Your Comments: Debate on Hourly Fees for Acupuncturists - Justice, Injustice and the Market
Written by John Weeks
Your Comments: Debate on Hourly Fees for LAcs- Justice, Injustice and the Market
Summary: Talk of money provokes responses. The discussion of fees paid to hired acupuncturists in the Community Acupuncturist Network (CAN) model continues to provoke response. Seven voices are represented here. Sherman Cohn, JD, Georgetown law professor and 30-year student of (and activist in) acupuncture's emergence focuses on the variable fees in private practice versus community settings. A 'retired acupuncturist' lambastes the lack of a 'job market' for acupuncturists, then wonders why schools don't offer training in two areas where hiring does take place: addiction and pain management. Bastyr dean and national accreditation leader Terry Courtney, LAc, MPH offers a response. Geoff Barkley, PhD, LCSW, believes that the low fees, while unjustified given the professional training, come with the territory of working for change. Finally, three affiliates of CAN explain why they feel the fees are justified - focusing on the apprenticeship which is offered.
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These individuals submitted comments followed an original Integrator article on Working Class Acupuncture and a follow-up Your Comments article in which the WCA payment of $15-$20/hour for its hired acupuncturist was challenged and rebutted. The comments offer broad and rich perspectives which apply to most emerging professions.
1. Georgetown Law's Cohn on Private and Community Pay
Shgerman Cohn, JD
Sherman Cohn, JD, is a professor at the Georgetown University Law Center and former Watergate lawyer who has been active in natural health care and integrative medicine through a board position at TAI Sophia and with the Integrated Health Care Policy Consortium. Cohn talks about the typical relationships between payments in community settings and typical private practice.
"I find the discussion interesting,
but one that we have all heard before in other settings. I am not an
acupuncturist, but rather a lawyer who has followed the acupuncture profession
rather closely for over thirty years. In law, too, there are
community-type practices of various types. They all pay at much lower
scales per hour than what can be earned by the private practitioner. Indeed, the ratio between the two is much greater in the law than has been
quoted here. In fact, in many community-type practices of law, one would
find pay at about the same hourly rates as are quoted here. The only
surprise that I have is that there is any surprise.
"As a student of professions in the United States, my only
surprise is that there is surprise that a community practice pays significantly
less per hour than one can collect in private practice from persons of greater
wealth."
- Sherman Cohn, JD
"As was pointed out, in the community setting, the professional has no overhead,
so that the pay is net pay and not gross which must then be reduced by
overhead. Moreover, in a community setting, the risk is taken out of the
practice. In private practice of any profession, when one starts a
private practice, there is usually much sitting around waiting for the phone to
ring. Moreover, even later, when a practice is full, there are no-shows
and there are people who do not pay. (I am not talking about intentional
pro bono, but rather the unintentional type when the patient or client just
fails to pay.)
"A community practice of the type mentioned, in any profession, pays less
because it collects less. The working-class person -- the term used -- is
just not able to pay what the more well-to-do can pay. It stands to
reason that if the money coming in one end of a business is small, the money
going out must be smaller -- or the economic enterprise cannot succeed and no
one has a job.
"Who goes into community practice? I expect that acupuncture is no
different from other professions: First, those who are adverse to risk,
who have no talent at marketing and no interest in acquiring that talent, who
have difficulty managing their own business. Second, those who are
beginning practice. Quite often, the community practice can be done on
less than full time, so that there is a guaranteed income while a private
practice is being built in one's home or other location. Third, those who
have had enough of the risks and stresses of a private practice and wish to
semi-retire without giving up the profession, sometimes out of a motive of
service.
"So, as I said before, as a student of professions in the United States, my only
surprise is that there is surprise that a community practice pays significantly
less per hour than one can collect in private practice from persons of greater
wealth." (Bold added.)
2. Are Schools Training for Pain, Addiction Where Acu Jobs May Be Avalable?
"Retired acupuncturist" wrote at length about what he saw as a non-existent job market for acupuncturists (see below) then got back to me with a comment that "the two areas with any
employment opportunities for acupuncturists are pain management and drug abuse
treatment." Then he asserted:
"However, many acupuncture schools teach neither of these
subjects. Seriously. Some of the schools may have added these
topics in recent years, but I doubt it. To my knowledge, neither
subject is required by the agency which accredits schools. Pain is
addressed as a symptom in TCM, but 'pain management' is not taught."
Terry Courtney, LAc, MPH
I contacted Terry Courtney, LAc, MPH, dean of the school of acupuncture and Oriental medicine at Bastyr University and a national leader in acupuncture accreditation, for her response.
"I am not sure why the 'retired acupuncturist'
states that pain management and drug abuse treatment are areas of employment
for acupuncturists. There may be some private chronic pain clinics around the
US that have acupuncture represented (hopefully!), but there is not a trend in
this direction in terms of salaried positions.
"In terms of drug abuse
treatment, some of the urban areas of the US have publicly funded programs that
include acupuncture, but these positions are generally part time as most
programs are not funded to be open for treatment 8 hours a day. These are
excellent programs and should be supported by the profession, but they were set
up to address the needs of the chemically-dependent population and not as
employment programs for acupuncturists.
"There may be some private chronic pain clinics around the
US that have acupuncture represented (hopefully!).
"But there is not a trend in
this direction in terms of salaried positions."
- Terry Courtney, LAc, MPH
"The 'retired acupuncturist' may not be aware
that
schools are required to offer several thousand hours of training in
core
curriculum (western sciences, Chinese medicine, clinic, etc.). The
clinical
sciences training as it pertains to the treatment of pain obviously
varies from
school to school. However, students are required to complete 800 hours
of
clinical training and given the preponderance of pain conditions in the
general
population, students have a fair amount of experience in developing
beginning
competencies in this area as part of their degree. There is also fairly
robust
curriculum in continuing education these days on various approaches to
the
clinical management of pain. Perhaps the writer has a different
definition of 'pain management' and if so, I would be curious as to
their concern.
"In regards to drug treatment, quite a number of
schools have curriculum in this area as part of their core program or as part
of continuing education programming. A number of schools also rotate
students through drug treatment programs as part of gaining public health
experience. Obviously if there is no public acupuncture program for drug
treatment in the vicinity of the school, then there will be limited exposure to
this topic. However, many people pursue additional training beyond their
masters program as part of professional continuing education." (Bold added.)
3. Member of Clinical Acu Network Testifies to Value Created in Austin, Texas
"Ms. Nancy Sherman's response to the Working Class
Acupuncture story was a disappointing reminder of how someone can focus criticism
on one detail and discredit the whole piece. Other than to say, 'This article is
very interesting as a business model,' the entire focus
of comments was on a fact question that was beside the point. Such criticism causes us all to suffer.
"I am a licensed acupuncturist in Texas who struggled for
seven years to make a living at a chiropractic clinic. Although it was suggested that I might do better by setting up practice in a wealthier part of
town, I resisted. Catering to those who are looking for yet another unique
spa experience didn't fit my style or values. I wanted to make acupuncture available to people like myself:
working people, students, and retired folks. But even though my practice was located on a busy street, I had to
charge close to the going rate because I saw patients one at a time in a
practice that accepted insurance.
Insurance coverage for acupuncture in Texas is such that few could afford my services.
"One of the best things about community medicine is that
it has the potential to make a real difference in the health of Texans ..."
Marti Calliham, LAc
"Then last May, I read about Working Class Acupuncture in
Portland. I quickly realized I'd found the answer to my problem. I attended WCA's conference in October.
On November 15, I opened a solo community-style practice, Peaceful Village Acupuncture, and sent a flyer
to 100 people. Within two weeks, my practice has expanded to my previous
(part-time) volume, the "trust" part of the sliding scale
is working just fine, and my sign has not even been installed yet! The low cost, insurance-free approach appeals to a broad spectrum of people, and since I enjoy
helping people improve their health, the future looks very bright
indeed.
"One of the best things about community medicine is that
it has the potential to make a real difference in the health of Texans, who
rank among the highest percentage of uninsured persons in the
country. If more people with chronic illnesses knew they could receive affordable
preventative care like this, our hospital emergency rooms would be less
stressed, thereby relieving pressure on the whole healthcare system. If more acupuncturists and other health practitioners could adopt this model, we could
raise the quality of life in our society.
Imagine what the future would look like then!" (Bold added.)
4. The System's Bias Against Wellness-Orientation Keeps Wages Low
Geoff Barkley, LCSW, PhD
Geoff Barkley, LCSW, PhD works in health promotion and wellness at the University of Virginia Medical Center. His last comment in the Integrator was on
how NIH NCCAM's bias toward randomized controlled trials may be
cloaking the value of Yoga and other more wholistic approaches.
"I
read with interest this discussion of the acupuncture wages, and the wide range
of emotions and thoughts that this discussion entailed.
"I work at a large
medical center. Not only does this facility treat large numbers of specialty
patients, but it also receives hundreds of millions of dollars annually in
research monies. As I watch yet another $60 million research building go up, it
appears that there is certainly no dearth of funding. The salaries here are
also quite high, but not atypical for traditional healthcare. Wage based nurses
(with a two year degree) can receive $40-50/hour, and the average doctor salary
is probably in the range of several hundred thousand dollars annually.
"I
point this out not to create shame or guilt in practitioners of CAM, but rather
to observe that there is an enormous medical-industrial complex that CAM
practitioners stand on the outside of, looking in. The US medical system is an
entrepreneurial model and there is little or no interest in CAM by mainstream medicine,
especially with practitioners who have a different philosophy than the
predominant model, and indeed may siphon off referrals. It is no secret that
the hospitals and doctors offices are filled with patients with preventable
illnesses, but there is no money to be made in prevention, so practically
nothing is done. Similarly, CAM treatments are often low tech, and offer little
profit potential, so also face the same obstacles.
"There
is no question that $15 to $20 an hour for an acupuncturist is inadequate pay
for their training, but as these acupuncturists stated, it has been a leaping
off point for them. If they wanted to be nurses, they could be making a lot
more. However, there are millions of people who are dissatisfied with
mainstream medicine and seek alternative care. The role of CAM researchers is
to demonstrate clinical effectiveness of CAM treatments, and promote a model of
health care, rather than illness care. CAM needs to continue to show benefits
of their treatments and thus be able to demand that these treatments are
reimbursed appropriately through health insurance. It is at times an uphill
battle, but one that needs to be fought." (Bold added.)
5. OCOM Doctoral Student Values Time Spent at Low Wages as Apprenticeship
Lumiel Kim-Hammerich, LAc, is a DAOM candidate at the Oregon College of Oriental Medicine, comments via the CAN member discussion on how for some students, this model, and its beginning pay rate, create an rare apprenticeship opportunity for acupuncturists.
"Being addicted to this forum is one of my downfalls this week, as I slide farther and farther behind in my schoolwork, wishing that I could have designated a CAN study for my capstone project, and wishing I could contribute to the Integrator blog.
"I think it's great that WCA has introduced this dimension of apprenticeship (long overdue) to our profession." - DAOM student
"Just want to throw in that WCA 'employees' shouldn't be compared to the going wages for acupuncturists because your employees are not really working FOR you. They are the students paying YOU for the privilege of working in your business, to learn the ropes, while they earn a minimal wage for the labor they contribute at the same time. Apprenticeships aren't legal here in the U.S. unless they are included in some kind of large-scale program (at least that's my understanding) but are very common in Europe. I think it's great that WCA has introduced this dimension (long overdue) to our profession."
6. "Retired Acupuncturist" Says There is No "Job Market" for LAcs The exchange was spiced-up by some
terse commentary by an individual who would only identify
himself as "Retired Acupuncturist."
"First, acupuncturists are a dime a dozen. Of
course their wages are low. For years I tried to talk to people about the lack
of a job market for acupuncturists, but it fell on deaf ears.
"There is no
market demand for acupuncturists freshly licensed and very little demand for
experienced acupuncturists, who naturally want more money if they have any
experience in practice. Of course, an acupuncturist in private practice can
"Job postings
for LAcs are
as rare as
hen's teeth.
"What kind of profession
has no job market?
"Answer: One with no future."
- Retired LAc
build a clientele and charge as they will. I'm talking about 'jobs.' Job
postings for acupuncturists are as rare as hen's teeth. Many acupuncturists
have never seen a job listing for "acupuncturist" and fewer still have ever
applied for such a position. (The main exception is drug treatment programs
which have provided employment to many acupuncturists.)
"What kind of profession
has no job market? Answer: One with no future.
"What's worse is that acupuncturists
have few transferable skills good for anything other than practicing acupuncture
and many are undereducated, lacking even a bachelors degree.
"Let me make this perfectly clear: Private
practice is self-employment and practitioners are free to do as they please and
charge what they can. The opportunities are almost unlimited. More power to
them. I just want to point out that there is almost no job market for
acupuncturists, even after all these years. As the supply of acupuncturists
keeps going up, it will further exceed demand. Demand will ultimately depend in part on evidence that
acupuncture is useful, but the evidence remains weak.
"For example, have your
read this by Derry: Systematic review of systematic reviews of
acupuncture published 1996-2005.
(The authors state:) "Systematic reviews of acupuncture have overstated
effectiveness by including studies likely to be biased. They provide no robust
evidence that acupuncture works for any indication. It's too bad that some are 'offended' by low wages
offered to acupuncturists (and not offered by some greedy HMO, but by some
fellow acupuncturists trying to do good in the world!). The acupuncturists may
decline the employment and seek a better wage elsewhere. Good luck to
them.
7. Community Model Working in the Greater Boston Area
Diana Di Gioia, LAc runs a clinic outside the Boston area called Community Acupuncture on Cape Cod. She comments on the "paid internship" aspect of the WCA rate.
"This is in response to your article about the Community Acupuncture movement, and specifically, the pay rate for hourly acupuncturists at Working Class Acupuncture in Portland.
"I definitely see the hourly positions (WCA) offers to area acupuncturists as paid internships."
Diana Di Gioia, LAc
"Having just spent a chunk of my own time & money to fly to Portland from the east coast and attend a seminar with the folks at WCA, I definitely see the hourly positions they offer to area acupuncturists as paid internships. The willingness of the WCA staff to be incredibly open about what they do, how they do it, and how you can too is a real service to the acupuncture community. They have created a practice model that works without relying on the ever-tenuous government funding or the many-strings-attached insurance reimbursement.
"Working in a state-funded detox clinic is not going to teach you how to create your own practice, because it doesn't address ways to broaden access to acupuncture beyond the people who can access it now -- the very poor (in states that even have free care acupuncture) and paying them at the same time. I call that a win/win." (Bold added.)
Comment: The issues of compensation are quite alive - touching on education, apprenticeship, public service, marketability and evidence. And while acupuncture is on display here, a similar conversation would likely emerge were we focusing on any other of the licensed professions - or even the integrative MD who wishes to be paid to explore his or her new skills. The Integrator will return to these themes.
Now, for some perspective. According to a recent article,
only 7% of radiologists consider themselves
"truly happy" despite the fact that 25% of radiologists make over $400,00, and 40% "have to struggle by on
less than $300, 000" according to blogger Mathew Holt at The Health Care Blog. Holt says that "if they don't like it now, the average
radiologist may be in for a rude shock in the next decade or two, as technology
will make their skills increasingly exportable to other countries abroad
and replaceable by computers reading images."
We don't have machines yet for finding needle location and delivering needles do we?
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