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November 23, 2021 – Providing quality healthcare is the primary goal of healthcare organizations and doctors. When internal claims are made that a physician or other provider has not provided quality care, organizations may initiate medical review actions in which a medical review committee will examine the basis of the allegations and determine whether action against the supplier is necessary.
In response to these actions, providers will often sue the organization or committee, alleging a range of causes of action, from libel to antitrust lawsuits. In response to these lawsuits and in an effort to provide quality medical care, Congress passed federal legislation – the Health Care Quality Improvement Act (“HCQIA”) – providing, in part, for immunity on behalf of organizations and individuals. committees for their actions during reviews.
The requirements for obtaining this immunity and the specific standards that organizations must set in court have been the subject of significant litigation, and organizations can gain insight by understanding how the courts have handled these cases.
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The HCQIA is divided into three sections: (1) the professional examination section; (2) the reports section of the National Practitioner Data Bank; and (3) the section establishing the requirements for healthcare organizations to request physician information from national practitioner data. The first section of the HCQIA, concerning immunity for actions involved in professional review activities, has given rise to the majority of disputes based on the HCQIA.
A professional review action is an action or recommendation of a professional review committee, which is based on the competence or professional conduct of a member of the medical staff. When professional review committees make recommendations that negatively impact the privileges of a medical staff member, they have been held accountable by the physicians who are the subject of the committee’s recommendations.
The HCQIA grants these professional review boards immunity from liability for their actions related to their professional examination when certain requirements are met. HCQIA provides immunity for so-called “professional review actions”.
To be entitled to HCQIA protection, four elements must be met: the professional review action must be taken:
(1) in the reasonable belief that the action is for the provision of quality health care;
(2) after reasonable efforts have been made to discover the facts of the matter in question;
(3) after sufficient notice and the opportunity to be heard have been given to the member of the medical staff concerned; and
(4) in the reasonable belief that the action taken is justified on the basis of the facts discovered.
Unless the recommendation is rebutted by the member of the medical staff when constituting the committee, it is more likely than not that he failed to establish one or more of the required elements, there is a presumption that the measure professional review is reasonable. The presumption of reasonableness focuses on the knowledge of the review committee at the time the review action was taken and does not take into account findings subsequent to the committee’s decision. If the member of the medical staff is able to rebut the presumption of reasonableness, there is no immunity under the HCQIA.
The HCQIA’s reasonable belief standards have been raised in summary judgment motions by health care organizations with a high degree of success. Several courts have expressly held that the question of whether a health care organization is immune from liability under the HCQIA is a question of law and is not appropriate to put to a jury.
In Poliner v. Texas Health Systems, a 2008 case, a major health care system received an unfavorable jury ruling on the reasonable belief standard issue, resulting in a multi-million dollar verdict. On appeal, the United States 5th Circuit Court of Appeals overturned the verdict, finding that, in law, the health care system had discharged its burden under the standard of reasonable belief and was therefore at l ‘immune from the plaintiff’s claims for damages.
While the second HCQIA element, that of adequate notice, may be an issue in cases of HCQIA immunity, the other three elements, regarding the reasonableness of the belief that the action is intended to promote health care quality, reasonableness of the investigation into the committee’s action, and the reasonableness that the action is warranted, have received increased attention from courts across the country.
To determine whether a medical review board made its decision in a reasonable belief that its action was aimed at providing quality health care, an objective standard of all the circumstances is applied.
In Johnson v. Spohn, a 2009 Fifth Circuit case arising from internal complaints filed with a review board that a staff physician failed to properly treat a patient, resulting in the patient’s death, the court applied the test of l all of the circumstances and considered whether the medical review committee’s decision would result in a decreased likelihood of poor patient care or an increased likelihood of better patient care.
The court ultimately concluded that the committee’s action, revoking the physician’s treatment privileges, met a reasonable belief that the action was intended to promote the element of quality health care, due to the fact that the decision was directly related to the death of the patient and the lower level of care provided by the physician to that patient. The summary judgment in favor of the health organization was ultimately upheld in the case.
The reasonable belief that the action was intended to promote the element of quality health care is easier to prove when the review action arises out of an incident of professional misconduct or near professional misconduct. However, even in review actions not involving malpractice incidents, committees should always consider their review decisions in the context of providing patient care. Providing patient care should take precedence over any competing interests, such as workplace harmony or cost analyzes.
A determining factor often taken into account by the courts on the element concerning the reasonableness of the discovery of information leading to the action of the committee, is whether the information obtained by the committee was provided falsely or with intent. malicious. For example, in Colantonio v. Mercy Medical Center, a 2010 case in the New York Supreme Court, Appeals Division, the appeals court found questions of fact to justify setting aside the summary judgment in favor of the defendant on the reasonableness of the HCQIA in the discovery of factor information.
The case concerned a decision by a medical review committee to revoke treatment privileges of a staff doctor based on a number of complaints from medical center employees that the doctor’s disruptive behavior was hampering the quality of care provided by the medical center. The doctor then sued the medical center for libel, and the center claimed HCQIA immunity.
On appeal from a summary judgment in favor of the medical center, the court held that because the plaintiff had at least raised potentially trialable factual issues regarding the falsity and malicious intent of the allegations made by the employees of the center to the medical examination committee, on the basis of the personal and opinionated nature of the complaints, the defendant had not fulfilled its burden of establishing the immunity of the HCQIA in this matter.
It is important that healthcare organizations keep detailed records of all efforts to uncover the facts surrounding HCQIA’s review actions, especially when hearing witnesses with relevant knowledge of the person. under investigation. Bias and personal opinions of witnesses should also be investigated to ensure the reasonableness of the investigation.
The final element required for HCQIA immunity, namely that the committee reasonably believes that the action it took was justified, is perhaps the least difficult element to establish once the prior elements have already been established. satisfied. Even if the conclusions of the medical review board ultimately prove to be inaccurate, there is still a presumption that the conclusions drawn are reasonable if the previous HCQIA elements have been met.
The key to the last element is whether the actions taken by the review panel were appropriate to address the harm caused by the person under investigation. A detailed report on the alleged misconduct, proposed corrective actions, and a written rationale linking the two can help healthcare organizations if they need to apply for HCQIA protection.
While the term “reasonableness” may seem vague and subjective to healthcare organizations and medical review boards attempting to approach their review decisions in a manner that will fall under the immunity of the HCQIA, the courts have made it clear that there are certain factors and policy objectives that they seek when analyzing the reasonableness of the committee’s action. Knowing these factors and goals can help organizations effectively structure their assessments, while ensuring the protection of the organization and committee members.
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