The National Practitioner Data Bank: the first 18 months.

In response to a need for information on the quality of professional practice and a perceived threat to the preservation of the peer review process, as well as to concern about the cost to society of incompetent physicians, Congress passed the Health Care Quality Improvement Act of 1986. The Act established a legal basis for protecting peer review and quality assurance activities. It also established a national reporting system, the National Practitioner Data Bank (NPDB), which is intended to ensure that appropriate information is available to be used in the peer review process.

In the 1980s, patient advocate organizations argued that peer review programs and state licensing and regulatory boards that monitored physician performance were ineffective. During the same period, a number of physicians had successfully and illegally moved their practices from one jurisdiction to another to avoid professional sanctions that had been taken against them. Hospital and medical staff authorities argued that peer review was hampered by the "chilling effect" of the fear of legal liability for those who offered information during the process of peer review. For example, in 1982 in Oregon, a surgeon's hospital privileges had been terminated through the process of peer review on the basis of physician negligence. The surgeon, Dr. Timothy Patrick, sued the hospital, alleging that the physicians that had participated in the peer review proceeding had terminated his hospital privileges because he was competing with them. A jury verdict in the case awarded $2.2 million to Dr. Patrick.

This alleged inability of the medical profession to discipline itself was attributed to the absence of accurate and complete information as well as to an unwillingness of physicians to render formal judgments on their peers. The Federation of State Medical Boards (FSMB) maintains the Board Action Data Bank, which is a repository of information on medical licensure. However, the FSMB does not track disciplinary actions taken by hospitals and professional societies. Also, although some states have laws requiring that malpractice claims or payments be reported to a state agency, other states are unable to gain access to this information.

As a result, Congress passed the Health Care Quality Improvement Act of 1986, Public Law 99-660. The Act established a legal basis for protecting peer review and quality assurance activities. It also established the National Practitioner Data Bank (NPDB), which is intended to ensure that appropriate information is available for the peer review process.

Part A of the Act provides immunity to peer reviewers, to individuals who provide information to the process, to hospitals relying on information they obtain from NPDB, and to NPDB. Part B of the Act authorizes the establishment of NPDB, which has been in existence since September 1990.

Through NPDB, Congress sought to ensure, in exchange for immunity, that the information needed for effective peer review would be accurate, complete, and available. NPDB collects information relating to professional competence and conduct of health care practitioners. This information is available for release only to specified organizations for use in hiring, licensing, credentialing, and other peer review procedures. The availability of NPDB information is intended to prevent incompetent doctors from moving their practices from hospital to hospital and from state to state.

Data Bank Operations

NPDB is the product of a cooperative effort between the public and private sectors. It is operated by Paramax Corporation, under contract with the Bureau of Health Professions within the Health Resources and Services Administration, a U.S. Public Health Service Agency. The contract has been in effect since January 1989. Representatives of both public and private organizations (professional societies, hospitals, state licensing bodies, malpractice insurers, and a patient advocacy group) constitute an executive committee that advises Paramax Corporation about NPDB affairs. NPDB is funded through government appropriations ($1 million in fiscal year 1992) and a $6 per query user fee.

NPDB is intended to augment, not replace, traditional forms of credential review. It serves as a resource to assist hospitals, state licensing boards, and other credentialing entities in conducting independent investigations of the qualifications of health care practitioners. It should be viewed as a supplement to a process of comprehensive and careful review of professional credentials.

NPDB contains information only on those health care practitioners on whose behalf a malpractice payment is made or against whom an adverse action is taken by a state licensing authority, a health care entity, or a professional society. Insurance companies and other entities must report to NPDB any malpractice payment they make on behalf of physicians, dentists, and other health professionals. State medical and dental boards must report disciplinary actions taken against health care practitioners.

Health care entities such as hospitals must report decisions that adversely affect, for more than 30 days, the clinical privileges of a health care practitioner. Professional societies must report adverse actions regarding members. Adverse actions on privileges or professional society membership are reportable only if they have been reached through formal peer review activity (see figure above). Information in NPDB identifies the practitioner, the entity that made the report(s), and the kind of report that was made (malpractice payment, adverse action). Access to individual practitioner information in NPDB is limited to state medical and dental boards, health care entities with formal peer review, and health care practitioners seeking information about themselves.

Discussion

NPDB has been a source of controversy among some health care organizations and practitioners. Some in the field worry about the adequacy of its safeguards to ensure confidentiality of NPDB information. Access to the Paramax facility and the data is governed by strict security precautions imposed by the Department of Health and Human Services (HHS) and the Department of Defense. HHS certified the security of the system on March 1991. Any organization that reports to or queries NPDB must certify in writing that it is authorized to request or receive information. Violation of the confidentiality of NPDB information is subject to civil penalties of up to $10,000 for each violation. Anyone who reports to or queries NPDB under false premises or who fraudulently gains access to NPDB information is subject to criminal penalties, including fines and imprisonment. To date, there is no evidence that NPDB has been compromising to any health care practitioner.

Another concern is the user fee charged for inquiries. Critics cite the fee as a financial impediment to the use of NPDB by state licensing agencies. The user fee is established by regulation and reflects the experienced-based cost of processing transactions. Other critics argue that NPDB information is of limited use, because the information dates only from September 1990. As NPDB acquires more reports and becomes a more complete source of information, it will become a more comprehensive database than is otherwise available. (For example, the state licensing boards do not provide malpractice payment information).

Others claim that NPDB is inefficient. An "NPDB Helpline" was instituted to provide NPDB users with telephone assistance in an effort to decrease the number of reporting and querying-form errors. During the first months of operation, the response time for reports was lengthy. Currently, the response time is within four weeks for a multiple person query and within one week for an individual query. A variety of modifications and improvements are planned to enhance NPDB's electronic system and improve its efficiency and productivity even further. For example, the paper-based information exchange system was augmented with systems of computer diskettes and telecommunication transmittal beginning in September 1992.

The possible inaccuracy of reports is also a concern. Reports are made to NPDB on a prescribed form. After processing this form, NPDB sends a copy of the reported information to both the practitioner and the organization submitting the report, allowing them to verify the accuracy of the information. The reporting organization is sent a verification document; the practitioner is provided with the content of the report and is allowed to dispute any item that is believed to be factually inaccurate. The practitioner may also dispute whether or not the reported information should have been reported to NPDB. In this latter case, the practitioner must first attempt to resolve the dispute with the reporting entity. When there is no resolution with the reporting entity, the practitioner may request the Secretary of the HHS to review the disputed information and make the final determination. During the first 18 months of operations, 2,712 disputes of information reported to NPDB were filed. Only 248 practitioners proceeded to the Secretarial level for a review of the disputed information.

The First 18 Months

Analysis of NPDB data from the first 18 months suggests that NPDB is operating in accord with its mandated purpose--aggregating adverse actions and malpractice payment reports and making them available to credentialing authorities. Data generated by NPDB are providing global information on malpractice payments, patterns of adverse actions, and professional disciplinary behavior that have never before been available.

Of the 30,299 reports in NPDB, 25,608 (85 percent) were a result of malpractice payments and 4,691 (15 percent) were the result of adverse actions taken with respect to a health care practitioner's license, clinical privileges, or professional society membership. Seventy-one per cent of the adverse actions were the result of licensure actions and 28 percent involved privilege actions. NPDB received only 46 reports of adverse actions involving professional society membership.

Approximately 1.2 million queries were made to NPDB during the first 18 months of operation, averaging more than 3,000 queries per working day. About 80 percent of the nation's hospitals sent at least one query to NPDB. Additionally, 602 other health care entities (for example, HMOs or group practices with formal peer review) queried NPDB, as did 37 state licensing boards. Information about themselves was requested by 6,300 practitioners. Of the total queries made to NPDB, 20,817 resulted in a "match"--a disclosure of information in NPDB on a practitioner named in the query.

It is difficult to interpret these data to determine the degree of participation in the collection and use of NPDB information, because there is no prior year's data or data from a similar institution with which to compare. It will be possible to address the issue of participation only after some years of NPDB operation. Nonetheless, the 18-month data can be used to assess the early impact of NPDB.

The total number of queries represents more than one query for every physician and dentist in the nation and indicates active participation on the part of hospitals. The number of malpractice payments and adverse actions reported is lower than anticipated. In 1987, the General Accounting Office (GAO) reported that, in a one-year period, there were 22,864 paid claims reported on behalf of physicians. NPDB received, during its first year of operations, 11,721 malpractice payment reports or about one half of the GAO figure. Over the first 18 month of NPDB operation, the malpractice payment reports averaged about 17,000 per year, a notable increase. Nonetheless, the average annual number of reports received by NPDB still is lower than the GAO figure and represents underreporting, an actual decrease in the number of claims paid, an increase in the tendency of physicians and carriers to litigate claims rather than settle them, or nonreporting of physicians named in a settlement/judgment who are corporate employees when payments are made on behalf of the corporation. (The Act requires that individuals, not corporations, be reported). Likewise, during the first 18 months, the average annual number of licensure actions taken against licensed physicians (2,221), clinical privilege actions taken by hospitals (875), and professional society actions taken against memberships of health care practitioners (46) reported to the NPDB are notably higher than the respective first year figures. However, they still seem lower than anticipated. Further investigation is required to determine whether these data reflect the full extent to which hospitals and professional societies are engaged in disciplinary action.

Future Plans

State medical boards and privileging entities are the only entities empowered to sanction, restrict, or revoke licenses and privileges. NPDB offers the opportunity for these institutions to gain access to timely, accurate, nationally acquired information. However, NPDB information must be incorporated into the peer review process by the state medical boards and hospitals to be "useful" and productive in identifying incompetence. Future evaluation studies will attempt to assess the utility of NPDB information. A current study examines the impact of NPDB on peer review and licensing and NPDB's ability to serve as a national repository and distribute useful information effectively. In addition, HHS is examining whether a lower limit should be set on the dollar amount of malpractice payments reported to NPDB and whether all claims--open or closed-- should be reported.

Further Reading

Mullan, F., and others. "The National Practitioner Data Bank, Report from the First Year." JAMA 268(1):73-9268, July 1, 1992.

Iglehart, J. "Health Policy Report. Congress Moves to Bolster Peer Review: The Health Care Policy Improvement Act of 1986." New England Journal of Medicine 316(15):960-4, April 9, 1987.

Peer Review Immunity Task Group. Immunity for Peer Review Participants in Hospitals: What Is It? Where Does It Come from? How Do You Protect It? Chicago, Ill. American Academy of Hospital Attorneys of the American Hospital Association, Dec. 29, 1989.

Health Care Quality Improvement Act of 1986. H.R. 5540, in the House of Representatives, 99th Congress, Second Session, Sept. 17, 1986. Washington, D.C.: U.S. Government Printing Office, 1987.

Horner, S. "The Health Care Quality Improvement Act of 1986: Its History, Provisions, Applications, and Implications." American Journal of Law and Medicine 16(4):455-98, 1990.

Wechsler, H. Handbook of Medical Specialties. New York, N.Y.: Human Sciences Press, 1976.

Michele A. Puryear, MD, PhD, is a medical officer, Division of Vaccine Injury Compensation; Robert M. Politzer, MS, ScD, is Associate Director, Primary Care Policy; Jerry Anderson, JD, is an attorney, Division of Quality Assurance; and Fitzhugh Mullan, MD, is a Director, all in the Bureau of Health Professions, Health Resources and Services Administration, Public Health Service, Department of Health and Human Services, Rockville, Md. The views expressed in this article are strictly those of the authors. No official endorsement by the Department of Health and Human Services or by any of its components is intended or should be inferred.