Data bank: Risk managers say it is not as helpful or threatening as hoped

Reliable? Hardly, critics say

The National Practitioner Data Bank (NPDB) was hailed as a step forward in monitoring doctors’ errors, but also feared as a central source for information that could be used against health care providers by plaintiffs and regulators. Now it appears neither of those may come to pass. The problem, some say, is that the data bank has little data that could be used either for good or bad. A new report from the government says 84% of managed care organizations have never reported an adverse action against a health care practitioner to the data bank.

In its critical report, the Health and Human Services’ (HHS) Office of Inspector General (OIG) concludes that the low rate of reporting to the NPDB raises a broader concern about patient safety and underscores the importance of hospitals, physician groups, and state licensure boards in reporting doctors who pose a threat to patients. The OIG says many health plans rarely report to the data bank because they devote little attention to clinical oversight. That, in turn, is blamed in part on their heavy use of contracted panels of physicians, rather than salaried doctors, to perform those duties.

Health plans also depend on hospitals, physician group practices, and state licensure boards to monitor and report questionable physicians, a system the OIG says may be ineffective. The American Association of Health Plans responded to the OIG report with its own written report that insists health plans do identify quality problems and take action. However, the association points out that many situations require further review by medical groups, hospitals, and medical boards, so the health plan does not report the physician.

The OIG report is the latest criticism of the NPDB, but certainly not the first. Physicians’ groups have criticized the NPDB since its inception and now say the report illustrates a weakness of the system.

"The OIG report confirmed what we’ve been saying all along about the NPDB — that it’s flawed, incomplete, and it’s not reliable," says Robert Mills, a spokesman for the American Medical Association (AMA) in Chicago. He says the group has opposed the NPDB for years because it provides an incomplete picture of disciplinary action and other incidents. An earlier report from the General Accounting Office (GAO) reached a conclusion similar to that of the OIG, saying, "While the National Practitioner Data Bank is presently the nation’s only central source of medical malpractice payment information, it is not clear that all such data are being properly reported."

The Nov. 17, 2000, report goes on to say that "while GAO sampled one month’s submissions, its review suggests that NPDB information may not be as accurate, complete, or as timely as it should be. Inaccuracies in the way reported information was coded could confuse or mislead querying organizations about the severity of actions taken against practitioners. Additionally, duplicate reports overstate the amount of information the NPDB has on a particular practitioner."

Thomas R. Reardon, MD, AMA immediate past president, says the government reports confirm the AMA’s view that the NPDB is "seriously flawed." He says the data bank is "riddled with duplicate entries, inaccurate data, and incomplete and inappropriate information. In addition, many of the medical malpractice citations name the patient as well as the practitioner — raising a serious red flag regarding patient privacy." He adds that the NPDB "is clearly struggling to fulfill its mandate."

Federal law requires hospitals and health plans to inform the government of any disciplinary action taken against a physician for incompetence or misconduct. The OIG report, however, reveals that over the past 10 years 84% of health plans and 60% of hospitals have never reported even a single adverse action. The OIG notes that this finding is particularly surprising in the wake of the recent furor over medical errors, in which research suggested that tens of thousands of people die each year from errors and at least some are attributable to doctors’ mistakes.

The OIG report is the result of an 18-month study. Between 1990 and 1999, health plans reported only 715 adverse actions, even though the plans became the dominant form of health care during that period, covering 100 million people. Physician groups reported 60 adverse events. (See "Are the data bank’s big numbers useful?" in this issue for a summary of what information now is in the data bank.)

The NPDB may be less useful than risk managers had originally hoped, but it also appears to be less threatening than they feared, says John Metcalfe, JD, BA, FASHRM, director of risk management services at Memorial Health Services in Long Beach, CA. "There were a lot of fears surrounding the data bank when it first started out, with people wondering how all that information would be used and how plaintiffs’ attorneys might get hold of it. People were afraid it would turn into a witch hunt," he says. "None of those things that we all feared seems to have come to pass. It appears that in terms of the information being used against us in court, that’s not really happening."

However, Metcalfe is familiar with several cases in which physicians have sued the individuals or institutions who reported them to the data bank. He has been asked to serve as an expert witness in those cases but declined. "The data bank does give the physician an opportunity to challenge the information, but if it is not modified then the physician can pursue litigation against those reporting," he says. "I don’t know if that discourages institutions from reporting, but I suppose it could."

Even with that risk, Metcalfe says he thinks of the data bank as largely benign for risk managers. "I look at the data bank as more of a resource for the medical staff office," he says. "It can be helpful in their process of evaluating new medical staff members and re-evaluating medical staff members for reappointment and so forth. But in terms of assisting the risk manager in our everyday activities, it doesn’t provide a very valuable service."

The data bank may be of more use to risk managers whose work includes quality issues more than some of the financial and legal issues. Metcalfe cautions that risk managers who use the data bank should think carefully about what the data really mean. "One problem with the data bank, in my experience, is that some of the best physicians who treat high acuity with the most frequency are at high risk for fallout," he says. "When they have an aberrational outcome, those are the ones that turn into a lawsuit. One of the problems with the data bank is that it doesn’t indicate the best of the physicians. It indicates the worst, but the best might be blemished by the frequency of claims."

Data bank managers unhappy with trends

The NPDB is managed by the Health Resources and Services Administration (HRSA), an HHS agency based in Chantilly, VA. HRSA has made it clear that health care providers are not reporting information as they should. "HRSA continues to be concerned about the low level of clinical privileges actions reported by hospitals and other clinical privileges reporters such as health maintenance organizations," the agency said recently in a public statement. The level of reporting is "unreasonably low. Nationally, over the history of the NPDB, there are 3.9 times more licensure reports than clinical privileges reports. Moreover, 52.5% of the hospitals currently in active’ registered status with the NPDB have never submitted a clinical privileges report. Clinical privileges reporting seems to be concentrated in a few facilities even in states which have comparatively high overall clinical privileging reporting levels."

Kay Garvey, a spokeswoman for the HHS, tells Healthcare Risk Management that the OIG report could lead to changes in how the database is managed. HHS is preparing a formal response to the OIG conclusions, but Garvey says it is clear that information is not being reported to the data bank in the way the HHS intends. "I think the folks who have been using it so far have found it reliable, but we will be looking at ways to improve the information in the data bank and how that information is obtained," Garvey says. "The data bank is only as good as the information in it, so we are interested in improving the data collection if that’s possible."