BILL ANALYSIS                                                                                                                                                                                                    �



                                                                  AB 655
                                                                  Page  1

          Date of Hearing:   May 3, 2011

              ASSEMBLY COMMITTEE ON BUSINESS, PROFESSIONS AND CONSUMER 
                                     PROTECTION
                                 Mary Hayashi, Chair
                 AB 655 (Hayashi) - As Introduced:  February 16, 2011
                             (As Proposed to be Amended)
           
          SUBJECT  :   Healing arts: peer review.

           SUMMARY  :   Revises the medical peer review process by requiring 
          a peer review body to respond to the request of another peer 
          review body and produce specified information concerning a 
          licentiate under review.  Specifically,  this bill  :  

          1)Requires a peer review body to respond to the request of 
            another peer review body and produce relevant peer review 
            information about a licentiate that was subject to peer review 
            by the responding peer review body.

          2)Permits the responding peer review body to determine the means 
            of producing requested information and to elect to do so 
            through:

             a)   A written summary of relevant peer review information; 
               or

             b)   Relevant peer review records.

          3)Specifies that relevant peer review information or records 
            includes any allegations and findings, any explanatory or 
            exculpatory information submitted by the licentiate, any 
            conclusions made, any actions taken, and the reasons for those 
            actions, to the extent not otherwise prohibited by applicable 
            state or federal law.

          4)Requires the information produced to be used solely for peer 
            review purposes.

          5)Prohibits the information produced from being subject to 
            discovery to the extent provided in current law, as specified, 
            and from identifying any person except the licentiate.

          6)Exempts a responding peer review body acting in good faith 
            from civil or criminal liability for providing information to 








                                                                  AB 655
                                                                  Page  2

            the requesting peer review body.

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

          8)Prior to the release of any peer review information, requires 
            the requesting peer review body to sign a mutually agreeable 
            peer review sharing agreement with the responding peer review 
            body, upon request.

          9)Requires the requesting peer review body to indemnify the 
            responding peer review body for any and all claims, demands, 
            liabilities, losses, damages, costs and expenses, as 
            specified, resulting from the receiving peer review body's 
            improper release or disclosure of information shared.

          10)Prior to the release of any peer review information, requires 
            the licentiate under review by the requesting peer review body 
            to release the responding peer review body, its members, and 
            the health care entity for which the responding peer review 
            body conducts peer reviews from liability for the disclosure 
            of information, upon request.  If the licentiate does not 
            provide a release that is acceptable to the responding peer 
            review body, the responding peer review body shall not be 
            obligated to produce any information.

           EXISTING LAW  

          1)Establishes the Medical Board of California (MBC), which 
            regulates and licenses physicians and surgeons.

          2)Provides for the professional review of specified healing arts 
            licentiates through a peer review process conducted by peer 
            review bodies, as specified. 

          3)Provides various due process rights for licentiates who are 
            the subject of a final proposed disciplinary action of a peer 
            review body, as codified under Section 809, et seq.  These 
            include authorizing a licensee to request a hearing concerning 
            a final action, which must be held before either an arbitrator 
            mutually acceptable to the licensee and the peer review body 
            or a panel of unbiased individuals, as specified.  These due 
            process requirements do not apply to peer review proceedings 
            conducted in state or county hospitals, University of 








                                                                  AB 655
                                                                  Page  3

            California hospitals, or to other teaching hospitals, as 
            defined.

          4)Requires the chief of staff of a medical or professional staff 
            or other chief executive officer, medical director, or 
            administrator of any peer review body and the chief executive 
            officer or administrator of any licensed healthcare facility 
            or clinic to file an 805 report to the MBC within 15 days 
            after the effective date of any of the following occurring as 
            a result of an action of a peer review body:

             a)   A licentiate's application for staff privileges or 
               membership is denied or rejected for a medical disciplinary 
               cause or reason;

             b)   A licentiate's membership, staff privileges, or 
               employment is terminated or revoked for a medical 
               disciplinary cause or reason; or,

             c)   Restrictions are imposed, or voluntarily accepted, on 
               staff privileges, membership, or employment for a 
               cumulative total of 30 days or more for any 12 month 
               period, for a medical disciplinary cause or reason.

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

           COMMENTS  :   

           Purpose of this bill  .  According to the author's office, "AB 655 
          will improve the peer review system in California to ensure 
          quality health care is being provided to patients by 
          facilitating the sharing of peer review records.  It is 
          essential that California has a robust and equitable peer review 
          system that ensures quality healthcare and patient safety.  Peer 
          review cannot be effective unless physicians feel that it is a 
          fair system, free from bias, and physicians are able to report 
          incidents of substandard care or unprofessional conduct.

          "Physicians are often reluctant to serve on peer review 
          committees due to the risk of involvement in related future 
          litigation, including medical malpractice lawsuits against a 
          physician under review.  In addition, there has been rising 
          concern relating to "sham peer review," the use of the peer 
          review system to discredit, harass, discipline, or otherwise 
          negatively affect a physician's ability to practice medicine or 








                                                                  AB 655
                                                                  Page  4

          exercise professional judgment for a non-medical or patient 
          safety related reason.  Sharing summaries between peer review 
          bodies will both increase consumer protection and protect 
          physicians."

           Background  .  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.  

          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 Section 809 of the Business and Professions Code, 
          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, 








                                                                  AB 655
                                                                  Page  5

          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.  The study, conducted by 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 the citizens of California." 

          AB 1235 (Hayashi) of 2010 amended the medical peer review 
          process by recommending external peer review in limited 
          circumstances, requiring peer review bodies to share 
          information, establishing the duties of a hearing officer, and 
          setting parameters for attorney representation.  In his veto 
          message for this bill, Governor Schwarzenegger stated, "I vetoed 
          two bills on this subject last year, with a clear message for 
          the interested stakeholders to work together, along with my 
          Administration, on this extremely complicated and complex issue. 
           Unfortunately, this consensus did not occur.  As California 
          stands ready to implement health reform, we need hospitals and 
          physicians to work in new and more efficient ways.  I believe 
          both parties are working to provide quality care to patients but 
          there are better ways to work together.  Litigation and 
          protracted contract disputes are not going to be mechanisms to 
          achieve this common goal.

          "I would encourage the author to keep working with these parties 
          in the coming year.  This problem must be addressed.  I believe 
          that a final consensus product that first, and most importantly, 
          protects patients while also allowing hospitals and physicians 
          to work together can be reached."

          This bill is the product of continued discussions between 
          stakeholders that narrowly addresses the issue of shared records 
          between peer review bodies, and is being presented today as 
          proposed to be amended to reflect the most recent negotiations.  
          It contains protections for peer review bodies, physicians and 








                                                                  AB 655
                                                                  Page  6

          patients by prohibiting information from being subject to 
          discovery, exempting a responding peer review body from civil or 
          criminal liability, and requiring confidentiality protections 
          for responding peer review bodies.  

          Under this bill, peer review bodies must sign a sharing 
          agreement and use information solely for peer review purposes.  
          Requesting peer review bodies must indemnify the responding peer 
          review body for specified liabilities in the event that the 
          receiving peer review body improperly releases or discloses 
          shared information.

          If the physician under review by the requesting peer review body 
          does not release the responding peer review body, its members, 
          and the health care entity for which the responding peer review 
          body conducts peer reviews from liability for the disclosure of 
          information to the satisfaction of the responding peer review 
          body, the responding peer review body is not obligated to 
          produce any information.

           Previous legislation  .  AB 1235 (Hayashi) of 2010 amends the 
          medical peer review process by recommending external peer review 
          in limited circumstances, requiring peer review bodies to share 
          information, establishing the duties of a hearing officer, and 
          setting parameters for attorney representation.  This bill was 
          vetoed.

          AB 120 (Hayashi) of 2009 amends the medical peer review process 
          by recommending external peer review in limited circumstances, 
          requiring peer review bodies to share information, establishing 
          the duties of a hearing officer, and setting parameters for 
          attorney representation.  This bill was contingent on SB 820, 
          which was vetoed.

          SB 820 (Aanestad and Negrete McLeod) of 2009 makes various 
          changes related to disciplinary reporting by specified healing 
          arts boards, including adding to the central file if a court 
          finds that a peer review was held in bad faith and the filing of 
          an additional report under certain circumstances.  This bill was 
          vetoed by Governor Schwarzenegger, stating in part: "While 
          perhaps well-intentioned, this bill does not provide a solution 
          to the problem, but rather, jeopardizes the entire process by 
          narrowing the reporting element to "serious" cases of 
          incompetence involving only patients.  How is this good policy?  
          For example, what about a physician that engages in egregious 








                                                                  AB 655
                                                                  Page  7

          behavior against hospital staff or even other physicians? How 
          does this serve the public by keeping these reports from the 
          Medical Board?
           
          "This bill also fails to align with recent Joint Commission 
          requirements that hospitals adopt a 'zero tolerance' policy 
          towards physicians engaging in disruptive behavior in their 
          interactions with nurses and other hospital staff.   A peer 
          review body should not be limited from acting on this type of 
          behavior and in fact, should be encouraged to act more swiftly."

          SB 58 (Aanestad) of 2009 makes various changes relating to the 
          Business and Professions Section 805 reporting process.  This 
          bill was held in Senate Appropriations Committee.   

          SB 700 (Negrete McLeod), Chapter 505, Statutes of 2009, defines 
          peer review and changes what is included in the definition of 
          peer review body.  The bill also allows the Medical, Dental, or 
          Osteopathic Boards of California to inspect and copy any peer 
          review minutes or reports in a disciplinary proceeding that 
          results in a Business and Professions Section 805 report.

           REGISTERED SUPPORT / OPPOSITION  :   

           Support 
           
          None on file.

           Opposition 
           
          None on file.
           
          Analysis Prepared by  :    Angela Mapp / B.,P. & C.P. / (916) 
          319-3301