On (Not) Transforming Healthcare, Part One
a personal story of disillusionment, from a DAOM
Recently POCA Tech got a query from a prospective student who wanted to “integrate (acupuncture) with the standard model of Western medical care”, and who wanted to know whether our program would allow her to do so. It seems that the goal/dream/mirage/tar pit of getting acupuncturists into the Healthcare Industrial Complex en masse has established itself even among people who are otherwise savvy enough to do research before enrolling in acupuncture school.1
Thanks to subscriber Amelia Zahm, DAOM, we’re going to tackle that goal/dream/mirage/tar pit in detail. This is Part One of a three part account of how an acupuncturist who did everything, and I mean everything, right according to the standards of the acupuncture profession, ended up disillusioned with the system. Here’s Amy’s story:
I’ve been practicing acupuncture for 21 years. Before I start unpacking all my thoughts about the dysfunction of the profession, the predatory nature of acupuncture schools, and the myths surrounding integrating acupuncture into medical clinics, I must be clear that I love practicing acupuncture and Chinese medicine. I’ve worked in a fairly successful private practice, but often had to work side jobs to keep myself afloat. I’ve also worked as an employee of a federally qualified health center (FQHC).
I treasure the experiences I’ve had and the relationships I’ve built with patients over the years. I’ve seen the power of acupuncture to relieve a host of symptoms and provide relief for people when every other modality has failed. I’ve studied with, learned from, and worked alongside practitioners who are truly masters of this art, and my own practice has helped me understand the world, other people, and myself in new and profound ways. I’m grateful for this journey. And as things stand right now, I would not recommend embarking on this kind of career in acupuncture to anyone who asked me. This makes me really sad.
The idea that embedding acupuncture within the healthcare system will save money and give acupuncturists six figure salaries is one of the many myths floating around out there.
We’re all familiar with the conversation about Medicare coverage and acupuncture. Medicare approved payment for acupuncture for low back pain, but acupuncture must be provided by a Medicare provider (chiropractor, physical therapist or MD) or under the direct supervision of an MD. The current bill to allow acupuncturists to become Medicare providers2 is being touted as the solution for struggling acupuncturists everywhere and the key to open the doors for those long-promised jobs for acupuncturists in medical clinics.
If only it were that easy (and profitable).
I opened my private practice in a rural community right after graduating. This was my home town, so I knew many of the doctors. Over the years I built good relationships and had a positive reputation with the medical community. When one of the community’s two medical clinics was awarded funding to become an FQHC, I went to the medical director and asked her if they had considered including acupuncture as part of their program. Her response: “We’d love to. Write us a proposal. What is your dream?” I wrote a proposal. They responded with an offer, and I had the coveted salaried position.
The salary was around $40K, which was less than my gross income in private practice, but I figured that without business overhead and with the benefit package, I’d be coming out ahead. From the beginning, the question was always, how are we going to make this program viable? For me, this meant training the referrals team about where, how and when to get prior authorizations for acupuncture services, working with the billing team on correct coding for acupuncture claims, training the front desk staff to answer questions about scheduling and services, and educating doctors, nurses, and medical assistants about how and when to refer patients for acupuncture. I was lucky in that I already knew many of the people I was working with, and several of my colleagues, both admin and medical staff, had seen me for acupuncture.
Filling my schedule with patients was easy. Making sure the clinic got paid adequately for my services was the challenge.
I wrote my DAOM3 Capstone on the integration of acupuncture into the primary care setting, using data from the clinic I worked for. The study looked at a variety of patient data as well as financial viability of the acupuncture program. It showed that revenue for acupuncture services exceeded costs by 4%, hardly enough to support a six-figure salary for the acupuncturist. This narrow margin also assumes that insurance continues to pay for acupuncture at existing rates. Having an in-house acupuncturist certainly improved access to care and supported a more collaborative model of care, but it didn’t save money.
As anyone who’s worked in a medical clinic or been a patient knows, the time between getting a referral and receiving care is long. Staff must process the referral, determine benefits and eligibility, and then request and receive prior authorizations before scheduling patients. Visit counts must be tracked and new authorizations requested, often with additional paperwork. In our clinic, we had one staff member dedicated to working referrals for acupuncture and massage therapy. She was on the phone with insurance companies, including Medicaid, all day, every day, and it still took 2-3 weeks from the date of referral for a patient to get approval and an appointment. I can only imagine how the addition of Medicare patients will add to that burden.
Every year, the conversations in staff meetings were the same – how can we make this program pay for itself? Can we bill more? How do we reduce rejected claims? How do we simplify our work flow? Can we cut overhead? Do we need to limit services? As an FQHC, our clinic offered a sliding fee for medical services (required by law), including acupuncture and massage (not required by law). Patients without insurance and with low incomes could get acupuncture for $15/visit and massage therapy at a similarly reduced rate. It quickly became clear that this model wasn’t sustainable and all fees for ‘alternative’ services were increased to market rates: $100-150 for massage and $100 for acupuncture.
When money gets tight, the alternative services in the integrated model of care are the first to go, as we’ve seen with the recent elimination of acupuncture, massage and chiropractic care by OHSU’s pain center. I’ve heard (but not confirmed) that the clinic where I worked recently eliminated all acupuncture and massage therapy services as well.
I worked as an employee for five years. At the beginning of that time I started and completed my DAOM (advanced clinical doctorate) at OCOM, in hopes that this would increase my value to my new employer. This proved to be another myth. While the additional training was personally valuable and the publication of a case study and my capstone paper added to my professional CV, my degree did not increase the amount that could be billed for my services. As it turns out, the traditional medical world doesn’t really recognize or even understand what a clinical doctoral degree from an acupuncture school is, so there really wasn’t much professional advancement to be had, at least not in my situation.
Working for an FQHC was a valuable experience. I learned a lot and enjoyed being part of a team, but eventually I returned to private practice. I realized I could make the same money working fewer hours with less bureaucracy, and I was willing to sacrifice stability for freedom. I had enough previous experience to know what I was getting myself into. I’d already learned all the hard business lessons through mistakes I made when I set up my first practice right out of school (with basically zero genuine business training).
to be continued
See also, Who Should Go to Acupuncture School?
You can read about the different acupuncture degrees and what they mean here.
DAOM means Doctor of Acupuncture and Oriental Medicine. This is an advanced clinical doctorate, and currently the highest degree in the field awarded in the United States. The DAOM requires an additional 2 years of study beyond a master’s degree and is thus significantly longer than the first professional doctorate. It cannot be earned online. The DAOM also requires some sort of research project, and gives formal training in a specialty field (this is the only acupuncture degree in the US that gives formal specialty training).
From what I've heard the only way the Doctorate might increase pay is if you are teaching, which doesn't help the education affordability issue.