Unmanaged Care?

Is New Jersey’s Board of Medical Examiners doing enough to protect patient safety?

A recent national healthcare report is filled with dry data, statistics and details — but the story it tells is dire. It suggests that New Jersey may not be doing enough to police its doctors.

Take the case of doctor 212829, who lost hospital admitting privileges in 2004, but continued working elsewhere in the state. Three years later a surgical complication cost a patient his life and the physician nearly $200,000 in a medical malpractice settlement.

Physician number 165597 had his hospital privileges suspended twice in 2004, but was back in surgery a few years later. By 2008 he had paid close to $2 million in a pair of medical malpractice settlements and, because of improper surgical procedures or a failure to order appropriate tests, two patients had suffered “significant permanent injury.”

Those doctors are among the 183 New Jersey physicians over the past two decades who have had their hospital privileges suspended but who were not disciplined by the state Board of Medical Examiners (BME). In fact, they were allowed to continue in private practice or at another hospital.

All told, 320 doctors in the Garden State had their admitting privileges suspended or revoked; 137 of these were also reprimanded by the state medical board. This ratio mirrored the national trend.

Those findings are included in a recent report from the nonpartisan advocacy organization Public Citizen.

In the Garden State, the Public Citizen report has stirred debate over the proper role of the Board of Medical Examiners, which licenses the state’s 33,000 doctors, and has raised questions about its level of resources. Some physicians strongly defend the board’s record and insist that the numbers alone do not reflect the board’s activity — and certainly don’t indicate the public is in danger. Others say the board could take a more aggressive role in policing physicians.

The study was based on data from 1990 to 2009 in the National Practitioner Data Bank, a repository of state medical board actions, hospital reports and medical malpractice payouts against physicians.

Trenton Testimony

One of report’s authors, Dr. Sidney Wolfe, recently testified in Trenton. He said that the disparity between the number of doctors who were sanctioned and those reprimanded by the state board is a serious problem that could harm patient care. He also said that he and the other authors are urging state medical licensing boards to be far more aggressive in rooting out and banning unqualified doctors.

Wolfe is the director of Public Citizen’s Health Research Group.

The results of last month’s report also prompted Public Citizen to send the report to the office of federal health secretary Kathleen Sebelius, something it hasn’t done for nearly a decade. The group red-flagged 33 states — including New Jersey, New York, Pennsylvania and most of New England — for their low rates of licensing actions against physicians. Public Citizen also contacted the state boards in these states directly.

The report also came in for some strong criticism.

“Naked statistics…. are not indicative of whether the board is properly performing its duties,” said Larry DeMarzo, deputy director of New Jersey’s Division of Consumer Affairs, which oversees the board. Speaking at a recent Senate hearing, DeMarzo said he “could not disagree more strongly” with any suggestion that the board is lax in its enforcement.

The hearing was called by health committee chair Sen. Loretta Weinberg (D-Teaneck), who invited healthcare advocates, state officials and physicians to testify about the board’s performance and resources. Weinberg noted at the start that the BME has been without a full-time medical director for a few years and is struggling to find new members for several of its 21 seats.

“New Jersey depends on our Board of Medical Examiners to ensure that the public health is protected and physicians are held to a high standard of safety and professionalism,” Weinberg said in a statement later. “We need to make sure the Board has the tools it needs to pursue cases of suspected wrongdoing, and to make sure doctors and other healthcare professionals are held to the highest professional standard.”

The board is funded entirely by medical license fees — not taxpayers — with a $10.5 million budget this year and $12.2 million requested for 2011.

Peer Review

Public Citizen focused on the disparity between hospital actions and board actions, noting that discipline reports from hospitals are valuable peer-review findings and “one of the most valuable sources of information” for state medical boards. “Subsequent state medical board action against a physician’s license is a crucial next step to protect patients.”

The study also shows that New Jersey’s board has long ranked near the bottom of the group’s list of physician disciplinary rates; in 2009 it was 40th in the nation, with a rate of 2.36 serious board actions per 1,000 physicians. Pennsylvania, ranked 31st; has 43,726 doctors and a recent disciplinary rate of 2.71 serious board actions per 1,000 doctors. On the other end is Ohio, ranked 4th, with 39,125 doctors and a disciplinary rate of 5.43 per 1,000 doctors.

Several doctors and state officials took issue with the Public Citizen report, explaining that the board has a range of methods to protect patient care — from suspending or revoking licenses to requiring more training or oversight — and not all actions show up in the federal data bank. In the past five years, the board has revoked, suspended or caused to be surrendered more than 300 physicians’ licenses, and it has reprimanded several hundred additional doctors. It has also collected $2.8 million in fines.

“Knee-jerk disciplinary action” is not always the most effective route, explained DeMarzo. He said “most, if not all” of the 183 doctors who were not officially reprimanded by the board despite hospital discipline either underwent some kind of retraining, were assigned a chaperone, or surrendered their license voluntarily.

Board president Dr. Paul T. Jordan made a similar argument in an op-ed published earlier this month. He asserted that Public Citizen’s data doesn’t reflect the “carefully tailored alternative approaches” used by the board to improve doctor’s performance.

“The expectation that the board should publicly discipline every physician who has an adverse action report from a hospital reflects a basic misunderstanding of the board’s many functions,” he wrote. “Well-reasoned and appropriate analysis underlies the decisions in which the board took no action.”

Dr. Donald J. Cinotti, president of the Medical Society of New Jersey, largely agreed. He also raised concerns about the reliance on medical malpractice data, since high dollar awards don’t always equate with shoddy care, and they can skew the reports against doctors in high-risk fields, like neurology and obstetrics.

Cinotti also underscored the board’s role in helping doctors to get better or avoid future mistakes. “It’s much better to save the career of a good physician than it is to ruin his career by revoking his license,” he said.

Wolfe had several suggestions for raising the board’s discipline rate. In addition to a dedicated resource stream, adequate staffing and strong leadership, he urged New Jersey’s group to make more use of the data available through the national data bank, sanction lists maintained by hospital and federal health care programs, and the criminal justice system. He also underscored the need for the board to maintain independence from politics and the state’s medical society.

“When boards are able to [be more aggressive], sometimes it’s a matter of funding — it is almost always a case that they increase the amount of discipline they do,” Wolfe said. “It is not that the doctors get worse, it’s that the boards get better.”

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