Opinion ID: 808085
Heading Depth: 2
Heading Rank: 1

Heading: hcqia

Text: Dr. Cohlmia first challenges the grant of HCQIA immunity. Enacted in 1986, HCQIA provides immunity to hospitals or doctors who perform peer reviews or challenges to professional conduct where patient care is at issue. HCQIA was adopted out of concern “that medical professionals who were sufficiently fearful of the threat of litigation will simply not do meaningful peer review, thus leaving patients at the mercy of people who should have been corrected or removed from their positions.” IB Phillip E. Areeda & Herbert Hovenkamp, Antitrust Law 19 n.1 (3d ed. 2006) (internal quotation omitted). HCQIA provides immunity from “damages under any law of the United States or of any State . . . with respect to [a professional review] action.” 42 U.S.C. § 11111(a)(1). A “professional review action” is “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.” Id. at § 11151(9). The entity or persons that undertake the professional review are immune under HCQIA as long as they substantially comply with a list of objective standards set forth in the Act. Id. at § 11111(a)(1). The “immunity applies only to hospital or clinic dismissals in -9- which the subject’s professional conduct is at issue. It creates no immunity whatsoever for purely ‘commercial’ terminations, such as dropping a specialist when a hospital enters into an exclusive agreement with a different specialist.” IB Areeda & Hovenkamp 21. The Act sets forth the procedures the professional review action should honor, and provides for immunity when actions are undertaken based on a reasonable belief that patient health is at issue. The immunity applies to actions 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). Id. at § 11112(a). A professional review action is presumed to have met the standards for HCQIA immunity unless the presumption is rebutted by the preponderance of the evidence. Id. “Courts apply an objective standard in determining whether a peer -10- review action was reasonable under [§ 11112(a)].” Brown v. Presbyterian Healthcare Servs., 101 F.3d 1324, 1333 (10th Cir. 1996). The district court focused its analysis on the fact that Dr. Cohlmia’s evidence failed to rebut the presumption of regularity and concluded that no reasonable jury could find that Dr. Cohlmia had overcome the presumption. On appeal, Dr. Cohlmia argues the evidence would support an inference rebutting SJMC’s procedures and reasonableness, relying solely on Brown. 3 In Brown, we held a plaintiff had successfully rebutted the HCQIA presumption at trial by presenting an expert who argued that the hospital’s review of two cases prior to revoking the plaintiff-physician’s privileges was unreasonably narrow and that the hospital should not be entitled to a presumption under the second factor, which provides immunity only after a “reasonable effort to obtain the facts of the matter.” Id. at 1333–34. 3 The district court distinguished Brown and rejected Dr. Cohlmia’s reliance on the case, finding: It was clear in Brown that an economic competitor had instigated the review, made false misstatements to the National Practitioner Databank, that the doctor had been found negligent and the competitor testified against the plaintiff[. I]n that case there was overwhelming proof of conjuring up evidence against the doctor. Here, the evidence of ulterior motive is inferential and in this case the Court concludes that the plaintiff has not rebutted the presumptions set out under the statute. Aplt. App. at 3123. -11- But two important differences exist between this appeal and Brown. First, Brown went to trial and the jury determined that the hospital should not be entitled to immunity under HCQIA. We were reviewing the hospital’s argument that the district court failed to find it immune as a matter of law. We rejected that argument and affirmed, finding the disputed facts at trial would support the jury’s verdict. Id. at 1334. Second, and more importantly, the district court below evaluated the record evidence presented by Dr. Cohlmia and found that it was not sufficient to rebut the HCQIA presumption in this case. In Brown, the claimed malpractice at issue developed over a long period of time, and could not be evaluated except through a lengthy review of the entire period, something the hospital failed to do. Here, in contrast, SJMC and the requisite reviewing bodies were only concerned with the two, acute patient incidents at issue that preceded Dr. Cohlmia’s initial suspension. 4 SJMC argues that the record is undisputed it undertook “reasonable efforts to obtain the facts of the matter before its Board made a final decision.” Aple. Br. at 34. For example, SJMC brought in three independent, outside physician 4 Likewise, Brown does not stand for the proposition that a mere battle of the experts is sufficient to overcome the presumption. “[W]hen the issue subject to peer review only concerns a single incident, summary suspension will inherently require less intensive fact finding and data compilation than would be the case with a review of a physician’s care over several years.” Johnson v. Christus Spohn, No. C-06-138, 2008 WL 375417, at  (S.D. Tex. Feb. 8, 2008). In Johnson, the court held that a hospital took reasonable efforts to obtain the facts when it investigated only one case, involving a lack of adequate and timely care for a chicken pox patient, prior to terminating a doctor’s staff privileges. -12- experts to review the cases, and all testified under oath that the pre-surgery workup was inadequate and that the surgeries were unnecessary. SJMC also consulted a cardiac surgeon, a pathologist, a pulmonologist, and a medical oncologist in regards to the care Dr. Cohlmia provided, each of whom expressed concerns that the treatment of the two patients fell well below the standard of care required of a cardiothoracic surgeon. Finally, it retained an independent arbiter to review the evidence, and Judge Brett’s report thoroughly documents and supports SJMC’s methodology and conclusions. In response, Dr. Cohlmia points to a memo written by Dr. Allred on June 26, 2003—prior to the suspension, but after the two surgeries were performed— criticizing Dr. Cohlmia’s professional judgment. See Aplt. App. at 1333. In the memo, which appears to be a note for Dr. Allred’s personal files detailing an inperson conversation he had with a colleague, Dr. Allred opines about a “significant problem” with Dr. Cohlmia’s care and states: “[i]t is very difficult to remove someone from the staff once they have full privileges.” Id. Dr. Cohlmia argues this memo is the best evidence showing that the suspension proceedings were merely a pretext in order to take away his privileges. He believes this is evidenced by the fact that the memo does not specifically mention the two cases that were then under review that precipitated the suspension in early July. But it is unclear why this inference would follow from the memo. The memo is detailing a conversation that Dr. Allred had already had with a -13- colleague. Dr. Allred was listening to and responding to concerns articulated by another physician and Dr. Allred had not yet made public his concerns about the two surgeries. It would have been odd—and potentially a violation of privacy or medical ethics—for Dr. Allred to disclose his investigation to an unrelated physician prior to its completion, which did not occur until ten days later. We agree with the district court that nothing about the memo undercuts the thorough and independent review completed by SJMC in the course of its decision to terminate Dr. Cohlmia’s medical staff privileges. And, despite the allegations of bad faith, “[t]he real issue is the sufficiency of the basis for the [Hospital’s] actions.” Bryan v. James E. Holmes Regional Med. Ctr., 33 F.3d 1318, 1335 (11th Cir. 1994). It is the objective reasonableness of the review body’s actions and determinations that count. And it is worth noting that Dr. Allred, who initiated the peer review investigation as a part of his position as Vice-President of Medical Affairs, is a colorectal surgeon and not a medical competitor of Dr. Cohlmia. But even if he were a competitor, application of HCQIA immunity is based on “the sufficiency of the basis for the [Hospital’s] actions,” and not who initiates the peer review process. Id. (quotation omitted); see also IB Areeda & Hovenkamp 21 n.6 (noting that peer review actions initiated -14- by a physician’s competitors are permissible) (citing Monroe v. AMI Hosps., 877 F. Supp. 1022, 1028–29 (S.D. Tex. 1994)). 5 As the Eleventh Circuit has said, “[t]he role of federal courts on review of [HCQIA] actions is not to substitute our judgment for that of the hospital’s governing board or to reweigh the evidence regarding the renewal or termination of medical staff privileges.” Bryan, 33 F.3d at 1337 (internal quotation omitted). Instead, “[t]he intent of [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.” Id. The record does not rebut the presumption afforded SJMC by HCQIA. Accordingly, the district court did not err in granting summary judgment based on immunity under HCQIA.