I am happy to report some good news: chiropractors, naturopaths, acupuncturists and assorted other practitioners of pseudo-medicine didn’t fare too well in the 2013-2014 state legislative sessions.
We’ve been following their legislative efforts all year over at the Society for Science-Based Medicine. Some state legislatures meet in yearly sessions. At the end of the year, pending bills die with the session. Some meet only every other year. Others meet in two-year sessions and, in some of these, legislation introduced in one year carries over to the next year. All states with two-year sessions ended these sessions at the close of 2014, except New Jersey and Virginia. If you want to see how your state operates, several websites can help you: MultiState Associates, National Conference of State Legislatures and StateScape.
Chiropractors are already licensed in all 50 states and all of their practice acts permit the detection and correction of the non-existent subluxation. Having achieved that goal, the focus of chiropractic legislative efforts is to expand their scope of practice (the holy grail, for some, being primary care physician status), turf protection and mandates requiring insurance reimbursement or their inclusion in various activities, such as sports physicals, concussion treatment, and scoliosis detection programs.
The most interesting chiropractic bill, one from Oklahoma, didn’t fall into any of those categories:
Chiropractic physicians in this state shall obtain informed, written consent from a patient prior to performing any procedure that involves treatment of the patient’s cervical spine and such informed consent shall include the risks and possible side effects of such treatment including the risk of chiropractic stroke.
The Oklahoma Chiropractors’ Association thinks informed consent legislation is “dangerous.” According to Chris Wadell, President of the Oklahoma Board of Chiropractic Examiners, informed consent “isn’t needed”:
“We don’t hide from this but it just hasn’t been necessary to do it,” Wadell said. He insists that chiropractors are helping people and are being unfairly blamed for strokes after a patient’s neck is adjusted.
The bill was watered down to a “Task Force on Neck Manipulation.” It passed in the House but not the Senate.
Fortunately, a bill passed and was signed into law by the governor in Wisconsin requiring chiropractors (who already had a duty to obtain informed consent) to inform patients of reasonable treatment alternatives and the risks and benefits of those alternatives. It does not require disclosure of “extremely remote possibilities that might unduly alarm the patient.” The standard for determining what must be disclosed is that of a “reasonable chiropractor,” not what a “reasonable patient” would want to know. We’ll have to see whether chiropractors will inform patients of the risk of cervical manipulation from now on, since the official position seems to be that chiropractic cervical manipulation is not a cause of stroke at all.
Bills in New Mexico and Hawaii sought to expand the chiropractic scope of practice, but both failed. In New Mexico, which I’ve discussed before, chiropractors wanted to get their hands on even more drugs than their limited formulary already allows, which includes injection of “nutritional medicine,” bioidentical hormones and glandulars, among other substances. (They must have all of 90 additional hours of training for this privilege.) This time, they wanted to expand their formulary to include all drugs, including “dangerous drugs” (other than Schedule I and II) used in primary care practice. They’d need a “post-graduate degree in a clinical specialty” (not otherwise defined) for this, plus 650 hours in a supervised “clinical rotation” (again, not otherwise defined).
Both the New Mexico and Hawaii bills contained language which would essentially allow the decision regarding chiropractic scope of practice to default to the chiropractic schools and boards. Of course, the bills don’t say that specifically. What they do say is that chiropractors could diagnose and treat any disease or condition for which they are “educated and trained” (New Mexico) or diagnose and treat with methods taught by chiropractic schools and approved by the state chiropractic board (Hawaii). Even though these bills didn’t pass, I think we are going to see more of this type introduced in the future, pressed by the “DC as PCP” faction. Like naturopathic schools, chiropractic schools could claim they train DCs to be primary care physicians, and thus they would – voila! – become PCPs under state law.
Chiropractors are threatened by physical therapists because PTs are educated and trained to use manual manipulation, but without all the mumbo-jumbo. In California, a bill failed that would have prevented PTs from performing joint manipulations, while in Washington, the governor signed a law that specifically allows PTs to perform spinal manipulations. The law has a comical provision that prevents PTs from using exactly the sort of mumbo-jumbo they avoid in the first place — “adjustments” and “maintenance or wellness manipulation.”
Finally, and thankfully, chiropractors won’t be performing mandated scoliosis screening in New York or sports physicals and commercial driver’s license exams in Washington. Those bills failed as well.
During 2013-2014, 10 naturopathic licensing bills were introduced, all of which attempted to give naturopaths a broad scope of practice. Treatments specifically permitted in some bills include colonic irrigation and prescription of “natural” medicines, vitamins, minerals and homeopathic substances, including administration by injection or IV. Pennsylvania would allow “visceral manipulation.” An interesting feature of many licensing bills is a provision allowing naturopaths to perform or order diagnostic testing, such as x-rays or those “commonly used” by MD PCPs, as long as it is “consistent with naturopathic education and training.” This is the same sort of open-ended permission we are seeing in chiropractic bills, defaulting to the schools to determine the scope of practice.
Eight of these naturopathic licensing bills were rejected (New York, Massachusetts, Michigan, Pennsylvania, Illinois, Iowa, Idaho, Rhode Island) leaving naturopaths licensed or registered in only 17 states and D.C. One bill, in New Jersey, is still pending because NJ is one of the two states to carry 2014 legislation over to 2015.
Only one licensing bill, in Maryland, passed, albeit with a scope far short of what they wanted. Maryland will not permit naturopaths to call themselves primary care physicians (or even “physicians,” for that matter). Nor will it allow them to prescribe drugs, use colon hydrotherapy or practice under the jurisdiction of their own board. Instead, they will be under the jurisdiction of the Maryland Board of Physicians, which is currently working on regulations, a subject I covered in a previous post.
Naturopaths also fought to have restrictions on their practice removed in Colorado. In 2013, after numerous attempts by naturopaths (also here), the legislature finally passed a registration (but not licensing) bill. The law prevents them from seeing patients under 2 years of age at all, and places severe limitations on their ability to treat patients between 2 and 8: they must disclose they are not physicians, recommend that the child have a relationship with a licensed pediatric practitioner, and give parents the CDC-recommended vaccination schedule. One of the main purposes of these restrictions was to thwart their efforts to dissuade parents from vaccinating their children. Fortunately, the bill watering down patient protections did not pass and those restrictions remain in place. On the other hand, a Colorado bill to eliminate their ability to prescribe drugs in their formulary and perform minor office procedures did not pass.
Another bill designed to protect patients was passed in Hawaii but only after having been defanged as it moved through the legislature. What began as a bill requiring that naturopaths who wanted to prescribe drugs have the same education as an MD or DO ended up as a law requiring more continuing education.
Naturopaths did get an expansion of their scope of practice in 3 states, but it was significant only in Connecticut, a topic I covered in an earlier post. (A humorous aside: There is a slide presentation, “About Naturopathic Medicine,” on the American Association of Naturopathic Physicians’ website comparing naturopathic “medical” school education to that of the Yale School of Medicine. You’re in good hands, Connecticut!) They can now practice “telemedicine” in Arizona and perform minor office procedures in Utah. A practice expansion bill in Alaska failed.
CAM providers crave coverage of their services by public and private health insurance. This can be a mixed blessing, since private insurers generally won’t cover diagnoses and treatments with insufficient evidence to support their use, such as many diagnostic and treatment methods used by chiropractors. This leads CAM practitioners to call on their friends in the legislature to force insurers to cover their services. (State mandates become more problematic under the Affordable Care Act, although the ACA has its own troublesome non-discrimination provision.)
Because bills mandating coverage are so numerous, we don’t follow them on SFSBM. One bill bears mentioning, though, because it is a good example of how CAM providers try to force themselves on health insurance programs via state legislatures.
Oregon created “coordinated care organizations” to provide health care services to Medicaid patients. Obviously, the state gets more value for the taxpayer dollar when ineffective treatments are excluded. So that is what the state did, by requiring that all CCO providers practice evidence-based medicine. Naturopaths, naturally, balked at this.
Not to worry, though. Legislators came to the rescue with a bill that required CCOs to include all state-licensed healthcare providers in sufficient numbers and geographical distribution to give all patients reasonable access. This would include:
Reasonable access to chiropractic physicians [and] naturopathic physicians . . . for all primary care services that are within the scope of the provider’s license . . .
Acupuncturists would have to be included as specialty care providers.
The CCO would have to pay:
. . . the same reimbursement rate for a service to all providers who are acting within the scope of their license . . . and may not vary reimbursement rates solely on the basis of a provider’s license . . .
Fortunately, this bill didn’t pass. Of course, CCOs can choose to include naturopaths, chiropractors and acupuncturists in their provider panels, they just won’t be forced to by the state. Nor would they have to pay the same rate they pay MD or DO physicians.
Acupuncture, TCM and oriental medicine
Acupuncturists really struck out. Of the 7 acupuncture bills proposed, only one passed, and it wasn’t much. Pennsylvania acupuncturists must refer a patient to a physician if they treat a “condition” beyond 60 days. Now they can avoid referring if the patient doesn’t present with a “condition.” This is mystifying, because I can’t imagine why a patient would be getting acupuncture treatments at all if he didn’t have a “condition” that needed treating. The Pennsylvania House also passed a resolution making Oct. 24, 2014, “Acupuncture and Oriental Medicine Day,” because those modalities have been:
used for thousands of years to diagnose and treat illness, prevent disease and improve well-being.
“Used,” maybe. Effective, no.
On a brighter note for consumers, the Pennsylvania acupuncturists must now carry $1 million in liability insurance, which will be enough to attract a personal injury attorney to take a plaintiff’s case should matters go south with the acupuncturist.
Speaking of going south, things did exactly that for acupuncturists in the Deep South. A licensing bill failed in Alabama, Louisiana wouldn’t even create a committee to look into licensing, and Mississippi refused to ditch a requirement that patients have a physician’s referral to see an acupuncturist.
Arizona didn’t pass a bill expanding the scope of “auricular acupuncture” to include PTSD treatment. A bill to create a “Traditional Chinese Medicine Traumatologist” certification passed the California Senate but not the House. If it had become law, these practitioners could treat musculoskeletal conditions by stimulation of “acupressure points” to:
open the body’s defensive chi and stimulate energy movement in the meridians.
“Alternative Health Care Practitioners”
“Alternative Health Care Practitioners” are pretty much anyone who wants to hang out a shingle and advertise himself as such. The Colorado legislature passed a law in 2013, which I call “the Quack Full Employment Act,” allowing folks to do exactly that, but put the same sort of restrictions on their treating children as it did on naturopaths. (Not very flattering for the naturopaths, if you think about it.) A bill tried to remove those restrictions, but failed.
All in all, the 2013-2014 legislative session (or sessions, depending on where you live) were a bust for chiropractors, naturopaths, acupuncturists and assorted other practitioners of pseudo-medicine. Let’s keep it that way for 2015-2016. We’ll be following CAM bills over at SFSBM. These are target-rich subjects, making it inevitable that SBM bloggers will “review” them from time to time as well.
Even better, we at SFSBM aren’t stopping with the Maryland naturopaths in our efforts to give science and consumers a voice when CAM practitioners go for licensing or try to expand their scope of practice. You can help by keeping up with what is going on in your state using the vast amount of information on SFSBM and SBM to educate your legislators. Looks like they could use some help.