Where Are We Headed with Managed Care? A Five-Element Perspective
By David Vandenberg
Those of us in the acupuncture profession realize that in many ways, California now leads the way in developments in the field. California has by far the greatest number of practitioners; one of the largest number of practitioners per capita; and, most significantly, has been at the forefront of the codification of the field in the eyes of insurers.
This is exactly what disturbs me.
While I have a small practice in central Maryland, my main practice is in downtown Washington, D.C. For a few months last year, I worked in one of the busiest and most well-known practices in the city. I was able to see very clearly into the lives of MDs from my perch - literally - on Pennsylvania Avenue.
The MDs I met and conversed with are the lynchpins of a vast medical establishment that stretches to teaching hospitals, insurance providers and pharmaceutical companies. I cannot recall a single time the office was open in which at least one pharmaceutical representative was not cooling their heels in the waiting room with free samples and informational seminars to Cancun.
While phenomenal amounts of money flow into that and other practices in the city each day, the system the physicians and others have created is profoundly deadening. Not only is this my own observation; the MDs I spoke with were clearly in the midst of spiritual and financial crisis derived from the reimbursement, legal and treatment strictures placed on them by managed care.
I practice primarily five-element acupuncture. I do so because I can reach profound levels of a person's being I have not seen reached with the traditional Chinese medicine I also know and am certified in. My concern with the uncritical embracement of the insurance and legal industries is that we are reproducing a medical model whose most visible players - MDs and nurses - say is fundamentally unworkable. It reminds me of a concept my father taught me while learning to drive: if a car in front of you has its brake lights on, stop; don't rush headlong around the car into an accident.
Part of this rush into professionalism is witnessed in increased classroom hours under the belief that higher levels of competence can be had in the form of academic degrees. However, degrees guarantee neither competence nor respect, as the large number of malpractice cases against MDs (as well as public opinion) show.
What creates competence and respect is a refinement of one's skills and the ability to work with people in the personal space created by a true healer, concepts I doubt any book, lecture or homework assignment will adequately cover. Moreover, what California (and a few other jurisdictions) have done is mandate the practice of TCM as the only acceptable approach to Chinese medicine.
While there is nothing intrinsically wrong with TCM, it is not the only viable approach. I have been able to clear factors with needles alone that different TCM practitioners have told me is impossible. While the addition of classroom hours to training and certification requirements are often presented in terms of increased professionalization, safety and competence, I would suggest that an opposite effect will occur over the long term. California and other states with TCM-based licensing requirements restrict practitioners from entering because of their different knowledge and skills, blocking the propagation and practice of differing styles in those areas. This is justified with the belief that these restrictions protect citizens from inferior or fraudulent practices, yet there exists no basis for the assumption that TCM (or any other style of acupuncture or Chinese medicine) is more effective than another.
Were efficacy the issue, I would expect to see studies aimed, for instance, at Japanese versus Chinese acupuncture techniques. Restrictions such as those in California exist to create a formula for acupuncture that conforms more closely to the Western medical model and the assumptions Westerners have about the nature of reality. However, the reason acupuncture works at all, yet alone so beautifully and effectively, is precisely because it was created by Chinese who had insights into reality that differ markedly from the assumptions commonly held by Westerners.
Favoring the medical model that conforms most closely with Western medicine, and excluding those which depart from Western concepts, equates to moving away from the very source of the medicine we practice. This exclusionary movement reminds me of the end of the Roman empire. Whereas all religions had previously been tolerated as part of the great pax Romana, under the emperor Theodosius the Great, Christianity became the state religion. Historians mark the institution of a state religion at 400 A.D. as the beginning of the dark ages in Western European history. The persecution of religions resulted in a large stream of refugees to India, bringing their knowledge and skills to help create the golden age of Indian culture.
I am not saying that licensing regulations in some states amount to religious persecution. Rather, any suppression of knowledge and ability impoverishes the jurisdictions that institute those suppressions. The many threads of medical knowledge handed down generation after generation in China, in schools and families, and from master to apprentice, are all making their way to the United States. Unless we are wise enough to foster those strands, we will lose them and end up with only one system (or a ragged few).
It appears to me that in those quarters where professionalization means more classroom hours and greater insurance reimbursements, the heart of Chinese medicine is being lost. One thing I learned in five-element school is to never insert needles until the client's concept of their condition changes. To do otherwise could actually reaffirm a person's mental and energetic disease state within the body. By following the path of Western biomedicine, we are reaffirming the ills of managed care as well as the presumptive superiority of one medical style over others.
While the current biomedical system has taken about a century to create the current pickle it is in, acupuncture has existed for millennia. I would wager that if we look to the cultural models in which Chinese medicine thrived and adapted them to our current needs, we could create a more lasting and effective system, thereby ensuring not only the continuation of our medicine in the U.S., but its centrality as a method of healing for people and the country as a whole. Indeed, practitioners of Chinese medicine have a unique opportunity to fundamentally change how disease, healing and medicine are practiced in this country.
For some people, I imagine my suggestion may appear a bit impracticable, but I do not believe so. When I entered that medical practice on Pennsylvania Avenue, I did so expecting great numbers of referrals from MDs. My practice did thrive, although I received only one MD referral in three months. Likewise, when I signed up to become part of a discounted treatment network, I received large numbers of referrals and new clients, but only one through the network.
In building my practice, I realized I was the only one responsible - not the insurance or practitioner networks. It was up to me and how I felt about myself, other practitioners and my own skills. Similarly, what is crucial to the future of this profession is how we hold ourselves, our colleagues and our abilities, not the kinds of seminars we attend, how many hours we sit in class or how many books we read. The people who come to me need their hearts healed and their spirits mended, and they find their way to me through their symptoms. The present health insurance morass and the hodgepodge of licensing for acupuncture in this country are symptoms that, if followed to their root, point to a need for profound healing of the spirit within the acupuncture community.
We have some questions to ask ourselves. Will we decide to fracture ourselves further, creating enclaves exclusive to certain schools and systems, or will we decide to allow a free exchange of techniques and skills that can create new systems and insights for the future? Will we rush into an unworkable reimbursement system, or will we create a new system that reflects the values of Chinese medicine? Most of all, who will we be for the other acupuncturists, clients, and deals we get from another insurance company?
Chasing after respect through academia, when respect comes through cultivation of kindness of self and others, will only result in a waste of time and resources. Chasing after money through insurance reimbursement will only devalue our abilities in the minds of potential clients, until eventually, we will be perceived as just another quick fix and not a purposeful support for people throughout their lives.
Before we rush ahead, I suggest we -- not insurance brokers or adjusters -- define what we wish to create. I suggest we work through consensual support of our skills and knowledge and the mutual valuing of what our colleagues have to offer. In this way, Chinese medicine will become more professional, and its value will increase. I use primarily five-element acupuncture, although I incorporate TCM at times, because I find TCM works best for some clients and conditions. That being said, I would not like to do without either treatment option.
I have the great fortune of living and practicing in Maryland, the only state not to outlaw acupuncture in the early 1970s and a leader in national certification and state licensing, conscientiously creating an environment conducive to traditional Chinese medicine, five-element acupuncture, Korean hand acupuncture and so on. By having access to different models, the scope and effectiveness of my practice has increased in terms of who I can treat, what conditions I can treat and what forms of acupuncture I make available for myself. It is this American tradition of inclusiveness, expressly forged in the mid-Atlantic colonies, which I find lacking in the Western jurisdictions, and which I offer for our mutual benefit.