Talking about our Education

“We have over (2000 hours, 4000 hours, 3 years, 4 years) of education and they want to do acupuncture with (a weekend, less than ten, 200 hours) of training!The public is in danger.”

“The (PT’s, Chiropractors, MD’s) doing acupuncture are significantly undertrained! If they want to do acupuncture they need to go to acupuncture school, or at least take (400, 500,1000) hours of training.”

It’s a no brainer, right? But ….

1) We are comparing our total professional education to additional post-professional-degree hours.

An MSAOM curriculum includes: Biochemistry, Introduction to Organic Chemistry, Anatomy and Physiology, Microbiology, Introduction to Western Pathology, and a Survey of Western Clinic Sciences (3 semesters). M.D.’s have already covered these classes in their education.

2) Does the aspect of “our” medicine they want to use require a full TCM education?

Is Tai Qi, Qi Gong, Introduction to Botany, 40 credits of herbal medicine, a semester of auricular acupuncture and 3 semesters of point location needed for a PT to safely use a needle to release a trigger point? (If you insist they learn all of that, won’t they then argue that they can also do auricular acupuncture and distal points?)

3) How well-educated are most acupuncture school graduates? How worthwhile was most of their time spent in school?

ACAOM standards were based on the programs that existed at the time credentials were being established. They were not based on a careful analysis of what was needed to train safe, effective, successful practitioners. Acupuncture related Facebook groups include posts asking about using moxa to turn breech babies, how to treat TMJ (no pulse, tongue, or presentation information provided), and recommendations for treating people undergoing chemotherapy. With our thousands of hours of training, shouldn’t we know the answers to these questions? (Or have a better source than Facebook for answers?)

4) Is there a correlation between the length of a program and the quality of the graduates? Were the early U.S. practitioners (many of whom had less than 1300 hours of training) harming the public?

It is an article of faith in the acupuncture community — our training of X hours is necessary for safety, and anything less is an affront and a danger. Yet a colleague recently wrote “I am at a medical acupuncture conference. Exceeding my expectation. The presenters know their stuff. Lots of depth…. I am going to find out about their training. Maybe they are a special group….what i am seeing here meets any high standards TCM conference…. Very surprised.”

The more (as defined by us) = better has done us no favors. The numbers we fight for are arbitrary. The argument is easily refuted by other providers. Adopting it within our profession has increased the business strangling debt-burden new grads carry. And created internal divisions which only further harm our growth. (How long before a state (or the NCCAOM) demands the FPD to become an LAc?)

Please, let’s let the knee-jerk “less is dangerous, more is better” argument go.

Acupuncture & Insurance, Part 2 — Affordability

Many of us see it as a no-brainer. We want acupuncture to be affordable, insurance/Medicare makes it affordable, how could anyone be against that? This reasoning relies upon a superficial understanding of health care costs and affordability.

Consider:

  • Affordability must take into account premiums as well as co-pays and out-of-pocket expenses.
  • Both cost to the individual and sustainability of the system are part of affordability.
  • All medical costs are ultimately borne by the public.
  • When coverage is provided for the very sick, the premiums of many healthy people contribute to their medical expenses.
  • If health care spending exceeds what the insurance companies have planned for, premiums will go up and reimbursements for providers will go down.
  • Controlling health care spending depends upon providers accepting reduced payment for their services and upon a bureaucracy determining what services are appropriate.
  • The wealthiest in our system typically have the best insurance coverage.

A respected colleague said I give the impression that Community Acupuncture is the only way for people to get affordable acupuncture and that everyone should treat that way. My bad — I don’t believe that. I do believe it is a good way — it accepts the reality that acupuncture isn’t really more affordable if it doesn’t cost the system less. It provides affordable treatment to everyone, not just to those with the best insurance coverage. And it keeps big business out of treatment decisions.

I continue to treat one client at a time, in a private room. I have a generous sliding scale, available to all, to help a wide range of people afford acupuncture.  Some practitioners treat in private rooms and charge one low price to all patients. I have colleagues who reserve a certain percentage of their appointments for those who need steeply discounted services, and I have others who volunteer in free or low-cost clinics. These are all ways to make acupuncture affordable.

Disguising the cost of acupuncture by hiding the expense in co-pays and premiums (many so expensive that they are subsidized by taxpayers) doesn’t make it more affordable. Changing the way you treat so that your reimbursements match what you think you deserve doesn’t make acupuncture more affordable (or support arguments for cost effectiveness).

CA is not the only way to make acupuncture affordable and I certainly don’t think it is the only style of treatment that should be available.  But insurance increases the big picture affordability of acupuncture only to the extent that it limits reimbursement rates and access.  Insurance is not a magic wand, and those practitioners who believe it is are in for a rude surprise.

For more, check out this post, and these statistics about the increases in health care spending in the US.

Acupuncture & Insurance, Part 1 – Universal Impact

“It’s fine if you don’t want to take insurance/participate in Medicare, but don’t stand in my way. If you don’t want to participate you can make that choice.” — that’s the sort of thing practitioners pushing for insurance coverage of acupuncture lob at those who express reservations.

Although I personally believe third-party payer influence will be bad for our profession and our medicine, my greater concern is that most of those pushing for these changes have a limited understanding of how we will all be affected. If the profession as a whole understood what’s involved and still thought it was a good idea, I’d get off my soapbox. In the meantime, I’ll do my best to provide food for thought.

I have a client who is financially comfortable and she paid my fee for years without a second thought. At some point, her insurance began covering acupuncture. I collect full payment at the time of the treatment and provide a receipt which patients can submit for reimbursement if they choose. My typical treatment includes two sets of needles so I divide the payment into a 97810 and a 97811 code.

One day, though, I came into the treatment room after the first set of needles and there was that feeling of a great treatment. The room was peaceful, the patient was glowing, the pulses were balanced and lovely. Anything else I did would not make the treatment any better and most likely would make it worse. When I told the patient her pulses felt great she said, “I can tell.”

Before meeting her at the front desk, I spent some time struggling with her receipt. The treatment had still taken 50 minutes. But I hadn’t done two units of acupuncture, so I couldn’t use two codes. So, I used my 97810 code, and put the additional amount of the bill under other services, with no code.

This meant that the patient’s reimbursement was less than she expected, and she, of course, wanted to know why when she came for her next treatment.  I explained that I had done only one unit of acupuncture instead of my usual two. The conversation then covered why I couldn’t bill for two units even if I had only done one (fraud), why I couldn’t have just done two units even if she didn’t really need it (also fraud, plus, not good for her), and why I charged her the same amount as usual if I had done less (I set my fee based on my time, not the number of needles). My client, who had never before questioned my treatment decisions and had been happy to pay my full fee before insurance gave her any reimbursement, was now an unhappy client.

Do I refuse to give any receipts to avoid this issue? Do I lower my rates if I do only one set of needles, even though, since I don’t know what will be needed in advance I still have to schedule the same amount of time?

Let me know what you think, but, here’s one thing I know. Don’t tell me that my practice won’t be impacted by your efforts to have insurance cover acupuncture.

Health Insurance for the LAc — Important Point #1

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.)

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

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.

Culture and Access…. and, a loss.

A colleague recently posted a question related to a book of acupuncture case studies from China — “I was wondering if anyone could provide some insight into why the book lists only a handful of points used in their treatments and why the practitioners I’ve seen from China use many many more?  Does anyone have the back story of this book? …. 

 They also consider one course of treatment: 10-15 treatment daily with 2-3 days off. 

 In one of the cases they listed 30 daily treatments until some improvement was noticed…i find that amazing!  Here in the US if there’s no change in 5-8 treatments they’re done.   

 Thanks in advance for any insight….”

An expanded and edited version of my reply —

I believe the 5-8 treatment paradigm is relatively recent, somewhat local, and at least somewhat related to matters of time and money. Treatments multiple times/week for several weeks at the start of treatment is not unusual in China or the Asian community in the U.S.

Regarding factors other than time and money — because 5 Element acupuncture typically focuses on constitutional issues the idea of allowing time for the treatment to “ripple” through the system makes sense. Also, a 5 E appointment can be similar in structure to a therapy appointment, with time spent talking about feelings and emotions, for example. The population our U.S. predecessors were working with was familiar with that structure, so it made sense to present acupuncture in a similar way.

Still, issues of access shouldn’t be ignored – 30 visits at $80.00 is $2,400, so if someone has no experience with this medicine (or even if they do) that’s a big commitment, and more than many people can afford.  (Even if the cost is shared between a client and a third party payer, the same bottom line will be a factor.) Any study exploring the cost effectiveness of acupuncture is obviously impacted by the number of treatments given and the cost of each treatment — it is easier to show cost effectiveness after ten treatments than after thirty.

One of the things I like about my sliding scale is that if people do need to come more frequently, or come weekly on an ongoing basis, it is easier for them to do so.  Many practitioners who have gone from conventional private practice to community acupuncture find that more people come more frequently in the early weeks of treatment and report that patients make faster and more consistent progress.

Another consideration is the “time cost.” Many of my patients couldn’t manage to get to my office 2-3 times a week even if they wanted to and could afford to. I have limited evening hours and no weekend hours, traffic in this area is horrible, and most clients are already over-committed and over-scheduled. A clinic close to a metro station with drop-in hours and/or lots of early mornings or late evenings would make it possible for more clients to get treatment more frequently.

As for the number of points used – I have not yet seen studies comparing treatment protocols.  Miriam Lee wrote that a very limited number of points could help in most cases.  As more insurance companies start covering acupuncture it will be interesting to see if the data shows that more units of acupuncture per visit equals better results.

I’m not an acupuncture historian or scholar — just sharing my thoughts.  We should consider how much of how we practice is determined by the culture of our schools and communities. The results of greater data collection and the emphasis on EBM (evidence based medicine) could rock our world.

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And, a loss in the community —

I just saw the very sad news that Al Stone died.  I never met him, but I did have the privilege of working with him a bit over the years, and that was always a pleasure.  Al developed acupuncture.com back in the early days of the internet (and later sold it) and was also the creator of gancao.net.  It is a big loss to the community that he’s gone.

Thankful that he was.