Mounting tension over autonomy: Courts referee doctor-hospital battles

Physicians are worried about the impact on patient safety.

By Tanya Albert, amednews staff. July 21, 2003.

Relationships between hospital boards and medical staffs are showing signs of strain nationwide as more physicians open facilities that compete with hospitals and as hospital budgets tighten.

But physicians at a California hospital say their situation has reached the breaking point and that the hospital has stripped the medical staff of its right to self-governance.

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Medical staff members in Ventura, Calif., are speaking out -- and going to court -- because they say they don't want this to happen elsewhere.

Under new policies at Community Memorial Hospital of San Buenaventura, any physician who has a financial stake in an entity that competes with the hospital can't hold a medical staff leadership position. Nor can he or she vote as a staff member.

The hospital also adopted a 20-page "Medical Staff Code of Conduct," and gave itself authority to investigate and discipline physicians who don't meet the standards. Physicians say the hospital also unilaterally amended medical staff bylaws so they wouldn't conflict with new corporate bylaws and took control of the staff dues account.

"While we've seen attempts of erosion of bits and pieces, this is a full-blown assault," said Charles Bond, a Berkeley, Calif., attorney representing the medical staff.

Doctors in 5 states have filed lawsuits over medical staff independence.

The medical staff's lawsuit, filed in state court, claims that the hospital is "putting financial gain above the interests of patients" and claims the hospital has "embarked upon a dangerous and unlawful effort to destroy the legally recognized role of the medical staff in protecting patients in the hospital," according to court filings.

"If we don't win, it would not bode well for the medical staffs in California or even the country," said orthopedic surgeon John Hill, MD, the physician-elected medical staff president at Community Memorial. The hospital refuses to recognize Dr. Hill as president because he has a financial interest in a competing entity, although he said it is less than 2%. "It is going to be the patients that suffer if the hospital prevails."

Hospital officials dispute the doctors' portrayal of the new policies. They say the medical staff is still self-governing. They also say hospital board members have the right to protect financial information from competitors and that they had no choice but to appoint interim medical staff leaders after the elected ones did not meet the new rules.

They also say the hospital has a duty to patients to set standards for physician conduct unrelated to quality of care and to potentially discipline physicians after they are given due process. And hospital officials say they had a right to require a signature from the hospital leadership on money taken from the medical staff bank account because it has always been under the hospital's tax ID number.

Lowell C. Brown, an attorney representing Community Memorial Hospital said the new policies actually help ensure quality care, of which the hospital is the ultimate guarantor.

"A medical staff is a recommending body," Brown said. "The board can overrule a medical staff recommendation. The board is where the buck stops."

New York, Ohio see problems, too

A medical staff in New York is embroiled in its own lawsuit. Physicians on medical staffs in Ohio, New Hampshire and Florida have also had go-rounds with hospitals in recent years. In New Hampshire, the state Supreme Court late last year ruled that medical staffs there don't have the legal standing to sue a hospital or its trustees. But, the court said, a physician can go forward with his case asking for relief from a hospital-imposed "gag order."

Earlier this year, Brooklyn (N.Y.) Hospital Center's medical staff won a lawsuit challenging the hospital's decision to replace elected medical staff officers with people it chose.

Some physicians are turning to the AMA instead of the courts.

"It took away our independence," said Abdul Rehman, MD, an internist and hematologist-oncologist on Brooklyn Hospital's medical staff. "To speak on quality-of-care issues, physicians must have independence so they can express what they believe."

The judge reinstated the elected medical staff officers, but did not rule on whether the hospital could overrule mutually approved medical staff bylaws. The hospital has argued that the hospital bylaws supersede the medical staff bylaws when there is a conflict. The question is the subject of a second state lawsuit that the medical staff filed in June.

In Toledo, Ohio, medical staffs have not turned to the courts but have voiced concerns to the AMA and the Joint Commission on Accreditation of Healthcare Organizations.

The physicians say that The Toledo Hospital and the Toledo Children's Hospital, both owned by ProMedica Health System, gave reports to their hospital boards on the status of negotiations between Paramount -- a health insurance company also owned by ProMedica -- and local physician specialists, but withheld the reports from physicians on the board, saying those physicians had a conflict of interest.

Physicians say there were also situations where they were not allowed in the boardroom, even though regulations for the hospitals say the medical staff president and president-elect are to be ex officio members of the boards, with a vote.

In a statement, ProMedica said "to date, JACHO surveyors have indicated to us in their preliminary reports that our hospitals have not been found in violation of any of the governance accreditation standards."

AMA gets involved

California, Ohio and New York physicians brought their concerns to the AMA Annual Meeting in June, and the Association now will inform the Joint Commission of its concerns about medical staff autonomy, and ask it to better educate medical staffs and hospitals about the complaint process.

Harold Bressler, the Joint Commission's general counsel, said the group is looking at its standards for relationships between medical staffs and hospitals and considering how to handle them in the future.

The AMA-State Medical Society's Litigation Center also will consider cases and get involved when it is appropriate. It is already providing financial support in the California case. The California Medical Assn. is also supporting the medical staff, and California physicians say they'll continue to fight in court for medical-staff independence.

"If this thing were allowed to go forward, the physician is no longer responsible to the patient," said obstetrician-gynecologist Howard Lang, MD, an Arizona-based consultant who advises physicians on medical staff bylaws. "The physician is beholden to the [hospital's] corporate bottom line."