Terrible, Horrible, No Good, Very Bad Numbers: a Retrospective

Can I just say that I never intended to make this a series?

Back in 2009, Acupuncture Today published an article titled “AOM Soaring Dramatically: Use Jumps by 50%”. The article was based on a report from the National Health Interview Survey, which is conducted continuously by the CDC’s National Center for Health Statistics. Every year, interviewers visit (in person) between 35,000 and 40,000 households and get them to fill out a detailed questionnaire. Not a small sample.

In 2009, when I wrote the first Terrible, Horrible, No Good, Very Bad Numbers post, I wasn’t thinking particularly about where the numbers came from, I was busy trying to figure out what they meant. My conclusion was that if 3.1 million Americans got acupuncture in 2007, that’s no cause for celebration, because it suggests that the ratio of individual patients to individual acupuncturists was 155 patients for each one of 20,000 L.Acs — assuming every one of those patients got acupuncture from an L.Ac as opposed to another provider (an MD,  a DC, or even, God forbid, a PT) and of course we know that’s not how it works. In other words, not enough patients were receiving acupuncture to support a genuine acupuncture profession. If the numbers were correct, most acupuncturists couldn’t be working. And we’d need about ten times more patients for the profession to be economically viable. Also, the article suggested that nobody else was even trying to do the math.

As it turns out the NIH publishes data on the use of alternative medicine from the National Health Interview Survey once every 5 years.

On Feb 10 2015, they released the results from 2012.

And lo, once again they were terrible, horrible, no good, and indeed very bad for the acupuncture profession.

So I’d like to use this post not just to analyze those numbers, but to reflect on some things that have happened for the acupuncture profession between 2007 and 2012/now. In that time period I’ve had reason to revisit the terrible, horrible, no good, very bad numbers theme thanks to the NCCAOM’s Job Task Analysis demographic survey, so there’s more data to think about besides the NHIS’.

First, check out the birds-eye view courtesy of this nifty graph, accompanied by these raw numbers (scroll to the end of the report). If you look at the graph you will note that acupuncture use was not, in fact, “soaring dramatically” in 2007, it was just bouncing back slightly to where it had been in 1999. Over the past 13 years acupuncture utilization has pretty much stalled out, in the neighborhood of 1.5% of the US population.

I dare you to write an article about this, Acupuncture Today. I double-dog-dare you.

Let’s take a quick look at the updated numbers: 1.5% utilization in 2012, with a total US population of 312,780,968, gives us 4,691,715 individual acupuncture patients, divided by…hmm, let’s see, how many L.Acs do we think there were in 2012? If we guessed 20,000 in 2007, and every year about 2,000 acupuncture students graduate (I recall seeing that somewhere on the CCAOM’s website, but now I can’t find the reference), that would give us 30,000 L.Acs in 2012. 4,691,715 divided by 30,000 gives us…drumroll please…

156 individual patients per individual L.Ac.

Circa 2012, most acupuncturists still could not have been working.

So what’s been going on with those last 5+ years? I can think of several answers and no doubt my alert readers can think of more. The obvious one is the Great Recession. You can see that massage utilization had been rising until 2007 and then it dropped, which looks like people have just had less money to spend on “complementary approaches”. But I’m not sure we can blame the Recession for acupuncture staying exactly where it was in 2007.  It’s like the Causes of Disease that we teach first year acupuncture students: there are external causes and internal causes and I suspect our terrible, horrible, no good, very bad numbers are mostly our own fault.

Despite 10,000 more practitioners, the overall public demand for acupuncture has increased not at all. (OK, it’s increased .01% alongside a 50% increase in providers. No good!) Given that acupuncture is unfamiliar to a lot of people, there should be a kind of exponential increase happening: more acupuncturists in practice should equal more patients discovering how great acupuncture is and telling everybody they know, leading to a steady rise in utilization. (That is exactly what has happened with community acupuncture clinics since 2006, so please, don’t tell me it’s not possible. I watched it happen in my own clinic.)  Well then, maybe we didn’t really increase by 10,000 L.Acs. As I mentioned in the original post, holding an acupuncture license does not equate to working as an acupuncturist. Maybe that anecdotal 80% failure rate after 5 years is pretty accurate and we have almost the same number of providers now as we did in 2012. (There’s a hole in the bottom and we’re steadily leaking L.Acs. Very bad!) If so, then those 20,000 L.Acs, give or take, get 235 individual patients each, which is a little better but still nowhere near enough to make a living. Or to make a profession.

As a side note, does anyone want to estimate what percentage of total treatments were provided by L.Acs? I really have no idea, I just know that it can’t have been 100%.

Unfortunately, the Executive Summary from the NCCAOM’s 2013 Job Task Analysis (scroll down to the bottom of this page) synchs up with this very low estimate of individual patients for L.Acs. 78.5% of respondents reported that they saw 0-10 new patients each month.  Any working acupuncturist knows that a substantial portion of new patients are going to be one and done (more about that in a minute; it’s another area where we don’t have enough information). If you’re going to have a steady job, you need to have a robust stream of individual patients. Collectively, we don’t.

Let’s get some context about the popularity of acupuncture in general. Our friends over at Science Based Medicine (j/k) have this estimate, based on a range of studies in a few different countries: “The research data on acupuncture utilization suggests that from about 5-25% of people, regardless of nationality or ethnicity, will at some time try acupuncture…”  They cite a couple of studies from Taiwan, where acupuncture is covered by national health insurance, that show that in a given year somewhere between 6% and 11% of people use it. In Japan, the yearly proportions are 5-7%.  37% of those 5-7% reported they tried it once and wouldn’t use it again; over the course of a lifetime,  20-27% have tried it.

As someone who has worked at a busy community clinic that has grown steadily over the years (maybe 500 treatments in 2002 to 50,000+ in 2014), these numbers make intuitive sense to me. Working Class Acupuncture, my clinic(s), has about 3% of the population of Multnomah County in its patient database.  I know from experience there are more people who want to try acupuncture than  people who want to use it over and over again. Some people report miraculous cures after one treatment; some people decide it’s not their cup of tea. It seems like some people are just curious; some people like knowing they have options; some people who might want to use acupuncture over and over just can’t make it fit into their schedules; there are lots of human reasons. The reason we in POCA keep doing what we’re doing is that, whatever those percentages are, there are enough people out there getting a better quality of life from acupuncture — sometimes a profoundly better quality of life — to keep us motivated and busy. I don’t know about you, but I don’t need everybody to tell me that acupuncture saved their lives; having a couple of people tell me that, and having reason to believe them, is enough to keep me committed for decades. If we’re letting a lot of people exercise the power of choice, and we’re giving a few people life-changing results, that totally works for me.

The question is why it’s not working for the rest of the acupuncture profession. Looking back at that graph, the National Health Interview Survey indicates that the utilization of yoga really did soar, from 5% of the population in 2002 to something like 9.5% in 2012. That’s within the range of people getting acupuncture in Taiwan. If as many people in the US were trying acupuncture as are trying yoga, I would have to permanently retire my terrible, horrible, no good, very bad numbers theme.

I’d like to draw your attention to another Acupuncture Today article, this one from 2007 titled “AAOM and the Alliance Decide to Merge”. Be sure to check out the graphic that goes with the article — it pretty much says it all. One of the recurrent themes in the acupuncture profession is that our problems stem from a lack of unity, but in 2007, AKA the Year of Soaring Dramatically, that was all supposed to be taken care of. “A new era in acupuncture and Oriental medicine leadership has arrived… reunification is the first step in building a 10,000 member strong association that will represent and advocate for the AOM profession”. The article concludes, “ It will be interesting to see how the leadership of two distinct organizations operates as a single entity for the benefit of its membership and the profession.”

Yeah. It was definitely interesting.

Here’s the thing: unity doesn’t just happen. Unity isn’t a cause, it’s an effect. An effect of: 1) knowing what you’re trying to do because you took the time to think it out;  2) being able to communicate it clearly because it makes sense; and finally 3) doing the unglamorous work of organizing people around it. I don’t think the acupuncture profession has put enough effort into any of those things to be able to expect unity. And apparently, we’re still not interested in doing the math.

In a recent Integrator blog post, John Weeks noted that the NCCAOM has functionally taken over leadership of the acupuncture profession.  If you look at the NCCAOM’s 990 form from 2013, you will see that their total revenue is about $3.8 million a year. $3.5 million of that comes from “exams and related fees”. As the NCCAOM’s website explains, these exams are designed for entry-level practitioners. I think it’s safe to assume that this $3.5 million is largely coming from student loans.

Either way, it’s notable that in the last 5 years, the acupuncture profession in the US has lost any semblance of being led by practitioners who are actually working in the field.  Our new leadership is an organization that is underwritten not by working practitioners but by acupuncture school graduates who are not yet practicing, but hoping to enter the profession — graduates who are increasingly burdened by student debt.  One of the other notable trends of the last 5 years is how much acupuncture school tuition has risen (now there’s where you could justifiably use the words, “soaring dramatically”) and, to a lesser degree, NCCAOM exam fees.

And while we’re looking back on things that have happened between 2007 and now, let’s not forget the federal government’s growing interest in for-profit schools’ access to federal student loans. About 50% of the acupuncture schools in the US are for-profit. Almost all acupuncture schools rely heavily on federal student loans.

A smart person told me once, when describing his fears about acupuncture schools and student loans, that the thing about bubbles is that they are continuously expanding — right up until the moment that they pop.

So while on the one hand it seems like we are simply revisiting the terrible, horrible, no good, very bad numbers of 2007, in reality the context makes them even worse. And this should be a wake-up call.  Our profession justifies everything it does with the claim that the public wants what only L.Acs can provide — ideally L.Acs with first professional doctorates — and that that demand is growing every year. This story that we tell ourselves is one of the main ways we justify not rolling up our sleeves to do any real organizing work. But according to the data, the demand isn’t growing. All that’s growing, apparently, is the debt load of acupuncture school graduates, and now the rest of us are counting on a continuing stream of borrowers to hold the profession together.

We’d better hope they don’t look at that graph. That would be the moment right before the pop.

Author: lisafer

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  1. When I was in the middle of a shift at my ac(k)u-skool’s clinic, things got slow and some of my classmates started asking me what was different about my particular acupuncture organization from the other ones.

    I think my new standard answer to that question will be, “We do math.”

  2. Thanks, Chris, for catching that — I think I fixed it.

    Yeah, white men in black suits shaking hands in front of a corporate logo — like we’re titans of industry or something.

    Our profession’s self-image is so disconnected from reality, it’s no wonder we are where we are. Being delusional might make you proud, but it’s not going to make you productive.

  3. I am not sure that I can add much more meaningful insight than the things you have already deduced and pieced together.

    Doesn’t seem on the whole that many things have changed in the mainstream acu worldview in the past 5+ years since the last NIH survey on Alt Health usage.

    Our profession and acupuncture usage on the whole is either stable, or stagnant, depending on the point of view. Certainly not growing, at least by measure of usage from the NIH study. Maybe, maybe , growing slightly in the number of licensees. Ironically, one of the cheapest and most easily applied antidotes to stagnation is acupuncture. Maybe the profession needs to get some acupuncture.

    It’s interesting to ponder again, “what IS the acupuncture profession?” is it practitioners, new grads, students, schools, alphabet orgs, etc. Questions that you and others have addressed and pondered through the years. Does the profession consist of the educational or organizational beauracracy and what it takes to keep those components alive? Is it the rank and file acupuncturists? the students? What about the end users – the community of patients who uses acupuncture as a tool to improve health? Who are the most important stakeholders and what are we doing to support them?

    One reflection is that although the supposed number of LAcs grows by 2000 grads every year, time catches up with all professions, and attrition happens, be it great recession, or eventually people retiring, changing jobs, hating their career choice, having children, or people die. Does the number of new grads and grads who can make a living by the five year mark keep up with attrition from an aging profession at this point? and help to increase the availability of acupuncture for a growing population? I am guessing it doesn’t at this point or is a slight increase in the last few years — but that would need to be backed up by a new head count of licensees in all states to see what has happened in the last 5 years.

    Acupuncture as a whole would prob need double or triple the number of new grads to grow the profession consistently. Destined to be a cottage industry forever I imagine. Looks like worldwide usage, and even in Asia, the usage numbers aren’t spectacular.

    Depending on who you talk to, there may or may not be a shortage of doctors and nurses just based on sheer population numbers in the U.S. in the next 10-20 years. Likewise, unless there is a significant increase in the number of acupuncturists in the next decade, there will never be more than a 1.5% usage rate in the general populus.

    It is probably to be expected that the defacto leadership of the acupuncture profession is the NCCAOM ( proverbial “last person standing” ), as they economically exist from mandatory testing fees and have a reliable source of income, except for Califonia where CAB exists. I personally do not see any benefit to pay NCCAOM ongoing fees re-register as an ongoing practitioner. I am sure they have some good intentions to help us maintain our overall autonomy as practitioners and not be subject to more capricious and possibly draconian medical boards, or NMds, Chiros, PTs, etc to be able to poke the people. On the other hand, one has to wonder whether or not NCCAOM just needs to focus on testing and let the national leadership work itself out.

    Just some thoughts. Maybe soon we can get a new head count of licensees to see any trends.

    Warm thoughts from the desert,

  4. The morning of April 19th, I tuned into the local community radio station in Minneapolis-St.Paul and heard the Wave Project show ( https://kfai.org/waveproject ) discussing “hot topics” in acupuncture. What counted as “hot topics” in acupuncture for the four acupuncturists on the program seemed to involve testimonials of the explosion of interest in acupuncture, the great things that their acupuncture has done for people, and plugs for the clinics and health businesses for which they worked.

    Pretty disappointing to me since I understand the hottest topic in all of medicine in all of the United States is economic. Americans spend greater amounts of money on health care and get the least benefits of any developed country I understand.

    So I called into the radio program and asked the acupuncturists if they had heard of this blog post, and if they had heard of these debt to income studies, and if they if they had heard of the suggested “not sustainable” warning label? Well they sure wanted to interrupt me something awful and they cut off the phone line before they answered.

    Their statements amounted to saying that all of education is expensive and weirdly that America is just now “becoming ready for Chinese medicine” or something like that. They didn’t have any numbers as I remember. I’d characterize the answers I received as platitudes to sweep the elephant in the room under the carpet.

    I believe that America was ready for Chinese medicine back when Ing Hay was working in John Day, Oregon dealing with the Spanish Flu epidemic. What America has never been “ready for” is an entire profession based on bizarre “schools” that take idealistic, naive students, fleece them for a huge chunk of their future worth, while they experience classes that range from decent, to bizarre, to insulting.

    Some of the students that went to school with me professed crazy magical thinking or did reckless things in clinic. Some of the teachers acted pretty crazy too. The school tolerated everything except not coughing up student loan money continuously. I didn’t get to ask the acupuncturists if they thought America was ready to call all of this good medicine.

    Listening to these acupuncturists on the radio reminded me of the film “Commune.” 2005? This film features Harriet Beinfeld, Efrem Korngold, and Michael Tierra all in one place, Black Bear Ranch circa 1968. That film has a great discussion of how idealistic noncomformist people could end up in a profession that serves rich squares. I am glad that the acupuncturists that came out of Black Bear Ranch could at least recognize the unintended consequences of their investment. I didn’t get to ask the upbeat acupuncturists on the radio if they had a clue about this.