Only about 16% of America's managed-care organizations have ever reported an adverse action against a physician to the National Practitioner Data Bank, raising concerns by federal investigators that health plans may be ignoring the law.
But industry officials attribute the low level of reporting to uncertainty about the law, not to a deliberate effort to withhold information or sidestep regulation. They believe federal guidelines require managed-care organizations to report adverse actions to state licensing boards, which then pass the information to the national databank.
Last year, the number of disciplinary actions state medical boards took against physicians topped 4,600 (See chart).
"There is confusion about the original regulation," said Carmella Bocchino, vice president of medical affairs at the American Association of Health Plans, a Washington-based trade group that represents more than 1,000 health plans. "Many of the health plans believe, as we do, that health plans were directed to report adverse events to the state licensing boards, which were then to report to the National Practitioner Data Bank."
In a letter sent days before the release of HHS' report on the policing of adverse events, Karen Ignagni, the AAHP's president, asked HHS' inspector general's office to clarify the confusion.
"To our knowledge," she wrote, "health plans have not been notified of any regulatory requirements" involving direct reporting to the national databank. The AAHP said it has yet to receive a reply.
The inspector general's report represented a comprehensive effort to detail how managed-care organizations police the physicians and dentists who make up their networks. In a nine-year span ending Sept. 30, 1999, a time when managed care grew to provide healthcare benefits to more than 100 million Americans, managed-care organizations reported 715 adverse actions to the national databank, the report said.
Managed-care organizations are required to query the databank before adding a physician to their provider roster. In most cases, according to written comments from HHS, many managed-care organizations wishing to rid themselves of poorly performing physicians simply "terminate without cause."
"(Managed-care organizations) do little to contribute to (the databank's) usefulness as a credentialing resource either for themselves or for others who look to the databank as a patient-protection tool," the report said.
The report said only 225 of the 1,401 managed-care organizations registered with the databank reported an adverse action affecting the clinical privileges of a physician or dentist during that nine-year period.
Officials at the Health Resources and Services Administration, which oversees the databank, acknowledge that there is some confusion between HHS regulations and a national databank "guidebook." But a spokeswoman for the HRSA said, "(Managed-care organizations) must report to the databank and send a copy of the report to the state licensing board. It's the (National Practitioner Data Bank) guidebook they must follow, which fulfills the intent of the law."
Officials with managed-care organizations also said that hospitals, group practices and state boards are in a better position to identify questionable practitioners. They said they rely on the privileging functions of hospitals as a check on the competency of practitioners.
In some cases, when health plans raise quality concerns to hospitals or medical groups, any adverse action arising from that alert is supposed to be reported to the national databank by the investigating agencies, not by the health plans, according to the AAHP's four-page letter.
The report, however, noted that hospitals don't have much higher rates of reporting adverse actions. In fact, when the inspector general's office made a similar inquiry of disciplinary reports six years ago, the agency discovered that nearly 75% of all the hospitals in the country had never reported an adverse action to the databank from Sept. 1, 1990, to Dec. 31, 1993.
Despite a national conference on the issue and a second study that more closely examined hospital reporting, the situation wasn't much better at the end of the decade, the inspector general's report said. By that time, about 60% of all the hospitals in the country still had never reported an adverse event.
Last year, when Congress was considering opening the databank to public inspection, American Hospital Association President Richard Davidson acknowledged that many hospitals have altered the way they discipline physicians to avoid reporting adverse actions. In a letter to a House committee, Davidson acknowledged that hospitals sometimes use "alternative interventions" that sidestep reporting regulations.
The inspector general's report said, "We know from our prior studies and from the healthcare literature that there is ample basis for questioning how well (hospitals, physician-practice groups and state licensing boards) protect patients from those few practitioners who can be dangerous."