State medical boards that review doctors' behavior discipline physicians at rates far lower than some studies suggest are appropriate, according to a report by the Department of Health and Human Services.
The report said large case backlogs, limited resources and complex hearing procedures with tough standards of proof contribute to seemingly lenient behavior.
According to the report, prepared by HHS inspector general Richard P. Kusserow at the request of Rep. Ron Wyden (D-Ore.), the number of actions reported by the boards increased from 2,019 in 1985 to 2,587 in 1987. But of these, less than two-thirds represented serious actions such as license revocations, suspensions and probation.
The report said it is impossible to determine how many physicians warrant actions for delivering improper care, although other organizations -- such as physician-owned insurance companies -- discipline at a higher rate.
Even the actions reported by the state boards may overstate the number of physicians who are disciplined, the report said. If a board put a physician on probation, modified the probation, then terminated it, three actions would be tallied. "Similarly, if a physician were disciplined in one state and on the basis of that action in two other states in which he or she is licensed, that physician would account for three actions," the report said.
"It appears to me that the majority of boards are backlogged, understaffed and strapped down by various constraints; they often can't get into the guts of the case," said Wyden, whose House Small Business subcommittee on regulation will hold a hearing on the issue this week.
Often, the boards enter into consent decrees to settle complaints against a physician instead of going to a full hearing. A doctor, for example, may agree to enter a rehabilitation program for alcohol or drug abuse rather than be disciplined.
The boards are empowered to discipline doctors for malpractice, improper medical practices and other misconduct, and can lift a physician's license to practice.
Kusserow said that although there has been some progress since a 1986 review, "case backlogs remain a serious problem for state medical boards" and "significant staff shortages continue to impede the boards' disciplinary efforts." Although medical license renewal fees, "which can serve as a major funding source for addressing these shortages, have been increasing," much of the revenue "has not been going to the boards" but to other budgets in state governments.
Kusserow said that although more attention is being paid to poor quality of care by physicians, the majority of disciplinary actions continue to involve improper use of drugs or alcohol, whether "inappropriate prescribing, unlawful distribution or self-abuse."
In some states other agencies sometimes handle part of the investigation of a physician, leading to a fragmented authority, which can hinder effective action by the medical boards.
Moreover, most boards "must base any disciplinary actions they take on a 'clear and convincing evidence' standard of proof," which is more rigorous than the "preponderance of the evidence" standard that typically is required to justify damages for negligence in civil cases.
Kusserow said one recent study based on a national survey of 40 physician-owned insurance companies "found that the overall rate at which these companies disciplined physicians for 'substandard performance' was much higher than that of state medical boards." Another study, based on a review of records of 30,195 randomly selected patients in 51 New York state hospitals, found that the rate of negligent care provided to these patients was far greater than the rate of physicians being disciplined by the New York State Board.
The Federation of State Medical Boards could not be reached for comment.