MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

This article reports that Medicare is exploring whether to pay for acupuncture. Coverage would be for chronic low-back pain only. In its request for comments on acupuncture, the Department of Health and Human Services said that “in response to the U.S. opioid crisis, HHS is focused on preventing opioid use disorder and providing more evidence-based non-pharmacologic treatment options for chronic pain.” The agency said it hopes “to determine if acupuncture for [chronic low-back pain] is reasonable and necessary under the Medicare program.” A proposal is due by July 15, with a final decision by Oct. 13.

Medicare coverage “is long overdue,” said Tony Y. Chon, director of integrative medicine and health at the Mayo Clinic in Minnesota. “The opioid epidemic is going to be the momentum that’s really needed to push not just acupuncture but other kinds of non-pharmacological interventions to the forefront.”

Some proponents also note that acupuncture is one of the safest interventions available for pain — though some accidents have been reported. Even if it works only for some people, they argue, there is little harm in trying it when other options are not effective.

However, research shows that acupuncture is little more effective than placebo in many cases. When the government’s Agency for Healthcare Research and Quality reviewed research on a wide range of therapies for chronic pain in 2018, it found the “strength of evidence” that acupuncture works for chronic low-back pain is “low.”

The National Center for Complementary and Integrative Health, part of NIH, says “research suggests that acupuncture can help manage certain pain conditions, but evidence about its value for other health issues is uncertain.”

Critics go further, noting that hundreds of years of anatomical studies have not found evidence of the points in the body linked to the “energy channels” that acupuncture claims to be stimulating to provide pain relief. They contend that acupuncture shows all the signs of the placebo effect, with providers and recipients who believe it works and the elaborate ritual of placing the needles in specially selected spots. “The whole thing is a big scam,” said Steven Novella, an assistant professor of neurology at the Yale School of Medicine and editor of the “Science-Based Medicine” website. “The only honest interpretation of the data is that acupuncture is a theatrical placebo.” Novella said that the efficacy attributed to acupuncture could easily be explained by various research biases and that no drug would be allowed on the market based on that level of proof. “We never get that threshold of evidence that you need in medicine, where you get that persistent effect, and it’s replicable” across numerous studies, he said.

The evidence is indeed far from clear. NICE stated that it no longer recommends acupuncture because the evidence is not strong. Others have shown that acupuncture is superior to sham as well as no acupuncture control for back pain, with differences between groups close to .5 SDs compared with no acupuncture control, and close to .2 SDs compared with sham.

A further systematic review stated that acupuncture provides a short-term clinically relevant effect when compared with a waiting list control or when acupuncture is added to another intervention. Yet another systematic review found that acupuncture for chronic nonspecific low back pain was associated with significantly lower pain intensity than placebo but only immediately post-treatment (VAS: -0.59, 95 percent CI: -0.93, -0.25). However, acupuncture was not different from placebo in post-treatment disability, pain medication intake, or global improvement in chronic nonspecific low back pain. Acupuncture did not differ from sham-acupuncture in reducing chronic non-specific neck pain immediately after treatment (VAS: 0.24, 95 percent CI: -1.20, 0.73). Acupuncture was superior to no treatment in improving pain intensity (VAS: -1.19, 95 percent CI: 95 percent CI: -2.17, -0.21), disability (PDI), functioning (HFAQ), well-being (SF-36), and range of mobility (extension, flexion), immediately after the treatment. In general, trials that applied sham-acupuncture tended to produce negative results (i.e., statistically non-significant) compared to trials that applied other types of placebo (e.g., TENS, medication, laser). Results regarding comparisons with other active treatments (pain medication, mobilization, laser therapy) were less consistent Acupuncture was more cost-effective compared to usual care or no treatment for patients with chronic back pain.

The recent Lancet papers excited alternative therapists and their organisations who quickly jumped on the LBP  bandwagon. Others have claimed that my often critical verdicts of alternative therapies for LBP are out of line with this evidence. I am broadly in agreement with the evidence presented in Lancet-paper! But I also want to caution that things are complex.

I have therefore copied the non-pharmacological, non-operative treatments listed in the Lancet-paper together with the authors’ verdicts regarding their effectiveness for both acute and persistent LBP. I feel compelled to point out that the Lancet-paper merely lists the effectiveness of several therapeutic options, and that the value of a treatment is not only determined by its effectiveness. Crucial further elements are a therapy’s cost and its risks, the latter of which also determines the most important criterion: the risk/benefit balance. In my version of the Lancet table, I have therefore added these three variables for non-pharmacological and non-surgical options:

EFFECTIVENESS ACUTE LBP EFFECTIVENESS PERSISTENT LBP RISKS COSTS RISK/BENEFIT BALANCE
Advice to stay active +, routine +, routine None Low Positive
Education +, routine +, routine None Low Positive
Superficial heat +/- Ie Very minor Low to medium Positive (aLBP)
Exercise Limited +/-, routine Very minor Low Positive (pLBP)
CBT Limited +/-, routine None Low to medium Positive (pLBP)
Spinal manipulation +/- +/- vfbmae
sae
High Negative
Massage +/- +/- Very minor High Positive
Acupuncture +/- +/- sae High Questionable
Yoga Ie +/- Minor Medium Questionable
Mindfulness Ie +/- Minor Medium Questionable
Rehab Ie +/- Minor Medium to high Questionable

Routine = consider for routine use

+/- = second line or adjunctive treatment

Ie = insufficient evidence

Limited = limited use in selected patients

vfbmae = very frequent, minor adverse effects

sae = serious adverse effects, including deaths, are on record

aLBP = acute low back pain

So, should Medicare pay for acupuncture or any other SCAM? Please advise!

14 Responses to Should Medicare pay for acupuncture?

  • No Medicare should not pay for acupuncture.

    I am sure there are a few covens of witches who would be more effective and cauldrons are probably cheaper in the long run. Or perhaps we could see if an updated “laying on of the hands” by King Donald would be more effective.

    Battle-field acupuncture and now this! Still if we coordinate acupuncture for lower back pain with effective astrology the US Department of Health and Human Services might be on to a winner.

  • Ugh. No no no no! Just what I need. My tax dollars going toward magic. I get it. There are problems with opiods. But reverting to sticking needles in one’s body…. That’s just crazy.

    BTW: King Donald has said he’s going to issue an executive order that will bring US drug prices down

    “Why should other nations like Canada—why should other nations pay much less than us?” Trump said, declaring that he would handle the matter “in the form of an executive order.”

    I guess all that extra money can go to SCAM.

  • The problem persists: technology outpaces sociology 1000:1. Religious-approbation and magic are perceived as the true enemy by only a fraction of the population. Until that changes poking little needles in the skin, cracking joints to release innate, sucking sugar pills and mutilating childrens’ genitalia will sadly continue.

  • Kind of disappointed that we’re (US government) is taking the time to even debate this issue when the bigger picture of Medicare for All (or some form of universal healthcare coverage) should be on the table. This is kind of like choosing a color scheme for the lunar lander before the rocket’s launch pad is even designed.

    BTW, thank you, Edzard, for yet more concise and informative analysis. ‘ Always enjoy your insights. And, no, acupuncture should not be a covered Medicare expense.

    • Folks that have paid into the system for a lifetime shouldn’t be granted acupuncture, but folks that haven’t paid into the system should receive healthcare benefits ? …. this is the new liberal mindset.

  • Curious as to why you did not include painkillers of various types, especially as an important part of the conclusions would be the efficacy of combined approaches and it’s really a given that painkillers will be used to facilitate exercise and staying active.

  • Australia just introduced a set of changes to private health insurance, banning cover for assorted SCAMs (banned from policies receiving a government subsidy) but sadly acupuncture was not in the list of banned modes, despite the evidence that it is expensive and completely ineffective.
    We’ll have to try for it to be included in the next set of changes.
    https://www.health.gov.au/internet/main/publishing.nsf/Content/private-health-insurance-reforms-fact-sheet-removing-coverage-for-some-natural-therapies

  • “This is kind of like choosing a color scheme for the lunar lander before the rocket’s launch pad is even designed.”

    Nice!
    (Except for the spelling of ‘colour’!)

    Any money which could be allocated to ‘acupuncture’ should be spent on qualified counsellors – which is what that group of patients need.
    They don’t “have back pain” – they only think they do.

    I prefer to call sticking pins in unidentified ‘meridians’ – ‘Belonetherapy’.
    Sums it up better.
    (Greek: belone – a needle.)

  • I don’t think Ernst’s opinion will matter to Medicare, expecially if they determine that the use of acupuncture could prove less costly than addictive pain medications and subsequent risk of addictiion treatment and its cost. Economics 101.

  • Why not? Why are we pretending that evidence based medicine is the way medicine is practiced or the way the world works? Most of medicine is practiced by “tradition” or “expert consensus.” Chiropractics are already covered benefit. Will harms of acupuncture be worse than the current treatment of using procedures (injection, RFA, and spine stimulators)?For that matter, may be massage for pain should be covered, too. Per ACP article on heat, LBP, chiropractic was recommended with limited evidence. Also about 20 + years ago, we had multi-disciplinary approach to pain that appeared to work (psychologist, MD, pharmacist). Guess what? Insurance companies decided that approach was too expensive… So 20+ years later, we have opioid crisis plus expensive interventions that do not appear to be reliable.

    When medical practice changed radically in 80’s, it was not due to an evidence pointing to superior outcome with HMO care. It was simple economics – cost. Vickers et al. published articles documenting cost-benefits of acupuncture. There was a CMS technological assessment performed on acupuncture for knee pain (osteoarthritis) which showed some benefits.

    Below is a link on acupuncture – technological assessment published by U of Birmingham demonstration positive effect for treating pain.

    https://www.birmingham.ac.uk/Documents/college-mds/haps/projects/WMHTAC/REPreports/2006/MappingAcupunture.pdf

    It is a fact that in the US, armed forces, Tricare, and VA covers a form of acupuncture developed by Richard Niemtzow, MD MPH PhD focusing on pain relief through auricular acupuncture. Of note, Dr. Niemtzow’s protocol is being utilized by three academic institutions to conduct phase III clinical trial on using acupuncture for treating/preventing xerostomia.

    I agree with Sandra who wrote about economical decisions before evidence will likely to triumph…

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