Replicability and the Economics of Practice
This blog post originated from comments on More on Replicability. Eric asked a number of good questions and in the process of preparing meaningful answers to his questions, this post grew into a blog of its own. (I have noted the ‘question’ and ‘response’ for ease of following this conversation.)
Eric – thank you for taking the time to read the article published in the American Acupuncturist vol. 56. I’d like to address a few items that may help you understand the magnitude of collecting this data, analyzing and reporting it in a coherent manner, as well as the challenges of actually getting the article in print. As addressed in the Survey Methods section of our article, a number of investigators helped with the data collection. Since you are specifically curious about the CAN data, I will mainly address the items I am familiar with through discussions with my co-authors. The CAN data was collected for each of the 3 previous calendar years (2008, 2009 and 2010). As noted in the article, CAN surveys had to be recoded using methods that are conservative and commonly accepted in order to provide reasonable comparisons and identify trends in the data. The surveys were designed and administered by CAN board members that volunteer to undertake this effort. Authors of this article entered into a voluntary collaboration with the CAN, Balance Method (BM) and newly graduated (G09) investigators in an effort to uncover some of the factors that may influence economic success and business models used. In the spirit of full disclosure, I am the only author who also designed and administered a survey (the G09 survey to graduates that were 12 months post graduation).
The summary we present is the first of its kind. It’s important to note that there has never been a Bureau of Labor and Statistics (BLS) workforce survey of acupuncturists. Technically, we don’t ‘exist’ as a profession in their eyes. Acupuncturists get lumped in with all kinds of healthcare professionals, but acupuncture itself is not identified as an independent profession according to the BLS. The data we present is remarkably consistent with the only existing data summarized in the Stump et al. Workforce paper. (Stumpf S, Hardy, ML, Kendall, D, Carr, CR. Unveiling the United States Acupuncture Workforce. Complementary Health Practice Review 15(1) 31-39.). Now that you have little extra background, below are my responses to your specific questions.
Question: Page 32 in the comparative chart: It records CAN practitioners as making a mean monthly income as being $5,277. The median income is stated as being $4,796. If one does the math, 311 txs per month @ $21 per tx = $6,531 mean average income. While 209 txs a month @ $20 per tx = $4,180 median average.
Response: The data displayed in Table 2 cannot be over simplified by the math you have used above. The mean and median gross monthly income, fees and patient visits is a result of the data analysis from all 3 years of CAN surveys. In the Survey Methods section we address this issue and state “For purposes of analysis, responses to the three CAN surveys were collapsed.” We had to apply commonly accepted data analysis methods to make sense of it. We had to start somewhere. The bottom line is the gross picture is not in the small details.
Question: Multiply these by twelve months = $63,324 mean and $57,552 median yearly average income.
Response: I found your calculation error. If you could simplify everything down to what is displayed in Table 2, your multiplication should read $78,372 and $50,160 respectively. It is important to note that the numbers discussed in our summary are gross annual income not net income.
Question: Meanwhile, on page 33 the article states, “CAN averaged $78,523 annual income.” While the chart below this records that average to be $74,832. The math seems fuzzy, at best.
Response: I cannot speak to this directly. Possible transposed numbers between the paragraph and Figure 1? Keep in mind, this is the average gross annual income as reported by CAN clinics (not individual practitioners) from the collapsed data of all three CAN surveys. It continues to be true that many CAN clinics are run by 1 owner acupuncturist with or without reception staff. It might be useful for you to look at some of the summarized data from the 2010 CAN survey posted on this blog in April 2011. While this survey alone doesn’t detail all the data from 2008, 2009 & 2010, you should be able to see some tends in the shared results that help to explain the information in our article. Note the surge in clinic openings over the past 2-3 years and, although not a direct correlation, the large number of CAN clinic responses reporting gross annual incomes under $69,999. In 2010, 33 CAN clinics reported gross income between $70,000 and $479,999 (broken down into $20,000 increments).
Question: Then if you consider that all of the CAN propaganda (meant in the educational material definition, not the extremist dogma definition) that I have seen states that CAN clinic opportunities offer practitioners a working class wage that averages $35,000 a year.
Response: I do not know all the compensation details for each independently owned CAN clinic. I can only speak about my current employment at Working Class Acupuncture in Portland, Oregon. Lisa is as transparent as she can be while breaking things down in The 4 R’s post https://www.communityacupuncturenetwork.org/blog/jobs-post-1-4-rs. You would need to contact every CAN clinic to uncover this data before coming to any conclusions about your question above.
Question: Working class practitioners that treat working class people, right? Lisafer and Jessica, please correct me if I am off base.
Response: CAN clinics treat all kinds of people. Since CAN clinics do not ever ask for income verification, I cannot speak to this detail with 100% accuracy. What I do know as a practitioner in a CAN clinic is what my patients tell me directly. It usually involves some part of the phrase “I could not afford to get acupuncture……” or “I could not continue my acupuncture care……if this clinic didn’t exist”. The patients I provide care for are teachers, lawyers, bartenders, nurses, cashiers, chiropractors, home makers, HR managers, students, janitors, massage therapists, etc. There is no direct correlation that can made about their working class status or not from our summary.
Question: I could maybe see where a CAN clinic with two practitioners would report gross $75,000 a year. That would be about $37,500 a year each.
Response: If a clinic has a gross annual income of $75,000 and two practitioners work there, they are definitely not each taking home $37,500 per year. Remember the surveys are reporting gross annual income not net annual income for CAN clinics. Taxes, rent, insurance, licenses, CEU credits, business expenses, payroll dollars (if practitioners are even compensated in that manner), etc all must come out of that $75,000 pool. If a clinic is operating with two practitioners each taking home $37,500 per year, that clinic needs to be grossing around $150,000 per year.
Question: So, if my facts are straight, you doubled the average yearly income for a sole practitioner, painting a more rosy picture utilizing practitioners and a practice model that doesn’t even attempt to portray things as rosy as your study documents.
Response: The suggestion that our article is “painting a rosy picture” is odd given that all the results still pretty much suck (I could use other words but pretty much want to get right to the point). For a large percentage of acupuncturists earning a living is hardly rosy. This is why we included the student loan data for the G09 group as earning a living with such disproportionate income to debt ratio is one more factor that may influence economic success. Review the NCCAOM 2008 JTA one more time if you need another source of suckiness. The rosiest picture that our summary may paint is that average gross annual income of all reporting CAN clinics is comparable to the BM folks.
Question: I asked the owners of our local CAN clinic, Kelly and Melissa (sorry to drag your names into this fracas, my friends and colleagues) of WE The People Acupuncture in Santa Fe, NM what they thought of this stat and the response I got is: maybe just one, or maybe 3 owners in the network is making this kind of money (paraphrased). Please, Kelly, tell me if I misparaphrased you. Believe me, I’m not trying to pick a fight. I just want the facts. Sadly, there is little good data.
Response: I completely understand that you want the facts, good data and information about the profession that we belong to. Sadly our “leadership” organizations (NCCAOM, CCAOM, ACAOM, AAAOM, etc) that have paid staff aren’t really of much help in regards to workforce data collection, reporting and transparency. How can we even begin to tackle the issue of jobs (not ‘opportunities’, not ‘self-employment’) for acupuncturists when we don’t even investigate and uncover the real state of our profession? More work is desperately needed in this area. We already know there is a tendency within the profession to paint a rosy economic picture. It’s time for our profession to see if the reality of a ‘career’ in acupuncture matches the myth.
Question: I appreciate you working in this direction, but I cannot wrap my mind around your numbers. Could you please explain to me how this critique is unfounded? Curiously, Eric
Response: Thank you again Eric for your time and questions. It’s time to uncover the details and pay it forward to the current and prospective students who are coming up behind us before we fade away as profession and abandon our patients because the “acupuncture midlife crisis” got the best of us. Remember, we could always use additional curious acupuncturists. Don’t be afraid to let us know if you would like to help us continue this work.
Thank you for this, Shauna
And thank you to you and Steven and your co-authors for your article, which I finally got around to reading. Very sobering and important work; I hope it finds a wide audience, especially among the acupuncture education purveyors. I will print out a copy to have on hand for those folks who tell me they are thinking of attending acupuncture school: caveat emptor.
fuzzy math and defensability
Eric – Thanks for your close reading of our article. We very much appreciate that AA has published our research. We were cognizant of the data issues and addressed them throughout the piece. The problem with your secondary analysis lies wth understanding the difference between the median and the mean and how and when each is used in statistics. These are measures of central tendency that atempt to find the midpoiint in a distribution. Finding the midpoint gets iffy when there are outliers – extreme scores. Suppose we have 11 LAcs reporting incomes. The lowest earns $10K. The highest earns $400K. The mean or average is the sum of all scores divided by 11. What happens when the next highest report – the 10th score – is $70,000? The $400K influences the mean such that the “average” income is inflated and the best picture of “average” is misrepresented. The alternatve midpoint is the median which would be the 6th score in this set. Sppose that score is $50,000. Now we say the income more representative of the middle in the distribution is $50K. This is actually more “accurate” than the mean. By multiplying the average fee and multiplying by the average number of visits then comparing to a median or mean you have made some critical errors and crossed up the data. Your conclusions are not defensible meaning they cannot be defended upoon analysis because of your methods. This is exactly the issue we faced when trying to make data from three separate sources based upon three different sets of questions tell us something about LAc earnings. The big picture is that these surveys say a lot about what is important to working LAcs. The groups that asked us to help analyze their surveys suggest there is interest among some LAcs to learn more about their profession’s economics. They want to know how others are surviving and what are the metrics of success or failure. We try to flesh these out from these samples.
Thank you Shauna and Steve and Melissa
I really appreciate you taking the time to respond to my questions. The unfortunate aspect of this is that I seemed to have been confused between the simple discrepancy of gross and net. This misfortune gladly lead us to a greater clarification of your data collection and analysis.
This leads me back to Melissa from We Da Peeps that reminded me that when one looks at gross from net, when one is a sole proprietor or in a partnership, it is way way different than my circumstances as being an employee of a hospital. Single practitioners have to not only consider taxes, but also operating expenses, which come out of the gross income. So if one states 74,000 dollars as gross, than there is all of the expenses AND taxes which leaves a net around the realm of 35,000 to 40,000. My net to groos is far higher because I don’t pay rent or a front desk staff or for laundry expenses…
Now it all makes sense to me.
What does not make any sense at all is that we pay the same amount of money for our education as one who goes to a SECOND tier medical school. For instance, the University of New Mexico Medical School. I’m not talking Harvard or anything. But the shitty part is we aren’t Drs, we’re LAcs. A crappy MD makes 150,000 a year. An excellent surgeon or a radiologist makes 800,000 to 950,000 dollars a year. Someone who makes the investment in our education is penny and pound foolish. This is not sustainable if we want to spread our medicine to bring greater good to more people.
Therefore, we have been duped. For this medicine to be furthered in this country it needs to have the income to investment ratio equalize. The schools have manufacture a false economic bubble. This bubble will correct itself, there is no way around it. The question is whether it will do so voluntarily or violently. I would like it if it is voluntary. Sadly I don’t know if the those who decide will let that happen. Voluntary reform has mostly been the exception.
I appreciate a forum that allows us to speak the truth to those who deny it.
Eric
What should providers of health care really make?
Hi Eric,
I’m wondering if I’m mis-reading your comment, so do correct me if I’m wrong, but it sounds to me like you’re saying that since some healthcare providers take home disproportionally large amounts of money as income, that we acupuncturists should therefore expect to earn more money.
This surprises me because the cost of healthcare, obviously including those salaries to which you refer, is bankrupting our nation. Please look over the following information on medical debt, from Wikipedia with various references:
“Medical debt is an especially notable phenomenon in the United States – the US being the world’s only developed country not to offer universal health care. In less developed nations those on low income in need of treatment will often avail themselves of what ever help they can from either the state or NGOs without going into debt, but in the US medical debt has been found by a 2009 study to be the primary cause of personalbankruptcy.[2]
A 2007 survey had found about 70 million Americans either have difficulty paying for medical treatment or have medical debt.[3] Studies have found people are most likely to accumulate large medical debts when they do not have health insurance to cover the costs of necessarymedications, treatments, or procedures – in 2009 about 50 million Americans had no health coverage.[2] However, about 60% of those found to have medical debt were insured.[3] Health insurance plans rarely cover any and all health-related expenses; for insured people, the gap between insurance coverage and the affordability of health care manifests as medical debt. As with any type of debt, medical debt can lead to an array of personal and financial problems – including having to go without food and heat plus a reluctance to seek further medical treatment.[3] Aggressive debt collecting has been highlighted as an aggravating factor.[4] A study has found about 63% of adults with medical debt avoided further medical treatment, compared with only 19% of adults who had no such debt.[5″]
Is this really a system in which we want to participate as healthcare providers? Personally, I find the idea of profiting so enormously from someone’s ill health to be utterly repugnant. I feel that the sliding scale I offer allows me to be reasonably compensated for my time providing a service. After all, the median income in the U.S. for women is between 33-35K (up to 50K for men) according to the Census Bureau in 2006.
And while I found Chinese medical school to be sort of challenging in terms of having to memorize a lot of unfamilar terms, it was hardly rigorous in terms of scholarship or time. Most medical residents pull 60-hour workweeks, whereas my internships (and as a California student, I spent more time in education and internship than I would have been required to in any other state) was 12-16 hours a week.
Despite the acupuncture schools’ attempts to inflate our educational standards, the simple fact remains that performing surgery requires so much more in terms of training, education, supervision, and practice than acupuncture that it seems hardly fair to lump the two professions together in terms of expected income. Really, surgery or other medical specialties are hardly comparable to acupuncture. We are really much more on par with physical therapists than medical doctors.
And maybe you were just pointing out that it’s the schools who are creating these income expectation based on their tuition increases. In which case, while I see that could be true, there are many other graduate training programs (fine arts and psychology come immediately to mind) that impose similar debt loads, but surely don’t presume that their graduates will be able to command the kind of incomes you refer to above.
I totally agree that the investment for our education should be more commensurate with our expected income. But I do feel that I’m hearing from you that our expected income should be higher, and I’m not sure that’s really reasonable.
As much as they need to pay off their loans
Hi there,
I think we probably agree more than we don’t. I would not refute anything that you have said about our healthcare system. One exception to that is I think its the military that’s bankrupting our nation, not health care. We are in this so-called debt predicament not because we spend too much treating sick people or paying doctors, but because we spend a lot of money on more efficient ways to kill people. If we put the money that we spend on weapons into making sick people better, we’d all be rich and and people would get great healthcare. But that’s a different argument.
So, back to our story. When it comes to our education and its price compared to our ability to make money, I am actually undecided on what I think is just or fair compensation.
Firstly, I spent $100,000 on my schooling. AND I busted my ass to learn more than the dog pile that was given me as learning material In Chinese “medical school”. I took extra clinics and got a job working in the tough setting that is “healthcare,” a hospital. I didn’t work as a barista or a bartender because that’s not what I wanted to do. I wanted to be a healthcare provider because that’s how I saw myself. That came directly from my experience in VietNam, where acupuncture and herbal medicine providers are considered not separate from, but equal to, others that are healthcare providers. Not one of the acupuncturists that I learned from there had less than an medical degree that makes our Chinese “medical degree” look like fodder. That’s the real dope. So yeah, for my time AND investment and expertise, I want to make money.
By the way, funny that you should mention, I happen to make the same as a new Physical Therapist. And that is more than enough for me. It is the minimal that one can justify making with this kind of debt load. And remember, our degree is a technical degree, kind of like if you went to one of those tech schools that you see advertised on TV on Tuesday afternoons in between sitcom reruns (DeVry?). Technically, according to the DOE, I learned a TRADE. I want my salary to be commensurate with my investment.
Secondly, your last statement is really what I’m after. If my above statements are completely out of line with reality and it is not reasonable for me to expect income that is commensurate with our investment, then I want the price of our education to reflect the investment of time and money that we put into it. If we are not to see ourselves as healthcare providers, then our education should cost us about as much as it does to get a nursing degree at a community college, and not anything more. It should cost as much as being a Physical Therapy Assistant. How about an Associates in Water Coloring? I don’t know, but please, don’t give poorly trained and unfit people Masters Degrees if they have no more ambition than to be a tech.
This education, AS IT IS, offers us no more than an Associates Degree worth of knowledge, if your doing Acupuncture only. If you add herbs in, MAYBE a Bachelors, but maybe not. And the rigor of most schools in actually making people learn is a joke. They will pass you as long as you hand them money. And critical thinking? Non existent. The state of our schools is a fucking three ring circus. No wonder no one (including and especially ourselves) takes us seriously. It is a house of cards.
So there you have my rant for the day. Don’t take it personally. It’s actually not addressed to you specifically. Your questions tripped my circuits. I’m just as pissed as others on this forum. So, I’m sorry if I sound like a dick to you.
The school system is my real target. Even if I can’t change the past, I can influence the future. I think we need a school system reboot and do-over if we want to help more sick people and train more practitioners. And do it in a just way for everyone, patients AND practitioners.
Eric
healthcare, income and bankrupting the US economy
Thank you and Eric and Demetra for moving the conversation outside the particulars of our article. This is definitely one of my intentions as one of the authors – to generate discussion about where acupuncture fits in healthcare. Big picture: as a profit driven enterprise in the USA, healthcare is at odds with the purpose of taking care of a nation’s health. The largest healthcare systems are publicly traded corporations that require an 18% margin for stockholders. The costs of providing care come out of the balance. Taking care of patients is the last expense. The current healthcare reform initiative seeks to move to a single payer system like Medicare which would remove the profit margin and nationalize/socialize healthcare. The same publicly traded insurance/healthcare companies PLUS the pharmaceutical industry oppose such with all their dollars and influence. While this struggle plays out over the next couple decades the question remains…what is the role of acupuncture in the healthcare system (a smaller but more accessible picture – we could actually influence this outcome)? This is one of the principle reasons I got involved with needling/TCM/acupuncture. The nation does not need more highly paid surgeons. We need primary care providers (PCPs) – those are the “crummy docs” who only make $150K. They are trained in family medicine or internal medicine. Their scope of practice is remarkably similar to that of an LAc. The work a PCP does is also managed by Nurse Practitioners and Physiician Assistants (who start near $80K). There are not nearly enough of all of these providers to meet the need for newly insured patients under healtcare reform. I am happy to share articles on this. Send me an email and ask for them. In order for an LAc to work as a PCP s/he has to be trained in mainstream medicine. Many LAcs are not interested in this. However, LAcs such as Eric who are interested in working and being paid like other healthcare providers, or perhaps Demetra once she learns more about how an LAc can work in a comunnity clinic helping poor and uninsured people and getting paid $60K to do so, are simply not trained properly. If there is one thing an LAc needs that is currently not provided it is clinical experience working alongside mainstream providers. I have co-written a paper on this titled Mainstreaming Acupuncture. Ask and I will send it to you. To wrap this up, the current clinical training of an LAc in terms of mainstream experience is so minimal it falls below that of a PTA or an LVN. The schools do not wish to provide mainstream experience. The reasons include (1) cost to the schools, (2) cascade effect of providing prelim didactic content, and (3) resistance to despoiling the convenient commitment to Chinese Medicine as an “alternative” system that is mysteriously different and superior to mainstream medicine. This is where I quote Richard Dawkins “there is no alternative medicine; there is only medicine that works and medicine that doesn’t work.” Thanks for your interest.
nurses
as a nurse and an LAc I can attest that yes the intesity of learning in general and also the biomed content of the masters degree in acupuncuture is inferior to my bachelors of science in nursing (at roughly 1/3 of the cost).
If what acupuncturists are learning is more equivelent to an associates degree yet we are paying for a masters degree the answer is not to fill up the masters degree with more content to make it worthy of the title. In order to be helpful doing acupuncture you do not need to be a PCP.
The answer is to issue associates degrees or bachelors degrees. If acupuncture can be safely practiced with the minimal education we are getting then why call a spade a spade? Keep the program, cut the cost and make it an entry level degree. The cost of education would more accurately reflect the real world salary of working as an acupuncturist. Debt levels would be decreased so acupuncturists could invest in their practices. Community clinics could more easily hire people.
The only reason not to is “doctor envy”. This is a classist impulse that is suffered by many proffessions- nurses, physical therapists, chiropractors, naturopaths and so on.
Taking a humble position (entry level degree) would benefit patients by helping the spread of acupuncture.
If an acupuncturist really wanted to be a PCP they could continue on to the next “level” which could include more training and a masters degree or doctorate in oriental medicine. Or since most of the info that one would need to become a PCP is biomedical in nature why not go to nurse practitioner school or physician assistant school. Acupuncture should not be held hostage by advanced degrees. There is no need for a acupuncturist to be a PCP in order to practice acupuncture.
Eric– maybe you can help me understand something– whats the difference between an acupuncturist that is a “technician” and an acupuncturist that has more “ambition”?
Steven– Can you email me that paper? nick at adastraacupuncture.com
appropriate training levels and MD envy
Nick – Another well-used term for what you call “MD envy” is “degree creep” which means perpetually upping the standards for training until the hallowed doctorate level is attained. This vanity pursuit has created two kinds of doctorates: the PhD or traditional kind and the “clinical” kind. Simple example is the PhD in psychology vs. the PsyD. Only those grads with either degree who went to a regionally accredited program are permitted to sit for the clinical psych licensing exam enabling the licensee to open a private practice. Why two kinds of degrees? PhDs are trained to do research and “create knowledge”. PsyDs are trained to treat mental disease. PhDs also open private practices but for those who do not want the research training there is the PsyD.
This is precisely where acupuncture has gone wrong. The DAOM or OMD is a clinical degree. An MD is a clinical degree. The difference is not in the total hours; it is in the breadth and depth of clinical training. There are often back doors to the clinical license. For example, if you want to do counseling you can get an MA and apply for the MFCC license and still open yor own head shrinking practice. It makes perfect sense if one’s clinical goal is to just shrink heads. Therefore, to have an entry level degree strictly aimed at providing sufficient skills to do needling in a private practice is a good idea. Keep the hours and the cost low: perhaps 9 mos. and $15K. Ake a BA part of the minimum entry requirements (there are very good reasons for this). However, if you want to work in a community clinic you will need mainstream med clinical experience. That would require a longer training program (12 or 15mos.?), training alongside other providers n a community clinic, and more $$ ($20K?). Put these program in a community coillege.
So why have PhDs at all? To conduct the professional training research and guide the training programs so they meet standards of other similar health professions training programs. Everyone certainly does not need a doctorate to do competent clinical work. owever, every healthcare professions requires PhDs to make sure they are up to speed with all health professions training programs.