Transcript for Episode 5 of “On the Table” featuring special guest Ian Kamm
By Jannen Belbeck
This is a transcript of our conversation for episode 5 of our “On The Table” podcast.
Subject introduction: The act of massage therapy has been regulated for 100 years. In the recent 25 years, regulation has increased in complexity and the level of compliance demanded of its members. Fees to maintain the privilege of self-regulation have risen considerably, and some have become increasingly vocal in their disaffection for the regulatory body’s approach in Ontario. With self-regulation moving at a slow pace across the country, and health insurance companies finding ways to work with practitioners in non-regulated provinces, do the costs of self-regulation outweigh the benefits? Iam Kamm, RMT, speaks to these questions and more.
Jannen Belbeck: Ian, in your article Are the Costs and Rules Associated with Regulatory Bodies Too Burdensome?, you state, “We’re ‘stuck’ with the CMTO [College of Massage Therapists of Ontario, the regulatory body in the province] to retain insurance reimbursement for clients. But what if we’re not? In half the country treatment fees are reimbursed by insurers without the presence of a regulator.” In your view, is the primary driver for regulation a financial one – to allow practitioners to bill health benefit claims?
Ian Kamm: No that’s a good question but no—it’s not primary and I wouldn’t even say it’s the secondary. Regulation exists very much to protect the public, to create standards of practice, to enforce regulation in accordance—entry to practice examinations for the profession, and complaints. All of those are the primary or secondary purpose of regulation. The insurance reimbursement issue is basically an accidental side issue. Because as you just re-stated, in half the country there is no regulatory body and in those cases insurance companies use professional associations to – as a benchmark – for which receipts to reimburse. So when a province regulates massage therapy, insurance companies (quite understandably) use membership in the regulatory body as their benchmark for which receipts they should reimburse. In the absence of a regulatory body they have to look for something else because employers want to offer massage as a benefit, employees want to receive it, so insurers come up with a work-around, and work with a professional association instead.
The reason why I said we we’re “stuck” with the CMTO is that once you’ve got regulation in place, the mindset is in the profession was: “Oh well we’ve got no choice now–we must stay with the CMTO” because if an RMT ceases to be a member of the CMTO, then they are no longer able to use the protected title RMT. And also, their clients wont get reimbursed by insurance. I haven’t got a statistic but lets say 80% of my clients rely on insurance reimbursement to cover some or all of my fee. So if I could no longer offer that to my clients, my business would evaporate overnight.
Jannen: Later in your article you prompt the reader, “How would you respond if an insurance company required an annual fee for registration with them but dropped the requirement for registration with a provincial regulatory body?” What are you suggesting here as a possible relationship between practitioners and insurance companies?
Ian: I’m going to chicken out slightly and I don’t want to necessarily suggest what that relationship should be but I want RMTs to ask ourselves what we want it to be because I suspect at one point in the future this question might come to us. We might find ourselves having this conversation and I don’t think were ready for it. I don’t think were prepared for it. So what do I want that relationship to be or what am I suggesting it could be? The changes to the relationship with insurance companies are already happening in fact – and were just not talking as a profession, we’re not talking about how we want to respond to that.
Don Dillon: Ian, further to your article, you state “I’m not about to argue against regulation. I just want us to be clear why we might want to be regulated when clearly it’s a choice, not a necessity.” You further state, “I actually do want regulation for our profession….. I see so much disaffection with the way regulation is trending in Ontario that I worry we’re opening the door for insurance companies to re-write the relationships.” How, in your opinion, will insurance companies define the way massage therapists practice, going forward?
Ian: So what we’ve already seen, for example, SunLife has created profiles for every massage therapist—I think in the country—certainly in Ontario, and they’ve invited massage therapists to contribute to those profiles. Some of us have, some of us haven’t. I had a client (just as recently as last week) because he found me through my SunLife profile. So this is a new thing that didn’t exist even a few years ago: insurance companies interacting directly with massage therapists to create business. Now some massage therapists aren’t going to be happy with this. In conversations I’ve had, there’s been some pushback from some massage therapists but they’re nervous about getting too cozy with insurance companies. Sometimes, that’s because they’ve had a bad experience with an insurance company (either professionally or personally). Other times, it could be they just don’t know whether this is the right thing to be doing. I think this is great if we’re going to have this conversation right now because I think there are a lot of RMTs who want to know: “How should I respond? How should I react? What are my colleagues thinking about this idea that an insurance company is directly soliciting me to create an online presence within their own company’s portal?”
On another level, we can talk about what happened with Greenshield Canada talking to its clients (people who have benefits with Green Shield) about whether massage therapy is worth it or not. They were attempting to create a conversation, in this case not with massage therapists themselves but with users of massage therapy to say: “Do you really want massage therapy in your benefits package?”
So these kinds of conversations — and they’re not involving the CMTO, they are barely involving the professional association (the RMTAO) – these kinds of conversations are happening and I think we need to be talking more about how do we as a profession feel about it. Overlay that with what you also said in your question: Yes, I think there’s an undercurrent of dissatisfaction going on within the profession—in Ontario at least.
If you’ve got an undercurrent of dissatisfaction with the regulatory body and parallel to that new conversations happening directly with insurance companies, what’s going to come from that? That’s what I want to hear people talk about.
Don: And I really appreciate you bringing attention to this relationship because I was involved a number of years ago when the MTs represented the MT association in talks with auto insurers and it was clear the auto insurers wanted to go with a “preferred provider” list. They wanted a narrow number of providers that they could work with – practitioners that they could count on who were efficient, who could be cost-effective. They really didn’t want to open it up to allpractitioners they wanted to have a preferred provider list. This SunLife situation you’ve drawn attention to, I think its another example of how insurers are trying to influence how people they sell products to utilize MT and which massage therapist they utilize. I’m grateful that you’ve brought attention to this.
Ian: I think you’re dead right – it’s something we need to be talking about.
Don: And as you mentioned I mean despite this sense of regulation, giving a sense of safety, there are other influences imposing in on the profession and if we don’t talk to them then we are subject to their influence while not knowing it.
Let’s bring some of the discussion back to the disaffection and we certainly have seen that tension with the regulatory body, especially in the last number of years, especially with the rate increase last year and some of the regulation that seem more imposing. You are adamant for massage therapists to become involved, seek position on the regulatory council to influence policy. You also openly warn regulators that technology creates opportunities for practitioner-to-practitioner communication, but also interaction with insurance companies that hadn’t previously existed. What are you warning the regulators about here?
Ian: I mean the fact that we’re having this conversation on the podcast and other RMTs will listen to it is exactly what I’m trying to do – to raise awareness around for regulatory bodies.
Traditionally, if two or more RMTs wanted to talk to each other, they were limited to either sitting down together face to face perhaps in some sort of social setting or an annual conference and listening to a lecture and participating in discussions. Communication has traditionally been very top-down, from some sort of hierarchy. You have people in positions of authority talking in a linear downward direction to the people beneath them. What we have now have, is an unprecedented amount of peer-to-peer communication that is very new. Right now, as we are speaking, an RMT somewhere in the country is participating on a discussion on a Facebook page for example, or one of the many other social media platforms and hundred of other RMTs can chime in (and frequently do).
There are some people who are very active, some are passive just reading the comments, or chime in from time to time. This level of communication between RMTs – let alone with insurance companies–has never happened before. As a result, when a regulatory body or even a professional association does something that is not popular with the membership, the conversation might happen without the regulator being aware that the conversation is going on. So if (you asked what am I WARNING regulators about), I don’t know, maybe I’m backtracking a bit, but
I want the regulators in general to realize that RMTs are no longer going to sit back and passively take information handed down to them. In some senses we’re attempting to create policy ourselves almost. Which it should be, when you think about it, this is self-regulation after all.
We elect other RMTs to sit on the governing council and the major decisions have to come from that governing council. But we’ve gone from a half dozen sitting on a government council signing off on decisions, to 100s and 100s of RMTs simultaneously talking to each other about where we should go. I don’t think the governing councils and l and I don’t think the administration of some of the regulatory bodies have woken up to that reality yet or addressed it.
Jannen: Regarding regulation, it appears a main point of contention amongst RMTs is the rising fees – jumping nearly 30% in 2018. What accounts for this fee increase, as you understand it, and what is the impact to the general public? (ie: rising regulation fees may reflect rising costs for RMTs in practice, therefore affecting access to massage therapy by the general public.)
Ian: The 30% increase is a significant increase because of the percentage and not because of the dollar values in my opinion. I don’t believe there were any RMTs that needed to increase fees to their clients as a result of a couple hundred of dollars worth of increase in the registrations fee. But I do think the message the regulator sends (in this case the CMTO) by increasing registration fees by 30% is a bit tricky here.
The CMTO came up with a rationale for the fee increase last year and created four bullet points as to why they wanted to increase the fees. The first one was that the size of the registration base had increased by more than 40% since the last major fee increase. The fee increases have been going in line with increases in inflation. But this rationale – that they needed to increase fees because there were 40% more RMTs flies against the face of basic economic logic that if you have 40% more RMTs you also have 40% more revenue. I just don’t buy this argument that we need more money per RMT because there are more RMTs. More RMTs just gives you more revenue in general.
The second point they say is that the number and complexity of investigations and discipline hearings has increased. Fair enough, but if you have more RMTS funding that process then again why do you need more money. So if it’s not the number (because the number doesn’t’ make any sense) then the complexity is….
Fair enough. That’s about their only valid point. Because they then go on In that same bullet point they go on to say that the volume in investigations has increased by 30% so in the same period that they’re talking about, a 40% increase in RMTs, complaints have only gone up by 30% in other words, complaints are going up more slowly than the number of RMTs is increasing. Again, I don’t understand why they need more money.
Third point: they talk about meeting legislative requirements and public expectations mean they require more resources (I’m reading directly from their own press release here) so they’ve got to redesign the quality assurance program (and we’re still waiting on that by the way a year and a half later), they’ve got to develop new technology, or invest in new technology. All those points are valid but to me, that strikes me as one-off expenses. So I live in a condo, and if my condo has a one-off expense, they don’t increase my annual fee. Instead, they levy a one-time surcharge. So if they’ve got to invest in new technology as a one-time thing, then instead of permanently baking in a fee increase, why don’t we have a one-time additional fee this year? You’re going to have to pay a couple extra hundred dollars to cover the one time cost of the new technology or re-designing the QAP.
The fourth bullet point they have is that they have an increase in their number of staff—they need to increase number of staff. But again, back to my very first point, if you’ve got 40% more RMTs contributing revenues, then you’ve got 40% more revenue and so if you need to increase staff, you do that in line with the increase in the number of RMTs.
So I don’t think we have a valid rationale for the increase. Collectively RMTs in Ontario just rolled over and said “oh gosh I’ve got to fork over a couple extra hundred dollars, I’m not happy about it. But no one really did an analysis for the rationale for the increase. When the rationale doesn’t seem to make sense, it might not create riots in the street, but it creates a level of disassociation with the CMTO from the membership. And as I’ve said earlier, I don’t think the actual dollar amount is the issue—it’s the percentage in one year and the rationale is my opinion is lacking.
Jannen: Despite half the provinces (and all territories) being without self-regulation, the profession is still held accountable to public safety. Some in the media are denouncing self-regulation as self-serving and are pushing for umbrella government oversight (egs: Chiropractic and Naturopathic in the news). Where does your opinion lie with this notion?
Ian: I don’t mind the idea of us revisiting what regulation should look like, I said in my article and I said in my presentation to Sutherland-Chan alumni, I firmly believe we should have regulation for MT. It doesn’t mean from time to time we can re-visit if it’s being done in the best possible way. I think were also in a “wait and see” period to see what we’ve got in terms of a new provincial government in Ontario – who knows what they might want to weight in as a way to change regulation. But regulation doesn’t really cost very much. It’s incredibly cost effective because it’s self-regulation. We’re not chewing up hundreds and thousands of dollars of tax payer money to do this—were self-funding it. So I think it’s a relatively efficient thing to do because it’s self-funded and self-governed. The government bill for regulation is limited to the non-RMT members on council pretty much. I don’t think that costs tax payers very much more. While I have some complaints with the way that the CMTO is being run and while chiropractors are having their issues as well currently, I don’t think that enough reason to dismantle the entire process. In fact, I would love it if we could get regulation in more provinces. I think the profession benefits hugely when we are regulated in a province or in a jurisdiction and the more provinces we can get regulated the faster the better in my opinion.
Don: I attended your presentation at Sutherland-Chan in February this year where your topic was The Future of Massage Therapy in Ontario. Your lecture focused on the history of regulation and, moving forward, if self-regulation still served the profession. Your lecture was well attended, and you shared your frustrations with some actions of the regulatory body. You posed the question to the audience “Do RMTs still want to be self-regulated?”
I appreciated your analysis of painstakingly reviewing the CMTO disciplinary decisions over the past eight years. “Concurrent relationships” presented clearly as up-trending, as with the rise of inappropriate touch and insurance fraud. You reported that, while inappropriate touch is largely committed by male RMTs, 55% of insurance fraud was committed by female RMTs. What discussions would you like your analysis to generate in the profession?
Ian: You’re right. I spent hours combing over the reports. I think first thing to point out: The CMTO often talks about numbers of complaints and trends and part of their justification of the fee increase was along the lines of trends in complaints. The problem for me is that it’s very hard for me as an outside observer here to analyze what’s happening in complaints. It’s a lot easier for me to analyze discipline decisions because they’re published in detail and then we can analyze them and we can quantify what this discipline decision was about. So some complaints never end up and many complaints don’t go as far as a discipline decision and for those, and because confidentiality might need to be protected—we’re often in the dark about what’s gong on with complaints.
I want to first start by talking about discipline decisions because they’re public record and we can quantify them and put them on a spreadsheet.
As far as concurrent relationships, I think that was a temporary blip. My analysis was over the last 8 years. If we look back at concurrent relationships they would bump along at one or two a year (and this is Ontario), and then suddenly there’s an uptick in 2018. Remember as well that discipline decisions are a year or two after the original complaint so there’s a time lag in the time it takes for a complaint to be investigated and a decision to be enacted. So in 2018, this is a complaint that started in 2016 or 2017. I think the concurrent relationships thing will turn out to be a blip because we now have a great deal more clarity. On the one hand, I want to thank the CMTO for giving us a great deal more clarity about the fact that RMTs in Ontario are not allowed to have spouses as clients. And that’s been widely heard and received by RMTs in Ontario. I hear this over and over they’ve received this message loud and clear. So I don’t think this concurrent relationships issue is going to continue.
As a side note here I think we have a problem because I don’t think the regulatory body has been terribly clear about “can I still give my spouse a message recreationally and not bill insurance?” Is that still allowed? That seems to be unclear wording in the standards in my opinion. When I ask RMTs that question, I get 2 or 3 different answers – even when I asked the CMTO I got confusing responses.
Let me talk about insurance fraud for a second. Insurance fraud has completely outscored inappropriate touch and sexual abuse in the discipline statistics year after year after year. Yet we hear nothing from the CMTO about insurance fraud and what they want to do to combat it. The CMTO has talked at great length about inappropriate touch. Yes that’s great – I agree. But what about insurance fraud? If you look at the statistics, it shows up at 8 to10 to 12 cases a year — year after year in discipline decisions and as a percentage, something like half the discipline decisions relate to insurance fraud and yet we have no initiatives coming out of the CMTO about that. This is something I would like us to be talking more about—goes back to my earlier comments that insurance companies seem to be wanting to create new conversations and relationships with us, and insurance fraud is a big deal for them.
So why are we as a profession not talking about it in ways to clamp down on that? I think there’s ways we could do that—we could have that conversation. So if we talk about inappropriate touch, which is what the CMTO wants to talk about—well those numbers are–well anything above zero is too high–but those numbers are low relatively speaking, less than – I think its less than three-quarters of one percent will be involved in some sort of discipline decisions, and only a percentage of that is inappropriate touch. So I think we need to have more conversations and more analysis of – if there are trends in both complaints and eventual discipline decisions, what are we doing? Are we putting the right resources in the right places to address those trends?
Jannen: In a December 2017 interview with CTV News, you protested the consent forms related to the treatment of sensitive areas. You expressed a concern for damaging the client/practitioner relationship, that trust was essential to the professional relationship and the consent forms would impair that trust.
Prior to this interview, in a September 2017 letter to Lisa Tucker, president of Ontario’s regulatory body, you state “Mandating that RMTs gain written consent to treat certain areas of the body reinforces the stereotype that we have worked so hard for decades to change, that massage is inherently sexual unless we state in advance that it isn’t. That’s a horrible message to be sending the public in 2017.”
You posted this letter on social media, inviting RMTs to write in of their own concerns. You end your letter asking for the regulator to reverse its policy on mandatory written consent for sensitive areas. Tell us more about your perspective on this.
Ian: We absolutely need to decrease inappropriate touch. As a bit of an explanation: Often in massage we’re talking about sexual abuse. And there are 3 components to sexual abuse. The form of sexual abuse that is most prevalent in massage is the inappropriate touch. So sometimes I’m going to be talking about inappropriate touch and sometimes I’m going to be talking about sexual abuse. They’re the same thing – it’s one of the headings of and the biggest heading under the umbrella term sexual abuse.
We need to empower clients to speak up about inappropriate touch and we need to empower our clients to report it. Because by reporting inappropriate touch we can finally find out just how much of it is actually happening. It’s probably being underreported, and if we can identify who’s doing it, then we can remove them form the profession. What I find really interesting is that nowhere in the revised standards is there any obligation for an RMT to tell a client that the CMTO exists or if in another province, that another regulatory body exists.
There’s no obligation of RMTs to tell clients that there’s a complaints mechanism where they can make a complaint. We should be mandating that RMTs tell clients that they can complain. But what the CMTO has done instead is instead of telling us as RMTs to educate their clients that the regulatory body exists, that a complaints mechanism exits. Instead, were giving the client the impression that they’re now going to have a harder time making a complaint. Because once they’ve signed a written consent for consent to touch a sensitive area, the client may well say: “something happened in that massage that I didn’t like, but there’s no point complaining because the RMT now has (as a defence) a signed written consent from me.” In some cases, that consent could have been signed over and over again at every single treatment. The RMT might have 20, 30 different signed consent forms from that client.
If we’re going to eradicate inappropriate touch, we need to increase reporting of it. And we haven’t done anything to increase reporting. I believe what we’ve done (in Ontario) is put in a barrier that is going to decrease the reporting of inappropriate touch.
So if the CMTO turns around and says the consent form is working because we’re getting less complaints of inappropriate touch, then I think what they’ve done is pushed it underground and hidden it from our public view by discouraging clients from complaining.
You know what I would like to see? I’d like to see every treatment room in the province—in the country for that matter—I’d like to see it made mandatory that we have a poster on the wall that says “the CMTO exists—that if you are unhappy with this massage for any reason (and it could be other reasons – not just inappropriate touch)—but if you’re unhappy, here’s who you contact. And, if I’m going to have a client sign anything, it should be that the client confirms that I have pointed out that poster to them, that I’ve told them that the CMTO exists. That’s the kind of stuff that we should be telling clients. Instead of this permission to touch them in areas where they’ve been getting massage before–to their gluteals, to their pectorals, and now all of a sudden we’ve sexualized them by saying that: “oh these must be naughty areas,” because they need your consent to touch them now.
In fairness we do have a legal obligation if one RMT hears about inappropriate behaviour from another massage therapist or other health professional, we have a legal obligation to report that. But that presupposes that we even hear about it in the first place. So shutting down the conversation is not the way to do it in my opinion.
Don: Ian, we’ve got a few minutes left in our time together. What parting thought (or parting shot) do you wish to leave with the massage therapy profession?
Ian: I’ve said this a few times and I apologize that I’m repeating myself, but I think it’s worth doing. I really want us to be regulated in the entire country. I think as a profession we are stronger if we are regulated. So I don’t want my criticism of regulation to sound like disaffection with the idea of regulation – I just want it to be done in the best possible way.
We are self-governed. This means that RMTs sit on the regulatory body councils and even in unregulated provinces; professional associations are very much volunteer-run. So I know there are many RMTs that get involved with the profession on a volunteer level (or on a paid-level) across the county. I want to make sure that it’s being maximized, especially in a regulatory environment where I think the tendency is to sit back and say “well these government rules – I have to abide by them and I can grumble to my colleague but I cant do anything about it.” Well, no, you can do something about it. I was hugely gratified by the number of people who responded to the CMTO I guess it was in 2017. The CMTO even acknowledged their response rate was off the charts for the draping standard. I think we need to keep pushing. I don’t think we’ve gotten where we need to be. We need to remember to stay engaged, and I’m always encouraging both my students and other RMTs to do this: to speak up politely and firmly until the point gets heard. And this podcast is a great example of that and so I’d encourage anyone who listens to this – if they agree or even disagree with me, to comment about it and keep the conversation going.