In his pitch to state legislators for $500 million to help Mayo Clinic with its $5 billion expansion, Mayo Clinic President and CEO Dr. John Noseworthy has repeatedly said if Minnesota does not provide a taxpayer subsidy, other states would be eager for Mayo Clinic to expand.
Two of the most logical places would be Florida and Arizona, where existing Mayo Clinic campuses are growing steadily.
Mayo Clinic is investing hundreds of millions of dollars at all three of its campuses to strengthen each as a major regional medical hub.
Although the three campuses used to compete for money to expand, in the last four years that has changed, said Dr. William Rupp, vice president and CEO of the Florida campus.
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Today, developing the hospital and clinic system's national presence is a decision Mayo Clinic's senior leaders, including Rupp, make together, in Rochester.
"There really is a great sense of 'Let's put the next set of resources where they're going to help the most people,' " said Rupp, an oncologist. "That can be Arizona, that can be Rochester, it can be here. And that's why you actually see ongoing building at all three of those major sites right now."
That building is evident in the form of construction cranes and workers. Mayo Clinic is pumping more than $100 million into its Jacksonville, Fla., location and another $312 million into its facilities in Phoenix and Scottsdale, Ariz. By comparison, Mayo Clinic's current Rochester expansion falls right in the middle, at about $247 million.
The Florida expansion involves adding two new floors to the hospital, which was built just five years ago and is already at capacity. There's also new construction on a primary care site and an outpatient dialysis center.
The projects represent a long and steady growth spurt for the Jacksonville campus which was dubbed the "unadvertised clinic in the forest" when it opened its doors in northeast Florida. Times have changed.
"One, we advertise it now, and two, we're no longer in the woods," said Rupp. "There's city everywhere now. The city continues to grow."
When Mayo Clinic's Jacksonville campus was founded in 1986, it had 180 employees and was the system's first location outside of Rochester. By 2012, the hospital employed 5,211 employees. It cares for tens of thousands of patients every year.
A year after branching out to Florida, Mayo Clinic opened a second satellite clinic in the Sun Belt, this time in Arizona.
Today, Mayo Clinic's campuses in Phoenix and Scottsdale are growing steadily with nearly 6,000 employees between them.
"We don't aspire ... to be as large as we are in Rochester," said Dr. Wyatt Decker, vice president and CEO of Mayo Clinic's Arizona campuses. "What we want to do is use the depth and breath of Rochester effectively using technology, frankly, and be able to bring that to patients in the Southwest."
Construction is underway for a proton beam cancer therapy center in Phoenix. Decker, a professor of emergency medicine, said it's an example of how Mayo Clinic makes decisions about where to develop new medical technology. Its officials decided against building a proton cancer center in Florida, he said, because Jacksonville already had one.
MAP: Mayo's campuses across the U.S.
Mayo Clinic also is launching a branch of its Rochester-based Mayo Medical School, a partnership with Arizona State University.
Decker said the Mayo Clinic campuses are strong regional hubs, but not competitors.
When it comes to medical specialties, he said, the differences between the campuses are minor. Pediatrics, obstetrics and trauma are unique to Mayo Clinic's Rochester practice.
Otherwise, all the campuses specialize in various complex, adult medical care, Decker said. And patients tend to go to the campus that's closest to them.
"People just figure out what works for them. Sometimes, they want to go to Rochester, either because it's more convenient or because they know that's sort of the main hub for Mayo Clinic, which is great," Decker said. "Other times, if you're going to have radiation therapy and you're going to be somewhere for six weeks, they might choose to be in Arizona, which works well, too."
All three sites will continue to expand for the foreseeable future, Decker said.
But how that growth shifts between campuses could depend on how much support Mayo Clinic receives from Minnesota lawmakers.
"I think this will just play out naturally, and as it does, we will figure out as a leadership team where it makes sense for Mayo Clinic to grow based on how we serve patients best," Decker said.