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If we are not at the table, we are on the menu.

October 20, 2018 by Julie Onofrio Leave a Comment

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
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.”
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)
“When patients seek treatment for any of the myriad conditions that cause chronic pain, doctors should be encouraged to explore and prescribe

effective non-opioid alternatives, ranging from non-opioid medications (such as NSAIDs) to physical therapy, acupuncture, massage, and chiropractic care.”
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)
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 = ??????????

Dating Massage Clients

October 3, 2018 by Julie Onofrio 1 Comment

What if you really really really fall head over heels for a massage client and go on to date them?

What is happening is called counter-transference and it happens in every relationship really and is called projection in other relationships. Because you are meeting someone under the premise that you will provide massage therapy for them for a fee you have other obligations to be professional and create boundaries to protect the client at all cost. In a regular relationship where you meet someone in a coffee shop or at a party it is an equal relationship where both exchange information freely in order to get to know each other. When there is a client paying money for a service and one person is the health care provider or a person trained in something like massage therapy – it creates a power differential. The main focus of your massage sessions should be about meeting the needs of the client and NOT your needs to be liked or even loved.

There is a power differential in the relationship between the massage therapist and client where the client will put their trust into the hands of the massage therapist and will look to them for help with their health issues.

All of the excuses are just that, excuses for inappropriate behavior.

You can’t stop love.
It is my life.
You can’t tell me who to love and not love.
We are getting married so it will be OK.

Some states even have laws around it that often will give a time frame for when dating would be allowed. How they can put a time frame on it is beyond me. What time does it take to get through the counter-transference issues and be clear on your motives and clear your heart? Even if there is not a state law, dating clients is just one big NO.

The consequences of dating a massage client could come back to hurt your massage therapy business/career. If the person was just divorced or the divorce happened as a result of the new relationship, the ex-partner could take legal action against you especially if there is a law regarding dating in your state. If the relationship ends badly at a later date, the client may finally realize that you took advantage of them when they were in a vulnerable state and try to sue you or put claims against your license for inappropriate behavior and ethical violations.

If you as the massage therapist find yourself falling in love with your client in a way that you want to date them you need to get professional help and figure out what you are doing to create that situation. It usually starts with talking too much to the client and telling them about YOUR life rather then focusing on the client and their needs. Massage therapists work in such isolation that it is easy to fall into the trap of becoming friends with clients and telling them your problems. People who come in weekly for massage sessions for a long period of time also provides time to get to know clients.

Charging what you are worth is BS

September 1, 2018 by Julie Onofrio Leave a Comment

Where in the world has this idea of charging what you are worth or knowing what you are worth has come from? I see many massage therapists talking about it and high-fiving each other for every little thing that they do explaining that they now know their worth. It is BS. Somehow the ides that if you not earning the kind of money you would like to earn it’s often framed as evidence that you don’t believe in our worth enough.

Your worth has NOTHING to do with money. No one could ever pay you what you are truly worth – $1,000,000. How do you put a price tag on something that is beyond monetary value? What is it worth to have your life back after suffering in pain for a few weeks or a few years?

If you are an employee or IC, the employer will pay you what THEY THINK YOU ARE WORTH. If you are self employed, the customer will pay what they can afford and will pay for things that they value. If someone is charging more or less than you are – does that mean that they are worth less as a person. NO. Is Bill Gates or Jeff Bezo’s ‘more worthy’ of a person than you because they are billionaires? I doubt they ever sat around wondering what they were worth or if they were worthy of their wealth.

What you are being paid for is your time and the skills you have learned in massage school and for your experience as a massage therapist. Massage school is usually a one year or less program that the average cost is $12,000 or so.

Now I know the massage profession tends to attract many people who don’t understand business and would like to give their massage away at low costs and they don’t have cancellation policies in place and things like that. Is that because they don’t know their worth or they don’t understand business and that they would rather be a ‘nice’ person and have low rates so that everyone can get a massage? Is it because they know that they could never afford to get regular massage at higher rates? Is it their ‘noble poverty’ idea that it is better to help people than to get paid more concept and not understanding the meaning of money?

Most of our issues with money come from confusing money and love. We think people will love us more than the competitor with lower rates. We think we are being generous, giving and nice offering lower fees. We think we will be loved more. We give up parts of ourselves to be loved more but it just doesn’t work that way. We caretake rather than take care which is what I call the Code of the Caretaker. People can feel our neediness. They can feel us leaning on them. It makes them uncomfortable.

It is a math problem.

A client won’t pay you what you are worth. They will only pay you what they can afford. They will pay you what they perceive you are worth to them. They will pay more and come in more often when the value the outcomes that massage therapy can bring to their lives. Your job as a massage therapist – no matter if you are employed or self employed – is to bring value to the table. This idea that people don’t value YOU is ridiculous. What they don’t value is themselves. They don’t care enough about themselves to want to pay for a massage once a week or whatever it is. It isn’t about YOU.

Setting your fees is about math. What do you need to make to be able to pay the rent and business expenses and make a living for yourself and family? Just a math problem. What is the work worth? You went to massage school and paid maybe $12,000. That is nothing in comparison to other fields. When you attach the idea that pricing is about your worth, you are beating yourself up. Start tracking your personal expenses to see what you need to make each month to pay the mortgage/rent, groceries, gas etc. Start tracking what you need to pay your office rent and businesses expenses. It won’t become a math problem until you do this and just really understand the basics – you need to make more then you spend. If you don’t have enough clients, work on that. If you are spending too much – work on that. It’s just math.

And if you notice all those people telling you that you need to raise your rates so you charge what you are worth usually have some program, book or class that they want you to take to teach you how to ‘charge what you are worth’. They constantly cut you down and make you feel bad you aren’t making $100k or whatever it is that they think you should be charging – is that so you can pay them for their classes?

Getting comfortable with yourself and money

The things we do need to look at and deal with in the massage profession are the feelings massage therapists get when they think about raising their rates, charging late fees/cancellation fees and confusing that with the need to be a good person. We charge people less, thinking they won’t pay that or that you need to do that to get people on the table when others are charging such low rates. Doing that does not happen overnight. It happens as you gain experience and confidence in your work and do your personal work to learn more about the reasons behind those feelings. It comes from the old feelings that were ingrained in you as a child that you were not good enough, smart enough, valuable enough. Those feelings are best dealt with by an experienced counselor or psychologist.

Once you just start looking at the numbers – the rent, taxes, expenses and cost of living – it all just becomes a math problem. Take the emotions out of it. Take the idea that you are not charging what you are worth and bury it in the backyard. Stop beating yourself up and making yourself feel bad thinking you are not charging what you are worth. Everyone can make a decent living in massage therapy. Start where you need to start with your pricing and work your way up to top of the line pricing as your skills and experience grow.

Do your best work. Show up on time. Set your boundaries. Set your prices to reflect your expenses and to cover your needs for living. Work on removing the emotional baggage you have around getting paid for what you do. Stop with the get paid what you are worth and sleep easier knowing that your value has nothing to do with money.

The Future of the Massage Profession

August 29, 2018 by Julie Onofrio 3 Comments

In order to start planning for the future of the massage profession, it is important to learn where we have come and where we are currently at.

Right now we need more younger massage therapists to step up and become leaders in the profession to direct our future. Most of what happens in the massage profession happens because of the many volunteers for AMTA Chapters. Yes that’s right – volunteers are really the one’s who direct our future. If you want to make something happen – volunteer. Step up and run for a board member position or at least start attending your AMTA Chapter Board meetings. Most of the local volunteers really have a good heart, but AMTA National is not much help in directing where each state should go. I only recently learned that the Government relations volunteers in each chapter do not really network with each other. Instead they are just fighting fire in their own states rather than sitting down and figuring out what they want for the STATE and National Therapist – not themselves. I always thought that AMTA National had more influence and was leading the volunteers. (Correct me if I am wrong).

When you volunteer with AMTA you will see some of the politics outright. Many volunteers have been previously ‘fired’ and accused of insubordination and can’t even talk about it because of agreements they signed. I would love to write a whole book on that someday and call it “As the AMTA Turns”.

Currently, the main issues are:

Lack of a unified definition of massage therapy, deep tissue massage and other terms that make it confusing for consumers to figure out what to ask for and what they need. We have a Massage therapy Body of Knowledge that was trying to do that but the last update was 2011.
Lack of standards in education. The Alliance for Massage Therapy Education is working on it. The AMTA and ABMP also have a schools division but not sure if they are working on it. The Entry Level Analysis Project (ELAP – www.elapmassage.org) is the closest thing we have that should be implemented in all schools but that was done in 2012 and is starting to be outdated.
Low pay in many of the franchises and other financial factors have led to a shortage of massage therapists in the US. Not enough people are choosing massage therapy as a career. Franchises and other massage businesses are struggling to find therapists to work and rent rooms. For as long as I can remember, massage therapists have talked about unions for jobs yet no one is stepping up to form them. As far as I know, there would have to be a union for every franchise which is independently owned but not really sure on that one. It won’t work for massage therapists who own their own business. How many massage therapists are employees is really unknown.
There was also a time a few years ago when many massage schools were closing because they were schools that did not meet the requirements and were telling potential students inaccurate salary data when entering schools.
There are currently two main massage therapy associations – ABMP and AMTA. ABMP is a for profit business meaning they are all about the money while AMTA is a non-profit membership organization (501 C6) where they are obligated to provide for their members. To be a 501c6 organization, they must ” (from the IRS) the organization’s activities, must be meaningful. For this purpose, membership support includes the following items:
- Amounts derived from performing the organization’s exempt functions or from substantially related activities
- Contributions or gifts from the general public
  The activities that generate the income must contribute importantly to accomplishing the organization’s exempt purposes to be substantially related.”
They also have to make their financial reports public so that people can see what they are doing. AMTA was started first and then ABMP was started in about 1992 by a disgruntled massage therapist. At the time I thought it was a good idea, but now looking through the last 30 years or so I see how it has split up the profession and also made it so we have limited influence over anything in politics and policies. (Just think if massage therapy were covered by insurance in every state like it has been for over 20 years here in WA – would there be an Opioid epidemic?)
We also have two associations fighting over who will manage the CE requirements. NCBTMB and the FSMTB are at an all out battle over this. FSMTB even publicly stated that they would let the NCBTMB handle the CE approval process (as they had been since their inception) but then somewhere along the line changed their minds and now are working to take over the CE approval process.
The NCBTMB created Board Certifications and in the beginning it was called the National Certification Exam but nothing about it was National. It never meant that anyone could practice in any state and that confused many. Currently they are a struggling organization and a few years ago even had to sell the furniture and find new office space. AMTA now funds the NCBTMB which could be seen as a conflict of interest. The NCBTMB was originally meant to be an entry exam for AMTA and AMTA funded it to start and then stopped to make it stand on it’s own. At sometime AMTA actually withdrew their support of the exam. Currently the NCBTMB is playing around with something called specialty certifications but to me it is taking us 10 years or more backwards. The specialty exams are for specific schools. What we really need are true Board Certifications in things like spa therapies, rehabilitation massage, hospital massage, cancer massage and sports massage…and that is it really.
While we have been able to bill health insurance here in WA for over 20 years, we are now being hit by allowable fees being lowered significantly, by massage therapy benefits being reduced and other problems working with health insurance. It started about 7 years ago when the first one dropped their allowable fee from $120 something to under $60 per session. I went to AMTA WA and started asking around about what could be done and what is being done and the answer I got from volunteers there was that there isn’t anything that could be done or if there was they would be doing it. The problem is that no one has been at the table with the carriers and providing them with data they need to set their fees accordingly. I helped start a new organization in WA State – the WA State Massage Therapy Association to start getting to the table with carriers and start standing up for the profession.
As I learned more and more about what was going on politically in WA State, I also came to realize that the Political Action Committee was something that needed to be revived and built into at least a $100k business like the WA State chiropractors and Physical Therapists have. WA State is the only state that I know of that even has a PAC. This past spring I watched a bill that the PT’s and Chiropractors initiated that also included massage therapists regarding prior authorizations that were being done by a few major insurance companies to try to cut down on the number of sessions being done. I watched all the hearings on the bills and was actually amazed that the legislators were asking the right questions to the insurance companies who were of course fighting it all. The bill passed although with a compromise but I never in a million years even thought it would pass. It passed because of the many many years of lobbying, contributions to political campaigns and educating legislators about what is going on. (AMTA and ABMP are no where to be found in the arena – maybe AMTA in some states are now getting involved but they are mostly on their own.) I am now the secretary of the PAC – the WA Massage Alliance for Health (www.wamah.org). It was started in 2003 or so by some past AMTA members.
There is also NO National Political Action Committee. If there was, I imagine that massage would be covered by health insurance in every state to help combat the Opioid epidemic…or maybe there would not have been such a problem if massage therapy were covered – image that.
Sex scandals where massage therapists are attacking clients, and where clients are attacking therapists is becoming all too common. What is up with that?
Human trafficking is getting more attention but not really from the national associations that I have seen.
Discrimination is still a really big issue in the massage profession with men being discriminated against as well as minorities.
There is a split in the profession where spa/wellness/relaxation massage is looked upon as being less than or less qualified than medical massage therapists (which also needs a definition.) ALL massage therapy is healthcare.

So what can you do to get more involved?

Start paying attention. Read everything you can on reports of associations.
Attend conferences to network and learn from others.
First start with your local AMTA chapter to see what is going on.
Run for a board position in your state AMTA Chapter.
Run for a National AMTA Board Position.
Get involved with the NCBTMB and figure out what the heck they are doing/thinking. I have emailed them a few times but no replies.
Consider starting your own state massage association if you don’t get anywhere with AMTA. That is what happened in WA State – www.mywsmta.org was created after struggling with AMTA National for years and years over getting the support we needed here in dealing with insurance companies. (Many other professions also have their own state organizations that are not connected to a national organization.) I also am concerned about splitting the profession up more so more thought is needed.
Start a political action committee in your State!
Start a National PAC – I hope to do that after I learn more about running the state PAC.
Start your own massage school that teaches a new way of being a massage therapist that focuses on practice building and have a support team in place to help graduates do just that.
Start saying NO to low paying jobs with no benefits.
Start having meetups in your area with other local therapists and start brainstorming the answers together. Start a grassroots efforts to make changes in your area and teach others how to do that too.

We need more people under 45 doing these things. Now.

Most of what we have now in the massage profession has been created by the older generation of massage therapists – people like me over 60 years old. When you look at the list of volunteers in AMTA and other organizations, it is usually the same names over and over stepping up. The future really lies in the people younger than 45 – what do you really want for OUR profession?

Getting involved and learning what is going on is just the beginning really. What we need is a plan for our future and people with the guts to stand up for the profession. I see so many creative and inspiring stories of people creating things, community and even political action in other fields but nothing is really new in the massage profession. Here are some of the things I have thought about that need further research.

One National association that brings us together.
TV commercials on various topics like massage for headaches, fibromyalgia, pain issues (back, neck, knee, hand etc), carpal tunnel syndrome, stress etc. etc.
Ads in major magazines like Oprah, Prevention, Time, Newsweek, etc
Massage therapy covered in all states by health insurance that pay at least your cash rate if not more for rehab and medically necessary conditions.
Massage therapy covered by health insurance for stress/wellness options for massage sessions done once a week or as needed.
One universal definition of massage therapy that is adopted by all states in their laws that clearly states our scope of practice.
One standard number of hours of education for entry level therapists and one standard number of hours of required education hours for advanced care (rehab, hospital massage, cancer care) in all states.
TV commercials and ads that show massage is not a ‘happy ending’.
TV commercials and ads that create awareness about the problems with illegal massage businesses, human trafficking.
TV commercials showing people of color and black people getting and giving massage therapy.
Anatomy and basic massage taught in grade school or high school.
More higher paying jobs that pay over $30 an hour and you get paid that whether or not you have a client or not. (Yes I know that would seem nearly impossible financially.)
A union for franchise workers, spa workers and other employers. (Unions have been talked about since I have been a massage therapist in 1987, yet nothing has been done.)
Community clinics where massage therapy is offered for free or low cost for those in need.
Your idea here __________________________________.
Create paid activist positions or do things that make you money to help pay for volunteers time/energy. Too many volunteers and not enough paid positions.
Have AMTA State chapters hire an executive director, admin and others as needed to get away from volunteers having to do everything.
ALL massage therapy is healthcare.

Overcoming objections.

Getting people involved in this profession is often likened to “herding cats”.

Stepping up and making a difference takes time and energy. Most massage therapists are barely getting by enough to want to make time to do these things. It is difficult to get involved in AMTA as they are all volunteers at the local level and they are busy doing their work. This is a very well known place for non profit organizations, but I expect more support from AMTA National in this area. If you are not an AMTA member, it is also difficult to get involved as they try to keep it to members only but I got involved in WA without being a member. It depends on your local chapter and their leaders.

Getting involved has helped me come out of my own introverted shell and share my .02 and be a part of something greater than myself. I have met some great people and have learned more on how to deal with difficult people and situations. I will continue my ‘herding cats’ as someone once said “and Julie turns the massage therapists eastward and begins herding”. Massage therapy has been a great profession for me even with it’s ups and downs. As I think about retiring in the next 5-7 years, I feel sadness for the future of the profession and am concerned on what it will be if no one else starts standing up. Will it just be cheap massage done by poorly trained massage therapists who answer their phones in a session and say things like ” I am so bored doing massage and with all that free time in a session – what do I do?”

What will it take for you to make the time and step up and deal with the politics and such to start making a difference in creating the future of the massage profession instead of what is happening now which is that the future is happening without any input on where we would like it to go.

Where do you want the massage profession to go or not go for that matter?

My Vision:

I envision a massage therapy profession with one unified voice of the profession, that advocates ALL massage therapy is healthcare. Wellness/relaxation massage and medical/hospital massage are all as important and compensation for therapists should all be the same. All massage therapists should be able to make a living wage that will allow them to work 25-30 hour work weeks in a job or whatever it takes in private practice to own a house or live where they want, take vacations, save for retirement etc. I picture massage therapy offices in every hospital, cancer center, healthcare center/office. I picture every person in the US getting a massage once a week no matter their ability to pay.

I picture a community where we can all come together to support each other despite our difference of opinion and beliefs.

I would love to see schools that cater to people with business degrees/experience to learn the art and science of massage therapy to create more massage businesses where massage therapists can be fairly paid and respected. I hope schools can attract the students they need without having to give into the franchises and teaching the minimum and that schools would more carefully screen out felons and others who are giving our profession a bad name.

I see a profession that is no longer being confused by the public by illegal massage businesses offering ‘other types of so called massage’.

More associate and bachelors degrees in massage therapy are needed. Heck – what about a doctorate?

Full Disclosure: Just so you know… I was only an AMTA member for probably a year or two in the very beginning of my career. I was also a supporting member for a few years just so I could access their Fact sheets and attend the state convention at a discounted rate. I have been watching AMTA for over 30 years and never was a big supporter of them, but the fact is that they have the power and ability to hire lobbyists to help each state chapter. I helped set up the WA State chapter website in 2015. I later went on to help start the new WA State association – WA State Massage Therapy Association (www.mywsmta.org) and was the secretary of that organization for 2 years. I am currently the secretary for the WA Massage Alliance for Health – the PAC for massage therapists in WA State (www.wamah.org). I also am on the board of a new organization trying to find it’s way – The National Alliance of Medical Massage and Bodywork (www.nammb.net) that was started in CO and working on CO legislation first to get massage therapy covered by health insurance.

The CE Conundrum

August 5, 2018 by Julie Onofrio Leave a Comment

And now, the end is near
Could this be the final curtain?

First of all – it is CE (Continuing Education) NOT CE U. One CE credit is 60 minutes of instruction. One CE hour is 60 minutes of instruction. One clock hour is 60 minutes of instruction. One contact hour is 50 minutes of instruction. One continuing education unit (CEU) is equal to 10 contact hours. Got it?

The National Certification Board of Therapeutic Massage and Bodywork has overseen the

National Certification Board of Therapeutic Massage and Bodywork

The NCBTMB has a process for CE providers to become ‘approved providers’. Many states require CE classes that are approved by the NCBTMB.

These only requirements to become an approved provider with the NCBTMB:

Requirements to become an Approved CE Provider:

Submit a course description,

Submit a brief description of your learning outcomes,

Submit a syllabi/outline of course,

Demonstrate you have taught the course at least one time within the last year to a group of five or more participants, and

Submit completed feedback forms from five or more participants.

Costs to become an Approved CE Provider:

$225 for individuals for a three-year period,

$450 for organizations or conference/tradeshow providers for a three-year period, and

$25 per new class submitted.

More info on becoming a CE Provider with NCBTMB

The NCBTMB though has been under scrutiny for many years. In my opinion, it was actually doomed from the start. There was no research done at the time of their creation that said it was needed. The article Pro..National Certification…con… a Panel discussion sponsored by the Bay Area Body Therapy Guild June 5, 1990 Massage and Bodywork Journal brought up the many concerns.

In the article Calling for Excellence in the National Certification Program, Massage Magazine, May/June 1994, Patricia Benjamin openly questioned the integrity of the program because it was being started by AMTA. “There is a essential conflict of interest when one organization and their employees have inside information about another organization whose interests they are supposed to protect.” In the second part of the article, National Certification Perspectives II also talks about how there was no study or survey done to show that a National Certification Board was needed until AFTER it was created.

The problems we had back then are actually the same that we have now:

Lack of portability to practice in any state
A national credential to provide state regulatory agencies a defined standard for the massage profession
Lack of public recognition and professional respect of massage therapy as an important part of healthcare. (It could be the first response to pain, stress and our ever growing Opiod addiction problems.)
Lack of public awareness campaigns – commercials, advertising (Oprah Magazine)
Protecting the consumer from inappropriate touch
Advancement of the massage profession – what does that even mean?

Their income was drastically reduced when they stopped the National Certification Exam. They do have a Board Certification Exam that is just sitting there (or so it seems to me)… Do health care professionals know what it means? Do employers? Do consumers? NO.

The NCBTMB has been on the brink of financial failure since it released their rights to the national certification exam over to the FSMTB. The FSMTB had to pay the NCBTMB for a year for those rights. They should have held out and requested 5 years of payments since they were in such financial decline. Their past Executive Director who was a financial expert seemed to lack the expertise to hold this organization together which may indicate the severity of financial troubles. They were forced to move out of their office due to lack of rent payments and sold the furniture to stay afloat. Without the national certification exam, the income is down to only CE provider applications.

Also their approved CE classes and teachers have no requirements for being evidenced based and includes many classes on crystals and fairies. The problem is that many state boards require that CE be approved by the NCBTMB and they let them handle the process and approvals. Who is watching the NCBTMB? Where is the money coming from for them to stay afloat?

AMTA is providing financial assistance to the failing NCBTMB. While there is a separate board, we do not know the arrangements and what influence AMTA’s money is having.

Nov 15 2016 – AMTA announces funding for the NCBTMB.

AMTA to Support NCBTMB

AMTA has long supported certification as a vital part of the massage therapy profession and we continue to support its value. The AMTA Board of Directors was approached by the National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) and they have agreed to provide operational and logistical support to the organization to safeguard Board Certification.

NCBTMB will continue as an independent body, as AMTA ensures its long term sustainability through operational and logistical support. As this new collaboration evolves, AMTA and NCBTMB will keep everyone in the profession informed about the process.

Their New Board Certification and specialty certifications are questionable too. Why certify only one school or program and call it ‘Integrative Healthcare” (See More on NCBTMB website). Why can’t anyone trained in ‘integrative healthcare’ take a test and get certified in it???? That’s a whole other blog post…

Rick Rosen in his white paper Continuing Education in the Massage Therapy Field Proposal for an alternative to state and national regulation (Feb 2013) states that:

Of the 45 jurisdictions in the massage therapy field that regulate massage (43 states plus D.C. and Puerto Rico), 33 require continuing education for license renewal. Five states have regulations under development, and seven states have no CE requirements for renewal. Of those 33 states that currently require CE, 13 of them use the existing NCB Approved CE Provider program to determine what constitutes approved CE. 12 more recognize the NCB program in addition to state approval processes and other CE sources. Five states have their own CE approval process and do not recognize the NCB system, and three states have no specific CE approval standards (other than the course being relevant to the licensee’s scope of practice).

So not every state uses the NCBTMB anyways. What is happening in the states that do not have it? Are many clients getting injured or is there more claims on liability insurance from therapists in those states?

Here’s the clincher though as pointed out by Laura Allen in one of her blog posts:

As long as the NCBTMB is written into state statutes and rules, the regulatory boards are forced to blindly go along with whatever NCB does.

Federation of Massage State Boards.

The Federation of Massage State Boards (FSMTB) is a group of our state massage boards. State Massage Boards represent the public and work to protect the public from harm. They do not represent the massage therapists or work for the massage therapists.

When the Federation of Massage State Boards came into the picture and created a licensing exam, the NCBTMB lost it’s status as a licensing exam. In 2014, the Federation also started talking about creating a CE approval program. The way that came about was not very straight forward as explained by Whitney Lowe in his recent article in Massage Magazine: Opinion: New CE Approval Program is a Bad Idea for Many Reasons. The Board itself is not clear on how it came about which is very concerning. (That by the way is how the NCBTMB actually started. It was meant to be an entry exam for AMTA and someone ballooned into a full blown National Certification exam which was never really National in that it would allow for portability. There was also a lot of other controversy about the exam and creation of the NCBTMB exam. )

The state boards themselves will decide if they want to use the FSTMB system and if it will meet their needs. The job of massage boards is to protect the public. The amount of harm done to the public comes more in the way of ethics violations – touching them inappropriately and worse. That problem will not be solved by more expensive technique classes. What can help is requiring clinical supervision/peer supervision to help therapists deal with difficult feelings and situations.

So if the FSTMB wants to get into approving CE classes – wouldn’t that be a big conflict of interest – meaning the individual massage state boards would be influencing CE?

Choosing a CE Class

For many massage therapists the process of choosing a CE class is often choosing the cheapest class closest to home and finding online classes when it is accepted by their massage board. Many conventions/conferences/festivals offer short 2-8 hour classes. What can you really learn in that time frame? Most short classes may be giving an overview of a technique or an introduction to a method. More intensive learning experiences are often limited because of cost and not being offered in their area. Sure some therapists will take their CE more seriously, but we actually really don’t know. We don’t have any statistics on any of this. What CE is most effective and gives the therapists the best information to help them be successful massage therapists?

It is difficult to choose a good CE class because there are NO review sites out there for the approved NCBTMB classes or any of the CE providers/classes. While we all know reviews can be problematic, they also can provide good insights into whether or not this class would be for you. There are so many bad teachers and classes, that are providing misinformation on many topics – insurance billing, massage business practices etc. Who knows what we are getting really in hands on classes?

There are no requirements for teachers of CE classes – anyone… ANYONE can teach them. That’s a problem.

Many of the approved courses are not evidence based and don’t have anything to do with keeping up to date with the latest information. As far as keeping up with the latest techniques, they are all optional. If you are interested in a specific technique, that is fine. But requiring people to take technique classes is useless really.

Ask the tough questions

Does continuing education fill any problem that we are having in the profession?

Does Continuing Education ensure competency of massage therapists?

What harm to the public comes from having massage therapy sessions?

Are technique classes really needed or do we need more training in clinical reasoning?

What problems do we have that need solving? Rick Rosen is also asking in his Whitepaper Continuing Education in the Massage Therapy Field (PDF) (2013) with my emphasis in bold:

Before NCB and FSMTB continue any further down their respective pathways, we must address and get frank answers to these interlocking questions:
1. Should continuing education be mandatory for renewal of state licensure – and is it essential for the ongoing protection of the public?
2. Given the reported inconsistencies in the instructional design and delivery of CE courses, is it even possible for an approval process to provide quality assurance?
3. Does the cost of compliance for CE providers (both in terms of time and money) bring an equal or greater benefit to the massage therapy field, and to the public at large?
4. What kind of regulatory process – if any – is needed; and which organizational entity is best suited to perform this function?

Ralph Stephens on Massage Today is wondering some of the same things:

All of this dog fighting between organizations has obscured the real questions that must be addressed, “Is mandatory CE in the massage therapy field necessary to protect the public?” Studies conducted by the prestigious Pew Research Center show there is no improvement in public safety resulting from mandatory CE requirements in licensed professions.

Another question, “Does the massage therapy field need a formal approval process for CE providers and courses? Is it even possible for an approving agency to promise quality assurance?”

Without the kind of consistent standards found in other professions, it is impossible to build an effective CE approval system in the massage therapy field. Add that to the fact there are no teacher training requirements for CE instructors.

Should CE be monitored by the NCBTMB or the FSTMB???

Both Ralph Stephens and Rick Rosen suggest a National Continuing Education Registry. Rosen updated his position at a later date in a statement Model Regulations for Continuing Education (PDF) in the Massage Therapy Field A Simplified and Streamlined Approach for State Boards recommending that:

state boards craft their own solution based on a common template. Each agency must have a structure that is practical and defensible, andthat is not based upon false assertions or undeliverable promises. The model administrative rules for continuing education presented here focus on two important changes: the use of specific subject matter standards to determine what constitutes”approved continuing education”for license renewal, and the elimination of approval requirements for CE provide

Laura Allen explains in her blog post:

The overall structure of the Registry is similar in ways to the Multiple Listing Service concept in real estate. It will be based on a voluntary participation of CE providers, who agree to conduct their business according to a code of ethics. Like shopping for a house, therapists will have to perform their due diligence to find the courses and providers that meet their learning needs. There are no guarantees, but a provider’s reputation for integrity will be a great asset.

Rick Rosen has a complete explanation of how this would work in his white paper. (PDF)

From what I have gathered so far after researching this for the past few weeks, the National Registry option seems like the best answer to me….

But I still want to get some answers to these questions.

What is the problem that we are trying to solve?
Licensure Portability?
Protecting the Public from harm?
Promoting the Massage profession to get more recognition and respect?
Figure out what if any CE is required to protect the public from harm.
Figure out what CE if any is required to support massage therapists career
Create a specific criteria of required CE to be adopted by all the states. (Do some sort of study like the ELAP or something to determine what CE is needed and what works best)
Study the states that do not require any CE – is there a higher incidence of harm or lack of business/career success?
CO; HI; IN; ME; OH; RI; UT as of 2013 as reported in Rosen’s White Paper.
Study the states that are not using the NCBTMB approved classes. Is there a higher incidence of harm or lack of business/career success?
IL, IA, LA, WA
Figure out a system for monitoring CE teachers/classes. Could the NCBTMB use what they have already and make some big improvements?
Who should be in charge of this? The NCBTMB or the FSMTB? Both? None? One or the other?

Proposed CE Requirements

Also, after researching this for a few weeks and having my own personal challenges with the whole system of CE (having been injured in a class in 1999 to the extent that it affected my health TO THIS DAY…), I would like to propose some alternatives. What is it that could help advance our profession to get the respect it deserves? What we have been doing hasn’t been working. There are more law suits and claims against massage therapists for inappropriate touch than injuries by massage therapists (from what I see – we would need a study on that!)

Are all of our required ethics classes helping that? Will more techniques help that? Not from what I see….but yes we should investigate that.

I do know that one of the main reasons I have survived 28 years in the profession is because I have participated in peer supervision and supervision for over 17 years. I would like to see that be a required part of CE if anything…of course we would need studies to back that up!

Supervision and peer supervision group participation to help students transition from school to practice/job for first 5 years.
Supervision and peer supervision group participation to work with seasoned therapists (after 5 years of working in the profession)
The latest research and science for massage therapists – some sort of specific required information in webinar/ebook with test, that will keep us All up to date on the theories and practice of massage therapy. (Yes we can massage people with cancer. No, there are not any toxins cleared out with massage therapy)

What do you think should happen? Do you understand what is at risk and what is happening? It is time to make your voices heard. Contact the NCBTMB and the FSMTB and let them know what you want. Get involved with your local associations and start going to your Board of Massage Meetings. If you are not at the table, you are what is on the menu/what’s for dinner…

Could CE teachers be put out of business? Would more people take CE if it were not required? (I have a friend that teaches in Japan where massage therapy is a 4 year training program with no CE required. He is in extreme demand!)

Timeline:

NCBTMB creates CE provider approval process

2005 – Federation of Massage State Boards Created.

October 3, 2014 – The Federation of State Massage Therapy Boards (FSMTB) and the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) have worked cooperatively to reach an agreement that the NCBTMB will no longer provide examinations for licensure purposes and will now focus exclusively on delivering quality certification programs. NCBTMB announcement. ( There was once a link to the FSMTB announcement on their website but as of 08/05/2018 they have taken it down. There is a story on Massage Magazine regarding this agreement.)

On Oct. 3, 2014, FSMTB delegates voted to create a continuing education approval program, based on the recommendation of the FSMTB Continuing Education Task Force.

November 3, 2014 – AFMTE recommends consolidation of CE programs.

2014 – The delegate assembly at the FSMTB Annual Meeting officially voted to create a continuing education approval program to meet the needs of the massage therapy regulatory community. Following this directive, the license renewal committee developed a system to register providers, vet courses, and capture course completion data to be housed in the Massage Therapy Licensing Database. Licensee course completion data will be available to all Member Boards of the FSMTB that participate in the MTLD program. All details of the standards, guidelines, and associated policies will be published prior to the program launch. Providers are required to meet these standards to be eligible to offer courses.

The License Renewal Committee has established standards for the delivery of continuing education. These standards were developed by the membership and formally adopted by the FSMTB board of directors.

REGULATORY EDUCATION AND COMPETENCE HUB (REACH) REACH, the learning management system used by the FSMTB to offer educational programs, will house a diverse collection of titles related to regulatory education and public safety

March 1,2014 – AFMTE – Open letter to the massage community protesting the REACH (Proposed CE program of the FSMTB)

March 25, 2016 – NCBTMB and FSMTB release joint statement regarding CE Collaboration:

The National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) and the Federation of State Massage Therapy Boards (FSMTB) announced today the following joint statement:

“NCBTMB and FSMTB are working toward a partnership regarding Continuing Education. We look forward to open dialog and collaboration between the two organizations.”

April 1, 2016, NCBTMB and FSMTB announced a collaboration related to continuing education, but did not offer details about the partnership.

Nov 15 2016 – AMTA announces funding for the NCBTMB.

AMTA to Support NCBTMB

AMTA has long supported certification as a vital part of the massage therapy profession and we continue to support its value. The AMTA Board of Directors was approached by the National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) and they have agreed to provide operational and logistical support to the organization to safeguard Board Certification.

NCBTMB will continue as an independent body, as AMTA ensures its long term sustainability through operational and logistical support. As this new collaboration evolves, AMTA and NCBTMB will keep everyone in the profession informed about the process.

2017 – FSMTB has indicated that member boards have challenges that are not currently being met by the existing NCBTMB Approved Provider Program, so they have continued moving forward with the development of their own CE approval program.

Aug 3, 2018: NCBTMB announcement:

NCBTMB announced the following new Board Certification requirements as of August 3, 2018:

1. Graduate from a NCBTMB Assigned School

2. Passing score on the NCBTMB Board Certification Exam

3. Pass a criminal background check (performed by NCBTMB)

4. Verification of current massage therapy state licensure

5. Agree to uphold NCBTMB’s Code of Ethics and Standards of Practice

NCBTMB removed its previously mandated 750 hours of education and 250 hours of professional, hands-on work experience.

My commentary: This latest move by NCBTMB, takes the profession back 26 years to where they started. So essentially, removing the 750 hours and going back to 500 hours will help the NCBTMB get more members but to what end?

Without a proper board certification this profession is going nowhere….fast.

To top it off, the FSTMB also announced it is creating a CE Registry which if/when it catches on will surely put the NCBTMB out of business.

August 2018. FSTMB announce CE registry.

Following recommendations and input from the massage therapy regulatory community, licensed therapists, educators and professional associations, the member boards of the FSMTB voted to implement a program that provides reliable, unbiased and appropriate vetting of continuing education providers and the courses offered to the consuming public, and to adopt the FSMTB standards for continuing education.

As a result, the CE registry will enter the marketplace in 2018. We look forward to being of service to the regulatory boards, the licensed professionals seeking to maintain competence, and to the providers in the educational community.

Essential reading:

Opinion: New CE Approval Program is a Bad Idea for Many Reasons. Whitney Lowe. Massage Magazine

Model Regulations for Continuing Education (PDF) Jan 2014 Rick Rosen

Model Regulations for Continuing Education (PDF) in the Massage Therapy Field. A Simplified and Streamlined Approach for State Boards. Rick Rosen

New Massage Continuing Education Plan Met with Opposition November 2, 2016 Karen Menehan

NCBTMB financial Statements

Originally published: Published on: Apr 16, 2017 @ 21:01 Updated 08/05/2018

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Follow the Money

March 24, 2018 by Julie Onofrio Leave a Comment

This information has been obtained from the 990 forms that non-profit organizations are required to submit each year to the IRS. I accessed these reports on Guidestar.com on 3/23/2018. I am not an accountant or financial expert of any kind.

The main numbers that I find most interesting are the income from recertification, and approved provider programs:

2016

Program Service Income : $2,015,353
Recertification: $1,001,010
Examination: $281,785
Approved provider program: $226,695

2017

Program Services: $1,509,490
Recertification: $112,145
Examination: $52,620
Approved Provider Program: $61,010

Also, the CEO Steve Kirin, was compensated $154,389 in 2016 and O – (Zero) according to the report.

Laura Allen previously reported on this organization in 2014 on her blog.

During 2007, the revenue of the NCB was at an all-time high of $8,655,003. During 2012, the revenue was down to $4,616,227, a decline of over 4 million dollars in the past five years. If that isn’t the handwriting on the wall that it is past time for the NCBTMB to get out of the entry-level licensing exam business, I don’t know what is. AMTA, AFMTE, and ABMP have all supported the MBLEx as the licensing exam of choice. They just refuse to give it up.

How Long do you think they have?

Then… look at the note I found:

Part VI, Section A, Line 4: The Bylaws were amended in the following ways – An article appointing the American Massage Therapy Association as the sole member- The amended bylaws allow for the secretary to be the only officer – The term of office for Board members was shortened from four years to two.

What does that mean exactly? Who really knows. I do know that the back in 2016, the AMTA announced it would be supporting the NCBTMB financially.

National Certification Board for Therapeutic Massage and Bodywork

2016

Program Service Income : $2,015,353
Recertification: $1,001,010
Examination: $281,785
Approved provider program: $226,695

Investment Income: $31,568

Other Revenue: $188,939

Total: $2,235,860

Salaries: $1,066,871

Steve Kirin, CEO – $154,389

(8) Board of Directors Total Compensation :$43,625

Expenses: $1,066,871

Other expenses: $1,137,8987

Total expenses: $2,204,768
Intellicorp (testing) $161,277

GKG Law : $106,686

Revenue less expenses: $31,092

Total Assets: $1,338,085

Total Liabilities: $222,017

Net assets: $1,117,068

990 Schedule O Supplemental Information:

Part VI, Section A, Line 4: The Bylaws were amended in the following ways – An article appointing the American Massage Therapy Association as the sole member- The amended bylaws allow for the secretary to be the only officer – The term of office for Board members was shortened from four years to two.

2017

Program Services: $1,509,490
Recertification: $112,145
Approved Provider Program: $61,010
Examination: $52,620

Investment Income: $156.00

Other Revenue: $1,540,764

Salaries, other compensation, benefits: $897,206

Steve Kirin, CEO -$0

$0 to Board Members

Other expenses: $1,031,686

Total Expenses: $1,928,892

Revenue less expenses: $-388,128

Statement of Functional Expenses:

Compensation for officers, directors: $29,740

Other Salaries and Wages: $82,286

Exam expenses- $77,662

License fees $12,667

Certificant benefits – $8,905

Dues and subscriptions – $5,004

Other expenses – $1,010

Total Functional expenses: $324,285

Reconciliation of Net assets

Total revenue – $231,489

Total expenses – $324,285

Revenue less expenses -$92,766

Net Assets – $787,907

Net unrealized gains on investments – $24,138

Net assests or fund balances $719,249