Letters to the Editor: Alternative views on paramedical coverage

— Jennifer Paterson, editor, Benefits Canada

Read: Editorial: Hands off my massage benefits! 

Group benefits plan design is a worthwhile topic, but I feel that your column missed an important opportunity to address the actual imbalance in modern day insurance plans: the worrying shift away from protecting the most vulnerable in the name of cutting costs.

Though massage therapy is important and there may be down-the-road benefits for otherwise healthy individuals, there has been little or no policing of these benefits for fear that it will upset plan members who feel they are paying into their plan and getting nothing out of it. But this approach ignores the very purpose of insurance: to protect members from catastrophic loss.

Cost containment initiatives have been hurting chronically ill and physically disabled plan members for years and we in the industry have not done enough to stand up for them. In the last decade, our industry has created obstacles and time-consuming processes to help keep plans financially sustainable — lengthy prior authorization prescription drug approval processes for rare diseases that no one would pretend to have; added paperwork for life-saving medical devices like continuous glucose monitors; or lifetime maximums on medical supplies for conditions with no cure.

Read: Rising cost of drugs, benefits plans top priorities for employers: survey

You ask for balance in group benefits and I agree that an all-or-nothing cut to paramedical practitioner coverage is also not the solution. But we must first address the gross imbalance in coverage. For example, hearing aids have been stubbornly capped at a mid-1980s maximum of $300 per five years. Even at 100 per cent co-insurance, the plan ends up covering less than 30 per cent of the actual cost of even basic models on the market. Meanwhile, most plans will pay 100 per cent of the cost of a $90 massage — no questions asked.

While a healthy person may feel the pinch of a cut to their paramedical coverage, they are less likely to have any future financial consequence. However, workers who need medical supports like hearing aids, wheelchairs or high-cost, rare medications are more likely to face barriers that may reduce their ability to earn a living or pursue a higher level of their career.

We would step up a fundraiser for a co-worker whose daughter has been diagnosed with cancer,  recognizing that she will likely need to take time away from work, will be under more stress and her family may struggle financially through the treatments. So why aren’t we willing to give up full reimbursement for a massage to ensure her child’s drugs are covered through our workplace plan?

The other day, I was working with a member to help complete the paperwork to get his child’s costly medication paid through his group plan. He said to me, “I wish insurance companies understood what it feels like to have to go through all of this.” To tell the truth, I wish we did too.

— A service representative from a national carrier who wishes to remain anonymous

Read: Private drug plan claims, cost per claimant on the rise, finds new research

I generally agree in principle with your reflections. However, 30 years of claims audits have revealed a growing abuse of paramedical services — and particularly massage therapy. When you see couples and sometimes a full family getting massage therapy on a Sunday morning in a high-class ski resort, you can only have doubts on their medical necessity, even for preventive purposes. And what about massage while waiting to board your plane at the airport?

By no means can paramedical costs now represent double the drug costs, as I have seen on many plans I have audited recently, when they represented less than 50 per cent of drug costs only a few years ago. There is a limit on wellness!

— Marcel Poitras, retired benefits consultant

You make some good points. And taken in isolation you are right on in many aspects. The problem is that we see a huge amount of fraud in paramedical services and medical equipment  — just ask the Toronto Transit Commission and Baycrest Health Sciences. When we see as much as a quarter billion dollars in fraud in York region alone, it’s easy to see why employers have to make cuts to sustain plans.

Personally, I have seen a client’s employee (and family) take $15,000 in paramedical visits in one year. When audited, he said he paid cash for it all so couldn’t show proof of payment. The fraud squad was involved, but the employer was hit for this amount, which could have paid for a lot of legitimate drug or dental treatment.

Read: TTC fraud update: More than 220 employees fired or have resigned, retired

Read: Toronto hospital dismisses 150 staff for alleged benefits fraud

I am a user of [registered massage therapy] services, but won’t argue the science (or lack thereof) as to any evidence of long-term positives. In the end, employers do have to make choices as costs increase and cutting massage over life-saving drugs is one that they are often faced with.

— Dave Patriarche, president of Mainstay Insurance Brokerage Inc.