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Ethical and Managerial Considerations Regarding State Physician Health Programs

2012 Commentary in the Journal of Addiction Medicine by J. Wesley Boyd, MD, PhD, and John R. Knight, MD, (J Addict Med. 2012 Dec;6(4):243-6).  The authors report having 20 years of service as associate directors of one state PHP (Massachusetts), and are extensively familiar with PHP organization and practice throughout the nation.    

Send correspondence and reprint requests to J. Wesley Boyd, MD, PhD, 1493 Cambridge Street, Cambridge, MA 02139.   E-mail: jwboyd@cha.harvard.edu. The authors declare no conflict of interest.

Excerpts from this article:

"CONFLICT OF INTEREST IN REFERRALS FOR EVALUATION AND TREATMENT

Some PHPs perform their own evaluations of physicians and only refer the most complicated cases out for external review.  Other PHPs refer every physician who enters their program for an initial evaluation.  Also, if a physician who is being monitored tests positive for a substance of abuse, is known to have relapsed otherwise, or has a significant recurrence of a psychiatric disorder, the PHP may require an outside “independent” evaluation.  Although they perform an important function, these evaluations carry with them ethical dilemmas. 

First, evaluations are usually not covered by insurance and they are costly (as high as a $4500 minimum charge for a 96-hour evaluation) (Boyd, personal communication, 2010).   If the evaluators recommend treatment, clients are given the opportunity to go to various centers for treatment,  but they often elect to stay at the same site where they obtained their evaluation (with costs as high as $39,000 for a standard 90-day length of stay [LOS]; some even more costly).  This expense  can be prohibitive, especially for physicians in training and for those who are not working.  For example, an out-of-work physician received a grant from his state medical society’s “benevolent fund” to obtain an evaluation but could not afford to pay for treatment when it was recommended, so instead of staying he simply left the center.  If treatment is priced so high that it is out of the reach of potential physician patients, it does not serve the purpose for which it was created and thus represents an administrative and management failure on the part of the PHP. 

Furthermore, it is not clear to us why, for many PHP clients, the LOS should be so much longer than the LOS on average for non-PHP patients.  Although individuals who re-main in treatment do better than those who drop out, we could find no studies supporting a specific LOS for healthcare professionals.  Thus,  the only guarantee for requiring physicians to remain in treatment for 90 days compared to the more standard 21-to28-day LOS is that it will cost more, perhaps prohibitively so for some physicians. 

Also, because many centers that specialize in evaluating healthcare professionals also provide costly treatment, can any one ensure that financial incentives did not play a role in the recommendation?  In our experience, it is far more common for physicians to simply stay at the same facility for treatment rather than packing up and moving elsewhere. 

To further complicate matters, many evaluation/treatment centers depend on state PHP referrals for their financial viability. Because of this, if, in its referral of a physician, the PHP highlights a physician as particularly problematic, the evaluation center might—whether consciously or otherwise—tailor its diagnoses and recommendations in a way that will support the PHP’s impression of that physician.  Adding to the potential conflict of interest,  evaluation and treatment centers often sponsor exhibits at PHP regional and national meetings, thus supporting PHPs financially. The relationships between PHPs and evaluation/treatment centers are thus replete with potential conflicts of interest."

"INTERTWINED RELATIONSHIPS WITH STATE LICENSING BOARDS

A majority of PHPs in the United States (30 of the 43 PHPs that reported) receive a substantial portion of their funding from their state licensing board (Federation of Physician Health Programs, 2009). Thus, even if they are not run by their licensing boards, most PHPs are beholden to the licensing board and might act in ways to keep the board satisfied, rather than risk loss of financial support or even closure. After running afoul of its licensing board, for example, the PHP in California was shut down (California Physician Advocacy Group, 2009). Most PHPs thus have a potential conflict of interest any time they communicate with their licensing boards about any physician. To further complicate matters, the physicians on staff at PHPs are themselves licensed by their state boards and, as such, could be compromised in any dealings with their licensing board. As an example, Massachusetts regulation 243 CMR1.03 requires any licensed healthcare professional to report any physician suspected of being impaired (Massachusetts Board of Registration in Medicine, 2010). Therefore, physician members of PHPs could be professionally vulnerable if they do not report such colleagues, even though most PHPs would cease to exist if they fully adhered to this mandate."

Copyright 2012, American Society of Addiction Medicine

 

Challenges in Regulating Physician Health, the Oregon Experience 

Slide presentation given by Susan T. Haney, MD, FACEP, FAAEM, at OSMAP and The Forum for Medical Affairs 2011 annual meeting in Chicago, prior to American Medical Association House of Delegates 2011 meeting. 


The Wrong Rx for Addicted Doctors 

2013 article by Anne M. Fletcher, author of "Inside Rehab: The Surprising Truth About Addiction Treatment—and How to Get Help That Works" (Viking, Feb. 2013).  Published in The Fix, the world's leading website about addiction and recovery.  Describes systemic problems with PHP's (Physician Health Programs) and discusses alternatives.  Presents several case reports as examples.

Secular Recovery Programs to be Approved by Massachusetts Medical Officials

June 2013 press release by the American Humanist Association outlining formal request for non-AA (non-religious, non-12-step) secular program alternatives to be explicitly offered to physician licensees referred for assessment of (or treatment for) possible substance use disorders, from the AHA's Appignani Humanist Legal Center (also see supplemental July 2013 press release entitled AHA Legal Center Gets Desired Secular Treatment Program Language).

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