The Foundation for Acupuncture Research (FAR) was formed by California licensed acupuncturists to collect and evaluate the most current research on the efficacy of acupuncture for neuromusculoskeletal conditions, and to create acupuncture treatment guidelines based on this research for the utilization of acupuncture in any managed care system. Until now, no such evidence-based guidelines have been established specifically for acupuncture by the profession. It is crucial for the acupuncture profession to establish these guidelines for the implementation and proper utilization of acupuncture into the managed health care setting.
Over the past few months, FAR, in a joint effort with CAOMA (the Council of Acupuncture and Oriental Medicine Associations), has worked diligently to develop evidence-based treatment guidelines for evaluation and recommendation to the administrative director's office for adoption into California's workers' compensation system. FAR has gathered the support of other professional organizations, such as NOMAA (the National Oriental Medicine Accreditation Agency), CSOMA (the California State Oriental Medical Association), AIMS (Acupuncture and Integrated Medicine Specialists), NBAO (the National Board of Acupuncture Orthopedics), and other California and national professional associations to establish recommendations for treatment guidelines for acupuncture to replace the American College of Occupational and Environmental Medicine's (ACOEM) recommendations on acupuncture currently being used in the California workers' compensation system.
The administrative director's office will establish its own guidelines, which will replace the ACOEM guidelines by Dec. 1, 2004 per Senate Bills 228 and 899. The RAND Corporation was also contracted by the Commission of Health and Safety of Workers' Compensation (CHSWC) to collect and evaluate treatment guidelines currently being used in other states, and to make recommendations on appropriate treatment guidelines to be adopted by the California workers' compensation system, as required by these bills.
A significant number of injured workers are being denied medically necessary treatment because of the recent passage of SB 228 and SB 899, and the mandate that treatment in the workers' compensation system be "based upon the guidelines adopted by the administrative director pursuant to Section 5307.27 or, prior to the adoption of those guidelines, the updated American College of Occupational and Environmental Medicine's (ACOEM) Occupational Medicine Practice Guidelines."
Acupuncturists who treat injured workers are increasingly being denied authorization for treatment based on these guidelines. The reason for this is that the guidelines conclude that acupuncture is not effective or "lacking sufficient evidence" of efficacy for virtually all musculoskeletal injuries. These denials are forthcoming on new injuries and also for patients who have closed their cases but have been granted "future medical" per their medical treatment stipulations. As a result, acupuncturists' practices are being seriously affected by the adoption of the new ACOEM guidelines. Private insurance companies may take notice of these guidelines and potentially use them as a basis to deny acupuncture treatment, based on lack of scientific evidence of efficacy for many conditions commonly treatable with acupuncture.
FAR has contacted ACOEM regarding several issues that we have with the current recommendations on acupuncture in the Practice Guidelines, including the number of studies considered, the inclusion criteria used in the selection of these studies, the conclusions reached on the efficacy of acupuncture, the inability to understand on what the conclusions are based, and ACOEM's disregard for consulting with acupuncturists on the selection of studies and conclusions reached. To date, we have not yet received satisfactory answers to our questions. ACOEM has expressed an interest in revising its recommendations on acupuncture based on any research or supporting evidence that was not considered in the formulation of their recommendations. ACOEM has also expressed a willingness to publish an article in its bimonthly publication, Insights, which would address some of the issues that arise from the utilization of their guidelines in managed care settings such as California workers' compensation.
The real travesty is not so much the ACOEM guidelines themselves, but the mandate that all treatment in the California workers' compensation system be based on the ACOEM recommendations per SB 228 and SB 899. This was not the intent of the authors of the ACOEM guidelines. They made this clear in a letter sent to Sen. Richard Alarcon, author of SB 228, when SB 228 became law and mandated that treatment be "based on" the ACOEM Practice Guidelines. The letter emphasized two key points:
However, nothing became of this letter, since the law was already in effect, mandating that treatment be in accordance with the ACOEM guidelines in the California workers' compensation system.
As a result, we are stuck with the ACOEM recommendations, according to SB 899, until December 1, 2004, when the administrative director of the Department of Industrial Relations establishes its own treatment guidelines, which will presumably replace the ACOEM recommendations. FAR representatives met with both the administrative director's office and the CHSWC to discuss some of the issues affecting injured workers and present its own recommendations when we were told that they had contracted with RAND to evaluate treatment guidelines currently being used in other states, and to make recommendations to the administrative director's office based on their findings. RAND solicited recommendations for treatment guidelines until Aug. 2, 2004, and outlined the criteria that must be met for these guidelines to be considered acceptable, including: being nationally recognized, current, evidence-based, peer-reviewed, preferably comprehensive, developed by a multidisciplinary clinical team, up-to-date, and a potentially open source. FAR's intent was to ensure that its treatment guidelines satisfied as many of these criteria as possible.
FAR prepared a draft proposal of treatment guidelines and submitted these to RAND by the Aug. 2 deadline, along with research supporting the efficacy of acupuncture in the treatment of musculoskeletal disorders. A revision to these guidelines was submitted Aug. 9, and a second revision was submitted Aug. 20, which was accepted by RAND. FAR has enlisted the help of researchers to conduct a thorough search of the literature on acupuncture, selecting studies that meet specific criteria for inclusion into their critical review of the research. This critical review will take several months but, when completed, will add significantly to the evidence base for the recommendations in the guidelines.
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