Court Opinion

ID: 8922667
Source: CourtListenerOpinion
Date Created: 2022-11-27 06:24:12.777598+00
Date Added: 2024-06-11T17:09:19.661025
License: Public Domain

POLLACK, District Judge
(dissenting).
I would affirm the decision of the District Court.
Blum v. Yaretsky, 457 U.S. 991, 102 S.Ct. 2777, 73 L.Ed.2d 534 (1982), precludes any possible conclusion on a remand of these cases that a finding of a professional panel, including two institutional physicians, that inpatient care is not (or is no longer) “medically necessary” constitutes "state action."
Pursuant to 42 U.S.C. § 1395f(a)(3), an individual qualifies for benefits for inpatient hospital services or extended care services in a skilled nursing facility under the Medicare program only when there is a determination that such services are medically required and are necessary. Pursuant to the provisions of 42 U.S.C. § 1395x(k), the determination of medical necessity is made by a “Utilization Review Committee” (URC), which consists of health professionals, including two physicians. That statute requires each participating hospital or skilled nursing facility to have a URC. The URC evaluates each patient to determine whether his or her physical condition warrants hospital or skilled nursing in-facility services, basing its judgment upon medically acceptable criteria analyzed and established by autonomous hospital or nursing home staff physician members of the URC. 42 C.F.R. §§ 405.1035(e)(6)(i), 405.1137(d)(2).
The URC must also periodically review the condition of the facility’s inpatients to determine whether continued stay is “medically necessary.” The medical assessment is a professionally developed expression of the range of acceptable variations from usually observed performance. A hospital URC must review each patient’s diagnosis, the patient’s hospitalization stay, and the justification for continuing a patient beyond an expected stay period determined by experience. 42 C.F.R. § 405.-1035(e)(6)(i). A skilled nursing home URC must similarly review the justification for continuing a patient beyond an expected stay period established by the URC itself. 42 C.F.R. § 1137(d)(i).
If the URC has reason to find that continued stay is not “medically necessary,” the patient’s attending physician is notified and given an opportunity to present his or her views before the URC makes a final determination. 42 C.F.R. §§ 405.1035(g)(2), 405.1137(e)(2). If the final determination is that further stay is medically unnecessary, written notice is given to the facility, the attending physician and the patient within two working days. 42 C.F.R. §§ 405.-1035(g), 405.1137(e). The URC decision does.not constitute a discharge order and does not preclude the beneficiary from remaining in the facility or seeking alternative payment sources or accepting other care that is “medically necessary.” Moreover, the decision of the provider’s URC does not constitute a determination of the Secretary as to Medicare coverage. It is considered by the fiscal intermediary along with other evidence in making an initial coverage determination. 42 C.F.R. § 405.-706.
In Blum v. Yaretsky, 457 U.S. 991, 102 S.Ct. 2777, 73 L.Ed.2d 534 (1982), the Supreme Court held that the adjustment of Medicare Part A benefits to reflect the decision of a medical facility to dischargé a patient, or to transfer him or her to a lower level of care, does not constitute “state action.” The Court reasoned that such a determination is a private one, based on the professional medical judgment of private physicians and made in accordance with professional standards not dictated by the state. Id. at 1006-08, 102 S.Ct. at 2786-87. Regulations excluding from participation in the Medicare program a facility which furnishes medical care “substantially in excess of a beneficiary’s needs” do not transform the URC determination into “state action;” the “regulations themselves do not dictate *224the decision to discharge or transfer in a particular case.” Id. at 1010, 102 S.Ct. at 2788. In sum, the Supreme Court found no “state action” in “the judgment, made by concededly private parties, that [a patient] is receiving expensive care that he does not need.” Id. at 1009 n. 19, 102 S.Ct. at 2788 n. 19.
In the instant case, a URC determination that the level of care received by a Medicare Part A beneficiary is no longer “medically necessary” cannot possibly be held to constitute “state action,” even though that patient’s benefits might later be adjusted as a result. Such a determination, like the decision considered in Blum, rests on the professional medical judgment of private physicians. 42 C.F.R. §§ 405.1035(e)(4), 405.1137(b)(1). It is made in accordance with professional criteria established, not by the government, but by staff physicians themselves. 42 C.F.R. §§ 405.1035(g)(2), 405.1137(e)(2).
Although the URC determination must comport with a number of regulations, these regulations — like those analyzed in Blum — do not dictate a medical necessity determination in any particular case. Despite the appellants’ imaginative suggestion that these regulations somehow psychologically bias or corrupt the URC decision-making process, there is no factual basis shown in the record before this Court which indicates that a URC determination is based on anything other than the professional opinions of the staff physician members of the URC. The mere fact that waiver of liability procedures adopted pursuant to 42 U.S.C. § 1395pp encourage a URC to make medically accurate determinations, for example, does not demonstrate that that URC makes medical necessity determinations adverse to beneficiaries which, absent the procedures, would be favorable to beneficiaries.
In sum, an adverse URC determination is a judgment, made by private professional parties, that a patient is receiving expensive care which he or she does not medically need. Under Blum, such a determination cannot possibly constitute “state action.”
The argument which deprecates the patient’s treating physician as a possibly inadequate or inattentive advocate for his or her patient before a URC, thereby requiring input from laity, is unsupportable — it goes too far. It may properly be assumed that the treating physician will not abdicate or neglect the proper care of his or her patient.
The Medicare Act calls for a medical judgment, not an uninformed, sympathy-inspired, self-serving lay response from the patient, an interested family member, or other representative of the patient’s choice. Hobbling the resolution of a purely medical question by shackling consideration thereof to notice of impending URC deliberations and hearings of laypersons on the medical subject with attendant delays, confusion and controversy is not provided for by the Act or mandated either by the Constitution or sound reason. Patients and families of patients would be neither qualified nor appropriate participants in URC decision-making processes. The opportunity that the treating physician has to present his or her professional opinion to the two physicians on the URC conserves every legitimate expectation of the patient and requirement of the Medicare Act.
To impose classical due process requirements on the expression of professional medical determinations, moreover, would be akin to establishing government control of medicine. Blum happily teaches that doctors, and not laypersons, must evaluate the medical needs of patients and that doctors’ opinions are not state determinations saddled with procedural due process standards.
I respectfully dissent and would affirm the judgment below.