The American Hospital Association was backtracking last week after the release of a potentially damaging letter in which AHA President Richard Davidson told a key congressional committee that hospitals altered the way they discipline physicians to avoid having to report the doctors' actions to the National Practitioner Data Bank.
"We are unaware of hospitals' using alternate methods (to avoid reporting requirements)," said Thomas Nickels, the AHA's senior vice president for federal relations. "Whenever you set a legal standard, that's something that people would adhere to."
Nickels said Davidson's letter should not be interpreted to mean that hospitals skirt the rules.
However, in his letter Davidson told House Commerce Committee Chairman Tom Bliley (R-Va.) that when disciplining physicians, hospitals sometimes use "alternative interventions" such as short-term limitations on privileges or staff supervision. By law, those alternatives do not have to be reported to the databank (See chart).
Davidson's Dec. 13, 1999, letter said: "It is natural that the threshold for reporting to the (databank) may have become a benchmark for addressing more serious situations. Reporting and being reported are viewed as serious actions."
Bliley had asked the AHA, the American Medical Association and HHS whether the databank should be opened to the public, as he is considering a legislative move to open it. Both the AHA and the AMA oppose such a plan.
The AMA did not return calls for comment by deadline. Davidson was also unavailable for comment.
MODERN HEALTHCARE disclosed the content of the AHA's letter to Bliley earlier this month (Jan. 10, p. 2). After the disclosure, the committee made the letter available to the public.
Davidson's letter affirmed what many have long suspected.
Between 1994 and 1999, at least three studies found that many hospitals were not reporting adverse actions to the databank. Among those were a 1995 study by HHS' inspector general's office and a study published last July in the Journal of the American Medical Association (Aug. 9, 1999, p. 46).
The third study, published in October 1994 by the American Journal of Public Health, took the findings a step further: Twenty percent of 144 Northwest hospitals surveyed reported changing the way they discipline physicians to avoid reporting to the databank.
In a July 21, 1999, memorandum, HHS Inspector General June Gibbs Brown cited the three studies as evidence that tougher penalties could coerce hospitals into reporting more adverse actions.
The government can do little to enforce the reporting requirements, said Thomas Croft, director of the division of quality assurance at the Health Resources and Services Administration, which runs the databank.
"Frankly, the only thing we can do now is ask," Croft said. "It's not that the system is not working, but there are some issues still there. It isn't clear to us that granting immunity has made a difference (in the willingness to report)."
The Health Care Quality Improvement Act of 1986 called for the databank's creation and established the reporting and querying requirements. The law granted hospitals antitrust immunity for good-faith peer review in exchange for reporting to the databank.
Hospitals receive only a slap on the wrist if they dodge their reporting requirements. That includes sanctions from the Joint Commission on Accreditation of Healthcare Organizations, which requires accredited hospitals to report. At most, the JCAHO issues a recommendation for improvement to a hospital that has not complied with either the querying or reporting requirements of the databank.
The inspector general has recommended civil monetary penalties for hospitals that do not comply with the Health Care Quality Improvement Act. The HRSA has not made a final decision on that recommendation.
Despite the 1994 study, Nickels said evidence that hospitals avoid the reporting requirements is "clearly lacking."
"That study is six years old," he said.
The AHA has not produced evidence to the contrary, however. The association said in its letter that it has not surveyed its members about their compliance with or avoidance of the reporting requirements.
If the AHA were asked to perform such a survey, "it's clearly something we would look into," Nickels said. "But it hasn't risen to that level of concern."
Disclosure of the AHA's letter comes at a politically sensitive time for the nation's largest hospital trade group.
In late November, an Institute of Medicine report called for the mandatory reporting of medical errors to a national center for patient safety (Dec. 13, 1999, p. 3). President Clinton and members of Congress quickly vowed to investigate the matter and legislate changes if necessary.
Sen. Ron Wyden (D-Ore.), who as a House member ardently supported opening the National Practitioner Data Bank to the public, is also exploring the relationship between the databank and the reduction of medical errors.
"The healthcare marketplace has changed a lot since 1990, and he feels that in light of that and of the IOM report, the issue warrants additional review," a Wyden spokeswoman said.
The AHA and other hospital groups also plan to ask Congress this year for more relief from Medicare spending reductions included in the Balanced Budget Act of 1997 (Jan. 10, p. 3).