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Medicaid Pilot, Part #4: Acupuncturists and Massage Therapists and the Underserved Population PDF Print E-mail
Written by John Weeks   

Medicaid Pilot, Part #4: Acupuncturists and Massage Therapists and the Underserved, Chronic Pain Population

Summary:  A well-known adverse-effect of the cash basis for most complementary services is that use is skewed toward the wealthy. The Florida Medicaid Integrative Therapies Pilot Project Project, managed by Alternative Medicine Integration Group (AMI), suddenly changed the demographics of the practices of AMI's network of massage therapists and licensed acupuncturists. Part #4 of this series consists of interviews with 4 of these practitioners on their experiences with these patients, and their experience inside AMI's managed chronic pain plan.
Send your comments to
for inclusion in a future Your Comments forum.

Click here for Part #1, An Overview
Click here for Part #2, "Holistic Nurse Management of Benefit
for Licensed Massage and Acupuncturists"
Click here for Part #3 "Outcomes Data and Interviews with Patients"
Click here for a discussion of the pilot's whole system research challenges

A well-known adverse-effect of the cash basis for most complementary services is that, for consumers, access is skewed toward the wealthy. Less frequently considered is that practitioner experience is also skewed. First, most practitioners have a limited experience, demographically. Second - and the subject of somewhat more discussion - is that the experience of care-giving in cash-based practice is not encumbered by the often detrimental impact of third-party payment processes.

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Pilot program sponsor
In 2002, the legislature of the state of Florida gave a set of frequently disabled, chronic pain-ridden,
high cost Medicaid beneficiaries access to covered services of licensed massage therapists and acupuncturists. By doing so, the state turned this status quo for practitioners around. Suddenly, a whole new set of clients came calling, with the promise of typically 2 free visits a month in the unusual pilot program developed by Alternative Medicine Integration Group (AMI), an Integrator sponsor.

The patients - up to 500 a month - entered these practices as part of a whole system-oriented managed care model, administered by a nurse manager. Practitioners signed a contract with AMI and agreed to a flat fee for services. Both the population and the administrative structure were new to most of the practitioners.

For this article, Part #4 of the series, I interviewed four of the practitioners - 2 massage therapists and 2 licensed acupuncturists or "acupuncture physicians" (AP) as they are licensed in Florida. I called practitioners from a list provided by AMI.
Unfortunately for this article, no practitioner survey data are available to add quantitative information to these stories.

These interviews represent a small set of snapshots into the experience of practitioners with this new clientele, and with the AMI managed Medicaid system.

___________________________

1.   Massage Therapist: "Sometimes just a massage will help them turn a situation around ..."

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Patty Costello, LMT
Patty Costello, LMT
is one of the 55 massage therapists (as of November 2007) credentialed by AMI to provide massage services under the pilot. In a given month, Costello typically sees 10-15 patients.

When I reached her last fall, Costello had been working "in the program" for two years. Her language showed some of the exceptional nature of the AMI program. She did not speak of "signing up for a network" but of working with "the program." Included in that phrase were participation in outcomes gathering, enhancing care through use of "literature interventions" provided by AMI, and regular communication with AMI's nurse managers.

Costello, noting that she sees "mostly women," describes the clientele: "A lot of them have had emotional and mental abuse. For some of them it has been physical.  For the most part they are on disability. Most have experienced trauma."

She reflects: "
It's been rewarding to see these people - to give them a little peace.  Sometimes just from the massage they will take more of an initiative with something in their lives.  I have seen that it can help them turn a situation around that has been hard. It is clearly a little bit of heaven for them to get out of the hum-drum."

Costello says she's liked the program financially too. Rather than a payment per visit, each month she receives a check from AMI.  Depending on the month, the check runs anywhere from $300 to $1000, says Costello.

2.   Acupuncture Physician: Challenges of the Program's 2 Treatments Per Month Average

After meeting with AMI's nurse case managers and expressing their preference for treatment, a majority of the AMI clients under the pilot are sent to massage therapists. Cathy Hoffman, AP, RN is one of the two dozen acupuncture physician (AP) who helps treat the minority. Hoffman has been involved for a little over a year, and estimates she has seen 15-20 patients, many of them for months.

"Initially I wasn't going to (be in the AMI program). I did it more for the office I was in, rather than for the patients." Then something happened: "As I started working with the patients, now they are like my favorite patients."  Why is this? "Those I have encountered have so many strikes against them, so much to overcome, it could be overwhelming to anyone."

Hoffman imagined the many medical relationships most of these clients have: "I could see how a lot of the care they receive would be very assembly line. Most of my patients have been very pleasantly surprised to come across somebody who listens and really cares." She underscores the importance of the practitioner-patient dynamic: "With 90%, I have really developed a special therapeutic relationship." The others? "With the the other 10% I just can't connect. They are in such debilitating pain that natural methods are just not fast enough."


Clearly, the relationship-centered care appears to be valuable. So I asked her if she felt that acupuncture can be effective at just two treatments a month, since the plan approved by the state only allows an average of 2 treatments per month. Hoffman responded: "I think they are effective. For some, the treatment gives them a respite. They get a good night's sleep. Only a couple times a month is better than before. Many will art least sleep better.
The question is how long the positive balance (we effect) can stay that way."

The she adds: "(AMI) tries to be as creative as they can with the visit limits."

Along with the visit limit, AMI also pays on a scale which is less than customary charges. Why did she choose to participate? For Hoffman, a part of the reason was an insurance experience:  "I didn't do a lot of soul-searching. I just accepted it. I was putting my toe in the insurance waters." She notes that, with all the discounts on other insurance with which she is now involved, "I may be getting more (with AMI's rate) than some insurances."

Hoffman, who is also a nurse, credits AMI's nurse managers with doing an "outstanding job." She hasn't found the paperwork onerous. She notes it's just a Likert scale on
patient satisfaction, pre and post visit, with room for comment. She knows her patient mixhas changed: "Without hte po0rgrma, I would have had no interface with Medicaid patients."

3.   Acupuncture Physician: "I come from a family that didn't have access to any of this ..."

James Saylor, AP educated me on what an "acupuncture physician" can do in the state of Florida.
he asserts: "I'm a primary care provider. Were licensed here as primary care. Our scope is similar to naturopathic doctors elsewhere. We can do injections, order any lab, do everything but write script." [Note: In most states, NDs have some prescriptive rights.] 

Saylor, a former military man now in his 14th year of practice, does a lot of trigger-point, injection therapy. In fact, he uses the therapy in treating his AMI patients even though the dierct cost of the services - "$17-$18 including the syringe" - is not covered by AMI.


Image
James Saylor, AP
Explains Saylor: "Our thing in our office is, get the patient better, don't worry about the money. Most of these people
are considerably different than our usual, cash patients. They wouldn't have an opportunity to see us if it weren't for the program. I came from a family that didn't have access to any of this. I never turn away a client that can't pay me." Then he correct himself: "I only would if the patient was non-compliant and didn't show up."

Saylor does think that the treatment works best "when I see patients at least once a week." But even with the current plan, where visits tend to run less, he sees significant benefits. In Saylor's view, "being a Florida taxpayer, I think this would save us a ton of money if the implemented it right now for everyone." How so? "Reduction in medical visits. Reduction in medications." He alludes to his understanding of th AMI outcomes: "The program has shown itself in hard numbers and in quality of life."

Saylor believes that such an expansion could find significant support among medical doctors with whom he is associated: "We work with 10-12 (conventional) primary care offices. Every one of them would say, 'make it available now.'"

4.   Massage Therapist: "There is a lot that comes along with chronic pain ..."

Massage therapist Susan Williams, LMT, sees her AMI patients in group practice in an annex alongside a hospital. Williams has been seeing AMI patients from the beginning, for almost 4 years. She estimates that she and three other massage therapists with whom she works, who are also on the program, have 20 visits a month with clients of the pilot project.

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Susam Williams, LMT
"They're a needy group," states Williams, in a matter-of-fact way: "A lot of them have debilitating conditions. When you are dealing with people in chronic pain, there is always a lot that comes a long with that."

Interestingly, Williams sees that some of the value of a massage treatment is due to the complexity and layering of problems that can develop in these patients: "The have secondary problems that have developed off their primary problems." She believes that with these secondary issues "they can benefit a lot."

Summary: I have wished, while writing this, that AMI had some survey data of some kind on the practitioner experience of working with this population, and in this system, as they have data on patient experience. (See Part #3.). Constructed appropriately, such a survey could cast light, for educators, on the competencies which might be developed in massage therapists and acupuncturists for practice with this specialized population. My guess is that AMI's credentialed network of practitioners would have a good deal to teach.

I was also struck by the subtle change comments. No one was talking cure. They were supporting people through very complicated processes. Everyone was talking about helping make life better for individuals for whom life has presented especially trying challenges. Clearly, an active agent in the interventions offered by all of these practitioners appears to be simple human caring. Among other things, the massage and acupuncture treatments are without a doubt vessels for transmission of a generative kindness. I confess to yearning for an evidence based medicine that has the transmission of kindness, and an examination of its impacts, as valued items on its agenda.

Click here for Part #1, An Overview
Click here for Part #2, "Holistic Nurse Management of Benefit
for Licensed Massage and Acupuncturists"
Click here for Part #3 "Outcomes Data and Interviews with Patients"
Click here for a discussion of the program's whole system research challenges

Send your comments to
for inclusion in a future Your Comments forum.

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