I am stealing POCA volunteer Kristie Danis’ excellent title for some reflections I’ve got. It’s been an interesting couple of weeks. As you may know, at the beginning of November a bunch of POCA Circle volunteers converged in Portland for a leadership retreat. The weekend right after that, Skip and I went to Florida to teach a workshop for some fabulous POCA clinic owners and POCA punks. Whew! November has been kind of a whirlwind, but it’s also provided a great tour of the POCA-verse. Since we got back from Florida I’ve spent a lot of time collapsed on the couch alternately staring into space and at my laptop. The bad part about this is too much glazed-over Internet time; the good part is that I noticed two other POCA members who have blogs had put up interesting posts that got me thinking. And thinking and thinking. This is a long post so maybe you want to go get a cup of tea or something.
The first post was on Elaine Wolf Komarow’s blog, the Acupuncture Observer. It’s mainly directed at acupuncturists, but many POCA members would find it helpful in understanding the problems of the acupuncture profession. Elaine is great at clearly and concisely explaining issues that are otherwise confusing to many people. Here is her take on acupuncture and insurance:
“Insurance does not create money, it redistributes it. The money coming in via premiums or taxes must be equal to or greater than the payments for services and the expense of the bureaucracy (whether government or private) that manages the system…If someone pays a $150 monthly premium and expects to get ten acupuncture treatments/year, and you “deserve” $700 or more for those treatments, there isn’t much left to cover the bureaucracy or the costs of their neighbor with cancer, their father who just had a stroke, or their own colonoscopy, broken arm, or appendectomy.”
The comments are just as good as the post itself (and if you found your way here via those comments, welcome to POCA!). Anyway, as I read through them, I had a kind of visceral recollection of what I felt in the very early days of making my clinic. I hated dealing with insurance companies. Of course, most of the people I wanted to treat didn’t have insurance coverage for acupuncture in the first place, so part of what I doing was giving up the hope that they ever would, and moving on to design a business based on the acceptance that insurance companies didn’t care about my patients, and so I didn’t have to care about insurance companies. Which was great, because as many acupuncturists have cause to know, it’s awful dealing with third-party gatekeepers when you are trying to take care of people. It’s frustrating and demoralizing, and as Elaine points out, even if you are successful at it, it almost inevitably changes the way you practice and draws you into gaming the system. Many acupuncturists feel that they have to take insurance in order to make a living, even if they don’t want to; it’s not a big leap from there to feeling like you have to lie to insurance companies — even small lies about what you’re really treating your patient for — in order to survive.
I’ve written other places about how I started my clinic in part because I finally realized, on the heels of a mental health crisis, that I needed to be kinder to myself. I had been working in a public health clinic that provided a great service to the community, but its funding was always unstable, my job was always kind of in jeopardy, and the conditions were too chaotic for me. (The building once caught fire during my shift — that was my limit.) When I left public health to start my clinic, I was thinking hard about what kind of quality of life I needed. One conclusion that I came to was that I needed to be very clear about who I was working for. I didn’t want to work for insurance companies and deal with arbitrary, ever-changing rules. If I was going to take better care of myself, I couldn’t spend a lot of time interacting with complicated systems that would make me crazy — or make me lie. If I was going to take better care of myself, I needed to work for patients like me, who liked things to be simple and straightforward. I realized that, in essence, I had to build my own alternate universe where I could work how I wanted to work, and for whom I wanted to work. The effort required turned out to be really good for me.
It also turned out that a lot of other people were happy in my alternate universe. Plenty of people with ordinary incomes did in fact need and want acupuncture — and they really appreciated being able to get as much of it as they wanted, without having to consult any gatekeepers about whether or not their treatments were covered or they had the right diagnosis. What I really wanted, as an acupuncturist, was to provide unlimited amounts of acupuncture, and let people decide for themselves how they wanted to use it in their own lives. No insurance company would underwrite that, but lo and behold, my patients would.
This reciprocal relationship is what I think of as the beginning of the fractal that became the POCA cooperative. It repeated itself with other acupuncturists and other patients all over the continent. The relationship starts with the recognition that the system, as it stands, is not going to help acupuncturists care for patients of ordinary incomes in a way that is sane and sustainable, and it’s not going to help patients get acupuncture on their own terms. Or, as Dorothy Day put it, “Our problems stem from our acceptance of this filthy, rotten system.” Corollary: solutions stem from rejecting it, and trying to build something else.
The system isn’t going to help us (which is one of the many reasons it’s filthy and rotten); on the other hand, nobody can stop us from helping each other. That’s the principle of mutual aid, the foundation of all cooperatives. But sometimes it’s good to have a reminder, like Elaine’s post, that the system really is rotten. It’s easy to wish that things were easier, and to lose track of the big picture in the midst of the day to day effort to help each other. But there are much worse things than making the effort, and one of them is the place that we started from, the world without POCA. It’s a lot of work to build an alternate universe, but do you really want to live in the universe that the filthy rotten system built for you?
The second post that caught my attention was on Mike Gonzalez’s tumblr (which arguably has the best url ever: https://commie-unityacupuncture.tumblr.com/) about the fact that the term “community acupuncture” has become pretty much meaningless from a patient’s perspective, now that “there are more offices calling themselves community acupuncture popping up in different areas and offering various complications of the sliding schedule POCA clinics use”. I think “various complications of the sliding scale” is a very kind way to put it, and I’m going to try to remember to describe it that way from now on instead of shrieking and tearing my hair out. The whole post was a thoughtful and measured set of suggestions for patients about how to approach this situation.
Reading Mike’s blog and Elaine’s blog in the same evening made me remember that POCA is trying to do something much bigger than any individual acupuncturist could ever hope to accomplish — and many individual acupuncturists who describe their practice as “community acupuncture” don’t have the slightest interest in a project of this scale. POCA is trying to build a structured, interdependent, mutually beneficial relationship between patients and acupuncturists en masse. As a collective. That could bypass or replace completely any relationship of either group with insurance companies. This is not easy.
A lot of acupuncturists — and a lot of people period, I guess — would prefer to focus on themselves as individuals, and not their relationship to a system that they might or might not feel is filthy and rotten. A lot of acupuncturists are perfectly nice people, with a generally open-hearted, humanitarian inclination, even the ones who use community acupuncture as a loss-leader or a charitable exercise on alternate Tuesdays. If individual niceness was going to do anything to change the system and improve our collective situation, it would have happened by now.
One of the things we talked about during the workshop in Florida was the contrast between how POCA approaches the business of community acupuncture and how our culture in general does business. One participant had a well-meaning, business-savvy friend tell her that the next step for her clinic was obvious: since she was so busy, it was time to raise her prices a hefty notch. Another participant said her business-consultant friend just couldn’t get his head around why POCA wasn’t a for-profit franchise, and why Skip and I weren’t retired by now.
The short answer is: what Dorothy Day said.
The long answer is, you can’t just “make money”. Money always comes from somewhere, which is what Elaine is trying to get acupuncturists to understand about insurance. Often there is a cost to “making money”. When you raise your prices, you lose your ability to treat certain groups of people. If POCA were a for-profit franchise, the money for the franchise fees would have to come from somewhere; probably only acupuncturists who were starting out with a chunk of savings would be able to participate in the franchise. They’d want to recoup that investment, and then of course there would be ongoing franchise costs; these things would require clinics to raise their prices. (If such a scheme could work at all, which I doubt.) Everything we love about POCA wouldn’t exist, but we’d be able to retire? Sometimes making money just isn’t worth it. The acupuncturists who are branding their practices as “community acupuncture” while basically trying to get as much money as possible out of their patients don’t get this.
But you can’t really fault them for just doing what our society tells everybody to do, which is to make more money, regardless of the cost. Anyway, what I really got from reading Mike’s blog and Elaine’s blog was: 1) being a multi-stakeholder co-op is hard, but I’m so glad we’re doing it, and 2) we can’t afford to take each other for granted. Without each other, all we would have is the filthy, rotten system of gatekeepers, lies, and constantly inflating prices. So I thought it’d be worth writing out all the things we shouldn’t take for granted about each other, the efforts we all put in to build our alternate universe, by category. I’m sure there will be things I miss, so please add them into the comments.
Patient Members: pay their dues to POCA even though doing so does not get them a better deal on acupuncture. 99% of them are lovely to work with in the clinics. They are willing to graciously accommodate various limitations that POCA clinics have: patients being human in the clinic by snoring and the like, punks being human and making mistakes, clinic spaces not being perfect spa-like environments. They don’t act like entitled consumers, which makes it possible for the clinics to treat more people. By receiving lots of acupuncture, they teach punks its power and worth. The fees they pay give punks their jobs. They provide word of mouth marketing and other services that clinics couldn’t afford to pay for in a million years.
Clinic Owners: often they pour all of their resources, personal and financial, into their clinics, risking whatever savings they have, putting their names on leases, taking financial risks that get recouped — if they get recouped — only by a steady job and lots of great relationships with the community. They take the leap. They learn to do everything that has to be done to run a business, whether they want to or not, including the really unpleasant stuff like firing people. They accept a learning curve where their inevitable errors happen in public and potentially affect a lot of people. They have to listen to capitalists telling them how crazy they are. Nonetheless they create jobs, and spaces where the vision of POCA is made real.
Punk Employees (this category includes many clinic owners as well): often went to acupuncture school having been led to believe that after graduation, they would easily reap $100K per year for merely hanging up a shingle and thinking about Chinese Medicine. Often they’re up to their necks in school debt. Nonetheless they undertake the additional and often painful challenge of deprogramming themselves in order to work really hard and be useful to real people with real problems, for modest compensation at best. They accept a learning curve that also happens in public, in a roomful of patients. They put up with their employers’ cluelessness. They have to listen to other acupuncturists telling them that they’re hacks who Devalue The Medicine. They witness lots of suffering they can’t do anything about. But acupuncture, when people can get enough of it, is also profound and amazing, and hardcore punks don’t really want to do anything else.
Clinic Staff and POCA Office Staff: acupuncture gets all the attention, but clinics (and co-ops) couldn’t run without the people who answer the phones and do the bookkeeping and clean the bathrooms and answer the emails and keep track of the membership database. Many of them could get paid much better for the same work in the corporate world, but like the punks, they don’t want to work for corporations, they want to work for patients who need acupuncture.
POCA Volunteers: DO EVERYTHING. For many individual clinics and for the co-op as a whole. During the leadership weekend, I was overwhelmed by the lists of things that POCA Circle volunteers do that either make my own life better or create benefits for the co-op — all involving skills that I don’t have and don’t want to develop. I love it that POCA offers microloans, but I really don’t want to pore over the loan applications. Thank God the Finance Circle does. Back in the early days of my clinic, I used to spend many frustrating hours answering questions and fielding unannounced visits from acupuncturists who thought that they maybe wanted to do community acupuncture. Now the Clinic Success Circle oversees an organized process for peer mentorship, thus shielding me and all the other clinic owners from legions of curious acupuncturists. The individual clinics and the co-op as a whole could no more pay for all the work that volunteers do than they could fly to the moon. There would be no community acupuncture movement without them.
One thing about the filthy, rotten system is that — depending on your position in it — it can be well-upholstered, comfortably padded even, with money. It can feel reassuring and secure. Outside it, not so much. I think one of the functions of capitalism is to make people feel so independent that they can take things for granted, or at least count on always being able to buy more. The goal is to never have to worry about where your next (fill in the blank) is coming from. Punks, on the other hand, can’t take their jobs for granted; patients (and clinic owners) can’t take their clinics for granted; and none of us can take our co-op for granted. The only way we can be free of the filthy, rotten system is to depend on each other. Thanks, Elaine and Mike, for reminding me of that.