REPORT DIGEST ILLINOIS DEPARTMENT OF PROFESSIONAL REGULATION PROGRAM AUDIT: PHYSICIANS REGULATED UNDER THE MEDICAL PRACTICE ACT Release Date: May 1997  State of Illinois Office of the Auditor General WILLIAM G. HOLLAND |
SYNOPSIS
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REPORT DIGEST ILLINOIS DEPARTMENT OF PROFESSIONAL REGULATION PROGRAM AUDIT: PHYSICIANS REGULATED UNDER THE MEDICAL PRACTICE ACT Release Date: May 1997 State of Illinois Office of the Auditor General WILLIAM G. HOLLAND |
SYNOPSIS
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The Medical Practice Act guides the licensing and regulation of physicians in Illinois |
FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS REPORT CONCLUSIONS The Department of Professional Regulation (Department) is responsible for reviewing complaints and issuing disciplines against physicians licensed under the Medical Practice Act, including medical doctors, osteopathic doctors, and chiropractors. In Fiscal Years 1995 and 1996 combined, the Department received a total of 3,661 complaints and disciplined 236 physicians. We found that the Department lacked adequate management controls in its investigatory, disciplinary, and probationary processes. For instance, there were inadequate controls to ensure that cases are investigated, reviewed by the Medical Coordinator, and prosecuted in a timely manner. Only 14 percent of cases opened in Fiscal Years 1995 and 1996 (159 of 1,125) had investigations completed within the Department’s 90-day time limit. To further test procedural timeliness, we reviewed sample cases to identify three-month periods during which no substantive activity on the complaint took place. We found time lapses at the Medical Investigations Unit in 23 percent of opened cases (81 of 348) and lapses at the Medical Coordinator in 12 percent of opened cases (43 of 348). In our testing of closed cases we found 28 percent (20 of 72) of cases in the Prosecutions Unit had three-month periods during which there was no substantive activity on the complaint.
The Medical Investigation Unit did not have guidelines on how an investigation should be conducted or what evidence should be included in case files. Additionally, the Department did not have a basic training program for its medical investigators. We recommended that the Department ensure that all cases are adequately investigated and supported by necessary documentation. We further recommended that the Department develop a training policy for its medical investigators. We reviewed cases closed in Fiscal Years 1995 and 1996 to evaluate the adequacy of disciplinary actions. We found the Department has few written policies and procedures to ensure similar violations receive similar discipline. We questioned the adequacy of 35 percent (122 of 347) of the closed cases in our sample. Concerns included: cases closed without any investigation (59); inadequate investigations (46); questionable disciplinary actions (15); and missing case files (2). We recommended the Department and Medical Disciplinary Board develop criteria to help ensure their decisions in disciplinary actions are consistent. Our review of closed cases included 135 reports to the Department by professional liability insurers as a result of medical malpractice settlements. These settlements totaled more than $38 million, including 22 settlements of at least $500,000 each. The Medical Disciplinary Board closed 76 of these 135 cases without investigating the allegation. None of the physicians involved in the 135 reports was disciplined. Of the 236 physicians who were disciplined by the Department during Fiscal Years 1995 and 1996, we determined that 67 percent of cases (157 of 236) should not have required much investigative effort by the Department and should have been easy to prove. The two most common reasons for discipline were physicians who had been disciplined in another state and physicians who failed to renew their licenses on time. Discipline may include a probationary period during which the doctor must comply with a stipulated condition, such as submit to drug tests, perform community service or attend continuing education classes. We found that almost 36 percent (19 of 53) of the probation cases that we reviewed were inadequately monitored. In addition, the Department does not monitor physicians who have had their licenses placed on long-term suspension or revoked. We also noted that Probation/Compliance investigators work from their homes and have State vehicles assigned to them even though their duties appear to be mainly performed in the office, by mail or over the telephone. We recommended that the Department develop controls to ensure that probation cases are properly monitored and establish procedures for operation of the Probation/ Compliance Unit. BACKGROUND On February 5, 1996, the Legislative Audit Commission adopted Resolution Number 107 directing the Auditor General to conduct a program audit of the Department of Professional Regulation’s effectiveness in investigating complaints against physicians licensed under the Medical Practice Act of 1987. Resolution 107 specifically asked us to determine:
MEDICAL PRACTICE ACT OF 1987 The Medical Practice Act (225 ILCS 60/1 et seq.) guides the licensing and regulation of physicians in Illinois who are doctors of medicine, osteopaths, or chiropractors. The Act contains provisions which specify the requirements for obtaining a medical license in the State, as well as the disciplinary actions that may be taken against the license when warranted.
In addition, the Act lists certain disciplinary actions that may be taken against the physician’s license, including revocation, suspension, probation, and/or fine. It then lists the grounds for such actions. Among these are: dishonorable, unethical or unprofessional conduct likely to defraud or harm the public; gross negligence; disciplinary action in another state; overcharging or collecting fees for services not provided under the Public Aid Code; and immoral conduct related to the physician’s practice. The Act contains a total of 40 separate grounds for disciplinary action (225 ILCS 60/22). Digest Exhibit 1 shows the total number of disciplinary actions by type taken against physicians in Fiscal Year 1996. These 153 actions were taken against 110 physicians. Digest Exhibit 2 shows graphically where cases were closed in our sample of 347 cases closed in Fiscal Years 1995 and 1996. The largest category of cases is the 193 cases that were closed after investigation with no disciplinary action. |
Only a small portion of the investigations we reviewed were inadequate We recommended that the Department and the Medical Disciplinary
Board develop criteria to determine when medical records are needed The Department took an average of about ten months to close
cases during Fiscal Years 1995 and 1996 We recommended that the Department adopt and enforce standards
to ensure timely resolution of complaints The adequacy of disciplinary actions taken could not be
ascertained for 30 percent of the closed cases we reviewed We recommended that the Department and the Medical Disciplinary
Board develop criteria to help ensure consistency in disciplinary actions The Department took no disciplinary action in any of the 135 Mandatory Report cases in our sample |
INVESTIGATIVE ADEQUACY Investigations are initiated when complaints are forwarded to the Chief of Medical Investigations from the Complaint Intake Unit. The Chief of Medical Investigations begins the investigation by forwarding the complaint case file to the Licensing Assistant for a background check on the physician. Background checks are done to ensure that a physician is licensed and to determine if there were any prior complaints or disciplinary actions taken. Once background checks are completed, complaint case files are returned to the Chief of Medical Investigations. The Chief then assigns the case file to an Investigative Supervisor. Although only a small portion of the investigations we reviewed were inadequate, improvements are still needed. We examined 348 cases which were opened during Fiscal Years 1995 and 1996 to determine whether the investigations of those cases were adequate. Of the 348 cases examined, we found 23 cases (7 percent) with inadequate investigations. Digest Exhibit 3 shows that almost half (11 of 23) of the inadequate investigations were because relevant medical records were not obtained. We recommended that the Department and the Medical Disciplinary Board develop criteria to determine when medical records are needed. All 11 of these cases without medical records were mandatory reports, which are statutorily required reports received from various sources such as professional liability insurers. Unlike other complaints, mandatory reports are filed directly with the Medical Disciplinary Board. The Board then determines whether to close the case or to refer it for further investigation.
We also found that important interviews were not conducted in three cases. In two other cases Department records indicated that the existing complaint could not be modified. In these cases, a new complaint was received after a formal complaint had already been filed against the physician. Instead of adding an additional count to that complaint or pursuing these allegations separately, the new complaint was closed. Two other cases were closed to unrelated complaints. These cases were combined into existing cases which were unrelated. For example, a case of non-therapeutic prescribing of drugs was combined into a case which alleged that a physician performed unnecessary surgeries. The Medical Investigation Unit did not have guidelines on how an investigation should be conducted or what evidence should be included in case files. Additionally, the Department did not have a basic training program for its medical investigators. We recommended that the Department ensure that all cases are adequately investigated and supported by necessary documentation. We further recommended that the Department develop a training policy for its medical investigators. TIMELINESS The Department lacked adequate standards and management controls to ensure that cases are investigated, reviewed by the Medical Coordinator, and prosecuted in a timely manner. In Medical Investigations, our testing showed no compelling reasons which would explain why the investigative process could not be completed in a timely manner. Investigator caseloads average 29 cases, which appears reasonable. Only 14 percent of cases opened in Fiscal Years 1995 and 1996 (159 of 1,125) had investigations completed within the Department’s 90-day time limit. At the Medical Coordinator, for cases with completed investigations that had been forwarded for review and recommendation, we also identified timeliness problems. In Prosecutions, the Department has no standards for timeliness in initiating and completing the prosecutorial process. When a case resulted in disciplinary action, an average of 762 days elapsed from the date the complaint was received until a disciplinary order was signed. Overall, from our sample of closed cases, the Department took an average of about ten months to close cases during Fiscal Years 1995 and 1996. Three Months of Inactivity Of the 348 cases we examined in our sample, we found 81 cases (23 percent) had at least one period of three months during which no substantive investigative activity took place. Of these 81 cases, 24 had more than one period of three months with no activity. In total, there were 113 three-month periods with no documented activity. The Department also had serious problems in timeliness with cases awaiting review by the Medical Coordinator. Following completion of the investigation, cases are forwarded to the Medical Coordinator for review and recommendation. In our sample of cases, 12 percent (43 of 348) had at least one period of three months during which no activity by the Medical Coordinator was documented. A Report of Aged Cases produced by the Department’s computerized case tracking system in November 1996 showed that there were 358 cases that had been assigned to the Medical Coordinator for 121 days or longer. We also examined the cases referred to the Prosecutions Unit to identify lapses of three months during which no substantive activity took place. Of the 72 cases in our sample of cases closed that were referred to the Prosecutions Unit, 20 (28 percent) had at least one such lapse. Two cases each had ten three-month lapses with no substantive activity performed. Physicians against whom complaints have been filed generally continue practicing medicine while the Department investigates and prosecutes the case. Lack of timeliness in bringing a case to conclusion could result in delayed discipline and unnecessary risk to the public. We recommended that the Department adopt and enforce standards to ensure timely resolution of complaints. ADEQUACY OF DISCIPLINARY ACTION We noted several areas of concern regarding the adequacy of disciplinary actions in our review of 347 cases closed during Fiscal Years 1995 and 1996. We found 105 cases which were closed without investigation or had inadequate investigations and 15 cases in which we questioned the disciplinary action taken. In addition, there were two case files which the Department could not locate. The adequacy of disciplinary actions taken could not be ascertained for 105 of 347 (30 percent) of the closed cases we reviewed, either because the case was closed without any investigation (59) or because the investigation was inadequate (46). Mandatory reports accounted for all of the cases closed without an investigation. Of the 240 closed cases in which an investigation was conducted and the investigation was adequate, we found 15 cases (6 percent) in which we questioned the disciplinary action taken by the Department:
There are few written criteria which help the Prosecutions Unit or the Medical Disciplinary Board determine the need for and the nature of any disciplinary action levied against physicians. We recommended that the Department and the Medical Disciplinary Board develop criteria to help ensure consistency in disciplinary actions. The Department believes that it would be difficult to develop criteria for determining the need for and type of disciplinary action warranted because each case is unique. The Medical Disciplinary Board makes suggestions for disciplinary action based upon similar cases and previous offenses, also taking into account the accused physician’s remorsefulness, remediation, and ability to pay. The Medical Disciplinary Board is a control agent and has some guidelines, but those guidelines cover only a small portion of the provisions of the Medical Practice Act. As a board composed of external individuals, it should be an objective mechanism to assure that discipline is appropriate. The Board has established a schedule of fines for physicians who let their licenses lapse. Although this schedule is appropriate, there are many other potentially serious violations for which there is no guidance. Mandatory Reports When a professional liability insurer settles a claim of alleged negligence against a physician or a hospital revokes a doctor’s privileges, a report is required to be made to the Medical Disciplinary Board. Other entities having knowledge of a physician’s conduct are similarly required to file reports with the Board. These mandatory reports represent a large percentage of the total complaints against physicians received by the Department each year. In our sample of 347 closed cases, 145 or 42 percent were mandatory reports. Overall, we determined the Department’s handling of 64 percent of mandatory reports (93 of 145) was inadequate. We found that 59 mandatory reports were closed without investigation, 28 had inadequate investigations, 4 had questionable disciplinary actions, and 2 had case files which the Department could not locate.
Of the 145 mandatory reports contained in our sample of closed cases, 135 were reports from professional liability insurers paying settlements on behalf of physicians who had been accused of negligence or some other misconduct. Digest Exhibit 4 shows the breakdown of the 135 settlement amounts paid by physicians’ professional liability insurers. The Department took no disciplinary action in any of these 135 cases. Types of Violations Resulting in Discipline We determined that 67 percent of the physicians disciplined during Fiscal Years 1995 and 1996 were disciplined by the Department for reasons which would not require much investigative activity and would be easy to prove. The most common reason, accounting for 56 of the 157 doctors disciplined by the Department in those years, was a violation of a sister-state law by a physician also licensed in Illinois. Fourteen of the 20 physicians whose licenses were revoked during Fiscal 1995 or 1996 were disciplined for reasons that we considered easy to prove. PROBATION MONITORING The Probation/ Compliance Unit monitors physicians who have been disciplined by the Department. In Fiscal Year 1995, the Probation/ Compliance Unit received 53 medical cases to monitor. In almost 36 percent (19 of 53) of cases that we reviewed, appropriate action had not been taken when disciplined physicians had not fulfilled the requirements of their probation. In addition, the Department does not monitor physicians who have had their licenses revoked or placed on long-term suspension. We also noted that Probation/Compliance investigators work from their homes and have State vehicles assigned to them even though their duties appear to be mainly performed in the office, by mail or over the telephone. We recommended that the Department develop controls to ensure that probation cases are properly monitored and establish procedures for operation of the Probation/ Compliance Unit. OTHER ISSUES Since the Department of Professional Regulation’s Enforcement Case Tracking System is being replaced, Department officials should ensure that the new system has the capability of assisting management in its efforts to control the adequacy and timeliness of various elements of the enforcement process. Weaknesses in management controls over the evidence room were identified by management during the course of audit work. The evidence room contains prescription drugs, guns, and money that have been confiscated in investigations of medical cases or cases relating to other professions. During our audit, Department officials noted significant potential problems in this area and took actions to account for items in the evidence room. The Department of Professional Regulation has not established a policy that requires employees to remove themselves from a case if they have a conflict of interest. AGENCY RECOMENDATIONS The audit report contains 16 recommendations to the Department of Professional Regulation. The Department provided responses to the recommendations as well as other comments on the report. Portions of those comments have been incorporated in the report and the Department’s complete response is included as Appendix F of the audit report.
WGH:EKW May 1997 |