North Clackamas Community Hospital v. Harris

• Decision Date: 31 December 1980
• Docket Number: No. 77-2556,77-2556
• Citation: 664 F.2d 701
• Parties: NORTH CLACKAMAS COMMUNITY HOSPITAL, dba Dwyer Memorial Hospital, Plaintiff-Appellant, v. Patricia HARRIS, * Secretary of Health and Human Services, the United Statesof America; Provider Reimbursement Review Board; Blue Cross Association andBlue Cross of Oregon, Defendants- Appellees.
• Court: U.S. Court of Appeals — Ninth Circuit

Page 701

664 F.2d 701

NORTH CLACKAMAS COMMUNITY HOSPITAL, dba Dwyer Memorial Hospital, Plaintiff-Appellant, v. Patricia HARRIS, ^* Secretary of Health and Human Services, the United Statesof America; Provider Reimbursement Review Board; Blue Cross Association andBlue Cross of Oregon Defendants- Appellees.

No. 77-2556.

United States Court of Appeals, Ninth Circuit.

Argued and Submitted Sept. 12, 1979.

Decided Dec. 31, 1980.

Joy D. Abele, Jack, Goodwin & Urbigkeit, Oregon City, Or., for plaintiff-appellant.

Patrick E. McBride, Seattle, Wash., for defendants-appellees.

Appeal from the United States District Court for the District of Oregon.

Before WALLACE and KENNEDY, Circuit Judges, and ORRICK, ^** District Judge.

KENNEDY, Circuit Judge:

In 1971, North Clackamas Community Hospital (NCCH), an Oregon nonprofit corporation, purchased Dwyer Memorial Hospital. Thereafter, it sought reimbursement under the Medicare Act, 42 U.S.C. §§ 1395-1395rr (1976 & Supp. II 1978), for the yearly amortization of certain intangible assets acquired in the purchase. Blue Cross of Oregon, as agent of the United States, disallowed the reimbursement, and the appellee Secretary, ¹ through the Provider Reimbursement Review Board (PRRB), ² affirmed. NCCH appealed to the Oregon district court under 42 U.S.C. § 1395oo (f) (1976). That court affirmed the PRRB's decision. NCCH has again appealed. Our jurisdiction rests on 28 U.S.C. § 1291 (1976).

Robert Dwyer owned the only hospital in Milwaukie, Oregon, a town some ten miles south of Portland. In early 1970, certain citizens of Milwaukie became concerned upon hearing that Mr. Dwyer planned to sell the hospital to the Kaiser Health Plan. Kaiser is a closed group plan and the proposed sale would have effectively forced the residents and doctors of Milwaukie either to travel some seven miles to the nearest general hospital or to join Kaiser. To prevent this, NCCH was formed as an Oregon nonprofit corporation. After its incorporators discovered that the cost of building a new hospital and the cost of purchasing Dwyer's hospital were approximately the same, serious negotiations with Robert Dwyer and his family ³ began. The talks were extensive and time-consuming. Fourteen months after negotiations began, NCCH contracted with the Dwyers to sell the hospital, along with other related items, for the lump sum price of $2,674,015.

The parties had not reached agreement, however, on allocation of the price to the purchased assets. The PRRB found that they agreed that an independent appraiser would make the allocation. The appraiser chosen by the parties allocated the purchase price as follows:

                Land and buildings             $1,837,230
                Medical clinic                    290,369
                Operating company - net
                  tangible assets                 105,830
                Hospital license and
                  purchased operating value
                  (Going Concern Value)           440,586
                                               ----------
                         TOTAL. . . . . . . .  $2,674,015
                

NCCH began operations, retaining the name "Dwyer Memorial Hospital." As a qualified provider under the Medicare Act, ⁴ it applied to Blue Cross of Oregon, the Medicare intermediary, ⁵ for reimbursement of services provided to Medicare patients during its first year of operation. Among these services were the purchase costs of Dwyer Memorial allocable to Medicare patients. Specifically, NCCH sought reimbursement for depreciation taken on buildings and for amortization taken on the part of the purchase price allocated to what we refer to as "GCV" and what the appraiser referred to as "Hospital license and purchased operating value (Going Concern Value)." It also sought reimbursement for interest expense relating to these items.

Blue Cross approved the depreciation reimbursement, but disallowed reimbursement for GCV amortization or any interest expense related to it. The total amount disallowed was $53,135. NCCH then took its case to the PRRB. NCCH contended that the appraisal was inaccurate and that the tangible assets should have been valued at a higher price. As a second ground, it claimed that GCV was an intangible asset related to health care provision and thus reimbursable in any event. According to NCCH, the Dwyers made inclusion of GCV in the sale an essential part of the deal so that its purchase was a necessary condition of the purchase of the hospital. Since the intermediary allowed depreciation on other property purchased, such as buildings, NCCH argued that Blue Cross should have allowed amortization of GCV as well.

The PRRB declined to allow the reimbursement. It found that the parties contractually agreed to be bound by the appraiser's appraisal and allocation. It concluded that the amount allocated to GCV by the appraiser was excludable from tangible assets or any other reimbursable category. The PRRB concluded further that the $440,586 figure represented a type of goodwill, composed of the hospital's functioning professional and technical staff, its established reputation in the community, and the purchasers' collective desire to stay in Milwaukie for hospital care. The PRRB held this to be unrelated to the provision of medical services. The district court affirmed the PRRB's determination, finding it rational, within its discretion, and in accordance with applicable law.

NCCH seeks review of the PRRB's decision that the price paid in excess of the net appraised value was not related to patient care and thus not reimbursable under the Medicare Act. In such cases, 42 U.S.C. § 1395oo (f) (1976) requires us to apply the standard of review applicable to actions arising under the Administrative Procedure Act. Our review is "limited to determining whether the agency action was arbitrary, capricious, an abuse of discretion, not in accordance with law, or unsupported by substantial evidence on the record taken as a whole." Mercy Hospital & Medical Center, San Diego v. Harris, 625 F.2d 905, 907 (9th Cir. 1980). This standard is supplemented by deference to the agency's interpretation of its own regulations where, as here, the agency has expertise in the substantive area involved and the regulations were promulgated pursuant to congressional authorization. Id.; Pacific Coast Medical Enterprises v. Harris, 633 F.2d 123, at 130 (9th Cir. 1980); Columbus Community Hospital, Inc. v. Califano, 614 F.2d 181 (8th Cir. 1980); Good Samaritan Hospital, Corvallis v. Mathews, 609 F.2d 949, 954 (9th Cir. 1979). See also Ford Motor Credit Co. v. Milhollin, 444 U.S. 555, 566, 100 S.Ct. 790, 797, 63 L.Ed.2d 22 (1980). When this standard of review is applicable, the agency determination will not be set aside unless it is "clearly erroneous or inconsistent with the regulation," Pacific Coast Medical Enterprises, supra, or "demonstrably irrational." Milhollin, 444 U.S. at 565, 100 S.Ct. at 796.

NCCH's contentions on appeal are essentially the same as below. All agree, it asserts, that the hospital provides reimbursable medical services for Medicare patients. Further, NCCH maintains that the hospital could not have been acquired without some allocation of the purchase price to GCV. ⁶ It argues from this fact that since the acquisition of GCV was necessary to the ultimate provision of admittedly reimbursable services, the annual amortization of GCV is a necessary and reasonable cost. NCCH concludes that the denial of reimbursement violates 42 U.S.C. §§ 1395f(b) (1976 & Supp. II 1978) and 1395x(v)(1)(A) (1976), which define a reimbursable, reasonable cost as any "cost actually incurred." ⁷ It further contends that the Medicare regulations providing for reimbursement of those "costs which are appropriate and helpful in developing and maintaining the operation of patient care facilities and activities" are also violated by the agency ruling. See 42 C.F.R. § 405.451(b)(2) (1979). ⁸

As a corollary argument, NCCH contends that if we affirm the denial of reimbursement, it will be forced to charge non-Medicare patients proportionately more to recover its initial investment. NCCH points to statutory language ⁹ and regulations ¹⁰ which seemingly prohibit such a result.

We reject both arguments. The PRRB and the district court below both found that denial of reimbursement was consistent with the Medicare scheme. Under the applicable standard of review, we do not disturb these findings.

NCCH's first argument proves too much. If health care providers could automatically receive reimbursement for all components of an acquisition simply because they were a contractual condition of the sale, integrity of the reimbursement system would be undermined. Any such holding would have the effect of transferring the determination of what is a reasonable expense from the congressionally authorized agencies, i. e. the PRRB and the Health Care Financing Administration, to the seller of the hospital. There would be, inevitably, a temptation, then a tendency for buyers and sellers to include in the sale contract items totally unrelated to health care. This was not intended by Congress, and we decline the opportunity to graft such a requirement on the Medicare scheme.

The PRRB found that GCV "represent(ed) an amount the Provider was willing to pay beyond the fair market value of specific identifiable tangible assets in order to conduct its business," and that GCV was "more akin to goodwill than to any other asset." ¹¹ NCCH attempts to distinguish its case from established Medicare regulations ¹² and interpretive rules ¹³ prohibiting reimbursement for goodwill for profitmaking providers. Its attempted distinction rests on the fact that it is a nonprofit corporation.

We cannot say, however, that the PRRB's construction of the Medicare regulations, unmodified by the Secretary, was either "demonstrably irrational," Milhollin, 444 U.S. at 565, 100 S.Ct. at 797, or "clearly erroneous or inconsistent with the regulation." Pacific Coast Medical Enterprises, at 633 F.2d 130. We find that the Secretary was within his...