The Acupuncture National Discipline Database

Editor’s Note: The following is an interview with Michael Taromina, Esq., chair of the NCCAOM’s Professional Ethics and Disciplinary Committee (PEDC). He has drafted the NCCAOM Code of Ethics and Grounds for Discipline, and oversees the investigation and adjudication of ethics complaints nationwide. Michael has also served as a pro bono advocate for the profession for over 25 years. 

Tell us about the new Acupuncture National Discipline Database? ANDD is now live at https://pedr.nccaom.org. It offers a free, one-stop search engine that captures and publishes state and national public information on all discipline matters pertaining specifically to licensed and certified acupuncturists in the U.S. ANDD will, in my opinion, set the new standard of healthcare self-regulation, public disclosure and professional ethics, and hopefully serve as a model for other professions to replicate. 

What was the genesis for ANDD? The primary catalyst was bad actors slipping through the cracks. By cracks I am referring to inaccessible or difficult to navigate information about professional discipline on a national level. Patients, employers, insurers, schools, state regulators, etc., currently do not have easy access to a search engine that checks acupuncture licenses, certifications and discipline across every state. This is not an issue unique to acupuncture licenses; other licensed healthcare and non-healthcare professions have the same cracks for the same reasons.

What are those reasons? Some states do not publish discipline cases. Some do, but it is difficult to find or navigate their data. Others have user-friendly sites, but they only publish cases of disciplined licensees for their specific state. Information does not go into a national database. Consequently, opportunistic bad actors exploit this crack simply by state hopping. ANDD will remedy it by publishing all state disciplinary cases nationally in one site. 

Can you share a real example of a crack in the web of state systems? There are a few scenarios I am concerned with, but a common one involves dual state licensees. A dual-licensed practitioner disciplined in California leaves the state and opens a practice in Hawaii, where they are also licensed. Prospective Hawaiian employers, regulators or patients will only think to run a check for the Hawaii license – which won’t show California’s disciplinary records. No one will think to check California records for a Hawaiian practitioner unless someone tells them to.

Therefore, without a national database showing all states and NCCAOM discipline records combined, Hawaii residents would be, at best, not fully informed about a practitioner previously cited in California. At worst, they could be unknowingly in danger in some instances. This is what I mean by a “crack," and it is unacceptable to me, unacceptable to good-standing professionals and correctible. My mission is to fill in the notification cracks. ANDD fills them in. 

So, it is primarily a deterrence strategy? Absolutely. Disclosures, transparency combined with education and outreach are all important tools of deterrence. Good-standing members of the profession want to prevent misconduct, deter bad actors and certainly not hide unethical actions. Otherwise, a very small percentage of very bad apples – which are found in all professions – will dominate media coverage, as we have seen.

Ultimately, and here is the most important point of all – if a profession does not effectively self-regulate the government eventually will. This is not speculation; we have the proof. Ask other professions why states require two people in a treatment room with a patient. The answer is a very small percentage of very bad apples committed heinous acts that compelled state regulators and legislatures to change the law. 

I should also mention the data gathered in the database can be tapped and utilized for many educational purposes, not only deterrence. 

Have other associations engaged or supported this? I don’t know. I do know the project is an NCCAOM undertaking and responsibility – so no one else is being asked for financial support. Unlike other allied associations and organizations, the overarching mission of the NCCAOM is public safety. My committee, the PEDC, is the primary arm of the NCCAOM charged with protecting the public. I am proud to say we have done this for decades by drafting, revising and adopting the Code of Ethics and Grounds for Discipline, as well as enforcing ethical standards of competency and character via initiation, investigation and adjudication of complaints nationwide.

Doing this kind of sensitive and consequential work over the course of many years has reinforced to me that protecting the public is a critical component of protecting and serving licensed professionals. To me, they are essentially the same. This is why you will see me teaching and preaching about our code and risk management strategies across the U.S. – so that well-intentioned practitioners can avoid lawsuits and damaging misconduct exposure or allegations.  

Speaking of the Code of Ethics and Grounds for Discipline, how often are they revised? Every 5-7 years. It is a tedious process of research, discussion and surveying of stakeholders before I even start the process of drafting the changes, additions or subtractions. In reality, I am always revising by writing notes about cases and issues that come up in our monthly hearings. If a case involves a new area of concern or is not properly covered in our ethical guidelines, I note it for future reference.

For example, in our recent revision, you will find we decriminalized the requirements by reducing the type of crimes that are reportable. Before, you had to report to NCCAOM if you were charged with any and all crimes – misdemeanors and felonies. Our new revision eliminates mandatory reporting requirements for non-violent felony charges and misdemeanors unrelated to healthcare. Interestingly, I did not propose changing criminal reporting requirements due to the lack of crimes that were being reported to us. I proposed it due to the volume of certain crimes being reported that I felt did not meet a justifiable basis for further investigation or action by the PEDC.  

What crimes are you referring to? Predominately misdemeanor drug possession charges – many would not be crimes today due to decriminalization. Societies constantly change prompting criminal codes and ethical to change with them. This is a major reason why ethical standards are dynamic and require revision. The other major reason I would say is technology changes, so new concerns in this regard need to be addressed.  

How long did it take you to attain the support from NCCAOM Board of Commissioners? After completing the recent Code revisions, I first met with Mina Larson, CEO of NCCAOM. She knows better than anyone the sensitive work the PEDC does daily. We went over examples of how bad actors can exploit the state system by finding safe harbors in other states. She asked me how NCCAOM can fix it. I told her I would first need more staff to conduct a misconduct audit of every state; as well as a lot more resources to design, develop and maintain the proposed database.

Mina brought the idea to the NCCAOM Board of Commissioners, who have always – to its credit –  supported the work and semi-autonomy of my PEDC. This, of course, was by far my biggest ask of [the board], but it greenlit the project without any hesitation. 

So, what took longer than expected? I projected our comprehensive audit of every state would take a year. I was wrong. I underestimated the level of dedication and passion my new assistant, Chris Thompson, had for this project; as well as the number of hours my all-volunteer PEDC Committee members were willing to contribute. Without their dedication and countless volunteer hours, all my ideas would remain just those – ideas. Their expertise and service are a gift to me and the profession, yet none of them seeks an ounce of recognition and credit for it. In the end, we completed the audit in less than six months while also handling our largest year of caseload ever. 

Simultaneously, I also needed to drum up support from all the states, which was a whole other moon launch challenge. 

How do you garner support from the state regulators? By making the case directly to them, starting with town halls. Mina, Chris, and I have been engaged in ongoing meetings and communications with the states for several months now. Let me be clear: The data we gather can only remain timely and accurate with ongoing direct cooperation of state regulators and agencies. We are demonstrating to them that NCCAOM, via ANDD and other factors, is positioned to best serve as the missing conduit of national discipline disclosures. We can better inform and protect stakeholders by channeling state information combined with ours. Again, our model can and should serve as a model for all professions. 

I do want to stress I have a long way to go with signing all the states up, but that will not delay the launch. I believe the launch of ANDD will accelerate the cooperation agreements I am seeking signatures on. As you would imagine, it takes a while dealing with lawyers and officials from all states, but more and more are understanding sharing resources, and, in some cases, cooperating on investigations is the best way to mitigate risks and keep the public informed. I think – or I should say hope – my proposed cooperation model will ultimately be adopted for other professions. 

Before you ask, I will answer that I am hopeful to have most states signed on for cooperation in the near future, but I cannot project a specific date. 

Are only NCCAOM diplomates listed on ANDD? No. We publish all our discipline decisions and have for years. For ANDD we needed to audit and capture all the data on every acupuncturist in the U.S. and continue to do so. The data will obviously include my committee’s jurisdiction of over 21,000 National Board-Certified Acupuncturists; however, the ANDD database must capture misconduct from every acupuncturist throughout the U.S. or it will be incomplete.

Incomplete data means there would still be cracks. These cracks, in extreme cases, present potential dangers that I believe can be avoided in some cases. This is why states who require full NCCAOM certification enjoy the added oversight and regulation of my committee regulating standards of ethical conduct. I should also point out that PEDC code regulation is administered by subject-matter-expert professionals in the field – something states agencies do not and cannot often offer. 

What do you mean by potential avoidable dangers? A practitioner gets cited for a boundary violation in one state, but is able to get a license in another without disclosing it or lying on an application. Again, the public or licensing board in the new state has no way of knowing about the incident in the old unless they knew to check into other states. As a result, the practitioner effectively sweeps away past unethical conduct from any future consequences or disclosure.

Believe it or not, right now the only way to be sure someone has no ethical violations on their license is to check 50 different state websites plus our NCCAOM site. ANDD will ultimately do that state-by-state check for you in a one-stop location.  

What about criminal background checks? Don’t they play a role?  Absolutely, checking criminality for licensure is important. Many states do them – not all – but I cannot stress enough that they have limited value, especially once they are done.

Why? A background check provides a one-time snapshot of criminality from the date it is run backward. It is not ongoing or updated annually, so state regulators will typically not know of criminal conduct after a background check, particularly if the crime occurred in another state. Also, background checks are only for crimes – they do not provide data on misconduct sanctions, which is what ANDD corrects. The most egregious forms of misconduct are often crimes, but not all unethical behavior is criminal. I also know from experience that unenforced ethical standards lead to a greater likelihood of unethical behaviors and criminal misconduct.  

What trends are you seeing in misconduct complaints? As expected, post-Covid I have seen a dramatic increase in our caseload due to backlog from states, our increased diligence and uncertain economic times. Again, these same factors impact all professions, not just ours. Misconduct allegations, I am sure, are similarly up for other professions. 

My primary concern is the uptick of severity in some cases, which are the ones that receive media coverage and are thus most damaging to the profession. Unfortunately, I have emergency suspended certifications for more acupuncturists for criminal sexual misconduct allegations and convictions in 2023 than the previous few years combined. 

Again, I want to be clear, all professions – law, police, teachers, social work, doctors, nurses, massage, etc. – deal with ethical and criminal issues. Acupuncture does not have an inordinate number of complaints. To the contrary, I can say we have a lower percentage number of substance abuse cases compared to other healthcare professions. However, for a multitude of reasons – notably being a physical, mostly one-on-one delivery point medicine – we do contend with a high percentage of boundary ethical issues.

As chair of PEDC, it is my responsibility to not only respond to these cases swiftly and justly, but also educate the profession about them. ANDD represents my commitment to rooting out that small percentage of likely repeat bad actors from the shadows of secrecy and safe harboring. It also demonstrates to the media and public – and I cannot stress the political importance of this enough for our still relatively young profession – the unequivocal commitment of licensed and certified acupuncturists nationwide to vigorously self-regulate is equal to or superior to all other healthcare professions. ANDD is part of the proof. 

How is the database different from the National Practitioner Data Bank (NPDB)? ANDD is exclusive to the acupuncture profession and contains only data on misconduct and disciplined practitioners, not insurance settlements, malpractice or adverse events, which are mandated and gathered by the NPDB. ANDD will have public information and will not have restrictive or confidential viewing as is the case with the NPDB. Most significantly, ANDD is free to use, so it is readily accessible to anyone – the public, state regulators, employers, hospitals, agencies, employees, etc. 

The challenge with ANDD is I do not run the U.S Department of Health and Human Services, so I cannot mandate states to report their misconduct decisions to me. I must convince them it is in their best interest and the best interest of public safety beyond their individual state borders to cooperate with us. 

Do you think ethical standards and discipline regulations can become universal across the U.S.? I do think so. Scopes, statutes, titles and educational standards will never achieve universality in the U.S. in my lifetime, or likely ever – but I believe we can achieve universally adopted ethical standards sooner than later. It is definitely an uphill battle with the complications inherent in our legislative diversity within the U.S.

The reality is we are trying to grow, secure and prosper as one profession, yet we are legally defined in over 40 different ways. I can make a legal case that we are one network of over 40 state professions. This is why I have often mentioned how miraculously far the profession has come given its statutory impediments. The good news is regardless of all the different ways the profession is titled or its scope is defined, I believe we can establish uniformity and consensus on ethical standards of practice. All acupuncturists should be and want to be held to the same standards. In fact, I believe established national standards of ethics and vigorous accountability to them are hallmarks of credibility for any licensed profession. 

What is the one area of ethics you would like to see universalized that is not? Without question it would be the timeline for romance and/or sexual contact with former patients. The NCCAOM currently has a six- month “cool off” period, which I have said is probably too long, in my opinion, for the acupuncture field of medicine. Other states impose [shorter] or longer waiting periods. The codes I disagree with most are in states that subjectively determine inappropriateness on a case-by-case basis. This, to me, is patently unfair to licensed providers in any healthcare profession.

There is simply no way to guarantee compliance in the arena of sex and romance with former patients if there is no date certain timeline. Disparity and subjectivity in such a highly sensitive area of professional ethics is a slippery slope that does not serve the best interests of the public or licensed professionals.

What would you like to see moving forward for the profession? How much time do you have left? I’ll give you my short list. It may sound bold, but it is achievable. For one, I want the profession to compete on an equal playing field in the U.S. The single most alarming trend for me is that the medicine is growing, but the profession is contracting. Why? More and more professions are legally performing acupuncture that are not licensed or certified acupuncturists. This should be the number-one concern of every organization, school and practitioner in America. As Marilyn Allen says, “The government does not care who is holding the needle.”

Now, competition in the market does not worry me. I trust the expertise and training of licensed and certified acupuncturists to be the best deliverers of their medicine. The marketplace inequities are the problem. Other health professions have a huge competitive advantage because they operate within all markets – private out of pocket, insurance and public via federal and state reimbursable programs. Acupuncturists in the U.S. are not widely accessible via public markets, or insurance markets for that matter, so the playing field for potential patients is unequal and unfair.   

Second, I personally want the profession treating 100 million more of the most vulnerable and poorest communities in the U.S. – in other words I want our country’s best-trained experts helping the people who need their medicine most. Again, acupuncturists are widely inaccessible to low-income and senior populations; to me, this is not only economically indefensible, but also morally indefensible. 

The way – the only way – to accomplish both is through equal access via insurance and entitlement programs such as Medicare. This is why, for example, I strongly support HR 3133 – the Acupuncture for Our Seniors Act – and have raised money to assist the American Society of Acupuncturists (ASA), NCCAOM, state associations and other associations advocacy efforts.

Let me be very clear: it is not a panacea – I can go on and on how healthcare is irreparably broken in the U.S.; but it is the only pathway to thousands of new jobs and tens of millions of new patients who will benefit incalculably from acupuncture medicine. It will also finally place the profession at the healthcare table of full and equal patient access. If they are at the table, I am certain acupuncturists will be successful despite the growing list of other professions legally needling. 

Final question. The last time you were interviewed here, 15 years ago, it was concerning your proposed adverse events herbal database. Whatever happened with that? I will plead the 5^th on that one, Peter.