In Moore v. John Deere Health Care Plan, Inc., the Sixth Circuit affirmed summary judgment for John Deere—a health maintenance organization. Under the Health Care Quality Improvement Act (“HCQIA”), the Court held, John Deere was immune from damages in a suit brought by David Moore and his wife—the sole officers, directors, and shareholders of Community Health Care Clinics, Inc. (“CHCCI”), a “for-profit” corporation.
Pursuant to two contracts between John Deere and Moore, John Deere’s members visited CHCCI locations. After John Deere began receiving numerous complaints from its members concerning the quality of CHCCI’s care, John Deere investigated the complaints and decided to cancel the contracts. As was his right, Moore timely appealed the decision to a three-physician appeal panel. The appellate panel upheld John Deere’s decision to terminate the contracts. In compliance with federal law, John Deere filed an Adverse Action Report stating that it terminated Moore’s contracts due to patient complaints. Thereafter, Moore filed suit for defamation, tortious interference with current business relationships, breach of contract, and injunctive relief. John Deere filed for summary judgment, which the District Court granted finding that John Deere was immune under the HCQIA.
The purpose of the HCQIA is to effectively “monitor[] incompetent physicians, and to grant qualified immunity from damages for those who participate in peer review activities.” As long as the “professional review action” is reasonable, “the people participating in the review shall not be liable for damages under any law of the United States or of any State.” Because the HCQIA shifts the burden to the plaintiff to prove that the defendant’s actions failed to meet the requisite standards, the result, the Sixth Circuit held, is an “unusual” summary judgment standard: “Might a reasonable jury, viewing the facts in the best light for the plaintiff, conclude that he has shown, by a preponderance of the evidence, that the defendants’ actions are outside the scope of [immunity].” Therefore, the plaintiff must establish that the review process was unreasonable to overcome the presumption of immunity.
Before reaching the reasonableness inquiry, however, Moore argued that because he did not personally receive any complaints, the review did not address Moore’s physician competence and, thus, did not qualify as a “professional review action” under the HCQIA. The Sixth Circuit rejected that argument, holding that Moore did treat a complaining patient, and that “fact alone is enough to implicate Moore’s professional competence” and, thus, implicate HCQIA immunity. Further, under the appropriate, broad reading of the statute, the Court held, Moore’s decision to staff his clinics with other practitioners and then inadequately supervise them bears upon his professional conduct.
With respect to reasonableness, the Court held that Moore failed to establish, using HCQIA’s four factor reasonableness test, that John Deere’s actions were unreasonable. Moore could not show that: (1) that John Deere’s contract termination was not reasonably intended to improve the healthcare of its members, (2) that John Deere’s peer review action was conducted without a reasonable effort to obtain the relevant facts, (3) that John Deere’s peer review action was conducted without adequate notice, and (4) that John Deere’s reliance on the facts was obviously mistaken or so inadequate as to make that reliance unreasonable. Because John Deere qualified for immunity under the HCQIA, the Sixth Circuit affirmed the District Court’s summary judgment against each of Moore’s three claims for damages. Moore’s fourth claim for injunctive relief failed for a separate reason—the regulations do not afford a private cause of action to sue a reporting entity for an inaccurate adverse action report. The exclusive remedy is to dispute the report by requesting review by the Secretary.
