www.bensonhenryinstitute.org www.oshercenter.org

Mind Body Medicine: Emerging Science and Economics

Darshan Mehta, MD MPH Medical Director

Benson-Henry Institute for Mind Body Medicine Massachusetts General Hospital

Director of Education

Osher Center for Integrative Medicine Brigham & Women’s Hospital

Assistant Professor of Medicine, Harvard Medical School

dmehta@partners.org

Disclosure Statement

• Darshan Mehta has served as an educational consultant for the Academy of Integrative Health & Medicine

Case Study

• 35 y/o M with no significant PMH who presents for a routine physical examination

• FH: Father died of lymphoma; Mother with long-standing HTN

• SH: Recently married. Works in IT industry, requiring significant amount of travel. Denies tobacco, alcohol, or illicit drug use. Due to travel, he tends to eat a lot of fast food

Case Study (Continued) • Physical exam: BMI – 31; BP – 135/90; otherwise, no

remarkable findings • Labs: HDL – 41; LDL – 148; TG – 150; FPG - 120 • Assessment: Hypertension; ?Metabolic syndrome • Plan: Patient is adamant that he does not want

medication. In addition, to diet and exercise counseling, he wants to share with you something that he read:

Make a fist

How many of you were holding your breath?

Really Tight!

Global Disease Burden

Non-communicable diseases are the most important global health challenge of the 21st century in terms of disease

burden and mortality

(Narayan, Ali and Koplan, 2010)

Between 60-90% of healthcare

visits are related to stress J Chronic Dis. 1964 Oct;17:959-70

Stress Response and Development of Allostatic Load

McEwen B. N Engl J Med 1998;338:171-179

History of Mind Body Medicine in the United States

• Moving from Beatles to physiology

• Dialogues between contemplative practitioners and scientists

• Applying the scientific method to subjective phenomena

Relaxation Response • Initially described by Dr. Herbert

Benson in mid-1970s • Conditions by which it is evoked

– The repetition of a word, sound, prayer, thought, phrase or muscular activity

– The passive return to the repetition when other thoughts intrude

• Breaks the train of everyday thought

• Benefits seen when performed 15-20 minutes 1-2x/day

Relaxation Response

• State which is elicited by many mind-body practices, including meditation, tai chi, and yoga

• Conceptually the opposite of the stress response • Accompanied by physiological changes include:

– Decreased heart rate – Decreased blood pressure – Decreased respiratory rate – Increased exhaled nitric oxide

Eliciting the Relaxation Response Activates Specific Brain Areas

The right BA 9/10 superior frontal and middle gyri and sulci and right anterior insula are significantly thicker in meditators (Lazar, 2005)

Eliciting the Relaxation Response May Increase Cortical Thickness

What Neuroscience has Revealed

Ricard M et al. 2014. Sci Am. 311:38-45. Hasenkamp W et al. NeuroImage. 2012. 59:750–760

Dusek JA et al. 2008. PLoS ONE 3:e2576

…Apoptosis

…Inflammation

…Stress Response

Eliciting the Relaxation Response Impacts…

Mind Body Practice and Functional Genomics

• Enhanced expression of genes associated with – energy metabolism and

mitochondrial function – insulin secretion – telomere maintenance

• Reduced expression of genes linked to – inflammatory response – stress-related pathways

• Potential mechanisms for positive health effects

Bhasin MK et al. 2013. PLoS ONE 8:e62817 Niles H et al. Ochsner J. 2014. 14:681-95 Bower & Irwin. Brain Behav Immun. 2016. 51:1-11.

Yoga and Diabetes – Mechanistic Pathway

E. de G R Hansen and K. E. Innes. International Journal of Yoga Therapy, vol. 23, no. 2, pp. 71–83, 2013.

Overall Health

Pharmaceuticals Surgery

Self-care

A New Paradigm of Health

Health economics

• Economics: the science that deals with the production, distribution, and consumption of goods and services, or the material welfare of humankind.

• Health Economics: the branch of economics concerned with the production and consumption of health and healthcare – Health care systems – The burden of disease – Health behaviors

THE STATE OF OUR HEALTHCARE ECONOMY

Population trends

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Perc

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Year

Healthy weight (BMI from 18.5 to 24.9) 2

Overweight (includes obesity; BMI greater than or equal to 25.0)

Obesity (BMI greater than or equal to 30.0)

Wider Older

US age pyramid becomes a rectangle

More Diverse

0

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Trends in Ethnicity

White

Black

Hispanic

Asian

Indian

Other

US physique becomes round US becomes a pie chart

2015

White

Black

Hispanic

Asian

Indian

Other

1990

White

Black

Hispanic

Asian

Indian

Other

STRESS AND HEALTHCARE UTILIZATION

Disease Burden on Health system - allopathic

24

Complex, High-Cost,

Catastrophic

Full-onset Chronic; Rising

risk

Early chronic diseases; Acute but not catastrophic

illnesses

Healthy, well majority

• The top 1% of patients

• Those in the top 5% account for 50% of costs

Complex patients need: • Care plans • Self-management teaching • Advanced care planning • Strict attention to transitions of care • Social support systems • Addressing of concomitant mental

health/substance use issues • Optimized medication regimens

Physician office visits

• Number of visits: 1.0 billion • Number of visits per 100 persons: 332.2 • Percent of visits made to primary care physicians: 55.5% National Ambulatory Medical Care Survey 2010

Stress and Healthcare Utilization

• Poor psychological and physiologic resilience in response to stress drives a great deal of health care utilization

• > 80% of patients show evidence of lack of resiliency and psychological stress

• Stress related illnesses are 3rd highest cause of healthcare expenditures > $80 billion/year (2012) – After heart disease 1st and cancer 2nd (meps.ahrq.gov) each of which carries its own substantial stress burden – Allostatic load disorders

Stress and Primary care

• > 90% of people suffering from stress-related problems seek help through primary care and tend to be high healthcare utilizers - can comprise as much as 60-90% of physicians' case loads

- ~ 200 visits per 100 persons/year

• Common physical manifestations of stress - headaches, back pain, insomnia, gastroesophageal reflux disease, irritable

bowel, chest discomfort, etc. - among the most frequent reasons people seek care.

• In addition, primary care providers also simultaneously contend with many other stressors

Stress and Surgical care

• In patients, stress influences – Wound healing process – Use of pain medication – Susceptibility to infection

• In staff, stress influences – Burnout

• Increased length of stay • Cost • Morbidity and mortality

• Absenteeism • Presenteeism • Error

Stress and the surgical patient • Surgery creates complex response in patients, involving

– Inflammatory system – Nervous system – Endocrine system

• Some potential markers - IL-1a, IL-8, TGF a

• These are same systems mediated by the mind-body system • Low levels of pre-surgery fitness increase the risk of

complications and recovery duration – Improving patient pre-operative fitness as prevention*

Ditmyer M., Topp R., Pifer M., Prehabilitation in preparation for orthopaedic surgery, Orthop Nurs, 21 (2002), pp. 43–51 Topp R., Ditmyer M., King K., Doherty K., Hornyak J.,The effect of bed rest and potential of prehabilitation on patients in the intensive care unit,AACN Clin Issues, 13 (2002), pp. 263–276 Carli F., Charlebois P., Stein B.L., Feldman L., Zavorsky G., Kim D.J., et al.,Randomized clinical trial of prehabilitation in colorectal surgery, Br J Surg, 97 (2010), pp. 1187–1197

*

Sources of Costs

• In hospital costs • Re-admission costs • Medical error costs

• N.B., Aggregate surgical expenditures are expected to grow from $572 billion in 2005 (4.6% of US GDP) to $912 billion (2005 dollars) in the year 2025 (7.3% of US GDP).

*

*

In-Hospital costs

Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID), 2003–2011, and early State data, 2012

Avg LOS Avg Cost/Stay Avg Cost/day

Surgery 5.5 $21,200 $3855

Medical 4.6 $8,500 $1848

Maternal/ neonatal 3.2 $4,300 $1344

Setting Cost/min

ICU 1.75-4.5

Ward 1.2-1.5

OR 60-130

*

*

Stress and readmission • For patients with ACS

– High stress was associated with a 3-fold increased risk of 30-day readmission (HR = 3.21, 95% CI = 1.13, 9.10)

– Post hospital syndrome

• For post-CABG – Preoperative stress and post operative depression – -> 2 fold increase in readmissions with 6 mos

*

Donald Edmondson, Philip Green, Siqin Ye, Hadi J. Halazun, Karina W. Davidson Psychological Stress and 30-Day All-Cause Hospital Readmission in Acute Coronary Syndrome Patients: An Observational Cohort Study,PLoS One. 2014; 9(3): e91477.

Tully, P.J., Baker, R.A., Turnbull, D. et al. The role of depression and anxiety symptoms in hospital readmissions after cardiac surgery J Behav Med (2008) 31: 281. doi:10.1007/s10865-008-9153-8

**

**

*

Cost of readmission

Percent readmitted within 30 days for most common 30 surgical procedures = 9.75% (2%-22.8%) For less common procedures, e.g., transplant, this can be higher

Readmission Payment Adjustment Amount ~= Base * (Observed/Expected) readmission - Base

Weiss AJ (Truven Health Analytics), Elixhauser A (AHRQ), Steiner C (AHRQ). Readmissions to U.S. Hospitals by Procedure, 2010. HCUP Statistical Brief #154. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb154.pdf.

*

*

The cost of healthcare system errors • Medical errors cost the United States $19.5 billion (IOM 2008) • Nurse burnout -> decrease in quality of care • Major medical errors reported by surgeons are strongly related to a

surgeon’s degree of burnout and their mental QOL • Adverse events per hospitalization = 49/100 • 187,000 deaths per year and 6.1 million injuries

– Social cost ranges from $393 - $958 Billion – Equivalent to 18 percent and 45 percent of total US health care spending

(2006) • Avg. 10 yrs. loss of life, 10 million work-days of lost productivity

* **

*** † ‡

Poghosyan L, Clarke SP, Finlayson M, Aiken LH, Nurse Burnout and Quality of Care: Cross-National Investigation in Six Countries, Res Nurs Health. 2010 Aug; 33(4): 288–298

*

Burnout and Medical Errors Among American Surgeons, Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J, Freischlag J, Ann Surg. 2010 Jun;251(6):995-1000. doi: 10.1097/SLA.0b013e3181bfdab3.

**

Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A, James BC, Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured, Health Aff April 2011 30:581-589

***

Goodman JC, Villarreal P, Jones B, The Social Cost Of Adverse Medical Events, And What We Can Do About It, Health Aff April 2011 30:590-595; doi:10.1377/hlthaff.2010.1256 The Economics of Health Care Quality and Medical Errors, Charles Andel, Stephen L. Davidow, Mark Hollander, and David A. Moreno Journal of Health Care Finance, Vol. 39, No. 1, Fall 2012

†

‡

REFERRAL PATTERNS

Treating Patients with Mind Body Medicine

• Reduces frequency of medical symptoms – Pain, fatigue, gastrointestinal symptoms, etc.

• Decreases severity of psychiatric symptoms – Anxiety, interpersonal sensitivity, depression, etc.

• Increases health-promoting lifestyles – Spiritual growth, health responsibility and stress management

Samuelson et al., 2010

Cardiac Rehabilitation with Mind Body Component

COST-EFFECTIVENESS AND RETURN ON INVESTMENT

Cost-effectiveness and Return on investment

Incremental Cost-effectiveness Ratio:

Return on Investment:

Rate of Return:

Cost1 – Cost0

Effect1 – Effect0

Gain from Investment – Cost of investment

Cost of investment

Return on Investment

*time

*r = (1 + R)1/t - 1

Cost-Effectiveness Plane

Bad ?

? Good

+ Cost

- Cost

+ Effect - Effect

Center = base-case Always a comparison!

Tai Chi Better analyses done to date mostly looking at Tai chi as fall prevention tool

– Medical management of psychotropics and group tai

chi were the least-costly, most-effective options – Frick KD, Kung JY, Parrish JM, Narrett MJ., Evaluating the cost-effectiveness of

fall prevention programs that reduce fall-related hip fractures in older adults., J Am Geriatr Soc. 2010 Jan;58(1):136-41. doi: 10.1111/j.1532-5415.2009.02575.x.

– Tai Ji Quan cost an average of $175 less for each additional fall prevented and produced a substantial improvement in QALY gained at a lower cost.

– Li F, Harmer P, Economic Evaluation of a Tai Ji Quan Intervention to Reduce Falls in People With Parkinson Disease, Oregon, 2008-2011, Prev Chronic Dis. 2015 Jul 30;12:E120. doi: 10.5888/pcd12.140413.

Bad ?

? Good

+ C

+ E - E

- C

Yoga Better studies to date have looked at Yoga as a treatment for back pain • Yoga vs exercise therapy vs advice

– 159 pts 3 groups, yoga, standard exercise program, self-care – Treatment cost = 150 Euro – ICER < 11500 Euro/QALY – Aboagye E, Karlsson ML, Hagberg J, Jensen I. Cost-effectiveness of early interventions

for non-specific low back pain: a randomized controlled study investigating medical yoga, exercise therapy and self-care advice. J Rehabil Med. 2015 Feb;47(2):167-73. doi: 10.2340/16501977-1910.

• Multicenter trial for Yoga for chronic Low back pain – Yoga intervention yields an incremental cost-effectiveness ratio of £13,606 per QALY – Chuang LH, Soares MO, Tilbrook H, Cox H, Hewitt CE, Aplin J, Semlyen A, Trewhela A,

Watt I, Torgerson DJ. A pragmatic multicentered randomized controlled trial of yoga for chronic low back pain: economic evaluation. Spine (Phila Pa 1976). 2012 Aug 15;37(18):1593-601.

• Aetna experience – Kusnick C1, Kraftsow G, Hilliker M. Building bridges for yoga therapy research: the Aetna, Inc.

mind-body pilot study on chronic and high stress. Int J Yoga Therap. 2012;(22):91-2.

Bad ?

? Good

+ C

+ E - E

- C

MBSR/CT A broader range of topics have been looked at though the better ones have looked at stress related illness, cardiac disease and mental health • Assess cost-effectiveness of mindfulness-based cognitive

therapy (MBCT) for Medically Unexplained Symptoms – MBCT participants (n=55) had lower hospital costs and higher mental health care costs

than patients who received Usual Care (n=41). – Costs for MBCT were €6269, and €5617 for EUC – QALYs were 0.674 for MBCT and 0.663 for EUC. – MBCT was on average more effective and more costly than EUC, resulting in an ICER of

€56,637 per QALY gained • van Ravesteijn H1, Grutters J, olde Hartman T, Lucassen P, Bor H, van Weel C, van der Wilt GJ,

Speckens A., Mindfulness-based cognitive therapy for patients with medically unexplained symptoms: a cost-effectiveness study. ,J Psychosom Res. 2013 Mar;74(3):197-205. doi: 10.1016/j.jpsychores.2013.01.001. Epub 2013 Jan 29.

• MBSR for healthcare utilization – Royce William Knight , Jim Bean, Andrew S. Wilton, Elizabeth Lin, Cost-Effectiveness of

the Mindfulness-Based Stress Reduction Methodology, Mindfulness 2015 1: 1-8 • Estimates $250 reduction in healthcare utilization for 1 yr, costs return to baseline at year 2 except

for lab testing

Bad ?

? Good

+ C

+ E - E

- C

Problem statement

• Non-communicable diseases and stress-related illnesses are very expensive

• Mind-body medicine programs like the SMART-3RP have been shown to modify physiology and affect disease trajectory

• What is their effect on the economics of the healthcare system?

Stress Management and Resiliency Training Program

• Resiliency can be built through a three-tiered process – ongoing practice of techniques which elicit the relaxation

response (e.g., meditation, yoga) – building awareness of stress and its negative effects – promoting social connectedness and healthy lifestyle behaviors

• 8-week multimodal program which incorporates elements of modern psychotherapy with wisdom traditions through mind body practices

Methods • Propensity-score matched, retrospective, controlled cohort,

pre/post intervention database analysis • Resource utilization of all patients participating in RR

programs at MGH Benson-Henry Institute from 1/12/2006 to 7/1/2014, along with that of controls

• Measure: Healthcare resource utilization, 1-year before and after RR intervention

• Unit: Billable encounter and associated services – Face-to-face contact between a patient and provider whose

services are covered under an insurance provider.

Methods (cont’d.)

• Subgroup question • “Were patients referred to BHI high utilizers whose utilization

simply regressed to the mean over time?” • High-utilizer subgroup analysis

– Compared top ~10% of the control group utilizers with a matched subset of the intervention group

– Creating two groups with the same initial median utilization rate, maximum utilization rate and variance

Measuring the Economic Impact of Mind Body Interventions

Stahl JE, Dossett ML, LaJoie AS, Denninger JW, Mehta DH, et al. (2015) Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization. PLoS ONE 10(10): e0140212. doi:10.1371/journal.pone.0140212

Time 7/2014 1/2006

Billable encounters

Pt e

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ory

Intervention

pn

p5 32 p4 40 p3 64 p2 18

24 p1

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45

18

26

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Intervention Group

Billable encounters

Billable encounters

Patie

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tient

s #

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Post

Time 7/2014 1/2006

Billable encounters

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24 p1

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64

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Control Group

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Billable encounters

Patie

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tient

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Pre

Post

Results: Overall

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Utilization: Total

Total INT

Total CTL

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Utilization: High Utilizers

HU INT

HU CTL

Across all functional categories: Clinical, Imaging, Laboratory, Procedures i.e., What was done

Patterns of Healthcare Utilization with Mind Body Interventions

Stahl JE, Dossett ML, LaJoie AS, Denninger JW, Mehta DH, et al. (2015) Relaxation Response and Resiliency Training and Its Effect on Healthcare Resource Utilization. PLoS ONE 10(10): e0140212. doi:10.1371/journal.pone.0140212

0 1 2 3 4 5

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Total High Utilizers

General Medicine

Specialty Care

Emergency Care

Hospitalizations

Category: Site of service

i.e., Where was done

Mind Body Medicine and Healthcare Utilization • 43% reduction in billable encounters across all functional

categories • Amongst high utilizers, there was average relative utilization

reduction of: – 18.3% in functional categories – 24.7% reduction across clinical site categories

• Clinical encounters were 21.4% lower in the intervention group compared to controls

• Cost savings from reduced emergency room visits alone in the treatment group is on the order of $2360/patient/year.

• Expected range of cost savings of $640 - $25,500/patient/year

Present Reality

Systems Dynamics Argument

Vicious vs. Virtuous Cycles

Increased Demand

Over utilization

Burnout

Decreased access

Increased stress

Decreased Health

Stable demand

Stable utilization

Optimal function

Increased access

Increased Wellness Reduced

stress

Vicious cycle

Virtuous cycle

Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital

• Independent thematic center at MGH • Clinical practice, research and

education • Study ways to combat stress and

enhance resiliency • Focus on mind body practices in the

healthcare system: • Meditation • Yoga • Tai chi

Many Hurdles Left to Clear • Funding the science that needs to be

done • Proving clinical efficacy in specific

conditions • Determining specific biological

mechanisms • Demonstrating cost effectiveness • Overcoming bias, convincing skeptics • Creating culture change within medicine • Broadening acceptability and

accessibility in the community • Using evidence to convince payers and

governments to cover these interventions

Key Points

• Mind body medicine has a important role in primary and specialty care practice

• It has an epigenetic, physiologic basis that supports the health outcomes that have been measured

• It is easy to deliver in primary care settings, and can be cost-effective • Initial studies suggest that they may stave off the epidemic of

healthcare provider burnout

Next Best Steps

• Mind Body Medicine approaches should be considered as a part of a comprehensive treatment plan for medical conditions seen in the primary care setting

• These approaches will allow patients to be engaged in their healthcare in meaningful and clinically-relevant ways