The White House released an official statement confirming denial of all Medicare reimbursements for acupuncture services by licensed acupuncturists. This is the official response to the White House We The People website petition, which garnered over 30,000 signatures. The citizen petition requested that acupuncture be included in the Medicare system and notes, “Studies have shown that when an Acupuncturist is directly involved in patient care for pain management and other issues, the patient recovers quicker with less medication required.” The petition to the Obama Administration specifically requests that acupuncturists become recognized as health care providers.
In 2010, President Barak Obama commented that “it is pretty well documented through scientific studies that acupuncture, for example, can be very helpful in relieving certain things like migraines and other ailments — or at least as effective as more intrusive interventions.” However, there is no national legislation to support licensed acupuncturists in the Medicare system and the Centers for Medicare & Medicaid Services (CMS) is relying on antiquated research to block acupuncture from the Medicare system.
The Principle Deputy Administrator at the CMS, Jonathan Blum, gives a detailed account on the exclusion of acupuncturists from the Social Security Act and Medicare system in the official White House response. Blum outlines obstacles to providing acupuncture care within the Medicare system. The first two obstacles are largely legislative issues. He notes that acupuncturists are not defined as “providers” in Medicare regulations. Further, Blum cites that the Social Security Act does not include licensed acupuncturists as “physicians” in the Medicare system. There is another more serious obstacle to acupuncture access within the Medicare system that is generated by the CMS.
Blum writes that non-coverage of acupuncture in the Medicare system is based on three CMS National Coverage Determinations (NCDs). Blum notes that NCDs are developed by the CMS as required by law. These are national policies created within the federal bureaucracy that determine rules and guidelines for Medicare coverage. He notes that all three NCDs that have been made regarding acupuncture have denied coverage. On that basis, Blum notes that acupuncture is excluded from Medicare reimbursement.
Three NCDs are responsible for refusing acupuncture reimbursement for the treatment of nausea after chemotherapy and post-operative pain, fibromyalgia and osteoarthritis. The CMS notes in the NCDs that, “Until the pending scientific assessment of the technique has been completed and its efficacy has been established, Medicare reimbursement for acupuncture, as an anesthetic or as an analgesic or for other therapeutic purposes, may not be made.”
A major study demonstrating the efficacy of acupuncture for the treatment of post-operative nausea and vomiting was recently published. The sheer volume of quality research that has been released within the last two years demonstrating the specific benefits of acupuncture care supports a change in the NCDs but the timeframe for NCD public input expired years ago. As a result, the CMS NCDs prevent any acupuncture coverage on a case by case basis.
Taking a look at the CMS NCD determination, one discovers that exclusion of acupuncture from Medicare is partially due to timing. Lead analyst Joyce Eng of the CMS put a formal request for more information on acupuncture for the treatment of nausea after chemotherapy and for post-operative pain on June 5, 2000. The official process was closed on November 1, 2000 with the following response, “We have closed the acupuncture item for the time being because we did not receive any evidence in response to our request. However, we are open to reopening the item if additional information is submitted.” The total time for public comment allotted was from July 2000 to August 2000. This short window of time opened and closed long before the bulk of advanced research supportive of acupuncture care for the treatment of nausea after chemotherapy and for post-operative pain emerged.
New research has been completed and accepted in peer reviewed journals This suggests that the CMS revisits the NCDs.A recent meta-analysis (The Effectiveness of Acupuncture in Prevention and Treatment of Postoperative Nausea and Vomiting-A Systematic Review and Meta-Analysis) of 30 randomly controlled trials confirms that acupuncture at acupoint PC6 is successful in reducing postoperative nausea and vomiting. A total of 186 studies were initially investigated. Sorting was performed to include quality trials and exclusion criteria. A total of 30 studies met the final inclusion criteria for meta-analysis. The researchers concluded that acupuncture is effective and appropriate for the treatment of postoperative nausea and vomiting.
Another recent study concludes that acupuncture helps patients receiving chemotherapy for the treatment of ovarian cancer. A massive study of over 20,000 patients was conducted by top researchers from the Harvard Medical School, Massachusetts General Hospital, Boston; The New England School of Acupuncture, Newton; and the Dana-Farber Cancer Institute. The researchers discovered that social function scores significantly improved in the acupuncture group. The investigation was initially presented to The Society for Integrative Oncology's 6th International Conference in New York City.
One important feature of the study is the large sample size. Other important features of the study were that it was a randomized sham-controlled trial. The acupuncture results were tabulated against a control group that received sham-simulated acupuncture. The true acupuncture group social function scores were significantly better than the sham group thereby ruling out the placebo effect. Based on this and other recent studies, it is advisable that the CMS revise its NCDs.
NCDs are powerful documents. A 2004 NCD blocking acupuncture Medicare coverage for the treatment of fibromyalgia and osteoarthritis notes, “The NCDs are binding on all carriers, fiscal intermediaries, quality improvement organizations, health maintenance organizations, competitive medical plans, and health care prepayment plans. Under 42 CFR 422.256(b), an NCD that expands coverage is also binding on a Medicare+Choice Organizations. In addition, an administrative law judge may not review an NCD. ” NCDs block acupuncture from the Medicare system with no possibility of judicial review.
The CMS NCD process regarding acupuncture for the treatment of osteoarthritis was initiated in 2002 and included a public comment period of one month in January 2003. A decision memorandum was posted in October 2003. This was based on the two accepted studies for review: United Kingdom National Health Service (NHS) Center for Reviews and Dissemination: Effective Health Care on Acupuncture (2001) and Alberta Heritage Foundation for Medical Research (AHFMR) Health Technology Assessment of Acupuncture: Evidence from Systematic Reviews and meta-analyses (2002). Based on these studies, more studies were recommended. Only two public comments were submitted.
Expert opinions reported in the memorandum from individual physicians were supportive. The CMS NCD memorandum quotes a letter from a diplomat of the American Board of Medical Acupuncture, “…My experience with both of these conditions [fibromyalgia and osteoarthritis] is that, while acupuncture cannot cure either condition, it may cause significant improvement in the symptoms if used on a regular basis.” The Vice President of Clinical Operations and MD at a community medical center wrote, “… I practice acupuncture and find it very beneficial for osteoarthritis of the back, knee and shoulder in particular. Patients who undergo treatment utilize less medications, which put their GI tract and kidney function at risk. I believe that acupuncture should be a covered benefit for Medicare participants who suffer from osteoarthritis….” These personal accounts from physicians and the two public comments did not sway the CMS towards acupuncture inclusion in the system. However, the CMS carefully documented grants for future studies in the NCD memorandum and indicated a need for reviewing additional data.
Since that time, a 2012 study entitled Needle Acupuncture for Osteoarthritis of the Knee, A Systematic Review and Updated Meta-analysis concludes that acupuncture is more effective than sham acupuncture and conventional biomedicine for the treatment of knee pain. This meta-analysis of 14 random controlled clinical trials involving 3,835 patients states, “Acupuncture provided significantly better relief from knee osteoarthritis pain and a larger improvement in function than sham acupuncture, standard care treatment, or waiting for further treatment.” The study notes that acupuncture for the treatment of knee osteoarthritis is “better at relieving pain and restoring function” than both standard biomedical care and sham acupuncture.
A 2011 study entitled Serotonin Receptor 2A/C Is Involved in Electroacupuncture Inhibition of Pain in an Osteoarthritis Rat Model also addresses the additional data requirements of the CMS NCD. This National Institutes of Health (NIH) funded study concludes that electroacupuncture, “inhibits osteoarthritis-induced pain by enhancing 5-HT2A/2C [serotonin] receptor activity.” Activation of this serotonin receptor produces powerful anti-inflammatory effects. Researchers from the University of Maryland in Baltimore, Maryland; and Shanxi Medical University in Shanxi, China; showed that electroacupuncture attenuates osteoarthritis pain by activating serotonin receptors that, “play an important role in pain modulation at the spinal level.” The researchers also discovered that electroacupuncture activates serotonergic neurons that project into the spinal cord.
The results were tabulated and true acupuncture was found superior in comparison to a sham acupuncture control group. Electroacupuncture was shown to activate serotonin receptors, improve weight bearing, reduce pain and improve joint function. The researchers note that electroacupuncture, “activated serotonergic neurons… which sends serotonergic descending fibers to the spinal cord to modulate pain…. EA [Electroacupuncture] activates different areas in the brain that, in turn, modulate various functions.” The researchers concluded that electroacupuncture has the ability to, “induce spinal serotonin release and stimulate 5-HT2A/2c [serotonin] receptor activities at the spinal cord to inhibit osteoarthritis-induced pain.”
Many individualized studies measure the synergistic effects of acupuncture combined with conventional biomedicine. A recent study entitled Acupuncture for Osteoarthritis of the Knee concludes that acupuncture benefits patients with osteoarthritis of the knee. In this single-blinded, randomized, sham-controlled study conducted at the Department of Orthopedics at the Tel Aviv Medical Center in Israel, researchers examined 41 patients over 45 years of age who suffered from osteoarthritis of the knee accompanied by moderate to severe pain. Participants received either verum acupuncture or sham acupuncture twice a week for 8 weeks in addition to standard therapeutic care. On week 12 (a 4 week follow-up after treatment), researchers tabulated the results and concluded that, "Adjunctive acupuncture treatment seems to provide added improvement to standard care in elderly patients with OA (osteoarthritis) of the knee.”
One issue published in the CMS NCD memorandum was a need to clarify standard acupuncture protocols. Since the time of the memorandum, a significant body of research has addressed that issued to determine the most effective acupuncture treatment techniques, prescriptions and protocols. A 2012 study entitled Comparison of the Clinical Therapeutic Effects Between Electroacupuncture and Warming Needle Moxibustion for Knee Osteoarthritis of Kidney Deficiency and Marrow Insufficiency Pattern/Syndrome compared the effectiveness of electroacupuncture with warming needle acupuncture technique for the treatment of knee osteoarthritis for patients with kidney deficiency. A total of 74 cases were randomly divided into electroacupuncture and warming needle moxibustion groups. Local acupuncture points in the knee region were chosen for the study. This included acupoints ST35 (Dubi), Xiyan, SP10 (Xuehai), ST36 (Zusanli), GB34 (Yanglingquan) and others. In the electroacupuncture group, stimulation was applied with a 5 Hz continuous wave. For the warming needle moxibustion group, two moxa rolls were applied at each acupuncture point during every treatment. Acupuncture treatments were administered at a rate of three acupuncture treatments per week over a period of four weeks.
Over sixty-four percent of the electroacupuncture group received a score from markedly effective to completely cured. Forty percent of the warming needle moxibustion group received a score ranging from markedly effective to completely cured. The electroacupuncture group received a higher score for the relief of joint pain. The acupuncture with moxibustion group received higher scores for the relief of joint stiffness. The researchers concluded that each technique has specific advantages and noted that, “The total efficacy of electroacupuncture is superior to that of the warming needle moxibustion.”
In yet another study of the mechanisms of acupuncture (In Adjuvant-Induced Arthritic Rats, Acupuncture Analgesic Effects Are Histamine Dependent: Potential Reasons for Acupoint Preference in Clinical Practice), researchers find that acupuncture’s effectiveness for the relief of arthritis pain is dependent on acupuncture’s ability to stimulate histamines at the needling site. In a laboratory experiment, an injection of a histamine antagonist prior to acupuncture needling reduced the effectiveness of acupuncture’s ability to eliminate pain. This is one of numerous studies measuring the benefits of acupuncture for the relief of arthritis. The technology measuring the biological effective actions of acupuncture for pain relief include PET-CT, fMRI, Western Blot analysis and other modern techniques.
New research supporting acupuncture for the relief of medical conditions is not limited to osteoarthritis or the treatment of postoperative and chemotherapy related nausea and vomiting. New research published in Clinical Rheumatology concludes that acupuncture is effective for the treatment of fibromyalgia (FMS). Researchers concluded that acupuncture provides “beneficial effects” for the treatment of fibromyalgia in this 2012 study entitled: An overview of systematic reviews of complementary and alternative medicine for fibromyalgia. In a 2006 study published by the Department of Anesthesiology at the Mayo Clinic College of Medicine in Rochester, Minnesota, (Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial) researchers conclude, “We found that acupuncture significantly improved symptoms of fibromyalgia. Symptomatic improvement was not restricted to pain relief and was most significant for fatigue and anxiety.” This type of research also suggests that the CMS revise the NCD to support acupuncture as both safe and effective.
A related issue is that licensed acupuncturists are not listed as a profession by the US Dept. of Labor’s Bureau of Labor and Statistics. The NCCAOM (National Certification Commission for Acupuncture and Oriental Medicine) has worked with the CCAOM (Council of Colleges for Acupuncture and Oriental Medicine), AAAOM (American Association for Acupuncture and Oriental Medicine), FAOMRA (Federation of Acupuncture and Oriental Medicine Regulatory Agencies), ACAOM (Accreditation Commission for Acupuncture and Oriental Medicine) and the NAF (National Acupuncture Foundation) to have the acupuncturist profession listed. Currently, acupuncture is only listed as a treatment modality technique under the professions of nursing and chiropractic. This clerical issue blocks access to acupuncture. Inclusion will facilitate improvements with insurance reimbursements and contribute to the institution of Medicare coverage for acupuncture services.
As part of the acupuncture continuing education process, the Healthcare Medicine Institute (HealthCMi) has reported on major advances in research regarding acupuncture. This includes individual primary studies, meta-analyses secondary studies and basic research. There has been the publication of thousands of quality studies within the last two years. Many of these studies address the concerns of the CMS expressed in the NCDs. A call for a greater scientific understanding of acupuncture emerged as an underlying theme. This goes, in part, to the issue of basic research.
Basic research has recently verified the existence of acupuncture points. CT scans reveal anatomical structures of acupuncture points. This new finding demonstrates the physical existence of acupuncture points. A CT (computerized tomography) scan is a series of X-rays. In a study published in the Journal of Electron Spectroscopy and Related Phenomena (CT imaging of the acupoints based on synchrotron radiation), researchers used CT imaging with synchrotron radiation on both non-acupuncture points and acupuncture points. The CT scans revealed clear distinctions between the non-acupuncture point and acupuncture point anatomical structures. Acupuncture points have a higher density of micro-vessels and contain a large amount of involuted microvascular structures. Another study demonstrated that acupuncture points of the forearm are scientifically measurable because they have higher partial oxygen pressure than other areas (Heterogeneity of Skin Surface Oxygen Level of Wrist in Relation to Acupuncture Point). Acupuncture points can be identified, located and measured with amperometric oxygen microsensors.
Individual studies have found significant evidence that acupuncture is beneficial for specific conditions. Dr. L.C. Giudice, MD, PhD cited acupuncture as effective for the treatment of endometriosis related pain in the New England Journal of Medicine (NEJM). Dr. Giudice cited a randomized sham-controlled trial of women suffering from endometriosis pain. The study concluded that acupuncture definitively and significantly reduces endometriosis related pain. In another randomized controlled blinded trial confirmed by laparoscopy, researchers determined that both acupuncture and Chinese herbal medicine are effective for the relief of endometriosis pain.
Many studies have discovered that acupuncture is more effective than conventional methods of care. New research finds acupuncture more effective than medications for the treatment of a sty (hordeolum), a red lump near the edge of the eyelid. A total of 102 sty patients participated in the study. They were randomized into two separate groups. Group 1 received acupuncture and group 2 was given local applications of the antibiotics levofloxacin and erythromycin. Comparisons were made in pain reduction and swelling size reduction. On day 7, the acupuncture group demonstrated a 94.1% improvement and the medication group showed an 80.4% improvement. The researchers concluded that the data showed that acupuncture is effective for the relief of pain, reduction of sty size and acupuncture shortens the duration of the disease.
The biochemical mechanisms of acupuncture and its effects on the body have been measured in an enormous body of evidence. There is no shortage of laboratory experiments in this regard. A new laboratory experiment reveals that acupuncture regulates steroid hormones to reduce biochemical reactions to stress. Western blot analysis confirms that acupuncture reduces stress by regulating glucocorticoid receptor (GR) protein expression. Acupuncture simultaneously upregulates GR protein expression in the hippocampus, hypothalamic paraventricular nucleus (PVN) and pituitary gland while decreasing expression in the adrenal cortex when laboratory rats are exposed to stress. The researchers note that acupuncture balances bodily biochemistry in this dual-directional manner.
Sometimes the most interesting studies are simple investigations of everyday disorders. Researchers conclude that acupuncture effectively reduces frozen shoulder pain and restores functionality. All patients in the study suffered from shoulder periarthritis resulting in adhesive capsulitis. Two types of acupuncture were compared. Local acupuncture points scored a 71.8% effective rate and abdominal style acupuncture scored a 92.4% effective rate. The researchers concluded that acupuncture relieves frozen shoulder pain and improves shoulder functional ability.
President Obama On Migraines
In a 2010 town hall meeting in St. Louis, Missouri, President Barak Obama commented that “it is pretty well documented through scientific studies that acupuncture, for example, can be very helpful in relieving certain things like migraines and other ailments — or at least as effective as more intrusive interventions.” He also discussed the challenges of integrating preventative medicine into policy making noting that the Secretary of Health and Human Services, Kathleen Sebelius, former governor of Kansas; is charged with the task of implementing effective healthcare solutions. Recently, Dr. Molsberger, MD, of the Canadian Medical Association wrote “acupuncture is more effective than no acupuncture” and is at the very least “as effective as a B-blocker (beta blocker)” for the treatment of migraines. He reports that acupuncture is “effective and safe” as supported by evidence based medicine. The research notes that acupuncture is “more effective than flunarizine in decreasing the duration of migraine attacks.” He presented studies showing the efficacy of acupuncture for the treatment of headaches, arthritis, lower back pain and shoulder pain.
Dr. Molsberger’s report is not without controversy. He cited a study showing that true acupuncture and sham acupuncture are both effective in the treatment of migraines in the short term. However, the same study also notes that true acupuncture is more effective measured 8 weeks after the acupuncture treatment.
New research confirms that acupuncture reduces pain levels. Investigators discovered that electroacupuncture decreases pain by regulating the expression of several proteins in the hypothalamus, a part of the brain responsible for autonomic nervous system, endocrine and limbic system functions. A total of 17 hypothalmic proteins demonstrated significant changes as a result of electroacupuncture stimulation for the treatment of pain.
Another study focusing on acupuncture’s ability to reduce carpal tunnel pain discovered a brain pathway by which acupuncture exerts its therapeutic results. The researchers measured brain responses to neuropathic pain using fMRI technology. Acupuncture caused significant activation of the hypothalamus and greater deactivation of the amygdala. The researchers concluded that acupuncture benefits chronic pain sufferers “through a coordinated limbic network including the hypothalamus and amygdala.”
Similar findings show that acupuncture regulates the hypothalamus-pituitary-adrenal-axis. Researchers discovered that the application of electroacupuncture to acupoint ST36 reduces the production of stress induced hormones via this cortical pathway. Acupuncture prevented sympathetic nervous system elevations via the NPY pathway and also prevented elevations in ACTH and CORT.
Technology and medical research moves at a glaring pace. As a reference point, the iPhone was introduced in January 2007. Chip technology and industrial standards have changed quite a bit since then. The Tesla electric car is a great example. Car manufacturing standards have been revolutionized. The same is true for acupuncture research. Updated PET-CTs, fMRIs, Western blot analyses and other techniques have established the safety and efficacy of acupuncture in numerous recent studies. The last CMS NCD update for acupuncture was in 2004. That was the same year Apple introduced the iPod mini and the first flat screen iMac. It is time to revisit the acupuncture research and acknowledge the positive clinical outcomes and cost effectiveness of acupuncture care by licensed acupuncturists.
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