Middle of the End

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.

 

Copyright —

© Elaine Wolf Komarow and The Acupuncture Observer, 2013-2033. 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.

21 thoughts on “Middle of the End

  1. Thank you so much for this. I’m a new acupuncture student finishing up my first semester at a very NCCAOM-aligned school run by folks who definitely want us to be just like any other part of the American medical industrial complex.

    We’ve received so much marketing already pushing us towards herbs, doctorate programs, and anything else that makes the school money. Last week we had a presentation that was all about encouraging us to save up for the expensive NCCAOM licensing process. I asked about what NCCAOM does for us in return for those fees and was pretty sharply told that I should be grateful for all the lobbying they do “for me”.

    I love what I’m learning, and I do feel called to acupuncture. I’m lucky enough to have some inheritance, so I’m able to go to school without going deeply into debt. But I didn’t decide to join this profession because I want the experience of working in American healthcare. I bristle at the idea of having to adjust how I practice to suit the whims of the insurance companies. With my own experience as a disabled/chronically ill person, I know that insurance companies block access to care as much as they facilitate it.

    I’m quite nervous about our future. I just want to join someone’s established community clinic and provide high-quality care to as many people as possible. My approach so far has been to jump through the hoops and try not to let the perspective of my school’s leadership get in the way. Once I’m certified, I can move further from their rigidity. I hope to find the right mentor, read lots of books, and generally try to get as many perspectives from outside as possible.

    What advice, if any, do you have for me and my classmates? How can we weather the coming storm? How can we help prevent this disaster?

    • I don’t know how Elaine feels about your questions, but I do know what my answer(s) are. I’ve spent the last few weeks (years, in reality) trying to figure out how to leave things better than I found them.

      After much thought and conversations with other practitioners of medicine, a few lawyers, and a few folks who retired from state/local government, I’ve landed on: there’s not much I can do. I have therefore decided to focus on continuing to build myself as a practitioner, continuing to educate the public as best I can, and continuing to grow my practice.

      I practice in Missouri. NCCAOM is a requirement for initial licensure here, but we are not required to maintain NCCAOM certification to renew an existing license as the state specifies continuing education requirements. I suspect many states are in this position; losing NCCAOM doesn’t really mean much for the existing license base. I suspect most states would adapt pretty quickly, so NCCAOM going away would likely amount to a slight blip and that’s about it. In fact, I can see several scenarios where NCCAOM going belly up would benefit us in the long run.

      My advice – especially if you’re looking at practice in a community clinic – don’t worry about herbs (unless your state requires them), focus on Tan/Tung and get really good at Channel Theory/Channel diagnosis.

  2. When the eulogy of the American acupuncture profession is written, it will be the NCCAOM and many private acupuncture schools that should be held responsible for its demise. I am a recently retired acupuncturist after 25 years of practice. During those years, I also served on a state acupuncture society board, taught at an acupuncture school, participated as an examiner in the days of clean needle technique and point location practical exams, and went through the approval process to be an NCCAOM PDA provider. My opinions are based on all those experiences. In the 25 years I practiced, I am not aware of a single action taken by the NCCAOM that enhanced my professional life. The NCCA (OM) was and is supposed to be an organization that designs and administers an exam that sets the minimum standard for entry into the field. Every action and decision other than that,is and has been first and foremost in its own interest and secondarily in the interest of the profession. While many may disagree with me, they have become the de facto voice of the profession ( I believe by plan and purpose), They have convinced states that their exam must be used to acquire initial licensure (which is their mission and not a problem) and that certification must be maintained in order to maintain a license or move to another state to obtain a license. By constantly changing and making the recertification process more cumbersome complex and complicated they have in fact become the voice of the profession by setting the tone and expectation of what practitioners learn and even evolve into by deciding more and more specifically what constitutes continuing education. They claim to seek feedback from “stakeholders” but in fact practitioners are hostages. There’s no where else to go. Mr. Taormino’s quote as you report it, is a joke. I have seen so-called leaders (especially non acupuncturists) ignore any alternative points of view and strongly assert that they know what’s best for the profession. These are the same people who over time have pushed for and in many cases failed, all the while silencing opposition, to do the following: make a doctorate the entry into the profession, require herbs as part of the initial training as an acupuncturist, wasted time, money and energy unsuccessfully trying to fight off other professions from doing acupuncture instead of fighting for insurance parity and the list goes on.. It is not new that now they want to convince the profession that its future success is tied to Medicare and the broken American healthcare system. They have never been able to answer some of the most basic and important questions that practitioners might ask with regard to the pitfalls of participation (that other healthcare professions have suffered), yet are adamant about getting us onboard.

    These goals have been aided and abetted by many acupuncture schools whose primary interest is “behinds in seats” and secondarily the success of their graduates. The Venn diagram of schools and the NCCAOM has only a tiny little place that includes the actual profession.
    These battles have gone on for decades. I remember when a California contingency of mostly non-practitioners tried to assert their opinions on the profession and you spoke up and received some pretty harsh responses (as did I).
    I wish I had something positive to suggest or add, other than supporting your frustration and feeling very grateful that I got to practice this amazing medicine before it was destroyed largely from the inside. I gave up long before you did and I regularly mourn what has unfolded and continues to unfold.
    I have always said that acupuncture has survived for thousands of years, and regardless of ego and self interest it will survive here too ( sadly not how we hoped).
    It is my hope, that like the yin Yang symbol, this period of darkness transforms into a period of light where diversity of thought and actual practice are the norm.

    • I’ve been visiting with a colleague today and we were both expressing how lucky we felt to have been able to have a life in acupuncture in this slim window of time – when we could practice the richness of the medicine and make a decent living at it, and how we might just be able to make it out alive. Thank you for your comment. I really appreciate your input.

  3. Thank Elaine for your work and your writing. I just got an email from the ASA. They want to beat us over the head with their Medicare plan in exchange for a free PDA/CEU credit. Save the date, January 18th.

    • 1) It’s an interesting title — didn’t they just spend an hour telling us that the state of the profession was terrible and that where we were going from here was down the tubes? What are they going to say now — just kidding? Or just yell at us more?

      2) I won’t be listening. It’s time for a healthy boundary. I’ve given them enough chances to show up, show they care, show they can listen, show they are willing to accept some responsibility.

  4. Really beautiful Elaine! Thank you for this. It’s a sad state of affairs, but if sanity does not reign, what do we have left?

    • Seems like we might be doomed either way!

      All I’m asking for is some sign that the folks pushing for this are prepared for what happens if they win. Can they stop throwing their talking points at us and show us that they are ready? Can they make sure we have the information to make a good decision about opting out or participating? Can they let us know they’ll be ready if it looks like the opt out won’t be an option? All we’ve gotten so far is threats and fantasies.

  5. I’ve been so busy with family responsibilities and health challenges the last several years that I was largely clueless as to how bad things had become within our profession. I heard rumblings, and knew there was a lot of disagreement, but that’s about it. It hit me during the covid lockdown because I had the time to read up on things. I’ve seen how Medicare works via my experience helping my mom and brother maneuver through their own healthcare. It’s a mess, but then so is our entire healthcare system, generally speaking. Thank you, Elaine, for making your voice heard. I appreciate it!

  6. Amambuka, amambuka azothengisa izwe lakithi, izwe lakithi
    Amambuka, amambuka azothengisa izwe lakithi, izwe lakithi
    He was taken in the night
    Without any warning
    No time to hide or fight
    They came like the bees swarming
    The questions start to fly
    Will he break or will he defy
    Can he withstand the worst that is to come
    A child in a man’s clothing
    Resisting the fascist ploy
    The underground puts iron in the heart of any boy
    Swimming in a sea of pain, he knows this is the end
    He hears himself whisper the name of his best friend
    I never betrayed you, and I never betrayed the revolution
    I just didn’t want to die alone, I needed you to see me home
    And if I could save you, and if I could find a solution
    I would die a thousand times, to get you out of here
    Sharing the same cold cell
    Betrayer and betrayed
    An island with two frightened castaways
    Not a word is spoken,
    How can he explain
    Through swollen eyes they watch the dawn’s first rays
    It’s all over now
    They stand backs to the wall
    Waiting for the fascist’s sword to fall
    In the desperation of a young life about to end
    He turns before the bullet
    And forgives a friend
    I never betrayed you, and I never betrayed the revolution
    I just didn’t want to die alone, I needed you to see me home
    And if I could save you, and if I could find a solution
    I would die a thousand times, to get you out of here
    Amambuka, amambuka azothengisa izwe lakithi, izwe lakithi
    Amambuka, amambuka azothengisa izwe lakithi, izwe lakithi ( I never betrayed you )
    Amambuka, amambuka azothengisa izwe lakithi, izwe lakithi ( I never betrayed the revolution )
    I never betrayed you, and I never betrayed the revolution ( Amambuka, amambuka azothengisa izwe lakithi )
    I just didn’t want to die alone, I needed you to see me home ( Izwe lakithi )
    And if I could save you, and if I could find a solution ( Amambuka, amambuka azothengisa izwe lakithi )
    What more is there to say, we’re gonna die here anyway ( Izwe lakithi )
    Amambuka, amambuka azothengisa izwe lakithi, izwe lakithi ( I never betrayed you, I never betrayed you, I never betrayed you, never betrayed you )
    Amambuka, amambuka azothengisa izwe lakithi, izwe lakithi ( I never betrayed you, I never betrayed you, I never betrayed you, never betrayed you )

    Warsaw 1943 lyrics (Johnny Clegg and Savuka)

  7. The individual who sent me this wishes to remain anonymous. They have a history with other regulated health professions and have been involved with our organizations for some time.

    ” I couldn’t agree more.

    The Medicare and insurance questions really need answers. Prediction: This will not end well or as envisioned. Everyone wants that free lunch but few understand the costs associated with free.

    There’s also a lot of insurance fraud out there. One of my fertility patients decided to go in-network to reduce OOP costs. After exhausting those benefits, she returned to me and said the LAc was charging her BCBS insurance $1000 per session. Chiros did the same in the 80’s and 90’s and the ins carriers started capping fees with a global visit max. I look at rates set by NY Comp and they are ~$25/15 minute session. So we bill multiple segments. Is that what it’s about? Gaming the system. Don’t get me wrong, medical billers and hospitals do this too. Cat and mouse.

    I’m not sure how we got started down this road, and it’s not really a we/us since the (if I may call it so) profession has so many splintered groups all claiming to own the flag. The future of acupuncture looks bright, but not necessarily so for the LAc, MAc and DAc. Schools also got greedy since they would take any student who qualified for federal loan money, regardless of the student’s quality. I hear stories that would make your liver Qi rebel.

    Changing the direction of a ship with a history of moving in only one direction will not be easy. I do know that our ever increasing educational requirements and hours do little to make more competent practitioners. And other “needlers” from other professions, will be an increasing challenge as time goes on.

    It’s hard to say where this all fell off the rails, but it didn’t happen all of a sudden. And sadly, it may be too late to fix.”

    • Nothing we do in the legal/insurance space ends well or goes as predicted because we always expect the other players to play fair and we always forget that when money is on the line no one plays fair. There aren’t enough of us and we are not evenly distributed enough geographically to do what everyone seems to want to do.

      I’d also argue that, since more than 50% of us are practicing in NY, CA, and FL that things became too much about NY, CA, FL. The rest of the country, for the most part, doesn’t seem to exist.

      I’ve been saying for some time that unless an L.Ac. can go to any state, open a practice in any city, and in 2-3 years be profitable, as a profession we are not successful. MDs/DOs/DCs/PTs/NPs can all, for the most part, do exactly this – we cannot and we don’t seem to be motivated enough as a group to put aside the needs of the “big” states to address the issue.

  8. I saw recently there was an NCCAOM board seat open. I briefly thought about applying, but there was a requirement that prospective candidates had served on a board somewhere previously. I can see the argument that they’re wanting someone who knows how boards work, but this is exactly the problem – we don’t get any new thinking or new ideas.

    Prior to becoming an acupuncturist, I spend a great deal of time in the corporate world. One thing that people who’ve never been in that space may not realize is: there are multiple glass ceilings to promotion and one of them is “can this person demonstrate that they think like us?” If you can’t/don’t, there’s a point beyond which you cannot go. This is why leadership at these institutions appears stagnant and it’s difficult for them to adapt to changing circumstances. Acupuncturists, as a profession, are doing exactly the same thing.

    • Some years back (I’m old enough to have no clue whether it was 3 or 5 or 10) I did apply to serve on the NCCAOM board. I do have board experience. In the end they decided to go in another direction. And that is fine. I’m not confident I could have changed things from the inside either. Your description of life in the corporate world is spot on.

      It’s just so damn frustrating to hear one successful LAc after another saying — hey, I can’t find anyone to take over my practice, or come and work for me – they all have so much debt that they are demanding wages that I can’t pay. Or they have no way to buy my practice. And the response, year after year, is “I know, let’s figure out a way for you to make less!”

      • Yes, I have a similar problem with respect to finding L.Ac’s. I’m in an area of the country that is underserved, I have 3 clinics that need/want an acupuncturist and I’ve been trying to find people for almost 2 years. Even though cost of living here is low, and they’d be walking into a fantastic referral situation, I cannot find folks who want to move here. The ones who are interested in moving can’t without relocation assistance.

        What we need is some sort of loan forgiveness for moving to rural/underserved areas – similar to what MDs/DOs can get.

        I’ve never understood the push for insurance coverage. It doesn’t make any sense, especially in light of the fact that many conventional providers are looking for ways out – direct primary care agreements, concierge practice, and so on. Insurance coverage does not do anything to legitimize acupuncture or Chinese medicine, all it does is make sure we remain underpaid and under-utilized. With the exception of VA, I run an all cash practice and I’m fully booked week over week.

        • Even better than loan forgiveness, imo — making the education more affordable so that we don’t need so much forgiveness. We’ve increased the hours of education needed, even though we had a great safety record with much shorter training. We’ve convinced students they need herbs and a doctorate so they can treat anywhere they want. It does not need to cost so much to become a practitioner.

          In other professions, lots of direct patient care is provided by “medical extenders” with lesser training and lower wages. That’s how the insurance system can work. I see the MD for 10 minutes. Is that going to work for LAcs?

          • Agree it does not need to cost so much and definitely agree on herbs. I don’t/rarely use them, most practitioners I know don’t or rarely use them. There are only a few states that require herbal boards for licensure, so I didn’t see the point when I was in school and still don’t see the point now.

            I’m on the fence with the doctorates. On the one hand, I have one and, honestly, it has been a tremendous marketing tool. On the other hand, did getting it dramatically enhance what I was able to do or change my scope at all? No, it didn’t. I don’t think adding training hours solves our core problems. I do think changing what those hours consist of probably would help.

            No, 10 minutes with an LAc probably won’t work, but the reimbursement codes are built around 15 minute slices – is that any better? I spent some time learning acupuncture/Chinese medicine in China and the standard needle retention there is 30 minutes. In the US, with insurance, if I don’t change the needles half-way through, I’m only getting paid for the first 15 minutes of that 30 minute session. Not every plan/insurance company will allow E&M codes, so often I’m left holding the bag on the other 15. This is a big reason why I don’t take insurance.

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