Health Professions

National Practitioner Data Bank

Authorizing Legislation - Section IV, P.L. 99-660; Health Care Quality Improvement Act of 1986, as amended by P.L. 100-177; Section 5, Medicare and Medicaid Patient Protection Act of 1987 (P.L. 100-93), and Omnibus Budget Reconciliation Act of 1990 (P.L. 100-508).

FY 2008 Authorization.........................................................................................................Indefinite

Statement of the Budget Request - There is no FY 2008 Budget for this program. The NPDB will be operated solely on user fee collections of $18,900,000.

Program Description - To help ensure quality health care, the Health Care Quality Improvement Act of 1986 requires the Secretary of Health and Human Services to establish a national system (the National Practitioner Data Bank (NPDB)) for the receipt, storage and dissemination of information on: (1) paid medical malpractice judgments and settlements against all licensed health care practitioners; and (2) sanctions taken by Boards of Medical Examiners, losses of membership in professional societies, and certain professional review actions taken by health care entities against physicians and dentists. Malpractice insurance companies, State licensure boards, and health care entities and professional societies are required to report information to the data bank. As specified in the law, the NPDB makes reported information available to hospitals and other health care entities, State licensing authorities, and professional societies. The existence of the data bank makes it difficult for practitioners to hide this information by moving to another State. Language in appropriations legislation for FY 1993 and all subsequent years requires that user fee collections cover the full cost of NPDB operations. There is no appropriation for the NPDB.

Because of the similarities of both the NPDB and the Healthcare Integrity and Protection Data Bank (HIPDB), in FY 2008, we are proposing that these two programs be collapsed into one program, the NPDB. The HIPDB provides critical information to State and Federal agencies, law enforcement officials, and health plans concerning adverse actions, health care related civil judgments and criminal convictions of health care practitioners, providers and suppliers. This information helps prevent practitioners, providers, and suppliers with problem backgrounds from moving from State to State unnoticed by licensing and health plan officials, thus improving health care quality. It also helps law enforcement officials in the battle against health care fraud and abuse.

As of September 30, 2006, the NPDB contained 403,410 reports on 235,242 practitioners. Approximately 73 percent of these reports concerned malpractice payments and approximately 15 percent concerned licensure actions. Approximately 4 percent were clinical privileges actions and approximately 8 percent were exclusion actions. Other types accounted for fewer than one percent. During FY 2006, the NPDB processed 3,646,544 queries from 12,897 registered entities. Querying entities received 513,629 responses from the NPDB which contained reports on the queried practitioners.

Querying entities also received 3,132,915 responses which confirmed that the named practitioner had no malpractice payments, adverse actions, or exclusions since September 1, 1990. An estimated 46,400 licensure, credentialing, or membership decisions were affected by new information provided in responses during FY 2006.

Accomplishments

The NPDB continues to provide critical information to the Nation’s hospitals, health plans, and licensing boards for their use in credentialing and licensing practitioners, an important step in ensuring quality health care. This information assures that practitioners with poor practice records or inappropriate behavior cannot move from State to State unnoticed by the appropriate licensing and credentialing authorities.

According to projections based on the 2001 University of Illinois at Chicago and Northwestern University national survey of NPDB users, information supplied by the NPDB changes approximately 46,400 licensing and credentialing decisions annually.

Development has begun on the Proactive Disclosure Service (PDS). With this service, all eligible entities that choose to register their practitioners with the Data Banks will be notified of new reports that name any of their registered practitioners as subjects within one day of the Data Banks' receipt of the report. This service will be offered in addition to, and not as a replacement of, the current Data Bank querying service. While the method and timing of delivery will change; the format and the information contained in a Data Bank report, as well as the information required to be reported to each Data Bank will remain the same. The Data Banks and Data Banks customers consider this service appealing because it will improve the quality of health care by ensuring entities that credential, license, and employ health care providers are alerted of the existence of a report immediately, rather than learning of it during periodic reviews. This new initiative keeps the Data Banks on the forefront of technology by providing customers a choice in services. These efforts assure that the Data Banks continue to maximize advancements in information technology in furtherance of their missions. The PDS has already been recognized by Government Computer News as one of the Top 100 Federal and private sector programs having “the greatest impact on the government information systems community in 2005.” This is the third major award the Data Banks have won for information technology achievements in the last four years. The PDS will be operational as a prototype in April of 2007.

In addition,

• The Notice of Proposed Rulemaking relative to revising the existing regulations governing the National Practitioner Data Bank to incorporate statutory requirements under section 1921 of the Social Security Act, was published on March 21, 2006. Comments from thirty-three organizations/individuals were received before the comment period closed on May 22, 2006.
  
• Policy Forums were established for licensing boards to increase reporting timeliness and enhance the Data Bank’s relationships with boards.
  
• A reporting compliance plan was developed and portions were implemented.
  
• Over twenty presentations were given to licensing boards, credentialers and practitioner groups in order to increase timely reporting and/or to develop a better understanding of the Data Banks.

Operational Improvements

Over the past year, the NPDB underwent several technology enhancements to improve system availability, performance, and security. These enhancements include:

• Historical Query and Report Summary Enhancements: Provided entities with the capability to search for previously submitted queries and reports back through June 2000.
  
• Implemented a process where entities will automatically have to renew their entity registration every two-years.
  
• Entity/Agent Relationship Enhancements: If an entity has statutory authority to submit both queries and reports, then their agent can submit both queries and reports on their behalf.
  
• Implemented a process where agents no longer have to manually enter the DBID (identification number)of the entity for whom they wish to act on behalf of. Now they can simply select the entity to work on behalf of from a pre-populated list.
  
• Reduced the number of pages in a query response from three to one.
  
• Introduced a new service for reporters who wish to interface their data processing system directly with the Data Banks to submit reports and receive responses using the industry standard XML format.
  
• Implemented security enhancements to the web-based interface (i.e., IQRS)
  
  - User account password privacy
  - Expiring grace login period
  - Enforcing stronger passwords

In addition, NPDB technical enhancements that are planned for the future include implementation of Section 1921 of the Social Security Act. The current NPDB would expand to include access, by eligible entities, to information received under Section 1921.

Research Initiatives for Program Improvement

The NPDB actively assess the success of the program and identify areas for improvement:

• During FY 2006 HRSA awarded a contract to conduct a new national survey of data bank users and non-users to gauge user satisfaction, use of data bank information, and areas for improvement. The survey will be conducted during FY 2007 with results received during FY 2008.
  
• HRSA is reviewing all reported “high-low” agreement malpractice payment reports to improve reporting accuracy.
  
• HRSA reviewed a sample of clinical privileges reports for adequacy of report narratives to identify areas for improvement.
  
• HRSA conducted an American Customer Satisfaction Index survey of NPDB reporting and querying in FY 2003. Results indicated a very high level of customer satisfaction with the NPDB overall. The results of the survey are being used to identify areas for improvement.
  
• The NPDB is actively reviewing reports for possible duplicates and other reporting errors such as improperly coded Revision to Action Reports and improperly submitted Voids.

The NPDB has also undertaken a number of research efforts aimed specifically at increasing compliance with reporting and querying requirements:

• The NPDB’s Hospital Review project examines non-matches among hospitals between the American Hospital Association (AHA) “Hospital Guide” and the NPDB’s registered entities list. In cases where a hospital is listed in the AHA Guide but is not registered with NPDB, a letter is written to the hospital to determine its registration status. Staff then follows up with unregistered hospitals to ensure that they register and come into compliance with the statute.
  
• Staff has corresponded with several State boards of medicine or dentistry that have failed to report any actions against practitioners in 2004 when in previous years had reported multiple adverse actions.

• Staff reviews various legal publications which present suits involving practitioners/health care entities. In the majority of these cases the entity took an action against the practitioner's clinical privileges. The NPDB files are researched for adverse action reports and staff contacts the entity if none is found.
  
• The National Association of Insurance Commissioners (NAIC)/NPDB matching project is now entering its fifth year. The reviews of 2001 and 2002 are complete and with the exception of two malpractice payers (insurance companies) all discrepancies have been resolved. The 2003 payment data from the NAIC and the NPDB has been submitted to the insurers for reconciliation.
  
• Staff conducted a review of reports voided from the NPDB during calendar years 2001 and 2002. The majority of voids of adverse action reports occur when an entity has corrected a report or filed revision to action reports. Many of voids of the adverse action reports are either appropriate voids or there are other adverse action reports in the NPDB from this entity regarding the practitioner. In the cases of voids of reports of payments there appear to be little rational for many of the voids.

Rationale for the Budget Request - There is no FY 2008 Budget for the NPDB. Based on the assumption that Section 1921 will be implemented in FY 2007, the NPDB user fee collections will be $18,900,000.

User fees are established at a level to cover all program costs to allow the NPDB to meet annual and long term program performance goals. Program costs include all costs by the NPDB operating contractor and all government costs, including charged overhead and other expenses to operate the program. Fees are established based on query volume to result in adequate but not excessive revenues to pay all program costs to meet program performance goals. This includes the cost of operating the computer and communications systems necessary to receive reports and respond to queries in the established goal time periods and to continually improve the system so that the program will be able to meet annual and long term goals as query and report volumes grow. Program expenses also include other required program costs such as government oversight and the “Secretarial Review” disputed reports resolution process. The relationship between the amount of user fee revenue collected and the program’s ability to meet performance goals is a direct one since if revenues were inadequate to operate the system so that new reports and queries can be processed promptly, queriers would not receive responses in time for them to affect licensing and credentialing decisions or be considered useful to the querying entity. The relationship between user fee revenue and program goals is also direct because there is no incentive to collect more user fee revenue than is required; the money can legally only be spent on the NPDB program. Since 1990 user fees have been reduced several times when more revenue was collected than needed to cover expenses necessary to meet goals. Query fees have also been

increased in the past when the growth in the volume of queries and increased program efficiencies was not enough to offset increased costs required to meet program performance goals.

In FY 2006, the NPDB received 3,646,544 queries. The level of querying activity is only expected to increase slightly through FY 2008 if Section 1921 is not implemented. However, if Section 1921 is implemented the level of querying activity should increase by approximately 20%.

Operational costs of the NPDB include:

1. Contract Data Bank Operations

• Responding to requests for information and assistance
• Receiving and encoding information into the data bank
• Providing information to individuals who query the data bank about themselves
• Systems enhancements to make the data bank more accessible to users
• Support for fee collection
• Maintaining interactive access through the Internet for transmitting reports and requests for information

2. Non-contract Data Bank Operations

• Oversight of data bank operations and systems security
• Federal contract management
• Periodic contract recompetition
• Development and interpretation of data bank program policy
• Printing of program informational and marketing materials
• Management of a system to resolve disputes about the accuracy of data bank information
• Development of specifications for data bank systems enhancements Management of a research capability based on data bank information
• Management of a continuous quality improvement program
• Fee collection

User fee collections for the HIPDB program during the last five years reflect this effort and are as follows:

*Estimate includes user fees plus supplemental funds from the OIG as necessary

User fee collections for the NPDB program during the last five years reflect this effort and are as follows:

*The above data is based on the assumption of the implementation of Section 1921.

Performance Analysis - The National Practitioner Data Bank (NPDB) is a national data repository on significant adverse professional actions against physicians and dentists, as well as malpractice settlements and judgments against all licensed healthcare professionals. The Healthcare Integrity and Protection Data Bank (HIPDB) operates in conjunction with the NPDB, augmenting it with information on health care related criminal convictions and certain other data. A combined Program Assessment Rating Tool (PART) review of the NPDB and HIPDB was conducted in 2006 for the FY 2008 budget cycle. The programs, jointly, received a rating of Moderately Effective.

The number of queries to these databases provides an indication of the degree to which they are used to inform decisions regarding credentialing, licensing, and extension of clinical privileges to health care providers. Since 1998 the annual volume of queries to the data banks has grown by about 46 percent, from 3.1 million in FY 1998, to over 4.5 million in FY 2006, with corresponding increases in the number of decisions affected by NPDB or HIPDB data. At the same time, the data banks have been able to increase efficiency tremendously, reducing the amount of time required to process a query to less than 240 minutes (down from several days in 1990), and reducing user fees at the same time. A customer satisfaction survey completed in
FY 2001 by the University of Illinois at Chicago and Northwestern University found that 88 percent of those interviewed rated the NPDB as useful or very useful. Performance information is provided in “Details of Performance Analysis.”

Healthcare Integrity and Protection Data Bank

Authorizing Legislation - Title II, Subtitle C of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-191), establishes Section 1128E of the Social Security Act.

FY 2008 Authorization.........................................................................................................Indefinite
*Estimates include user fees plus supplemental HCFAC funds from the OIG as necessary.
**If Section 1921 is not implemented, we anticipate funding at the current level to continue, i.e., user fees, HCFAC funds.

Statement of Budget Request - There is no FY 2008 Budget for this program.

Program Description - To prevent or reduce fraud and abuse in the medical system and to enhance quality health care, Title II, Subtitle C of the HIPAA of 1996 establishes Section 1128E of the Social Security Act. This Section directs the HHS, acting through the Office of Inspector General (OIG), to establish a program to collect, maintain and report on final adverse actions taken against health care providers, suppliers and practitioners. This information is collected from and made available to Government agencies and health plans. This data collection program has been named the Healthcare Integrity and Protection Data Bank (HIPDB).

Through an agreement with the OIG, HRSA is responsible for the development and operation of the HIPDB. Final policy decision making remains with the OIG. The HRSA received allocations from the Health Care Fraud and Abuse Control (HCFAC) account for the development of the HIPDB system, which is modeled after the National Practitioner Data Bank (NPDB). All operating costs are paid by user fees and allocations by the OIG from the HCFAC account. There is no appropriation for the HIPDB.

The HIPDB provides critical information to State and Federal agencies, law enforcement officials, and health plans concerning adverse actions, health care related civil judgments and criminal convictions of health care practitioners, providers and suppliers. This information helps prevent practitioners, providers, and suppliers with problem backgrounds from moving from State to State unnoticed by licensing and health plan officials, thus improving health care quality. It also helps law enforcement officials in the battle against health care fraud and abuse.

The HIPDB opened for reporting on November 22, 1999. As of September 30, 2006, the HIPDB contained 255,879 reports of health care related civil judgments, criminal convictions, injunctions, licensing and certification actions, exclusions from State and Federal health care programs, and other adjudicated actions involving 147,499 individuals and 5,939 organizations. State licensure actions constituted 73.7 percent of all HIPDB reports and another 18.0 percent concerned exclusion actions. Judgment or conviction reports accounted for 4.0 percent of all HIPDB reports. Other actions accounted for the remaining 4.3 percent. Individuals were named in 248,196 of these reports and organizations were the subject of 7,683 reports. Of the individuals reported to the HIPDB, 53.0 percent were nurses and aides and 18.7 percent were physicians. Of the organizations reported to the HIPDB, durable medical equipment suppliers were responsible for 50.7 percent of reports, nursing facilities were responsible for 16.9 percent, and pharmacies were responsible for 11.2 percent.

The HIPDB opened for routine queries on March 6, 2000. By September 30, 2006, the HIPDB had responded to 6,194,850 queries from State and Federal agencies (including law enforcement) and health plans. Health plans were responsible for 78.4 percent of the queries. The HIPDB provides approximately 1,000 free queries for Center for Medicare and Medicaid Services (CMS) and other Federal agencies per week.

The HIPDB has processed almost 6.2 million queries since 2000 and maintains almost 256,000 reports. The HIPDB continues to help combat fraud and abuse in health insurance and health care delivery by alerting users that a comprehensive review of a practitioner's, provider's, or supplier's past actions may be prudent. The HIPDB continues to inform users, practitioners, providers, and suppliers about the value of its program and mandatory reporting requirements.

Rationale for the Budget Request - There is no FY 2008 Budget for the HIPDB. With the implementation of Section 1921 in FY 2007 there will be little unique information available from the HIPDB. The FY 2008 legislative proposal would sunset HIPDB and move the unique HIPDB reports not covered by Section 1921 into the NPDB by amending Section 1921. This will effectively move HIPDB revenue and associated costs into the NPDB. It is anticipated that this additional NPDB revenue will fund all additional government and contractor costs associated with the legislative proposal. HIPDB user fees are established to conform exactly to NPDB user fees on a cost per query basis; a HIPDB query costs the same as an NPDB query. As noted in the NPDB section, NPDB query fees are established at a level to cover all program costs to allow the NPDB to meet annual and long term program performance goals. The NPDB and HIPDB programs are jointly operated and costs are allocated to both programs. Costs include all costs by the data banks operating contractor and all government costs, including charged overhead and other expenses to operate the program. This includes the cost of operating the computer and communications systems necessary to receive reports and respond to queries in the established goal time periods and to continually improve the system so that the program will be able to meet annual and long term goals as query and report volumes grow. It also includes other required program costs such as government oversight and the “Secretarial Review” disputed reports resolution process. Although NPDB fees are established based on query volume to result in adequate but not excessive revenues to pay all program costs to meet program performance goals, HIPDB fees at the same level may not provide enough revenue to pay all allocated HIPDB costs because of a much higher HIPDB reports to query ratio and other factors. The Department, therefore augments HIPDB query fee revenue, as needed, with OIG Health Care Fraud and Abuse Control (HCFAC) funds. The relationship between the total of user fee revenue collected as augmented by HCFAC funds and the program’s ability to meet performance goals is a direct one since if revenues were inadequate to operate the system so that new reports and queries can be processed promptly, queriers would not receive responses in time for them to affect licensing and credentialing decisions or be considered useful to the querying entity. The relationship between user fee revenue and program goals is also direct because there is no incentive to obtain more user fee revenue and HCFAC funds than is required; the money can only be spent for HIPDB needs. Since the HIPDB fee per query falls or rises with the NPDB fee, adjustments in the amount of HIPDB funding are made through modifying the HIPDB’s allocation from the HCFAC funds. Some years no funds from HCFAC have been requested. Other years various relatively small amounts of HCFAC funds have been obtained when the growth in the volume of HIPDB queries and increased program efficiencies was not enough to offset increased costs required to meet program performance goals.

Operational costs of the HIPDB include:

   1.  Contract HIPDB Operations

• Responding to requests for information and assistance
• Receiving and encoding information into the data bank
• Providing information to individuals who query the data bank about themselves
• Systems enhancements to make the data bank more accessible to users
• Maintaining interactive access through the Internet for transmitting reports and requests for information to the data bank
• Support for fee collection

  2.   Non-contract HIPDB Operations

• Oversight of data bank operations and systems security
• Federal contract management
• Periodic contract recompetition
• Development and interpretation of data bank program policy
• Printing of program informational and marketing materials
• Management of a system to resolve disputes about the accuracy of data bank information
• Development of specifications for data bank system enhancements
• Management of a research capability based on data bank information
• Management of a continuous quality improvement program
• Fee collection

User fee collections for the HIPDB program during the last five years reflect this effort and are as follows:

*Estimate includes user fees plus supplemental funds from the OIG as necessary

Outputs

The above data is based on the assumption of the implementation of Section 1921.

Performance Analysis - The National Practitioner Data Bank (NPDB) is a national data repository on significant adverse professional actions against physicians and dentists, as well as malpractice settlements and judgments against all licensed healthcare professionals. The Healthcare Integrity and Protection Data Bank (HIPDB) operates in conjunction with the NPDB, augmenting it with information on health care related criminal convictions and certain other data. A combined Program Assessment Rating Tool (PART) review of the NPDB and HIPDB was conducted in 2006 for the FY 2008 budget cycle. The programs, jointly, received a rating of Moderately Effective (tentative).

The number of queries to these databases provides an indication of the degree to which they are used to inform decisions regarding credentialing, licensing, and extension of clinical privileges to health care providers. Since 1998, the annual volume of queries to the data banks has grown almost 46 percent, from 3.1 million in FY 1998, to over 4.5 million in FY 2006, with corresponding increases in the number of decisions affected by NPDB or HIPDB data. At the same time, the data banks have been able to increase efficiency tremendously, reducing the amount of time required to process a query to less than 240 minutes (down from several days in 1990), and reducing user fees at the same time. A customer satisfaction survey completed in FY 2001 by the University of Illinois at Chicago and Northwestern University found that 88 percent of those interviewed rated the NPDB as useful or very useful. Performance information is provided in “Details of Performance Analysis.”