Opinion ID: 891696
Heading Depth: 3
Heading Rank: 2

Heading: HCQIA Immunity Applies When the Fact-Finding Process is Objectively Reasonable.

Text: {13} While this Opinion marks the first opportunity this Court has had to consider the immunity provisions of the HCQIA, we previously have discussed the policy of utilizing professional peer review actions to assure quality health care. In Southwest Community Health Services v. Smith, we described the ROIA as promot[ing] the improvement of health care in New Mexico. 107 N.M. 196, 198, 755 P.2d 40, 42 (1988). [The ROIA] recognizes that candor and objectivity in the critical evaluation of medical professionals by medical professionals is necessary for the efficacy of the review process. Id. Likewise, the goal of the HCQIA immunity provision is to promote professional peer review to prevent the practice of medicine by incompetent medical professionals. 42 U.S.C. § 11101(2). The HCQIA provides immunity from damages, the threat of which unreasonably discourages physicians from participating in effective professional peer review. 42 U.S.C. § 11101(4). [3] Any consideration of the immunity provided by the HCQIA, therefore, must be conducted in light of the goal of promoting physician participation in professional peer review activities. {14} Immunity applies when a professional review action, as defined at 42 U.S.C. § 11151(9), is taken in compliance with the standards of Section 11112(a): (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). The statute presumes compliance, and thus immunity, unless the presumption is rebutted by a preponderance of the evidence. Id. At issue in this appeal is the second of the immunity requirements, whether Defendants permanently suspended Plaintiff's internal medicine and psychiatry privileges after a reasonable effort to obtain the facts of the matter. 42 U.S.C. § 11112(a)(2). In order to rebut the presumption of reasonableness, Plaintiff must produce evidence showing that the fact-finding process conducted by Defendants was not objectively reasonable. See Poliner, 537 F.3d at 379-80. {15} Under the HCQIA, a physician is entitled only to a reasonable investigation. See Poliner, 537 F.3d at 380 (noting that a physician is entitled to a reasonable effort, not a perfect effort); Singh, 308 F.3d at 43 (same). The HCQIA does not require participants at every level of a peer review action to perform an independent investigation of the facts. Participants in later stages of the review process are entitled to rely on information gathered in earlier stages; reliance on the information provided by other doctors is presumptively reasonable. See Poliner, 537 F.3d at 380 (stating that peer reviewers were entitled to rely on the information provided ... by the other doctors, and there is nothing to suggest that the information was facially flawed or otherwise so obviously deficient as to render [the d]efendants' reliance `unreasonable' (footnote omitted)); Gabaldoni v. Wash. Cnty. Hosp. Ass'n, 250 F.3d 255, 261-62 (4th Cir.2001) (finding it reasonable for the ultimate decision maker to rely on reports of various committees because [a]lthough the summaries [of the investigations] did notand indeed could notinclude every single fact and finding from every committee report, there is no evidence to suggest that the summaries provided to the Board were materially insufficient or misleading); Bryan, 33 F.3d at 1335 (concluding that the plaintiff did not overcome the presumption that reasonable effort was used to gather facts when three separate panels submitted reports to the board, which made its decision based upon the documentary record developed during the various peer review proceedings and after [the plaintiff] had the opportunity to make a presentation); N. Colo. Med. Ctr., 27 P.3d at 840 (holding that the board of directors acted reasonably to obtain the facts when it suspended the physician only after a lengthy investigation by a number of committees and independent parties). {16} The presumption of reasonableness is not overcome by simply identifying one piece of factually questionable evidence upon which the peer review committees relied. See Meyers v. Columbia/HCA Healthcare Corp., 341 F.3d 461, 469 (6th Cir.2003) (concluding a physician did not meet his burden by only making conclusory statements attacking individual items of evidence considered by the reviewers); Brader, 167 F.3d at 841 (holding the fact-finding process reasonable despite the plaintiff's argument that one study was flawed and his views were not heard when the ultimate decision was based on an initial review, first hand observations, testimony before an impartial panel, written submissions, and two levels of appellate review). To overcome the presumption of reasonableness, the physician must show that the fact-finding process is unreasonable in its totality. {17} Nor can the physician challenge the fact-finding process by questioning the integrity or motivations of the individuals conducting the professional peer review. See Mathews v. Lancaster Gen. Hosp., 87 F.3d 624, 637 (3d Cir.1996) (stating that a challenge to the integrity of one of the investigating committees did not rebut the presumption that the defendants had engaged in a reasonable effort to obtain the facts); Reyes v. Wilson Mem'l Hosp., 102 F.Supp.2d 798, 818-19 (S.D.Ohio 1998) (finding that the plaintiff did not rebut the presumption of reasonableness when the only evidentiary rejoinder ... consists of testimony impugning the motives of the [d]efendants and an argument that additional evidence could have been discovered). Because HCQIA immunity applies when the fact-finding process is objectively reasonable, an inquiry into the subjective intent of the individual members of the various review committees is inappropriate. {18} Additionally, the failure of a professional peer review to comply in full with applicable bylaws does not render the fact-finding process unreasonable. 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. Poliner, 537 F.3d at 381. Compliance with the bylaws is a good measure of the reasonableness of the peer review process, but doing so is not required by the HCQIA. {19} To rebut the presumption of reasonableness in the fact-finding efforts of the peer review action, a plaintiff must point to specific and material facts demonstrating that the fact-finding efforts were unreasonable. See Goodwich v. Sinai Hosp. of Baltimore, Inc., 103 Md.App. 341, 653 A.2d 541, 546 (1995) (concluding that the plaintiff did not meet his burden by present[ing] no evidence, absent his own bare allegations, that a reasonable effort was not made to obtain the facts). In Brown v. Presbyterian Healthcare Services, the Tenth Circuit held that the plaintiff successfully rebutted the presumption that the fact-finding process was reasonable by demonstrating, through expert testimony, that the peer review process consisted of one meeting, two chart reviews, and two hours of deliberation before the plaintiff's privileges were revoked. 101 F.3d 1324, 1333-34 (10th Cir.1996). Unlike the cases cited above, the Brown plaintiff presented sufficient evidence from which a reasonable jury could have found the panel's review to be unreasonably restrictive and not taken after a `reasonable effort to obtain the facts.' Id. at 1334.