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More Information on State Medical Boards' Disciplinary Actions

Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2008-2010

May 12, 2011

Sidney M. Wolfe, M.D.
Rebecca Kahn,
Cynthia Williams


View press release.
View report as pdf.
View tables (pdf).

Using an analysis of data just released by the Federation of State Medical Boards (FSMB) on all disciplinary actions taken against doctors in 2010, we have calculated the rate of serious disciplinary actions (revocations, surrenders, suspensions and probation/restrictions) taken by state medical boards in 2010. This rate of serious actions per 1,000 physicians is slightly lower than the rate in 2009 and continues to be significantly lower than the peak for the past 10 years (see figure below). The rate in 2010 alone — 2.97 serious actions per 1,000 physicians — is still 20 percent lower than the peak rate in 2004 alone of 3.72 serious actions per 1,000 physicians. If the national rate of doctor discipline per 1,000 doctors had remained as high in the year 2010 (2.97) as it was in 2004 (3.72), there would have been a total of 745 additional serious disciplinary actions in 2010 taken against U.S. physicians than there actually were. With a typical doctor having between 500 and 1,000 or more patients in their practice, the positive impact of this on the large number of patients going to these doctors would be enormous.

 

The most recent three-year average state disciplinary rates (2008-10) ranged from 1.29 serious actions per 1,000 physicians (Minnesota) to 5.98 actions per 1,000 physicians (Louisiana), a 4.6-fold difference between the best and worst state doctor disciplinary boards (see Methods at the end of this report for the details of our calculations).

10 Worst States (lowest three-year rate of serious disciplinary actions)

As can be seen in the table below, the bottom 10 states, those with the lowest serious disciplinary action rates for 2008-10, were (starting with the lowest):

          State

Actions/1,000 docs
2008-10

Times in bottom 10
since 2001-3

Minnesota

1.29

8

South Carolina

1.31

8

Wisconsin

1.59

8

Connecticut

1.69

5

Massachusetts

1.83

2

Rhode Island

1.92

3

Florida

1.94

3

New Hampshire

2.13

3

Utah

2.15

1

Vermont

2.18

2

This list includes not only small states such as New Hampshire and Vermont but also large states such as Florida, Massachusetts and Minnesota.

The table above shows that three of these 10 states (Minnesota, South Carolina and Wisconsin) have been consistently among the bottom 10 states for each of the last eight three-year periods. In addition, Connecticut has been in the bottom 10 states for each of the last five three-year cycles. Florida has now been in the bottom 10 boards for the last three three-year periods. For the first time since we have been reporting on state boards, Utah is among the bottom 10 boards.

This year we have again done further analyses to determine which states have had the largest decreases or increases in their rankings compared to other states between the year of their highest rate and the 2008-10 period. All of the states with the greatest decrease or increase in rankings had considerable changes in the actual rates between their highest year and 2008-10.

As can be seen below, five states had decreases of at least 24 in their ranking of state disciplinary actions from the year of their highest rate until the latest (2008-10) rate.

States with Largest Decreases in Rank for the Rate of Serious Disciplinary Actions from Their Highest Rank to 2008-10

State

Highest rate and rank (year)

2008-10 rank

Decrease in rank

Decrease in rate/ 1,000 docs

Massachusetts

23  (2004)

47

24

1.58

Georgia

15  (2003)

40

25

1.83

Vermont

8  (2007)

42

34

2.65

Utah

10  (2003)

43

33

3.28

Montana

8  (2004)

32

24

3.60

As can be seen in the table above, Massachusetts fell 24 places in ranking from 2002-4 until 2008-10. If the rate of serious disciplinary actions in 2008-10 had been as high as in 2002-4 (1.58 more serious actions per 1,000 doctors per year), there would have been 56 more serious disciplinary actions taken against Massachusetts physicians in 2008-10 than actually occurred.

10 Best States (highest three-year rates of serious disciplinary actions)

The top 10 states for 2008-10 are (in order from the top down):

State

Actions/1,000 docs
2008-10

Times in top ten
since 2001-3

Louisiana

5.98

3

Alaska

5.47

8

Ohio

5.36

8

Oklahoma

5.23

8

Wyoming

5.14

6

North Dakota

5.05

6

New Mexico

4.99

2

Arizona

4.82

8

Nebraska

4.57

3

Colorado

4.51

8

Table 2 also shows that five of these 10 states (Alaska, Arizona, Colorado, Ohio and Oklahoma) have been in the top 10 for all eight of the three-year average periods covered in this report.

States with Largest Increases in Rank (20 or more) for the Rate of Serious Disciplinary Actions from Year of Lowest Average Rank* to 2008-10

State

Lowest rank and rate (year)

2008-10 rank

Increase in rank

Increase in rate/1,000 docs

Hawaii

  51 (2003)

11

40

3.20

Delaware

  50 (2003)

13

37

2.69

Maine

  46 (2005)

19

27

1.68

North Carolina

  41 (2003)

16

25

1.62

Washington

  45 (2006)

18

27

1.70

Arkansas

  45 (2004)

23

22

1.02

*See Table 2.

For the state of North Carolina, the most populous of the above states with large increases in ranks, the increase of 1.62 serious actions per 1,000 licensed physicians translates into an increase of 46 more physicians seriously disciplined than if the rate had stayed as it was in 2001-3 (1.62 multiplied by 28.3, the number of thousands of physicians).

For the state of Washington, the second most populous of those states with large increases in rank, the increase in 1.70 serious actions per 1,000 licensed physicians translates into 1.70 multiplied by 21.4 (the number of thousands of physicians) for an increase in 36 more physicians seriously disciplined than if the rate had stayed as it was in 2002-4.

Overall, between the 2001-3 and the 2008-10 periods, a total of 25 states had changes in the rate of serious disciplinary actions of more than one physician disciplined per 1,000 licensed in the state. However, partly reflecting the much tighter state budgets now than then, those states decreasing their rates of serious disciplinary actions by at least one per 1,000 doctors outnumbered those increasing the rates 17-8. Other issues important in addition to budget considerations are discussed below.

Discussion

These data demonstrate a remarkable variability in the rates of serious disciplinary actions taken by the state boards. Once again, only one of the nation's 15 most populous states, Ohio, is represented among those 10 states with the highest disciplinary rates. For the third year in a row, one of the largest states in the country, Florida, is among the 10 states with the lowest rates of serious disciplinary actions. Absent any evidence that the prevalence of physicians deserving of discipline varies substantially from state to state, this variability must be considered the result of the boards’ practices. Indeed, the “ability” of certain states to rapidly increase or rapidly decrease their rankings (even when these are calculated on the basis of three-year averages) can only be due to changes in practices at the board level; the prevalence of physicians eligible for discipline cannot change so rapidly.

Moreover, there is considerable evidence that most boards are under-disciplining physicians. For example, in a report on doctors disciplined for criminal activity that we published in 2006, 67 percent of insurance fraud convictions and 36 percent of convictions related to controlled substances were associated with only non-severe discipline by the board. [1]

In this report, we have concentrated on the most serious disciplinary actions. Although the FSMB does report less severe actions, such as fines and reprimands, it is not appropriate to provide such actions with the same weight as license revocations, for example. A state that embarks on a strategy of switching over time from revocations or probations to fines or reprimands for similar offenses should have a rate and a ranking that reflects this decision to discipline less severely.

A relatively recent trend has been for state boards to post the particulars of disciplinary actions they have taken on the Internet. In October 2006, Public Citizen’s Health Research Group published a report that ranked the states according to the quality of those postings. [2] The report showed variability in the quality of those Web sites akin to that reported for disciplinary rates in this report. There was no correlation between state ranking in the Web site report and state ranking in that year’s disciplinary rate report (Spearman's rho = 0.0855; p=0.55). A good Web site is no substitute for a poor disciplinary rate (or vice versa); states should both appropriately discipline their physicians and convey that information to the public. However, no state ranked in the top 10 in both reports.

This report ranks the performance of medical boards by their disciplinary rates; it does not purport to assess the overall quality of medical care in a state or to assess the function of the boards in other respects. It cannot determine whether a board with, for example, a low disciplinary rate has been starved for resources by the state or whether the board itself has a tendency to mete out lower (or no) forms of discipline. From the patient’s perspective, of course, this distinction is irrelevant.  

What Makes the Better Boards “Better”?

Boards are likely to be able to do a better job in disciplining physicians if the following conditions are met:

  • Adequate funding (all money from license fees going to fund board activities instead of going into the state treasury for general purposes)
  • Adequate staffing
  • Proactive investigations rather than only reacting to complaints
  • The use of all available/reliable data from other sources, such as Medicare and Medicaid sanctions, hospital sanctions, malpractice payouts, and the criminal justice system
  • Excellent leadership
  • Independence from state medical societies
  • Independence from other parts of the state government so that the board has the ability to develop its own budgets and regulations
  • A reasonable legal standard for disciplining doctors (“preponderance of the evidence” rather than “beyond a reasonable doubt” or “clear and convincing evidence”)

Most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner. Serious attention must be given to finding out which of the above bulleted variables are deficient in each state. Action must then be taken, legislatively and through pressure on the medical boards themselves, to increase the amount of discipline and, thus, the amount of patient protection. Without adequate legislative oversight, many medical boards will continue to perform poorly.

Methods

Public Citizen’s Health Research Group has calculated the rate of serious disciplinary actions per 1,000 doctors in each state. Using state-by-state data just released by the FSMB on the number of disciplinary actions taken against doctors in 2010,[3] combined with data from earlier FSMB reports covering 2008 and 2009, we have compiled a national report ranking state boards by the rate of serious disciplinary actions per 1,000 doctors for the years 2008-10 (see Table 1) and for earlier three-year intervals (see Table 2).

Because some small states do not have many physicians, an increase or decrease of one or two serious actions in a year can have a much greater effect on the rate of discipline in such states (and their ranks) than it would in larger states. To minimize such fluctuations, we therefore calculate the average rate of discipline over a three-year period: the year of interest and the preceding two years. Thus, the newest ranking is based on rates from 2008, 2009 and 2010, not the rate for 2010 alone.

Our calculation of rates of serious disciplinary actions per 1,000 doctors by state is created by taking the number of such actions for each state (revocations, surrenders, suspensions and probation/restrictions — the first two categories in the FSMB data) and dividing that by the American Medical Association (AMA) data on total M.D.s as of December 2010[4] in that state.  We add to this denominator the number of osteopathic physicians[5] for the 37 boards that are combined medical/osteopathic boards. We then multiply the result by 1,000 to get board disciplinary rates per 1,000 physicians. This rate calculation is done for each year and the average rate for the last three years is used as the basis for this year’s state board rankings (Table 1). We then repeated these calculations for each of the seven previous three-year intervals (2001-3, 2002-4, 2003-5, 2004-6, 2005-7, 2006-8, and 2007-9, Table 2).

In previous years, we used AMA data on non-federal M.D.s, but since then the AMA now only provides information on the total number of licensed physicians, without a breakdown by federal/non-federal status. We therefore amended our traditional protocol to use data on the total number of M.D.s in each state as the denominator in calculating the rates. When we did this for the first time, to ensure that the ranks based on this new denominator are as comparable as possible to data from previous years, we entered the data for total physicians and re-calculated the rates of serious actions of every state for each year in the period from 2001-6, as well as the related three-year rankings. All states’ rates, as currently calculated, are therefore somewhat lower than rates in our previous reports because of the larger denominator. However, this had no effect on the rankings of most states because the larger denominators affect all states[6]: the ranks of 39 of the states for the 2002-4 interval, for example, were identical to what they had been in our report for that interval issued in 2005,[7] in which we used only non-federal physicians. Of the 12 states with different ranks, the rank of six increased by only one place and the other six decreased by one place. 


[1] Jung P, Lurie P, Wolfe SM. U.S. Physicians Disciplined For Criminal Activity. Health Matrix 2006; 16:335-50.

[2] Larson, M, Marcus B, Lurie P, Wolfe SM. 2006 Report of Doctor Disciplinary Information on State Web Sites: A Survey and Ranking of State Medical and Osteopathic Board Web Sites, available at http://www.citizen.org/Page.aspx?pid=700.

[3] Federation of State Medical Boards. Summary of 2010 Board Actions, available at http://www.fsmb.org/pdf/2010-summary-of-board-actions.pdf.

[4] Physician Characteristics and Distribution in the U.S. American Medical Association, 2011 Edition.

[5] Fact Sheet: American Osteopathic Association. Statistics as of August, 2004, available at http://www.osteopathic.org/index.cfm?PageID=aoa_ompreport_us#50.

[6] This is not surprising, as in the 2004 edition of the AMA publication, the last to include the federal/non-federal physician breakdown, only 2.46 percent of all physicians were federal employees.  Moreover, these physicians were disproportionately represented in a small number of states (e.g., Alaska, District of Columbia, Maryland and Hawaii).

[7] Wolfe, SM, Lurie P. Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions: 2002-2004, available at http://www.citizen.org/Page.aspx?pid=2381.

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