Opinion ID: 720639
Heading Depth: 2
Heading Rank: 2

Heading: Immunity under the Act

Text: 42 Dr. Mathews contends summary judgment was inappropriate because there were disputed issues of fact as to whether the defendants met the standard for immunity set forth in 42 U.S.C. § 11112(a). For immunity under § 11111(a) to attach, four requirements must be met. The professional review action must be taken: 43 (1) in the reasonable belief that the action was in the furtherance of quality health care, 44 (2) after a reasonable effort to obtain the facts of the matter, 45 (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 46 (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). 47 42 U.S.C. § 11112(a). We will undertake the inquiry mandated by each of § 11112(a)'s four prongs to determine whether the district court's grant of summary judgment on the basis of immunity was proper. 48
49 On appeal, Dr. Mathews argues he raised material issues of fact as to whether participants in the peer review proceedings at Lancaster General acted in the reasonable belief that [a restriction of his privileges] was in the furtherance of quality health care, as is required under § 11112(a)(1) of the Act. He maintains that defendants were in direct economic competition with him, which supports an inference of their bad faith. The district court held that § 11112(a)(1) mandates an objective standard, and assertions of bad faith and anticompetitive motive are irrelevant to the question of whether a decision was taken in a reasonable belief that it would further quality health care. Opinion and Order, 883 F.Supp. at 1030. 50 Other courts of appeals, in evaluating summary judgment orders granted on the basis of immunity, have uniformly applied an objective standard in assessing compliance with § 11112(a). See Imperial v. Suburban Hosp. Ass'n, Inc., 37 F.3d 1026, 1030 (4th Cir.1994) (The standard is an objective one which looks to the totality of the circumstances.); Smith v. Ricks, 31 F.3d 1478, 1485 (9th Cir.1994) (the 'reasonableness' requirements of § 11112(a) were intended to create an objective standard, rather than a subjective standard), cert. denied, --- U.S. ----, 115 S.Ct. 1400, 131 L.Ed.2d 287 (1995). They have held that a defendant's subjective bad faith is irrelevant under § 11112(a) and have upheld a finding of immunity if, on the basis of the record, the court could conclude that the professional review action would further quality health care. See, e.g., Bryan v. James E. Holmes Regional Medical Ctr., 33 F.3d 1318, 1335 (11th Cir.1994) (Plaintiff's assertions of hostility do not support his position [that the hospital is not entitled to the Act's protections] because they are irrelevant to the reasonableness standards of § 11112(a). The test is an objective one, so bad faith is immaterial. The real issue is the sufficiency of the basis for the [Hospital's] actions.), cert. denied, --- U.S. ----, 115 S.Ct. 1363, 131 L.Ed.2d 220 (1995); Austin v. McNamara, 979 F.2d 728, 734 (9th Cir.1992) (same); see also Opinion and Order, 883 F.Supp. at 1030-31. 51 We agree with our sister circuits that § 11112(a) imposes an objective standard. The House Committee on Energy and Commerce's report on the Act stated with regard to § 11112(a)(1): 52 Initially, the Committee considered a good faith standard for professional review actions. In response to concerns that good faith might be misinterpreted as requiring only a test of the subjective state of mind of the physicians conducting the professional review action, the Committee changed to a more objective reasonable belief standard. 53 H.R.Rep. No. 903, 99th Cong., 2d Sess. 10 (1986), reprinted in 1986 U.S.C.C.A.N. at 6392-93. Although the quoted passage relates to a previous version of the Act and to § 11112(a)(1) in particular, we believe that Congress' use of the words reasonable belief in both §§ 11112(a)(1) and (4) indicates an intention to create an objective standard with regard to § 11112(a) as a whole. 8 Under § 11112(a)(1), this standard will be satisfied if the reviewers, with the information available to them at the time of the professional review action, would reasonably have concluded that their actions would restrict incompetent behavior or would protect patients. H.R.Rep. No. 903, 99th Cong., 2d Sess. 10 (1986), reprinted in 1986 U.S.C.C.A.N. at 6393. The court should look to the totality of the circumstances. Imperial v. Suburban Hosp. Ass'n, Inc., 37 F.3d at 1030. 54 Dr. Mathews has presented evidence that defendants, including Lancaster General as a joint venturer in the MidAtlantic Orthopedic Institute, were his competitors. But he has not presented evidence that the professional review action taken by Lancaster General's Board was motivated by anything other than a reasonable belief that it would further quality health care. As the district court concluded after carefully reviewing the evidence, Dr. Mathews has failed to rebut § 11112(a)'s presumption that the peer reviewers' action met the standard for immunity from suit for monetary damages: 55 The undisputed evidence shows that, in making its decision, the Board relied on the findings of the Rothacker Committee and the independent expert Dr. Wilson, as reported to the Board by LGH CEO Mr. Young and defendant Dr. Hoke. The Rothacker Committee report represents the conclusion of a committee of three board certified orthopedic surgeons that 23 of Dr. Mathews' cases during a six-month period did not meet appropriate standards of care. These findings were confirmed by those of the independent expert, Dr. Wilson of Cornell Medical College.... 56 After reviewing the cases identified by the Rothacker Committee, Dr. Wilson submitted a detailed report in which he concluded that the pattern and trend of care reflected were substandard in fourteen separate respects, which he enumerated.... The restrictions voted on by the Board appear tailored to meet the concerns raised by Dr. Wilson's report. Thus, in addition to the statutory presumption in favor of defendants, the evidentiary record in this case provides ample support for the conclusion that the Board's action was taken in a reasonable belief that it would further quality health care.... 57 Dr. Mathews has produced no evidence that anticompetitive considerations actually entered into the Board's decisionmaking process.... There is no evidence that the reports contained or that the Board considered any supporting evidence that was not related to the quality of health care. Rather, Dr. Mathews appears to base his argument solely on his allegation that the defendants were his competitors and stood to gain by eliminating him from the market. 58 Mere participation by plaintiff's competitors in the Hoke or Rothacker Committee investigations or the Board's vote, however, does not run afoul of the [Health Care Quality Improvement Act]. Although the Act suggests that a hearing officer or individuals sitting on a hearing panel should not be in direct competition with the physician who is the subject of the hearing, see § 11112(b)(3)(A)(ii) & (iii), it imposes no such requirement on participants in other phases of the peer review process. To the extent plaintiff is attempting to suggest that it was not reasonable for the Board to rely on the Rothacker report because it was generated by orthopedic surgeons who are plaintiff's competitors, this contention is negated by the fact that the committee's findings were confirmed by Dr. Wilson, who is not in any way in competition with Dr. Mathews. Moreover, we note that although the [Act] does not require it, the physician members of the Board, defendant Drs. Hoke, Argires, and Shertzer, abstained from voting on the privilege restrictions. Thus plaintiff's arguments concerning his competitors' participation in the peer review process cannot serve to rebut the presumption in favor of defendants. 59 Opinion and Order, 883 F.Supp. at 1030-31. Because Dr. Mathews has not rebutted the presumption that defendants' actions were taken in the reasonable belief that they would further quality health care, and, in fact, the evidence supports the conclusion that defendants were motivated by legitimate health care concerns, the district court correctly found defendants met the requirements of the first prong of § 11112(a) of the Act. 9
60 Dr. Mathews also argues that defendants did not engage in a reasonable effort to obtain the facts under § 11112(a)(2) of the Act. He points to several problems in the factfinding process, specifically that the Rothacker Committee was composed of competitors, did not request formal authorization to begin a focused review of Dr. Mathews' cases, and did not reveal to the Board the extent of participation in the review process of each member of the committee. Dr. Mathews also emphasizes the Board did not undertake an independent investigation and did not consider Lancaster General routine internal quality reviews. Contrast Imperial v. Suburban Hosp. Ass'n, Inc., 862 F.Supp. 1390, 1399 (D.Md.1993) (Board questioned plaintiff's attorney and reviewed records), aff'd, 37 F.3d 1026 (4th Cir.1994). 61 Although Dr. Mathews challenges the integrity of the Rothacker Committee, he has not rebutted the presumption that defendants engaged in a reasonable effort to obtain the facts. The investigation of the Rothacker Committee, as a preliminary, investigative professional review activity, was not required independently to meet the requirements of § 11112(a). See supra part III.A. The Act contains no provision barring competitors from participating in professional review activities. Nor does it require formal authorization for preliminary professional review activities. Moreover, it is undisputed that Dr. Mathews' standard of care became the focus of attention during the Rothacker Committee's review of Dr. Kent's cases, which necessarily encompassed the cases of Dr. Mathews. 62 The relevant inquiry under § 11112(a)(2) is whether the totality of the process leading up to the Board's professional review action on September 16, 1993 evidenced a reasonable effort to obtain the facts of the matter. The Board relied on the recommendations of two separate reviews. The initial review by the Rothacker Committee took over two years to complete and reviewed 208 cases. The second review was performed by an independent outside reviewer retained by Lancaster General. The outside reviewer, Dr. Wilson, confirmed the findings of the Rothacker Committee. The district court correctly concluded that Dr. Mathews has not overcome the presumption that the Board undertook reasonable efforts to obtain the facts of the matter in compliance with § 11112(a)(2). See Opinion and Order, 883 F.Supp. at 1033-34.
63 Dr. Mathews does not contest on appeal that Lancaster General and the defendant individual physicians afforded him adequate notice and hearing procedures in accordance with § 11112(a)(3) of the Act. A review of the record confirms defendants complied with § 11112(a)(3). 64 Dr. Mathews was given notice of the progress of the professional review activities at each step. A copy of the March 19, 1992 letter of the Rothacker Committee was sent to Dr. Mathews at the same time its conclusions were reported to the Medical and Dental Staff. On April 30, 1992, Dr. Johnson sent a letter to Dr. Mathews informing him that an outside reviewer would review the 27 cases identified by the Rothacker Committee. This letter included minutes of the Medical and Dental Staff Executive Committee meeting, in which the Executive Committee indicated that the outside review may result in a recommendation regarding Dr. Mathews' clinical privileges. Before the outside reviewer, Dr. Wilson, commenced his review, Dr. Mathews was given the opportunity to provide additional materials, and he did so. Dr. Mathews was provided with a copy of Dr. Wilson's March 18, 1993 report. Lancaster General informed Dr. Mathews that it was considering placing restrictions on his privileges and it gave Dr. Mathews the opportunity to respond informally. After the Board voted to restrict Dr. Mathews' privileges on September 16, 1993, Dr. Young informed Dr. Mathews of the Board's decision by letter dated September 22, 1993. The letter informed Dr. Mathews of his right to request a hearing, stated the time limit for doing so, and provided a summary of the rights he would be afforded at the hearing. 10 The letter also stated that Dr. Mathews would be provided the procedural safeguards set for forth in the Act. 65 After Dr. Mathews requested a hearing, the Board suspended the proposed restrictions until the hearing could be held. Shortly thereafter, Dr. Mathews filed this suit, short-circuiting the completion of the review procedures called for by § 11112(b)(3). Even though the hearing has never been held, Lancaster General complied with the safe harbor provision, § 11112(b), in all respects until the time when Dr. Mathews filed suit. In fact, Lancaster General provided Dr. Mathews with additional notices and procedural rights during the conduct of preliminary professional review activities that were not required by the Act. We do not believe a plaintiff can deprive defendants of immunity by refusing to participate in the hearing required under § 11112(b)(3). Accordingly, we conclude Dr. Mathews has not raised a material issue of fact rebutting the presumption that defendants complied with § 11112(a)(3) of the Act. 66
67 Finally, Dr. Mathews disputes whether the Board's professional review action against him was taken in the reasonable belief that it was warranted by the facts known, as required under § 11112(a)(4) of the Act. 68 Dr. Wilson, the outside reviewer, concluded that Dr. Mathews had provided substandard care in spine surgery cases. The Board then placed restrictions on Dr. Mathews' privileges to conduct spine surgery. Because these restrictions were tailored to address the health care concerns raised by the reports of the Rothacker Committee and Dr. Wilson, we believe the evidence supports the conclusion that the restrictions were imposed based on a reasonable belief that they were warranted by the facts known. Moreover, Dr. Mathews has produced insufficient evidence to rebut the presumption that the Board's action was taken in the reasonable belief that it was warranted. As we have noted, Dr. Mathews relies on the opinion provided by his expert witness, Dr. Goldner, who disagreed with Dr. Wilson's conclusions. While the conflicting expert reports raise an issue of fact as to the adequacy of care provided by Dr. Mathews, they do not rebut the presumption that the Board made its decision in the reasonable belief that it was warranted by the facts known. The conclusions of Dr. Goldner's report were not among the facts known at the time of the professional review action. Furthermore, the Rothacker Committee report and the report of Dr. Wilson were not so obviously mistaken or inadequate as to make reliance on them unreasonable. The requirements of § 11112(a)(4) have been met as well.
69 We hold § 11112(a) of the Act imposes an objective standard. Under § 11112(a)(1), this standard is met when peer reviewers reasonably conclude that their actions will restrict incompetent behavior or protect patients. Because the record supports the district court's holding that Lancaster General and the individual defendants reasonably believed their actions would further quality health care and also fulfilled the remaining three prongs of § 11112(a) of the Act, we will affirm the district court's judgment that defendants are immune from suit for monetary damages.