ABSTRACT:
Introduction: The Colorado Physician Health Program (CPHP) provides evaluation, diagnosis, treatment referral, and monitoring for physicians, physician assistants and anesthesiology assistants experiencing health or psycho-social problems. We examined trends in complexity of cases presenting to CPHP between fiscal years 2016-2017 and 2020-2021.
Methods: Case complexity was rated as mild, moderate, or high based on clinical and administrative complexity. Differences in complexity were examined by year and participant demographic, practice, and case characteristics, using chi-square and logistic regression analysis.
Results: Mild complexity cases declined from 57% to 14% and moderate cases increased from 25% to 73% (P<.001). Cases with high complexity (15% of cases) remained relatively stable. Complexity was higher for older participants (P=.04), primary presenting problem of DUI/DWAI (P=.01), mandatory referrals (P<.001), and longer participation (P<.001), and lower for participants with work stress/burnout (P=.04).
Conclusion: Potential reasons for the changes in complexity observed include increased stress in work settings, proposed changes in the regulatory environment that could threaten confidentiality, and the emergence of in-house wellness programs. Physician health programs need to prepare for increases in case complexity and the accompanying need for more referrals for care, higher levels of monitoring, and greater skill in diagnosing and addressing health and behavioral issues.
Keywords:
Introduction
Physician Health Programs (PHP) began emerging across the United States in the late 1970s/early 1980s. These state-level initiatives are aimed at aiding physicians, health care professionals, and trainees in addressing various health issues. The scope of evaluation and monitoring across PHPs varies, but PHPs frequently receive referrals and address needs for an array of concerns, including mental health, physical health, cognitive problems, stress, substance use, well-being, and workplace behaviors. PHPs also vary in how they operate within their state and interact with the medical licensing board(s) and other entities. PHPs coordinate, monitor, and document the evaluation, diagnosis, and treatment for health care providers, with the goal of helping them improve their health, maintain their careers, and deliver safe and effective medical care. Most PHPs allow health conditions to remain confidential to licensing or other public facing entities, enabling health care professionals to access necessary supports without fear of a negative impact on their ability to practice.
The Colorado Physician Health Program (CPHP) was established in 1986 and was one of the first state level PHPs. CPHP serves physicians (MD/DO), physician assistants (PA), anesthesiology assistants (AA), and trainees in these professions throughout Colorado. CPHP maintains an active caseload of between 400 and 500 professionals at any time, with between 200 and 300 new referrals each year.
Starting in 2016, CPHP anecdotally observed changes in the clinical severity and complexity of the health problems experienced by participants. While no published literature reports this phenomenon occurring at other PHPs, there is literature describing changes among physicians over time in conditions that can lead to involvement with PHPs. For example, Shanafelt and colleagues examined longitudinal trends in physician burnout, depression, career satisfaction, and work-life integration between 2011 and 2021.1 They found significant differences for all these measures in 2021 compared to earlier years, which they attributed to the COVID-19 pandemic. Such findings underscore the dynamic nature of physicians’ experiences and the susceptibility of their well-being to external stressors. This increase of burnout, emotional exhaustion, and mental health challenges, confirmed by other studies,2 coincides with shifts in health care delivery, regulatory environments, and societal expectations, suggesting a complex nexus of factors influencing health care professionals’ experiences and overall health. The COVID-19 pandemic likely increased the complexity of challenges experienced by those presenting for help at CPHP.
In July 2016, CPHP began using a protocol to rate the complexity of participant cases upon completion of their involvement with the program. Complexity ratings are a combination of clinical complexity (ie, the number of challenges the individual is addressing in their work, personal life, mental and physical health; the severity of conditions as manifested through the impact on various aspects of the individual's life; and how these influence the elements of care such as need for and number of evaluations, referrals, and immediate interventions) and administrative complexity (ie, administrative management that may include involvement of CPHP leadership, legal counsel, and/or the licensing board; number of reports required; etc.). As a reflection of both the challenges experienced by participants and the intensity of their case management, case complexity is likely to affect the resources needed to guide participants towards regaining optimal functioning in their professional and personal lives. Higher levels of case complexity require greater resources for PHPs to meet the needs of the populations they serve.
The objectives of this paper are to describe: 1) CPHP's complexity measure; 2) how complexity ratings are distributed among the CPHP participants by types of presenting problems and length of participation in the program; and 3) how complexity ratings have changed over five years of referrals to the program, including referrals from fiscal year 2016-2017 (July 1, 2016 to June 30, 2017) through referrals in fiscal year 2020-2021 (July 1, 2020 through June 30, 2021). We hypothesized that complexity of cases had increased over time.
Methods
Study population
CPHP began rating the complexity of cases starting with cases that were completed on July 1, 2016. This study includes physicians, physician assistants, anesthesiology assistants, and trainees in each of these fields who were referred to CPHP between July 1, 2016 and June 30, 2021, and became “participants.” “Participation” was defined as having completed an evaluation with CPHP to identify problems and receive recommendations, which might include referral to outside services for additional evaluation or treatment, or no further intervention. Cases that received consultation only and did not complete a comprehensive intake assessment evaluation were not included.
Ratings of case complexity are made at the time of completion of a case (“inactivation”). The length of participation varies greatly by individual case from less than a month to over a decade. For this paper, we conducted two analyses. The first analysis examined complexity among participants referred to CPHP in the two earliest cohorts that received complexity ratings at inactivation (July 1, 2016 to June 30, 2017, and July 1, 2017 to June 30, 2018) and followed them for up to five years, at which time 90% of participants had reached inactivation. For these two cohorts combined, we examined the distribution of complexity ratings by length of participation and primary presenting problem.
For the second analysis, we examined longitudinal trends in complexity. To compare complexity ratings over time, it was necessary to create sequential cohorts that were each followed for a consistent period of time. We constructed cohorts using the fiscal year (July 1-June 30) over five sequential years starting with 2016-2017. Follow-up was limited to two years so that the 2020-2021 cohort could be followed for the same length of time as all preceding cohorts. This approach allowed us to maximize the number of cohorts included while maintaining an equivalent follow-up period. The historical experience of CPHP is that approximately 70% of cases are inactivated within two years. Thus, the longitudinal analysis we report in this paper is generalizable to the majority (approximately 70%) of the CPHP participant population, but systematically excludes those whose participation lasted more than two years.
Complexity rating
Using written criteria and examples of prototypic cases, a single rater assigned a level of mild, moderate, or high complexity after reviewing each case at the time of inactivation. The rater is a licensed clinical social worker with more than two decades of clinical experience serving this population and was not directly involved in the care of the study participants. Table 1 provides the factors considered for the complexity rating and Table 2 provides prototypic cases for each of the three levels of complexity.
Factors Considered for Complexity Rating
Prototypic Examples of Mild, Moderate, and High Complexity*
Other variables
In addition to the primary variable of complexity, in our analysis we incorporated variables collected at the time of intake into CPHP. Gender and race/ethnicity were reported by the participants. The following participant variables were captured from the CPHP electronic database, which is populated like a medical record throughout the participant's involvement: professional level (MD/DO, PA or AA, student, resident); specialty; primary presenting problem; referral source; and whether participation was voluntary or not. Year of referral was categorized according to the fiscal year from July 1 through June 30. See Tables 5 and 6 for further descriptions of these variables.
Analysis
Chi-square analysis was used to compare the three-level complexity rating by length of participation, primary presenting problem, and year of participation. Due to the relatively small proportion of participants assigned ratings of high complexity and to enable multiple binary logistic regression, for subsequent analyses we collapsed “high” complexity with “moderate” complexity. The collapsed complexity rating was compared across levels of all other variables using chi-square analysis. Multiple binary logistic regression was used to examine the relationship between complexity and year of referral while controlling for other variables that might confound the relationship between year and complexity. Initially all variables significantly related to complexity at P<.25 were included in the regression model and then variables that were not significant at P<.10 in the model were removed sequentially. A significance level of P<.05 was used to define statistical significance. We did not adjust the significance level to account for multiple testing so that we would not miss potentially important characteristics that should be controlled for and/or studied more in the future. Therefore, relationships between the control variables and complexity should be interpreted with caution and considered for hypothesis testing in future research.
This study was reviewed and approved as exempt research by the Colorado Multiple Institutional Review Board.
Results
Analysis 1: Distribution of complexity ratings in CPHP participant population
In fiscal years 2016-2017 and 2017-2018, 421 participants were referred to CPHP and completed evaluations. Of these, 380 (90%) completed the program within five years and were included in this analysis. As shown in Figure 1, length of time in the program was strongly related to complexity. Participants with mild complexity nearly always completed their participation within two years (97%), while 29% of those with moderate complexity and 39% of high complexity cases extended beyond two years of participation.
Time in Program by Complexity Rating for Participants Referred in 2016-2017 and 2017-2018, n=380*
Both complexity and program participation time varied by presenting problem, as shown in Table 3.
Time in Program and Case Complexity by Primary Presenting Problem for Participants Referred in 2016-2017 and 2017-2018 Who Completed Participation Within Five Years (n=380)
Participants who presented with stress, work stress/burnout, legal/documentation, and DUI/DWAI problems were more likely to finish the program within two years, and those with professional boundary, substance-related, physical/medical, psychiatric, and behavioral problems were less likely to finish within two years. The highest complexity ratings were for those with professional boundary, substance-related, and behavioral problems; these three groups were also among the least likely to finish the program within two years. While higher complexity was generally associated with longer participation, for some presenting problems this pattern did not hold. Those with physical/medical or psychiatric problems generally had lower complexity ratings but longer participation times. Physical/medical problems tend to be chronic health problems that are progressive and worsen over time, such as Parkinson's Disease or multiple sclerosis. Psychiatric symptoms are often depression or anxiety, which can often be rectified quickly with pharmacological interventions. However, CPHP strives for participants to experience sustained remission and thus longer interventions such as therapy are typically recommended. While these problems are not intensive with respect to clinical and administrative complexity, tracking may occur over a long period of time resulting in participation extending beyond 2 years. Aside from the primary presenting problem, there were no other participant characteristics significantly associated with participation longer than 2 years.
Analysis 2: Changes in complexity over time
In the five annual cohorts beginning in 2016 through 2020, 692 participants were evaluated and completed participation within two years. As shown in Table 4 and Figure 2, complexity ratings varied significantly over the five years. The proportion of cases rated as mild complexity varied between 49% and 57% for the years starting in 2016, 2017, and 2018. For the years starting in 2019 and 2020, mild cases decreased dramatically, ranging from 14% to 27% of cases. The decrease in mild cases was balanced by an increase in moderate cases. In the years starting with 2016 and 2017, 25% and 26% of cases, respectively, were rated as moderate complexity. In 2018, moderate cases rose to 39%, and in 2019 and 2020, they rose again to 61% and 73%. High complexity cases were the smallest in number and fluctuated between 12% and 20% of cases over the five years with no clear trend over time. The variation over time was statistically significant (P<.001).
Complexity Ratings for Participants Referred in Fiscal Years 2016-2017 through 2020-2021 Who Completed Participation Within 2 Years
Proportion of Cases Rated as Mild, Moderate, and High Complexity Over Five Cohorts (Fiscal Years 2016-2017 through 2020-2021). Includes Participants who Completed Participation Within 2 Years (n=692).
Table 5 provides case complexity (mild vs. moderate-high complexity) by participant characteristics (age, gender, race/ethnicity, level of practice, specialty, primary presenting problem, referral source, whether participation was voluntary or not, length of participation, and year of referral). There were no significant differences in complexity rating by gender, race/ethnicity, level of practitioner, or specialty. Complexity was lowest in the youngest age group compared to older ages (P=.046). For this group of participants who completed within two years, the primary presenting problems with the highest complexity ratings were DUI/DWAI, professional boundaries, and substance-related (P=.004), which is similar to the findings in Table 3 for those who were followed for five years. Among referral sources, the highest level of complexity was among those with Medical Board mandated referrals and lowest was among self-referrals (P<.001). Similarly, those whose participation was mandated by a Medical Board, workplace, or training program had higher complexity compared to those with voluntary participation (P<.001). Consistent with the findings reported in Figure 1, longer participation was associated with higher complexity (P<.001).
Participant Characteristics and Bivariate Relationships with Complexity (n=692)
The final results of the logistic regression model are shown in Table 6. This analysis verifies the relationship between year of referral and complexity after controlling for other participant characteristics. Higher complexity was significantly associated with being referred to CPHP in the years 2019-2020 and 2020-2021 compared to referrals in 2016-2017. There was no significant difference in complexity between the years 2016-2017, 2017-2018, and 2018-2019. In addition to year of referral, older participants (over age 60) had significantly higher complexity ratings compared to the reference category of age 30-39; participants with a primary presenting problem of DUI/DWAI had higher complexity and participants with work stress/burnout had lower complexity compared to the reference category of psychiatric presenting problem; mandatory participants had higher complexity compared to voluntary participants; and as length of participation increased, complexity increased. Referral source was significant in the bivariate analysis but dropped out of the multiple regression, most likely due to its strong relationship with mandatory versus voluntary referral status. Gender and race/ethnicity were tested in the multiple regression, found to be not significant, and were dropped from the model.
Results of Logistic Regression Examining Factors Related to Complexity (n=692)
Discussion
In this study of participants with the Colorado Physician Health Program, we found that case complexity increased significantly over time, especially between fiscal years 2019-2020 and 2020-2021. This increase began prior to the COVID-19 pandemic, and the finding was not changed after controlling for age, primary presenting problem, length of participation, and whether participation was voluntary or mandatory. Additionally, complexity was significantly associated with all of these covariates. The relationships found with covariates should be interpreted with caution as our primary purpose in this analysis was testing the relationship between year and complexity while controlling for potential confounders. However, the relationships we identified between complexity and covariates may be important in guiding future research.
Complex cases can involve a myriad of factors, including comorbidities, dual diagnoses, clinical acuity, access to care, as well as social, interpersonal, behavioral, systemic, and cultural dimensions.3,4,5 While CPHP does not provide treatment, the clinical evaluation and monitoring of its participants requires a perspective that takes these factors into account to improve resource allocation (ie, staffing), clinical decision-making, risk management, and client-centric holistic approaches. As problem complexity increases, so does the need for clinical attention, attunement, and action in both clinical and administrative aspects for all involved parties.6
The nature of the primary presenting problem often influences the quantity and intensity of these functions, including the level of care and time needed for established and sustained recovery. Cases involving psychiatric, substance, and boundary-related problems are often more complex due to the potential patient risks involved when these problems are unaddressed or treated inadequately. For example, participants evaluated and monitored for a diagnosis of a substance use disorder often require a minimum of four to five years of monitoring due to established evidence regarding recovery rates of physicians.7,8 In this respect, it is important to note the distinction between DUI/DWAI and substance use as primary presenting problems. A typical DUI/DWAI case involves an evaluation following the receipt of a driving citation and in the majority of cases does not lead to a diagnosis of a substance disorder. DUI/DWAI cases are typically resolved in less time and are rated as less complex compared to substance use problems.
The reason for the increase in complexity over time is not known, but we suggest several potential explanations. First, many evolving conditions in health care work settings have increased the stress experienced by health care providers. These include increasing time pressures, use of electronic health records (EHRs),9 changing administrative structures resulting in less autonomy over one's career (including the decline of physician-owned practices and increase in health care system owned practices),10 and misalignment between workplace and personal values.11 Amidst this backdrop of the changing health care environment, the COVID-19 pandemic added additional stress on the health care system and health care providers. It also created home and family stress due to stay-at-home orders, children being schooled remotely, etc. Within the increasingly stressful health care environment, health care providers may have perceived less time or access to services to address their health and behavioral problems at the time they were emerging. Providers may have delayed addressing mild problems, which may have progressed to become more complex.
These multi-dimensional factors could be responsible for the decline in mild complexity cases and dramatic increase in moderate complexity cases that we observed.
Second, beginning in the time period of this study and continuing to the present, PHPs have faced challenges in multiple states that include proposed reductions in funding, limitations to confidentiality, and eliminating PHPs altogether.12-14 National organizations such as the Federation of State Medical Boards, American Medical Association, and the Dr. Lorna Breen Heroes’ Foundation have advocated to maintain or expand protections for physician health.15-17 Given the paramount importance of confidentiality to health care providers and trainees seeking help, any real or proposed changes to a PHP's function may have discouraged some physicians, particularly those with mild complexity, from seeking assistance for their problems.18,19 Even with the national efforts to encourage help seeking among physicians, PAs, and trainees, there still exists both stigma and perceived professional consequences for seeking care for health conditions.20-22
Third, many health care systems have initiated in-house wellness programs and/or hired Chief Wellness Officers in recent years. These in-house wellness programs may successfully address mild issues, and this may explain the reduction in mild complexity cases presenting to CPHP. However, the dramatic increase in moderate cases seen over this period suggests that in-house efforts are not preventing the emergence of moderate to high complexity cases. With this expansion of resources available, education and partnership between PHPs and other wellness programs is of vital importance to address cases at all levels of complexity.
Most likely, mild complexity cases still exist, and these problems are either: 1) being treated elsewhere; 2) not being treated; or 3) rapidly progressing to moderate and high complexity. This suggests the need for outreach to health care providers for the recognition and treatment of problems before they progress in complexity. Allowing problems to go unaddressed can result in unnecessary distress to providers, families, and co-workers, and could potentially threaten patient safety.
Additionally, as cases present more complex problems, PHPs need to be prepared to provide high quality care and support. With higher complexity comes the need for more referrals for care, higher levels of monitoring, and greater skill in diagnosing and addressing health and behavioral issues. Administrative complexity increases due to shifting levels of care, additions to recommendations that require administrative processes for assessing availability of providers and facilities, sending referral information, coordinating treatment conferences, ongoing updates, discharge planning, and arranging aftercare. Additional updates to workplaces, attorneys, and the generation of reports to involved parties add to the administrative burden of clinically complex cases.
If the trend we have observed in Colorado is emblematic of other regions, PHPs can expect increased workloads to meet participant needs and provide the necessary support to maintain physician health as well as quality and safety in health care. To accommodate this, there is a need to strengthen PHPs nationwide and ensure stable and adequate funding.
Limitations
This study has certain limitations. First, while comprehensive in characterizing the experiences of health care providers in the state of Colorado, this study is limited to Colorado. The experiences of health care providers in other states may be different. Also, the availability and care approaches of physician health programs in other states are likely to be different. However, many of the pressures experienced in Colorado, including the changing health care environment and pressures on health care providers, are national or international trends. This study examined the experiences of health care providers who presented to the CPHP. It does not characterize the experiences of providers who seek care in private systems or whose problems go unaddressed.
Our rating of complexity reflects the support needed for each participant's clinical care and the administrative necessities of managing legal and other aspects of the case. Our focus was on the burden of case management at CPHP, and we are unable to separate the complexity of clinical management from administrative management with our current measure. While our measure does not directly measure clinical complexity, clinical complexity manifests itself as management complexity. That is, as the number and severity of clinical problems increase, often the complexity of clinical case management increases. Our measure of complexity was developed and implemented for clinical and administrative purposes and has not undergone formal reliability testing. Also, our data are limited to what was systematically recorded in CPHP record systems and reflects the perspectives of CPHP staff who recorded clinical factors and management of cases, and rated case complexity. We did not contact participants to ascertain their perspectives on these issues. These limitations should be addressed in future research.
In our statistical analysis, we were limited in our ability to characterize the experiences of all CPHP participants. To compare cohorts of participations over time, it was necessary to limit most analyses to those who completed their participation in two years. While this includes over 70% of participants, those who participated for longer than two years are known to experience more complex problems. Thus, we may have underestimated the increase in complexity that occurred over the five-year period we studied. Still, our study clearly demonstrates a dramatic trend in increased complexity of cases over time, even with this limitation. A related limitation is that CPHP only began systematically rating the complexity of cases in mid-2016. We are not able to speak to case complexity prior to that time.
Conclusion
This study documents a substantial increase in case complexity among physicians and other health care providers who became participants in the Colorado Physician Health Program over five years, between July 1, 2016 and June 30, 2021. Reasons for this increase in complexity are unknown, but we suggest it may be due to several factors including changes in the health care work and regulatory environments, the emergence of in-house wellness programs for health care providers, and the COVID-19 pandemic. This upward trend in complexity of clinical and administrative management will require enhanced readiness and increasingly skilled services within PHPs. Medical boards also need to be prepared for increased case complexity and be willing to support their state PHPs in addressing these trends.
Future research is needed to better understand the complexity of cases managed by physician health programs. This includes replicating these findings from Colorado in other states/regions; separating components of CPHP's complexity measure to better understand trends in both clinical and administrative complexity of cases; studies to understand the factors driving changes in complexity including further evaluation of the provider characteristics that we found to be related to complexity; and continued longitudinal collection and evaluation of complexity information to monitor trends.
Acknowledgments:
The authors gratefully acknowledge Cae Allison, LCSW, who reviewed and coded cases according to complexity level, and Laura F. Martin, MD, who critically reviewed and provided comments for this manuscript.
Footnotes
Open Access: © 2025 The Authors. Published by the Journal of Medical Regulation. This is an Open Access article under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC, https://creative-commons.org/licenses/by-nc/4.0/), which permits use and distribution in any medium, provided the original work is properly cited, and the use is noncommercial.
Funding/support: This study received no external funding.
Other disclosures: All authors received compensation from the Colorado Physician Health Program for their work on this study.
Author contributions: Study concept and design (all); Acquisition of data (AK, SE); Analysis and interpretation of data (all);
Drafting of the manuscript (LC, AK, SE, JD); Critical revision of the manuscript (all)
- Received July 25, 2024.
- Revision received January 3, 2025.
- Accepted February 19, 2025.
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