A performance audit of the Board of Podiatry Examiners

              STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
A PERFORMANCE AUDIT
OF THE
BOARD OF PODIATRY EXAMINERS
SEPTEMBER 1983
A REPORT TO THE
ARIZONA STATE LEGISLATURE
REPORT 83- 17
DOUGLAS R. NORTON. CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
September 19, 1983
Members of the Arizona L e g i s l a t u r e
The Honorable Bruce Babbitt, Governor
Dr. M. Barry Rosenthal, President
Board of Podiatry Examiners
Transmitted herewith is a report of the Auditor General, A Performance
Audit of the Board of Podiatry Examiners. This report is i n response t o a
January 18, 1982, r e s o l u t i o n of the J o i n t L e g i s l a t i v e Oversight
Committee. The performance a u d i t was conducted a s a part of the Sunset
Review s e t f o r t h i n A. R. S. SS41- 2351 through 41- 2379.
The blue pages present a summary of the r e p o r t ; a response from the Board
of Podiatry Examiners is found on the yellow pages.
My s t a f f and I w i l l be pleased t o discuss or c l a r i f y items i n the report.
~ o u ~ l Ry. s N orton
Auditor General
Enclosure
Staff : W i l l i a m Thomson
Peter Francis
Arthur Heikkila
Lisa Wormington
1 1 1 WEST MONROE SUITE 600 PHOENIX. ARIZONA 85003 ( 602) 255- 4385
OFFICE OF THE AUDITOR GENERAL
A PERFORMANCE AUDIT OF THE
BOARD OF PODIATRY EXAMINERS
A REPORT TO THE
ARIZONA STATE LEGISLATURE
REPORT 83- 17
TABLE OF CONTENTS
SUMMARY
INTRODUCTION AND BACKGROUND
SUNSET FACTORS
FINDINGS
FINDING I
Despite improvements i n t i m e l i n e s s , complaint- handling
procedures can be f u r t h e r strengthened.
CONCLUSION
RECOMMENDATIONS
FINDING I1
Board s t a t u t e s unnecessarily r e s t r i c t the p r a c t i c e
of podiatry.
CONCLUSION
RECOFIMENDATIONS
WRITTEN RESPONSE TO THE AUDITOR GENERAL'S REPORT
LIST OF TABLES
TABLE 1 - Board Work Load I n d i c a t o r s f o r F i s c a l Years
1979- 80 through 1983- 84
- Page
i
1
5
TABLE 2 - Board Actual Revenues and Expenditures f o r
F i s c a l Years 1979- 80 through 1982- 83 and
Estimated Revenues and Expenditures f o r
F i s c a l Year 1983- 84
SUMMARY
The Office of the Auditor General has conducted a performance a u d i t of t h e
Board of Podiatry Examiners i n response t o a January 18, 1982, r e s o l u t i o n
of the J o i n t L e g i s l a t i v e Oversight Committee. This performance a u d i t was
conducted a s a p a r t of the Sunset Review s e t f o r t h i n Arizona Revised
S t a t u t e s ( A. R. S.) § § 41- 2351 through 41- 2379 and is a follow- up t o the 1981
Sunset Review of the Board.
The Board w a s created a s the Board of Chiropody i n 1941 and renamed the
Board of Podiatry Examiners i n 1964. O r i g i n a l l y c o n s i s t i n g of t h r e e
p r o f e s s i o n a l members, the Board now has f i v e members, two of which a r e
laymen. Board members a r e appointed by the Governor f o r five- year terms.
Board d u t i e s include conducting examinations, evaluating a p p l i c a t i o n s f o r
l i c e n s u r e , renewing l i c e n s e s , promulgating r u l e s and regulations, and
resolving complaints.
The Board has made improvements i n two s p e c i f i c areas of l e g i s l a t i v e
i n t e r e s t . F i r s t , the Board has reduced its complaint r e s o l u t i o n time from
an average of eight months per complaint t o two months. Second, the Board
minutes now record a l l l e g a l a c t i o n s , and Board f i l e s a r e generally
complete. Also, the Board's Attorney General r e p r e s e n t a t i v e is now
providing s a t i s f a c t o r y and timely a s s i s t a n c e t o the Board. Our 1981
Sunset Review found t h a t previous Attorney General r e p r e s e n t a t i v e s d i d n o t
provide timely i n v e s t i g a t i v e services and formal hearing a s s i s t a n c e .
Since the l a s t Sunset Review, however, the Attorney General's Office has
not been involved i n complaint i n v e s t i g a t i o n s .
Complaint I n v e s t i g a t i o n s
Can Be Further Strengthened ( See page 11)
Although now more timely, complaint- handling procedures require f u r t h e r
improvement. The Board should contract f o r the s e r v i c e s of an independent
p r o f e s s i o n a l medical i n v e s t i g a t o r t o f r e e Board members from i n v e s t i g a t i n g
complaints. Board members may lack the time and e x p e r t i s e t o conduct
thorough complaint i n v e s t i g a t i o n s . A d d i t i o n a l l y , b o t h the Attorney
General's Office and t h e L e g i s l a t i v e Council caution a g a i n s t Board members
i n v e s t i g a t i n g and adjudicating complaints.
The Board should, as a matter of course, require t h a t complainants be
contacted and d o c t o r s ' medical records reviewed during complaint
i n v e s t i g a t i o n s . These a c t i o n s help t o ensure thorough i n v e s t i g a t i o n s and
i m p a r t i a l i t y i n t h e Board's decision- making process.
F i n a l l y , the Board h a s n o t complied with s t a t u t o r y provisions designed t o
p r o t e c t t h e c o n f i d e n t i a l i t y of complainants and p a t i e n t s . Names of
complainants have been improperly disclosed t o doctors involved i n the
complaint. Also, complainant and p a t i e n t names have been improperly
disclosed i n Board minutes. The Board should comply with s t a t u t o r y
provisions on c o n f i d e n t i a l i t y by withholding names of complainants from
doctors involved i n t h e case and keeping complainant and p a t i e n t names
from appearing i n minutes a v a i l a b l e t o the public.
Some S t a t u t e s Are
Unnecessary ( See page 19)
Some Board s t a t u t e s governing the p r a c t i c e of Podiatry do not serve a
v a l i d public purpose and could be eliminated. Statutory r e s t r i c t i o n s on
the offering of g i f t s ( such a s a d v e r t i s i n g f r e e examinations) a r e
unnecessary and could be eliminated. The Board has never received a
p a t i e n t complaint regarding g i f t s and has other s t a t u t o r y a u t h o r i t y t o
c o n t r o l fraudulent o r misleading a d v e r t i s i n g . The United S t a t e s
Department of J u s t i c e considers t h e Board's g i f t r e s t r i c t i o n s
a n t i c o m p e t i t i v e and recommends t h e i r removal from the s t a t u t e s .
R e s t r i c t i o n s on where p o d i a t r i s t s nay p r a c t i c e a r e a l s o unnecessary t o
p r o t e c t p u b l i c h e a l t h , s a f e t y and welfare. No other h e a l t h regulatory
Board i n Arizona has a s i m i l a r provision and Board members s t a t e t h e r e is
no need t o r e t a i n t h e s t a t u t o r y language which p r o h i b i t s p o d i a t r i s t s from
p r a c t i c i n g
". . . i n connection with a beauty p a r l o r , barbershop,
t u r k i s h bath, shoe s t o r e , department s t o r e , massage
p a r l o r , o r other such commercial establishment."
iii
INTRODUCTION AND BACKGROUND
The Office of the Auditor General has conducted a performance a u d i t of the
Board of Podiatry Examiners i n response t o a January 18, 1982, r e s o l u t i o n
of the J o i n t L e g i s l a t i v e Oversight Committee. This performance a u d i t was
conducted as a p a r t of the Sunset Review s e t f o r t h i n Arizona Revised
S t a t u t e s ( A. R. S.) SS41- 2351 through 41- 2379 and is a follow- up t o the 1981
Sunset Review of the Board.
Podiatry i s the s p e c i a l t y of medicine which Arizona law defines a s the
". . . diagnosis of medical, s u r g i c a l , mechanical,
manipulative or e l e c t r i c a l treatment of ailments of the
human foot and leg but does n o t i n c l u d e amputation of
f o o t , toe o r leg nor administration of a n e s t h e t i c other
t h a n l o c a l . "
There are 181 p o d i a t r i s t s licensed t o p r a c t i c e i n Arizona. Of t h o s e , 101
r e s i d e w i t h i n t h e S t a t e .
The Board was created a s the Board of Chiropody i n 1941 and renamed the
Board of Podiatry Examiners i n 1964. O r i g i n a l l y c o n s i s t i n g of t h r e e
professional members, the Board now has f i v e members, two of which a r e
laymen. Board members a r e appointed by the Governor f o r five- year terms.
The L e g i s l a t u r e i n 1982 enacted several changes i n the Board's s t a t u t e s .
These changes provided the Board a u t h o r i t y t o accept the r e s u l t s of a
w r i t t e n examination administered by the National Board of Podiatry
Examiners i n l i e u of a w r i t t e n examination prepared by the Board. In
a d d i t i o n , p o d i a t r i s t s were granted h o s p i t a l p r i v i l e g e s . F i n a l l y , various
unprofessional conduct r e s t r i c t i o n s were added including the charging of
excessive fees.
Board d u t i e s include conducting examinations, evaluating
a p p l i c a t i o n s f o r l i c e n s u r e and l i c e n s e renewal, promulgating r u l e s
and r e g u l a t i o n s and resolving complaints. Table 1 gives a summary
of the Board's a c t i v i t i e s f o r the l a s t f i v e years.
TABLE 1
BOARD WORK LOAD INDICATORS FOR
FISCAL YEARS 1979- 80 THROUGH 1983- 84"
Estimated
Licensing
Exam a p p l i c a t i o n s
New l i c e n s e s issued
License renewals
Complaint Actions
Complaints
I n v e s t i g a t i o n s
undertaken
Informal hearings/
interviews
Formal hearings
Discipline a c t i o n s
taken
* Source: budget requests f o r f i s c a l years 1979- 80 through 1983- 84 and Board records
S t a f f i n g and Funding
The Board has no full- time support s t a f f . A l l support functions
a r e provided by the Department of Administration through the
Arizona S t a t e Boards' Administrative Office ( ASBAO). The Office
was e s t a b l i s h e d i n 1976 and administers support functions t o 10
boards.
The Board derives its revenues from examination and l i c e n s e fees.
Currently, f e e s a r e $ 150 f o r examinations, $ 75 p e r l i c e n s e and $ 100
f o r renewals. Revenues and expenditures f o r f i s c a l years 1979- 80
through 1982- 83 and t h e Board's budget and a n t i c i p a t e d revenues f o r
f i s c a l year 1983- 84 a r e shown i n Table 2.
TABLE 2
BOARD ACTUAL REVENUES AND EXPENDITURES FOR
FISCAL YEARS 1979- 80 THROUGH 1982- 83 AND
ESTIMATED REVENUES AND EXPENDITURES FOR FISCAL YEAR 1983- 84*
w Revenues :
Balance from p r i o r
year
90 percent of
r e c e i p t s
Total revenues
Expenditures :
Personal s e r v i c e s /
ERE
Professional and
outside s e r v i c e s
I,
Travel :
In- State
Out- of- State
Other operating
expenditures
Equipment
Total
expenditures
Balance forward t o
next year
Estimated
1979- 80 1980- 81 1981- 82 1982- 83 1983- 84
* Source: budget requests f o r f i s c a l years 1979- 80 through 1983- 84
** Budget documents show a discrepancy of $ 100 between the amount c a r r i e d forward i n
f i s c a l year 1980- 81 and the balance from p r i o r year f o r f i s c a l 1981- 82. *** $ 4,600 of 1982- 83 90% f i g u r e is 1981- 82 renewal revenue received i n 1981- 82 f i s c a l
year but not deposited u n t i l ( J u l y ) 1982- 83 f i s c a l year.
Audit Scope
The a u d i t addressed the 11 Sunset f a c t o r s i n A. R. S. $ 41- 2354 and 3
s p e c i f i c l e g i s l a t i v e concerns found i n House B i l l 2325, Second Regular
Session, 1982:
" The sunset review of t h e s t a t e board of podiatry
examiners s h a l l consider i n p a r t i c u l a r whether t h e
board has :
1. Received the information and a s s i s t a n c e it needs
from the attorney g e n e r a l ' s o f f i c e t o comply with the
laws of t h i s s t a t e and t o resolve complaints i n a
timely and thorough manner.
2. Resolved complaints i n a timely and thorough manner.
3. Improved the documentation of its decision making
process t o allow f o r a thorough, independent
q u a l i t a t i v e evaluation of the process.
Additionally, we reviewed Board s t a t u t e s and r u l e s t o determine i f any
were unnecessary or anticompetitive.
The Auditor General and s t a f f express a p p r e c i a t i o n t o t h e Board of
Podiatry Examiners and t h e s t a f f of the Arizona S t a t e Boards'
Administrative Office f o r t h e i r cooperation and a s s i s t a n c e .
SUNSET FACTORS
In accordance with A. R. S. 541- 2354, the L e g i s l a t u r e should consider t h e
following 11 f a c t o r s i n det emining whether the Board of Podiatry
Examiners should be continued or terminated .
1. Objective and purpose i n e s t a b l i s h i n g the Board
In 1982, the L e g i s l a t u r e enacted HB 2325 which included a goals and
o b j e c t i v e s statement f o r the Board:
" The goals and o b j e c t i v e s of the s t a t e board of
podiatry examiners a r e t o help assure t h e competency of
p o d i a t r i s t s and prevent conduct on t h e i r part which
would tend t o do harm t o the h e a l t h and well- being of
the public."
The Board a s s u r e s t h e competency of p o d i a t r i s t s through its
q u a l i f i c a t i o n requirements, examinations of l i c e n s e applicants,
continuing education requirements, complaint i n v e s t i g a t i o n s and
review of malpractice a c t i o n s .
2. The e f f e c t i v e n e s s with which the Board has m e t its objective and
purpose and the e f f i c i e n c y with which the Board has operated
The Board has improved i n two areas found d e f i c i e n t i n the previous
Sunset Review. F i r s t , the Board has reduced the time it takes t o
resolve complaints from an average of eight months per complaint t o
two months. Second, the Board has developed and implemented an
improved examination grading procedure which is c o n s i s t e n t and f a i r .
Also, t h e Board's Attorney General r e p r e s e n t a t i v e is now providing
s a t i s f a c t o r y and timely a s s i s t a n c e t o the Board. Our 1981 Sunset
Review found t h a t previous Attorney General r e p r e s e n t a t i v e s did not
provide timely i n v e s t i g a t i v e s e r v i c e s and formal hearing a s s i s t a n c e .
Since the l a s t Sunset Review, however, the Attorney General's Office
has not been involved i n complaint i n v e s t i g a t i o n s .
Although the Board of Podiatry Examiners has improved the t i m e l i n e s s
of its complaint i n v e s t i g a t i o n s , complaint- handling procedures can be
f u r t h e r strengthened. The Board should c o n t r a c t f o r t h e s e r v i c e s of
an independent medical i n v e s t i g a t o r . Also, complainants should be
contacted and d o c t o r s ' medical records reviewed i n every case. In
a d d i t i o n , the Board h a s n o t complied with s t a t u t o r y provisions
designed t o safeguard t h e c o n f i d e n t i a l i t y of complainants and p a t i e n t s
( see page 11).
3. The extent t o which the Board has operated within the public i n t e r e s t
The Board's functions of l i c e n s i n g a p p l i c a n t s and i n v e s t i g a t i n g
complaints, i f done e f f e c t i v e l y , serve t o p r o t e c t the public from
incompetent or unscrupulous p r a c t i t i o n e r s . However, s t a t u t o r y
provisions p r o h i b i t i n g p o d i a t r i s t s from offering g i f t s and r e s t r i c t i n g
where p o d i a t r i s t s may p r a c t i c e a r e unnecessary and do not benefit the
public ( see page 19).
4. The extent t o which r u l e s and r e g u l a t i o n s promulgated by the Board a r e
c o n s i s t e n t with t h e l e g i s l a t i v e mandate
The Board's r u l e s and r e g u l a t i o n s were reviewed f o r consistency with
s t a t u t e s and were approved by the Attorney General. The Board is
presently d r a f t i n g new r u l e s and r e g u l a t i o n s i n accordance with the
new s t a t u t e s t h a t went i n t o e f f e c t July 24, 1982.
5. The extent t o which the Board has encouraged input from the public
before promulgating its r u l e s and r e g u l a t i o n s and the extent t o which
it has informed t h e public a s t o its a c t i o n s and t h e i r expected impact
on t h e public
The Board has not promulgated any r u l e s and r e g u l a t i o n s since t h e 1981
Sunset Review. The Board has retained a law c l e r k t o develop and
amend r u l e s and r e g u l a t i o n s based on the Board's 1982 l e g i s l a t i o n .
The Board appears t o have complied with the Open Meeting Law. Minutes
of Board meetings now record a l l l e g a l a c t i o n s and t r a n s c r i p t s of
formal hearings a r e a v a i l a b l e f o r public inspection a t the Board
off ice.
6. The extent t o which the Board has been able t o i n v e s t i g a t e and resolve
complaints t h a t a r e within i t s j u r i s d i c t i o n
The Board i n v e s t i g a t e s consumer complaints. The Board on advice from
its Attorney General r e p r e s e n t a t i v e h a s discontinued a c t i n g on
d o c t o r s ' complaints a g a i n s t other doctors' a d v e r t i s i n g on the premise
t h a t the Board should pursue only c a s e s 1) demonstrating t h a t a
complainant has been misled or 2) involving fraudulent p r a c t i c e s .
Although t i m e l i n e s s has improved, the ~ o a r d ' s complaint- handling
procedures can be f u r t h e r strengthened. The Board should contract f o r
t h e s e r v i c e s of an independent p r o f e s s i o n a l medical i n v e s t i g a t o r t o
provide more time and e x p e r t i s e required f o r thorough i n v e s t i g a t i o n s .
I n a d d i t i o n , the Board should require t h a t complainants be contacted
and doctors' medical records reviewed i n every case.
7. The e x t e n t t o which t h e Attorney General or any o t h e r a p p l i c a b l e
agency of S t a t e government h a s t h e a u t h o r i t y t o prosecute a c t i o n s
under enabling l e g i s l a t i o n
The Board's enabling l e g i s l a t i o n lists a c t s which a r e c l a s s i f i e d a s
misdemeanors and may be enforced by the county a t t o r n e y . In a d d i t i o n ,
the Attorney General has a u t h o r i t y t o seek i n j u n c t i v e r e l i e f a g a i n s t
v i o l a t i o n s of t h e Board's s t a t u t o r y provisions.
8. The e x t e n t t o which t h e Board has addressed d e f i c i e n c i e s i n the
enabling s t a t u t e s which prevent it from f u l f i l l i n g its s t a t u t o r y
mandate
L e g i s l a t i o n enacted i n 1982 made several changes i n Board and r e l a t e d
s t a t u t e s :
HB 2325 continued the Board and made changes i n a p p l i c a t i o n and
examination procedures, r e l i c e n s u r e and f e e provisions and other
areas; and
HB 2175 granted h o s p i t a l p r i v i l e g e s t o p o d i a t r i s t s .
L e g i s l a t i o n amending the insurance code t o require insurance companies
t o r e p o r t malpractice a c t i o n s against p o d i a t r i s t s , and providing
p e n a l t i e s f o r noncompliance was supported by the Board but f a i l e d t o
pass.
9. The extent t o which changes a r e necessary i n the laws of the Board t o
adequately comply with the f a c t o r s l i s t e d i n the Sunset law
The L e g i s l a t u r e should consider the following a d d i t i o n a l s t a t u t o r y
changes :
o Deleting s t a t u t o r y provisions and the corresponding r u l e which
r e s t r i c t p o d i a t r i s t s from offering g i f t s t o a t t r a c t p a t i e n t s and
l i m i t i n g where p o d i a t r i s t s may p r a c t i c e ( see page 19), and
Amending insurance s t a t u t e s t o require i n s u r e r s t o report
m a l p r a c t i c e c l a i m s or s e t t l e m e n t s t o t h e appropriate Arizona
regulatory boards and provide a p e n a l t y f o r noncompliance
( previously recommended i n Auditor General report 81- 19).
10. The extent t o which the termination of the Board would s i g n i f i c a n t l y
harm the public h e a l t h , s a f e t y or welfare
Termination of r e g u l a t i o n of p o d i a t r i s t s could s i g n i f i c a n t l y harm
p u b l i c h e a l t h , s a f e t y and welfare. Improper podiat r i c a l services
could r e s u l t i n s e r i o u s physical harm t o p a t i e n t s .
11. The extent t o which the l e v e l of r e g u l a t i o n exercised by the Board is
appropriate and whether l e s s or more s t r i n g e n t l e v e l s of r e g u l a t i o n
would be appropriate
The l e v e l of r e g u l a t i o n could be reduced by eliminating s t a t u t o r y
r e s t r i c t i o n s on offering g i f t s ( A. R. S. $ 32- 854.01.1), and the
l o c a t i o n s where p o d i a t r i s t s may p r a c t i c e ( A. R. S. $ 32- 854.01.6) ( s e e
page 19).
FINDING I
DESPITE IMPROVEMENTS I N TIMELINESS, COMPLAINT- HANDLING PROCEDURES CAN BE
FURTHER STRENGTHENED.
Although the Board of Podiatry Examiners resolves complaints i n a more
timely manner, complaint- handling procedures need f u r t h e r improvement.
The Board should contract f o r the s e r v i c e s of an independent p r o f e s s i o n a l
medical i n v e s t i g a t o r , review medical records and contact complainants more
frequently. In a d d i t i o n , the Board h a s n o t complied with s t a t u t o r y
provisions designed t o safeguard t h e c o n f i d e n t i a l i t y of complainants and
p a t i e n t s .
Timeliness IIas Im~ roved
The Board has improved the t i m e l i n e s s of i t s complaint i n v e s t i g a t i o n s
since the previous a u d i t . Auditor General report Number 81- 19 noted t h a t
the Board had not i n v e s t i g a t e d and resolved complaints i n a timely
manner. The Board averaged 8 months t o resolve 19 closed complaints
received between January 1, 1978, and October 1, 1981. Nine a d d i t i o n a l
open complaints had been pending an average of 11 months. By c o n t r a s t ,
the Board took l e s s than two months t o resolve nine complaints
i n v e s t i g a t e d between January 1, 1982, and July 15, 1983." As of July 15,
1983, s i x other complaints still open have been pending an average of
less than t h r e e months.
* Complaint t i m e l i n e s s was measured from the date the formal complaint
form was received t o the d a t e t h e Board resolved the complaint. The
Board only accepts complaints submitted on its formal complaint form.
The Board g e n e r a l l y m a i l s a formal complaint form t o the complainant
within a few days a f t e r the complainant's i n i t i a l contact with the
Board .
Some of t h e improvement i n t i m e l i n e s s can be a t t r i b u t e d t o revised
complaint procedures adopted by the Board i n September 1982. P r i o r t o
September 1982, t h e Board did not have standard w r i t t e n procedures f o r
i n v e s t i g a t i n g and resolving complaints. The new procedures d e t a i l each
s t e p i n t h e i n v e s t i g a t i v e process and guide t h e Board's a c t i o n s .
According t o Board members, the procedures have speeded complaint handling.
Complaint I n v e s t i g a t i o n s
Need Further Improvement
Although now more timely, Board complaint- handling procedures need f u r t h e r
improvement. S p e c i f i c a l l y , the Board should contract f o r t h e s e r v i c e s of
an independent p r o f e s s i o n a l medical i n v e s t i g a t o r . In a d d i t i o n ,
complainants should be contacted and doctors' medical records reviewed i n
every case.
Independent Medical I n v e s t i g a t o r Needed - The Board should c o n t r a c t f o r
the s e r v i c e s of an independent p r o f e s s i o n a l medical i n v e s t i g a t o r .
Currently, Board members i n v e s t i g a t e complaints e i t h e r c o l l e c t i v e l y o r
i n d i v i d u a l l y . Since Board members cannot devote much time t o
i n v e s t i g a t i o n s and lack proper t r a i n i n g and e x p e r t i s e i n gathering
evidence, complaints may not always be thoroughly i n v e s t i g a t e d . An
example of t h i s occurred e a r l i e r t h i s year when t h e Board, overlooking
c r i t i c a l pieces of evidence, prematurely dismissed the following complaint:
Case Example
In March 1983, the Board received a complaint alleging t h a t a
p o d i a t r i s t b i l l e d t h e complainant f o r l a b t e s t s and surgery never
performed and, i n a d d i t i o n , performed poor surgery. In April 1983,
the Board reviewed the case and discussed whether the Board had
j u r i s d i c t i o n over the matter, concluding it was a f e e dispute. The
Board decided t o i n v i t e the complainant t o the next Board meeting t o
examine t h e s u r g i c a l s i t e s . I n s t e a d , however, t h e Board s e c r e t a r y
wrote a l e t t e r t o t h e complainant a week l a t e r s t a t i n g t h e Board could
not determine i f a v i o l a t i o n occurred because it did not have
j u r i s d i c t i o n over f e e s a t the time of occurrence.
The Complainant subsequently r e f i l e d the complaint s i x weeks later.
This complaint is now open and an i n v e s t i g a t i o n is underway.
Comment
Although t h e complaint involved the q u a l i t y of care and possible
fraud, it was o r i g i n a l l y t r e a t e d as a f e e matter and not acted on.
The Board did not i n i t i a l l y pursue the complaint d e s p i t e t h e f a c t t h a t
the doctor had seven other complaints on f i l e regarding unnecessary
s e r v i c e s , excessive f e e s and insurance overcharges.
Using an independent medical i n v e s t i g a t o r t o i n v e s t i g a t e complaints r a t h e r
than Board members would a l s o s e p a r a t e t h e i n v e s t i g a t i v e and
decision- making aspects of the complaint- resolution process. The Attorney
General's Office and the l e g i s l a t i v e council c a u t i o n against having Board
members both i v e s t i g a t e and adjudicate complaints . In its Arizona Agency
Handbook, the Attorney General's Office notes t h a t challenges have been
r a i s e d i n recent years t o agencies i n v e s t i g a t i n g , prosecuting and
adjudicating charges a g a i n s t persons regulated by the agencies. The
National Association of Attorneys General s i m i l a r l y recommends t h a t t h e
functions of i n v e s t i g a t o r and decision maker be separated.
Board members who have been involved i n i n v e s t i g a t i n g a complaint may
l a t e r have t o serve as i m p a r t i a l decision maker i n a formal hearing. I f
the Board members have developed a preconceived view, b i a s or prejudice,
they may not be able t o maintain the appearance of i m p a r t i a l i t y of
proceedings without d i s q u a l i f y i n g themselves. I n a n opinion dated May 14,
1981, the L e g i s l a t i v e Council s t a t e d :
". . . It is fundamental t h a t a quasi- judicial
t r i b u n a l , similar to a court, must not only be f a i r , it
must appear t o be f a i r . Only thus can the proceeding
m e e t the basic requirement of due process. . . ."
The Board generates adequate additional revenue t o fund an independent
medical i n v e s t i g a t o r . The Board' s surplus revenue ( revenue generated i n
excess of appropriation) ' is estimated a t $ 11,200 f o r f i s c a l year 1982- 83,
with a surplus of $ 13,200 expected i n f i s c a l year 1983- 84. The Board of
Medical Examiners currently pays $ 100- 150 per day f o r professional medical
i n v e s t i g a t i v e services. BOMEX complaints usually require two paid days
f o r the i n v e s t i g a t o r to complete the investigation. Since the Podiatry
Board has few complaints per year* its additional surplus revenue could
cover i n v e s t i g a t i o n expenses.
Contact Complainant / Review Medical Records - The case cited above and
o t h e r c a s e s we reviewed also indicate t h a t t h e complainant should be
contacted and doctors' medical records reviewed during the course of the
i n v e s t i g a t i o n of every complaint. Routinely performing these steps during
t h e i n v e s t i g a t i v e process would ensure thoroughness of complaint
i n v e s t i g a t i o n s and i m p a r t i a l i t y i n the Board's decision- making process,
p a r t i c u l a r l y i f a complaint involves a Board member.** Both the Board of
Medical Examiners and the Veterinary Medical Examining Board review
medical records i n every case, even those involving f e e disputes.
* The Podiatry Board received 4 complaints i n calendar year 1982 and, as
of July 15, received 11 complaints i n 1983.
** Podiatry Board members were d i r e c t l y o r i n d i r e c t l y involved i n four of
the nine complaints investigated between January 1, 1982, and July 15,
1983. In two cases the complaint was against a Board member; i n the
other two cases, a Board member was the second doctor consulted by the
complainant.
Board Does Not Ensure
P a t i e n t C o n f i d e n t i a l i t y
The Board should adopt procedures t o ensure c o n f i d e n t i a l i t y of
complainants and p a t i e n t s . Although it appears t o be u n i n t e n t i o n a l , names
of complainants have been improperly disclosed t o doctors involved i n the
complaints, and complainant and p a t i e n t names have been improperly
disclosed i n Board minutes.
A. R. S. $ 32- 852.01 p r o h i b i t s the Board from d i s c l o s i n g names of
complainants except when necessary a s part of a d i s c i p l i n a r y proceeding:
". . . Any p o d i a t r i s t , a s s o c i a t i o n , h e a l t h c a r e
i n s t i t u t i o n or other person who reports or provides
information t o the board in good f a i t h s h a l l not be
subject t o c i v i l damages as a r e s u l t t h e r e o f , and the
name of t h e r e p o r t e r s h a l l not be disclosed unless the
information is e s s e n t i a l t o the d i s c i p l i n a r y
proceedings conducted pursuant t o t h i s section. . . ."
The Board has not complied with t h i s provision.* When a complaint is
received, the Board n o t i f i e s t h e doctor involved i n the complaint and
requests a response. In its correspondence with the doctor, the Board
r o u t i n e l y d i s c l o s e s the name of t h e complaining party. In an opinion
dated August 4, 1981, the L e g i s l a t i v e Council addressed t h i s matter a s it
r e l a t e s t o another h e a l t h regulatory board with similar s t a t u t o r y
provisions :**
* Both the Board and its Attorney General r e p r e s e n t a t i v e expressed
concern over the d i f f i c u l t y of complying with these r e s t r i c t i o n s .
They recommend t h a t complainants sign a waiver exempting the Board
from these provisions or t h a t s t a t u t o r y r e v i s i o n s be considerd. ** The board r e f e r r e d t o is t h e Board of Osteopathic Examiners i n
Medicine and Surgery. The Osteopathic Board, BOMEX and the Podiatry
Board a r e a l l prohibited from d i s c l o s i n g names of complainants except
when necessary a s part of a d i s c i p l i n a r y proceeding.
". . . t h e meaning of t h e ( s t a t u t o r y ) language . . . is
c l e a r . The name of any person who r e p o r t s or provides
information t o t h e Board i n good f a i t h s h a l l not be
d i s c l o s e d u n l e s s such person's testimony is e s s e n t i a l
t o a d i s c i p l i n a r y proceeding. . . . Giving t h e language
of t h i s s t a t u t e i t s p l a i n meaning does not r e s u l t i n
impossible o r absurd consequence."
The Board can c o r r e c t t h i s problem by requesting p a t i e n t records, without
i d e n t i f y i n g the name of the complainant. Although t h e p a t i e n t o f t e n is
t h e complainant, t h i s is not always the case; and the i d e n t i t y of the
complainant need not be made known t o the doctor involved.
Names i n Minutes - The Board has a l s o improperly disclosed names of
complainants and p a t i e n t s i n Board minutes. The Board has r e g u l a r l y
included names of complainants i n its minutes which a r e a v a i l a b l e t o the
public. We reviewed minutes of 16 Board meetings i n which complaints were
discussed held between June 5, 1981, and June 17, 1983. In 12 meeting
minutes, names of complainants a r e improperly disclosed.
Because the complainant is often the p a t i e n t involved i n the case,
d i s c l o s u r e of complainant names i n minutes v i o l a t e s s t a t u t o r y provisions
designed t o p r o t e c t the i d e n t i t y of the p a t i e n t . A. R. S. 532- 852.01 s t a t e s
t h a t
" L. . . . any information from which a p a t i e n t o r h i s
family might be i d e n t i f i e d or information received and
records kept by t h e board a s a r e s u l t of the
i n v e s t i g a t i o n procedure outlined i n t h i s chapter s h a l l
not be a v a i l a b l e t o the public."
The s t a t u t e f u r t h e r s t a t e s t h a t
" N. The Board and i t s employees, agents and
r e p r e s e n t a t i v e s s h a l l keep i n confidence the names of
any p a t i e n t s whose records a r e reviewed during the
course of i n v e s t i g a t i o n s and proceedings pursuant t o
t h i s chapter."
In a d d i t i o n , d i s c l o s i n g the names of complainants, both t o doctors
involved i n the complaints and i n minutes, could discourage i n d i v i d u a l s
from f i l i n g complaints. Disclosing names may a l s o s t r a i n the p a t i e n t ' s
r e l a t i o n s h i p with h i s doctor and r e s u l t i n f r i c t i o n , ill f e e l i n g and
subsequent problems f o r the p a t i e n t .
CONCLUSION
Although now more timely, Board complaint- handling procedures require
f u r t h e r improvement. An independent p r o f e s s i o n a l medical i n v e s t i g a t o r
should be used instead of Board members f o r complaint i n v e s t i g a t i o n s . In
a d d i t i o n , the complainants should be contacted and medical records
obtained during complaint i n v e s t i g a t i o n s . F i n a l l y , the Board has not
complied with s t a t u t o r y r e s t r i c t i o n s designed t o ensure p a t i e n t and
complainant c o n f i d e n t i a l i t y .
RECOMMENDATIONS
1. The L e g i s l a t u r e should c o n s i d e r i n c r e a s i n g t h e Podiatry Board's
appropriation t o allow the Board t o c o n t r a c t f o r the s e r v i c e s of an
independent professional medical i n v e s t i g a t o r .
2. The Board should contact complainants and review medical records
during complaint i n v e s t i g a t i o n s .
3. The Board should comply with s t a t u t o r y provisions on c o n f i d e n t i a l i t y
by withholding names of complainants from doctors involved i n the
cases and keeping complainant and p a t i e n t names from appearing i n
minutes a v a i l a b l e t o t h e public.
FINDING I1
BOARD STATUTES UNNECESSARILY RESTRICT THE PRACTICE OF PODIATRY.
Some Board s t a t u t e s governing the p r a c t i c e of podiatry do not serve a
v a l i d public purpose and could be eliminated. R e s t r i c t i o n s on the
offering of g i f t s t o a t t r a c t p a t i e n t s a r e not necessary t o p r o t e c t t h e
public and a r e anticompetitive. Statutory r e s t r i c t i o n s governing where
p o d i a t r i s t s may p r a c t i c e a l s o a r e not necessary t o p r o t e c t public h e a l t h ,
s a f e t y and welfare.
Statutory R e s t r i c t i o n s
Current Podiatry Board s t a t u t e s and r e g u l a t i o n s do n o t a l l o w p o d i a t r i s t s
t o provide g i f t s such a s coupons, f r e e examinations or monies t o procure
p a t i e n t s . A. R. S. $ 32- 854.01 s t a t e s t h a t
" Unprofessional conduct, under the provisions of t h i s
c h a p t e r , i n c l u d e s :
1. o f f e r i n g , giving, or promising, e i t h e r d i r e c t l y or
i n d i r e c t l y , any g i f t i n r e t u r n f o r t h e procurement of a
p a t i e n t o r p a t i e n t s f o r p o d i a t r i c a l treatment."
Board r e g u l a t i o n R4- 25- 01. B, d e f i n e s t h e term g i f t :
" The term g i f t a s used under A. R. S. $ 32- 854.01 s h a l l
include t h e following :
1. Monies, reimbursements and discounts
2. P r i z e s , merchandise, coupons
3. Free p o d i a t r i c s e r v i c e s , including f r e e
examinations, treatments and x- rays a s inducements
t o procure a p a t i e n t . "
In a d d i t i o n , A. R. S. $ 32- 854.01 r e s t r i c t s the l o c a t i o n where p o d i a t r i s t s
may p r a c t i c e :
"" Unprofessional conduct, under the provisions of t h i s
c h a p t e r , i n c l u d e s :
6 . Conducting the p r a c t i c e of podiatry i n connection
with a beauty p a r l o r , barbershop, t u r k i s h bath, shoe
s t o r e , department s t o r e , massage p a r l o r , or other such
commercial establishment."
P o d i a t r i s t s found i n v i o l a t i o n of these r e s t r i c t i o n s a r e subject t o
d i s c i p l i n a r y a c t i o n by t h e Board.
G i f t R e s t r i c t i o n s Unnecessary
Statutory r e s t r i c t i o n s on t h e offering of g i f t s a r e unnecessary and could
be eliminated. The Board has never received a p a t i e n t complaint regarding
g i f t s and h a s o t h e r s t a t u t o r y a u t h o r i t y t o c o n t r o l fraudulent or
misleading a d v e r t i s i n g . The United S t a t e s Department of J u s t i c e considers
the Board's g i f t r e s t r i c t i o n s anticompetitive and recommends t h e i r removal
from t h e s t a t u t e s .
Although the g i f t r e s t r i c t i o n s have been i n t h e s t a t u t e s f o r many years,
t h e Board has never received a r e l a t e d p a t i e n t complaint. Some
p o d i a t r i s t s i n the past few years have complained t o t h e Board about other
p o d i a t r i s t s a d v e r t i s i n g f r e e examinations. However, the Board on advice
from its Attorney General r e p r e s e n t a t i v e has discontinued acting on these
d o c t o r s ' complaints on t h e premise t h a t the Board should pursue only cases
1) demonstrating t h a t a complainant has been misled or 2) involving
fraudulent p r a c t i c e s .
This r e s t r i c t i o n is not necessary t o p r o t e c t the public from p o t e n t i a l l y
f a l s e o r misleading a d v e r t i s i n g . The Board has a u t h o r i t y t o a c t on these
v i o l a t i o n s under a separate s t a t u t o r y provision. A. R. S. s32- 854.01.7.,
e s t a b l i s h e s f a l s e , deceptive or misleading a d v e r t i s i n g a s unprofessional
conduct s u b j e c t t o Board d i s c i p l i n a r y action.
The United S t a t e s Department of J u s t i c e , A n t i t r u s t Division, began
i n v e s t i g a t i n g the podiatry Board's r e s t r i c t i o n s on g i f t s i n 1981 and now
recommends t h a t t h e r e l a t e d s t a t u t e and r e g u l a t i o n s be rescinded. In a
l e t t e r t o our Office, t h e J u s t i c e Department concluded t h a t the g i f t
r e s t r i c t i o n s a r e anticompetitive:
" These provisions, i f enforced or followed, would
i n h i b i t t h e manner i n which p o d i a t r i s t s a r e able t o
compete with one another since many p o d i a t r i s t s o f f e r
discounts and f r e e f i r s t o f f i c e v i s i t s . It is the
A n t i t r u s t Division's p o s i t i o n t h a t the s t a t u t e and
r e g u l a t i o n should be rescinded."
Additionally, the c o u r t s have ruled t h a t t h e r e is a consumer r e l a t i o n s h i p
between doctor and p a t i e n t . Doctors should be able t o provide and
consumers receive discounts, f r e e s e r v i c e s and g i f t s .
S i t e R e s t r i c t i o n s A r e Unnecessary
R e s t r i c t i o n s on where p o d i a t r i s t s may p r a c t i c e a r e a l s o unnecessary t o
p r o t e c t public h e a l t h , s a f e t y and welfare. No other h e a l t h regulatory
Board i n Arizona has a s i m i l a r provision.
According t o Board members, r e s t r i c t i o n s on l o c a t i o n s of podiatry
p r a c t i c e s a r e not necessary t o p r o t e c t public h e a l t h and s a f e t y . Board
members speculate t h a t these r e s t r i c t i o n s were o r i g i n a l l y intended t o
promote t h e s t a t u s and d i g n i t y of the profession, r a t h e r than t o b e n e f i t
the public.
No other h e a l t h regulatory board i n t h e S t a t e of Arizona r e s t r i c t s the
s i t e of p r a c t i c e . We examined the s t a t u t e s and r e g u l a t i o n s of 12 h e a l t h
regulatory boards. Only the Podiatry Board r e s t r i c t s l o c a t i o n of p r a c t i c e .
Removing site r e s t r i c t i o n could p o t e n t i a l l y b e n e f i t consumers.
P o d i a t r i s t s p r a c t i c i n g i n shared f a c i l i t i e s may provide more convenient
and a c c e s s i b l e s e r v i c e s t o the public.
CONCLUSION
Statutory provisions which p r o h i b i t p o d i a t r i s t s from offering g i f t s t o
a t t r a c t p a t i e n t s a r e unnecessary and anticompetitive. R e s t r i c t i o n s on
where p o d i a t r i s t s may p r a c t i c e a r e a l s o unnecessary and could be
eliminated .
RECOMMENDATIONS
1. The L e g i s l a t u r e should consider deleting s t a t u t o r y provisions which
r e s t r i c t p o d i a t r i s t s from offering g i f t s t o a t t r a c t p a t i e n t s and
l i m i t i n g where p o d i a t r i s t s may p r a c t i c e .
2. The Board should rescind r e g u l a t i o n R4- 25.01. B. r e l a t i n g t o g i f t s .
State of Arizona
Board of Podiatry Examiners
1645 W. Jefferson Room 41 8
Phoenix, AZ 85007
September 14, 1983
Mr. Douglas R. Norton
Auditor General
111 W. Monroe, Suite 600
Phoenix, Arizona 85003
Re: Performance Audit - Sunset Review
Dear Mr. Norton:
The Arizona State Board of Podiatry Examiners wishes to express
its appreciation to your staff for its handling of the sunset
review of the Board's activities. The Board has worked very
hard in the last two years to improve its performance. We
were pleased you found that complaint investigations are timely,
that our minutes and files are complete and that we have
developed and implemented an examination grading procedure
which is consistent and fair.
The Board agrees generally with the sunset factors delineated
in the report. We recognize that improvements always can be
made and assure you that we will endeavor to continue our
positive strides.
The Board agrees that the statutory provisions regarding patient
and complainant confidentiality need to be modified. As you
noted in your report, we believe current statutory restrictions
make compliance difficult. In most cases, the complainant is
the patient; consequently, it is impossible to request the patient's
records from his podiatrist without revealing the complainant's
name. The Board believes your conclusion that minutes " regularly"
include confidential names mistakenly gives the impression that
such information is routinely made public. It is not.
We endorse wholeheartedly your recommendation that the Legislature
increase our appropriation to allow us to contract for the services
of an independent professional investigator.
Mr. ~ ouglas R. Iiorton
Page Two.
September 1 4 , 1983
Thank you again f o r your courtesy and cooperation during
the course of t h i s a u d i t .
Sincerely, - I
/
M. Barry Rosenthal, D. P. M.
President
Arizona S t a t e Board of Podiatry Examiners