Q&A with Dr. Sidney Wolfe: Hospitals should cough up info about dangerous docs on staff

Dr. Sidney Wolfe, the acting president of Public Citizen and the head of its Health Research Group, is a guy you don't want to have as an opponent. He has an encyclopedic command of the facts and a delivery that manages to be both gracious and a little intimidating. He co-authored a report in May about the paucity of information in the National Practitioner Data Bank, a project that he has been involved with since its inception in 1990. I reached him at his office in Washington, D.C.

A recap of our conversation is below. It has been edited for clarity and space.

Q: With everything else going on in health care, and your own focus on a single-payer system of universal health insurance, what prompted this look at the National Practitioner Data Bank now? Why not wait until all the noise about health insurance had died down?

A: Either I or someone else from our group has been on the executive committee of the National Practitioner Data Bank pretty much since it started. We reported early on what was going wrong with the pitifully low amount of doctors being sent in to the data bank from hospitals. It is almost the 20th anniversary of the data bank, and very little has changed. But we do have a change now in the people running HHS. If you see our list of remedies, they include expanding the role of the Centers for Medicare & Medicaid Services. The previous secretary of HHS was not anyone who anyone would realistically ask to do anything progressive. And Kathleen Sebelius is. She is very smart. She comes from Ohio, where her father was the most progressive governor we had in Ohio. She testified right before me before the House Energy and Commerce Committee a few weeks ago, and we agreed to meet and talk about a bunch of things and this is one them. If one is concerned about the quality of medical care, fixing this problem is very important. The most serious kinds of injuries to patients almost always happen in the hospital, and we need to make sure that we are creating and maintaining a data bank that is critically useful to hospitals and medical boards. Instead, there's a huge hole in the data bank. Half the hospitals have never, in more than 17 years, reported one doctor.

Q: That's the centerpiece of your report. The fact that nearly half of the hospitals - meaning about 3,250 of 6,500 hospitals - have never reported a case of physician discipline. Why should we assume that physicians have done anything wrong in any of those hospitals? Isn't it possible that some hospitals have a very good vetting process when they are giving doctors privileges?

A: It's not believable that there are that many hospitals with that many doctors - we're talking hundreds of thousands of doctors who have never done anything wrong.

Q: So what are they doing to avoid reporting those doctors to the NPDB?

A: There's been a gaming on the part of hospitals. They will mete out discipline that falls short of the reporting requirements. If they haven't had one doctor that they have reported, they either have not disciplined any doctors or they have and they just have not reported it. Or they have managed to make the suspension 30 or 29 days, which is below the 31-day reporting threshold, and then they are gaming the system. The NPDB is secret from both patients and doctors. If I wanted to refer you to someone in Seattle, and I wanted to make sure that this doctor had not been thrown off the staff at Harborview, I can't get any information. The American Medical Association gets credit for keeping the data secret from patients and doctors. But you can get aggregate data from the data bank. When you look at these doctors who have been disciplined you see that many of them have been disciplined by state medical boards. The point is that there are a much larger number of doctors who have been disciplined by state medical boards than have been disciplined by hospitals. Yet, most of these doctors have admitting privileges. So there is a disconnect. Why is it that they did something so wrong that it merited action by a state medical board or resulted in some malpractice payout - because those are tracked by the data bank, too - but it merited no action by a hospital? This is the same response we get when we put out our rankings of state medical boards. Some states, in sort of silly way, respond by saying, "We don't have any bad doctors here. We take care of them at the front end." Well, the front end is a licensing test that is pretty much the same all over the country. Just as there is no reason to think one state licensing process is much better than another, there is no reason to think that Hospital A has such shoddy tests to allow in a doctor who shouldn't be in there and Hospital B is so tightly controlled that they only let in the good doctors.

Q: You say that prior to the opening of the NPDB, the Department of Health & Human Services (HHS) estimated that 5,000 hospital clinical privilege reports would be submitted to the NPDB each year. However, the average number of hospital reports per year has been 650.And the industry estimate was 10,000. As of December 2007, there was a total of only 11,221 such reports. Wasn't the agency flying a little blind at that point? There was no tracking system so how could they know?

A: That was based on their estimates of how many doctors had would be disciplined, given how many had been disciplined by state boards. They were all surprised 13 years ago when the AMA, the American Hospital Association and the people from the data bank and I met to talk about how there were so few hospitals reporting to the data bank. They were certainly aware of the extent to which any given states' doctors are disciplined by state medical board for various things. And they knew how many doctors were being sued for malpractice and having to make a payout. It isn't as if there was no other metric, to use the word of the day. And it's not like they were close. They were off by a factor of 8 or 15, depending on which number you use.

Q: Peer review is sort of this star chamber system with no public review, even in a public hospital setting. What are some windows that the public has into it? Where can people find out information about peer review at their hospital?

A: They can't other than by attending the annual meeting of the board of a hospital, which sometimes is open to the public. But even at those board meetings, the hospital says, "We came out $1 million ahead or we came out $1 million behind." And there is not enough attention to the quality of medical care. Hospitals are the places lives can be saved, but also where lives can be lost. If doctors who are doing more harm than good are allowed to stay on the staff, they are seriously undermining the quality of care.