Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caDC-07-05343/USCOURTS-caDC-07-05343-0/pdf.json

Nature of Suit Code: 895
Nature of Suit: Freedom of Information Act of 1974
Cause of Action: 

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United States Court of Appeals

FOR THE DISTRICT OF COLUMBIA CIRCUIT

Argued October 8, 2008 Decided January 30, 2009

No. 07-5343

CONSUMERS’ CHECKBOOK,

CENTER FOR THE STUDY OF SERVICES,

APPELLEE

v.

UNITED STATES DEPARTMENT OF HEALTH 

AND HUMAN SERVICES ET AL.,

APPELLANTS

AMERICAN MEDICAL ASSOCIATION,

INTERVENOR

Appeal from the United States District Court

for the District of Columbia

(No. 06cv02201)

Steve Frank, Attorney, United States Department of Justice,

argued the cause for the appellants. Gregory G. Katsas,

Assistant Attorney General, Jeffrey A. Taylor, United States

Attorney, and Leonard Schaitman, Attorney, were on brief. R.

Craig Lawrence, Assistant United States Attorney, entered an

appearance.

Jack R. Bierig argued the cause for intervenor American

Medical Association in support of the appellants.

USCA Case #07-5343 Document #1162054 Filed: 01/30/2009 Page 1 of 33
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Robert M. Portman was on brief for amici curiae American

Medical Association et al. in support of the appellants.

Nicole R. Rabner argued the cause for the appellee. Patrick

J. Carome and Paul R. Q. Wolfson were on brief.

Stacy J. Canan was on brief for amici curiae American

Association of Retired Persons et al. in support of the appellee.

Mark R. Savage was on brief for amicus curiae Consumers

Union of United States, Inc. in support of the appellee.

Before: HENDERSON, RANDOLPH and ROGERS, Circuit

Judges.

Opinion for the court filed by Circuit Judge HENDERSON.

Separate opinion filed by Circuit Judge ROGERS, concurring

in part and dissenting in part.

KAREN LECRAFT HENDERSON, Circuit Judge: Consumers’

Checkbook, Center for the Study of Services (CSS) filed this

action under the Freedom of Information Act (FOIA), 5 U.S.C.

§§ 552 et seq., seeking from the United States Department of

Health and Human Services (HHS) records for all Medicare

claims submitted to HHS by physicians in several localities

during 2004. The district court granted summary judgment in

CSS’s favor, concluding that the records are not exempt from

disclosure under FOIA Exemption 6, id. § 552(b)(6). See

Consumers’ Checkbook, Ctr. for Study of Servs. v. U.S. Dep’t of

Health & Human Servs., 502 F. Supp. 2d 79, 83-86 (D.D.C.

2007) (Memorandum Opinion). For the reasons set forth below,

we reverse the judgment of the district court.

I.

On March 27, 2006, CSS submitted a FOIA request to the

Centers for Medicare and Medicaid Services (CMS), a division

within HHS, seeking a subset of data elements from all

Medicare claims submitted by certain physicians in 2004. The

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Health service providers and suppliers must enroll in the

Medicare program “[t]o receive payment for covered Medicare items

or services from either Medicare . . . or a Medicare beneficiary.” 42

C.F.R. § 424.505. CMS discontinued the UPIN as of June 2007 and

replaced it with the National Provider Identifier (NPI). See CMS,

UPIN Directory, http://www.cms.hhs.gov/NonIdentifiable

DataFiles/08_UniquePhysicianIdentificationDirectory.asp (last visited

Jan. 23, 2009). The NPI is a unique identifier used to identify each

health care provider or supplier. See CMS, The Who, What, When,

Why & How of NPI: Information for Health Care Providers (2006),

http://www.cms.hhs.gov/MedicareProviderSupEnroll/downloads/

EnrollmentSheet_WWWWH.pdf. The NPI registry may be searched

online at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do. 

data elements include the diagnosis, the type and place of

service and the Unique Physician Identifying Number (UPIN)

of the physician who performed the services. CSS limited its

request to physicians in the District of Columbia, Illinois,

Maryland, Washington and Virginia. It did not request data that

identifies Medicare beneficiaries. At the time of the request,

every physician was assigned a UPIN when he enrolled in

Medicare.1 A physician’s name, office zip code, medical or

surgical specialty and UPIN are publicly available on the

internet. The fees a physician receives from Medicare for

performing a specific service or procedure are also publicly

available on the internet. Combined with the publicly available

fee schedule, the data requested by CSS can be used to calculate

the total payments Medicare made to any individually identified

physician for claims submitted in 2004.

CMS denied the FOIA request and CSS appealed to the

CMS Deputy Administrator. On December 26, 2006, CSS filed

a complaint in district court under FOIA seeking injunctive

relief. Both parties moved for summary judgment. HHS argued

that the requested records are exempt from disclosure under

FOIA Exemption 6. Alternatively, it argued that a twenty-nineUSCA Case #07-5343 Document #1162054 Filed: 01/30/2009 Page 3 of 33
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2

The district court also held that CSS is entitled to the requested

information without charge under 5 U.S.C. § 552(a)(4)(A)(iii).

Memorandum Opinion at 86-89. HHS does not appeal the fee waiver

determination. 

3

HHS also appeals the district court’s determination that the

Middle District of Florida’s permanent injunction does not bar

disclosure of the requested data from physicians who are AMA

members. See Fla. Med. Ass’n, 479 F. Supp. 1291. It argues that

under GTE Sylvania, Inc. v. Consumers Union of United States, Inc.,

445 U.S. 375 (1980), a requesting party may not obtain documents

under FOIA “when the agency with possession of the documents has

been enjoined from disclosing them by a Federal District Court.” 445

U.S. at 384. As we resolve this appeal on other grounds, we express

no opinion as to the merits of the argument under GTE Sylvania.

year-old permanent injunction issued by the United States

District Court for the Middle District of Florida bars disclosure

of the requested data from physicians who are American

Medical Association (AMA) members. See Fla. Med. Ass’n v.

Dep’t of Health, Educ. & Welfare, 479 F. Supp. 1291 (M.D. Fla.

1979). In an opinion and order filed August 22, 2007, the

district court granted summary judgment in CSS’s favor and this

appeal followed.2 Memorandum Opinion at 81, 89.

II.

HHS appeals the district court’s grant of summary judgment

as to the requested Medicare records the court held were not

exempt from disclosure under FOIA Exemption 6.3

 We review

the district court’s grant of summary judgment de novo.

Judicial Watch, Inc. v. FDA, 449 F.3d 141, 145 (D.C. Cir.

2006). FOIA provides that an agency must disclose all records

upon request by “any person,” 5 U.S.C. § 552(a)(3), unless a

statutory exemption applies. Id. § 552(b). FOIA Exemption 6

provides that FOIA “does not apply to matters that are . . .

personnel and medical files and similar files the disclosure of

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which would constitute a clearly unwarranted invasion of

personal privacy.” Id. § 552(b)(6). It is undisputed that the

requested Medicare records are personnel, medical, or “similar

files.” See Memorandum Opinion at 83. Accordingly, we must

determine whether “disclosure would compromise a substantial,

as opposed to a de minimis, privacy interest.” Nat’l Ass’n of

Retired Fed. Employees v. Horner, 879 F.2d 873, 874 (D.C. Cir.

1989). If a substantial privacy interest is at stake, then we must

balance the privacy interest in non-disclosure against the public

interest. Id. (citing Ripskis v. HUD, 746 F.2d 1, 3 (D.C. Cir.

1984)). Disclosure is not required if it “would constitute a

clearly unwarranted invasion of personal privacy.” 5 U.S.C.

§ 552(b)(6). The agency bears the burden to persuade the court

that the exemption applies. Ripskis, 746 F.2d at 3.

A.

We have consistently held that an individual has a

substantial privacy interest under FOIA in his financial

information, including income. In Multi AG Media v.

Department of Agriculture, 515 F.3d 1224 (D.C. Cir. 2008), we

found that the disclosure of information on “irrigation practices,

farm acreage, and the number and width of rows of tobacco and

cotton” implicated substantial privacy interests because it would

“in some cases allow for an inference to be drawn about the

financial situation of an individual farmer” receiving federal

subsidies. 515 F.3d at 1226, 1230. In Painting and Drywall

Work Preservation Fund, Inc. v. HUD, 936 F.2d 1300 (D.C. Cir.

1991), we found that contractors on federal construction projects

had a substantial privacy interest in their names, addresses,

hourly pay, hours worked and wages. 936 F.2d at 1301-02; see

also Sheet Metal Workers Int’l Ass’n, Local No. 9 v. U.S. Air

Force, 63 F.3d 994, 995, 998 (10th Cir. 1995) (government

contractors on federal construction projects have substantial

privacy interest in payroll records); Painting Indus. of Haw.

Market Recovery Fund v. U.S. Dep’t of Air Force, 26 F.3d 1479,

USCA Case #07-5343 Document #1162054 Filed: 01/30/2009 Page 5 of 33
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1484 (9th Cir. 1994) (same); Hopkins v. HUD, 929 F.2d 81, 86-

87 (2d Cir. 1991) (same). The Congress has also recognized the

privacy interest an individual taxpayer has in his tax return

information, including the “nature, source, or amount of his

income,” 26 U.S.C. § 6103(b)(2)(A), and has prohibited the

disclosure of tax return information with limited exceptions. Id.

§ 6103(a).

The information requested by CSS would reveal the total

Medicare payments received by a physician for covered

services. CSS notes that the information would not reveal a

physician’s gross revenue because it would not include income

from non-Medicare sources. Nor would it reveal a physician’s

net income because it would not include business operating

expenses. But the requested information need not reveal

completely an individual’s personal finances to implicate

substantial privacy concerns. See Multi AG Media, 515 F.3d at

1228-29 (substantial privacy interests implicated because

requested information “would necessarily reveal at least a

portion of the owner’s personal finances”) (quoting Nat’l Parks

& Conservation Ass’n v. Kleppe, 547 F.2d 673, 685 (D.C. Cir.

1976)). CSS also argues that a physician does not have a

privacy interest in Medicare payments because the payments

relate to business activities and not personal finances. We have,

however, recognized substantial privacy interests in businessrelated financial information for individually owned or closely

held businesses because the “financial makeup of the businesses

mirrors the financial situation of the individual family

members.” Multi AG Media, 515 F.3d at 1229 (internal

quotations omitted); cf. Wash. Post Co. v. U.S. Dep’t of Justice,

863 F.2d 96, 100 (D.C. Cir. 1988) (information related to

employees’ business decisions in developing and marketing

medication does not implicate privacy interests under FOIA

Exemption 7); Wash. Post Co. v. U.S. Dep’t of Health & Human

Servs., 690 F.2d 252, 261-62 (D.C. Cir. 1982) (no substantial

privacy interest in list of organizations in which scientific

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consultants have financial holdings related to their consulting

duties, but not dollar amounts of holdings). Accordingly, we

conclude that physicians have a substantial privacy interest in

the total payments they receive from Medicare for covered

services. 

B.

We next examine the public interest in disclosure. The only

relevant public interest in disclosure “is the extent to which

disclosure would serve the ‘core purpose of the FOIA,’ which is

‘contribut[ing] significantly to public understanding of the

operations or activities of the government.’” U.S. Dep’t of Def.

v. FLRA, 510 U.S. 487, 495 (1994) (quoting U.S. Dep’t of

Justice v. Reporters Comm. for Freedom of Press, 489 U.S. 749,

775 (1989)). The requested information must “shed[] light on

an agency’s performance of its statutory duties.” Reporters

Comm. for Freedom of Press, 489 U.S. at 773. “[I]nformation

about private citizens . . . that reveals little or nothing about an

agency’s own conduct” does not serve a relevant public interest

under FOIA. Id. The requesting party’s intended use for the

information is irrelevant to our analysis. See id. at 771 (“[T]he

identity of the requesting party has no bearing on the merits of

his or her FOIA request.”). 

CSS claims that disclosure of the requested records will

serve the public interest by revealing information about “(i)

HHS’s performance in maintaining and enhancing the quality

and efficiency of services provided under the Medicare program,

(ii) the agency’s ability to root out Medicare fraud and waste;

and (iii) the agency’s compliance with various transparency

initiatives.” Appellee’s Br. 21. We examine each contention in

turn.

1.

The Congress has charged HHS with “promoting the

effective, efficient, and economical delivery of health care

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Quality peer review organizations review whether services are

reasonable and medically necessary, the quality of services and

whether certain services can be performed more effectively and

economically on an outpatient basis. 42 U.S.C. § 1320c-3(a)(1).

services, and of promoting the quality of services of the type for

which payment may be made” by contracting with peer review

organizations.4 42 U.S.C. § 1395y(g). In 2003, the Congress

directed HHS to establish a demonstration program to “examine

health delivery factors that encourage the delivery of improved

quality in patient care.” Id. § 1395cc-3(b). While CMS has

certain responsibilities to promote quality healthcare for

Medicare beneficiaries, it is not authorized to “exercise any

supervision or control over the practice of medicine or the

manner in which medical services are provided, or over the

selection, tenure, or compensation of any officer or employee of

any institution, agency, or person providing health services.” Id.

§ 1395.

CMS is also responsible for enrolling health care providers

and suppliers, including physicians, in the Medicare program.

A “provider” or “supplier” must be enrolled in the Medicare

program to receive payment for covered services. 42 C.F.R.

§§ 424.505, 424.510. The term “supplier” refers to “a physician

or other practitioner, or an entity other than a provider, that

furnishes health care services under Medicare.” Id. § 400.202.

The term “physician” includes “a doctor of medicine or

osteopathy legally authorized to practice medicine and surgery

by the State in which he performs such function or action.” 42

U.S.C. § 1395x(r). CMS may exclude from participation in any

Federal health care program, including Medicare, “[a]ny

individual or entity . . . whose license to provide health care has

been revoked or suspended by any State licensing authority . . .

for reasons bearing on the individual’s or entity’s professional

competence [or] professional performance.” Id. § 1320a-7(b)(4).

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CMS may also exclude an individual or entity that “has

furnished or caused to be furnished items or services to

patients . . . substantially in excess of the needs of such patients

or of a quality which fails to meet professionally recognized

standards of health care.” Id. § 1320a-7(b)(6)(B).

CSS makes three arguments regarding how the requested

data will shed light on HHS’s performance of its mission to

promote quality healthcare for Medicare beneficiaries. First, it

claims that the requested data will indicate the quality of care

Medicare patients are receiving. The claim rests on the

assumption that the frequency with which a physician performs

a medical procedure indicates the quality of the procedure. The

medical community has not reached a consensus on whether the

number of procedures performed by a physician correlates to the

quality of those procedures. Compare John D. Birkmeyer et al.,

Surgeon Volume and Operative Mortality in the United States,

349 New Eng. J. Med. 2117, 2117 (2003) (“Patients can often

improve their chances of survival substantially, even at highvolume hospitals, by selecting surgeons who perform the

operations frequently.”), with Ethan A. Halm et al., Is Volume

Related to Outcome in Health Care? A Systematic Review and

Methodologic Critique of the Literature, 137 Annals Internal

Med. 511, 517 (2002) (“Twenty years of research have

established that, for some procedures and conditions, higher

volume among hospitals and physicians is associated with better

outcomes. However, the magnitude of the relationship varies

greatly among individual procedures and conditions. . . . Even

when a significant association exists, volume does not predict

outcome well for individual hospitals or physicians.”). Even

assuming a strong correlation between volume and quality, the

data CSS requests will not indicate total volume because it does

not include procedures performed by physicians for nonMedicare patients.

Second, CSS claims that the requested data will enable the

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public to determine if Medicare is paying physicians with

insufficient certifications, disciplinary histories or poor

evaluations for a large quantity, or any number, of procedures.

The public can determine through publicly available information

whether physicians with insufficient certifications, disciplinary

histories or poor evaluations are enrolled in the Medicare

program. See U.S. Dep’t of Def. Dep’t of Military Affairs v.

FLRA, 964 F.2d 26, 29-30 (D.C. Cir. 1992) (recognizing that

“alternative sources of information available that could serve the

public interest in disclosure” diminish public interest value of

disclosure). One can infer without the requested data that an

enrolled physician is performing at least some procedures. See

42 C.F.R. § 424.540(a)(1) (CMS may deactivate physician’s

Medicare billing privileges if no claims submitted for 12

consecutive months). Currently available information does not

enable an individual to know whether a physician with an

insufficient certification is performing a large number of (or

any) specific procedure, but this added knowledge does not shed

any additional light on whether CMS is following its enrollment

procedures contained in 42 C.F.R. § 424.510. Cf. Multi AG

Media, 515 F.3d at 1231 (requested data indicated entity’s

eligibility vel non to participate in federal benefits program).

Third, CSS claims the “requested records can also be

analyzed in conjunction with other treatment records to

determine whether individual Medicare doctors are providing all

services required to reach standards of recommended care.”

Appellee’s Br. 24. CSS does not explain how the requested data

can be used to perform this analysis. Rather, it cites articles

noting that the quality of care delivered to Medicare

beneficiaries has room for improvement and greater access to

information is necessary for improvement. See Stephen F.

Jencks et al., Change in the Quality of Care Delivered to

Medicare Beneficiaries, 1998-1999 to 2000-2001, 289 JAMA

305, 305 (2003); Elizabeth A. McGlynn et al., The Quality of

Health Care Delivered to Adults in the United States, 348 New

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Eng. J. Med. 2635, 2643-44 (2003).

Even if the requested data could be used to measure the

quality of care provided by Medicare-enrolled physicians, it

would not shed light on the “agency’s performance of its

statutory duties.” Reporters Comm. for Freedom of Press, 489

U.S. at 773. CSS argues that the requested data will indicate the

quality of care being provided by Medicare-enrolled physicians

and thereby permit the public to assess how well CMS is

fulfilling its statutory duty to promote quality. But we fail to see

how the requested data will allow the public to evaluate the

performance of any specific quality-promoting programs CMS

has a statutory duty to undertake. The data will not reveal how

well the peer review organizations with which HHS contracts to

promote quality healthcare are performing their duties, see 42

U.S.C. § 1395y(g), or how well the demonstration program

“examine[d] health delivery factors that encourage the delivery

of improved quality in patient care.” Id. § 1395cc-3(b). The

data will not assist the public in determining whether Medicare

is enrolling physicians who do not meet the enrollment

requirements. Nor will it enable the public to determine whether

CMS is properly excluding physicians who “fail[] to meet

professionally recognized standards of health care,” id. § 1320a7(b)(6)(B), because nothing indicates that a physician who

performs a procedure less often fails to meet recognized

standards of health care.

2.

CSS next contends that disclosure of the requested data will

serve the public interest by revealing fraudulent Medicare claims

made by physicians. For example, CSS notes that physicians

who submit claims for procedures outside their specialties or

who submit unusually high numbers of claims in general or for

specific procedures may be committing fraud. But CSS has not

provided any evidence of alleged fraud the requested data would

reveal. In United States Department of State v. Ray, 502 U.S.

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5

In Computer Professionals for Social Responsibility v. United

States Secret Service, 72 F.3d 897 (D.C. Cir. 1996), we found that no

164 (1991), the Supreme Court rejected the respondents’

“asserted [public] interest [under FOIA Exemption 6] in

ascertaining the veracity of the interview reports” prepared by

the State Department based on interviews with Haitian nationals

involuntarily returned to Haiti. 502 U.S. at 179. The

respondents had not presented “a scintilla of evidence . . . that

tends to impugn the integrity of the reports.” Id. The Court

noted: “If a totally unsupported suggestion that the interest in

finding out whether Government agents have been telling the

truth justified disclosure of private materials, Government

agencies would have no defense against requests for production

of private information.” Id. Similarly, if an unsupported

suggestion that an agency may be distributing federal funds to

a fraudulent claimant justifies disclosure of private information,

the agency would have no defense against FOIA requests for

release of private information.

CSS points to a Government Accountability Office (GAO)

report as general evidence that Medicare is especially

susceptible to fraud. In 1990, the GAO “designated the

Medicare program as high risk for fraud, waste, abuse, and

mismanagement, in part because of its sheer size and

complexity.” U.S. GAO, GAO 06-813, Medicare Integrity

Program: Agency Approach for Allocating Funds Should Be

Revised 1 (2006), http://www.gao.gov/new.items/d06813.pdf.

In 1997, the Congress established the Medicare Integrity

Program, under which CMS contracts with eligible entities to

safeguard Medicare payments, including investigating potential

fraud cases. Id. at 1, 11-12; 42 U.S.C. § 1395ddd(a), (b)(1).

Without more, the GAO’s report does not raise a cognizable

public interest under FOIA in verifying that CMS is adequately

detecting fraud.5

 In Multi AG Media, we did find that release of

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public interest would be served by disclosure under FOIA Exemption

7(C), 5 U.S.C. § 552(b)(7)(C), because the requesting party had

offered no evidence that the agency was engaged in illegal activity.

72 F.3d at 905. Similarly, in McCutchen v. United States Department

of Health and Human Services, 30 F.3d 183, 188 (D.C. Cir. 1994), we

found no public interest because the “mere desire to review how an

agency is doing its job, coupled with allegations that it is not, does not

create a public interest sufficient to override the privacy interests

protected by Exemption 7(C).” We recognize that the balancing

standard for disclosure is different under FOIA Exemption 7(C). See

5 U.S.C. § 552(b)(7)(C) (law enforcement records exempt from

disclosure if release “could reasonably be expected to constitute an

unwarranted invasion of personal privacy”) (emphasis added). But the

rationale of Computer Professionals and McCutchen for requiring

more than unsupported allegations that an agency is not doing its job

applies under FOIA Exemption 6 as well.

the requested data would serve the public interest by allowing

the public to “more easily determine whether [the United States

Department of Agriculture] is catching cheaters and lawfully

administering its subsidy and benefit programs.” 515 F.3d at

1232. The specific public interest in Multi AG Media, however,

was enabling the public “to look at the information the agency

had before it when [determining whether a particular farm is

eligible to participate in the benefit programs in the first place]

so that the public can monitor whether the agency is correctly

doing its job.” Id. at 1231. In contrast, the Medicare claims

data is irrelevant to whether physicians meet the Medicare

enrollment requirements.

3.

Finally, CSS argues that the requested data will shed light

on whether HHS is complying with its own transparency

initiatives. HHS recently proposed a new system of records “to

assist in projects that provide transparency in health care on a

broad-scale enabling consumers to compare the quality and price

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of health care services so that they can make informed choices

among individual physicians, practitioners and providers of

services.” Privacy Act of 1974; Report of New System of

Records, 72 Fed. Reg. 52,133, 52,133 (Sept. 12, 2007). Since

2001, HHS and CMS have launched quality initiatives “to assure

quality health care for all Americans through accountability and

public disclosure,” including publicly reporting certain quality

measures to aid consumer decision-making. CMS, Quality

Initiatives - General Information - Overview, http://www.

cms.hhs.gov/QualityInitiativesGenInfo/ (last visited Jan. 23,

2009).

Contrary to CSS’s assertion, the requested data will not

assist the public in determining whether CMS is complying with

its transparency initiatives to provide consumers with more

information about service providers. First, the public is already

familiar with the type of data contained in the Medicare claims

database, which includes the diagnosis, the type and place of

service and the physician’s UPIN, as evidenced by CSS’s FOIA

request. The public does not need the data itself to evaluate

whether CMS’s failure to disclose it constitutes a failure to

comply with CMS’s transparency initiatives. Nor does the

public need the data to evaluate whether the steps already taken

by CMS are in fact assisting consumers in making informed

decisions. Second, according to CSS’s logic, CMS must

disclose any information possibly relevant to consumer health

care decision making, regardless of privacy interests, simply

because CMS stated its intention to provide more information

relevant to consumer health care decisions. CMS has

undertaken certain transparency initiatives but at no point has it

pledged, or been directed by the Congress, to disclose any

information to the public that could possibly assist consumers in

health care decisions without regard to any countervailing

interest, including the FOIA-recognized privacy interest. See

HHS, Value-Driven Health Care Home: Transparency Leads to

Change, http://www.hhs.gov/valuedriven/ (last visited Jan. 23,

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6

CSS would have us place the public in a position akin to a judge

conducting in camera review of documents to determine whether a

party must produce information it deems irrelevant. See, e.g., Douglas

Oil Co. of Cal. v. Petrol Stops Nw., 441 U.S. 211, 236 n.8 (1979)

(Stevens, J., dissenting) ("[P]etitioners could have requested that the

District Judge view the transcripts in camera to test their relevance.").

The problem in the FOIA context is that once the Medicare data was

viewed by the public and the public had decided its "relevance" under

CSS’s transparency initiatives, the public would have compelled the

very action it wished to evaluate and the issue would be moot. 

2009) (“Transparency is a broad-scale initiative enabling

consumers to compare the quality and price of health care

services, so they can make informed choices among doctors and

hospitals. In cooperation with America's largest employers and

the medical profession, this initiative is laying the foundation for

pooling and analyzing information about procedures, hospitals

and physician services. When this data foundation is in place,

regional health information alliances will turn the raw data into

useful information for consumers.”). CSS in fact seeks to use

FOIA to compel CMS to comply with its transparency initiatives

as CSS views them, not to evaluate whether CMS is fulfilling its

duties.6

In sum, the requested data does not serve any FOIA-related

public interest in disclosure. Accordingly, we need not balance

the non-existent public interest against every physician’s

substantial privacy interest in the Medicare payments he

receives. See Nat’l Ass’n of Retired Fed. Employees v. Horner,

879 F.2d 873, 879 (D.C. Cir. 1989) (“We have been shown no

public interest in . . . disclosure . . . . We need not linger over

the balance; something, even a modest privacy interest,

outweighs nothing every time.”). Accordingly, disclosure of the

requested data “would constitute a clearly unwarranted invasion

of personal privacy.” 5 U.S.C. § 552(b)(6). And even were we

to find a FOIA-related public interest in disclosure, it would be

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negligible at best and insufficient to outweigh the significant

privacy interest in non-disclosure. See Painting & Drywall

Work Preserv. Fund, Inc. v. HUD, 936 F.2d 1300, 1303 (D.C.

Cir. 1991) (“attenuated public interest in disclosure does not

outweigh the construction workers’ significant privacy interest

in the requested information”).

For the foregoing reasons, we conclude that the requested

Medicare claims data CSS seeks is exempt from disclosure

under FOIA Exemption 6, 5 U.S.C. § 552(b)(6). Accordingly,

the judgment of the district court is reversed and the case

remanded for further proceedings consistent with this opinion.

So ordered.

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ROGERS, Circuit Judge, concurring in part and dissenting in

part: In holding that Exemption 6 of the Freedom of

Information Act (“FOIA”), 5 U.S.C. § 552(b)(6), is dispositive,

Op. at 15, the court has assessed a strong privacy interest for

private physicians who receive Medicare reimbursements while

ignoring the commanding public interest in disclosure of

information that would enhance the public’s ability to evaluate

how well the Department of Health and Human Services

(“HHS”) is performing its statutory duties under the Medicare

program. As subjective evaluations should not affect the

balancing of these interests, it is significant that two district

courts here, now and in 1979, and HHS itself have reached a

different conclusion about the importance of disclosing such

data to the public.

The district court concluded that the data requested by the

Consumers’ Checkbook, Center for the Study of Services (“the

Center”) would enhance the public’s ability to understand

whether HHS is effectively policing reimbursements and

physician practices. Consumers’ Checkbook, Ctr. for the Study

of Servs. v. Dep’t of Health & Human Servs., 502 F. Supp. 2d

79, 85-86 (D.D.C. 2007) (“Consumers’ Checkbook I”). Another

district court judge in this district reached much the same

conclusion in 1979. Pub. Citizen Health Research Group v.

Dep’t of Health, Educ. & Welfare, 477 F. Supp. 595, 604

(D.D.C. 1979) (“Public Citizen”), rev’d on other grounds, 668

F.2d 537 (D.C. Cir. 1981). HHS, in turn, has previously

released such data to at least one private enterprise unrelated to

the agency’s own initiatives, see Alley v. Dep’t of Health &

Human Servs., No. CV-07-BE-0096-E, slip op. at 3 (N.D. Ala.

May 8, 2008) (“Alley, N.D. Ala. 2008”), and also announced as

recently as 2007 that it would release much of the requested data

to research entities outside of the federal government as part of

a program of transparency, Privacy Act of 1974; Report of New

System of Records, 72 Fed. Reg. 52,133 (Sep. 12, 2007) (“2007

Records System”). HHS also has not appealed the waiver of

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2

FOIA fees for the Center premised on the determination that the

requested data is “in the public interest because it is likely to

contribute significantly to public understanding of the operations

or activities of the government,” 5 U.S.C. § 552(a)(4)(A)(iii).

Perhaps this is because, as Judge Gerhard Gesell wrote in 1979,

“[p]ractitioners who contract with the government to provide

medical services in exchange for federal payments perform a

quasi-public function,” and given “Congress’ abiding concern

to deliver cost-efficient public health care and physicians’ clear

prerogative to avoid government business,” important public

interests are at stake. Public Citizen, 477 F. Supp. at 604.

I.

The Freedom of Information Act requires agencies to

disclose all requested agency records, 5 U.S.C. § 552(a), unless

a statutory exemption applies, id. § 552(b). It is designed to

“‘pierce the veil of administrative secrecy and to open agency

action to the light of public scrutiny.’” Dep’t of Air Force v.

Rose, 425 U.S. 352, 361 (1976) (quoting Rose v. Dep’t of Air

Force, 495 F.2d 261, 263 (2d Cir. 1974)). Consistent with “the

basic policy that disclosure, not secrecy, is the dominant

objective of the Act,” the statutory exemptions are “narrowly

construed.” Id. at 361. Under Exemption 6 an agency may

withhold “personnel and medical files and similar files the

disclosure of which would constitute a clearly unwarranted

invasion of personal privacy.” 5 U.S.C. § 552(b)(6) (emphasis

added). If a court determines that a substantial privacy interest

is at stake, the court must then consider whether the “public

interest in disclosure outweighs the individual privacy

concerns.” Nat’l Ass’n of Home Builders v. Norton, 309 F.3d

26, 35 (D.C. Cir. 2002). FOIA’s “strong presumption in favor

of disclosure places the burden on the agency” to justify

nondisclosure. Dep’t of State v. Ray, 502 U.S. 164, 173 (1991).

This “presumption favoring disclosure . . . is at its zenith under

USCA Case #07-5343 Document #1162054 Filed: 01/30/2009 Page 18 of 33
3

Exemption 6.” Nat’l Ass’n of Home Builders, 309 F.3d at 37.

In March 2006, the Center requested HHS to release certain

Medicare claims data for health care providers in the District of

Columbia and the States of Illinois, Maryland, Washington, and

Virginia. This data includes the providers’ Medicare

identification number, procedure codes, diagnosis codes, and

geographic codes, but not patient identities. Although this data

does not directly reveal annual Medicare reimbursement

amounts for particular Medicare providers, the district court

found that the information can be used, in conjunction with free,

public information that Congress requires HHS to disseminate

to the public, see Omnibus Budget Reconciliation Act of 1990,

Pub. L. No. 101-508, § 4164, as amended, (“OBRA 1990”), 42

U.S.C. § 1395u note, and a free website for which HHS

contracts, to determine those amounts. See Consumers’

Checkbook I, 502 F. Supp. 2d at 84-85; Appellant’s Br. at 18.

The crux of the court’s determination today that physicians’

privacy interests outweigh the public interest in disclosure is its

conclusion that the requested data cannot assist the public in

assessing either the quality of Medicare services or HHS’s

efforts to combat fraud and waste. Op. at 14-15. In reaching

this conclusion the court overstates the inviolability of the

privacy interest and overlooks the near undeniable fact that the

requested data can be of some assistance to the public’s

evaluation of how HHS is carrying out its initiatives aimed at

measuring and improving health care quality and its efforts to

combat Medicare fraud and waste. 

A.

There is little doubt that the disclosure of the requested

material would implicate more than a de minimus privacy

interest. Privacy encompasses “the individual’s control of

information concerning his or her person,” Dep’t of Justice v.

USCA Case #07-5343 Document #1162054 Filed: 01/30/2009 Page 19 of 33
4

Reporters Comm. for Freedom of the Press, 489 U.S. 749, 763

(1989) (“Reporters Comm.”), and extends to protect an

individual’s name and address, see Nat’l Ass’n of Retired Fed.

Employees v. Horner, 879 F.2d 873, 876 (D.C. Cir. 1989); Fed.

Labor Relations Auth. v. Dep’t of the Treasury, 884 F.2d 1446,

1453 (D.C. Cir. 1989), as well as information that would “in

some cases allow for an inference to be drawn about the

financial situation of an individual,” even where the data reveals

only a portion of an individual’s financial situation, Multi AG

Media LLC v. Dep’t of Agric., 515 F.3d 1224, 1230 (D.C. Cir.

2008); see also Lepelletier v. FDIC, 64 F.3d 37, 47 (D.C. Cir.

1999); Nat’l Parks & Conservation Ass’n v. Kleppe, 547 F.2d

673, 685-86 (D.C. Cir. 1976). Indeed, “[w]hen there is a

substantial probability that disclosure will cause an interference

with personal privacy, it matters not that there may be two or

three links in the chain.” Nat’l Ass’n of Retired Fed. Employees,

879 F.2d at 878. HHS suggests that Medicare reimbursements

represent, on average, a quarter of a physician’s income, and can

account for a “large percentage” of total income for some

physicians. Reply Br. at 16.

Nevertheless, as the Center points out, the physicians’

privacy interest is “particularly limited,” Appellee’s Br. at 14-

15, because the requested data pertains to receipt of government

funds and would not reveal physicians’ take-home earnings.

Although the fact of federal government funding may not be

dispositive in assessing the privacy interest, see Multi AG

Media, 515 F.3d at 1230; Nat’l Ass’n of Retired Fed. Employees,

879 F.2d at 876; Painting & Drywall Work Pres. Fund v. Dep’t

of Housing & Urban Dev., 936 F.2d 1300, 1302-03 (D.C. Cir.

1991), it cannot be denied that there is an element of public

service involved when physicians participate in the Medicare

program. See Public Citizen, 477 F. Supp. at 604. Further,

because the requested data does not directly reveal total income

and because HHS has not shown that one can predictably

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5

determine total income using the Medicare reimbursement

amounts, “the privacy interest that may exist is [not] particularly

strong,” Multi AG Media, 515 F.3d at 1230; see also Getman v.

NLRB, 450 F.2d 670, 675 (D.C. Cir. 1971); Public Citizen, 477

F. Supp. at 603-04. The extent of that privacy interest varies

according to how much of the physician’s income is derived

from Medicare; a doctor whose patients are mostly Medicare

beneficiaries has a greater privacy interest in her Medicare

reimbursement amounts than a doctor who treats only a few

Medicare patients. Additionally, Congress has already required

HHS to publish some private information about Medicareparticipating physicians, see, e.g., OBRA 1990, 42 U.S.C. §

1395u note (requiring release of physicians’ identification

number, address, and related information), and HHS has

released data much as the Center seeks, see, e.g, Alley (N.D.

Ala. 2008). Thus, regardless whether a practitioner has many or

only a few Medicare patients, HHS fails to meet its burden to

show that the privacy invasion at issue would be overly

intrusive.

B.

By contrast, there is a commanding and important public

interest in disclosure of the data the Center seeks. The single

relevant public interest in FOIA balancing is the “extent to

which disclosure of the information sought would ‘she[d] light

on an agency’s performance of its statutory duties’ or otherwise

let citizens know ‘what their government is up to.’” Dep’t of

Def. v. Fed. Labor Relations Auth., 510 U.S. 487, 497 (1994)

(quoting Reporters Comm., 489 U.S. at 773) (alteration in

Reporters Comm.). The public interest inquiry focuses, not on

the absolute value, but on “the incremental value of the specific

information being withheld.” Schrecker v. Dep’t of Justice, 349

USCA Case #07-5343 Document #1162054 Filed: 01/30/2009 Page 21 of 33
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1

 Although in Schrecker the court was addressing FOIA Exemption

7(C) when it emphasized the incremental value of withheld

information, only the privacy considerations distinguish Exemptions

6 and 7(C), see Nat’l Archives & Records Admin. v. Favish, 541 U.S.

157, 164-66 (2004); the public interest inquiry is the same for both,

see Fed. Labor Relations Auth., 510 U.S. at 496 n.6. Because the

“incremental value” of withheld information is an appropriate publicinterest measure under Exemption 7(C), which “is more protective of

privacy than Exemption 6,” see id., it is no less of an appropriate

measure under Exemption 6. 

F.3d 657, 661 (D.C. Cir. 2003) (emphasis added).1 Because

Medicare “distributes extensive amounts of public funds,” there

is a “special need” for public oversight of HHS’s activities in

administering Medicare. Multi AG Media, 515 F.3d at 1232; see

generally Government Accountability Office, Medicare

Integrity Program: Agency Approach for Allocating Funds

Should Be Revised, GAO-06-813 (Sep. 2006). As this court

observed in Multi Ag Media, “Congress has recognized the

importance of ensuring the responsible use” of Medicare funds,

515 F.3d at 1232; see, e.g., Inspector General Act of 1978, Pub.

L. No. 95-452, § 2, 92 Stat. 101 (1978). Indeed, HHS itself has

acknowledged both that it “shares [the Center’s] broad policy

goals,” Appellant’s Br. at 39, in public disclosure, and, in

response to the Center’s fee waiver request, that it “do[es] not

dispute that the requested records pertains to operations or

activities of the Federal Government and that the disclosure of

the records would reveal meaningful information about

government operations or activities,” Letter from Herb B. Kuhn,

Acting Deputy Adm’r, Dep’t of Health & Human Servs., to

Robert Krughoff, President, Consumer’s Checkbook, Ctr. for the

Study of Servs. 2 (Mar. 16, 2007) (“Kuhn letter of Mar. 16,

2007”) (emphasis added).

There should be little dispute that the requested data would

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2

 During oral argument, the Center discussed 42 U.S.C.

§ 1395y(a)(1)(B), which precludes reimbursement for services that

“are not reasonable and necessary for the prevention of illness.” The

Center contends persuasively that the requested data, which includes

both the diagnosis and the procedure performed, could shed light on

whether HHS is paying providers for services in violation of this

prohibition. Additionally, the Center mentioned 42 U.S.C. § 1320a7(b), which provides that the Secretary of HHS has discretion to

exclude providers from participating in federal health care programs

for various reasons. One such reason is “claims for excessive charges

or unnecessary services.” 42 U.S.C. § 1320a-7(b)(6). The Center

contends that the requested data will shed light on the Secretary’s

exercise of discretion because an expert looking at diagnosis

information and procedure information could probably determine in

some cases whether certain procedures, and by implication any

charges for those procedures, were excessive or unnecessary.

However, I do not rely on § 1320a-7(b)(6) as it was not cited in the

Center’s brief, thus denying HHS an opportunity to respond in its

reply brief.

shed light on at least two types of HHS activities.2 First, the

data would enable members of the public to evaluate HHS’s

performance of its statutory duties regarding the quality of

Medicare-provided services. Even if HHS does not have

statutory authorization to supervise or control the practice of

medicine, see 42 U.S.C. § 1395, Op. at 8, HHS has a statutory

and regulatory duty to evaluate and work to improve the quality,

cost, and efficiency of services delivered by Medicare providers.

For instance, 42 U.S.C. § 1395y(g) requires HHS to enter into

contracts with “utilization and quality control peer review

organizations” in order to promote improved delivery and

quality of health services. See 42 U.S.C. § 1320c et seq.

(elaborating upon section 1395y(g)). Likewise, Congress has

required HHS to “establish a 5-year demonstration program” for

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projects examining “health delivery factors that encourage the

delivery of improved quality in patient care.” Id. § 1395cc-3(b).

Similarly, HHS’s 2007 Records System is designed “to assist in

projects that provide transparency in health care on a broadscale enabling consumers to compare the quality and price of

health care so that they can make informed choices among

individual physicians, practitioners and providers of services.”

72 Fed. Reg. at 52,133. Likewise, in 2006 President Bush

signed Executive Order No. 13,410, requiring HHS to

“implement programs measuring the quality of services supplied

by health care providers to the beneficiaries or enrollees” of

Medicare. See 71 Fed. Reg. 51,089, 51,090 (Aug. 22, 2006). 

Studies show that releasing the data the Center seeks would

enable members of the public to evaluate HHS’s effectiveness

in fulfilling its duties. One study utilized Medicare claims data

in determining that the number of procedures performed by a

surgeon was inversely related to patient mortality rates for each

of eight studied procedures. See John D. Birkmeyer et al.,

Surgeon Volume and Operative Mortality in the United States,

349 NEW ENG. J. MED. 2117, 2122-23 (2003). Other studies

indicate that information about the number of times a physician

has performed a particular procedure would shed at least some

light on that physician’s success rate. See, e.g., Jim C. Hu et al.,

Role of Surgeon Volume In Radical Prostatectomy Outcomes, 21

J. CLINICAL ONCOLOGY 401 (2003); Deborah Schrag et al.,

Hospital and Surgeon Procedure Volume as Predictors of

Outcome Following Rectal Cancer Resection, 236 ANNALS OF

SURGERY 583 (2002). That there may not be unanimity within

the medical profession about the closeness of the correlation

between experience and quality does not diminish the public

interest in disclosure, as the court implies, see Op. at 9 (citing

Ethan A. Halm et al., Is Volume Related to Outcome in Health

Care? A Systematic Review and Methodologic Critique of the

Literature, 137 ANNALS OF INTERNAL MED. 511 (2002)).

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Neither HHS nor intervenor the American Medical Association

(“AMA”) suggests there is no correlation between experience

and quality. Even assuming the link between quality and the

number of procedures a provider has performed is weak, and

even though the requested data will only partially reveal

physicians’ experience levels, the data has “incremental value”

for ascertaining the quality of services performed both at the

provider level and program-wide. See Schrecker, 349 F.3d at

661. 

The requested data also could be used to evaluate the

disciplinary and board certification histories of Medicare

providers and to study whether Medicare providers meet

recommended standards of care for patients with different

diagnoses. The data has value over and above currently

available information because the public could use it to evaluate

the extent of particular physicians’ Medicare participation and

to determine whether physicians have qualifications to provide

the services for which they seek federal reimbursement;

currently available information reveals only whether a physician

participates in Medicare. Such independent assessments of the

quality of Medicare-funded services, analyzed in the aggregate,

would serve as a check on HHS’s own quality-measuring

projects, helping the public ascertain possible weaknesses in the

Medicare program itself and in HHS’s statutorily-required

assessments of the program. 

Because “the purpose of FOIA is to permit the public to

decide for itself whether government action is proper,”

Washington Post Co., 690 F.2d at 264, the existence of internal

HHS quality-measuring programs does not diminish the public

interest in disclosure. The Supreme Court recognized in

Reporters Committee that “the FOIA’s central purpose is to

ensure that the Government’s activities be opened to the sharp

eye of public scrutiny.” 489 U.S. at 773. In National

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Association of Home Builders, this court held even though the

agency had released its method for designating owl habitats,

there was still a public interest in disclosure of the data used in

that determination. 309 F.3d at 363. Similarly, in Multi AG

Media, this court observed that the data at issue “sa[id]

everything about whether a particular farm is eligible to

participate in the [federal] benefit programs in the first place and

thus ‘shed[] light on the agency’s performance of its statutory

duties.’” 515 F.3d at 1231 (quoting Reporters Comm., 489 U.S.

at 773). The Center has requested several of the same data

elements (including provider identification number, diagnosis

information, and surgical procedures performed) that HHS has

announced it plans to use in the 2007 Records System as part of

its oversight and transparency initiatives. See 72 Fed. Reg. at

52,135. Thus, even assuming HHS does not use the requested

data in determining eligibility or deciding whether to pay a

claim, the public has an interest in disclosure of the requested

data elements. And even if the data would not specifically shed

light on a particular HHS initiative, see Op. at 11, the public

interest in the data is strong with respect to HHS’s fulfillment of

the goal underlying many of its statutory and regulatory

activities: improving the quality of health care provided under

Medicare.

HHS suggests that disclosure of physician-identifying

information (specifically, unique physician identification

numbers), even if the requested data could shed light on the

performance of HHS’s statutory duties, would not contribute

any additional public benefit and so any data release should

redact physicians’ names. To the contrary, physicianidentifying information would enable the public to analyze the

information in context. For example, using the data along with

the physician’s name, researchers would be able to ascertain

whether a physician’s low Medicare procedure volume is

explained by the number of younger patients being treated.

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3

 Although HHS suggests that courts have been disinclined to require

disclosure in instances of derivative use, neither the Supreme Court

nor this court has adopted a per se rule against derivative uses. See

Dep’t of State v. Ray, 502 U.S. 164, 179 (1991); Painting & Drywall

Work Pres. Fund v. Dep’t of Housing & Urban Dev., 936 F.2d 1300,

1303 (D.C. Cir. 1991). Indeed, in Getman, this court indicated that

use of data in further studies may implicate the relevant public

interest, and ordered release of the names and addresses of employees

for use in a study of labor representation elections. 450 F.2d at 677.

In two subsequent derivative use cases, the court concluded that the

public interest in disclosure did not outweigh the privacy interests,

distinguishing Getman on the ground that the information in Getman

was not otherwise publicly available, whereas the information at issue

in those cases could be accessed in other less intrusive ways. See

Painting & Drywall Work Pres. Fund, 936 F.2d at 1303; Fed. Labor

Relations Auth. v. Dep’t of the Treasury, 884 F.2d 1446, 1452 (1989).

Also, withholding identifying information would compromise

the public interest in connection with HHS’s reaffirmation of its

goal of “enabling consumers to compare the quality and price of

health care services so that they can make informed choices

among individual physicians, practitioners and providers of

services.” 72 Fed. Reg. at 52,133. As HHS’s stated policy is to

facilitate consumer choices about which providers to patronize,

it cannot credibly maintain that providing physician-identifying

information could not shed light on its own activities.

Moreover, because the data the Center seeks cannot be retrieved

in any other way, the public interest in disclosure is not

significantly diminished by the derivative nature of its proposed

use.3

Second, the requested data would shed light on HHS’s

fraud-detection and fraud-prevention efforts. For instance, the

data could identify providers who perform “a suspiciously large

number of procedures in a given time period” or “submit[]

claims for procedures that are outside [their] own practice

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12

areas.” Appellee’s Br. at 29. The data could therefore facilitate

public monitoring of HHS detection and prevention of fraud.

Additionally, to the extent that consumer choice could be

enhanced by knowing which physicians are potentially

responsible for wasteful or even fraudulent claims, release of

physician-identifying data is consistent with HHS’s goal of

improving consumers’ decisions about which medical providers

to patronize. See 72 Fed. Reg. at 52,133. The public could

utilize the requested information in determining whether HHS

is fulfilling this stated goal.

Again, that there may already be, as HHS and the AMA

assert, significant government oversight of physicians that the

public can oversee does not diminish the public interest in

disclosure of the requested data. For instance, the public can

currently use a public database to determine whether Medicare

is reimbursing any providers who have already been excluded

from Medicare for misconduct. However, FOIA’s purpose is

“to permit the public to decide for itself whether government

action is proper.” Washington Post Co., 690 F.2d at 264.

Consequently, the public’s interest in monitoring compliance is

not limited to ensuring that once HHS identifies a provider who

has engaged in misconduct, HHS does not reimburse that

provider for services. Rather, the public also has an interest in

monitoring the effectiveness of HHS’s identification of

providers responsible for misconduct. The court’s suggestion

that the Center failed to present evidence of alleged fraud that

the requested data would reveal creates a heightened disclosure

requirement that is without precedent. Op. at 11. Its reliance on

Ray, 502 U.S. 164 , is misplaced; the only issue in that case was

whether the redaction of names and identifying information was

lawful, see id. at 168, and the Supreme Court rejected the

asserted public interest in release of names and other identifying

information for studying the veracity of the released reports

because there was no evidence suggesting that the reports lacked

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13

integrity, id. at 179. The Center is not asserting a public interest

in disclosure of the physicians’ identities for purposes of

verifying the accuracy of the other requested data elements.

Rather, release of the physicians’ identities would enable the

public to place the released information in context and better

assess HHS’s fulfilment of it statutory and regulatory goals. As

noted by the Center, the Government Accountability Office

report, Medicare Integrity Program, Agency Approach for

Allocating Funds Should Be Revised, GAO 06-813 (Sep. 2006),

indicated that HHS had estimated $12.1 billion net of improper

payments to Medicare providers in 2005, offering support for

the proposition that HHS makes some Medicare payments to

fraudulent claimants. 

In sum, Medicare providers’ privacy interest in data that

would reveal part of their annual income is more than de

minimus but not particularly strong, especially given previous

and planned disclosures by HHS. On the other hand, the

requested data would shed light on at least two key HHS

responsibilities under Medicare: (1) measuring and improving

the quality of health care that is provided and (2) combating and

detecting fraud and waste. To the extent that the requested data

may shed little light on the quality of health care delivered by

physicians with only a few Medicare patients, such physicians

also have relatively weak privacy interests in Medicare

reimbursement amounts, which likely represent a small portion

of their annual income. For physicians treating many Medicare

patients, the privacy interest is greater but so is the usefulness of

the requested data. HHS has reached the same conclusion as the

Center about the meaningfulness of the requested data in

informing the public about HHS’s Medicare activities, see, e.g.,

Kuhn letter of Mar. 16, 2007; 2007 Records System, 72 Fed.

Reg. at 52,133. HHS, consequently, has not met its burden to

show that release of the requested data “would constitute a

clearly unwarranted invasion of personal privacy,” 5 U.S.C. §

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4

 In Florida Medical Association v. Department of Health, Education

and Welfare, 479 F. Supp. 1291 (M.D. Fla. 1979), the district court

enjoined HHS’s predecessor:

from disclosing any list of annual Medicare reimbursement

amounts, for any years, which would personally and

individually identify those providers of services under the

Medicare program who are members of the recertified class

in this case.

Florida Med. Ass’n v. Dep’t of Health, Educ. & Welfare, No. 78-178-

Civ-J-S, 1-2 (M.D. Fla. Oct. 22, 1979). The recertified class

comprised all physicians licensed to practice in Florida and all AMA

members who are not Florida physicians but are providers of Medicare

services and would be individually identified in a disclosure. Florida

Med. Ass’n, 479 F. Supp. at 1295-96. A federal court in Louisiana

issued a similar injunction in 1980. See Am. Ass’n of Councils of Med.

Staffs of Private Hosps. v. Health Care Fin. Admin., No. 78-1373

(E.D. La. May 5, 1980). In 2008, a district court in Alabama ruled

that the 1979 Florida injunction applies only to data that indicates

“annual Medicare reimbursement amounts” in a manner that would

personally and individually identify Medicare providers who are

members of the recertified class, or is tantamount to providing such

information. See Alley, N.D. Ala. 2008. 

552(b)(6) (emphasis added).

III.

Although FOIA Exemption 6 would not bar release of the

requested data, HHS contends that release is nonetheless barred

by an injunction issued by the United States District Court for

the Middle District of Florida in 1979.4 If the injunction would

bar release of the data that the Center seeks, then HHS would

not “improperly” be withholding it and the court would lack

jurisdiction to order disclosure. GTE Sylvania, Inc. v.

Consumers Union of the United States, Inc., 445 U.S. 375, 384

USCA Case #07-5343 Document #1162054 Filed: 01/30/2009 Page 30 of 33
15

(1980); see Dep’t of Justice v. Tax Analysts, 492 U.S. 136, 142

(1989). The district court concluded that the 1979 Florida

injunction was “immaterial” to its analysis because the Center

was seeking “different records.” Consumers’ Checkbook I, 502

F. Supp. 2d at 86 n.1. Although this is true, the Center appears

to understate the effect of releasing at least some of the

requested data in urging a narrow construction of the injunction

while HHS appears to overstate the scope of the injunction. 

The data requested by the Center does not coincide

precisely with the data elements that were covered by the list

addressed in the Florida injunction. The Center has requested

29 data elements for claims submitted to HHS, including the

physician provider’s identification number, the patient’s

diagnosis, the procedures performed, and the time and place of

service. It did not request the provider’s name, address, or

reimbursement amounts, the elements specifically covered by

the Florida injunction, see supra note 4. However, the district

court found that by combining the requested data with publicly

available information the public could calculate the

reimbursement amounts for particular procedures by individual

physicians. Consumers’ Checkbook I, 502 F. Supp. at 84. The

Center has not shown that this finding is clearly erroneous. 

The 1979 Florida injunction contains broad language and its

purpose to apply broadly is evident from the accompanying

declaratory judgment and opinion, see Haskell v. Kansas Nat.

Gas Co., 224 U.S. 217, 223 (1912). It “permanently enjoin[s]”

disclosure of “any list” of Medicare reimbursement amounts for

“any years” that would identify members of the recertified class.

 Florida Med. Ass’n v. Dep’t of Health, Educ. & Welfare, No.

78-178-Civ-J-S, 1-2 (M.D. Fla. Oct. 22, 1979). The

accompanying declaratory judgments states: “Any . . . disclosure

of annual Medicare reimbursement amounts, for any years, in a

manner that would personally and individually identify the

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providers of services under the Medicare program who are

members of the recertified class in this case is declared to be

contrary to federal law.” Id. at 2. The accompanying opinion

describes the issue presented as “whether the Secretary . . . of

[HHS’s predecessor] may disclose information concerning the

annual amounts of reimbursements paid to Medicare providers

in a way that would individually identify at least some of those

providers.” Florida Med. Ass’n, 479 F. Supp. at 1294. The

opinion concludes that the list at issue was a “similar file” under

FOIA Exemption 6, observing that “[c]ourts must look past

mere appearances and beneath labels, to the actual character and

nature of the information in question.” Id. at 1303. A 1982

modification provided that the injunction did not prohibit

disclosure of annual Medicare payment information about

individual physicians pursuant to the law enforcement exception

under the Privacy Act, 5 U.S.C. § 552a(b)(7). Florida Med.

Ass’n v. Dep’t of Health & Human Servs., No. 78-178-Civ-J-S

(M.D. Fla. Dec. 2, 1982). 

In these circumstances, Schering Corp. v. Illinois

Antibiotics Co., 62 F.3d 903, 906-07 (7th Cir. 1995), and ALPO

Petfoods, Inc. v. Ralston Purina Co., 913 F.2d 958, 972 (D.C.

Cir. 1990), on which the Center relies, may not counsel a

contrary conclusion about the scope of the 1979 Florida

injunction. Although injunctions are to be construed narrowly,

“the rule of strict construction of injunctions should not be

pressed to a dryly logical extreme,” Schering, 62 F.3d at 906,

and an injunction should be tailored to the harm redressed,

ALPO Petfoods, 913 F.2d at 972. HHS views the injunction as

protecting against invasions of privacy resulting from release of

reimbursement amounts for members of the recertified class,

presumably relying on this court’s FOIA precedent regarding

linkage, e.g., Nat’l Ass’n of Retired Fed. Employees, 879 F.2d

at 878. The Center points out, however, that HHS’s 2007

Records System for quality monitoring, designed to advance the

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public interest in transparency, would entail releasing to outside

researchers the information covered by the 1979 Florida

injunction. HHS has responded that such data might not include

the reimbursement amounts. See Reply Br. at 11. Where this

leaves HHS’s view of the scope of the 1979 Florida injunction

is unclear. In any event, the question remains whether any

doubt about the scope of the injunction requires it to be read

narrowly. See In re Baldwin-United Corp., 770 F.2d 328, 339

(2d Cir. 1985). 

Furthermore, by its specific terms, the 1979 Florida

injunction is limited to the recertified class, as HHS

acknowledged during oral argument; it does not reach the

release of data concerning other physicians. HHS responds that

segregating such data would be an arduous, lengthy task, subject

to error. Perhaps so, but HHS has yet to explain satisfactorily

why this would be in an age of computerized record keeping.

Given FOIA’s presumption in favor of disclosure, HHS is

obligated to segregate these records, see 5 U.S.C. §552(b), or at

least to “provide a more detailed justification than the

conclusory statements it has offered to date,” Mead Data Centr.,

Inc. v. Dep’t of Air Force, 566 F.2d 242, 260 (D.C. Cir. 1977),

as to why segregation would be unreasonable.

Accordingly, I would affirm the district court’s ruling that

FOIA Exemption 6 does not bar release of the Medicare data

that the Center seeks, at least as to records pertaining to

physicians who are not members of the recertified class covered

by the 1979 Florida injunction and perhaps with regard to others

as well, and I would remand the case to the district court for

further proceedings on the scope of the injunction, including an

opportunity for HHS to explain why an order requiring

segregation of the data would be unreasonable.

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