Massachusetts Medical Society v. Dukakis

Opinion

In this civil action plaintiffs challenge the validity and enforceability of a state statute bearing upon the licensure of physicians in the Commonwealth of Massachusetts, Chapter 475 of the Massachusetts Acts of 1985 (“Chapter 475” or the “Act”). Chapter 475 provides that the Board of Registration in Medicine

shall require as a condition of granting or renewing a physician’s certificate of registration, that the physician, who if he agrees to treat a beneficiary of health insurance under Title XVIII of the Social Security Act, shall also agree not to charge to or collect from such beneficiary any amount in excess of the reasonable charge for that service as determined by the United States Secretary of Health and Human Services.

The grounds of challenge include contentions that the statute and regulations implementing it violate due process and are inconsistent with preemptive federal legislation bearing upon balance billing of recipients of medical care who qualify for Medicare benefits under the Health Insurance for the Aged and Disabled Act, 42 U.S.C. §§ 1395, et seq. (Title XVIII of the Social Security Act) (the “Medicare Act”).

In their amended complaint, plaintiffs also challenge the Act on the basis of Articles I and X of the Massachusetts Declaration of Rights. Defendants contend that this court has no jurisdiction over that claim, citing Pennhurst State School and Hospital v. Halderman, 465 U.S. 89, 104 S.Ct. 900, 79 L.Ed.2d 67 (1984). Plaintiffs apparently concede this point as they have failed to press the state constitutional aspect of their challenge in any of the hearings or numerous briefs which have been filed. I thus address only the federal claims raised by plaintiffs.

I.

It will be helpful at the outset to take note of terms that will appear frequently in the discussion of Chapter 475 and the Medicare Act.

Under the Medicare Act, physicians are paid for their services on the basis of the “reasonable charge” set by the Department of Health and Human Services (“HHS”) for the service. The Medicare program pays 80 percent of the reasonable charge. The patient is responsible for the remainder of the physician’s charge.

The reasonable charge is calculated by HHS on the basis of the physician’s own “customary charge” for that service as well as the “prevailing charge” in the locality for similar services. 42 U.S.C. § 1395u(b)(3). 42 C.F.R. § 405.502(a).

The Medicare Act provides for two methods of payment. In the first, the physician accepts “assignment.” This means that the physician agrees to accept the reasonable charge set by HHS as payment in full. The physician receives 80 percent of the reasonable charge from Medicare and collects the remaining 20 percent of the reasonable charge, but no more, from the patient. 42 U.S.C. § 1395u(b)(3)(B)(ii).

Under the second method, the physician bills the patient directly for the service. 42 U.S.C. § 1395u(b)(3)(B)(i). The patient then collects reimbursement from Medicare in the amount of 80 percent of the reasonable charge. The physician’s actual charge under this method may be greater than the reasonable charge. In that circumstance the patient is responsible not only for the remaining 20 percent of the reasonable charge, but also for whatever amount in excess of the reasonable charge the physician has billed. The physician practice of charging an amount greater than the reasonable charge is called “balance billing.”

In 1984 Congress established a provision whereby physicians were given certain incentives to become “participating physi *687 dans.” 42 U.S.C. § 1395u(h)(l). Participating physidans agree to accept on assignment all of the Medicare beneficiaries whom they treat. That is, in return for certain advantages that do not go to “nonparticipating physicians,” participating physicians agree not to balance bill. “Non-participating physicians” are, as the name would suggest, those physicians who do not sign participating physician agreements.

“Medex” is a form of private insurance available to supplement medical care costs of Medicare beneficiaries in Massachusetts.

II.

Under the Supremacy Clause a state law that “stands as an obstacle to the accomplishment and execution of the full purposes and objectives of Congress,” is impermissible. Hines v. Davidowitz, 312 U.S. 52, 67, 61 S.Ct. 399, 404, 85 L.Ed. 581 (1941). To determine whether a particular state law stands as such an obstacle, a court must determine whether there is either “a congressional design to preempt the field,” or “such actual conflict between the two schemes of regulation that both cannot stand in the same area.” See Florida Lime & Avocado Growers, Inc. v. Paul, 373 U.S. 132, 141, 83 S.Ct. 1210, 1217, 10 L.Ed.2d 248 (1963).

In this case, plaintiffs contend that Chapter 475 violates the Supremacy Clause under both of these tests. First, they claim that when Congress enacted the Medicare Act, and those portions of the Deficit Reduction Act of 1984 that amended the Medicare Act (“1984 amendments”), it occupied the field of charges by and payments to physicians treating Medicare patients. Plaintiffs contend also that Chapter 475 directly conflicts with various provisions of the Medicare Act. Defendants contend that Congress did not manifest any intention to push the states out of the field of physician billing of Medicare recipients. Nor, according to defendants, does Chapter 475 conflict with any provision of the Medicare Act.

The first branch of the Supremacy Clause test — whether Congress has manifested its design to occupy the field — is purely a question of law. I conclude that Congress has not manifested any intent to preempt the states from enacting the kind of legislation at issue in this case.

In a case such as this, it advances the analysis little to ask merely whether Congress manifested an intent to occupy. There must be, as well, a determination of what the “field” is. .

Plaintiffs would have the court define that field broadly. In support of their contention that Congress intended to preclude states from enacting legislation such as Chapter 475, plaintiffs point to the fact that the system of Medicare payments is funded and administered entirely by the federal government. See, e.g., 42 U.S.C. § 1395j (“There is hereby established a voluntary insurance program ... financed from premium payments by enrollees together with contributions from funds appropriated by the Federal Government.”) Plaintiffs place particular emphasis on a statement by Congressman Wilbur Mills, Chairman of the House Ways and Means Committee and a leader in the passage of the Medicare Act, that “it will not be possible for a state agency to administer Medicare.” Ill Cong. Rec. H18382 (daily ed. July 27, 1965).

Plaintiffs’ references to the statute and to legislative history do not support a contention that the “field” that Congress occupied was all matters relating to the billing of Medicare recipients. Instead, they support a reading that Congress designed an exclusively federal program for payment of benefits toward the medical bills of Medicare recipients. That is, Congress provided that the “administration” of the voluntary medical insurance system called Medicare would be in the hands of the federal government only.

In the context of this question of the scope of the field that Congress occupied, the parties have engaged in some debate over §§ 1395 and 1395x(r). These sections provide respectively that no federal agency *688 or official will interfere with the practice of medicine and that the definition of “physician” is left to the states as a matter of state law. Defendants argue that these sections evidence Congress’ design to give the states an affirmative role in regulating physician behavior as it relates to Medicare patients, including billing practices. Plaintiffs contend that these sections do no more than proscribe any federal interference with physicians’ choice of treatment plans and recognize the states’ traditional role in determining technical proficiency requirements for physician licensure.

The most accurate reading of these sections lies somewhere between these contentions. Clearly the “practice of medicine,” with which the federal government is not to interfere, includes more than treatment choice. So also, the states’ role in determining who shall practice medicine and subject to what conditions must include more than the regulation of technical proficiency. The economics of physician practice play a role in both the practice of medicine and the licensure and supervision of physicians; in §§ 1395 and 1395x(r) Congress expressly indicated that both practice and licensure were outside its field of occupation.

On the other hand, defendants' reading of those sections taken broadly would allow the state, in the guise of licensing physicians and regulating the practice of medicine, to bootstrap all kinds of legislation that does overlap with matters expressly regulated by the Medicare Act. Thus, it cannot properly be said that any particular state law purportedly regulating physicians or the practice of medicine is automatically vindicated as an exercise of the authority granted (or, more precisely, not taken away), in §§ 1395 and 1395x(r). Instead, each state law must be scrutinized to see whether it indeed deals with a matter that Congress has taken as exclusively its own for regulation elsewhere in the Medicare Act or instead one that Congress has left in that residual unoccupied territory that ordinarily surrounds congressional action under our federal system.

Sections 1395 and 1395x(r) thus do not provide a shield for every state law purportedly enacted as a regulation of physicians or the practice of medicine. However, consistently with those sections of the statute and legislative history that describe the scope of federal regulation as including only the funding and administration of a system of voluntary medical insurance for the aged, these sections do evidence a congressional design to occupy only a limited portion of the broad “field” of medical care for the elderly.

Defendants have also made some suggestion that § 1395b expressly recognizes states’ authority to reduce the costs of medical care to Medicare beneficiaries by legislation. The section reads,

§ 1395b Option to individuals to obtain other health insurance protection

Nothing contained in this subchapter shall be construed to preclude any State from providing, or any individual from purchasing or otherwise securing, protection against the cost of any health services.

Read in context, the language “[njothing ... shall preclude any State from providing ... protection” clearly contemplates protection in the form of supplemental payments, not regulatory reduction of charges. It strains the language too far to suggest that Congress meant to address the issue of state regulation of health care costs in a section in which the subject at hand was supplemental insurance.

In summary, I conclude that nothing in the Medicare Act or its legislative history evidences a congressional design to occupy any field so broad that it would include regulation such as Chapter 475. There is nothing to indicate congressional preemption of all state regulation of physician billing as applied to recipients of Medicare. Particularly in an area such as medical care, a prototypically traditional local interest, there is no justification for inferring a congressional design to preempt state regulation absent strong evidence of such design. Cf. Philadelphia v. New Jersey, 437 U.S. 617, 621 n. 4, 98 S.Ct. 2531, *689 2534 n. 4, 57 L.Ed.2d 475 (1978); New York Dept. of Social Services v. Dublino, 413 U.S. 405, 413, 93 S.Ct. 2507, 2512, 37 L.Ed.2d 688 (1973). To do so here in the absence of any such evidence would be especially unjustified.

III.

In order to rule on plaintiffs’ arguments that Chapter 475 violates the second branch of the Supremacy Clause test because it is in conflict with the Medicare Act, I must first turn to the consideration of the role that “facts” play in this case. To clarify the relevance of the fundamental nature of the fact disputes to issues regarding how these disputes are to be resolved (including disputed contentions about admissibility of evidence), I proceed first to explain the conclusions I have reached as to the non-adjudicative nature of most, and perhaps all, of the disputes of fact in this case.

The term “adjudicative” fact is part of established usage. Cf. Fed.R.Evid. 201 (Notes of the Advisory Committee). In contrast, no settled terminology has been adopted as a common label to designate all of the various kinds of facts that, together, stand in contrast with “adjudicative” facts. In the remainder of this Opinion I use the term “non-adjudicative” to refer to the whole array of facts that are relevant to determining a generally applicable rule of decision and not (or at least, not alone) to deciding a particular controversy between particular parties.

Also a part of established usage is the term “finding,” used to refer to a trial court’s decision of an adjudicative fact dispute. In contrast, the terminology used to refer to the decision of a non-adjudicative fact dispute varies. “Finding” is sometimes used, but other terms, including “conclusion,” are also sometimes used. In the remainder of this Opinion I use either “finding” or “determination” to refer to the decision of a non-adjudicative fact dispute by whomever made (e.g., a trial court, a higher court or a legislature).

Aided by the Notes of the Advisory Committee, the commentaries of other writers there cited, and judicial opinions cited below, I conclude that some (though certainly not all) among the contrasting characteristics of adjudicative and non-adjudicative facts may be described in the following ways:

(1) Effect Generally of Fact Findings Upon Future Cases

An adjudicative fact finding in one case has no force as precedent and no effect in subsequent cases except to the extent determined by the law of res judicata, including issue preclusion. Cf. Second Restatement of Judgments §§ 17-29 (1982).

In contrast, a non-adjudicative fact finding does have force generally in later cases. Such a finding made by a legislature as a basis for enacting a statute (“legislative” fact) is reviewable in courts, if at all, only under standards developed in constitutional litigation. E.g., Railway Express v. New York, 336 U.S. 106, 109, 69 S.Ct. 463, 465, 93 L.Ed. 533 (1949) (for purposes of due process challenge to state regulation the court will not itself weigh evidence to determine wisdom of regulation but will defer to the judgment of local authorities unless that judgment is shown to be “palpably false”).

A non-adjudicative fact finding of a court as a reason for deciding an issue of law in a particular way (“precedential” fact) is effective not only in the case at hand (subject to review in higher courts) but also in future cases to the extent determined by the law of stare decisis. Cf. EEOC v. Trabucco, 791 F.2d 1 (1st Cir.1986).

“Legislative” fact findings made by a legislature as a basis for enacting a statute and “precedential” fact findings made by a court as a basis for deciding an issue of law are, in a sense, a part of the body of determinations that have force as law. Ordinarily, however, it is the legal rule itself rather than the factual determinations that were part of the explicit or implicit reasons for its adoption that we speak of as law. *690 Even so, a court is not free to hold a legal rule inapplicable to the case at hand because the court disagrees with the fact determinations on which that rule was explicitly or implicitly based. Instead, a court must apply the legal rule unless it determines that the rule is to be abrogated generally, and not just disregarded in the case at hand. A court may abrogate a rule by holding a statute unconstitutional, and a court may overrule its own precedents. If, for example, a court of last resort determines that the factüal premises of a precedent are incorrect — either because circumstances have changed or because advances in knowledge have revealed error — the court may overrule.

(2) Characteristics of Findings in Jury Trials

In a jury trial, adjudicative fact findings of the jury on issues as to which, under the evidence, reasonable persons could differ, are binding upon the parties and cannot be set aside either by the trial court or on appeal merely because a court would find differently on the evidence. E.g., Wright, Law of the Federal Courts § 95 at 473 (3d ed. 1976).

In contrast, non-adjudicative fact disputes are not properly submitted to a jury; they are resolved in the same way in jury trials as in non-jury trials.

(3) Characteristics of Findings in Non-Jury Trials

A trial judge’s adjudicative fact findings in a federal non-jury trial are reviewable under the standard prescribed in Fed.R. Civ.P. 52(a) and are set aside on appeal only if “clearly erroneous.” This proposition is amply supported by precedent. E.g., Icicle Seafoods, Inc. v. Worthington, — U.S. -, 106 S.Ct. 1527, 89 L.Ed.2d 739 (1986).

In contrast, I conclude, both on principle and with at least suggestive support in judicial opinions, that with respect to non-adjudicative fact findings higher courts owe no deference to a trial court’s findings and may make their own determinations of such facts. For example, a case recently before the Supreme Court of the United States presented a sharp dispute concerning the effects of “death qualification” of jurors, during voir dire, upon the impartiality of the trial jury in the guilt phase of trial upon a capital felony murder charge. The defendant, as respondent before the Supreme Court, argued that the “factual” findings of the District Court and the Eighth Circuit on the effects of “death qualification” were reviewable by the Supreme Court only under the “clearly erroneous” standard of Fed.R.Civ.P. 52(a). The Supreme Court answered:

Because we do not ultimately base our decision today on the invalidity of the lower courts’ “factual” findings, we need not decide the “standard of review” issue. We are far from persuaded, however, that the “clearly erroneous” standard of Rule 52(a) applies to the kind of “legislative” facts at issue here. See generally Dunagin v. City of Oxford, Mississippi, 718 F.2d 738, 748, n. 8 (CA5 1983) (en banc) (plurality opinion of Reavley, J.). The difficulty with applying such a standard to “legislative” facts is evidenced here by the fact that at least one other Court of Appeals, reviewing the same social science studies as introduced by McCree, has reached a conclusion contrary to that of the Eighth Circuit. See Keeten v. Garrison, 742 F.2d 129, 133, n. 7 (CA4 1984) (disagreeing that studies show relationship between generalized attitudes and behavior as jurors), cert, pending, No. 84-6187.

Lockhart v. McCree, — U.S.-,-n. 3, 106 S.Ct. 1758, 1762 n. 3, 90 L.Ed.2d 137 (1986).

A number of the reasons underlying the conclusion that non-adjudicative fact findings should not be subject to the “clearly erroneous” standard are discussed in the Dunagin plurality opinion. A question to which non-adjudicative facts are relevant “is not a question specifically related to this one case or controversy; it is a question of social factors and happenings which may submit to some partial empirical solu *691 tion but is likely to remain subject to opinion and reasoning. See Fed.R.Evid. 201 (advisory committee note).” 718 F.2d at 748 n. 8. It would thus be inappropriate to treat the findings reached by a particular judicial trier of fact on “social factors and happenings” with the same deference with which his or her findings on discrete occurrences between particular parties are treated. The Dunagin plurality opinion also noted the special role of the appellate courts in resolving issues of constitutional law. That role would be significantly eroded if the higher courts’ determinations were made to “hinge on the views of social scientists who testify as experts at trial.” Id. For these reasons and others stated in this Opinion, I conclude that higher courts will be free to examine non-adjudicative facts de novo rather than obliged to accept all but clearly erroneous findings of non-adjudicative facts by the trial court.

Of course, as noted in subdivision (1) above, neither a trial court nor an appellate court may set aside or disregard “legislative” determinations of fact on the basis of which a statute was enacted, except to the extent that the court determines that as a matter of constitutional law the legislature’s reliance on those facts cannot withstand scrutiny. See Railway Express, supra; see also Dunagin, 718 F.2d at 748 n. 8 (“If the legislative decision is not binding at this stage, at least it carries great weight. Certainly it cannot be thrust aside by two experts and a judicial trier of fact.”).

An underlying theme of the three qualities thus far discussed is that adjudicative facts are specific to the case at hand (“case facts” or “discrete facts”) and, in contrast, non-adjudicative facte bear upon the determination of what legal rule shall be applied to cases generally (“general facte”). Often, and perhaps typically, “general” fact findings are generalizations about human behavior or human institutions, including economic and social phenomena. However, “general” fact findings may be about other aspects of the broad context in which particular cases arise; they may be about “laws” of nature, for example.

(4) Historical and Evaluative (or Interpretive) Facte

A distinction may be observed between “historical” facte and “evaluative” (or “interpretive”) facte.

Typical of disputes of “historical” fact, as the term is used in this context, are disputes about who did what, when and where, and whether with or without a defined state of mind. Cf. Fed.R.Evid. 201 (Notes of the Advisory Committee); Sandstrom v. Montana, 442 U.S. 510, 521-23, 99 S.Ct. 2450, 2457-58, 61 L.Ed.2d 39 (1979) (requiring fact finding as to state of mind of defendant in criminal case rather than allowing imposition of criminal liability for presumed intent).

Typical of disputes of “interpretive” or “evaluative” fact are disputes about whether what was done violated a legal standard for evaluating conduct (such as the negligence standard or the “proximate” cause standard), cf. Second Restatement of Torts §§ 291, 431 (1965), or in some other way satisfied some prerequisite of liability. Cf. O’Neill v. Dell Publishing Co., 630 F.2d 685, 687 (1st Cir.1980) (ultimate finding of “substantial similarity” in copyright case is mixed question of fact and law, not to be decided on summary judgment if evidence must be weighed). As illustrated by the O’Neill opinion, the kind of determination that contrasts with a finding of “historical” fact is often described as a finding on a “mixed question of fact and law.”

In contrast with adjudicative fact disputes, which may involve either “historical” or “evaluative” (“interpretive”) facte, e.g., O’Neill, supra, non-adjudicative fact disputes rarely, if ever, concern “historical” facte. That is, disputes of non-adjudicative fact rarely center on happenings— who did what, when or where. Even when “data” are brought to bear, cf. EEOC v. Trabucco, supra, the emphasis of the dispute is not upon the uninterpreted multitude of historical facte that constitute the data but instead upon disputed assertions as to whether the data are complete, or at least constitute an adequately representa *692 tive sample, and upon what interpretive inferences or evaluative findings may properly be derived from or based upon them.

(5) Taking Judicial Notice

A court may take judicial notice of adjudicative facts “not subject to reasonable dispute.” Fed.R.Evid. 201(b).

It may reasonably be argued that the concept of “judicial notice” is inapplicable to non-adjudicative facts. See generally K. Davis, Administrative Law §§ 15:1-20 (2d ed. 1980) (discussing the role of adjudicative and legislative facts in agency and judicial decisionmaking and the role of judicial notice). In any event, if the phrase is used in relation to non-adjudicative facts, either its meaning must be sharply modified or else it applies to only a very small percentage of non-adjudicative facts. The reason is that non-adjudicative facts are typically in sharp dispute, as controversies over legislation well illustrate. Thus, if “judicial notice” is limited to facts “not subject to reasonable dispute,” it is inapplicable to all reasonably disputable non-adjudicative facts. Sometimes, however, “judicial notice” is used in a very different sense, merely to indicate that the court determines relevant facts independently of evidence offered at trial. In this broad sense, of course, the phrase might be extended to all non-adjudicative fact finding.

(6) Applicability of Rules of Evidence

In making adjudicative fact findings, courts apply formal rules of evidence and, at least if timely objection is made, may not base findings on evidence that is inadmissible under those rules.

In relation to non-adjudicative fact finding, it is difficult to find authority precisely in point. I conclude, however, that on principle, and with at least some suggestive support in judicial opinions, both trial courts and appellate courts, in making non-adjudicative fact findings, are free to draw upon sources of knowledge beyond evidence that is admissible under the formal rules of evidence that apply to adjudicative fact finding. An appellate court, in its decisionmaking, is not confined to the record of evidence presented to the trial court. It may consider additional sources referred to in appellate briefs, and may even resort to independent library research. For example, the Supreme Court did not confine itself to record evidence in considering the fundamental issues presented in Brown v. Board of Education, 347 U.S. 483, 494 n. 11, 74 S.Ct. 686, 692 n. 11, 98 L.Ed. 873 (1954). See also Dunagin, 718 F.2d at 748 n. 8; Fed.R. Evid. 201 (Notes of the Advisory Committee).

Although litigants may, either from an abundance of caution or for practical reasons of effective advocacy, present testimonial evidence of expert witnesses on disputed non-adjudicative fact questions — as the parties have done in this case — and trial courts may receive such evidence, it does not follow either that the parties must offer such evidence or that a trial court is bound to receive it, or having received it, is bound to consider it as if it were being presented in relation to a dispute of adjudicative fact.

In all but a small percentage of cases coming before the courts, disputes of fact that must be resolved to determine the outcome relate to adjudicative facts. Indeed, it is only a very small percentage of judicial opinions that even take note of a distinction between adjudicative and non-adjudicative facts. Partly for this reason, and partly as well because of fundamental differences between adjudicative and non-adjudicative facts, some (but by no means all) of which are outlined here, I conclude that rules of evidence and procedure fashioned for resolving adjudicative fact disputes were not designed for resolving non-adjudicative fact disputes and, at the least, must be reexamined before being applied in resolving non-adjudicative fact disputes.

(7) Applicability of “Standing” Requirements

Are “standing” requirements, fashioned to determine one’s qualifications for partid *693 pating in an adversarial proceeding for resolving adjudicative fact disputes, applicable as well to participation in resolution of non-adjudicative fact disputes? This issue will be examined briefly in Part VI below.

IV.

Before trial of this case commenced, holding some tentative but not fully considered views about the issues of adjudicative and non-adjudicative fact finding discussed in Part III above, and influenced substantially by prudential considerations concerned with sound judicial administration, I denied cross-motions for summary judgment without prejudice to renewal of the substantive contentions advanced by movants and, with the full cooperation of the parties and their counsel, set the case for expedited trial. With the evidence and post-trial submissions before me, I now address the remaining contentions of the parties.

V.

With respect to whether Chapter 475 conflicts with any of the various provisions of the Medicare Act, the parties on each side contend that they are entitled to judgment as a matter of law. Defendants also contend alternatively, if they are not entitled to judgment as a matter of law on this issue, that plaintiffs must prove as a matter of adjudicative fact, as I have used that term above, that there is a conflict between the two acts. In support of this alternative position, defendants cite Kargman v. Sullivan, 552 F.2d 2 (1st Cir.1977), a case in which a factual inquiry was undertaken to determine whether the plaintiff landlords were subject to conflicting requirements by local rent control regulations and the regulations promulgated by the Department of Housing and Urban Development. In Kargman, evidence was taken and factual findings made by the trial court. Both the trial court and appeals court apparently treated at least some of the facts in that case as adjudicative facts. Although I indicated at the early stages of the proceedings in this case that I was of the tentative view that findings of adjudicative facts made on the basis of evidence offered by the parties were unnecessary to a decision in this case, we proceeded with a trial in which all parties had an opportunity to offer the testimony of witnesses and other evidence so that a factual record would be developed in the event a higher court determines that, under Kargman or some other analysis, such an evidentiary record is necessary to decision.

After further consideration, I adhere to the view that this case is appropriately decided without reference to questions of adjudicative fact, and I rest my decision on purely legal grounds (legal grounds which, of course, take account of some non-adjudicative facts). Nevertheless, as a matter of sound judicial administration I shall proceed, as an alternative basis of decision, to make findings on those questions of fact that under a different theory of the case might be material “adjudicative” facts.

Before turning to my findings on those arguably material disputes of fact, I note one dispute that even if characterized as a dispute of fact (a dubious proposition), I conclude is not material under any theory of the case. The parties are in some disagreement about how Chapter 475 may ultimately be interpreted and enforced. For purposes of both the Due Process and Supremacy Clause challenges, however, this disagreement is not material.

Both sides agree that Chapter 475 prohibits Massachusetts physicians who have obtained a new license or have had an old license renewed on or after February 10, 1986, from requiring their Medicare-covered patients to pay more than the “reasonable charge” established by Medicare. That is, physicians may not “balance bill” patients for an amount greater than the reasonable charge. (Patients do continue to pay the 20 percent co-insurance required by Medicare, but that co-payment is included in the reasonable charge figure).

The parties do not agree over certain interpretation and enforcement issues. Plaintiffs, for example, fear that even accidental or good faith variance from statute *694 rily prescribed conduct may constitute an actionable violation of Chapter 475. Plaintiffs also fear that because the ban on balance billing is established as a condition of licensure that any violation will result in nothing less than the severe sanction of license revocation. Finally, plaintiffs fear that the Board of Registration will have no discretion in its choice of when and how to sanction. Defendants dispute all or most of these characterizations of how the Act will be administered.

I conclude that under no likely theory of the case is this dispute material. The difference between the two sides’ interpretations will have no bearing on whether Chapter 475 can withstand constitutional challenge. That is, the analysis stated below of the validity of Chapter. 475 under the Supremacy Clause and the Due Process Clause holds equally for the Act as interpreted by plaintiffs and as interpreted by defendants. For these reasons I need not resolve the parties’ conflicting interpretations of Chapter 475 (even assuming such a resolution could properly be characterized as a “finding,” or, in the alternative, as a determination of an unresolved issue of state law that would raise still more issues of federal-state comity and practice).

VI.

Another brief detour precedes consideration of factual disputes that might under some theory of the case be considered material.

The key dispute between the parties on which evidence was taken and findings are made below is this: will Chapter 475 have the effect of restricting the access to medical care of Medicare beneficiaries in Massachusetts? The parties apparently agree that such a restriction would conflict with an important purpose of the Medicare Act —namely, insuring the availability of medical care to the elderly.

There is a serious problem in this case, however, arising from the circumstance that it is plaintiff physicians who are attempting to prove the detrimental effects that Chapter 475 will allegedly have on the health care of the elderly. A serious and obvious conflict of interest exists between the physicians (who bill) and the class of elderly patients for whose benefit Medicare was enacted (and who must pay those bills). Indeed, two organizations whose stated purpose is the promotion of the interests of the elderly chose to intervene on the side of defendants in this case.

Where the court is treating a question as one of adjudicative fact, that is, taking evidence offered by adversarial parties and making findings based on the weight of that evidence, the requirements of “standing” — who may properly raise a particular issue — are appropriately stricter, at least in most circumstances, than where a question is treated as one of non-adjudicative fact. The underlying objective of assuring that a genuine case or controversy is before the court, with the adverse interests adequately represented, is more clearly implicated in adjudicative than in non-adjudicative fact disputes. Where the court is considering non-adjudicative facts — for example, the whole range of information on which a legislature did or might have relied — it is less important that the roles of who may present what information be sharply defined. Indeed, the court itself may go to reference books for enlightment with respect to this kind of information. See Part 111(6), supra. But where a court is considering evidence presented by opposing sides in accordance with the rules of evidence for the purpose of itself making a finding as to what is the truth of the matter (rather than determining what a legislature might reasonably have found to be fact), the Constitution and the decisional law have traditionally set well-defined limits on who is in a position to present what. See Singleton v. Wulff, 428 U.S. 106, 112, 96 S.Ct. 2868, 2873, 49 L.Ed.2d 826 (1976); Friedman v. Harold, 638 F.2d 262, 265-67 (1st Cir.1981).

In Singleton the Supreme Court enunciated two separate inquiries necessary to a standing determination: first, has the party alleged “injury in fact;” and second, “as a prudential matter,” is the party a “proper *695 proponent! ] of the particular legal rights” asserted. 428 U.S. at 112, 96 S.Ct. at 2873. Here, defendants do not dispute that plaintiffs have alleged injury in fact. They do assert, however, that as a prudential matter plaintiffs are inappropriate advocates of the rights of Medicare beneficiaries. I agree with defendants as to the applicability to this case of the teaching of Friedman v. Harold that as a prudential ma