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PubMedDate not supplied

Malpractice: provider risk or consumer protection?

The National Practitioner Data Bank (NPDB) began operation in September 1990 as a clearinghouse for adverse action, licensure, and malpractice information in an effort to protect consumers and promote quality in health care. This study analyzed 66,107 and 1291 records of payments made for 50,396 physicians and 1218 nurses, respectively, from 1994 through 1998, to describe characteristics, trends, and risk factors of malpractice payment for physicians and nurses. The median payments, more often settlements paid by insurance companies than judgments in courts of law, were higher for physicians than for nurses. Mean payments were higher for residents than for non-resident physicians; median payments for residents were slightly lower than other physicians when adjusted for number of providers included in the payment. On the state level, correlation analyses suggested a significant positive association between the nurse rate of malpractice payments that were made and median per capita income, number of physicians per 1000 residents, and number of attorneys per 1000 residents; analysis revealed a significant negative association between this rate and the percentage of residents residing in rural areas and the number of nurses per 1000 residents. Although findings suggested that payment trends remained stable, there was great regional variation in the risk of malpractice payment for both physicians and nurses. The physician risk ranged from a low of 0.73% per physician per year in Alabama to a high of 3.7% in Wyoming, and the nurse risk ranged from a low of 0% per nurse per year in Vermont to a high of 0.075% in the District of Columbia. If the quality of health care provided by physicians and nurses does not vary geographically in the United States, then such a great discrepancy seems to challenge the notion that the risk of malpractice litigation consistently promotes the quality of health care.

Benchmarking↗

PubMed1990

The Health Care Quality Improvement Act of 1986: its history, provisions, applications and implications.

Congress granted qualified immunity from liability for peer review participation to physicians, osteopaths and dentists, created a national practitioner data bank to track inept, incompetent or unprofessional physicians, and enacted procedural rules for due process, privilege restrictions, and reporting and disbursement of information. The Health Care Quality Improvement Act of 1986 is now in full force, and peer review participants are anxious to cloak themselves with immunity from actions brought by health care professionals. Although its goals are worthy, HCQIA's effects remain to be seen. Serious loopholes appear to exist, warranting close monitoring and possibly early amendment of the Act. Cautious judicial assessment is needed, in order to prevent not only circumvention of the Act's requirements by artful litigants, but also use of the national data bank by health care entities as a pretext for denying privileges and escaping antitrust liability.

Confidentiality↗

PubMed2002

Medical malpractice claims and quality improvement program as viewed by a forensic pathologist.

This is a review article dealing with the half-century evolution of the quality assurance program to improve patient care in the United States. The author attempted to point out some differences in approach to solving the medical error and medical malpractice problems between Japan and the U.S. In the 1970s, an increase in the medical malpractice claims resulted in such high premiums for medical liability insurance that it threatened the healthcare system in the U.S. Urgent legislative remedy, the Medical Injury Compensation Reform Act (MICRA) was put into place in the State of California. This act was the beginning of the definitive quality improvement in our health care system. It was followed by other improvement programs, such as the National Practitioner Data Bank (NPDB) for tracking physicians with malpractice judgments or settlements against them, or who have problems with the medical licensing Board or other impairments. By comparison, in recent years, in Japan, there has been a rash of medical malpractice claims, similar to the situation in the U.S. in the 1970's. The two pronged approach to maintaining and assuring quality health care are: (1) Set standards by inspection and accreditation of hospitals and healthcare facilities and (2) by credentialing and peer review program to assure the competency of the physicians and other healthcare personnel. Clinical medicine has made a major effort in setting up a quality assurance program and so has forensic medicine. Similar approaches have been used in both programs. The current emphasis in forensic medicine is on inspection and accreditation of the medical examiner and coroner's offices by the National Association of Medical Examiners (NAME) and re-certification for the medical license and specialty board and credentialing and peer review activities.

California↗

PubMedDate not supplied

Policy and medical-legal issues in the prescribing of controlled substances.

The physician who prescribes controlled substances is faced with an array of laws, regulatory policies, and professional attitudes about their use. Prescriptions for these scheduled drugs are furthermore monitored by the pharmacists who dispense them. Certain drugs, such as the opioids and the benzodiazepines, are considered so potentially abusive that special programs have been recommended to track the behavior of physician prescribers. Multiple copy programs have been implemented in some states. More recent proposals recommend electronic data transfer (EDT) of pharmacy information to centralized processing points so that misprescribing physicians and doctor-shopping patients can be identified. Regulators concerned about physician behavior and confronted by demands of nonphysicians to prescribe controlled substances may find EDT a good solution. Physicians should be concerned about being censured for misprescribing, because such actions may lead to inclusion in the National Practitioner Data Bank. With all of the regulatory concerns about controlled substances, those physicians who would employ long-term opioid therapy for their chronic pain patients must follow certain basic guidelines to be able to defend themselves against allegations of deviant professional behavior. Such procedures as conducting a history and physical examination, maintaining a written treatment plan, consulting with knowledgeable colleagues, and assessing for addictive behavior can provide the practitioner with safeguards.

Drug Prescriptions↗

PubMed2002

Caring and competency.

The long-term crisis in nursing, particularly in acute care hospitals, is demonstrated in studies on negligence by the Institute of Medicine in To Err is Human: Building a Safer Health System1 and Crossing the Quality Chasm: A New Health System for the 21st Century.2 A review of the nursing literature reflects unclear definitions of competency and its component caring, and no single theory of competency has been adopted from the literature and used in the education of nurses. The American Nurses 2001 Code of Ethics does not resolve this confusion, because it does not correct the individual acts of nursing incompetencies in acute care hospitals. The author defines caring and competency by providing examples of what they are not in examining 200 actual cases of hospital nursing acts of incompetence by nursing discipline. None of these examples of imputed negligence was reported to the National Practitioner Data Bank because the "corporate shield" protected the nurses by not being named in the complaint nor named as part of the settlement against the hospital.A new model of the hospitalist, the nurse hospitalist, is presented to act as a daily teacher and facilitator for hospital nurses based on a curriculum of day-to-day examples of substandard patient care. This nurse specialist is an inpatient generalist advanced practice nurse who is employed by the hospital and reports to the chief nurse executive. The author proposes that this new model of the nurse hospitalist be devoted entirely to collaborating with nurse leaders, educators, charge nurses, and floor nurses throughout disciplines in advancing the competency of nursing. This daily proactive and prospective model of improving nursing performance in a facultative manner offers strategies to mitigate the limitations of the retrospective model of quality control. Total quality improvement practiced retroactively is ineffective. The author recommends no structural change in the institution but an educational agenda by the nurse hospitalist, with hospital administration to assist nurses in a new learning environment.

Clinical Competence↗

PubMed1990

Risk management information for HIV infection.

This article discusses HIV infection in terms of the risk manager's information needs in the health care environment. The malpractice problem, increasing workman's compensation suits, the greater role of the ombudsman, implementation of the National Practitioner Data Bank, and the Joint Commission on Accreditation of Health Care Organizations' (JCAHO) emphasis on clinical excellence are conditions which have given greater importance to the risk manager's position. Included in this article are hedges to retrieve various components of risk management and a select bibliography from AIDSLINE.

Communicable Disease Control↗

PubMed1997

Physicians' experience with allegations of medical malpractice in the neonatal intensive care unit.

OBJECTIVE: To assess the personal experience of all practitioners of neonatal intensive care unit (NICU) medicine in the United States with the medical malpractice system; in particular, to assess the circumstances of malpractice allegations in which they themselves had personal experience, and to extrapolate from their individual experiences to the field of neonatology in general. DESIGN: Written survey of all MDs practicing NICU medicine in the US. PARTICIPANTS: Two thousand four hundred ninety-eight NICU physicians as determined from three sources: a) the American Board of Medical Specialists; b) the American Academy of Pediatrics Section of Neonatal/Perinatal Medicine; and c) a listing of neonatologists provided by Ross Laboratories. MAIN OUTCOME MEASURES: Responses to survey questions. RESULTS: We received 1813 responses, representing approximately 75% of all physicians practicing NICU medicine in the US. Overall, 43% of respondents had experienced at least one claim of malpractice against them. The probability of a malpractice allegation increased with years in practice, from approximately 20% for NICU physicians in practice </=5 years (65/337), to approximately 60% for NICU physicians in practice >15 years (276/469). Men and women were equally likely to have been sued, accounting for years in practice. Physicians practicing in community NICUs were more likely to be sued than those in university settings. On a scale of 1 to 4 (4 being most reasonable) the median assessment of the reasonableness of malpractice allegations was 1, mean 1.2. On a scale of 1 to 4 (4 being the highest) the median assessment of effectiveness of the current system in identifying true malpractice was 1, mean 1.4. The respondents believed that approximately 80% of malpractice allegations were inappropriate; conversely, they believed that approximately 80% of true medical malpractice escaped detection. On a scale of 1 to 4 (4 being the highest), the median assessment of the detrimental effect of the present malpractice system on health care was 4, mean 3.4. CONCLUSIONS: Most NICU physicians will be sued if they practice long enough. In this context, efforts to use malpractice claims to seek out evildoers (such as underlie the National Practitioners Data Bank) appear ill-conceived. Similarly, exhortations for physicians to become either more educated or more sensitive are unlikely to reduce malpractice claims. Our data suggest that malpractice in the NICU appears to function more like a lottery than like a mechanism for either quality assurance or just retribution.

Community Health Services↗

PubMed1990

Effective physician credentialing. Properly monitoring medical staffs can protect hospitals from liability.

Healthcare facilities today are finding themselves increasingly liable in malpractice suits if they have hired incompetent physicians or allowed them to remain on the medical staff. Thus appropriate processes for physician credentialing are important. The hospital medical staff has the authority to evaluate medical staff membership status and clinical privileges and to take disciplinary and corrective action. If the medical staff fails to do its job, however, the hospital governing board is responsible for making sure the credentialing process is carried out properly. The same rules apply to the reapplication process. The hospital must associate its credentialing process with its prevailing concern for high-quality patient care and document that ideal. Preservation of market share and elimination of competition must never enter into the credentialing process. Well-framed hospital bylaws will help provide protection from liability, if they are followed correctly. If a hospital deviates from its bylaws when processing an application or granting clinical privileges, it risks a lawsuit. Congress has passed the Health Care Quality Improvement Act of 1986-an act that not only protects patients from incompetent practitioners but also can help limit facility's risk of liability by requiring facilities and third-party payers to report any adverse actions taken against physicians. The National Practitioner Data Bank is an information clearing-house opened in September 1990 that hospitals must use to report and obtain professional information about physicians.

Constitution and Bylaws↗

PubMed1991

Risk management or political micromanagement?

A major healthcare issue of the 1990s is whether providers will create effective risk management programs to cope with government reform mandates or whether an increasingly costly and complex regulatory structure will force them to make changes. Compliance with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards on patient care will become increasingly important to healthcare risk management in the 1990s. The JCAHO standards create a benchmark from which government entities set their present standards and assemble agendas for the future. Another healthcare risk management factor is compliance with the National Practitioner Data Bank. The data bank is intended to protect healthcare consumers from providers who have demonstrated a tendency to commit malpractice. However, the data bank could cause problems for healthcare providers: Inaccurate or misleading data could unfairly haunt them. Healthcare risk managers should be familiar with the prohibitions on patient dumping found in the Consolidated Omnibus Budget Reconciliation Act of 1985. The amendments of the Omnibus Budget Reconciliation Act of 1989 (OBRA '89) do not create strict liability, nor do they impose traditional tort standards that could guide courts in cases that will inevitably result from new rules, creating a "litigation time bomb." And OBRA '90 significantly revises the law. Other risk management issues include the manner in which facilities handle and dispose of medical waste and the manner in which they resolve disputes.

Accreditation↗

PubMed1991

Civil money penalties for failure to report on medical malpractice payments and for breaching the confidentiality of information--HHS. Final rule.

This final rule establishes civil money penalties (CMPs) pursuant to title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986 (HCQIA), as amended by section 402(a) of Public Law 100-177. Section 421(c) of HCQIA establishes a CMP against any entity that fails to report information that is required to be reported on medical malpractice payments. Section 427(b) of HCQIA establishes a CMP against any person that breaches the confidentiality of information which is reported or furnished pursuant to HCQIA and which the Secretary has established the National Practitioner Data Bank to collect and disseminate.

Confidentiality↗

PubMed1993

Quality of care developments. 1993 update.

This monograph offers an overview of quality of care developments at the federal and state government levels, as well as in the private sector. Although health care reform legislation focuses on access, costs, and delivery systems, initiatives involving the quality of care not only will continue but are included in most of the reform efforts being proposed and those already under way. At the federal level... At the Health Care Financing Administration (HCFA), publication of Medicare mortality data is delayed and the Peer Review Organization (PRO) program is undergoing a major change of emphasis under a "quality improvement initiative." The Clinical Laboratory Improvement Act (CLIA) has taken effect amidst controversy and further rulemaking is expected to correct flaws. The Agency for Health Care Policy and Research (AHCPR) is forging ahead with new practice guidelines while it starts to evaluate their effectiveness. Data on the patient outcomes in organ transplant centers, first published last year, now will be published on a regular basis. The National Practitioner Data Bank continues functioning amidst criticism and varying recommendations for change, from excluding information on small malpractice claims (e.g., less than $30,000) to opening up the data bank to the public (as proposed by Rep. Ron Wyden). Other federal developments include various quality-related reports from the Inspector General of HHS, the General Accounting Office, the Prospective Payment Assessment Commission, and the Physician Payment Review Commission, plus QI initiatives in Veterans Administration hospitals and the CHAMPUS programs. Among the states... Florida has included outcome data reporting and dissemination in its health care reform plan while Illinois struggles with whether physician-specific data will be made public. An innovative effort to test whether practice guidelines can reduce malpractice costs is underway in Maine, while Indiana began an outcome data project. Among accreditation agencies and associations... The Joint Commission is moving ahead with its Agenda for Change, including nationwide reporting of quality indicators and an expansion of accreditation to health care delivery systems and hospice programs. The American Medical Association and the American Hospital Association continue to support practice guideline development with education and research, while a number of hospitals and health systems are using comparative outcome data and clinical benchmarking to study and improve care. Conclusion... There is certainly some duplication of effort and the question of value (return on investment) must be raised given the cost of all these efforts. Without question, however, quality of care initiatives are omnipresent and challenging.

Government Agencies↗

PubMed2000

Physicians caught in the Web. Thanks to Internet, doc disciplinary data now just a mouse click away.

The states are busy making more information available to the public about disciplinary actions taken against doctors. Streamlining the process is the Internet. Most states now post data on Web sites detailing actions taken against docs for unethical, questionable or criminal conduct. The next target for those seeking more information on their healthcare providers: the National Practitioner Data Bank. One lawmaker promises legislation that would open it to the public.

Community Participation↗

PubMed1992

Peer review: determining what's best for patients by professional self-assessment.

Many influences outside of physician control have begun to undermine traditional physician autonomy. Studies of physician practices reveal differences not based on patient case mix alone, but on variations in decisions and lack of intra-physician accountability. Failure of physicians to be accountable to each other is related to inadequate due process understanding, fear of legal recriminations from peers, and a traditional long-standing history of individuality and accountability. The malpractice crisis and the advent of a National Practitioner Data Bank of physicians whose privileges or licenses have been modified serves as an impetus to rebuild accountability into a new emphasis on peer review based on optimum patient-focused outcome. To get physician buy-in, a five-step process is described which is separate from professional review of privileges and is seen as collegial, educational, and patient focused.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed1990

New peer review reporting and disclosure requirements--Part I.

This article reviews the reporting and disclosure provisions of the Health Care Quality Improvement Act of 1986, the Medicare and Medicaid Patient and Program Protection Act of 1987, the Texas Medical Practice Act, and federal regulations promulgated in late 1989 to establish the operating rules and policies of the National Practitioner Data Bank. A table on pages 56-57 outlines the reporting requirements of these laws and regulations. Discussion focuses on the requirements the new federal regulations place on physicians and other health care practitioners, health care entities, and insurers.

Humans↗

PubMed1990

Risk managers see new regulations as boon and burden.

Health care risk managers have mixed feelings about the new regulations governing patient transfer and the National Practitioner Data Bank. Although cumbersome, the regulations give risk managers the teeth to enforce practices that may previously have been difficult to enact.

Legislation, Hospital↗

PubMed1994

The relationship between physicians' malpractice claims history and later claims. Does the past predict the future?

OBJECTIVE: To investigate whether an association exists between physicians' past and subsequent claims of medical malpractice, particularly whether a history of even unpaid claims ($0) or small claims (< $30,000) predicts subsequently higher rates of claims, especially large paid claims (> or = $30,000) (all in 1990 dollars). DATA: All medical malpractice claims closed in the state of Florida from January 1975 through August 1988 (N = 20,016, 92% involving physicians), matched with the American Medical Association's Physician Masterfile on all practicing physicians in the state of Florida during that period. Claims history was automated into physician-year claims files, then partitioned into a baseline period (1975 through 1980) and a subsequent period (1981 through 1983). Inconsequential claims were excluded, ie, cases closed without a named claimant and without expense for investigation (30.4% of raw claims). METHODS: Descriptive analysis of all physician claims; odds ratio analysis of physicians in practice throughout both periods (N = 8247), comparing claims experience in baseline vs subsequent period, adjusted for specialty of practice. RESULTS: For all consequential physician claims, 60% were unpaid claims, 17% were small paid claims, and 23% were large paid claims. The 8247 continuously practicing physicians had a total of 6614 claims, averaging 0.9 per year, but 59.2% of physicians had no claims in 9 years, only 13.4% had any paid claims, and 7.2% had multiple paid claims. Less than 8% of physicians had any large paid claims during the baseline period, and less than 7% had any in the subsequent period. Physicians with any baseline claims (whether paid or unpaid, small or large, single or multiple) had elevated odds of subsequent claims (whether defined as any claims, any paid claims, any large claims, or multiple claims) relative to physicians with no baseline claims. With a baseline of all small claims, the adjusted odds ratio for any subsequent claim was 2.84 (95% confidence interval [CI], 2.32 to 3.49), for any subsequent paid claim was 2.97 (95% CI, 2.34 to 3.77), for all large subsequent claims was 2.42 (95% CI, 1.76 to 3.33), and for subsequent multiple claims was 2.83 (95% CI, 2.08 to 3.86). Even having a single unpaid baseline claim approximately doubled the odds. CONCLUSIONS: Claims history had predictive value, even with only unpaid claims. Small paid claims were better predictors than unpaid claims, large paid claims were better predictors than small paid claims, and multiple paid claims were better predictors than single paid claims. Claims history of all kinds is a reasonable statistical measure, eg, for the screening purposes of the National Practitioner Data Bank.

Confidence Intervals↗

PubMedDate not supplied

The relationship between malpractice claims history and subsequent obstetric care.

OBJECTIVE: To determine the relationship between prior malpractice claims experience and the quality of clinical obstetric care. DESIGN: Historical cohort study of obstetricians, classified by their prior malpractice claims experience, with blinded review of medical records from their practices 5 to 10 years later. SETTING: Florida obstetricians who lost, settled, or defended malpractice claims between 1977 and 1983 and who were still practicing obstetrics in 1987. MAIN OUTCOME MEASURES: Objective and subjective assessment of quality of clinical care of patients attended by obstetricians with different histories of malpractice claims. RESULTS: No differences were found in any of the objective or subjective measures of the quality of clinical care provided to patients of obstetricians who were classified into one of four groups according to their prior claims history. CONCLUSIONS: No relationship was found between prior malpractice claims experience and the technical quality of practice by Florida obstetricians. Strategies that attempt to identify physicians at risk for future clinical errors by using data on prior malpractice claims (such as the National Practitioner Data Bank) may be misjudging the likelihood that substandard clinical care will be provided by physicians with prior claims.

Cohort Studies↗

PubMed1997

Malpractice in the lower Rio Grande Valley.

Data from the National Practitioner Data Bank were examined to assess malpractice payments in the Lower Rio Grande Valley in comparison with those for Texas and the United States as a whole. The Valley was found to have a high rate of malpractice payments when considered on a per physician basis and on a per unit of utilization basis, but an average rate when considered on a population basis. A number of possible explanations (such as the "bad apple" theory, the "settlement for convenience" theory, the case distribution theory, the physician qualifications theory, and the foreign medical graduate theory) were examined to explain the Valley's observed rate of malpractice payments per physician. No explanations are particularly satisfactory. More research is needed, but indications suggest that the observed rate may be driven more by the activities of some attorneys than by the actions of Valley physicians.

Delivery of Health Care↗