A federal program to protect patients from incompetent doctors is failing because health maintenance organizations and hospitals rarely report those doctors to the government as they are required to do, federal investigators say.
Under federal law, H.M.O.’s and hospitals are supposed to inform the government of any disciplinary actions taken against doctors for incompetence or misconduct.
But in the last decade, 84 percent of H.M.O.’s and 60 percent of hospitals never reported a single “adverse action” to the government, a report by the inspector general of the Department of Health and Human Services said.
This low level of reporting occurred even though a government study found that tens of thousands of Americans die each year because of medical errors.
Information on incompetent doctors is included in a computer system known as the National Practitioner Data Bank, created by Congress to protect patients against doctors who move from state to state without disclosing that they have been censured or disciplined in some way for providing poor care.
But, the report, based on an 18- month study, said that from 1990 to 1999, while managed care became the dominant form of health care in the United States, covering more than 100 million Americans, H.M.O.’s “reported only 715 adverse actions.”
Officials offered these examples of incompetence and misconduct: performing surgery on the wrong side of a patient’s body; providing a fatal overdose of drugs; performing unnecessary surgery; engaging in sexual relations with patients; prescribing narcotics for the doctors’ own use; repeatedly billing Medicaid for services never provided.
The inspector general’s explanation was stark. In a market more concerned about price than quality, the report said, H.M.O.’s have evolved into “bill-paying organizations,” and managed care plans “often have little incentive to devote many resources to quality assessment and improvement.”
Carmella Bocchino, vice president of the American Association of Health Plans, said many H.M.O.’s apparently did not realize they were required to tell the government when doctors were disciplined for incompetence or misconduct.
But Margaret E. O’Kane, president of the National Committee for Quality Assurance, which evaluates and accredits health plans, said, “Health plans are very nervous about reporting to the databank because they are afraid of being sued by doctors.”
Sometimes, some H.M.O. executives said, they work out quiet deals with inept doctors. Under such arrangements, a doctor resigns from a health plan, and in return the health plan promises not to file a report with the federal databank.
Senator Ron Wyden, Democrat of Oregon, the author of the 1986 law that created the National Practitioner Data Bank, said the low level of reporting was unacceptable.
“The inspector general’s study sounds an alarm bell,” Mr. Wyden said in an interview. “The databank is only as good as the information that goes into it. Health plans ought to do more than just pay lip service to the goal of quality in health care.”
The databank is for the use of hospital and other health care providers and federal law prohibits it from disclosing information on a specific doctor to the general public. Federal investigators said H.M.O.’s and hospitals frequently consulted the national databank to check on doctors’ qualifications, but rarely contributed any information of their own. In the last 10 years, managed care organizations submitted more than eight million inquiries, accounting for about half of all queries.
Discussion of the databank is part of a larger debate over medical errors and the quality of care. In November 1999, the National Academy of Sciences estimated that 44,000 to 98,000 Americans died each year as a result of medical errors, and it called for “a nationwide mandatory reporting system” to help health care providers learn from their mistakes.
Many H.M.O.’s have adopted clinical guidelines to ensure that doctors follow the best practices for diagnosing or treating specific conditions. And Karen M. Ignagni, president of the American Association of Health Plans, said that if the government did more to make H.M.O.’s aware of their obligations, those organizations would take “whatever steps are needed to comply with federal law and regulations.”
But the inspector general found that most H.M.O.’s did relatively little to monitor and assess the quality of care, or to protect patients from “poorly performing practitioners.”
H.M.O’s assume that hospitals and physician groups will evaluate the quality of care and report incompetent doctors, but that assumption is often unjustified, the report said.
“Hospitals find it difficult to hold individual practitioners responsible for poor care,” and they often perform only a cursory review of doctors’ qualifications when deciding whether to grant clinical privileges, the study said. From 1990 to 1999, physician groups reported 60 “adverse actions” to the national databank.
H.M.O.’s and hospitals cannot be sued for errors they investigate and properly report. But if they fail to report discipline involving those errors, the government may remove the legal protections, a penalty that is rarely invoked.
Doctors evaluate colleagues in a peer review process. But the report said that because of concerns about liability, hospitals, physician groups and H.M.O.’s “are reluctant to share information about the performance of individual practitioners.”
Senator Wyden said consumers ought to have access to information in the databank about flagrant misconduct by doctors. But doctors and hospitals say such disclosures would make it impossible to discuss errors and misconduct candidly in the rigorous peer review process because of the fears of lawsuits.
State medical boards license and discipline doctors, but they differ in how aggressively they investigate questionable doctors and in how much information they make available to the public or the databank.