THE ECONOMICS OF INTEGRATIVE HEALTHDR. CJ RHOADS, M.ED. D.ED.

PRESENTED AT THE INAUGURAL INTERNATIONAL MEDICAL TAI CHI AND QIGONG ASSOCIATION MEETING

OCTOBER 9, 2018

RESEARCH PROJECTS

Already Published

Currently Being Worked On

Planned for the Future

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 ReliefQigong 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

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 telehealtho Impact depended on useo On Committee to provide input to US Budget Office o Disenchanted with US budget approach

CURRENT PROJECT

Estimating the Economic Impact of Integrative Healthcarewith R. Jahnke, Joe Baumgarden, Kathy Levac, and perhaps Patricia Herman and Fred EspostoTargeting American Journal of Public Health

PLANNED FOR FUTURE Economic Impact of Pain Reducing Options

Looking for new targetTargeted 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

HEALTH ECONOMICS DIFFERENT

Based upon decision-making factors that are complex.

Economics, but doesn’t really follow economic ruleso Quality of Life factorso Complexity of cost factorso Public versus private costso Agency Theory influence

DECISION MAKING FACTORS GOVERNING HEALTHCARE Level of Pain

Level of Fear

Trust in Providero Society trusts physicians more than

other providerso Medical Standard of Care (SOC) is

Limitedo Drugs and Surgery often only

approved medical responseTrust in Provider

Level of Fear

Level of Pain/Impact

Notice what’s missing? COST. Cost is often not part of the decision because of third-party coverage: insurance.

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.

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.

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

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

INVASIVENESS RANK ORDER

Based on literature

Surgical more Invasive than others

Some approaches are specific to area of body

Invasive Rank

Category Approach Area of Body in Pain

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 Stellate Ganglion Block

abdominal pain or neck

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

adjustment Carpel Tunnel, knee surgery

28 Surgical Surgical Release and/or relocation of nerve carpal tunnel, cubital tunnel, tarsal tunnel, peroneal knee, thoracic outlet

29 Surgical Surgical Fusion Back

IMPACT TO LIFESTYLE RANK ORDERApproach 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 Ganglion Block

5. Major One-time impact Months

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

ECONOMIC IMPACT RANK ORDERApproach 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

FINAL PRIORITY RANK ORDERFinal 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 40 10 Integrative Massage Therapy 40 11 Physical Physical/Behavioral Therapy 42 12 Standard Prescription NSAIDS 68 13 Standard Muscle Relaxants 80 14 Standard Adjuvant Analgesics 104 15 Standard Trigger Point Botox injection 116 16 Standard Epidural Steroid Injection 116 17 Integrative Acupuncture, Acupressure 138 18 Physical TENS nerve stimulator 144 19 Integrative Chiropractic Adjustments 152 20 Standard Prescription Opioids 155 21 Surgical Anesthetic Injection 190 22 Surgical Surgical ligament release, removal, or adjustment 200 23 Surgical Spinal Cord Stimulation 205 24 Surgical Radiofrequency Ablation 205 25 Surgical Intrathecal Pump 235 26 Surgical Motor Cortex Stimulation 250 27 Surgical Deep Brain Stimulation 265 28 Surgical Surgical Release and/or relocation of nerve 270 29 Surgical Surgical Fusion 305

GRANT FROM CENTER FOR RURAL PENNSYLVANIA

JANUARY 2012 – MARCH 2013

PUBLISHED IN 2014 (FULL REPORT)

& 2016 (SCHOLARLY PUBLISHER

TELEHEALTH IN RURAL PENNSYLVANIAThe current & long term impact of Telehealth, and a study of the relationship between Policy, Telehealth Use, and Healthcare Costs

PROBLEMS WITH EXISTING HEALTHCARE SYSTEM

Rising Costs & Wasteful ProcessesRising Inequities & Lack of AccessMulti-layer Payment SystemLack of StandardsTreatment based (not prevention based)

18

TELEHEALTH A SOLUTION?

Provide an overview of telehealthAssess economic impact of telehealthDescribe current implementation of

telehealth in PAIdentify obstacles to wider

implementation

19

WHAT IS TELEHEALTH?

TelemedicineTelepsychiatryTelecaremHealthEHR

20

TELEHEALTH INCLUDES...Live VideoconferencingLive Romote MonitoringRecorded clinical or educational videoRecorded remote monitoringDiagnostic scans & intepretationElectronic Health Records

21

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

VOLATILITY

Political Aspects of Obamacare (Patient Protection & Affordable Care Act)

Recent Technology Quantum Leap in Mobile & Video

Recession & Financial Impact

23

FINDINGS

Overview

Current Implementation

Obstacles

Economic Impact

24

OVERVIEW – FUTURE TELEHEALTH USE

25

0

50

100

150

200

250

300

350

Increase Do Not Know Remain the Same Decrease

Estimates of Future Telehealth Use Unknown

Urban

Rural

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%

40%

47%

14%

9%

67%

24%

OVERVIEW – FUTURE TELEHEALTH USE

26

0

50

100

150

200

250

300

350

Increase Do Not Know Remain the Same Decrease

Estimates of Future Telehealth Use Unknown

Urban

Rural

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%

40%

47%

14%

9%

67%

24%

CURRENT IMPLEMENTATION

2727

8%

6%

10%

11%

15%

32%

39%

85%

14%

18%

19%

25%

37%

85%

Store & Forward Monitoring

Live Monitoring

Recorded Video

Diagnostic Decision Support

Other

Web Discussion

Store & Forward Images

Live Videoconferencing

Electronic Health Records

Types of Telehealth

Rural

Urban

Controlled Sample Physician Survey N = 239. Rural N = 62, Urban N = 177. Percent represents % of N (i.e. 85% of respondents from Rural Counties used Electronic HEalth Records).

8%

8%

10%

10%

11%

11%

13%

13%

15%

15%

16%

23%

31%

34%

37%

45%

15%

14%

8%

9%

13%

9%

7%

6%

9%

28%

17%

30%

32%

39%

6%

6%

6%

6%

69%

31%

25%

Integrative Medicine

Preventative Medicine

Dermatology

Neuro-Emergencies

Other

Neurology

Mental Health

General Practice

Physical Rehabilitation

Oncology

Pathology

Infectious Disease

Internal Medicine

Psychiatry

Emergency Medicine

Family Medicine

Radiology

Other Specialties using Telehealth

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).

4%

21%

20%

15%

24%

16%

4%

21%

14%

20%

22%

19%

100%

other

portable health records

consultation

patient education

provider education

followup care

remote diagnosis

Telehealth Uses

Rural

Urban

Controlled Sample Physician Survey N = 341. Rural N = 89, Urban N = 252. Percent represents % of N (i.e. 16% of respondents from Rural Counties used telehealth for remote diagnosis ).

OBSTACLES

28

6%

9%

12%

15%

20%

20%

24%

30%

33%

34%

40%

49%

51%

52%

16%

18%

12%

14%

29%

17%

41%

39%

27%

33%

30%

45%

53%

58%

9%

14%

21%

16%

26%

26%

44%

40%

28%

30%

53%

51%

65%

72%

Other

Fear of Fraud

Too New

Poor Project Planning

Poorer Quality than F2F

Staff Resist

Legal Issues Unresolved

Poor Training

Inaccessable Broadband

Lack Time

Poor Process & Procedure

Too Expensive

No Gov Ins Reimbursement

No Priv Ins Reimbursement

Obstacles to Telehealth Growth

Rural

Urban

Unknown

Total N = 378. Rural N = 86, Urban N = 249, Unknown N = 43. Percents represent % of N choosing that obstacle (i.e. 52% of Rural respondents chose No Private Insurance Reimbursement).

2.0%

2.0%

2.0%

4.6%

3.6%

2.3%

3.3%

6.5%

6.2%

1%

0.7%

1.3%

1.0%

1.3%

2.6%

0.3%

2.9%

2.0%

1.3%

2.0%

1.3%

1.0%

4.6%

1.6%

6.2%

6.9%

7.8%

1.3%

1.3%

2.9%

1.3%

0.0%

3.3%

0.7%

5.2%

5.9%

5.6%

5.9%

7.5%

7.8%

9.5%

9.8%

10.5%

21.6%

21.9%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0%

Use of Telehealth for Chronic Illness

Use of Telehealth to equalize access

Use of Telehealth for seniors

Use of Telehealth to Lower costs

Issues with Data Standards

Use of Telehealth for Prevention

Use of Telehealth to mitigate shortage

Reimbursement Restrictions

Legislative/Definition Restrictions

Themes In Interviews (Recurring Issues)

Community

Gov

Provider

Vendor

Rank

Large percent in box represents "rank" of importance for issue based upon Frequency/Total # of Statements. Smaller percentage represents 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 community influenced the ranking of Reimbursement Restrictions 6.5%.

ECONOMIC IMPACT – PA 1-20 YEARS

29

$114

$154

$324

$92

$118

$243

$95 $94

$130$113$144

$274

$110

$148

$316

$89 $84

$109

Year One Year Five Yr Twenty$0

$50

$100

$150

$200

$250

$300

$350

Billio

ns

PA Healthcare Cost Impact of Various Telehealth ImplementationsBase

Eliminate Admin Waste

Wellness & Prevention

Integrate EHR

Remote Monitoring

Combination of All of the Above

30

ECONOMIC IMPACT PER PERSON

-

5,000

10,000

15,000

20,000

25,000

30,000

Base Eliminate Administrative

Waste

Wellness & Prevention

Integrated EHR

Video & Remote

Monitoring Telehealth

Combination All of the Changes

Average Per Person Cost for Different Telehealth Program Impact Scenarios

Per Person Cost Yr TwentyPer Person Cost Yr FivePer person Cost Yr One

31

ECONOMIC IMPACT - % CONTRIBUTION

Eliminate Waste, $6,385

Wellness & Prevention,

$15,325

Telehealth (EHR, Video,

Remote Montoring),

$4,000

Contribution of Each Toward Combined Savings - Per Person Average

ECONOMIC IMPACT - CONCLUSIONSCurrent 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

CURRENT RESEARCH ON ECONOMICS OF INTEGRATIVE HEALTH PRACTICES

ORIGINALLY MET ROGER JAHNKEAT 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

LOOKING FOR INPUT

Asked others to join – in time

Model used in telehealth – good start?

Difficulty combining impacts

Difficulty in separating actual savings from future savings

$114

$154

$324

$92

$118

$243

$95 $94

$130$113$144

$274

$110

$148

$316

$89 $84

$109

Year One Year Five Yr Twenty$0

$50

$100

$150

$200

$250

$300

$350

Billi

ons

PA Healthcare Cost Impact of Various Telehealth ImplementationsBase

Eliminate Admin Waste

Wellness & Prevention

Integrate EHR

Remote Monitoring

Combination of All of the Above

DISCUSSION How to improve the

pain reducing economics study?

Thoughts on approach to economic impact of integrative medicine as standard of care?