A group of Montana healthcare workers says the state-mandated monitoring program designed to help them recover from addiction instead subjects them to “punitive, expensive, and clinically unwarranted” practices, according to a class-action lawsuit filed in federal court on October 28.

These programs were first developed as physician health programs (PHPs) for doctors struggling with substance use and mental health disorders. Over time, states and licensing boards expanded them to nurses, pharmacists, and other clinicians to help them recover and ensure safe practice.

The lawsuit reflects broader concerns from healthcare workers who say that seeking this type of help is prohibitively costly and threatens their professional reputations. 

States take different approaches to monitoring programs, with some administering them internally and others contracting with vendors, leading to variation in oversight and enforcement.

The plaintiffs — anesthesiologist Christopher Thacker, MD, and 10 nurses — allege that Montana’s program vendor, Maximus, Inc., a Virginia-based government contractor, “placed profit ahead of participant safety and recovery” by imposing requirements that were not evidence-based, blocking access to records, and interfering with their ability to work.

The plaintiffs’ attorney, Gregory Pinski, declined to comment or make his clients available for an interview. A Maximus spokesperson said the company cannot comment on pending litigation.

Maximus manages Medicaid and other state and federal contracts, but details about its role in clinician-monitoring programs are limited. The company has paid more than $48 million in penalties since 2000, including False Claims Act settlements over its handling of government contracts.

Concerns about how Maximus monitors clinicians are not unique to Montana. 

Nurses in California raised concerns last year about high program costs, including $300 per month for drug testing and fines exceeding $3000, as reported by KQED. Some nurses said they were forced to forfeit their licenses because they could not comply with the strict, expensive guidelines.

Another nurse told CalMatters that she paid more than $8000 in drug testing fees and thousands more for medical and psychological evaluations. Posters on Reddit called the company’s practices “draconian” and a “racket,” with one nurse alleging to have paid Maximus $26,000 in fees.

J. Wesley Boyd, MD, PhD, senior lecturer at the Department of Global Health and Science Medicine, Harvard Medical School, Boston, told Medscape Medical News that there is increasing awareness of “very real flaws” in how monitoring programs function. 

“Before 2012, you couldn’t find a single piece of peer-reviewed literature or media critical of PHP practices,” said Boyd, who researches physician impairment and rehabilitation. “Now folks who realize that they are not being treated fairly can [see] they are not alone, they’re not crazy, and they actually have legitimate concerns.”

From Nonprofit to For-Profit

Montana approved a 3-year, $1.63-million contract with Maximus in late 2022, with operations beginning in January 2023. 

State lawmakers expressed reservations about the partnership earlier this year after a Legislative Audit Division report found that the monitoring program experienced “significant organizational instability” from 2021 to 2023 during multiple vendor changes.

For more than three decades before that, a Billings-based nonprofit ran the program for physicians, later expanding to include dentists and, in 2017, nurses and pharmacists, the report noted. The state declined to renew the longtime contract in late 2021, after employees accused the nonprofit’s director of harassment and discrimination, and an investigation found reasonable cause to believe that sex-based discrimination and retaliation occurred. 

After the contract ended and the nonprofit dissolved, Montana’s Department of Labor and Industry (DLI) assumed program administration in 2022 until the for-profit vendor Maximus took over in 2023, the audit report said. 

“Injecting the profit motive into a situation where folks generally have no choice but to comply with any and every recommendation you make if they want to be able to continue practicing is a recipe for abusive practices,” said Boyd. 

Guidelines from the Federation of State Physician Health Programs (FSPHP) recommend that monitoring programs be based in the same state as the regulatory agency and operate without “the purpose of making a profit.”

Transition Fallout

Members of Montana’s Board of Medical Examiners questioned whether the abrupt transition left some participants unsupported and, at times, unmonitored, according to the audit. Participants told audit officials that Maximus’ approach felt punitive, citing unfair treatment, inconsistent guidelines, and unrealistic expectations for perfect compliance. 

The complaint claims the company lacks meaningful appeal processes, imposes arbitrary sanctions that prolong treatment, and engages in “excessive monitoring and profiteering” by using costly toxicology tests that are not clinically indicated. The plaintiffs say those practices cause financial and emotional harm that threatens their livelihood.

The lawsuit also alleges that one participant died by suicide in January and that Maximus did not appropriately report the incident to DLI.

Some Physicians Find PHPs Helpful

Despite criticisms, many clinicians still find value in the programs. A 2022 study in the American Journal on Addictions found that 85% of physicians viewed their PHP experience favorably 5 years after completing it but noted out-of-pocket costs ranged from $250 to $321,000.

Monitoring programs should remove financial conflicts of interest with treatment centers and adhere to enforceable national standards with independent audits, said Boyd. Clinicians also need an affordable, timely way to appeal decisions, he said, beyond hiring attorneys and going to court.

Christopher Bundy, MD, MPH, FAPA, FASAM, executive medical director of the Washington Physicians Health Program and chief medical officer of FSPHP, told Medscape Medical News that monitoring programs should contain key safeguards, such as regulatory independence, transparent policies, and individualized, evidence-based monitoring.

He said that Washington’s program sets clear expectations from the outset, including mechanisms for reviewing or appealing decisions and for accessing second-opinion assessments.

“While PHPs are often criticized as being costly, the reality is that the lion’s share of the cost burden is attributable to the specialized evaluation and treatment that physicians and other safety-sensitive workers require in order to credibly verify their safety to practice,” he said. “This is not a problem of the PHPs’ making. Rather, it underscores opportunities for healthcare employers and health insurance plans to do more to alleviate these cost burdens and support the workforce.”

In October, a state advisory council unanimously recommended extending Maximus’ contract through 2026 while it reviews the program, according to the Bozeman Daily Chronicle. It is unclear whether the recommendation has been approved.

Steph Weber is a Midwest-based freelance journalist specializing in healthcare and law.