Massachusetts General Hospital v. Rate Setting Commission

• Decision Date: 12 January 1977
• Citation: 359 N.E.2d 41,371 Mass. 705
• Parties: MASSACHUSETTS GENERAL HOSPITAL v. RATE SETTING COMMISSION et al. 1
• Court: United States State Supreme Judicial Court of Massachusetts Supreme Court

Page 41

359 N.E.2d 41

371 Mass. 705

MASSACHUSETTS GENERAL HOSPITAL

v. RATE SETTING COMMISSION et al. ¹

Supreme Judicial Court of Massachusetts, Suffolk.

Argued Oct. 4, 1976.

Decided Jan. 12, 1977.

Albert G. Tierney, Jr., Boston (Francis X. Flaherty, Jr., Brighton, with him), for plaintiff.

Mitchell J. Sikora, Jr., Asst. Atty. Gen., Boston, for defendants.

Before HENNESSEY, C.J., and BRAUCHER, KAPLAN and WILKINS, JJ.

KAPLAN, Justice.

The plaintiff Massachusetts General Hospital (hospital) sought a declaration that a certain 'information bulletin' of the defendant Rate Setting Commission (commission), purporting to elucidate one of the commission's regulations, was in fact itself a 'regulation,' and invalid for failure of the commission to afford notice and hearing prior to promulgation, as required for the effective adoption of an agency regulation by the State Administrative Procedure Act, G.L. c. 30A, §§ 2--3. ² A judge of the Superior Court entered judgment for the defendants declaring that the information bulletin had been issued validly. The hospital lodged an appeal in the Appeals Court from this decision, also claiming, incidentally, that the judge had committed further error in failing to act to certify it as representative of a class of 180 hospitals. We granted an application for direct appellate review. ³

In brief, the case is that the commission had in force as from October 1, 1974, a regulation 74--26 entitled 'Hospital Prospective Rate Setting Regulation' which described the basis on which the commission establishes rates of reimbursement of health care providers, including the hospital, for their services rendered to certain publicly assisted patients. ⁴ The information bulletin in question, 74--26--9, was issued as an explanation of certain provisions of the regulation which deal with applications by providers for adjustment of rates because of program changes.

The parties appear to be in agreement that there is such a thing as an advisory or informational pronouncement by an administrative agency that may be issued lawfully in relation to a regulation (or a statute) without going through the procedures required for promulgation of a regulation. They might also agree that it is no use trying to frame an airtight definition of such pronouncements which would serve to distinguish them from regulations; on the other hand, it may be possible to point to factors of differentiation in light of the functions or purposes that are furthered by notice and hearing in the given context.

Formal presentation by the agency with opportunity for 'input' and debate by the persons affected, and deliberate resolution of issues by the officials, may be thought wasteful of time and energy where the agency is intending to fill in the details or clear up an ambiguity of an established policy, rather than to inaugurate a material change of policy. ⁵ One can imagine, too, that in the degree that what the agency puts forward is complex, or of broad or pervasive coverage, notice and hearing will appear increasingly plausible and useful, so that the agency's proposition will be denominated a regulation. ⁶ There is likely to be a similar reaction as the proposition is seen to involve difficulties of compliance. ⁷ A holding that notice and hearing are not required for a particular agency promulgation is cushioned by the consequence that it does not have the binding force attributable to a full-blown regulation. ⁸

Such law as there is on the subject has been made largely by Federal courts in connection with the Federal Administrative Procedure Act. Those decisions are instructive for us even though the cognate State act is textually somewhat different from the Federal. ⁹ The case cited from our own reports as bearing on the question is in line with the suggestions set out above. Atlas Distrib. Co. v. Alcoholic Beverages Control Comm'n, 354 Mass. 408, 237 N.E.2d 669 (1968). There the agency had issued a circular letter to the trade requiring consumer retail price schedules to reflect more currently certain discounts ('post-offs') allowed by wholesalers to retailers. This was thought to be merely an intensification or elaboration of the existing practice which would enhance its basic, understood purpose: we called it a 'reinterpretation of the reasoning behind the application of existing rules' (at 414, 237 N.E.2d at 673), and thus held it to be free of the notice and hearing requirements that would attach to a regulation under the State Administrative Procedure Act.

Regulation 74--26 of the Rate Setting Commission is a twenty-one page, comprehensive statement of the commission's method of setting rates, with definitions of the several factors employed, prescriptions of the information to be furnished by the health providers to the commission and the records to be maintained by them, and outlines of other related procedures. The regulation covers rates of reimbursement for outpatient hospital services and rates for inpatient and well newborn services ¹⁰ (excepting aid to patients in long-term care facilities, covered more extensively in another regulation). It will be sufficiently illustrative to speak briefly of the inpatient rates. '(T)otal reimbursable inpatient operating costs' are computed for a 'base year,' two years earlier than the 'rate year' for which reimbursement is being computed. These costs are adjusted forward over the intermediate and rate years by the use of an inflation factor (initially set at ten per cent for each of the two years but subject to change in certain circumstances) to produce the provider's reimbursable inpatient operating costs for the rate year. To these are added the provider's 'reimbursable inpatient non-operating cost' as defined. ¹¹ The total is divided by the allowable inpatient days of the base year. This results in an all-inclusive per diem rate for each publicly assisted patient receiving inpatient treatment during the rate year. (As might be expected, the allowable costs are described and discussed in the regulation in particular detail.)

As one of the commissioners has written (in a communication to another hospital which appears in evidence), '(t)he underlying basis of a prospective rate setting system is that the rate is stable and predictable. Adjustments to that rate are exceptions granted under unusual and specifically defined situations.' Section 9.2 of Regulation 74--26 permits applications by providers for adjustments of rates in any of five situations, ¹² the one now pertinent being the occurrence of an 'incident' during the intermediate year in which the provider 'has undertaken . . . a substantial program change not requiring a determination of need from the Department (of Public Health).' (§ 9.3(b).) ¹³ The application 'shall contain . . . a statement of the justification for the program change and a description of any review of the program change that may have been undertaken by the Department or by a comprehensive health planning agency. . . . In reviewing applications . . ., the Commission may request, or may require that the applicant request, a review of the application by the Department or by a comprehensive health planning agency.' (Ibid.) An applicant here, as in other adjustment situations, 'shall have the burden of assuring the adequacy of information provided to the Commission to justify an adjustment,' and the application 'shall contain information sufficient and in such detail as to permit the Commission to translate the expenditures relating to the incident . . . into reimbursable operating and nonoperating costs . . ..' (§ 9.2)

The record shows that there was uncertainty among providers regarding adjustment for program changes under § 9.3(b) and especially, perhaps, about the condition that the change be 'substantial.' After conferences with the Massachusetts Hospital Association, the commission, utilizing § 17 of the regulation which states that the commission might from time to time 'issue informational bulletins interpreting or expanding upon provisions of this regulations,' ¹⁴ approved bulletin 74--26--9 (the ninth issued under Regulation 74--26) on February 6, 1975, with an effective date of October 1, 1974, and filed it with the Secretary of the Commonwealth on February 11, 1975.

The hospital's attack on the bulletin trembles on the brink of mootness because, as far as appears in the present record, the hospital had not applied or indicated any need to apply for adjustment for a program change undertaken during the intermediate year October 1, 1973, to September 30, 1974, the only pertinent intermediate year, since the bulletin was superseded and its substance issued after due formalities as a regulation with effect from October 1, 1975. ¹⁵ The trial judge, however, proceeded to the merits because he thought there was a chance that the hospital might yet find occasion to apply. We, too, shall go to the merits. On the merits we agree with the judge.

The bulletin was a one-page document. It defined a substantial program change as one involving an annual operating expense of more than $100,000 and constituting a 'new service, different in nature from existing services,' not merely an expansion or alteration in an existing service. The regulation contemplated that changes for which adjustments were sought would be considered separately and would not be aggregated. It was sensible to select some dollar amount for each, and the amount chosen was a not unfamiliar benchmark; a 'substantial capital expenditure' for health facility construction requiring a certificate of need under G.L. c. 111, §§ 25B--25G, means an outlay of $100,000 or more. To adjust a rate for a program change of less than $100,000 might be thought inappropriate if typically it would not materially affect the provider's rate (see note 13 supra). The reference to a new service, different in nature, harmonized with the general design of the regulation as...