cessibilit y, cost, and quality of health care, § 19-118 (d) (2) (i),3 and shall take into account the relevant methodologies of the Health Services Cost Review Comm ission. § 19-118 (d) (3). 4 The Commission also is autho rized to prom ulgate regu lations in orde r more eff ectively to manage 1 All future references will be to the 2005 Replacement Volume of the HealthGeneral Article unless otherwise indicated. 2 Section 19-118 (d)(1) provides: The Commission shall develop standards and policies consistent with the State he alth plan that relate to the ce rtificate o f need progra m. 3 Section 19-118 (d) (2) provides: (2) The standards: (i) Shall address the availability, accessibility, cost, and quality of health care; and (ii) Are to be reviewed and revised periodically to reflect new developments in health planning, delivery, and techno logy. 4 Section 19-118 (d) (3) provides: (3) In adopting standards regarding cost, efficiency, cost-effectiveness, or financial feasibility, the Commission shall take into account the relevant metho dologi es of th e Hea lth Serv ices Co st Revi ew C omm ission. and implement the duties prescribed under Md. Code § 19-118. Section 19-118 (c) provides: (c) The Commission shall adopt rules and regulations that ensure broad public input, public hearings, and consideration of local health plans in development of the S tate hea lth plan. The issue in this case is whether a request by a merged asset hospital system to relocate a portion of its existing cardiac surgery program from one location to another triggers or engages the comparative review process required upon application for a CON for a new cardiac surgery program, or whether such request is to be resolved by a CON process that is sep arate and distinct. T he problem, a nd accor ding ly, the resolution , relates solely to the interpretation of the Code of Maryland Administrative Regulations ( COMAR ) 10.24.17.04F, the section entitled Mer ged H ospital S ystems, and, sp ecifica lly, Policy 6.0 contained therein. COMAR 10 .24.17.04F provides: The regionalization of cardiac surgery services plays an important role in the strategic planning and placement of these programs to achieve an optimal balance b etween p romoting p atient access , containing costs, and maintaining quality of care. By regulating the number of cardiac surgery programs needed by Maryland residents in order to ensure adequate caseloads, the Commission acts to strength en quality and avoid unn ecessary costs to the healthcare system. In recent years, the Commission has encouraged and overseen several mergers and consolidations of two or more hospitals as part of statewide initiatives to promo te efficienc ies and con tain health costs. This has created an opportunity, under specified conditions, f or merged institutions to relo cate all or part of an existing service from one hospital to another under that merged system by o btaining an exe mption from C ertificate of Ne ed. While the General Assemb ly has created this opportunity for the reconfiguration of existing serv ices, its intention was not to promote the expansion of a service which otherwise would be subject to Certificate of Need coverage. The potential relocation o r dividing of cardiac surg ery program s may result in 2 proliferation of programs in the absence of need, and defeat the principles of regional planning. For this reason, the Commission establishes the following policy: Policy 6 .0 A merged hospital system may not re locate any part of its existing cardiac surge ry capacity to another hospital within its system without obtainin g a Ce rtificate o f Nee d. The Commission interpreted COMAR 10.24.17.04F to mean that a relocation of a portion of an existing cardiac surgery program is subject to the CON process required for a new program . In so doing , it rejected the interpretation advo cated by the ap pellant, Adventist Health Care, Inc., the parent of the merged hospitals, Washington Adventist Hospital and Shady Grove Hospital. Adventist had urged, and continue s in this Court to do so, that its relocation application w as entitled to be reviewed in a separate and distinct process from the c omparativ e review re quired for the establishment of a new program. Con sequ ently, it maintained on judicial review, and again in this Court, that, by interpreting Policy 6.0 and COMAR 10.24.17.04F the way it did, t he C omm issio n exceed ed its auth ority. On judicial review, the Circuit Cou rt for Baltimore City affirmed the Commission s interpretation. We also shall affirm. A. Adventist is a merged asset hospital system that includes, as indicated, both the Washington Adventist Hospital and Shady Grove Hospit al. The Washington Adventist Hospital has an existing cardiac surg ery progra m. Interested in relocating a portion of that 3 existing card iac surge ry pro gram to Sh ady Grove Hospital, Adventist submitted to the Commission a Letter of Intent ( LOI ) to do so. The LOI described the propose d project, the quantity and types of health services beds that would be affected, and, under the applicable need methodology in the SHP, the jurisdictions the new service would affect. Explaining that the new joint program would have common medical staffs for Program services, a single set of Program policies and procedures, Adventist concluded that the relocation would not result in the establishment of a new Program but rather [only in] the relocation of a portion of the existing Program at Washington Adventist. To be clear as to the latter point, Adventist submitted to the Commission, along with the LOI, a separate letter in which it reaffirmed that it was not seeking a Certificate of Need for a new prog ram, and state d tha t it was no t resp onding to an earli er no tice, issued by the Commission, requesting LOI s for new cardiac surgery programs.5 Adven tist explained , in that regard: We wish to avoid a situation wherein the Commission would either reject this letter of intent or a ny subseque ntly filed application. We are therefore seeking your guidance whether there is any reason why this letter of intent cannot be accepted. We further request a determination that the project proposed in the letter of intent is considered a partial relocation of an existing program and not the estab lishmen t of a ne w pro gram. 5 In the March 19, 2004 Maryland Register, the Commission had given notice that applicants seeking to file LOI s to apply for a CON for a new cardiac surgery program must do so by March 26, 2004, and that such applications for new programs would be considered pursuant to the Com mission s c omparativ e review p rocess as o utlined in COMAR 10.24.01.07B. 4 Responding, the Commission advised tha t it considered Adven tist s LOI to re locate a portion of its cardiac surgery program to be a request for a new program. It explained that [i]t is the Commission s view that Policy 6.0 . . . considers the relocation of a cardiac surgery program by a merged asset system as the establishment of a new program, and, therefore, subject to all of the policies and standards under COMAR 10.24.17. This prompted Adventist to file its Petition for Acceptance of Letter of Intent for Partial Relocation of an Existing Cardiac Surgery and Percutaneous Coronary Intervention Program ( Adventist Petition ). In a supporting memorandum accompanying the Petition, Adventist described what had already transpired, and argued that the LOI complied with Policy 6.0, that Policy 6.0 's plain langua ge required an indepe ndent, non-comparative review of its LOI, and that the health care resources that Adventist already possessed most efficie ntly wou ld be util ized by all owing the reloc ation. The Petition relied on three examples which, it maintained, demonstrated that the Commission s regulations allowed for the relocation of all, or part, of existing services between hospitals within a merged asset system: the Health Resources Planning Commission s granting of an exemption, pursuant to which Greater Laurel B eltsville Hospital (now L aurel Reg ional Hospital) was permitted to establish an obstetrics program under its merged asset system, the Com mission s approval of the partial relocation from Sinai Hospital of Baltimore to Northwest Hospital Center, of inpatient psychiatric services, without the need for establishing a need for a new health care service, and the Co mmission s 5 Proposed Decision granting the University of Maryland M edical System an exem ption to relocate an obstetrics program. As to this third example, Adventist pointed out that the Commission noted that a n allowab le change in patient services among the components of a merged organization included the establishment of a service at a facility within the merged organi zation. Adventist acknowledged that all of these examples involved a merger exemption, but insisted that they nevertheless reflected a distinction being drawn between the treatment of new and existing services. Furthermore, it asserted: [t]he Comm ission, in fact, h as adopte d other regulations permitting CON exemptions for merged asset systems for projects which otherwise would require CON coverage . It would b e illogical and inconsistent for the Commission to, on the one hand, apply the merger and consolidation exemption process to permit the establishment of a service that was not previously available at a hospital within a merged asset system while, on the other hand[,] treating a partial relocation of another service as a new service . Pursuant to this, Adv entist argued that treating its proposal as a new program would be inconsistent with these a nd other ex amples, an d with the C ommissio n s enabling statute. The petition further asserted that the langu age of Po licy 6.0 did not equate a partially relocated program to a new program. Over Adventist s objection, the Commission submitted Adventist s LOI and Petition to the hospitals p articipating in the comparative review for a new cardiac surgery program 6 for their review and comment, pursuant to § 19-126.6 Suburban Hospital, the other appellee in this case, and Holy Cross Hospital, responded as interested parties7 and opposed the Adventist Petition. Following the comparative review proceedings and as a part of the CON review process,8 the Commission issued its decision with respect to the proper forum for deciding 6 Section 19 -126 (a) pro vides: (a) If the Comm ission receives an application fo r a certificate of need for a change in the bed capacity of a health care facility, as required under § 19-120 of this subtitle, or for a health care project that would create a new health care service or abolish an existing health care service, the Commission shall give notice of the filing by publication in the Maryland Register and give the following notice to: (1) Each membe r of the G eneral As sembly in w hose district the action is planned; (2) Each membe r of the gov erning bo dy for the cou nty where the action is planned; (3) The c ounty execu tive, mayor, or ch ief executiv e officer, if a ny, in whose county or city the action is planned; and (4) Any health care provider, third party payor, local planning agency, or any othe r person the Co mmiss ion kno ws ha s an inte rest in the applica tion. What occurred in this case was unusual. Adventist submitted two letters and a Petition with memora ndum to the Com mission. Th e Comm ission took th ese docu ments and submitted them for comparative review as Adventist s application for a certificate of need. 7 An interested party may, pursuan t to Md. Code , Health-Gen § 1 9-126 (d) (7), submit written comments on the application in accordance with procedural regulations adopte d by the C omm ission. 8 Typically, when an application for a C ON for the c reation of a new h ealth care service has been filed with the Commission and circulated among the interested parties for r evie w an d comment, § 19-1 26 (a ), the Com miss ion s taff with in 10 wor king days shall re view it for co mplete ness an d may req uest fu rther inf ormatio n. § 19- 126 (d ) (3). Thereafter, the Commission 7 Adventist s relocation petition.9 It confirmed its preliminary determination, that the 2004 SHP required A dventist s pe tition for partial re location of its cardiac surgery program to be considered within the ongoing comparative review process no rmally engag ed to evalu ate CON s for new program s. The Co mmission reasoned : if every hospital that is a member of a merged asset system were able to establish an open heart surge ry program . . . the number of open heart surge ry may delegate to a reviewer the responsibility for review of an application for a certificate of need, including: (i) The holding of an evidentiary hearing if the Commission, in accordance with criteria it has adopted by regulation, considers an evidentiary hearing appropriate due to the magnitude of the impact the proposed project may have on the health care delivery system; and (ii) Preparation of a recommended decision for consideration by the full Commission, § 19-126 (d) (4), and shall designate a single Commissioner to act as reviewer for the application and any com peting applications. § 19-12 6 (d) (5). Thereafter, the review er, after review[ing] the application, any written comments on the application, and any other materials pe rmitted by this sec tion or by the C ommissio n s regulation s, shall presen t a reco mmended decision o n the application to the full C omm issio n. § 1 9-12 6 (d) (9). A ny applicant o r interested pa rty may be perm itted, upon re quest and consistent w ith Commission Regulations, to present oral argument to the reviewer, prior to the prepar ation of the reco mmen ded de cision o n the ap plication . § 19-1 26 (d) (1 0) (i). Finally, § 19-12 6 (d) (11) giv es interested p arties who have sub mitted written comme nts the right to submit written excep tions to the proposed de cision and oral argum ent before the Commission takes final action on the application. This pr ocess w as follo wed in this case . 9 Section 19-126 (d) (12) provides: (12) The Commission shall, after determining that the recommended decision is complete, vote to approve, approve with conditions, or deny the application on the basis of the recommended decision, the record before the staff or the reviewer, and exceptions and arguments, if any, before the Com mission . 8 programs would more than double, none of which would be considered new capa city, . . . undermin[ing] the intent of the policy and the principles of region al plann ing for speciali zed ser vices. Addressing directly the examples Adventist proffered as demonstrating that a relocation CON is subject to a different review process than is a new health care service CON, the Commission determined that there was no inconsistency between these cases and the Commission s rejection of Adven tist HealthCare s request for a separa te CO N revie w, pointing out that they involved the applicability of the merger exemption to the CON proces s, and are f ocused o n the Gen eral Assem bly s intent in creating the merger exemption for certain projects. It concluded that the merg er exemp tion was n ot at issue in this case and, in any event, the reconfiguration of obstetrics and psychiatric services in the way proposed by the hospital system s in those cases were the kind of service reconfiguration the Ge neral A ssemb ly intende d to per mit via th e CO N exe mption proces s. In addition, the Commission mentioned that the disposition of the cases relied on by Adventist was supported by the applicable SHP Chapter. It then observed: [B]y contrast, Policy 6 of the OHS Chapter is predicated on the Commission s determination that partial relocations of regionally-plannedfor services like open heart surgery services should be treated like new programs. As a practical matter, any partial relocation of these specialized services operates more like the establishment of a new program than does a relocation of obstetrics or psychiatric beds. For example, because of volume/q uality concerns present in planning for open heart surgery services and because the quality of an open heart surgery service is highly dependent on a team of health care practitioners working together on a high volume of surgeries, it is not possible , nor is Adven tist HealthC are propo sing, to simp ly relocate the [Washington Adventist Hospital s] staff to [Shady Grove Adventist Hospital] o r to divide Sta ff time betw een the tw o hospitals. Even 9 if the training protocols and the surgeons remain the same across the system, the [Shady Grove Adventist Hospital s] program will inevitably have a different support team of nurses and technicians who, through an integral part of the program, may not have the same e xperience working with each other or with the cardiac surgeons in [Washington Adventist Hospital s] high volume program. In this respect, the partial relocation of the [Washington Adventist Hosp ital] prog ram res emble s a new progra m. It conclude d, more ex plicitly, [a] partial reloc ation within a system can be expected to have some impact on volumes of other service providers just as a n ew pro gram w ould. . . . Reviewing these proposals separately, based simply on a distinction in nomenclature, makes no sense. Fina lly, the Commission rejected the argument that if Adventist s proposal was not a new program, it was obliged to tre at it as Adve ntist maintains , and review it as a separate and distinct matter. That, the Commission asserted, does not follow. Finding no legal requirement that it do so, the C ommissio n found it acceptable to treat Adventist s proposal and a typical CON application as similar types of prop osals in a single comparative review because both involved open heart services and both required a CON. The Commission concluded that adm inistrative effic iency and fair ness, as well as the public interest in the Commission making a reasoned decision in light of all material evidence, compel the conclu sion tha t a separ ate CO N revie w of th e Adv entist s p roposa l is unw arrante d. Adventist filed in the Cir cuit C ourt for B altim ore C ity a petition for judicial review, 10 pursuant to Maryland Rule 7-202.10 Following a hearing, the Circuit C ourt issued its Memorandum and Order affirming the Comm ission s decis ion. Perceiv ing the issue to be the interpretation of state regulations promulgated by [the Commission] the court noted, preliminary to proc eeding w ith its analysis, that [w]h en faced with a pro blem of sta tutory constructio n, this Court shows great deference to the interpretation given the sta tute by the offic ers or agen cy charged w ith its administration....When the constru ction of an administrativ e regulation rather than a statute is at issue, deference is even more clearly in order. Udall v. Tullman, 380 U.S. 1, 16, 85 S. Ct. 792, 80 1, 13 L . Ed. 2d 616, 62 5 (196 5). See also Maryland Transp. Authority v. King, 369 Md. 274, 288, 799 A.2d 1246, 1254 (2002); Maryland Comm n on Human Relations v. Bethlehem Steel, 295 M d. 586, 5 93, 457 A.2d 1 146, 1150 (1983). Then, finding the language of Policy 6.0 to be ambigu ous as to the mann er in which the Com mission sh ould address applications from new programs in relation to application for relocated progra ms, the court reviewed th e Policy s history an d the Com mission s inte nt in promulgating Policy 6.0, concluding: [i]t is clear from examinin g this history that insofar as cardiac programs w ere concerned, the Commission intended that new and relocated programs we re to be trea ted the s ame an d wou ld be rev iewed in the sa me ma nner. 10 Md. Rule 7-202, as relevant, provides: Method of Securing Review (a) By Petition. A person seeking judicial review under this chapter shall file a petition for jud icial revie w in a c ircuit co urt auth orized to provid e review . 11 Significant to that conclusion was an exchange between Adventist and the Commission staff, during the thirty-day informal c ommen t period, purs uant to COM AR 10.24.01 .08D (2) (b), 11 prior to the adoption of Rule 6.0, concerning its meaning. Adventist sought an interpretation consistent with the one it now advocates. Believing that the Policy, as proposed, could not be so interp reted, it wrote th e Comm ission, urging : The Draft Revision would continue to prohibit merged asset systems from operating a [cardiac surgery] program at more than one of its hospitals. We submit that where it can be demonstrated that two hospitals in the same region are part of a merged asset system and can put in place credentialing, staff training, and clinical su pport so tha t teams can function e ffectively at either institution, this sho uld not be considered the establishment of a new [cardiac surg ery] progra m . . . . The [Sta te Health P lan] should permit the o pportunity to demonstrate e ffective us e of merg ed asset system resources w ithout this being c onside red a n ew pr ogram . Letter from W illiam G. Ro bertson, Pre sident and C hief Exe cutive Of ficer of A dventist HealthCare, Inc., to the M aryland Health Care C ommission 8-9 (A ug. 20, 2003). The Staff responded, taking much the same position as the Commission takes on this appeal: Adventist HealthCare believe s that reconfiguration of existing ca pacity is not, and should not be, defined as the establishment of a new program. According to Adventist HealthCare, reconfiguration of open heart surgery capacity would not have an impact on the ability of other hospitals to apply for [Certificate of Need] approval to meet new identified need, and would not diminish the amou nt of new ly identified nee d. Staff w ould poin t out that if 11 COMA R 10.24.01.08D (2) (b) provides: (b) An e xplanation that a person who m eets the def inition of "inte rested party" in Regulation .01B(19) of this chapter may become an interested party to the review of this application by submitting written comments on the application within 30 days of its docke ting... 12 every hospital that is a member of a merged asset system were able to establish an open hea rt surgery progr am based on this princ iple, the number of open heart surgery programs in Maryland would more than double, none of which would be consid ered new capacity. The argument that reconfiguration of existing program capacity to another hospital within a merged asset system should not be considered a new program would clearly undermine the intent of the p olicy and the principles of regional planning for highly specialized service s. Analysis of Inform al Public C ommen ts and Staff Recomm endations, Maryland H ealth Care Commission 2 6-27 (Sept. 18, 2003 ). Moreover, the Circuit Court observed that there was a lack of a single instruction in the applicable regulations or in the Maryland Code that a relocated program must be subject to a review process separate from the comparative process established for new progra ms. Nor was the c ourt willing to take the inferential leap from the the mere fact that Policy 6.0 refers only to relocated programs to the conclusion that the whole Chapter 2004 delineates b etween n ew and relocated p rograms, to the extent tha t it requires separate review p roce ss. O n the contrary, it found, a far more reasonable explanation for Policy 6.0's requirem ent that reloca ted cardiac p rograms o btain Certificates of Need was that it was mea nt to distinguish cardiac p rograms f rom the oth er specialities in th e State Health Plan that allow relocation of programs without obtaining a new C ertificate of Ne ed. Adventist filed a petition for a writ of certiorari, which we granted, Adven tist Health v. Health Care, 389 M d. 398, 8 85 A.2 d 823 ( 2005) . As indicated, we shall affirm, and for the reasons that follow. 13 B. It is important clarify what is at issue in this case. The case sub judice presents a different issue, as well as different circumstances, than our recent decisions in Medstar Health v. Maryland Hea lth C are C omm 'n, 376 Md. 1, 827 A.2d 83 (200 3) ( Medstar I ), and Medstar Health v. M arylan d He alth C are C omm 'n, __ Md. __, __ A.2d __, 2006 WL 538634 (2006) ( Medstar II ). In both of those cases, the Commission was charged with exceeding its power under its enabling statute by the promulgation of invalid regulations. Nothing concerning the meaning of the regulation at issue was presented; each of the regulations was quite clear, in fact. Despite the contrasting results, both cases involved the Comm ission s quasi-legislativ e role, in wh ich the interpr etation of a re gulation pla yed no part. 12 12 To be sure, the interpretation of an agency s regulations can be important in a quasi-legisla tive c onte xt. It i s true that o rdinarily, Th[e] power of review, whether authorized by statute or assumed inherently, cannot be a substitution of the court's judgment for that of the agency. In those instances where an administrative agency is acting in a manner wh ich may be considered leg islative in nature (quasi-legislative), the judiciary's scop e of review of that particu lar action is limite d to assessin g whe ther the a gency w as acting within its legal b ounda ries. Weiner v. Ins. Admin., 337 Md. 181 , 190, 652 A.2d 1 25 (1995) (quoting Department of Natural Resources v. Linchester Sand & Gravel Corp., 274 Md. 211, 224, 334 A.2d 514, 523 (197 5); Judy v. Schaefer, 331 Md. 239, 265-66, 627 A.2d 1039, 1053 (1993) (recognizin g that the sco pe of judic ial review is m ore limited w hen the ag ency action is quasi-legislativ e, not quasi-ju dicial); Storch v. Zoning Bd. of Howard Co., 267 Md. 476, 487, 298 A.2d 8, 14 (1972). In Fogle v. H & G Restaurant, Inc., 337 Md. 441, 654 A.2d 449 (1995), for example, respondent sought to delay the implementation of a regulation prohibiting smoking in an enclosed workplace. We rejected the respondent s argument that promulgation of the regulation was an abuse of discretion by the Division of Labor and Indu stries, holding th at the agenc y s quasi-legislative decision w as entitled to deference and in substantial compliance with its enabling mandate. 337 Md. at 454, 654 14 Here, the critical issue is whether Adventist is entitled to a CON for the relocation of a portion of its existing cardiac surgery program from one hospital in the merged system to another. Resolution of that question requires the determina tion of the p roper proc edure to be used to address the issue. That in volves an interpretation of regulations relevant to the issue. Those regulations, as we have seen, were promulgated by the Commission, which now must interpret them. Thus, we are faced, specifically, with a situation involving an administrative agency interp reting its ow n regulation s in the context of its quasi-judicial role. Administrative agencies possess an exp ertise and, thu s, have a gre ater ability to A.2d at 456. Furthermore, we pointed out, deference is especially appropriate to be given to agenc ies workin g in the area of health a nd safety, wh ich rely extensiv ely on their specialized knowledge of that area in promulgating regulations. Fogle, 337 Md. at 455, 654 A.2d at 456 (citing Givner v . State, 207 M d. 184, 1 91, 113 A.2d 8 99, 902 (1955 )). See also Medstar I, 376 M d. at 21, 827 A.2d at 96 ; Medstar II, __ Md. __, __, __ A.2d __, __, 2006 WL 538634, 7. Nevertheless, in this context, an inward look by the agency at the original intent of the regulation in determining its validity may be appropriate. For exam ple, see Givner, supra, 207 M d. 184, 1 13 A.2 d 899. There, plaintiff challenged, as discriminatory, and therefore, invalid, a regulation promulgated by the Commissioner of Health which required separate bathing facilities for each dwelling unit, with exception of two-family dwellings, any two-story dwelling which contains not more than two dwelling units, provided there is at least one such facility available for the occupants of such dwelling. Id. at 187- 88, 113 A.2d a t 900-0 1. In upholding the exception, we concluded, in view of the agency s explanation, that most two-family dwellings were occupied by family groups which would presumably exercise greater care in regard to cleaning of facilities and to exercising health precautions, that the classification was a rational one . 207 Md. at 192 -193, 113 A.2d at 903. We reason ed: It is not the function of the courts to pass upon the wisdom of the regulation, or to approve or disapprove it, if it does not exceed constitutional limits, id. at 192, 113 A.2d at 903, thus recognizing that administrative agencies are in the best position to interpret the meaning and intent of the regulations they promulgate, and, thus, are entitled to deference regard ing their interpre tation. 15 evaluate and determine the m atters and issues that regularly arise, or can be expected to be presented, in the field in w hich they ope rate or in connection with the statute that they admin ister. In Board of Ph ys. Quality Assur., we stated: [A] 'court's task in review is not to substitute its judgment for the expertise of those persons w ho constitute the administrative agency.' ... [T]he expertise of the age ncy in its ow n field s hould b e respe cted. 354 Md. at 68-69, 729 A.2d at 381 (citations omitted). Consequently, the interpretation of a statute by the agency charged with administerin g the statute is e ntitled to great w eight. McCullough v. Wittner, 314 Md. 602, 612, 552 A .2d 881 , 886 (1 989). See, e.g., Board of Phys. Quality Assur., 354 M d. at 68-69, 7 29 A.2d at 381; Sinai H osp. v. Dep't of Employment, 309 Md. 28, 46, 522 A.2d 382 (1987); Balto. Gas & Elec. v. Public Serv. Com m'n, 305 Md. 14 5, 161, 501 A.2d 13 07 (1986 ); Consumer Protection v. Consumer Pub., 304 Md. 73 1, 759, 501 A.2d 48 (1985). More over, th[e] authority delegated to executive branch agencies may include a broad power to promulgate legislative-type rules or regulations in order to implement the statute. Such rules or regulations will often, of necessity, embody signific ant disc retionar y policy dete rminatio ns. Christ v. Department of Natural Resources, 335 M d. 427, 445 , 644 A.2d 34, 42 (19 94). This Court has stated that, in the exercise of that authority, [a] great deal of deference is owed an administrativ e agency s interpretation of its own regulation. Maryland T ransp. Au thority v. King, 369 Md. at 288, 799 A.2d at 1254 (2002). Furthermore: [A]gency rules are des igned to ser ve specific needs of the agency, are 16 promulgated by the agency, and are utilized on a day-to-day basis by the agency. A question concerning the interpretation of an agency s rule is as central to its operation as an interpretation of the agency s governing statute. Because an agency is best able to discern its intent in promulgating a regulation, the agency s expertise is more pertinen t to the interpretation of an agenc y s statute th an to the interpre tation of its gove rning sta tute. Maryland Comm n on Human Relations v. Bethlehem Steel Corp., 295 Md. at 593, 457 A.2d at 1150 ( 1983) . See also Pollock v. Patuxent Inst. Bd. of Review, 374 Md. 463, 477 n.6, 823 A.2d 626, 634 n.6 (2003) ( [A]n agency is best able to d iscern its intent in promulgating a regulation. Thus, an agency's interpretation of the meaning and intent of its own regulation is entitled to deference [citations om itted] ); Maryland Transp. Authority v. King, 369 Md. 274, 288-289, 799 A.2d 1246, 1254 (2002) ( [A]n agency s interpretation of an administrative regulation is of controlling weight unless it is plainly erroneous or inconsistent with the regulation [c itations omitted] ). Judicial review of the decision of an administrative agency rendered in a quasi-judicial proceeding is quite n arrow , Jordan T owing, In c. v. Hebb ville Auto Repair, Inc., 369 Md. 439, 449-52, 800 A .2d 768, 774-75 (2 002); Gigeous v. ECI, 363 Md. 481, 495-97, 769 A.2d 912, 921-22 (2 001); United Parcel Service, Inc. v. People's Counsel for Baltimore County, 336 Md. 569, 576-77,650 A.2d 226, 230 (199 4); Liberty Nursing Center, Inc. v. Department of Health and Mental Hygiene, 330 Md. 433, 442, 624 A.2d 941, 945 (1993) ( Judicial review of agency fact finding is narrow in scope and requires the exercise of a restrained and disciplined judicial judgm ent. ); Supervisor v. Asbury Methodist Home, 313 Md. 614, 626, 547 A.2d 190, 195 (1988), consisting of determining whether the administrative agency made 17 an error of law, i.e. the legality of the decision, and whether the record as a whole contains substantial evidence, that is, such relevant evidence as a reasonable mind might accept as adequate to support a conclusion, Bulluck v. Pelham Wood Apartm ents, 283 Md. 505, 512, 390 A.2d 11 19, 1123 (1978); Snowden v. Mayor and City Cou ncil of Baltimore, 224 Md. 443, 448, 168 A.2d 390 (1961) to supp ort the ad ministra tive dec ision. Baltimore Lutheran High Sc h. v. Emp loyment Sec . Admin ., 302 M d. 649, 6 62, 490 A.2d 7 01, 708 (1985 ). The legality of the proceedings may depend, as it must in the case sub judice if the petitioner is to prevail, on the meaning of the enabling legislation or the regulations promulgated pursuant thereto, as pertains here, Policy 6.0. Adventist argues that the Commission s decision to reject its application for a relocation CON was error, but only because the Commission s interpretation of Policy 6.0 as requiring its application to be considered in the CON process, with com parative rev iew, for ne w progra ms was in correct. Thus, in this sense, Adventist challenges the legality of the Commission s decision. Although the construction of statutes and regulations is a legal matter, not factual, this Court has made clear that, because the expertise of the age ncy in its own field should be respected, Board of Phys. Quality Assur., 354 Md. at 69, 729 A.2d at 381, that [e]ven with regard to some legal issues, a degree of deference should often be accorded the position of the administrative agency. Id. at 68, 729 A.2d at 381. As we have seen, that deference, which we characterized as considerable weight, id., is due the agency s interpretation and application of the statute it admin isters an d to the a gency s in terpreta tion of it s own regulati ons. King, 18 369 Md. at 288, 799 A.2d at 1254. Defer ence to the inte rpre tatio n of the a gency, however, does not mean acquiescence or abdication of our construction responsibility. Despite the deference, it is always within our prerog ative to determine wh ether an agency s conclusions of law are correct. Kushell v. Department of Natural Resources, 385 Md. 563, 576, 870 A.2d 1 86, 193 (2005 ). C. Because this case involves the interpreta tion of C OM AR 1 0.24.17 .04F, an d Polic y 6.0 contained within, and does not involve a challenge to the legality of the promulgated regulation itself, nor, except for the interpretation issue, a challenge to the Comm ission s decision to reject Ad ventist s prop osal, the prim ary question is w hich party is corre ct: the Commission or appellan t? Typically, a Maryland hospital that wishes to create a new cardiac surgery program must apply for and be granted a CON from the Commission. Md. Code Ann., Health Gen. § 19-120 (j) (2) (iii) (2). The Commission uses the CO N approval process to address and regulate the medical needs of the State of Maryland. Because CON reviews apply to all cardiac surgery services, this court defers to the Commission with regard to these programs because of their specialized nature. These services treat [t]he most complex health problems in segm ents of the population that are most severely ill and at the highest risk for poor outcom es, and are highly-specialized regional acute care programs] requiring the use of tech nologically-adv anced sk ills or equipm ent, or both. COMAR 10.24.17.02D. 19 Adventist claims that, giving Policy 6.0 its plain m eaning, the C ommissio n wrong ly treated the Adventist LOI as a request to o pen a new program , rather than, co nsistent with the policy, as a more limited request for a relocation CON. That, it asserts, violat[ed] two cardinal rules of statutory interpretation at the same time : the Commission s interpretation ignores the plain meaning of the words of the regulation, which allows a merged asset system with an e xisting prog ram to file a CON to relocate a ny part of its existing cardiac surgery capacity to another hospital within its system and inserts terms into Policy 6.0 that are not there, adding the ph rase for a n ew prog ram on th e end of P olicy 6.0, such th at it would read, a merged hospital system may not relocate any part of its existing cardiac surgery capacity to another hospital w ithin its system without obtaining a Certificate of Need for a new program. It relies heavily on our recent holding in Kushell, especially what we said with regards to the plain meaning of statutes: [O ]rdin ary, popular understanding of the English Language dictates interpretation of its terminology. In construing the plain language, a court may neither add nor delete language so as to reflect an intent not evidenced in the plain and unambiguous language of the statute; nor may it con strue the statute with fo rced or subtle in terpreta tion that limit or ex tend its a pplicatio n. 385 Md. at 57 6-577, 870 A .2d at 193 (internal citations omitted). In Kushell, this Court was asked to decide whether Maryland tax liability under § 8716 (c) (1) (iv) of the State Boat Act for the possession within the State of a vessel purchased outside the State to be u sed princip ally in the State, req uires that the o ut-of-state purchase have been made with the intent to use the vessel principally in Maryland. 385 Md. 20 at 566, 8 70 A.2 d at 187 . Md. C ode (197 3, 2000 R epl. Vol., 2001 Cum. Supp.) § 8-716 (c) of the State Boat Act, §§ 8-701 et seq. of the Natural Resources Article imposed M aryland s boat excise tax. Section 8-716(c) (1) (iv) provided: (1) Except as provided in § 8-715(d) of this subtitle and in subsections (e) and (f) of this sectio n, and in addition to the fees prescribed in subsection (b) of this section, an excise tax is levied at the rate of 5% of the fair market value of the vess el on: * * * * (iv) Th e posse ssion w ithin the State of a vesse l purch ased ou tside the State to b e used p rin Although Kushell had purchased his boat outside Maryland, without any intent of using it principally in Maryland, and, in fact, did not so use it, and relie d on, and abid ed by, the Departm ent s represe ntations w ith regard to w hat constitute d used p rincipally in Marylan d, 385 Md. at 567, 870 A.2d at 187, he was assessed excise taxes for the calendar year 2001. 385 Md. at 569, 870 A.2d at 189. Following an unsuccessful appeal of the assessme nt, the result of which was affirmed on judicial review, and Kushell s appeal to the Court of Spe cial Ap peals, w e grante d certior ari. Kushell v. Department of Natural Resources, 383 Md. 56 9, 861 A.2d 60 (2004). Both the Administrative Law Judge and the Circuit Court, construing § 8-716 (c) (1 ) (iv), held that it did not have a n intent elem ent, that the imposition of the tax did not depend on the purchaser s intention to use the boat principally in Maryland. 385 Md. at 569, 8 70 A.2d at 189. In this Court, Kushell argued, inter alia, relying on the plain and, he maintained, unambiguous, language of § 8-716 (c) (1) (iv), that the tax is imposed only on the possession of a vessel which, at the time of sale, was purchased with the specific intent of using it princip ally in Ma ryland. Id. at 570, 870 A.2d 21 at 190. To hold otherwise, he asserted, would render the phr ase, to b e, nug atory. Id. The Department Natural R esources c ontended otherwise , howev er. While maintaining that the interpretation given the statute by the Administrative Law judge and the Circuit Court, which it adopted a nd advo cated, 385 Md. at 570, 870 A.2d at 189, was correct, it urged that the result was also dictated bec ause its interpretation was entitled to judicial deference. 385 Md. at 573, 8 70 A.2 d at 191 . We held in f avor of Kush ell. 385 Md. at 581, 870 A.2d at 196. Recognizing that the issue was one of statutory construction, as to which our review is de novo, 385 Md. at 576, 870 A.2d at 193, and notwithstanding the deference due the interpretation of the administrative agency, after reviewing the applicable canons of construction,13 we concluded: 13 We stated: The legal issue in this case is one of statutory interpretation. The cardinal rule of statutory interpretation is to ascertain and effectuate the intent of the Legisla ture. See Collins v. S tate, 383 Md. 684, 688, 861 A.2d 727, 730 (2004). Statutory construction begins with the plain language of the statute, and ordinary, popular understanding of the English language dictates interpre tation of its termin ology. Deville v. S tate, 383 Md. 217, 223, 858 A.2d 484, 487 (2004). In constru ing the plain language , [a] court m ay neither add nor delete language so as to reflect an intent not evidenced in the plain and unambig uous lang uage of th e statute; nor m ay it construe the statute with forced or subtle interpretations that limit or exten d its application. Price v. State, 378 M d. 378, 387 , 835 A.2d 1221, 12 26 (2003 ); County Council v. Dutcher, 365 Md. 399, 416-417, 780 A.2d 1137, 1147 (2001). Statutory text should be read so that no word, clause, sentence or phrase is rendered superfluous or nug atory. Collins, 383 Md. at 691, 861 A.2d at 732 (quoting James v. Butler, 378 Md. 68 3, 696, 838 A.2d 1180, 1187 (20 03)). The plain language of a provision is not interpreted in isolation. Rather, we analyze the statutory scheme as a whole and attempt to harmonize 22 [u]nder ordinary rules of English grammar, ... the plain tex t suppo rts Kus hell's read ing. Id. at 577, 8 70 A.2 d at 194 . Thus, while Adventist is correct in its reliance on the legal principles articulated in Kushell, applica tion of th ose prin ciples, h owev er, do no t assist A dventis t s positio n. In Kushell, the statute was so plain, and clear, that the Department s expertise in the matter could not, and did not, make a diffe rence. Deference to the Department s expertise simply could not carry the day; no matter how much expertise the Department of Natural Resources had, it could not trump the statute itself. The plain meaning of the statute, lacking any ambiguities, dictated the result. Although the deference to w hich the Departm ent s interpretation was entitled could not, and did not, cause the Depa rtment s po sition to preva il, the proposition for whic h it advoca ted, that defe rence sho uld be aff orded to its decisions, was provisions d ealing with the same s ubject so tha t each may be given eff ect. Deville, 383 M d. at 223, 85 8 A.2d a t 487; Navarro-Monzo v. Washington Adventist, 380 Md. 19 5, 204, 844 A.2d 406, 411 (2004 ). If statutory lang uage is un ambiguo us when construed according to its ordinary and e veryday mean ing, then w e give eff ect to the statute as it is written . Collins, 383 Md. at 688-89, 861 A.2d at 730. If there is no ambiguity in that language, either inherently or by reference to other relevant laws or circumstances, the inquiry as to legislative intent ends; we do not need to resort to the various, and sometimes inconsistent, external rules of co nstruction, fo r the Leg islature is presu med to ha ve mean t what it said and said what it meant. Arunde l Corp. v. M arie, 383 Md. 489, 502, 860 A.2d 88 6, 894 (2004) (quoting Witte v. Azarian, 369 Md. 518, 525, 801 A.2d 160, 165 (2002)). Kushell v. Department Of Natural Resources, 385 Md. 563, 576-577, 870 A.2d 186, 193194 (2005). 23 by no me ans reje cted or u nderm ined. The case sub judice is an entirely different circumstance. The lan guage of Poli cy 6.0 and COMAR 10.24.17.04F is, at best, as articulated by the Circuit C ourt, amb iguous. T his is not a case where the regulation in question has no ambiguity such that we do not need to resort to the various, and sometimes inconsistent, external rules of construction... 385 Md. at 577, 8 70 A.2 d at 193 -194. In stead, giving deference to the Departmen t s interpretation of its regulation in the case sub judice may b e app ropr iate to res olve amb iguity, as long as there is a subs tantial ba sis, whe n all is said and do ne, for th at interp retation . Adventist argues that by interpreting Policy 6.0 the way it does, the Commission ignores the 2004 SHP s general distinctions between new and existing programs, citing to a number of sections of the 2004 SHP which explicitly govern each type of program separately. For example, it refers to the following sections involving new programs: Policy 1 .3 A Certificate of Need issued by the Commission for the establishment of a new cardiac surgery program will require as a condition of issuance that the program achieve minimum volume standards w ithin 24-months of beginning operation and maintain the minimum utilization level in subsequent years of operatio n. .05B Commission Program Policies; Consideration of New Program The Commission will consider a new program in a Regional Servic e Area under t he follo wing c ircums tances... .05C(2) Approval Policies Approval of a New Program. - The Commission will approve the establishment of a new progra m... By contr ast, Adventist cites a number of sections that refer to existing programs; 24 for example: .03B(3) If an existing program does not meet the required minimum volum es... .04(B) These existing programs focus primarily improv emen t relative t o CA BG su rgery... Policy 9 .1 The Commissio n will determine wh ether existing programs in a Regional Serv ice Area h ave dem onstrated co mpliance with the Com mission s public reportin g requi remen ts. on quality Based on these examples, Adventist argues that, implicitly, at least, the Commission intended for these new programs and existing programs to be treated differently. It concludes: Policy 6.0, cannot, as a matter of law, possibly mean that applicatio ns to partially relocate existing programs are no different than applications that seek to open a new program because that result is inconsistent grammatically and in relationship to other statutory provisions. Kushell, 385 Md. at 581 [, 870 A.2d at 196 .] 14 14 Three other arguments made by appellant also fall short. Adventist claims that by treating Polic y 6.0 as applica ble to new program s, the Com mission ren ders it superfluous and thus violates another statutory tenet, that one section of a statute cannot render me aningless a nother sectio n of the sam e statute. It does not follow , howev er, that , the mere f act that the 20 04 SHP refers in som e sections to existing pro grams an d in others, to new programs means that Policy 6.0 requires a separate and distinct CON process for existing programs. Adventist also argues that considering the Adventist LOI outside of comparative review would not violate the principles of regional planning as the Commission claimed. The Co mmission determine d, howe ver, that the im pact of a p artially relocated pr ogram to an area previously lacking a cardiac surgery program could be substantial, and thus, must be evaluated using the same principles as are applicable in the evaluation of new programs. Finally, Adventist denies that it should have known that, in view of the Comm ission Staff s addressin g of the issu e when the 2004 S HP w as being co nsidered, its 25 The Commission rejects all of Adventist s claims, offering instead, its own interpretation of Policy 6.0. It notes first that during the formulation of the 2004 SHP, in its Analysis of Informal Public Comments and Staff Recommendations, it stated: Staff would point out that if every hospital that is a member of a merged asset system were able to establish an op en heart sur gery program based on this principle, the number of . . . programs in Maryland would more than double. . . . [Adventist s] argument that reconfiguration of existing pro gram cap acity . . . should not be considered a new program would clearly undermine the intent of the polic y and the princ iples of regio nal plannin g for high ly specialized services. . . . Giv en the limited number of progra ms offer ing cardiac surgery, it seems appropriate that changes in the location of those programs be the subject of a full Certificate of Need review. Staff believes that the Commission should maintain the policy that a merged asset hospital system may not relocate any part of an existin g cardiac su rgery program to anothe r hospita l within its system w ithout o btaining a Certif icate of Need . It is the Commission s general position that CONs for relocation are no different than CONs for new programs. They have been addressed separately in the SHP simply to specify the situations in which the Commission exercises its control. It further notes that the Cardiac Surgery Chapter of the SHP had always prevented merged asset systems from operating cardiac surgery services at more than one of its ho spitals, ev en prio r to the 2 004 rev ision, a LOI to partially relocate would be treated as a request for a new program. It argues, rather, that the Staff comments did not, in fact, indicate an intent on the part of the Comm ission to treat relo cated prog rams and new pro grams the same. Inde ed, it points out that at no time did the Commission Staff indicate that a CON seeking partial relocation [would be] synonymous with a CON seeking a new program. . . Whether Adventist anticipated, or should have, the Commission s interpretation of Policy 6.0, does not answ er the questio n we m ust decide - w hether that inte rpretation, w henever a rrived at, is correct. 26 fact that Adventist was aware of and acknowledged.15 This, it contends, resolves any questio ns surro unding the statu tory intent o f Policy 6 .0. Furthermore, the Commission maintains that fairness and efficiency dictated its decision to submit the Adven tist proposal to compara tive review . As with a CON for a new program, the Commission was merely unde rgoing the s ame proc ess in order to fully ascertain the effect of a relo cated p rogram on surr oundin g hosp itals. Adventist is not entitled to override the Commission s choices about the effect ive adm inistratio n of its C ON p rogram , the Comm ission asserts, rem inding this C ourt that [t]h e Court of Appea ls will review the agency s decision in th e light most f avorable to the a gency, since decisions of administrative agencies are prima facie correct and carry with them the presumption of validity. (Quoting Carriage Hill Cabin John, Inc. v. M aryland Health Res. Plann ing Comm n, 125 Md. App. 183, 212, 724 A .2d 745, 760 (199 9)). In approach ing this question, we repeat the well-settled precedent: an administrative agency s interpretation and application of the statute it administers, Board of Phys. Quality Assur., 354 Md. at 69, 729 A.2d at 381, and the regulations it promulga tes pursuan t thereto and in furth erance thereof , King, 369 Md. at 289, 799 A.2d at 12 54, ordinarily is en titled to considera ble weigh t by review ing cou rts. Board of Phys. Quality Assur., 354 Md. at 69, 15 In a letter commenting on the Cardiac Surgery Chapter and Policy 6.0, Adven tist s CEO William G . Robertso n wrote th at the Dra ft Revision [to the State Health Plan] would continue to prohibit merged asset systems from operating a [cardiac surgery] p rogram at more than on e of its h ospitals . . . 27 729 A .2d at 38 1 (citatio ns omi tted). The Commission submitted the Adventist LOI to compa rative review pursuant to Policy 6.0 because it b elieved that a llowing req uests for relocation to circumvent the typical CON processes wo uld lead to th e unchec ked prolife ration of ca rdiac surge ry programs in violation of the overarching policy of the 2004 SHP favoring a system of higher volume programs as op pose d to a syste m w here all ho spita ls perfor m at o nly the minimum volum e. COMAR 10.24.17.04A (3). This issue was specifically addressed during the consideration of the 2004 SHP and prior to its promulgation. This is relevant to the Commission s intent in adopting Policy 6.0. Moreover, despite the use of new and existing in different sections of the 2004 SHP, there is no explicit indication that the Commission intended programs wishing to be relocated to be treated differently than new progra ms in re gards to the CO N app lication p rocess. Furthermore, reading Policy 6.0 in context with the other provisions of the SHP, as we are require d to do, Kushell, 385 Md. at 577, 870 A.2d at 193, we are satisfied that, while the Commission may recognize differences in the treatment of programs that already exist, and programs that wish to e xist, in a variety of other administrative areas, these distinctions do not indicate that the process through which an application for the placement of a program in a new area should be analyzed differently depending on the pre-placement status of such that program. The dire consequences that Adventist suggests will result from affirming the 28 Commission s interpretation, primarily that CONs for relocation will be treated unfairly under a traditional CON review proces s, rest primarily on the foundational premise that there is a difference between placing a new pro gram in an area prev iously lacking a cardiac surgery program, and partially relocating a previously existing cardia c surgery program to an area previo usly lackin g a card iac surg ery progr am. On this point, we de fer to the Comm ission s expertise. It has determined that there is no difference in the resulting impact to surrounding programs wheth er the pr ogram is new or reloc ated, a p olicy con cern of the Co mmiss ion s. Both program placements have the potential of affecting surrounding patient volumes. Thus, Adventist s foundational premise is unfirm, and the resulting conseque nces are sim ilarly ineffectua l. We agree with the Circuit C ourt s conc lusion, and th e Comm ission s position , that, absent a provision that explicitly requ ires that relocatio n CON s be subm itted to a different process than CONs for new programs or that demonstrate that the Commission intended for the two different types of programs to undergo the same evaluative procedure, we shall defer to the Commission s expertise. Accord ingly, there is no basis to reverse the C ircuit Court s judgmen t. AFFIRMED, WITH COSTS. 29

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