Freilich v. Upper Chesapeake Health, Inc. , 313 F.3d 205 ( 2002 )


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  •                            PUBLISHED
    UNITED STATES COURT OF APPEALS
    FOR THE FOURTH CIRCUIT
    LINDA FREILICH, M.D., P.A.; LINDA        
    FREILICH, M.D.,
    Plaintiffs-Appellants,
    v.
    UPPER CHESAPEAKE HEALTH,
    INCORPORATED, formerly know as
    Harford Memorial Hospital;
    BOARD OF DIRECTORS OF UPPER
    CHESAPEAKE HEALTH, INCORPORATED,
    formerly known as Harford
    Memorial Hospital; CECILIO T.
    CAMACHO, M.D., as a Director and
    individually; JOAN P. EDWARDS,
    M.D., as a Director and
    individually; SCOTT S. HASWELL,             No. 01-1890
    M.D., as a Director and
    individually; SHIRLEY S. KLEIN, as a
    Director and individually; JAMES
    LAMBDIN, as a Director and
    individually; ANTHONY J. MEOLI, as
    a Director and individually; LYLE E.
    SHELDON, as a Director and
    individually; DAVID F. GONANO, as a
    Director and individually; SHERIF H.
    OSMAN, M.D., as a Director and
    individually; ROGER E. SCHNEIDER,
    M.D., as a Director and
    individually; DIANE K. FORD, as a
    Director and individually;
    
    2              FREILICH v. UPPER CHESAPEAKE HEALTH
    H. WILLIAM ACKER, as a Director        
    and individually; RANDALL
    WORTHINGTON, SR., as a Director
    and individually; UNITED STATES OF     
    AMERICA; STATE OF MARYLAND,
    Defendants-Appellees.
    
    Appeal from the United States District Court
    for the District of Maryland, at Baltimore.
    Frederic N. Smalkin, Chief District Judge.
    (CA-00-3605-S)
    Argued: October 29, 2002
    Decided: December 13, 2002
    Before WILKINSON, Chief Judge, and WIDENER and
    KING, Circuit Judges.
    Affirmed by published opinion. Chief Judge Wilkinson wrote the
    opinion, in which Judge Widener and Judge King joined.
    COUNSEL
    ARGUED: Paul Steven Blumenthal, LAW OFFICE OF PAUL S.
    BLUMENTHAL, P.A., Annapolis, Maryland, for Appellants. Jona-
    than Barkasy Sprague, POST & SCHELL, P.C., Philadelphia, Penn-
    sylvania, for Appellees Upper Chesapeake Health, et al.; Wendy Ann
    Kronmiller, Assistant Attorney General, Baltimore, Maryland, for
    Appellee State of Maryland; Katherine Sutherland Dawson, Appellate
    Staff, Civil Division, UNITED STATES DEPARTMENT OF JUS-
    TICE, Washington, D.C., for Appellee United States. ON BRIEF:
    Jennifer M. Valinski, LAW OFFICE OF PAUL S. BLUMENTHAL,
    P.A., Annapolis, Maryland, for Appellants. Brian M. Peters, POST &
    FREILICH v. UPPER CHESAPEAKE HEALTH                   3
    SCHELL, P.C., Philadelphia, Pennsylvania, for Appellees Upper
    Chesapeake Health, et al. J. Joseph Curran, Jr., Attorney General of
    Maryland, Baltimore, Maryland, for Appellee State of Maryland.
    Robert D. McCallum, Jr., Assistant Attorney General, Thomas M.
    DiBiagio, United States Attorney, Mark B. Stern, Alisa B. Klein,
    Appellate Staff, Civil Division, UNITED STATES DEPARTMENT
    OF JUSTICE, Washington, D.C., for Appellee United States.
    OPINION
    WILKINSON, Chief Judge:
    Dr. Linda Freilich is a physician. Harford Memorial Hospital
    decided to terminate Dr. Freilich’s medical staff privileges after
    undertaking an extensive review of her application for reappointment.
    Dr. Freilich then filed a complaint challenging the constitutionality of
    the federal statute granting immunity to peer review participants and
    the Maryland physician credentialing statutes. In addition, Dr.
    Freilich alleged violations of both the Americans with Disabilities Act
    and the Rehabilitation Act and made various other common law
    claims. Dr. Freilich’s complaint is an attempt to have a federal court
    supervise what amounts to little more than a physician-hospital dis-
    pute over hospital policies and the expenditure of hospital resources.
    We affirm the judgment of the district court dismissing her claims.
    Freilich v. Bd. of Dir. of Upper Chesapeake Health, Inc., 
    142 F. Supp. 2d 679
     (D. Md. 2001).
    I.
    Dr. Linda Freilich is a Board Certified Internist and Nephrologist
    who maintained unrestricted hospital privileges at defendant Harford
    Memorial Hospital (HMH), a private, non-profit hospital, from 1982
    until April 12, 2000. During her tenure at HMH, Dr. Freilich states
    she advocated the rights of her patients in order to improve their qual-
    ity of care. Specifically, Dr. Freilich complained that the outsourcing
    of quality assurance and oversight services for dialysis patients led to
    an improper standard of care.
    4               FREILICH v. UPPER CHESAPEAKE HEALTH
    Maryland state regulations require physicians to apply for reap-
    pointment every two years. See Code of Maryland Regulations
    (COMAR) § 10.07.01.24. During the reappointment process, each
    hospital must collect specific information about the physician appli-
    cant. The hospital then must analyze the physician’s pattern of perfor-
    mance based upon seven factors, including "adherence to hospital
    bylaws, policies, and procedures" and "attitudes, cooperation, and
    ability to work with others." Id. Pursuant to COMAR regulations,
    HMH Medical Staff Bylaws provide that HMH will consider in the
    reappointment process "ethics and behavior in the Hospital, coopera-
    tion with Hospital personnel as it relates to patient care or the orderly
    operation of the Hospital, and general demeanor and attitude with
    respect to the Hospital, its patients and its personnel."
    In July, 1998, Dr. Freilich applied for reappointment to HMH. Her
    application went through several layers of review, passing before the
    HMH Credentials Committee, the Medical Executive Committee, and
    the Appellate Review Committee. Further, Dr. Freilich received a
    hearing before the Ad Hoc Hearing Committee. Although the differ-
    ent committees disagreed on whether to accept or reject Dr. Freilich’s
    application, on April 11, 2000, HMH’s Board of Directors voted to
    deny Dr. Freilich’s application and terminated her medical privileges.
    In a letter to Dr. Freilich explaining the basis for its decision, the
    Board quoted the "ethics and behavior" language in the HMH Bylaws.
    On December 11, 2000, Dr. Freilich filed a 14-count, 76-page com-
    plaint against HMH and fourteen individuals who were involved in
    her peer review (collectively the "hospital defendants"), the State of
    Maryland, and the United States. The complaint alleged that HMH
    and its Board of Directors denied Dr. Freilich’s application for reap-
    pointment because she did nothing more than advocate the rights of
    her patients. Specifically, Dr. Freilich alleged that the Health Care
    Quality Improvement Act (HCQIA), 
    42 U.S.C. § 11101
     et seq., which
    provides qualified immunity from damages to persons who participate
    in physician peer review, and the Maryland statute and regulations
    governing physician credentialing, Health-General Article § 19-
    319(e) and COMAR § 10.07.01.24(E), are all unconstitutional. She
    also brought a claim under 
    42 U.S.C. § 1983
     against the hospital
    defendants, contending that the termination of her staff privileges vio-
    lated her constitutional rights. Finally, Dr. Freilich alleged violations
    FREILICH v. UPPER CHESAPEAKE HEALTH                    5
    of both the Americans with Disabilities Act (ADA) and the Rehabili-
    tation Act (RA).
    In an extensive opinion, the district court dismissed the federal
    claims with prejudice and the state law claims without prejudice.
    Freilich v. Bd. of Dir. of Upper Chesapeake Health, Inc., 
    142 F. Supp. 2d 679
     (D. Md. 2001). Dr. Freilich now appeals. We review a
    dismissal for failure to state a claim de novo, Eastern Shore Mkts.,
    Inc. v. J.D. Assoc. Ltd. P’ship, 
    213 F.3d 175
    , 180 (4th Cir. 2000), and
    assume the facts as stated in the complaint are true. See Jenkins v.
    Medford, 
    119 F.3d 1156
    , 1159 (4th Cir. 1997) (en banc).
    II.
    Dr. Freilich brings several constitutional challenges to the Health
    Care Quality Improvement Act, 
    42 U.S.C. § 11101
     et seq. The
    HCQIA limits liability in damages for those who participate in profes-
    sional peer review. For HCQIA immunity to attach, however, the peer
    review action must comport with due process. More specifically, the
    professional review action must be taken (1) "in the reasonable belief
    that the action was in the furtherance of quality health care;" (2) "after
    a reasonable effort to obtain the facts of the matter;" (3) "after ade-
    quate notice and hearing procedures are afforded;" and (4) "in the rea-
    sonable belief that the action was warranted by the facts known after
    such reasonable effort to obtain facts." 
    42 U.S.C. § 11112
    . The
    HCQIA also sets forth detailed standards to ensure that a physician
    receives adequate notice and a hearing and exempts any claim alleg-
    ing a civil rights violation or claims for declaratory or injunctive
    relief. 
    Id.
    A.
    We first address Dr. Freilich’s due process and equal protection
    challenges to the HCQIA. Dr. Freilich first alleges that the HCQIA
    violates the Fifth Amendment because it "authorizes and encourages
    the Defendants [to] act irresponsibly in matters of credentialing, reap-
    pointment to the hospital staff, and wrongful denial of hospital privi-
    leges. . . ."1 Because the HCQIA does not burden any fundamental
    1
    Dr. Freilich argues that her challenge arises under the Fourteenth
    Amendment. The HCQIA is a federal law. Dr. Freilich’s due process and
    6               FREILICH v. UPPER CHESAPEAKE HEALTH
    right or draw distinctions based on any suspect criteria, it is subject
    only to rational basis review. Rational basis review is "a paradigm of
    judicial restraint," FCC v. Beach Communications, Inc., 
    508 U.S. 307
    ,
    314 (1993), which prohibits us from "sit[ting] as a super-legislature
    to judge the wisdom or desirability of legislative policy determina-
    tions." City of New Orleans v. Dukes, 
    427 U.S. 297
    , 303 (1976) (per
    curiam). According a strong presumption of validity to the HCQIA,
    we thus need only determine whether the HCQIA is rationally related
    to a legitimate governmental purpose. See Beach Communications,
    
    508 U.S. at 314-15
     (1993).
    The legitimacy of Congress’s purpose in enacting the HCQIA is
    beyond question. Prior to enacting the HCQIA, Congress found that
    "[t]he increasing occurrence of medical malpractice and the need to
    improve the quality of medical care . . . [had] become nationwide
    problems," especially in light of "the ability of incompetent physi-
    cians to move from State to State without disclosure or discovery of
    the physician’s previous damaging or incompetent performance." 
    42 U.S.C. § 11101
    . The problem, however, could be remedied through
    effective professional peer review combined with a national reporting
    system that made information about adverse professional actions
    against physicians more widely available. However, Congress also
    believed that "[t]he threat of private money damage liability under
    Federal laws, including treble damage liability under Federal antitrust
    law, unreasonably discourage[d] physicians from participating in
    effective professional peer review." 
    Id.
     Congress therefore enacted
    the HCQIA in order to "facilitate the frank exchange of information
    among professionals conducting peer review inquiries without the
    fear of reprisals in civil lawsuits. The statute attempts to balance the
    chilling effect of litigation on peer review with concerns for protect-
    ing physicians improperly subjected to disciplinary action." Bryan v.
    James E. Holmes Regional Med. Ctr., 
    33 F.3d 1318
    , 1322 (11th Cir.
    1994).
    Dr. Freilich’s complaint lists seventeen alleged defects with the
    statute, such as permitting hearsay during the hearing proceedings and
    equal protection challenges therefore more properly arise under the Fifth
    Amendment. See Int’l Sci. & Tech. Inst., Inc. v. Inacom Communica-
    tions, Inc., 
    106 F.3d 1146
    , 1156 (4th Cir. 1997).
    FREILICH v. UPPER CHESAPEAKE HEALTH                    7
    permitting the denial of privileges when there are no findings of
    incompetent behavior by the physician. Apparently, she would like
    this court to rewrite the HCQIA. Opinions may differ on what is the
    most effective way to improve the quality of our nation’s health care
    system. However, we cannot substitute our judgment, or that of Dr.
    Freilich, for Congress’s rationally based belief that the HCQIA is an
    effective means to achieve its goal. See Heller v. Doe, 
    509 U.S. 312
    ,
    333 (1993).
    B.
    The HCQIA adopts an objective reasonableness test. As noted ear-
    lier, the HCQIA only applies if a peer review action is taken in the
    reasonable belief that the action was taken (1) after a reasonable effort
    to obtain the facts; (2) after adequate notice and hearing procedures
    are afforded the physician involved; (3) in the reasonable belief that
    the action was warranted by the facts; and (4) in the reasonable belief
    that the action was in the furtherance of quality health care. 
    42 U.S.C. § 11112
    (a), (b). The standard, then, is one of objective reasonableness
    after looking at the "totality of the circumstances." Imperial v. Subur-
    ban Hospital Assoc., 
    37 F.3d 1026
    , 1030 (4th Cir. 1994).
    Dr. Freilich alleges that the HCQIA is unconstitutionally vague in
    violation of the Due Process Clause. She contends that the HCQIA
    reasonableness standard governing peer review immunity "authorizes,
    encourages, and permits HMH to act with impunity" because the
    "HCQIA does not specify what constitutes ‘reasonable belief.’"
    Dr. Freilich’s vagueness challenge is an odd one. To begin with,
    the HCQIA reasonableness standard does not even apply to Dr.
    Freilich’s own conduct. Rather, it is a standard that a peer review
    body must meet in order to obtain immunity for its actions.
    And the HCQIA’s objective reasonableness standard is a perfectly
    valid guide for peer review bodies. The "reasonable belief" standard
    embodies the discretion that health care professionals have tradition-
    ally exercised in determining whether or not their peers meet a requi-
    site level of professional competence. See, e.g., Doyle v. Bowen, 
    660 F. Supp. 1484
     (D. Me. 1987), vacated on other grounds, 
    848 F.2d 296
    (1st Cir. 1988). Courts respect this discretion because "[a]ny attempt
    8                FREILICH v. UPPER CHESAPEAKE HEALTH
    to catalog every medical practice that would fall into the prohibited
    category would result in the sort of encyclopedic and unwieldy statute
    [already] rejected as unnecessary." Id. at 1493. See also, Assoc. of
    Am. Physicians and Surgeons v. Weinberger, 
    395 F. Supp. 125
    , 138
    (N.D. Ill. 1975) (noting the difficult task of "drafting [a] . . . statute
    with sufficient specificity to give the physicians, practitioners and
    providers of health care service adequate notice of the new require-
    ments of the law and at the same time to maintain enough flexibility
    to cover a variety of medical cases").
    Furthermore, reasonableness standards have been consistently
    upheld in the context of qualified immunity. See, e.g., Trulock v.
    Freeh, 
    275 F.3d 391
    , 399 (4th Cir. 2001) ("Qualified immunity
    shields government officials from civil liability ‘insofar as their con-
    duct does not violate clearly established statutory or constitutional
    rights of which a reasonable person would have known.’") (quoting
    Harlow v. Fitzgerald, 
    457 U.S. 800
    , 818 (1982)). In cases brought
    under 
    42 U.S.C. § 1983
    , courts commonly apply an objective reason-
    ableness standard to afford public officers sufficient latitude to prop-
    erly perform discretionary functions. See, e.g., Gooden v. Howard
    County, 
    954 F.2d 960
    , 964 (4th Cir. 1992) (en banc). We therefore
    hold that the HCQIA reasonableness standard provides sufficient
    guidance to withstand a vagueness challenge.
    C.
    Dr. Freilich next alleges that the HCQIA violates the Tenth
    Amendment of the United States Constitution and Article Three of the
    Maryland Declaration of Rights by "invad[ing] subjects traditionally
    governed by state law," and by "attempting to immunize conduct
    otherwise actionable under state law."2
    The Tenth Amendment provides that "[t]he powers not delegated
    to the United States by the Constitution, nor prohibited by it to the
    States, are reserved to the States respectively, or to the people." U.S.
    Const. amend. X. A Tenth Amendment inquiry consists of two parts.
    2
    We construe "guarantees in the Declaration of Rights to be in pari
    materia with similar provisions of the federal constitution." Patterson v.
    Maryland, 
    741 A.2d 1119
    , 1128 (Ct. App. Md. 1999).
    FREILICH v. UPPER CHESAPEAKE HEALTH                     9
    First we must determine whether Congress has the constitutional
    power to enact the HCQIA. United States v. Johnson, 
    114 F.3d 476
    ,
    480 (4th Cir. 1997) (citing New York v. United States, 
    505 U.S. 144
    (1992)). If we answer this inquiry in the affirmative, we then ask
    whether the means of regulation employed by Congress impermiss-
    ibly infringe upon state sovereignty. 
    Id.
    Congress has the power under the Commerce Clause to enact stat-
    utes governing physician peer review. Hospitals are regularly engaged
    in interstate commerce, performing services for out-of-state patients
    and generating revenues from out-of-state sources. Summit Health,
    Ltd. v. Pinhas, 
    500 U.S. 322
    , 329-30 (1991). And the Supreme Court
    has already held that because "[r]eports concerning peer review pro-
    ceedings are routinely distributed across state lines and affect doctors’
    employment opportunities throughout the Nation," there is "no doubt
    concerning the power of Congress to regulate a peer review process."
    
    Id. at 327-28, 332
    .
    Having found that Congress has the power to enact the HCQIA, we
    now ask whether the means employed infringe upon state sovereignty.
    Johnson, 
    114 F.3d at 480
    . We hold that they do not. The HCQIA does
    not commandeer the state legislature or executive. "It does not require
    . . . [the Maryland Legislature] to enact any laws or regulations, and
    it does not require state officials to assist in the enforcement of federal
    statutes regulating private individuals." Reno v. Condon, 
    528 U.S. 141
    , 151 (2000). The HCQIA does not compel states to implement a
    federal regulatory program either. Under the HCQIA, health care pro-
    viders are required to collect and report information to the State
    Board of Medical Examiners. See 
    42 U.S.C. § 11133
    (a). The State
    Board of Medical Examiners then forwards that information to a fed-
    eral data bank. But more is required than the expenditure of time and
    effort on the part of state officials in order to offend the Tenth
    Amendment. See Condon, 
    528 U.S. at 150
    . "Any federal regulation
    demands compliance. That a State wishing to engage in certain activ-
    ity must take administrative and sometimes legislative action to com-
    ply with federal standards regulating that activity is a commonplace
    that presents no constitutional defect." South Carolina v. Baker, 
    485 U.S. 505
    , 514-15 (1988).
    All that the HCQIA requires of states is the forwarding of informa-
    tion. And the HCQIA specifically provides that "nothing in this part
    10               FREILICH v. UPPER CHESAPEAKE HEALTH
    shall be construed as changing the liabilities or immunities under law
    or as preempting or overriding any State law which provides incen-
    tives, immunities, or protection for those engaged in a professional
    review action that is in addition to or greater than that provided by
    this part." 
    42 U.S.C. § 11115
    . We thus agree with the district court’s
    conclusion that the HCQIA "does not require the state to do anything
    that the state itself has not already required, authorized, or provided
    by its own legislative command." Freilich, 
    142 F. Supp. 2d at 696
    .
    In sum, the HCQIA does not come close to offending the Tenth
    Amendment.
    III.
    We next turn to Dr. Freilich’s claims against the hospital under
    Titles II and III of the Americans with Disabilities Act (ADA) and
    under the Rehabilitation Act (RA).3 To the extent possible, we con-
    strue similar provisions in the two statutes consistently. See Ennis v.
    Nat’l Ass’n of Bus. and Educ. Radio, Inc., 
    53 F.3d 55
    , 57 (4th Cir.
    1995). Dr. Freilich makes three claims, which we address in turn.
    A.
    Dr. Freilich brings her first ADA claim on behalf of her dialysis
    patients. Dr. Freilich alleges that HMH violated the ADA and the RA
    by providing in-hospital quality assurance and oversight for all hospi-
    tal services provided by contractors except for dialysis services. See
    3
    Dr. Freilich also brings a section 1983 claim against the hospital
    defendants based on their decision to terminate her hospital privileges.
    The hospital defendants are all private actors. Therefore in order to prop-
    erly bring a section 1983 claim against them, Dr. Freilich must not only
    demonstrate that a constitutional violation occurred, but must also show
    that their actions can be properly characterized as those of the state.
    American Mfrs. Mut. Ins. Co. v. Sullivan, 
    526 U.S. 40
    , 50 (1999). The
    Maryland credentialing statute and regulation both require hospitals to
    establish a formal reappointment process. But the State plays no role
    whatsoever in the actual decision as to whether or not to terminate or
    reappoint any particular physician. Because the private hospital defen-
    dants cannot properly be considered state actors, Dr. Freilich’s section
    1983 claim is dismissed.
    FREILICH v. UPPER CHESAPEAKE HEALTH                   11
    
    42 U.S.C. §§ 12132
    , 12182; 
    29 U.S.C. § 794
    . Quality assurance and
    oversight for dialysis services is provided by an outside contractor.
    We do not reach the merits of this claim, however, because Dr.
    Freilich lacks standing to bring such a claim on behalf of her patients.
    Our standing inquiry "involves both constitutional limitations on
    federal-court jurisdiction and prudential limitations on its exercise."
    Warth v. Seldin, 
    422 U.S. 490
    , 498 (1975). Even if a plaintiff satisfies
    Article III standing requirements, "[f]ederal courts must hesitate
    before resolving a controversy, even one within their constitutional
    power to resolve, on the basis of the rights of third persons not parties
    to the litigation." Singleton v. Wulff, 
    428 U.S. 106
    , 113 (1976). To
    overcome the prudential limitation on third-party standing, a plaintiff
    must demonstrate: (1) an injury-in-fact; (2) a close relationship
    between herself and the person whose right she seeks to assert; and
    (3) a hindrance to the third party’s ability to protect his or her own
    interests. Powers v. Ohio, 
    499 U.S. 400
    , 410-11 (1991).
    The district court held that even assuming the existence of the first
    two elements, Dr. Freilich did not sufficiently allege a hindrance to
    her patients’ ability to protect their own interests. Freilich, 
    142 F. Supp. 2d at 699
    . Here Dr. Freilich fails to allege sufficient obstacles
    to the patients bringing suit themselves. The district court correctly
    pointed out that "the dialysis patients and indigent patients on whose
    behalf Dr. Freilich advocated are not constrained in bringing suit by
    any obstacles made known in the Complaint." Freilich, 
    142 F. Supp. 2d at 699
    . In her submission to this court, Dr. Freilich argues that
    dialysis patients are disabled and chronically ill, foreclosing them
    from presenting their own rights. But we cannot simply assume that
    every disabled or chronically ill person is incapable of asserting his
    or her own claims. In fact, such persons are typical and frequent
    plaintiffs under both the ADA and RA. Faced, then, with no evidence
    that Dr. Freilich’s dialysis patients are hindered from presenting their
    own claims, we adhere to the longstanding principle that "third parties
    themselves usually will be the best proponents of their own rights."
    Singleton, 
    428 U.S. at 114
    .
    B.
    Next, Dr. Freilich asserts a claim of associational discrimination
    under the ADA. See 
    42 U.S.C. § 12182
    (b)(1)(E). Dr. Freilich alleges
    12               FREILICH v. UPPER CHESAPEAKE HEALTH
    that HMH denied her reappointment because of her "patient advo-
    cacy." Under Title III of the ADA, 
    42 U.S.C. § 12182
    (b)(1)(E), it is
    discriminatory to "exclude or otherwise deny equal goods, services,
    facilities, privileges, advantages, accommodations, or other opportu-
    nities to an individual or entity because of the known disability of an
    individual with whom the individual or entity is known to have a rela-
    tionship or association." There is little case law applying this provi-
    sion. We therefore look for guidance from a similar provision in Title
    I of the ADA which governs associational discrimination in employ-
    ment. See 
    42 U.S.C. § 12112
    (b)(4).
    The associational discrimination provision in Title I "was intended
    to protect qualified individuals from adverse job actions based on
    ‘unfounded stereotypes and assumptions’ arising from the employees’
    relationships with particular disabled persons." Oliveras-Sifre v.
    Puerto Rico Dept. of Health, 
    214 F.3d 23
    , 26 (1st Cir. 2000) (citing
    Barker v. Int’l Paper Co., 
    993 F. Supp. 10
    , 15 (D. Me. 1998)). In
    Oliveras-Sifre, the plaintiffs alleged that they were punished for their
    advocacy on behalf of AIDS patients. However, the First Circuit
    rejected the plaintiffs’ contention that the defendants’ actions violated
    the associational discrimination provision of the ADA. The plaintiffs
    did not allege "a specific association with a disabled individual."
    Instead, they "contend[ed], in essence, that they were punished for
    their advocacy on behalf of individuals with AIDS." 
    Id.
     In Barker, the
    court granted summary judgment in favor of the defendants along the
    same lines: the plaintiff alleged that he was terminated because of his
    advocacy on behalf of the plaintiff’s disabled wife, which was held
    insufficient to support an associational discrimination claim. 
    993 F. Supp. at 15
    .
    Dr. Freilich’s allegations suffer from similar defects as the allega-
    tions in Oliveras-Sifre and Barker. Dr. Freilich alleges that HMH "co-
    erced, intimidated, threatened, or interfered . . . with [her] because she
    exercised rights protected by the ADA," and that HMH discriminated
    against her because she refused "to end her advocacy of the dialysis
    patients’ rights that were being violated under [the] ADA." She fur-
    ther alleges that she was "denied equal use of facilities, privileges,
    advantages or other opportunities because of her association with and
    her relationship to patients with disabilities." But such generalized
    references to association with disabled persons or to advocacy for a
    FREILICH v. UPPER CHESAPEAKE HEALTH                   13
    group of disabled persons are not sufficient to state a claim for associ-
    ational discrimination under the ADA. Every hospital employee can
    allege at least a loose association with disabled patients. To allow Dr.
    Freilich to proceed on such a basis would arm every hospital
    employee with a potential ADA complaint. A step of that magnitude
    is for Congress, not this court, to take.
    C.
    Finally, Dr. Freilich brings a claim for retaliatory discharge under
    the ADA and the RA. She alleges that HMH terminated her hospital
    privileges "because she strongly opposed and voiced her concerns
    about HMH’s practices in treating dialysis patients." Specifically, Dr.
    Freilich contends that her opposition to HMH’s decision to outsource
    quality oversight and quality assurance over dialysis services consti-
    tutes protected conduct under the ADA. Under 
    42 U.S.C. § 12203
    ,
    "[n]o person shall discriminate against any individual because such
    individual has opposed any act or practice made unlawful by this
    chapter or because such individual made a charge, testified, assisted,
    or participated in any manner in an investigation, proceeding, or hear-
    ing under this chapter." (emphasis added). In order to establish a
    prima facie case of retaliation, a plaintiff must allege (1) that she has
    engaged in conduct protected by the ADA; (2) that she suffered an
    adverse action subsequent to engaging in the protected conduct; and
    (3) that there was a causal link between the protected activity and the
    adverse action. Rhoads v. FDIC, 
    257 F.3d 373
    , 392 (4th Cir. 2001).
    In reviewing retaliation claims, courts recognize the need to balance
    the desire to encourage employees to oppose unlawful discrimination,
    with "an employer’s interest in maintaining a harmonious, productive
    and loyal workforce." Fitch v. Solipsys Corp., 
    94 F. Supp. 2d 670
    ,
    678 (D. Md. 2000).
    A plaintiff need not establish that the conduct she opposed actually
    constituted an ADA violation. Ross v. Communications Satellite
    Corp., 
    759 F.2d 355
    , 357 n.1 (4th Cir. 1985). But a complainant must
    allege the predicate for a reasonable, good faith belief that the behav-
    ior she is opposing violates the ADA. E.g., Weissman v. Dawn Joy
    Fashions, Inc., 
    214 F.3d 224
    , 234 (2nd Cir. 2000).
    14              FREILICH v. UPPER CHESAPEAKE HEALTH
    In her complaint, Dr. Freilich alleges what at most are violations
    of state medical malpractice law, not infractions of the ADA. Dr.
    Freilich says that she complained orally and/or in writing regarding
    the failure to transport a patient in a timely manner; the failure to
    adhere to skin protocols; the failure to address concerns regarding
    uncertified nurses; the failure to diagnose a cervical fracture on a
    patient; the unsupervised dialysis of a patient; and the failure to pro-
    vide correct dialysis services for several patients. While we do not
    overlook the importance of maintaining adequate levels of patient
    care, it is not the job of a federal court under the ADA to referee dis-
    agreements between a hospital and staff physician over what consti-
    tutes the appropriate funding or manner of such care. In essence, Dr.
    Freilich disagrees with the level of care being provided to some hos-
    pital patients, which she attributes to the outsourcing of quality assur-
    ance and quality oversight for dialysis patients.4 She could not,
    however, reasonably believe that her disagreement with HMH over
    the expenditure of hospital resources constituted a violation of the
    ADA.
    Every disagreement over the adequacy of hospital expenditures or
    the provision of patient care is not an ADA issue. If it were, courts
    would be drawn into medical resource disputes quite beyond their
    expertise and hospital personnel would be diverted by litigation from
    their primary task of providing medical attention to those in their
    charge. Hospitals are in the business of serving persons with many
    kinds of disabilities, and we have noted that "our federal disability
    statutes are not designed to ensure that persons with one type of dis-
    ability are treated the same as persons with another type of disability."
    Lewis v. Kmart Corp., 
    180 F.3d 166
    , 171-72 (4th Cir. 1999). Recog-
    nizing that the medical community is best equipped to conduct the
    balancing that medical resource allocations inevitably require, Con-
    gress declined to give courts a mandate to arbitrate such disputes.
    4
    It is not even clear that the provision of in-house quality assurance
    and quality oversight is a good, service, or advantage under the ADA.
    Rather, as the district court noted, quality assurance and oversight
    "seems more to be a service rendered to the hospital and practitioners."
    Freilich, 
    142 F. Supp. 2d at 702
    .
    FREILICH v. UPPER CHESAPEAKE HEALTH                    15
    Because Dr. Freilich has failed to allege any set of facts supporting
    her claim that she opposed practices made unlawful by the ADA, we
    affirm the district court’s dismissal of her retaliation claim.
    IV.
    We turn finally to Dr. Freilich’s due process challenge to the Mary-
    land statute and regulation which govern the credentialing process.
    Maryland Code Health-General Article § 19-319(e) governs the
    hospital credentialing process for physicians. Under the statute, hospi-
    tals must establish a credentialing process for physicians who are
    employed by or have staff privileges at the hospital. The statute fur-
    ther requires the Secretary of Health and Mental Hygiene to establish
    minimum standards for a credentialing process, which must include,
    among other things, a formal, written reappointment process to be
    conducted at least every two years. The reappointment process must
    document the physicians’ pattern of performance by "analyzing
    claims filed against the physician, data dealing with utilization, qual-
    ity, and risk, a review of clinical skills, adherence to hospital bylaws,
    policies and procedures, compliance with continuing education
    requirements, and mental and physical status." Id.
    Pursuant to § 19-319(e), COMAR § 10.07.01.24(E) requires each
    hospital in the state of Maryland to establish a process for the reap-
    pointment of physicians. As part of the reappointment process, hospi-
    tals must "collect, verify, review, and document" the physicians’
    pattern of performance based on an analysis of the following: "(i)
    claims filed against the physician; (ii) utilization, quality and risk
    data; (iii) a review of clinical skills; (iv) adherence to hospital bylaws,
    policies, and procedures; (v) compliance with continuing medical
    education requirements; (vi) an assessment of current mental and
    physical health status; and (vii) attitudes, cooperation, and ability to
    work with others." Id.
    Dr. Freilich alleges that Maryland’s credentialing regulation,
    COMAR § 10.07.01.24(E), violates due process. Specifically, Dr.
    Freilich alleges that she was deprived of "her liberty to practice her
    chosen profession in the locale where she has practiced for 18 years"
    because "Health-General Article, § 19-319 and the COMAR regula-
    16              FREILICH v. UPPER CHESAPEAKE HEALTH
    tion § 10.07.01.24(E) permit Hospital administrators to deny hospital
    privileges based solely upon the vague, ambiguous, and subjective
    ‘attitude’ criterion."
    The statute and regulation will survive a vagueness challenge so
    long as each provides physicians with reasonable notice as to the type
    of conduct that may cause a denial of their hospital privileges. See
    Village of Hoffman Estates v. Flipside, Hoffman Estates, 
    455 U.S. 489
    , 498-99 (1982). As we pointed out earlier, a provision cannot par-
    ticularize every different set of facts and circumstances that might
    lead a peer review committee to conclude that a physician’s privileges
    should be terminated. Hospitals have historically had wide discretion
    to make decisions regarding their medical staff. See, e.g., Glass v.
    Doctors Hosp., Inc., 
    131 A.2d 254
     (Md. 1957). "The governing board
    of a hospital must[ ] be given great latitude in prescribing the neces-
    sary qualifications for potential applicants." Woodbury v. McKinnon,
    
    447 F.2d 839
    , 845 (5th Cir. 1971). This includes the consideration of
    factors beyond technical medical skills. Schlein v. Milford Hosp., 
    423 F. Supp. 541
    , 544 (D. Conn. 1976) ("Due process does not limit the
    hospital’s consideration to technical medical skills.").
    Dr. Freilich’s vagueness argument would lead the uninformed
    observer to believe that a Maryland hospital can terminate a physi-
    cian’s privileges solely on a subjective determination that the physi-
    cian had a bad attitude. This is untrue. Dr. Freilich ignores the fact
    that the COMAR regulation requires hospitals to assess a physician’s
    pattern of performance based upon seven separate factors. The regula-
    tion does not authorize or encourage private "hospitals to terminate a
    physician’s privileges solely because of his/her ‘[a]ttitudes, coopera-
    tion, and ability to work with others.’" Complaint ¶ 89. By its own
    terms, the regulation requires hospitals to employ a broad based, for-
    mal written reappointment process that considers numerous criteria.
    COMAR § 10.07.01.24(E)(3)(b).
    Furthermore, most courts that have considered the use of criteria
    such as attitude and cooperation in a hospital’s reappointment deci-
    sions have refused to interfere with the discretion given to hospitals
    over substantive credentialing decisions, so long as those criteria are
    not applied arbitrarily. For example, in Sosa v. Board of Managers of
    the Val Verde Memorial Hospital, 
    437 F.2d 173
     (5th Cir. 1971), the
    FREILICH v. UPPER CHESAPEAKE HEALTH                    17
    Fifth Circuit considered a constitutional challenge to the Val Verde
    Memorial Hospital Credential Committee’s use of "character, qualifi-
    cations, and standing" in reviewing applicants seeking admission to
    the hospital medical staff. 
    Id. at 176
     (internal citation omitted). The
    court admitted that "standards such as ‘character, qualifications, and
    standing’ are very general, but . . . recognize[d] that in the area of per-
    sonal fitness for medical staff privileges precise standards are difficult
    if not impossible to articulate. The subjectives of selection simply
    cannot be minutely codified. The governing board of a hospital must
    therefore be given great latitude in prescribing the necessary qualifi-
    cations for potential applicants." 
    Id.
     Because "[n]o court should sub-
    stitute its evaluation of . . . [professional competency] for that of the
    Hospital Board," our review is limited to "assuring that the qualifica-
    tions imposed by the Board are reasonably related to the operation of
    the hospital and fairly administered." 
    Id. at 177
    .
    The Fifth Circuit is hardly alone in its view. Courts across the
    country have upheld bylaws employing similar factors as Maryland’s
    regulation. Freilich, 
    142 F. Supp. 2d at 689
    . In Yashon v. Hunt, 
    825 F.2d 1016
     (6th Cir. 1987), the Sixth Circuit held that "a physician’s
    unprofessional conduct, incompatibility and lack of cooperation on a
    hospital staff are appropriate considerations for denying staff privi-
    leges." 
    Id.
     at 1027 (citing Stretten v. Wadsworth Veterans Hosp., 
    537 F.2d 361
    , 368 (9th Cir. 1976)). See also Mahmoodian v. United Hosp.
    Center, Inc., 
    404 S.E.2d 750
    , 758 (W. Va. 1991) (finding "an ability
    to work with others" a "reasonably definite standard proscribing the
    conduct upon which the [clinical privileges] revocation or other
    adverse action is based"). Today’s health care environment has
    become increasingly complex. As Dr. Freilich’s complaint itself dem-
    onstrates, the operation of a hospital requires the coordination of
    numerous employees and departments, each with different responsi-
    bilities that build and depend upon each other. Thus, staff cooperation
    and communication are essential to ensuring a high quality of patient
    care. Disruptive behavior in the workplace can not only affect the
    morale and teamwork of the staff itself, but in so doing cause actual
    harm to patients. A hospital’s evaluation of a physician’s attitude and
    ability to work with others is not unduly vague and is directly related
    to the goal of good patient care. Accordingly, we reject Dr. Freilich’s
    challenge to Maryland’s physician credentialing system.
    18              FREILICH v. UPPER CHESAPEAKE HEALTH
    V.
    Dr. Freilich’s complaint invites courts to enmesh themselves in
    hospital governance. Both Congress and the Maryland legislature
    have proceeded in precisely the opposite direction, affording hospital
    authorities both the discretion and the protection to discharge their
    assigned tasks. We decline to interfere with these legislative judg-
    ments and affirm the judgment of the district court dismissing plain-
    tiff’s claims.
    AFFIRMED
    

Document Info

Docket Number: 01-1890

Citation Numbers: 313 F.3d 205, 2002 WL 31780983

Judges: Wilkinson, Widener, King

Filed Date: 12/13/2002

Precedential Status: Precedential

Modified Date: 11/5/2024

Authorities (35)

Association of American Physicians & Surgeons v. Weinberger , 395 F. Supp. 125 ( 1975 )

Singleton v. Wulff , 96 S. Ct. 2868 ( 1976 )

Hoffman Estates v. Flipside, Hoffman Estates, Inc. , 102 S. Ct. 1186 ( 1982 )

Barker v. International Paper Co. , 993 F. Supp. 10 ( 1998 )

Freilich v. Board of Directors of Upper Chesapeake Health, ... , 142 F. Supp. 2d 679 ( 2001 )

Fitch v. Solipsys Corp. , 94 F. Supp. 2d 670 ( 2000 )

South Carolina v. Baker , 108 S. Ct. 1355 ( 1988 )

Oliveras-Sifre v. Puerto Rico Department of Health , 214 F.3d 23 ( 2000 )

Marc A. Stretten v. Wadsworth Veterans Hospital , 537 F.2d 361 ( 1976 )

Doctor Robert Sosa v. Board of Managers of the Val Verde ... , 437 F.2d 173 ( 1971 )

Warth v. Seldin , 95 S. Ct. 2197 ( 1975 )

Summit Health, Ltd. v. Pinhas , 111 S. Ct. 1842 ( 1991 )

New York v. United States , 112 S. Ct. 2408 ( 1992 )

Federal Communications Commission v. Beach Communications, ... , 113 S. Ct. 2096 ( 1993 )

International Science & Technology Institute, Incorporated ... , 106 F.3d 1146 ( 1997 )

Steven Weissman, Plaintiff-Appellee-Cross-Appellant v. Dawn ... , 214 F.3d 224 ( 2000 )

22-socsecrepser-85-medicaremedicaid-gu-37121-robert-doyle-md-v , 848 F.2d 296 ( 1988 )

notra-trulock-iii-linda-conrad-v-louis-j-freeh-in-his-personal-capacity , 275 F.3d 391 ( 2001 )

roland-imperial-md-v-suburban-hospital-association-incorporated , 37 F.3d 1026 ( 1994 )

Schlein v. Milford Hospital , 423 F. Supp. 541 ( 1976 )

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