Although Medicare coverage of acupuncture will help to expand access, limited acupuncture availability remains a significant barrier that may diminish the impact of the CMS policy, particularly in communities hit hardest by the opioid crisis. In the USA, there are an estimated 38,000 licensed acupuncturists; however, nearly 50% are located in New York, California, and Florida, which have relatively low opioid prescription rates among Medicare patients compared with other states.4, 5 By contrast, states with high opioid prescription rates and rising trends in opioid-related deaths, such as Ohio, Michigan, and Kentucky, have fewer than 2 acupuncturists per 100,000 people, highlighting a potential gap between availability and demonstrated need for acupuncture services.4, 5 Acupuncture clinics also tend to be concentrated in urban, upper-income neighborhoods, raising concerns about access in rural or poor communities.6 Most acupuncturists operate private practices without supervision from Medicare providers and thus would not be eligible for coverage under the new CMS policy.
To date, approximately 10,000 physicians have received acupuncture training, but their clinical volume, practice models, and geographic distribution remain largely unknown. The majority of Medicare providers lack familiarity with acupuncture and may not be appropriately equipped to provide acupuncturist supervision required for Medicare coverage. These knowledge gaps also prevent providers from effectively counseling and educating patients on the role of acupuncture in pain management. Few patients treated by acupuncturists are referred by other healthcare providers.
These barriers—limited availability, lack of provider knowledge, and endorsement—all contribute to reluctance among patients to seek acupuncture. Our research suggests that a sizeable proportion of patients are not willing to use acupuncture for pain management, even if treatments are covered by insurance.7 Lack of knowledge or awareness about acupuncture remains a major barrier that may be particularly salient among those at higher risk of opioid-related mortality. For example, patients with low educational attainment are less willing to seek acupuncture and more likely to overdose on opioids.7 Similarly, black patients experience significant disparities in pain management, including a recent trend of higher increases in opioid-related deaths compared with white patients; however, black patients are typically less open to acupuncture.7 Practical considerations may also deter patients from engaging in acupuncture. A full treatment course, typically at least 6–10 weekly or bi-weekly in-person treatments, requires significant investment of time and frequent traveling that may be infeasible for an older Medicare population with greater comorbidity and physical or cognitive impairments, particularly those living in rural areas. Despite concerns about polypharmacy among older patients, it is often more convenient to take an analgesic than to grapple with these challenges.