Alvarado Community Hospital v. Shalala

155 F.3d 1115, 98 Daily Journal DAR 9854, 1998 U.S. App. LEXIS 22060
CourtCourt of Appeals for the Ninth Circuit
DecidedSeptember 11, 1998
DocketNo. 96-55967
StatusPublished
Cited by9 cases

This text of 155 F.3d 1115 (Alvarado Community Hospital v. Shalala) is published on Counsel Stack Legal Research, covering Court of Appeals for the Ninth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Alvarado Community Hospital v. Shalala, 155 F.3d 1115, 98 Daily Journal DAR 9854, 1998 U.S. App. LEXIS 22060 (9th Cir. 1998).

Opinion

REINHARDT, Circuit Judge:

One hundred and sixty-three hospitals (the “Hospitals”) seek payment for alleged shortfalls in -Medicare reimbursements for fiscal years 1985 (FY 1985) and 1986 (FY 1986). [1119]*1119The Hospitals, which provided care for patients whose hospital stays were unusually lengthy or costly, contend that they were not properly reimbursed under the Medicare program at a time when the method of payment was in transition. They assert, more particularly, that the total amounts paid to them failed to meet a minimum figure required by statute and that the payments were determined in a manner that violated the Administrative Procedures Act (“APA”). STATUTORY AND REGULATORY FRAMEWORK

The Secretary of the United States Department of Health and Human Services (the “Secretary”) reimburses health-care providers for medical services provided to Medicare patients under the Health Insurance for the Aged Act (“the Act”). 42 U.S.C. § 1395f(b)(l). Before October 1,1983, hospitals were reimbursed the lesser of their “customary charges” or the “reasonable costs” of their services. In an attempt to lower Medicare expenditures, Congress created the Prospective Payment System (“PPS”). Under PPS, the Secretary normally reimburses hospitals at a fixed amount for each patient discharged regardless of the costs incurred by the hospital. 42 U.S.C. § 1395ww(d)(l). Congress intended this method of payment to encourage hospitals to cut costs and increase efficiency. See Methodist Hosp. of Sacramento v. Shalala, 38 F.3d 1225, 1227 (D.C.Cir.1994) (citing Congressional Reports).

The fixed amount paid to hospitals under PPS is based on a standardized amount that is multiplied by a weighing factor. 42 U.S.C. § 1395ww(d)(2)(G), (3)(D). The standardized amount is a base amount that equals the average Medicare allowable cost per discharge for all hospitals participating in the Medicare program in a base year, which is adjusted according to regional wage variations, indirect medical education costs, and hospital case mix. 42 U.S.C. § 1395ww(d)(2). The weighing factor is a multiplier based on the diagnosis related group (“DRG”) in which the discharged patient’s illness falls. The Secretary has created 470 DRGs, each with a weight derived from the relative cost to treat a patient in that DRG. 42 U.S.C. § 1395ww(d)(4).

Hospitals first became subject to PPS in fiscal year 1984, beginning on October 1, 1983. 42 U.S.C. § 1395(d)(l)(A)(i). Thereafter, the Secretary phased in PPS over four years. During the phase-in years, Medicare reimbursements comprised two portions. The “hospital specific portion” was calculated under the prior system, based on the hospital’s actual costs. 42 U.S.C. §§ 1395ww(d)(l)(A), (C). The other portion, the “federal rate,” was determined under PPS. Id. The hospital specific portion of the reimbursements was 75% in FY 1984, 50% in FY 1985, 45% in 1986, and 25% in 1987, while the federal rate increased correspondingly. 42 U.S.C. § 1395ww(d)(l)(C). Thereafter, all reimbursements were calculated under PPS.

Under PPS Congress also provided for additional payments for patient discharges that qualified as “outlier” cases, which involved unusually costly or lengthy patient treatments. “Day outliers” occur when a patient’s length of stay (“LOS”), measured in days, exceeds the mean LOS for a particular DRG by a fixed number of days or standard deviations. 42 U.S.C. § 1395ww(d)(5)(A)(i). “Cost outliers” occur when the cost exceeds a fixed multiple of a particular DRG’s payment rate or exceeds the rate by a fixed dollar amount. 42 U.S.C. § 1395ww(d)(5)(A)(ii). The amount of additional payments for these cases “shall be determined by the Secretary and shall approximate the marginal cost of care” beyond the applicable cut-off point. 42 U.S.C. § 1395ww(d)(5)(A)(iii). Finally, the statute provides that

[t]he total amount of the additional payments made under this subparagraph for discharges in a fiscal year may not be less than 5 percent nor more than 6 percent of the total payments projected or estimated to be made based on DRG prospective payment rates for discharges in that year.

42 U.S.C. § 1395ww(d)(5)(A)(iv) (“Clause (iv)”) (emphasis added).

The Secretary derives the standardized amount from the cost of all hospitals’ discharges in a given year, including the outlier cases. In order to avoid overpaying hospitals generally for their expenses, the Secretary reduces the average standardized amount “by a proportion equal to the propor[1120]*1120tion (estimated by the Secretary) of the amount of payments under this section based on [outlier eases].” 42 U.S.C. §§ 1395ww(d)(2)(E), (3)(B). The Secretary then “sets aside” this amount to pay for the outlier cases. The outlier payment mechanism is designed not to increase the total amount of money paid out to hospitals; rather, it seeks to apportion in advance the anticipated total annual expenditure in a manner that will ensure that those hospitals specializing in “outlier” cases are not underpaid. However, under the Secretary’s interpretation of the statute, if the Medicare program fails to pay out the full amount it sets aside for outlier payments in a particular year, then in that year the total amount it would pay out would in all likelihood be less than the total estimated cost of all hospital discharges.

The Secretary publishes the methodology and data used in computing all DRG rates, including the thresholds to be used for calculating outlier payments, prior to the beginning of each fiscal year. See 42 U.S.C. § 1395ww(d)(6). For FYs 1984 and 1985, the Secretary used the 1981 Medicare Provider Analysis and Review file (“1981 MEDPAR”), a random sample of 20% of all hospital discharges during 1981, to set the thresholds so that total estimated outlier payments would equal 5.0% of total payments. 49 Fed.Reg. 34728, 34769, 34795 (Aug. 31,1984).1 For FY 1986, the Secretary set the outlier thresholds using data from FY 1984. 50 Fed.Reg. 35646, 35709 (Sept. 3, 1985).

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58 soc.sec.rep.ser. 383, 98 Cal. Daily Op. Serv. 7113, 98 Daily Journal D.A.R. 9853 Alvarado Community Hospital, Alvarado Hospital Medical Center, Central Plains Hospital, Century City Hospital, Cherokee County Memorial Hospital, Chico Community Hospital, Community Hospital of Los Gatos, Delray Community Hospital, Doctors Hospital, Dallas, Doctors Hospital of Lakewood, Doctors Hospital of Lakewood, Clark, Doctors Hospital of Lakewood, South, Doctors Hospital of Manteca, Doctors Hospital of Montclair, Doctors Hospital of Pinole, Doctors Medical Center of Modesto, Dominguez Medical Center, Garfield Medical Center, Harton Medical Center, Highland Hospital, Hillside Hospital, Hollywood Medical Center, J.E. smith/f.e. Hebert Hospital, Joellen Smith Medical Center, John F. Kennedy Memorial Hospital, Lake Seminole Hospital, Lincoln West Medical Center, Lodi Community Hospital, Los Alamitos Medical Center, Los Altos Hospital, Manteca Hospital, Meadowcrest Hospital, Ojai Community Hospital, Ontario Community Hospital, Palms of Pasadena Hospital, Placentia Linda Community Hospital, Redding Medical Center, Memorial Medical Center, Russell County Medical Center, San Diego Physicians and Surgeons Hospital, Trinity Medical Center, Twin Cities Community Hospital, University General Hospital, University Medical Center, West Boca Medical Center, Paracelsus Healthcare Corporation, Dba Bellwood Medical Corporation, Dba Bellwood General Hospital, Lincoln Community Medical Corporation, Dba Orange County Community Hospital of Buena Park and Formerly Dba Buena Park Community Hospital, Hollywood Community Hospital Medical Center, Inc., Dba Hollywood Community Hospital, Lancaster Hospital Corp., Dba Lancaster Community Hospital, Paracelsus Los Angeles Community Hospital, Dba Los Angeles Community Hospital, Norwalk Hospital Corp. Dba Norwalk Community Hospital, Paracelsus Van Nuys Community Hospital Operating Corporation, Dba Van Nuys Community Hospital, West Covina Health Center Corporation, Dba West Covina Hospital, Hollywood West Hospital Operating Corporation, Dba West Hollywood Hospital, Monrovia Hospital Corporation, Dba Monrovia Community Hospital, Chico Community Hospital, Inc. Dba Chico Community Hospital, Lodi Community Hospital, Inc. Dba Doctors Hospital of Lodi, Paracelsus Peninsula Medical Center, Inc. Dba Peninsula Medical Center, Paracelsus Clay County Hospital Inc., Dba Clay County Hospital, Paracelsus Fentress County General Hospital, Inc. Dba Fentress County General Hospital, Paracelsus MacOn County Medical Center, Inc. Dba Flint River Community Hospital and Formerly Dba MacOn County Medical Center, Ami Hospitals of Texas, Ltd., Dba Ami Brownsville Medical Center, Ami Heights Hospital, Ami Mid-Jefferson Hospital, Nacogdoches Medical Center, Ami Park Place Hospital, Ami Park Plaza Hospital, Ami Twelve Oaks Hospital, New H Arroyo Grande, Inc. Dba Arroyo Grande Hospital, Amisub of Georgia, Inc. Dba Barrow Medical Center, Lifemark Hospitals of Texas, Inc., Dba Ami Bellaire Hospital Byrd and Southwestern General Hospital, Brookwood Medical Center of Eufala, Inc., Dba Brookwood Medical Center of Eufala, Brookwood Health Services, Inc. Dba Ami Brookwood Medical Center, Lifemark Hospitals of Louisiana, Inc., Dba Byrd Memorial Hospital Dba Ami St. Judes Medical Center, Central Arkansas Hospital, Inc. Dba Central Arkansas Hospital, Amisub of North Carolina, Inc. Dba Central Carolina Hospital, New H Circle City, Inc. Dba Ami Circle City Hospital, Clairemont General Hospital, Inc., Dba Clairemont Community Hospital, Notami Hospitals of Oklahoma, Inc. Dba Claremore Community Hospital, Doctors Medical Center and Southwestern Medical Center, Clearwater Community Hospital, L.P. Dba Clearwater Community Hospital, Coastal Bend Hospital, Inc. Dba Coastal Bend Hospital, Lifemark Hospital of Missouri, Dba Ami Columbia Regional Hospital, Rocky Mount Sanitarium Development Corporation, Dba Community Hospital of Rocky Mount, Amisub (Culver Union Hospital), Inc. Dba Ami Culver Union Hospital, Denton Regional Medical Center, Inc. Dba Denton Regional Medical Center, 13th Street Corp., Dba Doctors Hospital of Opelousas, Doctors' Memorial Hospital, Inc., Dba Doctors' Memorial Hospital, East Cooper Community Hospital, Inc. Dba Ami East Cooper Community Hospital, Eastway General Hospital. Ltd., Dba Eastway General, Amisub French Hospital, Dba Ami French Hospital, Frye Regional Medical Center, Garden Park Community Hospital Lp, Dba Garden Park Community Hospital, Medical Center of Garden Grove, New H Glendora, Inc., Dba Ami Glendora Community Hospital, Amisub (North Plains Hospital), Inc. Dba Golden Plains Hospital, Gordon Crowell Memorial Hospital, Amisub (Mcintosh Trail Regional Medical Center), Inc. Dba Spalding Regional Hospital, Fka Griffin Spalding Hospital, Harris Hospital and Clinic, Dba Harris Hospital, Notami Hospitals of California, Inc. Dba Healdsburg General Hospital, Mission Bay Memorial Hospital and Valley Medical Center, Citizens General Hospital of Houston, Inc. Dba Institute for Immunological Disorders (Fka Citizens General Hospital), Natomi Hospitals of Louisiana, Inc. Dba Highland Park Medical Center and Westpark Community Hospital, Brookwood Medical Center of Houston, Inc. Dba Houston Community Hospital, Katy Medical Center, Inc., Dba Katy Medical Center, Amisub (American Hospital), Inc. Dba Ami Kendall Regional Medical Center (Fka American/miami), Notami Hospitals of Florida, Inc. Dba Lake City Medical Center, Lucy Lee Hospital, Inc., Dba Lucy Lee Hospital, Medical Arts Hospital of Dallas, Inc., Dba Medical Arts Hospital-Dallas, Medical Arts Hospital of Texarkana, Inc., Dba Medical Arts Hospital-Texarkana, Valley Doctor's Hospital, Dba North Hollywood Medical Center, Medical Plaza Hospital, Inc. Dba Medical Plaza Hospital, Memorial Hospital of Tampa, Ltd., Dba Memorial Hospital of Tampa, National Park Medical Center, Inc. Dba National Park Medical Center (Fka Ouachiata Memorial Hospital), North Fulton Medical Center, Inc. Dba Ami North Fulton Regional Hospital, Amisub (North Ridge Hospital), Inc. Dba North Ridge Medical Center, McKinney Joint Venture Dba North Texas Medical Center Lister Hill Hospital, Inc. Dba Northwest Alabama Medical Center, Odessa Hospital, Ltd. Dba Odessa Regional Hospital (Fka Odessa Women's and Children's Hospital), Palm Beach Gardens Community Hospital, Inc. Dba Ami Palm Beach Gardens Medical Center, Lifemark Hospitals of Florida, Inc. Dba Ami Palmetto General Hospital, Hospital Constructors, Ltd. Dba Ami Town & Country Hospital, Parkway Hospital, Inc. Dba Parkway Hospital, Parkway Regional Medical Center, Inc. Dba Parkway Regional Medical Center, Amisub of South Carolina, Inc. Dba Ami Piedmont Medical Center, Brookwood Medical Center of Orlando, Inc. Dba Ami Medical Center of Orlando (Fka Brookwood Community Hospital), Amisub of California, Inc. (Fka Rancho Encino Hospital), Hcmh, Inc. Dba Medical Park Hospital, Southwest Medical Center, Inc. Dba Riverside Community Hospital, Round Rock Hospital, Inc, Dba Round Rock Hospital, San Dimas Community Hospital, Inc. Dba Ami San Dimas Community Hospital, Amisub (Sierra Vista), Inc. Dba Ami Sierra Vista Regional Medical Center, New H South Bay, Inc., Dba South Bay Hospital, Amisub of Florida, Inc., Dba Ami Southeastern Medical Center, Creighton Saint Joseph Regional Healthcare System, L.L.C. Dba Saint Joseph Hospital, St. Mary's Hospital, Inc., Dba Ami St. Mary's Regional Medical Center, Ami/hti Tarzana Encino Joint Venture, Dba Tarzana Regional Medical Center, Terrell Community Hospital, Inc. Dba Terrell Community Hospital, Healthone, Dba Presbyterian/st. Luke's Medical Center (Fka St. Luke's Medical Center and Presbyterian-Denver Hospital), West Alabama General Hospital, Inc. Dba Ami West Alabama Hospital, Westbury Hospital, Inc. Dba Westbury Hospital, West Los Angeles Physician's Hospital, Lp Dba Westside Hospital, Unihealth America, Inc. Dba California Medical Center, Santa Monica Medical Center, Martin Luther Medical Center, and Valley Hospital Medical, County of Los Angeles, a Political Subdivision of the State of California, Owner & Operator of Los Angeles County/usc Medical Center, Harbor/ucla Medical Center, Martin Luther King, Jr./drew Medical Center, Olive View Medical Center & High Desert Hospital v. Donna E. Shalala, Secretary, United States Department of Health & Human Services
155 F.3d 1115 (Ninth Circuit, 1998)

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Bluebook (online)
155 F.3d 1115, 98 Daily Journal DAR 9854, 1998 U.S. App. LEXIS 22060, Counsel Stack Legal Research, https://law.counselstack.com/opinion/alvarado-community-hospital-v-shalala-ca9-1998.