Acupuncture Insurance in

North Carolina

Chris Helmstetter, L.Ac.Director of Government Affairs

North Carolina Association of Acupuncture and Oriental Medicine

The North Carolina Association of Acupuncture and Oriental Medicine, Inc., is a not-for-profit, professional organization of Licensed Acupuncturists, Oriental Medicine practitioners, related students and other interested parties

throughout the state of North Carolina.

Licensed Acupuncturists (L.Ac.)● Highly trained professionals, licensed nationally and by state licensing boards

● Complete a four year masters degree at acupuncture colleges accredited by the Accreditation Association for Acupuncture and Oriental medicine (ACAOM) and the Department of Education (1)

● National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) oversees the national exam, which involves 3 days of testing to demonstrate competency in Foundations of Oriental Medicine, Acupuncture and Biomedicine. Passing score results in Diplomate of Acupuncture.

● North Carolina Acupuncture Licensing Board (NCALB) requires transcripts from an accredited acupuncture college, passing grade of 70% or higher on the NCCAOM exam and:

○ Successful completion of Clean Needle Technique course ○ 40 CEUs every two years

● Strict standards of education and accreditation are essential to the practice of acupuncture to ensure public safety

● One of the fastest growing medical professions in the country

Why are so many Americans using Acupuncture?

- Effective for a variety of conditions from allergies to chemotherapy side effects to low back pain to fibromyalgia

- Can treat multiple conditions at the same time, no need to schedule appointments with multiple specialists (common practice to treat a patient’s knee pain and low back pain during the same treatment)

- Almost no side effects

- Promotes decreased use of opioids and narcotics for pain conditions

- L.Ac. spends 45 to 90 minutes with each patient

- Lower cost compared to other treatment options

Complementary and Alternative Medicine Use Among Adults and Children:

United States, 2007 (2)

This report presents selected estimates of complementary and alternative medicine (CAM) use among U.S. adults and children, using data from the 2007 National Health Interview Survey (NHIS), conducted by the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS). Trends in adult use were assessed by comparing data from the 2007 and 2002 NHIS.

Results—In 2007, almost 4 out of 10 adults had used CAM therapy in the past 12 months,

From the 2007 NHIS found that approximately one in nine children (11.8%) used CAM therapy in the past 12 months,

Between 2002 and 2007 increased use was seen among adults for acupuncture, deep breathing exercises, massage therapy, meditation, naturopathy, and yoga.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention

National Center for Health Statistics

Use of Complementary and Alternative Medicine (CAM) is on the rise

- Almost 40% of Americans used CAM within the past 12 months (2)

- Consumers spent $33.9 billion on CAM practitioners, products and classes

- The number of visits to acupuncturists between 2002 and 2007 rose 32%

- Acupuncture is considered one of the fastest growing CAM professions nationwide

The most common conditions consumers used acupuncture to treat were back pain, neck pain, joint pain, arthritis and fibromyalgia. (2)

Consumers are willing to pay out-of-pocket for acupuncture because it works. But what exactly is it most effective in treating?

Khusid MA. Clinical indications for acupuncture in chronic post-traumatic headache management. Mil Med. 2015; 2014;180:132-136.

- “shows that acupuncture is at least as effective as drug therapy for migraine prophylaxis and neurovascular and tension-type headaches” (3)

Witt C. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. Obstet Gynecol. 2008;198:166.e1-166.e8.

- “acupuncture in patients with dysmenorrhea was associated with improvements in pain and quality of life as compared to treatment with usual care alone and was cost-effective within usual thresholds” (4)

Haake M, Müller H, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for Chronic Low Back Pain. Arch Intern Med. 2007;167:1892.

- “Low back pain improved after acupuncture treatment for at least 6 months. Effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy.” (5)

Walker EM., Rodriquez Al, et al. Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial. J Clin Oncol. 2010 Feb 1;28(4):634-40.

- “ The venlafaxine group experienced 18 incidences of adverse effects (eg, nausea, dry mouth, dizziness, anxiety), whereas the acupuncture group experienced no negative adverse effects.” (6)

● Thermograms detect inflammation and pain (7)

● Inflamed regions appear red, orange, or yellow

● Over five minutes the acupuncture needles were effective at reducing the inflammation and pain

Physiological Effects of Acupuncture

More recently, meta-analysis of all studies on each condition gives higher degrees of confidence for what acupuncture is known to effectively treat.

- only randomly controlled trials included- significantly higher number of patients analyzed

Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Arch Intern Med. 2012;172(19):1444-1453. (8)

“Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain.”

“Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs, with a total of 17,922 patients analyzed.”

“Results: In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition “

“Conclusions: Acupuncture is effective for the treatment of chronic pain”

Parallel Trend in cost effectiveness studies as more and more insurance carriers wanted supporting evidence for effectiveness and cost efficiency. (9)

Ambrósio EMM, Bloor K, MacPherson H. Costs and consequences of acupuncture as a treatment for chronic pain: A systematic review of economic evaluations conducted alongside randomised controlled trials. Complement Ther Med. 2012;20:364-374. (10)

“The economic burden that chronic pain conditions impose on individuals and society is significant. Acupuncture appears to be a clinically effective treatment for some chronic pain conditions. Given the need for policy decisions to be informed by economic evaluations, the objective of this systematic review was to synthesise data from economic evaluations to determine whether acupuncture for the treatment of chronic pain conditions is good value for money.”

“Conditions treated included low back pain, neck pain, dysmenorrhoea, migraine and headache, and osteoarthritis. From the seven cost-utility analyses, acupuncture was found to be clinically effective”

“The cost per QALY gained in all seven cost-utility studies was found to be below typical thresholds of willingness to pay. Acupuncture appears to be a cost-effective intervention for some chronic pain conditions.”

Meta-analyis of cost effectiveness studies shows high degrees of confidence that acupuncture is a lower cost option for effective treatment

for specific conditions

Further analysis of cost effective studies show the optimization of acupuncture in states incorporating acupuncture into state wide insurance coverage

Comparison of Health Care Expenditures Among Insured Users and Nonusersof Complementary and Alternative Medicine in Washington State: A Cost Minimization Analysis (11)

The purpose of this analysis was to compare health care expenditures between insured patients with back pain, fibromyalgia syndrome, or menopause symptoms who used complementary and alternative medical (CAM) providers for some of their care to a matched group of patients who did not use any CAM care. Insurance coverage was equivalent for both conventional and CAM providers.

Results: Both unadjusted tests and linear regression models indicated that CAM users had lower average expenditures than nonusers. (Unadjusted: $3,797 versus $4,153, p1⁄40.0001; b from linear regression -$367 for CAM users.) CAM users had higher outpatient expenditures which were offset by lower inpatient and imaging expenditures. The largest difference was seen in the patients with the heaviest disease burdens among whom CAM users averaged $1,420 less than nonusers, p < 0.0001, which more than offset slightly higher average expenditures of $158 among CAM users with lower disease burdens.

Conclusions: This analysis indicates that among insured patients with back pain, fibromyalgia, and menopause symptoms, after minimizing selection bias by matching patients who use CAM providers to those who do not, those who use CAM will have lower insurance expenditures than those who do not use CAM.

All 3 independent analyses of consumer use, clinical effectiveness and cost utility show acupuncture to be a desired, cost effective treatment that yields exceptional

results treating:

- low back pain

- neck pain

- osteoarthritis

- migraines and tension headaches

- dysmennorhea

- side effects of chemo therapy

- fibromyalgia

S

States that now provide insurance coverage of acupuncture to state employees include:

Alaska Louisianna Ohio

Arizona Maryland Oregon

California Massachusettes Pennsylvania

Connecticut Michigan New Jersey

Florida Minnesota New Mexico

Iowa Montana New York

Illinois Nevada Vermont

Currently North Carolina has several insurance carriers that offer acupuncture as a covered benefit:

- United Health Care (10-20 acupuncture treatments per year)

- Aetna (20-24 acupuncture treatments per year)

Along with many group plans that include acupuncture benefits for large companies in NC.

- SAS - The Home Depot - Costco

- Mission Hospitals - The Cheesecake Factory - REI

- Qualcomm - Oracle - USB

- Town of Holly Springs - GlaxoSmithKline - Raytheon

And one of the largest supporters for the use of acupuncture is the Veterans Administration

- VA hosptials in NC pay for veterns to receive 18 - 54 acupuncture treatments per year for chronic pain conditions (12)

- VA studies find that acupuncture not only successfully treats chronic pain, but is also an important tool to decrease dependence on narcotic and opiod use amongst the chronic pain population

- Led the Joint Commission to revise their Pain Management Standard to include non-pharmacological strategies such as acupuncture for all veterans

The State Employees Association of North Carolina has a Policy Platform Objective supporting acupuncture for medical conditions when shown to be therapeutically effective,

especially for certain proven conditions

Their members and Association as a whole want acupuncture to be a covered benefit

“Acupuncture has been a tremendous benefit to our family. It allowed me to successfully treat my migraines and stop all the medications I was using for them. And this year my husband had two surgeries on his feet. Acupuncture after his surgery allowed him to not rely on pain killers and heal quickly. We saved a lot of money in medical expenses and not missing time

from work. And his doctors were amazed at how fast his recovery was. Can you please include acupuncture in the state health plan!?! It has helped us so much and I know other

state employees would benefit from it as well.”

Kim B.

Acupuncture works,

Acupuncture is a cost effective treatment,

Many North Carolinians receive acupuncture benefits currently,

And North Carolina State Employees want coverage of acupuncture in the NC State Employees Health Plan.

References (abstracts included)1. National Certification Commission for Acupuncture and Oriental Medicine website. Diplomate of Acupuncture. http://www.nccaom.org/consumers/acupuncture-certification

2. Patricia M. Barnes, M.A., and Barbara Bloom, M.P.A. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. Division of Health Interview Statistics, National Center for Health Statistics, National Center for Complementary and Alternative Medicine, National Institutes of Health

3. Khusid MA. Clinical indications for acupuncture in chronic post-traumatic headache management. Mil Med. 2015; 2014;180:132-136.Abstract: Chronic post-traumatic headache (PTH) is one of the most common complaints after mild traumatic brain injury, yet evidence to date is insufficient to direct conventional treatment of headaches with this etiology. Therefore, the current guidelines recommend a symptomatic approach for the three patterns of PTHs: migraine-like, tension-like, and mixed symptomatology. To improve response rates and minimize the potential for polypharmacy, adverse effects, and risk of dependency, effective nonpharmacologic options should be employed to support faster and safer patient rehabilitation. Current evidence shows that acupuncture is at least as effective as drug therapy for migraine prophylaxis and neurovascular and tension-type headaches. Because of its safety, cost-effectiveness, and long-lasting benefits, adjunctive acupuncture should be offered to patients with chronic PTHs and may be a valuable primary treatment alternative for those with contraindications to pharmacotherapy. Future head-to-head, adequately powered, well-controlled randomized clinical trials are needed to investigate acupuncture efficacy for PTHs.

4.Witt C. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. Obstet Gynecol. 2008;198:166.e1-166.e8.Abstract: Objective: To investigate the clinical effectiveness and cost-effectiveness of acupuncture in patients with dysmenorrhea.Study Design: In a randomized controlled trial plus non-randomized cohort, patients with dysmenorrhea were randomized to acupuncture (15 sessions over three months) or to a control group (no acupuncture). Patients who declined randomization received acupuncture treatment. All subjects were allowed to receive usual medical care.Results: Of 649 women (mean age 36.1 ± 7.1 years), 201 were randomized. After three months, the average pain intensity (NRS 0-10) was lower in the acupuncture compared to the control group: 3.1 (95% CI 2.7; 3.6) vs. 5.4 (4.9; 5.9), difference −2.3 (−2.9; −1.6); P<.001. The acupuncture group had better quality of life and higher costs. (overall ICER €3,011 per QALY).Conclusion: Additional acupuncture in patients with dysmenorrhea was associated with improvements in pain and quality of life as compared to treatment with usual care alone and was cost-effective within usual thresholds.

5. Haake M, Müller H, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for Chronic Low Back Pain. Arch Intern Med. 2007;167:1892.Abstract: To our knowledge, verum acupuncture has never been directly compared with sham acupuncture and guideline-based conventional therapy in patients with chronic low back pain. A patient- and observer-blinded randomized controlled trial conducted in Germany involving 340 outpatient practices, including 1162 patients aged 18 to 86 years (mean ± SD age, 50 ± 15 years) with a history of chronic low back pain for a mean of 8 years. Patients underwent ten 30-minute sessions, generally 2 sessions per week, of verum acupuncture (n = 387) according to principles of traditional Chinese medicine; sham acupuncture (n = 387) consisting of superficial needling at nonacupuncture points; or conventional therapy, a combination of drugs, physical therapy, and exercise (n = 388). Five additional sessions were offered to patients who had a partial response to treatment (10%-50% reduction in pain intensity). Primary outcome was response after 6 months, defined as 33% improvement or better on 3 pain-related items on the Von Korff Chronic Pain Grade Scale questionnaire or 12% improvement or better on the back-specific Hanover Functional Ability Questionnaire. Patients who were unblinded or had recourse to other than permitted concomitant therapies during follow-up were classified as nonresponders regardless of symptom improvement. At 6 months, response rate was 47.6% in the verum acupuncture group, 44.2% in the sham acupuncture group, and 27.4% in the conventional therapy group. Differences among groups were as follows: verum vs sham, 3.4% (95% confidence interval, -3.7% to 10.3%; P= .39); verum vs conventional therapy, 20.2% (95% confidence interval, 13.4% to 26.7%; P < .001); and sham vs conventional therapy, 16.8% (95% confidence interval, 10.1% to 23.4%; P < .001. Low back pain improved after acupuncture treatment for at least 6 months. Effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy.

6. Walker EM., Rodriquez Al, et al. Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial. J Clin Oncol. 2010 Feb 1;28(4):634-40. Abstract: PURPOSE: Vasomotor symptoms are common adverse effects of antiestrogen hormone treatment in conventional breast cancer care. Hormone replacement therapy is contraindicated in patients with breast cancer. Venlafaxine (Effexor), the therapy of choice for these symptoms, has numerous adverse effects. Recent studies suggest acupuncture may be effective in reducing vasomotor symptoms in menopausal women. This randomized controlled trial tested whether acupuncture reduces vasomotor symptoms and produces fewer adverse effects than venlafaxine.PATIENTS AND METHODS: Fifty patients were randomly assigned to receive 12 weeks of acupuncture (n = 25) or venlafaxine (n = 25) treatment. Health outcomes were measured for up to 1 year post-treatment. RESULTS: Both groups exhibited significant decreases in hot flashes, depressive symptoms, and other quality-of-life symptoms, including significant improvements in mental health from pre- to post-treatment. These changes were similar in both groups, indicating that acupuncture was as effective as venlafaxine. By 2 weeks post-treatment, the venlafaxine group experienced significant increases in hot flashes, whereas hot flashes in the acupuncture group remained at low levels. The venlafaxine group experienced 18 incidences of adverse effects (eg, nausea, dry mouth, dizziness, anxiety), whereas the acupuncture group experienced no negative adverse effects. Acupuncture had the additional benefit of increased sex drive in some women, and most reported an improvement in their energy, clarity of thought, and sense of well-being.CONCLUSION: Acupuncture appears to be equivalent to drug therapy in these patients. It is a safe, effective and durable treatment for vasomotor symptoms secondary to long-term antiestrogen hormone use in patients with breast cancer.

7. Litscher G. High-tech laser acupuncture is Chinese medicine. Medical Acupuncture. 2008;20:245-254.Abstract: Acupuncture is gaining in popularity as a complementary method to medical treatment. Scientific investigations will be essential for the acceptance of acupuncture not only by the Western medical community but the rest of the world.Since 1997, the Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, and now the TCM Research Center Graz of Graz Medical University in Austria, has been dealing with the demystification of acupuncture and examining, using noninvasive methods, how different stimulation modalities (manual needle acupuncture, laser needle acupuncture, and electroacupuncture) affect peripheral and central functions. The laser needle acupuncture, which was examined scientifically for the first time in Graz, represents a new painless acupuncture method for which 8-16 laser needles are glued to the skin, but not inserted into it. This review summarizes some of the peripherally and centrally measured effects of acupuncture.

8. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Arch Intern Med. 2012;172(19):1444-1453.Abstract; Background: Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain.Methods: We conducted a systematic review to identify randomized controlled trials (RCTs) of acupuncture for chronic pain in which allocation concealment was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs, with a total of 17 922 patients analyzed. Results: In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition (P < .001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar across pain conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, 0.13–0.33), 0.16 (95% CI, 0.07–0.25), and 0.15 (95% CI, 0.07–0.24) SDs lower than sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to no-acupuncture controls were 0.55 (95% CI, 0.51–0.58), 0.57 (95% CI, 0.50–0.64), and 0.42 (95% CI, 0.37–0.46) SDs. These results were robust to a variety of sensitivity analyses, including those related to publication bias.Conclusions: Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.

9. Jabbour M, Sapko M, Miller D, Weiss L, Gross M. Economic evaluation in acupuncture: Past and future. American Acupuncturist. 2009;49(11) No Abstract

10, Ambrósio EMM, Bloor K, MacPherson H. Costs and consequences of acupuncture as a treatment for chronic pain: A systematic review of economic evaluations conducted alongside randomised controlled trials. Complement Ther Med. 2012;20:364-374.The economic burden that chronic pain conditions impose on individuals and society is significant. Acupuncture appears to be a clinically effective treatment for some chronic pain conditions. Given the need for policy decisions to be informed by economic evaluations, the objective of this systematic review was to synthesise data from economic evaluations to determine whether acupuncture for the treatment of chronic pain conditions is good value for money. A literature search was conducted using health and economics databases, with additional hand-searching. Economic evaluations conducted alongside randomised controlled trials were eligible. Eight economic evaluations were included in this review, seven cost-utility analyses and one cost-effectiveness analysis. Conditions treated included low back pain, neck pain, dysmenorrhoea, migraine and headache, and osteoarthritis. From the seven cost-utility analyses, acupuncture was found to be clinically effective but cost more. The cost per quality adjusted life year (QALY) gained ranged from £2527 to £14,976 per QALY, below the commonly quoted threshold used by the UK National Institute for Health and Clinical Excellence of £20,000 to £30,000. The one cost-effectiveness study indicated that there might be both clinical benefits and cost savings associated with acupuncture for migraine. There was heterogeneity across the eight trials in terms of professional who provided the acupuncture, style of acupuncture, and country of origin. The cost per QALY gained in all seven cost-utility studies was found to be below typical thresholds of willingness to pay. Acupuncture appears to be a cost-effective intervention for some chronic pain conditions.

11. Bonnie K. Lind, Ph.D.,1,2 William E. Lafferty, M.D.,3 Patrick T. Tyree, A.A.,1 and Paula K. Diehr, Ph.D.1,4. Comparison of Health Care Expenditures Among Insured Users and Nonusers of Complementary and Alternative Medicine in Washington State: A Cost Minimization Analysis. THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 16, Number 4, 2010, pp. 411–417a Abstract: Objectives: The purpose of this analysis was to compare health care expenditures between insured patients with back pain, fibromyalgia syndrome, or menopause symptoms who used complementary and alternative medical (CAM) providers for some of their care to a matched group of patients who did not use any CAM care. Insurance coverage was equivalent for both conventional and CAM providers.Design: Insurance claims data for 2000–2003 from Washington State, which mandates coverage of CAM pro- viders, were analyzed. CAM-using patients were matched to CAM-nonusing patients based on age group, gender, index medical condition, overall disease burden, and prior-year expenditures. Results: Both unadjusted tests and linear regression models indicated that CAM users had lower average expenditures than nonusers. (Unadjusted: $3,797 versus $4,153, p1⁄40.0001; b from linear regression -$367 for CAM users.) CAM users had higher outpatient expenditures that which were offset by lower inpatient and imaging expenditures. The largest difference was seen in the patients with the heaviest disease burdens among whom CAM users averaged $1,420 less than nonusers, p < 0.0001, which more than offset slightly higher average expenditures of $158 among CAM users with lower disease burdens. Conclusions: This analysis indicates that among insured patients with back pain, fibromyalgia, and menopause symptoms, after minimizing selection bias by matching patients who use CAM providers to those who do not, those who use CAM will have lower insurance expenditures than those who do not use CAM.

12. A complimentary publication of The Joint Commission November 12, 2014. Published January 1st 2015. http://www.jointcommission.org/assets/1/23/jconline_november_12_14.pdf