Public Funding of Acupuncture Services

Nov 17, 2010

 

Introduction
The rapidly aging population, rising health care costs and failed attempts to find solutions for a system that risks to go "bankrupt" within the next 20 years should convince the government of the need to explore options that may seem controversial but that have a proven record of cost-efficiency and effectiveness in other countries such as China. (1) Despite the fact that about half the population of industrialized countries regularly use complementary medicine and this trend continues to grow, development of government policy has failed to provide adequate solutions regarding the inclusion of complementary medicine in their health care system. (2) Many developing countries have long since integrated complementary medicine successfully in their health care system. Maybe we should learn from their experiences. 

Gerard Bodeker, Chair of the Commonwealth Working Group on Traditional and Complementary Health Systems (University of Oxford), comes to some very important conclusions regarding Traditional and Complementary Health systems in his article on integration from developing world's experience (2)

1. Integration works best when based on self-regulation to standards of practice and training. 

Acupuncture is regulated in Quebec, Alberta and BC. The regulation of acupuncturists is still relatively young but has already shown to lessen the confusion of Canadians to find practitioners with acceptable standards of practice and competency and gives them an avenue for addressing concerns or comments. 

2. When conventional medicine dominates complementary medicine, loss of essential features of complementary medicine can occur, and professional conflicts can arise. Policy should take aim to keep fees for complementary medicine affordable and within reach of all levels of society. 
By refusing to publicly fund acupuncture, a two-tier system is created where Canadians with less financial resources are denied access to acupuncture and Traditional Chinese Medicine (TCM). Often the situation exists where conventional health care professions are able to access funding for acupuncture services as they use them as "a modality" of their profession. In most cases these health care providers have inferior training in acupuncture or TCM (see section 3.2.: Acupuncture training in Canada). 

3. Major sectoral investment is a prerequisite for the development of effective services for complementary medicine; under investment risks perpetuating poor standards of practice, services and products.


Until now the majority of investments in health care by the government are done in conventional medicine. The best example for this is the very limited amount of money for acupuncture research. The little research that is sponsored by the government is usually done by researchers with a conventional medical background and very limited training in TCM, which may not always result in unbiased studies. 

The popularity of acupuncture and the steady increase in the use of acupuncture in North America is only possible if it is driven by results. These results cannot be dismissed anymore as anecdotal, even if research is not always clearly of high quality as is often suggested. Acupuncturists would not survive if their treatments would not have a positive effect. Without results patient satisfaction would not be as high as it is now. The successes of acupuncture and inability to address certain complex complaints with a conventional approach has also caused physicians, physiotherapists and other health care providers to take additional acupuncture training in great numbers. 

Federal and Provincial authorities are experiencing one of the richest opportunities that health care has ever had for improvement of the health care system: provide public funding for acupuncture to address the crisis in the current health care system. 

1. The Acupuncture-Traditional Chinese Medicine Society of Alberta (ASA)
The ASA was established and incorporated in 1978. The main goal of this Society is to ensure that the general public receives high quality acupuncture/TCM from its members and to actively participate in the further regulation and development of the profession. The ASA has over the years been a driving force behind regulation in Alberta and in other Canadian jurisdictions.
2. Acupuncture training and safety considerations.
The extensive sixth report of the Select Committee on Science and Technology, ordered by the House of Lords, UK in 2000 (3) states that high quality, accredited training of practitioners in the principal CAM disciplines is vital in ensuring that the public is protected from incompetent and dangerous practitioners. Acupuncture has compared to other health care modalities and disciplines, including conventional medicine, throughout the world a remarkable safety record. (4,5)In the United States for example only ten incidents have been reported between 1965 and 2000. Since the start of certification of acupuncturists in the U.S. by the NCCAOM (National Certification Commission for Acupuncture and Oriental Medicine), with over 9000 practitioners certified, the NCCAOM has never had any reason to take action against a Diplomate due to negligent or harmful treatment to a patient. (5)
3. Acupuncture provision in Canada.
3.1. Regulation of Acupuncture and Traditional Chinese Medicine (TCM) 

Acupuncturists are regulated in Quebec, Alberta and British Columbia. British Columbia also regulates TCM practitioners. There is a great interest and desire from other provinces, especially from Ontario, to adopt similar regulation. Candidates for registration usually require formal comprehensive training in acupuncture and/or TCM to be eligible for taking the registration examination. 

3.2 Acupuncture training and education in Canada. 

There are two main types of training available in acupuncture. 

? The first one is often referred to as "focused training". This type of training is provided to health care professionals such as physicians and physical therapists who wish to learn certain acupuncture techniques and include them within the scope of their practice. Because of the rather limited time, during which it is impossible to teach the complete body of knowledge of TCM/acupuncture, this kind of training is insufficient for registration as an acupuncturist. The training is usually offered as continuing education and viewed as such by the regulating bodies of the health care professionals taking these courses. The amount of lecture hours for focused training is in the area of 200 to 300 hours with very little supervised clinical practice with patients, compared to 2000 to 4000 hours including 500 - 600 hours of clinical practice with patient in comprehensive training. 

? The second type training - comprehensive training - is much more extensive and delivers professional acupuncturists and TCM practitioners. The amount of training includes not only a vast amount of basic conventional medical sciences but also extensive training in TCM/Acupuncture theory and practice. Supervised clinical practice with patients exceeds 500 hours, which is often required by the regulating bodies of acupuncturists. 

3.3. Formal Comprehensive training institutes In Canada, the majority of programs providing comprehensive training in excess of 2000 hours of instruction are privately operated. There is one public institute offering this kind of training in Ontario (Michener institute) and one in Alberta (Grant MacEwan College). 

3.4. Focused training providers. The Acupuncture Foundation of Canada Institute, with its main office in Toronto, Ontario; the Acupuncture program through the Faculty of Extension of the University of Alberta and McMaster University in Hamilton, Ontario are the main providers of "Focused training". They are well attended by mainly physicians and physical therapists.
4. Scope of Practice for acupuncturists
The World Health Organization (WHO) published a list of diseases and disorders that could benefit from acupuncture treatments. (6) This list includes eye disorders, ear, nose and throat disorders, respiratory disorders, neurological and musculo-skeletal disorders, stress disorders, emotional disorders, gastro-intestinal disorders and gynecological disorders. The Standards of Practice and Competencies for acupuncturists, identified by the Acupuncture Committee in Alberta, reflect the expectation that Acupuncturists are able to treat the wide variety of disorders, mentioned in the WHO list and more. In discussions between regulatory bodies of Quebec, Alberta and B.C., it was quite obvious that these standards of practice and competencies were shared in the three provinces with acupuncture regulation.
5. Acupuncture effectiveness
There is an endless debate between proponents and opponents of acupuncture regarding the effectiveness of acupuncture. The main criticism that keeps coming back is that there is not enough evidence for the effectiveness of acupuncture to treat a variety of diseases. The following statement from the National Institute of Health (NIH) published in a report on acupuncture may be a good answer to this kind of criticism: "While it is often thought that there is substantial research evidence to support conventional medical practices; this is frequently not the case. This does not mean that these treatments are ineffective. The data in support of acupuncture are as strong as those for many accepted Western medical therapies." (7) For example evidence supporting conventional medical interventions for fibromyalgia, myofacial pain and epicondylitis is no better than that for acupuncture while the acupuncture intervention has fewer side-effects. Nevertheless the body of evidence for the benefits of acupuncture is constantly growing. This resulted in recent changes of government policies and opinion, particularly in the United States. In stead of citing hundreds of good research studies that show that acupuncture is a very cost effective way to prevent and treat disease, it may be better in this report to mention the following important source of research information: Acupuncture Efficacy: A Summary of Controlled Clinical Trials by Stephen Birch, L.Ac. and Richard Hammerschlag, Ph.D., published by The National Academy of Acupuncture and Oriental Medicine in August, 1996. This book reviewed over 70 high quality research studies, covering the use of acupuncture for a wide variety of diseases. One of the stated purposes of this book is to serve the needs of governmental regulators, insurance and HMO policy makers, legislators and educators. (8) What needs to be done also is to compare and evaluate acupuncture with other more accepted forms of conventional treatments. The outcomes of such studies are often very favorable for acupuncture and leave us again with the same questions: When will there be public funding for this kind of inexpensive and effective treatments? Why is there public funding for conventional interventions and not for acupuncture when acupuncture is as effective if not more? A well designed pilot study in which the effects of acupuncture versus ultrasound on pain level, grip strength and disability in individuals with lateral epicondylitis were examined, showed that acupuncture was significantly more effective than ultrasound in reducing pain immediately following each treatment session (p<0.05). (9) Other similar studies have been done that show that acupuncture can be as effective as conventional methods of treatment, if not more. (10)
6. Acupuncture and Prevention of Disease.
The experience in prevention, gathered over more than 2000 years in TCM and acupuncture, may offer better perspectives for the modern health care system than conventional medicine where the focus has always been mainly on the curative aspect. Indeed ancient texts such as the Nei Jing already pointed out the importance of prevention. This makes acupuncture even more actual suitable in a modern and effective health care system. Public funding may prove to be part of the solution for the ever-increasing cost of providing health care for the aging population of Canada. For example, heart disease is recognized as one of the most important problems for an aging population. A cost-benefit analysis of acupuncture and self-care education in the treatment of patients with angina pectoris in Denmark, produced the following promising results: The estimated cost-savings during 5 years were $32,000 (U.S.) per patient, mainly due to a 90% reduction in hospitalization and 70% reduction in needed surgery. No increased risk for myocardial infarction or cardiac death was observed. (16)
7. Patient benefits
Acupuncturists are primary health care providers in Alberta and B.C. Through their comprehensive training which includes a sufficient amount of basic conventional medicine, acupuncturists know their own abilities and limitations in relation to the risks of treating systemic diseases and making appropriate judgments about whether or not to treat. They also have the knowledge and skills to make referrals where appropriate. (Alberta Standards of Competency and Practice for the Acupuncturist) Improved health seems to be the main benefit for patients as demonstrated already in several Asian countries such as China. Another benefit for the patient would be increased access to affordable health care by reducing the burden on an already over-burdened system.
8. Volume of services
It is estimated that in Alberta a Registered Acupuncturist provides on average 40 acupuncture treatments per week. With less than 200 Registered acupuncturists in Alberta this would mean that the cost of public funding for acupuncturists to the health care system would be rather small compared to the expenses that are incurred by other funded services including physical therapy, chiropractic and others.
9. Cost of services
The White House Commission on Complementary and Alternative Medicine states: "Cost is not always a threshold for coverage. Health plans cover a number of costly conventional medical interventions, including heart and lung transplants. The Commission believes that the cost of CAM services and products should not in itself pose a barrier to coverage. Rather, cost should be approached in the same manner as the cost of conventional interventions." Acupuncture and TCM is a health care system that is intrinsically inexpensive as proven in countries such as China. Acupuncture is performed with materials that are relatively inexpensive.
10. Fee guidelines for acupuncture services.
Fee for service has to reflect different aspects such as expertise, training background, and expenses for materials, professional insurance, continuing education requirements, office accommodation, length or complexity of the treatment and others. It should also be noted that acupuncture treatments as a rule take often 6 to 10 times longer per treatment than a doctor's visit or the visit to a chiropractor and this should be reflected in the fees. 

A simple market survey in the Calgary and Edmonton area showed that the average fee for an acupuncture treatment varied between $40.00 - $80.00 per treatment.
11. Funding of Acupuncture Services
11.1. General considerations 

The White House Commission on Complementary and Alternative Medicine has identified several barriers to coverage of safe and effective Complementary and Alternative Medicine (CAM). (13)These barriers do not only include the need for more and better research and the need for more effective communication of the findings, but also the need for equivalent and impartial consideration of safe, effective CAM interventions. It does indeed not make sense that acupuncture would only be considered for public funding if administered by practitioners with a conventional medical background while more in depth trained acupuncturists would be excluded for coverage of their services. Other designated health professions would never accept this kind of situations for their field of expertise. 

More and better research is not only needed for acupuncture but for other medical therapies as well. The official newsmagazine of the Canadian Physiotherapy Association states that inconclusive scientific evidence does not mean a therapeutic approach should not be used. It simply means that more evidence through better designed research must be carried out. (14) This does not pose a problem for public funding. Indeed clinical experience is an equally important aspect for decisions regarding funding policies. 

Barriers for private and public funding can also include: 

? Lack of communication between patients and insurance providers: Insurance providers are often perceived as not very open to patients' requests for inclusion of acupuncture in their insurance package. When it is included, the restrictions for the use of acupuncture make it often impossible to make use of it. For example the restriction is quite often that the acupuncture has to be provided by a Medical Doctor or a Naturopathic Doctor without a reasonable rationale for this restriction. As mentioned above these health care providers often have inferior acupuncture training and therefore this kind of restrictions could reduce the quality, efficiency, effectiveness and safety of acupuncture. 

? Lack of communication between insurance providers and acupuncturists. 

? Advisors for insurance providers such as WCB, Veteran's affairs and most private insurance companies have often a conventional medical background and are hesitant to include the services of Registered acupuncturists in insurance packages. 

? Lack of regulation in the Canadian provinces other than Alberta, B.C. and Quebec: Since only a minority of provinces have established regulation for acupuncturists, the insurance industry is hesitant to implement policies that would reflect trust in regulations that protect, maintain and improve standards of acupuncture. 

? Lack of basic knowledge by the conventional medical community of what acupuncturists have to offer, resulting in sometimes negative perceptions about the other. Very rarely are professional acupuncturists consulted or included in committees for designing policy regarding acupuncture or in research groups. 

11.2. Categories of services to be funded 

Treatment systems that have a proven record of effectiveness and safety should be funded regardless of the amount of research and regardless of this treatment being conventional or complementary/alternative in nature. Acupuncture clearly falls in this category as its safety record is extremely good and it survived the rigorous test of thousands of years of testing on millions of patients. 

It is tempting to go with suggestions that acupuncture should only be considered for public funding if there is an adequate evidence base. This however brings up the question what an adequate evidence base is. The Science and Technology sixth report ordered by the House of Lords (UK) noted that "an adequate evidence base" is hard to define. (3) Accepting this kind of ideas could mean that several valuable and common conventional treatments would not be considered for public funding. Psychiatric treatments, physical therapy or chiropractic modalities, counseling for addictions among a myriad of other treatments are often based on research that is less rigorous than what is requested for acupuncture. The Royal London Homoeopatic Hospital phrased this as follows: "It would be difficult to define minimum required standards of evidence in a hard and fast manner." {3) 

It is also very likely that public funding of acupuncture will facilitate the expansion of research in this field, a need that is identified in many reports. (15) 

When public funding will be available for acupuncture, it is only reasonable that this should be made available to the services of regulated acupuncturists - registered acupuncturists and TCM practitioners- with the best training in this field, whose scope of practice is mainly acupuncture.
12. Examples of public funding in other countries.
Obviously TCM and acupuncture are strongly incorporated in Asian countries with a long history of acupuncture and herbal medicine. Gerald Bodeker recognizes two basic policy models in Asia: an integrated approach, where modern and traditional medicine are integrated through medical education and practice and a parallel approach, where modern and traditional medicine are separate within the national health system. In China, about 200 million outpatients and almost three million inpatients are treated with Traditional Chinese Medicine and Acupuncture. Also the majority of general hospitals in China have traditional medicine departments. (2) 

The integration of TCM and acupuncture in Canadian Hospitals may receive opposition from conservative conventional medicine practitioners but it may very well prove to be beneficial in saving health care dollars by speeding up the recovery of patients as demonstrated in China. Further research into this area is needed. In the same article from Gerard Bodeker as mentioned above the author mentions the severe difficulties that occurred in South Korea when conventional medical practitioners through focused training joined the traditional sector and seeked to dominate. The Canadian government should learn from this experience and protect the authority and governing of the acupuncture profession by comprehensively trained professional acupuncturists. Mutual respect between conventional medicine and CAM will be key for a successful and safe integration of CAM in a new accountable health care system. A parallel model was adapted successfully in India where a counsel insures good standards of training and practice and where training in both conventional and traditional methods is provided in separate colleges.(2)
13. Treatment for substance abuse and addictions.
By waiting for more advanced research to demonstrate the usefulness of acupuncture in the treatment of addictions, before implementing public funding for acupuncture treatments, a good opportunity to relief human suffering and to safe a lot of money is wasted. This is evidenced by examples of some of the best addiction treatment centres in the United States. Several of these treatment centres where acupuncture is one of the most important treatment modalities are funded by the municipal, state or national government or by the courts. The following quick statistics are self-explanatory why immediate implementation of public funding of acupuncture for treatment of addiction is needed (8)

? Several crack cocaine and methadone addiction programs at Lincoln Hospital in New York City produced 60% recovery success rates. (The average rate of recovery prior to adding the use of acupuncture to recovery programs was 10%) 

? 89% of defendants who successfully completed the Miami Drug Court, which uses acupuncture, herbs and a counseling program, have not been arrested again; previously the court had a recidivism rate of 70% 

? 15% of prisoners participating in a similar drug/alcohol study conducted by San Francisco's City Jail system, with its use of acupuncture and herbs, did not return to the jail system. 

A retrospective cohort study using data on clients discharged from public funded detoxification programs in Boston between January 1993 and September 1994 showed clearly that acupuncture detoxification programs are a useful component of a substance abuse treatment system. (12)
14. Summary
With over 20 years of experience in assisting the province of Alberta in dealing with acupuncture and TCM related matters, the Acupuncture-Traditional Chinese Medicine Society of Alberta is pleased to submit their opinions regarding public funding of acupuncture to the government. 

There are three provinces with regulatory status for acupuncture, Alberta B.C. and Quebec. It is the opinion of the ASA (Acupuncture-Traditional Chinese Medicine Society of Alberta) that public funding is not only needed but also beneficial in a new and revised Canadian health care system. There is a lot of evidence available for the safety, effectiveness and cost-effectiveness of this system. Criticism about quality of research is unfair as the research that is available is quite often as good if not better than health care delivery systems that are publicly funded. Similar to all other health disciplines, there is a never ending need for more research. Other countries such as the United States are looking closely at the potential of acupuncture and CAM to improve the health of their citizens without burdening their health care system. This is not only possible but also very likely to happen as demonstrated in certain Asian countries like China. Public funding of acupuncture should be reserved for well-trained professional acupuncturists as they can provide the best quality of acupuncture in a safest manner.
15. Recommendations
? Inclusion of professional acupuncturists (with comprehensive training) in research and policy design regarding acupuncture. 

? Further research and pilot studies demonstrating how acupuncture and TCM can benefit Canadians should be encouraged by providing additional grants for this kind of work. 

? Government should assist with the exchange of information between all health care workers, regarding the potential benefits of acupuncture. 

? Government should start covering acupuncture services provided by regulated professional acupuncturists immediately, while holding acupuncture to the same standards as conventional medicine. 

? Government should provide the same support to quality comprehensive training in acupuncture as they do for conventional medical training programs. 

? Dominance of acupuncture by conventional medicine, using standards of conventional medicine has to be avoided by utilizing the expertise of comprehensively trained acupuncturists.
16. References
1. Hu T., The financing and the economic efficiency of rural health services in the People's Republic of China. http://www.bmj.com 

2. G. Bodeker, Lessons on integration from the developing world's experience, British Medical Journal 2001; 322: 164 - 167 (20 January)http://www.bmj.com 

3. Science and Technology - Sixth Report, Chapter 6 http://www.publications.parliament.uk/pa/ld199900/ldselect/ldsctech/123/12302.htm#a1 

4. Safety Record of Acupuncture The National Acupuncture Foundation. http://www.acupuncturealliance.org 

5. Vincent C., The Safety of Acupuncture. British Medical Journal 2001; 323: 467-468 http:www.bmj.com 

6. World Health: The Magazine of the World Health Organization, 1979. Appendix 3. 

7. NIH Consensus Statement on Acupuncture. http://odp.nih.gov/consensus/cons/107/107_introhtm 

8. Birch s., Hammerschlag R. Acupuncture Efficacy: A Summary of Controlled Clinical Trials. The National Academy of Acupuncture and Oriental Medicine. August, 1996. 

9. Davidson J., Vandervoort A., Lessard L., Miller L., The effects of acupuncture versus ultrasound on pain level, grip strength and disability in individuals with lateral epicondylitis: A pilot study. 2001 Physiotherapy Canada 53 (3); 195-202 

10. Liguori A., Petti F., Bangrazi A., Camaioni D., Guccione G., Pitarei GM, Bianchi A., Nicoletti WE. Comparison of pharmacological treatment versus acupuncture treatment for migraine without aura. Analysis of socio-medical parameters. Journal of Traditional Chinese Medicine. 2000 Sep. 20 (3): 231-240 

11. Press release from NADA National Acupuncture Detoxification Association, January 28, 29, 2000 

12. Shwartz M., Saitz R.,Mulney K., Brannigan P. The Value of Acupuncture Detoxification in a Substance Abuse Treatment System. Journal of Substance Abuse Treatment, Vol. 17, No. 4, pp.305 - 312, 1999 Elsevier Science Inc. 

13. White House Commission on Complementary and Alternative Medicine Policy. Final report. http://www.whccamp.hhs.gov. 

14. Canadian Physiotherapy Association. E-Access. Contact. July/August 2002 p.8 

15. Leggett Tait P., Brooks L., Harstall C. Acupuncture: Evidence from Systematic Reviews and Meta-analyses. Health Technology Assessment, editor. Edmonton, Alberta: Alberta Heritage Foundation for Medical Research; May 2002. 

16. Ballegaard S., Johannessen A., Karpatschof B., Nyboe J., Addition of acupuncture and self-care education in he treatment of patients with severe angina pectoris may be cost beneficial: an open, prospective study. Journal of Alternative and Complementary Medicine, 1999, http://www.bmj.com