PHYSICIAN ASSISTANTS AND MALPRACTICE RISK: FINDINGS FROM THE NATIONAL PRACTITIONER DATA BANK

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1 PHYSICIAN ASSISTANTS AND MALPRACTICE RISK: FINDINGS FROM THE NATIONAL PRACTITIONER DATA BANK James F Cawley, MPH, PA-C. Professor of Health Care Sciences, School of Medicine and Health Sciences; Professor of Prevention and Community Health, Professor of Epidemiology, School of Public Health and Health Services; The George Washington University. Washington, DC. Richard C Rohrs, PA-C. Administrative Director, Housestaff Services, Northwest Hospital. Randallstown, Maryland. Roderick S Hooker, PhD, PA, MBA. Department of Rheumatology, Kaiser Permanente Northwest; Associate Professor, Physician Assistant Program, School of Physician Assistant Studies, Pacific University. Portland, Oregon. Introduction: As the utilization of physician assistants (PAs) has expanded over the past three decades, a good deal of information has been obtained regarding the performance and efficacy of these providers in clinical practice. Working with physicians, PAs have been shown to be well accepted by patients and other health providers, to be cost-effective, and to deliver medical services at a level of quality indistinguishable from physician care. 1,2 Yet despite the extensive body of research comprised on the practice performance of PAs and similar health providers, relatively little is understood about the impact employing a PA has on medical malpractice risk. In this report, we examine the malpractice record of physician assistants as determined by statistics re p o rted to the National Practitioner Data Bank (NPDB). BACKGROUND Statutes authorizing state medical and health occupations boards to regulate medical practitioners constitute the legal basis of PA practice. PAs are recognized as health care practitioners authorized to perform physician-delegated medical diagnostic and therapeutic tasks by health professions licensing boards in 49 states and the District of Columbia; Mississippi is the only state which does not formally recognize PA practice. In 1999, PAs are authorized by statute or regulation to prescribe in 46 states, Guam, the District of Columbia, and recognized as health providers by federal agencies and systems including the military, the US Public Health Service, and the Veterans Administration. Typical state regulatory acts establish PAs as agents of their supervising physicians, and PAs maintain direct liability for the services they render to patients. Supervising physicians define the broad parameters of PA practice activities and the standard to which PA services are held, and are vicariously liable for services performed by their PAs. Qualification for entry to practice as a PA in nearly all states requires that individuals be either graduates of a PA educational program accredited by the Accreditation Review Committee, Physician Assistant (ARC-PA) of the Commission on Accreditation of Allied Health Educational Programs (CAAHEP), and/or pass the Physician Assistant National Certifying Examination (PANCE) administered by the National Commission on Certification of Physician Assistants. At present, more than 34,000 PAs are in active clinical practice in the United States. The legal basis of PA practice is founded on the doctrine of respondeat superior, which affirms and defines the authority of a licensed physician to delegate medical tasks to a qualified PA. A key stipulation is the physician must appropriately supervise the practice activities of the PA and assume liability. Health occupations statutes and regulations emanating from this tenet set forth the range of clinical activities (scope of practice), prescribing activities, and terms of physician supervision of PA s. 2, 3 Working with supervising physicians, PAs perf o rm a wide range of delegated medical diagnostic and patient management tasks required in primary care and specialty practice settings, including prescribing medications. While their clinical practice duties overlap considerably with those of physicians, PAs are required always to work in a dependent practice mode. Page 242 Federation Bulletin vol 85 Number

2 METHODS The NPDB is a computerized re p o s i t o ry of malpractice-related payments made by insurers for a variety of clinicians licensed by states. It also documents adverse disciplinary actions involving clinicians by l i c e n s i n g b o a rds, hospitals, the Drug Enforcement Agency (DEA), and professional societies. Created in 1986 by the Health Care Quality Improvement Act, the NPDB became operational in The intent of the NPDB is to identify or alert health plans, re g u l a t o ry agencies, law enforcement officials, and e m p l o y e r s regarding medical incompetence or adverse incidents involving physicians, dentists, and other health practitioners including nurses, nurse practitioners, physician assistants, pharmacists, podiatrists, and chiropractors. Occasionally, physicians and dentists are excluded from Medicare or Medicaid payments for various reasons. Medicare/Medicaid exclusion reports were added to the NPDB under an agreement with the Health Care Financing Administration and the Office of Inspector General. Medicare/Medicaid exclusions are now disclosed to queries along with malpractice and adverse actions reports. Federal and state health care criminal convictions are the latest addition to the NPDB service. 4 The NPDB is a computerized repository of malpractice-related payments made by insurers for a variety of clinicians licensed by states. Medical malpractice payment reports represent the greatest proportion of all reports contained in the NPDB 77.4% at the end of Malpractice payments are required to be reported to the NPDB regardless of the settlement amount. The NPDB requires hospitals initially granting clinical privileges to health care professionals and periodically thereafter to query its data bank. During 1997, the NPDB received 18,929 such reports. 4 Cumulative data on malpractice payments and adverse action reports are available in annual reports from the NPDB. RESULTS From September 1990 through December 31, 1997, the NPDB produced information on more than 176,000 reportable actions, malpractice payments, and Medicare/Medicaid exclusions involving 118,142 individual practitioners. Of these, 73% are physicians (including MD/DO residents and interns), 15% are dentists, and 12% comprise other health care practitioners. The majority of physicians (69.6%) have only one re p o rt in the NPDB and 99.7% have fewer than 10 re p o rts. The cumulative number of malpractice payments for the first 88 months of operation (September 1990 through December 1997) reported to the NPDB averaged $139,256, with a median payment of $40,000. This represents 6,643 payments. For PAs, the mean payment was $55,241 and the median $12,500 for a total of only 24 payments during this period (Exhibit 1). During 1997, approximately 59% of re p o rt e d actions concerned malpractice payments, although cumulatively malpractice payments comprised more than 77%. Physicians were responsible for 80% of the 15,112 malpractice payments in 1997, dentists were responsible for 13%, and all other health care practitioners were responsible for the remaining 7%. PAs were responsible for a total of only four payments representing 0.03% of the total for These figures are similar to percentages observed in previous years. Because PAs re p resent a negligible amount of overall malpractice claims re p o rted in the NPDB data, we looked more closely at the cumulative number of medical malpractice payments by specific reason for payment. The most frequently cited reason for all malpractice payments was diagnosis related, followed by surg e ry and treatment related reasons (Exhibit 2). Physicians totaled 104,353 medical malpractice payments spanning from September 1990 through December PAs had a total of 252 payments during the same re p o rting time period. The leading category of reason for medical malpractice payment for both physicians (34,021 of 104,353) and for PAs (129 of 252) was diagnosis erro r. From 1990 through 1997, PAs were responsible for a total of only four payments representing 0.03% of the total for Federation Bulletin vol 85 Number Page 243

3 a mean number of 611,459 physicians were in active practice, of which 74,663 were responsible for malpractice claims. During that same period, a mean of 25,000 PAs were practicing, of which 234 were responsible for re p o rted claims. 4 The NPDB data suggest the rate and amount of malpractice payments for PAs is relatively low. Medication-related malpractice payments represented 6.35% (6,622 reports) of physician reports and 9.5% (24 re p o rts) of physician assistant malpractice re p o rts. Exhibit 3 shows the number of medicationrelated medical malpractice payments by reason for payment. For physicians, 6,622 physician medical malpractice payments were made for the cumulative period 1991 to For PAs, the comparable figure was 24 medication-related payments. The leading subcategory of medication-related medical malpractice payments was for both physicians (2,094 of 6,622) and PAs (five of 24) were errors in medication administration; a sizable proportion (1,797 of 6,622) of payment for physicians and PAs (four of 24) fell under the category of improper management of medication regimen. The ratio of medi c a t i o n - related claims per practitioner type for the years 1995 through 1997 also is shown in Exhibit 3. DISCUSSION The NPDB data suggest the rate and amount of malpractice payments for PAs is relatively low. In fact, the NPDB data reveal one claim per eight practicing physicians vs one claim per 107 PAs. These findings support previously held perceptions that PAs pose a low risk of malpractice liability for employing practices. It has been postulated one reason for this low risk is the improvement in communication with patients that may accompany PA utilization. 5 Corroborating evidence of a low liability profile for PA utilization is seen in the relatively low premium rates for medical malpractice insurance coverage. Similarly low rates of reported malpractice rates have been reported for other types of non-physician health providers. The malpractice payment rate for advance practice nurses (which include nurse practitioners) is 0.6% to 0.7%, 6 (and NPDB payment report rates for this group are 30 times less than physicians. Important limitations should be considered when interpreting these data. Most would argue NPDB data is not totally inclusive of all malpractice events. Both physician and consumer groups have noted flaws in the re p o rting process. If such flaws are present, however, they would be applicable to both physicians and PAs. Most would argue NPDB data is not totally inclusive of all malpractice events. Both physician and consumer groups have noted flaws in the re p o rting pro c e s s. The NPDB provides useful information with regard to patterns of malpractice settlements and practice restrictions, and sheds light on assessments of overall provider safety. In future assessments, rates of litigation inquiry per 10,000 patients seen per practitioner may, for instance, be a more accurate measure of the overall rate of provider malpractice risk. Additionally, information incorporating practice setting, population type (urban vs rural), type of specialty (primary care, medical subspecialties, surgery, s u rg e ry subspecialties, psychiatry, etc), and employer (solo practitioner, HMO, group practice, military ) may be variables to consider. In summary, data from the NPDB indicate PAs have low rates of reported malpractice payments. This finding supports the notion these health care professionals pose a minimal malpractice liability risk in clinical practice. REFERENCES 1. Hooker RS, Cawley JF. Physician Assistants in American Medicine Churchill Livingstone. New York, New York. 2. Jones PE, Cawley JF. Physician assistants and health care reform: clinical capabilities, practice activities, and potential roles. JAMA. 1994;272: Page 244 Federation Bulletin vol 85 Number

4 3. Gilliam JW. A contemporary analysis of medicolegal concerns for physician assistants and nurse practitioners. Legal Medicine. 1994;5: National Practitioner Data Bank, 1997 Annual Report. Bureau of Health Professions, Health Resources and Services Administration, US Public Health Service. US Department of Health and Human Services. 5. Brock R. The malpractice experience: how PAs fare. Journal of the American Academy of Physician Assistants. 1998;11: Birkholz G. Malpractice data from the National Practitioner Data Bank. Nurse Practitioner. 1995;20: EXHIBIT 1 NUMBER, MEAN, AND MEDIAN MEDICAL PRACTICE PAYMENT REPORTS BY PRACTITIONER ( ) PROVIDER PAYMENT AMOUNT Physicians Mean Payment $139,581 Number 8,619 Median Payment $40,000 Total MD/DOs in ,186* Payment Ratio: MD/DO 2.4% Physician Assistants Mean Payment $ 55,241 Number 24 Median Payment $12,500 Total PAs in ,500* Payment Ratio: PA 0.76% *NOTE: Physicians: The number of physicians in 1997 is the number of total physicians less the number of physicians listed as inactive or address unknown as of December 31, From Table D-7 of The American Medical Association s Physician Characteristics and Distribution in the U.S edition. Physician Assistants: The number of PAs in 1997 is the number of total practicing PAs as of October From the AAPA Physician Assistant Census Report. AAPA, Alexandria, Virginia. EXHIBIT 2 MEDICAL MALPRACTICE PAYMENTS BY REASON FOR PAYMENT, AND PRACTITIONER TYPE ( ) MALPRACTICETYPE PA PHYSICIAN Diagnosis ,021 Anesthesia 1 3,455 Surgery 13 28,556 Medication 24 6,622 IV and Blood Products Obstetrics 0 9,279 Treatment 76 18,478 Monitoring 4 1,223 Equipment/Product Miscellaneous 5 1,825 Total ,353 Federation Bulletin vol 85 Number Page 245

5 EXHIBIT 3 MEDICATION-RELATED MEDICAL MALPRACTICE PAYMENTS BY REASON FOR PAYMENT AND PRACTITIONER TYPE ( ) MALPRACTICE TYPE PA PHYSICIAN Failure to order appropriate medication Wrong medication ordered Wrong dosage ordered of correct medication Failure to instruct on medication Improper management of medication regimen 4 1,797 Consent issues 2 99 Error (not otherwise coded) Failure to medicate Wrong medication administered Wrong dosage administered Wrong patient 0 1 Wrong route 0 30 Improper technique Administration (not otherwise coded) 5 2,094 Total 24 6,622 MEDICATION-RELATED CLAIMS PER PRACTITIONER Physicians: 1:836 1:726 1:808 # Claims PAs: 1:7,000 1:4,500 1:3,571 # Claims Page 246 Federation Bulletin vol 85 Number

6 As an added point of interest that augments the article Physician Assistants and Malpractice Risk: Findings From the National Practitioner Data Bank included in this issue, the Federation has compiled information about which medical boards have oversight of physician assistants. Physician Assistants Regulated by the state medical board (39) Alabama Alaska Arkansas California Colorado Delaware District of Columbia Georgia Idaho Illinois Indiana Kansas Kentucky Louisiana Maryland Michigan Minnesota Montana Nebraska Nevada New Hampshire New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania South Carolina South Dakota Tennessee Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Regulated by separate/other boards (7) Arizona Connecticut Hawaii Maine Massachusetts Rhode Island Texas NOTE: No response from Florida, Guam, Iowa, Mississippi, Missouri, New Jersey, Puerto Rico, Virgin Islands Federation Bulletin vol 85 Number Page 247