Category Archives: reciprocity

Gainful Employment and Strategic Errors

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The Gainful Employment final regulations have been announced. Forgive my commenting prior to a complete and thorough analysis of the 941 page document. (You can see some analysis here.) The gist is that for-profit schools (which includes half of US acupuncture programs) will soon have to show that graduates’ student loan payments are manageable with the profession’s available employment (not taking IBR into account). If they can’t, federally guaranteed student loans will no longer be available.

Why should taxpayers continue to provide loans for educations that history shows aren’t worth the investment? Imagine tuition rates and post-graduate employment assistance if the schools provided and guaranteed loans, and took the hit if they weren’t paid back in a timely fashion.

It is no surprise that for-profit schools are displeased about the impending end of the gravy train. Many for-profit schools, and their related organizations, did everything they could to block the regulations. And, just under the wire, the acu-educational establishment contributed comments (see ACAOM gainful employment word).

(The more expensive FPD, and pressure away from “acupuncture-only” degrees now carry a significant downside for the schools.)

Did ACAOM think their letter might exempt them from the rules or impact the final regulations? It seems unlikely that this little community would shift the tide. It was an unforced error for ACAOM to write a letter that reveals such little concern for graduates and such a strong desire to dodge responsibility. (Some of the more significant issues in ACAOM’s letter are discussed here.)

But our own strategic errors have allowed ACAOM and other other alphabets to disregard our well-being.

The petition that asked the alphabets to stop denying their role in our circumstances received 227 signatures. Petitions to stop dry needling often receive thousands of signatures. Which is more likely to limit professional success — a school that leaves students with extensive debt, poor business skills, and no job placement or alumni support, or a little competition? If we can’t survive the competition from those “untrained” professionals our education is surely lacking.

The Feds and the taxpayers pay a price when schools sell an education for far more than it is worth. We graduates pay a far more personal price. It’s too late for us, but at least the Feds are willing to look out for the interests of those who will follow in our footsteps.

What’s your Acupuncture Degree Worth?

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Answer: Less than it used to be.

(Please, sign the petition.)

If you earned an MAc and Dipl. Ac (NCCAOM) twenty years ago, you thought you had it made. You could get a license in almost all states with licensure. The schools and the NCCAOM touted the caliber of the education and credentials. You knew you had plenty to learn about this medicine, but you could practice safely.

In the gainful employment letter ACAOM points to the (supposed) earnings of those long-ago grads to minimize the financial struggles of recent grads.

But in 1995 the NCCAOM added the Herbal exam, and later the OM. Some states now require those additional credentials of all practitioners. ACAOM has increased hourly requirements for school accreditation several times. And the NCCAOM has put additional limits on who can take their exams.

Some of our most esteemed teachers do not meet the current requirements for sitting the exams. Many practitioners are trapped, unable to relocate.

By increasing the range of degrees and credentials available before our “brand” was established and our profession was strong, the alphabets increased division and confusion. No wonder the public can’t figure out how an LAc’s education compares to that of other providers.

And here comes the First Professional Doctorate. With this new degree, my alma mater announces,

“[graduates] will be recognized as doctors, both professionally and publicly, and will have increased credibility and standing.”

If graduates with an FPD have increased credibility and standing, what has happened to the credibility and standing of graduates of Masters programs?

According to ACAOM’s gainful employment letter, licensure requirements just happen, and practice success is a simple matter of practitioner choice.

Really, though, the “alphabets” have played a significant role in the expansion of requirements and credential creep, and most of the schools do little to teach students how to make wise business choices.

If, as ACAOM wrote, the graduates of twenty years ago do so well, why have entry level requirements been increased so much? Why are grads struggling to pay off existing loans encouraged to return to school to maintain their credibility? Will the NCCAOM require an FPD to sit their exams? Will the alphabets encourage states to require it for licensure?

ACAOM/NCCAOM/CCAOM/AAAOM — if you represent us, defend the value of our degrees and credentials. Your “options” too often become a requirements.

Colleagues, did the gainful employment letter represent your views? If not, sign the petition. 129 people have, which means ACAOM etc. can still claim to represent 32,871 of us.

For additional information and analysis about educational costs and value, check out this from The New York Times and two posts from Dr. Phil Garrison

 

 

It’s Like Herding Cats

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It’s a common refrain about reaching consensus in the acupuncture profession. But why try to herd cats? I learned a long time ago that opening a can of tuna would bring kitty running.

If there were an attainable action that would:

  • Increase patient access to Licensed Acupuncturists,
  • Assist in national marketing for the profession,
  • Decrease educational costs and student debt,
  • Decrease licensing expenses,
  • Increase political power,
  • Expand professional opportunities, flexibility, and mobility, and,
  • Increase the value of your practice,

Would that be like tuna to a kitty?

(Whirrr of can opener)

Tuna for me = Identifying the least restrictive licensure requirements necessary to protect the public and create successful practitioners and working to establish that as a standard in all states.

Before panic ensues, consider some of the situations I’ve heard about in the past few years:

  • Highly experienced and qualified LAcs unable to obtain licensure, even in states where there are so few LAcs that the public has little choice but to get their acupuncture treatment from Chiropractors.
  • Practitioners who want to sell their practices but have a limited pool of buyers because of the unique licensure requirements in their state.
  • Practitioners travelling many, many hours in order to practice, or leaving the profession, because life has taken them to a state in which they can’t obtain a license.
  • Practitioners and students who have no interest in using herbs being required to spend tens of thousands of dollars and thousands of hours learning herbal medicine in order to obtain an acupuncture license.
  • Acupuncturists supporting discriminatory laws or regulations such that the only group of people in a state who can not practice herbal medicine are other Acupuncturists.
  • Practitioners having to maintain licenses in multiple states because changing regulations mean that if they give up a license they will be unable to obtain it in that state again.
  • Acupuncturists being unable to advance reasonable state or national legislation because restrictive practices keep practitioner numbers so low that political support is unavailable.
  • The profession being unable to effectively educate the public about their excellent education and credentials because those credentials vary so much from state to state.
  • Acupuncturists struggling to build a practice in overserved areas, but unable to obtain licensure in nearby underserved areas.
  • Acupuncture organizations fighting for inclusion in managed care and federal health programs, even though many states have too few LAcs to serve the population. (Demographic data can be found at these links: Acupuncture Today LAc Map, US Population, Physicians per State.)

The current system in which some states require graduation from particular schools, others have their own exams, and others have their own educational requirements does not serve us as a profession. The situation is getting worse, not better, as states like Florida increase their requirements. Yes, states have differing scopes. (Those who advocate for scope changes should be required to consider and advertise the impact the changes will have on licensure requirements.) Yes, it is in the interest of the public and the profession to insist that practitioners limit their practice to the tools and skills in which they have been trained. Additional, optional, training can always be required for those who wish to practice more advanced techniques or modalities. The least restrictive licensure requirements have shown themselves to be sufficient for safe practice.

Limited, standardized, licensure requirements would lower practitioner expenses, promote mobility, ease national marketing, and help the profession grow. It sounds great — as good as tuna smells to a cat. Does it make you make you want to come running? Many changes in licensure requirements could be made at the regulatory level and are within our reach. It does not depend on establishing reciprocity. One problem — the LAcs within a state have the power to make or block change, and, especially in restrictive states, the small group that set up the rules is often in power. Another problem — many LAcs don’t care about this until they are directly impacted.

This is a place where national coordination is needed. I hope the CSA sees that this is a place where they could make a positive difference. Let your state association know if you support a more standardized and simpler licensure environment. It should not require any herding.

Cat Food

Cat Food

 

 

The Acupuncture Profession, News and Analysis

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Three dedicated AAAOM Board members and AAAOM (super-qualified, knowledgeable, and committed) Executive Director, Denise Graham (my last hope that things could get better) resigned recently.

One board member spoke of an uncomfortable and increasingly controlled board environment, a declining membership (now less than 2% of the profession), and poor relationships with national and state leaders. Another stated that the AAAOM doesn’t have the support, revenue, or credibility to make progress towards legislative goals.

This isn’t the first time AAAOM has been on the ropes. If it hadn’t been for money from the AAC and support from other organizations, I doubt they would have survived this long. Somehow, though, they still manage to control the conversation.

In other news, NCASI, the National Center for Acupuncture Safety and Integrity, has appeared on the scene. NCASI’s list of “10 Facts” should be titled “10 Things We Insist are True and/or Important.”  Dry Needling by PT’s is legal in many states. Review my past posts on dry needling and scope for more background. We take real risks when we files lawsuits like these.

For twenty years, the acupuncture organizations have insisted that our success depends upon —

  • Increasing credentials/educational requirements/scope. It doesn’t matter if the old education, credentials, and scope worked fine. It doesn’t matter if it increases practitioner expense, decreases practitioner flexibility, or prevents some LAcs from utilizing techniques available to any other citizen.
  • Getting someone else to pay for acupuncture. Fight for third-party payment systems even if other professions report they make good medicine more difficult and practice less enjoyable. Ignore the hypocrisy of participating in a system that requires discounting services while also criticizing LAcs who offer low-cost or discounted treatments directly to patients. Insist that practitioners who don’t want to participate won’t be impacted, and turn a blind eye to the fraud that many practitioners engage in to make the $’s work.
  • Demanding a monopoly.  There’s no need to earn your market share by providing the best product — instead establish it through litigation and turf battles. Don’t worry if this requires you to disparage your fellow health providers or contradict your message that the public should be able to choose their providers.

After twenty years many LAcs struggle to stay in business, and most voluntary acupuncture organizations struggle to survive. Got questions about ADA compliance, insurance billing, privacy issues, advertising questions, disciplinary actions? You won’t get answers from the AAAOM and you probably won’t get them from your state organization.

It’s time to change our strategy. We have enough training, clients who seek our services, and other providers who respect the medicine so much they want use it themselves. Yes, we always need be aware of and informed about the regulatory/legislative landscape, but we also need business skills, PR, positive marketing, and an easing of the regulatory burden.  We need a good hard look at the cost of education. We need legal advice and business tools and positive interactions with potential referral sources and colleagues. We don’t need more legal battles, more regulation, more legislation, more degrees that further divide us.

When our organizations provide these things, we’ll have successful organizations, and successful practitioners. (If you don’t believe me, ask POCA.)

 

News Update

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and a bonus at the end —

October 1st, NCCAOM, Facbook —

 NCCAOM has received a significant volume of responses, and the results of this feedback will be taken into consideration during the development of the final policy and standards, as NCCAOM continues to strive for increased customer satisfaction. We are always eager to hear your suggestions for changes that will benefit you, the Diplomate, and the AOM profession overall. It is with your feedback that we can continue to meet your needs.
We are listening!

Spin?

October 2nd, date of scheduled AAAOM Town Hall, AAAOM website —

Legislative Town Hall

CALL POSTPONED – DATE TO BE DETERMINED

No additional news.

October 9th, Richmond, VA, Meeting of Virginia Acupuncture Advisory Board.

Agenda includes discussion of an alternate path to licensure due to conflicts between Virginia law and the NCCAOM proposed policy changes.

The representative from the state association (ASVA) was against any discussion of the NCCAOM issues. ASVA stated  — “lowering of standards…would do harm to both our profession and the public.” Who mentioned lowering standards? Is there evidence that anyone is harmed in states that do not rely on the NCCAOM credential?  Here is my post-meeting email to the association  –  ASVA comments.

The NCCAOM rep at the meeting was clear — the proposals were just proposals, stakeholder comments will be taken into consideration, any language referring to the effective dates of the changes was referring to effective dates for the proposed changes, not the actual changes. I envisioned someone pedaling backwards.

Questions of the Day — We attack when another profession “interferes” with our practice (DVM’s “stealing animal acupuncture”, PT’s “stealing acupuncture”, MD’s wanting to see our patients) even when we have little or no power to change anything. Why are we unwilling to even discuss it when an organization supported by our money, controlling our profession, at our request, takes action that costs us or limits us? We made a difference this time (we hope) – why aren’t our professional associations helping?

Here is a new page on Legislation and Regulation. It contains important and valuable information. Please, read it and pass it on.

I’ll be working on a page about the Acupuncture orgs (the alphabets) and another for potential acupuncture students in the coming weeks.

Dry Needling, Herbs, and Scope — How to Regulate a Profession

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A regulatory Board is contacted.  Your licensees are doing X, that isn’t (or, is that?) in your scope.

Ask a PT Board about Dry Needling and the answer usually goes something like this — We trust our licensees. Many learn this technique and it helps their clients. We find room in our regulation to include this in our scope.  We have a few concerns and suggest that those who want to utilize this technique have some additional training and take additional precautions. Our existing system for addressing unsafe practice is sufficient to address risk to the public.

Ask an Acupuncture Board or organization about herbs and the answer usually goes like this. We are being threatened again!  We’d better legislate, and fast! Help! Thanks NCCAOM and schools. We are so grateful for your efforts to ensure that any acupuncturist who wants to utilize this dangerous aspect of our medicine add your $20,000 education and your formal $800.00 seal of approval to their already extensive education and credentials. In fact, in the name of raising standards we should require that from all LAcs. It might prevent some of our most qualified practitioners from practice, but, hey, it is a step toward getting the respect we deserve.

Is something wrong with this picture?

It’s a radical idea, but how about we respect ourselves. Let’s recognize the safety of our medicine and the depth of our education.  Let’s trust our colleagues’ professional judgement and open doors rather than close them and let’s stop deferring to those who profit from our love of this medicine.

For additional reading, check out an example.  In this case, I agree with Dr. Morris when he wrote,

To avoid conflicts of interest, no individual who stands to profit from seminars should determine competencies and educational standards, nor should they testify in legislature on behalf of the common good.

(Of course, he was talking about the PT’s when he wrote it, so maybe in this case he doesn’t agree with himself.)

You have until Monday, 9/30, to comment on the NCCAOM’s “proposals.” Does the current CEU arrangement put the public at risk? Are the states incapable of effective regulation?

One more thing — during the great FPD debate, many expressed concern that once the degree was available the NCCAOM could, by fiat, require it for entry level practice. We were assured that would be impossible. Informed by history, it seems very possible indeed.

If I Had 3 Million Dollars

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I would buy you all a boat.

Just kidding.

I would —

  • Compile and make available a list of the specific requirements necessary to obtain an acupuncture license in each state, making sure to highlight current and oncoming obstacles. (For example, as of October 1, 2014, Florida will require passage of the NCCAOM Oriental Medicine Module for licensure. Although the Florida rules will continue to show that those enrolled in school prior to August 1, 2007 need complete only a two-year course of study which does not need to include herbs, the new examination requirement means that no one with only the two-year education will be able to obtain a Florida license.)
  • Compile data on the professional success of acupuncture graduates of every US school. The data would be available to all.
  • Explore why those who aren’t practicing have left the profession and whether there are different rates of success among graduates of different schools. If there is a difference in graduate success, are there factors common to the more successful schools?
  • Gather data on the safety record of acupuncturists in various states. Does it matter if the state requires NCCAOM exams or credentials? In acupuncture? In herbs? If the states require graduation from ACAOM schools?
  • Use the data to identify the lowest common denominator. Identify the least restrictive education/credentialing necessary to ensure public safety and prepare practitioners for success.
  • Show how uniform and non-burdensome state standards are a critical step in providing acupuncture to the 313.9 million people in the US. Build consensus for reasonable minimum standards, and work for their adoption in all states.
  • Establish a team of public policy professionals with expertise in regulation and legislation to help develop a set of attainable and effective strategic initiatives.

Where would I get my 3 million dollars? Not by yet another “now is the time, we must submit legislation that mandates access to the federal healthcare system” fundraising effort. We’ve heard this before. We should know by now that submitting legislation is guaranteed to suck up resources, it is passing laws that can make a difference – if we’re prepared for the consequences of success.

Please, respond to the AAAOM’s call for comments by August 31st. With, at best, 30,000 acupuncturists available to 313.9 million people, is submitting legislation which has a snowball’s chance in hell of passage really the best use of 3 million dollars?

And, if you really want to do something that will improve access, ten minutes and two stamps will do it – here’s how.

Making a Difference, in ten steps.

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  1. Write a letter to the Delaware Acupuncture Advisory Council, and mail it by this Friday, August 23rd. Here is a new, improved template!  Do this now! (Please cc Gayle MacAfee at the board and send a copy to de@theacupunctureobserver.com. Thanks!)
  2. Share this post on facebook.
  3. Tune in. Subscribing to this blog is a good start but I can’t keep track of everything. Check in at websites for the AAAOM, NCCAOM, ACAOM, your state association, POCA, etc.  A few current issues (which I’ll be posting more about soon) — AAAOM is calling for public comment by August 31st on draft legislation, NCCAOM wants public comment on proposed changes by September 30th, ASVA (Acupuncture Society of Virginia) is having a town hall October 19th to discuss possible changes to scope, and the IHPC wants us to stay involved regarding implementation of section 2706 of the Affordable Care Act. Any one of these issues could impact your ability to practice.
  4. Question Authority. Is X really the biggest problem facing the profession? Is the public better off in a state that requires the OM certification rather than the AC certification? Is an independent board better for acupuncturists? Will an FPD degree lead to greater respect? Does scope mean what you think?
  5. Know the system. For example, boards can only regulate their own licensees. And the executive branch doesn’t determine what Medicare covers, regardless of how many signatures are on a petition.
  6. Avoid us/them thinking. In Our Worst Enemy I wrote about the practitioners in focused on increasing standards as a “them.” That was a mistake.
  7. Remember, we are all in this together. What happens in another state or a change that seems to impact only new students or new licensees might end up affecting you in unforeseen ways.
  8. Assume good intentions. Assuming bad intentions (the PT’s want to do dry needling to make money, for example) doesn’t lead to productive dialogue.
  9. Be consistent. Do we support the right of people to choose their healthcare provider? Are herbs safe? Is acupuncture safe? When we change our answers to these questions based on the circumstances we create a negative impression.
  10. Learn from history. Has participation in  health insurance been good or bad for healthcare? For providers? Has a standardized system of Chinese Medicine led to greater effectiveness?

In the short run it is easier to ignore the big issues, to figure you’ll be okay, or to decide you can’t really make a difference. Staying involved takes time and energy you’d rather use to see clients or spend time with your family or learn that new technique. Do it anyway. Tune in, question, participate. The future you save may be your own.

You Can Make a Difference

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Many LAcs do their best to ignore the “politics” of acupuncture. The experience of participating in professional dialogue can be disheartening and discouraging. It isn’t easy to participate even when we want to — things are happening at the state level, with schools and ACAOM (the coming FPD), or with credentialing (proposed changes at NCCAOM), for example. All too often the debate gets heated and divisive. It is hard to get the whole story and figure out the possible consequences of a change or know what action might be effective. When the licensure legislation was developing in DE few outside of the state were involved. Some of my colleagues in DE had concerns, but they eventually gave up what felt like a fight for a better bill.

Five years after the DE legislation went into effect, there are approximately 35 LAcs serving a population of over 900,000 people and many of those practitioners were either grandfathered in or granted a waiver. Two years went by without a single non-waivered approval. Clearly, the legislation is not giving the people of DE access to qualified LAcs. As I wrote about in my last post, I know of two excellent practitioners who have recently been denied licensure even though their credentials surpass those of many practitioners in the state.

In the long run, the Delaware legislation should be changed. Rules that exclude the majority of NCCAOM credentialed Acupuncturists make no sense, especially when acupuncture can be done by other professionals with far less training. In the short run, the Acupuncture Advisory Council should acknowledge the record of safety of NCCAOM AC practitioners and consistently grant waivers to those with that credential.  In the very short term, the Council should grant waivers to Virginia LAc Sharon Crowell and Maryland LAc Sue Berman.  To facilitate those short term goals I ask that all of you write to the Acupuncture Advisory Council expressing your support of such a waiver.  Please mail your letters by August 22nd!  Feel free to post a copy of your letter in the comments section to inspire others. Email a copy to de@theacupunctureobserver.com. That will help if further action is necessary.

You can see the letter I sent (and borrow from it if appropriate) —  DE Observer Letter.  I’ve also generated a DE LAc sample letter that you can personalize. You could add some of these Possible concerns or your own concerns (please share any additional concerns in the blog comments). The letter can be modified for clients or others who are interested. If you’d like an excuse to visit Dover, DE, the next Advisory Council meeting is September 12th. It should be lovely at that time of year – but don’t count on being able to find an LAc in town :).

 

Our Worst Enemy

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How do you feel about a regulatory situation that increases the odds that patients will receive acupuncture from minimally trained, non-LAcs while making it difficult for extensively trained LAcs to practice?  Is it better or worse if it is a state’s very own LAcs who are creating this situation?

The Delaware Acupuncture Council recently refused to grant a license to one of the most excellent practitioners I know.  This Virginia LAc,  a NCCAOM AC Diplomate and a Nurse, has had a very successful practice for over 13 years.  She is a former president of the Acupuncture Society of Virginia and has studied Medical Qi Gong extensively for the past three years.  The three LAcs on the DE Council present for the June meeting refused to grant her a license because she does not have NCCAOM OM Diplomate status.  Although the Council was reminded that they could grant an exception, they refused to do so.

It appears that only one of the four LAcs on the Council has the full NCCAOM OM status and one has NCCAOM AC status.  A third LAc has no formal acupuncture education or NCCAOM status, holding a degree in ayurvedic medicine granted for overseas study. I could not discover any information about the fourth LAc on the Council.

Delaware passed legislation related to the practice of Acupuncture in 2008, which you can read about here.  The legislation required full NCCAOM OM certification, including herbs but included three caveats, as noted in the AT article:  1) acupuncturists practicing in the state at the time the legislation was passed, regardless of education and credentials, were grandfathered in;   2) the legislation did not interfere with the activities of other professionals who were allowed to perform acupuncture; 3) the Acupuncture Council was expressly allowed to waive the requirements as appropriate.

Remember – herbs are not regulated by the FDA, and products containing Chinese herbs are available in the grocery store (see Airborne), or on-line, and are available to the public without prescription or the involvement of any health care professional.

Delaware currently has about 35 LAcs serving a population of about 1 million people. According to my research, there are 9 NCCAOM AC Diplomates in DE, and another 6 OM Diplomates.  The decision of the Council only increases the odds that the people of Delaware will receive treatment from non-LAcs.

The way I see it, it isn’t the lack respect from the western world, competition from other professions, or inequities in insurance reimbursement that are the biggest problems facing the profession.  It is a system in which small groups of LAcs in various states have determined that more credentials and education are necessary, even for those who are already extensively trained in Acupuncture and Oriental Medicine. They work for laws and regulations that increase the cost and time necessary to obtain an acupuncture degree and limit practice opportunities for LAcs.  This increases the odds that the public will receive treatment from providers who are not LAcs.

With friends like this….