Full opinion text
TABLE OF CONTENTS I. INTRODUCTION..................... 886 II. THE PARTIES..........................................................886 III. THE FEDERAL MEDICAID PROGRAM.................................887 IV. THE NEW JERSEY MEDICAID REIMBURSEMENT SYSTEM...........888 A. GENERAL CONSIDERATIONS ......................'...............888 B. CALCULATION OF NURSING PAYMENTS.........................891 C. ADVISORY STANDARDS FOR NURSE STAFFING..................892 D. INFLATION ADJUSTMENTS.......................................893 V. PRELIMINARY INJUNCTION STANDARDS.............................893 VI. PROCEDURAL COMPLIANCE WITH THE BOREN AMENDMENT ......893 A. THE PROCEDURAL LAW.....:........!...........................893 B. THE FINDINGS REQUIREMENT...................................895 C. THE ADEQUACY OF NEW JERSEY’S PROCEDURE................895 VII. SUBSTANTIVE COMPLIANCE WITH THE BOREN AMENDMENT......898 A. THE SUBSTANTIVE CHALLENGE........................•.........898 B. THE EXPERTS AND THEIR ROLES...............................898 C. PRESUMPTION OF VALIDITY.....................................899 D. COST-RATE ANALYSIS............................................899 E. INDIVIDUAL COMPONENTS OF NEW JERSEY’S PLAN ...........907 i. NURSE STAFFING ANALYSIS.................................907 ii. CONTRACT NURSING COSTS..................................913 in. INFLATION ADJUSTMENTS...................................914 iv. GEOGRAPHICAL WAGE EQUALIZATION . i....................916 VIII. IRREPARABLE HARM..................................................917 A. THE LEGAL STANDARDS ..............■...........................917 B. PLAINTIFFS’ALLEGATIONS OF IRREPARABLE HARM...........917 C. ELEVENTH AMENDMENT CONSIDERATIONS.....................927 IX. BALANCING OF HARDSHIPS AND THE PUBLIC INTEREST ..........928 X. CONCLUSION..........................................................929 OPINION RE DENIAL OF PRELIMINARY INJUNCTION LIFLAND, District Judge. I.INTRODUCTION 1. Plaintiffs bring this action under 42 U.S.C. § 1983, alleging that defendants have deprived plaintiffs of rights secured under Title XIX of the Social Security Act, 42 U.S.C. § 1396 el seq. (commonly referred to as the “Medicaid program”). Specifically, plaintiffs allege that defendants’ Medicaid payment rates are not “reasonable and adequate to meet the costs which must be incurred by efficiently and economically operated facilities in order to ... provide care and services in conformity with applicable State and Federal laws, regulations,' and quality and safety standards----” 42 U.S.C. § 1396a(a)(13)(A) "(commonly referred to as the “Boren Amendment”); Complaint at ¶ 3. Plaintiffs also allege that defendants have failed to follow certain procedures required by the Boren Amendment. This Court has jurisdiction over plaintiffs’ claims pursuant to 28 U.S.C. § 1331. 2. Plaintiffs filed a motion for a preliminary injunction, seeking the following specific relief: (a) adjustment of the method for calculating reimbursement for nursing costs; (b) inclusion of the costs of contract nursing in the calculation of the limit on nursing costs; (c) modification of the State’s salary region groupings; (d) use of a different inflation index in calculating rates; and- (e) reimbursement of all allowable costs for all facilities that fall below the statewide median for such costs. 3. The evidentiary record on the pending motion is extensive. Plaintiffs filed affidavits from representatives of each of the named plaintiff facilities as well as an affidavit from their expert witness, Dr. Barbara Manard (“Dr. Manard”), which was accompanied by a lengthy report prepared by Dr. Manard (“Manard Report”). Defendants filed declarations from Saul Kilstein (“Kilstein”), the Director of the New Jersey Division of Medical Assistance and Health Services (“DMAHS”), the division of the New Jersey Department of Human Services responsible for administering and developing policy for the Medicaid program, Ann Kohler (“Kohler”), the Assistant Director of DMAHS, and defendants’ expert witness, Dr. Gretchen Engquist (“Dr. Engquist”). These affidavits and declarations were accompanied by numerous exhibits. The lengthy depositions of both experts and the representatives of the named plaintiffs were also filed as part of the record. A six-day hearing on the preliminary injunction motion was held at which the two experts testified and presented additional exhibits. The parties have also provided the Court with oral argument, extensive briefing and supplemental correspondence relating to relevant cases decided subsequent to oral argument. On the basis of this entire record, the Court finds that the plaintiffs are not entitled to a preliminary injunction. II. THE PARTIES 4.The named plaintiffs in this class action are two non-profit associations of nursing facilities and four individual facilities. Three of the named plaintiff facilities are non-profit facilities: Greenwood House Home for the Jewish Aged, Inc. (“Greenwood House”); Presbyterian Homes of Northern New Jersey, Inc., d/b/a Robert Wood Johnson, Jr. (“Robert Wood Johnson”); and Mega Health Care Center, Inc., d/b/a Llanfair House (“Llanfair House”). The fourth facility, Holiday Medical Center, d/b/a Medicenter of Lakewood (“Medicenter”), is a for-profit facility. The proportion of for-profit and non-profit facilities among the named plaintiffs is not reflective of the industry as a whole; approximately two-thirds of New Jersey nursing homes are for-profit and one-third are non-profit. Hearing Transcript (“Tr.”) at 3.84-3.85. Defendant Alan J. Gibbs (“Gibbs”) was the Commissioner of the New Jersey Department of Human Services (“DHS”), the state agency designated pursuant to 42 U.S.C. § 1396a(a)(5) to administer the Medicaid program in New Jersey and the agency which enters into agreements with individual nursing facilities for. the provision of services to Medicaid patients. Complaint at ¶ 15. Defendant Kilstein is the. Director of DHS, which has day-to-day responsibility for administering New Jersey’s Medicaid program. Id. at ¶ 16. Defendants are responsible for assuring compliance by DHS with state and federal law. Id. at ¶¶ 15-16. By Memorandum and Order dated March II, 1991, the Court granted plaintiffs’ motion for class certification under Fed.R.Civ.P. 23(a) and 23(b)(2). The class is comprised of all proprietary and not-for-profit nursing facilities which render care to beneficiaries of the New Jersey Medicaid program. ■ III. THE FEDERAL MEDICAID PROGRAM 5. The Medicaid program is a joint federal-state program designed to provide medical assistance to individuals “whose income and resources are insufficient to meet the cost of necessary medical services.” 42 U.S.C. § 1396. Although a state is not required to participate in the program, once a state has been accepted into the program it must comply with the Medicaid statute and federal regulations. Harris v. McRae, 448 U.S. 297, 301, 100 S.Ct. 2671, 2679, 65 L.Ed.2d 784 (1980). 6.Payment rates for nursing facilities are governed by an amendment to the Medicaid Act known as the Boren Amendment. Enacted as part of the Omnibus Budget Reconciliation Act of 1980 (“OBRA ’80”), Pub.L. No. 96^99, § 962(a), 94 Stat. 2599, 2650 (1980), the Amendment requires that states pay rates: which the State finds, and makes assurances satisfactory to the Secretary [of the Department of Health and Human Services], are reasonable and adequate to meet the costs which must be incurred by efficiently and economically operated, facilities in order to provide care and services in conformity with applicable State and Federal law, regulations, and quality and safety standards____ 42 U.S.C. § 1396a(a)(13)(A). 7. In 1987, as part of the Omnibus Budget Reconciliation Act of 1987 (“OBRA ’87”), Congress enacted extensive nursing home reform legislation. Pub.L. No. 100-203, § 4211, 101 Stat. 1330-186. OBRA ’87 mandated that nursing facilities meet numerous requirements relating to patient care, staffing levels and training, facility administration, resident assessment and related plans for care, and residents’ rights generally. All of these requirements were designed “to attain or maintain the highest practicable level of physical, mental and psychosocial well-being of each resident.” Id., § 4211(a), 100 Stat. 1330-185. States were required to bring their Medicaid programs into compliance with these new requirements no later than October 1, 1990. 42 U.S.C. § 1396r. 8. OBRA ’87 also amended the Boren Amendment to require that reimbursement rates for nursing facilities, take into account the costs of complying with the specific new staffing and service provisions established by OBRA ’87. Pub.L. No. 100-203, § 4211(b)(l)(AL.), 100 Stat. 1330-203 (1987). 9. In the Omnibus Budget and Reconciliation Act of 1990 (“OBRA ’90”), Congress amended the 1987 amendment to the Boren Amendment to specify that states include “the costs of services required to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each Medicaid resident” when taking into account the costs of complying with OBRA ’87. Pub.L. No. 101-508, § 4801(e)(1)(A), 104 Stat. 1388-215 (1990). With the addition of the 1987 and 1990 amendments, the Boren Amendment now reads: [A] State plan for medical assistance must provide for payment ... of the hospital services, nursing facility services, and services in an intermediate care facility for the mentally retarded provided under the plan through the use of rates (determined in accordance with methods and standards developed by the State) which, in the case of nursing facilities, take into account the costs (including the costs of services required to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident eligible for benefits under this title) of complying with subsections (b), (c) and (d) of section 1919 [the nursing home reform provisions of OBRA-87] ... which the State finds, and makes assurances satisfactory to the Secretary, are reasonable and adequate to meet the costs which must be incurred by efficiently and economically operated facilities in order to provide care and services in conformity with applicable State and Federal laws, regulations, and quality and safety standards____ 42 U.S.C. § 1396a(a)(13)(A). 10. The Secretary of Health and Human Services has delegated responsibility for administering the Medicaid program to the Health Care Financing Administration (“HCFA”). Under HCFA regulations, and consistent with the Medicaid statute, states wishing to participate in the Medicaid program must submit a “state plan” describing the “methods and standards” by which providers of Medicaid services will be reimbursed. 42 C.F.R. § 447.252(b). 11. In order to receive approval for a state plan, or a change in payment methods and standards, states must submit certain assurances to HCFA. These assurances must be supported by “findings,” which need not be submitted to HCFA. However, findings must be made whenever a state changes its methods and standards, and not less often than annually. 42 C.F.R. § 447.253(b). The required finding at issue in this case is' one that closely tracks the substantive standard of the Boren Amendment: that payment rates “are reasonable and adequate to meet the costs that must be incurred by efficiently and economically operated providers to provide services in conformity with applicable State and Federal laws, regulations, and quality and safety standards.” 42 C.F.R. § 447.253(b)(1). 12. OBRA ’87 required each state to submit a Medicaid plan amendment no later than April 1, 1990 “to provide for an appropriate adjustment in payment amounts” for services which were required under that statute to be furnished after October 1, 1990. Pub.L. No. 100-203, § 4211(b)(2), 100 Stat. •1330-203 (1987). With respect to the plan amendments required by OBRA ’87, the Secretary of Health and Human Services was required “to review” each state’s OBRA ’87 amendment “for compliance” with the requirements of the Boren Amendment, as amended by OBRA ’87, and to approve or disapprove the amendment by September 30, 1990. Id. at 1330-203-204. IV. THE NEW JERSEY MEDICAID REIMBURSEMENT SYSTEM A. GENERAL CONSIDERATIONS 13. Reimbursement rates for nursing facilities in New Jersey are set using a methodology known as the Cost Accounting and Rate Evaluation (“CARE”) system. Kilstein Decl. at ¶8. The CARE methodology is codified at N.J.A.C. § 10:63-3.1 et seq. The CARE system is a prospective system, which means that rates are determined in advance of the rate year in which costs are actually incurred. If an individual facility’s costs exceed its prospective rate, the facility must absorb the difference; on the other hand, if the facility maintains its costs below its reimbursement rate, it may keep the difference. 14. Under the CARE system, reimbursement rates are recalculated annually on the basis of each facility’s prior year costs. Kilstein Decl. at ¶14. Facilities must submit cost reports to the Health Facilities Rate Setting Unit of the New Jersey Department of Health within 90 days of the close of their individual fiscal years. The period for which costs are reported is known as the facility’s “base period.” Base period costs are used in establishing the prospective per diem rates for each facility for the year beginning six months after the end of each facility’s base period. N.J.A.C. § 10:63-3.1(a). The six-month gap between the end of the base year and the beginning'of the rate year is neeessary to compile the cost reports, process them and calculate the rates. Tr. at 1.48. For most facilities in New Jersey, the report year is the calendar year, id., and the rate year therefore runs from July 1 to June 30. 15. Cost reports are subjected to a “desk review,” a process during which adjustments are made for arithmetical errors, for reclassification of costs from one category to another, or for costs which are clearly unallowable. Tr. at 1.46. The desk review is not designed to remove all costs that might be disallowed in the course of a full field audit. Tr. at 1.106, 3.6, 4.86-4.87; Engquist Written Testimony at ¶ 11. 16. Following the desk review, adjusted data on the cost reports are entered into a computer system known as “CSNURSE;” the CSNURSE system is used to analyze reported costs and calculate limits or screens on the reported base period costs. Tr. at , 1.106, 5.7. 17. The CARE system recognizes two broad categories of costs: operating costs and capital costs. Operating costs are reported in 16 separate cost categories. The 16 operating cost categories consist of the following: raw food, non-food general services, legal fees, administrator/managemerit, assistant administrator, utilities, property insurance, maintenance and replacement, nursing compensation, medical director, patient activities, pharmaceutical consultant, non-legend drugs, medical supplies, social services, and oxygen. N.J.A.C. § 10:63-3.1 et seq. Limits or “screens” for 10 of the 16 operating cost categories are set at the median cost plus a certain percentage above the median. Kohler Decl. at ¶ 11. The median is defined as that level at which half of the facilities have costs that are higher than the median and half have costs that are lower. Tr. at 1.57. The percentage of the median used to calculate the limit ranges from 110% to 150%, depending upon the cost category. The percentages used for those cost areas where the screen is established solely by a percentage of the median are: assistant administrator (125%); raw food (120%); nonfood general services (105%); medical director (110%); medical supplies (150%); patient activities (150%); social services (110%); non-legend drugs (110%); pharmacy consultant (110%); and oxygen (110%). N.J.A.C. § 10:63-3.1 et seq. Limits established using the median are recalculated each year based on the facilities’ prior year costs. Kilstein Decl. at ¶ 14; Tr. at 4.36-4.37. 18. In certain cost categories, the State combines the use of a median vrith other factors in calculating the reasonableness limits. Kilstein at ¶ 16. One such category of particular importance in this case is the nursing cost category, which is discussed in greater detail below. 19. Capital costs are reimbursed by means of a Capital Facilities Allowance (“CFA”). This payment is designed to reimburse facilities for such non-operating capital costs as depreciation, interest or indebtedness, amortization of leasehold improvements, return on equity, and other costs associated with construction, purchase, alteration or leasing of property, buildings, and fixed equipment. Kilstein Decl. at ¶ 32. In contrast to reimbursement for operating costs, the CFA is not calculated on the basis of annually reported costs but rather on the basis of the appraised value of the facility at the time the CARE system was implemented, or in the case of new Medicaid facilities, at the time of the facility’s initial Medicaid certification. Kilstein Decl. at ¶33. 20. Facilities report depreciation costs even though such costs are not used in calculating the CFA. Double reporting of depreciation costs can occur if a facility includes as a depreciation expense a cost previously reported as a maintenance and replacement cost. Kilstein Decl. at ¶ 36. 21. The State makes several adjustments, to reported costs before applying the reasonableness limits. Because of the 18-month lag between the commencement of the report year and the beginning of the rate year, the State adjusts the screened base period operating costs to account for inflation. Kilstein Decl. at ¶14. New Jersey’s inflation factor has two components: (a) the average hourly earnings of manufacturing employees in New Jersey, which comprises approximately 60% of the factor; and (b) the Consumer Price Index, which accounts for the remaining 40%. N.J.A.C. § 10:63-3.18. 22. The State also makes adjustments in reported salaries in certain operating cost areas to reflect geographical wage differences. Kilstein Decl. at ¶ 27. In connection with these adjustments, the State has been divided into three salary regions — high, medium and low. Salary costs reported by the facilities are adjusted on the basis of an equalization factor determined by comparing the median salaries for nurses and general services personnel, excluding administrative employees, in each region to the median salaries for each geographical region.. Kilstein Decl. at ¶¶ 28-29. 23. Under the CARE system, facilities receive, in addition to a per diem rate based on reported Medicaid patient days, payments for “bed-hold.” These are full per diem payments made to facilities to reserve a bed for up to 10 days for a Medicaid patient who is temporarily transferred to a hospital. Bed-hold payments increase facility revenue by an amount roughly equal to 2% of total reported patient days. Kohler Decl. at' ¶ 30; Engquist Decl. at ¶ 18. 24. Facilities that incur higher costs because of unique needs can increase their level of reimbursement by applying for a “Schedule C” adjustment. Such adjustments are made to the cost data submitted by facilities that expect to incur increased costs in the prospective year in order to meet new legal requirements or to improve quality of care. Facilities that can demonstrate that their rates are inequitable or inadequate because of unique circumstances may also request a “hardship adjustment.” Kilstein Decl. at ¶ 38. 25. The State’s screen on nursing costs, which is central to this dispute has three components: (a) a median wage standard; (b) an hourly component; and (c) a 115% enhancement factor. The median wage standard is determined by adjusting the statewide median wages for nursing personnel to account for geographic variations in wages. See N.J.A.C. § 10:63-3.3(a)(l)-(8). Wages are equalized for each of three categories of nursing staff: registered nurses (“RNs”), licensed practical nurses (“LPNs”) and nurse aides. The hourly standard is based on mandatory licensure standards for nursing facilities as established by the New Jersey Department of Health (“DOH”). The 115% enhancement factor is designed to permit flexibility in staffing patterns. N.J.A.C. § 10:63-3.8(b)(6); Kilstein Decl. at ¶¶ 17-18. 26.In 1990, after several years of study and deliberation in which the nursing home industry participated, the DOH implemented new nurse staffing requirements which generally increased the number of hours of nursing care required in order for facilities to be licensed by the State. The new licensure standards- require an average of 2.5 hours of nursing care per day for each patient. The new regulations also require that 20% of the required nursing hours be provided by LPNs or RNs, with the remaining 80% of nursing time provided by nurse aides. Defs.Exh. 2 at 323. Supplemental nursing hours are added for patients with one or more of seven special conditions known as “acuities.” The additional nursing time ranges anywhere from .75 to 1.5 hours, depending on the severity of the condition. Kilstein Decl. at ¶21. Patients with more than one acuity receive cumulative additional hours of care for each acuity suffered. Kilstein Decl. at ¶ 21; Defs.Exh. 2 at 333. The supplemental acuity hours are revised every six months to reflect changes in patient needs. Kilstein Decl. at ¶ 22; Tr. at 5.48. Because the new DOH licensure standards generally increased the number of nursing hours required of facilities, they also caused DMAHS to change its reimbursement formula so that facilities would be reimbursed for those additional required nursing hours, effective October 1, 1990. 27. As noted above, OBRA ’87 required states to submit by April 1, 1990 a plan amendment demonstrating adequate reimbursement for compliance with that statute’s new patient care standards. This requirement coincided with implementation by the New Jersey Department of Health of the new mandatory nursing facility licensure standards and the corresponding change in the reimbursement formula. Accordingly, on March 30, 1990, the State submitted written assurances and related information concerning the adequacy of the rates that would result under the revised CARE methodology. Kilstein Decl. at ¶ 10; Defs.Exh. 2. HCFA approved the new plan on September 13, 1990. Kilstein Decl. at ¶ 10; Defs.Exh. 3. Rates calculated under the new system went into effect October 1, 1990. Kohler Decl. at ¶ 7. The change in the hourly standard for calculating nursing reimbursement increased the aggregate annual reimbursement by $14 million. Id. B. CALCULATION OF NURSING PAYMENTS 28. In New Jersey, the nursing cost component accounts for approximately 40% of nursing facility costs. Tr. at 2.4. 29. Unlike most of the other components of its payment system, DHS does not establish a single limit on nursing costs based upon a facility’s total nursing costs per patient per day. Rather, DHS applies a series of limits in calculating the maximum payments for nursing services. Tr. at 1.73-1.75. Specifically, there are limits on (i) the maximum number of hours that will be reimbursed, (ii) the proportion of professional or skilled nursing time that will be recognized within the maximum hours reimbursed, (iii) the wage levels that will be recognized for each hour reimbursed, (iv) the categories of wages that will be recognized in computing the wage limits, and (v) the recognition of costs incurred by a facility employing the mandated director of nursing. Id. 30. The first limit, i.e., maximum hours reimbursed, uses the minimum hours required to maintain facility licensure in the state as promulgated by DOH. N.J.A.C. § 10:63 — 3.8(b); Tr. at 1.73-1.74. Specifically, DOH has established a minimum of 2.5 nursing hours per day for each patient in a nursing facility, N.J.A.C. § 8:39 — 25.2(b), with additional hours allotted for acuities. Tr. at 1.76-1.77. Thus, under the first limit, DHS determines a facility’s maximum reimbursable hours by multiplying the number of Medicaid patients by 2.5 and adding the additional hours for acuities. After adding the hours for the acuities, maximum reimbursable hours of nursing care per patient per day are about 2.63. Pl.Ex. 40 (Table 22); Tr. at 1.78. 31. While DHS directly reimburses a maximum of approximately 2.63 hours per patient per day, nursing facilities in New Jersey provide an average of approximately 3.0 hours per patient per day. Pl.Ex. 40 (Table 22); Tr. at 2.6. 32. Under the second limit, the maximum hours of care that DHS will reimburse are divided by staff category. Under the DOH licensure regulations, 20% of the hours must be provided by professional, licensed personnel, i.e., RNs and LPNs, and the remaining 80% may be provided by nurse aides. See N.J.A.C. § 8:39 — 25.2(f); Tr. at 1.74. As with total hours, DHS uses these staffing requirements as a ceiling. Tr. at 1.73-1.74. For example, for a patient with no .acuities, DHS will recognize a maximum of 2.5 hours of care, with a maximum of 20% of that care, or 30 minutes, provided by licensed personnel. 33. The DOH licensure regulations also require that facilities with more than 150 beds must have at least one RN on duty at all , times, whereas facilities with fewer than 150 beds need only have an RN on duty for one eight-hour shift per day. N.J.A.C. § 8:39-25.2(e). DHS likewise uses these requirements as a ceiling on reimbursable RN hours. 34. On average, the combined effect of these staffing ceilings is that maximum reimbursement for nursing, including acuities, is based on the following staffing pattern: RN (.13 hours); LPN (.40 hours); nurse aide (2.10 hours). Pl.Ex. 40 (Table 22). The aetual staffing patterns of facilities in New Jersey are as follows: RN (.50 hours); LPN (.45 hours); nurse aide (1.99 hours). Id. 35. The third limit is the hourly wage rate for each staff category. Determination of this limit begins with a calculation of the median wage for such staff category. This figure, as adjusted, is multiplied by 115% to establish the hourly wage rate limit for each staff category. N.J.A.C. § 10:63-3.8(b)6. This amount is further adjusted to account for the salary differential for the geographic region in which' the facility is located. N.J.A.C. § 10:63-3.8(b)4. The resulting hourly wage rate in each staff category is multiplied by the maximum nursing hours in that category. The sum of the amounts for each category represents the screen. A facility’s' payment for nursing services is based on the lower of its actual nursing costs or the screen. 36. The fourth limitation pertains to the treatment of nursing labor obtained on a contract basis. Because of nurse shortages and other factors, facilities periodically obtain nursing services on a contract basis from nursing agencies or “pools” in order to maintain adequate staffing. Lewin/ICF Report at 34-39; Tr. at 1.74. The cost of such contracted labor significantly exceeds the wages paid to salaried staff. Id. In calculating the hourly wage rate screen, DHS does not include the hourly amounts reported by facilities for labor obtained on a contract basis from nurse staffing agencies. Tr. at 1.74. DHS does reimburse for contract nursing costs, but the lower rate applicable to salaried nurses. 37. The fifth limitation relates to the costs incurred by a facility in employing a director of nursing. Under DOH regulations, all facilities must have a director of nursing. N.J.A.C. § 8:39-25.1(a). In addition, the State requires that facilities with 150 or more licensed beds have an assistant director of nursing who is an RN. N.J.A.C. § 8:39-25.2(c). As the role of the director of nursing is supervisory, see N.J.A.C. § 8:39-25.1, most directors of nursing have only limited direct patient care responsibility. Tr. at 5.17. While facilities are required to have a director of nursing, there is nothing in the calculation of the nursing screen that directly reflects the non-patient care portion of this cost. Tr. at 1.75. Accordingly, the computation of maximum reimbursable hours under the nursing screen does not account for the mandatory, or non-patient care, duties performed by the director of nursing. Id. Based on the five limitations applied to the nursing cost center, plaintiffs assert that only 20-35% of facilities receive payments for nursing services that are adequate to cover their nursing services costs. See, e.g., Pl.Ex. 6 (Part III, Section 3c, Table 1); Defendants’ Exhibit (“Def.Ex.”) 11; Tr. at 5.48-5.49; Lewin/ICF Report at 58. C. THE ADVISORY STANDARDS FOR NURSE STAFFING 38.In addition to the minimum hours required for licensure, the DOH regulations also contain “Advisory Standards” for nurse staffing. N.J.A.C. § 8:39-26.1 et seq. The preamble to the proposed DOH staffing regulations identified the Advisory Standards as a “major innovation of licensure reform.” 20 N.J.R. 469(a), 470 (1988). The standards “are intended to ..'. [ejncourage facilities and their staff to do more than merely meet minimal standards in providing care to patients.” Id. While the Advisory Standards for nursing contain several elements, as a general matter, nursing hours per patient per day are 10% higher than under the minimum standards (i.e., 2.75 hours v. 2.5) and assign a higher proportion of that time to licensed nursing personnel (i.e., 30% v. 20%). Under the Advisory Standards, a patient would receive at least 50 minutes per day of professional nursing time as opposed to the 30 minutes provided under the minimum standards. The “unit staffing” Advisory Standard would further increase the recommended amount of professional nursing time. See N.J.A.C. § 8:39-26.3(e). Facilities in New Jersey on average provide about 59 minutes of professional nursing time per patient per day. Pl.Ex. 40 (Table 22). D. INFLATION ADJUSTMENTS 39. DHS uses an inflation factor to adjust the prospective rates (excluding certain capital items) from the midpoint of the base (cost reporting) period to the midpoint of the rate year. The inflation factor used by the State is based upon a weighted calculation of two indices: (1) Average hourly earnings of manufacturing employees in New Jersey as published by the Bureau of Labor Statistics (weighted'at 60%); and (2) The Consumer Price Index as published by the Bureau of Labor Statistics (weighted at 40%). • N.J.A.C. § 10:63-3.18; see generally Manard Affidavit at ¶¶ 1-5. V. PRELIMINARY INJUNCTION STANDARDS 40. Under relevant Third Circuit precedent, a district court must consider four factors in ruling on a motion for preliminary injunctive relief. Initially, “the moving party must demonstrate both a likelihood of success on the merits and the probability of irreparable harm if relief is not granted.” Morton v. Beyer, 822 F.2d 364, 367 (3d Cir.1987) (emphasis in original). In addition, when relevant, the Court should consider the possibility of harm to other interested persons from the grant or denial of the injunction and the public interest. Id.;. Hoxworth v. Blinder Robinson & Co., Inc., 903 F.2d 186, 197-198 (3d Cir.1990). “Only if the movant produces evidence sufficient to convince the trial judge that all four factors favor preliminary injunctive relief should an injunction issue.” Opticians Ass’n of America v. Independent Opticians of America, 920 F.2d 187, 192 (3d Cir.1990); ECRI v. McGraw-Hill, Inc., 809 F.2d 223, 226 (3d Cir.1987). 41. Plaintiffs allege that deféndants have violated both procedural and substantive provisions of the Boren Amendment. See generally, Wilder v. Virginia Hospital Ass’n, 496 U.S. 498, 110 S.Ct. 2510, 110 L.Ed.2d 455 (1990). The substantive provisions entitle providers to rates that are reasonable and adequate to meet the costs that must be incurred by efficiently and economically operated facilities in order to provide care and services in compliance with state and federal standards. Id. The procedural provisions entitle providers to enforce the State’s obligation to make the assurances and findings required by the Boren Amendment. ■ Plaintiffs contend that the State has violated both of these rights, entitling them to preliminary injunctive relief. VI. DEFENDANTS’ COMPLIANCE WITH THE PROCEDURAL PROVISIONS OF THE BOREN AMENDMENT A. The Procedural Law 42. As noted supra, the Medicaid statute and its implementing regulations require a state Medicaid agency to make findings regarding the adequacy of nursing facility payment rates whenever the state agency amends its methods and standards, but not less often than annually. 42 U.S.C. § 1396a(a)(13)(A); 42 C.F.R. § 447.253(b). The state is required to submit assurances to the Secretary only when it makes a change in its payment methods or standards. 42 C.F.R. § 447.253(a). 43. In AMISUB (PSL) v. State of Colorado Department of Social Services, 879 F.2d 789 (10th Cir.1989), the Tenth Circuit first articulated what has now become the accepted test for procedural compliance under the Boren Amendment. The State must, at a minimum, make findings which identify and determine: (i) efficiently and economically operated facilities; (ii) the costs that must be incurred by such facilities; and (iii) payment rates which are reasonable and adequate to meet the costs of efficiently and economically operated facilities. AMISUB, 879 F.2d at 796, see also Nebraska Health Care Ass’n v. Dunning, 778 F.2d 1291, 1294 (8th Cir.1981), cert. denied 479 U.S. 1063, 107 S.Ct. 947, 93 L.Ed.2d 996 (1987); Missouri Health Care Association v. Stangler, 765 F.Supp. 1413, 1415 (W.D.Mo.1991). The Third Circuit approved this formulation of the procedural standard in Temple University v. White, 941 F.2d 201, 209, n. 10 (3d Cir.1991). 44. The Supreme Court has recognized the critical importance of the Boren Amendment’s ■ “findings” requirement, noting that such findings are “a necessary prerequisite to the subsequent requirement that the State provide ‘assurances’ to the Secretary.” Wilder v. Virginia Hospital Ass’n, 496 U.S. 498, 512, 110 S.Ct. 2510, 2519, 110 L.Ed.2d 455 (1990); see also Pinnacle Nursing Home v. Axelrod, 928 F.2d 1306, 1314 (2d Cir.1991) (“although procedural requirements may reduce some of the state’s ‘flexibility’ in determining their own schemes of reimbursement, this is what the plain language of the statute requires”). 45. While the State is free to create its own method for arriving at the required findings, this does not absolve the State from its obligation tó make findings. AMISUB, 879 F.2d at 797 (“[m]ere recitation of the wording of the federal statute is not sufficient for procedural compliance”); see also Wilder, 496 U.S. at 516-21, 110 S.Ct. at 2522-23 (State must judge the reasonableness of its rates against the objective benchmark of an efficiently and economically operated facility); Temple University, 941 F.2d at 209 (finding that State failed to satisfy procedural duties based on failure to conduct “empirical analysis” using objective criteria). 46. The procedural requirements of the federal regulations are satisfied if the State .has engaged in a “bona fide finding process” and has made assurances to HCFA based upon its findings. See AMISUB, 879 F.2d at 797; Folden v. Washington State Department of Social and Health Services, 744 F.Supp. 1507, 1532 (W.D.Wash.1990), aff'd, 981 F.2d 1054 (9th Cir.1992). The State’s findings are not proper if the process, rather than being bona fide and objective, is merely an exercise to make the best case to support the State’s rates, and the State considers only factors favorable to its position while failing to consider relevant factors that are unfavorable. See Multicare Medical Center v. State of Washington, 768 F.Supp. 1349, 1392 (W.D.Wash.1991); California Hosp. Ass’n v. Schweiker, 559 F.Supp. 110, 117 (C.D.Cal.1982), aff'd, 705 F.2d 466 (9th Cir.1983); Wilder, 496 U.S. at 516-21, 110 S.Ct. at 2522-23. 47. It is important with respect to the procedural challenge to understand Congress’ purposes in enacting the Boren Amendment. In addition to fostering cost-containment, the other principal purpose of the statute was to “reduce potentially stifling and expensive federal oversight of state methodologies.” West Virginia University Hospitals, 885 F.2d 11, 23 (3d Cir.1989). Under the Boren Amendment, states were to have “considerable freedom in pursuing ways of limiting Medicaid costs,” id. at 23, with the federal role limited to the “minimum necessary to assure proper accountability.” S.Rep. No. 139, 97th Cong., 1st Sess. 478 (1981), reprinted in 1981 U.S.Code Cong. & Adm.News 396, 744. HCFA has confirmed that Congress expected the agency to “develop regulations that would increase states’ discretion in setting payment rates, and would employ a federal review process which would be less administratively burdensome.” 48 Fed.Reg. 56047 (Dec. 19, 1983). 48. Consistent with these purposes, the Boren Amendment does not require a formal, detailed or technical findings process. The State is free to create its own method of findings. AMISUB, 879 F.2d at 797. Indeed, the findings process does not require any special studies or even written findings. Colorado Health Care Ass’n v. Colorado Department of Social Services, 842 F.2d 1158, 1168 (10th Cir.1988); Massachusetts Federation of Nursing Homes, 772 F.Supp. 31, 40 (D.Mass.1991); Folden, 744 F.Supp. at 1532, 1534; Mary Washington Hospital, Inc. v. Fisher, 635 F.Supp. 891, 899 (E.D.Va.1985). Such a requirement would be entirely inconsistent with congressional intent not to overburden the states with cumbersome and excessive paperwork requirements. Massachusetts Federation of Nursing Homes, 772 F.Supp. at 40; West Virginia Univ. Hosp., 885 F.2d at 23. 49. Under the informal and flexible findings procedures contemplated by Congress and HCFA, “[i]t is sufficient if [the State] has considered, on the basis of some reasonably principled analysis, whether its payment rates meet the substantive requirements of the Boren Amendment.” Folden, 744 F.Supp. at 1532; Massachusetts Federation of Nursing Homes, 772 F.Supp. at 37; Thomas v. Johnston, 557 F.Supp. 879, 910 (W.D.Tex.1983). Such a reasonably principled analysis must “establish a nexus between the costs of operating efficient and economic nursing facilities and the proposed reimbursement rates under the state plan.” Pinnacle Nursing Home v. Axelrod, 928 F.2d at 1314. B. The Findings Requirement 50. As noted above, the Boren Amendment requires states to submit certain assurances to HCFA which must be supported by findings that the rates comply with the statute’s substantive standard. Plaintiffs allege that New Jersey failed to satisfy these procedural requirements. In particular, they allege that the State failed to make the requisite findings so that the assurances, although concisely filed with HCFA, were invalid. 51.Defendants admitted in their answers to interrogatories that DHS has not formulated a definition of an efficiently and economically operated facility. See Pl.Ex. 9. Furthermore, in responding to plaintiffs’ discovery requests, defendants did not produce any tangible evidence of DHS findings in the form of empirical analyses which specifically addressed the overall adequacy of defendants’ Medicaid rates. However, during the course of the instant litigation, defendants have described in detail the process by which DHS made its federallyrrequired findings of compliance with the Boren Amendment in terms of the kinds of data collected and evaluated by the State during its findings process. See Kohler and Kilstein Decís. 52. The principal tools in New Jersey’s findings process are the annual median runs. Kilstein Deck at ¶¶ 13-18; Kohler Deck at ¶¶ 9-11. At the heart of New Jersey’s complex reimbursement scheme is the presumption that facilities incurring costs below the median in individual cost centers are those that are efficient and economical in those areas. Kilstein Deck at ¶¶ 13,15. Although defendants do not have an explicit definition of economic and efficient facilities, the State deems as economic and efficient facilities at least those facilities that are able to keep costs below the costs incurred by half of the facilities in each cost category. Kilstein Deck at ¶¶ 13, 15; Tr. at 5.8. Significantly, the experts for both parties in this case agree that it is proper for a state to assume that efficient and economically operated facilities are those below the median in terms of costs. Tr. at 1.40, 4.39. C. The Adequacy of New Jersey’s Procedure 53. Defendants’ expert witness testified that the State uses the reasonableness screens themselves to identify the costs of efficiently and economically operated facilities. Tr. at 5.8. Plaintiffs argue that such reasoning is circular and does not represent a “finding” which is based on objective criteria. - 54. In New Jersey, the State does not base its findings on the fact that the system pays what the State has determined in advance that it should pay. Instead, the rate-setting methodology, by identifying facilities below the median in terms of cost, contains an objective mechanism for identifying efficiently and economically operated facilities with respect to each cost category. Under the New Jersey system, the identification of efficiently and economically operated facilities is closely tied to, and indeed constitutes an integral part of, the rate-setting process. 55. In light of plaintiffs’ expert’s testimony, based upon her extensive practical experience, that it is difficult, if not impossible, to identify and determine efficient and economic facilities with precision, see Tr. at 1.56, 1.65, 2.99, 2.116, the Court is reluctant to conclude that a state plan must identify, by name or by some identifying characteristic other than its costs relative to the costs of its peers, those facilities that are efficiently and economically operated. As noted by both the district court and the Ninth Circuit in Fol-den, “HCFA has specifically rejected the suggestion that states should be required to define efficiently and economically operated facilities, because ‘the State’s methods and standards implicitly act as the State’s definition of an efficiently and economically 'operated facility.’ ” Folden, 981 F.2d 1054, 1057-1058, quoting 744 F.Supp. at 1532. The Fol-den court unequivocally rejected plaintiffs’ contention “that the State is required to set up a model of an efficiently and economically operated facility and then match the cost of all facilities against that model.” Folden, 981 F.2d at 1057. The Court rejects plaintiffs’ contention in the instant case that New Jersey must establish or designate a “gold star” facility against which all New Jersey facilities must be measured; such a process is neither a requirement of the Boren Amendment nor a requirement of AMISUB. As noted supra, AMISUB required only that “the State Medicaid Agency, at a minimum, ... make findings which identify and determine (1) efficiently and economically operated hospitals; (2) the costs that must be incurred by such hospitals; and, (3) payment rates which are reasonable and adequate to meet the reasonable costs of the state’s efficiently and economically operated hospitals.” AMISUB, 879 F.2d at 796 (emphasis in original). “It is important to recognize that the AMISUB decision does not require definition, but only identification and determination of such facilities.” Folden, 744 F.Supp. at 1532 (emphasis in original). An automobile’s efficiency and economy is evaluated by comparing its costs of operation with those of other automobiles; a person’s efficiency can be evaluated by comparing output with time expended, in relation to that of his/her peers; no different analysis can be expected with respect to nursing facilities. 56. Furthermore, “there is a presumption that a state will engage in a bona fide finding process before it makes assurances to HCFA that the required findings have been made.” AMISUB, 879 F.2d at 797; Folden, 744 F.Supp. at 1533. Plaintiffs must come forward with “credible evidence to overcome the presumption that the State engaged in. a bona fide finding process.” Folden, 744 F.Supp. at 1533. 57. Plaintiffs’ assertion that the State failed to make proper findings is based upon the State’s admission that it did not have a definition of an efficiently and economically operated facility. This “admission,” without more, does not establish non-compliance because federal law does not require states to define efficient and economically operated facilities. Folden, 744 F.Supp. at 1532. Indeed, HCFA specifically rejected the suggestion that its regulations require states to develop such a definition. 48 Fed.Reg. 56049 (Dec. 19,1983). In HCFA’s view, “no explicit definition is necessary” because “the state’s methods and standards implicitly act as the state’s definition of an efficiently and economically operated facility.” Id. As the federal agency responsible for administering the Medicaid statute, HCFA’s interpretation of the statute is entitled to deference from the courts. Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc., 467 U.S. 837, 844, 104 S.Ct. 2778, 2782, 81 L.Ed.2d 694 (1984). 58. Plaintiffs also contend that the Court should find in their favor because defendants have not produced a specific “findings” document. This argument is rejected because, as noted supra, the absence of a specific “findings” document is not dispositive, as states are not required to make their findings in writing. See, Colorado Health Care Ass’n, 842 F.2d at 1168; Massachusetts Federation of Nursing Homes, 772 F.Supp. at 40; Folden, 744 F.Supp. at 1532, 1534; Mary Washington Hospital, 635 F.Supp. at 897. 59. Additionally, it is clear from the Kilstein and Kohler Declarations that the relevant officials considered information in addition to the median runs that are generated in the operation of the rate-setting methodology. This information included special studies conducted in response to identified problems, information received from the facilities and developed by the State during the State administrative appeals process, other information provided by the industry through formal and informal contacts, information available from other state agencies regarding relevant matters such as industry health, patient access to care, and information regarding the quality of care. Kohler Deel. at ¶ 6. This is therefore not a case like Temple University v. White, 941 F.2d 201, 208-209 (3d Cir.1991), or Wesf Virginia University Hospitals v. Casey, 885 F.2d 11, 30 (3d Cir.1989), where the defendants failed to collect data or to make findings at all. 60. The State also evaluated studies that demonstrated a low cost-rate ratio. In January 1990, as part of a petition for rulemaking, the nursing home industry filed a cost-rate analysis that indicated results similar to those found by plaintiffs’ expert in her subsequent study prepared for this litigation. See Plts.Exh. C. However, the State determined that the study presented by the nursing facility industry was not reliable evidence of deficiencies in the reimbursement methodology. Kohler Deel. at ¶¶ 24-32. 61. A formal State study of nursing costs conducted in 1989 also revealed that many facilities had costs above the screen. Examination of -the data upon which this study was based demonstrated that the primary reason for facilities incurring costs above the screen was the presence of nursing hours far in excess of the required number. Kohler Deel. at ¶ 13. The State also believed that it was addressing any legitimate concerns raised by this study because it was about to increase the number of nursing hours to be reimbursed and because it had recently injected an additional $15 million into the rates of high Medicaid occupancy facilities in order to enable them to meet temporarily higher nursing costs. Kohler Deck at ¶¶ 13-14; Kilstein Deck at ¶¶4&-41. 62. Presumably, the procedural “findings” requirement would be met had New Jersey incorporated in the plan something like the following: The state finds that an efficiently and economically operated nursing facility is one whose costs are at or below the median of costs incurred by nursing facilities generally in the following relevant categories____ The State further finds that costs must be incurred if they are in fact incurred in each category of cost by the lower-cost half of the facilities. We further find that the DOH licensure standards are adequate to provide legally-mandated levels of care. All of the foregoing is implicit in the New Jersey methodology.. The Court does not believe that Congress intended that findings which are implicit in a state’s Medicaid reimbursement methodology must be set out separately or in some particular format, and, given the dire consequences of invalidating a state plan, the Court is reluctant to impose such a requirement. Such a requirement would be inconsistent with Congress’ expressed intent to relieve the states of burdensome administrative requirements, and in any event could have been specified if Congress (or HCFA) had wished to impose this requirement on the states. ' 63. Moreover, as discussed in detail supra, the Court’s concern over the scope of the “findings” requirement is largely resolved by the holding in Folden that the process of identification and determination called for in AMISUB may. be accomplished through the terms of the state plan itself. Folden, 744 F.Supp. at 1533, affd 981 F.2d at 1057. 64.Plaintiffs bear the burden of coming forward with evidence demonstrating a substantial likelihood that they can prove a procedural violation of the Boren Amendment. This they have failed to do. Given the flexibility that the Boren Amendment affords states in devising their findings process, the Court cannot say that New Jersey has been arbitrary or capricious in evaluating efficiency and economy, in part, on a eomponent-bycomponent basis. The defendants’ system of identifying economic and efficient facilities is thus implicit in the rate methodology. It is also inherent in the methodology that facilities whose costs are below the median in a particular cost category will receive reimbursement for costs in that category. There is nothing circular about this process. Therefore, the State appears to have done all that the law requires to identify and determine efficiently and economically operated facilities and the costs that must be incurred by such facilities. Because the reimbursement formula ensures that facilities will receive reimbursement for costs below the medians in the various cost categories, the State is justified in finding that its rates are reasonable and adequate to meet the costs incurred by efficiently and economically operated facilities. On its face, the evidence presented by the State appears to demonstrate substantial compliance with the procedural standard of the Boren Amendment. VII. DEFENDANTS’ COMPLIANCE WITH THE SUBSTANTIVE REQUIREMENTS OF THE BOREN AMENDMENT A. The Substantive Challenge 65. As noted supra, plaintiffs’ allegations, as presented by their expert, deal primarily with defendants’ method of calculating reimbursable nursing costs. Plaintiffs assert that analysis of the DHS payment methodology demonstrates that the Medicaid rates paid to nursing facilities by New Jersey are inadequate and that the majority of facilities purportedly receive Medicaid payments lower than their actual allowable costs. Plaintiffs also allege that the overall rates paid under the New Jersey system are inadequate, primarily because only a small percentage of facilities receive 100% of what they deem to be their allowable costs. As indicated above, defendants impose certain limitations on those costs in the course of setting the screens, or limits, on reimbursement; plaintiffs challenge the reimbursement system itself insofar as it contains what plaintiffs’ expert regards as an inordinate number of restrictive separate limits. Plaintiffs also challenge the inflation factor that is applied to all costs, the geographical wage adjustment methodology, the failure to include the costs of contract nursing in calculating the nursing screen and the nursing screen itself. Each of these challenges will be considered separately. B. The Experts and their Roles 66. Plaintiffs rely upon a study conducted by their expert, Barbara B. Manard, Ph.D. Dr. Manard is a Vice President of the health care consulting firm of Lewin/ICF, Inc. Her findings and conclusions are set forth in her affidavit and the attached report (“Lew-in/ICF Report”) and were described in detail in her hearing testimony. See generally, Tr. at 1.35-3.128; 5.70-5.117. 67. Dr. Manard has a broad range of experience in the design and analysis of Medicaid rate setting systems for nursing facilities, including assistance to states and the federal government on Medicaid rate setting matters. Tr. at 1.37-1.38. The Court has accepted Dr. Manard as an expert in this case. 68. Defendants’ expert is Dr. Gretchen Engquist, a principal in the Compass Group of KPMG Peat Marwick, specializing in health policy development and evaluation. Like Dr. Manard, she has a broad range of experience in the design and analysis of Medicaid rate setting systems for nursing facilities, including assistance to states on Medicaid rate setting matters. She has served as the director of the Medicaid program for the State of Missouri. Tr. 3:129-130. The Court also has accepted Dr. Engquist as an expert in this case. 69. Neither expert has purported to address directly the legal question of the State’s compliance with the Boren Amendment. On the contrary, they have eschewed reference to legal authorities or doctrines and have appropriately confined their analyses primarily to the impact on nursing facilities of the State system and their respective views as to the considerations and methodology which are appropriate in the design of Medicaid reimbursement systems. C. Presumption of Validity 70. Initially, defendants note that New Jersey’s current plan was approved by HCFA in September, 1990; defendants assert that the Court must therefore accord to the State’s Medicaid plan a presumption of validity, because, “as a general rule, HCFA approval of a state plan indicates state compliance with applicable statutes and regulations.” Massachusetts Federation of Nursing Homes, Inc. v. Commonwealth of Massachusetts, 772 F.Supp. 31, 39 (D.Mass.1991). The Court notes that the rationale underlying this presumption relates to the fact that “HCFA certainly has more expertise in this complicated area of the law than the courts.” Id. 71. However, in light of the Third Circuit’s recent decision in Erie County Geriatric Center v. Sullivan that, “[to] be satisfied with a state’s assurance that its method for, determining reimbursement rates results in reasonable and adequate reimbursement to eligible facilities as required by the Medicaid Act, the Secretary must be convinced that a state has made findings that its rates do in fact provide such reimbursement,” Erie County, 952 F.2d 71, 81-82 (3d Cir.1991); and HCFA’s litigation position in that case that the Secretary need “focus simply on the state’s assurances of compliance without examining the bases underlying these assurances,” id. at 79, the Court declines to extend any such presumption of validity to HCFA’s approval of New Jersey’s plan in the instant ease. Given the Secretary’s .erroneous interpretation of his obligations with respect to state plans until the decision in Erie County in 1991, the Court concludes that it is unlikely that HCFA gave anything other than perfunctory consideration to the New Jersey plan. The Court therefore finds that a presumption of validity based solely on the cursory HCFA approval is unwarranted. D. The Cost-Rate Analysis 72. For purposes of determining whether New Jersey’s overall reimbursement rates fall within the range of reasonableness prescribed by the Boren Amendment, it is the entire reimbursement methodology taken as a whole that is relevant, not the individual components that comprise the rate. See Colorado Health Care, 842 F.2d at 1167; Folden, 744 F.Supp. at 1535. This is because “even if payments in one cost center are less than reasonable and adequate, there may be no violation of the Boren Amendment because the proper analysis under the Amendment focuses on the. total rate.” Folden, 744 F.Supp. at 1535. The fundamental inquiry regarding compliance with the Boren Amendment’s substantive standard is whether the rates, overall, are adequate to meet the costs that must be incurred by efficiently and economically operated facilities in serving Medicaid patients. Id. 73. While New Jersey’s rate methodology is complex and multifaceted, the primary consideration in resolving plaintiffs’ cost-rate challenge is whether the actual rates paid by the New Jersey Medicaid program are, in fact, reasonable and adequate. See generally, Kansas Health Care Ass’n v. Kansas DSRS, 754 F.Supp. 1502, 1512-1515 (D.Kan.1990); Folden, 744 F.Supp. at 1534-1537. Plaintiffs argue that objective analyses of the DHS payment methodology demonstrate that ,the Medicaid rates paid to nursing facilities are not adequate because the overwhelming majority of facilities receive Medicaid reimbursement payments lower than their actual allowable costs; defendants disagree and further assert that the State’s multi-component rate-setting methodology is reasonable in design and thus satisfies the Boren Amendment. For the reasons enumerated below, the Court concludes that plaintiffs have not demonstrated a reasonable likelihood of success on the merits of this substantive claim. 74. The parties have submitted to the Court extensive and extraordinarily detailed statistical analyses, as well as rebuttal and surrebuttal analyses, regarding the adequacy of the New Jersey reimbursement scheme. The divergent methodologies employed by the experts in this case reflect the differing positions of the parties as to precisely what the substantive provisions of the Boren Amendment require of a state’s Medicaid reimbursement plan. 75. Defendants assert initially that the appropriate standard for reviewing the New Jersey plan is that articulated in West Virginia University Hospitals, where the Third Circuit stated, “[w]hat matters ... is whether the reimbursement rates to [facilities] in the aggregate are arbitrary and capricious.” West Virginia University Hospitals, 885 F.2d at 26 (emphasis added). Defendants thus conclude that the relevant analysis for determining whether New Jersey’s rates fall within the range of reasonableness and therefore comply with the Boren Amendment should consist of a comparison between the industry’s aggregate costs and the aggregate reimbursement provided by the State. Defendants assert that, under plaintiffs’ method of calculation, New Jersey reimburses 86.3% of the aggregate costs incurred by Medicaid providers. On its face, this figure appears to the Court to be an impressive percentage that may preclude the Court, at this preliminary stage of the litigation, from finding in plaintiffs’ favor. As noted supra, rates will comply with the Boren Amendment if they fall within a range of reasonableness. The Court is reluctant to conclude that a reimbursement system-that, under plaintiffs’ own method of calculation, reimburses 86.3% of the industry’s aggregate costs is outside the range of reasonableness, particularly when it is clear that Congress did not intend the Boren Amendment to require payment of all costs by a state. It appears neither arbitrary nor capricious to assume at this preliminary stage that 13.7% of the aggregate costs are unnecessary costs for which the State is not required to provide reimbursement under the Boren Amendment. 76. Moreover, and as will be discussed in greater detail infra, in connection with plaintiffs’ cost-rate calcu