By: Karen Owens, Coppersmith Brockelman PLC
In two related cases before the Arizona Court of Appeals, the Court affirmed important Arizona peer review principles and answered some outstanding questions in this area of law. The predicate for both cases (and a third case, discussed at the end) was the decision of a hospital governing board to revoke the medical staff membership and privileges of a cardiologist (“Physician”) based on patient care issues, disruptive behavior, and alteration of medical records.
- Sharifi Takieh v. O’Meara, 252 Ariz. 50 (App. Aug. 10, 2021) (“Takieh”) was the first published Arizona Court of Appeals decision addressing substantive peer review issues since 2005. The Opinion affirmed the prohibition on discovery of peer review documents and made clear that hospitals cannot be required to prepare privilege logs in connection with claims of peer review confidentiality.
- In Sharifi v. Banner Health, 1 CA-CV 20-1001 (Ariz. App. May 13, 2021) (“Sharifi”), a non-published memorandum decision arising from the same peer review proceeding, the Court affirmed that a Physician challenging a hospital peer review decision must bring a statutory claim and may not file a contract action. The Court also made clear that a hearing officer may limit the length of a peer review hearing even without express direction in the fair hearing plan.
The Sharifi Memorandum Decision
In Sharifi, the trial court conducted judicial review of the hospital board’s revocation decision under A.R.S. § 36-445.02. The Court of Appeals upheld the trial court’s ruling affirming the hospital board’s revocation of the Physician’s medical staff membership and privileges. Relying on A.R.S. § 36-445.02, Hourani v. Benson Hospital, 211 Ariz. 427, 122 P. 3d 6 (App 2005), and other prior Arizona decisions, the Court noted the importance of peer review immunity and articulated the standard of review as review of “peer review proceedings for both procedural and substantive errors [employing] a deferential standard of review.”
The appellant Physician contended that there were numerous procedural defects in the in-hospital peer review proceedings. Citing the statute, the Court limited its review of these challenges to the administrative record to determine whether the hospital substantially complied with its Bylaws. In perhaps the most important procedural issue, the Physician challenged the hearing officer’s imposition of a time limit on the hearing. The Court upheld the time limit, noting that the hearing panel members said they felt they had enough information and that any timing problem was “entirely of [the Physician’s] own making.” The Court saw “no evidence that the time allotted was insufficient or resulted in prejudice.”
The Physician also challenged the revocation decision on the merits. The Court agreed with the trial court that it should not substitute its own judgment for the hospital board’s “where expertise is involved,” and upheld the hospital board’s substantive decision.
The Court made short work of the Physician’s separate contract claim. Acknowledging that the medical staff bylaws create a contract with staff, the Court said the statute barred any claims other than a claim for injunctive relief based on the record.
Finally, the Physician contended that he was entitled to a new trial based on declarations he belatedly presented to the trial court – declarations which alleged bias based on race and religion. The Court explained that the Physician needed to “cite to evidence in the record making it affirmatively probable the alleged bias or misconduct changed the outcome of the administrative proceeding.” The Court rejected the Physician’s claim, noting not only that the declarations were late and not in the record, but also that they failed to prove any actual bias.
While Sharifi is an unpublished memorandum, it still provides insight into the Court’s view of peer review principles and confirms some critical standards. And while memorandum decisions are not precedential, Arizona Supreme Court Rule 111(c) allows citation of memorandum decisions to in certain circumstances: to establish claim preclusion, issue preclusion, or law of the case; to assist the appellate court in deciding whether to issue a published opinion, grant a motion for reconsideration, or grant a petition for review; or for persuasive value if the memorandum was issued on or after January 1, 2015, no opinion adequately addresses the issue before the Court, and the citation is not to a de-published opinion or portion of an opinion.
Takieh Opinion
The Physician also filed a separate state court lawsuit alleging that the Chief of Staff, another cardiologist and cardiology group, the hospital‘s chief medical officer, and the hospital’s in-house attorney all had made defamatory statements about him. The trial court dismissed all but one cardiologist and the in-house attorney from the case, largely because the dismissed defendants’ actions and statements were made during peer review proceedings. The Physician did not challenge those dismissals.
However, in an amended complaint, the Physician alleged the following instances of defamation by the remaining defendants:
- That the remaining defendant cardiologist had told another cardiologist the Physician was “an idiot” who had “administered blood thinner ‘to an obvious case of intracerebral hemorrhage.’”
- That the in-house attorney had composed letters and other communications containing false information designed to destroy the Physician’s reputation.
The Physician moved to compel the in-house attorney to disclose several categories of her own correspondence related to the peer review proceedings. The trial court refused to order a privilege log for peer review protected documents.
On the other hand, the trial court did order the in-house attorney to produce a log of her correspondence outside the peer review process. The in-house counsel submitted no log, explaining that all her communications in the matter were protected peer review materials. At this point, after the close of discovery, the Physician for the first time submitted affidavits from two former hospital employees (quite similar to the ones produced in the Sharifi case). In one of them, the affiant alleged she had heard the in-house attorney make disparaging remarks about the Physician (that he was a terrible doctor, an idiot, a danger to patients.) The other affiant alleged that she had heard other Physicians say the in-house attorney had encouraged them to make false statements about the Physician at the hearing. The in-house attorney moved to strike the affidavits as untimely, and the trial court agreed.
The trial court held on summary judgment that there was no dispute the Physician had administered blood thinners to a patient with a cerebral hemorrhage, and the other cardiologist’s alleged “idiot” statement was opinion and thus not actionable. The trial court further held that the Physician had failed to produce any admissible evidence showing the in-house attorney had made “any comments about him, defamatory or otherwise,” outside the peer review process.
The Court of Appeals affirmed both rulings. With respect to the cardiologist’s alleged comments, the Court agreed with the trial court that the “idiot” statement was opinion, and the record “lacked clear and convincing evidence that a reasonable listener could have understood [the cardiologist’s] ‘obvious’ statement as conveying an objective fact.” Regarding the defamation claim against the in-house attorney, the Court of Appeals affirmed the trial court’s decision refusing to order production of a privilege log for peer review privileged correspondence. The Court cited the “overriding public interest in peer-review proceedings” and the need for confidentiality to ensure candid peer review. The Court also agreed that the affidavits were not admissible evidence based on the Arizona discovery rules.
Ultimately, the Court affirmed the trial court’s conclusion that the Physician’s claim against the in-house attorney was groundless and pursued in bad faith. The in-house attorney was awarded attorney fees in both the trial court and appellate court.
Interestingly, in the two state court lawsuits arising from the peer review proceeding described in these cases, there were no depositions, no written discovery and no document production. Judicial review of the in-hospital administrative proceedings was limited to a review of the record, as set forth in the statute. While no one can prevent disgruntled physicians from naming individuals in lawsuits arising from peer review, the two cases are reassuring that Arizona law provides strong protection of the integrity of the peer review process.
Postscript: The Federal Court Case
In addition to the two state court actions discussed above, the Physician filed a complaint in federal court alleging under 42 U.S.C. § 1981 that the hospital system and multiple individuals discriminated against the Physician based on his race in terminating his physician services agreement (PSA). Takieh v. Banner Health, No. CV-10-05878-PHX-MTL (D. Arizona Jan. 27, 2021), aff’d. No. 21-15326 (9th Cir. Feb. 16, 2022). The District Court dismissed the case in an unpublished Order, finding that the Physician himself had alleged numerous non-discriminatory reasons for the termination of the PSA, and taking into account the trial court’s decision in Sharifi. The District Court refused to allow the Physician to amend his pleading, holding in part based on the Sharifi trial court decision that amendment would be futile. The Ninth Circuit Court of Appeals affirmed the District Court’s decision and reliance on Sharifi because it was relevant and provided non-discriminatory reasons for the PSA termination.
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Meeting the Physician Shortage in AZ with J-1 Waivers
By: Rachel Bus, Law Offices of Brelje and Associates P.C.
It‘s no secret that Arizona is experiencing a chronic physician shortage. Arizona’s Primary Care Office reported in 2021 that Arizona contains 644 federally designated Health Professional Shortage Areas (HPSAs) along with 37 Medically Underserved Areas (MUAs) and 10 Medically Underserved Populations (MUPs).[1] Arizona will require an additional 558 full-time primary care physicians to eliminate its shortage, and the issue will only worsen as our state’s population continues to explode. A fact not widely reported is that the recruitment of U.S.-trained International Medical Graduates, seeking a “J-1 Waiver” can be an important strategy to combat Arizona’s physician shortage.
International Medical Graduates (IMGs) are physicians who earned their medical degree abroad and then met certain credentialing and licensing requirements in order to gain acceptance into U.S. medical residency and fellowship programs. In order to be admitted to the U.S., many IMGs seek a J-1 exchange visitor visa sponsored by the Educational Commission for Foreign Medical Graduates (ECFMG). The J-1 visa comes with a stipulation, however. All J-1 physicians sponsored by ECFMG are subject to a two-year home residence requirement, under which they must return to their country of last residence for at least two years, before being allowed to come back to the U.S. under an H-1B work visa, and before receiving U.S. permanent residence (a “green card”).[2]
One way in which a J-1 physician may waive the two-year home residence requirement is through a commitment to full-time employment for three years in a medically underserved location.[3] This is one of those rare “win-win” scenarios: The IMG receives the opportunity to remain in the U.S. and put his or her medical training into practice, and some of the nation’s most underserved locations retain the talents of a physician who might not otherwise consider employment in the area.
In order for a J-1 waiver to be approved, the physician and the prospective employer must first seek the recommendation of a state health agency or an interested government agency. The state health agency recommendation is granted under a set of federal guidelines called the Conrad 30 program. Each state, irrespective of geographic size or population, has 30 J-1 waiver slots that it may award.[4] Here, the Arizona Department of Health Services (ADHS) administers the Conrad 30 program. In addition to the general federal guidelines of a contract covering three years’ full-time employment in a HPSA or MUA/P designated location, ADHS further requires that the employer demonstrate that it spent at least 6 months attempting to recruit a U.S. physician to the position and that the facility will offer sliding fee scale discounts to uninsured patients. Additionally, there are contract guidelines that must be adhered to.
Prospective employers and J-1 physicians should carefully review the ADHS requirements on its website.[5] The Arizona Conrad 30 program typically accepts applications through an electronic portal during a filing window that opens in October and closes in November each year. If more than 30 qualified applications are received, ADHS will score and rank the applications and award waiver recommendations to the top-scoring applicants.
Aside from the Conrad 30 program, J-1 physicians may also seek a clinical care waiver recommendation through U.S. Health and Human Services if they will be providing primary care services in HPSA locations with a score of 7 or higher.[6] The U.S. Department of Veterans Affairs may also serve to recommend J-1 physician waivers, with a commitment to work for three years providing healthcare within the agency, but only after all efforts to recruit a U.S. physician have been exhausted.[7]
Once the state health agency or interested government agency has recommended a J-1 waiver, the waiver application is then screened by the U.S. Department of State and finally approved by the U.S. Citizenship and Immigration Services. In all, applicants should anticipate the waiver process to take six to eight months. With the J-1 waiver approval in hand, the IMG’s employer may then petition for the physician to change from J-1 visitor status to H-1B work visa status, in which the physician will serve out the three-year waiver commitment. The physician may not change employers during that three-year period unless there is evidence that “extenuating circumstances” necessitated the change.[8]
With the challenges inherent in physician recruitment and retention, it is important to understand all of the available options. The use of the J-1 waiver programs available in Arizona may be one additional tool to combat Arizona’s rising physician shortage.
[1] https://www.azdhs.gov/documents/prevention/health-systems-development/data-reports-maps/reports/primary-care-needs-assessment-final.pdf
[2] 8 USC § 1182(e)
[3] 8 USC § 1184(l)
[4] 8 USC § 1184(l)(1)(B)
[5] https://www.azdhs.gov/prevention/health-systems-development/workforce-programs/j-1-visa-waiver/index.php
[6] https://www.hhs.gov/about/agencies/oga/about-oga/what-we-do/visitor-exchange-program/supplementary-b-clinical-care.html
[7] VHA Handbook 5005.01
[8] 8 USC § 1184(l)(1)(C)(ii)
New Peer Review Decisions Confirm Basic Principles and Answer Some Questions
By: Karen Owens, Coppersmith Brockelman PLC
In two related cases before the Arizona Court of Appeals, the Court affirmed important Arizona peer review principles and answered some outstanding questions in this area of law. The predicate for both cases (and a third case, discussed at the end) was the decision of a hospital governing board to revoke the medical staff membership and privileges of a cardiologist (“Physician”) based on patient care issues, disruptive behavior, and alteration of medical records.
The Sharifi Memorandum Decision
In Sharifi, the trial court conducted judicial review of the hospital board’s revocation decision under A.R.S. § 36-445.02. The Court of Appeals upheld the trial court’s ruling affirming the hospital board’s revocation of the Physician’s medical staff membership and privileges. Relying on A.R.S. § 36-445.02, Hourani v. Benson Hospital, 211 Ariz. 427, 122 P. 3d 6 (App 2005), and other prior Arizona decisions, the Court noted the importance of peer review immunity and articulated the standard of review as review of “peer review proceedings for both procedural and substantive errors [employing] a deferential standard of review.”
The appellant Physician contended that there were numerous procedural defects in the in-hospital peer review proceedings. Citing the statute, the Court limited its review of these challenges to the administrative record to determine whether the hospital substantially complied with its Bylaws. In perhaps the most important procedural issue, the Physician challenged the hearing officer’s imposition of a time limit on the hearing. The Court upheld the time limit, noting that the hearing panel members said they felt they had enough information and that any timing problem was “entirely of [the Physician’s] own making.” The Court saw “no evidence that the time allotted was insufficient or resulted in prejudice.”
The Physician also challenged the revocation decision on the merits. The Court agreed with the trial court that it should not substitute its own judgment for the hospital board’s “where expertise is involved,” and upheld the hospital board’s substantive decision.
The Court made short work of the Physician’s separate contract claim. Acknowledging that the medical staff bylaws create a contract with staff, the Court said the statute barred any claims other than a claim for injunctive relief based on the record.
Finally, the Physician contended that he was entitled to a new trial based on declarations he belatedly presented to the trial court – declarations which alleged bias based on race and religion. The Court explained that the Physician needed to “cite to evidence in the record making it affirmatively probable the alleged bias or misconduct changed the outcome of the administrative proceeding.” The Court rejected the Physician’s claim, noting not only that the declarations were late and not in the record, but also that they failed to prove any actual bias.
While Sharifi is an unpublished memorandum, it still provides insight into the Court’s view of peer review principles and confirms some critical standards. And while memorandum decisions are not precedential, Arizona Supreme Court Rule 111(c) allows citation of memorandum decisions to in certain circumstances: to establish claim preclusion, issue preclusion, or law of the case; to assist the appellate court in deciding whether to issue a published opinion, grant a motion for reconsideration, or grant a petition for review; or for persuasive value if the memorandum was issued on or after January 1, 2015, no opinion adequately addresses the issue before the Court, and the citation is not to a de-published opinion or portion of an opinion.
Takieh Opinion
The Physician also filed a separate state court lawsuit alleging that the Chief of Staff, another cardiologist and cardiology group, the hospital‘s chief medical officer, and the hospital’s in-house attorney all had made defamatory statements about him. The trial court dismissed all but one cardiologist and the in-house attorney from the case, largely because the dismissed defendants’ actions and statements were made during peer review proceedings. The Physician did not challenge those dismissals.
However, in an amended complaint, the Physician alleged the following instances of defamation by the remaining defendants:
The Physician moved to compel the in-house attorney to disclose several categories of her own correspondence related to the peer review proceedings. The trial court refused to order a privilege log for peer review protected documents.
On the other hand, the trial court did order the in-house attorney to produce a log of her correspondence outside the peer review process. The in-house counsel submitted no log, explaining that all her communications in the matter were protected peer review materials. At this point, after the close of discovery, the Physician for the first time submitted affidavits from two former hospital employees (quite similar to the ones produced in the Sharifi case). In one of them, the affiant alleged she had heard the in-house attorney make disparaging remarks about the Physician (that he was a terrible doctor, an idiot, a danger to patients.) The other affiant alleged that she had heard other Physicians say the in-house attorney had encouraged them to make false statements about the Physician at the hearing. The in-house attorney moved to strike the affidavits as untimely, and the trial court agreed.
The trial court held on summary judgment that there was no dispute the Physician had administered blood thinners to a patient with a cerebral hemorrhage, and the other cardiologist’s alleged “idiot” statement was opinion and thus not actionable. The trial court further held that the Physician had failed to produce any admissible evidence showing the in-house attorney had made “any comments about him, defamatory or otherwise,” outside the peer review process.
The Court of Appeals affirmed both rulings. With respect to the cardiologist’s alleged comments, the Court agreed with the trial court that the “idiot” statement was opinion, and the record “lacked clear and convincing evidence that a reasonable listener could have understood [the cardiologist’s] ‘obvious’ statement as conveying an objective fact.” Regarding the defamation claim against the in-house attorney, the Court of Appeals affirmed the trial court’s decision refusing to order production of a privilege log for peer review privileged correspondence. The Court cited the “overriding public interest in peer-review proceedings” and the need for confidentiality to ensure candid peer review. The Court also agreed that the affidavits were not admissible evidence based on the Arizona discovery rules.
Ultimately, the Court affirmed the trial court’s conclusion that the Physician’s claim against the in-house attorney was groundless and pursued in bad faith. The in-house attorney was awarded attorney fees in both the trial court and appellate court.
Interestingly, in the two state court lawsuits arising from the peer review proceeding described in these cases, there were no depositions, no written discovery and no document production. Judicial review of the in-hospital administrative proceedings was limited to a review of the record, as set forth in the statute. While no one can prevent disgruntled physicians from naming individuals in lawsuits arising from peer review, the two cases are reassuring that Arizona law provides strong protection of the integrity of the peer review process.
Postscript: The Federal Court Case
In addition to the two state court actions discussed above, the Physician filed a complaint in federal court alleging under 42 U.S.C. § 1981 that the hospital system and multiple individuals discriminated against the Physician based on his race in terminating his physician services agreement (PSA). Takieh v. Banner Health, No. CV-10-05878-PHX-MTL (D. Arizona Jan. 27, 2021), aff’d. No. 21-15326 (9th Cir. Feb. 16, 2022). The District Court dismissed the case in an unpublished Order, finding that the Physician himself had alleged numerous non-discriminatory reasons for the termination of the PSA, and taking into account the trial court’s decision in Sharifi. The District Court refused to allow the Physician to amend his pleading, holding in part based on the Sharifi trial court decision that amendment would be futile. The Ninth Circuit Court of Appeals affirmed the District Court’s decision and reliance on Sharifi because it was relevant and provided non-discriminatory reasons for the PSA termination.
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8 Ways Healthcare Attorneys Can Reduce Racial Disparities in Maternal Mortality
By: Marki Stewart, Coppersmith Brockelman PLC
Maternal mortality in the United States has more than doubled in the last 30 years—women living in the United States today are 50% more likely to die in childbirth than their mothers were a generation ago. Researchers estimate more than half of these deaths are preventable.
Alarmingly, the path to motherhood is significantly deadlier for women of color than it is for their white counterparts. Nationally, black women are three to four times as likely to die from pregnancy-related causes than white women, a disparity that has only widened in recent years.[i] Surprisingly, these disparities increase with age and education; data from the Centers for Disease Control and Prevention demonstrates that pregnancy-related deaths for black women with at least a college degree are five times higher than white women with a similar education.
Closer to home, the rates are likewise alarming. On October 22, 2021, the Arizona Society for Healthcare Attorneys (AzSHA) presented a panel discussion regarding the data in Arizona showing that women of color have higher rates of maternal mortality than their white peers. Native Americans have the highest maternal mortality rates in Arizona, at more than four times higher than white non-Hispanic women.[ii]
Although the causes of death vary—including cardiovascular diseases, hypertension, pulmonary embolism, and hemorrhage, among others—by and large, women die because they do not receive early, effective, and aggressive lifesaving treatment. Despite most preventable events being preceded by vital sign changes, structural racism and health care providers’ implicit biases may lead to delayed responses to clinical warning signs.[iii] A provider’s failure to quickly identify warning signs to rescue a pregnant woman or new mother can lead to catastrophic consequences.
Healthcare attorneys must help clients address this dire situation. Whether serving as general counsel for a hospital, counsel to a payor, or representing individual physicians or physician groups, attorneys can use their positions of power to influence key decisionmakers who directly impact this problem. Attorneys should impress upon their clients that increased maternal mortality for women of color is not only an issue of justice in healthcare, but any situation in which sub-standard care is provided also creates potential liabilities and must be urgently addressed.
Here are eight ways attorneys can leverage their influence to enact positive change:
Administered by the Arizona Hospital and Healthcare Association, AIM is a quality improvement initiative that helps hospitals implement Patient Safety Bundles, a series of evidence-based practices that reduce provider bias and ensure a timely and tailored response to a wide variety of objective clinical warning signs. In addition to addressing certain clinical symptoms, the Patient Safety Bundles address patient support, including standards for recognizing and treating perinatal depression and anxiety. Participating hospitals also provide valuable data to better understand the challenges in Arizona and track progress toward state and national goals.[iv]
Implicit bias training uses techniques to recognize and understand the magnitude of unconscious bias, helping to de-bias patient care. A variety of programs are available, and can be performed in-person or virtually, both free or for cost. The March of Dimes’ Breaking Through Bias in Maternity Care, a training session that can be done in-person or by virtual learning experience, provides an overview of implicit bias and personal assessment, strategies to mitigate racial bias in maternity care, and a plan for building a culture of equity within an organization.[v] Some healthcare organizations choose to perform internal implicit bias training sessions that are tailored to their needs.
Tragically, as with their mothers, black newborns die at three times the rate of white infants in the United States. Research demonstrates that black newborns cared for by black physicians have 50% reduced mortality compared to black newborns treated by white physicians. Furthermore, racial concordance with one’s physician can increase health care utilization among under-resourced communities.[vi] If the hospital or physician group finds it difficult to recruit providers of color, encourage them to start a scholarship program to invest in young medical and nursing students of color.
Doulas are non-clinical professionals who provide physical, emotional, and informational support to mothers before, during, and after childbirth. Data shows doulas increase patient satisfaction with the birthing process, decrease the risk of C-section, and decrease the risk of newborns being sent to the NICU.
Women who participate in group prenatal care with other women at similar gestation ages receive approximately 20 hours of prenatal care over the course of their pregnancies, compared to approximately two hours in traditional individual care settings. The American College of Obstetricians and Gynecologists determined that group prenatal care resulted in reductions in pre-term birth and NICU admissions, increased birth weight for infants, decreased emergency department visits in the third trimester, and increased patient satisfaction.
Health insurers have a critical role to play because providers may not pursue necessary care if reimbursement will not follow. Payment policies that encourage good maternal care include an extension of AHCCCS coverage for pregnant women for up to one year after birth. Currently, when someone enrolled in AHCCCS gives birth, their coverage may expire just sixty days after their pregnancy ends, meaning that many low-income mothers are forced to forego necessary postpartum health care because they can’t afford the expense; indeed, almost 20% of maternal deaths occur 43 days to 1 year after delivery.[vii] Payors should also expand reimbursement for doulas, group prenatal care, home visits, and mental health treatment for pregnant and post-partum women. Some payors have begun to reimburse for implicit bias training, and others should follow suit. [viii] Payors can also provide outcome-based reimbursement incentives for providers to close gaps in maternal health.
The physical distance between Native American communities and hospitals makes it hard for Native women to access care; some studies show that Native American women have half as many prenatal visits as their white counterparts, making it difficult to identify health problems at an early stage. Hospitals and physicians can adopt a home visit program in which doulas, midwives, nurses, or social workers travel to the woman’s home to provide care and offer support on a wide variety of issues impacting social determinants of health.[ix]
Excellent examples of existing programs and tools include:
The United States’ increasing maternal mortality rate, borne largely on the backs of women of color, has become a public health crisis that all players in the health care industry should work to improve, including health care attorneys. AzSHA is committed to continue addressing this issue, and we welcome our members’ feedback and insight into creative ways that attorneys can help. If you are interested in collaborating with other attorneys on this issue, please reach out to Marki Stewart, at mstewart@cblawyers.com.
[i] See Khiara M. Bridges, Racial Disparities in Maternal Mortality, 95 N.Y.U. L. Rev. 1229 (2020).
[ii] A 2017 report from the Arizona Department of Health Services’ Maternal Mortality Review Program
demonstrates that Arizona’s maternal mortality rate is at 25.1 deaths per 100,000 live births (2012-2015). This
ranks Arizona 25th in the nation. Native American/Indigenous women died at four times the rate (70.8
per 100,000 live births) compared to White non-Hispanic women (17.4 per 100,000 live births) despite
Native Americans representing only 6.0% of the births. The maternal mortality rate for Hispanic/Latina
women was 22.4 per 100,000 live births while the maternal mortality rate for Blacks, Asian, and Pacific
Islander women combined was 44.0 per 100,000 live births. See ADHS maternal Mortality Action Plan, June 2019, available at https://azdhs.gov/documents/operations/managing-excellence/breakthrough-plans/maternal-mortality-breakthrough-plan.pdf.
[iii] For additional information about health care providers’ implicit biases impacting their perception of pain and treatment plans for patients of color, see “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs About Biological Differences Between Blacks and Whites,” Kelly M. Hoffman, et al., Proc Natl Acad Sci U S A. 2016 Apr 19; 113(16): 4296–4301, available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/.
[iv] For more information about how to participate in AIM, see https://www.azhha.org/arizona_aim_collaborative.
[v] Further information about this training can be found here: https://ww.ahapac.org/system/files/media/file/2020/12/march-of-dimes-breaking-through-bias-maternity-care.pdf. Organizations can inquire about an in-person training session by completing this form: https://www.marchofdimes.org/professionals/implicit-bias-training-form.aspx.
[vi] “Physician-Patient Racial Concordance and Disparities in Birthing Mortality for Newborns,” Brad N. Greenwood, et al., PNAS September 1, 2020 117 (35) 21194-21200, available at: https://www.pnas.org/content/117/35/21194.
[vii] The Build Back Better package passed by the U.S. House of Representatives would mandate one year of postpartum Medicaid care. If enacted by the Senate without this provision, Arizona’s legislature would need to grant AHCCCS statutory authority to enact this change.
[viii] See https://www.forbes.com/sites/debgordon/2021/04/20/us-health-insurer-announces-new-plan-to-reduce-racial-disparities-in-maternal-health-by-50-in-five-years/?sh=3f6ad5b11ebd.
[ix] For more information on the benefits of home visits, see https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview. For information about reimbursement for home visits, see https://www.americanprogress.org/article/home-visiting-programs-vital-maternal-infant-health/.
[x] See https://www.acog.org/advocacy/policy-priorities/maternal-mortality-prevention.
[xi] See https://www.awhonn.org/education/hospital-products/post-birth-warning-signs-education-program/.
[xii] See https://www.ahrq.gov/hai/tools/perinatal-care/index.html.
[xiii] See https://www.ahrq.gov/patient-safety/patients-families/engagingfamilies/index.html.