Margo Hein-Muniz v. Aiken Regional Medical Centers

UNPUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
No. 12-2439
MARGO J. HEIN-MUNIZ, MD; PARKSIDE MEDICAL CONSULTANTS LLC,
d/b/a Magnolia Medical,
Plaintiffs - Appellants,
v.
AIKEN REGIONAL MEDICAL CENTERS; UNIVERSAL HEALTH SERVICES,
INC.; AIKEN OBSTETRICS & GYNECOLOGY ASSOCIATES PA; CARLOS A.
MILANES; K. D. JUSTYN; OLETHA R. MINTO, MD; JAMES F.
BOEHNER, MD; ROBERT D. BOONE, MD; JONATHAN H. ANDERSON, MD;
THOMAS P. PAXTON, MD; UHS OF DELAWARE, INC.,
Defendants – Appellees.
Appeal from the United States District Court for the District of
South Carolina, at Aiken. Joseph F. Anderson, Jr., District
Judge. (1:10-cv-00986-JFA)
Submitted: June 14, 2013 Decided: July 5, 2013
Before NIEMEYER and AGEE, Circuit Judges, and HAMILTON, Senior
Circuit Judge.
Affirmed by unpublished per curiam opinion.
Thornwell F. Sowell, III, David C. Dick, Alexis K. Lindsay,
SOWELL GRAY STEPP & LAFFITTE, LLC, Columbia, South Carolina, for
Appellants. Travis Dayhuff, NELSON MULLINS RILEY & SCARBOROUGH,
LLP, Columbia, South Carolina, for Appellees.
Unpublished opinions are not binding precedent in this circuit.
2
PER CURIAM:
Margo J. Hein-Muniz, M.D. (“Muniz”), 1 a physician whose
clinical privileges at Aiken Regional Medical Center (“ARMC”)
were terminated after a peer review proceeding, appeals the
district court’s entry of summary judgment on the civil action
she subsequently brought against the Appellees, in which she
attacked the peer review process and the ultimate decision by
ARMC’s Board of Governors (“Board”) to terminate her privileges.
We affirm.
We forgo a full recounting of the facts, which are
well known to the parties. The bulk of the parties’ arguments
on appeal concern the applicability of the Health Care Quality
Improvement Act (“HCQIA”), 42 U.S.C. § 11101-11152 (2006), which
immunizes those who participate in a “professional review
action” from monetary damages as long as the action is 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 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
1
Muniz’s practice, Parkside Medical Consultants LLC, d/b/a
Magnolia Medical, joins this appeal. For the sake of brevity,
we refer to Appellants collectively as “Muniz.”
3
reasonable effort to obtain facts and after
meeting the requirement of paragraph (3).
42 U.S.C. § 11112(a) (2006); Wahi v. Charleston Area Med. Ctr.,
Inc., 562 F.3d 599, 606-07 (4th Cir. 2009).
“A professional review action shall be presumed to
have met the preceding standards necessary for [immunity] unless
the presumption is rebutted by a preponderance of the evidence.”
42 U.S.C. § 11112(a). In view of this presumption, whether the
participants in the peer review action are entitled to summary
judgment necessitates application of an “unconventional”
standard: “whether a reasonable jury, viewing all facts in a
light most favorable to [the plaintiff], could conclude that
[she] had shown, by a preponderance of the evidence, that [the
peer review participants’] actions fell outside the scope of
section 11112(a).” Gabaldoni v. Wash. Cnty. Hosp. Ass’n, 250
F.3d 255, 260 (4th Cir. 2001).
Having reviewed the record, we are persuaded that no
reasonable jury could have concluded that the Appellees failed
to meet any of the four requirements of the HCQIA. First, no
reasonable jury could have concluded that Muniz carried her
burden of showing that the Board was not motivated by a
reasonable belief that its termination of Muniz’s privileges was
in the furtherance of quality health care — a goal that
certainly includes ensuring that physicians affiliated with ARMC
4
are candid and truthful in their interactions with colleagues
and patients. See, e.g., 42 U.S.C. § 11151(9) (2006); Singh v.
Blue Cross/Blue Shield of Mass., Inc., 308 F.3d 25, 39 (1st Cir.
2002). Because § 11112(a)(1) requires only a “reasonable
belief” that the action was in furtherance of quality health
care, the test is “an objective one which looks to the totality
of the circumstances.” Imperial v. Suburban Hosp. Ass’n, Inc.,
37 F.3d 1026, 1030 (4th Cir. 1994); see also Gabaldoni, 250 F.3d
at 261.
Due to the objective nature of this court’s inquiry,
“to the extent [Muniz’s] case relies on inferences of a
conspiracy to oust [her], . . . such inferences do not create
any genuine issues of fact . . . . In the HCQIA immunity
context, the circuits that have considered the issue all agree
that the subjective bias or bad faith motives of the peer
reviewers is irrelevant.” Sugarbaker v. SSM Health Care, 190
F.3d 905, 914 (8th Cir. 1999); see Cohlmia v. St. John Med.
Ctr., 693 F.3d 1269, 1279 (10th Cir. 2012). And “[t]he fact
that some of the specific concerns [identified by the hearing
panel and the Medical Executive Committee] shifted or changed
over time does not rebut the presumption that the hospital acted
in the reasonable belief that it was furthering quality health
care.” Lee v. Trinity Lutheran Hosp., 408 F.3d 1064, 1071 (8th
Cir. 2005) (internal quotation marks omitted). Notwithstanding
5
Muniz’s attempt to portray the Medical Executive Committee’s
conduct as a conspiratorial ploy to eject her from ARMC, we can
only conclude on the record that there was “enough evidence
against [Muniz] for the Board to believe that it was furthering
the quality of health care in terminating [her] privileges.”
Gabaldoni, 250 F.3d at 261 (internal quotation marks omitted).
Given the extensive peer review process conducted in
Muniz’s case, we likewise conclude that no reasonable jury could
find that the Board had failed on the HCQIA’s second prong — to
make a reasonable effort to obtain the pertinent facts. See 42
U.S.C. § 11112(a)(2); Moore v. Williamsburg Reg’l Hosp., 560
F.3d 166, 175-76 (4th Cir. 2009); Singh, 308 F.3d at 43;
Gabaldoni, 250 F.3d at 261.
Muniz’s argument as to the third prong of § 11112(a)
must meet the same fate. Even assuming that the safe harbor
provisions found in 42 U.S.C. § 11112(b) (2006) apply only
partially to the Board’s peer review action, but see, e.g.,
Moore, 560 F.3d at 176, we nonetheless think it inescapable that
the Board terminated Muniz’s privileges “after such other
procedures as are fair to the physician under the
circumstances.” 42 U.S.C. § 11112(a)(3). We do not believe
that a reasonable jury could find that the procedural
irregularities involving the hearing officer — unwise though
some of them were — rendered Muniz’s peer review process unfair
6
or objectively unreasonable. See Wahi, 562 F.3d at 610, 614(noting standard). Nor do we countenance Muniz’s assertion that
she was insufficiently on notice that she was required to tell
the truth during her peer review process and that her privileges
could be terminated if she did not do so. A reasonable jury
could only conclude that it was “fair” for the Board to
terminate Muniz after giving her extensive opportunity in a
lengthy hearing to explain her misrepresentations. 42 U.S.C.
§ 11112(a)(3). See also Moore, 560 F.3d at 175 (“[T]he entire
purpose of an immunity provision is to afford some discretionary
latitude to decisionmakers to make close calls unhaunted by the
specter of civil liability.”).
Finally, Muniz’s arguments as to the HCQIA’s fourth
prong cannot forestall summary judgment, either, given that a
reasonable jury could conclude only that the Board’s conduct was
taken “in the reasonable belief that the action was warranted by
the facts known” to it. 42 U.S.C. § 11112(a)(4). Because Muniz
has failed to show that the facts relied upon by the Board were
“so obviously mistaken or inadequate as to make reliance on them
unreasonable,” she cannot defeat the presumption that the
Board’s action complied with § 11112(a)(4). Meyers v.
Columbia/HCA Healthcare Corp., 341 F.3d 461, 471 (6th Cir. 2003)
(internal quotation marks omitted). See also Moore, 560 F.3d at
172 (“HCQIA immunity allows hospitals to take prophylactic
7
measures that need not involve proof of improper conduct beyond
a reasonable doubt so long as statutory procedures designed to
protect the reputation and livelihood of the physician have been
observed.”). Nor does the HCQIA require the Board to consider
less severe disciplinary options as long as the one chosen is
reasonably warranted by the facts. Id. at 176; Singh, 308 F.3d
at 38.
Because Muniz “has not met [her] burden of showing
that the requirements in § 11112(a)(1)-(4) were not met” by the
Board, the district court properly determined that the Appellees
are immune from damages under the HCQIA. Moore, 560 F.3d at
176. 2 To the extent that any of Muniz’s substantive state law
claims survive the operation of the HCQIA, we also conclude that
the district court properly entered summary judgment on each of
them. See id. at 176-78.
Accordingly, we affirm the judgment of the district
court. We dispense with oral argument because the facts and
legal contentions are adequately presented in the material
2
Despite Muniz’s arguments that the district court abused
its discretion in excluding certain expert testimony proferred
by her and in declining to draw an adverse evidence on the basis
of spoliated evidence, we disagree. See F.C. Wheat Mar.
Corp. v. United States, 663 F.3d 714, 723 (4th Cir. 2011)
(noting standard); Vulcan Materials Co. v. Massiah, 645 F.3d
249, 260 (4th Cir. 2011) (same).
8
before this court and argument will not aid the decisional
process.
AFFIRMED
9