Monthly Archives: November 2013

Acupuncturists and Medicare, Questions for the AAAOM

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I’m thankful I spend my days helping people. I’m grateful I’m my own boss and that I’m able to treat every client as a unique, complex, individual, not as a diagnostic code. I could write a whole post on what I’m thankful for, but, this coming Sunday, it’s time for another AAAOM Town Hall. There are other things I’d rather be doing the evening of December 1, but I plan to participate, and I hope you will too. So, before we head off to sweet potatoes and cranberry sauce, here are my questions for the AAAOM —

  • Given the current political climate and the current level of involvement from the profession, what are the odds these bills will be successful within the next 5 years.
  • How many LAcs intend to become participating providers in the Federal Health Programs?
  • Does the small number of contributions from practitioners to the AAAOM legislative fund indicate that this effort is not a priority for the community?
  • Given that there are fewer than 30K active licensees in the US, and that not all will participate, could legislative success benefit other professionals who use acupuncture more than it helps LAcs?
  • Do the Medical Acupuncture and the Chiropractor communities support this legislation? Will they participate in the legislative effort?
  • Many LAcs treat Medicare beneficiaries. If acupuncture becomes a covered service won’t LAcs who opt-out lose most of that portion of their clientele to providers choosing to participate?
  • How many LAcs are providing acupuncture via the Medicaid system in the five states that permit it?
  • Is it possible that the opt-out provisions could be stripped as part of the legislative process (related to the small number of potential providers)?  Would the AAAOM be able to stop the legislation if that happened?
  • Can you clarify the distinction between enrolling, participating, and opting in?
  • On page 8 of the FAQ it refers to patients falling into the opt-out exceptions.  Is it providers or patients who opt out?
  • On page 10 of the FAQ it states that the legislation will not require LAcs to use electronic medical records.  Is it true that participating providers will be penalized a percentage of their reimbursements starting in 2015 if they do not use EMR’s?
  • If you opt-in, and the beneficiary reaches the limit for their number of treatments and/or wants treatment for a condition that isn’t covered, are you able to treat them and bill them for those services?
  • If you opt-out could you still treat Medicare beneficiaries who have surpassed their treatment limit without impacting their future benefits?
  • If opting-in, can practitioners limit the number of Medicare beneficiaries they accept as clients?

There are other things the AAAOM could focus on that would be more helpful to the average LAc and be more likely to succeed. But this Town Hall is limited to the AAAOM legislative efforts. I am thankful they are asking for input, and I will oblige.

Happy Thanksgiving everyone — and thanks for reading.

LAcs = Tea Party & Acupuncture Today = Fox News?

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The threat to acupuncture from dry needling is like the threat to “traditional” marriage from gay marriage. That is, the real threat is our obsession with the issue and our willingness to make any argument, no matter how ridiculous, to keep people from connecting with the provider of their choice.

Despite thousands of years of experience and a big head-start, we didn’t establish ourselves as the undisputed experts of this method of pain relief. Having failed to convince the PT Boards that PT’s performing dry needling is a danger to the public, or that LAcs should get to determine the appropriate training for this technique, we are now arguing that we’ll accept it, as long as it hurts.

The November 2013 issue of AcupunctureToday included Dry Needling: Averting a Crisis for the Profession, here is my response to AT —

Dr. Amaro’s “obvious solution” to Dry Needling, that PT’s be judicially mandated to use a hypodermic needle, is awful. Has it come to this? Despite our 2,000+ year head-start our plan for success is to require other providers to use a tool that causes tissue damage and pain? There is no non-political reason for a board to require its licensees to use an unnecessarily harmful tool. To present it as a possibility is an embarrassment to the profession.

While some auto insurance and worker’s compensation will reimburse for dry needling, for the most part Trigger Point Dry Needling is not a billable service when performed by a physical therapist. It is considered “experimental and unproven” by Medicare and major medical insurance companies. And, if it were true that PT’s were getting rich on reimbursements for this technique, is that an argument against allowing them to perform an effective procedure? Don’t we support people getting relief from pain, regardless of who is paying the bill?

It would be tragic if we were successful in requiring everyone using a filiform needle to use the term acupuncture while losing the battle to prevent non-LAcs from performing the technique. Given various rulings of state AG’s, and of the regulatory boards responsible for other professions, this is a strong possibility. Then, we will have lost our ability to distinguish what we do from what others do. (And, ironically, would help PT’s obtain reimbursement.)

We had decades to establish ourselves as the experts in this technique. We didn’t, and, frankly, many of us are unpracticed with it and uninterested in making it a major part of our clinic offerings.  Addressing unfair reimbursement scenarios is reasonable. Respectfully presenting evidence-based concerns about risks to the public is part of our civic duty. Our ongoing panicked response to TPDN, with arguments based on misinformation or a misunderstanding of such basic topics as scope and the regulatory process, culminating in the argument in Acupuncture Today – that it’s okay as long as it hurts –  is the real threat to our reputation and our future.

I encourage you to read all of my posts on this topic (you can get them via the categories or tags on the homepage) and on scope of practice. It is time for the acupuncture profession to stop shooting itself in the foot.

Health Insurance for the LAc — Important Point #1

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Insurance does not create money, it redistributes it. The money coming in via premiums or taxes must be equal to or greater than the payments for services and the expense of the bureaucracy (whether government or private) that manages the system. (With government programs we have chosen to ignore the imbalance between what is coming in and what goes out. Eventually, we’ll have to face it.)

The system depends on lots of healthy people paying in more than they get back in services. That offsets the folks who need lots and lots of care.

Here are some costs (yes, this term can mean a lot of different things):

  • Type 2 Diabetes — Annual Medical expenses of $13,700 with $7,900 attributed to diabetes.
  • High Blood Pressure — costs of $733/person in 2010.
  • Stroke — Average cost for first 90 days after a stroke is $15,000.
  • Breast Cancer — Average annual cost of $22,000 to manage the early stages with management of stages 3 and 4 costs in excess of $120,000.

Some of the ways insurance companies made sure they took in more than they paid out:

  • limited the amount paid out over a lifetime — reach a million and you are on your own.
  • refused to cover pre-existing conditions — your diabetes will cost a lot, so we won’t cover it.  (This also kept people from waiting until they were sick to buy coverage.)
  • charged “sick” people significantly higher premiums — you have diabetes and HTN likely to cost $1000/month, so your premiums will be $1300/month.

Most of us were bothered by these limitations (especially when we think of individuals – your patient, your cousin). The PPACA eliminates or greatly limits these practices — you can’t be denied coverage for pre-existing conditions, there are no lifetime limits for EHB, and premiums are determined by age and type of coverage, not medical status. These changes force the companies to pay out more per person, and limits what they can take in per person.

To keep premiums from being unaffordably high many healthy people need to pay into the system. This is why the PPACA requires everyone to buy insurance or to pay a penalty.  It is also why the system collapses if everyone expects to get services equivalent to (or greater than) what they pay in premiums.

If someone pays a $150 monthly premium and expects to get ten acupuncture treatments/year, and you “deserve” $700 or more for those treatments, there isn’t much left to cover the bureaucracy or the costs of their neighbor with cancer, their father who just had a stroke, or their own colonoscopy, broken arm, or appendectomy.

This has real implications for your acupuncture practice — whether or not you are a participating provider, whether or not acupuncture is an EHB in your state, and whether or not you expect the AAAOM’s federal legislation to succeed.  Stay tuned for more.

(Here is an NYT article looking at medical choices and costs.)

Smart Policy for the Acupuncture Profession

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That’s my agenda —  to help acupuncturists and their affiliated organizations (AAAOM, NCCAOM, ACAOM, state organizations, schools, etc.) explore and analyze policy choices to help identify smart and effective policies and to avoid knee-jerk wild goose chases and unintended consequences.

My agenda is not to overthrow the NCCAOM, undermine the AAAOM, or to create conflict and division.

We are suffering from a professional auto-immune disease. How many subjects have been the greatest threat to the profession? How many LAcs have walked away from professional affiliations disheartened at the amount of energy spent attacking other professions or colleagues? How many of us react with outrage the moment we hear of some challenge, ready to mount an attack before we have all the information?

As acupuncturists, we see the suffering that results from an overactive immune system. Let’s stop making that mistake.

Last month I shared my email to my state association regarding their comments at an Advisory Board meeting. Here is ASVA’s response, and here is my reply. (I include the documents to show how challenging it can be to have non-triggered dialogue on an issue facing the profession. Rest assured, I am grateful to those who serve.)