Document: 452 U.S. 378 101 S.Ct. 2415 69 L.Ed.2d 89 NATIONAL GERIMEDICAL HOSPITAL AND GERONTOLOGY CENTER, Petitioner,v.BLUE CROSS OF KANSAS CITY and Blue Cross Association. No. 80-802. Argued April 29, 1981. Decided June 15, Syllabus Prior to the completion of its construction, petitioner, a private, acute-care community hospital in Kansas City, Mo., metropolitan area, sought enter into participating agreement with respondent City (Blue Cross), nonprofit provider individual group health-care reimbursement plans area. refused on basis policy barring participation by any new that could not show it was meeting clearly evident need for services service relied petitioner's failure obtain approval construction from Mid-America Health Systems Agency (MAHSA), nonprofit, federally funded corporation which local "health system agency" (HSA) designated area under National Planning Resources Development Act 1974 (NHPRDA). MAHSA's major function is health planning Petitioner had MAHSA because latter's announced would approve addition beds view determination there surplus Alleging wrongful refusal deal conspiracy between MAHSA, resulted competitive disadvantage it, petitioner filed suit against respondents Association violation Sherman Act. Respondents contended NHPRDA impliedly repealed antitrust laws as applied conduct question. The District Court granted judgment respondents, finding clear repugnancy laws, congressional intent repeal this context. Appeals affirmed. Held : Although may have acted only highest motives seeking implement HSA, they cannot defeat claim assertion immunity requirements Pp. 388-393. (a) Implied can be justified convincing showing regulatory system. Even when an industry regulated substantially, does necessarily evidence respect every action taken within industry. And much clearer agency has been empowered regulate type challenge. 388-389. (b) challenged here neither compelled nor approved governmental body. Instead, spontaneous response advisory body, HSA which, NHPRDA, no authority over providers. And, application Cross' frustrate particular provision or create conflict orders Nor require take that, essence, enforce decision MAHSA. There reason believe Congress specifically contemplated "enforcement" decisions private insurance providers, let alone such actions put "teeth" noncompulsory process. 389-391. (c) so incompatible concerns "pervasive" failed make necessary exemption all actions. 391-393. 8th Cir., 628 F.2d 1050, reversed remanded. Erwin N. Griswold, Washington, D. C., petitioner. Sol. Gen. Wade H. McCree, Jr., United States amicus curiae special leave Court. Joshua F. Greenberg, New York respondents. Carl Weissburg J. Mark Waxman, Los Angeles, Cal., Federation American Hospitals curiae. Justice POWELL delivered opinion 1 case, Gerimedical Hospital Gerontology Center (National Gerimedical) Cross) national Association, challenging accept member plan. issue presented whether immunized scrutiny intended aid implementation systems 1974. 2 * opened 1978 area.1 Cross, Missouri Kansas. Under agreement, hospitals receive direct full costs covered rendered subscribers.2 When subscribers care are members, pays 80% cost, these payments made subscriber, rather than directly hospital. 3 official "a defined area."3 In determining satisfied requirement, "HSA"—the (MAHSA).4 This corporation, (NHPRDA), 88 Stat. 2229, amended, 42 U.S.C. § 300l (1976 ed. Supp.IV). Its 4 conducting functions, determined hospitals. As result policy, did seek leading status Cross. 5 Claiming at disadvantage, Western It claimed violations §§ Act, 15 1, 2, alleging MAHSA.5 relief treble damages injunction prevent future violations. 6 moved dismiss complaint ground anti-trust question.6 treated motion one summary judgment, 479 F.Supp. 1012 (1979). reasoned if parties effectuate objectives subjected liability, accomplishment goals frustrated. Id., 1021. Having found "clear repugnancy,"id., 1024, court largely legislative history "Congress pursuant scope exempt laws," ibid. Eighth Circuit affirmed, essentially adopting reasoning 1050 (1980). agreed Court's "finding scheme call now become claim." 1055-1056. then quoted argument 7 We writ certiorari review important 449 1123, 938, 67 108 (1981). II 8 Our case requires careful attention structure well implied repeals laws. begin description complex agencies established order assess legal significance brought here. 9 whose prompted hospital, but part larger statutory scheme. 300k et seq., created federal, state, bodies coordinate their activities policy. Building existing development statutes,7 assist preventing overinvestment maldistribution facilities. See Senate Report, 39; U.S.Code Cong. & Admin.News 1974, p. 7842. 10 HSA's concerned generally H.R.Rep.No.93-1382, pp. 40-41 (1974). Each public regional single unit government, serving area." -1(b)(1). statute majority board members consumers least 40% "providers." -1(b)(3)(C). "primary responsibility" each "effective promotion services, manpower, facilities meet identified needs, reduce documented inefficiencies, agency." -2(a). originally enacted, four general goals: "improving residents," "increasing accessibility . ., acceptability, continuity, quality services," "restraining increases cost "preventing unnecessary duplication resources." -2(a).8 To accomplish goals, formulate "detailed statement goals" called plan," §300l -2(b)(2), "annual plan" describing will achieve plan, -2(b)(3), "specific projects achieving the" annual -2(b)(4). instructed "seek, extent practicable, [its plans] assistance individuals entities -2(c)(1). addition, provide "technical assistance" programs, -2(c)(2), should use grants contracts encourage -2(c)(3). do possess 11 At state level, two separate bodies. first, State Agency, Governor Federal Government. 300m. perform certain crucial functions undertaken HSA's: 12 "Specifically, integration synthesis areawide Statewide establishment priorities State, performance most appropriately carried out level. latter government." 52. 13 must governed "State Program," Secretary Human Services meets guidelines set 300m-1, 300m-2. Included requirement establish "certificate need" program institutional prior construction. 300m-2(a)(4)(A).9 procedure "the basic component overall effort control capital expenditures contribute greatly total bill." S.Rep.No.96-96, (1979), 1979, 1306, 1310 (hereinafter 1979 Report). 14 advised Coordinating Council, composed representatives HSA's. council HSA's, revise plans, recommendations applications federal funds States. 300m-3(c). various Government plays role concerning appropriate supply, distribution, organization resources. 300k-1; see CFR 121.1 seq. Finally, Council advise administration 300k-3. 16 elaborate remedy perceived deficiencies existed problems addressed fall categories. First, concern marketplace forces produce efficient investment minimize care.10 facilities.11 17 amended substantially Amendments Pub.L. 96-79, 93 592. A purpose "[d]irect consideration given throughout process importance maintaining improving competition industry." 3, 1308.12 Toward end, added number provisions requiring local, levels. 300k-2(b), 300l-2(a)(5) ed., Supp.IV); 300n-1(c)(11), (12) H.R.Conf.Rep.No.96-420, 58 doing, however, recognized distinction areas where serve useful those some other allocation resources remained necessary.13 III 18 contends denial violated defends plan further purposes NHPRDA. argues despite absence reference creation summarized above conduct. 19 On occasions, faced similar claims context industries. principles applicable established. represent "fundamental economic policy." Carnation Co. v. Pacific Westbound Conference, 383 213, 218, 86 781, 784, 709 (1966); Lafayette Louisiana Power Light Co., 435 389, 398-399, 98 1129, 55 364 (1978). "Implied favored, system." Securities Dealers, 422 694, 719-720, 95 2427, 2442-2443, 45 486 (1975); Gordon Stock Exchange, 659, 682, 2598, 2611, 463 Philadelphia Bank, 374 321, 350-351, 83 1715, 1734, 915 (1963). "Repeal regarded [subsequent law] work, even minimum necessary. guiding principle reconciliation schemes." Silver 373 341, 357, 1246, 1257, 389 20 sure, intend governs, supra; supra, clear. E. g., Otter Tail States, 410 366, 372-375, 1022, 1027-1028, 35 359 (1973); Radio Corp. America, 358 334, 346, 79 457, 464, 354 (1959). Intent authorize 730-734, S.Ct., 2448-2450; U.S., 689-690, 2614-2615. 21 present we apply precedents quite different considered previously. area.14 Indeed, aspects NHPRDA—controlled agencies—were place Missouri. simply regulation construction.15 22 result, weaker previous cases. argued record discloses formal request refrain accepting made, more advice body—albeit body fact crucial, especially disfavored implications business entity. 339, 461, 464; cf. Tail, 374, 1028 ("When relationships first instance coercion, courts hesitant conclude override fundamental policies embodied laws"). 23 rely eliminate -2(a)(4) Supp.IV), point language [health area," Here, argue, duplicating unnecessarily, merely "implementation" finding. 24 unpersuaded, cited sufficient repugnancy" facts case. n. 18, infra. Nothing themselves required cooperation "to practicable." expected implemented mainly through persuasion cooperation. If recommendation used justify act enforcement, effectively give greater force intended.16 25 here, respondents' remaining immunizes Arguably, assumption Congress, particularly passed original Act,17 relevant so, although comprehensive fashion, might concluded without interference suits. 26 force, light prominence gave respond classic forces." 39. Perhaps makes little sense entertain suits promote protect free competition. clear, providers recommendations. industrial contexts, blanket exemption, substitution 217-219, 784-785 (maritime industry); 373-374, 1027-1028 (electric power industry). These holdings based possible, proper approach analysis reconciles operation both schemes another, holding completely ousted." Silver, 1257. indication One manifestation alter structure, plain "competition consumer choice" favored wherever "can constructively advance assurance, effectiveness, access." 300k-2(a)(17) Supp.IV).18 27 hold, therefore, Moreover, discussed above, specific Act.19 below 28 ordered. licensed Division since September 1977. also certified Medicare Department Services. All members. January l976, issued "Prerequisites" guided deciding App. 141a. included following: "The institutions shall approved, and/or law, necessary, respectively; or, effective, provided Public Law 93-641, 'National 1974.' " 146a. retained final discretion warning contemplating construction: "Because lack knowledge applicant waiving groups urged consult expect time actual construction." Ibid. supra. newsletter July 21, 1976, "[a]ll reviewed Agencies reimbursable City." 147a. named defendant. Missouri's argued, unsuccessfully, immune attack McCarran-Ferguson 1011 prepaid medical "trade commerce" meaning allegations were insufficient. before S.Rep.No.93-1285, 4-39 (1974) 1972, example, 1122 Social Security 1320a-1, authorizes agreements willing approving 1122, reimbursements programs including Medicaid include expenses received approval. chose renew thus eliminating Brief 6, 6. (1979 Amendments), 103(c), 595, another goal, "preserving -2(a)(5) provides reductions participate 300m(d). Report it: strengthened coordinated personal growing apparent day. Committee forces. highly technical nature together growth third party mechanisms attenuate usual influencing behavior services. "Investment costly resources, beds, coronary units radio-isotope treatment centers frequently regard existence equipment already operating Investment results accumulation, establishes ongoing demand payment support "A recently published study indicates 1975, 67,000 unneeded "Hospital though unused, substantial additional stated: "Widespread access distribution exist many urban areas, hospitals, clinics crowded relatively tiny sectors, while large go poorly served unserved. Many rural communities physician service, adjacent oversupplied." threat domination decisionmaking stake 57-59. Rosenblatt, Care Reform Administrative Law: Structural Approach, Yale L.J. 243, 304-330 (1978) (describing establishing representation HSA's). subsection, 300k-2(b)(1) effect respecting supply diminished," causing "duplication excess facilities." allocates consistent plans," "give priority strengthen services." 300k-2(b)(3). But, inpatient allocate supply," "take 300k-3(b)(2). Significantly, insurers incentives hold down institutions, mention restraining calls "reimbursement [to] utilization positive actively less equal alternatives care, develop uniform programs." 67a. But asserts "[c]apital [shall] controlled 7, done probably arisen. conditioned issuance need." 385-386. Parties pursuing certificate subject penalties. 300m-2(a)(4)(A) subsequently enacted legislation. Mo.Rev.Stat. 197.300 (Supp.1980). knew how effect. -2(e) approval—subject Secretary—is programs. noted 387-388, prominent thinking Congress. Nevertheless, convinced operate parts industry, e. 300k-2(b) emphasize our foreclose factual contexts. favoring reversal "there must, implication, HSAs exercise authorized powers." Amicus Curiae 16, 11. Where, expressly advocated form cost-saving among "necessary [NHPRDA] work." 124 Cong.Rec. 34932 (Rep. Rogers) ("The who voluntarily work them carrying mandate were, 93-641 implemented.") Such differ one, insurer's heed HSA. not, course, suggest anything about merits matters remain litigated remand, alleged "refusal deal" took place.

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