Tag Archives: aaaom

2013 Review for Acupuncture Professionals

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As 2013 was dawning, the WhiteHouse.gov petition to include acupuncture in Medicare was circulated by the AAAOM, NCCAOM, and loads of school and practitioners. Because coverage is not determined by the executive branch, over 30,000 signatures made no difference. That our professional organizations either didn’t know enough or didn’t care enough to educate acupuncturists about how the system works did give me the final push to create The Acupuncture Observer. From the first post last January through # 49 today, I’ve tried to provide thought-provoking strategic analysis of where we are and where we are headed.

The planned March AAAOM conference on a cruise ship didn’t set sail, making 2013 the second consecutive year without a conference. Things began looking up with April’s announcement that experienced professional Denise Graham was named AAAOM Executive Director.

However, by mid December, Ms. Graham and three Board members had resigned. (Previous ED, Christian Ellis, managed only three months in the fall of 2010.) A majority of the current board members have been appointed rather than elected. Something at the AAAOM smells. The Whistleblower Protection Policy, prepared in conjunction with the Confidentiality Policy adopted in April 2012, never resurfaced after it was pulled by then President Michael Jabbour (who is now managing the “operational transition”). We’ll probably never learn what is really going on in the board room, but 2013 marks the year I gave up hope that the AAAOM could become a viable organization serving the profession. It’s now become a single-interest (Federal legislation) organization, under the control of a small number of people, and without the resources to accomplish its priorities.

Throughout 2013 qualified LAcs were denied licensure by the Delaware Acupuncture Advisory Council’s insistence on the NCCAOM OM credential. New Florida regulations will limit licensure to those with NCCAOM Herb credentials beginning in October 2014, putting another state off limits to many practitioners and greatly increasing educational costs and the regulatory burden for those who intend to practice in those jurisdictions.

Outrage at  P.T. Dry Needling continued throughout the year. Some LAcs made arguments that reflect poorly on our concern for the public, such as suggesting we’d drop our objections if PT’s agree to use hypodermic needles for this technique. Various state associations began efforts to redefine acupuncture and to push for discriminatory insurance policies in response to dry needling and the end of 2013 brought newcomer NCASI (and their lawsuit against Kinetacore) onto the scene.

Late Summer brought proposed policy changes from the NCCAOM that would move the group several steps closer to becoming a regulating rather than credentialing body. In a bit of good news, comments from the profession sent the proposals back to the drawing board.

Over the course of the year growing numbers of practitioners added insurance billing to their practices.  We’ve been quick to throw stones at the billing practices (or rumored practices) of PT’s, yet many acupuncturists offer justifications for questionable practices and few seem clear on the exact nature of their agreements with the insurance companies.

In the waning days of 2013 a job opening for a Licensed Acupuncturist at Brooke Army Medical Center was posted on Facebook. Initial responses cast an interesting light on our profession’s self-regard. There were complaints that the salary (about 70k) was too low, some suggested that a PT would certainly get the job, and others complained about the requirement for a flu shot.

In a few days I’ll be back and begin looking forward. What will serve us in the year of the Wood Horse? When the dragon brings the energy of the spring back to earth, how should the seeds of the profession grow?

The Acupuncture Profession, News and Analysis

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Three dedicated AAAOM Board members and AAAOM (super-qualified, knowledgeable, and committed) Executive Director, Denise Graham (my last hope that things could get better) resigned recently.

One board member spoke of an uncomfortable and increasingly controlled board environment, a declining membership (now less than 2% of the profession), and poor relationships with national and state leaders. Another stated that the AAAOM doesn’t have the support, revenue, or credibility to make progress towards legislative goals.

This isn’t the first time AAAOM has been on the ropes. If it hadn’t been for money from the AAC and support from other organizations, I doubt they would have survived this long. Somehow, though, they still manage to control the conversation.

In other news, NCASI, the National Center for Acupuncture Safety and Integrity, has appeared on the scene. NCASI’s list of “10 Facts” should be titled “10 Things We Insist are True and/or Important.”  Dry Needling by PT’s is legal in many states. Review my past posts on dry needling and scope for more background. We take real risks when we files lawsuits like these.

For twenty years, the acupuncture organizations have insisted that our success depends upon —

  • Increasing credentials/educational requirements/scope. It doesn’t matter if the old education, credentials, and scope worked fine. It doesn’t matter if it increases practitioner expense, decreases practitioner flexibility, or prevents some LAcs from utilizing techniques available to any other citizen.
  • Getting someone else to pay for acupuncture. Fight for third-party payment systems even if other professions report they make good medicine more difficult and practice less enjoyable. Ignore the hypocrisy of participating in a system that requires discounting services while also criticizing LAcs who offer low-cost or discounted treatments directly to patients. Insist that practitioners who don’t want to participate won’t be impacted, and turn a blind eye to the fraud that many practitioners engage in to make the $’s work.
  • Demanding a monopoly.  There’s no need to earn your market share by providing the best product — instead establish it through litigation and turf battles. Don’t worry if this requires you to disparage your fellow health providers or contradict your message that the public should be able to choose their providers.

After twenty years many LAcs struggle to stay in business, and most voluntary acupuncture organizations struggle to survive. Got questions about ADA compliance, insurance billing, privacy issues, advertising questions, disciplinary actions? You won’t get answers from the AAAOM and you probably won’t get them from your state organization.

It’s time to change our strategy. We have enough training, clients who seek our services, and other providers who respect the medicine so much they want use it themselves. Yes, we always need be aware of and informed about the regulatory/legislative landscape, but we also need business skills, PR, positive marketing, and an easing of the regulatory burden.  We need a good hard look at the cost of education. We need legal advice and business tools and positive interactions with potential referral sources and colleagues. We don’t need more legal battles, more regulation, more legislation, more degrees that further divide us.

When our organizations provide these things, we’ll have successful organizations, and successful practitioners. (If you don’t believe me, ask POCA.)

 

AAAOM Medicare Town Hall

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A few folks asked me to post after the Town Hall, so here goes —

Sorry to say I missed the beginning of the call — the instructions to join were not easily available or straightforward.  At the peak, there were about 70 participants.

Bottom line, the AAAOM lacks the level of expertise they need before moving this legislation forward. The AAAOM does not have an idea of how many LAcs are likely to opt in, didn’t have the correct history of why the Chiropractors do not have the opt-out clause (and seemed to believe they currently can opt-out), didn’t realize that becoming part of the system would limit the amount non-participating providers could bill Medicare clients (a participant provided correct information), wasn’t clear that other providers would be able to bill for acupuncture if it becomes a covered service, hadn’t considered the impact on the practices of practitioners opting out, etc. The information about enrolling, opting in or out, participating or non-participating was still unclear.

A caller suggested it is premature to ask practitioners whether they’ll be likely to opt in — there are too many unknowns. I understand, but don’t we need some idea before we spend millions moving forward with the legislation? A few callers seemed confused about the difference between acupuncture as an EHB and the proposed legislation. Others seemed to think the legislation had already been introduced.

The bill writer/lobbyist wasn’t willing to make predictions, but I’ll go out on a limb. The AAAOM says they need about $1,000,000/year to move this legislation forward and the fundraising remains at around $25,000. According to the lobbyist she’s only been contracted for a month. The current Congress (113th) ends January 3rd, 2015. I say there is a 0% chance any of these bills will pass in the next year.

Would the AAAOM please focus their efforts on things that could help all practitioners now? In an ideal world they could work on both long term and short term projects, but this isn’t an ideal world. Without evidence that a significant majority of the profession intends to participate, why oh why is this legislative effort their only focus?

I hope everyone had a great Thanksgiving.  I did.

Acupuncturists and Medicare, Questions for the AAAOM

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I’m thankful I spend my days helping people. I’m grateful I’m my own boss and that I’m able to treat every client as a unique, complex, individual, not as a diagnostic code. I could write a whole post on what I’m thankful for, but, this coming Sunday, it’s time for another AAAOM Town Hall. There are other things I’d rather be doing the evening of December 1, but I plan to participate, and I hope you will too. So, before we head off to sweet potatoes and cranberry sauce, here are my questions for the AAAOM —

  • Given the current political climate and the current level of involvement from the profession, what are the odds these bills will be successful within the next 5 years.
  • How many LAcs intend to become participating providers in the Federal Health Programs?
  • Does the small number of contributions from practitioners to the AAAOM legislative fund indicate that this effort is not a priority for the community?
  • Given that there are fewer than 30K active licensees in the US, and that not all will participate, could legislative success benefit other professionals who use acupuncture more than it helps LAcs?
  • Do the Medical Acupuncture and the Chiropractor communities support this legislation? Will they participate in the legislative effort?
  • Many LAcs treat Medicare beneficiaries. If acupuncture becomes a covered service won’t LAcs who opt-out lose most of that portion of their clientele to providers choosing to participate?
  • How many LAcs are providing acupuncture via the Medicaid system in the five states that permit it?
  • Is it possible that the opt-out provisions could be stripped as part of the legislative process (related to the small number of potential providers)?  Would the AAAOM be able to stop the legislation if that happened?
  • Can you clarify the distinction between enrolling, participating, and opting in?
  • On page 8 of the FAQ it refers to patients falling into the opt-out exceptions.  Is it providers or patients who opt out?
  • On page 10 of the FAQ it states that the legislation will not require LAcs to use electronic medical records.  Is it true that participating providers will be penalized a percentage of their reimbursements starting in 2015 if they do not use EMR’s?
  • If you opt-in, and the beneficiary reaches the limit for their number of treatments and/or wants treatment for a condition that isn’t covered, are you able to treat them and bill them for those services?
  • If you opt-out could you still treat Medicare beneficiaries who have surpassed their treatment limit without impacting their future benefits?
  • If opting-in, can practitioners limit the number of Medicare beneficiaries they accept as clients?

There are other things the AAAOM could focus on that would be more helpful to the average LAc and be more likely to succeed. But this Town Hall is limited to the AAAOM legislative efforts. I am thankful they are asking for input, and I will oblige.

Happy Thanksgiving everyone — and thanks for reading.

Health Insurance for the LAc — Important Point #1

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Insurance does not create money, it redistributes it. The money coming in via premiums or taxes must be equal to or greater than the payments for services and the expense of the bureaucracy (whether government or private) that manages the system. (With government programs we have chosen to ignore the imbalance between what is coming in and what goes out. Eventually, we’ll have to face it.)

The system depends on lots of healthy people paying in more than they get back in services. That offsets the folks who need lots and lots of care.

Here are some costs (yes, this term can mean a lot of different things):

  • Type 2 Diabetes — Annual Medical expenses of $13,700 with $7,900 attributed to diabetes.
  • High Blood Pressure — costs of $733/person in 2010.
  • Stroke — Average cost for first 90 days after a stroke is $15,000.
  • Breast Cancer — Average annual cost of $22,000 to manage the early stages with management of stages 3 and 4 costs in excess of $120,000.

Some of the ways insurance companies made sure they took in more than they paid out:

  • limited the amount paid out over a lifetime — reach a million and you are on your own.
  • refused to cover pre-existing conditions — your diabetes will cost a lot, so we won’t cover it.  (This also kept people from waiting until they were sick to buy coverage.)
  • charged “sick” people significantly higher premiums — you have diabetes and HTN likely to cost $1000/month, so your premiums will be $1300/month.

Most of us were bothered by these limitations (especially when we think of individuals – your patient, your cousin). The PPACA eliminates or greatly limits these practices — you can’t be denied coverage for pre-existing conditions, there are no lifetime limits for EHB, and premiums are determined by age and type of coverage, not medical status. These changes force the companies to pay out more per person, and limits what they can take in per person.

To keep premiums from being unaffordably high many healthy people need to pay into the system. This is why the PPACA requires everyone to buy insurance or to pay a penalty.  It is also why the system collapses if everyone expects to get services equivalent to (or greater than) what they pay in premiums.

If someone pays a $150 monthly premium and expects to get ten acupuncture treatments/year, and you “deserve” $700 or more for those treatments, there isn’t much left to cover the bureaucracy or the costs of their neighbor with cancer, their father who just had a stroke, or their own colonoscopy, broken arm, or appendectomy.

This has real implications for your acupuncture practice — whether or not you are a participating provider, whether or not acupuncture is an EHB in your state, and whether or not you expect the AAAOM’s federal legislation to succeed.  Stay tuned for more.

(Here is an NYT article looking at medical choices and costs.)

Smart Policy for the Acupuncture Profession

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That’s my agenda —  to help acupuncturists and their affiliated organizations (AAAOM, NCCAOM, ACAOM, state organizations, schools, etc.) explore and analyze policy choices to help identify smart and effective policies and to avoid knee-jerk wild goose chases and unintended consequences.

My agenda is not to overthrow the NCCAOM, undermine the AAAOM, or to create conflict and division.

We are suffering from a professional auto-immune disease. How many subjects have been the greatest threat to the profession? How many LAcs have walked away from professional affiliations disheartened at the amount of energy spent attacking other professions or colleagues? How many of us react with outrage the moment we hear of some challenge, ready to mount an attack before we have all the information?

As acupuncturists, we see the suffering that results from an overactive immune system. Let’s stop making that mistake.

Last month I shared my email to my state association regarding their comments at an Advisory Board meeting. Here is ASVA’s response, and here is my reply. (I include the documents to show how challenging it can be to have non-triggered dialogue on an issue facing the profession. Rest assured, I am grateful to those who serve.)

News Update

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and a bonus at the end —

October 1st, NCCAOM, Facbook —

 NCCAOM has received a significant volume of responses, and the results of this feedback will be taken into consideration during the development of the final policy and standards, as NCCAOM continues to strive for increased customer satisfaction. We are always eager to hear your suggestions for changes that will benefit you, the Diplomate, and the AOM profession overall. It is with your feedback that we can continue to meet your needs.
We are listening!

Spin?

October 2nd, date of scheduled AAAOM Town Hall, AAAOM website —

Legislative Town Hall

CALL POSTPONED – DATE TO BE DETERMINED

No additional news.

October 9th, Richmond, VA, Meeting of Virginia Acupuncture Advisory Board.

Agenda includes discussion of an alternate path to licensure due to conflicts between Virginia law and the NCCAOM proposed policy changes.

The representative from the state association (ASVA) was against any discussion of the NCCAOM issues. ASVA stated  — “lowering of standards…would do harm to both our profession and the public.” Who mentioned lowering standards? Is there evidence that anyone is harmed in states that do not rely on the NCCAOM credential?  Here is my post-meeting email to the association  –  ASVA comments.

The NCCAOM rep at the meeting was clear — the proposals were just proposals, stakeholder comments will be taken into consideration, any language referring to the effective dates of the changes was referring to effective dates for the proposed changes, not the actual changes. I envisioned someone pedaling backwards.

Questions of the Day — We attack when another profession “interferes” with our practice (DVM’s “stealing animal acupuncture”, PT’s “stealing acupuncture”, MD’s wanting to see our patients) even when we have little or no power to change anything. Why are we unwilling to even discuss it when an organization supported by our money, controlling our profession, at our request, takes action that costs us or limits us? We made a difference this time (we hope) – why aren’t our professional associations helping?

Here is a new page on Legislation and Regulation. It contains important and valuable information. Please, read it and pass it on.

I’ll be working on a page about the Acupuncture orgs (the alphabets) and another for potential acupuncture students in the coming weeks.

Dry Needling, Herbs, and Scope — How to Regulate a Profession

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A regulatory Board is contacted.  Your licensees are doing X, that isn’t (or, is that?) in your scope.

Ask a PT Board about Dry Needling and the answer usually goes something like this — We trust our licensees. Many learn this technique and it helps their clients. We find room in our regulation to include this in our scope.  We have a few concerns and suggest that those who want to utilize this technique have some additional training and take additional precautions. Our existing system for addressing unsafe practice is sufficient to address risk to the public.

Ask an Acupuncture Board or organization about herbs and the answer usually goes like this. We are being threatened again!  We’d better legislate, and fast! Help! Thanks NCCAOM and schools. We are so grateful for your efforts to ensure that any acupuncturist who wants to utilize this dangerous aspect of our medicine add your $20,000 education and your formal $800.00 seal of approval to their already extensive education and credentials. In fact, in the name of raising standards we should require that from all LAcs. It might prevent some of our most qualified practitioners from practice, but, hey, it is a step toward getting the respect we deserve.

Is something wrong with this picture?

It’s a radical idea, but how about we respect ourselves. Let’s recognize the safety of our medicine and the depth of our education.  Let’s trust our colleagues’ professional judgement and open doors rather than close them and let’s stop deferring to those who profit from our love of this medicine.

For additional reading, check out an example.  In this case, I agree with Dr. Morris when he wrote,

To avoid conflicts of interest, no individual who stands to profit from seminars should determine competencies and educational standards, nor should they testify in legislature on behalf of the common good.

(Of course, he was talking about the PT’s when he wrote it, so maybe in this case he doesn’t agree with himself.)

You have until Monday, 9/30, to comment on the NCCAOM’s “proposals.” Does the current CEU arrangement put the public at risk? Are the states incapable of effective regulation?

One more thing — during the great FPD debate, many expressed concern that once the degree was available the NCCAOM could, by fiat, require it for entry level practice. We were assured that would be impossible. Informed by history, it seems very possible indeed.

Control

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Who determines your professional future? First, read An Example of one person, wearing two hats, limiting opportunities for LAcs. (He’s received honors for the work he’s done.)

We have one week to comment on the NCCAOM’s “proposed” policy changes. Do that here. Some of us think these changes are wise, some of us wouldn’t be personally impacted. We all should participate in the conversation. Ask your professional communities to comment. (You can see the NCCAOM’s response to my initial comments here.)

My follow-up comments are below. The NCCAOM is the most powerful organization in our profession. I have seen them, with our help, control regulation (or essentially subvert it) and legislation. Our interests may overlap, but don’t think your future is their primary concern.

Dear NCCAOM and Ms. Basore,

Thank you for your response regarding the proposed policy changes.  Here are some additional questions and comments.

  1. You wrote “The Criminal Background Screening Program for new applicants will not take effect until January 2014.” Has the final decision to implement these policies been made?
  2. The Criminal Background Check and language requirements go beyond your mission as a “national organization that validates entry-level competency.” These policies usurp the role of state regulatory boards. (For example, Virginia exempts those serving certain communities from our language requirements.)
  3. Many states use the NCCAOM exams but do not require the NCCAOM credential. Establishing background checks and language requirements as part of the testing application circumvents those states’ specific desire to maintain an independent credentialing process.
  4. How many students responded to the assessment regarding the foreign language exams and what were their responses? Please define the demand “sufficient to offer a psychometrically valid defensible examination.”
  5. Is it significant to an applicant if the background check fee goes to the NCCAOM or to a third party? Could NCCAOM staff involvement ultimately increase exam costs?
  6. Can you describe the criminal background check appeals process? Would the NCCAOM risk legal liability if applicants were allowed to sit the exam upon appeal?
  7. Is there any documented case of harm from practitioners who had a criminal history at the time of sitting the exams?
  8. If public protection is the justification for requiring the background check prior to examination, should it be required prior to school admittance? This would protect individuals from making a huge investment in a career they will ultimately be unable to practice.
  9. Could the recertification process be simplified by trusting Diplomates to use their best judgment regarding continuing education?  Has there been any documented patient harm as a result of unreviewed or unmonitored continuing education?

 

I believe that for much of the past twenty years the NCCAOM has provided a net benefit to the profession while honoring its commitment to the public welfare.  More recently the NCCAOM has repeatedly acted out of self-interest, choosing control over the profession and the attendant financial rewards ahead of either the profession or the public. Your push for the full OM credential as a requirement for licensure in DE is a prime example of action that served the NCCAOM at the expense of all others. The stakeholder comment you request is routinely disregarded.

Re-consider these proposals. Acupuncture practitioners have an incredible record of safety. The imposition of additional de facto regulation is unnecessary and burdensome.

Sincerely,

Elaine Wolf Komarow, LAc (VA)

NCCAOM Diplomate (Ac)

A Very Important Question

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Dear NCCAOM,

Will feedback received influence your proposed(?) policy changes?  Ms. Basore’s comments to my previous post indicate the changes are a done deal. Please let the readers of The Acupuncture Observer know so that we can effectively use our qi.

Thank You.

Dear Readers,

I’ll send my many questions and comments about the policy changes to the NCCAOM (and post them here) if our input matters.  In the meantime, please  —

  • Contact NCCAOM via Facebook to weigh in on the proposed(?) changes. (Are they listening?)
  • Contact AAAOM via Facebook to share your thoughts on the NCCAOM’s proposed(?) changes.
  • Respond to the AAAOM’s latest Call for Comments (deadline September 19th), and let them know if you think they should be focusing on the proposed(?) changes.
  • Contact your state professional association to point out that the proposed(?) changes interfere with the state regulation of acupuncture and ask them to get involved.
  • Ask your state association to raise this topic with the Council of State Associations. (There doesn’t seem to be any way for the average professional to contact that group directly.)

That’s a good start while we wait to hear back from the NCCAOM. Oh, and spread the word!

P.S.:  Here’s a story about background checks.  Keep in mind, in the NCCAOM’s proposal, the poor applicant wouldn’t even be allowed to sit the exams.