Clinical peer review in the United States: History, legal development and subsequent abuse

Table 1 Congressional reasons for law enactment

The increasing occurrence of medical malpractice and the need to improve the quality of medical care have become nationwide problems that warrant greater efforts than those that can be undertaken by any individual state

There is a national need to restrict the ability of incompetent physicians to move from State to State without disclosure or discovery of the physician’s previous damaging or incompetent performance

This nationwide problem can be remedied through effective professional peer review

The threat of private money damage liability under Federal laws, including treble damage liability under Federal antitrust law, unreasonably discourages physicians from participating in effective professional peer review

There is an overriding national need to provide incentive and protection for physicians engaging in effective professional peer review

Table 2 Part A Health Care Quality Improvement Act peer review immunity requirements

Peer review action is taken:

In the reasonable belief that the action was in furtherance of quality of care

After a reasonable effort to obtain the facts of the matter

After adequate notice and hearing procedures are afforded to the physician involved or after such other procedures as are fair to the physician under the circumstances

In the reasonable belief that the action was warranted by the facts known after such reasonable efforts to obtain the facts

Table 3 Causes of reports to the National Practitioner Data Bank (Satiani 2004)

Adverse actions (17%)

Peer review findings adversely affect the clinical privileges of physicians or dentist for more than 30 d

Privileges are restricted or surrendered while under peer review investigation for possible incompetence or improper professional conduct

Privileges are restricted or surrendered in exchanged for peer reviewers not conducting an investigation

Physician’s or Dentists’ license are revoked, suspended, or surrendered

Physicians or Dentists are censured, reprimanded, or put on probation

Malpractice payments (82%)

Insurers settling claims or judgments relating medical malpractice on behalf of physicians

Medicare/medicaid exclusion reports (1%)

Percentage refers to proportion of reports attributable to 132896 physicians in the National Practitioner Data Bank in 2002.