in need of skilled nursing facilities but who have been denied access to them. Defendants are four nursing homes; their administrators; the Health Care Facilities Association of Pennsylvania (hereafter HCFAP), which is a trade organization representing 215 non-profit, proprietary and governmental nursing homes; and two HCFAP officers. Plaintiffs allege that these defendants have conspired to fix the rates which the Commonwealth of Pennsylvania pays under the medical assistance program to skilled nursing facilities for providing care to indigent patients. Plaintiffs assert that defendants have conspired to deny such care as part of an effort to increase their prices, contending this activity constitutes per se violations of the Sherman Antitrust Act, 15 U.S.C. §§ 1, 2, as well as common law tortious conduct.
Taking as true the allegations of the complaint and all reasonable inferences deducible therefrom, Curtis v. Everette, 489 F.2d 516, 518 (3d Cir. 1973), cert. denied 416 U.S. 995, 94 S. Ct. 2409, 40 L. Ed. 2d 774 (1974), the operative facts may be briefly stated. Under ordinary circumstances, a skilled nursing facility participating in the Pennsylvania Medical Assistance Program (hereafter Medicaid), 42 U.S.C. §§ 1396 et seq.; 62 P.S. §§ 441.1 et seq., enters into a contract with the Pennsylvania Department of Public Welfare, executing a "Skilled Nursing Home Care Agreement." This agreement obligates the facility to provide skilled nursing care to eligible medical assistance patients in return for which the facility receives reimbursement presently set at $20. per patient per day from the welfare department. At some unknown date prior to June 26, 1975, defendants began a series of discussions which culminated in a conspiracy to 1) have the rate of reimbursement raised to $27.25 per day; 2) boycott and refuse to accept any new Medicaid patients until this rate was increased, this boycott to begin on August 1, 1975; and 3) further coerce the Commonwealth to increase the rate by threatening to terminate their provider agreements with the state. The culmination of this conspiracy occurred on June 26, 1975, when a HCFAP press release was issued, detailing the above-described action the defendants would undertake and its objectives (Complaint, paragraphs 32, 35; Exhibit II). In furtherance of this conspiracy, defendants refused to admit plaintiff DeGregorio, although he had been approved by the Medicaid program as eligible for skilled care and each of the homes had beds available for male patients. Mr. DeGregorio's sole source of income was and still is a monthly Social Security check of approximately $130. Plaintiff Gouedy was subjected to a similar concerted refusal of admission, although she also had been declared eligible for skilled care. Mrs. Gouedy's sole source of income also was a monthly Social Security check for $168.50.
Defendants' objections to the complaint are many, but basically they can be broken down into two main categories: standing and the sufficiency of the allegations of effect on interstate commerce. I shall consider them separately.
The threshold requirement of standing is statutory in antitrust cases.
An antitrust plaintiff has standing if he alleges a violation of the antitrust laws, demonstrates that he has suffered injury to his business or property, and shows that his injury was incurred "by reason of" the other party's illegal activities. These requirements are imposed because Congress did not intend, by enacting Section 4 of the Clayton Act, to "provide a remedy in damages for all injuries that might conceivably be traced to an antitrust violation." Hawaii v. Standard Oil Co., 405 U.S. 251, 263 n. 14, 92 S. Ct. 885, 891, 31 L. Ed. 2d 184 (1972). Rather, treble damage relief has been confined, at least in the Third Circuit, "to those individuals whose protection is the fundamental purpose of the antitrust laws." Cromar Co. v. Nuclear Materials and Equipment Corp., 543 F.2d 501, 505 (3d Cir. 1976), quoting In Re Multidistrict Vehicle Air Pollution M.D.L. No. 31, 481 F.2d 122, 125 (9th Cir.), cert. denied sub. nom. Morgan v. Automobile Mfgrs. Assn., 414 U.S. 1045, 94 S. Ct. 551, 38 L. Ed. 2d 336 (1973).
At the outset, it is apparent that plaintiffs have sufficiently alleged a violation of the antitrust laws. Group boycotts, concerted refusals by competitors to deal with others, long have been held unreasonable or illegal per se under the federal antitrust laws, and beyond justification. Klor's, Inc. v. Broadway-Hale Stores, Inc., 359 U.S. 207, 79 S. Ct. 705, 3 L. Ed. 2d 741 (1959); Northern Pacific R. Co. v. United States, 356 U.S. 1, 78 S. Ct. 514, 2 L. Ed. 2d 545 (1958).
Trade associations must necessarily regulate the conduct of their members, but regulations or rules which require the members to refuse to deal should be upheld only if they are reasonable and not directed at specific individuals. Radiant Burners, Inc. v. Peoples Gas, Light & Coke Co., 364 U.S. 656, 81 S. Ct. 365, 5 L. Ed. 2d 358 (1961). Here, defendants' policies were directed, by their very nature, against plaintiffs.
Therefore, plaintiffs have alleged an antitrust violation, and if they can demonstrate individual injury sustained by reason of the violation, they may maintain this suit.
a. Daniel DeGregorio's Allegations of Injury Under Section 1
Mr. DeGregorio first alleges that he suffered a cognizable injury to his business in that defendants' act denied him the opportunity to be restored to employability. From early on, it has been recognized that the language "business interest" should be given a broad interpretation to accomplish the Act's objectives, Quinonez v. Nat. Assn. of Securities Dealers, Inc., 540 F.2d 824, 829 (5th Cir. 1976), that it "denotes the employment or occupation in which a person is engaged to procure a living." Roseland v. Phister Mfg. Co., 125 F.2d 417, 419 (7th Cir. 1942). One who has lost the opportunity to perform work as the result of an antitrust violation has stated an injury to his business or property and is entitled to recovery, Nichols v. Spencer International Press, Inc., 371 F.2d 332, 334 (7th Cir. 1967), and salaries or commissions lost as a result of antitrust practices are recoverable as well. Vandervelde v. Put and Call Brokers and Dealers Ass'n, 344 F. Supp. 118 (S.D. N.Y. 1972). However, this does not mean that everyone can bring an action because he was denied the opportunity to enter a business. Numerous courts have rejected the idea that there need be an actual on going business to obtain standing, see, e.g. Triangle Conduit & Cable Co. v. Nat. Electric Products Corp., 152 F.2d 398, 400 (3d Cir. 1945); N.W. Controls, Inc. v. Outboard Marine Corp., 333 F. Supp. 493, 507 (D. Del. 1971); Delaware Valley Marine Supply Co. v. American Tobacco Co., 184 F. Supp. 440, 443-4 (E.D. Pa. 1960), aff'd 297 F.2d 199 (3d Cir. 1961), cert. denied 369 U.S. 839, 82 S. Ct. 867, 7 L. Ed. 2d 843 (1962), but they have required at the very least that plaintiff demonstrate the intention and preparedness to enter the business. A simple hope or expectation to enter a business is insufficient.
Plaintiff DeGregorio has failed to allege that he is prepared to enter a business.
He argues that it would be superfluous and unjust to require him to show preparedness to be employed, because it is precisely plaintiff's preparedness to be employed that has been deprived by defendants' activities. I find this argument to be unacceptable. It is nothing more than a bootstrap attempt to alleviate the necessity of demonstrating that he has suffered some economic injury. Were I to follow this line of reasoning, then anyone denied skilled nursing care, no matter if that person was incapable of ever working again, could contend that he could possibly have been restored to employability and thus has suffered injury. The antitrust laws were not enacted to protect this type of person. Plaintiff has failed to demonstrate that the deprivation of such an elusive opportunity constitutes an injury to his business, and therefore he has no standing to sue on this basis.
Mr. DeGregorio's second assertion of injury to his business or property is that he was denied the benefit of two income exemptions to which he would have otherwise been entitled as a Medicaid patient had he been admitted to a skilled nursing care facility. I find this argument persuasive, and accordingly hold that he has standing to pursue his antitrust action on this ground.
By way of brief background: the Medicaid Program, Title XIX of the Social Security Act, 42 U.S.C. §§ 1396-1396g, is a cooperative program, whereby participating states reimburse qualified "providers" of services which also choose to participate. The Act requires that the participating states make services available to all individuals receiving cash assistance under one of the federally-aided public welfare programs.
These individuals are termed "categorically needy". 45 C.F.R. § 248.1(a)(1). In addition, the Act authorizes states to elect to make medical assistance available to individuals whose income and resources exceed the amount allowed to qualify them for cash assistance, but which are insufficient to meet the costs of necessary medical care and services. These individuals are termed "medically needy." 45 C.F.R. § 248.1(a)(2).
Normally, an individual who receives Social Security benefits and who requires some kind of skilled nursing care pays all of his benefits to the treating institution. This is true simply because of economics -- the Social Security monthly payment is not enough to meet the cost of the care and his savings or his family must make up the difference. But those characterized as medically needy are entitled to the benefit of two income exemptions granted by the Department of Public Welfare, i.e., the individual is not required to pay out all of his income to the nursing facility. Specifically, the Department regulations provide for a total annual income exemption of $1,225. for a single adult which is applicable during the first six months of the individual's stay in a public medical institution or an intermediate care or private skilled nursing facility. In addition, a patient staying six months or more in such a facility receives a $25. monthly income exemption for personal care items. Pennsylvania Department of Public Welfare -- Public Assistance Manual §§ 9223.31a, 9223.32a.
As mentioned previously, plaintiff DeGregorio qualified as a medically needy individual. He desired placement in a skilled nursing facility. Had he been accepted, he would have had the benefit of these exemptions. Instead, he was required to gain admission at Riverview, the county nursing home for Philadelphia, occupy a non-skilled, residential care bed, and turn over to the home all of his income from Social Security as a condition of his retention there. See Amended Complaint, paragraph 28. Thus, as a result of defendants' alleged practices, Mr. DeGregorio has been deprived of income.
The questions remain whether this asserted injury is sufficient to satisfy the "injury to business or property" standard necessary to confer standing and that it was suffered by reason of defendants' activities. "Injury to business or property" has been construed by the Supreme Court to mean that a "person whose property is diminished by a payment of money wrongfully induced is injured in his property," Chattanooga Foundry & Pipe Works v. Atlanta, 203 U.S. 390, 396, 27 S. Ct. 65, 66, 51 L. Ed. 241 (1906); accord, Hanover Shoe, Inc. v. United Shoe Mach. Corp., 392 U.S. 481, 489-90, 88 S. Ct. 2224, 2229, 20 L. Ed. 2d 1231 (1968); and a consumer of service who has been illegally overcharged has been granted standing. Hawaii v. Standard Oil Co., supra, 405 U.S. at 262-64, 92 S. Ct. at 891-92. Generally, this requires that plaintiff suffer a pecuniary loss in order to recover. See Delaware Valley Marine Supply Co., supra, 184 F. Supp. at 449. This does not require, however, that a payment of money be made, for in Congress Building Corp. v. Loew's Inc., 246 F.2d 587, 594 (7th Cir. 1957), the court held that a lessor's rights under a lease which could be sold or traded were within the term property and any impairment to the value of those rights constituted an injury. Even if a money payment were necessary, plaintiff has alleged that the denial of admission to a skilled nursing facility thereby required him to expend certain Social Security income he could have otherwise retained. This is clearly within the pecuniary loss and diminishment of property test contemplated in Delaware Valley Marine Supply Co., supra, and one induced "by reason of" the alleged wrongful conduct. In this regard, given the directness of the relationship between plaintiff and defendants and the directness of injury, plaintiff also fits well within the guidelines of Cromar, supra, 543 F.2d at 505. For these reasons, I conclude that plaintiff has standing to bring his antitrust action.
b. Pearl Gouedy's Standing
Since plaintiff Gouedy
has alleged also that she was deprived of the benefit of the income exclusions and had been qualified as medically needy prior to her being denied admission to skilled nursing facilities,
it is apparent, for the same reasons as mentioned previously, that she suffered a cognizable injury under the antitrust laws and has standing to maintain this action.
Standing to Bring Suit
PWRO contends that it has standing to maintain its antitrust action in that defendants' alleged activities operated to thwart its social purpose, i.e., defendants' refusal to admit medical assistance patients eligible for skilled nursing care "impairs PWRO's ability to improve the conditions of life for those who must rely upon public welfare programs, including medical assistance." Amended Complaint, paragraph 11. Defendants, on the other hand, assert that the emerging rule in antitrust actions is that an association lacks standing to bring suit on behalf of its members to recover for their injuries and argue that this injury, in any case, does not qualify as an injury to business or property which merits Sherman and Clayton Act protection. I conclude that it would be inappropriate to confer standing upon PWRO, but do so for reasoning which differs from that offered by defendants.
An association may obtain standing in either of two ways: it may have standing in its own right to seek relief from injury to itself and to vindicate whatever rights and immunities the association itself may enjoy, NAACP v. Alabama, 357 U.S. 449, 458-60, 78 S. Ct. 1163, 1169-71, 2 L. Ed. 2d 1488 (1958), or it may have standing solely as the representative of its members even where it has suffered no injury from the challenged activity. Hunt v. Washington State Apple Advertising Commission, 432 U.S. 333, 97 S. Ct. 2434, 53 L. Ed. 2d 383 (1977); Warth v. Seldin, 422 U.S. 490, 95 S. Ct. 2197, 45 L. Ed. 2d 343 (1975); Philadelphia Welfare Rights Organization v. Embry, 438 F. Supp. 434, 437 (E.D. Pa. 1977). In the latter instance, the association must allege
. . . that its members, or any one of them, are suffering immediate or threatened injury as a result of the challenged action of the sort that would make out a justiciable case had the members themselves brought suit [citation omitted]. So long as this can be established, and so long as the nature of the claim and of the relief sought does not make the individual participation of each injured party indispensible to proper resolution of the cause, the association may be an appropriate representative of its members, entitled to invoke the court's jurisdiction [emphasis added]. Warth v. Seldin, supra, 422 U.S. at 511, 95 S. Ct. at 2211-12.