Remedies hard to prescribe

Patient advocates say Hawaii needs to take swift action to suspend licenses of doctors who lose privileges in another state.

The state needs to overhaul its website to give consumers more information about physician backgrounds.

And it needs to place more public members on a medical board dominated by doctors.

Those are among the many improvements that would make Hawaii’s regulatory system for physicians more transparent and useful to the public, boosting consumer protections, they say.

The advocates were responding to a Honolulu Star-Advertiser investigation that found numerous flaws in the state’s oversight of Hawaii physicians.

Some former members of the Hawaii Medical Board, which makes licensing and discipline decisions, are among those favoring reforms.

"It would certainly be in keeping with this whole notion of protecting the public. That’s the bottom line," said Hawaii gerontologist Cullen Hayashida, who was a public (nonphysician) member from 1997 to 2006.

The newspaper’s investigation found many ways in which the public-safety mission was compromised. The most serious ones were linked to the slowness of the discipline process.

Hawaii physicians whose licenses were revoked, suspended or surrendered in other states have been able to continue practicing here for months or even years because of the sluggish pace of the process, even though regulators say the time to resolve medical complaints has been cut substantially over the past decade.

"Obviously, the board needs a strong law that tells them if a doctor’s license is suspended in another state, the board has to take action of some type," said Lisa McGiffert, director of a patient safety project with the national advocacy group Consumers Union. Allowing physicians with revoked or suspended credentials elsewhere to continue practicing in Hawaii is outrageous, she added.

Risking ‘big trouble’

Hawaii already has a law that allows the medical board to summarily suspend a physician’s license to deter a public-safety threat.

Since the law was enacted in 2013, the board has yet to exercise that authority. The Department of Commerce and Consumer Affairs, which regulates doctors and administers the board, says it has not had a case that met the law’s criteria or the agency instead negotiated early in the process to take away the license.

Yet the Star-Advertiser found three pending cases in which Hawaii physicians still have active licenses here despite getting them revoked or suspended elsewhere roughly two years ago. All three have Hawaii practices.

In California a doctor whose license is suspended or revoked elsewhere automatically has his or her credentials suspended for at least 90 days while the board decides whether to pursue more permanent discipline. If formal charges aren’t filed after 90 days, the suspension is lifted, according to the law.

In examining Hawaii’s reciprocal discipline cases over the past decade, the newspaper found that more than half weren’t resolved for at least two years after the doctor was sanctioned in another state. In some cases, the process dragged on for at least five years.

Consumer advocates say such time lags are too long, potentially putting patients at risk.

And officials in half a dozen states told the Star-Advertiser that of all sanction cases, reciprocal discipline ones are the quickest to decide because another board already has done an investigation and taken action.

But DCCA officials said the agency needs to do its own investigation to determine whether Hawaii licensing laws were violated, given that a violation elsewhere might not be a violation here. They said cases involving physicians who lose their licenses in another state because of questions about medical competence get a higher priority here.

Consumer advocates say cases that take too long to resolve are red flags.

"One of the most basic things an agency needs to do is make timely decisions," said Randy Bovbjerg, senior fellow for the Urban Institute’s Health Policy Center and co-author of a 2006 study on state medical boards and physician discipline. "Agencies get in big trouble when they fall behind."

DCCA officials said cases that take unusually long to resolve are the exception rather than the rule. Still, they said the department is looking at ways to improve the reciprocal discipline process, including reviewing other state statutes for possible streamlining ideas.

"If there are additional tools that may be available to our board, we will be reaching out to (the) industry and lawmakers to consider them," DCCA Deputy Director Jo Ann Uchida Takeuchi said in written responses to Star-Advertiser questions.

Dr. Danny Takanishi, former chairman of the medical board and a University of Hawaii professor of surgery, said that while the regulatory system generally fulfills its mission of protecting the public, the process would be improved if it worked faster.

Asked about cases involving doctors who lose their licenses elsewhere, Takanishi voiced concern, though he stressed that he wasn’t speaking for the board or the university.

If a physician loses a license in another state because of egregious misconduct but is able to continue practicing here for six months to a year, "in my opinion the system is not working," he said.

Diversifying board voices

Hayashida, the gerontologist, agreed that an expedited discipline process is needed to better protect the public.

He also said more public members should be added to the 11-member medical board to strike a better balance — an idea supported by at least several current members. Hawaii law requires two of the 11 to be public members, or nonphysicians, and the other nine to be physicians. That equates to 18 percent public membership. Only nine other states have a lower rate, according to a Star-Advertiser analysis of data from the Federation of State Medical Boards.

Dr. Niraj Desai, Hawaii board chairman, said adding more public members could amplify the voice of patients concerned about public health and the potential damage that can be done by an impaired physician. "Yes, that voice is fairly quiet, I would say, because of the numbers we have," he added, stressing he was not speaking on behalf of the board.

Like other advocates, Hayashida also said DCCA needs to include more useful consumer information on its online physician profiles. The profiles have only about a third of the approximately 20 information categories recommended years ago by the federation, which represents all state boards.

The Web profiles, for instance, don’t even list a physician’s business address, making it difficult to determine whether the doctor is practicing in Hawaii or elsewhere.

Consumer advocates also criticized DCCA’s practice of removing discipline information from its website five years after a physician compiles with a sanction order. Asked whether that policy should continue, Hayashida was emphatic: "Absolutely not."

The agency has a $1.3 million project underway to replace its licensing database and eventually expects to replace its enforcement database as well. Both data systems are about 30 years old, helping explain why the website is so clunky to navigate.

While the replacement projects are expected to make the site more efficient and user-friendly, creating more seamless physician profiles on a single page, DCCA officials could not say whether the profiles would have more information than what is found on them now. They stressed that the agency must continue to comply with existing law.

Push to add resources

Other reform ideas touted by consumer advocates include making the application process more transparent and establishing a dedicated enforcement staff for medical complaint cases, which can be highly complex if the level of care is an issue.

When the Hawaii board denies a physician license or grants one with conditions imposed, the public record on the decision — the board minutes — lists the laws that the board relies on to justify the action but not the underlying details. If a physician, for example, gets a restricted license partly based on the board’s concern that he or she lost a license recently in another state, the revocation wouldn’t be reflected in the minutes.

DCCA officials say the minutes are drafted in compliance with Hawaii law, which exempts from public disclosure information compiled to determine an applicant’s fitness to get a license.

But until 2014, board minutes sometimes included specific details, such as a doctor being addicted to the painkiller fentanyl, to justify denying physician licenses. Last year the group began omitting such details and only referred to the general laws supporting the denials.

It was not clear why the agency made the switch. The law wasn’t changed.

The idea of having a dedicated staff for medical cases also is one floated by consumer advocates to make the process more effective and timely.

"It’s not right to have investigators and prosecutors doing a barber case one day and a medical case the next," said Julianne Fellmeth, administrative director of the Center for Public Interest Law at the University of San Diego.

Not having a dedicated enforcement staff and budget for the medical board is among the challenges the department faces, according to DCCA officials.

INVESTIGATING THE DOCTOR

Here’s the general process the state Department of Commerce and uses to investigate complaints against licensed physicians:

» Staff determines whether complaint raises questions about violations of Hawaii licensing laws and whether there is sufficient information to initiate investigation.

» If so, investigator gathers evidence, which may include documents and witness interviews.

» Licensee may be questioned.

» Outside expertise may be sought from a medical advisory committee member, especially in more complex cases.

» If sanctions are pursued, a petition for disciplinary action is filed. This contains the formal charges.

» Where appropriate, cases may reach settlement before or after petition is filed.

» If no settlement is reached, a hearing is held. An attorney with the agency’s Regulated Industries Complaints Office, the enforcement arm of DCCA, presents its case. The physician is offered an opportunity to present a defense. Witnesses may be called to testify.

» After considering the evidence, the hearings officer makes a recommendation to the medical board, which issues the final decision. To maintain impartiality, the board is not involved with the process until this stage. A decision to discipline requires a majority vote of the board.

» Sanctions can range from reprimands or censures, the least severe, to probation, suspension, license surrender or revocation. License surrender and revocation are the most severe — licensee is prevented from practicing for five years and must reapply for a new license. Fines or restitution also may be imposed.

Source: DCCA, Star-Advertiser

CHECKING UP ON YOUR DOCTOR

Does your doctor have a clean record? Are there limitations placed on his or her license? Has he or she been subjected to disciplinary action in recent years? Are there pending complaints with state regulators? Check these web sites for answers, but keep in mind some limitations. For instance, the Department of Commerce and Consumer Affairs, which regulates doctors, removes discipline information from its web site five years after a physician has complied with terms of the discipline order.

License status:
https://pvl.ehawaii.gov/pvlsearch/

Hawaii complaint history:
http://web.dcca.hawaii.gov/RICO/RICO_RCNT_NAMES/RICO_Disclaimer.aspx

Hawaii board discipline:
http://web.dcca.hawaii.gov/OAHdecisions/PDF_INDEX/Public_ShowPDF_INDEXTable.aspx

Discipline in other states:
http://www.docinfo.org/#/search/query

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