Court Opinion

ID: 9428878
Source: CourtListenerOpinion
Date Created: 2023-08-02 23:25:02.624251+00
Date Added: 2024-06-11T17:23:15.741284
License: Public Domain

Justice Brennan,
with whom Justice Marshall joins, dissenting.
If the Fourteenth Amendment is to have its intended effect as a restraint on the abuse of state power, courts must be sensitive to the manner in which state power is exercised. In an era of active government intervention to remedy social ills, the true character of the State’s involvement in, and coercive influence over, the activities of private parties, often through complex and opaque regulatory frameworks, may not always be apparent. But if the task that the Fourteenth Amendment assigns to the courts is thus rendered more burdensome, the courts’ obligation to perform that task faithfully, and consistently with the constitutional purpose, is rendered more, not less, important.
*1013In deciding whether “state action”1 is present in the context of a claim brought under 42 U. S. C. §1983 (1976 ed., Supp. IV), the ultimate determination is simply whether the § 1983 defendant has brought the force of the State to bear against the §1983 plaintiff in a manner the Fourteenth Amendment was designed to inhibit. Where the defendant is a government employee, this inquiry is relatively straightforward. But in deciding whether “state action” is present in actions performed directly by persons other than government employees, what is required is a realistic and delicate appraisal of the State’s involvement in the total context of the action taken. “Only by sifting facts and weighing circumstances can the nonobvious involvement of the State in private conduct be attributed its true significance.” Burton v. Wilmington Parking Authority, 365 U. S. 715, 722 (1961). See Lugar v. Edmondson Oil Co., ante, at 939-942.2 The Court today departs from the Burton precept, ignoring the *1014nature of the regulatory framework presented by this case in favor of the recitation of abstract tests and a pigeonhole approach to the question of state action. But however correct the Court’s tests may be in the abstract, they are worth nothing if they are not faithfully applied. Bolstered by its own preconception of the decisionmaking process challenged by respondents, and of the relationship between the State, the nursing home operator, and the nursing home resident, the Court subjects the regulatory scheme at issue here to only the most perfunctory examination. The Court thus fails to perceive the decisive involvement of the State in the private conduct challenged by the respondents.
I
A
The Court’s analysis in this case is simple, but it is also demonstrably flawed, for it proceeds upon a premise that is factually unfounded. The Court first describes the decision to transfer a nursing home resident from one level of care to another as involving nothing more than a physician’s independent assessment of the appropriate medical treatment required by that resident. Building upon that factual premise, the Court has no difficulty concluding that the State plays no decisive role in the transfer decision: By reducing the resident’s benefits to meet the change in treatment prescribed, the State is simply responding to “medical judgments made by private parties according to professional standards that are not established by the State.” Ante, at 1008. If this were an accurate characterization of the circumstances of this case, I too would conclude that there was no “state action” in the nursing home’s decision to transfer. A doctor who prescribes drugs for a patient on the basis of his independent medical judgment is not rendered a state actor merely because the State may reimburse the patient in different amounts depending upon which drug is prescribed.
But the level-of-eare decisions at issue in this case, even when characterized as the “independent” decision of the nurs*1015ing home, see ante, at 1000, have far less to do with the exercise of independent professional judgment than they do with the State’s desire to save money. To be sure, standards for implementing the level-of-care scheme established by the Medicaid program are framed with reference to the underlying purpose of that program — to provide needed medical services. And not surprisingly, the State relies on doctors to implement this aspect of its Medicaid program. But the idea of two mutually exclusive levels of care — skilled nursing care and intermediate care — embodied in the federal regulatory scheme and implemented by the State, reflects no established medical model of health care. On the contrary, the two levels of long-term institutionalized care enshrined in the Medicaid scheme are legislative constructs, designed to serve governmental cost-containment policies.
The fiscal underpinning of the level-of-care determinations at issue here are apparent from the legislative history of the “intermediate care” concept. In 1967, Congress was concerned with the increasing costs of the Medicaid program. Congress’ motivation in establishing a program of reimbursement for care in intermediate-care facilities flowed directly from these fiscal concerns. Thus the Senate Finance Committee Report on the Social Security Amendments of 1967, S. Rep. No. 744, 90th Cong., 1st Sess., 188 (1967), expressed concern with the fact that only skilled mu-sing care was available under Medicaid: “[Bjecause of a decided financial advantage to a State under present matching formulas,” States tended to classify recipients as in need of “‘skilled nursing home’ care.” As a consequence, the Report noted, “a strong case exists for introducing another level of care for which vendor payments would be available.” Ibid. The result was an amendment to Title XI of the Social Security Act, creating a new treatment track for “categorically needy” medicaid patients, called “intermediate care.” As summarized on the Senate floor:
“The committee bill would provide for a vendor payment in behalf of persons . . . who are living in facilities *1016which are more than boarding houses but which are less than skilled nursing homes. The rate of Federal sharing for payments for care in those institutions would be at the same rate as for medical assistance under title XIX. Such homes would have to meet safety and sanitation standards comparable to those required for nursing homes in a given state.
“This provision should result in a reduction in the cost of title XIX by allowing States to relocate substantial numbers of welfare recipients who are now in skilled nursing homes in lower cost institutions.” 113 Cong. Rec. 32599 (1967) (emphasis added).
To implement this cost-saving mechanism, the Federal Government has required States participating in the Medicaid Program to establish elaborate systems of periodic “utilization review.”3 With respect to patients whose expenses are not reimbursed through Medicaid, these attempts to assign the patient to one of two mutually exclusive “levels of care” would be anomalous. While the criteria used to determine which patients require the services of “skilled-nursing facilities,” which require “intermediate care facilities,” and which require no long-term institutional care at all, obviously have a medical nexus, those criteria are not geared to the *1017specific needs of particular residents as determined by a physician; the level-of-care determination is not analogous to choosing specific medication or rehabilitative services needed by a nursing home patient. The inherent imprecision of using two broad levels to classify facilities and residents has been noted by the commentators.4 The vigor with which these reviews are performed in the nursing home context, see infra-, at 1022-1024, is extraordinarily tmmedical in character. From a purely medical standpoint, the idea of shifting nursing home residents from a “higher level of care” to a “lower level of care,” which almost invariably involves transfer from one facility to another, rarely makes sense. As one commentator has observed: “These transfers eject helpless, disoriented people from the places they have lived for months or even years to facilities, not of their own choosing, that they have never seen before. The evidence is overwhelming that, without extraordinary preparatory efforts that are hardly ever made, any move is harmful for the preponderance of the frail elderly.” B. Vladeck, Unloving Care 140 (1980).
The arbitrariness of the statutory system of treatment levels is evident from a comparison of the proportion of nursing home residents in skilled nursing facilities (SNF’s) and those in intermediate care facilities (ICF’s) in different States. A 1973 survey of 32 States revealed that 47.9% of Medicaid patients were in SNF’s, 52.1% were in ICF’s. But the proportion of SNF and ICF beds varied enormously from State to State. For example, less than 10% of Medicaid recipients receiving long-term institutional care in States such as Louisiana, Maine, Oregon, and Virginia were in SNF’s; the number housed in SNF’s in New York and Pennsylvania was nearly 80%, and in Florida and Georgia the figure was closer *1018to 90%.5 Quite obviously, the answer to this disparity lies not in medical considerations or judgments, but rather in the varying fiscal policies, and the vigor of enforcement, in the participating States.
In New York, the nursing home operator is required to “maintain a discharge planning program to . . . document that the facility has made and is continuing to make all efforts possible to transfer patients to the appropriate level of care or home as indicated by the patient’s medical condition or needs.” 10 NYCRR §416.9(d)(1) (1980) (emphasis added). See also §421.13(d)(l).6 The responsibility the State assigns to nursing home operators to transfer patients to appropriate levels of care is, of course, designed primarily to implement the State’s goal of reducing Medicaid costs,7 and the termination or reduction of benefits follows forthwith upon the facility’s discharge or transfer of a resident. As the court below noted: “The state has, in essence, delegated a de-*1019cisión to . . . reduce a public assistance recipient’s benefits to a ‘private’ party,” 629 F. 2d 817, 820 (CA2 1980), by assigning to that private party the responsibility to determine the recipient’s need. But we should not rely on that fact alone in evaluating the nexus between the State and the challenged private action. Here the State’s involvement clearly extends to supplying the standards to be used in making the delegated decision.
B
Ignoring the State’s fiscal interest in the level-of-care determination, the Court proceeds to a cursory, and misleading, discussion of the State’s involvement in the assignment of residents to particular levels of care. In my view, an accurate and realistic appraisal of the procedures actually employed in the State of New York leaves no doubt that not only has the State established the system of treatment levels and utilization review in order to further its own fiscal goals, but that the State prescribes with as much precision as is possible the standards by which individual determinations are to be made.
The Court notes that at the time of admission the admitting physician is required to complete a long-term placement form called the DMS-1. 10 NYCRR §§ 415.1(a), 420.1(b) (1978). The Court dismisses the significance of the form by noting blandly that a “completed form provides ... a numerical score corresponding to the physician’s assessment of the patient’s mental and physical health,” and then commenting: “As petitioners note, . . . the physicians, and not the forms, make the decision about whether the patient’s care is medically necessary. A physician can authorize a patient’s admission to a nursing facility despite a ‘low’ score on the form. See 10 NYCRR §§415.1(a)(2), 420.1(b)(2) (1978).” Ante, at 1006 (footnote omitted and emphasis added). The Court concludes: “We cannot say that the State, by requiring completion of a form, is responsible for the physician’s decision.” *1020Ante, at 1006-1007 (emphasis added). A closer look at the regulations at issue suggests that petitioners have been less than candid in their characterization of the admission process and the role of the numerical score.
New York’s regulations mandate that the nursing home operator shall
“admit a patient only on physician’s orders and in accordance with the patient assessment criteria and standards as promulgated and published by the department (New York State LongTerm Care Placement Form [DMS-1] and New York State Numerical Standards Master Sheet [DMS-9]) . . . which shall include, as a minimum:
“(1) an assessment, performed prior to admission by or on behalf of the agency or person seeking admission for the patient, of the patient’s level of care needs according to the patient assessment criteria and standards promulgated and published by the department.” 10 NYCRR §415.1 (1978) (emphasis added).
The details of the DMS-9 Numerical Standards Master Sheet also bear more emphasis than the Court gives them, for that form describes with particularity the patients who are entitled to SNF care, ICF care, or no long-term residential care at all. The DMS-9 provides numerical scores for various resident dysfunctions. For example, if the resident is incontinent with urine often, he receives a score of 20; if seldom, a score of 10; if never, a score of 0. A similar rating is made as to stool incontinence: often, 40; seldom, 20; never, 0. A tabulation is made with respect to “function status.” For example, if the resident can walk only with “some help,” he receives 35 points; only with “total help,” 70 points; if he cannot walk, 105 points. If the resident needs “total help” to dress, he receives 80 points; if “some help” is required, 40 points. Ratings are also made of the patient’s “mental status.” For example, if the patient is never alert, he receives 40 points; if sometimes alert, 20 points; always alert, 0 points. *1021If his judgment is always impaired, he receives, 30 points; sometimes, 15 points; never, 0 points. And ratings are also set forth for other physical “impairments.” For example, if the patient’s vision is unimpaired, he receives 0 points; if he has partial sight, 1 point; if he is blind, 2 points.
The criterion for admission to a SNF is a DMS-9 “predictor score” of 180. 10 NYCRR § 415.1(a)(2) (1978). For admission to an HRF (health-related facility), the required score is 60. § 420.1(b)(2). Where the admission, or denial of admission, is based on the guidelines set forth in these regulations, there is, of course, no doubt, that the State is directly, and solely, “responsible for the specific conduct of which the plaintiff complains,” ante, at 1004 (emphasis omitted), even if it has chosen to authorize a private party to implement that decision.8
*1022The Court dismisses the specific state standards for denying admission set forth in the regulations, and tabulated according to the DMS-9, by emphasizing what it perceives as an alternative method for gaining admission to a nursing home. In the Court’s view, this alternative route to admission takes the whole seheme outside the realm of state action because it hinges on a “physician’s assessment” of what is medically necessary. In characterizing the admission process as the independent assessment of a physician, the Court relies upon, but fails to quote, the following state regulations. The language of those regulations bears noting:
“[F]or those patients failing to meet the criteria and standards for admission to the . . . facility [as measured by the DMS-9], a certification signed by a physician member of the transferring facility’s utilization review agent or signed by the responsible social services district local medicaid medical director or designee indicating the reason(s) the patient requires [the facility’s level of care, is required].” 10 NYCRR § 415.1(a)(2) (1978) (emphasis added).
See also §420.1(b)(2).
As this provision makes clear, if the potential resident does not qualify under the specific standards of the DMS-1, as tabulated on the DMS-9, the patient can be admitted only on the basis of direct approval by Medicaid officials themselves, or on the basis of a determination by the utilization review agent of the transferring facility — and, of course, such agents are themselves clearly part and parcel of the statutory cost-control process.9 See n. 8, supra. No decision is made on *1023the basis of a medical judgment exercised outside the regulatory framework, by the resident’s personal physician acting on the basis of his personal medical judgment. The attending physician’s role is, at this stage, limited to “scoring” the patient’s condition according to standards set forth by the State on the DMS-9.
Yet the State’s involvement does not end with the initial certification. Within five days after admission, the matter is again subjected to assessment, this time by the operator of the transferee facility. This time the transferee nursing home operator is required to tabulate the DMS-9 score. If the patient’s score is not adequate by the standards of the DMS-9, admission must be denied unless sanctioned by the facility’s utilization review agent.10 The utilization review agent of the admitting facility, like that of the transferring facility, operates under a “written utilization control plan, approved by the department [of health].” 10 NYCRR §§ 416.9, 421.13 (1980). And that statutory body has the final say in *1024each instance. There can thus be little doubt that in the vast majority of cases, decisions as to “level of treatment” in the admission process are made according to the State’s specified criteria. That some deviation from the most literal application of the State’s guidelines is permitted cannot change the character of the State’s involvement. Indeed, absent such provision for exceptional cases, the formularized approach embodied in the DMS-9 would be unconscionable. And indeed, even with respect to these exceptional cases, the admissions procedure is administered through bodies whose structure and operations conform to state requirements, and whose decisions follow state guidelines — albeit guidelines somewhat more flexible than the DMS-1, in allowing some “psychosocial” factors to be taken into account. See infra, this page and 1025-1026.
The Court dismisses all this by noting that “[w]e cannot say that the State, by requiring completion of a form, is responsible for the physician’s decision.” Ante, at 1006-1007. The Court then notes that “[i]n any case, respondents’ complaint is about nursing home decisions to discharge or transfer, not to admit, Medicaid patients.” Ante, at 1007. This is true, of course. But where, one might ask, is the Court’s discussion of the frequent utilization reviews that occur after admission? The State’s regulations require that the operator shall provide for “continued stay reviews . . . to promote efficient and effective use of available health facilities and services every 30 days for the first 90 days, and every 90 days thereafter, for each nursing home patient.” 10 NYCRR § 416.9(b)(1) (1980) (skilled nursing facilities) (emphasis added). See also §421.13(b)(1) (health-related facilities, every 90 days).
The continued stay reviews parallel the admission determination with respect to both the State’s procedural and substantive standards.11 Again, the DMS-1 and the DMS-9 *1025channel the medical inquiry and function as the principal determinants of the resident’s status, for whenever a resident does not achieve an appropriate score on the DMS-1, as determined by a nonphysician representative of the utilization review agent, the resident’s case is directed to a physician member. That physician member does not personally examine the resident, but rather relies on the DMS-1 and other documentary information. See App. 172-173. If the matter is resolved adversely to the resident, only then must the attending physician be notified. The attending physician is allowed to present relevant information, though the final decision remains with the utilization review agent. See 10 NYCRR §§ 416.9(b)(2), 421.13(b)(2) (1980). And again, the State’s substantive standards, not independent medical judgment, pervade review determinations. Evaluations are based only on the DMS-1 and DMS-9 tabulation, on a “psychosocial” evaluation respecting the resident’s response to transfer and other physical, emotional, and mental characteristics of the patient, on the resident’s discharge plan (prepared according to state regulations), and upon “additional criteria and standards . . . which shall have been approved *1026by the department [of health].” 10 NYCRR §§ 416.9(b)(4), 421.13(b)(4) (1980) (emphasis added).12
The Court concludes with this assessment of the statutory-scheme:
“These regulations do not require .the nursing homes to rely on the forms in making discharge or transfer decisions, nor do they demonstrate that the State is responsible for the decision to discharge or transfer particular patients. Those decisions ultimately turn on medical judgments made by private parties according to professional standards that are not established by the State.” Ante, at 1008.
The Court is wrong. As a fair reading of the relevant regulations makes clear, the State (and Federal Government) have created, and administer, the level system as a cost-saving tool of the Medicaid program. The impetus for this *1027active program of review imposed upon the nursing home operator is primarily this fiscal concern. The State has set forth precisely the standards upon which the level-of-care determinations are to be made, and has delegated administration of the program to the nursing home operators, rather than assume the burden of administering the program itself. Thus, not only does the program implement the State’s fiscal goals, but, to paraphrase the Court, “[t]hese requirements . . . make the State responsible for actual decisions to discharge or transfer particular patients.” See ante, at 1008, n. 18. Where, as here, a private party acts on behalf of the State to implement state policy, his action is state action.
II
The deficiency in the Court’s analysis is dramatized by its inattention to the special characteristics of the nursing home. Quite apart from the State’s specific involvement in the transfer decisions at issue in this case, the nature of the nursing home as an institution, sustained by state and federal funds, and pervasively regulated by the State so as to ensure that it is properly implementing the governmental undertaking to provide assistance to the elderly and disabled that is embodied in the Medicaid program, undercuts the Court’s sterile approach to the state action inquiry in this case. The private nursing homes of the Nation exist, and profit, at the sufferance of state and federal Medicaid and Medicare agencies. The degree of interdependence between the State and the nursing home is far more pronounced than it was between the State and the private entity in Burton v. Wilmington Parking Authority, 365 U. S. 715 (1961). The State subsidizes practically all of the operating and capital costs of the facility, and pays the medical expenses of more than 90% of its residents. And, in setting reimbursement rates, the State generally affords the nursing homes a profit as well. Even more striking is the fact that the residents of those homes are, by definition, utterly dependent on the State for *1028their support and their placement. For many, the totality of their social network is the nursing home community. Within that environment, the nursing home operator is the immediate authority, the provider of food, clothing, shelter, and health care, and, in every significant respect, the functional equivalent of a State. Cf. Marsh v. Alabama, 326 U. S. 501 (1946). Surely, in this context we must be especially alert to those situations in which the State “has elected to place its power, property and prestige behind” the actions of the nursing home owner. See Burton v. Wilmington Parking Authority, supra, at 725.
Yet, whatever might be the status of the nursing home operator where the State has simply left the resident in his charge, while paying for the resident’s support and care, it is clear that the State has not simply left nursing home patients to the care of nursing home operators. No one would doubt that nursing homes are “pervasively regulated” by State and Federal Governments; virtually every action by the operator is subject to state oversight. But the question at this stage is not whether the procedures set forth in the state and federal regulatory scheme are sufficient to protect the residents’ interests. We are confronted with the question preliminary to any Fourteenth Amendment challenge: whether the State has brought its force to bear against the plaintiffs through the office of these private parties. In answering that question we may safely assume that when the State chooses to perform its governmental undertakings through private institutions, and with the aid of private parties, not every action of those private parties is state action. But when the State directs, supports, and encourages those private parties to take specific action, that is state action.
We may hypothesize many decisions of nursing home operators that affect patients, but are not attributable to the State.13 But with respect to decisions to transfer patients *1029downward from one level of care to another, if that decision is in any way connected with the statutory review structure set forth above,14 then there is no doubt that the standard for decision, and impetus for the decision, is the responsibility of the State. Indeed, with respect to the level-of-care determination, the State does everything but pay the nursing home operator a fixed salary. Because the State is clearly responsible for the specific conduct of petitioners about which respondents complain, and because this renders petitioners state actors for purposes of the Fourteenth Amendment, I dissent.

 As the Court noted in Lugar v. Edmondson Oil Co., ante, at 926-932, the state action necessary to support a claimed violation of the Fourteenth Amendment, and the action “under color of law” required by 42 U. S. C. § 1983 (1976 ed., Supp. IV), represent parallel avenues of inquiry in a case claiming a remedy under § 1983 for a violation of the Fourteenth Amendment’s Due Process Clause. Of course, the “color of law” inquiry required by § 1983 focuses directly on the question whether the conduct of the particular § 1983 defendant is sufficiently connected with the state action that is present whenever the constitutionality of a state law, regulation, or practice is properly challenged. But this question may just as easily be framed as whether the § 1983 defendant is a “state actor.”

 In Lugar, we addressed a decidedly different question of “state action.” In that case, the § 1983 plaintiff sought damages against a private party who had availed himself of an unconstitutional state attachment procedure, and had enlisted the aid of government officials to impair plaintiff’s property for his own benefit. We concluded that “a private party’s joint participation with state officials in the seizure of disputed property is sufficient to characterize that party as a ‘state actor’ for purposes of the Fourteenth Amendment.” Ante, at 941. Here the State affirmatively relies upon and requires private parties to implement specific deprivations of benefits according to standards and procedures that the State has established and enforces for its own benefit. The imprint of state power on the private party’s actions would seem in this circumstance to be even more significant.

 The State must provide for the periodic review of patient care “to safeguard against unnecessary utilization of such care and services and to assure that payments ... are not in excess of reasonable charges consistent with efficiency, economy, and quality of care.” 42 U. S. C. § 1396a(a)(30). See 42 U. S. C. §§ 1395x(k), 1396a(a)(31), 1396b(g)(l)(C) (1976 ed. and Supp. IV); 42 CFR §§456.305, 456.406 (1981). There is no need here to dwell on the very detailed federal requirements, except to note that if the State fails to ensure that the physician certifications and utilization review procedures are implemented for each patient in each facility, the State is subject to a loss of Medicaid funds commensurate with the extent of the failure to ensure such utilization review. See 42 U. S. C. §§ 1396b(g), (i)(4) (1976 ed. and Supp. IV); 42 CFR §§456.650-456.657 (1981).

 See, e. g., Bishop, Plough, & Willemain, Nursing Home Levels of Care: Problems and Alternatives, 2 Health Care Financing Rev., No. 2, pp. 33, 36 (1980).

 See B. Vladeck, Unloving Care 138 (1980). “There is no reason to believe that Medicaid recipients in Georgia or Pennsylvania are ten times as likely to need skilled care as those in Oklahoma or Oregon, but they are ten times as likely to get it, or at least to get something called ‘skilled care.”' Id., at 137.

 If the nursing home fails to assign the patients to the level of care the State deems appropriate, it is subject to sanction. Federal regulations provide that health care providers who furnish “items or services that are substantially in excess of the beneficiary’s needs” may be excluded from participating in the program. 42 CFR §420.101(a)(2) (1981). A nursing home that fails to follow state regulations is also subject to state-imposed daily penalties. See 10 NYCRR § 414.18 (1978).
It is also clear that under the federal scheme, the State’s responsibility extends to ensuring proper assessment of every resident. See 42 U. S. C. §§ 1396a(26)(A), 1396a(31)(A), 1396b(g)(l)(D) (1976 ed. and Supp. IV).

 To acknowledge that the active system of utilization review serves a primarily fiscal purpose is not to demean the importance of that purpose, or the extent of overplacement of Medicaid recipients in skilled nursing facilities. That figure has been variously estimated at 10 to 40 percent. See Bishop, Plough, & Willemain, supra n. 4.

 The Court mistakes the significance of the DMS-1, and the relevant inquiry, when it attempts to characterize that form as merely an instrument for recording the exercise of an independently exercised medical judgment. See ante, at 1006, n. 15. Of course, a medical background is essential in filling out the forms. But it remains clear that the State’s standards are to be applied in making the transfer determination.
The Court concludes that the patient assessment standards prescribed by the State may be easily disregarded. But the regulations themselves clearly demonstrate that those standards are not merely precatory. Notably, the regulations specify that “patient assessment standards shall not be applied to residents admitted to the residential health care facility prior to March 1, 1977.” 10 NYCRR §§ 416.9(a)(1), 421.13(a)(1) (1980) (emphasis added). See also §§ 416.9(b)(4)(vi), 421.13(b)(4)(vi). If the forms merely recorded the exercise of an independent medical judgment, rather than prescribed the standards upon which that judgment must be exercised, why would it be necessary to exempt certain patients from the inquiry? Indeed, the regulations specifically provide for a different set of standards to be applied to the continued stay review of patients admitted to a facility prior to March 1, 1977. See 10 NYCRR §§ 416.9(b)(4)(vii), 421.13 (b)(4) (vii) (1980) (“the standards for residents admitted to the facility prior March 1,1977 shall be developed by the utilization review agent and approved by the department”). Again, if the determination were in reality based on an independent medical assessment, it seems inconceivable to me that the State would have any interest in requiring different *1022standards for different patients depending on when the patient had been admitted.

 Federal regulations require each nursing home to establish a utilization review committee whose functions include review of admission decisions, and the periodic assessment of the resident’s condition to determine whether the resident’s continued stay in the facility is justified. See 42 CFR §§ 456.301, 456.406 (1981). These review agents, as they are deemed *1023in the New York regulations, are composed of physicians not directly responsible for the patient whose care is being reviewed. §§456.306, 456.606. Under New York law, the physicians of the review agent may not have a financial interest in a residential care facility. 10 NYCRR §§ 416.9(b)(2), 421.13(b)(2) (1980). In New York, the review agent generally consists of two or more physicians selected and appointed by the facility. Medicaid provides reimbursement for their services. App. 173.

 A physician member of the utilization review agent has the power to determine that the patient qualifies for the type of care that the facility offers, even if the patient’s score on the DMS-1 is insufficient. 10 NYCRR §§ 416.9(a)(2)(i), 421.13(a)(2)(i) (1980). If that physician member confirms that the patient is not in need of the facility’s level of care, he must then notify the patient’s attending physician “and afford that physician an opportunity for consultation.” § 416.9(a)(2)(ii). But even if the attending physician disagrees with the adverse admission finding of the utilization review agent physician, it is the utilization review agent, not the attending physician, that makes the admission decision. §§ 416.9(a)(2)(iv), 421.13(a)(2)(iv). The utilization review agent must, however, notify “the responsible social services district” of “any adverse admission decision.” §§ 416.9(a)(3), 421.13(a)(3).

 The Court takes issue with our reliance on the nature of continued stay-reviews performed by the utilization review agent, noting that “patient *1025transfers to lower levels of care initiated by utilization review committees are simply not part of this case.” Ante, at 1007, n. 17. The Court’s position with respect to the work of the utilization review committee is schizophrenic at best: The Court expressly relies on its characterization of the review committee’s work as representing an independent physician’s assessment in reaching its conclusion that the DMS-1 and DMS-9 do not supply the criterion controlling the nursing home operator’s decision to admit or retain a patient in the home. Ante, at 1006; see discussion supra, at 1022. In any event, the Court simply misses the point. The nursing home operator is under a continuing duty “to make all efforts possible to transfer patients to the appropriate level of care or home as indicated by the patient’s medical condition or needs.” 10 NYCRR §§ 416.9(d)(1), 421.13(d)(1) (1980). Whether performed through the utilization review agent, or whether undertaken by the nursing home operator directly, transfers premised on the “patient’s medical condition or needs” are to be made with reference to the States definition of “need.”

 If it is finally determined by the utilization review agent that the patient should be assigned to a lower level of care, the regulations set forth an elaborate scheme of review before the State Department of Health. See 10 NYCRR §§ 416.9(f), 421.13(f) (1980). These provisions apply even when the attending physician concurs in the determination. The utilization review committee must notify the Department of Health of its adverse finding and
“send to the department a written statement setting forth, in specific detail, the changed medical conditions or other circumstances of the individual which support the utilization review agent’s decision for transfer, and a copy of the completed patient assessment form (DMS-1) used by the utilization review agent in this review. The department shall review the adverse continued stay finding." §§ 416.9(f )(2)(i), 421.13(f )(2)(i) (emphasis added).
See also §§ 421.13(f)(3)®, 416.9(f)(3)®. Of course, there is no doubt that the determinations made on this review represent state action because they are performed by state officials. But if the initial determinations were not made according to state-established standards and for the State’s purposes, and were in fact “independent” medical decisions as characterized by the Court, it is difficult to understand the State’s active role in reviewing the substance of those determinations.

 Of course, the nursing home operator’s power to make transfer decisions for other than medical reasons is severely limited by regulation. He may only *1029discharge or transfer the resident for valid medical reasons, for the welfare of the affected patient or other patients, or for nonpayment. 42 CFR §§ 405.1121(k)(4), 442.311(c) (1981); 10 NYCRR §414.14(4) (1980).

 The issue presented in this case — the issue that the Court decides presents a live controversy — concerns facility-initiated discharges or transfers. See ante, at 1000. Transfers initiated by the Utilization Review Committee are within the terms of the consent decree entered by the District Court below, and are not before the Court today. These transfers even more clearly show the State’s hand in the transfer decision — indeed, it appears that the physicians on the Committees are reimbursed for their services by Medicaid. But there is absolutely no basis upon which to conclude that that decision to transfer a patient to a lower level of care can be made in any meaningful way independently of the state regulatory standards described in text. Of course, we might hypothesize a decision of the resident’s personal physician, not premised on the State’s view of what constitutes an appropriate level of care for the patient, to remove the patient from the particular facility. In these circumstances, I would agree that the nursing home owner, in simply responding to the personal physician’s request, is not a state actor. But it appears to me that the Court’s decision sweeps more broadly than that, and clearly reaches transfers based directly upon and arising from the State’s procedures and standards.