AAMT Member Bulletin 7Government, Industry, Practise
In the 2012 May Budget Paper, the Federal Government forecast a return to surplus and announced various cost saving measures. The review of the Private Health Insurance Rebate (PHIR) for Natural Therapies commenced July 1, 2012 under the jurisdiction of the Department of Health and Ageing, and the Chief Medical Officer (CMO), Professor Chris Baggoley.
The Review applied a Cochrane research standard to guide the review of the studies. As a result, the vast majority of the studies that were submitted or discovered by the Reviewers were excluded because they fell outside the prescribed scope and limitations.
In its simplest form, factors or variables that made the results of studies difficult to interpret, or draw conclusions with a high degree of confidence, were the primary reason for exclusion from the DoH Review. These included:
- literature searches that were not systematic reviews published in English within the past five years (2008 to 2013)
- studies that did not include randomised controls
- confounded comparisons such as where more than one treatment was used in the study
- small-scale studies or results that were not statistically significant
- lack of masking (blinding) of intervention
- variations in the populations studied.
Overall, it was claimed that there was not reliable, high-quality evidence available to allow assessment of the clinical effectiveness of any of the natural therapies for any of the health conditions.
A total of 99 Systematic Reviews (SRs) were included that assessed the effectiveness of massage therapy for health outcomes in a total of 46 clinical conditions. AAMT submitted over 750 studies alone which, due to the eligibility criteria drawn after submissions were made, were excluded.
A further 20 SRs were excluded due to language limitations.
Of the 46 clinical conditions assessed, three involved clinical conditions (low back pain, neck pain, pre-term infants) for which the body of evidence was consistent and of low to moderate quality, enabling the effect of massage therapy to be estimated.
No SRs were identified that assessed the effectiveness of Myotherapy interventions. Only four SRs were found on dry needling and interventions associated with TENS which was performed within the context of physiotherapy.
The reviewers stated that due to the paucity of good-quality primary studies with sufficient sample size, or the lack of replication of study results, it was not possible to make any firm statements as to the effectiveness of massage therapy for many clinical conditions included in this overview.
The DoH Report also states that the absence of evidence does not mean that the therapy does not work. Importantly, to improve the understanding of the effectiveness of massage, the authors concluded that developments in research are required:
- more rigorous, multicentre, and well-designed clinical studies assessing the effectiveness of massage for a particular patient population
- a combined treatment approach that properly reflects the way that massage is applied in practice
- optimal treatment parameters such as number of sessions or duration of sessions, combined with longer-term follow-up of patients.
The Report’s findings in regard to the quality of evidence are not new. A 2012 AAMT-commissioned study, by the University of South Australia International Centre for Allied Health Evidence, looking at the effectiveness of massage therapy for the treatment of non-specific low back pain, reported similar challenges. It should be noted that this AAMT-commissioned study was also excluded as it was a meta-analysis.
At the heart of the issues concerning rebates and insurance cover is evidence supporting the clinical efficacy of massage as an intervention.
In other words: Can the health benefits be proved beyond doubt according to the Cochrane Standards?
AAMT supports evidence-based treatment and efforts to weed out false or misleading health claims.
Consequently, we welcomed the finalisation of the Review and called on the Federal Government to prioritise a program of research funding in areas where the evidence suggests that therapies are of likely benefit, and where more research would be beneficial.
Importantly, the authors of the report supported this call, stating that it is also more likely that further research may identify clinical conditions for which particular therapies are effective, such as massage therapy.
The challenge is to develop suitable research methodologies of a recognised and accepted standard that become mechanisms for measuring uncertainty around treatments.
Gaining acknowledgement and collaboration with the NHMRC on developing appropriate and reliable mixed methods of studies for particular modalities, as an alternative to simply applying a rarely obtainable ‘gold plated’ research standard, is essential for the growth of a professional and skilled massage sector in Australia.
Each massage business will be affected differently depending on the mix of services offered and the number of clients that depend on Health Fund cover and government rebates to fund the massage therapies they need.
Already, during 2015, many Health Funds reduced annual coverage from $400 to $100 for health expenses related to remedial massage therapy. While the income derived from funds and rebates is now significantly less, the economic outlook for massage therapy in Australia is positive.
The massage sector has grown by a rate of 62.3 per cent over the past 10 years, and created an additional 3,300 jobs in the past five years. Jobs growth including turnover, during the five years between November 2014 and 2019, is expected to average between 10,001 and 25,000.
Therapists should consider clinical business models with less reliance on rebated services to ensure their business is viable in the future.
Australian Government rebates are only available if the client has a complying health insurance policy with a registered health fund or insurer.
This is their commercial decision based on their market trends. Funds have the final say on what and who they choose to cover based on their commercial needs and requirements.
Given this, the strongest voice will come from health consumers, your clients with insurance cover. As a collective and as individuals, it is up to them to demand the services they need from their health fund and the benefits they expect.
You can encourage your clients to discuss this issue with their Health Fund and local Federal Member of Parliament, and request continued and increased cover for remedial massage and Myotherapy services.
You should also seek to diversify your Clinic’s income streams in order to counter any loss of income from a reduction in the Private Health Insurance Rebate. Increasing your client base with individuals who are not health fund dependant is one way you can do this.
Building a strong sustainable business model will ensure you are able to provide massage services in the future as the Health Fund landscape remains unpredictable.
Undertaking further professional development to expand or deepen your knowledge base, focussing on specialised treatment, and professional marketing of your services will also help to build your resilience.
Visit the AAMT website. AAMT provides further information and many opportunities to assist your development as a professional massage therapist and will be continuing our political education campaign with all Australian Health Ministers during 2016.
The final report of the Department of Health (DoH) was released during November 2015. It reviewed 99 massage studies, and is available on line from the DoH website: http://www.health.gov.au/internet/main/publishing.nsf/content/phi-natural-therapies