Regulation of Acupuncture

136 Pages·2004·0.46 MB·English

by  Little Hoover Commission

State of California
L I T T L E H O O V E R C O M M I S S I O N
September 30, 2004
The Honorable Arnold Schwarzenegger
Governor of California
The Honorable John L. Burton The Honorable Dick Ackerman
President pro Tempore of the Senate Senate Minority Leader
and members of the Senate
The Honorable Fabian Núñez The Honorable Kevin McCarthy
Speaker of the Assembly Assembly Minority Leader
and members of the Assembly
Dear Governor Schwarzenegger and Members of the Legislature:
In 2002, the Commission was asked by the Governor and Legislature to assess some long-
standing and contentious issues regarding the State’s regulation of the acupuncture
profession. Specifically SB 1951 and AB 1943 requested that the Commission review the scope
of practice and educational requirements for acupuncturists, the process for accrediting
acupuncture schools and for examining licensees.
In conducting this review, the Commission sought out detailed and technical analysis – from
experts at the University of California, California State University and RAND – to help sort
through the conflicting claims that have frustrated the policy-making process. The
Commission heard hours of public testimony, and engaged in even more hours of less formal
public discussions. The Commission solicited and reviewed written comments from any
individual and organization that desired their view to be considered, and it reviewed volumes of
scientific and other treatises on acupuncture and Oriental medicine.
The Commission, as an independent and bipartisan panel, also explored the underlying
tensions that have contributed to the persistent debates and probed the broader public interest
aspects that are embedded in the specific regulatory issues that were before the Commission.
Through this process, the Commission developed an appreciation for the profession and for
acupuncture and traditional Oriental medicine. It also developed and assembled a substantial
body of technical analysis that could be used by regulators and lawmakers to resolve the
precise issues that were before the Commission, as well as other challenges.
One source of confusion emanates from the Legislature’s declared intent to regulate
acupuncture as a primary health care profession without specifying in statute the full
authority or limits of acupuncturists to diagnose and treat patients. This ambiguity – along
with the legal opinions crafted to resolve confusion over the scope of practice – raise the
potential for conflict between practitioners of traditional Oriental therapies and modern
Western medical doctors. And when the two paradigms conflict – rather than complement –
the opportunity for patient harm increases and the potential for patient benefit decreases. The
Commission recommended specific ways to amend the scope of practice to resolve this issue.

Regarding educational requirements, the increased standards that will go into effect on
January 1, 2005 appear to provide adequate time to teach the knowledge, skills and abilities
needed for entry-level practitioners to perform this clarified scope of practice. The Commission,
however, recommended ways to make sure that this training provides the information
necessary to protect the public.
The Commission concluded that the Accreditation Commission of Acupuncture and Oriental
Medicine should be relied upon to validate the quality of acupuncture training schools. The
Commission, however, concluded that the State should continue to use its own examination as
the regulatory threshold to practice in California, rather than rely on the national exam.
The Commission also identified additional opportunities for the State’s consumer protection
agencies, including the Acupuncture Board, to safeguard patients against practices or products
that can threaten their safety and the public health – perhaps more importantly, measures to
control infections. These safeguards begin with the qualifications of board members, and by
making sure that vacancies on the Acupuncture Board – which currently number six out of
nine seats – are expeditiously filled.
California’s fundamental policy toward alternative health care has been to provide patients
with the freedom to choose. That path confers onto regulators the primary responsibilities of
making sure that practitioners meet minimum standards, and that consumers have the
information needed to make informed choices. Disclosure statements and other consumer
education materials should provide patients with information regarding treatment efficacy and
safe practices.
An important underlying tension is the trend toward blending traditional Oriental Medicine
with Western biomedicine. While both healing paradigms can benefit the public, those benefits
will be jeopardized if the two regulatory schemes are not kept separate and distinct. The
Commission’s recommendations would clarify the role for acupuncturists and – if enacted
immediately – would prevent greater confusion and even potential harm to consumers in the
future.
The Commission sincerely appreciates the willingness on the part of state regulators,
acupuncturists and other health professionals to inform its process. The Commission also
appreciates the straightforward analysis provided by researchers at the University of California,
San Francisco, California State University, Sacramento and elsewhere who contributed to its
understanding of the issues. But as always, the conclusions and recommendations are the
Commission’s own.
Sincerely,

Regulation of Acupuncture
A Complementary Therapy Framework
September 2004

Table of Contents
Executive Summary.....................................................................................................................i
Introduction.................................................................................................................................1
Background.................................................................................................................................3
The Scope of Practice ............................................................................................................15
The Move to Direct Access......................................................................................................17
The Debate Over Diagnosis....................................................................................................19
And Which Diagnosis?.............................................................................................................20
Unraveling the Confusion.........................................................................................................24
Summary..................................................................................................................................25
Education...................................................................................................................................27
A Steady Increase in Educational Requirements....................................................................28
Arguments for Going Beyond 3,000 Hours.............................................................................32
Arguments Against Increasing Hours......................................................................................34
Implementation Concerns........................................................................................................35
Implementation Opportunities..................................................................................................36
Perspectives from Other Health Professions and Nations......................................................37
Summary..................................................................................................................................38
Continuing Education.............................................................................................................41
Raising the Standards for All...................................................................................................42
Concerns About Continuing Education....................................................................................43
Summary..................................................................................................................................45
Examination...............................................................................................................................47
International and American Examination in Context...............................................................47
Policy Considerations..............................................................................................................48
Test Analysis............................................................................................................................49
Good Tests, But Room for Improvement.................................................................................51
Refinement Approaches..........................................................................................................52
Summary..................................................................................................................................53
School Accreditation Practices............................................................................................55
The Value of Accreditation.......................................................................................................56
Comparing ACAOM and California's Approvals......................................................................57
Questions for Policy-makers....................................................................................................59
Can California Rely on ACAOM and Control Standards?.......................................................60
Should Costs Matter?...............................................................................................................60
Summary..................................................................................................................................61
Oversight Concerns................................................................................................................63
Accurate Public Information.....................................................................................................63
Disease Protection...................................................................................................................64
Herb Safety...............................................................................................................................66
Board Structure........................................................................................................................68
Conclusion.................................................................................................................................71
Appendices................................................................................................................................73
Appendix A: Little Hoover Commission Public Hearing Witnesses.......................................75
Appendix B: Advisory Committee Members...........................................................................77
Appendix C: UCSF Study of Scope of Practice – Executive Summary.................................79
Appendix D: UCSF Study of Education Issues – Executive Summary.................................83
Appendix E: CSUS Evaluation and Comparison of Examinations – Executive Summary....87
Appendix F: UCSF Study of School Approval and Accreditation – Executive Summary......91
Appendix G: Legislative Counsel – Legal Opinion on Scope of Practice..............................95
Notes.........................................................................................................................................103
Table of Sidebars and Charts
Acupuncture Efficacy......................................................................................................................iii
The Legislative Request..................................................................................................................1
Defining Acupuncture.......................................................................................................................3
Healers and Licensing.....................................................................................................................5
Techniques Should Be Evaluated....................................................................................................9
Valuing Ancient Wisdom in an Integrative Model..........................................................................10
From Terminal Cancer Patient to Vibrant Healer..........................................................................12
Shaping Policy with Evidence: Efficacy, Competency & Consumer Experience........................13
Authorized Modalities.....................................................................................................................16
Defining Primary Care....................................................................................................................18
Spectrum of Integration..................................................................................................................22
Acupuncture Stands Out................................................................................................................23
California's Education Timeline......................................................................................................29
Acupuncture Board Task Force on Competencies and Outcomes..............................................30
California Association Leaders on Education................................................................................33
Beyond Minimum Competency......................................................................................................44
Evaluation Summary of the State and National Examination Programs......................................50
"Must Pass" Exam Components...................................................................................................52
Accreditation and Effort to Increase Professional Standing..........................................................58
Safety Concerns Include:...............................................................................................................63
Acupuncture Needles.....................................................................................................................65
The Fox and the Hen House..........................................................................................................69