December 2011 John Weeks Integrator Round-up
AMA’s Influence on the Relative Value Payment Scale Attacked in Court, Congress
Under a two-decade old relationship, a panel dominated by tertiary-care-based specialty societies of the American Medical Association has met behind closed doors to set fee structures which, over 90% of the time, guide reimbursement policies of the US government. AMA’s Relative Value Scale Update Committee, known as the RUC, is a 29-member panel of representatives from MD medical specialties. RUC determines the relative value of specific medical services then makes recommendations to the Center for Medicare and Medicaid Services (CMS). CMS typically rubber stamps these over 90% of the time. Now a group of primary care physicians based in Atlanta, Georgia is suing the US government to end the practice and make the advisory group a US panel that will operate with transparency.
The suit is supported by Congressman Jim McDermott (D-WA). McDermott, a psychiatrist, has independently introduced legislation that, while it would not strip the RUC away from the AMA, would create more balance in its membership and openness in its processes. McDermott told Medpage that he supports efforts, whether judicial or legislative that seek to limit the influence of high-end specialties on rate-setting at the Centers for Medicare and Medicaid Services. On March 30, McDermott posted on his website that “for two decades now, this panel has been dominated by specialists who undervalue the essential and complex work of primary care providers and cognitive specialists, while often favoring unnecessarily complex, costly and excessive specialty medical services,” said McDermott in a statement posted on his website in March 2011. The American Academy of Family Physicians supports the McDermott legislative, which is entitled the Medicare Physician Payment Transparency and Assessment Act of 2011 (H.R. 1256).
The Atlanta doctors argue in their August 5, 2011 posting on their webpage, that the relationship between the RUC and CMS “creates systemic incentives to provide unnecessary and unnecessarily complex services.” They add that “it is not unreasonable to argue that this single relationship is the core driver of runaway healthcare costs, threatening the stability of American healthcare economy and the larger U.S. economy.” The doctors are also collecting donations for the lawsuit through the site.
Comment: I agree that the power of the specialists as expressed through RUC is a huge barrier to change. Any honest SWAT analysis, or treatment plan, would identify the RUC diversion of resource and target a plan to remove this obstacle to cure. Good for these Atlanta doctors and for McDermott. Each of the integrative practice fields should file amicus briefs, in they haven’t already.
Accountable Care Organization CEO calls integrative medicine a financial asset in Obamacare model
“For the first time ever, the payment will change toward keeping people healthy … For the first time in 100 years it will be our job at Allina to keep the village healthy.” So spoke Ken Paulus, CEO of Minnesota’s huge Allina Hospitals & Clinics at the November 10, 2011 Integrative Medicine in Action event hosted by the Bravewell Collaborative. This shift, Paulus believes, will be “the point of inflection” for integrative medicine. He is quoted in this Huffington Post article:
“When I first heard of integrative medicine, I saw you as an expense. But [as payment in Accountable Care Organization (ACO) structures] kicks in that supports keeping people healthy, you will be an asset. Integrative medicine will be an asset.”
Paulus did not describe the exact details of how ACOs will support this shift. Instead he referenced the story of Chinese barefoot doctors who were only paid by communities if the people in their charge were kept healthy. Paulus positioned integrative approaches as aides in such health creation.
Comment: I had the opportunity to hear Paulus’ comments and felt a certain giddiness that may only be explained as the promised resolution of unrequited desire for economic alignment for integrative medicine. Capitalism in US medicine tends toward the big margins of what might be called SUV medicine: inpatient services, patented drugs and high-tech machines. Paulus suggested that the ACOs established by the Obama-Pelosi reform are creating a context for developing what some of us 10 years ago dubbed “a thriving industry of health creation.” This provoked a re-publication of the Design Principles for Healthcare Renewal for which this phrase was crafted as part of Principle #9.
Patient-Centered Medical Home leaders Zunin and Trompeter see exceptional opportunities for integrative teams
In preparation with integrative pediatrician Larry Rosen, MD for a February 11, 2012 presentation on ACOs, PCMHs and integrative medicine at the Integrative Healthcare Symposium, I recently interviewed two integrative health leaders with emerging patient-centered medical homes (PCMHs). The topic: How do they see they see the potential fit with integrative health approaches? Tom Trompeter, MHA, is CEO of Healthpoint, a network of 10 federally-qualified health centers in the Seattle-area. For 15 years, these centers have integrated services of naturopathic physicians, licensed acupuncturists and massage therapists with their PhD psychologists, nutritionists, dentists and MD/RN staff. Trompeter speaks of the PCMH, which he prefers to call a “health home,” as a “break from the paradigm of a physician owning a patient.” Similarly: “It’s not about the billable visit.” The concept of patient ownership shifts, in Trompeter’s view: “My patient needs to transition to our patient.” He believes this opens the door to teams and “the team approach opens the door for diversity” of providers and services. The Trompeter interview is here.
Integrative physician Ira Zunin, MD, MPH, MBA is the founder of the 40 practitioner Manakai O Malama center in Honolulu. Zunin’s clinic was approached by leaders of the local delivery system to merge his center with the area hospital and payers through linked electronic medical records (EMR). Zunin describes significant immediate value via increase in referrals that the EMR created for his acupuncturists, massage therapists and naturopathic doctor. He underscores Trompeter’s point on payment: “In the PCMH, payment plays into our hand. You have unassigned dollars that aren’t directly connected to a provider or a procedure or a code. You can use the dollars from an integrative perspective.” In this Integrator interview, Zunin speak also to the significant challenges. Yet his overall view is positive: “The PCMH model is supposed to help the whole person, in his or her community. We’ve always been looking at everything with a bigger tool set, with a focus on health. We’re oriented to this model. We’re oriented to teams.”
Comment: Since these interviews, I found myself listening to a local practitioner bemoaning the awkward fit of the insurance coding dance for a whole person practice that is relationship-based, time-intensive and individualized. I was pleased to say: You might check in with the leaders of the local ACO movement to see if you can get paid to keep people healthy. Their may be light at the end of integrative medicine’s economic tunnel.
Integrative medicine loses a friend in a high place as Berwick gets “pink slip” from Republicans
Comment: Healthcare writer Joe Nocera caught up with Donald Berwick, MD within a week of Berwick’s exit from his recess appointment as administrator of the Centers for Medicare and Medicaid Services (CMS). In his December 5, 2011 New York Times op-ed piece (Berwick’s Pink Slip) Nocera writes: “Dr. Berwick, I’m here to tell you, was the most qualified person in the country to run Medicare at this critical juncture, and the fact that he is no longer in the job is the country’s loss.” I agree. The fact that Berwick once spoke favorably about the British health system model that costs half as much as that in the US and produces better outcomes sealed his fate before his Republican executioners. Berwick’s extension of evidence-based medicine to evidence-based policy-making is apparently as palatable to medical business-as-usual as is the science behind global warming for Big Oil. The waste-trough of US medicine, estimated by leaders at the Institute of Medicine to be at 50% of the $2.6-trillion spent annually, seems to have only produced compelling evidence of a donor base, not scientific base, for the Republicans who pushed him out.
Meantime, when Berwick stepped down, integrative medicine lost a friend in a high place. As noted here, Berwick’s positive perspective on integrative medicine is on record. He was a keynoter at the February 2009 IOM Summit on Integrative Medicine and the Health of the Public. Berwick elucidated his “Basic Principles for Integrative Medicine.” They are worth restating here on his exit.
- Place the patient at the center.
- Individualize care.
- Welcome family and loved ones.
- Maximize healing influences within care.
- Maximize healing influences outside of care.
- Rely on sophisticated, disciplined evidence.
- Use all relevant capacities – waste nothing.
- Connect helping influences with each other.
This is a pretty darned good list to hang on the mirror as a daily reminder for those in the field of integrative health. Now, let’s see what Berwick, the founder of the Institute for Healthcare Improvement (IHI) will be up to next.
Freelancers Union’s insurance company to innovate alternative care in patient-centered medical home
The Freelancers Insurance Company (FIC) is pioneering strategies to bring alternative care into a patient–centered medical home, according to an article, Health Care for a Changing Work Force, in the December 1, 2011 New York Times. FIC reportedly has revenues of roughly $100 million and covers 25,000 independent workers. Because FIC maintains a close relationship with its insureds, “it can be more effective [than most plans] helping its members make good health care decisions.” Sara Horowitz, the founder of the Freelancers Union, which owns FIC, explains: “We’re moving away from fee-for-service medicine to one where a primary care doctor aggressively coordinates care … We’re also trying to innovate with alternative care — promoting meditation, yoga, and nutrition which can have long-term beneficial effects.” The article notes that in 2012, the organization will be opening up the Brooklyn Freelancers Medical Practice. This center will be a patient centered medical home (PCMH) based on the model of Rushika Fernandopulle, MD who “pioneered a team-based model of care that is attracting attention across the country.” The FIC’s rates are already a third below market. (Thanks to Integrator adviser Glenn Sabin for the link to this article.)
Grand Rapids ER’s new Center for Integrative Medicine anticipated to save system over $10-million each year
A new strategy for emergency room services based on a close partnership with an integrative medicine center is expected to save upwards of $300 million a year when expanded to 8 hospitals. In an MP3 available interview, Corey Waller, MD explains that the person-centered, time-intensive approach that will be mounted in Grand Rapids, Michigan focused on high-utilizers. Waller’s team identified 953 people in the system who accounted for 20,000 visits in 2007-2011. A pilot study of just 30 patients found ER services could be reduced visits by 85% for each participant for a savings of $1-million. The intensive treatment at the integrative medicine center begins with a 4 hour visit. This includes an hour each with an MD, a nurse case worker, an MSW for psychiatric and substance-related diagnosis and then a “regular social worker” and office staff who focus on community support issues. Patients are being recruited to the center by directly calling those who used the ER 10 or more times in the previous year. The program is expected to cost $950,000 a year but is expected to save the ER $3.5 million and also reduce costs by some $25-$35 million for the two feeder hospitals. Spectrum health’s news release is here.
Comment: My first feeling on listening to the MP3 regarded the horror of current practices. How can we have drifted to a point where such huge savings are ostensibly such low-hanging if we just organize some caring contact? Why are we only getting on this now?
I also find it interesting and even ironic that Spectrum chose to call their new clinic a “center for integrative medicine.” While the program is patently “integrative,” no one associated appears to have any direct relationship to what may be called the movement for integrative medicine. The re-frame brings to mind the way that Christy Mack, head of the Bravewell Collaborative, pointedly declares that “integrative medicine is not CAM.” Now the Spectrum group appears to be declaring that integrative medicine is not integrative medicine. The Spectrum version is a bio-psycho-social-environmental team-based approach with no apparent connection with the integrative medicine in academic medicine field, such as Mack and Bravewell have backed. Nor does the Spectrum model reflect services advanced in the holistic medical community, or in the CAM disciplines. One way to look at this is to simply declare success. That said, it would be interesting to see how integrative medicine and CAM leaders might add value to this already remarkable integrative medicine initiative.
Arizona Center for Integrative Medicine partners with Maricopa County to pilot test integrative primary care clinic
According to a November 28, 2011 release, the University of Arizona Center for Integrative Medicine (AzCIM) has engaged a partnership with Maricopa County, Arizona [Phoenix] to pilot delivery of integrative medicine to the county’s 13,000 public employees. Medical outcomes and costs will be compared between patients receiving conventional medical care and those receiving integrative care. The Adolph Coors Foundation funded the pilot, which is expected to generate publishable data on the effect of integrative medicine on patients’ health.
The Phoenix Integrative Primary Care Clinic is slated to open in July 2012. Says Andrew Weil, MD, founder of the Arizona Center: “We believe this is the first step toward changing priorities of reimbursement, away from disease management and dependence on costly pharmaceutical drugs and other high-tech interventions, and toward sustainable wellness,” said Andrew Weil, MD. Roughly 1500 employees are expected to access services the first year. David Smith, Maricopa County manager explains the county’s interest this way: “Given the current health-care cost spiral and obesity crisis in the United States, the Maricopa County Board of Supervisors has decided to make preventive integrative care and treatment options more accessible to our employees.” Initial information on the program does not specify what sort of integrative services would be offered. A useful article on the project is here. A PDF of the agreement between the two entities is here.
Comment: The program, while certainly not the “first step toward changing priorities of reimbursement,” is an interesting and perhaps even high-risk gambit for the University of Arizona Center. The Center is not known for the clinical components of its training. It’s signature fellowship is principally online. What will an “integrative medicine intervention” include? What population(s) will the clinic target? A smart move might be to emulate the Spectrum Health program, reported above, and bring in those high utilizers.
Donna Karan brings Urban Zen Integrative Therapy program to UCLA
The New York-based Urban Zen Integrative Therapy Program is now officially bi-coastal. The Donna Karan backed program announced on November 18, 2011 that it is partnering with UCLA. A first group of 30 doctors, nurses and other allied health professionals began training in September. Gillian Cilibrasi, Urban Zen’s program director explains: “During this curriculum, medical professionals from the UCLA Health System (are) trained in five modalities of treatment: yoga therapy, Reiki, essential oil therapy, nutrition and contemplative care.” In comments contained in the release, David Feinberg, MD, MBA, president of the UCLA Health System, positions the Karan initiative as advancing UCLA’s long-time commitment to integrative approaches. Referenced were the UCLA Center for East-West Medicine and UCLA’s Mindful Awareness Research Center. The Ronald Reagan UCLA Medical Center, part of the UCLA Health System, is the first UCLA hospital and the first on the West Coast to adopt the Urban Zen program.
Comment: I confess to wondering when I first heard about Urban Zen’s go-it-alone expansion plans. Hollywood is clearly the next best place to leverage Karan’s name and involvement to secure the additional philanthropic support that UCLA has already announced that it will be seeking.
Business of Integrative Medicine
Update from Roger Jahnke, OMD: Advancing the understanding, science and adoption of Qigong and Tai chi
An early leader in integrative health is author, consultant, organizer and teacher Roger Jahnke, OMD. Jahnke has a list of organizations with which he as consulted over the past 15 years that is as long as your arm. He contacted me recently on what was being done, if anything, with the Design Principles for Healthcare Renewal. He and I were involved in developing these in 2001.
The contact provided a chance to catch up with Jahnke. The co-founder and past chair of the National Qigong association recently keynoted Mindbody Week in Washington, DC with Herbert Benson, MD. A year ago, Jahnke was lead author for A Comprehensive Review of Qigong and Tai Chi published in the influential American Journal of Health Promotion. With that foundation, the author of The Healer Within and other books is presently involved in training staff at the Veteran’s Administration on the values of Qigong and Tai chi. Jahnke and his group also recently completed a Phase 1 SBIR trial with NIH National Center for Complementary and Alternative Medicine. He reports “excellent results.” They are preparing a Phase 2 submission. Meantime, his own Institute for Integral Qigong and Tai Chi Jahnke has surpassed 1000 in the total number of “teachers and practice leaders” trained.
Comment: The challenges in finding business models for integrative medicine have swallowed many a sailor. That Jahnke has persevered is testament to the broad set of skills and abilities he brings to diverse integrative health stakeholders. Jahnke has one of the more interesting resumes of survivors. He wrote: “I remain inspired by the ‘principles’, when do you think you will resurrect? Would be honored to participate.” Below is a minor resurrection. It’s timely, for reasons I note.
10 Years After: “Design Principles for Healthcare Renewal” Resonate for Integrative Medicine’s Future
Recently long-time integrative health author, system-consultant and pioneer Roger Jahnke, OMD urged me to “resurrect” a document from the early years of integrative health that we called the Design Principles for Healthcare Renewal. I realized on considering this that it is almost exactly a decade since these were well-received in October 2001 as a clarifying document by the members of the White House Commission on Complementary and Alternative Medicine Policy. Jahnke’s request also resonated with a presentation at the Bravewell Integrative Medicine in Action event November 10, 2011. There Allina CEO Ken Paulus (see above) suggested that the US might finally be on the verge of an economic incentive structure to support a “thriving industry of health creation” (Principle #9). Those 10 principles, borne out of a Task Force on Principles from the 2000 Integrative Medicine Industry Leadership Summit are reprinted in this article.
Comment: Do these have useful resonance for you? I view 3 sections as particularly potent, yet under-expressed in the evolution of integrative medicine since 2001. These are the concepts of the “hierarchy of treatment” (#4), the respect for the “fullness of diverse health care systems” (#5) and then, the principle that stimulated this re-publication, the need to stimulate development of a “thriving industry of health creation” (#9). The Obama-Pelosi health reform appears to be a boost to the latter. Is there yet more value in “resurrecting” these principles further?
Academic Health Care
Why complementary and integrative medicine stakeholders should piggy-back on the interprofessional education/care movement
Roughly 750 professionals and clinicians involved in interprofessional education and care (IPE/C) attended the 3rd biennial Collaboration Across Borders conference in Tucson, November 19-21, 2011. The robust gathering, double the size of previous events, was described as a point of arrival for interprofessional education by the leaders of the movement. Team-care focused health professions education has a stronger foot-hold in Canada than in the United States. Speaker David Moen, MD, president of a 1300 physician Fairview Physician Associates told attendees that the value of interprofessional teams in US healthcare is advancing dramatically under changes in payment stimulated by Obama’s Affordable Care Act. These include payments related to patient satisfaction, limiting re-admission rates and lowering of tertiary care costs. Enhanced teamwork is anticipated to help produce these financial benefits. This in turn is expected to stimulate investment in IPE/C. Moen and others view this shift toward teams as a “culture change” throughout academic medicine and delivery.
Comment: IPE/C was first advanced in US medicine via the community clinic movement in the late 1960s and early 1970s. The field failed to gain traction as costs, waste and errors increased under a specialist-dominated system. The present rebirth of IPE/C followed the 1999 publication of To Err is Human by the Institute of Medicine. The report found that medicine kills over 100,000 a year, ranking it among the nation’s major killers. Subsequent analysis, published by the IOM in 2001 as Crossing the Quality Chasm, indicated that the most significant factor in medical errors is the lack of communication, understanding and mutual respect among doctors, nurses and other professions.
The parallel perspectives of Moen, regarding IPE/C’s re-emergence, and those of Allina leader Paulus, noted above, relative to the more positive horizon for integrative medicine, are striking. The changed payment structure under the Obama reform is opening interest in both IPE/C and integrative medicine. Enhancing teamwork is core to IPE/C and sometimes central to the integrative medicine effort. Colleagues in the Academic Consortium for Complementary and Alternative Health Care (ACCAHC) organized a donor-backed campaign that stimulated roughly a dozen representatives from educational institutions in these disciplines to attend the conference. This multi-disciplinary, allied-health-dominated community was quite receptive to integrative health ideas and disciplines. While the academic integrative medicine community was not well-represented in this conference, success of integrative medicine may be closely linked to IPE/C even as each appears to be linked to the shifting financial incentives under Obamacare.
The Collaboration Across the Borders IV meeting will be in Vancouver, BC in 2014. Another significant IPE/C conference will take place May 18-19, 2012 at Jefferson University entitled “Interprofessional Care for the 21st Century: Redefining Education and Practice.”
Pacific College of Oriental Medicine announces new holistic nursing program
Pacific College of Oriental Medicine (PCOM) announced on November 30, 2012 that it will begin offering a unique holistic nursing Bachelor of Science Completion Program in Holistic Nursing through its New York Campus. This is the first bachelor degree nursing program within a CAM school in the country. The program was developed in consultation with Carla Mariano, EdD, RN, AHN-BC, FAAIM, who also initiated the holistic nurse practitioner program at New York University and is past-president of the American Holistic Nurses Association. Mariano told the Integrator that the program is particularly timely as the nursing profession has a growing commitment to establish a bachelors’ level as the basic educational standard for professional nursing. “BSN in 10” refers to the pending legislation requiring associate degree registered nurses to obtain the baccalaureate degree in nursing within 10 years of initial licensure. The states of New York and New Jersey each have legislation promoting this change. This direction for the nursing field was propelled by the October 2010 Future of Nursing report from the Institute of Medicine and Robert Wood Johnson Foundation.
Comment: Mariano, an Integrator adviser, notes other features of the PCOM program that are expected to draw nurses: “Integrative holistic health care is becoming more mainstream and nurses are increasingly focused the whole person and holism as a practice framework. PCOM nursing students will be prepared in holistic theory and therapies for health, healing, and wellness as well as leadership, community, and research.” She thinks that “a nursing program in a CAM school” will be attractive for the “interdisciplinary nature of the learning environment.” Students from acupuncture, massage, and nursing programs will share a number of required and elective courses. In addition, the nursing students are expected to have the opportunity to participate in various PCOM community health and health promotion programs.
Comment: This is a smart, intriguing link for PCOM, an entrepreneurial, for-profit AOM school. It will be interesting to see how this model of integrated education matures.
First naturopathic student participates in month-long integrative medicine elective at Weil’s Arizona program
A November e-bulletin from the Association of Accredited Naturopathic Medical Colleges notes that earlier this year Adrienne Stewart became the first naturopathic medical student selected to participate in the month-long elective rotation in integrative medicine at the Arizona Center for Integrative Medicine. Stewart, now a naturopathic physician graduate from the Southwest College of Naturopathic Medicine (SCNM), jointed a group of MD students and residents from across the United States. A brief note in the SCNM news states:
“Dr. Stewart finished this rotation with a great sense of community and gratitude. As the first naturopathic physician to attend this rotation, she recognizes the need for naturopathic physicians to be involved in the discussion of integrative medicine. She says, ‘Making positive changes from the current health paradigm requires one of our greatest principles-docere. Docere not only involves the doctor and patient relationship, but also extends to doctors as educators throughout our evolving healthcare system.'”
Comment: Kudos to the Az Center for opening the door and to Stewart for walking through. My guess is that the interprofessional component of this educational experience may have been as rich for both Stewart and her conventional classmates as were any of the courses.
Holistic leader Forbes and ABIHM on grandfathering plans for the Arizona Center’s new Board Certification in Integrative Medicine
“The proposed merging process, we anticipate, will include ‘grandfathering’ of current ABIHM diplomates, making the value of becoming certified over this next year a highly valuable proposition that any interested physician (MDs and DOs) should strongly consider. Now is the time!” So writes David Forbes, MD, ABIHM, past president of the American Holistic Medical Association (AHMA) in the recent issue of AHMA’s newsletter. The italics are his. He expands: “Movement is occurring to merge interests with the Arizona Center for Integrative Medicine in an endeavor to further hone an Integrative Medicine Board Exam and increase the clout and credentials that such certification would bring.” Forbes concludes by underscoring the potential future value of the getting certified through the American Board of Integrative Holistic Medicine (ABIHM) today: “If you are not certified yet by ABIHM, I urge you to do it next year! It is a deeply valuable experience, an unparalleled exposure to the best of holistic/integrative education, and a credential that is only going to exponentially increase in value over the coming years.”
The web-page of the ABIHM makes it clear that the ABIHM is fully backing the University of Arizona-led effort to create a more formal board certification in integrative medicine through a relationship with the American Board of Physician Specialties (ABPS). Grandfathering appears to be understood: “At this time, it appears that ABIHM Diplomates whose status is current will be forgiven the fellowship requirement for sitting for the [new] exam. All ABIHM Diplomates who wish to become certified by the ABPS will be required to sit for the new exam.”
Comment: It’s a foolish medical doctor with any interest in integrative medicine who will not get moving on getting the ABIHM certification if he or she hasn’t got it already. “Forgiving the fellowship” forgives a $30,000 tuition fee, plus a significant time commitment.
OBGyns re-publish CAM booklet written by Tracy Gaudet, MD
The October 2011 edition of Clinical Updates Women’s Health Care from the American College of Obstetricians and Gynecologists is entitled Complementary and Alternative Medicine. The author is Tracy Gaudet, MD, former director of integrative medicine programs at the University of Arizona and at Duke University. The 98-page monograph was first published in 2004. The intent is stated in the abstract: ” … to help (OBGyns) guide patients in their treatment choices, including guiding them away from potentially dangerous alternative treatments and supporting their use of potentially beneficial treatments.” Herb-drug negative interactions are highlighted early. Figure 1 provides readers a helpful “protocol for integrating complementary and alternative medicine with conventional medicine.” Page 78 offers a 16 question exam that can be taken to gain CME credit. Chiropractors will not be pleased to see that the very first question asks about “the most significant risk” from their services.
Battle between licensed acupuncturists and “dry-needling” escalates
Portland, Oregon-based Marilyn Walkey, MD, LAc is a rare medical doctor who has also completed discipline-level training in acupuncture and Oriental medicine (AOM) and gained licensing in that field. Walkey is not a fan of medical doctors or other practitioners who take short courses to practice “dry-needling” or other techniques that appear to the common person to be acupuncture. On November 25, 2011, she sent a link which she editorialized in an e-mail was “wonderful news from Medicare regarding ‘dry-needling.'” The document noted that one Mark Bucksbaum, MD from the Center for Integrative Medicine in Rutland, Vermont had paid $35,000 to settle with Medicare. The reason: Bucksbaum billed the federal agency for “trigger point injections” when these were actually “dry needling,” according to assistant US attorney Kevin Doyle. Doyle said that the only legitimate way to bill for such services was to use acupuncture codes, which are not covered by Medicare.
Meantime, across the country, in Walkey’s homestate of Oregon, the Oregon Association of Acupuncture and Oriental Medicine received a supportive finding in its suit against the state’s Board of Chiropractic Examiners and the University of Western States, which is principally a chiropractic school. The acupuncture association argues that “dry needling” as practiced by chiropractors is “substantially the same” as acupuncture, and therefore should be illegal. Walkey sent notice in mid-November that the judge has found the OAAOM had a “likelihood of winning on merits.”
Comment: Inside the multidisciplinary Academic Consortium for Complementary and Alternative Health Care (ACCAHC) we call these guild-battles “hotspots.” They come up a lot. One field’s expansion of practice by adding a modality threatens another’s basic practice. AOM practitioners may add Western herbs or homeopathy to their score with no additional required education. These cross over into the naturopathic doctor’s core training. Or to reverse the situation AOM-DC battle over needles, the AOM practitioner may use limited training in Tuina to effectively cause spinal adjustment but without education in chiropractic manipulation. Similarly, naturopathic doctors practice spinal manipulation based on far fewer hours than chiropractors. And NDs have the right to practice acupuncture in some states, as many states chiropractors and medical doctors do, based on 200-300 or fewer hours of education. Virtually all licensed integrative practitioners can give massage, regardless of whether their training touches even a 500 hour basic massage curriculum. Meantime, integrative medical doctors piece together practices through a series of weekend or multi-weekend courses that rarely come close to matching the educational background of naturopathic doctors. At the same time, NDs and DCs claim rights as “primary care doctors” without completing post-graduate residencies.
We in ACCAHC have attempted to find “cooling places” for the “hotspots.” What are the principles that might guide educators through this mine-field of guild sniping and bombing?
Our ACCAHC discussions (we have no position statement) have suggested that all disciplines make significant distinctions between modality-level education and discipline level education. Educators in any discipline that adds therapies through “modality level” training (such as acupuncture for pain) would optimally be required to make a point of thoroughly educating students to the substantially higher standards of those who have completed discipline-level training. Example: the licensed acupuncture and Oriental medicine practitioner. Then there is the basic Pew Commission koan, as my colleague and ACCAHC co-founder Pamela Snider, ND learned through an examination of the naturopathic profession by the UCSF Center on Health Professions: Training to tested competency to scope. Something tells me that the acupuncturist versus dry needling battle will persist for some time regardless of any reasonable cooling points.
Acupuncturist job listing for the Army puts salary at $73,000-$95,000
In mid-November a federal government jobs listing asked for two licensed acupuncturists for the Army Madigan Medical Center, joint Base Lewis-McChord outside Tacoma, Washington. The listing is for a salary range of $73,4200-$95,444 per year. The two professionals will be part of the Interdisciplinary Pain Management Center. The Center is described as:
” … focus(ing) on pain management strategies that are holistic, multidisciplinary, and put Soldiers quality of life first. As a licensed Acupuncturist, you will offer a full array of current and emerging evidenced-based approaches for patients with acute and chronic pain who have not responded well to conventional treatment modalities. You will work within a multidisciplinary team to provide assessment, planning, implementation, coordination, evaluation, and monitoring of patients for health options and services. You will assist in developing, analyzing, integrating, monitoring, and managing healthcare delivery systems through communication and use of resources to promote quality and cost-effective outcomes across the continuum.”
Comment: We are accustomed to seeing high-tech developments created in the military then translated for civilian use. Makes me smile to think that it is the military that is testing out the deeper integration of licensed acupuncturists for later export to regular medicine. (Thanks to Stacy Gomes, EdD, vice president for academic medicine at the Pacific College of Oriental Medicine for the tip.)
Model naturopathic standards of practice and ethics sections expected to be added to Hawai’i law
The state of Hawai’i has passed into law a new section on Standards of Practice, Care & Ethics for naturopathic physicians. The American Association of Naturopathic Physicians honored the state society for its work in passing the amendments to its practice act, calling it a “model for all states.” Some components of the Ethics section include:
- A requirement on “sufficient time” for individualized assessment and treatment (6C)
- Referral (7C)
- Requirement to not only “communicate but to educate” (8A)
- Disclosure of any financial benefit from selling natural products (9B)
The Standards of Practice portion includes a section on the NDs role in health promotion. A focus on health optimization is declared, as is the NDs responsibility to “encourage a patient toward independence and self-direction.”
Comment: For individuals not familiar with the primary care naturopathic practice, this document may be a particularly useful read.
Industry group calls on FDA to withdraw “hugely flawed” program for new dietary ingredients
The American Herbal Products Association has called on the US Food and Drug Administration to “withdraw” its “hugely flawed” proposal for regulating new dietary ingredients (NDI) used in herbal and other dietary supplements. The FDA posted its plan in July of this year. In a December 5, 2011 release, AHPA took the following position:
“Instead of providing guidance regarding [Dietary Supplement Health and Education Act’s] DSHEA’s NDI notification provision, as directed by section 113(b) of the Food Safety Modernization Act (FSMA), the draft guidance seeks to erect extra-legal barriers to market entry, impose food additive- and pharmaceutical-type evaluative criteria, require multiple NDI notifications for dietary supplements beyond those required by law, and transform the legal requirements for marketing of dietary supplements that contain NDIs from the notification process described under law to an FDA approval process.”
AHPA executive director Michael McGuffin notes that the organization’s intention is to work with the agency. “One of the key features of AHPA’s comments is that it includes proposed solutions that specifically recommend revisions to the draft guidance,” McGuffin added. “AHPA has provided FDA with a thoughtful, thorough-and most importantly, lawful-starting point for revised guidance.” The full text of AHPA’s comments are here.
Comment: The American Botanical Council (ABC) took a position that focused on clarifying “old dietary ingredients. The 501c3 charitable organization urged that an expert advisory panel be created to develop such a list. The ABC response is here. Late breaking: AHPA sent a release December 6, 2011 noting that the 5 top trade associations are all calling for the FDA to withdraw the NDI document.
Chiropractic organization suggests regulation of NDIs may require legislation to restrain the FDA
In a release entitled “ACA Seeks Preservation of Patient Access to Dietary Supplements”, the American Chiropractic Association notified members that it believes that following a comment period, the FDA plan for new dietary ingredients (NDIs) will be “somewhat improved” over than the original proposal. However:
” … the Association believes it is unrealistic to expect the FDA to satisfactorily address the full range of the industry’s concerns, and that the final FDA requirements will still prove overly burdensome and harmful to the interest of DCs and their patients. If this proves to be the case, then the ACA and the supplement industry will have to turn to Congress in order to seek the enactment of a responsible legislative ‘fix’ to reign in the over-reach of the FDA with respect to the NDI guidance requirements — and the ACA fully anticipates supporting and cooperating with the industry in seeking enactment of the required legislative solution, and engaging the ACA’s grassroots resources in that battle. The ACA is monitoring the NDI issue on an on-going basis and will inform its membership if and when grassroots action is needed.”
A query to the American Association of Naturopathic Physicians (AANP) yielded a response at press-time. Their statement is posted here. The laud aspects of the regulation then note that access to 25% of products on the market may be impacted. Bottom line: “We believe it is in the consumers’ best interest to minimizing the use if overly burdensome regulations that do not impact the issues central to ensuring quality and patient safety.”
Marc Micozzi, PhD, MD co-authors Your Emotional Type with Michael Jawwer
“Your Emotional Type may be the Rosetta Stone we’ve been waiting for – a code for matching a particular therapy to a particular patient. Micozzi and Jawer have found gold.” So writes author Larry Dossey, MD in his liner note for this book co-authored by long-time integrative medicine leader Marc Micozzi, PhD, MD. Micozzi, the former director of integrative medicine at Jefferson University School of Medicine, was editor of the first textbook on complementary and integrative medicine. The new book appears to be hitting the public as an interesting hybrid: a science-based book, back-end loaded with references, that is also self-help and filled with useful resources. The authors, according to one reviewer, “look at the ways in which alternative healing modalities work in relation to not only particular illnesses, but also the personalities of people seeking treatment.”
In Memoriam: Canadian integrative oncology leader Roger Hayward Rogers, MD – 1929-2011
Roger Rogers, BA, BSW, MD, OBC died peacefully on November 22, 2011 in Victoria, BC. A note from backers of the Dr. Rogers’ Prize award that was established in his name stated simply: “His contributions to the field of integrative medicine and his tireless efforts to gain widespread recognition for – and acceptance of – complementary and alternative cancer treatments in this country have created a great legacy. His warm spirit will be greatly missed by his family, friends, and colleagues.” Rogers’ work will most certainly live after him. His integrative cancer model, InspireHealth was embraced last year by the government of British Columbia and effectively became provincial policy through a program to roll the model out to 5 new clinics. The biennial $250,000 Dr. Rogers’ Prize award will continue on, regularly gathering leaders of the North American integrative health community in Rogers’ name, to honor leaders among them. Rogers obituary is available here.