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Keeping Our Future in Our Hands

In this piece I have purposely chosen a serious and foreboding perspective to challenge what I perceive as our collective unease and unwillingness in this profession to discuss and deal with the hard issues. By “hard” I mean the politico-cultural issues, the discomfiting flaws in our “group think” that hamstring our growth and evolution.


August 4, 2011
By Don Quinn Dillon


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In this piece I have purposely chosen a serious and foreboding perspective to challenge what I perceive as our collective unease and unwillingness in this profession to discuss and deal with the hard issues. By “hard” I mean the politico-cultural issues, the discomfiting flaws in our “group think” that hamstring our growth and evolution.

Our discourse has perhaps been impaired by our protective maternal nature, our default to political correctness or a lack of confidence (maybe perspective) to debate the issues.  It’s imperative our dialogue elevate here and now to ensure our profession’s future remains in our hands.

I refer the reader to real opportunities for massage therapists (see MTC Winter 2011 and Spring 2011 columns) where our profession can position itself more favourably.  Subsequent articles that I will write in this column will further explore tangible options for the viability and longevity of massage therapy practice.

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THE RISE OF MASSAGE THERAPY: HISTORICAL CONTEXT
Since their distinct separation from the physiotherapy and nursing professions, massage therapists have been largely self-employed, working from a home base or contracting work from a spa, chiropractor, physiotherapist or another massage therapist/clinic owner.

In the period following the Second World War, massage therapists benefited from a strong North American economy. Industrial manufacturing led to industrial illnesses such as workplace-related musculoskeletal disorders (most prevalent were repetitive strain injuries) and job-related stress syndromes. The athletic/fitness movement and the information/computer technology age ushered in further musculoskeletal and nervous/mental conditions requiring remedy.

During this boom period, workers accessed generous employee benefit plans, higher discretionary income, comprehensive health care, and worker’s compensation plans or auto-insurance funding for rehabilitation.

Registered massage therapists (RMTs) are not covered by government provincial health plans, and therefore rely heavily on patients/clients with high discretionary income, generous workplace benefit plans, third-party coverage from auto insurance / worker’s compensation claims and direct referrals from “gatekeeper” health-care providers to build a practice.

A NEW ECONOMY, A NEW REALITY
Boom has turned to bust in North America, imposing change in the employment landscape and affecting the viability of practice for massage therapists. Among the changes that influence the profession are:

  • Workplace benefits clawback – The disappearance or decline of manufacturing and other sector jobs in economically recessive North America negatively impacts employee benefit plans and worker utilization of massage therapy.
  • Disproportionate taxation – Massage therapy is subject to the “harmonized” Goods and Services Tax (HST) while competing services, chiropractic and physiotherapy, are not.  This creates a clear competitive disadvantage.
  • Barriers to funding – Auto insurance and workers compensation claims require gatekeepers to authorize massage therapy plans. RMTs are positioned as ancillary health providers with controlled access to capped (limited) funding.
  • Growing competition – Health-care provision is shifting from physicians and nurses to lower-cost and more readily available physiotherapists, pharmacists and nurse practitioners. These professions employ assistants to deliver health care at lower cost to a larger number of people.  Physio/occupational therapy assistants, kinesiologists and other assisting providers may usurp RMT employment by providing “massage” in house.  Gatekeepers earn profits from this, keeping care in house rather than referring down the street to an independent RMT.
  • Employment upgrade – Large, business-savvy, well-financed spas and rehab facilities draw more RMTs to employment. Self-employed small-scale RMT practices find it tough to compete.
  • Insufficient credibility – Insurers and governments are skeptical of RMT results without degree-level education and evidence-based practices, elements that are standard requirements for other health disciplines. No credibility translates to no funding.
  • Threat to primary funding – Insurance fraud, association with prostitution and illegitimate business taint public and media perception of massage therapy.
  • Exploitation – Problems internal to the profession (discussed in the next section) leave the profession vulnerable to commoditization and exploitation by ignoble profiteers hoping to cash in on massage popularity.

ENTROPY FROM WITHIN
The massage therapy profession is ill-prepared to respond to the aforementioned encroachments in part because of problems inherent in its own political culture. Some of these problems are explored here:

Unsustainable time- and labour-intensive business model. Given the physical labour of providing care, an RMT’s capacity is often limited to 15-20 hours per week. Massage therapists are relegated to a part-time work schedule yet require full-time wages. RMTs must charge exorbitant rates to earn a basic income – possible if only serving affluent patrons but not in rehabilitative capped, fee-for-service insurance environments. It should be pointed out that the rehabilitative origins of massage therapy in physiotherapy and nursing limited massage application and turned it into only one of many interventions provided in a day’s work. Nurses and physiotherapists did not intend to provide massage therapy all day – it’s curious the massage therapy profession adopted such an idea.

Practitioners may elect to: i) apply spa or rehab modalities to reduce hands-on care, thus increasing physical capacity and providing more service per day (and hence increasing income); or ii) relegate providing massage to part-time hours and seek secondary sources of income from other employment. Innovative practitioners design, field-test and implement better, viable models of providing care.

Strained, dysfunctional business relationships. Clinic owners often give 60 to 70 per cent of the service fees to the contracting associate. What sustainable business can assume business risk, pay the operating expenses, make a profit and still give the lion’s share to the worker? These ill-conceived terms are financially foolish and potentially ruinous to the clinic owner. In addition, the contact list is rightfully an asset of the business, but aggressive associates may attempt to leave with as many clients/patients as possible.

The associate mistakenly believes the grass is greener elsewhere. With the lopsided terms favouring the associate, her/his expenses are in many cases supplemented by the clinic owner. Ironically, the associate is financially better off staying put.  Understandably, many associating RMTs are not trained in business and don’t understand the true costs of operation. The associate may feel cheated if they pay what amounts to be the true costs borne by the clinic owner. And, of course, there are situations where the associate really isn’t treated fairly.

In most cases, I suspect the problem stems from the miscalculation you can work part-time hours and generate a full-time income. It’s not that the clinic owner’s rent is too high, but that the associating RMT needs a more lucrative business model that provides a full-time income.

Many clinic owners realize their contract terms are unsustainable, but feel trapped in a culture that distrusts clinic owners and disapproves of profit motives. A business must earn a profit for contingency, expansion and as a reward to the business owner for bearing the risk and costs of creating a business. Sadly, many clinic owners only experience strife and financial ruin.

Divisive viewpoints.
Massage therapists lag behind other health disciplines in evidence-based practices, public relations strategy, school accreditation, regulation and credibility. A particular point of tension is the polarity between spa and rehab-focused massage therapists.  We’re trying to squeeze two entirely different identities into one, and mitigate the differences. The product (service), pricing, distribution, promotion, funding and marketplace needs are vastly different for these two identities, yet our professional culture maintains an umbrella-like inclusion. Is massage therapy a health-care profession or a personal service? 

Government policy makers, insurance adjudicators, other health professions, the public and media are trying to grasp our identity and are confused. An overly broad and unfocused identity attempting an unmanageable scope of practice leads to marketplace confusion and impaired credibility. Reluctance to refer and withheld funding dollars are the result.

Another inherent divisive argument involves education and training. Some RMTs oppose degree-level programs and research as onerous and expensive. Many RMTs vie for status and recognition as health-care professionals; they feel entitled to the same privileges bestowed on other health-care providers, despite avoiding research literacy and refusing to support evidence-based practice and higher educational requirements as other health professionals have. Many RMTs concur that laypeople should be formally restricted from applying massage therapy – yet they themselves won’t support the mechanisms that lay groundwork for restricted application (controlled acts) to laypersons. Further to the problem, teaching institutions display a wide variance in quality of education and training. Most are non-accredited.  A certain standard of quality for entry-level massage therapists cannot be guaranteed – this raises the credibility issue again.

Perhaps a third point of divisiveness is the “self-employed mentality” and distrust of organizations – including regulatory colleges and professional associations. Some RMTs oppose regulation – they view regulation by government as a cash grab and intrusive – and are unsure of the benefits of self-regulation. Massage therapy professional associations wrestle with insufficient membership, working with limited resources while attempting to provide value and gain a majority of practising RMTs as members. 

Massive and clearly targeted resources are required to advocate RMT interests and position the profession favourably with government, the insurance industry, gatekeeper health disciplines, the public and media. If you consider your work a profession, you should be supporting the efforts of your professional association.

“We have met the enemy, and he is us”.1 The massage therapy profession faces many threats to its integrity and longevity – perhaps the most pervasive are those we are unwilling to engage. Here’s what I (and you) can do. Take this dialogue to social media, challenge your associations, schools and regulatory bodies to have town-hall meetings to identify the problems and explore solutions. Capture this chance to attack the problems and perceptions (rather than each other), redefine the profession and pool resources to get past chronic sticking points. For certain, if we are unwilling to entertain uncomfortable intra-professional conversations to refine our identity and focus, influential and powerful bodies outside the profession will do it for us.

If you would like to contribute your ideas on some of these issues, please visit www.massagetherapycanada.com and see my blog question, “How do you think RMTs should respond individually, locally and nationally to the threats and inherent politico-cultural issues in the profession?”  I look forward to reading what you have to say. 

Reference

Walt Kelly, Pogo comic strip, “The first earth day.”


Donald Q. Dillon is a practitioner, author and adviser to massage therapists. Find him at DonDillon-RMT.com


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