Opinion ID: 585038
Heading Depth: 3
Heading Rank: 2

Heading: Marrese's Peer Review

Text: 20 On February 8, 1978, at the suggestion of defendant William H. Allen, M.D., the Medical Staff Executive Council (MSEC) of Deaconess decided to request an audit of back surgeries by the Department of Surgery. The Department of Surgery formed an audit subcommittee consisting of defendants Allen, Thomas Evans, M.D., Ahmet K. Percinel, M.D., and Ronald Rabin, M.D. The audit subcommittee agreed to conduct an audit of both lumbar laminectomies and lumbar spinal fusions performed between June 1, 1977 and May 31, 1978. 21 The two audits were conducted as screening audits to determine if any anomalies or problems existed with the two types of surgery under study. The spinal fusion audit disclosed frequent but questionable justification for spinal fusions based on extensive laminectomies. 2 After further examination, the audit subcommittee reported no particular problems with Marrese's laminectomies but did report that there was inadequate objective evidence to justify many of the 32 spinal fusions Marrese performed. 22 On January 9, 1980, the MSEC decided that the audit subcommittee should meet with Marrese to go over cases in which the subcommittee found problems and discuss those problems with Marrese. Marrese met with the audit subcommittee on January 23, 1980. The 50 page transcript of the meeting reveals that the audit subcommittee succeeded in discussing only one case with Marrese. 23 On August 13, 1980, Allen reported to the MSEC that the audit subcommittee had again reviewed eight of Marrese's charts which raised concerns about Marrese. The MSEC took no action against Marrese. Subsequently, however, the audit subcommittee provided for further review the same eight charts (without x-rays) to George F. Rapp, M.D., an orthopedic surgeon in Indianapolis. 24 Rapp reported to John C. Render, an attorney for Deaconess, in a letter dated February 2, 1981. Rapp concluded that it would be difficult ... to truly evaluate these patients or their surgical results by reviewing their charts alone. However, Rapp stated that from his review, it appeared that Marrese extended the indications for spinal fusion considerably and questioned the long term benefit to the patients. Rapp suggested that Deaconess consult an outside national firm that could compare Marrese's overall work with the general standards of the orthopedists of the United States and with those in Evansville. Rapp also suggested that at least two experts be assigned to conduct the evaluation, one selected by Marrese and one selected by Deaconess. 25 Deaconess retained InterQual, Inc. 3 to make a special audit of Marrese's surgical procedures, and InterQual reported problems with Marrese's surgeries to Deaconess in February 1982. Based in part on the results of the InterQual report, the audit subcommittee recommended to the MSEC that Marrese be summarily suspended pursuant to the Medical Staff Bylaws. On March 11, 1982, however, the MSEC decided that Marrese would be given a copy of the InterQual report, that Marrese would be invited to a special MSEC meeting, and that no action would be taken until the meeting was held. 26 Marrese attended the two special MSEC meetings with his attorneys, testified, presented expert testimony, objected to formation of the audit subcommittee, and questioned InterQual's qualifications. Following these meetings, the Chairman of the MSEC notified Marrese that the MSEC had voted to revoke his staff membership and clinical privileges but stayed the effect of the revocation until Marrese had exhausted his rights under the Fair Hearing Plan provided under the Medical Staff Bylaws. 27 Subsequently the MSEC attempted to negotiate with Marrese to settle the matter and avoid official revocation of privileges, but these settlement efforts failed. The president of the medical staff then named the following physicians to the hearing panel: T.J. Rusche, M.D., R. Sowa, M.D., J.A. Rang, M.D., R. Wagner, M.D., and R.F. Carlson, M.D. All of these physicians are defendants in this action. The MSEC then postponed the Fair Hearing procedures pending the disposition of an antitrust suit that Marrese filed in federal court against Deaconess, members of the medical staff and others. Upon dismissal of the action, the MSEC voted to proceed with the Fair Hearing. 28 The MSEC decided to amend the charges against Marrese before proceeding with the Fair Hearing. The MSEC had received several reports of Marrese's belligerent and disruptive conduct since the MSEC had voted to revoke his privileges. Furthermore, Deaconess had been forced to sue Marrese to obtain the return of patient x-rays. 4 The MSEC notified Marrese of these new charges of disruptive conduct on May 18, 1983 5 and specified 20 patient charts that illustrated his medical care was below acceptable standards. 29 The MSEC gave Marrese the option to retain the previously selected panel or replace it with four physicians who were not on staff at Deaconess. Marrese chose to have a panel of physicians from Deaconess as provided in the Fair Hearing Plan but requested the opportunity to select half the members of that panel. The MSEC responded that it would not substitute the members of the panel unless Marrese could show actual inability of panel members to remain impartial. 6 The hearing was scheduled for July 9, 1983. 7 30 At the hearing, Baker resigned at Marrese's request. His resignation left only four members on the panel. After questioning the panel members and eliciting their personal and professional opinions of Marrese, Marrese's counsel stated that he had no objection to the reduced number of panel members or to the panel's make-up. Marrese's counsel elaborated by saying Mr. Powell, we have no objections to the members of the Hearing Panel, we think they are taking their position here quite seriously and it seems to us that they are going to make an effort to give an objective hearing today. (Defendants' Motion for Summary Judgment, Affidavit of David A. Johnson, Exhibit 1, Fair Hearing Tr. at 15). 31 Frederick W. LaCava, a defendant in this case, represented the audit subcommittee at the hearing and presented evidence on its behalf. The evidence included both testimonial and documentary evidence. Because the members of the audit subcommittee agreed that the InterQual report contained inaccuracies, the audit subcommittee did not introduce it into evidence at the hearing. 32 Marrese's counsel cross-examined the witnesses against Marrese, called Marrese and four other physician witnesses, and introduced 26 exhibits. Marrese was not permitted to introduce either the testimony of staff physicians who would testify to Marrese's character or letters or affidavits of anyone not available for cross-examination. The panel made these evidentiary rulings pursuant to the Procedural Guidelines for the Fair Hearing Concerning Dr. R.A. Marrese, which specified how the panel should handle evidentiary matters anticipated to arise the Fair Hearing. The hearing panel adopted these procedures prior to the hearing, and Powell provided them to all counsel in advance. 33 The hearing panel issued its findings on September 7, 1983. The findings stated that Marrese had consistently performed extensive surgery in cases where the indications of need for surgery were below acceptable community standards, that Marrese had shown consistent patterns of abusive and disruptive conduct and that Marrese's practice materially endangered the health of patients and the safe provision of patient care at Deaconess. Because it thought that Marrese had demonstrated an unwillingness to cooperate with his peers, any monitoring of his surgery or conditions placed on his privileges would be insufficient to assure effective patient care. Therefore, the hearing panel recommended that Marrese's privileges be terminated. The hearing panel recommended that the MSEC suspend Marrese's privileges during the pendency of any appeal. The MSEC accepted the recommendations of the hearing panel and recommended termination to Deaconess' Board of Directors. 34 Marrese requested and received appellate review before the Board of Directors of Deaconess pursuant to the Fair Hearing Plan. The Board of Directors accepted the recommendation of the MSEC.