Tuesday, August 5, 2008

Role of state medical boards in disciplining physicians

A study was commissioned by the Bush Administration in 2005 to assess the role of medical state licensing boards in physician discipline. Okay. Fine use of taxpayer dollars. Now what?

In 2005 experts commissioned by the Bush Administration to assess the role of state licensing boards in physician discipline charged medical boards with being too lenient on doctors who practice poor medicine. The experts suggested that more effective disciplining would help curb the costs of malpractice insurance.

The project, headed by Randall R. Bovjberg of the Urban Institute, focused on six case studies looking at state medical boards’ processes for disciplining physicians as well as practices that board staff or other experts believed to be effective in improving their impacts on quality. The study findings were released in February 2006 and showed that the physician disciplinary process is predominantly a complaint-driven, reactive process generating a large volume of cases, most of which are closed without any action.

Many of the state medical board members and managers surveyed for the study said they wanted to do more than react to complaints and were looking for proactive alternatives, including audits of physician practices, non-disciplinary use of clinical assessment centers or CACs (where physicians are referred for remediation/re-education), and efforts to encourage ongoing maintenance of competence.

The Urban Institute case study participants also identified existing improvements in their disciplinary processes:

· Establishing advance rules where possible to improve practice without waiting for complaints;

· A special review process by board sub-panels to resolve a subset of quality-related complaints;

· Use of national clinical assessment centers as an adjunct to discipline;

· Patient education through physician profiles posted online;

· Medical board review of hospital incidents and responsive safety mechanisms, wholly separate from discipline; and

· Cooperation with hospitals for early detection of physicians with deficits in capabilities, for remediation in place of discipline.

Unlike the state of Illinois, some medical state boards, fueled by public scrutiny and greater awareness of medical errors, have begun to take a more aggressive stance toward physician discipline. For example:

1. Massachusetts: Rather than wait for a complaint to be filed, the Massachusetts Board of Registration in Medicine now conducts a clinical review of any doctor who has lost or settled three or more medical malpractice cases but has never received any disciplinary penalties.
2. Maryland: A few years ago, when the Board of Physicians came under fire for failing to discipline physicians who had serious malpractice cases, the state legislature expanded the board from 15 members to 21 and lowered the standard of proof required to take formal disciplinary action.

According to Robert Berenson, M.D., a senior fellow at the Urban Institute and an expert in health care policy, while medical licensing boards spend a significant amount of time and effort engaging competent physicians to improve their performance, the primary role of boards is dealing with the outliers. "While most of the activities around quality improvement are trying to focus on raising the performance of good physicians, the boards really need to deal with the ‘tail,’ or the unacceptable," he says.

Dr. Berenson maintains that weeding out these poor performers will impact quality improvement, explaining that while such disciplinary actions may not show up in broad aggregate measures, they are certainly protecting patients from harmful physicians. "It’s the kind of activity that is not uplifting in that sense, but, if the number of patients who avoid egregious errors were a quality measure, then disciplining, or even weeding out bad doctors, should, by and large, impact quality improvement."

Dr. Berenson explains that medical boards’ role in disciplining physicians is made even more important (albeit more difficult) by the increasing numbers of physicians who do not practice in hospitals. Many services performed in hospitals can now safely and conveniently be performed in ambulatory settings and physician offices, so many doctors do not take part in the institutional credentialing process. According to Dr. Berenson, since the hospitals are no longer obligated to credential physicians and no longer corporately liable for their actions, the hospitals have less formal control over the quality of the physician’s performance. Dr. Berenson believes that this necessarily leads to a greater burden being placed on the licensing board because there is no other institution looking at individual physicians.

This information was obtained from Miriam Reisman’s February 2007 article (Role of Medical Board Discipline) published in the Physician’s News DIgest http://www.physiciansnews.com/cover/207pa.html

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