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Wesley Health System, LLC v. Forrest County Board of Supervisors

United States District Court, Fifth Circuit

January 22, 2014



KEITH STARRETT, District Judge.

For the reasons stated below, the Court rules as follows:

• The Court denies Wesley's Motion for Declaratory Judgment and Injunctive Relief [168];
• The Court grants Forrest General's Motion for Summary Judgment [253];
• The Court grants AAA's Motion for Summary Judgment [255, 261, 270];
• The Court denies AAA's Motion to Dismiss [150]; and
• The Court denies as moot Wesley's Motion to Exclude Expert Testimony [251], Wesley's Motion to Strike [264], and AAA's Motion to Dismiss in Part [266].


Plaintiff Wesley Medical Center alleges that Defendants - Forrest General Hospital and AAA Ambulance Service - conspired to divert patients from Wesley to Forrest General. Wesley alleges that the Defendants ignored patients' desire to receive medical services at Wesley, intentionally falsified medical records to justify transporting patients to Forrest General, fraudulently obtained a disproportionate share of trauma funds from the State of Mississippi, intentionally interfered with Wesley's business practices, defamed Wesley by making false statements about the quality and type of services it offered, and ignored Mississippi's Trauma System Destination Guidelines. Wesley asserted claims under the Racketeer Influenced and Corrupt Organizations ("RICO") Act, [1] claims under the Sherman Act, [2] civil conspiracy, intentional interference with business relations, and defamation.[3] Wesley also seeks a declaratory judgment that Mississippi law requires emergency medical service ("EMS") providers, such as AAA, to transport a patient to the hospital of their choice. If the Court finds to the contrary, Wesley seeks a declaratory judgment that the Mississippi Trauma Guidelines and related regulations are unconstitutional under both the Mississippi and United States Constitutions. The parties have filed many motions, and they are all fully briefed and ready for the Court's review.


Wesley requests a declaratory judgment on two questions of law related to this dispute:

1. Does the Plan allow an EMS provider, such as AAA, to ignore a lucid patient's expressed choice to receive medical services from a specific facility?
2. Under Mississippi law, once a choice is clearly and expressly made by a lucid patient, may an EMS provider attempt to dissuade patients to be transported to another facility by providing false or misleading information?

Wesley contends that the answer to both questions is "No." Wesley also requests that the Court order AAA and Forrest General to "comply with patient choice and/or to fully satisfy the requirements of informed consent laws in Mississippi."

The Court uses a three-step analysis to determine whether it should consider a declaratory judgment claim. Sherwin-Williams Co. v. Holmes County, 343 F.3d 383, 387 (5th Cir. 2003). The Court considers: "(1) whether the declaratory action is justiciable; (2) whether the court has the authority to grant declaratory relief; and (3) whether to exercise its discretion to decide or dismiss the action." Id.

The first element, justiciability, hinges on "whether the facts alleged, under all the circumstances, show that there is a substantial controversy, between the parties having adverse legal interests, of sufficient immediacy and reality to warrant the issuance of a declaratory judgment." Rowan Cos. v. Griffin, 876 F.2d 26, 28 (5th Cir. 1989). "A controversy, to be justiciable, must be such that it can presently be litigated and decided and not hypothetical, conjectural, conditional or based upon the possibility of a factual situation that may never develop." Id. A substantial controversy exists between the parties, and a legal question posed by Wesley's motion is necessary to the resolution of this case.

As for the second element, "a district court does not have authority to consider the merits of a declaratory judgment action when: (1) the declaratory defendant previously filed a cause of action in state court; (2) the state case involved the same issues as those in federal court; and (3) the district court is prohibited from enjoining the state proceedings under [the Anti-Injunction Act]." Sherwin-Williams, 343 F.3d at 388 n. 1. The Court is unaware of any previous or concurrent cases addressing these issues in state court.

The final element incorporates a nonexclusive list of factors for the Court to consider:

(1) whether there is a pending state court action in which all of the matters in controversy may be fully litigated;
(2) whether the plaintiff filed suit in anticipation of a lawsuit filed by the defendant;
(3) whether the plaintiff engaged in forum shopping in bringing the suit;
(4) whether possible inequities in allowing the declaratory plaintiff to gain precedence in time or to change forums exist;
(5) whether the federal court is a convenient forum for the parties and witnesses;
(6) whether retaining the lawsuit would serve the purposes of judicial economy; and
(7) whether the federal court is being called on to construe a state judicial decree involving the same parties and entered by the court before whom the parallel state suit between the same parties is pending.

Id. at 388 (quoting St. Paul Ins. Co. v. Trejo, 39 F.3d 585, 590-91 (5th Cir. 1994)).

None of these factors counsel dismissal of the entire declaratory judgment claim. The factors of judicial economy and party convenience counsel that the Court should render a decision - at least in part. The questions posed by Wesley in its motion [168] do not mirror the declaratory relief requested in Count One of the Second Amended Complaint [145]. Both questions vary from Count One insofar as they raise the issue of lucidity, and they do not limit the Court's analysis to cases involving trauma patients. Furthermore, the second question's concern with "attempt[s] to dissuade patients... by providing false or misleading information" is wholly outside the scope of Count One.

When broadly construed, though, the motion raises a legal question within the scope of Count One and necessary to the resolution of this case: whether Mississippi law gives EMS providers authority to transport trauma patients to a designated trauma center despite their expressed desire to receive treatment at a different hospital that is not a designated trauma center. That is the question the Court will address.

A. Mississippi Statewide Trauma Care System

The Mississippi legislature directed the Department of Health to "establish and maintain a program for the improvement and regulation of emergency medical services... in the State of Mississippi." MISS. CODE ANN. 41-59-5(1). Among other things, the legislature provided:

The [Department of Health]... shall develop a uniform nonfragmented inclusive statewide trauma care system.... The department is assigned the responsibility for creating, implementing and managing the statewide trauma care system.... The department shall develop and administer trauma regulations that include, but are not limited to, the Mississippi Trauma Care System Plan, trauma system standards, trauma center designations, ... [and] trauma care system evaluation.... The department shall promulgate regulations specifying the methods and procedures by which Mississippi-licensed acute care facilities shall participate in the statewide trauma system. Those regulations shall include mechanisms for determining the appropriate level of participation for each facility or class of facilities.... The department shall promulgate rules and regulations necessary to effectuate this provision.... The department shall take the necessary steps to develop, adopt and implement the Mississippi Trauma Care System Plan and all associated trauma care system regulations necessary to implement the Mississippi trauma care system.

MISS. CODE ANN. 41-59-5(5).[4] The legislature provided that the Trauma Care System shall be funded by the Mississippi Trauma Care Systems Fund and Mississippi Trauma Care Escrow Fund. MISS. CODE ANN. § 41-59-75.

Pursuant to this authority, the Department of Health developed the Mississippi Trauma Care System Plan.[5] "The goal of the Mississippi Trauma Care System is an inclusive model, where the trauma patient is transported directly from the scene of injury to a designated trauma center, staffed and equipped with the appropriate resources to care for the specific needs of the patient." See Mississippi Trauma Care System Plan, at 5. The Department requires all "Mississippi licensed hospitals with a functioning emergency department [to] apply for trauma center designation." MISS. ADMIN. CODE 15-2-32:1.2.1. After an application and inspection process, the Department designates hospitals as either Level I, II, III, or IV trauma centers, depending upon the resources available at each facility. MISS. ADMIN. CODE 15-2-32:1.2.4, 1.2.5. "Every Mississippi licensed acute care facility (hospital) having an organized emergency room service or department shall participate in the Mississippi Statewide Trauma Care System." MISS. ADMIN. CODE 15-2- But "[a]ny hospital that chooses not to participate in the Trauma Care System..., shall be assessed and shall pay a non-participation fee...." MISS. ADMIN. CODE 15-2-32:1.3.13.

B. Trauma Care Regions

Because different regions of the state may have different trauma care needs, the state is divided into several Trauma Care Regions. MISS. ADMIN. CODE 15-2-32:1.5.1, 1.5.2. Each Trauma Care Region has a Board of Directors which exercises "administrative authority over the operation of the Trauma Care Region and subsequent trauma system programs." MISS. ADMIN. CODE 15-2-32:1.5.3. At least one purpose of the Trauma Care Regions is to "develop policies which provide a clear understanding of the structure of the trauma system and the manner in which it utilizes the resources available to it." MISS. ADMIN. CODE 15-2-32:1.5.8. Therefore, each Trauma Care Region is required to develop a Regional Trauma Plan, "which describes the policies procedures and protocols for a comprehensive system of prevention and management of major traumatic injuries in a specific geographical region." MISS. ADMIN. CODE 15-2-32:1.1.4, 1.5.6. The Regional Trauma Plans are incorporated within the statewide Mississippi Trauma Care System Plan. See Mississippi Trauma Plan, at 4. "All participating hospitals and licensed EMS providers in each Region shall abide by the Region Trauma Plan and policies." MISS. ADMIN. CODE 15-2-32:1.5.9.[6]

C. Southeast Trauma Care Region

The parties here are in the Southeast Trauma Care Region ("SETCR"). The SETCR is governed by a twelve-member Board of Directors comprised of representatives from hospitals within the SETCR's thirteen counties. SETCR Trauma Plan, at 19.[7] The SETCR is managed - under direction of the Board - by Defendant AAA Ambulance Service, and the CEO of AAA, Defendant Wade Spruill, serves as the CEO of the SETCR. Id. at 4-5. There are currently thirteen hospitals with emergency rooms in the SETCR. Id. at 26. One of them, Defendant Forrest General Hospital, is a Level II Trauma Center. Id. at 27. Of the remaining twelve, one is a Level III Trauma Center, and ten are Level IV Trauma Centers. Id. at 27-28. Plaintiff Wesley Medical Center only recently elected to participate in the Trauma Care System; it is seeking designation as a Level III Trauma Center.[8] On November 7, 2013, the Mississippi Department of Health advised the SETCR that Wesley could be treated as if it had already received a Level III designation, but Wesley did not participate in the Trauma Care System at any time relevant to this case.

D. Destination Guidelines

The Mississippi Trauma Plan directs Trauma Care Regions to establish "destination protocols" to "assure trauma patients receive access to the most appropriate care based on their injuries, " and which are "designed to deliver trauma patients to the closest, most appropriate facility, regardless of the nearest facility or the affiliation of the ambulance service." Mississippi Trauma Plan, at 10. The SETCR elected to adopt the Department of Health's Consolidated Activation Criteria and Destination Guidelines:

All ambulance services operating within the Southeast Trauma Care Region will utilize Mississippi State Department of Health approved policies, procedures, and protocols for the purpose of patient treatment and activation and destination guidelines. The policies, procedures, and protocols for determining triage criteria and patient destination adopted by the State will be followed by the region.

SETCR Trauma Plan, at 67.

Therefore, in the SETCR "[a]ll trauma care patients will receive initial evaluation for categorization as Alpha or Bravo using State approved activation criteria, " and "[p]atient destination will be in accordance with State approved destination guidelines." Id. The SETCR Plan also provides that "[l]ocal ambulance provider(s) shall be dispatched to scene under authority of provider's medical control plan, " and the "[l]ocal medical control plan shall direct ambulance provider to nearest appropriate designated trauma center in accordance with the State Activation and Destination Guidelines...." Id. at 51.

Mississippi's Consolidated Trauma Activation Criteria and Destination Guidelines consist of a flow chart with instructions.[9] EMS providers must first measure a patient's vital signs and level of consciousness and assess their injury. Id. Injuries/conditions are categorized as either Alpha or Bravo, but both categories broadly include room for "EMS/Health Provider Judgment." Id. For patients over fifteen years of age, both Alpha and Bravo patients require transport to a Level I, II, or III Trauma Center "as appropriate for injuries." Id. If the patient is not qualified as either Alpha or Bravo, the Guidelines say to "[t]ransport according to local EMS protocol (consider contacting Medical Control)." Id. They also include a list of "SPECIAL CONSIDERATIONS, " such as: "Patients > 55 years are at increased risk of injury/death, " and "Anticoagulents and bleeding disorders." Id. They also provide: "If there is any question concerning appropriate patient destination, or if requested by the patient or another person to deviate from this protocol, CONTACT MEDICAL CONTROL." Id. (emphasis original).

E. Medical Control

"Medical Control" is "[p]hysician direction over pre-hospital activities to ensure efficient trauma triage, transportation, and care, as well as ongoing quality management." MISS. ADMIN. CODE 15-2- All EMS providers must establish a "plan of medical control" which includes "patient destination criteria and treatment protocols for the patient...." MISS. ADMIN. CODE 15-12-31:1.1.5. "All Medical Control Plans shall comply with the Mississippi State Trauma Plan and all other ...

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