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HMOs Not Reporting on Questionable Doctors

HMOs Not Reporting

By Sean Martin
WebMD Feature

Reviewed By Charlotte Grayson

May 29, 2001 (Washington) -- The nation's managed care plans are not reporting -- and may not even be taking -- formal disciplinary actions against doctors to the government, according to a new report from federal health investigators.

The report, issued this month by the Office of Inspector General, or OIG, which is the investigatory arm of the Department of Health and Human Services, also notes that enrollment in managed care plans increased from 34 million in 1990 to 81 million in 1999.

But during that same time span, HMOs reported only a total of 715 disciplinary actions against questionable doctors to a federal databank. Moreover, 84% of the nation's 1,400 health plans never reported any formal action against a healthcare practitioner.

The databank under scrutiny is the National Practitioner Data Bank, which Congress originally established in 1986 to help identify the "bad apples" among providers, such as doctors who lose their state medical licenses but continue practicing elsewhere.

The information is not for public use. Instead, it is intended to help hospitals, HMOs, and state licensure boards determine whether a doctor has paid malpractice settlements or received disciplinary actions before they give the practitioner credentials, a job, or a license.

In late 1999, the Institute of Medicine estimated that medical errors kill nearly 100,000 patients each year. The institute focused the blame not on the skills of individual caregivers but rather on information and cultural shortcomings in the nation's health system. Still, the OIG's recent report emphasizes that initiatives such as the database are key to efforts to protect patients from potentially dangerous practitioners.

But according to the OIG report, HMOs "do little to contribute to [the data bank's] usefulness as a credentialing resource either for themselves or for others who look to the data bank as a patient protection tool."

There are two "especially convincing" reasons why HMOs have filed so few reports to the database, suggesting that the plans "rarely consider adverse actions against practitioners, let alone take actions and then not report them to the data bank," according to the report.

The first is that the economic demands of the health marketplace have led HMOs to "devote little attention to clinical oversight," focusing on keeping prices down rather than devoting resources to costly monitoring systems. Health plans may also believe that kicking out doctors can hurt them competitively, because it would cut down on the choice they can offer their enrollees.

The second reason, the report says, is that HMOs rely on quality monitoring from other entities -- hospitals, physician practice groups, and state licensure boards.

A spokesperson for the National Committee for Quality Assurance, a national group that accredits HMOs based on their performance on various clinical quality measures, said that its executives were traveling and could not comment on the OIG report.

Susan Pisano, spokeswoman for the American Association of Health Plans, tells WebMD that plans are not reporting because they thought they were only supposed to make their reports to state medical boards. "Health plans take their reporting obligations very seriously," she says. "They have understood that their responsibility is to report to states. The original regulations relating to the data bank tell plans to report to the state licensing boards, and that the boards will in turn report to the practitioner data bank."

Others buy more into the economic argument. Jeff Stoddard, MD, a physician researcher with the Center for Studying Health System Change, tells WebMD: "Managed care organizations have neither the resources nor the motivation to really identify or take action against practitioners who are performing poorly. The state medical boards have a hard enough time doing it."

Stoddard also says that plans would pay a "political" cost with their doctors, if they aggressively monitored competence and reported disciplinary actions. "You've already seen relations reach all-time lows in the last few years," he says. "I can't think of many ways in which a managed care organization could jeopardize itself more with its providers than to get heavy-handed in this kind of realm."

Pisano tells WebMD that health plans do prefer a lighter touch with their doctors. She says, "Plans aim to do, when they need to, a short-term intervention that solves a small problem, rather than letting a small problem escalate to a big problem."

She adds, "If what you are doing is providing doctors information on the latest medical science in a way that makes their everyday practice easier, and you are providing them information on how their practice compares to other doctors, that is kind of information that most physicians respond to."

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