I used to be an Associate Director in a state physician health program (PHP) and I served as a consultant when the state of North Carolina audited its PHP. Now, roughly twice a month I am contacted by a physician somewhere in the U.S. who is, effectively, being extorted.

How are they being extorted? These physicians are forced to either pay tens of thousands of dollars to for-profit evaluation/treatment centers or else lose their ability to practice medicine.

Here is how the extortion evolves: First, a physician gets referred to their state PHP because of some sort of concern—possible substance use or erratic behavior or inability to keep up with expectations or being a bit too loud in advocating for patient care. The physician then (often) blithely goes to the PHP, not realizing the very serious threat to their . The PHP then refers them to a multiday psychological evaluation that costs between $6,000 and $10,000, which insurance rarely covers. These evaluations, in turn, frequently result in the physician being told that they need to stay for 30 to 90 days for treatment.

If physicians pony up the money and do the required time, they often are allowed to continue practicing medicine, generally with some kind of monitoring program in place. If physicians refuse to comply with the PHP or evaluation center recommendations, the PHP informs the state board of medicine as much, often resulting in the physicians losing their ability to practice, no matter how flimsy the initial referral.

How did we get here?

PHPs snuck into the powerful position they now hold under the radar. They started off 50 years ago as benevolent, rag-tag groups of physicians, often those who had kicked their own addictions, helping other physicians get clean and sober. Boards of medicine came to trust them for good reasons, but the problem is that boards continue to trust them despite a radical change in how PHPs do business.

PHPs are now corporate entities with significant financial conflicts of interest that routinely refer doctors, no matter how unsupported or minor the concerns about them might be, to out-of-state evaluations at for-profit centers. (Some state PHPs do their own evaluations and only refer complex cases for these evaluations but this is not the norm.) Many of these centers offer “treatment” that can cost tens of thousands of dollars and often recommend it, no matter if a physician actually has a problem or not.

If the physician thinks that they’ve been referred inappropriately to their physician health program, they are basically out of luck, because around the country there are generally no avenues of appeal once a PHP has made its “recommendation." Either do what the PHP tells you or the PHP will inform the board of medicine that you didn’t follow their directions.

The problem is that state boards of medicine now generally defer any and all questions about physicians who might be impaired to PHPs and if the PHP tells the board a physician is impaired or is uncooperative—for example, balking at the demand to go to a treatment center—the board generally yanks that physician’s license.

But what the boards of medicine either don’t know or choose to overlook is the fact that PHPs have extensive financial ties to centers around the country to which they refer doctors. Evaluation/treatment centers often sponsor local, regional, and national PHP meetings. Given these financial arrangements, is it surprising that the centers that sponsor PHP meetings are the ones that become “preferred”?

What happens if a physician asks to go to an academic medical center instead? Overwhelmingly the answer is no. What about an evaluation by one of the top 20 departments in the country? No. What about an evaluation by a local psychologist or forensically trained psychiatrist? No. What if that same clinician were a full professor at a top medical school? Still, the answer is overwhelmingly no. What if a physician asks to go to the single best psychological or psychiatric department in the country? Again, the answer is no. Instead of being able to be evaluated in the best facilities, doctors are sent for evaluations that are financially motivated in a multitude of ways; boards of medicine are either complicit or being duped.

Why do abuse and extortion persist?

For the most part, physicians don’t know that they ought to be concerned about PHPs and evaluation/treatment centers and only become concerned once they’ve been referred. And if they complain once they’ve been referred to a PHP, they are generally seen as belly-aching or as addicts in denial, instead of having their concerns taken seriously. (When I submitted my first piece about PHP abuses to JAMA I received a call from the editor-in-chief who asked if I or my co-author had been referred to a PHP; only after I told her no was she willing to send the paper out for review.) The result is that there has been no effective voice to cause boards of medicine to question PHPs and not enough legal action to cause PHPs to change their practices.

Something has to give. Physicians who need help need to get it in a manner that is free of financial and other conflicts of interest. Physicians need to be able to appeal unfair and unethical referrals by PHPs quickly and inexpensively. We all need to know that if our doctors need help it is readily available to them in places other than centers with financial conflicts of interest. Forensically trained and/or academic clinicians would be best. Boards of medicine ought to take note and stop essentially giving PHPs carte blanche to dictate what physicians need.

Every physician in the U.S.—and, in fact, every patient—ought to join in calling for fairness and transparency in PHP recommendations. Physicians with mental health or problems need to know that the recommendations and treatment they receive are free of conflicts of interest and are the best available. Physicians also ought to call for PHPs to begin sending doctors to local non-profit academic institutions for evaluation and treatment. And, given how compromised PHPs are, everyone ought to encourage their board of medicine to stop accepting any and all PHP recommendations about physician treatment. Until there is a groundswell of opposition against standard practices, profiteering on the backs of vulnerable physicians will continue.

I look forward to the day when my phone stops ringing and my email inbox goes silent from doctors who have unnecessarily been forced into the PHP-evaluation racket.