In the last post, we took another look at Section 2607 of the Affordable Care Act, which prohibits “discrimination” against licensed CAM practitioners by insurers, and how chiropractors are continuing their PR campaign to rebrand themselves as primary care physicians. This time, we review a recent white paper by the Academic Consortium of Complementary and Alternative Healthcare, an organization that might be seen as CAM’s answer to the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM). The Academic Consortium for Complementary and Alternative Health Care (ACCAHC) is a group of “complementary and alternative medicine” educational organizations representing chiropractors, naturopaths, acupuncturists, homeopaths, ayurvedic practitioners, direct entry midwives and massage therapists. The executive director is John Weeks, a relentless promoter of “integrative medicine,” both on the Integrator Blog website and in the Huffington Post. The ACCAHC is dedicated to ensuring that its members and the practitioners they represent are included in all aspects of health care, such insurance reimbursement, financial resources for education and delivery models. ACCAHC’s stock-in-trade is its practitioners’ supposed expertise is being patient-centered, holistic, taking into account the whole person and such, as well as an alleged emphasis on healthy lifestyles, nutrition, well-being, and the like.
In fact, the stated vision of the ACCAHC is remarkably similar to that of the CAHCIM:
ACCAHC envisions a healthcare system that is multidisciplinary and enhances competence, mutual respect and collaboration across all healthcare disciplines. This system will deliver effective care that is patient centered, focused on health creation and healing, and readily accessible to all populations.
The CAHCIC’s vision is:
A comprehensive and compassionate health care system offering seamless integration of effective complementary and conventional approaches to promote healing and health in every individual and community.
Indeed, there is an overlap in governance of the two organizations. Benjamin Kligner, MD, Adam Perlman, MD, Mary Jo Kreitzer, PhD, RN, and Aviad Haramati, PhD, are all on the ACCAHC’s Board of Advisers, as well as being either current or former members of the CAHCIM’s Executive Committee. The Board of Advisers also includes other integrative medicine luminaries such as Brian Berman, MD, Wayne Jonas, MD, and David Katz, MD. The two organizations have worked together in several endeavors. One wonders why the they don’t just go ahead and merge. (Actually, one knows perfectly well why they don’t.)
As might be imagined, actual evidence that CAM practitioners can deliver on the lofty generalities of its vision and mission is in short supply. That has not stopped the ACCAHC from several initiatives aimed at cheerleading its way into modern healthcare. In this it has attained some success, according to its website.
The ACCAHC has issued “Meeting the Nations Primary Care Needs: Current and Prospective Roles of Doctors of Chiropractic and Naturopathic Medicine, Practitioners of Acupuncture and Oriental Medicine, and Direct-Entry Midwives,” a white paper “developed through the Primary Care Project of the ACCAHC,” under the editorship of Michael S. Goldstein, PhD, of the UCLA Center for Health Policy Research and John Weeks, published in March, 2013.
The paper laments that, despite the shortage of MD/DO primary care physicians and the consideration of other health care providers as means of addressing this gap, such as nurse practitioners and physicians assistants,
workforce analyses and healthcare delivery practices have not to date engaged the potential contributions of chiropractors, naturopaths, acupuncturists and direct-entry midwives as providers of primary care.
the goal of this paper is to assist policy makers, regulators, third-party payers, delivery system administrators, practitioners, and other concerned parties as well as the disciplines themselves in considering the optimal use of these professions as part of the nation’s primary care matrix.
Toward this end, teams were chosen by the Association of Accredited Naturopathic Medical Colleges, Association of Chiropractic Colleges, Council of Colleges of Acupuncture and Oriental Medicine, and the Midwifery Education Accreditation Council to set forth how each field meets, or does not meet, “conventionally used definitions of primary care.” (The Midwifery Education Accreditation Council has jurisdiction over direct-entry midwives. These midwives do not have the equivalent education and training of nurse midwives. I will not cover their portion of the paper in this post.)
We should note here that, according to one of the “conventional” definitions of primary care referenced in the paper, primary care includes the ability to meet the health care needs of the “undifferentiated patient”, that is
persons with any undiagnosed sign, symptom, or health concern . . . not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.
(From the American Academy of Family Physicians [AAFP], 2010)
According to the same definition, primary care physicians must also be able to “treat acute and chronic illness in a variety of health care settings.” This is not all that they do, of course. The AAFP’s definition of primary care also includes health promotion, disease prevention, health maintenance, counseling, patient education, promotion and maintenance of wellness.
In supposedly answering the question posed, the paper provides a lot of platitudinous statements about wellness, health promotion, patient-centered care, the whole person, natural remedies, the body’s self-healing abilities, and so on. There is also a great deal of talk about being a “first contact” provider for patients, insurance coverage, what the scope of practice acts say, the fact that this or that provider is called a “physician” or “doctor,” what government programs include or do not include, accreditation by the U.S. Department of Education, what their patients think about them and other information not directly relevant to two key components of primary care practice if one is to practice independently, without supervision of an MD or DO. If these components are not part of the practitioner’s skill set, then he or she shouldn’t be claiming rights to the PCP title.
To determine whether these key components are present two questions must be answered: (1) does the chiropractor, naturopath, or acupuncturist have the education, training and ability to see the undifferentiated patient in his office and know what to do with her, that is, can he diagnose the undifferentiated patient, either deciding to treat her or refer her to another provider? And, (2) does he have the education and training to treat acute and chronic illness in a variety of health care settings?
Let’s see how this paper addresses these critical aspects of primary care because, if CAM practitioners can’t convincingly argue that they can do these things safely and effectively, they shouldn’t be considered for the job, credulous legislators aside.
“Acupuncture and Oriental Medicine Practitioners in Primary Care”
(Statement approved by Council of Colleges of Acupuncture and Oriental Medicine)
The acupuncturists admit that they do not have sufficient “biomedical training” (their term) to serve as primary care providers if one’s definition of primary care means that the practitioner meets all of the biomedical and health needs of the patient. Depending on which accreditation agency oversees a particular acupuncture school, students have between 450 and 588 hours of biomedical training, although the subject matter and quality of these courses is not addressed. They add that there have been no published studies examining AOM providers as primary care providers.
However, like chiropractors, there is a faction within acupuncture which supports the development of acupuncturists as primary care practitioners. This group formed the National Certification Commission for Acupuncture and Oriental Medicine, but the organization has not been recognized as an accrediting body by the U.S. Department of Education. The authors believe acupuncturists must reach a consensus that they want to be PCPs before this idea moves forward, but “the acupuncture terrain is rapidly changing and this situation could change within 3-5 years.”
Oddly, they say that
there has been an opinion within the CAM community that a one year primary care training program would prepare AOM practitioners to work within mainstream medicine, with training similar to that of a physician assistant (PA).
The authors note that there are three states (California, Florida and New Mexico) which define acupuncturists as “primary care physicians” in their practice acts. These statutes
imply that providers in these states provide comprehensive biomedical care commensurate with the training of a primary care biomedical provider. This issue has led to some providers within the profession to assume that they have the same primary care mandate as a medical doctor or nurse practitioner without the commensurate level of biomedical training and to push for an expanded role within primary care, even with the current level of training in the US.
On the other hand, the authors vigorously defend their ability to be a first contact health care provider seeing patients who have not been seen by a medical doctor, provide care for those who do not need “more intensive biomedical care” either initially or during the course of being under an acupuncturist’s care, and are trained to make both emergency and non-emergency referrals when necessary. No matter what their actual education and training, the authors point to studies that patients actually used acupuncturists for musculoskeletal complaints, anxiety, depression and other mood disorders, and other conditions including digestive disorders, respiratory disorders, urinary and reproductive disorders, infections conditions, autoimmune disorders, headaches, fatigue, stress, and allergies, among others.
“The Chiropractic Profession and Primary Care”
(Endorsed by the Association of Chiropractic Colleges)
The chiropractors claim, right off the bat, that they are primary care physicians. This is based on the Council on Chiropractic Education, the American Chiropractic Association, International Chiropractors’ Association and other chiropractic organizations saying that they are. The authors say that chiropractors can practice as a first-contact provider for patients of all ages and genders, assess a patient’s health status, formulate a clinical diagnosis, develop a case management plan that includes treatment, prognosis, and any necessary referrals. They can (according to the ACA) address “a large majority of personal health care needs.” The ICA says that the chiropractor can “provide all three levels of primary care interventions and therefore is a primary care provider, as are MDs and DOs.” The authors further claim that chiropractors “are trained to appropriately diagnose and manage the majority of healthcare issues that may present to their offices.”
If that is the case, it is certainly not proven in this document. Although studies and various surveys were cited, none supports the claim that DCs are capable of acting as primary care physicians nor do they support the assertions made by the CCE, the ACA or the ICA.
The chiropractor portion of the white paper ends by seeking to bifurcate primary care into two different types: primary medical care and primary health care. This allows the authors to hold forth on two of the CAM practitioners favorite subjects: how “holistic” they are and how bad medicine is.
The distinction aligns with the holistic biopsychosocial model of health as opposed to the biomedical focus on disease alone. . . Primary health care pays attention to both objective and subjective findings; it is truly patient-centered. Instead of medical specialists, the emphasis is on generalist health professionals who are trained and willing to work together. In this view, while primary medical care is dominated by medical physicians and internally focused on its own institutions and behaviors, primary health care explicitly seeks community participation and a wide range of professionals, always working the with patients as partners in the relationship.
However, in discussing barriers to chiropractors playing a greater role in primary care, the authors have (most certainly unintentionally) provide an unflattering picture of what chiropractic primary health care would look like. They note that some payers won’t “reimburse DCs for primary care services. An egregious example is that Medicare that pays for manipulative treatment but not for the diagnostic work that must precede it.” What they are referring to is the fact that Medicare pays for manual manipulation of the spine to correct a “subluxation” but does not reimburse for an x-ray to “detect” the subluxation. Of course, the chiropractic subluxation doesn’t exist and it can’t be detected at all, on an x-ray or otherwise. The “holistic biopsychosocial model” indeed.
“Naturopathic Physicians in Primary Care”
(Endorsed by the Association of Accredited Naturopathic Medical Colleges)
Naturopaths, as did the chiropractors in their report, like the Institute of Medicine’s definition of primary care because of its appealing vagueness when plucked from the context in which it was created.
Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.
The actual 1996 IOM report from which this definition is taken is 400-plus pages long. Nowhere in the report does it indicate that the IOM thinks medical education and residency should be chucked for PCPs or that chiropractors or naturopaths should be primary care physicians. (Quite the contrary – see chapter 7.) Yet naturopaths seem to think that declaring they can meet the IOM definition, without knowing what the IOM was talking about, is sufficient to claim the role:
By philosophy, training and practice, modern naturopathic primary care satisfies these criteria by providing individualized, comprehensive, patient-centered care for all conditions and demographics.
Does it? Let’s look at the evidence presented.
There is virtually nothing about naturopathic education and training in the report, much less any hard evidence that it is sufficient to support a PCP scope of practice. (Mark Crislip came to a similar conclusion in his review of an earlier attempt by naturopaths to convince us.) In attempting to address their lack of clinical education, they make the curious argument that, since most primary care occurs in community settings and in-patient care is provided by hospitalists, their lack of hospital-based training is not problematic. The authors apparently hold the misguided impression that training in a hospital is simply for learning about “hospital-managed pathology” (their term) and therefore unnecessary. (Of course, this also ignores the 3 additional years of clinical training an MD or DO primary care physician must undergo.)
As for research, the authors claim that naturopathic “principles are continually being reexamined in light of scientific advances.” But in the very next paragraph, they say that some naturopaths specialize, giving as an example the specialty of homeopathic medicine, a naturopathic principle that is most certainly not examined in the light of science at all, much less scientific advances. They then go on to claim:
Although the literature based on naturopathic outcomes in disease and health is limited, there is increasing evidence demonstrating effectiveness and cost-effectiveness.
Eleven studies (one of which was addressed by David Gorski here) are cited, but they don’t tell us what these studies actually concluded. There is also a reference to the Naturopathic Physician’s Research Institute but that is equally unimpressive. Some of this research is downright disturbing, such as “Safety and efficacy of oral DMSA therapy for children with autism spectrum disorders: part B – behavioral results.” This study, done at the Southwest College of Naturopathic Medicine,
investigated [DMSA’s] use for an off-label application, namely treating children with ASD who have evidence of significant heavy metal exposure (based on urinary excretion after DMSA challenge). DMSA preferentially binds to lead, but can also increase the excretion of several other toxic metals (including tin, bismuth, thallium, mercury, antimony, and tungsten) to a lesser extent. Another paper resulting from this study discusses the strong correlation of the initial severity of autism with the body burden of toxic metals.
What the Academic Consortium for Complementary and Alternative Health Care white paper demonstrates more than anything is that the state practice acts for chiropractors, naturopaths and acupuncturists give all of these practitioners a scope of practice that far exceeds their abilities. Acupuncture practice is more limited in most states but, as the acupuncturists themselves noted, they have a scope of practice in three states they are not properly educated or trained to assume. Even where they are not specifically defined by law as PCPs, they believe they can see the undifferentiated patient as an acupuncture and oriental medicine provider, while referring patients when they need “biomedical” care. Yet they fail to realize that without “biomedical” education, they cannot reliably determine when such care is required.
Chiropractors in all states can see any patient with any disease or condition, although there are a handful of diseases they are, by law, prevented from treating. The same is true for naturopaths in most states where they are licensed. But given the opportunity to present evidence that they can safely and effectively act as primary care physicians, that is, first contact providers who can diagnose and treat (or safely refer) all patients, they have fallen far short.
The ACCAHC has unwittingly provided an excellent resource for anyone lobbying for reform of the CAM provider practice acts. This is especially true in light of Section 2607 of the Affordable Care Act, which mandates reimbursement based on scope of practice allowed by the state, not the provider’s actual abilities.