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Mitchell

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Figure 1. Number of health care services in which a CON is required (2023).

providers than for hospitals. In Maine, for example, hospitals must obtain a CON when they undertake capital expenditures in excess of $12.365 million, while ambulatory surgery cen ters must obtain a CON for expenditures in excess of $3 million. 29(p. 79) CON application fees also vary (see Table 2). Arizona charges a flat fee of $100 while Maine charges a flat fee of $250 000. 29(p. 4) Many states charge fees that are in proportion to proposed capital expenditures. Hawaii, for example, charges a fee equal to 0.1% of the cost of the project. This applies to the first $1 million of the project; it charges an additional 0.05% for any costs above this amount. 29(p. 49) At $15 000, Tennessee has the highest minimum fee. At the other end of the spectrum, most states cap fees, but 8 states have no limit. Compliance and opportunity costs appear to be more sig nificant than fees. While we lack systematic data on compli ance costs, we do know that providers can spend months or even years preparing applications and that they may employ the services of boutique consulting firms to help them. Beyond these direct costs, providers lose the opportunity to provide services and generate revenue. This lost revenue can amount to hundreds of thousands of dollars in opportunity costs. 30 We lack systematic data on approval rates across all states, but one analysis found that the approval rate in Virginia was 51%, that of Georgia was 57% and that of Michigan was 77%. 31

South Carolina enacted sweeping reforms, eliminating 16 CON requirements upon enactment and phasing out its hos pital CON requirement over 3 years (In addition, the hospital CON requirement will not be enforced in counties that cur rently lack hospitals). Figure 1 shows the number of health care services requir ing a CON in each state in late 2023 while Table 1 shows which services are most-frequently regulated by CON. In Arizona, Minnesota, and New Mexico, CONs are only required for ambulance services. In Indiana, Ohio (and soon, South Carolina) CONs are only required for nursing homes. Hawaii, which requires a CON for 28 services and technolo gies, regulates more activities than any other state. The most common CON requirement, found in 34 states (including DC), is for nursing home beds. The next-most common requirements are for psychiatric services (regu lated in 31 states), new hospitals (29 states), and intermediate care facilities for those with intellectual disabilities (28 states). The least-common CONs are for ultrasounds (required in 2 states) and subacute services (only regulated by Illinois). The investment thresholds that trigger a CON requirement vary from state to state. In New York, for example, projects undertaken by general hospitals in excess of $30 million necessitate a CON, while in Iowa projects in excess of just $1.5 million require a CON. 29(pp. 64, 139) The thresholds that trigger a CON review are typically lower for non-hospital

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