We are part of a healing community that practices or supports acupuncture and Oriental medicine (AOM), the indigenous healing system of China and East Asia. Indigenous healing systems reflect the way a culture perceives how human beings interact with or relate to nature and the cosmos - how do we as humans fit into the order of the universe? Many of the Westerners who practice and promote AOM have embraced the indigenous healing system of East Asia because of the perceived differences between AOM and modern allopathic medicine. We experience a personal resonance with the way traditional Asian medicine attempts to re-establish harmony within our body systems. We perceive modern allopathic medicine and many aspects of modern Western life as divorced from the natural world, and unconcerned with creating balance on either a macro or a micro level.
Philosophically, AOM and modern allopathic medicine are two very different world views. In the current realities of our society (despite inroads made by "complementary" medicine), they are often competing world views. Just what are we asking patients to accept? We are asking them to accept a model of health and treatment which often competes with the medical system that dominates our society and that is a driving force in the U.S. economy. In the U.S., $1.7 trillion is currently spent on health care annually, but only two percent of this is spent on complementary and alternative medicine goods and services. This spending covers massage, chiropractic, naturopathy, vitamin and herbal products, and other similar products and services, including AOM.
Over the past 25 years, AOM interests in the U.S. have developed into a community of our own. The members of this community are the national and state professional associations, the AOM schools and the Council of Schools, AOM-related businesses, and the NCCAOM. With the exception of a few schools and AOM businesses, none of these entities existed in 1979. All of these organizations exist in the common interest of offering and supporting a medical system that is or was alien to most people in the United States. The percentage of the American public that receives AOM therapy is still very tiny compared with the population in general.
In my opinion, we are trying to change the way people in America approach dealing with life and health. We must try to appreciate what a significant challenge that really is for both our patients and us. While the world view represented by AOM appeals to many, there are still a great number of Americans who are content to surrender their health care to a centralized system that others consider to be expensive and toxic. The pressure to present Oriental medicine in a watered-down and Westernized way to make it palatable to these patients is strong. In order for AOM to survive in this culture, we need to do a better job of articulating who we are and what we have to offer, based on the strengths of AOM. Some of these strengths are:
Each patient is treated as an individual; all symptoms, however seemingly unrelated, are treated as a part of a whole. There are different treatments for the same disease, depending on the presenting pattern. There are comparatively few dangerous side effects from AOM.
A Short Historical Perspective on Our Health Care Delivery System
The health care delivery system has gone through numerous changes in the past 60 years. How are we as AOM providers to participate in this system? I will take a moment to summarize some of the changes of recent times.
Sixty years ago, health care was delivered primarily by fee for service. In those times, medicine technology was much less advanced and fees were much more in range with what many people were able to pay. After World War II, organized labor and companies with large numbers of employees started to provide health insurance as a benefit.
As medical technology progressed, medical costs were on their way to exceeding what most people could afford to pay. The new advances in modern medicine came with a high price. Since the 1980s, the emerging profit-driven managed health care system pushed health care costs in an increasingly upward spiral. Some people in the business world perceived managed care as a magic cure to rising health care costs. It was thought at that time that if directing patients through a health care system could contain costs, all parties would benefit. The American health care system was transformed into a system in which profits for distant business entities became the highest priority. Health care providers became frustrated because the nonmedical accounting profession increasingly supervised the care health providers were able to deliver. To save costs, many patients were denied time-sensitive medical treatment. The very practice of having a profit-driven system created higher health care costs instead of reducing them.
Since the 1980s, AOM has been growing and developing as well. More and more states have obtained legal status for AOM. More and more AOM schools have been founded all over the U.S. There were about five schools that I was aware of in 1982; now, there are at least 51.
As the legal status of AOM improved and the cost of education steadily increased, many AOM providers worked to be integrated into the managed care system. Most managed care companies resisted payment for services that they considered unorthodox therapy. AOM practitioners found ways to participate in this system and worked to find ways to bill for the services they provide. In 1994, when the Eisenberg study showed that Americans were spending over 28 billion dollars out of pocket for alternative therapies, the insurance companies saw a money stream that they were not participating in and this provided an opening for many more AOM providers. However, the continuing goal of these companies is to retain as much of the premiums that are paid to them as possible. This means delaying and denying treatment and payment whenever possible. Participating in this system has meant that AOM practitioners must spend more time and money interacting with reluctant-to-pay insurance providers in order to get paid for their services.
One of the truths of health care is that the party that pays for the service determines how much and what services are delivered. As the American economy has tightened and dollars available for out-of-pocket services has declined, it has become more difficult for AOM practitioners and especially new practitioners to prosper. This has occurred simultaneously with higher operating costs and high debt from school loans. At this time AOM services are not typically available to either low-income or fixed-income Americans who are restricted to publicly paid programs. All of these factors are threatening the future growth of AOM in the U.S.
As long as our society is saddled with a health care system that values profit over the welfare of the patient and health care provider, we will be doomed to an increasingly expensive and dysfunctional system. The AOM profession as well as our society in general must keep an open mind to more functional and humane ways to provide health care.
Stagnation in Our Profession
Over the Past three or four years, the number of AOM practitioners in the U.S. has hovered at around 15,000. During this time period there have been over 4,000 students per year enrolled in accredited AOM schools. With this number of students enrolled, there should be a corresponding increase in the number of new practitioners each year. Yet, in reality the number of practitioners has remained stagnant for the past four years.
In the U.S. there are over 65,000 doctors of chiropractic, over 60,000 massage therapists and over 300,000 medical doctors. I would guess by looking at these numbers that there is room for another 30,000 AOM providers in the U.S. medical marketplace. Many parties indicate that the patient demand and acceptance of AOM are increasing.
I perceive a number of factors inhibiting the growth of AOM in the U.S. The dollar amounts being paid to AOM providers through insurance are under constant downward pressure. There are political factors at work, as well as the fact that insurance companies are constantly working to lower the payments made to medical providers in general. AOM providers are in many areas still considered non-conventional, and whenever possible patients are denied coverage for AOM services.
Much of the growth in the AOM profession in the 1990s was because a growing number of Americans were willing to pay for AOM services with cash. In recent times a growing number of white-collar service jobs have been outsourced to overseas operations. Higher paying manufacturing jobs have also continued to be exported to operations in foreign countries. There has been an increasing level of economic insecurity for American workers throughout the U.S. This has meant that the amount of disposable income available to Americans has been steadily shrinking.
The cost of an AOM professional education has increased dramatically over the past 25 years. The content and the course material have also increased. In the early 1980s, the total tuition for my three years of AOM professional education was $6,000. Today, AOM students are graduating with a debt of between $40,000 and $100,000. Unlike in conventional medicine, there are no loan forgiveness programs currently available. AOM practitioners new to practice are having difficulty coping with this debt. Many are even reluctant to enter full-time practice because they are unable to generate sufficient income from their AOM practice to cover their debt and make a living. A great many new graduates are forced to work outside of the AOM profession just to pay their bills. I have been told that five years after graduation, 50 percent of AOM graduates do not maintain an active practice. The high cost of AOM professional education also puts upward pressure on fees charged to patients at a time when patients are less able to pay higher fees.
What Positive Actions Can Be Taken to Help the Further Growth and Development of AOM as a Profession?
The passage of the federal acupuncture bill known as the Medicare Bill HR 818, sponsored by N.Y. Congressman M. Hinchey, would be a tremendously positive milestone. This law would give Medicare patients and federal employees access to acupuncture treatment. This would give access to an additional 40 million Americans who do not currently benefit from AOM treatment. There are certainly practitioner concerns with having to work with a government agency for payment for service. Many AOM practitioners have great reservations about the possibility of getting tied into what they perceive as a bureaucratic system that they see as severely underfunded, underpaying, and demanding. However, MDs have been working with Medicare for decades and have found ways to work within that system. It is important to remember that providers are not forced to work with Medicare patients if they do not wish to. Having recognition of AOM by the U.S. government would give a much-deserved higher status to AOM. I may be wrong, but I believe that this recognition, as well as making AOM available to many millions of Americans who cannot afford it, will have a positive impact for the future of AOM in America. Until we have this kind of recognition, AOM will continue to an under-utilized medical practice reserved to the shrinking number of Americans who can afford to pay out of pocket. We will otherwise continue to be an upper middle class curiosity.
Finding ways to reduce the negative effects of the high cost of AOM education would be beneficial to the profession. These would include more scholarships, loan forgiveness through any means available, and more employment opportunities for new graduates. Many students do not receive adequate support and training in how to build and manage a successful AOM practice. At the present time most AOM practitioners remain in solo private practices and are not integrated into the general health care delivery system, so job opportunities are limited.
Marketing the profession of AOM and educating the American public about the many benefits of AOM would have a great impact. The increase in the utilization of AOM is purely a result of word-of-mouth, grassroots activity. Americans need to learn more about how AOM is a complete health care system that can address most health care needs and can assist greatly with conventional therapies to make them more safe and effective. People also need to know the advantages of seeing a fully trained AOM practitioner instead of a MD or DC with scant AOM training. The cost-saving benefits to our whole society would be really significant if AOM were truly integrated into our health care delivery system. Public education is very important because in the end the patient will demand the therapy that they best respond to. This public education and marketing of AOM needs to be initiated and supported by all of the members and constituencies in the AOM community.
Conclusion
In order for AOM to prosper and flourish in the 21st century, several things need to be developed. AOM needs to take steps to reach a greater maturity and become a viable medical profession. By this I mean a medical system that reaches and is readily available to all Americans regardless of class or economic status. It means that people interested in becoming practitioners are able to afford to attend educational programs and are able to financially support themselves and their families by practicing the medicine they love. AOM providers need to be more effective in finding ways to deliver medical services both inside and outside of the conventional health care delivery system. Many observers feel that the current U.S. health care system is on the verge of collapsing. I believe that one of the strengths of AOM is that it is not dependent on distant power structures to operate. The basic tools of needles, moxa, and herbal medicine are the primary healing instruments. These are not expensive to obtain, maintain, or operate compared to the tools of conventional medicine.
AOM education must be economically accessible to the largest possible number of practitioners. Better economic and career support must be developed for new practitioners who are entering the profession.
All of the national AOM constituencies must cooperate to market and educate the general public about what AOM has to offer as a health care system. What is the entire scope of benefits and possibilities, and the Why would one go to a qualified AOM practitioner instead of an MD or DC? It is only because of consumer demand that AOM has made the progress that it has in the past 25 years. More must be done to create a stronger demand from consumers for AOM services.
AOM providers must participate at every level of the health care delivery system to allow access to the greatest possible range of Americans. This means participation in privately and publicly funded programs, and access to low-, middle- and upper-income Americans. How can we make AOM available to every American? This is our long-term challenge.
Chronic pain afflicts over 20% of the adult population. Sadly, most MDs have essentially no education in treating pain, beyond offering a few toxic medications. Then they tend to steer people with pain away from those health practitioners who are trained. This puts the acupuncture community on the front lines for addressing this epidemic.
When the body is going through a stressful event, the sympathetic system is activated. This activation will help the body with a life-threatening situation. If this state is activated for prolonged periods of time, it starts to consume energy. These traumatic events that generate stressors in the autonomic nervous system (ANS) will eventually become internalized.
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One of the things that makes acupuncture so difficult to measure is that the medicine actually does contain some esoteric aspects. There have been numerous studies that demonstrate the neurochemical reasoning behind why acupuncture points stimulate the autonomic nervous system to enact change However, not all the benefits of TCM can easily be measured by randomized, controlled trials. But does that make them fundamentally and definitively untrue?
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