This article began to take shape after a presentation by the AAAOM at the October 2009 Building Bridges conference. Once again, I heard acupuncturists demanding actions that I felt would be ultimately detrimental to our profession. This article focuses on the main issues addressed at that meeting and is, to a certain extent, directed to the AAAOM. However, I was motivated to write in part because I’ve heard us act and react in similar ways with other issues.
I know that many of us don’t want to get involved in the messy world of legislation, regulation, or professional politics. When we don’t, we let those who are involved drive the movement, and whether or not we like where they are going, we’re in the same boat and we’ll end up in the same place.
When it comes to the legal/regulatory side of things we, as a profession, all too often act as a practitioner who treats only the branches without ever considering the roots of the condition. Such treatment does not result in deep healing, and in the long run may hasten the decline of the patient.
Those who know me know I am rather opinionated. However, I hope they’d also say that I listen to other viewpoints and am happy to be proven wrong. Forgive me any errors I’ve made in the article and feel free to disagree.
Our Path to the Future, by Elaine Wolf Komarow, L.Ac.
Stop! Listen! Learn! I find myself wanting to shout those words, and a few more, when I listen to my fellow practitioners who are saying:
“We should be included in the Medicare system.” “We need to get increased reimbursement for acupuncture services.” “We need to stop other providers from doing acupuncture.” “Dry Needling.” “Not enough opportunities.” “Too hard to make a living.”
in response to the question, “What are the biggest problems facing acupuncture today,” by Michael Taromina, Esq., on behalf of the American Association of Acupuncture & Oriental Medicine (AAAOM) at a session entitled “The Future of AOM in the US” at the October 2009 Building Bridges conference.
By joining the AAAOM, Mr. Taromina urged, acupuncturists could take advantage of this critical moment in our history, solving our problems by passing HR 646, Medicare Coverage for Acupuncture, and continuing the fight against those who would try to steal our profession.
I am concerned about the future of AOM (Acupuncture and Oriental Medicine) in the US. I write this as an appeal to the AAAOM, and to all of us within the profession. We are indeed at a critical moment. Yet time and again I find that we act without considering the consequences, without considering whether there is a better way to reach our goals, and without regard to how action in one area could complicate our efforts in another. In this article I focus primarily on HR 646 and Physical Therapist Dry Needling because these are currently “hot topics.” However, many of my concerns can be and should be generalized to other issues.
I’ve been involved with the Legal and Regulatory aspects of our profession since I joined the Acupuncture Society of Virginia (ASVA) as a student in 1992. Over the years I served the organization as newsletter editor, membership secretary, legislative liaison, and president. I joined The Alliance as a charter member in 1994. In 2005 I was appointed to the Advisory Board on Acupuncture to the Virginia Board of Medicine. I’ve seen successes but also many times when we’ve unknowingly made our lives much more difficult. I find that many fellow acupuncturists agree with me. However, far too many of us are not speaking up.
I agree with noted practitioner Miki Shima, OMD, who has been involved with acupuncture in California since the 1980’s, and who, interviewed in The American Acupuncturist, Winter 2007, said, “I’ve never seen a group of people like acupuncturists who do not give any money to their profession!” and, “The utter lack of political awareness among our profession is astounding to me!” Now we have a revitalized national organization, the AAAOM. I am pleased with the new visibility and professionalism of the group. I also believe that some of their efforts, though well intentioned, are misguided and carry significant risk for the future of AOM in the US.
The health care system in the United States is broken. Many people go without the most basic care while others have more care than is good for them. We have a system in which health is seen as an absence of symptoms. It is difficult or impossible for most to find a health care provider who will take the time to truly listen, to point out lifestyle changes that might address problems, or who sees health as more than making pain stop. One of the reasons acupuncture has been successful in the US is because we do offer our clients what they have been missing. We know that symptoms are flags pointing us to deeper issues. We know that health is a rich and varied thing that cannot be seen as merely having all the lab values fall into the right range.
Our wider view of health is, I believe, one of the reasons we have done well here in the U.S. According to the “Economic Evaluation in Acupuncture: Past and Future” in the Fall 2009 American Acupuncturist, “Over 3.1 million adults visited an acupuncturist in 2007, a figure that has risen sharply over the past decade; in 1997 there were 27 visits to an acupuncturist per 1,000 adults compared to 79.2 visits in 2007.” An article in Consumers’ Checkbook, a well-respected non-profit consumer journal says “Our subscribers certainly like their acupuncturists. Of all the services for which we collect Neighbor-to-Neighbor comments, acupuncturists are at the very top for customer satisfaction.” It seems that not a week goes by that acupuncture isn’t mentioned as a promising treatment for an ailment or pictured on a TV show.
Many of us have been led to believe that if Medicare covered our services we could share the gifts of our medicine with greater numbers of people, people from varied walks of life. Sadly, the realities of the Medicare system make it likely that, were our services to be covered, we’d become yet another cog in the machine, limited to treating symptoms as quickly and cheaply as possible. Rather than leading to business success, Medicare coverage of acupuncture might drive us out of business.
I urge you to look at the evidence. The New England Journal of Medicine, in Key Findings of “The Physicians Perspective: Medical Practice in 2008” Survey, reports that only 17% of physicians rated the financial position of their practices as “healthy and profitable.” 36% said that Medicare reimbursement is less than their cost of providing care, 82% said that their practices would be “unsustainable” if proposed cuts to Medicare reimbursement are made, and 63% said non-clinical paperwork has caused them to spend less time per patient.
In addition, The “2009 Annual Report of the Boards of Trustees of The Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds”, reports on page 10 (of 245), “The Financial outlook for the Medicare program continues to raise serious concerns.” “In the long range projected expenditures and scheduled tax income are substantially out of balance.” And, finally, “Closing deficits of this magnitude will require very substantial increases in tax revenue and/or reductions in expenditures.” Current calculations have the Medicare Trust Fund going broke by 2017, less than ten years away.
I urge you to do your homework. Practitioners who support Medicare coverage of acupuncture should speak with physicians and other health care providers about the impact the Medicare system has had on their ability to provide quality care. I hear again and again about their struggles to sustain a viable health care practice given the rate of reimbursement and the effort required to get those reimbursements.
Year after year in Virginia medical doctors have advocated for changes that allow Physician’s Assistants to provide more care. Why? Because the rates of insurance or Medicare reimbursement make it impossible for primary care physicians to provide the majority of direct patient care. The AMA spent over $8 million dollars on lobbying in the first 6 months of 2009, no small portion of that spent to make sure that Medicare reimbursement rates to physicians will be maintained. Will acupuncturists be able to mount a similar effort to maintain our fair share when the inevitable cuts to Medicare come? If the AAAOM is successful in their efforts on HR 646 this is the arena we will be forced to enter.
Who is more likely to participate profitably in the Medicare system, a chiropractor or physician able to bill for a multitude of services, including acupuncture in many states, and already set-up for Medicare billing, or an acupuncturist? Additionally, although the huge increase in potential clients is touted as a benefit of Medicare coverage of acupuncture, without sufficient numbers of Licensed Acupuncturists to serve this population we make it more likely that the public will receive acupuncture from chiropractors and physicians.
Involvement with a system of reimbursement, whether through private companies or the government, inserts a layer of complexity between practitioner and client. It takes control of treatment from the client and practitioner and gives it to a third party. Forms must be submitted and decisions made about whether a particular treatment should be covered for a particular condition.
The information we give about a treatment might well determine whether the third party agrees to cover it. One of AOM’s greatest gifts to Western Medicine is our view that health care should not focus primarily on making a symptom or illness go away, but should keep the organism well and balanced so that illness does not occur. Yet, in Medicare and most third-party insurance systems maintenance care is not considered to be medically reasonable and necessary and is therefore not reimbursable. Practitioners often code for secondary or tertiary conditions to obtain reimbursement. In some cases, using a particular code might alter the treatment we give – better add something for that knee pain, just in case they review the file.
Many believe that third-party coverage of AOM would save money. The formula used by the Congressional Budget Office (CBO), which determines the cost of government programs, does not show acupuncture to be a money saver. Their formula is flawed, as it assumes that people will continue to use other medical services as before even with the addition of acupuncture, but we have no convincing data to prove our claim of savings. Using a code that does not reflect the actual goal of treatment skews the data about the efficacy of acupuncture. And, if coverage limits discourage people from receiving maintenance treatment, is acupuncture still a money-saver? If Medicare covers only acupuncture, not moxibustion and cupping, for instance, will clients chose not to receive those treatments, even if they would be most effective? Once clients expect a third party to pay for treatment they are far more likely to begin or discontinue treatment based on the third party’s limits on coverage.
There are many critical details about Medicare’s impact on our profession that are unknown. What conditions would be covered, limits on services, how much we’ll be reimbursed, even whether we will have the option to opt out of the program (chiropractors cannot), won’t be determined until the law is passed. The answers, in addition to defining our practices, will define how the public views AOM. We do know that, if included and participating, we will be unable to collect payment beyond the Medicare reimbursement from Medicare Beneficiaries.
Passage of HR 646, or similar legislation, would be a terrible treatment for AOM in the US. Some practitioners will no doubt find a way to make it profitable. And no doubt additional people will have access to something called acupuncture or AOM. But like a treatment that results in a brief improvement followed by a worsening of symptoms, it isn’t the right treatment. Looking at the experience of those who have gone before us, it seems likely we’d end up spending less time with patients and more time with paper. We’d need to treat with the goal of fixing a symptom rather than for overall health (or fraudulently claim to be doing so). It would increase the odds that individuals receive treatment from someone other than a fully trained practitioner. Based on the experience of other professionals it would have a negative impact on the financial health of our practices. If we contribute to an unsustainable system does it help the public? If we add to the layers of bureaucracy (either governmental or private) does it help our clients? If we add to the public disconnect between the value of a service and its cost, do we help the future of health care?
There are far better options to reach our goal of making acupuncture available to many, to increase our business opportunities, and to increase our legitimacy in the eyes of the establishment.
Likewise, our desire for respect from other health care providers is not served when we attack the motives and practices of those who should be our allies.
Many acupuncturists, along with the AAAOM , have responded forcefully to the desire of the physical therapists to add dry needling to their scope of practice. The arguments include: “They are doing acupuncture without a license and without proper training. They’re going to hurt people; there will be miscarriages and punctured lungs. People won’t know they’re not getting real acupuncture — it might help them feel better, but it won’t address their underlying issues,” and on and on.
That list of horrors is eerily similar to the arguments used by the establishment when they fought against acupuncture licensure here in Virginia. I remember the anger I felt toward those who implied that we were putting our own self-interests ahead of the public. It gave me great incentive to keep up the fight. Furthermore, it was easy enough to discredit our accusers by pointing to the experiences of the states that already had acupuncture licensure. There was no record of risk to the public, and the public was ready to advocate for our cause.
I strongly believe that when we attack other health care professionals in this way we do harm to our reputation.
But “they” are doing acupuncture, I’ve heard many say. When we want to keep physicians and chiropractors from doing acupuncture we make the convincing argument that acupuncture is far more than sticking needles in people. It’s based on a complex and complete system that cannot be learned in a weekend class, we say. Now many in our profession are making the opposite argument to the very same legislators and regulators: if it involves sticking needles in people it is acupuncture and no one else should be allowed to do it. Contradicting ourselves does not help our credibility.
Many of us did not learn trigger point release as part of our basic acupuncture education, and I expect that many of us use it infrequently in our practices. Additionally, physical therapists did not gain entry to our secret texts and steal this technique from the world of acupuncture. The use of a needle (originally syringes were used) to release a trigger point developed organically from Janet Travell’s work dating back more than fifty years.
Will the patients who have received relief from dry needling, or physical therapy patients in general, accept our argument that we’re concerned about their well being? Or might they feel we are depriving them of the treatment they need, especially in those areas where there is no acupuncturist for 50 or 100 miles? Would we feel better if physical therapists used hollow-bore needles, causing greater pain and tissue damage to their patients, but protecting them from the “they’re doing acupuncture” argument? What message would that send the public?
Scope of practice questions are complicated. In general, scope of practice describes what is within a profession’s realm; it does not exclude that practice from all other professions. Certainly, this leads to many turf battles, easily recognized despite each party’s claim that they are fighting to protect the public, not protect their business.
When professions do manage to gain an exclusive claim in an area of practice it can become ridiculous. Recently the president of the Washington D.C. dietician’s association wrote to The Washington Post. The paper had printed an article in which a local chef was giving advice on eating a nutritious diet. The dietician wrote that ONLY dieticians are allowed to give dietary advice in the District of Columbia. Is that reasonable? Are we advocating for a world in which each health profession owns a technique or bit of information and forbids all others from using it? There is little within the physical therapy scope of practice that does not overlap with that of other professions. Do we argue that their field should not exist?
Many acupuncturists use techniques not specifically within our defined scope of practice, techniques that do not easily fall into either the most commonly used technical definitions of acupuncture or the wider philosophical descriptions of AOM. Is Tui Na within your scope of practice? It certainly isn’t acupuncture. Gua Sha? Might the massage therapists in your state have an issue if you wanted to include it in your scope of practice? Is Laser acupuncture within our scope of practice? Acutonics? What about muscle testing? What about ear staples for weight loss? Detox foot baths? NAET? Are we willing accept the same limitations we’d like to put on the on others and not do anything that might overlap with another profession’s scope?
Before we take up our banner and march into battle, let us take a step back and consider whether our arguments can be backed up by data. Can we show that the public has been harmed by the technique in question? Are we making an argument consistent with our past and one that will not be used against us in the future? We must also consider whether our reasoning and our relative power are sufficient for us to prevail. This will vary from state to state and from year to year. If we are unlikely to persuade the legislators and regulators to support our position will our arguments do more harm than good? Are our efforts likely to damage our relationship with those we may have to work with in the future, win or lose?
The AAAOM believes that the passage of HR 646, Medicare coverage for acupuncture, and their actions in the physical therapy dry needling conversation occurring on a state level, will increase opportunities for acupuncturists, show that we are respected, enable more individuals to receive our services, and overall be a good thing for our future. My experience and the experience of those health care industries that have gone before us leads me to believe that these efforts not only not solve our problems, they will instead contribute to them, weakening our ability make a positive contribution to health in the US.
Of course, there is plenty of work that needs to be done. Many people, even those who receive acupuncture, don’t understand the value and richness of AOM. Potential patients often don’t know how to choose between a Licensed Acupuncturist and a Chiropractor or M.D. who is able to do acupuncture. Some insurance policies unfairly discriminate against Licensed Acupuncturists. We still don’t have recognition in every state. Many areas, even in states with licensure, are underserved, with no acupuncturists in many counties. Success as a practitioner is still as dependent (or perhaps more dependent) on our business skills as on our clinical skills. Most research studies a medicalized type of acupuncture. Many legislators are completely ignorant of what we have to offer, and are unaware of their constituents who have benefited from AOM.
Health care, what it means and how it is provided, is in the news every day. We have a huge contribution to make to that conversation and to the health and well being of our fellow citizens. We now have a unified national organization committed to take advantage of this moment. What we do now will indeed shape the future. In my opinion, the points below are critical to our success.
- We must agree on a working definition of acupuncture and AOM. It won’t be easy. Most of us want the definition to be as broad as possible. We don’t want to accept that perhaps our side business selling supplements isn’t part of acupuncture or have to find descriptions of acupuncture for facial rejuvenation in the ancient texts. However, keeping it as open as we can carries risks. Will it help us present a consistent argument when dealing with the ever-present scope of practice issue? Is it something we are all trained in and qualified to do? Is it bringing the depth of AOM to the public or does it dilute our art and complicate our brand? Until we can agree on what AOM is, and what it is that we are fighting to have recognized, we can’t make accurate claims about the nature and effectiveness of our modality.
- We need to increase the number of qualified practitioners. We are too few in number for AOM to be fully accessible to the public regardless of financial or legal limitations. We are too few in number, in most areas, to have enough political power to change the system. Now is not the time to increase the expense and length of our training, as would happen if we adopted doctorate for entry-level at this time. It would slow our progress towards critical mass, and would leave far too many people without access to qualified practitioners for too long.
- We must evaluate whether our schools are successfully training qualified and competent practitioners. A significant percentage of acupuncture school graduates are not in practice five years after graduating. Do some schools have better success rates than others? Is that data available to prospective students? Are the schools with lower success rates learning from those schools that are successful? Are schools teaching students the business skills they need to establish and run a practice?
- We must treat others with respect. The practitioners of other healing professions might be our biggest allies in the future. Or, they can become our biggest enemies. With our relatively small number of practitioners our future success, in our individual businesses and as a profession, is likely to depend on whom we can count among our friends and who will work against us. It is critical that we collaborate with other professional groups and regulatory boards, sharing concerns and ideas, in ways that build mutual respect and give mutual assistance, not in ways that divide and lead to distrust.
- We need to continue to develop ways to provide AOM to all. The Community Acupuncture model may well borrow from the insurance model, but it allows us to see our clients as often as we think necessary without having to justify it to an insurance company and without having to fill out a multitude of forms. How many of us offer a sliding scale? How many of us volunteer at free clinics for several hours a week? The need is there; let’s meet it in a way that does not transform us into a cog in a machine.
- We need to take a leadership role in educating the public about AOM. When a TV star gets immediate pain relief after their on-air treatment that is a great thing for us. And, it doesn’t help the public understand that we offer far more than pain relief. When another facial rejuvenation photo shows up in the paper next to an article about acupuncture, how many people does it scare away from treatment? If people don’t know the difference between the acupuncture that we do and the dry needling that a physical therapist does, that is our failure.
I recommend that you read Joe Pandolfo’s article Strategies for Legislative Success: You Can Do It! and Jerusha DeGroote Stephens article, Helpful Hints for Passing Acupuncture Legislation, both in the Fall 2009 NCCAOM newsletter. Additionally, the Winter 2007 edition of The American Acupuncturist, the 25th Anniversary Commemorative issue of the AAAOM’s Official publication, has a wonderful series of interviews with leaders in AOM. Sadly, the lessons of many of those leaders seem to be ignored as our profession works toward the future.
I agree with the AAAOM. Now is a critical time for our profession. We have much to contribute to healthcare in the U.S. and we need to be involved in the nationwide conversation. However, the current activities of the AAAOM seem to be focused on carving out our piece of a broken and failing system, not improving the system.
If we want to change things, let’s not make the same mistakes as other health care providers, spending our energy fighting about who can do what or who will pay for what. Instead, let’s spend our energy and our money educating the public (that includes the politicians) about what we have to offer and finding ways to make it available to all without sacrificing our freedom. Let’s make sure there are enough qualified practitioners to serve those who want what we have to offer. Let’s build alliances with other groups who share our vision. Rather than living in the world of it’s not fair, it’s too hard, and we get no respect, let’s live in a world where we stand by what we do, where we earn respect, and where we create our own opportunities.