Ryals v. St. Mary-Corwin Regional Medical Center
SUPREME COURT, STATE OF COLORADO
No. 99SC137
[Announcement Date]September 18, 2000
JARVIS D. RYALS, M.D., Petitioner,
v.
ST. MARY-CORWIN REGIONAL MEDICAL CENTER,
a Colorado not-for-profit corporation;
PUEBLO RADIOLOGICAL GROUP, P.C., a Colorado
professional corporation; MICHAEL E. BALL,
M.D., individually and as President of
Pueblo Radiological Group, P.C.; LYNN PHELPS,
M.D.; MARK FORTE, M.D.; MARC JOHNSON, M.D.;
GARY LAMONTE, M.D.; MARK MOUNTFORD, M.D.;
STAN W. JONAS, individually and in his
capacity as Interim Chief Executive Officer
of St. Mary-Corwin Regional Medical Center;
WALTER SACKETT, individually and in his
capacity as the Chief Executive Officer of
St. Mary-Corwin Regional Medical Center,
Respondents.
Certiorari to the Colorado Court of Appeals
EN BANC JUDGEMENT REVERSED
AND CASE REMANDED
Caplan and Earnest LLC
Sharon E. Caulfield
Sarah E. Meshak
Boulder, Colorado
Attorneys for Petitioner
Kennedy & Christopher, P.C.
John R. Mann
Daniel R. McCune
Dean A. McConnell
Denver, Colorado
Attorneys for Respondents St. Mary-Corwin Regional Medical
Center, Stan W. Jonas and Walter Sackett
Hogan & Hartson L.L.P.
Kathryn Webb Bradley
John W. Cook
H. Thomas Coghill
Denver, Colorado
Attorneys for Respondents Pueblo Radiological Group, P.C.;
Michael E. Ball, M.D.; Lynn Phelps, M.D.; Mark Forte, M.D.;
Marc Johnson, M.D.; Gary LaMonte, M.D. and Mark Mountford,
M.D.
Montgomery Little & McGrew, P.C.
Robert N. Spencer
Englewood, Colorado
Amicus Curiae for Colorado Medical Society
Ken Salazar, Attorney General
Richard H. Forman, First Assistant Attorney General
Business and Licensing Section
Denver, Colorado
Amicus Curiae for Committee on Anticompetitive Conduct
JUSTICE KOURLIS delivered the Opinion of the Court.
JUSTICE BENDER does not participate.
This case deals with the question of whether a physician is required to file
a claim against a hospital that has denied him privileges with the Committee on
Anticompetitive Conduct (CAC) rather than with the court. We hold that if the
denial of privileges does not arise out of professional review committee
activity at the hospital, then the physician need not seek review before the
CAC. In this case, St. Mary-Corwin Regional Hospital (the Hospital) denied Dr.
Jarvis D. Ryals, a neurologist, privileges to read MRIs at the Hospital based on
a long-standing exclusive contract between the Hospital and a group of
radiologists. Ryals filed suit claiming that the Hospital had engaged in
anticompetitive conduct. The trial court dismissed his suit, holding that Ryals
was first required to exhaust his administrative remedies with the CAC. The
court of appeals affirmed. See Ryals v. St. Mary-Corwin Reg?l Med.
Ctr., 987 P.2d 865 (Colo. App. 1999).
We reverse. We hold, based on the plain language of the Colorado Professional
Review Act (CPRA) and the statutory scheme as a whole, that the CAC has
jurisdiction only over those claims of anticompetitive conduct that arise out of
professional review committee activity. Professional review committees assess
physician qualifications, physician conduct, and the quality and appropriateness
of patient care. In this case, the Hospital did not engage in any professional
review committee activity in denying Ryals?s privileges. Rather, the Hospital
made a business decision unrelated to Ryals?s qualifications or conduct. If that
decision has antitrust implications, then Ryals?s claims against the Hospital
and other Defendants were anticompetitive conduct claims arising independently
of a peer review process. Therefore, Ryals was not required to file his claims
with the CAC before seeking a remedy in district court.
I.
St. Mary-Corwin RegionalThe Hospital(the Hospital) has employed Dr. Ryals as
a licensed neurologist since 1976. Prior to 1995, the Hospital did not own an
MRI scanner, and Ryals interpreted MRI scans for the Hospital?s patients outside
of the Hospital at Southern Colorado MRI, Ltd. (SCMRI). Ryals, the Hospital, and
Pueblo Radiological Group (PRG) were joint partners in SCMRI. In December 1995,
SCMRI closed. Shortly thereafter, the Hospital obtained its own MRI machines to
read MRIs “in-house.”
Because Ryals did not have privileges to read MRIs at the Hospital, Ryals
began to make inquires regarding obtaining privileges. After several informal
inquiries with the Hospital staff, Ryals submitted a request for privileges to
the Hospital?s Medical Qualifications Committee on February 1, 1996. PRG had a
long-standing exclusive contract with the Hospital to perform radiology services
at the Hospital. The Medical Qualifications Committee decided that this
exclusive contract prevented other doctors from reading MRIs. Ryals wrote PRG on
February 6, 1996 requesting PRG to renegotiate their exclusive contract with the
Hospital so as to permit him to read MRIs. PRG declined.
Ryals submitted a second request to the Medical Qualifications Committee,
which the Committee again denied at its meeting on March 1, 1996. The Committee
found that although Ryals was qualified to read MRIs, he was not eligible to do
so because of PRG?s exclusive contract. The Hospital?s acting chief executive
officer, Stan Jonas, wrote Ryals on March 4, 1996 to inform him of the
Committee?s decision to deny his request. On March 12, 1996, the Hospital
Governing Board then passed a resolution affirming its exclusive contract with
PRG. The resolution did not specifically address Ryals?s requests for
privileges. Ryals did not receive a copy of the resolution until May 29, 1996
when he requested a copy of the exclusive contract from the Hospital.
Ryals then filed suit against St. Mary-Corwin Hospital, Hospital officers,
and PRG in district court claiming three antitrust violations, breach of
contract, promissory estoppel, tortious interference with contractual and
prospective contractual relations, and outrageous conduct. The defendants moved
to dismiss the complaint alleging that Ryals failed to exhaust his
administrative remedies by first filing his complaint with the Colorado
Committee on Anticompetitive Conduct (CAC). The trial court agreed and granted
the motion without an evidentiary hearing.
The court of appeals affirmed the trial court?s decision, holding that Ryals
must first present his claims to the CAC. See Ryals, 987 at 869.
The court of appeals held that the CAC had jurisdiction because the Hospital?s
denial constituted a professional review activity within the parameters of the
CAC?s enabling legislation. See id. The court reached this
conclusion by reasoning that the Hospital?s Medical Qualifications Committee and
the governing board operated pursuant to valid written bylaws, and therefore,
they constituted professional review committees for the purpose of the CPRA.
See id. The court further held that the Hospital?s actions, taken
as a whole, could constitute final action and appropriate notice of the denial
of privileges to Ryals in these circumstances. See id. at 868. The
court also held that the
CAC?s jurisdiction extended to Ryals?s common law claims. See
id. at 870. We granted certiorari.1
II.
Maintaining standards of patient care is of preeminent importance in a
hospital. In service of that goal, hospitals rely upon peer review processes to
oversee physician conduct and promote appropriate patient care. During the peer
review process, a peer review committee may be critical of the physician, and
may issue a corrective action or sanction. See Fredrick Yu, The
Committee on Anticompetitive Conduct: New Agency on the Block, 21 Colo.
Lawyer 31, 31 (1992). However, a peer review committee is necessarily composed
of peers who may be competitors of the physician being reviewed. Accordingly,
when a peer review committee issues an adverse decision, it is possible that the
committee?s decision was based not on a deficiency in the physician?s
performance, but rather on a desire to remove the physician from competition.
See id. This possibility raises antitrust liability concerns.
In 1988, the Supreme Court ruled that a hospital?s peer review committee was
not immune from federal antitrust liability because the state did not actively
supervise the committee. See Patrick v. Burget, 486 U.S. 94, 100
(1998). Because the committee did not qualify for immunity, the individual
members of the peer review committee could be subject to suit for violating
federal antitrust laws. See id. at 102. In order to qualify for
state action immunity,2 the Supreme Court held that a state must
actively supervise the private peer review committee?s activities so that the
state exercises “ultimate control over the challenged anticompetitive conduct.”
Id. at 101.
In order to assure the continuation of the peer review process, many states,
including Colorado, reacted to Patrick by enacting legislation to
establish the requisite level of state supervision. The Colorado Professional
Review Act (CPRA), was Colorado?s answer to the dilemma. See ??
12-36.5-101 to ?106, 4 C.R.S. (1999). It allows private entities to establish
professional review committees that operate as an arm of Colorado?s Board of
Medical Examiners. See ? 12-36.5-103(3)(a), 4 C.R.S. (1999). In the
enabling legislation, the General Assembly observed that the Board of Medical
Examiners could not feasibly assume responsibility over every single allegation
that a physician?s conduct deviated from a professional standard of care.
See ? 12-36.5-103(1). The legislature, therefore, intended to employ
professional review committees to assist the Board in reviewing “in good faith
the professional conduct of physicians, including the quality and
appropriateness of patient care.” ? 12-36.5-103(2).
A hospital may establish a professional review committee as long as the
committee operates pursuant to written bylaws, which are approved by the
hospital?s governing board. See ? 12-36.5-104(4), 4 C.R.S. (1999).
Professional review committees are charged with investigating the qualifications
of a licensed physician or “the quality or appropriateness of patient care
rendered by or the professional conduct” of any licensed physician. ?
12-36.5-104(6)(a)(II); see also ? 12-36.5-104(1) (stating that a
professional review committee may be established “to review and evaluate the
quality and appropriateness of patient care provided by and the professional
conduct of any physician”). To assist the committees in carrying out these
functions, the legislature expressly provided that the committees would be
granted immunity from liability for their activities, as long as the committees?
actions were taken in good faith. See ? 12-36.5-105(1), 4 C.R.S.
(1999).
If the professional review committee makes an adverse finding against a
physician, the physician may appeal to the entity?s governing board. The
governing board then reviews the committee?s work and takes final action on the
recommendation of the professional review committee. See ?
12-36.5-104(7)-(8). The CPRA defines a governing board as any board authorized
to take action “regarding the recommendations of any authorized professional
review committee.” ? 12-36.5-102(2), 4 C.R.S. (1999).
If a physician believes that a decision made by a peer review committee or a
governing board stems from anticompetitive motivations, the physician may appeal
the committee?s decision to the Committee on Anticompetitive Conduct (CAC).
See ? 12-36.5-106, 4 C.R.S. (1999). The CAC is a state board comprised of
four licensed physicians and one attorney with expertise in the area of
antitrust. See ? 12-36.5-106(2). In order to appeal to the CAC, the
physician must have been “the subject of a final action by a governing board,
which action results in the denial, termination, or restriction of privileges at
or membership in or participation in an organization, and who believes that such
action resulted from unreasonable anticompetitive conduct.” ? 12-36.5-106(7).
The CPRA makes the CAC the “sole and exclusive remedy” for physicians believing
their adverse peer review decisions were the result of anticompetitive
motivations. Id. “Failure to exhaust this administrative remedy . . .
shall preclude the right of de novo review on the merits of the issue of
unreasonable anticompetitive conduct.” Id.
The CPRA limits the CAC?s jurisdiction to “the sole issue of whether such
final board action resulted from unreasonable anticompetitive conduct.”
Id. The CAC may hold a hearing to review the record and take evidence
solely on the issue of anticompetitive conduct, “except when, in the discretion
of the committee, the interests of a fair hearing demand otherwise.” ?
12-36.5-106(9)(f).
If the CAC finds that the final action of the governing board resulted from
anticompetitive conduct, then the CAC may issue an order disapproving, setting
aside, or modifying the final action. See ? 12-36.5-106(9)(k). The CAC is
not authorized to award money damages or grant any other equitable remedies.
Following the CAC?s final determination, the party may challenge the action of
the governing board, rather than the CAC?s review of the action, in district
court. See ? 12-36.5-106(10)(b).
III.
With that background, we now turn to the first question on certiorari: to
wit, whether Ryals was required to present his claims to the CAC before seeking
a remedy in district court. We conclude that the CAC?s jurisdiction is limited
to those claims arising out of professional review committee activity as defined
in the CPRA. Because Ryals?s claims did not arise from a professional review
committee activity, the CAC lacked jurisdiction, and Ryals was not required to
exhaust his administrative remedies with the CAC.
The question of the scope of the CAC?s jurisdiction is a matter of statutory
interpretation. This is a question of law, and therefore, we review the case de
novo. See Fogg v. Macaluso, 892 P.2d 271, 273 (Colo. 1995).
A.
We recognize that general logic would lead to the conclusion that since Ryals
alleged anticompetitive conduct claims and the General Assembly created the CAC
to deal with claims of anticompetitive conduct, then a fortiori, the CAC should
have heard this case. However, upon closer examination of the applicable
legislation, we conclude that the CAC was not intended to be the repository of
all claims of anticompetitive conduct between a physician and a hospital.
Rather, the General Assembly limited the CAC?s jurisdiction to issues of
physician qualification, professional conduct, and quality of patient care,
arising out of qualified professional review committee activities. See ?
12-36.5-104(8). Qualified professional review committees are in turn limited to
issues of physician qualifications, quality of patient care, and professional
conduct. See ?? 12-36.5-104(1), -104(6)(a). As a result, the CAC?s
jurisdiction encompasses only antitrust allegations arising out of adverse
decisions regarding physician competency.
The sections of the CPRA cross reference each other, and reinforce the
conclusion that the scope of CAC?s authority is limited to anticompetitive
claims arising out of peer review activities assessing physician competence. For
example, professional review committees are defined as committees authorized to
review professional conduct and the quality and appropriateness of patient care.
See ? 12-36.5-102(3). In addition, professional review committees act as
extensions of the Board of Medical Examiners to evaluate physician competence.
See ? 12-36.5-103(1). The overall purpose of the CPRA, which includes the
establishment of the CAC, is to protect the public from unprofessional conduct,
not from anticompetitive conduct. See id. (stating that the Board
of Medical Examiners cannot assess every alleged deviation from the quality
standards, professional conduct standards, or appropriate care standards);
see also ? 12-36.5-101(2), 4 C.R.S. (1999) (providing in the legislative
declaration that the purpose of the CPRA is to protect members of the public who
lack the knowledge, experience, or education to properly evaluate the quality of
medical practice or professional conduct of physicians).
In addition, the CPRA contemplates that the CAC will not have jurisdiction
over all claims. The statute expressly authorizes physicians to pursue judicial
remedies for claims outside the CAC?s jurisdiction. See ? 12-36.5-106(8)
(“Nothing in this article shall preclude a physician or health care provider
otherwise aggrieved by the final action of a governing board from seeking other
remedies available to them by law, except as provided in subsection (7)”). We
read that provision to state, in part, that claims not arising from professional
review committee activity may be litigated in district court. This would include
claims that are antitrust allegations separate from any peer review process.
A reading of a limited role for the CAC is further supported by the CAC?s
limited ability to provide remedies for an aggrieved physician. The CAC may only
disapprove, set aside, or modify a governing board?s decision. See ?
12-36.5-106(9)(k). The agency has no authority to provide economic damages or
other remedies at law. The agency?s ability to conduct hearings and accept
evidence is likewise limited. See ? 12-36.5-106(9)(h).
Other sections of the CPRA also reflect an understanding that the CAC?s role
is expressly limited. Part Two of the CPRA is intended to conform the CPRA to
federal law and regulations. That part defines “professional review action” as
“an action or recommendation of a professional review body . . . which is based
on the competence or professional conduct of an individual physician, which
conduct affects or may affect adversely the clinical privileges of or membership
in a professional society of the physician.” ? 12-36.5-203(3)(a), 4 C.R.S.
(1999).3 Part Two specifically excludes some activities from the
professional competence or conduct of a physician, including the physician?s
competitive acts to retain business, the physician?s association with a
particular group of professionals, or any other matter not relating to the
competence or professional conduct of the
physician. See id.4 These provisions focus
professional review activities on the abilities and qualifications of
physicians, rather than general hospital oversight or management.
The CAC?s regulations similarly limit the scope of the CAC?s jurisdiction.
The regulations provide the CAC with jurisdiction over the final action of a
governing board involving “at least one of the following subjects:
qualifications of a member physician; quality of patient care; appropriateness
of patient care; or the professional conduct of a member physician.” 3 CCR
713-13, Rule 6(a)(1)(C). We normally will defer to an agency?s own
interpretation of its statutory mandate. See Northern Colo. Med. Ctr.,
Inc. v. Committee on Anticompetitive Conduct, 914 P.2d 902, 907 (Colo.
1996). The agency regulations indicate that peer review procedures are designed
to address deviations from accepted standards by a physician, rather than a
hospital?s business decisions or general policies to promote patient care. The
regulations do not provide the CAC with jurisdiction over antitrust allegations
as a category in and of themselves.
B.
Although we need not resort to legislative history, we note that the
legislative history of the CPRA indicates that the General Assembly created the
CAC in order to further the intended purpose of protecting peer review
committees from antitrust liability, while still providing a limited remedy to
physicians injured by anticompetitive decisions of a peer review committee.
During committee debate, Representative Tim Foster stated:
“[m]ainlyMainly what [the CAC] are charged with doing is reviewing any
appeals geared solely for issues of anticompetitive behavior by the peer
review committee. They?re not intended to be an appellate board which
reviews any sort of admonition or other actions taken by the peer review
committee, but to look at what the peer review committee has done in the
context of the anticompetitive and antitrust. [sic]”antitrust [sic].
Hearings on S.B. 89-122 Before the Health, Env?t, Welfare and Insts. Comm.,
57th Legis. 1st Sess. (Colo. 1989) (statement of Representative Foster). The
legislation?s sponsor, Dottie Wham, explained that the bill was a response to
the Supreme Court?s decision in Patrick, and that because of
Patrick, “it has been very difficult to get physicians to serve on peer
review. And, because that process is of great importance to us in assuring
quality of care and appropriateness of care,” the bill would offer antitrust
protections. Id. (statement of Senator Wham).
As a result, we find that the General Assembly did not intend for the CAC?s
jurisdiction to encompass review of a hospital?s denial of privileges that is
unrelated to professional conduct. Courts cannot expand authority of an
administrative agency beyond the statute?s authorization. This is especially
true when a statute derogates the common law. See Brooke v. Restaurant
Servs., Inc., 906 P.2d 66, 68 (Colo. 1995). A statute may modify or restrict
a common law right “only to the extent embraced by the statute, which may not be
enlarged by construction, nor its application extended beyond its specific
terms.” Farmers Group, Inc. v. Williams, 805 P.2d 419, 423 (Colo.
1991)(quoting Robinson v. Kerr, 144 Colo. 48, 52, 355 P.2d 117, 119-20
(1960).
As the CAC points out in its amicus brief, this court should exercise caution
in broadly construing the CAC?s jurisdiction. Were we to expand the breadth of
the CAC?s authority, we simultaneously would expand the scope of state action
immunity established by the CPRA. The General Assembly has not suggested that
either the State or the CAC should exercise supervision over a governing board?s
decisions regarding either economic efficiencies or general policy directives
regarding patient care. To construe the CPRA broadly in these circumstances
would move beyond the General Assembly?s stated purpose. See, e.g.,
Common Sense Alliance v. Davidson, 995 P.2d 748, 753 (Colo. 2000)
(stating that courts should exercise caution to refrain from adding language to
a statute).
C.
We turn then to the facts of this case. The outcome of this case hinges on
whether the Hospital?s denial of privileges was a decision regarding Ryals?s
competency that could fall within the rubric of professional review activities.
The trial court granted Defendants? motion to dismiss and found that Ryals was
required to file his claim with the CAC. However, the trial judge did not make
any findings of fact as to the nature of the Hospital?s actions. We, therefore,
review the record de novo.
PRG argues that the governing board?s resolution in this case was an effort
to improve patient care, and thus, the governing board acted as a professional
review committee. We disagree and conclude that the Hospital?s actions are
properly characterized as business decisions.
The Hospital?s March 4, 1996 letter to Ryals informed him of the Medical
Qualification Committee?s decision to deny his privileges based on the
Hospital?s exclusive contract with PRG. The letter indicated that the reasons
for the exclusive contract were “(a) to provide prompt and reliable coverage by
qualified physician specialists to meet and satisfy [the Hospital?s] patient
needs for diagnostic imaging services, (b) to develop on-going quality
assessment and continuous quality improvement programs . . . (c) to enhance the
effective and cost-effective administration of [the Hospital?s] diagnostic
imaging department.” Nothing in the record indicates that the Committee?s
decision was made as a part of a peer review process to assess Ryals?s
performance or credentials. Although the Committee couched the exclusive
contract in terms of general concerns for patient care, its denial of privileges
was based on the exclusive contract, and not on Ryals?s competence or conduct as
a physician.
The Hospital?s governing board affirmed the exclusive contract on the grounds
that such contracts:
(a) arrange for and provide prompt and reliable coverage by qualified
physician specialists to meet and satisfy Hospital?s patient needs . . . (b)
develop and implement timely and on-going quality assessment and continuous
quality improvement programs . . . (c) enhance the efficient and
cost-effective administration and management of Hospital . . . (d)
coordinate and develop comprehensive and efficient educational
programs.
The Hospital?s governing board resolution similarly concerned the PRG
exclusive contract and not Ryals?s privileges. The resolution did not reference
Ryals or his professional competence. Most importantly, the governing board
resolution does not indicate that it was a review of an adverse professional
review committee action. As we have explained, we read CPRA to provide that only
the final action of a governing board relating to professional review committee
activities may be appealed to the CAC.
Because the Hospital did not engage in a professional review committee
activity with regard to Ryals?s privileges, the CAC does not have jurisdiction
over his anticompetitive conduct claims. Because Ryals was not required to file
his claims with the CAC, no state administrative remedy existed for him to
exhaust. Therefore, we conclude that the trial court and the court of appeals
erred in their decisions to dismiss Ryals?s complaint for lack of subject matter
jurisdiction.
IV.
On appeal to this court, Ryals also contested the court of appeals?
determination that the actions of the Hospital constituted a final action for
purposes of the CPRA. Because we find that the CAC is without jurisdiction over
Ryals?s claims, we need not determine whether there was a triggering final
action in this case.
Similarly, the third issue on which we granted certiorari was whether the
CAC?s jurisdiction extended to Ryals?s common law claims. It is unnecessary for
us to resolve this issue, as we determine that Ryals need not seek relief for
any of his claims with the CAC before filing his claims in district court.
V.
We reject a broad reading of the CAC?s jurisdiction. After considering the
plain language of the statute, the structure of the CPRA as a whole, and the
legislative history, we conclude that the CAC?s jurisdiction is limited to
claims of anticompetitive conduct arising from professional review activities
that focus on a physician?s qualification or conduct or on the quality of
patient care. Because the Hospital?s actions with regard to Ryals were not
professional review committee activities as defined in the statute, we hold that
the CAC was without jurisdiction over Ryals?s claims. Accordingly, we reverse.
reverse the judgment of the court of appeals, and remand the case to that
court to return it to the district court for further proceedings consistent with
this opinion.
JUSTICE BENDER does not participate.
We granted certiorari on the following issues:
(1) Whether the court of appeals erred in holding that denial of Ryals?s
request for privileges to read MRI scans was a professional review activity
subject to review by the Committee on Anticompetitive Conduct where the denial
was based solely on the hospital?s exclusive contract and not on Ryals?s
qualifications, professional conduct or quality of care.
(2) Whether the court of appeals erred in holding that a resolution of the
hospital?s governing board affirming an exclusive contract for imaging services
constituted the board?s final action denying Ryals?s request for privileges
where the resolution did not reference Ryals and was not provided to Ryals until
two months after Ryals?s request for privileges was denied.
(3) Whether the court of appeals erred in holding that Ryals was required to
pursue his common law tort, contract and equitable claims before the Committee
on Anticompetitive Conduct.
2
In the Health Care Quality Improvement Act of 1986 (HCQIA), Congressprovided some antitrust immunity for peer review action taken “in the reasonable
belief that [it] was taken in the furtherance of quality health care.”
See 42 U.S.C. ? 11112(a)(1) (2000). States are free to immunize other
peer review actions that do not meet the federal standard. See
Patrick, 486 U.S. at 105-06. The CPRA in part duplicates the immunity
provided by the HCQIA. See Northern Colo. Med. Ctr., Inc. v. Committee
on Anticompetitive Conduct, 914 P.2d 902, 906 (Colo. 1996).
3
Part Two of the CPRA states that its provisions are intended tocomplement the provisions of Part One. See ? 12-36.5-201, 4 C.R.S.
(1999). To the extent that the parts conflict, the provisions of Part One should
prevail. See id. Although the definition of professional review
activity focuses more closely on the conduct of an individual physician, we find
that the thrust of both parts is substantially the same, and that the parts may
be read harmoniously.
4
The HCQIA similarly defines professional review activities to excludeactions based on a physician?s association with a professional society or a
particular class of health care professionals or “any other matter that does not
relate to the competence or professional conduct of the physician.” 42 U.S.C. ?
11151(9) (2000).