Healthcare Quality Improvement Act
Encyclopedia
The Healthcare Quality Improvement Act of 1986 (HCQIA) was introduced by Congressman Ron Wyden
from Oregon
. (Title 42 of the United States Code
, Sections 11101 - 11152)
It followed a federal antitrust suit by a surgeon against an Astoria
hospital and members of its clinic in which he claimed antitrust actions were effected through the mechanism of peer review in the hospital. He claimed that a general surgeon of the clinic initiated the action due to an ongoing dispute between him and the clinic.
He prevailed in a jury trial. (The antitrust suit was later overturned by the U.S. Court of Appeals on the grounds that existing Oregon statutes already protected the peer review committee members from prosecution and that these protections should extend to federal antitrust suits brought by individuals for monetary (but not injunctive) relief.)
Soon thereafter Congressman Wyden introduced HCQIA in an effort to extend state peer review immunities on a federal level.
lawsuits during the preceding decade played a factor in the passage of the act. It was claimed that physicians with a history of malpractice suits could move easily from state to state with no mechanism of interstate reporting available.
Consumer groups therefore lobbied extensively for passage in the name of patient safety. They claimed, supported by statistics from the US Office of the Inspector General, that although the number of physicians was rising, disciplinary actions against physicians' licenses had not risen in proportion.
These concerns coincided with an exponential increase in malpractice lawsuits against physicians. The Medical Malpractice Trial Bar, with its system of contingency fees, had been blamed for encouraging an increasing number of frivolous, non-meritorious lawsuits over the preceding 2 decades.
In this environment, physicians and hospitals appeared reluctant to report their peers and thereby increase the overall legal liability for their profession. Malpractice insurance premiums had already begun to skyrocket due to the malpractice environment, and physicians were not inclined to make the situation worse.
During the ensuing debate, studies were published that asserted that only a small fraction of medical negligence was ever brought to a lawsuit. Several medical malpractice attorneys, such as Harvey Waschman in his text American Law of Medical Malpractice, asserted that most "malpractice lawsuits involve the type of slip-up that would be obvious to a first year medical student." The fact that only a very small number of lawsuits win on their merits (even when they are filed) suggested that the standard of negligence used by medical malpractice attorneys was not the same one used by medical professionals and the courts.
Furthermore, the studies of negligence did not attempt to separate the contribution of systems failures (not attributable to a single medical practitioner) from that of an individual physician. It has been shown since that time that system failures are common in healthcare.
lobbied for confidentiality and legal immunity for healthcare peer review processes. It theorized that only in such an environment could system failures be identified and corrected and physician participation be increased.
This immunity became incorporated into the HCQIA.
It argued that the NPDB would be subjected to reporting of actions by non-peer reviewed committees.
Their objection proved correct.
In California
, this move was echoed as insurance agencies and health plans were enabled to perform "peer review."
This combination of events ended the ability of physicians to conduct peer review of themselves, and "peer review" of physicians became transformed into "performance appraisal" done by physicians and non-physicians alike.
Although the original HCQIA had afforded immunity to physician peer reviewers only (which were originally assumed to constitute the group of peers), the OBRA amendment conferred immunity to a widening circle of non-physician performance appraisers as well.
Ron Wyden
Ronald Lee "Ron" Wyden is the senior U.S. Senator for Oregon, serving since 1996, and a member of the Democratic Party. He previously served in the United States House of Representatives from 1981 to 1996....
from Oregon
Oregon
Oregon is a state in the Pacific Northwest region of the United States. It is located on the Pacific coast, with Washington to the north, California to the south, Nevada on the southeast and Idaho to the east. The Columbia and Snake rivers delineate much of Oregon's northern and eastern...
. (Title 42 of the United States Code
Title 42 of the United States Code
Title 42 of the United States Code is the title of the United States Code dealing with public health, social welfare, and civil rights.—The Public Health Service—The Public Health Service, Supplemental Provisions—Sanitation and Quarantine—Leprosy—Cancer—Viruses, Serums, Toxins, Antitoxins,...
, Sections 11101 - 11152)
It followed a federal antitrust suit by a surgeon against an Astoria
Astoria, Oregon
Astoria is the county seat of Clatsop County, Oregon, United States. Situated near the mouth of the Columbia River, the city was named after the American investor John Jacob Astor. His American Fur Company founded Fort Astoria at the site in 1811...
hospital and members of its clinic in which he claimed antitrust actions were effected through the mechanism of peer review in the hospital. He claimed that a general surgeon of the clinic initiated the action due to an ongoing dispute between him and the clinic.
He prevailed in a jury trial. (The antitrust suit was later overturned by the U.S. Court of Appeals on the grounds that existing Oregon statutes already protected the peer review committee members from prosecution and that these protections should extend to federal antitrust suits brought by individuals for monetary (but not injunctive) relief.)
Soon thereafter Congressman Wyden introduced HCQIA in an effort to extend state peer review immunities on a federal level.
Context for the passage of the Act
The rising numbers of medical malpracticeMedical malpractice
Medical malpractice is professional negligence by act or omission by a health care provider in which the treatment provided falls below the accepted standard of practice in the medical community and causes injury or death to the patient, with most cases involving medical error. Standards and...
lawsuits during the preceding decade played a factor in the passage of the act. It was claimed that physicians with a history of malpractice suits could move easily from state to state with no mechanism of interstate reporting available.
Consumer groups therefore lobbied extensively for passage in the name of patient safety. They claimed, supported by statistics from the US Office of the Inspector General, that although the number of physicians was rising, disciplinary actions against physicians' licenses had not risen in proportion.
These concerns coincided with an exponential increase in malpractice lawsuits against physicians. The Medical Malpractice Trial Bar, with its system of contingency fees, had been blamed for encouraging an increasing number of frivolous, non-meritorious lawsuits over the preceding 2 decades.
In this environment, physicians and hospitals appeared reluctant to report their peers and thereby increase the overall legal liability for their profession. Malpractice insurance premiums had already begun to skyrocket due to the malpractice environment, and physicians were not inclined to make the situation worse.
During the ensuing debate, studies were published that asserted that only a small fraction of medical negligence was ever brought to a lawsuit. Several medical malpractice attorneys, such as Harvey Waschman in his text American Law of Medical Malpractice, asserted that most "malpractice lawsuits involve the type of slip-up that would be obvious to a first year medical student." The fact that only a very small number of lawsuits win on their merits (even when they are filed) suggested that the standard of negligence used by medical malpractice attorneys was not the same one used by medical professionals and the courts.
Furthermore, the studies of negligence did not attempt to separate the contribution of systems failures (not attributable to a single medical practitioner) from that of an individual physician. It has been shown since that time that system failures are common in healthcare.
Principles of immunity for peer review participation
The American Medical AssociationAmerican Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...
lobbied for confidentiality and legal immunity for healthcare peer review processes. It theorized that only in such an environment could system failures be identified and corrected and physician participation be increased.
This immunity became incorporated into the HCQIA.
National Practitioner Databank
The AMA objected to the creation of a National Practitioner Databank (NPDB) unregulated by medical boards, claiming that the number of frivolous suits that would be reported would be misleading. It claimed that there was already a databank used by state medical boards that kept a record of physician disciplinary actions.It argued that the NPDB would be subjected to reporting of actions by non-peer reviewed committees.
Their objection proved correct.
Amendments to the Act
In 1991 Omnibus Budget Reconciliation Act (OBRA) required state medical boards to report "any negative action or finding" by "any peer review or accreditation entity," wresting the notion of peer review by physicians away from the National Practitioner Databank.In California
California
California is a state located on the West Coast of the United States. It is by far the most populous U.S. state, and the third-largest by land area...
, this move was echoed as insurance agencies and health plans were enabled to perform "peer review."
This combination of events ended the ability of physicians to conduct peer review of themselves, and "peer review" of physicians became transformed into "performance appraisal" done by physicians and non-physicians alike.
Although the original HCQIA had afforded immunity to physician peer reviewers only (which were originally assumed to constitute the group of peers), the OBRA amendment conferred immunity to a widening circle of non-physician performance appraisers as well.