From ‘safe harbor’ to stranded

During some of the darkest days of his addiction, Alan Atwood thought he’d never be able to work as a nurse again. 

He’d originally sought help for his substance use disorder from a support program during nursing school in 2011, thinking he could get his illness under control. But after about four years of staying sober and working a variety of jobs as a professional nurse, Atwood relapsed with methamphetamine. Within a year, his drug use led to a downward spiral. Hospital leadership at one of his jobs reported him to the state board of nursing after colleagues found him unresponsive in his car during work hours. Months later, he landed in the Yellowstone County Detention Center on drug possession charges.

During an interview at the jail, described in a report to the nursing board about his professional conduct, Atwood told a representative from the state labor department that his addiction was “out of control” and he could not safely work with patients. His license was revoked in 2017.

“I never really thought about getting my license back,” said Atwood, now 41, who recently celebrated four years of sobriety. “I was just kind of hopeless and homeless and all the things that go with addiction.”

Atwood’s turnaround didn’t happen overnight. He eventually stopped using and found housing at a sober living home in Billings. As he progressed in his recovery he met other health care providers who had regained their licenses by working with a state-contracted nonprofit based in Billings called the Montana Professional Assistance Program, or MPAP. 

He walked through the program’s doors in 2019 and, after being accepted, signed a contract agreeing to MPAP’s rules: follow a treatment plan, complete daily check-ins and submit random drug tests. Another cornerstone of the program was peer support. Atwood started attending twice-monthly meetings with other health care providers in recovery, often over breakfast at Perkins in Billings. 

After roughly a year in the program, the MPAP staff agreed Atwood was ready to reapply for licensure. His progress and stability won over the nursing board, whose members voted unanimously in October 2020 to grant him another chance to practice, with the condition that he complete his monitoring contract with MPAP. He credits the program with helping him progress in his recovery and overcome the shame, stigma and dejection that can isolate health care providers struggling with addiction.

“Those people helped me get my license back,” Atwood said. “They genuinely cared. It was amazing. I didn’t feel like somebody was watching me and they were all like, suspicious, you know what I mean? I just felt very supported.”

Almost a year after Atwood regained his license, the state labor department decided to abruptly end its contract with MPAP, notifying the program and professional licensing boards a month before its termination. The agency assumed oversight of the program’s caseload for a year before soliciting a new contract and accepting a bid from the global company Maximus Inc. to operate a new recovery and monitoring program for medical professionals. 

Current program participants, former MPAP staff, and some members of state medical boards and associations say the tumultuous transitions and the operation of the current program have weakened a critical resource for health care workers, unraveling a home-grown network of trust, peer support and oversight that can’t be easily remade.

“I don’t think the impact’s been good at all,” said Dr. Ron Hull, a former director of MPAP and mentor to other physicians in recovery. “Whatever there had been in terms of predictability, assurance, some sense that there would be help if and when you need it — that wasn’t there anymore.”

‘YOU DON’T HAVE TO DIE OF EMBARRASSMENT AND SHAME’

The Montana Professional Assistance Program existed in various forms for more than three decades, following the blueprints of other professional peer support groups founded by and for physicians. The prevalence and mainstreaming of those groups increased in the 1970s, after the publication of new recommendations from the American Medical Association. Doctors experience mental illness and addiction at rates similar to the rest of the population, experts advised, and need avenues for rehabilitation to stabilize themselves and protect the public from medical malpractice and impairment.

States around the country, including Montana, began codifying medical professional assistance programs in state law, often operated by licensing boards or independent nonprofits. Evidence of the recovery-and-monitoring model’s efficacy for people with substance use disorders has come with time. One study found that more than 80% of participants stayed with an assistance program for five years, with 78.7% continuing to practice during that time with no restrictions to their licenses. Additional research has found lower and less frequent rates of relapse for health care professionals in an assistance program and a lower rate of malpractice claims against physicians who completed a recovery program compared to those who did not. 

In its latest guidelines, the Federation of State Physician Health Programs, a leading national association of which MPAP was a member, emphasizes the specific role assistance programs occupy. In a landscape where licensing boards and employers can contribute to stigma about addiction and mental illness, the guidelines say, medical professionals need to have access to nondisciplinary, confidential resources to help them stay healthy and safe to practice.

“Healthcare professionals in safety-sensitive occupations must be encouraged to access treatment without fear of reprisal,” the guidelines say. “… PHPs offer the best means available to balance personal privacy and public trust.”

Hull, a retired anesthesiologist who took the helm at MPAP in the late 1980s, said the Montana program used regular drug testing, individualized treatment plans and peer support groups to achieve those intertwined missions: supporting the health of physicians and, in doing so, protecting the public. 

“One [aspect] was definitely peer support. Realizing [that] just because you’re a doctor, you don’t have to die of embarrassment and shame because you have alcoholism or addiction,” Hull said. “The second was public safety.”

MPAP eventually received an expanded state contract to serve additional types of medical professionals — dentists, pharmacists and nurses — through agreements with the respective licensing boards within the Department of Labor and Industry that oversee those professions. By the end of 2021, an MPAP quarterly report counted 112 health care professionals enrolled in the program. 

In line with the standards developed by the federation of physician health programs, MPAP was designed with both voluntary and disciplinary tracks, meaning participants could refer themselves to the program if they self-determined they needed help, or they could be directed by their profession’s licensing board as part of a disciplinary action. In return for voluntary participation, MPAP agreed not to report participants to their licensing board unless they became seriously non-compliant or put patients at risk. State records show that typically more than half of MPAP’s participants were on the disciplinary track and known to their respective licensing boards. 

Hull said MPAP tried to balance acting as advocates for recovering health care providers with protecting patients from doctors or pharmacists who might be practicing while impaired. Supporters of MPAP’s approach said that twinned focus gave the program its strength: The public is ultimately better protected when medical providers are encouraged to seek help early and stay involved in recovery long-term.

“You have to have a hammer, in a sense, or a lever, but not to the point that it’s all about a punishment approach or a do-or-die approach,” Hull said.

MPAP used peer support and accountability to help keep tabs on participants, Hull said, fostering a network of current and former health care providers who could check in on one another and intervene when someone was struggling. That tactic, Hull said, was critical to the program’s success and only possible because of professionals’ buy-in.

“You would feel assured that they were on the beam, that they were on the path,” Hull said.

‘THE DEPARTMENT ANTICIPATES A SMOOTH TRANSITION’

Despite MPAP’s tenure and relationships in the medical community, the Department of Labor and Industry decided in December 2021 not to renew its contract. Instead of contracting for continued operation of the program, the department planned to provide recovery and monitoring services internally, and hire not-yet-existing clinical staff to handle patient evaluations and referrals. The decision, according to a letter sent to licensing boards on Dec. 2, would be effective at the start of 2022. 

“The department anticipates a smooth transition, maintaining assistance for licensees, protection of the public, and efficient use of board resources,” the letter read. 

While DLI did not publicly specify a reason for discontinuing MPAP’s contract, the nonprofit had recently raised red flags. 

The program’s director, Mike Ramirez, had been accused by three female former employees in March 2021 of creating a hostile work environment, reports which were later supported by the findings of a late-October investigation by the Montana Human Rights Bureau. 

The labor department had also issued Ramirez a letter that year about other issues, including a complaint from a female employee about disparate pay between her and a male colleague with the same job duties. The April letter, a copy of which the department provided to Montana Free Press, also mentioned a participant who wanted approval to attend a secular alternative to the program’s required Alcoholics Anonymous group meetings, and another concern about how the program worked with participants who used medical marijuana for chronic illnesses. 

Eric Strauss, the current administrator of the labor department’s Employee Standards Division, which includes professional licensing boards, cited the issues raised in that letter and MPAP’s handling of the complaints as the department’s primary drivers for ending the contract.

“From what I understand, none of the responses were adequate from our perspective or satisfied our concerns,” Strauss said in a recent interview with MTFP. Strauss began his current job in January 2022, roughly a month after the state announced its decision to discontinue the nonprofit’s contract.

For Ramirez, the department’s action came “out of the blue,” and with little guidance on how to help participants transition to the new program. He was given 10 days to transfer all participant records to the state, Ramirez told MTFP, creating legal and ethical conflicts regarding the program participants whose involvement was undisclosed to the licensing boards. 

Ramirez and other supporters of the MPAP model were alarmed by the end of the contract and concerned about the agency’s plan. The Federation of State Physician Health Programs urged the state in a December letter addressed to Gov. Greg Gianforte to continue working with MPAP while seeking another contractor.

“Please consider the risk and disadvantages of transitioning these services abruptly to the Department of Labor and Industry which has no experience providing services to physicians for potentially impairing conditions such as mental health and substance use disorders,” the federation wrote. With the COVID-19 pandemic still in full swing, the letter continued, “this could not be a worse time to consider abandoning a critical and effective workforce safety net.”

Other former MPAP employees echoed that concern in recent interviews with MTFP, suggesting that the program was well-designed and operated regardless of Ramirez’s conduct. 

The former director said the state’s decision undermined a recovery community that generations of medical professionals had built over time.

“The big loss in this is this network that we had established — grassroots, homegrown, throughout the state,” said Ramirez, who retired in 2022. “We had a lot of network that was lost on the day that we closed down. And they just can’t replace that.”

By many accounts, the labor department’s decision did not maintain stability for participants in the recovery program. 

Two sets of quarterly reports submitted by state employees to the Board of Medical Examiners and the Board of Nursing in 2022 and obtained by MTFP through a public records request show sporadic data collection about the program’s 111 enrolled participants and no data about participating dentists or pharmacists. The state later said information about those professionals, who make up a smaller number of the program’s enrollees, was mostly communicated verbally by state employees to board staff. 

In the first reports about physicians and nurses, state employees told board members that MPAP’s recordkeeping and transfer of files was inadequate and that “many files of participants were completely missing.” 

Current participants who continued or joined under the labor department’s management told MTFP the state’s program was largely run by one person, whom they described as compassionate and respectful. But they also said the employee struggled to keep up with the diverse and complicated caseload, and that phone calls and emails sometimes went unanswered. Some participants said they kept up with random drug testing but skipped other requirements of their contract, realizing the state couldn’t keep close track of everyone. 

Strauss said he quickly began hearing frustrations from licensing boards about inadequate communication from the state throughout the transition. The boards, he said, were also dubious about the labor department’s ability to run the program effectively, pointing to the absence of clinical staff and some participants’ lack of trust about confidentiality because of the close relationship between the state and the licensing boards. 

“Kind of that perception of the fox watching the hen house,” Strauss said, adding that both concerns were “fair criticism.” With the slate of difficulties the state had encountered and remaining tensions with the boards, Strauss said, “It just made a lot more sense to move forward with [finding] a third party to provide the services again.”

Within a few months of assuming responsibility for the program, the department convened a hiring committee of state employees to select a new operator before the end of 2022. While the boards were invited to submit comments and questions to the hiring committee, Strauss said, board members were not official participants in the selection process.

Applicants for the new contract included an Idaho recovery services provider that was currently working with physicians, nurses and other professions. A second would-be vendor was a newly created Montana nonprofit formed for the express purpose of operating the state’s recovery program. That group touted endorsements from local addiction experts and the support of industry groups including the Montana Medical Association and the Montana Hospital Association. 

Another contender was Maximus Inc., a publicly traded global government contractor, currently valued at roughly $5 billion, that has operated health care industry recovery programs in only one other state, California, since 2003. 

Maximus, a Virginia-based company, had unsuccessfully applied to run Montana’s assistance programs in 2017, the year the contract to cover all four state medical boards was awarded to MPAP. This time, Maximus received the highest marks on a score sheet created by the selection committee, ranking particularly well in its experience monitoring participants and administering a program at Montana’s scale. The company declined MTFP’s requests for interviews.

“For more than 40 years, Maximus has been solving the complex problems of government programs,” the company’s application letter said. “… Our solutions will help Montana see high program completions and recovery rates, and participants to return safely to work.”

The state awarded Maximus a three-year contract totaling $1.6 million in October 2022, making Montana the second state in which the company operates recovery and monitoring programs for health care workers. 

The state’s decision conflicts with some of the recommendations from the Federation of Physician Health Programs. The group’s latest guidelines recommend that local nonprofits, medical society affiliates, or regulatory agencies operate a state’s assistance programs. When it won the contract, Maximus had no existing footprint in Montana, though the company has previously held contracts with the state unrelated to physician health programs.

“It is preferred that the PHP is based in the same state as the Regulatory Agency and does not operate for the purpose of making a profit,” the 2019 recommendations state. 

The company previously had one known connection to Montana: Gov. Gianforte held approximately $115,000 worth of stock in Maximus in 2017, according to business disclosures filed when Gianforte was in Congress. More recent disclosures, including those filed after he became governor, do not show Gianforte has continued to invest in the company. 

Asked if Gianforte currently holds Maximus stock, or when he sold his shares, spokesperson Kaitlin Price said the blind trust agreement Gianforte established upon his election to Congress gives an investment manager the power to make all trades “without the governor’s advice, direction, or consent.” That agreement, she added, prohibits communication between Gianforte and the investment manager. 

“​​Because the governor does not have control over his investments, we do not know what investments he owns. The investment manager, with whom he cannot communicate per the terms of the blind investment agreement, does,” Price said. 

She also said Maximus employees had no communication with the governor’s office in 2021 or 2022 and that Gianforte trusts the state employees who “identified the best, most qualified contractor” for the program.

During and after the state’s hiring process, members of the Board of Medical Examiners discussed at public board meetings their perception of being boxed out of deliberations for selecting a new contractor, and raised concerns about contracting with an out-of-state company for a local recovery program. 

“Well, as you know, this is pretty much a done deal,” Dr. Bruce Robertson, one member who kept tabs on the selection process, told board members at a September 2022 public meeting. “I was extremely disappointed that this board was specifically excluded from that process, despite numerous requests and offers to be involved.”

Robertson also expressed doubts about Maximus at the same meeting. 

“This program appears to me to be an abstinence-based program rather than a recovery-based program,” he said. “So I think it’s incumbent upon us to continue to push to be involved in the oversight of this program going forward.”

‘I FEEL LIKE I’VE BEEN CONVICTED OF A CRIME’

The transition to a new recovery and monitoring program operated by an out-of-state company created significant waves for participants. Current enrollees expressed frustration and anxiety to MTFP about how the company is operating what is now called the Montana Recovery Program. 

In its application materials, obtained through a public records request, Maximus placed a strong emphasis on protecting public safety through intensive monitoring but spent less time describing how the program would support the well-being of participants or reduce stigma about substance use and mental health needs during case management.

Now, four months into the company’s tenure, some participants described the new approach as “punitive” and detrimental to maintaining long-term sobriety and successful careers. Others said the schedule of check-ins, frequent drug tests, and other monitoring requirements — including required permission to accept jobs, change work hours or take vacations — have made them feel presumed guilty by Maximus employees, even if they had years of sobriety and strong track records under prior programs.

“Last week I actually had a panic attack,” said Sarah Carson, a Missoula nurse with three years sober and less than two years left in the contract she signed with MPAP. “I was like, ‘Wow, it’s been almost two years since this has happened to me.’ And I attribute that to the added stress of what this program is putting us through.”

A spokesperson for Maximus diverted a request to interview staff of the Montana Recovery Program to the state Department of Labor and Industry, saying “our Montana customer will take point” in speaking about the program.

Much of Maximus’s expertise to fulfill the Montana contract comes from its decades-long contracts in California. Despite that track record, the process for getting the Montana Recovery Program up and running has faced challenges, according to onboarding materials and interviews with participants. 

In an initial digital presentation, the company told enrollees that case managers planned to hold one-on-one meetings with participants throughout January and February 2023. Daily virtual check-ins, where participants are notified whether to submit a drug test, and monthly self-assessments were scheduled to begin Feb. 1. But in a later webinar, described as “part two” of the onboarding process, the timeline for one-on-one meetings and self-assessments was pushed back to March. 

As of early April some participants told MTFP they still had not been able to schedule a personal meeting with their case manager, who is based in Billings but does not have a physical office for seeing participants. Without a brick-and-mortar presence, they said, most program communication takes place through video chats or is routed through an online portal, where participants may not know who will read their messages or when.

Participants say Maximus has rolled out a rigorous slate of drug tests, including blood, hair and urine analyses, to establish a “baseline” for each person in the program. In some cases, increased testing began before participants had spoken with their case managers or been told why the type and frequency of tests were changing. Some who were in their third or fourth year of the program, when the number of tests was previously scheduled to decrease, said they were suddenly being directed to complete multiple tests in a single week, requiring them to pay hundreds of dollars each month, take time off work and coordinate drop-offs at labs. 

“They call it a baseline, I call it a waste of resources,” said Atwood, the Billings nurse who is in his final year of the program and has been perplexed by the increased testing. “This whole thing’s a mess.”

“It’s ludicrous,” said Kris, a nurse with more than four years in the program who asked to be identified only by her first name to avoid professional repercussions. “It’s absolutely ludicrous.”

Maximus’ program handbook instructs participants to avoid a variety of products that could trigger positive tests, including “hand sanitizer, cleaning products, lotions, and medications,” noting that “Use of these products may cause you to test positive for a metabolite of alcohol.”

Any positive drug test result, including one that is ultimately determined to be false, can result in a participating employee being removed from work until they test negative and a report to the licensing board, according to the handbook. That protocol is markedly different from how MPAP handled a positive test result, participants said. After more testing to confirm the presence of prohibited substances and additional meetings with participants, removal from work and a board report would happen only if case managers determined someone had relapsed and was unsafe to work. 

Sharon Hancock, 53, has been in the program for four and a half years and expected to complete her contract in August. In late March, she said, a doctor who reviews drug tests for the program flagged her blood test as positive for alcohol — a result Hancock said she can’t comprehend because she has not relapsed. 

Regardless of that claim, Hancock said, Montana Recovery Program Director Anita Mireles told her the test must be an indication that she had used alcohol, perhaps even accidentally. Though she would not be prohibited from working, Hancock said, Mireles directed her to sign a new contract, re-start the steps of the 12-step program, attend 90 peer support group meetings in 90 days, and change her sobriety date — a personal anniversary marking a turning point in recovery.

Since then, Hancock described feeling like she’s in limbo. She’s taken additional drug tests that have not shown positive results and maintains that she hasn’t relapsed. While Maximus has not yet delivered her a new contract to sign, Hancock said, she does not want to agree to new terms or extended monitoring based on the fear of being labeled noncompliant. If the program reports her to the board, Hancock said, she’ll continue to advocate for her innocence. 

“I haven’t been in the criminal system with drug monitoring, but that’s what it felt like to me,” Hancock said. “I even said to them, ‘I feel like I’ve been convicted of a crime I haven’t committed and I have no alibi.’”

Hancock and other providers said that while they understand that relapse can be a part of recovery, none of them would feel comfortable disclosing a relapse to Maximus or seeking help from their current case manager. The trust and environment of support that existed with prior programs has crumbled, Hancock said, a circumstance she said could make patients less safe in the long run.

“We know that a person with the disease of addiction flourishes better in a supportive, inclusive environment. And so treating us like we’re just numbers and not humans with a disease, and [like] we’re in the criminal system, I would think could lead to more relapses, because it’s a stressful environment, not a healing environment,” she said. 

Other participants expressed similar feelings, suggesting that the program should remove the word “recovery” from its title and call itself the “Montana Monitoring Program.” They also described the program’s complicated rollout, protocols and inconsistent communication as a source of increased anxiety that they will lose their jobs — not because they are unfit to serve patients, but because they will fail an obstacle course of bureaucratic hoops.

“I feel like I’m a felon now,” said Michelle Muri, a Billings nurse of 26 years who enrolled with the program about three years ago. “… I’m scared about everything. And I didn’t feel that way before.”

Carson, the nurse in Missoula, said the “overwhelming” requirements have made her think about using substances in a way she hadn’t in years, a trigger she associates with increased stress. She and others in the program told MTFP they are considering looking for different jobs instead of continuing with the program. Walking away from their licenses, they said, might be preferable to continuing with Maximus. 

“I’m wondering if I can make a living without my nursing license at this point,” Carson said. “Is the added stress of this company trying to micromanage our lives worth it?”

‘WE CARE ABOUT THEIR RECOVERY’

Other participants told MTFP that despite their frustrations with Maximus, they will carry on with the program for the sake of continuing in the profession they love. Still others expect to complete the terms of their contract soon and said they feel solid in their recovery because of other supportive resources and peers. 

But longtime participants said they also worry for future generations of health care providers who may feel wary about seeking help from a program unless it’s strongly recommended by coworkers and industry peers.

“Wouldn’t it be safer if we had everyone monitored and talked to like it used to be?” said Kris, the nurse who expects to finish the program this year. “Now we’re going to be hiding … They’re not going to want to come forward.”

Former MPAP employees voiced the same fears, forecasting long-term consequences for the state and licensing boards if medical workers don’t see Maximus as a resource they can lean on.

“I think it’s going to come back to bite them,” said Meghan McGauley, who worked as a case manager at MPAP. Without a trusted safety net for professionals who need help, she said, the state may see an increase of providers in crisis and malpractice lawsuits. 

“They also need a safe harbor,” McGauley said. “Which is what the programs are supposed to be … If they have a more anonymous place to go for help where they’re not judged, then you’re going to have better outcomes.”

Strauss, the administrator with the state labor department, said in April that the agency is confident it selected the vendor with the most experience and capacity to run Montana’s program. He added that the staff overseeing and managing the Montana Recovery Program appear compassionate and caring about the work the contract entails. 

“Everything, the full scale of the conversations we had with them, from the written proposal and then the follow-up interviews, all indicated to us that Maximus was a premier provider for the services that adhere closely to industry best practices and are a good and robust company that would serve our needs and the participants needs fully,” Strauss said. 

Strauss said participants’ complaints and negative experiences are concerning, and that he would like to hear them directly from participants in the future.

“We care about licensees, we care about their recovery, and we want to make sure that they get back to work in a productive way,” he said.

Other parts of the medical industry are also finding ways to expand resources for workers. Citing a rise in burnout, mental health issues and substance use disorders in recent years, the Montana Medical Association in February announced a new partnership with Frontier Psychiatry, a Montana company, to provide confidential virtual therapy sessions for health care providers paid for by the association. 

“Timely access to these services has never been more important,” MMA CEO Jean Branscum said in the announcement. “Telehealth ensures anonymous, low-barrier access to important care.”

Members of the state Board of Medical Examiners continued their discussions about Maximus and their hopes for the future of the program in a March public meeting. Dr. Bruce Robertson, now the board’s vice president, reported back from a meeting he and another board member had with Maximus managers with a slightly softer tone about the program. The company’s staff, Robertson said, had been receptive to more board involvement and feedback.

“The bottom line here is, despite my dissatisfaction with the entire process … and my concerns about having an out-of-state entity administering this program, I feel better about it than I did before — put it that way,” Robertson said.

Throughout the changes to Montana’s recovery programs, Atwood has remained in touch with some of the first mentors and case managers he met through MPAP. They dog-sit for one another, he said, meet up for coffee and still have breakfast a few times a month. 

This month, four years after he enrolled in MPAP, Atwood’s current case manager notified him that the program is ready to discharge him, barring objection from the Board of Nursing. Atwood said the call was welcome news. 

“No complaints about that,” he said. “I feel really good.”

Regardless of Maximus’ operations or the state’s future contracts, Atwood said, he and other providers will keep supporting one another and their peers. He believes that kind of community  reduces stigma and helps more people work toward recovery. 

“I’m not ashamed of it anymore. I use it to help people,” Atwood said of his own journey. “It’s like they say in [Narcotics Anonymous]. The therapeutic value of one addict helping another goes without parallel.”

Editor’s note: 

In late April, public relations staff from Maximus, Inc. reached out to Montana Free Press in response to some statements and characterizations about the company in this article. The article was updated on May 9, 2023, to accurately reflect the length of Maximus’ contract with the state, which is three years, not two years as previously reported.

Maximus also noted that prior to receiving the state contract for professional health programs, the company has held various contracts with Montana state agencies since 1995 and has employed people who live in the state. Maximus clarified that “the nature of our current work in the state does not require a physical office location.”

The company further said that, contrary to program participants’ perceptions and experiences as quoted in the article, its program is “clearly focused on recovery” and “there is no punishment involved in the Maximus program at all.”