}

If You Can’t Be a Good Example…

My life is different in many ways now that POCA has a school, and one of them is that when a colleague sends me an email that starts out with “holy shit” and ends with a link to a news story about an acupuncturist getting arrested for financial crimes, I don’t just *facepalm* and move on with my day, I think, “hmm, probably better discuss this with the students”.

That goes double when the acupuncturist who got arrested was doing (among other things) community acupuncture.

So this is a blog post about why I think insurance billing and community acupuncture don’t mix; it might be part of a series about how CA is being weirdly interpreted out there in the wilds of capitalism. It might also be an item on a list titled, Things You Can’t Help When You’re Running an Open Source Community/Knowledge Commons. (Both this acupuncturist and one of the founders of Modern Acupuncture had a POCA punk membership for a year, in other words, just long enough to access the information on this website and go on their merry way.)

Normally I don’t find the details of insurance fraud particularly interesting, but check this out (nerd alert: juicy numbers!)

According to county officials, the county’s health-insurance plan paid out more than $1.1 million to Jaynes’ Absolute Integrated Medicine, from October 2015 through September 2016. To put that number is perspective: The Indian River Medical Center billed the county only $1.6 million for treating county employees and their dependents during that same period; and the Sebastian River Medical Center was paid only $560,000 – half of what Jaynes’ small acupuncture office collected.

The $1.1 million paid to Jaynes covered 34,340 visits for 253 plan members who sought treatment at Absolute.

County officials said employees flocked to Jaynes’ practice because of her policy of not requiring a co-payment, essentially allowing patients to seek free, unlimited treatment.

The issue prompted county commissioners in December 2016 to place a cap on acupuncture benefits in the health-insurance plan offered to county employees.

Following the change in county policy, the number of county employee visits to Jaynes’ office plummeted. In the fiscal year that ran from October 2016 through September 2017, only 126 members submitted claims for 3,863 visits and less than $180,000 was paid to Jaynes’ practice.

As I’m reading this article, I can’t help remembering the conversation I had back in 2003 with somebody who knew a lot more than I did about the acupuncture business, who told me: there’s no demand for affordable acupuncture. You could offer people free, unlimited treatments with the best acupuncturist in Portland and they still wouldn’t come.

POCA changed that narrative and proved that, when cost isn’t a barrier, people DO want acupuncture and they’ll get a lot more of it than anybody previously thought they would.

That said...  34,340 treatments divided by 253 patients is 135.7 treatments per patient. In a single year. Granted, that’s 2-3 treatments per week, which in theory is possible, but in reality...let’s talk about acupuncture utilization patterns for a minute.

This topic has been a major preoccupation for WCA because we have more than one community partnership where we offer unlimited treatments at either a fixed cost to our partner or no cost at all. We give away a lot of acupuncture. We don’t freak out about these arrangements, because in our experience, if you offer a whole bunch of people free, unlimited acupuncture:

1. Most of them won’t take you up on it. They’ll be grateful that you gave them the option, but they won’t ever try it.

2. Of the ones who try it, a large percentage will get acupuncture only once or twice, before deciding it’s not their cup of tea or their schedules are already too full. People’s lives are complicated; making time for regular acupuncture just isn’t that easy. Nonetheless, these people (we sometimes call them tourists) will also be grateful you gave them the option.

3. Of the people who get more than one or two treatments, a number will get a course of treatments -- like ten in a row -- and then after that, drop in sporadically. Others will come faithfully every week for awhile, but not forever.

4. The smallest percentage, but the ones who motivate us to maintain these community partnerships,  are the ones who get life-changing/life-saving results from acupuncture, often for chronic conditions. These are the people who come once a week, or multiple times a week, forever.

There are not that many of these people.

WCA’s average number of treatments per patient is about 6. We do have a lot of people who are getting enormous amounts of acupuncture at our clinics, but their treatments are more than offset by the one-and-done crowd, the tourists. In years of experimenting with giving acupuncture away, this proportion has never changed. Then again, we've never offered anything but acupuncture; no free herbs or supplements, no incentives to try to convert tourists into high utilizers. Our high utilizers self-select.

To be fair to Absolute Integrated Medicine, a different Florida news outlet reported different numbers for the county insurance company: 221 members getting acupuncture in 2016 for a total of 8242 treatments -- which reflects a more reasonable 37 treatments per patient per year. That’s still a bafflingly high average by POCA standards. And 8242 treatments for a private practitioner who is also running a community clinic --with presumably more volume -- is still outlier-high, though not so improbably high as 34,340 treatments in a year with 135 visits per patient. And it still cost the plan over a million dollars, which is when they started asking questions. If you look at the practice’s website, there’s almost no difference between private treatment hours and CA treatment hours; the main difference is that the CA-clinic was entirely drop-in, so I guess everything was happening at once? This arrangement sounds bananas for a high volume clinic, even with multiple employees.

But I digress. To get to the point of this post:

Do I think some of the details of this fraud (if it was indeed fraud, and not some colossal misunderstanding) were “inspired” by POCA? (Shudder.) Yeah, I kind of think maybe they were. Especially if you consider the likelihood that this same acupuncturist experimented with involving patients in, um, advocacy and organizing. (Triple shudder.)

And people wonder why I don’t like being called “inspiring”.

So for the record, and because I think there’s a non-zero chance that community acupuncture/saving patients money will be invoked as part of this acupuncturist’s defense (see: “she saved many people from opioid addiction/ her patients are going to rave about everything she did”): I don’t think insurance billing and community acupuncture are a good combination. I don’t think the principles of community acupuncture are as flexible as people would like them to be.

One of the reasons community acupuncture is successful as a business model, and a clinical model, is that it recognizes that real life is messy. People’s health problems often don’t fall into neat diagnostic categories. Sometimes people need treatment every day for weeks for an out of control pain issue. Sometimes people just need one treatment every so often to manage their stress, before it turns into a diagnosable physical problem. Sometimes the best way to treat somebody is to treat the family member who drove them to their appointment. When it comes to acupuncture, insurance won’t cover a lot of what people actually need. Trying to fit all of that messy real life into an insurance billing structure is a nightmare.

The community acupuncture model was designed so that we don’t have to try, ever; so that we don’t have to engage with insurance at all.

If you read Cory Doctorow’s novel Walkaway (highly recommended!) you could say that the community acupuncture model was designed for walkaways. Walkaways, as in, the Ones Who Walk Away from Omelas. The people who can’t stand the system, not the people who are hoping to make bank from it or the people who think if you just tinker with it enough, you can force it to work. There’s a price for walking away, of course, but we think it’s worth paying.

I’ve been wanting to link anyway to a nifty blog post my friend Ellen wrote, riffing on the theme of, community acupuncture isn’t something acupuncturists do to patients, it’s something people do together: I know I can speak for all of the practitioners at PCA when I say that we understand that we are not the only ones practicing community acupuncture at the clinic. All of our patients, every time they come in for a treatment, are also practicing community acupuncture, developing their skills of relaxing, accessing support, and being in a social setting while in pain, the skills of using their community clinic.

The community acupuncture model was designed to disrupt the story of the amazing healer who saves people, in order to make room for a better story -- about communities taking care of themselves.

The community acupuncture model wasn’t designed to inspire, it was designed to be used for a concrete, specific purpose. You know the saying, if you can’t be a good example, you’ll just have to serve as a horrible warning? This story might be a warning about trying to use bits and pieces from community acupuncture while also trying to remain part of (and profit from) the system that it was meant to help people walk away from.

It might also serve as a kind of experiment, set up to answer the question: Is acupuncture cost-effective, from the perspective of the health care system, if people can access unlimited treatment? The answer seems to be: not at market rates, it's not, and not within the paradigm of an amazing healer saving people. Maybe Absolute Integrated Medicine wasn't a good example in a conventional sense, but if this story helps illuminate that particular question, I'm grateful.

This story was posted on August 27 2018 by Lisafer.

Comments

  • August 28 2018 at 2:04 PM
    engerin writes:

    I’m curious to hear more on why/how you think that POCA was an “inspiration” for the alleged fraud? It seems like the POCA model very transparently doesn’t encourage accepting insurance, and that is something that sort of (proudly?) sets it apart from other business models.
    Thanks!

      1 likes
  • August 28 2018 at 2:14 PM
    Lisafer writes:

    Because (if it is fraud) it depends on the concept that people need and want a LOT more acupuncture than conventional acupuncturists typically promote (in the early days of CA, there was huge resistance from conventional acupuncturists to the idea that patients would ever come more than once a week for treatment)and because a justification for waiving the co-pays (which is a form of fraud) is going to be, but people are in pain and they need more treatment than they can afford. Make sense? In our recent Lib Acu workshop, we spent a lot of time talking about the value of creating relationships where certain groups of people could access unlimited treatment. That’s an area that historically, conventional acupuncturists were never interested in and often dismissive of.

      3 likes
    • tatyana
    • weedyknees
  • August 28 2018 at 8:33 PM
    Lisafer writes:

    #pocaforevil

    (thanks Skip)

      3 likes
    • whitney
    • mitylene
    • tatyana
  • August 30 2018 at 4:23 PM
    annye02 writes:

    It seems that a lot of people are looking at this from afar as if she was simply waiving co-pays/ co-insurance and was arrested for it. As if her intentions were good and according to how much she cares about the patients, and as if she had no idea that it was illegal to do so. Many of us that are more familiar with her locally, have a different perspective.
    My own experience with her is awful. For the sake of not making this a super long post, I’ll just leave that there. Here is however, a link to another article detailing more of the charges and investigation against her:
    https://www.tcpalm.com/story/news/crime/indian-river-county/2018/08/24/investigators-detail-vero-beach-acupuncturist-jill-jaynes-1-5-m-insurance-fraud-racketeering-charges/1077564002/

    Check out some of these bits from the article:

    “One woman had 259 claims billed to insurance before she filled out new patient paperwork.”
    “More than 800 appointments deleted from the system were billed anyway.”
    “While the office was closed for five days in November 2013, insurance was billed for 185 claims totaling more than $22,000.”
    “A review of patient files showed less than half of Jaynes’ claims between 2012 and 2016 had documentation.”

    This smells more and more like fraud and less and less like a “misunderstanding.”
    I love that I no longer do insurance billing. I am happy with my community acupuncture clinic with no hassle with insurance at all. I agree that it’s great not to mingle CA with insurance. I do, however, have friends who have hybrid clinics and it works well for them and the patients. They do insurance billing in the conventional setting, and when the benefit expires, they have an affordable option for those patients to receive continued care. They do not do insurance fraud! What happened with Jill is she was running a shady practice and she got caught. I don’t think it reflects on POCA or community acupuncture, or acupuncture, or even herself as an actual acupuncturist. She was literally breaking the law in order to make more money. These people exist in every field. I hope they do throw the book at her and they do make an example of her. As much as we are working with POCA on making acupuncture accessible, other people are working just as hard to get acupuncture covered by insurance in order to make acupuncture accessible to other demographics. Her greed nearly cost the county its acupuncture insurance benefits. Enter Angela King, who went before the commission on behalf of her patients, and saved acupuncture as a covered benefit, with added limitations. (Go Angela!)
     
    I see the perspective a little about how this fraud could all be POCA inspired, but I think it’s a stretch. From what I’ve heard, she only ever began doing community acupuncture to try to find more people to bring over to her conventional insurance practice. People were not getting acupuncture in the group setting and having insurance billed for it. I don’t think any of this was about what was best for the patient, and was more likely about how much money she could get out of it. Like the linked article noted:
    “‘You will never have to pay anything out of pocket,’ one patient said Jaynes told her.”
    And then it goes on to say,
    “Records seized showed since 2010, Jaynes’ practice has consisted primarily of county-insured patients, some of whom were receiving treatment multiple times per week.
    County employees visited Jaynes’ office 65 percent more than other patients between the alleged dates of fraud, peaking at 83 percent more in 2016, according to the warrant.
    A typed guide in her office included a handwritten note about the plan covering county employees reading “only insurance — carte blanche,” a French phrase meaning complete freedom or a blank check.”

    So she was encouraging people to come as frequently as they were because she was getting paid more for those visits, not due to an inspired idea that people may need more frequent treatments. Plus, we don’t know at this point if people were even actually coming that frequently, or if that was just how it was being billed.
    I imagine it sucks to feel like you can somehow be responsible. I just think she was doing some shady stuff, and ultimately it was related to the fraudulent use of insurance and not related to finding ways to give people affordable acupuncture. There were a lot of people in that community, however, who were receiving acupuncture by other practitioners at that clinic, in the group setting, without billing insurance- and they have POCA to thank for THAT inspiration.
    Let me say again, SO glad not to be a part of the insurance billing mess! And I feel very blessed to have received my POCA inspiration, as are the patients in my community acupuncture clinic! I appreciate the work you are doing, don’t let a couple of bad apples bring you down! 

      3 likes
  • August 31 2018 at 6:48 AM
    Lisafer writes:

    Thanks for that perspective! Watching something from afar, over the internet, is no substitute for having first-hand experience (in this case I’m sorry the first hand experience was terrible).

    It’s going to be fascinating to hear more details emerge from this case; I’m especially curious about the “incentives” that were used to get people to utilize more acupuncture than they would have normally.

    To be clear, I don’t think any of this was POCA’s “fault”; this post is more because I’m fascinated by the interplay of issues here, and also, because the nature of conversations on the internet makes me suspect that we might get blamed for it anyway. One of the first responses I got from hostile acupuncturists, circa 2004 or so, was that community acupuncture was illegal because my practices were so different from what insurance billing practices were. I was told flat out that sliding scales were illegal. I think it’s very likely that this particular acupuncturist (or her lawyer) is going to use community acupuncture (and our language about access, especially for patients with chronic pain) as part of her “no really, I’m a good person” defense—not unlike the way that Modern Acupuncture has adopted a lot of CA language. And as a result, it’s all going to get mixed up in the general narrative about community acupuncture. So this discussion is a good way to get out ahead of that—and your examples about practitioners who have figured out how to do both insurance billing and CA, with clear lines between them and (key!) NO FRAUD are definitely an important part of the discussion. As you said, some practitioners really are using CA as a way for patients to keep getting treated once their insurance benefits run out; good for them.

    I have such vivid memories, still, of how much resistance there used to be to the concept of frequent,regular acupuncture treatment—did I ever tell you about the acupuncturist who wrote to me to tell me that he could always cure fibromyalgia in one treatment, and if my patients needed frequent treatments for pain it was because I was doing acupuncture all wrong?—that I have to wonder if the “frequent utilization” aspect of the fraud would have happened if we hadn’t normalized frequent utilization. I definitely hear you that much of that utilization might not have actually happened, like the treatments billed when the office was closed wink

    In the insurance fraud article, when the author talks about over utilization of services, the example he uses is physicians exploiting people who are hypochondriacs, and giving them medical care they don’t need. How much acupuncture people “need” is not something acupuncturists have historically agreed upon (and it’s subjective and individual anyway). It’ll be fascinating to see how this plays out in the court case.

      2 likes
    • annye02
    • Spartacus
  • August 31 2018 at 2:26 PM
    Lisafer writes:

    And…right on cue…a new article: http://veronews.com/2018/08/30/acupuncturist-jill-jaynes-closes-popular-clinic-now-facing-fraud-charges/

    “Prior to her arrest, Jaynes previously said that she often waived the co-pay for patients experiencing financial hardship.

    After the county’s cap was put in place, many county employees started choosing treatment in a group setting in Absolute’s less-costly community room, rather than a more expensive private room.

    “What the county doesn’t want to admit is Jill has been saving them money,” Butler said. “Many people with opioid addictions seek acupuncture treatment, which is much less expensive than a traditional treatment facility.””

    I might have to work a little harder to keep my “wow, this is fascinating!” attitude as opposed to OMG WHY

      1 likes
    • jencorbin
  • August 31 2018 at 3:48 PM
    annye02 writes:

    UGH! The worst. I will be optimistic though, this could be a greatly needed wake up call for acupuncturists doing questionable billing. I hope it doesn’t turn out bad for acupuncturists, but I do hope she gets everything that is coming to her!
    I don’t like all this being mixed up with community acupuncture, or even acupuncture in general, but don’t they say all press is good press? We shall see…..

      1 likes
  • August 31 2018 at 4:29 PM
    Lisafer writes:

    Yes, the “press” part is where I’m very relieved that you POCA folks in Florida are organized and so if there’s a need to set the record straight, you’re in a position to do that in a way that I think people would hear and respect. Just in case a reporter starts wondering, my goodness, what’s all this about community acupuncture?

    I totally agree with you that this is a teachable moment/wake up call.

      0 likes

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