Opinion ID: 200100
Heading Depth: 1
Heading Rank: 2

Heading: Blue Cross's Immunity Under the HCQIA

Text: 17 When Congress passed the HCQIA in 1986, it was responding to a crisis in the monitoring of health care professionals. Although state licensing boards had long monitored the conduct and competence of their own health care workers, Congress found that [t]he increasing occurrence of medical malpractice and the need to improve the quality of medical care have become nationwide problems that warrant greater efforts than those that can be undertaken by any individual State. 42 U.S.C. § 11101(1). Finding that incompetent physicians find it all to[o] easy to move to different hospitals or states and continue their practices in these new locations, Congress mandated the creation of a national database that recorded incidents of malpractice and that was available for all health care entities to review when screening potential employees. H.R.Rep. No. 99-903, at 2, reprinted in 1986 U.S.C.C.A.N. 6384, 6385 (hereinafter H.R.Rep. No. 99-903). 3 Before passage of the HCQIA in 1986, threats of antitrust action and other lawsuits often deterred health care entities from conducting effective peer review. In order to encourage the type of peer review that would expose incompetent physicians, the HCQIA shields health care entities and individual physicians from liability for damages for actions performed in the course of monitoring the competence of health care personnel. 4 See Mathews v. Lancaster Gen. Hosp., 87 F.3d 624, 632 (3d Cir.1996) (describing legislative history of the HCQIA); Bryan v. James E. Holmes Reg'l Med. Ctr., 33 F.3d 1318, 1332 (11th Cir.1994) (listing Congressional motivations for passing the HCQIA). 18 The HCQIA mandates that a health care entity's review of the competence of a physician shall not result in its liability in damages under any law of the United States or of any State, if such a peer review meets all the standards specified in section 11112(a) of this title. 42 U.S.C. § 11111(a). In order for immunity to attach to a professional review action, it 19 must be taken — 20 (1) in the reasonable belief that the action was in the furtherance of quality health care, 21 (2) after a reasonable effort to obtain the facts of the matter, 22 (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). 23 42 U.S.C. § 11112(a). The HCQIA standards 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 action would restrict incompetent behavior or would protect patients. H.R.Rep. No. 99-903 at 10, reprinted in 1986 U.S.C.C.A.N. 6384, 6392-93 (discussing the proper test to use in applying the first HCQIA standard). Adopting objective `reasonable belief' standard[s], the HCQIA advances the Congressional purpose of permitting a determination of immunity without extensive inquiry into the state of mind of peer reviewers. Id. at 12, reprinted in 1986 U.S.C.C.A.N. at 6394 (stating that these provisions [are designed to] allow defendants to file motions to resolve the issue of immunity in as expeditious a manner as possible). 24 Our sister circuits have uniformly applied all the sections of § 11112(a) as objective standards. See Mathews, 87 F.3d at 635 (collecting cases); 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); Bryan, 33 F.3d at 1335 (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.); Austin, 979 F.2d 728, 734 (9th Cir.1992); but see id., 979 F.2d at 741 n. 3 (Pregerson, J., dissenting) (Evidence of motive and intent is relevant to show whether the defendants possessed a reasonable belief that [an adverse professional review action] was warranted by the facts known.). We apply these objective standards here.
25 The statute establishes a rebuttable presumption that immunity attaches to a professional review action: [a] professional review action shall be presumed to have met the [four HCQIA] standards... unless the presumption is rebutted by a preponderance of the evidence. 42 U.S.C. § 11112(a). In considering the defendants' motions for summary judgment based on HCQIA immunity, we ask the following: [m]ight a reasonable jury, viewing the facts in the best light for [Dr. Singh], conclude that he has shown, by a preponderance of the evidence, that the defendants' actions are outside the scope of § 11112(a)? Austin, 979 F.2d at 734 (citing Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 254, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986)); see also Bryan, 33 F.3d at 1333 (quoting this language from Austin ). Therefore, Dr. Singh can overcome HCQIA immunity at the summary judgment stage only if he demonstrates that a reasonable jury could find that the defendants did not conduct the relevant peer review actions in accordance with one of the HCQIA standards. 26 Dr. Singh suggests that the statutory presumption of immunity effectively denies him his Seventh Amendment right to a jury trial. However, Dr. Singh misconstrues the significance of the statutory presumption in the context of summary judgment. Dr. Singh's burden is no different than that of the nonmovant who must demonstrate the existence of a genuine issue as to any material fact on all of the elements of the claim alleged once a movant for summary judgment files a properly supported motion. See Anderson, 477 U.S. at 254, 106 S.Ct. 2505 (The movant has the burden of showing that there is no genuine issue of fact, but the plaintiff is not thereby relieved of his own burden of producing in turn evidence that would support a jury verdict.); see also William W. Schwarzer, Alan Hirsch, and David J. Barrans, The Analysis and Decision of Summary Judgment Motions 47 (1991) (describing further the burden on the nonmoving party once a party moving for summary judgment points out to the district court that there is an absence of evidence to support the nonmoving party's case). With the benefit of the statutory presumption, the nonmovant is relieved of the initial burden of providing evidentiary support for its contention at summary judgment that there is no genuine issue of material fact on its compliance with the HCQIA standards. 5 For Dr. Singh, however, the burden of defeating summary judgment remains similar to the burden faced by any plaintiff confronted with a properly supported motion for summary judgment. 6 Summary judgment would not be proper if Dr. Singh raised a genuine issue of fact material to the determination of whether Blue Cross met one of the HCQIA standards during its peer review. Therefore, the statute does not unconstitutionally deny Dr. Singh his right to a jury trial. 27 Dr. Singh also argues that the district court denied him his right to a jury trial through improper application of the summary judgment standard — namely, by resolving against him the reasonableness issues under the HCQIA that should have been resolved by a jury. It is true, as our formulation here of the summary judgment question suggests (asking whether a reasonable jury could find that a defendant did not meet one of the standards for HCQIA immunity), that the statutory scheme contemplates a role for the jury, in an appropriate case, in deciding whether a defendant is entitled to HCQIA immunity. The weight of authority from our sister circuits reflects this proposition. See Gabaldoni v. Washington Cty. Hosp., 250 F.3d 255, 260 (4th Cir.2001) (Due to the presumption of immunity contained in section 11112(a), we must apply an unconventional standard in determining whether [the health care entity] was entitled to summary judgment — whether a reasonable jury, viewing all facts in a light most favorable to [the plaintiff], could conclude that he had shown, by a preponderance of the evidence, that [the health care entity's] actions fell outside the scope of section 11112(a).); Sugarbaker v. SSM Health Care, 190 F.3d 905, 912 (8th Cir.1999); Brader v. Allegheny Gen. Hosp. 167 F.3d 832, 839 (3d Cir.1999); Brown v. Presbyterian Healthcare Servs., 101 F.3d 1324, 1334 n. 9 (10th Cir.1992) (determining whether the plaintiff provided sufficient evidence to permit a jury to find she has overcome, by a preponderance of the evidence, any of the four statutory elements required for immunity under 42 U.S.C. § 11112(a)); Austin, 979 F.2d at 734; Bryan, 33 F.3d at 1333. This jury involvement is not limited to disputes over subsidiary issues of fact. 7 Rather, a jury could be asked to decide the ultimate issues of reasonableness set forth in the immunity statute. 28 In this allocation of responsibility between judge and jury, there is an important difference between qualified immunity under the HCQIA and qualified immunity under 42 U.S.C. § 1983. 8 Qualified immunity determinations under § 1983 are question[s] of law, subject to resolution by the judge not the jury, Prokey v. Watkins, 942 F.2d 67, 73 (1st Cir.1991), 9 while HCQIA immunity determinations may be resolved by a jury if they cannot be resolved at the summary judgment stage. This distinction is appropriate because qualified immunity analysis under § 1983 involves a quintessential legal question: whether the rights at issue are clearly established. See Anderson v. Creighton, 483 U.S. 635, 638, 107 S.Ct. 3034, 97 L.Ed.2d 523 (1987) (explaining that whether an official protected by qualified immunity may be held personally liable for an allegedly unlawful official action generally turns on the objective legal reasonableness of the action assessed in light of the legal rules that were clearly established at the time it was taken (internal quotation marks and citations omitted)). There is no comparable legal question involved in the immunity analysis under the HCQIA. Moreover, immunity under the HCQIA is immunity from damages only, whereas qualified immunity under § 1983 is an immunity from suit rather than a mere defense to liability [that] is effectively lost if a case is erroneously permitted to go to trial. Mitchell v. Forsyth, 472 U.S. 511, 526, 105 S.Ct. 2806, 86 L.Ed.2d 411 (1985). Hence, there is less reason under the HCQIA to exclude the jury entirely from involvement with the dispositive determinations. 29 Also, the Supreme Court has suggested a helpful functional approach in deciding the proper allocation of functions between judge and jury: 30 At least in those instances in which Congress has not spoken and in which the issue falls somewhere between a pristine legal standard and a simple historical fact, the fact/law distinction at times has turned on a determination that, as a matter of the sound administration of justice, one judicial actor is better positioned than another to decide the issue in question. 31 Miller v. Fenton, 474 U.S. 104, 114, 106 S.Ct. 445, 88 L.Ed.2d 405 (1985). Such a functional inquiry involves several factors, including whether the issue falls within the common experience of jurors, whether its resolution involves the kinds of decisions traditionally entrusted to jurors, and whether a judgment of peers is desirable. William W. Schwarzer, Alan Hirsch, and David J. Barrans, The Analysis and Decision of Summary Judgment Motions 18-19 (1991) (reprinted at 139 F.R.D. 441). Although peer review actions are not within the common experience of jurors, they are not so esoteric that they cannot be fairly evaluated by jurors, perhaps with the assistance of expert witnesses. Also, we routinely ask jurors to evaluate the quality of medical care in medical malpractice cases. As this case illustrates, the quality of medical care is often at the core of a peer review dispute under the HCQIA. Therefore, we see no reason why juries should be excluded entirely from immunity determinations under the HCQIA. 32 However, Congress unmistakably recognized the usefulness of summary judgment proceedings in resolving immunity issues under the HCQIA prior to trial. Again, the comparison to qualified immunity under § 1983 is instructive. As already noted, pursuant to Supreme Court precedents, a state official is immune from suit under § 1983 when his conduct does not violate clearly established statutory or constitutional rights of which a reasonable person would have known. Harlow v. Fitzgerald, 457 U.S. 800, 818, 102 S.Ct. 2727, 73 L.Ed.2d 396 (1982) (citations omitted). By defining the limits of qualified immunity essentially in objective terms, the Supreme Court has indicated that this defense would turn primarily on objective factors, and would therefore be amenable to resolution at the summary judgment stage, when judges could determine whether the rights at issue in the case were clearly established at the time of the alleged offense. Id. at 819, 820, 102 S.Ct. 2727. The Supreme Court has repeatedly emphasized that the qualified immunity determination should be made as soon as possible during the course of litigation. See id. at 815-16, 102 S.Ct. 2727 (referring to the Court's holding in Butz v. Economou, 438 U.S. 478, 508, 98 S.Ct. 2894, 57 L.Ed.2d 895 (1978), that insubstantial claims should not proceed to trial). Like the Supreme Court in Harlow, Congress indicated in the legislative history of the HCQIA that its immunity determinations should also be made expeditiously. See H.R.Rep. No. 99-903, at 12, reprinted in 1986 U.S.C.C.A.N. 6384, 6394 (stating that these provisions [are intended to] allow defendants to file motions to resolve the issue of immunity in as expeditious a manner as possible, and anticipating that courts would determine at an early stage of litigation that the defendant has met the [section 11112(a)] standards). 33 In asserting that the district court deprived him of his right to a jury trial with its summary judgment ruling, Dr. Singh overlooks the import of Congress's adoption of objective standards for the HCQIA immunity determination. Given the objective standards set forth in the statute, reasonableness determinations under the HCQIA may often become legal determinations appropriate for resolution by the judge at summary judgment. If there are no genuine disputes over material historical facts, 10 and if the evidence of reasonableness within the meaning of the HCQIA is so one-sided that no reasonable jury could find that the defendant health care entity failed to meet the HCQIA standards, the entry of summary judgment does no violence to the plaintiff's right to a jury trial. With these considerations in mind, we turn to the summary judgment record. 34
35 There are many elements of a peer review, including investigation, deliberation, recommended actions and final decisions. The HCQIA addresses professional review actions. A professional review action is defined in the HCQIA as: 36 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. Such term includes a formal decision of a professional review body not to take an action or make a recommendation described in the previous sentence and also includes professional review activities relating to a professional review action. 37 42 U.S.C. § 11151(9). Professional review activities are generally precursors to professional review actions. Professional review activities include a health care entity's efforts 38 (A) to determine whether the physician may have clinical privileges with respect to, or membership in, the entity, 39 (B) to determine the scope or conditions of such privileges or membership, or 40 (C) to change or modify such privileges or membership. 41 42 U.S.C. § 11151(10). When a court considers whether a health care entity is immune from damages for a given professional review action, it considers whether that action, considered as a whole, and including all the professional review activities relating to it, meets the standards set forth in § 11112(a). 42 The district court determined that Blue Cross took three professional review actions with respect to Dr. Singh. As a result of the first audit, Blue Cross (1) decided not to permit Dr. Singh to become a provider for the Baystate Line, and (2) decided to freeze his HMO Blue patient panel. As a result of the second audit, Blue Cross (3) terminated Dr. Singh as a Blue Cross provider. 11
43 Since Dr. Singh argues that Blue Cross failed to meet all of the HCQIA standards in each of the two audits it conducted, we examine each in turn.
44 Dr. Singh argues that the RAC's refusal to admit him to the Baystate Line and its recommendation that his Blue Cross patient panel be frozen were not in accordance with HCQIA standards. 12 With these contentions in mind, we review the record to determine whether a reasonable jury could determine that Dr. Singh overcame the statutory presumption that Blue Cross performed these professional review actions in accordance with the strictures of § 11112(a): 45 (1) in the reasonable belief that the action[s were] in the furtherance of quality health care, 46 (2) after a reasonable effort to obtain the facts of the matter, 47 (3) after adequate notice and hearing procedures [were] 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[s were] warranted by the facts known after such reasonable effort to obtain facts and after meeting the requirement of paragraph (3). 48 42 U.S.C. 11112(a). We follow the district court's thoughtful opinion and consider these two professional review actions in tandem because they both resulted from the first audit of Dr. Singh, conducted by Dr. Clayton. 49
50 The RAC decided to freeze Dr. Singh's patient panel and to deny him admission to the Baystate product line because of Dr. Clayton's audit. Dr. Singh claims that Blue Cross could not have reasonably believed that these actions would further quality health care and were warranted by the facts known. 51 First, Dr. Singh argues that, in some other cases where a health care entity was granted immunity, the health care entity only disciplined a physician in response to demonstrated harm to patients, or took less drastic measures than those recommended for Dr. Singh before opting to discipline the physician. See Gabaldoni v. Wash. Cty. Hosp. Ass'n, 250 F.3d 255, 261 (4th Cir.2001) (granting immunity where plaintiff physician had been subject to multiple lawsuits); Egan v. Athol Mem'l Hosp., 971 F.Supp. 37, 41, 44 (D.Mass. 1997) (granting immunity where defendants repeatedly received complaints from staff and plaintiff was required to complete courses); Mathews, 87 F.3d at 628, 629 (immunity granted where plaintiff physician injured patient with high speed drill). Dr. Singh essentially argues that the RAC could only have reasonably believed that professional review actions adverse to him would further quality health care if it was responding to documented patient injuries or if it prefaced its decisions to freeze his patient panel and deny him entry to the Baystate plan with other, less severe reeducation measures. 52 Neither position comports with the purpose of the HCQIA, or precedent interpreting it. The HCQIA was designed to prevent patient harm, not to assure an adequate response after it occurred. See 42 U.S.C. § 11101(1) (describing Congressional finding that peer review was necessary in order to keep incompetent physicians from harming patients). Therefore, Blue Cross was under no obligation to wait until a patient was actually harmed by Dr. Singh before it took preventive action limiting his access to Blue Cross customers and further investigating his practice. Blue Cross's failure to reeducate Dr. Singh also does not demonstrate that the RAC could not have reasonably... concluded that [its] actions would restrict incompetent behavior or would protect patients. H.R.Rep. No. 99-903 at 10, reprinted in 1986 U.S.C.C.A.N. 6384, 6392-93 (discussing the proper test to use in applying the first HCQIA standard). The RAC suspected that Singh could harm patients, and therefore restricted his access to them. Dr. Singh cites no authority for the proposition that Blue Cross was obliged to take the response least disruptive to Dr. Singh upon receiving evidence that his practices did not comply with the relevant standards of care. 53 Dr. Singh also argues that Blue Cross could not have reasonably believed that its professional review actions would further quality health care because Dr. Clayton's audit was not entirely critical. Dr. Clayton observed in his audit report that Singh appear[ed] to make a sincere effort to try to deal with ... multiple problems which are at the most challenging and at the very least many times difficult to attain satisfactory conclusions. However, Dr. Clayton also stated that Singh's documented treatment showed evidence of care somewhat below recognized standards of care. Dr. Clayton's praise for Dr. Singh's apparent good faith effort to help his patients does not so vitiate the negative aspects of his audit as to discredit Blue Cross's decision to base its adverse professional review actions on the Clayton audit. 54 Finally, Dr. Singh claims that Blue Cross took its professional review actions not because of quality of care issues, but because his practice was not cost efficient. He also notes that the first audit in part focused on over utilization of office visits and lab tests. Noting that almost all other HCQIA cases involved hospitals, providers of health care, Dr. Singh argues that it could reasonably be inferred that Blue Cross's primary concern was not to further quality health care, but to provide health care insurance to its members at a profit. 55 Dr. Singh offers a false dichotomy between furthering quality health care and overutilization of medical procedures and tests. If patients are being subjected to unnecessary procedures and tests, the consequences are both economic and medical. Dr. Singh offers no evidence that Blue Cross's RAC was acting only as a cost-cutting body when it reviewed his performance. The Clayton audit focused on health care concerns. Like the plaintiff physician who failed to overcome the statutory presumption of immunity in Mathews, Dr. Singh 56 has produced no evidence that [economic] considerations actually entered into the [RAC]'s decisionmaking process.... Rather, Dr. [Singh] appears to base his argument solely on his allegation that the defendants ... stood to gain by eliminating him.... 57 Mathews, 87 F.3d at 636. Although Dr. Clayton's audit did refer to a pattern of overutilization of medical resources in Dr. Singh's practices — including excessive and inappropriate lab tests, too-frequent office visits, and overly long treatment regimens of antibiotics — all of these criticisms are inextricably intertwined with medical concerns. No reasonable jury could conclude that the RAC's actions were not taken in the reasonable belief that its actions were warranted by the facts known from the Clayton audit to further quality health care. 58
59 For HCQIA immunity to attach to a professional review action, the decision must be taken after a reasonable effort to obtain the facts of the matter. 42 U.S.C. § 11112(a)(2). Dr. Singh's only challenge to the statutory presumption that Blue Cross acted in accordance with this standard while conducting the first audit is his assertion that the RAC focused on all of the patient files containing narcotic prescriptions even though Clayton's three-page report barely mentioned Singh's narcotic prescription practices. Even if we assume arguendo that the RAC did focus on patient files containing narcotic prescriptions, and was wrong to do so, those mistakes relate to the RAC's interpretation of the facts — not its effort to obtain the facts. Id. Blue Cross hired an independent auditor, Dr. Clayton, to conduct the first audit, which was based on twenty-five randomly selected patient files. The RAC carefully reviewed Clayton's report. Given these steps, no reasonable jury could find that Blue Cross failed to take its professional review action after a reasonable effort to obtain the facts of the matter. Id. c. Adequate Notice and Procedures 60 A professional review action must be 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. 42 U.S.C. § 11112(a)(3). The controlling question is whether the plaintiff has shown by a preponderance of the evidence, that the defendant[] did not provide him with fair and adequate process under the circumstances. Islami v. Covenant Med. Ctr. Inc., 822 F.Supp. 1361, 1377 (N.D.Iowa 1992). 61 Dr. Singh alleges that the first audit was not fair because Blue Cross did not select a mutually agreeable peer review consultant as required under the Audit Agreement. However, the record demonstrates that Dr. Singh was largely responsible for this state of affairs. The parties initially could not agree on a peer reviewer, with Dr. Singh refusing to accept any of the physicians nominated by Blue Cross. Although the physician nominated by Dr. Singh (Dr. Criss) worked at the same hospital as Dr. Singh, Blue Cross agreed to permit him to conduct the review. However, when that physician received the relevant paperwork, he decided not to conduct the review. After Dr. Singh failed to respond to Blue Cross's request that he nominate another physician, Blue Cross appointed Dr. Clayton to perform the review. Therefore, Dr. Singh was at least as responsible for the unfair appointment of Dr. Clayton as was Blue Cross. Dr. Singh cannot claim that Blue Cross's failure to appoint a mutually agreeable peer reviewer made the first audit unfair when his failure to cooperate with Blue Cross led to this result. 62 Dr. Singh also claims that Blue Cross should have permitted him to discuss Dr. Clayton's audit with Dr. Clayton before the RAC voted to deny Singh participation in the Baystate product line and to freeze Dr. Singh's patient panel. However, the HCQIA procedural standard does not require peer review bodies to guarantee the accused such a procedural safeguard. [N]othing in the Act requires that a physician be permitted to participate in the review of his care. Sklaroff v. Allegheny Health Educ. Found., No. CIV. A. 95-4758, 1996 WL 383137, at  (E.D.Pa. July 8, 1996); see also Smith, 31 F.3d at 1487 (stating that the HCQIA does not require peer review proceedings to look like regular trials in a court of law). Blue Cross's failure to permit Dr. Singh to discuss the first audit with Dr. Clayton, and its unilateral selection of Dr. Clayton as the peer reviewer after Singh's failure to assist in the selection of a mutually agreeable peer reviewer, did not so compromise the first audit as to permit a reasonable jury to find that Dr. Singh had overcome the statutory presumption that Blue Cross afforded adequate notice and fair procedures.
63 Dr. Singh argues that the RAC's recommendation that Blue Cross remove him from its panel of providers was unreasonable and based on a shoddy investigation. We again review the record to determine whether Dr. Singh has demonstrated that a reasonable jury could find that he overcame the statutory presumption that Blue Cross performed this professional review action in accordance with the strictures of § 11112(a). 64
65 We first consider whether Dr. Singh has rebutted the presumption that the RAC recommended his termination in the reasonable belief that the action was in the furtherance of quality health care and in the reasonable belief that the action was warranted by the facts known. 42 U.S.C. § 11112(a)(1) and (4). To overcome the presumption, Dr. Singh must demonstrate that a reasonable jury could find that Blue Cross could not have concluded that [its] action would restrict incompetent behavior or would protect patients. Egan, 971 F.Supp. at 42 (internal quotation marks omitted); accord Bryan, 33 F.3d at 1334-35. As explained herein, he fails to meet this burden. 66 Dr. Singh argues that the Fair Hearing Panel's ultimate decision to reverse the RAC's recommendation of his termination would permit a reasonable jury to find that the RAC could not have terminated him with a reasonable belief that this action would further quality health care. We disagree. The reversal of a peer review committee's recommendation of an adverse professional review action by a higher level peer review panel does not indicate that the initial recommendation was made without a reasonable belief that the recommendation would further quality health care. Austin, 979 F.2d at 735 (granting immunity even where a Judicial Review Committee reversed a Medical Executive Committee's recommendation of adverse professional review action). The Fair Hearing Panel had more information before it when it reviewed Dr. Singh's case than the RAC did. The appropriate inquiry is whether the decision was reasonable in light of the facts known at the time the decision was made, not in light of facts later discovered. Sklaroff, 1996 WL 383137 at . Although the Fair Hearing Panel's ultimate disposition of the case suggests that the RAC erred, it does not resolve the question whether the RAC had reasonable grounds to believe that its decision would further quality health care. See Imperial, 37 F.3d at 1030 ([T]he Act does not require that the professional review result in an actual improvement of the quality of health care. Rather, the defendants' action is immune if the process was undertaken in the reasonable belief that quality health care was being furthered.). 67 When the RAC reviewed Dr. Singh's case, the primary source of information before it was Dr. White's audit, which extensively criticized Dr. Singh. Dr. White reported substandard care in thirty-three of the thirty-seven files he reviewed. As in Gabaldoni, the record is replete with objective evidence of [Dr. Singh's] deviations from ... the applicable standard of care; [Blue Cross] reasonably relied on ... such evidence in support of its professional review action. 250 F.3d at 261. Although Dr. Singh alleges several procedural irregularities in Dr. White's audit, he does not directly challenge Dr. White's conclusions in any particular case. 14 Moreover, Dr. Singh offers no reason why the RAC should have doubted the accuracy of Dr. White's assessment in any particular case. 68 Dr. White's report questioned Dr. Singh's care of patients with chronic back and neck pain ..., patients with emotional disorders ..., and asthma patients. Singh v. Blue Cross & Blue Shield of Mass., Inc., 182 F.Supp.2d 164, 174 (D.Mass.2001). Dr. White concluded that [t]here is a general pattern of inadequate or delayed evaluation and treatment, and failure to refer. Competent [expert] care is rarely seen. Id. (citation omitted). Furthermore, the physician members of the RAC did not just take Dr. White's report on faith — they also reviewed several of the patient records upon which it was based prior to the vote. Thus, Dr. Singh has not demonstrated that a reasonable jury could find that he rebutted the statutory presumption that the RAC took its professional review action in the reasonable belief that its action was in furtherance of quality health care and was warranted by the facts known. 42 U.S.C. § 11112(a)(4). 15 69
70 For HCQIA immunity to attach to a professional review action, the decision must be taken after a reasonable effort to obtain the facts of the matter. 42 U.S.C. § 11112(a)(2). Dr. Singh claims that Blue Cross used an unreasonably narrow procedure in obtaining the facts it relied upon in deciding his case. He asserts that this case is analogous to Brown, where the court determined that a reasonable jury could have found that the hospital's peer review action was not taken after a reasonable effort to obtain the facts of the matter because a witness testified that a peer review panel's reliance on only two charts prior to revoking a doctor's privileges was unreasonably narrow and did not provide a reasonable basis for concluding Dr. Brown posed a threat to patient safety. 101 F.3d at 1334. Dr. Singh argues that his review was as unreasonably narrow as Dr. Brown's, at least with respect to the type of cases used, since, [o]f the total of thirty-seven patient files submitted to Dr. White, 21(57%) contained narcotic prescriptions. 71 Dr. Singh misconstrues Brown. There, the court criticized the review as narrow because of the small sample of cases it contained, not because the sample focused on one particular type of case. Courts have found that peer reviewers made a reasonable effort to obtain the facts of the matter even when they concentrated on areas of special concern. See Smith, 31 F.3d at 1483 (review committees focused on problem cases of the plaintiff doctor); Bryan, 33 F.3d at 1326-28 (review panels focused on incidents in which mercurial doctor abused hospital staff). Health care entities are entitled to focus on certain types of cases when these types of cases have caused concern. Moreover, Dr. Singh concedes that sixteen of the patient files submitted to Dr. White did not contain narcotic prescriptions. Thus, Dr. White and the RAC reviewed at least eight times as many randomly selected cases as Presbyterian Hospital's peer reviewer did in Brown. 16 72 In a further challenge to Dr. White's audit, Dr. Singh asserts that [t]he RAC: (1) erroneously reviewed the files of at least two (2) patients who were not treated by Dr. Singh; (2) selected a nonrandom sample of patient files showing exaggerated narcotic prescriptions practices. However, Dr. Singh does not explain why the inclusion of these two files in Dr. White's review invalidated the conclusions drawn from the review of the numerous files that were indisputably his. As we have discussed above, Blue Cross was entitled to review a nonrandom sample of Dr. Singh's files. See Smith, 31 F.3d at 1483; Bryan, 33 F.3d at 1326-28. Admittedly, Blue Cross should have told the peer reviewer, Dr. White, that the sample was weighted toward cases involving narcotics prescriptions. However, this oversight was not material to Dr. White's findings. 73 Dr. White did not simply give a global evaluation of the cases he reviewed. Rather, he analyzed each case individually and concluded, in nearly all cases, that Dr. Singh provided substandard care. For example, Dr. White observed in one case that 74 [c]hronic back pain is treated with narcotic analgesics (Darvon and Percocet) in addition to Lodine. Most internists would have tried to avoid the narcotic analgesics, which were prescribed in significant quantities over the year. In a similar case, Dr. White observed: 75 [L]ow back pain is treated with narcotic analgesics (Percocet) in addition to Motrin. Most internists would have tried to limit analgesic therapy to Motrin and other [nonprescription drugs]. 76 Dr. White's twenty pages of notes on individual patients and five-page letter explaining his conclusions criticized Dr. Singh for far more than his narcotics prescription practices; they touched on many other areas of concern. Dr. White criticized Dr. Singh's care of patients with chronic back and neck pain as significantly `sub-standard,' stated that Dr. Singh failed to meet the minimal standards of the medical community in his treatment of patients with emotional disorders, and failed to deliver quality care to asthma patients. Dr. White concluded that [t]here is a general pattern of inadequate or delayed evaluation and treatment, and failure to refer. Competent expert care is rarely seen. 77 The relevant inquiry under § 11112(a)(2) is whether the totality of the process leading up to the [RAC]'s `professional review action' [recommending that Blue Cross terminate Dr. Singh's participation] evidenced a reasonable effort to obtain the facts of the matter. Mathews, 87 F.3d at 637. Prior to the termination vote, Blue Cross had conducted two audits of Dr. Singh's practice (by two independent physicians), and the five physician members of the RAC had reviewed the audit reports and many underlying patient records. Although Blue Cross made some mistakes in forwarding the files to Dr. White for his review, the [p]laintiff is entitled to a reasonable investigation under the Act, not a perfect investigation. Egan, 971 F.Supp. at 43 (citing 42 U.S.C. § 11112(a)(2)) (internal quotation marks omitted). Given the two audits and the level of attention Dr. White gave to each chart he reviewed, no reasonable jury could find that Dr. Singh overcame the statutory presumption that Blue Cross engaged in a reasonable effort to obtain relevant facts. 78
79 Dr. Singh only presents one argument that the second audit did not afford him fair process, faulting Blue Cross for failing to give him an opportunity to discuss with Dr. White the results of the second audit. However, again, nothing in the [HCQIA] requires that a physician be permitted to participate in the review of his care. Sklaroff, 1996 WL 383137 at ; see also Smith, 31 F.3d at 1487 (explaining that the HCQIA does not require peer review proceedings to look like regular trials in a court of law). Moreover, Blue Cross gave Dr. Singh the opportunity to challenge the White audit at the Fair Hearing Panel. Dr. Singh successfully challenged it there. Under these circumstances, no reasonable jury could find that Dr. Singh overcame the statutory presumption that Blue Cross provided him with procedures that were fair.
80 We have examine[d] the evidence and the inferences reasonably to be drawn therefrom in the light most favorable to the nonmovant. Wagenmann v. Adams, 829 F.2d 196, 200 (1st Cir.1987) (citations omitted). Summary judgment is warranted here because the evidence is so one-sided that the movant is plainly entitled to judgment, for reasonable minds could not differ as to the outcome. Gibson v. City of Cranston, 37 F.3d 731, 735 (1st Cir. 1994) (describing standard for granting judgment as a matter of law, which also applies at the summary judgment stage). Given the overwhelming evidence of the care taken in the peer review process and the absence of any material dispute over historical facts, no reasonable jury could reject Blue Cross's assertion that its professional review actions were taken in the reasonable belief that they would further quality health care, were warranted by the facts known, were based on adequate fact-finding, and afforded Dr. Singh fair notice and procedure. Blue Cross is thus immune from liability for damages for the professional review actions which resulted from the first and second audits. Dr. White is also immune from liability because HCQIA immunity extends to any person who participates with or assists [a peer review] body with respect to actions arising out of a peer review. 42 U.S.C. § 11111(a)(1)(D).