Study Questions Database That Tracks Disciplined Doctors

The number of disciplinary actions taken by the nation’s hospitals against physicians has declined during the last decade, raising questions about the adequacy of information in the national computerized databank that hospitals and health plans rely on for information about doctors’ records, researchers reported last week in the Journal of the American Medical Assn.

Results of the study, conducted by researchers from the University of Washington and the federal Bureau of Health Professions, underscore growing concern among patient advocates and federal health officials about the utility of the National Practitioner Data Bank.

Launched in 1990, the databank is designed to create a permanent paper trail of malpractice payments and disciplinary actions against physicians, thereby preventing bad doctors from moving from hospital to hospital or state to state with impunity.

The study is the latest indication that the databank may have unintended consequences as some doctors seek to evade scrutiny. A 1995 report by the inspector general of the Department of Health and Human Services found that underreporting to the databank appears to be a serious problem.

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Since the databank began operating in 1991, “physicians have become totally intransigent about settling a case in a reasonable way,” said Roger A. Rosenblatt, a physician at the University of Washington and coauthor of the JAMA study. “Its existence has transformed physician behavior. The contortions people go through to stay out of the databank are truly stunning.”

Federal law requires that hospitals and health plans query the databank before granting a doctor privileges and every two years after that. The databank is closed to consumers at the insistence of the American Medical Assn. The AMA, the nation’s largest and most powerful physicians’ group, has long argued that patients would misinterpret malpractice information in the databank because even good doctors get sued. Currently the databank has files on more than 130,000 physicians, about 20% of the nation’s doctors.

Besides malpractice payments, the databank contains reports of disciplinary actions taken by hospitals, professional societies and state medical boards. Hospitals must notify the databank if a doctor’s privileges are revoked, surrendered or suspended for more than 30 days. Suspensions of less than 30 days are not reportable.

As a result, hospital officials and patient advocates say, a growing number of hospitals impose 29-day suspensions and other penalties that needn’t be reported.

To gauge the databank’s impact on hospital disciplinary actions, Rosenblatt, Dr. Laura-Mae Baldwin of the University of Washington and their colleagues examined all reports of actions taken to restrict privileges between 1991 and 1995.

They found that about 75% of 4,743 hospitals reported taking no actions against any doctor over a three-year period. Baldwin’s team also reported that the percentage of hospitals taking at least one action affecting privileges decreased from 11.6% in 1991 to 10% in 1995.

That decline has continued, according to officials at the Health Resources and Services Administration, which oversees the databank. HRSA officials said that in 1997, 950 suspensions of doctors’ privileges were reported to the databank, a number that dropped to 800 in 1998.

Those numbers are far below initial projections. Based on estimates by the American Hospital Assn., databank officials expected to receive about 14,000 reports of suspensions or other hospital disciplinary actions annually.

Mary Grealy, chief Washington counsel to the AHA, said she does not regard the decline documented in the study as dramatic, and that the source of the initial projections was not clear.

“I think we have to remember that hospitals’ taking adverse action [against a doctor] is very, very serious,” she said. “We look for a variety of ways to work with physicians to improve the quality of care.”

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Querying the databank is not the only way hospitals check a doctor’s record, Grealy said. “There are a lot of other checks and balances in place.”

Baldwin said her team discovered significant variation among hospitals. Rural hospitals were more likely than urban hospitals to have no disciplinary actions to report. So were hospitals in the South and the 269 institutions--all of them academic medical centers--that comprise the Council of Teaching Hospitals for the Assn. of American Medical Colleges.

Hospitals in the three states--California, New Jersey and West Virginia--that impose fines of more than $5,000 for failing to report actions on privileges to state medical boards had significantly higher rates of reporting to the databank than states without such laws, the researchers found.

Although this study did not go into it, there are several ways a doctor’s missteps may not be reported to the databank.

The most common is known as “the corporate shield.” Under the 1986 law that created the databank, payments made by doctors to settle malpractice cases must be reported. But payments made by health plans, professional corporations, group practices or hospitals do not need to be reported.

Plaintiffs’ lawyers say that as a condition of settlement, a doctor often insists on being dismissed as a defendant in a lawsuit, thereby avoiding a databank report. Hospitals, which are often named as co-defendants, typically accede to such requests to minimize the unwanted publicity that results when a claim goes to trial.

The Department of Health and Human Services has proposed regulations that would close the corporate shield by requiring that the name of a doctor whose action was the basis of a paid claim be reported to the databank.