Congress enacted the Health Care Quality Improvement Act (Title IV) in 1986, which created the National Practitioner Data Bank (NPDB). Since that time, three other laws have been ratified that have shaped the guidelines used today. Congress created the NPDB as a nationwide information clearinghouse to gather and publish matters related to the professional competence, quality, and behavior of health care professionals. Congress feared that physicians and dentists could move from state to state to evade any prior medical misadventures or inappropriate conduct. At the time, Congress perceived that a rising rate of malpractice litigation was commensurate with a declining quality of medical care provided. Irrespective of the legitimacy of this claim, the NPDB was born, and it survives today.
Explore This IssueACEP Now: Vol 38 – No 02 – February 2019
As with many other federal mandates (eg, EMTALA), the NPDB reporting guidelines have morphed considerably over the years. It will be a rare emergency physician who is not ensnared into the data bank from either a malpractice payment made on their behalf or other reasons related to their professional activities.
In October 2018, a new NPDB guidebook was released addressing updates and clarifications to the prior 2015 guidelines. The revised guidebook was designed to assist “eligible entities” to perform mandated reporting or queries of the data bank. Medical malpractice payers, hospitals, and professional societies are just some of the entities that are required to query and report various clinical outcomes to the data bank.
Information in the data bank that is available to eligible entities or those wishing to self-query their accounts includes medical malpractice payments, adverse actions related to licensure, changes in clinical privileging, professional society review actions of its members, Drug Enforcement Administration actions, and exclusions from federal health care programs (eg, Medicare and Medicaid). The totality of the guidelines can be viewed online at www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp.
What Must Be Reported to NPDB?
- Medical malpractice payments
- Federal and state licensure and certification actions
- Adverse clinical privileges actions
- Adverse professional society membership actions
- Negative actions or findings by private accreditation organizations and peer-review organizations
- Health care–related criminal convictions and civil judgments
- Exclusions from participation in a federal or state health care program (including Medicare and Medicaid exclusions)
- Other adjudicated actions or decisions
Although the 2018 guidelines do not necessarily add novel pathways to end up in the data bank, there are significant clarifications focusing on any “restrictions” in clinical privileges.
Relevant Clarifications in the 2018 Updates
- An agreement to not exercise privileges or surrendering/restricting clinical privileges mandates NPDB reporting.
- Taking a leave of absence while under clinical investigation mandates NPDB reporting.
- Resignation while under a quality review plan (for clinical competence) or a quality review plan that lasts beyond 30 days in duration mandates NPDB reporting.
- Any state licensing or governing board’s adverse action against one of its licensees mandates NPDB reporting.
- Any adverse state licensing or board action that curtails a licensee’s practice of medicine due to mental illness, alcohol, or drug abuse mandates NPDB reporting.
- Surrendering a license, not under investigation, for mental illness, physical illness, or simply entering a substance abuse center is not reportable.
- Payment of a malpractice claim from a physician’s corporate account (PC, PA, PLLC, LLC, etc.) is reportable, while those payments made from their private funds or that of a group practice are not reportable.
In addition to the general inclusion rules noted above, the following are a few more obscure means by which emergency physicians in particular might find themselves included in the data bank.
What Emergency Physicians Need to Know
A professional society, such as ACEP, must report professional review actions based on reasons related to professional competence or professional conduct that adversely affect or may adversely affect the membership of a physician. The professional competence or professional conduct must adversely affect or potentially adversely affect the health or welfare of a patient. If, however, censure, reprimand, or admonishment is the sole result of an adverse membership action, that action should not be reported to the NPDB.