Trends In The Education And Practice Of Alternative Medicine Clinicians

Transcription

1 Trends In The Education And Practice Of Alternative Medicine Clinicians Alternative medicine practitioners (chiropractors, naturopaths, and practitioners of oriental medicine) are a growing part of the health care workforce. These providers must be tallied and taken into account as we look to the future. by Richard A. Cooper and Sandi J. Stoflet DATAWATCH ABST RA CT : T his study projects that the per capita supply of alternative medicine clinicians (chiropractors, naturopaths, and practitioners of oriental medicine) will grow by 88 percent between 1994 and 2010, while physician supply will grow by 16 percent. This increase is associated with growth in the number and size of alternative medicine colleges and in the opportunities these graduates have for licensure and practice. This study calls for an assessment of the education and regulation of clinicians across the range of disciplines who will be providing patient care in the twenty- first century. ALTHOUGH THE NUMBER of physicians per capita has more than doubled over the past forty years, physicians have not filled all of the sectors within the health care field. Rather, they have clustered disproportionately in the areas of greatest medical and surgical intensity At the same time, the number of nonphysician clinicians has increased in a range of disciplines, some that complement traditional medicine and some that compete with it. Nonphysician clinicians fall into three broad categories. First is nonphysician providers, such as advanced practice nurses and physician assistants. The second group is traditional nonphysician clinicians who practice in specialty fields that overlap physicians scope of practice, such as podiatrists, psychologists, optometrists, and nurses certified in midwifery and anesthesiology. The third group is nonphysician clinicians whose therapies are characterized as unorthodox or complementary, such as chiropractors, naturopaths, Richard Cooper, a physician, is professor of medicine and health policy and director of the Health Policy Institute at the Medical College of Wisconsin in Milwaukee. Sandi Stoflet is a research assistant at the institute. H E AL T H AF F AI R S - V o l u m e 1 5, N u m b e r The People-to-People Health Foundation, Inc

2 A L T E R N A T I V E M E D I C I N E C L I N I C I A N S and practitioners of acupuncture and oriental medicine. As nonphysician clinicians have gained greater opportunities to practice, their numbers have increased, and further increases are projected. 2 This is occurring at a time when most analysts are projecting an excess supply of physicians, although its magnitude is debated. 3 Nonphysician clinicians thus must be considered in weighing the potential impact of a future surplus of physicians. Among the nonphysician clinicians, those in alternative medicine have largely been ignored, despite their growing participation in clinical care. 4 Some such clinicians practice under the general supervision of physicians, but most practice independently. 5 In recent years they have been granted greater independence in many states, and some states have mandated the inclusion of their services in health benefits coverage. 6 More managed care organizations are using their services, and more patients are seeking their care. 7 As a result, growing numbers of students have been attracted to careers in these fields, and expanded educational opportunities are being created for them. The purpose of this study is to explore the significance of alternative medicine clinicians within the broader array of clinical practitioners. To do so, we estimate the current number of alternative DATAWATCH 227 medicine clinicians, project their supply over the next fifteen years, and examine characteristics of their clinical practices. Methods We analyzed clinicians in the three alternative disciplines that are licensed and regulated chiropractic, oriental medicine, and naturopathy. We estimated the current number of clinicians in each of these disciplines using information obtained from the American Chiropractic Association, the National Acupuncture Foundation, and the American Association of Naturopathic Physicians. 8 We obtained information concerning licensure, certification, and practice from these sources, national registries and directories, and licensing boards. 9 Information on current and future student enrollment in these disciplines was obtained from deans and admissions directors and/ or published materials from all colleges of chiropractic and naturopathy and from all schools and colleges that are members of the Council of Colleges of Acupuncture and Oriental Medicine. Institutions in this latter category designate their programs as acupuncture and oriental medicine, acupuncture and herbal medicine, oriental medicine, or traditional Chinese medicine; they are referred to collectively here as oriental medicine. We excluded programs limited to acupuncture training for clinicians holding other degrees. We obtained data regarding the supply of physicians, H E AL T H AF F AI R S - F a l l

3 nonphysician practitioners, and traditional nonphysician clinicians and population data from various published sources. 10 Results 228 DATAWATCH Licensed practitioners. Although chiropractic dates from the turn of the century, there were relatively few practitioners until the 1950s. In 1970 there were 13,000 chiropractors (six per 100,000 population), who treated approximately 5.5 million patients (3 percent of the population) (Exhibit 1). 11 By 1990 the number of chiropractors had tripled to 40,000 (sixteen per 100,000), and the number of their patients grew proportionately to 16.5 million. There were approximately 50,000 active chiropractors in 1994 (19.2 per 100,000) (Exhibits 1 and 2). They practice under the title Doctor of Chiropractic (D.C.). Licensure is available in all fifty states and the District of Columbia (Exhibit 3). Practitioners of oriental medicine are licensed or registered in twenty-four states and the District of Columbia. Licensure under the supervision of a physician is available in another three states. In many states licensure is very recent. Oriental medicine is practiced without licensure in at least five other states. The use of the title doctor or physician by practitioners of oriental medicine is restricted in many states unless the practitioner also holds a degree in medicine or osteopathy; some states mandate specific titles, such as Registered Acupuncturist, Acupuncture Physician, or Doctor in Oriental Medicine (O.M.D.). In 1994 there were approximately EXHIBIT 1 Growth In Supply Of Alternative Nonphysician Clinicians, SOURCE: Authors calculations, based on published and unpublished sources, as cited in text. a Chiropractors, naturopaths, and practitioners of oriental medicine. b Projected. H E A L T H A F F A I R S - V o l u m e 1 5, N u m b e r 3

4 A L T E R N A T I V E M E D I C I N E C L I N I C I A N S EXHIBIT 2 Supply Of Alternative Nonphysician Clinicians, 1994 And Number p er 100, a In states Number Iicensing Number Number p er 100,000 practitioners Number p er 100,000 Chiropractic 50, , Oriental medicine 7, , Naturopathy 1, , Total 59, , SOURCE: Authors calculations, based on published and unpublished sources, as cited in text. a Projected. 7,200 practitioners of oriental medicine (2.8 per 100,000), 6,500 of whom were licensed (4.2 per 100,000). Naturopaths practice under the title Doctor of Naturopathy (N.D.). They now are licensed in only ten states. (One of these states, Florida, no longer issues new licenses.) However, naturo- DATAWATCH 229 paths practice in at least twenty-eight states that have no licensure laws, sometimes under the supervision of a physician but frequently as independent practitioners. The profession aims to have licensure available in twenty states by the year There were 1,800 naturopaths in 1994 (0.7 per 100,000), 870 of whom were licensed in one of the states offering licensure (4.1 per 100,000 in only those states that offer licensure). Collectively, there were 59,000 alternative medicine clinicians practicing in chiropractic, oriental medicine, and naturopathy in 1994-equivalent to 10 percent of the number of patient care physicians (including osteopaths) in that year. 12 This is equal to 22.7 alternative medicine clinicians per 100,000 (27.5 per 100,000 when considering only those states in which these practitioners are licensed or registered), compared with 212 physicians per 100,000. When regulation of alternative medicine clinicians took place, a board specific to each profession was used 78 percent of the time (as opposed to a board that also regulated physicians or other health professionals). E ducation. There were sixteen chiropractic colleges, twenty nine colleges of oriental medicine, and three colleges of naturopathy as of 1994 (Exhibits 3 and 4). Admission requirements to colleges of chiropractic and naturopathy are similar to those of med ical schools; colleges of oriental medicine require less rigorous training. H E AL T H AF F AI R S - F a l l

5 E X H IB IT 3 Distribution Of Alternative Nonphysician Clinicians And Colleges Licensed or registered practitioners (C olleges)/graduates In 1994 per 100,000 population O riental O riental C hiropractic m edicine N aturopathy C hiropractic medicine Naturopathy H E AL T H AF F AI R S - V o l u m e 1 5, N u m b e r 3

6 A L T E R N A T I V E M E D I C I N E C L I N I C I A N S E X H IB IT 3 Distribution O f Alternativ e Nonphy sician Clinicians And C olleges (cont.) Licensed or registered practitioners (C olleges)/graduates In 1994 per 100,000 population O riental O riental C hiropractic medicine N aturopathy C hiropractic medicine Naturopathy SOURCE: Authors calculations, based on published and unpublished sources, as cited in text. a No known practitioners. b Practitioners in states not offering licensure; number not available. c Licensure for oriental medicine in North Carolina and naturopathy in New Hampshire is new. d e Licensure under physician supervision only. Florida no longer offers licensure for naturopathy. These forty-eight colleges are clustered in only nineteen states, and the majority of graduates are clustered in even fewer states. In 1994, 80 percent of chiropractic graduates were from colleges in only five states (California, Georgia, Iowa, Missouri, and Texas), and slightly more than 50 percent of oriental medicine graduates were from colleges in California. The duration of the curriculum in each of these disciplines ranges from three to four years. E X H IB IT 4 Matriculation And Graduation Of Alternative Nonphysician Clinicians, Number G raduates, Matrlcuiants, G raduates, of colleges (projected) a C hiropractic 16 3,180 4,397 3,737 O r ie nta l m e d ic in e , Naturopathy T otal 48 4,177 5,738 4,828 SOURCE: Authors. calculations, based on published and unpublished sources, as cited in text. a New clinicia ns only; graduates holding other professional degrees excluded. H E AL T H AF F AI R S - F a l l

7 232 DATAWATCH Many of the sixteen chiropractic colleges have been in existence for forty years or more, and only one was established after Accreditation by the Council on Chiropractic Education is more recent for most of these colleges, with seven accredited since 1985 and two in the past two years. Oriental medicine is a newer discipline in the United States. All twenty-nine colleges of oriental medicine were begun after 1970, and eleven have begun since All are members of the Council of Colleges of Acupuncture and Oriental Medicine. Of these twenty nine colleges, nineteen offer a master s degree, and ten offer a diploma. Accred itation is through the National Commission for Schools of Acupuncture and Oriental Medicine, but only twenty colleges have achieved such accreditation. In 1995 these twenty nine colleges graduated 866 students. However, 5-10 percent of graduates had been trained in another clinical discipline. There are now three colleges of naturopathy in the United States, and a fourth is expected. There also is a college in Canada. Those in the United States were founded in 1956, 1978, and 1992, and two are accredited by the Council on Naturopathic Medical Education. Many current naturopaths received their training either at chiropractic colleges that offered courses in naturopathy or through correspondence courses. Future supply: There is a general trend of increasing enrollment in each of these three disciplines. Combined enrollment in 1994 was 5,738. Adjusting for attrition, approximately 18 percent more chiropractic students are projected to graduate in 1998 than graduated in Among existing oriental medicine colleges, 8 percent more graduates are projected in 1998 than there were in 1995, and more colleges are expected. Graduates from the three naturopathic colleges have increased 15 percent over the past three years and are projected to increase by an additional 21 percent by The combined number of new clinicians who will graduate in the three disciplines is projected to grow 17 percent (Exhibit 4). Future supply: In projecting the supply of alternative medicine clinicians to the year 2010, we made two sets of assumptions. First, based on recent trends and discussions with college deans and admissions directors, we made the following assumptions regarding future enrollment: (1) The number of students enrolled in chiropractic colleges will increase 25 percent over the next five years and plateau thereafter. (2) The number of colleges of oriental medicine will increase from twenty-nine to thirty-three, and the total number of students enrolled will increase by 50 percent over the next five years, after which it will plateau. (3) The number of naturopathic colleges will increase from three to five, and H E AL T H AF F A I R S - V o l u m e 1 5, N u m b e r 3

8 A L T E R N A T I V E M E D I C I N E C L I N I C I A N S the total number of naturopathy graduates will double over the next five years. The second set of assumptions concerns the retirement and death rates of current practitioners. We assumed that 27 percent of current chiropractors, 20 percent of oriental medicine practitioners, and 15 percent of naturopaths will leave practice over the next fifteen years. These rates were influenced by the young average age of alternative medicine clinicians. Based on these assumptions, the number of chiropractors is projected to double by 2010 (Exhibits 1 and 2). The number of oriental medicine practitioners (exclusive of those holding other clinical degrees) will approximately triple; and the number of naturopaths will grow by a similar magnitude. Together, this represents a 124 percent increase in the number of alternative medicine clinicians. At the same time, physician supply will grow by only 16 percent (from 212 per 100,000 to 247 per 100,000). 13 As a result, the supply of alternative medicine clinicians will increase from 11 percent of physician supply in 1994 to 17 percent in Chiropractors now account for both the largest number of alternative medicine clinicians and the largest projected increase in supply. However, their distribution among states varies from as low as seven per 100,000 to more than forty per 100,000. To bring the supply of chiropractors in all states to a minimum ratio of thirty per 100,000 in 2010 would require a total of 92,000 chiropractors nationally. The projected supply for 2010 exceeds this by 12 percent. The most dramatic change in projected supply over the next fifteen years is in the number of oriental medicine practitioners (230 percent). However, it should be noted that although Asian Americans are not the only recipients of care from these practitioners, they do receive a disproportionate share, and that while the U.S. population will increase by only 20 percent between 1995 and 2010, the Asian American population is projected to increase by 95 percent. 14 The errors associated with our projections relate principally to the number of new graduates in the years , which will be affected by changes in class size and in the number of colleges training alternative medicine clinicians. Our projections assume an increase in both. If growth in the number of graduates is only half as great as we assumed, the total number of alternative medicine clinicians practicing in 2010 will be 124,900, 5 percent fewer than we projected. Conversely, if growth in training positions exceeds our assumption by 50 percent, the total number of alternative medicine clinicians practicing in 2010 will be 139,100, 5 percent more than we projected. Taken together, this represents a range of ±7,100 alternative medicine clinicians. DATAWATCH 233 H E AL T H AF F AI R S - F a l l

9 We project a doubling in the number of alternative medicine clinicians over the next fifteen years. 234 DATAWATCH Discussion Growth in supply of alternative medicine clinicians. We project a doubling in the number of alternative medicine clinicians over the next fifteen years, an increase of 88 percent per capita. Over this same period nonphysician practitioners (advanced practice nurses and physician assistants) will increase by 128 percent, and traditional nonphysician clinicians (for example, optometrists and psychologists) will increase by 16 percent. 15 In the aggregate, the per capita supply of these three groups of clinicians will increase by 66 percent, compared with a projected 16 percent increase in the number of physicians per capita over the next fifteen years. Distribution. As with physicians and nonphysician practitioners, there are disparities in the distribution of alternative medicine clinicians throughout the country. 16 It is not clear why this variation exists. The number of chiropractors in each state does not appear to be related to whether or not there is a chiropractic college in that state. In general, southern states have fewer chiropractors. Mississippi, which has among the fewest, also has the lowest numbers of physicians and nonphysician practitioners per capita. For naturopaths and practitioners of oriental medicine, the most influential factor in distribution is licensure; these clinicians are concentrated in states in the Northeast and West, where the greatest professional opportunities exist. Similar observations have been made about nonphysician practitioners, whose number per capita in each state correlates with the professional prerogatives granted to them. 17 Scope of practice. Alternative medicine practitioners scope of practice overlaps that of both primary care and the low-tech segments of specialty medicine as practiced by physicians and broadly overlaps primary care as practiced by nonphysician practitioners. It excludes surgery. The overlap is greatest for naturopaths, whose major distinction is the use of natural products and natural treatments as their only forms of therapy There also is a considerable degree of overlap for practitioners of oriental medicine, who, in addition to treating pain and substance abuse, treat many common ailments using both acupuncture and herbal medicine and emphasize prevention and wellness. Chiropractors scope of practice is sharply skewed to neuromusculoskeletal conditions (85 percent of patient visits). In this H E AL T H AF F AI R S - V o l u m e 1 5, N u m b e r 3

10 A L T E R N A T I V E M E D I C I N E C L I N I C I A N S realm, chiropractors overlap not only primary care physicians but also specialists in orthopedic surgery and physical medicine. However, chiropractors also treat other minor disorders, and the profession increasingly is emphasizing its role as a primary care provider, serving as the portal of entry into the health care system for both adults and children; treating many common disorders in a drug-free, natural way; and collaborating with other health professionals in care of patients. Moreover, a new Doctor of Chiropractic Medicine (D.C.M.) degree, which combines current training with primary care clinical experience, is being discussed within some colleges. Licensure, regulation, and reimbursement. State laws and insurance practices have favored the expansion of the services of alternative medicine clinicians in several ways. First, the number of states in which these disciplines are licensed or registered has increased progressively (Exhibit 3). Although recent legislative attempts to establish licensure for naturopaths and practitioners of oriental medicine have failed in some states, statutes are being reconsidered in several of these states, and new legislation is being considered in several others. 18 However, licensure is not limiting in all jurisdictions. Some alternative medicine clinicians practice in states with no licensure laws, often under the license of a physician, DATAWATCH 235 but also independently. Second, chiropractic care is reimbursed by Medicare and other federal programs and, in many states, by Medicaid. All states mandate that chiropractic care be covered by workers compensation; forty-one states also require private insurers to offer chiropractic coverage, and six require private insurers to cover acupuncture. 19 In addition, ten states have passed any-willing-provider or freedomof-choice laws that, in general, prohibit health plans from denying access to any licensed provider willing to meet a plan s terms and conditions; an additional six states have such laws applicable to specific professions, including chiropractic. 20 Finally, health plans (including managed care) are offering increased access to alternative medicine clinicians. As a result, the portion of clinical revenues derived by chiropractors from private insurance rose from 20 percent in 1975 to 40 percent in 1993, and this is likely to increase further in the future. 21 Public and professional acceptance. Neither the growth in the number of alternative medicine clinicians nor the laws and insurance practices that facilitate their access by patients likely would have occurred without broad public acceptance of alternative and complementary medicine. 22 The establishment of the Office of Alternative Medicine at the National Institutes of Health is one indication of the public s interest in learning more about these modali- H E AL T H AF F AI R S - F a l l

11 236 DATAWATCH ties; the popularity of books on this subject is another. This interest extends beyond the three alternative disciplines discussed here to more than twenty other disciplines and practices whose therapeutic scope is limited to diet and nutrition, herbal medicine, traditional and folk remedies, pharmacological and biological treatments, manual healing methods, mind/ body control, and bioelectromagnetics. Patients willingly pay out of pocket for these therapies; patients spent $13.5 billion in 1990, an amount equal to approximately half of out-of-pocket spending for physician services that year. 23 Some experts have questioned the value of many of these therapies, but other evaluations have led to the development of medical student and continuing medical education (CME) courses dealing with alternative and complementary medicine at a number of medical schools. The American Academy of Family Physicians now recognizes CME credits for courses in spinal manipulation, and many physicians use acupuncture, herbal therapy, and other alternative measures in their practices. 24 Among the 438 licensed clinicians in the United States who identify themselves as homeopaths, 20 percent are physicians. Finally, many physicians, particularly those in primary care, refer patients to alternative medicine clinicians. 25 Thus, there appears to be a reciprocal process: Alternative medicine clinicians are taking primary responsibility for patients; some physicians are expanding their therapeutic repertoire to include alternative practices; and both groups are referring patients to each other. Implications The first implication of this study relates to the number of alternative medicine clinicians. No previous studies have examined their supply, even within the context of major analyses of the nation s health personnel. However, this DataWatch indicates that their numbers now and in the future are sufficiently large and their acceptance by the public sufficiently broad that alternative medicine clinicians must be considered. A second implication relates to the substantial overlap of services provided by physicians, alternative medicine clinicians, and other nonphysician clinicians. Planning within most disciplines usually proceeds with little attention to the potential impact of other, overlapping disciplines. The public would be well served by an ongoing, comprehensive assessment of both the number of practitioners in the various clinical disciplines and the scope of services that each provides, drawing on existing sources where possible and supplementing them with new data analyses where needed. The third implication relates to variation in the accreditation of colleges that train these practitioners and in the education they H E AL T H AF F A I R S - V o l u m e 1 5, N u m b e r 3

12 AL TERNATIVE MEDICINE CLINICIANS receive. Neither is there uniformity in the licensure and regulation of these practitioners, even though they may treat the same clinical conditions. Licensure examinations vary among states even within disciplines, and in some states there are no examinations. In most states the regulation of alternative medicine clinicians occurs separately from the regulations of physicians or other health professionals. Some alternative medicine clinicians practice in states that lack licensure laws altogether, often under the supervision of a physician. A recent report from the Institute of Medicine defined primary care providers as clinicians who use a recognized scientific knowledge base and have the authority to direct the delivery of personal health services to patients. 26 Many nonphysician clinicians fit this definition. The public would be well served by a cross-disciplinary assessment of the institutions training nonphysician clinicians and of the education, licensure, and regulation of the clinicians who will be authorized to care for patients in the twenty-first century. N O T E S 1. Council on Graduate Medical E ducation, Recommendations to Improve Access to Health Care through Physician Workforce Reform (Washington: U.S. Department of Health and Hu man Services, 1994); and R.A. Cooper, Seeking a Balanced Physician Workforce for the Twenty-first Century, Journal of the American Medical Association 272 (1994): R.A. Cooper, Per spectives on the Physician Workforce to the Year 2020, Journal of the American Medical Association 274 (1995): K.N. Lohr. N.A. Vanselow, and D.E. Detmer, eds., The Nation s Physician Workforce: Options for Balancing Supply and Requirements (Washington: National Acad emy Press, 1996); S.A. Schroeder, The U.S. Physician Su pply: Generalism in Retreat, Bulletin of the New York Academy of Medicine 70 (1993): ; E.M. Whitcomb, A Cr os s-national Compar is on of Generalist Physician Workforce Data, Journal of the American Medical Association 274 (1995): ; J.P. Weiner, Forecasting the E ffects of Health Reform on U.S. Physician Workforce Requirements: Evidence from HMO Staffing Patterns, Journal of the American Medical Association 272 (1994): ; and S. Gamliel et al., Managed Care on the March: Will Physicians Meet the Challenge? Health Affairs (Summer 1995): Bureau of Health Professions, Health Personnel in the United States, 1991 (Washing ton: DHHS, 1992); and American Chiropractic Association, Chiropractic: State of the Art (Arlington, Va.: ACA, 1994). 5. National Acupuncture Foundation, State Acupuncture Laws, 1994 ed. (Washington: NAF, 1993). 6. Ibid.; and American Managed Care and Review Association, 1995 State Managed Care Legislative Resource (Washington: AMCRA, 1994). 7. D.M. Eisenberg et al., Unconventional Medicine in the United States: Prevalence, Costs, and Patterns of Use, The New England Journal of Medicine 328 (1993): ; H.H. Moffet, Alter native Medicine and Managed Car e: Are We Making Progress? Alternative and Complementary Therapies 1 (1994): 14-16; B. Carton, Health Insurers Embrace Eye-of-Newt Therapy, The Wall Street Journal, 30 January B1; and B.R. Cassileth and C.C. Chapman, Alternative and Complementary Cancer Therapies, Cancer 77 (1996): DATAWATCH 237 H E AL T H AF F AI R S - F a l l

13 238 DATAWATCH ACA, Chiropractic: State of the Art; NAF, State Acupuncture Laws; Official Directory (Longmon t, Colo.: Feder ation of Chiropractic Licensin g Boar ds, 1994); and ACA, 1994 Annual Survey and Statistical Study (Alexandria, Va.: Association Research Group, 1994). The Book of States, ed., vol. 30 (Lexington, Ky.: The Council of State Governments, 1994) ; L. Smith-Peters, ed., Directory of Professional and Occupational Regulation in the United States and Canada (Lexington. KY.: Council on Licensure, Enforcement, and Regulation. 1994); and Alternative Medicine Yellow Pages (Puyallup, Wash.: Future Medicine Publishing, Inc., 1995). Cooper, Seeking a Balanced Physician Workforce; BHPr, Health Personnel in the United States, 1991; E.S. Sekscenski et al., State Practice Environments and the Supply of Physician Assistan ts, Nu rse Practitioners, and Cer tified Nur se- Midwives, The New England Journal of Medicine 331(1994): ; L.H. Aiken and M.E. Salmon, Health Care Workforce Priorities: What Nursing Shou ld Do Now, Inquiry (Fall 1994): ; C.D. DeAngelis, Nurse Practitioner Redux, Journal of the American Medical Association 271 (1994): ; Cooper, Perspectives on the Physician Workforce; and U.S. Bureau of the Census, Population Projections of the United States by Age, Sex, Race, Hispanic Origin: , Current Population Report P (Washington: U.S. Government Printing Office, 1993). ACA, Chiropractic: State of the Art. Cooper, Seeking a Balanced Physician Workforce; and Cooper, Perspectives on the Physician Workforce. Cooper, Perspectives on the Physician Workforce. Ibid.; and U.S. Bureau of the Census, Population Projections of the United States by Age, Sex, Race, Hispanic Origin: Cooper, Perspectives on the Physician Workforce. Ibid.; and Sekscenski et al., State Practice Environments. Sekscenski et al., State Practice Environments. AMCRA, 1995 State Managed Care Legislative Resource. Carton, Health Insurers Embrace Eye-of-Newt Therapy. AMCRA, 1995 State Managed Care Legislative Resource. ACA, 1994 Annual Survey and Statistical Study. E isenberg et al., Un con ventional Medicin e in the United States; and Cassileth and Chapman, Alternative and Complementary Cancer Therapies. Eisenberg et al., Unconventional Medicine in the United States. L. Page, Manipulative Therapy Gains Interest; DOS Seek More Study, American Medical News, 26 June 1995, 5. J. Borkan et al., Referrals for Alternative Therapies, Journal of Family Practice 39, no. 6 (1994): M. Donaldson, K. Yordy, and N. Vanselow, eds., Defining Primary Care (Washington: National Academy Press, 1994). H E AL T H AF F AI R S - V o l u m e 1 5, N u m b e r 3