AAMT Stakeholders Bulletin 10 – April 14 2015
An update on developments in the massage therapy sector
Health insurance and massage
Legitimate remedial massage therapists are feeling the pinch of an uneven playing field that is undermining the commercial viability of legitimate remedial massage clinics and limiting the choice of services for health consumers.
The problems stem from an inadequate regulatory framework, competitive market barriers and biased insurance cover for remedial massage that is administered by a remedial massage therapist.
Added to this is the pending decision regarding the Review of the Private Health Insurance Health Insurance Rebates (PHIR) for Natural Therapies, which may see remedial massage therapy lose eligibility.
For AAMT members alone, changes to the rebate and illegibility for Provider status of the PHIR directly affects the 6,500 AAMT registered massage businesses. It is also worth noting that all of these are small businesses with a ratio of 2.5:1 women to men.
The impact of this becomes more apparent considering that an independent study commissioned by the AAMT showed that around 80 per cent of the Association’s 8,000 members are qualified remedial massage therapists and around 86 per cent of AAMT members depend on Third Party Insurance Cover for a portion of their income.
Major sources of income from third party insurance cover
This flies in the face of sensible economic management because as a professional health service, remedial massage is now an integral part of the health care system, being widely accepted as a legitimate and effective treatment of symptoms for a variety of conditions.
The subsequent articles outline the challenges now facing the remedial massage sector.
Of particular concern is the compounding regulatory bias against qualified, professional remedial massage therapists.
Cuts to health insurance cover for remedial massage discriminates against legitimate remedial massage therapists, who have significantly more training in the application of massage than some allied health practitioners providing massage. For example, Osteopaths and Physiotherapists who administer massage receive higher levels of insurance cover, yet undergo significantly less training in massage.
Medicare definitions concerning eligibility for Allied Health Provider status also do not recognise the advanced qualifications and extensive training of remedial massage therapists, which are equivalent to or in many cases higher than those of allied health practitioners administering massage therapies under Medicare provisions.
This is significant because Medicare definitions are used in the delivery and access to subsidised massage services which include the Department of Veterans Affairs but exclude remedial massage therapists.
Generally, remedial massage therapy costs less than physiotherapy and delivers the same or more pain and stress relief, and can contribute to a more cost effective and accessible health care service.
Research reported in the British Medical Journal found that the cost effectiveness ratio and the cost utility ratios of manual therapy (spinal mobilisation) was less costly and more effective that physiotherapy and general practice for treating neck pain.1
Another recent study indicates that patients whose general practitioner has additional complementary and alternative medicine training have lower health care costs and mortality rates than those who do not. Reduced costs were the outcome of fewer hospital stays and fewer prescription drugs.2
1 Korthals-de Bos IBC et al.,’Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial’, British Medical Journal, 2003, 326: 911–916.
2 Kooreman P, Baars EW, ‘Patients whose GP knows complementary medicine tend to have lower costs and live longer’, European Journal of Health Economics, 2012, 13(6):769–776.
Excessive levels of competition compound the commercial problems already facing the legitimate massage sector.
In Australia, around 25,000 therapists offer massage therapy, not including allied health professionals such as physiotherapists and osteopaths.
Combined with median costs that vary from $65 to $80 exclusive of GST per massage session, a very narrow range, there is also very limited price elasticity and it is very unlikely that the market will bear rate increases to offset losses in income from lower health insurance cover and the potential loss of the PHIR.
The sector has simply grown beyond the capabilities of the current regulatory system and resources. Being funded by member subscriptions, the AAMT and the massage sector as a whole do not have the resources to regulate all massage education providers and all of the 25,000 plus massage therapists operating in Australia today.
Competition to secure members and hence funding creates a number of market barriers to addressing the problems and limits the level of industry-wide cooperation.
Competition between associations for membership has seen an ad-hoc delivery of Codes of Conduct, which is likely to continue even under a National Code; and a lack of transparency and conflicts of interest in the registration system which encourages poor monitoring of standards and codes of practice.
Loopholes in the regulatory system continue to plague the industry, allowing unscrupulous operators to abuse the system and make spurious claims about their qualifications and services.
Unfortunately, anyone with poor or in some cases no training can hang out a sign and offer health advice and pseudo treatments, in order to take advantage of the uninformed health consumer.
These unscrupulous massage therapists undermine self-regulation and the professional standing of the legitimate massage sector. For example an increase in the prevalence of questionable qualifications, illegal prostitution, and work practices associated with the plethora of so-called ‘wellbeing’ massage clinics now appearing across Australia have become a gateway for sex offenders and sex workers to masquerade as legitimate massage therapists.
This is evidenced by a growing incident of police raids in Victoria, Queensland and NSW, on illegal brothels masquerading as massage therapy clinics.
Recent investigations by Medibank Private also revealed that a number of massage parlour workers registered as remedial massage therapists were abusing the Private Health Insurance Rebate system.
Although the proposed National Code of Conduct for Health Workers is a very welcome development it relies too heavily on the current regulations, and reactive measures which have failed to curb these illegal practices.
By relying on complaints, the National Code is not in line with current moves towards screening and monitoring-based regulation where individual safety is at risk.
While regulatory reforms to the massage sector are desperately needed, a failure to respond to the needs of the sector and health needs of consumers that depend on remedial massage will compound the economic loss to the health system and remedial massage therapy sector and far outweigh any immediate savings from current and proposed regulatory change.
A collaborative approach involving governments, health funds and the massage sector is needed to achieve policies and programs that can weed out unscrupulous and unprofessional operators for the benefit of patients and the health system as a whole. The goal is to achieve a collective response to tighten regulations where required and address the unfair penalties and market barriers affecting the legitimate remedial massage therapists.
Overseas industry update
The Minnesota State Legislature has enacted a new voluntary register for massage and bodywork therapy.
Placed in the ‘too hard basket’ by many regulators, jurisdictions, and member-based massage associations, the voluntary registration system which is already in place in Washington State, addresses a variety of registration issues and hurdles and sets in place a model for other jurisdictions such as Australia.
Definitions and descriptions within the Act include Definitions involving the use of terms, Limitations on Practice, Protected Titles and Restrictions on Use, Registration Requirements, Power of the Board and Advisory Council, requirements for Education Providers, and Board disciplinary powers and procedures.
The legislation enshrines that as of January 1, 2016 no individual may use the title of ‘registered massage and bodywork therapist’ or any abbreviations or insignias that might imply that an individual is registered or might be eligible for registration as a massage therapist in the State unless they comply with the requirements of the Act.
Massage and body work therapy are defined as a health care service involving the systematic and structured touch and palpation and pressure and movement of muscle, tendons, ligaments, and fascia in order to reduce tension, relieve tissue pain, improve circulation, increase flexibility, increase activity of the parasympathetic branch of the autonomic nervous system or to promote general wellness, by use of the techniques and applications described in other sections the act.
In Australia and worldwide, health care consumers are redefining the rules of market engagement where, for a given condition many patients are no longer referring to their General Practitioners as a first or primary health advisor.
While this trend reduces the burden of health cost on government budgets, it can place health consumers at risk when self medication, or inadequate training leads to misdiagnosis and incorrect treatment.
In the interests of public safety, health providers are required to stay within their areas of expertise. However, health consumers are demanding a greater number of options, outside surgery and pharmaceutical care.
The IBIS World report, April 2013, reported that Australians spend around 3.5 billion a year on natural health and natural health care and that this trend is expected to grow by around 5.3 per cent to 2018.
Despite being the most highly trained and skilled providers of primary care, the trend places pressure on General Practitioners to provide advice and guidance outside their training, in the use of Allied, Complementary and Alternative medicines and healthcare.
In the forword of the World Health Organisation’s (WHO) Traditional Medicine Strategy, 2014–2023, Dr Margaret Chan, Director-General writes: ‘Many countries now recognize the need to develop a cohesive and integrative approach to health care that allows governments, health care practitioners and, most importantly, those who use health care services, to access Traditional and Complementary Medicine in a safe, respectful, cost-efficient and effective manner.’
In Australia, during 2013, the National Health and Medical Research Council (NHMRC) conducted public consultations on the Complementary and Alternative Medicine (CAM) Resource for Clinicians. The stated aims of the resource were to facilitate discussion between clinicians and their patients about CAM use, and also provide further information on CAMs. The resource is available on the NHMRC website.
As a response to changing market demand, the resource also promised to aid Clinicians with ways and methods of alerting their patients to consider peer reviewed evidence that supports the use of these practices.
The WHO Strategy, 2014–2023 reports that in Australia, visits to complementary health professionals such as acupuncturists, chiropractors and naturopaths saw an increase of over 30 per cent between 1995 and 2005, when750,000 visits were recorded in a two-week period.
A more specific example is, L Skovgaard et al., also reported in the WHO Strategy, which found that an extensive number of patients with multiple sclerosis resort to Complementary and Alternative Medicine (CAM) treatments with the prevalence of use ranging from 41 per cent in Spain to 70 per cent in Canada and 82 per cent in Australia.
It is now a commonly held view that the ageing population will continue to present a greater burden of age-related disease and disorders, and place additional pressure on the health budget, the cost of health insurance and health care in general. As such, it can be expected that the trend toward complementary health will continue.
The WHO strategy also cited the work of Korthals-de Bos IBC et al. 2003, indicating that patients whose general practitioner has additional complementary and alternative medicine training have lower health care costs and mortality rates than those who do not.
A growing number of successful health care clinics are emerging as integrative healthcare services. These clinics promise to stand as a model not only because of the improved level of individual health care offered to patients but also because of the efficiency gains and improved profitability.
Where clinical efficacy is known, or the body of reasonable evidence suggests worthwhile benefits in order to deliver an effective and affordable health care service, a sensible regulatory framework that encourages integration of contemporary medicine and health care with complementary medicines and health services such as remedial massage seems a likely solution to addressing the growing burden of health care costs in Australia.
Australian Association of Massage Therapists Ltd