A new report details how hospitals minimize the discipline of doctors for negligent or unethical behavior to avoid alerting the government to potential dangers and to sustain profits.
By Barbara Holzer
Public Citizen
Between 1992 and 2002, two physicians at Redding Medical Center in Redding, Calif., performed what were unnecessary heart bypass and valve surgeries on hundreds of patients.
Disciplinary actions were never taken against these physicians during this period. It took an FBI raid and investigation sparked by a whistleblowing patient to stop the harm these two doctors were doing.
Patients filed hundreds of lawsuits against the hospital, owned and operated by Tenet Healthcare Corp. Ultimately, Tenet settled with 769 patients for $395 million and with the federal government for $54 million, the largest penalty ever imposed for accusations of billing federal health programs for unnecessary care. The company did not admit any wrongdoing.
This is an extreme example of the breakdown of hospital peer review, but it demonstrates that patients cannot be adequately protected from becoming victims of medical malpractice if hospitals neglect to discipline doctors for incompetent care or inappropriate behavior.
Monitoring doctors has always depended on the presumed integrity of the hospital peer review process, in which a committee of doctors evaluates the work of fellow physicians.
However, that integrity has been seriously eroded, Public Citizen says in a new report, "Hospitals Drop the Ball on Physician Oversight." The report documents a dangerous finding about the health care system in the U.S.:
Hospitals minimize disciplinary actions against doctors for negligent or unethical behavior so they can avoid the need for lengthy suspensions or restrictions, which hospitals are required to report to the federal government.
This very questionable practice helps to preserve a physician's hospital admitting privileges so he can funnel his patients to hospitals, keeping beds filled and hospital profits up.
"Peer-to-peer evaluation in health care has become an unreliable measuring stick for quality," said Dr. Sidney Wolfe, acting president of Public Citizen and director of its Health Research Group. "It's terrible that the public cannot depend on doctors to faithfully monitor and report on the care being provided in hospitals when the issues at stake are nothing short of life and death."
Pulling back the curtain
Public Citizen researcher Al Levine compiled the report, spending more than a year analyzing independent studies and government reports about the National Practitioner Data Bank (NPDB).
"This resource was intended to protect patients from malpractice by doctors who, after being disciplined in one state, could simply go to another state to practice where their records were unknown," Levine said.
Established by the Health Care Quality Improvement Act of 1986, the databank is supposed to be a repository for the nation's hospital reports on disciplined doctors. The legislation requires hospitals and managed care organizations to submit reports to the NPDB about any disciplinary action that adversely affects a physician's hospital privileges for more than 30 days. However, Public Citizen's report reveals that nearly half (49 percent) of U.S. hospitals have never submitted a single report to the databank in the 17 years it has existed.
Non-reporting hospitals are violating federal law and breaking with traditional methods of gauging quality assurance in health care.
"By downplaying mistakes and misbehavior, hospitals have minimized infractions reportable to the NPDB, allowing them to use milder alternatives to handle problems, such as counseling or leaves of absence," Wolfe said.
Checkered reality
Operated by the Health Resources and Services Administration (HRSA), part of the Department of Health and Human Services (HHS), the NPDB was designed to be a searchable resource for hospitals and other medical entities to check practitioners' backgrounds to help them make informed hiring and disciplinary decisions.
Prior to the opening of the NPDB in September 1990, the federal government estimated that 5,000 hospital disciplinary action reports would be submitted annually to the databank. The health care industry put the number at 10,000 yearly reports. However, HRSA data show that the average number of annual reports has been only 650 over 17 years - one-eighth of the government estimate and about one-sixteenth of the industry estimate.
The databank was originally supposed to be accessible to the public, but the American Medical Association and other health care organizations made sure that didn't happen.
"The AMA threatened to use its influence to kill the databank bill back in the 1980s unless it was kept secret from consumers," Wolfe said.
The pretense the association gave was that the public would be confused by the information. Even individual doctors have been prevented from using the NPDB unless they have been reported to it themselves - and they can seek information only from their own files.
It's not brain surgery
The underreporting problem has been well-known for many years, but it has never been comprehensively studied prior to the Public Citizen report, which summarizes the extent to which hospitals have dropped the ball on doctor oversight.
The study offers specific suggestions for making hospital peer review, hospital reporting and hospital oversight more accountable to the public. The leading recommendation: to make all aspects of peer review and compliance with reporting requirements to the NPDB a condition of participation in the Medicare program.
In this time of hotly debated health care reform, the dismal failure of the NPDB must be made a priority.
Wolfe wants HHS Secretary Kathleen Sebelius to stop these hospital scofflaws by taking the necessary steps to compel their long overdue obligation to report to the databank.
In a letter he sent to Sebelius, Wolfe explained that hospitals in states with strong penalties for failure to report disciplined doctors have a better record of reporting disciplinary actions for substandard care.
"The alarm on reporting loopholes was first sounded thirteen years ago and, since then, HHS has done almost nothing to alter this situation," wrote Wolfe.
He asked to meet with Sebelius to discuss ways to improve the process.
"The more difficult task will be adjusting doctors' professional aversion to reporting on colleagues," Wolfe said. "Rather than see it as snitching, they must understand it is a responsibility that makes an important contribution to quality assurance and better patient health care."
Barbara Holzer is Public Citizen's broadcast and marketing manager.
