Massachusetts General Hosp. v. Commissioner of Public Welfare

• Decision Date: 04 May 1966
• Citation: 350 Mass. 712,216 N.E.2d 434
• Parties: MASSACHUSETTS GENERAL HOSPITAL v. COMMISSIONER OF PUBLIC WELFARE (and a companion case).
• Court: United States State Supreme Judicial Court of Massachusetts Supreme Court

Page 434

216 N.E.2d 434

350 Mass. 712

MASSACHUSETTS GENERAL HOSPITAL v. COMMISSIONER OF PUBLIC WELFARE (and a companion case).

Supreme Judicial Court of Massachusetts, Suffolk.

Argued April 8, 1966.

Decided May 4, 1966.

Albert G. Tierney, Boston (Colette Manoil, Boston, with him) for petitioners.

Nelson I. Crowther, Jr., Asst. Atty. Gen., for respondent.

Before WILKINS, C.J., and SPALDING, WHITTEMORE, CUTTER and SPIEGEL, JJ.

CUTTER, Justice.

These cases are petitions under G.L. c. 30A for judicial review of decisions of the commissioner denying payment to the hospital (MGH) for care given (a) to Mrs. Anna Schmidt, a recipient of old age assistance (see G.L. c. 118A §§ 1--12), and (b) to one Smith, a recipient of disability assistance (see G.L. c. 118D). Appeals had been taken to the State Department of Public Welfare from the refusal of the Boston board of public welfare to pay for the later part of the hospital care of each aid recipient on the grounds, in the case of Mrs. Schmidt, that MGH's medical reports submitted were not sufficient, and, in the case of Smith, that he no longer needed 'acute' hospital care. In each case the Superior Court affirmed a decision of the commissioner (acting through a department referee) denying compensation to MGH for a portion of the aid recipient's care.

We first outline facts which appear in the Schmidt record. The referee found that Mrs. Schmidt, age 82, was admitted to MGH on November 12, 1962, with a fracture of her right femur. She was discharged on April 1, 1963.

A letter to the Boston board from MGH, signed by a Dr. Wohl (January 3, 1963), reported that Mrs. Schmidt was admitted to MGH 'with intratrochantetic fracture of the right hip. The following day she had open reduction and Jewett nail fixation of the fracture, and did very well subsequently except for some post-operative (difficulty) and phlebitis and arterial occlusion, possible secondary to a displaced bone fragment compressing the femoral artery and vein. Because of relative ischemia and skin breakdown of the right leg secondary to that, she may require hospitalization for another two to four weeks. She will eventually be discharged to a nursing home for several months until she is able to resume normal activity and return home to the care of her daughters.' On February 20, 1963, Dr. Wohl wrote again, adding the following information: 'Post-operatively she suffered from phlebitis and from a markedly displaced trochanteric fragment compressed the profunda femoris artery, causing eschemia and an eschemic ulcer of the right leg. On January 25th she underwent exploration of the groin with excision of the displaced trochanteris fragment and skin grafting of the ulcer. She has had only a partial take of the skin graft, and may also require arterial reconstruction at some time. Her expected hospital stay is three to six weeks after which she can be discharged to a nursing home.' On April 12, 1963, a Dr. Lawson reported for MGH that following the operation of January 25, 1963, Mrs. Schmidt 'did well except for a recalcitrant ulcer over the lateral surface of the right tibia, and she was discharged on the 1st of April 1963 for further convalescent care at the Lemuel Shattuck Hospital.'

Dr. Clay, assistant director of MGH, who had approved each of the three letter reports, testified before the referee. ¹ He gave as his opinion, after a review of the records, that Mrs. Schmidt required hospitalization for the period of time represented by the record and that the medical information in the three letter reports was sufficient to explain the hospitalization and its duration.

The Boston board's objections to payment seem to have been based upon advice given in a mimeographed form letter to a social worker at the Roxbury Crossing division of the board by, or in behalf of, a Dr. Lynch, medical consultant of the board. This form letter suggested that, if MGH 'has failed to submit the required medical data in accordance with our Dept's. procedures, payment could be denied on that basis.' Dr. Lynch did not testify before the referee. Dr. Clay testified that the MGH had no record 'at any time that Dr. Lynch had any contact with the hospital.' There was no testimony that Dr. Lynch, or any doctor in his behalf, ever saw Mrs. Schmidt.

After the hearing before the referee, the referee sent a memorandum to one Jack Guveyan, a medical social consultant of the State welfare department, enclosing a transcript of the hearing and the exhibits already mentioned. It concluded, 'Would you kindly review all these materials and advise me as to your medical opinion (see fn. 10) concerning necessity of hospitalization involved' (emphasis supplied). Guveyan did not testify before the referee or in the Superior Court. There is no evidence in the record that Guveyan is a doctor or concerning his qualifications. The referee testified in the Superior Court that he himself had never attended any school of medicine, and that he had referred the material to Guveyan '(t)o get his opinion and advice on the medical evidence * * * at the hearing.' Guveyan replied, giving what, without more, was described as 'medical review team's finding (after review).' The reply said, 'The information submitted obviously is confusing in view of fact that as of 1/3/63 * * * the diagnosis of arterial occlusion and phlebitis had been made and it was stated * * * (Mrs. Schmidt) would require an additional two to four weeks of hospitalization. Approval for reimbursement of prolonged hospitalization costs is therefore limited at most, through the month of February 1963.'

In the Superior Court, the referee testified that when he submitted the material to Guveyan he had not made up his mind how he was going to decide MGH's appeal, but that '(w)hen * * * (he) received all the material back * * * (he) reviewed the material * * * procured at the hearing, and then * * * rendered a decision.' The trial judge concluded 'that the ultimate decision was made by the referee and * * * there was no resort to any extra-record facts.' He also concluded that the 'evidence before the referee was sufficient to support his finding.'

The Smith case is in many respects like the Schmidt case. On April 13, 1963, Smith, age 44, was admitted to MGH for spinal cord injury and chronic alcoholism with traumatic encephalopathy and symptomatic epilepsy. He was discharged on December 2, 1963, to the Lemuel Shattuck Hospital. The Boston Board refused to pay his hospital expenses after July 30. A letter dated October 23, 1963, was sent to MGH by a Miss Roston, a social worker for the Boston board, stating that the board was 'not going to cover * * * (Smith) as of July 30, 1963.'

MGH conceded before the referee that, after October 15, 1963, Smith did not need 'acute care.' His discharge apparently was delayed until December 2 because MGH's efforts to place him in other facilities where he could be given less expensive, but necessary, care had been unsuccessful. ²

Dr. Kermond, an orthopedic surgeon, then an assistant in that field at MGH and an instructor at the medical schools of Boston University and Harvard, testified that he himself attended Smith, and that Smith, in his opinion, 'required this hospitalization.' Dr. Kermond stated at length and in detail the history of Smith's hospitalization and medical problems. ³ He said that, in the early part of October, it was determined that 'home care' for Smith was 'unrealistic' and that it 'would be necessary for him to have some kind of institutional care' as a lifetime program.

No medical testimony was offered by the Boston board. An intra office memorandum of Dr. Lynch, read into the record, was essentialy only a direction to resist payment for hospitalization after July 30. It stated that 'it is felt that around 7/30/63 this patient should have been transferred to a facility such as the Lemuel Shattuck Hospital or Holy Ghost Hospital for physiotherapy and prolonged rehabilitation services.' There is no evidence that Dr. Lynch ever saw the patient. Dr. Clay, also a witness in the Smith case, testified that Dr. Lynch never got in touch with him about Smith. ⁴

1. Mrs. Schmidt was entitled to '(a)dequate assistance' as a person 'in need of relief and support' who had reached the minimum age for old age assistance. See G.L. c. 118A, § 1 (as amended through St.1962, c. 411), which in its fourth paragraph (as amended through St.1961, c. 615) provided, 'Such assistance shall also provide for adequate medical care for every recipient of assistance * * * and shall include provision for the services of a physician of such recipient's choice * * *.' ⁵

Smith was entitled to disability assistance under G.L. c. 118D, § 1 (as amended through St.1961, c. 127, § 2), which provides that each local board 'shall give adequate assistance to every needy person resident therein who has reached the age of eighteen * * * but has not reached the minimum age * * * for old age assistance, who is permanently and totally disabled * * *.' Under § 4 (as amended by St.1960, c. 659, § 1), such assistance 'shall also provide for adequate medical care for every recipient * * * and shall also include a provision for the services of a physician of such recipient's choice, subject to such * * * regulations as shall be made by the department. Assistance * * * shall include * * * payment for medical care,' which, under § 5 (as amended through St.1961, c. 267), in the case of 'hospital services' shall be made 'directly to the institution * * * furnishing such services.'

The applicable statutes, in part at least, were adopted in connection with comparable Federal programs of medical assistance. See Fenton v. Department of Pub. Welfare, 344 Mass. 343, 345--346, 182 N.E.2d 528; Massachusetts Gen. Hosp. v. Commissioner of Pub. Welfare, 347 Mass. 24, 25, 196 N.E.2d 214. They are to be reasonably interpreted to carry out the obvious legislative and social purpose in devising...