Integrating Acupuncture into Primary Care

Introduction

Although acupuncture is entering the mainstream as an option for the treatment of a variety of pain conditions, acupuncture providers have not been widely integrated into the biomedical setting. Numerous studies demonstrate the effectiveness of acupuncture for pain, both in primary care and with underserved populations ^{1 –4} ; however, there is a scarcity of research that examines the integration of acupuncture into the primary care home. Vickers et al., in their 2018 updated meta-analysis of acupuncture for chronic pain, not only concluded that acupuncture is a reasonable referral option for patients with chronic pain, but also called for more research on the successful incorporation of acupuncture into the multidisciplinary health care setting. ³ A 2011 study (Acupuncture to Decrease Disparities in Outcomes of Pain Treatment—ADDOPT) examined the use of group acupuncture for pain in a specifically low-income ethnically diverse medically underserved population in four community health centers in Bronx, New York. Researchers concluded that new models of care are needed to address barriers to access for these populations. ¹

Winding Waters Community Health Center (WWCHC), located in Wallowa County, Oregon (population 6864), serves 4400 unique patients annually in 29,500 visits. According to the Rural Health Information Hub (RHIH), ⁵ a frontier county has fewer than seven people per square mile. Frontier communities face many unique challenges to providing adequate health care. These include recruitment of health care professionals and transportation for low-income and elderly people. According to RHIH, “Rural communities are at higher risk for substance abuse, suicide, motor vehicle fatalities, obesity, cigarette smoking, and death from unintentional injuries.” ⁵ Based on current population and a geographic area of 3146 square miles, Wallowa County currently has 2.2 people per square mile and is located 323 miles from Portland, which is Oregon's primary population center.

As the community's largest health care clinic, WWCHC serves all residents but targets those with income <200% of the federal poverty level (FPL), the range at which children and adults are more likely to experience poor health and engage in high-risk behaviors. ⁶ Thirty-five percent of Wallowa County residents are within the target population. The age breakdown of those living in poverty is as follows: 46.5% of those aging 35–44 years, 35.2% of those aging 45–54 years, 16% of those 55–64 years, and 35.6% of those 65 years and older. ⁷

Although population has been stable over the past 100 years, the median age in Wallowa County has continued to increase and is currently 52.7 years, which is significantly older than the statewide median (39.2 years). ⁸ 46.8% of the population is over 55 years and 27% is over 65 years, ⁹ a number that is projected to increase by 59% between 2010 and 2030. ¹⁰ A 2019 Needs Assessment Survey for Wallowa County shows that 44.9% of the population over the age of 65 years is retired, and 46.2% of households receive social security income, whereas 24.5% receive retirement income. ⁹ WWCHC serves patients with all types of health insurance. Whereas 93.8% of the population has health insurance, 64.4% has private and 50.6% has public insurance (Oregon Medicaid and Medicare), 6.2% of people are uninsured. ⁹

WWCHC integrated acupuncture services with a licensed acupuncturist into clinic-wide services in 2016. The acupuncturist had access to all support staff and services, including front desk staff for patient scheduling, Care Coordination Team for referral and prior authorization processing, and billing staff for all accounts receivable and insurance billing. As a Federally Qualified Healthcare Center (FQHC), WWCHC has an income-based sliding fee scale for all medical services, including acupuncture services.

The primary objective of this analysis and chart review was to investigate the integration of acupuncture services within a Patient-Centered Primary Care Home (PCPCH) and FQHC located in a frontier community. The study had two primary aims: (1) to assess demographics, clinical characteristics, and utilization patterns of patients who accessed acupuncture services at Winding Waters Community Health Center (WWCHC) and (2) to perform a cost analysis using a basic revenue versus expense calculation. Cost is a recognized implementation outcome, ¹¹ so study results may contribute to a more comprehensive implementation study within a similar clinical environment.

Methods

This observational study consisted of two primary components: (1) a retrospective chart review and (2) a basic cost versus revenue assessment. The retrospective chart review analyzed data from WWCHC's Epic Ochin electronic health record (EHR). To be included in the analysis, patients were required to be ≥18 years and must have accessed acupuncture services at WWCHC between January 2017 and December 2018. Demographic data gathered included gender, age, and income level (based on percentage of FPL). Data also included the number of acupuncture visits received by each patient, primary diagnosis codes for acupuncture visits, methods of payment, and number of in-house acupuncture referrals generated. All patient records were deidentified.

Demographic and clinical data were gathered using SAP's Business Objects Tool ¹² and exported to Excel version 16.16.6 for basic descriptive analysis. Filters were applied to sort demographic data by gender, age, and income levels to determine trends in frequency of use and common diagnoses.

The cost-benefit analysis comprised a basic comparison of acupuncture-related revenue versus expenses. Revenue included net charges for acupuncture services, less adjustments. Adjustments included write-offs for sliding fee scale, claims denied by insurance companies, shortfalls in insurance payments versus claims billed, and nonpayment by self-pay patients. Expenses included wages and benefits, payroll taxes, occupancy (square footage of treatment space and insurance), licensing and malpractice insurance, professional development (continuing education and related travel), acupuncture supplies, and membership dues and subscriptions. Financial viability of acupuncture services was determined based on whether or not revenue exceeded expenses for the calendar year 2018, which is the first full year that current accounting software and systems have been in place at WWCHC.

Results

Data were analyzed from 3210 acupuncture visits with 551 unique patients at WWCHC. Some of these patients were referred by a medical provider and others were self-referred. The number of treatments received by each patient during this time varied from 1 to >20. Fifty percent of patients (277) received between two and five treatments, and the mean number of visits was 6 (±9.9) (Table 1).

The age of patients utilizing acupuncture services varied from 18 to 93 years. One of the most notable demographics in the analysis was the prevalence of older patients. Sixty percent of acupuncture patients were aging 50 years and older (Table 1). Twenty-six percent were over the age of 65 years. The median age was 55 years, which is slightly higher than the median age within the community. Mean age was 53 years (±16.9). Data outlining the gender of patients were incomplete. Fifty-four percent of patients identified as female, 20.5% identified as male, and 25% of patients did not respond. This is in contrast to Wallowa County demographics, which show 48% of the population identifies as male and 51% as female. ¹³

In keeping with prevalence of evidence supporting the use of acupuncture for the treatment and management of pain, ³ the majority of primary diagnosis codes billed were for pain conditions. The most common conditions treated (46.6%) were back and neck pain (30.7% for low back and sciatic pain, 3.4% for thoracic back pain conditions, and 12.5% for neck pain). 8.8% of visits were for migraines or headaches, 3.6% were for knee pain, and 4.9% were for shoulder pain. All other pain conditions made up 19.5% of total visits (Table 1).

Data regarding referrals indicated that WWCHC medical providers actively refer patients to acupuncture. Of 551 unique patients, ∼538 (98%) received in-house referrals placed by 10 medical providers and visiting residents (Table 1). (WWCHC is a Campus for Rural Health for Oregon Health Sciences University and, as such, has an active rotation of family medicine residents on staff.)

WWCHC serves a large number of people living in poverty and offers a sliding fee scale for all medical services, including acupuncture services. Sliding fees are determined by the patient's reported income relative to FPL. Data show that, despite discounts, the majority of acupuncture visits (65.9%) were utilized by patients above the 200% FPL threshold. Eighteen percent of visits were utilized by patients with the most economic challenges, those at or below 100% of FPL (Table 1).

WWCHC and its providers are credentialed with and bill a variety of insurance companies for services, including the Oregon Health Plan, Oregon's Medicaid plan. From 2017 to 2018, the number of patients who self-paid for acupuncture visits and claims billed to commercial insurance payors increased, whereas Medicaid claims decreased. Rates of payment on all claims billed remained low (Table 2). Approximately 30% of WWCHC patients receive Medicaid benefits, which authorizes payment for acupuncture services for certain conditions. In 2017, 30% of acupuncture claims were billed to Medicaid. In 2018, that number dropped to 22%. In 2017, 22% of all services billed were billed to patients, whereas in 2018, 31% of services billed were billed to patients. 2018 also saw a slight increase in claims billed to commercial insurance, from 39% in 2017 to 42%. Claims billed through VA Choice also decreased from 8.6% in 2017 to 4.6% in 2018 (Table 2). Overall, WWCHC showed an increase in acupuncture claims billed in 2018, billing 12% more claims than in 2017 but did not show any significant increase in the rate of payment on claims billed.

There was a discrepancy between the amount billed for services versus actual reimbursement (Table 2). In 2017, commercial insurance companies paid 38% of claims billed. This number increased slightly to 48% in 2018. Medicaid paid 36% of claims billed in 2017 and 34% in 2018. VA Choice was steady in reimbursement rates, paying 69% of claims billed in both years. Despite the low rates of reimbursement, overall revenue for acupuncture services exceeded basic expenses by 4%.

Discussion

When acupuncture exists only as a private practice, separate from the biomedical environment, services are often cost-prohibitive for low income patients. ^1,14 Community acupuncture models offer an affordable option, providing acupuncture in a group setting with a sliding fee scale. ¹⁵ In the ADDOPT feasibility study, student interns performed acupuncture in four Bronx health centers for patients with chronic pain, including osteoarthritis, neck and back pain. Patients not only expressed a positive response to acupuncture but also indicated that cost and access to treatment were significant barriers. ¹⁴ Although this group acupuncture approach provides increased access to low income individuals in urban environments, clinical experience suggests that the group treatment environment is not always desirable for patients, especially in a small rural community, where privacy and transportation issues are concerns.

Researchers in the ADDOPT study concluded that “New models are needed to address issues of cost and access to care for this [low-income, ethnically diverse, medically underserved] population.” ¹⁴ This study, implemented in a medically underserved rural community within a Federally Qualified Health Center, begins to address these research needs by examining the age and income levels of patients utilizing acupuncture services, the willingness of medical providers to refer patients to acupuncture, and the limitations around insurance reimbursement for acupuncture services.

At WWCHC, patients have been able to engage acupuncture services within the clinic, regardless of socioeconomic status. Although the majority of patients receiving acupuncture had income levels >200% of FPL, 18% had income levels <100% of FPL. High utilization at lower economic levels is likely due to the availability of Medicaid benefits covering acupuncture services for certain conditions.

In the WWCHC clinical setting, a majority of patients utilizing acupuncture services are over the age of 50 years, which is consistent with the community's median age, and 26% of acupuncture patients were >65 years. In a community with a large number of older residents, these numbers indicate that acupuncture is a reasonable and acceptable form of treatment, especially when it is available within the primary care clinic. Given the frontier setting of this community, it is worth further exploring how barriers, such as transportation, education, and lack of insurance coverage, prevent many patients from utilizing acupuncture services.

Studies from the United Kingdom provide some evidence for integrating acupuncture into primary care. A 2004 study investigating the addition of acupuncture to usual care for the treatment of chronic headache resulted in clinically significant benefits and authors recommended the expansion of National Health Services coverage to include acupuncture. ¹⁶ Another 2004 study surveyed primary care providers about the integration of complementary and alternative medicine (CAM) services, including acupuncture, into the primary care environment. ¹⁷ Survey results indicated that most respondents were in favor of integration and many, in response to patient demand, were already referring patients for CAM therapies. Data from WWCHC add to the existing evidence base and suggest that, even without access to student interns, the integration of a licensed acupuncturist into the medical provider team is a viable model and can provide affordable access to acupuncture services for populations that might not otherwise have the opportunity to take advantage of them.

More than 74% of patients receiving acupuncture treatment had a pain diagnosis—low back, neck, and other pain disorders. Owing to data extraction barriers, only primary diagnosis codes were available. Many visits were coded with multiple diagnoses but, for insurance billing purposes, appropriate pain codes were always prioritized. The inability to assess secondary and tertiary diagnoses limits the scope of these findings; however, results do support existing evidence that acupuncture provides a reasonable and acceptable alternative for the management of pain conditions. Most patients utilizing acupuncture receive multiple treatments. The majority of patients receive between 2 and 5 treatments, but 9.3% of patients received >13 treatments.

Within this primary care setting, medical providers actively refer patients for acupuncture treatment. Under the guidance of WWCHC medical providers, the willingness of visiting residents from Oregon Health Sciences University to refer patients for acupuncture treatment suggests that this integrated model of care may provide an opportunity to educate new medical providers about acupuncture services. Further study should explore other implementation outcomes ¹¹ through provider surveys, interviews, or focus groups to determine acceptability, perceived appropriateness, and feasibility of integrating acupuncture and an acupuncture provider into the medical treatment team.

Although this Primary Care Clinic is actively billing a variety of insurance plans, including Oregon Medicaid, adequate reimbursement for services remains a challenge. It is possible that changes in requirements for referrals and prior authorizations through Medicaid contributed to the decrease in Medicaid claims and the increase in patients who self-paid for services in 2018. Another possibility is that in 2018, more patients did not have Medicaid insurance. The increase in acupuncture claims paid by commercial insurance plans could reflect an increase in commercial insurance coverage or could be attributed to a better understanding of the prior authorization and billing processes for acupuncture services by clinic staff. The significant decrease in claims billed through VA Choice in 2018 may relate to increased requirements for veterans to receive authorization for acupuncture services. In an underserved and economically challenged frontier community, offering a sliding fee scale based on FPL may increase access to acupuncture services, and some patients who do not have insurance coverage for acupuncture are willing to pay cash.

Frontier communities face many unique challenges. Barriers to health care, especially alternative options, such as acupuncture, are often significant. Embedding acupuncture services in an FQHC that is focused on improving access to care removes many of these obstacles. With access to the full range of clinic care team services, patients receive assistance with transportation, fuel cost, insurance applications, and appointment scheduling. Working within a multidisciplinary treatment team allows staff acupuncturists to actively coordinate care with medical providers, mental and behavioral health specialists, and dental providers. The opportunity to serve patients as an employee of a clinic rather than assuming the risks of sole proprietorship will make acupuncture practice more sustainable in these communities and improve recruitment and retention of acupuncture providers.

Given patient utilization and medical provider referrals, it appears that acupuncture is an accepted and accessible method of treatment within the WWCHC clinical setting. Although adequate reimbursement for acupuncture services is a challenge, it remains a financially viable addition to the clinic's overall medical services. This study used only the most basic revenue versus expense analysis to determine the cost of integrating acupuncture services into the clinic model. A more thorough assessment of cost-effectiveness and cost-benefit analysis would be useful to determine the long-term sustainability of integration. A closer look at referral and billing procedures could also illuminate specific challenges with implementation by optimizing reimbursement. Areas to consider include staff familiarity with billing and prior authorization requirements for acupuncture services, medical provider understanding of referral requirements, acupuncture provider understanding of correct coding and documentation, and patient education regarding insurance benefits.

Based on these study results and the limited amount of existing research about the addition of acupuncture services to the primary care environment, more study into the implementation of this integrated model of care is warranted. Future research questions could consider benefits and challenges to integrating acupuncture into an existing primary care clinic by investigating other implementation outcomes through qualitative methods. Comparisons of integrated models and patient demographics in frontier versus rural versus urban settings, viability comparisons between models using acupuncture students versus employee acupuncturists, and changes in patient health outcomes when acupuncture is added to primary care services could provide insight into implementation successes and barriers.

Conclusion

The acupuncture program at WWCHC is economically feasible and well utilized by patients. Adequate reimbursement is a challenge, but this program remains financially viable, while providing a nonpharmacologic treatment option in this frontier setting. Revenue for acupuncture services exceeded costs by 4%. Further study into the implementation of this integrated model of care is warranted.