New York State Ass'n of Counties v. Axelrod

577 N.E.2d 16, 78 N.Y.2d 158, 573 N.Y.S.2d 25, 1991 N.Y. LEXIS 1000
CourtNew York Court of Appeals
DecidedJune 27, 1991
StatusPublished
Cited by143 cases

This text of 577 N.E.2d 16 (New York State Ass'n of Counties v. Axelrod) is published on Counsel Stack Legal Research, covering New York Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
New York State Ass'n of Counties v. Axelrod, 577 N.E.2d 16, 78 N.Y.2d 158, 573 N.Y.S.2d 25, 1991 N.Y. LEXIS 1000 (N.Y. 1991).

Opinions

OPINION OF THE COURT

Bellacosa, J.

The defendants, collectively referred to as the Department of Health (DOH), adopted a new method in 1986 for Medicaid reimbursement to nursing homes. Shortly thereafter, to contain costs and reduce all reimbursements, DOH effected an across-the-board percentage reduction to the new reimbursement rate method as a purported "corrective measure”. Plaintiff, New York State Association of Counties (NYSAC), sued to annul this Medicaid reimbursement recalibration regulation (10 NYCRR 86-2.31). We hold that NYSAC’s lawsuit was timely commenced and that the regulation should be [162]*162annulled as lacking a rational basis. Thus, the order of the Appellate Division granting DOH summary judgment should be reversed and NYSAC’s motion for summary judgment should be granted.

FACTUAL AND LITIGATION CONTEXT

NYSAC is a nonprofit association of all 62 counties in this State, 42 of which own and operate nursing homes or residential health care facilities. Prior to January 1986, Medicaid reimbursement rates were calculated based on a per-day per-patient cost determined on the basis of allowable costs in a prior year — the base year — increased by a trend factor to account for inflation but limited by certain ceiling costs. Under that method, a facility received the same per diem rate for all patients in its care, regardless of the severity of each patient’s care needs or condition.

In October 1985, DOH promulgated the "Long Term Care Case Mix Reimbursement System” (System) effective January 1986. The System is composed of four components: direct, indirect, noncomparable and capital costs (10 NYCRR 86-2.10 [b] [1] [ii]). The only aspect at issue in this case is the "direct” component of the rate formula, arrived at by a methodology known as RUG-II ("Resource Utilization Group”) (see, 10 NYCRR subpart 86-2). The System was designed to produce reimbursement rates that reflect the relative resource needs of patients and to provide an incentive to facilities to reduce expenditures and to admit patients requiring more resource-intensive services and care. It was designed to be budget-neutral, i.e., it was not intended to increase over-all Medicaid reimbursement. Based on extensive study and analysis of patients and data in 1984 and 1985, 16 patient classification categories or "Resource Utilization Groups” were established (see, 10 NYCRR Appendix 13-A). Under this RUG-II formula, each patient is categorized based on a "Patient Review Instrument” (the PRI form), completed semiannually by a qualified registered nurse (10 NYCRR 86-2.30 [c] [2]). The PRIs require detailed information evaluating patients’ conditions, treatments, dependencies and required care, needs and services. PRIs are also certified by the facility’s operator and the responsible nurse assessor (10 NYCRR 86-2.30 [c] [4]). The weighted sum of a facility’s patient distribution in the 16 categories is its "case mix index” (CMI). Reimbursement rates under the RUG-II method were based on the number of [163]*163patients in each category for whom a facility was caring, i.e., the facility’s total CMI.

The reimbursement rates were initially based on the Statewide average CMI derived from the data submitted on PRIs in 1985. Facilities were notified in November 1985 of their 1986 reimbursement rates based on the 1985 PRIs. However, on August 6, 1986, just seven months after the RUG-II method went into effect, DOH proposed to the State Hospital Review and Planning Council that the payment rates under the RUG-II method should be reduced. The process was dubbed "recalibration” and was then defined as the resetting of prices that correspond to the CMIs, that is, new reduced rates were to be assigned to the CMI figures (see, 10 NYCRR Appendix 13-A). The proffered justification for this "recalibration” was to set rates for the RUG-II system "on the basis of the most accurate data available regarding patient mix.” (Emphasis added.) DOH explained that from 1985-1986 the facilities’ understanding of the patient assessment system had improved in such a way as to increase the accuracy of the PRIs in 1986, thus increasing facilities’ CMIs. DOH determined the reimbursement rates should therefore be adjusted downward, i.e., recalibrated, because 1986 PRIs were being completed based on "a fuller understanding of the implications of the PRI regulations, and thus [were] more representative of the future PRI data the Department [would] receive.”

DOH recognized that to determine the justifiable percentage it would be necessary to separate the change in CMI attributable solely to more accurate PRI data from the increase in CMIs attributable to actual change in patient conditions, care needs and resource utilization. In an effort to document that differentiation, DOH compared CMIs for patients in 1985 with CMIs for patients in 1986, excluding data for patients whose length of stay at a facility was fewer than 90 days and those admitted after January 1, 1986. DOH determined that the average increase in CMI was 3.92%, or 3.2% if rehabilitation patients were excluded. DOH then concluded that the improved accuracy in PRI completion, or "paper optimization”, had resulted in an increase in RUG-II categorization and consequently CMI unrelated to patient condition or care needs. This, in turn, resulted in larger reimbursements without a correlative increase in resource utilization. That is, increasingly more accurate PRIs resulted in higher reimbursement to facilities, while the level of care remained unchanged, according to DOH’s cost containment calculus. The apparent [164]*164explanation is that DOH found it unacceptable that some facilities were garnering increased reimbursements by achieving improved compliance under the new methodology and its reporting requirements. DOH, in effect, penalized all providers by altering the reimbursement formula downward.

The Hospital Review and Planning Council adopted and the Commissioner of Health approved the uniform reduction or "recalibration” of 3.035%, effected by the following challenged regulation:

"86-2.31 Recalibration, (a) For rate periods commencing on or after January 1, 1987, notwithstanding any other provisions of this Subpart, the direct component of facility rates, determined in accordance with sections 86-2.10 and 86-2.11 of this Subpart, shall be reduced by 3.035 percent to reflect a recalibration adjustment based on the change in the aggregate statewide case mix index attributable to factors other than changes in patient population or condition.” (10 NYCRR 86-2.31 [emphasis added].)

The recalibration reduced the direct component of every facility’s Medicaid reimbursement rate by 3.035% regardless of actual change — if any — experienced by a facility in its CMI. DOH did not reset rates that corresponded to the CMI values, as it had explained it would do.

DOH filed the recalibration regulation with the Secretary of State on December 10, 1986. The implementation date was July 1, 1987, retroactive to January 1, 1987 (10 NYCRR 86-2.31 [b]). Rate computation notices for 1987 were sent to NYSAC’s members from October 1986 through June 1987 indicating that the respective facility’s reimbursement rates would be subject to a "zero percent” recalibration rate.

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Bluebook (online)
577 N.E.2d 16, 78 N.Y.2d 158, 573 N.Y.S.2d 25, 1991 N.Y. LEXIS 1000, Counsel Stack Legal Research, https://law.counselstack.com/opinion/new-york-state-assn-of-counties-v-axelrod-ny-1991.