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The Rapid Growth of APPs and Burgeoning Risk for MPL

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Federal Administrative Actions Impact MPL

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Inside Medical Liability

Second Quarter 2022

 

 

Physician Health Programs: Changing the Culture of Medicine

Creating a New Model for Addiction Treatment

By Amy Buttell

 

The impact of untreated addiction on society is genuinely horrific. For millennia, people have struggled with finding solutions to deal with the problem effectively. According to the Centers for Disease Control, in the 12 months ending in April 2021, more than 100,000 Americans lost their lives because of drug overdoses, an increase of 28.5% from the 78,056 deaths during the same period the year before.1

Incredibly, the highest overdose death rate was in adults aged 35-44. This age group represents individuals in the prime of their productivity. Considering the exponential increases in technology over the last century, it is remarkable that our current approaches to address this crisis continue to fail.

A striking exception is the Physician Health Program (PHP), utilized by physicians and other healthcare professionals for more than 40 years. PHPs have produced some of the highest rates of documented long-term recovery of any patient population. PHP services may be unfamiliar to most physicians and even less familiar to the public. Recognizing the effectiveness of these programs and promoting their services can help change the culture of medicine by demonstrating that rehabilitation does work. This will support physicians and may serve as a template for helping all people with addictive disorders and other potentially impairing mental health issues.

The ABCs of PHPs

One of the easiest, most effective ways to support physicians with mental health issues, including addiction, is utilizing PHP services. PHPs are organizations that provide confidential support and advocacy for physicians and other healthcare professionals who suffer from potentially impairing health conditions including addiction, psychiatric illness, nonpsychiatric medical conditions, cognitive disorders, and workplace-related stress and burnout.

PHPs have been in existence since the late 1970s. The Federation of State Physician Health Programs (FSPHP), the national association for PHPs, was established in 1991. The Federation evolved from initiatives taken by the American Medical Association, the Federation of State Medical Boards, state medical societies/associations, and individual state physician health programs. A primary objective of the Federation is to raise awareness regarding PHP services. The Federation established updated guidance for individual state PHPs with the 2019 FSPHP Physician Health Program Guidelines. Currently, PHPs operate in 47 states and the District of Columbia.

Physicians, like all other individuals, are human and suffer from mental health issues such as addiction. Physicians experience addiction at rates of 10% to 15%, which is comparable to the general public.2 Because the prospect of a physician practicing medicine with an untreated addiction is quite concerning, it’s important to distinguish between illness and impairment. Illness exists on a continuum of severity. The aim of PHPs is to identify and address illness before it progresses to impairment, ensuring safe practice.

Utilizing the expertise of PHPs to provide education, support, and monitoring promotes the effectiveness of rehabilitation. PHPs provide an essential role in maintaining a healthy physician workforce. Their confidential services are protected by legislation and regulations that help reduce stigma by providing privacy for healthcare professionals who need support while balancing concerns about impaired practice.

PHP management is predicated on the understanding that potentially impairing conditions may worsen without treatment and longitudinal health monitoring, placing individual health and public safety at risk. PHP management of a participant includes initial evaluation, referral to appropriate treatment when indicated, and ongoing monitoring to document the participant’s compliance, assuring the health and wellness of the participant. Typical monitoring agreements with physician participants are for two to five years, thus ensuring long-term disease management.

Supported by organized medicine, PHPs often operate independently with some affiliation to their respective state medical association. PHPs are often nonprofit organizations and typically have formal agreements with respective regulatory agencies that clarify roles and responsibilities, avoid potential conflicts, and prioritize the professional's well-being while safeguarding public health. Finally, PHPs are a trusted resource that can provide ongoing verification of health status and safety to practice for employers, credentialing entities, and others supporting the physician’s continuation or return to clinical practice. In this way, PHPs serve a critical role in sustaining a healthcare workforce strained by the COVID pandemic and retiring senior physicians.

Addiction and Stigma

“Stigma pervades medicine, policy, and communities,” stated Dr. Nora Volkow, director of the National Institute of Drug Abuse. “We still keep addiction in the shadows, regarding it as something shameful, reflecting lack of character, weakness of will, or even conscious wrongdoing, not a medical issue warranting compassionate medical care.”3

This animus is reflected in the crisis of drug overdose deaths in the United States. Because overdose deaths impact society, it would seem reasonable that society and medical systems would respond aggressively to confront the predicament. However, any actions thus far to remedy the problem have proved ineffective based on the persistent and dramatic increases in overdose deaths during the last 20 years.

Addiction-related stigma also explains the relative lack of resources devoted to the addiction-related education of healthcare professionals. Most curricula represent a fraction of curricula dedicated to education about other chronic disease processes.4

Stigma impacts treatment utilization. Less than 11% of the 20 million Americans who needed treatment received any form of treatment in 2019, according to the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health & Human Services. Clearly, changing the culture of medicine to deal with this problem is necessary. Addiction-related stigma and the behaviors that contribute to it should be recognized and acknowledged so that improved systems and treatments that save lives can be devised. An approach that will result in meaningful cultural transformation requires extensive changes in educational priorities along with dedicated resources. Education about every facet of addiction, including etiology, presentation, course, and treatment options, should be taught to all medical students, residents, and practicing physicians.

Addiction-related harmful behaviors are the engines that drive persistent stigma, resulting in marginalization by medical systems and society. The unique behavioral manifestations of addiction are different from other chronic health problems, such as diabetes or heart disease in that they may directly harm others. Like addiction, diabetes and heart disease may result from or be exacerbated by lifestyle choices and require lifelong care. However, social externalities unique to addiction are more highly stigmatized and medically marginalized than other conditions.

Most people can recall at least one event in which they or their loved ones have been negatively impacted by the behavior of someone with untreated addiction. People with untreated addiction act out, especially while under the influence of mood-altering and disinhibiting substances. When a physical or emotional injury occurs, anger ensues. When this happens, the harmful behavior should not be justified or enabled but recognized as a manifestation of a disease markedly different from behavior associated with other chronic conditions. People with diabetes or heart disease do not typically engage in behaviors that tear apart families or result in homelessness or criminal prosecution. Unfortunately, these behaviors are frequently associated with addiction. While physicians with addiction do not typically engage in behavior resulting in criminal prosecution, their behavior before treatment often results in various adverse psychosocial consequences.

PHPs and Peer Reporting

One reason why PHPs have been so successful is that they operate in a manner that protects the privacy and dignity of the physician participants. PHP services follow state and federal laws customarily outlined in formal agreements with regulatory agencies. When appropriately authorized, PHPs may offer unique benefits while still respecting regulatory limitations to privacy. This includes provisions for a haven where licensees are not required to disclose psychiatric, addictive, or other potentially impairing illnesses to their regulatory agencies when such licensees are compliant with the monitoring requirements of their respective PHP. PHP records are often governed by Title 42 of the United States Code of Federal Regulations and other confidentiality protections. These measures may also prevent discovery in lawsuits.

PHP services usually align with peer review committees, and some PHPs offer peer review privilege, which protects all communication of a PHP in the same way that peer review committee activities are protected. 5 This assures confidentiality of communication between physician clients and PHPs, protecting against discovery and lawsuits and facilitating a safe space for the physician client to discuss their situation.

Confidentiality is an amazingly effective incentive for prompt treatment. With appropriate treatment, participants recover quickly and avoid the personal and professional consequences that can occur with the progression of untreated illness. PHPs in most states report a rapid and sustained increase in program utilization when this type of reporting requirement is implemented. A PHP must offer a confidential therapeutic alternative to discipline for their participants to qualify as a state member of the Federation.

PHP Monitoring and Public Safety

An obvious concern relates to public safety and the possibility of physicians being monitored by PHPs practicing while impaired. Fortunately, physicians monitored by PHPs who follow their monitoring agreement requirements can practice medicine safely. The monitoring process is rigorous and effective, with studies showing that 75% to 80% of participants remain substance-free throughout the monitoring period. 6,7 6,7 An additional study shows similar success for those monitored for behavioral health conditions.8 Depending on the circumstances, physician participants who experience a return to using prohibited substances during the monitoring process will have monitoring requirements intensified or be required to cease clinical practice until they are re-evaluated, treated, and deemed safe to return to work. Abstinence from substance use is documented with frequent, random toxicology testing.

As noted above, PHP participants have some of the highest rates of long-term documented recovery. Additionally, a 2013 study of 818 physician health program monitored physicians revealed that physicians who completed PHP monitoring requirements had a 20% lower malpractice risk than the matched cohort of physicians that had never been involved in the PHP.9 Monitored physicians also had 50% lower malpractice risk compared to their own risk before monitoring.

How to Support Physicians in Need

Supporting PHPs and utilizing their services is one of the most productive ways to help physicians in their time of need. This support can be provided in several ways, including collaborating with state PHPs on developing educational programs about PHP services; implementing policies that ensure timely referral for PHP services when concerns arise about healthcare professionals’ well-being; financially supporting PHPs to ensure adequate resources to meet the needs of participants; and providing PHP contact information to increase awareness about their services.

The PHP model of confidentiality, treatment rather than discipline, and long-term disease management illuminates the factors that can be successfully deployed to manage physicians with potentially impairing health conditions and serves as an effective template for all people with stigmatized health conditions.

References

1. Centers for Disease Control and Prevention. National Center for Health Statistics. Drug overdose deaths in the U.S. top 100,000 annually. Retrieved from https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm on 2022, February 14.
2. Baldisseri MR. Impaired healthcare professional. Crit Care Med. Feb 2007;35 (2 Suppl): S106-16. doi:10.1097/01. Ccm.0000252918.87746.96.
3. National Institute of Drug Abuse. 2021, November 8. To end the drug crisis, bring addiction out of the shadows. Retrieved from https://nida.nih.gov/aboutnida/ noras-blog/2021/11/to-end-drug-crisis-bring-addiction-out-shadows on 2022, February 14.
4. Miller NS, Sheppard LM, Colenda CC, Magen J. Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Academic Medicine. May 2001;76(5):410-8. doi:10.1097/00001888-200105000-00007.
5. Grossbaum DA. The sanctity of the peer review privilege. Physician Health News. 2021; 1: 9-10. https://www.fsphp.org/assets/docs/FSPHP%20Spring %202021%20Issue_FINAL2.pdf.
6. Domino KB, Hornbein TF, Polissar NL, et al. Risk factors for relapse in health care professionals with substance use disorders. JAMA. Mar 23 2005;293(12):1453- 60. doi:10.1001/jama.293.12.1453.
7. McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ. Nov 4 2008;337:a2038. doi:10.1136/bmj.a2038.
8. Knight JR, Sanchez LT, Sherritt L, Bresnahan LR, Fromson JA. Outcomes of a monitoring program for physicians with mental and behavioral health problems. J Psychiatr Pract. Jan 2007;13(1):25-32. doi:10.1097/00131746-200701000-00004.
9. Brooks E, Gendel MH, Gundersen DC, et al. Physician health programmes and malpractice claims: reducing risk through monitoring. Occup Med (Lond). Jun 2013;63(4):274-80. doi:10.1093/occmed/kqt036. Pull Quotes “Addiction-related harmful behaviors are the engines that drive persistent stigma, resulting in marginalization by medical systems and society.” “Supporting PHPs and utilizing their services is one of the most productive ways to help physicians in their time of need.”


 
Scott Hambleton, MD, DFASAM,
is the president of the Federation of State Physician Health Programs and Chair, Mississippi Physician Health Committee.

 
Michael Baron, MD, MPH, DFASAM,
is the president-elect of the Federation of State Physician Health Programs and medical director of the Tennessee Physician Health Program.
 .

 
Chris Bundy, MD, MPH, FASAM,
is the past-president of FSPHP and executive medical director of the Washington Physicians Health Program.

 
Linda Bresnahan, MS,
is the executive director of the Federation of State Physician Health Programs.