Category Archives: Doctors and Nurses

Health system not doing enough to protect patients, experts

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Physician and Nurse Pushing Gurneyby Marshall Allen
ProPublica

WASHINGTON, D.C. — The health care community is not doing enough to track and prevent widespread harm to patients, and preventable deaths and injuries in hospitals and other settings will continue unless Congress takes action, medical experts said today on Capitol Hill.

“Our collective action in patient safety pales in comparison to the magnitude of the problem,” said Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine. “We need to say that harm is preventable and not tolerable.” Continue reading

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Nurses delaying retirement – study

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Woman_doctor_surgeonBy Shefali Luthra
KHN / JULY 16TH, 2014

Despite predictions of an impending nurse shortage, the current number of working registered nurses has surpassed expectations in part due to the number of baby-boomer RNs delaying retirement, a study by the RAND Corp. found.

The study, published online Wednesday by Health Affairs, notes that the RN workforce, rather than peaking in 2012 at 2.2 million – as the researchers predicted a decade ago – reached 2.7 million that year and has continued growing.

The trend of nurses delaying retirement accounted for an extra 136,000 RNs in 2012, the study suggests. Continue reading

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State disciplines health care providers – July 15 update

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Seal_of_WashingtonPeriodically Washington State Department of Health issues an update on disciplinary actions taken against health care providers, including suspensions and revocations of licenses, certifications, or registrations of providers in the state.

The department also suspends the credentials of people who have been prohibited from practicing in other states.

Information about health care providers is also on the agency’s website.

To find this information click on “Provider Credential Search” on the left hand side of the Department of Health home page (www.doh.wa.gov).

The site includes information about a health care provider’s license status, the expiration and renewal date of their credential, disciplinary actions and copies of legal documents issued after July 1998.

This information is also available by calling 360-236-4700.

Consumers who think a health care provider acted unprofessionally are also encouraged to call and report their complaint.

Here is the July 16th update issued by the Washington State Department of Health: Continue reading

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New respect for primary care docs?

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Blue doctorBy Jay Hancock
KHN Staff Writer
This KHN story also ran in wapo.

BALTIMORE — A few years ago it struck the D.C. region’s biggest medical insurer that the doctors who saw its members most often and knew them best got the smallest piece of the healthcare dollar.

By paying primary care doctors to cut specialist and hospital revenue, CareFirst is helping to alter the medical spoils system.

CareFirst BlueCross BlueShield spent billions on hospital procedures, drugs and specialty physicians to treat sick patients.

Only one dollar in 20 went to the family-care doctors and other primary caregivers trained to keep people healthy.

The company’s move to shift that balance tells a lesser-known story of the Affordable Care Act and efforts to change the health system. Continue reading

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After court’s home health aide ruling, fewer state workers to organize

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U.S. Supreme CourtBy Jake Grovum
Stateline

The U.S. Supreme Court’s recent ruling in a case brought by home health care aides in Illinois casts doubt on labor agreements between such workers and state governments in nine other states.

It also closes off—or at least complicates—one of labor’s clearest paths to reversing a decades-long trend of declining ranks and shrinking clout.

The petitioners in Harris v. Quinn were home health care aides who did not want to join a union, though a majority of their co-workers had voted to join. Continue reading

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School nurses’ role expands with access to students’ online health records

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Although the school nurse is a familiar figure, school-based health care is unfamiliar territory to many medical professionals, operating in a largely separate health care universe from other community-based medical services.

Now, as both schools and health care systems seek to ensure that children coping with chronic conditions such as diabetes and asthma get the comprehensive, coordinated care the students need, the schools and health systems are forming partnerships to better integrate their services. Continue reading

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When doctors need advice, it might not come from a human

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This story was produced in collaboration with 

Long Island dermatologist Kavita Mariwalla knows well how to treat acne, burns and rashes. But when a patient came in with a potentially disfiguring case of bullous pemphigoid—a rare skin condition that causes large, watery blisters—she was stumped.

The medication doctors usually prescribe for the autoimmune disorder wasn’t available. So she logged in to Modernizing Medicine, a Web-based repository of medical information and insights, for help.

Within seconds, she had the name of another drug that had worked in comparable cases.

“It gives you access to data, and data is king,” she said of Modernizing Medicine. “It’s been very helpful especially in clinically challenging situations.” Continue reading

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Want to see a doctor? Get in line.

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Stethoscope DoctorBy Jenny Gold
KHN

Need to see a doctor? You may have to wait.

survey of physician practices in 15 metropolitan areas across the country found that the average wait time for a new patient to see a physician in five medical specialties was 18.5 days.

The longest waits were in Boston, where patients wait an average of 72 days to see a dermatologist and 66 days to see a family doctor.

The shortest were in Dallas, where the average wait time is 10.2 days for all specialties, and just 5 days to see a family doctor.

Seattle: 16.5 days for a specialist; 23 days for a family practice doctor.

Continue reading

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ER docs give Washington a D+

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The American College of Emergency Physicians has given Washington state a “near failing D+” in the its annual state-by-state report card assessing the nation’s emergency services.

Overall the state ranked 35th in the nation, down from its ranking of 19 in the College’s 2009 report, which that year gave Washington a C.

Screen Shot 2014-01-16 at 15.21.58 Continue reading

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Big data + big pharma = big money

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Data GlobeBy Charles Ornstein
ProPublica – January 10, 2014

Need another reminder of how much drugmakers spend to discover what doctors are prescribing?

Look no further than new documents from the leading keeper of such data.

IMS Health Holdings Inc. says it pulled in nearly $2 billion in the first nine months of 2013, much of it from sweeping up data from pharmacies and selling it to pharmaceutical and biotech companies. The firm’s revenues in 2012 reached $2.4 billion, about 60 percent of it from selling such information.

The numbers became public because IMS, currently in private hands, recently filed to make a public stock offering. The company’s prospectus gives fresh insight into the huge dollars – and huge volumes of data – flowing through a little-watched industry. Continue reading

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Are there enough doctors for the newly insured?

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doctors-300By Michael Ollove
Stateline Staff Writer

Signing up for health insurance on the new state and federal exchanges was supposed to be the easy part of the Affordable Care Act. The really dicey part, lots of health policy experts have always feared, will come on Jan.1.

That is when Americans who have enrolled in health insurance for the first time under the ACA are likely to discover that having coverage doesn’t guarantee them easy access to a primary care doctor, dentist or mental health professional.

Some changes in the works, such as the use of new technologies and allowing mid-level medical providers to perform some functions usually reserved for doctors and dentists, should improve health care access in the long run.

“In the meantime,” said Linda Rosenberg, president of the National Council for Behavioral Health, “people are going to suffer.”

According to the Health Resources and Services Administration , the federal agency charged with improving access to health care, nearly 20 percent of Americans live in areas with an insufficient number of primary care doctors.

Sixteen percent live in areas with too few dentists and a whopping 30 percent are in areas that are short of mental health providers.

Under federal guidelines, there should be no more than 3,500 people for each primary care provider; no more than 5,000 people for each dental provider; and no more than 30,000 people for each mental health provider.

According to the Association of American Medical Colleges (AAMC), unless something changes rapidly, there will be a shortage of 45,000 primary care doctors in the United States (as well as a shortfall of 46,000 specialists) by 2020.

In some ways, the shortage of providers is worse than the numbers indicate. Many primary care doctors and dentists do not accept Medicaid patients because of low reimbursement rates, and many of the newly insured will be covered through Medicaid. Many psychiatrists refuse to accept insurance at all.

Christiane Mitchell, director of federal affairs for the AAMC, predicted that many of the estimated 36 million Americans expected to gain coverage under Obamacare will endure long waits to see medical providers in their communities or have to travel far from home for appointments elsewhere.

During the debate over the ACA, Mitchell said the AAMC pushed for the federal government to fund additional slots for the training of doctors, but that provision was trimmed to keep the ACA from costing more than a trillion dollars over 10 years.

Aging Boomers

There are various reasons for the shortages. Certainly a big contributor is the aging of the baby boomers, who may still love rock ‘n roll but increasingly need hearing aids to enjoy it. The growing medical needs of that large age group are creating a huge burden for the existing health care workforce. The retirement of many doctors in the boomer cohort is compounding the problem.

During the course of their careers, primary care physicians earn around $3 million less than their colleagues in specialty fields.

The federal government estimates the physician supply will increase by 7 percent in the next 10 years. But the number of Americans over 65 will grow by about 36 percent, according to the U.S. Census Bureau.

Money also is a factor in the shortages. During the course of their careers, primary care physicians earn around $3 million less than their colleagues in specialty fields, which makes primary care a less appealing path for many medical students.

In mental health, the problem is that much of the work is in the public sector, where the pay is far less than it is for providers in other medical specialties, who tend to work in the private sector. As an example, according to the National Council for Behavioral Health, a registered nurse working in mental health earns $42,987 as compared to the national average for nurses of $66,530.

Valuing Work-Life Balance

“Half of the physicians in training are women. You find more of them are looking for a career that might be compatible with part-time hours, that don’t involve being on call.”

But financial factors are not the leading reason that medical students are avoiding primary care, Mitchell said. In surveys of medical students conducted by AAMC, students valued “work-life balance” more than money when they were choosing their specialties. Because primary care often involves long hours and night and weekend calls, it is far less desirable to this generation of students.

“Half of the physicians in training are women,” Mitchell said. “You find more of them are looking for a career that might be compatible with part-time hours, that don’t involve being on call. Men are more engaged in child care today, and they have similar concerns as they consider their career choices.”

A steady stream of negative attention has made medicine in general a far less attractive career choice than it once was, according to Rosenberg of the National Council for Behavioral Health. Insurance headaches, pricey technologies, long hours and the risk of liability have convinced many talented students to eschew medicine as a career choice.

“Nowadays,” Rosenberg said, “the best and the brightest are talking about becoming investment bankers or going off to Silicon Valley.”

Dwindling Dentists

To some extent, dentistry created its own problem. Richard Valachovic, president of the American Dental Health Association, said today’s shortage of dentists can be traced to the closing of seven dental schools in the 1980s and 1990s. In 1980, he said, the United States produced 6,300 dentists. Ten years later, the number was down to 4,000.

Why did the schools close? “There was a perception that we had conquered dental disease,” Valachovic said. “Kids weren’t getting cavities anymore so we thought we wouldn’t need as many dentists.” Dental health did improve, he said, but not for the poor and those without insurance.

Twelve new dental schools — smaller than their predecessors — have opened since 1997, Valachovic said, so the U.S. is back to graduating 5,700 dentists a year. But the ACA has made pediatric dental care coverage a requirement for all insurance, which will extend benefits to as many as 8.7 million children by the year 2018. Demand will far exceed capacity to produce dentists for years to come.

Some Cause for Optimism

Despite the shortages, many believe that new technologies will extend the reach of medicine in ways that will ameliorate the problem.

For example, health care professionals can serve more people by using Skype or other telemedicine technologies to examine, treat and monitor patients.

Similarly, patients can be fitted with electronic devices that remind them to take their medications and provide other guidance about their conditions. These and other technologies are already keeping patients out of hospitals and doctors’ offices.

Changes in the way medicine is delivered, such as the use of “medical homes” and “accountable care organizations” to better coordinate patient care, are also expected to improve efficiency and keep patients out of the hospital.

These organizational changes will make primary care physicians more important than ever, which might make primary care a more appealing — and lucrative — career choice.

A more controversial idea is to allow nurse practitioners, physician assistants, pharmacists and dental aides to do some of the work usually reserved for doctors and dentists. Many states have passed such legislation while others are eyeing similar measures. The Pew Charitable Trusts, which funds Statelinehas supported such efforts.

The American Dental Association, however, opposes allowing mid-level dental workers to perform some of the functions of dentists, such as routine preventive and restorative work.

The organization, which represents 157,000 dentists, questions federal data on a dentist shortage, suggesting the problem is more of an uneven distribution of dentists.

Some groups representing doctors are resisting similar efforts to allow nurse practitioners to, for example, write prescriptions and admit patients to the hospital. But many believe the trend is unstoppable.

“Health care is not a zero-sum game where there’s a limited amount of care to be given,” said Polly Bednash, the head of the American Association of Colleges of Nursing. “If there’s more care needed than we can deliver in the world, we have to decide who else can provide quality care.”

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A Health Professional Shortage Area (HPSA) is a geographic area or population group with too few health care providers to serve people’s medical needs.  Under federal guidelines, there should be no more than 3,500 people for every one primary care provider; no more than 5,000 people for every one dental provider; and no more than 30,000 people for every one mental health care provider. The graphs below show the percentage of the population in each state that lives in an HPSA.

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Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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Group Health and Bartell Drugs to open retail clinics

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Group Health IconGroup Health Cooperative and Bartell Drugs will open three retail clinics early next year in Ballard and University Village in Seattle and at Crossroads, Bellevue.

The “CareClinics” will be staffed by nurse practitioners from Group Health and provide walk-in service to the general public for common minor illnesses and procedures, such as cold and flu, sinus infections, allergies, minor injuries (burns, rashes, and cuts), pinkeye, sore throat, headaches, sprains and strains, bronchitis, ear infections, urinary tract infections, and diarrhea.

Care will be provided for adults and children over two years of age. Patients will not have to be Group Health members to receive care

The clinics are slated to open between mid-January and early March.

The initial locations will be:

  • Ballard – 1500 NW Market St, Suite 101, Seattle, WA  98107-5211
  • Crossroads – 653 156th Ave NE, Bellevue, WA 98007
  • University Village – 2700 NE University Village St., Seattle, WA 98105

 

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Why doctors stay mum about mistakes their colleagues make

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propublica thumbnailby Marshall Allen
ProPublica

Patients don’t always know when their doctor has made a medical error. But other doctors do.

A few years ago I called a Las Vegas surgeon because I had hospital data showing which of his peers had high rates of surgical injuries – things like removing a healthy kidney, accidentally puncturing a young girl’s aorta during an appendectomy and mistakenly removing part of a woman’s pancreas.

I wanted to see if he could help me investigate what happened. But the surgeon surprised me.

Before I could get a question out, he started rattling off the names of surgeons he considered the worst in town. He and his partners often had to correct their mistakes — “cleanup” surgeries, he said. He didn’t need a database to tell him which surgeons made the most mistakes.

By some estimates, medical errors are one of the leading causes of death in the United States. Physicians often see the mistakes made by their peers, which puts them in a sticky ethical situation: Should they tell the patient about a mistake made by a different doctor? Too often they do not.

A new report in The New England Journal of Medicine, “Talking With Patients About Other Clinicians’ Errors,” suggests it’s a common problem.

The report’s lead author, Dr. Thomas Gallagher, an internist and professor at the University of Washington School of Medicine, said he conducted a survey of doctors in which more than half said that, in the prior year, they identified at least one error by a colleague. (The survey, unrelated to the NEMJ report, did not ask what the doctors did about it, Gallagher said.)

There’s wide agreement in the medical community that doctors have an ethical duty to disclose their own errors to patients, Gallagher said. But there’s been less discussion about what physicians should do when they discover that someone else’s mistake.

For the NEJM report, Gallagher led a team of 15 experts who discussed the problem. They identified many reasons why doctors may want to stay silent about errors by their peers.

One is that doctors depend on each other for business. So a physician who breaks the code of silence may become known as a tattler and lose referrals, a financial penalty.

Or maybe they aren’t sure exactly what happened to the patient and don’t want to take the time to try and unravel it. In some cases, issues related to cultural differences, gender, race and seniority come into play.

The report notes that doctors also may be wary of becoming entangled in a medical malpractice case, or of causing a colleague to face legal consequences.

Dr. Brant Mittler, a cardiologist who now works as a medical malpractice attorney in Texas, told me that he frequently saw errors made by other physicians during almost four decades in medicine.

Mittler remembers a scan read by a radiologist that said a patient had an “ejection fraction” — the amount of blood pumped by the heart with each beat — of zero. But that would only be possible if the patient was dead, he said. He noted the error to the radiologist, who thanked him.

Many times Mittler stayed quiet, he said. He saw many errors reading electrocardiograms at a 500-bed hospital in San Antonio. He said he didn’t know the details of each case, so he couldn’t tell if the errors affected the outcome for the patient.

But he did not go to the other doctors to point out the errors — there would have been hostility if he had, he said.

“There’s not a culture where people care about feedback,” Mittler said. “You figure that if you make them mad they’ll come after you in peer review and quality assurance. They’ll figure out a way to get back at you.”

Gallagher said physicians experience the normal range of human emotions when they find a colleague’s error. They wonder if they can keep it to themselves or whether they’re compelled to tell someone. Or they consider what they would want to happen if they had made the error.

That results in too much leniency toward mistakes, he said.

The bottom line: Too often doctors aren’t learning from errors, Gallagher said. Nor are patients getting the information they need to receive proper treatment or compensation when the outcome is harmful, he said.

Even after patients do learn about an error, the lack of communication by doctors often continues.

Almost 400 people who have completed the ProPublica Patient Harm Questionnaire, and more than 1,800 are members of ProPublica’s Patient Harm Facebook Community. Many reported that they experienced the silent treatment from doctors after experiencing harm during medical care.

The NEJM report stresses that patients come first and recommends that doctors should explore, not ignore, a colleague’s error. They should start by collecting the facts, starting with a one-on-one conversation with the physician who made the error so they can decide how to inform the patient.

Hospitals and other health-care institutions must lead by supporting such conversations, the NEJM group reported.

Dr. David Mayer is vice president of quality and safety at Medstar Health, which runs 10 hospitals in Maryland and Washington, D.C. Mayer said reporting of medical errors is a top priority at the organization so everyone can learn from mistakes.

When doctors identify an error, made by themselves or a colleague, they’re required to tell their supervisor, whether the error resulted in harm to the patient or not, he said.

Each month there are about 1,400 reported safety events, Mayer said. Most are “near misses,” though some involve actual harm to a patient (Medstar declined to disclose how many).

The safety events are analyzed for trends that need to be corrected or that need immediate attention to protect patients, Mayer said. Cases in which a patient was harmed are investigated so that the cause can be disclosed to the patient and family, an apology can be made, and compensation can be offered, he said.

Mayer and Larry Smith, Medstar’s vice president of risk management, said their organization is unusual for its proactive approach to reporting medical errors. Smith said most institutions seem to only report them when it’s obvious the harm will be discovered by some other means.

“Far fewer are doing this kind of work when the information would never surface,” Smith said.

Dr. Humayun Chaudhry, president and CEO of the Federation of State Medical Boards, which provides guidance for how state boards regulate doctors, said that physicians and health-care organizations need to be more assertive about reporting errors.

Failing to divulge another doctor’s mistake undermines the doctor-patient relationship, Chaudhry said. “It makes patients wonder if they can trust their own physicians,” he said, “and the profession of medicine.”

DISCUSS: Join us for a discussion on why doctors stay silent on Monday, November 11th at 4 PM ET, on Google+. Reporter Marshall Allen will lead the discussion. Dr. Thomas Gallagher, the study’s lead author, and Brant Mittler, a cardiologist and medical malpractice attorney.

Have you worked in the health-care industry? Please help ProPublica’s reporting on patient safety by completing the ProPublica Provider Questionnaire.

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Medical schools see record numbers of enrollees

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The_Anatomy_LessonBy Ankita Rao

In the face of projected doctor shortages and debate about the future of medicine, a record number of students applied to, and started, medical school this year.

About 20,000 students enrolled in medical school in 2013, around 2.8 percent more than the year before, according to the data distributed by the Association of American Medical Colleges on Thursday. First-time applications were also up by almost 6 percent.

“We haven’t seen a level like this since 1996,” said Darrell G. Kirch, president and CEO of the organization.

He said four new medical schools, and some expanded class sizes, were responsible for the growth. Kirch also said the number of first-time applicants spoke to the sustained interest in the medical field.

Meanwhile, osteopathic medical schools saw a continued surge in their new student pool, with an 11.1 percent growth in enrollment, according to the Association of American Colleges of Osteopathic Medicine. These students, who graduate with a Doctor of Osteopathy, or D.O. degree, practice in the same capacity as M.D.s.

“We’re enjoying the highest increase in applications of any other health profession in the U.S.,” said Bryan Moody, director of enrollment management at Marian University College of Osteopathic Medicine, one of the four new D.O. schools that opened in the past year.

Moody said the school has looked to recruit diverse applicants with strong academic records, and is hoping to help address a growing shortage of doctors in the surrounding Indiana area, as well as other communities.

And while both Moody and Kirch said they were encouraged by the number of enrollees this year, they acknowledged that there are still questions ahead for the medical profession: Congress has yet to reach a decision on proposals to increase the Medicare budget to support additional residency slots.
Without such a fix, medical students could graduate from their programs without a way to continue their training.

Moody said schools are turning to their senators and representatives to advocate for this change, while hospitals look at additional ways to fund the programs.

The biggest lobbying force may be the students themselves.

“The students are clear-headed about this, they’re some of the strongest advocates,” Kirch said.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

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Consumer group knocks Oregon’s malpractice mediation law

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A judge's wooden gavelBy Michael Ollove
Stateline Staff Writer

A new Oregon law establishing a medical malpractice mediation process will undermine patient safety by withholding the names of negligent doctors from a national database, the watchdog organization Public Citizen has complained to the U.S. Department of Health and Human Services (HHS).

“It is imperative that HHS act swiftly to close the loophole created by (the) new Oregon law, which threatens the viability of our national system for performing background checks on physicians,” said Michael Carome, director of Public Citizen’s Health Research Group.

Signed this year by Democratic Gov. John Kitzhaber, the law sets up a process of confidential mediation to resolve medical malpractice claims outside the courts. The legislation, supported by both health provider groups and trial lawyers, is intended to avoid costly litigation.

But the law also bars the reporting of malpractice pay-outs that arise out of that mediation to HHS’s National Practitioner Data Bank. Congress created the data bank in 1986 as a central repository of information about malpractice and medical disciplinary actions that is available to hospitals, medical boards, health maintenance organizations and others who employ doctors.

The data bank was established after doctors with numerous malpractice claims or disciplinary actions against them were found to be able to hide that background when they moved from one state to another.

The provision in the law to keep mediations confidential and any settlements out of the national database helped win its support from health providers.

Tim Raphael, Kitzhaber’s spokesman, defended the law Tuesday. “Oregon’s bi-partisan medical liability reform is designed to improve patient safety and quality of care and more effectively compensate people who have been injured,” he said. The (national data bank) will remain an important tool in identifying practitioners who have a history of injuring people or creating harm.

Robert E. Oshel, who works with Public Citizen, took issue. “The law is an attempt to increase mediation and that’s to the good,” he said Wednesday. “The problem is that it comes at possible expense to the public.”

Oshel, who was associate director for research and disputes at the National Practitioner Data Bank from 2001 to 2008, noted that malpractice settlements that go through the court system often include confidentiality agreements, but those cases still had to be reported to the data base under federal law.

Public Citizen said that it is concerned that the Oregon law will be a model for other states that are eager to limit the cost of medical malpractice litigation.

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Stateline is a nonpartisan, nonprofit news service of the Pew Center on the States that provides daily reporting and analysis on trends in state policy.

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