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Legislative Alchemy: Naturopathy 2013

A fresh season of state legislative sessions is upon us and with it comes the ubiquitous attempts by purveyors of so called “complementary and alternative medicine” (or “CAM”) to join the health care provider fraternity. Via the magic of legislative alchemy, state legislatures transform pseudoscientific diagnoses (e.g., “chronic yeast overgrowth”) and treatments (e.g., homeopathy) into faux, but legal, health care. Once the imprimatur of legitimacy is bestowed by the state in the form of a health care practice act tailored to their special brand of quackery, these newly licensed health care providers are free to foist their practices onto an unsuspecting public and charge them for the privilege. All of this is done under the false assumption that such legislation is necessary to protect the public health, safety and welfare.

We might well want to consider how far this whole thing is going. Will practitioners of CAM split into an ever-expanding number of CAM provider guilds, all with their own practice acts? First, chiropractors were the only CAM practitioners who managed to get themselves licensed in all 50 states. Then along came acupuncturists, who are now licensed to practice in over 40 states. A few states license homeopaths. Some states licensed naturopaths early on. Now the naturopaths, licensed in 16 states, are in a full court press to catch up and legitimize themselves with licenses to practice “naturopathic medicine.”

Why? Because, according to Lorilee Schoenback, ND, a Vermont practitioner and American Association of Naturopathic Physicians (AANP) Board member:

If the law [the Affordable Care Act, or ACA] is implemented as intended NDs in 16 states will immediately be covered by insurance.

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Posted in: Herbs & Supplements, Homeopathy, Legal, Naturopathy, Pharmaceuticals, Politics and Regulation, Public Health

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Here we go again: A bill licensing naturopaths rears its ugly head in Michigan

If I’ve pointed it out once, I’ve pointed it out a thousand times. Naturopathy is a cornucopia of almost every quackery you can think of. Be it homeopathy, traditional Chinese medicine, Ayurvedic medicine, applied kinesiology, anthroposophical medicine, reflexology, craniosacral therapy, Bowen Technique, and pretty much any other form of unscientific or prescientific medicine that you can imagine, it’s hard to think of a single form of pseudoscientific medicine and quackery that naturopathy doesn’t embrace or at least tolerate. Indeed, as I’ve retorted before to apologists for naturopathy who claim that it is scientific, naturopathy can never be scientific as long as you can’t have naturopathy without homeopathy and naturopaths embrace homeopathy. Unfortunately, naturopaths have over the years been having some success in persuading state legislatures to license naturopaths, in some cases even giving them the privilege of being considered primary care practitioners. It’s part of an organized effort, too, and I don’t expect that effort to let up. True, the governor of Massachusetts did veto a naturopathic licensing bill that came across his desk recently, but no one following this issue expects the naturopaths to let up. As Jann Bellamy put it, the naturopaths will be back. They always are.

Indeed, in the wake of the failure to pass a naturopathic licensing bill in Massachusetts, Michael Cronin, the president of the American Association of Naturopathic Physicians (AANP) lamented:
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Posted in: Naturopathy, Politics and Regulation

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Naturopaths push for licensing in Massachusetts (again)

I have some good news and some bad news about a Massachusetts naturopathy practitioner licensing bill.

First the bad news: the bill passed both the Massachusetts House and Senate in December of last year.

Now, I am certainly no expert in the arcane workings of the Massachusetts legislature, but after doing a bit of research I’ve come to wonder if the way the bill passed was entirely above board. I’ll spare you most of the details, but here’s what I found out. See if you don’t agree with me that the whole thing smells a bit fishy.

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Posted in: Legal, Naturopathy, Politics and Regulation

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SCAMlandia

I quite like Portlandia. I find it funny and it captures a part of Portland. I recognize large swaths of the city’s culture in the show. Other representations of the city I recognize less. Sunset publishes beautiful photographs of the NW, but when I look at the photos I think, that section of the city never looks that good. It is quite wonderful how Photoshop can improve on reality.

Like most major cities, Portland has a monthly magazine, Portland Monthly. The city represented in that magazine is mostly alien to me. I look at the advertisement, the articles, the photographs, and wonder when did Portland become a city with an average 7 figure income? The Portland in which I grew up and currently live is rarely found in the pages of Portland Monthly. If you are extremely well to do, I suppose you are in the demographic Portland Monthly. But when I flip through the pages of the magazine, I see little I recognize, but I have never completely abandoned the hippie/grunge aesthetic of my younger days.

Every January they have the best Doctors issue* and this year, for the first time, they offer The Portland Alternative Medicine Guide. Well, less a guide and more an extended infomercial filled with ‘facts’ that deserve the quotes. (more…)

Posted in: Acupuncture, Chiropractic, Dentistry, Energy Medicine, Homeopathy, Legal, Naturopathy, Politics and Regulation, Science and Medicine, Traditional Chinese Medicine

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Naturopathy Embraces the Four Humors

The ancient Greeks posited a system of health and disease based on the four humors: blood, phlegm, black bile and yellow bile. According to this system, health is defined as a harmony of these four humors and disease is caused by an imbalance among them. Restore the balance, and health is restored. Bleeding is a familiar example of humoral medical treatment based on a diagnosis of an “excess” of blood. Fortunately, the humoral system of diagnosis and treatment died out with the advent of modern scientific medicine.

But as David Gorski asked (sarcastically, of course) in his presentation on quackademic medicine at CSICon in October, if supposedly ancient philosophies of diagnosis and treatment such as Traditional Chinese Medicine and Ayurveda are so beloved by CAM proponents, despite their implausibility and lack of evidence of effectiveness, why not the humoral model of health and disease? Why not include humorism in the CAM practitioner armamentarium?

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Posted in: Faith Healing & Spirituality, History, Naturopathy, Politics and Regulation, Religion, Traditional Chinese Medicine

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Disingenuous: Deconstruction of a naturopathic white paper

Science is the Concept by which
we measure our reality
I don’t believe in magic
I don’t believe in I-ching…
I just believe in science…and that reality.

John Lennon. Sort of.

As regular readers of the blog are aware, I am science/reality based.  I think the physical and basic sciences provide an excellent understanding of reality at the level of human experience.  Physics, chemistry, biology, anatomy, biochemistry, physiology, evolution etc. provide a reliable and reproducible framework within which to understand health and disease.  My pesky science may not know everything about reality, but day to day it works well.

“There are more things in heaven and earth, Horatio, Than are dreamt of in your philosophy. – Hamlet (1.5.166-7).”  

Perhaps, but all the medical advances in my lifetime have been not yielded new science, just (amazing) variations and extensions of known processes.  I sometimes think the blog should have been called reality based medicine, but science is the tool by which we understand reality, and while the tool is constant, our understanding of reality is prone to changing.  An understanding of the rules of the universe combined with an awareness of the innumerable ways whereby we can fool ourselves into believing that those rules do not apply to us is part of what makes a science and reality based doctor.

We are often told of the need to keep an open mind, but I like to keep it open to reality.  Not that I do not like fantasy and magic, it is a common category for my reading.  I just finished Red Country by Joe Abercrombie, and while I love the world he has created, I would not want to apply the rules of that imaginary world to my patients.   Well, one exception.  As Logen Ninefingers  would say, “You have to realistic about these things.” Fictional worlds should be limited to the practice of art, not the practice of medicine.
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Posted in: Humor, Naturopathy, Politics and Regulation, Public Health, Science and Medicine

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Oregon Naturopaths v. Evidence-Based Medicine

Like every state, Oregon is struggling with the unsustainable costs of taxpayer-funded health care programs. In an attempt to tame this beast, Oregon recently established a system of coordinated care organizations, or CCOs, to (as the name suggests) coordinate medical, mental health, and dental care for residents enrolled in Oregon Health Plan, the state’s Medicaid program. The new system requires supervision of this coordinated effort by the participant’s primary care physician (PCP). Not one of the 15 newly-minted CCOs has credentialed a naturopath as a PCP even though naturopaths are licensed as such by the state. Needless to say, the naturopaths are not pleased by this development.

The big stumbling block appears to be the state’s requirement that CCOs practice evidence-based medicine as a cost control measure. Unfortunately for naturopaths, evidence-based medicine is not their strong suit. Apparently scientific plausibility is not much of a concern either.

As one chief medical officer of a CCO explained in a news report,

We have an obligation to the state and to the community that the providers on our panel will deliver the evidence-based care required by the Oregon Health Plan. . . . We need to make sure that all of the providers who are empanelled meet those basic standards of care.

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Posted in: Legal, Naturopathy, Politics and Regulation, Vaccines

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Obamacare and CAM III: Great Expectations

In a previous post, we looked at how so-called “complementary and alternative medicine” (or “CAM”) might fit into the definition of “essential health benefits,” which must be covered by insurers pursuant to the Patient Protection and Affordable Care Act (“Obamacare,” or the “ACA”). In another, we contemplated what it might mean for insurers to “discriminate” against CAM providers, which is prohibited by the ACA. In both posts, the conclusion reached was that these provisions of Obamacare might not incorporate CAM practices into health care at the level CAM providers were hoping for. Here again we examine how the great expectations of CAM promoters may not be met in health care reform.

This time, we take a look at some additional provisions of the ACA that CAM lobbyists and their friends in Congress managed to insert into the healthcare overhaul. Of course, whether the ACA is around for much longer will depend on the outcome of the November elections, although Gov. Romney’s promise to “repeal Obamacare” if elected president will happen only if his party wins a majority in both the House of Representatives and Senate.  (more…)

Posted in: Acupuncture, Chiropractic, Legal, Naturopathy, Politics and Regulation

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Don’t call CAM “cost-effective” unless it’s actually effective

Your health insurance plan probably covers anti-inflammatory drugs. But does it cover acupuncture treatments? Should it? Which health services deliver good value for money? Lest you think the debate is limited to the United States (which is an outlier when it comes to health spending), even countries with publicly-run healthcare systems are scrutinizing spending. Devoting dollars to one area (say, hospitals) is effectively a decision not to spend on something else, (perhaps public health programs). All systems, be they public or private, allocate funds in ways to spend money in the most efficient way possible. Thoughtful decisions require a consideration of both benefits and costs.

One of the consistent positions put forward by contributors to this blog is that all health interventions should be evaluated based on the same evidence standard. From this perspective, there is no distinct basket of products and services which are labelled “alternative”, “complementary” or more recently “integrative”. There are only treatments and interventions which have been evaluated to be effective, and those that have not. The idea that these two categories should both be considered valid approaches is a testament to promoters of complementary and alternative medicine (CAM), who, unable to meet the scientific standard, have argued (largely successfully) for different standards and special consideration — be it product regulation (e.g., supplements) or practitioner regulation.

Yet promoters of CAM seek the imprimatur of legitimacy conferred by the tools of science. And in an environment of economic restraint in health spending, they further recognize that showing economic value of CAM is important. Consequently they use the tools of economics to argue a perspective, rather than answer a question. And that’s the case with a recent paper I noticed was being touted by alternative medicine practitioners. Entitled, Are complementary therapies and integrative care cost-effective? A systematic review of economic evaluations, it attempts to summarize economic evaluations conducted on CAM treatments. Why a systematic review? One of the more effective tools for evaluating health outcomes, a systematic review seeks to analyze all published (and unpublished) information on a focused question, using a standardized, transparent approach to evidence analysis. When done well, systematic reviews can sift through thousands of clinical trials to answer focused questions in ways that are less biased than cherry-picking individual studies. The Cochrane Review’s systematic reviews form one of the more respected sources of objective information (with some caveats) on the efficacy of different health interventions. So there’s been interest in applying the techniques of systematic reviews to questions of economics, where both costs and effects must be measured. Economic evaluations at their core seek to measure the “bang for the buck” of different health interventions. The most accurate economic analyses are built into prospective clinical trials. These studies collect real-world costs and patient consequences, and then allow an accurate evaluation of value-for-money. These types of analyses are rare, however. Most economic evaluations involve modelling (a little to a lot) where health effects and related costs are estimated, to arrive at a calculation of value. Then there’s a discussion of whether that value calculation is “cost-effective”. It’s little wonder that many health professionals look suspiciously at economic analyses: the models are complicated and involve so many variables with subjective inputs that it can be difficult to sort out what the real effects are. Not surprisingly, most economic analyses suggest treatments are cost-effective. Before diving into the study, let’s consider the approach:

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Posted in: Acupuncture, Chiropractic, Energy Medicine, Herbs & Supplements, Homeopathy, Naturopathy, Science and Medicine

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Obamacare and CAM II: Discrimination (or not) against CAM

Supporters of science-based medicine have expressed concern over this provision in the Patient Protection and Affordable Care Act (“Obamacare,” or the “ACA.”):

SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.

(a) PROVIDERS.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

Section 2706 (now codified as 42 U.S.C. Sec. 300gg-5) goes into effect in 2014 and covers virtually all individual and group insurance market policies, although it is not clear whether it will apply to existing policies “grandfathered” in 2010 by the ACA.

Section 2706 was not part of the U.S House of Representatives version of the ACA but was included in the Senate version (which ultimately passed) under the guidance of (surprise!) Sen. Tom Harkin (D-Iowa). It was heavily lobbied by the American Chiropractic Association and other “CAM” providers, as well as some “conventional” providers like nurse anesthetists and optometrists. The legislative history (reports, committee minutes, floor debates and the like which precede a vote on a bill) indicates it was specifically included to prevent discrimination against CAM providers.  This is of obvious concern to anyone who supports science-based, or for that matter evidence-based, medicine, as there is nothing to indicate that scientific plausibility or evidence (or the lack thereof) actually affects CAM practices. It should also concern insurers and those who pay for insurance (employers and individuals) to the extent it might require payment for CAM treatments, as ineffective treatments will negatively affect their bottom line. The U.S. Departments of Health and Human Services (HHS) and Labor and the Treasury Department, which are charged with issuing regulations implementing the ACA, have not yet promulgated regulations for Section 2706. The American Medical Association House of Delegates has already passed a resolution seeking its repeal.

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