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Letter: The Truth about PHPs

doi: 10.1097/01.EEM.0000482490.68236.7e
Letter

Editor:

Many thanks for continuing to cover the physician mental health issue by way of the recent article on physician health programs. (“Physician Health Programs: Coercive or Supportive?” EMN 2016;38[2]:20; http://emn.online/Feb16PHPs.)

I do not believe PHPs report positive drug test results or noncompliance directly to credentialing agencies or employers but rather directly to Medical Licensure Boards (MLBs). The MLBs then typically take adverse actions against the physician's license, actions that by law must be reported to the National Practitioner Databank. All current and future (potential) licensure boards, credentialing agencies, and employers are required by law to query the databank for such reports.

Despite this protocol, there are a few reports of PHPs informing employers that physicians labeled as “possibly abusing alcohol” (without meeting criteria for alcohol abuse) have been admitted to evaluation or “rehabilitation” facilities, essentially thereby divulging protected health information to the public. There is even one state MLB that was for a time also tweeting all disciplinary actions, in addition to the newsletter and website reporting that is now routinely done by most MLBs.

The North Carolina state audit of the NCPHP is readily available online. (NCOSA #8141, 2014; http://bit.ly/1QgkXSv.) Although dismissed by Warren Pendergast in the article as having made a few minor recommendations, the auditor's report was actually quite comprehensive, and almost uniformly critical of him as the executive and clinical director of the program for the lack of objectivity, lack of meaningful due process and very clear opportunities for conflict of interest operant in the program, and its relationships with “selected” diagnostic and treatment facilities that are “selected” on the basis of no documented criteria, which supported the PHP and FSPHP financially in a variety of ways, and many of whose diagnostic findings would then determine the length and type and therefore the costs of treatments mandated.

Robert DuPont, MD, quoted extensively in the article as an authority on PHPs, was the drug policy director under Presidents Nixon and Ford. He co-founded the sixth largest employee assistance program (EAP) in the United States which promotes, manages, and profits from drug testing for more than 10 million people including, no doubt, physicians. One need only Google him to see that he is hardly a disinterested person considering the entire emerging Federation of State Physician Health Programs/American Society of Addiction Medicine (FSPHP/ASAM; they are two faces of the same group of individuals) paradigm which he coauthored, the central tenet of which is frequent, prolonged, and random drug testing. And that testing is applied to nearly all PHP participants, whether or not there is any evidence of actual substance use.

His assertion that “programs (PHPs) have no leverage. They have no punishment; they have no consequences” is specious. PHPs have all the leverage that they need in the contingency management systems they utilize because the threat of MLB reporting hangs like a sword of Damocles over any physician who does not comply with “each and every recommendation” made by the PHP and memorialized in a contract of adhesion.

Abstinence-only lifelong faith-based programs for addiction management based on a 12-step philosophy (to the exclusion of more scientifically grounded substance use programs, as explored in the Feb. 23, 2016, New York Times at http://nyti.ms/21jP2re) is now the established modus operandi of all physician health programs in the United States. Some suggested reasons for this takeover are explored in-depth in Greg Horvath's “The Business of Recovery” (http://bit.ly/1oKijKF) and also by Janet Parker. (“Whistleblower: Abuse and Neglect in USA Residential Treatment Centers,” pp. 48-72, http://bit.ly/1Q4AoM2.)

The cost of PHP-mandated treatment was also grossly underestimated by DuPont. A 2011 survey by an emergency physician of many of the “selected/preferred” treatment programs used exclusively by PHPs revealed that the lowest cost for an inpatient treatment program was $32,000 and the average was about $45,000. These were the costs five years ago for stays as short as 30 days. While typical rehabilitation inpatient stays for non-physicians are dictated by insurance and average about 28 days, certain self-interested organizations such as FSPHP/ASAM have been promulgating the notion (without any evidence) that the “standard of care” for inpatient rehabilitation of physicians is now 90 days.

The notion that physicians are financially able to pay more for the same treatment than a non-physician for the same treatment is odious and unattributed but probably came from an article quoting Mr. Pendergast in the Journal of Medical Licensure and Discipline, “Physicians assistants as a whole don't have the same ability to pay for long-term treatment. They just don't have as deep of pockets as the physicians when they get into trouble.” (Andrews, L JMLD 91:4; 2005 at 8.)

This to me is a deeply troubling assertion. Not only does it hint at a kind of price-fixing based on ability to pay (which is illegal when there is pressure to comply and no real ability to comparison-shop between vendors or products such as in the PHP setting), but it hints very directly at the real motive behind the supposed “patient safety concern” being addressed by PHPs. It is little wonder that the PHP paradigm is now being touted as the ideal standard of care for all. This is mission creep at its most flagrant.

More about these issues is collected at my website, www.Black-Bile.com: http://bit.ly/1oKj8Dh.

Louise Andrew, MD, JD

Sidney, British Columbia, Canada

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