J Manipulative Physiol Ther. 2016 (Sep); 39 (7); 500–509 ~ FULL TEXT
Patricia M. Herman, ND, PhD, Ian D. Coulter, PhD
Santa Monica, CA.
OBJECTIVES: The purpose of this project was to examine the policy implications of politically defining complementary and alternative medicine (CAM) professions by their treatment modalities rather than by their full professional scope.
METHODS: This study used a 2-stage exploratory grounded approach. In stage 1, we identified how CAM is represented (if considered as professions vs modalities) across a purposely sampled diverse set of policy topic domains using exemplars to describe and summarize each. In stage 2 we convened 2 stakeholder panels (12 CAM practitioners and 9 health policymaker representatives), and using the results of stage 1 as a starting point and framing mechanism, we engaged panelists in a discussion of how they each see the dichotomy and its impacts. Our discussion focused on 4 licensed CAM professions: acupuncture and Oriental medicine, chiropractic, naturopathic medicine, and massage.
RESULTS: Workforce policies affected where and how members of CAM professions could practice. Licensure affected whether a CAM profession was recognized in a state and which modalities were allowed. Complementary and alternative medicine research examined the effectiveness of procedures and modalities and only rarely the effectiveness of care from a particular profession. Treatment guidelines are based on research and also focus on procedures and modalities. Health plan reimbursement policies address which professions are covered and for which procedures/modalities and conditions.
CONCLUSIONS: The policy landscape related to CAM professions and modalities is broad, complex, and interrelated. Although health plan reimbursement tends to receive the majority of attention when CAM health care policy is discussed, it is clear, given the results of our study, that coverage policies cannot be addressed in isolation and that a wide range of stakeholders and social institutions will need to be involved.
KEYWORDS: Clinical Practice Guideline; Complementary Therapies; Health Policy; Health Services Research; Health Workforce; Insurance Coverage; Integrative Medicine; Licensure; Professional Practice; Research Support
From the FULL TEXT Article:
One generally recognized characteristic of complementary and alternative medicine (CAM) is holism, which is a focus on treating the whole person. [1, 2] Complementary and alternative medicine practitioners use a wide range of techniques embedded within various broad healing paradigms to provide treatment. However, despite this broad approach and holistic goal, CAM is often addressed in policy and research as individual procedures (ie, modalities or treatments). In sociology, this dichotomy is one of CAM practitioners as members of professions vs members of skilled occupations, with professions having broader authority and autonomy because of a systematic body of theory that goes beyond skills. 
Each CAM profession has at least 1 signature modality — for example, spinal manipulation for chiropractors, acupuncture for practitioners of Oriental medicine, or herbal medicine for naturopathic doctors. However, these modalities are delivered within a patient encounter that includes much more; for example, they may include patient education (eg, on stress reduction, lifestyle improvements), monitoring of general health indicators, a trusting patient–practitioner relationship, and a range of wellness interventions such as exercise programs, nutrition counseling, weight management, and preventive care. In addition, the training in some of the CAM professions includes diagnosis, appropriate referral, and other traits of primary medical care. These also involve the provision of services (eg, laboratory diagnostics, imaging, physical examinations, patient counseling) beyond the signature modality.
Despite the broad range of services provided, much of health care policy addresses CAM as individual therapies or modalities. Although this problem is often described as one of terminology or of semantics, it is not just a problem of definition or perception. Policies that define a profession only in terms of its therapeutic modalities or reduce a profession’s scope to only a few of these modalities have a direct impact on patient access and care. These policies have substantial political consequences as the CAM professions strive to obtain full legal and social legitimization.
Therefore, this study examined the policy implications of how the dichotomy between CAM as modalities and CAM as professions is addressed across a number of health policy topic areas, including coverage, licensure, scope of practice, institutional privileges, and research.
Policies that define a profession only in terms of its therapeutic modalities, or reduce a profession’s scope to only a few of these modalities, have direct impacts on patient access and care. However, as pointed out by our panels, so do policies that limit the professions included in the health care workforce. The workforce policies identified earlier affect where members of particular CAM professions are allowed to practice (eg, CPOM laws, VHA and DoD restrictions) and influence their training (eg, loan repayment and residencies). Licensure affects the states in which CAM professionals practice and can limit the modalities they can offer to patients for use in practice. Research seems to be focused on the effectiveness of procedures and modalities and only rarely on the health care outcomes associated with receiving care from a member of a particular profession. Guidelines are based on research, and thus, it is not surprising that they also focus on procedures and modalities because research only focuses on modalities, not the professions. Finally, health plan reimbursement policies limit which professions are covered and for which procedures or modalities and conditions they may be reimbursed. In summary, the policy landscape related to CAM professions and modalities is broad, complex, and interrelated.
Because of its direct effects on access, [69, 69] health plan coverage tends to receive the majority of attention when CAM health care policy is discussed. [70, 71] However, given the results of our study, it becomes clear that coverage policies cannot be addressed in isolation. Health plan coverage decisions depend on a number of factors, including evidence of effectiveness or efficacy and safety, guidelines, and consumer demand. [72, 73] In addition, members of the CAM professions have to be available in the health care workforce to serve the health plan’s members and licensed to offer those services. Therefore, any attempts to change reimbursement policy will also have to address other types of policies.
During our observation, we noticed that our expert panelists paid little attention to how research affects and is affected by other policies. Given that research evidence is essential to the setting of clinical guidelines, and because both influence coverage, it seems that examining research policy would be a good place to start. However, although most researchers would like their work to have a large impact, many would probably agree that research is necessary but insufficient for policy change. The following 3 studies show how research could support changes in policy, moving from a focus on modalities to a focus on professions:
One study examined reduced likelihoods of continued work disability, 
another looked at early magnetic resonance imaging use (which is
associated with increased costs and poorer outcomes), 
and a third analyzed whether lumbar spine surgery  was performed
if a patient with back pain went first to a DC rather than a medical doctor.
The challenge to overcome being treated only as modalities seems somewhat daunting for the CAM professions. Policy is created, implemented, and evaluated in a political process. However, the required process is no different from what each profession faced to obtain licensing or certification. Thus, the political wherewithal exists. One possible difference in the political processes involved with licensure vs those required for other or broader policy change is that up until now the CAM professions have faced pushing for policy change singularly and, on occasion, in opposition to one another. For many policy changes, a collective strategy may be more productive.
Despite the daunting nature of policy change, there have been some successes. For example, the chiropractic profession was successfully licensed in every state in America by the mid-1970s despite fierce opposition from the medical profession.  This paper and the full RAND report on the underlying study  are intended to assist CAM professions in navigating the health care policy landscape toward their goals. Our hope is that, as a result of this study, future attempts to change the health care policies affecting the CAM professions will proceed with an awareness of the broader policy landscape and thus be more successful.
This is an exploratory study covering a new, not previously delineated, area, and as such, it faced a number of challenges. Our intent was to describe the health policy landscape in which the CAM professions face being diminished to modalities. However, as early explorers in this line of study, it is possible that we missed important policy issues or important nuances to the issues identified. Nevertheless, a key limitation is that although the information offered and suggestions made by the panelists were vetted to the best of our ability, detailed descriptions and analyses were not included in this study.
The wide range of interrelated policies identified in this study as affecting patients’ CAM access and care means that a wide range of stakeholders and social institutions need to be involved in making policy changes. A large number and variety of groups involved will add considerably to the complexity surrounding any attempt to create solutions. Given the number of vested interests, we suggest that what is best for the patient and for health care delivery to the population should be the single driving force.
A wide range of interrelated policies affect patients’ access to care by
complementary and alternative medicine providers, and because
of this interrelatedness, a wide range of stakeholders and
social institutions will need to be involved in making
The large number and variety of groups involved will add considerably to
the complexity surrounding any attempt to change policy.
Given the number of vested interests at play, perhaps the single driving force
for policy change should be what is best for the patient and
for health care delivery to the population.
Herman PM, Coulter ID:
Complementary and Alternative Medicine: Professions or Modalities?
Policy Implications for Coverage, Licensure, Scope of Practice,
Institutional Privileges, and Research.
RAND Corporation, Santa Monica, California: (2015. pp. 1–76)
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