Category Archives: regulation

Middle of the End

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The opinions in this post are mine alone, and do not represent any organizations or associations with which I am affiliated.

The profession is in trouble. And as of the October 26 NCCAOM/ASA Town Hall even our leaders admit it. That last bit is new. But what isn’t new — as far as those leaders are concerned, there is only one way to save the profession. It’s their way. And it depends upon working LAcs to shut up about our concerns, and do what they tell us to do.

My experience with the ASA in the Spring 2020 was yet another reminder of the profession’s dysfunctional patterns. I believed (despite previous experience) that a mainstream Acupuncture organization was willing to transparently explore the risks and the benefits of a proposed course of action – in this case, of becoming Medicare providers – with the thought that in so doing we could prepare to mitigate the risks, increase the likelihood of benefits, and build consensus on a course of action.

Instead, at the 11th hour, after 100’s of volunteer hours from a group of individuals invited to participate, almost every mention of “cons” disappeared. A slanted pro-inclusion document was released, followed by a poll designed to tilt pro-Medicare. Still, support for the fight was, and continues to be, tepid. And rather than address or acknowledge the legitimate concerns of working practitioners, what we get from the leadership is exhortation and pressure.

This is a repeated pattern.The organizations choose a direction: increase hours of training, add credentials, become doctors, increase insurance coverage, fight other professions. It’s our only hope. Practitioners who raise concerns are ignored, sidelined, or attacked. When the success we were promised doesn’t arrive, it’s our fault. The organizations may change, but the song remains the same.

A year ago I was privileged to have lunch with Mina Larsen and I made the following request —

The ASA and NCCAOM have decided that becoming Medicare Providers is the only way forward. I keep being told that I have nothing to worry about, that I’ll be able to opt out and continue to practice the way I do now. As a way to show working professionals that you have our backs, let’s pretend the language passes tomorrow, boom. Can the ASA and NCCAOM prepare a document, “So, We Won, What Next?” Lay it out for us. What, specifically, do we need to do to Opt Out? Is it a one time thing? Can I change my mind? How does opting out impact my patients? If I want to be a provider, how do I sign up? Do I need to make changes to my record keeping? Are there any accessibility issues regarding my office? If I make errors in billing am I in any greater legal risk? What are the profession’s plans for lobbying on an ongoing basis? Won’t we need to prepare to fight rate cuts? What’s the budget for that?

(I’ve been asking these questions for a decade!)

So far, crickets. There hasn’t been any effort to help us prepare for what happens on the other side of “success.” Just as we’ve been left to fight with the insurance companies and devote more time and money to training.

Other thoughts while listening on the 26th —

– Has anyone explored how many LAcs are likely to choose to participate in Medicare? What percentage of the 50 million Medicare beneficiaries Mr. Taromina mentioned will LAcs end up serving? If other professionals provide more of the acupuncture treatments, could it speed our demise as a relevant profession?

– Why hasn’t increased insurance coverage increased LAc satisfaction and practice success? Is it true that increased insurance coverage hasn’t impacted non-participating providers at all? (It isn’t true, but that’s what we were told at the time, and now we’re being told the same about Medicare.)

– Is there evidence showing that treatments from LAcs are more efficacious than acupuncture treatments provided by others?

– The presenters raved about a future in which, in a pediatric oncology setting (a weird example for a discussion about Medicare), LAcs would treat not just physical pain, but also the emotions and spirit of patients and their families. Are third party payers reimbursing for treatment of emotions and spirit? Do practitioners feel that the time and visit constraints of third party payers impacts ability to deliver deep, holistic, treatments?

– Mr. Taromina mentioned that the lack of unity in the profession resulted in missed opportunities when it came to Covid, the opioid crisis and the ACA. What’s a specific thing he thinks we could have done differently? (I mean, sure, working together, but for what specifically?)

– Mr. Taromina said that no one has come to the leadership with “better ideas” about helping the profession. Why have suggestions to revamp our educational and credentialing process to create a shorter and cheaper path to entering and remaining in the profession been ignored? (I raised these ideas years ago, and I’m not the only one.)

Was the presentation on the 26th too alarmist? No. It might not be alarmist enough – “the profession” is in trouble, there will be consequences for most of us, and the only “solution” under consideration by those in power won’t help.

It’s critical for regulated professions to have healthy organizations and institutions and I’ve devoted huge amounts of time and energy to supporting these groups. Facing, once again, their lack of learning from the past and their disregard for the actual lived experiences of working professionals is painful as hell.

I have no suggestions about what we do next. For me, it’s time for a healthy boundary. There’s no point in continuing conversation with those who refuse to hear. I’ll save my energy for the treatment room.

Good luck to us all.

Another NCCAOM Post. Sorry.

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I know, three posts in two weeks is too many posts. I need a break as much as you do.

My post last week was an open letter to the NCCAOM, so I think it’s fair to share the response from the Chair of the NCCAOM Board of Commissioners.

Dear Elaine,

It was nice to meet you at the CCAOM conference.  Thank you for your concern and dedication to our profession.  My apologies on the delayed reply and acknowledgement of your letter to the NCCAOM Board-I did not want to respond with only a cursory acknowledgement given the energy and effort of your letter.  I will share your letter with the rest of the Board of Commissioners.

That said, I do want to address some of the points you made in the letter.  I hope you will not take my comments as a dismissal of your concerns – I would simply like to clear up some misunderstandings. I am not able to address all of them in this moment, but I would like the opportunity to clarify in the future.  A few points:

-The CEO is not responsible for setting up recertification criteria- that process is done by the Recertification committee(again within the parameters of maintaining our certification).   Continuing education is a non-negotiable.  That said, it has been noted and suggested that the process be more streamlined.

-Exam content is driven by a specific process dictated by NCCA standards; it is acknowledged that the end result is an exam that weighs heavily on TCM.  That is a challenge that we continue to attempt to address.  We are always looking for new suggestions – within the parameters that we must maintain to keep our certification.  As was mentioned, there are budgetary considerations to developing additional psychometrically valid exams as well as the challenge of having enough practitioners to determine psychometric validity and objectivity.

-States that have added herbal certification to their licensing act have initiated that either through the professional association or the state regulatory board. We have not initiated this despite some of the rumors.

-With regards to stakeholder input: whenever possible and applicable, we do seek stakeholder input.  There are times where stakeholder input does not weigh in on a decision – i.e. compliance with new requirements from NCCA, exam validity requirements, ; and issues where we actively sought stakeholder input – i.e. the revision of the code of ethics, the herbal safety certificate creation, etc.

Thank you again,

Best regards,

Afua

Afua Bromley, L.Ac., MSOM, Dipl.Ac. NCCAOM

Chair, NCCAOM Board of Commissioners

I fear my frustration at hearing the same old talking points resulted in a brusque response.

Dear Afua,

Thank you so much for taking the time to respond. I appreciate it.

Will you be at the ASA meetings this coming weekend? I’ll be participating. If you will be attending, perhaps we’d have a chance to talk through these issues in person? In the meantime, I’ll share some thoughts.

Perhaps I shouldn’t take it so literally, but I don’t think there are any misunderstandings here. Perhaps my comments at the CCAOM meetings, and in my blog, could not thoroughly illustrate my  knowledge of these issues. I’m well aware of the complexities of the NCCAOM’s situation. We may certainly have some differences of opinion about what is possible, ideal, effective, or desirable, but I don’t think any misunderstanding is the issue.

Specifically, in response to your email –

  • I understand that CEO’s generally defer to committees for policy proposals. And yet it would be unusual if the CEO did not influence, to some degree, the work of the committee and decisions about how to refine, implement, or adopt committee proposals. In any case, I hope my letter, and the input of the profession as a whole, will be considered by the recertification committee. I agree that continuing education is a standard aspect of ongoing certification for health professionals and others. But the degree of involvement the NCCAOM has in approving classes, and the level of reporting it requires of Diplomates, is outside of normal practices. Requiring providers to pay you to have their courses approved raises questions about your motivations. I look forward to seeing how the committee can better align the cost to the profession of your system of approvals and tracking, with the benefit to the profession of such an onerous system.
  • I’ve heard, over the years, several versions of the “We realize the TCM focus of the exam is a problem, we share your concerns, we’d love to hear your proposals, but the NCCA guidelines, and budgetary constraints, mean we aren’t going to be able to do anything about it” response. If your understanding of the NCCA requirements you have been working under leave you seeing no path forward for a non-TCM based exam, wouldn’t it be more honest to acknowledge that? I can imagine several possible solutions – dropping the lineage based portions of the exam completely and leaving it to schools to verify that aspect of a student’s training, just as it currently defers to CCAOM for CNT testing, is one. I understand from those with more expertise than I, that the JTA used by the NCCAOM has significant flaws, so developing a new JTA would be another approach. Perhaps working with a group other than the NCCA would be helpful. I don’t believe there is no solution to this problem, but if those at the NCCAOM who are most familiar with the NCCA requirements don’t see any room for change, acknowledge that. Let’s not waste the time of others by pretending you’ll consider other options.
  • I was tracking the NCCAOM participation in the original DE licensure law in real time, and have media reports [An Example]from the time, showing Mr. Taromina actively pushing for the herbal requirement for all licensees. The professional association reported being persuaded by Mr. Taromina that the herbal requirement would be the best path forward. In Utah [We Have Met the Enemy], any investigation would have shown that the position of the professional association (no longer functional, I believe) was taken in response to one individual’s desire to retaliate against graduates of a particular school. The NCCAOM made no attempt to assess the position of the many Diplomates in the state who were unaffiliated with the professional association. And the NCCAOM has yet to offer any correction of the letter, written by that association and distributed by the NCCAOM, saying that the NCCAOM agreed with the proposed change. Last, but not least, the NCCAOM says it supports all Diplomates. If so, the proper participation of the NCCAOM in response to proposed regulation that would  eliminate licensure for Diplomates of Acupuncture would be a vehement renunciation of such efforts and a statement that it believes that Board Certification in Acupuncture is the only Certification that should be required for licensure.
  • In a recent example, the NCCAOM announcement of changes to testing procedures was met with expression of concern from stakeholders. In response, the NCCAOM made adjustments so that the changes would be less onerous to those about to graduate. Checking in with schools prior to the initial announcement would have meant those changes could have been made proactively, and schools would have been prepared for their student’s concerns. Clearly, there was some room for adjustment. There is not such a bright line between where stakeholder input is possible and applicable, and where it isn’t, as the NCCAOM repeatedly states.

Perhaps you didn’t notice the wish in my letter —  “that when concerns were brought to your attention you didn’t deny or evade or misrepresent what happened.” Your reply here contains all of the denials, evasions and misrepresentations I’ve heard before. As the saying goes, don’t micturate on my leg and tell me it’s raining. Don’t tell me that someone else is making you aim this way, or that budgetary constraints are to blame. It is possible for the NCCAOM to do better. The first step is owning the problem. I’m still waiting for that.

With hopes for a better future,

Elaine Wolf Komarow, LAc, Dipl. Ac.

The good news is that it looks like I will be able to talk with NCCAOM folks this weekend. I hope that gives me some good news to share. The bad news – it means there will be another blog post.

 

NCCAOM Issues – Here’s a Real-Life Example.

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Last week’s post generated lots of feedback – in the comments and elsewhere. Several people reached  out to me with stories about how their professional success was negatively impacted by NCCAOM policies or procedures.

An individual trained to be an acupuncturist wrote:

I graduated from an acupuncture school outside the country in November 2017. The NCCAOM requires that those trained outside the US must have their documents evaluated by a third party in order to apply and sit for the NCCAOM exams. As of November 2017 the NCCAOM only accepts documents evaluated by the International Consultants of Delaware (ICD).

In December 2017 I began my long ordeal with this organization. After 8 months of emails and phone calls going unanswered or minimally responded to with a form letter, I contacted NCCAOM to inform them that the company they were requiring me and others to use had appalling business practices that were preventing me from taking the NCCAOM exams, applying for a state license and starting a job that was being held for me.

Happily, I did get immediate help from the contact at NCCAOM. They intervened on my behalf and took my educational documents for their own review. However, I was then notified that I still needed ICD evaluation as the NCCAOM could not approve a “non-traditional” transcript. They also said they were not familiar with the school.

The school I attended has been graduating American students for over 15 years, and many have returned, successfully sat for the NCCAOM exams, and obtained licensure in the US. However, now it seems that the format of the provided transcripts are unacceptable; nothing has changed from the school’s perspective.  The only suggestions offered by the NCCAOM are not feasible, such as giving them the names and other personal information of past American students in order to compare what would be identical transcripts, my completing a 2 year apprenticeship (not acceptable for licensure in my state), or the school rewriting their program.

It has now been 18 months since I started this process and am no closer to being allowed to even apply for the NCCAOM exams. It seems incredible to me, and many others, that the format of transcripts, paperwork really, is all that is keeping me from fulfilling my dream. The NCCAOM has nothing to lose by allowing me to take the exams only the gain of my $1500. If I fail, then that is on me.

P.K.

 

The LAc who wants to hire P.K. wrote:

Dear NCCAOM,

As a licensed acupuncturist in practice since 1995, I have been saddened to watch the new generation of acupuncturists struggle with ballooning student loan debt and escalating practice requirements. The combination is eating away at our numbers. This acutely affects the public, our clinics, and those of us hoping to retire some day and pass our clinics on.

As an employer, I am immensely frustrated, because your practices are blocking me from hiring.

P. K. has been my clinic’s office manager, front desk staffer and clinical assistant for more than 3 1/2 years.  She is bright, committed, compassionate and skilled.  She excelled in her three years as a student at a well regarded European acupuncture school.  She comes highly recommended by the school’s president. She has been a delight and a pleasure to work with, continually exceeding my expectations, and our patients are very fond of her.

Meanwhile, I am busy, frequently over booked, and have been looking to add to my clinical staff, with no luck, for quite some time. There is a shortage of licensed acupuncturists in my area interested in a high volume, low fee, community style of practice. I offered P. a position as a community acupuncturist in early 2018, contingent on her obtaining a Massachusetts acupuncture license, and she accepted. Since then, I have been waiting, watching as she does what she can to obtain licensure, while the NCCAOM has been a roadblock in that process.

P. has spelled out in her own narrative the details of her efforts to get approved to take your exam.  When I reached out to you on this matter, we were asked to provide information on previous grads of her school who have sat for the NCCAOM exam — information that neither of us has any access to, but which no doubt, resides in your own files.

Consequently, P. has been left in limbo, with no path forward to practice in the US.  My clinic remains understaffed, and I have no ability to hire the person I’ve chosen, who is best prepared to succeed in this position.  Our state is unable to add a skilled acupuncturist to our numbers. It is all very frustrating, and sad.

A final thought — the whole idea of a licensing exam is to evaluate whether or not a graduate is prepared to enter the field.  If you trust your exam’s ability to function as it was designed, blocking graduates from taking the exam makes no sense.

D. D., Lic Acupuncturist

 

I (The Acupuncture Observer) do believe that requiring a combination of education and examination is the best way to increase the odds that a licensee will be a safe and effective practitioner. Folks with good study skills and an ability to memorize can pass exams without being able to apply what they know in practice. The NCCAOM exams can’t test whether a candidate can identify the signs used in diagnosis, for example. And, the schools have an incentive to say all of their students know enough to be practitioners.

I acknowledge that, for better or worse, the NCCAOM currently requires graduation from an ACAOM-accredited school, or an overseas equivalent. And that means they have to have some method of determining equivalence.

And, yet, is there no solution here? Is it really better for the public, or the profession, that a business and a community goes without the help it needs, while a well-educated and well-trained individual who wants to fill that need is sidelined, with an expensive education wasted?

I think the NCCAOM can and should do better. If they can’t, we need to allow another path to licensure.

 

Dry Needling – Winning, and Losing.

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The Battle of Cold Harbor, in May – June 1864, was one of the last victories for the Confederates in the Civil War. (Or, as it was referred to in the South, the War for Southern Independence.) The victory did not change the outcome of the war.

In January, a state judge ruled that Dry Needling is not within scope for Physical Therapists in Florida. This ruling was proclaimed a great victory and widely celebrated on Facebook and here, in Acupuncture Today.

FSOMA won in Florida, because, as appears in the ruling, “A simple reading of the physical therapy scope of practice statute, section 486.021(11), in light of the definition of “acupuncture” in section 457.102(1), makes plain that dry needling is not within the statutory scope of practice for PTs in the State of Florida. The Board had no basis for moving forward with the Proposed Rule.”

FSOMA did not win because the FDA limits the use of filiform needles to LAcs, there aren’t standards for the practice of dry needling, the physical therapists aren’t adequately trained, dry needling would harm patients, dry needling is “cultural misappropriation,” or any of the other many arguments made in Florida and elsewhere.

This ruling sets no precedent for any other state because it is based on the definition of Acupuncture and the scope of PT practice as found in Florida law. If state level rulings did set a precedent in other jurisdictions, FSOMA would likely have lost. We’ve lost in more states than we’ve won.

Of course, you wouldn’t know any of this from that Acupuncture Today article, or all those celebratory posts on Facebook.

Meanwhile, we’ve lost a significant and costly battle. One which should never have been fought. This loss hasn’t yet made the news.

The North Carolina Physical Therapy Association recently announced a settlement agreement, in which the North Carolina Acupuncture Licensing Board would pay the NCPTA a six-figure settlement and agree that all current and future members would stop sending cease-and-desist letters to physical therapists who offer dry needling, and would honor the North Carolina Supreme Court’s decision that dry needling is within the scope of practice of physical therapy.

This loss should surprise no one. The NCALB incurred significant legal debt persisting in a battle that no one outside of the profession thought they could win. And they attracted negative attention from lawmakers in the process. Why, oh why, did they do this?

I’ve stopped hoping that yet another blog post will change our behavior. Will a six-figure settlement? How will the NCALB continue to function without resources?

Even the few battles we’ve won could later be lost. Scopes of health professions can change via legislation. Physical Therapists outnumber us in every state. The trend is away from scope “monopolies” – understandable when we need to improve access to services and reduce health care spending. (Consider the history of scope and Advanced Practice Nurses, Optometrists, Social Workers, and Dental Therapists.)

Both the Acupuncturists and the Physical Therapists might refer to this multi-year hostility as The War of Defending the Profession, or The War of Protecting our Patients. Undoubtedly, each side has been motivated by the belief that they were doing what was right. But, war is costly. And, as the smaller and poorer profession, we have suffered greatly for our few victories.

In the past few years we’ve done a good job increasing the demand or and interest in acupuncture. But the number of people entering the acupuncture profession is dropping. In the vast majority of the country we don’t have enough practitioners to meet the need. Meanwhile, qualified and experienced practitioners can’t practice because of regulatory loopholes that seem to benefit only the NCCAOM. The NCCAOM is looking for a new Executive Director, and it’s critical that we be involved in the selection process. Acupuncturists can’t pay off their student loans while others argue for additional educational requirements. Our schools are closing. We’re increasingly participating in the insurance system, increasingly concerned that the system doesn’t support our work, and increasingly, getting into insurance-related legal trouble.

It’s past time to give up the war. There is no one person who can proclaim the end to hostilities. General Lee could only surrender the Army of Northern Virginia on April 9, 1965 1865.* Other Generals continued to fight. I’m sure some state association somewhere will continue to beat the drums of war, insisting that we fight on. What a shame.

We have far better things we could be doing with our time and our money. Let’s.

(Yes, I’m so tired of writing about dry needling I studied up on some Civil War history to spice things up.)

* When I first published this I goofed and wrote 1965. When it was pointed out (thanks astute reader!) I quickly corrected it. But I’ve been thinking. The consequences of the Civil War are still very much with us. Freedom Summer was in 1963, for example. When I see suppliers marketing that they don’t sell needles to PT’s, and LAcs boycotting suppliers who don’t make that promise, well, it’s heartbreaking. The sooner we reconcile the better. And, yup, some LAcs see me as a Profession Traitor for saying this.

Updates: Education, Dry Needling, Professional Organizations and Associations

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Tri-State College of Acupuncture has lost accreditation and closed. Founder Mark Seem was unwilling or unable to save the program.

It’s a loss for the students, and for all practitioners and patients.

In the early development of the U.S. acupuncture profession the modern TCM lineage was primed to dominate. Mark Seem at Tri-State, and Bob Duggan and Diane Connelly at The Traditional Acupuncture Institute fought to maintain acupuncture diversity and the strong curriculum at those two schools enabled other traditions to gain a foothold.

Now Tri-State is closed and the school formerly known as The Traditional Acupuncture Institute (The Maryland University of Integrative Health) has little in common with its earlier iteration. The NCCAOM is increasingly powerful. Their TCM-focused exam controls entry to the profession. The outlook for non-TCM traditions is not good.

On December 7th the North Carolina Supreme Court affirmed the legality of the Board of Physical Therapy’s decision that dry needling falls within the scope of physical therapy in the state.

If you believe that our future success depends upon what other professions do with filiform needles, it’s bad news. It’s also bad news for the NCALB, which previously reported legal debt of $150,000. And it’s terrible news for those named in the antitrust suit Henry vs. NCALB, which was on hold awaiting this decision. The odds are not in their favor.

If you’re committed to continuing the fight with PT’s, please read the ruling.

A recent letter from the Utah Association of Acupuncture and Oriental Medicine reports that the group has no paying members and has been “permanently dissolved until further notice.”

Perhaps the association’s 2018 effort to require the NCCAOM Herb credential for new graduates who wish to practice in Utah was not a big membership motivator? If not, why did they pursue the change? At the time, the NCCAOM cited practitioner support as the driving factor in their participation.

(The NCCAOM now insists they took no position on this issue. Yet they have refused to disavow the letter they distributed showing their support.)

In the “dissolution letter” we read, “There is important work to done and we have the full support of the NCCAOM in our effort.” Who is the we if there are no paid members? What does the NCCAOM support (and why)?

Pay attention! I don’t believe the plan is to make entry into the profession easier or less expensive.

In early 2019 I’ll be writing about Modern Acupuncture, developments at the NCCAOM, and trends in the profession. Until then, I wish you all a peaceful and restful holiday season.

A Feature or a Bug?

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When a trusted business or organization screws up, it’s good to give them the benefit of the doubt. We all make mistakes.

I have trusted the NCCAOM. They were important to our acceptance as a legitimate profession. In 2014 I encouraged people to support a transition to their exams in California, hopeful that one national standard of entry would further the growth of the profession.

But I’ve noticed a pattern – the NCCAOM makes a big announcement and seems unprepared for the response. They scramble to address the upset, explaining why we don’t understand their good intentions or their difficult position.

I used to think it was a bug. They just weren’t as competent as I’d thought. And Acupuncturists mostly don’t understand their role and are quick to react.

But now I think it’s a feature.

We don’t understand their role because they talk out of both sides of their mouth – they say or do contradictory things depending on their immediate desire.

In the “NCCAOM Questions and Clarifications” document (released in draft format), their response to the reaction to the changes in testing policies, the NCCAOM writes:

“There are some policies where we may ask our stakeholders’ opinions and use that to determine policy.  There are many other policies where this is not appropriate because of the requirements of our accrediting body, fiduciary responsibilities (the fiscal health of NCCAOM), or impacts to public safety need to drive our policy decisions.  NCCAOM is not a membership organization, it is a credentialing organization. Examples of this include: the elimination of the apprenticeship-only route, elimination of the pre-graduation route, and the revisions to the NCCAOM® Code of Ethics and the Grounds for Professional Discipline. These are examples that our policies are driven by our NCCA accreditation standards.”

But the NCCAOM did ask for input on the Code of Ethics and Professional Discipline, and their revised code reflected that input.

And the NCCAOM did step back from some of their announced changes in response to concerns from stakeholders. Clearly they had some flexibility, and could have done this prior to their announcement.

And in 2016 the NCCAOM shared –  “Breaking News! New Membership Organization Announcement!” describing their “Academy of Diplomates.” The Academy Board is a subset of the NCCAOM Board, your NCCAOM recertification fees support this organization, and links on the Academy website take you back to the NCCAOM. No wonder we’re confused.

In “Questions and Clarifications” we read – “It is no secret that the number of students taking the exams, annually, has dropped dramatically over the past decade.” Their upbeat NCCAOM Spring 2018 newsletter doesn’t mention it, nor has it been a topic in their frequent Acupuncture Today articles. Study their annual reports and you can uncover the truth, but that isn’t the news they’ve been sharing.

Fewer people taking the tests means fewer new practitioners. Shouldn’t the profession give scrupulous consideration to any policy or regulatory changes that make it harder to enter the field?

The NCCAOM’s current honesty regarding their financial concerns is appreciated. It also demands that we reconsider their previous denials that money drives their policy positions. Their support of efforts to require the herb exam of all practitioners (UtahNCCAOMletter), and their complicated PDA system, make sense from a financial perspective, not from a safety one.

The NCCAOM denies that their exams shape our education. They say schools should not teach to the test. They also advertise, “It is recommended that ACAOM Approved Schools Faculty members sign up for [the NCCAOM] practice tests to familiarize themselves with the process.”

They dismiss concerns that a new voluntary certificate program could become mandatory. They simultaneously support efforts to make the voluntary herb testing mandatory.

Underneath it all is the refrain, the “NCCAOM’s number one priority and mission is to protect the public.” This is as it should be. But one insurer recently reported receiving 1-3 reports of harm per week, including reports of pneumothorax, burns, and infections. In a profession of, at best, 30,000 practitioners, shared between multiple insurers, that’s alarming. Is there evidence that patients in Maryland or West Virginia, where there is no NCCAOM testing requirement, are more likely to suffer harm?

With great power comes great responsibility. The NCCAOM denies their power and their responsibility, but they are the gatekeeper to the profession. They have us by the short hairs. Their denials aren’t believable.

I’ve given them the benefit of the doubt for years. I’ve explained away their errors as bugs and defended their good intentions. It’s painful to acknowledge that I no longer trust the NCCAOM.

They need to get a lot more honest and a lot more competent quickly, or we need to get serious about finding an alternative.

 

 

 

NCCAOM Updates and Links of Interest

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The NCCAOM has responded to community concerns about changes to their testing procedures.

Here is an explanation of why they needed to change to limited testing windows and delays in providing preliminary results, along with a statement that they will delay this change to 2020. They will also work with the schools to set the testing windows to coordinate with graduation dates. Please do read it so you understand why these (temporary) changes will happen.

And here is the FAQ regarding the elimination of the Pre-graduation eligibility route. The date for this change is still September 1, 2018, and the FAQ isn’t quite so transparent. I do understand that the NCCAOM has to treat all applicants the same. Under the current system students of ACAOM-accredited schools can begin testing prior to graduation, while those in apprenticeship or foreign programs can’t. So, that’s not right. But some of the supposed benefits in the NCCAOM FAQ don’t seem all that beneficial. The answer to Q2 doesn’t actually answer Q2. And could they address the problem with less disruption? Allowing all students to sit all but one exam prior to graduation might address some of the problems mentioned by the NCCAOM without leaving new graduates in limbo for quite so long.

Here are some interesting links in no particular order. The issues may not be directly related to the acupuncture profession, but affect the bigger ecosystem.

A Dark Side of Chinese Medicine

Results of VT Medicaid Pilot Project using Acupuncture

The Value of the Doctor-Patient Relationship

For Fun if You are in New York City

Increasing Tuition at For-Profit Schools as GI Benefit Grows

Healthcare for those with Disabilities

Family Physicians on Nurse Practitioner Scope

Occupational Licensing for those with Criminal Records

The Acupuncture Observer’s Odds, Ends, and Action Items

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I can’t keep up, so prepare for some less polished posts as I play catch up.

First, housekeeping —

I’ve been using the blog for essays and analysis and using The Acupuncture Observer and Acupuncture Regulation-US Facebook pages to share articles of interest. Follow those pages, and if the FB algorithm cooperates, you’ll get important background and stay on top of current events.

I kind of hate Facebook and may give it up one of these days. Subscribe (if you haven’t already) to The Acupuncture Observer blog by entering your email address in the box in the upper right (under the banner photo) of the home page. Don’t count on Mark Zuckerberg to show you what’s important.

I’m considering a weekly (or so) blog post with links to a selection of the articles I’ve been posting to FB. Good idea?

Regarding The Acupuncture Observer —

I am not a journalist. I am an acupuncturist with experience on the board of state and national associations and the state regulatory agency. I am also a news junkie.

I have a point of view.

That point of view is informed by my experience, research, insider reports, news, transcripts of meetings, etc. I link to supporting information. My opinions are not based on hearsay or one individual’s report.

If I am wrong, let me know. That’s what the comments are for. I moderate to exclude spam and to reduce unnecessary rudeness, not to shut down differences of opinion. Reach out if you’d like to run a guest post.

If the position of you or your organization is already widely known, and especially if you have ready access to Acupuncture Today or widely distributed organizational newsletters, don’t expect equal time here. You already have a forum for your positions.

I’ll issue a correction if you can show me that I’ve got faulty information. But just telling me that I’m wrong or stupid or “clearly don’t understand” isn’t helpful. Show me the evidence.

And, an Action Item —

The NCCAOM has recently announced changes to their testing procedures.

1)      As of this September, people will no longer be able to sit the exams before they graduate.

2)      As of 2019, the exams will only be offered during four 12-day windows. There will be two testing windows for foreign language exams and reinstatement exams.

3)      People will no longer get preliminary results immediately after taking the exams and will need to wait eight weeks to find out whether they passed. That will give people a week, at best, to register for and re-take any exams in the next testing window.

See page 11 –  http://www.nccaom.org/wp-content/uploads/pdf/2018%20NCCAOM%20Spring%20Update%20to%20CCAOM.pdf

Unlike some changes at the NCCAOM, I don’t blame a profit motive. Each change, in and of itself, has a reasonable explanation. But, the sum total of the changes will have a negative impact on the ability of recent graduates to obtain state licenses in a timely manner. Enrollment in ACAOM schools dropped 18% between 2014 and 2018. Meanwhile, the demand for acupuncture is growing. It’s a terrible time to drag out the licensure process.

I hope you will sign the petition. (The petition language incorrectly refers to regulatory changes. The changes are to NCCAOM policy and procedures.)

 

 

 

We have met the Enemy

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It’s not paranoia if they are really out to get you.

Our siege mentality is understandable. Doc Hay was charged with practicing medicine without a license in the early 1900’s, as was Miriam Lee in 1974. In some places we’re still seeking legal recognition of our right to practice. It’s not unusual to read that acupuncture is quackery.

So it’s not terribly surprising when multiple participants in an official government meeting announce that your practice is a danger to the public and that the NCCAOM Acupuncture credential is insufficient. It’s not the first time we’ve heard that it would be better for the public if we were excluded.

But it’s different when the people saying these things are Acupuncturists.

It’s shocking. And upsetting. And bad for the profession.

We complain about PT’s, Medical Acupuncturists, insurance companies and even the perceived disrespect of some of our clients. But those groups aren’t building coalitions to restrict our ability to practice, or to put hurdles in the path of new practitioners. I can imagine the outrage and the calls to action if they did.

Instead, it’s Acupuncturists who are on the record (warning audio autoplay) slandering colleagues and attempting to slow growth of the profession.

Our safety record and our well-established and generally respected educational and credentialing systems don’t seem to matter. Nor are these Acupuncturists concerned about our small numbers or student debt.

Why is this happening? One school that is concerned about student debt, accessibility, and the growth of the profession, asked ACAOM and NCCAOM to reconsider the hourly requirements for acupuncture education and sitting the credentialing exams. There was no move to lower standards (read more here) or change competencies, only to use the same hourly requirements that served our teachers and most experienced practitioners so well.

ACAOM hasn’t responded to the proposal, and NCCAOM did not respond favorably (NCCAOM Response Ltr to POCA Board 11-9-17 Final with signatures.doc). But members of Utah’s Acupuncture Advisory Board and the Utah Association of Acupuncture and Oriental Medicine were so upset by POCA Tech’s request that they launched a preemptive strike, moving to require the NCCAOM herb credential of all practitioners, whether or not they want to use herbs.

Listen, and ask yourself – how does this help our future?

By the way –

The participants’ claim that this is a clarification of existing law is “alternative fact.” The evidence shows that the Utah action is in direct response to the POCA Tech proposal, and the representative of the Department of Professional Licensing makes clear that existing law would not support this action.

In a prior meeting a board member insisted that there is no need to require specific education or curriculum for practitioners who use injection therapy, since acupuncturists know their limits. The same board member argues here that all practitioners need to obtain the herb credential. (The board member performs injection therapy.)

The exemption of those already licensed works to undermine opposition to changes like this. Don’t be fooled – increasing debt for the next generation of practitioners isn’t good for our future, even if it doesn’t impact your ability to practice.

The Advisory Board and the Utah Association, with the help of the NCCAOM, promoted the Board’s proposed changes. The letter (UtahNCCAOMletter) they distributed is inaccurate. For example, a growing number of states are not requiring the herbal exam of all practitioners, and acupuncture and Chinese Medicine have not always been inextricably linked.

A letter written by a professional association, signed by the Chair of the Advisory Board, and distributed and supported by the NCCAOM (which would benefit financially from the change) raises significant ethical and good governance concerns.

The NCCAOM’s message in the February meeting – that they defer to the will of the profession – is a questionable position for a credentialing agency. It also differs from their position in cases where the will of the profession was for changes not in NCCAOM’s interests, such as a state removing the requirement to maintain active Diplomate status.

There’s good news – the Utah Advisory Board can’t add a requirement for the herbal credential via regulation.

There’s bad news – the parties involved seem eager to pursue legislation to make this change.

There’s terrible news – the enemy is us. It isn’t the PT’s, MD’s, or insurance companies undermining Acupuncturists. It’s Acupuncturists.

 

Firefighting

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More than 42,000 Americans died from opioid overdoses in 2016. In 2009 at least 23.5 million people over the age of 12 needed treatment for illicit drug or alcohol use in the US. That number is growing dramatically.

People are dying.

LAcs are rightfully enthusiastic about the use of acupuncture to treat the physical and emotional pain that can lead to the use of and dependence on addictive medications and drugs. We have been proud of the history of auricular acupuncture helping those who struggle with addiction.

The development of a profession of Licensed Acupuncturists and the spread of acupuncture detox specialists happened comfortably, side-by-side, for a long while. Lincoln Recovery in the Bronx was treating addicts with acupuncture in 1974. In 1975 (More History ) the Traditional Acupuncture Institute was founded in Maryland. The AAAOM was incorporated in 1983, NADA in 1985. In many states, auricular acupuncture programs predated the regulation of acupuncture. Their safety and effectiveness was used promote acupuncture and lobby for Licensure.

In 2005 South Carolina (currently 123 LAcs, 658 deaths in 2016 related to prescription opioids and heroin) passed a licensure law with a dark side. Although 53 Acupuncture Detox Specialists (ADSes) had been working without incident in South Carolina, language was included that required an LAc be on site to supervise ADSes. With zero LAcs at the time the law passed, no ADS could continue to treat. (The force behind the legislation was Acupuncturist and then-president of the AAAOM, Martin Herbkersman, whose brother was and is SC state Representative Bill Herbkersman. Rep. Herbkersman also shut down a 2007 bill that would have removed the direct supervision requirement.)

Programs to provide the NADA protocol to addicts have been limited by the supervision requirement.

People are dying.

Unfortunately, South Carolina is not a fluke. The only voices against New Hampshire HB 575, allowing for the certification of acupuncture detox specialists, were the voices of LAcs. Luckily for New Hampshire (127 LAcs, almost 400 opioid related deaths in 2015, over 2000 opioid-related ED visits), the bill passed.

Connecticut (323 LAcs, 539 overdose deaths in the first six months of 2017) did pass a law expanding use of ADSes, but comments in response to the legislation from LAcs included gems like, “acupuncture should be left to the experts, the licensed acupuncturists” and ADSes “have absolutely no idea what it truly entails to safely provide acupuncture to others whether it be one needle or many.”

People are dying.

Remember, at least 42,000 opioid deaths in 2016. The number of Acupuncturists in the US? About 32,000 at best. Dealing with the epidemic is expensive, funding is limited.

It’s a crisis.

  • If you believe ADSes require in-person supervision, become a supervisor.
  • If you believe only LAcs should provide the NADA protocol, commit to weekly shifts at recovery centers, jails, and other programs, and take responsibility for daily staffing of those programs. Remember, funding will be minimal or nonexistent, and, unreliable.
  • If you believe that everyone deserves the benefits of full body treatment, commit to provide them to everyone – even if they can’t pay, don’t have reliable transportation, and aren’t as tidy as your typical clientele.
  • If you believe ADSes should work only within treatment programs available to those in active addiction, make sure your services are accessible to those struggling to maintain their recovery, whatever their circumstances.

Remember, some of the people most needing treatment won’t have insurance, housing, financial resources, steady employment, or reliable transportation. Where and how will you provide the services you think they should have?

If you don’t want to supervise, don’t want to treat everyone who walks through your door regardless of ability to pay, and don’t want to take regular shifts at treatment facilities, then, please, get out of the way of the people who do. Better yet, support them.

People are dying.

I’ve joined NADA, I’m making plans to receive training, and I’ll keep supporting efforts to increase access to NADA-trained providers in all states.

People are dying.

 

This post is in honor of Dr. Michael O. Smith. May his memory be for a blessing.