Central Maine Healthcare

Cancer Institute

Certificate of Need Application

I. Abstract

Please include an abstract of the project, not to exceed one to two (1-2) page(s) in length.

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A. Project Overview
Central Maine Healthcare and its affiliates (CMH) propose to replace and enhance the existing
oncology services provided at the Central Maine Medical Center (CMMC) campus in Lewiston.
This will be a $38 million dollar project to replace existing linear accelerators with state-of-the-
art equipment and enhance oncology services by placing radiation oncology and medical
oncology in one convenient location. CMH proposes to build a freestanding Cancer Institute to
bring together two essential outpatient subspecialties-radiation oncology and medical oncology-
that are currently located at opposite ends of the CMMC campus to provide more cohesive,
efficient, accessible and patient-centered care. This project is scheduled to commence in the
summer of 2020 and open in the winter of 2021.

Currently, CMH is limited in its ability to provide comprehensive cancer care by equipment that
will reach the end of its useful life in December of 2021, aging infrastructure, and the significant
distance between the radiation oncology and medical oncology departments. CMH’s historical
and current growth support the need to strengthen and enhance this service line. In addition,
Maine has both a higher rate of cancer compared to other states and higher cancer deaths than
the national average. Lewiston-Auburn also has a higher cancer rate than the Maine state
average (Source 1). In light of these factors, it is critical to invest in these cancer care services
not only to continue to provide but strengthen and enhance comprehensive cancer care for the
region and the Lewiston-Auburn community.

Please see Exhibit A, Cancer Institute Plans, and Exhibit B, Cancer Institute Space Program

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II. Fit, Willing and Able

Relevant criteria for inclusion in this section are specific to the determination that the applicant is fit,
willing and able to provide the proposed services at the proper standard of care as demonstrated by,
among other factors, whether the quality of any health care provided in the past by the applicant or a
related party under the applicant's control meets industry standards.

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Deeming Standard
This section is subject to a deeming standard. The Certificate of Need Act provides:

If the applicant is a provider of health care services that are substantially similar to those
services being reviewed and is licensed in the State, the requirements of this paragraph
are deemed to have been met if the services previously provided in the State by the
applicant are consistent with applicable licensing and certification standards.

22 M.R.S.A. § 355(7)(A). CMH currently provides radiation oncology and medical oncology services that
are substantially similar to those services being reviewed, is fully licensed and provides radiation
oncology and medical oncology services consistent with applicable licensing and certification standards.
Accordingly, CMH should be deemed to be fit, willing and able to provide the proposed radiation
oncology and medical oncology services at the appropriate standards of care.

A. Profile of Applicant
The applicant for the Certificate of Need is CMH based in Lewiston, Maine. CMH is a Maine nonprofit,
501(c)(3) tax-exempt corporation. CMMC is a Maine nonprofit 501(c)(3) tax exempt corporation and
tertiary hospital with its main campus located at 300 Maine Street, Lewiston, Maine 04240. CMMC is
licensed for 250 beds, and is state licensed, Medicare and Medicaid certified and Joint Commission
accredited.

CMH’s core services network of affiliates includes one regional hospital (CMMC), two critical
access hospitals (Bridgton Hospital and Rumford Hospital), an ambulatory surgery center,
ambulatory care centers, population health management services, a reference laboratory, a
retail pharmacy, and ground and air emergency transport services.

B. CMH Hospital Affiliations and System Development

In the past 24 months, CMH has established the following affiliations:
 2017 Shields Healthcare, LLC
 2018 Central Maine Orthopedics (CMO) ASC in Auburn, Maine

C. Sites of Care
The sites of care map depicts the range and depth of CMH’s services across Maine (Figure 1).
CMH has developed an extensive provider network to provide inpatient, outpatient, and post-
acute care to a region comprised of 400,000 Maine residents.

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 Figure 1: Sites of Care of CMH Services in Maine
Source: Central Maine Healthcare

D. Mission, Vision and Values

Through collaboration with community organizations, independent physician groups, better
coordination of care for patients and increased access, CMH continues to shift to a value-based
healthcare model in the State of Maine. As described herein, the proposed Cancer Institute will
support and enhance CMH’s mission, vision, and values.

CMH Mission
To provide exceptional healthcare services in a safe and trustful environment, through the
expertise, commitment and compassion of our team of caregivers.

CMH Vision
Safe, reliable, high-quality care of every patient, every day.

CMH Values
Compassion, Citizenship, Integrity, Service, Excellence, Commitment

CMH strives to make health care work for the people of Maine by providing high value, low cost
health care. For example, all three of CMH’s hospitals hold 340b status and serve as
disproportionate share hospitals (DSH) in the State.

E. Awards and Recognitions

CMH’s Cancer program is accredited by numerous organizations including:
 The American College of Surgeons Commission on Cancer
 The American Society of Clinical Oncologists Quality Oncology Practice Initiative
 The American College of Radiology
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  The National Accreditation Program for Breast Centers

The medical leadership and providers associated with CMH’s cancer program are highly skilled
clinicians with distinguished track records. As of the fall of 2019, CMMC received a Leapfrog
Hospital Safety Grade of A.

F. Executive Team
Jeffrey L. Brickman, President and CEO. Jeffrey L. Brickman, FACHE, is the President and Chief
Executive Officer of Central Maine Healthcare. Mr. Brickman came to CMH from Centura Health
in Colorado, where he served as group president, Mountains and North Denver Operating
Group, as well as President/CEO of St. Anthony Hospital. Before joining Centura Health,
Brickman was system senior vice president of Provena Health and the regional CEO of two
hospitals and an ambulatory network. He served as the executive vice president and chief
operating officer of the Meridian Health System, and earlier in his career was Chief Operating
Officer of Baystate Medical Center, a 685-bed regional referral medical center for Western New
England.

Mr. Brickman earned a bachelor’s degree in biological sciences at the University of Connecticut,
Storrs, and a master’s in business administration with an emphasis in health care administration
from Temple University in Philadelphia. He is a Fellow of the American College of Healthcare
Executives and serves on numerous other civic and professional groups.

John Whitlock, CFO and Treasurer. John Whitlock, CPA, CGMA is the Chief Financial Officer and
Treasurer of CMH. Mr. Whitlock joined CMH as Vice President, Finance in June 2018. His career
has included positions in both the non-profit and for-profit sectors, ranging from mergers and
acquisitions to financial planning and analysis to general accounting. Prior to joining CMH, Mr.
Whitlock was Vice President at National Church Residences in Columbus, OH, where he was
responsible for all facets of the finance division. Prior to his role at National Church Residences,
John led financial planning and analysis at Mount Carmel Health System, a $1.7B, five-hospital
system based in Columbus OH, along with senior management positions at Adena Health System
in Ohio and Vanderbilt University in Tennessee.

Mr. Whitlock received his BA in Business Administration and Finance from Emory University and
MS in Accounting from Louisiana State University.

David Tupponce, MD, EVP, FACHE and CMMC President. David Tupponce, M.D., is the Executive
Vice President of CMH and President of Central Maine Medical Center. In this dual role, Dr.
Tupponce works with the system CEO to provide leadership and management support to CMH’s
Continuum of Care and Managed Care Support corporations, programs, and initiatives. Prior to
joining CMH in October 2017, Dr. Tupponce spent the previous nine years with Tenet
Healthcare’s Abrazo Scottsdale Campus and Paradise Valley Hospital, most recently serving as
CEO. Before moving into formal administration roles, Dr. Tupponce established himself as a
family practice physician in Pittsburgh, PA, and a hospitalist at Holyoke Medical Center where he
also served as Chief Medical Information Officer and Chief of Staff.

Dr. Tupponce earned his Bachelor of Science in Zoology, Master of Science in Biology, and
Doctor of Medicine from George Washington University in Washington, DC, as well as his
Master of Medical Management from Carnegie Mellon University in Pittsburgh. He completed
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his Family Medicine Residency and served as Chief Resident at University of Pittsburgh Medical
Center and is a Fellow of the American College of Healthcare Executives.

Peter Wright, FACHE, President of Bridgton and Rumford Hospitals. Peter Wright, FACHE joined
CMH in March 2019 after serving for six years as President and CEO at Valley Regional
Healthcare in Claremont, NH. Highly regarded for his service-oriented leadership, Mr. Wright
demonstrates outstanding knowledge and understanding of the unique nature of rural health
care. His entire career has been spent in northern New England. Previously, Mr. Wright served
as Chief Operating Officer at Littleton (NH) Regional Hospital; Senior Director of Planning,
Development, and Medical Group Operations at Copley Health Systems in Morrisville, VT; and
Managing Director of the Stowe (VT) Marathon.

Mr. Wright earned his Bachelor of Science in business administration from Lyndon State College,
his Master of Science in Administration from St. Michael’s College, and his Master of Health Care
Delivery Science from the Tuck School of Business/Geisel School of Medicine at Dartmouth
College. He currently serves on the Board of Trustees of the American Hospital Association and
is a Fellow of the American College of Healthcare Executives.

Jason Krupp, MD, Chief Physician Executive. Jason Krupp, MD, FACP joined CMH in August 2019
as Chief Physician Executive. In this role, Dr. Krupp leads the system’s more than 300 providers,
overseeing all matters involving provider performance and clinical programs, and is responsible
for leading efforts toward more value-based care. Prior to joining CMH, Dr. Krupp served as
Senior Vice President for physician practice services at Community Health Systems, based in
Franklin, TN. In that role, he had operational, quality and financial oversight for providers across
19 states serving 100 communities. A board-certified internal medicine specialist, Dr. Krupp also
served in leadership roles at Catholic Health Initiatives in Omaha, Nebraska and at Banner
Health in Phoenix. He has held multiple roles, including Chief Medical Officer, at hospitals in
Arizona and Massachusetts.
A native of Boston, Dr. Krupp received his medical degree from Jefferson Medical College in
Philadelphia and has practiced, worked and lived across the country.

Michele Talka, Chief Human Resources Officer. Michele A. Talka, SPHR, CEBS, is the Chief
Human Resources Officer for CMH. In this role, Ms. Talka provides strategic human resources
leadership for the system and is responsible for supporting the organization’s goals through the
provision of HR programming and services. Ms. Talka joined CMH in June 2017 following three
years as the Vice President of HR Operations and Total Rewards at Baystate Health System. Prior
to that experience, Ms. Talka held numerous HR leadership positions at organizations that
include Moffitt Cancer Center & Research Institute, Experian and General Electric.

Ms. Talka earned her Bachelor of Arts in Psychology from the University of Georgia in Athens
and her Master of Science in Industrial Relations from Georgia State University in Atlanta. She
holds a Senior Professional Human Resources Certification, a Certified Employee Benefits
Specialist Certification and has been a fellow of the International Foundation of Employee
Benefits & Wharton School of Business since 2005.

Nancy Ban, VP of Operational Innovation and Integration. Nancy Ban joined CMH in 2016 as
Vice President of Operational Innovation and Integration. In this role, Ms. Ban is accountable for

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the day-to-day operations of CMH’s ambulatory and post-acute care footprint which includes
the Maine Urgent Care Center, Topsham Care Center, North Bridgton Family Practice & Walk-in
Clinic, Bolster Heights Residential Care Center and Rumford Community Home. Ms. Ban also
oversees CMH’s enterprise-wide project management office, known as the Results Management
Office, which facilitates projects in support of CMH’s strategic plan.

Prior to CMHC, Ms. Ban served both as the Group Internal Strategic Communications Manager
and an Administrative Project Manager for the Mountains and North Denver Operating Group of
Centura Health. Before her time at Centura Health, Ms. Ban held roles in strategic marketing
and business analytics for retail organizations such as The Sports Authority, Office Depot and
Lehman Brothers, Inc. Ms. Ban earned her Bachelor of Science in Communications from Florida
State University; her Master of Arts in Public and Corporate Communications from Seton Hall
University; and is pursuing her Master of Business Administration in Healthcare from The
George Washington University.

Mary-Anne Ponti, Chief Nursing Officer. Mary-Anne D. Ponti, R.N., MSN, DBA, FACHE, is Senior
Vice President and Chief Nursing Officer at CMH. In this role, she is responsible for overseeing
system-wide nursing operations and ensuring a continuous commitment to clinical practice at all
hospitals and ambulatory care locations.

Prior to joining CMH in June 2017, Ms. Ponti was president of M.A. Ponti & Associates, LLC, in
Boyne City, MI, an independent health care consultancy providing progressive leadership and
management expertise on many facets of health care. Before starting her consulting business,
Ms. Ponti held several nursing and health care administration roles, including Chief Operating
Officer of McLaren Northern Michigan (MNM) Hospital in Petoskey, MI; and Chief Operating
Officer/Chief Nurse Executive at Northern Michigan Regional Hospital, MNM’s predecessor.

No stranger to Maine, Ms. Ponti previously held nursing executive roles at St. Mary’s Regional
Medical Center in Lewiston and Penobscot Bay Medical Center in Rockport. She also has served
at Saint Francis Hospital in Poughkeepsie, NY; North Adams (MA) Regional Medical Center;
Berkshire Medical Center in Pittsfield, MA; and Duke University Medical Center in Durham, NC.

Ms. Ponti earned her Bachelor of Science in Nursing from the University of Vermont; her Master
of Science in Nursing from Russell Sage College in Troy, NY; her Master of Business
Administration from Thomas College in Waterville; and her Doctor of Business Administration
from Walden University in Minneapolis. She is also an affiliate member of the American College
of Healthcare Executives and a member of the American Organization of Nurse Executives.

Michael Anderegg, VP Service Line Strategy. Michael Anderegg joined CMH in July, 2019 as the
Vice President of Service Line Strategy. Mr. Anderegg has been working in health care
management in the Greater Boston area for over thirty years with a focus on clinical program
development and management. Most recently he worked at Boston Children’s Hospital leading
the development of the Heart Center. His twenty years at Massachusetts General Hospital
included development of their Cancer Center. Additionally, he spent three years at Southern
New Hampshire Health System in Nashua, NH as Vice President of Systems of Care.

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 Mr. Anderegg received his Bachelor of Science from the University of British Columbia and his
MBA from Boston University. He has also served on the Board of the National Comprehensive
Cancer Network and many of its committees for four years.
G. Board of Directors
Austin Albert, CPFA
Lewiston, Maine
Deborah Dunlap Avasthi
Chair
Durham, Maine
Jeffrey L. Brickman, FACHE
President and Chief
Executive Officer
Freeport, Maine
William P. Clifford
Portland, Maine
Devore S. Culver
Brunswick, Maine
Jolan Ippolito
Rumford, Maine
Janet Koski, SHRM-SCP
Weld, Maine
 LPL Financial Advisor, Twin City Financial Group
 B.A., Union College, managerial economics
 Also: Vice President, Lewiston Education Fund; Board
Member, L/A Metropolitan Chamber of Commerce
 Previously, Bose Corp., CIGNA Insurance
 B.A., University of Vermont
 Board member, and former president, Maine Better
Transportation Association
 Previously, Centura Health, Englewood, Colo.
 Group president of Centura Mountains and North Denver
 President/CEO of St. Anthony Hospital
 Senior Vice President, Provena Health, Joliet, Ill.
 Executive Vice President, Meridian Health, Wall, N.J.
 COO Baystate Medical Center, Springfield, Mass.
 B.S., University of Connecticut
 M.B.A., Temple University
 Fellow of the American College of Healthcare Executives
 Vice President, Cross Benefit Solutions
 Previously, Employee Benefits Regional President, USI
Insurance Services LLC
 COO, TD Insurance
 B.A., Colby College
 Healthcare consultant
 Previously, CEO of HealthInfoNet
 M.S., Management, Northwestern University
 B.A., Brown University
 Retired insurance consultant.
 Former board member, the Maine Employers’ Mutual
Insurance Co. (MEMIC)
 B.A., Colby College
 Director of Human Resources, ND Paper
 M.B.A., University of Phoenix
 M.S.N., Simmons University
 B.S.N., University of Vermont
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 William Lee, MD  Retired physician specializing in Internal Medicine
Auburn, Maine  M.D., Indiana School of Medicine,

John McAnuff, CPA  Chief Financial Officer and Treasurer, Spurwink Services
Cape Elizabeth, Maine  Treasurer, TruChoice Federal Credit Union
 M.B.A., Accounting Services, University of Southern Maine
 B.A., Boston University
 Certified Public Accountant
Sherwood C. Moody  President and CEO, Trustee, Claremont (NH) Savings Bank
Lewiston, Maine  Previously, President and CEO, Mechanics Savings Bank
 Former Corporator and Director of the Board of Valley
Regional Hospital
 M.S., Stonier Graduate School of the American Banking
Association
 B.S., Cornell University
Kevin L. Morneault, DO  Anesthesiologist and Chief of the Medical Staff, Central
Yarmouth, Maine Maine Medical Center
 D.O., University of New England College of Osteopathic
Medicine
 Fellowship, the Cleveland Clinic
 B.S., University of New England
Craig Tribuno  CEO and Chairman of the Board, Systems Engineering
Auburn, Maine  Member of boards including Maine Chapter, Multiple
Sclerosis Society; Ronald McDonald House of Portland, and
Community Financial Literacy.
 B.S., University of Southern Maine
 United States Coast Guard
Jennifer Weiner-Smith, MD  Chief of OBGYN, Central Maine Medical Center
Greene, Maine  Owner, Forage Market
 M.D., University of Vermont College of Medicine
 Residency, Maine Medical Center
 B.A., Smith College

H. Financial Sustainability

Section III Economic Feasibility addresses CMH’s ability to finance this project.

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III. Economic Feasibility

Relevant criteria for inclusion in this section are specific to the determination that the economic
feasibility of the proposed services is demonstrated in terms of the:

A. Capacity of the applicant to support the project financially over its useful life, considering the
rates the applicant expects to be able to charge for the services to be provided by the project;
and

B. The applicant's ability to establish and operate the project in accordance with existing and
reasonably anticipated future changes in federal, state and local licensure and other applicable
or potentially applicable rules.

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Deeming Standard
This section is subject to a deeming standard. The Certificate of Need Act provides:

If the applicant is a provider of health care services that are substantially similar to those
services being reviewed and is licensed in the State, the applicant is deemed to have
fulfilled the requirements of this subparagraph if the services provided in the State by the
applicant during the most recent 3-year period are of similar size and scope and are
consistent with applicable licensing and certification standards.

22 M.R.S.A. § 355(7)(B)(2). CMH currently provides radiation oncology and medical oncology services
that are substantially similar to the services being reviewed and has provided such services of this scale
and scope for decades and in compliance with all applicable licensing and certification standards.
Accordingly, CMH should be deemed to have fulfilled the economic feasibility requirements.

A. Capacity of the Applicant to Support the Project Over Its Useful Life

CMH will partner with a developer to construct the proposed Cancer Institute. The new
facility is necessary in order for CMH to replace the two existing linear accelerators that
will reach the end of their useful lives in 2021 and cannot be replaced with new
equipment in the current location. The replacement linear accelerators and relocation to
the Cancer Institute will provide enhanced treatment capabilities, operational
efficiencies, improved access, and a better patient experience.

The plan of finance for the project involves developer financing of the facility construction
costs and a long-term building lease by the developer to CMH. The plan of finance for the
project also involves a long-term ground lease by CMH to the developer. These terms,
accompanying operating and capital costs, projected volumes and the proposed rates have
been incorporated into the financial pro forma for the proposed project. The cost of the
replacement equipment and the two linear accelerators, will be paid by CMH with cash reserves.

The financial projection for the proposed project spans the first three years of operation of the
Cancer Institute beginning with its projected fiscal year of opening in 2022 through 2024.
Because the project involves the replacement and enhancement of existing services, the
financial projection assumes only a modest increase in utilization. CMH has assumed modest
annual growth in utilization based on the underlying utilization trend for cancer services in the
region as projected by IBM Watson1, as well as the increased retention of new cases due to the
enhanced access, patient experience and capabilities of the Cancer Institute.

The assumptions underlying the financial projection are presented in Table 1. The overall or
average annual rate of growth for cancer services is projected to be 2.5%. The projected annual
rate of growth for outpatient radiation therapy services is estimated to be 1.5% based upon IBM
Watson projections for the region and a modest increase in retained patient cases in the region.
More detail on IBM Watson’s projected growth in outpatient radiation oncology and hematology
for CMH’s service area is provided in Section V Orderly and Economic Development, Figure 7.

Inflation rates in the financial projection for the proposed Cancer Institute are included in Table
1. The projected inflation rates reflect both the current and prior future experience at CMH. The

1
IBM Watson is a leading national resource for healthcare utilization projections.
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 weighted average increase in net patient revenue by payor mix is projected to be 2.2% each year
based on CMH’s historical experience.

Table 1: Baseline CMH Cancer Institute Projections

Volume Growth FY 2022 FY 2023 FY 2024
Volume Growth – 2.5% 2.5% 2.5%
Overall
Volume Growth –
Radiation Therapy 1.5% 1.5% 1.5%
Inflation Rates
Salary & 3.0% 3.0% 3.0%
Wages
Medical 3.0% 3.0% 3.0%
Supplies
Drugs 9.0% 9.0% 9.0%
Supplies 3.0% 3.0% 3.0%
Other
Source: Central Maine Healthcare

Table 2 presents a summary of the financial projections for the Cancer Institute project, inclusive of
capital and lease costs. The financial projection demonstrates the financial feasibility of the project. The
project is expected to have a positive contribution margin toward overall system operational, fixed and
overhead costs. The proposed projected lease and operating costs are financially sustainable within a
projected future environment of modest rate increases and volume growth that reflects moderate
projected growth in cancer rates e and service utilization combined with modest increased retention of
patients for diagnosis and treatment in the CMH service area.

Table 2: Financial Projections for Proposed Cancer Institute

FY 2022 FY 2023 FY 2024
Net Patient Revenue $41,851,966 $43,888,804 $47,351,733
Total Operating Expense Before
$32,342,568 $34,854,419 $37,902,477
Interest/Depreciation
Total Operating Expense After
$32,952,717 $35,435,080 $38,457,769
Interest/Depreciation
Contribution Margin $9,509,398 $9,034,385 $9,449,256
Source: Central Maine Healthcare

Please see the CON Financial Module and Exhibit C, CMH’s audited financials for June 30, 2019 and
2018. These exhibits further demonstrate CMH’s ability to support the project over its useful life.

B. Ability to Establish and Operate the Project in Accordance with Existing and Reasonably
Anticipated Future Changes in Federal, State and Local Licensure and Other Applicable Rules
CMH has successfully operated a comprehensive cancer program, including radiation oncology
services, for decades. During that time, CMH and its cancer program have successfully managed
significant changes in the payment environment, new treatment protocols, rapidly escalating
costs for pharmaceutical therapies and other challenges that have confronted providers of
cancer care nationally. The proposed replacement and enhancement project does not rely on
rate increases above historical trends or material shifts in market share to be financially feasible.

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CMH has assumed little or no increase in Medicare and Medicaid payments, modest
achievement of operational efficiencies, stable utilization of outpatient services and stable levels
of bad debt and charity care. Given these reasonably anticipated assumptions, the proposed
Cancer Institute is financially feasible.

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IV. Public Need

Relevant criteria for inclusion in this section are specific to the determination there is a public need for
the proposed services as demonstrated by certain factors, including, but not limited to:

A. Whether, and the extent to which, the project will substantially address specific health problems
as measured by health needs in the area to be served by the project;
B. Whether the project will have a positive impact on the health status indicators of the population
to be served;
C. Whether the services affected by the project will be accessible to all residents of the area
proposed to be served; and
D. Whether the project will provide demonstrable improvements in quality and outcome measures
applicable to the services proposed in the project.

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A. The Project Will Substantially Address Specific Health Problems as Measured by Health
Needs in the Area
1. Overview. Cancer has been specifically identified as a health problem by the 2019
Androscoggin County Community Health Needs Assessment (CHNA). CMH’s cancer program
serves as a critical resource to the community that ensures access to high quality, essential
cancer diagnosis and treatment for the residents of Androscoggin, Oxford, Franklin, and
adjacent parts of Cumberland, Kennebec, and Sagadahoc counties. This need is highlighted
by the fact that CMH’s service area has a higher rate of cancer than state and national
averages.

2. Service Area. CMH’s service area for the cancer program is defined by looking at the contiguous
ZIP codes that comprise 92% of outpatient radiation therapy patients for 2019. Outpatient
radiation therapy was used as the benchmark service line for establishing the cancer program
service area due to the limited supply of outpatient radiation oncology service providers in Maine
(only six facilities in the state provide this service), its critical role in the treatment of a wide
variety of cancers, and the frequency and serial nature of radiation oncology treatment. Based on
the outpatient radiation patient origin, CMH’s service area is composed of 55 contiguous ZIP
codes as shown in Figure 2.

Figure 2: CMH Service Area - 92% Patient Origin for Radiation Oncology in 2019
Sources: Open Street Map and Central Maine Healthcare

CMH

CMH

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 According to IBM Watson, the region comprised of these ZIP codes is home to approximately
216,896 people (2018 estimate). The population of the service area is projected to increase
slightly over the next five years by 557 people (0.3%) to 217,453 (Source 2). The service area,
and specifically Androscoggin and Oxford counties, is characterized by incidence rates for cancer
that are higher than the Maine state average. Oxford County has an age-adjusted incidence rate
for cancer of 482.4 per 100,000 people per year. Androscoggin County has an age-adjusted
incidence rate for cancer of 476.2 per 100,000 people per year compared to the Maine state
average of 471.5 as shown in Table 3 (Source 3).

Table 3: Age-Adjusted Cancer Incidence Rates per 100,000 People per Year for Counties in CMH
Service Area
 = higher than Maine state average

Age-Adjusted Rate per 100,000 People Per Androscoggin Oxford Franklin State of
Year County County County Maine

Incidence 476.2 482.4 458.3 471.5

Lung and Bronchus Cancer

83.0 87.7 58.2 72.5
Incidence

Tobacco Related Cancer Incidence 138.7 152.8 137.8 132.7

Prostate Cancer Incidence 84.6 76.1 92.9 85.2

Female Breast Cancer Incidence 111.8 124.0 122.4 126.6

Colon and Rectum Cancer

35.4 42.0 45.9 36.6
Incidence

Urinary Bladder Cancer Incidence 31.3 25.9 30.7 26.6

Obesity-Associated Cancer
165.4 184.1 164.2 170.9
Incidence

Human Papillomavirus –
14.0 14.8 7.1 13.4
Associated Cancer Incidence
Source: The Maine 2018 Annual Report of Cancer

This investment to strengthen CMH’s oncology services by replacing linear accelerators nearing
the end of their useful lives and offering a patient-focused, comprehensive Cancer Institute is an
investment in the well-being of an entire region of Maine.

The greater precision and effective targeting of treatment made available by the state-of-the-art
linear accelerators will provide patients in the region with enhanced treatment options close to
home.

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3. Building and Equipment Need. The proposed project will replace critical radiation oncology
treatment equipment that is approaching the end of its useful life. Failing to replace the
equipment would burden cancer patients and their families in central Maine by increasing both
travel distances and time to access care. Delaying replacement would increase the risk of service
disruptions and delayed or interrupted treatment for patients battling cancer because of the
growing maintenance needs of the aging equipment. Maintenance costs are expected to
increase as the equipment ages because the original supplier of the linear accelerators is not
extending its service agreements beyond the current term. Alternative options exist to service
the equipment, but they are suboptimal because of the remote location of technicians once the
current service agreement expires. As a result, if the equipment is not replaced, it is reasonably
anticipated that the existing linear accelerators will experience additional down time in the
future.

Replacing the linear accelerators from another supplier at the current location is not feasible,
because there are no linear accelerators on the market at this time that can be accommodated
by the existing vaults in the current facility. Retrofitting the current location is inadvisable. It
would result in significant disruptions to radiation oncology services, considerable costs and
involve continuing in a suboptimal location relative to medical oncology and patient access.
Furthermore, the new linear accelerators would be immediately adjacent to the oldest portions
of the facility while being landlocked on two sides by two public roadways.

The CMH Cancer Institute project provides the opportunity to locate medical and radiation
oncology services at CMH in the same location which will enable enhanced coordination of care
and easier physical access for patients and their families. No longer will cancer care services be
located at opposite ends of the CMMC campus (see Figure 3). It is estimated that 450 - 500 of
CMH cancer patients receive both radiation oncology and medical oncology treatment annually
(Source 4). Patients will no longer need to complete the long walk of over 1,200 steps from the
radiation oncology services department to the medical oncology services department. Simply
put, the proposed project will benefit central Maine by ensuring continuous, proximate access to
radiation oncology and other cancer services without interruption for the region’s patients.

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Figure 3: Distance Between Medical Oncology and Radiation Oncology
Source: Central Maine Healthcare

4. Population Need. Cancer patients are often a fragile population that includes older and sick
individuals. In CMH’s cancer program service area, there are currently 40,592 people or
18.7% of the entire cancer program service area population who are age 65 or older.
Nationally, the rate of individuals over 65+ is 15.2%. As a result, CMH’s service area has a
23% greater share of its population age 65+ than the US average (Source 5). The number of
service area residents age 65+ is projected to increase to 46,093, or 21.2% of the entire
cancer program service area population over the next five years (Source 2). Growth in the
age 65+ cohort is projected to offset declines in younger populations over this time period as
shown in Table 4. A full-service Cancer Institute closer to home will ease patient and family
burdens during treatment and help with recovery for the growing 65+ population.

Table 4: Population Change by Age Cohort within the CMH Service Area 2018-2023
Source: IBM Watson

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B. Positive Impact on Health Status Indicators
The proposed project will have a positive impact on the health status indicators of patients in
the service area by strengthening and enhancing a critical cancer treatment resource for the
region. The existing equipment will end its useful life in 2021 and must be replaced. The
proposed new equipment will provide more precise targeting capabilities, offering patients
enhanced treatment options close to home. The investment in creating a comprehensive Cancer
Institute will allow all cancer services to be provided in one location, supporting a
multidisciplinary approach to cancer care diagnosis and treatment. Sick and often elderly
patients will no longer have to walk long distances through multiple hospital corridors or be
transported across the CMMC campus between outpatient service locations in order to receive
integrated components of their cancer care. Finally, as discussed in Section C below, providing
cancer care locally at CMH saves substantial travel costs and travel time for vital care needed by
an older, high incidence population.

C. Continued Access to Cancer Care

The CMH cancer program provides critical regional access to cancer care for cancer patients and
their families. As the sole regional access point for outpatient radiation oncology services and
the leading local option to access comprehensive cancer diagnosis and treatment services, it is
important to understand the value of proximate geographic access to these vital resources
within the region.

It is also important to understand the incremental costs that would be borne by residents of the
region if CMH were not able to renew and reinvest in its radiation oncology program and
associated cancer care services. Of the 55 ZIP codes that make up CMH’s cancer program service
area, 49 are closest to CMH’s linear accelerator site based on travel distance in miles (Figure 4).
These 49 ZIP codes comprise a population of 205,687 (Source 2). Out of the 55 ZIP codes in the
service area, 46 are closest to CMH’s linear accelerator site in terms of travel time in minutes
(Figure 5).2 These 46 ZIP codes have a total population of 189,052 (Source 2). Access to radiation
oncology and comprehensive cancer care services that are nearby saves older, sicker patients
and their caretakers travel time, travel costs, and lost work time associated with receiving
treatment farther from home. Close regional access to these vital cancer care resources
alleviates the economic and personal burdens of travel costs and travel time on cancer patients
and their caretakers.

The enhancements will foster improvements in the patient care experience and the quality of
care available in the region which will allow CMH to maintain vital access to cancer care in the
region.

2
Distance and time were measured from CMH to each ZIP code using a destination within each ZIP code based on
the actual distribution of mail deliveries. Based on this metadata, the points are located where higher distributions
of mail deliveries happen within each ZIP code, a metric more likely tied to population center than the ZIP code’s
geographic center. This data provides a detailed estimate of the travel distance and time for residents of a given
ZIP code to CMH’s radiation oncology program compared with travel distance and travel time from each ZIP code
to alternative radiation oncology treatment options. Those ZIP codes that are closer to CMH than to any other
radiation oncology programs are highlighted in the maps below. Figure 4 shows the travel distance differential by
ZIP code in miles. Figure 5 shows the travel time differential in minutes.

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Figure 4: ZIP Codes Where CMH Is the Closest Facility and Incremental Difference to
the Next Closest Site in Miles

CMH

Figure 5: ZIP Codes Where CMH Is the Closest Facility Incremental Difference to the
Next Closest Site in Minutes

CMH

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 Without the CMH cancer program site, patients in the CMH cancer program service area would
have to travel an additional 39.3 miles round trip on average to the next closest linear
accelerator site. This figure is based on the weighted average of the CMH cancer visit totals
distributed across the 55 ZIP codes based upon actual CMH patient origin. With an average of
42,825 trips out of the
Table 5: Time and Cost Savings for Population by Locating a Linear Accelerator at cancer program service
CMH area annually at a cost of
Year Costs Miles Time (hrs) $0.58 per mile (per IRS
2021 $ 1,065,602 1,729,839 40,862 reimbursement
2022 $ 1,113,355 1,753,734 41,426 guidelines), the cost of the
2023 $ 1,163,248 1,777,958 41,998 increased travel without
2024 $ 1,215,377 1,802,517 42,579 the CMH cancer program
2025 $ 1,269,842 1,827,415 43,167
for 2019 is $976,153. If
2026 $ 1,326,747 1,852,658 43,763
2027 $ 1,386,203 1,878,249 44,367
CMH builds and completes
2028 $ 1,448,323 1,904,193 44,980 the Cancer Institute by
2029 $ 1,513,227 1,930,496 45,602 2021, using a 3.1%
2030 $ 1,581,039 1,957,162 46,232 compound annual growth
2031 $ 1,651,890 1,984,196 46,870 rate (CAGR) for
2032 $ 1,725,916 2,011,604 47,518 transportation costs based
2033 $ 1,803,260 2,039,391 48,174
on IRS rates from 2000 –
2034 $ 1,884,070 2,067,561 48,839
2035 $ 1,968,501 2,096,120 49,514 2019 and a 1.38% CAGR in
2036 $ 2,056,715 2,125,074 50,198 volume based on IBM
2037 $ 2,148,883 2,154,428 50,891 Watson projections, the
2038 $ 2,245,181 2,184,187 51,594 CMH Cancer Institute
2039 $ 2,345,795 2,214,358 52,307 would save patients in the
2040 $ 2,450,917 2,244,945 53,029
CMH cancer program
Total $ 33,364,091 39,536,086 933,910
service area more than
Table 6: CMH Financial Assistance $33.3 million in travel costs, 933,910 in travel time hours, and
Threshold 39.5 million miles of driving over the its first 20 years of
Source: Central Maine Medical Center operation, as shown in Table 5.

CMH has a generous financial assistance policy, consistent with its

mission to provide access to medically necessary health care to all
patients regardless of their ability to pay. Assistance is offered to
Maine residents who are at or below the Maine Financial Assistance
income levels as shown in Table 6. CMH’s financial policy allows
access to cancer services for all residents of the service area. CMH
plans to continue this financial assistance policy in order to
maintain patient access to cancer services provided at the Cancer
Institute.

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D. Improvements in Quality and Outcome Measures
The proposed relocation of all cancer services in one location at the Cancer Institute is also
expected to result in higher quality and better coordinated care. Having clinical and support staff
in one location will allow CMH providers to quickly and easily consult with each other enhancing
their communication and care coordination.

In addition, it is necessary to strengthen critical components of the cancer program to avoid a

deterioration of essential services available to cancer patients in the region. Sustaining this
critical clinical resource for the region requires a periodic reinvestment. Simply stated, without
the proposed investment in CMH’s comprehensive cancer program, CMH’s ability to provide
high quality comprehensive cancer care would deteriorate, causing cancer patients in the region
to experience significant burdens to access necessary care in another region. Only very limited
public transportation options exist to provide access to the next closest radiation oncology
service. This investment in a comprehensive cancer program at CMH is also essential to sustain
oncology clinic satellites at Rumford Hospital and Bridgton Hospital. These clinics provide access
to cancer services at two additional locations within the catchment area and are an important
component of ensuring access to necessary diagnostic, treatment and ongoing management of
post-treatment populations who are in remission. Strengthening and reinvesting in this critical
regional resource helps to sustain these resources at CMH and other locations throughout
central Maine.

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V. Orderly and Economic Development

Relevant criteria for inclusion in this section are specific to the determination that the proposed services
are consistent with the orderly and economic development of health facilities and health resources for
the State as demonstrated by:

A. The impact of the project on total health care expenditures after taking into account, to the
extent practical, both the costs and benefits of the project and the competing demands in the
local service area and statewide for available resources for health care;
B. The availability of state funds to cover any increase in state costs associated with utilization of
the project's services; and
C. The likelihood that more effective, more accessible or less costly alternative technologies or
methods of service delivery may become available.

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A. Impact on Health Care Expenditures
The proposed Cancer Institute is not projected to have a material impact on health care
expenditures in the State. The proposed project replaces out-of-date linear accelerators with
state-of-the-art equipment that will provide for enhanced treatment options involving higher
dose rates, as needed, that will be delivered with even greater precision. Future volume is
derived from the volume of existing programs with modest annual increases in baseline volume
for the project occurring as a result of an increased need for services from an aging population
experiencing an increasing incidence of cancer as projected by IBM Watson. Cancer rate
increases are projected to be in line with historic trends. Because the project is a replacement
project and does not rely upon volume increases beyond the underlying projected demand for
services in the region, this project is anticipated to have a negligible impact on health care
expenditures.

1. Alternatives to the Project

The alternatives that were evaluated as part of the planning process for the CMH Cancer
Institute include the following:

a. Defer the Proposed Investment. Given that the existing linear accelerators are approaching
the end of their useful lives, deferring the proposed investment is not a viable or prudent
course of action. In the coming years, the cost of maintaining the linear accelerators will
increase as will disruptions in patient care as the maintenance needs of the old equipment
increase. If the investment were deferred long enough, access to vital cancer treatment
resources for more than 216,000 central Maine residents would be compromised and more
than $33 million in incremental travel costs over the useful life of the proposed project
would be borne by cancer patients and their families. See Section IV Public Need.

b. Replace the Existing Equipment in Retrofitted Existing Space. The existing vaults cannot
accommodate new replacement linear accelerators. Given the shielding required for linear
accelerators and the associated construction costs and complexity, replacing the linear
accelerators in their existing location would create lengthy disruptions in care. Construction
at the current location would be further complicated by two existing public roadways that
are immediately adjacent to the existing facility. The existing radiation oncology facility is
also adjacent to the oldest portions of the hospital as shown in Figure 6, creating the
potential for future service disruptions and dislocation when that wing is renewed, replaced
or removed. Updating the current linear accelerators is not a viable option because the
original supplier of the eight-year-old linear accelerators no longer produces them. CMH
cannot purchase similar machines, and the incremental maintenance costs associated with
such aging linear accelerators is a larger issue. The proposed new replacement accelerators
can provide a faster dose rate with enhanced precision in targeting tumors and lesions. A
new CMH Cancer Institute featuring state-of-the-art equipment with enhanced capabilities
will improve the quality of care for radiation therapy patients.

26
 Figure 6: Building System Condition Map
Source: Central Maine Healthcare

c. Develop an Integrated Cancer Institute at a New Site to Achieve Enhanced Access,

Improved Efficiency and a Better Patient Experience. This option allows for a new facility to
be developed while existing programs continue to operate, avoiding lengthy and adverse
disruptions in access to cancer care services. A new facility would not be severely
constrained by public roadways or bounded by the oldest portions of the CMMC facility.
Avoiding these disadvantageous space restrictions reduces future complexity, costs and
disruptions when those facilities are renewed or replaced. The blank slate provided by such
a facility would also allow for the facility to create improved access, adjacencies, patient and
family treatment and recovery spaces. In short, the facility can be designed and constructed
to meet current standards without constraint or compromise imposed by a landlocked site.

For the reasons described above, the proposed replacement and enhancement project to
develop the Cancer Institute is the most economical, most beneficial and least disruptive
option.

B. Availability of State Funds: Impact on MaineCare

The proposed project does not rely upon an increase in utilization to be financially feasible.
Rather, the proposed project depends upon organic growth in projected utilization of services
primarily driven by the increasing incidence of cancer due to the aging population in the region
and other factors; the higher prevalence of cancer as the proportion of treatable cancers
increases with longer remissions and greater survivability (as documented by IBM Watson); and
a modest projected increase in patients who will remain in the region for their diagnostic and
treatment needs. As one of six outpatient radiation oncology sites in the state, the projected
decrease in outmigration is quite modest and would not have an adverse impact on other
service providers.

27
 Because the proposed project is a replacement and enhancement project, it does not introduce
new capacity into the health care delivery system and its impact on state expenditures is
projected to be modest. All of the projected growth in volume for the project will occur as a
result of an increased need for services from an aging population with increasing incidence of
cancer as projected by IBM Watson. Rate increases for Medicaid are projected to be 1%
annually. The projected Medicaid covered lives are sourced from IBM Watson projections, with a
modest decrease in Medicaid covered lives projected before the impact of Medicaid expansion.
Given that Medicaid expansion is occurring independent of this project, this project’s impact on
state expenditures will be negligible.

The demand for cancer services is projected to grow in the region, with 40.6% of these services
taking place in an outpatient setting2. Additionally, CMH assumes that patient outmigration will
experience a modest decrease by the proposed project, reducing transportation costs borne by
patients, their families and the state in relation to Medicaid patients.

Figure 7: Outpatient Estimates and Projections for Chemotherapy and Radiation Oncology Services
for Cancer Services 2019 – 2024
Source: IBM Watson

Outpatient estimates for radiation oncology and chemotherapy show a five-year percentage
increase of 12.9%, or a compound annual growth rate (CAGR) of 2.45%. Cancer services are
projected to grow at a faster rate over the next five years compared to the overall outpatient
market utilization for all services within CMH’s service area, for which a five-year change of 6.8%
is projected. The projected annual growth in the need for cancer services within the region are in
line with the projected growth assumed in the financial projection. Modest increases in patients
remaining within the region due to clinical capability enhancements from the proposed project
have been assumed.

C. Alternatives: Potential for More Effective, Accessible, Less Costly Technologies or Methods
Currently, there are no alternative technologies available to replace radiation oncology’s role as
an essential treatment option for a wide array of cancers. Given the need to replace the existing
linear accelerators by 2021, no practical existing alternative technologies would make the
proposed investment unnecessary or imprudent. Deferring the proposed investment for five
years or more until a newer alternative technology and method of delivery is available is not a
feasible option for the residents of the region served by CMH. A significant delay in replacing this
equipment poses substantial risk of disruption to these critical cancer treatment modalities and
greatly increases the possibility of additional travel- and access-related adverse outcomes for
patients.

The most significant driver of increased oncology costs related to cancer treatment in the region
is pharmaceutical costs. For the CMH cancer program, the fastest growing cost driver is the cost
of chemotherapy drugs. While the efficacy of these treatments has advanced rapidly over the
last decade and more, so has their cost. Drugs currently comprise 49% of operating costs and are
28
projected to increase to 61% of operating costs in 2026. Given the complexity of cancer
treatment and the associated research and development costs and timelines for approval of new
treatment options, there are no practical, more effective or less costly alternative treatment
options. Moreover, in light of the expense associated with chemotherapy drugs, the cost of the
proposed Cancer Institute is not a significant cost driver in the operation of the delivery system.

In addition, radiation oncology already takes place in the more accessible and cost-effective
outpatient setting. The major drivers of the cost of the proposed project include the linear
accelerators themselves and the shielding and patient and staff safety provisions that must be
met when harnessing radiation for cancer treatment. The replacement linear accelerators will be
more efficient, allowing for faster treatment sessions and more patient throughput per unit and
more precise targeting of tumors and lesions. The proposed replacement project will take
advantage of the outpatient care delivery setting and enhance treatment efficiencies associated
with the new linear accelerators.

Demand for cancer care services increases in older populations. Maine is the oldest state in the
country and the service area is projected to grow older over the next five years. Based on these
demographic trends and other factors, the need for cancer care services in the service area is
projected to increase in the future, according to IBM Watson. While cancer treatment will
continue to evolve and improve, as one of six radiation oncology sites in Maine, uninterrupted
access to these services at CMH is anticipated to remain important to the orderly and economic
performance of health care delivery in the region.

Renewal of the radiation oncology capabilities in the region is consistent with the orderly and
economic development of health facilities and resources in Maine. The proposed project is not a new
service but will strengthen and enhance an existing, vital service without disrupting regional access to
radiation therapy services. Further, the proposed investment in replacing existing linear accelerators
by 2021 is a critical element to sustain access to comprehensive cancer care services in the region.
The failure to strengthen and invest in CMH’s radiation and medical facilities would result in a
significant erosion of CMH’s cancer care capabilities with resulting adverse consequences for more
than 216,000 Maine residents.

29
VI. Outcomes and Community Impact
Relevant criteria for inclusion in this section are specific to the determination that the project ensures
high-quality outcomes and does not negatively affect the quality of care delivered by existing service
providers.

30
A. High Quality Outcomes
CMH’s quality accreditations are listed in Section I. A. 4. The proposed Cancer Institute will
improve the quality of care delivered by CMH. Further, the benefits of enhanced patient access,
service adjacencies and the critical mass to provide enhanced hours of service delivery will
improve patient care and the patient experience.

By moving both departments into one cohesive Cancer Institute, CMH will be able to realize
efficiencies from co-location and provide quality care in a greatly enhanced and more patient
accessible suite of cancer care services. Many patients being treated for cancer undergo
chemotherapy 3-8 hours per day on schedules that range from daily to three times per week or
every two to three weeks. Chemotherapy can last for up to six months or more depending on
the treatment protocol. Radiation oncology treatments can be daily and last from two to seven
weeks. Often, radiation oncology treatment is given in combination with chemotherapy.
Currently, the radiation oncology and the medical oncology services are located at opposite
ends of the CMH campus as seen in Figure 3. The walk between treatment locales is circuitous
and takes about 15 minutes walking indoors to get from one department to the other.
Alternatively, a patient has the option to go outside and around the building and possibly utilize
automobile transport between departments. The significant distance between medical and
radiation oncology is a hardship for patients and is suboptimal for coordination of care and rapid
consultation among specialists and across the clinical disciplines providing care to these
patients. These patient access issues are compounded by the frailty and age of the treatment
population, which affect the overall quality of care available.

Both departments will become more efficient as patients will no longer have to travel long
distances that waste time and energy and risk the patient getting lost in other departments.
Communication and access to timely consults will be enhanced due to physician offices being
nearby. Providers will be able to stop into patient appointments if one of their peers has a
request, creating greater communication channels between providers in different departments
and more comprehensive quality care for the patient. Quality of care delivered by existing
service providers would be improved due to closer proximity of departments. Further, co-
locating services will enable CMH to enhance the hours of service, allowing patients undergoing
cancer treatment to avoid unnecessary emergency department visits when addressing
treatment complications.

B. No Negative Effect on Existing Service Providers’ Quality of Care

The quality of care currently delivered by existing providers will not be negatively affected by
proposed replacement and enhancement project. Because it is a replacement project, it is not
expected to have any direct impact on the five other radiation oncology programs or on other
providers in the area. The project is anticipated to retain those existing services rather than
redirect services from other providers. As a result, the proposed Cancer Institute is not
expected to have any material impact on the quality of care provided by existing service
providers in other regions of the State. The proposed project will allow for high quality, well-
coordinated, proximate and uninterrupted outpatient radiation oncology services within the 55
ZIP codes closest to the CMH cancer program.

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VII. Service Utilization
Relevant criterion for inclusion in this section is specific to the determination that the project does
not result in inappropriate increases in service utilization, according to the principles of evidence-
based medicine adopted by the Maine Quality Forum.

32
A. Risk of Inappropriate Increases in Service Utilization
CMH seeks to replace and enhance existing services in the Lewiston-Auburn market and continue to
provide services as a regional Cancer Institute as a natural extension of CMH’s current role as a
provider of regional services for orthopedics, cardiovascular, and surgical care. It also continues to
build on the subspecialized infrastructure in place today at the CMMC campus. To ensure access to
high-quality care in the region and state, CMH must continue to provide radiation and medical
oncology services.

This project is designed to meet CMH’s existing need for replacement equipment to better serve
CMH’s patients in the region rather than create demand for new health care services. This
project will not increase health care utilization and will not create inappropriate or unnecessary
demand. The growth rates projected for the cancer program will not impact existing local
competitor institutions and aims to maintain local access for medical and radiation oncology
services.

CMH anticipates modest market growth in radiation and medical oncology principally as a result
of offering the community infrastructure and enhanced services for cancer care. Today, CMH is
the only provider of radiation oncology services in Androscoggin County, posing a major risk to
patients if the service does not continue.

Sources:

1. Solomon, Jennifer. “Maine Among the Highest Incidence Rates of Lung Cancer in the
Country, According to New Report by American Lung Association.” American Lung
Association, 28 Feb. 2018, www.lung.org/local-content/_content-items/about-
us/media/press-releases/maine-among-highest-incidence-rates.html. The American Lung
Association identified the high lung cancer rate and growth in the state as alarming in 2018
calling for immediate action.
2. IBM Watson Truven Health Analytics, www.ibm.com/watson
3. Maine CDC Cancer Registry, et al. “The Maine 2018 Annual Report of Cancer.” Maine
Department of Health and Human Services, 12 July 2019.
www.maine.gov/dhhs/mecdc/public-health-systems/data-research/vital-
records/mcr/reports/documents/ACR-Maine-2018-Annual-Report-of-Cancer-081219.pdf
4. Central Maine Healthcare Administration
5. United States Department of Health and Human Services Administration for Community
Living. “2017 Profile of Older Americans.” April 2018.
https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2017Older
AmericansProfile.pdf

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