“It would take me the entire hour to get rid of all the trigger points along your spine,” the massage therapist tells me during a recent visit to a Toronto clinic. I mumble surprise into the face pillow and agree she should focus on the knots in my shoulders. As she kneads, she casually suggests I should see her colleagues for physiotherapy — which can include personal training — and chiropractic treatment.
She hands me a coupon for 60 per cent off at the end of the massage for chiropractic services. After all, I have a great benefits plan, she says, and if I spend an amount that’s equivalent to maximizing the coverage for three paramedical services on my plan, the clinic will throw in $100 of free chiropractic care. It’s quite the sales effort in the name of patient education and it’s surprising to see a clinician doling out financial tips in the middle of a treatment.
Of course, such interactions aren’t necessarily unusual. Many paramedical clinics “are being run by hybrid craftspeople/businesspeople,” says Yafa Sakkejha, general manager at the Beneplan Co-operative in Toronto.
Read: What is driving the rising demand for paramedical services?
When the co-operative was at one point looking to buy a clinic, prospective sellers — who were all health-care practitioners — kept emphasizing the potential profits from employee benefits and auto insurance. “So we ended up not purchasing any of these clinics, because there’s such a disconnect between what employers want — which is, ‘Really, I just want you to take care of the health of my people so they can go to work’ — as opposed to these clinics that are just focused on profit maximization,” says Sakkejha.
So at a time of increased pressure on employee benefits plans, do such approaches to services like massage therapy suggest it’s time to reconsider plan design to put more emphasis on medically necessary treatments? Or, putting aside the service provider’s obvious interest in maximizing profits, does massage have other wellness and health promotion benefits for employees that employers may want to support? Or is massage simply a perk Canadians have come to expect that companies would do well to provide as a way of keeping their staff happy and engaged?
“The goal in providing coverage for massage therapy is to address or correct a medical condition that an employee or plan member has,” says Shelly Selinger, senior manager of health claims and managed health programs at the Co-operators Group Ltd. in Regina. Those conditions, she adds, should tie to physical illness or injury.
Read: Editorial: Massage issue reflects tough choices for plan sponsors
Others view the issue differently. “I don’t believe that ‘medically necessary’ is probably the best way to put it,” says Andrew Lewarne, executive director and chief executive officer of the Registered Massage Therapists’ Association of Ontario.
“I think it should be clinically or therapeutically indicated massage therapy because we are preventative, not just an intervention based on an acute presentation.”
Many employers, in fact, are open to the prevention message. The 2016 Sanofi Canada health-care survey, for example, found employers were more willing to invest in programs that could prevent claims from happening in the future (43 per cent) than in those that could reduce current ones (18 per cent). Another 40 per cent would invest in programs that target both current and future claims.
Read: Is massage therapy a worthwhile benefit?
“It’s important that plan sponsors step back and articulate the prevention of future claims as an objective, and then strategically look at that in the context of current plan design,” Lisa Callaghan, assistant vice-president of product and group benefits at Manulife Financial, said in the report. “Is there a willingness to shift current investments? This can be a difficult exercise to go through, but it’s necessary if plan sponsors want to prevent future claims.”
Millennials and their perks
There are plenty of views on how to best approach benefits coverage for massage. Joan Weir, director of health and dental policy at the Canadian Life and Health Insurance Association in Toronto, says massage coverage should “prevent injury, support wellness, ensure members are healthy and productive at work, take care of any workplace issues that could put stresses on backs and repetitive stress injuries and those sorts of things.”
Then there’s the attitude that massage is an employee perk, which is more common among millennials, says Brian Lindenberg, senior partner and health and benefits leader at Mercer in Calgary. “If you think — ‘I’m young and somewhat immortal, how am I going to get value from a benefit program?’ — well, it’s in areas such as massage therapy. It makes me feel good. I can control when I go and how much I spend.”
Read: Employee benefit plan design: 5 reasons for change
The Sanofi survey found nearly half (47 per cent) of those aged 18 to 34 use massage to relax, compared to 33 per cent who get it to treat a particular condition or injury. The cohort of those aged 55 to 64 years old is much more likely to use massage to treat conditions (58 per cent) than for stress (31 per cent).
Lewarne points out patients’ nonclinical language may cause confusion around the goals of massage. Employees may say they’re getting a massage “because it makes [them] feel better. And so that translates as, ‘That’s a perk.’ But remember, that’s the patient’s language. That’s not the clinician’s language. So when somebody comes in to see me and says, ‘I’m tight, I’m this, I’m this, I’m this, I’m this,’ my response is to clinically assess them . . . and to provide preventative health care.”
Among the areas where it can be effective, Lewarne says massage is particularly good for issues such as chronic headaches and peripheral nerve entrapment. But even if massage doesn’t prevent future claims — the Sanofi survey noted the data linking massage and stress relief is unclear — some employers are happy to provide generous benefits for it, says Lindenberg. “Some would say: ‘If it makes my employees feel they’re getting more value from their benefit program, great. Why put limitations around that? Currently, it’s not a huge cost, so why be too concerned about that?’”
Read: CLHIA concerned about benefit plan impact of proposed change to chiropractor services
But considering massage therapy as a perk moves the treatment away from being an insurer’s responsibility, says Selinger, since policies should kick in “when you have some event you didn’t plan for and needed massage treatment, which would relate to a physical injury.”
And as Lindenberg points out, the attitudes about paramedical services like massage are quite different in countries such as the United States. In that country, he notes, health coverage “is primarily focused on acute care” for services such as physician and hospital visits. “The current health-care commitment is significant, particularly related to cost, so there is no burning need or desire to expand on this commitment by providing access to these other services.”
The December binge
Of course, employee massage binges can add up. Weir has seen “a fairly dramatic increase” in paramedical claims recently, with massage claims growing the most rapidly of the various services last year. Some of the increase may reflect end-of-year messaging from the wellness industry that encourages plan members to use their benefits before they expire on Dec. 31.
“I think almost all health-care professionals out there who can bill through private insurance probably give some kind of message at the end of the year,” says Weir. “We see it in the dental area as well: ‘Your annual benefits are coming to a close. Use them.’ And they do definitely drive people to come back in to take advantage.”
Read: Balancing wants versus needs as plan sponsors seek to ensure sustainability and effectiveness
Whether motivated by splashy spa ads or not, many plan members spend more on paramedical treatments at the end of the year. “We see four or five times as many claims submitted in January than in any other part of the year,” says Sakkejha. 
Some employers do respond to the ballooning costs. In 2007, as the economy was starting to turn, one of Beneplan’s clients determined it would have to lay off staff if it didn’t cut its benefits costs. But its unionized workforce demanded the company maintain its $500 coverage for massage therapy.
“We found in the U.S., [health maintenance organizations] actually require pre-approval for all paramedicals,” says Sakkejha, noting they typically will require a physician’s diagnosis before approving coverage.
“We had to do that for our one client because there was nothing else they could do. They were in a really extreme situation. But it worked so well. Their claims actually dropped by two-thirds,” she adds, noting the company was able to increase coverage to $1,000 for employees with serious conditions.
While the Co-operators doesn’t routinely ask plan members for documentation of physical injuries, Selinger says it reserves the right to do so if it suspects fraud or abuse. Some employers, she adds, are considering dividing paramedical coverage between treatments focused on well-being — such as massage — and those focused on addressing acute injuries — such as physiotherapy — and could set different annual limits for each pot.
Read: Catastrophic illness coverage needed to address outdated benefit plans
“I think it’s certainly an option [plan sponsors] are willing to entertain,” says Selinger. “They want more information about it. They want to understand what carriers can do to address this focus towards overall well-being and associated mental health.”
Time-wasting prescriptions
According to Weir, insurers work to ensure appropriate coverage by only reimbursing plan members in Ontario, British Columbia, New Brunswick and Newfoundland who visit registered massage therapists. In other jurisdictions that don’t regulate massage therapists, provincial associations share information on their governance and ethics with insurers, which in turn decide whether they want to accept claims for those organizations’ members on a carrier-by-carrier basis.
Insurers are also keen to make sure treatments are medically necessary. “Certainly, when you see receipts coming in from spas indicating couples’ massage and other sorts of probably recreational types of activities, it’s easier to spot those than any other,” says Weir. “So we do rely upon massage therapists to make sure they are seeing [plan members] for therapeutic reasons and properly document that in some kind of chart or receipt . . ..”
Despite the concern, few insurers require patients to provide doctors’ notes. “We were finding that it was just unnecessary administration,” says Selinger. “Physicians will quite readily provide a referral for a massage service, so in that way, it was implementing an unnecessary step. It also created some unnecessary burden to provincial plans.”
Read: What’s keeping employers up at night?
Other options for reducing massage costs include reducing annual limits, combining all paramedical coverage into one pot and cancelling the plan altogether. But in the last two to three years, according to Selinger, fewer than 10 per cent of the Co-operators’ clients have taken any steps to reduce their coverage.
“More and more plan sponsors, as they start to invest in workplace wellness [and] see that as something they want to embrace, we tell them, ‘If you’re going to go down that road, let us make sure that your benefit plans support that in an appropriate way,’” says Lindenberg. “As you get more employers that are more in tune with that, I’d say they would be less focused on massage therapy just being for medically necessary services. They’d be more comfortable with having that opening up a bit.”
Employees at Boeing Canada, for example, receive 80 per cent coverage for massage to a maximum of $600 each year. “I think it’s for both,” says Nancy Mackenzie, a Boeing benefits specialist in Winnipeg, in reference to the benefits of massage for physical and mental health. “We do have a lot of people who have very physical jobs, so I think that to use massage therapy would probably help physically for them to be able to withstand the pressure of doing their jobs.”
The company has seen an increase in claims over the past five years but it isn’t looking to reduce costs, says Mackenzie. “We just assume that people can seek out that kind of help if they need.”
Sara Tatelman is an associate editor at Benefits Canada.
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