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

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.

 

Copyright —

© Elaine Wolf Komarow and The Acupuncture Observer, 2013-2020. Unauthorized use and/or duplication of this material without express written permission from Elaine Wolf Komarow is prohibited. Excerpts and links are encouraged, provided that full and clear credit is given with specific direction to the original content.

33 thoughts on “Medicare and Acupuncture: End of the Beginning, or Beginning of the End?

  1. What to do? What to do? I turned 70 last month and now in my 40th year of practice. I will be receiving full Social Security benefits from here on out. I can’t run the meter any longer. So how much income I generate will not be an issue. It never has been for me. Some years have been better than others. There were times when I tried to help my clients secure insurance reimbursement but it was frequently time-consuming and frustrating. I stopped decades ago. I have worked in medical offices, group practices, and as a solo practitioner. I now work out of my home office. I only take clients by referral from other licensed providers or current clients. I do not make a lot of money. I never have. I have never cared. Do I think it is a good idea to secure Medicare reimbursement for acupuncture services? Personally, I think it will be a multi-pronged disaster for all. But I understand why some might be looking to throw that Hail Mary pass from the 50-yard line when they are down by 5 points and there are only 10 seconds left in the game. Has anyone talked about Electronic Medical Records? How far down will our reimbursement levels be ‘adjusted’ if we fail to utilize Certified Electronic Health Record (EHR) Technologies? This consideration alone should give you nightmares. Me? I don’t care one way or another. I will continue to do what I have done for the last 40 years. Some years are better than others. None are that great. I don’t rely on insurance so I don’t have ‘a dog in the race’. The race is ‘rigged’ anyway. The insurance industry is among the most corrupt. Best not to believe the propaganda generated by the NCCAOM, the ‘malpractice’ insurance providers, accreditation agencies, acupuncture boards, and the representatives of the multitude of ‘all so precious’ esoteric ‘traditions’. They must all be feeling desperate at this point. The oxygen has been sucked out of this ‘profession’. Best not to believe what I say either. Think for yourself. Do your own research. Decide. Act. If you care.

  2. so is this why you won’t post the Medicaid survey on the ASVA website?
    I never got a reply to my email inquiry to ASVA about the survey. The ASA makes you go to your state acupuncture association to find the survey, I can’t find it on ASVA’s so I asked but did not get a reply.

    • Lisa –

      1) It’s a Medicare survey, not a Medicaid Survey.
      2) The survey was distributed to all ASVA members. A newsletter went out via email last week and there was a link to the survey there. Have you been getting other emails from ASVA? Did you see our update last week?
      3) No, this is not why the survey was not posted on the website. I don’t take care of the website.
      4) ASVA needs volunteers. Please let us know if you are willing to help out!
      5) This blog is independent of ASVA, and I am only one member of a five person Board, so the “you” in your comment doesn’t make sense.
      6) You didn’t get a response to your email because it wasn’t sent to the correct address, so got hung up in a admin file.

    • Lisa — ASVA has confirmed that the newsletter and survey were emailed to the address you’ve given ASVA. If you’d like to change that email address for future mailings, log into your profile.

  3. I can’t add anything ….. it’s all been well said in the comments. I truly believe we are sending the profession into the trash can. I was talking to a MD (generalist practitioner) friend who is spending more time typing notes for the insurance company than interacting with the client. He’s frustrated. The system sucks. AND we are signing up for this????

    NCCAOM is useless. When covid hit NY and I couldn’t figure out if I needed to close the practice…..could I find anything on their site on how to handle the situation. I have nothing nice to say. But add in Medicare….ugh. What are we doing??? Just lost in the woods.

  4. The original ending for Dr. Strangelove was supposed to be a pie fight in the war room. But instead, Dr. Strangelove gets up and walks, and the world ends. I prefer the comedic benevolence of the pie fight scenario, but when they filmed it, the actors couldn’t stop laughing, and there was so much pie flying around the screen went dark.

    I appreciate The Observer for her integrity and stamina. For several decades you have had my admiration. So what now? Is it time for us to “stop worrying and learn to love the bomb?” Pie fight anyone? I am coping with my grief by investing more of my time and energy in Zero Balancing and Qi Gong.

    And, if the dissolution of our autonomy as practitioners is inevitable, I’m curious about the possibility of treating Medicare beneficiaries in a meaningful way regardless of the source or amount of compensation. Can we continue to set a high standard for relationship-based care? Yeehaw?

    https://www.newyorker.com/news/news-desk/almost-everything-in-dr-strangelove-was-true

    • Will you be able to continue to set a high standard for relationship based care if you are forced by economics in to a situation where in order to make a living you have to see a patient every 10 minutes? How about being constrained to a certain set of points based on the Chinese Dx if you expect reimbursement?

      I appreciate that some people see this as an opportunity – and maybe it is. That being said, we seem to be trodding the flower lined path with rose colored glasses on. Go take a look at how the insurance industry has impacted the delivery of healthcare and why physicians were concerned about insurance’s increasing role starting in the 1950s-60s. I worked in the health insurance field for 8 years, I’ve seen it from the inside, and I’d prefer not to have anything to do with it.

    • I am beginning to ponder what next for my practice. If the day comes when it’s no longer tenable to treat the way I am committed to treat, what will I do.

      I am at a place where I don’t think I can keep fighting. At least not this particular fight.

      The one potential saving grace, although it is also a deep sadness to me, is that the unwillingness or inability to really look at this move, warts and all, and take the time to REALLY address the concerns (as opposed to just telling us that they’ve got it figured out, we’ve got nothing to worry about) is that it interferes with the possibility that “they” will win. If there are enough LAcs who aren’t on board calling their Reps and Senators and expressing concerns, it’s not going to help what would already be what I think will be an uphill fight.

      I guess I don’t really know, but I don’t see this particular issue being one that’s very important to most politicians in the next few years.

  5. Maybe I’m completely jaundiced and cynical, but I assumed we were going to get pushed into this one way or the other before I read your note. Of course, I said I would rather not be in Medicare on the survey,… UGG! Maybe I’ll go into real estate

    • The problem is that Medicare added coverage for acupuncture in low back pain before adding LAc’s as recognized providers. The cart got put before the horse and now people feel like they’re going to lose patients to other providers if they don’t hurry up and get acupuncturists recognized at the federal level.

      The other problem, at least in my opinion, is that the LAc’s and organizations pursuing these agendas apparently haven’t studied the history of insurance coverage and don’t understand the downsides. They’re desperate to be included in “the system” without stopping to think what that inclusion is going to do to the practice of this medicine.

      Traditional medical systems, properly practiced, do not dovetail with the requirements insurance is going to make. We are delusional if we think this type of inclusion isn’t going to have long term repercussions on how we practice. It’s only going to be a short hop from being under paid but still relatively free to treat as the individual patients’ presentation dictates to being constrained by diagnosis to a short list of points and not being reimbursed if we treat “off the plan”. This is exactly what’s happened to MDs/DOs/NPs and we don’t have nearly the acceptance and leverage they do/did.

      • These were point I really wanted to address in the materials we were distributing and in the conversation as a whole. Both participating in private insurance and Medicare has benefits and has costs. I’d like an honest appraisal of just how significantly we’d be impacted. At least then we could be prepared, and explore ways to mitigate the costs.

        The idea that somehow the 20-30K LAcs will have significant leverage inside the system seems unrealistic.

        • Agree – at 20-30k we aren’t even a blip. Even at 10x those numbers the system is in place, it has rules and it’s not going to change for us. It’s wrong-think in the extreme to take the position that we’ll be included now and then slowly change the system to be more friendly to us. What’ll happen is that we’ll be included and then we will have to change in order to squeeze a living out of the system.

          In my opinion we should be taking the extreme opposite position. There aren’t many of us, we tend to concentrate in just a few geographic areas, science supports acupuncture as a valid modality in the treatment of a multitude of disease states. We tried inclusion in the 1970s-80s and were rebuffed. Even though we’re a small group, we hold the cards. All we need to do is hold the line and make them come to us. It might take a few years, but if we played things correctly we could probably get there.

          • I also think the whole idea that we’ve got to do this or someone else will — not a good argument. Given our small numbers, even if we gain inclusion, other professions will also end up being acupuncture providers. We can’t meet the need.

            I keep thinking of the scene in Tom Sawyer – if you don’t take this chance to paint the fence, you’ll miss out completely!

          • Looks like this blog format limits the number of nested replies. This comment is directed at the 7 July 1:18 PM post – yes, that’s the point. We have very small numbers and very uneven geographic distribution. We’d be far better served continuing to advance NCCAOM (or similar) national board certification as *the* credential for acupuncture practice.

            We also need to make it much easier for new grads to start successful businesses or find places to work, and our licenses need to be more portable. If we can keep even 1/2 of new grads in business past 5 years and expand our footprint in states where we currently have low numbers we will hold a much stronger bargaining position. None of these things are dependent on insurance or medicare coverage. They are things we could agree to work on as a profession, however, I don’t see the collective will.

          • You mention the NCCAOM credential — one issue I have is the need to maintain “active” status, which feels like extortion on their part. They are the group bankrolling the Medicare push, and have already been in communication with Judy Chu’s office. Assuming they proceed, I will make an issue of the requirement to pay them every year to maintain a credential I earned 25 years ago.

            One of the arguments for Medicare inclusion is that it would increase the liklihood (I’ve been told) that new grads would be hired by medical practices.

          • Maintaining board cert credentials is not that unusual a thing in the grander scheme of medical practice. I work with an NP and MD – they’re both required to maintain their board cert credentials. The MD has to periodically re-test to maintain hers. Overall the maintenance and continuing education requirements are probably ok.

            That being said, I’m not a big fan of NCCAOM as an organization. I think it could be much better.

            It’s possible that Medicare inclusion might increase some job opportunities in some areas for new grads. I’d expect the pay rates to be low which is going to drag our median down. Of course, people will take those jobs which will make the lower pay/reimbursement rates in to something of a self-fulfilling prophecy.

            On the other hand, we have a few states where acupuncture insurance coverage is the norm (CA, NY, WA, OR) and we don’t see serious hiring upticks in those places. If there was really that much money in it for practice groups, I suspect we’d already be seeing them playing in the market place in those states and, as far as I’m aware, they don’t.

          • Maintaining Board credentials is typical for Specialty Boards – not for an entry level credentialing exam. An MD can give up a specialty board credential and still practice. I can’t give up the NCCAOM “active” status and still practice in Virginia.

            And, the NCCAOM gives preference to the CEU’s on which they make $. How come we can get two PDA’s for a one hour NCCAOM Town Hall, but when teaching a CEU event on my own I have to account for every fifteen minutes?

            But I digress. Not really relevant to this conversation.

        • I think that’s a state level thing. My initial license was in CO and that state only requires NCCAOM cert for the initial license, after that you’re free to let the NCCAOM credential lapse without impacting your ability to maintain a CO practice license. I’m now in MO which has the same requirement as VA – I have to keep my NCCAOM cert active. On top of that, MO has it’s own CE requirements which must be met every 2 years (but that’s another issue).

          I’ve often wondered about the CE/PDA thing myself – especially with the town hall thing going on currently. While I appreciate 2 PDA credits just for logging on, I would think an in-person class would have more leeway.

          What you’re really getting at with these two points is one of my own personal sticky issues – consistency. Right now we have a patchwork of requirements and scope of practice and it seems to me our time would be better spent trying to level the field from a national perspective.

          • Yes – state level requirement that remains on the books due to heavy NCCAOM lobbying when we discussed changing it.

            And, yes, consistency! Hypocrisy is a big problem as well.

  6. Thank you. My sentiments exactly. I watched the June 24th town hall and was commenting the entire time and not one of my concerns was addressed. Prior to being an acupuncturist I was in public relations and the town hall felt like a one sided, scripted sales pitch. As I was watching I was thinking-follow the money-who’s going to benefit from this? Not the acupuncturists (I don’t believe in volume, volume, volume!) but the lobbyists and insurance billers. Our insurance company reimbursements have already been cut and we aren’t even able to be in network with them, this doesn’t bode well. I believe this rush for inclusion will be detrimental to our profession. I hope I’m wrong.

  7. There is a limit to rates .. unless I am incorrect you can only charge up to 115% of the rate. If you opt out, so it’s very important to know the fees . Why do acupuncturists work so hard against their own interests to be included in a broken system ?

    • There is a description of rates in the original Medicare brief, which I link to in the post. I don’t believe there is a limit on people who opt out. So, if opt out is “definite” the reasoning is you don’t have to worry about the rates. (Of course, insurance companies will also likely use the rates as the benchmark, so if you opt out of Medicare but intend to participate in other insurance, you will be impacted.)

  8. To the point, as always; thank you. Sorry to hear this “took a lot out of you”. I bet being in the minority implies more work.

  9. I’ve never understood why we’re in such a hurry, as a profession, to double down on the insurance side. Conventional physicians were strongly against insurance reimbursement in the 1950s and 60s when it was starting to roll out. Turns out most of their worries about how that system might impact the practice of medicine came true – in spades. Why we think it’ll turn out any different for us is a mystery.

    I spent 16 years working inside the conventional system, 8 of those years were spent at one of the larger health insurers in the US. Despite advertising to the contrary, there is little ‘patient centric’ about their processes. They are businesses, mostly public traded businesses, and as such their fist responsibility is to shareholders.

    When I finished acupuncture school and went in to practice, I danced around the insurance issue. Ultimately I found that reimbursement rates simply don’t justify the added cost in terms of claim processing. In order to make the dollars work out I either have to perform services I may not think are medically necessary or I have to commit insurance fraud. I’m not about to do either one of those things.

    For the last couple of years I’ve been a cash only practice. I’m fortunate in that I practice in an area of the country where it’s unusual for insurance carriers to offer acupuncture coverage. I have no plans to participate in Medicare.

  10. Is it possible to post your original unedited document? Many of us have been preoccupied with other issues and this is the first time we are seeing this.

    • There is a link to the original document released by the ASA in the post. By original, I mean, this was before the further dramatic edits rushed out last week. I don’t feel comfortable releasing the drafts we submitted to the Board, since that didn’t make it through the review process. I will say that the edit that led me to disavow the document was that a “risk” item looking at how the Medicare emphasis on reimbursement of procedures for the treatment of pain and illness might shape the profession, was left in the risk of inclusion column but changed to be about how if we didn’t provide these services others would. There was some last minute edits to make it less egregious.

  11. I got their survey online. I started to answer, finding that I reached the end of the survey sooner than I thought I should. (Why weren’t they going to ask me details about my objections to using Medicare or any insurance, for example?) I submitted the survey and two days later I received the official position statement which did not seem to take into account my additional comments. Oh, well, thought I, I’m just one person, and maybe they already had their position in mind before asking us. Since I’m “retired” (meaning, I work only a very part time), I really don’t have much stake in the outcome, except that my “very part time patients” will all be wanting to use Medicare. I really hate it when somebody asks my opinion and they’ve not only made up their own minds, but they’ve taken steps toward the ends they wanted all along. Why bother asking? I’d be happier if they at least TRIED to hide their unilateral actions. At least I wouldn’t be convinced they disrespected my time. Sheesh.

    So I’ll wait and see what transpires. Thanks Elaine, for hanging in with all the messy stuff about the politics, finances, and power. You’re a “better man that I, Gunga Din.”

    • The way the organization is set up, they can’t take an official position without finding out what the member states want. And the survey is the way for member states to assess what their members want.

      I really and truly had hopes that they would be fair about this. I accepted that the pro Medicare folks prevail, since we see that becoming part of the medical mainstream is a regular rallying cry. And practitioners keep being told this will resolve the student debt issue. (Couldn’t we just address the student debt issue directly?)

      My days of hanging in there may be over. This one took a lot out of me.

  12. Does the document state what the reimbursement rate will be? If not why are LAc’s rushing to get in? It is my understanding that even with the opt out clause, a provider can only charge 115% of the Medicare rate . Why would anyone enter into a business arrangement without knowing the full information? Yet again something that doesn’t actually serve the interests of actual practitioners

    • The original Medicare Educational Brief included quite a bit about reimbursement rates. The specifics were removed in the updated copy, and since the ASA is now reporting that the Opt Out is definite, they figure they don’t need to get into specifics, since no one will be limited by those rates. Oh, and they also said in the second Town Hall that we’ll be able to get higher rates.

      See, nothing to worry about here!

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.