Assistance for the Working Acupuncturist

I went down the Facebook rabbit-hole, and while I was there I learned a few things.

For instance, “just a quick look” and “I’ll just scan my notifications” can quickly lead to a month without a blog post. I will not let that happen again.

Also, based on posts about HIPAA, insurance billing, choosing office space, maintaining records, etc., we have  a lot of questions and we are looking for answers. It’s great that we’ve got communities of colleagues to ask. It is also inefficient, and sometimes downright dangerous that our colleagues are often the only source of answers.

Looking at HIPAA and ADA for example, we see that some professions (but not acupuncturists) have access to lots of resources from their national associations.

  • a search of the AAAOM site gets one, not very useful hit, regarding HIPAA-related responsibilities.
  • Here’s information from the APTA (American Physical Therapy Association) site on HIPAA.
  • Here are the search results for HIPAA over at the American Chiropractic Association.
  • I can find no information on the AAAOM site about acupuncture offices and ADA compliance.
  • APTA provides these useful links about ADA compliance.
  • The American Psychological Association has great information about ADA compliance.

While acupuncture organizations are working on national legislation, increasing insurance coverage for acupuncture, adding an entry level degree, and fighting with other professions to limit the use of the acupuncture needle, we search for authoritative assistance on current practice issues in vain. (Luckily, the links above are pertinent to our practices.)

To make matters worse, sometimes it seems that we prefer ignorance. In my time on Facebook I was reprimanded for self-promotion when I shared useful links to this blog, and I was threatened with banishment from Acupuncturists on Facebook because I “acted like [I] know it all.” (I don’t know it all. I do know a few things.)

When many of us don’t understand or comply with our obligations under the ADA and HIPAA, are we ready to be a part of the Medicare system or have acupuncture be an EHB? Isn’t accurate information about ADA compliance an important part of our stated goal of having acupuncture accessible to all? It’s past time for our schools and organizations to make sure we have the skills, knowledge, resources and information to be successful practitioners now. The FPD, Medicare inclusion, higher standards, and expanding our scope/suing our competitors should wait.

Petitions, Medicare, and Licensure

Notable news items in the acu-world this week:

1)  We finally got a response to the petition to the White House to add acupuncturists to the list of Medicare providers. My regular readers already knew that a petition to the White House is not going to create the legislative and administrative changes that would be required.  (Newbies, you can use the tag cloud to find previous posts on the petition and Medicare.)  The response has (no surprise) created the usual teeth-gnashing, with acupuncturists (who seem not to have read the response) lamenting that Obama doesn’t like acupuncture, that it’s all about money and power, that we’re doomed,…. The conversation also shows that even among those most strongly advocating for becoming part of the system, there is still significant ignorance about what would be needed to succeed and the consequences for the profession of “success”.  Also not surprising — no response from the AAAOM or NCCAOM who helped distribute the petition — even though they should have known enough to predict the response and had a year to prepare.

2)  The latest Acupuncture Today newsletter included an article on the six states in “licensure limbo.”  I suspect that overzealous regulation on our part (for example, Delaware and Florida requiring extensive herbal credential requirements for acupuncture licensure) contributes to the lack of enthusiasm for a practice act among practitioners.  I also believe that the acupuncture community’s aggressive and disrespectful response to PT Dry Needling and to MD’s and DC’s who do acupuncture is a significant factor in the unwillingness of those communities to support a practice act in those states.  Actions have consequences.

3)  A new “threat” on the horizon — some LAcs on Facebook are up in arms about Tattoo artists who are doing “dry tattooing” for skin rejuvenation.  You know the drill — how dare they, we have so much training, we need to gather the troops to fend off this encroachment. My points — tattoo artists can use needles, they can do cosmetic work (tattooing eyebrows for people with alopecia and tattooing nipples for people who have had breast reconstruction, for example) and they could tattoo someone’s face completely blue if the client wanted it.  Facial rejuvenation acupuncture is typically not taught in acupuncture school. Is there any reason (other than arrogant self-importance) why we believe we should have control over this technique?

I’m still adjusting to the addition of Facebook into my life. I haven’t figured out how to stay informed and involved there without taking the energy and the dialogue away from The Acupuncture Observer.  For those of you on Facebook, like the Observer page and you’ll get breaking news updates between blog posts.

Also, for those of you interested in learning more about navigating the political/regulatory system I’ll be doing a breakout session at POCAfest,  on March 15th in Tucson.  I’d also be happy to come to your state association meeting, conference, or other event. Knowledge is power.

2013 Review for Acupuncture Professionals

As 2013 was dawning, the WhiteHouse.gov petition to include acupuncture in Medicare was circulated by the AAAOM, NCCAOM, and loads of school and practitioners. Because coverage is not determined by the executive branch, over 30,000 signatures made no difference. That our professional organizations either didn’t know enough or didn’t care enough to educate acupuncturists about how the system works did give me the final push to create The Acupuncture Observer. From the first post last January through # 49 today, I’ve tried to provide thought-provoking strategic analysis of where we are and where we are headed.

The planned March AAAOM conference on a cruise ship didn’t set sail, making 2013 the second consecutive year without a conference. Things began looking up with April’s announcement that experienced professional Denise Graham was named AAAOM Executive Director.

However, by mid December, Ms. Graham and three Board members had resigned. (Previous ED, Christian Ellis, managed only three months in the fall of 2010.) A majority of the current board members have been appointed rather than elected. Something at the AAAOM smells. The Whistleblower Protection Policy, prepared in conjunction with the Confidentiality Policy adopted in April 2012, never resurfaced after it was pulled by then President Michael Jabbour (who is now managing the “operational transition”). We’ll probably never learn what is really going on in the board room, but 2013 marks the year I gave up hope that the AAAOM could become a viable organization serving the profession. It’s now become a single-interest (Federal legislation) organization, under the control of a small number of people, and without the resources to accomplish its priorities.

Throughout 2013 qualified LAcs were denied licensure by the Delaware Acupuncture Advisory Council’s insistence on the NCCAOM OM credential. New Florida regulations will limit licensure to those with NCCAOM Herb credentials beginning in October 2014, putting another state off limits to many practitioners and greatly increasing educational costs and the regulatory burden for those who intend to practice in those jurisdictions.

Outrage at  P.T. Dry Needling continued throughout the year. Some LAcs made arguments that reflect poorly on our concern for the public, such as suggesting we’d drop our objections if PT’s agree to use hypodermic needles for this technique. Various state associations began efforts to redefine acupuncture and to push for discriminatory insurance policies in response to dry needling and the end of 2013 brought newcomer NCASI (and their lawsuit against Kinetacore) onto the scene.

Late Summer brought proposed policy changes from the NCCAOM that would move the group several steps closer to becoming a regulating rather than credentialing body. In a bit of good news, comments from the profession sent the proposals back to the drawing board.

Over the course of the year growing numbers of practitioners added insurance billing to their practices.  We’ve been quick to throw stones at the billing practices (or rumored practices) of PT’s, yet many acupuncturists offer justifications for questionable practices and few seem clear on the exact nature of their agreements with the insurance companies.

In the waning days of 2013 a job opening for a Licensed Acupuncturist at Brooke Army Medical Center was posted on Facebook. Initial responses cast an interesting light on our profession’s self-regard. There were complaints that the salary (about 70k) was too low, some suggested that a PT would certainly get the job, and others complained about the requirement for a flu shot.

In a few days I’ll be back and begin looking forward. What will serve us in the year of the Wood Horse? When the dragon brings the energy of the spring back to earth, how should the seeds of the profession grow?

Acupuncture & Insurance, Part 2 — Affordability

Many of us see it as a no-brainer. We want acupuncture to be affordable, insurance/Medicare makes it affordable, how could anyone be against that? This reasoning relies upon a superficial understanding of health care costs and affordability.

Consider:

  • Affordability must take into account premiums as well as co-pays and out-of-pocket expenses.
  • Both cost to the individual and sustainability of the system are part of affordability.
  • All medical costs are ultimately borne by the public.
  • When coverage is provided for the very sick, the premiums of many healthy people contribute to their medical expenses.
  • If health care spending exceeds what the insurance companies have planned for, premiums will go up and reimbursements for providers will go down.
  • Controlling health care spending depends upon providers accepting reduced payment for their services and upon a bureaucracy determining what services are appropriate.
  • The wealthiest in our system typically have the best insurance coverage.

A respected colleague said I give the impression that Community Acupuncture is the only way for people to get affordable acupuncture and that everyone should treat that way. My bad — I don’t believe that. I do believe it is a good way — it accepts the reality that acupuncture isn’t really more affordable if it doesn’t cost the system less. It provides affordable treatment to everyone, not just to those with the best insurance coverage. And it keeps big business out of treatment decisions.

I continue to treat one client at a time, in a private room. I have a generous sliding scale, available to all, to help a wide range of people afford acupuncture.  Some practitioners treat in private rooms and charge one low price to all patients. I have colleagues who reserve a certain percentage of their appointments for those who need steeply discounted services, and I have others who volunteer in free or low-cost clinics. These are all ways to make acupuncture affordable.

Disguising the cost of acupuncture by hiding the expense in co-pays and premiums (many so expensive that they are subsidized by taxpayers) doesn’t make it more affordable. Changing the way you treat so that your reimbursements match what you think you deserve doesn’t make acupuncture more affordable (or support arguments for cost effectiveness).

CA is not the only way to make acupuncture affordable and I certainly don’t think it is the only style of treatment that should be available.  But insurance increases the big picture affordability of acupuncture only to the extent that it limits reimbursement rates and access.  Insurance is not a magic wand, and those practitioners who believe it is are in for a rude surprise.

For more, check out this post, and these statistics about the increases in health care spending in the US.

The Acupuncture Profession, News and Analysis

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.)

 

AAAOM Medicare Town Hall

A few folks asked me to post after the Town Hall, so here goes —

Sorry to say I missed the beginning of the call — the instructions to join were not easily available or straightforward.  At the peak, there were about 70 participants.

Bottom line, the AAAOM lacks the level of expertise they need before moving this legislation forward. The AAAOM does not have an idea of how many LAcs are likely to opt in, didn’t have the correct history of why the Chiropractors do not have the opt-out clause (and seemed to believe they currently can opt-out), didn’t realize that becoming part of the system would limit the amount non-participating providers could bill Medicare clients (a participant provided correct information), wasn’t clear that other providers would be able to bill for acupuncture if it becomes a covered service, hadn’t considered the impact on the practices of practitioners opting out, etc. The information about enrolling, opting in or out, participating or non-participating was still unclear.

A caller suggested it is premature to ask practitioners whether they’ll be likely to opt in — there are too many unknowns. I understand, but don’t we need some idea before we spend millions moving forward with the legislation? A few callers seemed confused about the difference between acupuncture as an EHB and the proposed legislation. Others seemed to think the legislation had already been introduced.

The bill writer/lobbyist wasn’t willing to make predictions, but I’ll go out on a limb. The AAAOM says they need about $1,000,000/year to move this legislation forward and the fundraising remains at around $25,000. According to the lobbyist she’s only been contracted for a month. The current Congress (113th) ends January 3rd, 2015. I say there is a 0% chance any of these bills will pass in the next year.

Would the AAAOM please focus their efforts on things that could help all practitioners now? In an ideal world they could work on both long term and short term projects, but this isn’t an ideal world. Without evidence that a significant majority of the profession intends to participate, why oh why is this legislative effort their only focus?

I hope everyone had a great Thanksgiving.  I did.

Acupuncturists and Medicare, Questions for the AAAOM

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

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

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

Happy Thanksgiving everyone — and thanks for reading.

Health Insurance for the LAc — Important Point #1

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

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

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

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

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

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

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

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

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

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

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

Please support discrimination?!?

Another entry in our Hypocrites with Double Standards (HWDS) files?

I’ve been reading about the importance of Section 2706 of the Affordable Care Act for our profession. It wouldn’t be right for insurance companies to cover acupuncture only if performed by an MD, right? The concerns within our community, according to the press, are that the section might be undermined by the actions of the AMA (this makes us angry!) or not strongly enforced.

Okay, non-discrimination good.

Wait a second — AOMSM, the Massachusetts acupuncture association, is pushing legislation that discriminates.  Section 7 of S1107 and H2021 reads “The use of needles on trigger points, Ashi points, and/or for intramuscular needling for the treatment of myofascial pain will be considered the practice of acupuncture” (does it matter what type of needles?) and Section 8 reads “Only licensed acupuncturists or medical doctors shall be reimbursed for acupuncture services.” Is anyone surprised that “political agents for PTs in MA have taken measures to prevent “An Act Relative to the Practice of Acupuncture” from advancing”?

So — discrimination is good if it works in my favor, bad if it works against me?  How does this reflect on our profession and the future of integrated health? Not well, in my opinion.  What do you think?

If I Had 3 Million Dollars

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.