Case Title: Lopez v. Ledesma

Citation: 

Docket Number: S262487A

State: california

Court: California Supreme Court

Date: 2022-02-24T00:00:00Z

Document:
IN THE SUPREME COURT OF 
CALIFORNIA 
 
MARISOL LOPEZ, 
Plaintiff and Appellant, 
v. 
GLENN LEDESMA et al., 
Defendants and Appellants; 
BERNARD KOIRE, 
Defendant and Respondent.  
 
S262487 
 
Second Appellate District, Division Two 
B284452 
 
Los Angeles County Superior Court 
BC519180 
 
 
February 24, 2022 (reposting corrected version) 
 
Justice Liu authored the opinion of the Court, in which Chief 
Justice Cantil-Sakauye and Justices Corrigan, Kruger, 
Groban, Jenkins, and Meehan* concurred. 
 
 
 
*  
Associate Justice of the Court of Appeal, Fifth Appellate 
District, assigned by the Chief Justice pursuant to article VI, 
section 6 of the California Constitution. 
1 
LOPEZ v. LEDESMA 
S262487 
 
Opinion of the Court by Liu, J. 
 
Under a provision of the Medical Injury Compensation 
Reform Act (MICRA), damages for noneconomic losses shall not 
exceed $250,000 in “any action for injury against a health care 
provider based on professional negligence.”  (Civ. Code, § 3333.2, 
subds. (a), (b); all undesignated statutory references are to the 
Civil Code.)  An action is based on “professional negligence” and 
thereby subject to section 3333.2’s cap on noneconomic damages 
only if a health care provider’s services are “within the scope of 
services for which the provider is licensed” and “are not within 
any restriction imposed by the licensing agency or licensed 
hospital.”  (§ 3333.2, subd. (c)(2).) 
We granted review to determine whether section 3333.2 
applies to actions against physician assistants who are 
nominally supervised by a doctor but receive minimal or no 
actual 
supervision 
when 
performing 
medical 
services.  
Construing the statute in light of its purposes and our 
precedent, we hold that section 3333.2 applies to a physician 
assistant who has a legally enforceable agency relationship with 
a supervising physician and provides services within the scope 
of that agency relationship, even if the physician violates his or 
her obligation to provide adequate supervision. 
We also granted review on a second issue:  whether a 
delegation of services agreement (DSA) between a supervising 
physician and a physician assistant is legally effective where the 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
2 
physician is disabled and unable to practice medicine.  On closer 
examination, we decline to decide this issue, which was not 
considered by the trial court or by the Court of Appeal. 
I. 
Because no party disputes the trial court’s factual 
findings, we rely on the trial court’s statement of decision to 
summarize the pertinent facts in this case.  (See In re Marriage 
of Fink (1979) 25 Cal.3d 877, 887.) 
Dr. Glenn Ledesma, a dermatologist, owned and operated 
a dermatology clinic in Southern California.  Dr. Bernard Koire, 
a plastic surgeon, contracted with the clinic to provide physician 
services, physician assistant supervisor services, and consulting 
services.  Suzanne Freesemann and Brian Hughes worked as 
physician assistants at the clinic.  In 2009, Freesemann and Dr. 
Ledesma 
signed 
a 
DSA 
designating 
Dr. Ledesma 
as 
Freesemann’s supervising physician.  According to the trial 
court, “Neither party formally revoked the DSA and it was thus 
nominally . . . in effect” at the time of the events giving rise to 
this case.  Hughes and Dr. Koire signed a DSA designating Dr. 
Koire as Hughes’s supervising physician.  Although the DSA 
between Hughes and Dr. Koire was undated, the trial court 
found that it established a supervising physician-physician 
assistant relationship. 
O.S. was a patient at Dr. Ledesma’s dermatology clinic 
who received treatment from Freesemann and Hughes on 
several occasions in 2010 and 2011.  O.S. first visited the clinic 
on December 8, 2010, after her mother, Marisol Lopez, noticed 
a dark spot on O.S.’s scalp when she was seven or eight months 
of age.  During this appointment, Freesemann obtained a 
medical history, examined O.S.’s scalp, and recommended an 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
3 
“excision and biopsy” treatment plan.  On January 3, 2011, 
Hughes performed a “shave biopsy” of O.S.’s lesion and sent the 
biopsied tissue to be reviewed by a physician.  O.S. attended a 
followup appointment with Hughes on January 17, 2011, during 
which Hughes reviewed the biopsy report and found that the 
biopsied lesion was “benign” and that “everything [was] 
normal.” 
Lopez returned to Ledesma’s clinic on June 11, 2011, after 
noticing that O.S.’s lesion was growing back.  Freesemann 
assessed the lesion as “wart(s)” and recommended that it be 
burned off with liquid nitrogen.  O.S. received the liquid 
nitrogen treatment at the clinic on July 27, 2011.  She returned 
to the clinic on September 9, 2011, after the lesion grew back yet 
again.  During this visit, Hughes assessed the lesion as “warts” 
and prepared a treatment plan referring O.S. to a general 
surgeon to remove the “large growth.”  Dr. Koire reviewed and 
countersigned the treatment plan 88 days later.  In December 
2011, a general surgeon removed the lesion and diagnosed it as 
“benign pigmented intradermal intermediate congenital nevus.” 
In early 2013, Lopez noticed a bump on O.S.’s neck.  A 
doctor excised the neck mass and referred O.S. to an oncologist, 
who diagnosed O.S. with “metastatic malignant melanoma.”  
O.S. died on February 27, 2014. 
At the time of Freesemann’s clinical encounters with O.S., 
Dr. Ledesma was no longer fulfilling any of his supervisory 
obligations under the 2009 DSA.  According to the trial court, 
Dr. Ledesma was “involved in operating the clinic facilities in a 
business sense,” but “he was no longer in active practice as a 
physician.”  During Hughes’s clinical encounters with O.S., “Dr. 
Koire 
was 
not 
available 
in 
person 
or 
by 
electronic 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
4 
communications at all times.”  Dr. Koire also “was no longer 
engaged in active practice.”   
In 2013, Lopez filed a medical malpractice action asserting 
negligence claims against Hughes, Freesemann, Dr. Ledesma, 
Dr. Koire, and others.  After O.S. died, Lopez amended the 
complaint to assert a wrongful death claim.  The trial court 
found in favor of Lopez on her negligence claims against 
Freesemann and Hughes, holding that they did not take 
adequate steps to diagnose O.S.’s condition and did not seek 
guidance from a physician.  The court held that Dr. Ledesma 
was vicariously liable for the negligent actions of Freesemann 
and that Dr. Koire was vicariously liable for the negligent 
actions of Hughes.  The court awarded Lopez $11,200 in 
economic damages.  It also awarded Lopez $4.25 million in 
noneconomic damages but reduced this amount to $250,000 
pursuant to MICRA’s cap on noneconomic damages.  (§ 3333.2, 
subd. (b).)  
On appeal, Lopez argued that the trial court’s reduction in 
damages was improper because Freesemann’s and Hughes’s 
conduct fell within the proviso that excludes from section 
3333.2’s coverage conduct that is outside “the scope of services 
for which the provider is licensed” or “within any restriction 
imposed by the licensing agency or licensed hospital.”  (§ 3333.2, 
subd. (c)(2); see Lopez v. Ledesma (2020) 46 Cal.App.5th 980, 
985 (Lopez).)  The Court of Appeal rejected this argument and 
affirmed the trial court’s reduction in damages.  (Lopez, at 
pp. 985, 999.)  It held that “a physician assistant acts within the 
scope of his or her license for purposes of section 3333.2, 
subdivision (c)(2) if he or she has a legally enforceable agency 
agreement with a supervising physician, regardless of the 
quality of actual supervision.”  (Id. at p. 985.)  Justice 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
5 
Ashmann-Gerst dissented on the ground that Freesemann and 
Hughes were not permitted to provide care to patients without 
receiving actual supervision and thus acted outside the scope of 
services for which they were licensed.  (Id. at pp. 1005–1006 (dis. 
opn. of Ashmann-Gerst, J.).)  We granted review. 
II. 
 
The Legislature enacted MICRA in 1975 (Stats. 1975, 2d 
Ex. Sess., ch. 1, § 1, p. 3949; see id., § 24.6, p. 3969) to address a 
statewide “crisis regarding the availability of medical 
malpractice insurance.”  (Reigelsperger v. Siller (2007) 40 
Cal.4th 574, 577.)  “The problem . . . arose when the insurance 
companies which issued virtually all of the medical malpractice 
insurance policies in California determined that the costs of 
affording such coverage were so high that they would no longer 
continue to provide such coverage as they had in the past.  Some 
of the insurers withdrew from the medical malpractice field 
entirely, while others raised the premiums which they charged 
to doctors and hospitals to what were frequently referred to as 
‘skyrocketing’ rates.  As a consequence, many doctors decided 
either to stop providing medical care with respect to certain high 
risk procedures or treatment, to terminate their practice in this 
state altogether, or to ‘go bare,’ i.e., to practice without 
malpractice insurance.  The result was that in parts of the state 
medical care was not fully available, and patients who were 
treated by uninsured doctors faced the prospect of obtaining 
only unenforceable judgments if they should suffer serious 
injury as a result of malpractice.”  (American Bank & Trust Co. 
v. Community Hospital (1984) 36 Cal.3d 359, 371.)   
 
In the Legislature’s view, “[t]he continuing availability of 
adequate medical care depends directly on the availability of 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
6 
adequate insurance coverage, which in turn operates as a 
function of costs associated with medical malpractice litigation.”  
(Western Steamship Lines, Inc. v. San Pedro Peninsula Hospital 
(1994) 8 Cal.4th 100, 111 (Western Steamship).)  “Accordingly, 
MICRA includes a variety of provisions all of which are 
calculated to reduce the cost of insurance by limiting the amount 
and timing of recovery in cases of professional negligence.”  
(Ibid.) 
Section 3333.2 is one such provision.  It provides:  “(a) In 
any action for injury against a health care provider based on 
professional negligence, the injured plaintiff shall be entitled to 
recover noneconomic losses to compensate for pain, suffering, 
. . . and other nonpecuniary damage.  [¶] (b) In no action shall 
the amount of damages for noneconomic losses exceed two 
hundred fifty thousand dollars ($250,000).”  It defines 
“professional negligence” as “a negligent act or omission to act 
by a health care provider in the rendering of professional 
services, which act or omission is the proximate cause of a 
personal injury or wrongful death, provided that such services 
are within the scope of services for which the provider is licensed 
and which are not within any restriction imposed by the 
licensing agency or licensed hospital.”  (§ 3333.2, subd. (c)(2).) 
In the same year it passed MICRA, the Legislature 
enacted the Physician Assistant’s Practice Act (PAPA).  This 
latter act established the position of “physician assistant” to 
address “the growing shortage and geographic maldistribution 
of health care services in California.”  (Bus. & Prof. 
Code, § 3500.)  The act aims “to encourage the effective 
utilization of the skills of physicians . . . by enabling them to 
work with qualified physician assistants to provide quality 
care.”  (Ibid., as amended by Stats. 2019, ch. 707, § 1. )  It defines 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
7 
a “physician assistant” as “a person who meets the requirements 
of this chapter and is licensed by the [Physician Assistant 
B]oard.”  (Bus. & Prof. Code, § 3501, subd. (d).)  To practice as a 
physician assistant, an individual must complete an approved 
training program and pass a licensing examination.  (Id., § 3519, 
subds. (a), (b).)  Once licensed, a physician assistant may 
perform medical services “under the supervision of a licensed 
physician.”  (Id., § 3502, subd. (a)(1).)  Several sections of the 
PAPA were amended effective January 1, 2020, pursuant to 
Senate Bill No. 697 (2019–2020 Reg. Sess.).  (See Stats. 2019, 
ch. 707.)  We apply the law as it existed at the time of the 
relevant events.  
The issue in this case is whether section 3333.2’s cap on 
noneconomic damages applies to actions against physician 
assistants where a licensed physician has legal responsibility for 
supervising the physician assistant but provides minimal or no 
actual supervision.  We review this question of statutory 
interpretation de novo.  (People v. Prunty (2015) 62 Cal.4th 59, 
71; Ghirardo v. Antonioli (1994) 8 Cal.4th 791, 801.)   
We turn first to the language of the statute.  As noted, 
section 3333.2 applies only to actions “based on professional 
negligence.”  (§ 3333.2, subd. (a).)  The definition of “professional 
negligence” in section 3333.2 has four elements:  (1) “a negligent 
act or omission to act by a health care provider in the rendering 
of professional services,” (2) “which act or omission is the 
proximate cause of a personal injury or wrongful death,” 
(3) “provided that such services are within the scope of services 
for which the provider is licensed,” and (4) “which are not within 
any restriction imposed by the licensing agency or licensed 
hospital.”  (§ 3333.2, subd. (c)(2).)  The parties do not dispute 
that the first two elements are satisfied.  The question is 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
8 
whether a physician assistant who receives negligible 
supervision from his or her supervising physician provides 
services outside “the scope of services for which the provider is 
licensed” or “within [a] restriction imposed by the licensing 
agency or licensed hospital.”  (Ibid.)  We address these elements 
in turn. 
A. 
The language “scope of services for which the provider is 
licensed” (§ 3333.2, subd. (c)(2)) is naturally understood as the 
general range of activities encompassed by the provider’s 
license.  A psychiatrist, for instance, is licensed to provide 
psychiatric treatment.  Thus, a psychiatrist’s conduct arising 
out of the course of psychiatric treatment falls within the scope 
of services for which the psychiatrist is licensed.  (See Waters v. 
Bourhis (1985) 40 Cal.3d 424, 436 (Bourhis) [“it is clear that the 
psychiatrist’s conduct arose out of the course of the psychiatric 
treatment he was licensed to provide”].)  By contrast, a 
“psychologist perform[ing] heart surgery” does not provide 
services within the scope of his or her license.  (Ibid.) 
The PAPA and the regulations promulgated by the 
Physician Assistant Board set forth the medical services that a 
licensed physician assistant “may perform.”  (Bus. & Prof. 
Code, former § 3502, subd. (a); see Cal. Code Regs., tit. 16, 
§ 1399.540, subd. (a).)  “A physician assistant may only provide 
those medical services which he or she is competent to perform 
and which are consistent with the physician assistant’s 
education, training, and experience, and which are delegated in 
writing by a supervising physician who is responsible for the 
patients cared for by that physician assistant.”  (Cal. Code Regs., 
tit. 16, § 1399.540, subd. (a).)  During the relevant time period, 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
9 
the writing that delegated medical services to a physician 
assistant was called a DSA.  (Id., § 1399.540, subd. (b).)  A 
physician assistant “may perform” the services delegated in the 
DSA when the services are rendered “under the supervision of a 
licensed physician and surgeon.”  (Bus. & Prof. Code, former 
§ 3502, subd. (a).)  In addition to these general rules, the PAPA 
specifies particular areas of practice, such as “[t]he practice of 
dentistry,” that physician assistants may not perform even 
under the supervision of a licensed physician.  (Id., former 
§ 3502, subd. (d).) 
The question here is whether a physician assistant who 
establishes a legal relationship with a supervising physician 
through a DSA, but in practice receives minimal or no 
supervision, is nonetheless practicing within “the scope of 
services for which the provider is licensed.”  (§ 3333.2, 
subd. (c)(2).)  Because a physician assistant is only authorized 
to perform services “when the services are rendered under the 
supervision of a licensed physician and surgeon,” this boils down 
to a question of what it means for a physician assistant to be 
“under the supervision” of a licensed physician.  (Bus. & Prof. 
Code, former § 3502, subd. (a).) 
According to Lopez, that phrase means that the level of 
supervision provided by the assigned supervising physician 
must be adequate under the governing statutes and regulations.  
By contrast, Freesemann and Hughes contend that a physician 
assistant is “under the supervision” of a licensed physician so 
long as the physician has taken on the legal responsibility to 
supervise the physician assistant through the formation of a 
DSA, regardless of the adequacy of supervision at any given 
time.  Both are reasonable interpretations of the statute’s 
ambiguous text.  But we do not read the text in a vacuum; our 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
10 
task is to construe the statutory language in a manner that 
“comports most closely with the apparent intent of the 
Legislature, with a view to promoting rather than defeating the 
general purpose of the statute, and avoid an interpretation that 
would lead to absurd consequences.”  (People v. Jenkins (1995) 
10 Cal.4th 234, 246.) 
The version of Business and Professions Code section 3501 
that applies to this case defined “supervision” to mean that a 
licensed physician “oversees the activities of, and accepts 
responsibility for, the services rendered by the physician 
assistant.”  (Bus. & Prof. Code, former § 3501, subd. (a)(6) [now 
subd. (f)(1)].)  This language suggests that a physician 
“supervis[es]” a physician assistant when the physician 
undertakes legal responsibility for the physician assistant’s 
conduct.  While that provision has recently been amended to 
additionally specify that supervision requires “[a]dherence to 
adequate supervision as agreed to in the practice agreement,” 
the amended law is not before us today.  (Bus. & Prof. Code, 
§ 3501, subd. (f)(1)(A).) 
Further, as noted, the Legislature enacted MICRA “in 
response 
to 
rapidly 
increasing 
premiums 
for 
medical 
malpractice insurance” that threatened the availability of 
adequate medical care in California.  (Preferred Risk Mutual 
Ins. Co. v. Reiswig (1999) 21 Cal.4th 208, 214; see Western 
Steamship, supra, 8 Cal.4th at p. 111.)  “MICRA provisions 
should be construed liberally in order to promote the legislative 
interest . . . to reduce [these] premiums.”  (Preferred Risk, at 
p. 215.)  The act aims “to contain the costs of malpractice 
insurance by controlling or redistributing liability for damages, 
thereby maximizing the availability of medical services to meet 
the state’s health care needs.”  (Western Steamship, at p. 112.)  
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
11 
“Section 3333.2 constitutes a key component of this program.”  
(Western Steamship, at p. 114.)  The $250,000 cap was designed 
“to control and reduce medical malpractice insurance costs by 
placing a predictable, uniform limit on the defendant’s liability 
for noneconomic damages.”  (Salgado v. County of Los Angeles 
(1998) 19 Cal.4th 629, 641 (Salgado).)  An interpretation of the 
“scope of services” proviso based on adequacy of supervision 
“would threaten not only this goal but also the broader purpose 
of MICRA” (Western Steamship, at p. 112) for several reasons. 
First, a standard based on adequacy of supervision could 
create inconsistencies in damages depending on whether a 
plaintiff sues the supervising physician or the physician 
assistant.  A supervising physician who provides inadequate 
supervision to a physician assistant may be directly liable for 
his or her own negligence.  (See Delfino v. Agilent Technologies, 
Inc. (2006) 145 Cal.App.4th 790, 815 [“Liability for negligent 
supervision and/or retention of an employee is one of direct 
liability for negligence, not vicarious liability.”].)  Under such a 
theory of liability, any noneconomic damages would be subject 
to the cap in section 3333.2 because a supervising physician who 
negligently supervises a physician assistant who commits 
malpractice acts “within the scope of services for which the 
provider is licensed.”  (§ 3333.2, subd. (c)(2).)  But, in Lopez’s 
view, if the plaintiff pursued a negligence claim against the 
physician assistant, the limit on noneconomic damages would 
not apply because the inadequate supervision would render the 
physician assistant outside the scope of his or her license.  
“Permitting an unlimited award of noneconomic damages 
against the physician assistant and only a limited award against 
the supervising physician based upon the same harm would be 
both irrational and inconsistent with MICRA’s goal of 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
12 
predictability in damage awards.”  (Lopez, supra, 46 
Cal.App.5th at p. 998.) 
Second, the regulations governing physician assistants 
place most of the onus of ensuring compliance with day-to-day 
supervisory obligations on the supervising physician, not the 
physician assistant.  Those regulations provide that a 
“supervising physician shall be available in person or by 
electronic communication at all times when the physician 
assistant is caring for patients,” a “supervising physician shall 
observe or review evidence of the physician assistant’s 
performance” of all delegated tasks and procedures, and a 
“supervising physician has continuing responsibility to . . . make 
sure 
that 
the 
physician 
assistant 
does 
not 
function 
autonomously.”  (Cal. Code Regs., tit. 16, § 1399.545, subds. (a), 
(c), (f).)  As a practical matter, a physician assistant may have 
little ability to monitor or control whether a supervising 
physician complies with his or her supervisory obligations, such 
as the obligation to be available at all times. 
The trial court in this case found it likely that Freesemann 
and Hughes knew they were not adequately supervised.  To take 
into account a physician assistant’s knowledge, one could craft 
a rule that deems a physician assistant’s services to be outside 
the scope of his or her license when the physician assistant 
knows that the supervising physician violated a supervisory 
obligation and the physician assistant proceeds to treat patients 
nonetheless.  It may be that such a rule would protect the health 
and welfare of some patients by disincentivizing physician 
assistants from acting autonomously in the face of known 
supervisory violations. 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
13 
But such a rule, which no party urges us to adopt, would 
require case-by-case inquiry into the nature, timing, and extent 
of a physician assistant’s knowledge of lapses in supervision.  In 
circumstances where an injury is attributable to multiple 
lapses, would it be enough to take a physician assistant’s 
activities outside the scope of his or her license if the physician 
assistant knows of some but not all of the lapses?  And for what 
period of time in relation to the injury must the physician 
assistant know of the lapses?  The latter question may be 
especially relevant in the context of a missed diagnosis or failure 
to provide appropriate treatment over several months or years.  
Detailed inquiry into and potential litigation over these fact-
intensive questions would be at odds with MICRA’s goal of 
ensuring predictability in damage awards.  Moreover, it remains 
the case that such knowingly autonomous conduct by physician 
assistants constitutes professional negligence that may result in 
legal liability (albeit limited by MICRA) and professional 
discipline.  Although these consequences do not go as far as 
Lopez would like, they do disincentivize rogue conduct in the 
known absence of meaningful supervision. 
An interpretation of the “scope of services” proviso based 
on the legal agency relationship between the supervising 
physician and physician assistant avoids the unpredictability 
discussed above.  Under this interpretation, a physician 
assistant acts within the scope of his or her license as long as he 
or she acts under an established agency relationship with a 
licensed physician, provides the type of medical services he or 
she is authorized to provide as the physician’s agent, and does 
not engage in an area of practice prohibited by the PAPA. 
A standard based on the formation of a legal agency 
relationship also comports with MICRA’s goal “to control and 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
14 
reduce medical malpractice insurance costs.”  (Salgado, supra, 
19 Cal.4th at p. 641.)  “In medical malpractice litigation, 
noneconomic damages typically account for a large part of a total 
damage award and, therefore, a large part of the insurance 
carriers’ expense.”  (Perry v. Shaw (2001) 88 Cal.App.4th 658, 
668 (Perry).)  The size of noneconomic damage awards against a 
physician 
assistant 
affects 
the 
supervising 
physician’s 
insurance premiums because after an agency relationship is 
formed, the supervising physician is legally responsible for any 
malpractice committed by the physician assistant.  (See Cal. 
Code Regs., tit. 16, § 1399.545, subd. (f) [“The supervising 
physician shall be responsible for all medical services provided 
by a physician assistant under his or her supervision.”].)  The 
risk of unpredictable, large noneconomic damage awards 
against a physician assistant therefore may impact the 
malpractice insurance premiums of both the physician assistant 
and the supervising physician.   
To be sure, there are reasonable policy arguments for 
excluding physician assistants who perform medical services 
without actual supervision from a cap on noneconomic damages, 
and the Legislature is well equipped to weigh and reweigh the 
competing policy considerations.  But our role is confined to 
interpreting the statute before us in the manner that comports 
most closely with the Legislature’s purpose in enacting MICRA.  
We hold that a physician assistant practices within the scope of 
his or her license for purposes of MICRA’s cap on noneconomic 
damages when the physician assistant acts as the agent of a 
licensed physician, performs the type of services authorized by 
that agency relationship, and does not engage in an area of 
practice prohibited by the PAPA.  (Bus. & Prof. Code, former 
§ 3502, subd. (d).) 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
15 
B. 
 
Next, we turn to the proviso exempting from section 
3333.2 services that are “within any restriction imposed by the 
licensing agency or licensed hospital.”  (§ 3333.2, subd. (c)(2).)  
In Bourhis, we interpreted an identical provision in another 
section of MICRA.  (Bourhis, supra, 40 Cal.3d at pp. 435–436; 
see Bus. & Prof. Code, § 6146, subd. (c)(3).)  Bourhis involved a 
psychiatrist who allegedly induced the plaintiff “to participate 
in sexual conduct by suggesting that it was part of the therapy 
designed to alleviate her sexual inhibitions, and at other times 
he coerced her to participate by threatening to have her 
institutionalized if she did not cooperate.”  (Bourhis, at p. 428.)  
The case settled before trial, and the attorney retained a higher 
percentage of the settlement amount than he would have been 
permitted to retain under the MICRA contingency fee limitation 
in Business and Professions Code section 6146.  (Bourhis, at 
pp. 427–428.) 
The attorney argued on appeal that “because sexual 
misconduct by a psychiatrist toward a patient has long been a 
basis for disciplinary action by the state’s licensing agency 
[citation], any cause of action which is based on such misconduct 
falls within the proviso, as a ‘restriction imposed by the licensing 
agency.’ ”  (Bourhis, supra, 40 Cal.3d at p. 436, fn. omitted.)  We 
rejected this argument, explaining that the proviso “obviously 
was not intended to exclude an action from section 6146 — or 
the rest of MICRA — simply because a health care provider acts 
contrary to professional standards or engages in one of the many 
specified instances of ‘unprofessional conduct.’  Instead, it was 
simply intended to render MICRA inapplicable when a provider 
operates in a capacity for which he is not licensed — for 
example, when a psychologist performs heart surgery.”  (Ibid.)  
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
16 
We held that “the psychiatrist’s conduct arose out of the course 
of the psychiatric treatment he was licensed to provide.”  (Ibid.) 
 
Lopez argues that a physician assistant who treats 
patients without adequate supervision renders services “within 
[a] restriction imposed by the licensing agency.”  (§ 3333.2, 
subd. (c)(2).)  We disagree.  The trial court found that the 
negligible supervision in this case violated several regulations 
governing the conduct of supervising physicians and physician 
assistants.  (See, e.g., Cal. Code Regs., tit. 16, §§ 1399.545, 
subds. (a) [“A supervising physician shall be available in person 
or by electronic communication at all times when the physician 
assistant is caring for patients.”], (f) [“The supervising physician 
has continuing responsibility to follow the progress of the 
patient and to make sure that the physician assistant does not 
function autonomously.”], 1399.540, subd. (d) [“A physician 
assistant shall consult with a physician regarding any task, 
procedure or diagnostic problem which the physician assistant 
determines exceeds his or her level of competence or shall refer 
such cases to a physician.”].)  But these regulations, which 
describe various requirements of appropriate supervision, are 
not restrictions imposed by a physician assistant’s licensing 
agency.  As we explained in Bourhis, the proviso was not 
intended to exclude an action from MICRA “simply because a 
health care provider acts contrary to professional standards or 
engages in one of the many specified instances of ‘unprofessional 
conduct.’  Instead, it was simply intended to render MICRA 
inapplicable when a provider operates in a capacity for which he 
is not licensed . . . .”  (Bourhis, supra, 40 Cal.3d at p. 436.) 
 
The PAPA provides several examples of restrictions that, 
if imposed by the licensing agency, would limit a physician 
assistant’s license and place particular services outside the 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
17 
ambits of MICRA.  The Physician Assistant Board may issue a 
probationary license that imposes “[r]estrictions against 
engaging in certain types of medical services” or “restrictions on 
issuing a drug order for controlled substances.”  (Bus. & Prof. 
Code, former § 3519.5, subd. (a)(7), (2).)  And when a physician 
assistant is accused of engaging in “unprofessional conduct,” 
including the violation of the supervisory regulations at issue 
here, the Physician Assistant Board may, after a hearing, 
impose “probationary conditions upon a [physician assistant] 
license.”  (Id., § 3527, subd. (a).)  Such probationary conditions 
would by definition amount to a “restriction imposed by the 
licensing agency.”  (Civ. Code, § 3333.2, subd. (c)(2).)  But 
unprofessional conduct, without more, does not.  We agree with 
the Court of Appeal that “the ‘restriction’ mentioned in this 
clause must be a limitation on the scope of a provider’s practice 
beyond simply the obligation to adhere to standards of 
professional conduct.”  (Lopez, supra, 46 Cal.App.5th at p. 997, 
fn. 17.) 
If unprofessional conduct of the kind at issue here were 
alone sufficient to trigger the “within any restriction imposed by 
the 
licensing 
agency” 
proviso 
in 
section 
§ 3333.2, 
subdivision (c)(2), then medical malpractice plaintiffs could 
avoid MICRA’s damages cap by identifying one member of a 
health care team who violates a single regulation governing that 
team.  That individual, and potentially the supervising 
physician under a theory of vicarious liability, would then be 
subject to unlimited liability for noneconomic damages.  
Allowing medical malpractice plaintiffs to avoid the MICRA cap 
in this way would be at odds with MICRA’s purpose to “control 
and reduce medical malpractice insurance costs by placing a 
predictable, uniform limit on a defendant’s liability for 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
18 
noneconomic damages.”  (Salgado, supra, 19 Cal.4th at p. 641.)  
Neither the language of MICRA nor the legislative history 
provides any indication that the Legislature intended to enact 
such a broad exemption from the cap.  We hold that a physician 
assistant does not render services “within [a] restriction 
imposed by the licensing agency” (§ 3333.2, subd. (c)(2)) simply 
by 
engaging 
in 
unprofessional 
conduct, 
such 
as 
the 
noncompliance with supervisory regulations at issue in this 
case. 
C. 
Lopez cites Perry for the proposition that MICRA’s cap on 
noneconomic damages should be construed narrowly.  But the 
Court of Appeal in Perry reached no such conclusion.  Instead, 
the court declined to apply MICRA’s cap on noneconomic 
damages to intentional torts because “section 3333.2 applies 
only in actions ‘based on professional negligence,’ ” and nothing 
in the legislative history “suggest[s] the Legislature intended to 
exempt intentional wrongdoers from liability by treating such 
conduct as though it had been nothing more than mere 
negligence.”  (Perry, supra, 88 Cal.App.4th at p. 669.)  No 
intentional wrongdoing is at issue here. 
Lopez also argues that the “purpose of [s]ection 3333.2 is 
to provide a benefit to health care professionals” by limiting 
their liability for noneconomic damages and that physician 
assistants who act without adequate supervision should not 
“reap the benefits” of MICRA’s “protections.”  But this 
misapprehends the purpose of the noneconomic damages cap.  
“ ‘[T]he $250,000 limitation . . . does not reflect a legislative 
determination that a person injured as a result of medical 
malpractice does not suffer such damages’ ” and “is not a 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
19 
legislative attempt to estimate the true damages suffered by 
plaintiffs.”  (Salgado, supra, 19 Cal.4th at p. 641.)  Nor is it a 
licensing provision or part of a code of professional standards 
designed to protect health care providers who adhere to certain 
standards or comply with particular statutes and regulations.  
Rather, the $250,000 cap is an “attempt to control and reduce 
medical malpractice insurance costs.”  (Ibid.)  The damages cap 
inherently concerns health care providers alleged or proven to 
have engaged in negligent conduct; it is not designed to reward 
or protect health care providers who, acting within the scope of 
their education and training, adhere to professional standards 
while exempting those who do not. 
Lopez further argues that because Freesemann’s and 
Hughes’s conduct could subject them to professional discipline 
or criminal liability, the conduct is not “professional negligence” 
under section 3333.2.  But the question of whether a physician 
assistant’s conduct provides a basis for professional discipline or 
criminal liability is distinct from the question of whether such 
conduct constitutes “professional negligence” within the 
meaning of section 3333.2.  As we have held, MICRA may apply 
to the misconduct of a health care provider even if the 
misconduct could serve as the basis for professional discipline.  
(Bourhis, supra, 40 Cal.3d at p. 436 [rejecting defendant’s 
argument that MICRA does not apply because “sexual 
misconduct by a psychiatrist toward a patient has long been a 
basis for disciplinary action by the state’s licensing agency”].) 
Likewise, the possibility that criminal liability could 
attach to a health care provider’s conduct does not necessarily 
render MICRA inapplicable.  In Bourhis, we held that MICRA 
applied to an action against a psychiatrist who compelled his 
patient to submit to sexual intercourse by “threatening to have 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
20 
her institutionalized if she did not cooperate.”  (Bourhis, supra, 
40 Cal.3d at p. 428.)  It is possible that such conduct could give 
rise to criminal liability.  (Pen. Code, § 261.)  But we held that 
the limitation on damages still governed because “the 
psychiatrist’s conduct arose out of the course of the psychiatric 
treatment he was licensed to provide.”  (Bourhis, at p. 436; see 
also Larson v. UHS of Rancho Springs, Inc. (2014) 
230 Cal.App.4th 336, 351–352; David M. v. Beverly Hospital 
(2005) 131 Cal.App.4th 1272, 1278.)   
Neither our case law nor the language of MICRA suggests 
that the possibility of professional discipline or criminal liability 
necessarily places a health care provider’s actions outside “the 
scope of services for which [he or she] is licensed” or “within any 
restriction imposed by the licensing agency or licensed hospital.”  
(§ 3333.2, subd. (c)(2).)  We thus conclude that the fact that 
Freesemann’s and Hughes’s conduct could give rise to 
professional discipline or criminal liability does not render 
MICRA inapplicable. 
III. 
We also granted review on a second issue:  whether a DSA 
between a supervising physician and a physician assistant is 
legally effective where the physician is disabled and unable to 
practice medicine.  On closer examination, we decline to 
consider this issue, which was neither raised in the trial court 
nor timely raised in the Court of Appeal. 
The trial court held that the DSA between Dr. Ledesma 
and Freesemann was nominally in effect at the time of 
Freesemann’s clinical encounters with O.S. because “[n]either 
party formally revoked the DSA.”  Likewise, the trial court held 
that 
Dr. 
Koire 
and 
Hughes 
“had 
a 
[supervising 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
21 
physician-physician assistant] relationship” by virtue of their 
DSA.  Lopez raised no challenge to these findings in the trial 
court.  Nor did Lopez challenge these findings in her briefing in 
the Court of Appeal.   
In her petition for rehearing before the Court of Appeal, 
Lopez argued for the first time that there was no DSA legally in 
effect between Dr. Ledesma and Freesemann because the DSA 
was “revoked by operation of law” due to “incapacity of the 
principal.”  In her petition for review before this court, Lopez 
argued for the first time that the DSA between Dr. Koire and 
Hughes had also been revoked. 
“[A] reviewing court ordinarily will not consider a 
challenge to a ruling if an objection could have been but was not 
made in the trial court.”  (In re S.B. (2004) 32 Cal.4th 1287, 
1293.)  As a matter of policy, “we normally do not consider any 
issue that could have been but was not timely raised in the briefs 
filed in the Court of Appeal.”  (Flannery v. Prentice (2001) 26 
Cal.4th 572, 591 (Flannery); Cal. Rules of Court, rule 
8.500(c)(1).)   
Lopez asks us to exercise our discretion to consider an 
issue of DSA revocation that was neither raised in the trial court 
nor timely raised in the Court of Appeal.  (See Midland Pacific 
Building Corporation v. King (2007) 157 Cal.App.4th 264, 276.)  
But Lopez’s case-specific argument that the disabilities of Dr. 
Ledesma and Dr. Hughes severed the agency relationship 
established in their respective DSAs does not raise “ ‘extremely 
significant issues of public policy and public interest’ [citation] 
such as may have caused us on infrequent prior occasions to 
depart from” our ordinary policy.  (Flannery, supra, 26 Cal.4th 
at p. 591.)  Moreover, it turns on facts not addressed by the trial 
LOPEZ v. LEDESMA 
Opinion of the Court by Liu, J. 
 
22 
court, such as the severity of Dr. Ledesma’s disability.  We 
therefore decline to consider this issue. 
CONCLUSION 
 
We affirm the judgment of the Court of Appeal. 
 
LIU, J. 
 
We Concur: 
CANTIL-SAKAUYE, C. J. 
CORRIGAN, J. 
KRUGER, J. 
GROBAN, J. 
JENKINS, J. 
MEEHAN, J.*
 
*  
Associate Justice of the Court of Appeal, Fifth Appellate 
District, assigned by the Chief Justice pursuant to article VI, 
section 6 of the California Constitution. 
 
 
See next page for addresses and telephone numbers for counsel who 
argued in Supreme Court. 
 
Name of Opinion  Lopez v. Ledesma 
__________________________________________________________  
 
Procedural Posture (see XX below) 
Original Appeal  
Original Proceeding 
Review Granted (published) XX 46 Cal.App.5th 980 
Review Granted (unpublished)  
Rehearing Granted 
__________________________________________________________  
 
Opinion No. S262487 
Date Filed:  February 24, 2022 
__________________________________________________________  
 
Court:  Superior  
County: Los Angeles  
Judge: Lawrence P. Riff 
__________________________________________________________   
 
Counsel: 
 
Esner, Chang & Boyer, Stuart B. Esner; Law Office of Neil M. Howard 
and Neil M. Howard for Plaintiff and Appellant. 
 
Steven B. Stevens for Consumer Attorneys of California as Amicus 
Curiae on behalf of Plaintiff and Appellant. 
 
Cole Pedroza, Kenneth R. Pedroza, Matthew S. Levinson and Zena 
Jacobsen for Defendants and Appellants.  
 
Reback, McAndrews & Blessey and Thomas F. McAndrews for 
Defendant and Appellant Glen Ledesma. 
 
LaFollette Johnson De Haas Fesler & Ames and Louis DeHaas for 
Defendant and Appellant  Suzanne Freesemann. 
 
Peterson Bradford Burkwitz and Avi A. Burkwitz  for Defendant and 
Appellant Brian Hughes. 
 
 
 
Fred J. Hiestand for the Civil Justice Association of California as 
Amicus Curiae on behalf of Defendants and Appellants. 
 
Tucker Ellis and Traci L. Shafroth for California Medical Association, 
California Dental Association, California Hospital Association, 
California Academy of Physician Assistants, and the American Medical 
Association as Amici Curiae on behalf of Defendants and Appellants. 
 
Prindle, Goetz, Barnes & Reinholtz, Jack R. Reinholtz and Douglas S. 
de Heras for Defendant and Respondent. 
 
 
Counsel who argued in Supreme Court (not intended for 
publication with opinion): 
 
Stuart B. Esner 
Esner, Chang & Boyer LLP 
234 East Colorado Boulevard, Suite 975 
Pasadena, CA 91101 
(626) 535-9860 
 
Matthew S. Levinson 
Cole Pedroza LLP 
2295 Huntington Drive 
San Marino, CA 91108 
(626) 431-2787