HHS CLAIMS HMOs DO NOT REPORT ACTIONS TAKEN AGAINST PHYSICIANS ON THEIR PANELS - Department of Health and Human Services - Brief Article

Healthcare Financial Management, July, 2001

Most HMOs are not reporting incidences of incompetence and/or misconduct of physicians to the National Practitioner Data Bank (NPDB), according to a study by HHS. Between 1990 and 1999, 84 percent of the 1,401 HMOs studied by HHS reported no adverse actions to the NPDB, though Federal law requires them to do so.

The NPDB was created in response to the requirements of the Health Care Quality Improvement Act of 1986 to protect patients from poorly performing physicians, dentists, and other practitioners. The data bank contains information on healthcare practitioners who have had medical malpractice payments made on their behalf and/or adverse actions taken against them by a licensure board, professional society, or healthcare entity, such as a hospital or managed care organization. Although the NPDB is not available to consumers, state licensing boards use the information in their reviews of physicians.

According to the HHS study, managed care organizations rarely submit adverse action reports to the NPDB. Between September 1, 1990, and September 30, 1999, managed care enrollment grew to more than 100 million, but only 715 adverse actions were reported by HMOs, and 84 percent of HMOs reported no adverse actions. The two most likely explanations for the low level of reporting by HMOs over the decade are a limited focus on clinical oversight and a reliance on "downstream entities"--hospitals, physician practice groups, and state licensure boards--to conduct quality monitoring of physicians, according to HHS.

In the report, HHS targeted seven issues that call for greater attention if patients are to be adequately protected:

* Dealing with unsafe practitioners as part of patient-safety efforts;

* Patient protection role of managed care organizations;

* Patient protection role of physician practice groups;

* Effectiveness of hospital privilege granting practices;

* Performance of licensure boards in quality-of-care cases;

* Managed care organizations' understanding of their reporting responsibilities; and

* Managed care organizations' compliance in reporting adverse actions.

In response to the HHS findings, the American Association of Health Plans commented that some HMOs have misunderstood their responsibility to report adverse actions directly to the NPDB rather than to state licensure boards.

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