LITTLE HOOVER COMMISSION - September 30, 2004

Little Hover Commission 2004

State of California
LITTLE HOOVER COMMISSION
September 30, 2004

Regulation of Acupuncture: A Complementary Therapy Framework

The Honorable Arnold Schwarzenegger
Governor of California

The Honorable John L. Burton, President pro Tempore of the Senate,
The Honorable Dick Ackerman, Senate Minority Leader,
and members of the Senate

The Honorable Fabian Núñez, Speaker of the Assembly,
The Honorable Kevin McCarthy, Assembly Minority Leader,
and members of the Assembly

Dear Governor Schwarzenegger and Members of the Legislature:

In 2002, the Commission was asked by the Governor and Legislature to assess some long-standing and contentious issues regarding the State's regulation of the acupuncture profession. Specifically SB 1951 and AB 1943 requested that the Commission review the scope of practice and educational requirements for acupuncturists, the process for accrediting acupuncture schools and for examining licensees.

In conducting this review, the Commission sought out detailed and technical analysis - from experts at the University of California, California State University and RAND - to help sort through the conflicting claims that have frustrated the policy-making process. The Commission heard hours of public testimony, and engaged in even more hours of less formal public discussions. The Commission solicited and reviewed written comments from any individual and organization that desired their view to be considered, and it reviewed volumes of scientific and other treatises on acupuncture and Oriental medicine.

The Commission, as an independent and bipartisan panel, also explored the underlying tensions that have contributed to the persistent debates and probed the broader public interest aspects that are embedded in the specific regulatory issues that were before the Commission.

Through this process, the Commission developed an appreciation for the profession and for acupuncture and traditional Oriental medicine. It also developed and assembled a substantial body of technical analysis that could be used by regulators and lawmakers to resolve the precise issues that were before the Commission, as well as other challenges.

One source of confusion emanates from the Legislature's declared intent to regulate acupuncture as a primary health care profession without specifying in statute the full authority or limits of acupuncturists to diagnose and treat patients. This ambiguity - along with the legal opinions crafted to resolve confusion over the scope of practice - raise the potential for conflict between practitioners of traditional Oriental therapies and modern Western medical doctors. And when the two paradigms conflict - rather than complement - the opportunity for patient harm increases and the potential for patient benefit decreases. The Commission recommended specific ways to amend the scope of practice to resolve this issue.

Regarding educational requirements, the increased standards that will go into effect on January 1, 2005 appear to provide adequate time to teach the knowledge, skills and abilities needed for entry-level practitioners to perform this clarified scope of practice. The Commission, however, recommended ways to make sure that this training provides the information necessary to protect the public.

The Commission concluded that the Accreditation Commission of Acupuncture and Oriental Medicine should be relied upon to validate the quality of acupuncture training schools. The Commission, however, concluded that the State should continue to use its own examination as the regulatory threshold to practice in California, rather than rely on the national exam.

The Commission also identified additional opportunities for the State's consumer protection agencies, including the Acupuncture Board, to safeguard patients against practices or products that can threaten their safety and the public health - perhaps more importantly, measures to control infections. These safeguards begin with the qualifications of board members, and by making sure that vacancies on the Acupuncture Board - which currently number six out of nine seats - are expeditiously filled.

California's fundamental policy toward alternative health care has been to provide patients with the freedom to choose. That path confers onto regulators the primary responsibilities of making sure that practitioners meet minimum standards, and that consumers have the information needed to make informed choices. Disclosure statements and other consumer education materials should provide patients with information regarding treatment efficacy and safe practices.

An important underlying tension is the trend toward blending traditional Oriental Medicine with Western biomedicine. While both healing paradigms can benefit the public, those benefits will be jeopardized if the two regulatory schemes are not kept separate and distinct. The Commission's recommendations would clarify the role for acupuncturists and - if enacted immediately - would prevent greater confusion and even potential harm to consumers in the future.

The Commission sincerely appreciates the willingness on the part of state regulators, acupuncturists and other health professionals to inform its process. The Commission also appreciates the straightforward analysis provided by researchers at the University of California, San Francisco, California State University, Sacramento and elsewhere who contributed to its understanding of the issues. But as always, the conclusions and recommendations are the Commission's own.

Sincerely,
Michael E. Albert, Chairman

Executive Summary - Underlying Tensions

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework As a destination for dream seekers, California has inherited the treasures of cultures Occidental and Oriental. Predictably, government is occasionally required to arbitrate, even regulate, how some traditions and practices are used in the public interest. Such is the case of acupuncture and Oriental medicine, a healing art with ancient roots and modern branches. In 30 years, the State has evolved a full-scale professional regulatory scheme that licenses more than one in four acupuncturists in the United States. This practice has flourished in the Golden State in part because of Asian immigration and...

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Executive Summary - To Protect Consumers

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework To protect consumers, the State must regulate acupuncturists and other professionals by appropriately applying the following tools: A clear scope of practice. For the most part, the scope of practice for acupuncturists clearly focuses professionals on some of the traditional Oriental healing methods. Controversy, however, has arisen over their authority to diagnose patients and their role as primary care practitioners. In those aspects, clear statutory language is needed to affirm that consumers have direct access to acupuncturists who can diagnose patients using traditional Oriental techniques and should coordinate treatment and refer patients to...

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Finding and Recommendation 1

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Finding 1: While the legal scope of practice clearly defines the modalities that acupuncturists can use, the statute is silent on issues that are important in defining their role as health care providers. To establish a sound regulatory scheme, policy-makers must clearly define the practice that the State intends to regulate. This legal "scope of practice" is the foundation on which health care regulation is built. The scope determines the minimal educational requirements that will be necessary for a practitioner to enter the field. The scope of practice defines the breadth of the...

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Finding and Recommendation 2

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Finding 2: The new 3,000-hour educational requirement is adequate to prepare entry-level practitioners and to protect the public safety. A primary goal of educational requirements is to provide some assurance that professionals have the knowledge, skills and abilities necessary to safely practice the profession. And the standard for professional licensing is to ensure that incoming licensees can perform the legally authorized scope of practice as entry-level practitioners.2 Effective January 1, 2005, new students in acupuncture schools will need to complete 3,000 hours in training before they will be able to take the licensure...

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Finding and Recommendation 3

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Finding 3: The steadily increasing educational requirements for new entrants into the acupuncture profession potentially creates different levels of competency, and could confuse or mislead the public regarding the knowledge, skills and ability of those previously licensed. Acupuncture Board regulations require practitioners to take 30 hours of continuing education every two years.4 However, when the new 3,000-hour standard goes into effect, many practicing acupuncturists will have been licensed with only 1,350 hours of training, and were licensed prior to the time that acupuncturists could practice independently of M.D.s and were allowed to make...

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Finding and Recommendation 4

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Finding 4: The examination of candidates for licensure is a critical quality control measure for assuring competency of providers and is an essential mechanism for ensuring that evolving public policy goals are met. California's regulator has had difficulties with the acupuncture examination, including documented fraud and criminal charges during the 1980s that spawned security improvements that require continuous refinement. In debating improvements to the examination, policy-makers also have considered replacing the California test with the examination offered by the National Certification Commission for Acupuncture and Oriental Medicine. Most other California health professionals...

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Finding and Recommendation 5

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Finding 5: The process used by the Accreditation Commission of Acupuncture and Oriental Medicine appears to be superior to the school approval process used by the Acupuncture Board and could be used by the State to ensure the quality of education for potential licensees. Prior to taking the California licensing exam, potential licensees must graduate from a school approved by the Acupuncture Board. In addition, schools also must be approved by California's Bureau of Private Postsecondary and Vocational Education, or similar bureaus in other states, which guard against diploma mills and fraudulent business...

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Finding and Recommendation 6

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Finding 6: The California Acupuncture Board has missed significant opportunities to protect the public, particularly in the areas of consumer information and herb-related safety. Many of the specific issues that the Governor and the Legislature asked the Commission to review have festered because the Acupuncture Board too frequently acted as a venue for promoting rather than regulating the profession. As a result, the board has missed opportunities to protect the public by providing accurate and complete information about the therapies that licensees can provide. The board also has not adequately incorporated emerging scientific...

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Introduction

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Two bills passed by the Legislature and signed by the Governor in 2002 requested that the Little Hoover Commission assess and make recommendations on six issues concerning the regulation of acupuncture in California. The measures grew in part out of the Legislature's sunset review of the Acupuncture Board, which identified but did not resolve some issues of concern to policy-makers. The legislation also reflected an ongoing effort by some professional associations to raise minimum educational requirements for incoming professionals. To explore these issues, the Commission augmented its standard public, bipartisan and independent...

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Background

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Acupuncture originated in China over 2,000 years ago and has been used in Japan for 1,500 years.5 It was first described in Chinese literature in approximately 100 B.C. in The Inner Classic of the Yellow Emporer.6 Over time and with trade, the use of acupuncture spread throughout Asia, into Europe and beyond. By the 1600s acupuncture was discussed in European medical literature.7 Different countries and regions evolved different approaches to the use of acupuncture. For example, the Chinese evolved the use of electro-acupuncture, whereas the Japanese are known for a gentle approach...

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Acupuncture in the United States

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework In the United States, acupuncture had been used primarily by Asian immigrants until President Nixon traveled to China and re-established diplomatic ties in 1972.13 Since that time, acupuncture has gained increasing acceptance with the public and the complementary medicine clinics of academic medical centers. In 2004, the National Center for Health Statistics at the U.S. Centers For Disease Control reported that 1.1 percent of the U.S. public had used acupuncture in the previous12 months and that 4 percent had used it at some time.14 Following President Nixon's visit to China, the U.S. Food...

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Legalization, Licensure and Education in California

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework 1972 AB 1500 (Duffy) authorized "an unlicensed practitioner to practice acupuncture under the direct supervision of a licensed physician if conducted in an approved medical school for the sole purpose of scientific investigation."24 1975 SB 86 (Moscone-Song) authorized certification of acupuncturists. The measure also required a prior diagnosis and referral from a licensed physician and surgeon, dentist, podiatrist or chiropractor and required that at the completion of treatment, the acupuncturist was to report to the referring provider "the nature and effect of treatment." Certifications were authorized to be granted to applicants without taking...

Context for Policy-making in California

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework In the course of its study, the Commission identified a number of contextual issues important to formulating policies related to acupuncture....

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Conditions vs. Modalities of Treatment

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Acupuncture is defined in law in terms of authorized modalities of treatment (e.g., needle therapy, herbal and nutrition therapy, etc.). However, the scientific evidence is evolving around which diseases or conditions can be successfully treated with particular modalities. In particular, NIH has found that acupuncture needle therapy is effective for "postoperative and chemotherapy nausea and vomiting and postoperative dental pain." Multiple promising studies are underway. For instance, Stanford University's psychiatry department has conducted a pilot study indicating that for women suffering from depression during pregnancy, acupuncture may hold promise as a safe treatment...

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Cancer Treatment

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework One important example of where policy-makers have distinguished between modalities of treatment and appropriate conditions to be treated is cancer. However, during advisory committee meetings it was brought to the Commission's attention that there was some confusion among practitioners and the Acupuncture Board about the appropriateness of cancer patients receiving acupuncture. State law limits the specific treatment modalities that can be used to treat cancer and does not authorize acupuncture. However, the attorney for the Acupuncture Board and Department of Consumer Affairs reviewed the issue at the request of the Commission. In his...

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Scope of Practice

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework In SB 1951, the Legislature asked the Commission to: "Review and make recommendations on the scope of practice for acupuncturists." Finding 1: While the legal scope of practice clearly defines the modalities that acupuncturists can use, the statute is silent on issues that are important in defining their role as health care providers. The legal scope of practice is the foundation on which health care regulation is built. The scope determines the minimal educational requirements that will be necessary for a practitioner to enter the field. The scope of practice defines the breadth...

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The Move to Direct Access

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework When acupuncturists were first licensed in California in 1975, they could only see patients who had been diagnosed and referred by physicians. In 1979, lawmakers were concerned that physicians were not referring patients, and so eliminated the referral requirement, allowing patients to have direct access to acupuncturists. The following year, the Legislature created a committee separate from the Board of Medical Quality Assurance to license acupuncturists and it added to the list of modalities that could be used by acupuncturists, including the use of herbs. The Legislature also added the following "intent" language:...

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The Debate Over Diagnosis

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework The ambiguity in the law emerges as a controversy in regard to the authority of acupuncturists to diagnose patients. Unlike the practice act for other health care professions, the acupuncture statute does not explicitly authorize the diagnosis of patients. However, in a series of legal opinions and memoranda, the Department of Consumer Affairs has concluded that in removing the physician referral requirement the Legislature implicitly gave acupuncturists the authority to diagnose patients before treating them.49 In early opinions, the department's attorneys concluded that acupuncturists could diagnose patients, but were limited to a traditional...

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And Which Diagnosis?

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework In order to affirm whether acupuncturists can diagnose patients, policy-makers are confronted with the next issue : Are acupuncturists limited to traditional Oriental medicine, or an evolving blend of traditional Oriental medicine and modern biomedicine? While some in the profession want to stay focused on traditional practices (those included in the statute), other advocates are pushing for both a modern interpretation of how acupuncture affects the body, as well as access to modern technologies that were developed as part of the biomedical model. The intent language in statute refers to an "art and...

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Unraveling the Confusion

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Policy-makers will find it difficult to address one of these issues without addressing all of them. And without squarely dealing with the fundamental questions, the tensions will not be eased and the public will be denied the benefits that clarity will bring. To unravel the confusion, policy-makers will need to do the following: Clarify the role of acupuncturists in the health care system. The law should clarify that patients have direct access to acupuncturists. The statute also could go beyond a list of modalities to include disease-specific guidelines or limitations, such as those...

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Scope of Practice: Summary and Recommendation

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Summary The existing scope of practice is both precise and insufficient. To provide an adequate framework, lawmakers will need to go beyond listing some traditional Oriental modalities to define in statute what is meant by traditional Oriental medicine. The policy choice to give patients direct access to acupuncturists was clear, but the statutory intent to regulate acupuncturists as a "primary care health care profession" is not. The term has many potential meanings. While some people may turn to acupuncturists first for everything that ails them (one potential meaning), it is difficult to see...

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Education

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework In SB 1951, the Legislature asked the Commission to: "Review and make recommendations on the education requirements for acupuncturists." In AB 1943, the Legislature asked the Commission to: "Review increasing curriculum hours for the licensure of acupuncturists in excess of 3,000 hours up to 4,000 hours to fully and effectively provide health services under their scope of practice." Finding 2: The new 3,000-hour educational requirement is adequate to prepare entry-level practitioners and to protect the public safety. Requiring specific education and other training is one way that government regulators can establish minimum competencies...

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A Steady Increase in Educational Requirements

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Between 1976 and 1978, when acupuncturists were first certified in California, approximately 900 practitioners with between two to five years of experience were "grandfathered" into licensure.63 Those with five years of experience (or three years if affiliated with approved medical school programs) were "grandfathered-in" without education or examination requirements. Those who could prove two years of experience were still required to take an examination, but did not need to present proof of education.64 From 1976 to 1984, board regulations required new practitioners who did not have two to five years of experience to...

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Arguments For Going Beyond 3,000 Hours

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework In raising the educational standard to 3,000 hours, the Legislature also opened the door to an even higher standard by asking the Commission to assess the need for 4,000 hours for acupuncturists to "fully and effectively provide health services under their scope of practice." Some proponents argue that an even greater increase in training is necessitated by patient safety issues, including lack of knowledge of "red flag" medical conditions, first-aid and CPR, herb-drug interactions and communicating with Western providers.72 But the persistent argument for raising the standards to 4,000 hours is based...

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Arguments Against Increasing Hours

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework As explained previously, the purpose of education is to ensure minimum competence. Raising educational standards - beyond what is required for public safety - can discourage or delay new entrants into the marketplace, resulting in higher fees and lower access for consumers. When regulations unnecessarily limit competition, the options available to consumers are diminished. An expert from the National Institutes of Health testified that there is no evidence indicating a need to raise education hours. He also stated that by doing so, consumer access could be unnecessarily restricted, particularly to promising addiction therapy.78...

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Implementation Concerns

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework The increase in minimum educational standards - as well as the Acupuncture Board's implementation of those standards - raises a number of concerns that the board, officials with the Department of Consumer Affairs, or lawmakers may need to address. Schools might not have expertise. Most accredited colleges have not been required to teach human physiology and other courses grounded in Western science. Expanding into this area will present challenges to those schools and particular efforts need to be taken to ensure that quality teaching takes place....

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Implementation Opportunities

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework While there are fervent efforts to increase the hours associated with preparation, there are other avenues for increasing preparation that may better serve students, patients and the public interest. Require prerequisite degrees. California could do as other states and adopt prerequisite standards to ensure that students have a grounding in Western health sciences. New Hampshire, for example, requires applicants for licensure to have either a bachelor's degree, nursing degree, or physician's assistant's license, in addition to completion of their acupuncture coursework....

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Perspectives from Other Health Professions and Nations

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Some stakeholders argued that California should raise its educational standards to match those in Asian schools. However, in Asia there are multiple paths for studying acupuncture, including tutorial, vocational, college and university training. 84 The education of acupuncturists and traditional practitioners in Asia is not significantly incorporated into the training in modern medical schools. Acupuncture in Asia is taught primarily in schools devoted to traditional practices. In addition, some modern medical schools have sections exploring the scientific application of acupuncture.85...

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Education: Summary and Recommendation

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Summary Until the new standards are implemented, and the performance of students assessed, there is no way of determining whether an increase in hours above the 3,000-hour standard is necessary - particularly if the scope of practice is focused on traditional Oriental medicine. But there are steps that can be taken to make sure that existing requirements are better preparing practitioners....

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Continuing Education

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework In AB 1943, the Legislature asked the Commission to: "Review the competence of licensed acupuncturists who are not subject to the 3,000-hour minimum curriculum requirement, and training, testing or continuing education that would be required for these individuals to meet the standards for continued licensure." Finding 3: The steadily increasing educational requirements for new entrants into the acupuncture profession potentially creates different levels of competency, and could confuse or mislead the public regarding the knowledge, skills and ability of those previously licensed....

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Raising the Standards for All

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Most health professions have tried to raise the standards for both new entrants, as well as seasoned professionals. The University of California identified several options: Additional coursework. Recommending or requiring educational programs to develop and implement "catch up" programs to enable practitioners to gain required competencies. Testing. Using test-out options to enable practitioners to demonstrate knowledge or skills in required competency areas for the purposes of acquiring updated training and credentials. Grace periods. Establishing a feasible schedule upon which supplemental education or examinations can be completed considering the professional responsibilities and workload of...

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Concerns About Continuing Education

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework There are persistent concerns that continuing education in many fields is ineffective, and there is no assurance that practitioners acquire specific skills. This is especially relevant for the California acupuncture profession, given that the push to increase educational requirements has been officially predicated on concerns that acupuncturists are unprepared to treat patients as independent practitioners. The Department of Consumer Affairs does not have strong rules for ensuring the quality of continuing education that could be applied for all professional boards. Among the concerns across the professions are: No examination. Regulators do not typically...

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Continuing Education: Summary and Recommendation

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Summary Given the dramatic rise in educational standards, policy-makers and the Acupuncture Board cannot assume that the experience of practitioners alone is protecting the public. The State has reasonable options for ensuring that all practitioners are developing the knowledge skills and abilities that are necessary to protect patients....

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Examination

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework In SB 1951, the Legislature asked the Commission to: "Evaluate the national examination, administered by the National Certification Commission for Acupuncture and Oriental Medicine, and make recommendations as to whether or not the national examination should be offered in California in lieu of, or as part of, the state examination." Finding 4: The examination of candidates for licensure is a critical quality control measure for assuring competency of providers and is an essential mechanism for ensuring that evolving public policy goals are met....

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International and American Examination in Context

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Most other California health professionals are licensed based on a national examination. However, the acupuncture profession is still 47 relatively new in its evolution within the United States and the profession in California has evolved somewhat differently than it has developed nationally. Just as different nations take different regulatory approaches to acupuncture, herbs and other modalities of traditional Oriental medicine, so do different states. One significant difference among states and nations is whether acupuncture and herbs are regulated as separate skills and professions. That basic decision is one factor that drives the breadth...

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Policy Considerations

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Whether California should continue to have a unique examination has been a contentious issue. Among the concerns: Profession-wide standards. Many professionals advocate for establishing one standard examination used nationwide, which like other health professions, allows for reciprocity within the United States. But some California acupuncture associations, especially those advocating for blending the practices of Western and Eastern medicine, are opposed to national standards and testing. To the degree that the NCCAOM exam does not test Western science and practices, the California professional organizations are concerned that it does not comport with the direction...

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Test Analysis

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework For this study, a comprehensive review and psychometric analysis of the state and the NCCAOM examinations was conducted by consultants from California State University, Sacramento and RAND. The analysis found that both tests meet professional psychometric standards. However, the California examination was determined to be more rigorous than the NCCAOM examination. The analysis also found that the test items on the California examination are on average more difficult than the NCCAOM examination. Further, California's underlying documentation - upon which examinations are built - was stronger. The chart on the following page provides...

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Good Tests, But Room For Improvement

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework In summary, the psychometrical and statistical comparison of the two examinations concluded the following: Based on all of the documentation made available for this project, one cannot help but conclude that, despite some weaknesses or documentation failures here and there, both testing programs conscientiously strive toward excellence and have in fact produced very good products. The two testing programs have each captured a weighted composite of the tasks performed in professional practice, have generated items of high quality, and have determined passing criteria in accord with accepted practice....

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Refinement Approaches

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework While both examinations meet professional standards, policy-makers may wish to consider the following opportunities for improvement: Require essential safety knowledge. It is possible to establish must-pass components of the examination to ensure that applicants for licensure demonstrate proficiency in each of the areas that are deemed to be essential for public safety. The box below provides further details on the consultant's conclusions regarding a modular approach for testing critical knowledge....

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Examination: Summary and Recommendation

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Summary In choosing between the two examinations, policy-makers should consider the soundness of the testing instruments and whether they were appropriately developed from a valid occupational analysis. The tests also must be statistically valid and securely administered. In this case, both examinations were found by independent statistical and psychometric analysis to be sound. However, California's more extensive technical documentation of the underlying exam factors was determined to be superior.53...

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School Accreditation Practices

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework In SB 1951, the Legislature asked the Commission to: "Evaluate and make recommendations on the approval process of the Accreditation Commission of Acupuncture and Oriental Medicine, the approval process of the Bureau of Private Postsecondary and Vocational Education and the board's approval process." Finding 5: The process used by the Accreditation Commission of Acupuncture and Oriental Medicine appears to be superior to the school approval process used by the Acupuncture Board and could be used by the State to ensure the quality of education for potential licensees....

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The Value of Accreditation

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework School approval procedures provide multiple values to students and the general public. One primary goal is to make sure that students receive a quality education in the subject matter that regulators deem necessary for entry level professionals. Similarly, the approval process protects students by making sure that they receive a solid education from a credible institution. The federal government requires accreditation as a way to safeguard the federal investment in student aid. The U.S. Department of Education follows a stringent process for approving private accrediting bodies, deputizing them to perform the function as...

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Comparing ACAOM and California's Approvals

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Through a survey of school administrators and other research, UC's Center for the Health Professions identified similarities and differences between California's review process and that used by ACAOM. Both agencies express similar philosophies, use similar procedures and look for similar factors when visiting programs. In the past, they have even coordinated their school visits....

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Education Standards

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework As of July 2004, ACAOM requires schools to have a minimum of 2,625 hours for its Oriental medicine accreditation, which includes both acupuncture and herbs.113 California's current requirement is 2,348 hours, but effective January 1, 2005, California's standard will increase to 3,000 hours. California's curriculum requirements also are more specific than ACAOM's....

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Which Process Best Ensures Quality?

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Questions for Policy-makers While there is clearly animosity between some members of the California profession and ACAOM, the question for policy-makers is how to best ensure that schools are providing a quality education to students who will sit for the acupuncture exam....

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Can California Rely on ACAOM and Control Standards?

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework California has - and should - maintain control over its educational standards for the sole purpose of ensuring adequate minimum competency for entry-level practitioners. Some stakeholders oppose involvement by organizations that are active throughout the United States, preferring to evolve the California profession independent of national and international trends. But as others suggest, the Acupuncture Board could have ACAOM accredit schools and still reserve final approval for the board. 116...

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Should Costs Matter?

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework In UC's survey, the greatest criticism of the approval process pertained to the fees charged by ACAOM. And UC calculated that a school could spend 10 times as much on fees to ACAOM over a 10-year period than it would pay to the Acupuncture Board....

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School Accreditation Practices: Summary and Recommendation

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Summary The efforts to raise educational standards even higher have spilled over into the policy debate over how to best assess the quality of education that schools provide. The best information available indicates that ACAOM's process is sound, and in some ways better than the review provided by the California Acupuncture Board. California can make use of this capacity without sacrificing control over curriculum standards or other aspects that ensure adequate preparation....

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Oversight Concerns

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Finding 6: The California Acupuncture Board has missed significant opportunities to protect the public, particularly in the areas of consumer information and herb-related safety....

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Accurate Public Information

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework One critical example is the board's presentation of the scientific evidence regarding the efficacy of acupuncture. The National Institutes of Health found that acupuncture needle therapy is effective for "postoperative and chemotherapy nausea and vomiting and postoperative dental pain." NIH also stated that it may be appropriate therapy for a variety of other conditions for which there is not yet clear evidence. However, the Acupuncture Board's Web site, fact sheet and consumer brochure implies efficacy for a broad range of ailments. Moreover, those materials do not provide cautionary information to consumers about the...

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Disease Protection

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework The board also has not forcefully responded to emerging information about basic public safety concerns. The Council of Acupuncture and Oriental Medical Associations, in arguing for improved education standards, submitted to the Commission an audit by a managed care company which found that "18 percent of acupuncturists did not have the required sanitary hand washing facilities and 15 percent did not comply with safe needle disposal requirements."119...

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Herb Safety

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Much greater attention also needs to be placed on the portion of the scope of practice related to prescribing herbs. These substances are not regulated for purity, potency or effectiveness by the federal Food and Drug Administration nor California authorities.126 Yet there are growing concerns about herb-drug interactions, mislabeling and impurities....

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Board Structure

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Regulatory capture is a long-standing concern with professional boards, and should clearly be of concern in this case. At one point during this study, the board's chairperson confirmed this concern by asserting in writing that: "The Chair of the Acupuncture Board Acupuncture Board is is the only representative and advocate speaking on behalf of the only representative the entire profession in California."138 Domination of the board by elements of the profession - rather than by consumers, health advocates and others who do not economically benefit from the profession - appears to limit the...

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Oversight Concerns: Recommendation

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework Recommendation 6: The Governor and the Legislature, through the Sunset Review Process or other mechanisms, should ensure that the California Acupuncture Board becomes a strong advocate for consumers....

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Conclusion

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework The issues before the Commission are central and routine to essentially all professional licensure. Moreover, it is not uncommon for disputes, particularly over scope of practice, to be raised in both the regulatory and the legislative arenas. But in the case of acupuncture, policy-makers have had difficulty resolving these issues. The debates have been confused by conflicting facts and by the fundamental and philosophical differences between traditional Oriental medicine and Western biomedicine. And while some in the profession want to preserve and enhance traditional therapies, others see the profession's future as a blend...

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Notes

Little Hover Commission 2004

Regulation of Acupuncture: A Complementary Therapy Framework The Acupuncture Board also has "adopted for reference" a document prepared by a professional acupuncture association describing "standards of practice" for acupuncturists (The Council of Acupuncture and Oriental Medical Associations,1997, "Scope of Practice for Licensed Acupuncturists"). That document varies from California statute and regulation. The Acupuncture Board's attorney, Donald Chang, stated that the board's action was the equivalent of receiving a report, October 21, 2003, direct communication). Larry Meyers, Ph.D., Professor, Department of Psychology, California State University, Sacramento, July 2004, written communication regarding "Standards for Educational and Psychological Measurement." Kathleen Hamilton, former Director,...

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