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Legislative Research Services130 Seward Street, Room 218

Juneau, AK 99801907-465-3991

907-463-3351 (fax)www.legis.state.ak.us/research/home.htm

Cost Effectiveness of AcupunctureCost Effectiveness of Acupuncture

Legislative Research ServicesDivision of Legal and Research ServicesLegislative Affairs AgencyAlaska State Legislature

Prepared by Kathleen L. Wakefield, Legislative Analyst

Legislative Research Report 99.013December 15, 1998

Legislative Research Report 99.013 - Date, 1998 - Page 1

SUMMARY.....................................................................................................................................................1

COST-BENEFITS OF ACUPUNCTURE ..............................................................................................................2

University of Lund, Sweden....................................................................................................................2

Klampenborg, Denmark..........................................................................................................................2

United States ...........................................................................................................................................3

STUDIES ON THE EFFECTIVENESS OF ACUPUNCTURE AND ALTERNATIVE MEDICINE........................................3

INSURANCE COVERAGE.................................................................................................................................5

LIST OF ATTACHMENTS .................................................................................................................................7

Attachment A – American Association of Oriental Medicine ................................................................7

Attachment B – “Acupuncture,” NIH Consensus Statement...............................................................7

Attachment C – “Acupuncture Works,” Time Magazine ......................................................................7

SUMMARY

You asked if any studies showed savings to a patient and insurance company if acupuncture was used in lieu of conventional medical treatment. After a brief summary, this report describes methodologies of some cost-benefit studies of acupuncture, research on the effectiveness of acupuncture and alternative medicine, and the current status of insurance coverage of alternative therapies.

Although at least four studies report that using acupuncture treatments reduced costs, we were unable to find any definitive research study which focused on or included treatment costs. Most of the major studies funded by organizations like the National Institutes of Health (NIH) and the Robert Wood Johnson Foundation focus on clinical issues such as how acupuncture works and its effectiveness in treating certain diseases and addictions.1 NIH investigators did conclude last year that there is “sufficient evidence of acupuncture’s value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value.”2

According to the American Association for Oriental Medicine, a 1993 study at the University of Lund in Sweden showed an estimated savings of $26,000 per patient when acupuncture was used as part of the treatment of paralysis in stroke victims.3 Researchers at the Acupuncture Center in Klampenborg, Denmark, in the mid-1990s, measured the cost-benefit of using a combined approach of acupuncture, Shiatsu (pressure-point massage), and lifestyle changes to treat patients with severe angina pectoris.

1 We contacted the National Institutes of Health, National Center for Complimentary & Alternative Medicine, American Association of Medical Acupuncture, American Association for Oriental Medicine, National Conference of State Legislatures, Bastyr University in Seattle, and Dr. Andrew Weil’s Program in Integrative Medicine at the University of Arizona Health Sciences Center in Tucson. In addition, we checked the web sites of the World Health Organization, National Institute on Drug Abuse, National Institute for Neurological Disorders & Stroke, and the Robert Wood Johnson Foundation (a source of grant funding for health studies).

2 “Acupuncture” NIH Consensus Statement 1997 Nov 3-5; 15(5): 1-34, p. 12.

3 American Association of Oriental Medicine, information faxed December 8, 1998.


They estimated savings of $12,000 per patient.4 Claire M. Cassidy, Ph.D., director of research at theTraditional Acupuncture Institute, estimated that the number of visits per client over a three-monthperiod averaged six visits for acupuncture with an average total cost of $265, and 2.2 visits fortraditional medical care with an average cost of $409.5 According to an article in Psychology Today,

“[w]hen one insurance company compared 300 patients at Dr. Benjamin’s center [theArizona Center for Health & Medicine offers herbal medicine, body work, meditation andother alternative therapies along with conventional medical care] with patients with similardiagnoses – such as autoimmune diseases, lower back pain, or migraines – who were notseen at the center, the trends were startling. Treatment costs were cut by 56 percent.Emergency room visits were down. The level of patient satisfaction was 92 percent at thecenter and 76 percent outside.”6

COST-BENEFITS OF ACUPUNCTURE

University of Lund, Sweden

Researchers at the University of Lund divided patients into two groups: the "acupuncture group” with38 patients, whose average age was 76 years, and the “no acupuncture group” with 40 patients,whose average age was 75. All patients in the study were tested at one week post-stroke and at one,three, and twelve months later. Both groups received physical and occupational therapy for tenweeks. The acupuncture group also received two acupuncture treatments per week during those tenweeks. According to researchers, patients in the acupuncture group spent less time in nursing homesand rehabilitation facilities. Patients in the no-acupuncture group spent approximately $56,000 eachfor treatment, and the patients who received acupuncture spent approximately $30,000 each. Aftertwelve months, 89% of the patients in the acupuncture group were living at home, but only 66% of thepatients in the no-acupuncture group were able to live at home. The report stated that a “significantlybetter outcome was observed in walking, balance, activities of daily living and quality of life, mobility,and emotion” for the acupuncture group.7

Klampenborg, Denmark

Researchers in Klampenborg, Denmark treated 69 patients with severe angina pectoris with thecombined treatments of acupuncture, Shiatsu, and lifestyle adjustments. The surveyors followed thepatients for two years. Of the 69 patients, 49 were candidates for coronary artery bypass surgery.These patients were also compared with patients in another trial study who underwent coronary arterybypass surgery or coronary angioplasty. The comparison showed that 21% of the bypass patients and15% of the angioplasty patients, but only 7% of the acupuncture patients, subsequently had heartattacks or died. Although researchers found little difference in pain relief between the three groups,61% of the patients in the acupuncture group experienced improvement in their health. These patientsavoided or postponed invasive medical treatments, and they spent 90% fewer days in the hospital thanthe patients who did not receive the combined treatment, leading to an overall economic savings ofapproximately $12,000 per patient.

4 National Conference of State Legislatures, information faxed December 9, 1998.

5 Claire M. Cassidy, Ph.D, “Patients Vote an Overwhelming “Yes” for Acupuncture,” Meridians,http://acupuncture.com/Acup/AcuStats.htm.

6 Jill Niemark, “On the Front Lines of Alternative Medicine,” Psychology Today, February 1997, p.4.http://204.179.122.62.9912/topicsearch/.

7 American Association of Oriental Medicine.


United States

Cassidy’s study of six private and public acupuncture clinics in five states, with 575 respondents,measured patient satisfaction, the complaints and symptoms patients reported, and demographicinformation as well as estimated costs. Among the information collected in the survey:

♦ 91.5% of respondents reported “disappearance” or “improvement” of symptomsafter acupuncture treatment.

♦ 84% said they see their medical doctors less often as a result of acupuncturetreatment.

♦ 79% said they use fewer prescription drugs as a result of acupuncture treatment.

♦ 70% of those to whom surgery had been recommended by a conventionalmedical doctor said they avoided surgery through the use of acupuncture.8

The American Association for Oriental Medicine also provided information they believe shows thatacupuncture is a successful modality of treatment and is cost effective. This information is inanecdotal form rather than part of a controlled study, and is included in this report as Attachment A.

STUDIES ON THE EFFECTIVENESS OF ACUPUNCTURE AND ALTERNATIVE MEDICINE

Several studies show that an increasing number of people in the United States are turning toacupuncture and other forms of complementary and alternative medicine. In 1993, the New EnglandJournal of Medicine published a study showing that one-third of survey respondents had used“unconventional therapies” during the past year (1990). Extrapolating that to the U.S. population as awhole, the surveyors estimated that 61 million Americans had used at least one of the therapiesmentioned in the study (which includes relaxation techniques, chiropractic, massage, homeopathy, andacupuncture) and that patients made 425 million visits to providers of alternative therapies. Thenumber of visits exceeded the estimated 388 million visits made in 1990 to all primary care physicianscombined (general and family practitioners, pediatricians, and specialists in internal medicine).Americans spent approximately $13.7 billion in 1990 for these visits and commercial diet supplementsand megavitamins. The total projected out-of-pocket expenditures were $10.7 billion, which wascomparable to out-of-pocket expenditures for all hospital care in the U.S. in 1990 ($12.8 billion), andwas nearly half the out-of-pocket amount for all physicians’ services ($23.5 billion).9

In 1997, the authors did a follow-up survey, and found that total visits to alternative practitioners hadincreased 47.3% since 1990, exceeding total visits to primary care physicians. Total out-of-pocketexpenditures for alternative therapies in 1997 were “conservatively estimated” at $27.0 billion, whichexceeded the out-of-pocket expenditures for that year for all U.S. hospitalizations and physicianservices.10

In November 1997, the National Institutes of Health (NIH) released a “consensus statement” onacupuncture (“Acupuncture, NIH Consensus Statement,” included as Attachment B). NIH publishes

8 Cassidy, p. 1.

9 David M. Eisenberg, M.D., et al., “Unconventional Medicine in the United States,” New England Journal of Medicine, January 28,1993, pp. 246-252.

10 David M. Eisenberg, M.D., “Trends in Alternative Medicine Use in the United States, 1990-1997: Results of a Follow-up NationalJournal of the American Medical Association, November 11, 1998, pp. 1569-75. http://www.ama.assn.org/sci-

pubs/journals/archive/jama/vol_28018/joc80870.htm.


consensus statements on a variety of health issues. Panels of twelve members, who are not federalemployees and are not considered advocates for the issue being studied, research questions anddevelop conclusions based on evidence presented in open forums and in the scientific literature.These panels prepare draft statements, which are circulated to the audience and the experts forcomment, and then resolve conflicting recommendations and release a final statement. In this case,the panel consisted of representatives from the fields of acupuncture, pain, psychiatry, physicalmedicine, rehabilitation, drug abuse, family and internal medicine, health policy, epidemiology,statistics, physiology, biophysics, and the public. Twenty-five experts from these same fieldspresented data to the panel, and the panel and conference audience were provided with an extensivebibliography of references and abstracts.11

The acupuncture panel recognized acupuncture’s effectiveness in relieving adult postoperative andchemotherapy nausea and vomiting, and postoperative dental pain. The panel also agreed thatacupuncture may be useful as an adjunct treatment or alternative treatment for addiction, strokerehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis,low back pain, carpal tunnel syndrome, and asthma. The panel stated that further research “is likely touncover additional areas where acupuncture interventions will be useful.”12

The consensus panel called for continuing studies to assess the effectiveness of acupuncture, notingthat “relatively few high-quality, randomized, controlled trials” have been published aboutacupuncture.13 The panel cautioned that “acupuncture practice is based on a very different model ofenergy balance” than conventional Western medicine, that acupuncture focuses on a “holistic, energy-based approach to the patient rather than a disease-oriented diagnostic and treatment model.”14 Theybelieve these differences need to be better understood in order to facilitate the integration ofacupuncture into the modern health care system.

The panel also noted that “[c]ontinued access to qualified acupuncture professionals for appropriateconditions should be ensured . . . There is evidence that some patients have limited access toacupuncture services because of inability to pay. Insurance companies can decrease or removefinancial barriers to access depending on their willingness to provide coverage for appropriateacupuncture services.”15

NIH’s National Center for Complimentary & Alternative Medicine (NCCAM – formerly the Office ofAlternative Medicine) provides grant funding for research into complimentary and alternative therapies.NIH recently requested proposals for clinical trial pilot grants to study acupuncture.16 The NationalInstitute of Neurological Disorders & Stroke, a part of NIH, is studying the effectiveness of acupuncturein treating chronic pain.17 The National Institute on Drug Abuse, also a part of NIH, is studying the use

11 NIH, p. 2.

12 NIH, p. 3. Fibromyalgia is a chronic disorder with fatigue and musculoskeletal pain, especially in the neck, spine, shoulder, andhips. Myofascial pain is also called “temporomandibular joint syndrome” or TMJ, which is joint pain and inflammation in the jaw.Osteoarthritis is a degenerative joint disease.

13 NIH, p.10.

14 NIH, pp.11, 8.

15 NIH, p. 9.

16 “PA-98-033 Acupuncture Clinical Trial Pilot Grants,” http://www.nih.gov.

17 “Chronic Pain – Hope Through Research,” National Institute for Neurological Disorders & Stroke.http://www.ninds.nih.gov/healinfo/disorder/chrpain/chronic-pain.htm.


of acupuncture in treating drug addictions, and included a session on complimentary and alternativetherapies at its 1998 National Conference on Drug Addiction Treatments.18

Although Time magazine reported last year that approximately one million Americans use acupunctureand spend about $500 million on treatments each year, there are still those in the medical andscientific communities who are not convinced of acupuncture’s usefulness (or that of other alternativetherapies).19 The editor of the New England Journal of Medicine says that unconventional therapiesare “cheaper than seeing a physician,” but that “roughly a third of unconventional practices entailtheories that are patently unscientific and in direct competition with conventional medicine. . . .”20

According to the Council on Scientific Affairs of the American Medical Association, “[c]ritics contendthat acupuncturists, including many traditionally trained physicians, merely stick needles in patients asa way to offer another form of treatment for which they can be reimbursed. . . . [C]ritical reviews ofacupuncture . . . conclude that no evidence exists that acupuncture affects the course of anydisease.”21 The National Council Against Health Fraud states that

[a]cupuncture is an unproven modality of treatment . . . Its theoryand practice are based on primitive and fanciful concepts of healthand disease that bear no relationship to present scientificknowledge. Perceived effects of acupuncture are probably due to acombination of expectation, suggestion, counter-irritation, operantconditioning, and other psychological mechanisms . . . .22

INSURANCE COVERAGE

According to Time magazine, “[a] Boston researcher told the [NIH acupuncture consensus] panel thatthe saving from just faster stroke rehabilitation and effective carpal-tunnel-syndrome treatment couldcut the nation’s annual medical bill by $11 billion. Such a saving is sure to catch the eye of HMOs and

23 This article is included as Attachment C. NIH panel member MarcellusWalker, MD, a primary care physician who uses acupuncture in his practice, told the Journal of theAmerican Medical Association that in view of the panel’s recommendations, “it would seem reasonablethat third-party reimbursement for acupuncture be considered. Failure to reimburse for the procedureis one of the challenges to patients gaining access to it…”24

Insurance companies are taking another look at alternative therapies. Several companies cover somealternative therapies, either through offering reduced rates for those services and allowing patientsdirect access, or by allowing patients to be referred by their primary physician. The American Board of

18 “Drug Abuse Treatment – Research Findings 3,” National Institute on Drug Abuse,

http://165.112.78.61/ICAW/treatment/treatmentfindings3.html. “National Conference on Drug Addiction Treatment – Abstracts,”http://165.112.78.61/MeetSum/TX/Txinfo3a.html.

19 Dick Thompson, “Acupuncture Works,” Time, November 17, 1997, p. 84.

20 Edward W. Campion, M.D., “Why Unconventional Medicine?” The New England Journal of Medicine, January 28, 1993.http://www.nejm.org/content/1993/0328/0004/0282.asp.

21 “Report 12 of the Council on Scientific Affairs: Alternative Medicine,” American Medical Association CSA Reports, June 1997, p. 12.http://www.ama.assn.org/med-sci/csa/1997/r12full.htm.

22 “NCAHF Position Paper on Acupuncture,” National Council Against Health Fraud, September 16, 1990, p.1.http://www.ncahf.org/pos-pap/acupunct/html.

23 Dick Thompson, p. 84.

24 Charles Marwick, “Acceptance of Some Acupuncture Applications,” Journal of the American Medical Association, December 3,1997, p.2. http://www.ama-assn.org/sci-pubs/journals/archive/jama/vol_278/no_21/jmn71154.htm.


Eastern Medicine publishes a list of 55 insurance companies that “cover acupuncture in some way.”25

The list includes such major insurers as Aetna, Blue Cross of Washington & Alaska (as well as BlueCross of Oregon and of California), Cigna, Mass Mutual, Metlife, New York Life and Prudential. In1996, Oxford Health Plans, a major health maintenance organization, was the first HMO to offer aprogram of comprehensive coverage for complimentary and alternative therapies, allowing patients tosee alternative practitioners as their primary caregivers rather than receiving alternative care onlythrough referral by a medical doctor.26 Kaiser Permanente covers alternative therapies on a limitedbasis as a non-defined benefit.27 These businesses explain that they are responding to consumerdemand. Other companies say they would consider such coverage if consumers and employersdemanded it.

Some insurance companies, like some members of the conventional medical establishment, stillquestion alternative medicine’s effectiveness. But the NIH consensus panel cautioned that, “[w]hile itis often thought that there is substantial research evidence to support conventional medical practices,this is frequently not the case. This does not mean that these treatments are ineffective. The data insupport of acupuncture are as strong as those for many accepted Western medical therapies.”28 Thepanel continued:

One of the advantages of acupuncture is that the incidence ofadverse effects is substantially lower than that of many drugs orother accepted medical procedures used for the same conditions.As an example, musculoskeletal conditions, such as fibromyalgia,myofascial pain, and tennis elbow, or epicondylitis, are conditionsfor which acupuncture may be beneficial. These painful conditionsare often treated with, among other things, anti-inflammatorymedications (aspirin, ibuprofen, etc.) or with steroid injections. Bothmedical interventions have a potential for deleterious side effectsbut are still widely used and are considered acceptable treatments.The evidence supporting these therapies is no better than foracupuncture.29

The Journal of the American Medical Association recently reported on a study that analyzedmalpractice claims against chiropractors, massage therapists, and acupuncturists from 1990 through1996. Researchers found that “claims against these practitioners occurred less frequently and typicallyinvolved injury that was less severe than claims against physicians during the same period.”30

In some cases, the push for coverage of alternative medicine is coming from the government ratherthan consumers. In 1996, Washington State lawmakers mandated that insurers cover expenses fortreatment by all licensed, registered, or certified health providers, including acupuncturists, massagetherapists, naturopaths, and midwives. A federal judge ruled against the state in an industry lawsuit,

25 American Board of Eastern Medicine, “Insurance Companies that Cover Eastern Medicine.”

http://www.easternmedicine.com/insurance.html.

26 Christina Nifong, “Alternative Treatments Make Gains in Medical Community,” Christian Science Monitor, October 23, 1996, p.1.

27 Lynna Gosch, “Alternative Medicine Moves into the Mainstream,” Best’s Review Life-Health Insurance Edition, March 1997, pp. 84-88.

28 NIH, pp. 10, 6.

29 NIH, p. 6.

30 David M. Studdert, LLB, ScD, MPH; et al, “Medical Malpractice Implications of Alternative Medicine,” Journal of the AmericanMedical Association, November 11, 1998, pp. 1610-1615. http://www.ama-assn.org/sci-pubs/journals/archive/jama/vol_280/no_18/lm71042a.htm.


but the 9th U.S. Circuit Court of Appeals ordered the law reinstated.31 In March 1996, the Food andDrug Administration removed acupuncture needles from the list of experimental medical devices andnow regulates them the same as other accepted medical instruments such as scalpels andhypodermic syringes. Experts suggest this change may “open the door,” allowing Medicaid andMedicare programs to someday cover expenses for acupuncture treatment.32

Federal lawmakers introduced two bills addressing alternative therapies in recent sessions ofCongress, but never took final action on them. Rep. Peter DeFazio (D-Oregon) introduced HR 746,the Access to Medical Treatment Act, which would permit “any individual to be treated by a healthcare practitioner with any medical treatment that the individual desires (including a treatment that is notapproved, certified, or licensed by the Secretary of Health and Human Services) if: (1) the practitioneragrees to treat the individual; and (2) the administration of such treatment does not violate licensinglaws.” 33 Rep. Maurice Hinchey (D-NY) introduced HR 1038, the Federal Acupuncture Coverage Actof 1997, which would provide “coverage of acupuncturist services under the Federal Employees HealthBenefits Program and part B (Supplementary Medical Insurance) of title XVIII (Medicare) of the SocialSecurity Act.”34 Although consumer health advocacy groups expected the bills to be reintroduced,sponsors did not reintroduce either bill in 1998.35

I hope you find this information useful. Please do not hesitate to contact us if you have questions orneed additional information.

LIST OF ATTACHMENTS

Attachment A – American Association of Oriental Medicine

Attachment B – “Acupuncture,” NIH Consensus Statement

Attachment C – “Acupuncture Works,” Time Magazine

31 Associated Press, “Appeals Court OKs Insurance Mandates,” Spokane.net, June 19, 1998.

http://www.spokane.net/stories/1998/Jun19/s409022.asp.

32 Kris Hudson, “Acupuncture,” The Stuart News, November 24, 1996, p. 2. http://tcgo.com/archives/11_24_96/acupunct.htm.

33 “Bill Summary & Status for the 105th Congress, H.R. 746,” http://thomas.loc.gov.

34 “Bill Summary & Status for the 105th Congress, H.R. 1038,” http://thomas.loc.gov.

35 Citizens for Health, http://www.citizens.org.

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