Our Worst Enemy

How do you feel about a regulatory situation that increases the odds that patients will receive acupuncture from minimally trained, non-LAcs while making it difficult for extensively trained LAcs to practice?  Is it better or worse if it is a state’s very own LAcs who are creating this situation?

The Delaware Acupuncture Council recently refused to grant a license to one of the most excellent practitioners I know.  This Virginia LAc,  a NCCAOM AC Diplomate and a Nurse, has had a very successful practice for over 13 years.  She is a former president of the Acupuncture Society of Virginia and has studied Medical Qi Gong extensively for the past three years.  The three LAcs on the DE Council present for the June meeting refused to grant her a license because she does not have NCCAOM OM Diplomate status.  Although the Council was reminded that they could grant an exception, they refused to do so.

It appears that only one of the four LAcs on the Council has the full NCCAOM OM status and one has NCCAOM AC status.  A third LAc has no formal acupuncture education or NCCAOM status, holding a degree in ayurvedic medicine granted for overseas study. I could not discover any information about the fourth LAc on the Council.

Delaware passed legislation related to the practice of Acupuncture in 2008, which you can read about here.  The legislation required full NCCAOM OM certification, including herbs but included three caveats, as noted in the AT article:  1) acupuncturists practicing in the state at the time the legislation was passed, regardless of education and credentials, were grandfathered in;   2) the legislation did not interfere with the activities of other professionals who were allowed to perform acupuncture; 3) the Acupuncture Council was expressly allowed to waive the requirements as appropriate.

Remember – herbs are not regulated by the FDA, and products containing Chinese herbs are available in the grocery store (see Airborne), or on-line, and are available to the public without prescription or the involvement of any health care professional.

Delaware currently has about 35 LAcs serving a population of about 1 million people. According to my research, there are 9 NCCAOM AC Diplomates in DE, and another 6 OM Diplomates.  The decision of the Council only increases the odds that the people of Delaware will receive treatment from non-LAcs.

The way I see it, it isn’t the lack respect from the western world, competition from other professions, or inequities in insurance reimbursement that are the biggest problems facing the profession.  It is a system in which small groups of LAcs in various states have determined that more credentials and education are necessary, even for those who are already extensively trained in Acupuncture and Oriental Medicine. They work for laws and regulations that increase the cost and time necessary to obtain an acupuncture degree and limit practice opportunities for LAcs.  This increases the odds that the public will receive treatment from providers who are not LAcs.

With friends like this….


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© 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.

18 thoughts on “Our Worst Enemy

  1. I read your article and some of the comments and I am a little surprised. I practice in Delaware and at the time licenses were given away due to grandfathering, I was the only practitioner that had actually taken and passed the NCCAOM OM examinations. I understand the value of grandfathering, but some of those people should not have received licenses, thereby granting them the same status of much more qualified people. The Ayurveda guy that you mentioned being on the board actually granted himself a license, claiming that he learned acupuncture from his wife. That really bothered me, too.

    So, knowing their non-discrimination and leniency, I am surprised that they haven’t been giving out licenses left and right. I received paperwork about serving on the Acupuncture Advisory Council, and I threw it away because the whole thing became a joke. I worked with some other to get the legislation passed, and it became a joke.

    I do like that DE has higher standards than most states, requiring the Dipl. OM, and that can be argued against, but CA has even higher standards than that, requires more education, and has their own exam. Plus, they have way more acupuncturists than any other state, so it isn’t like people are being excluded. People work for it and get it. They earn it.

    The reason that DE requires the Dipl. OM. is because herbs are explicitly within the scope of practice. I think this is important for various reasons, and other states have that in their scope as well. However, if that is going to be in the scope, then people need the herbal training and some sort of mark of achievement, such as what the NCCAOM offers. Rather than requiring both the Acu and the Herb exams, the people from the Board of Medicine thought it would be better to require the OM exam because of the western bio-medical component. That’s fine, too, because the Acupuncture Advisory Council was given the right to grant exceptions, and in meetings that I had with them, they promised that they wouldn’t be exclusionary to long time licensed and credentialed practitioners of other States. In a way, I am surprised that are being that way, but judging how screwed up it all ended up being, I guess I am not really that surprised.

    • Thanks for your comments. Delaware has definitely not been lenient since the first folks got through. It would seem that some of the people who were grandfathered in have decided that no one else with their level of training should be licensed? It is a shame you didn’t consider serving on the council — the individuals serving on it have a great deal of control over what happens with the profession in the state. It can only be as good as its members.

      I’m not sure why you are in favor of the higher standards. Have the “lower” standards in other states harmed the public? Interestingly, there were more malpractice claims involving practitioners in CA between 2008 and 2012 than all the other states combined. Does all that additional training accomplish anything. I’m not even sure it is true that CA has higher standards — it just has different standards. That means folks who may already be well trained still need to spend more money and get more training — but that doesn’t mean they are better practitioners. The number of practitioners in CA probably has something to do with the size of the state, the long history of acupuncture in the state, and the population.

      As for it making sense to require the OM because herbs are explicitly in scope — that doesn’t really follow. Regardless of what is in a written scope, practitioners should not be practicing beyond their level of training. An LAc in DE isn’t required to recommend herbs just because it is in scope. Injection therapy is explicitly in scope in NM, but that doesn’t mean all LAcs need to get special training in it. Neurosurgery is in the scope for MD’s, but that doesn’t mean all MD’s need to get board certified in Neurosurgery. I think this points to our professions overall misunderstanding of scope.

      In any case, give your history with the council and your recollection that they said they wouldn’t be exclusionary, perhaps you could write a letter to the Council asking them to honor their pledge not to be exclusionary. They are reconsidering their refusal to grant a waiver at their meeting on December 12th, so there is still time>

    • Hi Brian,

      I just read your post and want to second Elaine’s suggestion that you write a letter to the Members of the DE Acupuncture Advisory Council and say what you said in your post – that the legislation was not meant to exclude experienced practitioners. The next meeting is Dec 12th, and there will be several Dipl. Acs. on the agenda who will be requesting that the waiver provisions included in the law be invoked by the Council Members. Thanks for your post.

    • Dear Brian,

      Thanks for your comments on licensing in Delaware. The council in my opinion has been exclusionary in their decisions. According to the minutes of their meetings, there have been eleven applications for licensure since June 2011; two were approved with a waiver of education, one was approved through apprentice grandfathering, and eight were denied. That’s over a 70% denial rate. Not a single acupuncturist who has applied for a license in the last two and a half years qualified for licensure without a waiver or grandfathering. Most of the applicants denied are NCCAOM Diplomates who have been licensed in other states for years. Is this really what the legislation intended?

      I’ve been following the last three license denials. Two have been practicing for over a decade, and at the next council meeting on Dec 12 in Dover they will have a hearing asking for a waiver. The latest denial, which happened at the last meeting, is an M.D., board certified in two western specialties, who graduated from acupuncture school in Maryland, took and passed the NCCAOM AC exam (how many docs do that?), is licensed as an acupuncturist in MD and DC, and practices acupuncture at the VA hospital in DC. The council denied her application. Really.

      Do you think there would be any interest in Delaware to make the law more fair to those who practice acupuncture only? There are many styles that don’t use TCM herbs (Japanese, French, Korean, European) which are taught at east coast acupuncture schools. There isn’t much diversity of styles in China, where non TCM styles have been historically suppressed. But I think we like freedom in America, and I believe that acupuncturists who find their passion in non-herbal styles should have the opportunity to serve the public.

  2. The Delaware acupuncture law and regulations that require NCCAOM OM certification discriminate against age and experience in practice, and create an economic hardship on those who were practicing before there even was an OM certification. (The Chinese Herb Certificate at Maryland University of Integrative Health is now 2 years, 24 weekends, $19,092 tuition).

    The law and regulations also discriminate against the 16% of NCCAOM diplomates who have formal training in styles of acupuncture from Europe and Asian countries that do not include the herbal medicine of the People’s Republic of China (percentage shown in the NCCAOM 2008 Job Task Analysis).

    The law and regulations limit licensing to only 40% of NCCAOM diplomates who have the OM certification. The other 60% do not qualify for licensing.

    So highly experienced acupuncturists do not qualify to practice acupuncture in Delaware, even though other professionals are allowed to do so. When I googled “acupuncture Delaware,” the first seven hits were chiropractors, not acupuncturists. Is it really safer for the public to receive acupuncture from a non-NCCAOM credentialed chiropractor than from an experienced NCCAOM certified Acupuncturist with 13 years of experience?

  3. I’ve heard the argument that the Delaware licensing requirements elevate the status of the profession in the eyes of the public and insurance companies. I think the insurance company argument here is a red herring. Insurance companies don’t care if I am certified to practice herbs, since they don’t have benefits for herbs. In my experience insurance companies are interested in what research shows about the effectiveness of acupuncture and whether it is medically necessary for a patient. If every acupuncturist in the country gets certified in herbs, I doubt it will make a bit of difference in elevating the status of acupuncture in the eyes of insurance companies. To compare with another profession, physical therapists recently changed their entry degree from master’s level to a doctorate, and I doubt that it elevated their status or changed how insurance covers physical therapy.

    I also think the public argument is a red herring here also. I don’t think my patients especially care if I am nationally certified in herbs or not. They care if acupuncture can help them. What raises our status to the public is being safe, effective and professional. To compare again with physical therapy, I doubt the ordinary PT patient has any idea that the newer PTs how have doctorates or what that even means.

    I’ve also heard the argument that the Delaware board is merely attempting to make it safer for clients of Chinese medical practitioners to receive appropriate herbal treatment when herbs are in the scope of practice.

    As for patient safety, it would be equally safe for patients if the herbal certification was required for prescribing herbs, while the acupuncture certification was required for performing acupuncture, as in Massachusetts. Simple.

    I’ve been practicing for 24 years and have performed at least 15,000 successful treatments. Of course I cultivate my knowledge and safety every year, but I don’t believe that I need to be able to prescribe herbs in order to be a safe and effective acupuncture practitioner. If the requirements are unified around the country to match Delaware, I wouldn’t be able to move out of Maryland and still be able to practice.

    Then there is cost of the herbal education. The tuition cost for the Maryland Institute of Integrative Health two-year Chinese herbal certificate program is $19,092.00!! It’s nuts that I need to spend that money (at the age of 66) in order to be licensed to practice acupuncture in Delaware. Further, why should new acupuncturists have to spend that much money in order to be able to set up an acupuncture practice and start helping people?

    When did it happen that deeply cultivating the skill to do acupuncture isn’t enough?

    • The arguments about being elevated in the eyes of the public and about what the insurance companies want are especially interesting in light of the profession’s concerns about dry needling. If the arguments are correct, why are we worried about what the PT’s are doing. And even within our own profession, wouldn’t these arguments be proven by letting the market decide?

      If we can’t trust our colleagues to be wise about what modalities they practice then we’ve got bigger concerns than “insufficient” educational and credentialing requirements. One thing I’ll be taking a look at in the future — what sort of helpful standard-setting could be undertaken before people start or graduate from acupuncture school. If we don’t trust a person’s professional judgment I’d rather tell them that before I separate them from tens of thousands dollars of tuition $.

  4. Sometimes it’s very hard for people who became acupuncturists because they wanted to spend their time treating patients to even know about pending legislation and regulatory actions, let alone take time out to fight against laws and policies that hurt them professionally and restrict the public’s access to acupuncture. Most professions have a national organization that tracks both state and national legislation and regulatory changes that could affect their profession and lobbies and organizes against restrictions pushed through by special interest groups. Unfortunately we don’t have such an organization, and the result is that other professionals with little to know training can practice acupuncture (sometimes by calling it something else) far more easily than a full trained acupuncturist. Sigh.

    • It’s true. The crazy patchwork of rules that keep experienced and expert practitioners from moving from one state to another cannot be good for a profession, and is certainly unknown to many recent graduates. Seems like this should be a no-brainer focus for a professional organization. And something that Acupuncture Today should be writing about.

      It seems that our organizations prefer to spend time and energy complaining about how other professions are regulated — something it is very difficult for us to change, rather than trying to ease things for those within our profession — something that we can change.

  5. The Delaware Acupuncture Council ALSO denied licensure to a Maryland NCCAOM- certified L.Ac. Not only does this L.Ac have 13 years of experience as an acupuncturist, she has served for over a decade as adjunct faculty at an accredited school of acupuncture (the same school that one of the Delaware Acupuncture Council members attended). Her other background includes 30 years in psychotherapy practice as a Licensed Social Worker and continuing education in using psychotherapy with acupuncture to support victims of trauma. Again, it is difficult to understand how denying this L.Ac. the ability to practice in Delaware is in any way serving the safety, needs or interests of the DE public.

    • I can’t think of any reasonable explanation for why these licenses weren’t granted. That the folks making the decision are acupuncturists themselves, in some cases with less training than the applicants, is infuriating.

  6. I would encourage any state revisiting old or creating new acupuncture legislation, and is using NCCAOM standards, to make sure BOTH Diplomate of Acupuncture AND Diplomate of Oriental Medicine are recognized as adequate certification. A fine point, but so important to those who choose to study only acupuncture or who have the older version of Dipl Ac plus a separate Dipl Chinese Herbs (as I do) instead of Dipl OM. Please be very careful when writing your laws. Once they are done they are hard to change.

    • Makes sense, Kathleen. I believe it was the DE Medical Board that pushed for the herbal requirement in the DE legislation, and that allowing for exceptions was a way to take care of those who might not meet the requirement. I don’t understand why the current board members, the majority of whom do not meet the requirements, would be so resistant to granting the same consideration to their fellow practitioners.

  7. Elaine, in your experience is what happened in Delaware typical of most states? Is this the direction that most State Acupuncture Council’s – or regulatory bodies – are going in? Is there a history here?
    AND moreover, what, if anything can be done?

    • One of the difficulties in our profession is knowing what the situation is on a state-to-state basis, so I can’t say for sure. I don’t believe most states expressly give the board/council the ability to make exceptions, so having that ability and not granting it might be exceptional. That being said, I do know of cases when it is acupuncturists themselves who are making it difficult for other acupuncturists to get licensure in a state. For example, Virginia requires active NCCAOM diplomate status. Not all states do, and so even LAcs who did get NCCAOM status but then let it lapse might have to re-test depending on how long they allowed it to lapse. The Virginia Advisory Board recently discussed changing the regulations to require only initial NCCAOM status. This is the case in other states, and other professions regarding their board exams. It was the majority of the LAcs on the Board, and the state association, that did not support making this change.

      Additionally, the situation with herbs being accessible to the public without the input of any provider is the case across the country. So, any state that requires LAcs to have herbal certification for licensure or to recommend herbs is creating only one class of people — other LAcs, who are limited in doing so. This requirement is typically pushed by our colleagues.

      As for what can be done — letters to the DE Board seem appropriate. Personally, I will mention that refusing to license practitioners whose credentials meet or exceed those of current board members is hardly protecting the public — which should be the only concern of a regulatory board.

      • One other thing that can be done — letting the legislators and Governor of DE know that the Board’s actions do not serve the public or the profession. This is especially helpful coming from people who own property in the state. In most states, the Governor appoints the people who serve on the Boards, often at the recommendation of Legislators. Different board members might have different opinions on the wisdom of excluding qualified practitioners.

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