Middle of the End

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The opinions in this post are mine alone, and do not represent any organizations or associations with which I am affiliated.

The profession is in trouble. And as of the October 26 NCCAOM/ASA Town Hall even our leaders admit it. That last bit is new. But what isn’t new — as far as those leaders are concerned, there is only one way to save the profession. It’s their way. And it depends upon working LAcs to shut up about our concerns, and do what they tell us to do.

My experience with the ASA in the Spring 2020 was yet another reminder of the profession’s dysfunctional patterns. I believed (despite previous experience) that a mainstream Acupuncture organization was willing to transparently explore the risks and the benefits of a proposed course of action – in this case, of becoming Medicare providers – with the thought that in so doing we could prepare to mitigate the risks, increase the likelihood of benefits, and build consensus on a course of action.

Instead, at the 11th hour, after 100’s of volunteer hours from a group of individuals invited to participate, almost every mention of “cons” disappeared. A slanted pro-inclusion document was released, followed by a poll designed to tilt pro-Medicare. Still, support for the fight was, and continues to be, tepid. And rather than address or acknowledge the legitimate concerns of working practitioners, what we get from the leadership is exhortation and pressure.

This is a repeated pattern.The organizations choose a direction: increase hours of training, add credentials, become doctors, increase insurance coverage, fight other professions. It’s our only hope. Practitioners who raise concerns are ignored, sidelined, or attacked. When the success we were promised doesn’t arrive, it’s our fault. The organizations may change, but the song remains the same.

A year ago I was privileged to have lunch with Mina Larsen and I made the following request —

The ASA and NCCAOM have decided that becoming Medicare Providers is the only way forward. I keep being told that I have nothing to worry about, that I’ll be able to opt out and continue to practice the way I do now. As a way to show working professionals that you have our backs, let’s pretend the language passes tomorrow, boom. Can the ASA and NCCAOM prepare a document, “So, We Won, What Next?” Lay it out for us. What, specifically, do we need to do to Opt Out? Is it a one time thing? Can I change my mind? How does opting out impact my patients? If I want to be a provider, how do I sign up? Do I need to make changes to my record keeping? Are there any accessibility issues regarding my office? If I make errors in billing am I in any greater legal risk? What are the profession’s plans for lobbying on an ongoing basis? Won’t we need to prepare to fight rate cuts? What’s the budget for that?

(I’ve been asking these questions for a decade!)

So far, crickets. There hasn’t been any effort to help us prepare for what happens on the other side of “success.” Just as we’ve been left to fight with the insurance companies and devote more time and money to training.

Other thoughts while listening on the 26th —

– Has anyone explored how many LAcs are likely to choose to participate in Medicare? What percentage of the 50 million Medicare beneficiaries Mr. Taromina mentioned will LAcs end up serving? If other professionals provide more of the acupuncture treatments, could it speed our demise as a relevant profession?

– Why hasn’t increased insurance coverage increased LAc satisfaction and practice success? Is it true that increased insurance coverage hasn’t impacted non-participating providers at all? (It isn’t true, but that’s what we were told at the time, and now we’re being told the same about Medicare.)

– Is there evidence showing that treatments from LAcs are more efficacious than acupuncture treatments provided by others?

– The presenters raved about a future in which, in a pediatric oncology setting (a weird example for a discussion about Medicare), LAcs would treat not just physical pain, but also the emotions and spirit of patients and their families. Are third party payers reimbursing for treatment of emotions and spirit? Do practitioners feel that the time and visit constraints of third party payers impacts ability to deliver deep, holistic, treatments?

– Mr. Taromina mentioned that the lack of unity in the profession resulted in missed opportunities when it came to Covid, the opioid crisis and the ACA. What’s a specific thing he thinks we could have done differently? (I mean, sure, working together, but for what specifically?)

– Mr. Taromina said that no one has come to the leadership with “better ideas” about helping the profession. Why have suggestions to revamp our educational and credentialing process to create a shorter and cheaper path to entering and remaining in the profession been ignored? (I raised these ideas years ago, and I’m not the only one.)

Was the presentation on the 26th too alarmist? No. It might not be alarmist enough – “the profession” is in trouble, there will be consequences for most of us, and the only “solution” under consideration by those in power won’t help.

It’s critical for regulated professions to have healthy organizations and institutions and I’ve devoted huge amounts of time and energy to supporting these groups. Facing, once again, their lack of learning from the past and their disregard for the actual lived experiences of working professionals is painful as hell.

I have no suggestions about what we do next. For me, it’s time for a healthy boundary. There’s no point in continuing conversation with those who refuse to hear. I’ll save my energy for the treatment room.

Good luck to us all.

Medicare and Acupuncture: End of the Beginning, or Beginning of the End?

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The opinions in this post are mine alone, and do not represent any organizations or associations with which I am affiliated.

 

When I started this post in early June I wrote –

Join your state association. The states will be distributing ASA-developed Educational materials and a survey regarding Medicare inclusion soon.

I was honored to be asked to participate in the ASA Medicare Working Group developing the materials. My goal, as always, is to provide vetted information and analysis so that we can make wise decisions and be prepared for consequences. The ASA Board knows I won’t tolerate anything less. It’s concerning that the NCCAOM made statements that they’re already pursuing Medicare inclusion, but the ASA insists they won’t move ahead without the support of the community.

By mid-June, I was concerned.

There was an inexplicable urgency to complete our work. There had been no attempt to work with outside experts to get definitive answers to issues still up for debate. Academics have studied Medicare’s impact on medical practice and physician satisfaction, and there are lawyers who specialize in Medicare law. Why not give us the time to hear from them about the likelihood of an opt out, or whether we can really expect better reimbursement rates?

I noticed a double-standard as we debated which opportunities and risks to include on our list. But I reminded myself that perception wasn’t reality, and that the ASA doesn’t have a ton of resources. That preparing legislation would take time. I still believed the ASA was committed to an honest process and I told myself that the board would correct any bias when they received the document for review.

I was going to write that the process was challenging, and the document wasn’t perfect. But it was the result of a good-faith effort and everyone should participate in the survey.

By late June, I was distressed.

The slight pro-inclusion tinge had been amplified by the Board’s edits. Several changes were so extreme that two of us (given only a few hours to express our concerns) asked that our names not appear on the ASA-Medicare-Educational-Brief (in the end it was signed “The Medicare Working Group”).

I was going write about where the document fell short, and where it was wrong. I’d share my growing sense that the ASA BOD wanted the survey results to give them a particular answer.

I’d encourage everyone to watch the recording of the June 24th ASA/NCCAOM Town Hall, because all of the scrambling to sell Medicare inclusion didn’t completely obscure hard realities. (Sure you’ll lose a little money on every treatment, but you’ll make up for it in volume!)

By the first days of July, I was dismayed.

Perhaps the ASA BOD doubted they’d get their hoped for outcome? Suddenly, the most controversial issues were no longer a concern. We’d definitely get opt out, reimbursement rates would be better. The ASA Revised Medicare Educational Brief was rushed out, which shows only two potential risks of Medicare inclusion. The old survey and any responses were killed and a new survey was distributed. There was a new Town Hall, and now we were told that we had nothing to worry about. The ASA newsletter asked “Are L.Ac.’s ready to take their rightful place in the federal medical system and reap the benefits of being a recognized part of mainstream medicine?” Look, Ma, NO Risks!

Had they finally consulted with experts and gotten better information? No, the sources were the lobbyists – those who make a living from convincing others that what the lobbyist advocates for is a good thing. Incorrect information about settled issues (such as the proper use of Advanced Beneficiary Notification) continues to be circulated.

(Will the lobbyists accept a contract based on Medicare reimbursement rates?)

I surrender.

The NCCAOM has resources and the ASA has the power to speak for the profession. It seems clear that, at some point, they will pursue legislation to add LAcs to the list of Medicare Providers. If this survey doesn’t turn out the way they want, there will be another.

The more we become enmeshed in the mainstream medical system, the more we’ll need the money of the NCCAOM (our money) to protect us, the more we’ll need to support the ASA so that they can look out for us. The lobbyists will have job security. I’m not so sure about us.

My upset isn’t because I believe Medicare inclusion will be bad for practitioners and the profession, though I do. It’s because our leadership is selling us a fairy tale rather than preparing us for the challenges that await.

I was recently described by a member of the ASA BOD as a straight shooter with great credibility. Believe me when I say that the ASA Medicare Educational Brief, in its current form, is a slanted document that presents an inaccurate picture of what life will be like for LAcs as Medicare providers. If you answer the survey keep this in mind.

Good luck to us all.

The Center Cannot Hold: Another Acupuncture Association Spins Apart

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The history of acupuncture professional organizations is a sad tale. We’ve had so many. Some thrived for a few years then withered away. Some live on as zombies. New ones are formed with high hopes. So much energy has been wasted when organizations implode, explode, and disintegrate. We need to do better.

The plethora of organizations, many with a small membership, drain our limited resources. And governments can’t determine how to help us when multiple acupuncture groups demand different things.

This is a problem for the profession as a whole. Recently it’s been a particular problem in California, where there are close to thirty professional groups. There may be more Acupuncturists in California than any other state, but there aren’t THAT many.

In early 2018 California Assemblyperson Evan Low encouraged the formation of a new association (here’s the memo ), hoping to unify the profession with one umbrella organization that could communicate needs and goals to the legislature, the licensing Board, and various departments and agencies. A series of meetings confirmed that there was significant interest within the acupuncture community for such a group and in May 2018 a steering committee was formed to establish a new non-profit association.

The original steering committee was a robust group with 4 at-large members, 1 student, and members representing nine existing associations. They volunteered countless hours and eventually adopted working documents and by-laws for the new association (CalATMA).

In October 2018 the steering committee announced that CalATMA was open for membership and that Board elections would take place in November. Twenty-one individuals applied to serve on the Board.

Meetings of the new Board were contentious. There were objections to the recently adopted bylaws and to committee chair assignments. The leadership did not agree on priorities. Board meetings became a war of wills. An Executive Director was hired, but resigned in short order, sharing his experience of the infighting and obstruction.

Recently, a number of CalATMA board members have resigned. Their resignation letters mention:

“the narcissism and egotistical nature of far too many of the members of the Board of Trustees whose primary interest is self-promotion, prestige, and status”

“the clear misunderstanding of what the role of the officers of the Board of Trustees truly is, and an overstepping and abuse of those positions by these officers.”

“A lack of will and support in creating a genuine effort to build a diverse and broad membership in the organization. This includes recent initiatives that are focused on the desires of a small group of the acupuncture and TEAM profession rather than the broader legislative and advocacy mission originally intended.”

“Notwithstanding the thousands of hours that I have invested in the unification effort, proposals are being made even now by the president and vice president to disassemble all that work for the benefit of their own legacy organizations. There continues to be blatant disregard for the ultimate mission and vision to elevate CalATMA from an amateur organization to a professional trade organization.”

When we learn of conflict within a group, we must decide whether to walk away, or to stay involved. We don’t want to support an organization that works against our best interests. But how can things get better if people leave when it gets difficult?

I consider — Is the leadership is acting in good faith? Are they competent, and doing their best to meet the demands of a diverse membership? Are they prioritizing good governance? Is there a commitment to establishing management and administrative support so that the organization can thrive? Are they manipulating an organization to drive a personal agenda? Is that agenda self-serving, or one they believe will benefit the profession as a whole?

I’ve been a member of multiple acupuncture organizations over the past 27 years, and been on boards for most of that time. Sometimes I’ve been enthusiastic about our work, sometimes I’ve had to force myself to write my membership check, and sometimes I’ve walked away, even sending up a warning flare as I left.

I am thankful to CalATMA’s departing board members for their efforts to create a strong voice for the practitioners in California. And I am glad they are sending up the flares now. What a shame that their hard work has been co-opted.

Our profession isn’t without accomplishments. A relatively small number of people have devoted a lot of energy to our organizations. (Yes, those people usually have practices, and families and other interests, just like you.) If you haven’t yet served our profession by working with one of our organizations, please do. And, please, don’t be too hasty to walk away from a group that is trying to do good work, but sometimes fails.

(Kenny Rogers was right – “Know when to hold ’em, know when to fold ’em, know when to walk away, know when to run.”)

(Also, register for the ASA conference. So far, they are doing good work!)

 

Medicare & Acupuncture: The Good, the Bad, the Ugly, the Unknown.

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Did you hear? Medicare now covers acupuncture. (For chronic low back pain (cLBP), with restrictions.)

January 22nd’s announcement was met with cheers, jeers, and confusion. There’s a lot we don’t know. And a fair bit we do. Let’s be informed and thoughtful.

Here’s the formal decision memo. The one page summary covers the important stuff. Please read it. And take a deep breath.

Here’s the helpful announcement released by the ASA and NCCAOM.

Please note – 1) LAcs with Master’s degrees from ACAOM accredited schools and a state license are included, no need for the NCCAOM credential, active or otherwise, unless your license requires it, and 2) LAcs won’t be able to bill directly for their services due to bureaucracy, not disrespect.

This announcement was a surprise. Just a few months ago CMS proposed clinical trials to evaluate acupuncture’s usefulness for cLBP. Perhaps the input from the ASA (CMS Commentary ASA) and the ANF, among others, made a difference.

My thoughts —

  • There is an opportunity here for LAcs interested in working in physician’s offices, and for physicians who want to provide their clients with non-pharmacological pain relief. That’s good.
  • It’s bad that reimbursement is limited to cLBP that is “nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease).” This limitation rules out many causes of pain that are likely to respond to treatment. The requirement that the pain be chronic, present for a minimum of 12 weeks, will also rule-out reimbursement for treatment in most hospital settings.
  • It’s bad that the billing arrangement and requirement of some (“appropriate”) supervision, as well as the administrative costs and reimbursement rates, will limit the number of participating practitioners thereby limiting the number of Medicare recipients who can access treatment.
  • Despite that, the limitation on direct billing by LAcs, and our designation as auxiliary personal, is, in my opinion, good, at least for now. Those of us who don’t want to participate don’t need to opt out, and LAcs won’t face restrictions on who we see and what we charge.
  • It’s bad that the profession is still relying on volunteers to navigate the complex bureaucracy involved with both public and private third party payer systems, and for keeping the profession informed. Those volunteers have been doing a great job, but it is a huge job. Until we, as a profession, provide the resources to hire professionals with expertise in these areas, we’re going to keep being surprised and unprepared.
  • We have spent decades demanding that the establishment appreciate the benefits of acupuncture, and also insisting that no one other than LAcs provide treatment. It’s ugly to sneer at the doors that have now opened. If we’re serious that Acupuncture should be accepted by the establishment and made widely available, and that the only qualified providers are LAcs, it’s on us to figure out a way to provide it.
  • It’s unknown how, or if, the United States will address our out-of-control health care spending. It is known that the problem is not just CEO compensation or administrative overhead. A system which rewards those who provide the most services is going to be expensive. It’s not sustainable to have “the system” pay more for acupuncture treatment than individuals could or would. We will be facing increasing limits on what third-party payers will cover. We need to spend more time preparing and less time whining about how unfair it is.

Over the years, the profession has given support to those advocating for greater participation in the system. Acupuncturists concerned that many benefits of East Asian medicine would be left behind, or that we’d regret our lost independence, didn’t get traction. We chose which wolf to feed. The future is here and we can’t go back.

Let’s think through our next steps, and be prepared for what we create.

 

 

The Last Acupuncture Observer Post?

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The planet is burning, the country is splitting apart.

I can imagine the despair of the climate scientists. They sounded the alarm when there was time to change course. But those in power prioritized their own short term interests. The rest of us were powerless to make the big changes. And we remain mostly unwilling to suffer the discomfort that smaller (though still helpful) changes require. We take long hot showers, drive big cars, take cruises, crank the air-conditioning on hot days, and lament the loss of the natural world we know. Being really good at recycling isn’t enough.

In the grand scheme of things, the loss of a Profession isn’t as serious as the loss of cool summer evenings and Orangutans and New Orleans. The knowledge and wisdom of this medicine preceded Licensed Acupuncturists and will live on without us.

I’m no Greta Thunberg. But I will sound the alarm again, and hope that the Profession I love will change course before it’s too late.

  • We have created a growing demand for acupuncture. Patients want it, insurance companies want to include it in their offerings, governments – federal 1,state and local, want to provide it to their citizens. There are lots of jobs, and lots of practices available.
  • There are many Acupuncturists who are leaving the field.
  • There are many areas with no Acupuncturists at all.
  • Enrollment in entry-level Acupuncture programs is down more than 20% in the last five years.

It’s an odd combination. High demand, unfilled jobs, LAcs leaving the profession, and fewer people entering the profession.

Representatives from ACAOM and the NCCAOM, asked about the drop in school enrollment at the ASA conference2, chalked it up to “the economy” and the “overall drop in people attending graduate school” and the change in “employment goals” for “the current generation.” And, “as we have more jobs more people will see it as a viable profession.” In short, ¯\_(ツ)_/¯

They aren’t being honest – maybe not with themselves, certainly not with us.

It’s simple. The investment required to become an LAc, and the education and training students receive, is disconnected from the job skills, jobs, and compensation available to most acupuncture school graduates.

People are spending four plus years in school, graduating with significant student debt, offered jobs that don’t match that investment, and without resources to start or purchase a practice. In some states even four years of education isn’t enough. Florida just added a requirement for training in injection therapy for licensure.

Meanwhile, most entry-level acupuncture jobs don’t require injection therapy or herbal skills. (Not necessary for Modern Acupuncture or most Community Acupuncture jobs, for example).

In order to pass Board exams, extensive study of TCM is needed, even though that system is not required to practice safely and competently, which is what licensing exams are supposed to test.3 The NCCAOM acknowledges the problem, but hasn’t offered a solution.

Existing LAcs spend a lot of time bitter that things aren’t better. Many believe that if only “the profession” fought harder they’d get the higher pay and monopoly on techniques they believe they deserve.

Now is the time to speak clearly.

  • The vast majority of LAcs will never be paid physician level salaries. We can spend more time in school, we can get more titles, we can all refuse to work for reimbursements we consider insufficient, and, still, average net incomes of even 80K are a long way off.
  • We cannot, in general, prevent others from using techniques we consider to be “ours.” 4
  • The higher the demand for acupuncture and the higher our expectations for compensation, the more quickly the system will shift to having non-LAcs provide acupuncture.
  • There is a bipartisan consensus that restrictive Occupational Licensing harms the economy.
  • We are vastly outnumbered by most of the professions we view as competition.
  • If you think that we haven’t been able to “protect the profession” because we haven’t fought hard enough you have not been involved and have no grounds on which to judge.

There are things we can do, powerful things within our control, that could help us survive. We must –

  • Streamline our schooling. The focus must be on competencies, not hours. Safe and competent practitioners can be trained in far less than 2000 hours. We know, because we used to do it all of the time.5
  • Minimize the expense of the necessary training. Much could be accomplished through distance education. Bring back apprenticeships which served us well for many generations (we can call them clinical internships, if we’re afraid of what the mainstream will think). Employers can provide additional post-graduate training in specific techniques and modalities.
  • Demand that the NCCAOM develop licensure exams that test minimal standards for safe and competent practice, not specific knowledge irrelevant to practice.6 The NCCAOM bears the responsibility of designing a JTA that supports the development of an appropriate exam. Particular settings or styles that want to do additional testing can chose to do so. Schools bear responsibility for assessing  knowledge of their particular traditions/lineages.
  • Protect licensure for everyone who has sufficient training in acupuncture, which includes teaching that all health providers have a duty to limit their practice to their own training and experience. Requiring all Acupuncturists to have additional training in herbs, or any other specific, optional, modality shall not be a requirement for licensure.
  • Understand that our success as a profession depends upon our having sufficient LAcs to provide treatment in a timely and affordable fashion in most communities in the US, not on whether the Cleveland Clinic has a few OMD’s on staff. We must provide resources to help and support those willing to practice in underserved areas.7
  • Drop the expectation that “the system” will pay us what we think we deserve. Everyone wants to pay less for health care – people, insurance companies, governments.

We must reclaim Acupuncture as a simple, straightforward interaction between a practitioner and a patient, and recreate the accessible path to licensure we once had. Otherwise, we are creating a future with fewer Acupuncturists, who may manage to pay for their extensive education and keep up with demand only by handing off patient care to minimally-trained assistants working for low wages.

Individual acupuncturists and our professional organizations must acknowledge that we have a problem. It may be a little uncomfortable, but we have the power to make changes that will, at least, delay the day when an Acupuncturist in the US is as rare as the critically endangered Sumatran Orangutan.8 It’s not too late.

 

Notes:

1) Please read this, and comment, on the CMS proposal! Deadline August 15!

2) The ASA did a great job with their first conference. Excellent speakers, well-organized, great facility. Very impressive right out of the starting gate.

3) “The sole purpose of a licensing examination is to identify persons who possess the minimum knowledge and experience necessary to perform tasks on the job safely and competently–not to select the “top” candidates or ensure the success of licensed persons. Therefore, licensing examinations are very different from academic or employment examinations. Academic examinations assess how well a person can define and comprehend terms and concepts. Employment examinations can rank order candidates who possess the qualifications for the job.” (from https://www.clearhq.org/resources/Licensure_examinations.htm)

4) Vermont recently deregulated auriculotherapy. Here’s an opinion from Washington state regarding Nurses and Acupuncture.

5) Other Professions have altered training and education in order to address worker shortages and minimize debt (which also encourages increased diversity). Acupuncturists in Nevada were finally able to bring their licensing requirements closer to what we find in other states.

6) My individual conversations with NCCAOM reps at the ASA conference didn’t move beyond quick chats in passing. I’ve got some hope that they’ll work to improve the recertification process. I’m less hopeful that there will be progress in the other areas in which I’ve expressed concerns. Meanwhile, a big congratulations to Mina Larson on her appointment as the next NCCAOM CEO. I know that she understands the challenges facing the profession.

7) Dealing with the shortage of rural providers.

8) Current population of the Sumatran Orangutan estimated at 14,613.

 

 

Another NCCAOM Post. Sorry.

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I know, three posts in two weeks is too many posts. I need a break as much as you do.

My post last week was an open letter to the NCCAOM, so I think it’s fair to share the response from the Chair of the NCCAOM Board of Commissioners.

Dear Elaine,

It was nice to meet you at the CCAOM conference.  Thank you for your concern and dedication to our profession.  My apologies on the delayed reply and acknowledgement of your letter to the NCCAOM Board-I did not want to respond with only a cursory acknowledgement given the energy and effort of your letter.  I will share your letter with the rest of the Board of Commissioners.

That said, I do want to address some of the points you made in the letter.  I hope you will not take my comments as a dismissal of your concerns – I would simply like to clear up some misunderstandings. I am not able to address all of them in this moment, but I would like the opportunity to clarify in the future.  A few points:

-The CEO is not responsible for setting up recertification criteria- that process is done by the Recertification committee(again within the parameters of maintaining our certification).   Continuing education is a non-negotiable.  That said, it has been noted and suggested that the process be more streamlined.

-Exam content is driven by a specific process dictated by NCCA standards; it is acknowledged that the end result is an exam that weighs heavily on TCM.  That is a challenge that we continue to attempt to address.  We are always looking for new suggestions – within the parameters that we must maintain to keep our certification.  As was mentioned, there are budgetary considerations to developing additional psychometrically valid exams as well as the challenge of having enough practitioners to determine psychometric validity and objectivity.

-States that have added herbal certification to their licensing act have initiated that either through the professional association or the state regulatory board. We have not initiated this despite some of the rumors.

-With regards to stakeholder input: whenever possible and applicable, we do seek stakeholder input.  There are times where stakeholder input does not weigh in on a decision – i.e. compliance with new requirements from NCCA, exam validity requirements, ; and issues where we actively sought stakeholder input – i.e. the revision of the code of ethics, the herbal safety certificate creation, etc.

Thank you again,

Best regards,

Afua

Afua Bromley, L.Ac., MSOM, Dipl.Ac. NCCAOM

Chair, NCCAOM Board of Commissioners

I fear my frustration at hearing the same old talking points resulted in a brusque response.

Dear Afua,

Thank you so much for taking the time to respond. I appreciate it.

Will you be at the ASA meetings this coming weekend? I’ll be participating. If you will be attending, perhaps we’d have a chance to talk through these issues in person? In the meantime, I’ll share some thoughts.

Perhaps I shouldn’t take it so literally, but I don’t think there are any misunderstandings here. Perhaps my comments at the CCAOM meetings, and in my blog, could not thoroughly illustrate my  knowledge of these issues. I’m well aware of the complexities of the NCCAOM’s situation. We may certainly have some differences of opinion about what is possible, ideal, effective, or desirable, but I don’t think any misunderstanding is the issue.

Specifically, in response to your email –

  • I understand that CEO’s generally defer to committees for policy proposals. And yet it would be unusual if the CEO did not influence, to some degree, the work of the committee and decisions about how to refine, implement, or adopt committee proposals. In any case, I hope my letter, and the input of the profession as a whole, will be considered by the recertification committee. I agree that continuing education is a standard aspect of ongoing certification for health professionals and others. But the degree of involvement the NCCAOM has in approving classes, and the level of reporting it requires of Diplomates, is outside of normal practices. Requiring providers to pay you to have their courses approved raises questions about your motivations. I look forward to seeing how the committee can better align the cost to the profession of your system of approvals and tracking, with the benefit to the profession of such an onerous system.
  • I’ve heard, over the years, several versions of the “We realize the TCM focus of the exam is a problem, we share your concerns, we’d love to hear your proposals, but the NCCA guidelines, and budgetary constraints, mean we aren’t going to be able to do anything about it” response. If your understanding of the NCCA requirements you have been working under leave you seeing no path forward for a non-TCM based exam, wouldn’t it be more honest to acknowledge that? I can imagine several possible solutions – dropping the lineage based portions of the exam completely and leaving it to schools to verify that aspect of a student’s training, just as it currently defers to CCAOM for CNT testing, is one. I understand from those with more expertise than I, that the JTA used by the NCCAOM has significant flaws, so developing a new JTA would be another approach. Perhaps working with a group other than the NCCA would be helpful. I don’t believe there is no solution to this problem, but if those at the NCCAOM who are most familiar with the NCCA requirements don’t see any room for change, acknowledge that. Let’s not waste the time of others by pretending you’ll consider other options.
  • I was tracking the NCCAOM participation in the original DE licensure law in real time, and have media reports [An Example]from the time, showing Mr. Taromina actively pushing for the herbal requirement for all licensees. The professional association reported being persuaded by Mr. Taromina that the herbal requirement would be the best path forward. In Utah [We Have Met the Enemy], any investigation would have shown that the position of the professional association (no longer functional, I believe) was taken in response to one individual’s desire to retaliate against graduates of a particular school. The NCCAOM made no attempt to assess the position of the many Diplomates in the state who were unaffiliated with the professional association. And the NCCAOM has yet to offer any correction of the letter, written by that association and distributed by the NCCAOM, saying that the NCCAOM agreed with the proposed change. Last, but not least, the NCCAOM says it supports all Diplomates. If so, the proper participation of the NCCAOM in response to proposed regulation that would  eliminate licensure for Diplomates of Acupuncture would be a vehement renunciation of such efforts and a statement that it believes that Board Certification in Acupuncture is the only Certification that should be required for licensure.
  • In a recent example, the NCCAOM announcement of changes to testing procedures was met with expression of concern from stakeholders. In response, the NCCAOM made adjustments so that the changes would be less onerous to those about to graduate. Checking in with schools prior to the initial announcement would have meant those changes could have been made proactively, and schools would have been prepared for their student’s concerns. Clearly, there was some room for adjustment. There is not such a bright line between where stakeholder input is possible and applicable, and where it isn’t, as the NCCAOM repeatedly states.

Perhaps you didn’t notice the wish in my letter —  “that when concerns were brought to your attention you didn’t deny or evade or misrepresent what happened.” Your reply here contains all of the denials, evasions and misrepresentations I’ve heard before. As the saying goes, don’t micturate on my leg and tell me it’s raining. Don’t tell me that someone else is making you aim this way, or that budgetary constraints are to blame. It is possible for the NCCAOM to do better. The first step is owning the problem. I’m still waiting for that.

With hopes for a better future,

Elaine Wolf Komarow, LAc, Dipl. Ac.

The good news is that it looks like I will be able to talk with NCCAOM folks this weekend. I hope that gives me some good news to share. The bad news – it means there will be another blog post.

 

NCCAOM Issues – Here’s a Real-Life Example.

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Last week’s post generated lots of feedback – in the comments and elsewhere. Several people reached  out to me with stories about how their professional success was negatively impacted by NCCAOM policies or procedures.

An individual trained to be an acupuncturist wrote:

I graduated from an acupuncture school outside the country in November 2017. The NCCAOM requires that those trained outside the US must have their documents evaluated by a third party in order to apply and sit for the NCCAOM exams. As of November 2017 the NCCAOM only accepts documents evaluated by the International Consultants of Delaware (ICD).

In December 2017 I began my long ordeal with this organization. After 8 months of emails and phone calls going unanswered or minimally responded to with a form letter, I contacted NCCAOM to inform them that the company they were requiring me and others to use had appalling business practices that were preventing me from taking the NCCAOM exams, applying for a state license and starting a job that was being held for me.

Happily, I did get immediate help from the contact at NCCAOM. They intervened on my behalf and took my educational documents for their own review. However, I was then notified that I still needed ICD evaluation as the NCCAOM could not approve a “non-traditional” transcript. They also said they were not familiar with the school.

The school I attended has been graduating American students for over 15 years, and many have returned, successfully sat for the NCCAOM exams, and obtained licensure in the US. However, now it seems that the format of the provided transcripts are unacceptable; nothing has changed from the school’s perspective.  The only suggestions offered by the NCCAOM are not feasible, such as giving them the names and other personal information of past American students in order to compare what would be identical transcripts, my completing a 2 year apprenticeship (not acceptable for licensure in my state), or the school rewriting their program.

It has now been 18 months since I started this process and am no closer to being allowed to even apply for the NCCAOM exams. It seems incredible to me, and many others, that the format of transcripts, paperwork really, is all that is keeping me from fulfilling my dream. The NCCAOM has nothing to lose by allowing me to take the exams only the gain of my $1500. If I fail, then that is on me.

P.K.

 

The LAc who wants to hire P.K. wrote:

Dear NCCAOM,

As a licensed acupuncturist in practice since 1995, I have been saddened to watch the new generation of acupuncturists struggle with ballooning student loan debt and escalating practice requirements. The combination is eating away at our numbers. This acutely affects the public, our clinics, and those of us hoping to retire some day and pass our clinics on.

As an employer, I am immensely frustrated, because your practices are blocking me from hiring.

P. K. has been my clinic’s office manager, front desk staffer and clinical assistant for more than 3 1/2 years.  She is bright, committed, compassionate and skilled.  She excelled in her three years as a student at a well regarded European acupuncture school.  She comes highly recommended by the school’s president. She has been a delight and a pleasure to work with, continually exceeding my expectations, and our patients are very fond of her.

Meanwhile, I am busy, frequently over booked, and have been looking to add to my clinical staff, with no luck, for quite some time. There is a shortage of licensed acupuncturists in my area interested in a high volume, low fee, community style of practice. I offered P. a position as a community acupuncturist in early 2018, contingent on her obtaining a Massachusetts acupuncture license, and she accepted. Since then, I have been waiting, watching as she does what she can to obtain licensure, while the NCCAOM has been a roadblock in that process.

P. has spelled out in her own narrative the details of her efforts to get approved to take your exam.  When I reached out to you on this matter, we were asked to provide information on previous grads of her school who have sat for the NCCAOM exam — information that neither of us has any access to, but which no doubt, resides in your own files.

Consequently, P. has been left in limbo, with no path forward to practice in the US.  My clinic remains understaffed, and I have no ability to hire the person I’ve chosen, who is best prepared to succeed in this position.  Our state is unable to add a skilled acupuncturist to our numbers. It is all very frustrating, and sad.

A final thought — the whole idea of a licensing exam is to evaluate whether or not a graduate is prepared to enter the field.  If you trust your exam’s ability to function as it was designed, blocking graduates from taking the exam makes no sense.

D. D., Lic Acupuncturist

 

I (The Acupuncture Observer) do believe that requiring a combination of education and examination is the best way to increase the odds that a licensee will be a safe and effective practitioner. Folks with good study skills and an ability to memorize can pass exams without being able to apply what they know in practice. The NCCAOM exams can’t test whether a candidate can identify the signs used in diagnosis, for example. And, the schools have an incentive to say all of their students know enough to be practitioners.

I acknowledge that, for better or worse, the NCCAOM currently requires graduation from an ACAOM-accredited school, or an overseas equivalent. And that means they have to have some method of determining equivalence.

And, yet, is there no solution here? Is it really better for the public, or the profession, that a business and a community goes without the help it needs, while a well-educated and well-trained individual who wants to fill that need is sidelined, with an expensive education wasted?

I think the NCCAOM can and should do better. If they can’t, we need to allow another path to licensure.

 

Dear NCCAOM

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Dear Ms. Ward-Cook, NCCAOM Board of Directors, and NCCAOM staff:

The selection of Chief Executive Officer is a critical time for an organization. Continuity might be the primary goal when a business is thriving. When things haven’t been going well, the best choice might be someone with a fresh perspective and a willingness to shake things up.

As you know, the number of people entering the profession has dropped significantly. Without a change, the growing demand for acupuncture will increasingly be met by people who are not Licensed Acupuncturists. The profession we have worked so hard to build is at risk of becoming little more than a footnote, even while acupuncture itself becomes widely accepted. We must face this issue head on. Every decision made by our organizations must consider which choice supports growth of the profession, and which will contribute to our demise.

With such a small profession anything that divides us, or limits opportunities, is problematic. So is anything that inflates the cost of our education or entry to the profession. These all increase the odds that an interested person will choose another profession, or, having entered the profession, will struggle to succeed.

Over the years, the NCCAOM has made a number of decisions that have, in fact, divided us, limited us, and complicated educational choices and entry to the profession.

I hereby request you select a CEO committed to change, so that the NCCAOM can be an organization that unites, and that removes any barriers for entry to the profession that are not necessary for the protection of the public.

Your new Chief Executive Officer should –

  • Understand that it is in our best interest that everyone who passes the NCCAOM exams finds it easy and inexpensive to obtain and maintain their NCBA (Diplomate) status. In the absence of any findings of unsafe practice, active status should renew automatically, and at a minimal cost. With such a small number of practitioners, we can’t afford to exclude any competent and safe practitioners from employment or licensure. As it is, significant numbers of Licensed Acupuncturists are excluded from job opportunities even after passing the NCCAOM exams. The current system of CEU verification is complicated, and has no measurable impact on practitioner quality.
  • Develop exams that test only what is necessary for safe practice, focusing on crucial tasks and red flags. No particular lineage has been shown to be safer or more effective than any other. Testing requiring knowledge of one specific lineage adds to the cost of an education, complicates school choice, divides the profession, and increases NCCAOM expenses, all without benefit to the public. Since knowledge of a particular lineage is not required for competence, a Job Task Analysis focused on knowledge of a lineage is flawed and must be redesigned.
  • Fight any attempt to exclude any Licensed Acupuncturist from practicing to the limits of their knowledge and experience. The NCCAOM should never support efforts to limit, for example, the use of herbs to any subset of acupuncturists. They should be clear – the herb credential is optional, and acupuncturists without that credential should not be disadvantaged compared to all other individuals in a jurisdiction. Using resources gathered from Diplomates to support efforts to limit their practice feeds resentment and division. The addition of requirements for the herbal credential limits opportunities for practitioners, increases barriers to practice, and increases educational costs.
  • Ensure that the NCCAOM changes policies or procedures only after extensive consultation with all potentially affected parties, allowing us to minimize and mitigate harm. Changes that lead to additional costs or stress to students, schools, and licensing boards work against success and growth.
  • Prioritize execution. User friendly and functional portals are important. So is accurate information. Errors (such as incorrectly reporting licensure requirements) can have a huge impact on educational choices and employment decisions. For practitioners who have a choice, a frustrating hour spent fighting with the recredentialing process can be a deciding factor in whether or not they maintain active status.
  • Keep the focus on the core of the NCCAOM’s mission – ensuring the safety of the public through credentialing Acupuncturists. Lobbying costs money. Taking a position on a matter of politics leads to division and disappointment. The NCCAOM needs to minimize expenses for Diplomates, not use our money to fund activities that we may not support.
  • Leave education to the schools. When the NCCAOM develops educational programs, such as content for the CHCS COQ, it increases concern that the NCCAOM could one day move to make this certificate mandatory due to self-interest. Likewise, the approval system for CEU’s adds to the cost of classes and complicates maintaining certification. This system has no discernible benefit to the public, and stands in marked contrast to the practice of many other credentialing bodies.

I’ve held NCCAOM certification for the past 25 years. I have spent decades as a Board member – of my State Association, State Regulatory Advisory Board, and even the AAAOM. I know that many of my colleagues are quick to demand action, resistant to reconsidering their positions on issues, and eager to place blame. I know it’s frustrating to work hard to give people what they want, only to be criticized for your efforts.

I write now as a Licensed Acupuncturist, and do not speak for any other group or organization.

The existence of a national credential was a great help during our efforts to establish licensure in Virginia in the early 90’s. Over the years I have defended the organization countless times. But when I last renewed my board certification I had to grit my teeth.

As it stands, I’m no longer clear that the NCCAOM is a net benefit for the profession. I don’t trust you to look out for my best interests, even though I’ve been a Diplomate for all these years.

I would like to be able to defend you again. I’d like to know that you had my back. That my fees weren’t being used exclude me from practice. That lapsed status wasn’t keeping colleagues out of the profession. That your exam didn’t require people to learn a lot of information they’ll never need to practice safely. That my fees weren’t being used to fund futile turf wars. That the information you provided could be trusted. That your systems worked. And that when concerns were brought to your attention you didn’t deny or evade or misrepresent what happened.

It’s time for a CEO who understands the changing landscape, and understands that without a change in direction there will be no profession left to protect. For the sake of the profession, and the future of all of us associated with it, I hope that you choose wisely.

 

Sincerely,

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

 

 

Dry Needling – Winning, and Losing.

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The Battle of Cold Harbor, in May – June 1864, was one of the last victories for the Confederates in the Civil War. (Or, as it was referred to in the South, the War for Southern Independence.) The victory did not change the outcome of the war.

In January, a state judge ruled that Dry Needling is not within scope for Physical Therapists in Florida. This ruling was proclaimed a great victory and widely celebrated on Facebook and here, in Acupuncture Today.

FSOMA won in Florida, because, as appears in the ruling, “A simple reading of the physical therapy scope of practice statute, section 486.021(11), in light of the definition of “acupuncture” in section 457.102(1), makes plain that dry needling is not within the statutory scope of practice for PTs in the State of Florida. The Board had no basis for moving forward with the Proposed Rule.”

FSOMA did not win because the FDA limits the use of filiform needles to LAcs, there aren’t standards for the practice of dry needling, the physical therapists aren’t adequately trained, dry needling would harm patients, dry needling is “cultural misappropriation,” or any of the other many arguments made in Florida and elsewhere.

This ruling sets no precedent for any other state because it is based on the definition of Acupuncture and the scope of PT practice as found in Florida law. If state level rulings did set a precedent in other jurisdictions, FSOMA would likely have lost. We’ve lost in more states than we’ve won.

Of course, you wouldn’t know any of this from that Acupuncture Today article, or all those celebratory posts on Facebook.

Meanwhile, we’ve lost a significant and costly battle. One which should never have been fought. This loss hasn’t yet made the news.

The North Carolina Physical Therapy Association recently announced a settlement agreement, in which the North Carolina Acupuncture Licensing Board would pay the NCPTA a six-figure settlement and agree that all current and future members would stop sending cease-and-desist letters to physical therapists who offer dry needling, and would honor the North Carolina Supreme Court’s decision that dry needling is within the scope of practice of physical therapy.

This loss should surprise no one. The NCALB incurred significant legal debt persisting in a battle that no one outside of the profession thought they could win. And they attracted negative attention from lawmakers in the process. Why, oh why, did they do this?

I’ve stopped hoping that yet another blog post will change our behavior. Will a six-figure settlement? How will the NCALB continue to function without resources?

Even the few battles we’ve won could later be lost. Scopes of health professions can change via legislation. Physical Therapists outnumber us in every state. The trend is away from scope “monopolies” – understandable when we need to improve access to services and reduce health care spending. (Consider the history of scope and Advanced Practice Nurses, Optometrists, Social Workers, and Dental Therapists.)

Both the Acupuncturists and the Physical Therapists might refer to this multi-year hostility as The War of Defending the Profession, or The War of Protecting our Patients. Undoubtedly, each side has been motivated by the belief that they were doing what was right. But, war is costly. And, as the smaller and poorer profession, we have suffered greatly for our few victories.

In the past few years we’ve done a good job increasing the demand or and interest in acupuncture. But the number of people entering the acupuncture profession is dropping. In the vast majority of the country we don’t have enough practitioners to meet the need. Meanwhile, qualified and experienced practitioners can’t practice because of regulatory loopholes that seem to benefit only the NCCAOM. The NCCAOM is looking for a new Executive Director, and it’s critical that we be involved in the selection process. Acupuncturists can’t pay off their student loans while others argue for additional educational requirements. Our schools are closing. We’re increasingly participating in the insurance system, increasingly concerned that the system doesn’t support our work, and increasingly, getting into insurance-related legal trouble.

It’s past time to give up the war. There is no one person who can proclaim the end to hostilities. General Lee could only surrender the Army of Northern Virginia on April 9, 1965 1865.* Other Generals continued to fight. I’m sure some state association somewhere will continue to beat the drums of war, insisting that we fight on. What a shame.

We have far better things we could be doing with our time and our money. Let’s.

(Yes, I’m so tired of writing about dry needling I studied up on some Civil War history to spice things up.)

* When I first published this I goofed and wrote 1965. When it was pointed out (thanks astute reader!) I quickly corrected it. But I’ve been thinking. The consequences of the Civil War are still very much with us. Freedom Summer was in 1963, for example. When I see suppliers marketing that they don’t sell needles to PT’s, and LAcs boycotting suppliers who don’t make that promise, well, it’s heartbreaking. The sooner we reconcile the better. And, yup, some LAcs see me as a Profession Traitor for saying this.

Does it Tingle?

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Acupuncturists believe we’re the best-trained, most-qualified, most-effective providers of acupuncture. Many of us believe that our personal style of practice is superior to other styles and traditions.

And, we panic when faced with competition.

News of non-acupuncturists using filiform needles, a low-cost clinic opening in the area, or, a splashy franchise, are met with a combination of outrage and disdain, and fear that our practice, our clinic, the profession, won’t survive.

It’s an interesting juxtaposition. We’re the best, and, if the public has options we’re doomed.

There are reasons for concern. We’re burdened with debt. There’s consumer confusion. Reimbursement rates are falling, and, yes, competition is growing.

Efforts to increase educational hours, require additional training and certifications, add new titles and degrees, increase involvement of third party payers, and to “protect our turf,” have too often contributed to those problems rather than being the promised solutions.

We haven’t, with few exceptions, explored why clients would chose someone else’s services. Or considered how we might respond to client needs in mutually beneficial ways.

One notable exception — in 2002 Lisa Rohleder and Skip Van Meter founded a clinic to make it easier for more people to get more treatment, while also providing a stable income for practitioners. Lisa wrote a series of columns for Acupuncture Today to share her system with the profession as a whole. (These columns are excellent reading for all practitioners, whether or not sliding scale/community acupuncture is of any interest. Visit POCA for more information.)

After her sixth column, the Executive Editor of Acupuncture Today wrote to Lisa – “we are concerned about continuing your column under its current “theme”, for lack of a better word. While the concept of social entrepreneurship, particularly the “pay according to what you can afford” aspect, is admirable, it has dangerous potential from the perspective of professional advancement.”

Crazy, right?

Contrast that with AT’s love for Modern Acupuncture. Marilyn Allen, AT’s editor-in-chief has a new mantra – “Modern Acupuncture will save the profession.” She exhorts us to appreciate their “different” marketing, which, after all, has been designed by a top advertising firm to appeal to the “target demographic” (people with money). She even says we we should join the NCCAOM in promoting their advertising campaign.

I dislike MA’s marketing campaign, and I won’t promote their advertising. I’m sad that instead of, for example, exploring barriers to practice in underserved areas, we’ve got powerful voices touting acupuncture for hipsters. And I’m angry that Marilyn Allen and AT rave about MA but saw danger in “pay what you can afford.”

Meanwhile, rather than dwell on my judgements about how others practice, I choose to learn from my competition. Are they filling an unmet need? Is my pricing, location, schedule, office procedures, or technique keeping me from being more successful? How can I better serve my clients?

My patients don’t owe me anything. It’s their right to decide whether I serve their needs. If I don’t, I hope they will find someone who does. I wouldn’t be happy if there were serious competition down the street, but I’d try to learn from the experience.

We don’t have evidence that patient outcomes or satisfaction depends how long the practitioner went to school, the style of treatment, the treatment setting, or the practitioners titles or certifications. Different patients have different preferences and priorities.

There are many reasons to think the new acupuncture franchises won’t save the profession. Running the numbers raises doubts. Reports from early employees have been less than glowing.

So, I’m not counting on Modern Acupuncture to save us. Nor do I fear they’ll destroy the medicine. (It’s survived quite a lot over the millenia). My concerns for the future of the profession have nothing to do with competition, whether from LAcs or others.

My concern is that we don’t seem very interested in what our potential clients tell us they want. My concern is that we chase after the respect and acknowledgement of the establishment, even as the cracks in that establishment and the unhappiness of the participants grows. My concern is that some of the most powerful voices in the profession seem so clueless about what it’s really like to be a working LAc, and how their plans and policies so often hinder rather than help.

I don’t know whether that tingle I’ve been hearing about is the precursor to a pleasant thrill or shingles. I’ll focus my efforts on taking good care of my clients, supporting increased access to acupuncture for those who want it, and hoping that those with power use it for good. I hope you’ll do the same.