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.
“Implemented as intended” refers to Section 2706 of the ACA, which prohibits “discrimination” in insurance coverage of services provided by any state licensed health care provider. According to the AANP (per Schoenback) this
suggest[s] that if insurers cover a health condition, they must pay any providers are licensed to treat that condition. If the insurer covers a service provided by medical doctors . . ., for example, it must also cover that service when provided by another legal provider, such as NDs, acupuncturists or chiropractors.
it’s a change our nation needs. Our health care system needs prevention-oriented, low-cost primary care that’s effective for chronic illness. There’s no profession that does that better than us.
It is just this sort of evidence-free delusion about their competency that makes further licensure of naturopaths such a disturbing prospect.
One true and many false assumptions
So let’s turn to their current efforts to become licensed primary care providers. The AANP announced licensure in 11 more states as its goal for 2013, and licensing legislation has been introduced to date in six: Arkansas, Colorado (for the umpteenth time), Illinois, Maryland, Massachusetts (also for the umpteenth time) and Michigan. David Gorski discussed the Michigan bill in his Monday post, but we’ll analyze it further here.
[I have copies of the bills introduced in all states except Maryland. The office of its sponsor promised to fax me a copy, but I never got it. My discussion will exclude Maryland except for what little information I can get from a summary of the bill, provided courtesy of the Maryland Association of Naturopathic Physicians.]
All bills share certain common assumptions, one of which is true. The others, both express and implied, are made without any evidence and are, in my opinion, false. These assumptions (in italics) and my comments follow.
First, the true assumption: There are naturopaths already practicing in the state even though they aren’t licensed.
Why are they allowed to practice? This is an incongruous state of affairs that no one seems to question. Apparently the way a group of CAM providers bootstraps its way into legality is to practice medicine in some form illegally until the state says it’s o.k. and gives them a license to do so. Why aren’t they being prosecuted for the unlicensed practice of medicine prior to their being licensed? And doesn’t this reward breaking the law?
And now for the false assumptions.
There is a demand for naturopathic health care.
This is stated in the findings of the Arkansas legislature as the raison d’etre for licensing:
A significant number of the citizens of this state are turning to naturopathic practitioners for their healthcare needs.
Other than the self-serving statements of naturopaths and perhaps a few of their patients, how do they know that there is any need or even desire for naturopaths? Specifically to Arkansas, a “significant number” should be, well, a “number” that is “significant.” Unquantified citizens cannot, by definition, be a “number,” and obviously cannot be “significant.”
So what is the evidence that such citizens exist? They don’t cite any. But I happen to have some stats. According to the Centers for Disease Control’s 2007 survey of complementary and alternative health care use, a miniscule three tenths of one percent of American adults saw a naturopath in 2007, up a mere one tenth of a percent from 2002. (National Health Statistics Report No. 12) Even in Washington State, where health insurance coverage of naturopathic services is mandated per state law, a study revealed that only one percent of a large sampling of insured pediatric patients (age birth-17 years) made a claim for naturopathic care in 2002, while 97.5 percent made a claim for a visit to a conventional medical provider. Of 600,000 insured persons (all ages) in Washington, another study found that only 1.6 percent made an insurance claim for naturopathic services in 2002. If giving NDs licenses to practice as primary care physicians and having insurance pay for their services doesn’t bring them in, what will?
Because there is a fictional market for naturopaths, the state must license them as health care providers. Among other presumed reasons, which are not stated, the public has “freedom of choice in health care.” Illinois and Arkansas specifically mention this “freedom” as a mandate for licensing.
Assuming, for the purposes of argument, that citizens desire licensing of naturopaths, let’s address the proposition that state licensing must necessarily follow. This means that licensing of health care providers is basically a popularity contest and equally available to all comers who profess they are such and can chum up enough legislators to agree with them. Whether these self-appointed health care providers actually provide safe and effective health care apparently is not open to question. If they say they do, then, ipso facto, they do. Otherwise, states obviously would not have licensed chiropractors, acupuncturists, homeopaths and naturopaths.
Having dispensed with the notion that safety and effectiveness are relevant to the issue, let’s move on to “freedom of choice.” Outside the inventive minds of naturopaths and other CAM providers, I know of no state or federal constitutional provision specifically guaranteeing a “freedom of choice” in healthcare which would translate into a state mandate that naturopaths be licensed. Apparently this is like those terms that CAM devotees use to sound “science-y.” “Freedom of choice” in health care sounds “legal-y” so they use it without defining what it means or citing the source of this allegedly guaranteed “freedom.”
Regulation of naturopathic practice is necessary to the health, welfare and safety of the state’s citizens.
This is necessarily an assumption behind all health care licensing because it is the constitutional basis of the state’s authority to regulate health care. But as we’ve demonstrated at SBM over and over, licensing naturopaths is anathema to the very notion of health, safety or welfare. One need only read Kimball Atwood’s informative series on naturopathy to thoroughly debunk that notion. Or Mark Crislip’s deconstruction of a naturopathic white paper, which discusses many of their pseudoscientific diagnostic methods and treatments as well as their opposition to vaccination.
And as David Gorski said just this past Monday:
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.
Obtaining a “naturopathic doctor” degree from a school accredited by the Council on Naturopathic Medical Education, which is recognized by the U.S. Department of Education as the accrediting agency for naturopathic medicine, and passing an exam administered by the North American Board of Naturopathic Examiners qualifies one to practice primary care medicine. (As we’ll see below, this is essentially the scope of practice allowed by the pending bills.)
First, as we know, the Department of Education does not care one whit about course content in general or its scientific validity in particular, and it has said as much. The Department looks only at administrative issues, like record keeping, conflicts of interest and financial stability. Department recognition of an accrediting agency says virtually nothing about the quality of education received at an accredited institution. This leaves a private agency created by and for naturopaths at the controls of naturopathic education.
And it shows. While naturopathic schools have misappropriated the term “medical” and pasted it onto their names, what they teach is nothing like a real medical school. Outside of naturopathy, little is known about the actual content of these courses – the only information available to the outside world are course names and brief descriptions. However, the Textbook of Natural Medicine (2013), the foundational text of naturopathy, provides some insight.
As we’ve previously seen, this text includes a chapter on humoral medicine, the ancient Greek system based on the presumed control over bodily function by the “four humors,” and not just as a matter of historical interest. The Textbook also includes chapters on Ayurveda (ancient Hindu medicine), fasting, glandular therapy, virtually universal food “sensitivities,” chronic candidiasis, functional toxicology and vaginal depletion packs. No responsible physician would use of these therapies or employ these diagnoses in the manner suggested by the Textbook. In addition, the Textbook suggests the use of dietary supplements for illnesses in cases which there is insufficient, or no, evidence of safety or effectiveness.
To add insult to injury, none of the licensing statutes has any residency requirement. Once they’ve graduated from medical or osteopathy school, real primary care physicians must go through residency training, an additional three years of hospital based training caring for the most vulnerable and sick patients.
After ND school, ND graduates head, sans residency, straight for the NPLEX exam, which, again, is created by naturopaths, for naturopaths. No one outside the naturopathic fraternity appears to know what is on this exam or whether it has any relevancy whatsoever to the actual practice of primary care. If anyone knows anything about this mysterious document, please advise. We are all anxious for information.
Apparently, none of this makes the slightest difference to the credulous legislators who introduce and vote for naturopathic licensure.
Now let’s look at what these legislators — based on the false assumptions they’ve made about naturopathic licensing — are going to let NDs do.
Scope of practice:
In all six states an ND can “diagnose” or “evaluate” any human condition, illness or disease in any patient, including children. In other words, they are licensed as primary care physicians, which, as noted earlier, is what they want. In other words, they are limited only by the methods they can use to diagnose and treat, but there is no limitation on what they can diagnose and treat. Here is what they should be able to do, according to one definition of primary care provided by the American Association of Family Physicians (emphasis added):
Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the “undifferentiated” patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.
Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and managed by a personal physician often collaborating with other health professionals, and utilizing consultation or referral as appropriate.
Primary care provides patient advocacy in the health care system to accomplish cost-effective care by coordination of health care services. Primary care promotes effective communication with patients and encourages the role of the patient as a partner in health care.
Other than providing some routine, non-controversial advice about exercise and diet (widely available from other sources, often at no cost) NDs are not properly educated and trained to practice the necessary elements of primary care, nor should they be allowed to until they can provide adequate evidence – not self-serving conclusory statements – that they have the appropriate skills and training.
The only limitation on their treatment of any condition or disease is in the Colorado bill. When a patient seeks treatment for cancer from an ND, the ND must
“recommend . . . that the patient consult with a licensed physician specializing in oncology.”
Note the disturbing implication here: that an ND is qualified to treat cancer.
“Natural” Treatments and OTC drugs:
All states allow use of some form of “natural substances,” including dietary supplements and homeopathy, which, as David Gorski correctly surmised:
Homeopathy is the perfect quackery. The reason that homeopathy is so perfect as a form of quackery is because it is quite literally nothing.
Most bills specifically include OTC drugs. Some bills also allow amino acids, enzymes, “natural” antibiotics, bioidentical or “natural” hormones and barrier contraceptives and NDs can sell at least some of these products to their patients in all states. By the way, according to the highly regarded publication, The Medical Letter, bioidentical hormones can have the same adverse effects as conventional hormone prescriptions. It concludes:
There is no acceptable evidence that ‘bioidentical’ hormones are safe or effective. Patients should be discouraged from taking them.
These are permitted, including controlled substances, if on the naturopathic formulary, in Michigan (with additional training) and Colorado. “Some pharmaceutical drugs” are permitted in Maryland if on their formulary. As Mark Crislip said:
I will pause here to point out that if a provider believes that homeopathy is a reasonable therapeutic intervention, they cannot be trusted to understand modern pharmacology. . . If I were Pfizer I would be turning my sales force loose on the 800 plus ND’s in Oregon [who can prescribe drugs]: they have no background to understand the truth of what they are told, they have no critical thinking skills, they are used to accepting authority over evidence, they have no issues with being subsidized by industry, and crave respectability. Perfect fodder for the drug rep. They don’t have a chance. And neither do their patients.
This generally includes some combination of manual therapy, electrotherapy, diathermy, ultraviolet light, ultrasound and hydrotherapy. All of these have legitimate uses, but some have the potential to become quackery in the hands of naturopaths. For example, “hydrotherapy” includes colonic irrigation to remove “toxins,” alternating hot and cold footbaths, and wrapping patients in wet towels. “Electrotherapy” includes “electroacupuncture” and “manual medicine” includes craniosacral therapy.
NDs can perform “minor office procedures” in all states but only with additional training in Arkansas and Michigan. (Maryland unknown.) Surgery is not specifically included or excluded in Illinois (best I can tell).
NDs can employ lab testing, physical exam and radiological studies in Massachusetts, Michigan and Colorado, and in Arkansas if permitted by rule. Michigan allows use of “minor office procedures” to diagnose, so presumably can do tissue biopsies. (Not specifically mentioned in Illinois; Maryland unknown.)
As I pointed out in the previous post on last year’s ND licensing bill in Massachusetts:
I will leave it to others to evaluate naturopaths’ level of understanding of conventional lab tests and x-rays. But it is worth noting that the Textbook of Natural Medicine (2013), the foundational text of naturopathic education and practice, has an entire section (Section 2) titled “Supplementary Diagnostic Procedures.” I take “supplementary” to mean “not used in conventional medicine, at least not in this way.” The twenty-two chapters include several tests for detection of the ubiquitous “toxins” naturopaths believe are causing ill health in us all. Other tests address “functional nutritional analysis,” a standard of “functional medicine,” and “immune function assessment,” because, as we know, naturopathy is all about “boosting the immune system,” another fuzzy and essentially meaningless term they use. In addition to being unnecessary themselves, the results of these tests can lead to all sorts of unnecessary treatments, such as vitamins, minerals and “detoxification.”
Governance and Oversight:
Board of Naturopathy (i.e., self-governance) in Colorado and Massachusetts; Board of Medicine or a state licensing department, with advice from naturopathy advisory board, in Michigan, Arkansas and Maryland (which puts one ND on medical board); Board of Medicine, to which an ND will be appointed, in Illinois.
Yes, if allowed by rule enacted by governing board, in Massachusetts and Arkansas.
Licensure by endorsement:
In other words, NDs can practice in the state if licensed in another state and if they meet certain minimum requirements. Licensure by endorsement is permitted in Illinois, Michigan, Arkansas and Colorado. (Maryland unknown.) This is important because underemployed and unemployed NDs will likely want to move to other states where there is more work. The four ND schools in the U.S. graduate more students than is currently necessary to meet demand, which is negligible.
In states where NDs are already licensed, the following legislation is proposed:
Bills filed in the Senate and House makes the legislative finding that “naturopathic physicians [who apparently don’t subscribe to The Medical Letter] are known for their expertise in bio-identical hormones.” Thus, if passed, Hawaii would allow NDs to prescribe bio-identical testosterone, a controlled substance in that state.
I previously posted about NDs not getting included in coordinated care organizations (CCOs), which are designed to reduce Medicaid costs, because they don’t practice evidence-based medicine, a statutory requirement for CCO care. As noted in that post, they went crying to their friends in state government to make the mean old CCOs let them participate. This effort has come to fruition in the form of House Bill 2522, which forces CCOs to provide members with access to chiropractic and naturopathic services as primary care and access to acupuncturists and massage therapists for specialty care. The CCOs must pay these providers for their services at the same reimbursement rate they pay to all providers without regard to the license or certification of the provider. So even though the law requires the practice of evidence-based medicine it will also require the inclusion of practitioners who don’t practice evidence-based medicine. Go figure.
Senate Bill 108 attempts to tighten up the regulation of NDs by the Naturopathic Medicine board. According to an article in the Portland Business Journal dated January 30, 2013 (which is no longer available online), the most common complaints “involve personal boundary issues between the caregiver and the patient, as well as the writing of prescriptions for chronic pain management.” Complaints are directed at 4 per cent of licensed NDs (n = about 1,000) but that doesn’t indicate how many are actually practicing, which is likely a lower number.
On the other hand, Senate Bill 302 abolishes the Oregon Board of Naturopathic Medicine (and the State Board of Chiropractic Examiners, along with other regulatory boards) and transfers all of their duties, including discipline and rulemaking, to a single entity, the Oregon Health Licensing Agency. Whether this will provide some reasonable regulation and oversight remains to be seen.
Help is on the way
Other than the glimmer of hope offered by the possibility of abolishing the Oregon ND Board, these bills continue to demonstrate a remarkable lack of critical thinking on the part of state legislators. So, as you will see in Fighting Back, above, I decided to help them out.
I just learned that a naturopathic licensing bill was introduced in Pennsylvania on February 6. The text of House Bill 612 is not available yet, but a summary provided by its sponsor, Rep. Mark Mustio, contains many of the evidence-free assumptions discussed above:
Licensure of Naturopathic Doctors will help to fill the medical void in many communities lacking general practice doctors. Naturopathic Doctors complete a four-year, graduate level medical school program and pass medical boards. These Doctors are highly trained specialists in the areas of nutrition, herbal medicine, homeopathy, and are the only group of medical providers trained in herb-drug and herb-nutraceutical interactions. . . . Licensure of Naturopathic Doctors will help patients who are seeking naturopathic medical care select qualified and accredited practitioners. . . .Licensure of Naturopathic Doctors would give Pennsylvania residents a choice in their health care and provide for an integrative model of healthcare. The patients of Pennsylvania Naturopathic Doctors deserve access to the care their doctors can provide and the State of Pennsylvania needs quality care providers who will reduce the burden of chronic disease.