Opinion ID: 74019
Heading Depth: 2
Heading Rank: 3

Heading: The Doctors' Challenge

Text: 40 In their petition for review, the Doctors challenge the Non-Physician Involvement Provision in paragraph (e) of the Standard, which for the first time allows non-physician licensed health care professionals, as opposed to only physicians, to perform the required medical evaluations to the extent permitted under state law. The Doctors contend that OSHA gave insufficient notice to interested parties of its intent to adopt this new policy, that the Non-Physician Involvement Provision is void for vagueness, and that the Non-Physician Involvement Provision is not supported by substantial evidence. 10 41
42 Medical evaluation to determine whether an employee is able to use a given respirator . . . is necessary to prevent injuries, illnesses, and even, in rare cases, death from the physiological burden imposed by respirator use. 63 Fed. Reg. at 1207. To this end, 29 C.F.R. 1910.134(e)(1) provides that [t]he employer shall provide a medical evaluation to determine the employee's ability to use a respirator, before the employee is fit tested or required to use the respirator in the workplace. Paragraph (e) goes on to specify the procedures that should be followed in these medical evaluations. Initially, the employee either completes a medical questionnaire that identifies employees who may need further examination, or undergoes a physical examination that yields the same information. 29 C.F.R. 1910.134(e)(2). Employees for whom further examination is indicated are then subject to a follow-up medical examination including any medical tests, consultations, or diagnostic procedures that the [physician or other licensed health care professional] deems necessary to make a final determination. 29 C.F.R. 1910.134(e)(3). 43 The Standard does not distinguish between physicians and other licensed health care professionals. Rather, it allows all of the tasks associated with medical evaluations to be performed by any licensed health care professional to the same extent as they may be performed by a physician, to the extent permitted under state law. The Standard uses the term physician or other licensed health care provider, which is defined as an individual whose legally permitted scope of practice (i.e., license, registration, or certification) allows him or her to independently provide, or be delegated the responsibility to provide, some or all of the health care services required by paragraph (e) of this section. 29 C.F.R. 1910.134(b). Because licensure, registration, and certification of health care professionals is basically a matter of state law, the Standard essentially defers to state law on the question of who may provide the medical evaluation services required by paragraph (e). In contrast, the prior standard provided that [p]ersons should not be assigned to tasks requiring use of respirators unless it has been determined that they are physically able to perform the work and use the equipment. The local physician shall determine what health and physical conditions are pertinent. 29 C.F.R. 1910.134(b)(10) (1997) (emphasis added).
44 The Doctors' first challenge to the Non-Physician Involvement Provision is that OSHA failed to satisfy the statutory notice requirements of the OSH Act. See 29 U.S.C. 655(b)(2) (The Secretary shall publish a proposed rule promulgating, modifying, or revoking an occupational safety or health standard in the Federal Register and shall afford interested persons a period of thirty days after publication to submit written data or comments.). The thrust of this argument is that prior to issuance of the Standard, OSHA's proposed rule failed to give notice that OSHA was contemplating the total elimination of federally mandated physician involvement. Rather, the Doctors argue, OSHA had suggested merely that its revisions to the respiratory protection standard might allow non-physician health care professionals to function under the supervision of a physician, or to perform some but not all medical evaluation tasks. The Doctors argue that they were blindsided by an outcome that went further than any of the proposed alternatives. 45 The D.C. Circuit provided guidance on an analogous question in National Mining Ass'n v. Mine Safety & Health Admin., 116 F.3d 520, 531 (D.C. Cir. 1997). In National Mining Association, the regulation at issue abandoned the Mine Safety & Health Administration's (MSHA) longstanding policy of requiring pre-shift examinations to determine methane and oxygen levels in a coal mine three hours before shifts begin, in favor of a new policy requiring examinations at fixed intervals. The abandonment of the old three-hour policy occurred suddenly in the final rule, whereas the proposed rule (1994 Draft) had adhered to the three-hour policy and thus no comment had been submitted to MSHA on that matter. The petitioner protested that had it known MSHA was reconsidering the three-hour policy, it would have submitted comment pointing out that state law already requiredfrequent examinations, making such a change unnecessary. 46 The D.C. Circuit, recognizing that [a]gencies are not limited to adopting final rules identical to proposed rules and that [n]o further notice and comment is required if a regulation is a 'logical outgrowth' of the proposed rule, identified the controlling legal principle as whether the purposes of notice and comment have been adequately served. National Mining Association, 116 F.3d at 531 (internal quotation marks omitted). Specifically, notice is inadequate if the interested parties could not reasonably have anticipated the final rulemaking from the draft rule. Id. (internal quotation marks omitted). Applying this test, the D.C. Circuit held that the fixed-interval examination regulation was not a logical outgrowth of the 1994 Draft. The discussion accompanying the proposed rule dealt with preshift examinations in some detail, but the agency did not mention any problems with the timing of the examinations, and it did not express any interest in changing that aspect of the rule. Id. Since [n]one of this would have alerted a reasonable interested party that the final rule might alter the provisions about when preshift examinations must be conducted, the notice was defective. Id. 47 In the instant proposed rulemaking, OSHA opened its discussion of medical evaluation procedures by noting that there appears to be considerable difference of opinion as to what circumstances should trigger a physical examination, what the physical examination should consist of, who is to administer such an examination, and what the specific criteria should be for passing or failing. 59 Fed. Reg. 58884, 58907 (Nov. 15, 1994) (emphasis added). Further and more specifically, OSHA said that [c]ommenters questioned the preproposal draft requirement that the medical evaluation be performed by a licensed physician. . . . . OSHA requests comments on this issue and on the extent of the role that should be given to [non-physician] health professionals. Id. at 58910. The extent of non-physicians' appropriate role was also thoroughly explored at the public hearings on the Standard, as is demonstrated by the transcripts of those hearings. 48 Under these circumstances, interested parties were adequately put on notice that the Standard might establish an expanded role for non-physician health care professionals and, concomitantly, a diminished mandatory role for physicians. The Doctors could reasonably have anticipated that the final Standard might eliminate a mandatory role for physicians. See Alabama Power Co. v. OSHA, 89 F.3d 740, 744 n.2 (11th Cir. 1996) (notices of proposed rulemaking and hearing sufficiently put petitioners on notice that OSHA was proposing to regulate not only synthetic, but also natural, fabrics, because the notices requested comments pertaining to the flammability of fabrics generally); United Steelworkers of America v. Schuylkill Metals Corp., 828 F.2d 314, 317-18 (5th Cir. 1987) (notice of proposed rulemaking regarding anti-retaliation regulations that solicited comment as to the appropriate scope of protection for employees removed from dangerous workplaces gave adequate notice that production bonuses might be included as protected employment privileges in the final standard). This is so even though language in the draft standards did not go so far as to eliminate any federally mandated role for physicians. The Non-Physician Involvement Provision was a logical outgrowth of the notice-and-comment process.
49 The Physicians' second argument is that the Non-Physician Involvement Provision is so vague, indefinite and incapable of consistent and uniform enforcement that it contravenes the OSH Act and the constitutional guarantee of due process. According to the Physicians, the definition of physician or other licensed health care provider in 1910.134(b) is inherently circular and ambiguous, andemployers cannot be certain whether they are in compliance with the standard. We reject this argument as wholly without merit. First, we apply the void-for-vagueness doctrine outside of the First Amendment context only rarely. A rule that does not reach constitutionally protected conduct is not void for vagueness unless it is impermissibly vague in all of its applications. Hoffman Estates v. Flipside, Hoffman Estates, Inc., 455 U.S. 489, 499, 102 S. Ct. 1186, 1193 (1982); see also Exxon Corp. v. Busbee, 644 F.2d 1030, 1033 (5th Cir. May 11, 1981) (appropriate test is whether statute is substantially incomprehensible), cert. denied, 454 U.S. 932 (1981). Under 1910.134(e), an employer must arrange for medical evaluations performed on respirator-using employees by an individual whose legally permitted scope of practice . . . allows him or her to independently provide, or be delegated the responsibility to provide, the service of administering a medical evaluation. 29 C.F.R. 1910.134(b). This language is neither impermissibly vague in all its applications nor substantially incomprehensible. Employers may consult state law to determine to what extent, if any, a non-physician health care professional may be used to satisfy the Standard. 50 Second, the thrust of the Non-Physician Involvement Provision is permissive rather than prohibitory. It expands an employer's range of options, permitting him to retain a non-physician licensed health care professional to perform medical evaluations in lieu of a physician, to the extent permitted by state law. The void-for-vagueness doctrine typically applies where a statute prohibits conduct without clearly defining that conduct. City of Mesquite v. Aladdin's Castle, Inc., 455 U.S. 283, 289, 102 S. Ct. 1070, 1075 (1982). The Non-Physician Involvement Provision, in contrast, does not prohibit employers from doing anything. The Physicians cite no case law extending the void-for-vagueness doctrine to invalidate a clause whose sole effect is to give a regulated person an additional, optional means of compliance with a statute or regulation. 51
52 Finally, we turn to the question whether OSHA's decision to allow non-physician licensed health care professionals to provide medical evaluation services to the same extent as physicians is supported by substantial evidence in the record as a whole. OSHA's statement in the notice of proposed rulemaking that it was considering diminishing the role of physicians in the medical evaluation process provoked a wide range of comment from multiple perspectives. As OSHA explains in the preamble to the Standard, some commenters recommended that non-physicians be permitted to administer questionnaires under the supervision of a physician. 63 Fed. Reg. at 1211. Some commenters recommended that only physicians be involved in medical evaluation programs. Id. Some commenters recommended that only health care professionals with certain degrees of specialization in occupational medicine be involved, without regard to whether they were physicians or not. Id. OSHA decided to allow non-physician licensed health care providers to perform medical evaluations to the extent allowed under state licensure laws. OSHA cited record evidence that non-physician health care professionals generally are qualified to assess an employee's ability to use a respirator based on uniform, accepted medical questionnaires, that they have in fact done so safely and effectively on many occasions, and that permitting their involvement would contribute to an efficient and effective allocation [of] health care resources. Id. at 1212. Moreover, OSHA concluded that non-physician health care professionals are capable of identifying cases that need to be referred to physicians, and would so refer cases when necessary or appropriate. OSHA noted the absence of any record support for continuingthe mandatory, exclusive role of physicians. Id. 53 We have reviewed the record and find OSHA's decision to be supported by substantial evidence. 11 While the comments were extremely varied, a common thread running through many of the comments was that registered nurses, physician's assistants, and other such health care providers are well-equipped to perform basic medical functions, such as assessing responses to medical questionnaires, provided that appropriate measures are in place for referring non-routine cases to a physician. There also was evidence from several commenters to the effect that they had safely and efficaciously used non-physician licensed health care professionals in the past for medical evaluations involving respirators. 63 Fed. Reg. at 1212. Moreover, the Non-Physician Involvement Provision does not automatically allow non-physician individuals to perform medical evaluation services; rather, it merely defers to state law on the extent of permissible involvement. State licensure laws can be trusted, as they are relied upon in similar contexts, to ensure that individuals performing medical evaluations under the Standard have the requisite competence, and such laws in fact typically provide for physician oversight over other health care professionals. See, e.g., Ala. Code 34-24-292; Fla. Stat. 458.347; O.C.G.A. 43-34-26.1. 54 The Doctors also make some arguments that are more closely akin to legal challenges than factual challenges. First, they claim that the Non-Physician Involvement Provision's deference to state law on who may perform medical evaluations abdicates OSHA's responsibility to promote the OSH Act's policy of uniform national standards. We reject this challenge. While the goal of the OSH Act is indeed to create uniform national standards for worker safety, the Doctors cite no case law saying that OSHA is statutorily bound to override state law on matters of general applicability, e.g., the licensure of health care professionals, to the extent that those matters happen to intersect with an occupational safety or health standard. Moreover, the Doctors have not demonstrated that the challenged deference to state law is likely to result in nonuniformity in the quality of the evaluation workers receive or in actual worker safety and health. Second, the Doctors suggest that the decisionto allow non-physician licensed health care professionals to perform medical evaluations may have been improperly motivated by economic considerations, i.e., that it would be too costly to require employers always to use physicians. We also reject this challenge. The record in this case makes it clear that economic considerations were not considered improperly. Rather, the record demonstrates that the decision to allow non-physician licensed health care professionals to perform the necessary evaluations was influenced by factual evidence to the effect that such persons are generally qualified to perform such services, and that state law provides an effective and sufficient way to gauge such qualification. OSHA did not conduct a cost-benefit analysis. Indeed, contrary to the Doctors' argument, the record suggests that economic considerations exercised little or no influence on OSHA's decision in this regard. Cf. 63 Fed.Reg. at 1173 (explaining that OSHA's final economic analysis did not attempt to factor in the offsetting value of cost savings from . . . allowing employers to use licensed health care providers in addition to physicians to perform medical evaluations). For all of these reasons, we uphold the Non-Physician Involvement Provision.