Biles v. Department of Health and Human Services

931 F. Supp. 2d 211, 2013 WL 1154207, 2013 U.S. Dist. LEXIS 39269
CourtDistrict Court, District of Columbia
DecidedMarch 21, 2013
DocketCivil Action No. 2011-1997
StatusPublished
Cited by10 cases

This text of 931 F. Supp. 2d 211 (Biles v. Department of Health and Human Services) is published on Counsel Stack Legal Research, covering District Court, District of Columbia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Biles v. Department of Health and Human Services, 931 F. Supp. 2d 211, 2013 WL 1154207, 2013 U.S. Dist. LEXIS 39269 (D.D.C. 2013).

Opinion

MEMORANDUM OPINION

ROYCE C. LAMBERTH, Chief Judge.

Plaintiff Brian Biles, MD, MPH (“Dr. Biles”), brings an action against defendant U.S. Department of Health and Human Services (“HHS”) under the Freedom of Information Act (“FOIA”), 5 U.S.C. § 552 (2012), for injunctive relief, claiming that HHS is unlawfully withholding information that Dr. Biles requested in a proper FOIA request. HHS claims that the information is properly withheld under FOIA’s Exemption Four because the release of the information would cause substantial competitive harm to the private health insurance companies that submitted the requested data to HHS in 2010 and would impair HHS’s ability to obtain accurate information in the future.

Before the Court is defendant’s Motion for Summary Judgment, ECF No. 20, April 30, 2012, and plaintiffs Cross Motion for Summary Judgment, ECF No. 24, July 13, 2012. Upon consideration of defendant’s motion, plaintiffs cross motion and opposition, defendant’s reply and opposition, ECF No. 27, Aug. 13, 2012, plaintiffs reply, ECF No. 30, Sept. 10, 2012, the applicable law, and the record herein, the Court will DENY defendant’s motion and GRANT plaintiffs motion.

I. BACKGROUND

On July 18, 2011, plaintiff Dr. Biles — a professor at The George Washington University School of Public Health and Health Services who studies the Medicare Advantage (“MA”) program- — -filed a FOIA request with defendant HHS’s Centers for Medicare and Medicaid Services (“CMS”), which oversees the Medicare Advantage (“MA”) program. Pl.’s Mem. in Opp’n to Def.’s M. Summ. J. & in Supp. of Pl.’s M. Summ. J. (“PL’s Mem.”) 2, ECF No. 24-1; Biles Decl. ¶ 1, Exh. A(CV), ECF No. 24-2; Def.’s Mem. in Supp. of Def.’s M. Summ. J. (“Def.’s Mem.”) 4, ECF No. 20. In order to analyze the efficiency and effectiveness of the MA and Medicare programs, Dr. Biles requested “specific data and other information for 2009 provided to CMS, in or about June 2010, by all Medicare Part C Medicare Advantage Organizations on WORKSHEET 1 — MA BASE *215 PERIOD EXPERIENCE AND PROJECTION ASSUMPTIONS.” Pl.’s Complaint ¶ 1; Def.’s Mem. 4; Biles Decl. Ex. F, at 1 (FOIA Request).

Medicare Advantage organizations (“MAOs”) are private insurance companies that offer health insurance coverage to Medicare beneficiaries and are required, pursuant to 42 C.F.R. § 422.254, to submit a Bid Pricing Tool to CMS by the first Monday of June each year. Rice Decl. ¶¶ 5, 7-9, ECF No. 20-1; Pl.’s Mem. 2. The Bid Pricing Tool is an Excel workbook comprised of seven worksheets of data that determine the projected costs and revenue for an MAO to provide coverage to MA beneficiaries in the next calendar year. Def.’s Mem. 4; Pl.’s Mem. 1-3; Rice Decl. ¶¶ 5-7, 12. The “bid” submitted by MAOs is not like a traditional bid in a competitive arena where one winner takes all, as in bids for government contracts. Pl.’s Mem. 7. CMS explains:

[T]he MA ... program[ ][is] not competitive in the way that term is normally understood. Although [MAOs] do compete for members, primarily through the benefits offered and the cost (member cost sharing and premium) of those benefits, they do not directly compete for the payments that CMS makes. 1

CMS “approve[s] all sustainable bids that are otherwise qualified without preference for the lowest bidder.” 2 76 Fed. Reg. at 21,518.

Further unlike a competitive bid for a contract where the bidder can choose his desired bid amount, an MAO’s “bid” is based on the MAO’s actual costs expended by the MAO in the previous year to provide its offered Medicare benefits; this data is called the MAO’s “base period” data and is the category from which Dr. Biles has requested specific data. PL’s Mem. 7; see Rice Decl. ¶6. Base period data must be verified by an actuary. PL’s Mem. 15, 42; Rice Decl. ¶ 12; 76 Fed. Reg. at 21,518 (statement by CMS/HHS) (“Utilization, costs, and trends must be certified by a qualified, independent actuary prior to bid submission.”); 42 C.F.R. § 422.254(b)(5) (2012).

Ultimately, the “bid” data is trended forward to the next year by a series of formulae, like inflation and other factors, embedded in the seven Excel worksheets of the Bid Pricing Tool. PL’s Mem. 7; see Rice Decl. ¶ 6; 76 Fed. Reg. at 21,517. The formulae calculate the bid data to determine the expected revenue needed to cover the MAO’s projected Medicare costs for the next year. PL’s Mem. 7; Rice Decl. ¶ 6; 42 C.F.R. § 422.254(a)(1) (2012). This “payment plan” is the basis for CMS’s payments to an MAO, and CMS pays MAOs one year in advance to cover its portion of the MAOs’ projected cost and *216 revenue requirements for the next year. See id.; Rice Decl. ¶¶ 6-11; Pl.’s Mem. 7; 42 C.F.R. § 422.254(a)(1) (2012). For example, an MAO’s 2011 payment plan is based on 2009 actuarial data. See Pl.’s Mem. 7; Rice Decl. ¶ 12.

Additionally, while the payment plan is determined according to the MAO’s estimated internal costs, the payment amount is limited by a federally-set benchmark, which is the maximum amount CMS will pay an MAO in a given locality. See 42 U.S.C. § 1395w-23 (b) (1) (B) (2012); 42 C.F.R. § 422.258 (2012). The benchmarks are publicly announced by the first Monday in April of the year prior to the bid submissions to which the benchmarks will apply. 42 U.S.C. § 1395w-23(b)(l)(B).

Dr. Biles requested “retroactive,” “historical” cost and utilization data from Sections I, II, III, and VI of Worksheet One 3 of the Bid Pricing Tool and claims to have not requested any data that “disclose[s] MAO assumptions, predictions, projections, or expectations for how th[o]se costs may change in the future.” PL’s Mem. 8; Def.’s Mot. Summ. J. Ex. 1; Def.’s Mem 4 (“Def.’s Statement of Material Facts Not in Genuine Dispute”) ¶ 3; Biles Decl. ¶¶ 58-60, 95. Section I was released to Dr. Biles by CMS and is therefore not in dispute. Biles Decl. ¶ 96; Def.’s M. Summ. J. Exs. 1-3, Ex. 4 at 2. Sections II, III, and VI are in dispute, as CMS refuses to disclose those sections in their entirety pursuant to FOIA’s Exemption Four. PL’s Mem. 3, Exs. 3-4; Marquis Decl. ¶¶ 21-27, ECF No. 20-2.

Section II contains base period background information that defines the period of time that Section III data 4

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931 F. Supp. 2d 211, 2013 WL 1154207, 2013 U.S. Dist. LEXIS 39269, Counsel Stack Legal Research, https://law.counselstack.com/opinion/biles-v-department-of-health-and-human-services-dcd-2013.