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Is There "Gold" To Be Had In
Practicing Medical Acupuncture?
In the early 80s, my main concerns were not financial regarding the practice of Medical Acupuncture. Instead, at the time, the major obstacles were psychological. In 1982, at a county medical society meeting, a colleague asked: "Well, Rotchford, we hear you are doing some acupuncture, tell us how it works." I responded, "I don't know, Bob, but some of my patients definitely respond well to it." A droll look then came over Bob's face and he turned away. Had I said something taboo? In any event, the discussion changed to other topics and I felt rather shunned.
And there was also the stress of trying to integrate acupuncture into a busy rural family practice.1 But, fortunately, I didn't have to convince my colleagues. I was in solo practice in an underserved rural area. The demands on my time and skills were immense, and to alternate from a standard Western approach to an acupuncture mode was often challenging.
Potential pressures also surfaced because of practicing outside of the "standards of care." In the early 80s, much more than now, practicing medical acupuncture was considered outside of common "standards" of medical care. Hence, there were potential legal as well as financial landmines. I, like others, just carried on. We were bolstered by our patients' not-uncommon dramatic improvement and the gratitude they expressed. And rational risk/benefit analyses often made medical acupuncture a good therapeutic choice.2,3
Indeed, medical acupuncture is most often accepted as a reasonable therapeutic choice. What has changed for the worse, however, are the economic pressures many physicians are currently experiencing. More and more, third-parties are dictating what becomes the implicit "standards of care," and how much a physician is to be reimbursed.
I recognize that financial concerns have almost always been a part of the practice of medicine. I lament, though, that money seems to be more and more the determining factor of what we do and don't do in medicine. This being as it is, I will now review possible ways of securing a good financial future while continuing to provide medical acupuncture.
Earning a respectable income depends upon a whole set of contextual issues – income and expenses being primary ones. In my experience, I have always filtered it down to how much income I have to generate per hour of work in order to meet my expenses and make a solid living. Some physicians are salaried but inevitably, many physicians or their employers are asking the same questions.
For discussion purposes, let us assume that one needs to generate $300/hour of work in order to meet financial objectives. Then that defines the equation...One can see 1 patient during that hour and charge him/her $300 or see 6 patients and charge them $50 each (or, a small amount more because of the extra expenses involved in seeing 6 patients per hour).
For practical reasons, most of us are not able to see 6 or more patients per hour. For others, that volume does not provide the professional satisfaction that comes with spending more time with a patient. While I routinely spend 20 minutes or more with my acupuncture patients and conservatively estimate that I help 70% of them, in an 8-hour day, I then only can help about 17 patients.
A clinician who only spends 10 minutes with a patient and perhaps helps no more than 50% of them has helped at least 24 patients who might otherwise not have been able to obtain acupuncture.
Which clinician is doing the better job? Let us be careful not to judge another's practice. Each physician must determine what works best for him/her based on a host of contextual factors. I strongly believe, though, that if money is the primary driving force, then we are corrupting medicine and not upholding the basic ethics of our profession.
Consequently then, what are some ways, outside of a cash practice, to allow one to spend some time with a patient while not being so exclusive that only the wealthy can/will afford the service? If one depends on third-party coverage/reimbursement for acupuncture, even when it does exist, rarely will the $300/hour objective be met. Here are some ways, though, that I have worked with third-party carriers and made it work...
One strategy is to provide standard care and code according to time spent with the patient in counseling and/or informing them of options, writing prescriptions, etc. One then supplements this with a supplemental charge if/when acupuncture is provided. There are third-party carriers that recognize that dry needling of trigger points is just as effective as injecting them, and will pay accordingly. This clearly can supplement the charges for an office visit. So, if a patient has a painful complaint and I can justify a trigger point code, I use it. (With Medicare, this strategy cannot be utilized.)
There are also physical therapy codes one may use. Heat therapy and electrical stimulation are among the most common physical therapy codes I use. I have also at times injected a trigger point because the payment for same allows me to justify further time with the patient and provide some acupuncture. I am not aware of any legal or ethical problem with this – as long as the patient is aware of the risks and benefits of injecting lidocaine, procaine, and/or B12 into a trigger point.
I also now require patients to be referred to me for a consultation for pain management/medical acupuncture by their primary care provider (PCP). This can make it more difficult when building a practice, but our colleagues would often rather refer to a physician than a nonphysician for acupuncture. Given the right marketing strategy, it may even help a practice grow.
This policy allows me to charge the third-party a consulting fee for the first visit - while helping me avoid the "time drain" liability that a patient without a PCP can exact. One last strategy I have employed to avoid third-parties not paying for my services is to separate my acupuncture notes from my standard notes. (My computer program allows me to not routinely print out my acupuncture notes.) If asked, I send to the third party the office visit notes that correspond simply to the charges incurred.
In the past, some third-parties have viewed my acupuncture notes and, as a result, have disallowed the entire visit. Needless to say, this was unfair because my patients inevitably benefit from my covering bases both from a Western and acupuncture point of view. As most of us know, however, being "reasonable" with third-parties is not often productive or rewarding. So, as much as I can, I've learned to avoid the discussions while being honest about what I have done. (I am not aware of any legal requirement to send all my notes to any third-party unless specifically court-ordered to do so and/or have formally agreed upon. But, I am not an attorney, so please do not perceive any of the above as "legal" advice.)
Finally, be prepared to also provide "free" medical acupuncture. Acupuncture is different than psychotherapy and other forms of medicine. One can "give it away" and it can still be readily appreciated and helpful. Having practiced my entire career in rural settings, my patients have often been my neighbors and friends. All the more reason that providing free acupuncture has been rewarding.
My take-home message is this... Patients recognize when they are being cared for. If we care for them as best we can, then we don't need to be shy about asking for what we need. Remember, our gold is not common gold.
-- James K. Rotchford, MD, MPH
Guest Editor
REFERENCES
- Rotchford JK. Integrating acupuncture into a general medical practice. Medical Acupuncture. 2001;13(1):27-31.
- Rotchford JK. Letting the horses run. Patient Care. October 30, 1998:123-124.
- Rotchford JK. Attributable risk and acupuncture events. AAMA Symposium Syllabus. 1999:317-330.
Editor's Note: We welcome submissions of Guest Editorials for the journal.
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