In this study we started out with the intention of: (1) determining the extent to which managed care organizations are reporting adverse actions they take against health care practitioners to the National Practitioner Data Bank and (2) identifying the factors that influence their level of reporting. As we became more aware of the explanations for a low level of reporting, we developed a broader concern that goes beyond our initial intent. That concern centers on the limitations of the entities that managed care organizations increasingly rely upon to protect patients from poorly performing practitioners. In the report, we elaborate on that concern and review ways in which it might be addressed.