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The purpose of this project was to examine the policy implications of politically defining complementary and alternative medicine (CAM) professions by their treatment modalities rather than by their full professional scope.
Methods
This study used a 2-stage exploratory grounded approach. In stage 1, we identified how CAM is represented (if considered as professions vs modalities) across a purposely sampled diverse set of policy topic domains using exemplars to describe and summarize each. In stage 2 we convened 2 stakeholder panels (12 CAM practitioners and 9 health policymaker representatives), and using the results of stage 1 as a starting point and framing mechanism, we engaged panelists in a discussion of how they each see the dichotomy and its impacts. Our discussion focused on 4 licensed CAM professions: acupuncture and Oriental medicine, chiropractic, naturopathic medicine, and massage.
Results
Workforce policies affected where and how members of CAM professions could practice. Licensure affected whether a CAM profession was recognized in a state and which modalities were allowed. Complementary and alternative medicine research examined the effectiveness of procedures and modalities and only rarely the effectiveness of care from a particular profession. Treatment guidelines are based on research and also focus on procedures and modalities. Health plan reimbursement policies address which professions are covered and for which procedures/modalities and conditions.
Conclusions
The policy landscape related to CAM professions and modalities is broad, complex, and interrelated. Although health plan reimbursement tends to receive the majority of attention when CAM health care policy is discussed, it is clear, given the results of our study, that coverage policies cannot be addressed in isolation and that a wide range of stakeholders and social institutions will need to be involved.
Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine.
Complementary and alternative medicine practitioners use a wide range of techniques embedded within various broad healing paradigms to provide treatment. However, despite this broad approach and holistic goal, CAM is often addressed in policy and research as individual procedures (ie, modalities or treatments). In sociology, this dichotomy is one of CAM practitioners as members of professions vs members of skilled occupations, with professions having broader authority and autonomy because of a systematic body of theory that goes beyond skills.
Each CAM profession has at least 1 signature modality—for example, spinal manipulation for chiropractors, acupuncture for practitioners of Oriental medicine, or herbal medicine for naturopathic doctors. However, these modalities are delivered within a patient encounter that includes much more; for example, they may include patient education (eg, on stress reduction, lifestyle improvements), monitoring of general health indicators, a trusting patient–practitioner relationship, and a range of wellness interventions such as exercise programs, nutrition counseling, weight management, and preventive care. In addition, the training in some of the CAM professions includes diagnosis, appropriate referral, and other traits of primary medical care. These also involve the provision of services (eg, laboratory diagnostics, imaging, physical examinations, patient counseling) beyond the signature modality.
Despite the broad range of services provided, much of health care policy addresses CAM as individual therapies or modalities. Although this problem is often described as one of terminology or of semantics, it is not just a problem of definition or perception. Policies that define a profession only in terms of its therapeutic modalities or reduce a profession’s scope to only a few of these modalities have a direct impact on patient access and care. These policies have substantial political consequences as the CAM professions strive to obtain full legal and social legitimization.
Therefore, this study examined the policy implications of how the dichotomy between CAM as modalities and CAM as professions is addressed across a number of health policy topic areas, including coverage, licensure, scope of practice, institutional privileges, and research.
Methods
Because CAM is a term that encompasses a broad range of therapies, modalities, and professions, we limited the CAM professions in this study to those recognized by the National Institutes of Health as CAM,
and those that “have an accrediting agency recognized by the US Department of Education, have a recognized certification or testing organization, and are licensed for professional practice in at least 1 state.”
Application of these criteria resulted in the inclusion of the following professions: acupuncture and Oriental medicine (AOM), chiropractic, naturopathic medicine, and massage therapy. Although we limited this study to these 4 professions, the results of this study may also be of use to other CAM disciplines because they will also encounter the types of policies discussed in this report that might affect their practice.
Because the health care policy landscape facing CAM practitioners had not previously been charted, we used a 2-stage exploratory grounded approach.
In stage 1, the objective was to describe the way CAM is identified (as professions vs modalities) and represented across a purposely sampled diverse set of policy topic domains. Although much of the policy attention for CAM has been on coverage, we also examined licensure (where the profession’s scope of practice is defined), published research (which provides justification for care and guides coverage), and treatment guidelines (which are based on research and guide coverage). To do this, we reviewed the research literature for the targeted CAM professions and reviewed published treatment guidelines for the conditions most often treated with CAM. We also reviewed licensure laws and available health plan coverage policies for each of the 4 professions in 2 exemplar states (California and Texas) and examined the national health care policies of Medicare, the Veterans Health Administration (VHA), and Department of Defense (DoD).
In stage 2, we convened 2 panels of stakeholders (1 panel of 12 CAM practitioners and 1 panel of 9 health policymaker representatives). The general makeup of each panel is shown in Figure 1. Using the results of stage 1 as a starting point and framing mechanism, we engaged each group in a 1-day discussion of how they each see the profession vs modality dichotomy and its impacts. To participate, panel members were asked (and all panelists agreed) to step away from representing the specific organizations to which they belong and instead represent the perspective of their type of CAM and its relationship with policy (CAM expert panel) or the perspective of decision makers involved with their type of policies (health policy decision makers panel). Each panel’s meeting was audiotaped, and notes were taken documenting the panel members’ thoughts on the health policy issues that were most important to them. The CAM expert panel was held first, and its members' insights were incorporated into the stage 1 document and provided to the health policymaker panel in advance of its meeting. We vetted the statements made by panelists to the extent possible but also reported their statements and opinions as appropriate.
Fig 1Stakeholder groups represented in the 2 expert panels. CAM, complementary and alternative medicine.
Complementary and Alternative Medicine: Professions or Modalities? Policy Implications for Coverage, Licensure, Scope of Practice, Institutional Privileges, and Research.
This article focuses on the policy issues identified and the ramifications of their number and interrelatedness. The RAND Human Subjects Protection Committee determined that this project was exempt.
Results
The following sections describe how CAM is characterized (as professions vs as modalities) across the policy areas examined. Each is a result of both stages of our research methodology, such that each contains information on the various policy domains from the original material gathered from the various literatures in stage 1 and incorporates the edits and additions made by both panels.
Licensure
The 4 types of CAM professions discussed in this project are all licensed in at least some states. Licensing laws are a means by which the states can bestow authority, rights, and privileges on a profession. We examined the language used in a sample of 2 states’ laws to better understand variances in how each discipline is discussed, with a focus on scope of practice. Although the language used in each state is unique, in stage 1 we examined the laws in California and Texas as exemplars. We then supplemented this information with comments provided by the panelists.
Individual states set the scope of practice for the health care professions practicing in that state. For a profession to have a national presence, there needs to be consistency across states in the authority, rights, and privileges bestowed by licensure.
There also has to be consistency in education and training requirements across states. Although our review of licensure statutes is brief, it indicates that a CAM profession’s scope of practice can vary widely across states. Licensure of CAM is mixed in terms of whether it is treated more as a profession or a modality.
Acupuncture and Oriental Medicine
The profession of Oriental medicine is mentioned in California and Texas licensure laws, but most of the text refers to the modality of acupuncture. Nevertheless, it is interesting that sometimes the term acupuncture may be considered to include acupuncture in combination with a number of other therapies. For example, in Texas the term acupuncture includes “the administration of thermal or electrical treatments or the recommendation of dietary guidelines, energy flow exercise, or dietary or herbal supplements in conjunction with” acupuncture itself.
(p1) In California, an acupuncturist’s license authorizes the holder to “perform or prescribe the use of Asian massage, acupressure, breathing techniques, exercise, heat, cold, magnets, nutrition, diet, herbs, plant, animal, and mineral products, and dietary supplements to promote, maintain, and restore health” in addition to engaging in the practice of acupuncture.
(§4937) The authors of a recent article on acupuncture research comment that the term acupuncture “has been used to refer to either a specific procedure involving acupuncture needling or a multicomponent treatment that also involves history taking, physical examination, diagnosis, and education.”
Acupuncture and Oriental medicine practitioners do not always have autonomy, which is one of the privileges of a profession, to determine the patients who should see them or the length of treatment. In Texas, an acupuncturist can “perform acupuncture on a person for smoking addiction, weight loss, alcoholism, chronic pain, or substance abuse.”
(Rule §183.7) However, any other health conditions require a referral from a physician, a dentist, or a doctor of chiropractic (DC). For any condition other than smoking addiction and weight loss, the acupuncturist must “refer the person to a physician after performing acupuncture 20 times or for 2 months” if no substantial improvement occurs in the condition for which the referral was made.
Chiropractic in California is licensed more as a profession than in Texas. In both California and Texas, DCs are allowed to manipulate and adjust the musculoskeletal system, and they have the authority to diagnosis and treat. However, in Texas, this authority is restricted to the musculoskeletal system.
(§201.002) In contrast, in California, DCs may diagnose and “treat any condition, disease, or injury…so long as such treatment or diagnosis is done in a manner consistent with chiropractic methods and techniques and so long as such methods and treatment do not constitute the practice of medicine by exceeding the legal scope of chiropractic practice as set forth in this section.”
(p4) Examples of what would exceed chiropractic’s legal scope in California include surgery, childbirth, dentistry, optometry, prescription medicine, and mammography. In California, DCs are allowed to “use all necessary mechanical, hygienic, and sanitary measures incident to the care of the body, including, but not limited to, air, cold, diet, exercise, heat, light, massage, physical culture, rest, ultrasound, water, and physical therapy techniques in the course of chiropractic manipulations and/or adjustments.”
Naturopathic medicine is licensed in California and 16 other states, but not in Texas. In Texas, anyone can call themselves a naturopathic doctor (ND).
The broadest scope of practice for NDs is found in Oregon, Washington, Arizona, Vermont, and Hawaii. Where NDs are licensed, they tend to be licensed as members of a profession in that they have a broad scope of practice that includes the authority to diagnose and treat, use a variety of modalities, and in some states, prescribe drugs. In many of these licensure laws, there is little discussion of specific procedures. For example, in California, naturopathic medicine is defined as “a distinct and comprehensive system of primary health care practiced by a naturopathic doctor for the diagnosis, treatment, and prevention of human health conditions, injuries, and disease.”
In California, massage therapists must be certified, and in Texas, massage therapists are licensed. Although sometimes certification is considered voluntary and licensure mandatory, all massage therapists (and massage practitioners) in California must be certified as such to practice.
(§4611) Massage therapy seems to be exclusively treated as a modality or procedure in its certification and licensure laws. The laws in both states clearly state that massage therapists cannot diagnosis and treat, and they keep the definition of what constitutes massage fairly narrow, spending many more words on what massage therapists cannot do.
As can be seen, licensure laws for these 4 CAM professions vary across states in allowed scopes of practice and in representation of the profession as such vs as providers of specific modalities. Massage therapists are the most restricted in terms of scope of practice, with these practitioners only being allowed to offer 1 modality: massage therapy. Naturopathic doctors are only licensed in 17 states, but where they are licensed, the laws tend to give them a scope of practice as a profession. The licensure laws for AOM and chiropractic seem to vary by state as to the extent of these practitioners’ scopes of practice and the degree to which they are treated as members of professions. Doctors of chiropractic in California seem to have a full professional scope of practice, whereas DCs in Texas are restricted to diagnosis and treatment of the musculoskeletal system. Similarly, licensure laws for AOM can be restrictive as to the types of conditions treated and the duration of treatment. Although most of the laws’ text relating to AOM focuses on the modality of acupuncture, the term acupuncture is often defined to include a number of other therapies, apparently applied at the professional’s discretion.
Research
One reason to do research is to inform policy, and if policies are to be made about CAM professions, we need research that addresses the effectiveness and safety of the profession as a whole, rather than research that is limited to its procedures. For example, research could address the effect of going to a practitioner who is a member of a profession, rather than addressing only the effect of the modalities the practitioner uses.
Whole systems or whole practice research is one method that can be used to study the influence of a discipline or profession.
the difficulty experienced in identifying examples of these studies seems to indicate that the majority of research dollars in CAM (and health care in general) go to studies of individual therapies or procedures. In this section, we provide information on the state of whole systems research for each profession and include examples.
Acupuncture and Oriental Medicine
The AOM profession in the United States has invested extensive time and effort in efficacy research for acupuncture, including creating 2 documents to guide researchers on how to report on studies of acupuncture.
Below is an excerpt from a whole systems (profession-level) study of AOM and naturopathic medicine that indicates that the interventions studied were treatment by a practitioner of a system of care or profession rather than particular procedures.A whole-systems approach was used in designing the CAM interventions. TCM [traditional Chinese medicine] and NM [naturopathic medicine] clinicians and investigators collaboratively developed treatment protocols for each CAM intervention arm. These protocols were developed … with the intention of maintaining the theoretical perspective of each system of care [emphasis added]. … Most importantly, in both arms, practitioners were to treat all aspects of the patient, not just the TMD [temporomandibular disorder], in a manner consistent with their medical systems.
Because chiropractic has been covered by health plans for a number of years, a portion of chiropractic research has used claims data to examine the effect of going to a DC vs a conventional medical practitioner for care of musculoskeletal conditions.
The association between use of chiropractic care and costs of care among older medicare patients with chronic low back pain and multiple comorbidities.
First-contact care with a medical vs chiropractic provider after consultation with a Swiss telemedicine provider: comparison of outcomes, patient satisfaction, and health care costs in spinal, hip, and shoulder pain patients.
Factors associated with early magnetic resonance imaging utilization for acute occupational low back pain: a population-based study from Washington State workers' compensation.
These can be considered to be studies of the impact of the chiropractic profession. Nevertheless, there have been a number of efficacy studies of spinal manipulation itself.
Naturopathic medicine is not clearly associated with a unique modality as are the other CAM professions. Each of the different modalities used in naturopathy has its own set of efficacy and effectiveness studies. Most of the studies of naturopathic medicine itself are whole systems or whole practice (profession-level) studies.
The TMD study mentioned earlier is an example of an effectiveness study of the profession of naturopathic medicine.
Massage Therapy
Although massage is often categorized as one type of treatment or procedure, there are many types of massage, and each of these may be (and many have been) subject to their own tests of efficacy.
Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial.
A randomised, controlled, single-blinded study on the impact of a single rhythmical massage (anthroposophic medicine) on well-being and salivary cortisol in healthy adults.
The following is an excerpt from what could be considered an effectiveness study of the massage profession:Individuals in the massage group (Clinic B) met with a registered massage therapist (RMT) on the first week of the program to set up a weekly massage schedule. This protocol is based on typical treatment plans used by massage therapists [emphasis added] for novice runners. … It was important that each subject received an individualized treatment program…[, which] is the form of treatment that actually takes place in regular massage practice [emphasis added].
Treatment guidelines are written by various groups within the health care system and indicate the therapies that are recommended for treatment of a particular condition. We reviewed US guidelines for conditions for the CAM professions that are most used according to the 2007 National Health Interview Survey.
In all cases, these guidelines refer to procedures, not to professions. For example, several guidelines include recommendations for the modalities of spinal manipulation,
Neck pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association.
Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.
Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.
that recommended referral to “a trained spinal care specialist” and listed the professions: “physical therapist, chiropractor, osteopathic physician or physician who specializes in musculoskeletal medicine.” Note that the Canadian guideline is unique in that it recommends practitioners who are members of a particular set of professions, including DCs, instead of a procedure (eg, spinal manipulation).
Health plan coverage is one of the policy areas of most interest to CAM providers, and it has a direct impact on patient access. The determination of which provider and what procedures are covered is based on 3 things
Themes of holism, empowerment, access, and legitimacy define complementary, alternative, and integrative medicine in relation to conventional biomedicine.
the condition for which the treatment is given. Thus, health plan coverage policies address both ends of the profession vs modality dichotomy. Sometimes, instead of covering particular procedures, a health plan will allow coverage of care by a provider type (profession) up to a particular dollar amount per year. Although a detailed analysis of coverage is beyond the scope of this project, the following is a brief discussion of these 3 dimensions.
Profession/License of the Practitioner
Health plans will cover the services of only some types of providers (ie, members of particular professions), and these individuals are often required to contract with the health plan. In general, health plans have control over the profession types they cover. However, there have been at least 2 laws that affect the coverage of CAM professions.
For example, in 1995, Washington State passed the Every Category of Health Care Providers Law (WAC 284-43-205), which states that “health carriers (health insurance plans/payers) shall not exclude any category of providers licensed by the state of Washington who provide health care services or care within the scope of their practice.”
This resulted in coverage in the state for the services of DCs, NDs, acupuncturists, and massage therapists.
On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA) into law. Section 2706 of this law is titled “Non-discrimination in Health Care," and part “a" of this section says, “A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.”
At first glance, this wording looks as if it would support expanded coverage of CAM. However, the law goes on to say, “This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer.”
the law is written in such a way that may limit its impact on coverage decisions.
Procedures Being Offered and Procedure Codes
Even if members of a CAM profession are included in a health plan, they may be covered only for particular procedures or modalities. Providers will bill a health plan using current procedural terminology (CPT) codes to describe the services rendered. At present, there are specific CPT codes for massage (97124; 15 minutes), acupuncture (97810, 97811, 97813, and 97814; 15 minutes each), and chiropractic (98940-43; number of spinal regions adjusted or if extraspinal) procedures. In contrast to the massage and acupuncture CPT codes that can be used by any practitioner who is licensed to provide those services, the chiropractic codes are specific for use by DCs. There are other procedures practiced by CAM providers that are within their scope of practice but for which no CPT code exists (eg, for moxibustion or cupping used in AOM). This lack of CPT codes further restricts reimbursement for these services when offered.
Some health plans allow CAM practitioners to bill for evaluation and management (E&M codes), which cover services such as history taking and physical examination, patient education/guidance/counseling, ordering of diagnostic or imaging studies, and development of a treatment plan. Being able to bill for these E&M codes seems to be a proxy indicator of whether a practitioner type is being treated as a member of a profession trained in patient evaluation and management—that is, a doctor or “patient manager.” To move toward equity, a chiropractic national organization has been working toward allowing the charge of E&M codes for Centers for Medicare and Medicaid Services visits when appropriate.
Sometimes health plans reimburse for services of a profession up to a certain dollar amount each year. In these cases, procedure codes are not needed and the practitioner can provide the services they deem appropriate. However, other types of problems arise in this situation. Because all services offered by the provider, including diagnostic procedures such as laboratory tests and imaging, are included under the dollar limit, the practitioner has to choose either to use some of the dollar allocation on testing and thus possibly not order all needed tests, or to delay care by sending the patient back to his or her primary medical provider to order the tests.
Similar to CPT codes, health plans may be limited to 1 type of provider or to provider-type specific spending caps simply because it is easier for them to perform utilization reviews and implement the caps in which they only have to look at a single data field: provider type (profession).
Conditions for Which Treatments Are Given
A health plan may limit the types of conditions for which a particular CAM modality is covered. For example, the Kaiser California Gold HMO plan will cover acupuncture provided by a participating licensed acupuncturist but only for a neuromusculoskeletal disorder, nausea, or pain.
This same plan limits chiropractic coverage to participating DCs offering chiropractic services determined to be medically necessary to treat or diagnose a neuromusculoskeletal disorder. As with limits on covered procedures, limits on conditions covered confine a profession’s ability to practice fully and treat the whole person.
Public Plans (Medicare, VHA, TRICARE)
This section provides a brief review of what is known about public program coverage of CAM. At this time, the only CAM profession covered by Medicare (Part B) is chiropractic and only for 1 procedure: chiropractic manipulative treatment involving 1 to 5 regions of the spine, CPT codes 98940-2. See more on Medicare coverage in the Workforce Issues section.
The 2011 VHA report indicates that CAM therapies, including acupuncture and massage, are offered at 90% of VHA facilities.
In general, TRICARE does not cover CAM for active deployment service members when supplied by providers outside military treatment facilities—that is, from civilian providers. However, acupuncture and chiropractic are offered at some military treatment facilities and approved for certain active deployment service members. TRICARE specifically excludes naturopathy and massage from coverage.
Workforce Issues
CAM Professions Recognized by Medicare
Medicare is allowed to reimburse care only for a physician’s services as defined in the Social Security Act (Section 1861), and DCs are included in the Medicare physician definition. For members of other CAM professions to be covered by Medicare, this act would need to be changed by an act of Congress to include those provider types. In addition to this affecting Medicare coverage, other health-related policies are based on whether a profession is covered under Medicare. For example, according to our panelists, some state Medicaid systems limit coverage to the provider types covered by Medicare, the VHA reimburses for outside care based on Medicare’s guidelines, some medical education loan repayment programs limit eligibility to providers covered by Medicare, and residency funding is tied to appropriations for Medicare.
CAM Professions Within the VHA and the DoD
The VHA and the medical health system of the DoD hire health care providers on a salaried basis. To do this, both organizations use the Office of Personnel Management (OPM) job code lists. At present, job code lists do not include specific codes for members of CAM professions other than chiropractic. Members of the other CAM professions (eg, acupuncturists) have been hired using alternate codes such as the General Health Science Series or as a Health Technician. However, their job descriptions are not uniform, and these codes have lower salary limits. New OPM codes would be needed for the other CAM professions to be recognized. According to our expert panelists, the VHA central office is currently going through the process of getting a new OPM code for licensed acupuncturists.
Primary Care Providers in the ACA
The Patient Protection and ACA identify a limited number of practitioners as primary care providers. The evidence concerning which professions are primary care providers under the ACA is circumstantial at best. Nonetheless, our expert panelists report that the act comes as close as the federal government ever has to stating definitively the professions that are considered to be primary care providers. The ACA states that medical physicians trained in general internal medicine, family practice, and pediatrics; nurse practitioners; and physician assistants practicing in primary care are primary care practitioners.
This stance on the types of providers considered to offer primary care is similar to that taken in the 1996 Institute of Medicine report on primary care.
Whereas DCs and “licensed complementary and alternative medicine providers” are included in the definitions of the health care workforce and of health professionals in the ACA, they are listed as separate from primary care providers.
The DoD uses a fee schedule scheme (ie, relative value units [RVUs]) to capture the workload and value (ie, hypothetical revenue-generating capacity) of its medical facilities. Under this system, providers who are provider type 01 (eg, physicians, dentists, DCs) or 02 (eg, physician assistants, nurse practitioners, social workers, psychologists, physical therapists) record the work they do using CPT codes that have been assigned RVUs and regionally adjusted dollar values. Provider types other than types 01 or 02 generate no RVUs from the work they perform; thus, they are considered a cost to the facility. In addition, if they reduce the work of the type 01 or type 02 providers, they also reduce the facility’s RVUs. Provider type definitions and their connection to RVUs are decided in the DoD Business Rules. Without a change to these rules, all CAM practitioners other than DCs would be considered cost add-ons to military treatment facilities and thus less attractive to include in the facilities’ team of providers.
Regulatory Practice Constraints
Some state and federal laws directed at consumer protection designate business relationships, including ownership of or financial interest in related businesses and employer–employee relationships. For example, some states have laws that regulate whether a physician or physicians' group may own or have a financial relationship in a laboratory or magnetic resonance imaging center to which they refer their patients. These laws may also delineate employees and credentials, again to protect the consumer from unlicensed providers. One category of laws is collectively considered part of the Corporate Practice of Medicine (CPOM) Doctrine, which was developed at the end of the 1800s.
Among other things, these laws have been used to distinguish medical doctors from “irregulars” (ie, those without a medical education) and prevent regular physicians from practicing with irregular (ie, CAM) providers.
For example, Washington State law creates obstacles to medical physicians being employed by a DC. Similarly, New York State law and Texas regulations preclude DCs from having direct ownership interests in medical practices. Solutions are not straightforward because such laws and regulations can be difficult to identify, and changing them may entail litigation, legislative changes, and broad stakeholder support.
Academic and Residency Financial Assistance
Substantial federal funding is given to members of certain health care professions to support education and residency programs. This funding enables more practitioners to enter the workforce and to be better trained. Funding for educational loan repayment and residency training for CAM providers is limited. The Indian Health Service Loan Repayment Program
offers loan repayment assistance to any US citizen with a health profession degree and a valid license to practice who is committed to practicing at an Indian health facility. However, the larger loan repayment program offered by the National Health Service Corps
to those who agree to practice in a medically underserved area is only available to practitioners who are covered by Medicare. Funding for residencies is usually included in appropriations for Medicare and thus only open to practitioners covered by Medicare. Therefore, the numbers and training of most types of CAM providers are limited by Medicare exclusion.
Discussion
Policies that define a profession only in terms of its therapeutic modalities, or reduce a profession’s scope to only a few of these modalities, have direct impacts on patient access and care. However, as pointed out by our panels, so do policies that limit the professions included in the health care workforce. The workforce policies identified earlier affect where members of particular CAM professions are allowed to practice (eg, CPOM laws, VHA and DoD restrictions) and influence their training (eg, loan repayment and residencies). Licensure affects the states in which CAM professionals practice and can limit the modalities they can offer to patients for use in practice. Research seems to be focused on the effectiveness of procedures and modalities and only rarely on the health care outcomes associated with receiving care from a member of a particular profession. Guidelines are based on research, and thus, it is not surprising that they also focus on procedures and modalities because research only focuses on modalities, not the professions. Finally, health plan reimbursement policies limit which professions are covered and for which procedures or modalities and conditions they may be reimbursed. In summary, the policy landscape related to CAM professions and modalities is broad, complex, and interrelated.
However, given the results of our study, it becomes clear that coverage policies cannot be addressed in isolation. Health plan coverage decisions depend on a number of factors, including evidence of effectiveness or efficacy and safety, guidelines, and consumer demand.
In addition, members of the CAM professions have to be available in the health care workforce to serve the health plan’s members and licensed to offer those services. Therefore, any attempts to change reimbursement policy will also have to address other types of policies.
During our observation, we noticed that our expert panelists paid little attention to how research affects and is affected by other policies. Given that research evidence is essential to the setting of clinical guidelines, and because both influence coverage, it seems that examining research policy would be a good place to start. However, although most researchers would like their work to have a large impact, many would probably agree that research is necessary but insufficient for policy change. The following 3 studies show how research could support changes in policy, moving from a focus on modalities to a focus on professions: One study examined reduced likelihoods of continued work disability,
Factors associated with early magnetic resonance imaging utilization for acute occupational low back pain: a population-based study from Washington State workers' compensation.
was performed if a patient with back pain went first to a DC rather than a medical doctor.
The challenge to overcome being treated only as modalities seems somewhat daunting for the CAM professions. Policy is created, implemented, and evaluated in a political process. However, the required process is no different from what each profession faced to obtain licensing or certification. Thus, the political wherewithal exists. One possible difference in the political processes involved with licensure vs those required for other or broader policy change is that up until now the CAM professions have faced pushing for policy change singularly and, on occasion, in opposition to one another. For many policy changes, a collective strategy may be more productive.
Despite the daunting nature of policy change, there have been some successes. For example, the chiropractic profession was successfully licensed in every state in America by the mid-1970s despite fierce opposition from the medical profession.
Complementary and Alternative Medicine: Professions or Modalities? Policy Implications for Coverage, Licensure, Scope of Practice, Institutional Privileges, and Research.
are intended to assist CAM professions in navigating the health care policy landscape toward their goals. Our hope is that, as a result of this study, future attempts to change the health care policies affecting the CAM professions will proceed with an awareness of the broader policy landscape and thus be more successful.
Limitations
This is an exploratory study covering a new, not previously delineated, area, and as such, it faced a number of challenges. Our intent was to describe the health policy landscape in which the CAM professions face being diminished to modalities. However, as early explorers in this line of study, it is possible that we missed important policy issues or important nuances to the issues identified. Nevertheless, a key limitation is that although the information offered and suggestions made by the panelists were vetted to the best of our ability, detailed descriptions and analyses were not included in this study.
Conclusions
The wide range of interrelated policies identified in this study as affecting patients’ CAM access and care means that a wide range of stakeholders and social institutions need to be involved in making policy changes. A large number and variety of groups involved will add considerably to the complexity surrounding any attempt to create solutions. Given the number of vested interests, we suggest that what is best for the patient and for health care delivery to the population should be the single driving force.
Practical Applications
•
A wide range of interrelated policies affect patients’ access to care by complementary and alternative medicine providers, and because of this interrelatedness, a wide range of stakeholders and social institutions will need to be involved in making policy changes.
•
The large number and variety of groups involved will add considerably to the complexity surrounding any attempt to change policy.
•
Given the number of vested interests at play, perhaps the single driving force for policy change should be what is best for the patient and for health care delivery to the population.
Funding Sources and Potential Conflicts of Interest
Funding for this project was provided by the NCMIC Foundation. No conflicts of interest were reported for this study.
Contributorship Information
Concept development (provided idea for the research): P.M.H., I.D.C.
Design (planned the methods to generate the results): P.M.H., I.D.C.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): P.M.H., I.D.C.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): P.M.H., I.D.C.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): P.M.H., I.D.C.
Literature search (performed the literature search): P.M.H.
Writing (responsible for writing a substantive part of the manuscript): P.M.H., I.D.C.
Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): P.M.H., I.D.C.
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First-contact care with a medical vs chiropractic provider after consultation with a Swiss telemedicine provider: comparison of outcomes, patient satisfaction, and health care costs in spinal, hip, and shoulder pain patients.
Factors associated with early magnetic resonance imaging utilization for acute occupational low back pain: a population-based study from Washington State workers' compensation.
Corticosteroid or placebo injection combined with deep transverse friction massage, Mills manipulation, stretching and eccentric exercise for acute lateral epicondylitis: a randomised, controlled trial.
A randomised, controlled, single-blinded study on the impact of a single rhythmical massage (anthroposophic medicine) on well-being and salivary cortisol in healthy adults.
Neck pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association.
Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.
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