The Proposed Strategy

Our proposed strategy is to offer innovative health-promotion and disease-prevention interventions to high-cost cases and thereby reduce medical expenditures. This strategy is a refinement of previous public health approaches that were directed to the entire population, which often wasted much time, energy, and funds urging people who were already relatively healthy to change their behavior. This new strategy would focus resources on the least healthy people, who are incurring the majority of our nation's medical expenses. We propose that a small amount of resources could be directed to a narrow segment of society and possibly leverage a large reduction in expenditures.

Since this plan demands that such prevention strategies first be rigorously tested before implementation, we recommend the implementation of the Transcendental Meditation program, which has already been scientifically verified by over 500 published research studies for its effectiveness in promoting good health. Such an intervention would demonstrate the benefits and cost savings resulting from the use of one prevention program that has been ascertained to meet the necessary criteria of scientifically validated effectiveness.

Maharishi's Transcendental Meditation Program as a Proven Technology for
Disease Prevention and Health Promotion

The previous sections of this paper have established that the implementation of an effective prevention strategy is central to addressing the current crisis in health care costs. The key to the success of an effective prevention initiative will be cost-effective measures that work. Those measures currently in wide use have been shown to be of limited benefit and to be inadequate to reduce national health care expenditures. In contrast, Maharishi's Transcendental Meditation program has been shown through extensive scientific research to be particularly effective in the reduction of health care costs through effective disease prevention and health promotion. Moreover, application of this program to high health care utilizers-the 10% of the population responsible for over 75% of national health care expenditures-has demonstrated its consistent effectiveness both in improving the quality of life of these patients and in lowering medical expenditures.

Below we summarize the most pertinent areas of research on the Transcendental Meditation program concerning the alleviation of health problems that contribute most to rising national health care expenditures.

Studies on Health Care Utilization and Costs

Several studies have shown that Transcendental Meditation substantially reduces rates of health care utilization and costs. Orme-Johnson (1987, 1988) conducted two field studies using Blue Cross/Blue Shield data to compare the health care utilization rates of Transcendental Meditation practitioners with matched control groups. In the first study, over 2000 subjects were followed over a five-year period. The Transcen-dental Meditation subjects had a 50% reduction in both inpatient and outpatient medical utilization when compared with controls matched for age, gender, occupation, and health insurance coverage. As Figure 3 shows, for people practicing Transcendental Meditation, utilization was strikingly reduced in every major category of health care examined, including heart disease, cancer, and mental health.

In the second study, the medical insurance utilization of 400 individuals who practiced Transcendental Meditation and other prevention programs of Maharishi Ayurveda in the midwestern United States was 83% lower than the national norm. The greatest utilization decrease was in the older subjects.

In a longitudinal study, Herron (1993) expanded upon Orme-Johnson's research by evaluating the impact of Transcendental Meditation practice on the medical care costs of 600 French Canadians. This carefully controlled study used the Québec government's health care system's own data. Health care utilization was compared for the three years preceding and the three years following instruction in the Transcendental Meditation technique. The Transcendental Meditation participants' expenses declined approximately 36% over three years. Older participants showed even greater reductions in their expenses-a 57% decline over three years.

Figure 3. Effect of the Transcendental Meditation program on health care utilization.

Transcendental Meditation in the Treatment of Hypertension

Hypertension is a major health problem throughout the United States, and is an even greater problem among African Americans. Approximately 40% of African American adults are afflicted with hypertension. This rate averages about 33% higher than for Caucasians. Furthermore, the rates of hypertension-related diseases, such as stroke, heart attack, and kidney disease, are significantly higher in African Americans compared to whites (for example, death from stroke is 60% greater) (Schneider et al., 1992).

One of the major reasons for the disproportionately high levels of blood pressure in African Americans is excessive stress from disadvantaged social and environmental conditions. For this reason, Schneider et al. (1992) conducted a well-controlled field trial of the effects of stress management for treating hypertension in older African Americans. The study was funded by a national research foundation and conducted at an inner-city community health center in Oakland, California. After three months, the results showed that the Transcendental Meditation group had reduced their systolic blood pressure by 11 points (mm Hg) and their diastolic blood pressure by 6 points (mm Hg). A "relaxation" control group showed about half these reductions, and the usual care group did not change at all.

These results are highly significant because the magnitude of reductions in blood pressure with Transcendental Meditation were the same as the reductions normally produced by drug treatment. Over a few years these reductions in blood pressure would prevent an average of 40% of strokes and 20% of heart attacks that normally occur without adequate blood pressure treatment.

A second major advantage of treatment with Transcendental Meditation was the lack of adverse side effects that are commonly experienced with conventional drug therapy. Instead of negative side effects, the Transcendental Meditation group reported several improvements in subjective health and quality of life measures.

A third advantage is compliance with the program. Normally, less than 50% of patients with hypertension take their medication regularly as prescribed. However, in this inner-city project, approximately 90% of the Transcendental Meditation group followed their prescribed program regularly throughout the study. In addition, the Transcendental Meditation group rated their stress management program as "excellent" on the average, and all participants reported that they planned to continue the program and would feel comfortable recommending it to their friends.

In a study directed towards nonminority elderly, Alexander et al. (1989) examined the effects of the Transcendental Meditation program and other relaxation and self-development techniques on mental and physical health. After three months of follow-up, the Transcendental Meditation group showed a 12-point reduction in blood pressure, similar to the African American study above, as well as improvements in mental agility and health. Also, a higher proportion of the Transcendental Meditation group regularly practiced their technique (80%) as compared to the other programs. Most important, after three years, the survival rate for the Transcendental Meditation group was 100%, as compared to an average survival rate of 76.6% for the control groups.

Transcendental Meditation and Prevention of Cardiovascular Disease

The two other major risk factors for heart disease, namely, cholesterol and smoking, have been significantly reduced in Transcendental Meditation practitioners. Thus, it is not surprising that Orme-Johnson (1987) found an 87% lower rate of hospitalization for heart disease in Transcendental Meditation meditators compared to matched nonmeditators.

Alcohol, Substance Abuse, and Mental Health

In an area overlapping the consideration of stress, it is estimated that 80% of the health problems seen by general practitioners are related to alcohol, drug abuse, and mental health. Substance abuse and mental health problems are a major source of excessive health care utilization and costs. Research shows that Transcendental Meditation is effective in alleviating these problems.

Twenty-four studies on alcohol and drug abuse found significant effects of Transcendental Meditation on reduction of substance misuse for all classes of illegal drugs, as well as for alcohol, cigarettes, and prescribed drugs (Shafii et al., 1974 and Gelderloos et al., 1991). These studies include large surveys of students in addition to well-controlled studies of drug rehabilitation patients.

For example, in a very carefully designed study of 120 skid-row chronic alcoholics in Washington, D.C., 65% of Transcendental Meditation subjects were found to be completely abstinent 18 months after completion of training, compared to 25% of the patients receiving standard treatment (Gelderloos et al., 1991). The Transcendental Meditation technique was also consistently more effective in enhancing mood and reducing negative emotions.

In addition to increasing the risk of heart disease, cigarette smoking is probably the single most important risk factor for lung cancer. With most smoking cessation programs, the quit rate gradually decreases over time (to about 10%), while with the Transcendental Meditation program the quit rate actually increases gradually over time to over 90% after 60 months (Gelderloos et al., 1991).

The National Institute of Health of Japan has also conducted a study on more than 800 Transcendental Meditation practitioners and found significant decreases in physical complaints, anxiety, depression, smoking, insomnia, digestive problems, neurotic tendencies, and psychosomatic problems (Haratani and Itsumi, 1990a and Haratani and Itsumi, 1990b).

Several studies have also shown that Transcendental Meditation is effective in reducing anger, hostility, anxiety, and depression. For example, a nationwide epidemiological study by the Swedish government's National Health Board found that psychiatric hospital admissions were 150-200 times less common among the 35,000 Transcendental Meditation meditators in Sweden than for the population as a whole (Suurküla, 1989).

Cost-Benefit Analysis of Health Care Savings through the Transcendental Meditation Program
-Example: the Washington, D.C. Medicaid Program

The following analyses provide an example of the large savings that would accrue if the Transcendental Meditation program were implemented in the treatment of hypertensive patients and high-cost health care utilizers. Using the Medicaid program of the District of Columbia as an example, these analyses show that the Transcendental Meditation program would greatly reduce the burden on the health care system.

Analysis 1: Reduction of Hypertension and Prevention of Heart Disease and Stroke

According to population-based estimates, approximately 26,000 Medicaid recipients in Washington, D.C., are diagnosed hypertensives. We estimate that average medical expenses for these individuals are about $1000 per year for medicines, doctor visits, and hospital costs. Thus, Medicaid in Washington, D.C., pays $26 million per year for the care of hypertension alone. Since the majority of people with hypertension have mild hypertension (80%-90%), and since research has shown that Transcendental Meditation by itself is capable of correcting mild hypertension, the Transcendental Meditation program could potentially lower the blood pressure to normal levels in at least 80% of the hypertensive patients. Therefore, the Washington, D.C. Medicaid system could save at least $21 million per year if these hypertensive patients were to begin the Transcenden-tal Meditation technique. If only 50% of these patients began Transcendental Meditation, then the savings would be $10.5 million.

Furthermore, over a four- to five-year period, since the Transcendental Meditation program reduces blood pressure without side effects, we would expect substantial reductions in the incidence of heart attacks and strokes, which could save the District additional millions of dollars in acute medical care costs. We would also expect that the prevention of such disabling diseases would result in significant savings in productivity and human quality of life costs.

Analysis 2: Reduction of Health Care Utilization

Approximately 100,000 people are currently enrolled in the District's Medicaid system, and last year's Medicaid budget was $206 million. As mentioned above, 75% of all health care dollars are consumed by 10% of the population-the high utilizers of health care. For the District's Medicaid program, this means that 10,000 of the 100,000 participants use approximately $154.5 million of the total Medicaid budget. The upper line in Figure 4 projects the current $154.5 million of Medicaid expenditures attributable to high utilizers through the next five years, assuming a yearly increase of 11.6%, which is the published national norm for health care inflation (Jencks & Schieber, 1991).

Herron (1993) has demonstrated that, on average, the health care costs of high utilizers decrease at least 19% per year for five years following instruction in the Transcendental Meditation technique. The lower line in Figure 4 projects Medicaid expenses over five years if all high utilizers were to begin the Transcendental Meditation program. The savings in the first year would be $29.4 million. The savings for five years would be $667.9 million. If only 50% of the high health care utilizers in Medicaid were to learn Transcendental Meditation, the savings would be $14.7 million in the first year and $334 million for five years. It is clear that this program would result in huge savings to Medicaid: approximately $30 would be saved for every dollar invested in Transcendental Meditation instruction, at an average cost of instruction of $1000 per subject in this income group.

Figure 4. Projected Medicaid Expenditures for the District of Columbia.

The above analysis indicates that implementation of the Transcendental Meditation program for even a modest proportion of the members of the hypertension and high utilization groups of Medicaid participants would reduce the District's Medicaid costs substantially. This cost-benefit analysis provides an example of the enormous cost savings that can be realized by adopting this effective prevention strategy. Extending this analysis to the national level indicates that proportional savings would accrue to the national health care budget if this program were implemented on a national scale.

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[The International Health Care Cost Crisis]

[The Need For Prevention: Identifying New, Cost-Effective Strategies]

[The High-Cost Case Phenomenon: A Way to Leverage Medical Expenditure Savings through Prevention]

[The Proposed Strategy]

[Conclusions and Future Research Directions]