Pub Ctzn Inc v. HHS

Jun 20, 2003

01-5294

Versions:332 F.3d 654

*2 Before: E DWARDS , R OGERS , and G ARLAND , Circuit Judges . Opinion for the Court filed by G ARLAND , Circuit Judge . G ARLAND , Circuit Judge : When a Medicare beneficiary files a complaint with a Peer Review Organization (PRO) about the quality of medical services that he or she has received, the Peer Review Improvement Act requires the PRO to ‘‘inform the individual of the organization’s final disposi- tion of the complaint.’’ 42 U.S.C. § 1320c–3(a)(14). Accord- ing to the Health Care Financing Administration (HCFA) of the Department of Health and Human Services (HHS), a PRO can comply with this requirement by sending the com- plainant a form letter that merely states that the PRO has examined the complainant’s concerns and that it will take appropriate action if warranted. Indeed, if the complainant’s health care practitioner objects to the PRO providing infor- HHS has recently renamed PROs as Quality Improvement Organizations, and has changed the name of HCFA to the Centers for Medicare & Medicaid Services. See 67 Fed. Reg. 36,539 (May 24, 2002); 66 Fed. Reg. 35,437 (July 5, 2001). For convenience, this opinion will continue to use the PRO/HCFA terminology, following the practice of the parties and of the district court.

mation that explicitly or implicitly identifies the practitioner, HCFA bars the PRO from saying anything more.

We conclude that the statutory command to inform a complainant of the ‘‘final disposition’’ of the complaint re- quires more than what HCFA currently permits. At a minimum, it requires the organization to notify the complain- ant of the results of its review. We therefore affirm the district court’s order invalidating those provisions of the Department’s Peer Review Organization Manual that bar PROs from providing such information to complaining benefi- ciaries.

I A In 1982, Congress amended the Social Security Act by enacting the Peer Review Improvement Act of 1982, Pub. L. No. 97–248 §§ 141–150, 96 Stat. 324 (1982) (codified as amended at 42 U.S.C. § 1320c et seq. ). The 1982 Act called for HHS to contract with PROs to perform a range of quality improvement and professional review activities. PROs are private, geographically based organizations composed of li- censed doctors ‘‘engaged in the practice of medicine or sur- gery in the area.’’ 42 U.S.C. § 1320c–1. HCFA contracts with PROs to review the quality, reasonableness, and efficien- cy of medical services provided under Medicare, as well as to determine whether the services provided are within Medi- care’s statutory coverage. Id. § 1320c–3(a)(1); see also id. § 1395y(g).

Section 1320c–3(a)(1) of the statute requires each PRO to ‘‘review some or all of the professional activities’’ of physi- cians and other providers of services for which payment may be made under Medicare. Id . § 1320c–3(a)(1). The statute also contains a number of confidentiality provisions, including § 1320c–9(a), which states:

Any data or information acquired by any such organiza- tion in the exercise of its duties and functions shall be held in confidence and shall not be disclosed to any *4 person except—(1) to the extent necessary to carry out the purposes of this part, (2) in such cases and under such circumstances as the Secretary shall by regulations provide to assure adequate protection of the rights and interests of patients, health care practitioners, or provid- ers of health care, or (3) in accordance with [provisions permitting specified disclosures to federal and state agencies].

42 U.S.C. § 1320c–9(a).

On April 17, 1985, pursuant to the delegation of authority contained in § 1320c-(9)(a)(2), HCFA issued regulations de- fining ‘‘confidential information’’ to include: ‘‘(1) Information that explicitly or implicitly identifies an individual patient, practitioner or reviewer[;] (2) Sanction reports and recom- mendations[;] (3) Quality review studies which identify pa- tients, practitioners or institutions[; and] (4) PRO delibera- tions.’’ 42 C.F.R. § 480.101(b). The regulations, however, also incorporate the statutory exceptions for disclosure of confidential information enumerated in § 1320c–9(a)(1) & (3) and set out above. 42 C.F.R. § 480.103. They further provide that a PRO ‘‘may disclose to any person, agency or organization, information on a particular practitioner or re- viewer with the consent of that practitioner or reviewer provided that the information does not identify other individu- als.’’ Id. § 480.133(a)(2)(iii). The regulations became effec- tive on May 17, 1985, and have not changed in relevant part since that time. Compare 42 C.F.R. §§ 476.101(b), 476.103, 476.133 (1985), with 42 C.F.R. §§ 480.101(b), 480.103, 480.133 (2002).

In October 1986, approximately a year and a half after HCFA promulgated its confidentiality regulations, Congress amended § 1320c–3 to impose upon PROs the further duty that is specifically at issue in this case. The new section, § 1320c–3(a)(14), provides as follows:

The organization shall conduct an appropriate review of all written complaints about the quality of services TTT not meeting professionally recognized standards of health care, if the complaint is filed with the organization by an individual entitled to benefits for such services TTT (or a person acting on the individual’s behalf). The *5 organization shall inform the individual (or representa- tive) of the organization’s final disposition of the com- plaint. Before the organization concludes that the quali- ty of services does not meet professionally recognized standards of health care, the organization must provide the practitioner or person concerned with reasonable notice and opportunity for discussion.

42 U.S.C. § 1320c–3(a)(14) (emphasis added). HHS has not promulgated any regulation that implements or addresses § 1320c–3(a)(14).

On December 15, 1998, Doris Shipp went to Baptist East Hospital in Louisville, Kentucky, complaining of abdominal pain. Over the next few months, Mrs. Shipp was seen by Drs. Peter Thurman, Thomas C. Dedman, and David Jolgren. Mrs. Shipp died of cancer in June 1999. On December 6, 1999, her husband, David Shipp, wrote to Health Care Excel (Excel), the PRO responsible for monitoring the delivery of Medicare services in Kentucky, and asked Excel to investi- gate and respond to his concerns about the quality of care that his wife had received.

In response, Excel sent Mr. Shipp three letters—one for each of the three physicians—entitled ‘‘Notice: Quality of Care Determination.’’ The first letter, concerning Dr. Thur- man, informed Shipp that ‘‘[n]o quality of care concerns were identified with the services provided by Dr. Thurman,’’ and that ‘‘[i]t has been determined that the examination your wife received on March 24, 1999, was appropriate and not expected to reveal the cecal cancer diagnosis that was discovered later.’’ J.A. 58. This language approximates the model response provided in HCFA’s Medicare Peer Review Organi- zation Manual for use in situations ‘‘[w]hen the involved practitioner consents to disclosure of information that identi- fies him/her.’’ HCFA, Medicare Peer Review Organization Manual Transmittal 84, Ex. 5–17 (Dec. 21, 2000) [hereinafter PRO Manual].

The letters concerning Drs. Dedman and Jolgren, by con- trast, advised Mr. Shipp that, because those doctors did not *6 consent to the release of information about the care they provided, Excel could not provide specific information about the results of its review. Each letter contained the following paragraph:

We have carefully examined all the issues raised in your correspondence and conducted a thorough review of the care your wife received . Federal laws and regulations prohibit us from releasing information about your care without the consent of your physician. Your wife’s phy- sician did not give consent; therefore, we are unable to provide any specific information about the results of our review. Our inability to provide this information does not mean that we found any problem with the care she received. However, please be assured that if we did find a problem, we will take all necessary action when our review findings warrant it.

J.A. 54, 56 (emphasis added). This response approximates the model provided in the PRO Manual for use ‘‘[w]hen the involved practitioner does not consent to disclosure of infor- mation that explicitly or implicitly identifies him/her,’’ PRO Manual, Ex. 5–17, ^[2] and follows the instructions contained in the manual’s narrative sections. ^[3] PRO manuals since 1990 HCFA’s model letter states:

We have carefully examined your concern(s) and conducted a thorough review of the medical records pertaining to the services that (you or name of beneficiary) received . Federal regulations prohibit us from releasing information that identi- fies the involved practitioner without his or her consent. Be- cause the involved practitioner did not give (his or her) consent, we are unable to release information that would explicitly or implicitly identify him/her. This does not necessarily mean that we found a problem with the services (you or name of beneficiary) received. However, we will take appropriate ac- tion if warranted by our review findings .

PRO Manual, Ex. 5–17 (italics added; underlining in original). The manual instructs the PRO to write the complainant and: (i) ‘‘Assure that you conducted a complete review of the medical

have expressed a similar nondisclosure policy.

Mr. Shipp is a member of Public Citizen, Inc., a nonprofit consumer advocacy organization. On behalf of Mr. Shipp and other similarly situated members, Public Citizen sued HHS and HCFA under the Administrative Procedure Act, 5 U.S.C. § 706(2)(A), contending, inter alia, that the PRO Manual’s instructions violate § 1320c–3(a)(14)’s requirement that PROs inform complainants of the ‘‘final disposition’’ of the com- plaint. Public Citizen asked the district court: (i) to declare invalid the regulations and policies that prohibit PROs from disclosing the results of PRO investigations when to do so would identify a nonconsenting practitioner; and (ii) to direct the defendants to retract those manual provisions and inform PROs that they must disclose the results of their investiga- tions. First Am. Compl. at 4–5 (J.A. 35–36).

On cross-motions for summary judgment, the district court found it clear from ‘‘ ‘the history, structure, and underlying policy purpose of the statute’ TTT that § 1320c–3(a)(14) re- quires a PRO to inform beneficiary complainants of the substantive disposition of the complaint.’’ Public Citizen, Inc. v. Department of Health & Human Servs. , 151 F. Supp. records and thoroughly examined all issues raised by the complain- ant’’; (ii) ‘‘Explain that you are unable to provide any information that explicitly or implicitly identifies the involved practitioner be- cause applicable regulations prohibit the release of such information without the practitioner’s consent’’; (iii) ‘‘Explain that your inability to disclose information that explicitly or implicitly identifies the involved practitioner does not mean that you found any problem with the care furnished’’; and (iv) ‘‘Assure that even though you are unable to disclose information that identifies the involved practitioner, you are taking necessary action if your review war- rants it.’’ PRO Manual § 5030(C). See HCFA, Medicare Peer Review Organization Manual Trans-

mittal 76 § 5030(C) (Sept. 1999) (J.A. 99–100); HCFA, Medicare Peer Review Organization Manual Transmittal 41 § 5250(B) (Oct. 1994) (J.A. 116); HCFA, Medicare Peer Review Organization Man- ual Transmittal 27 § 5045(B) (1990) (J.A. 127).

2d 64, 71 (D.D.C. 2001) (quoting Bell Atl. Tel. Cos. v. FCC , 131 F.3d 1044, 1048 (D.C. Cir. 1997)). The court granted Public Citizen’s motion for summary judgment and, inter alia, held that ‘‘the provisions in HCFA’s PRO Manual prohibiting disclosure of the results of § 1320c–3(a)(14) investigations are contrary to law.’’ Id. at 77.

We review the district court’s grant of summary judgment de novo. Arizona v. Thompson , 281 F.3d 248, 253 (D.C. Cir. 2002). The government contends that our analysis is gov- erned by the standard of review articulated by the Supreme Court in Chevron U.S.A. Inc. v. Natural Resources Defense Council , 467 U.S. 837 (1984). Under that decision, when reviewing an agency’s construction of a statute that it admin- isters, we first ask ‘‘whether Congress has directly spoken to the precise question at issue.’’ Chevron , 467 U.S. at 842. If so, ‘‘that is the end of the matter’’ and we ‘‘must give effect to the unambiguously expressed intent of Congress.’’ Id. at 842–43. If, however, ‘‘the statute is silent or ambiguous with respect to the specific issue,’’ we move to the second step and must defer to the agency’s interpretation as long as it is ‘‘based on a permissible construction of the statute.’’ Id. at 843.

The one thing that is indisputably clear about the statute at issue here is that it does not unambiguously mandate the government ’s interpretation, and the government does not contend otherwise. See Appellants’ Br. at 14, 40–41. The district court concluded that § 1320c–3(a)(14) unambiguously supports the plaintiff ’s interpretation and requires PROs to advise complainants of the results of the peer review investi- gation. It therefore held, under step one of Chevron , that the government’s interpretation—which construes the section as requiring PROs to do nothing more than inform beneficiaries that their complaint has been disposed of, without describing the content of that disposition—cannot stand. We find con- siderable merit in the district court’s view of congressional *9 intent. For the reasons discussed below, however, we need not (and therefore do not) rest our decision on Chevron ’s first step.

Nor do we rely on the second step of Chevron . As the Supreme Court has recently held, not all statutory interpreta- tions by agencies qualify for the level of deference afforded by that step. See United States v. Mead Corp. , 533 U.S. 218, 227–31 (2001); Christensen v. Harris County , 529 U.S. 576, 587 (2000). In Mead , the Court declared Chevron deference appropriate only where Congress has ‘‘delegated authority to the agency generally to make rules carrying the force of law, and the agency interpretation claiming deference was promulgated in the exercise of that authority.’’ 533 U.S. at 226–27.

There is no dispute that the first part of this requirement is met by Congress’ delegation to the Secretary of the authority to promulgate ‘‘regulations’’ governing PROs in general, 42 U.S.C. § 1320c–3(a)(8), and the disclosure of PRO information in particular, id. § 1320c–9(a) (forbidding disclosure of PRO data except in accordance with the statute, or ‘‘in such cases and under such circumstances as the Secretary shall by regulations provide to assure adequate protection of the rights and interests of patients, health care practitioners, or providers of health care’’ (emphasis added)). But the Secre- tary has not promulgated any regulation that interprets or even mentions § 1320c–3(a)(14). The only potentially rele- vant regulations, the confidentiality regulations of 42 C.F.R. pt. 480 described above, were promulgated before § 1320c– 3(a)(14) was enacted in 1986. See Medicare Program; Acqui- sition, Protection, and Disclosure of Utilization and Quality Control Peer Review Organization (PRO) Information, 50 Fed. Reg. 15,347 (Apr. 17, 1985). Accordingly, as counsel for the government conceded at oral argument, those regulations cannot provide a basis for deferring to the defendants’ inter- pretation of the meaning of the subsequently enacted phrase, ‘‘final disposition of the complaint.’’ See Christensen , 529 U.S. at 587 (declining to apply Chevron deference to regula- tion that did not address statutory issue).

The only agency pronouncement upon which the defen- dants’ claim for deference relies is HCFA’s PRO Manual. It is true, as defendants note, that Chevron deference is not necessarily limited to regulations that are the product of notice-and-comment rulemaking. See Barnhart v. Walton , 535 U.S. 212, 221 (2002); Mead , 533 U.S. at 231. But the Supreme Court has twice cited ‘‘agency manuals’’ as an archetype of the kind of document that is not entitled to such deference. Mead , 533 U.S. at 234 (declaring that interpreta- tions such as those ‘‘in policy statements, agency manuals, and enforcement guidelines’’ are ‘‘beyond the Chevron pale’’ (internal quotation marks omitted)); Christensen, 529 U.S. at 587 (‘‘[I]nterpretations contained in policy statements, agency manuals, and enforcement guidelines, all of which lack the force of law—do not warrant Chevron -style deference.’’); see also Washington State Dep’t of Soc. & Health Servs. v. Guardianship Estate of Keffeler , 123 S.Ct. 1017, 1026 (2003) (applying Skidmore v. Swift & Co ., 323 U.S. 134 (1944), rather than Chevron , to statutory interpretations contained in the Social Security Administration’s Program Operations Manual System).

Whether or not some agency manuals might still be worthy of Chevron deference, there is nothing to distinguish the one at issue here from those disfavored by the Supreme Court. Indeed, this court has previously held that similar sections of HCFA’s PRO Manual do not involve ‘‘substantive rights.’’ American Hosp. Ass’n v. Bowen , 834 F.2d 1037, 1045, 1049– 51 (D.C. Cir. 1987). To the contrary, we said that ‘‘[a] peer review organization is essentially an enforcement agent of the federal government,’’ id. at 1048, and that the manual merely See also Power v. Barnhart , 292 F.3d 781, 785–86 (D.C. Cir. 2002) (noting the government’s concession that Chevron did not apply to the Social Security Administration’s Hearings, Appeals and Litigation Law Manual); American Fed’n of Gov’t Employees v. Veneman , 284 F.3d 125, 129 (D.C. Cir. 2002) (holding that the model meat inspection program at issue there had ‘‘no more status than opinion letters, policy statements, agency manuals, and en- forcement guidelines, all of which are undeserving of Chevron deference’’).

‘‘maps out an enforcement strategy for the PROs with whom HHS contracts,’’ id. at 1049; see id. at 1050–51 (holding that the manual’s commands are neither legislative nor interpre- tive rules); see also Mead , 533 U.S. at 234 (declaring that interpretations contained in agency ‘‘enforcement guidelines’’ fail to qualify for Chevron deference). And while the PRO statute expressly authorizes the Secretary to promulgate ‘‘regulations’’ to carry out its provisions, 42 U.S.C. § 1320c– 3(a)(8), it contains no mention of agency manuals.

In a short passage in its opening brief, the government argues that the manual has the force of law because the contracts between HCFA and the PROs require PROs to adhere to the confidentiality provisions of the manual. Ap- pellants’ Br. at 43 (referring to sample contract, at J.A. 131). But the contracts with the PROs are not materially different from a myriad of contracts entered into by a myriad of agencies. See Bowen , 834 F.2d at 1048 (‘‘Like an indepen- dent contractor hired to construct a government building, the PRO carries out a task for pay at the behest of the govern- ment.’’). No court has read Mead as extending Chevron deference to a contract entered into between an agency and a private party, and we are loathe to permit agencies to bootstrap documents that otherwise would not warrant Chev- ron deference into a more exalted status merely by mention- ing them in such a contract. Cf. J.A. 131 (sample PRO contract, requiring PRO to adhere to ‘‘the Code of Federal Regulations, the PRO Manual, and other administrative directives’’ (emphasis added)). Indeed, according Chevron deference would be particularly inappropriate in this case be- cause the complaining Medicare recipient—for whose benefit § 1320c–3(a)(14) was enacted—is a stranger to the contract upon which the government seeks to rely.

Finally, even if we were prepared to accord Chevron defer- ence to the PRO Manual, that document contains no interpre- We further held in Bowen that ‘‘any contract provisions that are legislative are subject to [5 U.S.C.] § 553’s notice and comment requirements.’’ Id. at 1054. To our knowledge, none of the manual provisions at issue here has been subjected to notice and comment.

tation of § 1320c–3(a)(14) to which we might defer. In an introductory paragraph, the manual does contain a reference to § 1320c–3(a)(14)’s requirement that the PRO ‘‘inform bene- ficiaries or their designated representatives of the final dispo- sition of the complaint,’’ PRO Manual § 5000, but this does little more than repeat the statutory language. As authority for its nondisclosure policy, the manual cites only the confi- dentiality regulations promulgated before § 1320c–3(a)(14) appeared on the scene. ^[7] And the part of the manual that contains the model response letters and instructions does not reference § 1320c–3(a)(14) at all, relying instead on those preexisting confidentiality regulations. ^[8] Most important, there is no place in the manual where the agency explains why it believes that a PRO satisfies the statutory injunction to inform a complainant of the ‘‘final disposition’’ of the complaint simply by telling him that it has investigated the matter and will take action if appropriate. Because the manual thus contains no reasoning that we can evaluate for its reasonableness, the high level of deference contemplated in Chevron ’s second step is simply inapplicable.

^[7] See PRO Manual § 5000 (stating that ‘‘42 CFR 480.32 addresses disclosure of information about practitioners, reviewers, and institu- tions,’’ and that ‘‘[t]he regulations also limit your ability to give specifying details about a complaint review’’); id. § 5035 (‘‘[D]isclo- sure of PRO quality review information is governed by federal confidentiality regulations at 42 CFR Part 480.’’). See PRO Manual § 5030(C) (‘‘Explain that you are unable to

provide any information that explicitly or implicitly identifies the involved practitioner because applicable regulations prohibit the release of such information without the involved practitioner’s con- sent.’’ (emphasis added)); id. Ex. 5–17 (model letter, noting that ‘‘[f]ederal regulations’’ bar release of the information). Cf. Adamo Wrecking Co. v. United States , 434 U.S. 275, 287 n.5

(1978) (stating that ‘‘the mere promulgation of a regulation, without a concomitant exegesis of the statutory authority for doing so, obviously lacks ‘power to persuade’ as to the existence of such authority’’); SEC v. Sloan , 436 U.S. 103, 118 (1978) (reaching the same conclusion ‘‘where this Court can only speculate as to the Commission’s reasons for reaching the conclusion that it did’’

Although Chevron deference is unwarranted, HCFA’s in- terpretation of § 1320c–3(a)(14) is nevertheless due a degree of deference under the rule of Skidmore v. Swift & Co. , 323 U.S. 134 (1944). As Mead explained, under Skidmore an agency’s statutory interpretation remains ‘‘eligible to claim respect according to its persuasiveness.’’ Mead , 533 U.S. at 221; see Christensen , 529 U.S. at 587 (holding that where ‘‘ Chevron -style deference’’ is unwarranted, agency interpreta- tions are ‘‘ ‘entitled to respect’ , but only to the extent that those interpretations have the ‘power to persuade’ ’’ (quoting Skidmore , 323 U.S. at 140)).

III

In determining the proper construction of § 1320c–3(a)(14), both parties urge us to examine the statute’s text, structure, legislative history, and purpose. See Bell Atl. Tel. Cos. , 131 F.3d at 1047. We proceed to that task in the following sections.

‘‘We turn first, as we must, to the language of the statute, ‘the most important manifestation of Congressional intent.’ ’’ California ex rel. Brown v. Watt , 668 F.2d 1290, 1304 (D.C. Cir. 1981). Section 1320c–3(a)(14) states that the PRO ‘‘shall inform the individual (or representative) of the organization’s final disposition of the complaint.’’ HCFA contends that the term ‘‘final disposition’’ has merely a procedural meaning— that the PRO must inform the complainant that the matter has been finally disposed of, but that it need include nothing about the substance of that disposition. As the agency points out, there are dictionary definitions that are somewhat sup- portive of that view, although even these are ambiguous. See M ERRIAM W EBSTER ’ S C OLLEGIATE D ICTIONARY 335 (10th ed. 1996) (defining ‘‘disposition’’ as ‘‘the act or the power of disposing’’); because the agency’s orders did not ‘‘address[ ] in any detail the statutory authorization under which it took [the] action’’).

B LACK ’ S L AW D ICTIONARY 423 (5th ed. 1979) (defining ‘‘disposi- tion’’ as the ‘‘[a]ct of disposing’’).

We note at the outset that even if this were the appropriate definition of ‘‘final disposition,’’ the PRO Manual’s instruc- tions and model letter would still be invalid. The manual’s provisions do not require the PRO to advise the complainant that the matter has been disposed of, but only that the PRO has reviewed the matter and ‘‘ will take appropriate action if warranted by our review findings.’’ PRO Manual, Ex. 5–17 (emphasis added); see also Letter from Excel to David Shipp (Aug. 7, 2000) (J.A. 56) (advising that ‘‘ if we did find a problem, we will take all necessary action when our review findings warrant it’’ (emphasis added)). In short, because they speak of the possibility of future action and not of a final disposition that has already occurred, the manual’s provisions do not even comply with the defendants’ own construction of § 1320c–3(a)(14).

But we are not, in any event, persuaded by HCFA’s construction. To the contrary, the far more persuasive read- ing is that to inform someone of the ‘‘final disposition’’ of a matter means to inform him of its substantive result or conclusion. See, e.g. , D ANIEL J. O RAN, O RAN ’ S D ICTIONARY OF THE L AW 134 (1983) (defining ‘‘disposition’’ as final ‘‘settlement or result’’); W ILLIAM C. B URTON, B URTON ’ S L EGAL T HESAURUS 187 (3d ed. 1998) (including as synonyms ‘‘conclusion, deci- sion, TTT final settlement of a matter, finding, order, pro- nouncement, TTT resolution, settlement, [and] solution’’); B LACK ’ S L AW D ICTIONARY 484 (7th ed. 1999) (‘‘[a] final settle- ment or determination’’). ^[11] The context that comes quickest Compare Appellants’ Br. at 16 (arguing that the statute should be ‘‘read as permitting a PRO to inform the complainant TTT that the complaint was received, that it was investigated, and that corrective action was taken if appropriate’’ (emphasis added)). See also Administrative Procedure Act § 1(6), 5 U.S.C. § 551(6) (defining ‘‘order’’ as ‘‘the whole or a part of a final disposition’’); 42 U.S.C. § 405(j)(6) (requiring the Social Security Commissioner to report to Congress on the ‘‘final disposition,’’ ‘‘including any crimi- nal penalties imposed,’’ of certain restitution cases); 42 U.S.C.

to the judicial mind, of course, is the disposition of a case. See, e.g. , M ERRIAM W EBSTER ’ S C OLLEGIATE D ICTIONARY , at 335 (defining ‘‘disposition’’ as the ‘‘final arrangement’’ of a case); W ILLIAM S TATSKY, W EST ’ S L EGAL T HESAURUS/ D ICTIONARY (1985) (defining ‘‘disposition’’ as ‘‘[t]he final arrangement or decision (we awaited the court’s disposition)’’); O RAN ’ S D ICTIO- NARY OF THE L AW , at 134 (‘‘A court’s disposition of a case may be to give a judgment, dismiss the case, pass sentence on a criminal, etc.’’ (emphasis omitted)). After hearing argument, judges frequently tell the parties that they will advise them of the disposition of the matter. We expect that litigants, including the parties to this appeal, would be both surprised and puzzled if all we told them at the end of the day was that ‘‘the case has been decided’’—without telling them what that decision was. This view is, if anything, reinforced by the fact that the statute commands the PRO to inform the complain- ant ‘‘of’’ the final disposition, not simply ‘‘when’’ that disposi- tion has taken place.

This view is further reinforced by considering the context in which the information command that is contained in § 1320c–3(a)(14)’s second sentence appears. The preceding sentence defines the types of complaints that PROs must investigate: ‘‘ complaints about the quality of services TTT not meeting professionally recognized standards of health care .’’ 42 U.S.C. § 1320c–3(a)(14) (emphasis added). The following sentence (the section’s third) imposes an administrative due process requirement before the PRO may make a certain § 3759(b)(1) (requiring the improvement of criminal justice records by ‘‘complet[ing] TTT criminal histories to include the final disposi- tions of all arrests for felony offenses’’); 29 U.S.C. § 794a (describ- ing remedies for an employee ‘‘aggrieved by the final disposition of [a Rehabilitation Act] complaint’’); 42 U.S.C. § 2000e–16(c) (same for federal employee ‘‘aggrieved by the final disposition of his [EEOC] complaint’’). Cf. F ED. R. A PP. P. 21(b)(7) (directing the appeals court’s clerk

to ‘‘send a copy of the final disposition’’ to the trial court judge when the appellate court decides a petition for mandamus); F ED. R. A PP. P. 28 (requiring that appellant’s brief contain ‘‘a statement of the case briefly indicating the disposition below’’).

kind of finding: ‘‘Before the organization concludes that the quality of services does not meet professionally recognized standards of health care , the organization must provide the practitioner with reasonable notice and opportunity for discussion.’’ Id. (emphasis added). This context confirms that the information that is to be imparted to the Medicare beneficiary—after the PRO investigates the complaint and affords the practitioner due process—should contain the PRO’s determination as to whether the quality of services received met ‘‘professionally recognized standards of health care.’’

At oral argument, the government contended that the procedural protections of the third sentence of § 1320c– 3(a)(14) were designed not to afford practitioners due process before sharing adverse findings with complainants, as one would conclude from the two preceding sentences, but rather to protect practitioners from unwarranted notification to state licensing boards. It is true that another section, § 1320c– 3(a)(9)(B), requires a PRO to notify a state licensing board if it finds that a physician has furnished services not meeting professionally recognized standards of health care. 42 U.S.C. § 1320c–3(a)(9)(B). Section 1320c–3(a)(9)(B), however, con- tains its own due process provision, permitting such notifica- tion only ‘‘after notice and hearing.’’ Id. It would be illogical to conclude that the procedural protections of § 1320c– 3(a)(14) were intended not to precede the beneficiary notifica- tion required by that section, but merely to duplicate protec- tions that § 1320c–3(a)(9)(B) already provides as prerequi- sites to its state board notification requirement. Moreover, there is an even more fundamental flaw in the government’s argument: because § 1320c–3(a)(9)(B) was not enacted until 1990, four years after § 1320c–3(a)(14) became law, it simply is not possible that the third sentence of § 1320c–3(a)(14) was intended to provide due process protections for the not-yet- enacted notification requirement of § 1320c–3(a)(9)(B). See Pub. L. No. 101–508 § 4205(d)(1)(A), 104 Stat. 1388 (1990). No similar provision existed in 1986, when § 1320c–3(a)(14) was enacted. See 42 U.S.C. § 1320c–3 et. seq. (1982 & Supp. IV 1986).

In sum, both the text and the context of the second sentence of § 1320c–3(a)(14) persuade us that it was intended to require a PRO to inform a complainant of the results of its review of his complaint, and specifically of whether the ‘‘quali- ty of the services’’ that the recipient received met ‘‘profession- ally recognized standards of health care.’’ 42 U.S.C. § 1320c–3(a)(14).

HCFA next urges us to look beyond the words of § 1320c– 3(a)(14), both to other provisions of the PRO statute and to its overall structure, arguing that the district court’s interpreta- tion of the section is inconsistent with the statutory scheme. We find no such inconsistency.

The government’s first contention is that requiring PROs to notify beneficiary complainants of the results of their reviews would abrogate the confidentiality provisions of the PRO statute. The principal confidentiality provision is § 1320c–9(a), which, as noted above, states:

Any data or information acquired by any such organiza- tion in the exercise of its duties and functions shall be held in confidence and shall not be disclosed to any person except —(1) to the extent necessary to carry out the purposes of this part, (2) in such cases and under such circumstances as the Secretary shall by regulations provide to assure adequate protection of the rights and interests of patients, health care practitioners, or provid- ers of health care, or (3) in accordance with [provisions permitting specified disclosures to federal and state agencies].

42 U.S.C. § 1320c–9(a) (emphasis added).

HCFA contends that requiring disclosure of the results of the PRO review is contrary to § 1320c–9(a)(2) because such disclosure is not affirmatively authorized by the Secretary’s regulations. But § 1320c–9(a)(2) does not permit the Secre- tary to impose his own nondisclosure requirements; rather, it authorizes the Secretary to promulgate regulatory exceptions to the general nondisclosure requirement. Other exceptions

are contained in the statute itself, including the exception for disclosures ‘‘necessary to carry out the purposes of this part.’’ Id. § 1320c–9(a)(1). Since one of those ‘‘purposes’’ is speci- fied in § 1320c–3(a)(14), a disclosure made pursuant to that section cannot fairly be said to abrogate the statutory scheme.

The government’s second argument invokes the canon that, where ‘‘Congress includes particular language in one section of a statute but omits it in another section of the same Act, it is generally presumed that Congress acts intentionally and purposely in the disparate inclusion or exclusion.’’ Russello v. United States , 464 U.S. 16, 23 (1983) (internal quotation marks omitted). According to the government, ‘‘Congress has demonstrated time and again throughout the PRO statute that it knows how to require, in plain language, the disclosure of otherwise confidential PRO peer review results or find- ings ,’’ by using either of those two words rather than ‘‘dispo- sition.’’ Appellants’ Br. at 19 (emphasis added).

The problem with this argument is that neither of those two words, ‘‘results’’ or ‘‘findings,’’ is materially plainer—or more substantive—in meaning than the word ‘‘disposition.’’ Indeed, each is a synonym for the latter. See, e.g. , O RAN ’ S D ICTIONARY OF THE L AW , at 134 (defining ‘‘disposition’’ as ‘‘[f]inal settlement or result’’); B URTON ’ S L EGAL T HESAURUS , at 187 (listing ‘‘finding’’ as a synonym for ‘‘disposition’’). ^[15] And See, e.g. , 42 U.S.C. § 1320c–3(e)(3)(A)(ii) (1982 & Supp. IV 1986) (requiring a PRO that has reviewed a hospital’s denial of inpatient care to provide the patient with ‘‘notice’’ of the ‘‘results of the review’’), repealed by Pub. L. No. 106–554 § 521(c), 114 Stat. 2763 (2000); 42 U.S.C. § 1320c–3(a)(9)(B) (requiring a PRO that finds a care deficiency to notify the appropriate state licensing boards of its ‘‘finding and of any action taken as a result of the finding’’); id. § 1320c–3(a)(6)(B)(ii) (directing each PRO to ‘‘pub- lish’’ and ‘‘distribute’’ a report that includes its ‘‘findings with respect to the types of cases in which [it] has frequently deter- mined’’ that services did not meet professionally recognized stan- dards or were otherwise improper). See also Tyler v. Cain , 533 U.S. 656, 663 n.4 (2001) (describing

‘‘holdings’’ as including ‘‘the final disposition of a case as well as *19 because we could just as readily conclude that more detail is required to reveal the ‘‘disposition’’ of an investigation than merely to disclose its ‘‘results,’’ application of the Russello canon to this statute is simply indeterminate. Accordingly, we agree with the district court that, in this case, Congress’ use of slightly different words to describe various reporting requirements shows little more than that the legislature employed a modestly varied vocabulary to express similar meanings. Public Citizen , 151 F. Supp. 2d at 74. Moreover, ‘‘[e]ven if Congress can be presumed to have intended that different amounts of information be provided’’ by the use of the different words, ‘‘there is no basis to infer that TTT the term ‘final disposition’ should be limited to nothing more than a procedural fact.’’ Id.

The government’s third contention is that requiring disclo- sure of the results of PRO reviews would ‘‘effectively nullif[y] Congress’ prohibition on the discovery’’ of sensitive PRO information. Appellants’ Br. at 22. That prohibition is con- tained in § 1320c–9(d), which was enacted four years after § 1320c–3(a)(14) and reads as follows:

No document or other information produced by such an organization in connection with its deliberations in mak- ing determinations under section 1320c–3(a)(1)(B) or 1320c–5(a)(2) shall be subject to subpoena or discov- ery in any administrative or civil proceeding TTTT the preceding determinations necessary to that result ’’ (internal quotation marks and emphasis omitted; emphasis added)); Green v. Bock Laundry Mach. Co. , 490 U.S. 504, 527 (1989) (Scalia, J., concurring) (describing a particular statutory interpretation both as ‘‘an absurd, and perhaps unconstitutional result’’ and as ‘‘an un- thinkable disposition’’). Application of the canon to the use of the word ‘‘findings’’ is

further problematic because the sections that contain it were not enacted until after § 1320c–3(a)(14) became part of the PRO statute in 1986. See Pub. L. No. 101–508 § 4205(d)(1), 104 Stat. 1388 (1990) (enacting 42 U.S.C. § 1320c–3(a)(9)(B)); Pub. L. No. 100–203 § 4094(c), 101 Stat. 1330 (1987) (enacting 42 U.S.C. § 1320c– 3(a)(6)(B)(ii)).

42 U.S.C. § 1320c–9(d). ^[17] The government argues that § 1320c–9(d) bars disclosure of any document produced by a PRO ‘‘in connection with its deliberations,’’ and further ar- gues that the complaint response contemplated by the district court constitutes just such a document.

It is plain on the face of this section, however, that the district court’s interpretation of § 1320c–3(a)(14) cannot ‘‘nul- lify’’ § 1320c–9(d), because the latter has no application to a document that is disclosed pursuant to § 1320c–3(a)(14). Section 1320c–9(d) expressly protects the described docu- ments against being subject to ‘‘subpoena or discovery.’’ It does not insulate them from compliance with the statutory command of § 1320c–3(a)(14).

Indeed, if the government’s construction of § 1320c–9(d) were correct, then it would not only bar a PRO from issuing the kind of letter contemplated by the district court, but would also bar it from issuing the letters that Excel actually sent to Mr. Shipp. See supra Part I.B. If the letter contem- plated by the district court must be viewed as being produced ‘‘in connection with’’ a PRO’s deliberations, then surely the actual letters must be as well. Section 1320c–9(d) mentions neither the degree of substantive detail revealed by a docu- ment nor the consent of the practitioner as a factor in its vulnerability to subpoena. It simply states that ‘‘no’’ docu- ment ‘‘produced by such an organization in connection with its deliberations’’ is subject to discovery. 42 U.S.C. § 1320c–9(d) (emphasis added).

The referenced sections, § 1320c–3(a)(1)(B) and § 1320c– 5(a)(2), contain general delegations of authority to PROs to conduct quality of care reviews. It is also questionable whether a section like § 1320c–9(d),

which was enacted four years after § 1320c–3(a)(14), can be used to constrain the meaning of the earlier provision. There is certainly no ground for believing that § 1320c–9(d) repealed § 1320c– 3(a)(14), even partially. See County of Yakima v. Confederated Tribes & Bands of the Yakima Indian Nation , 502 U.S. 251, 262 (1992) (‘‘[I]t is a cardinal rule that repeals by implication are not favored.’’ (internal quotation marks omitted)).

Nor is the logical difficulty of the government’s construc- tion limited to the disclosure required by § 1320c–3(a)(14). That section is just one of several mandating specific disclo- sures. See, e.g., id. § 1320c–3(a)(9)(B) (requiring disclosure to state boards); see also PRO Manual § 5035(A) (requiring PROs to inform the complainant of ‘‘findings’’ relating to institutional providers). Because § 1320c–9(d) provides ex- ceptions for none of these, it is not reasonable to read it as governing the disclosure of documents in any context other than that expressly covered by its terms: namely, disclosure in response to subpoena or other administrative or civil discovery mechanism.

Finally, the government argues more generally that it would make no sense for Congress to require disclosure to a beneficiary complainant of a document that may not be disclosed in discovery to a civil litigant. They make a similar argument based on another provision of § 1320c–9(a), which exempts PRO documents from the requirements of the Free- dom of Information Act (FOIA), 5 U.S.C. § 552. But it is hardly surprising that Congress would permit disclosure to the party with the most direct interest in the information— the person who received the medical services at issue and whose complaint initiated the investigation—while barring disclosure to others, or even to the same recipient in a litigation context. Indeed, FOIA itself provides an example of such a statutory scheme. Although certain files regarding individuals are generally unavailable to FOIA requesters, the Privacy Act, 5 U.S.C. § 552a, permits requesters to obtain such information pertaining to themselves. Moreover, al- Compare 5 U.S.C. § 552(b)(6) (FOIA exemption for ‘‘personnel and medical files and similar files the disclosure of which would constitute a clearly unwarranted invasion of personal privacy’’), with id. § 552a(d)(1) (Privacy Act requirement that an agency permit an individual access ‘‘to his record or to any information pertaining to him’’). See Wren v. Harris , 675 F.2d 1144, 1146 (10th Cir. 1982) (‘‘[T]he [Privacy Act] provides rights to the individual with respect to his own records greater than the rights of the public generally.’’).

though ‘‘[d]iscovery limitations’’ may generally bar the pro- duction of certain documents in civil or criminal litigation, such limitations ‘‘do not apply when FOIA requests are presented in a discrete’’ FOIA action. North v. Walsh , 881 F.2d 1088, 1096 (D.C. Cir. 1989).

In sum, we find no inconsistency between the requirement that a PRO advise a complainant of the results of his com- plaint and the remainder of the PRO statute. To the con- trary, such a requirement is very much in keeping with the legislative scheme.

We turn next to an examination of the legislative history. Each side points to a different precursor bill as evidence that its interpretation of the final statute is correct. Although we do not find this exercise in legislative tracking to be particu- larly productive, there is another element of the legislative history that is helpful.

As the government points out, the original House version of § 1320c–3(a)(14) would have required a PRO to ‘‘inform the [complainant] of the organization’s conclusions TTT and final disposition of the complaint.’’ H.R. 5300, 99th Cong. § 10241(e)(1) (1986). Because the section as enacted speaks only of the complaint’s ‘‘final disposition,’’ the government contends that Congress must have rejected the House’s re- quirement that the complainant be advised of the PRO’s conclusions. It further insists that the only meaning left for ‘‘disposition’’ is a procedural one. Public Citizen, on the other hand, points out that the original Senate bill contemplated a purely procedural notification similar to that propounded by HCFA, requiring the PRO merely to ‘‘inform the individual that the organization has received the complaint and will take appropriate action.’’ S. 2706, 99th Cong. § 633(b)(1) While we have no occasion to decide the issue here, we note that the fact that the results of a PRO’s reviews must be disclosed to a beneficiary pursuant to § 1320c–3(a)(14) does not necessarily mean that they are admissible against a practitioner in civil litiga- tion.

(1986). Public Citizen contends that the absence of this language from the enacted version indicates Congress’ rejec- tion of purely procedural notice.

We are not persuaded by either argument. The deletion of the word ‘‘conclusions’’ from the House draft could simply indicate that Congress regarded the use of both ‘‘conclusions’’ and ‘‘disposition’’ as redundant, or that the legislature con- templated a more bare-bones but still substantive notification: just the bottom-line result (disposition), unencumbered by the PRO’s reasoning (conclusions). On the other hand, the dele- tion of the Senate provision requiring notification that the PRO ‘‘has received’’ the complaint would not by itself demon- strate that Congress would have disapproved of HCFA’s procedural construction—which requires notification not only that the complaint has been ‘‘received’’ but also that it has been ‘‘disposed of.’’

Hence, if Congress had left us with these precursor bills alone, without any explanation for its ultimate resolution of the matter, our understanding would not be much advanced. Fortunately, Congress provided one further piece of informa- tion. The Conference Committee explained the final confer- ence agreement as follows: ‘‘If a PRO makes a final determi- nation with respect to whether the services which are the subject of a complaint did or did not meet professionally recognized standards of care, the PRO would be required to inform the beneficiary of any final action taken .’’ H.R. C ONF. R EP. N O. 99–1012, at 361 (1986) (emphasis added). It would be a particularly cramped reading to construe the italicized phrase as requiring nothing more than notification that final action was taken, rather than notification of what that action was.

The government poses one final variant on the argument from legislative history: implicit congressional ratification. In support, it cites Merrill Lynch, Pierce, Fenner & Smith, Inc. v. Curran , 456 U.S. 353, 382 n.66 (1982), in which the Supreme Court said: ‘‘Congress is presumed to be aware of an administrative or judicial interpretation of a statute and to adopt that interpretation when it re-enacts a statute without *24 change.’’ The government contends that because the PRO Act was amended numerous times after the 1986 addition of § 1320c–3(a)(14), during which period HCFA was interpret- ing that section to require nothing more than procedural notification, Congress’ failure to statutorily reverse that inter- pretation demonstrates its implicit concurrence.

The Supreme Court, however, has added several caveats to the ratification canon that render it of limited utility here. See Solid Waste Agency v. United States Army Corps of Eng’rs , 531 U.S. 159, 169 (2001) (‘‘Although we have recog- nized congressional acquiescence to administrative interpreta- tions of a statute in some situations, we have done so with extreme care.’’). First, the canon is of little assistance here because, unlike Merrill Lynch , this is not a case in which ‘‘Congress re-enact[ed] a statute without change.’’ 456 U.S. at 382 n.66. Congress has neither re-enacted the entire PRO statute nor amended § 1320c–3(a)(14) at all. Rather, it has simply enacted a series of isolated amendments to other provisions. See Appellants’ Br. at 28 n.14 (collecting amend- ments). Compare Alexander v. Sandoval , 532 U.S. 275, 292 (2001) (‘‘[W]hen Congress has not comprehensively revised a statutory scheme but has made only isolated amendments, TTT [i]t is impossible to assert with any degree of assurance that congressional failure to act represents affirmative con- gressional approval of the Court’s statutory interpretation.’’ (internal quotation marks omitted)), with Barnhart v. Walton , 535 U.S. 212, 220 (2002) (according weight where ‘‘Congress has frequently amended or reenacted the relevant provisions without change’’ (emphasis added)).

Moreover, because ‘‘the rationale of [this] canon must be, either that those in charge of the amendment are familiar with existing rulings, or that they mean to incorporate them,’’ See also Alexander v. Sandoval , 532 U.S. 275, 292 (2001) (noting that ‘‘we recently criticized Curran ’s reliance on congres- sional inaction, saying that ‘[a]s a general matter [the] argu- men[t] deserve[s] little weight in the interpretive process’ ’’ (quoting Central Bank of Denver v. First Interstate Bank of Denver , 511 U.S. 164, 187 (1994))).

Thompson v. Clifford , 408 F.2d 154, 164 (D.C. Cir. 1968) (internal quotation marks omitted), the government’s argu- ment has little weight absent some evidence of (or reason to assume) congressional familiarity with the administrative in- terpretation at issue. The government points to no such evidence here. Even if it could be assumed that Congress was aware of HCFA’s more high-profile interpretations of the Medicare statute, its interpretation of § 1320c–3(a)(14) would hardly qualify. As we have noted above, no formal regulation addressed the question; indeed, if any ‘‘interpretation’’ exist- ed at all, it would have to have been teased out of the model letter and instructions buried deep within the PRO Manual.

Finally, we note that HCFA’s most prominent presentation of its position on the issue during much of the relevant period was actually one in which the agency took the opposite view from that which it maintains on this appeal, and precisely the position that Public Citizen urges us to adopt. In 1989, HCFA published a notice of proposed rulemaking (NPRM) soliciting comments on a proposed regulation that would have required PROs to ‘‘inform the beneficiary or the beneficiary’s representative whether the quality of care meets professional- ly recognized standards of health care, and, if not, the correc- tive action to be taken.’’ Medicare and Medicaid Programs; Denial of Payment for Substandard Quality Care and Review of Beneficiary Complaints, 54 Fed. Reg. 1956, 1964 (Jan. 18, 1989). In that NPRM, HCFA stated that while it had ‘‘considered precluding PROs from providing any information to the beneficiary that might identify the concerned physician or practitioner,’’ the agency rejected that position because ‘‘ we believe that section 1154(a)(14) of the Act [42 U.S.C. § 1320c–3(a)(14)] requires that the information discussed above be provided to the beneficiary. ’’ Id. at 1960 (emphasis added). Although the proposed rule was never promulgated, See Brown v. Gardner , 513 U.S. 115, 121 (1994) (holding that where ‘‘there is no TTT evidence to suggest that Congress was even aware of the [agency’s] interpretive position[,] we consider TTT re-enactment to be without significance’’ (quotation marks omit- ted)).

it remained pending at least through 1993, ^[23] and a similar rule remained under consideration through 2001; the latter was not withdrawn until after the institution of this lawsuit.

The interpretation contained in the agency’s proposed rule does not, of course, bind it here. See Commodity Futures Trading Comm’n v. Schor , 478 U.S. 833, 845 (1986). But it does effectively counter the government’s argument that Con- gress implicitly ratified the contrary interpretation by not amending the statute. If there is any prospect that Congress was aware of the agency’s views regarding the meaning of § 1320c–3(a)(14) during the relevant period, what it would have known was that the agency was espousing views similar to those of Public Citizen and was moving toward formalizing those views in a regulation. If Congress shared those views, it would have had no reason to amend the law.

Finally, the government urges us to consider the congres- sional purpose underlying the PRO statute. We conclude, however, that the argument based on legislative purpose cuts strongly against the government’s position.

The government points to the various confidentiality provi- sions of the statute, and argues that they were intended both See Unified Agenda, 58 Fed. Reg. 56,355, 56,355 (Oct. 25, 1993) (mentioning 1989 proposed rule). See Unified Agenda, 63 Fed. Reg. 21,989, 21,996 (Apr. 27, 1998)

(announcing that HCFA was considering issuing a proposed rule that ‘‘would permit the disclosure of PRO information about physi- cians TTT without their permission to the extent necessary to comply with section 1154(a)(14) of the Social Security Act [42 U.S.C. § 1320c–3(a)(14)],’’ and noting that ‘‘[t]his section requires PROs to conduct reviews of beneficiary complaints about the quality of services and inform each beneficiary of the final disposition of his or her complaint’’); 63 Fed. Reg. 61,735, 61,737 (Nov. 9, 1998) (referencing same rule); 64 Fed. Reg. 64,411, 64,424 (Nov. 22, 1999) (same); 65 Fed. Reg. 73,838, 73,844 (Nov. 30, 2000) (same); 66 Fed. Reg. 25,466, 25,468 (May 14, 2001) (noting withdrawal of 1998 proposed rule as of February 13, 2001).

to protect the privacy of health care practitioners and to assure the confidentiality necessary to encourage practition- ers to evaluate their peers honestly. We do not doubt that these considerations were important to Congress and that they underlie the confidentiality provisions of the statute. See Armstrong v. Dwyer , 155 F.3d 211, 219 (3d Cir. 1998). As we have discussed above, however, the confidentiality provisions are not absolute; they contain both specific excep- tions, see 42 U.S.C. § 1320c–9(a)(3), and the general exception for disclosures ‘‘necessary to carry out the purposes of this part,’’ id. § 1320c–9(a)(1). The fact that § 1320c–3(a)(14) breaches absolute confidentiality by requiring a narrow dis- closure to beneficiaries is no more remarkable than, for example, the requirement of § 1320c–3(a)(9)(B) that disclo- sures be made to a physician’s state licensing board.

Moreover, although protecting confidentiality was undoubt- edly the purpose of the PRO statute’s confidentiality provi- sions, that was hardly the only—or even the overriding— purpose of the statute as a whole. See S. R EP. N O. 97–494, at 41 (1982) (stating that PRO contracts are for ‘‘the purpose of promoting the effective, efficient, and economical delivery of quality health care services under Medicare’’). And when we turn to the specific provision at issue here, § 1320c–3(a)(14), the sole evidence we have of congressional purpose is the Conference Committee’s statement that the section was in- tended to ‘‘[i]mprove peer review responsiveness to beneficia- ry complaints.’’ H.R. C ONF. R EP. N O. 99–1012, at 361 (1986). Indeed, § 1320c–3(a)(14) is expressly phrased as a require- ment that the PRO provide information; considerations of confidentiality are not mentioned at all.

It is hard to see how § 1320c–3(a)(14), if interpreted as the government suggests, would improve peer review responsive- ness to beneficiary complaints. HHS’s own Office of Inspec- tor General (OIG) has concluded that HCFA’s confidentiality policy ‘‘hinder[s] the PROs’ ability to be responsive to benefi- ciaries who complain.’’ HHS, OIG, The Beneficiary Com- plaint Process of the Medicare Peer Review Organizations, at 6 (Nov. 1995); see HHS, OIG, The Medicare Beneficiary Complaint Process: A Rusty Safety Valve, at ii, 16 (Aug. *28 2001) (stating that ‘‘current procedures continue to pre- clude the PROs from responding substantively,’’ resulting in a deficiency in ‘‘responsiveness’’). The government contends that, even under its limited interpretation, § 1320c–3(a)(14) ‘‘directly improve[s] PRO responsiveness to beneficiary com- plaints’’ because it makes the investigation of beneficiary complaints mandatory—which was not the case prior to 1986. Appellants’ Br. at 32. But the requirement to investigate comes from the first sentence of § 1320c–3(a)(14), not the second. See 42 U.S.C. § 1320c–3(a)(14) (first sentence) (‘‘The organization shall conduct an appropriate review of all written complaints TTTT ’’). And we, of course, are required to ‘‘give effect, if possible, to every clause and word of a statute.’’ Moskal v. United States , 498 U.S. 103, 109–10 (1990) (cita- tions and internal quotation marks omitted).

Indeed, it is hard to see what purpose the second sentence of § 1320c–3(a)(14) would serve at all under the government’s construction. According to HCFA, that sentence merely requires the PRO to advise a complaining beneficiary of three things: that the complaint was received, that it was investi- gated, and that corrective action will be taken if appropriate. But the beneficiary could learn the first of these simply by including a Certified Mail Return Receipt along with his complaint, and the latter two promise nothing more than that the agency will do what the law requires. As both Public Citizen and HHS’s Inspector General suggest, this seems little more than an empty gesture. See OIG, The Medicare Beneficiary Complaint Process, at ii (concluding that the PRO complaint process ‘‘fails to provide a meaningful response to complainants’’). Because ‘‘[w]hen Congress acts to amend a statute, we presume it intends its amendment to have real and substantial effect,’’ Stone v. INS , 514 U.S. 386, 397 (1995), we reject the government’s interpretation of § 1320c–3(a)(14) as wholly unpersuasive.

We agree with the government that the PRO Act delegated policymaking authority to the Secretary and not to the OIG. We cite the OIG’s views—supported, as they are, by that Office’s experience and expertise—not because they legally command our deference, but because we find them logically persuasive.

29 IV We conclude that, to ‘‘inform’’ a Medicare beneficiary of the organization’s ‘‘final disposition’’ of the complaint as required by § 1320c–3(a)(14), a PRO must notify the complainant of the results of its review. At a minimum, this means that the PRO must disclose its determination as to whether the quali- ty of the services that the recipient received met ‘‘profession- ally recognized standards of health care.’’ 42 U.S.C. § 1320c–3(a)(14). We therefore affirm the judgment of the district court, which held that the provisions of the PRO Manual prohibiting disclosure of the results of § 1320c– 3(a)(14) investigations are invalid because they are contrary to law. Public Citizen , 151 F. Supp. 2d at 77.

At one place in its brief, Public Citizen suggests that the term ‘‘final disposition’’ goes further than this, requiring the PRO to advise the complainant not only of its final judgment regarding the quality of care received, but also of the correc- tive action that it has taken. See Appellee’s Br. at 15. While this suggestion certainly represents a reasonable elaboration of the meaning of the term, it does not have—as does the phrase ‘‘meet[s] professionally recognized standards of health care’’—the virtue of coming verbatim out of the first and third sentences of § 1320c–3(a)(14). We need not decide today, however, whether this additional information is statu- torily required. The district court’s order did not expressly require it, and Public Citizen has not sought modification of that order. Moreover, because even our more limited ‘‘dispo- sition’’ will require HCFA to rethink the kind of notification The district court also held invalid those of ‘‘HCFA’s regula- tions’’ that prohibit such disclosures. 151 F. Supp. 2d at 77. As noted in Part I.A, however, the agency’s confidentiality regulations incorporate the statutory exception for disclosures ‘‘necessary to carry out the purposes’’ of the PRO statute. 42 U.S.C. § 1320c– 9(a); see 42 C.F.R. § 480.103(b)(1). Because the disclosures re- quired by § 1320c–3(a)(14) fall within this exception, see supra Part III.B, that portion of the district court’s decision is without effect. *30 required of PROs, there remains ample room for an adminis- trative resolution of this question.

The judgment of the district court is Affirmed .