Louisiana Department of Health and Human Resources, DAB No. 731 (1986)

GAB Decision 731

March 21, 1986

Louisiana Department of Health and Human Resources;
Docket No. 84-247
Ballard, Judith A.; Settle, Norval D.  Ford, Cecilia Sparks

The Louisiana Department of Health and Human Resources (DHHR, State,
Louisiana) appealed a disallowance by the Health Care Financing
Administration (HCFA, Agency) of $1,761,997 in federal financial
participation (FFP) claimed under Title XIX of the Social Security Act
(Medicaid).  The claims were for services provided to Medicaid
recipients during the period January 1, 1983 to August 31, 1983.

During the time period in question, the Louisiana State plan limited
payments under Medicaid for hospital outpatient services to three visits
per recipient per year and payments for physician services to 12 visits
per recipient per year.  The issue here is whether charges billed by
DHHR charity hospitals for certain costs associated with physician
services provided in hospital outpatient clinics are subject to the
three visit limit or the 12 visit limit.  We determine that the charges
are outpatient services costs subject to the three visit limit and,
therefore, affirm the disallowance of FFP in these charity hospital
charges for recipient visits in excess of that limit.

Background

The federal Medicaid regulations authorize FFP in expenditures for both
physician services and outpatient hospital services furnished to
Medicaid recipients, subject to such limitations as are imposed by the
State in its plan as approved by the Secretary of the Department of
Health and Human Services.  Prior to January 1, 1979, the State plan did
not limit the number of outpatient hospital services visits covered by
Medicaid.

In 1979, by an amendment to its State plan eventually approved on
December 5, 1979, but effective January 1, 1979,(2) Louisiana limited
Medicaid recipients to three outpatient hospital services visits per
year.  The State had limited Medicaid recipients to 12 physician
services visits per year for several years preceding, possibly as far
back as 1975 or 1976. /1/


As originally proposed by the State, the 1979 State plan amendment would
have imposed a three-visit limit only on hospital emergency room
outpatient services visits.  As explained in greater detail in the
Analysis, infra, pp. 6-7, that version of the proposed amendment was
rejected by HCFA.

In addition to emergency room services, charity hospitals in Louisiana
also had outpatient clinics where physicians' services were available to
Medicaid recipients.  These facilities were referred to in this case as
outpatient hospital clinics and were staffed by physicians on the
faculty of the State-owned Louisiana State University School of Medicine
(LSU) under a contract between DHHR and LSU.

The aforesaid contract has two provisions which relate to the issue in
this case:

   II.a.3.  All professional services of physicians, related to direct
patient care, and related health educational activities or the
administrative support of the affiliated programs which are included in
this agreement will be contracted through the University or negotiated
after agreement by the University that such action is warranted.  The
Dean of the School of Medicine will have ultimate authority and
responsibility through his administrative staff and department heads for
the faculty physicians assigned to hospitals and patient care programs
affiliated with the DHHR.

   * * * *(3)

   II.a.7.  The DHHR will provide well-equipped health care facilities
and related resources for the care of patients and the construction of
medical education.  This includes the provision of a sufficient staff of
nursing and allied health personnel to accomplish the objectives listed
above and acceptable employee-to-patient ratios in keeping with the
normal of other such programs in the area.

   * * * *

   III.A.2.  DHHR . . . agrees to allow the University, through its
billing agency (LSU Clinics), to bill for physician services provided to
patients who have third party coverage for such services.

(Louisiana Exhibit A to submission of August 23, 1985, p. 2.) Thus, LSU
agreed to provide all professional services of physician related to
direct patient care including those services of a non-emergency nature
which physicians with private offices ordinarily provide as part of an
office visit.  For its part, DHHR agreed to provide the physicians with
well-equipped health care facilities and related resources, including
nurses and allied health personnel.

When a Medicaid recipient visited one of these clinics and was seen by a
physician on a non-emergency "office visit" basis, two types of billings
for reimbursement were generated:  LSU billed the Medicaid program for
the professional services of the contract physician (using HCFA 1500, a
uniform claim form) and the hospital billed the program for the costs
incurred by it incident to the service provided to the Medicaid
recipient (using TCC 103, a Medicaid claim form).  A cost report showing
how one of the charity hospitals calculated its costs includes such
items as, for example, salaries of unspecified personnel, a
proportionate share of the intern-resident service program, medical
records and library, laundry, housekeeping, supplies, and depreciation.
The State referred to these and other related costs as a "facility fee"
and as facility "overhead." From these items the hospital arrives at a
per diem cost upon which its billing is based.  This cost is identified
in the State's financial data by procedure code 90045. /2/

(4)

   Regulatory and Other Provisions Involved

42 CFR 440.2:

   (a) Specific definitions.  "Outpatient" means a patient who is
receiving professional services at an organized medical facility, or
distinct part of such a facility, which is not providing him with room
and board and professional services on a continuous 24-hour-a-day basis.

   "Patient" means an individual who is receiving needed professional
services that are directed by a licensed practitioner of the healing
arts toward the maintenance, improvement, or protection of health, or
lessening of illness, disability, or pain.

42 CFR 440.20:

   (a) "Outpatient hospital services" means preventive, diagnostic,
therapeutic, rehabilitative, or palliative services that --

   (1) are furnished to outpatients;

   (2) Except in the case of nurse-midwife services, as specified in
Sec. 440.165, are furnished by or under the direction of a physician or
dentist;  and. . . .

42 CFR 440.50:

   "Physicians' services," whether furnished in the office, the
recipients's home, a hospital, a skilled nursing facility, or elsewhere,
means services provided --

   (a) Within the scope of practice of medicine or osteopathy as defined
by State law;  and

   (b) By or under the personal supervision of an individual licensed
under State law to practice medicine or osteopathy.

Louisiana State Plan Attachment 3.1(A), Item 2:

   OUTPATIENT HOSPITAL SERVICES

   Effective January 1, 1979, the Office of Family Security, will make
payment to a licensed hospital for three outpatient hospital visits per
recipient per calendar year. There are no provisions for any additional
visits.

(Louisiana Exhibit 5 to submission of February 8, 1985)(5) Louisiana
State Plan Attachment 3.1A, Item 5, effective November 20, 1980:

   PHYSICIANS' SERVICES WHETHER FURNISHED IN THE OFFICE, THE PATIENT'S
HOME, A HOSPITAL, A SKILLED NURSING FACILITY OR ELSEWHERE are provided
with limitations as follows:

A.  Physician Services

   Payment is made to duly licensed Doctors . . . for the following
services:

   (1) up to 12 out-patient physician visits per calendar year with
provision for extension If medically approved.

   * * * *

(Louisiana Exhibit 4, supra)

DHHR Policy Manual dated March 1, 1979, at 19-220:

   The following physician services are provided and are counted as one
of the up to 12 allowable physician out-patient visits per year:

   (a) Physician office visit

   (b) Physician visit in the home

   (c) Physician visit in a nursing home

   (d) Physician visit in outpatient hospital setting (Louisiana Exhibit
3, supra)

The parties' arguments

Louisiana argued that the 1979 amendment to its State plan limiting
Medicaid recipients to three visits for outpatient services did not
cover the facility's costs associated with physician services in charity
hospital clinics. The State contended that its creation and consistent
use of a special billing code (90045) for the hospital charges proved
that the 1979 amendment did not apply, even though the services were
provided in an outpatient hospital setting.  (6)

HCFA argued that the disputed costs were billed by the hospital as
outpatient services using hospital outpatient claim forms and thus under
the 1979 amendment could not be treated as physician services.  HCFA
distinguished the allowability of FFP for the physician services billed
for by LSU, up to the 12 visit limit, from the facility "overhead" costs
billed for by the hospital, which HCFA argued were subject to the three
visit limit imposed by the 1979 amendment to the State plan.

Analysis

This dispute arose because the State, by the language of the 1979 State
plan amendment ultimately approved by HCFA, limited itself to FFP in
three billings per year by a hospital for outpatient services.  We
recognize that had the State submitted no amendment in 1979, it could
have validly claimed these costs.  This recognition does not mean that
we can ignore the clear language of the 1979 amendment.

The State introduced a number of documents to support its contention
that it did not intend to impose a three-visit limit on the type of
expenditures involved here. Certainly, the amendment first offered would
not have done so;  that proposed language would have limited only use of
emergency room outpatient facilities to three visits per year.  /3/ This
proposed amendment was rejected by HCFA in September 1979 because it was
deemed contrary to Medicaid regulation 42 CFR 440.230( c)(1), which
prohibits denying or reducing the amount, duration, or scope of a
required service to a recipient because of diagnosis, type of illness,
or condition.  The State responded with another effort to persuade HCFA
to allow the State to restrict only emergency outpatient services, but
was unsuccessful. /4/ On December 5, 1979 HCFA approved the version
which was the focus of this appeal.


(7)

In its briefs and through the testimony of DHHR officials at the hearing
in this case, the State took the position that the 1979 State plan
amendment as finally approved imposed the three-visit limit on such
outpatient services as emergency room care, laboratory tests, and
x-rays, but not on the hospital's costs for the outpatient clinics.

We do not find these after-the-fact (and largely self-serving)
statements by the State and its witnesses to be credible.  The State
provided no written, contemporaneous evidence to support the position
that the State intended to treat these costs as physicians' services,
rather than outpatient services.  To the contrary, the record shows that
the State was accepting billing for the services on outpatient forms,
calculated according to the methods used for and appropriate to
outpatient services, rather than physicians' services. /5/ Below, we
discuss the following reasons why we do not adopt the State's position.


* The fact that the State was paying the bills without imposing the
three-visit limit does not constitute an administrative practice
embodying the interpretation advanced here, given that the State also
failed to apply the limit to other services which the State admits were
subject to it.  When HCFA repeatedly pointed out that the State was not
applying the limit to all outpatient services, the State never responded
by differentiating the costs in question here.(8)

* The testimony of the State's principal witness regarding the nature of
the hospital's clinic program and why it was unique and thus should be
treated differently was contradicted and unpersuasive.

* Most important, the State's position is not supported by an analysis
of the wording in the State plan.

The record here indicates that when given the opportunity to confront
HCFA with an interpretation which might have been viewed as
contradicting the basis for HCFA's approval of the 1979 amendment, the
State instead responded in a way apparently intended to reassure HCFA
that the State accepted an interpretation of the 1979 amendment
consistent with that espoused by HCFA in this appeal.  This is shown by
the State's responses to the Agency findings in reviews of the State
Medicaid program subsequent to the approval of the 1979 amendment to the
State plan.

In September 1980 HCFA sent the State a copy of a draft assessment
report for Fiscal Year 1980 (10/1/79 - 9/30/80) containing this finding
and recommendation:

   The State is placing inappropriate limits on outpatient hospital
services by allowing only 3 visits for emergency room charges while
allowing unlimited visits for other services.

   * * * *

   This practice is contrary to the Louisiana State Plan amendment
approved on December 5, 1979 specifying that all outpatient hospital
services are limited to 3 visits per recipient per year regardless of
the reason for the visit. It is also contrary to 42 CFR 440.230(c)(1)
which specifies that a State may not arbitrarily deny or reduce the
amount, duration or scope of a required service solely because of the
diagnosis, type of illness or condition.  42 CFR 440.210 designates
outpatient hospital services as a required item of service to the
categorically needy and Louisiana has, by authority of 42 CFR 440.220,
designated it as a required item of service to the medically needy.
Further, 42 CFR 440.20(a) defines outpatient hospital services as those
" . . . preventive, diagnostic, therapeutic, rehavilitative or
palliative services provided to an outpatient. . . ."

   Recommendation

   The State should correct its practice of applying only emergency room
services to the 3-visit limit on(9) out-patient hospital services.  Any
limit should be uniformily applied to all services provided by the
outpatient hospital (sic).

(HCFA Exhibit CC, submission of November 26, 1985)

To this the State responded, in December 1980:

   The State Plan limits outpatient hospital visits to three per
calendar year.  Because of a systems limitation of the Fiscal agent, the
control has been limited to the emergency room visits under Code 00086
which represents the vast majority of outpatient services.  This control
has been deleted and the limit applied to outpatient services.
Limitation will be on place of services (hospital) rather than the type
of service. . . .

(Louisiana Exhibit 4, submission of November 7, 1985)

In June 1981 HCFA sent the State a copy of a narrative report for Fiscal
Year 1981 (10/1/80 - 9/30/81) containing this finding and
recommendation:

   The State's limit of three outpatient hospital visits per year is not
being enforced. . . . inappropriate procedure codes are being used to
control the State's outpatient hospital limit.

   Recommendation

   The State should determine those procedure codes which should be
controlled under its outpatient hospital limit.  As indicated in the FY
1980 Louisiana State Assessment, any limit which the State establishes
should be applied uniformly to all services provided by the outpatient
hospital.

(HCFA Exhibit EE, submission of November 26, 1985)

To this the State responded, in August 1981:

   TCC (The Computer Company) has been instructed to place edits on
outpatient services of three per calendar year.  These will be uniformly
applied to all outpatient services. . . .

(Louisiana Exhibit 5, submission of November 7, 1985)

The August 1981 letter referred to in the State's Response adds
additional support to HCFA's position that the 1979(10)

State plan amendment limited all hospital outpatient services:

   We are requesting approval of our plan to exempt hemodialysis and
radiation therapy services from the three (3) hospital out-patient
visits limitation per calendar year.

   In January 1979, we imposed a limitation of three hospital
out-patient visits per calendar year to control abuses and to bring
expenditures within the appropriation.  The EDS Federal system could
apply this limitation only by procedure code.  Therefore, all claims
containing an emergency room visit were limited to three per calendar
year.  Information showed that applying the limitation in this manner
controlled more than 90% of the out-patient claims to three per calendar
year.

   The Computer Company is now able to apply this limitation by place of
service, which means that all claims showing the place of service as an
out-patient hospital are now limited to three per calendar year.  It is
our position, however, that hemodialysis and radiation therapy services
are not truly hospital out-patient services even though they may be
provided on an out-patient basis.  The same hospital facility also
provides the services on an in-patient basis. . . .

(Ibid.; HCFA Hearing Exhibit 1)

In August 1982 HCFA sent the State a copy of a narrative report for
Fiscal Year 1982 (10/1/81 - 9/30/82) containing this finding and
recommendation:

   The State does not uniformly apply its outpatient hospital limit to
all applicable procedure codes.  Procedure code 90045 is exempt from the
three visit limit.  We were informed by State staff that this is a
special code used by Charity Hospital only for services in its
outpatient clinic.

   * * * *

   RECOMMENDATION

   The State should count all services performed in an outpatient
setting toward the three visit per year limit.

(HCFA Exhibit FF, submitted November 26, 1985) (11)

The State's Response, dated September 30, 1982, set out, as the State's
"proposed policy to fulfill the requirements" of the above quoted
Recommendation, a statement of "Outpatient Hospital Services"
paralleling in part and amending in part the wording of the 1979 State
plan amendment.  The first sentence is identical to the first sentence
of the plan amendment.  Then, in lieu of "(there) are no provisions for
any additional visits," the following is inserted:

   Additional visits may be determined medically necessary by the OFS
Medical Review Section.  Prior approval may be requested for the
following reasons:

   (a) Extenuating circumstances that warrant hospital outpatient
treatment rather than treatment in a physician's office setting.

   (b) the patient's medical condition would endanger the patient's life
or permanently impair his/her health, if not treated;  and

   (c) availability of medical facilities to provide required services
warranted by the individual's illness.

(Louisiana Exhibit 6, submission of November 7, 1985;  HCFA Exhibit HH,
Attachment 7, page 1, submission of November 26, 1985)

The record does not show that the State plan was amended to incorporate
the State's new policy as set out above.  Instead, in a March 1983
letter to HCFA, the State proposed an amendment to "correct a compliance
issue" by revising the "limit of three outpatient visits" so that "if a
provider has a physician clinic in the outpatient hospital setting,
these services would be applied to the physician office visit limit of
twelve (12) per annum rather than the three visit limit." Louisiana
Exhibit 7, submission of February 8, 1985.  The resulting amendment,
approved by HCFA on October 26, 1983 (to be effective September 1,
1983), provided under "Outpatient Hospital Services" that "physician
services . . . in an outpatient hospital setting shall(12) be considered
physician services, not outpatient services.  (Louisiana Exhibit 8,
submission of February 8, 1985) /6/

 

 

 


The record also contains letters from DHHR officials to HCFA in January
and February 1984 stating that it was Louisiana's position that even
prior to the 1983 State plan amendment, the charges associated with
physician services in a hospital outpatient clinic setting, billed for
by the hospital, were physician services, not outpatient services, and
thus were not subject to the three-visit limit.  (Louisiana Hearing
Exhibit 1 and Louisiana Exhibit 17, submitted November 7, 1985) This
correspondence preceded the November 1984 disallowance and was related
to that decision by HCFA.

Carolyn Maggio, DHHR official, testified that she was familiar with the
circumstances of the 1979 State plan amendment and that Louisiana had
not then communicated to HCFA that Louisiana assumed that in limiting
outpatient hospital services to three visits the State was not limiting
the hospital-billed costs associated with physician services(13) in an
outpatient hospital setting.  Tr., p. 444. /7/ Ms. Maggio also testified
that the reason Louisiana did not point out to HCFA at the time that the
hospital-billed "overhead" was considered a physician's service and not
an outpatient service was because Louisiana regarded its system of
providing such services in its charity hospitals as unique.


As explained by another State program official, the Louisiana system is
unique because 1) the State owns the hospitals;  2) the State staffs the
hospitals with teaching physicians from the State medical school under
contract to provide a variety of services in an outpatient setting;  and
3) the contract authorizes the hospital to bill for the facility
"overhead" cost. Tr., pp. 20-21, 30, 31, and 60.  See also, Tr., pp.
95-97.

This claim of uniqueness was later disputed in testimony by a HCFA
regional program official.  The HCFA official contended that many states
offer medical services to Medicaid recipients under a system similar to
that in Louisiana.  He cited as examples Oklahoma and Texas, where
privately owned hospitals provide a full range of outpatient services,
including the physician services under discussion here, in an outpatient
setting located in the hospital, utilizing teaching physicians from a
medical school.  Tr., pp. 375-380 and 387-388.  He said that these
hospitals viewed the facility charges as an outpatient cost.  Tr., p.
407.

We are not presuaded that the Louisiana system is as unique as the State
contended here.  Whether it is or is not, the State clearly chose in
1979 to limit all outpatient services to three visits per year.  The
costs here were for services rendered by a hospital to an outpatient,
even though incident to a physician's service.  Moreover, the costs were
calculated in the same way as other outpatient costs (see HCFA Brief of
July 24, 1985 and accompanying exhibits) and billed for by the hospital
in the same manner and using the same forms it did with other outpatient
costs.  Thus, even if the State mistakenly assumed that these hospital
costs were counted under the twelve-visit limit, it is bound by the
all-encompassing use of the term "all outpatient(14) services" in its
1979 State plan to limit these outpatient visits to three per year.

Even if we read the 1979 amendment in pari materia, as the State urges,
with other State plan provisions and policy manuals defining physician
services as including those rendered in an outpatient setting, we do not
find that hospital-billed costs are thus converted into physician
services.  The Medicaid regulations define outpatient hospital services
as being services furnished under the direction of a physician (or
dentist), and although the State was free to subject such services to
the same 12 visit limit covering physician services under its State
plan, it did not accomplish that result by its 1979 State plan
amendment.

We reach this conclusion also because at issue were costs admittedly
incurred by and billed by hospitals.  Hospitals basically provide two
kinds of services -- inpatient and outpatient.  To receive an inpatient
service, one must be an inpatient and the Medicaid recipients in
question here were not inpatients.  They were outpatients, even though
they received a physician's service during their
less-than-inpatient-duration stay in the hospital.  Thus, the costs
billed were, for the hospital's part, for outpatient services and a
State plan provision limiting all outpatient services to three visits
per year necessarily limits the outpatient services associated with
physician services provided in an outpatient hospital setting. /8/


The Board has, in several past decisions, given deference to a state's
interpretation of its own plan.  Michigan Department of Social Services,
Decision No. 224, October 29, 1981;  but see Arkansas Department of
Human Services, Decision No. 357, November 15, 1982. Such deference is
not warranted under the circumstances here, however, for the following
reasons:

* The State did not provide any evidence of a contemporaneous, written
interpretation or a consistent administrative practice to support the
view advanced here.(15)

While the State had discretion to set its own limits in the State plan,
it was important that the State communicate to HCFA what those limits
were so that HCFA could determine whether they were consistent with
federal requirements such as the prohibition on discrimination based on
diagnosis.  Here, the State plan did not contain any provision
sufficient to give rise to a duty on the part of HCFA to inquire
further;  the plan does not address the question of a hospital billing
for costs incurred by the hospital associated with physicians' visits.

* The failure to articulate an exception in the State plan might have
frustrated HCFA in its audit efforts.  If HCFA examined the
reasonableness of the physicians' charges for their services without
being aware that associated costs were also being reimbursed to the
hospital, it could not effectively monitor whether the payments for the
services were excessive.

* Since State hospitals are involved, and the State is essentially
reimbursing itself, the State's actions should be subject to greater
scrutiny.  See Massachusetts Department of Public Welfare, Decision No.
730, March 20, 1986.

Finally, we note that the State was the only one of these two parties
which could set desired limits on the various outpatient services by
amending the State plan.  The State presumably knew its program,
including the nature of its charity hospital outpatient clinics.  The
State nevertheless opted to flatly limit outpatient services and is thus
bound by the action it took.  Moreover, the State failed to change this
plan provision even after the Agency repeatedly pointed out its
problems.

   Conclusion

Accordingly, we affirm the disallowance.  /1/ The 1979 amendment is set
        out on page four, infra.  The State plan provision originally
limiting physician visits to 12 per year was not put in evidence, but
Carolyn O. Maggio, Assistant Director, Primary Medical Services of
Medical Assistance Program of the Office of Family Security, DHHR,
testified that the 12 visit limit had been in place several years prior
to the 1979 amendment limiting outpatient hospital visits.  Transcript
(Tr.), p. 437.         /2/ In the parties's initial briefs there was an
underlying assumption that the only billing for the clinic
visits/physician services were the billings at issue here.  However,
Louisiana ultimately brought out the contractual arrangement between the
hospitals and LSU and the fact that the hospitals and LSU each billed
DHHR separately.  Louisiana Brief, August 23, 1985.         /3/ See
Louisiana Exhibit 12 to submission of November 7, 1985, which is
incorrectly indicated in the exhibit and the accompanying affidavit by
Carolyn Maggio as the approved version.  /4/ On November 6, 1979, an
        Assistant Secretary of DHHR wrote to the HCFA Regional Medicaid
Director (Region VI) submitting additional documentation requested by
HCFA and citing an attached document by hospital administrators who were
described as believing that the unlimited use of emergency facilities
within the hospital was a means by which Medicaid recipients were
"getting around" their 12 outpatient physician service limitation.
Louisiana Exhibit 15, November 7, 1985. The document, the February 22,
1977 Minutes of the Louisiana Hospital Association Liaison Committee,
quoted Association members as complaining that DHHR case workers were
encouraging unwarranted use of emergency room services and expressed the
need to make the case workers aware that nonemergency visits to the
emergency room would be billed to the patient.  Ibid.  Although this
indicates that concern over improper and excessive use of emergency room
services was the rationale for the amendment originally proposed, it
does not prove that HCFA understood the amendment approved in December
1979 to exclude costs billed by a charity hospital for its clinic.
/5/ Hospitals use reimbursement methods related to costs allocated to
the various services provided.  A physician charges a fee, which may
reflect the physician's underlying costs, but only in a more general
way.         /6/ The amendment set these limits:  Outpatient Hospital
Services (1) Emergency room services - three emergency room visits per
calendar year per recipient;  (2) Rehabilitation services - number of
visits in accordance with a rehabilitation plan prior authorized by the
Medical Review Section of the Office of Family Security;  and (3) All
other outpatient services, including, but not limited to, therapeutic
and diagnostic radiology services, chemotherapy, hemodialysis and
laboratory services, shall have no limit imposed other than the medical
necessity for the service. (4) Clinic services - physician services
provided in a clinic in an outpatient hospital setting shall be
considered physician services, not outpatient services, and shall be
included in the limit of twelve physician visits per year per recipient.
(See Item 5 of Attachment 3.1-A). There are no provisions for any
additional visits beyond the limits specified above.  /7/ In its brief
of January 8, 1986, the State contended that Ms.  Maggio testified that
HCFA "understood and agreed" that the overhead cost was to be counted in
the limit of 12 per year, but the State did not offer a supporting
citation and a review of the transcript reveals no such testimony.
Brief, p. 6.         /8/ While some of the types of costs here are
similar to costs which might be incurred by a physician who sees a
patient for an office visit, the key factor here is that hospital
employees were assisting the physicians in providing services to the
recipients of a preventive, diagnostic, therapeutic, rehabilitative or
palliative nature, using hospital facilities and the range of supportive
services a hospital has available.