The Study Question
Massage therapy is well-known for improving both physiological and psychological symptoms across multiple types of cancer and other terminal illnesses. Yet, little is known about the extent to which U.S. hospices employ massage therapists or the role they play as part of an interdisciplinary care team at end of life.
This article describes the results of a national survey that was conducted in 2009 and published in June 2015. While interdisciplinary care is a foundation of the hospice philosophy and a key component of high-quality hospice care, complementary and integrative health care practitioners such as massage therapists are not a required component of the hospice interdisciplinary team under the Medicare Hospice Benefit. In addition, because Medicare reimburses hospices on a per diem basis, hospices cannot separately bill Medicare for the services of massage or other integrative therapists.
Specific aims of the survey included determining the extent to which hospices nationwide employ massage and other integrative therapists, as well as estimating the association between the employment of therapists and hospice characteristics such as nonprofit or for-profit status, size, whether the hospice is part of a chain, proportion of at-home hospice care and the geographic region.
The Study Methods
A total of 914 hospices from the 2006 and 2008 Medicare Provider of Services lists were randomly selected to participate. Researchers then sent an introductory email to hospice medical directors inviting participation, and a follow-up email containing a link to the web-based survey. Hospice medical directors were asked to have the survey completed by the individual at their hospice with the most knowledge about the survey questions.
The survey used a cross-sectional design, comparing hospice characteristics to the number of full-time equivalent (FTE) massage therapists employed. Nonparametric tests such as chi-square were used to determine the degree of association between hospice characteristics and the extent to which massage and other integrative therapists were employed, either part-time or full-time.
Of the 914 hospices randomly selected for the survey, 208 were excluded because they were no longer providing hospice care or had closed their facility at the time of the survey. Of the remaining 706 hospices that were eligible to respond, 591 completed the survey, a response rate of 84 percent.
Less than one-third of respondents (169 or 29 percent) reported having hired an integrative practitioner, with massage therapist being the most frequently hired. Twenty-one percent of total respondents (125 of 591) and 74 percent of those who hired any integrative practitioner (125 of 169) reported hiring a massage therapist.
Hospices that employed a massage therapist had significantly higher odds of being larger and nonprofit, and therapist employment also varied by region, extent of reported market share concern and years since hospice certification.
The average number of full-time equivalent employees of a hospice with 100 or more patients per day was 2.5, compared with 1.3 for hospices with 50–99 patients per day, 0.8 for hospices with 20–49 patients per day and 0.7 for hospices with 20 or fewer patients per day. Hospices that reported having concerns about their market were less likely to have hired an integrative practitioner. Those in the South Atlantic (2.77 FTE) and Mountain Pacific (1.66 FTE) regions were more likely to have hired an integrative practitioner, compared to the New England/Mid-Atlantic (1.43 FTE), North Central (1.28 FTE) or South Central (1.21 FTE) regions.
Limitations of the Study
This study has a number of limitations. As is common in surveys, data are based on self-report, and were not independently verified. While the total response rate was high, for-profit hospices were less likely to have responded than nonprofit ones, so the result that 29 percent of hospices employ some type of integrative therapist may be an overestimate.
The survey also did not ask about the provision of services, only whether integrative therapists were employed. Strangely, the survey did not ask if licensed massage therapists attended interdisciplinary team meetings, so the extent of their inclusion as team members cannot be determined. Finally, while the survey was published in 2015, the data was collected from 2007–2008, so it is possible that these numbers may have declined or increased in the interim.
Implications for Evidence-Informed Practice
It seems odd, given the documented benefits of massage therapy for symptom management, especially pain and anxiety, and the hospice emphasis on interdisciplinary care and quality of life, that more hospices do not employ massage therapists.
Cost is a likely factor, in spite of the evidence (Herman, Craig, and Caspi, 2005) that suggests massage may be cost-effective through avoiding or saving additional costs of care.
Massage therapists wishing to approach hospices for employment might want to stress the potential cost-savings or cost-avoidance benefits of massage therapy, as well as evidence regarding improvement in quality of life for patients and their caregivers, and reducing the severity of symptoms such as pain and anxiety.