The Center Cannot Hold: Another Acupuncture Association Spins Apart

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!)

 

Insurance, Again. The s**t got real.

Photos of an acupuncturist in a prison jumpsuit, bond reduced to $455,000, facing charges of racketeering, insurance fraud, engaging in an organized scheme to defraud, patient brokering, and unlawfully waiving copays and deductibles. It’s bad for the profession.

It’s worse when the acupuncturist taught insurance billing seminars.

Whether or not she is ultimately found innocent, I’m sure none of us want to be in her shoes. Let’s learn what we can from the case, and from the discussions about it happening on social media and elsewhere.

(Here are additional stories about the case: Indian River Meeting MinutesMarch 2017August 24, IRC MemoFlorida CFO, September 13)

My takeaways –

  • There are wonderful, respected, kind, people who engage in criminal activity. Encomiums about the accused show us humans aren’t one-dimensional, but are irrelevant to guilt or innocence.
  • Insurance billing is no game, despite books, seminars, and conversations presenting it as one.
  • As a profession (the community acupuncture folks being the main exception), we haven’t accepted the conflict between wanting people to get as many acupuncture treatments as we think appropriate/they desire, earning what we “deserve”, practicing in our preferred style, and the overall health care economy. We grabbed insurance as the savior. It isn’t.
  • It is easy to rationalize wrongdoing. Practitioners justify creative billing to help their clients or counteract an unfair system. That’s bad for our profession, personally risky, and, because “insurance money” comes from people buying insurance, ultimately costly to anyone buying insurance.  If a plan doesn’t cover acupuncture for depression, explaining that to your clients, and giving them a discount if you’d like, is honest. Believing that the insurance company is forcing you to figure out a way to “treat them for pain so it gets covered” is dishonest.
  • If you want to advocate for better coverage, be prepared with data to show the economic benefits. Do you want your premiums to cover other non-medically necessary choices? Who should decide?
  • We need to be honest when discussing the efficacy and cost of acupuncture. Many practice websites, and much of our lobbying for increased coverage, refer to a course of treatment of eight to twelve visits. If an average of almost forty treatments/year, as in this case, is appropriate “for today’s complex patients” (as many commenters stated) we need to own that. If it varies based on condition (of course it does), let’s make sure we let patients and insurance companies know. If you are treating for a complex condition, but code for a simple one to facilitate reimbursement, you’re skewing the data about acupuncture efficacy.
  • There are lots of acupuncturists eager to give definitive answers to questions outside their area of expertise. Having a successful insurance-based business does not make one an expert on insurance law.
  • Our burdensome systems for approving CEU/PDA classes don’t provide quality control.
  • Having demanded entry to the system, we owe it to ourselves (as consumers and providers) to speak up when we see wrongdoing. We need to acknowledge that our colleagues who review charts and advise insurance companies are necessary if we are going to be part of the system. It’s a bad sign when those within the profession who work to protect the consumer are dismissed as the enemy. The insurance companies will find problems even without our participation.
  • Context is important when determining legality. Patterns of individually legal actions (in this case, waiving co-pays was permissible) can add up to illegal activity.

Here’s more on Health Care Fraud – from an investigator.

Being a health care provider is serious business. Participating in the insurance system is serious business. Let’s be careful out there.

 

(And the sad conclusion of this case, July 29, 2020.)

We have met the Enemy

It’s not paranoia if they are really out to get you.

Our siege mentality is understandable. Doc Hay was charged with practicing medicine without a license in the early 1900’s, as was Miriam Lee in 1974. In some places we’re still seeking legal recognition of our right to practice. It’s not unusual to read that acupuncture is quackery.

So it’s not terribly surprising when multiple participants in an official government meeting announce that your practice is a danger to the public and that the NCCAOM Acupuncture credential is insufficient. It’s not the first time we’ve heard that it would be better for the public if we were excluded.

But it’s different when the people saying these things are Acupuncturists.

It’s shocking. And upsetting. And bad for the profession.

We complain about PT’s, Medical Acupuncturists, insurance companies and even the perceived disrespect of some of our clients. But those groups aren’t building coalitions to restrict our ability to practice, or to put hurdles in the path of new practitioners. I can imagine the outrage and the calls to action if they did.

Instead, it’s Acupuncturists who are on the record (warning audio autoplay) slandering colleagues and attempting to slow growth of the profession.

Our safety record and our well-established and generally respected educational and credentialing systems don’t seem to matter. Nor are these Acupuncturists concerned about our small numbers or student debt.

Why is this happening? One school that is concerned about student debt, accessibility, and the growth of the profession, asked ACAOM and NCCAOM to reconsider the hourly requirements for acupuncture education and sitting the credentialing exams. There was no move to lower standards (read more here) or change competencies, only to use the same hourly requirements that served our teachers and most experienced practitioners so well.

ACAOM hasn’t responded to the proposal, and NCCAOM did not respond favorably (NCCAOM Response Ltr to POCA Board 11-9-17 Final with signatures.doc). But members of Utah’s Acupuncture Advisory Board and the Utah Association of Acupuncture and Oriental Medicine were so upset by POCA Tech’s request that they launched a preemptive strike, moving to require the NCCAOM herb credential of all practitioners, whether or not they want to use herbs.

Listen, and ask yourself – how does this help our future?

By the way –

The participants’ claim that this is a clarification of existing law is “alternative fact.” The evidence shows that the Utah action is in direct response to the POCA Tech proposal, and the representative of the Department of Professional Licensing makes clear that existing law would not support this action.

In a prior meeting a board member insisted that there is no need to require specific education or curriculum for practitioners who use injection therapy, since acupuncturists know their limits. The same board member argues here that all practitioners need to obtain the herb credential. (The board member performs injection therapy.)

The exemption of those already licensed works to undermine opposition to changes like this. Don’t be fooled – increasing debt for the next generation of practitioners isn’t good for our future, even if it doesn’t impact your ability to practice.

The Advisory Board and the Utah Association, with the help of the NCCAOM, promoted the Board’s proposed changes. The letter (UtahNCCAOMletter) they distributed is inaccurate. For example, a growing number of states are not requiring the herbal exam of all practitioners, and acupuncture and Chinese Medicine have not always been inextricably linked.

A letter written by a professional association, signed by the Chair of the Advisory Board, and distributed and supported by the NCCAOM (which would benefit financially from the change) raises significant ethical and good governance concerns.

The NCCAOM’s message in the February meeting – that they defer to the will of the profession – is a questionable position for a credentialing agency. It also differs from their position in cases where the will of the profession was for changes not in NCCAOM’s interests, such as a state removing the requirement to maintain active Diplomate status.

There’s good news – the Utah Advisory Board can’t add a requirement for the herbal credential via regulation.

There’s bad news – the parties involved seem eager to pursue legislation to make this change.

There’s terrible news – the enemy is us. It isn’t the PT’s, MD’s, or insurance companies undermining Acupuncturists. It’s Acupuncturists.

 

Ethical Questions

Our future requires a willingness to explore beyond our quick conclusions of what is “right” and what is “wrong.” How do we proceed when two “rights” are in conflict with each other, or when a good end might depend upon a questionable means (or vice versa)?

Providing safe, effective, and accessible treatment to everyone who wants/needs treatment while also supporting ourselves and our families requires us to face various ethical quandaries. Many ethics classes are short on teaching principles to guide ethical decision-making and are long on lists of rules like “don’t have sex with your patients.”

Marilyn Allen’s recent column on ethics demands our attention. She’s had a significant role in shaping the acupuncture profession, and she teaches ethics. She has power.

The column focused on a discussion about “gainful employment” that has since been removed from the AAAOM practitioner forum.

The forum included colleagues sharing concerns about their debt, and upset at schools that exaggerated the future acupuncture job market while glossing over the skills and financial backing needed for success.

Ms. Allen (who has given considerable funding to the AAAOM over the years) is angry that this discussion was permitted. She insists that it is in the best interest of the profession, and our future colleagues, to keep concerns to ourselves. Even a shared conversation in a practitioner forum is too risky. We “should have shown support for the schools,” she writes.

Ms. Allen proposes the Rotary’s Four-Way test in her column. It’s not my preferred guideline for ethical decision-making, but since she refers to it I’ll use it —

 

1) Is it true? Many graduates of acupuncture schools do struggle to pay off debt. Schools did use misleading data in promotional materials, leading to unrealistic career expectations. The proposed Gainful Employment regulations did raise concerns about acupuncture programs. The forum topic is no longer present to allow for a complete fact check, but my assessment is that much of the content was true.

2) Is it fair to all concerned? What do we mean by “fair.” Who is “all concerned?” And what is “it?” I could write a post on each question. When a topic is being explored by many people, in many settings, does each contribution need to reflect the views and feelings of each stakeholder? Is it unfair to share our personal experiences and opinions about a system in which we have little power and bear the consequences? Is it fair for a membership association to solicit the opinions of its members? My assessment – it was fair for the AAAOM to provide a forum and for practitioners to use it.

3) Will it build goodwill and better friendships? Humans do better when we know we are not alone. Sharing our concerns and our experiences is a way to build community and friendships, which support us in our sometimes isolated professional life. Knowing that other regulated fields share these concerns can also help build goodwill and understanding. If we feel that a friend (or, in this case, a system) is taking advantage of us, does it strengthen the friendship and build goodwill if we speak up, or stay quiet and suffer? Yes, the discussion had the potential to build friendships and goodwill. Ms. Allen’s column, by advocating denial and repression, does not.

4) Will it be beneficial to all concerned? My list of people who would benefit from the conversation, even if it escaped the private forum: current debt holders who feel alone and unheard, schools who care whether graduates are satisfied, potential students who may not have fully explored the economics of entering their dream career, and taxpayers who may not want to subsidize ineffective programs. The discussion isn’t beneficial for the schools that want to keep raking in loan money while avoiding responsibility. Should we be censored for their benefit?

Ms. Allen writes “It is sad when you read an article about the profession that contains negativity coming from inside the profession. Essentially, this is giving the other professions (those looking to treat acupuncture patients) the ammunition they need to diminish acupuncture and attain their own goals.

I say, it’s sad when those with the power to change things for the better instead advocate for a flawed status quo. It’s a danger sign when secrecy is demanded for the good of the group. The Catholic Church and the Penn State Football program are examples of the moral failure that comes with that argument.

Thank goodness we’re dealing with finances and not child abuse. Nonetheless, shutting down conversation and preaching secrecy is neither ethical nor effective. If Ms. Allen wants to uphold acupuncture as the place “where hope and healing meet” then we need to delve into our challenges, not hide them.

 

 

Success is Accessible!

When choosing or upgrading your office there is one consideration that will have a profound impact. Prioritizing it will help you —

  • retain clients for decades
  • appeal to clients who need your services regularly
  • decrease the need to make house calls
  • contract with insurance companies
  • participate in federal programs (such as Veterans Choice and ACA plans)
  • gain respect and referrals from other health care providers
  • keep your office in one location for the duration of your career
  • reduce legal threats
  • minimize workplace injuries to you and your staff
  • comply with civil rights law.

It’s a win, win, win, win, win, win, win,win, win, win.

That consideration is compliance with the Americans with Disabilities Act of 1990 (ADA), a federal civil rights law that prohibits discrimination against individuals with disabilities in every day activities, including medical services. Any private entity that owns, leases or leases to, or operates a place of public accommodation (that includes your office) is responsible for complying with Title III of the ADA. (Source – DOJ/HHS Publication)

19% of the US population reported having a disability in the 2010 census.

If you are blessed with good client retention and a lengthy career your patient population is likely to increasingly include those with disabilities. You might develop your own temporary, or permanent, mobility issues.

Acupuncture schools need to teach students about our responsibilities under the ADA. Ethics classes should address the de facto discrimination that occurs when we choose inaccessible work spaces. And, when practitioners seek advice from peers about potential office arrangements, renovations, or accommodations (such as interpreters) emphasis should be on the legal, ethical, and practical benefits of compliance. Preemptive absolution is offered too often, especially by those who don’t understand the law.

The ADA does include exemptions to protect small businesses from accommodations that would be an “undue burden.” Is a $2,000 lift table an undue burden? How much have you spent on Biomats, lasers, tuning forks, and travel to conferences? Rent for a first floor office might be more, but house calls also affect your bottom line. (If you rely on house calls to comply with the ADA requirements for accessibility, remember: you can’t charge more, you must offer the same level of service, you have to offer flexible scheduling as you would to your in-office clients, and, if you are accepting new clients it is discrimination not to accept those whose disability would make your office inaccessible.)

It’s true, individual practitioners who don’t comply are unlikely to suffer legal consequences and many Practices flourish despite a lack of accessibility.

“Getting away” with not complying is no way to run a business or a health care profession. Doing all we can to meet the needs of those with disabilities is good business, good for the profession, and good for the public. It should be a top priority.

Here are some resources to help you understand the ADA and our responsibilities —

Access to Medical Care for Individuals with Mobility Disabilities

Americans with Disabilities Act Title III Regulations

Title III Highlights

ADA Q & A for Health Care Providers

ADA Checklist for Existing Facilities

ADA and Small Businesses

NPR Story about Accessing Care for People with Disabilities

Post on California Law impacting Lease negotiations

ADA Enforcement Activities

ADA in a Health Care Context

ADA for Deaf and Hard of Hearing

Acupuncture Exceptionalism

American Exceptionalism is the idea that The United States of America is inherently different from other nations. That our founding and background gives the US a unique mission to transform the world and a superiority over all of other nations.

I’ve recently noticed that practitioners of Chinese/East Asian Medicine have their own version of this, which I call Acupuncture Exceptionalism.

The attitude of exceptionalism skews the interpretation of events. Our own actions are given the benefit of the doubt and ascribed to the best of intentions. The actions of others are considered with a critical eye.

Some examples of Acupuncture Exceptionalism:

We regularly advise clients regarding vaccinations, pharmaceuticals, procedures, and dietary plans suggested by other health care providers. When other providers advise about acupuncture and herbs we are outraged at their presumption.

We widely share studies and news reporting positive results from acupuncture treatment. Studies and news showing a negative outcome are dismissed because “they aren’t doing it right” or didn’t tell the whole story.

When a patient reports harm from “Western medicine” or a treatment done by a non-LAc we rant about the failings of the system or the provider. When a patient reports harm after a treatment provided by an Acupuncturist we find ways to deny that harm occurred, find another cause for the situation, or place responsibility on the patient.

We encourage patients who have been harmed by dry needling to report it to the authorities, and if they won’t we will. We are shocked and angry when a patient files a formal complaint pertaining to treatment received from an Acupuncturist.

We complain that PT’s are engaging in insurance fraud by using the Manual Therapy code for Dry Needling. We justify the use of pain codes for every client, because, well, everyone has pain and, after all, the system is stacked against us.

We are furious that other professions are using “our” medicine, especially without what we determine to be appropriate training. We add homeopathy to our scope without a second thought.

We support and celebrate a lawsuit filed against a PT Regulatory Board as an appropriate defense of our profession. We are outraged when a counter-suit is filed against our board.

 

An attitude of American Exceptionalism does not increase the standing of the US in the eyes of the world. You can’t learn from mistakes when they are denied or explained away. Hypocrisy and double-standards impress no one.

Likewise, Acupuncture Exceptionalism does a disservice to our medicine and to our future as health care providers. If our medicine is powerful enough to help people, it is powerful enough to cause harm. Denying risk puts our patients and our profession at risk. Dismissing valid concerns about acupuncture and herbs from other professionals prevents us from establishing collaborative and respectful connections. If we want to improve our skills and training and service, we must take a clear-eyed look at where we are succeeding and where we could do better.

I’m confident enough about the benefits and overall safety of this medicine that I’m not afraid of looking inward with a critical eye. Are you?

 

 

NCCAOM Code of Ethics & Grounds for Professional Discipline, Part II

The NCCAOM’s call for comments on the Code of Ethics and Grounds for Professional Discipline ends September 12, 2015 .We owe it to ourselves and our profession to share our thoughts with them.

Here’s what I’ll tell them —

Dear NCCAOM,

Thank you for the opportunity to comment on the Code of Ethics and Grounds for Professional Discipline. My significant concerns with these documents can be traced to three overarching issues —

  1. The NCCAOM credential is required to maintain state licensure for many acupuncturists. You advocate for this arrangement. Yet the current Code of Ethics is more suitable for a voluntary exceptional standard adopted by choice.
  2. States that require NCCAOM credentials have their own regulatory boards, ethical codes, and disciplinary process. The NCCAOM Grounds for Professional Discipline empowers you to pull a practitioner’s credential, removing them from practice, even when a state board would allow continued practice for the same violation. This turns the NCCAOM into de facto regulators and creates double jeopardy for practitioners.
  3. The NCCAOM reserves the right to take disciplinary action against any practitioner who violates the Code of Ethics. The Code covers behaviors ranging from serious threats to the public safety to those in the realm of Public Relations. The NCCAOM should explicitly limit the use of disciplinary action to violations that risk the public safety.

A few specific examples —

  • “Exceeding the scope of practice as defined by law or certification” is grounds for discipline. Scope is defined by the state, and may not be accurately determined by written language in code or regulation. Since state regulatory boards ultimately rule on whether or not a procedure is within scope, and since that board would determine proper discipline for any violation, no action from the NCCAOM is needed. References to scope should be removed from the NCCAOM document.
  • “I will continue to work to promote the highest standards of the profession” is listed in the Code. Must practitioners promote the FPD or DAOM, the addition of herbal exams to licensure requirements, and the expansion of the NCCAOM credential requirement to all states? Who determines the highest standard? This language is coercive at best.
  • The Code of Ethics requires credential holders to report peers who violate the Code. It is untenable to expect Diplomates to report every peer in violation of any aspect of this far-reaching code, and it is unfair to wield the power to hold us responsible for any failure to do so.

I support rigorous professional ethics and respect the NCCAOM’s intent to establish high standards for the benefit of our patients and our profession. However, your role for the profession is to validate entry-level competency. Much of the current Code of Ethics and Grounds for Professional Discipline goes far beyond this role. Continued overreach into areas best left to regulators and voluntary affiliations puts at risk the NCCAOM’s position as a credentialing organization.

Thank you for your consideration of these comments,

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

Those of you who would like more background on the role of the NCCAOM in our profession should look at Part I of this post.  I encourage those who are interested in another viewpoint of the NCCAOM and its impact on the profession to review these comments and consider signing this petition.