Credentialing Complementary and Alternative Medical Providers

Since the late 19th century, state legislatures and professional medical organizations have developed mechanisms to license physicians and other conventional nonphysician providers, establish standards of practice, and protect health care consumers by establishing standardized credentials as markers of competence. The recent explosion in the popularity of complementary and alternative medical (CAM) therapies (for example, chiropractic, acupuncture, naturopathy, massage therapy, homeopathy, and herbal medicine) presents new questions. Legislative recognition trumps medical recognition: State legislatures can license providers and thereby grant citizens access to certain therapies, even if scientific debate has not concluded in favor of those modalities. We describe the central issues in credentialing CAM providers and provide a framework for use by physicians, health care administrators, insurance companies, and national professional organizations. Current Credentialing Practices Licensing and Credentialing of Medical Doctors, Doctors of Osteopathy, Registered Nurses, and Other Conventional Health Care Professionals Credentialing is the process of obtaining, verifying, and assessing the qualifications of a health care practitioner to provide patient care services in or for a health care organization (1). Such qualifications may include a state license (granting the right to practice), which includes, in the case of providers other than medical doctors, a legislatively designated scope of practice (that is, the right to offer a specified range of clinical services that is narrower than medical diagnosis and treatment). Clinical privileges, also known as medical staff privileges, are the authorization granted by the appropriate authority (for example, a governing body) to a practitioner to provide specific care services in a health care organization or network within well-defined limits (2). Thus, credentialing a provider to deliver clinical services does not necessarily make the provider a member of the medical staff with clinical privileges. Licensure requirements for medical doctors and doctors of osteopathy include graduation from a Liaison Committee on Medical Education (LCME)accredited school or the equivalent, a passing grade on all three parts of the United States Medical Licensing Examination, and a minimum of 1 year postgraduate training in an accredited program (Appendix Table 1). Requirements for nursing licensure include graduation from an accredited nursing program and a passing grade on the National Council Licensure Examination (NCLEX) (3). Licensing requirements and scope of practice for other conventional health care providers, such as physical therapists, optometrists, and podiatrists, vary by profession and by state (Appendix Table 2) (4). Licensing and Credentialing of CAM Providers Licensing of CAM practitioners also varies by type of practitioner and by state (Appendix Table 3). For example, chiropractic is licensed in every state, whereas massage therapy is licensed in some states but not others and is less amenable to a national credentialing process. Some practices (for example, homeopathy) by and large lack formal recognition through state licensure and, therefore, afford hospitals and health plans no coherent credentialing process (5) (Table 1). Moreover, the type of license granted to each kind of provider varies by state (that is, mandatory license, title license, or registration) (6). Finally, as with conventional nonphysician providers, legal recognition of CAM providers through licensure is a political process, with attendant debates over scope of practice, prescriptive authority, and role of physician supervision (4). Table 1. Overview of Licensing Requirements for Complementary and Alternative Medical Practitioners Chiropractic Chiropractic, first licensed in 1904 by Illinois, is now licensed in all states. Currently, approximately 70 000 licensed chiropractors are practicing in the United States (Figure 1 and Appendix Table 4) (7). Students train at 1 of 16 chiropractic colleges accredited by the Council on Chiropractic Education, an organization recognized by the U.S. Department of Education (DOE) (7, 8). The Federation of Chiropractic Licensing Boards has developed uniform standards of education and examination, including the National Board of Chiropractic Examiners' four-part standard national certification examination; parts 1 to 3 are required for licensing by almost all states (Table 1) (9, 10). Figure 1. Complementary and alternative medical and conventional practitioners. However, obstacles to standardized credentialing persist, including understanding the scope of practice variations across states for chiropractors (6). For example, states vary in authorizing chiropractors to dispense or sell dietary supplements or to use ancillary CAM therapies, such as homeopathy and acupuncture (7). Indeed, current debates surrounding the safety and efficacy of dietary supplements highlight dilemmas involved in regulating providers' authority to recommend or offer such supplements (11, 12). Yet another conundrum is the status of chiropractors as primary care providers (PCPs). The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) defines a primary care provider as an individual who provides primary care services (that is, basic health care) and manages routine health care needs, including referral to a specialist for consultation or continued care (13). The American Chiropractic Association defines chiropractors as a first-contact gatekeeper for patients with neuromusculoskeletal conditions in the primary health care system (14), and, in smaller communities with fewer physicians, chiropractors frequently serve as providers of first contact (7). In Illinois, chiropractors who meet rigorous standards, including review by a credentialing committee composed of conventional physicians, can receive reimbursement under a Blue Cross/Blue Shield plan as PCPs (15). The PCP status of chiropractors thus remains controversial. Acupuncture and Traditional Oriental Medicine Acupuncture, first licensed by Nevada, Oregon, and Maryland in 1973, currently is licensed in 42 states and the District of Columbia (16). More than 14 000 practitioners are licensed in the United States (17), and an additional estimated 3000 medical doctors have studied formally and incorporate acupuncture into their practices (18). Of the more than 70 schools of acupuncture in the United States, 37 are accredited by and 9 are in candidacy status with the U.S. DOErecognized Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) (Figure 2 and Appendix Table 4). Figure 2. Complementary and alternative medical and conventional schools About one third of the states that license nonphysician acupuncturists require graduation from an ACAOM school or one with an equivalent curriculum (17). In addition, approximately one third of licensing states require the study of biomedical sciences, including anatomy, physiology, and pathology (Table 1). The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) offers separate certification programs in Acupuncture, Chinese Herbology, and Oriental Bodywork Therapy (19). As with chiropractic, almost all states licensing acupuncturists require passage of a national written examination offered by NCCAOM (17). Twelve states also require passage of the NCCAOM practical examination (9, 17). Credentialing problems persist. First, state requirements to practice acupuncture vary (Table 1 and Appendix Table 5). In many states, acupuncture training requirements for medical doctors, dentists, and other allopathic providers are minimal or nonexistent (Table 1) (17, 20). Some states permit licensed CAM providers, such as chiropractors, to practice acupuncture (with varying levels of training) whereas other states prohibit it (17). Second, states vary in their defined scope of practice for acupuncture and Oriental medicine. Definitions may include, in addition to needling, the following: magnets, laser biostimulation, cupping, Oriental bodywork (such as Shiatsu or acupressure), dietary counseling, reflexology, and other treatments (17). Some states specifically permit use of Chinese herbal medicine or western dietary advice and nutritional supplements; at least one state (Illinois) specifically prohibits use of herbal preparations (17). Colorado specifically prohibits use of western medical diagnostic tests and procedures; New Mexico's Board of Oriental Medicine authorizes doctors of Oriental medicine to order computed tomography, magnetic resonance imaging, and radiographs (17). Four states (Arkansas, Illinois, Utah, and Virginia) expressly prohibit spinal manipulation or chiropractic techniques (17). Third, only 14 states have an independent board of acupuncture or Oriental medicine; in other states, acupuncturists are under the board of medical examiners or regulated by the departments of commerce or health (17, 21). Fourth, only two states (Florida and New Mexico) specify that acupuncturists provide primary care (22, 23). Approximately one quarter of the states licensing acupuncturists require prior referral from, diagnosis by, or collaboration with a licensed medical doctor (Appendix Table 5) (17, 21). Finally, ongoing intraprofessional disputes include educational prerequisites for licensure; use of the title doctor (of acupuncture or Oriental medicine); supervision, referral, and prior diagnosis requirements; and educational requirements for inclusion of Chinese herbology within scope of practice (21). Naturopathy Naturopathy, although practiced in the United States for more than a century, is licensed by only 11 states (Table 1). The 1400 licensed naturopaths in the United States (8) have trained at one of four naturopathic colleges accredited by the Council on Naturopathic Medical Education of the American Association of Naturopathic Phy