Insurance, Again. The s**t got real.

Photos of an acupuncturist in a prison jumpsuit, bond reduced to $455,000, facing charges of racketeering, insurance fraud, engaging in an organized scheme to defraud, patient brokering, and unlawfully waiving copays and deductibles. It’s bad for the profession.

It’s worse when the acupuncturist taught insurance billing seminars.

Whether or not she is ultimately found innocent, I’m sure none of us want to be in her shoes. Let’s learn what we can from the case, and from the discussions about it happening on social media and elsewhere.

(Here are additional stories about the case: Indian River Meeting MinutesMarch 2017August 24, IRC MemoFlorida CFO, September 13)

My takeaways –

  • There are wonderful, respected, kind, people who engage in criminal activity. Encomiums about the accused show us humans aren’t one-dimensional, but are irrelevant to guilt or innocence.
  • Insurance billing is no game, despite books, seminars, and conversations presenting it as one.
  • As a profession (the community acupuncture folks being the main exception), we haven’t accepted the conflict between wanting people to get as many acupuncture treatments as we think appropriate/they desire, earning what we “deserve”, practicing in our preferred style, and the overall health care economy. We grabbed insurance as the savior. It isn’t.
  • It is easy to rationalize wrongdoing. Practitioners justify creative billing to help their clients or counteract an unfair system. That’s bad for our profession, personally risky, and, because “insurance money” comes from people buying insurance, ultimately costly to anyone buying insurance.  If a plan doesn’t cover acupuncture for depression, explaining that to your clients, and giving them a discount if you’d like, is honest. Believing that the insurance company is forcing you to figure out a way to “treat them for pain so it gets covered” is dishonest.
  • If you want to advocate for better coverage, be prepared with data to show the economic benefits. Do you want your premiums to cover other non-medically necessary choices? Who should decide?
  • We need to be honest when discussing the efficacy and cost of acupuncture. Many practice websites, and much of our lobbying for increased coverage, refer to a course of treatment of eight to twelve visits. If an average of almost forty treatments/year, as in this case, is appropriate “for today’s complex patients” (as many commenters stated) we need to own that. If it varies based on condition (of course it does), let’s make sure we let patients and insurance companies know. If you are treating for a complex condition, but code for a simple one to facilitate reimbursement, you’re skewing the data about acupuncture efficacy.
  • There are lots of acupuncturists eager to give definitive answers to questions outside their area of expertise. Having a successful insurance-based business does not make one an expert on insurance law.
  • Our burdensome systems for approving CEU/PDA classes don’t provide quality control.
  • Having demanded entry to the system, we owe it to ourselves (as consumers and providers) to speak up when we see wrongdoing. We need to acknowledge that our colleagues who review charts and advise insurance companies are necessary if we are going to be part of the system. It’s a bad sign when those within the profession who work to protect the consumer are dismissed as the enemy. The insurance companies will find problems even without our participation.
  • Context is important when determining legality. Patterns of individually legal actions (in this case, waiving co-pays was permissible) can add up to illegal activity.

Here’s more on Health Care Fraud – from an investigator.

Being a health care provider is serious business. Participating in the insurance system is serious business. Let’s be careful out there.

 

 

 

We have met the Enemy

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.

 

Happy AOM Day??

“Acupuncture is a safe and cost-effective treatment that could benefit so many. If only the medical establishment could see the benefits of what we do.”

That was our mantra decades ago.

So one might think, now that Acupuncture has become accepted and of increasing interest to the establishment, we’d be happy, thriving, and confident.

But that isn’t the prevailing feeling. We love our work and most of us couldn’t imagine doing anything else. And yet AOM Day 2017 finds us fearful and disheartened.

Many of us carry significant debt and are not earning enough to pay it down in a timely fashion. Many of us are limited in where and how we practice due to varying state rules. The hoped for benefits from insurance reimbursement came with significant administrative burden and limits on what will be covered. Increasingly acupuncture is being provided by non-acupuncturists. Meanwhile, the profession isn’t growing. Based on figures from Acupuncture Today, there are fewer LAcs now (24,612) than there were in November 2013 (24,707).

So it is not surprising that we aren’t hopeful. The public and the medical establishment see the value of acupuncture, but we aren’t thriving.

There are things we control that could change our trajectory.

Those of us who completed acupuncture training prior to 1990 (some of our most admired mentors and colleagues) probably got about 1000 hours of formal schooling. If you graduated in 2000 you likely had about 1725 hours of schooling, and if you completed your training after 2011 your program was at least 1905 hours.

You can see, here, how the Virginia regulations have changed over the years. The hourly requirements did not change in response to concerns about practitioner safety or skill, but to keep the regulations compatible with the ACAOM and NCCAOM requirements.

In 1988 tuition at The Traditional Acupuncture Institute (now MUIH) was $11,000 (about $23,000 in today’s dollars). When I started in 1992 it was about $18,540, ($32,616 in today’s dollars). By 2003 tuition had increased to $32,865 ($43,722 in 2017 dollars). And, if I wanted to begin at MUIH today, the program would take almost four years to complete with tuition of $75,924. For a Masters in Oriental Medicine, necessary to practice in Florida, California, and Nevada, I’d pay $99,604.

A student loan of $40,000 at 6.8% interest can be paid off in 10 years at $460/month – considered manageable with an annual salary of about 50K. A $100,000 loan will take over $1150/month and you’d need to make almost 140K/year to manage that.

So it’s not surprising that the profession isn’t growing and that acupuncturists are worried.

Sure, the NCCAOM can embark on a major public education campaign touting our training and credentials.(Well, touting their credential, actually). That’s fine. But with the downward pressure on health care spending in this country, and the impact of debt considerations on professional training, it’s going to take some damn fine PR to make a difference. (Big Pharma & Health Products spent about 245 million on lobbying in 2016.)

A far more direct way to help the profession grow, help future graduates make a living, and make Acupuncturists available to those who want acupuncture would be to address our training. If those who graduated in 1989 were safe with a 1000 hour $18,000 education, why do current students need at least 1905 hours and $75,000? Can we simplify the path and reduce the cost of becoming an Acupuncturist? (Yes, we can!)

If people want acupuncture they will find a way to get it. If we’re not there to provide it, someone else will be. We do have the power to change this, and it won’t take 245 million. In honor of AOM Day 2017, let’s agree that more Acupuncturists and less debt would be a very good thing.

 

 

Ethical Questions

Our future requires a willingness to explore beyond our quick conclusions of what is “right” and what is “wrong.” How do we proceed when two “rights” are in conflict with each other, or when a good end might depend upon a questionable means (or vice versa)?

Providing safe, effective, and accessible treatment to everyone who wants/needs treatment while also supporting ourselves and our families requires us to face various ethical quandaries. Many ethics classes are short on teaching principles to guide ethical decision-making and are long on lists of rules like “don’t have sex with your patients.”

Marilyn Allen’s recent column on ethics demands our attention. She’s had a significant role in shaping the acupuncture profession, and she teaches ethics. She has power.

The column focused on a discussion about “gainful employment” that has since been removed from the AAAOM practitioner forum.

The forum included colleagues sharing concerns about their debt, and upset at schools that exaggerated the future acupuncture job market while glossing over the skills and financial backing needed for success.

Ms. Allen (who has given considerable funding to the AAAOM over the years) is angry that this discussion was permitted. She insists that it is in the best interest of the profession, and our future colleagues, to keep concerns to ourselves. Even a shared conversation in a practitioner forum is too risky. We “should have shown support for the schools,” she writes.

Ms. Allen proposes the Rotary’s Four-Way test in her column. It’s not my preferred guideline for ethical decision-making, but since she refers to it I’ll use it —

 

1) Is it true? Many graduates of acupuncture schools do struggle to pay off debt. Schools did use misleading data in promotional materials, leading to unrealistic career expectations. The proposed Gainful Employment regulations did raise concerns about acupuncture programs. The forum topic is no longer present to allow for a complete fact check, but my assessment is that much of the content was true.

2) Is it fair to all concerned? What do we mean by “fair.” Who is “all concerned?” And what is “it?” I could write a post on each question. When a topic is being explored by many people, in many settings, does each contribution need to reflect the views and feelings of each stakeholder? Is it unfair to share our personal experiences and opinions about a system in which we have little power and bear the consequences? Is it fair for a membership association to solicit the opinions of its members? My assessment – it was fair for the AAAOM to provide a forum and for practitioners to use it.

3) Will it build goodwill and better friendships? Humans do better when we know we are not alone. Sharing our concerns and our experiences is a way to build community and friendships, which support us in our sometimes isolated professional life. Knowing that other regulated fields share these concerns can also help build goodwill and understanding. If we feel that a friend (or, in this case, a system) is taking advantage of us, does it strengthen the friendship and build goodwill if we speak up, or stay quiet and suffer? Yes, the discussion had the potential to build friendships and goodwill. Ms. Allen’s column, by advocating denial and repression, does not.

4) Will it be beneficial to all concerned? My list of people who would benefit from the conversation, even if it escaped the private forum: current debt holders who feel alone and unheard, schools who care whether graduates are satisfied, potential students who may not have fully explored the economics of entering their dream career, and taxpayers who may not want to subsidize ineffective programs. The discussion isn’t beneficial for the schools that want to keep raking in loan money while avoiding responsibility. Should we be censored for their benefit?

Ms. Allen writes “It is sad when you read an article about the profession that contains negativity coming from inside the profession. Essentially, this is giving the other professions (those looking to treat acupuncture patients) the ammunition they need to diminish acupuncture and attain their own goals.

I say, it’s sad when those with the power to change things for the better instead advocate for a flawed status quo. It’s a danger sign when secrecy is demanded for the good of the group. The Catholic Church and the Penn State Football program are examples of the moral failure that comes with that argument.

Thank goodness we’re dealing with finances and not child abuse. Nonetheless, shutting down conversation and preaching secrecy is neither ethical nor effective. If Ms. Allen wants to uphold acupuncture as the place “where hope and healing meet” then we need to delve into our challenges, not hide them.

 

 

Accomplishments of the Acupuncture Profession

We know acupuncture can treat pain and chronic illness, assist with recovery from addiction, increase fertility, and help people manage stress (just to start). Acupuncturists know it would be good if more people could get more acupuncture.

Many dedicated individuals have devoted significant qi to increase insurance coverage, to add acupuncture to Medicare covered services, and to bring acupuncture to hospitals and clinics. All with the hope of increasing access.

Other practitioners are committed to gaining mainstream respect and acceptance to further the goal of greater access. They’ve published research, increased training and credentialing requirements, and fought to keep others from using acupuncture techniques without that training and credentialing.

Our “return on investment” has not been great.

We’re still a lot of money and many years away from Medicare inclusion. How much time and energy gets taken from clients to deal with insurance? How many potential patients have meaningful coverage, and how long will that last? Increased training and credentialing and variations in requirements from state to state slows entry into the field and increases expenses, further diminishing our political strength. In areas with few LAcs, efforts to block other professionals from utilizing pain-relieving acupuncture techniques leaves the public with no access at all.

We’re not using our qi efficiently. Our efforts haven’t done much to shorten the path between most practitioners who want to treat, and most people who want treatment.

It’s motivating, helpful, and informative to read a book illustrating the power of a direct path between practitioner and patient. Acupuncture Points are Holes, is a great read.

It’s several books in one: a captivating personal story, an exploration of the process of establishing an acupuncture practice, and an analysis of some common limitations in acupuncture training. It examines the focus required to keep the path between practitioner and patient clear. The book and appendices contain lots of direct, straightforward, easy-to-read help for you and your business, whether it’s a POCA clinic or not.

The author’s decision to directly address the impediments that keep people in need from accessing acupuncture led to: adoption of a practice model which was then shared with others, establishment of a Co-op to support the system and interested practitioners, and, as of 2014 , an affordable acupuncture school to train future POCA practitioners. The 158 POCA clinics that answered a 2016 survey provided 880,596 treatments. One three-location group sees over 8000 unique patients each year. So far, POCA Tech students have a 100% pass rate on NCCAOM Exam Modules.

All this in less than twenty years.That’s a lot of accomplishments.

Getting the book will be an excellent return on investment. Get the e-book here, the paperback here or here. All proceeds go to POCA Tech.

 

Acupuncture Organizations New and Old

We have a lot of organizations and associations for a small profession. Here’s some of what they’ve been up to.

AAAOM

Finally, communication from the AAAOM. According to their April mailing they’ve revamped their membership structure and are planning their first annual conference in over five years.

The new membership structure includes a free “Basic Membership” category. Does the basic membership give access to the annual report or permit the member to vote in BOD elections? If not, it isn’t a membership, it’s a mailing list. Calling it a membership gives the AAAOM cover to inflate their numbers (they’ve been throwing 7000 around) and mislead policy-makers about their strength.

ASA

The first Annual Meeting of the American Society of Acupuncturists was held March 4-5. You can read the full summary here. It includes updates on the activities of many other professional groups. Check it out, including the links.

CCAOM

I’ve only recently been alerted to significant problems in the 7th Edition of the CNT Manual released in July 2015.

One example – is wiping a point with alcohol prior to needling still required? In the position paper on their website and the July 2015 AT article CCAOM indicates that the skin does not necessarily need to be swabbed prior to insertion. Page 97 (or 73 in internal pagination) of the CNT manual puts swabbing with alcohol on the Critical (required) list, with the text “swabbing continues to be recommended.” Which is it, critical, or recommended?

The manual also contradicts itself regarding the cleaning of chairs and tables between patients. Must each table and chair be disinfected or cleaned? Between each patient, or only daily?

With our many traditions and practice styles it is difficult to define or describe a “standard of care” for many aspects of our medicine. This gives documents such as the CNT manual extra weight in the legal system.

This area of practice is outside my bailiwick. Is there an expert out there willing to do a thorough review and write a guest post? It is critical (not recommended) that we get this document right.

NCCAOM Academy of Diplomates

Yes, another new national organization. My feelings about it are as conflicted as my feelings about the NCCAOM.

On the one hand, NCCAOM Diplomates are a significant portion of the profession, and the NCCAOM has the money, power, and support staff to get things done. Earning a seat on the CPT committee (see the ASA report), for example.

On the other hand, an organization that promotes Diplomates only (and how can they vouch for anyone else) runs the risk of deepening a fault line in the profession. The NCCAOM’s history in the regulatory arena shows 1) they are persuasive and 2) their positions often benefit the NCCAOM and some subset of practitioners at the expense of the profession as a whole.

We don’t have a balance of power in the profession. The NCCAOM is in a weight class by itself and the Academy further tilts the scales in their direction.That concerns me. On the other hand, we’ve got no other group heavy enough to get in the ring with non-Acupuncture groups right now.

Let’s keep a close watch on the Academy.

NGAOM

The sparsely attended (30 practitioners?) February Town Hall covered why the NGAOM-affiliated malpractice insurance is such a bargain, how the OPEIU can help the NGAOM, and what’s happening in various states regarding dry needling and insurance reimbursements.

What I didn’t hear was further discussion of NGAOM’s baffling goal of mandating malpractice insurance for licensees in all states. Despite their claims, there is no evidence that lack of mandated coverage has had any impact on scope of practice issues or on how we are seen by other professions. Any insurance plan, landlord, wellness center, or employer can choose to require malpractice coverage. But if a self-employed or unemployed (by choice or circumstance) practitioner decides to bear the risk of working without malpractice insurance, they should be allowed to do so.

If this is the NGAOM’s idea of helping practitioners, we’re in trouble.

 

A few months ago I mentioned that change might be coming to The Acupuncture Observer. I haven’t yet resolved the tension between sharing breaking news and saving my limited time to explore the broader philosophical and strategic issues facing the profession. Would any of you like to be a breaking news blogger? (ASA, would you like a state update column every now and then?) For now, I’ve added a Facebook feed to the home page of the blog. Checking there (or liking The Acupuncture Observer on Facebook) should help you stay informed between posts.

 

 

Gainful Employment and Strategic Errors

The Gainful Employment final regulations have been announced. Forgive my commenting prior to a complete and thorough analysis of the 941 page document. (You can see some analysis here.) The gist is that for-profit schools (which includes half of US acupuncture programs) will soon have to show that graduates’ student loan payments are manageable with the profession’s available employment (not taking IBR into account). If they can’t, federally guaranteed student loans will no longer be available.

Why should taxpayers continue to provide loans for educations that history shows aren’t worth the investment? Imagine tuition rates and post-graduate employment assistance if the schools provided and guaranteed loans, and took the hit if they weren’t paid back in a timely fashion.

It is no surprise that for-profit schools are displeased about the impending end of the gravy train. Many for-profit schools, and their related organizations, did everything they could to block the regulations. And, just under the wire, the acu-educational establishment contributed comments (see ACAOM gainful employment word).

(The more expensive FPD, and pressure away from “acupuncture-only” degrees now carry a significant downside for the schools.)

Did ACAOM think their letter might exempt them from the rules or impact the final regulations? It seems unlikely that this little community would shift the tide. It was an unforced error for ACAOM to write a letter that reveals such little concern for graduates and such a strong desire to dodge responsibility. (Some of the more significant issues in ACAOM’s letter are discussed here.)

But our own strategic errors have allowed ACAOM and other other alphabets to disregard our well-being.

The petition that asked the alphabets to stop denying their role in our circumstances received 227 signatures. Petitions to stop dry needling often receive thousands of signatures. Which is more likely to limit professional success — a school that leaves students with extensive debt, poor business skills, and no job placement or alumni support, or a little competition? If we can’t survive the competition from those “untrained” professionals our education is surely lacking.

The Feds and the taxpayers pay a price when schools sell an education for far more than it is worth. We graduates pay a far more personal price. It’s too late for us, but at least the Feds are willing to look out for the interests of those who will follow in our footsteps.

What’s your Acupuncture Degree Worth?

Answer: Less than it used to be.

(Please, sign the petition.)

If you earned an MAc and Dipl. Ac (NCCAOM) twenty years ago, you thought you had it made. You could get a license in almost all states with licensure. The schools and the NCCAOM touted the caliber of the education and credentials. You knew you had plenty to learn about this medicine, but you could practice safely.

In the gainful employment letter ACAOM points to the (supposed) earnings of those long-ago grads to minimize the financial struggles of recent grads.

But in 1995 the NCCAOM added the Herbal exam, and later the OM. Some states now require those additional credentials of all practitioners. ACAOM has increased hourly requirements for school accreditation several times. And the NCCAOM has put additional limits on who can take their exams.

Some of our most esteemed teachers do not meet the current requirements for sitting the exams. Many practitioners are trapped, unable to relocate.

By increasing the range of degrees and credentials available before our “brand” was established and our profession was strong, the alphabets increased division and confusion. No wonder the public can’t figure out how an LAc’s education compares to that of other providers.

And here comes the First Professional Doctorate. With this new degree, my alma mater announces,

“[graduates] will be recognized as doctors, both professionally and publicly, and will have increased credibility and standing.”

If graduates with an FPD have increased credibility and standing, what has happened to the credibility and standing of graduates of Masters programs?

According to ACAOM’s gainful employment letter, licensure requirements just happen, and practice success is a simple matter of practitioner choice.

Really, though, the “alphabets” have played a significant role in the expansion of requirements and credential creep, and most of the schools do little to teach students how to make wise business choices.

If, as ACAOM wrote, the graduates of twenty years ago do so well, why have entry level requirements been increased so much? Why are grads struggling to pay off existing loans encouraged to return to school to maintain their credibility? Will the NCCAOM require an FPD to sit their exams? Will the alphabets encourage states to require it for licensure?

ACAOM/NCCAOM/CCAOM/AAAOM — if you represent us, defend the value of our degrees and credentials. Your “options” too often become a requirements.

Colleagues, did the gainful employment letter represent your views? If not, sign the petition. 129 people have, which means ACAOM etc. can still claim to represent 32,871 of us.

For additional information and analysis about educational costs and value, check out this from The New York Times and two posts from Dr. Phil Garrison

 

 

Loans for Acupuncture School

It’s been too long. September brought a rush of obligations. And my post of X things (X to be replaced with a number when the list was completed) wrong with ACAOM’s gainful employment letter made it to 25 things by the time I got to the bottom of page 2 (of 7).

The gist of ACAOM’s letter — It’s not our fault. The cost of the education and the inability of many of our graduates to pay off their loans in a timely fashion has nothing to do with ACAOM, the schools, or CCAOM. It’s the fault of the system and the poor choices of our grads.

If you believe the schools and professional organizations should spend less time denying responsibility and more time taking responsibility, let them know by signing this petition.

My top 7 issues with the letter:

  • The authors absolve the schools of responsibility for the success or failure of their graduates. Where is their evidence that “the primary determinant for success in earnings is dependent upon the students who make their own personal choices….”  And doesn’t an effective education include helping students make choices that lead to success?
  • The organizations claim to represent the entire profession without justification.
  • With the exception of CCAOM, the participating organizations are operating far outside their missions. For example, NCCAOM’s job is to provide a means of credentialing practitioners to protect the public. Why are they weighing in on student loans?
  • The authors conflate the impact of the proposed gainful employment rules with the impact of student debt on establishing a practice. It is student debt that limits practice choices, not plans that would prevent excessive debt for ineffectual schools.
  • While the authors blithely refer to the “realistic” time frame to establish a health care practice, materials provided to prospective acupuncture students are silent on such matters.
  • Putting schools in charge of the metrics (like graduation rates) that determine loan availability is a classic fox guarding the hen-house scenario.
  • The salary figures reported in the letter are questionable at best and mostly irrelevant. Even if it were true that the median salary of practitioners with 20+ years of experience is $122,500, which is doubtful, an acupuncture education 20+ years ago was far less expensive and shorter. (Perhaps the lack of federally guaranteed student loans had something to do with that?) Graduates who could not establish a successful practice are not around twenty years later. What are grads supposed to do about their loans for the first twenty years of their professional life?

It’s requiring a good deal of self-restraint not to continue with my list, but enumerating the failings of ACAOM’s letter doesn’t create momentum for positive change. A petition signed by some of those 30,000 people the organizations claim to represent might create momentum. It isn’t easy to determine how best to lower costs and increase practitioner support. It will require careful analysis and consultation with experts. But if the powers don’t care enough to ask the questions, we’ll never approach the answers. Sign the petition.

(Before you say it isn’t possible, here is a school that has designed an affordable acupuncture program with a focus on creating successful practitioners.)

Acupuncture and Insurance

I keep hearing questions and complaints about insurance billing and acupuncture.  I don’t have an original post ready. This is adapted from an email exchange with some colleagues and thought it might be a good starting point for a conversation, despite the odd lack of context. But if you’ve been around for a while you can probably imagine what preceded it! (Then again, we should probably be out enjoying a holiday weekend rather than pondering our profession’s future.) —

“I am absolutely fine with practitioners pursuing all of the various business models that are available to us.  I want anyone who wants acupuncture to find a way to access it. Depending on both the practitioner and the patient, there may be certain models that are more appropriate or appealing than others.  Private room treatments at varying levels of cost with the money coming directly from the patient or indirectly via an insurance company, sliding scale models, in group or private settings, treatments as part of other medical care, I’m good with all of it.  I don’t believe that a patient’s willingness to make life changes is related to what they are paying for treatment. I don’t believe that lots of talk and time is necessary for people to benefit from treatment, though I believe it can have benefits.

“I do believe that lots of graduates come out of acupuncture programs with very little information about how to choose which model might be best for them or for the community in which they wish to work. I believe they often come out having been told some version of “if you build it they will come.” It makes me sad and angry when folks who invested so much in their education don’t have the business skills to make a go of it, especially when there are so many areas so underserved by LAcs.

“I don’t believe that fraud is necessary to make a living from an insurance based practice, and, I have seen many conversations about insurance billing for acupuncture that revolve around questionable practices. I certainly don’t think all practitioners engage in these practices, but some do. I also see practices that are by the book, but are still likely to have unconsidered consequences.  How many acupuncture treatments that are not billed to insurance involve three distinct sets of needle insertions, compared to those that are billed.  Does it take more sessions to treat back pain with acupuncture when the treatments are covered by insurance?  (Does the billing provider think of the treatments as being preventative once the back pain is in remission while the non-billing provider might not be thinking about back pain at all and instead pondering the client’s inability to relax even when on vacation?)  How do the answers to these questions impact data on the cost effectiveness of acupuncture?  As purchasers of health insurance, how do we feel if we think an MD is doing a more complicated procedure, with a higher reimbursement rate, than another, cheaper procedure that is equally effective?

“I did not mean to give the impression that offering a higher level of service when warranted will get a provider kicked out of a plan. However, if a provider’s patients consistently need a higher level of service that will get noticed by an insurance company. It may well be audited. And, it will be taken into account when the insurance company is deciding whether to continue to contract with a particular provider.  When you refer to this as an urban myth is it your position that insurance companies do not care whether a provider consistently bills for more services than other providers serving a similar population?”

Thoughts?