Healthcare Integrity and Protection Data Bank

There are two physician federal data bank reporting entities in operation, the National Practitioner Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB or "Integrity Data Bank"). Both are intended to be a clearinghouse for disciplinary action:  one to facilitate reporting of matters felt to be significant in credentialing and licensure (NPDB); the other to facilitate the reporting of matters significant to government payers and private health plans in making contracting decisions (Integrity Data Bank).

The NPDB provides for due process in credentialing and state licensure disciplinary proceedings. Hospitals and other health care entities risk losing peer review immunity protections if they fail to provide due process when reporting adverse events. A listing of recommended procedural and substantive rights constituting due process is included in the legislation.

The Integrity Data Bank also had due process provisions included with respect to reportable actions. However, with respect to required reporting of private health plans, the minimal process typically provided in state law prior to contract termination still results in a required report according to interpretations of data bank administrators.

The Integrity Data Bank adopted the following health plan interpretation of required reportable events:

The Texas law regarding terminations from a preferred provider network is contained in Article 3.70-3C, Tx. Ins. Code.  In short, Texas law requires written reasons for the action and a right, upon request, to a review mechanism for the decision.  Dr. _______ has been provided several letters regarding his practice.  By letter date Sept. 6, 1996, he was advised of termination and the reason for the termination. Additionally, he was advised of his right to appeal the determination. Dr. ________ took the opportunity to appeal the decision and appears to have presented documentation to support his position. The advisory committee recommended that Dr. ______ be decrendentialed, and he was so notified by a letter dated Oct. 11.

The minimal requirements for Texas insured preferred provider plans and HMO contracting entities do not assure due process. For example:

1. There is no required hearing in which the accused physician is able to address in person the "peer review committee" reviewing the contracting issues. It is a paper review process only;
2. The names and credentials of the expert physician or physicians reviewing the medical records of the physician in question and providing a written report to the peer review committee are anonymous;
3. The names and credentials of the peer review committee are not available;
4. Since there is no hearing, there is no right to cross examination;
5. There is no way to adequately assess or challenge statistical data provided to the peer review committee to assure that comparisons of cost and "quality" or "evidenced based" data with other "like physicians" is accurate; and
6. There is no way to assure that the five medical records selected for review are representative of the hundreds or thousands or medical records documenting the medical treatment provided by the physician.

Although pending legislation supported by the Texas Medical Association in the Texas Legislature (SB 1170 and HB 2016) would require due process in contracts between insured health plans and contracting physicians, this legislation is being resisted by the health plans operating in Texas. If enacted into law, it still may not cover employer-funded health plans.

The Council on Socioeconomics urges the House of Delegates to adopt the following recommendations.

Recommendation 1: That the Texas Medical Association strive to assure that the Healthcare Integrity and Protection Data Bank enabling legislation and regulations and interpretive guidelines be amended to assure that due process is provided before any reporting to its data bank.

Recommendation 2 : That the Texas Medical Association Delegation to the American Medical Association House of Delegates introduce a resolution that would call on the AMA to work aggressively to amend federal laws, rules, and interpretive guidelines such that due process would be required prior to any reports by private health care entities to the Healthcare Integrity and Protection Data Bank.

TMA House of Delegates: TexMed 2007