Report 2006-116R Summary - June 2007
Medical Board of California's Physician Diversion Program:
While Making Recent Improvements, Inconsistent Monitoring of Participants and Inadequate Oversight of Its Service Providers Continue to Hamper Its Ability to Protect the Public
Our review of the Medical Board of California's (medical board) Physician Diversion Program (diversion program) revealed the following:
- Case managers are contacting participants on a regular basis and participants appear to be attending group meetings and completing drug tests, as required.
- The diversion program does not adequately ensure that it receives required monitoring reports from its participants' treatment providers and work-site monitors.
- The diversion program has reduced the amount of time it takes to bring new participants into the program and begin drug testing, but the timeliness of testing falls short of its goal.
- The diversion program has not always required a physician to immediately stop practicing medicine after testing positive for alcohol or a nonprescribed or prohibited drug, thus putting the public's safety at risk.
- Twenty-six percent of drug tests in June and October 2006 were not performed as randomly scheduled.
- The diversion program's current process for reconciling its scheduled drug tests with the actual drug tests performed needs to be improved.
- The diversion program has not been formally evaluating its collectors, group facilitators, and diversion evaluation committee members to determine how well they are meeting program standards.
- The medical board has not provided consistently effective oversight of the diversion program.
RESULTS IN BRIEF
The Medical Board of California (medical board), a consumer protection agency with the goal of protecting the public by ensuring the initial and continued competence of the health care professionals under its jurisdiction, administers a program designed to rehabilitate physicians impaired by substance abuse or by mental health disorders. This program—the Physician Diversion Program (diversion program)—monitors participants' attendance at group meetings, facilitates random drug testing, and requires reports from work-site monitors and treatment providers. State law authorizes the diversion program and charges the medical board with its oversight and administration.
In addition to state employees who are principally responsible for the administration of the diversion program, other outside service providers, such as urine collection monitors (collectors) and group facilitators, participate in the monitoring and treatment of program participants. The program also uses seven regional diversion evaluation committees (DECs), made up of individuals with experience in the evaluation and management of persons impaired due to alcohol or drug abuse or a physical or mental illness, to determine prospective participants' appropriateness for and terms of participation in the program, as well as to make decisions on participants' successful completion of or termination from the program.
In our review of the diversion program, we focused on activities occurring after the November 2005 report was issued by an independent entity known as the enforcement monitor. Legislation passed in 2002 required that such an entity conduct a review of the medical board's enforcement and diversion programs. A November 2004 interim report issued by the enforcement monitor raised a number of concerns and made recommendations related to the diversion program. The November 2005 final report provided an update on these issues. We found that although the diversion program has made a number of improvements since the enforcement monitor's final report, it must continue to improve its performance and procedures in some specific areas to adequately protect the public.
The diversion program has established requirements designed to monitor participating physicians as they seek to overcome addictions and ailments that have the potential to impede their ability to practice medicine. Our review found that although the diversion program is generally complying with some of these requirements, its compliance with other requirements falls short. Specifically, case managers appear to be contacting participants on a regular basis, as required, and participants generally appear to be attending group meetings and completing drug tests. However, the diversion program is not adequately ensuring that it receives required monitoring reports from participants' treatment providers and work-site monitors and receives all required meeting verification cards from participants. For example, for the sample of participants we reviewed, the diversion program should have obtained 51 reports from participants' therapists, but it obtained only 17 (33 percent). This low level of compliance may actually be an improvement over that achieved in the past, as indicated by the statistics obtained during the enforcement monitor's review. However, by not adequately ensuring that it receives required monitoring and treatment reports and meeting verification cards, the diversion program has less assurance that its participants are complying with their treatment plans and program requirements.
In addition to the monitoring requirements it has established, the diversion program has set goals related to the timeliness with which participants will be brought into the program. Of the three goals it has established for this purpose, the diversion program appears to be meeting two, and it has made substantial improvement in all three areas in recent years. Specifically, case managers, on average, are completing intake interviews with prospective participants within the goal of seven days from initial contact with the program, and participants are appearing before a DEC for final approval to join the program within the goal of 90 days from initial contact. Although the length of time from initial contact to first drug test decreased from an average of 35 days in 2003 and 2004 to an average of 18 days in 2005 and 2006 for the sample of participants we reviewed, the diversion program has not yet reached its goal of seven days for this activity.
In reviewing the diversion program's response to positive drug tests and other indications that a physician has relapsed into drug or alcohol abuse, we found that in some instances the program did not always respond in a timely manner and did not demonstrate that its actions were adequate, thus putting the public's safety at risk. Specifically, the diversion program has not always required a physician to immediately stop practicing medicine after testing positive for alcohol or a nonprescribed or prohibited drug, as required by program policy; has determined that positive drug tests were not a relapse without providing any justification for such a determination; and has not followed the advice of its advisory committee to have a trained medical review officer review contested results.
In addition, we found that the diversion program has generally not overseen its drug test system and its service providers in an adequate manner. Specifically, although it has shown improvement in this area in recent years, a large number of drug tests are still not being performed according to the randomly generated schedule. The most frequent reason given for drug tests not being completed as scheduled was that participants had requested vacations on those days. However, a significant portion of these vacation requests never received approval from appropriate program personnel. Other reasons drug tests were not completed as scheduled were that collectors moved the tests to other dates and participants did not show up to take the tests. In these instances, the program did not document the inadequate performance of collectors and did not ensure that collectors submitted an incident report for each missed test, as required by program policy.
Further, the diversion program's current process for reconciling its scheduled drug tests with the actual drug tests performed does not adequately or quickly identify missed drug tests or data inconsistencies between collectors' reports and lab results. We also found that although the diversion program relies heavily on its collectors, group facilitators, and DEC members in the monitoring and treatment of its participants, it has not been formally evaluating these individuals to determine how well they are meeting program standards.
For its part, the medical board has not provided consistently effective oversight of the diversion program. The medical board uses a committee made up of some of its members to oversee the program (diversion committee). However, the diversion committee's ability to oversee the program is hindered by a reporting process that does not give it a complete view of the program's performance and by a policy-making process that does not ensure that adopted policies are incorporated into the program's policy manual. Consequently, rather than discovering deficiencies through the reporting process and correcting them through a policy-making process that maintains some level of continuity, the diversion committee has been notified of program deficiencies in recent years by an outside entity—the enforcement monitor. Although improvements have been made, most of the enforcement monitor's recommendations have not yet been fully implemented, even though almost two years have elapsed since the publishing of the enforcement monitor's final report. Therefore, it does not appear that the diversion committee has made a diligent effort to ensure that the program promptly implements those recommendations with which it agreed.
To better monitor diversion program participants, program management should create mechanisms to ensure that group facilitators, therapists, and work-site monitors submit required reports, and that the participants submit required meeting verifications.
To ensure a timely and adequate response to positive drug tests or other indications of a relapse, the diversion program should do the following:
- Immediately remove practicing physicians from work when notified of a positive drug test.
- Require DECs to provide justification when they determine that a positive drug test does not constitute a relapse.
- Have a qualified medical review officer evaluate all disputed drug test results if its new advisory committee determines that this action is needed.
To provide adequate oversight of participants' random drug tests, the diversion program should ensure that both the case manager and group facilitator approve all vacation requests and should establish a more timely and effective reconciliation of scheduled drug tests to actual drug tests performed by comparing the calendar of randomly generated assigned dates to the lab results.
To ensure that it adequately oversees its collectors, group facilitators, and DEC members, the diversion program should formally evaluate the performance of these individuals annually.
To effectively oversee the diversion program, the medical board should require it to create a reporting process that allows the medical board to view each critical component of the program.
To ensure that it adequately oversees the diversion program, the medical board should have its diversion committee review and approve the program's policy manual. Thereafter, the diversion committee should ensure that any policy change it approves is added to the manual.
The medical board should ensure that areas of program improvement recommended by the enforcement monitor are completed within the next six months.
The State and Consumer Services Agency agrees with our audit recommendations and has directed the Department of Consumer Affairs (department) to follow through with the medical board to ensure their implementation. The department also concurs with the recommendations and describes specific actions it would take to assist and encourage the medical board to ensure timely completion. The medical board agrees with each recommendation and describes a number of programmatic changes it has already implemented in response to the audit.