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Blaine v. North Brevard County Hospital District

United States District Court, M.D. Florida, Orlando Division

August 22, 2019




         Before the Court is Defendant North Brevard County Hospital District, d/b/a Parrish Medical Center's (“PMC”) Motion for Summary Judgment. (Doc. 137 (“Motion”).) Plaintiffs responded (Doc. 148), and PMC replied (Doc. 154). On review, the Motion is granted.

         I. Background [1]

         This case is about a public hospital's decision to deny seven doctors reappointment of medical privileges and the process it used to get there. Plaintiffs are oncologists employed by Health First, a health system based in Brevard County, who practice in Brevard County at various facilities. (Doc. 81, ¶¶ 2, 7.) Each successfully applied for medical privileges at PMC and had been re-appointed every time their terms came up. (Id. ¶ 12.) So when it came time to renew in 2017, they followed the same process outlined in PMC's Medical Staff Bylaws (“Bylaws”): submitting applications for PMC's CEO George Miktarian to review. (Id.; Doc. 33-1, ¶ 9; Doc. 81-1, pp. 33-38 (Bylaws reappointment process).) Dr. Miktarian then transmitted Plaintiffs' applications to the Credentials and Medical Ethics Committee (“CMEC”), which sent the applications to PMC's Medical Executive Committee (“MEC”). (Doc. 81, ¶¶ 21-22.) The MEC reviewed the applications and, on November 21, 2017, provided a favorable recommendation regarding Plaintiffs' reappointment to PMC's Board of Directors (“Board”). (Id. ¶ 23.) All seemed well; Plaintiffs believed their applications would be approved again. (Doc. 81, ¶ 12; e.g., Doc. 143-4, p. 57:19-23; Doc. 143-7, pp. 82:5-83:3.)

         Meanwhile PMC had been seeking renewal of accreditation of their cancer program from the Commission on Cancer (“CoC”). This process began in 2016 and involved providing data and working closely with CoC staff, who would do a site visit. (Doc. 143-11, pp. 16:1-15, 40:17-41:2, 51:21-54:12.) When the process started, Plaintiff Dr. Dalal was chair of PMC's Cancer Committee and the representative of Health First. (Doc. 143-4, pp. 40:6-17, 41:6-43:7, 64:20-22.) At the September meeting, PMC's accreditation initiative was discussed and the subject of data came up, specifically that PMC needed data from Health First physicians to complete the accreditation process. (Id. at 40:6-17, 41:6-43:7.) Dr. Dalal said he would work on it and at a later meeting reported back that Nancy Payne, Health First's System Director, was the person to talk to. (Id.; Doc. 145-1, pp. 33:24-43:8; Doc. 143-8, p. 14:10-12.) He said he would coordinate with her, and PMC separately reached out to her requesting data. (Doc. 143-4, pp. 40:6-17, 41:6-43:7; Doc. 145-1, pp. 33:24-43:8; Doc. 143-8, pp. 27:1-28:8, 30:12-13, 32:7-12; 34:13-15, 41:17-22, 40:23-41:8 (Payne received emails over two years regarding data and received instructions not to provide certain information to PMC).) PMC didn't get everything they were looking for and continued to reach out to Nancy Payne over the next year, as all data requests were funneled her way. (Doc. 143-8, pp. 41:17-22, 52:5-8, 55:18-56:25, 57:24-58:10, 61:1-63:10, 64:6-65:4, 67:8-25, 75:4-25.) Separately, PMC asked Dr. Bryant for some specific information regarding radiation and she complied. (Doc. 143-2, pp. 100:18- 101:19; Doc. 145-4, pp. 33:17-34:18.) Nancy Payne, however, was unresponsive to numerous inquiries PMC made about the data. (Doc. 143-8, pp. 41:17-22, 52:5-8, 55:18- 56:25, 57:24-58:10, 61:1-63:10, 64:6-65:4, 67:8-25.)

         While this was going on, the composition of PMC's Cancer Committee changed. Dr. Dalal was replaced by Dr. Deligdish, an oncologist in charge of a different practice group, as head of the committee. (Doc. 143-4, pp. 90:13-92:6; Doc. 143-5, pp. 10:4-20, 105:18-24, 124:12-20.) PMC noticed a decline in the amount of patients Plaintiffs treated at PMC, and chalked it up to Plaintiffs' association with Health First, which had its own facilities. (Doc. 145-2, p. 35:7-24; Doc. 33-3, ¶¶ 8-12.) So sometime in September 2017, after learning that PMC's numerous requests for data from Health First were outstanding, Dr. Deligdish phoned several Plaintiffs on PMC's behalf to discuss their association with Health First and mentioned the data requests to some. (Doc. 145-1, pp. 89:24-90:11; Doc. 143-5, pp. 105:4-106:19, 109:8-14.) He met with Dr. Dalal in person. (Doc. 143-5, pp. 105:4-106:19.) At that time, Plaintiff Dr. Muwalla was the medical director of Health First, and on hearing of this data issue, he went to Nancy Payne. (Doc. 143-7, pp. 42:7-9, 43:11-13.) According to Dr. Muwalla, she told him she'd get back to him and couldn't release the data PMC was requesting absent approval from her superiors. (Id. at 43:16-24.) Those in charge at Health First decided not to release the data. (Id. at 56:16-25.)

         Matters came to a head when Plaintiffs sought reappointment. Their employer, Health First, had decided not to comply with PMC's requests for data for re-accreditation purposes. (Doc. 145-3, pp. 18:6-18, 20:24-25:22.) PMC informed the CoC surveyor during the on-site visit of the data issues with Health First, who empathized with PMC's situation and created workarounds for some of the data requests. (Doc. 143-11, pp. 51:21- 54:12, 73:10-74:17, 81:19-83:6.) Yet at the time Plaintiffs sought reappointment, there were still outstanding data inquiries from Health First. (Id. at 73:10-74:17, 81:19-84:25.) So although the MEC recommended approving Plaintiffs' reappointment, when their applications went to the Board, Dr. Miktarian distributed a memo he had Marsha Richardson, PMC's Director of Oncology Services, prepare that detailed all the times PMC had requested data from Health First, naming Plaintiffs. (Doc. 145-2, pp. 12:1-24, 79:23-81:3; Doc. 145-4, pp. 24:20-25, 87:18-92:2.) He also circulated a draft letter prepared by PMC's legal counsel addressed to each Plaintiff. (Doc. 145-2, pp. 85:1-86:3.) At the meeting, the Board decided to send back Plaintiffs' reappointment applications to the MEC because of these data issues (“December 4 Meeting”). (Id. at 57:3-8; Doc. 33-2, pp. 2-15.)

         The next day, Dr. Miktarian sent each Plaintiff a letter notifying them their refusal to provide data constituted a breach of PMC's Bylaws and could be a reason to deny reappointment. (Doc. 33-2, pp. 16-29 (“December 5 Letter”).) He gave them five days to turn over any outstanding data and noted that even if they attempted to cure now, their applications could still be denied. (Id.)

         Plaintiffs went to Health First management with the letters, as they didn't own the data and couldn't individually provide it. (Doc. 143-1, pp. 45:4-49:23; Doc. 143-2, pp. 93:15-99:24; Doc. 143-3, pp. 33:19-22, 41:20-46:1; Doc. 143-3, pp. 44:13-50:8; Doc. 143-7, pp. 57:17-64:3; Doc. 143-9, pp. 20:3-22:18; Doc. 143-10, pp. 59:25-60:3, 78:14-81:18.) Health First decided it would handle the entire situation through its legal department, taking the position that it didn't need to hand over the data as PMC was wrongfully attempting to deny these reappointment applications since Plaintiffs had no clinical issues. (Doc. 33-3, pp. 30-33; Doc. 143-1, pp. 53:12-56:2, 63:18-75:14; Doc. 143-2, pp. 101:22-108:13; Doc. 143-3, pp. 55:2-64:24; Doc. 143-4, pp. 57:7-62:16; Doc. 143-7, pp. 57:17-64:3, 74:2-24; Doc. 143-9, pp. 20:3-22:18, 100:5-19; Doc. 143-10, pp. 82:3-83:22.) Letters were exchanged staking out the parties' respective positions. (Doc. 33-1, ¶¶ 26-31, 33, 35-39; Doc. 33-2, pp. 36-49, 51-62; Doc. 33-3, pp. 30-33, 35-41.)

         The MEC met after the Board sent back Plaintiffs' applications to the MEC and discussed Plaintiffs' reappointment. (Doc. 33-2, pp. 31-34.) Plaintiff Dr. Sprawls appeared at the meeting to provide his side of the story: he objected to the revocation of his privileges, the Bylaws didn't permit denial of his reappointment for this data reason, the provision of data had no bearing on his clinical capabilities, the data requests hadn't been made to him, and he had no control over the data. (Doc. 143-10, pp. 97:4-101:11.) The MEC decided to support the Board if the applications were denied. (Doc. 33-2, p. 33.)

         The Board met again and heard Plaintiffs hadn't complied with data requests as Health First was refusing to turn it over. (Doc. 145-1, pp. 67:6-68:6.) At the same time, PMC was working with CoC to get an extension on its time to comply with two outstanding data requests and learning what to do to finish the accreditation process despite this missing data. (Doc. 143-11, pp. 81:19-87:13.) The Board decided to deny Plaintiffs' reappointment applications at the January 8 Meeting, and Dr. Miktarian sent each Plaintiff a letter notifying them of the denial and the expiration of their privileges. (Doc. 33-2, pp. 64-77.) He offered them the opportunity to appear before the Board for an interview and appeal the decision as the Bylaws allow. (Id.)

         Feeling steamrolled, Plaintiffs responded via letter prepared by Health First's counsel. (Id. at 79-99.) They initially accepted the interview offer but then didn't respond to Dr. Miktarian's request to provide dates and times, later deciding “to forego” the interview. (Id.; Doc. 33-3, pp. 2-28, 43-44, 46-47.) They also didn't send any patient information or attempt to provide coordination of care plans. (Doc. 143-1, pp. 73:20-74:6; Doc. 143-2, p. 122:20-15; Doc. 143-3, pp. 60:2-13, 62:6-15; Doc. 143-7, pp. 72:15-73:3; Doc. 143-9, p. 97:1-12; Doc. 143-10, p. 115:21-25.)

         With privileges gone, Plaintiffs filed this lawsuit alleging two claims initially: PMC violated their procedural due process by denying them reappointment without a hearing, and PMC breached the Bylaws by denying the applications for not providing the data, which Plaintiffs dub a non-clinical business reason. (Doc. 1.) For the breach claim, they say Dr. Miktarian committed intentional fraud by telling the Board Plaintiffs failed to comply with numerous data requests made to them, repeating this in the December 5 Letter, and telling this to the MEC. (Id. ¶¶ 18, 24-25, 28-31, 61-62, 64-66.) With the Complaint, Plaintiffs moved for preliminary injunction. (Doc. 5.)

         Following briefing and a hearing on the preliminary injunction (Docs. 32, 33, 35, 38, 39), the Court granted the motion in part on the procedural due process claim, ordering PMC to provide Plaintiffs a hearing in conformity with its Bylaws and reinstating Plaintiffs' privileges in the meantime. (Doc. 42 (“First PI Order”).) PMC complied, holding a hearing on Plaintiffs' reappointment applications in conformity with the Bylaws before a neutral decisionmaker where Plaintiffs were represented by counsel and presented witness testimony and evidence (“Ad Hoc Committee”). (Doc. 81-1, pp. 92-96; Docs. 66-4, 66-5 (hearing transcript).) The focus was on the data: whether PMC requested data from Plaintiffs, whether Plaintiffs received data requests, how Plaintiffs responded, should their responses cost them reappointment, whether they provided the data, and whether denial of their reappointment applications was appropriate for not providing the data. (Doc. 81-1, p. 93.)

         On consideration, the Ad Hoc Committee issued Findings and Recommendations. (Doc. 81-1, pp. 94-95.) First, the Ad Hoc Committee addressed “the central question-do the Medical Staff Bylaws require [Plaintiffs] to have supplied, or caused to be supplied, the requested data?” (Id. at 94.) It found:

         (Image Omitted)

(Id. at 94-95.) So the Ad Hoc Committee answered the first question:

[Plaintiffs] were aware of the unfulfilled requests for Patient Data and even if they did not have control of the data, they had a duty to supply it, or cause it to be supplied, as part of their obligations as staff members of [PMC].

(Id. at 96.)

         Next, the Ad Hoc Committee asked, “Was denial of [Plaintiffs'] reappointment applications allowed under the Medical Staff Bylaws for the ...

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