THE ECONOMICS OF INTEGRATIVE HEALTH

Transcription

1 THE ECONOMICS OF INTEGRATIVE HEALTH DR. CJ RHOADS, M.ED. D.ED. PRESENTED AT THE INAUGURAL INTERNATIONAL MEDICAL TAI CHI AND QIGONG ASSOCIATION MEETING OCTOBER 9, 2018

2 RESEARCH PROJECTS Already Published Currently Being Worked On Planned for the Future

3 PUBLISHED ARTICLES Prior-to-exam: What Activities Enhance Performance? in Journal of Instructional Pedagogies (with T. Healey) Mechanism of Pain Relief through Tai Chi and Qigong in Journal of Pain and Relief Qigong in Cancer Care: A Systematic Review And Construct Analysis Of Effective Qigong Therapy in Supportive Care in Cancer (with P.J. Klein and R. Schneider) Asklepios research group logo

4 PUBLISHED BOOKS Telehealth Research Report for Center for Rural PA (multi-year research project) Telehealth in Rural Hospitals (CRC Press, Taylor & Francis Group) o Economic impact of telehealth o Impact depended on use o On Committee to provide input to US Budget Office o Disenchanted with US budget approach

5 CURRENT PROJECT Estimating the Economic Impact of Integrative Healthcare with R. Jahnke, Joe Baumgarden, Kathy Levac, and perhaps Patricia Herman and Fred Esposto Targeting American Journal of Public Health

6 PLANNED FOR FUTURE Economic Impact of Pain Reducing Options Looking for new target Targeted Journal of Health Economics (but was rejected) Refining the Economic Impact Estimate of Integrative Healthcare targeting Health Economics Methods for Double-Blind Behavioral Practice Research in Tai Chi and Qigong targeting Advances in Health Sciences Education

7 HEALTH ECONOMICS DIFFERENT Based upon decision-making factors that are complex. Economics, but doesn t really follow economic rules o Quality of Life factors o Complexity of cost factors o Public versus private costs o Agency Theory influence

8 DECISION MAKING FACTORS GOVERNING HEALTHCARE Level of Pain Level of Fear Trust in Provider o o o Society trusts physicians more than other providers Medical Standard of Care (SOC) is Limited Drugs and Surgery often only approved medical response Notice what s missing? COST. Cost is often not part of the decision because of third-party coverage: insurance. Level of Fear Level of Pain/Impact Trust in Provider

9 PUBLIC HEALTH Costs are major concern Quality of Life not so much Perceived healthcare provided important rather than actual results of healthcare End of Life issues No one wants to admit futility, but if drugs and surgery are only acceptable standard of care, costs are unacceptably high for unacceptably low quality of life.

10 OBSTACLES AND INCONVENIENCE Often counter-intuitive. Simple answers disbelieved. Simple, not easy. More inconvenient, more expensive more trusted. 33% of all treatments influenced by placebo effect. Expectations are short term, not long term. Long term quality of life issues not addressed.

11 PAIN REDUCING OPTIONS ECONOMIC IMPACT ORIGINALLY STARTED LAST SUMMER PRESENTED AT INTERNATIONAL CONGRESS OF INTEGRATIVE MEDICINE AND HEALTH IN BALTIMORE IN MAY, 2018 LOOKING TO START WORKING ON IT AGAIN WOULD LIKE INPUT FOR IMPROVING IT

12 PAIN REDUCING OPTIONS IDENTIFIED Spinal Cord Stimulation Intrathecal Pump Biofeedback/Meditation Therapy Mind/Body Physical Practices CBT/ACT Therapies Physical/Behavioral Therapy Nutrition Therapy Anesthetic Injection: Celiac Plexus Block or Stellate Ganglion Block Radiofrequency Ablation Deep Brain Stimulation Motor Cortex Stimulation Surgical ligament release, removal, or adjustment Surgical Release and/or relocation of nerve Surgical Fusion Benign Neglect Cold/Heat Over The Counter Analgesics Topical Analgesic Folk Remedies Prescription NSAIDS Muscle Relaxants Adjuvant Analgesics Massage Therapy Chiropractic Adjustments TENS nerve stimulator Acupuncture, Acupressure Epidural Steroid Injection Trigger Point Botox injection Prescription Opioids

13 INVASIVENESS RANK ORDER Invasive Category Approach Area of Body in Pain Rank 1 None Benign Neglect Any 2 Folk Cold/Heat Any 3 Folk Over The Counter Analgesics Any 4 Folk Topical Analgesic Any 5 Folk Folk Remedies Any 6 Standard Prescription NSAIDS Any 7 Standard Prescription Opioids Any 8 Standard Muscle Relaxants back, neck, tension headaches, fibromyalgia. 9 Standard Adjuvant Analgesics Any 10 Integrative Massage Therapy back, neck, tension headaches, appendages 11 Physical Physical/Behavioral Therapy back, neck, tension headaches, appendages 12 Integrative Nutrition Therapy Any 13 Integrative Biofeedback/Meditation Therapy Any 14 Integrative Chiropractic Adjustments back, neck, tension headaches 15 Integrative Mind/Body Physical Practices Any 16 Integrative CBT/ACT Therapies Any 17 Physical TENS nerve stimulator back, neck, appendages 18 Integrative Acupuncture, Acupressure Any 19 Standard Epidural Steroid Injection neck, arm, back, leg 20 Standard Trigger Point Botox injection back, neck, appendages, tension headaches, myofascial pain fibromyalgia 21 Surgical Anesthetic Injection: Celiac Plexus Block or abdominal pain or neck Stellate Ganglion Block 22 Surgical Radiofrequency Ablation neck, arm, back, leg 23 Surgical Spinal Cord Stimulation back and limbs, failed back syndrome, reflex sympathetic dystrophy, arachnoiditis, and peripheral neuropathy 24 Surgical Intrathecal Pump back and limbs, failed back syndrome, reflex sympathetic dystrophy, arachnoiditis, and peripheral neuropathy 25 Surgical Deep Brain Stimulation Cancer pain, phantom limb pain 26 Surgical Motor Cortex Stimulation Post stroke pain, trigeminal neuralgia 27 Surgical Surgical ligament release, removal, or Carpel Tunnel, knee surgery adjustment 28 Surgical Surgical Release and/or relocation of nerve carpal tunnel, cubital tunnel, tarsal tunnel, peroneal knee, thoracic outlet Based on literature Surgical more Invasive than others Some approaches are specific to area of body 29 Surgical Surgical Fusion Back

14 IMPACT TO LIFESTYLE RANK ORDER Approach Impact on lifestyle Typical Pain Relief Benign Neglect 1. No Impact Hrs. Cold/Heat 2. Minor temporary impact Hrs. Over The Counter Analgesics 2. Minor temporary impact Hrs. Topical Analgesic 2. Minor temporary impact Hrs. Folk Remedies 2. Minor temporary impact Days Prescription NSAIDS 2. Minor temporary impact Hrs. Muscle Relaxants 2. Minor temporary impact Hrs. Adjuvant Analgesics 2. Minor temporary impact Hrs. Massage Therapy 2. Minor temporary impact Days Chiropractic Adjustments 2. Minor temporary impact Days TENS nerve stimulator 2. Minor temporary impact Days Acupuncture, Acupressure 2. Minor temporary impact Days Epidural Steroid Injection 2. Minor temporary impact Weeks Trigger Point Botox injection 2. Minor temporary impact Weeks Prescription Opioids 3. Major ongoing negative impact Hrs. Spinal Cord Stimulation 3. Major ongoing negative impact Months Intrathecal Pump 3. Major ongoing negative impact Ongoing Biofeedback/Meditation Therapy 3. Major ongoing positive impact Days Mind/Body Physical Practices 3. Major ongoing positive impact Ongoing CBT/ACT Therapies 3. Major ongoing positive impact Ongoing Physical/Behavioral Therapy 3. Major temporary positive impact Ongoing Nutrition Therapy 4. Major ongoing positive impact Ongoing Anesthetic Injection: Celiac Plexus Block or Stellate 5. Major One-time impact Months Ganglion Block Radiofrequency Ablation 5. Major One-time impact Months Deep Brain Stimulation 5. Major One-time impact Months Motor Cortex Stimulation 5. Major One-time impact Months Surgical ligament release, removal, or adjustment 5. Major One-time impact Months Surgical Release and/or relocation of nerve 5. Major One-time impact Years Surgical Fusion 5. Major One-time impact Years

15 ECONOMIC IMPACT RANK ORDER Approach Rank Order of Costs (5 year) Impact of Potential Side Effects Benign Neglect 1 None Cold/Heat 2 None Folk Remedies 3 Small Over The Counter Analgesics 4 Small Topical Analgesic 5 Small Trigger Point Botox injection 6 Medium Epidural Steroid Injection 7 Medium Biofeedback/Meditation Therapy 8 Positive Nutrition Therapy 9 Positive Prescription NSAIDS 10 Medium Muscle Relaxants 11 Medium Spinal Cord Stimulation 12 High Anesthetic Injection: Celiac Plexus Block or Stellate Ganglion Block 13 High Radiofrequency Ablation 14 High Adjuvant Analgesics 15 Medium Intrathecal Pump 16 High CBT/ACT Therapies 17 Positive Surgical ligament release, removal, or adjustment 18 Medium Motor Cortex Stimulation 19 High Surgical Release and/or relocation of nerve 20 High Chiropractic Adjustments 21 Medium Mind/Body Physical Practices 22 Positive Prescription Opioids 23 High Deep Brain Stimulation 24 High Physical/Behavioral Therapy 25 Positive Acupuncture, Acupressure 26 Small Surgical Fusion 27 High Massage Therapy 28 Positive TENS nerve stimulator 29 Small

16 FINAL PRIORITY RANK ORDER Final Ranking Category Approach PMA Priority Index 1 None Benign Neglect 6 2 Folk Cold/Heat 10 3 Integrative Biofeedback/Meditation Therapy 23 4 Folk Over The Counter Analgesics 24 5 Integrative Nutrition Therapy 27 6 Folk Folk Remedies 30 7 Folk Topical Analgesic 30 8 Integrative Mind/Body Physical Practices 33 9 Integrative CBT/ACT Therapies Integrative Massage Therapy Physical Physical/Behavioral Therapy Standard Prescription NSAIDS Standard Muscle Relaxants Standard Adjuvant Analgesics Standard Trigger Point Botox injection Standard Epidural Steroid Injection Integrative Acupuncture, Acupressure Physical TENS nerve stimulator Integrative Chiropractic Adjustments Standard Prescription Opioids Surgical Anesthetic Injection Surgical Surgical ligament release, removal, or adjustment Surgical Spinal Cord Stimulation Surgical Radiofrequency Ablation Surgical Intrathecal Pump Surgical Motor Cortex Stimulation Surgical Deep Brain Stimulation Surgical Surgical Release and/or relocation of nerve Surgical Surgical Fusion 305

17 TELEHEALTH IN RURAL PENNSYLVANIA The current & long term impact of Telehealth, and a study of the relationship between Policy, Telehealth Use, and Healthcare Costs GRANT FROM CENTER FOR RURAL PENNSYLVANIA JANUARY 2012 MARCH 2013 PUBLISHED IN 2014 (FULL REPORT) & 2016 (SCHOLARLY PUBLISHER

18 PROBLEMS WITH EXISTING HEALTHCARE SYSTEM Rising Costs & Wasteful Processes Rising Inequities & Lack of Access Multi-layer Payment System Lack of Standards Treatment based (not prevention based) 18

19 TELEHEALTH A SOLUTION? Provide an overview of telehealth Assess economic impact of telehealth Describe current implementation of telehealth in PA Identify obstacles to wider implementation 19

20 WHAT IS TELEHEALTH? Telemedicine Telepsychiatry Telecare mhealth EHR 20

21 TELEHEALTH INCLUDES... Live Videoconferencing Live Romote Monitoring Recorded clinical or educational video Recorded remote monitoring Diagnostic scans & intepretation Electronic Health Records 21

22 RESEARCH TEAM Multi-phase intense search of the literature Open survey healthcare professionals (n=190) Controlled survey of PA physicians (n=323) Interviews of experts and hospitals (n=169) 22

23 VOLATILITY Political Aspects of Obamacare (Patient Protection & Affordable Care Act) Recent Technology Quantum Leap in Mobile & Video Recession & Financial Impact 23

24 FINDINGS Overview Current Implementation Obstacles Economic Impact 24

25 350 OVERVIEW FUTURE TELEHEALTH USE Estimates of Future Telehealth Use Unknown % Urban Rural % 40% % 47% 14% Increase Do Not Know Remain the Same Decrease Total N = 513, Controlled N = 323 and Widely Disbursed N = 190. Percent represents % of those who answered that question (i.e. 24% who said "Increase" were from Rural counties). 23% 63% 15% 25

26 350 OVERVIEW FUTURE TELEHEALTH USE Estimates of Future Telehealth Use Unknown % Urban Rural % 40% % 47% 14% Increase Do Not Know Remain the Same Decrease Total N = 513, Controlled N = 323 and Widely Disbursed N = 190. Percent represents % of those who answered that question (i.e. 24% who said "Increase" were from Rural counties). 23% 63% 15% 26

27 Radiology remote diagnosis 16% Electronic Family Health Medicine Records Emergency Medicine Live followup Videoconferencing care 24% Psychiatry Internal Medicine Store Infectious & Forward Disease Images provider education 15% Pathology Web Discussion 15% Oncology 15% patient education 20% 13% Other 11% Physical Rehabilitation General Practice Diagnostic Mental consultation Decision Health Support 21% Recorded Other Video10% 6% portable health records 21% Dermatology Live Monitoring Preventative Medicine other 4% 4% Store & Forward Monitoring CURRENT IMPLEMENTATION 15% 13% 11% 10% 9% 14% Neurology 11% 8% Neuro-Emergencies Integrative Medicine 10% 8% 8% 23% 16% 8% Types Telehealth of Telehealth Uses Other Specialties using Telehealth 37% 34% 31% 45% 39% 32% 9% 22% 14% 15% 19% 20% 18% 13% 85% 25% 37% 85% Rural Urban Controlled Sample Physician Physician Survey Survey N = 341. N = Rural 239. N Rural = 89, Urban N = 62, N = Urban 252. Percent N = 177. represents Percent represents % of N (i.e. 16% % of of N (i.e. respondents 85% of from respondents Rural Counties from used Rural telehealth Counties for used remote Electronic diagnosis HEalth ). Records). 6% 7% 9% 14% 19% 6% 6% 17% 28% 32% 30% 6% 6% 39% 100% 31% 25% 69% Rural Urban Unknown Total N = 239. Rural N = 64, Urban N = 159, Unknown N = 16. Percents represent % of N choosing that specialty (i.e. 45% of rural respondents chose Radiology as one of the specialties using telehealth in their facility). 27

28 Legislative/Definition Restrictions No Priv Ins Reimbursement Reimbursement Restrictions No Gov Ins Reimbursement Too Expensive Use of Telehealth to mitigate shortage Poor Process & Procedure Use of Telehealth for Prevention Lack Time Issues with Data Standards Inaccessable Broadband Poor Training Legal Issues Unresolved Staff Resist Poorer Quality than F2F Poor Project Planning Too New Fear of Fraud 20% 20% 15% 12% 12% 9% 34% 33% 30% Use of Telehealth to Lower costs 24% Use of Telehealth for seniors Use of Telehealth to equalize access Use of Telehealth for Chronic Illness 52% 51% 49% 40% 14% 18% 17% 29% 16% 1% 21% 14% 27% 39% 41% 30% 33% 26% 26% OBSTACLES Themes In Interviews (Recurring Issues) Obstacles to Telehealth Growth 6.5% 3.3% 0.3% 2.3% 2.0% 1.3% 1.3% 0.7% 2.0% 2.0% 2.0% 3.6% 4.6% 6.2% 2.6% 1.3% 1.6% 45% 58% 53% 28% 30% 1.0% 1.0% 1.3% 1.3% 1.3% 1.3% 53% 72% 65% 51% 10.5% 9.8% 9.5% 40% 7.8% Rural 44% 7.5% Urban 5.9% Unknown 5.6% Large percent in box represents "rank" of importance for issue based upon Frequency/Total # of Statements. Smaller percentage Other represents 6% 16% 9% the percentage of influence that constituency had within that particular issue compared to all of the constituencies for all of the issues. I.E. Out of all the issues, interviewees from the Total community N = 378. Rural influenced N = 86, Urban the ranking N = 249, of Reimbursement Unknown N = 43. Restrictions Percents represent 6.5%. % of N choosing that obstacle 2.0% 6.2% 2.9% 4.6% 2.9% 3.3% (i.e. 52% of Rural respondents chose No Private Insurance Reimbursement). 0.7% 0.0% 7.8% 6.9% 5.9% 5.2% 21.9% 21.6% Community Gov Provider Vendor Rank 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 28

29 ECONOMIC IMPACT PA 1-20 YEARS PA Healthcare Cost Impact of Various Telehealth Implementations Base Eliminate Admin Waste $324 $316 $350 Wellness & Prevention Integrate EHR $274 $300 Remote Monitoring $243 $250 Combination of All of the Above $114 $92 $148 $154 $144 $113 $118 $110 $95 $89 $94 $84 $130 $109 $200 $150 $100 Billions $50 Year One Year Five Yr Twenty $0 29

30 ECONOMIC IMPACT PER PERSON 30,000 25,000 Average Per Person Cost for Different Telehealth Program Impact Scenarios Per Person Cost Yr Twenty Per Person Cost Yr Five Per person Cost Yr One 20,000 15,000 10,000 5,000 - Base Eliminate Administrative Waste Wellness & Prevention Integrated EHR Video & Remote Monitoring Telehealth Combination All of the Changes 30

31 ECONOMIC IMPACT - % CONTRIBUTION Contribution of Each Toward Combined Savings - Per Person Average Wellness & Prevention, $15,325 Eliminate Waste, $6,385 Telehealth (EHR, Video, Remote Montoring), $4,000 31

32 ECONOMIC IMPACT - CONCLUSIONS Current uses of telehealth are too expensive, too difficult, and too restricted to be of benefit. More value from telehealth wellness & prevention programs currently not funded at all. More value from online medical education. 32

33 CURRENT RESEARCH ON ECONOMICS OF INTEGRATIVE HEALTH PRACTICES ORIGINALLY MET ROGER JAHNKE AT INTEGRATIVE MEDICINE SYMPOSIUM BROAD-BRUSH TRILLION DOLLARS SAVINGS IF INTEGRATIVE MEDICINE WAS INCLUDED IN SOC (But that was SWAG) Decided to work together to put some meat on the bones Started with same model as Telehealth

34 LOOKING FOR INPUT Asked others to join in time Model used in telehealth good start? Difficulty combining impacts PA Healthcare Cost Impact of Various Telehealth Base Implementations $324 Eliminate Admin Waste $316 Wellness & Prevention $274 Integrate EHR Remote Monitoring $243 Combination of All of the Above $148 $154 $144 $113 $130 $114 $118 $110 $109 $92 $95 $89 $94 $84 Year One Year Five Yr Twenty $350 $300 $250 $200 $150 $100 $50 $0 Billions Difficulty in separating actual savings from future savings

35 DISCUSSION How to improve the pain reducing economics study? Thoughts on approach to economic impact of integrative medicine as standard of care?