Consider the insurer's perspective
In mid-December 2018, Andrew Lewarne, Executive Director of the Registered Massage Therapists' Association of Ontario (RMTAO) met with Greenshield Canada (GSC) representatives David Willows – Chief Innovation and Marketing Officer, and Ned Pojskic, Leader of Pharmacy & Health Provider Relations. Lewarne requested the meeting regarding a provocative Autumn 2010 news post on the Greenshield Canada website, Elephant in the (Waiting) Room.
Lewarne expressed "firm objection to the article's false and misleading messages and emphasized the important role of massage therapy in health care." Willows and Pojskic agreed to adjust some of the inflammatory wording but declined to remove the post. Promisingly, the GSC pair took RMTAO materials highlighting research in massage therapy, and agreed on future meetings which include RMTs with higher level education and research perspective.
On the heels of the RMTAO objection, Deetria Egeli, RMT and board member with the Registered Massage Therapists' Association of British Columbia (RMTBC) submitted a January 4th, 2019 letter to address the angst suffered by RMTBC's membership on this same issue.
Egeli's letter reflected her perspective as a practitioner, highlighting populations she has served and conditions treated, with an emphasis on her rigorous education and training. Egeli provided several examples of massage therapy research, and posed the question to GSC, "(have you asked) why patients value massage therapy?" Egeli challenges the "deliberate and discriminatory" statements made by GSC in the "Elephant" post. Egeli assures the insurers, "I do not see anyone for hedonistic purposes".
In both rebuttals, the RMT associations are effectively rebuking the inflammatory comments and pointing to available research, which insurers are clearly asking for. I suspect there are deeper objections the insurance industry has, and if the profession is to continue working alongside them to assure access to massage therapy care, an insurer's worldview must be considered.
The interests of insurers are different from massage therapists. The insurer has cost-constraints and must work with a limited pool of resources to pay claims, operating costs, salaries, advertising, taxes and profit margins for growth and investment. This fixed amount compels insurers to demand value for dollars, anticipate strong outcomes and justify expenses.
Ned Pojskic, Leader, Pharmacy and Health Provider Relations responded to Egeli's letter, affirming insurers are "stewards of our plan sponsors' precious health care dollars...(we take) utmost responsibility in ensuring every dollar spent produces maximum value in terms of health outcomes."
The customer of the insurer is not the employee, but the employer or "plan sponsor," who purchases insurance products to attract and retain good employees. The insurance broker (salesperson) strongly influences employer buying decisions. Pojskic is understandably concerned that evidence supporting massage therapy – according to GSC's assessment – "is limited in both quality and quantity." Pojskic confirms "(We will) present this state of affairs to our clients (the employers) in order to educate and inform them in future decisions they make concerning benefit plans".
What can we imagine employers will do with this perspective?
As far as insurers can tell, massage therapy provides short-term pain relief, and is expensive (compared to fee schedules for WSIB and auto-insurance). Insurers are unclear if massage therapists consistently measure or demonstrate functional outcomes or positive associated sequelae (example, effect on anxiety, depression or cessation of pain) and whether costs borne for massage therapy care are worth the investment.
In the "Elephant" post, GSC questioned whether autonomous activities like yoga, taking a walk or (pejoratively) a "nap" could produce the same or better outcomes, and at much lower cost.
Egeli's remark "I do not see anyone for hedonistic purposes" likely falls flat for the insurer. Insurance analysts poring over data regularly observe many examples where massage therapy services are exploited by corporate businesses and sole practitioners encouraging plan members to "use up your benefits." Insurers see themselves as guardians of health care dollars, and expect demonstration of improved physical function, reduced time off work, reduction in anxiety, depression or other secondary sequalae oft quoted as benefits of massage therapy. However there appears to be little accountability in the system – employers purchase benefits to retain employees, employees use at their own discretion, and practitioners of all stripes find it easy to create open treatment plans. Plan purchasers (employers) need some way to know the insurance products they purchase are benefitting their workforce.
"Not for hedonistic purposes" is likely not reflective of GSC's experience with many massage therapist claims and reflects poorly on the profession's ability to reduce abuse.
Insurers have taken steps to weed out exploitative practices. During auto-insurance negotiations in Ontario, insurers posited a "preferred provider" network – providers that demonstrated efficacious outcomes and cost savings that insurers would work with exclusively. More recently, some insurers have created subjective practitioner rating systems to measure customer satisfaction (and I suspect to de-list exploitive providers). GSC has been publicly critical of massage therapy claims before.
Pojskic outlined a pilot project planned, "pay-for-performance" reimbursement for pharmacists demonstrating better health outcomes with patients. This may be a harbinger for things to come with other paramedical services.
Massage therapists know their work is efficacious...they see it in the outcomes produced in session every day. Because musculoskeletal complaints fall outside the realm of provincial health insurance plans and squarely with health and dental benefit providers, the relationship between massage therapists and insurers is critical to access for many patients.
Egeli's letter invited GSC to open a dialogue to further substantiate the benefits of massage therapy care. Pojskic reciprocated, citing GSC is sensitive to the angst caused by the posts and hopes for "productive dialogue and further collaboration." Encouragingly, Pojskic stated GSC sees itself as a change-agent, wants to support efforts to enhance evidence, and in 2019 will be announcing "research grants to the paramedical community to generate evidence to support current practices".
If these grants are an olive branch offered by major insurers, massage therapists and their advocates must be ready for the opportunity. I suggest the profession prepare:
• Compose a cross-national "insurer relations committee" to ensure regular and productive dialogue between insurers and massage therapist advocates.
• Form working groups of RMT academics to organize and review available and relevant research. Create a steering committee to promote research measuring massage therapy effects on bio-psycho-social outcomes.
• Create or utilize standardized outcome measures (both functional and bio-psycho-social outcomes) that RMTs across Canada patently use.
• Work with software providers to develop a central database where practitioners and patients/clients can report results (and therefore statistics accumulated). If patient experience is the best testament to massage therapy efficacy, they need a platform to report it.
• Vernacular re: outcome measures and research literacy should be cultivated across the profession.
• Engage insurers in problem solving and cost-savings ideas - how can MT be delivered more efficiently and effectively?
• Identify populations and conditions currently underserved by massage therapists that would be prospective clients for insurer products, thereby serving interests of the public, the practitioners and the insurers.
This time is a critical juncture in relations between insurers and massage therapists. Support your professional association in urgently and diligently working with insurers towards continued funding of massage therapy care.
Donald Quinn Dillon is a practitioner, author and practice coach. Find him at DonDillon-RMT.com.
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