Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
NATIONAL  PRACTITIONER  DATA  BANK 
REPORTS  TO  MANAGED  CARE 
ORGANIZATIONS: 
THEIR  USEFULNESS  AND  IMPACT 
JJ  sERbs./,. 
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$?  ~  JUNE  GIBBS BROWN 
/  Inspector  General 
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vd3a & 
OEI-01-94-OO032  OFFICE  OF INSPECTOR  GENERAL 
The missionof the Officeof InspectorGeneral(OIG),as mandatedby PublicLaw95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This 
statutorymissionis carried outthrougha nationwidenetworkof audits, investigations,and 
inspectionsconductedby three OIGoperatingcomponents: the Officeof AuditServices,the 
Office of Investigations, and the Office of Evaluation and Inspections. The OIG also informs the 
Secretary of HHS of program and managementproblems and recommendscourses to correct them. 
OFFICE  OF AUDIT  SERVICES 
The OIGSOfficeof AuditServices(OAS)providesall auditingservicesfor HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying out 
their respectiveresponsibilitiesandare intendedto provideindependentassessmentsof HHS 
programs and operations in order to reduce waste, abuse, and mismanagementand to promote 
economy and efficiency throughout the Department. 
OFFICE  OF INVESTIGATIONS 
The OIGSOfficeof Investigations(01) conductscriminal, civil, and administrativeinvestigations 
of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment 
byproviders.  The investigativeeffortsof 01 leadto criminalconvictions,administrative 
sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud control units which 
investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE  OF EVALUATION  AND INSPECTIONS 
The OIGSOfficeof Evaluationand Inspections(OEI)conductsshort-termmanagementand 
program evaluations (called inspections)that focus on issues of concern to the Department, the 
Congress, and the public.  The findings and recommendationscontained in these inspection reports 
generaterapid, accurate, andup-to-dateinformationonthe efficiency,vulnerability,and 
effectiveness of departmental programs. 
This report was prepared in the Boston Region Office under the direction of Mark R. Yessian, 
Ph.D., Regional Inspector General and Martha B. Kvaal, Deputy Regional Inspector General. 
Project staff included: 
BOSTON  REGION  HEADQUARTERS 
David Veroff, ProjectLeader  Alan Levine, ProgramSpecialist

Joyce Greerdeaf, ProgramAnalyst

Barry McCoy, ProgramAnalyst

Michael Sullivan, SummerZntern

Foradditionalcopiesof this report,please contacttheBostonregionalofice  by telephoneat

(61~ 565-1050, or byfa  at (617)565-3751.
 EXECUTIVE  SUMMARY 
PURPOSE: 
To assess the usefulness  and impact of the information  in the National  Practitioner  Data 
Bank to managed  care organizations. 
BACKGROUND 
Since September  1, 1990, the National Practitioner  Data Bank (hereafter  referred  to as the 
Data Bank) has received  and maintained  records  of malpractice  payments  and adverse 
actions against licensed health care practitioners.  It provides  hospitals  and other health 
care entities  with information  relating to the professional  competence  and conduct  of 
health care practitioners.  Hospitals  are required  to request  information  from the Data 
Bank about every physician  and dentist who applies for appointment.  In addition, 
hospitals  must query at least once every 2 years on every practitioner  who is on their 
medical  staff or has privileges.  Other health care entities,  such as health maintenance 
organizations  (HMOS), preferred  provider  organizations  (PPOS), and group practices  may 
query as long as they provide  health care services and engage in professional  review 
activities  through  a formal peer review process.  As of February  25,  1994, HMOS, PPOS, 
and group practices  had received,  in response to queries,  31,377  reports  of malpractice 
payments  or adverse  actions against physicians,  dentists,  and other health care 
practitioners. 
In February  1993, we released  a report  that evaluated the usefulness  and impact of reports 
to hospitals  through  March  1992.  In December  1993, the Administrator  of the Health 
Resources  and Services  Administration  (HRSA) asked us to update the information  in the 
February  1993 report  using more recent data.  We agreed to conduct that study and 
another  study of the experiences  of HMOS, PPOS, and group practices  with using Data 
Bank information.  For purposes  of this study we are referring  to these as managed  care 
organizations.  In this report  we refer to some findings of the updated  hospital  report, 
particularly  where we found major differences  between managed  care organizations  and 
hospitals. 
The data in this report  are from a survey we conducted  of managed  care organizations  that 
received  reports  of malpractice  payments  or adverse actions from the Data Bank.  We 
sampled 400 matches--instances  when a querying  managed care organization  received  a 
report  of a specific incident--from  the universe  of 30,016 HMO,  PPO,  and group practice 
matches  from March  20,  1992 through  February  25,  1994.  We asked the managed  care 
officials questions  about how they used and what their assessments  were of the reports;  we 
received  203 useable  responses.  Appendix A gives details of our methodology. 
i  FINDINGS 
USEFULNESS:  Managed  care officials found  nearly all Data Bank reports to be 
useful. 
 Managed  care officials found 96 percent  of the Data Bank reports  they received  to 
be useful.  This compares  with 83 percent  of hospital officials who found the Data 
Bank reports  to be useful. 
 Twenty-two  percent  of the Data Bank reports  provided  information  previously 
unknown  to managed  care organizations. 
 The managed  care officials most-often  cited reason for usefulness  was that the 
reports  confirmed  information  about practitioners  that organization  officials  already 
knew.  Other common reasons cited include that the reports  help in making 
judgments  about practitioners  professionalism  and competency. 
 The managed  care officials reported  that, upon additional  inquiry,  3 percent 
(5 of 203) of the Data Bank reports  appeared  inaccurate.  No hospital  reported 
that,  upon additional  inquiry,  the Data Bank reports  appeared  inaccurate. 
 Overall,  the Data Banks median response time to a query from a managed  care 
organization  was 23 days.  With electronic  queries,  the median dropped  to 
13 1/2 days; without electronic  queries,  it increased to 35. 
IMPACT  ON DECISIONS:  The managed  care officials  seldom made different 
privile~ng decisions  than they would have made without the Data Bank reports. 
 According  to managed  care officials,  3 percent  (5 of 183) of the Data Bank reports 
led them to make different  decisions than they would have made without the 
reports.  Among the officials who did not make different  decisions,  65 percent 
reported  that the reports  made them feel more confident  about their decisions. 
 Eighty-one  percent  (148 of 183) of the Data Bank reports  had little chance  to have 
an impact on managed  care organizations  privileging  decisions.  These reports 
either  named practitioners  who did not complete  the privileging  process,  were not 
received  prior  to the decisions,  or provided  information  already  known. 
 Sixteen percent  (30 of 183) of the reports  arrived  before the managed  care 
organizations  made final privileging  decisions and contained  information  that 
neither  the physician  nor any other source had provided,  yet did not have an 
impact on the privileging  decisions. 
ii  CONCLUSION 
The information  in this report  contributes  to an understanding  of the usefulness  and impact 
of the Data Bank in managed  care organizations.  Almost all--96 percent--managed  care 
organizations  receiving  information  from the Data Bank find it usefid.  In fact,  this 
percent  is considerably  higher than the percent  of hospitals finding the information  useful 
(83 percent).  At the same time,  our data reveal that Data Bank reports  seldom affect 
privileging  decisions  of managed  care organizations. 
During  this and prior  inspections on the Data Bank, we have become  ever more  aware of 
differing  expectations  of the Data Bank.  Thus,  any assessments  of the Data Banks 
usefulness  and impact will depend heavily  on how these expectations  are expressed  and on 
the relative  emphasis  given to them.  In that context,  we offer the following  concluding 
observations  concerning  three  important  expectations  about the Data Bank. 
 Data Bank as a Reliable,  Centralized  Source of Inforrn&on.  In the sense that 
the Data Bank is expected to serve as such a source of information  about adverse 
actions and medical malpractice  payments,  it seems to be working  quite well.  It is 
a timely,  accurate  source that is widely regarded  as useful--mainly  because  it 
confirms  information  available  from other (presumably  less reliable)  sources. 
 Data Bank as a Unique Source of Information.  In the sense that the Data Bank is 
expected  to serve as a unique source of information--that  is, one unavailable 
elsewhere--it  clearly  has some value.  In our sample,  22 percent  of the reports 
provided  new information  to managed care organizations.  That 22 percent  projects 
to 6,483  reports  providing  new information  to managed care organizations  over a 
period  of almost 2 years. 
 Data Bank as a Mechanism  to Prevent Incompetent  and/or  Unprofessional 
Practitioners from  Practicing  in HMOS, PPOS, or Group Practices.  Clearly  this 
is the most ambitious  and controversial  of these expectations.  It is also the one 
most difficult  to assess without more information.  In one sense, the fact that 
3 percent  of reports  are having an impact on privileging  decisions  may seem 
inappropriately  low.  It may suggest that managed  care organizations  are overly 
reluctant  to take adverse actions against incompetent  and/or  unprofessional 
practitioners. 
Yet,  to the extent that only a small percent  of practitioners  are unfit to practice, 
one may argue that nothing is necessarily  inappropriate  about 3 percent  of reports, 
which projects  to 930 reports  over a period  of almost 2 years,  having an impact on 
privileging  decisions.  These 930 reports  involve hundreds  of practitioners  and 
affect thousands  of patients they serve.  Finally,  it is important  to recognize  that 
the very existence  of the Data Bank may deter  some unfit practitioners  from even 
applying  to managed  care organizations  for practice  privileges  and may encourage 
other practitioners  to be more forthcoming  in the applications  they submit for 
managed  care organization  privileges. 
... 
111  COMMENTS  ON  THE  DRAFT  REPORT 
We solicited  and received  comments  on the draft report  from the Public Health  Service 
(PHS),  the Assistant  Secretary  for Planning  and Evaluation  (ASPE),  the National 
Committee  on Quality Assurance  (NCQA),  and the American  Medical  Association 
(AMA).  We include the complete  text of their comments  in appendix  C.  Below we 
summarize  comments  of the respondents  and,  in italics,  offer our responses. 
PHS  Comments 
The PHS indicated  that the report  would be  helpful.  It called for one minor  change  in 
the background  section of the report  where we explain the Data Bank law.  We appreciate 
the positive  response from  PHS.  We made the change requested. 
ASPE  Comments 
The ASPE supported  the purpose  of our inquiry and noted that the methodology  seemed to

be appropriate.  It added,  however,  that the conclusion  that the Data Bank is useful  is

questionable  and that the data in the report  might be used to support a contrary

conclusion.  We did not conclude that the Data Bank is usefid.  We elaborated  on how

ones assessments  of usefulness and impact will depend heavily on ones expectations  of

the Data Bank.

NCQA  Comments 
The NCQA responded  that it was heartening  to learn that most respondents  found the 
Data Bank reports  to be useful,  but  disturbing  to find that some queries to the Data 
Bank were made after the credentialing  decisions had been made.  It also offered  some 
clarification  concerning  NCQA credentialing  standards.  We made minor changes  in our 
text in accord with NCQAs  clari~cations  on its credentialing  standards. 
AMA  Comments 
The AMA expressed  its reservations  about the cost-effectiveness  of the Data Bank and 
stressed  that our report  offered  an incomplete  and misleading  picture  of the Data Banks 
usefulness  and impact.  Among the major points it emphasized  were that:  (1) our report 
focuses on Data Bank matched  reports  rather  than the larger universe  of queries  to the 
Data Bank,  (2) some of the data we presented  appeared  to be inaccurate,  and (3) the 
49 percent  of managed  care organizations  that failed to respond to our questionnaire  may 
have a less positive  view of the Data Bank than those who did respond. 
We disagree  with the AMA  over the value of focusing  on matches.  We have done so in 
this and other reports because we determined  that it would provide  discrete, practical 
information  about what the Data Bank actually produces for  querying  organizations.  Such 
information  can contribute  to broader assessments  of the Data Bank.  On the other points 
raised,  we  (I) conjlrmed  the accura~  of the data that was questioned  and  (2) have no 
basis for  knowing  if nonrespondents  are more or less favorably  disposed  toward the Data 
Bank. 
iv  TABLE  OF  CONTENTS 
PAGE

EXECUTIVE  SUMMARY

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3


usefulness  toManagedCare  Organizations  . . . . . . . . . . . . . . . . . . . . . . ...3


Impacton  Managed care organizations  . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

CONCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

COMMENTS  ON THE DRAFT  REPORT  . . . . . . . . . . . . . . . . . . . . . . . .  10

APPENDICES

A:  Methodology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  A-1

B:  Summary  ofResponses  totheOIG  Mail Survey  . . . . . . . . . . . . . . . . . . . .  B-1

c:  Complete Comments ontheDraft  Report.  . .  . . . . . . . . . . . . . . . . . . . . . ,c-1

D:  Notes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..D-l
 INTRODUCTION 
PURPOSE 
To assess the usefi.dness and impact of information  in the National  Practitioner  Data Bank 
to managed  care organizations. 
BACKGROUND 
Since September  1, 1990, the National Practitioner  Data Bank has received  and 
maintained  records  of malpractice  payments  and adverse actions taken by hospitals,  other 
health care entities,  licensing boards,  and professional  societies against licensed health 
care practitioners.  It provides  hospitals and other health care entities with information 
relating  to the professional  competence  and conduct of physicians,  dentists,  and other 
health care practitioners.  The Data Bank was established  by Title IV of the Health  Care 
Quality Improvement  Act of 1986 (P.L.  99-660),  as amended,  and is fimded by user  fees. 
It is operated  by Unisys Corporation  under contract  to the Health Resources  and Services 
Administration  (HRSA) of the Public Health  Service. 
Hospitals  are required  to request  information  from the Data Bank about every physician 
and dentist who applies for appointment.  Hospitals must also query about all medical  and 
dental  staff and other health care practitioners  with clinical privileges  at least once every 
2 years.  They have the option of querying  about any practitioner  with privileges  (or who 
is seeking privileges)  at any time.  The Data Bank is intended to provide  information  to 
hospitals  to help them make decisions  about hiring,  granting privileges  to, and disciplining 
practitioners. 
Other health care  institutions,. such as health maintenance  mganizations  (HMO@,.preferred 
provider  organizations  (PPOs),  and group practices  also query the Data ?3arik. in  order  to 
query,  these other institutions  must provide  health care services  and engage  in professional 
review  activity  through  a formal peer review process.  Unlike hospitals,  which are 
mandated  to query,  HMOS, PPOS, and group practices  query voluntarily.  However,  in 
1993 the National  Committee  for Quality Assurance  issued credentialing  standards  that 
serve to encourage  HMOS seeking accreditation  to query the Data Bati- for practitioners 
seeking credentials. 1 
As of February  25,  1994, the Data Bank issued  144,649 matched  reports  of malpractice 
payments  or adverse  actions against physicians,  dentists,  and other health care 
practitioners  to querying  health care entities.  We summarized  in detail the profiles  of 
these  matches  in a report  released  in August  1994.2  The HMOS, PPOS, and group 
practices  received  31,377  (or 22 percent)  of those  144,649 reports  in response  to their 
queries  during  this 3 1/2 year period.  Queries and matches from these organizations 
have grown  since the Data Bank was established.3 
1
 In February  1993, we released  a report that evaluated the usefulness  and impact of reports 
to hospitals  through  March  1992.4  That report provided  officials in the Department  and 
other parties  interested  in the Data Bank with an early evaluation  of the Data Banks 
effectiveness  and utility.  In December  1993, the Administrator  of HRSA asked us to 
update  the information  in the February  1993 report using more recent  matches.  He 
cited significant  changes  in the operation  of the Data Bank,  a more sizable universe  from 
which to draw experiences,  and the usefulness  of the report  to officials  in HRSA as 
reasons  for his request.  We agreed to conduct that study and issue another  report. 5  In 
addition to that updated  study,  we conducted  this study of the experiences  of HMOS, 
PPOS, and group practices  with using Data Bank information.  For the purposes  of this 
study we are referring  to these as managed  care organizations.  In this report  we refer  to 
some findings  of the updated  hospital report,  particularly  where we found major 
differences  between managed  care organizations  and hospitals. 
METHODOLOGY 
The data presented  in this report  are derived  from a survey of HMOS, PPOS, and group 
practices  that received  reports  of malpractice  payments  or adverse  actions from the Data 
Bank.  We drew a sample of 400 matches from the universe  of 30,016  HMO,  PPO,  and 
group practice  matches  from March 20,  1992 through  February  25,  1994 (our prior  study 
was based  on a sample from September  1, 1990 through  March  19, 1992).  A match 
occurs when a querying  organization  receives  a report  of a specific incident  from the Data 
Bank.  We received  203 useable  responses,  the majority  (94 percent)  from HMOS: 
190 from HMOS, 6 from PPOS, and 7 from group practices.  Our findings can be 
projected  to the universe  of 30,016 matches.  Appendix A gives details of our 
methodology  and provides  information  about the reports  and practitioners  included  in the 
study. 
We conducted  this study in accordance  with the Quality Standards for  Inspections  issued 
by the Presidents  Council  on Integrity  and Efficiency. 
2
 FINDINGS

USEFULNESS:  Managed  care officials found  nearly all Data Bank reports to be 
useful. 
Whether  a report  from the Data Bank is useful to a managed care organization  depends on 
several  factors.  Some factors can be determined  objectively,  such as whether  the report 
provides  new information  or duplicates  other reports,  whether  it is accurate,  and whether 
the report  arrives  in time to be used in the privileging  process.  Other factors  are more 
subjective,  such as whether  the report  is relevant  to the practitioners  competency  and 
professionalism.  Measured  by both objective  and subjective criteria,  the Data Bank 
appears  to provide  useful  information. 
	 Managed  care officials found 96 percent  of the Data Bank reports  they received  to 
be useful.  This compares  with 83 percent  of hospital officials who found the Data 
Bank reports  to be useful. 
The above finding refers  to instances when a query to the Data Bank produces  a report

having malpractice  or adverse  information  on a practitioner.  When making  queries,

managed  care organizations  are more likely to get responses  indicating that the Data Bank

has no malpractice  or adverse  information  on a practitioner.  We asked them how usefi.d

such responses  are:  extremely  usefi.d, very useful,  moderately  useful,  somewhat useful,

or not useful.  Among the 96 percent  who answered that the reports  were useful,  the

majority  designated  the  extremely  or very useful categories.  They cited documenting

the privileging  process,  confirming  other sources,  and increasing  confidence  to explain

why such responses  were useful.  Seventy-seven percent  of the hospitals  also found such

responses  to be extremely,  very,  or moderately  useful.

We asked managed  care officials,  whether,  considering  all things,  it was worthwhile  to

query the Data Bank.  Ninety-five  percent  of them reported  that it was worthwhile.  They

mentioned  that querying  was quick, easy,  and helped them document  their privileging

process,  especially  in light of the National  Committee  for Quality Assurance  accreditation

standard  calling  for Data Bank queries.

We also asked managed  care officials to rate the usefulness  of the four types of Data Bank

information:  licensing  board actions,  hospital actions,  malpractice  payments,  and

professional  society actions. G The majority  rated all types as extremely  useful:

79 percent  rated  licensing board actions as extremely  useful;  75 percent,  hospital  actions;

68 percent,  malpractice  payments;  and 60 percent,  professional  society actions.  Hospitals,

on the other hand,  were less likely to rate adverse action reports  (from hospitals  or

licensure  boards)  as useful.

	 Twenty-two  percent  of the Data Bank reports provided  information  previously 
unknown  to managed  care organizations. 
3
 The managed  care officials judged  as useful all of the reports  that provided  new 
information  and 94 percent  of those that provided  information  they already  knew. 
For some managed  care organizations,  the Data Bank appears to fill gaps in information 
from other common  sources,  such as practitioners,  malpractice  insurers,  and State 
licensure  boards.  For example,  we found that 31 percent  of the Data Bank reports 
provided  information  that practitioners  did not provide  themselves  to the organizations.  In 
hospitals,  42 percent  of the reports provided  information  that the practitioners  did not. 
Varying  disclosure  and privileging  policies,  awareness  of the Data Bank,  assumptions 
about other entities disclosing  relevant  information,  and/or  desire to withhold  information 
could all influence  the extent to which practitioners  disclose details about their  own 
backgrounds. 
The Data Bank appears to be a particularly  important  source of information  on adverse 
actions for some managed  care organizations.  The officials reported  already  knowing 
about malpractice  payments  more often than adverse actions.  They were already  aware  of 
the information  in 80 percent  of the reports  concerning  malpractice  and 58 percent  of the 
reports  concerning  adverse  actions. 
	 The managed  care officials most-often  cited reason for usefulness  was that the 
reports  confirmed  information  about practitioners  that organization  officials  already 
knew.  Other common reasons cited include that the reports  help in making 
judgments  about practitioners  professionalism  and competency. 
The Data Bank may in fact be filling a need for a reliable  source of information.  Of the 
Data Bank reports judged  usefi.d, 75 percent  were considered  usefi,d because  they 
confirmed  information  available  elsewhere.  Hospital  officials cited that same reason  for 
65 percent  of the reports judged  useful.  If the managed  care officials found other  sources 
of information  to be very reliable  or trustworthy,  they might find Data Bank reports  to be 
less useful because  they were duplicative.  Indeed,  duplicative  information  was the reason 
cited by seven of the eight managed care officials who judged  the reports  not useful. 
The second and third reasons cited more closely reflect the Data Banks purpose  to 
provide  information  on professional  competence  and conduct:  67 percent  of the reports 
were considered  useful because they helped organizations  in judging  practitioners 
competency,  52 percent  for judging  professionalism.  Hospital respondents  cited those 
reasons  less often:  32 percent  for competency  and 25 percent  for professionalism. 
The fourth  reason managed  care officials cited to explain usefulness  was providing 
information  unavailable  elsewhere.  Of the Data Bank reports judged  useful, 
19 percent  were judged  useful in part because they provided  new information.  For 
hospitals,  24 percent  of the reports  were considered  useful for this reason. 
Finally,  for those pursuing  accreditation  from the National  Committee  for Quality 
Assurance,  querying  the Data Bank satisfies an accreditation  standard.  Several managed 
4
 care officials  reported  that the Data Bank reports provide  important  documentation  for 
both their  own privileging  and the accreditation  process. 
	 The managed  care officials reported  that, upon additional  inquiry,  3 percent 
(5 of 203) of the Data Bank reports  appeared  inaccurate.  No hospital  reported 
that, upon additional  inquiry,  the Data Bank reports  appeared  inaccurate. 
Managed  care organizations  have other sources for information  about practitioners,  which 
gives them the opportunity  to compare  information  among sources.  These comparisons 
may prompt  some organizations  to make fi.mtherinquiries;  other organizations  make 
further  inquiries  as a matter  of course. 
In our sample,  3 percent  (5) of the managed care officials reported  that, upon additional 
inquiry,  the Data Bank reports  appeared  inaccurate.  In one case,  for example,  the official 
noted that the Data Bank wrongly characterized  the type of payment  and the number  of 
practitioners  involved  in the payment.  In another the official said the Data Bank had the 
wrong settlement  amount.  And another noted the report  to be inaccurate  because  it 
included  claims the malpractice  insurer  did not--making  the Data Bank report  appear  to be 
more comprehensive  than the insurers  report.  These inaccuracies  warrant  additional 
scrutiny  and have been called to the attention of the Public Health  Service. 
In our draft report,  we had indicated that 5 percent  (10) of the officials noted that the Data 
Bank reports  supplied to them should have had additional  information  on the practitioner 
in question.  They reported  being aware of 13 sanctions  (4 disciplinary  actions and 
9 malpractice  payments)  since September  1, 1990 that the Data Bank reports  did not 
include. 
Upon further  inquiry  since the issuance of our draft report,  we found that  11 of the 
13 missing  actions or payments  were explainable  as respondent  errors  or as timing  issues 
(wherein  a managed  care organization  learned  of a malpractice  payment  or disciplinary 
action from another  source before  it was sent to the Data Bank).  In two cases,  both 
involving malpractice  payments,  it appears that there may have been nonreporting  to the 
Data Bank.  We are still investigating  this. 
	 Overall,  the Data Banks median response time to a query from a managed  care 
organization  was 23 days.  With electronic  queries,  the median dropped  to 
13 1/2 days; without electronic  queries,  it increased  to 35. 
Managed  care organizations  can query the Data Bank two ways:  electronically  or through 
the mail.  In our sample,  managed care organizations  obtained  53 percent  of the reports 
electronically. 
Receiving  the reports  in time for decisions can also be an important  factor  affecting 
usefulness.  The majority  of managed care organizations  received  their requested  reports 
before  they made their final privileging  decisions  (86 percent).  In some cases,  however, 
5
 they queried  late in their decision-making  process or after the decision had been made, 
making  it impossible  for the reports  to arrive  in a timely manner.  Of the 9 percent 
(18) that received  their reports  after a decision was made,  61 percent  (11),  submitted  their 
queries  after they had made their decisions. 
IMPACT  ON DECISIONS:  The managed  care officials  seldom made different 
privile~ng decisions  than they would have made without the Data Bank reports. 
The information  from the Data Bank can affect managed  care organizations  in several 
ways.  It may give their administrators  confidence  that they have complete  information 
about their medical  staffs.  It may add information  to practitioners  files that could be 
used in the future  should questions arise.  But Data Bank reports  can have their most 
direct  impact by affecting  the outcome  of decisions on practitioners  who are undergoing 
the privileging  process  for the first time or for renewed  credentials.  For this reason,  we 
asked managed  care officials the following question:  Would your decision  regarding  the 
practitioner  have been different  if you had not received  the Data Bank report?  Because 
our measurement  of impact focused on the privileging  decisions,  we excluded  most of the 
cases with pending  decisions  from our analysis.7  We did include four cases with pending 
decisions  because  the managed  care officials made it clear that even though the decisions 
were pending,  they were indeed affected by the information  in the Data Bank report. 
Figure  1 depicts the proportion  of reports that had impact,  no potential  for impact,  and 
potential  for impact. 
Figure  1 
IMPACTOF DATABANKREPORTS 
le to Have Impacg 
DidNot  16% 
J 
Had An Impact  3% 
Unlikely to Have  VI  (lkciaiona Different) 
Impact  81% 
I  SOlnw  HHsofamOfrlqmtm  omEralsIlrw0yf3ndo,FTo, andgmppdicecllkida 
	 According  to the managed  care officials,  3 percent  (5 of 183) of the Data Bank 
reports  led them to make different  decisions than they would have made without 
6  the reports.  Among the officials who did not make different  decisions,  65 percent 
reported  that the reports  made them feel more confident  about their decisions. 
One managed  care organization  was involved in three of these decisions.  The official 
there  noted that the Data Bank information  caused a delay in the privileging  decisions  that 
otherwise  would have been made right away.  In one case the Data Bank report  described 
a $3,375  surgery-related  malpractice  payment  and in another  a $25,000  malpractice 
payment  for a medication  error. 
Another  managed  care organization  decided that, based on the information  in the report, 
the practitioner  had to undergo  reprivileging  every year rather  than every  other year as the 
organization  policy  requires.  That report  described  a $200,000  malpractice  payment 
related  to failure  to diagnose. 
Finally,  one managed  care organization  reported  that,  without the Data Bank report,  it 
would have granted privileges  as requested  by the practitioner.  Instead,  it revoked  the 
practitioners  participation  in the organization.  That report  described  a 
$12,500  malpractice  payment  related  to inappropriate  behavior  of the practitioner  and 
improper  management  of the medication  regimen. 
	 Eighty-one  percent  (148 of 183) of the Data Bank reports had little chance to have 
an impact on managed  care organizations  privileging  decisions.  These reports 
either  named practitioners  who did not complete  the privileging  process,  were not 
received  prior  to the decisions,  or provided  information  already  known. 
Of these  148 reports: 
11 named practitioners  who did not complete  the privileging  process.  These 
practitioners  either withdrew their applications,  retired,  terminated  their 
relationship  with the organization,  or failed to submit a completed  application. 
17 were not received  prior  to the managed care organizations  decisions.  For 
10 of these reports,  the organization  did not query the Data Bank until after 
making  their decisions. 
120 provided  information  already known to the managed  care organization. 
We also asked managed  care officials why the reports  did not lead them to make different 
decisions.  The top reason,  cited by 63 percent  of responding  officials,  was already 
knowing the information.  The next reason,  cited by 44 percent  of responding  officials, 
was that the information  in the Data Bank report  did not warrant  restricting  or denying 
privileges.  Respondents  cited other reasons less often:  that the report  failed to arrive  in 
time (7 percent)  and that they would have denied or restricted  privileges  anyway 
(1 percent). 
7
 	 Sixteen percent  (30 of 183) of the reports  arrived  before the managed  care 
organizations  made final privileging  decisions and contained  information  that 
neither  the physician  nor any other source had provided,  yet did not have an 
impact on organizations  privileging  decisions. 
We asked the organization  officials who said their decisions would not have been different 
without the Data Bank report  why that was so.  Of the responding  officials,  63 percent 
said that at least part of the reason the reports  failed to have impact was that the reports 
did not indicate  a problem  warranting  restricting  or denying privileges.  The organizations 
considered  all of these reports  useful even though they had no impact on privileging 
decisions. 
8
 CONCLUSION 
The information  in this report  contributes  to an understanding  of the usefulness  and impact 
of the Data Bank in managed  care organizations.  Almost all--96 percent--managed  care 
organizations  receiving  information  from the Data Bank find it useful.  In fact, this 
percent  is considerably  higher than the percent  of hospitals finding the information  useful 
(83 percent).  At the same time,  our data reveal that Data Bank reports  seldom affect 
privileging  decisions  of managed  care organizations. 
During  this and prior  inspections on the Data Bank, we have become  ever more  aware of 
differing  expectations  of the Data Bank.  Thus,  any assessments  of the Data Banks 
usefulness  and impact will depend heavily on how these expectations  are expressed  and on 
the relative  emphasis  given to them.  In that context,  we offer the following  concluding 
observations  concerning  three  important  expectations  about the Data Bank. 
	 Data Bank as a Reliable,  Centralized Source of Information.  In the sense that 
the Data Bank is expected to serve as such a source of information  about adverse 
actions and medical  malpractice  payments,  it seems to be working  quite well.  It is 
a timely,  accurate  source that is widely regarded  as useful--mainly  because  it 
confirms  information  available  from other (presumably  less reliable)  sources. 
	 Data Bank as a Unique Source of Information.  In the sense that the Data Bank is 
expected  to serve as a unique source of information--that  is, one unavailable 
elsewhere--it  clearly  has some value.  In our sample,  22 percent  of the reports 
provided  new information  to managed care organizations.  That 22 percent  projects 
to 6,483  reports providing  new information  to managed  care organizations  over a 
period  of almost 2 years.8 
	 Data Bank as a Mechanism  to Prevent  Incompetent  and/or  Unprofessional 
Practitioners from  Practicing  in HMOS, PPOS, or Group Practices.  Clearly  this 
is the most ambitious  and controversial  of these expectations.  It is also the one 
most difficult  to assess without more information.  In one sense, the fact that 
3 percent  of reports  are having an impact on privileging  decisions  may seem 
inappropriately  low.  It may suggest that managed  care organizations  are overly 
reluctant  to take adverse  actions against incompetent  and/or  unprofessional 
practitioners. 
Yet,  to the extent that only a small percent  of practitioners  are unfit to practice, 
one may argue that nothing is necessarily  inappropriate  about 3 percent  of reports, 
which projects  to 930 reports  over a period  of almost 2 years,  having  an impact  on 
privileging  decisions. 9  These 930 reports  involve hundreds  of practitioners  and 
affect thousands  of patients they serve.  Finally,  it is important  to recognize  that 
the very existence  of the Data Bank may deter  some unfit practitioners  from even 
applying to managed  care organizations  for practice  privileges  and may encourage 
other practitioners  to be more forthcoming  in the applications  they submit for 
managed  care organization  privileges. 
9
 COMMENTS  ON  THE  DRAFT  REPORT 
We solicited  and received  comments  on the draft report  from the Public Health  Service 
(PHS),  the Assistant  Secretary  for Planning  and Evaluation  (ASPE),  the National 
Committee  on Quality Assurance  (NCQA),  and the American  Medical Association 
(AMA).  We include the complete  text of their comments  in appendix  C.  Below we 
summarize  the comments  of the respondents  and,  in italics,  offer our response. 
PHS  COMMENTS 
The PHS expressed  its appreciation  for our efforts and indicated  that the report  would be 
helpful.  It called for one minor change in the background  section of the report  where 
we explain  the Data Bank law.  We appreciate  the positive  response from  PHS.  We made 
the change requested. 
ASPE  COMMENTS 
The ASPE commented  that the purpose  of our inquiry was  commendable  and that the 
survey methodology  seemed  appropriate.  It added,  however,  that the conclusions  we 
drew  are a matter  of interpretation  and that the findings of the report  could be used to 
support conclusions  other than those supported by the OIG.   It recommended  that we 
discuss why we conclude  that the Data Bank is useful when some evidence  in the report 
might be used to reach  a contrary  conclusion. 
We did not draw the conclusion,  as ASPE  stated,  that the Data Bank  is useful.  In our

concluding  section,  we pointed  out that the data in the report contribute  to an

understanding  of the useji.dness and impact of the Data Bank.  We indicated  that

assessments  of usefulness and impact will depend heavily on ones expectations  of the Data

Bank and the relative  emphasis given to them.  We then o~ered some pertinent

observations  concerning  each of three sets of expectations.

The ASPE also commented  that our major  finding that supports the usefulness  of Data 
Bank reports  is based on only 60 of 200 respondents,  or 30 percent  of the sample 
answering  question  27.  Therefore,  ASPE suggested:  One could interpret  this finding to 
indicate that only 30% of the sample could answer positively.  
Our major finding  that 96 percent  of managed care oflcials  found  Data Bank  reports to 
be useji.d was based on 177 positive  responses  (96 percent) f70m manuged  care oficials 
answenng question  30, not question 27.  The 177 respondents answenngpositively  to 
question  27 represent  87 percent  of all those questioned. 
NCQA  COMMENTS 
The NCQA  indicated  that it was heartening  that most respondents  found Data Bank 
reports  to be useful,  but  disturbing that some queries to the Data Bank were made  after 
the credentialing  decisions  had been made.  It also offered  some clarification  concerning 
10
 NCQA credentialing  standards.  We made minor changes in our text in accord with 
NCQAs  clarifications  on its credentialing  standards. 
AMA  COMMENTS 
The AMA concluded  that our report provided  anincompleteand  misleading  picture  of 
the Data Bank,  which it increasingly  believes  is neither  a reliable  nor a cost effective 
mechanism...    The AMAs overarching  concern  about the report  is that it focuses on the 
universe  of Data Bank matches rather than the much larger universe  of queries  made to 
the Data Bank.  In this context,  it urged that we incorporate  more information  about 
queries  into the report  and that we clarify  in our background  section that the reports  we 
are addressing  are  matched reports. 
The AMA questioned  the accuracy  of our statement that 42 percent  of reports  to hospitals 
provided  information  that practitioners  themselves  did not report  to the hospitals.  It based 
this concern  on a reference  made in our parallel  report  on hospitals that noted that 
28 percent  of the matched  reports provided  information  previously  unknown  to hospital 
staffs.  The AMA also questioned  the accuracy  of our finding that 3 percent  of Data Bank 
reports  to managed  care organizations  led these organizations  to make different  decisions 
than they would have made otherwise.  However,  it did not elaborate  on why it felt that 
this percentage  might be inaccurate. 
Other observations  that the AMA offered were (1) that the 49 percent  of managed  care 
organizations  that failed to respond to our questionnaire  may have a less positive  reaction 
to the Data Bank than those that did respond,  (2) that the reasons for querying  the Data 
Bank may help explain  respondent  assessments  of the Data Bank,  and (3) that two of our 
findings warrant  further  investigation.  These were the findings that 3 percent  (5) Data 
Bank reports  appeared  to be inaccurate  and that Data Bank response time to reports  not 
made electronically  had increased. 
We disagree  with the MA  over the value of focusing  on Data Bank matches.  We have 
done so because  we concluded  that it would provide  discrete, practical  information  about 
what the Data Bank actually produces for  querying  organizations.  Such information  can 
contribute  to broader assessments  of the worth of the Data Bank. 
We have not provided  additional projile  information  about the Data Bank  in the report. 
We provided  a considerable  amount of such information  in a prior  report entitled, 
National Practitioner  Data Bank: Projile of Matches  Update (OEI-01-OO031). However, 
as the AMA  suggested,  we have clarified,  in the background  section  of the report,  that the 
Data Bank  reports we are referring to are  mutched reports. 
Our statement  that 42 percent  of reports to hospitals provided  information  that 
practitioners  themselves  did not report is, in fact,  correct.  The 28 percent  that the AMA 
referred  to does not apply to the same universe,  but rather to the larger universe  of 
reports coming from  any non-Data Bank source,  not just practitioners.  Our finding  that 
3 percent  of the respondents  informed us that Data Bank reports led them to make 
diflerent  decisions  than they would have made without the reports is accurate.  It is not 
clear to us why the AMA  questions the accuracy  of this finding. 
11
 In regard to the AMAs jinal points,  we  (1) have no basis for  knowing whether 
nonrespondents  are more or less favorably  disposed toward the Data Bank,  (2) agree that 
knowing  the reasons for  querying  the Data Bank could help explain respondent 
assessments  (but we are unable to conduct such inquiry at this time),  and  (3) believe  that 
the two jindings  noted by AMA  warrant scrutiny and have called them to the attention  of 
the Public Health  Service. 
12
 APPENDIX  A 
METHODOLOGY 
We collected  the data presented  in this report  through  a mail survey of health maintenance 
organizations  (HMOS), preferred  provider  organizations  (PPOS), and group practices 
conducted  from May to July 1994.  We drew our sample from the universe  of all Data 
Bank matches  involving HMOS, PPOS, and group practices  between  March  20,  1992 and 
February  25,  1994.  A match is a pairing  of a report  and a query to the Data Bank that 
name the same practitioner.  We requested  and received  from Unisys Corporation,  the 
Data Bank contractor,  a computer  file containing  records  of all Data Bank queries  and 
reports  that identified  the same practitioner,  We restructured  and analyzed the data using 
SAS@Release  6.08 on a mainframe  computer  and Version  6.04 of the SAS@System for 
Personal  Computers. 
We drew  a simple random  sample of 400 matches from the universe  of 30,016  matches 
involving  HMOS, PPOS, and group practices.  In May  1994, we mailed  a questionnaire 
about each report  to the organization  involved.  There were  144 managed  care 
organizations  that received  questionnaires: 
69 organizations  were each sent questionnaires  on 1 practitioner; 
26 were each sent questionnaires  on 2 different practitioners  (1 received 
2 reports  about  1 practitioner); 
22 were each sent questionnaires  on 3 different practitioners  (1 received 
2 reports  about  1 practitioner); 
14 were each sent questionnaires  on 4 different practitioners  (1 received 
2 reports  about  1 practitioner). 
3 were each sent questionnaires  on 5 different practitioners; 
3 were each sent questionnaires  on 6 different practitioners; 
1 was sent questionnaires  on 7 different practitioners; 
1 was sent questionnaires  on 8 different practitioners; 
1 was sent questionnaires  on 10 different  practitioners; 
2 were  sent questionnaires  on 11 different practitioners; 
1 was sent questionnaires  on 13 different practitioners;  and, 
1 was sent questionnaires  on 61 different practitioners. 
A-1
 We followed  with a second mailing to nonrespondents.  All responses  used in the analysis

were received  by July 20,  1994.  Appendix B shows the questionnaire  and simple

frequencies.

Questionnaires  were addressed  to the person whose name appeared  on the original  query

to the Data Bank.  Most respondents  held the position of medical  staff coordinator  or the

equivalent.

Our response  rate was 51 percent  (203).  Most of the responses  (93 percent)  concerned

malpractice  reports;  7 percent  concerned  adverse action reports.  Overall,  malpractice

matches  accounted  for 89.5 percent  of the universe  of matches,  so the distribution  of

report  types in our response  was similar.

Ninety-four  percent  of the respondents  were HMOS; 3 percent  PPOS; and 3 percent  group

practices.

Sixty-eight  percent  of the respondents  queried the Data Bank on initial privileging  or

employment  applications,  11 percent  on the 2-year review  requirements,  and

21 percent  queried  for professional  review purposes.  Of the 14 responses  based on

adverse  actions,  half were State licensing board actions and half were hospital  clinical

privileges  actions.  Ninety-eight  percent  of the respondents  queried  about physicians  (the

other practitioners  were dentists and podiatrists).  The specialties  of the physicians  are

listed in table A.

There  were  88 organizations  represented  in the responses:

Of the 69 organizations  sent questionnaires  on 1 practitioner,  42 responded; 
Of the 26 sent questionnaires  on 2 practitioners,  18 responded  (1 for 
1 practitioner,  17 for 2); 
Of the 22  sent questionnaires  on 3 practitioners,  14 responded  (2 for 
2 practitioners,  12 for 3); 
Of the  14 sent questionnaires  on 4 practitioners,  7 responded; 
Of the 3 sent questionnaires  on 5 practitioners,  none responded; 
Of the 3 sent questionnaires  on 6 practitioners,  3 responded; 
The  1 sent questionnaires  on 7 practitioners  did not respond; 
The  1 sent questionnaires  on 8 practitioners  responded; 
The  1 sent questionnaires  on 10 practitioners  did not respond; 
Of the 2 sent questionnaires  on 11 practitioners,  2 responded  (1 for 
9 practitioners  and 1 for 11) 
A-2
 The  1 sent questionnaires  on 13 practitioners  responded;  and, 
The  1 sent questionnaires  on 61 practitioners  did not respond. 
Unless otherwise  noted,  survey results presented  as percentages  have a margin  of error  of 
approximately  5 percent  at the 95 percent  confidence  level.  For example,  we are 
95 percent  confident  that the true percentage  of Data Bank reports judged  useful  is 
between  78 and 88 percent  (83 percent  plus or minus 5 percent).  Confidence  intervals  for 
the statistics presented  in this report  are summarized  in table B. 
A-3
 TABLE  A 
TYPES  OF PRACTITIONERS 
TYPEOFPRACZITONER  NUMBEROFMATCHES  PERCENTAGEOFMATCHES 
TOTA  203  100.0% 
PHYSICIANS  199  98.0 
Obstetrics and Gynecology  34  16.7 
General Surgery  25  12.3 
Orthopedic Surgery  20  9.9 
Family Medicine  16  7.9 
Pediatrics  11  5.4 
Missing or Miscoded  11  5.4 
Neurological Surgery  10  4.9 
Internal Medicine  8  3.9 
Ophthalmology  8  3.9 
General Medicine  7  3.4 
Cardiology  6  3.0 
Eye, Ear, Nose, and Throat  5  2.5 
Urology  5  2.5 
Anesthesiology  4  2.0 
lloracic  Surgery  4  2.0 
Plastic Surgery  4  2.0 
Oncology  3  1.5 
Pubnona~ Medicine  3  1.5 
Radiology  3  1.5 
Osteopathic Gynecology  2  1.0 
Psychiatry  2  1.0 
Allergy  1  0.5 
Cardiac Surgery  1  0.5 
Gastroenterology  1  0.5 
Hematology  1  0.5 
InfectiousDiseases  1  0.5 
Neonatology  1  0.5 
Pathology  1  0.5 
Perinatology  1  0.5 
1  I 
DENITSTS and ORAL SURGEONS  1  21  1.0 
PODIA21US~  2]  1.0 
Source:  OIG Survey of HMOS, PPOS, and Group Practices, May -July, 1994. 
A-4
 TABLE B 
CONFIDENCE  INTERVALS  FOR KEY STATISTICS 
Description  Page  Value  95% Confidence 
(%)  Interval 
(+  or -) 
Proportion of reports considered useful  3  95.7%  I  2.9% 
Proportion of respondenta who consider it worthwhile--all  3  95.0  I  3.4 
things considered--to query the Data Bank 
Proportion of respondents rating reports without adverse  3 
information extremely or very usefil 
Proportion of respondents rating reports without adverse  3 
information moderately useful 
+----= 
Proportion of respondents rating licensing board actions  3  78.6  6.2 
extremely useful  1 
Proportion of respondents rating hospital actions extremely  I  3  74.6  I  6.6
useful 
Proportion of respondents rating malpractice payments  3  68.0  I  7.0 
extremely useful 
Proportion of respondents rating professional society actions  3 
extremely useful 
Proportion of reports providing information previously  3  21.6  5.9 
unknown 
Proportion of reports providing information previously  3  100.0	 I  o 
unknown considered usefid 
I 
Proportion of reports providing information that the practitioner  4  30.5  6.6 
did not self-report 
Proportion of malpractice reports of which managed care  4  79.8  I  5.9
organizations were aware 
Proportion of malpractice reports of which managed care  I  4  58.3  I  27.9
organizations were aware 
Proportion of respondents who considered reports useful  4 
because they confirmed information available elsewhere 
Proportion of respondents who considered reports usetid  4  66.7  I  6.9 
because they helped judge competency 
Proportion of respondents who considered reports useful  4 
because they helped judge professionalism 
Proportion of respondents who considered reports useful  4  18.6  5.7 
because they provide information unavailable elsewhere 
Proportion of respondents that, upon additional inquiry, found  5 
the reports to be inaccurate 
Proportion of respondents that reported the Data Bank reports  5  4.9  I  3.0 
to be incomplete 
Proportion of reports obtained electronically  5 
A-5
 Proportion of reports that arrived prior to final decisions  5  86.2  5.9 
Proportion of reports that arrived after the decision  5  9.3  4.2 
Proportion of reports that were not on time because of a late  5  58.8  23.4 
query 
Proportion of reports with decisions pending  6  11.8  4.4 
Proportion of reports that made a difference in a decision  6  3.1  2.7 
Proportion of reports that made respondent feel more confident  7  65.2  8.0 
about a decision 
Proportion of reports that had little chance of impact  7  80.8  5.7 
Proportion of reports that named practitioners who did not  7  6.0  3.4 
complete the credentialing process 
Proportion of reports providing information already known  7  65.6  6.9 
(though received on time) 
Proportion of reports where respondents said at least part of the  7  62.7  7.7 
reason for no impact was that reports gave them information of 
which they were already aware 
Proportion of reports where respondents said at least part of the  7  43.7  7.9 
reason for no impact was that reports did not warrant 
restricting or denying privileges 
Proportion of reports where respondents said at least part of the  7  7.2  4.1 
reason for no impact was that reports did not arrive in time 
Proportion of reports where respondents said at least part of the  7  2.0  2.2 
reason for no impact was that they would have denied or 
restricted privileges anyway 
Proportion of reports that could have had impact but did not  8  16,4  5.4 
Proportion of reports that could have had impact and  8  63.3  17.3 
respondents indicated that the report did not warrant restricting 
or denying privileges 
Proportion of reports that could have had impact but did not  8  100  0 
that were considered useful 
A-6
 APPENDIX  B 
SUMMARY  OF  MANAGED  CARE  ORGANIZATION  RESPONSES 
TO  OIG  MAIL  SURVEY 
B-1  U.S.  DEPARTMENT  OF HEALTH  AND HUMAN  SERVICES 
USE AND  UTILITY OF THE

NATIONAL  PRACTITIONER  DATA  BANK

NOTE:  The first 32 questions in this survey concern the case of Practitioner  A, whose identity is given on the 
last page of this questionnaire.  Unless otherwise specified, please confine your responses to your knowledge 
of the particular  practitioner  and event referred  to on that page. 
BASIC  FACTS  AND  CHRONOLOGY 
1  What is Practitioner  As specialty?  3Zdzfierent  specialties  represented  1 
2  On  what  date  did  Practitioner  A  sign  an  application  wide range of dates  2 
requesting  privileges  (either new or continued)? 
3  On what  date  did  you  request  htformation  about  3 
Practitioner  A  from  the  National  Practitioner  Data  wide range of dates 
Bank? 
4  Did you request  information  about Practitioner  A  Yes: 99  4 
using  electronic  querying  methods  (QPRAC)?  No: 89 
Missing: 15 
5  On what date did you receive  a response from the  wide range of dates  5 
Data Bank?  (Write  NR if you have not yet received  5 had not received a 
response yet 
a response. ) 
6  On  what  date  did  your  organization  make  its  initial  ~de range of dates  6 
decision  regarding  Practitioner  privileges?  (W)-ite  15 initial:ecisi~ns 
As 
were pending 
PEWIATG lf the organizations  initial decision has 
not yet been mude,  then skip to 15.) 
7	 Was your organizations  initial decision a temporary  Yes: 38  7 
one pending  further  information?  No: 128 
Missing: 37 
(If no, skip to 9) 
8  (Skip if you answered NO to 7)  wide range of dates  8 
On what date did your organization  make its final  9final  decisions 
decision  regarding  Practitioner  As privileges?  (Write  ending 
PENDING 17organizations final  decision has not 
yet been made,  then answer 9 through 14 with respect 
to the organizations  initial decision. I 
9	 Were  privileges  granted to Practitioner  A as requested  yes:158  9 
by Practitioner  A?  No: 5 
Missing: 40 
(If yes, skip to 15) 
10	 (Skip if you answered  YES to 9)  Yes: 2  10 
Were  Practitioner  As privileges  denied (for initial  No: 2 
Missing: 1 
application)  or revoked  (for renewal  application)? 
(If yes, skip to 15) 
NATION& PRACTnIONER DATA BANK QUESTIONNAIRE--PAGE 2  11	 (Skip if you answered  YES to 9 or 10)  Yes: 1  11 
Were  Practitioner  As  privileges  restricted  or  amended  0:1 
Missing: 3 
in  any  way? 
(If no, skip to 15) 
12	 (sk@  if you  answered  YES to 9 or 10 or NO to 11)  12 
In  what  way  were  Practitioner  As  privileges  restricted  or  amended? 
a  All privileges  suspended (IF YES, FOR HOW  Yes:0  a 
LONG?  ) 
b  May not perform  certain  procedures  yes:0  b 
c  May perform  certain procedures  only with another  Yes:CI  c 
practitioner 
d  May co-admit patients only  Yes:0  d 
e  Mandatory  consultation  for certain  conditions  yes:0  e 
f  Mandatory  review before patient  admission or  yes:0  f 
discharge 
g  Proctor  assigned to review Practitioner  As work  yes:0  g 
h  Other (IF YES,  SPECIFY:  Yes: 1  h 
) 
13  (Skip if you answered  YES to 9 or 10 or NO to 11)  Yes: O  13 
Were  these  restrictions  on  Practitioner  As  privileges  No: 1 
Missing: 4 
in place prior  to the application? 
14  (Sktj  if you answered  XZS to 9 or 10 or NO to 11)  (Check one)  14 
Which  of the following best describes  the restrictions 
applied to Practitioner  As privileges? 
a  Routine  (e. g.,  procedure(s)  not approved  in this  o  a 
organization,  restriction  applied to all new hires,  etc.) 
b  Specific to Practitioner  A (e. g.,  applied because of  1  b 
particular  event(s)  in Practitioner  As history) 
15	 Were  any  other  actions  taken  with  regard  to  Yes: O  15 
Practitioner  As  employment,  privileges,  or  No: 1 
Missing: 4 
credentials  (e.g.,  education  requirements,  drug testing, 
etc.)? 
(IF YES,  EXPLAIN: 
NATIONALPRACTITIOh!ERDATA BANK QUESTIONNAIRE--PAGE 3  AVAILABILITY  AND  ACCURACY  OF INFORMATION

16	 Were  you  aware,  from  sources  other  than  the  Data  Yes: 149  16 
Bank,  of  the  adverse  action  or  malpractice  payment  No: 41 
Missing: 13 
mentioned  on  the  last  page  of  this  form? 
(If no, skip to 19) 
17	 (skip  ~ you answered NO to 16)  17 
From  which  of  the  following  sources  were  you  aware  of  the  adverse 
action  or  malpractice  payment? 
a  Practitioner  A (self-report)  yes:132 
a 
No:  16 
Missing: 14 
N/A: 41 
b  Licensing  board in your state  yes:10  b 
No: 137 
Missing: 15 
N/A: 41 
c  Licensing  board in another  state  yes:1  c 
No: 146 
Missing: 15 
N/A: 41 
d  Malpractice  insurer  in your state  Yes:53  d 
No: 94 
Missing: 15 
N/A: 41 
e  Malpractice  insurer  in another  state  Yes:4  e 
No: 143 
Missing: 15 
N/A: 41 
f  Hospital  in your state  Yes:12  f 
No: 135 
Missing: 15 
N/A: 41 
g  Hospital  in another  state  Yes:1  g
No: 146 
Missing: 15 
N/A: 41 
h  Professional  society in your state  yes:2  h 
No: 145 
Missing: 15 
N/A: 41 
i  Professional  society in another  state  ye~:0  i 
No: 147 
Missing: 15 
N/A: 41 
NATIONA  PRACTITIONERDATA BANK QUESTIONNAIRE--PAGE 4  j  Other source in your state  Yes:II  j 
(IF YES,  SPECIFY:  flj$::;  15 
) 
N/A: 41 
k  Other source in another  state  Yes:I  k 
(IF YES,  SPECIFY:  &;S;::  If 
)  ~,A: ~~ 
18  (Mb  if you answered NO  to 16)  Yes: 27  18 
Was the information  you received  in the Data Bank  No: 111 
Missing: 65 
response  inconsistent  in any way with the information 
reported  by  any  of  the  above  sources? 
(IF  YES,  WHICH  SOURCES? 
) 
19  Did  you  make  additional  inquiries  (for  example,  to  a  Yes: 49  19 
malpractice  insurer  or  a hospital)  to  confirm  the  No: 139 
Missing: 15 
accuracy  of  the  Data  Bank  response  or  to  obtain  more 
(If no, skip to 21) 
detailed  information  on its content? 
20  (sic@ if you  answered NO  to 19)  Yes: 39  20 
Did  your  additional  inquiries  show  the  Data  Bank  No: 5 
Missing: 158 
response  to  be  accurate? 
(IF NO,  EXPLAIN: 
) 
NOTE:  Questions 21-24 refer to the entire Data Bank response, not just to the report attached to this 
questionnaire.  Therefore,  if you received more than one report from the Data Bank on Practitioner  A, 
please consider them all in answering Questions 21-24. 
21	 Were  you  aware  of  any  disciplinary  actions,  or  Yes: 39  21 
malpractice  payments  involving  Practitioner  A  that  No: 149 
Missing: 15 
were  M  contained  in  the  response  from  the  Data 
(If no, skip to 25) 
Bank? 
22	 (M@  if you answered NO  to 21)  22 
How many disciplinary  actions and malpractice  payments  were you aware 
of that were ~t  contained  in the response from the Data Bank? 
a  Number  of disciplinary  actions	 4 resP. aware of 1  a 
2 aware of 2 
1 aware of 4 
b  Number  of malpractice  payments	 .20resp. aware of I  b 
10 aware of 2 
2 aware of 3 
1 aware of 4 
1 aware of 7 
NATION& PRACTITIONERDATA BANK QUESTIONNAIRE--PAGE 5  23	 (Skip if you answered NO to 21)  23 
How many of these disciplinary  actions and malpractice  payments 
occurred  ~  September  1, 1990? 
a  Number  of disciplinary  actions  .2rw.  u~~reOY1   a
1 aware of 2 
b  Number  of malpractice  payments	 7 rew. awareof ~  b 
1 aware of 2 
24	 (Skip if you answered NO to 21)  24 
Which  of the following  sources provided  information  about disciplinary 
actions or malpractice  payments  that were @  contained  in the response 
from the Data Bank? 
a  Practitioner  A (self-report)  Yes:32  a 
b  Licensing  board in your state  yes:1  b 
c  Licensing board in another  state  Yes:~  c 
d  Malpractice  insurer  in your state  Ya:17  d 
e  Malpractice  insurer  in another  state  Yes:1  e 
f  Hospital  in your state  yes:3  f 
g  Hospital  in another  state  Yes:O  g 
h  Professional  society in your state  yes:0  h 
i  Professional  society in another  state  yes;o  i 
j  Other source in your state  yes:~  j 
(IF YES,  SPECIFY: 
k  Other source in another  state  yes:o  k 
(IF YES,  SPECIFY: 
) 
h?ATION~ PRACTITIONERDATA BANK QUESTIONNAIRE--PAGE 6  CONSIDERATION  OF INFORMATION 
25  BaSedon  tienotes  in  Practitioner  A's  file  andyour  personal  ~owledge  25 
of  Practitioner  As  application,  which  of  the  following  people  or  groups 
had  access  to  and  used  the  response  from the Data Bank in making  a 
decision regarding  Practitione~ As application? 
a  Department  chair  Yes: 32  a 
No: 23 
Missing or N/A: 148 
b  Chief of medical  staff  Yes: 52  b 
No: 19 
Missing or N/A: 132 
c  HMO/PPO/Group  Practice  administration  (CEO,  Vice  Yes: 99  c 
President,  etc.)  No: 27 
Missing or N/A: 77 
it  Credentials  committee  Yes: 176  d 
No: 5 
Missing or N/A: 22 
e  Medical  staff executive  committee  Yes: 26  e 
No: 24 
Missing or N/A: 153 
f  HMO/PPO/Group  Practice  board subcommittee  Yes: 35  f 
No: 39 
Missing or N/A: 129 
g  Full HMO/PPO/Group  Practice  board  Yes: 17  /3 
No: 43 
NATIONAL PRACTITIONERDATA BANK QUESTIONNAIRE--PAGE 7  UTILITY  OF INFORMATION	
26  Including  the report  on the last page,  how many Data  131resp. rec d 1  26 
Bank reports  on Practitioner  A did you receive  in total  5  ~:~  ~ 
from this request? 
2 rec d 4 
1 rec d 5 
(If 1, skip to 30) 
27  (Sk@ if you answered  1to 26)  Yes: 59  27 
Overall,  was the information  contained  in the  No: 1

Missing or N/A: 143

complete  Data Bank response  (i.e.,  all reports 
combined)  useful to you? 
IF YES, WHY?  (Check all that 
apply) 
a  Information  was unavailable  elsewhere  Yes: 16  a 
b  Information  confirmed  other reports  that were  Yes: 45  b 
available elsewhere 
c  Information  helped us to judge  practitioners  Yes: 42  c 
competency 
d  Information  helped us to judge  practitioners  Yes: 26  d 
professionalism 
e  Other (EXPLAIN:  )  Yes: 2  e 
IF NO, WHY NOT?  (Check all that 
apply) 
f  Information  was available elsewhere  Yes: O  f 
g  Information  was inaccurate  Yes: O  g 
h  Information  did not help us to judge  practitioners  Yes: 1  h 
competency  or professionalism 
i  Information  was not provided  in a timely manner  Yes: O  i 
j  Other (EXPLAIN:  )  Yes: 1  j 
28  (Skip if you answered  1to 26)  Yes: 1  28 
Would  your decision regarding  Practitioner  A have  No: 41 
been different  if you had ~  received  the reports  from  isSing r A:  161 
the Data Bank? 
IF YES, HOW  (then skip to 31)?  (Check one) 
a  Would have granted requested privileges  yes: I  a 
b  Would not have granted  requested privileges  yes: o  b 
NATIONA  PRACTITIONERDATA BANK QUESTIONNAIRE--PAGE 8  Would have restricted  privileges  Yes: O  c 
c 
d  Would not have restricted  privileges  Yes: O d 
e  Other (EXPLAIN:  )  Yes: O e 
IF NO, WHY NOT?  (Check all that 
apply) 
f  Would have restricted  or denied privileges  anyway  Yes: O 
g  Already  knew,  from	 other sources,  about information  Yes: 25 
reported  in Data Bank responses 
h  Data Bank responses  did not indicate a problem  that  Yes:18  h 
warranted  restricting  or denying privileges 
i  Did not receive  Data Bank responses  in time	 to affect  Yes: 2  i 
decision 
j  Other  (EXPLAIN:  )  Yes: O 
29	 (Skip if you answered  YESto 28)  29 
Did the reports  you received  make you feel more 
confident,  less confident,  or no different  about the 
decision  you made regarding  Practitioner  A?  (Check one) 
Missing or N/A: 165 
a  More confident  27  a 
b  Less  confident  1 b 
c  No different  lo  c 
30	 Overall,  was the information  contained  in the Data  Yes: 177  30 
Bank report  on the last page useful to you?  No: 8 
Missing: 18 
IF YES, WHY?  (Check all that 
apply) 
a  Information  was unavailable  elsewhere  Yes: 33  a 
b  Information  confirmed  other reports  that were  Yes: 133  b 
available elsewhere 
c  Information  helped us to judge  practitioners  Yes: 118  c 
competency 
d  Information  helped us to judge practitioners  Yes: 92  d 
professionalism 
e  Other (EXPLAIN:  )  Yes: 17  e 
IF NO, WHY NOT?  (Check all that 
apply) 
f  Information  was available elsewhere  Yes: 7  f 
NATIONALPRACTITIONERDATA BANK QIJESTIONNAIRE--PAGE 9  t!  Information  was inaccurate  yes: o  g 
h  Information  did not help us to judge  practitioners  yes: .2  h 
competency  or professionalism 
i  Information  was not provided  in a timely manner  yes: o  i 
j  Other  (EXPLAIN:  )  Yes: 2  j 
31	 Would  your  decision  regarding  Practitioner  As  Yes: 5  31 
No: 156 
privileges  have  been  different  if you  had  n~  received 
Missing: 42 
the  report  on  the  last  page  from  the  Data  Bank? 
IF  YES,  HOW? 
(Zf H?S, check one.) 
a  Would have granted  requested  privileges  Yes: 1  a 
b  Would not have granted requested  privileges  Yes: O  b 
c  Would have restricted  privileges  Yes: O  c 
d  Would not have restricted  privileges  Yes: O  d 
e  Other (EXPLAIN:  ~  Yes:4  d 
IF NO, WHY NOT?  (Check all that 
apply) 
f  Would have restricted  or denied privileges  anyway  yes: 3  f 
g  Already  knew,  from other sources,  about information  yes: 96  g 
reported  in Data Bank response 
h  Data Bank response did not indicate a problem  that  yes: 67  h 
warranted  restricting  or denying privileges 
i  Did not receive  Data Bank response  in time to affect  yes: ZI  i 
decision 
j  Other (EXPLAIN:  ~  Yes:z  j 
32  (W@  if you answered  ZES to 31)  32 
Did the report  you received  make you feel more 
confident,  less confident,  or no different  about the 
decision  you made regarding  Practitioner  A?  (Check one) 
Missing: 58 
a  More contldent  90  a 
b  Less  confident  2  b 
c  No  different  46  c 
NATION~  PRACTLT.IONERDATA BANK QUESTIONNAIRE--PAGE 10  NOTE:  The remaining  questions  do not concern  the  specific case  of Practitioner 
A, but rather  your general  experience  with and attitudes about the Data Bank. 
GENERAL  QUESTIONS  ON THE 
NATIONAL  PRACTITIONER  DATA  BANK 
33  How,  if at all, have the other parts of your credentialing  procedures  been  33 
affected  by the availability  of the Data Bank? 
72 respondents discussed how the Data Bank helps confirm other sources of information, 
identifies problems, and provides extra detail, 19 discussed how the Data Bank is required 
for credentialing, 19 discussed how the Data Bank has aided streamlining in the credentialing 
process by eliminating the need for other  sources,  and 9 discussed  how the Data bank has 
added  costs  and delays  to the credentialing  process.  A host of other  issues  were  also 
mentioned. 
Please rate the following  four types of information  maintained  in the Data  q1

Bank in terms  of their usefulness  to you--in practice  or in theory--in  the

practitioner  credentialing  process.  (Let 1 =  extremely  useful and

4  =  not at all usefi.d.)

a  Hospital  disciplinary  actions/privilege  restrictions  RATING:  a 
Mean: 1.43 
S.D.:0.89 
b  Licensing  board actions  RATING:  b 
Mean: 1.43 
S.D.:0.93 
c  Malpractice  payments  RATING:  c 
Mean: 1.53 
S.D. :0.86 
d  Professional  society disciplinary  actions  RATING:  d 
Mean: 1.90 
S.D.:1.22 
How useful to you are responses  from the Data Bank  (Check one)  35 
that do not list any adverse  information? 
Missing: 29 
a  Extremely  useful  49  a 
NATIONALPRACTITIONERDATA BANK QUESTIONNAIRE--PAGE 11  c  Moderately  useful  40  c 
d  Somewhat useful  15  d 
e  Not useful  15  e 
Pk%LSe eX@iiIX  68 explained it was useful because it provides documentation for the 
credentialing process, it conjirmed other sources, or increased confidence; 14 mentioned 
concerns about the timeliness, adequacy, and completeness of data available in the data 
Bank, and; 3 mentioned it was not usefil because it repeats information in the que~. 
34  All things considered,  do you feel it is worthwhile  to  Yes: 153  36 
query the Data Bank?  No:  8 
Missing: 42 
PhXiSe  eXplaiIl:  93 mentioned that the Data Bank confirms other sources, documents the 
Data credentialing process, or is quick and easy; 5 mentioned it is not worth the time nor 
cost when information is readily available elsewhere, and; 3 mentioned that the Data Bank 
lacks historical information or may be incomplete due to hospitals not jiling. 
35  What kind of information  ~t  currently  maintained  by the Data Bank  37 
would be usefi.d to you? 
36  Please  list any additional comments  and suggestions you have about the  38 
o~eration  of the National Practitioner  Data Bank. 
This is the end of the survey.  Thank you for taking the time to complete  it.  Please  return 
your completed  survey in the business-reply  envelope to: 
Office of Evaluation  and Inspections 
Office of Inspector  General 
U.S.  Department  of Health and Human Services 
Room 2475, J.F.K.  Federal  Building 
Boston,  MA 02203 
If you have questions,  please call David Veroff or Barry McCoy at 617-565-1050. 
NATION& PRACTITIONERDATA BANK QUESTIONNAIRE--PAGE 12  APPENDIX  C 
COMPLETE  COMMENTS  ON  THE  DRAFT  REPORT 
c-1  ,,so-me
*P+  
. 4
.  c  DEPARTMENT  (IF 14MLTH  & HIJMA3J SERVICES  PublicHealthSewics 
$ 
e
+.,
*W,  Memorandum 
fEB2f199!5 
D8r8 
Assistant  Secretary  for  Health 
ffatl 
Office  of  Inspector  General  (OIG)  Draft  Reports  on  the 
U6alhlrAtBs83  and  Impact  of  National  PxactLtLone=  Data  Bank 
Reports  to  Hospitals  and  Managed  Care  Organizations, 
OEI-01-94-00030  and  OEI-01-94-00032 
To 
Inspector  Generalt  OS 
Attached  are  the  Public  ~ealth  Service  ctmnmerits  on  the  .subj~Ct 
OIG  draft  reports.  We  appreciate  the  efforts  Of  OIG  s~aif  in 
developing  these  reports.  F7e offer  only  a  few  general 
comments and a sugges$,ededitorial change. 
(///Aq
&  .~ 
,,
i 
Philip  . Lee,  X.D. 
Attachment  PUBLIC  HEALTH  SERVICE  (PHSI  C014FfE NTS ON THE  OFFICE  OF  INSPECTOR 
GENERAL  (OIG\  DRAFT  REPORTS  ON  THE  ~~  OF  TH 
NATIONAII  PIUACTTT~ONER  nATA  BANK  TO HOS PITALS  IUJD  MANAGED  CARQ 
ORG~IZATICIFJS,  (_)EI  01-94-00030  AND  0EI-01-94-00032A 
DECEMBE  R  1994 
The  OIG  inspections  were  performed  at the request  Of  the  Health 
Resouxce8 and  Sezvices  Administratfun  (HRSA).  Tha  HRSA asked  OZG 
to  update  the  February  1993  inspection  repo- on  the  usefulness 
and  impact  of  National  Practitioner  ilata  Bank  reports  to 
hospitals,  and  to  consider  the  Data  Banks  relevance  to  managed 
care  organizations. 
We appreciate  the  efforts  of  the  OIG  staff  and  their  cooperation 
with  program officials in HRSA  in developing these reports. 
These reports reflect many of the changes that we suggested to 
OIG  staff during the exit conference  and  on  subsequent  occasions. 
We believe that  these reports will be helpful in administering 
the program. 
Nevertheless, we believe that a wording change is needed to 
pxovide greater  clarity in the Background section of  the 
Executive Summary  of both reports.  Thefirst paragraph in these 
sections states  that [ll)ospitalsare required to request 
information fzom  the Data Bank about every physician and dentist 
who  applles  for appointment (they must queryat  least every two 
years).  The  requirement might be better understood by readers 
if the parenthetical  phrase was deleted  and replaced  with  the 
following  sentence:  In addition, hospitals must querY at least 
once every two years  on every  practitioner  who  is on  their 
meaical  staff  or who has privileges.    *w- ~ 
/ 4
E  (L
DEPARTMENT OF HEALTH & HUMAN SERVICES  -ka  Ot tho 6euotwv 
~ 
  . 
%19N 
Wmhmgton,  O.C,  z~ol 
FEB z 7  B9!5
To:  June  Gibbs  Brown 
Inspector General 
From:  Assistant  Wixetary  for 
Planning and Evacuation 
Subject  OIG Draft Repom  on the Usefulness and Impact of the National  Practitioner 
nata  Bank 
1 have reviewed two draft inspection_  entitled, National Practitioner  Data Bank 
lleports to Hospitals:  Ileir  Impact and Usefulness and Nationai Practitioner Data Bank 
Repons to Managed Care Organizations: Their impact and Usefulness.   The purpose of the 
surveys, as indicated  in the titfes, is co determineif the users consider the data bank to be 
usefii  in making decisions about gmnting privkges  to  physicians.  The purpose of OIGS 
inquiry is commendable and the sumey methodology seems appropriate. 
I think, however,  that the conclusions drawn by OIG am a matter of interpretation  and hat 
the findings of the report  could be used to support conclusions other than those drawn by 
OIG.  For exampic,  the findings fiwm the sumy  of managed care entities suggest that the 
data bank is, contsary  to 01(3s contention, dupkatk  as indicated by the following 
responses. 
Officiais  said they sefdom or rarely relied on a repofl from  the data  bank in deciding 
to deny pnviiegcs.  In fact, only 8% (questionnaire item  27, page 8) of the 
information was reported unavailable ekewhere.  This impIies that92% found  the 
information  avaiiablc  elsewhere, 
The major finding  that supporttsheOIGSconcision  of data bank usefulness is the 
answer  to the quesuon,  Ovcrail. was the information contained in  the  complete  Data 
Bankrespons(ei .ea.i,lr eportcso mbinedu)s efu1l0 you?(questionnaiitreem2 7,
page8).  Of those who answered, 96% tid  yes; however,  oniy 60 of 200 
respondents or 30% of (he sampie answerd  the question.One could jnkxpre~this 
finding to Indimti  that only 30% of the ~rnple  could answer positivcl y. 
I recommend that OIG discuss why its conciu.sionthat the data bank is usefid  is a better 
nxding  of(heeviden=  than the conclusion reached ab~c- -~ 
c.. 
&,/:/) 
David  T. EIIw~ 
Prepared by; Mary Bymes 690-7388  F:2ti0Jl:li hllllllllk!!  1.350Ncw  1(vi+A.cmx. ;\. \\  !.,111:  :!) U(12S. S7XI  FAX;  2[)2628-0344 
forQualitv  Assus-ancc  Suite 700  ;J!.lflnlltfl ;lrl~ Dcvcmpmcrr!:  202/662-8610 
Washmgon.  L).C. 2W05  ,ccrcut;:ulon:  202/662- 1S85 
NCQA 
January 23,  1995 
Ms.  Gibbs Brown 
June 
Inspector General 
Office of the Inspector  Geneml 
Department  of Heaith and  Human Services 
330 Independence Avenue,  S.W. 
Washington,  D.C.  20201 
IXxUMs.  Brown: 
I read  with  dzaft inspection  report,  Nationai  Practitioner  Data  Bank Reports  to 
interest  the 
Managed Care  Organizxions:  Their  Usefulness  and  impact, OEI-01-94-00032.  It  was 
hwtening  to karn  that  managed  me  orga.nhtions  fmd the majori~  of reports  they  receive 
fim  the National Practitioner  Data Bank (NPDB)  to be useful.  Conversely,  it was disturbing 
to note that some queti=  to the NPDB occur after a privileging  decision  has already  ken made. 
I would like to offer  one  point  of  citification  reiative  to the repcms  references  to Nationai 
Committee for Quality Assurance (NCQA) credentialing  sra,ndards (contzked  on pages 3 and 4). 
NCQA standards state that the managed careorganization  shouid request  information  from  the 
NPDB.  We have clarified  this statement as applicable  tothoseorgtitions  that are required 
to parucipa[me tieNPDB.  Orgamzations which do not pardcipate  in the NFDB  may meet the 
standardby requestinag malpractice  history  of  the  appiicant.  ~  requesting  five  years  of 
malpracmx  history from  the maipract.ice ca.mier, ~  requesting reformation  on the application 
regarding acucms taken by hospitals and managed  care organizations  that limited,  suspended or 
abolished  the practitioners  privdeges,  ti  queryingtheFederationof State Medical  Boards.  I 
hopethatthischmfkation  is usefutlo you as you prepare  thefinalreport. 
Thank you for(heopportunittyoreviewthis repat  prior  to itsrelease. 
Sincerely, 
\ 
j+~luLL  ,- ---
MargareLE.  dIhne: 
%esiaen r  -. \\Ml,, 
$  JO 
;\ 
;#  ~.- : 
@ , ,A8 
 --
suet,  S. ToddM, D  515North !We  StreP!  312 464-.YM 
&sseIIuvWc rcPruhient  Chiugo.  [itinois 60610  312 W-4194  f-ax
Febtuary 1. 1995 
IIM I-IonorabfeJune Gibbs &own 
- ~~ 
Of!icc ofInspectoGrencrai 
Department of Heaith & Human Semicea 
330 Independe=c  Avenue. Sw - Room 5246 
Cohen Budding 
Waahingwn. D.C. 20201 
RE:  DraftInspection I@xxI.  .%tionai  Pnzctuioner Data Rank Repons ro Managed 
Gare Organfzafrons:  I%eir L@Wness and impacr 
The  erican Medical Association (AMA] is pleased to respond to your request for 
comments  on the Off~ceof Insp=mr  @wtis  (OIG) dratl  inspectionxport,AImonaf 
Pmtiitioner Data Oti  Repons to Mwged  Care Orgaruzztimas: 77Wr i@Wness  and 
i~act.  Dcccrnbcr 1994  ~  SWedwpose  of b  sudy 
W- to  assess  *  UScfuhess 
im~accof  (NPDB) to managed 
and  Momation  in  IJIC ~atiod  f%mtioner  Data  Bank 
care organizations. 
After reviewing  the Dcccrnber drafi  report. the AMA conckdes  thatthe report  provides 
an incompieu  and rmsicadkg  picture  of rhe useftthaessand impacotf the bJPDB. 
Funher.  we senouiy  question the OIGs concluding observations in the report.  Evidence 
increasingly  ieads us m believe  that  the Data Bank is ncitk  a reiiable nor a cost
effcctive  mechanism  forprcvenfing  tic  pubiic  from  ifmrnpcrmt  or unprofmsiotud 
hospital-based  practitioners.  The AMA is very disappointed  m see the serious  flaws we 
identifiedin the February,  1993 OIG rcpo~ repeated in this repot%,with no apparent 
?uempt  co correct  fmdty or misleading  reformation.  The &lA  offers  the following 
comments  on M  OIGScurrent draft KporL 
Ile  draftreportwam  fails to disciosethe total utiveR= of quemzsor any operatiomti 
mformauon that m@t  CmKCan accurate COYIUXfotr the data pt=eawd.  Since the AMA 
cited this as a most serious deficiency in the Februag.  1993 OIG report on the usefiiness 
and  impact ofrepom  [O hospiais.  we quesuon why the OIG is ttot presenting  a more 
cornprdcnsxve  and accumti  assessment  of the usefulness  and  impacc of the NPDE.  The 
AMA Mievcs  tit  some of tic cnti=i  information fmrn the August. 1994 OIG mpott. 
Mstional PracImoner Data Bank:  Proflie of Marches Up&e.  must be includedin this  Page 2

February 1. 1995

Tbc Hmtotablc June Gibbs Brown

c~nt  report.  For example. the following information should be inciuded in the

background section of the draft report:

Aa of A@.  1994, dw Data W  had rcccived 3.462.297  requests for 
Mnsnatiost ad  82.623- of mhmae actions or mdpcdce  payments. 
w  of b  wri=  de  W APrii of 19!%  152.941  matches  had 
a red 
cxxumed  (144.649  mad=  =  Of Felnuary of 1994). 
This information provides a match raw of 4.4  percent.  Approximately 96 percent  of 
the queries ESUIM  in no advc~e  action or maipmcttce information.  Yet the 
backgroundsection of tic draft rcpon presents a  different picture.  The draft 
vay 
rcpm  SWCS.  as  of February 25.  1994. ~OS.  PPOS. and grouPp~CtiCCS  had 
rcccivcd, in response  queries. 31.377 reports of maiptitctice payments or adverse 
to 
actiom against physici-.  dentis~. ad  other heaith cam practitioners.   The 
statement is wrung. ad  the AMA ~iievcs  that tie  WOrd matefted  must  be inaetred 
between he  words  31.377  @  rm~  m propdy  rcinfme  the faa  that this 
report is only 100icingat approximately 4 pm=  of the universe of queries. 
%  AMA notes Wt  oniy 51 p=ent  of h  managed care organizations  returned fhe 
qum;omire.  TIIe organizations that fti  to return the questioariairc my  not fed 
as strongIy that the NPDB is uscfil. 
IM  muon  managed  fou~  a Mhcr  percent of the matched rcpoxu 
c=  Omciafs 
usefid may be re~atetdoticremon hey queri~theNPDB.  Sixty-eight percent  of 
the managed  care vrgatition  queries  wem for initiai privileging and 21 percent were 
forprofessiormelv iewpurposes.  (My  i 1 percent of the queries were fortherwo
Yearreview rcquuemencscotnpmd  [O hospitalswhich had 69 percent of their queries 
for tic  two-year  review.  Inaddition. -gd  cam  orimnizations have  been 
tigomusiy crcdcmi@  pmctitioners for a-h  shorter period of time. 
On page 4 of ~c  drafi won.  tic  ~JG comw- tie  ~a~  B*  ww  tit  provided 
informauon tit  practitioners did not provide f.hemseivesto rhe organimion  and 
compares that to hoapimls.  me  42 percent for hospitals may be incorrect since the 
OIG Lkcemb=.  1994 drafi ~POII  On the  use~iness  of the NPDB to hospitals srates 
duu 13 perunt  of the matched reports in period B provided information previously 
unkncwn  (o hospital  staffs. 
Two {Mngs h thidsmfirepon that shouid be investigated inciudc the 3 percent of 
rcpo~thatapi=- 10 be fiwumm  and tie  increase in paper query response time. 
PreYmus  studies of the NPDB have fo~d  it-$ti~  10 be  Miabie.  w  new ftiittg 
raises some questiom  mgmd~g  tie  SCCUmCYof b  NPDB.  The NPDB hada.ko 
madesignificimmtprovement co redu~  @  response time;  *  increaM to 35 days is  -3-

Page3 
February  1.1995 
The Honorable  June Gibbs Brown 
disturbing because some reports were rcceivd  w  he  to have an @act  on the 
. . 
cm@nna@  decision. 
mtnoatimpt=m  -mof=-ti~*r=@=d-Mm

mon~  dscisiotts.  According to tbe returmd qmbmaim.  only 3

percent of the matched reports made a difference in  privileging  dccisiom  17ds 
a 
numbemray  even k  iuwer if ail of the managed care oqpizations  would have 
mtumed the sumy.  Witi  a match rate of 414 percent and 3 PC=  of matched 
reporrs having  an impact on privileging,  cite overaii impact is 0.13  _  or about 
one out of every  750 queries. 
M&  reviewof  the drafi rqxm  the AMA seriousiy questiotnhseOIGsconcluding 
observatioTnhse. idemificaroifo3n p ercenotf thematchedr eporrasppears 
inaccuraatned raiseqsu estioanbsout the NPDB being a tdiable  source of 
information.  In addition, the data bank is not a cost%ff=tive  nor a usefial mechanism 
to protect the pubiic by preventing inco~tem  an~or  unprofeasiod  practitioners 
fmm practicing in managed care oetiom.  Vev  rarciY did a lWDEqueryaff=t 
privileging decisions  of managed care organizations.  Only 0.13  percent of the queries 
at%ecta cmdentiaiing  decision. 
In cmchxsion. based upon die above discussion. we Meve  !hat it is diflkuit  to justifi 
the direct and indimx  costs of operating the NPDB.  We urge you to carcftdly 
consider our conunems h  order to ade~cciy  m*SS tie UtiV  and impact of ti 
IvPI)B to hospitals. 
JZJLJ4,I9 
&lllcS  S. Todd. MD  APPENDIX  D 
NOTES 
1. National  Committee  for Quality Assurance  (NCQA), Accreditation  Standards, 
Credentialing  Standards  7.1 and 11.1 (1993) 28, 30.  In commenting  on our draft report, 
NCQAnoted  tiatapplicants  maymeet  tiecredentialing  stindard  byrequestinga 
malpractice  history  of the applicant,  @  requesting  five years of malpractice  history  from 
the malpractice  carrier,  @  requesting  information  on the application  regarding  actions 
taken by hospitals  and managed  care organizations  that limited,  suspended,  or abolished 
the practitioners  privileges,  @  querying the Federation  of State Medical  Boards. 
2.	 Office of Inspector  General,  National  Practitioner Data Bank: ProJle  of Matches 
Update,  August  1994, OEI-01-94-00031. 
3.  Health maintenance  organizations  and group practices  accounted  for 6.5 percent  of 
matches  (i.e.,  a querier  requests  information  on a certain practitioner  from the Data Bank, 
and that practitioner  has been reported  to the Data Bank--a request-report  pair)  in the 
period  from September  1, 1990 through March  19, 1992.  They accounted  for 
24.2 percent  of matches  for the period March  20,  1992 through  February  25,  1994. 
4.	 Office of Inspector  General,  National  Practitioner Data Bank:  Usefulness and Impact 
of Reports  to Hospitals,  February  1993, 0EI-01-90-O0520. 
5.	 Office of Inspector  General,  National  Practitioner Data Bank Repoits  to Hospitals: 
Their  Usefulness and Impact,  Date,  0EI-01-94-OO030. 
6.  The question  read  Please rate the following four types of information  maintained  in 
the Data Bank in terms  of their usefulness to you--in theory  or in practice--in  the 
practitioner  credentialing  process.  
7.  In our sample,  10 percent  (24) of the Data Bank reports  involved practitioners  for 
whom the initial or final decisions  were pending. 
8.  We are 95 percent  confident that the proportion  of reports  that provide  new 
information  to managed  care organizations  is between 4,727  and 8,239. 
9.	 We are 95 percent  confident that the proportion  of reports  that affect managed  care 
organizations  credentialing  decisions  is between 215 and 1,646. 
D-1