A Level Playing Field

This was a comment to It’s Not Fair.  You can see the beginning of the exchange there.  Frank raises some great issues, so I’ve cut and pasted his comment below, along with my responses in italicsI’ll split it into a few posts to keep the length under control.

Frank writes:  Here is why I think we are not on a level playing field:

(I’m not a sports fan,so my analogy is probably off, but there is a difference between a non-level field and not knowing how to put together a team or play the game to your advantage.  My position is that while there are things that put us at a disadvantage we could still develop a winning strategy and a winning team. Underdogs can and do win.)

Exogenous factors  (All have endogenous aspects.)

1) Licensing. Not every state even licenses acupuncture, and of those not all include the scope of practice (herbs,nutrition, tuina) that people are taught in school. As far as I know, every state licenses PT.

If you haven’t seen my post about Scope, please read it. Most of our “leaders” don’t seem to understand the term, and, subsequently, we spend a lot of time and energy fighting unnecessary battles. A technique does not need to be specified in your legislation to be within your scope. Herbs, for example, are unregulated by the FDA and so anyone, including the check-out guy at the 7-11 can sell them.  (Check out the ingredients of Airborne, for example.)

Sometimes I wonder whether licensure has done more harm than good (a discussion alive in the ND community) but, accepting, for the moment, the conventional  wisdom that it is a good thing, shouldn’t we focus on licensure in all 50 states before pushing for Medicare coverage?  Shouldn’t we pay attention to reciprocity, agreeing on a mutually agreeable minimal set of requirements for licensure so that qualified and experienced LAcs in one state are likely to be able to practice in all states? (I’ll be posting more on this, but I find it tragic that within the profession we are setting rules that exclude so many of our colleagues!)

2) Money. PT is a $30 billion industry. A lot of the big clinics are funded with private equity money. They use aggressive Starbucks style positioning and can run clinics at a loss in hopes of pushing other big clinics out of business. Plus, they can fund advertising campaigns that make PT seem like a normative activity, and of course they can generously donate to candidates.

Yes, there are more PT’s and it is an industry. I don’t know enough about the specific business practices to comment, but I do know that many investors in PT practices are MD’s, powerful allies to have.  They also seem to have a strong national association.  Meanwhile we’ve got associations which have been promising they’ve turned the corner for years.  And we’ve spent so much energy fighting with other providers over our fear that they will “steal” our medicine that we’ve made enemies rather than friends (check out Love the Bomb). From what I can tell, there are enough people open to acupuncture that it is normative.  WebMD talks about it on a regular basis. Folks often report the great results they’ve seen when their pets receive treatment, for example. Our problem is that we have been unable to make good use of the positive buzz that is out there.

As for advertising, again, we have the money to do this, we just do it poorly. The AAAOM spent two years coming up with information cards that were intended to carry a positive message about our profession.  Instead, the first line reads — “Many healthcare providers are performing unlicensed therapies similar to acupuncture, but each state licensed acupuncturist has extensive training in an accredited college that ensures their dedication to providing excellent healthcare.”   We can’t even start on a positive note without casting aspersions on professionals who could be allies. This one sentence contains several inaccuracies/inconsistencies:  a) professions are licensed, not therapies, b) hasn’t the profession been arguing (foolishly imo) that these therapies are not similar to acupuncture but are acupuncture,and c)not all licensed acupuncturists graduated from accredited schools — it depends on the state and on whether they attended a US school. I’m no advertising executive, but that isn’t a helpful introductory line.  How many MD’s or PT’s (who could refer to us) would agree to display a card like that in their office?

It doesn’t take necessarily take big bucks to influence legislation — it does take a winning strategy, choosing issues wisely and building alliances whenever possible. We have not done that.

It’s Not Fair!!!

A Virginia colleague asked – “How is it that Chiropractors can do acupuncture and LAcs cannot do manipulations?”

Exploring why things are the way they are (here in Virginia, anyway) might help us move beyond the usual “we’re getting the short end of the stick again” attitude and could teach useful lessons about how the system works.

1)     How is it that DC’s can do acupuncture?

DCs, MDs, and DOs were doing acupuncture in Virginia, without incident, prior to licensure for LAcs. You can imagine the strong opposition that would have arisen from that powerful lobby if, despite our position that acupuncture was safe and effective, we now attempted to pass legislation that would have removed this technique from their scope. The role of regulation is to protect the public from danger, not ensure that people are limited to the “best” care. When the Dieticians introduce licensure legislation in Virginia (not yet successfully) – the Advisory Board on Acupuncture indicates that support of the Acupuncture community depends upon the LAcs retaining the ability to make dietary recommendations. The Dieticians might think our training in this area is grossly insufficient, but we can show a history of safe practice, and the state has no compelling reason to choose a winner and loser among professions in this case.

2)     Why can’t LAcs do manipulations?

The Virginia legislation specifically rules out PT, Chiropractic, and Osteopathic manipulations.  Since acupuncture training does not typically include Osteopathic, Chiropractic or PT adjustments, and since our exams don’t test knowledge of these techniques, it would have been difficult to counter the arguments of the existing providers that this should be excluded from our scope.  When the ND’s introduce legislation for licensure (so far unsuccessfully and not fully supported even within the ND community) the Advisory Board on Acupuncture always reports that support is dependent on language that would specifically exclude acupuncture from the ND scope.

If a Licensed Acupuncturist could show evidence of education in Tui Na manipulation techniques, included the technique in their informed consent, and was careful with insurance coding it would probably be acceptable.  A few years ago I would have suggested that a formal request be made to the Advisory Board to explore whether Tui Na manipulations were within scope. The board could have explored the issue and developed recommendations regarding education and documentation that would have put practitioners on solid ground.  However, our profession’s recent behavior regarding the PT Board’s similar discussions on TPDN have given our fellow health care providers many arguments they might be itching to throw back in our direction. You might want to check out Scope and Dry Needling for more background. This is probably not the best timing for requesting a formal ruling.


Survey, Part Two

I want to get back to the ASVA survey I mentioned in the “Know Before You Go” post. Again, I’m glad ASVA wants member feedback. And I don’t want to be that annoying critic sitting back and complaining. And, we need to analyze our options if we want to work smarter.

Imo, surveys are often worse than useless. Many issues are too complex for a simple yes or no, and without background it is all too easy come up with a knee-jerk answer that, when allowed to drive policy, can take us where we don’t want to go. (Definitely a problem not limited to the acupuncture world.)

Here are the other questions on the ASVA survey, and my commentary —

  1. Should ASVA support efforts to have “Acupuncturists” included as a provider in the Social Security Act?  (What efforts? Is some group preparing to introduce a bill? Have practitioners received any more information about what it would mean for us if we were succesful? What happened with past efforts and why would it be different now?)
  2. Should ASVA support the national effort to include acupuncture as a federally mandated essential benefit (EHB) through the Patient Protection and Affordable Care Act (PPACA)? (What national effort? Who is working on this? Wasn’t it determined that the states would determine their own EHB, and if they didn’t the Feds would rely on plans within a state?  What is ASVA talking about?)
  3. Should ASVA consider fundraising for the purposes of introducing state legislation to update the scope of practice for licensed acupuncturists in Virginia? (Is there a problem with the current scope? Does ASVA have particular changes in mind?)
  4. (The one I wrote about in the other post.)
  5. Should ASVA explore fundraising for legislative avenues to restrict other professions from practicing acupuncture in Virginia? (Really?!?!?!! Is there any chance that a majority of legislators would vote for a bill like this given the relative numbers of other professionals? What would our reasoning be — we want to maintain a monopoly? Do we think other professions will accept this? Might there be blowback?)
  6. Will you serve on a committee? (Well, good for them for asking.)

I suppose I’ll find out on Sunday whether members gave a knee-jerk yes, yes, yes (except for #6 of course). I won’t be surprised if they did.

Legislative battles are often messy and expensive and can take years of ongoing commitment. Last minute changes to legislation can be harmful. Could we use our limited resources in ways that would bring a more immediate and direct benefit? How about asking what sort of business support members could use? I often get questions about the legality of various billing arrangements, could the state association focus on finding answers? How about educating members about existing state regulations?

Legislation: Know Before You Go

Yesterday I received a survey from ASVA (The Acupuncture Society of Virginia). My excitement at being asked for my opinion quickly turned to surprise as I read the questions. Several deserve a post of their own. (The discussion is pertinent for other states as well.) Today I’ll look at “Should ASVA organize a grassroots campaign and fundraising to support the election of legislators that would be favorable to licensed acupuncturists in Virginia?” Perhaps it seems like a no-brainer to you — of course! Why not?

Here are my questions:

  1. What makes a legislator favorable to licensed acupuncturists?  If they think acupuncture is great and should be covered by insurance, but feel strongly that MD’s and DC’s should continue to provide acupuncture with short training, is that favorable?
  2. If our positions are unlikely to be amenable to MD’s, PT’s and DC’s, will any legislator go for support from the 400 Virginia LAcs without regard for the 34,000 MD’s, 7000 PT’s, and 1600 DC’s?
  3. Does their position on other issues matter?
  4. There are 100 Delegates and 40 Senators in Virginia – in how many races will we get involved?
  5. There are few open seats in any election year.  Do we support a challenger knowing that incumbents usually win and may bear grudges?  (In 2011 two Delegate races were won by challengers.) Does an incumbent need our support?
  6. In those two races each candidate spent about $500,000 on the race.  What is our best estimate of the amount we could raise and is it enough to have an impact?

What could we do that would be far easier? As individual practitioners we could know and support our state legislators and local candidates and be sure that they know us.  Make a few $20.00 donations over the course of a campaign to your local legislators (unless they are really awful, in which case support the challenger). Attend your Senator’s or Delegate’s Town Halls during the session and their Meet and Greets during the campaigns.  If you think they are decent, work for their campaign. Do what you can to educate them about our issues while making sure they know who you are and what you do. This is best to do when the legislature is not in session, as they have more time then. (Of course, if you ask them one week to get rid of the form that recommends a visit to a physician for patients because, after all, acupuncture is safe, and ask them the next week to make sure PT’s can’t do acupuncture because, after all, it puts the public at risk, it may confuse them.)

Making a difference in state politics doesn’t require a big campaign and, in Virginia and many other states, the acupuncture community is probably too small to be a special interest to be reckoned with any time soon. As individuals, though, we excel at building relationships. Build connections on a personal level and create legislators who are favorable to acupuncture — it’s the easier way.