Acupuncture Degrees and Debt

“Federal options for debt forgiveness” is often given as a reason why we must seek Medicare inclusion. And the expense of our education is considered a big factor in why people aren’t entering the field. So why aren’t we laser-focused on what can be done to keep costs down and prevent that debt from accruing?

Wouldn’t that be in keeping with everything we know and teach our patients?

When our patients have a lifestyle that is leading to depletion, we don’t encourage them to keep expending Qi beyond their means, with a promise that if they fight hard enough somewhere down the line they’ll find a miracle cure.

The history of the Acupuncture profession in the US has included a steady increase in the required hours of training. With some state-level variations, required training to enter the profession has gone from 1000 hours prior to 1990 to a minimum 1905 hours as of 2011. If you are in a state that requires herbs it’s 2525.

I have never seen any evidence or even heard anyone arguing that the increase in required hours was a response to a revealed deficiency in the education or preparation of entry-level practitioners. That’s not to say there weren’t and aren’t deficiencies. (A lot can be done to improve education and training without adding hours.) But lots of those early program-grads, the ones that took those shorter programs, went on to have long and very successful careers.

The expansion in hours of education required seemed to be primarily…marketing. We want legitimacy and respect. “The establishment respects education.” They respect “Doctors.” We point to our hours of training with the expectation that “they” will defer to our expertise. And we are dismayed when they (still) don’t.

My best recollection is that my acupuncture-only training in the early 90’s cost about $26,000, or $55,411 in today’s dollars. Multiply by 160% to reflect the increase in hours (it’s a bit complicated because I was in a window when training was described in credit hours), and we get $88,658, which is about what a Master’s degree will set you back these days. Wouldn’t there be less debt with a $56,000 degree? And being mostly out of the workforce for a 2-3 year program, while not easy, is likely to result in less debt than being mostly out of the workforce for 4 years.

There’s another problem with our current degree situation. Prospective students have a much more complicated decision to make than we used to back in the day when it was an MAc or nothing. Now, if someone is considering a career in acupuncture, they need to consider where they might want to practice for their entire career. If they want to keep their options open they’ll be encouraged to get a more expensive OM degree. And if they are worried about building a practice they might feel pressured to go for the Doctorate – for the marketing value if nothing else. And they might learn that for some states there will be additional requirements (Florida and injection therapy training) or credentials (the CA exams). It’s easy to imagine potential students, stuck between choosing a degree they can almost afford but fear will limit them, or a degree that’s a real stretch but keeps their options open, giving up and choosing a different career.

Let’s focus on making acupuncture degrees more affordable. This would make our training more accessible and decrease the educational debt of our future practitioners. Isn’t that a better bet than focusing on a way to access debt forgiveness programs that might be available in the future if we manage to get the massive health-care bureaucracy to let us in?

Anyway, I only started this post to ask everyone to listen to this podcast and read this post. They are great and absolutely worth your time.

Powerless

Regular readers might recall that I’m trying to set healthy boundaries. When a leader in the push for Medicare wrote recently “New Rule: Old guard practitioners who paid $10K for their education in this field don’t get to even weigh in on federal advocacy” it was only surprising in its bluntness. It’s been clear for ages that those calling the shots don’t care what the “old guard” has to say.

As Clive James wrote about Tyrion Lannister “in an unreasonable society, to have reasoning power guarantees nothing except the additional mental suffering that accrues when circumstances remind you that you are powerless.

I can’t manage additional mental suffering right now, and so I’ve been focusing on things where my involvement has a better chance of making a difference. Not easy when I know that giving up and checking out doesn’t help make the world a better place.

So I’m super-grateful that Lisa Rohleder is still out there, keeping an eye on things, and doing what she can to appeal to reason and to make the world a better place. Please read this post about the latest Town Hall. And also this, and this one, about Acupuncture as a business.

Just tool around the Acu Safety Nerd site. It’s a fantastic blog with many great articles, and unlike The Acupuncture Observer at the moment, putting out new content regularly.

(Admittedly, plenty of my old content is still relevant. I wrote this about insurance almost a decade ago.)

(Lisa doesn’t only write. She makes stuff happen. While I’ve been trying to work within the “system” she’s been the motivating force for the community acupuncture business model, which made huge strides in making acupuncture accessible without depending on our flawed third party payer system. AND, she’s the force behind POCA Tech, a fully accredited acupuncture school that provides an affordable education. Yet I see comments on FB dismissing her writing as “lacking solutions.” Huh?!? The lack of informed discourse on FB is one of the reasons I started this Blog, fwiw.)

And here’s another blog post worth reading, about the number of folks entering the profession in California. When things aren’t going well in California, how well can they be going elsewhere?

One last, off-topic thing. Am I the only person who wants to scream/cry/laugh/vomit when I see non-Asian, US-trained, Acupuncturists accusing non-LAcs of Cultural Appropriation for wanting to use acupuncture needles? (Hey, if you prioritize honoring the culture, how about respect for the elders?)

 

The Last Acupuncture Observer Post?

The planet is burning, the country is splitting apart.

I can imagine the despair of the climate scientists. They sounded the alarm when there was time to change course. But those in power prioritized their own short term interests. The rest of us were powerless to make the big changes. And we remain mostly unwilling to suffer the discomfort that smaller (though still helpful) changes require. We take long hot showers, drive big cars, take cruises, crank the air-conditioning on hot days, and lament the loss of the natural world we know. Being really good at recycling isn’t enough.

In the grand scheme of things, the loss of a Profession isn’t as serious as the loss of cool summer evenings and Orangutans and New Orleans. The knowledge and wisdom of this medicine preceded Licensed Acupuncturists and will live on without us.

I’m no Greta Thunberg. But I will sound the alarm again, and hope that the Profession I love will change course before it’s too late.

  • We have created a growing demand for acupuncture. Patients want it, insurance companies want to include it in their offerings, governments – federal 1,state and local, want to provide it to their citizens. There are lots of jobs, and lots of practices available.
  • There are many Acupuncturists who are leaving the field.
  • There are many areas with no Acupuncturists at all.
  • Enrollment in entry-level Acupuncture programs is down more than 20% in the last five years.

It’s an odd combination. High demand, unfilled jobs, LAcs leaving the profession, and fewer people entering the profession.

Representatives from ACAOM and the NCCAOM, asked about the drop in school enrollment at the ASA conference2, chalked it up to “the economy” and the “overall drop in people attending graduate school” and the change in “employment goals” for “the current generation.” And, “as we have more jobs more people will see it as a viable profession.” In short, ¯\_(ツ)_/¯

They aren’t being honest – maybe not with themselves, certainly not with us.

It’s simple. The investment required to become an LAc, and the education and training students receive, is disconnected from the job skills, jobs, and compensation available to most acupuncture school graduates.

People are spending four plus years in school, graduating with significant student debt, offered jobs that don’t match that investment, and without resources to start or purchase a practice. In some states even four years of education isn’t enough. Florida just added a requirement for training in injection therapy for licensure.

Meanwhile, most entry-level acupuncture jobs don’t require injection therapy or herbal skills. (Not necessary for Modern Acupuncture or most Community Acupuncture jobs, for example).

In order to pass Board exams, extensive study of TCM is needed, even though that system is not required to practice safely and competently, which is what licensing exams are supposed to test.3 The NCCAOM acknowledges the problem, but hasn’t offered a solution.

Existing LAcs spend a lot of time bitter that things aren’t better. Many believe that if only “the profession” fought harder they’d get the higher pay and monopoly on techniques they believe they deserve.

Now is the time to speak clearly.

  • The vast majority of LAcs will never be paid physician level salaries. We can spend more time in school, we can get more titles, we can all refuse to work for reimbursements we consider insufficient, and, still, average net incomes of even 80K are a long way off.
  • We cannot, in general, prevent others from using techniques we consider to be “ours.” 4
  • The higher the demand for acupuncture and the higher our expectations for compensation, the more quickly the system will shift to having non-LAcs provide acupuncture.
  • There is a bipartisan consensus that restrictive Occupational Licensing harms the economy.
  • We are vastly outnumbered by most of the professions we view as competition.
  • If you think that we haven’t been able to “protect the profession” because we haven’t fought hard enough you have not been involved and have no grounds on which to judge.

There are things we can do, powerful things within our control, that could help us survive. We must –

  • Streamline our schooling. The focus must be on competencies, not hours. Safe and competent practitioners can be trained in far less than 2000 hours. We know, because we used to do it all of the time.5
  • Minimize the expense of the necessary training. Much could be accomplished through distance education. Bring back apprenticeships which served us well for many generations (we can call them clinical internships, if we’re afraid of what the mainstream will think). Employers can provide additional post-graduate training in specific techniques and modalities.
  • Demand that the NCCAOM develop licensure exams that test minimal standards for safe and competent practice, not specific knowledge irrelevant to practice.6 The NCCAOM bears the responsibility of designing a JTA that supports the development of an appropriate exam. Particular settings or styles that want to do additional testing can chose to do so. Schools bear responsibility for assessing  knowledge of their particular traditions/lineages.
  • Protect licensure for everyone who has sufficient training in acupuncture, which includes teaching that all health providers have a duty to limit their practice to their own training and experience. Requiring all Acupuncturists to have additional training in herbs, or any other specific, optional, modality shall not be a requirement for licensure.
  • Understand that our success as a profession depends upon our having sufficient LAcs to provide treatment in a timely and affordable fashion in most communities in the US, not on whether the Cleveland Clinic has a few OMD’s on staff. We must provide resources to help and support those willing to practice in underserved areas.7
  • Drop the expectation that “the system” will pay us what we think we deserve. Everyone wants to pay less for health care – people, insurance companies, governments.

We must reclaim Acupuncture as a simple, straightforward interaction between a practitioner and a patient, and recreate the accessible path to licensure we once had. Otherwise, we are creating a future with fewer Acupuncturists, who may manage to pay for their extensive education and keep up with demand only by handing off patient care to minimally-trained assistants working for low wages.

Individual acupuncturists and our professional organizations must acknowledge that we have a problem. It may be a little uncomfortable, but we have the power to make changes that will, at least, delay the day when an Acupuncturist in the US is as rare as the critically endangered Sumatran Orangutan.8 It’s not too late.

 

Notes:

1) Please read this, and comment, on the CMS proposal! Deadline August 15!

2) The ASA did a great job with their first conference. Excellent speakers, well-organized, great facility. Very impressive right out of the starting gate.

3) “The sole purpose of a licensing examination is to identify persons who possess the minimum knowledge and experience necessary to perform tasks on the job safely and competently–not to select the “top” candidates or ensure the success of licensed persons. Therefore, licensing examinations are very different from academic or employment examinations. Academic examinations assess how well a person can define and comprehend terms and concepts. Employment examinations can rank order candidates who possess the qualifications for the job.” (from https://www.clearhq.org/resources/Licensure_examinations.htm)

4) Vermont recently deregulated auriculotherapy. Here’s an opinion from Washington state regarding Nurses and Acupuncture.

5) Other Professions have altered training and education in order to address worker shortages and minimize debt (which also encourages increased diversity). Acupuncturists in Nevada were finally able to bring their licensing requirements closer to what we find in other states.

6) My individual conversations with NCCAOM reps at the ASA conference didn’t move beyond quick chats in passing. I’ve got some hope that they’ll work to improve the recertification process. I’m less hopeful that there will be progress in the other areas in which I’ve expressed concerns. Meanwhile, a big congratulations to Mina Larson on her appointment as the next NCCAOM CEO. I know that she understands the challenges facing the profession.

7) Dealing with the shortage of rural providers.

8) Current population of the Sumatran Orangutan estimated at 14,613.

 

 

Dear NCCAOM

Dear Ms. Ward-Cook, NCCAOM Board of Directors, and NCCAOM staff:

The selection of Chief Executive Officer is a critical time for an organization. Continuity might be the primary goal when a business is thriving. When things haven’t been going well, the best choice might be someone with a fresh perspective and a willingness to shake things up.

As you know, the number of people entering the profession has dropped significantly. Without a change, the growing demand for acupuncture will increasingly be met by people who are not Licensed Acupuncturists. The profession we have worked so hard to build is at risk of becoming little more than a footnote, even while acupuncture itself becomes widely accepted. We must face this issue head on. Every decision made by our organizations must consider which choice supports growth of the profession, and which will contribute to our demise.

With such a small profession anything that divides us, or limits opportunities, is problematic. So is anything that inflates the cost of our education or entry to the profession. These all increase the odds that an interested person will choose another profession, or, having entered the profession, will struggle to succeed.

Over the years, the NCCAOM has made a number of decisions that have, in fact, divided us, limited us, and complicated educational choices and entry to the profession.

I hereby request you select a CEO committed to change, so that the NCCAOM can be an organization that unites, and that removes any barriers for entry to the profession that are not necessary for the protection of the public.

Your new Chief Executive Officer should –

  • Understand that it is in our best interest that everyone who passes the NCCAOM exams finds it easy and inexpensive to obtain and maintain their NCBA (Diplomate) status. In the absence of any findings of unsafe practice, active status should renew automatically, and at a minimal cost. With such a small number of practitioners, we can’t afford to exclude any competent and safe practitioners from employment or licensure. As it is, significant numbers of Licensed Acupuncturists are excluded from job opportunities even after passing the NCCAOM exams. The current system of CEU verification is complicated, and has no measurable impact on practitioner quality.
  • Develop exams that test only what is necessary for safe practice, focusing on crucial tasks and red flags. No particular lineage has been shown to be safer or more effective than any other. Testing requiring knowledge of one specific lineage adds to the cost of an education, complicates school choice, divides the profession, and increases NCCAOM expenses, all without benefit to the public. Since knowledge of a particular lineage is not required for competence, a Job Task Analysis focused on knowledge of a lineage is flawed and must be redesigned.
  • Fight any attempt to exclude any Licensed Acupuncturist from practicing to the limits of their knowledge and experience. The NCCAOM should never support efforts to limit, for example, the use of herbs to any subset of acupuncturists. They should be clear – the herb credential is optional, and acupuncturists without that credential should not be disadvantaged compared to all other individuals in a jurisdiction. Using resources gathered from Diplomates to support efforts to limit their practice feeds resentment and division. The addition of requirements for the herbal credential limits opportunities for practitioners, increases barriers to practice, and increases educational costs.
  • Ensure that the NCCAOM changes policies or procedures only after extensive consultation with all potentially affected parties, allowing us to minimize and mitigate harm. Changes that lead to additional costs or stress to students, schools, and licensing boards work against success and growth.
  • Prioritize execution. User friendly and functional portals are important. So is accurate information. Errors (such as incorrectly reporting licensure requirements) can have a huge impact on educational choices and employment decisions. For practitioners who have a choice, a frustrating hour spent fighting with the recredentialing process can be a deciding factor in whether or not they maintain active status.
  • Keep the focus on the core of the NCCAOM’s mission – ensuring the safety of the public through credentialing Acupuncturists. Lobbying costs money. Taking a position on a matter of politics leads to division and disappointment. The NCCAOM needs to minimize expenses for Diplomates, not use our money to fund activities that we may not support.
  • Leave education to the schools. When the NCCAOM develops educational programs, such as content for the CHCS COQ, it increases concern that the NCCAOM could one day move to make this certificate mandatory due to self-interest. Likewise, the approval system for CEU’s adds to the cost of classes and complicates maintaining certification. This system has no discernible benefit to the public, and stands in marked contrast to the practice of many other credentialing bodies.

I’ve held NCCAOM certification for the past 25 years. I have spent decades as a Board member – of my State Association, State Regulatory Advisory Board, and even the AAAOM. I know that many of my colleagues are quick to demand action, resistant to reconsidering their positions on issues, and eager to place blame. I know it’s frustrating to work hard to give people what they want, only to be criticized for your efforts.

I write now as a Licensed Acupuncturist, and do not speak for any other group or organization.

The existence of a national credential was a great help during our efforts to establish licensure in Virginia in the early 90’s. Over the years I have defended the organization countless times. But when I last renewed my board certification I had to grit my teeth.

As it stands, I’m no longer clear that the NCCAOM is a net benefit for the profession. I don’t trust you to look out for my best interests, even though I’ve been a Diplomate for all these years.

I would like to be able to defend you again. I’d like to know that you had my back. That my fees weren’t being used exclude me from practice. That lapsed status wasn’t keeping colleagues out of the profession. That your exam didn’t require people to learn a lot of information they’ll never need to practice safely. That my fees weren’t being used to fund futile turf wars. That the information you provided could be trusted. That your systems worked. And that when concerns were brought to your attention you didn’t deny or evade or misrepresent what happened.

It’s time for a CEO who understands the changing landscape, and understands that without a change in direction there will be no profession left to protect. For the sake of the profession, and the future of all of us associated with it, I hope that you choose wisely.

 

Sincerely,

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

 

 

Updates: Education, Dry Needling, Professional Organizations and Associations

Tri-State College of Acupuncture has lost accreditation and closed. Founder Mark Seem was unwilling or unable to save the program.

It’s a loss for the students, and for all practitioners and patients.

In the early development of the U.S. acupuncture profession the modern TCM lineage was primed to dominate. Mark Seem at Tri-State, and Bob Duggan and Diane Connelly at The Traditional Acupuncture Institute fought to maintain acupuncture diversity and the strong curriculum at those two schools enabled other traditions to gain a foothold.

Now Tri-State is closed and the school formerly known as The Traditional Acupuncture Institute (The Maryland University of Integrative Health) has little in common with its earlier iteration. The NCCAOM is increasingly powerful. Their TCM-focused exam controls entry to the profession. The outlook for non-TCM traditions is not good.

On December 7th the North Carolina Supreme Court affirmed the legality of the Board of Physical Therapy’s decision that dry needling falls within the scope of physical therapy in the state.

If you believe that our future success depends upon what other professions do with filiform needles, it’s bad news. It’s also bad news for the NCALB, which previously reported legal debt of $150,000. And it’s terrible news for those named in the antitrust suit Henry vs. NCALB, which was on hold awaiting this decision. The odds are not in their favor.

If you’re committed to continuing the fight with PT’s, please read the ruling.

A recent letter from the Utah Association of Acupuncture and Oriental Medicine reports that the group has no paying members and has been “permanently dissolved until further notice.”

Perhaps the association’s 2018 effort to require the NCCAOM Herb credential for new graduates who wish to practice in Utah was not a big membership motivator? If not, why did they pursue the change? At the time, the NCCAOM cited practitioner support as the driving factor in their participation.

(The NCCAOM now insists they took no position on this issue. Yet they have refused to disavow the letter they distributed showing their support.)

In the “dissolution letter” we read, “There is important work to done and we have the full support of the NCCAOM in our effort.” Who is the we if there are no paid members? What does the NCCAOM support (and why)?

Pay attention! I don’t believe the plan is to make entry into the profession easier or less expensive.

In early 2019 I’ll be writing about Modern Acupuncture, developments at the NCCAOM, and trends in the profession. Until then, I wish you all a peaceful and restful holiday season.

Safety: Dry Needling and Acupuncture

We worry about the public’s well-being.

The excellent safety record of Licensed Acupuncturists is part of our “brand” and has been a focus in the fight against the use of filiform needles by those without our extensive training.

Are we walking our talk?

At a recent professional gathering a representative of a malpractice insurance company recited a terrifying list of problems that turned into insurance claims against acupuncturists: a double pneumothorax, infections from needles manufactured in unsterile conditions, broken bones from tui na, burns from heat lamps. The message – Buy Malpractice Insurance!

On Facebook, Acupuncturists regularly look for support after a patient reports a post-treatment issue.The equivocations quickly pour in: Is that really where you needled? Are they on medication? It’s a healing reaction. Did you have them sign a waiver? There is such a thing as a spontaneous pneumothorax….

Yes. Malpractice insurance is a good idea. And sometimes post-treatment issues aren’t treatment related. But the lack of concern about the problems, and the lack of interest in how they might be avoided, calls into question our supposed devotion to public safety. Not only are we advised to never admit responsibility to our patients, we’re encouraged to never admit it to ourselves.

In 1999 The Institute of Medicine released a report, To Err is Human: Building a Safer Health System.

“The committee’s approach was to emphasize that “error” that resulted in patient harm was not a property of health care professionals’ competence, good intentions, or hard work. Rather, the safety of care—defined as “freedom from accidental injury” (p. 16)—is a property of a system of care, whether a hospital, primary care clinic, nursing home, retail pharmacy, or home care, in which specific attention is given to ensuring that well-designed processes of care prevent, recognize, and quickly recover from errors so that patients are not harmed.”

Lisa Rohleder writes –

“It’s impossible to effectively promote safety when we don’t know where WE are going wrong. An important part of developing a culture of safety is to establish, as much as possible, a compassionate, neutral, and curious attitude toward safety errors and adverse events. Nobody wants to make an error (either large or small) or have a patient suffer an adverse event — and yet anybody who practices acupuncture for long enough will experience those things. Acupuncture is a practice that involves humans on both ends of the needle, which means sometimes, unfortunately, things will go wrong.”

“Acupuncture legislation and regulation are not the same as creating a culture of safety. Training cannot ensure that the people who receive it will never play a role in an adverse event. A culture of safety requires an active, ongoing, self-reflective, cooperative process.”

An adverse event does not necessarily mean that a mistake was made. It means that something didn’t turn out as we would have liked. It can happen when a practitioner does everything right. The more we know about what happened, the more we can confront and minimize the risks involved in treatment.

But we can’t know what happened without collecting the data. And we can’t collect the data if 1) there is no mechanism to report adverse events and 2) people are afraid to share about and discuss adverse events.

Until recently, no acupuncture organizations have been interested in collecting such data. Alarmingly, in the name of acupuncture safety, one shadowy acupuncture group has created what it calls an Adverse Event Reporting system for the sole purpose of weaponizing reports of adverse events related to dry needling. The data are not anonymous. (The board of the group collecting the data is.) The goal is not to improve the safety of a practice, but to attack competitors. It makes it more difficult to develop a culture of safety.

Finally, we have the opportunity to participate in a voluntary and anonymous database for reporting adverse events in acupuncture, developed with the goal of promoting safety.

Some questions and answers from POCA’s materials about the AERD they created –

Why Should All LAcs Voluntarily Report Adverse Events and Errors?

POCA created this AERD for ourselves but it is designed to be used by anyone who provides acupuncture services and anyone who is a consumer of acupuncture services. We are hoping that many L.Acs will participate, and that other acupuncture school clinics will want to join us in collecting safety data.

Using a voluntary and anonymous AERD is a way for the acupuncture profession to encourage a culture of safety. AERDs are standard in other healthcare professions and it is notable that the acupuncture profession has not had one; that’s a problem that needs to be fixed, especially in light of acupuncturists’ practicing in integrative medical settings.

 Why Did the POCA Cooperative Create an AERD?

POCA loves data, and collecting our own safety data has been a topic of discussion in the co-op for years. Having POCA Tech as a resource to manage an Adverse Events Reporting Database, along with getting support from Dr. Suzanne Morrissey (medical anthropologist and professor of anthropology at Whitman College), allowed us to make an AERD a reality.

Why Voluntary and Anonymous?

Research suggests that it’s possible to collect better safety data, and thus do a better job of improving safety practices, when reporting adverse events and errors is voluntary and anonymous. Nonconfidential and mandatory reporting systems may discourage practitioners from disclosing adverse events and errors.

The goal is to focus on safety practices and systems, not on errors made by individuals.

Here’s the place to report adverse events.

Additionally, membership in POCA provides many excellent perks, whether you provide community acupuncture or not. I encourage you to check it out. Thank you, POCA, for establishing the AERD, and Lisa Rohleder, for starting this discussion. This post borrows heavily from her writing. Any errors, however, are mine alone.

 

 

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.)

A Feature or a Bug?

Quote

When a trusted business or organization screws up, it’s good to give them the benefit of the doubt. We all make mistakes.

I have trusted the NCCAOM. They were important to our acceptance as a legitimate profession. In 2014 I encouraged people to support a transition to their exams in California, hopeful that one national standard of entry would further the growth of the profession.

But I’ve noticed a pattern – the NCCAOM makes a big announcement and seems unprepared for the response. They scramble to address the upset, explaining why we don’t understand their good intentions or their difficult position.

I used to think it was a bug. They just weren’t as competent as I’d thought. And Acupuncturists mostly don’t understand their role and are quick to react.

But now I think it’s a feature.

We don’t understand their role because they talk out of both sides of their mouth – they say or do contradictory things depending on their immediate desire.

In the “NCCAOM Questions and Clarifications” document (released in draft format), their response to the reaction to the changes in testing policies, the NCCAOM writes:

“There are some policies where we may ask our stakeholders’ opinions and use that to determine policy.  There are many other policies where this is not appropriate because of the requirements of our accrediting body, fiduciary responsibilities (the fiscal health of NCCAOM), or impacts to public safety need to drive our policy decisions.  NCCAOM is not a membership organization, it is a credentialing organization. Examples of this include: the elimination of the apprenticeship-only route, elimination of the pre-graduation route, and the revisions to the NCCAOM® Code of Ethics and the Grounds for Professional Discipline. These are examples that our policies are driven by our NCCA accreditation standards.”

But the NCCAOM did ask for input on the Code of Ethics and Professional Discipline, and their revised code reflected that input.

And the NCCAOM did step back from some of their announced changes in response to concerns from stakeholders. Clearly they had some flexibility, and could have done this prior to their announcement.

And in 2016 the NCCAOM shared –  “Breaking News! New Membership Organization Announcement!” describing their “Academy of Diplomates.” The Academy Board is a subset of the NCCAOM Board, your NCCAOM recertification fees support this organization, and links on the Academy website take you back to the NCCAOM. No wonder we’re confused.

In “Questions and Clarifications” we read – “It is no secret that the number of students taking the exams, annually, has dropped dramatically over the past decade.” Their upbeat NCCAOM Spring 2018 newsletter doesn’t mention it, nor has it been a topic in their frequent Acupuncture Today articles. Study their annual reports and you can uncover the truth, but that isn’t the news they’ve been sharing.

Fewer people taking the tests means fewer new practitioners. Shouldn’t the profession give scrupulous consideration to any policy or regulatory changes that make it harder to enter the field?

The NCCAOM’s current honesty regarding their financial concerns is appreciated. It also demands that we reconsider their previous denials that money drives their policy positions. Their support of efforts to require the herb exam of all practitioners (UtahNCCAOMletter), and their complicated PDA system, make sense from a financial perspective, not from a safety one.

The NCCAOM denies that their exams shape our education. They say schools should not teach to the test. They also advertise, “It is recommended that ACAOM Approved Schools Faculty members sign up for [the NCCAOM] practice tests to familiarize themselves with the process.”

They dismiss concerns that a new voluntary certificate program could become mandatory. They simultaneously support efforts to make the voluntary herb testing mandatory.

Underneath it all is the refrain, the “NCCAOM’s number one priority and mission is to protect the public.” This is as it should be. But one insurer recently reported receiving 1-3 reports of harm per week, including reports of pneumothorax, burns, and infections. In a profession of, at best, 30,000 practitioners, shared between multiple insurers, that’s alarming. Is there evidence that patients in Maryland or West Virginia, where there is no NCCAOM testing requirement, are more likely to suffer harm?

With great power comes great responsibility. The NCCAOM denies their power and their responsibility, but they are the gatekeeper to the profession. They have us by the short hairs. Their denials aren’t believable.

I’ve given them the benefit of the doubt for years. I’ve explained away their errors as bugs and defended their good intentions. It’s painful to acknowledge that I no longer trust the NCCAOM.

They need to get a lot more honest and a lot more competent quickly, or we need to get serious about finding an alternative.

 

 

 

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.

 

Third Night – Lowering Standards!?

In recent conversations with colleagues I’ve heard a few exclaim “we won’t agree to lower our standards!” and “we aren’t going to go backwards on our education!”

I haven’t heard anyone suggesting that we lower our standards or go backwards, so I was baffled.

Only momentarily, though, because then I remembered -The Acupuncture Revisions Proposal from the POCA Tech BOD to “revise acupuncture education and testing standards so as to benefit current and future (1) acupuncture students, (2) acupuncture schools, (3) acupuncturists, and (4) the general public.”

They make clear that their proposed standards are based around students meeting all of the competencies required for ACAOM accreditation and preparing graduates to be safe and effective practitioners. (The proposal is concise, well-written, and worth reading. Please do.)

Unfortunately, “high standards” in this profession has come to mean number of hours spent in school. So any change in the number of hours is interpreted as a lowering of standards.

I understand how it happened. When we’ve fought for acceptance, we’ve stressed our hours of training to establish our worth. When clients mention that they got acupuncture from their Chiropractor, we talk about how much time we spent in acupuncture school compared to the D.C.’s short courses. Hours of education has been a battle cry in the dry needling fight. (Which has been mostly unpersuasive since the PT’s 1) deal in competencies, and 2) we use different rules when we count our hours and we count theirs.)

Actually, a standard is “a conspicuous object (such as a banner) formerly carried at the top of a pole and used to mark a rallying point especially in battle.” (Merriam-Webster).

So, hours has become our standard. But it’s such a meaningless standard. I’m sure I’m not the only person who’s been to three-day CEU classes that have been a complete waste of time while a one-hour class contains a transformative nugget. I’ve spoken to people who have taught at some acupuncture schools and the picture they paint is not of hour after hour of quality programming.

We’ve got a workforce that needs to grow. And levels of educational debt that are an impediment to professional success. Affording graduate school and repaying loans isn’t going to get easier.

Read the Acupuncture Revisions Proposal with an open mind.

Our banner should be more meaningful than a number.