2013 Review for Acupuncture Professionals

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?

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.

Control

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)

Making a Difference, in ten steps.

  1. Write a letter to the Delaware Acupuncture Advisory Council, and mail it by this Friday, August 23rd. Here is a new, improved template!  Do this now! (Please cc Gayle MacAfee at the board and send a copy to de@theacupunctureobserver.com. Thanks!)
  2. Share this post on facebook.
  3. Tune in. Subscribing to this blog is a good start but I can’t keep track of everything. Check in at websites for the AAAOM, NCCAOM, ACAOM, your state association, POCA, etc.  A few current issues (which I’ll be posting more about soon) — AAAOM is calling for public comment by August 31st on draft legislation, NCCAOM wants public comment on proposed changes by September 30th, ASVA (Acupuncture Society of Virginia) is having a town hall October 19th to discuss possible changes to scope, and the IHPC wants us to stay involved regarding implementation of section 2706 of the Affordable Care Act. Any one of these issues could impact your ability to practice.
  4. Question Authority. Is X really the biggest problem facing the profession? Is the public better off in a state that requires the OM certification rather than the AC certification? Is an independent board better for acupuncturists? Will an FPD degree lead to greater respect? Does scope mean what you think?
  5. Know the system. For example, boards can only regulate their own licensees. And the executive branch doesn’t determine what Medicare covers, regardless of how many signatures are on a petition.
  6. Avoid us/them thinking. In Our Worst Enemy I wrote about the practitioners in focused on increasing standards as a “them.” That was a mistake.
  7. Remember, we are all in this together. What happens in another state or a change that seems to impact only new students or new licensees might end up affecting you in unforeseen ways.
  8. Assume good intentions. Assuming bad intentions (the PT’s want to do dry needling to make money, for example) doesn’t lead to productive dialogue.
  9. Be consistent. Do we support the right of people to choose their healthcare provider? Are herbs safe? Is acupuncture safe? When we change our answers to these questions based on the circumstances we create a negative impression.
  10. Learn from history. Has participation in  health insurance been good or bad for healthcare? For providers? Has a standardized system of Chinese Medicine led to greater effectiveness?

In the short run it is easier to ignore the big issues, to figure you’ll be okay, or to decide you can’t really make a difference. Staying involved takes time and energy you’d rather use to see clients or spend time with your family or learn that new technique. Do it anyway. Tune in, question, participate. The future you save may be your own.

You Can Make a Difference

Many LAcs do their best to ignore the “politics” of acupuncture. The experience of participating in professional dialogue can be disheartening and discouraging. It isn’t easy to participate even when we want to — things are happening at the state level, with schools and ACAOM (the coming FPD), or with credentialing (proposed changes at NCCAOM), for example. All too often the debate gets heated and divisive. It is hard to get the whole story and figure out the possible consequences of a change or know what action might be effective. When the licensure legislation was developing in DE few outside of the state were involved. Some of my colleagues in DE had concerns, but they eventually gave up what felt like a fight for a better bill.

Five years after the DE legislation went into effect, there are approximately 35 LAcs serving a population of over 900,000 people and many of those practitioners were either grandfathered in or granted a waiver. Two years went by without a single non-waivered approval. Clearly, the legislation is not giving the people of DE access to qualified LAcs. As I wrote about in my last post, I know of two excellent practitioners who have recently been denied licensure even though their credentials surpass those of many practitioners in the state.

In the long run, the Delaware legislation should be changed. Rules that exclude the majority of NCCAOM credentialed Acupuncturists make no sense, especially when acupuncture can be done by other professionals with far less training. In the short run, the Acupuncture Advisory Council should acknowledge the record of safety of NCCAOM AC practitioners and consistently grant waivers to those with that credential.  In the very short term, the Council should grant waivers to Virginia LAc Sharon Crowell and Maryland LAc Sue Berman.  To facilitate those short term goals I ask that all of you write to the Acupuncture Advisory Council expressing your support of such a waiver.  Please mail your letters by August 22nd!  Feel free to post a copy of your letter in the comments section to inspire others. Email a copy to de@theacupunctureobserver.com. That will help if further action is necessary.

You can see the letter I sent (and borrow from it if appropriate) —  DE Observer Letter.  I’ve also generated a DE LAc sample letter that you can personalize. You could add some of these Possible concerns or your own concerns (please share any additional concerns in the blog comments). The letter can be modified for clients or others who are interested. If you’d like an excuse to visit Dover, DE, the next Advisory Council meeting is September 12th. It should be lovely at that time of year – but don’t count on being able to find an LAc in town :).

 

Our Worst Enemy

How do you feel about a regulatory situation that increases the odds that patients will receive acupuncture from minimally trained, non-LAcs while making it difficult for extensively trained LAcs to practice?  Is it better or worse if it is a state’s very own LAcs who are creating this situation?

The Delaware Acupuncture Council recently refused to grant a license to one of the most excellent practitioners I know.  This Virginia LAc,  a NCCAOM AC Diplomate and a Nurse, has had a very successful practice for over 13 years.  She is a former president of the Acupuncture Society of Virginia and has studied Medical Qi Gong extensively for the past three years.  The three LAcs on the DE Council present for the June meeting refused to grant her a license because she does not have NCCAOM OM Diplomate status.  Although the Council was reminded that they could grant an exception, they refused to do so.

It appears that only one of the four LAcs on the Council has the full NCCAOM OM status and one has NCCAOM AC status.  A third LAc has no formal acupuncture education or NCCAOM status, holding a degree in ayurvedic medicine granted for overseas study. I could not discover any information about the fourth LAc on the Council.

Delaware passed legislation related to the practice of Acupuncture in 2008, which you can read about here.  The legislation required full NCCAOM OM certification, including herbs but included three caveats, as noted in the AT article:  1) acupuncturists practicing in the state at the time the legislation was passed, regardless of education and credentials, were grandfathered in;   2) the legislation did not interfere with the activities of other professionals who were allowed to perform acupuncture; 3) the Acupuncture Council was expressly allowed to waive the requirements as appropriate.

Remember – herbs are not regulated by the FDA, and products containing Chinese herbs are available in the grocery store (see Airborne), or on-line, and are available to the public without prescription or the involvement of any health care professional.

Delaware currently has about 35 LAcs serving a population of about 1 million people. According to my research, there are 9 NCCAOM AC Diplomates in DE, and another 6 OM Diplomates.  The decision of the Council only increases the odds that the people of Delaware will receive treatment from non-LAcs.

The way I see it, it isn’t the lack respect from the western world, competition from other professions, or inequities in insurance reimbursement that are the biggest problems facing the profession.  It is a system in which small groups of LAcs in various states have determined that more credentials and education are necessary, even for those who are already extensively trained in Acupuncture and Oriental Medicine. They work for laws and regulations that increase the cost and time necessary to obtain an acupuncture degree and limit practice opportunities for LAcs.  This increases the odds that the public will receive treatment from providers who are not LAcs.

With friends like this….