Community Model Improves Access
By Sara Calabro
Back in 2006, John Weeks, editor of The Integrator Blog, called the community acupuncture model “one of the most exciting recent developments in the business of integrated care.” His conclusion was based on discussions with Lisa Rohleder, founder of Working Class Acupuncture in Portland, OR, and author of The Remedy and Acupuncture Is Like Noodles.
Rohleder has become the public voice of the community acupuncture movement, which she believes has the power to create major change in healthcare. In the four years since Weeks endorsed the model, Rohleder has evolved her thinking on some issues—namely, the ease with which Working Class Acupuncture‘s success can be replicated—while steadfastly continuing to champion the clinical and social benefits of community acupuncture.
AcuTake recently spoke with her.
AcuTake: The community model, with slide-scale fees between $15 and $40, makes acupuncture financially accessible. But is community acupuncture, where people are treated in a group setting and receive less one-on-one attention, as clinically effective as private practice?
Lisa Rohleder: I have been an acupuncturist for 16 years, and as far as I can tell, all forms of acupuncture work equally well—community acupuncture, private acupuncture, and all the various traditions and styles of practice. In fact, as we’ve seen with many recent studies, acupuncture is so powerful that even sham acupuncture works! What makes community acupuncture most effective is its accessibility.
Acupuncture works beautifully for lots of conditions, but it rarely works fast. That is the trade off you get for something that is so gentle and non-toxic. There are plenty of instances of dramatic outcomes from acupuncture, but you should not go into it expecting that.
A more realistic expectation is that it will work gradually over time. With that in mind, you really want to think about not just how to get an acupuncture treatment but how to get a complete course of treatment.
A lot of people can scrape together $75 for one treatment, but not $750 for a course of 10 treatments. Under the conventional private-practice model, even if people can come up with enough money to get acupuncture for a while, the minute they are barely better enough to stop, they do. Maintenance treatments, the ones that take place after the original condition has subsided, are what prevent the same problems from coming back. Acupuncture is preventative, but only when administered regularly.
Do all conditions require ongoing treatments?
No, but a lot of the people who can benefit most from acupuncture are those whose jobs are a big factor is whatever condition they’re suffering from. For example, baristas with wrist pain, construction workers with back pain, hairdressers with wrist and neck pain, teachers with high stress. In these situations, the condition might get better after a few treatments, but because daily circumstances and environment directly contribute to the ailment, the odds are high that it’ll come back. Community acupuncture helps people maintain themselves so they can keep doing their jobs.
Are there certain ailments for which community acupuncture is especially appropriate?
The accessibility of community acupuncture makes it beneficial for all kinds of problems. If it’s an acute issue, such as a sprained ankle, multiple treatments within a short period of time are recommended. Because community acupuncture is affordable, it’s realistic that the patient can come in five days in a row. For chronic problems, it’s no contest—community acupuncture is better. Acupuncture does not reverse chronic illness; it helps manage the condition and alleviate side effects from medications. When treating chronic conditions with acupuncture, there is not necessarily a beginning and end point. It’s more about maintenance. With community acupuncture, patients can make acupuncture an ongoing part of their overall healthcare plan.
In addition to accessibility, community acupuncture can be more beneficial in cases where illness or pain has an isolating effect. Certain kinds of chronic pain, for example, can cause people to feel very alone. The community setting, because it includes other patients, encourages people to interact with their conditions in ways that are not possible in a one-on-one private-practice setting. Being treated with other people can be healing.
What about conditions that are typically thought of as more private, such as depression or perhaps pain in certain parts of the body?
The feedback we’ve gotten is that community acupuncture is infinitely more private than any hospital setting, and more than most doctors’ offices. For pain conditions, we do not need to directly access the painful parts of the body. Most pain conditions can be treated distally, with points below the elbows and knees. Regarding patients who seek acupuncture for mental health issues, we don’t need to engage in a lengthy, intimate discussion in order to help them. We see acupuncture as something that is not verbal. If you are talking a lot during acupuncture, you’re missing the point.
Extensive verbal interaction does not have anything inherently to do with acupuncture. People can get that kind of one-on-one interaction from another type of practitioner, such as a psychotherapist. I don’t dispute the value of that kind of interaction, but if someone wants that, there are other modalities that are more appropriate. It is a conversation worth having whether the lengthy verbal interaction that has become common in private practice is something that belongs with acupuncture. We are not trained for that kind of emotional clinical work. You can open up whole cans of worms that acupuncture education does not prepare students to deal with.
In your books, The Remedy and Acupuncture Is Like Noodles, you talk about how community acupuncture is a more viable and sustainable career option for acupuncturists than private practice. From an acupuncturist’s perspective, why is community-style practice the way to go?
The way acupuncture works, if you’re not able to provide a full course of treatment, you won’t see results. It’s enormously painful and frustrating from a professional standpoint to have someone come in with something you know you can help them with and not be able to because they can’t afford it. It’s hard in terms of your relationship with the person and it also, over time, has a terrible effect on your confidence. What I see with a lot of acupuncturists, especially new ones out of school, is that when they don’t see enough people, they start to doubt themselves and their skills start to erode. There can be an unpleasant viscous circle that gets set in motion: Because of the prices, people don’t come for acupuncture frequently enough, which then leads them to think acupuncture doesn’t work. After a while, the acupuncturist starts to think the same thing.
It sounds like the community model addresses a lot of the issues associated with limited accessibly to acupuncture. Why aren’t we seeing more community clinics pop up?
It’s actually amazing to me that we have as many community acupuncture clinics as we do. [According to the Community Acupuncture Network (CAN) website, there are currently 166 full-time community clinics throughout the U.S.] It took us a while to realize this in terms of opening up clinics and getting acupuncturists interested in this. We originally thought, if people don’t want to do community acupuncture, they’ll probably open up a private practice. But the reality is that an incredible number of acupuncture-school graduates do neither.
There are two reasons that so few acupuncturists actually do acupuncture for a living. One is that a lot of people come out of school terrified to stick needles in anyone because of the way the schooling is, overly focused on book learning without nearly enough clinical practice. The second reason is that it’s asking a lot to expect people to be acupuncturists and entrepreneurs. Most of us aren’t. The schools exclusively groom students for private practice. And admittedly, the community movement has not done anything so far to address this difficulty. Regardless of whether you’re talking about private or community acupuncture, the question is, are you going to be able to open up a clinic, period? Most people don’t.
Considering the challenges of entrepreneurship, do you still believe community acupuncture is a feasible career path for acupuncturists?
It is a viable model, but it depends on the person executing the model. You can see the acupuncturists who have an entrepreneurial streak. For those people, no matter what model they chose, they’re going to do pretty well. People who don’t have that streak are going to struggle. The community model has some built-in benefits because startup costs are less and it’s easier to market, but it still doesn’t solve the problem of asking people to start businesses.
One of the big misconceptions among acupuncturists in general is that it’s not hard to start or run a business. You can spend a lot of time thinking about what kind of acupuncture you want to do, but if you’re not thinking about how to set up QuickBooks, you’re not going to be doing acupuncture at all. When I first started talking about the community acupuncture model, I really underestimated how hard it is for people to start businesses, regardless of what model they’re using.
Whether or not community acupuncture provides a feasible career path also depends on your definition of making a living. Some people define that as taking home $80,000 a year. I don’t. My goal was always to be able to support myself just doing acupuncture, without having a second job. I see more community acupuncturists doing that than I see private-practice acupuncturists doing it. A lot of people are very attached to the private-practice model and they continue to do it until they give up on acupuncture all together.
The discussions we’re having with CAN now have to do with acupuncturists having employees—managing people, hiring, setting up structures for payrolls. I have never seen those discussions happening anywhere in the acupuncture world. If private acupuncturists were doing as well as they say they are, someone would have talked about hiring a long time ago. We are the ones starting this conversation.
What role can acupuncture education play in encouraging acupuncturists to join the community acupuncture movement, and in better preparing students for the realities of acupuncture practice in general?
We have tried, unsuccessfully, to get community acupuncture into the schools. Acupuncture education is off in its own world, and it’s able to be because taxpayers subsidize it. The way the business of schooling works, schools are not accountable for their results. They just need people to keep signing on the dotted line for student loans. Acupuncture education is itself the product; it’s the reason we have an industry. The acupuncture education industry is infinitely more stable and real than the actual business of delivering acupuncture treatments. Acupuncture education has no relationship whatsoever to what happens in the real world. That’s the bigger gulf than community acupuncture versus private.
So what’s your advice to acupuncturists who want to get involved in community acupuncture?
The best way to get acquainted with this movement is to connect with the community that’s already moving it forward. If there is a community clinic near you, go get a treatment. Also, join CAN and read the member forums on the website. If you can get to a workshop, take one. One way or another, connect with the CAN community.
CAN requires some specific parameters in order for community clinics to be considered part of the network. For example, clinics must be open a certain number of days per week and charge according to defined sliding-scale fees. Why is this necessary?
Early on, we didn’t have parameters. But we ran into some problematic situations very quickly and kept running into them. One situation was a practitioner saying, “I work in a very wealthy community, where an appropriate sliding scale is $80-$200.” Regardless of where you’re working, charging $80 and up for treatments is obviously at odds with the larger mission of the community acupuncture movement. Situation number two, which happened with disturbing frequency, was practitioners using community acupuncture as a loss leader. They’d advertise a community practice that’s open one day a week, then when the patient went in for treatment they were told that in order to get the full benefits of acupuncture they’d need to sign up for private treatments at higher costs. That totally defeats the purpose of what we’re trying to do.
The reason we started CAN was to have more places to send patients and their family members for acupuncture. In many ways, CAN is a collective branding exercise, meaning that we want people to know what to expect when they walk into a community acupuncture clinic. Without consistency, we can’t get any collective momentum.
You talk in Acupuncture Is Like Noodles about how community acupuncture is essentially a microcosm of healthcare reform in that it can flourish outside prohibitive institutions like managed care and the pharmaceutical industry. Is there a way for community acupuncture to coexist with mainstream medicine?
We get dozens of referrals per month from physicians in our area. We don’t know these doctors and we don’t actively market to them. They find out about us through word-of-mouth recommendations from patients. And we treat people all the time who go to a private acupuncturist for their 10 visits per year that are covered by insurance and then come to us once those run out. So we’re coexisting with mainstream systems in that way. But in general, I don’t see that the larger healthcare system has any interest in acupuncture. I am just pragmatic about it.
What I see so far is that insurance coverage for acupuncture rarely meshes with how acupuncture works best. When people have coverage for acupuncture, they either get a limited number of visits per year or a lot of visits for very specific conditions—nausea from chemotherapy, for example. That is a marketing nightmare for acupuncturists. The way acupuncture works in real life, with real people, does not jibe with insurance.
Insurance is similar to acupuncture education in that it’s a radically different business model from the real-life business of administering acupuncture. Acupuncture tends to work slowly over time, for prevention. Under the insurance model, how could you code for “acupuncture isn’t helping the patient’s bone spur, the condition she came in for, but she is now sleeping better, has more energy, and feels less stressed.” That happens all the time. It’s the reality of clinical practice.
Featured photo by Sara Calabro
Photo of Lisa Rohleder by Ellen Vincent