In September 2002, then-Governor Gray Davis signed into law Senate Bill 1951 and Assembly Bill 1943, two pieces of legislation that, among other things, extended the life of the California Acupuncture Board (CAB) through July 1, 2005; altered the structure of the board's membership; and mandated all California schools that offer programs in acupuncture "shall include a minimum of 3,000 hours of study in curriculum pertaining to the practice of an acupuncturist" in order for the school to receive CAB approval.1,2
In addition to these provisions, both bills mandated that a little-known government agency, the Milton Marks Commission on California State Government Organization and Economy (also known as the "Little Hoover" Commission), conduct an analysis of the acupuncture profession in California. Specifically, the bills requested that the commission review and make recommendations on the scope of practice and educational requirements for acupuncturists; evaluate the National Certification Commission for Acupuncture and Oriental Medicine's (NCCAOM) national certification exam and make recommendations as to whether the NCCAOM's exam should be offered as part of, or a replacement for, California's own certifying exam; and evaluate and make recommendations on the approval process of the CAB, the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM), and the Bureau for Private Postsecondary Education.
The Little Hoover Commission was required to provide its findings to the Legislature by Sept. 1, 2004. The result of the commission's work is a newly published report, Regulation of Acupuncture: A Complementary Therapy Framework, which makes several far-reaching observations about the current state of the profession, and is sure to affect the practice of acupuncture in California for years to come.
To accomplish its mission, the commission held a series of advisory committee meetings and public hearings between August and October 2003. During these meetings, the commission received written and oral testimony from licensed acupuncturists and CAB members on matters pertaining to licensure, the competency of practitioners, curriculum hours, the role of regulatory agencies, protecting the public, and other issues. Representatives from several state and national organizations also provided input, including officials from NCCAOM, ACAOM, the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM), the Council of Acupuncture and Oriental Medicine Associations, the California State Oriental Medical Association, the National Guild for Acupuncture and Oriental Medicine, and the National Board of Acupuncture Orthopedics.
In addition to the public meetings, the commission received several reports on the profession from the University of California at San Francisco, California State University, Sacramento, and the RAND Corporation.
After gathering the information presented to it, the commission spent several months analyzing the data before issuing its report. The completed version of Regulation of Acupuncture contains a total of six relevant findings, each relating to an individual component of the profession. Along with the findings, the report offers a series of recommendations the commission believes will help define and strengthen the profession, thereby improving the practice of acupuncture and providing California's citizens with competent, highly-trained health care providers. A review of the commission's findings and recommendations is presented below.
Findings and Recommendations
Finding #1: While the legal scope of practice clearly defines the modalities that acupuncturists can use, the statue is silent on issues that are important in defining their role as health care providers.
Existing California law clearly states which treatments acupuncturists may use. However, it does not give them the authority to diagnose patients, nor does it place any limits on the conditions acupuncturists may treat. Legal opinions, not changes to the state's Business and Professions Code, have expanded the scope of practice for acupuncturists to the degree that they are now allowed to perform exams and procedures that may not be allowed in other states, including X-rays, blood tests, MRIs and other types of care. This combination of law and opinion has resulted, in the view of the commission, in a "murky legal framework" that "has the potential to confuse the public about the capacity of acupuncturists, and could potentially compromise public health."
Recommendation: The governor and the Legislature should clarify in statue the role of acupuncturists in the health care system. Specifically, the statute should:
Finding #2: The new 3,000-hour educational requirement is adequate to prepare entry-level practitioners and to protect the public safety.
Effective Jan. 1, 2005, new students enrolled in an acupuncture program in California must complete a minimum of 3,000 hours in training before being allowed to take the state's licensure examination. The reason for the increase remains a hotly contested issue. Some state associations and individual acupuncturists have put forth the position that the increase in hours is critical to patient safety, and is part of a long-term goal to raise the training and professional standing of acupuncturists to that of Western medical doctors. The Department of Consumer Affairs has countered that increases in license requirements - such as an increase in the hours of training - should be tied to the profession's scope of practice as defined by law.
Based on those standards, the commission believes there is "no evidence to support the need to further increase the educational requirements." Furthermore, information provided by the University of California at San Francisco and others suggests that "implementing the new requirements will be difficult for some schools, and may result in fewer schools generating fewer students eligible to take the California exam.
Recommendation: The number of educational hours should not be increased, and should be focused on traditional Oriental healing practices within a modern framework for patient safety. Specifically, the California Acupuncture Board should implement the following policies:
Finding #3: The steadily increasing educational requirements for new entrants into the acupuncture profession potentially creates different levels of competency, and could confuse or mislead the public regarding the knowledge, skills and ability of those previously licensed.
Current CAB regulations require acupuncturists to undergo 30 hours of continuing education every two years. However, many acupuncturists currently practicing in California have only 1,350 hours of training, and were licensed prior to the time when they could practice independently of medical doctors and were allowed to diagnose patients. In addition, approximately 900 acupuncturists who were licensed in the mid- 1970s or "grandfathered" into licensure will be practicing with considerably less formal training than most recently licensed practitioners. This has created several levels of educational "unevenness" among practicing acupuncturists, which could compromise public safety.
Based on this situation, the commission feels that "it is difficult to accept that new students should receive additional training on issues directed at improving patient safety without requiring current licensees to receive at least some of that training in a meaningful way," and suggests that regulatory agencies ensure patient safety is incorporated into the practices of all acupuncturists regardless of the amount of time they have been in practice.
Recommendation: The governor and the Legislature should reallocate - and consider increasing the number of - continuing education hours required of currently licensed practitioners as a mechanism to update patient safety requirements. The law should:
Finding #4: The examination of candidates for licensure is a critical quality control measure for assuring competency of providers, and is an essential mechanism for ensuring that evolving public policy goals are met.
One of the biggest issues facing California's acupuncturists has to do with the examination required for licensure. While most health care providers in California are licensed based on the passage of a national examination, and while most acupuncturists in the U.S. receive licensure based on the NCCAOM's certifying exam, California has its own licensing exam for acupuncturists.
In the past few years, the question of whether to replace California's licensing exam with the NCCAOM's exam has become the subject of much debate. After analyzing both exams, the commission has concluded: "... while both the California and national examinations are statistically sound and meet all other measures of quality, the California examination was somewhat more robust." However, they feel that the California exam "does need to be refined to ensure that critical knowledge is tested and passed."
Recommendation: The California Acupuncture Board should continue to control its examination to ensure that the state's policy goals are met. Among the policy goals that the state should ensure:
Finding #5: The process used by the Accreditation Commission of Acupuncture and Oriental Medicine appears to be superior to the school process used by the acupuncture board, and could be used by the state to ensure the quality of education for potential licensees.
In order to sit for the California licensing exam, a potential licensee must graduate from a school approved by both the CAB and either the state's Bureau of Private Postsecondary and Vocational Education or a similar bureau in another state. Most acupuncture schools seek accreditation from ACAOM; in fact, every other state that licenses acupuncturists in the U.S. relies on ACAOM to ensure the quality of acupuncture schools. California is the only state that has its own school approval process.
The commission is of the opinion that, compared to California, "ACAOM's process appears to be more rigorous and appears to put more focus on improving the quality of education over time." In addition, ACAOM has an established process for reviewing accredited schools to ensure they continue to meet certain standards; California doesn't. By relying on ACAOM to assess schools, the commission believes the acupuncture board could devote more time and resources to other important issues.
Recommendation: California should rely on ACAOM to accredit acupuncture schools, and other institutions for accreditation that are recognized by the Secretary of Education, while developing a mechanism to ensure that state-specific curriculum standards are met. To achieve that goal, policy-makers have two options:
Finding #6: The California Acupuncture Board has missed significant opportunities to protect the public, particularly in the areas of consumer information and herb-related safety.
The commission saved some of its harshest criticism for the California Acupuncture Board, the state's regulatory agency, blaming it for many of the problems the profession currently faces.
"Many of the specific issues that the governor and the legislature asked the commission to review have festered because the acupuncture board too frequently acted as a venue for promoting rather than regulating the profession," the commission observed. "As a result, the board has missed opportunities to protect the public by providing accurate and complete information about the therapies that licensees can provide. The board also has not adequately incorporated emerging scientific evidence into board policies, regulations and public communications."
Recommendation: The governor and the Legislature, through the sunset review process or other mechanisms, should ensure that the California Acupuncture Board becomes a strong advocate for consumers. Among the steps that should be taken:
Full Report Available Online
Regulation of Acupuncture: A Complementary Therapy Framework is available for viewing and can be downloaded at the Little Hoover Commission's Web site (www.lhc.ca.gov/lhcdir/report175.html). In addition to the report, the commission's site contains copies of related studies on the scope of practice for acupuncturist, educational issues and programs, school approval and accreditation, and the California acupuncture license exam.
Interested parties may also purchase a hard copy of Regulation of Acupuncture from the commission via an online order form, available at the URL listed above.
References
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