(1) Acceptability of Central Licensing State centralized licensing agencies for the health care professions do not appear to be acceptable, despite their successful use in States with both large and small practitioner (registrant) populations. A number of States have adopted central licensing operations to perform administrative tasks such as processing applications, handling renewals, and collecting and accounting for fees; these States responding to the pertinent questions felt that existing licensing actions are satisfactory. However, a substantial number of State professional association representatives indicate that they have not considered a central licensing agency. Some respondent association members were ambivalent on the need for improvement in the licensing system. As a result, emphasis should be placed on making existing licensing mechanisms more satisfactory to all par ties involved. A special effort should be made to ensure adequate and timely dissemination of information to enhance the decision-making process relating to the controlled substances problem. (2) Development of Nationwide Clearinghouse Because they recognize the problems of practitioner mobility and the resulting requirements for licensure endorsement (reciprocity), the professional association representatives responding to our questionnaire supported the idea of a nationwide clearinghouse(s) to exchange information on the backgrounds of health care professionals. They indicated that the clearinghouse should include available information on all actions taken against a practitioner's license. Nursing, medical (MD's), pharmacy, and veterinary professionals said that information which would assist in evaluating qualifications of graduates of foreign health care professional institutions should be included. There is, as there was on the part of regulatory board respondents, considerable reluctance concerning Federal Government involvement in any. clearinghouse program. The respondents felt that data should be collected by the appropriate national association of health care professional regulatory or examining boards, and that these groups should also administer the data dissemination. (3) Regional and Joint Continuing Education There is apparently little activity among the States on continuing education on drug abuse by health care practitioners, patients, or controlled substance abuse in general. This may reflect a lack of interest as well as the difficulties involved in obtaining quality programs. However, it is recommended that serious consideration be given the development of regional continuing education programs and joint continuing education programs involving smaller States with large States if specific programs on drug-related issues are to be presented effectively. (4) Use of Peer Review in Controlled Substances Problem Activities The mixed feelings of the respondents toward peer review indicates the importance of this issue. It is recommended that, until peer review programs gain wider national acceptance, any comprehensive program using peer review as a means to reduce drug diversion (leakage) or improve prescribing and/or dispensing practices be delayed. This would not preclude the gradual devel opment of model State programs in those States and professions where effective and accepted programs exist or are proposed. (5) Use of Drug Utilization Reviews A substantial majority of the represented and affected professions (medicine, dentistry, and pharmacy) are not opposed to the use of drug utilization reviews. However, these respondents desire that any such programs be conducted under the auspices of either State and local professional associations or the State professional licensing/regulatory boards. They would strongly resist any national health care professional association or Federal involvement. 3. SUMMARY OF FINDINGS DERIVED FROM THE QUESTIONNAIRE SURVEY An initial survey of State regulatory activities produced observations which were further refined for application to the individual States. A follow-up was made to assess the validity of these findings. The following results indicate the responses of the professional health care association representatives to controlled substances problems which confront their constituencies. (1) Controlled Substances-Drug Abuse and Diversion The most likely sources of controlled substances diversion are multiple prescription orders and pharmacy theft. The most desired control for drug diversion is increased enforcement. Professional association representatives indicated that the most likely source of controlled substances diversion was patients who obtain prescription orders for the same ailment from a number of practitioners. Pharmacy theft was the next most likely source of diversion (leakage). Physicians (DOS) felt that pharmacy theft was the least likely source of diversion, while pharmacists felt it was the largest. However, a substantial number of physicians (DOS) did not respond to these questions. The pharmacists also listed a substantial number of other diversion sources, as did veterinary medicine professionals. Almost all respondents answered the questions by indicating the existence of a number of sources of diversion or abuse of controlled substances. As one would expect, pharmacists were the most responsive profession in answering this question. (2) Association-Sponsored Self-Regulation There is a trend toward association-sponsored self-regulation. This is demonstrated by the relatively large proportion of associations which have recently instituted programs or have programs planned. The majority of the respondents indicated that positive consideration had been given to both self-regulation and peer review, and that their association would probably be involved in administering such a program, either alone or in conjunction with the State licensing boards under local association components. Self-regulation pertaining to violation of ethics was the area of most interest to association representatives. (3) Continuing Education When asked about continuing education, respondents almost universally encouraged such efforts. However, a large group felt that it should be a voluntary rather than a required activity and that it should be sponsored by the State association. A substantial number of respondents felt that a mix of local, State, and national organizations, coupled with schools and universities, was an appropriate approach. (4) Disciplinary Proceedings Most respondents felt that private and informal hearings, rather than public, formal hearings should be held. However, a substantial number of respondents preferred that no private proceedings be held at all. Although a minority of the associations held formal proceedings, the formal proceedings which were held were, in most cases, initiated by public complaint. (5) Complaint Review Process The review process to handle complaints against professionals varies considerably among the States. Most State associations do not have a statutory or legal basis for imposing corrective action in the form of license suspensions or revocations. However, State associations have the option both to inform and defer action to the State professional boards. The survey found that respondents initially handle complaints through the association's ethics committee. As the complaint or case is processed, the board and association work closely on most cases. However, many respondents felt that the quantity and quality of the investigative support provided by boards could be improved. (6) Use of the Professional Standards Review Organization Throughout the country, the establishment of PSROS and their effect on medical prescribing 4. PROBLEM SITUATION Various enforcement agencies have welcomed self-regulation efforts of health care professional groups. Self-regulation is defined as the monitoring and control of actions of the members of the professions by the professional groups, professional colleagues, and the individual professional. If controlled substances diversion and abuse programs are to obtain the benefits of an effective association self-regulatory program, the professional associations must focus more upon the problems, methods, and developments in areas related to controlled substances statutes, rules, and enforcement policies. (1) The "Sick or Impaired Professional”* Interviews with leaders in the health professions in government and industry indicate that practitioners unfit for public practice due to alcoholism, drug dependency, or senility present a problem. State association officials prefer rehabiliating "sick or impaired professionals" rather than the harsh application of criminal sanctions. Two approaches have been proposed: •The Council on Mental Health Approach1 The Council on Mental Health suggests the following referrral patterns on matters relating to sick or impaired professionals: The individual should be persuaded informally to seek help through professional counseling or similar approaches * Recent changes in the approach to the problem practitioner have broadened the scope of the efforts described in this subsection; there has been general substitution of "impaired professional" for "sick professional" in much of the writing on this topic. • The "California" Approach 2 This method of referral involves extensive State agency participation. The steps in the California approach are as follows: The State of California's Medical Board The Medical Board investigators and a law- Corrective actions resulting in probation • A Comparison of the Two Approaches A comparison of these two methods of referral patterns indicates that: In the first case, self-regulation is a responsibility of the professional association. The legal sanctions of the State are used only as a last resort - In the second case, State involvement takes place at virtually all levels of the referral pattern. The professional association's role is of secondary importance. (2) Interpretation of Association and Board Roles in Self-Regulation The association or society has no legal or statutory basis for investigating and punishing its members. Any contribution that these organizations can make toward regulating their members therefore is limited to unofficial and informal actions. The control which these organizations exert over their members is what we term self-regulation. Given the membership of most health care regulatory boards, the role of self-regulation in regulating health care professionals also can be ascribed to the regulatory boards themselves. If this approach is taken, self-regulation might be defined to include the State regulatory board and its activities. Regulatory boards can be viewed as a form of self-regulation because: • The professional association plays a central (and often dominant) role in appointing new members to the board • Members of the board most often are members of the profession they must regulate • The association often acts with the regulatory board on legislative action relating to the profession. The degree of association involvement in selfregulation pertains to the level of control exercised by officers of the professional association, especially with regard to preparation by the association of a list of nominees. Very often the associations are asked to review or "investigate" nominees to the State licensing board before the list is submitted to the governor. (3) Self-Regulation and Other Regulatory Action Professionals who are subject to regulation by an enforcement agency such as a licensing board may choose to adopt their own codes of conduct in lieu of strict regulatory codes. The advantages of choosing such a program are: • It makes the members of the profession active participants in the regulatory process. By making the members conscious of problem areas and providing for an adequate peer review** process, mechanisms for the discovery of improper conduct may result in increasing the submission of complaints by peers, and more effective and timely corrective action. Association-sponsored self-regulation has considerable potential because it most often will be undertaken early enough to allow the offending professional to continue as a productive member. Where association-sponsored self-regulation occurs, the "errant" practitioner's activities are monitored to assure compliance with previously violated statutes. Handling the offender is the responsibility of the concerned professional group. With the exception of the most serious cases, the group or association is not concerned with punishing the offender. The emphasis in these self-regulatory efforts is on modifying the individual's behavior and retaining the practitioner as a productive member of the profession. Threat of suspension or revocation of the professional's license may be an incentive to corrective action, and a deterrent to the admis **Peer review may be defined as examination of the actions of the individuals of a profession by selected members of the same profession. sion by a health professional of a personal problem. Self-regulatory programs can be initiated before a serious offense takes place, avoiding those stronger measures necessary after an actual violation has occurred and been adjudicated. (4) Limitations of Self-Regulation Without statutory support, association-sponsored self-regulatory programs can not serve as the sole constraint upon the professional practitioner. This is especially true where a voluntary and loosely structured intraprofessional regulatory program exists. In these situations, the voluntary program will not prevent serious problems created by individual members of the profession. However, if self-regulation results in revocation of membership in a professional association, certain privileges of membership, e.g., hospital privileges, also may be revoked, thus inhibiting the practice of the "errant practitioner." • The Willful Öffender If an individual practitioner chooses to disregard his professional responsibilities or to violate the law, a voluntary program of self-regulation might be useful in identifying the offender but could not be effective in preventing future violations. In this situation, it is necessary to take legal measures against the offender. • Serious Offenses Where serious harm to a patient is involved or a major criminal act occurs, intraprofessional measures are unsuitable. The private association of professionals does not have the legal authority or jurisdiction necessary to place the proper level of sanctions against an offending colleague. (5) Issues that Conflict with the Economic Interest of the Professional A program such as self-regulation involves the commitment of the individual members if it is to be effective. Self-regulatory programs can reinforce the power of the professional group. Hence, the fears that the members' financial interests may outweigh regulatory responsibilities may be heightened. Although there have been persuasive arguments that economics will not outweight professional considerations, there has also been persistent criticism of the regulatory effectiveness of the professions. In response to such criticism, one professional summarized the conflict of professional responsibility and economic interest which affects health professionals: "...we dentists who resist so strongly, and correctly, government interference with the private practice of dentistry seem unwilling to appreciate that the profit motive, appropriately tempered by the laws of supply and demand, still exerts a beneficial effect on human initiative at all levels. We are no exception. Our professionalism, and our determination to do a job well, not our cost accounting, will ensure the effectiveness of continuing education in the long run."3 5. COMPILATION OF DATA RESULTS This section of the report presents the data collected on State professional associations. The major sources of information developed for this chapter include: • Field survey of selected States • Questionnaire survey (presented as Sections 6, 7, and 8 in this Chapter). (1) Field Survey in Three States Based on the field survey of State professional associations in Maryland, New York, and Virginia, the following observations were made: • Liaison with State Agencies Although the association maintains a close working relationship with the State medical board, no conflict of interest was apparent. Liaison is maintained with the board of pharmacy compliance inspectors with respect to drugrelated violations committed by practitioners. The association relies on the inspectors to report to the State medical board. The State board, in turn, notifies the association of the actions taken by the board. Legislative Support Group As an action group, the association reviews legislation or bills introduced in the State assembly which may affect its members. Drug Abuse Among Health Professionals Some State associations have been reluctant to admit that a drug abuse problem may exist among its members. For example, the Nurses Association in the State of New York disclaims encounters with the drug problem. However, nurses comprise about 45% of the health professionals against whom charges were filed in the fiscal year 1974. (2) Nationwide Questionnaire Survey The nationwide survey presented in the following three sections shows the direction and current status of professional associations' efforts in the area of controlled substances. The following considerations were used in compiling the many tables which summarize the association study: • Those responses, too infrequent to be treated specifically and/or mentioned, were combined under the classifications "other" or "other responses." • The % (percent) row represents the number of responses compared to the total number of questionnaire respondents or, if appropriate, the total number of professional association representatives responding to a previous qualifying question. (Respondents often were asked what agency should administer a program. Only the responses of those individuals who had indicated in previous questions that they favored the program were presented although, in all such cases, all responses were tabulated and analyzed.) The S row indicates the number of States for which a specific condition exists. For purposes of this survey, the 50 States and the District of Columbia are referred to as "51 States." • "Total" represents the professions of dentistry, medicine and osteopathic medicine, nursing, pharmacy, and veterinary medicine. "Total Medicine" represents the professions of medicine and osteopathic medicine. For a number of questions, multiple responses were encouraged. In tabulating these responses, the % (percent) row again compares the number of responses to the total number of respondents. Recognizing the desirability of comparing overall responses to the individual by-profession responses, each of the six individual or by-profession responses is presented adjacent to the "total medicine" responses. Because readability would have been impaired by reducing the size of print further, it was necessary to abbreviate the respondents' answers and comments in a number of the data tabulations. Whenever this step was necessary, the "actual responses" are presented as a part of the discussion, as a part of the data, or immediately above the tabular presentation of the data. |