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Insurers question value of massage therapy – a signal of changes to come?

In a Benefits Canada website post, Time for More Hands-On Management of Massage Therapy Benefits, writer Kenneth MacDonald admits “Most people agree massage offers some therapeutic benefits, such as reduction of muscle tension and pain related to soft tissue strains and injuries. Studies have also shown it’s helpful in treating symptoms related to anxiety, digestive disorders, headaches and several other conditions.” He reports massage therapy claims have soared in utilization and exceed claims for other interventions. “Massage is the highest used paramedical service and represents the fastest growing cost.”

MacDonald implicates massage therapy as a perk employers are paying for, with practitioners applying lucrative business models to tap generous benefit plans. MacDonald proposes cost-sharing with employees, limiting coverage to employees only (family excluded), campaigning employees to empathize with the employer’s costs of providing benefits, and looking to lower cost alternatives like yoga and relaxation methods. MacDonald finishes, “While many employees use massage therapy for a genuine need, if too many people are taking advantage of it, plan sponsors may need to reduce or eliminate coverage.”

Insurers are increasingly cynical of practitioner profit motives. In a related Benefits Canada article, What are the Goals of Massage Therapy as an Employee Benefit?, Yafa Sakkejha, general manager at Beneplan Co-operative asserts many paramedical clinics “are being run by hybrid craftspeople/businesspeople.” Sakkejha admonishes employers are exploited when clinics are focused primarily on profit maximization. “(Employers say) I just want you to take care of the health of my people so they can go to work.”

In Green Shield Canada’s (GSC) April 2019 podcast, Chiropractic in Canada, A Tale of Self-Regulation guests Wayne MacPhail and Paul Benedetti (Globe & Mail contributors), investigate the regulation of chiropractic. GSC Vice-President David Willows and Pharmacy and Health Provider Strategy Director, Ned Pojskic hosted the show. Concerns and criticisms raised in the podcast can extrapolate to parallel issues in the massage therapy profession.

MacPhail and Benedetti state there is insufficient oversight by Health Professions Regulatory Advisory Council (HPRAC) regarding scope of practice. Practitioners can create proprietary methods – not necessarily evidence-informed – and “get a free ride” by falling within scope.

Practitioners equate self-regulation with credibility and expect insurers not to object to claims, despite the paucity of evidence that may exist for these interventions. Practitioners claim any evidence – even a single study – demonstrates proof of efficacy. GSC representatives contrast this expectation to their dealings with pharmaceutical companies, who must provide extensive information regarding drug benefits and risks before insurance reimbursement is considered.

Pojskic asserts the insurance reimbursement model contributes to a profit-focused health service industry, and practitioners or commercial businesses have created models to exploit it. He states, “If insurance pays for something, there will be a business model (generated) around it. We need to reform our (insurance reimbursement) processes, so we only pay for evidence-based methods.”

Pojskic went on to identify a problem with acute, non-returning cases as problematic for practitioner businesses. He says “(with acute care cases) there’s not a lot of business. You have to address chronic conditions…you have to have patients coming back or else where’s the business going to be?” Pojskic condemns health professions that can’t provide data on adverse events. “Adverse reports are not done very well”, he concludes.

Pojskic is critical of the broad, sweeping blanket that is scope of practice. He believes regulatory bodies must go beyond simply defining scope and instead link scope to evidence-supported outcomes for health conditions. “Assigning specific conditions to scope of practice…that could be the next layer”, Pojskic maintains. Insurers then can determine what interventions show promise and demonstrate efficacy in addressing health conditions insurers regularly pay claims for.

MacPhail and Benedetti finish with a bold statement, “(The chiropractic profession) has shown itself – in Ontario anyway – incapable of regulating themselves…there’s too much self-interest.” They suggest a dissolution of the self-regulatory model in favour of a centralized, government-controlled regulator.

Listeners of our On The Table podcast will recall our interview with Andrew Lewarne, Executive Director, RMTAO, when we discussed a particularly inflammatory November 2018 blogpost by GSC entitled “Elephant in the (Waiting) Room.” In the podcast, GSC representatives shared the high cost of pharmaceutical claims their customers would submit. They stated hard choices would need to be made, and positioned a moral argument to their customers…consider forgoing some services – massage therapy in particular – so Greenshield could reimburse customers for expensive drug claims.

Further, in GSC’s September 2018 podcast, “Reimagining Health Benefits,” Pharmacy and Health Provider Strategy director, Ned Pojskicdescribed how health benefits should be geared to services that deliver perceived value, better outcomes, and that have evidence behind them. In an October 2018 press release, “We spend more on massage than mental health services…time for a change?” Erin Crump, GSC’s Leader of Strategic Innovation shares that for every dollar spent on a visit to the psychologist, four dollars are spent on massage therapy claims. GSC’s spending account model – SMARTSpend – would exclude massage therapy services from this product.

What can we extrapolate from all these admonishments from the insurance industry? Insurers play a gatekeeper role in health care funding, given that musculoskeletal complaints – realm of physiotherapists, chiropractors and massage therapists – are not funded by provincial health insurance plans. Insurer relations therefore are important to these professions, and insurers are asking for more accountability and evidence.

Without exigency in addressing the concerns of insurers, I predict a progressive removal of massage therapy from many insurance products. Insurers will continue to campaign both employers and employees to critically consider their massage therapy utilization.

For the plans that provide paramedical coverage, insurers will institute more oversight, only funding those interventions deemed evidence-backed, and only in cases where a less expensive option promising the same outcome is not available. Employees will need to share the cost via co-payments and will likely see coverage pared for family members.

Stakeholders in the massage therapy profession should clarify benefits of care as distinct from physiotherapy, chiropractic and other disciplines/practices espousing remedy for stress, strain and pain. Massage therapy should position hard in the bio-psycho-social model, linking to benefits in mental health, sleep quality and returning injured workers to work.

Our profession should look for strategic alliances and pool resources to campaign against the image of profit-focused, insurance-exploiting practitioners to contributors in public health and economic accountability.

– Donald Quinn Dillon, RMT is a practitioner, writer/speaker and practice coach. He co-produces the popular podcast, On the Table with MTC editor Jannen Belbeck. Find Don at DonDIllon-RMT.com.