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14 May 2008
What are Licensing Board Funds for Anyway?
Having recently written about licensing board budgets, my eye was caught by a Sacramento Bee article on an item in the California Governor's latest budget proposal — "borrowing" from special funds until 2010-2011 (or later), including the funds of licensing boards. The boards affected include:
- State Board of Barbering and Cosmetology Fund – $10 million
- Psychology Fund – $2.5 million
- Accountancy Fund – $16 million
- Contractors’ License Fund – $13 million
- Contingent Fund of the Medical Board of California – $6 million
- Board of Registered Nursing Fund – $2 million
- Pharmacy Board Contingent Fund – $1 million
- Professional Engineers’ and Land Surveyors’ Fund – $4 million
- Behavioral Science Examiners Fund – $3 million
- Vocational Nursing and Psychiatric Technicians Fund – $1 million
- Occupational Therapy Fund – $3 million
As I mentioned in my recent licensing board budget post, the issue of borrowing from boards was discussed in a 2005 document on cross-cutting issues from the Joint Legislative Committee on Boards, Commissions, and Consumer Protection. As Yogi Berra quipped, "It's deja vu all over again."
For those who really might have preferred a state licensing board to the private, state-overseen, credentialing organization proposed in SB 731, the phrase "Be careful what you wish for, lest it come true" comes to mind. It's all too easy, in these days of state fiscal woe, for such a board to find itself impacted by a state hiring freeze with the state tapping into the resulting accumulation of funds to balance the budget. A private certifying organization — even one specially created by state law, under legislative oversight (as is appropriate to ensure public accountability), and affecting local regulation — lies outside of the state budget and state hiring restrictions.
04 May 2008
Credentialing of CAM Practice
In his CAMLaw Blog, Michael Cohen recently posted testimony he gave in 2001 on Training, Education, Credentialing of CAM Practice to the White House Commission on Complementary and Alternative Medicine Policy.
Fraser Institute Report on CAM use in Canada
In 1999, The Fraser Institute published the first ever comprehensive study of Canadians' use of and public attitudes towards complementary and alternative medicine (CAM). Last year, a new study was published to capture any changes that have occurred.
Canadians spent an estimated approximately $7.8 billion out of pocket on alternative medicine in the latter half of 2005 and first half of 2006, which is a significant increase from the nearly $5.4 billion (inflation-adjusted) estimated to have been spent in the latter half of 1996 and first half of 1997. Despite incurring large out of pocket expenses, the majority of Canadians believe that alternative therapies should be paid for privately and not by provincial health plans.
In 2006, more than one-half (54%) of Canadians reported using at least one alternative therapy in the year prior to the survey. Massage therapy, was the most common CAM use in the prior year, having been used by 19% of respondents. Average out of pocket payments for massage therapy over the prior 12 months increased from $211 in 1997 to $365 in 2006. If given $100 for treatment of low-back pain, study respondents would have spent, on average, $31 for surgery, $30 for chiropractic treatment, and $40 for massage and exercise therapies.
Esmail, Nadeem. 2007. Complementary and Alternative Medicine in Canada: Trends in Use and Public Attitudes, 1997–2006. The Fraser Institute. ISSN: 1206–6257
Diversity, Creating a Profession, and Calls for Two Tiers
I find it interesting that I've been seeing calls for two tiers of massage licensing in a diversity of places. Doug Barhorst recently wrote a good piece on the need and benefits of two tiers on his Texas Licensed Massage email list. When I opened my newly arrived copy of Massage Magazine, I found a guest editorial by Phyllis Nasta on “It's Time for Two Tiers of Licensing”. My friend Robert, long hostile to any thought of licensing, has shifted over to separation of licensing, with the lower tier or tiers providing background checks and disciplinary oversight of a more simply oriented provision of commercial touch. That's espoused on his newest blog and another meet-up site called CARPET (California Associated Receivers and Providers of Enlightening Touch). In a survey a couple of years ago, ABMP found considerable support among California massage schools for two-tier licensing. Two-tiers are currently in the proposed CA bill, SB-731, although only on an interim basis. Still, the lower tier wouldn't be eliminated before the measure itself sunsets—there would be five years to work on the legislature. What's common to all of these voices is the feeling that worthwhile services by good-hearted people are being eliminated by the current technically-oriented mindset of massage therapy and its push toward being a health care profession. At its heart, the two-tier movement is a “back to basics” movement—a movement about providing the service of simple touch and connection to those who need it.
Interestingly, a two-tier way of thought is also a result of trying to improve the positioning of massage therapy as a health care profession. In a recent white paper, Rick Rosen presents his views On Becoming a Profession.
Despite the fact that it has become commonplace to refer to this occupational domain as “the massage therapy profession”, it lacks a number of essential elements that are considered to be hallmarks of a full-fledged profession. These include: a well-defined body of knowledge; educational standards; teacher training requirements; common terminology; standards of practice; and a regulatory system that affords public protection and allows inter-state mobility for practitioners. While some of these elements exist on a limited scale, there is little consistency among them.
I agree with Rick on a number of issues, although I have much less faith in the process of accreditation in achieving cost-effective training quality. In general, I've spent too many years employed as a physicist at a national laboratory to not have become skeptical of the efficiency of large bureaucracies. Yesterday's posting delved sufficiently into accreditation, however, and I won't expand on that further.
I do strongly agree with Rick that massage therapy, as currently regulated, lacks a single, coherent knowledge base typical of a health profession. The regulation of massage was not approached to create a health care profession, but to cast a wide regulatory net over the commercial provision of touch services. Looking back to 2000, there was a Massage Magazine articles on The Regulatory Net Part One: The Catch-All Effect of Massage Laws. The effect of this history is that regulatory laws are vague on knowledge and outcomes. Required hours of training may create an entry hurdle, but they don't define a cohesive profession. Many caught within the current net also have little interest or willingness to be herded together.
Resolving the issue requires distinguishing between massage therapy as a health care profession and massage provided as a more general, less defined (or definable) service. Not making the distincition still makes it, but simply by eliminating those not interested in the “professional progression”. In essence, making the distinction is what the title act for massage therapy accomplishes in British Columbia. Massage therapy, as included in the health professions, is regulated, yet it includes no restricted acts. In is unlikely in the U.S., however, that commercial provision of touch will not be regulated at some level of government. The only way of resolving the issue is to split the practices. For basic touch, define what training in knowledge and skills is essential, then provide disciplinary oversight. If you can't define a specific knowledge or skill requirement, it isn't essential. For massage as health care, start work on defining the outcomes of training; the sum total of what the health care massage therapist should be able to do and the auxiliary conditions and contexts under which they should be able to do it. The knowledge and skill training will follow from the outcomes. Among the resources, include books such as Working Minds A Practitioner's Guide to Cognitive Task Analysis by Beth Crandall, Gary Klein and Robert R. Hoffman.
03 May 2008
Education, Training, and the Conundrum of Accreditation
Unless the universities begin preparing students to participate in the “Great Conversation that began with the dawn of history and continues at the present day,” the outlook for Western civilization is indeed grim. — Robert Maynard Hutchins (Time, Monday, Sep. 21, 1953)
Maynard Hutchins' reference to the “Great Conversation” is a reference to the classical ideal of a liberal education that was forwarded by himself and Mortimer Adler. Adler's comment was:
What binds the authors together in an intellectual community is the great conversation in which they are engaged. In the works that come later in the sequence of years, we find authors listening to what their predecessors have had to say about this idea or that, this topic or that. They not only harken to the thought of their predecessors, they also respond to it by commenting on it in a variety of ways.
Hutchins, as noted in the review in Time, added a stronger statement on the purpose of education.
Education should be neither a means toward earning a living nor of promoting social reform. Education should be liberal, its object “to prepare the young to educate themselves throughout their lives.” With such an education, a man can take part in the continuing Great Conversation, and himself seek the answer to the overwhelming question: “What is the nature and destiny of man?”
This view of education, a view that separates education from the more pragmatic and immediate goals of training, is, I suspect, why the process of accreditation is what it is and why it has in recent times found itself caught on the shoals of controversy. Accreditation has its roots in the “Great Conversation” and those schools that supported it.
Accreditation has always been about the larger educational processes of creating the stability and environment to sustain and foster the academic world view. It was not created to ensure the quality of any specific section of training, but to sustain the quality of discussion as a whole. Academic discussion, however, is more often about knowing and discussion than about the mundane features of skills and doing, a feature noted by Paula Alsher in a article on Validating Knowledge Through Testing and Assessment for the Center for Effective Performance.
Because the roots of learning in the business world are found in the academic model, it’s not surprising that testing and assessment also typically follow that model. … At the end of the training, learners are tested on their ability to recall the content. True-false or multiple-choice questions are used to test the learners’ knowledge. If learners are able to answer questions more or less correctly, they are deemed “trained” and job-ready. But when those same learners go back to their jobs, managers quickly discover that they are not fully ready to perform, despite the knowledge they might have attained in training.
What started out, however, as a means for the academic world to maintain its academic integrity, to determine who was or was not part of the academic club, became more complicated when the federal government adopted accreditation in the 1950's as a gatekeeping function for federal financial aid. The move was not a bad one in itself; an institution that conforms to the larger picture of education is unlikely to be one lacking in educational value and simply wasting federal funds. The conundrum, however, is that this association opened the door to viewing accreditation as the benchmark of quality in training, something quite apart from its origins. That thought, however, moves us into the current realms of discussion and controversy surrounding accreditation. To exemplify the seriousness of this discussion, consider a statement from a January 2007 report from the Association of College Trustees and Alumni (ACTA) titled “Why Accreditation Doesn't Work and What Policymakers Can Do About It”.
Nothing in the accreditation process concretely measures student learning, instructional quality, or academic standards. Nothing measures whether students have made intellectual progress since high school or have attained a level of basic knowledge and competence that would be expected of college graduates. If the accrediting process were applied to automobile inspection, cars would “pass” as long as they had tires, doors, and an engine—without anyone ever turning the key to see if the car actually operated.
This report was a follow up (and the answer) to a prior ACTA report, “Can College Accreditation Live Up to Its Promise?” A reply to both reports was offered up by the Council for Higher Education Accreditation (CHEA) under the title “Here we go Again …Sin, Salvation, and Accreditation.”
CHEA also has a number of its own reports covering issues of reforming accreditation—making it more accountable to consumers and more focused on student outcomes. Notable among them are “Accreditation and Accountability: A CHEA Special Report” and “Accreditation and Student Learning Outcomes: A Proposed Point of Departure”.
All of the above is also occurring within the context of the report from the Secretary of Education's Commission on the Future of Higher Education. The Issue Papers section contains a number of papers on accreditation and its much needed reform.
Finally, there were two comparisons between accreditation and state-approval of schools done in California in 2004. When he was Chair of the California Assembly Business & Professions Committee, Lou Correa requested a report from the California Research Bureau. The California Postsecondary Education Commission also wrote a similar contrast report.
Ultimately, the quality of a program that is oriented toward training rather than broad education derives from the stipulation of clear outcomes and assessment that they actually occur from training. At least at the present time, it appears that accreditation is far too diffuse a mechanism and in far too much flux of its own to further these goals is an efficient, cost effective manner.
At the same time, there are efforts underway in learning and competency information management from a diverse consortium of defense, business, and education stakeholders that may reshape training as much as the Internet has reshaped communication. In fact, the consortium is much like that which created the Internet itself, as a means of having a distributed (and thus attack resistant) communication network. That, however, is another story for another, near-future MPS post.
01 May 2008
How much does a California Regulatory Board cost per Licensee?
A combination of the Governor's budget for the regulatory boards within the CA Department of Consumer Affairs and the recent DCA Annual Report paint an interesting picture of regulatory board costs. The budget gives the total expenditures and the annual report lists the number of licensees for the individual boards.
As background, boards are generally self-financed by licensing and other fees. Some boards may also get revenue from other services provided to the public or licensees. However, spending the money they receive from such fees still requires legislative approval. State boards also are subject to state staff hiring freezes, so they can, at times, collect funds but be unable to hire needed staff to spend them. A 2005 Joint Legislative Committee report discussed issues related to accumulating funds and state budget balancing.
The following table lists a number of the professional boards, their total expenditures for the 2007-2008 fiscal year in thousand of dollars (k$), the number of licensees, the expenditure per licensee in dollars, and a fit to the dollars per licensee (see below). None of the boards above had an expenditure budget less than $1 million annually.
| Board Name | Expenditures |
Licensees | $ / Lic | Fit of $ / Lic |
|---|---|---|---|---|
| California Board of Accountancy | 12,410 | 45,004 | $276 | $75 |
| California Architects Board | 4,230 | 21,998 | 192 | 96 |
| Board of Behavioral Science | 5,821 | 64,665 | 90 | 69 |
| Board of Barbering & Cosmetology | 17,653 | 476,352 | 37 | 57 |
| Dental Board of California | 12,901 | 42,660 | 302 | 76 |
| Board for Geologists & Geophysicists | 1,311 | 7,602 | 172 | 173 |
| Medical Board of California | 52,699 | 139,299 | 378 | 61 |
| Acupuncture Board | 2,653 | 8,502 | 312 | 161 |
| Physical Therapy Board | 2,457 | 25,298 | 97 | 91 |
| Physician Assistant Committee | 1,184 | 6,595 | 180 | 191 |
| California Board of Podiatric Medicine | 1,355 | 2,579 | 525 | 404 |
| Board of Psychology | 3,432 | 17,500 | 196 | 106 |
| Respiratory Care Board | 2,903 | 16,511 | 176 | 110 |
| California Board of Occupational Therapy | 1,046 | 9,682 | 108 | 148 |
| State Board of Optometry | 1,205 | 9,692 | 124 | 148 |
| Osteopathic Medical Board of California | 1,276 | 5,171 | 247 | 229 |
| California State Board of Pharmacy | 9,729 | 103,408 | 94 | 64 |
| Board for Prof. Engineers & Land Surveyors | 9,179 | 114,299 | 80 | 63 |
| Board of Registered Nursing | 24,092 | 425,115 | 57 | 57 |
| Veterinary Medical Board | 2,266 | 16,976 | 133 | 108 |
| Board of Vocational Nursing & … | 8,542 | 85,198 | 100 | 66 |
In the following graph, board expenditures per licensee are plotted with blue symbols. An approximate fit to the less expensive boards is shown in gold symbols. The fit is based on a fixed board cost of $900,000 and an additional cost per licensee of about $55. As a reminder, these data represent annual expenditures, not expenditure per license renewal period. The higher cost boards include the medical board, dental board, and board of accountancy. The differences in cost appear to follow staff size relative to the number of licensees. For example, the medical board, pharmacy board, and board for professional engineers & land surveyors all have somewhat over 100,000 licensees. They have staff sizes of 265, 51, and 53, respectively. The latter two boards have comparable staff sizes and comparable expenditures. Staff needs would vary with the need for onsite inspections and the complexity of disciplinary investigations and prosecutions.
The physical therapy board, the occupational therapy board, and the registered nursing board all lie along the fitted curve. The fitted curve thus likely gives a reasonable estimate for the annual expenditures to be expected of a massage board, unless the need for onsite inspections by board staff was significantly higher for massage. While a private certification agency under legislative supervision is contemplated for California under SB 731, it is likely that it would require similar expenditures to a board. One major difference would be that it would not be subject to state hiring freezes.
The greater cost per licensee for smaller professions (<10,000) motivates why legislatures would consider placing regulation, if needed, under an existing board or administrative bureau rather than creating a new board.
23 January 2008
Massage Kiosks, Costs, and Profitability
Last Sunday's San Francisco Chronicle ran a story on the massage kiosk (Zubio) effort being floated by David Palmer and Sam Keller. The article notes the difficulties of finding space and achieving profitability in a commercial environment. Palmer has long been an advocate of bringing massage into people's work lives rather than forcing people to come to massage.
Arizona May Consolidate Health Care Boards
A story in the Arizona Republic reports that Arizona Governor Janet Napolitano is pushing to consolidate a number of health care and personal service regulatory boards under a single administrative umbrella. Napolitano is supporting a series of bills in the Legislature to eliminate nine inactive boards and consolidate more than 30 others. The result might be along the lines of the Texas Department of State Health Services (DSHS) or New York State's Office of the Professions (OP). Such consolidation rarely makes individual professions happy, but it does provide a means of regulating for the public benefit and lowers administrative costs. Having such consolidations doesn't imply that domain experts can't be consulted as needed by the regulatory agency.
Another take on Colorado's Massage Regulation
An article from Colorado Spring's KOAA TV notes that El Paso County is frustrated with the state neither licensing massage practice nor allowing the county to do so. Such input may put more pressure on DORA, which recently recommended against state licensing. This is another reminder that much of the push for state licensing has little to do with the actual practice of massage and more with oversight of commercial touch.
The article links to a nonprofit working against human trafficking started by a massage school. The nonprofit, in turn, links to a number of other NGO's involved in such work against trafficking. In some ways, however, prostitution and trafficking are not synonymous, as brought out in a recent Economist article on a conference on Selling Sex (19-25 Jan 2008 issue) and by a Canadian article on decriminalizing sex work and activism by sex workers. I've also run across a European article extensively reviewing both demand and economic forces enabling trafficking. The latter article is especially significant in discussing that for some, the economic hope and life possibilities are so poor that being trafficked looks better than staying home. It's also worth noting, that whatever the cultural myths, trafficking and prostitution both require relatively local demand. This demand is coming from within the same culture trying to suppress its visible effects — a clear indication of a significant, undealt with social schism. In any case, there is much that can be worked on at an earlier stage than law enforcement. As an example, I'll point to my Ramblemuse Touchpoints blog on Three Cups of Tea linking to Greg Mortenson's work in creating schools in remote areas of Pakistan. A little hope and opportunity could greatly reduce the supply side of trafficking. It would seemingly take a lot more early training in empathy and social connection to reduce the demand side.
The regulatory association between massage practice and sex work is one that massage practitioners consider to be about on the same level as most people consider spam — something that they would be happy to see go away and never come back. Moving regulation from the local to the state level hasn't done away with that tacit association. The structure is still about control of commercial touch rather than about defining explicit outcomes for competence. The advantage is not in structure, but in uniformity of entry requirements and in escaping the unwillingness of a relatively few local agencies to recognize that massage therapy is a well-established profession in its own right. A recent foray into Google Books turned up book references to “Swedish Massage” dating back into the late 19th century.
01 January 2008
MPS Entries for 2007 Archived
The MPS entries for 2007 have been moved into their own archive file. There's also a link to the old index page from the archive index page on the navigation bar to your left.
If you came here via a link or search to the old index entries, there may be a date hash of the form "#pyymmdda" following the "index.html" at the end of the URL in your browser's address bar. When you get to the archived file, go to that date to see the entry you were seeking. You can even copy the "#pyymmdda" hash here, and paste it on the new page, then hit the enter key to go there. Here's a JavaScript based link that does all of that for you.
It is through each of our individual efforts that together we work to keep or get our profession and practices independent of unnecessary and/or onerous regulation. It is the responsibility of the state to protect the public from harm. It is the job of the profession itself, independent of the state, to develop norms of practice for particular client populations and contexts.
Liberty means responsibility. That is why most men dread it. — George Bernard Shaw, Man and Superman, "Maxims: Liberty and Equality", 1905
