Secrecy around data bank protects ‘Practitioner No. 222117′

Alan Bavley of The Kansas City Star provides us with a stark illustration of why new restrictions on the use of the National Practitioner Data Bank are not in the public interest.

In the most straightforward example yet, Bavley reports on “Practitioner No. 222117,” a doctor whose medical licenses have been revoked or suspended by 20 states, who was banned from billing Medicaid or Medicare and whose license to prescribe was yanked by the Drug Enforcement Administration. Bavley learned all of that from perusing the data bank’s Public Use File.

The NPDB includes reports on malpractice payments and disciplinary actions involving health care professionals. Hospitals and state medical boards can use the data when deciding to grant staff privileges or when reviewing license applications, though AHCJ found state medical boards do that less than you might expect. The NPDB’s Public Use File, available for download on a public website, removes identifying information. Bavely’s article explains more about how they de-identify the data.

Despite all we know about Practitioner No. 222117, we don’t know if he or she is still practicing medicine. The public, including journalists, is restricted from using the data to identify this doctor.

In the past, reporters have used information in the Public Use File, in combination with other records, to identify to flesh out their reporting on troubled doctors and show the failure of medical boards to act against doctors with multiple malpractice awards.

That ended on Sept. 1, when the U.S. Health Resources and Services Administration, which runs the database, removed the public use file because one doctor complained about stories that Bavley was writing.

AHCJ, along with other journalism groups and patient-safety advocates, decried the database’s removal. In November, HRSA restored the Public Use File – but with restrictions on how it can be used. Reporters and researchers have to agree not to connect any individual to information in the database. Reporters can be barred from future access to the database if HRSA decides they have violated the rules. For more background, please see AHCJ’s Right to Know page or this timeline.

How might retail clinics change health care delivery in your community?

I don’t routinely blog about the work of AHCJ board members (which doesn’t mean you shouldn’t read Charles Ornstein’s latest on Florida’s slow reaction to physicians who treated and prescribed drugs under Medicaid “amid clear signs of possible misconduct.”)

But I’m making an exception to my self-imposed rule for Julie Appleby’s recent Kaiser Health News piece “The Walmart Opportunity: Can Retailers Revamp Primary Care?“

I’ve read other pieces about the future of retail clinics, including their potential for treating chronic disease. But I thought Appleby did a terrific job of asking – and often answering – many interlocking questions about the delivery of primary care, the management of chronic disease, the quality of care and what this all has to do with health reform.

While asking big-picture questions, she also wove in details that gave the story texture and made it a good read. If you saw my tweet, you’ll know I was particularly taken by the bit about how long-distance truckers can pull up in the parking lot of more than 600 centers to get their mandatory federal checkups.

As Appleby noted, the clinics – which sometimes lose money but bring customers into the stores – started with the low-hanging fruit, the “relatively healthy patients looking for convenient, low-cost care for simple problems.” The next stage is to try to start treating more expensive chronic diseases, such as diabetes and heart disease, which are big drivers of health care spending. Treating chronic disease, however, is definitely a problem in search of a primary care solution. As her story said:

“It’s sad that the existing health care establishment has not figured out a way to make primary care affordable and accessible,” says Jerry Avorn, a professor of medicine at Harvard. “We should not be surprised if someone outside of our world comes in and does it for us.”

Some of the retail clinics are already venturing into aspects of chronic care: diabetes management, weight-loss programs. (I think we can safely say that primary care physicians have not solved the U.S. obesity problem). Some employers are using the clinics for wellness and routine screening programs.

The costs tend to be lower. Appleby cited a study in the American Journal of Managed Care that costs are 30 percent to 40 percent lower than in the doctor’s office and 80 percent cheaper than in the emergency department. Consumers like the predictability and transparency of the costs (although insurance can also pay) . They don’t get pricing clarity up front at the doctor’s office or hospital.

Several provisions of the federal health law may further spur interest in the clinics. For instance, small businesses will have incentives to offer worker wellness program. The clinics may help fill in some gaps in primary care which are expected to get worse before they get better because of the pent-up demand for care that may burst out when coverage expands under the health law starting in 2014. The Association of American Medical Colleges estimates a shortfall of 21,000 primary care doctors by 2015. Not everyone agrees that there is an across-the-board shortage, as opposed to a shortage in specific underserved areas.

How clinics make the jump from flu shots and throat cultures to the far more complex task of monitoring chronic disease is not completely clear. Remember that patients, particularly older patients, often have multiple chronic diseases (i.e. diabetes and hypertension and congestive heart failure and arthritis, etc.). Some questions remain: Will the clinics turn out to be good at managing relatively stable patients in the early stage of disease – where the convenient locations and evening and weekend hours may enhance compliance? What about with the more advanced illnesses? Will the retail clinics add to fragmentation and miscommunication? Or will the clinics somehow form relationships with “new, integrated collaborations between doctors, hospitals and insurers?”

I don’t want this post to get longer than Appleby’s article so, when you read it, pay attention to the other issues she raises, and think about how they are playing out in your community:

• Scope of practice. What is the role of nurses/nurse practitioners/physicians assistants versus physicians? Turf battles can produce good sources and good stories.
• Does your state have laws about clinics directly employing physicians?
• Will clinics “skim off” healthy patients from physician practice and leave them with all the sickest and most expensive ones, without greater reimbursement? Or, by taking on some routine medical tasks, will clinics allow physicians to spend more time doctoring?
• Who are the patients? (Other than truck drivers and high school students needing sports physicals.) Are clinics just a convenient way for insured middle-class people to get routine care? (I’ve taken my son in for a throat culture at 7 p.m. when he’s feeling scratchy and I know there’s strep in his class. It’s way better than waiting until the next morning to go to the pediatrician when he might be sicker, and he has to miss school and I have to miss work. And, if he does need antibiotics, I’d have to go the drug store anyway.) Or are the clinics avoiding poorer neighborhoods, meaning the underserved stay underserved?
• Appleby didn’t mention this explicitly but it’s worth adding to the mix: To the extent the clinics are in underserved communities, are they helping low-wage hourly workers who don’t have paid sick leave or the flexibility to take an hour or two off in the middle of the day to get their kid (or their mother-in-law) to the doctor?
• Are any of the clinics – anywhere – starting to share information with patients’ primary care physicians? Or, in the case of diabetes, heart disease, etc., are they sharing information with specialists? It can be as simply as faxing something, sharing electronic medical records or using secure email. If I take my kid for that throat culture, it’s really not a catastrophe if I forget to tell his pediatrician (and I don’t need to bother if it’s negative). But for things like immunizations, or A1C levels for diabetics, or blood pressure spikes or changes in medications - someone needs to keep track of the big picture. Of course, communication isn’t all that great right now between doctors without the clinics but, since health reform has some incentives for improving coordination, where do the retail clinics fit in?

That question about integration, which Appleby raised, doesn’t yet have a clear answer. Could the clinics end up having some kind of relationship with the “medical home” or the “Accountable Care Organization” or other models of integrated care? I am not sure of all the legal or contractual problems. If someone has written about this, please chime in. But I can envision ways that clinics can be brought into the coordinated or accountable care loop. It may turn out to be in everyone’s interest – patient, physician and clinic – to do the looping.

Numbers reveal how often, or how rarely, states check doctors’ disciplinary records

How often does your state medical board search doctors in the National Practitioner Data Bank?

Surprisingly not often, according to data provided to the Association of Health Care Journalists by the U.S. Health Resources and Services Administration, which runs the data bank.

AHCJ and other media groups have been pushing the government to restore unfettered access to the Public Use File of the data bank, citing important stories that journalists have written about lax oversight of doctors by state medical boards.

State medical boards have access to complete information within the data bank about a doctor’s disciplinary history, hospital sanctions and malpractice payouts. The Public Use File, which had been available to reporters and researchers for years, provided the same information without identifying information about the doctors involved.

HRSA removed  the Public Use File from its website on Sept. 1 following complaints from a doctor that a reporter from The Kansas City Star inappropriately used it to identify him. The agency restored the file last week, but with new restrictions that seek to bar reporters from using it with other data sets to identify physicians. AHCJ and other media groups call the new restrictions unworkable and an unconstitutional prior restraint.

AHCJ requested data from HRSA so reporters could see how often their states check the backgrounds of MDs and DOs, as well as interns and residents. The numbers are available in two different charts. Beyond that, HRSA said, three state boards have a relationship with HRSA in which they automatically get updates when new information is entered on a physician. They are: Nevada (DO), Oregon (MD) and Pennsylvania (MD).

“I encourage journalists to look up their state medical boards in our chart and see how often they consult the data bank,” AHCJ President Charles Ornstein said. “If they are not looking physicians up, they should be asked how they are sure they are protecting the public from dangerous or incompetent doctors.”

HRSA spokesman Martin Kramer said in an email that,

HRSA is also working proactively to protect the public by reducing potential barriers for State licensing boards to receive NPDB information.

One step that HRSA took in the past year was to conduct a small pilot study with the Federation of State Medical Boards to determine if hospitals and medical malpractice payers send a copy of  the NPDB report, as required, to the licensing board.

To assure that Medical Boards receive the hospital and medical malpractice payment reports, in January 2012 the reporters (hospitals and medical malpractice payers) will be able to send an electronic copy to the State medical board through the NPDB.

We believe this change will be cost saving and time effective for the reporters and State medical boards.”

For more background, this timeline tracks the story:

Grassley blasts HRSA over data removal after seeing letter exchange with doc

The action taken by the U.S. Health Resources and Services Administration to remove the public version of the National Practitioner Data Bank came only after the urging of a Kansas neurosurgeon with a long history of malpractice payouts, according to records released Thursday by U.S. Sen. Charles Grassley.

The doctor, Robert Tenny, sent six letters to HRSA both before and after the Kansas City Star wrote a story that said he had been sued at least 16 times for malpractice and had paid out roughly $3.7 million since the early 1990s.

Grassley blasted HRSA for making a hasty decision to remove the data bank’s Public Use File from its website without doing independent research and he called for its immediate restoration.

“Instead of conducting its own research into the professional conduct of Dr. Tenny, HRSA appears to have over reacted to the complaint of a single physician based on no evidence other than that he received a call from the press,” Grassley wrote Thursday in a letter to Health and Human Services Secretary Kathleen Sebelius.

The documents released by Grassley also show that HRSA warned 28 hospitals and health plans throughout Kansas about discussing the data bank records of Tenny following the doctor’s allegation that a hospital must have leaked information about him to Star reporter Alan Bavley.

The National Practitioner Data Bank is a confidential system that compiles malpractice payouts, hospital discipline and regulatory sanctions against doctors and other health professionals. For years, HRSA has posted aggregate information from the data bank in a Public Use File that did not identify individual providers.

HRSA officials removed the public file from the data bank website on September 1 because a spokesman said they believe it was used to identify physicians inappropriately. The Association of Health Care Journalists has protested the action, along with Investigative Reporters and Editors, Society of Professional Journalists, National Association of Science Writers, Reporters Committee for Freedom of the Press, and National Freedom of Information Coalition.

Grassley released the documents Thursday in response to a letter he received from HRSA administrator Mary Wakefield.
 
Among them was an email showing that the data bank’s director quickly notified Tenny’s lawyer about a letter she sent to Bavley threatening the reporter with civil penalties if he ran a story based on information from the data bank. Cynthia Grubbs, director of HRSA’s division of practitioner data banks, forwarded the letter to Tenny’s lawyer, Charles R. Hay, less than three hours after sending the warning to Bavley. (HRSA subsequently backed off its threat against Bavley.)

 “HRSA’s response makes it apparent that HRSA simply accepted the complaint of the physician involved at face value and jumped to conclusions about how Mr. Bavley obtained the information,” Grassley wrote. “Once HRSA learned of its mistake, it then compounded the error by shutting down access to information that Congress intended to be public” through the Public Use File.

“All Mr. Bavley did was use publicly available data, and HRSA’s response to that was to shut down access to that data for everyone,” Grassley wrote.

AHCJ President Charles Ornstein, responding to the documents Grassley released Thursday, reiterated his call for HRSA to republish the Public Use File immediately.

“We are past due for HRSA to acknowledge its mistake, apologize and restore access to this file on its website,” he said. “Journalists have used this information responsibly for years to write about questionable physicians, and their stories have led to new laws and regulations that have improved patient protections.”

Ornstein also said the documents released by Grassley “raise troubling questions about HRSA’s due diligence before taking this major action.”

According to the documents, Tenny repeatedly wrote Grubbs, questioning the motives of a hospital that he contends hired a publicist to try to destroy his career and impugning Bavley.

In another letter, he alleged a “coordinated attack.” And in another, he told Grubbs to “stay strong and keep up the good work!”

In response, Grubbs wrote Tenny on Sept. 26, saying, “We have contacted the hospitals and health centers…who have queried on you in the past 6 years to remind them of the confidentiality requirements and the sanctions for violations of confidentiality. We instructed the hospitals to examine their records and report back to us with any potential confidentiality breaches. We will act swiftly to investigate any potential violations of confidentiality.”

In her letter to Grassley, dated Tuesday, Wakefield said HRSA is working toward “a solution that meets its responsibilities regarding confidentiality under the Data Bank statute while reflecting its commitment to facilitating important research.”

“Our goal is to make as much information available as soon as we can, but we do not have a specific timeline at this point,” she wrote.

In addition to calling for restoration of the public file, Grassley asked for an immediate briefing by the HRSA official responsible for the decision to remove it in the first place.

Journalists, researchers renew call for access to data during public call

Officials at the U.S. Health Resources and Services Administration held a conference call on Thursday to seek input from the public about the future of the National Practitioner Data Bank’s Public Use File. Reporters and researchers had a similar response: Bring it back.

HRSA removed the public version of the doctor discipline database last month because officials said they were concerned a reporter had used it inappropriately to identify physicians.

But journalists, led by AHCJ president Charles Ornstein, and researchers told HRSA officials they believe the agency overreacted or was misinterpreting the law. Ornstein and others pointed out that  the public version of the data bank had been used by reporters to expose faulty oversight of physicians by state medical boards, leading to greater transparency and additional patient protections.

“I implore you not to go backwards and implore you not to increase secrecy but rather to restore the Public Use File as it was,” said John Ensslin, president of the Society of Professional Journalists.

The National Practitioner Data Bank is a confidential system that compiles malpractice payouts, hospital discipline and regulatory sanctions against doctors and other health professionals. Pursuant to the law, the public version of the database did not identify physicians by name or address, but did provide other useful information about hospital sanctions, malpractice payouts and state disciplinary actions against doctors across the country.

HRSA says it took the Public Use File offline after a lawyer representing a physician complained that Kansas City Star reporter Alan Bavley had obtained information improperly from the data bank. HRSA threatened Bavley with monetary sanctions if his paper ran the story. His article ran Sept. 4, prominently featuring the doctor and using the Public Use File to fill in details about him. HRSA did not pursue fines against Bavley.

Six national journalism organizations, as well as consumer groups and academic researchers, have formally objected to HRSA’s decision to take the database off its website. Sen. Charles Grassley, R-Iowa, condemned the decision in a letter to HRSA Administrator Mary Wakefield and HHS Secretary Kathleen Sebelius.

“The idea of taking down the Public Use File is really a big deal. There is no substitute for having it,” said Sidney Wolfe, M.D., director of Public Citizen’s Health Research Group. “The case can’t be stronger for having the data bank in the form that it used to be in.”

Cynthia Grubbs, director of the division of Practitioner Data Banks, gave no commitment about whether the Public Use File would return or in what format.

“We understand you have concerns with that decision,” she said at the beginning of the call. “We are trying to balance the need to protect confidentiality under the data bank statute with our continued desire to shine a bright light” on the quality and safety of patient care across the country.

Grubbs asked a series of questions about how HRSA could provide usable information on its website, including charts and graphs.

But Jeremy Kohler, a reporter for the St. Louis Post-Dispatch, said, “It is not even close to a substitute for restoring the raw data that was on the data bank before.”

‘On The Media’ covers NPDB controversy

This week’s “On The Media” show features AHCJ President Charles Ornstein discussing the public use file of the National Practitioner Data Bank.

Listen to On The Media

As regular readers of Covering Health know, this is an important file that has been used by patient safety advocates, reporters and other researchers to report on medical disciplinary actions, lax oversight and loopholes at state medical boards. The Health Resources and Services Administration, part of the federal Department of Health and Human Services, took the file offline on Sept. 1 following a complaint from one doctor’s lawyer.

AHCJ and other journalism groups have protested the removal of the file and have called for it to be returned to the public site. U.S. Senator Charles Grassley has joined the protest with a letter to the HRSA administrator that demands answers to his questions about why this file is no longer publicly available.

Duff Wilson of The New York Times wrote a blog post about the file being taken offline and Grassley’s letter. For complete coverage of the issue, please see AHCJ’s Right to know news.

More journalism groups join effort to restore access to National Practitioner Data Bank

Three additional journalism organizations have joined the campaign calling for the Obama administration to restore access to a public version of the National Practitioner Data Bank. And letters are going out to key members of Congress asking for their assistance.

The National Association of Science Writers, Reporters Committee for Freedom of the Press, and National Freedom of Information Coalition have signed the letter, along with the Association of Health Care Journalists, Investigative Reporters & Editors, and the Society of Professional Journalists.  The groups have more than 15,000 members.

The U.S. Health Resources and Services Administration removed the Public Use File (PUF) from the data bank website earlier this month because officials believe it was used to identify physicians inappropriately.

The National Practitioner Data Bank is a confidential system that compiles malpractice payouts, hospital discipline and regulatory sanctions against doctors and other health professionals. For years, HRSA has made a public version of it available without identifying information about the health providers.

“The Public Use File, while it didn’t identify doctors by name or address, provided invaluable information about the functioning of state medical boards and hospital disciplinary systems,” said the letter from the groups to members of Congress. “Reporters for years have used the data to identify holes in their states’ regulatory systems that have led to patient harm. As a result of these stories, states have enacted new legislation and medical boards have taken steps to investigate problem doctors.”

The groups also provided the representatives and senators with details of major stories written with the assistance of the Public Use File and descriptions of the changes that resulted.

Finally, the letter once again expressed concern that HRSA sent a threatening letter on Aug. 26 to Alan Bavley, a health reporter at the Kansas City Star. The letter, signed by Division of Professional Data Banks director Cynthia Grubbs, said that Bavley could be subject to a civil monetary penalty of up to $11,000 if he identified a physician based upon confidential information in the data bank. The threat came even though other reporters have done the same thing for years without penalty.

In news reports, HRSA acknowledged that the letter–and the agency’s subsequent decision to remove the Public Use File–was prompted by a single complaint: from the lawyer of a doctor who was the subject of Bavley’s story.

Although HRSA said in some news reports that it will not pursue sanctions against Bavley, he has not received an apology.

“Without stories written by our members, it’s fair to say that some unsafe doctors would continue to be practicing with clean licenses and patient protection legislation in several states likely would not have been enacted,” the letter said.

Calif. prison doc made $777,000 for not treating patients

Using state records, Jack Dolan of the Los Angeles Times found that one of the most highly paid state employees in California is a doctor who has not been allowed to treat patients in six years.

Dr. Jeffrey Rohlfing is a prison surgeon who has a history that includes a psychiatric crisis, revocation of his clinical privileges after a patient died and allegations of substandard care that led to his being fired.

While appealing his termination, he has “been relegated to reviewing paper medical histories, what prison doctors call ‘mailroom’ duty.”

Last year, Rohlfing made $777,423 – that’s his base pay of $235,740 plus back pay for two years when he didn’t work while he successfully appealed his termination.

Rohlfing isn’t the only doctor in California’s cash-strapped prisons earning big money to shuffle paper. Dozens have been relegated to the chore in recent years, according to Kincaid, who said it’s the standard assignment given to physicians when questions arise about their clinical ability. Some eventually return to treating patients, some quit and others are ultimately fired, she added.

Dolan writes that California’s prison system has a history of employing doctors with problems. In 2006, judges said that contributed to the “fact that a prisoner died ‘needlessly’ every six to seven days in a state lockup.”

Hat tip to @wheisel, who has tips from this investigation.

Related

• Tip sheet: Covering health care in jails

Shifts in health care delivery raise questions

Christopher Weaver at Kaiser Health News has done two stories recently on new care models driven by insurers eager to save money. Both stories lay out issues that AHCJ members can examine in their own communities, particularly regarding the influence insurers will have over health care delivery and how it differs – or does not differ – from the HMOs of the 1990s.

The first story, in May,  (Health Insurers Opening Their Own Clinics To Trim Costs) was about insurers (specifically Medicare Advantage plans)  opening clinics to treat some of their patients that need a lot of health care, and tend to get it in costly (to the insurer) as well as unpleasant (to the patient) places like emergency departments.  Giving high-needs patients easy access to care in a clinic – which one could think of broadly as a type of “medical home” – can give them continuity of care, avoid health crises, and cost less money in a closed system where the insurer can shape the payment incentives and share in savings.

The second, more recent, story (Managed Care  Enters the Exam Room as Insurers Buy Doctor Groups) reported on a trend that isn’t getting too much attention. Big insurers are buying up physician medical groups, or launching physician management companies. Weaver wrote that it’s “part of a strategy to curb rising health costs that could cut into profits and to weather new challenges to their business arising from the federal health law.”

As Weaver and other reporters have noted, more doctors are giving up solo and small practices in favor of large groups, multi-specialty groups, or staff positions at hospitals. (This Washington Post piece looked at the related trend of hospitals hiring primary care physicians.) Many health policy experts believe the trend toward larger groups and more integrated practices will help reduce fragmentation and duplication, saving money and improving quality.

But what happens when the insurers control the purse strings?  Weaver wrote:

“The doctors, at the end of the day, control the patients and currently [in the regular fee for service system, not this insurer-owned model] they’re financially incentivized to do more tests, more procedures,” said Chris Rigg, a Wall Street analyst for Susquehanna Financial Group. “But, if they’re employed by a managed care company, they’re financially incentivized” to do less.

That thought unnerves consumer advocate Anthony Wright of Health Access in Sacramento, Calif., who worries profit pressure could affect care decisions. But Wright also said there may be upsides to more tightly managed care: “No patient wants to get more procedures than they actually need.”

So that’s the dilemma. Will these insurer-owned and operated systems be curbing costs by getting rid of the unnecessary, wasteful and sometimes harmful care, or will they skimp on care? If they formally become Accountable Care Organizations under Medicare, they will have to be accountable for not only the cost but the quality, in defined and measurable ways. But if they are just slapping an “accountability” label on themselves, it’s less clear who they are accountable to, and what they are accountable for.  It’s not a given that it will be a reprise of the HMOs.

The business environment – purchasers of insurance wanting quality and value – is different than the 1990s. State-based exchanges starting in 2014 may be able to inject more accountability into the system. Medicare and Medicaid as well as state governments are doing more on quality measurements, value-based purchasing etc.  But it’s not clear exactly how all that will play out in the insurer-driven model and whether consumers will resist in ways reminiscent of the managed care backlash 10 or 15 years ago.

“There’s a gigantic Murphy’s law emerging here,” Weaver quoted a health care consultant as saying.  “The very people who were the demons in all of this, that the public can’t stand” – managed-care firms – “are the big winners.”

How will aging doctors affect your community?

AHCJ member Ryan Sabalow, a reporter at the Redding (Calif.) Record Searchlight, recently looked at the age of doctors in his county, finding that “nearly two thirds of Shasta County’s doctors are older than 50, and there aren’t nearly enough young doctors lining up to replace their retiring peers.”

Sabalow freely admits he’s not the first to cover the topic and acknowledges the work of Ventura County Star reporters over the summer. In a Reporting on Health blog post, Sabalow suggests that reporters contact the state medical board and request the an age range of physicians in their county.

The Association of American Medical Colleges forecast that the “passage of health care reform will increase the need for doctors and exacerbate a physician shortage driven by the rapid expansion of the number of Americans over age 65.” For a look at how many physicians are practicing in each state, as well as how many are in school, see the organization’s state-by-state statistics.

Some resources on workforce issues for AHCJ members:

• AHCJ article: How will retiring boomers affect the national health agenda?
  
• AHCJ article: Caring for aging population will require health care transformation
• Tip sheet: Addressing current and future health workforce hurdles
• Tip sheet: Assessing health reform: Is there a looming doctor shortage?
• Report: VA facilities face shortage of nurse anesthetists
  
• Report: Preparing for aging boomers
• Report: AAMC’s 2009 workforce report
• Award entry: ‘State struggles with primary care workforce incentives,’ KHI News Service
• Presentation: The Health Workforce Dream Team: Who Will Provide the Care?

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