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Doubletree Hotel
Plaza Ballroom I & II
Rockville Pike
Rockville, Maryland
Thursday, February 21, 2002 &
Friday, February 22, 2002
Friday, February 22, 2002 - Afternoon Session
- Meeting Contents and Participants (10K bytes)
- Thursday, February 21, 2002 - Morning Session (180K bytes)
- Thursday, February 21, 2002 - Afternoon Session (251K bytes)
- Friday, February 22, 2002 - Morning Session (304K bytes)
- Friday, February 22, 2002 - Afternoon Session (277K bytes)
A F T E R N O O N S E S S I O N
[Reconvened at 1:42 p.m.]
Access and Delivery of CAM
DR. GORDON: We are now up to the Access and Delivery
Section. Linnea.
MS. LARSON: We, on the Access and Delivery team, have been
working on what the recommendations would address. How we looked at
it was from a definition of, how do we define "access" for the
purposes of this report, and how do we define "delivery" for the
purposes of this report. Two criteria under access were, what CAM is
available and what is affordable, and what are the models of delivery.
Under "available and affordable," we recognized that we needed to
address the issue of legal authority. Then we came up with a schema
about readiness for licensure, emerging profession, and finally
licensure issues.
I think that was the schema. Out of that, then came these
recommendations. Is that the logic of it? What is available and what
is affordable.
DR. GORDON: Tieraona, are you okay?
DR. LOW DOG: I just wasn't sure why we were going through
all that. We hadn't really done that for the other ones.
DR. GORDON: The format for this section is going to be a
little bit different. That is, that what is going to happen is Linnea
presented, just in a few sentences, a brief schema. I don't know if
there is anything more you want to say. Then we are going to go
through the recommendations as we have for the other sections. The
difference in this section is that the text is not as ready for prime
time as in the other sections. So rather than a line-by-line critique
of the text after we have gone through the recommendations, what I am
going to be asking is general considerations, what should be included
to ground and back up the recommendations that we are making; what
others issues should be raised in the text; what issues have you seen
in the previous text you don't think should be there.
Everybody with me on this? So we are not at the same level of
specificity with this section as we are with others, for a variety of
reason.
So what we will focus on, as we do in the other sections, is
the recommendations. The text that will bolster the recommendations
will be then written out of a variety of previous drafts that have
been composed before, as well as about some new work.
In the new work that is going to happen, both Maureen and Max
Heirich, who is consulting with us, are going to work on developing
that new text, and then they will get it to us as quickly as possible
so we can all see it.
Everybody with me on this? So the format is slightly
different, but not that different for this section.
So let's turn, first, to Recommendation No. 1 on page 5. It
reads: "Access to qualified and competent practitioners, and to safe,
effective, affordable CAM services and beneficial CAM products, should
be improved for all Americans."
Do you think it would be helpful if I read both Nos. 1 and 2
here, Joe and Linnea, or should we just start with No. 1?
DR. PIZZORNO: I think, No. 1.
DR. GORDON: Just No. 1, okay. So let's begin with No. 1,
then. Under Nos. 1 and 2, the action items are really under No. 2
rather than under No. 1, Joe? Or, would you say they are under both
Nos. 1 and 2?
DR. LOW DOG: So, what does that mean exactly, that first
recommendation?
MS. LARSON: I am going to tell you a little history. This
was written this way, I believe, to make room for an overall plan for
legal authority. I think that is why it was written that way. What I
see this actually saying, Tieraona, is let's redo the whole Commission
report. I mean, it could be a little bit tighter.
DR. GORDON: I would like to make a suggestion, that we read
Recommendations 1 and 2, and the action items that follow, to give us
a context, and then we can go back and reshape according to that,
because then that gives much more latitude, rather than focusing just
on this recommendation. Joe.
DR. FINS: I think this is a leftover from the discussion
about setting up the need for access. People said, oh, there are all
these people that need access. I don't think this says anything that
we haven't said 100 times, much better, elsewhere. I would just
suggest that we go to Recommendation No. 2. I would just suggest,
also, the framework that I think the text will have, once it gets
done, of a micro-to-macro sort of perspective, that access is
predicated on the ability to deliver services, and that there are
three tiers: there is the practitioner level; there is the hospital,
the community health center level; and then the health care system
level, and that we are going to address regulatory issues that impact
on the ability to provide access for those three tiers. So, with that
in mind, I think I agree with Jim. Maybe if we went to the second
recommendation, which really focuses at the first step on that ladder
of the practitioner. Let me read it, and then let me say what I think
we really meant to say.
DR. GORDON: Let me read it, and then you can say what we
really meant to say: No. 2, and this is page 9. I do think, Joe, I
would like people to at least look at the action statements that
follow, so they have a context. Julia?
MS. SCOTT: I'm trying to say this coherently, but I will
just say it. When I read this section, it looks to me as if
Recommendation No. 1, the Action Items 6, 7 and 8 fall under No. 1,
and Actions 1 through 5 seem to fall under Recommendation No. 2, which
deals with practitioners.
DR. GORDON: Yes, it does look that way.
MS. SCOTT: I think that separation might make it a little
easier to look at both these recommendations. Just a thought.
DR. ORNISH: I have a somewhat radical proposal, which is
that we just delete this chapter and be done with it.
[Laughter.]
DR. ORNISH: I'm serious about that. The reason is that,
first of all, I think we are making so many recommendations anyway,
that making fewer recommendations has value, but the major problem
that I have with this chapter goes back to what we were talking about
this morning. I mean, the first recommendation about having access
available presumes that there is enough data that we should be
advocating that. Issues of licensure and credentialing, and so on,
are already covered in other chapters.
MS. LARSON: No, they aren't.
DR. FINS: That's just education.
MS. LARSON: That's education.
DR. ORNISH: Well, if we could maybe just take that part of
it and put it into that chapter, and then just leave the rest of the
chapter behind, it might be worth considering.
DR. GORDON: There is a suggestion on the floor. Are there
responses, at this point.
MS. SCOTT: I guess I would just like to go on record saying
I am on this task force, but this is so foreign to me, what is here,
when I remember all of the things that we recommended, demonstration
projects and community health centers for low income people, and
whatever. So I am almost on a wavelength with you, Dean, but I don't,
I really don't feel that access has been dealt with in the other
sections.
DR. ORNISH: What about incorporating it into those sections?
DR. GORDON: Maybe if you could clarify a bit for people.
DR. GROFT: I think what was attempted here was to take this
section and put it into the format of the rest of the report. Due to
a series of circumstances, it did not come off well, obviously. So I
think the approach that we were trying to take today is, let's go and
look at all the recommendations and actions, see if there are areas of
agreement that we can reach, then build from there.
We feel that there is probably sufficient information on
previous versions of the document that we can then bring them in, get
it out to you, and then have a telephone conference where we can
discuss this, probably over a two-hour session. I am asking a lot
here, because this is so convoluted from where we were at the December
meeting.
Again, attempts were made -- it was so long and the
recommendations were all at the end -- trying to bring the
recommendations and the action items back up into the report, closer
to where the subject material was actually discussed, again, to try to
bring some consistency, and we obviously failed. I think, now, trying
to salvage it in a way that it will make sense and still get the
points across that we would like to make, or you would like to make, I
think we should make an attempt at it.
DR. GORDON: Tieraona.
DR. LOW DOG: I think that, again, this was one of our
executive charges or whatever. We were supposed to deal with this, so
we have to deal with it. I think a lot of us are sort of
shell-shocked because the text is really problematic. The point is
what we have come back to again and again and again, before you can
assure access, depending upon what you mean for access -- people
accessing versus reimbursement and what you're paying for -- you have
to have some sort of evaluation of what people should have access to.
So we have sort of skipped through a lot of that. Like the first
recommendation, if we are talking about that one, even with or without
the second one, we are talking about improving that for everyone. I
don't even know what that means. I just think that we need to step
back again, and we need to have recommendations that talk about
evaluation and who is going to do the evaluation, get back to the
demonstration projects that were originally in there, et cetera.
DR. GORDON: Dean.
DR. ORNISH: I completely agree with what Tieraona is saying.
Steve, while I think that if we had more time, your idea makes perfect
sense, we don't. The idea that in a two-hour conference call, we are
somehow be able to fix this, even talking about it today, I think is
overly optimistic, particularly since we are going to be getting the
entire report fairly soon that we are going to have to go through, and
a lot of us are doing a lot of other stuff, too. So if we could just
take one or two key issues here and somehow combine it into another
chapter, I just think that is a much more practical goal.
DR. GORDON: Joe, go ahead.
DR. PIZZORNO: As Tieraona said, No. 4 in the directions we
received from the President was quite clear that we are supposed to be
determining how to improve access to safe and effective alternative
and complementary health care. Clearly, a majority of this health
care is being provided by CAM practitioners. Our job is to make sure
that health care that is being provided is as high quality as we can.
We have, right now, in the country, a situation where we have
licensing and registration of CAM providers, and we have already
received data that shows when they are licensed and registered as
appropriate, we have a safer practice. We have a lot of people out
there who are claiming to be CAM practitioners who do not have
credentialing and for which we already have data that they are not
safe and they do public harm. We must provide guidance to Congress
and to the states to differentiate between these two groups of
practitioners; utterly critical.
DR. GROFT: And to mention, too, I think, as you can see from
the table, Max Heirich is here, who we have brought on board as a
consultant to the group to help us. Maureen and Gerri, Corinne and
Joe, we have all agreed that whatever needs to be done, we will do to
bring to you the best possible section of this document.
DR. GORDON: George.
MR. DeVRIES: Well, first of all, I think a lot of good work
has been done here, and I really appreciate the work of the committee.
It shows a lot of effort, and there is information here that I think
is important to make sure that is in the Final Report. I think maybe
the comment that I would make that I think a couple of others have
made -- and I really don't think it is going to take that much time,
and we have an external consultant now to help us -- but we need to go
back and we need to look at it, and perhaps put it into a format that
more reflects the format that we have seen in the other chapters, so
far, of the report, and that seems to be working pretty well for us.
There is a lot of good material here. Some reformatting and some
editing would probably help in getting it more like the other
chapters, but it is important to have its own separate chapter.
Again, the Executive Order. I don't need to repeat it, but I think it
is important that it be in its own chapter.
DR. GORDON: Joe, and then Tieraona, and Julia, and Joe.
DR. PIZZORNO: I wonder if it would improve things if we
simply eliminated Recommendation No. 1 and just go to Recommendation
No. 2, because I think Recommendation No. 1 is pretty vague, and it
could be interpreted a lot of ways, some which we may not want.
Whereas, Recommendation No. 2 gets to the whole issue of safety and
access.
DR. LOW DOG: Well, I would be open to the dropping of
Recommendation No. 1, sort of keeping that as an option thing there.
I was just going to talk about a process issue so we can keep moving,
that perhaps we should just dive in here and just start looking at
this recommendations and seeing what we think.
DR. GORDON: I would like to hear just a couple more opinions
around the table, and make sure they get out, and then we will move
in. Julia.
MS. SCOTT: I am just very uncomfortable with this section
because of what I see as an over-balance of recommendations having to
do with the credentialing of practitioners. I am uncomfortable with
that, and I think it probably should have been dealt more with
Education and Training, but I want to see a balance in this section
that not only deals with the practitioners being credentialed with
access/delivery issues involving consumers, and the protection of
consumers. There is not a lot to work with with what is here.
DR. GORDON: Conchita, you had your hand up. I'm sorry.
MR. PAZ: I was very much concerned about the access -- or,
actually, the delivery part as well, because I didn't think that part
was developed very much.
DR. GORDON: Joe, and then Effie.
DR. FINS: I think that the one thing here that is most
valuable, and would be valuable to the states -- and one of the
reasons recommendations were not as readily makeable in this
situation, was a lot of the regulatory questions related to
practitioners devolved to the prerogative of the state. So I think
what we see on pages 7 and 8, sort of the taxonomy, is a guide,
really, for states to take under consideration. One action item or
recommendation that I think follows from that, and we heard this from
Max and other folks, is to maybe look at his study, what the
experiences have been, based on the different models that have been
adopted in various states, and how it relates to consumer protection.
I would add consumer protection is covered in the Information Section
under DSHEA and labeling, and so it is elsewhere as well. I also
think it is important to state, and Joe Pizzorno and I were talking
about this, that it is necessary, that one of the linchpins in our
analysis -- and I must say that this document doesn't reflect where we
were, I thought, after our December meeting -- was the issue that the
ability to practice has a real impact on access. So that, the focus
on practitioners was because we had a lot of testimony and saw a lot
of data saying that if you don't have the ability to practice in a
jurisdiction, then all the people don't have access to your services.
So that's why that relationship is there. Maybe it needs to be
expressed more clearly, but that's why the focus was on the
practitioner side.
The eventual idea was really to go up and deal with hospital
and clinic/community health center issues and demonstration projects
there, and then up to health care delivery systems and how managed
care systems integrate, and all that. I would recommend the staff go
back and look at the December draft, because I think a lot of that was
in there and it has gotten cut out as this gets reworked.
DR. GORDON: Effie.
DR. CHOW: I appreciate what Joe just explained, but I just
wanted to say that I feel very strongly, too, that this is heavily
overloaded with licensure and registration. That part is important,
but the accessibility by locale, and by availability and dollars, and
all that, accounts for people being able to use the facilities.
DR. GORDON: Any other general comments? I want to try to
summarize what we have heard so far. Wayne, did you want to say
something?
DR. JONAS: I just want to point out that, at least to the
degree that licensing and credentialing is concerned, it is really
only indirectly related to research. Most of it is about
competencies, professional standards, and that type of thing. I am
talking about conventional medicine. So those things have to be
addressed, but to put it in a framework of, access is dependent upon
established safety and efficacy to practitioners is a confusion of
categories.
DR. GORDON: Let me say a couple things that I am hearing,
and let's see if we are all hearing the same thing. One is that the
chapter is not in anywhere near the shape that we would hope it would
be in, No. 1. No. 2 is, there is a lot of information from previous
drafts that could make it much stronger and much more coherent. No.
3, that there is a sizeable concern of people who feel that there is
an overemphasis on regulation and licensure, and not nearly enough
discussion about access from the consumer side.
So here are some issues. Max, as the consultant, and
admittedly as one who hasn't had a lot of time, I'm wondering if you
have any kind of general schema that you think might help to resolve
some of these issues, both the concern about what has been left out,
the improper development of the argumentation for regulation that just
has not been in this draft, and the concerns about consumers.
Is there a way that we can put it together? I have a
fundamental question, should we look at this now, or should we take
another kind of leap and allow a group of people to work on this and
then give it back to us in a slightly different form in a couple of
days.
I am not crazy about that option, but I don't want us, also,
to make ourselves miserable by going through something and just
feeling incredibly frustrated with it. Anyway, Max, please go ahead.
DR. HEIRICH: Well, I am going to be answering off the top of
my head because I just took on this assignment about 15 minutes ago.
It seems to me that the format for the chapter, it would be very
important in the text to lay out clearly the range of issues that need
addressing, the incomplete state of evidence for resolving them and
the need for a strategy to move forward. One could then, as was just
suggested, say that there are several levels which are important to
consider. We need to look at the level of access to individual
services, the access at hospital/clinical/community center concerns,
access for the system as a whole. After we set that kind of framework
of what needs to be done -- and I haven't seen the earlier draft, so I
don't know what is useable within them -- we could then discuss the
recommendations within that kind of framework.
DR. GORDON: The question I want to raise is -- and Joe, you
in particular, and Linnea -- should we do our best to address the
recommendations now?
DR. FINS: I think if we can salvage some of them, that the
text then could be built around those recommendations, but I think we
should go through this and not be wedded to the recommendations,
because they, too, have more. No one, I think, is really necessarily
wedded to the way they are written right now.
DR. HEIRICH: I would like to suggest that there may be
additional recommendations that will emerge from this discussion.
DR. GORDON: Let me make a suggestion based on the comments
that have been made, that we read Recommendations 1 and 2, and Action
Items 1 through 8, and then we go back and begin to address, because
that way we will cover a fair amount of the territory. Maureen?
MS. MILLER: I just wanted to comment, I think that would be
a useful way to spend some time, as long as everybody understands that
once we work on this and absorb this, that the recommendations might
be slightly different. I'm hoping Max will agree with this, I think
that it would be helpful to have a sense of the Commission before we
leave and do this work.
DR. HEIRICH: Absolutely.
MR. PAZ: The only thing is, once some of the text comes out
from earlier stuff, that this may not be all the recommendations.
MS. MILLER: Exactly.
DR. LOW DOG: I just have a process issue, since this is
going to be done by a conference call, because everybody has committed
to be here during this time, and I know a lot of us have travel and
stuff, that I would certainly hope that there is going to be real
accommodation made, because this is one of the toughest sections that
I personally had the most problems with. I am not going to be very
happy, after making the time to be here, if now, days later, I am not
available for the conference call.
DR. ORNISH: Yes. I feel the same way. I agree. If we're
going to do it, we might as well do it. I just cancelled my flight,
too, and I would feel really dumb if we just postponed the whole
thing. So, why don't we get as far as we can with the current
recommendations. If there are more recommendations later, we will
deal with them at that time, but at least we can deal with what is in
front of us.
DR. GORDON: Steve.
DR. GROFT: We will try to get a time in which all of you are
available. I can't make a guarantee that 19 Commission members are
going to be available at one time, but I think we have to get as close
as what we can on the recommendations. We have spent a half hour
here. It is important to do this, so I think if we can get moving on
them now, do the best we can, and even if it's a weekend where people
seem to be a little bit more available, or an evening, that we can get
people, that's what we will attempt to do. Hopefully, by Thursday we
will have something ready for you to look at, Wednesday or Thursday.
DR. GORDON: What I would also like to say is, to get a
commitment that we will work on this now, and if need be, we will
spend time on it after Public Comment as well. So we can do as much
as possible while we are together, and then, I think, go to
Reimbursement, which I think we would generally agree is a section in
much better shape. Can I have that commitment? Good. I think that
the best way to get a view of the territory in the beginning here is
to read both recommendations and read all the action items. Everybody
take a little time. Recommendation No. 1 is on page 5, and
Recommendation No. 2 on page 9.
[Pause.]
DR. GORDON: Let's begin. Joe, did you want to begin?
DR. FINS: Just big picture structure. I think Julia's idea
is something that we really should just adopt as a placeholder here,
that the Action Item 6, No. 6 certainly, and No. 8, are ones that look
like, what is the demography of the need and what is the need for the
workforce out there as the first thing. I think, on Recommendation
No. 1 --
DR. GORDON: I'm sorry, you didn't finish your sentence, that
those two go with Recommendation No. 1.
DR. FINS: I think, in the beginning. They don't necessarily
go with Recommendation No. 1, but the issue to know what the workforce
is. How does the workforce relate to access, is the first question.
Then the question is, what is the workforce, and where are they, and
how are they distributed. Those are questions that Action Item 6
would answer, and would be a predecessor to intelligent policymaking
downstream. So that would be, I think, a good place to start, sort of
diagnostics versus therapeutics; let's diagnose the state of the
problem.
Recommendation No. 1, in my view, is overly broad, vague. We
are talking about practitioners and services and products. I have
said this before, this is about practitioners here. We deal with
services. We deal with products elsewhere. Services are often
related to the practitioner. It is really about, here, the licensing
of individual practitioner types, at least in this section. So I
think products is something that shouldn't be here, because we deal
with it in other places. Or, if we are going to deal with it, we
should deal with it as a separate recommendation because there are
enough specific issues about that.
DR. GORDON: Yes, Tom. Tom, Dean, George, Conchita, so far.
MR. CHAPPELL: I agree with Joe. We are dealing with the
product issues significantly elsewhere, and it does confuse things to
have it here.
DR. ORNISH: I also agree with Joe, and I would take it even
further and say, look, what question are we trying to answer. To me,
the question is, how can I know that the CAM practitioner is qualified
and competent. I mean, that is, to me, the most basic question. Then
the next question is, how can I get access to people who are competent
and qualified. But the first question is, how do I know that someone
I am going to has any kind of licensure, training, qualifications,
credentials, and what are they. Of course, then the question is, what
should those credentials be for somebody. I think that's the first
tier. The second tier, then, is, how can people get greater access to
whomever those people are. So I would like to focus just on narrowing
this down to how can people in the general public know if somebody is
qualified, what are the standards, and what should they be.
DR. GORDON: George.
MR. DeVRIES: I think, on Recommendation No. 1, there has
been a tendency to want to underplay the recommendation concerns of
states rights, because that is ultimately what this comes down to. I
am going to suggest that we reword Recommendation No. 1, and that we
go consistent with other recommendations we have in the report. It
might be something to the effect of: The Commission recommends that
states provide adequate licensure, registration, certification or
nonregulation of providers, consistent with their scope of practice
and education, something like that, which I think goes right to the
heart of the matter of what is in Recommendation No. 1, which is
really talking about making sure providers are appropriately licensed,
certified, credentialed, consistent with scope of practice and
education.
DR. FINS: Jim, may I answer?
DR. GORDON: No. Let's let everybody talk, and then we can
come back to you, Joe. Conchita.
MR. PAZ: I agree with that. I think we need to separate out
the providers, or the practitioners, and we need to separate out the
products. Even though we have talked about products, we haven't
talked about access to the products.
DR. GORDON: So you're saying products ought to be a separate
section within this.
MR. PAZ: Yes.
DR. GORDON: Okay. Effie.
DR. CHOW: I think Recommendation No. 1 is a broad, general
statement. Action Item 6, 7, 8 goes more with Recommendation No. 1,
and I would move that to the beginning. I am a little bit confused
that we have both recommendations and then the actions after the two
recommendations. So that is what I would recommend. I do agree that
services and products should be separated and dealt with accordingly.
DR. GORDON: Any other comments? Don.
DR. WARREN: Didn't we hear about the House of Lords report
that said that licensure did not guarantee competent treatment? Isn't
that right? I am wondering why we are worried about licensure at all.
I think we ought to be licensed in our respective professional fields
as dentists, chiropractors, NDs, DDSs, the whole gamut -- excuse me,
DOs, and then have registration as the alternative. Licensure of a
CAM practitioner is not going to guarantee competent care. It is not
going to guarantee access.
MS. SCOTT: Again, I hear the focus going on the
practitioner, and if we are dealing with the practitioner first and
then going to get to access to the consumer, and delivery to the
consumer, I am fine with that, but just licensing or credentialing or
registering the practitioner does not ensure that the consumer is
going to have access and delivery. I want us to keep that in mind as
we are looking at this chapter.
DR. LOW DOG: Don, what in Recommendation No. 2 doesn't
address your comments? Because this says accountability to the
public, and contains provisions for registration, licensure, and
exemptions, so that there is room for all of it.
DR. WARREN: Well, when they put "licensure," in there, next
to it I put "no," the entire recommendation. I just don't believe
licensure should be part of it.
DR. LOW DOG: But there are CAM practitioners that are
licensed, so shouldn't there be --
DR. WARREN: Are they licensed as CAM practitioners?
"Naturopaths," they are licensed in how many states? But they are not
licensed in Arkansas. So a CAM practitioner or a naturopath in
Arkansas is practicing unlicensed. Patients still have access to
them.
MR. DeVRIES: They don't.
DR. WARREN: Oh, yes, they do.
DR. LOW DOG: They still can go.
DR. WARREN: They can still go. That is access, isn't it?
They just don't get it paid for, except out of pocket.
DR. GORDON: Let me just say that what we are doing here is
very important, and what I want is to make sure that everybody's
general concerns get heard, and that will enable us to focus more on
the specifics. So Don has expressed his concern. He has pointed out
that at least in his state licensure is not what is happening for some
of these CAM professions. So we will keep going around. Joe, and
Dean, and Tom.
DR. PIZZORNO: Don, I think it is true that there is some
access to some aspects of CAM services in states with no licensing,
but it is a significant problem. One is, they can't practice their
full scope of practice. Second is, they can't differentiate
themselves from other health care professionals. Third, they can't
diagnose and prescribe. I can go on. Of course, there is the whole
issue of reimbursement. So what happens is, in those states you might
get one or two who show up who have proper credentials, but those with
credentials will go to states with licensing because that is where
they can actually do their scope of practice and have a defined
practice right for their patients. It does not work.
DR. GORDON: Dean.
DR. WARREN: Would registration not accomplish this? I still
don't like licensing.
DR. GORDON: This is important. It is important that we have
a common understanding of some of the issues. Dean.
DR. ORNISH: Well, I think it is important. I remember one
of the people who testified before the committee, saying that
basically anybody should be free to practice any kind of CAM, no
matter how they define it, no matter how unproven, no matter how safe,
as long as they disclose what they are doing. For myself, at least, I
am really uncomfortable with that. It is not just a question of
access. I would like to take a stronger statement, in the spirit of
the other discussions that we have been having that I think will
ultimately give our report a lot more credibility, is if we talk about
the need to, not just limit licensure, but even the practice of
certain types of modalities or approaches to those that have at least
some evidence of safety and efficacy, recognizing that that is going
to be a real problem for some people who say, gosh, I have been doing
this for a long time; and, why should I have to submit to those kinds
of standards. I think if we are talking about protecting the public,
we need to perhaps consider a stronger statement about, not just
licensure, but even access.
DR. GORDON: I want to point out something that I think is an
important part of the discussion that got left out of this draft, but
that has been there previously, that there are experiments underway,
including one that we heard a great deal about in Minnesota, where
exactly that principle is there. The belief on the part of the state
is that registration, with the opportunity to register complaints
about registrants, will be effective. What I think is that it is
important for us in this report to take account of these natural
experiments that are underway, and to think through why we are making
the recommendations that we are, and at the same time, to acknowledge
and have a respectful attendance to what is happening with these
natural experiments. I am not saying where we should ultimately come
down, I am saying that we need to look broadly at the terrain and
understand that we have observed what is going on. Tom, and then
Tieraona, and Joe, and Don.
MR. CHAPPELL: I think one of the goals of this whole section
is to understand how a consumer can translate competency or the
standards of the professional. We found, in our work over the last
two years, that the professional associations that set standards for
themselves, and ongoing training and so forth, was the best source of
competency and standards. I recall our feeling that we are powerless
over the states' control on these issues, but that we really could
draw from the experience that each professional association had gone
through over time to raise up the standards of their membership.
DR. GORDON: Tieraona.
DR. LOW DOG: I think you raise a good point about the
different models, if you will, that are currently underway. I don't
think anybody has really evaluated them. I hate to come back to
evaluation, but when you are looking very different models, such as
Minnesota or what is going on in Washington State, they are very, very
different. I think at this point, nobody really knows how it is going
to turn out. So perhaps, someplace, in a recommendation, an action
item, someplace, maybe it should be, at an appropriate time for the
evaluation of these different models, to see what works and what
doesn't work, to try to determine what is the best path.
DR. GORDON: Joe.
DR. FINS: I agree. I think is in the spirit of the rest of
the report that there are questions that we don't have answers to. We
have identified a problem. I think that what we have offered here is
a framework for states to consider. One of the action items should be
to protect the public health, funding should be made available,
perhaps, to the states from the federal government through the health
care or health professions, or HRSA, or the appropriate agency, AHRQ,
to evaluate the various regulatory patterns that exist, from the
libertarian Minnesota model to ones that might be more stringent. I
know that Minnesota's model would never work in New York. That is
because it is different and we're different.
DR. GORDON: We do know that. Effie.
DR. CHOW: Starting on page 11, "Delivery Issues Affecting
Access to CAM," speaks to some of the concerns that I think we have
spoken about and are central to my heart. Some of these are finances,
proximity, professional practitioners, quality of the location, the
facility, the quality of care, and safety, of course, and the
language, and then knowledge by the people, or having knowledge or
having access to information that tells them about the program. We
don't have a recommendation here that speaks to those points. All of
it has been on regulation and licensure.
DR. GORDON: I'm sorry, can you summarize the points, Effie,
that we don't speak to?
DR. CHOW: Well, there is something here about "cannot afford
to pay out of pocket," and so forth. What I am saying is a
recommendation doesn't speak to these points that are missing,
considering the finances of the individuals, the proximity of the
available services, the professional practitioners, having available
professional practitioners there, and the quality of care, and safety
of care, of course, and then language considerations, and then the
information and knowledge that is available for people.
DR. GORDON: So what you are referring to is a number of
specific issues that may affect access of people to services.
DR. CHOW: These all affect access. Of the people, yes, and
there is no recommendation that speaks to that.
DR. GORDON: And you would suggest that there should be such
a recommendation.
DR. CHOW: Yes. There are some things that are stated here,
from page 11 to 13, and so forth.
DR. GORDON: Any other general statements? Charlotte, Wayne,
and Conchita.
SISTER KERR: I just want to comment on what I think is an
emphasis in some of the actions, or maybe the spirit of some of this.
I wonder where we individually feel. Before you look at the whole
issue of access and delivery, and particularly under Action Item 2,
there is this statement that the federal government, and it does say,
"In collaboration with states, CAM practitioners will work on a
definition of professions and practice." The point I want to make is,
it seems to me -- this may not be the best thing -- but
self-regulatory and federal government working on defining CAM rules
and regulations is an issue. For me, I can't think of any medical
school or school of nursing who would go to the federal government to
say, help us work out our guidelines for directing our profession.
This seems really puzzling to me in here. Thank you.
DR. GORDON: You are expressing a concern about federal
intrusion into regulation of these professions. Wayne.
DR. JONAS: I think that this is an area where the federal
government does not have a lot of direct jurisdiction. They can have
indirect jurisdiction by helping to facilitate producing guidelines
and things like this that are then used by the states. I think this
can be a very helpful win/win situation. I have a question for those
who worked on this. The relationship between this and the Access to
Medical Treatment Act, which has been evolving and circulating for a
number of years now, and has looked at and developed a variety of sets
of guidelines in terms of assuring safety, competence of the practice,
and freedom to choose. Can someone speak to that? I didn't really
see that referenced. I didn't see the same language, and yet that
seems to be dealing with a lot of these same issues and is directed
towards the consumer, not the practitioner, per se. Can someone
comment on that?
DR. GROFT: It may have come up at one point in time.
Because it was proposed legislation, and not enacted legislation, I
think the decision was made that we really weren't going to address
that specific piece of legislation.
DR. JONAS: I am not asking that it be addressed
specifically, but I mean, here is a whole body of effort that has gone
in, several years, trying to do the very same thing. I am just
wondering if that was used as a consultant.
DR. GORDON: Wayne, you are suggesting that we need to
include that.
DR. JONAS: Well, I think that needs to be looked at, because
a lot of people have worked on that for a long time in terms of trying
to figure out, how do you address access and maintain safety, et
cetera, et cetera. I am not saying that that is the way it ought to
go, but I am saying that here is a whole thing dealing with access
that isn't a licensing issue, per se, that should be evaluated.
DR. GORDON: What we are doing now, and you are doing it very
clearly, and others have done it, is we are raising some of the issues
that need to be addressed in this chapter. Conchita, and then Tom.
Then I think we need to, pretty soon, as we come to a conclusion with
general statements, start focusing on the recommendations and where we
want to go with them.
MR. PAZ: What I wanted to emphasize was, in the spirit of
trying to promote the CAM practices in states that have no licensing
or registration, it possibly may be antagonistic if the state is
having some snags in trying to develop their criteria, or giving some
major resistance to it, I think that is where they can enlist the help
of the federal government to try and facilitate that type of
development. I think No. 2 is pretty succinct in saying that.
DR. GORDON: Tom.
MR. CHAPPELL: I don't see what value we will be able to add
to the state licensure issue. So that, I feel that our
recommendations ought to be where we can add value, make a difference
and so forth, as I mentioned earlier in my last comment. I also just
wanted to say goodbye. I have to leave now, and I wanted to thank you
all.
DR. GORDON: Thank you, Tom.
[Applause.]
DR. GORDON: We will be in touch. So, with all these things
in mind, let's begin to see what we can do with the recommendations
and the action items, see which ones are appropriate, how they may
need to be altered, what might need to be added, and then having heard
the shape that the Commission would like the chapter to have, we need
to come back to it. So let's, then, move ahead. George.
MR. DeVRIES: Can I go ahead and just start on Recommendation
No. 1?
DR. GORDON: Yes.
MR. DeVRIES: First of all, just a couple of quick comments.
Tom's comment, just as he left, what value do we add, we add
tremendous value. It goes back to the fact that there are 50 state
legislatures who are trying to manage and regulate health care, and
this is a federal body that can make tremendous recommendations. The
second part of this is that, many of you are medical physicians or
dentists, and you have your license and you are able to practice, you
are able to practice your professions, but there are other professions
out there, and the naturopathic is one of them, where they only
licensed in 11 states.
When they are licensed, their scope of practice or education
says that they can diagnose a condition, that they can treat a
condition. If they don't have a license, if they go to the State of
Arkansas and do that on their own, they are basically practicing
medicine without a license. So the license really gives them the
ability to practice. That is why it is our ability as a White House
Commission to make a recommendation to the state. I think this
committee has done just a superb job balancing all the issues, from
the exemptions, those like the Minnesota law, allowing there to be
flexibility in the system, up to saying to states, it is important for
a profession like a naturopath or acupuncturist, these people who,
their education, their scope of practice is such that they diagnose
medical conditions, they treat conditions, they need to be licensed.
That protects the member, but it also allows the provider to practice
their profession.
So I want to say that on the front end, that really I believe
this is just a critical part of the report to keep in. I still go
back to an earlier recommendation I made in terms of Recommendation
No. 1, changing the wording, being more direct. I support leaving in
what has been done here, and splitting out the products, perhaps, into
a second recommendation, and really letting this focus solely on the
ability of the provider to be legally empowered to practice their
profession. Now, I say that with the caveat, Julia, I support 100
percent that this section needs to be balanced with facilitating
patient access to services, too. So this is just a part of this
Access Section.
DR. GORDON: George, do you want to repeat the wording you
had for Recommendation No. 1.
MR. DeVRIES: Sure. Sure.
DR. PIZZORNO: Could I ask a question first, George? The
wording you came up with sounded more like a recommendation for No. 2,
rather than for No. 1.
MR. DeVRIES: Okay.
DR. PIZZORNO: Because No. 2, I think, is more about the
credentialing. I think No. 1 is about the access issues that are
independent of credentialing.
DR. GORDON: Do we want to begin with No. 2, or do we want to
begin with No. 1? Wayne?
DR. JONAS: I'm not going to answer that question. I had a
suggestion that is different.
DR. GORDON: Please, give us your suggestion.
DR. JONAS: I would like to suggest a modification of these
recommendations along these lines, my suggestion is that we start
first with, not licensing and credentialing, but we start as our first
recommendation with a recommendation that looks at access directly to
the consumer. I would suggest that the action items that are at the
end, actually, are the ones that address those, more than the ones at
the beginning. So those should be moved up front. I don't have a lot
of problem with those action items as they are written, but I think
they should be framed with an actual recommendation that goes over
them that might go something like that, and addresses specifically
looking at the barriers to consumer access, again, to safe and
effective, and to qualified practitioners.
DR. GORDON: Is one of the staff taking down this? Yes?
Okay, good.
DR. JONAS: And here is some suggested wording for a
recommendation that I would say would be No. 1, and these would follow
as action items, and perhaps they could be modified: The federal
government should evaluate current barriers to consumer access to safe
and effective CAM practices and qualified practitioners, and develop
guidelines for removing those barriers and increasing access. So this
is a general recommendation. It is directed at the federal
government. They are looking at the barriers, focusing on safe and
effective practices, and qualified practitioners as the initial focus.
DR. GORDON: That, then, would be a replacement for the
current Recommendation No. 1.
DR. JONAS: Correct.
DR. GORDON: Repeat it again, Wayne, so everyone can hear.
DR. JONAS: The federal government should evaluate the
current barriers to consumer access of safe and effective CAM
practice, and to qualified practitioners, and develop guidelines to
remove those barriers and increase access. Then the action items,
Nos. 6 through 8 actually largely address that.
DR. GORDON: I would like to have discussion on this
substitute recommendation that Wayne is making. People's responses to
it? Charlotte.
SISTER KERR: I just want to complement that. I think in the
case of the wording of this recommendation, I agree with the role of
the federal government to do that.
DR. GORDON: Julia.
MS. SCOTT: I like Wayne's. I was trying to get some
language together, and I like what he has done with that
recommendation. What I would add is that, while Nos. 6, 7, and 8 seem
to go under that, perhaps with a little rewording, there are
additional action items that need to go there.
DR. GORDON: Thank you, Julia. Effie.
DR. CHOW: I just want to thank you, Wayne. That was the
recommendation I was saying was needed. Thank you.
DR. GORDON: Dean.
DR. ORNISH: Well, I don't want to sound like Eyore, but it
just sounds like there is a greater body of evidence that these
various practitioners are effective than, I think, exists for most of
them, and that we should therefore try to really knock down those
barriers and open the floodgates to people, when I am not sure that
for many modalities that we are even close to that point.
DR. JONAS: That's right. I mean, it may turn out that there
is only three, but I can tell you that I know I have made many
attempts -- and I am licensed -- to get acupuncture available for
chemotherapy-associated nausea and vomiting, proven safe and
effective, et cetera. Cannot do it. There are barriers to that. We
need to examine those. I can tell you there about a half dozen, at
least, herbs that have good evidence that they are safe and effective
for a particular clinical condition. So I think the issue is that we
ought to examine those. That is what this is for. I would suggest
that there may not be a whole lot, but there is probably enough to
actually address this issue.
DR. ORNISH: Is there a way to somehow put language in there
that is a little more modest in terms of recognizing what you're
saying? Tieraona, do you have any thoughts about that? I'm just
curious.
DR. LOW DOG: Well, I think, again, if you're talking about
evaluation -- I guess my main concern is evaluation of barriers -- and
that is the only thing you're talking about.
DR. JONAS: So you would add opportunities with barriers and
challenges?
DR. GORDON: Wayne, and then Effie and Joe also have
something to say. Do you want to say something at this point?
DR. JONAS: Well, I was going to suggest that we pair access
with accountability in each of those statements that I mentioned, so
that they look at barriers, not only to access but barriers to
accountability, to assuring accountability.
DR. GORDON: How would that sound, Wayne?
DR. JONAS: It would sound cumbersome, but I think it would
address the issue that this is not just about, give me more, give me
more, but what we are doing is making sure that the practitioners that
are delivering this, and the practices, are accountable, that they are
addressing safety issues.
DR. GORDON: I'm sorry, I want to hear from Effie, and from
Joe and Buford.
DR. CHOW: In our discussion it seems like the interpretation
of these recommendation are for immediate action, and we are talking
about short-term and long-term, because these are recommendation for
change into the future, way into the future, and not just these next
years. So therefore, it might be just three now, but it lays the
groundwork for others as the research is proven and so forth.
DR. FINS: I think the issue about removing the barrier
presupposes that there is efficacy, and all that stuff, but if we look
at Action Item No. 6, and we took part of that, I think it gets the
spirit of what Wayne has just said, and what Effie just said about
current and future, and says, "HHS and other appropriate federal
agencies should seek to identify current and future health care needs
or access that qualified CAM practitioners may address." Then they
should seek to remove barriers that preclude their provision of things
that have been deemed to be safe and effective and beneficial, and
then we should get data, workforce data, national surveys, et cetera.
Then the other action items sort of follow. The point is that you
want to try to identify current and future health care needs that this
workforce might address.
DR. GORDON: Buford.
MR. ROLIN: Thank you. My concern is with Action Item No. 8
here, this whole issue of traditional healing, and the recommendation
that the Secretary should identify common uses and practices of
indigenous healing in the United States, and on down where we are
talking about dealing with the issues of how to protect cultural
heritages, and things of this nature. We had some real discussion on
that many times, and I don't think that captures the original
statement that we had come up with.
DR. GORDON: Can you redraft it the way you think it should
be?
MR. ROLIN: Well, we had some language there before, and I
thought it was acceptable, and this has been tweaked.
DR. GORDON: And the difference between that language and
this language is what?
MR. ROLIN: Well, the difference is the approach here, I
guess, in the matter of saying the Secretary should. I don't know, in
the case of American Indians, if we are going to ever get to the point
of where we are going to share our cultural heritage and what is
happening in that process. That is what I am concerned about.
DR. GORDON: Maybe if you could take a minute while we are
talking about some of the others, or at some point say how you think
it should be written, because nobody is wedded to the exact form of
any of these recommendations or action items. So if you make a
proposal, that would be very helpful.
DR. LOW DOG: Buford, I think part of the problem here as
well is this sort of invasiveness of coming in and expecting people to
share rituals, song, practices. Also, the feeling amongst many
peoples that they have just about been researched to death, and they
are sick of it. I don't think this is what it is getting at at all.
DR. GORDON: Tieraona, I would like it rewritten in a way
that feels appropriate. I think we're ready for that, we're up for
that.
DR. LOW DOG: Where is the language from the last one? Do
you have that in your pocket, Julia?
MS. SCOTT: I do, but it's at home.
DR. GORDON: I think Wayne's substitute recommendation for
No. 1 is very appropriate. If there are three or 30 that are safe and
effective, the point of it is it provides an avenue, it provides a
rationale that is well within the approach to scientific medicine. So
it seems to me a very way to express the issues. The basic issue --
and I just want to repeat what he said -- for patients is, how can I
get this thing that is effective, that is safe for me, whether it is
through a licensed doctor, through an acupuncturist, whoever it is.
Their concern is getting the services, and I think we really need to
recognize that. It is fine to say safe and effective, but we need to
recognize what everybody on this side of the room has said, which is
that there is a real consumer issue here.
DR. JONAS: Well, just to address the accountability issue, I
have a paired recommendation that would then address that together.
So we can talk about that when we are finished discussing this.
DR. GORDON: Tieraona.
DR. LOW DOG: I am getting ready to leave you all. So I had
just a couple of things that I just want to say, for whatever they are
worth. When you are talking about access, the ability for somebody to
go could be limited by income, but that is true of many things. We
have published studies that actually show watching comedic movies are
very beneficial to health, but do we pay for people to go to the
movies? We have evidence that Resveratrol and red wine is very
beneficial for the cardiovascular system. I would love for the
government to pay for my chianti, I really would, and would argue for
its health benefits. However, I think it is more to me, when you are
talking about access, of something just being safe and effective.
There are a whole lot of other consideration that has to go into what
we are paying for, and what we are not paying for.
I would like to encourage again that we just keep in mind
about evaluation and going back to demonstration projects to begin to
explore team approaches, exploring ways to begin to determine who
needs what and how it will benefit us, but to be thoughtful in that
process. Just because something is safe and effective, it doesn't
mean we pay for it. We deal with this with OTCs all the time. Many
of these are safe and effective, but you pay for them out of your
pocket.
The last thing, is to keep in mind that I have some personal
issues. I want to be very careful about what we are going to
recommend is covered when many people don't have access to basic
medicine, a prescription.
As a Navajo gentleman told me recently, "Have you thought that
maybe some of us may perceive that you are trying to give us
second-class medicine, medicine that has not been proven, medicine
that has not been shown to be effective, because you think it's
cheaper, and that maybe that is the way you are going to deal with our
health problems?" I think that we have to be sensitive to that
perception. Thanks a lot.
DR. GORDON: Before you go, and before we thank you,
Tieraona, I would like to ask you if you have any thoughts about how
to address that last issue that you just raised.
DR. LOW DOG: I think part of it is through demonstration
projects, evaluation and demonstration projects, which I do believe
were in earlier iterations of this draft, which I think, then, address
these issues in a way that doesn't let us believe that is what we are
actually doing to underserved populations.
DR. GORDON: Including the issue of people perhaps feeling
they are getting second-class health care.
DR. LOW DOG: Yes. Yes.
DR. GORDON: So through demonstration projects.
DR. LOW DOG: And evaluation.
DR. GORDON: And evaluation.
DR. LOW DOG: You have got to have the evaluation to
determine what you are going to do a demonstration project on.
DR. GORDON: Good. I just wanted to make sure we had your
thoughts on it.
DR. LOW DOG: Thank you and thank everybody for this process.
DR. GORDON: Thank you.
[Applause.]
MS. SCOTT: I want to support what Ti just said, because the
formation of recommendations of action items under this section, I
would encourage us to look at what is already being explored for these
populations of people in existing work, such as the Medical Practice
Act, looking at the Surgeon General's Report. All of these deal with
access, so I don't think we have to reinvent the wheel, but I think we
need to have a couple of them that are applicable to access to safe
and effective CAM services.
DR. GORDON: Julia, does it make sense to you to come back to
the recommendation that Wayne put forward, and for us to discuss that
at this point? Or, are you looking for another recommendation on the
section?
MS. SCOTT: No, no, I'm not looking for another
recommendation. I am supporting what he put forward. All I am
suggesting is there are places we can go to look for action items,
other than the ones that are listed here.
DR. GORDON: I've got that. I hope we all have that
understanding, that even if this recommendation comes forward, there
are other concerns that you have. Joe.
DR. FINS: We have sort of come full circle, because we are
having conversations that we had on the very first day when we were
going around the table and somebody was asking for each of our own
world views.
I was struck by what Tieraona just said, what that Navajo gentleman
was concerned about, and what the gentleman who did the Spanish radio
shows -- I think it was in Washington --
DR. Huerta, I
believe his name was.
I think it is really important that our purview is really not
to address access in general. That is not within our mandate. We
appreciate that any recommendation that we are making is in the
context of access for complementary and alternative medical services,
practitioners, or whatever.
We would say as a guiding principle, and I think we all can
agree, that access to CAM is meant to complement, it is meant to
augment, it is never meant to substitute for, conventional access to
health care. I think that should be stated clearly, so that that
Navajo gentleman, who was instructing us from 2,500 miles away, would
be reassured, because I think separate is not equal.
DR. GORDON: Joe, it is important that that be made clear and
adumbrated in the text. Yes?
DR. FINS: Yes.
DR. GORDON: Are we in agreement about that point, that we
are not talking about getting acupuncture instead of antibiotics if
what you need is antibiotics?
DR. WARREN: Separate is not equal, but separate doesn't
imply superiority by one or the other.
DR. FINS: I'm saying, look, people are free to choose what
they want. If somebody is sick and they want to go for acupuncture
instead of bypass, or they want to do the Ornish diet instead of
acupuncture, one of our principles is they have the right to choose.
What I am saying is, that as policy we should say that separate is not
equal, this is not as a substitute for. The presumption is that all
the people who are calling
DR. Huerta's radio show wanted
conventional health care and they were obliged, because of their
poverty and their disenfranchisement, to seek this alternative sort of
care because they could pay for it, it was accessible.
DR. GORDON: I think, Joe, without quoting Huerta, your point
is well taken. I think the point is basically we are not saying that
people should not have access to conventional medicine and instead
they should have access to CAM. We are saying that whatever access
they may have to CAM, they also should have access to conventional
medicine. This is not an either/or.
DR. FINS: I just want, for the record, to say I don't mean
to misquote
DR. Huerta.
DR. GORDON: I think we understand the principle here. I
want to get head nods to make sure we have this general principle,
that we are not saying throw out conventional medicine and give them
CAM instead. We are saying that there are many systems. Yes. We've
said it.
DR. WARREN: We are saying free choice by the consumer as to
which, as long as they have got equal access to both. They can take
free choice, and it is their informed consent that implies that,
correct?
DR. FINS: Choice implies voluntariness, and if one is
uninsured, they may not have as much free choice. The goal here is to
never have them feel, based on any government policy, that we are
giving them a second-tier intervention, because there may be
situations where it is as good as or better than. I think I said what
I meant to say, and I hope somebody was recording it or whatever.
Just as a principle, the Navajo gentleman's concerns are ones we have
to resonate with, but also, at the same time say that people are free
to make their own choices. Some people are coerced into certain
choices because of their poverty.
DR. GORDON: I think there is general agreement on this
principle. Do we have general agreement on this principle? Okay.
Yes, Dean.
DR. ORNISH: I agree with that principle, but a corollary of
that principle is that, with access there needs to be information.
One of the things that you said earlier which didn't account for that,
was that this is only about access. I think a direct function of
access is information about efficacy, the kind of things that Tieraona
was talking about in terms of demonstration projects, and the kind of
things that Wayne is talking about in terms of accountability. It is
not only accountability in terms of accountability to standards of
your own profession, but information that the consumer can use to make
those kinds of decisions.
DR. GORDON: I think that's a very good point. Now, I would
like to get, if we can, a Recommendation No. 1, and then take a break
and have public testimony, which we are scheduled to have, and then
come back and move through the rest of the recommendations.
DR. ORNISH: Since some people have to leave, like me, is it
possible that the public testimony could be delayed for half an hour
so we can continue this, and then continue it? I mean, there are
several people that have to leave, but if not, then fine. I just want
to put that out there.
DR. GORDON: Let me ask, how many of the people are here who
are going to be giving public testimony?
[Show of hands.]
DR. WARREN: I would like for all the commissioners to have a
chance to listen to public testimony. We have walked out on them
before, and I don't think we ought to do it again.
DR. GORDON: In fairness to the people who have come here and
set aside their time, I think we should have public testimony at the
appointed time. We will pick up a half hour later. I would like to
come back to Recommendation No. 1, if we could. Wayne, do you want to
state it how you have fashioned it?
DR. JONAS: I think if the first one is accepted to deal
directly with the access issue and not the licensing issue, then I
think, as we discussed, barriers in access are the appropriate focus,
again, focus on safe and effective, identifying those things that are
safe and effective. The second recommendation, then, I think, can
address the licensing issue, and the primary focus there is
accountability. Now, the problem we have discussed with that is, that
is not in the federal purview, unlike what could be done initially on
the first recommendation. So here, I think the federal government's
role could be in facilitating the states in developing their own
guidelines. So I would like to propose some wording to help that so
that it does give a role for the federal government, but it is not a
role in which it is dictating any kind of guidelines to them.
Again, this can be reworded. What I have done, actually, is,
I have taken Action Item No. 2 and reworded this as a potential thing
to address this, because I think this got at least as close as
possible. To say something like, "The federal government should
assist states," and one could say "by" or "in" "developing guidelines
for" -- and I scribbled around in this. I've got to make sure I get
this right -- "for establishing accountability and competence in CAM
delivery, including," and then list: standards of practice; scope of
practice; education and training; registration, licensure or
exemption; and professional oversight. So in other words, list some
of the items that are involved in what those accountability items are,
which are already in that paragraph, but we just pushed them down
towards the bottom.
DR. GORDON: So, would that be Recommendation No. 2?
DR. JONAS: I think that would be Recommendation No. 2.
DR. GORDON: Then come back to Recommendation No. 1, if you
would, and then read Recommendation No. 2 again, so we have them both
together.
DR. JONAS: All right. I should have written out in more
detail. Recommendation No. 1 is actually on the board in the back.
It is, "The federal government should evaluate current barriers to
consumer access to safe and effective CAM practices and qualified
practitioners, and develop guidelines to remove those barriers and
increase access." So that addresses the direct access issue.
Recommendation No. 2 is, "The federal government should assist states
by developing," or "in developing guidelines for assuring
accountability and competence in CAM delivery, including standards of
practice; scope of practice; education and training; registration,
licensure or exemption; and professional oversight."
DR. GORDON: Can we discuss these two recommendations? Thank
you, Wayne, very much for the reworking. Joe, do you want to comment
on these? Wayne, do you want to read them again?
Let's read them once more, and if we can discuss them in the
next little period of time, great. If not, we will put off the
discussion. I would like everybody, though, if people are leaving, to
have a chance to address both of them before they go. So read them
again, Wayne, please.
DR. JONAS: No. 1 is about access, and it is that, "The
federal government should evaluate current barriers to consumer access
for safe and effective CAM practices and qualified practitioners, and
develop guidelines to remove those barriers and increase access."
That is No. 1. The second one is that, "The federal government should
assist states in" or "by" -- I'm not sure -- "developing guidelines of
accountability and competence in CAM delivery, including standards of
practice; scope of practice; education and training; registration,
licensure or exemption; and professional oversight."
DR. GORDON: Thank you very much. Comments on either No. 1
or 2? Dean and Charlotte first, and then Joe.
DR. ORNISH: I liked Wayne's recommendations. I just wonder,
is there any way within Recommendation No. 1 to put anything about
accountability or safety, efficacy, anything beyond just -- pardon me?
DR. GORDON: Safety and efficacy, I believe, is in there.
DR. FINS: But I think accountability is a practitioner.
DR. ORNISH: I missed the safety and efficacy part. Is that
part of No. 1?
DR. JONAS: That is No. 1, actually. That's why I suggested
we look at the barriers.
DR. ORNISH: Fine. I like them. I think they are really
good.
DR. GORDON: Joe just pointed out that accountability is more
a practitioners issue than a practice issue.
DR. ORNISH: I like it.
DR. GORDON: Other comments about these two? Charlotte.
SISTER KERR: Wayne, you've done No. 2 and you remembered my
concern. I'm not sure if I have copied right: "The federal
government should assist states in developing guidelines" -- I need
your feedback -- "for establishing accountability and competence in
CAM." I mean, it doesn't even say in this case that you are going to
collaborate with anybody. Again, I don't have it exactly in front of
me. "The federal government is going to assist the states to develop
guidelines in these areas."
DR. JONAS: Well, this is why I said "in" or "by." One could
say, assist the states in developing accountability and competence
"by" developing guidelines, in which case then the federal government
would simply do it. They would say, here are guidelines that we think
are appropriate for accountability. These are some things that states
can now take and individualize to their particular requirements.
DR. FINS: Developing and assessing guidelines. In other
words -- I'm looking to Don -- because it is the issue of assessing,
because there is a heterogeneity, a possibility, developing and
assessing. I liked Max's idea, the states are the laboratory of
democracy; let's assess it a little bit. That is not exactly what he
said, but it's the spirit of what he said.
DR. HEIRICH: That's a nice sentence.
DR. FINS: It wasn't mine, it was Jefferson. But assessing.
SISTER KERR: I think this is real important. I am still not
clear -- and I want to see it in front of me -- is the federal
government going to offer guidelines to different disciplines as to
how they should regulate themselves? If we are saying that, I am not
for it.
DR. GORDON: I am going to suggest that this is going to
require more discussion. What I would like to do is take a
five-minute break, and then come back for public testimony, and then
we will pick up and go into these issues after public testimony. A
five-minute break. Could we call the first panel to come forward? We
will have public testimony, and then we will come back to this
discussion.
[Break.]
Public Comment Session
Joyce Frye, DO, MBA, National Center for Homeopathy
DR. FRYE: My name is Joyce Frye of the National Center for
Homeopathy. A year or so ago, Joe Fins made the astute observation
that CAM is a symptom of the diseased health care system. The
homeopathic treatment of that disease, according to the law of
similars, would be to stimulate CAM until the organism brings itself
back into balance. Clearly, that is what the Commission is attempting
to do in its recommendations, and with the establishment of CAM
Central for implementation. So we congratulate you on your
homeopathic perspective in creating this remedy.
There is considerable overlap between your recommendations and
those from the NCH, which you have at place. So, to the extent that
they can be carried forward into specific CAM Central activities
relative to homeopathy, we will be very happy.
Speaking for myself, I have one very deep concern. That is,
while your remedy is correct, the potency may not be. Specifically,
the word "should" is universal in your recommendations. There are no
carrots and no sticks, and "shoulds" only go so far in changing
behavior. We should exercise and eat right. One hundred years after
the Civil War, Rosa Parks should have been able to sit anywhere on the
bus, but it took years of mandated integration and affirmative action
to gain something approaching equal opportunity.
In the last several months, we have provided testimony to the
House Committee on Governmental Reform, and to NIAD, and to NCCAM, and
to Secretary Thompson about the potential benefits of investigative
homeopathic history in treating bioterrorism, and we were politely
dismissed. CDC and NIAD should have been beating down our door,
trying to figure out how they could use this and investigate it.
For CAM to move forward, conventional medicine is going to
have to share its seat on the bus, and sometimes even sit in the back.
It will not do that without a fight. So at the very minimum, your
Recommendation No. 1.1 for CAM Central has to include the word
"authority" along with "budget" and "staff" in order to carry out
these recommendations.
I would like to suggest that you take an even bigger step and
recommend to Congress that they enact legislation mandating
affirmative action in the study and implementation of CAM procedures
and protocols for a defined period of time until this health care
system can come back into balance.
DR. GORDON: Thank you. Let's wait until all the speakers
have spoken, then we can ask questions. Madan Khare. Is that the
proper pronunciation?
DR. KHARE: Good enough.
DR. GORDON: Okay, thank you. Madan Khare, DVM, MS, PhD,
American Complementary and Alternative Veterinary Medicine Association
DR. KHARE: On behalf of the Complementary and Alternative
Veterinary Medical community, I thank you for giving me the
opportunity to speak with you today. My name is
DR. Khare,
and I am a microbiologist and a practicing veterinarian. I do not
need to emphasize the bond between humans and their family pets. Even
the President of the United States, when stepping off the helicopter
on the White House lawn, he picks up his dogs, Barney and Spot,
instead of his wife and kids. The family pet has proven to be
therapeutic and valuable to cancer, psychiatric, and nursing home
patient management. More and more, pet owners are demanding CAM
health care for their other family members, their pets. Academia and
associations are making concentrated efforts to ensure continuous
training and education of CAVM practitioners. We need validation and
acceptance of their efforts. Recognition of this vital process by
this commission will tremendously ensure that the consumer receives
high quality CAVM care for their pets.
The CAVM academic and individual research communities are
engaged in shared research. Through research and quality control, the
CAVM industry is engaged in production of quality products. However,
we need more support and cooperation from local, state, and federal
providers. Recognition of this need by this commission will help
increase our resources. CAVM practitioners are active in promoting
consumer awareness. However, again, we do need your help in our quest
to educate pet owners about CAVM.
CAVM practitioners are providing efficient and effective
modalities to their patients. However -- I am repeating like a broken
record -- we do need resources to standardize the implementation of
standards. On behalf of the CAVM community, I request that this
commission recognize the role and place of CAVM in pet health care. I
urge this commission to mention and include in your report the need of
a certain level of policy and procedures regarding CAM for the family
pet.
Finally, I thank every member of this commission for giving me
the opportunity to express my views.
DR. GORDON: Thank you very much, and thank you for
presenting a viewpoint we have not heard before. So I really
appreciate it.
DR. KHARE: Thank you, sir.
DR. GORDON: Boyd Landry.
MR. LANDRY: I follow
MR. Kriegel.
DR. GORDON: I don't think
MR. Kriegel is here.
Boyd J. Landry, MPA, The Coalition for Natural Health
MR. LANDRY: Well,
MR. Chairman and members of the
Commission, my name is Boyd Landry, as you all know, and I am
executive director of the Coalition for Natural Health. At the close
of today, this part of your journey will be over, and what remains is
how your work will be received, reviewed, and acted upon. Further, as
commissioners, you should be wary of being labeled as a self-serving
body. I say that because at the last two meetings, this issue was
brought forth at the beginning of the meeting for you to look at and
realize and be cognizant of.
Since I do not have a copy of the text of the report, I can
only speak to recommendations and action items. Initially, I want to
address the usage of the terms "safe and effective." This phrase is
used over and over throughout the report, and it creates an
interesting dichotomy because consumers have a right and expect all
products to be safe. Effectiveness is a relative term, defined by
science to some extent, and by consumers of the products themselves.
You may not realize it, but you only recommend that CAM
products be safe. There is no mention of effectiveness. Practices
have to be safe and effective, but products need only be safe. Where
is the consistency? Where is the difference? Let consumers decide
effectiveness, and the let the government attempt to guarantee safety.
On the issue of elevating CAM providers to primary care
physician status, we agree with
DR. Fins, there are vast
differences in the education and training of conventional medical
providers and CAM providers. If CAM providers want to be viewed as
primary care, they must receive the same level of education and
training that conventional medical providers receive, which includes
comprehensive residencies and internships.
By continuing the proverbial carrot of loan forgiveness and
tuition reductions by way of scholarships, to recruit providers to
underserved areas, is a faulty premise. In a recent AM News article,
in the American Medical News, it stated that statistics show that
providers are born and raised in underserved areas more so than they
are recruited to them. All you have to do is look back to the CBS
series "Northern Exposure" for a comical example of that.
Access and delivery is a major issue for the Coalition. I
want to use the majority of time of my last public opportunity to
address this issue. I cannot hammer enough the fact that this
commission, in its recommendations and action items, has ignored and
disrespected the most comprehensive piece of state legislation in this
area in the last five years, and that is the Minnesota Health Freedom
law.
The Minnesota law has now formed the basis of legislation that
has been introduced in Rhode Island, New York, and California. Rhode
Island and California have an excellent chance of passing their
versions of the legislation in their respective legislatures this
year. The Minnesota law created access to CAM providers for the
entire public, and provided public accountability and public redress.
The Rhode Island State legislature recognized that CAM is a
growing industry, and it also recognized that the state cannot afford
to license, certify, or register every modality, therapy, or their
derivatives. By grouping these practices, modalities, and therapies
into one group that is accountable to the public, without
overburdening the state and the practitioners with unnecessary
regulation, guarantees the widest net of access.
MS. AXELROD:
MR. Landry, your time is up.
MR. LANDRY: I'm sorry. I have two short paragraphs. With
respect to coverage and reimbursement, I caution you against falling
into the trap that coverage and reimbursement is the key to greater
access. It is our fundamental opinion that issues involving access
and delivery must be worked out long before discussions should take
place regarding coverage and reimbursement. There is a plethora of
issues surrounding coverage and reimbursement.
Finally, I want to thank you for the multiple opportunities to
address the Commission. It is my hope that the many points that I
have made, and the points made by the constituency I serve, make their
way into the report and the recommendations.
At this time, the recommendations do not reflect the needs of
a large percentage of the CAM community. I cannot comment about the
text of the report because I was not given a copy, which you have but
we don't. Thank you for your time and attention, and good luck in
these final weeks in preparing your Final Report.
DR. GORDON: Thank you very much. Hiroshi Nakazawa. Hiroshi
Nakazawa, MD, American Board of Medical Acupuncture
DR. NAKAZAWA:
MR. Chairman and the Commissioners,
good afternoon. My name is Hiroshi Nakazawa. I am chairman of the
American Board of Medical Acupuncture, ABMA. I was educated in Japan
and the United States, and completed my residency in surgery at the
St. Agnes Hospital in Baltimore, where I am senior attending
physician in the Department of Surgery and Anesthesiology. I have
practiced medicine since 1962, and medical acupuncture since 1995. I
am a past president of the Baltimore City Medical Society, past
executive committee member of the Maryland State Medical Society, and
have spoken around the world on the topic of medical acupuncture,
which is a combination of ancient Chinese medicine and Western
medicine, as practiced by the Western-trained physician.
I have presented my credentials to underscore the respect I
have for education and competence in health care training. Today, I
would like to focus on one credential in particular, my certification
by the American Board of Acupuncture, the ABMA, because it represents
a milestone in the level of expertise which medical acupuncture has
achieved in areas of training, education, certification, and
accountability.
The ABMA was created in April 2000 as a separate entity within
the American Academy of Medical Acupuncture, AAMA. It has an
independent board of trustees responsible for the direction and
operation. The mission of the ABMA is to promote safe, ethical, and
effective medical acupuncture to the public by maintaining high
standards for the examination and the certification of physicians as
medical specialists. As in other medical specialties such as
radiology or pediatrics, the ABMA establishes requirements for
qualified applicants, conducts the exam, and issues certification to
those who successfully complete these criteria. The certification
process is intended to provide the public with physicians who have
completed an ABMA-approved education program and passed the board
examination in medical acupuncture covering a multiplicity of
acupuncture paradigms.
To date, nearly 200 of the Academy's members are certified, up
from 83 just six months ago. Enthusiasm for the program is clear.
Candidates for board certification must have graduated from an
accredited allopathic or osteopathic medical school in the U.S. or
Canada, or possess a certificate of ECFMG, namely the Educational
Council for the Medical Graduate. They also must have a valid medical
license and good ethical standing in the community. Applicants must
complete a minimum of 300 hours of acupuncture training acceptable to
the ABMA, at least 200 of them in a formal course program which meets
WFAS standards and includes instruction in auricular, energetics, TCM,
neuro-anatomic, and other acupuncture disciplines. Further, at least
100 of these hours must be in an approved clinical setting. Eight
schools have been, so far, approved. Those candidates who meet the
above eligibility and educational requirements may sit for the
certification exam.
In addition, applicants must certify that they have two years
of medical acupuncture experience subsequent to the basic 200 hours
training, and a case history of no fewer than 500 medical acupuncture
treatments. They must also provide three physician references as to
their character, professionalism, and adherence to standard clinical
practice.
In effect, the ABMA has designed a program that brings medical
acupuncture into the spectrum of the Western medicine specialties, and
by so doing, will raise the awareness and the reputation that
complementary medicine in the minds of the American public.
The requirements and oversight of the certification program
will continue to raise the bar for all practitioners of acupuncture.
We ask your support in recognizing that medical acupuncture is a
practice and approach unto itself whose standards are in keeping with
the most advanced health care system in the world, and whose guardians
are committed to its success.
Thank you very much.
DR. GORDON: Thank you all very much. Questions from
commissioners? Charlotte, you had one earlier?
SISTER KERR: How much time do we have for questions? All
right, I have three questions.
Now, this is
DR. Frye, correct? What was the outcome on the
offering to assist in the bioterrorism? Basically, they kept
referring you back to NCCAM to get money?
DR. FRYE: You have the two letters at place, I think, that
we received back.
SISTER KERR: I have, yes.
DR. FRYE: Basically, they gave us pat information about what
was going on, and said thank you very much, we can do this.
SISTER KERR: And you feel you have something more to offer in
that area, specifically?
DR. FRYE: We think we have a great deal.
SISTER KERR: You are, at this point, at a dead end, right?
DR. FRYE: Right.
SISTER KERR: Thank you. Boyd, thank you for being loyal to
your people and all of us. I was concerned, at the end of your report
you said that you couldn't review because it is not given to you. I
thought everything was on the computer.
MR. LANDRY: No, that's not true. We are only given the
recommendations and the action items.
SISTER KERR: So you are given the recommendations.
MR. LANDRY: Right, because what appears to be the case, is
the text is somewhat different. Although it is supposed to be in
conjunction with the recommendations and action items, we are not able
to review that information until its final form.
SISTER KERR: Thank you.
DR. Nakazawa, thank you very much for your presentation. I
am around the corner from you in Columbia. May I have some
clarification? This new board that was formed, it is a separate
entity. So you are not in any formal relationship with the American
Academy of Medical Acupuncture? If that is so, I am interested in the
board certification. Would you be separate or considered to have much
higher requirements than being just a member of the American Medical
Acupuncture?
DR. NAKAZAWA: About two years ago, the ABMA group has been
actually established within, as I mentioned, AAMA. So that, at this
moment, we are at the beginning stage, we are not completely separated
yet. We have, now, at least a separate entity, at least nothing to --
what do you call it -- interfere by the AAMA. However, financially,
we are not anything. We just started off. We are still in the embryo
stage, I should say, for that matter.
DR. GORDON: Other questions? Effie.
DR. CHOW: Thank you all for your input.
DR. Nakazawa, can you explain why was the ABMA established
within the AAMA? What is the purpose of having the two?
DR. NAKAZAWA: This has been, as you know, 1987 when AAMA was
established. The physicians of the group, I understand, they all some
day would like to have one separate board for a medical specialty like
a board certified surgery and so forth. At that same time, we should
have to elevate our standards to certify the physician, certify the
acupuncturist. So in a way, they tried to establish a little higher,
let's say, level, because if you just become a graduate from a bona
fide acupuncture school -- as you know, we have so many in the United
States -- as long as you apply to AAMA, you can be a member, but it is
not necessary that everybody has upgraded education and that they have
to take so many courses and so forth. And so, they decided to have
some, perhaps, higher standards which needed some kind of
certification. As you know, AAMA has the same thing. Someone can be
an internist, graduate from a bona fide training school, but he or she
may not be board certified. To have board certification, he or she
has to go take an examination, which can be quite difficult. They
have to go through so many hours of training, et cetera. So this kind
of, a little bit, distinguishes the physician, so to speak.
DR. CHOW: I guess I am not quite clear. I guess the AAMA
and the ABMA, you have the same number of hours of training, and then
the ABMA requires continued education, and AAMA does not require
continued education? How do you get that extra status?
DR. NAKAZAWA: Well, we have bylaws which are set by the
so-called membership in AAMA, but the highest is a fellow, and the
next to the regular members and so forth, we have to have at a
minimum, to qualify, 75 hours education in three years to be in a
fellowship. ABMA, however, you have to not only finish school,
college, you have take an examination, a board certification
examination. Once you pass that examination, he or she has to prove
that this person has two years in addition to that, has a minimum of
medical training in acupuncture, and also, as I said, no fewer than
500 medical treatments. This has to be proven with an affidavit.
DR. GORDON: Thank you. Wayne, or Charlotte, or both of you.
SISTER KERR: Just one quick question.
DR. Nakazawa,
one of the things that I value, both in this work and in my own
professional work, is collaboration and partnership. My own
experience has been -- and I have such respect, in my own background
in teaching nursing, for the medical community -- that we would
partner and collaborate in our continuing education. I have often
seen many good workshops from the doctors. I am wondering if you have
ever considered any leadership in working to bring us all together,
the non-physician acupuncturist and the doctors, because the bottom
line is we work together; there is so much we share. It seems like we
are still having trouble coming together. Would you comment on that?
DR. NAKAZAWA: I appreciate very much your concern, and I am
so glad to inform you that we now, at the AAMA and the ABMA, we have,
as you know, an annual symposium. We have about 400 to 500 physicians
get together every year. This year, we are open to everybody. So
anyone who wants to come -- you mentioned something, licensed
practitioners -- anyone who would like to come in, that's fine. As a
matter of fact, we are going to have a speaker. It's not necessary to
be a physician.
SISTER KERR: I really commend you on that, and I cannot thank
you enough for that offering to the community. Thank you.
DR. GORDON: Any other questions or comments? Wayne, please.
DR. JONAS: I want to thank the panel and I want to thank,
Jim, for making sure that we did this, and I think some others who
suggested that we do this, because we saw this huge list of public
testimony over the past two years. Somehow, as we get involved in the
discussions, it seems to rapidly fade. I am speaking for myself here,
it seems to rapidly fade. So doing this on a regular basis just flips
off those neurons again and reminds me that this is in fact a massive
effort of individuals calling out and saying, we want something
different in health care and we are doing something different in
health care; pay attention.
I would like to ask
DR. Frye if she would elaborate a bit on
her organizational analogy around homeopathy. If complementary
medicine is the disease and we are trying to select a remedy for this,
would you suggest that a constitutional approach would be more
effective, in which we pick a single remedy infrequently given and
focus on a very particular core issue, the essence, if you will:
time; compassion; healing interactions; and healing function?
Or, should we take a more clinical diagnostic, mixed approach
in which we make sure we have covered all of the symptoms, a head
remedy for CAM Central, an ear remedy for the information, a feet
remedy for payment, and give it more frequency at a lower potency?
And the second question, what is the potency? My
understanding is that if you more precisely select the remedy, you can
often get a very high potency at a very minimum dose, in which case,
are we giving too much too often?
DR. FRYE: Can you do that again, one at a time?
DR. JONAS: Yes. What is the approach? Is it
constitutional, where we need to prioritize all these massive
recommendations we are making in saying, this is the one we need to do
now? Or, is a more mixed approach, in which we need to cover all
bases and give more?
DR. FRYE: Well, I think it is an approach that looks at all
of the symptoms and understands that all of those ultimately need to
be healed, but there are some priorities about in what order that will
happen. I certainly can't tell you what priority that should be. I
haven't been sitting here for two years giving thought to that, but I
am sure that that could be done. Some of it, again, addressing the
issue of mandating this kind of thing is allowing each part of the
organism, each structure to figure out for itself what it means to
heal, and just simply giving it the mandate that this is what has to
be done, and figure out how to do it.
A similar example might be in the City of Philadelphia, where
I am from, there is a mandate that when you erect a new structure of
any significant size, it has to have an art component to it. Nobody
tells them what that art has to look like. It might be a particular
garden or a particular fence, or a particular sculpture, but as long
as it is something that is generally considered to be art, they can
figure out for themselves how to prioritize that.
So I think if you tell NIH that a certain percentage of its
budget has to go to CAM, you can let them figure out how they want to
do that, but that the mandate has to be there across the board.
DR. JONAS: So it sounds like a constitutional approach to
me, then.
DR. FRYE: I think so.
DR. JONAS: Okay.
DR. GORDON: Thank you all very much. I especially want to
thank Boyd Landry for his coming again and again, and presenting his
point of view to us.
[Applause.]
DR. GORDON: We have one more panel, Riva Touger-Decker and
Cassandra Wimbs. Riva, would you like to begin, please. Riva
Touger-Decker, PhD, University of Medicine and Dentistry of New Jersey
DR. TOUGER-DECKER: Good afternoon. I Riva Touger-Decker,
and I come as acting director of the Center for the Study of
Alternative and Complementary Medicine at the University of Medicine
and Dentistry of New Jersey. I don't think anyone can say that 10
times fast. The need for allied health, medical, nursing, and dental
education programs to prepare students with the knowledge and skills
they need for good patient care is driven, in part, by increases in
CAM use by consumers.
These health providers must be able to understand the spectrum
of practices known as CAM, efficiently question their patients,
understand and evaluate their individual reasons for use of CAM, be
familiar with the potential harm of these therapies, whether they are
used independently or in combination with conventional medicine, and
the potential benefits, and advise consumers accordingly about the use
of such therapies to provide the best possible care.
They must be able to understand and adapt to changes in health
practices, collaborate across disciplines, and develop referral
systems among those disciplines. Education of traditionally trained
health professionals just has not kept pace with consumer usage
patterns of CAM. All health professionals need to be able to provide
consumer with scientifically sound, credible guidance about CAM.
Although several allied health and medical associations have formed
special interest groups, their efforts continue to remain inadequate
to meet the needs of students in these disciplines.
The Society of Teachers of Family Medicine has published
guidelines for CAM education of medical students. No such guidelines
exist for teaching students in allied health or dentistry. Although
U.S. medical schools have formed a consortium of academic health
centers for integrative medicine, there is no organized effort to
integrate CAM in allied health and dental schools.
This past July, our dean, DR. David Gibson, the dean of UMDNJ
- School of Health Related Professions, conducted an Email survey I
designed to look at allied health profession schools in the U.S. who
are members of the Association of Schools of Allied Health
Professions. Less than one-third of the schools responding had
elective courses, and none of them had required courses on CAM.
It is imperative that all health professionals have a detailed
understanding of scientifically sound CAM practices. Such
professionals must be able to apply rigorous scientific standards when
examining CAM modalities to promote comprehensive care, reduce risk of
interactions and potential harm, and enhance benefits. The ability to
differentiate between practices supported by sound research and those
that have no scientific basis is important for public safety.
The establishment of core competencies and curriculum
guidelines for CAM education is critical for integrative and safe
patient care. Such guidelines should be available for adoption by
educational programs for allied health professional, and all health
professionals with direct patient care responsibilities.
The collaboration of key professional associations in
developing these guidelines in competencies would be invaluable to
help to establish and broadcast them to their constituents.
DR. GORDON: Thank you very much.
Questions from the Commissioners?
[No response.]
DR. GORDON: I just want to raise a question, which I don't
know if you were for earlier discussion, when Tom Chappell was asking
about schools of dentistry, and we have a discussion with some staff
input. What do you think the issue is with schools of dentistry? Why
is there what seems like a lack of interest in these approaches?
DR. TOUGER-DECKER: I don't know that it is a lack of
interest. As a nutritionist by discipline, with a doctorate in
nutrition and oral health -- I work in a school of dentistry, as well
as with our allied health school -- I think, in part, part of what has
affected medical education is they don't see the direct link. In many
ways, dental education, like some others, is almost bulimic in its
approach, in that there is so much to absorb, and how much do they
have to spit back. It is just a practical example. I sit in the
American Association of Dental Research in their Nutrition Section.
As a research group, we are trying to approach it. The ADEA, The
American Dental Education Association, hasn't embraced it as a
competency priority.
One of our goals at UMDNJ -- and I was here earlier, and
pleased that we broadened it to all health professions -- is that we
are center that represents our three medical schools: nursing; allied
health; dental; and biomedical science schools, but we are housed in
an allied health school.
Our goal is to come up, unless others come up sooner, with
curriculum guidelines and competencies, because there is an interest
in some dental schools. Our feeling is if we do take the beginning
approach, others will start to adopt and collaborate.
So I don't think it is a lack of interest, I don't think it
has become a priority on their radar screen.
DR. GORDON: Thank you. Don.
DR. WARREN: On the dental school front, there is so much
information to be taken in just to pass the boards. If we put in a
CAM course, I get the indication from Tennessee, possibly, that that
might affect their accreditation for the school, because the American
Dental Association doesn't really approve of any CAM. Is that a
potential possibility?
DR. TOUGER-DECKER: I don't know that ADA, ADEA, doesn't
approve of any CAM, it is not a competency. I am not sure that they
need a specific course. In other words, it may need to be that those
competencies in CAM are integrated throughout the curriculum in
courses like clinical medicine, like preventive care, that it is not a
course, that it becomes part of the other competencies that have.
That may be a more effective approach, rather than to keep starting
new courses.
DR. WARREN: But to do something like that, you have to have
the faculty educated in CAM before you ever start that integration
into the courses.
DR. TOUGER-DECKER: Exactly. It has to be something that the
academic deans embrace, and then get their faculty to embrace it. We
have taken the approach of trying to embrace faculty, because if we
don't, students won't get to implement it or learn it. I agree with
you.
DR. GORDON: Any other questions?
[No response.]
DR. GORDON: Thank you very much. I would be curious, Riva,
as this develops, if you would at least keep me informed about what is
happening with dental schools and allied health professions.
DR. TOUGER-DECKER: I will. I will be out at their meeting
in two weeks, so we will let you know.
DR. GORDON: Great. Thank you. Public testimony, the time
has concluded, and we are going to return to our deliberations on
Access and Delivery. Do you need a two-minute break? Let's have a
five-minute break -- do you want 10 minutes? Does everybody want 10
minutes here? Okay, let's take 10 minutes, and then let's come
prepared to move through Access and Delivery to the end.
[Break.]
DR. GORDON: Let me remind everyone that what we are going to
be doing is we are going to moving through Access and Delivery, then
we are going to go to Reimbursement, and at the end we are just going
to remind everyone who is still standing, or sitting, what the
procedures are going to be for the next couple of weeks.
MR. DeVRIES: In terms of a time check, Chair, what is the
time frame, given it is 4:00 now, to get these things completed?
DR. GORDON: My hope is that within the next hour to hour and
15 minutes, we will be able to finish Access and Delivery. I think
Reimbursement is in pretty good shape, is my estimate, and I am hoping
we can do that all together in 45 minutes to an hour. So I am hoping
we will finish shortly after 6:00, or by 6:00.
MR. DeVRIES: I need to leave at 6:15. Obviously, if you all
want to continue until 9:00 or 10:00 tonight.
DR. GORDON: You're not staying for the pajama party? My
hope is that by 6:15, we will all have completed our work and will
happily go home. Charlotte, you raised a question at the end of the
discussion that I wanted to come back to. We are currently discussing
Recommendation Nos. 1 and 2, and then we are going to move into action
items, discussion both of the ones that are present, and also of other
ones that commissioners feel are needed.
We were in the process of discussing the recommendations, and
Charlotte had a concern, which I would like to come back to. The
recommendations are behind me, Recommendation No. 1, and then for
Recommendation No. 2 there are two options for some of the wording
that Wayne worked with with Don, I believe. Right?
So everyone cam look at those to refresh their memories. Can
you read them? No? Let me read. Recommendation No. 1: "Federal
government should evaluate current barriers to consumer access to safe
and effective CAM practices and qualified practitioners, and develop
guidelines to remove those barriers and increase access." Then, the
notation here is that Action Item Nos. 6, 7, and 8 would change tone,
and perhaps additional ones would go under that.
Recommendation No. 2: "The federal government should assist
states and professional organizations in developing guidelines for
practitioner accountability and confidence in CAM delivery, including
either standards of practice, scope of practice, education and
training, registration, licensure or exemption," which is spelling out
the different categories that were present in the action item, "or
just regulate the practice," and end there.
DR. JONAS: There is one item missing, which is professional
oversight, which is peer review from the organizations itself. That
would have to be in there in any case.
DR. WARREN: Is that where we were talking about assessments?
DR. JONAS: Professional oversight.
DR. GORDON: Where would that go?
DR. JONAS: It would go in one or the other. My feeling is
that that should be in it, regardless of whether we use A or B. "B"
was the suggestion to summarize all of A to make it less cumbersome.
"A" spells out more specifically some of the items, but in any case,
professional oversight should be on there because that is what the
professions would be responsible for, and the guidelines should
include that. That is different than, simply, regulation. The
professional organizations provide that, not the states.
DR. GORDON: Charlotte, let's come back to your issue, and
then we can move ahead.
SISTER KERR: I want Boyd to listen to this, too. He is not a
commissioner, but a brother. Anyway, my concern that I need to talk
out is, I tried to image this, and I'm trying to think if I were
president of the Maryland Acupuncture Society, for example, and I got
a phone call, and we have worked on this for years, and the government
wanted to help us develop new guidelines for our practice
accountability, I suppose, depending on who I was, I would either say,
"Well, that's good and creative," or, depending on how they were going
to proceed, maybe I would say, "Well, how come they're coming in now
and it's all this work." Now, it could be that the intention of this
is that the federal government says, "Look, every discipline has
disparity and diversity. We would like to hold a convocation where
you bring all your folks together, and we would like to help
facilitate a partnership of us, you, and state representatives, if we
are all on track, are we serving the people the best we can, and let's
talk about it."
I really need some feedback here, because my sense is, when I
read this -- particularly when I read that article that somebody
brought on yoga and I was realizing how people are perceiving, maybe,
things we are doing -- that I thought, "Gee whiz, everybody is getting
scared that we are going to tell the yoga people what to do." I
thought, "Oh my gosh." I have felt, actually, pretty comfortable
thinking we are not doing any of these things.
So this sounds a little bit more back to what I have tried to
express. This is probably important to me, to feel comfortable about
it before we leave.
DR. GORDON: So, what are asking for?
SISTER KERR: The concern is, are we saying the federal
government is going to call everybody in and say, "Well, how are you
all doing," and "What did you all do," write it down, tell us," or are
we going to say, "Let's get together and talk about, are we up to
speed, can we be of service to you." I mean, say there is a state
that has no law. For example, I can't practice in -- or, maybe we
just changed the law, but I think South Carolina, even, which is my
home state, you can be a dentist, you can work under a doctor. My
point is that that state, for example, might benefit from some
national regulations, and we are trying to get it together in
acupuncture. Maybe the federal government is the person to convene
this, I don't know.
DR. GORDON: Charlotte, you are asking for feedback from
other commissioners? Okay. Joe and Joe, to begin, and Linnea.
DR. PIZZORNO: Well, I think this conversation has been
really quite good because it has helped me to understand the
multiplicity of factors that seem to be getting a little confused
here. It seems like there are three things here. One is the
recommendation of licensure, certification or exemption as appropriate
to promote public safety and differentiate amongst practitioner types.
The second is, the government providing assistance to the states, and
to try to figure out how to do it, because this is a huge challenge
for the states.
The third part, which is something that has come up that's
new, that Wayne brought up, which I thought was really good was, some
kind of evaluative process. Because we do have licensing right now,
we do have certification, and we now have this experiment in
Minnesota, it would be nice if the federal government could provide
some kind of evaluative process as this goes on. So five years from
now, we take a look and say, well, what actually happened.
In at least the limited numbers of states where naturopathic
doctors are licensed, we look at malpractice data, and we look at
court decisions, and things like that, that the safety is actually
pretty good, but that is something that has got to be studied for
everything that is going on to see what the situation is.
So I think, by looking at what Wayne has here, that looks to
me more like an action item, because it doesn't embrace all these
ideas. So I would like to have one idea which says what we want to
accomplish, and then a series of action items.
DR. GORDON: Joe Fins.
DR. FINS: I want to respond to Charlotte, and then also to
Joe. I think using a phrase like "offer assistance," was never ever
meant that we could impose guidelines upon the professional societies.
The acupuncturists and the TCM folks didn't agree to get along at
public meetings here, they couldn't get it together.
I think this is one of the functions that the central office
might be able to facilitate. So I think offering assistance versus
requiring compliance with a federally mandate. So offering
assistance.
The other thing is, I would add I totally agree with Joe said,
that when there is a change in the law or a new guideline, there
should be an evaluative piece. The professions, HRSA, AHRQ, are all
the kinds of agencies that could help with that evaluative process.
Then the other thing is that the federal central office can
help disseminate and share information between states, although there
was something in our earlier draft. There is an entity -- I forget
the name of it -- where state legislatures communicate with each
other. I think that is something that needs to be re-excavated from
the December draft as well, as a clearinghouse function.
DR. GORDON: Joe, how do you respond to Joe P's thoughts
about, these should be action items rather than recommendations?
DR. FINS: I think they are action items. I mean, I think
the recommendation is that we should offer assistance, and these
specific things could be delineated as action items.
DR. GORDON: Linnea? No? Anyone else?
[No response.]
DR. GORDON: We have two recommendations here. Wayne?
DR. JONAS: I just liked the idea that Joe suggested about
evaluation. If we do anything with that, I would suggest it should be
a third thing.
DR. GORDON: A third recommendation, or an action item?
DR. JONAS: A third recommendation, yes, because that is a
role the federal government could supply, is evaluating what these
various types of models of access and integration are.
DR. GORDON: I think that is a great idea. I would like to
get some decision on these two recommendations that are here. So
let's talk about Recommendation No. 1. Are we in agreement with
Recommendation No. 1? Yes? Can we have heads, hands, hearts?
[Show of hands.]
DR. GORDON: Recommendation No. 2, are we in agreement? Are
we with this one? Yes? Okay.
SISTER KERR: No. No.
DR. GORDON: No. Charlotte, okay. Charlotte is not on for
No. 2.
SISTER KERR: I feel unheard, except for what Joe said, to say
that we would offer to assist states and professional organizations.
DR. GORDON: What would you like to have happen?
SISTER KERR: Well, I want you all to respond to my concern,
do you think anybody might feel like this? I am delighted to think
there would be a federal office that would say -- I said it a few
minutes ago -- "We wo | |
