Hawaii was the second state to license the practice of acupuncture in 1974. There are many things occurring in the Hawaii Oriental medicine (OM) community. The current composition of the Hawaii Board of Acupuncture is one of the most disturbing.
The board consists of five members: three professional and two public. Currently, one of the professional members is the president of one of Hawaii's three accredited schools. A recently appointed public member sits as a board member of the same school.
The Hawaii Revised Statutes states, among other things, that the board shall:
"Adopt rules ... with special emphasis on the health and safety of the public."
"Develop standards for licensure."
"Prepare, administer, and grade examinations..."
"Issue, suspend, and revoke licenses."
Obviously, if board members are directly affiliated with a school, those board members might benefit from the board's decisions, and therefore be in conflict. This might preclude them from being able to protect the health and safety of the public, develop unbiased standards for licensure, etc. When students from the school whose representatives sit on the board are discussed or considered, two of the board's five members must automatically recuse themselves. In many states, the licensing act clearly prohibits a board member from being an owner, principal or director of an academic program. This makes good sense, and should be considered in Hawaii.
In Hawaii, a licensed acupuncturist's scope of practice is currently described as consisting of "pain relief and analgesia; functional and musculoskeletal disorders, including functional components of diseases; and the maintenance of well-being, promotion of health and physiological balance." The law allows us to stimulate "certain acupuncture point or points on the human body for the purpose of controlling and regulating the flow and balance of energy in the body. The practice includes the techniques of piercing the skin by inserting needles and point stimulation by the use of acupressure, electrical, mechanical, thermal therapy, moxibustion, cupping, or traditional therapeutic means."
This broad definition has served us in the past by allowing us to practice whatever we have learned that might benefit our patients. Of course, we must always possess and exercise the degree of skill, learning and care expected of a well-trained acupuncturist. However, our law does not specifically give us the right to dispense herbal medicine, mobilize joints, teach remedial exercises or give lifestyle and nutritional counseling, etc. With the rapid changes the practice of medicine is undergoing, it might be to our advantage to list all of the modalities we currently use (and which accredited schools are currently teaching) so that we can clearly identify what is within our scope, avoiding any ambiguity. We could describe all the techniques; modalities; equipment; herbal medicine; nutriceuticals; and biomedical interventions we are trained to use.
In the arena of workers' compensation, acupuncture reimbursement in Hawaii has not increased in over eight years, and the workers' compensation fee schedule is applied to no-fault reimbursement as well. Since the Hawaii Medical Fee Schedule acupuncture billing code is not part of the CPT or Medicare fee schedule codes, we have not experienced the annual cost-of-living increases other medical codes have been given. Although our reimbursement has not increased, massage therapists have received more than a 40 percent increase in the same time period. In addition, we cannot bill for an examination, initial evaluation, or re-evaluation, and are currently restricted to billing in time increments. In other words, we are restricted to billing for each 15 minutes spent with the patient. Massage therapists are the only other providers billing for time. Efforts could to be made to establish equitable raises in the reimbursement acupuncturists receive, commensurate with cost of living and other raises in related fields, and to adopt a new billing structure allowing us to bill for exams, reports, modalities, etc. Our services are valuable, and we need to be reimbursed accordingly. Several years ago, the state auditor assessed the utilization rate for acupuncture services in Hawaii within workers' compensation. The audit showed that in a review of 1,000 claims for permanent injuries, acupuncturists accounted for only 0.6% of the costs. Therefore, even if the reimbursement to acupuncturists is increased, the financial risk to insurers (and thus consumers) will be minimal.
Another issue relates to acupuncture within no-fault insurance. In 1997, after heavy lobbying by State Farm Insurance Co. and other insurance interests, acupuncture was ousted from the motor vehicle insurance law in Hawaii. Prior to that time, all insured motorists with benefits were entitled to receive acupuncture services. Treatment was not restricted, and was allowed as long as it was "medically necessary." However, after the legislative session, during which chiropractic, acupuncture and massage were temporarily ousted, only acupuncture was eliminated as a covered therapy. After five months, we managed to be reinstated in the motor vehicle insurance law, but only by piggybacking on the number of visits granted chiropractors. In other words, consumers are now given a maximum of 30 visits, to be shared between chiropractic and acupuncture, provided they have not yet exhausted their medical benefits. In many instances, this results in consumers not being able to receive much-needed acupuncture treatment after having tried chiropractic services first (or vice-versa). An improvement to the current law might be to separate acupuncture and chiropractic within the insurance benefit, allowing consumers a maximum of 30 visits for each therapy. After that, an upgrade would be to abolish the maximum number of visits, and instead include both acupuncture and chiropractic services as part of the core medical benefits, allowing for care as "reasonable and appropriate." Surely, additional complementary medical approaches such as acupuncture could be made readily available to consumers, especially given the frequency that more costly and invasive surgical approaches are avoided.
The island of Hawaii has one accredited OM school; the island of Oahu has two. Oahu has an overall ratio of total acupuncturists to population of 26 to 100,000; Kauai has a ratio of 28 to 100,000; the big island of Hawaii has a ratio of 42 to 100,000; and Maui has an overall ratio of 45 to 100,000. The ratio on Maui County matches some of the highest concentration ratios for counties in California adjacent to an acupuncture school. However, Maui has no such school. You may think this is due to demographic profiles of providers and patients, but because the concentration has increased rapidly in recent years, it may instead be due to Maui being perceived as a desirable living location. Perhaps this has contributed to acupuncture being advertised for $35 a treatment in one of the finest clinics on Maui. Are we selling ourselves short? Will these "discounted" rates result in cuts in our reimbursement through workers' compensation and no-fault?
An acupuncturist can graduate from a master's of acupuncture program, complete minimal herbal training and dispense herbal medicine under his or her acupuncture license in Hawaii, without ever having demonstrated competence in herbal medicine. In fact, only 20 of Hawaii's 378 resident licensed acupuncturists are certified as Chinese herbalists. The state board and OM community have discussed creating a Hawaii herbal exam. A logical solution might be to require herbal certification through NCCAOM. Several states have already adopted this requirement, in an effort to insure competence and protect the public.
Hawaii uses the NCCAOM exam as a vehicle for licensure, yet does not require certification or maintenance of diplomate status. This means that not only can you practice herbal medicine in Hawaii without ever having demonstrated competence, but also that you can remain licensed without demonstrating continued education, activity or involvement in the field of OM. Hawaii currently does not require continuing education to maintain an active acupuncture license. The board and OM community have discussed how to implement a continuing education (CE) requirement, but the state previously refuted efforts of the Hawaii Acupuncture Association to require CEs for acupuncturists. Hawaii could require NCCAOM certification, where diplomates must complete at least 60 professional development activity (PDA) points every four years to maintain their status. At least 17 states that use the NCCAOM exam as a route for licensure currently require certification. There are obviously some significant advantages for state regulatory boards that have elected to use NCCAOM certification for licensure as opposed to requiring only the passage of the NCCAOM examination(s).
Although we have many issues to address, discuss and work together to improve, the Hawaii OM community is striving for excellence.
Click here for previous articles by Kabba Anand, DAc, LAc, Dipl. Ac., Dipl. CH.