Despite finalizing the rules over the last 18 months, DORA decided to make a substantial last-minute change to where natural medicine services can take place.
The original rules, which became official in July, permitted natural medicine services in a participant’s home without restrictions. At the last minute, and without notice, DORA quietly gutted the rule by limiting at-home facilitation to only individuals currently receiving palliative care. This change, just days before the final scheduled hearing of the year, could effectively prohibit at-home facilitation for many who need it. Adding to the controversy, state officials made blatantly false and misleading statements to the public during the final hearing on these rule changes, which were originally billed as simple language cleanups.
The option to receive Natural Medicine outside the confines of Healing Centers, specifically in private residences, has been expected in Colorado’s Natural Medicine program since voters approved Proposition 122, which expressly included it. Both the NMAB and public stakeholders overwhelmingly supported this option, celebrating increased access to Natural Medicine, both physically and financially. Allowing administration in private residences is crucial to ensure equity and access to Natural Medicine Services for populations such as rural communities far from a Healing Center, home-bound individuals who cannot easily travel, and those who cannot afford the anticipated price tag of administration at Healing Centers.
With facilitation-related rules having been finalized by July 2024, most believed the question of at-home facilitation was settled. However, on September 12th, the agency announced an additional rulemaking, proposing changes to some existing rules. This rulemaking was characterized as a “cleanup,” allegedly to streamline and clarify certain rules. The proposed changes received significant feedback from public stakeholders and the NMAB throughout September and October, through proper notice, official rulemaking proceedings, and stakeholder engagement. The permanent hearing on these changes was scheduled for November 19th. Then, in a move that shocked many stakeholders, DORA made substantial changes to the rules on the evening of Friday, November 15th, just days before the scheduled final hearing. In addition to potentially violating Colorado administrative laws requiring proper notice to the public of proposed changes, this move undermines public trust in the rulemaking process.
Under DORA’s proposed changes, at-home facilitation would only be available to individuals currently receiving palliative care. Additionally, only Healing Center-affiliated facilitators may provide at-home facilitation services under the changes. The specific change that elicited outcry from nearly every commenter at the hearing reads as follows:
6.18 Additional Requirements for Administration Sessions Outside of a Healing Center
A facilitator who is employed by, contracted with, or holds a healing center license may facilitate an administration session in a location other than a healing center in accordance with these rules if they are facilitating for a participant requiring palliative care.
Seemingly in response to the overwhelming public pushback to the changes, DORA reversed course, quietly removing the controversial changes before submitting the remaining cleanup changes for the final steps of the process. Then, on December 13th, the Office published yet another rulemaking notice, this time focusing specifically on rules related to at-home facilitation and microdosing – which once again included the same problematic restrictions. We applaud DORA for going through a more inclusive process to address this issue. However, the substance of their proposed policy change restricting at-home care is still incredibly problematic.
Nonetheless, the story doesn’t end there. In what some may perceive to be a post hoc attempt to justify the agency’s distaste for at-home facilitation, at the December 20th meeting of the NMAB, guest speaker Dr. Anita Kumar was invited to provide her opinion on at-home facilitation. No one was invited to provide a counter opinion.
Dr. Kumar, who identified herself as a psychiatrist and “staunch advocate of Natural Medicine” was of the opinion that at-home facilitation should be limited to palliative care patients. Her brief presentation began with a personal anecdote, in which she shared her recent experience of using natural medicine in a private residence with a group of her family and peers. This experience, it was implied, led to her “realizing the need for an impeccable container.” Without providing any further background or supporting evidence, Dr. Kumar stated simply:
“The bottom line is . . . we all want safety, and I feel like the safety is going to come from the client’s confidence that their experience will be a positive one. And that comes from having a positive mindset in a safe setting… I’m recommending to this group that the general population journey in Healing Centers, and the exception be palliative care and end of life.”
Dr. Kumar did, however, suggest that expanding residential access may be acceptable to her in the future, after more data has been collected.
Responding to Board questions regarding her own experiences with at-home facilitation, Dr. Kumar’s answers essentially amounted to more anecdotes and opinions. When asked about issues she had experienced regarding at-home facilitation, Dr. Kumar identified only the “looseness of the container” in one of her personal experiences as a participant. She also shared an experience in an Oregon Service Center, stating that [the structure of the service center] “gave me what I needed.” To be sure, many individuals would similarly benefit from a structured environment. However, generalizing the conditions that would be best for the larger population based on one’s limited personal experiences is, at best, a questionable way to determine policies affecting countless unique individuals, each with unique needs and preferences.
Responding to additional questions from the Board, Dr. Kumar shared the following:
- She has personally received Natural Medicine in a residential setting, without significant issue;
- She has provided group facilitation in a private setting, without significant issue;
- She has not provided 1-on-1 facilitation services as a facilitator personally.
Several members of the Board pushed back on Dr. Kumar’s position. Dr. Sophia Chavez shared that in the curandero and indigenous-rooted communities of which she is part, at-home facilitation is both a common occurrence and considered quite safe. Dr. Sue Sisley pointed out that, once established, corporate Healing Centers will be economically incentivized to oppose at-home facilitation. Dr. Sisley also pointed out the reality that underground at-home facilitation is already commonly occurring and has been for quite some time. Skippy Upton-Mesirow noted that many underground facilitators, who are already reluctant to join the regulated market, will be further pushed away by this prohibition. Dr. Alisa Hannum, a clinical psychologist, expressed strong support for expanding at-home facilitation access beyond palliative care.
Following the lengthy discussion, Dr. Sisley proposed a motion that would permit at-home facilitation in the following circumstances:
- If a participant is homebound, has a physical disability, or is receiving palliative care;
- If recommended by the participant’s treating provider;
- For Indigenous purposes;
- If the participant lives more than 50 miles from a Healing Center;
- Financial hardship.
Unfortunately, before voting on Dr. Sisley’s motion, the Board entered a closed-door Executive Session that consumed the remainder of the meeting time. Upon returning, the motion was tabled, leaving this significant issue unresolved for at least another month.
Viewed holistically, the last-minute changes, unprecedented interagency support, and a single guest “expert” with limited at-home facilitation experience, have left some feeling as though DORA is attempting a post hoc justification of an incredibly unpopular change to at-home facilitation.
Emails obtained through a CORA request show that the Office of Natural Medicine Licensure approached Dr. Kumar to speak about restricting residential administration on December 3rd, after the agency received significant pushback in the November 19th hearing. In those emails, during which a phone call was scheduled with Dr. Kumar, the Director clearly stated the Office’s position is to only allow administration by facilitators that are associated with Healing Centers. Unfortunately, the substance of the phone conversation is not available to the public.
Rule Changes: Supervised Practice Requirements
While certainly less controversial than at-home facilitation, Supervised Practice (“practicum”) requirements have seen more revisions than nearly any rule. Although the final version put forth for November’s permanent hearing is less prescriptive than prior versions, several individuals speaking on behalf of facilitator training programs felt the rules are still burdensome.
Specifically, representatives from training programs felt that more flexibility is needed around the 30 hours of required administration session hours, particularly as the program gets off the ground. Additionally, changing the practicum rules substantially at this late stage is certain to cause additional headaches for training programs, many of which have been left in limbo for the past several months.
Distribution and Timing of Practicum Hours
While a previous proposed version of the rules prescribed a rigid distribution of practicum hours, the final version is slightly more flexible. Welcome language changes now make clear that practicum may take place in Oregon. Under the final proposed changes, the 30 hours of required in-person experience in administration sessions may be as a participant, observer, or co-facilitator, with a maximum of 10 hours from experiencing natural medicine.
Non-administration hours, comprising 10 of 40 total practicum hours, may be virtual or in-person. These hours may be a mix of preparation, integration, and consultation. group facilitation.