If you want a preview of Monday’s big wellness debate, look no further than a 3-way exchange (us, New York Times, Ron Goetzel) from late 2014.
First, our November 25th Health Affairs blog did for the wellness industry what Upton Sinclair did for meatpacking. Despite its Thanksgiving-week publication date, it became the #1 most-read for November and #12 for all of 2014, in Health Affairs. (This was the article generating the famous Los Angeles Times moniker for wellness: Scam.)
Next, New York Times “Incidental Economists” Austin Frakt and Aaron Carroll had a field day with their followup column. It should be read in its entirety. It’s basically a cut-and-pasted version of our own, with some hilariously scathing color commentary (and we have always said the greatest value wellness vendors deliver is humor).
Their lead line says it all:
Finally, let’s look how Ron spun their elegant smackdown, using his best Goetzel “The Pretzel” twisting and turning of their words:
The recent Health Affairs Blog post by Al Lewis, Vik Khanna, and Shana Montrose titled, “Workplace Wellness Produces No Savings” has triggered much interest and media attention. It highlights the controversy surrounding the value of workplace health promotion programs that 22 authors addressed in an article published in the September 2014 issue of the Journal of Occupational and Environmental Medicine titled, “Do Workplace Health Promotion (Wellness) Programs Work?” That article also inspired several follow-up discussions and media reports, including one published by New York Times columnists Austin Frakt and Aaron Carroll who answered the above question with: “usually not.”
Four observations about that one paragraph presage Ron’s strategy for Monday.
First, How do you translate Frakt and Carroll saying: “We’ve said it before, many times and in many ways: workplace wellness programs don’t save money” into: “usually not”? Simple, you reference the December “follow-up discussion” by these NYT columnists…but then link to a previous discussion, in September. (Try the link — really.)
Second, our article didn’t “highlight the controversy surrounding” the value of wellness. Our article “highlighted” that pry-poke-and-prod wellness has no value. There is no controversy. We have a proof — now backed with a $1-million reward, in case anyone doesn’t understand the meaning of proof.
Third, Ron writes: “22 authors addressed this” in September 2014. Ron needs to understand that math is not a popularity contest. It doesn’t matter how many wellness vendors want to protect their revenue stream, because the rules of math are strictly enforced. This is a typical Goetzel tactic, sort of like Claude Rains saying: “Owing to the seriousness of this crime we’ve rounded up twice the usual number of suspects.” In any event, two of the non-wellness-vendor authors were horrified to learn that this article had endorsed the Nebraska fraud as a “best practice.”
Finally, he appears to conflate the Journal of Occupational and Environmental Medicine with Health Affairs. The latter is the most respected journal in health policy (impact factor: 4.966), which is why our essay got picked up so broadly. The former is largely a wellness industry mouthpiece with an impact factor of 1.630. Sort of like the old tag line for Hustler: “The Magazine Nobody Quotes.”
What he will try to do is sow doubt, the classic last resort when the facts all go the other way. You saw it from the tobacco industry, and more recently from climate change-deniers. He will bring up all his articles and all his authors and say they are all “peer-reviewed” and say that there is “evidence” on both sides. He’ll use words like “controversy” and “discussion” when in reality it’s settled science (and more importantly, settled math) that prying, poking and prodding employees is nothing more than the Wellness Vendor Full Employment Act, and it’s time to repeal it.
If engineers learn more from one bridge that falls down than from 100 that stay up, this new Aetna-Newtopia study is the Tacoma Narrows of wellness industry study design. No article anywhere — including our most recent in Harvard Business Review — has more effectively eviscerated the fiction that wellness saves money than Aetna just did in a self-financed self-immolation published in the Journal of Occupational and Environmental Medicine. Hopefully the people who give out Koop Awards to their customers and clients will read this article, and finally learn that massive reductions in the cost of participants associated with trivial improvements in risk are due to self-selection by participants, not wellness programs. And certainly not wellness programs centered around DNA collection.
Aetna studied Aetna employees who, by Aetna’s own admission, didn’t have anything wrong with them, other than being at risk for developing metabolic syndrome, defined as “a cluster of conditions that increase your risk for heart attack, stroke and diabetes.”
In other words, taking the wellness industry’s obsession with hyperdiagnosis to its extreme, the subjects’ “diagnosis” was being at risk for being at risk. Not only did they not have diabetes or heart disease, but they didn’t even have a syndrome that put them at risk for developing diabetes or heart disease. You and I should be so healthy.
As this table shows, after one year, the changes in health indicators between the control and study groups were trivial (like a difference in waist measurement under 3/10 of an inch), and only triglycerides was barely statistically significant (p=0.05). Additionally, the control group actually outperformed the study group in 3 of the 6 measured variables, as would be predicted by random chance. Bottom line: nothing happened.
And yet, Aetna reported savings of $1464/participant in the first year. This savings figure is more than 20 times higher than what Aetna’s co-authored HERO Report says gets spent in total on wellness-sensitive medical events. It’s also far higher than Katherine Baicker’s thoroughly discredited 3.27-to-1 ROI, that she has basically retracted, published six years ago–that, yes, in keeping with wellness industry tradition, their article cited. (Only now, because the study is now six years old, Aetna feels compelled to insist that it is “recent.”)
How did they achieve such a high savings figure in a legitimate RCT? Simple. That savings was not the result of the legitimate RCT. Having gone through the trouble of setting up an RCT, they then proceeded to largely ignore that study design, since as their own table above shows, nothing happened.
Spending was a bit lower for the invited group, but obviously there couldn’t have been attribution to the program. A responsible and unbiased researcher might have said: “While there is a slight positive variance between the spending on the control group and the spending on the invitee group that wouldn’t begin to cover the cost of our DNA testing, we can’t attribute that variance to this program anyway. The subjects were healthy to begin with, there was no change in clinical indicators, and we didn’t measure wellness-sensitive medical events even though we know from our own HERO report both that those represent only a tiny fraction of total spending, and that those are the only thing that a wellness program can influence.”
Instead, they coaxed about 14% of the invitees to give up their DNA, and measured savings on them. More than coincidentally, that decidedly uninspiring 14% participation rate was about the same as the Aetna-Newtopia debacle at their Jackson Labs reference site-from-hell. Basically, employees don’t want their DNA collected, and DNA turns out to be quite controversial as a tool to predict heart disease down the road, let alone during the next 12 months. Further, Newtopia admits they store employee DNA, lots of people have access to it, and they could lose it.
The DNA also seems to have had precious little to do with the actual wellness program itself–and for good reason given the links above. This seems like a classic wellness intervention of exactly the type that has never been shown to work, with the DNA being only an entertaining sidebar. The subjects themselves exhibited no interest in hearing about their DNA-based predictions.
This is the first time a study has compared the result of an RCT to the result of a participants-only subset of the same population. The result: a mathematically and clinically impossible savings figure on the subset of active participants, and an admission of no separation in actual health status between the control and invitee groups by the end of the program period.
So Aetna — in this one article — accidentally proved what we’ve been saying for years about the fundamental bias in wellness study design that creates the illusion of savings:
Participants will always massively outperform non-participants, period — even when the program doesn’t change health status or even when there was no program for the “participants” to participate in.
Number of deaths attributable to eating processed meat, according to the World Health Organization (WHO): 34,000
Number of people struck by lightning annually: 240,000
And yet the WHO generated a huge headline by saying that eating red and processed meat could increase your risk of colon cancer by 18%.
Let us assume that they are right. (And we will let the trade associations debate them on the scientific merits of that 34,000 figure.) Even if they are right, this is a perfect example of confusing an increase in relative risk of one disease with absolute risk of dying. To use the lightning example, you probably have a 1-in-a-billion chance of being struck by lightning if a thunderclap is audible but the sky above is clear. Some states close public pools when that happens. If the sky above is clear but you can see lightning in the distance, your odds of getting struck may jump to 1-in-100,000,000. That’s a 10-times relative increase, but only a 9-in-a-billion absolute increase. So these states inconvenience parents and fidgety kids for basically no reason other than misunderstanding relative and absolute risk.
To make matters worse, the WHO conflates the risk of smoking and asbestos with red meat. Both the former cause perhaps something like an 18% increase in age-adjusted death rates in total, not an 18% increase in one form of cancer. The difference? Probably about a thousand times in total, unvarnished, absolute risk.
Yes, I know it’s not always about me (my ex-wife was quite clear on this) but this is exactly what Quizzify teaches. Newscasters who had taken the Quizzify quiz (and relative-vs-absolute risk is in the advanced level…but they are newscasters so they should get to that level) would have led with the headline: “WHO Demonstrates No Understanding of Health” instead of “You Could Die from Eating Red Meat”.
That’s it for now. Funny thing, I used to be a quasi-vegetarian because I was concerned about the impact of red meat and processed meats on my colon cancer risk. But anyone who understands health research would read this the same way I do: it’s OK to live on the edge. Don’t deprive yourself of red meat for this reason. I myself am headed out for a burger. Not just any burger but a bacon burger. In the immortal words of the great philosopher Sammy Davis Jr., I’ve got a lot of living to do.
In keeping yet again with the Koop Award tradition of bestowing awards upon themselves, the 2015 award went to one of Ron Goetzel’s own clients, McKesson. Curiously, not one but two other Koop Award sponsors (Alere and Vitality) are also listed as McKesson wellness vendors. This new record for undisclosed Koop sponsor self-awarding would make Nero proud.
And in keeping yet again with the Koop Award committee’s tradition of not noticing invalidating mistakes, none of what you are about to read — not one single invalid, mathematically impossible or self-contradictory datapoint that were all self-evident — was noticed by any of the Koop Award Committee members. They saw nothing. Our previous Koop Committee posting, entitled Koop Award Committee Meets Sergeant Schultz, seems presciently titled indeed.
Highlights of Risk Reduction and Wellness Activities
McKesson employees attended 160,000 Weight Watchers meetings. McKesson claims their employees collectively lost 24,000 pounds. That’s about 2.5 ounces lost per meeting for all attendees combined.
So if 10 people attended the average meeting, literally the amount of weight each lost (0.25 ounces) could be accounted for by walking to and from the meeting room, plus maybe a sneeze or two. Here’s a surprise: Weight Watchers has been a total failure in the corporate weight control market. Truven and McKesson must have missed this memo.
Oh, and did we mention that this weight-loss figure is self-reported, doesn’t count dropouts, and apparently contradicts McKesson’s own screening results — in which employees actually gained weight? (See below)
As the chart below shows, McKesson showed roughly a 2% decline across all risk factors, in the half of the company willing to be measured. The other half of the employee population declined to participate despite massive incentives. This is typical because employees hate wellness so much that even the biggest bribes can’t generate participation. So that 2% risk reduction amongst the 50% of repeat participants means – optimistically assuming the half who dropped out or didn’t participate stayed the same risk-wise – a 1% reduction in risk factors for McKesson as a whole.
Some other curiosities about this chart below that no one noticed. First, only 1% of its employees have an “elevated” risk of being a problem drinker, not bad for a company that used to be in the liquor distribution business. By contrast, the rest of the country’s alcoholism rate is 4.7% (women) or 9.4% (men) — and that’s an actual diagnosis of alcohol use disorder, not simply “elevated” risk.
Second, despite 160,000 Weight Watchers meetings and the 0.25 ounces each participant lost, the average employee who bothered to show up twice to be weighed-in actually gained weight. So which is it? Did they lose weight or gain weight?
Answer: they gained weight. Participants always outperform non-participants, and when you recombine the two groups, you always show that performance by participants is a misleading indicator of actual overall performance by everyone in total.
Third, despite McKesson’s claims of smoking cessation, note that a large chunk of employees refused cotinine (nicotine) testing. So 27% of employees self-reported tobacco use but only 9% of those willing to be tested were positive for tobacco use. 27% of employees admitting tobacco use might be a record for a company winning a wellness award. It’s about 9 points higher than the national average.
Finally, McKesson — reading datapoints off this very chart — claims a 9% reduction in risk, using the simple expedient of ignoring the people whose risk factors increased. This fallacy is the classic way to overstate savings. We call it “Lake Wobegon meets wellness” because everyone improves in this calculation. Still, we’ve never seen evaluators simply ignore the people getting worse when the data was right in front of them like this.
The Koop Committee reviewers somehow ignored or overlooked all of these things, and yet still they wonder why they are known as the Wellness Ignorati. Ah, well, as Tom Friedman wrote: “We wouldn’t be human if we didn’t ignore facts that dash our hopes upon the cliffs of reality.”
This 1% risk reduction across the population generated more than $13,000,000 in gross savings. McKesson’s graph below shows it spends about $4000 for each of its 45,000 eligible adults—or roughly $180,000,000 overall (excluding dependents). That means a 1% risk reduction creates a 7% spending reduction.
Using that logic, a 14% risk reduction would save 14 times as much–or $180,000,000, enough to wipe out all of McKesson’s healthcare spending, using the McKesson/Goetzel math.
The Dog that Didn’t Bark in the Nighttime
What makes this even more of a head-scratcher is that most people and organizations on this award committee – and a large number of the vendors and consultants involved in McKesson – also produced the HERO Outcomes Guidelines Report, which is quite insistent that the wellness-sensitive medical event rate (“potentially preventable hospitalizations” as they call them) be tallied as the only indicator of wellness program success, since no other costs decline and probably actually increase:
And yet no one noticed this event rate wasn’t disclosed — despite the insistence of everyone on the committee in this HERO report that these events are the only element of cost reduced by wellness.
Had this rate been disclosed, Sergeant Schultz himself – or even a Koop Award Committee member — might actually have noticed that the decline (if any) in these events would account for roughly 1% of McKesson’s claimed savings from wellness, about $12/person/year. The other 99%? Those are what we call the “wishful thinking multiplier,” which is the basis for all savings reported by the wellness industry.
Recently we promised a Part 2 to our original proof that wellness savings are mathematically impossible. Commenters said: “How can you have a Part 2 to a proof? You just proved it.”
The previous proof showed wellness can’t save money, even if programs were perfect. This installment proves that even if wellness could save money, it hasn’t. Meaning even if wellness were free, it couldn’t pay for itself. So this proof is independent of the previous proof. For wellness to save money, the wellness true believers would have to find fallacies in both proofs. Either is sufficient to make our case…but we have both.
Quite literally, forcing employees to “do wellness” or lose money has avoided basically zero wellness-sensitive medical events in the 13 years ending 2013 (2014 data isn’t in yet), according to the federal government. If the name “federal government” sounds familiar, it’s because it’s the very same federal government that has passed a law encouraging vendors to pitch “pry, poke and prod” programs to you despite their complete lack of evidence basis, lack of effectiveness, and potential for harm.
Here is the way our analysis was done. We used the government database called the Healthcare Cost and Utilization Project, or HCUP. That database tracks all hospitalizations due to all causes, by population. So it is possible to focus on just the commercially insured population, which they call “privately insured.”
The privately insured population is 100% sensitive, meaning everyone whose workplace “offers” wellness is in that database. The database isn’t specific, meaning plenty of people in it do not have access to wellness. Nonetheless, the dramatic increase over the 13 years in the number of people whose employers push wellness should produce an equally dramatic decrease in wellness-sensitive medical events. While wellness was rare at the start of this analysis in 2001, today most large companies, nonprofits, and governments have wellness. In total, one can project from the Kaiser Family Foundation data that about 75-million people (or roughly half of all privately insured people) are subject to what Jon Robison has termed wellness-or-else.
Keep in mind that all hospitalizations have been declining over this 13-year period, due to shifts to outpatient, better usual care, etc. So the question is not whether WSMEs have been declining, but whether they have been declining faster than the rates of all other hospitalizations in combination.
Instead, as you can see, these WSME admissions have trended essentially flat over the period, as a percentage of all admissions. In other words, there is no difference between the decline in admissions for WSMEs – despite $7-billion/year being spent on vendors to prevent them – and the declines in every other category of hospitalization. 13 years ago about 6.9% of events were wellness-sensitive. Now it’s about 7.0%. (This is 2013. 2014 is also in, for our customers for whom we track WSMEs, and shows no change.)
This is based on ICD9s 401-405, 410, 430-438, and 250 — strokes, hypertensive events, heart attacks, and diabetes events.
Prima facie, the debate is over, again, just like it was over after our last proof.
Needless to say, the true believers aren’t about to give up their revenue stream just because we’ve double-proved they’re fabricating savings. They will make two arguments against this proof of their own ineffectiveness. First, they’ll argue that wellness reduces all events and other costs equally, so really we should credit wellness for the total cost reduction, not the reduction in just wellness-sensitive admissions. This might seem like a pollyannish view of wellness, but wellness true believers attribute everything that’s good to wellness. True believer Bruce Sherman has even argued that wellness actually reduces industrial waste, so to a wellness true believer, eating more spinach makes every employee a Popeye.
Unfortunately for Bruce and others, the wellness industry’s own HERO report says wellness can only reduce WSMEs. Other costs go up, it says:
Second, one could argue that there isn’t enough penetration of wellness yet to bend this trend, since the HCUP privately insured population includes tons of people without access to wellness, and even many people with wellness access refuse to participate.
Unfortunately, that argument self-immolates. Vendor fees are $7 billion. All these WSME ICD9s combined (using the HERO-estimated admission cost of $22,500) amount to about $11.3 billion. That $11.3 billion includes the half of privately insured people who don’t have access to wellness. Already, when you cut that figure in half to account for those employees with employers who’ve decided not to “do wellness” to them, the $7 billion size of the wellness industry exceeds the size of avoidable events ($5.7 billion). This is consistent with our first proof, which showed the same thing, but on an individual company level. Now—assuming participation is 50%, you need to cut the WSME hospitalization total in half once again. You’re down to $2.85 billion in potentially avoidable events — that companies are spending $7 billion on vendors to avoid.
So, no matter how you look at it, “pry, poke and prod” programs have been singularly ineffective in reducing WSMEs. And if the HERO Guide is right that these are the only admissions wellness can avoid (while other costs increase, as they admit), wellness does not and cannot save money.
Instead, wellness-or-else is basically a pile of, um, industrial waste.
Anyone still want to try to claim the million-dollar reward for showing pry, poke and prod programs aren’t a total waste of resources? I didn’t think so.
Note: This graphical analysis is copyright 2015 to Quizzify. However, any disinterested researcher or journalist may request a copy of the backup material from us.
Total Wellness, having been “profiled” on this blog for being second only to Star Wellness in “playing doctor” with inappropriate employee screening, isn’t about to lose this race to the bottom without a fight.
So in order to try to out-stupid Star Wellness, Total is offering yet another test (they are now up to 8) either rated D by the United States Preventive Services Task Force or (in the case of Chem-20s and Complete Blood Counts) not rated as preventive screens at all because [WARNING: Spoiler Alert]: these two aren’t preventive screens. They are tests, but Total Wellness apparently doesn’t know the difference between a screen and a test.
For those of you who also don’t know it — and you aren’t required to because you’re not poking employees with needles to fulfill your mother’s fantasy of you becoming a doctor — a screen is done wholesale on everyone in order to hunt for disease and then brag about how many sick people you found. You’ll find plenty if you force employees to either participate or forfeit lots of money. Like Total Wellness says, you need to be “stern” about making employees submit to these worthless and harmful screens. And being “stern” means it’s wellness–or else:
By contrast, a test is what a real doctor might order — if an actual patient presents with relevant symptoms. Chem-20s and CBCs haven’t been used as screens for decades. Even the professional organization whose physician members get paid to perform them doesn’t recommend them. “These tests rarely identify clinically significant problems when performed routinely on an outpatient population.”
Here is Total Wellness’s Totally Inappropriate Screen #8, along with the USPSTF grade:
Doctors routinely performing and billing these 8 “preventive” screens could and should lose their licenses. The good news for Total Wellness is that they aren’t going to lose their license for inappropriately screening employees, for the simple reason that you don’t need a license in order to inappropriately screen employees.
Quite the contrary. Unlike in regular grown-up type healthcare, in the wellness industry any idiot can perform these screens and tests as long as that idiot can find an even bigger idiot willing to pay for them.
Is this a great country or what?
The following is a guest post by George D. Burns. George is an employee benefits and tax Consultant who has developed the Burns ERP, which significantly reduces the costs of providing employee health benefits. He can be reached at email@example.com He is also a frequent Top Contributor to many LinkedIn groups and is a message board moderator at BenefitsLink.com.
The truth about wellness programs was revealed at the recent NBGH conference. Two studies in combination explain both that wellness fails and why wellness fails.
The first was a Towers Watson survey showing that wellness fails because employees don’t like it. (In the wellness industry, this counts as an insight.) In contrast to every other study showing high satisfaction among participants–who of course are largely “satisfied” by the money–this one surveyed all employees, not just participants. It showed that 52% of employees did not participate in even a single wellness program or activity. Employers offered a maximum of $880 but paid out an average of $365 with 40% of employees receiving $0. “[Employees] feel like it’s too hard or not worth it, or that it adds unneeded complexity to their lives.” said Shelly Wolff, a consultant at Towers. “Whatever the reason, it’s a big disengagement number.”
The second, an employee poll at Bright Horizons LLC, showed why wellness fails. Wellness programs have failed because they targeted the wrong goals with the result that — even if employees had been interested when cash was offered and even if the program had been successful — a conventional wellness program would have little impact on well-being.
Specifically, this employee poll showed that physical health, the highly profitable obsession of wellness vendors and consultants, counts for only 5% of employee well-being — far less than job satisfaction, stress, financial wellness and personal issues.
Further, “physical health” was a catch-all category including current acute issues such as colds and back pain, not just chronic major issues like diabetes or heart disease or “risk factors” that are the focus of wellness programs. So even the 5% figure dramatically overstated the impact of risk factors on well-being.
So we’ve found two more reasons wellness vendors need to falsify their results to stay in business. According to the Bright Horizons study, they are chasing the wrong goal to begin with…and according to TowersWatson, they are failing at chasing the wrong goal.
One recalls the old Woody Allen joke about the two old ladies in the Catskills. One says, “You know, the food here is terrible.” The other replies: “Yes, and the portions are so small.”