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

November ’15 Acupuncture News Update, Chapter 1

It isn’t easy keeping up with Acupuncture News. Now and then a “clear the decks” post (or two, or three) is needed. Here goes:

HR 3849: Representative Judy Chu (CA) introduced “The Heroes and Seniors Act ” which would add acupuncturist services to Medicare and would increase the availability of acupuncture to members of the military and Veterans. The bill has a long list of endorsing organizations. Supporters should share their analysis of what would happen in the twenty states with fewer than 100 LAcs*. In a business with competitors, creating demand for a service without the ability to provide it is a bad move.  I’d be more worried if I didn’t agree with govtrack.us – there is a 0% chance of the bill being enacted.

Dry Needling: In late September the North Carolina Acupuncture Licensing Board filed a complaint in the General Court of Justice against the North Carolina Board of Physical Therapy Examiners, asking the court, among other things, to declare dry needling the unlawful practice of acupuncture. In early October the North Carolina Board of Physical Therapy filed their counter suit in US District Court seeking triple damages for the NCALB’s illegal and anticompetitive acts. Not surprisingly the same LAcs who cheered on the NCALB suit were outraged that the NCPTE would return fire. Given the SCOTUS ruling from this past year I believe the acupuncture community is in a risky place. If the PT’s prevail it will be a game changer nationwide. Did the AG’s office (which had previously ruled that Dry Needling could be within PT scope) advise the NCALB on their complaint? Are all North Carolina Licensees picking up the legal tab for what looks like outside counsel?

In other news the acupuncture community has been touting the revised AAMA Policy on Dry Needling. The Middle Eastern saying “The enemy of my enemy is my friend” comes to mind. It’s a strategy that can win battles, and can create more of them. I don’t think of Medical Acupuncturists or PT’s as enemies. I do remember our insistence that the 200 (or 300?) hour training of the MD Acupuncturists is insufficient. And I wonder whether the PT’s could increase their training to 200 (or 300?) hours and then argue that all of acupuncture is open to them.

Nevada: The minutes of the November 5th Nevada Board of Oriental Medicine haven’t yet been posted, but I understand from attendees that the Board is planning to hire legal counsel, the cost of which will fall on existing licensees. Why does the Board need to hire legal counsel? Because they continue to pursue actions that go against existing code and legislation, rejecting the counsel of the Attorney General’s office. The news from Nevada is a reminder that having an independent acupuncture board isn’t necessarily great for the public or the profession.

Looks like there will be at least one more “Clear the Decks” post. Coming soon  – news about: acupuncture and insurance, NCCAOM’s annual report and more, ACAOM’s hot news, regulation in the District of Columbia, Lamar Odom and the future of herbal regulation, and what’s happening in the AAAOM.

 

* I use LAc to refer to all professionals holding the proper government license to provide primarily acupuncture and TCM services. Having no clear way to refer to, define, or describe this group of individuals is representative of our challenges!

Acupuncture Licensing and Regulation – The Future

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.

 

 

 

Court Ruling will Impact Acupuncture Boards

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?

 

 

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.

 

 

 

An Acupuncturist Looks for Balance

How do I help the greatest number of people?

The wisdom of Acupuncture/East Asian Medicine has improved my health and the health of my clients for more than two decades. Throughout that time I’ve worked with professional regulation, legislation, and our organizations, with the goal of increasing public access to the full benefits of this medicine.

My involvement in the political sphere of our profession has taken significant qi that I could have used to study the medicine, improve my technical skills, and increase my own well being.  Most days at my clinic include at least one moment when I know that with deeper study I could have provided better care.

This fall I felt that I should choose, Practitioner or Advocate? My clients weren’t getting my best. Could I find a way to support myself through advocacy and leave my practice? Would I be happier if I focused on the intellectual challenge of working toward a widely shared vision of success for the profession, and developing a path to that success? Or should I leave the advocacy work and focus on my patients? In the clinic the appreciation doesn’t carry a side order of harassment and ill will. When I treat I see the positive impact of acupuncture and Asian medicine every day.

It’s winter. I’ve been taking a break. I can’t quite follow the Nei Ching and sleep until the sun rises, but I’ve stepped back. I’ve read the communications from ACAOM and the AAAOM (and this, and this (apologies for it being post-deadline, it was hidden), followed the complaints about health insurance (what it costs, what it covers, what it pays, the work involved in getting those payments), wondered about our dry needling strategy, and pondered whether blogging about these things is “worth” the qi.

It’s still winter….

 

 

 

 

17 Foundational Beliefs of The Acupuncture Observer

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.

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.

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