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by Corey

An ethical model of health care

When considering the most ethical model for the relationship between mainstream and alternative medicine, one that allows for all approaches to coexist within the current landscape of U.S. health care should be considered. The current state of mainstream medicine is a varied system that already has created a precedent for various practice models to arise. Imposing change on this will inevitably marginalize some providers and their disciplines.

Some conventional doctors have chosen to opt-out of contracts with insurance companies and third-party payers and deal directly with patients themselves. This approach, for all intents and purposes in the context of this analysis, is analogous with an opposition model. Whether collecting fees at the time of services rendered or as a retainer system like in direct primary care, both mainstream and alternative providers are already choosing to practice outside the mainstream insurance payment model.

An integrative approach is ethical to include in health care as it widens the marketplace and offers more services to benefit patients and potentially reduce overall costs for payers. An integrative model typically implies a collaborative multi-disciplinary approach to integration and not an opportunity for complete assimilation of one form medicine by another. This would need to hold in order to respect ethical concerns related to practitioners’ boundaries and scope of practice issues.

Plauralism offers a compatible model aligned with the values of today’s health care industry. If the U.S. decides to move to a universal coverage system, tolerance for the opposition model would still be most ethical, however, regulation of quality and safety of services would still be needed if those type of providers want to self-identify with practicing with medically-based relevance.

A health care system that reinforces an open exchange of ideas and cooperative efforts can support progress in methodology and policy arenas, both of which are imperative to address as ongoing reform continues.

by Corey

Acceptance of an integrative model of health care

As alternative medicine practitioners, we have reached the time where integration into the conventional U.S. medical system is occurring regardless of member’s resistance or support of it happening. While past efforts to promote this integration have helped provide a path to the present state, our patient population has quickened the process by growing in numbers as users of alternative practices such as acupuncture, herbal supplementation, and energy therapies while concurrently seeking conventional health care. Even though more and more doctors are being exposed to positive patient experiences with alternative medicine, it is clear that this is not sufficient evidence for the current conventional model to accept patient claims as actionable “truth” and include alternative therapies in their care plans. Efforts have been taken within alternative professions like acupuncture, already in existence with thousands of years of documented clinical expertise, to expand their practice to include a conventional medical understanding as well as advancement of their training to a doctorate level. This growth towards integrative practice can provide a segue towards a more collaborative approach, however, currently, qualitative patient testimonials and clinical expertise together do not create an adequate basis for comfort in most medical professionals to recommend alternative therapies as a common practice.

Research appears to be a key element that could lead to more widespread adoption of alternative therapies in the conventional system. By providing a systematically measurable and analyzable body of information and accepted facts, research is what motivates the current medical system to support new ideas into practice. However, varying paradigms among conventional and alternative approaches precipitates the need for a common agenda, language, and reporting guidelines for research and new evidence for it to be “universally” accepted. This can help to validate patient’s qualitative experiences, making this useful in research along with quantitative data.

More valid and accepted data will likely create a tipping point for recognition of proven alternative therapies but true acceptance, collaboration, and creation of integrative care plans by members of the conventional system will be necessary for integration on a national scale. Biases must be uncovered and shed by some of these conventional practitioners towards acceptance of new extrinsic ideas that may change or even challenge what they have established into the monolithic system in the U.S. This bias can extend to mistaking faith in a familiar paradigm and self-preservation for truly knowing that evidence is factual and actionable. By taking a deeper look into the underlying beliefs that influence their practical clinical relationship with scientific research, conventional practitioners may be more open to effectively evaluate alternative medical research and become more amenable to realizing a robust integrative model of health care in our country.

by Corey

A snapshot of acupuncture health policy

In recent years, there has been a growing demand from the public for acupuncture services in the U.S., leading to increased interest and scientific investigation into its effectiveness, safety, and potential uses within the U.S. health care system. The National Center for Complementary and Integrative Health (NCCIH), formerly known as the National Center for Complementary and Alternative Medicine (NCCAM), has funded the most rigorous acupuncture research to date to evaluate its use to ease the pain of chronic conditions such back and neck pain, osteoarthritis, shoulder pain, and headache (Vickers et al, 2012). Findings of this meta-analysis suggest that acupuncture’s effects on chronic pain are clinically significant, supporting the recommendation by NCCIH of referrals for acupuncture as a reasonable treatment option for people with chronic pain (NIH, 2018).

For most doctors practicing within the biomedical paradigm of the heath care system, these findings along with the growing base of evidence for acupuncture’s effectiveness may not be enough to promulgate regular referrals for acupuncture treatment in the context of standard care. However, amidst a growing concern for the widespread misuse of prescription opioids contributing to over 17,000 deaths in 2016 and $504 billion in economic costs (CEA, 2017), many in the health care system are looking to non-pharmacologic alternatives to manage chronic pain. This response to the Opioid Epidemic has drawn interest towards promoting acupuncture and other integrative therapies and inclusion of them in legislation like the Comprehensive Addiction and Recovery Act (CARA), signed into law in 2016, that mandated the Veterans Administration (VA) to expand acupuncture and other integrative health services as well as related research and education.

In fact, the VA has championed integrative health delivery on a national level through the creation of the Integrative Health Coordinating Center, a branch of the Office of Patient Centered Care and Cultural Transformation (OPCC&CT). The VA offers acupuncture or other integrative services in 93 percent of its nation-wide centers that treat more than six million veterans annually (Reddy, 2018). In addition, the VA’s 2018 policy to establish an occupational qualification standard for employment positions of state-licensed acupuncturists within the VA Health Administration further recognizes the advanced professional education, training, and experience of state-licensed acupuncturists and distinguishes their knowledge and skills from that of a certified acupuncturist physician with less acupuncture-specific training (NCCAOM, 2018). This status for licensed-acupuncturists to be acknowledged by a government standard (GS) rating of GS 9-12 helps to lend credibility to the profession of acupuncture and its perception in the national health care arena.

Similarly in 2018, acupuncturists earned a distinct Standard Occupational Code (SOC) by the Bureau of Labor and now have their own federally recognized labor category based on data that confirmed growth within their profession (NCCAOM, 2018). These developments in understanding on a government-level will undoubtedly help to advance the acupuncture profession as it continues to establish itself as a mainstay in standard medical care and make its way into future public policy initiatives.

Preserving the integrity of the profession of acupuncture by its licensed members has long been a priority within the community as most biomedical physicians are also permitted to practice acupuncture within the scope of their medical practices with little to no additional related training. Only three states (Hawaii, Montana, New Mexico) require that physicians obtain acupuncture licenses by completing an accredited program and two states (Vermont and Rhode Island) decreased their requirements over the past two decades, allowing physicians to deliver acupuncture within their scope of practice where in the past this was prohibited. State regulations for training and competency have been focused on safety, recognizing contraindications and complications, and observing the procedures of clean-needle technique (Lin & Tung, 2017). Licensed acupuncturists, who provide acupuncture according to East Asian medical theories of diagnosis and treatment, often criticize the lack of this holistic basis of understanding by certified acupuncture physicians and cite it as a key motivation in preserving the extent of their scope. Further investigation into the differences in outcomes by the two approaches to acupuncture is necessary to address the associated strengths and weaknesses.

Similar issues regarding preserving scope of practice and safety have recently come into question with regard to the use of acupuncture techniques by practitioners other than acupuncturists, specifically physical therapists, who are using a procedure called intramuscular manual therapy, commonly called “dry needling.” This physical therapy service involves the insertion needles into trigger-points of muscles and is sometimes being sought after in lieu of services by licensed acupuncturists because of its access through insurance coverage of physical therapy and rehabilitative services. State regulations in California, Utah, New York, Idaho, Hawaii, and Florida do not allow dry needling in their states because it involves puncturing the skin (Kinetacore, 2018). The American Academy of Physical Medicine and Rehabilitation (AAPMR) recognizes the risks associated with dry needing, such as bruising, hematoma, pneumothorax, nerve injury, vascular injury, and infection. Despite the legality of physical therapists being able to utilize this controversial procedure in most states, The AAPMR maintains their position that dry needling “should only be performed by practitioners with standard training and familiarity with routine use of needles in their practice, such as licensed acupuncturists or licensed medical physicians” (NCCAOM, 2012).

With the potential of future legislation providing greater access of acupuncture to a vast number of Americans, it is clear that may factors and stakeholders will be taken into consideration when crafting related policies and regulations. Licensed acupuncturists may continue to practice a form of the medicine most true to its origins and traditions but they also may need to share in the delivery of acupuncture with other health care providers to meet growing demand. Their role in shaping what that ultimately becomes will be a critical part in establishing the competencies required to maximize the impact that acupuncture can have within the wider landscape of America’s evolving health care system.

 

References

Kinetacore. (2018). Scope of practice. Retrieved from: <https://www.kinetacore.com/about/scope-of-practice/>

Lin K., Tung C. (2017). The regulation of the practice of acupuncture by physicians in the United States. Medical Acupuncture, 2017, 29(3):121-127. http://doi.org/10.1089/acu.2017.1235

National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). (2012). AAPM&R policy on dry needling. Retrieved from: <http://www.nccaom.org/resource-center/press/press-releases/aapmr-policy-on-dry-needling/>

National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). (2018). Acupuncturists now included in the Veterans Health Administration. Retrieved from: <http://www.nccaom.org/blog/2018/03/01/acupuncturists-in-va/>

National Institutes of Health (NIH). (2018) Acupuncture: In depth. Retrieved from:<https://nccih.nih.gov/health/acupuncture/introduction>

Reddy B. (2018). A model for integrative health in the U.S.. Acupuncture Today, 2018, 19(6):1526-7784

The Council of Economic Advisers (CEA). (2017). The Underestimated cost of the Opioid Crisis. Washington, DC: U.S. Government Printing Office.

Vickers A.J., Cronin A.M., Maschino A.C., Lewith G., Macpherson H., Foster N.E., Sherman K.J., Witt C.M., Linde K. (2012). Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Archives of Internal Medicine, 2012 Oct 22; 172(19):1444-53. http://doi.org/10.1001/archinternmed.2012.3654

by Corey

Fanaticism: Addressing a common response to the topic of acupuncture, “I don’t believe in it.”

Enthusiasm and passion are qualities often seen as being supportive to achieving goals and explaining ideas. Increased interest in any subject manner boosts people’s engagement level when speaking to others and often makes their message richer with details and personal insights. Zeal commonly has an interdependent relationship with a person’s beliefs and behaviors. Extreme enthusiasm can correlate with having a more defined belief system, yielding self-affirming behaviors and a use of language that reinforces faith in defined ideas. When this narrows tolerance for other ideas that may challenge those established, fanaticism can limit people’s discourse on any subject in view. Defensive arguments, judgments, and blind faith can grow while a person clings to their ideas as being infallible and integral to their perception of self-identity.

In the context of an inter-professional health care team, there is fanaticism in both the conventional and alternative communities. Fanaticism reinforces independence, which can be counter-productive to collaboration and the exchange of ideas from all members of the team. For acupuncturists interested in integration, I’m not sure if there’s clarity that we are even included yet on the “team” by the conventional medical community to reputably participate in the exchange of ideas and potentially be heard by their members.

As the position to have acupuncture firmly instated into our modern health care system is gaining traction, the focus seems to be about growing the amount of evidence in the form of data to carry the decision into common acceptance. However, for fanatics on both the conventional and alternative sides whose belief systems may be influencing their critical analysis of the efficacy of acupuncture, maintaining an impartial and inclusive perspective in our language and actions will be helpful to build bridges towards the open-mindedness that will be required, despite meeting the undefined threshold for a conclusive amount of data.