An April 13th article in the Toronto Star titled, “Rise of the Three Amigos in Health Care,” clearly illustrates how far we have to climb in building insurer relations. The Star reporter Adam Mayers interviewed Green Shield vice-president David Willows in a critical review of how employer-sponsored benefit plans are utilized. Willows described physiotherapy, chiropractic and massage therapy as “the three amigos of health care” suggesting they provide only “soft benefits” – i.e. harder to measure – and detract resources from the treatment of more pernicious illnesses.
I responded to Mayers and Willows (see my blog on massagetherapycanada.com) and Willows replied with interest. I felt some satisfaction in convincing the Green Shield executive to meet with RMTAO representatives regarding his critical viewpoint of massage therapy, but the context of The Star article continued to bother me.
Willows and his cohorts are bang on in some of their observations. Employee benefit plans – a tool used by employers to attract and retain highly skilled employees – appear to have been increasingly exploited by some practitioners. Although the patient/claimant can report improvement, there is no direct evidence showing massage therapy care resulted in fewer days off work, higher productivity and performance, or higher quality of life in sleep, lower anxiety or pain – what the insurance industry would call “hard benefits.”
Practitioners may frame treatment plans based on available coverage, as opposed to crafting clear goals and outcome measures. Further, employee benefits in their current administration don’t strengthen employers’ confidence they are receiving a return on investment for resources spent to keep employees healthy and productive. There is no accountability to ensure workers make comprehensive lifestyle changes leading to lower morbidity, hence lower employer and public health costs. As a result, insurance claims go up, insurers report costs back to employers, employers slash purchase of employee benefits, and the cost to access chiropractic, physiotherapy or massage therapy for work-related strain comes out of the employee’s pocket – likely discouraging use.
To complicate matters, insurers report a progressive element of insurance fraud – altered receipts, inflated treatment plans, questionable positive outcomes – exploited by a faction of despicable practitioners and the businesses they work for. In social media, some practitioners are critical of colleagues working outside the rehab/remedial sector – spa, workplace wellness/mobile massage, human potential – because functional/physiologic outcomes are less clear. Rather than condemn RMTs for the market sectors they work in, however, we need ways to show efficacy in all sectors and assist the insurance industry in
precluding payment for exploitive, profiteering, unethical services.
Practitioners and their advocate associations can do something about the ill reputation of massage therapy in the marketplace. I offer three suggestions:
1) Shift perceptions
For RMTs to become positively associated with public health, we need to shift the perception of massage to be seen as a contributor to public good – not just a hedonistic pursuit. In Carla-Krystin Andrade’s, Outcome-Based Massage, she outlines desired structural/functional outcomes considered in the remedial massage purview: reduction in pain, improvement in joint mobility and postural awareness, greater motor power, connective tissue pliability and muscle extensibility, as well as psycho-neuro-immunologic, cardio-pulmonary and neurological benefit.
Andrade goes beyond structural/functional benefits and injury rehabilitation to recognize wellness and whole systems objectives, including: improved energy and sleep, better social functioning and family relationships, a sense of well-being, improved mood, relaxation and coping skills, mindfulness and greater life satisfaction, positive attitude and empathy towards others.
Massage therapy has a larger role to play in public health. The profession needs to employ outcome measures beyond functional/physiologic benefit and measure improvements in wellness/whole systems too. Employers and insurers can be seen as supporting society by ensuring comprehensive benefits to workers, contributing to a higher quality of life, well-being and the prevention of more pernicious diseases.
2) Shift from insurer as cost scapegoat to investor in public good
In 2001, I attended a Whiplash Congress where Nikoli Bogduk, emeritus professor, medical doctor and co-author of Biomechanics of Back Pain, shared that insurers in his native Australia play a significant role in rehabilitation research. Bogduk stated, for insurers to provide auto insurance products to the public they must pay into a fund that supports research and evaluation of best treatment approaches for persons injured in auto collisions. The insurers – not the small, resource-strapped practitioner associations – were responsible in some respect for funding research.
Insurers might become interested in funding research if it saves costs. Funding could also cast a more favourable light on the insurance industry in helping weed out ineffective, resource-wasting applications. This could be a big public relations score for insurers, and a significant boost finally in the efficacy of massage therapy care.
3) Increase accountability of gatekeepers, practitioners and patients
There’s a paucity of massage therapy studies demonstrating improvements to productivity and worker health. Our profession has the ability to improve significantly on that.
Looking at the Workplace Safety and Insurance Board (WSIB) model, claim approval and funding are linked directly with measured outcomes. Practitioners must complete – at the outset and end of treatment plan – measurement devices such as the Oswestry or Vernon-Mior questionnaires (for lower back and neck pain respectively), the Lower Extremity Functional Scale, numeric pain scale, or the DASH (for upper extremity injuries). The WSIB considers these standardized outcome measures in evaluating intervention success and the relevance of any further intervention.
With standard outcome measures, efficacy of massage therapy would improve, fraud could dramatically decrease, and insurers and employers would retain higher confidence in funding care. Accountability will increase if: 1) practitioners receive a clear diagnosis and direction from gatekeeper health-care providers who prescribe specifically for functional and wellness objectives that can be measured and treated; 2) practitioners and employers apply appropriate measures to gauge current health status, and improvements over time with interventions that contribute specifically to comprehensive health and wellness; 3) outcomes are posted online (patient information is first depersonalized) to a central database where data can be examined by government health administrators, insurers, employers and practitioners to show efficacy and cost-savings from these interventions. Funding policy would be shaped using outcomes data.
Rather than fighting for credibility and legitimacy, massage therapists can clearly show efficacy and attract investment based on positive outcomes clearly implicated in the data.
There’s a lot massage therapy advocates can do to shift the perspective from massage as discretionary “treat” to public health good. With the reformation of the Canadian Massage Therapist Alliance, coupled with increasing collaboration by professional associations, the opportunity to reposition RMTs positively in the eyes of government, insurers and employers, gatekeeper health-care providers and the public/media are within our collective influence.
Watch: Practice Points with Don Dillon on changing insurer perceptions
Donald Quinn Dillon, RMT is a practitioner, author, speaker and mentor. Find him at MassageTherapistPractice.com.
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