Act Now – Help the Acupuncture Profession With Sensible Regulation

We have a little more than a week to influence regulations that will impact our profession. The regulatory and legislative process typically includes long periods of incremental movement suddenly replaced by small windows of major activity. One of those windows is open in the District of Columbia, but only until December 26th.

The proposed regulations are especially important because Washington DC is the seat of our Federal Government. If Acupuncturists hope to influence policy at that level we’ll need a strong community of practitioners, the more experienced the better, ready to serve in our governmental agencies.

The good news is that a small group of practitioners worked diligently to move the regulatory activity in a positive direction over the past three years. The bad news is that amidst the positive proposed changes are a few problematic sections. The additional bad news is that we are now late in the process. But maybe not too late. It would be good for the profession and for individual practitioners if we were able to correct those problematic sections. Let’s try.

You can see the text of the new regulations here. Comment by clicking on the blue “Make Comment” box at the bottom of the page (the tab at the top doesn’t seem to work). The comment form will only accept 500 characters, which meant a boatload of editing and three separate comments for me. Feel free to borrow my Three Issues DC2 language for your comments.

In addition, I’ve sent this Dear NCCAOM letter to Mina Larson, (MLarson@thenccaom.org) and Kory Ward-Cook (kwardcook@thenccaom.org) asking for their assistance. Again, the more letters the better. Feel free to use my letter as a template.

Remember, a regulatory change anywhere sets a precedent for changes everywhere. If we want people to get their acupuncture from LAcs, we need to remove obstacles to licensure. Please submit comments and share this post with other’s who would like to weigh in. It doesn’t cost anything except a little bit of time. Imagine what we could do if we took the energy and funds used to battle other professions and focused more on improving our own situation.

I limited my comments to the issues I consider most problematic and easiest to correct.

As I discussed in this post, these regulations will impact us all. Some of our colleagues thought it best to keep these proposed changes from the greater community, and that’s a shame. We need to be in the loop. The more we know, the more we can do to bring about positive change.

 

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

NCCAOM Code of Ethics & Grounds for Professional Discipline, Part II

The NCCAOM’s call for comments on the Code of Ethics and Grounds for Professional Discipline ends September 12, 2015 .We owe it to ourselves and our profession to share our thoughts with them.

Here’s what I’ll tell them —

Dear NCCAOM,

Thank you for the opportunity to comment on the Code of Ethics and Grounds for Professional Discipline. My significant concerns with these documents can be traced to three overarching issues —

  1. The NCCAOM credential is required to maintain state licensure for many acupuncturists. You advocate for this arrangement. Yet the current Code of Ethics is more suitable for a voluntary exceptional standard adopted by choice.
  2. States that require NCCAOM credentials have their own regulatory boards, ethical codes, and disciplinary process. The NCCAOM Grounds for Professional Discipline empowers you to pull a practitioner’s credential, removing them from practice, even when a state board would allow continued practice for the same violation. This turns the NCCAOM into de facto regulators and creates double jeopardy for practitioners.
  3. The NCCAOM reserves the right to take disciplinary action against any practitioner who violates the Code of Ethics. The Code covers behaviors ranging from serious threats to the public safety to those in the realm of Public Relations. The NCCAOM should explicitly limit the use of disciplinary action to violations that risk the public safety.

A few specific examples —

  • “Exceeding the scope of practice as defined by law or certification” is grounds for discipline. Scope is defined by the state, and may not be accurately determined by written language in code or regulation. Since state regulatory boards ultimately rule on whether or not a procedure is within scope, and since that board would determine proper discipline for any violation, no action from the NCCAOM is needed. References to scope should be removed from the NCCAOM document.
  • “I will continue to work to promote the highest standards of the profession” is listed in the Code. Must practitioners promote the FPD or DAOM, the addition of herbal exams to licensure requirements, and the expansion of the NCCAOM credential requirement to all states? Who determines the highest standard? This language is coercive at best.
  • The Code of Ethics requires credential holders to report peers who violate the Code. It is untenable to expect Diplomates to report every peer in violation of any aspect of this far-reaching code, and it is unfair to wield the power to hold us responsible for any failure to do so.

I support rigorous professional ethics and respect the NCCAOM’s intent to establish high standards for the benefit of our patients and our profession. However, your role for the profession is to validate entry-level competency. Much of the current Code of Ethics and Grounds for Professional Discipline goes far beyond this role. Continued overreach into areas best left to regulators and voluntary affiliations puts at risk the NCCAOM’s position as a credentialing organization.

Thank you for your consideration of these comments,

Elaine Wolf Komarow, L.Ac, Dipl. Ac. (NCCAOM)

Those of you who would like more background on the role of the NCCAOM in our profession should look at Part I of this post.  I encourage those who are interested in another viewpoint of the NCCAOM and its impact on the profession to review these comments and consider signing this petition.

NCCAOM Code of Ethics & Grounds for Professional Discipline

The NCCAOM is preparing to update the Code of Ethics and Grounds for Professional Discipline and is asking for input. Informed comment requires not only a review of the documents, but also an understanding of the role of the organization.

The path to become an MD in the US is straightforward. Go to college and medical school, sit the licensing exams, complete a residency, apply to a state regulatory board, and, if desired, obtain a board certification in a specialty.  (It is not necessary to be board certified to become a licensed medical doctor, and it is not possible to become an m.d. without successful completion of the licensing exams.)

When the NCCAOM (then the NCCA) was established in 1982 few states had formal licensure. Rigorous credentialing was thought necessary to gain acceptance by the medical establishment. Having a group supported by the profession to ease the regulatory burden on states regarding this new profession was also helpful. Some states weren’t (and still aren’t) at all interested in licensing acupuncturists. In those states, a formal credential to attest to an ongoing fitness to practice was appealing.

But conflict in the early days of the profession, both within the community and from the outside led to disparate paths to practice. There was disagreement about how to test and evaluate the huge knowledge base and varied traditions of the medicine, and how much power to give to any one group. Additionally, the political climate in the various jurisdictions differed greatly.

The NCCAOM‘s official role is to validate “entry-level competency in the practice of acupuncture and Oriental Medicine through professional certification.” But, the NCCAOM is really a chimera, a hybrid, due to the factors mentioned above. It has become a quasi-regulatory agency in some states, establishing practice standards and acting as a disciplinary agency. In other ways it is more like a specialty board — attesting to a particularly high level of qualification (but not exactly, since some states require NCCAOM certification for entry level practice). And, the ongoing weakness and dysfunction of the AAAOM (I’m still waiting on membership numbers, but the practitioner search function reveals the weakness) has led the NCCAOM to fill promotional needs and provide professional support, roles typically handled by professional organizations.

So, does the Code of Ethics and Grounds for Professional Discipline support the NCCAOM’s role of validating entry-level competence? Should it fill the role of a regulatory agency with control over whether or not individuals can obtain or maintain their license? Should it uphold a particularly high standard of practice, suitable for a selected subset of practitioners? Should it fulfill a PR need for the profession? These all need to be considered as we get ready to provide feedback to the NCCAOM.

The NCCAOM has requested input by September 12th.  In part II of this post, coming soon, I’ll share more background information and provide my own thoughts about the documents. I look forward to hearing what you think about the documents and encourage all of us to offer input by September 12th.

AOM Leaders?

Who decides the future of the profession?

Did you know about the meeting of the Acupuncture and Oriental Medicine “leaders” last weekend?

Who represents working acupuncturists at these meetings?

These meetings started in 2005. You can read about previous meetings herehere, and in CCAOM newsletters. Attendees typically include reps from ACAOM, CCAOM , NCCAOM, SAR, NFCTCMO, CSA, AAAOM, AOBTA, and sometimes COMRE. It’s good (I think) that these groups are communicating. It’s not good that most acupuncturists in the US are several degrees of separation away from representation there.

There’s not yet a publicly available report of the 2015 meeting. I do know —

The AAAOM continues to be invited and to attend, despite being out of compliance with their bylaws for years. The AAAOM website currently has no news of the recent elections, the board information is outdated, and there is still no whistleblower protection policy. Word is that the current board overlaps significantly with the board of the NGAOM. Michael Jabbour continues to fill the board position of Immediate Past President (what happened to the real immediate past President Don Lee?) and was present at the AOM Leaders meeting. Membership numbers of the organization are a mystery and I hear the AAC continues to provide much of their funding.

The others present at these meetings know that the AAAOM is a deeply troubled organization that represents only the smallest handful of practitioners. Why, oh why, does the AAAOM rate a seat at the table?

Representatives of the Council of State Associations are also in attendance at these meetings. I am glad that the CSA exists, working to mitigate the damage done by the lack of a functional national organization. I’m concerned, though, that few practitioners have any direct knowledge of this group and what they have to say at the AOML meetings. If you are involved with a state organization, and if the state organization participates in the CSA and communicates back to the membership, then you’ll find out about the CSA. Otherwise, you’re in the dark.

Why isn’t POCA invited? I don’t suppose they’d enjoy being there, but if the AAAOM with their mystery membership is invited, and the NFTCTCMO is invited, why isn’t POCA?

It’s difficult to find the right tone for this post.  I know the groups representing acupuncturists depend on volunteers who are doing their best. I also know that working practitioners too often find themselves at the mercy of the “good ideas” of credentialing agencies, accreditors, schools, and a few powerful colleagues. To make it worse, most practitioners have been misled about what actions are likely to be effective and create positive change.

When I look at who is invited to the AOM Leaders meetings, and how far most of us are from what happens there, it’s no surprise that so many of the developments within the profession seem to work against the best interests of acupuncturists. It reminds me of Congress, and that’s not a good thing.

 

 

It was Twenty Years Ago Today

….. that I was granted my Virginia Acupuncture License (#4). I’d been licensed in Maryland for a few months, but the Virginia License was special. Throughout my years of acupuncture school I’d been involved with the Acupuncture Society of Virginia, working to establish a practice act. We were finally successful in 1994, and my documents were ready and waiting when the regulations were promulgated.

I’m happy I found this wonderful medicine when I did. I feel lucky to be doing this work, and look forward to continuing to practice for decades to come. And yet, these days, I’m mostly sad about the acupuncture profession.

Back in the day, when only MD’s could do acupuncture in Virginia, we argued that the public should have the right and the ability to choose their provider.

We discussed how our medicine could treat the whole person, and that treatments were uniquely tailored to the individual.  We didn’t see patients as a collection of ailments, to be sent from one specialist to the next.

We talked about the good value of our medicine and our belief that it could reduce health care spending.

We got used to the medicine being dismissed by the medical establishment, but held out hope that, some day, they would see the value of what we did.

We knew that this medicine would require lifelong study and learning, but experience told us that about 1500 hours of training was sufficient to produce competent practitioners.

We were happy when we were finally able to receive student loans to attend acupuncture school.

We had concerns about relying on one standardized exam as a precursor to licensure, especially one that was based primarily on one tradition. But we knew that it would relieve some of the burden on the states, and so might help with national acceptance.

It was a time of promise.

Now, my Facebook feed is full of rants — we’ve now decided that, just as the MD’s wanted to protect the public from us, we now must protect the public from the PT’s.

Rather than celebrating the professionals who see the value in this medicine and want to offer it to their clients, we scream that they are stealing our medicine and must be stopped.

We’ve justified our increasing fees (after all, if the MD’s deserve it, we deserve it), and, then chased the insurance dollar so that our patients can afford our services. We’ve adopted the billing games that come along with that, fudging fees, adding services, figuring out what diagnoses to use to get reimbursement, and expressing outrage when we’re called on our behavior. Some of us have gone so far as to attack those who have designed a system to make acupuncture truly affordable to the majority of the population.

We decided that more education would get us more respect, and so increased and increased, and increased again the hours required for entering the profession.  The number and complexity and cost of the exams increased. In a solution to a problem that didn’t exist, practitioners in some states decided an acupuncture education was not enough.  Acupuncturists now must also learn and be tested on herbal medicine, whether they want to use it or not. Various states added additional requirements, so any relocation runs the risk of shutting a practitioner out of the profession. The student loans we celebrated enabled schools to ignore the disconnect between the cost of the education and the likely income of graduates.

I could go on. I won’t.

Shaking my head at the missteps we’ve made, I comfort myself with the confidence that the medicine will survive, even if the profession won’t. Happy Anniversary.

 

 

 

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

 

 

Who Speaks for You?

ACAOM’s letter to the Department of Education regarding the proposed gainful employment rules begins —

On behalf of the Commissioners of the Accreditation Commission for Acupuncture & Oriental Medicine (ACAOM), and in partnership with the Council of Colleges of Acupuncture & Oriental Medicine (CCAOM), the National Certification Commission for Acupuncture & Oriental Medicine (NCCAOM) and the American Association of Acupuncture & Oriental Medicine (AAAOM), we write to offer comments…. Collectively, we represent over 33,000 students and graduate acupuncturists in the United States, and 56 colleges of Acupuncture & Oriental Medicine.

Are there 33,000 students and graduate acupuncturists? Where did they get that number? Do they represent me? Reading the rest of the ACAOM gainful employment letter confirmed it – their letter doesn’t reflect my position on the proposed rules, or on the state of the profession.

ACAOM‘s existence depends on the schools and a steady flow of students, CCAOM represents the schools, and the NCCAOM‘s income depends primarily upon new graduates taking credentialing exams.  Once these groups get their money the future of acupuncture school grads is of little consequence to them.

Of course they would make the case for maintaining the status quo, but they should not be telling the DOE that they represent me.

I’ve just sent this email to the ED of ACAOM (mark.mckenzie@acaom.org) with CC’s to the leaders of NCCAOM, CCAOM, and AAAOM (kwardcook@thenccaom.org; executivedirector@ccaom.comcastbiz.net; DonLeelac@gmail.com), and to ashley.higgins@ed.gov (of the DOE) and bduran@mpamedia.com (of Acupuncture Today) —

 

ACAOM’s May 23rd letter to the DOE regarding the proposed gainful employment rules includes this phrase —

“Collectively, we represent over 33,000 students and graduate acupuncturists in the United States.”

Neither ACAOM nor any of the other organizations mentioned represents me.

The only organization listed that even pretends to serve graduate acupuncturists is the AAAOM. Their professional and student membership is a thousand or so, optimistically, and they were not in partnership with you for this letter.

I am not surprised that organizations that profit off students and new graduates would write a self-serving letter avoiding responsibility for the number of acupuncturists struggling to pay off huge educational debt.

I am not even surprised that you would claim to represent me. But I am angry that you did so.

Unless you can provide documentation that you do represent 33,000 students and graduate acupuncturists please retract your statement to the Department of Education and make clear that you are speaking on behalf of your organization, which depends on schools and a steady flow of students to survive.

Speaking for myself,

Elaine Wolf Komarow, LAc

In coming weeks I’ll explore more of the distortions and spin in the ACAOM letter. But for now I hope you agree that standing by while these organizations claim to speak for us is a mistake.

Borrow my text or use your own, but, let ACAOM and the other alphabets know they don’t represent you — and make sure the Department of Education knows that too.

Acupuncture Careers

ACAOM gainful employment — This deserves its own post.  I don’t have the head-space to write such a post at the moment.  I don’t even have the time to fully read and digest this document.  The little bit I can digest is making me sick to my stomach. I’m betting some of my readers would like to dig into this. I’d love to hear what you think.