Public health care systems face criticism when they spend money on treatments that don’t work. With ageing populations and the rising cost of treatments, there’s more and more scrutiny of what these programs pay for. One of the most effective ways that insurance programs can reduce the use of a health service or treatment is to simply stop paying for it. But this is relatively uncommon, because once a benefit’s in place, there tends to be a lot of resistance to change – even if the move was wrongheaded to begin with. That’s one of the (many) reasons this blog has been critical of permitting the licensing of alternative-to-health providers like homeopaths and naturopaths. Legislation gives the alternative medicine a veneer of legitimacy (scientific or otherwise), and this legislative alchemy is the first step towards insurance coverage.
When public insurance doesn’t pay, private insurance may step in. And private insurance programs, from my observation, tend to be less evidence-based than public programs. They’re often offered as a benefit to employees, and so the occasional massage may be seen as a nice perk, even though it may not be medically necessary. Australia has a comprehensive public healthcare system which is supplemented by private insurance to cover the cost of treatments and service that are not publicly funded. In 2012 the Australian government announced a review of “natural” treatments covered by these private insurance plans to determine if these therapies were effective, safe, and provided good value for money. While you might wonder why a government would care about what private insurance covers, it’s because the Australian government offers a rebate on insurance premiums, effectively subsidizing their cost. The review sought to determine if a variety of treatment were backed by good scientific evidence and deserved tax subsidies. The answer may not surprise you.
The Review of the Australian Government Rebate on Natural Therapies for Private Health Insurance
In 2015, the Australian government completed a review of natural products covered by private health insurance plans. The authors looked for direct evidence of efficacy, focusing on systematic reviews and randomized controlled trials (for which there was little evidence.) The review evaluated the following treatments:
- Alexander technique, a form of physical therapy with elements of mindfulness, was not supported by much evidence beyond short-term back pain.
- Aromatherapy, the use of essential oils with therapeutic intent, had no convincing evidence of effectiveness for any purpose.
- Bowen therapy, a form of massage, had insufficient evidence to make any conclusions about safety or efficacy.
- Buteyko is a Russian breathing technique claimed to be effective for asthma and other respiratory disorders, but with a lack of objective efficacy.
- Feldenkrais is a gentle form of physical therapy lacking good evidence of efficacy.
- Herbalism/western herbalism (Chinese and Ayurvedic medicine were excluded from the review) encompasses hundreds (thousands) of what are effectively impure, non-standardized drugs. There was no data on the overall efficacy identified.
- Homeopathy is an elaborate placebo system where sugar pills are felt to offer medicinal effects. There was no evidence found to suggest homeopathy was effective for any condition.
- Iridology is the study of irises based on the belief that patterns can help diagnose disease. There is a lack of evidence for the practice, for any condition.
- Kinesiology, or more properly “applied” kinesiology, is a pseudoscientific combination of chiropractic, acupuncture, and biomechanics. Unlike the science of kinesiology, “applied” kinesiology has no evidence to support its use.
- Massage or manual therapies can encompass a variety of physical treatments. This is another difficult-to-evaluate field, and there’s a lack of good evidence for many of the conditions treated with massage.
- Naturopathy is an alternative medicine practice still based on the idea of vitalism that encompasses many of the therapies on this list, but also conventional therapies. The overall evidence for naturopathic approaches is weak.
- Pilates is an exercise practice based on strengthening the “core” muscles. While it’s very popular there is little evidence in place to support claims of benefit, with the possible exception of low back pain.
- Reflexology is the practice of applying pressure to different parts of the soles of the feet – effectively a form of massage, with the intent of treating other organs in the body. There’s no evidence to show any objective health benefits.
- Rolfing is form of physical therapy with elements of energy medicine and massage. There’s a lack of evidence evaluating Rolfing and demonstrating its effectiveness.
- Shiatsu is a combination of acupressure and massage intended to open your “energy flows”. There’s a lack of evidence showing it’s effective for any condition.
- Tai chi is a slow martial art intended to balance your chi or “life force”. Despite the extensive evidence, the quality of evidence to support efficacy is low. It was felt to be safe, however.
- Yoga can encompass strengthening, mobilization, flexibility and meditation. There was weak evidence found for yoga helping forms of depression, but insufficient evidence for most conditions.
As I discussed earlier, the review didn’t consider plausibility in its review, which was a huge oversight. Practices like homeopathy and iridology are pure pseudoscience, while therapies like Pilates, yoga and tai chi are forms of exercise which have far more potential to offer some therapeutic benefits. The authors concluded, however, that the lack of evidence signaled that these treatments could not fairly be considered “evidence based”.
The end of insurance subsidies
Not surprisingly, based on the report, the Australian government has now removed coverage for all 17 therapies studied in the initial review. This move is part of an overall strategy to reduce the cost of private insurance for consumers, and boosting coverage for services like mental health. Not surprisingly, organizations like the Australian Homeopathic Association are not impressed. What this means is that while people can still choose to access these therapies, they cannot be offered benefits under these private insurance programs. Notably, not on the list are chiropractic, acupuncture and reiki, none of which were included in the initial review – it’s not clear to me what their current status is under these programs.
While Australian government should be commended for acting on the expert advice it received, it’s worth noting that the committee, had they considered plausibility, might have arrived at slightly different conclusions about some of these interventions. Ultimately, however, it’s fair to ask if any of these modalities deserve tax subsidies, which was the overall point of this work. As I noted earlier, cutting entitlements is difficult, and Australia’s decision to end these subsidies, on the basis of a lack of evidence, will hopefully trigger similar reviews in other countries.