- Email: [email protected]
The National Practitioner Data Bank: Information for and About Midwifery
BRIEF REPORTS The National Practitioner Data Bank: Information for and About Midwifery Cecilia Jevitt, CNM, PhD, Kerri Durnell Schuiling, CNM, PhD, and Lisa Summers, CNM, DrPH The National Practitioner Data Bank (NPDB), mandated by federal legislation in 1986, serves as a mechanism to protect the public from unsafe practitioners who attempt to avoid discovery of prior negligent behavior or malpractice record(s) by moving from state to state. Reporting to the NPDB about malpractice payments on behalf of nurse-midwives began in 1990. Reporting of providers excluded from Medicare and Medicaid program participation began in September 1999. Practitioners who were already in an excluded status at that time were reported. Reports of adverse action against a nurse-midwife can be submitted to the NPDB by a state licensure board, a governmental agency, hospitals, health maintenance organizations, or other health care organizations. Reporting of licensing actions and clinical privilege actions are not required, although these may be voluntarily reported. The NPDB received 484 reports about nurse-midwives from September 1, 1999, to March 31, 2005. Of the 484 reports, 375 have an obstetric malpractice code. The median claim payment made on behalf of nurse-midwives during this period is $225,000. Although limited, the NPDB is the only systematic national source of nurse-midwifery malpractice data collection. J Midwifery Womens Health 2005;50:525–530 © 2005 by the American College of NurseMidwives. keywords: National Practioner Data Bank, Healthcare Integrity and Protection Data Bank, adverse action reports, malpractice, nurse-midwifery, midwifery, credentialing
INTRODUCTION State licensure of health care providers is intended to protect the public from unsafe practitioners. The National Practitioner Data Bank (NPDB) was mandated by the Health Care Quality Improvement Act of 1986 (Title IV, PL 99-660) as a response to growing public dissatisfaction with the ability of incompetent or negligent practitioners to avoid oversight and discipline by moving from state to state.1 This article describes how the NPDB functions and collects data about nurse-midwifery licensure actions and malpractice data. In 1996, under the Health Insurance Portability and Accountability Act, the Healthcare Integrity and Protection Data Bank was created to combat fraud and abuse in health insurance and health care delivery. This article focuses data from the NPDB; however, it is important that practitioners also understand reporting requirements of the Healthcare Integrity and Protection Data Bank. Table 1 provides a comparison of the 2 data banks.2 Outcomes discussed in this article come from analysis of data from the NPDB Public Use File. The Public Use File has 1 record for each report in the NPDB but excludes identifying information about the practitioner and reporting entity. The NPDB became operational on September 1, 1990. There are approximately 30,000 new reports added to the NPDB each year.1
Address correspondence to Cecilia Jevitt, CNM, PhD, College of Nursing, University of South Florida, MDC Box 22, 12901 Bruce B. Downs Boulevard, Tampa, FL 33612. E-mail: [email protected]
Journal of Midwifery & Women’s Health • www.jmwh.org © 2005 by the American College of Nurse-Midwives Issued by Elsevier Inc.
There are 5 categories related to nursing in the NPDB: 1) registered professional nurse (RN); 2) nurse-midwife (CNM); 3) nurse practitioner (NP); 4) advanced practice nurse, retitled clinical nurse specialist after September 9, 2002; and 5) nurse anesthetist (CRNA). Non–nurse-midwives, such as certified midwives and certified professional midwives, are in a separate category: midwife, lay (non-nurse).3 At the time this article was written, there were only 10 reports in the NPDB non–nurse-midwife category. Data analyzed for this article are from reports about nurse-midwives. Reports specific to an individual are not available to the general public, although the public benefits from the reports in the NPDB database. Licensing agencies, employers, and peer review systems, such as those required by the Medicare Peer Improvement Act, obtain information from the data bank that supplements traditional ways of reviewing a practitioner’s credentials: licensure, professional society membership, medical malpractice payment history, and record of clinical privileges. The NPDB publishes aggregate statistical data and research reports about medical malpractice and disciplinary issues. A Public Use File is available to researchers and organizations investigating malpractice claims and payments.3 SOURCES OF MATERIAL SUBMITTED TO THE NATIONAL PRACTITIONER DATA BANK The NPDB receives reports from a variety of private and governmental organizations in all 50 states and all other areas under US jurisdiction. Table 1 lists the agencies that are required to submit reports to the NPDB.2 Three kinds of 525 1526-9523/05/$30.00 • doi:10.1016/j.jmwh.2005.08.008
Table 1. National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank
The National Practitioner Data Bank (NPDB) was established under Title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986. NPDB is an information clearinghouse that collects and releases information related to the professional competence and conduct of physicians, dentists, and other health care practitioners, including nurse-midwives.
Medical malpractice payers Boards of Medical/Dental Examiners Hospitals and other health care entities Professional societies with formal peer review Health and Human Services Office of Inspector General Drug Enforcement Agency (DEA)
The Healthcare Integrity and Protection Data Bank (HIPDB) was established under section 1128E of the Social Security Act as added by Section 221(A) of the Health Insurance Portability and Accountability Act of 1996. HIPDB was implemented to combat fraud and abuse in health insurance and health care delivery and to promote quality care. HIPDB alerts users that a more comprehensive review of past actions by a practitioner, provider, or supplier may be prudent. Who Reports? Federal and state government agencies (including DEA, Department of Defense, Department of Veterans Affairs, Public Health Service, Center for Medicaid and Medicare Services and HSS Office of Inspector General) Health plans
What Information Is Reported? Medical malpractice payments (all health care practitioners) Licensing and certification actions Œ Revocation, suspension, censure, reprimand, probation Adverse actions: based on reasons relating to professional competency Œ Any other loss of license— or right to apply for or renew—a license of and conduct (primarily physicians/dentists) the provider, supplier, or practitioner, whether by voluntary surrender, Œ Licensing, revocation, suspension, censure, reprimand, probation, nonrenewal, or otherwise and surrender Œ Any negative action or finding by a federal or state licensing and Œ Clinical privileges certification agency that is publicly available information Œ Professional society membership Medicare and Medicaid exclusions (all health care practitioners) Civil judgments (health care–related) Criminal convictions (health care–related) Exclusions from federal or state health care programs Other adjudicated actions or decisions (formal or official actions, availability of due process mechanism and based on acts or omissions that affect or could affect the payment, provision, or delivery of a health care item or service) Who Can Query? Hospitals Federal and state government agencies Other health care entities with formal peer review Health plans Professional societies with formal peer review Health care practitioners/providers/suppliers (self-query) Boards of Medical/Dental Examiners and other health care practitioner Researchers (statistical data only) State Licensing Boards Plaintiffs’ attorneys or plaintiffs representing themselves (limited) Health care practitioners (self-query) Researchers (statistical data only)
Practitioner Data Banks Branch, Office of Workforce Evaluation and Quality Assurance, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services.2
data are received: 1) reports on malpractice payments for all kinds of practitioners; 2) reports on practitioner exclusions from Medicare/Medicaid (providers who are prohibited from participating in those plans); and 3) reports on adverse actions taken against physicians and dentists regarding licensing, clinical privileges, or professional society membership.3 In addition, revocation of any practitioner’s reg-
istration by the Drug Enforcement Agency is required to be reported to the NPDB.3 Reports about licensing actions and clinical privilege actions concerning nurse-midwives are not required, although these actions may be voluntarily reported to the NPDB. However, licensing and certification actions regarding nurse-midwives must be reported to the Healthcare Integrity and Protection Data Bank.
Cecilia Jevitt, CNM, PhD, is Assistant Professor of Midwifery and Nursing with the University of South Florida Colleges of Nursing and Medicine. She is the Chair of ACNM’s Professional Liability Section. Kerri Durnell Schuiling, CNM, PhD, FACNM, is Professor and Associate Dean for Nursing Education at Northern Michigan University School of Nursing, Marquette, Michigan. She is a senior staff researcher for the American College of Nurse-Midwives. Lisa Summers, CNM, DrPH, is Senior Technical Advisor in the Department of Professional Services at the American College of Nurse-Midwives.
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All payments made by an insurer on behalf of a practitioner must be reported to the NPDB. This payment is reportable whether it is partial or full payment of a claim settled out of court or a payment made after a court judgment. No report is required when a practitioner is named in a claim but dropped from the claim prior to settlement. The act of Volume 50, No. 6, November/December 2005
making a malpractice payment triggers reporting whether or not an act of malpractice was committed.3 After a 1993 US Court of Appeals decision in the DC Circuit, self-insured practitioners no longer have to report settlements made from personal funds. Insurers may make payments in the name of a hospital or corporate group practice rather than an individual practitioner. This “corporate shield” is most often used when the hospital or other health care organization is responsible for the malpractice coverage of the practitioner.3 This corporate shield affects the accuracy of data bank statistics related to individual practitioners because an individual’s malpractice settlement may be buried in a group payment. Many nurse-midwives have liability insurance provided by employing hospitals or professional corporations and, therefore, may not have settlements made under their individual names. Exclusion from Medicare/Medicaid The Department of Health and Human Services Office of Inspector General notifies the NPDB each time action is taken to exclude a practitioner from Medicaid or Medicare reimbursement.3 A nurse-midwife, for example, might be found guilty of fraudulent Medicaid billing and then excluded from future Medicaid payments. This exclusion is reported to the NPDB and published in the Federal Register. Adverse Action Reports NPDB Adverse Action Reports come from a variety of agencies and organizations (Table 1). Adverse Action Reports must be submitted to the NPDB when a state licensure board takes disciplinary action against a physician, such as license restriction, suspension, or revocation involving practitioner incompetency or misconduct. Revisions to those actions or changes in licensure status, such as removal of restrictions, also must be reported.3 As stated above, Adverse Action Reports are required for physicians but are not required for nurse-midwives, although Adverse Action Reports can be made about a nurse-midwife if the licensing board so chooses. Adverse licensing actions against nurse-midwives, such as suspension of a license by a state board of nursing, are, however, required to be reported to the Healthcare Integrity and Protection Data Bank. Professional societies and certifying entities, such as American College of Nurse-Midwives and the American Midwifery Certification Board, Inc. (AMCB), formerly the ACNM Certification Council, Inc., may report professional review actions based on professional misconduct or incompetence that adversely affect professional membership to the NPDB as an adverse action. ACNM disbanded its Discipline Committee in 1995. In 1998, the ACC (now the AMCB) adopted a policy on professional discipline. Consistent with the contractual agreement between the AMCB and ACNM, the discipline policy applies to all CNMs, Journal of Midwifery & Women’s Health • www.jmwh.org
Table 2. Basis for Adverse Action Reports ● ● ● ● ● ● ● ● ●
Practice beyond the scope of privileges Patient abuse Unsafe practice by reason of alcohol or substance abuse Incompetence Negligence Malpractice Fraud Narcotics violation or other violation of drug statutes Other
Adapted with permission from US Department of Health and Human Services. Health Resources and Services Administration. National Practitioner Data Bank Guidebook.2
regardless of whether they were originally certified by ACNM or ACC. Decertification is an example of an action that triggers an Adverse Action Report to the HIPDB. Revisions to prior reported actions must also be filed. Hospitals, health maintenance organizations (HMOs), and other health care entities must report actions taken against physicians that adversely affect the clinical privileges or panel membership of the provider for more than 30 days.4 Physicians who voluntarily restrict or surrender medical staff privileges while under investigation for incompetence or unprofessional conduct must be reported to the NPDB through a clinical privilege report. Voluntarily surrendering medical staff privileges through retirement or stopping hospital obstetric practice is not reportable to the NPDB. Any revisions to clinical privilege reports must be filed by the health care organization that originated the report.3 Clinical privileges reports are not required for nursemidwives but may be submitted. Some categories of reportable adverse clinical privileges actions include revocation of privileges, suspension of privileges, and limitation of privileges.3 Table 2 details conduct that can be the basis for Adverse Action Reports. Hospitals or other agencies can report up to five actions (such as suspension of privileges followed by probation) and five reasons for actions on a single report. DISPUTED NATIONAL PRACTITIONER DATA BANK REPORTS When the NPDB receives a report about a practitioner, A Notification of a Report in the Data Bank is mailed to the cited practitioner.3 The practitioner is expected to review the report for accuracy. If the practitioner finds errors in the report or believes it was erroneously submitted, he or she should “dispute” the report with the NPDB and request that the entity that filed the report either submit a correction or void the report. The practitioner may also add a statement to the report explaining his or her view of the matter. If the reporting entity is unwilling to correct the report, the practitioner may request a “Secretarial Review,” so that the Secretary of the Department of Health and Human Services review the matter. The review focuses on the verity of the report. The review can examine only whether the report 527
concerned an event that is required or permitted to be reported and whether the report accurately describes the action or payment and its basis. The secretary cannot review whether an action should have been taken or whether a payment should have been made. Practitioners can submit statements or dispute reports at any time. Practitioners can request Secretarial Review 30 days after disputing the report. The Secretarial Review may be requested sooner if the reporting entity refuses to correct the report when notified by the practitioner of the alleged error. Reports are assumed to be correct unless the practitioner disputes the report or claims in a statement within the report that it is inaccurate. The Department of Health and Human Services only makes a determination of the accuracy of a report if the practitioner requests Secretarial Review.
self-querying that must be paid by credit card at the time of the query.
REQUESTING INFORMATION FROM THE NATIONAL PRACTITIONER DATA BANK
NURSE-MIDWIFERY REPORTS IN THE NATIONAL PRACTITIONER DATA BANK
Hospitals, state licensure boards, and professional societies may request information from the NPDB through a process termed “making a query.” The Health Care Quality Improvement Act requires that hospitals routinely query the NPDB when credentialing new medical or clinical staff or when staff appointments are renewed.3 This includes courtesy appointments and appointments for nonphysician practitioners, such as nurse-midwives, who are granted clinical privileges. Hospitals may voluntarily request information during any professional review activity.3,5 Plaintiff attorneys may query the NPDB under limited situations after authorization from Health and Human Services.4 Plaintiff attorneys can query the NPDB only if they can demonstrate to the Department of Health and Human Services that the plaintiff is suing the hospital for negligent credentialing and the hospital failed to make a required query on that practitioner. The plaintiff attorney receives only what the hospital would have received had it made the required query before approving medical staff privileges. Hospitals, other health care entities, and state boards, in addition to “querying” the NPDB, may request statistical information. A hospital might, for example, query the NPDB for data on national trends in obstetric malpractice to determine focus areas for internal risk management programs. The public may also request statistical information but cannot obtain information that identifies individual practitioners.3 State licensure boards may query the NPDB at any time. Nurse-midwives are most often involved in state board queries at the time of initial licensure and at the time of licensure renewal. Other health care organizations, such as managed care organizations, may make a query when entering an employment or affiliation agreement with a practitioner. Practitioners may query the NPDB about themselves at any time; however, they may not request information on other practitioners.6 There is a fee for
To provide an example of the types of data available in the NPDB pertinent to nurse-midwifery practice, data were obtained from the NPDB Public Use Data File for the period September 1, 1990, to March 31, 2005. Reports specifying a nurse-midwifery–related report were selected. It should be noted that nurse-midwives with reports in the NPDB practice a median of 10.12 years before a payment is reported to the NPDB. This is because time in practice is required for a problem to occur and because years pass during investigation, settlement, or trial.
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Confidentiality of Information in the NPDB The Health Care Quality Improvement Act mandates the confidentiality of all NPDB information that could identify individual practitioners, entities, or patients. Individuals and agencies who query the NPDB are authorized to use data only for the stated purpose of the query. A person violating the confidentiality of NPDB information is subject to civil penalty of up to $11,000 per violation. Individuals who query under false pretenses or who fraudulently gain access to the NPDB face criminal penalties including fines and imprisonment. Individuals who knowingly report false information to the NPDB are also subject to criminal prosecution and penalties.3,4
Malpractice Claims Data From September 1, 1990, to March 31, 2005, there were 484 nurse-midwifery malpractice payment reports in the NPDB, 375 of which are reports with an obstetricsrelated malpractice code. Table 3 identifies the top 10 specific malpractice allegations reported to the NPDB for nurse-midwives. However, the most common obstetrics-
Table 3. Top 10 Obstetrics-Related Malpractice Allegations for Certified Nurse-Midwives in the National Practitioner Data Bank Specific Malpractice Allegation
Frequency n (%)
Not otherwise classified Improper management Failure to treat fetal distress Delay in performance Improperly performed vaginal delivery Failure to diagnose Improper choice of delivery method Delay in treatment of identified fetal distress Failure to identify fetal distress Delay in diagnosis
126 (26.8) 103 (21.9) 40 (8.5) 37 (7.9) 37 (7.9) 25 (5.3) 20 (4.3) 18 (3.8) 14 (3.0) 7 (1.5)
Adapted from US Department of Health and Human Services. Health Resources and Services Administration. National Practitioner Data Bank.1
Volume 50, No. 6, November/December 2005
related report is “obstetrics-not otherwise classified,” which account for 26.8% (n ⫽ 126) of all obstetricsrelated reports. The dollar range of malpractice payments made on behalf of nurse-midwives is $1500 to $3,450,000, and the median payment on behalf of nurse-midwives is $225,000. The median payment best reflects the “average” malpractice payment because a few extremely high payments will skew the statistical mean. It is also important to appreciate that these numbers are based on the Public Use File, which reports amounts only in ranges. Therefore, the actual maximum payment is somewhere between $3,400,001 and $3,500,000, and the actual minimum payment is somewhere between $1001 and $2000. Similarly, the median payment indicated previously was calculated on the basis of the range figure and may not be exactly $225,000 if it were calculated on the actual exact payment amounts. In addition, it is important to know that most payments made on behalf of nurse-midwives are single payments rather than multiple payments (e.g., a series of payments over time). The year with the most nurse-midwifery obstetricsrelated reports during September 1, 1990 to March 31, 2005, is 2004 (n ⫽ 58 [12.3%]). However, it is important to understand that the median time from incident to payment for nurse-midwives in the NPDB is 4 years. Thus, although 2004 is currently the year with the most reports, other years may eventually surpass the number of reports for 2004. The state location of the malpractice event is included in 90% of NPDB nurse-midwifery reports, limiting reliable data about state malpractice occurrences. When the state location variable was missing, the home state (residence) of the midwife was used as a proxy variable. Using the proxy variable for speculative purposes, the state with the greatest number of nurse-midwife obstetrics-related malpractice reports for the time frame of this report is Florida (n ⫽ 84 [17.9%]) followed by New York (n ⫽ 61 [13.0%]) and Pennsylvania (n ⫽ 58 [12.3]). The states with the fewest nurse-midwife obstetrics-related reports (1 each [0.2%]) in the NPDB are Louisiana, Maine, Mississippi, Montana, Vermont, and Wisconsin. Important to consider when interpreting the meaning of these statistics is the number of nurse-midwives licensed in each of these states and the number of births they are attending. For example, as of 2004, Louisiana had 43 licensed nurse-midwives, whereas Florida had 598 (John Boggess, Director of Member Services and Industry Relations, ACNM, personal communication, August 3, 2005). The number of licensed nursemidwives may include both nurse-midwives who have moved out of those states and retired nurse-midwives. Thus, the higher number of reports may simply reflect a larger population of nurse-midwives. Adverse Action Reports There are approximately 50 Adverse Action Reports for nurse-midwives in the NPDB. They were not analyzed Journal of Midwifery & Women’s Health • www.jmwh.org
because adverse actions are not comprehensively reported. The 50 reports do not represent all the adverse actions involving nurse-midwives, given the voluntary nature of the reporting, nor are they a true random sample of actions.
DISCUSSION The NPDB contains limited data about nurse-midwifery malpractice claims and payments; however, it is the only national source of these data available. Insurers do not routinely share or make public their malpractice claims data. When a nurse-midwife reports an incident to a professional liability insurer, the insurer sets aside funds to settle claims that might be litigated. However, many of these incidents never become malpractice claims; thus, data on incidents reported are not available for analysis. In addition, no national data are collected on malpractice claims that are settled in favor of the nurse-midwife. Settlement of obstetric malpractice claims takes longer than other medical malpractice claims. One to 3 years may pass while assessment of infant development occurs and the plaintiff’s attorney prepares a claim. This extends the median time from incident to payment, which for nursemidwives is currently 4 years. Therefore, annual data from the NPDB reflect the activity of many prior years, not simply the previous calendar year. Legislative changes can affect the timing of filing obstetric malpractice claims. The state of Florida, for example, legislated a $500,000 cap on noneconomic damages in malpractice suits, effective January 1, 2004.7 Plaintiffs’ attorneys rushed to file negligence claims that would avoid the cap. If payments are made for these malpractice claims, there could be an increase in Florida settlements reported to the NPDB 3 to 5 years later. Data from the NPDB are updated every 3 months and can reveal trends in obstetric allegations and settlements. NPDB malpractice allegation data are nonspecific. A claim based on a shoulder dystocia that resulted in permanent brachial plexus palsy could be labeled as: 1) improper management, 2) delay in performance, or 3) improper choice of delivery method. Settlements related to improper interpretation of fetal heart rate recordings could be included in: 1) delay in treatment of identified fetal distress or 2) failure to identify fetal distress. One quarter of allegations are in the “not otherwise classified” category. The potential variability in allegation classification limits the usefulness of NPDB data in identifying practice areas for risk management strategies. More specific allegation categories would allow better identification of practice areas needing review and would assist with safety improvement planning by professional organizations, hospitals, or educators. 529
CONCLUSION It is important for midwives to understand the reporting requirements and the information available from the NPDB. This data bank is regularly queried by state licensing boards, nurse-midwifery employers, and other health care entities. Although data available from the NPDB are limited, analysis can provide insights in designing effective risk management activities for midwives. The authors thank Robert E. Oshel, PhD, Associate Chief, Practitioner Data Banks Branch, U.S. Department Health and Human Services. His knowledge and guidance were essential to completion of this manuscript. Dr. Schuiling and Dr. Summers are both staff members of American College of Nurse-Midwives. The views expressed in this manuscript do not necessarily reflect the opinions or official policies of their employer.
REFERENCES 1. US Department of Health and Human Services. Health Resources and Services Administration. Division of Practitioner Data Banks. National Practitioner Data Bank. 2003 Annual Report. Available from: http://www.npdb-hipdb.com/pubs/stats/2003_NPDB_Annual_Report.pdf [Accessed June 29, 2005]. 2. Practitioner Data Banks Branch, Office of Workforce Evaluation and Quality Assurance, Bureau of Health Professions, Health Re-
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sources and Services Administration, U.S. Department of Health and Human Services. 3. US Department of Health and Human Services. Health Resources and Services Administration. Division of Practitioner Data Banks. National Practitioner Data Bank. National Practitioner Data Bank Guidebook, September 2001. Available from: http://www. npdb-hipdb.com/npdbguidebook.html [Accessed June 29, 2005]. 4. US Department of Health and Human Services. Health Resources and Services Administration. Division of Practitioner Data Banks. National Practitioner Data Bank. Fact Sheet for Attorneys, October 2001. Available from: http://www.npdb-hipdb.com//pubs/fs/ Fact_Sheet-Attorneys.pdf [Accessed June 29, 2005]. 5. US Department of Health and Human Services. Health Resources and Services Administration. Division of Practitioner Data Banks. National Practitioner Data Bank. Fact Sheet on Professional Review Immunity, October 2001. Available from: http://www.npdbhipdb.com/pubs/fs/Fact_Sheet-Professional_Review_Immunity.pdf [Accessed June 29, 2005]. 6. US Department of Health and Human Services. Health Resources and Services Administration. Division of Practitioner Data Banks. National Practitioner Data Bank. Fact Sheet on Self-Querying, September 2004. Available from: http://www.npdb-hipdb.com/pubs/ fs/Fact_Sheet-Self-Querying.pdf [Accessed June 29, 2005]. 7. Florida Statute 766.118 Determination of Noneconomic Damages. 2004. Available from: http://www.flsenate.gov/statutes/ index.cfm?App_mode⫽Display_Statute&URL⫽Ch0766/ch0766.htm [Accessed June 30, 2005].
Volume 50, No. 6, November/December 2005
INTRODUCTION State licensure of health care providers is intended to protect the public from unsafe practitioners. The National Practitioner Data Bank (NPDB) was mandated by the Health Care Quality Improvement Act of 1986 (Title IV, PL 99-660) as a response to growing public dissatisfaction with the ability of incompetent or negligent practitioners to avoid oversight and discipline by moving from state to state.1 This article describes how the NPDB functions and collects data about nurse-midwifery licensure actions and malpractice data. In 1996, under the Health Insurance Portability and Accountability Act, the Healthcare Integrity and Protection Data Bank was created to combat fraud and abuse in health insurance and health care delivery. This article focuses data from the NPDB; however, it is important that practitioners also understand reporting requirements of the Healthcare Integrity and Protection Data Bank. Table 1 provides a comparison of the 2 data banks.2 Outcomes discussed in this article come from analysis of data from the NPDB Public Use File. The Public Use File has 1 record for each report in the NPDB but excludes identifying information about the practitioner and reporting entity. The NPDB became operational on September 1, 1990. There are approximately 30,000 new reports added to the NPDB each year.1
Address correspondence to Cecilia Jevitt, CNM, PhD, College of Nursing, University of South Florida, MDC Box 22, 12901 Bruce B. Downs Boulevard, Tampa, FL 33612. E-mail: [email protected]
Journal of Midwifery & Women’s Health • www.jmwh.org © 2005 by the American College of Nurse-Midwives Issued by Elsevier Inc.
There are 5 categories related to nursing in the NPDB: 1) registered professional nurse (RN); 2) nurse-midwife (CNM); 3) nurse practitioner (NP); 4) advanced practice nurse, retitled clinical nurse specialist after September 9, 2002; and 5) nurse anesthetist (CRNA). Non–nurse-midwives, such as certified midwives and certified professional midwives, are in a separate category: midwife, lay (non-nurse).3 At the time this article was written, there were only 10 reports in the NPDB non–nurse-midwife category. Data analyzed for this article are from reports about nurse-midwives. Reports specific to an individual are not available to the general public, although the public benefits from the reports in the NPDB database. Licensing agencies, employers, and peer review systems, such as those required by the Medicare Peer Improvement Act, obtain information from the data bank that supplements traditional ways of reviewing a practitioner’s credentials: licensure, professional society membership, medical malpractice payment history, and record of clinical privileges. The NPDB publishes aggregate statistical data and research reports about medical malpractice and disciplinary issues. A Public Use File is available to researchers and organizations investigating malpractice claims and payments.3 SOURCES OF MATERIAL SUBMITTED TO THE NATIONAL PRACTITIONER DATA BANK The NPDB receives reports from a variety of private and governmental organizations in all 50 states and all other areas under US jurisdiction. Table 1 lists the agencies that are required to submit reports to the NPDB.2 Three kinds of 525 1526-9523/05/$30.00 • doi:10.1016/j.jmwh.2005.08.008
Table 1. National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank
The National Practitioner Data Bank (NPDB) was established under Title IV of Public Law 99-660, the Health Care Quality Improvement Act of 1986. NPDB is an information clearinghouse that collects and releases information related to the professional competence and conduct of physicians, dentists, and other health care practitioners, including nurse-midwives.
Medical malpractice payers Boards of Medical/Dental Examiners Hospitals and other health care entities Professional societies with formal peer review Health and Human Services Office of Inspector General Drug Enforcement Agency (DEA)
The Healthcare Integrity and Protection Data Bank (HIPDB) was established under section 1128E of the Social Security Act as added by Section 221(A) of the Health Insurance Portability and Accountability Act of 1996. HIPDB was implemented to combat fraud and abuse in health insurance and health care delivery and to promote quality care. HIPDB alerts users that a more comprehensive review of past actions by a practitioner, provider, or supplier may be prudent. Who Reports? Federal and state government agencies (including DEA, Department of Defense, Department of Veterans Affairs, Public Health Service, Center for Medicaid and Medicare Services and HSS Office of Inspector General) Health plans
What Information Is Reported? Medical malpractice payments (all health care practitioners) Licensing and certification actions Œ Revocation, suspension, censure, reprimand, probation Adverse actions: based on reasons relating to professional competency Œ Any other loss of license— or right to apply for or renew—a license of and conduct (primarily physicians/dentists) the provider, supplier, or practitioner, whether by voluntary surrender, Œ Licensing, revocation, suspension, censure, reprimand, probation, nonrenewal, or otherwise and surrender Œ Any negative action or finding by a federal or state licensing and Œ Clinical privileges certification agency that is publicly available information Œ Professional society membership Medicare and Medicaid exclusions (all health care practitioners) Civil judgments (health care–related) Criminal convictions (health care–related) Exclusions from federal or state health care programs Other adjudicated actions or decisions (formal or official actions, availability of due process mechanism and based on acts or omissions that affect or could affect the payment, provision, or delivery of a health care item or service) Who Can Query? Hospitals Federal and state government agencies Other health care entities with formal peer review Health plans Professional societies with formal peer review Health care practitioners/providers/suppliers (self-query) Boards of Medical/Dental Examiners and other health care practitioner Researchers (statistical data only) State Licensing Boards Plaintiffs’ attorneys or plaintiffs representing themselves (limited) Health care practitioners (self-query) Researchers (statistical data only)
Practitioner Data Banks Branch, Office of Workforce Evaluation and Quality Assurance, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services.2
data are received: 1) reports on malpractice payments for all kinds of practitioners; 2) reports on practitioner exclusions from Medicare/Medicaid (providers who are prohibited from participating in those plans); and 3) reports on adverse actions taken against physicians and dentists regarding licensing, clinical privileges, or professional society membership.3 In addition, revocation of any practitioner’s reg-
istration by the Drug Enforcement Agency is required to be reported to the NPDB.3 Reports about licensing actions and clinical privilege actions concerning nurse-midwives are not required, although these actions may be voluntarily reported to the NPDB. However, licensing and certification actions regarding nurse-midwives must be reported to the Healthcare Integrity and Protection Data Bank.
Cecilia Jevitt, CNM, PhD, is Assistant Professor of Midwifery and Nursing with the University of South Florida Colleges of Nursing and Medicine. She is the Chair of ACNM’s Professional Liability Section. Kerri Durnell Schuiling, CNM, PhD, FACNM, is Professor and Associate Dean for Nursing Education at Northern Michigan University School of Nursing, Marquette, Michigan. She is a senior staff researcher for the American College of Nurse-Midwives. Lisa Summers, CNM, DrPH, is Senior Technical Advisor in the Department of Professional Services at the American College of Nurse-Midwives.
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All payments made by an insurer on behalf of a practitioner must be reported to the NPDB. This payment is reportable whether it is partial or full payment of a claim settled out of court or a payment made after a court judgment. No report is required when a practitioner is named in a claim but dropped from the claim prior to settlement. The act of Volume 50, No. 6, November/December 2005
making a malpractice payment triggers reporting whether or not an act of malpractice was committed.3 After a 1993 US Court of Appeals decision in the DC Circuit, self-insured practitioners no longer have to report settlements made from personal funds. Insurers may make payments in the name of a hospital or corporate group practice rather than an individual practitioner. This “corporate shield” is most often used when the hospital or other health care organization is responsible for the malpractice coverage of the practitioner.3 This corporate shield affects the accuracy of data bank statistics related to individual practitioners because an individual’s malpractice settlement may be buried in a group payment. Many nurse-midwives have liability insurance provided by employing hospitals or professional corporations and, therefore, may not have settlements made under their individual names. Exclusion from Medicare/Medicaid The Department of Health and Human Services Office of Inspector General notifies the NPDB each time action is taken to exclude a practitioner from Medicaid or Medicare reimbursement.3 A nurse-midwife, for example, might be found guilty of fraudulent Medicaid billing and then excluded from future Medicaid payments. This exclusion is reported to the NPDB and published in the Federal Register. Adverse Action Reports NPDB Adverse Action Reports come from a variety of agencies and organizations (Table 1). Adverse Action Reports must be submitted to the NPDB when a state licensure board takes disciplinary action against a physician, such as license restriction, suspension, or revocation involving practitioner incompetency or misconduct. Revisions to those actions or changes in licensure status, such as removal of restrictions, also must be reported.3 As stated above, Adverse Action Reports are required for physicians but are not required for nurse-midwives, although Adverse Action Reports can be made about a nurse-midwife if the licensing board so chooses. Adverse licensing actions against nurse-midwives, such as suspension of a license by a state board of nursing, are, however, required to be reported to the Healthcare Integrity and Protection Data Bank. Professional societies and certifying entities, such as American College of Nurse-Midwives and the American Midwifery Certification Board, Inc. (AMCB), formerly the ACNM Certification Council, Inc., may report professional review actions based on professional misconduct or incompetence that adversely affect professional membership to the NPDB as an adverse action. ACNM disbanded its Discipline Committee in 1995. In 1998, the ACC (now the AMCB) adopted a policy on professional discipline. Consistent with the contractual agreement between the AMCB and ACNM, the discipline policy applies to all CNMs, Journal of Midwifery & Women’s Health • www.jmwh.org
Table 2. Basis for Adverse Action Reports ● ● ● ● ● ● ● ● ●
Practice beyond the scope of privileges Patient abuse Unsafe practice by reason of alcohol or substance abuse Incompetence Negligence Malpractice Fraud Narcotics violation or other violation of drug statutes Other
Adapted with permission from US Department of Health and Human Services. Health Resources and Services Administration. National Practitioner Data Bank Guidebook.2
regardless of whether they were originally certified by ACNM or ACC. Decertification is an example of an action that triggers an Adverse Action Report to the HIPDB. Revisions to prior reported actions must also be filed. Hospitals, health maintenance organizations (HMOs), and other health care entities must report actions taken against physicians that adversely affect the clinical privileges or panel membership of the provider for more than 30 days.4 Physicians who voluntarily restrict or surrender medical staff privileges while under investigation for incompetence or unprofessional conduct must be reported to the NPDB through a clinical privilege report. Voluntarily surrendering medical staff privileges through retirement or stopping hospital obstetric practice is not reportable to the NPDB. Any revisions to clinical privilege reports must be filed by the health care organization that originated the report.3 Clinical privileges reports are not required for nursemidwives but may be submitted. Some categories of reportable adverse clinical privileges actions include revocation of privileges, suspension of privileges, and limitation of privileges.3 Table 2 details conduct that can be the basis for Adverse Action Reports. Hospitals or other agencies can report up to five actions (such as suspension of privileges followed by probation) and five reasons for actions on a single report. DISPUTED NATIONAL PRACTITIONER DATA BANK REPORTS When the NPDB receives a report about a practitioner, A Notification of a Report in the Data Bank is mailed to the cited practitioner.3 The practitioner is expected to review the report for accuracy. If the practitioner finds errors in the report or believes it was erroneously submitted, he or she should “dispute” the report with the NPDB and request that the entity that filed the report either submit a correction or void the report. The practitioner may also add a statement to the report explaining his or her view of the matter. If the reporting entity is unwilling to correct the report, the practitioner may request a “Secretarial Review,” so that the Secretary of the Department of Health and Human Services review the matter. The review focuses on the verity of the report. The review can examine only whether the report 527
concerned an event that is required or permitted to be reported and whether the report accurately describes the action or payment and its basis. The secretary cannot review whether an action should have been taken or whether a payment should have been made. Practitioners can submit statements or dispute reports at any time. Practitioners can request Secretarial Review 30 days after disputing the report. The Secretarial Review may be requested sooner if the reporting entity refuses to correct the report when notified by the practitioner of the alleged error. Reports are assumed to be correct unless the practitioner disputes the report or claims in a statement within the report that it is inaccurate. The Department of Health and Human Services only makes a determination of the accuracy of a report if the practitioner requests Secretarial Review.
self-querying that must be paid by credit card at the time of the query.
REQUESTING INFORMATION FROM THE NATIONAL PRACTITIONER DATA BANK
NURSE-MIDWIFERY REPORTS IN THE NATIONAL PRACTITIONER DATA BANK
Hospitals, state licensure boards, and professional societies may request information from the NPDB through a process termed “making a query.” The Health Care Quality Improvement Act requires that hospitals routinely query the NPDB when credentialing new medical or clinical staff or when staff appointments are renewed.3 This includes courtesy appointments and appointments for nonphysician practitioners, such as nurse-midwives, who are granted clinical privileges. Hospitals may voluntarily request information during any professional review activity.3,5 Plaintiff attorneys may query the NPDB under limited situations after authorization from Health and Human Services.4 Plaintiff attorneys can query the NPDB only if they can demonstrate to the Department of Health and Human Services that the plaintiff is suing the hospital for negligent credentialing and the hospital failed to make a required query on that practitioner. The plaintiff attorney receives only what the hospital would have received had it made the required query before approving medical staff privileges. Hospitals, other health care entities, and state boards, in addition to “querying” the NPDB, may request statistical information. A hospital might, for example, query the NPDB for data on national trends in obstetric malpractice to determine focus areas for internal risk management programs. The public may also request statistical information but cannot obtain information that identifies individual practitioners.3 State licensure boards may query the NPDB at any time. Nurse-midwives are most often involved in state board queries at the time of initial licensure and at the time of licensure renewal. Other health care organizations, such as managed care organizations, may make a query when entering an employment or affiliation agreement with a practitioner. Practitioners may query the NPDB about themselves at any time; however, they may not request information on other practitioners.6 There is a fee for
To provide an example of the types of data available in the NPDB pertinent to nurse-midwifery practice, data were obtained from the NPDB Public Use Data File for the period September 1, 1990, to March 31, 2005. Reports specifying a nurse-midwifery–related report were selected. It should be noted that nurse-midwives with reports in the NPDB practice a median of 10.12 years before a payment is reported to the NPDB. This is because time in practice is required for a problem to occur and because years pass during investigation, settlement, or trial.
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Confidentiality of Information in the NPDB The Health Care Quality Improvement Act mandates the confidentiality of all NPDB information that could identify individual practitioners, entities, or patients. Individuals and agencies who query the NPDB are authorized to use data only for the stated purpose of the query. A person violating the confidentiality of NPDB information is subject to civil penalty of up to $11,000 per violation. Individuals who query under false pretenses or who fraudulently gain access to the NPDB face criminal penalties including fines and imprisonment. Individuals who knowingly report false information to the NPDB are also subject to criminal prosecution and penalties.3,4
Malpractice Claims Data From September 1, 1990, to March 31, 2005, there were 484 nurse-midwifery malpractice payment reports in the NPDB, 375 of which are reports with an obstetricsrelated malpractice code. Table 3 identifies the top 10 specific malpractice allegations reported to the NPDB for nurse-midwives. However, the most common obstetrics-
Table 3. Top 10 Obstetrics-Related Malpractice Allegations for Certified Nurse-Midwives in the National Practitioner Data Bank Specific Malpractice Allegation
Frequency n (%)
Not otherwise classified Improper management Failure to treat fetal distress Delay in performance Improperly performed vaginal delivery Failure to diagnose Improper choice of delivery method Delay in treatment of identified fetal distress Failure to identify fetal distress Delay in diagnosis
126 (26.8) 103 (21.9) 40 (8.5) 37 (7.9) 37 (7.9) 25 (5.3) 20 (4.3) 18 (3.8) 14 (3.0) 7 (1.5)
Adapted from US Department of Health and Human Services. Health Resources and Services Administration. National Practitioner Data Bank.1
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related report is “obstetrics-not otherwise classified,” which account for 26.8% (n ⫽ 126) of all obstetricsrelated reports. The dollar range of malpractice payments made on behalf of nurse-midwives is $1500 to $3,450,000, and the median payment on behalf of nurse-midwives is $225,000. The median payment best reflects the “average” malpractice payment because a few extremely high payments will skew the statistical mean. It is also important to appreciate that these numbers are based on the Public Use File, which reports amounts only in ranges. Therefore, the actual maximum payment is somewhere between $3,400,001 and $3,500,000, and the actual minimum payment is somewhere between $1001 and $2000. Similarly, the median payment indicated previously was calculated on the basis of the range figure and may not be exactly $225,000 if it were calculated on the actual exact payment amounts. In addition, it is important to know that most payments made on behalf of nurse-midwives are single payments rather than multiple payments (e.g., a series of payments over time). The year with the most nurse-midwifery obstetricsrelated reports during September 1, 1990 to March 31, 2005, is 2004 (n ⫽ 58 [12.3%]). However, it is important to understand that the median time from incident to payment for nurse-midwives in the NPDB is 4 years. Thus, although 2004 is currently the year with the most reports, other years may eventually surpass the number of reports for 2004. The state location of the malpractice event is included in 90% of NPDB nurse-midwifery reports, limiting reliable data about state malpractice occurrences. When the state location variable was missing, the home state (residence) of the midwife was used as a proxy variable. Using the proxy variable for speculative purposes, the state with the greatest number of nurse-midwife obstetrics-related malpractice reports for the time frame of this report is Florida (n ⫽ 84 [17.9%]) followed by New York (n ⫽ 61 [13.0%]) and Pennsylvania (n ⫽ 58 [12.3]). The states with the fewest nurse-midwife obstetrics-related reports (1 each [0.2%]) in the NPDB are Louisiana, Maine, Mississippi, Montana, Vermont, and Wisconsin. Important to consider when interpreting the meaning of these statistics is the number of nurse-midwives licensed in each of these states and the number of births they are attending. For example, as of 2004, Louisiana had 43 licensed nurse-midwives, whereas Florida had 598 (John Boggess, Director of Member Services and Industry Relations, ACNM, personal communication, August 3, 2005). The number of licensed nursemidwives may include both nurse-midwives who have moved out of those states and retired nurse-midwives. Thus, the higher number of reports may simply reflect a larger population of nurse-midwives. Adverse Action Reports There are approximately 50 Adverse Action Reports for nurse-midwives in the NPDB. They were not analyzed Journal of Midwifery & Women’s Health • www.jmwh.org
because adverse actions are not comprehensively reported. The 50 reports do not represent all the adverse actions involving nurse-midwives, given the voluntary nature of the reporting, nor are they a true random sample of actions.
DISCUSSION The NPDB contains limited data about nurse-midwifery malpractice claims and payments; however, it is the only national source of these data available. Insurers do not routinely share or make public their malpractice claims data. When a nurse-midwife reports an incident to a professional liability insurer, the insurer sets aside funds to settle claims that might be litigated. However, many of these incidents never become malpractice claims; thus, data on incidents reported are not available for analysis. In addition, no national data are collected on malpractice claims that are settled in favor of the nurse-midwife. Settlement of obstetric malpractice claims takes longer than other medical malpractice claims. One to 3 years may pass while assessment of infant development occurs and the plaintiff’s attorney prepares a claim. This extends the median time from incident to payment, which for nursemidwives is currently 4 years. Therefore, annual data from the NPDB reflect the activity of many prior years, not simply the previous calendar year. Legislative changes can affect the timing of filing obstetric malpractice claims. The state of Florida, for example, legislated a $500,000 cap on noneconomic damages in malpractice suits, effective January 1, 2004.7 Plaintiffs’ attorneys rushed to file negligence claims that would avoid the cap. If payments are made for these malpractice claims, there could be an increase in Florida settlements reported to the NPDB 3 to 5 years later. Data from the NPDB are updated every 3 months and can reveal trends in obstetric allegations and settlements. NPDB malpractice allegation data are nonspecific. A claim based on a shoulder dystocia that resulted in permanent brachial plexus palsy could be labeled as: 1) improper management, 2) delay in performance, or 3) improper choice of delivery method. Settlements related to improper interpretation of fetal heart rate recordings could be included in: 1) delay in treatment of identified fetal distress or 2) failure to identify fetal distress. One quarter of allegations are in the “not otherwise classified” category. The potential variability in allegation classification limits the usefulness of NPDB data in identifying practice areas for risk management strategies. More specific allegation categories would allow better identification of practice areas needing review and would assist with safety improvement planning by professional organizations, hospitals, or educators. 529
CONCLUSION It is important for midwives to understand the reporting requirements and the information available from the NPDB. This data bank is regularly queried by state licensing boards, nurse-midwifery employers, and other health care entities. Although data available from the NPDB are limited, analysis can provide insights in designing effective risk management activities for midwives. The authors thank Robert E. Oshel, PhD, Associate Chief, Practitioner Data Banks Branch, U.S. Department Health and Human Services. His knowledge and guidance were essential to completion of this manuscript. Dr. Schuiling and Dr. Summers are both staff members of American College of Nurse-Midwives. The views expressed in this manuscript do not necessarily reflect the opinions or official policies of their employer.
REFERENCES 1. US Department of Health and Human Services. Health Resources and Services Administration. Division of Practitioner Data Banks. National Practitioner Data Bank. 2003 Annual Report. Available from: http://www.npdb-hipdb.com/pubs/stats/2003_NPDB_Annual_Report.pdf [Accessed June 29, 2005]. 2. Practitioner Data Banks Branch, Office of Workforce Evaluation and Quality Assurance, Bureau of Health Professions, Health Re-
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sources and Services Administration, U.S. Department of Health and Human Services. 3. US Department of Health and Human Services. Health Resources and Services Administration. Division of Practitioner Data Banks. National Practitioner Data Bank. National Practitioner Data Bank Guidebook, September 2001. Available from: http://www. npdb-hipdb.com/npdbguidebook.html [Accessed June 29, 2005]. 4. US Department of Health and Human Services. Health Resources and Services Administration. Division of Practitioner Data Banks. National Practitioner Data Bank. Fact Sheet for Attorneys, October 2001. Available from: http://www.npdb-hipdb.com//pubs/fs/ Fact_Sheet-Attorneys.pdf [Accessed June 29, 2005]. 5. US Department of Health and Human Services. Health Resources and Services Administration. Division of Practitioner Data Banks. National Practitioner Data Bank. Fact Sheet on Professional Review Immunity, October 2001. Available from: http://www.npdbhipdb.com/pubs/fs/Fact_Sheet-Professional_Review_Immunity.pdf [Accessed June 29, 2005]. 6. US Department of Health and Human Services. Health Resources and Services Administration. Division of Practitioner Data Banks. National Practitioner Data Bank. Fact Sheet on Self-Querying, September 2004. Available from: http://www.npdb-hipdb.com/pubs/ fs/Fact_Sheet-Self-Querying.pdf [Accessed June 29, 2005]. 7. Florida Statute 766.118 Determination of Noneconomic Damages. 2004. Available from: http://www.flsenate.gov/statutes/ index.cfm?App_mode⫽Display_Statute&URL⫽Ch0766/ch0766.htm [Accessed June 30, 2005].
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