Julie Onofrio

If you are not at the table, you are on the menu is a political saying that supposedly comes out of WA DC in about 2000 with no known origin.  I first heard it said that the Alliance for Massage Therapy Education Conference (I think in about 2010) in Tuscon AZ by John Weeks, publisher/editor of the Integrator Blog News and Reports.

What it means is that if you/we don’t have a seat at the table with the insurance carriers, insurance commissioners, hospitals, doctors, nurses, legislators in every state, legislators in WA DC – we will be on the menu.  You will have other agencies, politicians, insurance companies creating policies, rules, laws and you won’t have a say in creating allowable fees, benefits and policies.  For example: one of the biggest issues we are having currently in WA state is that the insurance companies are drastically reducing allowable fees.  The insurance companies set allowable fees using formulas that consider the amount of work the provider does(time and intensity), liability insurance costs and practice expense data. The insurance companies do not have any data on practice expense from the massage profession so they just guess and use their own data.  We haven’t had any association representing us with the insurance carriers.

In terms of having massage therapy covered by health insurance, it is clear that there is a movement calling for massage therapy to be involved in fixing the Opioid epidemic.

• Comprehensive Accreditation Manual for Hospitals: The Official Handbook of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), updated in August 2000, recommends massage as a non-pharmacological therapy that can be used successfully in pain management.
• The Joint Commission (PDF) has been mentioning massage therapy in their reports in 2015, 2016 and 2018
• The ACA 2010 provided an opportunity for massage therapists to organize and demand coverage of massage therapy.ABMP on the ACA
  

  ABMP believes Section 2706 provides additional justification for insurance companies to reimburse massage therapists. For example, when massage therapy is a covered benefit of a health plan, it is not uncommon for an insurance company to reimburse massage provided by a physical therapist, chiropractor, or osteopathic doctor – but not massage therapy provided by a massage therapist. Evidence shows that massage therapy, especially when performed by a massage therapist, is a cost-effective delivery method of health care.

  Integrative Healthcare Policy Consortium – calls for massage therapy

  When a massage therapist treats any health condition covered in an insurance plan (e.g., back pain, neck

  pain, etc),the massage therapist is eligible for reimbursement, so long as that provider is licensed by his or her state and can treat the condition within his or her scope of practice.

  AMTA of course said they did not want massage therapy to be covered under the ACA. See Laura Allen’s blog post.  citing that 50% of their members did not want that to happen. What about the other 50% that did?

  ABMP wrote a position paper supporting massage therapy.  -“A comment on the Prevention Strategy of the National Prevention,Health Promotion, and Public Health Council December 2010

January 2012: The Integrative Health care Policy Consortium (IHPC) Announces State-by-State Campaign for “Correct Implementation” of Section 2706 (The integrator blog – http://theintegratorblog.com/index.php?option=com_content&task=view&id=858&Itemid=1)

IHPC Launches Campaign with Former WA Insurance Commissioner Deborah Senn to Secure Non-Discrimination (Section 2706) announcing a critically important campaign to help implement the ACA.

Section 2706 of the Affordable Care Act of 2010 promises “non-discrimination in health care.” The provision was lobbied by the American Chiropractic Association and the Integrated Healthcare Policy Consortium (IHPC) and championed by U.S. Senators Tom Harkin and Barbara Mikulski, MD. The intention was to honor citizen choice by broadening access to non-MD providers. Of greatest interest to Harkin and the duo lobbying organizations are those classified as licensed complementary and alternative medicine practitioners.

2011: 42 percent of hospitals are using complementary and alternative therapies (AMTA statistic).

 2012: The Hospital-Based Massage Therapy task force (HBMT-TF) was formed within the Academic Collaborative for Integrative Health (ACIH, formerly known as the Academic Consortium for Complementary and Alternative Health Care). The purpose was to explore the need for a set of standards or competencies, gather information about current standards for the field, and possibly develop HBMT-specific competencies that could be shared with all interested parties, particularly hospitals, massage therapy educators, and massage therapists in the field. HBMT-TF membership consisted of MK Brennan, RN, LMT (ACIH CWG member), Dale Healey, DC, Ph.D. (ACIH EWG co-chair), Carolyn Tague, MA, CMT (ACIH EWG member), and Beth Rosenthal, Ph.D., MBA, MPH (ACIH Assistant Director).

 Massage Magazine: Hospital-Based Massage Therapy: A Call for Competencies

Hospital Based Massage Therapy: A Call for Competencies

2013: 51% of AMTA members do NOT want massage therapy covered by health insurance, while 49% do.

Feb 2013: The Integrative Health Care Policy Consortium (IHPC) creates a blog for integrating massage into health care. https://ihpcmassage.wordpress.com/

07/10/2013: Laura Allen’s Blog reports that Diana Thompson, well-known author and leader in the massage profession, wrote a letter to AMTA requesting support for the ACA and integrating massage therapy into health care.

“With the exception of the massage representative from the AMTA, all the clinical speakers were excellent and very supportive of the ACA and interested in doing everything possible to support coverage by practitioners within their discipline. These clinicians expressed similar concerns regarding the ACA and how it may or may not affect CAM services. There were also clinical examples provided about how the ACA may positively impact certain disciplines, particularly NDs who provide primary care… On a side note, I am very concerned about the position of the AMTA…”

AMTA: Supporting Massage Therapists for the Affordable Care Act (or Not?)

August 2013: The AMTA’s approach to the Affordable Care Act is still undecided and the organization has taken limited action. https://www.amtamassage.org/articles/1/News/detail/2805/amtas-approach-to-the-affordable-care-act

“The American Massage Therapy Association (AMTA) understands there has been much discussion and debate about the Affordable Care Act (ACA) and the potential role for massage therapists that it might provide within health insurance based third-party reimbursement. Similar debates are taking place among other health care professionals as the ACA presents many challenges for everyone involved in health care, from professionals to consumers. While the law was enacted more than 3 years ago, it continues to be debated, analyzed and scrutinized. Meanwhile, the law has evolved and implementation will continue to evolve, especially as states determine their approaches to it.”

June 2014: IHPC letter to Centers for Medicare & Medicaid Services Department of Health and Human Services calls for the inclusion of massage therapy in health care under the Affordable Care Act section 2706. https://www.amtamassage.org/uploads/cms/documents/ihpc_6.5.14.pdf

2014: Diane Mastnardo creates Massage Northern Ohio Practice-Based Research Network.

2014: Integrative Health Policy Consortium www.ihpc.org (IHPC ) creates www.covermycare.com to help implement the Affordable Care Act section 2706.

2015: Over 125 hospital-based programs listed on the Society for Oncology Massage website.  http://www.s4om.org/health-care-professionals/hospitals-incorporating-oncology-massage

September 2016: Hospital-Based Massage Therapy Task Force Presentation 2016

https://integrativehealth.org/hbmt-ewg-cwg

https://integrativehealth.org/hbmt_competencies

• July 19, 2013.  Kahn’s keynote speech at the Alliance for Massage Therapy Education conference as reported by Massage Magazine, noted that “We get in each others’ way as a profession,” she said. For example, “There are people really concerned [about working in the health care system], they don’t want to take insurance and have someone 20 miles away … tell them how many sessions they can do [on a client], and so they’re going to say we shouldn’t go there.“I want to say, you shouldn’t go there if you don’t want to deal with those problems—[but] if you don’t want to do that, let’s figure out a way you don’t have to and I still can,” she added.Another barrier to moving through the doorways of opportunity, Kahn said, is the lack of a clear, articulate voice in Washington representing therapeutic massage “and helping policymakers and the public underhand how we can fit into the new health care system in a an expanded way.”

2017: AMTA Fact Sheet (https://www.amtamassage.org/infocenter/economic_industry-fact-sheet.html) reports:

“Massage therapists and consumers favor the integration of massage into health care.

• Nearly two-thirds of adult Americans (64 percent) would like to see their insurance cover massage therapy.⁴
• The vast majority of massage therapists (97 percent) believe massage therapy should be considered part of the health care field.^”

Feb 2017. American College of Physicians recommends massage therapy for back pain.

Sept 2017. The National Association of insurance commissioners have asked for it to be used to battle the drugs.  (See the letter PDF)

October 24, 2018, the President signed into law: H.R. 6, the “Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act” or the “SUPPORT for Patients and Communities Act,” which addresses the opioid crisis by reducing access to and the supply of opioids and by expanding access to prevention, treatment, and recovery services. Passage was overwhelmingly bipartisan (98-1 in the Senate and 396-14 in the House).   (www.ihpc.org newsletter)

October 2017: The inaugural Integrative Pain Care Policy Congress was an invitation-only meeting that brought together approximately 70 leaders from 50+ organizations. They represented the full scope of licensed and certified healthcare professionals involved in pain care, along with insurers, regulators, people with pain, researchers, and policy experts. AMTA was invited but has not reported on whether or not a representative attended and what happened. https://www.integrativepainmanagement.org/blogpost/1677160/294358/The-Integrative-Pain-Care-Policy-Congress-Why-We-Came-Together

2018: AMTA Fact Sheet (https://www.amtamassage.org/research/Consumer-Survey-Fact-Sheets.html) claims:

Massage for Health and Wellness:

“67 percent of individuals surveyed claim the primary reason for receiving their last massage in the previous 12 months was medical (41 percent) or stress (26 percent) related, according to the 22nd annual consumer survey sponsored by the American Massage Therapy Association (AMTA).”

September 4, 2018: AMTA announces the organization reached out to Medicare advantage plans asking them for coverage of massage therapy.

November 28, 2018: CMS announces up to 270 Medicare Advantage Plans will include massage therapy in 2019.

2019: New Hampshire Bill proposal. HB 610-FN http://www.gencourt.state.nh.us/bill_status/billText.aspx?id=131&txtFormat=html&sy=2019&fbclid=IwAR2X1kg6FALvSkN6FfnkWLxNelzvyN8Gf9kRNBqmdlVfWDjFmEFP9KE_uGw

“When patients seek treatment for any of the myriad conditions that cause pain, a health care practitioner shall refer or prescribe to a patient any of the following treatment alternatives, when applicable, before starting a patient on an opioid; chiropractic, physical therapy, occupational therapy, acupuncture, massage therapy, and/or osteopathic manipulation. “

“2 New Section; Coverage for Nonopioid Treatment for Pain; Individual. Amend RSA 415 by inserting after section 6-w the following new section:

“415:6-x Coverage for Nonopioid Treatment for Pain; Individual. Each insurer that issues or renews any individual policy, plan, or contract of accident or health insurance providing benefits for medical or hospital expenses shall provide to persons covered by such insurance who are residents of this state coverage for the costs of options to patients for evidenced-based non-opioid treatment for pain, including but not limited to*, chiropractic care, osteopathic manipulative treatment and acupuncture treatment. Policies issued pursuant to this section shall not have annual or lifetime numerical limits on visits for the treatment of pain. Reimbursement, coinsurance, copayment, and deductible amounts for pain management care utilizing chiropractic, acupuncture, and/or osteopathic manipulation shall be determined as a service under the Patient Protection and Affordable Care Act of 2009, as amended, definition of rehabilitation and habilitation.”

**”including but not limited to”–We need to make sure it says massage therapy!

2019: Virginia Bill Proposal: https://law.lis.virginia.gov/vacode/title38.2/chapter34/section38.2-3419/

2019: Oklahoma Bill Proposal: http://www.oklegislature.gov/BillInfo.aspx?Bill=HB+2652&session=1900&fbclid=IwAR3un4CZr0oHNWwloMCwbReEwCd6P0E31dqYx-svYRiO454GdI4l2N6qMrU

“Any health plan, including the State and Education Employees Group Health Insurance plan, that is offered, issued or renewed in this state on or after January 1, 2020, shall provide coverage for complementary and alternative medicine.”

2019: Bill in Maine: http://www.mainelegislature.org/legis/bills/bills_129th/billtexts/HP025501.asp

“This bill clarifies that massage therapists and massage practitioners are health care practitioners and that massage therapy is a health care practice. It prohibits unlicensed persons from claiming to provide procedures that are described as “massage,” “bodywork,” “body therapy,” “manual therapy,” “neuromuscular therapy,” “touch therapy” or “myotherapy” or related terms.”

2019: Bill in North Carolina. Bill Summary for S 544 (2019-2020)

Bill: ESTABLISH NON-OPIOID TREATMENT ALTERNATIVES. (https://lrs.sog.unc.edu/bill/establish-non-opioid-treatment-alternatives)

PART I. NON-OPIOID DIRECTIVE FORPROVIDERS OF PAIN MANAGEMENT 12CARE13SECTION 1.1.G.S.90-106 reads as rewritten: 14″§ 90-106. Prescriptions and labeling. (a3) Limitation on Prescriptions Upon Initial Consultation for Acute or Chronic Pain. –A  Upon the initial consultation and treatment of a patient for acute or chronic pain, a practitioner, as a first line of treatment, shall provide the patient with a referral to, or a prescription for, any  of the following alternatives to targeted controlled substances, when appropriate: (1) Acupuncture. (2) Chiropractic care. (3) Massage therapy. (4) Occupational therapy. (5)Osteopathic manipulative treatment. (6)Physical therapy.

AMTA 2019 Massage Profession Report (highlights):

“Approximately 47.5 million people had a total of 214 million massages in the U.S. in 2018, compared to 47.1 million people having a total of 179 million massages in 2017. “

“Massage therapists supported the integration into health care, with 95% believing massage should be integrated with health care. But how that integration looks varied greatly. The two most prevalent ways therapists preferred to see health care integration was by having massage prescribed or referred by health care providers, or by having massage therapists work on a team with other complementary practitioners.”

“The primary reason consumers obtained massage continued to be for medical, health and wellness purposes, or for stress reduction. Sixty-two percent of massage consumers had a massage in 2018 for health or medical reasons. Of these, 41% had their last massage for a health or medical reason. Sixty-six percent of massage consumers got a for relaxation/stress reduction in 2018, with 26% getting their last massage for this reason.”

“Consumers continued to believe in the efficacy of massage:

• Eighty-eight percent of consumers agreed that “Massage can be effective in reducing pain.”
• Eighty-eight percent of consumers agreed that “Massage can be beneficial to your health and wellness.”
• Seventy percent of consumers agreed that “Massage therapy should be considered a form of health care.”
• Sixty-seven percent of all consumers said they have or would recommend massage to a relative or to someone they knew in 2018.
• Thirty percent of consumers expected to get a massage in the next 12 months.”

“The number of massage therapists receiving insurance reimbursement increased in 2018Twenty-five percent of massage therapists were reimbursed by insurance for massage, up three percent from last year. Insurance reimbursement includes multiple types of insurance, not only health insurance. For practicing massage therapists, 11% were reimbursed by health insurance (either private payer or public system), 8% by auto insurance, 5% were reimbursed through workers’ compensation, and 2% accepted other insurance reimbursement.”

• “The 2018 AMTA Industry Survey provides information on insurance reimbursement for auto, medical, workers’ compensation and other insurance.
• Insurance reimbursement makes up between 12% and 28% of the total revenue for the average therapist that accepts insurance. Those that accept private payer medical insurance having the highest percentage of total revenue from insurance, and those that bill workers’ compensation insurance have the lowest percent of total revenue from insurance, consistent with 2017 data.
• Depending on the type of insurance, the average amount of reimbursement received varied widely”

“The average amount of reimbursement increased for auto and worker’s compensation insurance increased last year and declined for medical and “other” insurance. Insurance reimbursement is determined by each state and health care policy and not all states permit insurance reimbursement for massage provided by a massage therapist.”

March 2019: The Veterans Administration lists massage therapists as Health Technicians, allowing the VA to hire massage therapists. See the VA Handbook for complete details (Document number 005/108: Staffing – Appendix G56 Health Technician (Massage Therapy) Qualification Standard). https://www.va.gov/vapubs/Search_action.cfm?formno=&tkey=&dType=2&SortBy=issue&sort=desc&oid=0&fbclid=IwAR148-S0ux6V2aQj1CrYppE1JIxV66VTH4BNRMLfg4WQpVWX7S01wvOMIWk

(It took over 15 years to make this happen. Now that it’s official the VA accepts massage therapy as a valid method of treatment, my guess is that having their insurance cover massage will be next. The VA has created a definition of massage therapy—something the massage profession has failed to do.)

May 2019: In 2016, the Comprehensive Addiction and Recovery Act of 2016 was passed and created The Pain Management Best Practices Inter-Agency Task Force. The purpose of the task force was to propose updates to best practices and issue recommendations that address gaps or inconsistencies for managing chronic and acute pain. The U.S. Department of Health and Human Services oversaw this effort with the U.S. Department of Veterans Affairs and U.S. Department of Defense.

The result is a new report on pain management best practices that includes calling for the use of massage therapy. The U.S. Pain Foundation has created a toolkit for taking action. https://uspainfoundation.org/advocacy/inter-agency-task-force-toolkit/

IF this does not get us moving, I don’t know what will.

Let’s get to the table.

Whether you like it or not, whether you want it or not, massage therapy will most likely be covered by health insurance….eventually….or so it seems with so many calling for it’s use.  The thing is that we are not at any table at all.  We do not have associations stepping up to the table to be our voice.  It is important to start having these conversations NOW so that the massage therapy profession can bring our message to the table and create what we want as far as benefits and allowable fees.  We need to be at the tables in each state with insurance commissioners, health care insurance carriers, and in state capitals where laws are being created.  Otherwise it will be too late and we will be handed the leftovers.

To be at the table means that the massage therapy profession needs to attend meetings with State Insurance Commissioners offices, be talking to state and national health insurance plans and be involved in all efforts to help combat the Opioid epidemic.   To get to the table requires making connections like the one that started it all here in WA State.  The Insurance commissioner back in 1992 was Deborah Senn, who also had an office assistant who was also a massage therapist (Lori Belinski – now Lori Grassi who is the executive director of the WA state chiropractic association and lobbyist for the same group).

We need legislators in office at the state and national level that support massage enough to create laws that will make it so massage therapy is covered by health insurance.  We need state and national lobbyists and political action committees.   WA State has one of the of the only Political Action Committees that I know of in the US – the WA Massage Alliance for Health (www.wamah.org).  We also have a person in the house of representatives, Shelly Kloba, that has been a massage therapist for over 20 year and sponsored a bill in 2017 on prior authorization.

There are some that also say that we need to up our education standards before anything can happen with insurance companies and laws…but I personally think that it is more an legislative effort because of watching what has happened here in WA.  When the Every Category Law was created, WA MT’s were only required to have the minimum of 500 hours of education which was the norm at that time and still is the basis for licensing in many states.

Do we need more evidence as many MT say?  I personally don’t think so based on what I have seen.  We do have enough evidence right now to get started.  More is coming out every day.  We don’t have to wait any longer.

We just need people to step up and sit at the table for us.

• State legislators that support massage therapy
• State insurance commissioners that are willing to create laws that include massage therapy like the WA Every Category Law
• Health care specialists (Lawyers, healthcare executives) who know how to deal with insurance companies to negotiate contracts and help us determine the best ways to talk to insurance companies.  Do we need physicians networks or clinically integrated networks like some hospitals/physicians are moving to so that they can negotiate contracts while also providing health care services that are paid based on their results (values based care) instead of just fees for services?
• Massage awareness networks that work to educate doctors, legislators and insurance carriers on just what massage therapy can do.  (It is clear to me that the insurance companies still see massage therapy as a burden and think that they have to pay out the $25k or more for surgeries or thousands in drugs rather than using massage to eliminate those costs.) We do not have enough data on things like how much is massage therapy saving the insurance companies.  The only thing we do have is the report from AMTA on Integrative Care and Pain Management.
• Political Action Committees for every state and One National one.  PAC’s raise money to help get the right candidates into office that support massage therapy.

Learn to bill insurance NOW so you can start to understand the issues at hand and start learning about how insurance works so we can have more therapists and clients behind the people we get at the table.  There is power in numbers. 350k + massage therapist and their clients = ??????????