Acupuncture- An Essential Health Benefit (Part 1)
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Acupuncture- An Essential Health Benefit (Part 1)

In November 2013, the American Association of Acupuncture and Oriental Medicine (AAAOM) asked the public to support a petition asking Congress to designate acupuncture as an Essential Health Benefit (EHB) under the Patient Protection and Affordable Care Act (PPACA). EHB are primary care prevention & wellness services, emergency services, maternity & newborn services, and prescription drugs services, etc. "Insurance policies must cover these benefits in order to be certified and offered in the Health Insurance Marketplace" (Healthcare.gov).

Despite my permission that this is a good & feasible thing, I signed the AAAOM petition out of respect for AOM, a Whole Medicine System that has already proven itself to be an EHB in Asian countries and the U.S. Military. View AAAOM Position Statement. See  AAAOM Petition.

Preliminary Steps
There are many preliminary steps that Acupuncture & Oriental Medicine (AOM) must go through (other than petitions) in order to be considered an EHB. AOM must first be deemed an "independent healthcare profession" by the Standards Occupational Classification System (SOC). Only then will AOM be considered to participate in state & federal programs like Medicare, Medicaid, and the Veterans Administration etc. 

The March 2014 issue of Acupuncture Today has very good article entitled "Aiming for Independent Occupational Code" by Dr. K Ward-Cook CEO & M. Larson, Deputy Director of NCCAOM. The article explains the steps that the NCCAOM (in collaboration with all other AOM governing bodies) must take to prepare data for a proposal to the SOC THIS YEAR! It is a critical time because calls for proposals only happen every 8 years.

The Bigger Picture Under PPACA
It may be beneficial for practitioners of AOM to understand the bigger picture under the PPACA. It is called Pay-for-Performance, in which health care providers will be required to:

  • publicize quality of care ranking
  • provide continuity of care through “Medical Homes” 
  • focus on Primary Care & Prevention
  • use an Electronic Health Record (EHR)
  • etc.

These requirements will effect reimbursement form the Center for Medicaid and Medicare Services (CMS), and possibly private third-party payers. Healthcare providers who successfully meet CMS reporting requirements (for Medicare part B) will eventually be financially rewarded; or penalized for not. The reporting criteria determines if a population of patients received the appropriate care & outcome within an appropriate timeframe; with a high level of quality & patient satisfaction. To these ends, CMS has developed a set of specially designed quality reporting codes (quality measures) that address various aspects of patient care:

  • primary care & prevention
  • chronic disease management
  • acute episode care management
  • procedure related care
  • resource & utilization
  • care coordination

PQRS Pay-For-Performance Program
Explaining further how pay-for-perfomance works is a complex mission. Here are some resources on the CMS and Physician Quality Reporting System (PQRS) pay-for-performance programs:


Is AOM  Compatible with PPACA
The CMS's systematic documentation format is understood by Congress and third-party payers. Whereas, AOM differs in culture, philosophy & environment of care than what they are accustomed to overseeing. AOM is a qualitative medicine. A lot can get lost in qualitative clinical & cultural translation; and the use of quantitative vs. qualitative proof. Will AOM be compatible with a quantitative documentation format? 

Given the holistic nature of AOM, are practitioners prepared and willing to demonstrate to Congress that AOM is an EHB by: (1) providing primary care & prevention, chronic disease & pain management, rehabilitation & mental health services etc; (2) complying with the same pay-for-perfomance measures that Western healthcare providers will; (3) qualifying, quantifying, then documenting the outcomes, benefits, and satisfaction patients receive under ones care; (4) routinely fulfill some PQRS Measures (see Part 2); and (5) follow-up/ follow-through  on established treatment plans.

It might seem IMPOSSIBLE to practice Chinese Medicine in this way in the U.S., because the Western healthcare system is supported by "sickness" not "wellness". Wellness is a complex concept that includes the patient's and provider's' perception of a cure vs. perceptions of wellbeing. It might be UNDESIRABLE to be accountable to the requirements under the PPACA, given the holistic nature, complexity and diversity of AOM. 

Cost vs. Benefit
Systematic documentation might also involve documenting a prognosis: time, energy & resources a patient can expect to spend on treatment to achieve a certain (preferably measurable) outcome/ benefit for their complaint. Third-party payers and patients in the U.S. think on these lines of consumers of health care vs. an expensive commodity (cost vs. benefit). The 2009 report by AAAOM entitled “Economic Evaluation in Acupuncture: Past and Future” summarizes research assessing the cost-benefit and cost-effectiveness of acupuncture as compared with common treatment modalities (AAAOM, 2012, p. 8). See AAAOM Outcome Studies.

Eligible Profession and Reimbursement
Voluntarily adopting some PQRS measures, may help promote AOM as an EHB. The problem is, DOMs and LAcs are not on the PQRS List of Eligible Professionals. Even if voluntarily participating, would AOM practitioners be acknowledged! In order to get on the list, I think a better focus is placed upon getting AOM recognized as an "independent healthcare profession". And then, upon the Public Health Service Act (PHS Act) section 2711, as added by the Affordable Care Act, which states:

 "A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable state law."  

PHA 2711 would ensure patient access to covered services  from practitioners of AOM, as well as Chiropractors, Naturopathic physicians, massage therapists, non-nurse certified professional midwives (for home births), and medical doctors who practice integrative medicine (Weeks, 2013). 

EHB in the U.S. Military
The U.S. Military circumvents the eligible professional & reimbursement, and cost vs. benefit obstacles. AOM services are provided by Medical doctors and Registered Nurses who are trained in acupuncture, and who are reimbursed (very well!) under military benefits. While the military does conduct studies, these studies are focused on the problems of military service men and women; and are revealed to be of poor quality for clinical application in the general population. However, service men and women perhaps already have access to AOM as a EHB:



References
American Association of Acupuncture and Oriental Medicine. (2013).  Acupuncture as an
     essential health benefit - public input.
American Association of Acupuncture and Oriental Medicine. (2012). Position statement in
     support of the designation of acupuncture as an essential health benefit service.
Weeks, J. (2013). Beltway battle over patients' rights to integrative medicine and health.
     Huffington Post. Retrieved from http://www.huffingtonpost.com/john-weeks/integrative
     medicine_b_3732460.html
WeMed. Historical milestones; Becoming mainstream; Research and academia.  Retrieved from  http://www.wemedclinic.com













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