My life is different in many ways now that POCA has a school, and one of them is that when a colleague sends me an email that starts out with “holy shit” and ends with a link to a news story about an acupuncturist getting arrested for financial crimes, I don’t just *facepalm* and move on with my day, I think, “hmm, probably better discuss this with the students”.
That goes double when the acupuncturist who got arrested was doing (among other things) community acupuncture.
So this is a blog post about why I think insurance billing and community acupuncture don’t mix; it might be part of a series about how CA is being weirdly interpreted out there in the wilds of capitalism. It might also be an item on a list titled, Things You Can’t Help When You’re Running an Open Source Community/Knowledge Commons. (Both this acupuncturist and one of the founders of Modern Acupuncture had a POCA punk membership for a year, in other words, just long enough to access the information on this website and go on their merry way.)
According to county officials, the county’s health-insurance plan paid out more than $1.1 million to Jaynes’ Absolute Integrated Medicine, from October 2015 through September 2016. To put that number is perspective: The Indian River Medical Center billed the county only $1.6 million for treating county employees and their dependents during that same period; and the Sebastian River Medical Center was paid only $560,000 – half of what Jaynes’ small acupuncture office collected.
The $1.1 million paid to Jaynes covered 34,340 visits for 253 plan members who sought treatment at Absolute.
County officials said employees flocked to Jaynes’ practice because of her policy of not requiring a co-payment, essentially allowing patients to seek free, unlimited treatment.
The issue prompted county commissioners in December 2016 to place a cap on acupuncture benefits in the health-insurance plan offered to county employees.
Following the change in county policy, the number of county employee visits to Jaynes’ office plummeted. In the fiscal year that ran from October 2016 through September 2017, only 126 members submitted claims for 3,863 visits and less than $180,000 was paid to Jaynes’ practice.
As I’m reading this article, I can’t help remembering the conversation I had back in 2003 with somebody who knew a lot more than I did about the acupuncture business, who told me: there’s no demand for affordable acupuncture. You could offer people free, unlimited treatments with the best acupuncturist in Portland and they still wouldn’t come.
POCA changed that narrative and proved that, when cost isn’t a barrier, people DO want acupuncture and they’ll get a lot more of it than anybody previously thought they would.
That said… 34,340 treatments divided by 253 patients is 135.7 treatments per patient. In a single year. Granted, that’s 2-3 treatments per week, which in theory is possible, but in reality…let’s talk about acupuncture utilization patterns for a minute.
This topic has been a major preoccupation for WCA because we have more than one community partnership where we offer unlimited treatments at either a fixed cost to our partner or no cost at all. We give away a lot of acupuncture. We don’t freak out about these arrangements, because in our experience, if you offer a whole bunch of people free, unlimited acupuncture:
1. Most of them won’t take you up on it. They’ll be grateful that you gave them the option, but they won’t ever try it.
2. Of the ones who try it, a large percentage will get acupuncture only once or twice, before deciding it’s not their cup of tea or their schedules are already too full. People’s lives are complicated; making time for regular acupuncture just isn’t that easy. Nonetheless, these people (we sometimes call them tourists) will also be grateful you gave them the option.
3. Of the people who get more than one or two treatments, a number will get a course of treatments — like ten in a row — and then after that, drop in sporadically. Others will come faithfully every week for awhile, but not forever.
4. The smallest percentage, but the ones who motivate us to maintain these community partnerships, are the ones who get life-changing/life-saving results from acupuncture, often for chronic conditions. These are the people who come once a week, or multiple times a week, forever.
There are not that many of these people.
WCA’s average number of treatments per patient is about 6. We do have a lot of people who are getting enormous amounts of acupuncture at our clinics, but their treatments are more than offset by the one-and-done crowd, the tourists. In years of experimenting with giving acupuncture away, this proportion has never changed. Then again, we've never offered anything but acupuncture; no free herbs or supplements, no incentives to try to convert tourists into high utilizers. Our high utilizers self-select.
To be fair to Absolute Integrated Medicine, a different Florida news outlet reported different numbers for the county insurance company: 221 members getting acupuncture in 2016 for a total of 8242 treatments — which reflects a more reasonable 37 treatments per patient per year. That’s still a bafflingly high average by POCA standards. And 8242 treatments for a private practitioner who is also running a community clinic –with presumably more volume — is still outlier-high, though not so improbably high as 34,340 treatments in a year with 135 visits per patient. And it still cost the plan over a million dollars, which is when they started asking questions. If you look at the practice’s website, there’s almost no difference between private treatment hours and CA treatment hours; the main difference is that the CA-clinic was entirely drop-in, so I guess everything was happening at once? This arrangement sounds bananas for a high volume clinic, even with multiple employees.
But I digress. To get to the point of this post:
Do I think some of the details of this fraud (if it was indeed fraud, and not some colossal misunderstanding) were “inspired” by POCA? (Shudder.) Yeah, I kind of think maybe they were. Especially if you consider the likelihood that this same acupuncturist experimented with involving patients in, um, advocacy and organizing. (Triple shudder.)
And people wonder why I don’t like being called “inspiring”.
So for the record, and because I think there’s a non-zero chance that community acupuncture/saving patients money will be invoked as part of this acupuncturist’s defense (see: “she saved many people from opioid addiction/ her patients are going to rave about everything she did”): I don’t think insurance billing and community acupuncture are a good combination. I don’t think the principles of community acupuncture are as flexible as people would like them to be.
One of the reasons community acupuncture is successful as a business model, and a clinical model, is that it recognizes that real life is messy. People’s health problems often don’t fall into neat diagnostic categories. Sometimes people need treatment every day for weeks for an out of control pain issue. Sometimes people just need one treatment every so often to manage their stress, before it turns into a diagnosable physical problem. Sometimes the best way to treat somebody is to treat the family member who drove them to their appointment. When it comes to acupuncture, insurance won’t cover a lot of what people actually need. Trying to fit all of that messy real life into an insurance billing structure is a nightmare.
The community acupuncture model was designed so that we don’t have to try, ever; so that we don’t have to engage with insurance at all.
If you read Cory Doctorow’s novel Walkaway (highly recommended!) you could say that the community acupuncture model was designed for walkaways. Walkaways, as in, the Ones Who Walk Away from Omelas. The people who can’t stand the system, not the people who are hoping to make bank from it or the people who think if you just tinker with it enough, you can force it to work. There’s a price for walking away, of course, but we think it’s worth paying.
I’ve been wanting to link anyway to a nifty blog post my friend Ellen wrote, riffing on the theme of, community acupuncture isn’t something acupuncturists do to patients, it’s something people do together: I know I can speak for all of the practitioners at PCA when I say that we understand that we are not the only ones practicing community acupuncture at the clinic. All of our patients, every time they come in for a treatment, are also practicing community acupuncture, developing their skills of relaxing, accessing support, and being in a social setting while in pain, the skills of using their community clinic.
The community acupuncture model was designed to disrupt the story of the amazing healer who saves people, in order to make room for a better story — about communities taking care of themselves.
The community acupuncture model wasn’t designed to inspire, it was designed to be used for a concrete, specific purpose. You know the saying, if you can’t be a good example, you’ll just have to serve as a horrible warning? This story might be a warning about trying to use bits and pieces from community acupuncture while also trying to remain part of (and profit from) the system that it was meant to help people walk away from.
It might also serve as a kind of experiment, set up to answer the question: Is acupuncture cost-effective, from the perspective of the health care system, if people can access unlimited treatment? The answer seems to be: not at market rates, it's not, and not within the paradigm of an amazing healer saving people. Maybe Absolute Integrated Medicine wasn't a good example in a conventional sense, but if this story helps illuminate that particular question, I'm grateful.