Evidence-Informed Massage Therapy

Last month, I wrote about the ten Essential Health Benefits (EHB) listed in the Affordable Care Act. These benefits are designed to restructure the way insurance works – new policies (including the benchmark plan and the plans in the exchanges) will all have to cover these ten criteria. Some of the benefits are broad, and I wrote about how a few of them could be interpreted to include massage services. Sounds like pretty good news!

But now I have something even better to share: In a project funded by AMTA-WA, massage therapists and researchers joined together to present a document outlining how massage therapy specifically relates to three of the EHB listed in the ACA. The document includes descriptions and citations of everything you need to convince someone on the efficacy of massage.

Check it out:
Evidenced-Informed Massage Therapy: The Research Supporting Massage Therapy is an Integral Component in the Affordable Care Act’s Essential Health Benefits [PDF]

Contents of the document:
EHB (5): Mental health and substance use disorder services, including behavioral health treatment
Anxiety & Depression
Sexual Abuse Recovery & Post-Traumatic Stress

EHB (7): Rehabilitative and habilitative services and devices
Scars
Athletic Injury and Post-exercise Recovery
Post-Operative Recovery

EHB (9): Preventive and wellness services and chronic disease management
Headache
Neck and Shoulder Pain
Low Back Pain
Fibromyalgia
Cancer
Temporomandibular Joint Disorder (TMJ)
Osteoarthritis
Emerging Evidence with High Clinical Value [other areas of wellness]

Download a copy of the PDF and share it with friends and colleagues!

Research in Washington State

This is part of a larger article I wrote several years ago on the Affordable Care Act. Read the whole thing here.

Beginning in 1996, the state of Washington mandated that private insurance companies must cover every category of health care provider given that the provider is giving treatment for a basic service that he or she is licensed for. In short, that means CAM providers in the state of Washington are covered under private insurance policies in the same way that conventional providers are covered. A visit to an acupuncturist, for example, would be available as readily as a visit to a medical doctor.

From the mandate:

“(1) Every health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 1996, shall:
(a) Permit every category of health care provider to provide health services or care for conditions included in the basic health plan services to the extent that:
(i) The provision of such health services or care is within the health care providers’ permitted scope of practice; and
(ii) The providers agree to abide by standards related to:
(A) Provision, utilization review, and cost containment of health services;
(B) Management and administrative procedures; and
(C) Provision of cost-effective and clinically efficacious health services.” [source]

This wouldn’t mean that everyone in Washington would start getting CAM treatments, but it would mean that those who did utilize CAM weren’t just those who could afford to pay out-of-pocket. Recently, researchers took a look at two years worth of claims to see if patients who did and did not use CAM treatments differed in total medical expenses. Read the full analysis here.

Because most CAM research relies on self-reported data (ie, whether the patient feels better after a treatment), these studies often have an inherent bias. Whether or not CAM treatments provide tangible evidence of being effective, they often lead to a general sense of well-being. While the interaction between mental and physical health cannot be denied, this was not what researchers wanted to study. Rather, this study took a “cost-minimization approach” in order to find out whether CAM users differed from nonusers in their medical costs.

In an analysis of insurance expenditures for matched groups of CAM users and CAM nonusers, it was found that CAM users had significantly lower overall expenditures. Specifically, while they did have a slightly higher expenditure for outpatient visits (including massage appointments, chiropractic adjustments, etc, which the other group – by definition – did not utilize), inpatient expenditures and other expenditures (imaging, lab work, etc) were significantly lower. It was found that CAM users were less likely to be hospitalized, less likely to get a hysterectomy within one year of diagnosis, and more likely to have some type of imaging done and done early. Although having more imaging done should seemingly be more expensive, the imaging was typically of a less expensive variety. And because the imaging was done early, it had the benefit of being a preventative measure.

Researchers predicted that, given the findings, CAM users would save an enormous amount of money:

“Given the expected $356 lower expenditures for each CAM user, we would expect an overall $9.4 million lower expenditure in a group of 26,466 CAM patients with these medical conditions compared to a similar group of CAM nonusers of equal size.”

For some analyses, subjects were divided into three levels of “disease burden”, which created groups based on their expected resource use. The low disease burden group were generally healthy individuals, high disease burden group were generally unhealthy individuals, and the medium disease burden group was in between these two. When divided in this way, CAM users in the low and medium groups had higher overall expenditures than CAM nonusers – they had more outpatient visits to CAM providers, and neither group had many inpatient visits or labs. But in the high disease burden group, CAM users had significantly lower expenditures than nonusers, which more than made up for the higher expenses of the healthier groups. CAM was used for preventative care by the high risk group, just like in the other groups, but it was also the less expensive way to treat acute problems.

What should we take away from this study? First of all, it means that insurance companies are currently doing things exactly backwards. When they limit CAM coverage to those who are already healthy or those who can afford to pay extra, they lose money. Insurance companies should be begging their less healthy clients to utilize CAM treatments for both acute issues and preventative care.

We’ll be hearing from some LMTs in Washington later on to see how these laws affect the providers on a day-to-day level. I’ll also be interviewing Deborah Senn, JD, the architect of the Washington law, who is now working with IHPC for the implementation of Section 2706 of the Affordable Care Act.

Massage Research

Very often I run into the argument that massage shouldn’t be covered by insurance because too many people view massage as a luxury. There’s no medical benefit to massage, they say; people just get massages because they feel good. Why would insurance pay for that?

If that’s the strongest argument they can come up with, then the problem isn’t with massage. Rather, the problem is with perception.

Massage therapy is already used regularly for PIP (personal injury protection) insurance claims. Motor vehicle accidents, workers compensation claims; every state (except, due a recent change, Florida) allows LMTs to participate in and bill insurance for these types of injuries. Whiplash? Go get a massage. Slipped and fell at work? Here, have a massage. And yet somehow, when it comes to health insurance footing the bill, massage therapy is suddenly belittled and overlooked, and insurers couldn’t possibly see a reason why it should be covered.

But I’ve got a whole host of reasons here.

Massage is useful for specific age groups, from infants (1, 2) and pediatrics (1, 2) to the elderly and those in hospice care. Massage has been found over and over to be beneficial for cancer patients, most notably for pain relief and decreased anxiety. Massage has been shown to help both those with eating disorders and those with fibromyalgia.

Getting a massage immediately after a strenuous workout has been found to reduce muscle fatigue and increase muscle tone. Massage helps with headaches, both tension headaches and migraines, along with TMJ and associated pain.

And perhaps the biggest, most obvious finding is that massage helps to reduce muscle pain.

And what about stress relief? Just “feeling good” has so many benefits on its own, including better job performance and increased mental well-being. No one can claim that a relaxation massages serves no medical purpose when there’s a whole field of psychology dedicated exclusively to the benefits of happiness.

We shouldn’t have to accept the belief that massage isn’t medically useful just because that’s the general consensus. We have so much evidence that suggests otherwise.

The next time someone asks you why massage should be a covered part of the healthcare, flip the tables around on them. Why shouldn’t it be covered? Getting massages is an integral part of self-care. And taking care of yourself is not a luxury. It’s a necessity.