BILL ANALYSIS                                                                                                                                                                                                    



                                                                  AB 120
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          ASSEMBLY THIRD READING
          AB 120 (Hayashi) 
          As Amended  June 1, 2009
          Majority vote 

           BUSINESS & PROFESSIONS     11-0                                 
           
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          |Ayes:|Hayashi, Emmerson,        |     |                          |
          |     |Conway, Eng, Hernandez,   |     |                          |
          |     |Nava, Niello,             |     |                          |
          |     |John A. Perez, Price,     |     |                          |
          |     |Ruskin, Smyth             |     |                          |
          |-----+--------------------------+-----+--------------------------|
          |     |                          |     |                          |
           ----------------------------------------------------------------- 
           
          SUMMARY  :  Amends the medical peer review process by recommending  
          external peer review in limited circumstances, requires peer  
          review bodies to share information, establishes the duties of a  
          hearing officer, and sets parameters for attorney  
          representation.  Specifically,  this bill  :  


          1)Declares the public policy of the state that healthcare  
            licentiates who may be providing substandard care be subject  
            to the peer review hearing and reporting process set forth, as  
            specified. 


          2)Prohibits a member of a medical or professional staff, by  
            contract or otherwise, from being required to alter or  
            surrender staff privileges, status, or membership solely due  
            to the termination of a contract between that member and a  
            health care facility to ensure that the peer review process is  
            not circumvented.


          3)States that with respect to services that may only be provided  
            by members who have, or who are members of a medical group  
            that has a current exclusive contract for certain identified  
            services, termination of the contract, or termination of the  
            member's employment by the medical group holding the contract,  
            may result in the member's ineligibility to provide the  
            services covered by the contract.








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          4)Requires the peer review body of a health care facility to be  
            entitled to review and make recommendations to the governing  
            body of the facility regarding quality considerations whenever  
            the selection, performance evaluation, or any change in the  
            retention or replacement of licentiates with whom the health  
            care facility has a contract occurs, and requires the  
            governing body to give great weight to these recommendations.


          5)Preserves the right of a governing body's ability to take  
            action against a licentiate, as specified.


          6)Declares the policy of the state that in certain limited  
            circumstances, external peer review may be necessary to  
            promote and protect patient care in order to eliminate  
            perceived bias, obtain needed medical expertise, or respond to  
            other particular circumstances.


          7)Encourages a peer review body to obtain external peer review  
            for the evaluation or investigation of an applicant, privilege  
            holder, or member of the medical staff in the following  
            circumstances:


             a)   Committee or department reviews that could affect a  
               licentiate's membership or privileges do not provide a  
               sufficiently clear basis for action or inaction;


             b)   No current medical staff member can provide the  
               necessary expertise in the clinical procedure or area under  
               review; and,


             c)   To promote impartial peer review.


          8)Requires a peer review body to respond to the reasonable  
            request of another peer review body and produce the records  
            requested concerning a licentiate under review to the extent  
            not otherwise prohibited by state or federal law, upon  








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            reasonable receipt of copying costs. 



          9)Prohibits the records produced from being subject to discovery  
            to the extent provided in Section 1156.1 and 1157 of the  
            Evidence Code, and any other applicable sections of law. 



          10)Requires the peer review body responding to the request to be  
            entitled to all confidentiality protections and privileges  
            provided by law as to the information and records disclosed.



          11)Requires a hearing be held, as determined by the peer review  
            body, before a trier of fact, which shall be an arbitrator or  
            arbitrators selected by a process mutually acceptable to the  
            licentiate and the peer review body, or before a panel of  
            unbiased individuals, as specified.



          12)Prohibits a hearing officer from gaining direct financial  
            benefit from the outcome of a hearing, requires the hearing  
            officer to disclose all actual and potential conflicts of  
            interest within the last five years as reasonably known to the  
            hearing officer, prohibits the hearing officer from acting as  
            a prosecuting officer or advocate, and prohibits the hearing  
            officer from voting. 



          13)Requires the hearing officer to be an attorney licensed to  
            practice law in the State of California.  Except as otherwise  
            agreed by the parties, attorneys from a firm utilized by the  
            hospital, the medical staff, or the involved licentiate within  
            the preceding two years shall not be eligible.



          14)Requires that the timeframe within which a hearing must  
            commence, as specified, be tolled for purposes of complying  
            with the process of selecting a hearing officer, provided the  








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            parties are engaged in a good faith attempt to select a  
            mutually acceptable hearing officer.



          15)Requires the hearing officer to endeavor to ensure that all  
            parties maintain proper decorum and have reasonable  
            opportunity to be heard and present all relevant oral and  
            documentary evidence. 



          16)Requires the hearing officer to be entitled to determine the  
            order of, or procedure for, presenting evidence and argument  
            during the hearing and shall have the authority and discretion  
            to make all rulings on questions pertaining to matters of law,  
            procedure, or the admissibility of evidence. 



          17)Requires the hearing officer to take all appropriate steps to  
            ensure a timely resolution of the hearing, but may not  
            terminate the hearing process.  However, in the case of  
            flagrant noncompliance with the procedural rules governing the  
            hearing process or egregious interference with the orderly  
            conduct of the hearing, the hearing officer may recommend that  
            the hearing panel terminate the hearing, provided that this  
            activity is authorized by the applicable bylaws of the medical  
            staff. 



          18)States that during a hearing concerning a final proposed  
            action for which reporting is required to be filed, as  
            specified, both parties shall have the right to be represented  
            by an attorney of the party's choice at the party's expense,  
            however:



             a)   Prohibits a peer review body from being represented by  
               an attorney if the licentiate notifies the peer review body  
               in writing no later than 15 days prior to the hearing that  
               he or she has elected to not be represented by an attorney.  
                Except as otherwise agreed to by the parties, this  








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               election shall be binding; 



             b)   If the licentiate does not provide the written notice  
               described within the required timeframe, the peer review  
               body may be represented by an attorney even if the  
               licentiate later elects to not be represented by an  
               attorney; and, 



             c)   Dental professional society peer review bodies may be  
               represented by an attorney even if the licentiate declines  
               to be represented by an attorney. 



          19)Defines "external peer review" as peer review provided by  
            licentiates who are not members of the peer review body, who  
            are impartial, and who have the necessary expertise in the  
            clinical procedure or area under review.


          20)Makes legislative findings and declarations.

           FISCAL EFFECT  :   Unknown.  This bill is keyed non-fiscal.

           COMMENTS  :  According to the author's office, "This bill will  
          improve the peer review system in California to ensure quality  
          health care is being provided to patients.  Currently, the peer  
          review system can be open to manipulation and unreasonable  
          delay.  This bill will provide for a more effective peer review  
          process in which physicians and surgeons are continuously  
          monitored and assessed to improve the quality of care that is  
          provided to patients."

          Medical peer review is the process by which a professional  
          review body considers whether a practitioner's clinical  
          privileges or membership in a professional society will be  
          adversely affected by a physician's competence or professional  
          conduct.  The foremost objective of the medical peer review  
          process is the promotion of the highest quality of medical care  
          as well as patient safety.  









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          Variations exist on the procedures, commencement, practice and  
          subject of peer review.  All medical entities set their own  
          standards for peer review, some more rigorous than others, and  
          some adhere to them more meticulously than others.  The peer  
          review process is often lengthy and can take months or even  
          years.  Although peer review is supposed to be an objective  
          review of professional skills, there has been rising concern  
          relating to "sham peer review."  Sham peer review is the use of  
          the peer review system to discredit, harass, discipline, or  
          otherwise negatively affect a physician's ability to practice  
          medicine or exercise professional judgment for a non-medical or  
          patient safety related reason.  Other criticisms of peer review  
          include over legalization of the process, lack of transparency  
          in the system, and burdensome human and financial toll peer  
          review brings not only to the hospital but also to a physician  
          under review.

          California law entitles a licentiate who is the subject of a  
          final action of a peer review body to specified due process  
          rights.  Under Business and Professions Code Section 809, a  
          physician about whom an 805 report may be filed is entitled to  
          notice of the proposed action and an opportunity for a hearing  
          with full procedural rights, including discovery, examination of  
          witnesses, formal record of the proceedings and written  
          findings.  A physician may contest the results of this hearing  
          with judicial review in Superior Court.  

          When a licensee is disciplined for a medical cause or reason by  
          a peer review committee, the MBC receives an 805 report so that  
          it may take appropriate action.  According to the MBC in 2007,  
          it received 138 reports from a licensee pool of 125,612  
          physicians.  Of these reports, one accusation was filed, 92  
          cases are pending disposition, and 45 cases were closed.  The  
          number of 805 reports varies from year to year.   

          SB 231 (Figueroa) Chapter 674, Statutes of 2005, required the  
          MBC to contract with an independent entity to conduct a  
          comprehensive study of the existing peer review process.  SB 231  
          required the study to include a comprehensive description of the  
          various steps of, and decision makers in, the peer review  
          process; a survey of peer review cases to determine the  
          incidence of peer review; and an assessment of the cost of peer  
          review to licentiates.  In the report, Lumetra concluded that  
          "the present peer review system is broken for various reasons  
          and is in need of a major fix, if the process is to truly serve  








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          the citizens of California." 

          The Lumetra Study focused heavily on the reporting process to  
          the MBC that follows peer review.  This bill does not address  
          those issues, but it does attempt to resolve the report's  
          recommendation that the process be redesigned to afford for  
          greater fairness to the physician under review.  One of the more  
          significant changes to current law is the selection process for  
          the 809 hearing officer; the bill affords for mutual agreement  
          of either the officer or a third party selection service, but if  
          this is not achieved, each side chooses candidates which are  
          ranked and chosen according to score, and in case of a tie, by  
          drawing lots.           
           

          Analysis Prepared by  :    Sarah Huchel / B. & P. / (916) 319-3301  



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