The vital importance of ensuring confidential access to peer assistance for medical students, physician assistants and physicians
by Polly Washburn
Featured in the Feb-Apr 2021 Colorado Medicine Colorado Medicine.
For over 30 years, Colorado physicians, physician assistants and medical students have paid into a state physician peer assistance program that allows them to access necessary physical, mental and behavioral health care, without fear of discovery by the Colorado Medical Board (CMB).
In any given year, hundreds of physicians, physician assistants and anesthesiology assistants self-refer or are referred to the program, which coordinates support for physical and mental health, substance use, education programs, and other rehabilitation options, experts, and tools.
In June 2020, the Department of Regulatory Agencies (DORA) announced its intention to award the program’s contract to Peer Assistance Services (PAS) instead of the current provider, Colorado Physician Health Program (CPHP). When it was revealed that all physicians accessing the program, both mandated and voluntary participants, would be required to sign a waiver to share their medical information with the CMB, the response was swift, strong and sustained to prevent this breach of confidentiality regardless of who the vendor is.
CMS has helped to lead the charge, working in collaboration with the House of Medicine, COPIC, Colorado Hospital Association, the Colorado Association of Health Plans, both medical schools, individual physicians, medical students and residents, hospitals, patients and legislators to object. In a letter to DORA, CMS Past President David Markenson, MD, MBA, stated, “Colorado must ensure the confidentiality of physician mental health treatment and not discourage voluntary self-referral by the implied threat to one’s license/job and the loss of professional esteem.”
Few issues have united the health care community so rapidly and feverently, obliterating any misconception that this is a minor disagreement stemming from a contracting dispute. Over 3,200 health care professionals and concerned citizens protested the change by signing a House of Medicine petition to CMB last fall to emphasize that confidentiality protections are a critical component of patient safety and physician wellbeing, and that these changes will negatively impact the practice of medicine in Colorado.
While the petition reinforces how much concern has grown over the last six months about the integrity of confidentiality protections in the peer assistance program, CMS actually started raising alarms almost two years ago in the spring of 2019. Given the priority nature of the issue, CMS advocacy has proceeded on a number of fronts including direct outreach to CMB, DORA, the governor’s office, legislative leaders and the press.
Continuous attempts to discuss this issue with DORA in order to find solutions have been stonewalled (see timeline on page 9). DORA has withheld CMS communications from CMB members, told legislators and CMB members that physicians are not interested in this issue, and claimed that confidentiality would still be preserved despite evidence to the contrary. The end of last year witnessed a bewildering series of events, including attacks by DORA’s legal counsel toward advocacy efforts by CMS and partners, last minute cancellations of public CMB meetings where confidentiality protections were to be discussed, and a November decision by an administrative law judge that vacated DORA’s procurement decision to award the next contract to PAS, citing direct violation of law because CMB was never consulted.
Throughout all of these events, CMS has doggedly emphasized that the issue here is not about which vendor is selected, but rather the importance of protecting confidential treatment for those in the peer assistance services program.
Help for those that help others
In light of the ongoing uncertainty, there have been alarming reports that voluntary usage of peer assistance services have decreased in comparison to past years.
Steven R. Lowenstein, MD, MPH, Associate Dean for Faculty Affairs, University of Colorado School of Medicine, is concerned that DORA’s decision adds to the stigmatization of mental illness. “Absent a promise of confidentiality — absent this ‘safe haven’ — students and physicians often fear for their careers and will not seek mental health care --- care that is highly effective, helps them practice safely and may save their life.”
The situation is taking place during a devastating pandemic, when medical professionals are suffering more stress, anxiety, isolation and mental illness than ever. Connie Savor Price, MD, chief medical officer at the Denver Health and Hospital Authority, says, “We’re a group vulnerable to mental health issues, and COVID has only exacerbated that. Our profession sees a lot of death, particularly now. We experience a lot of moral distress, we watch cancers go untreated, we see people getting kicked out for not being able to pay, and people dying alone. We have a higher rate of suicide, depression, and substance abuse in our profession. We want to encourage health professionals to seek help when they are experiencing a mental health issue.”
Neill Epperson, MD, the executive director of the Helen and Arthur E. Johnson Depression Center at the University of Colorado School of Medicine, agrees. “They may not be able to see for themselves how they’re doing,” she says. “Doctors are taught to be strong. There’s so much stigma to even say ‘We want you to see someone.’ Anything we add to make it more difficult will cause more harm.”
Dr. Epperson points out that for physicians who get their care where they work, confidentiality and anonymity are especially important. “For too many physicians, they are concerned how colleagues see them, or are worried it could impact their ability to get promoted. If they’re not ensured confidentiality, the problem is they are not going to go.”
In fact, a 2017 study by the Mayo Clinic revealed that nearly 40% of physicians say1 they would be reluctant to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure.
A “Game Changer”
Dr. Epperson says the peer counseling service has been a “game changer” for some faculty at the University. “To be able to get treatment, retain jobs, do well in their jobs, and just be happier people. That’s what all department chairs that refer someone want. We are not referring people to be punitive. This is to help people feel the best they can feel in difficult situations.”
Dr. Jeremy Lazarus, CMS past president, and past president of the American Medical Association puts the issue this way: “If a physician thinks another physician could be harming patients, there’s an ethical obligation to refer him -- there’s a strong collegial credo about that. That’s why having a trusted, confidential resource [to refer them to] is vital.”
The service is not just for physicians deep into their professional careers. Brian Dwinnell, MD, FACP, Dean of Student Life at the University of Colorado, says that about a dozen students use the service at any given time. “It’s very important to these students, and the thousands of patients they interact with. For students at the School of Medicine, we talk about getting mental health assistance starting at orientation. We’re trying to remove the stigma for students.”
Studies have shown that between 33-45% of medical students suffer anxiety and depression.2 Dr. Lowenstein says, “In a recent survey, one in four doctors knows another doctor who has taken their own life. None of us — students, residents, faculty, practicing physicians — should hesitate to seek mental health treatment if we need it. No one should ever second-guess themselves or feel ashamed.”
Committed to a Solution
Moving forward, CMS is pursuing all options to protect confidential peer assistance. “This is a priority for our organization,” says CMS President Sami Diab, MD. “Our physician members have been very clear about the urgent need to find a solution and we will not stop until this issue is fixed.”
Advocacy efforts are focused on both the CMB and the legislature. A CMB subcommittee is considering policy options and CMS will continue to be actively involved in those meetings. That same intensity has driven numerous conversations with legislators statewide over the past six months. The bi-partisan interest and support to ensure confidential peer assistance have been robust.
As a practicing pediatrician and a legislator, Rep. Yadira Caraveo, MD (D-31), is not only uniquely positioned to understand why a bill protecting physician confidentiality is necessary, she has also agreed to sponsor legislation this year to fix the problem if necessary. “We have a culture in medicine of ‘heal thyself’ and ‘powering through’ and that seeking help is somehow showing a sign of weakness. We want to combat that and encourage them to seek treatment. But we need to ensure that it’s a peer treatment program that provides confidentiality... If DORA continues to show reticence to working with the Medical Board and the House of Medicine and continues to push an option that does not include confidentiality and peers, then we will use the powers of the legislature to make sure those two tenets are preserved.”
The other co-sponsor, Rep. Kevin Van Winkle (R - 43), says he first heard of the issue of confidentiality from his local physician and CMS. “Almost two years ago now they educated me on the importance of the confidentiality portion and how important the program is to Colorado physicians. I was hoping it could be solved without legislative input, but with the coronavirus raging, it’s the wrong time to injure a program that is working so well for doctors.”
As of press time, CMB has created two subcommittees: one to reassess RFP for the next vendor and the other to “consider CMB policy to clarify parameters of voluntary confidential treatments.” The timing of the CMB review, recommendations and ultimate selection are yet to be determined. In the meantime, the State has extended CPHP’s current contract until April 30, 2021.
Whether the process is fixed through CMB policy or legislation, CMS will continue to fight for physicians. So please, if you need help, continue to take advantage of the current program. ■
Medical Licensure Questions and Physician Reluctance to Seek Care for Mental Health Conditions; Dyrbye LN;West CP;Sinsky CA;Goeders LE;Satele DV;Shanafelt TD; https://pubmed.ncbi.nlm.nih.gov/28982484/