What to Do if You Have a Concern About the Quality of Care from a Pennsylvania Doctor

Advice and resources for dealing with quality concerns

For many of us, our doctor is one of the most important people in our lives. We trust him or her to help keep us well or care for us when we're sick. There are over 49,000 actively practicing doctors in Pennsylvania, and most provide high-quality care to their patients. There are times, however, when people have concerns about the quality of care received from a doctor. If this happens to you or a loved one, this tip sheet can help. It gives you:

• Practical advice about what to do and who to talk with, including phone numbers and addresses
• Links to resources that can help

This tip sheet explains steps you can take in your doctor's office to deal with your concerns about quality. It also tells you how to contact places that regulate or oversee doctors.

Is it worth it to pursue a concern about quality?

For many of us, it's not easy to act on a concern about the quality of physician care that we or our loved ones receive. It's even harder if we try to talk with a doctor or their staff about our concerns, but don't feel we're getting anywhere. The process can be stressful, frustrating and take a long time. In the end, it's possible that others may not agree with the way we see the situation.

Is it worth the time and energy to take action about the quality of a doctor? Only you or your loved one can decide. In making the decision, think about the continued harm that might take place if you do nothing—and think about how the actions you take might lead to better care for future patients and their families.

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What is quality of care?

Quality health care is doing the right thing, at the right time, in the right way, for the right person and with the best possible results. Generally, care delivered by doctors and other health professionals must meet a "standard of care." That standard is the expected level and type of care provided by the average competent health professional in a given situation. A standard of care is based on good scientific studies or agreement among experts.

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What can you expect as a patient regarding the quality of physician care?

To become a doctor, students have to go through a long training process. This includes hands-on learning in hospitals and other health settings. When they finish training, doctors promise to "do no harm" to their patients.

As professionals, doctors voluntarily follow codes of ethics that lay out the way they are to behave. For example, the American Medical Association Code of Ethics notes some patient rights in the patient-physician relationship:

• The patient has the right to receive information from physicians and to discuss the benefits, risks and costs of treatment options.
• The patient has the right to make decisions regarding health care recommended by his or her physician and may refuse any recommended treatment.
• The patient has the right to courtesy, respect, dignity, and timely attention to his or her needs.

The American Board of Internal Medicine Foundation and other partners has published a new physician code or charter. The Foundation works with an organization that certifies physicians caring for adults. This document specifically addresses quality and competence in what is expected of doctors:

• Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care.
• Physicians must be dedicated to continuous improvement in the quality of health care. This commitment means not only keeping their skills up-to-date, but also working with other professionals to reduce medical error, increase patient safety, keep an eye on costs and make sure patients are getting the best possible care.
• Physicians are required to provide care that is based on the wise and cost-effective management of limited resources. This includes avoiding unneeded tests and procedures that expose patients to avoidable harm and expense.

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What are examples of quality concerns you might experience?

Health care quality concerns could arise for a variety of reasons while you are under a doctor's care. Some concerns are the result of a specific action a doctor or staff member takes (or doesn't take) as they treat you or a family member. This includes misdiagnosing a condition or prescribing a drug that you shouldn't take.

Other quality concerns result from how well the doctor's staff work together to safely care for you—for example, making sure that the right medical chart goes with the right patient or that patient messages are delivered on time.

Some of these actions in a doctor's office may not affect your health at all; some may cause inconvenience or pain; others may cause serious harm.

The most common complaints received by organizations that oversee or regulate doctors nationwide are:

• Over-prescribing drugs or prescribing the wrong drug
• Failing to diagnose a medical problem that is found later
• Misreading x-rays to identify a medical problem
• Failing to get back to a patient with medical results in a timely manner, which leads to harm to that patient
• Failing to provide appropriate care after a surgical procedure

What should concern patients the most—and what concerns organizations that oversee doctors— is when there is a pattern of problems with a doctor. If something happens once, it is usually a mistake. If it happens again and again, it may indicate a larger problem of competence or quality that could hurt any patient.

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What steps should you take if you have a concern about quality?

Depending on what kind of problem you have and your relationship with your doctor, you might talk directly to him or her or to another office staff member about your concern. For example, if your concern relates to the way the doctor's office is organized, the doctor and staff may not know how it feels to be a patient in their office. They might be particularly interested if you thought mistakes could result from what you see. Speaking honestly about your concerns gives your doctor or another staff member the opportunity to explain why things happen the way they do. It may also lead to changes in the office.

If your concern is more medical in nature—for example, getting the wrong prescription, the wrong dose, or the wrong referral—you should speak with the doctor directly to correct the problem. Then think about whether this has happened before and be alert to whether it happens again.

If your concern is with a doctor that you've been referred to for specialty care, share your concerns about that physician with your personal doctor. It will help your doctor decide whether to refer other patients to that physician. Or, if your concern is with a doctor you're seeing while in the hospital or another health organization, again, let your personal doctor know. He or she may be able to tell you who in the facility can help you.

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If you continue to have concerns about the quality of a doctor and their staff, you have the option to leave the practice and go to another doctor. Remember to check with your health insurance plan to see which doctors work with your plan and which are taking new patients.

You do not need to tell your doctor why you are leaving, but you might consider writing a note with your concerns. The more specific you are, the more he or she might be able to understand your views and possibly take action on them.

If you leave the practice, you should request copies of your medical records to take with you. Under the law, you have the right to request a copy of your records. In 2014, the doctor can charge for copying and mailing up to $1.44 per page for the first 20 pages, $1.06 per page for pages 21-60 and $.35 per page after page 61.

For additional information: What You Need to Know About Your Medical Records in Pennsylvania from the Pennsylvania Patient Safety Authority:
http://patientsafetyauthority.org/NewsAndInformation/Brochures/Pages/
brochure_medical_records.aspx

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If you feel you should take action to protect yourself and other patients from a doctor who you think poses a safety threat, you can file a complaint with the Professional Compliance Office within the Pennsylvania Department of State. Complaints against doctors are reviewed there to determine if they should be sent to the State Board of Medicine, which is also within the Department of State. The Board's mission is to protect the health and safety of the public through licensure and discipline of physicians and other health professionals such as physician assistants, nurse midwives and athletic trainers. This means the Board can decide whether and how doctors and other health professionals can practice in Pennsylvania.

Be aware that if the Board pursues your case, the process can take a long time and involve many steps before action, if needed, is taken against a doctor. And if it goes forward, your concerns will become the Board's concerns. That means that you will not be able to decide what happens with the case. State lawyers will present the case before the Board on behalf of the public. They do not represent you personally.

The Board received over 2,900 complaints about doctors in 2012-2013. Only a small number (190) resulted in some type of action being taken against a doctor's license.

Filing the Complaint: The Board has a consumer complaint form that you should use to file your complaint. It is available online to print out, fill in and mail, or you can call them and have them mail you a copy: 800-822-2113 or 717-783-4854 if outside of Pennsylvania.

State Board of Medicine Statement of Complaint Form
http://www.portal.state.pa.us/portal/server.pt/
gateway/PTARGS_0_160329_648242_0_0_18/comp.pdf

Mail to:
Department of State
Professional Compliance Office
2601 North Third Ave.
P.O. Box 2649
Harrisburg, PA 17105-2649

Note: There is also a Pennsylvania State Board of Osteopathic Medicine for doctors who have received osteopathic training (training on moving muscles and joints). They generally have a D.O. after their name rather than an M.D. For more information about complaints against Osteopathic Doctors, see the following information:

http://www.portal.state.pa.us/portal/server.pt/community/
state_board_of_osteopathic_medicine/12517/consumer_information/572061

The investigation:  When the Professional Compliance Office receives your complaint, legal staff review whether:

• It concerns a doctor or other type of health professional subject to the Board's actions, and
• The complaint involves potential unprofessional or immoral conduct by the doctor or other health professional as described in the law.

Examples of unprofessional or immoral conduct include:

• Practicing medicine incompetently
• Guaranteeing that a cure will result from medical treatment
• Revealing personal information about a patient
• Failing to make the medical record available to a patient upon their written request
• Harassing, abusing or intimidating a patient
• Abandoning a patient without giving them time to get care elsewhere

For additional information about unprofessional or immoral conduct:
http://www.pacode.com/secure/data/049/chapter16/s16.61.html

If the complaint goes forward, it is assigned to an investigator for review. The investigator may contact you, request medical records, and review other data about the doctor. In some cases, an outside expert doctor reviews the records.

After the investigation, if no misconduct is found, the case is closed and you are notified. You may request that different staff review it. Bear in mind that information about the investigation is maintained on file so if others complain about this doctor, there is evidence of your concern in the records. However, those files are confidential.

Next Steps: If potential misconduct is found, Board lawyers prepare charges against the doctor. The doctor is allowed to have a hearing if he or she wants one. If so, a Hearing Examiner (a state lawyer) listens to all of the evidence at the hearing. You may be asked to testify. The Hearing Examiner makes a decision on the case and issues a "written order" or recommendation about what they think should happen.

The State Board will then consider the Hearing Examiner's recommendation. The State Board is made up of doctors, government officials and members representing the public. They decide whether they agree or not with what the Hearing Examiner recommends for the doctor. They also decide what the discipline or punishment for the doctor will be if the doctor broke the law. Discipline can range from a warning letter to taking away the doctor's license to practice. The doctor can appeal the case to the Pennsylvania legal system.

If the Board decides to discipline a doctor, that information is available to the public on the Board's website (See Pennsylvania Online License Verification System website information below).

It's important to note that the Board at any point along the way may agree to settle the case with the doctor. In these instances, Board lawyers and the doctor mutually agree to a settlement, which is outlined in a formal "consent agreement." This consent agreement must be approved by the Board and would end the case. Those decisions are also available to the public.

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How long does this process take?  It can take anywhere from 6 months to over a year if a case goes through the whole process. The average length of a case is 236 days (or almost 8 months).

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Can I remain anonymous when I file a complaint?  A complaint can be filed anonymously—that is, you don't give your name or contact information to the Board. However, it may be difficult for them to investigate such complaints. You also won't be able to follow up and find out what happened.

You may also ask to remain confidential—that is, the doctor doesn't know that you are the one who filed the complaint. However, it may be necessary to make your identity known in order for investigators to get your medical records and other information from the doctor. And if the case goes forward, it may be important for you to tell your story in public during a hearing.

Additional information about the State Board of Medicine Complaint process:
http://www.portal.state.pa.us/portal/server.pt/community/
state_board_of_medicine/12512/consumer_information/599422

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Where else can you go with a concern about the quality of a Pennsylvania doctor?

Medicare: If Medicare (the federal health insurance program for people over age 65 or people under 65 who are disabled) pays for the care you're receiving from a doctor, you have an additional place to go with a quality concern. Medicare pays a Quality Improvement Organization (QIO) to take complaints from Medicare patients. Be advised up front, however, that these organizations primarily help doctors improve the care they provide. They do not punish doctors.

In Pennsylvania, the QIO is called Livanta. You can call Livanta at the following number: 866-815-5440

Explain to the person who answers the phone what your concerns are. Depending on the type of problem you are having, they may be able to help you right away. For example, with your permission, they may be able to call the doctor's office to see if they can help solve your problem. In other cases, they may ask you to send your complaint in writing using a complaint form.

After you file a complaint with Livanta and allow release of your medical records, a doctor will review your records. After the review, you will get a letter indicating whether the standard of care was met in your case or not—that is, whether the expected level and type of care was provided.

For more information about the Livanta complaint system and to access an online complaint form:

http://bfccqioarea1.com/

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Other Health Organizations

Doctors often practice as part of larger organizations such as a medical group, hospital or managed care plan or HMO. Each of these organizations might have a process that patients can use to express concern about the quality of a doctor. Generally, these organizations will review a concern about a particular doctor's quality through a process called "peer review." This means that other doctors in the same field review the practices of a doctor in question.

If the health organization confirms that there's a quality concern with your doctor, they can limit the doctor's ability to practice in a hospital or HMO. Under certain circumstances, the organization must report its actions to the Pennsylvania State Board of Medicine. As noted above, that office can then conduct an investigation.

A health organization may also be required to report its actions against a doctor to the federal National Practitioner Data Bank. The Data Bank includes information on doctors who have a record of unprofessional behavior or malpractice. The public does not have access to the Data Bank, though it should be checked by any hospital or health plan in the country where that doctor might try to work.

If you're a patient of a large medical group:  Look on the website of your medical group for any information about voicing a complaint. It might be in a section on "Member Rights" or in the "Customer Service" or "Contact Us" section. You can also ask an administrative staff member whether there is a number to call or a process to follow.

Your health insurance plan or HMO:   Doctors usually work with a health insurance plan or HMO. Call your health plan's customer service number, explain the problem and ask whether you can file a complaint about the care provided by a doctor affiliated with their health plan. Or look in the section of the HMO's website that is devoted to complaints, appeals or grievances for information or forms to file.

 

Physician Organizations

The physician's specialty society:  A few physician specialty societies (the professional association affiliated with the physician's type of practice—for example, pediatrics or orthopedics) accept and have a process to review complaints against their members. For example, the American College of Physicians (ACP), an association of internal medicine doctors who generally treat adult patients, has a process for addressing "ethical complaints" from patients against their physician members.

For more information about the ACP process:

http://www.acponline.org/running_practice/ethics/complaints

Local medical societies: In most Pennsylvania counties, local medical societies receive and try to respond to patient complaints about their doctors. They try to mediate between a member physician and a concerned patient through education and problem solving.

For additional information, call the Consumer Assistance Line of the Pennsylvania Medical Society: 717-558-7855

 

Consumer Organizations

The Consumer Health Coalition is a non-profit Pittsburgh-based consumer health advocacy organization that provides information on health care quality and access. The Coalition provides educational workshops and trainings to consumers. As part of its Patient Safety Initiative, the Coalition is collecting stories about patients' experiences and concerns with their care in hospitals and from doctors.

http://consumerhealthcoalition.org

The Safe Patient Project (SPP) is a project of Consumers Union (the publishers of Consumer Reports magazine) that seeks to end medical harm in the health system. The Project is also collecting stories about patients' experiences and concerns with their care in hospitals and from doctors across the nation, including Pennsylvania. While they can't help with your specific complaint, the collective power of stories from patients and families can help pass laws and seek other changes to make the health care system safer.

http://safepatientproject.org/

In a joint effort with the Empowered Patient Coalition, the Safe Patient Project is conducting a survey about medical events from the perspective of the patient. For more information about the survey:  http://empoweredpatientcoalition.org/report-a-medical-event

ProPublica is a nonprofit investigative journalism organization. They have an online patient harm questionnaire that asks for details about your concern. They write articles about people's experience of patient harm to bring public attention to these issues. The organization won't publish any information that would identify you without your permission. ProPublica also sponsors a Facebook group that can connect you with other patients who have been harmed.

Here is a link to their patient harm questionnaire:
http://www.propublica.org/getinvolved/item/have-you-been-harmed-in-a-medical-facility-share-your-story

On Facebook, search for: ProPublica Patient Harm Community

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Where can you find out information about doctors in Pennsylvania?

Pennsylvania Online License Verification System:  A database that allows you to see that your doctor is licensed in Pennsylvania and whether there have been any disciplinary actions against them.
http://www.licensepa.state.pa.us/

Pennsylvania Health Care Cost Containment Council: A state agency that provides some information about Pennsylvania heart surgeons and other hospital information such as infection rates.

http://www.phc4.org/

Pennsylvania Patient Safety Authority: Provides consumer-oriented tips about preventing medical errors, how to choose health facilities and a variety of other information about receiving good care.

http://www.patientsafetyauthority.org/PATIENTSCONSUMERS/
PatientConsumerTips/Pages/PatientConsumerTips.aspx

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Other useful information:

If you're concerned about the quality of care in a Pennsylvania hospital, managed care plan or HMO, or nursing home, or the care provided by registered nurses, here's where to go for more information:

Hospitals
What to Do if You Have a Concern About Quality in a Pennsylvania Hospital
http://www.informedpatientinstitute.org/HOSQuality-PA.php

Managed Care
Bureau of Managed Care
Pennsylvania Department of Health
http://www.portal.state.pa.us/portal/server.pt/community/managed_care/14157

Health Care section of the Pennsylvania Office of the Attorney General
http://www.attorneygeneral.gov/seniors.aspx?id=395

Nursing Homes
What to Do if You Have a Concern About Quality in a Pennsylvania Nursing Home
http://www.informedpatientinstitute.org/NUHQuality-PA.php

Registered Nurses
Pennsylvania State Board of Nursing
http://www.portal.state.pa.us/portal/server.pt/community/
state_board_of_nursing/12515/consumer_information/572053