Five Important Dry Needling Developments

Yes, more on dry needling.  More about education will have to wait.

Five things to know —

  1. The Oregon Ruling did not (despite the Acupuncture Today headline) determine that “Dry Needling is Acupuncture.”  For a full exploration of the case, read this post. In summary, the ruling of the court was that Dry Needling is not physiotherapy.
  2. On April 1st Utah Governor Gary Herbert signed HB 367, legislatively adding Dry Needling to the scope of Physical Therapists.
  3. On April 24th Arizona Governor Jan Brewer signed SB 1154, legislatively adding Dry Needling to the scope of Physical Therapists.*
  4. On March 25th Massachusetts HB 3972 advanced. This redraft of acupuncture bills HB 2051 and SB 1107 was necessary because the bill could not advance with the language that “dry needling is acupuncture.”
  5. At the end of April the Illinois Department of Professional Regulation issued an informal ruling that dry needling was not within the scope of practice for Physical Therapists “as the acts are currently written.”  That last phrase is important. From what I can tell there are about 550 LAcs in IL and over 9,000 PT’s.  The PT’s aren’t ready to call it quits. Time will tell if the victory for the LAcs is a lasting one. The PT’s could well look to Arizona and Utah and work for a legislative change.

(A colleague practicing in Delaware recently told me of the urgent phone calls and emails she’s been receiving — she must get involved in the fight against PT Dry Needling! Delaware is a state in which a few LAcs on the Advisory Board refuse to grant licenses to qualified acupuncturists. There are so few LAcs (less than 40) that they can’t maintain an association and citizens are far more likely to get acupuncture from a DC or an MD than an LAc. Now the profession wants to take on the PT’s? If there’s an urgent need for action from the LAcs of DE, perhaps it should be action to bring LAcs to the state?)

For those who insist we must do something about this serious risk to our profession, here are some suggestions. They would do far more to benefit our profession than this ongoing battle with the PT’s.

* One of the acupuncture profession’s strategies from the start of the Dry Needling issue was to argue, as the AAAOM wrote in their 2013 position paper,– “the addition of TPDN to physical therapy practice is being determined by physical therapy regulatory boards, deleteriously circumventing transparency and public health safety protections provided by standard legislative process.”  This was a mistake. Given the relative political strength of the PT profession and their MD supporters legislative victories are likely. Had we been willing to work with our health-care colleagues in the regulatory arena we might well have had input and influence in the use of this procedure.

It’s Like Herding Cats

It’s a common refrain about reaching consensus in the acupuncture profession. But why try to herd cats? I learned a long time ago that opening a can of tuna would bring kitty running.

If there were an attainable action that would:

  • Increase patient access to Licensed Acupuncturists,
  • Assist in national marketing for the profession,
  • Decrease educational costs and student debt,
  • Decrease licensing expenses,
  • Increase political power,
  • Expand professional opportunities, flexibility, and mobility, and,
  • Increase the value of your practice,

Would that be like tuna to a kitty?

(Whirrr of can opener)

Tuna for me = Identifying the least restrictive licensure requirements necessary to protect the public and create successful practitioners and working to establish that as a standard in all states.

Before panic ensues, consider some of the situations I’ve heard about in the past few years:

  • Highly experienced and qualified LAcs unable to obtain licensure, even in states where there are so few LAcs that the public has little choice but to get their acupuncture treatment from Chiropractors.
  • Practitioners who want to sell their practices but have a limited pool of buyers because of the unique licensure requirements in their state.
  • Practitioners travelling many, many hours in order to practice, or leaving the profession, because life has taken them to a state in which they can’t obtain a license.
  • Practitioners and students who have no interest in using herbs being required to spend tens of thousands of dollars and thousands of hours learning herbal medicine in order to obtain an acupuncture license.
  • Acupuncturists supporting discriminatory laws or regulations such that the only group of people in a state who can not practice herbal medicine are other Acupuncturists.
  • Practitioners having to maintain licenses in multiple states because changing regulations mean that if they give up a license they will be unable to obtain it in that state again.
  • Acupuncturists being unable to advance reasonable state or national legislation because restrictive practices keep practitioner numbers so low that political support is unavailable.
  • The profession being unable to effectively educate the public about their excellent education and credentials because those credentials vary so much from state to state.
  • Acupuncturists struggling to build a practice in overserved areas, but unable to obtain licensure in nearby underserved areas.
  • Acupuncture organizations fighting for inclusion in managed care and federal health programs, even though many states have too few LAcs to serve the population. (Demographic data can be found at these links: Acupuncture Today LAc Map, US Population, Physicians per State.)

The current system in which some states require graduation from particular schools, others have their own exams, and others have their own educational requirements does not serve us as a profession. The situation is getting worse, not better, as states like Florida increase their requirements. Yes, states have differing scopes. (Those who advocate for scope changes should be required to consider and advertise the impact the changes will have on licensure requirements.) Yes, it is in the interest of the public and the profession to insist that practitioners limit their practice to the tools and skills in which they have been trained. Additional, optional, training can always be required for those who wish to practice more advanced techniques or modalities. The least restrictive licensure requirements have shown themselves to be sufficient for safe practice.

Limited, standardized, licensure requirements would lower practitioner expenses, promote mobility, ease national marketing, and help the profession grow. It sounds great — as good as tuna smells to a cat. Does it make you make you want to come running? Many changes in licensure requirements could be made at the regulatory level and are within our reach. It does not depend on establishing reciprocity. One problem — the LAcs within a state have the power to make or block change, and, especially in restrictive states, the small group that set up the rules is often in power. Another problem — many LAcs don’t care about this until they are directly impacted.

This is a place where national coordination is needed. I hope the CSA sees that this is a place where they could make a positive difference. Let your state association know if you support a more standardized and simpler licensure environment. It should not require any herding.

Cat Food

Cat Food

 

 

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?

Smart Policy for the Acupuncture Profession

That’s my agenda —  to help acupuncturists and their affiliated organizations (AAAOM, NCCAOM, ACAOM, state organizations, schools, etc.) explore and analyze policy choices to help identify smart and effective policies and to avoid knee-jerk wild goose chases and unintended consequences.

My agenda is not to overthrow the NCCAOM, undermine the AAAOM, or to create conflict and division.

We are suffering from a professional auto-immune disease. How many subjects have been the greatest threat to the profession? How many LAcs have walked away from professional affiliations disheartened at the amount of energy spent attacking other professions or colleagues? How many of us react with outrage the moment we hear of some challenge, ready to mount an attack before we have all the information?

As acupuncturists, we see the suffering that results from an overactive immune system. Let’s stop making that mistake.

Last month I shared my email to my state association regarding their comments at an Advisory Board meeting. Here is ASVA’s response, and here is my reply. (I include the documents to show how challenging it can be to have non-triggered dialogue on an issue facing the profession. Rest assured, I am grateful to those who serve.)

Please support discrimination?!?

Another entry in our Hypocrites with Double Standards (HWDS) files?

I’ve been reading about the importance of Section 2706 of the Affordable Care Act for our profession. It wouldn’t be right for insurance companies to cover acupuncture only if performed by an MD, right? The concerns within our community, according to the press, are that the section might be undermined by the actions of the AMA (this makes us angry!) or not strongly enforced.

Okay, non-discrimination good.

Wait a second — AOMSM, the Massachusetts acupuncture association, is pushing legislation that discriminates.  Section 7 of S1107 and H2021 reads “The use of needles on trigger points, Ashi points, and/or for intramuscular needling for the treatment of myofascial pain will be considered the practice of acupuncture” (does it matter what type of needles?) and Section 8 reads “Only licensed acupuncturists or medical doctors shall be reimbursed for acupuncture services.” Is anyone surprised that “political agents for PTs in MA have taken measures to prevent “An Act Relative to the Practice of Acupuncture” from advancing”?

So — discrimination is good if it works in my favor, bad if it works against me?  How does this reflect on our profession and the future of integrated health? Not well, in my opinion.  What do you think?

News Update

and a bonus at the end —

October 1st, NCCAOM, Facbook —

 NCCAOM has received a significant volume of responses, and the results of this feedback will be taken into consideration during the development of the final policy and standards, as NCCAOM continues to strive for increased customer satisfaction. We are always eager to hear your suggestions for changes that will benefit you, the Diplomate, and the AOM profession overall. It is with your feedback that we can continue to meet your needs.
We are listening!

Spin?

October 2nd, date of scheduled AAAOM Town Hall, AAAOM website —

Legislative Town Hall

CALL POSTPONED – DATE TO BE DETERMINED

No additional news.

October 9th, Richmond, VA, Meeting of Virginia Acupuncture Advisory Board.

Agenda includes discussion of an alternate path to licensure due to conflicts between Virginia law and the NCCAOM proposed policy changes.

The representative from the state association (ASVA) was against any discussion of the NCCAOM issues. ASVA stated  — “lowering of standards…would do harm to both our profession and the public.” Who mentioned lowering standards? Is there evidence that anyone is harmed in states that do not rely on the NCCAOM credential?  Here is my post-meeting email to the association  –  ASVA comments.

The NCCAOM rep at the meeting was clear — the proposals were just proposals, stakeholder comments will be taken into consideration, any language referring to the effective dates of the changes was referring to effective dates for the proposed changes, not the actual changes. I envisioned someone pedaling backwards.

Questions of the Day — We attack when another profession “interferes” with our practice (DVM’s “stealing animal acupuncture”, PT’s “stealing acupuncture”, MD’s wanting to see our patients) even when we have little or no power to change anything. Why are we unwilling to even discuss it when an organization supported by our money, controlling our profession, at our request, takes action that costs us or limits us? We made a difference this time (we hope) – why aren’t our professional associations helping?

Here is a new page on Legislation and Regulation. It contains important and valuable information. Please, read it and pass it on.

I’ll be working on a page about the Acupuncture orgs (the alphabets) and another for potential acupuncture students in the coming weeks.

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)

A Very Important Question

Dear NCCAOM,

Will feedback received influence your proposed(?) policy changes?  Ms. Basore’s comments to my previous post indicate the changes are a done deal. Please let the readers of The Acupuncture Observer know so that we can effectively use our qi.

Thank You.

Dear Readers,

I’ll send my many questions and comments about the policy changes to the NCCAOM (and post them here) if our input matters.  In the meantime, please  —

  • Contact NCCAOM via Facebook to weigh in on the proposed(?) changes. (Are they listening?)
  • Contact AAAOM via Facebook to share your thoughts on the NCCAOM’s proposed(?) changes.
  • Respond to the AAAOM’s latest Call for Comments (deadline September 19th), and let them know if you think they should be focusing on the proposed(?) changes.
  • Contact your state professional association to point out that the proposed(?) changes interfere with the state regulation of acupuncture and ask them to get involved.
  • Ask your state association to raise this topic with the Council of State Associations. (There doesn’t seem to be any way for the average professional to contact that group directly.)

That’s a good start while we wait to hear back from the NCCAOM. Oh, and spread the word!

P.S.:  Here’s a story about background checks.  Keep in mind, in the NCCAOM’s proposal, the poor applicant wouldn’t even be allowed to sit the exams.

If I Had 3 Million Dollars

I would buy you all a boat.

Just kidding.

I would —

  • Compile and make available a list of the specific requirements necessary to obtain an acupuncture license in each state, making sure to highlight current and oncoming obstacles. (For example, as of October 1, 2014, Florida will require passage of the NCCAOM Oriental Medicine Module for licensure. Although the Florida rules will continue to show that those enrolled in school prior to August 1, 2007 need complete only a two-year course of study which does not need to include herbs, the new examination requirement means that no one with only the two-year education will be able to obtain a Florida license.)
  • Compile data on the professional success of acupuncture graduates of every US school. The data would be available to all.
  • Explore why those who aren’t practicing have left the profession and whether there are different rates of success among graduates of different schools. If there is a difference in graduate success, are there factors common to the more successful schools?
  • Gather data on the safety record of acupuncturists in various states. Does it matter if the state requires NCCAOM exams or credentials? In acupuncture? In herbs? If the states require graduation from ACAOM schools?
  • Use the data to identify the lowest common denominator. Identify the least restrictive education/credentialing necessary to ensure public safety and prepare practitioners for success.
  • Show how uniform and non-burdensome state standards are a critical step in providing acupuncture to the 313.9 million people in the US. Build consensus for reasonable minimum standards, and work for their adoption in all states.
  • Establish a team of public policy professionals with expertise in regulation and legislation to help develop a set of attainable and effective strategic initiatives.

Where would I get my 3 million dollars? Not by yet another “now is the time, we must submit legislation that mandates access to the federal healthcare system” fundraising effort. We’ve heard this before. We should know by now that submitting legislation is guaranteed to suck up resources, it is passing laws that can make a difference – if we’re prepared for the consequences of success.

Please, respond to the AAAOM’s call for comments by August 31st. With, at best, 30,000 acupuncturists available to 313.9 million people, is submitting legislation which has a snowball’s chance in hell of passage really the best use of 3 million dollars?

And, if you really want to do something that will improve access, ten minutes and two stamps will do it – here’s how.