Mindfulness Training: A Case Study in Managed Care
Health costs continue to steadily rise. Some of the reasons driving that increase:
- Distorted incentives motivate providers to oversupply expensive diagnostic and treatment procedures while encouraging patients to over-consume services.
- Inexpensive lifestyle approaches to health improvement are rarely covered for individuals, despite accumulated data showing their effectiveness, while expensive treatments are often covered in full.
- The U.S. medical delivery system is stellar at delivering acute care, but it’s highly fragmented and inefficient at delivering chronic care.
- The American population is simultaneously getting more obese, less healthy and older.
Clearly, our focus needs to move to more efficient care for chronic health conditions. Is there a solution anywhere in sight? Yes. The demand for care is largely driven by chronic diseases, which are largely driven by unhealthy behaviors, many of which are inadequate attempts to cope with stress. Stress is widespread. The American Psychological Association recently estimated that 43 percent of U.S. adults suffer adverse health effects from stress. Some examples include: reduced immunity, increased diabetes risk, increased cardiovascular risk and weight gain.
A growing body of research shows that stress and its associated unhealthy behaviors have a considerable impact on chronic diseases such as cancer, diabetes, heart disease, and musculoskeletal pain. More than 133 million Americans have one or more chronic conditions, and account for 70 percent of all deaths. Additionally, 75 percent of the $2.5 trillion spent annually in medical care expenditures are related to such chronic conditions[2,3] .Modifiable health risk factors now account for 25 percent of total employer healthcare expenditures.
Several studies have showInsurann that employees under high stress levels experience higher healthcare costs (and lower productivity) than those with normal stress levels. In a 1998 study of 46,000 workers, healthcare costs were nearly 50 percent greater for workers reporting high levels of stress in comparison to “low risk” workers.
In a large 2011 studya major insurance carrier working with researchers at Duke Integrative Medicine, the University of Pennsylvania and an evidence-based mind-body wellness company found that annual healthcare costs for the previous year were $1,992 higher for the most highly stressed employees (top quintile) than for the least-stressed quintile.
Getting stress under control, then, can have a significant impact on behavior, chronic disease and ultimately the demand for healthcare services. Abundant research indicates that learning personal stress management skills is both effective and worth the time investment. Recent brain science research and demonstrations in the workplace wellness field are pointing to numerous personal health, quality of life, workplace performance and economic benefits tied to mind-body interventions. One of the most effective of those mind-body interventions is mindfulness training and practice.
Mindfulness is the practice of bringing one’s attention to the present moment, in a gentle, curious and non-judgmental way. Since most feelings of stress stem from ruminating on the past (this morning’s argument with a spouse, divorce, etc.) and worrying about the future (college savings for your children, retirement fund, etc.), learning to re-train attention on the present moment significantly alleviates stress. Further, concentrating on the present enhances our ability to perform well on a current task. Mindfulness skills can be learned in classes of one to two hours in duration, usually meeting weekly for a period of eight to twelve weeks.
Randomized controlled trials have shown that mindfulness training not only reduces psychological distress¸ but also improves coping skills, feelings of well-being and even physiological indicators of health including improved functioning of the nervous system and of the immune system.
Reducing Workplace Stress: A Case Study
Hines & Associates, a Chicago-based provider of personalized managed care services to employers and insurers, began exploring new offerings to differentiate its suite of utilization review, case management, disease management and other services. Hines selected a wellness program partner after seeing the evidence that mindfulness-based practices reduce stress and that stress impairs productivity at work. In their unique online virtual classroom, employees can participate in live, interactive classes from the convenience of their workplace or home.
Hines decided to pilot the wellness company’s eight-week online program in Mindfulness-Based Stress Reduction (MBSR). Hines offered the course to its staff, and enrollment filled the class to capacity within a day. Thirty-three employees from Illinois and Iowa participated in the online program.
Participants completed assessments before and after the course. Their scores showed significant improvements in perceived stress and total mood disturbance including subscales on tension, anger, fatigue, confusion and vigor. While the change in depression scores was not statistically significant, the scores did improve. Since the depression scores were not elevated at the start of the course however, a significant improvement was not expected.
|Mean (and Standard Deviation) Scores Before and After
the Online Mindfulness-Based Stress Reduction Program
|Indicator||Before Program||After Program||t statistic|
|Perceived Stress||17.66 (6.9)||13.50 (5.8)||3.78*|
|Total Mood Disturbance||19.09 (14.9)||6.23 (12.1)||4.64*|
|Tension||5.34 (2.9)||3.39 (2.6)||3.89*|
|Depression||3.24 (2.5)||2.24 (2.3)||1.90|
|Anger||4.80 (3.0)||2.94 (2.4)||3.85*|
|Fatigue||8.52 (4.4)||4.23 (3.2)||5.12*|
|Confusion||4.54 (2.3)||3.09 (1.9)||3.46*|
|Vigor||6.36 (3.8)||10.28 (4.0)||-5.63*|
(*Indicates that value is significant at p < .001. Decreases in mean scores indicate improvement on all measures with the exception of “Vigor” where increased values indicate improvement.)
Hines hasn’t yet tracked its claims experience to determine the hard-dollar savings, but it already sees how the improvements in stress levels have changed the lives of the nurses and supervisors who attended the MBSR program.
“We were hearing from staff that if something urgent came up they needed to respond to, instead of getting excited about it, they were doing what we were taught, to stop and keep yourself calm,” says Hines Executive Vice President Lynn Breitbach, RN. “Almost everyone commented that they found that was influential.
“The nurses emerged from the course with the ability to focus and listen better, to manage stressful situations more efficiently and with less distress, and to have better work-life balance,” she continued. “Most reported improved satisfaction in all areas of their lives.”
1- Just a few of the studies linking stress to chronic health conditions include Hemingway et al. (1999), Antoni et al. (2006), Hu et al. (2004), Garcia-Bueno et al. (2008), Van Houdenhove et al. (2009), Black (2003), and Finestone et al. (2008).
2- 2009 health expenditure data from the U.S. Center for Medicare and Medicaid Services
3- Loeppke (2008)
4- Anderson (2001), Goetzel et al. (1998)
5- See for example Baime (2011) and Goetzel, et al. (1998).
6- Goetzel, et al. (1998)
7- Results presented by Michael Baime, M.D., at the Society for Behavioral Medicine, April 2011
8- See Davidson et al. 2003; Greeson 2009; Gross et al., 2010; Jung et al., 2010; McCraty et al., 2003; Mino et al.; 2006; Hartfiel et al. 2010; McCraty et al., 2003; Hartfiel et al. 2010; and Limm et al., 2010
Ander, D.R., et al. (2001). The relationship between modifiable health risks and group-level health care expenditures. Health Enhancement Research Organization (HERO) Research Committee. American Journal of Health Promotion. Jan-Feb;15 (3) : 191.
Antoni, M.H., Lutgendorf, S.K., Cole, S.W., Dhabhar, F.S., Sephton, S.E., McDonald, P.G. et al. (2006). The influence of bio-behavioural factors on tumor biology: pathways and mechanisms. National Review of Cancer. 6 (3), 240-8.
Baime, M.J., Wolever, R.Q., Pace, W., Morris, W.M., Bobinet, K.J. (April 2011) Perceived Stress Scale Correlates with Health Care Costs. Poster presented at the 32nd Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine, Washington DC.
Black, P.H. (2003). The inflammatory response is an integral part of the stress response: Implications for atherosclerosis, insulin resistance, type II diabetes and metabolic syndrome X. Brain, Behavior, and Immunity, 17, 350-364.
Davidson, R.J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S.F., Urbanowski, F., Harrington, A., Bonus, K., Sheridan, J.F. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65(4), 564-70.
Finestone, H.M., Alfeeli, A., & Fisher, W.A. (2008). Stress-induced physiologic changes as a basis for the biopsychosocial model of chronic musculoskeletal pain: A new theory? Clinical Journal of Pain, 24(9), 767-775.
Garcia-Bueno, B., Caso, J.R., & Leza, J.C. (2008). Stress as a neuroinflammatory condition in brain: damaging and protective mechanisms. Neuroscience and Biobehavioral Reviews, 32, 1136-1151.
Goetzel, R.Z., Anderson D.R., Whitmer, R.W., Ozminkowski, R.J., Dunn, R.L., Wasserman, J. et al. (1998). The relationship between modifiable health risks and health care expenditures. An analysis of the multi-employer HERO health risk and cost database. Journal of Occupational and Environmental Medicine, 40(10), 843-54.
Greeson, J.M. (2009). Mindfulness Research Update 2008. Complementary Health Practice Review Online First, published on January 13, 2009 as doi: 10.1177/1533210108329862.
Gross, C.R., Kreitzer, M.J., Thomas, W., Reilly-Spong, M., Cramer-Bornemann, M., Nyman, J.A., Frazier, P., Ibrahim, H.N. (2010). Mindfulness-based stress reduction for solid organ transplant recipients: a randomized controlled trial. Alternative Therapies in Health and Medicine, 16(5), 30-8.
Hartfiel, N., Havenhand, J., Khalsa, S.B., Clarke, G., Krayer, A. (2010). The effectiveness of yoga for the improvement of well-being and resilience to stress in the workplace. Scand J Work Environ Health, Online First, Retrieved October 26, 2010, from Pub Med Database.
Hemingway, H. & Marmot, M. (1999). Evidence based cardiology: psychosocial factors in the aetiology and prognosis of coronary heart disease. Systematic review of prospective cohort studies. British Medical Journal, 318, 1460-7.
Hu, F.B., Meigs, J.B., Li, T.Y., Rifai, N., Manson, J.E. (2004). Inflammatory markers and risk of developing type 2 diabetes in women. Diabetes, 53, 693–700.
Jung, Y.H., Kang, D.H., Jang, J.H., Park, H.Y., Byun, M.S., Kwon, S.J., Jang, G.E., Lee, U.S., An, S.C. (2010). The effects of mind-body training on stress reduction, positive affect, and plasma catecholamines. Neuroscience Leterst, 479(2), 138-42.
Limm, H., Gundel, H., Heinmuller, M. et al. (2010). Stress management interventions in the workplace improve stress reactivity: a randomized controlled trial. Occupational and Environmental Medicine, doi: 10.1136/oem.2009.054148.
Loeppke, R. (2008). The Value of Health and the Power of Prevention. International Journal of Workplace Health Management, 2(1), 95-108.
McCraty, R., Atkinson, M., & Tomasino, D. (2003). Impact of a workplace stress reduction program on blood pressure and emotional health in hypertensive employees. Journal of Alternative and Complementary Medicine, 9(3), 355-369.
Van Houdenhove, B., Van Den Eede, F. & Luten, P. (2009). Does hypothalamic-pituitary-adrenal axis hypofunction in chronic fatigue syndrome reflect a ‘crash’ in the stress system? Medical Hypotheses, 72, 701-705.
About The Author
Ruth Quillian Wolever, Ph.D., serves as Chief Scientific Adviser for eMindful, the evidence-based mind-body wellness provider that Hines selected for this intervention. Dr. Wolever also is a clinical health psychologist and Director of Research for Duke Integrative Medicine. Dr. Wolever conducts research on the integration of mind, body, and spirit treatments into mainstream medicine. She has specifically explored such applications to improve sleep, eating behaviors, weight management, diabetes control, and cardiovascular risk factors, along with other health conditions.
Kevin Renner is eMindful’s Vice President of Marketing. He also has helped build emerging companies involved in health and technology innovation including Epic Systems Corp., FEI Co. (Nasdaq, FEIC) and Planar Systems (Nasdaq, PLNR). Kevin received his MBA from the University of California at Berkeley, and attended the Kellogg School of Management’s executive marketing program.