With clinicians and hospital administrators strained by the COVID-19 pandemic, some are raising questions about whether oversight of clinician quality and performance is falling through the cracks.
Emergency actions against physician licenses dropped 59% in April through June compared to the previous year, according to data from the Health Resources and Services Administration (HRSA), which oversees the National Practitioner Data Bank (NPDB).
An analysis of data from the Federation of State Medical Boards (FSMB) Physician Data Center from January to June of this year shows a 14% decline in disciplinary actions.
“A number of factors could contribute to the 14% decline we are seeing,” says Joe Knickrehm, vice president of communications for FSMB. “This could be caused by a significant decrease in the number of in-person physician visits or a decrease in the number of patient complaints to state boards during this time frame. We have been in close contact with our member boards. While their operations were initially impacted early on in the pandemic, they have adapted to mostly all virtual meetings and workflows that have allowed them to continue their work without significant interruption.”
FSMB does not have data on the number of furloughs at state boards, but “we have heard anecdotally that some boards may have been impacted,” Knickrehm says. This could be another contributing factor to the decrease in disciplinary actions.
“The FSMB has always strongly advocated for states to adequately fund their state medical boards in order to ensure their important work of public protection is allowed to move forward without impediment, especially during a global public health crisis,” Knickrehm says.
There has been a significant decline in nonemergent surgeries, imaging, and routine care, which has permeated hospitals during the pandemic, notes Elizabeth L.B. Greene, JD, partner with Mirick O’Connell in Worcester, MA. This decline and the significant changes in hospital-based care during the pandemic have affected the statistics regarding clinician discipline in many states, she says.
That providers have adapted to care in the pandemic over time does not equate to them returning to their prepandemic levels of care, including surgeries, Greene says. She questions any assertion of a correlation between a significant reduction in action by some state licensing boards and a minimal reduction in disciplinary reports from hospitals during the COVID-19 crisis.
The correlation is unclear as hospitals are not the only source of disciplinary reports, Greene notes. Other sources, such as patient complaints, peer complaints, and law enforcement, may have been significantly affected during the pandemic, she says.
There have been backlogs at licensing boards that predate the COVID-19 crisis, and these have persisted. Greene also notes the statistics on disciplined physicians, especially those who lost their licenses, involve small numbers, so the statistical variations are more easily dramatized.
Greene says she does not see cause for alarm, at least not yet. “I suggest one must look at the region, the impact of the pandemic on hospital systems and medical providers in that region, the status of the licensing boards, and the cause of any significant decline in discipline,” she says. “It is difficult to draw analogies between disciplinary actions in the first six months in one year as compared to another when the numbers of providers disciplined are small in most states, and where the conditions have changed so dramatically due to the pandemic.”
Greene says she does not believe there is a reason for patients or hospital administrators to be overly concerned about quality of medical care related to the frequency of disciplinary actions against physicians. It appears the vast majority of the decline in discipline is related to the changes in practice during the pandemic.
The best approach to this issue is to maintain regular oversight of clinicians as much as possible despite any added challenges from the pandemic, Greene suggests.
“Credentialing and risk management professionals will want to continue to perform their routine inquiries when onboarding providers, including obtaining information from the prior hospitals where they practiced. The routine databanks that are queried, including but not limited to the NPDB, should be queried,” Greene says. “Addressing quality issues continues to be important, regardless of the pandemic, when staffing permits. Hospital quality leaders will want to continue to attend to patient complaints and incidents. To the extent possible, when there are concerns or issues with a provider, following your routine best practices is advised whenever possible.”
Greg Hammer, MD, a pediatric intensive care physician, pediatric anesthesiologist, and professor at Stanford University Medical Center, says he has heard speculation that hospitals are reluctant to report discipline issues because of a shortage of doctors during the COVID-19 response. He doubts that is true.
“I don’t think there’s any more of a shortage of doctors now compared to five or 10 years ago. Clearly, in New York City, at the height of the COVID problem, there was a shortage of physicians there, and doctors went to help out. But generally, I don’t know of any shortage of doctors in other states where this lack of physician discipline is supposedly a problem,” Hammer says. “During the peak of COVID, I think you had a great deal of inequity in terms of the supply and demand of physicians, and New York had a local shortage. But around this area of California, it was almost the opposite. We stopped doing elective surgeries in February or March, and that cut our surgery schedule to one-quarter of what it is normally.”
(Editor’s Note: A January 2019 poll conducted by the California Health Care Foundation revealed one-third of Californians surveyed believed their communities are not staffed with enough primary care physicians or specialists. A 2019 map created by the California Health Care Foundation indicates there is an overall physician shortage in the state, but not every area is the same.)
Similarly, other physicians saw their patient visits drop dramatically as healthcare organizations restricted non-essential appointments, Hammer notes. That substantial drop in workflow for physicians means there were far fewer patient interactions. Hammer surmises that may play a role in the occurrence of fewer disciplinary actions. Fewer interactions with patients means fewer opportunities for discipline problems.
“Additionally, you have a tremendous backup in discipline actions by the state medical boards, which doesn’t have anything to do with COVID. When we see a recent reduction in discipline, we don’t necessarily know that it is a true indicator of what is going on now or in recent months,” Hammer says. “I can believe that state medical boards are understaffed ... but to say that any recent reduction is attributable to COVID might not be substantiated. There are hotbeds for COVID, but I don’t think it accounts for any national decline in reporting.”
Hammer says he is confident hospitals are vigilant about monitoring clinicians and responding appropriately to concerns. But he says there are times when a physician who is bringing in a lot of revenue is treated with kid gloves.
“We had a surgeon who brought a lot of patients to the center ... It’s not that he made mistakes, but he behaved poorly and probably should have been fired long before he was. But he was filling a lot of beds, and it was a profitable enterprise,” Hammer says. “That happens in exceptional cases where you have exceptional revenue to bear. But there is so much emphasis on quality and safety now in hospitals that I don’t think mistakes are being ignored. There’s too much at stake.”
(Editor’s Note: At the time of publication, a request to the National Council of State Boards of Nursing for similar discipline data on nurses remained pending. Hospital Peer Review will work to obtain these data, learn more from the HRSA about the NPDB data referenced in this article, and report an update in an upcoming issue.)
- Elizabeth L.B. Greene, JD, Partner, Mirick O’Connell, Worcester, MA. Phone: (508) 860-1514. Email: firstname.lastname@example.org.
- Greg Hammer, MD, Stanford (CA) University Medical Center. Phone: (650) 723-5495.
- Joe Knickrehm, Vice President, Communications, Federation of State Medical Boards, Washington, DC. Phone: (202) 601-7803.