Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

NATIONAL PRACTITIONER DATA BANK 

REPORTS TO MANAGED CARE 

ORGANIZATIONS: 

THEIR USEFULNESS AND IMPACT 

JJ sER”bs./,. 

.$)’ -0’-f 

$?’ ~ JUNE GIBBS BROWN 

/ Inspector General 

-

“vd3a & z APRIL 1995 

OEI-01-94-OO032 
OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General (OIG), as mandatedby Public Law 95-452, 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 

statutory mission is carried out through a nationwidenetwork of audits, investigations, and 

inspectionsconducted by three OIG operating components: the Office of Audit Services, 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 OIG’SOffice of Audit Services(OAS)provides all auditing servicesfor 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 respective responsibilitiesand are intendedto provide independentassessmentsof HHS 

programs and operations in order to reduce waste, abuse, and mismanagementand to promote 

economy and efficiency throughout the Department. 

OFFICE OF INVESTIGATIONS 

The OIG’SOffice of Investigations(01) conductscriminal, civil, and administrative investigations 

of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment 

by providers. The investigativeefforts of 01 lead to criminal convictions, 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 OIG’SOffice of Evaluation and Inspections(OEI) conductsshort-term management and 

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 

generate rapid, accurate, and up-to-date informationon the 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, Project Leader Alan Levine, Program Specialist


Joyce Greerdeaf, ProgramAnalyst


Barry McCoy, ProgramAnalyst


Michael Sullivan, SummerZntern


For additional copies of this report,please contact the Boston regional ofice by telephone at


(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 Bank’s 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 Bank’s 

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


one’s assessments of usefulness and impact will depend heavily on one’s 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 NCQA’s 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 Bank’s 

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 Bank’s 

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 President’s 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 practitioner’s 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 Bank’s 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 insurer’s 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 Bank’s 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 

IMPACT OF DATA BANKREPORTS 

Unlikely to Have 

Impact 81% 

I SOlnw HHsofamOfrlqmtm 

le to Have Impacg 

DidNot 16% 

Had An Impact 3% 

VI J (lkciaiona Different) 

omEralsIlrwy0f3ndo,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 

practitioner’s 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 Bank’s 

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 one’s 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 

answen”ng question 30, not question 27. The 177 respondents answen”ngpositively 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 

NCQA’s 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 AMA’s 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 AMA’s 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 

2 reports about 1 practitioner); 

22 were each sent questionnaires 

2 reports about 1 practitioner); 

14 were each sent questionnaires 

2 reports about 1 practitioner). 

on 2 different practitioners (1 received 

on 3 different practitioners (1 received 

on 4 different practitioners (1 received 

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 

PHYSICIANS 

Obstetrics and Gynecology 

General Surgery 

Orthopedic Surgery 

Family Medicine 

Pediatrics 

Missing or Miscoded 

Neurological Surgery 

Internal Medicine 

Ophthalmology 

General Medicine 

Cardiology 

Eye, Ear, Nose, and Throat 

Urology 

Anesthesiology 

lloracic Surgery 

Plastic Surgery 

Oncology 

Pubnona~ Medicine 

Radiology 

Osteopathic Gynecology 

Psychiatry 

Allergy 

Cardiac Surgery 

Gastroenterology 

Hematology 

InfectiousDiseases 

Neonatology 

Pathology 

Perinatology 

203 100.0% 

199 98.0 

34 16.7 

25 12.3 

20 9.9 

16 7.9 

11 5.4 

11 5.4 

10 4.9 

8 3.9 

8 3.9 

7 3.4 

6 3.0 

5 2.5 

5 2.5 

4 2.0 

4 2.0 

4 2.0 

3 1.5 

3 1.5 

3 1.5 

2 1.0 

2 1.0 

1 0.5 

1 0.5 

1 0.5 

1 0.5 

1 0.5 

1 0.5 

1 0.5 

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 

things considered’’--to query the Data Bank 

3 95.0 I 3.4 

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 

extremely useful 

Proportion of respondents rating hospital actions extremely 3 

useful I 

Proportion of respondents rating malpractice payments 3 

extremely useful 

Proportion of respondents rating professional society actions 3 

extremely useful 

Proportion of reports providing information previously 3 

unknown 

Proportion of reports providing information previously 3 

unknown considered usefid 

Proportion of reports providing information that the practitioner 4 

did not self-report 

Proportion of malpractice reports of which managed care 4 

organizations were aware 

Proportion of malpractice reports of which managed care 4 

organizations were aware I 

Proportion of respondents who considered reports useful 4 

because they confirmed information available elsewhere 

Proportion of respondents who considered reports usetid 4 

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 

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 

to be incomplete 

Proportion of reports obtained electronically 5 

78.6 6.2 

1 

74.6 6.6 I 

68.0 I 7.0 

21.6 5.9 

100.0	 I o 

I 

30.5 6.6 

79.8 5.9 I 

58.3 27.9 I 

66.7 I 6.9 

18.6 5.7 

4.9 I 3.0 

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 A’s 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 

a response. ) response yet 

6 On what date did your organization make its initial ~“de range of dates 6 

decision regarding Practitioner A’s privileges? (W)-ite 15 initial:ecisi~ns 

“PEWIATG” lf the organization’s initial decision has were pending 

not yet been mude, then skip to 15.) 

7	 Was your organization’s 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 A’s privileges? (Write ‘ending 

“PENDING” 17organization’s final decision has not 

yet been made, then answer 9 through 14 with respect 

to the organization’s 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 A’s privileges denied (for initial No: 2 

application) or revoked (for renewal application)? Missing: 1 

(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 A’s privileges restricted or amended ‘0:1 

in any way? Missing: 3 

(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 A’s 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 A’s 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 A’s privileges 

in place prior to the application? 

No: 1 

Missing: 4 

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 A’s 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 A’s history) 

15	 Were any other actions taken with regard to Yes: O 15 

Practitioner A’s employment, privileges, or No: 1 

credentials (e.g., education requirements, drug testing, Missing: 4 

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 

mentioned on the last page of this form? Missing: 13 

(If no, skip to 19) 

17	 (skip 

From 

action 

a 

b 

c 

d 

e 

f 

g 

h 

i 

~ you answered NO to 16) 17 

which of the following sources were you aware of the adverse 

or malpractice payment? 

Practitioner A (self-report) 

Licensing board in your state 

Licensing board in another state 

Malpractice insurer in your state 

Malpractice insurer in another state 

Hospital in your state 

Hospital in another state 

Professional society in your state 

Professional society in another state 

yes:132 a 

No: 16 

Missing: 14 

N/A: 41 

yes:10 b 

No: 137 

Missing: 15 

N/A: 41 

yes:1 c 

No: 146 

Missing: 15 

N/A: 41 

Yes:53 d 

No: 94 

Missing: 15 

N/A: 41 

Yes:4 e 

No: 143 

Missing: 15 

N/A: 41 

Yes:12 f 

No: 135 

Missing: 15 

N/A: 41 

Yes:1 g No: 146 

Missing: 15 

N/A: 41 

yes:2 h 

No: 145 

Missing: 15 

N/A: 41 

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 

response inconsistent in any way with the information 

No: 111 

Missing: 65 

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 

accuracy of the Data Bank response or to obtain more 

detailed information on its content? 

Missing: 15 

(If no, skip to 21) 

20 (sic@ if you answered NO to 19) Yes: 39 20 

Did your additional inquiries show the Data Bank No: 5 

response to be accurate? Missing: 158 

(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 

were M contained in the response from the Data Missing: 15 

Bank? (If no, skip to 25) 

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~~reOY 1a

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) 

b Licensing board in your state 

c Licensing board in another state 

d Malpractice insurer in your state 

e Malpractice insurer in another state 

f Hospital in your state 

g Hospital in another state 

h Professional society in your state 

i Professional society in another state 

j Other source in your state 

(IF YES, SPECIFY: 

k Other source in another state 

(IF YES, SPECIFY: 

) 

Yes:32 a 

yes:1 b 

Yes:~ c 

Ya: 17 d 

Yes:1 e 

yes:3 f 

Yes:O g 

yes:0 h 

yes;o i 

yes:~ j 

yes:o k 

h?ATION~ PRACTITIONERDATA BANK QUESTIONNAIRE-- PAGE 6 
CONSIDERATION OF INFORMATION 

25 BaSedon tienotes in Practitioner A's file andyour personal ~owledge 25 

of Practitioner A’s application, which of the following people or groups 

had access to and 

decision regarding 

a 

b 

c HMO/PPO/Group 

it 

e 

used the response from the Data Bank in making a 

Practitione~ A’s application? 

Department chair 

Chief of medical staff 

Practice administration (CEO, Vice 

President, etc.) 

Credentials committee 

Medical staff executive committee 

Yes: 32 

No: 23 

Missing or N/A: 148 

Yes: 52 

No: 19 

Missing or N/A: 132 

Yes: 99 

No: 27 

Missing or N/A: 77 

Yes: 176 

No: 5 

Missing or N/A: 22 

Yes: 26 

No: 24 

Missing or N/A: 153 

Yes: 35 

No: 39 

Missing or N/A: 129 

Yes: 17 

No: 43 

a 

b 

c 

d 

e 

f 

/3 

f HMO/PPO/Group Practice board subcommittee 

g Full HMO/PPO/Group Practice board 

NATIONAL PRACTITIONERDATA BANK QUESTIONNAIRE-- PAGE 7 
UTILITY OF INFORMATION	

26 

27 

a 

b 

c 

d 

e 

f 

g 

h 

i 

j 

28 

a 

b 

Including the report on the last page, how many Data 

Bank reports on Practitioner A did you receive in total 

from this request? 

(Sk@ if you answered “1”to 26) 

Overall, was the information contained in the 

complete Data Bank response (i. e., all reports 

combined) useful to you? 

IF YES, WHY? 

Information was unavailable elsewhere 

Information confirmed other reports that were 

available elsewhere 

Information helped us to judge practitioner’s 

competency 

Information helped us to judge practitioner’s 

professionalism 

Other (EXPLAIN: ) 

IF NO, WHY NOT? 

Information was available elsewhere 

Information was inaccurate 

Information did not help us to judge practitioner’s 

competency or professionalism 

Information was not provided in a timely manner 

Other (EXPLAIN: ) 

(Skip if you answered “1”to 26) 

Would your decision regarding Practitioner A have 

been different if you had ~ received the reports from 

the Data Bank? 

IF YES, HOW (then skip to 31)? 

Would have granted requested privileges 

Would not have granted requested privileges 

131resp. rec ‘d 1 26 

5 ~:~ ~ 

2 rec ‘d 4 

1 rec ‘d 5 

(If 1, skip to 30) 

Yes: 59 27 

No: 1


Missing or N/A: 143


(Check all that 

apply) 

Yes: 16 

Yes: 45 

Yes: 42 

Yes: 26 

Yes: 2 

(Check all that 

apply) 

Yes: O 

Yes: O 

Yes: 1 

Yes: O 

Yes: 1 

a 

b 

c 

d 

e 

f 

g 

h 

i 

j 

Yes: 1 28 

No: 41 

‘isSing ‘r “A: 161 

(Check one) 

yes: I a 

yes: o b 

NATIONA PRACTITIONERDATA BANK QUESTIONNAIRE-- PAGE 8 
c 

d 

e 

f 

g 

h 

i 

j 

Would have restricted privileges 

Would not have restricted privileges 

Other (EXPLAIN: ) 

IF NO, WHY NOT? 

Would have restricted or denied privileges anyway 

Already knew, from	 other sources, about information 

reported in Data Bank responses 

Data Bank responses did not indicate a problem that 

warranted restricting or denying privileges 

Did not receive Data Bank responses in time	 to affect 

decision 

Other (EXPLAIN: ) 

29	 (Skip if you answered “YES”to 28) 

Did the reports you received make you feel more 

confident, less confident, or no different about the 

decision you made regarding Practitioner A? 

a More confident 

b Less confident 

c No different 

30	 Overall, was the information contained in the Data 

Bank report on the last page useful to you? 

a 

b 

c 

d 

e 

f 

IF YES, WHY? 

Information was unavailable elsewhere 

Information confirmed other reports that were 

available elsewhere 

Information helped us to judge practitioner’s 

competency 

Information helped us to judge practitioner’s 

professionalism 

Other (EXPLAIN: ) 

IF NO, WHY NOT? 

Information was available elsewhere 

Yes: O c 

Yes: O d 

Yes: O e 

(Check all that 

apply) 

Yes: O 

Yes: 25 

Yes: 18 h 

Yes: 2 i 

Yes: O 

29 

(Check one) 

Missing or N/A: 165 

27 a 

1 b 

lo c 

Yes: 177 30 

No: 8 

Missing: 18 

(Check all that 

apply) 

Yes: 33 a 

Yes: 133 b 

Yes: 118 c 

Yes: 92 d 

Yes: 17 e 

(Check all that 

apply) 

Yes: 7 f 

NATIONALPRACTITIONERDATA BANK QIJESTIONNAIRE-- PAGE 9 
t! Information was inaccurate yes: o g 

h Information did not help us to judge practitioner’s 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 A’s Yes: 5 31 

privileges have been different if you had n~ received No: 156 

the report on the last page from the Data Bank? Missing: 42 

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 q’1


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 No: 8 

query the Data Bank? 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”+ 

. . DEPARTMENT (IF 14MLTH & HIJMA3J SERVICES PublicHealthSewics 

$ 

e

+.,4c 

*W,” Memorandum 

D8r8 fEB2f199!5 

ffatl Assistant Secretary for Health 

Office of Inspector General (OIG) Draft Reports on the 

U6alhlrAtBs83 and Impact of National PxactLtLone= Data Bank 

Reports to Hospitals and Managed Care Organizations, 

To OEI-01-94-00030 and OEI-01-94-00032 

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. 

i ,, (///Aq& .~ 

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 

Resoux’ce8 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 Bank’s 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- ~ 

/’

E’ 

~ 

� 4(L


“’%19N 

To: 

From: 

Subject 

DEPARTMENT OF HEALTH & HUMAN SERVICES -ka Ot tho 6euotwv 

. 

Wmhmgton, O.C, z~ol 

FEB z 7 B9!5 June Gibbs Brown 

Inspector General 

Assistant Wixetary for 

Planning and Evacuation 

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 OIG’S 

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(3’s 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 supportstheOIG’S concision of data bank usefulness is the 

answer to the quesuon, “Ovcrail. was the information contained in the complete Data 

Bankresponse (i.e.,ail reports combined) useful 10you?”(questionnaire item27,

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. June Gibbs Brown 

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 interest the dzaft inspection report, “Nationai Practitioner Data Bank Reports to 

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 repcm’s 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[e m tieNPDB. Orgamzations which do not pardcipate in the NFDB may meet the 

standardby requesting a 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 practitioner’s privdeges, ti queryingtheFederationof State Medical Boards. I 

hope thatthischmfkation is usefulto you as you prepare thefinalreport. 

Thank you for(heopportunitytoreviewthis repat prior to itsrelease. 

Sincerely, 

“\ 

j+~luLL ,-

MargareLE. d’Ihne: 

%esiaen r 
-. \\Ml,, 

$ JO 

;\ 

;

# -: ~. 

@ , ,A8 

‘ --

suet, S. Todd,MD 515North !We StreP! 312 464-.YM 

&sseIIuvcWrcPruhient Chiugo. [itinois 60610 312 W-4194 f-ax

Febtuary 1. 1995 

IIM I-IonorabfeJune Gibbs &own 

- ~~ 

Of!icc of InspectorGencrai 

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 @wti’s (OIG) dratl inspectionxport, AI’m”onaf 

Pmtiitioner Data Oti Repons to Mwged Care Orgaruzztimas: 77Wr i@Wness and 

i~act. Dcccrnbcr 1994 ~ SWed wpose of b sudy W- to assess * UScfuhess 

and im~accof Momation in IJIC ~atiod f%mtioner Data Bank (NPDB) to managed 

care organizations. 

After reviewing the Dcccrnber drafi report. the AMA conckdes thatthe report provides 

an incompieu and rmsicadkg picture of rhe useftthaessand impactof the bJPDB. 

Funher. we senouiy question the OIG’s concluding observations in the report. Evidence 

increasingly ieads us m believe that the Data Bank is ncitk a reiiable nor a costeffcctive 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 OIG’Scurrent draft KporL 

Ile draftreportwam fails to disciosethe total utiveR= of quemzsor any operatiomti 

mformauon that m@t CmKCan accurate COYIUXt for 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 mpot’t. 

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 a red of b wri= de W APrii of 19!% 152.941 matches had 

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 vay different picture. The draft 

rcpm SWCS. ‘as of February 25. 1994. ~OS. PPOS. and gr’ouPp~CtiCCS had 

rcccivcd, in response to queries. 31.377 reports of maiptitctice payments or adverse 

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 c= Omciafs fou~ a Mhcr percent of the matched rcpoxu 

usefid may be re~atedtoticremon hey queri~theNPDB. Sixty-eight percent of 

the managed care vrgatition queries wem for initiai privileging and 21 percent were 

forprofessioml reviewpurposes. (My i 1 percent of the queries were fortherwoYearreview 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 thisdmfirepon 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 

madesignificmt improvement 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. 

mtnoatimp’t=m -mof=-ti~*r=@=d-Mm


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


percent of the matched reports made a difference in a privileging dccisiom 17ds 

numbermay 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& review of the drafi rqxm the AMA seriousiy questionstheOIG’sconcluding 

observations. Theidemificarion of3 percent ofthematched reporrsappears 

inaccuratendraises questions about 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. 

JZJLJ’’4,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 practitioner’s 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