Tag Archives: regulation

How we Grow – The Acupuncture Profession in 2015

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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

Acupuncture Licensing and Regulation – The Future

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Imagine that your acupuncture license meant you could easily practice in every state.

Imagine that licensure exams focused on the skills and knowledge needed to practice safely.

Imagine that acupuncture schools used the time spent teaching things “you won’t need in practice but they’ll be on the exam” to teach things that you really will need in practice, including all that business stuff.

Imagine that acupuncture boards, associations, and organizations worked to make it easier and less expensive for practitioners to obtain and maintain licenses and practice within their skill set.

I wish I could say “it’s easy if you try” – but for most of us it isn’t. (Unless you look to other professions.)

The Florida Acupuncture Board now requires all new practitioners to spend thousands of hours and tens of thousands of dollars on additional education and testing to become Board-certified in herbs. Even though there was no evidence of public harm under the previous rules, and even for those who won’t use herbs in practice.

The Nevada Board is trying to change the regulations to require a DOM or DAOM of all applicants (about 40K on top of an 80K MAOM). Not because there is evidence of public harm, but because that’s the way it is in China. And never mind that the entire state is served by fewer than 50 acupuncturists.

In July 2015 the White House released Occupational Licensing: A Framework for Policymakers. While acknowledging that licensing can provide health and safety protections to consumers and benefits to workers, it concludes,

“State legislators and policymakers should adopt institutional reforms that promote a more careful and individualized approach to occupational regulation that takes into account its costs and benefits, and harmonizes requirements across States. If they are successful, the collective effect of their efforts could be substantial: making it easier for qualified workers to find jobs and move where they choose, increasing access to essential goods and services, and lessening heavy burdens on certain populations….”

Acupuncturists are the policymakers in our profession. Wouldn’t it be great to determine what’s truly needed for public safety and to adjust educational and licensing requirements accordingly? Rather than blaming others for our difficulties, wouldn’t it be more productive to direct our energy to changing the things we can control? We can demand that the insurance companies pay us more because our education cost so much, or we can make our education less costly. We can sue the PT Boards to try and protect our turf, or we can make sure that anyone who wants acupuncture is able to access convenient and affordable services from an acupuncturist.

I’ll be sharing actions you can take to change our practice environment for the better. Like the Acupuncture Regulation US page on Facebook and stay tuned in here, at The Acupuncture Observer, for updates.

 

 

 

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

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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

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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.

Acupuncture and Oriental Medicine in Nevada, What’s the Deal?

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A regulatory board working against the best interests of the public and the profession  — it’s tragic, and it happens too often.

It has never been easy to become an acupuncturist in Nevada. Despite having the country’s first licensing law, passed in 1973, there are only about 50 individuals now practicing in Nevada, the 7th largest state.

It’s not only the $1,000.00 application fee, or the $1,000.00 practical exam fee. In the 2001 the press explored how Nevada’s unique rules caused problems for the profession.  The regulations may have changed, but similar issues remain.

Given the excellent safety record of practitioners licensed in states with less stringent educational requirements and via the widely accepted NCCAOM credential, it’s long overdue for the Nevada Board of Oriental Medicine to change their regulations, making it possible for the citizens of Nevada to get access to the safe and effective acupuncture and Oriental Medicine services that are available in so many other states.

The board is moving to update the regulations. To make it harder, not easier, to get a Nevada license. Not in response to harm to the public, not to bring the process in line with other states, but, because “the degree of MSAOM is odd and absurd.” Look for the “Justifications to amend,” on page 18 in this set of Nevada workshopdocs. You’ll shake your head.

The workshop docs show two sets of proposed revisions. The set dated June 16, 2014, was proposed by a previous Board, has made its way through the regulatory process, and could quickly be officially adopted after two more public meetings. However, the newly appointed Board members have decided not to act on those regulations, and have proposed new revisions. The lawyer in the Attorney General’s office isn’t quite sure what will happen now — it seems that “our” Board is unique in introducing a new set of revisions at this point in the process. (See ** below for more info on the Nevada Regulatory Process.)

The Nevada 2014 proposed regulations would have been somewhat problematic. The Nevada 2015 proposed regs would be a disaster. The reasonable aspects of the 2014 proposed regs are discarded and more restrictive provisions are introduced. The “grandfathering” provision, specifically excluding CEU’s from the 3000 hour requirement, takes away the one avenue for licensure available to most experienced practitioners. The insistence on a DOM or DAOM for all graduates after November 2017 is a significant financial burden for practitioners.

The proposed changes would slow access to and increase the expense of acupuncture in Nevada. They won’t help the schools meet those new gainful employment figures. The proposal dismisses the attempt (for better or worse) to defer to ACAOM for school accreditation, instead establishing an expensive and closely held accreditation process. A change which would allow applicants to sit the practical exam (offered only twice yearly) while their training and background is being vetted is discarded. The regs allow for an increase to $1,000.00 to the license renewal fee, rather than $500.00, and deletes a section on professional ethics from the current regulations. It’s hard to imagine that such awful regulations were written by our colleagues, not acupuncture-hating skeptics. Amazingly, the President of the Board certifies that, “having made a concerted effort” to determine the impact of these regulations on small businesses, there is none.  (See the workshop docs.)

My suggestions on what the profession could and should do in response to these regulations will come soon in a separate post. In the meantime, review the documents and consider how the changes would impact the profession Even those of us who don’t know a soul in Nevada and expect that we’d never practice there will see problems. At the moment, the LCB has not put these proposed revisions on the agenda.  Stay tuned.

 

** Nevada regulatory process —  the Legislature meets only every other year, for 120 days. Nevada law establishes a Legislative Commission, made up of 6 legislators from each house, that can approve regulations when the legislature is not in session. See more here, (generalize since this was written for a particular commission). Regulatory changes do not need to be approved by either the governor or the full legislature.

 

Court Ruling will Impact Acupuncture Boards

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The Supreme Court ruled yesterday that the North Carolina Board of Dental Examiners violated federal law when it tried to prevent non-dentists from offering teeth whitening services.

What does this have to do with acupuncture?

The ruling has the potential to impact all professional regulatory boards.  I’m travelling and don’t have time or an internet connection sufficient to do a thorough report. I encourage you to click through and read the links below — I think most of you will be able to come up with a few areas where LAcs have been sounding an awful lot like those NC dentists….

No anti-trust immunity for Professional Licensing Boards

Unfair Competition

Dentists can’t decide who whitens your teeth

State Licensing Boards not Protected

Board Prevented from Limiting Competition

As Justice Kennedy, writing for the majority, said

“state boards composed mostly of active market participants run the risk of self-dealing.

“This conclusion does not question the good faith of state officers but rather is an assessment of the structural risk of market participants’ confusing their own interests with the state’s policy goals,” he said.

 

Many LAcs insist the only reason they want to stop PT’s and DC’s from doing Dry Needling is concern for the public. Could they be confused?

 

 

A Little Humor

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Here in the DC area a few bulbs are sending leaves up through the cold ground. As their energy rises so does mine. Soon, I’ll share my response to ACAOM’s latest communication and news that yet another jurisdiction seems poised to put licensure off-limits for those without full NCCAOM herb credentials. (DC. Once again, this is happening out of sight of most US practitioners. Shouldn’t we be care more about this than what the PT’s are doing?)

But, for today, I decided to share a humorous bit that I posted to Acupuncturists on Facebook the other day. For those who, understandably, avoid that group, enjoy. For those whole already saw it, apologies.

The Six Stages of Cold Induced Illness in LAcs —

1) Dignity — I’ve been so healthy this year! I do lots of Qi Gong and eat right and get good sleep and take Jade Screen. Don’t worry about me, I’m great.

2) Denial — Hmm, the air in the house must be dry. Or maybe I’m allergic to something. I’m fine.

3) Dosing — Echinacea, Ginger Tea, Chicken Soup/Bone Broth, Jing Fang Bai Du San. More tea. I’ll throw in some Airborne. And some Yin Chiao.

4) Delusion — Really, I’m fine. Let me step out for another box of needles (copious nose blowing and repeated handwashing). Oh, yes, just a little sniffle, it’s nothing.

5) Decompensation — My nose is dripping, can I get the needle in before it’s too late. How many clients do I still have today — can someone please be a no-show. Why is everyone on time? Oh, can I put my head on my desk for a minute. Do I have any Sudafed around here?

6) Despair — This is ridiculous, I surrender. Begin the phone calls to clear the day tomorrow. Of course I’ve had two good weeks in a row for a change — where can I put these folks. 🙁

I hope that all of you are well and healthy. Enjoy these last weeks of hibernation.

17 Foundational Beliefs of The Acupuncture Observer

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Embracing the season of gratitude and thanks, it’s time for The Acupuncture Observer to take a step back and share some of her foundational beliefs about the medicine, the profession, and life.

  1. Acupuncture/OM works. The unique situation of the patient and the unique skills of the provider influence effectiveness. No single tradition provides all of the answers or benefits.
  2. Acupuncture/OM has fewer negative side effects and risks than conventional treatment for many conditions.
  3. Access is a necessary precursor to effective treatment.
  4. Effective treatment will increase wellbeing and could decrease health care costs.
  5. Every means to increase access carries trade-offs. Those trade-offs must be understood as we determine our path forward. We should learn from the experiences of other professions.
  6. Understanding and explaining the mechanism of acupuncture from the knowledge base of modern biology and physiology is useful and interesting, but is not necessary for acceptance by the medical establishment.
  7. The current “science-based” understanding of health is known to be limited. Insisting that Acupuncture/OM be taught, thought of, or explored only in the language of modern medicine/science is unscientific and risks centuries of experience and wisdom.
  8. Consumers should have significant freedom of choice in health care. Understandable and clear information about potential benefits and risks, as well as an exploration of the costs (financial and otherwise) is necessary for good decision-making.
  9. Self-serving thinking leads to hypocrisy. Special attention is needed when an argument for patient protection creates an economic benefit for particular providers.
  10. Simple, easily learned treatments can be effective and safe.
  11. There is the potential for growth and success within the acupuncture/OM profession.
  12. Many acupuncture programs do not provide sufficient or accurate information about post-graduation life and do a poor job of teaching business skills. This can be changed easily and inexpensively.
  13. The financial and karmic ROI (Return on Investment) of positively promoting our profession is superior to that of engaging in political/regulatory battles with others.
  14. The future of the medicine and of the profession are interconnected but not identical.
  15. Thoughtful and respectful analysis can identify areas of common ground.
  16. Focusing on areas of common ground decreases factionalism, and builds unity, understanding, and participation.
  17. The profession lacks venues for respectful dialogue on these issues. As a result, many scholars and potential leaders within the profession avoid involvement.

Do we agree on some of these? Can respectful dialogue increase the areas of agreement? What if we read the Tao Te Ching, the I Ching, and The Art of War first? What if we go deeper than our Wei level response to some of these issues? I believe it is possible that we’ll be able to find a new path forward, one we can walk together, with our hair flowing free. After all, I’m an acupuncturist.

More on Acupuncture Education

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The for-profit schools don’t want to take responsibility for the circumstances of their graduates. And they won’t let the new gainful employment regulations go into effect without a fight.  Within days of the posting they filed suit to block the regulations. They did the same thing when similar regulations were announced in 2012, so I expect the DOE wrote the new regulations carefully to withstand an expected legal challenge.

However, with a pro-business and anti-regulation majority in the House and Senate as a result of last week’s election, even regulations found to be legal might not be enforced.  If the funds to track compliance aren’t in the budget, for instance, enforcement can’t happen.

Of course, if the schools and alphabets were committed to doing the right thing — producing the best possible graduates at the lowest possible cost to the students, regulations wouldn’t be needed, and wouldn’t threaten the schools even if they were adopted. I don’t expect that commitment from large businesses like Corinthian. I wish I could expect it from acupuncture schools. But most acupuncture schools seem to have little interest in what happens to their grads, and continue to present an unrealistic picture of life after graduation to potential students.

We’ve gotten to the point where even prominent conservatives acknowledge that the current system is a “bad deal for students and parents” and at least some are advocating for change. And it’s true that regulations, however carefully written, often have unintended negative consequences. All too often the well-off and powerful find ways to exploit loopholes and other tricks to avoid regulation, while smaller businesses find themselves significantly disadvantaged. (Consider what happened with the organic label.)

If the schools were on the hook for the money students borrowed no doubt things would be a lot different — from materials provided to prospective students, to the admissions process, to the education provided, to alumni support.

I don’t expect that will happen. And with the change in the political picture here in the US, who knows what will happen with the gainful employment regulations. For now, all acupuncturists can help the market work by helping prospective acupuncturists look past the pitch. Anyone entering the profession should do so with eyes wide open.

(Read this for more on how the November elections will impact the future of acupuncture and complementary medicine in the US.)

Gainful Employment and Strategic Errors

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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.