Court Opinion

ID: 9726101
Source: CourtListenerOpinion
Date Created: 2023-08-26 12:30:50.136501+00
Date Added: 2024-06-11T18:25:23.467725
License: Public Domain

ANDERSON, G. BARRY, Justice
(concurring).
I reluctantly concur in the result reached by the majority. Minnesota Statutes § 145.63 (2006) clearly contemplates a cause of action against a review organization for negligent credentialing when the organization fails to make a reasonable effort to inform itself of the facts or fails to act reasonably on those facts. That said, I am skeptical of the efficacy of negligent credentialing litigation as a method of improving health care. I write separately, however, to express my concern that our peer review statute may not be fulfilling the intended purpose and to encourage the legislature to revisit this important issue.
The main administrative body or governing board that is responsible for overseeing the activities of a hospital is often comprised primarily or entirely of non-physicians. Ronald G. Spaeth et al., Quality Assurance and Hospital Structure: How the Physician-Hospital Relationship Affects Quality Measures, 12 Annals Health L. 235, 236 (2003) (citing Paul L. Scibetta, Restructuring Hospital-Physician Relations: Patient Care Quality Depends on the Health of Hospital Peer Review, 51 U. Pitt. L.Rev. 1025, 1031-32 (1990)). The board thus must rely on the hospital’s staff physicians to evaluate peer performance, and “the level of quality provided to patients depends upon how well the processes of credentialing and peer *314review are carried out by their physicians.” Id. at 237.
Despite the central role of peer review in ensuring quality care, physicians are often reluctant to participate in the peer review process and have little motivation to participate aggressively and meaningfully. Peer review participants receive no compensation for their time. Id. at 238. They face the social tension that comes with evaluating and criticizing peers along with the possibility of reprisal in the form of lost patient referrals. Id. They may also face legal repercussions from their decisions. Id. at 237-38. The threat of lawsuits, and burdensome discovery, stifles the “[f]ree, uninhibited communication of information to and within the peer review committee [that] is imperative to the professed goal of critical analysis of professional conduct.” Richard L. Griffith & Jordan M. Parker, With Malice Toward None: The Metamorphosis of Statutory and Common Law Protections for Physicians and Hospitals in Negligent Credentialing Litigation, 22 Tex. Tech. L.Rev. 157, 159 (1991). When Congress enacted the Health Care Quality Improvement Act, it found that “[t]he threat of private money damage liability under [state and] Federal laws, including treble damage liability under Federal antitrust law, unreasonably discourages physicians from participating in effective professional peer review.” 42 U.S.C. § 11101(4) (2000).
Review by one’s peers within a hospital is not only time-consuming, unpaid work, it is also likely to generate bad feelings and result in unpopularity. If lawsuits by unhappy reviewees can easily follow any decision * * * then the peer review demanded by [the law] will become an empty formality, if undertaken at all.
Scappatura v. Baptist Hosp., 120 Ariz. 204, 584 P.2d 1195, 1201 (1978).
To encourage robust peer review, all states and the federal government have enacted statutes that protect peer review participants through immunity, privilege, confidentiality, or some combination of the three. Susan O. Scheutzow, State Medical Peer Review: High Cost but No Benefit—Is It Time for a Change?, 25 Am. J.L. & Med. 7, 9 (1999). These statutes run counter to the general trend in the law, which has been to abrogate privileges and immunities. Id. at 17.
It is open for debate, however, whether these measures actually promote effective peer review. A 1999 article in the American Journal of Law and Medicine analyzed data available from the National Practitioner Data Bank (NPDB)7 and concluded that they do not. See Scheutzow, supra, at 8. The article suggests that peer review protection statutes are insufficient because they do not address “the loss of referrals and general ill-will that may be generated by sanctioning a colleague.” Id. at 19.
Minnesota law contemplates a cause of action by a patient against a peer review organization (MinmStat. § 145.63), but protects the work product of the organization with privilege and confidentiality (Minn.Stat. § 145.64 (2006)). A plaintiff who alleges negligent credentialing must show that the peer review organization failed to act reasonably, but is prohibited *315by section 145.64 from discovering the basis for the peer review organization’s decision — the most obvious source of evidence of the reasonableness of that decision. See B. Abbott Goldberg, The Peer Review Privilege: A Law in Search of a Valid Policy, 10 Am. J.L. & Med. 151, 162 (1984). “[A]s a matter of public policy it makes little sense to create a cause of action and then, by creating a privilege, destroy the means of establishing it.” Id. at 159.
Furthermore, there appear to be no reliable studies of how, exactly, privilege and confidentiality statutes affect negligent credentialing lawsuits and whether plaintiffs, peer review participants, or both suffer in the end. The conventional wisdom is that the bar to discovery of peer review documents will burden the plaintiff, because the plaintiff bears the burden of proof. See, e.g., Christina A. Graham, Comment, Hide and Seek: Discovery in the Context of the State and Federal Peer Review Privileges, 30 Cumb. L.Rev. 111, 114-15 (2000). This is probably true in most circumstances, but in certain cases the confidentiality requirement may hamper defendants by preventing a hospital from demonstrating that the hospital did not and could not obtain information that called a physician’s competence into question.
Whatever the theoretical merits of Minn.Stat. § 145.64’s confidentiality and privilege protections, they may ultimately be of little consequence because the statute allows disclosure and discovery of any information — such as incident reports, patient charts, records, billing information, and general medical error and safety information — available from an original source. Minn.Stat. § 145.64, subd. 1 (“Information, documents or records otherwise available from original sources shall not be immune from discovery or use in any civil action merely because they were presented during proceedings of a review organization * * *.”). Thus, it is only documents originally created by the peer review organization that are truly off-limits. “[D]e-spite current immunity and confidentiality legislation, it is not uncommon for a large portion of the peer review documents to be considered discoverable in a medical malpractice action.” Spaeth et al., supra, at 243 (citing Jason M. Healy et al., Confidentiality of Health Care Provider Quality of Care Information, 40 Brandeis L.J. 595, 597 (2002)). Therefore, “denial of the privileged documents should have little impact on any patient’s ability to maintain a cause of action for medical malpractice.” Doe v. Ill. Masonic Med. Ctr., 297 Ill.App.3d 240, 231 Ill.Dec. 411, 696 N.E.2d 707, 711 (1998). Of course, limiting the privilege in this manner prevents hospitals faced with a malpractice suit from hiding incriminating information by funneling it through the peer review committee. See May v. Wood River Twp. Hosp., 257 Ill.App.3d 969, 195 Ill.Dec. 862, 629 N.E.2d 170, 174 (1994). But the discoverability of incident reports and similar quality assurance measures “constitutes a significant impediment to the peer review process. Physicians will be reluctant to create such records if parties to lawsuits can subsequently discover them.” Kenneth R. Kohlberg, The Medical Peer Review Privilege: A Linchpin for Patient Safety Measures, 86 Mass. L.Rev. 157, 160 (2002).
Peer review participants also enjoy qualified immunity under Minn.Stat. § 145.63. Like Minnesota, “[t]he majority of states have qualified the immunity, imposing as statutory hurdles the threshold requirement that the peer review actions be taken without malice, in good faith or reasonably in order to invoke the immunity.” Smith v. Our Lady of the Lake Hosp., Inc., 639 So.2d 730, 742 (La.1994).
*316But the qualified immunity afforded by section 145.63 is likely to be of little comfort to a peer review participant. Under the statute, a negligent-credentialing plaintiff must demonstrate that the peer review organization did not act based on a reasonable belief or make reasonable efforts to ascertain the facts — but failure to exercise reasonable care is always the basis of a negligence action. See, e.g., Funchess v. Cecil Newman Corp., 632 N.W.2d 666, 674 (Minn.2001) (citing Restatement (Second) of Torts § 323 (1965)). In order to recover, therefore, a negligent credentialing plaintiff would need to prove that the peer review organization’s decision was unreasonable even in the absence of Minn.Stat. § 145.63. With or without the statute, a negligent-credentialing case will most likely proceed at least to the summary judgment stage, as the reasonableness of a peer review organization’s decision will not generally be disposed of on the pleadings but will require discovery and expert testimony. It is therefore not clear to me what section 145.63 accomplishes, other than preventing negligent-credentialing and privileging from turning into strict liability torts.
An obvious response would be to strengthen the immunity provision and immunize peer review participants from liability to patients unless the peer review organization performed its duties recklessly or with malice. But for those who argue, as the appellant does here, that the prospect of a negligent-credentialing claim forces hospitals to shore up defective credentialing procedures, a stronger immunity provision may discourage adverse peer review decisions. The argument advanced by appellants is essentially that “institutions and individuals held responsible to injured patients for failing to perform effective peer review will be more diligent in policing the profession and taking corrective actions.” Scheutzow, supra, at 56.
It may be that a partial solution is found in changes to these confidentiality and immunity provisions. Or perhaps part of the solution may lie in revisiting the credentialing machinery. It is also worth noting that negligent-credentialing actions are a very small piece in a much larger puzzle, medical malpractice litigation, and it is possible that the best route to reform runs through the larger issues present in the medical malpractice debate. But whatever suggested improvements might surface, the place to address these issues is in the executive and legislative branches of our government, an exercise I would encourage forthwith.

. The NPDB is a computerized national directory of information on malpractice judgments, settlement payments, disciplinary actions, and license suspensions and revocations. Scheutzow, supra, at 8 n. 9. It was established by Congress to provide for effective interstate monitoring of incompetent physicians and "serves as an information clearinghouse that peer review boards can check when evaluating a physician’s ability to practice quality medicine.” Id.