I am a relatively new practitioner and have spent the last year doing continuing education in women's health including fertility and pregnancy. I attended Debra Bett's wonderful seminar in Chicago and have been trying to pursue opportunities to work more with this patient population. I called my malpractice carrier (Scott Danahy Naylon) who uses the American Acupuncture Council and was told that my standard malpractice does not cover essentially any pre-natal care including turning the baby, being in the delivery room, etc. I was told that anything that is done must be done under MD supervision and that the doctor must be aware of the treatment and consent. I was told that I would need to apply for the OB/GYN addendum and that the premium for such a thing is "steep." Can anyone provide further information? From the addendum that I was sent it also listed gynecology as a specialty category which makes me worry that the standard policy would also not cover anything relating to fertility?? I would greatly appreciate any guidance or advice. Thanks!
Malpractice Coverage-OB/GYN Addendum
Please do not take this as certain. But as it was explained to me a few years ago by acupuncture insurance guy at the American Acupuncture Council, we are safe as long as we are treating within our scope of practice. Turning a breech is not a TCM treatment strategy, but relieving qi stagnation in the lower jiao is. We can not "induce labor" but we can "freecourse the qi" with such points as LI4 and SP6. He said that the main distinction was how we approach and document it.
I was told this a few years ago, when they first offered the OB riders. As I understand it, the riders are more for working in an OB setting like a hospital. But again, please do not take this information as true. Things could have changed since then.
Jason Bussell
President - Illinois Association of Acupuncture and Oriental Medicine
Thanks for your response Jason.
My question then is what do you put down as chief complaint when someone comes in for induction, breech, morning sickness, or ivf (stress??) and does it become a matter of semantics? That client is coming in requesting help with the western condition for which we are not covered. It would seem to me that we can write Qi stagnation all we want on the chart, but when it comes down to it they are under the understanding that we are helping to treat the symptom for which they have come in for. How do we explain it in a way that we are not treating breech but qi stagnation and yet still try and and market our services as being helpful to treat conditions of infertility and pregnancy? My concern is that I say I am treating the TCM pattern, but the article I just wrote for a midwife network says it can help relieve symptoms such as morning sickness, breech presentation, etc. Does that not imply that we are treating the western conditions? I guess I am having trouble how to appropriately bridge the east/west gap??
Rebecca
The Chief Complaint is subjective. You can put down what the patient says. But in your assessment or TCM pattern differentiation, this is where you "diagnose" and set your treatment plan. It is like a mechanic: the customer comes in and thinks the problem is with his brakes, the mechanic tells him the problem is his transmission. In our note, the patient says she has morning sickness, I tell her she has counterflow qi.
You may have to be conservative in how you document. There are a few things that we are lot supposed to do: induce labor, stop labor, provide anesthesia during labor, and turning a breech. The patient may come in and say " I want to be induced", and you can tell her, "I am not allowed to intentionally induce. What I can help you with is to relax your sinews and rectify your qi. and this may help your baby come naturally" (of course explaining that as you would to a non-acu). If the patient agrees to that, then your presenting complaint can be "tension" and your assessment can be qi stagnation and your treatment strategy to free course qi.
Again, this is not intended to be definitive nor legal advice.
Jason Bussell
President - Illinois Association of Acupuncture and Oriental Medicine
I have extensively looked into this issue as I treated at least one pregnant woman a day on average for the last 9 years. I have American Acupuncture Council insurance as well and have had conversations with them as well as my clinic attorney. What I have learned is that treating breech presentation, inducing labor, and treatment during labor and delivery is considered the practice of obstetrics which in the eyes of the malpractice carrier is out of our scope of coverage. Unless you get the malpractice rider. (Which last time I checked a couple of years ago hovered around $18,000- $20,000 per year. I did speak to an AAAOM representative about this issue of it being so high and he thought it was a good cause for the AAAOM to take up.) Treating other conditions such as nausea & vomiting, back pain, and acid reflux, for example, is not the practice of obstetrics as long as the patient is under the care of a birth attendant- Ob/Gyn or midwife and you are not the one providing the primary care.
Some TCM practitioners are under the impression that if you document something using TCM terminology that you are covered. I believe that is wishful thinking. Let me give you an example. A woman calls you and she is 35 weeks pregnant. She tells you that her OB has just told her that the baby is breech. The patient does not want an external version or c-section and calls you for acupuncture. You have her come in and you evaluate her and give her an acupuncture treatment using acupuncture and moxibustion on UB 67 with some other constitutional points. You chart it as Qi & Blood stagnation in the lower jiao. Maybe she comes in a couple I times more.
So let's talk about the worst case scenario. The baby had a knot in the cord and at 39 weeks the knot cinched up and there was fetal demise. The family is distraught and names you as well as her OB in a lawsuit. One of the first things that will happen is that your malpractice insurance company will determine if you are covered under your policy or not. What they will see in the lawsuit as well as your medical notes is that a 34 week pregnant woman came in for acupuncture for turning of a breech baby. It will not matter if you called it Qi and Blood stagnation. Facts are facts. You still used UB 67 which has been proven by research to turn breech babies and it is documented by her OB that she was breech. Do you think that the insurance company would stand by your side when you practiced out of the scope of your policy which would potentially cost them millions of dollars? I would not count on it.
Treating pregnant women is risky business in the United States. You mentioned that you saw Debra Betts. She is great I agree and she lives in New Zealand. It does not seem like she has the limitations that we do here in the US. Thus she is able to practice these methods. We are medical practitioners and we have to abide by the same rules and account for the liabilities that MD's, DO's, Naturopath's, Midwives, Nurse's and the like do. It does not change because we use different terminology, the cause/effect relationship whether it is real or perceived is the same.
I am not saying to stop treating pregnant women but with all endeavors in life it is good to know the potential consequences of of your actions. In my practice I do not treat breech, induce labor or perform acupuncture during labor and delivery as I am not willing loose my livelihood and assets. You can make the choice for yourself. So if you have more questions the best thing to do is spend the money and consult with an attorney. They will have your best interest in mind. I would be hesitant to get advice from the malpractice company. They have given me wrong information in the past which is a whole different long post.
While we are an the subject of malpractice insurance. If you own a practice and you have people working for you say another acupuncturist or a massage therapist. You need to have the name of your business added to you policy in addition to your name. This costs $55 a year. The reason is that if your business is named in a lawsuit and it it not on your policy it will not be covered. For example: your acupuncturist employee has injured someone and they want to sue. They most likely will name the acupuncturist and the name of your clinic in the lawsuit. If all you have is your name on your malpractice policy your clinic will not be recognized. Again, I am not an attorney and I did not know this until I paid an attorney to go through all of my documents.
Dr. Dana Price DOM, L.Ac., Dipl.OM
ilumina: A Peaceful Path to Pregnancy and Healing
Scottsdale, Arizona
Hi As was mentioned I live in New Zealand and although we do not have the legal problems you are faced with I did face resistance from the medical professional at the start of practice – which included a specialist making all midwives sign a document that they would not practice acupuncture as hospital employees – ten years later he is on a radio show ( talking about the rise of pudoscience in medicine and how this is like asking Drs to work with witchdoctors ) saying that some alternative medicine may be useful – for instance acupuncture for morning sickness which he had seen as being useful and saw no harm, as it was safe for the women and baby ….
An example of change happening slowly from his exposure to acupuncture
My practice does not rely on treating women for the conditions that you are having limitations put on – breech, induction and being at labour - as 50 % of women come for prebirth acupuncture – which as I understand it, you would be able to advertise as offering in your practise
Breech – my question here would be that if you cannot use treatment to help with this can you direct women to sites that explain to them how to use moxa? You would not even need to directly give these web sites out to women – if you type moxa and breech into Google the first two sites come up contain this information ( including a video from Lorne Brown on you tube )
While turning breech may not be a large part of your practice I see problems for you as profession if you are restricted from practicing this – I am in Canada at the moment and in a local bookstore of the 26 pregnancy books - 12 books (mostly American publications from memory) recommended seeking a qualified acupuncturist to use moxa for breech due to the research that it is safe and effective – if women present at your clinic asking for this treatment and you are forced to say that you cannot do this I can imagine women wondering if indeed you are sufficiently qualified …..
As for inducing labour – this is something that I offer as a free treatment if it is needed for the women who have received prebirth treatment – and obviously I do this because this is something I only need to do infrequently – you could also advise women to seek out the use of acupressure to induce – again on the internet (including my acupressure booklet)- again something like 19 of those books recommended seeking acupuncture for this so you have the same problem with professionalism
As for attending labours – this has never been part of my practice (apart from friends) but I do train midwives who use it in labour – even then it is not something they routinely use – preferring to use acupressure unless there are problems …..
So my suggestion from what I understand, from the documents I have seen - would be that you could still build an obstetric practice using acupuncture using treatments for women for nausea , back pain, pelvic pain, haemorrhoids, heart burn, constipation, insomnia, anxiety, postnatal treatments etc incorporating prebirth treatments and acupressure for use during labour and if possible at some level challenge your association as to why you are not allowed to practice treatment for conditions that are recommended in the pregnancy books women are buying and that they can freely access over the internet ….
Free downloads on using prebirth acupuncture and acupressure booklets – http://acupuncture.rhizome.net.nz
d betts
http://acupuncture.rhizome.net.nz
Debra, thanks for the post. I would like to clarify that it is not our association that is limiting our practice. It is the malpractice insurance that most acupuncturists in America have. They have determined that turning breech, inducing labor, and performing acupuncture during labor and delivery carries too much risk. An acupuncturist can perform these without criminal ramifications as we are trained and qualified but when it comes to civil litigation one would have to go through it without the aid of our malpractice carrier.
I can tell you how we approach it in my clinic. When anyone calls for a new patient visit my receptionist always asks the reason they are coming in. If they say one of the above mentioned conditions they are told that we no longer perform those services as our malpractice does not cover it. My receptionist does not refer them to the web or give any information regarding moxa and breech because if it came to a lawsuit she would get sued for giving out medical advice and then my business would also get sued for not properly supervising her. Additionally, if someone called and wanted to buy moxa sticks and they were not a patient or even if a patient wanted to buy moxa sticks from me to turn breech I would not sell it to them because I still have some responsibility with the outcome. It is too bad and this is the price of living in a highly litigious society.
I wholeheartedly agree that one can have a thriving practice working with pregnant women and helping them tremendously. Acupuncture is such a perfect therapy for women during this time.
Dr. Dana Price DOM, L.Ac., Dipl.OM
Southwest Center for Oriental Medicine
Phoenix, Arizona
Hi Dana
Thanks for your comments – I was assuming that your association arranged the insurance cover with a certain provider (which is what happens in New Zealand). As a private practitioner I have the choice of several companies but it makes sense to join the cover offered through our association - they offer the most inclusive cover and have a close working relationship with the organisation.
Again being totally ignorant of your system, could your organisation not challenge these insurance providers?
It just seems so weird to me that women in America are being denied treatments that are being preformed by midwives with a few weeks training in other health care systems – and being recommended in American pregnancy books –
Most of our patients come with some kind of medical diagnosis …..
It seems along the lines of having your total practice limited – where you would not be able to treat lower back pain until a Dr had determined that it wasn’t Ca of the spine or a headache until a MRI had been done to rule out tumours – as I personally know two practitioners who picked up these conditions while treating, it seems a more likely scenario for an acupuncturist to be sued for continuing to treat while missing these symptoms than being sued for attempting moxa for turning breech or problems after induction – where I personally no of no problems or documented cases ….
PS In the case of the headaches the practitioner noted an uneven gait and asked him to do a few simple tests such as touch his nose with his index finger
With the back pain the practitioner asked about urination and the women calmly said that she had started wearing incontinence pads for the leakage and on further questioning admitted there was some loss of bowel control as well! – she had not told the GP who referred her to the acupuncturist this…….
d betts
http://acupuncture.rhizome.net.nz
Joined: 2007-11-15