Physician health programs: ‘Diagnosing for dollars’?

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Source:  Clinical Psychiatry News

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As medicine struggles with rising rates of physician burnout, dissatisfaction, depression, and suicide, one solution comes in the form of Physician Health Programs, or PHPs. These organizations were originally started by volunteer physicians, often doctors in recovery, and funded by medical societies, as a way of providing help while maintaining confidentiality. Now, they are run by independent corporations, by medical societies in some states, and sometimes by hospitals or health systems. The services they offer vary by PHP, and they may have relationships with state licensing boards. While they can provide a gateway to help for a troubled doctor, there has also been concern about the services that are being provided.

stethoscope with lots of money

Physicians find their way to PHPs in a number of ways. A doctor whose behavior suggests impairment can be referred to the PHP by his employer, or by a licensing board, following a complaint. In these instances, participation often is a condition of employment or of continued licensure, and the PHP serves as an agent of the hospital or the state. Doctors may also be referred to PHPs for monitoring if they ascribed to having a diagnosis of psychiatric illness or substance abuse, either now or in the past, and are with or without obvious impairment. Finally, PHPs serve as a portal to treatment for physicians who self-identify and self-refer in an effort to get help. Their use is encouraged in an effort to prevent bad outcomes from mental health conditions, stress, and substance abuse, in those who are suffering in ways that would not otherwise call attention to their plights. In these situations, the PHP may serve as the agent of the patient or client, but there may remain dual-agency issues if the physician says something that leads the PHP to be concerned about the doctor’s fitness. Compliance with PHP recommendations, including drug screening, might be mandated, and physicians may resent these requirements.Louise Andrew, MD, JD, served as the liaison from the American College of Emergency Physicians (ACEP) to the the Federation of State Medical Boards from 2006 to 2014. In an online forum called Collective Wisdom, Andrew talked about the benefits of Physician Health Programs as entities that are helpful to stuggling doctors and urged her colleagues to use them as a safe alternative to suffering in silence.

More recently, Dr. Andrew has become concerned that PHPs may have taken on the role of what is more akin to “diagnosing for dollars.” In her May, 2016 column in Emergency Physician’s Monthly, Andrew noted, “A decade later, and my convictions have changed dramatically. Horror stories that colleagues related to me while I chaired ACEP’s Personal and Professional WellBeing Committee cannot all be isolated events. For example, physicians who self-referred to the PHP for management of stress and depression were reportedly railroaded into incredibly expensive and inconvenient out-of-state drug and alcohol treatment programs, even when there was no coexisting drug or alcohol problem.”

Dr. Andrew is not the only one voicing concerns about PHPs. In “Physician Health Programs: More harm than good?” (Medscape, Aug. 19, 2015), Pauline Anderson wrote about a several problems that have surfaced. In North Carolina, the state audited the PHPs after complaints that they were mandating physicians to lengthy and expensive inpatient programs. The complaints asserted that the physicians had no recourse and were not able to see their records. “The state auditor’s report found no abuse by North Carolina’s PHP. However, there was a caveat – the report determined that abuse could occur and potentially go undetected.

“It also found that the North Carolina PHP created the appearance of conflicts of interest by allowing the centers to provide both patient evaluation and treatments and that procedures did not ensure that physicians receive quality evaluations and treatment because the PHP had no documented criteria for selecting treatment centers and did not adequately monitor them.”

Finally, in a Florida Fox4News story, “Are FL doctors and nurses being sent to rehab unnecessarily? Accusations: Overdiagnosing; overcharging” (Nov. 16, 2017), reporters Katie Lagrone and Matthew Apthorp wrote about financial incentives for evaluators to refer doctors to inpatient substance abuse facilities.

Dr. Dinah Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016)

Dr. Dinah Miller

“Medical professionals who enter the programs must pay for all treatment out-of-pocket, which could add up to thousands of dollars each year. There are also no standards on how much treatment can cost.”The American Psychiatric Association has made it a priority to address physician burnout and mental health. Richard F. Summers, MD, APA Trustee-at-Large noted: “State PHPs are an essential resource for physicians, but there is a tremendous diversity in quality and approach. It is critical that these programs include attention to mental health problems as well as addiction, and that they support individual physicians’ treatment and journey toward well-being. They need to be accessible, private, and high quality, and they should be staffed by excellent psychiatrists and other mental health professionals.”

PHPs provide a much-needed and wanted service. But if the goal is to provide mental health and substance abuse services to physicians who are struggling – to prevent physicians from burning out, leaving medicine, and dying of suicide – then any whiff of corruption and any fear of professional repercussions become a reason not to use these services. If they are to be helpful, physicians must feel safe using them.

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).

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12 thoughts on “Physician health programs: ‘Diagnosing for dollars’?

    • I have been on both sides of the PHP system. I had a good experience as a physician needing help.
      But the practice of evauating a physician at a facility and then treating that same physician is a conflict of interest.
      Another problem is the high cost of treatment programs which are usually out of state. Most physicians do not have that kind of money and being away from family and work for 3 months or more adds significant additional expenses.
      I believe the PHPs should develop
      Local evaluation assets and should use the least restrictive treatment possible including day and intensive outpatient programs locally available.

      Liked by 2 people

      • I am not sure how William Griffith’s comment jumped the chronological line, but WG’s comment strikes a very soft tone. This is okay, and I do not find myself at natural odds with his view of what could or should be. Yes, if the PHPs as-they-are-today were not made up of the coagulated blood of Satan, they might be okay. If they were reformed? If they actually saved the lives of healthcare providers rather than destroy them, would I support them? Certainly. I am not spewing venom because I am a natural venom spewer. I was the first one to comment on this article and I think I set the tone. The tone is that the problem is much, much worse than the article’s author, Dr. Miller has described. My comment was followed by others who expanded on this important fact in an exceptionally useful and revealing manner. It is not right that WG’s moderately toned comments should have squeezed into a place of primacy in this string. The comment is okay. It’s placement misleads the reader.

        Liked by 1 person

  1. Kudos to Dr. Miller for this article. The reality of the matter is that it is so much worse than she describes. Anyone who writes on this topic must strategically understate matters because the full truth is among the things most find too far fetched to believe. What is going on here is pure racketeering perpetrated by an organized crime syndicate. Doctors, who are at the very heart of healthcare are held hostage and “encouraged” to make medical decisions and to embrace healthcare methods which are profitable to the syndicates. Consequences can be stiff for doctors who resist and instead, endeavor to to preserve the integrity of medicine and its reputation. Out of nowhere, problems arise in doctors’ lives – problems of the type that the syndicate can solve. The only way to survive? Become part of the syndicate. For those who do not join after a stint in the PHP clink or during extended “on-going” investigations, suspension, or temporary interim stipulated agreements (during which time doctors can’t work, lose jobs, lose clientele and reputations) … for those doctors, life becomes VERY hard. Constitutional law is laid to rest as real judiciaries allow jurisdictions’ executive branches to exploit a gangster’s gun called Administrative Law. Appointed – not elected officials are granted broad immunities from accountability for wrong doings, and these persons in turn are allowed to bestow these immunities on any entities which are willing to grow rich with them. Administrative Law takes place in figurative dark alleys where they cannot be seen by accountable elected officials who would have to provide them with oversight. For a share of the pot, it becomes convenient for elected officials to look away and to feign ignorance. I will comment again after some others do so. If I have proposed so much corruption that it is hard to believe, stay open to the believe a little longer. Dismissal of preposterous things allows preposterous things to happen. Those who commit preposterously evil acts count on the majority of people to dismiss the accounts of what they do.

    Liked by 4 people

  2. OH I know only too well how the back alley kangaroo Admin Law court works. Very few rules to follow, the Phx Admin law court you can have a ALJ hear the entire case, all witness objections, denial of motions, when closing arguments go in , and that ALJ in the court is “substituted ” with ANOTHER ALJ , who has the case for awhile and refuses to sign what the agency wants, so they “judge shop” and find a third ALJ , and he signs what they want and declare that TWO of the witnesses are “credible” . Three Judges playing musical chairs , like a scene from the Judge Ito , dancers on Saturday night live prancing around, switching places, the last two ALJ’s were NEVER IN THE COURT ROOM . Never saw the respondent , the witnesses . Witness #1 criminal record and fired ; Witness #2 risk mgr who testified and put in writing she is a “nurse paralegal ” signed RN , ‘worked as a NURSE in the facility . The risk mgr worked at that hospital (yuma ) for 13 years without a nursing license ! When discovered it was turned into the BON who did NOTHING. Oh she also said she worked as a DEA agent before that although when asked if she ever received a paycheck from DEA “no”. This is the person this 3rd judge marked credible , once this happens it is very hard to get off the record ! .

    Liked by 4 people

  3. It is good to see that the author is drawing attention to this matter, however where the tenor of it “sounds like” a yellow caution light-what it should sound and look like is huge red flashing lights and extremely loud warning bells alerting the reader to Svengali like figures who smile and say ‘we’re here to help’ when the reality is that anything you say (or sometimes don’t say) can and will be used against you in a kangaroo court of zero due process. I encourage the reader to see sites like http://www.harbr-USA.org and ideal medical care.org. Both the above organizations care about providers and aren’t about pushing out those they don’t like or don’t agree with.

    Liked by 3 people

  4. OH and the AZ BON determined that a squabble amongst kids (age 8), over 5 decades prior that in order for this nurse to be ‘safe to practice ” would be required to go to counseling , and work ‘supervised ” ! After working over 25 years in acute care in nursing alone. All based on the ‘witnesses ” who lied about being a nurses! ALTHOUGH the Boards own “expert ” who turned out to be nothing more than a ‘court whore”. Said that counseling ‘could do more harm ” ; be said MAY engage in counseling. His THIRD opinion , without any further testing or evaluation changed his opinion! Although he did not agree with the BON who ‘s only NPA (nurse practice act violation ) was listed as unprof conduct, : mentally incompetent to practice nursing with out the counseling. ! NO ONE of the AZBON has the medical degree that can diagnose someone with that label . Junk Science .

    Thanks for the article something needs to be done about this abuse of discretion !

    Liked by 4 people

  5. It is astonishing to me that physicians are not accorded the same respect, choice of treatment and privacy accorded by HIPPA all other citizens are. Physicians are in an excellent intellectual position to research and choose a treatment modality and provider that they believe will meet their needs. Yet physicians, unlike any other citizen, are being ordered into specific treatment facilities which are often uncredentialed and have no evidence of success. This treatment is ordered by a board who all too often are the only ones to perceive the need for treatment based on an attempt to restrict fair trade or because they personally disagree with another physicians acceptable treatment approaches or plain old personality conflicts. Once again finances come into play as many of these mandated treatment facilities only accept referrals from boards, thus putting them in a position of cutting off their only funding source if their findings run contrary to that of the referring board. The Medical Board’s abuse of power and misuse of the Administrative Law are destroying both innocent physician’s and those who need appropriate assistance. This is a national shame and our legislators need to prioritize correcting this system as the loss of even one brilliant caring professional is too many.

    Liked by 3 people

  6. Administrative law in the USA is usually outside the experience of individual US citizens. The perception is that it somehow is all about corporate regulations, resisting fines from the EPA or OSHA, insider trading and the like. But in no domains more than professional licensure and workers compensation is an individual more likely to encounter the inadequacies, or even abuses, of administrative law courts. When an ordinary individual sees these proceedings for the first time, it is common for them to conclude that they are utter travesties of justice. Interestingly, in the case of state professional license sanctions, states agencies have concluded that these ALJ venues do not give sufficiently great advantages to the state. So, they have turned to Physician Health Programs to accomplish their ends. The basic requirements of administrative law proceedings are minimal. There is a requirement for a hearing and there is a requirement for notice of that hearing. Absent meeting these standards, essentially anything else done in an administrative law proceeding is deemed a non-fatal error. The point is that licensing boards need only properly initiate and give notice of an administrative hearing to ALWAYS prevail. PHP’s have become very useful tools in the initiation of these proceedings. Unlike licensing boards, PHP’s need not render even rudimentary due process in most states and licensing boards take summary, immediate action on their “recommendations”. While they are almost always sole-source contractors, in most jurisdictions they have yet to be classified as “state actors” within the meaning of 42 USC 1983 and are unconstrained in their powers to make “recommendations”. This absolute power has had the expected outcomes of corrosion and corruption. In a particular Western state that you will hear much more about in 2018, the state medical board has been documented to “direct” its PHP to render a particular diagnosis, communicate this “diagnosis” back to the medical board, and then take summary action against a licensee to protect the public health and safety. Ironically, the state was moved to take this action against a licensee who pointed out the failings of the state to regulate physician medical practice in the field of workers compensation. The bleak venues provided by state administrative law courts have allowed state agencies to heap “corruption upon corruption” in implementing ultra right wing state policy.

    Liked by 1 person

  7. This is clearly a Kafkaesque nightmare few can comprehend. Generally the only ones who do are the traumatized victims who, when they can get their head around how they’ve been screwed (usually takes at least a year after the hit job), and then blown away by it.

    The cascade of ethics and legal abuses is so extensive that it is almost by definition inherently incomprehensible. It violates that many cognitive schemas we hold about integrity, especially about the medical profession. Here’s the thing though – these predatory PHPs operate under the masquerade of being legitimate psychiatric entities! I’ve written to the editor of the Clin Psych News which published Dr. Miller’s piece and hope that my essay will be published.

    As we well know from the Medscape pieces and our colleagues’ many discussions, horror stories abound. Physicians with no more than a remote history of a benign and fully resolved depressive episode may have been compulsorily sent out of state for “evaluation” (at programs featuring polygraph interrogators) and “treatment” at “preferred” inpatient programs for stays of 3 months – or longer, especially if they balked. They were likely then placed on five year “monitoring” programs in which they would be subjected to humiliating weekly onsite urine toxicology tests (self-paid of course) and compelled to attend any number of PHP-authorized treatment and behavior-correction programs. Urine toxicology tests, mandatory attendance at AA programs, compulsory psychotherapy with “approved” therapists … for physicians with no substance abuse history and no active mental health history.

    But in response, medical boards and PHPs arrogantly shrug their shoulders and say they have the right to do this, that the well-placed catchphrase “potentially impairing condition” allows them this latitude, and besides, they’re just “protecting the public” and “making sure docs get the help they need.”

    The harm done has been immense and irreparable. In my discussion with over a hundred medical colleagues over the last five years investigating these abuses (and yours probably approaches over a thousand contacts!), it is widely conjectured that multiple physicians have committed suicide specifically as a result of such arrogantly sadistic Kafkaesque ensnarement.

    Liked by 1 person

  8. from Dr. Jesse Cavenar via email:

    I agree with Dr. Andrew. In North Carolina, four highly respected psychiatrists happened to discuss among themselves physician patients who had been evaluated at the NCPHP and were subsequently seen by one of the four psychiatrists. It was noted that there was a marked discrepancy between the diagnoses that the NCPHP had made and the diagnoses established by the private psychiatrists. For example, one physician patient had been diagnosed by the NCPHP as having alcohol abuse, but six substance abuse specialty psychiatrists stated that the physician patient did not meet the required diagnostic criteria for alcohol abuse. A physician who was on the NCPHP Board in the past and who evaluated patients for the NCPHP evaluated this patient and noted in writing that the physician patient did not meet the required diagnostic criteria for alcohol abuse, but that the diagnosis could be made even if the patient did not meet the required diagnostic criteria for the diagnosis. Do tell!! While NCPHP personnel would not tell this physician patient on what basis he was mandated to be in the NCPHP program upon threat of report to the Medical Board as a substance abuser as he did not meet the criteria for the diagnosis for alcohol abuse, he was kept in the NCPHP program for thirteen months at a cost of over $100,000 for time, lost wages, laboratory tests, and the like.

    Another patient was diagnosed as having delusional disorder by the NCPHP because he thought unknown persons were following him. He lost his license to practice medicine! However, I have in writing from a retired FBI agent who has a PhD and who is a practicing attorney that in fact this man was being followed. It is very hard to make a diagnosis of a delusional disorder when in fact it is reality.

    The NCPHP and NC Medical Board have refused to discuss with me how one makes a diagnosis of an illness when the patient meets none of the required diagnostic criteria for that illness. “Diagnosing for Dollars” is a catchy title for this article and many people would believe it to be so true.

    Jesse O. Cavenar, Jr.
    Professor and Vice Chairman Emeritus
    Department of Psychiatry
    Duke University School of Medicine

    Associate Chief of Staff (Ret)
    Department of Veterans Affairs Medical Center
    Durham, NC

    Colonel, Medical Corps, U.S. Army

    Liked by 1 person

  9. Medical boards are a bunch of market actors with their own biases and desires. This is why the US Supreme Court stripped them of sovereign immunity. North Carolina State Board of Dental Examiners v. Federal Trade Commission, 574 U.S. ___ (2015).
    If that isn’t bad enough these market actors almost always “defer” to the career employees at the board and allow them to corruptly abuse the system.
    Just as there are term limits for the appointed board members, there must be term limits for those employees as well. That is the only way to begin fighting this corruption.
    It is terrible that these corrupt employees with their entrenched networks are allowed to destroy society’s most learned persons, people who chose medicine in order to do good.
    Having lived under communism in East Europe I am already familiar with the concept of taxi drivers being more powerful and regarded than university professors. The same situation exists in our medical boards where the career employees treat all doctors with undisguised contempt.
    The entire system is one of playing gotcha, with no respect at all accorded to the years and decades it takes to become a doctor and acquire a medical license.
    An investigative journalist, Kevin Hall, noted recently that psychiatry is the only field where the patient may be forced to submit to “treatment” and still have to pay for it.
    This is magnified a thousand-fold when the doctor is coerced into complying with the Board-PHS industrial complex under threat of losing his or her license and livelihood.
    All the guff about caring about physician burnout is a dreadful lie given the reality that doctors face.
    Just more salt on a very raw wound.

    A viable solution going forward is for physicians to form cooperative companies that then actively compete with the PHPs run by medical societies for the contracts under which doctors are consigned to PHPs by state boards. Competition is always healthy as hospitals discovered when the Joint Commission was dethroned as the only game in town. Cheers!

    Liked by 1 person

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