1. 1 指導教授：周天 所長 報 告 人：碩專班二年級 9520701 林俊農 國立高雄第一科技大學 科技法律研究所 案例討論 課程：醫療與法律 案號： 747 F.2d 583, 53 USLW 2237, 7 Soc.Sec.Rep.Serv. 198, Med & Med GD (CCH) P 34,198

2. 2 Plaintiff: Estate of MS Smith Colorado 護理之家 Defendant Secretary of DHHS M. Heckler Defendant Colorado 州政府 Title XIX of the Social Security Act 違反 Medicaid Act 10th Circuit （上訴至巡迴法院 原告勝訴 District court （原告敗訴） Plaintiff in Intervention Title XIX of the Social Security Act 違反 Medicaid Act Title XIX of the Social Security Act 違反 Medicaid Act 敗訴 勝 訴

3. 3 美國 DHHS 歷任部長

4. 4 Born June 21, 1931June 211931 A Republican politician from MassachusettsRepublicanMassachusetts Served in the United States House of Representatives for eight terms, from 1967 until 1983United States House of Representatives The Secretary of Health and Human ServicesSecretary of Health and Human Services Ambassador to Ireland under President Ronald Reagan.Ronald Reagan Margaret Mary Heckler

5. 5 背景（一） Plaintiffs instituted the lawsuit in an effort to improve the deplorable conditions at many nursing homes. (1975) Plaintiffs and the Colorado governmental defendants stipulated to dismissal, without prejudice, of the claims against the Colorado governmental defendants. (1978) The state defendants filed a complaint in intervention on behalf of the people of Colorado against the federal defendants. Lawsuit against the federal defendant proceeded to trial in June 1982. The trial court denied relief. 原告 : Colorado nursing home operators 被告 : Federal and Colorado state governmental agencies and officials.

6. 6 背景（二） The Medicaid Act 目的： To enable the federal government to assist states in providing medical assistance to “aged, blind or disabled individuals, whose income and resources are insufficient to meet the costs of necessary medical services, and... rehabilitation and other services to help such... individuals to attain or retain capabilities for independence or self care. 審核： To receive funding, a state must submit to the Secretary and have approved by the Secretary a plan for medical assistance which meets the requirements of XIX of the Social Security Act.

7. 7 爭點 Whether the trial court erred in finding that the Secretary does not have a statutory duty to develop and implement a system of nursing home review and enforcement which focuses on and ensures high quality patient care? If the Secretary has such a duty, whether the enforcement mechanism promulgated by the Secretary satisfies that duty?

8. 8 原告主張 （一） Secretary has a statutory duty to develop an enforcement system whereby to receive medicaid funds states would be forced to use a patient care management system Actually, continuously receiving their Medicaid entitlements to optimal medical and psychosocial care in a safe, sanitary, rehabilitatively supportive, accessible, personalized environment…. Surveys assess the care provided almost totally on the basis of the records, documentation and written policies of the facility being reviewed….

9. 9 原告主張（二） 目前對於 Medicaid 的評鑑制度只是紙上作業 The Secretary has violated her statutory duty to assure that federal Medicaid monies are paid only to facilities which meet the substantive standards of the Act-facilities which actually provide high quality medical, rehabilitative and psychosocial care to resident Medicaid recipients.

10. 10 初審法院判決 原告所提出的方案確實可行 目前的監督制度是以機構為導向（是不正 確的） Failure to implement and require the use of a “patient oriented” system is not a violation of the Secretary's statutory duty. The State of Colorado, not the federal government, is responsible for developing and enforcing standards

11. 11 初審法院判決理由 ( 一 ) Medicaid Act provides that States are responsible for establishing and maintaining health standards for provider institutions the states determine what kind and how many professional medical and supporting personnel will be used to administer the state plan. The state plan must include standards and methods which the state will use to assure that the medical assistance provided is of high quality. Responsibility for inspecting nursing homes for survey and certification purposes lies with the state. Even if the Secretary has a duty to promulgate such regulations, the Secretary has satisfied that duty by promulgating the detailed regulations

12. 12 初審法院判決理由 ( 二 ) Under Colorado law, the State of Colorado is responsible for licensing nursing homes, suspending a license if the public health or welfare is endangered, for regulating nursing home administration, and licensing and regulating the various professions which provide care in nursing homes

13. 13 上訴法院判決 The Secretary has a duty to establish a system to adequately inform herself as to whether the facilities receiving federal money are satisfying the requirements of the Medicaid Act By promulgating a “facility-oriented” enforcement system, rather than a “patient-oriented” system, the Secretary failed to follow the focus of the Act Mandamus relief was appropriate.

14. 14 上訴法院判決要旨 District court improperly defined the Secretary's duty under the statute. The federal government has more than a passive role in handing out money to the states. The Secretary has a duty to establish a system to adequately inform herself as to whether the facilities receiving federal money are satisfying the requirements of the Act. This duty to be adequately informed is not only a duty to be informed at the time a facility is originally certified, but is a duty of continued supervision.

15. 15 上訴法院判決理由（一） 依法典 States must inform the Secretary what methods they will use to assure high quality care. In addition to the “adequacy of the services available,” the periodic inspections must address “the care being provided” in nursing facilities.

16. 16 上訴法院判決理由（二） 依法典 Nothing in the Act to indicate that the state function relieves the Secretary of all responsibility to ensure that the purposes of the Act are being accomplished. The Secretary, not the states, determines which facilities are eligible for federal funds

17. 17 上訴法院判決理由（三） 依立法史 The Committee is concerned that, without the authority to validate State agency compliance reviews and to make an independent judgment as to the extent of compliance by particular facilities, the Secretary lacks the means necessary to assure that Federal matching funds are being used to reimburse only those skilled nursing facilities……

18. 18 上訴法院判決理由（四） 依事實 Secretary's current method of informing herself as to whether the facilities in question are satisfying the statutory requirements is “facility oriented,” rather than “patient oriented.” By promulgating a facility oriented enforcement system, the Secretary has failed to follow that focus and such failure is arbitrary and capricious. ( 恣意專斷 )

19. 19 憲法 第 13 章 基本國策 第 4 節 社會安全 第 155 條 國家為謀社會福利，應實施社會保險制度。人民之老 弱殘廢，無力生活， 及受非常災害者，國家應予以適 當之扶助與救濟。

20. 20 台灣相關法規 護理人員法第 16 條第 2 項 護理人員法 護理機構設置標準第 9 條 護理機構設置標準 老人福利法第 5 條 老人福利法第 5 條 老人福利法施行細則第 12-13 條 老人福利法施行細則 內政部補助或委託辦理老人服務及照顧 辦法 內政部補助或委託辦理老人服務及照顧 辦法 。。。。。。