Where’s doc dis­ci­plinary data?

Fed­er­a­tion of State Med­i­cal Boards drops an­nual sum­mary; Pub­lic Cit­i­zen vows its con­tro­ver­sial rank­ing still in the works

Modern Healthcare - - PHYSICIANS -

Peo­ple wait­ing to read the Fed­er­a­tion of State Med­i­cal Boards’ an­nual re­port sum­ma­riz­ing national statis­tics for doc­tor dis­ci­pline are wait­ing in vain. The FSMB has qui­etly killed its An­nual Sum­mary of Board Ac­tions re­port. The Fed­er­a­tion, which has pub­lished the re­port since 1985, prom­ises that a new and im­proved re­port—which will not nec­es­sar­ily in­clude statis­tics on each state med­i­cal board’s dis­ci­plinary ac­tions—should be out in the fall.

The change will make it harder for the con­sumer ad­vo­cacy group Pub­lic Cit­i­zen to pub­lish its widely fol­lowed an­nual re­port rank­ing state med­i­cal boards by their num­ber of dis­ci­plinary ac­tions against physi­cians. Its rank­ings, first pub­lished in 1999, have been based on the FSMB re­port. Pub­lic Cit­i­zen con­tends that the fed­er­a­tion deep-sixed its re­port to stop Pub­lic Cit­i­zen from putting out the rank­ings that state med­i­cal boards and physi­cian groups hated. But Pub­lic Cit­i­zen has vowed to con­tinue rank­ing state boards even if the FSMB no longer sup­plies it with the read­ily avail­able raw ma­te­rial to do so.

“We’ll fig­ure out a way to keep do­ing the rank­ings,” says Dr. Sid­ney Wolfe, founder and a se­nior ad­viser of Pub­lic Cit­i­zen’s health re­search group. “We’re not throw­ing in the towel be­cause that’s not our style.”

Un­der­ly­ing the back and forth over the fed­er­a­tion’s re­port are long­stand­ing dis­agree­ments over how to mea­sure state med­i­cal boards’ ef­fec­tive­ness in polic­ing doc­tors and how best to en­sure that doc­tors are prac­tic­ing and be­hav­ing well.

The FSMB rep­re­sents the 70 li­cens­ing boards of the 50 states, Dis­trict of Columbia and U.S. ter­ri­to­ries (15 states have sep­a­rate os­teo­pathic boards). The FSMB has com­piled dis­ci­plinary ac­tions taken against physi­cians the pre­vi­ous year by its mem­ber or­ga­ni­za­tions. The an­nual sum­mary has listed the num­ber of physi­cian li­censes re­voked, sus­pended, mod­i­fied and or­dered to be sur­ren­dered or re­tired by each med­i­cal board.

Lisa Robin, the FSMB’s chief ad­vo­cacy of­fi­cer, says the fed­er­a­tion is re­vis­ing the for­mat of the re­port. While the an­nual sum­mary re­leased in 2012 was the last of its kind, it won’t be the last re­port the FSMB ever pub­lishes com­pil­ing in­di­vid­ual board ac­tiv­ity. “It’s not that there’s

“It’s not that there’s not go­ing to be any data re­ported in the fu­ture, it’s just that it’s go­ing to be dif­fer­ent. (The re­port) was never meant to be used as a rank­ing that this board is bet­ter than that board.” —Lisa Robin, chief ad­vo­cacy of­fi­cer, Fed­er­a­tion of State Med­i­cal Boards

not go­ing to be any data re­ported in the fu­ture, it’s just that it’s go­ing to be dif­fer­ent,” she says.

Tra­di­tion­ally, the fed­er­a­tion’s an­nual re­ports are re­leased in the spring. They have be­gun with the same qual­i­fy­ing state­ment: “Be­cause states op­er­ate with dif­fer­ent fi­nan­cial re­sources, lev­els of au­ton­omy, le­gal con­straints and staffing lev­els, the FSMB dis­cour­ages us­ing data from this re­port to com­pare or rank states.”

Rat­ing the states

Since 1999, Pub­lic Cit­i­zen has ig­nored the fed­er­a­tion’s warn­ing, us­ing fed­er­a­tion data to rank the state boards by num­ber of dis­ci­plinary ac­tions. Pub­lic Cit­i­zen has done this by cal­cu­lat­ing a three-year aver­age of the num­ber of li­censes re­voked, sus­pended or mod­i­fied by the state board. It di­vided that fig­ure by the num­ber of doc­tors in a state to cre­ate a “se­ri­ous ac­tions per thou­sand physi­cians” met­ric. Its re­port is typ­i­cally widely cov­ered in the gen­eral news me­dia and of­ten used to crit­i­cize or praise state boards for their pur­ported lax­ity or rigor in scru­ti­niz­ing physi­cian con­duct.

The fed­er­a­tion, med­i­cal board of­fi­cials and physi­cian groups have ac­cused Pub­lic Cit­i­zen of pre­sent­ing mis­lead­ing in­for­ma­tion, ar­gu­ing that the num­ber of board dis­ci­plinary ac­tions is heav­ily af­fected by the num­ber of bad doc­tors in a state rather than whether the board is do­ing its job well or not. The fed­er­a­tion’s re­port “was never meant to be used as a rank­ing that this board is bet­ter than that board,” Robin says.

But Pub­lic Cit­i­zen has opened its re­port with this state­ment: “Ab­sent any ev­i­dence that the preva­lence of physi­cians de­serv­ing of dis­ci­pline varies sub­stan­tially from state to state, this vari­abil­ity must be con­sid­ered the re­sult of the boards’ prac­tices.” Wolfe ar­gues that it’s likely that states all have the same per­cent­age of mis­be­hav­ing doc­tors—around 1%, he es­ti­mates—so dif­fer­ences in board ac­tiv­ity are likely to be linked to vari­ables such as board lead­er­ship and re­sources.

He charges that the FSMB’s de­ci­sion to cease pub­li­ca­tion of the an­nual sum­mary was mo­ti­vated by the Pub­lic Cit­i­zen an­nual re­ports and the de­sire to avoid the con­tro­versy they cre­ated each year with their state-by-state com­par­isons. “It doesn’t take any great in­sight to re­al­ize that they didn’t like the re­ports,” he says. “‘In­fan­tile’ is the best way to de­scribe it: ‘We don’t like th­ese re­ports, so we’re not go­ing to make the data pub­lic.’ ”

Pub­lic Cit­i­zen’s sup­port­ers say the rank­ing re­port pro­vides a valu­able tool that has prompted state leg­is­la­tures to take ac­tion and in­crease the re­sources avail­able to low-rank­ing med­i­cal boards so they can do a bet­ter job.

But crit­ics such as Mark Grapen­tine, the Wis­con­sin Med­i­cal So­ci­ety’s se­nior vice pres­i­dent of govern­ment re­la­tions, call the rank­ings mis­lead­ing and un­help­ful. “We’ve had a pretty long his­tory of ques­tion­ing the use­ful­ness of that (Pub­lic Cit­i­zen) re­port,” Grapen­tine says. “It’s an ap­ples-to-or­anges com­par­i­son be­cause dif­fer­ent med­i­cal boards han­dle things dif­fer­ently. Some boards tend to be puni­tive. Wis­con­sin tends to be re­ha­bil­i­ta­tive.”

Grapen­tine notes how Wis­con­sin and neigh­bor­ing Min­nesota tend to be “bot­tom feed­ers” on the Pub­lic Cit­i­zen rank­ing even as fed­eral mea­sures in­di­cate the states are lead­ers in de­liv­er­ing high-qual­ity and high-value care. “We sup­port hav­ing a strong, well-funded li­cens­ing board that can do the job it’s ex­pected to,” he says. The big ques­tion, he says, is “how do you pro­mote high-qual­ity health­care and give the most value to con­sumers? Dr.

Wolfe’s re­port doesn’t move us to that.”

Steve Alexan­der, a pub­lic af­fairs con­sul­tant and for­mer pres­i­dent of the Med­i­cal Board of Cal­i­for­nia, ar­gues that the Pub­lic Cit­i­zen rank­ings don’t ad­vance the gen­eral mis­sion of med­i­cal boards, which he says is to pro­vide con­sumers with ac­cu­rate, timely and use­ful in­for­ma­tion. “The Pub­lic Cit­i­zen rat­ings are highly con­tro­ver­sial—you can do any­thing you want with data,” Alexan­der says. “The Pub­lic Cit­i­zen rank­ings aren’t re­flec­tive of how ef­fec­tive med­i­cal boards are.”

He ex­plains that, for ex­am­ple, boards can take on highly volatile cases that take a long time to pros­e­cute, thus re­duc­ing their dis­ci­plinary ac­tions in a given year, and that this not be re­flected in the rank­ings. But Alexan­der, who served as board pres­i­dent in 2006-07, ac­knowl­edged that Wolfe’s as­ser­tion that the level of a state board’s ac­tiv­ity is re­lated to its level of staffing and fund­ing “is likely to be ac­cu­rate.”

“The med­i­cal board was al­ways ham­pered by limited re­sources,” Alexan­der says.

Pa­tient-safety ad­vo­cate Helen Haskell, a mem­ber of the National Pa­tient Safety Foun­da­tion’s board of gov­er­nors and founder of Columbia, S.C.-based Mothers Against Med­i­cal Er­ror, says “des­per­ate un­der­fund­ing” has kept her state’s board at the bot­tom of the Pub­lic Cit­i­zen rank­ings.

“I feel sorry for med­i­cal boards be­cause of­ten their hands are tied by their leg­is­la­tures,” says Haskell, whose 15-year-old son died while un­der­go­ing elec­tive surgery at the Med­i­cal Univer­sity of South Carolina in Novem­ber 2000. “I think Pub­lic Cit­i­zen plays a vi­tal role, and they’re the only peo­ple tak­ing on this is­sue,” she adds. “If doc­tors are li­censed by the state, they need to be reg­u­lated by the state, and some­one needs to keep an eye on (the state boards) to make sure that hap­pens.”

Haskell also sug­gested that the rea­son why states such as Mas­sachusetts, Min­nesota and Wis­con­sin ranked low in Pub­lic Cit­i­zen’s re­ports is be­cause the boards there may be overly con­cerned with pro­tect­ing the rep­u­ta­tions of their states’ physi­cians and health­care in­sti­tu­tions.

The fed­er­a­tion’s Robin says, how­ever, that she has never seen any statis­tics link­ing “the num­ber of ac­tions taken by a board and pa­tient safety and qual­ity of care in a state.”

When the fed­er­a­tion first be­gan pub­lish­ing the an­nual re­ports, Robin says, dis­ci­plinary ac­tions were the only met­ric avail­able, and in­for­ma­tion on board ac­tiv­i­ties was hard to ac­cess and com­pile in the pre-In­ter­net days. But now ev­ery board has its own web­site, and it’s time for the FSMB to in­clude dif­fer­ent in­for­ma­tion such as board struc­ture, board staffing, fre­quency of board meet­ings, what au­thor­ity a board re­ports to and the num­ber of non­physi­cians on a board, she says.

She says the Fed­er­a­tion is work­ing with HHS’ Health Re­sources and Ser­vices Ad­min­is­tra­tion on a “min­i­mum data set” for state boards to post in­for­ma­tion on in­di­vid­ual li­censees so con­sumers can see “who’s prac­tic­ing where.”

Though the dis­con­tin­u­a­tion of the fed­er­a­tion’s an­nual sum­mary took many by sur­prise this spring, the FSMB started on the path to do so in June 2011 when a work­group was as­sem­bled to con­sider al­ter­na­tives to the an­nual dis­ci­plinary-ac­tion sum­mary. Among the work­group’s rec­om­men­da­tions ap­proved by the FSMB’s House of Del­e­gates at its April 2012 meet­ing was to stop pub­li­ca­tion of the sum­mary in 2013. “I don’t re­call any­one be­ing op­posed to it,” Robin says.

Wolfe says the com­plaints about the Pub­lic Cit­i­zen med­i­cal board rank­ings are “noth­ing I haven’t heard be­fore.” He’s heard the ar­gu­ment that Pub­lic Cit­i­zen doesn’t con­sider board ac­tions such as rep­ri­mands and get­ting doc­tors into ed­u­ca­tion pro­grams or al­co­hol and drug treat­ment. His re­sponse has been that they want his or­ga­ni­za­tion to give state boards “credit for slaps on the wrist.”

But Kevin Bohnen­blust, ex­ec­u­tive di­rec­tor of the Wy­oming Board of Medicine, says the is­sue is more com­pli­cated than that. Bohnen­blust, who chaired the work­group on re­vis­ing the an­nual sum­mary’s for­mat, says the re­port needs to change with the times—and that in­cludes ac­knowl­edg­ing the re­al­i­ties of physi­cian short­ages in states such as Wy­oming. “If we can make a physi­cian bet­ter—with ad­di­tional train­ing or drug and al­co­hol treat­ment—then tak­ing a li­cense away doesn’t ul­ti­mately serve the com­mu­nity if you can get a doc­tor to prac­tice safely again,” Bohnen­blust says.

He says the old re­port didn’t ex­plain the driv­ing forces be­hind the statis­tics be­ing re­ported. The goal of the planned new re­port is to “give the full fla­vor and fab­ric of what boards are do­ing and what re­sources they have to do it with.” Ul­ti­mately, he says, what the pub­lic wants is in­for­ma­tion on the in­di­vid­ual doc­tor treat­ing them.

Bohnen­blust didn’t put much stock in his own Wy­oming board re­ceiv­ing the top rank­ing from Pub­lic Cit­i­zen last year (See chart). The physi­cian work­force in Wy­oming is so small, he says, that if the state board’s num­ber of dis­ci­plinary ac­tions de­clines slightly, its rank­ing would “drop pre­cip­i­tously.”

“We have the same staff, the same bur­den of proof that we had three years ago when we were 20th,” Bohnen­blust says.

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