Category Archives: regulation

Fourth Night – Service

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Join your state acupuncture association.

At least once in your professional life, serve on the Board of that association, or, serve on the Board of another professional group, or serve on a committee that serves the profession, or serve in a regulatory position.

If you support other groups, like AWB, SAR, POCA, join them too. But not instead.

Join your state association even if you are thinking “but they haven’t done anything that I agree with” or “they don’t do anything at all” or “they are a bunch of a-holes who actively work against my interests” or, “I already support these other organizations that actually do the stuff I care about.”

Trust me, when I get a newsletter telling me that a top priority for my state association is continuing the fight against dry needling, I struggle to write that membership check. (Because the fight has sucked up our resources and poisoned relations with potential allies and there is no chance we’ll win.)

Why give your hard-earned and too often insufficient money to a group that you believe uses it poorly?

  1. Membership organizations are designed to represent the needs and desires of their membership. To think “I’ll join when they stop doing stupid stuff I hate” is asking them to put the preferences of non-members over members, and that’s unreasonable.
  2. Health care is regulated by the states, and the state association has some degree of power (it varies from state to state) over regulations, legislation, and appointments. It’s good to have a say in how they’ll use that power.
  3. The policies of our best hope for a productive, consensus-building, national organization meant to serve all LAcs, the ASA, are determined by a Council, the membership of which is determined by state associations.
  4. There aren’t that many of us. Even if state associations have 25% of their state’s practitioners as members (optimistic – though maybe our lower percentage is related to misperceptions in how many LAcs practice in the state) that’s still a small number. It’s hard to do much if your organization is supported by and represents fifty people.

You should serve on a Board at least once because –

  1. The experience of: working to give people what they want, balancing the demands of those who want very different things, explaining that there is no shortage of good ideas just resources, explaining (again) why the association can’t provide a health insurance plan, giving people what they’ve asked for only to find out they weren’t really going to take advantage of it (you all said you wanted inexpensive monthly CEU classes, but only two of you came) – is educational. It builds compassion and understanding for those who serve.
  2. It will teach you a lot about regulation, legislation, and how some of what people insist we could do if we just FOUGHT, is not actually doable, even when everyone involved fights their hardest.
  3. Numbers again. A fifty person organization, with a five person board, and three committees of three people means about a third of the members have to be serving at any given time.
  4. People usually become willing to make the sacrifice of serving when they get worked up about something. They feel strongly about a particular issue. It’s good to have balance so one strong leader doesn’t shut out other voices.

Now, for my friends who are serving –

  1. Thank You!
  2. Working for consensus is good. Compromise is good. Listen to the concerns of all of your colleagues and don’t automatically respond with the party line. Be thoughtful.
  3. We’d have an easier time getting people to serve if Board members didn’t end up burdened with tons of administrative work. $$ for political action is important, but let’s not neglect the benefits of $ for organizational support.
  4. Criticism is not the same as negativity. Some positions and actions are deserving of criticism. If we don’t dismiss it, we can learn.

 

And, for all of us — let’s not take our differences personally.

 

(It’s not dark yet. I made it.)

 

(Note to self, 8 posts in 8 days requires advance planning. Not a good spur of the moment project.)

 

 

Third Night – Lowering Standards!?

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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.

 

 

Second Night – Census Time!

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How many Acupuncturists are there?

As we strive to increase opportunities for acupuncturists, we should know if we have the workforce to fill the demand we’re trying create. If we don’t have the workforce available, others will step up to fill the need. That may still be a win for the population able to receive acupuncture from other providers, but it won’t be the win the profession has been working for.

The new Standard Occupational Code with the BLS may, eventually, give us a good sense of our numbers. In the meantime, different sources give wildly different numbers of our strength. The NCCAOM, relying on state figures and their active Diplomate data gives a count of under 20K. Others who have gathered date from all of the states (no easy task) have been presenting a figure of almost 35K (Fan AY, Faggert S. Number of Licensed Acupuncturists and Educational Institutions in the United States in Early of 2015. J Integrat Med. 2017 September; Epub ahead of print. doi:10.1016/S2095-4964(17)60371-6).

I’ve historically used the numbers provided by Acupuncture Today. They’ve had the resources to purchase mailing lists and the financial incentive, at least in the days of paper publications, not to send multiple copies to the same practitioner, even if they were licensed in multiple states. I’m not sure their numbers are as accurate in the days of their digital edition, but they are currently showing about 28K LAcs.

In my experience a significant number of practitioners are licensed in multiple states, and a not insignificant number keep an active license when they are rarely or never treating. When getting a license is complicated and expensive, we don’t let them go lightly. For instance, if there were actually 25,000 practitioners, and 20% are licensed in two states, 5% in 3, and 2% in 4, there would be 34,000 state issued licenses.

(To put the numbers in perspective, there are 456,389 primary care physicians in the US. And a lot of patient care is still provided by nurses, PA’s, and other providers.)

Whether there are 20,000 of us or 34,000, it’s a small number to serve the population we hope to serve. And if we’ve got inaccurate numbers we may be writing checks with our ego that our bodies can’t cash.

The Hanukkah story celebrates a miracle – one night’s worth of oil lasted for eight nights. Maybe we’ll have a workforce miracle too. But it would be better if we knew how much “oil” we were starting with. And if we used that information when deciding where to focus our limited resources.

 

 

Eight mini-Posts for Eight Nights! First Night – Acupuncturists, Weigh In!

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The NCCAOM is looking for feedback on a possible Safe Compounding and Dispensing certificate program. I don’t work with herbs so I’m not considered a stakeholder, but please reply if you are eligible. My questions/concerns —

  1. Will the certificate be available to anyone or just those with an NCCAOM herbal credential? Practitioners often delegate herbal preparation to office staff, so staff might benefit the most from the training. Additionally, some excellent and well-trained practitioners aren’t able to sit the NCCAOM herbal exam due to the nature of their herbal education. Could they still obtain this certificate?
  2. Will this certificate result in restrictions on the practices of those without it? The NCCAOM has previously developed credentials promoted as optional, which have, in short order, become requirements.

There are many areas of practice in where some of us could use more knowledge and training. It’s nice to have a way to show that you’ve got some special training or skills. At the same time, we’ve got enough battles with other professions and within the profession, and too often new credentials lead to new fault lines and new tensions.

Share your thoughts with the NCCAOM if you’re a stakeholder. Let’s help them serve our needs and understand our concerns.

 

 

 

Proposal regarding Acupuncture Education

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The POCA Tech Board of Directors has been studying what it takes to become an LAc and wondering whether there isn’t a better way. POCA Tech has been approved by ACAOM as a candidate for accreditation, and has graduates who are NCCAOM-credentialed, state-licensed and working in the field. The POCA Tech BOD is in a good position to know what works. Here’s what they propose –

Acupuncture Revisions Proposal

I’ve been around long enough to expect the proposal will be met with some outrage. We’ve been insisting that it is the hours of education we have that set us apart. And that almost 2000 hours of training only scratches the surface of what there is to know about Acupuncture and Asian Medicine.

I’ve also been around long enough to know that 1305 hours of training is enough to produce competent providers. That there are countless CEU programs and additional degree programs to help us deepen our knowledge. And that there is no clear evidence that our more extensive training leads to better outcomes.

People want acupuncture. We need more practitioners to meet the demand. And 100K in debt helps no one. I think the POCA Tech proposal makes a lot of sense. What do you think?

 

 

Happy AOM Day??

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“Acupuncture is a safe and cost-effective treatment that could benefit so many. If only the medical establishment could see the benefits of what we do.”

That was our mantra decades ago.

So one might think, now that Acupuncture has become accepted and of increasing interest to the establishment, we’d be happy, thriving, and confident.

But that isn’t the prevailing feeling. We love our work and most of us couldn’t imagine doing anything else. And yet AOM Day 2017 finds us fearful and disheartened.

Many of us carry significant debt and are not earning enough to pay it down in a timely fashion. Many of us are limited in where and how we practice due to varying state rules. The hoped for benefits from insurance reimbursement came with significant administrative burden and limits on what will be covered. Increasingly acupuncture is being provided by non-acupuncturists. Meanwhile, the profession isn’t growing. Based on figures from Acupuncture Today, there are fewer LAcs now (24,612) than there were in November 2013 (24,707).

So it is not surprising that we aren’t hopeful. The public and the medical establishment see the value of acupuncture, but we aren’t thriving.

There are things we control that could change our trajectory.

Those of us who completed acupuncture training prior to 1990 (some of our most admired mentors and colleagues) probably got about 1000 hours of formal schooling. If you graduated in 2000 you likely had about 1725 hours of schooling, and if you completed your training after 2011 your program was at least 1905 hours.

You can see, here, how the Virginia regulations have changed over the years. The hourly requirements did not change in response to concerns about practitioner safety or skill, but to keep the regulations compatible with the ACAOM and NCCAOM requirements.

In 1988 tuition at The Traditional Acupuncture Institute (now MUIH) was $11,000 (about $23,000 in today’s dollars). When I started in 1992 it was about $18,540, ($32,616 in today’s dollars). By 2003 tuition had increased to $32,865 ($43,722 in 2017 dollars). And, if I wanted to begin at MUIH today, the program would take almost four years to complete with tuition of $75,924. For a Masters in Oriental Medicine, necessary to practice in Florida, California, and Nevada, I’d pay $99,604.

A student loan of $40,000 at 6.8% interest can be paid off in 10 years at $460/month – considered manageable with an annual salary of about 50K. A $100,000 loan will take over $1150/month and you’d need to make almost 140K/year to manage that.

So it’s not surprising that the profession isn’t growing and that acupuncturists are worried.

Sure, the NCCAOM can embark on a major public education campaign touting our training and credentials.(Well, touting their credential, actually). That’s fine. But with the downward pressure on health care spending in this country, and the impact of debt considerations on professional training, it’s going to take some damn fine PR to make a difference. (Big Pharma & Health Products spent about 245 million on lobbying in 2016.)

A far more direct way to help the profession grow, help future graduates make a living, and make Acupuncturists available to those who want acupuncture would be to address our training. If those who graduated in 1989 were safe with a 1000 hour $18,000 education, why do current students need at least 1905 hours and $75,000? Can we simplify the path and reduce the cost of becoming an Acupuncturist? (Yes, we can!)

If people want acupuncture they will find a way to get it. If we’re not there to provide it, someone else will be. We do have the power to change this, and it won’t take 245 million. In honor of AOM Day 2017, let’s agree that more Acupuncturists and less debt would be a very good thing.

 

 

Dry Needling Updates for LAcs

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Not again! Yes, again.

[If nothing else, read: NC AG Opinion, NC Order and Opinion, Henry v NCALB, and TX AG Opinion. If you have an opinion on dry needling, and you want it to be an informed opinion, these documents are necessary reading.]

North Carolina has been a major DN battlefield. It’s been a rallying cry for strong action elsewhere. How’s it going?

Not well.

Some history –

In 2011, the North Carolina Acupuncture Licensing Board (NCALB) requested an opinion from the NC Attorney General regarding the North Carolina Board of Physical Therapy Examiners’ (NCPTE) decision that Dry Needling was within the PT scope of practice. The AG opinion was that the NCPTE could make this determination if it conducted appropriate rule-making.

Subsequent to that decision, but before the NCPTE concluded the rule-making process, the NCALB sent “cease-and-desist” letters to PT’s practicing dry needling, accusing them of illegal activity. And, in 2015, the NCALB filed a complaint, demanding a ruling that DN was the unlawful practice of acupuncture, and insisting that the PT Board inform its licensees that DN was not within the scope of practice of PT’s.

Given the AG opinion it’s no surprise that the NCPTE (and individual PT’s who had received the cease-and-desist letters) weren’t ready to roll over for the NCALB.

On August 2nd, the Court issued this NC Order and Opinion affirming the NCPTE’s decision that dry needling is within scope for PT’s, and that it is distinct from acupuncture.

(Again, please read the documents. They are critical to understanding why our arguments aren’t leading to more wins.)

In January the court ruled that Henry v NCALB could proceed. This is not good news for the NCALB and its members, who may be found (subsequent to the NC Board of Dental Examiners Supreme Court ruling) guilty of antitrust violations.

My top takeaways —

  • Don’t request an AG opinion if you won’t accept the answer. (A colleague recently wrote that he’s gearing up to “CRUSH dry needling” in Texas. Here’s the Texas AG opinion.)
  • If it’s determined that a PT Board has the power to pursue rulemaking on dry needling, we should make a good faith effort to offer respectful input. We should focus on minimizing risk to the public, while accepting that we don’t get to call the shots. Obstructing the regulatory process or making unrealistic demands puts the public at greater risk. (Also, we should make well-informed arguments. Insisting that dry needling is outside of PT scope after it’s been ruled otherwise, for example, doesn’t help our case.)
  • Don’t use dud ammunition. NCASI and others still argue, for example, that it’s illegal for anyone other than acupuncturists to possess acupuncture needles. The court wrote (highlighting mine)

¶¶ 16–20.) In particular, the Acupuncture Board contends that the needles used in dry needling “must carry a specific FDA warning as required under 21 CFR §880.109(b)(1), stating ‘Caution: Federal law restricts this device to sale by or on the order of a [qualified practitioner of acupuncture licensed by the law of the State in which he practices to use or order the use of the device.]’” (Petition ¶ 19) (brackets
and emphasis in original).
50. The Petition takes glaring liberties with the cited regulation, however. The full text of the regulation requires medical devices, such as the solid filament needles at issue here, to include a label bearing: The symbol statement “RX only” or “℞ only” or the statement “Caution: Federal law restricts this device to sale by or on the order of a ____”, the blank to be filled with the word “physician”, “dentist”, “veterinarian”, or with the descriptive designation of any other practitioner licensed by the law of the State in which the practitioner practices to use or order the use of the device[.]
21 C.F.R. § 801.109(b)(1). As such, the cited regulation does not support the Acupuncture Board’s argument that the needles used in dry needling are “medical devices” only for use by acupuncturists.

  • Our professions’ news sources are full of misleading, inaccurate, and incomplete information. This AT article, this NGAOM post, and this blog post, are inaccurate – repeating the false needle argument, misstating the finding of the NC rules review commission, and/or misrepresenting what the NCPTE told licensees. We need to do better.
  • Long-term, there may be a few states where PT’s are not permitted to do dry needling, just as there are a few states still not open to LAcs. There is already PT DN in most states. Making the argument that dry needling is acupuncture, as the NCCAOM did in their recent statement, is a terrible mistake. Do we want the PT next door to advertise “now offering acupuncture”? Our statements encourage them to do so. We need to adjust to the current reality.

In 2013 I wrote Imagine, or, How I Learned to Stop Worrying and Love the Bomb. I can still only imagine where we’d be if we had spent the last four years doing those 11 things, instead of what we’ve done (and continue to do). Let’s stop doing what we’ve done. We can get something better if we understand what’s gotten us here.

 

 

 

Continuous Improvement and Feedback

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It’s difficult to make things better when you don’t know what’s wrong.

I’m glad when a client lets me know that something isn’t working. It gives me a chance to change things, or help them find something that better meets their needs. Things are better for both of us when we’re honest.

That’s why I’m having trouble moving on from a column that equates discussion about our problems with treason (“giving the other professions … the ammunition they need to diminish acupuncture”) and so many of the responses to the Gainful Employment regulations. (Here’s a selection — ACAOM gainful employment word, Acupuncture school response, and the ASA’s response.)

The cost of an acupuncture education, how that cost compares to future income, and the likelihood of that income being sufficient to pay off loans in a timely fashion while also sustaining oneself, are critical issues for the profession. Welcoming feedback from those who have “been there and done that” is necessary to guide improvement.

The Gainful Employment rules require transparency and accountability from for-profit career colleges. The regulations don’t close schools. They may, in time, keep students from receiving federal Title IV student aid to attend programs that don’t meet the accountability standards.

Although the impacted schools insist that the education they provide is a good value, they are correct to fear that, absent federal guarantees, students will have trouble coming up with enough money to attend.

Ideally, their concern would translate into concerted efforts to gather data about their graduates’ experiences and provide it to prospective students. They’d focus on what could be done to reduce expenses for students, and develop programs to ease those first few years post-graduation when they acknowledge income may be low. They’d make sure that all prospective students had an understanding of the economic realities of life as an LAc before collecting that first tuition payment.

Instead, when I read the responses from our schools and organizations, I hear, mainly, this isn’t fair, it’s not our fault, and it shouldn’t apply to us.

They argue that the responsibility is on prospective practitioners to educate themselves about the field and educational options, but also say that the data available doesn’t reflect the true picture. (And they fail to mention that before the Gainful Employment rules required it, they paid little to no attention to what happened to their students post-graduation.)

Try comparing the earnings of graduates from various programs, or finding out the percentage of graduates still in the field 5 years later. That data doesn’t exist. How will prospective students get a fair picture if practitioners who are share their struggles are told to keep quiet and say only nice things? If the concern is that some of the things being said are inaccurate or overly negative, take the opportunity to provide correct information and the other side of the story.

Working part-time, having employment structures that don’t accurately reflect all money earned as taxable income, and a lag in the time it takes to reach full earning potential are not unique to acupuncture school graduates.

Low student loan default rates aren’t evidence that all is well. Default carries significant and long-term harms and, luckily, acupuncturists are responsible enough to make payments and take advantage of options to defer or reduce payments when necessary. Of greater significance – do we earn enough to pay off our loans in a timely fashion while also supporting ourselves? Can we save for retirement and purchase disability and health insurance? Will we ever be able to buy a home, or build up a cushion in case of hard times? The overall financial health of the average graduate should be the focus of attention. The highly successful grads are the exception, not the rule.

I’m not surprised that the schools are fighting to avoid consequences for the struggles of their graduates. I am surprised that other organizations and voices are supporting their evasions.

There are more than sixty Acupuncture and Oriental Medicine Programs in the US. What’s a bigger threat to our future – that a few might close or that a significant number of graduates, burdened by debt, leave the profession before they can get established? How about the impact of student loan debt on the affordability of our services? Is that important?

Understanding and acknowledging our problems is the first step in making things better. We need more data and discussion, not less. More transparency and accountability, not less. A greater emphasis on making things better, not making excuses for why they aren’t. It’s time for us to own our challenges, not blame and deflect. Let’s get honest.

 

 

Accomplishments of the Acupuncture Profession

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We know acupuncture can treat pain and chronic illness, assist with recovery from addiction, increase fertility, and help people manage stress (just to start). Acupuncturists know it would be good if more people could get more acupuncture.

Many dedicated individuals have devoted significant qi to increase insurance coverage, to add acupuncture to Medicare covered services, and to bring acupuncture to hospitals and clinics. All with the hope of increasing access.

Other practitioners are committed to gaining mainstream respect and acceptance to further the goal of greater access. They’ve published research, increased training and credentialing requirements, and fought to keep others from using acupuncture techniques without that training and credentialing.

Our “return on investment” has not been great.

We’re still a lot of money and many years away from Medicare inclusion. How much time and energy gets taken from clients to deal with insurance? How many potential patients have meaningful coverage, and how long will that last? Increased training and credentialing and variations in requirements from state to state slows entry into the field and increases expenses, further diminishing our political strength. In areas with few LAcs, efforts to block other professionals from utilizing pain-relieving acupuncture techniques leaves the public with no access at all.

We’re not using our qi efficiently. Our efforts haven’t done much to shorten the path between most practitioners who want to treat, and most people who want treatment.

It’s motivating, helpful, and informative to read a book illustrating the power of a direct path between practitioner and patient. Acupuncture Points are Holes, is a great read.

It’s several books in one: a captivating personal story, an exploration of the process of establishing an acupuncture practice, and an analysis of some common limitations in acupuncture training. It examines the focus required to keep the path between practitioner and patient clear. The book and appendices contain lots of direct, straightforward, easy-to-read help for you and your business, whether it’s a POCA clinic or not.

The author’s decision to directly address the impediments that keep people in need from accessing acupuncture led to: adoption of a practice model which was then shared with others, establishment of a Co-op to support the system and interested practitioners, and, as of 2014 , an affordable acupuncture school to train future POCA practitioners. The 158 POCA clinics that answered a 2016 survey provided 880,596 treatments. One three-location group sees over 8000 unique patients each year. So far, POCA Tech students have a 100% pass rate on NCCAOM Exam Modules.

All this in less than twenty years.That’s a lot of accomplishments.

Getting the book will be an excellent return on investment. Get the e-book here, the paperback here or here. All proceeds go to POCA Tech.

 

Professional Harmony, Professional Growth

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Acupuncturists know that good health isn’t acquired by attacking invaders. Instead, we advocate living in balance with our environment to develop a strong, self-reliant, vessel. We are healthy when our system excludes threats without our even being aware of them.

As individuals, most of us practice (most of the time) what we preach. We strive for balance.

As a profession, though, we’ve chased the equivalents of miracle cures, mega-antibiotics, and the promises of “experts.” Like our clients who seek well-being that way, we are tired and struggle to maintain our tenuous health.

What if practitioners, schools, organizations, regulators, and credentialing agencies saved the energy and money that went to filing lawsuits against PT’s, (and having to defend ourselves when we are sued in return), establishing new degrees, and changing state regulations to require more training and exams? What if, instead, they identified the minimal standard necessary to practice safely and effectively and committed to work, state by state, to establish that standard as sufficient for licensure? What if we took as a guiding principle and goal that an acupuncture license in one state, and a history of safe practice, should be sufficient for licensure in any state?

Other professions are doing this. PT’s, Nurses, and MD’s are all working to make it easier for practitioners to relocate. Even lawyers can be “waived” into a state based on prior experience. These professionals don’t have to start school wondering whether their degree will be sufficient. A family move doesn’t mean giving up a career.

Acupuncture school is a risky investment, especially when requirements for licensure vary widely and change regularly.

Unlike our other battles, moving toward standardization (of licensure NOT lineage), doesn’t require convincing any judge or insurance company of our position or value. We hold the power to create a system that supports acupuncture professionals and serves the public.

It shouldn’t be difficult. It will be. We are better at vehemently disagreeing and walking away than we are at overcoming differences and finding compromise.

Both herbal credentialing and the FPD degrees were enacted despite concerns we now know were prescient.The ACAOM-sponsored DELPHI process (to establish degree titles), an after-the fact attempt to address some of those concerns, is moving forward, but not without challenges.

We lack an organization for regulators. This increases the tendency for states go their own way, and will make coming together even more difficult. Too often regulators have focused on their personal visions for the profession rather than serving the public. Many of them also sit on the boards of, or work for, acupuncture schools, raising the potential for conflicts of interest.

We could overcome these challenges. We could focus on the benefits and commit to sticking together. We could ensure the public can access Acupuncturists when they want acupuncture. We’ve spent enough on the antibiotics of legal action and the miracle cures of being Doctors and pursuing third-party payment. Now we need to focus on establishing common ground and common requirements, building our strength and our stamina. That would be a huge step toward good health for the profession.