350 Mass. 704 | Mass. | 1966
One Early, a recipient of old age assistance, was eligible for full payment of hospital costs under the program known as “medical assistance for the aged” (MAA). See G. L. c. 118A, §§ 13-32, inserted by St. 1960, c. 781, § 8. He had no resources which could be used to reduce hospital costs. On August 6, 1963, he was admitted to The Springfield Hospital (Springfield). Springfield promptly notified the Chicopee board of public welfare of the admission and received from that local board authorization to send bills directly to it.
Early remained in the hospital for eighteen days, until August 24,1963. A bill dated August 27,1963, was sent by Springfield covering (a) hospital care (at $25 a day) in the sum of $450, and also (b) laboratory, X-ray, special drug, and supply charges amounting to $173.50, a total of $623.50. On August 30, 1963, the Chicopee board requested Springfield to bill at the so called “all-inclusive per diem” (AIPD) rate ($23.18 a day for Springfield) mentioned in G. L. c. 7, § 30K, inserted by St. 1953, c. 636, § 2.
Springfield then sought in the Superior Court (under Gr. L. c. 30A, § 14) judicial review of the department’s decision. The trial judge ruled
Springfield’s principal, and somewhat diffusely presented, contentions are (a) that to provide “the maximum benefits available to a [recipient” of MAA (c. 118A, §§ 13-32) or of AFDC (GK L. c. 118) requires that the appropriate State or local authorities “meet the actual cost to the [recipient of purchasing his necessary care,” in accordance with the recipient’s “actual need ... or the expense in
The commissioner, on the other hand, contends that the right of the hospitals to reimbursement for the expense of caring for any recipients of any form of public assistance is governed by G. L. c. 7, § 30K, and that, within the meaning of § 30K, the local boards and State department, in making such reimbursement, are purchasing hospital care.
1. In Massachusetts Gen. Hosp. v. Cambridge, 347 Mass. 519, 521 (hereinafter referred to as the Cambridge case), we considered the right of a hospital to receive reimbursement from a city for hospital care necessarily incurred by one of its residents in need of public assistance. We held that the right was statutory, and that, under the statutes there applicable, the hospital’s recovery from the city was limited (347 Mass. 519, 523) to the expense of care necessarily incurred at the maximum rate established under G. L. c. 7, § 30K. See G. L. c. 117, § 24A, c. 122, § 20.
The Cambridge case arose under G. L. c. 117, which provides (see § 1) for public assistance to “poor and indigent” persons, and for “hospital care ... [to be] furnished to a person in need of public assistance.” See § 24A, inserted by St. 1959, c. 584
Two cases are based on G. L. c. 118, § 2 (as amended through St. 1962, c. 556, § 1), providing that local boards of public welfare, subject to the supervision and valid regulations of the State department, shall grant aid (AFDC) to certain families with dependent children “sufficient to enable . . . [the] parent to bring up such child or children properly in his . . . own home.” The aid is to be paid in
Springfield argues that the Federal statutes contemplate that the money obtained from Federal grants shall be used for aid furnished to individuals, in accordance with a generous estimate of such individuals’ need, and that each of these individual recipients of aid in effect makes a contract with the hospital furnishing services which is binding on the individual and must be paid for by the local board in accordance with Springfield’s fair and reasonable charges. Doubtless, the care furnished to eligible recipients and the payments to those giving that care are intended to be fully adequate. We perceive nothing, however, in the Massachusetts statutes governing these special types of assistance (MAA and AFDC), which establishes that the Legislature intended hospital services to such aid recipients be provided and paid for under c. 118 and c. 118A in a manner different from the method applicable to similar services (to welfare recipients and certain others) under c. 117.
The whole structure of these chapters shows that the local boards of public welfare, under the general supervision (see c. 118, § 5; c. 118A, § 20) of the State department, were to reimburse the hospitals (see c. 118, § 2; c. 118A, § 14) for aid furnished. In a practical sense, the local boards are providing the aid recipients with hospital care by “purchasing” that care from the hospitals, and we interpret c. 7, § 30K, as limiting the obligation of the local boards to making payments at the AIPD rate for included
2. Springfield further contends that the AIPD rate set for it for 1963 was not adequate or properly compensatory in various respects.
Section 30K provides a convenient, simple method of computing “fair and just” compensation to hospitals furnishing care to aid recipients under Gr. L. cc. 117,118,118A, and 118D (disabled persons). See 1953 House Doc. No. 2400, pp. 23-24, 26. Because of the obvious difficulties of determining in each case the appropriate charge for the particular hospital services rendered, the all inclusive per diem rate has been developed. In effect, by § 30K, the Commissioner of Administration has been directed to perform a function much like that of the Commissioner of Insurance in fixing “adequate, just, reasonable, and nondiscriminatory” charges under Gr. L. c. 175, § 113B (as amended through St. 1964, c. 391), and that of the Department of Public Utilities in approving various utility rates. See Gr. L. c. 164, § 94, as amended through St. 1963, c. 615, § 1.
Nonprofit hospitals have not been made public utilities, although they resemble utilities in that they conduct enterprises greatly affected with a general public interest and are subject to State regulation. Even if, as in the Cambridge case, 347 Mass. 519, 522, a hospital may not be
In any event, without regard to whether hospitals are utilities or are legally obliged to care for welfare patients, § 30K is the statutory method provided to ensure their receipt of adequate compensation from public funds when they do furnish such care. It is not now necessary to determine whether the standards of fixing AIPD rates set by § 30K (see fn. 2) are valid and nonconfiscatory, or how they shall be interpreted. Cf. Massachusetts Bonding & Ins. Co. v. Commissioner of Ins. 329 Mass. 265, 270. We decide only (a) that the remedy for any inadequacy of the AIPD rates (including any constitutional relief concerning those rates) must be sought under § 30K before the Commissioner of Administration, and upon review of his action under c. 30A, § 7; and (b) that evidence concerning the adequacy of the AIPD rates (although appropriate in proceedings under § 30K) is not relevant in proceedings before the State Department of Public Welfare under GL L. c. 118, § 8, and e. 118A, § 21, concerning amounts payable for the care of individual aid patients, or upon review under c. 30A, § 14, from the department’s decision. As we said of the hospital in the Cambridge case, 347 Mass. 519, 522, Springfield in
3. The two cases (fn. 1) brought by MGrH raise questions concerning the income resources of aid recipients under the MAA program and the effect of those resources upon the hospital’s claim to the whole AIPD rate for each day of the recipient’s care. The governing statute is Gr. L. c. 118A, § 18, inserted by St. 1960, c. 781, § 8.
In the Lynch case, the patient was a single male. He had monthly income of $181.02. From this in computing the amount of Lynch’s need, and thus of the MAA help to be given, the exclusion of $150 (see language of clause [a] in fn. 8 following point [X]) was deducted, leaving a total of $31.02 of income available to Lynch with which to pay MG-H in part for bis care. The total bill at the AIPD rate was $530.27. Of this Blue Cross paid $401.96. From the balance of $128.31, was deducted $31.02, leaving a balance to be paid by the local board in Somerville where Lynch lived. The State department ordered the local board to pay this sum and the final decree in the Superior Court, upon MGrH’s petition for review, affirmed the department’s decision.
In the Passemato case, the patient was a wife residing in Everett. She was cared for by MGrH for one day. The AIPD rate was $35.66. Although the State department concluded that the Everett board had no liability to grant any MAA help, the trial judge in the Superior Court (upon
The final decrees correctly reflect the application of the terms of § 18 to the facts. As in the cases brought by Springfield, no question concerning the adequacy of' the AIPD rate may be considered in these proceedings.
5. In each of the five cases, the final decree is affirmed.
So ordered.
Section 30K, as enacted in 1953, reads, ‘ ‘ The director of hospital costs and finances shall determine from time to time and certify to the commissioner of administration, at least as often as annually, the average all-inclusive per diem charge to the general public for public ward accommodations or their equivalent, the all-inclusive per diem cost of care in such accommodations and the all-inclusive per diem cost of care for all patients of each hospital . . .
The judge also ruled that the AIPD rate was not established by the State Department of Public Welfare but by the Commissioner of Administration under § 3OK, so that no hearing by the State department on the AIPD rates was necessary. The trial judge stated that the record was too meager and ambiguous to make any determinations with respect to the establishment of the AIPD rates by the Commissioner of Administration.
Section 24A was later amended by St. 1964, c. 515, effective September 10, 1964, long after Springfield furnished to Early the care here discussed.
There was evidence (1) that the 1963 AIPD rate was based upon the lower costs for a twelve months period ended fifteen months prior to January 1, 1963, thus causing serious financial losses to Springfield in a period of rapidly rising costs; (2) that Springfield, to offset operating losses largely incurred in caring for welfare patients at an inadequate AIPD rate, has been obliged to use substantial amounts of its unrestricted endowment income to meet operating costs; (3) that funding by Springfield of depreciation (and of reserves for hospital plant expansion and replacement) has not been possible because of the losses; and (4) that, over the period 1952-1963, the per diem expenses of welfare patients t'a the hospital (and also the per diem charges to paying patients) had in each year very greatly exceeded the welfare per diem reimbursement at the AIPD rate.
This obligation in some instances may be reinforced by the requirements of Federal grants. See Simkins v. Moses H. Cone Memorial Hosp. 323 F. 2d 959 (4th Cir.), cert. den. 376 U. S. 938.
For example, the evidence showed that Chicopee has no hospitals. Its welfare .board uses hospitals in surrounding cities. - The Chicopee board’s director testified that he doubted “if any hospital could properly deny service to a person in need of . . . medical care. That would be Unlikely to happen. ’ ’
Section 18, as originally inserted, reads in part, “A person entitled to . . . [MAA] shall receive such assistance on the basis of need. The amount of such need shall be determined, in accordance with standards approved by the department, after consideration of the degree to which an applicant's income and resources are insufficient to meet the costs of necessary medical care. In determining such income, where a person has need of a residence apart from a licensed chronic hospital, licensed nursing home or public medical institution, [X] there shall be excluded (a) if unmarried or if married and the applicant is the husband, income of applicant of one hundred and fifty dollars a month, and (b) if married, and the applicant is the wife, combined income of husband and wife of two hundred and twenty-five dollars a month. ’ ’ Then follow provisions, not here relevant, concerning complete disqualification of persons from the receipt of MAA help by reason of the possession of stated amounts of property. The letter [X] in the quotation from § 18 is inserted for convenience in referring to the language immediately following. Section 18 was later amended by St. 1964, c. 591, and St. 1965, c. 657, § 1, but the amendments are not applicable to these cases.