Tags: Comments: October 12th, 2011 Should information about a physician’s medical malpractice claims and disciplinary actions be made public? You would think that the answer is a simple, yes, of course, but the question is being hotly debated right now in the news media.
The controversy began when the removed the public use file from its website on September 1 st. Now to make the database public again What’s the Big Deal?
The NPDB is an agency that compiles information about disciplinary actions and sanctions against physicians, as well as payouts in malpractice claims. That: “Congress created the NPDB in 1986 to give hospitals, insurers, state medical boards, and other government entities a way to check up on physicians, dentists, and other licensed healthcare professionals.” Journalists and others feel that making the information available protects the public from unsafe doctors.
The idea is that people could use the information to avoid physicians that have had claims frequency problems, or who have had their licenses suspended. In a letter written by several journalism organizations and sent to HRSA, it is stated this way: “Without stories written by our members, it’s fair to say that some unsafe doctors would continue to be practicing with clean licenses and patient protection legislation in several states likely would not have been enacted.” In an effort to protect the doctors’ reputations, the public use file actually leaves out the physicians’ names and details that would identify them. However, recently a reporter from the Kansas City Star was able to piece together information from court documents and the NPDB to identify 21 doctors who had 10 or more claims where money was paid out, but no disciplinary action had been taken. The HRSA to remove the database from public view.
Their stance is that information about individual physicians is to remain confidential according to federal law. Physician groups, including the, would like to keep the information confidential for several reasons. “The AMA has long opposed public access to the National Practitioner Data Bank and welcomes the decision to stop posting its public data file online to prevent breaches of physician confidentiality in the future,” AMA President Peter Carmel said in a written statement. Carmel also claims the information is often inaccurate and incomplete.
Many times there are duplicate entries, which make a doctor’s history look worse than it really is. Plus, some say it’s not fair to make a judgment about a doctor based on data alone. There are many factors that can lead to a medical malpractice claim such as area of specialty or even geographic location. On the Other Hand Coincidentally, Illinois Governor, Pat Quinn, signed a bill in August mandating the creation of an online database containing information on judgments, convictions, and settlements in malpractice lawsuits.
Is designed to protect consumers from physicians with a history of problems. Proponents of the bill said we get the information we need online to make important decisions like banking or buying a home. So why not also for one of the most important decisions: Choosing a doctor? Illinois is not the first state in the U.S. To make a move like this. Conclusion There is no doubt that this debate will go on for a long time.
Even if HRSA agrees to put the information back up online for public viewing, the controversy won’t go away. We live in a country where the free flow of information is valued, and the freedom of the press has always been a given.
But even these freedoms, as important as they are, have some restrictions. It appears that the trend to let each state decide what’s best for its physicians and healthcare consumers might be the way to go. How eQuoteMD™ Helps Doctors Save on Medical Malpractice Insurance. Quotes from Multiple “A” Rated Medical Malpractice Insurance Companies — Compare premiums to get the highest quality coverage at the lowest rates possible. Coverage is Available for All Physician Specialties, Groups & Clinics in All 50 States. Prior Acts Coverage Included — No need to purchase separate tail coverage. Access to Multiple Discounts —.
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Failure of Hospitals to Discipline and Report Doctors Endangers Patients May 27, 2009 Alan Levine Sidney Wolfe, M.D. Executive Summary Lack of detection and widespread under-reporting to the National Practitioner Data Bank raise serious questions about hospital peer review.
The National Practitioner Data Bank (NPDB) was established by the Health Care Quality Improvement Act of 1986 to protect patients from questionable physicians. The legislation included a requirement that hospitals report to the NPDB whenever they revoke or restrict a physician’s hospital privileges for more than 30 days for problems involving medical competency or conduct. As the only national repository for the records of doctors disciplined by their peers for unprofessional or incompetent behavior, the usefulness of the data bank has been historically handicapped by the failure of thousands of hospitals to report to the NPDB.
As of December 2007, almost 50 percent of the hospitals in the U.S. Had never reported a single privilege sanction to the NPDB. Prior to the opening of the NPDB in September 1990, the federal government estimated that 5,000 hospital clinical privilege reports would be submitted to the NPDB on an annual basis, while the health care industry estimated 10,000 reports per year. However, the average number of annual reports has been only 650 for the 17 years of the NPDB’s existence, which is 1/8th of the government estimate and about 1/16th of the industry estimate.
Hospital reporting varies by state. For example, about 70 percent of the hospitals in Louisiana have never reported while only about 25 percent of the hospitals in Connecticut have never reported. Public Citizen, through its Health Research Group, compiled this report by reviewing a number of studies by the Office of Inspector General (OIG), work by the Citizen Advocacy Center, medical journal articles, and recommendations from an October 1996 national meeting on hospital under-reporting. Public Citizen also analyzed the NPDB Public Use File to examine the relationship between hospital reports and actions taken by state medical boards on the same physicians. Operated by the Health Resources and Services Administration (HRSA), part of the Department of Health & Human Services (HHS), the NPDB was designed as a searchable resource for hospitals and other medical entities to check practitioners’ backgrounds and to consider taking their own action based on the information in the data bank. Prior to its launch, this function was not being provided in any systematic way. The NPDB’s goal was to reduce the likelihood that disciplined doctors might continue to injure patients by relocating to another hospital or state where their reputations and track records were not known.
The OIG at HHS did an initial assessment after the NPDB had been in operation for three years. This assessment found that a wide variation in reporting rates from state to state could suggest differences in the quality of care rendered, or perhaps in the capacity or willingness of hospitals to discipline doctors and to submit reports to the NPDB. In response to the OIG report, HRSA convened a national conference in October 1996 of many stakeholders such as the American Hospital Association, American Medical Association, the Joint Commission on Accreditation of Healthcare Organizations (“Joint Commission”), Center for Medicare and Medicaid Services, Public Citizen and OIG. The consensus report from the conference found that the number of reports in the NPDB is unreasonably low, compared with what would be expected if hospitals pursued peer review effectively. Collectively, the OIG report, the 1996 national conference, and a 2002 HRSA funded study of hospital compliance made a total of 10 different recommendations to remedy this serious problem. However, as of December 31, 2008, only one of the recommendations has been fully implemented. The Journal of the American Medical Association (JAMA) has called hospital peer review one of the pillars of quality assurance in the United States.
Hospital under-reporting raises questions about the effectiveness of hospital peer review. Under-reporting to the NPDB suggests that hospital peer review is not fulfilling the public trust. Our review identified and focused on two factors associated with under-reporting: failure of hospitals to report and failure of hospitals to take action on questionable physicians. HRSA and CMS should work together to achieve a regulatory and statutory change so that the Medicare conditions of participation require fulfillment of hospitals’ reporting responsibilities to the NPDB under the Health Care Quality Improvement Act. CMS should require that the standards for compliance with the Medicare conditions of participation include all aspects of peer review.
Congress should provide CMS with the statutory authority to impose financial and other sanctions on hospitals and physicians for failure to perform peer review. Congress should amend the Health Care Quality Improvement Act to impose a civil money penalty on hospitals for failure to report. HRSA should seek legislative authority for conducting compliance reviews of clinical privilege reporting, including authority to mandate access to peer review records. The OIG should review hospital peer review practices relating to granting and renewing hospital admitting privileges. HRSA should initiate corrective educational and compliance activities involving hospitals that have not reported.
To address hospitals’ concerns about the effectiveness of peer review immunity, HRSA should update its 1996 survey of case law which found that the peer review immunity provisions of the statute were protecting peer review in the vast majority of cases. State medical boards should request their respective state legislatures to adopt those provisions of the Citizen Advocacy Center model act that have the potential to increase reporting. Congress should provide the OIG with authority to investigate state medical boards’ handling of adverse hospital clinical privilege reports. Hospital compliance officers should be required to monitor hospital peer review and reporting to the NPDB. The OIG, HHS, should use corporate integrity agreements to assure hospital compliance with NPDB reporting requirements.
Reporting and Disciplining of Doctors by U.S. Hospitals National Practitioner Data Bank Reporting Rates, 1990 – 2007 Federal law requires hospitals to report a physician to the National Practitioner Data Bank (NPDB) whenever a hospital revokes or restricts the physician’s privileges for more than 30 days for an issue involving medical competency or conduct. The NPDB opened for reporting and querying September 1, 1990. Although the NPDB has been open for nearly two decades, 49 percent of U.S. Hospitals (2,845 of 5,823) have never submitted a clinical privilege sanction report on a physician; at the end of CY 2007, the NPDB contained only 11,221 adverse hospital clinical privilege reports, which is significantly below government and private sector estimates.
Prior to the opening of the NPDB, there was a range of estimates of annual hospital reports, as follows:. The Public Health Service (PHS) submitted a planning document to the Office of Management and Budget in 1989 that estimated 5,000 hospital adverse actions a year would be reportable. The American Medical Association (AMA) estimated 10,000 reports per year.
This estimate was based on an American Hospital Association (AHA) study, which found that the number of hospital disciplinary actions averaged 2.5 per year per hospital for hospitals in the study. Contrary to these initial estimates, since the NPDB opened, the range of total reports per year has varied from a high of 830 in 1991 to a low of 532 in 2006 (see Appendix A). The trend has been toward fewer reports recently than in the first years after the NPDB opened. The average number of reports per year has been 650, which is 1/8th of the PHS estimate and about 1/16th of the AMA estimate.
Failure to report disciplinary actions to the NPDB violates the law and deprives health care organizations such as hospitals and state licensure boards of potentially useful information for their credentialing and regulatory activities, respectively. Furthermore, in discussions with Bill Moran, senior vice president for Strategic Management, a hospital compliance consulting company, he advised us that “a hospital compliance officer informed him that while his hospital reports to the NPDB when required, he and his staff are disheartened that many other hospitals do not.” National Practitioner Data Bank The Health Care Quality Improvement Act of 1986 (hereafter referred to as “the Act”), as amended, created the National Practitioner Data Bank. Since it became operational in September 1990, the NPDB has received and maintained records of medical malpractice payments and adverse actions taken against licensed health care practitioners by hospitals, other health care entities, licensure boards, and professional societies. The NPDB makes these reports, with doctor identification, available to hospitals, licensure boards, and managed care organizations to facilitate their background checks and credentialing. As a result of resistance from the AMA and other health care organizations, the NPDB statute does not allow for public access to the doctor-specific information. The NPDB is operated by the Health Resources and Services Administration (HRSA) within the Department of Health & Human Services. The NPDB does not currently receive a congressional appropriation; it is self-supporting through user fees (Congress provided funds for start up costs).
Users are charged $4.75 per query. Hospitals, by law, are required to query in certain circumstances, such as when a physician applies for clinical privileges at the hospital and every two years thereafter. Other health care organizations, such as HMOs, may query provided they have a formal peer review process. Medical licensing boards may also query.
Health care practitioners may query but only to get their own reports. One-third of all queries are mandatory, i.e. From hospitals; two-thirds are optional. In 2007, the NPDB received 3.8 million queries and about 537,600 of these queries matched practitioner reports in the NPDB (a match rate of 14 percent). HRSA has estimated that, based on a national survey, for a one year period, 48,075 licensure, credentialing, or membership decisions were affected by new information provided in NPDB responses.
The legislative history is clear as to why Congress enacted this legislation. The House Committee on Energy and Commerce report noted, as follows: The Committee has reviewed testimony from numerous sources indicating that this legislation is essential to protect the public health and safety.
This bill is needed to deal with one important aspect of the medical malpractice problem in this country – incompetent and unprofessional physicians. The bill’s focus is on those instances in which physicians injure patients through incompetent or unprofessional service, are identified as incompetent or unprofessional by their medical colleagues, but are dealt with in a way that allows them to continue to injure patients. Unfortunately, groups such as state licensing boards, hospitals and medical societies that should be weeding out incompetent or unprofessional doctors often do not do so. Even when such bodies do act against bad physicians, these physicians find it all too easy to move to different hospitals or states. Section 423 of the Act addresses incompetent or unprofessional physicians in hospital settings. Section 423 requires that each hospital or health care entity which takes a professional review action that adversely affects the clinical privileges of a physician for a period of longer than 30 days report to the NPDB the name of the physician involved and a description of the acts or omissions or other reasons for the action. Hospitals are also required to forward a copy of the NPDB report to each board of medical examiners where the practitioner is licensed.
The House Report further noted: The purpose of requiring reports even for circumstances in which physicians surrender their privileges is to ensure that health care entities will not resort to ‘plea bargains’. While such agreements may serve the immediate self interests of the two parties involved, they may jeopardize the health and safety of future patients. Congress was also concerned that the threat of private money damage liability under federal law, or lawsuits against hospital peer review physicians, including treble damage liability under federal antitrust law, would discourage physicians from participating in peer review. Thus, to encourage effective hospital professional review activities (i.e. Peer review), Section 411(a) of the Act provides immunity for such activities. Specifically, the statute states, “any person who participates with or assists the body with respect to the action, shall not be liable in damages under any law of the United States or of any state.” The statute stipulates that in order for hospital professional review actions to qualify for immunity, the peer review action must be taken as follows:. In the reasonable belief that the action was in the furtherance of quality health care.
After a reasonable effort to obtain the facts of the matter. After adequate notice and hearing procedures are afforded to the physician. In the reasonable belief that the action was warranted by the facts.
Hospitals that fail to report reportable actions to the NPDB risk losing the liability protection afforded to their professional review activities under the Act. The regulations implementing the Act require the Secretary of HHS to (1) investigate hospitals that appear to be substantially failing to comply with reporting requirements, (2) provide them with an opportunity to correct their practices if they are found to be in non-compliance, and (3) remove the liability protections for three years if they are found in non-compliance. For a hospital to lose its immunity, the hospital has to “substantially” violate the reporting requirement, meaning there has to be a pattern of non-compliance. Although HRSA has investigated a small number of cases of non-compliance, as of November 2008, 18 years after the NPDB began, no hospital has ever been penalized through the loss of peer review immunity. Finally, the importance of hospital credential and privilege reviews cannot be overstated. The Journal of the American Medical Association has noted the following: Historically, there have been three pillars of quality assurance in health care: self-regulation by hospital credentialing committees, malpractice litigation, and external regulation by licensure boards. Hospital oversight of credentials and privileges reflects the professional commitment to self-regulation.
A random sample survey in 2000 of NPDB users who had received matched responses from the NPDB about the physician for whom they were making a query found that it is an important aspect of the credentialing process for these users. The user survey included a wide variety of health care entities such as hospitals, managed care organizations, group practices, professional societies, state licensing boards, and ambulatory surgical centers. The survey found that: a wide variety of different committees and individuals used practitioner NPDB reports in their credentialing and disciplinary decision making. On average, between 4 and 5 different individuals or committees reviewed each NPDB matched report.
The entity’s credentialing committee was most likely to use the report. Other organizational groups that frequently reviewed NPDB reports included the medical staff committee. Individuals who were likely to use the report included the chief of medical staff, the department chair and the chief executive officer. Analysis of Hospital Compliance State Variation in Hospital Reporting As of December 31, 2007, according to HRSA data, 2,845 of all 5,823 U.S. NPDB-registered hospitals (49 percent) had never reported a clinical privilege sanction to the NPDB. A 2007 analysis of accumulated HRSA data shows that extremely large state-by-state variation in the rate of non-reporting hospitals exists.
For example, 75 percent of the 56 hospitals in South Dakota have never reported; 70 percent of the 47 hospitals in North Dakota have never reported; 69 percent of the 150 hospitals in Kansas have never reported; and 69 percent of the 29 hospitals in Wyoming have never reported. About one-third of the hospitals in Illinois, New Jersey, and California have never reported. And about 48 percent of the 110 hospitals in Massachusetts have never reported. However, only 24.1 percent of hospitals (7 of 29 hospitals) in New Hampshire, 25 percent of hospitals (10 of 40) in Connecticut, and 28.5 percent of hospitals (68 of 239) in New York have never reported. The HRSA analysis that used hospital-specific data found that “clinical privilege reporting seemed to be concentrated in a few facilities even in States with comparatively high overall hospital clinical privileging reporting levels.” Several previous studies of hospital reporting have used “bed size” or “admissions” as a surrogate for physician exposure. A 1995 Office of Inspector General (OIG) study of hospital reporting for the period September 1990 (when the NPDB opened) to December 31, 1993, found that:.
The approximately 6,500 hospitals in the U.S. Submitted only 3,154 adverse action reports to the NPDB. This represented 2.6 reports per 1,000 hospital beds during the 3 1/3 year period.
With the focus on the number of reports per 1,000 hospital beds rather than on number or percent of reporting hospitals, the state-by-state picture changed somewhat. For instance, New Jersey, which ranked first in the proportion of hospitals sending at least one report to the NPDB, ranked 18th in the number of reports per 1,000 beds. More striking, New York shifts from 4th to 33rd. Reporting rates per 1,000 hospital beds varied greatly state to state – ranging from 8.5 in Nevada to 0.7 in South Dakota. In most states, the reporting rate was between 1.5 and 4.0.
The median rate was 2.5 adverse action reports per 1,000 hospital beds. Some of the differences among states in reporting rates per 1,000 hospital beds were considerable. For example, California, the state with the largest number of hospital beds, the rate of adverse actions was 3.7 per 1,000 beds. In New York, the state with the second largest number of hospital beds, the rate was “considerably less,” 2.1. In Ohio, the rate was 2.9; in nearby Illinois, the rate was 1.5.
The OIG report also noted that “Whatever the State-to-State differences, there is also reason to suspect that the level of reporting in the nation may be unreasonably low.” As an example, OIG cites the 1991 Harvard Medical Practice study of hospitalized patients in New York State that found 1 percent of hospitalizations in a random sample involved adverse events caused by negligence. On the basis of the sample, it was estimated that during one year, negligent care provided in New York State was responsible for 27,179 injures, including 6,895 deaths and 877 “permanent and total disabilities.” A July 28, 1999, article in the JAMA addressed hospital reporting to the NPDB. The article, which was based on a HRSA funded-study by the University of Washington, examined the variation in clinical privilege reporting, the changes in reporting over time, and the association of hospital characteristics with reporting. The study looked at 4,743 hospitals between 1991 and 1995; the majority of the hospitals were non-governmental, not-for-profit, and accredited by the Joint Commission; they were equally distributed between urban and rural hospitals. The study, which found evidence of a low and declining level of reporting, noted the following:.
About a third of the hospitals (34.2 percent) reported at least one action over the study period. The range of the privileges action rates for individual hospitals that had taken actions was between 0.40 and 52.27 per 100,000 admissions. The overall privileges action rate for the study hospitals in aggregate was 2.36 per 100,000 admissions.
Urban hospitals and hospitals accredited by the Joint Commission were more likely to have reported one or more privileges actions and had higher rates of reported actions per 100,000 admissions than their counterparts for nearly all bed size categories. State and local hospitals were least likely to have reported. The majority of hospitals that were members of the Council of Teaching Hospitals of the American Association of Medical Colleges, and had bed sizes of 300 or more, had lower rates of reporting than non-member hospitals. There were significant regional differences in privilege action reporting.
Hospitals in the east south Central region, such as Alabama, Kentucky, Mississippi and Tennessee, had some of the lowest reporting rates. Importance of Hospital Reporting For State Licensure Board Actions The OIG report noted earlier found that, during the period of the OIG review, 1990 – 1993, hospitals reported about 3,154 practitioners to the NPDB. During the same time period, state medical boards took disciplinary actions against about 8,000 physicians. The OIG notes “these numbers are not directly comparable, but the discrepancy is sufficiently large to raise legitimate questions about whether hospitals are being sufficiently rigorous in taking adverse actions against practitioners on their staffs.” A similar observation was made in the July 1999 JAMA article, which noted that “there were nearly three times the number of licensing actions than privileges actions over the study period. In addition, licensing actions increased between 1991 and 1995, while privileges actions decreased.” Every year HRSA calculates a ratio comparing the sum of adverse action reports for both hospitals and managed care organizations to adverse licensure reports for in-state physicians. According to HRSA data, during the seventeen-plus year history of the NPDB, state licensure adverse action reports have been more than double the number of adverse (hospital and HMO) clinical privilege reports: 32,748 vs. From state to state, the ratio of adverse clinical privilege reports to adverse licensure action reports range from a low of one clinical privilege report for every five state licensure actions in Colorado and Connecticut to a high of 1.51 clinical privilege reports in Hawaii for every adverse licensure action report.
According to HRSA, “While these ratios reflect variations in the reporting of both State licensure actions and clinical privileges actions, the extreme variation from State to State is instructive. It seems likely that the extent of the observed differences may at least in part reflect variations in willingness of hospitals and medical boards to take actions rather than a substantial difference in the conduct or competence of the physicians practicing in various States.” This is reinforced by the lack of evidence that the overall quality of physician practice varies from one state to another.
A 1999 article in the American Journal of Law and Medicine makes a point about the role of hospital peer review and its relationship to state licensing boards: The peer review system should address problems of physicians before they impact a physician’s license to practice medicine. Notwithstanding the differences between what the hospital peer review system is designed to accomplish and the state physician licensing system, the significantly higher rate of state actions raises the question of whether hospital peer review is taking place at an adequate level.
From the perspective of state medical licensure boards, hospital reports are an important source of data for regulatory oversight. Results of a Citizen Advocacy Center (CAC) survey on hospital reporting highlighted the importance of hospital reports to state medical boards:. Several medical boards emphasized the high quality of the information in hospital reports. Boards value hospital reports because they are based on peer investigation and review. Because hospitals are so concerned about being sued by doctors against whom they take clinical privilege actions, when a hospital does report, there is substantial evidence of a serious problem. The acting director of the Office of Professional and Medical Conduct in New York State said that 31 percent of the facility reports her board receives have led to charges of misconduct or surrender of license. This means that nearly one in three mandatory reports results in the board opening a disciplinary action.
In many states, fewer than 10 percent of consumer complaints lead to disciplinary action. The executive director of the Arizona board indicated that while only 2 percent of the complaints received by his board in 1995 were from hospital mandatory reports, 66 percent of these had to do with quality of care (as opposed to 54 percent of complaints from all sources) and 17 percent of hospital reports ultimately led to discipline and 11 percent to stipulated limitations on practice, as opposed to 2 percent and 5 percent complaints from all sources. Representative responses to the CAC survey included:. ‘This information would be kept confidential from the board if not for mandatory reporting laws.’. ‘The mandatory reports provide useful ‘leads’ for the Board about the possibility of substandard practice which otherwise may not be known.
The Board would never receive the information without mandatory reporting.’ CAC also asked boards about oversight of state hospital reporting laws. “Many state medical boards replied that they had no jurisdiction over hospitals. While their state statute may require a hospital to report adverse actions to the medical board, actual enforcement authority is usually the responsibility of another state office, such as the agency that licenses hospitals.” Under-reporting of hospital privilege sanctions deprives state regulators and other users of the NPDB of critical information. To help increase hospital reporting, CAC, in collaboration with the Administrators in Medicine, an organization composed of the Executive Directors of State Medical Boards, wrote and issued a Model Act in March 1999 that addressed hospital reporting to state boards. The AHA and hospital legal representatives should educate their hospital members and clients, as soon as practical, on the effectiveness of legal protections under the Health Care Quality Improvement Act’s immunity protections, as them have been interpreted by most courts.
Source: Conference Facilitator, Oct. 1996, National Conference on Hospital Reporting to the NPDB Status: The American Hospital Association (AHA) could not find any record of an AHA response to this recommendation. The AHA advised Public Citizen Health Research Group that “Based on the information currently available we do not know how AHA may have responded to the report”. The American Medical Association and physician legal representatives should educate their physician members and clients, as soon as practicable, on the effectiveness of legal protections under the Health Care Quality Improvement Act’s immunity provisions. Source: Conference Facilitator, October 1996, National Conference on Hospital Reporting to the NPDB Status: The AMA provided Public Citizen Health Research Group a list of three NPDB links from the AMA web site.
Although two of the web links, which contain duplicative wording, describe the statutory protection for “medical peer review,” the links do not address the conference recommendation asking the AMA to advise members about the effectiveness of such protections. HRSA should seek legislative authority and funding for conducting compliance reviews of clinical privilege reporting, including authority to access peer review records.
Source: PricewaterhouseCoopers LLP, Nov. 15, 2002 Status: No action taken. Public Citizen Health Research Group Recommendations A.
HRSA and CMS should work together to achieve a regulatory and statutory change so that the Medicare conditions of participation specifies hospitals’ reporting responsibilities under the Health Care Quality Improvement Act. The 1995 OIG report recommended such a regulatory and statutory change.
The OIG noted that “this inclusion would compel the Joint Commission to devote greater oversight to hospitals’ performance of the responsibilities.” Also, since the Medicare Improvements for Patients and Providers Act of 2008 allows organizations other than the Joint Commission to conduct accreditation reviews, our recommendation would impact all hospital accreditation organizations. CMS should require that the standards for compliance with the Medicare conditions of participation include all aspects of peer review.
Events at Redding Medical Center demonstrate that ineffective or non-existent peer can affect patient safety. Currently, a violation of an element of a Medicare Condition of Participation is not sufficient to rule the entire Condition violated. According to CMS, partial compliance is good enough. Although one critical element, peer review for cardiac services, remained in non-compliance, Redding was still accredited. Congress should provide CMS with the authority to impose sanctions on hospitals and physicians for failure to perform peer review.
For hospital departments where peer review is absent, CMS should stop payment for selective services in such departments. Congress should amend the Health Care Quality Improvement Act to impose a civil money penalty for failure to report. Research has shown that states with financial penalties for failure to report have higher levels of hospital reporting to the NPDB. The “Model Act” developed by CAC and the Administrators in Medicine recommends a penalty of $1,000 per day per unreported adverse action. Cooler master fans.
Even the Joint Commission believes that a strong penalty provision would likely encourage reporting. Furthermore, a July 1999 Inspector General Report recommended a civil money penalty of up to $10,000 or each instance of non-compliance. In response to the OIG recommendation, HRSA developed a legislative proposal that would have created a $25,000 civil monetary penalty for failure to report. As noted in the body of this report, HHS did not approve the HRSA proposal. Congress should amend the Act to authorize a civil money penalty of up to $25,000 for each instance of a hospital or other health care entity’s (e.g. HMO) failure to report an adverse action to the National Practitioner Data Bank. HRSA should also seek legislative authority for conducting compliance reviews of clinical privilege reporting, including authority to access peer review records.
In 2002, HRSA contracted with PricewaterhouseCoopers LLP (PwC) to establish a pilot assessment of the extent of hospital non-compliance with NPDB reporting. The assessment was to use the voluntary cooperation of hospitals. As noted earlier, the study could not be conducted because of the failure of the sample hospitals to cooperate. We support the PwC recommendation to HRSA that the agency seek legislative authority for HRSA to access peer review records for the purpose of assessing the level of clinical privileges compliance reporting. The Office of Inspector General should review hospital practices relating to granting and renewing privileges. When a hospital grants privileges to a physician, the institution has evaluated the physician’s education and experience and determined that physician can perform within a specified scope of practice. This peer review, which takes place at the time of hiring and periodically thereafter, is critical to assuring that the practitioner has the necessary knowledge and skills to provide patient care within the designated scope of practice.
Unfortunately, there are numerous examples of physicians who provided questionable and/or unnecessary care. There is also evidence that Joint Commission surveys do not go far enough in evaluating hospital privileging activities. According to the Medicare Conditions of Participation, hospitals must ensure that all patient care is provided in accordance with medical staff criteria for the granting and renewing of privileges.
Although OIG has reviewed credentialing and privileging activities at HHS funded hospitals, i.e. At Indian Health Service facilities, OIG has apparently not focused on “private sector” hospitals. The OIG should investigate non-federal hospitals’ compliance with the Medicare Conditions of Participation relating to medical staff privileges.
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HRSA should initiate educational and compliance activities involving hospitals that have not reported. As a first step, HRSA should send letters to all hospitals reiterating reporting responsibilities, asking if they understand the reporting requirement and expressing a willingness to discuss their concerns in a confidential manner.
A copy of the letter should be shared with Public Citizen and other members of the National Practitioner Data Bank Executive Committee. At the end of six months, HRSA should identify those hospitals that still have not reported and refer them to the OIG for follow-up. HHS should implement specific recommendations from the 1996 Chicago National Conference on Under-Reporting. The conference recommended that HRSA study the problem further, possibly through case studies. As soon as possible, HRSA should address the issue of “peer review immunity.” Notwithstanding the peer review immunity protection afforded by NPDB legislation, hospitals apparently remain concerned about lawsuits.
HRSA should update the survey of court decisions that was prepared for the October 1996 national conference in Chicago. As noted earlier, the survey concluded that the immunity provisions of the Act were protecting professional review activities in the vast amount of cases.
HRSA should make results of the updated survey available to the AHA and AMA to share with the hospital and medical community, respectively. The 1996 national conference recommended that the Joint Commission make reporting by hospitals of adverse actions taken against hospital privileges a specific point of review. Following the national conference, HRSA and CMS wrote the Joint Commission asking for assistance. To date, the Joint Commission has not taken steps to include hospital reporting in its accreditation surveys.
The Joint Commission should amend its standards to incorporate compliance with NPDB reporting. State medical boards should request their respective state legislatures to adopt those provisions of the CAC model act that have the potential to increase reporting. Strong state laws (such as monetary penalties) and enforcement activities have the potential to improve hospital reporting to the NPDB. State medical boards and HRSA should work together to facilitate reporting to the NPDB. According to the Citizen Advocacy Center, “a number of states report that they frequently visit with hospital executives on their responsibilities under state mandatory reporting laws.” CAC recommended, and Public Citizen agrees, that HRSA staff should explore with state officials the feasibility of including hospitals responsibilities to report to the NPDB as part of these “educational” visits. Congress should provide the Office of Inspector General, HHS, with authority to review state medical boards’ handling of adverse clinical privilege reports.
The value of hospital mandatory reports is clear. This raises the question of how to explain the fact that 952 physicians with two or more clinical privilege reports in the NPDB had no disciplinary action imposed by a licensing board. Until 1993, the OIG at HHS conducted evaluations of the performance of state medical boards.
However, because of legal concerns involving OIG authority to conduct reviews of state health professional licensing boards, OIG no longer considers performing such studies. OIG believes that since state health professional boards do not receive HHS funding, it has no authority to focus on state medical boards.
However, these boards regulate the practitioners who provide medical services to millions of Medicare and Medicaid beneficiaries. Therefore, Congress should give OIG the authority to conduct such reviews. Hospital compliance officers should monitor hospital peer review and reporting to the NPDB. Hospital Compliance Programs have their origin in the Federal Sentencing Guidelines of 1987 (Guidelines). On May 1, 1991, the Guidelines, which had focused only on the behavior of individuals, were broadened to include “organizations.” The organizational guidelines “provide incentives for far reaching compliance programs and have produced a new occupation that advises organizations on how to build effective programs that promote ethical behavior. Furthermore, by promoting compliance and ethics programs, the organizational guidelines not only provide incentives for substantial changes in organizational behavior, but also further some of the main goals of the Sentencing Reform Act: the prevention and deterrence of criminal conduct.” On February 23, 1998, the OIG, HHS, issued a guidance entitled “Compliance Program Guidance for Hospitals.” This guidance covers quality of care and financial risk areas.
Npdb Public Use
According to Strategic Management Systems, a consulting company to hospitals on compliance issues, there are four elements of the quality of care risk area: accuracy of quality-reporting data; medically unnecessary services; deficient care (failure to meet accepted standards of care) and, practitioner qualifications. The Health Care Compliance Association (HCCA) is a national non-profit professional membership organization made up of health care compliance and ethics professionals. According to HCCA, it has approximately 6,000 members. Many of these compliance and ethics professionals work in hospitals while others work for health care organizations such as health plans and nursing homes. Hospital compliance officers are in the unique position of independence from medical and management staff.
Compliance officers should therefore monitor hospital peer review, including sitting in on such reviews, and evaluate hospitals compliance with NPDB reporting law. To achieve this, we specifically recommend the following:. HRSA and the Health Care Compliance Association should work together in publicizing the NPDB reporting requirement through joint letters, webinars, and other training opportunities. The Health Care Compliance Association should include NPDB reporting in its agenda for national and regional conferences. The OIG should consider revising the Feb. 23, 1998 Compliance Guidance for Hospitals to include hospital peer review and NPDB reporting as risk areas.
The Office of Inspector General, HHS, should use corporate integrity agreements to assure hospital compliance with NPDB reporting requirements. OIG often negotiates compliance obligations with health care providers including hospitals as part of a settlement of federal health care program investigations arising from a variety of civil false claim statutes. A provider consents to these obligations as part of the civil settlement and in exchange to the OIG’s agreement not to seek an exclusion from Medicare or Medicaid or other federal health care programs.
There are currently over 400 corporate integrity agreements and related agreements posted on the OIG web site. These agreements encompass both quality of care and/or financial issues. The agreements require the hospital to establish a program to monitor corrective action and compliance. One such agreement notes: Hospital Corporation ‘A’ has established, and shall maintain during the term of the CIA, a Clinical Quality Department for monitoring clinical quality at Hospital A’s hospitals, including the credentialing, privileging, and peer review programs.” Currently OIG does not require hospital compliance programs to assure compliance with the NPDB reporting requirement. OIG should include compliance with NPDB reporting as part of future hospital Corporate Integrity Agreements. Appendices Appendix A: Total Number of Adverse Hospital Privileges Reports by Year - Source: Unpublished HRSA data Appendix B: Current Active Registered Non-Federal Hospitals That Have Never Reported to the National Practitioner Data Bank by State, September 1, 1990 - December 31, 2007, Source: Unpublished HRSA Data.
Failure of Hospitals to Discipline and Report Doctors Endangers Patients May 27, 2009 Alan Levine Sidney Wolfe, M.D. Executive Summary Lack of detection and widespread under-reporting to the National Practitioner Data Bank raise serious questions about hospital peer review. The National Practitioner Data Bank (NPDB) was established by the Health Care Quality Improvement Act of 1986 to protect patients from questionable physicians.
The legislation included a requirement that hospitals report to the NPDB whenever they revoke or restrict a physician’s hospital privileges for more than 30 days for problems involving medical competency or conduct. As the only national repository for the records of doctors disciplined by their peers for unprofessional or incompetent behavior, the usefulness of the data bank has been historically handicapped by the failure of thousands of hospitals to report to the NPDB. As of December 2007, almost 50 percent of the hospitals in the U.S. Had never reported a single privilege sanction to the NPDB.
Prior to the opening of the NPDB in September 1990, the federal government estimated that 5,000 hospital clinical privilege reports would be submitted to the NPDB on an annual basis, while the health care industry estimated 10,000 reports per year. However, the average number of annual reports has been only 650 for the 17 years of the NPDB’s existence, which is 1/8th of the government estimate and about 1/16th of the industry estimate. Hospital reporting varies by state.
For example, about 70 percent of the hospitals in Louisiana have never reported while only about 25 percent of the hospitals in Connecticut have never reported. Public Citizen, through its Health Research Group, compiled this report by reviewing a number of studies by the Office of Inspector General (OIG), work by the Citizen Advocacy Center, medical journal articles, and recommendations from an October 1996 national meeting on hospital under-reporting.
Public Citizen also analyzed the NPDB Public Use File to examine the relationship between hospital reports and actions taken by state medical boards on the same physicians. Operated by the Health Resources and Services Administration (HRSA), part of the Department of Health & Human Services (HHS), the NPDB was designed as a searchable resource for hospitals and other medical entities to check practitioners’ backgrounds and to consider taking their own action based on the information in the data bank. Prior to its launch, this function was not being provided in any systematic way. The NPDB’s goal was to reduce the likelihood that disciplined doctors might continue to injure patients by relocating to another hospital or state where their reputations and track records were not known. The OIG at HHS did an initial assessment after the NPDB had been in operation for three years.
This assessment found that a wide variation in reporting rates from state to state could suggest differences in the quality of care rendered, or perhaps in the capacity or willingness of hospitals to discipline doctors and to submit reports to the NPDB. In response to the OIG report, HRSA convened a national conference in October 1996 of many stakeholders such as the American Hospital Association, American Medical Association, the Joint Commission on Accreditation of Healthcare Organizations (“Joint Commission”), Center for Medicare and Medicaid Services, Public Citizen and OIG. The consensus report from the conference found that the number of reports in the NPDB is unreasonably low, compared with what would be expected if hospitals pursued peer review effectively. Collectively, the OIG report, the 1996 national conference, and a 2002 HRSA funded study of hospital compliance made a total of 10 different recommendations to remedy this serious problem.
However, as of December 31, 2008, only one of the recommendations has been fully implemented. The Journal of the American Medical Association (JAMA) has called hospital peer review one of the pillars of quality assurance in the United States. Hospital under-reporting raises questions about the effectiveness of hospital peer review.
Under-reporting to the NPDB suggests that hospital peer review is not fulfilling the public trust. Our review identified and focused on two factors associated with under-reporting: failure of hospitals to report and failure of hospitals to take action on questionable physicians. HRSA and CMS should work together to achieve a regulatory and statutory change so that the Medicare conditions of participation require fulfillment of hospitals’ reporting responsibilities to the NPDB under the Health Care Quality Improvement Act. CMS should require that the standards for compliance with the Medicare conditions of participation include all aspects of peer review.
Congress should provide CMS with the statutory authority to impose financial and other sanctions on hospitals and physicians for failure to perform peer review. Congress should amend the Health Care Quality Improvement Act to impose a civil money penalty on hospitals for failure to report. HRSA should seek legislative authority for conducting compliance reviews of clinical privilege reporting, including authority to mandate access to peer review records.
The OIG should review hospital peer review practices relating to granting and renewing hospital admitting privileges. HRSA should initiate corrective educational and compliance activities involving hospitals that have not reported. To address hospitals’ concerns about the effectiveness of peer review immunity, HRSA should update its 1996 survey of case law which found that the peer review immunity provisions of the statute were protecting peer review in the vast majority of cases. State medical boards should request their respective state legislatures to adopt those provisions of the Citizen Advocacy Center model act that have the potential to increase reporting. Congress should provide the OIG with authority to investigate state medical boards’ handling of adverse hospital clinical privilege reports. Hospital compliance officers should be required to monitor hospital peer review and reporting to the NPDB. The OIG, HHS, should use corporate integrity agreements to assure hospital compliance with NPDB reporting requirements.
Reporting and Disciplining of Doctors by U.S. Hospitals National Practitioner Data Bank Reporting Rates, 1990 – 2007 Federal law requires hospitals to report a physician to the National Practitioner Data Bank (NPDB) whenever a hospital revokes or restricts the physician’s privileges for more than 30 days for an issue involving medical competency or conduct. The NPDB opened for reporting and querying September 1, 1990. Although the NPDB has been open for nearly two decades, 49 percent of U.S. Hospitals (2,845 of 5,823) have never submitted a clinical privilege sanction report on a physician; at the end of CY 2007, the NPDB contained only 11,221 adverse hospital clinical privilege reports, which is significantly below government and private sector estimates. Prior to the opening of the NPDB, there was a range of estimates of annual hospital reports, as follows:. The Public Health Service (PHS) submitted a planning document to the Office of Management and Budget in 1989 that estimated 5,000 hospital adverse actions a year would be reportable.
The American Medical Association (AMA) estimated 10,000 reports per year. This estimate was based on an American Hospital Association (AHA) study, which found that the number of hospital disciplinary actions averaged 2.5 per year per hospital for hospitals in the study.
Contrary to these initial estimates, since the NPDB opened, the range of total reports per year has varied from a high of 830 in 1991 to a low of 532 in 2006 (see Appendix A). The trend has been toward fewer reports recently than in the first years after the NPDB opened. The average number of reports per year has been 650, which is 1/8th of the PHS estimate and about 1/16th of the AMA estimate. Failure to report disciplinary actions to the NPDB violates the law and deprives health care organizations such as hospitals and state licensure boards of potentially useful information for their credentialing and regulatory activities, respectively. Furthermore, in discussions with Bill Moran, senior vice president for Strategic Management, a hospital compliance consulting company, he advised us that “a hospital compliance officer informed him that while his hospital reports to the NPDB when required, he and his staff are disheartened that many other hospitals do not.” National Practitioner Data Bank The Health Care Quality Improvement Act of 1986 (hereafter referred to as “the Act”), as amended, created the National Practitioner Data Bank. Since it became operational in September 1990, the NPDB has received and maintained records of medical malpractice payments and adverse actions taken against licensed health care practitioners by hospitals, other health care entities, licensure boards, and professional societies.
The NPDB makes these reports, with doctor identification, available to hospitals, licensure boards, and managed care organizations to facilitate their background checks and credentialing. As a result of resistance from the AMA and other health care organizations, the NPDB statute does not allow for public access to the doctor-specific information. The NPDB is operated by the Health Resources and Services Administration (HRSA) within the Department of Health & Human Services. The NPDB does not currently receive a congressional appropriation; it is self-supporting through user fees (Congress provided funds for start up costs). Users are charged $4.75 per query. Hospitals, by law, are required to query in certain circumstances, such as when a physician applies for clinical privileges at the hospital and every two years thereafter.
Other health care organizations, such as HMOs, may query provided they have a formal peer review process. Medical licensing boards may also query. Health care practitioners may query but only to get their own reports.
One-third of all queries are mandatory, i.e. From hospitals; two-thirds are optional. In 2007, the NPDB received 3.8 million queries and about 537,600 of these queries matched practitioner reports in the NPDB (a match rate of 14 percent).
HRSA has estimated that, based on a national survey, for a one year period, 48,075 licensure, credentialing, or membership decisions were affected by new information provided in NPDB responses. The legislative history is clear as to why Congress enacted this legislation. The House Committee on Energy and Commerce report noted, as follows: The Committee has reviewed testimony from numerous sources indicating that this legislation is essential to protect the public health and safety. This bill is needed to deal with one important aspect of the medical malpractice problem in this country – incompetent and unprofessional physicians. The bill’s focus is on those instances in which physicians injure patients through incompetent or unprofessional service, are identified as incompetent or unprofessional by their medical colleagues, but are dealt with in a way that allows them to continue to injure patients. Unfortunately, groups such as state licensing boards, hospitals and medical societies that should be weeding out incompetent or unprofessional doctors often do not do so. Even when such bodies do act against bad physicians, these physicians find it all too easy to move to different hospitals or states.
Section 423 of the Act addresses incompetent or unprofessional physicians in hospital settings. Section 423 requires that each hospital or health care entity which takes a professional review action that adversely affects the clinical privileges of a physician for a period of longer than 30 days report to the NPDB the name of the physician involved and a description of the acts or omissions or other reasons for the action. Hospitals are also required to forward a copy of the NPDB report to each board of medical examiners where the practitioner is licensed. The House Report further noted: The purpose of requiring reports even for circumstances in which physicians surrender their privileges is to ensure that health care entities will not resort to ‘plea bargains’. While such agreements may serve the immediate self interests of the two parties involved, they may jeopardize the health and safety of future patients. Congress was also concerned that the threat of private money damage liability under federal law, or lawsuits against hospital peer review physicians, including treble damage liability under federal antitrust law, would discourage physicians from participating in peer review.
Thus, to encourage effective hospital professional review activities (i.e. Peer review), Section 411(a) of the Act provides immunity for such activities. Specifically, the statute states, “any person who participates with or assists the body with respect to the action, shall not be liable in damages under any law of the United States or of any state.” The statute stipulates that in order for hospital professional review actions to qualify for immunity, the peer review action must be taken as follows:. In the reasonable belief that the action was in the furtherance of quality health care. After a reasonable effort to obtain the facts of the matter. After adequate notice and hearing procedures are afforded to the physician. In the reasonable belief that the action was warranted by the facts.
Hospitals that fail to report reportable actions to the NPDB risk losing the liability protection afforded to their professional review activities under the Act. The regulations implementing the Act require the Secretary of HHS to (1) investigate hospitals that appear to be substantially failing to comply with reporting requirements, (2) provide them with an opportunity to correct their practices if they are found to be in non-compliance, and (3) remove the liability protections for three years if they are found in non-compliance.
For a hospital to lose its immunity, the hospital has to “substantially” violate the reporting requirement, meaning there has to be a pattern of non-compliance. Although HRSA has investigated a small number of cases of non-compliance, as of November 2008, 18 years after the NPDB began, no hospital has ever been penalized through the loss of peer review immunity. Finally, the importance of hospital credential and privilege reviews cannot be overstated. The Journal of the American Medical Association has noted the following: Historically, there have been three pillars of quality assurance in health care: self-regulation by hospital credentialing committees, malpractice litigation, and external regulation by licensure boards.
Hospital oversight of credentials and privileges reflects the professional commitment to self-regulation. A random sample survey in 2000 of NPDB users who had received matched responses from the NPDB about the physician for whom they were making a query found that it is an important aspect of the credentialing process for these users. The user survey included a wide variety of health care entities such as hospitals, managed care organizations, group practices, professional societies, state licensing boards, and ambulatory surgical centers. The survey found that: a wide variety of different committees and individuals used practitioner NPDB reports in their credentialing and disciplinary decision making.
On average, between 4 and 5 different individuals or committees reviewed each NPDB matched report. The entity’s credentialing committee was most likely to use the report.
Other organizational groups that frequently reviewed NPDB reports included the medical staff committee. Individuals who were likely to use the report included the chief of medical staff, the department chair and the chief executive officer. Analysis of Hospital Compliance State Variation in Hospital Reporting As of December 31, 2007, according to HRSA data, 2,845 of all 5,823 U.S.
NPDB-registered hospitals (49 percent) had never reported a clinical privilege sanction to the NPDB. A 2007 analysis of accumulated HRSA data shows that extremely large state-by-state variation in the rate of non-reporting hospitals exists. For example, 75 percent of the 56 hospitals in South Dakota have never reported; 70 percent of the 47 hospitals in North Dakota have never reported; 69 percent of the 150 hospitals in Kansas have never reported; and 69 percent of the 29 hospitals in Wyoming have never reported. About one-third of the hospitals in Illinois, New Jersey, and California have never reported. And about 48 percent of the 110 hospitals in Massachusetts have never reported. However, only 24.1 percent of hospitals (7 of 29 hospitals) in New Hampshire, 25 percent of hospitals (10 of 40) in Connecticut, and 28.5 percent of hospitals (68 of 239) in New York have never reported. The HRSA analysis that used hospital-specific data found that “clinical privilege reporting seemed to be concentrated in a few facilities even in States with comparatively high overall hospital clinical privileging reporting levels.” Several previous studies of hospital reporting have used “bed size” or “admissions” as a surrogate for physician exposure.
A 1995 Office of Inspector General (OIG) study of hospital reporting for the period September 1990 (when the NPDB opened) to December 31, 1993, found that:. The approximately 6,500 hospitals in the U.S.
Submitted only 3,154 adverse action reports to the NPDB. This represented 2.6 reports per 1,000 hospital beds during the 3 1/3 year period. With the focus on the number of reports per 1,000 hospital beds rather than on number or percent of reporting hospitals, the state-by-state picture changed somewhat. For instance, New Jersey, which ranked first in the proportion of hospitals sending at least one report to the NPDB, ranked 18th in the number of reports per 1,000 beds. More striking, New York shifts from 4th to 33rd. Reporting rates per 1,000 hospital beds varied greatly state to state – ranging from 8.5 in Nevada to 0.7 in South Dakota. In most states, the reporting rate was between 1.5 and 4.0.
The median rate was 2.5 adverse action reports per 1,000 hospital beds. Some of the differences among states in reporting rates per 1,000 hospital beds were considerable. For example, California, the state with the largest number of hospital beds, the rate of adverse actions was 3.7 per 1,000 beds. In New York, the state with the second largest number of hospital beds, the rate was “considerably less,” 2.1. In Ohio, the rate was 2.9; in nearby Illinois, the rate was 1.5. The OIG report also noted that “Whatever the State-to-State differences, there is also reason to suspect that the level of reporting in the nation may be unreasonably low.” As an example, OIG cites the 1991 Harvard Medical Practice study of hospitalized patients in New York State that found 1 percent of hospitalizations in a random sample involved adverse events caused by negligence. On the basis of the sample, it was estimated that during one year, negligent care provided in New York State was responsible for 27,179 injures, including 6,895 deaths and 877 “permanent and total disabilities.” A July 28, 1999, article in the JAMA addressed hospital reporting to the NPDB.
The article, which was based on a HRSA funded-study by the University of Washington, examined the variation in clinical privilege reporting, the changes in reporting over time, and the association of hospital characteristics with reporting. The study looked at 4,743 hospitals between 1991 and 1995; the majority of the hospitals were non-governmental, not-for-profit, and accredited by the Joint Commission; they were equally distributed between urban and rural hospitals. The study, which found evidence of a low and declining level of reporting, noted the following:.
About a third of the hospitals (34.2 percent) reported at least one action over the study period. The range of the privileges action rates for individual hospitals that had taken actions was between 0.40 and 52.27 per 100,000 admissions.
The overall privileges action rate for the study hospitals in aggregate was 2.36 per 100,000 admissions. Urban hospitals and hospitals accredited by the Joint Commission were more likely to have reported one or more privileges actions and had higher rates of reported actions per 100,000 admissions than their counterparts for nearly all bed size categories. State and local hospitals were least likely to have reported. The majority of hospitals that were members of the Council of Teaching Hospitals of the American Association of Medical Colleges, and had bed sizes of 300 or more, had lower rates of reporting than non-member hospitals. There were significant regional differences in privilege action reporting. Hospitals in the east south Central region, such as Alabama, Kentucky, Mississippi and Tennessee, had some of the lowest reporting rates. Importance of Hospital Reporting For State Licensure Board Actions The OIG report noted earlier found that, during the period of the OIG review, 1990 – 1993, hospitals reported about 3,154 practitioners to the NPDB.
During the same time period, state medical boards took disciplinary actions against about 8,000 physicians. The OIG notes “these numbers are not directly comparable, but the discrepancy is sufficiently large to raise legitimate questions about whether hospitals are being sufficiently rigorous in taking adverse actions against practitioners on their staffs.” A similar observation was made in the July 1999 JAMA article, which noted that “there were nearly three times the number of licensing actions than privileges actions over the study period. In addition, licensing actions increased between 1991 and 1995, while privileges actions decreased.” Every year HRSA calculates a ratio comparing the sum of adverse action reports for both hospitals and managed care organizations to adverse licensure reports for in-state physicians. According to HRSA data, during the seventeen-plus year history of the NPDB, state licensure adverse action reports have been more than double the number of adverse (hospital and HMO) clinical privilege reports: 32,748 vs.
From state to state, the ratio of adverse clinical privilege reports to adverse licensure action reports range from a low of one clinical privilege report for every five state licensure actions in Colorado and Connecticut to a high of 1.51 clinical privilege reports in Hawaii for every adverse licensure action report. According to HRSA, “While these ratios reflect variations in the reporting of both State licensure actions and clinical privileges actions, the extreme variation from State to State is instructive. It seems likely that the extent of the observed differences may at least in part reflect variations in willingness of hospitals and medical boards to take actions rather than a substantial difference in the conduct or competence of the physicians practicing in various States.” This is reinforced by the lack of evidence that the overall quality of physician practice varies from one state to another.
A 1999 article in the American Journal of Law and Medicine makes a point about the role of hospital peer review and its relationship to state licensing boards: The peer review system should address problems of physicians before they impact a physician’s license to practice medicine. Notwithstanding the differences between what the hospital peer review system is designed to accomplish and the state physician licensing system, the significantly higher rate of state actions raises the question of whether hospital peer review is taking place at an adequate level. From the perspective of state medical licensure boards, hospital reports are an important source of data for regulatory oversight. Results of a Citizen Advocacy Center (CAC) survey on hospital reporting highlighted the importance of hospital reports to state medical boards:.
Several medical boards emphasized the high quality of the information in hospital reports. Boards value hospital reports because they are based on peer investigation and review. Because hospitals are so concerned about being sued by doctors against whom they take clinical privilege actions, when a hospital does report, there is substantial evidence of a serious problem. The acting director of the Office of Professional and Medical Conduct in New York State said that 31 percent of the facility reports her board receives have led to charges of misconduct or surrender of license. This means that nearly one in three mandatory reports results in the board opening a disciplinary action. In many states, fewer than 10 percent of consumer complaints lead to disciplinary action. The executive director of the Arizona board indicated that while only 2 percent of the complaints received by his board in 1995 were from hospital mandatory reports, 66 percent of these had to do with quality of care (as opposed to 54 percent of complaints from all sources) and 17 percent of hospital reports ultimately led to discipline and 11 percent to stipulated limitations on practice, as opposed to 2 percent and 5 percent complaints from all sources.
Representative responses to the CAC survey included:. ‘This information would be kept confidential from the board if not for mandatory reporting laws.’. ‘The mandatory reports provide useful ‘leads’ for the Board about the possibility of substandard practice which otherwise may not be known. The Board would never receive the information without mandatory reporting.’ CAC also asked boards about oversight of state hospital reporting laws. “Many state medical boards replied that they had no jurisdiction over hospitals.
While their state statute may require a hospital to report adverse actions to the medical board, actual enforcement authority is usually the responsibility of another state office, such as the agency that licenses hospitals.” Under-reporting of hospital privilege sanctions deprives state regulators and other users of the NPDB of critical information. To help increase hospital reporting, CAC, in collaboration with the Administrators in Medicine, an organization composed of the Executive Directors of State Medical Boards, wrote and issued a Model Act in March 1999 that addressed hospital reporting to state boards. The AHA and hospital legal representatives should educate their hospital members and clients, as soon as practical, on the effectiveness of legal protections under the Health Care Quality Improvement Act’s immunity protections, as them have been interpreted by most courts.
Source: Conference Facilitator, Oct. 1996, National Conference on Hospital Reporting to the NPDB Status: The American Hospital Association (AHA) could not find any record of an AHA response to this recommendation. The AHA advised Public Citizen Health Research Group that “Based on the information currently available we do not know how AHA may have responded to the report”.
The American Medical Association and physician legal representatives should educate their physician members and clients, as soon as practicable, on the effectiveness of legal protections under the Health Care Quality Improvement Act’s immunity provisions. Source: Conference Facilitator, October 1996, National Conference on Hospital Reporting to the NPDB Status: The AMA provided Public Citizen Health Research Group a list of three NPDB links from the AMA web site. Although two of the web links, which contain duplicative wording, describe the statutory protection for “medical peer review,” the links do not address the conference recommendation asking the AMA to advise members about the effectiveness of such protections.
HRSA should seek legislative authority and funding for conducting compliance reviews of clinical privilege reporting, including authority to access peer review records. Source: PricewaterhouseCoopers LLP, Nov. 15, 2002 Status: No action taken. Public Citizen Health Research Group Recommendations A.
HRSA and CMS should work together to achieve a regulatory and statutory change so that the Medicare conditions of participation specifies hospitals’ reporting responsibilities under the Health Care Quality Improvement Act. The 1995 OIG report recommended such a regulatory and statutory change. The OIG noted that “this inclusion would compel the Joint Commission to devote greater oversight to hospitals’ performance of the responsibilities.” Also, since the Medicare Improvements for Patients and Providers Act of 2008 allows organizations other than the Joint Commission to conduct accreditation reviews, our recommendation would impact all hospital accreditation organizations. CMS should require that the standards for compliance with the Medicare conditions of participation include all aspects of peer review. Events at Redding Medical Center demonstrate that ineffective or non-existent peer can affect patient safety. Currently, a violation of an element of a Medicare Condition of Participation is not sufficient to rule the entire Condition violated. According to CMS, partial compliance is good enough.
Although one critical element, peer review for cardiac services, remained in non-compliance, Redding was still accredited. Congress should provide CMS with the authority to impose sanctions on hospitals and physicians for failure to perform peer review. For hospital departments where peer review is absent, CMS should stop payment for selective services in such departments. Congress should amend the Health Care Quality Improvement Act to impose a civil money penalty for failure to report. Research has shown that states with financial penalties for failure to report have higher levels of hospital reporting to the NPDB. The “Model Act” developed by CAC and the Administrators in Medicine recommends a penalty of $1,000 per day per unreported adverse action. Even the Joint Commission believes that a strong penalty provision would likely encourage reporting.
Furthermore, a July 1999 Inspector General Report recommended a civil money penalty of up to $10,000 or each instance of non-compliance. In response to the OIG recommendation, HRSA developed a legislative proposal that would have created a $25,000 civil monetary penalty for failure to report. As noted in the body of this report, HHS did not approve the HRSA proposal. Congress should amend the Act to authorize a civil money penalty of up to $25,000 for each instance of a hospital or other health care entity’s (e.g. HMO) failure to report an adverse action to the National Practitioner Data Bank. HRSA should also seek legislative authority for conducting compliance reviews of clinical privilege reporting, including authority to access peer review records.
In 2002, HRSA contracted with PricewaterhouseCoopers LLP (PwC) to establish a pilot assessment of the extent of hospital non-compliance with NPDB reporting. The assessment was to use the voluntary cooperation of hospitals. As noted earlier, the study could not be conducted because of the failure of the sample hospitals to cooperate. We support the PwC recommendation to HRSA that the agency seek legislative authority for HRSA to access peer review records for the purpose of assessing the level of clinical privileges compliance reporting. The Office of Inspector General should review hospital practices relating to granting and renewing privileges.
When a hospital grants privileges to a physician, the institution has evaluated the physician’s education and experience and determined that physician can perform within a specified scope of practice. This peer review, which takes place at the time of hiring and periodically thereafter, is critical to assuring that the practitioner has the necessary knowledge and skills to provide patient care within the designated scope of practice. Unfortunately, there are numerous examples of physicians who provided questionable and/or unnecessary care.
There is also evidence that Joint Commission surveys do not go far enough in evaluating hospital privileging activities. According to the Medicare Conditions of Participation, hospitals must ensure that all patient care is provided in accordance with medical staff criteria for the granting and renewing of privileges. Although OIG has reviewed credentialing and privileging activities at HHS funded hospitals, i.e. At Indian Health Service facilities, OIG has apparently not focused on “private sector” hospitals.
The OIG should investigate non-federal hospitals’ compliance with the Medicare Conditions of Participation relating to medical staff privileges. HRSA should initiate educational and compliance activities involving hospitals that have not reported.
As a first step, HRSA should send letters to all hospitals reiterating reporting responsibilities, asking if they understand the reporting requirement and expressing a willingness to discuss their concerns in a confidential manner. A copy of the letter should be shared with Public Citizen and other members of the National Practitioner Data Bank Executive Committee. At the end of six months, HRSA should identify those hospitals that still have not reported and refer them to the OIG for follow-up. HHS should implement specific recommendations from the 1996 Chicago National Conference on Under-Reporting.
The conference recommended that HRSA study the problem further, possibly through case studies. As soon as possible, HRSA should address the issue of “peer review immunity.” Notwithstanding the peer review immunity protection afforded by NPDB legislation, hospitals apparently remain concerned about lawsuits. HRSA should update the survey of court decisions that was prepared for the October 1996 national conference in Chicago. As noted earlier, the survey concluded that the immunity provisions of the Act were protecting professional review activities in the vast amount of cases. HRSA should make results of the updated survey available to the AHA and AMA to share with the hospital and medical community, respectively. The 1996 national conference recommended that the Joint Commission make reporting by hospitals of adverse actions taken against hospital privileges a specific point of review. Following the national conference, HRSA and CMS wrote the Joint Commission asking for assistance.
Playstation 2 ps3 virtual memory card save zip north. To date, the Joint Commission has not taken steps to include hospital reporting in its accreditation surveys. The Joint Commission should amend its standards to incorporate compliance with NPDB reporting. State medical boards should request their respective state legislatures to adopt those provisions of the CAC model act that have the potential to increase reporting. Strong state laws (such as monetary penalties) and enforcement activities have the potential to improve hospital reporting to the NPDB.
State medical boards and HRSA should work together to facilitate reporting to the NPDB. According to the Citizen Advocacy Center, “a number of states report that they frequently visit with hospital executives on their responsibilities under state mandatory reporting laws.” CAC recommended, and Public Citizen agrees, that HRSA staff should explore with state officials the feasibility of including hospitals responsibilities to report to the NPDB as part of these “educational” visits. Congress should provide the Office of Inspector General, HHS, with authority to review state medical boards’ handling of adverse clinical privilege reports. The value of hospital mandatory reports is clear. This raises the question of how to explain the fact that 952 physicians with two or more clinical privilege reports in the NPDB had no disciplinary action imposed by a licensing board.
Until 1993, the OIG at HHS conducted evaluations of the performance of state medical boards. However, because of legal concerns involving OIG authority to conduct reviews of state health professional licensing boards, OIG no longer considers performing such studies.
OIG believes that since state health professional boards do not receive HHS funding, it has no authority to focus on state medical boards. However, these boards regulate the practitioners who provide medical services to millions of Medicare and Medicaid beneficiaries. Therefore, Congress should give OIG the authority to conduct such reviews. Hospital compliance officers should monitor hospital peer review and reporting to the NPDB.
Hospital Compliance Programs have their origin in the Federal Sentencing Guidelines of 1987 (Guidelines). On May 1, 1991, the Guidelines, which had focused only on the behavior of individuals, were broadened to include “organizations.” The organizational guidelines “provide incentives for far reaching compliance programs and have produced a new occupation that advises organizations on how to build effective programs that promote ethical behavior. Furthermore, by promoting compliance and ethics programs, the organizational guidelines not only provide incentives for substantial changes in organizational behavior, but also further some of the main goals of the Sentencing Reform Act: the prevention and deterrence of criminal conduct.” On February 23, 1998, the OIG, HHS, issued a guidance entitled “Compliance Program Guidance for Hospitals.” This guidance covers quality of care and financial risk areas. According to Strategic Management Systems, a consulting company to hospitals on compliance issues, there are four elements of the quality of care risk area: accuracy of quality-reporting data; medically unnecessary services; deficient care (failure to meet accepted standards of care) and, practitioner qualifications. The Health Care Compliance Association (HCCA) is a national non-profit professional membership organization made up of health care compliance and ethics professionals. According to HCCA, it has approximately 6,000 members.
Many of these compliance and ethics professionals work in hospitals while others work for health care organizations such as health plans and nursing homes. Hospital compliance officers are in the unique position of independence from medical and management staff. Compliance officers should therefore monitor hospital peer review, including sitting in on such reviews, and evaluate hospitals compliance with NPDB reporting law. To achieve this, we specifically recommend the following:.
HRSA and the Health Care Compliance Association should work together in publicizing the NPDB reporting requirement through joint letters, webinars, and other training opportunities. The Health Care Compliance Association should include NPDB reporting in its agenda for national and regional conferences. The OIG should consider revising the Feb. 23, 1998 Compliance Guidance for Hospitals to include hospital peer review and NPDB reporting as risk areas. The Office of Inspector General, HHS, should use corporate integrity agreements to assure hospital compliance with NPDB reporting requirements. OIG often negotiates compliance obligations with health care providers including hospitals as part of a settlement of federal health care program investigations arising from a variety of civil false claim statutes.
A provider consents to these obligations as part of the civil settlement and in exchange to the OIG’s agreement not to seek an exclusion from Medicare or Medicaid or other federal health care programs. There are currently over 400 corporate integrity agreements and related agreements posted on the OIG web site. These agreements encompass both quality of care and/or financial issues. The agreements require the hospital to establish a program to monitor corrective action and compliance.
One such agreement notes: Hospital Corporation ‘A’ has established, and shall maintain during the term of the CIA, a Clinical Quality Department for monitoring clinical quality at Hospital A’s hospitals, including the credentialing, privileging, and peer review programs.” Currently OIG does not require hospital compliance programs to assure compliance with the NPDB reporting requirement. OIG should include compliance with NPDB reporting as part of future hospital Corporate Integrity Agreements.
Appendices Appendix A: Total Number of Adverse Hospital Privileges Reports by Year - Source: Unpublished HRSA data Appendix B: Current Active Registered Non-Federal Hospitals That Have Never Reported to the National Practitioner Data Bank by State, September 1, 1990 - December 31, 2007, Source: Unpublished HRSA Data.
Consumers Union’s Safe Patient Project calling for public access to information in the National Practitioners Data Bank (NPDB), a federal agency that collects information on problem doctors with a history of sanctions by state medical boards and hospitals and lawsuit payouts for harming patients. A Consumer Reports national poll found that almost 9 in 10 Americans (88%) said the public should have access to federally collected information about problems with doctors. Under pressure, the HHS restored access to the NPDB’s Public Use Data File last week, which it removed in September after the agency received a complaint from a doctor whose history of malpractice claims was revealed in a newspaper article. Now that the data has been restored, journalists may query the Data Bank, but there are that fly in the face of the meaning of “public information” as it is used in federal law.
But let’s talk about the real problem here: consumers cannot easily find public information about doctors with a history of bad behavior. For example, state medical boards are supposed to keep track of important information on doctors, but when doctors practice in multiple states, one board may not be aware of what another board has done. It is possible for a doctor to lose a license in one state for harming patients and continue to practice in another, leaving innocent patients unaware of the doctor’s prior problems.
And while some states are more transparent than others, overall, state medical boards do a “terrible job protecting patients and informing the public,” according to a The National Practitioner Database is the one place where all of this information is pulled together. If the federal government opened this data to the public, with physicians’ names, it would go a long way towards helping consumers get the information they need when choosing a doctor. Most doctors do not have a history of problems, but consumers have no way of distinguishing those who don’t from those who do.
Hospitals, insurers, state licensing boards and other health care entities have always had full access to the information in the Public Use Data File, including doctors’ names. We think patients should be given the same access – and most Americans agree with us. There is no rational reason for keeping such information secret.
There will never be physician and hospital accountability! There will never be transparency into what goes on behind the closed doors of a physician’s practice!
Too much money and power protects doctors! If you want changes you aren’t going to get it by playing fair–they don’t! Patients must “out” bad doctors some place where it is safe to do so, free of being sued by the doctor they out. A doctor’s gross negligence and unethical practice ruined my life, yet every data base indicates he has never done anything wrong. After expensive legal research it was uncovered that he had been forced out of practice in 4 states, and worked in close to a dozen with no explanation why he left.
Npdb Codes
He is still practicing! I haven’t had a physical in over a decade. I am 45 years old, have double insurance coverage now, have always had good insurance coverage and just want to find a doctor I will feel comfortable going to again. A few bad and/or uncomfortable experiences with 2 male doctors and one aggressive female doctor, (two of which were part of a large group in a city I live near) during and after the time I had my last child in 1994 caused me to slow down and eventually stop going for physicals all together. I do go to a small town clinic for small needs and for my children. I was so sick of being passed off, feeling like I was bothering them.
(I’m a quiet person and never complained – just stopped going).
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