Case Title: St. Lukes v. Bd of Commissioners of Gem Co

Citation: 

Docket Number: 45614

State: idaho

Court: Idaho Supreme Court (civil)

Date: 2019-02-27T00:00:00Z

Document:
1 
 
IN THE SUPREME COURT OF THE STATE OF IDAHO 
 
Docket No. 45614 
 
 
Re:  Medical Indigency Application of C.H. 
(Gem County Case No. 16-026) 
-------------------------------------------------------- 
ST. LUKE'S HEALTH SYSTEM, LTD., 
  
               Plaintiff-Appellant, 
 
v. 
 
BOARD OF COMMISSIONERS OF GEM 
COUNTY, IDAHO, 
  
               Defendant-Respondent. 
_______________________________________ 
)
)
)
)
)
)
)
)
)
)
)
)
)
) 
Boise, December 2018 
Term 
 
Filed: February 27, 2019 
 
Karel A. Lehrman, Clerk 
 
Appeal from the District Court of the Third Judicial District of the State of Idaho, 
Gem County. Hon. George A. Southworth, District Judge. 
 
The Board’s Amended Determination of Approval for Benefits is vacated, and the 
case is remanded.   
 
Hawley Troxell Ennis & Hawley, LLP, Boise, for appellant. Mark C. Peterson 
argued.  
 
Erick Thomson, Gem County Prosecuting Attorney, Emmett, for respondent. 
Tahja Lee Jensen argued.  
 
_____________________ 
BRODY, Justice. 
This appeal arises from a medical indigency application filed by St. Luke’s with Gem 
County. On January 26, 2016, St. Luke’s accepted an indigent patient suffering from meningitis, 
seizures, and brain lesions. The patient was ready for transfer to another medical facility by 
February 18, 2016, but was refused by multiple care providers because they did not want to 
admit an indigent patient without a payor source. St. Luke’s finally contracted with Life Care, 
another medical facility, to take the patient on the condition that St. Luke’s would guarantee 
payment for a thirty day period.  The patient was transferred to Life Care on March 9, 2016.  
2 
 
St. Luke’s applied for medical indigency benefits covering the period of time from the 
patient’s initial hospitalization until she was transferred to the Life Care facility. Gem County 
initially approved the application for benefits through February 3, 2016. St. Luke’s appealed that 
determination, and after a hearing, the Board approved medical indigency benefits from January 
26, 2016, until February 18, 2016. The Board entered a written determination titled “Amended 
Determination of Approval for County Assistance” which set forth the various bills that were 
approved for payment, but did not in any way reflect the denial of benefits or the reasoning of 
the Board.   
St. Luke’s then sought judicial review of the Amended Determination before the district 
court, which affirmed the Board’s decision. St. Luke’s appealed. We vacate the Board’s 
Amended Determination because it does not reflect the partial denial of benefits and because 
there are no findings of fact or conclusions of law setting forth the basis for the Board’s denial.  
I. 
FACTUAL AND PROCEDURAL BACKGROUND 
On January 26, 2016, emergency medical personnel transported a 63 year-old woman to 
Valor Health because she was unresponsive. She had a tonic-clonic seizure en route. She was 
then transferred to St. Luke’s Meridian Medical Center and began treatment for meningitis and 
brain lesions. Her health improved over the next several weeks.   
Both St. Luke’s and Gem County agree that the patient did not require care from an acute 
care inpatient hospital after February 18, 2016. However, while St. Luke’s made multiple 
attempts to place her with another, lower care facility, she was consistently denied by providers 
citing concerns over payment. Ultimately, Life Care agreed to accept the patient on the condition 
St. Luke’s would guarantee payment for daily care for a period of thirty days. St. Luke’s agreed 
and transferred her to Life Care on March 9, 2016. The discharge report explained it was unsafe 
for the patient to return home at that time. St. Luke’s sought reimbursement from Gem County 
pursuant to Idaho’s Medical Indigency Act for care provided from the time the patient was 
hospitalized through March 9, 2016.  
Following an investigation, the Gem County Clerk of the Board, filed a cursory statement 
of findings with the Board indicating that the patient was an indigent county resident, the 
services were medically necessary, the application was complete, and the county was the last 
resource. The Board approved St. Luke’s application five days later for dates of service from 
3 
 
January 26, 2016, through February 3, 2016. St. Luke’s appealed that decision approximately ten 
days later. 
The clerk had Dr. Doug Dammrose, a utilization management reviewer retained by 
counties and the State Catastrophic Health Care Program, examine the patient’s medical records 
at four different times, with each of his successive reports expanding the medical record before 
the Board as St. Luke’s submitted new records. In his medical reviews, Dr. Dammrose changed 
the recommended cutoff date for medically necessary services from February 3 to February 12, 
and finally to February 18. He explained his last opinion only in the following summary:  
The additional clinical notes indicate the patient was medically stable on 02/19 
and it appears she no longer needed the services of an acute care inpatient 
hospital. Her medical care was at a maintenance level, and her needs were 
rehabilitative in nature. The inpatient stay from 02/19/2016 to 03/09/2016 is 
considered not medically necessary for purposes of payment. IC 31-
3502(18)A(E)B(d).  
At the hearing on St. Luke’s appeal, the Board voted to amend the approved dates of 
service to January 26, 2016, through February 18, 2016—the same dates recommended in 
Dammrose’s final amended report. However, the Board did not explicitly address the remaining 
dates of service from February 19, 2016, to March 9, 2016. The transcript of the appeal hearing 
shows a cursory discussion and vote by the Commissioners:  
COMM. REKOW: Mr. Chair, I move on Case No. 16-026 that we amend our 
dates of service from January 26 to February the 3rd for the previous dates to 
January 26 to February the 18th as presented by our indigent clerk for 
recommendation and as noted by the medical provider. 
COMM. BUTTICCI: That would be 2017? 
COMM. REKOW: 2016. 
COMM. BUTTICCI: Okay. 
COMM. ELLIOTT: I’ll second. 
COMM. BUTTICCI: Second by Mr. Elliott. Further discussion? All in favor say 
aye.  
(Vote taken.) 
COMM. BUTTICCI: There we go. We’ve approved the amended dates. Thank 
you for coming over. 
The Amended Determination that was issued by the Commissioners following the hearing 
likewise did not set reflect the partial denial of benefits or set forth the findings of fact and 
conclusions of law justifying that denial.    
4 
 
St. Luke’s then filed a petition for judicial review before the district court. Upon review 
of the agency record, the district court concluded that the Medical Indigency Act was not meant 
to provide long-term rehabilitative care to indigent patients, nor was the treatment medically 
necessary after February 18, 2016. Accordingly, the criteria for medical necessity—as required 
by the statute—were no longer met on February 18 when the patient became “medically stable.” 
The district court then affirmed the Board’s decision at the October 10, 2017, judicial review 
hearing and in an Order on Judicial Review the following day. St. Luke’s timely appealed to this 
Court.  
II. 
STANDARD OF REVIEW 
While a county board of commissioners is not a state agency, express statutory provisions 
require a county’s denial of medical indigency benefits to be reviewed under Idaho’s 
Administrative Procedure Act (APA). Mercy Med. Ctr. v. Ada Cnty., Bd. of Cnty. Commissioners 
of Ada Cnty., 146 Idaho 226, 229, 192 P.3d 1050, 1053 (2008) (citing I.C. §§ 31–3505G, 31–
3511(5), 31–1506). This Court freely reviews the county board’s legal conclusions, and it will 
not alter factual determinations as long as the board’s findings are supported by substantial and 
competent evidence. Id. When the district court acts in an appellate capacity under Idaho’s 
Administrative Procedure Act, this Court reviews the agency’s determination independent of the 
district court’s decision. Id.; St. Joseph Reg’l Med. Ctr. v. Nez Perce Cnty. Commissioners, 134 
Idaho 486, 488, 5 P.3d 466, 468 (2000).  
III. 
ANALYSIS 
A. The Board failed to make the necessary findings of fact and conclusions of law 
and explicit denial of benefits.  
St. Luke’s contends that the indigent patient’s care from February 19 to March 9 was 
medically necessary. Before we can address this question, however, we must first answer 
whether the Board rendered a final decision that is reviewable. We hold that it did not.  
Under Idaho’s Administrative Procedure Act, “[a] party aggrieved by a final order in a 
contested case decided by an agency other than the industrial commission or the public utilities 
commission is entitled to judicial review under this chapter if the person complies with the 
requirements of sections 67-5271 through 67-5279.” I.C. § 67-5270(3). The APA specifically 
requires an order to be in writing and include:  
5 
 
(a) A reasoned statement in support of the decision. Findings of fact, if set forth in 
statutory language, shall be accompanied by a concise and explicit statement of 
the underlying facts of record supporting the findings. 
(b) A statement of the available procedures and applicable time limits for seeking 
reconsideration or other administrative relief. 
I.C. § 67-5248(1).  
“[S]pecificity in the findings and reasons of the lower tribunal is vital” to appellate 
review because the “resolution of factual issues cannot be made for the first time by the district 
court nor can they be made by this Court on appeal.” Mercy Med. Ctr., 146 Idaho at 232, 192 
P.3d at 1056 (quoting Intermountain Health Care, Inc. v. Bd. of Cnty. Comm’rs of Caribou 
Cnty., 108 Idaho 757, 762, 702 P.2d 795, 800 (1985)). Pursuant to the APA, those findings 
properly belong to the county board of commissioners. Id. Accordingly, it is “appropriate to set 
aside a board’s decision and remand the matter for further proceedings after determining that a 
county . . . failed to fulfill its investigative duties regarding an application for indigent benefits.” 
Id. 
The reality is that the Board denied St. Luke’s medical indigency application in part and 
granted it in part. The Amended Determination explains why the application was granted, but it 
does not show that benefits were denied or how that decision was reached. While factual findings 
do not have to be exhaustive, some record support and written explanation is required. It is vital 
for the Board to provide specificity in the findings such that there was “a reasoned statement in 
support of the decision.” I.C. § 67-5248(1)(a). While there may be a temptation to simply 
shortcut the legal process and address both legal conclusions reached in Dr. Dammrose’s report, 
this Court resolves disputes not by diving into every issue raised by the parties, but rather, by 
carefully considering whether an issue must be decided and upon what grounds. Moreover, 
resolution of factual issues cannot be made for the first time by this Court. Mercy Med. Ctr., 146 
Idaho at 232, 192 P.3d at 1056. Those findings belong to the Board. Id. Therefore, we vacate the 
Amended Determination and remand this case for the entry of findings of fact and conclusions of 
law. 
B. St. Luke’s is not entitled to attorney’s fees on appeal.  
St. Luke’s contends that the Court should award it attorney’s fees because the Board had 
no authority or evidence to deny services from February 19 to March 9, 2016. Idaho Code 
section 12-117(1) provides: “. . . the court hearing the proceeding, including on appeal, shall 
award the prevailing party reasonable attorney’s fees, witness fees and other reasonable 
6 
 
expenses, if it finds that the nonprevailing party acted without a reasonable basis in fact or law.” 
However, the Board failed to make factual findings and legal conclusions. Because neither party 
has prevailed, we decline to make a fee award.  
IV. 
CONCLUSION  
The Board’s Amended Determination of Approval for Benefits is vacated, and the case is 
remanded for proceedings consistent with this opinion. Costs to St. Luke’s.  
 
Chief Justice BURDICK, and Justices BEVAN, STEGNER, and HORTON CONCUR.