Features Op-Ed
What Does The Future Hold For The Massage Therapy Profession?

Massage therapists have benefitted, like many other professions, from a strong economy – and the industrial diseases such as workplace-related musculo-skeletal disorders (WRMDs) and job-related stress they’ve helped manufacture.

Canadian workers have access to generous employee benefit plans, comprehensive provincial health care and/or worker’s compensation plans, and auto-insurance funding for rehabilitation. Add to this a rise in popularity of complementary and alternative medicine practises, cutbacks in funding for services normally covered under provincial health insurance, and the increased regulation of massage therapy in more provinces, and we see the potential for tremendous growth in the demand for massage therapy, and personal health services in general.

However, there are storms emerging, metaphorically, at the borders of the massage therapy industry. Rising demand by the public and government agencies for health professionals to work from evidence-based best practices; economic markers that signal a downward shift in the economy, including extended health plans and other work benefits; struggling massage therapy associations, where low membership equals low advocacy and promotion for all; the advancement of other health professions towards degree-level education and the peer pressure that creates; and the emerging strength of the spa industry and its impact on how massage therapists practice.

These are just a few of the factors affecting the outcome of the massage therapy industry over the next five to 10 years.

There are some opportunities too: Potential for integration into complementary and alternative medicine wards in hospitals; the stress and strain of the information age and what on-site therapies can provide; greater regulation and training in the spa industry; movement by massage therapy professional associations and regulatory bodies to pool knowledge and resources and improving cross-country standards; and the advancement by several dedicated colleagues towards increasing research literacy and practice.

In this issue, we’ll examine some of the challenges in detail. The opportunities that those challenges present, now and in the future, will be addressed in the Fall issue of Massage Therapy Canada magazine.

The Challenges
The College of Massage Therapists of Ontario commissioned several surveys to examine the landscape of the massage therapy industry in Ontario. In one of the reports entitled Report on the Massage Therapy Census 2003 – Membership Survey Report,1 Collis & Reed accumulated a number of interesting facts on the income levels of massage therapists.

Almost 43 per cent of massage therapists polled said their income did not meet their expectations.

When asked what they expected to earn compared to actual earnings, the difference was significant, $20,377.18. This gap does seem to lessen with time, as 68.4 per cent of therapists in seven-plus years of practice stated their income met their expectations.

Massage Therapist Incomes Aren’t Meeting their Expectations
Conversely, this also means a third of seasoned therapists are not happy with their income.

If we are in some of the strongest economic times we’ve seen in decades, it’s worth considering why almost 1/3 of senior therapists are not satisfied with their level of income.

Furthermore, according to the survey a full 55 per cent or more of therapists need to work at more than one operation to make ends meet, with greater than half of therapists earning less than $30,000 annually.

With several economic markers, including real estate, car manufacturing and the U.S. economy indicating
a slowdown, we may project how that will affect the income levels of massage therapists.

Collis & Reed calculated that 6.1 per cent of Ontarians will receive massage therapy this year, with estimations of a 0.5% increase in utilization over the next two decades.

Collis & Reed further observed the utilization of massage therapy “is likely affected by economics, public knowledge, health insurance coverage and recommendations from health care providers.”²

What impact might health insurance coverage have on the income levels of massage therapists? In an associated report “Report of the Massage Therapy Census 2003 – Consumer Panel Survey,” 74.7 per cent of massage therapy patients reported their sessions were paid by extended health care benefits.

The majority of patients received treatment once/month (39 per cent), with 28.4 per cent receiving treatment a few times/month. The greatest reason currently for receiving treatment was for relaxation (39.9 per cent), with 27.5 per cent seeking treatment for a chronic physical problem. Other reasons given included: sports injury, motor vehicle collision injury, workplace-related injury, chronic injury, and as a part of regular health care.

With 75 per cent of massage therapy clients/patients utilizing extended health care benefits to access massage therapy, we must be concerned with what’s happening in this industry. According to the Aventis Health Care Survey 2001, Canadians and Their Health Care Benefits, 15 per cent of benefit users say their benefit plans have gotten worse over the past five years.

At Least Extended Health Plans Are Secure … Aren’t They?
Only 24 per cent of respondents would pay a higher portion to maintain their benefits. “Despite their apparent willingness to pay more, if required, to maintain benefit coverage, Canadian employees seem to have lingering concerns about their plan. Most respondents agree that their employer is more concerned about limiting costs than ensuring that the best health benefits are available to them.” Further “more than half (55 per cent) of employees feel they don’t have any say in their employee health care benefit plan.”

“Drug coverage continues to be the most valued benefit among Canadian employees. Six out of 10 respondents agree that if they could have only one benefit, they would choose their prescription drug coverage above all others.” ³

In this report, dental and vision care were also cited as priorities. What are the implications for massage therapy if plans are scaled back? If patients had a fixed amount of health care dollars to spend, and they had a choice between drug therapy, dental, vision care, and massage therapy, what can we imagine they would be more likely to preserve?

Prior to January 1, 2002, all citizens of British Columbia could access massage therapy under the medical services plan. In efforts to reduce expenses, the provincial government nixed massage therapy coverage from the medical services plan, except for supplementary patients. With health care costs rising, and a struggle by most provinces to overcome a chronic deficit, it is unlikely we will see access by massage therapists to public health funding in the near future.

How About Auto Insurance?
Another level of third party re-imbursement for massage therapy treatment is auto insurance.

The Collis & Reed survey in Ontario reported that at least 72 per cent of massage therapists have had patients pay via their auto insurance for injuries sustained in a motor vehicle collision. Therapists stated that,
on average, they estimate auto insurance claims form about 11 per cent of their business.

A number of recent legislative changes may have caused decreased access for massage therapists to the auto insurance rehabilitation billing.

In Alberta, the introduction of Diagnostic and Treatment Protocols calls for enhanced skill sets by
massage therapists who hope to treat persons injured in motor vehicle collisions.

“The new Protocols were designed around evidence-based medicine, meaning the conscientious, explicit and judicious use of current best practice in making decisions about the care of the patient, integrating individual clinical expertise with the best available external clinical evidence from systematic research.

The information will be monitored to track outcomes for patients and effectiveness of the treating in accordance with the protocols.

If massage does not prove effective, we may lose the opportunity to participate in future funding schemes for treatments of WAD (whiplash-associated disorders) injuries … we must finely tune our assessment skills, follow the most proven techniques available and then accurately document the results in a manner that can be included in the data collection and analysis process. This pool of data will be reviewed on an ongoing basis by the government to evaluate the efficacy and cost-efficiency of the care provided.”4

Auto insurers have been looking for ways to reduce costs in their industry. The following is from the Insurance Bureau of Canada’s website:

“Although property and casualty insurers every year spend more than $1 billion on medical fees and rehabilitation costs, there is little confidence within the industry that all of this money is well-spent. Insurers believe that the industry needs a system for ensuring that insurers and claimants are receiving good value. The (property and casualty) insurance industry is the largest direct funder of rehabilitation services in Canada.

Automobile insurance health care levies (money paid by insurers in lieu of case-by-case subrogation) are a growing source of funds for provincial health care systems.

Medical services funded by auto insurers are typically more costly per treatment and frequently involve more treatments with longer time frames to achieve the best possible health status for each patient, compared with workers’ compensation or provincial medical plans. This evidence raises doubts about the value of the current system of caring for traffic accident victims.

The industry is working with health care service providers and other stakeholders to ensure that medical and rehabilitation resources are used efficiently to help victims of automobile accidents recover as well as possible as quickly as possible.

While there has been a trend of fewer road crashes and fewer accident victims, paradoxically the number of crash victims receiving treatment has risen – with persistent high average costs of treatment. More intensive and costly rehabilitation treatment often does not appear to contribute to better outcomes for road accident victims.”⁵

It appears that a significant source of massage therapists’ income (from extended health benefits and auto insurance) may continue to be affected over the next economic cycle.

The Powerful Spa Industry
Spas have become a major employer of massage therapists. The International Spa Association’s 2002 Spa Industry Survey puts the average annual growth of medi-spas at 18 per cent, with cumulative growth of 143 per cent since 1997.

• An estimated 51 per cent of industry revenue comes from treatment rooms, 49 per cent of that number is from massage treatments.
• Forty per cent of guests are first-time spa-goers.
• The number of spa visits increased 71 per cent between 1999 and 2001. The total revenues for spas in 2001 was reported at $10.7 billion.⁶

The shear power of the Spa industry may have considerable influence on salaries paid to massage therapists, work hours and the way spa-therapists practise.

Because massage therapists tend to be the highest paid staff in the aesthetics/spa environment, we can expect continued downward pressure on their salaries.

Health Care: Are We In Or Out?
In a publication which was put out by the Niagara Health System (NHS), The ABCs of Allied Health Professionals, a large number of health professional positions are identified and described as working within the health care system. Audiologist, biomedical technologist, chiropodist, kinesiologist, pharmacist, physiotherapist and psychotherapist are some of the professions highlighted and described.

The publication cites “there are currently 500 OPSEU members of the Hospital Professional Division working within the NHS.” Massage therapist is not listed among them.

In his commission’s famous report, “Building on the Future of Health Care in Canada,” Roy Romanow
outlines a number of changes to preserve and rebuild the health care system. Romanow makes particular reference to investing in health care providers, and the need for integrated teams in providing care.

“One of the best ways of ensuring that health care providers are able to work effectively in new, more integrated settings is to begin with their education and training. Education programs should be changed to focus more on integrated, team-based approaches to meeting health care needs and service delivery.”⁷

Romanow’s recommendations, echoed by the Liberal federal election campaign, focus on rural and remote access, diagnostic services, removing obstacles to primary health care, home care and catastrophic drug coverage. Massage therapy is not mentioned in this 392-page report.

Recently, chiropractic and physiotherapy services have been de-listed from the OHIP (Ontario) funding schedule. It appears the primary fields massage therapy serves – rehabilitation, spa services, the treatment of physiological stress and occupational strain – will be left to the private insurance plans and out-of-pocket financing.

If the massage therapy industry does not take steps to be included in the primary health system, it will continue to rely on patients that pay out-of pocket with after-tax dollars.⁸  This works fine in strong economic times, but can be significantly affected in economic down-turns.

The need for degree level education
Massage therapy is one of the few regulated health professions without a controlled act under the Regulated Health Professions Act (RHPA), and without a University degree program.

In The Need for Degree Education, Trish Dryden reports that “Massage therapy has been well taught in both private and public educational institutions at the diploma level; changes in consumer utilizations, health care delivery, information technology and economic trends have created a demand for degree level education … There is broad stakeholder support for this … The evolving educational demands in massage therapy parallel the evolution of other health professions such as nursing, physiotherapy, chiropractic and midwifery, which have evolved from diploma to baccalaureate and in some cases graduate degree preparation.”⁹

Dryden further states: “Senior policy analysts in Health Canada and leading academic researchers in CAHC (complementary and alternative health care) all acknowledged that the lack of evidence base, and the limited research literacy and capacity in massage therapy education must be addressed as the Canadian health care system moves towards the increased integration of complementary and alternative health care and conventional medicine for the benefit of all Canadians.”¹⁰

A university-level education would provide additional benefits, including the blending of primary courses in health sciences with students in allied professions, thus building relationships at an early level.  Research initiatives into massage therapy would also be far more viable, with more dollars available and more students interested in writing their thesis on a massage therapy topic.

In the Collis & Reed sub-survey, entitled, “Report of the Massage Therapy Census 2003 – Other Health Care Practitioners Survey,” practitioners surveyed suggested a higher community profile of massage therapy would help boost utilization of massage therapy. Providers stated they most often receive health care information from professional journals, magazines and newsletters.

Massage therapists in an associated survey indicated at least 32 per cent of patient referrals came from other health care providers. It appears familiarity plays an important role in the referral by other health care professionals to massage therapists, and that common education streams may play a key role in the future inclusion of massage therapy in health care services.

Advocacy: Is there strength in these numbers
The professional association representing the interests of massage therapists in Ontario is the Ontario Massage Therapist Association (OMTA). Current membership is about 20 per cent of active massage therapists in Ontario. This is considerably lower than association membership percentage by allied health practitioners such as chiropractors and physiotherapists.

One of the key roles of a professional association is to build relationships with other health care professions. This is essential to keenly position the profession in cultivating alliances and maintaining leverage in negotiation with government bodies and the insurance industry. A key question we may ask is: Can the OMTA adequately represent the interests of massage therapists with hamstrung resources?

Without a properly funded association representing them, therapists would be required to act as sole proprietors, entirely responsible for their own public relations and advocacy. They would be forced to individually lobby against unfavourable conditions, such as the move by some municipal governments to require “body rub parlour” licenses for all massage clinics in their vicinity. Any event, such as the challenge the chiropractors have faced with several deaths linked to cervical spine mobilization, would greatly threaten our profession with its current state of adequate organization and representation.

Every professional needs a professional association to perform these expensive and elaborate tasks that are impossible on an individual scale.

Conclusions
Massage therapists have benefitted from economic growth and the resultant industries that have needed their services. The economy is changing, and massage therapists must be pro-active to enjoy continued growth and vitality in the industry. Part 2 of this feature, will examine opportunities the massage therapy industry can capitalize on.

REFERENCES

1. Collis & Reed: Report on the Massage Therapy Census 2003 – Membership Survey Report
2. ibid, page 3
3. Aventis Health Care Survey 2001 – Canadians and Their Health Care Benefits, pp 10-13
4. What Do MVA Reforms Mean to Massage Therapists? A document from the Massage Therapist    Association of Alberta
5. www.ibc.ca
6. International Spa Association 2002 Spa Industry Survey as reported in Massage & Bodywork:    August/September 2003, pg 17
7. Romanow, R: Building on Values: The Future of Health Care in Canada.   November 2002. Executive Summary, p xxvii
8. Dillon, D: Looking into the Future: Trends Affecting the Massage Therapy Industry in Ontario. Body Politic, Vol 2, # 3  pp 6-8
9. Dryden, T: The Need for Degree Education.  Massage Therapy Canada, Fall 2002.  p 28
10. ibid, p 30

Donald Quinn Dillon, MT, has been in private practice for 14 years. He is a therapist, writer and business coach for massage therapists. You can contact him at www.MTSeminars.com or www.MTCoach.com