Transcript Use of Complementary and Alternative Medicine

Acupuncture Insurance
in
North Carolina
Chris Helmstetter, L.Ac.
Director of Government Affairs
North Carolina Association of Acupuncture and Oriental Medicine
The North Carolina Association of Acupuncture and Oriental Medicine, Inc., is a not-for-profit, professional
organization of Licensed Acupuncturists, Oriental Medicine practitioners, related students and other interested parties
throughout the state of North Carolina.
Licensed Acupuncturists (L.Ac.)
● Highly trained professionals, licensed nationally and by state licensing boards
● Complete a four year masters degree at acupuncture colleges accredited by the Accreditation
Association for Acupuncture and Oriental medicine (ACAOM) and the Department of Education (1)
● National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) oversees the
national exam, which involves 3 days of testing to demonstrate competency in Foundations of Oriental
Medicine, Acupuncture and Biomedicine. Passing score results in Diplomate of Acupuncture.
● North Carolina Acupuncture Licensing Board (NCALB) requires transcripts from an accredited
acupuncture college, passing grade of 70% or higher on the NCCAOM exam and:
○ Successful completion of Clean Needle Technique course
○ 40 CEUs every two years
● Strict standards of education and accreditation are essential to the practice of acupuncture to ensure
public safety
● One of the fastest growing medical professions in the country
Why are so many Americans using Acupuncture?
- Effective for a variety of conditions from allergies to chemotherapy side effects to low
back pain to fibromyalgia
- Can treat multiple conditions at the same time, no need to schedule appointments with
multiple specialists (common practice to treat a patient’s knee pain and low back pain
during the same treatment)
- Almost no side effects
- Promotes decreased use of opioids and narcotics for pain conditions
- L.Ac. spends 45 to 90 minutes with each patient
- Lower cost compared to other treatment options
Complementary and Alternative Medicine Use Among Adults and Children:
United States, 2007 (2)
This report presents selected estimates of complementary and alternative medicine (CAM) use among U.S.
adults and children, using data from the 2007 National Health Interview Survey (NHIS), conducted by the Centers
for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS). Trends in adult use
were assessed by comparing data from the 2007 and 2002 NHIS.
Results—In 2007, almost 4 out of 10 adults had used CAM therapy in the past 12 months,
From the 2007 NHIS found that approximately one in nine children (11.8%) used CAM therapy in the past 12
months,
Between 2002 and 2007 increased use was seen among adults for acupuncture, deep breathing exercises,
massage therapy, meditation, naturopathy, and yoga.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Center for Health Statistics
Use of Complementary and Alternative Medicine (CAM) is on the rise
- Almost 40% of Americans used CAM
within the past 12 months (2)
- Consumers spent $33.9 billion on
CAM practitioners, products and
classes
- The number of visits to acupuncturists
between 2002 and 2007 rose 32%
- Acupuncture is considered one of the
fastest growing CAM professions
nationwide
The most common conditions consumers used acupuncture to treat were back pain,
neck pain, joint pain, arthritis and fibromyalgia. (2)
Consumers are willing to pay out-of-pocket for acupuncture
because it works. But what exactly is it most effective in treating?
Khusid MA. Clinical indications for acupuncture in chronic post-traumatic headache management. Mil
Med. 2015; 2014;180:132-136.
- “shows that acupuncture is at least as effective as drug therapy for migraine prophylaxis and
neurovascular and tension-type headaches” (3)
Witt C. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and
cost-effectiveness in usual care. Obstet Gynecol. 2008;198:166.e1-166.e8.
- “acupuncture in patients with dysmenorrhea was associated with improvements in pain and quality of life
as compared to treatment with usual care alone and was cost-effective within usual thresholds” (4)
Haake M, Müller H, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for Chronic Low
Back Pain. Arch Intern Med. 2007;167:1892.
- “Low back pain improved after acupuncture treatment for at least 6 months. Effectiveness of
acupuncture, either verum or sham, was almost twice that of conventional therapy.” (5)
Walker EM., Rodriquez Al, et al. Acupuncture versus venlafaxine for the management of vasomotor
symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial. J Clin
Oncol. 2010 Feb 1;28(4):634-40.
- “ The venlafaxine group experienced 18 incidences of adverse effects (eg, nausea, dry mouth, dizziness,
anxiety), whereas the acupuncture group experienced no negative adverse effects.” (6)
Physiological Effects of Acupuncture
Thermograms detect
inflammation and
pain (7)
Inflamed regions appear
red, orange, or yellow
Over five minutes the
acupuncture needles
were effective at
reducing the
inflammation and pain
More recently, meta-analysis of all studies on each condition gives higher degrees of confidence for what
acupuncture is known to effectively treat.
- only randomly controlled trials included
- significantly higher number of patients analyzed
Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for Chronic Pain: Individual Patient Data Metaanalysis. Arch Intern Med. 2012;172(19):1444-1453. (8)
“Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value.
We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain,
osteoarthritis, chronic headache, and shoulder pain.”
“Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs, with a total of
17,922 patients analyzed.”
“Results: In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and noacupuncture control for each pain condition “
“Conclusions: Acupuncture is effective for the treatment of chronic pain”
Parallel Trend in cost effectiveness studies as more and more insurance carriers wanted supporting
evidence for effectiveness and cost efficiency. (9)
Meta-analyis of cost effectiveness studies shows high degrees of
confidence that acupuncture is a lower cost option for effective treatment
for specific conditions
Ambrósio EMM, Bloor K, MacPherson H. Costs and consequences of acupuncture as a treatment for chronic
pain: A systematic review of economic evaluations conducted alongside randomised controlled trials. Complement
Ther Med. 2012;20:364-374. (10)
“The economic burden that chronic pain conditions impose on individuals and society is significant. Acupuncture appears
to be a clinically effective treatment for some chronic pain conditions. Given the need for policy decisions to be informed
by economic evaluations, the objective of this systematic review was to synthesise data from economic evaluations to
determine whether acupuncture for the treatment of chronic pain conditions is good value for money.”
“Conditions treated included low back pain, neck pain, dysmenorrhoea, migraine and headache, and osteoarthritis. From
the seven cost-utility analyses, acupuncture was found to be clinically effective”
“The cost per QALY gained in all seven cost-utility studies was found to be below typical thresholds of willingness to pay.
Acupuncture appears to be a cost-effective intervention for some chronic pain conditions.”
Further analysis of cost effective studies show the optimization of acupuncture in states incorporating
acupuncture into state wide insurance coverage
Comparison of Health Care Expenditures Among Insured Users and Nonusers
of Complementary and Alternative Medicine in Washington State: A Cost Minimization
Analysis (11)
The purpose of this analysis was to compare health care expenditures between insured patients with back pain,
fibromyalgia syndrome, or menopause symptoms who used complementary and alternative medical (CAM)
providers for some of their care to a matched group of patients who did not use any CAM care. Insurance
coverage was equivalent for both conventional and CAM providers.
Results: Both unadjusted tests and linear regression models indicated that CAM users had lower average
expenditures than nonusers. (Unadjusted: $3,797 versus $4,153, p1⁄40.0001; b from linear regression -$367 for
CAM users.) CAM users had higher outpatient expenditures which were offset by lower inpatient and imaging
expenditures. The largest difference was seen in the patients with the heaviest disease burdens among whom
CAM users averaged $1,420 less than nonusers, p < 0.0001, which more than offset slightly higher average
expenditures of $158 among CAM users with lower disease burdens.
Conclusions: This analysis indicates that among insured patients with back pain, fibromyalgia, and menopause
symptoms, after minimizing selection bias by matching patients who use CAM providers to those who do not,
those who use CAM will have lower insurance expenditures than those who do not use CAM.
All 3 independent analyses of consumer use, clinical effectiveness and cost utility
show acupuncture to be a desired, cost effective treatment that yields exceptional
results treating:
- low back pain
- neck pain
- osteoarthritis
- migraines and tension headaches
- dysmennorhea
- side effects of chemo therapy
- fibromyalgia
S
States that now provide insurance coverage of acupuncture to state employees include:
Alaska
Louisianna
Ohio
Arizona
Maryland
Oregon
California
Massachusettes
Pennsylvania
Connecticut
Michigan
New Jersey
Florida
Minnesota
New Mexico
Iowa
Montana
New York
Illinois
Nevada
Vermont
Currently North Carolina has several insurance carriers that offer acupuncture as a covered benefit:
- United Health Care (10-20 acupuncture treatments per year)
- Aetna (20-24 acupuncture treatments per year)
Along with many group plans that include acupuncture benefits for large companies in NC.
- SAS
- Mission Hospitals
-
- Qualcomm
- Town of Holly Springs
The Cheesecake Factory
-
-
The Home Depot
-
REI
Oracle
GlaxoSmithKline
Costco
-
USB
Raytheon
And one of the largest supporters for the use of acupuncture is the
Veterans Administration
-
VA hosptials in NC pay for veterns to receive 18 - 54 acupuncture treatments
per year for chronic pain conditions (12)
-
VA studies find that acupuncture not only successfully treats chronic pain, but is
also an important tool to decrease dependence on narcotic and opiod use
amongst the chronic pain population
-
Led the Joint Commission to revise their Pain Management Standard to include
non-pharmacological strategies such as acupuncture for all veterans
The State Employees Association of North Carolina has a Policy Platform Objective
supporting acupuncture for medical conditions when shown to be therapeutically effective,
especially for certain proven conditions
Their members and Association as a whole want acupuncture to be a covered benefit
“Acupuncture has been a tremendous benefit to our family. It allowed me to successfully treat
my migraines and stop all the medications I was using for them. And this year my husband
had two surgeries on his feet. Acupuncture after his surgery allowed him to not rely on pain
killers and heal quickly. We saved a lot of money in medical expenses and not missing time
from work. And his doctors were amazed at how fast his recovery was. Can you please
include acupuncture in the state health plan!?! It has helped us so much and I know other
state employees would benefit from it as well.”
Kim B.
Acupuncture works,
Acupuncture is a cost effective treatment,
Many North Carolinians receive acupuncture benefits
currently,
And North Carolina State Employees want coverage of
acupuncture in the NC State Employees Health Plan.
References (abstracts included)
1. National Certification Commission for Acupuncture and Oriental Medicine website. Diplomate of Acupuncture.
http://www.nccaom.org/consumers/acupuncture-certification
2. Patricia M. Barnes, M.A., and Barbara Bloom, M.P.A. Complementary and Alternative Medicine Use Among Adults and Children:
United States, 2007. Division of Health Interview Statistics, National Center for Health Statistics, National Center for
Complementary and Alternative Medicine, National Institutes of Health
3. Khusid MA. Clinical indications for acupuncture in chronic post-traumatic headache management. Mil Med. 2015; 2014;180:132136.
Abstract: Chronic post-traumatic headache (PTH) is one of the most common complaints after mild traumatic brain injury, yet evidence to date is
insufficient to direct conventional treatment of headaches with this etiology. Therefore, the current guidelines recommend a symptomatic approach for the
three patterns of PTHs: migraine-like, tension-like, and mixed symptomatology. To improve response rates and minimize the potential for polypharmacy,
adverse effects, and risk of dependency, effective nonpharmacologic options should be employed to support faster and safer patient rehabilitation. Current
evidence shows that acupuncture is at least as effective as drug therapy for migraine prophylaxis and neurovascular and tension-type headaches. Because
of its safety, cost-effectiveness, and long-lasting benefits, adjunctive acupuncture should be offered to patients with chronic PTHs and may be a valuable
primary treatment alternative for those with contraindications to pharmacotherapy. Future head-to-head, adequately powered, well-controlled
randomized clinical trials are needed to investigate acupuncture efficacy for PTHs.
4.Witt C. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual
care. Obstet Gynecol. 2008;198:166.e1-166.e8.
Abstract: Objective: To investigate the clinical effectiveness and cost-effectiveness of acupuncture in patients with dysmenorrhea.
Study Design: In a randomized controlled trial plus non-randomized cohort, patients with dysmenorrhea were randomized to acupuncture (15 sessions
over three months) or to a control group (no acupuncture). Patients who declined randomization received acupuncture treatment. All subjects were
allowed to receive usual medical care.
Results: Of 649 women (mean age 36.1 ± 7.1 years), 201 were randomized. After three months, the average pain intensity (NRS 0-10) was lower in the
acupuncture compared to the control group: 3.1 (95% CI 2.7; 3.6) vs. 5.4 (4.9; 5.9), difference −2.3 (−2.9; −1.6); P<.001. The acupuncture group had better
quality of life and higher costs. (overall ICER €3,011 per QALY).
Conclusion: Additional acupuncture in patients with dysmenorrhea was associated with improvements in pain and quality of life as compared to treatment
with usual care alone and was cost-effective within usual thresholds.
5. Haake M, Müller H, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for Chronic Low Back Pain. Arch Intern Med.
2007;167:1892.
Abstract: To our knowledge, verum acupuncture has never been directly compared with sham acupuncture and guideline-based conventional therapy in
patients with chronic low back pain. A patient- and observer-blinded randomized controlled trial conducted in Germany involving 340 outpatient practices,
including 1162 patients aged 18 to 86 years (mean ± SD age, 50 ± 15 years) with a history of chronic low back pain for a mean of 8 years. Patients underwent
ten 30-minute sessions, generally 2 sessions per week, of verum acupuncture (n = 387) according to principles of traditional Chinese medicine; sham
acupuncture (n = 387) consisting of superficial needling at nonacupuncture points; or conventional therapy, a combination of drugs, physical therapy, and
exercise (n = 388). Five additional sessions were offered to patients who had a partial response to treatment (10%-50% reduction in pain intensity). Primary
outcome was response after 6 months, defined as 33% improvement or better on 3 pain-related items on the Von Korff Chronic Pain Grade Scale
questionnaire or 12% improvement or better on the back-specific Hanover Functional Ability Questionnaire. Patients who were unblinded or had recourse to
other than permitted concomitant therapies during follow-up were classified as nonresponders regardless of symptom improvement. At 6 months, response
rate was 47.6% in the verum acupuncture group, 44.2% in the sham acupuncture group, and 27.4% in the conventional therapy group. Differences among
groups were as follows: verum vs sham, 3.4% (95% confidence interval, -3.7% to 10.3%; P= .39); verum vs conventional therapy, 20.2% (95% confidence
interval, 13.4% to 26.7%; P < .001); and sham vs conventional therapy, 16.8% (95% confidence interval, 10.1% to 23.4%; P < .001. Low back pain improved
after acupuncture treatment for at least 6 months. Effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy.
6. Walker EM., Rodriquez Al, et al. Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with
hormone receptor-positive breast cancer: a randomized controlled trial. J Clin Oncol. 2010 Feb 1;28(4):634-40.
Abstract: PURPOSE: Vasomotor symptoms are common adverse effects of antiestrogen hormone treatment in conventional breast cancer care. Hormone
replacement therapy is contraindicated in patients with breast cancer. Venlafaxine (Effexor), the therapy of choice for these symptoms, has numerous
adverse effects. Recent studies suggest acupuncture may be effective in reducing vasomotor symptoms in menopausal women. This randomized controlled
trial tested whether acupuncture reduces vasomotor symptoms and produces fewer adverse effects than venlafaxine.
PATIENTS AND METHODS: Fifty patients were randomly assigned to receive 12 weeks of acupuncture (n = 25) or venlafaxine (n = 25) treatment. Health
outcomes were measured for up to 1 year post-treatment. RESULTS: Both groups exhibited significant decreases in hot flashes, depressive symptoms, and
other quality-of-life symptoms, including significant improvements in mental health from pre- to post-treatment. These changes were similar in both groups,
indicating that acupuncture was as effective as venlafaxine. By 2 weeks post-treatment, the venlafaxine group experienced significant increases in hot
flashes, whereas hot flashes in the acupuncture group remained at low levels. The venlafaxine group experienced 18 incidences of adverse effects (eg,
nausea, dry mouth, dizziness, anxiety), whereas the acupuncture group experienced no negative adverse effects. Acupuncture had the additional benefit of
increased sex drive in some women, and most reported an improvement in their energy, clarity of thought, and sense of well-being.CONCLUSION:
Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to
long-term antiestrogen hormone use in patients with breast cancer.
7. Litscher G. High-tech laser acupuncture is Chinese medicine. Medical Acupuncture. 2008;20:245-254.
Abstract: Acupuncture is gaining in popularity as a complementary method to medical treatment. Scientific investigations will be essential for the acceptance
of acupuncture not only by the Western medical community but the rest of the world.
Since 1997, the Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, and now the TCM Research Center Graz of Graz Medical
University in Austria, has been dealing with the demystification of acupuncture and examining, using noninvasive methods, how different stimulation
modalities (manual needle acupuncture, laser needle acupuncture, and electroacupuncture) affect peripheral and central functions. The laser needle
acupuncture, which was examined scientifically for the first time in Graz, represents a new painless acupuncture method for which 8-16 laser needles are
glued to the skin, but not inserted into it. This review summarizes some of the peripherally and centrally measured effects of acupuncture.
8. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Arch Intern Med.
2012;172(19):1444-1453.
Abstract; Background: Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine
the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain.
Methods: We conducted a systematic review to identify randomized controlled trials (RCTs) of acupuncture for chronic pain in which allocation concealment
was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs, with a total of
17 922 patients analyzed. Results: In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for
each pain condition (P < .001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar
across pain conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, 0.13–0.33), 0.16 (95% CI, 0.07–0.25), and 0.15 (95%
CI, 0.07–0.24) SDs lower than sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to noacupuncture controls were 0.55 (95% CI, 0.51–0.58), 0.57 (95% CI, 0.50–0.64), and 0.42 (95% CI, 0.37–0.46) SDs. These results were robust to a variety of
sensitivity analyses, including those related to publication bias.
Conclusions: Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true
and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition
to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.
9. Jabbour M, Sapko M, Miller D, Weiss L, Gross M. Economic evaluation in acupuncture: Past and future. American Acupuncturist.
2009;49(11)
No Abstract
10, Ambrósio EMM, Bloor K, MacPherson H. Costs and consequences of acupuncture as a treatment for chronic pain: A systematic
review of economic evaluations conducted alongside randomised controlled trials. Complement Ther Med. 2012;20:364-374.
The economic burden that chronic pain conditions impose on individuals and society is significant. Acupuncture appears to be a clinically effective treatment
for some chronic pain conditions. Given the need for policy decisions to be informed by economic evaluations, the objective of this systematic review was to
synthesise data from economic evaluations to determine whether acupuncture for the treatment of chronic pain conditions is good value for money. A
literature search was conducted using health and economics databases, with additional hand-searching. Economic evaluations conducted alongside randomised
controlled trials were eligible. Eight economic evaluations were included in this review, seven cost-utility analyses and one cost-effectiveness analysis.
Conditions treated included low back pain, neck pain, dysmenorrhoea, migraine and headache, and osteoarthritis. From the seven cost-utility analyses,
acupuncture was found to be clinically effective but cost more. The cost per quality adjusted life year (QALY) gained ranged from £2527 to £14,976 per QALY,
below the commonly quoted threshold used by the UK National Institute for Health and Clinical Excellence of £20,000 to £30,000. The one cost-effectiveness
study indicated that there might be both clinical benefits and cost savings associated with acupuncture for migraine. There was heterogeneity across the eight
trials in terms of professional who provided the acupuncture, style of acupuncture, and country of origin. The cost per QALY gained in all seven cost-utility
studies was found to be below typical thresholds of willingness to pay. Acupuncture appears to be a cost-effective intervention for some chronic pain
conditions.
11. Bonnie K. Lind, Ph.D.,1,2 William E. Lafferty, M.D.,3 Patrick T. Tyree, A.A.,1 and Paula K. Diehr, Ph.D.1,4. Comparison of Health
Care Expenditures Among Insured Users and Nonusers of Complementary and Alternative Medicine in Washington State: A Cost
Minimization Analysis. THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 16, Number 4, 2010, pp. 411–417a
Abstract: Objectives: The purpose of this analysis was to compare health care expenditures between insured patients with back pain, fibromyalgia syndrome,
or menopause symptoms who used complementary and alternative medical (CAM) providers for some of their care to a matched group of patients who did not
use any CAM care. Insurance coverage was equivalent for both conventional and CAM providers.
Design: Insurance claims data for 2000–2003 from Washington State, which mandates coverage of CAM pro- viders, were analyzed. CAM-using patients were
matched to CAM-nonusing patients based on age group, gender, index medical condition, overall disease burden, and prior-year expenditures. Results: Both
unadjusted tests and linear regression models indicated that CAM users had lower average expenditures than nonusers. (Unadjusted: $3,797 versus $4,153,
p1⁄40.0001; b from linear regression -$367 for CAM users.) CAM users had higher outpatient expenditures that which were offset by lower inpatient and
imaging expenditures. The largest difference was seen in the patients with the heaviest disease burdens among whom CAM users averaged $1,420 less than
nonusers, p < 0.0001, which more than offset slightly higher average expenditures of $158 among CAM users with lower disease burdens. Conclusions: This
analysis indicates that among insured patients with back pain, fibromyalgia, and menopause symptoms, after minimizing selection bias by matching patients
who use CAM providers to those who do not, those who use CAM will have lower insurance expenditures than those who do not use CAM.
12. A complimentary publication of The Joint Commission November 12, 2014. Published January 1st 2015.
http://www.jointcommission.org/assets/1/23/jconline_november_12_14.pdf