|18.1||The Department of Health and Human Services should assist the States in evaluating the impact of legislation enacted by various States on access to CAM practices and on public safety. [How useful this would be would depends on whether it is done properly.]|
|18.2||The Department of Health and Human Services and other appropriate Federal agencies should use health care workforce data, data from national surveys on use of CAM, regional public health reports on CAM activities and other studies to identify current and future health care needs and the relevance of safe and effective CAM services for helping address these needs. [This falsely assumes that there are many safe and effective "CAM" activities. No data can identify a "need" for "CAM" products or services that have not been proven safe and effective.]|
States, in exercising their authority over health care practitioners, should consider where a regulatory infrastructure for CAM practitioners might be necessary in order to promote quality of care and patient safety. The primary mechanisms used by states to regulate health care practitioners are:
State and Federal policy-makers and others with an interest in these issues should recognize three unique challenges that face regulation of CAM practitioners. First, views vary among CAM practitioners regarding how much training should be required for licensure in any given field, the extent to which such training should be required for licensure, and whether and how such education and training can incorporate intuitive skills and individualized approaches to providing health care services. [This falsely assumes that "CAM" services are individualized. Many "CAM" practitioners treat everyone the same way.] For many CAM providers, licensure presents a tension between the desire to increase standardization of CAM education, training, and practices across states and the desire to keep CAM practice flexible, non-standardized, and linked to subjective, interpersonal and intuitive aspects of care. [What should count is whether they offer valuable services, which most do not.] While increased licensure of CAM may help facilitate research, ease referrals, enhance patient access, and increase consumer protection, it may decrease individualization of services, time spent per patient, and range of patient options, qualities of CAM practice valued by practitioners and patients alike. [This paragraph is absolute baloney. Our laws should be designed to protect people from practitioners who are not qualified to diagnose or treat disease. Most people who offer "CAM" services are not qualified to do either.]
Second, variation in what constitutes "CAM" makes any assessment of CAM as value-added services difficult. Disagreement also surrounds the nature and scope of various CAM professions. [Defining one's scope requires scientific evidence of effectivess.] In 2001, the University of California, San Francisco Center for Health Professions published a report that addresses this issue . Questions it raised include: How does the profession describe itself in terms of the types of care it provides, and the types of care that are beyond its professional scope? Are there differences of opinion within the profession about the range of care that is appropriate for the profession to provide? What interventions and modalities does the profession use? Answers to these questions will help define the various CAM professions.
A third, related concern involves the confusion and potential legal consequences that arise from the overlap of approaches and techniques used by CAM practitioners. For example, some states include homeopathy and acupuncture within the definition of the practice scopes for naturopathy or chiropractic, whereas others do not. Practitioners from states with a broad scope of practice who move to states with a more limited one may be unsure whether they risk state censure by providing these services. Confusion and legal risk can occur within a state if the legal authority to practice is not well defined or lacks clarity as to boundaries for practice. The potential for liability creates fear and uncertainty for some CAM practitioners. All providers, CAM and conventional, can be prosecuted if they are considered to have exceeded their scope of practice. [Generally speaking, licensing laws are far too liberal and insufficiently enforced to protect the public against irrational practices.]
To address some of these issues the Pew Health Professions Commission, established in 1989, conducted an in-depth study of reform in the regulation of health care practitioners. They recognized that health care workforce reform would necessitate regulatory reform and created a task force to propose new approaches that would better serve the public's interest. In 1995, they published 10 recommendations for regulatory reform and offered policy options, hoping to stimulate debate and discussion by states . The recommendations focus primarily on regulation of conventional health care practitioners but they are applicable to CAM practitioners as well. Recommendations from the Pew Commission Taskforce are in Appendix B. [Strengthening state regulation of practitioners is a good idea, but if competency standards were uniformly raised, the professions of acupuncture, chiropractic, and naturopathy would be decimated, and no other "CAM" practitioners would be permitted to practice independently.]
Recommendation 19: The Federal Government should offer assistance to states and professional organizations in 1) developing and evaluating guidelines for practitioner accountability and competence in CAM delivery, including regulation of practice, and 2) periodic review and assessment of the effects of regulations on consumer protection.
|19.1||The Secretary of Health and Human Services should create a policy advisory committee, including CAM and conventional practitioners and representatives of the public, to address issues related to providing access to qualified CAM practitioners, provide guidance to the states concerning regulation possibilities, and provide a forum for dialogue on other issues related to maximizing access. [Although standard biomedicine can apply criteria of facts and reason in order to develop effective methods of training and qualification, "CAM" possesses no such body of evidence or method. Rational methods need no special protection. Irrational methods cannot be made safe by writing guidelines.]|
|19.2||The Secretary of Health and Human Services, in collaboration with states, should assist CAM organizations that wish to develop consensus within their field of practice regarding standards of practice, including education and training. The conclusions reached by CAM professional groups concerning these matters should be considered by states and regulatory bodies in determining the appropriate status of these practitioners for such regulatory options as registration, licensure or exemption. [Although standard biomedicine can apply criteria of facts and reason to develop practice standards, "CAM" possesses no such body of evidence. There can be no objective standards for determining who is a "qualified CAM practitioner." The basic requirement for professional practice should be knowledge of scientifically sound practices. Self-identification or recognition as a "CAM" or "conventional" professional is irrelevant.]|
Recommendation 20: States should evaluate and review their regulation of CAM practitioners and ensure their accountability to the public. States should, as appropriate, implement provisions for licensure, registration, and exemption consistent with the practitioners' education, training, and scope of practice.
|20.1||The Department of Health and Human Services' policy advisory committee, in partnership with state legislatures, regulatory boards, and CAM practitioners, should develop model guidelines or other guidance for the regulation and oversight of licensed and registered practitioners who use CAM services and products. This guidance should balance concerns regarding protection of the public from the inappropriate practice of health care, provide opportunities for appropriately trained and qualified health practitioners to offer the full range of services in which they are trained and competent, maintain competition in the provision of CAM and other health services, preserve CAM styles and traditions that have been valued by both practitioners and consumers, and determine the extent of the public's choice among health care modalities. [This falsely assumes that there are many "appropriately trained and qualified "CAM" practitioners and that consumer use is a measure of effectiuveness. Moreover, there is no logical reason why guidelines and standards should depend on whether or not somthing is marketed as "CAM." This recommendation calls for weakening consumer protection against quackery.]|
Hospitals, Nursing Homes, Hospice, Community Health Centers, and other Health Care Delivery Organizations
Hospitals and Other Conventional Health Care Settings
Because of the increased use of CAM, access and safety issues involving delivery of CAM in hospitals, hospices, nursing homes, community health centers, and other health delivery organizations are increasing. Patients sometimes bring CAM products and even CAM practitioners into inpatient settings. Health delivery organizations vary in their policies and procedures regarding such situations, and there is little monitoring of interactions between CAM and conventional health care in these settings.
Health care facilities credential practitioners who provide services at their facilities. The question of who may practice and under what conditions within health delivery facilities is not addressed consistently for CAM practitioners. In some facilities, CAM practitioners who are not credentialed are permitted to provide services to patients; in others, only practitioners already credentialed by the facility may provide services.
Issues of safety and quality of care also arise when conventional practitioners who are credentialed by a facility use CAM in their practice. An increasing number of physicians use CAM practices for their patients in both inpatient and outpatient settings.
One way to address the growing number of issues related to the use of CAM interventions in hospitals, nursing homes, hospices, other clinical settings, and home health care is through the initiatives and leadership of nationally recognized accrediting organizations, including those that accredit health care networks and managed care organizations. For example, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an independent nonprofit organization, surveys and accredits nearly 18,000 facilities, other health delivery settings, and health plans using professionally based standards to measure compliance. Other nationally recognized accrediting organizations include the National Committee for Quality Assurance and the American Accreditation HealthCare Commission. The efforts of these organizations to address CAM in all health care settings will contribute greatly to the public's safety. In addition, these efforts will assist state and Federal regulators of health delivery organizations and health plans, who often use accreditation as a proxy for government oversight.
One important initiative that national accrediting organizations may take is to review their standards, guidelines, and interpretations for areas that affect or are affected by trends in CAM. For instance, one JCAHO standard addresses "the relationship of the hospital staff and its staff members to other health care providers, educational institutions, and payers." In this case, more specific guidance is needed as to how a facility can meet the standard when incorporating CAM interventions into hospital services, serving as a component of an integrated delivery system that includes CAM, or participating in collaborative treatment plans with CAM providers. [Credentialing standards should be the same for everyone. They should not be lowered because they label their practices as "CAM."]
The work of national accrediting organizations includes not only a wide range of standards and guidance, but also measurement tools, quality and performance improvement initiatives, and surveys. The work usually is conducted by staff along with representatives of the health care industry, other industry experts, and consumers who serve on various committees and special working groups. It is important for national accrediting organizations to include CAM experts and representatives of CAM organizations on any group that addresses issues related to CAM. [This improperly suggests that only people who consider themselves as "CAM" experts are qualified to judge other "CAM" practitioners. It also bypasses the issue of whether it is possible to be an expert in a field whose methods have not been proven effective.]
Recommendation 21: Nationally recognized accrediting
bodies should evaluate how health care organizations under their
oversight are using CAM practices and should develop strategies
for the safe and appropriate use of qualified CAM practitioners
and safe and effective products in these organizations.
|21.1||National accrediting bodies, in partnership with other public and private organizations, should evaluate present uses of CAM practitioners in health care delivery settings and develop strategies for their appropriate use in ways that will benefit the public. [This falsely assumes that there are many such uses. It deliberately avoids mention of inappropriate uses and what to do about them.]|
|21.2||Nationally recognized accrediting bodies of health care organizations and facilities should consider increasing on-going access to CAM expertise to ensure that processes to develop accreditation standards and interpretations reflect emerging developments in the health care field. [Credentialing standards should be the same for everyone. They should not be lowered because they label their practices as "CAM." This recommendation falsely assumes that "CAM" advocates are producing significant new developments.]|
|N.||Nationally recognized accrediting bodies, using CAM experts, should review and evaluate current standards and guidelines to ensure the safe use of CAM practices and products in health care delivery organizations. [This falsely assumes that there are many safe "CAM" practices and products. As usual, it also fails to call for review intended to exclude unsafe and ineffective modalities.]|
Community Health Centers, Hospices, Independent Centers
and Other Programs
A growing number of Americans use community health centers and other public health programs to meet their health care needs, including help with mental health and substance abuse treatment. These centers and programs often emphasize patient-centered care. A few community health centers have begun to use the services of CAM practitioners such as chiropractors, naturopathic physicians and acupuncturists. These centers might serve as models for the use of CAM practitioners by other community health centers and other public health service programs; however, they need to be evaluated to determine their impact on health care access and cost-benefits. [This appears to assume that close evaluation will be favorable.]
Hospice care for the terminally ill is another important model
that should be evaluated further. Some hospice programs are beginning
to include CAM practitioners on the treatment team. Some of the
CAM practices they use are chiropractic, acupuncture, music therapy,
meditation, and visualization. In some instances, these services
are believed to help reduce anxiety and pain.
Some independent CAM centers, which may not have any direct hospital affiliation and may not have a physician on staff, also offer a variety of CAM services. These centers tend to be client-oriented with flexible hours and a broad spectrum of practitioners available. Many of the centers encourage patients to actively improve their health and concentrate on health maintenance rather than disease care and encourage coordination and collaboration among CAM practitioners who are seeing the same patient or client. More information is needed on who uses these centers, their impact on access and delivery, whether appropriate referral procedures are in place, and the quality of care provided. Only when more systematic data are available can the advantages and disadvantages of independent CAM centers be assessed. [This falsely assumes that most of the "independent CAM centers" offer appropriate treatment.]
Special and Vulnerable Populations
Special populations, such as racial and ethnic minorities, and vulnerable populations, such as the chronically and terminally ill, have unique challenges and needs regarding access to CAM. Efforts to address access to CAM need to be balanced with the need for access to conventional health care. Scarce resources need to be carefully allocated so that these populations are not denied opportunities available to others to access safe and effective conventional and CAM services. [This falsely assumes that minority groups and chronically and termianlly ill people are suffering from a lack of access to "CAM." The biggest barrier to "CAM" use is not access but lack of scientific evidence of effectiveness.]
Increased information on CAM use and barriers to access for these populations is needed. Although some studies have described CAM use among African Americans, Native Americans, Hispanics, and Asian Americans, reliable access and utilization data are largely lacking. In the case of Native Americans, information gathering is limited by their status as sovereign nations. Nonetheless, the Indian Health Service has a program to encourage communication with practitioners of traditional Indian medicine, which will help ensure safety when both Native American and conventional medical systems are used.
Surveys of CAM use in the general population indicate that it is being used disproportionately by highly educated, and upper-income Americans . [That's because upper-income Americans have more money that they can afford to waste.] However, early studies used telephone interviews with English speakers, thus providing little information about CAM use among those who do not speak or have limited ability in English, who have lower income, or who lack telephones [5.]. Later studies corrected for these biases, but they did not use adequate statistical sampling to estimate the use of CAM in minority populations [6-11]. Other surveys have focused on low-income and ethnic groups, but these studies frequently had small, unrepresentative samples 12-15]. The National Center for Health Statistics is conducting a nationwide survey on access to and use of CAM among racial and ethnic minorities that is expected to provide statistically reliable estimates of CAM use in these groups.
In an October 2000 letter to community health centers and other public health programs, the Health Resources and Services Administration's Bureau of Primary Health Care (BPHC) endorsed the use of CAM in these centers where appropriate . In 2001 they began surveying the use of CAM by persons receiving health services from BPHC-funded community health centers. Information being gathered includes participants' use of six modalities (acupuncture, manual healing, botanicals and herbs, homeopathy, traditional healing, and mind-body techniques); whether the CAM service was provided onsite or by referral, either with or without payment by the community health center; and demographic data. Results should be available in 2002 and will provide a significant, statistically reliable portrait of the use of a variety of CAM services and products by community health center clients, whose come disproportionately from rural, low-income, and minority populations. It is important to continue collecting this kind of information in the future. [Knowing the extent of use will provide no indication of what might be needed, because no data exist to determine whether adding "CAM" practices is beneficial and more important than increasing standard practices.]
Discussions are currently underway between BPHC and the National Center for Complementary and Alternative Medicine to include clients of community health centers in CAM clinical trials, in order to increase the relevance of findings for application to the health needs of minority populations.
Use of CAM is especially high among populations with potentially life-threatening diseases. Surveys show that people with cancer use CAM practices and products more frequently than the population as a whole, with CAM most often being used in conjunction with conventional therapies [17-19]. Similarly, there is high use of CAM by people who are terminally ill and their caretakers. Many people in these vulnerable populations are using CAM services regardless of whether they have insurance coverage and sometimes without the knowledge or cooperation of their conventional physician.
The chronically and terminally ill consume more health care resources than the rest of the population. Approximately 75 percent of all health care spending in the U.S. currently is for the treatment of chronic disease , and 25 percent of Medicare spending is for costs incurred during the last year of life . The great interest in CAM practices among the chronically ill, those with life-threatening conditions, and those at the end of their lives suggests that increased access to some CAM services among these groups could have significant implications for the health care system [This implies that many chronically and terminally ill people would bebefit from availability of unspecified "CAM" practices. Health services research, demonstrations, and evaluations are needed to assess whether CAM services can improve care and quality of life for people in these groups, and possibly lessen the use of expensive technological interventions. [Research of this type should not be done unless it appears likely to have a significant practical effect.]
With the number of older Americans expected to increase dramatically over the next 20 years, alternative strategies for dealing with end-of-life processes will be increasingly important in public policy. This demographic shift should influence priorities for the kinds of research and demonstration projects that would be carried out in the near future. A more careful assessment of the potential and limitations of CAM approaches in the health care system as a whole might lead to more effective use of resources. For example, Congress could direct the Center for Medicare and Medicaid Services to develop a demonstration project to study evidence-based CAM interventions as part of comprehensive care of persons with chronic disease in both the Medicare and Medicaid programs. [This falsely assumes that such research would find substantia benefit.] The demonstrations would assess health outcomes and total costs of care for beneficiaries in settings where physician leaders are committed to evidence-based medicine, high quality, client-centered care, and openness to CAM approaches. If evaluations show that some uses of CAM can lessen the need for more expensive conventional care in these populations, the economic implications for these Medicare and Medicaid could be significant. [This falsely assumes that this is the likely outome.]
If safe and effective CAM practices become more available to the general population, special and vulnerable populations should also have access to these services, along with conventional healthcare. CAM would not be a replacement for conventional health care, but would be part of the options available for treatment. In some cases, CAM practices may be an equal or superior option. [This falsely assumes that safe and effect "CAM" practices are abundant.]
Evidence for assessing the potential of CAM interventions in treating vulnerable and special populations is still being gathered. While it is too early to judge the effectiveness of CAM in addressing their health care needs, CAM nonetheless offers the possibility of a new paradigm of integrated health care that could affect the affordability, accessibility, and delivery of health care services for millions of Americans. [This paragraph is wishful thinking.]
Recommendation 22: The Federal government should facilitate and support the evaluation and implementation of safe and effective CAM practices to help meet the health care needs of special and vulnerable populations.
|22.1||The Department of Health and Human Services and other Federal Departments should identify models of health care delivery that include safe and effective CAM practices, evaluate them, and then support those models which are successful for use with special and vulnerable populations, including the chronically and terminally ill. [This repeats the false assumtpion that many such "CAM" methods exist.]|
|22.2||The Department of Health and Human Services should sponsor the development and evaluation of demonstration projects that integrate the use of safe and effective CAM services as part of the health care programs in hospices and community health centers. [This repeats the false assumtpion that many such "CAM" methods exist.]|
|22.3||The Department of Health and Human Services should identify ways to support the practice of indigenous healing in the United States and to improve communication among indigenous healers, conventional health care professionals, and CAM practitioners. [This falsely assumes that there are many safe and effective indigenous healing practices.]|