Malpractice Payments and State Medical Board Discipline: National Evidence From the National Practitioner Data Bank

Background: Malpractice payments and state medical board discipline are often assumed to identify the same physicians, yet that assumption has never been tested nationally. Methods: National retrospective cohort study using the National Practitioner Data Bank Public Use Data File (March 31, 2026 release). A total of 76 353 allopathic and osteopathic physicians without prior state licensure actions were followed from their first observed paid malpractice report (2004–2018) through March 2026. The primary outcome was any substantive new state licensure action; secondary outcomes classified actions as quality-of-care–related, nonclinical, or severe. All outcomes describe the first subsequent action in a time-to-first-event design. Results: Overall, 71 372 physicians (93.5%) had no subsequent state licensure action during observed follow-up; a severe first action occurred in 2.1% within 15 years, including license revocation in 0.2%. Among the 4981 physicians (6.5%) with a subsequent action, the first action occurred a median of 5 years after the index report, and 43.7% involved exclusively nonclinical conduct. The 15-year cumulative incidence was 2.54% for quality-of-care actions and 2.94% for nonclinical actions. Severe injury or death in the index report was not associated with subsequent quality-of-care discipline (adjusted hazard ratio, 1.01; 95% CI, 0.90-1.12). Conclusions: Board discipline following a paid malpractice report was uncommon, delayed, and frequently unrelated to clinical care. These accountability systems appear to serve complementary rather than interchangeable roles in assessing physician quality.