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.

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.

"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.)

"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 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.)

Marti Calliham, LAc

Marti Calliham, LAc is part of the Clinical Acupuncture Network started through Working Class Acupuncture model. She offers acupuncture in a community room in her Austin, Texas-based clinic, Peaceful Village Acupuncture.

"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.)

"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."

"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.

"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.)

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