Eight mini-Posts for Eight Nights! First Night – Acupuncturists, Weigh In!

The NCCAOM is looking for feedback on a possible Safe Compounding and Dispensing certificate program. I don’t work with herbs so I’m not considered a stakeholder, but please reply if you are eligible. My questions/concerns —

  1. Will the certificate be available to anyone or just those with an NCCAOM herbal credential? Practitioners often delegate herbal preparation to office staff, so staff might benefit the most from the training. Additionally, some excellent and well-trained practitioners aren’t able to sit the NCCAOM herbal exam due to the nature of their herbal education. Could they still obtain this certificate?
  2. Will this certificate result in restrictions on the practices of those without it? The NCCAOM has previously developed credentials promoted as optional, which have, in short order, become requirements.

There are many areas of practice in where some of us could use more knowledge and training. It’s nice to have a way to show that you’ve got some special training or skills. At the same time, we’ve got enough battles with other professions and within the profession, and too often new credentials lead to new fault lines and new tensions.

Share your thoughts with the NCCAOM if you’re a stakeholder. Let’s help them serve our needs and understand our concerns.

 

 

 

Growing Opportunities for Acupuncturists

The Acupuncture Observer is still working to bring you the latest news relevant to the profession, despite the summer lull in posts.

BLS Code:  After years of effort, Acupuncturists will have a distinct Standard Occupational Code in the 2018 Bureau of Labor Statistics Occupational Handbook. The announcements have repeated the enthusiastic claims that accompanied the multi-year effort to make it happen —

 “Earning a distinct Standard Occupational Code for Acupuncturists is a milestone moment for the acupuncture and Oriental medicine profession. This event positions acupuncturists for a number of new opportunities,” said Kory Ward-Cook, Ph.D., CAE, chief executive officer of NCCAOM. “The classification of ‘Acupuncturists’ as its own federally-recognized labor category both validates and bolsters the profession and positions the industry for growth.”

Data is good. A unique code will distinguish acupuncture as a profession from acupuncture as a modality, and may make it easier to be included in certain state and federal programs. And yet, as far as I know, the only direct outcome of this accomplishment is that soon there will be a report like this for the profession of Acupuncture. Will the data encourage people to enter the field? Will it justify the cost of an Acupuncture Degree? Will it provide evidence that would support increased reimbursement rates? I’m not so sure. Self-employed folks aren’t included these reports and I’ve been unable to determine whether the category will be based on education, license, or just whatever your employer decides.

Like some of our past accomplishments (student loans for Acupuncture School and insurance coverage for acupuncture) the outcome may be a bit more complicated than expected. I’d love to hear more specifics about what we can expect from those who led the effort.

Delaware: No herbal credential? For years that meant you couldn’t be licensed in Delaware, even if you had no interest in using herbs in your practice. On July 19th Governor Markell signed into law HB 387 creating tiered licensing. The law also limits the use of the term “oriental,” eliminates some requirements for ADS’s, and removes the grandfathering provisions. It’s not the best bill text I’ve ever read, but it’s a wonderful improvement over the previous situation. It’s terrific that the Delaware Board of Medicine supported increasing access to acupuncture.This is one example of a jurisdiction where the BOM has been more welcoming to Acupuncturists than the LAcs serving on the Council.

Nevada: Yes, Nevada is another state where the (independent) Acupuncture Board has seemed intent on keeping practitioners out of the state. That explains why the state that had licensure first has so few practitioners. Now it seems that things may be taking a turn for the better. The Nevada Board of Oriental Medicine has had a change in membership. Fingers crossed that this will be the start of a new era with increased access to Acupuncture (and related therapies) for the people of Nevada.

 

I’ll count Delaware as a solid win — increased opportunities for Acupuncturists and increased access for the public. The change in Nevada should be a change for the better, though time will tell. As for our unique SOC, I’ll be interested to see what that changes.

I still expect to write about the The Acupuncture Observer and Facebook fiasco. In the meantime, please share this post on AOF and with others who might be interested. And please let me know of any acupuncture news. In the meantime, enjoy these last days of summer.

 

 

9 Reasons why Acupuncture Regulations There Matter Here!

Changes in acupuncture regulation in any state matter to each of us individually, and to the profession as a whole.

Here are 9 reasons why —

  • We don’t know what the future holds. Unexpected moves happen.
  • You may need to hire practitioners or sell your practice. Can interested parties easily move to your state?
  • Your patients might move and want a practitioner just like you. Will one be available?
  • Growth in the profession is not keeping up with demand. Regulatory uncertainty diminishes the appeal of the profession.
  • High educational and credentialing costs interfere with business growth. If the requirements vary from state to state, the impact is multiplied. (See this report on Occupational Licensing.)
  • Regulatory differences lead to divisions within the profession. With fewer than 25k acupuncturists in the US unity is critical.
  • What happens in one state impacts every state. States look at what has happened elsewhere when considering regulatory changes.
  • Changes in one state can lead to changes for everyone. When CA increased required educational hours every school and ACAOM soon changed as well.
  • Different regulations, training requirements, and titles make it difficult to educate the public about our qualifications, draw contrasts with other professionals, or advocate for our profession as a whole.

Staying informed is not easy. Neither is getting involved. We are all busy, we don’t always know how to assess the pros and cons of a possible change, and things can get heated and unpleasant when there are differences of opinion.

And, the future of our profession and our businesses is greatly impacted by regulatory changes – even those happening across the country.

Please, stay involved.

Forgive two posts in quick succession, but regulatory changes are on the way. You’ll hear from me again soon.

(Note — I advocate for standardizing and simplifying the regulatory process for acupuncture licensure. I am not advocating for standardizing the medicine itself. Our diversity is powerful indeed.)

Herbal Regulation and the Acupuncture Profession – A Better Way.

We’ve got competition. PT’s, MD’s, and DC’s are excited about filiform needles and LAcs are freaking out.

While our energy has been focused on that competition (our training and skills are superior, right?) we haven’t been paying attention to increasing restrictions on our ability to practice the fullness of our medicine. Adding insult to injury, the restrictions on practice are “coming from inside the house.”

I’m talking about restrictions on our use of herbs.

Yes, herbal medicine is powerful and complex and carries both potential risk and potential benefit. Yes, it takes many thousands of hours to come close to mastery of this branch of our medicine. Yes, people have been harmed by the improper use of herbs and supplements. And, yes, at some point the damage done by the misuse of herbs may result in stricter regulation. We may indeed lose access to more herbs.

It’s good that we want to be proactive, protecting the public and the profession from harm. It’s not so good if our actions don’t have the desired result. And not good at all if our actions increase risk to the public and the profession.

Let’s consider the terrain —

  • What portion of harm from herbs/supplements is the result of poor practice by Acupuncturists?
  • What portion of harm from herbs is from the use of raw herbs, what portion is from pre-made herbal formulas?
  • Does preventing certain LAcs from recommending herbs or supplements limit public access to these products?
  • Is the average LAc, even without herbal training, likely to have a positive or negative impact on client’s proper use of herbs and supplements?
  • Which are better tailored to the individualized treatment that is a hallmark of Chinese Medicine — pre-made/patent formulas or raw herbs?
  • Which are more likely to be contaminated with banned substances or prescription medicine – patent formulas or raw herbs?
  • Is it possible to draw a bright line between dietary therapy and herbal therapy?
  • Does limiting LAc recommendation of herbs interfere with the ability of other health care providers or salespeople to recommend or sell herbs or supplements?

See where I am going with this?

Anyone can get Chinese herbs, even dangerous ones. Increasing the regulatory burden on Acupuncturists would make sense if it would protect the public or our access to the full pharmacopoeia on an ongoing basis. It would make sense if LAcs were routinely endangering the public through unregulated use of herbs.

It doesn’t make sense for a subset of our profession to become the only group of health professionals not able to recommend herbs to their clients.

If the only groups weighing in are the schools and NCCAOM, formal (and expensive) training and credentialing will be increasingly required.

Let’s stand united against unnecessary restrictions. LAcs have an excellent safety record. Stay tuned for real-time developments and your opportunity to weigh in on the regulation of herbal medicine for Acupuncturists.

 

How we Grow – The Acupuncture Profession in 2015

One Physician per 371 non-institutionalized civilians was the US average in 2012.

One Acupuncturist per 20,000 non-institutionalized civilians was the US average in 2014.

NCCAOM’s 2014 Annual Report is an important read for anyone who cares about Acupuncture in the US. From it we learn:

  • Applications for certifications dropped from 1744 in 2013 to 1494 in 2014.
  • The number of new certifications dropped from 1144 in 2013 to 972 in 2014.
  • 532 of those new certifications were in Oriental Medicine. Another 16 were for Chinese Herbology (likely existing LAcs choosing or being required to add the Herb certification).

I don’t know how many practitioners are leaving the profession, but many of my peers who were licensed 20+ years ago are stepping back from active practice.

Several current initiatives, including HR 3849 and state-level efforts to mandate insurance coverage of acupuncture would increase demand for acupuncture. (There are 49,435,610 Medicare beneficiaries in the US and 5.5 million Gulf War Vets.) If fully trained Acupuncturists aren’t able to meet the demand, who will provide those services?

At this rate, how long will it take to grow the profession to even one Acupuncturist per 2000 people?

Shouldn’t we focus on that?

I’m baffled. We’ve sued, signed petitions, and marched in the street, all to try to stop the “greatest threat to our profession” – other professions wanting to use the acupuncture needle.

But there’s been silence, or even approval, when Florida (with one DOM for every 17,760 people) changed their regulations in 2014 to require all 4 NCCAOM exams for licensure. Ditto in NJ where new practitioners will need the NCCAOM herb exam to use herbs in their practice. (How many citizens had been harmed by use of herbs by practitioners without the herbal credential? Was regulation needed?) In Nevada (approximately 1 Acupuncturist for every 47,000 citizens) the Board of Oriental Medicine is moving to require a DAOM of all licensees. Meanwhile, many insurance plans are limiting their provider pool to those with active NCCAOM certification, even in states that don’t require that credential. (After all, the vision of the NCCAOM is that “Acupuncture and Oriental medicine provided by NCCAOM credentialed practitioners [emphasis mine] will be integral to healthcare….”)

If we want the public to obtain services from well-trained Acupuncturists we need to make sure providers are available. One thousand new practitioners a year and growing self-inflicted restrictions on where and how we can practice aren’t going to do it.

The greatest threat to our future is an Acupuncture workforce insufficient to meet demand or effectively advocate for ourselves. Allowing or supporting credential creep, educational bloat, and practice restrictions are sowing the seeds of our demise.

Can we please focus on growing our profession?

 

Demographic Information From:

Acupuncture Today Density Map

Physician Data

Population Data

Medicare Data

Veteran Data

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.

Licensure News

Finally! At the May 6th Delaware Board of Medicine meeting two experienced and NCCAOM-credentialed acupuncturists were granted Delaware licenses, bringing the number of the LAcs in the state to just under forty. This is good news for the people of Delaware. It is also good news for the profession as whole. And hopeful news for the practitioners who are now commuting to Maryland, or not practicing, because they were unable to obtain a Delaware license.

Why did it take action from the MD’s on the BOM to get these practitioners licensed?

These LAcs had appeared before the Acupuncture Advisory Board four times since applying for licensure in late 2012/early 2013. At several of these appearances the Acupuncture Advisory Board members acknowledged the applicants’ excellent qualifications but refused to grant licenses despite having the authority to do so.

For decades one of our “sacred cows” has been that we need our own boards. Then we’ll have the power to control our destiny. Sadly, when given the chance, some of us prefer to control our destiny right down the tubes.

Consider the history of the independent California Acupuncture Board, with its unique accreditation and exam process, and its ongoing problems. Or Nevada, with an independent board, 53 LAcs, a $1000 application fee and $700 per year renewal fee.  If Delaware had an independent board my colleagues would have had to go to the courts to present the argument (made by a public member of the Board of Medicine) that requiring an herbal education and exam for individuals who do not want to use herbs in their practice, in a state in which anyone can sell and recommend herbs, is restraint of trade.

It isn’t the M.D.’s and “the system” that is limiting the growth of our profession these days. It is other acupuncturists. I’ve asked and asked, but I have yet to find anyone who can explain why the Florida (independent) Acupuncture board is increasing the education and testing requirements for licensure. Have patients been harmed? If a change is needed are there options that would be less burdensome for the profession?

I’ll be interested to see the full minutes of the May 6th DE BOM meeting. In a classic conjunction of issues, a practitioner instrumental in drafting the restrictive Delaware law, and a current Acupuncture Board member who had voted against granting licenses to the two qualified acupuncturists, appeared before the BOM to ask them to do something to stop PT’s from doing dry needling.

Did either of these practitioners consider that their previous actions that limit the number of LAcs in Delaware increase the odds that citizens will seek treatment from non-LAcs? Or that our political power is limited by our small numbers? Did the BOM wonder what’s up with this profession — they don’t want anyone to use a needle, even other LAcs?  (FWIW, the BOM doesn’t regulate PT’s.)

You’d think that our own self-interest would prevent the credential and educational creep that costs us so much. But it hasn’t. The AMA Code of Medical Ethics states “A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.” Restrictive laws and rules that limit access to qualified acupuncturists are contrary to the best interests of patients. Let’s work for change – for the people who need acupuncture and the qualified individuals who want to provide acupuncture. Credential creep hurts us all.

Late March Update

The weekend is winding down and I didn’t make it to my planned “The Biggest Problem Facing the Profession” post.  However, there is lots of news in Acu-World. Here are some items to keep you busy until I get back to the keyboard.

  • Want to support the profession in a positive way? You may have contributed to funds for inter-professional squabbles or federal legislation. That money hasn’t helped us in a lasting or tangible way. Support POCATech and you’ll be supporting an acupuncture school committed to providing an affordable education. How would your practice be different if you didn’t have educational debt? Check it out here! POCATech will help more people get acupuncture from acupuncturists — it is a win/win.
  • ACAOM is considering changes to the post-Graduate Doctoral Program and they want to hear from you.  The survey took me about 15 minutes, most of that for reading. Personally, I support a Doctoral track open to those who have an acupuncture-only education. There is a long history of practitioners choosing one specialty.  The movement in some states to insist on complete OM or Herbal training and credentialing is discriminatory against acupuncturists and expensive! It is important that we all weigh in, whether or not we plan to pursue a doctoral degree. Deadline for response — April 17th.
  • In January NCASI was celebrating a ruling they believed meant PT’s would not be able to do dry needling in Utah. In March, Utah HB 367, legislation which would add dry needling to PT scope of practice, went to the Governor’s desk for a signature. Shouldn’t be a surprise to anyone. Utah has fewer than 100 LAcs and about 4000 PT’s.
  • Likewise, “despite the warning” of AZSOMA, SB 1154, which would add dry needling to PT scope of practice, has passed the Senate and made it through two committees of the House. The votes have not been close.
  • Last, and maybe least, the AAAOM collapse continues.  Acupuncture Today printed part II of their article, now with updates. The AAAOM came out with a response (prior to the latest updates). Given the latest updates it probably isn’t worth the time to go through the AAAOM response. Suffice it to say, it contains plenty of spin and quite a few inaccuracies. Mostly, I continue to note that we’ve heard nothing from the AAAOM about who is currently in charge there. And, no practitioners really seem to care.

That should be enough to keep everyone busy.  Back soon, with “The Biggest Problem Facing the Profession.” (No, it isn’t Dry Needling.)

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)