American Hospital Association v. Alex Azar, II ( 2020 )


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  •  United States Court of Appeals
    FOR THE DISTRICT OF COLUMBIA CIRCUIT
    Argued November 8, 2019               Decided July 31, 2020
    No. 19-5048
    AMERICAN HOSPITAL ASSOCIATION , ET AL.,
    APPELLEES
    v.
    ALEX MICHAEL AZAR, II, IN HIS OFFICIAL CAPACITY AS THE
    SECRETARY OF HEALTH AND HUMAN SERVICES AND UNITED
    STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES,
    APPELLANTS
    Consolidated with 19-5198
    Appeals from the United States District Court
    for the District of Columbia
    (No. 1:18-cv-02084)
    Alisa B. Klein, Attorney, U.S. Department of Justice,
    argued the cause for appellants. With her on the briefs were
    Mark B. Stern and Laura E. Myron, Attorneys, Robert P.
    Charrow, General Counsel, U.S. Department of Health &
    Human Services, Janice L. Hoffman, Associate General
    Counsel, Susan Maxson Lyons, Deputy Associate General
    Counsel for Litigation, and Robert W. Balderston, Attorney.
    2
    Thomas R. Barker and Andrew M. London were on the
    brief for amicus curiae Federation of American Hospitals in
    support of defendants-appellants.
    William B. Schultz argued the cause for plaintiffs-
    appellees. With him on the brief was Margaret M. Dotzel.
    Before: SRINIVASAN, Chief Judge, and MILLETT and
    PILLARD , Circuit Judges.
    Opinion for the Court filed by Chief Judge SRINIVASAN .
    Opinion dissenting in part filed by Circuit Judge PILLARD.
    SRINIVASAN, Chief Judge: When hospitals provide
    outpatient care to patients insured by Medicare Part B, the
    federal government reimburses the hospitals for the care. Until
    recently, the government reimbursed all hospitals at a uniform
    rate for providing covered drugs. In 2018, though, the
    Department of Health and Human Services reduced the
    reimbursement rate for covered drugs by 28.5% for certain
    hospitals known as “340B hospitals” by virtue of their
    participation in the federal 340B Drug Pricing Program for
    underserved populations. HHS cut the reimbursement rate for
    340B hospitals because they can obtain drugs far more cheaply
    than other hospitals. As HHS saw it, Medicare should not
    reimburse hospitals more than they paid to acquire the drugs.
    Several hospitals and hospital associations challenge
    HHS’s decision, claiming that it rests on an impermissible
    construction of the governing statute. The district court agreed
    with the plaintiffs that HHS had exceeded its statutory
    authority by reducing drug reimbursement rates for 340B
    hospitals. We disagree. We hold that HHS’s decision to lower
    3
    drug reimbursement rates for 340B hospitals rests on a
    reasonable interpretation of the Medicare statute.
    I.
    A.
    The Medicare program provides health insurance to the
    elderly and disabled. Medicare Part A provides coverage for
    inpatient care, i.e., care provided while a patient is admitted to
    a hospital or skilled nursing facility. Medicare Part B covers
    various other services including outpatient (or same-day)
    hospital care. Part B thus pays for certain drugs, such as
    immunosuppressants or chemotherapy drugs, administered in a
    hospital setting on an outpatient basis. Part B beneficiaries
    generally pay 20% of their bill out of pocket as coinsurance.
    The Department of Health and Human Services (HHS)
    annually establishes Part B reimbursement rates through
    notice-and-comment rulemaking. In setting the rates, HHS
    uses the “Outpatient Prospective Payment System,” or OPPS.
    See 42 U.S.C. § 1395l(t). See generally Am. Hosp. Ass’n v.
    Azar, No. 19-5352, slip op. at 3–6 (D.C. Cir. July 17, 2020).
    The OPPS requires HHS to fix the amounts it will pay
    providers for certain services before the year begins (rather
    than after the care has been provided). Congress moved to that
    prospective system to enhance HHS’s ability to control Part B
    costs. See Medicare Program; Prospective Payment System for
    Hospital Outpatient Services, 
    65 Fed. Reg. 18,434
    , 18,436–37
    (Apr. 7, 2000); Paladin Cmty. Mental Health Ctr. v. Sebelius,
    
    684 F.3d 527
    , 528–29 (5th Cir. 2012).
    For most types of covered care, the Medicare statute
    instructs HHS to set annual OPPS reimbursement rates through
    a complex formula that gives the agency significant discretion.
    4
    See 42 U.S.C. § 1395l(t)(2). For certain kinds of services,
    however, the OPPS limits that discretion and sets out a specific
    methodology for calculating payment rates. That is the case
    for certain drugs covered by Part B, known as “specified
    covered outpatient drugs” or SCODs.
    The statute requires HHS to calculate the reimbursement
    rate for SCODs in one of two ways. First, under 42 U.S.C.
    § 1395l(t)(14)(A)(iii)(I), which we will refer to as subclause
    (I), HHS may use “the average acquisition cost for the drug . . .
    as determined by the Secretary taking into account . . . hospital
    acquisition cost survey data.” Second, under 42 U.S.C.
    § 1395l(t)(14)(A)(iii)(II), which we call subclause (II), “if
    hospital acquisition cost data are not available,” HHS must use
    “the average price for the drug” as established by a separate,
    cross-referenced statute. In the event HHS uses average price
    under subclause (II), that price metric may be “adjusted by
    [HHS] as necessary for purposes of this paragraph.” Id.
    Since 2006, when those two statutory pricing alternatives
    took effect, HHS has not had the “hospital acquisition cost
    survey data” contemplated by subclause (I). As a result, HHS
    has had to use the average price metric. See Medicare and
    Medicaid Programs: Hospital Outpatient Prospective Payment
    and Ambulatory Surgical Center Payment Systems and Quality
    Reporting Programs, 
    77 Fed. Reg. 68,210
    , 68,385–86 (Nov. 15,
    2012). The parties here agree that, by virtue of a statutory
    cross-reference, a drug’s default “average price” equals 106%
    of its “average sales price,” or ASP. See 42 U.S.C.
    § 1395l(t)(14)(A)(iii)(II) (citing 42 U.S.C. § 1395w-3a(c)).
    HHS calculates ASP every quarter using sales data
    confidentially provided by drug manufacturers.
    HHS’s average price “methodology . . . has always
    yielded a finalized payment rate [for SCODs] in the range of
    5
    ASP+4 percent to ASP+6 percent,” or 104% to 106% of ASP.
    77 Fed. Reg. at 68,386. As a result, all hospitals have been paid
    the same rate—104% to 106% of ASP—for SCODs. Medicare
    Program: Hospital Outpatient Prospective Payment and
    Ambulatory Surgical Center Payment Systems and Quality
    Reporting Programs, 
    82 Fed. Reg. 52,356
    , 52,494–95 (Nov. 13,
    2017). From 2013 to 2017, that rate was 106% of ASP,
    unadjusted from the statutory default average price.
    B.
    That changed in late 2017, when HHS announced SCOD
    payment rates for the upcoming 2018 OPPS year. Invoking its
    subclause (II) authority to “adjust” the average price metric,
    HHS for the first time established two separate rates: one rate
    for hospitals participating in a drug discount program known
    as the “340B program,” and another rate for all other hospitals.
    The rate for non-340B hospitals remained at ASP+6%, or
    106% of ASP. The rate for 340B hospitals was “adjusted”
    down to ASP minus 22.5%, or 77.5% of ASP.
    To understand HHS’s reasons for reducing SCOD
    reimbursement rates for 340B hospitals, it is helpful to review
    the background of the 340B program. The program takes its
    name from the section of the Public Health Service Act that
    authorizes it. See Pub. L. No. 102-585, § 602, 
    106 Stat. 4943
    ,
    4967–71 (1992). The program allows covered entities
    (including eligible hospitals) to purchase drugs from
    manufacturers at heavily discounted rates. See 42 U.S.C.
    § 256b(a)(4).    The covered entities generally care for
    underserved populations, and the discounted rates enable the
    providers to “stretch scarce Federal resources as far as
    possible.” H.R. Rep. No. 102-384 (II), at 12 (1992).
    6
    The program requires manufacturers, as a condition of
    having their drugs covered by Medicaid, to sell each covered
    drug to 340B entities at a “ceiling price” (set by statutory
    formula). 42 U.S.C. § 256b(a). The program covers at least
    3,500 drugs, 82 Fed. Reg. at 52,494, and the government
    estimates that 340B sales make up approximately 2.8% of the
    total U.S. drug market. Health Resources and Services
    Administration, Justification of Estimates for Appropriations
    Committees Fiscal Year 2018, at 244, https://www.hrsa.gov/
    sites/default/files/hrsa/about/budget/budget-justification-
    2018.pdf.
    Over the past several years, observers have raised concerns
    about the intersection of the 340B program with Medicare Part
    B. Government reports found that 340B hospitals typically pay
    between 20% and 50% below ASP for covered drugs. When
    hospitals provide 340B drugs that qualify as SCODs to
    patients, the hospitals then seek reimbursement from Medicare
    Part B. Until 2018, the reimbursement rate was 106% of ASP.
    There was thus a large gap between the amount a 340B hospital
    would spend to acquire a SCOD and the higher amount
    Medicare would reimburse that hospital. The gap ranged from
    25% to 55% of the cost of the drug. See, e.g., U.S. Government
    Accountability Off., GAO-15-442, Medicare Part B Drugs:
    Action Needed to Reduce Financial Incentives to Prescribe
    340B Drugs at Participating Hospitals (June 2015),
    https://www.gao.gov/assets/680/670676.pdf.
    When it came time to set 2018 OPPS rates, HHS decided
    to address the 340B-Part B payment gap. HHS believed that
    the gap “allow[ed] [340B] providers to generate significant
    profits when they administer[ed] Part B drugs.” 82 Fed. Reg.
    at 52,494. Seeking to shrink those revenues, HHS imposed a
    28.5% cut, from 106% of ASP to 77.5% of ASP, to the rates at
    which it would reimburse 340B hospitals for SCODs. See id.
    7
    at 52,496. The new rate was based on a “conservative”
    estimate, presented by the Medicare Payment Advisory
    Committee, that 22.5% below ASP equaled the “average
    minimum discount that a 340B participating hospital
    receive[d]” when purchasing SCODs. Id. HHS estimated that
    its 28.5% cut to SCOD reimbursement rates for Part B hospitals
    would save Medicare $1.6 billion in 2018. Id. at 52,509. As
    called for by the OPPS statute, HHS did not pocket the savings,
    but instead redistributed them to all hospitals in a budget-
    neutral manner by raising other Part B reimbursement rates. Id.
    at 52,623; see 42 U.S.C. § 1395l(t)(14)(H).
    By addressing the 340B-Part B payment gap, HHS hoped
    to mitigate “unnecessary utilization and potential
    overutilization of [Part B] drugs.” Medicare Program: Hospital
    Outpatient Prospective Payment and Ambulatory Surgical
    Center Payment Systems and Quality Reporting Programs, 
    82 Fed. Reg. 33,558
    , 33,633 (July 20, 2017). HHS cited a GAO
    study which found that 340B hospitals prescribed more drugs
    than other hospitals, a disparity unexplained by salient
    distinctions between the hospitals or their patient populations.
    
    Id. at 52,494
    . HHS also sought to reduce the disproportionate
    coinsurance payments borne by Medicare Part B beneficiaries
    (mostly elderly patients) for 340B SCODs: because the
    amount of a patient’s coinsurance payment is a fixed
    percentage of the medical bill as measured by the OPPS
    payment level, and because the latter amount for SCODs
    exceeded 340B hospitals’ actual costs to obtain the drugs,
    patients’ out-of-pocket coinsurance payments for SCODs
    became inflated, sometimes even exceeding a hospital’s costs
    to acquire the drugs. See 
    id.
    Ultimately, HHS found it “inappropriate for Medicare to
    subsidize other activities” by 340B hospitals—as laudable as
    those activities may be—“through Medicare payments for [Part
    8
    B] drugs.” 
    Id. at 52,495
    . In order to “better and more
    appropriately reflect the resources and acquisition costs that
    [340B] hospitals incur,” HHS acted to close the Part B-340B
    gap. 
    Id.
     (formatting modified). HHS relied on its authority to
    “adjust” the average price metric under subclause (II) of the
    statute:
    We believe our authority under section
    [1395l](t)(14)(A)(iii)(II) of the Act to “calculate
    and adjust” drug payments “as necessary for
    purposes of this paragraph” gives the Secretary
    broad discretion to adjust payments for drugs,
    which we believe includes an ability to adjust
    Medicare payment rates according to whether
    or not certain drugs are acquired at a significant
    discount.
    
    Id. at 52,499
    .
    C.
    The plaintiffs here are three hospitals and three hospital
    associations, to whom we will refer collectively as the
    Hospitals. On November 13, 2017, the day HHS published the
    rule reducing 340B reimbursement rates for SCODs, the
    Hospitals brought a challenge to HHS’s action. See Am. Hosp.
    Ass’n v. Hargan, 
    289 F. Supp. 3d 45
    , 50 (D.D.C. 2017). The
    district court dismissed the suit on the ground that the Hospitals
    had yet to present a concrete claim for payment to HHS, as
    required by statute. See 
    id. at 47
    . We affirmed. Am. Hosp.
    Ass’n v. Azar, 
    895 F.3d 822
    , 828 (D.C. Cir. 2018).
    The Hospitals quickly submitted payment claims as
    required. HHS rejected them, claiming that the Medicare
    statute precludes administrative review of adjustments to OPPS
    9
    payment rates, including SCOD reimbursement rates. The
    Hospitals then filed this action. Before the district court ruled,
    HHS promulgated OPPS rates for fiscal year 2019, which
    retained the 28.5% SCOD reimbursement cut for 340B
    hospitals that the Hospitals had initially challenged. 
    53 Fed. Reg. 83,818
     (Nov. 21, 2018). After submitting additional
    payment claims, the Hospitals filed a supplemental complaint
    challenging the 2019 Rule as well. See Suppl. Compl. ¶¶ 73–
    75 (Dkt. 39).
    This time, the district court reached the merits. After
    concluding that the Medicare statute did not preclude its review
    of the reductions in SCOD reimbursement, the court held that
    the rate cut exceeded HHS’s statutory authority to “adjust”
    SCOD rates. Am. Hosp. Ass’n v. Azar, 
    348 F. Supp. 3d 62
    , 79
    (D.D.C. 2018). The court remanded to the agency to come up
    with a remedy in the first instance. The court then entered final
    judgment, paving the way for this appeal.
    II.
    We must first address a threshold challenge to our
    jurisdiction.    The government asserts that paragraph
    1395l(t)(12) of the OPPS statute, 42 U.S.C. § 1395l(t)(12),
    precludes judicial review of HHS’s adjustments to SCOD rates.
    The district court disagreed, and so do we. Unable to find
    “clear and convincing evidence that Congress intended” that
    result, as would be required to overcome the “strong
    presumption that Congress intends judicial review of
    administrative action,” we conclude that the challenged rate
    adjustment is subject to judicial review. Amgen, Inc. v. Smith,
    
    357 F.3d 103
    , 111 (D.C. Cir. 2004) (quoting Bowen v. Mich.
    Acad. of Family Physicians, 
    476 U.S. 667
    , 670 (1986)).
    10
    Paragraph 1395l(t)(12) states that “[t]here shall be no
    administrative or judicial review” of certain enumerated
    actions undertaken by HHS in administering the OPPS. The
    question is whether changes to SCOD reimbursement rates are
    among the listed, nonreviewable actions. The government says
    yes, contending that changes to SCOD reimbursement rates fall
    within two provisions of paragraph (12): subparagraphs
    (12)(A) and (12)(C).
    The first provision, subparagraph (12)(A), bars review of
    the “development of the classification system under paragraph
    (2), including the establishment of groups and relative payment
    weights for covered OPD [outpatient department] services, of
    wage adjustment factors, other adjustments, and methods
    described in paragraph (2)(F).” 42 U.S.C. § 1395l(t)(12)(A);
    see also Am. Hosp. Ass’n, No. 19-5352, slip op. at 11. The
    second provision, subparagraph (12)(C), bars review of
    “periodic adjustments made under paragraph ([9]).” Id.
    § 1395l(t)(12)(C). (While the provision in fact refers to
    “paragraph (6),” all agree that the reference contains a
    scrivener’s error and that Congress in fact intended to refer to
    paragraph (9).) The reach of subparagraphs (12)(A) and
    (12)(C) turns on the scope of the provisions they cross-
    reference: paragraphs (2) and (9), respectively.
    Begin with paragraph (2), which sets out the general
    methodology HHS must use to set standard OPPS payments.
    Under paragraph (2), HHS “develop[s] a classification
    system.” Id. § 1395l(t)(2)(A). In doing so, HHS groups certain
    medical services together that are “comparable clinically and
    with respect to the use of resources.” Id. § 1395l(t)(2)(B). The
    resulting groups are known as ambulatory payment
    classifications, or APCs. Next, HHS establishes “relative
    payment weights” for the grouped services in an APC based on
    hospital costs. Id. § 1395l(t)(2)(C). HHS then sets default
    11
    payment amounts for the services in each APC corresponding
    to the weights.
    Paragraph (9), meanwhile, requires HHS to annually
    review and adjust the standard OPPS payment rates initially set
    under paragraph (2). Specifically, HHS must reassess its
    grouping and weighting decisions, as well as the other separate
    payment adjustments it makes under paragraph (2) (such as
    labor-cost adjustments), to “take into account changes in
    medical practice, changes in technology, the addition of new
    services, new cost data, and other relevant information and
    factors.” Id. § 1395l(t)(9)(A).
    HHS determines most annual OPPS payment levels
    through the exercise of paragraph (2) and (9) authority. Recall,
    however, that the Medicare statute does not allow HHS to use
    that discretion-laden authority to establish payment rates for all
    Part B services. Reimbursement rates for specified covered
    outpatient drugs—the rates at issue here—instead must be
    keyed to one of two statutory formulas set out in paragraph
    1395l(t)(14): average acquisition cost (if hospital cost data are
    available) under subclause (I), or average price under subclause
    (II). SCOD payments “shall be equal” to one of those two
    options. Id. § 1395l(t)(14)(A)(iii).
    Returning to our original question of whether HHS’s
    adjustment to SCOD reimbursement rates fall within the bars
    on judicial review set out in subparagraphs (12)(A) or (12)(C),
    the answer is no as a textual matter. Neither (12)(A) nor
    (12)(C) addresses—and thus neither purports to preclude—any
    action taken by HHS under paragraph (14) of the statute. And
    none of the actions described in subparagraphs (12)(A) or
    (12)(C) plausibly, let alone clearly, comprises SCOD
    reimbursement adjustments.
    12
    In particular, subparagraph (12)(A) precludes review of
    “the development of the [APC] classification system,” “the
    establishment of groups and relative payment weights,” “wage
    adjustment factors,” and “other adjustments.”               Id.
    § 1395(t)(12)(A). As just discussed, SCOD rates are not set
    using the paragraph (2) grouping and weighting process, so a
    change to SCOD rates does not come under the first two of
    those descriptions. Such a change is also not a “wage
    adjustment[].”     Nor is it covered by the term “other
    adjustments,” which we have read to reach only the
    “adjustments . . . necessary to ensure equitable payments”
    under subparagraph (2)(E) (i.e., “equitable adjustments”), see
    Amgen, 
    357 F.3d at 113
    .
    Subparagraph (12)(C), similarly, does not by its plain
    terms appear to cover SCOD payment reductions. It covers
    “periodic adjustments made under paragraph [9].” 42 U.S.C.
    § 1395l(t)(12)(C). By the terms of paragraph (9), that annual
    adjustment power extends only to actions initially taken under
    paragraph (2). And as just discussed, none of those actions
    textually corresponds to a decision to reduce SCOD rates.
    Our analysis of the text draws support from Congress’s
    history of amendments to the OPPS statute. When adding new
    provisions to subsection 1395l(t), Congress has tended to say
    expressly when it wishes to preclude judicial review of
    decisions made under an added provision. In 1999, Congress
    added paragraphs (5), (6), and (7) to subsection (t). In the same
    legislation, Congress also added clause (E) to paragraph (12),
    which provided that certain “determination[s]” made under
    paragraphs (5) and (6), but not any decisions under paragraph
    (7), would not be judicially reviewable. See Pub. L. No. 106-
    113, § 201(d), 
    113 Stat. 1501
     (1999). In 2015, Congress
    included a preclusion-of-judicial-review provision directly
    within the newly added paragraph (21), rather than amending
    13
    paragraph (12). See Pub. L. No. 114-74, § 603, 
    129 Stat. 584
    ,
    598 (2015). By contrast, when Congress added paragraph (14)
    in 2003, it did so without any indication of an intention to
    preclude judicial review of SCOD rate-setting decisions.
    According to the government, though, Congress had no
    need to expressly preclude judicial review of actions taken
    under paragraph (14) because those actions are inherently ones
    under paragraphs (2) and (9) (and thus necessarily fall within
    the judicial-review bars in subparagraphs (12)(A) and (12)(C)).
    The nub of the government’s argument is that paragraph (14)
    does not in fact set up a “standalone payment regime” outside
    the general paragraph (2) system. Appellant’s Reply Br. 15.
    Rather, the government contends, paragraph (14) merely
    “provides instructions to HHS about how to exercise its
    paragraph 2 and 9 authority when setting and revising
    payments” for SCODs. 
    Id.
     On that view, even though HHS
    must follow paragraph (14)’s specific commands when setting
    the SCOD reimbursement rate, when HHS does so, it exercises
    authority located not in (14) but in paragraphs (2) and (9).
    Ultimately, it is the government’s burden to support that
    theory by “clear and convincing evidence,” Amgen, 
    357 F.3d at 111
    , especially given the absence of statutory text
    unambiguously precluding judicial review. Applying that
    standard, we are insufficiently persuaded of the proposition
    that HHS’s authority to annually set SCOD rates is located in
    paragraphs (2) and (9) rather than paragraph (14).
    First, Congress on several occasions has specifically
    noted, directly in the statutory text, that certain OPPS-related
    decisions fall under paragraph (2). When Congress authorized
    HHS to make “outlier adjustments” and “pass-through
    payments,” it fleshed out how those actions would work in
    paragraphs (5) and (6) respectively, but lodged the authority to
    14
    make the adjustments in the newly added subparagraph (2)(E).
    See 42 U.S.C. § 1395l(t)(2)(E). When Congress added
    paragraphs (13) and (18), which address adjustments for rural
    and cancer hospitals, respectively, it similarly provided that
    those adjustments would fall under subparagraph (2)(E). 42
    U.S.C. § 1395l(t)(13)(B) (“the Secretary shall provide for an
    appropriate adjustment under paragraph (2)(E)”); id.
    § 1395l(t)(18)(B) (“the Secretary shall . . . provide for an
    appropriate adjustment under paragraph (2)(E)”). But when
    Congress added the SCOD reimbursement provisions of
    paragraph (14) in 2003, it included no such language
    referencing paragraph (2).
    Second, both the statute’s text and HHS’s longstanding
    practice strongly suggest that paragraph (2) and (9)’s
    “adjustment” authorities do not encompass paragraph (14). If
    setting SCOD rates were an exercise of paragraph (2) authority,
    HHS would be authorized to use its subparagraph (2)(E)
    equitable-adjustment authority to change the rates. But it does
    not appear HHS may make such adjustments to SCOD rates.
    As a matter of statutory text, paragraph (14) provides its
    own authorizations for HHS to adjust SCOD rates. Subclause
    (I) of paragraph (14), which sets out the average-acquisition-
    cost formula, says that the Secretary “may vary [the calculated
    reimbursement rate] by hospital group.”              42 U.S.C.
    § 1395l(t)(14)(A)(iii)(I). Subclause (II), which requires SCOD
    reimbursement to reflect a drug’s average price, allows the
    Secretary to “calculate[] and adjust[] [the average price metric]
    as necessary for purposes of this paragraph.”                 Id.
    § 1395l(t)(14)(A)(iii)(II). And both the average-acquisition-
    cost and average-price formulas are “subject to subparagraph
    (E),” which authorizes the Secretary to “adjust” SCOD
    payments to account for “overhead and related expenses, such
    as pharmacy services and handling costs.”                     Id.
    15
    § 1395l(t)(14)(E). It would be odd for Congress in paragraph
    (14) to provide HHS with those specific authorities to “adjust”
    SCOD rates if HHS nonetheless has the general authority to
    adjust those rates as it sees fit under paragraph (2) or (9).
    HHS’s longstanding practice, and the 2018 and 2019 Rules
    at issue here, corroborate that understanding. HHS has never
    purported to use its paragraph (2) or (9) authorities either to set
    SCOD rates or to deviate from the default “average price” rate
    set out in subclause (II). And it did not do so here. Instead, in
    the 2018 Rule, HHS grounded its action in in the “calculate and
    adjust” provision of paragraph (14), subclause (II). 82 Fed.
    Reg. at 52,499–500. The government claims that HHS invoked
    its paragraph (9) authority in the 2018 Rule’s preamble. But
    the preamble stated only that the Rule would “describe [that]
    and various other statutory authorities in the relevant sections
    of this final rule.” Id. at 52,362. And in the section of the Rule
    explaining HHS’s statutory authority to make the 340B-related
    reduction to SCOD rates, there is no reference to paragraph (9).
    See id. at 52,496, 52,499–502.
    Of particular note, HHS made no claim that the rate cut at
    issue here was an exercise of its subparagraph (2)(E) equitable-
    adjustment authority, even though the change might be seen to
    serve equitable goals. HHS relied solely on its paragraph (14),
    subclause (II) adjustment authority, even as it invoked its
    subparagraph (2)(E) equitable-adjustment power in connection
    with at least two other rate changes in the 2018 OPPS Rule.
    See id. at 52,364–65 (explaining that HHS makes an additional
    payment for radioisotopes used in diagnostic imaging “based
    on the authority set forth at section [1395l](t)(2)(E)”); id. at
    52,421 (“we are using our equitable adjustment authority” to
    change reimbursement for retinal procedure).
    16
    Third, paragraph (14) operates as a standalone payment
    regime for all practical purposes. The statute contemplates that
    HHS will set SCOD payment rates in a vacuum, without taking
    into account other OPPS rate-setting decisions. SCOD rates
    are not set through relative weighting with rates for other
    reimbursable care. And if HHS changes the payment weights
    for other APCs, SCOD prices need not change because SCOD
    rates are unaffected by the statute’s budget-neutrality
    requirement. Recall that SCOD rates must equal either average
    acquisition cost or average price. Although subparagraph
    (14)(H) requires that “[a]dditional expenditures resulting from
    this paragraph” be “taken into account” for overall budget
    neutrality for the OPPS, that language recognizes that the
    expenditures “resulting” from the application of paragraph (14)
    will be calculated first, irrespective of other adjustments made
    to other OPPS payments. 42 U.S.C. § 1395l(t)(14)(H). Only
    then are those set-in-stone numbers put into the budget-
    neutrality calculator.
    On this score, HHS again has consistently read the statute
    the way we do. See, e.g., 77 Fed. Reg. at 68,262 (“Payments
    for [SCODs] are included in the budget neutrality
    adjustments . . . but the budget neutral weight scaler is not
    applied to their payments because they are developed through
    a separate methodology, outside the relative payment weight
    based process.”). That understanding of the statute’s structure
    sits uncomfortably, to say the least, with HHS’s position in this
    case that paragraph (14) does no more than instruct HHS how
    to exercise its paragraph (2) and (9) authorities.
    The government lastly relies on subparagraph (14)(H),
    reading that provision to indicate that setting of SCOD rates is
    an exercise of paragraph (9)’s annual-adjustment authority.
    Subparagraph (14)(H), enacted along with the rest of paragraph
    (14) in 2003, requires that SCOD payments be counted for
    17
    budget-neutrality purposes in years after 2005, but specifies
    that the payments “shall not be taken into account” for budget-
    neutrality purposes in 2004 and 2005.              42 U.S.C.
    § 1395l(t)(14)(H) (emphasis added); see also id.
    § 1395l(t)(9)(B).      According to the government, the
    specification that SCOD payments would not be subject to
    budget neutrality in 2004 and 2005 suggests that budget
    neutrality otherwise applies, which would be the case if SCOD
    rate-setting were an exercise of paragraph (9) authority (given
    that all paragraph (9) adjustments must be budget neutral, see
    id. § 1395l(t)(9)(B)).
    We disagree with the premise that SCOD rates can factor
    into OPPS budget neutrality only if the setting of SCOD rates
    is an exercise of paragraph (9) authority. It is at least possible,
    if not probable, that Congress conceived of the SCOD rate-
    setting program as entirely distinct from the general paragraph
    (2) and (9) program, yet still wanted the output of the SCOD
    program to matter for overall budget neutrality. Recall that
    Congress required HHS to move to the prospective OPPS
    system, constrained by a budget-neutrality requirement, in
    order to control Medicare Part B spending and promote more
    predictable annual growth. In view of those goals, Congress,
    when creating a standalone payment regime for SCODs, might
    still have wanted to achieve budget neutrality for Part B
    payments as a whole. Thus, Congress’s choice to make that
    desire explicit for years after 2005 (and to carve out the two
    prior years) does not necessarily imply that HHS exercises
    paragraph (9) authority whenever it adjusts SCOD rates.
    To sum up: subparagraphs (12)(A) and (12)(C) do not, by
    their terms, clearly cover HHS’s decision to cut SCOD
    reimbursement to 340B hospitals. While the government
    argues that SCOD rate-setting is merely a species of general
    OPPS rate-setting under paragraphs (2) and (9), and that
    18
    Congress thus intended SCOD payment decisions to be
    similarly insulated from review, that account, at a minimum, is
    not clearly correct. As a result, the government has failed to
    “overcom[e] the strong presumption that Congress did not
    mean to prohibit” our review. Bowen, 
    476 U.S. at 672
    .
    III.
    Proceeding to the merits, the sole question before us is
    whether HHS had statutory authority to impose its 28.5% cut
    to SCOD reimbursement rates for 340B hospitals. HHS
    located its authority in subclause (II) of paragraph (14) of the
    OPPS statute. Under that provision, when HHS sets SCOD
    payment amounts tethered to average drug prices, HHS has
    express authority to “adjust[]” the amounts “as necessary for
    purposes      of     this    paragraph.”          42     U.S.C.
    § 1395l(t)(14)(A)(iii)(II). In our view, HHS reasonably
    interpreted subclause (II)’s adjustment authority to enable
    reducing SCOD payments to 340B hospitals, so as to avoid
    reimbursing those hospitals at much higher levels than their
    actual costs to acquire the drugs.
    On that issue of statutory interpretation, HHS is entitled to
    Chevron deference, which it has invoked here (although it did
    not do so expressly until a post-argument letter submitted to the
    Court). See Chevron U.S.A., Inc. v. Nat. Res. Def. Council,
    Inc., 
    467 U.S. 837
    , 842 (1984). When an agency “interpret[s]
    a statute it is charged with administering in a manner (and
    through a process) evincing an exercise of its lawmaking
    authority,” that interpretation is entitled to Chevron treatment,
    and the agency cannot forfeit Chevron’s applicability.
    SoundExchange, Inc. v. Copyright Royalty Board, 
    904 F.3d 41
    ,
    54–55 (D.C. Cir. 2018).              HHS established SCOD
    reimbursement rates for 340B hospitals through notice-and-
    comment rulemaking and explained why it “believe[d] that [its]
    19
    proposal [was] within [its] statutory authority to promulgate.”
    82 Fed. Reg. at 52,499. HHS’s understanding of its statutory
    authority thus is entitled to Chevron deference. See Am. Hosp.
    Ass’n, No. 19-5352, slip op. at 14; Tenet HealthSystems
    HealthCorp. v. Thompson, 
    254 F.3d 238
    , 248 (D.C. Cir. 2001);
    see also Barnhart v. Walton, 
    535 U.S. 212
    , 222 (2002).
    Under Chevron, we first ask whether “Congress has
    directly spoken to the precise question at issue.” Chevron, 
    467 U.S. at 842
    . Here, the “precise question at issue” is whether
    HHS’s adjustment authority in subclause (II) encompasses a
    reduction to SCOD reimbursement rates aimed at bringing
    reimbursements to 340B hospitals into line with their actual
    costs to acquire the drugs. If the statute does not directly
    foreclose HHS’s understanding, we defer to the agency’s
    reasonable interpretation. See 
    id. at 844
    . We conclude that
    HHS’s interpretation of subclause (II) is not directly foreclosed
    and is reasonable.
    By way of brief review, paragraph (14), as its title
    confirms, addresses “[d]rug . . . payment rates”—specifically,
    the rates at which hospitals are reimbursed for SCODs
    furnished to beneficiaries in supplying covered care. 42 U.S.C.
    § 1395l(t)(14). Under subclause (I) of the paragraph, the
    “amount of payment,” as a default matter, “shall be equal” to
    hospitals’ “average acquisition cost for the drug.” Id.
    § 1395l(t)(14)(A)(iii)(I). But if pertinent “hospital acquisition
    cost data are not available,” then payment levels are determined
    under subclause (II). Under that provision, the amount of
    payment equals “the average price for the drug”—which, by
    statutory cross-reference, is the drug’s average sales price
    (ASP) charged by manufacturers—but subject to
    “adjust[ment] . . . as necessary for purposes of this paragraph.”
    Id. § 1395l(t)(14)(A)(iii)(II).
    20
    Much is undisputed about HHS’s application of subclause
    (II)’s adjustment authority to reduce SCOD payment rates to
    340B hospitals. First, HHS properly found that the “hospital
    acquisition cost data” contemplated by subclause (I) was
    unavailable, such that HHS needed to determine payment rates
    in accordance with subclause (II)’s fallback reliance on average
    drug prices. Second, 340B hospitals obtain SCODs at
    substantially lower cost than other providers, such that
    reimbursing those hospitals at the same rate as other providers
    would give sizable revenues to the hospitals. Third, HHS’s
    28.5% SCOD rate reduction for 340B hospitals is a fair, or even
    conservative, measure of the reduction needed to bring
    payments to those hospitals into parity with their costs to obtain
    the drugs. See 82 Fed. Reg. at 52,500. Fourth, absent the
    reduction, at least some Medicare beneficiaries served by 340B
    hospitals (generally underserved populations) would pay out-
    of-pocket copayments for the drugs that substantially exceed
    the normal copay share of providers’ cost to obtain the drugs—
    with beneficiaries’ copayments sometimes exceeding 340B
    hospitals’ full cost to purchase the drugs. And fifth, the roughly
    $1.6 billion in savings from reducing SCOD reimbursement
    payments to 340B hospitals is not kept by the agency but is
    redistributed to all providers as additional reimbursement
    payments for other services. See generally pp. 6–8, supra.
    That is the backdrop against which we consider whether
    HHS permissibly understood its subclause (II) adjustment
    authority to encompass its reduction to reimbursement
    payments to 340B hospitals for SCODs. Was HHS obligated
    to continue reimbursing 340B hospitals for SCODs in amounts
    substantially exceeding their costs to obtain the drugs, with the
    resulting effects that concerned the agency on out-of-pocket
    copayments owed by Medicare beneficiaries? We think the
    agency was not compelled to continue doing so.
    21
    The central question is whether HHS permissibly
    conceived of the “purposes of this paragraph,” i.e., paragraph
    (14), in exercising its subclause (II) authority to “adjust[]”
    payment rates “as necessary for the purposes of this
    paragraph,” 42 U.S.C. § 1395l(t)(14)(A)(iii)(II). According to
    the agency, a “manifest purpose of paragraph 14 is to
    compensate providers for the average acquisition cost” of
    SCODs. Appellant’s Br. 30. In accordance with that
    understanding, HHS explained in the 2018 Rule that “a
    payment amount of ASP minus 22.5 percent for drugs acquired
    under the 340B Program is better aligned to hospitals’
    acquisition costs and thus this adjustment . . . is necessary for
    Medicare OPPS payment policy.” 82 Fed. Reg. at 52,501.
    Paragraph (14)’s structure supports HHS’s understanding
    that the provision’s core purposes include reimbursing
    hospitals for their costs to acquire SCODs. Paragraph (14)’s
    primary (and default) instruction for determining SCOD
    payment amounts, set out in subclause (I), is to equate them to
    “average acquisition cost.” 42 U.S.C. § 1395l(t)(14)(A)(iii)(I).
    That alone indicates that Congress’s primary goal is to
    reimburse providers for their acquisition costs. And if direct
    acquisition-cost data of a kind contemplated by subclause (I) is
    unavailable, HHS must then, as a fallback matter under
    subclause (II), equate payment amounts to “average price,”
    subject to adjustment. 42 U.S.C. § 1395l(t)(14)(A)(iii)(II). By
    prescribing the use of ASP as a backup when the requisite
    acquisition-cost data is unavailable, Congress signaled that
    average price functions as a stand-in for costs.
    HHS has long understood average price under subclause
    (II) to serve as a “proxy for average acquisition cost.” 77 Fed.
    Reg. at 68,386. HHS has used ASP since 2006, stating then
    and all along that its “intent” in using ASP was “to pay for
    drugs and biologicals based on their hospital acquisition costs.”
    22
    Medicare Program; Changes to the Hospital Outpatient
    Prospective Payment System and Calendar Year 2006 Payment
    Rates, 
    70 Fed. Reg. 68,516
    , 68,642 (Nov. 10, 2005). For non-
    340B hospitals, ASP is an accurate approximation of
    acquisition costs: HHS’s Inspector General has found that, for
    non-340B hospitals, ASP comes within roughly 1% of
    acquisition costs.      HHS Office of Inspector General,
    Memorandum Report: Payment for Drugs Under the Hospital
    Outpatient Prospective Payment System 1, 9 (Oct. 22, 2010).
    But for 340B hospitals, ASP substantially exceeded SCOD
    acquisition costs by the time of the 2018 Rule—hence the need
    for an adjustment under subclause (II) to bring payments to
    340B hospitals into line with their costs.
    The OPPS statute exhibits in other ways Congress’s
    evident purpose of aligning SCOD reimbursement with
    hospital costs. Paragraph (14) itself expressly authorizes a
    separate adjustment to SCOD payment rates to account for
    “overhead costs” and “related expenses” (“such as pharmacy
    services and handling costs”). 
    Id.
     § 1395l(t)(14)(E). And more
    broadly, many other OPPS provisions reflect the goal of
    aligning payments to hospitals with their costs. See id.
    § 1395l(t)(2)(C) (grouping and weighting under paragraph (2)
    must be “based on median . . . hospital costs”); id.
    § 1395l(t)(2)(D) (“wage adjustment factor” must account for
    “relative differences in labor and labor-related costs”); id.
    § 1395l(t)(5)(B) (“outlier adjustments” must “approximate the
    marginal cost of care”); id. § 1395l(t)(9)(A) (“periodic . . .
    adjustments” must be based on “new cost data”); id.
    § 1395l(t)(13)(A) (authorizing adjustments if “costs incurred
    by hospitals located in rural areas . . . exceed those costs
    incurred by hospitals located in urban areas”); id.
    § 1395l(t)(18)(B) (same for cancer hospitals).
    23
    All of that supports HHS’s understanding that the
    “purposes” of paragraph 14 for which the agency can “adjust[]”
    SCOD payments under subclause (II) include aligning
    payments to hospitals with their drug acquisition costs. Id.
    § 1395l(t)(14)(A)(iii)(II). That is precisely what HHS did
    when it imposed its 28.5% reduction in payments to 340B
    hospitals for SCODs.
    In arguing that HHS lacked authority under subclause (II)
    to undertake that measure, the Hospitals focus on subclause
    (I)’s requirement that, if payment amounts are keyed to
    “average acquisition cost” under that provision—as opposed to
    average price under subclause (II)—then the agency must take
    “into account the hospital acquisition cost survey data under
    subparagraph (D).”         Id. § 1395l(t)(14)(A)(iii)(I).       And
    subparagraph (D) imposes stringent data-quality requirements,
    mandating that the cost surveys “shall have a large sample of
    hospitals that is sufficient to generate a statistically significant
    estimate of the average hospital acquisition cost for each
    [SCOD].” Id. § 1395l(t)(14)(D)(iii).
    Because Congress required HHS to “tak[e] into account”
    robust study data when setting SCOD rates at average
    acquisition cost under subclause (I), the Hospitals argue, HHS
    cannot use its subclause (II) authority to adjust ASP in order to
    approximate acquisition cost. As the Hospitals see it, if HHS
    wants to set SCOD rates based on the cost to hospitals to
    acquire the drugs, the agency must get the data contemplated
    by subclause (I). If it were otherwise, the Hospitals contend,
    subclause (I)’s requirement to take into account the data
    collected under subparagraph (D) would be meaningless: HHS
    could simply forgo the study required by subclause (I) and
    instead use subclause (II) to approximate drug acquisition
    costs. Our dissenting colleague, too, stresses the same point.
    Dissenting Op. 5.
    24
    That argument, on which the district court relied, see Azar,
    348 F. Supp. 3d at 82–83, is not without force. We, though,
    are ultimately unpersuaded. For the Hospitals’ argument to
    carry the day under Chevron, we would need to conclude that
    Congress unambiguously barred HHS from seeking to align
    reimbursements with acquisition costs under subclause (II), or
    that HHS’s belief that it could do was unreasonable. And HHS
    would be barred from doing so even if, as here, it is undisputed
    both that payment amounts otherwise would substantially
    exceed hospitals’ costs and that the proposed adjustment
    accurately and reliably approximates procurement costs.
    Given that the survey data contemplated by subclause (I)
    aims to assure the reliability of cost-acquisition data, we do not
    read the statute to foreclose an adjustment to ASP under
    subclause (II) that is based on reliable cost measures of the kind
    undisputedly at issue here. That is particularly so because,
    whereas the Hospitals question whether HHS’s interpretation
    could enable sidestepping subclause (I)’s data-reliability
    requirements altogether, the Hospitals’ own reading raises a
    similar interpretive dilemma. Subclause (II), as explained,
    expressly empowers HHS to “adjust” payments based on ASP
    “as necessary for purposes of” paragraph (14). And under the
    Hospitals’ reading, those “purposes” cannot include the goal of
    approximating hospital acquisition costs. But the Hospitals
    point to no other “purpose” that could permissibly support an
    adjustment. The Hospitals’ argument thus renders subclause
    (II)’s adjustment authority superfluous.
    The Hospitals submit that “[t]he purpose of paragraph (14)
    is to establish the rate for separately payable drugs.”
    Appellees’ Br. 42–43. That may be true at a high level of
    generality—indeed, the title of paragraph (14) is “Drug APC
    payment rates”—but it is unhelpful to the Hospitals for our
    25
    purposes. After all, HHS’s rate reduction for payments to 340B
    hospitals does “establish the rate for separately payable drugs.”
    The Hospitals also suggest that subclause (II)’s adjustment
    authority enables adjustments to account for overhead costs.
    Appellees’ Br. 49. But that reading would leave subclause
    (II)’s adjustment authority duplicative of authority already
    conferred by subparagraph (14)(E). That subparagraph, as
    noted, authorizes HHS to make adjustments to account for
    “overhead and related expenses, such as pharmacy services and
    handling costs.” 42 U.S.C. § 1395l(t)(14)(E)(i). If subclause
    (II)’s adjustment authority were merely meant to reinforce
    subparagraph (14)(E)’s authority to account for overhead costs,
    then why would subclause (II) not simply say so, in comparable
    language? Instead, subclause (II) frames its grant of authority
    in notably broader terms addressed to the overall purposes of
    paragraph (14), not just the specific, “overhead and related
    expenses” focus of subparagraph (14)(E).
    The Hospitals’ reading of subclause (II)’s adjustment
    authority as addressed to overhead costs, it bears noting, would
    necessarily mean that the purpose of granting that authority is
    to enable bringing ASP closer to drug acquisition costs—
    precisely what the Hospitals otherwise say the agency cannot
    aim to do when exercising its subclause (II) authority. But
    under the Hospitals’ evident understanding, the agency can try
    to get ASP closer to actual costs only to the extent of taking
    into account overhead costs, without going further to bring
    ASP all the way into alignment with acquisition costs. That
    half-measure understanding of subclause (II)’s adjustment
    authority is incompatible with its broad terms, which speak
    generally to the “purposes” of paragraph (14), including, in
    particular, approximating drug acquisition costs.
    26
    Our dissenting colleague nonetheless endorses the
    Hospitals’ suggestion that subclause (II)’s adjustment
    authority, while framed generally, should be read as focused on
    overhead costs. Dissenting Op. 5–8. Our colleague briefly
    suggests that there may be no redundancy between subclause
    (II) and subparagraph (14)(E) under that reading because, she
    posits, the two provisions both allow for adjustments to account
    for overhead costs, but at different times, with (14)(E) in the
    nature of a time-limited, naturally-expiring allowance and
    subparagraph (II) an ensuing, ongoing one. Id. at 5–6. Again,
    though, if the provisions were designed to cover the same
    terrain (even if at different times), one would expect them to
    use similar language in defining the territory, which they
    conspicuously do not. And at any rate, the statutory text
    confirms that the provisions are designed to work side-by-side
    contemporaneously, not at different times: Congress rendered
    subclause (II)’s provisions expressly “subject to paragraph
    (E),” such that the agency, when acting under subclause (II),
    could make adjustments to ASP both under that provision’s
    own, broadly-framed adjustment authority and under
    subparagraph (14)(E)’s more specific authority addressed to
    overhead costs. 42 U.S.C. § 1395l(t)(14)(A).
    Our dissenting colleague ultimately allows that the
    Hospitals’ overhead-costs interpretation of subclause (II)’s
    adjustment authority means that the provision may reiterate—
    i.e., make “double sure”—subparagraph (14)(E)’s express
    authority to account for overhead costs. Dissenting Op. 6. But
    our colleague still believes that the Hospitals’ reading of the
    statute is unambiguously compelled at Chevron step one. Id.
    at 1. In her evident view, any superfluity occasioned by that
    reading is less substantial than the superfluity occasioned by
    the agency’s reading. Id. at 8–9. But even assuming there is a
    reliable metric for comparing degrees of superfluity across
    readings in that fashion, that kind of comparison is not the stuff
    27
    of a Chevron step one resolution. Rather, when competing
    readings of a statute would each occasion their own notable
    superfluity, that manifests the kind of statutory ambiguity that
    Chevron permits the agency to weigh and resolve. See
    National Ass’n of Home Builders v. Defenders of Wildlife, 
    551 U.S. 644
    , 666 (2007); Peter Pan Bus Lines, Inc. v. Fed. Motor
    Carrier Safety Admin., 
    471 F.3d 1350
    , 1354 (D.C. Cir. 2006)
    (“[S]ection 13902 contains surplusage under either reading
    and, as a result, we cannot say that either proffered construction
    reflects the Congress’s unambiguously expressed intent.”).
    The Hospitals separately suggested in oral argument that
    subclause (II)’s adjustment authority could pertain to
    improving the accuracy of the sales-price metric specifically
    for hospitals (as opposed to other providers). ASP reflects
    sales prices to all manner of medical providers, including
    pharmacies, clinics, independent physician practices, and the
    like. See 42 U.S.C. § 1395w-3a(c). As the Hospitals see it,
    HHS can adjust ASP to arrive at a metric that better reflects the
    prices paid by hospitals alone. But nothing in subclause (II)’s
    general adjustment authority suggests that it is so narrowly
    focused. And in any event, to the extent HHS might adjust ASP
    to more accurately reflect prices paid by hospitals, it is unclear
    whether there would then remain any appreciable difference
    between such a hospital-specific ASP and hospital acquisition
    costs. Yet the Hospitals’ whole point is that HHS cannot rely
    on its subclause (II) adjustment authority to approximate
    acquisition costs.
    Especially in view of the Hospitals’ inability to present an
    interpretation of HHS’s subclause (II) adjustment authority that
    would give it meaningful independent content, we cannot
    conclude that the statute forecloses HHS from reducing SCOD
    reimbursement rates for 340B hospitals with the object of
    bringing payments into alignment with acquisition costs.
    28
    Rather, in the specific circumstances of this case, HHS
    permissibly read the statute to allow it to implement the 340B
    payment reduction. Although subclause (I) calls for the
    “average acquisition cost” payment metric to “tak[e] into
    account” subparagraph (D)’s survey data, here, HHS relied on
    data of undisputed reliability. Moreover, the agency acted on
    that data in a cautious way, adopting a “conservative, lower-
    bound estimate” of the 340B discount’s size. 82 Fed. Reg. at
    52,504 (quotation marks omitted). In those circumstances,
    HHS reasonably concluded that it need not continue
    subsidizing 340B providers with Part B (i.e. taxpayer) funds
    and Medicare beneficiaries’ copayments. We of course do not
    consider the wisdom of that decision as a policy matter in the
    first instance, but only whether the agency had statutory
    authority to reach it. See Chevron, 
    467 U.S. at 845
    . We
    conclude that the agency’s decision rests on a permissible
    understanding of its statutory authority.
    Shifting tack, the Hospitals contend that even if HHS can
    seek to approximate acquisition costs in exercising its
    subclause (II) adjustment authority, HHS’s 28.5% rate cut is
    simply too large and sweeping to qualify as an “adjustment.”
    That argument falls short under a straightforward application
    of Chevron. The statutory term “adjust” is ambiguous as to
    size. The Hospitals offer various definitions of “adjust” that
    include qualifiers such as “slightly,” e.g., Adjust, Oxford
    Dictionaries, https://www.lexico.com/definition/adjust (“alter
    or move (something) slightly in order to achieve the desired fit,
    appearance, or result”), but HHS responds with many
    definitions that lack such qualifiers, e.g., Adjust, Merriam-
    Webster, https://www.merriam-webster.com/dictionary/adjust
    (“to bring to a more satisfactory state”).
    The Hospitals point to our decision in Amgen, which
    considered an “adjustment” under HHS’s subparagraph (2)(E)
    29
    authority to make equitable adjustments. In the course of
    upholding the challenged adjustment, we observed that
    “similar limits inhere in the term ‘adjustments’ to those the
    Supreme Court found in the word ‘modify’” in MCI
    Telecomms. Corp v. Am. Tel. & Tel. Co., 
    512 U.S. 218
    , 225
    (1994). Amgen, 
    357 F.3d at 117
    . And the MCI Court stated
    that “modify” means “to change moderately or in minor
    fashion.” MCI, 
    512 U.S. at 225
    . But we do not read Amgen to
    prescribe that “adjust” in the OPPS statute refers only to minor
    changes. To the contrary, Amgen explained that it “ha[d] no
    occasion to engage in line drawing to determine when
    ‘adjustments’ cease being ‘adjustments.’” 
    357 F.3d at 117
    .
    Even if there are limits to what HHS could permissibly
    consider an “adjustment,” that line has not been crossed here,
    where the agency acted on a conservative estimate drawn from
    data of undisputed reliability.
    The Hospitals’ last argument is that HHS’s subclause (II)
    adjustment authority does not allow adjusting reimbursement
    rates for 340B hospitals alone. According to the Hospitals, the
    reimbursement rate set under subclause (II) must be uniform
    across all hospitals. The Hospitals rely on subclause (I)’s
    statement that payment rates set under that provision must
    equal “the average acquisition cost for the drug for that year
    (which, at the option of the Secretary, may vary by hospital
    group (as defined by the Secretary based on volume of covered
    OPD services or other relevant characteristics)).” 42 U.S.C.
    § 1395l(t)(14)(A)(iii)(I) (emphasis added). The Hospitals
    stress that subclause (II), by comparison, says nothing about
    authority to vary the average price metric by hospital group.
    That silence, to the Hospitals, means that when HHS sets
    SCOD reimbursement rates under subclause (II), it must apply
    the same rate to every recipient hospital.
    30
    Congress, however, was not silent about HHS’s
    adjustment power in subclause (II). Whereas subclause (I)
    does not grant HHS any general authority to adjust
    reimbursement rates, subclause (II) affirmatively grants HHS
    general adjustment authority for deployment “as necessary for
    purposes of” paragraph (14). And as explained, HHS
    reasonably believes that a central purpose of paragraph (14) is
    to accurately reimburse hospitals for their acquisition costs.
    There is no reason to think that HHS’s general adjustment
    authority when acting under subclause (II) excludes the more
    focused license to vary rates by hospital group when acting
    under subclause (I). In particular, the Hospitals provide no
    reason why, if HHS knows that a certain group of hospitals has
    far lower (or far higher) costs than others, Congress would
    want to preclude HHS from acting on that information in a
    suitably tailored fashion when exercising its adjustment
    authority under subclause (II). At a minimum, the statute does
    not clearly preclude HHS from adjusting the SCOD rate in a
    focused manner to address problems with reimbursement rates
    applicable only to certain types of hospitals. That is enough to
    reject the Hospitals’ argument under Chevron.
    *   *    *   *    *
    For the foregoing reasons, we reverse the judgment of the
    district court.
    So ordered.
    PILLARD, Circuit Judge, dissenting in part: I agree with
    my colleagues that the Medicare Outpatient Prospective
    Payment System (OPPS) statute does not preclude judicial
    review of HHS’s 28.5% reduction in reimbursement rates to
    340B hospitals that administer Specified Covered Outpatient
    Drugs (SCODs). On the merits, however, I disagree that
    subclause (II) authorized HHS to implement for 340B hospitals
    alone the challenged rate reductions in its 2018 and 2019 OPPS
    rules.
    The statute sets forth two alternative bases for HHS’s
    calculation of the relevant reimbursement rates: It may set
    those rates under subclause (I) based on average acquisition
    cost (reflecting the average cost that hospitals actually incurred
    in purchasing the drug), or under subclause (II) based on
    average sales price (reflecting the average price, updated
    quarterly, at which manufacturers sold the drug to most
    purchasers, not limited to hospitals).            See 42 U.S.C.
    § 1395l(t)(14)(A)(iii)(I)-(II). When the two subclauses at issue
    here are read together, the conclusion is unavoidable that HHS
    may institute its large reductions, tailored for a distinct hospital
    group, only under subclause (I), which requires the agency to
    take into account specific data undisputedly absent here.
    The majority concludes that HHS may act on other data
    (not meeting Congress’ specifications) to make those
    reductions pursuant to subclause (II).           That reading
    impermissibly nullifies subclause (I) and the data requirements
    spelled out at length in subparagraph (D).              See id.
    § 1395l(t)(14)(D). I would therefore hold that the agency’s
    interpretation of subclause (II) is foreclosed at Chevron step
    one. Because HHS’s actions cannot be squared with the text of
    the OPPS statute, I respectfully dissent from part III of the
    majority opinion.
    *    *    *
    2
    Reproduced in full, subclauses (I) and (II) provide that, for
    every year after 2005, the reimbursement rate “shall be equal,
    subject to subparagraph (E)”—
    (I) to the average acquisition cost for the drug for
    that year (which, at the option of the Secretary, may
    vary by hospital group (as defined by the Secretary
    based on the volume of covered [outpatient
    department]       services    or     other    relevant
    characteristics)), as determined by the Secretary
    taking into account the hospital acquisition cost
    survey data under subparagraph (D); or
    (II) if hospital acquisition cost data are not available,
    the average price for the drug in the year established
    under      section     1395u(o)      of     this    title,
    section 1395w-3a of this title, or section 1395w-3b
    of this title, as the case may be, as calculated and
    adjusted by the Secretary as necessary for purposes
    of this paragraph.
    42 U.S.C. § 1395l(t)(14)(A)(iii). Subparagraph (E) in turn
    authorizes the Secretary to make “adjustment[s] in payment
    rates for overhead costs,” for instance to account for “pharmacy
    services and handling costs,” based on the findings of a 2005
    Medicare Payment Advisory Commission (MedPAC) report.
    Id. § 1395l(t)(14)(E).
    The two subclauses together provide that, if HHS sets
    reimbursements rates based on hospitals’ actual average
    acquisition costs, HHS must consider congressionally specified
    acquisition-cost data. See id. § 1395l(t)(14)(D). And—crucial
    for the challenged differential reimbursement rate for 340B
    hospitals—HHS may only segment reimbursement rates by
    hospital group if it has collected the specified data and set the
    rates keyed to hospital acquisition costs in view of that data.
    3
    The two subclauses operate as alternatives:
    Subclause (I) lays out what the agency may do when it has
    collected and taken into account the “hospital acquisition cost
    survey data under subparagraph (D),” whereas subclause (II)
    lays out what the agency may do “if the hospital acquisition
    cost data are not available.” Id. § 1395l(t)(14)(A)(iii). If the
    agency has that data, it may set reimbursement rates based on
    the “average acquisition cost for the drug for that year,” and
    “vary by hospital group” any reimbursement rates. Id.
    § 1395l(t)(14)(A)(iii)(I). But “if hospital acquisition cost data
    are not available,” id. § 1395l(t)(14)(A)(iii)(II), the agency
    must set reimbursement amounts under subclause (II) by resort
    to what it has previously called the “statutory default” rate for
    a given drug in a given year, see, e.g., 2013 OPPS Rule, 
    77 Fed. Reg. 68,210
    , 68,386 (Nov. 15, 2012). That statutory default
    rate is the drug’s average sales price charged to hospitals,
    clinics, pharmacies, and other providers, drawn from data that
    drug manufacturers submit to HHS every quarter. See 
    id.
    §§ 1395w-3a(c), 1396r-8(b)(3)(A)(iii).          Subclause (II)
    provides for the average sales price to be “adjusted . . . as
    necessary for purposes of this paragraph” but, unlike
    subclause (I), grants no authority to vary the reimbursement
    rates by hospital group. Id. § 1395l(t)(14)(A)(iii)(II).
    As everyone agrees, HHS has never collected the “hospital
    acquisition cost data” that the statute contemplates, so must
    proceed under its subclause (II) authority to set reimbursement
    rates for the 2018 and 2019 OPPS rules. See, e.g., HHS Br. 9;
    2018 Proposed OPPS Rule, 
    82 Fed. Reg. 33,558
    , 33,634
    (proposed July 20, 2017). The question before us is whether
    the agency may set and vary by hospital group SCOD
    reimbursement rates in the manner that subclause (I)
    authorizes, without collecting and considering the data that
    subclause (I) specifies, by invoking its authority under
    subclause (II) to adjust the average-sales-price-based
    4
    reimbursement rate and, in effect, simply deem that to be a rate
    reflecting hospitals’ average acquisition cost. The majority
    concludes that the agency’s circumvention of subclause (I) in
    this manner is a permissible construction of the statute for
    several reasons, none of which I find persuasive.
    First, the majority argues, based primarily on the text of
    subclause (I) and other provisions in the OPPS statute, that
    Congress’ “primary goal is to reimburse providers for their
    acquisition costs.” Maj. Op. at 21.           But the statute’s
    overarching goal is not its only goal, to be achieved however
    the agency sees fit. When it comes to Medicare Part B
    payments for SCODs, paragraph (14) specifically tells us when
    and how Congress intended HHS to pursue acquisition-cost-
    based reimbursement. Only subclause (I), not subclause (II),
    authorizes HHS to set different reimbursement rates for distinct
    hospital groups—rather than a uniform, drug-by-drug “average
    price for the drug in the year,” 42 U.S.C.
    § 1395l(t)(14)(A)(iii)(II)—and to do so only by taking into
    account the different acquisition costs identified in the robust,
    hospital-specific data that Congress required the agency to
    collect.
    The majority finds it inconceivable that Congress would
    require the same sales-price-based reimbursement rate for all
    types of hospitals when hospitals’ acquisition costs vary
    widely. See, e.g., Maj. Op. at 24. But in authorizing the
    average-sales-price methodology, which takes account of most
    discounts and rebates that purchasers receive, Congress was
    attuned to the many factors rendering non-uniform the amounts
    different hospitals actually pay for the same drugs. Given
    Congress’ awareness that various hospitals—not only 340B
    hospitals—pay more or less than others, I see nothing
    inconceivable about Congress requiring disparities in
    reimbursement rates to certain types of hospitals to be
    5
    identified and acted upon based only on the most complete and
    accurate data.
    If Congress wanted HHS, in the absence of subclause (I)’s
    hospital-specific data regarding average acquisition costs, just
    to do its best to approximate those costs and then vary them by
    hospital groups according to its unchecked policy judgment, it
    easily could have written the statute to say so. Instead,
    subclause (II) mandates that the base reimbursement rate “shall
    be equal” to the specified drug’s statutory default rate premised
    on average sales price, subject to adjustments, and entirely
    omits the authority granted in subclause (I) to “vary by hospital
    group” the pricing data or resultant rate.             42 U.S.C.
    § 1395l(t)(14)(A)(iii). I cannot discern in the statute any
    congressional intention that the adjustment authority be used to
    set markedly different prices for different hospital groups. I
    would instead affirm the district court’s conclusion that HHS
    “cannot fundamentally rework the statutory scheme—by
    applying a different methodology than the provision requires—
    to achieve under sub[clause] (II) what [it] could not do under
    sub[clause] (I) for lack of adequate data.” Am. Hosp. Ass’n v.
    Azar, 
    348 F. Supp. 3d 62
    , 82 (D.D.C. 2018).
    Second, the majority reasons that this data-sensitive
    reading of the two subclauses cannot be correct because it
    “renders subclause (II)’s adjustment authority superfluous.”
    Maj. Op. at 24. But the Hospitals’ reading of the subclause (II)
    adjustment authority as primarily cross-referencing
    incremental modifications like the overhead-cost adjustment
    described in subparagraph (E) does not make the former
    altogether redundant.        As the Hospitals explain,
    subparagraph (E) authorized adjustments for overhead with
    reference to a one-time, 2005 MedPAC report, whereas
    subclause (II)’s authority to make “adjust[ments] . . . as
    necessary for purposes of this paragraph,” 42 U.S.C.
    6
    § 1395l(t)(14)(A)(iii)(II), encompasses “adjustments” for
    overhead in the same manner on an ongoing basis. See
    Hospitals Br. 5-6, 49.
    In any event, reading section 1395l(t)(14) to contain
    overlapping references to a limited adjustment authority—
    making “double sure” the point is made—does not create the
    kind of superfluity that renders a statute ambiguous. Mercy
    Hosp., Inc. v. Azar, 
    891 F.3d 1062
    , 1068 (D.C. Cir. 2018)
    (quoting Fla. Health Scis. Ctr., Inc. v. HHS, 
    830 F.3d 515
    , 520
    (D.C. Cir. 2016)). As we have recognized with respect to the
    Medicare statute, a “little overlap, either by accident or design,
    is to be expected in any complex statutory scheme with
    interdependent provisions” and does not alone create
    ambiguity. 
    Id.
     The fact that average price data lumps together
    pharmaceutical sales to hospitals from sales to non-hospital
    providers seems to explain Congress’ clear decision to omit
    from subclause (II) the authority in subclause (I) to vary
    reimbursement by hospital group. Without subclause (I)’s
    hospital-specific cost data, billion-dollar decisions
    differentiating among particular hospital groups could rest on
    significantly less exact information.
    Moreover, to the extent that past agency practice bears on
    the question of statutory construction before us, it only
    confirms the Hospitals’ reading that the agency’s
    subclause (II) adjustment authority references overhead
    adjustments like those contemplated by subparagraph (E). As
    the agency described at length in 2012, during the preceding
    six years HHS had made no adjustments to its estimate of
    average sales prices other than occasional small tweaks to
    account for overhead costs (and, in any case, purported to rely
    only on its subclause (I) authority). See 2013 OPPS Rule, 77
    Fed. Reg. at 68,383-86 (explaining the agency’s methodology
    year by year over this period); see also 2016 OPPS Rule, 80
    
    7 Fed. Reg. 70,298
    , 70,439 (Nov. 13, 2015) (providing a similar
    summary of the agency’s past methodology); Hospitals Br. 49
    (“[W]hen HHS previously made adjustments to the ASP-plus-
    6% rate, it explained at the time that it was doing so to account
    for estimates of overhead.”). Indeed, the focus of the agency
    in those years was on collecting more accurate overhead-cost
    data to better tailor its adjustments. See, e.g., 2013 OPPS Rule,
    77 Fed. Reg. at 68,385. And, in the five years before the two
    challenged rules at issue, the agency simply adopted the
    statutory default rate of 106% of the average sales price under
    subclause (II) without making any adjustments at all. See 2018
    OPPS Rule, 
    82 Fed. Reg. 52,362
    , 52,490 (Nov. 13, 2017).
    In sum, at no point in any of the materials that the majority
    cites—and at no point of which I am aware—has HHS ever
    previously used its subclause (II) adjustment authority to make
    adjustments that are not modest changes to account for
    overhead. HHS itself has not claimed otherwise in its briefing
    before us. And HHS certainly has never used that adjustment
    authority to implement variations by hospital group. See, e.g.,
    HHS Br. 13 (“The final rule for 2018 established a new sub-
    classification for drugs purchased by 340B providers . . . .”
    (emphasis added)).
    The Hospitals’ limited reading of the adjustment authority
    that subclause (II) confers is supported by our previous caution
    that the term “adjustment” in this statute—like the term
    “modify” at issue in MCI Telecommunications Corp. v. AT&T
    Co., 
    512 U.S. 218
    , 225 (1994), which the Court held “means to
    change moderately or in minor fashion”—cannot permit “basic
    and fundamental changes in the scheme.” Amgen, Inc. v.
    Smith, 
    357 F.3d 103
    , 117 (D.C. Cir. 2004) (quoting MCI,
    
    512 U.S. at 225
    ). The majority distinguishes Amgen by
    quoting our observation there that we had “no occasion to
    engage in line drawing to determine when ‘adjustments’ cease
    8
    being ‘adjustments.’” 
    Id.
     But that observation made eminent
    sense in a dispute “involving only the payment amount for a
    single drug,” and we went on to warn that a “more substantial
    departure from the default amounts would, at some point,
    violate the Secretary’s obligation to make such payments and
    cease to be an ‘adjustment.’” 
    Id.
     (alteration omitted). Given
    the scale and segmentation of the rate cut at issue—reducing
    SCOD reimbursements by nearly a third, thereby eliminating
    $1.6 billion annually in reimbursements to many of the most
    financially vulnerable hospitals in the Medicare program—I
    disagree that, “[e]ven if there are limits to what HHS could
    permissibly consider an ‘adjustment,’ that line has not been
    crossed here.” Maj. Op. at 29.
    Not only is the majority wrong to reject the Hospitals’
    reading as creating unexplained surplusage, see Maj. Op.
    at 24-27, but the superfluity concerns cut decisively the other
    way. As discussed above, the majority essentially reads
    subclause (I) out of the statute by permitting the agency to do
    under subclause (II) without the requisite data what
    subclause (I) authorizes only with that data. The majority also
    renders superfluous the entirety of subparagraph (D). See
    42 U.S.C. § 1395l(t)(14)(D). That subparagraph, occupying
    nearly a full column in the U.S. Code, specifies in detail how
    the “[a]cquisition cost survey for hospital outpatient drugs” is
    to be conducted, first by the Government Accountability Office
    (GAO) and later by HHS, after that agency has “tak[en] into
    account” the Comptroller General’s “recommendations” as to
    the “frequency and methodology of subsequent surveys.” Id.
    § 1395l(t)(14)(D)(i)-(ii). Subparagraph (D) further includes a
    provision dealing with “survey requirements,” mandating that
    the GAO and HHS surveys “shall have a large sample of
    hospitals that is sufficient to generate a statistically significant
    estimate of the average hospital acquisition cost for each
    specified covered outpatient drug.” Id. § 1395l(t)(14)(D)(iii).
    9
    And a later clause details how acquisition-cost variations by
    hospital group are to be identified in GAO’s initial surveys if
    they are to justify reimbursement-rate variations, noting that
    the Comptroller General “shall determine and report to
    Congress if there is (and the extent of any) variation in hospital
    acquisition costs for drugs among hospitals based on the
    volume of covered [outpatient department] services performed
    by such hospitals or other relevant characteristics of such
    hospitals (as defined by the Comptroller General).” Id.
    § 1395l(t)(14)(D)(iv).
    The majority’s reading drains each of these provisions of
    meaning.      It allows the agency simply to purport to
    approximate hospital acquisition costs, and to claim authority
    to vary reimbursement rates by hospital group, based on
    adjusted average price data that HHS recasts as acquisition cost
    data, but that lacks the characteristics and process of collection
    that Congress specified in subclause (I). The Hospitals’
    reading does give distinct meaning to subclause (II)’s
    allowance for adjustment; it is the majority’s reading that
    occasions significant superfluity without regard to Congress’
    structural decision to make subclauses (I) and (II) distinct
    alternatives.
    Finally, the majority repeatedly justifies its reading by
    reference to the policy benefits of the agency’s rate reductions
    and the reasonableness of the agency’s alternative data and
    resulting estimates. See, e.g., Maj. Op. at 18, 20, 22, 24, 27-28.
    The majority views it as relevant “backdrop,” for example, that
    one result of the agency’s proposed cuts will be to lower
    copayments for Medicare beneficiaries served by 340B
    hospitals, and to avoid the prospect of any beneficiary possibly
    paying more in a copayment than the hospital paid to buy the
    prescribed drugs. Id. at 20; but see HHS Off. of Inspector Gen.,
    OEI-12-14-00030, Part B Payments for 340B-Purchased
    10
    Drugs 9 n.26 (Nov. 2015) (OIG Report) (noting that 340B
    hospitals “may waive all or part of the beneficiary’s
    coinsurance”). And the majority notes HHS’s worries that
    340B hospitals might overprescribe drugs that bring
    reimbursement revenue. See Maj. Op. at 7; but see U.S. Gov’t
    Accountability Off., GAO-15-442, Medicare Part B Drugs:
    Action Needed to Reduce Financial Incentives to Prescribe
    340B Drugs at Participating Hospitals 31 (June 2015) (noting
    HHS’s view that “higher spending for Part B drugs at 340B
    hospitals” might “lead to better clinical outcomes” for patients
    served by those safety-net hospitals, who often are in
    “meaningful[ly]” poorer health than other patients). The
    majority also expresses confidence that the agency examined
    “data of undisputed reliability,” Maj. Op. at 28, “acted on that
    data in a cautious way,” id., and implemented a “fair, or even
    conservative, measure of the reduction needed to bring
    payments to those hospitals in parity with their costs to obtain
    the drugs,” id. at 20. “In those circumstances,” the majority
    declares, “HHS reasonably concluded that it need not continue
    subsidizing 340B providers with Part B (i.e. taxpayer) funds
    and Medicare beneficiaries’ copayments.” Id. at 28.
    Those circumstances would perhaps be relevant were this
    a challenge to the agency’s rules as arbitrary and capricious.
    But concerns about the program’s effects, and confidence in
    the agency’s care in using data other than those the statute
    requires, cannot somehow authorize the agency to do what the
    statute does not. As the Supreme Court has held, an “agency
    has no power to ‘tailor’ legislation to bureaucratic policy goals
    by rewriting unambiguous statutory terms.”              Util. Air
    Regulatory Grp v. EPA, 
    573 U.S. 302
    , 325 (2014). And,
    unmoored from the statute’s express data-quality requirements,
    the asserted reliability of the quite different data HHS gathered
    here provides no assurance for its next rulemaking. Whether
    HHS’s actions might have perceptible policy advantages does
    11
    not affect whether the statute authorizes what the agency has
    done.
    It bears noting that, even were they relevant, the claimed
    policy benefits of the agency’s new rate reductions are far from
    clear. The Section 340B drug discount program, enacted in
    1992 as part of the Public Health Service Act, see 42 U.S.C.
    § 256b, permits 340B hospitals to “generate revenue” through
    “insurance reimbursement[] that may exceed the 340B price
    paid for the drugs.”         U.S. Gov’t Accountability Off.,
    GAO-11-836, Manufacturer Discounts in the 340B Program
    Offer Benefits, But Federal Oversight Needs Improvement 2
    (2011) (GAO Report). As HHS itself has recognized, Congress
    anticipated that such above-cost reimbursement revenue would
    help to fund the public and nonprofit safety-net hospitals that
    qualify for 340B pricing: “Under the design of the 340B
    Program and Part B payment rules, the difference between
    what Medicare pays and what it costs to acquire the drugs is
    fully retained by the participating covered entities, allowing
    them to stretch scarce Federal dollars in service to their
    communities.” OIG Report i (Executive Summary); see also
    HHS Off. of Inspector Gen. Memorandum Report: Payment for
    Drugs Under the Hospital Outpatient Prospective Payment
    System 8 (Oct. 22, 2010) (describing above-cost SCOD
    reimbursements to 340B hospitals as “an expected result given
    the purpose of the 340B Program”).
    The challenged rules took a major bite out of 340B
    hospitals’ funding. Often operating at substantial losses, 340B
    hospitals rely on the revenue that Medicare Part B provides in
    the form of standard drug-reimbursement payments that exceed
    those hospitals’ acquisition costs. 340B hospitals “have used
    the additional resources to provide critical healthcare services
    to communities with underserved populations that could not
    otherwise afford these services.” Hospitals Br. 9 (citing GAO
    12
    Report at 17-18); see also Cares Cmty. Health v. HHS,
    
    944 F.3d 950
    , 955 (D.C. Cir. 2019). Although stakeholders
    have debated “whether statutory changes should be made to
    enable Medicare and/or Medicaid to share in these savings,”
    OIG Report 2, Congress has not made any such change. And,
    as written, subparagraph (E) does not empower the Secretary
    to “adjust” away from 340B hospitals substantial annual
    revenue they garner under the separate, unchallenged 340B
    statute to provide care to underserved communities.
    The net effect of HHS’s 2018 and 2019 OPPS rules is to
    redistribute funds from financially strapped, public and
    nonprofit safety-net hospitals serving vulnerable populations—
    including patients without any insurance at all—to facilities
    and individuals who are relatively better off. If that is a result
    that Congress intended to authorize, it remains free to say so.
    But because the statute as it is written does not permit the
    challenged rate reductions, I respectfully dissent.