Opinion ID: 62897
Heading Depth: 1
Heading Rank: 3

Heading: Health Care Quality Improvement Act

Text: Congress passed the Health Care Quality Improvement Act because it was concerned about [t]he increasing occurrence of medical malpractice and the need to improve the quality of medical care, and because [t]here is a national need to restrict the ability of incompetent physicians to move from State to State without disclosure or discovery of the physician's previous damaging or incompetent performance. [20] Congress viewed peer review as an important component of remedying these problems, but recognized that lawsuits for money damages dampened the willingness of people to participate in peer review. [21] Accordingly, Congress grant[ed] limited immunity from suits for money damages to participants in professional peer review actions. [22] When a professional review action as defined by the statute meets certain standards, the HCQIA provides that participants in the peer review shall not be liable in damages under any law of the United States or of any State (or political subdivision thereof) with respect to the action. [23] The statute establishes four requirements for immunity: For purposes of the protection set forth in section 11111(a) of this title, a professional review action must be taken (1) in the reasonable belief that the action was in the furtherance of quality health care, (2) after a reasonable effort to obtain the facts of the matter, (3) after adequate notice and hearing procedures are afforded to the physician involved or after such other procedures as are fair to the physician under the circumstances, and (4) in the reasonable belief that the action was warranted by the facts known after such reasonable effort to obtain facts and after meeting the requirement of paragraph (3). [24] The Act includes a presumption that a professional review [action] meets the standards for immunity, `unless the presumption is rebutted by a preponderance of the evidence.' [25] We agree with our sister circuits that the HCQIA's reasonableness requirements were intended to create an objective standard of performance, rather than a subjective good faith standard. [26]
HCQIA immunity extends to professional review actions. The Act defines a professional review action in part as an action or recommendation of a professional review body which is taken or made in the conduct of professional review activity, which is based on the competence or professional conduct of an individual physician (which conduct affects or could affect adversely the health or welfare of a patient or patients), and which affects (or may affect) adversely the clinical privileges, or membership in a professional society, of the physician. [27] The jury was charged that the May 14 abeyance and the extension of the abeyance were both professional review actions. We agree. Both restrictions on Poliner's cath lab privileges meet the substantive elements of this definition. While there could be no extension of the abeyance without the initial abeyance, the extension of the abeyance resulted from an independent decision that another period of restriction was needed. To put it differently, the May 14 abeyance and the extension, although imposing the same substantive restrictions, enjoyed distinct justification and in this sense independently limited Poliner's privileges. [28] Thus, we evaluate the abeyance and the extension separately for compliance with § 11112(a). To be clear, the abeyances are temporary restrictions of privileges, and we use that terminology, which comes from the Medical Staff bylaws, in our discussion; but for the purposes of HCQIA immunity from money damages, what matters is that the restriction of privileges falls within the statute's definition of peer review action, and what we consider is whether these peer review actions satisfy the HCQIA's standards, and not whether the abeyances satisfy the bylaws. We deal with one other preliminary matter now. The decision to extend the abeyance was made after the ad hoc committee reported the results of its review to Knochel and the IMAC; however, because of the district court's pre-trial order of July 7, the jury did not learn of this. This does not impede our consideration of the evidence because the district court's summary judgment and July 7 orders establish the relevant historical facts [29] and the propriety of the ad hoc committee review for HCQIA purposes. The district court found that the ad hoc committee members were entitled to HCQIA immunity, and more to the point, the ad hoc committee's review undergirded the grant of HCQIA immunity for the June 12 suspension. Neither of the orders has been challenged on appeal. They are the law of the case.
We begin with whether each peer review action was taken in the reasonable belief that the action was in the furtherance of quality health care. It is plain that they were by the controlling standards. Other circuits have explained, as relevant under the facts of this case, that [t]he `reasonable belief' standard of the HCQIA is satisfied if `the reviewers, with the information available to them at the time of the professional review action, would reasonably have concluded that their action would restrict incompetent behavior or would protect patients.' [30] [T]he Act does not require that the professional review result in an actual improvement of the quality of health care, [31] nor does it require that the conclusions reached by the reviewers were in fact correct. [32] It bears emphasizing that the good or bad faith of the reviewers is irrelevant; [33] rather it is an objective inquiry in which we consider the totality of the circumstances. [34] It is indisputable that Poliner's treatment of Patient 36 raised serious questions about what had happened and why. Missing the LAD was a critical diagnostic error, made all the more troubling by the fact that Das and Levin saw the LAD; indeed, Poliner described the LAD as obvious and clear in his addendum. The concerns that flow from the LAD are amplified by the problems with Poliner's other patients that had been brought to Knochel's attention. It was in relatively quick succession that Knochel was presented with separate cases that called into question Poliner's medical judgment. That Poliner had over 20 years of experience and an apparently clean record before these cases only serves to heighten the concern: why was this experienced physician now having these problems? On May 14, there was ample basis for concern. The ad hoc committee's review, upon which the extension of the abeyance rested, speaks for itself. A group of six cardiologists reviewed 44 of Poliner's cases and concluded that he gave substandard care in more than half of the cases. We conclude that, as to both peer review actions, the belief that temporarily restricting Poliner's cath lab privileges during an investigation would further quality health care was objectively reasonable. Poliner defends the jury's verdict by arguing that the evidence demonstrates that had Poliner actually administered the purported `care' demanded by the critics, he would have affirmatively endangered his patients. Setting aside the fact that the evidence is not so unequivocal, this argument suffers from two interrelated flaws. First, our inquiry focuses on the information available to Defendants when they made the critical decisions. Defendants did not have the benefit of post-hoc expert analyses at that time. [35] Second, this focuses on whether Defendants' beliefs proved to be right. But the statute does not ask that question; rather it asks if the beliefs of Poliner's peers were objectively reasonable under the facts they had at the time. [36] If a doctor unhappy with peer review could defeat HCQIA immunity simply by later presenting the testimony of other doctors of a different view from the peer reviewers, or that his treatment decisions proved to be right in their view, HCQIA immunity would be a hollow shield. Poliner's urging of purported bad motives or evil intent or that some hospital officials did not like him provides no succor. We have serious doubts that Poliner proved that the restrictions resulted from anti-competitive motives, and more to the point, the inquiry is, as we have explained, an objective one. Our sister circuits have roundly rejected the argument that such subjective motivations overcome HCQIA immunity, [37] as do we.
The HCQIA does not require the ultimate decisionmaker to investigate a matter independently, but requires only a `reasonable effort to obtain' the facts. [38] We consider the totality of the process leading up to the professional review action. [39] No reasonable jury could conclude that Defendants failed to make a reasonable effort to obtain the facts. Prior to May 14, Patients 3, 9, and 18 had been reviewed by the CRRC, which identified the care issues involved and forwarded the cases to Knochel. Each of these cases was reviewed by a cardiologist for Knochel and the IMAC. As to Patient 36, Knochel spoke with Weinmeister, Das, Levin, and Harper. Levin reviewed the films and spoke with Poliner briefly about the case, while Harper reviewed the patient's chart and films. Das saw the LAD while the procedure was occurring and spoke with Poliner. Weinmeister had treated the patient post-procedure. And, as to the abeyance extension, Knochel relied on the review of 44 cases conducted by the ad hoc committee. As explained above, the district court's summary judgment established the propriety of the ad hoc committee review, and that remains unchallenged, for good reason. Knochel was entitled to rely on the information provided to him by the other doctors, [40] and there is nothing to suggest that the information was facially flawed or otherwise so obviously deficient so as to render Defendants' reliance unreasonable. [41] Poliner urges that omissions in the investigation and Knochel's admission at trial that further investigation was necessary before Poliner's privileges could be summarily suspendedthat is, there was insufficient evidence to denominate Poliner a present danger under the bylawssupport the jury's findings that a reasonable effort was lacking. As to the former, Poliner was entitled to a reasonable effort, not a perfect effort. [42] Poliner's latter argument is unavailing because HCQIA immunity is not coextensive with compliance with an individual hospital's bylaws. Rather, the statute imposes a uniform set of national standards. Provided that a peer review action as defined by the statute complies with those standards, a failure to comply with hospital bylaws does not defeat a peer reviewer's right to HCQIA immunity from damages. [43] It bears emphasizing that this does not mean that hospitals and peer review committees that comply with the HCQIA's requirements are free to violate the applicable bylaws and state law. The HCQIA does not gainsay the potential for abuse of the peer review process. To the contrary, Congress limited the reach of immunity to money damages. The doors to the courts remain open to doctors who are subjected to unjustified or malicious peer review, and they may seek appropriate injunctive and declaratory relief in response to such treatment. [44] The immunity from money damages may work harsh outcomes in certain circumstances, but that results from Congress' decision that the system-wide benefit of robust peer review in rooting out incompetent physicians, protecting patients, and preventing malpractice outweighs those occasional harsh results; that giving physicians access to the courts to assure procedural protections while denying a remedy of money damages strikes the balance of remedies essential to Congress' objective of vigorous peer review. [45] The doctor may not recover money damages, but can access the court for other relief preventive of an abusive peer review. It is no happenstance that this congressional push of peer review came in a period of widespread political efforts at the state level to achieve tort reform and protect medical doctors from the debilitating threat of money damages. It would have been quixotic at best if those efforts were accompanied by tolerance of money damages suits by doctors facing peer review where tort reformers assured that discipline of doctors would be found.
Section 11112(a)(3) imposes certain procedural requirements, namely that a peer review action is taken after adequate notice and hearing procedures are afforded to the physician involved or after such other procedures as are fair to the physician under the circumstances. Section 11112(b) provides a safe harbor set of procedures that, if given, means that the health care entity is deemed to have met the adequate notice and hearing requirement. Finally, § 11112(c) provides, (c) Adequate procedures in investigations or health emergencies For purposes of section 11111(a) of this title, nothing in this section shall be construed as (1) requiring the procedures referred to in subsection (a)(3) of this section (A) where there is no adverse professional review action taken, or (B) in the case of a suspension or restriction of clinical privileges, for a period of not longer than 14 days, during which an investigation is being conducted to determine the need for a professional review action; or (2) precluding an immediate suspension or restriction of clinical privileges, subject to subsequent notice and hearing or other adequate procedures, where the failure to take such an action may result in an imminent danger to the health of any individual. The peer review actions satisfy the HCQIA's procedural requirements. The May 14 restriction falls squarely within § 11112(c)(1)(B)'s scope. The abeyance was a restriction of privileges that was imposed to allow for an investigation to determine whether other action, such as a suspension, was necessary. Poliner urges that the provision does not apply because the restriction lasted for 15 days, one day longer than is permissible. We are not persuaded. The ad hoc committee completed its review and reported its results to Knochel and the IMAC on May 27. Upon receipt of the ad hoc committee report, Defendants had an objectively reasonable basis to take another peer review action. The IMAC decided that same day that a further restriction of Poliner's privileges was necessary. For immunity purposes it is of no moment that they requested Poliner's consent to the extension of the abeyance on May 29, the purported fifteenth day, because the decision to further restrict his privileges was made within the required 14 days. We conclude that the extension of the abeyance falls within § 11112(c)(2)'s curtilage, [46] and in any event, Defendants imposed the restriction after procedures that were fair to Poliner under the circumstances. The emergency provision requires only that a failure to act may result in an imminent danger to the health of any individual. That the ad hoc committee concluded that Poliner gave substandard care in half of the cases reviewed, and considering the seriousness of the diagnostic error with Patient 36 and the serious risks that attend cardiac catheterizations, Defendants were fully warranted in concluding that failing to impose further temporary restrictions may result in an imminent danger. Poliner contends that this provision applies in extraordinary cases in which a physician suddenly becomes impaired or grossly incompetent. Poliner cites no authority for this proposition, and the plain language of the statute is not so limited. Moreover, authority from our sister circuits and the district courts conclude that the provision is not so narrow, [47] as does an unpublished decision from our court. [48] Poliner received the subsequent notice and hearing or other adequate procedures that the provision contemplates. To the point, the district court ruled at summary judgment that, as to the June 12 suspension, Poliner received notice and hearing adequate to satisfy the HCQIA. That ruling, which has not been challenged, establishes that Poliner received adequate process for purposes of the emergency provision. Our review confirms this, and further leads us to conclude that the extension was imposed after such other procedures as are fair to the physician under the circumstances. The May 14 letter provided notice to Poliner of the peer review, which patient triggered it, the other patients then-of concern, that an ad hoc committee review would be taken and a general description of how that review would be conducted, and finally that Poliner would have an opportunity to meet with the [IMAC] and me in person to respond to or clarify any clinical concerns that could result in a recommendation for corrective action prior to that action being taken. Poliner and his lawyer knew what was happening and why before the extension. The ad hoc committee's conclusions justify Defendants' decision to impose another period of the same restrictions without immediately giving a hearing. The committee review raised serious problems with Poliner's cases, and rather than acting precipitously, Defendants sought out further information. It is difficult to conceive of a meaningfully different response from Defendants. Upon receipt of the ad hoc committee's review, it would have been untenable to restore full privileges while a hearing was scheduled and Poliner was given time to prepare. Had Defendants immediately held a hearing, there would have been no opportunity for Poliner to review the cases at issue, and we have no doubt that we would be considering whether such a hearing was fair. Further informing our analysis is the fact that Poliner had engaged counsel prior to the extension of the abeyance. It bears emphasizing that the restriction on privileges was temporary in nature and limited in scope, tailored to the objective facts before the hospital officials. Poliner received fair procedures under these circumstances. Once the decision was made, Poliner was quickly notified that the extension was needed, given further details of the ad hoc committee review, and told again that he would have an opportunity to address the IMAC. Ten days after extending the restrictions, a date for a hearing was set and Poliner was notified of the hearing, told which patients had been reviewed and the concerns in those cases, and given access to the patient records. The hearing, in which Poliner personally participated, was promptly held on June 11. This case demonstrates how the process provisions of the HCQIA work in tandem: legitimate concerns lead to temporary restrictions and an investigation; an investigation reveals that a doctor may in fact be a danger; and in response, the hospital continues to limit the physician's privileges. The hearing process is allowed to play out unencumbered by the fears and urgency that would necessarily obtain if the physician were midstream returned to full privileges during the few days necessary for a fully informed and considered decision resting on all the facts and a process in which the physician has had an opportunity to confront the facts and give his explanations. The interplay of these provisions may work hardships on individual physicians, but the provisions reflect Congress' balancing of the significant interests of the physician and the public health ramifications of allowing incompetent physicians to practice while the slow wheels of justice grind. [49] Defendants satisfied the notice and hearing requirements, and no reasonable jury could conclude otherwise.
Finally, we consider whether each peer review action was taken in the reasonable belief that the action was warranted by the facts known after such reasonable effort to obtain facts. Our analysis under § 11112(a)(4) closely tracks our analysis under § 11112(a)(1). [50] In both instances, the temporary restrictions were tailored to address the health care concerns that had been raised [51]  procedures in the cath lableaving untouched Poliner's other privileges. Nor was the information relayed to Knochel so obviously mistaken or inadequate as to make reliance on [it] unreasonable. [52] There was an objectively reasonable basis for concluding that temporarily restricting Poliner's privileges during the course of the investigation was warranted by the facts then known, and for essentially the reasons given above, we hold that Defendants satisfy this prong. To allow an attack years later upon the ultimate truth of judgments made by peer reviewers supported by objective evidence would drain all meaning from the statute. The congressional grant of immunity accepts that few physicians would be willing to serve on peer review committees under such a threat; as our sister circuit explains, `the intent of [the HCQIA] was not to disturb, but to reinforce, the preexisting reluctance of courts to substitute their judgment on the merits for that of health care professionals and of the governing bodies of hospitals in an area within their expertise.' [53] At the least, it is not our role to re-weigh this judgment and balancing of interests by Congress.