- Email: [email protected]
Adverse action reports against optometrists: Perspectives from the National Practitioner Data Bank over 18 years
Optometry (2011) 82, 318-321
Adverse action reports against optometrists: Perspectives from the National Practitioner Data Bank over 18 years Robert S. Duszak, O.D.,a and Richard Duszak, Jr., M.D.b,c a
Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania; bMid-South Imaging and Therapeutics, Memphis, Tennessee; and cThe University of Tennessee Health Science Center, Memphis.
KEYWORDS National Practitioner Data Bank; Optometrist; Adverse action; Professional misconduct
Abstract PURPOSE: The aim of this analysis is to describe characteristics of National Provider Data Bank (NPDB) adverse action reports against optometrists. METHODS: NPDB public use files were analyzed for details of reported optometrist adverse actions from 1991 through 2008. Types of actions, basis for actions, and reporting source were identified, along with geographic and demographic data. RESULTS: Between 1991 and 2008, a total of 216 adverse actions against optometrists were recorded nationally. Exclusion from Medicare or another government program accounted for 92% of all reports; the remaining 8% were related to unfavorable privileging decisions. Most cases with identifiable explanations were the result of either defaults on student loans (55%) or charges of fraud and abuse (39%). Over two thirds of all reports originated in just 12 states, and 74% involved younger optometrists (age 30 to 49). Repeat offenses were reported for 38% of sanctioned optometrists. CONCLUSION: NPDB reported adverse actions against optometrists are infrequent but most commonly involve exclusion from Medicare or similar government programs. Student loan default, particularly by younger optometrists, is the single most common cause, followed by allegations of fraud and abuse. Because this national database is permanently archived and widely used by licensing and credentialing bodies, optometrists should endeavor to be ethically responsible and strive to avoid behaviors that mandate such action reports. Optometry 2011;82:318-321
Public expectations have increased for health care provider accountability and information transparency. Of particular interest to both patients and credentialing bodies are previous adverse action reports about their providers. To date, comprehensive analyses of optometrists’ adverse action reports (e.g., revocation or suspension of license, clinical privileges, or professional society membership, and actions resulting in Medicare or Medicaid exclusion) have not been available to guide optometrists in the Disclosure: The authors have no financial or other relationships that might lead to a conflict of interest. Corresponding author: Robert S. Duszak, O.D., Philadelphia Veterans Affairs Medical Center, 3800 Woodland Avenue, Philadelphia, PA 19104. E-mail: [email protected]
management of their professional affairs or to alert patients about their doctor’s professional behavior. The National Practitioner Data Bank (NPDB) was created as a result of the Health Care Quality Improvement Act of 1986. This electronic repository contains reports of malpractice payments made on behalf of all licensed health care practitioners, exclusion actions taken by Medicare and other payers, and adverse licensure, privileging, and membership actions.1,2 The NPDB includes both mandatory and voluntarily reported data (beginning September 1990) and is maintained under the authority of the United States Department and Health and Human Services (HHS).2 Public use files from the NPDB have been used to study malpractice payments made by physicians (both medical
1529-1839/$ - see front matter Published by Elsevier Inc. on behalf of the American Optometric Association. doi:10.1016/j.optm.2010.09.015
Duszak and Duszak
Public Health
doctors and doctors of osteopathy), anesthesia providers, dentists, physical therapists, and optometrists.3-7 Adverse action reports in the NPDB have been analyzed for dentists but have otherwise received relatively little attention.6 Although objective information regarding the types, origins, and sources of such reports would potentially aid optometrists in minimizing their exposure, to our knowledge, no such evaluation has been performed. We report that analysis herein.
Materials and methods Public use data files were acquired from the NPDB in late 2009. These raw data files contain selected variables pertaining to medical malpractice payments for physicians, dentists, and other licensed health care professionals. In addition, a variety of information is included regarding adverse licensure, privileging, and professional society membership obtained by the agency. It similarly includes reports of Medicare and Medicaid exclusionary actions taken by the HHS Office of Inspector General (OIG). Those patient- and provider-redacted raw data files were subsequently reformatted for both database and spreadsheet analysis. The parent data file included a total of 464,921 adverse health care provider reports between September 1990 and September 2009. Incomplete initial and final year data were excluded, resulting in 446,443 reports between January 1, 1991 and December 31, 2008. The NPDB identifies providers by their state license type (e.g., physician, dentist) using approximately 100 codedesignated categories. Optometrists are all assigned a unique license field code (636), and those reports were isolated for analysis. Of the 216 optometrist adverse reports identified, encounter-specific data were extracted. Adverse report information included the age of the optometrist (grouped by decade), year, and state in which the action took place, the type of action by predefined categories (e.g., revocation or suspension of license or exclusion from Medicare or Medicaid), the basis or reason such action was taken, and the length of time of imposed penalty. The NPDB reports adverse actions by code number for categories with somewhat ambiguous overlapping distinctions (e.g., exclusion from Medicare, Medicaid, and other federal programs versus exclusion from Medicare and state health care programs). To facilitate more meaningful reporting, after preliminary analysis, overlapping subcategories were combined into 2 groups that accounted for all reports: (1) exclusion from Medicare or another government payer program and (2) revocation, suspension, restriction, or denial of clinical privileges or membership. Although NPDB public use files redact provider identity information, all health care providers are assigned unique anonymous code numbers, which thus allowed us to identify optometrists subject to multiple adverse action reports.
319 All analyses was performed using commercially available database and spreadsheet software (Access 2007 and Excel 2007, Microsoft Corporation, Redmond, Washington).
Results Of all 216 encounter reports, 73% of optometrists were between the ages of 30 and 49, and 91% were between the ages of 30 and 59. The age distribution by NPDB decade groupings is outlined in Figure 1. More than two thirds (68%) of all adverse action reports originated in just 12 states or United States territories (See Figure 2). In contrast, no reports originated from 15 states. No adverse actions were identified between 1991 and 1994. Between 1995 and 2008, the number of reports per year ranged from 0 to 118 (mean, 15.4 6 30.3), with no identifiable trend either upward or downward. Adverse reports fell into 2 clearly differentiated and identifiable groups: 198 (92%) were related to exclusion from Medicare or other government payer program and 18 (8%) pertained to revocation, suspension, restriction, or denial of clinical privileges or organization membership (See Table 1). The basis or reason for the adverse action was not reported in 53 cases. Of the 149 for which such information was complete, the largest basis for an adverse NPDB report was default on a student loan or scholarship. Several overlapping category codes for coding, billing, or regulatory fraud and abuse together comprised the second most common basis group for adverse reports. These category groups are outlined in Table 1. Most reports (198 cases, 92%) to the NPDB originated from the HHS OIG. In the minority 18 cases (8%), the reporting body was a managed care organization or other health plan. Of all 216 reported actions, only 156 optometrists were involved. Single offenses were reported for 97, 2 offenses for 58, and 3 offenses for just 1. For all optometrists with multiple reports, the adverse action was exclusion from Medicare or another government payer program. These multireport cases were the result of defaults on student loan or scholarship obligations in 68%, and fraud and abuse in 25%. Details regarding the length of imposed sanctions were not available in 55 reports. Of the 161 reports for which
Figure 1 report.
Age of optometrist, by decade, at time of adverse action
320
Optometry, Vol 82, No 5, May 2011
Figure 2
Percentage of adverse actions by state or territory. More than two thirds of all adverse action reports against optometrists originated in these 12 states or territories.
details were available, penalties were categorized as indefinite in length in 96 (60%), permanent in 13 (8%), and time-limited in 52 (32%). Those time-limited sanctions ranged from 3 to 17 years (mean, 6.5 6 3.0).
Discussion Although commonly considered a repository only of malpractice claim information, the NPDB similarly records adverse health care provider action reports from a variety of agencies. For optometrists, these entries are less common than malpractice payments (609 malpractice payments during the same period), but nonetheless notable.7 Professionalism and accountability are receiving everincreasing interest in the health care community, and optometrists are not immune from this trend.8-15 Scrutiny of health care professionals is at an all-time high, with fraud and abuse investigations receiving considerable attention.10,16 Additionally, many are calling on more complete disclosure of provider quality information via medical error self-reporting.17-19 Optometrists, like all other health care professionals, are subject to mandatory NPDB reporting by HHS OIG. Unlike physicians and dentists, however, for whom all other adverse Table 1 Most frequent optometrist adverse action reports in the NPDB and the reported rationale for those actions Adverse action type Exclusion from Medicare or other government program Privilege or membership revocation, suspension, restriction or denial Basis for adverse action report Default on student loan or scholarship obligation Fraud, abuse, or similar payment allegation Unprofessional conduct or similar action Alcohol or drug abuse or violation
92% 8%
55% 39% 4% 2%
Note. For adverse actions, percentages are of all 216 reported events. For basis groups, percentages are of the 149 cases for which basis information is recorded in the NPDB.
action reports mandate NPDB notification, the reporting of other actions by optometrists is voluntary. The true incidence of such actions is thus unknown, but given widespread reluctance within the health care community to self-report errors and adverse events, the NPDB almost certainly underreports these actions, and their frequency is likely higher.9,20 Because HHS OIG reporting is mandatory and usually related to exclusion from Medicare or another federal payment program participation, we believe that the reported incidence of events from this source to be reasonably complete and accurate. Because the majority of adverse actions reported to the NPDB for optometrists entail defaulting on federal student loans, optometrist compliance with such loan obligations is critical. Given the clear willingness of the federal government to avail itself to Medicare exclusion as a tool in seeking redress for default, optometrists must, we believe, take student loan responsibilities more seriously, because these reports may adversely affect future employability.21 Similarly, the long-term career implications of fraud and abuse cannot be underestimated, and likely have much more significant long-term professional and financial impact on optometrists. Although many young professionals might treat student loans much like any other bank loan obligations (e.g., automobile, home mortgage), these frequently federally guaranteed or subsidized loans incur much more serious consequences for default. Besides the HHS disqualifying defaulting health care providers from the Medicare and Medicaid programs, providers can also be referred to the Department of Justice for possible litigation, wage garnishment, seizure of bank accounts and property, tax refund withholding, and reporting to credit bureaus.21 In fiscal year 2007 (the most recent year data are available), the United States Department of Education estimated that 6.7% to 6.9% of federally guaranteed student loans were in default.22,23 During the 2008 to 2009 academic year alone, federal student loan disbursements increased 25% from the previous year.24 Given the increasing student loan debt that today’s professional students bear and the large number of student loan defaults, the younger NPDB age distribution than that reported for malpractice payments is not unexpected and emphasizes the importance of educating young clinicians on the ramifications of their federal student loan obligations.7,23,24 The retrospective analysis of bureaucratic database information limits us to a purely descriptive description of reports but nonetheless demonstrates the importance of optometrist awareness of the NPDB and the fact that its reach extends beyond just malpractice, as previously reported.7 Many states currently require NPDB reports for optometrists as a condition of licensure, and some insurance companies require the same for credentialing purposes. Additionally, the newly formed American Board of Optometry plans to use an NPDB clearance search as an initial qualification requirement for optometric board certification.25 Because optometrists have only voluntary reporting requirements for all but exclusion from Medicare
Duszak and Duszak
Public Health
or another government agency, these reports are by definition limited in their scope and may not provide the level of professional transparency many expect. If the NPDB intends, at least in part, to protect patients by preventing health care professionals who have lost their license to practice in one state to practice in another, it is sensible that optometrists should be mandated to report all adverse actions, as physicians and dentists are so required.26 With such inclusiveness, the NPDB would become a more suitable tool for licensure, credentialing, and certification purposes. These goals notwithstanding, it should be noted that although many of these processes are widely accepted as surrogates of quality, they are not a qualitative assessment of the care delivered and serve only as an indication that a sanction has occurred.27 Although NPDB data analysis provides a large amount of report data, the categorical database nature of the redacted information introduces a number of limitations in an analysis such as ours. The seemingly arbitrary and overlapping allegation categories (e.g., how exactly does one distinguish ‘‘conviction re: fraud’’ from ‘‘felony conviction related to health care fraud’’?) combined with the fact that all adverse actions are not subject to mandatory reporting for optometrists, precludes us from establishing as comprehensive a list of practical ‘‘take home’’ risk management tips as we might like. Additionally, because the NPDB database is unable to capture all adverse actions actually made by health care providers (only those that lead to sanctions), it likely underestimates the true incidence of such events. Those limitations aside, the fact that more than one half of complete adverse action reports involve student loan default should serve as a reminder to all in the optometric community that seemingly innocent defaults on federal student loans have serious long-term professional consequences. NPDB adverse action reports against optometrists are infrequent but typically involve exclusion from Medicare or similar government programs. Because default on federal student loans, particularly by younger optometrists, is the most common single cause for reporting, further efforts are necessary to educate young practitioners on the consequences of nonpayment. Mandating more complete adverse actions reporting to the NPDB would facilitate transparency and accountability, particularly with regard to licensure and credentialing, and continue to stress the importance and the many ethical responsibilities of optometrists.
References 1. West RW, Sipe CY. National practitioner data bank: information on physicians. J Am Coll Radiol 2004;1:777-9. 2. US Department of Health and Human Services. National Practitioner Data Bank Guidebook. Available at: http://www.npdb-hipdb.hrsa.gov/ pubs/gb/NPDB_Guidebook.pdf. Last accessed December 22, 2009. 3. Chandra A, Nundy S, Seabury SA. The growth of physician medical malpractice payments: evidence from the National Practitioner Data Bank. Health Aff (Millwood). 2005 Jan-Jun;Suppl Web Exclusives: W5-240-W5-249.
321 4. Sandstrom R. Malpractice by physical therapists: descriptive analysis of reports in the National Practitioner Data Bank public use data file, 1991-2004. J Allied Health 2007;36:201-8. 5. Kain ZN. The National Practitioner Data Bank and anesthesia malpractice payments. Anesth Analg 2006;103:646-9. 6. Shulman JD, Sutherland JN. Reports to the National Practitioner Data Bank involving dentists, 1990-2004. J Am Dent Assoc 2006;137:523-8. 7. Duszak RS, Duszak R. Malpractice payments by optometrists: an analysis of the National Practitioner Data Bank over 18 years. Optometry 2011;82:32-7. 8. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med 2002; 347:1933-40. 9. Yeon HB, Lovett DA, Zurakowski D, et al. Physician discipline. J Bone Joint Surg Am 2006;88:2091-6. 10. Jung P, Lurie P, Wolfe SM. U.S. physicians disciplined for criminal activity. Health Matrix Clevel 2006;16:335-50. 11. Wachter RM, Pronovost PJ. Balancing ‘‘no blame’’ with accountability in patient safety. N Engl J Med 2009;361:1401. 12. Mueller PS. Incorporating professionalism into medical education: the Mayo Clinic experience. Keio J Med 2009;58:133-43. 13. Cascardo D. OIG demands transparency for physicians and staff in 2010: Welcome to the modern era of compliance. J Med Pract Manage 2009;25:156-9. 14. Cruess RL, Cruess SR. Expectations and obligations: professionalism and medicine’s social contract with society. Perspect Biol Med 2008; 51:579-98. 15. Health care reform, board certification, and optometry’s next step to preserve our future: Part one in a series of policy briefings for AOA members. Available at: http://www.aoa.org/documents/cert/AOAChapter-1-Value-Health-Care-and-Optometry.pdf. Last accessed February 1, 2010. 16. Kesselheim AS, Studdert DM. Whistleblower-initiated enforcement actions against health care fraud and abuse in the United States, 1996 to 2005. Ann Intern Med 2008;149:342-9. 17. Docs not reporting peers’ medical errors, bad behaviors. Modern Physician. Available at: http://www.modernphysician.com/article/2007 1217/MODERNPHYSICIAN/312090016/-1. Last accessed February 1, 2010. 18. Witham MD, Kendall PA. A prospective, physician self-reported adverse incident audit on a general medical unit. J Qual Clin Pract 2001;21:61-5. 19. Moore JD Jr. Hospitals warming up to JCAHO policy. Number of sentinel events has remained constant, but more hospitals are self-reporting. Mod Healthc 1999;29:34,36 20. Romano M. System failure. Mod Healthc 2005;35:6-14. 21. United States Department of Health and Human Services. HHS kicks loan defaulters out of Medicare and Medicaid: names also posted on new internet web site. Available at: http://www.hhs.gov/news/pres s/1998pres/980120a.html. Last accessed February 1, 2010. 22. United States Department of Education. Student loan default rates increase. Available at: http://www2.ed.gov/news/pressreleases/2009/ 09/09142009.html. Last accessed February 1, 2010. 23. Chaker AM. Student loans: default rates are soaring. The Wall Street Journal 21 Apr 2009. Available at: http://online.wsj.com/article/ SB124027600001437467.html. Last accessed February 1, 2010. 24. Chaker AM. Students borrow more than ever for college. The Wall Street Journal 4 Sep 2009. Available at: http://online.wsj.com/article/ SB10001424052970204731804574388682129316614.html. Last accessed February 2, 2010. 25. Association of Regulatory Boards of Optometry. Draft model, American Board of Optometry initial certification process. Available at: http://www.arbo.org/Documents/Public/JBCPT_Framework_Final. pdf. Last accessed February 2, 2010. 26. McLellan F. US government warns practitioner database underused. Lancet 2001;357:1855. 27. Bartholomew LA. Quality of care and the National Practitioner Data Bank: are the two related? J Med Pract Manage 1999;15:64-7.
Adverse action reports against optometrists: Perspectives from the National Practitioner Data Bank over 18 years Robert S. Duszak, O.D.,a and Richard Duszak, Jr., M.D.b,c a
Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania; bMid-South Imaging and Therapeutics, Memphis, Tennessee; and cThe University of Tennessee Health Science Center, Memphis.
KEYWORDS National Practitioner Data Bank; Optometrist; Adverse action; Professional misconduct
Abstract PURPOSE: The aim of this analysis is to describe characteristics of National Provider Data Bank (NPDB) adverse action reports against optometrists. METHODS: NPDB public use files were analyzed for details of reported optometrist adverse actions from 1991 through 2008. Types of actions, basis for actions, and reporting source were identified, along with geographic and demographic data. RESULTS: Between 1991 and 2008, a total of 216 adverse actions against optometrists were recorded nationally. Exclusion from Medicare or another government program accounted for 92% of all reports; the remaining 8% were related to unfavorable privileging decisions. Most cases with identifiable explanations were the result of either defaults on student loans (55%) or charges of fraud and abuse (39%). Over two thirds of all reports originated in just 12 states, and 74% involved younger optometrists (age 30 to 49). Repeat offenses were reported for 38% of sanctioned optometrists. CONCLUSION: NPDB reported adverse actions against optometrists are infrequent but most commonly involve exclusion from Medicare or similar government programs. Student loan default, particularly by younger optometrists, is the single most common cause, followed by allegations of fraud and abuse. Because this national database is permanently archived and widely used by licensing and credentialing bodies, optometrists should endeavor to be ethically responsible and strive to avoid behaviors that mandate such action reports. Optometry 2011;82:318-321
Public expectations have increased for health care provider accountability and information transparency. Of particular interest to both patients and credentialing bodies are previous adverse action reports about their providers. To date, comprehensive analyses of optometrists’ adverse action reports (e.g., revocation or suspension of license, clinical privileges, or professional society membership, and actions resulting in Medicare or Medicaid exclusion) have not been available to guide optometrists in the Disclosure: The authors have no financial or other relationships that might lead to a conflict of interest. Corresponding author: Robert S. Duszak, O.D., Philadelphia Veterans Affairs Medical Center, 3800 Woodland Avenue, Philadelphia, PA 19104. E-mail: [email protected]
management of their professional affairs or to alert patients about their doctor’s professional behavior. The National Practitioner Data Bank (NPDB) was created as a result of the Health Care Quality Improvement Act of 1986. This electronic repository contains reports of malpractice payments made on behalf of all licensed health care practitioners, exclusion actions taken by Medicare and other payers, and adverse licensure, privileging, and membership actions.1,2 The NPDB includes both mandatory and voluntarily reported data (beginning September 1990) and is maintained under the authority of the United States Department and Health and Human Services (HHS).2 Public use files from the NPDB have been used to study malpractice payments made by physicians (both medical
1529-1839/$ - see front matter Published by Elsevier Inc. on behalf of the American Optometric Association. doi:10.1016/j.optm.2010.09.015
Duszak and Duszak
Public Health
doctors and doctors of osteopathy), anesthesia providers, dentists, physical therapists, and optometrists.3-7 Adverse action reports in the NPDB have been analyzed for dentists but have otherwise received relatively little attention.6 Although objective information regarding the types, origins, and sources of such reports would potentially aid optometrists in minimizing their exposure, to our knowledge, no such evaluation has been performed. We report that analysis herein.
Materials and methods Public use data files were acquired from the NPDB in late 2009. These raw data files contain selected variables pertaining to medical malpractice payments for physicians, dentists, and other licensed health care professionals. In addition, a variety of information is included regarding adverse licensure, privileging, and professional society membership obtained by the agency. It similarly includes reports of Medicare and Medicaid exclusionary actions taken by the HHS Office of Inspector General (OIG). Those patient- and provider-redacted raw data files were subsequently reformatted for both database and spreadsheet analysis. The parent data file included a total of 464,921 adverse health care provider reports between September 1990 and September 2009. Incomplete initial and final year data were excluded, resulting in 446,443 reports between January 1, 1991 and December 31, 2008. The NPDB identifies providers by their state license type (e.g., physician, dentist) using approximately 100 codedesignated categories. Optometrists are all assigned a unique license field code (636), and those reports were isolated for analysis. Of the 216 optometrist adverse reports identified, encounter-specific data were extracted. Adverse report information included the age of the optometrist (grouped by decade), year, and state in which the action took place, the type of action by predefined categories (e.g., revocation or suspension of license or exclusion from Medicare or Medicaid), the basis or reason such action was taken, and the length of time of imposed penalty. The NPDB reports adverse actions by code number for categories with somewhat ambiguous overlapping distinctions (e.g., exclusion from Medicare, Medicaid, and other federal programs versus exclusion from Medicare and state health care programs). To facilitate more meaningful reporting, after preliminary analysis, overlapping subcategories were combined into 2 groups that accounted for all reports: (1) exclusion from Medicare or another government payer program and (2) revocation, suspension, restriction, or denial of clinical privileges or membership. Although NPDB public use files redact provider identity information, all health care providers are assigned unique anonymous code numbers, which thus allowed us to identify optometrists subject to multiple adverse action reports.
319 All analyses was performed using commercially available database and spreadsheet software (Access 2007 and Excel 2007, Microsoft Corporation, Redmond, Washington).
Results Of all 216 encounter reports, 73% of optometrists were between the ages of 30 and 49, and 91% were between the ages of 30 and 59. The age distribution by NPDB decade groupings is outlined in Figure 1. More than two thirds (68%) of all adverse action reports originated in just 12 states or United States territories (See Figure 2). In contrast, no reports originated from 15 states. No adverse actions were identified between 1991 and 1994. Between 1995 and 2008, the number of reports per year ranged from 0 to 118 (mean, 15.4 6 30.3), with no identifiable trend either upward or downward. Adverse reports fell into 2 clearly differentiated and identifiable groups: 198 (92%) were related to exclusion from Medicare or other government payer program and 18 (8%) pertained to revocation, suspension, restriction, or denial of clinical privileges or organization membership (See Table 1). The basis or reason for the adverse action was not reported in 53 cases. Of the 149 for which such information was complete, the largest basis for an adverse NPDB report was default on a student loan or scholarship. Several overlapping category codes for coding, billing, or regulatory fraud and abuse together comprised the second most common basis group for adverse reports. These category groups are outlined in Table 1. Most reports (198 cases, 92%) to the NPDB originated from the HHS OIG. In the minority 18 cases (8%), the reporting body was a managed care organization or other health plan. Of all 216 reported actions, only 156 optometrists were involved. Single offenses were reported for 97, 2 offenses for 58, and 3 offenses for just 1. For all optometrists with multiple reports, the adverse action was exclusion from Medicare or another government payer program. These multireport cases were the result of defaults on student loan or scholarship obligations in 68%, and fraud and abuse in 25%. Details regarding the length of imposed sanctions were not available in 55 reports. Of the 161 reports for which
Figure 1 report.
Age of optometrist, by decade, at time of adverse action
320
Optometry, Vol 82, No 5, May 2011
Figure 2
Percentage of adverse actions by state or territory. More than two thirds of all adverse action reports against optometrists originated in these 12 states or territories.
details were available, penalties were categorized as indefinite in length in 96 (60%), permanent in 13 (8%), and time-limited in 52 (32%). Those time-limited sanctions ranged from 3 to 17 years (mean, 6.5 6 3.0).
Discussion Although commonly considered a repository only of malpractice claim information, the NPDB similarly records adverse health care provider action reports from a variety of agencies. For optometrists, these entries are less common than malpractice payments (609 malpractice payments during the same period), but nonetheless notable.7 Professionalism and accountability are receiving everincreasing interest in the health care community, and optometrists are not immune from this trend.8-15 Scrutiny of health care professionals is at an all-time high, with fraud and abuse investigations receiving considerable attention.10,16 Additionally, many are calling on more complete disclosure of provider quality information via medical error self-reporting.17-19 Optometrists, like all other health care professionals, are subject to mandatory NPDB reporting by HHS OIG. Unlike physicians and dentists, however, for whom all other adverse Table 1 Most frequent optometrist adverse action reports in the NPDB and the reported rationale for those actions Adverse action type Exclusion from Medicare or other government program Privilege or membership revocation, suspension, restriction or denial Basis for adverse action report Default on student loan or scholarship obligation Fraud, abuse, or similar payment allegation Unprofessional conduct or similar action Alcohol or drug abuse or violation
92% 8%
55% 39% 4% 2%
Note. For adverse actions, percentages are of all 216 reported events. For basis groups, percentages are of the 149 cases for which basis information is recorded in the NPDB.
action reports mandate NPDB notification, the reporting of other actions by optometrists is voluntary. The true incidence of such actions is thus unknown, but given widespread reluctance within the health care community to self-report errors and adverse events, the NPDB almost certainly underreports these actions, and their frequency is likely higher.9,20 Because HHS OIG reporting is mandatory and usually related to exclusion from Medicare or another federal payment program participation, we believe that the reported incidence of events from this source to be reasonably complete and accurate. Because the majority of adverse actions reported to the NPDB for optometrists entail defaulting on federal student loans, optometrist compliance with such loan obligations is critical. Given the clear willingness of the federal government to avail itself to Medicare exclusion as a tool in seeking redress for default, optometrists must, we believe, take student loan responsibilities more seriously, because these reports may adversely affect future employability.21 Similarly, the long-term career implications of fraud and abuse cannot be underestimated, and likely have much more significant long-term professional and financial impact on optometrists. Although many young professionals might treat student loans much like any other bank loan obligations (e.g., automobile, home mortgage), these frequently federally guaranteed or subsidized loans incur much more serious consequences for default. Besides the HHS disqualifying defaulting health care providers from the Medicare and Medicaid programs, providers can also be referred to the Department of Justice for possible litigation, wage garnishment, seizure of bank accounts and property, tax refund withholding, and reporting to credit bureaus.21 In fiscal year 2007 (the most recent year data are available), the United States Department of Education estimated that 6.7% to 6.9% of federally guaranteed student loans were in default.22,23 During the 2008 to 2009 academic year alone, federal student loan disbursements increased 25% from the previous year.24 Given the increasing student loan debt that today’s professional students bear and the large number of student loan defaults, the younger NPDB age distribution than that reported for malpractice payments is not unexpected and emphasizes the importance of educating young clinicians on the ramifications of their federal student loan obligations.7,23,24 The retrospective analysis of bureaucratic database information limits us to a purely descriptive description of reports but nonetheless demonstrates the importance of optometrist awareness of the NPDB and the fact that its reach extends beyond just malpractice, as previously reported.7 Many states currently require NPDB reports for optometrists as a condition of licensure, and some insurance companies require the same for credentialing purposes. Additionally, the newly formed American Board of Optometry plans to use an NPDB clearance search as an initial qualification requirement for optometric board certification.25 Because optometrists have only voluntary reporting requirements for all but exclusion from Medicare
Duszak and Duszak
Public Health
or another government agency, these reports are by definition limited in their scope and may not provide the level of professional transparency many expect. If the NPDB intends, at least in part, to protect patients by preventing health care professionals who have lost their license to practice in one state to practice in another, it is sensible that optometrists should be mandated to report all adverse actions, as physicians and dentists are so required.26 With such inclusiveness, the NPDB would become a more suitable tool for licensure, credentialing, and certification purposes. These goals notwithstanding, it should be noted that although many of these processes are widely accepted as surrogates of quality, they are not a qualitative assessment of the care delivered and serve only as an indication that a sanction has occurred.27 Although NPDB data analysis provides a large amount of report data, the categorical database nature of the redacted information introduces a number of limitations in an analysis such as ours. The seemingly arbitrary and overlapping allegation categories (e.g., how exactly does one distinguish ‘‘conviction re: fraud’’ from ‘‘felony conviction related to health care fraud’’?) combined with the fact that all adverse actions are not subject to mandatory reporting for optometrists, precludes us from establishing as comprehensive a list of practical ‘‘take home’’ risk management tips as we might like. Additionally, because the NPDB database is unable to capture all adverse actions actually made by health care providers (only those that lead to sanctions), it likely underestimates the true incidence of such events. Those limitations aside, the fact that more than one half of complete adverse action reports involve student loan default should serve as a reminder to all in the optometric community that seemingly innocent defaults on federal student loans have serious long-term professional consequences. NPDB adverse action reports against optometrists are infrequent but typically involve exclusion from Medicare or similar government programs. Because default on federal student loans, particularly by younger optometrists, is the most common single cause for reporting, further efforts are necessary to educate young practitioners on the consequences of nonpayment. Mandating more complete adverse actions reporting to the NPDB would facilitate transparency and accountability, particularly with regard to licensure and credentialing, and continue to stress the importance and the many ethical responsibilities of optometrists.
References 1. West RW, Sipe CY. National practitioner data bank: information on physicians. J Am Coll Radiol 2004;1:777-9. 2. US Department of Health and Human Services. National Practitioner Data Bank Guidebook. Available at: http://www.npdb-hipdb.hrsa.gov/ pubs/gb/NPDB_Guidebook.pdf. Last accessed December 22, 2009. 3. Chandra A, Nundy S, Seabury SA. The growth of physician medical malpractice payments: evidence from the National Practitioner Data Bank. Health Aff (Millwood). 2005 Jan-Jun;Suppl Web Exclusives: W5-240-W5-249.
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