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The Proposed New Hospital

Is the Move of FMC in the Best Interest of the Community?

May 15, 2023 

F3 spoke with the Mayor and several Council members in the last week about the many questions and concerns that F3 hopes will be addressed by Council during conversation at the dais. These are represented below:

Is the move of Flagstaff Medical Center in the best interest of the community? This is the most important question the Council needs to answer. It requires looking at the community through a wide lens, one that takes into account the impact on the community as a whole. And it requires careful deliberation on whether the values we uphold are reinforced or diminished by the move.  

This is the conversation we hope will take place on the dais. Below are some of the questions and concerns that we hope will be addressed in that conversation.

1.  The Importance of the Regional Plan: 

Written as a vision for the community and approved by community vote, the Regional Plan specifically affirms the value of creating a vibrant urban core through density and infill and eschews sprawl. For more than two decades, residents have affirmed a commitment to high density residential development in order to create lively, walkable, and sustainable neighborhoods.

The NAH proposal does not comply with this vision. Not only does it induce sprawl but it also threatens to devastate a vibrant urban neighborhood. These impacts seriously undercut the Regional Plan. Any decision to approve the hospital move must have sufficient justification to override the current Regional Plan commitments to density, to refrain from sprawl, and to sustain currently-existing vibrant urban neighborhoods.

Is the NAH proposal of such importance to the interests of the community that these commitments should be overruled? Should both the Regional Plan and the decision of the citizen-led P&Z Commission be set aside? What guiding principles would inform such a decision?

2.  Social Justice:

Part of looking after the best interests of the city is the question, “Who is harmed by the move of the hospital out of the city’s core?” The most intimate harm is to those patients, families of patients, and employees who walk, bike, or rely on public transportation in order to reach the hospital. A hospital on the outskirts of town without adequate transportation severely disadvantages lower income residents.The unsheltered who will be released from the hospital will be even more handicapped.

A second level of harm is to the Hospital Hill neighborhood and to the businesses, small and large, that are located near the hospital and involved in health-related activities. It seems fair to assume that many will vacate their current locations. What will become of these buildings? What will become of this neighborhood? Will we see the same pattern we saw all over the country when malls were built on greenfields and downtowns deserted?  (In a conversation with a hospital CEO in Florida, we were told of a hospital move that resulted in medical offices left vacant for 5-10 years after the move.) 

A third level of harm is to the patients. Will we see increases in the cost of healthcare in Flagstaff as a consequence of this extensive hospital development? Will patients be billed more for private rooms, advanced technology, etc.? And how can we be assured that the “Village” won’t become an enclave for the wealthy with luxury homes, expensive restaurants, and high-end retail? (Currently most health villages are constructed in wealthy neighborhoods and/or are meant to attract wealth, especially wealthy seniors.) 

3.  Cost of the proposal to the taxpayers

Moving the hospital comes with a high cost to taxpayers. We do not yet have a clear understanding of the full costs to the taxpayer, though we know it is substantial. Costs include $45M for Beulah Blvd widening, an unknown amount for improvements of city intersections impacted by the changed traffic patterns, the purchase of additional transit buses and the operation of the new hospital route, 50% of the $4.75M in costs for purchasing land and building a new Fire Station No. 6, and $1.4M/year for a fully staffed ladder company (9 employees). What is the full amount of money the City is being asked to contribute to this project? Will this project increase individual taxes? What projects will not be funded in order to fund the hospital move?

4.  Overarching Healthcare Needs and Accessibility:

The NAH Community Health Needs Assessment Report (2022) lists the following health needs of Flagstaff and the region: worsening mental health and lack of providers, chronic diseases including heart disease and stroke, cancer, respiratory disease, diabetes, substance abuse, and access to healthcare. Nowhere in the report is mention made of the need for a capital project. And NAH’s proposal does not show how a new hospital will address these community health needs. In what ways will a new hospital at a new location further the healthcare related to these needs?

Most of the health needs cited in NAH’s assessment report do not regularly require in-hospital treatment. What they require is accessible outpatient care. And an out-patient or ambulatory model is more efficient and less costly. It is the model we currently have in place in the community. In 2019 this goal was outlined in the NAH Strategic Plan and in 2020 announced that it would be renovating the hospital and increasing “the creation of new facilities throughout the region, especially in east Flagstaff.” Then CEO Flo Spyrow said, “We need to bring our services more to the community than centralized locations.” (Daily Sun, March 2, 2020) What changed? Why is NAH now proposing a consolidated hospital and centralized health services?

5.  The Carbon Neutrality Plan and the Climate Emergency:

The impacts of the new hospital location and the resulting predicted large increased Vehicle Miles Traveled (VMT) must be considered in light of the City’s Climate Emergency, the Flagstaff Carbon Neutrality Plan, and the standard and policies of the Regional Plan. F3 believes you understand this issue and that Council does not have to ignore carbon emissions just because it is not being considered in the staff’s findings.

6.  Why Reinvent the Wheel? What are Other Hospitals in the Country Doing and Why? 

The challenges faced by NAH are not unique. Operating margins are slim for all hospitals; hospitals across the country are struggling to hire nurses and specialists; technological updates are constantly needed. 

How are other hospitals responding to these challenges? 

What is the evidence that a new hospital will decrease staffing shortages and draw specialists to the region? (In fact, the evidence shows that specialized physicians tend to stay where they have done their residencies.) 

What safeguards, if any, can we count on if the hospital development tanks? How likely is it that a Private Equity Firm would try to acquire FMC? Then what do we do?

7.  Renovation and Expansion as Viable Options:

A health economist told us that “almost no new hospitals are being built today.” Almost all hospitals are choosing to renovate in place. This is true of the nation’s most prestigious hospitals, most of which are built on highly limited urban sites. It is not cheap to do so, nor is it easy but it is possible–and it is the choice made by the great majority of hospitals. New technology makes it possible to update hospitals so they can accommodate the latest medical advances. One hospital CEO who has overseen three building projects called the choice between building a new hospital or failing to provide state-of-the-art healthcare, “a bunch of hooey.” Many world class hospitals are hundreds of years old. 

Why is Flagstaff Medical Center an exception to this rule? What is about the current location that makes it impossible to renovate? What would an independent architectural analysis tell us about renovation possibilities and costs? (Can we invite the University of Arizona School of Architecture to carry out a charette?)

What are the true costs to the community as well as NAH of moving the hospital from a core part of town to its outskirts? When these costs are factored into the analysis, is hospital renovation in the best interest of the community as a whole? 

F3’s Talking Points for comments to Council (May 2 and May 16)

Conduct a Needs Assessment

  • Having good healthcare options in Flagstaff is important to our community. 
  • Is the proposal to move the hospital from its current location to the edge of town good for the health of the community? We don’t really know. The only information we have comes almost entirely from Northern Arizona Healthcare and represents the hospital’s interests. 
  • A needs assessment will identify Flagstaff’s capacities and deficits related to the community’s well-being with an unbiased and comprehensive study conducted by a neutral party to determine how and whether a new hospital in the proposed location will benefit or harm the community. 
  • A needs assessment can tell us if consolidating all medical care in a single hospital as NAH is proposing, is better than the current out-patient model we now have in Flagstaff, where patients receive medical care such as orthopedics, etc. outside of the hospital itself. It could tell us if it’s possible to renovate and upgrade the existing hospital, thereby saving many tens of millions of dollars on related city infrastructure.
  • Flagstaff’s urgent community health issues include homelessness, unaffordable housing, food insecurity, climate resilience, social isolation, insufficient wages, and mental health. Added to these are the health impacts of carbon intensity. Let’s spend our limited city funding to address these needs.
  • NAH’s request to build a new hospital complex on the edge of town is not in line with our current Regional Plan, specifically our desire to maintain vibrant neighborhoods and avoid sprawl. 
  • Postpone making a decision on NAH’s proposal until our community has the information we need to be fully informed of its implications for overall community health and well-being.

NAH Must Adequately Address Flagstaff’s Carbon Neutrality Goals 

  • The NAH proposal does not comply with a very important Regional Plan policy (LU.5.2) that guides the City to promote infill development over peripheral expansion. Council must carefully consider ways to mitigate the impact to the community’s goals of this proposal. Mitigation measures could include offsetting the expected increase in Vehicle Miles Traveled through an overall reduction in carbon emissions from construction and operation of new NAH buildings.
  • The NAH proposal does not adequately address the carbon neutrality goals and policies of our Regional Plan. 
  • NAH has committed to reaching Energy Star 75 within the first year of operation of the hospital and Ambulatory Care Center. This does not go far enough for a new health care building in Flagstaff. 
  • NAH must make a strong commitment to meet the Regional Plan’s carbon neutrality goals and policies because in-patient hospitals are among the largest commercial consumers of energy. The health care sector is responsible for 8.5% of U.S. greenhouse gas emissions, and inpatient healthcare is ranked by the EPA as the second-largest commercial energy user in the United States.
  • Because health care facilities consume close to 10% of the total energy used in U.S. commercial buildings, it makes the most sense that new hospitals be built to be carbon neutral from the start.
  • Nothing is as potentially threatening to public health as climate change. The US can immediately improve the health of Americans, reduce diseases, and slash health care costs by decarbonizing the health care sector.
  • To meet the medical professionals goal, under the Hippocratic oath of physician ethics, is to do no harm — then addressing climate change needs to take priority. Therefore, it’s imperative that NAH minimizes its own climate impact and join other hospitals around the world who are committed to carbon neutral health care.
  • NAH’s public commitment to carbon neutrality by 2050 is not adequate in a city that has a carbon neutrality goal of 2030. 
  • NAH must commit, at a minimum, to net zero for its Scope 1 emissions (emissions an organization produces directly, for example through heating/cooling and/or its fleet of vehicles), and Scope 2 emissions (emissions from purchased electricity). 
  • Because of the high energy use of inpatient healthcare facilities, NAH must commit to securing off-site renewable electricity in year two and onward to cover the greenhouse gasses emitted from the hospital and Ambulatory Care Center buildings even with the Energy Star 75 rating. The NAH consultant from WSP said that this could be accomplished through partnership with APS to purchase renewable electricity.
  • NAH must commit to use low embodied carbon materials in the construction of these buildings. The impact of upfront embodied carbon emissions in building materials is becoming increasingly significant. According to the New Buildings Institute, construction materials alone are responsible for about 11% of all carbon emissions. 
  • The impact of carbon and methane emissions from inpatient hospitals is well known and acknowledged by hospitals in the U.S. and internationally. Research indicates that annual greenhouse gas emissions associated with health care in the United States alone would cause 123,000 to 381,000 disability-adjusted life-years (DALYs) in future health damages, with malnutrition being the largest damage category. DALYs for a health condition are the sum of the years of life lost due to premature mortality and the years lived with a disability due to prevalent cases of the disease or health condition in a population. 

Planning & Zoning Commission

FINDING: The Commission made a recommendation to City Council to deny to rezoning request and the submitted Specific Plan for Phase 1. Read the story in the AZ Daily Sun.


Documents related to the proposed hospital

1) The NAH Specific Plan, Combined Application Narrative, the Traffic Impact Analysis, the Fire Analysis, and other project reports can be viewed on the Aspey, Watkins & Diesel website
2) The Draft Development Agreement (DA) between the City and NAH is where financial commitments from both parties are disclosed, specifically for  commitments to share in the cost of important infrastructure such as Fire Services and road widening. The draft DA can be found here.
3) The City of Flagstaff Staff Reports can be read here and here.

Some of F3’s Comments

Coconino Voices: Friends of Flagstaff’s Future wants more answers on NAH’s new campus

Published in the AZ Daily Sun on 4/30/2023 (link here)

Everyone wants good health care. No question about it. But is the proposal to move Flagstaff Medical Center from its current location to the edge of town good for the health of the community? We can’t know given the information we have. We do not yet have an objective analysis of how the hospital move will impact the overall well-being of our community. The only information we have comes almost entirely from Northern Arizona 

Healthcare and represents the hospital’s interests. 

We need an independent, comprehensive assessment of how and whether a new hospital on the periphery of town will benefit or harm the community. Until that information is available, we urge Council to postpone a decision on NAH’s proposal. 

Healthcare is a public good. Unlike other businesses or nonprofits, the hospital is at the center of a web of social and economic relations. A move from its current location has ramifications for thousands of people involved in some aspect of healthcare. For this reason, an unbiased community needs assessment is warranted. 

A community needs assessment, conducted by a neutral party, will be able to help us answer the following questions: 

  • Why is a consolidation or district model better than the current out-patient or ambulatory model Flagstaff has now, where patients receive medical care outside of the hospital? Out-patient, ambulatory care has been embraced by many hospitals—including FMC—precisely because it provides healthcare at a fraction of the cost and time required by in-hospital care.
  • How will a consolidation approach affect the many medical providers whose practices–orthopedics, radiology, pediatrics, surgical services, etc.—are currently located on Hospital Hill? Will we lose medical providers who operate independently? Will the offices and complexes currently occupied by these providers become empty and drain the area of its economic and social vitality? 
  • NAH’s proposal includes an increase of 30 beds, more private and upgraded rooms, and redesigned  space for the use of  new, high-tech equipment. Is it possible to achieve these same goals through renovation and expansion of the current hospital rather than building an entirely new facility? This would save on infrastructure expenses, including the substantial ones related to widening Beulah Avenue, funding a new fire station, and providing public transit. It would avoid the enormous environmental impacts related to building a new hospital on the periphery. And by remaining in the center of town, it would avoid the untold economic and social consequences of hollowing out a part of the city’s core. When these elements are factored into the equation, does renovation look like  a better all-round option? 
  • The commitment to community wellness is part of a national shift in medicine, intended to keep costs down by encouraging healthy lifestyles. We are fortunate to live in a city that ranks in the top 100 livable cities in the country with an outstanding urban trail system, easy access to outdoor recreation, and clean air and pristine drinking water. Our pressing community health issues have to do with homelessness, unaffordable housing, food insecurity, social isolation, insufficient wages, and mental distress. Added to these are the health impacts of carbon intensity. These are health issues that require well-integrated community systems. Are they better addressed by a free-standing hospital complex located on the outskirts of town or by a hospital that is situated within a neighborhood and surrounded by established community organizations with an expertise in these health-related issues? 
  • Flagstaff has a great many needs and limited financial ability to meet those needs. It is no small matter that NAH’s proposal comes with significant costs to the City of Flagstaff, including half the capital cost of a new fire station and yearly staffing costs of $1.4 million dollars. How does NAH’s proposal align with the City’s priorities, especially those related to overall community wellbeing (e.g. affordable housing, carbon neutrality, water, etc.)? 

Hospitals all over the country are recognizing their responsibility to improve community health and intentionally strengthen the neighborhoods in which they reside. NAH’s proposal to build a new hospital complex, removed from the city core, is an exception to what most hospitals are doing. It is also an exception to the commitment of our Regional Plan to maintain vibrant neighborhoods and avoid sprawl. After many hours of respectful deliberation, our Planning and Zoning Commission denied NAH’s request for rezoning. Council should give P&Z’s decision careful consideration as it evaluates whether this proposal merits the exceptions being requested. 

While NAH is eager to move forward as quickly as possible, we urge Council to postpone any decision until an independent, comprehensive analysis of the impacts of NAH’s proposal on the health and well-being of the community at large has been conducted. We need to get this right, for ourselves and for future generations. An objective, thorough, and holistic community health assessment will benefit all of us.

Friends of Flagstaff’s Board

F3 has multiple concerns related to both the new hospital campus as well as future use of the existing campus. These concerns are outlined clearly in the following Coconino Voices editorial written by F3’s Executive Director and published in the Arizona Daily Sun.

Coconino Voices: F3 concerned with financial costs to community for proposed new hospital

March 9, 2022

Michele James

Friends of Flagstaff’s Future (F3) is concerned about the financial impacts to the Flagstaff community for the proposed Northern Arizona Hospital (NAH) relocation. In 2021, NAH announced their desire to build a new regional hospital and adjacent “health & wellness village” just north of Fort Tuthill. 

NAH is nearing completion of the required City applications for Phase 1 of the project which includes rezoning of 98 acres to allow for the building of a new ambulatory center and a 751,000 sq foot hospital that includes a tower up to 160 feet in height. Phase 2 of the project will come later and is composed of rezoning for the adjacent “health and wellness village” and for 270-315 dwelling units, as well as commercial and industrial/research uses.

As a part of the City’s process, NAH is required to complete a specific plan, and a Development Agreement that will outline NAH’s financial commitments to the City to pay their fair share of the related infrastructure costs associated with building the hospital in this location. 

It’s our view that, in order to qualify for rezoning approval by City Council, NAH must make significant written financial commitments to the City in their Development Agreement to pay a fair share of costs related to the placement and operation of the proposed hospital in this location (Phase 1) and “wellness village,” etc. (Phase 2). Financial commitments from NAH must be in alignment with the City’s requests and needs, and should not unduly impact City finances or be a burden to the tax-paying public. 

Infrastructure costs for a new hospital in this location include the $45M dollar road widening of Beulah Ave. south of University Heights Dr. to the JW Powell bridge (the City & NAH are hoping to receive a Federal grant to cover all of this cost), and a very significant expansion of City Fire services required to adequately fight a fire in the (up to) 160-foot tall hospital tower (note: the tallest building in Flagstaff currently is about 85 feet).

The Fire Chief recently told City Council that necessary City Fire service coverage requires the purchase of a taller ladder truck and a new fire station to house this ladder truck for $9.5M, an additional $2.4M in related operations and maintenance, as well as an unreported dollar amount for twelve or more additional EMS and other personnel needed on a daily basis.

The proposed new hospital is located within an Urban Activity Center, and, according to Flagstaff’s Regional Plan, the provision of public transit is required. F3 was therefore surprised to learn in December that NAH has chosen not to provide funding for a reasonable portion of the $1.2 million annual costs for a new public transit route.

The City must provide equitable access to healthcare, including for those without a vehicle. In addition, Flagstaff’s commitment to reach carbon neutrality in seven years time requires the increased use of public transit and multi-modal transportation to reduce Vehicle Miles Traveled and carbon emissions. Public transit to the proposed new hospital must be provided.

Beyond commitment to infrastructure costs, F3 wants to see NAH commit to design, build, and operate the hospital and ambulatory center in a manner that aligns as closely as possible with Flagstaff’s Carbon Neutrality Plan. And, F3 wants a written commitment to fund and produce a community-driven plan for the re-purposing and redevelopment of the existing hospital campus that ensures benefits to the Flagstaff community. 

The proposed hospital move and associated development on NAH-owned land would be the first of what will be significant development in this area (and is in alignment with our Regional Plan). The City of Flagstaff has no mechanism in place to spread the costs of growth to other developers who will build in the adjacent areas in the future.  We understand that this is a significant limitation and a systemic issue with the City’s current means of managing growth.  Nevertheless, we don’t believe it should fall to taxpayers to pay for the public infrastructure costs. 

The decision by NAH to not fund a reasonable portion of the public transit costs increases F3’s concerns that NAH may not commit to paying a reasonable and significant portion of the other necessary costs of this project. We don’t want to see Flagstaff citizens burdened with more than $57M in public infrastructure costs as a result of the hospital move. 

The Flagstaff Planning and Zoning Commission will hold a public hearing on Wednesday, March 22, 2023, at 4:00 pm at City Hall Chambers (211 W. Aspen Ave.) and Wednesday, April 12, 2023, at 4:00 pm at the City of Flagstaff Aquaplex Community Meeting Room (1702 N 4th St.). 

The public hearings are to consider the adoption of a Specific Plan for the development of 172.62 acres, and a proposed amendment to rezone 63.18 acres from Rural Residential (RR) and Estate Residential (ER) to Highway Commercial (HC) and 35.21 acres from RR and ER to Public Facilities (PF). The Specific Plan and Rezoning will allow for the development of a new regional hospital and ambulatory care facility and support a larger Health Village and a broad mix of commercial, retail, research, and housing opportunities in a future rezoning.

Michele James is Executive Director of Friends of Flagstaff’s Future