TGIF! In a little known but important case argued in November of 2022, the family of a Medicaid nursing home resident in Indiana began a suit against a publicly owned nursing home (originally 2016), Valparaiso Care and Rehabilitation. The nursing home is operated by the Health and Hospital Corp. of Marion County. The corporation’s board is appointed by the mayor of Indianapolis and the Marion County Commission and city council. A ruling is expected from the Court soon.
The Talevski family sued the Health and Hospital Corp. after their father was denied readmission to the facility, alleging he was cared for by Valparaiso and other facilities, negligently. He passed away due to complications from dementia but during his initial stay and subsequent travels among nursing homes, the family argued that he was excessively drugged – six psychotropics. The nursing home claimed that the elderly gentlemen became violent, sexually aggressive, necessitating a transfer to another facility more capable of caring for him. The other facility was an hour away from the family. The family said the facility tried to transfer him to another facility even farther away – 2 plus hours. The facility, Valparaiso, refused to take him back.
After the facility refused to accept the readmission, the family sued. One of the daughters is an attorney. The basis of the suit against the Health and Hospital Corp. is that the extensive use of medication, unwarranted and against federal law (SNF Conditions of Participation), and his unauthorized transfers against his rights, violated his rights under federal law. This law, the Federal Conditions of Participation for SNFs, regulates care provided to Medicaid and Medicare beneficiaries. The suit alleges that it is fundamentally illegal to harm patients, provide substandard care, and received Medicaid reimbursement. The suit seeks redress for the rights violations against the County.
At issue is whether a beneficiary can sue a governmental entity for breaches of rights under a federal program or denial of benefits under a federal program such as Medicaid. The argument against the suit is that programs like Medicaid are a joint federal-state funding contract and as such, beneficiaries don’t have the right to sue based solely on this relationship. The question thus is, can individuals interfere with or become a party to, a contractual relationship between the state and federal government?
The implications of this suit are enormous for seniors in the Medicaid program and for providers that care for Medicaid beneficiaries. For beneficiaries, the risk of loss in this case is that they would not be able to sue a government or governmental agency for things as simple as a denial of benefits, even if they are eligible under Medicaid criteria. Administrative procedure may be the only method for addressing complaints or benefit issues.
Providers and governments take the opposite approach indicating that a codification of a right of a beneficiary to sue could create havoc for key programs such as Medicaid waiver (home, community-based services) programs, PACE, Special Needs Plans, etc. They say that lawsuits don’t create a remedy but do ultimately, push unnecessary litigation costs and damage claims into the program such that funding elements would be harmed.
Court watchers see parallels with a decision and the recent Dobbs abortion ruling – a question of rights and access to certain care and services. Some believe the Court may attempt to place limits around certain beneficiaries and litigation such as the ability to sue nursing homes using provisions in the Federal Conditions of Participation as a basis; a patient/resident rights violation. The thought here is that rule enforcement or rule violations when not enforced or addressed, is a regulatory function. There is no likelihood that the Court would speak to any issue of harm due to poor care which, is a different matter and not part of this suit directly.
I’m fascinated by this case as there is so much at stake for Medicaid beneficiaries and providers in the Medicaid program. Its nuances and challenges are many. It is a poster case, in my opinion, for the overall argument that these programs, Medicaid and Medicare, have become too bureaucratic, over-regulated, and incapable of truly supporting and addressing, the real needs of their beneficiaries.
A good synopsis of the case and the issues is here: https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2022/11/28/supreme-court-case-could-curtail-rights-of-medicaid-patients