Transtn Hosp Corp LA v. Shalala, Donna E.

222 F.3d 1019, 343 U.S. App. D.C. 82, 2000 U.S. App. LEXIS 21119, 2000 WL 1133605
CourtCourt of Appeals for the D.C. Circuit
DecidedAugust 22, 2000
Docket99-5166
StatusPublished
Cited by44 cases

This text of 222 F.3d 1019 (Transtn Hosp Corp LA v. Shalala, Donna E.) is published on Counsel Stack Legal Research, covering Court of Appeals for the D.C. Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Transtn Hosp Corp LA v. Shalala, Donna E., 222 F.3d 1019, 343 U.S. App. D.C. 82, 2000 U.S. App. LEXIS 21119, 2000 WL 1133605 (D.C. Cir. 2000).

Opinion

Opinion for the Court filed by Circuit Judge GARLAND.

GARLAND, Circuit Judge:

The Medicare program reimburses certain categories of hospitals on a “reasonable cost” basis, rather than under the generally applicable, and less remunerative, “Prospective Payment System.” Long-term care hospitals are one such category. Plaintiffs own two new facilities for which they sought classification as long-term care hospitals before they began admitting patients. The Department of Health and Human Services (HHS) rejected plaintiffs’ request, citing regulations that require new hospitals to have six months of experience before they can qualify as “long-term.” In enacting those regulations, the Secretary of HHS took the position that an initial data-collection period is statutorily required. Plaintiffs, challenging the regulations in the district court, took the opposite position: that the *1021 Medicare statute does not mandate an initial data-eollection period and in fact manifestly requires HHS to reimburse them as long-term hospitals from the first day of operation. The district court agreed with plaintiffs and declared HHS’ regulations invalid.

We do not find the statute as clear as either side suggests, but rather conclude that Congress intended the Secretary to exercise discretion in determining the manner in which a hospital qualifies as a long-term care facility. We therefore reverse the decision of the district court. However, because the Secretary mistakenly believed that she lacked such discretion, we remand the case to permit her to determine whether she wishes to retain the existing regulations knowing that other options are permissible.

I

Medicare is a federal health insurance program for the aged and disabled that is administered by the Health Care Financing Administration (HCFA) of HHS. See 42 U.S.C. §§ 1395 et seq. Under Medicare Part A, institutional health care providers are reimbursed for their services to eligible patients. See id. §§ 1395c to 1395Í-5. From its inception until 1983, Medicare reimbursed hospitals for the “reasonable cost” of providing inpatient care, subject to certain limitations. Id. § 1395f(b) (1982); see also id. § 1395x(v).

By 1983, Congress had become concerned that hospitals reimbursed on a reasonable cost basis lacked incentives to operate efficiently. This concern led to the revision of the Medicare payment system in that year. See Social Security Amendments of 1983, Pub.L. No. 98-21, § 601, 97 Stat. 65, 149. See generally County of Los Angeles v. Shalala, 192 F.3d 1005, 1008-09 (D.C.Cir.1999). In place of the reasonable cost method, Congress enacted the Prospective Payment System (PPS) as the principal method of compensating hospitals for inpatient care provided to eligible patients. Under PPS, hospitals are reimbursed according to flat rates established in advance for the various categories of patient diagnoses (known as “diagnosis-related groups” or “DRGs”). 42 U.S.C. § 1395ww(d). The rates reflect the average cost associated with treating a patient for a specific condition, and encourage hospitals to keep costs within the anticipated reimbursement levels. For the care of patients whose hospitalizations are extraordinarily costly or lengthy, the statute authorizes the Secretary to make “outlier payments” to supplement the standard PPS disbursement. Id. § 1395ww(d)(5)(A)(i)-(vi); see County of Los Angeles, 192 F.3d at 1009.

Because PPS was “developed for short-term acute care general hospitals,” Congress acknowledged that it did not “adequately take into account special circumstances of diagnoses requiring long stays.” S. Rep. No. 98-23, at 54 (1983), U.S. Code Cong. & Admin. News at 143, 194. Thus, Congress altogether excluded from PPS certain types of hospitals that treat atypical patient populations. These hospitals instead receive reimbursement for inpatient care under the reasonable cost system. See 42 U.S.C. § 1395ww(d)(l)(B). One type of hospital subject to the statutory exclusion is a long-term care hospital, which the statute describes as “a hospital which has an average inpatient length of stay (as determined by the Secretary) of greater than 25 days.” Id. § 1395ww(d)(l)(B)(iv)(I). 1 The availability *1022 of this exclusion is the central issue in the case before us.

A

HHS implemented the new PPS reimbursement scheme by enacting regulations in 1984. In issuing its final rule, although not in the rule itself, HHS announced that it intended to apply the statutory exclusions prospectively only: any change in a hospital’s status (i.e., whether it was subject to or excluded from PPS) that occurred during one cost reporting period would generally take effect only at the start of the next period, with each period typically lasting one year. See Medicare Program; Prospective Payment for Medicare Inpatient Hospital Services, 49 Fed. Reg. 234, 243 (1984). Thus, a new hospital would not qualify for the exclusion at least until the initial reporting period was over. To accommodate new hospitals, HHS permitted an abbreviated initial cost reporting period of six months, rather than the usual one year. See 42 C.F.R. § 405.471(c)(5)(i), (c)(5)(ii)(B) (1983), now codified at 42 C.F.R. § 412.23(e)(1), (e)(3)(ii). 2

In 1992, HHS formalized its prospective approach to exclusions by proposing and then adopting the following rule:

For purposes of exclusion from the prospective payment systems ..., the status of each currently participating hospital ... is determined at the beginning of each cost reporting period and is effective for the entire cost reporting period. Any changes in the status of the hospital are made only at the start of a cost reporting period.

42 C.F.R. § 412.22(d). Thus, a hospital that qualifies for the exclusion in the middle of a reporting period will not benefit until the next reporting period. By the same token, a hospital that ceases to qualify in the midst of a cost reporting period will nevertheless be compensated as though it were exempt for the entire period. See Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 1993 Rates, 57 Fed.Reg. 23,618, 23,657 (1992). For a new hospital, HHS’ rule confirmed that the exclusion does not begin until the first six months of data collection have passed.

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Bluebook (online)
222 F.3d 1019, 343 U.S. App. D.C. 82, 2000 U.S. App. LEXIS 21119, 2000 WL 1133605, Counsel Stack Legal Research, https://law.counselstack.com/opinion/transtn-hosp-corp-la-v-shalala-donna-e-cadc-2000.