Galen Hospital Alaska, Inc. v. Azar

District Court, District of Columbia·Decided July 21, 2020·No. Civil Action No. 2018-0728·Published

Opinion

UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA

)

GALEN HOSPITAL ALASKA, INC. d/b/a ) ALASKA REGIONAL HOSPITAL, et al., )

)

Plaintiffs, )

)

v. ) Civil Action No. 18-728 (RBW)

)

ALEX M. AZAR, II, in his official ) capacity as Secretary of the United States ) Department of Health and Human Services, )

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Defendant. )

)

MEMORANDUM OPINION

The plaintiffs, 168 hospitals, bring this civil action against the defendant, Alex M.

Azar, II (the “Secretary”), in his official capacity as the Secretary of the United States Department of Health and Human Services (the “Department”), pursuant to Title XVIII of the Social Security Act, 42 U.S.C. §§ 1395–1395lll (2018); the Administrative Procedure Act (“APA”), 5 U.S.C. §§ 701–706 (2018); and the Declaratory Judgment Act, 28 U.S.C. §§ 2201– 2202 (2018). See Complaint for Declaratory Relief and Sums Due Under the Medicare Act (“Compl.” or the “Complaint”) ¶ 5. Currently pending before the Court are (1) the Secretary’s Motion to Dismiss for Failure to State a Claim (“Def.’s Mot.” or the “motion to dismiss”) and (2) the Plaintiffs’ Motion for Leave to File Supplemental Complaint[] (“Pls.’ Mot.” or the “motion to supplement”). Upon careful consideration of the parties’ submissions, 1 the Court

1 In addition to the filings already identified, the Court considered the following submissions in rendering its decision: (1) the Memorandum in Support of Motion to Dismiss for Failure to State a Claim (“Def.’s Mem.”); (2) the Plaintiffs’ Opposition to Defendant’s Motion to Dismiss (“Pls.’ Opp’n”); (3) the Reply Memorandum in Support of Motion to Dismiss (“Def.’s Reply”); (4) the Plaintiffs’ Notice of Supplemental Authority in Opposition to Defendant’s Motion to Dismiss (Apr. 17, 2019) (“Pls.’ 1st Not.”); (5) the Secretary’s Response to Plaintiffs’ Notice of Supplemental Authority in Opposition to Defendant’s Motion to Dismiss (Apr. 18, 2019) (“Def.’s 1st (continued . . .)

concludes for the following reasons that it must deny the Secretary’s motion to dismiss and grant the plaintiffs’ motion to supplement.

I. BACKGROUND

A. Statutory Background 1. Medicare Outlier Payments Established under Title XVIII of the Social Security Act, the Medicare program provides federally funded medical insurance to elderly and disabled persons. See generally 42 U.S.C. §§ 1395–1395lll. Under this program, hospitals are not reimbursed for the actual operating costs that they incur in providing inpatient care. See Billings Clinic v. Azar, 901 F.3d 301, 304 (D.C. Cir. 2018). Instead, hospitals are paid at fixed rates under a scheme known as the Inpatient Prospective Payment System (the “Payment System”). See generally 42 U.S.C. § 1395ww(d). Pursuant to the Payment System, the Secretary defines categories of medical conditions known as “diagnosis-related groups[,]” Billings Clinic, 901 F.3d at 303, and, for each diagnosis-related group, the Secretary sets a standard payment amount known as the “[diagnosis-related group] prospective payment rate[,]” id. at 304. This payment amount for any given diagnosis-related group is calculated to reflect the estimated average cost of treating a patient with that diagnosis, but in any individual case, the actual cost that the hospital incurs in providing care to the patient may be higher or lower than the diagnosis-related group payment amount. See id.

(. . . continued) Resp.”); (6) the Brief of Nonprofit Hospitals as Amici Curiae[] in Support of Plaintiffs’ Opposition to Defendant’s Motion to Dismiss (“Amicus Brief”); (7) the Secretary’s Response to Brief of Nonprofit Hospitals as Amici Curiae in Support of Plaintiffs’ Opposition to Defendant’s Motion to Dismiss (“Def.’s Amicus Resp.”); (8) the Secretary’s Opposition to Plaintiffs’ Motion to Supplement Complaint (“Def.’s Opp’n”); (9) the Plaintiffs’ Reply in Support of Motion for Leave to File Supplemental Complaint (“Pls.’ Reply”); (10) the Secretary’s Notice of Supplemental Authority (Feb. 14, 2020) (“Def.’s 1st Not.”); (11) the Plaintiffs’ Notice of Supplemental Authority in Opposition to Defendant’s Motion to Dismiss (Apr. 2, 2020) (“Pls.’ 2d Not.”); (12) the Secretary’s Response to Plaintiffs’ Notice of Supplemental Authority (Apr. 6, 2020) (“Def.’s 2d Resp.”); (13) the Secretary’s Notice of Supplemental Authority (May 18, 2020) (“Def.’s 2d Not.”); and (14) the Plaintiffs’ Response to Secretary’s Notice of Supplemental Authority (May 21, 2020) (“Pls.’ Resp.”).

When Congress enacted the Payment System, it “recognized that healthcare providers would encounter patients with needs well outside the norm.” Id. “To account for those abnormally costly cases and to protect against large financial losses for hospitals, . . . hospitals [ ] [can] request additional ‘outlier payments.’” Id. (quoting 42 U.S.C. § 1395ww(d)(5)(A)(ii)). A hospital may seek these outlier payments when its “cost-adjusted charges” 2 for a case exceed the “fixed-loss cost threshold[,]” which is defined as the sum of (a) the diagnosis-related group prospective payment rate, (b) any payment adjustments, and (c) a fixed dollar amount that is determined by the Secretary through an annual rulemaking process for each federal fiscal year (“FFY”). Id. at 304; see Univ. of Colo. Health v. Azar, Civ. Action No. 14-1220 (RC), 2020 WL 1557134, at *1 (D.D.C. Mar. 31, 2020). Any cost-adjusted charges above the fixed-loss cost threshold are eligible for outlier compensation, see Billings Clinic, 901 F.3d at 305, and are “reimbursed at a rate intended to approximate the marginal cost of care, currently set at [eighty] percent in most cases,” Univ. of Colo. Health, 2020 WL 1557134, at *1.

“[T]he Medicare statute also limits the total amount of all outlier payments the Department can make in a given fiscal year[.]” Billings Clinic, 901 F.3d at 306. Under the Medicare program, the total amount of outlier payments made in a fiscal year “may not be less than [five] percent nor more than [six] percent of the total payments projected or estimated to be made based on [the diagnosis-related group] prospective payment rates for discharges in that year.” 42 U.S.C. § 1395ww(d)(5)(A)(iv). “To satisfy this directive, [the Department] conducts an annual rulemaking to set the fixed loss threshold at a level that it estimates will result in total payments within the statutorily-determined range.” Univ. of Colorado Health, 2020 WL

2 A hospital’s “cost-adjusted charges” is “intended to estimate the provider’s real cost of care” for the patient at issue “without any markups[.]” Univ. of Colo. Health, 2020 WL 1557134, at *1. This monetary figure is calculated by multiplying the hospital’s actual charges by a historical “cost-to-charge ratio[,]” a fraction that represents “the percentage of that hospital’s charges attributable to actual costs.” Billings Clinic, 901 F.3d at 305.

1557134, at *2. “[S]ince 1989, [the] [Department] has attempted to set an annual threshold that will result in total outlier payments being 5.1 percent of all Medicare payments.” Id.

2. Judicial Review

Under the Social Security Act, “‘[n]o findings of fact or decision of the [Secretary] shall be reviewed by any person, tribunal, or governmental agency’ except as the [Social Security] Act itself provides jurisdiction.” Billings Clinic v. Azar, 901 F.3d 301, 312 (D.C. Cir. 2018) (citing 42 U.S.C. § 405(h)). Here, the relevant source of judicial jurisdiction provided by the Social Security Act is 42 U.S.C. § 1395oo(f). See id. at 312. “That provision allows providers to seek review of a final decision of the Provider Reimbursement Review Board [(the ‘Board’)] and to seek expedited judicial review where the Board lacks ‘authority to decide’ a question of law relevant to the matter at [issue].” Id. (citing 42 U.S.C. § 1395oo(f)).

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