Insurance Partnerships Threaten Profession

The sole motivation for seeking IR for massage therapy is money. I am sure that many proponents of IR believe this to be easy money. As a maturing profession, it is natural to compare ourselves to other professional groups. In our society, the ultimate health-care provider is the physician. Physicians are well-paid, held in high esteem and receive IR for their services. I assume that the logic used by proponents of IR goes something like this:

Point A. Physicians are health-care providers who are: 1) very well-paid; 2) receive IR for their services; and 3) are held in high esteem and are respected.

Point B. Therefore, as health-care providers receiving IR, massage therapists: 1) will be very well-paid; and 2) will be held in high esteem and respected. Unfortunately, B will not follow A for the following reasons:

• IR will take control of professional practice and standards away from the therapist, and put control in the hands of insurance companies and physicians;
• IR will increase costs to consumers while eroding the income of therapists;
• Regardless of the profession, IR always degrades ethical practice;
• IR will limit client/patient access;
• IR will advance mediocrity in the profession.

It is beyond the realm of logical thought to assume that if IR becomes common for massage therapy, it will be administered in a manner different from the current model used for other health-care providers.

A few simple facts need to be discussed regarding insurance companies. The sole purpose of an insurance company is to make a profit. The customers of so-called health-care insurance are employers who want to pay the least amount of money possible for coverage of their employees. Insurance companies hire physicians as advisers. In this capacity, physicians help insurance companies decide which services should be offered, at what rate the services should receive compensation, who should provide the service, and how often a service should be covered per year or lifetime. State and federal governments have legislative control of insurance companies. State and federal governments use physicians as advisers in roles that are very similar to that which they serve in insurance companies.

While there are a handful of insurance companies that actually pay for health care or have some token coverage for illness prevention, the majority of coverage offered by so-called health-care insurance is actually illness treatment insurance. Illness treatment is the core approach used by allopathic medicine. Those who control IR are only interested in immediate and quantifiable results. As an example, there is universal IR for the treatment of lung cancer, but almost no IR for smoking cessation.

Access to insurance-covered health-care services is, for the most part, controlled by physicians. A sister profession, physical therapy (PT), illustrates this point.

State government controls access to PT. There are two basic models of access: self-referral and physician-only referral. In states that allow self-referral, insurance companies will only pay for PT ordered by a physician. In states that only allow physician referral, a physical therapist can only perform those services ordered by the physician in his or her prescription.

To get a prescription, a person must visit his or her physician. This adds to the overall cost of health care. The physician is not required to honor a patient’s request for any specific treatment, and is most likely to order treatments that will directly reimburse that doctor. For example, a physician is far more likely to inject a joint with cortisone rather than order physical therapy.

Any prescription by a physician must have an associated diagnosis to justify the prescription. This may seem to be an innocuous process, but once a diagnosis becomes a part of a person’s medical record, it can haunt him or her for life. Certain diagnoses can be used as a reason to deny employment and future insurance coverage.

We must remember that it will be physician advisers who will play the primary role in helping an insurance company decide what diagnosis warrants massage therapy. They will also determine how many sessions per year or lifetime will be covered. Considering the level of ignorance that physicians have about massage, other than as a form of relaxation, and the fact that massage is a nonphysician-performed modality, how many times per year do you a think a physician adviser will recommend payment for “a nice relaxing massage”?

In my experience over the years, physicians have changed their practice by usually ordering only those services that are covered by IR. Those suffering from fibromyalgia receive great relief from manual therapies, but manual therapy is rarely ordered by physicians because few insurance companies recognize fibromyalgia as a “legitimate” diagnosis, let alone have provisions for nonallopathic care.

Another area of control that is imposed on health-care providers by IR is the issue of documentation. Both nursing and PT illustrate my concerns. The roles of the registered nurse and physical therapist have moved from direct patient care to those of management and documentation. Why this focus? Because insurance companies really do not care about outcomes, but they do care very much about documentation. Without “proper” documentation, there is no payment, and those agencies employing RNs and PTs are justifiably interested in being paid. Will massage therapy have to develop another level of professional, such as massage technician or massage assistant, in the same way that nursing has licensed practical nurses and nursing assistants, and physical therapy has physical therapy assistants and PT techs?

Documentation can be used as a delaying tactic by insurance companies. It is perfectly legal for an insurance company to delay or deny payment of legitimate claims based on typos or minor documentation technicalities. This practice has given rise to a whole new bureaucracy of medical billing, which adds another layer of cost to the health-care consumer and increases the cost of providing health care.

Since documentation is the tool for reimbursement, massage therapists will have to become “creative” when documenting to maximize payment. Physicians are masters of this practice, finding obscure symptoms or combining symptoms in such a way that a higher-paying diagnosis can be used in their documentation. While not illegal, it is unethical, but such behavior is almost mandated by IR. I personally know of one physician who retired early just because his conscience would not allow him to be “creative.” He was greatly ridiculed by his peers; after all, when it comes to creative documentation, “everybody does it.”

Insurance companies will set the rate of reimbursement for a massage session. As with other health-care professionals, massage therapists will be forced to set their fees to maximize IR. The fees will have to be higher than those now charged to offset the higher cost of doing business and to offset the weeks, months or years waiting for the reimbursement check to come in from the insurance company.

Acceptance of IR also determines what a therapist must charge all of their clients/patients. Once any health-care professional accepts IR, all fees must be the same for all patients. Having different fee scales for the insured and noninsured is considered insurance fraud. Conviction of this crime can include fines and jail time.

IR also causes most client/patients to develop an “insurance” mentality. This mentality means that if a service that was once covered by IR is dropped, a person will now refuse to pay for it out of pocket. I have personally lost clients, who could easily afford my fees, when their IR changed and no longer covered massage. This story has been repeated to me by many other health-care professionals, such as chiropractors and counselors.

For reasons noted above, once a service is covered by insurance, it becomes more expensive. While the proponents of IR claim they want to make massage more available to those currently unwilling or unable to pay out of pocket, the increased cost related to IR will make massage therapy prohibitively high for the very populations they say they wish to serve.

IR will not make massage inflation-proof, or protect us from downturns in the economy. When economic times are bad, employee benefits are cut, and it is naïve to think that massage would escape the ax when a company is trying to save money on insurance costs. During hard times, fewer people are working, and nonworking individuals are less likely to have IR, let alone be able to afford the out-of-pocket expense of massage.

I am also concerned that IR will attract those to this profession simply because they will see it as a source of easy money. This will ultimately promote mediocrity. A good massage therapist does not go into the profession simply because training is readily achievable and does not require a college education. The last thing we need are individuals who think a massage therapist is getting paid for just rubbing a body. The recent increased demand for massage has unfortunately attracted this kind of individual. Too many times in the recent past, I have heard comments like, “Well, I couldn’t make it in the nursing program, or the nail technician program, or cosmetology program, so I am going to try massage.” While many of these individuals do make it through massage training, few stay in the profession very long once they encounter the actual demands of a viable practice. If IR becomes a standard practice, I am afraid that more and more individuals will be attracted to massage therapy to collect an easy income, rather than for the chance to provide quality health care.

If I haven’t convinced you, I hope that I have at least given you something to ponder. Please do something to stop the lemming’s race to IR. IR will not increase access to massage therapy. IR will not increase the level of professionalism and quality of care. IR will add layers of bureaucracy and outside control. IR will probably not increase income, and if it does, it will only be temporary. And at what price? I believe that widespread IR for massage will lead massage therapy to become a profession of excellent accountants and recordkeepers, and mediocre bodyworkers.

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David M. Frederick, CMT, BSN/RN, has 25 years of nursing experience, specializing in emergency room nursing. He also has 12 years of experience as a massage therapist. He is based in North Street, Michigan, and can be reached via E-mail at: jndhabs@miweblink.net.