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I know it’s not always about me (my ex-wife was quite clear on that point), but I was deeply saddened to see one of the Blues – specifically, Blue Cross of Tennessee — descending into the fabricated-wellness-outcomes abyss.
In all fairness, wellness vendors have to lie, since it turns out that achieving savings is mathematically impossible. If they told the truth, they’d all be fired. Even so, Blues should be held to a higher standard for integrity than independent wellness vendors, because lies told by one Blue affect all the others by sullying one of the most readily identified and respected trademarks in America.
Before continuing, I do want to emphasize that this isn’t about “the Blues,” which are all independent of one another. It’s specifically about Blue Cross of Tennessee (BCBSTN). By contrast, other Blues – Massachusetts, Rhode Island, Louisiana, Northeast Pennsylvania, Carefirst and South Carolina come to mind (along with the Blue Care Network subsidiary of Blue Cross of Michigan) – have created exemplary outcomes reports. For them, integrity trumps impossibility. Two have even been validated by the Care Innovations Validation Institute, the gold standard in outcomes measurement.
Not so BCBSTN. They published a report in which Onlife Health showed some of the best outcomes in wellness history. BCBSTN calls Onlife their “partner” company in this report. However, a corporate lawyer – or BCBSTN itself, in this other press release – would call Onlife a “subsidiary,” for the simple reason that BCBTN owns Onlife. By contrast, you don’t own your partner (though my ex-wife tried).
In other words, BCBSTN is “validating” itself, not a partner. Normally “validation” is not performed by the entity being validated any more than an attorney is allowed to render the verdict in a case he or she is arguing.
The “intervention” was that these admittedly overweight employees walked an extra 2500 steps (about 19 minutes) a day. Here’s what those literal and figurative “baby steps,” as the report calls them, achieved. This is verbatim from the report:
- Emergency room visits and inpatient hospital stays were more than 50 percent lower in the moderate exercise group, as well. There were 219.6 ER visits and 59.9 inpatient stays per 1,000 for overweight non-exercisers compared to 73.6 ER visits and 30.1 inpatient stays per 1,000 for overweight moderate exercisers.
Let’s consider ER and inpatient separately. About 40-million ER visits a year are specifically caused by injuries, or roughly 126 per 1000 people. This injuries-only figure dwarfs BCBSTN’s all-in ER visit figure of 73.6 per 1000 allegedly achieved by this program. In other words, walking an extra 19 minutes a day not only wiped out every single non-injury-related ER visit, but also about 40% of all injury-related ER visits.
Next, let’s consider the inpatient stays. Their 30 stays per 1000 includes birth events, as compared to the more typical figure, which BCBSTN also experienced in the control group, of about 60 per 1000. All birth events combined are about 15 to 20 per 1000. Taking those birth events out of the BCBSTN tally yields 10-15 admissions per 1000, a Nobel Prize-winning figure.
And all achieved by walking an extra 19 minutes a day.
Another way of looking at it: here are the top 21 admissions categories for Tennesseans insured through their employers. With the exceptions of categories #9 and #10 (morbid obesity and heart attacks), probably not one single admission in any of these categories could have been prevented by walking an extra 19 minutes a day. Even in those two categories, optimistically only a handful of admissions would be prevented by short walks.
In addition – this is also part of wellness vendor DNA as this Wellsteps example shows – BCBSTN’s numbers contradict themselves. Compare these three bullet points from the study (italics are ours):
- Contrary to the popular guideline of 10,000 steps a day, employees who took as few as 5,000 steps per day, had annual healthcare costs nearly 20 percent lower than their sedentary counterparts who did not exercise. Spending was $2,038 per member per year (PMPY) for non-exercisers compared to $1,646 PMPY for moderate exercisers.
- Average claims cost PMPY dropped from $5,712 for non-users to $4,248 for employees who participated in one program and $3,120 for those participating in two programs. Employees engaged in three programs saw their claims cost cut almost in half at $2,892.
- Looking at BCBST overall, Danny Timblin, president and CEO of Onlife Health, noted, “Over a three-year period of time when we did this study, their claims were essentially flat.
Well, which is it? (And you gotta click through here.) Is it $2,038 per year for non-exercisers, or $5,712? How is it that “moderate exercisers” only spend $1,646 in the first bullet point but $2,892 in the second? And how can any sizable group of people only spend $1646 per year per person, vs. the more typical $5000-$6000? (Even adding up the cost of just those impossibly low ER and Inpatient utilization figures totals half of the $1646, leaving only enough room in the budget for a couple of doctor visits and non-specialty prescriptions.)
And how does “their claims were essentially flat” in the third bullet point reconcile with the massive decline in claims in the second bullet point?
Yet another head-scratcher: these massive savings were achieved despite the wellness industry’s own report admitting wellness loses money. You might say: “So what? Maybe Onlife disagrees with their own industry’s report.” Except that Onlife co–wrote that report, unless there is a different Onlife Health that is listed as a collaborator on it:
This Onlife “study,” if nothing else, validates the observation in our book Surviving Workplace Wellness: “In wellness, you don’t have to challenge the numbers to invalidate them. You merely have to read the numbers. They will invalidate themselves.”
Which brings us back to what Blue Cross of Tennessee needs to do next, now that their numbers have self-immolated (along with their ability to define the word “partner”). It seems they have, in the immortal words of the great philosopher Ricky Ricardo, some ‘splainin’ to do. At the very least, perhaps an apology to the Blue Cross Association and to their fellow Blues.
And I owe an apology to my ex-wife, who served the purpose of a humorous literary device in this posting, but who in reality is quite charming and lovely, and is inviting us over for Thanksgiving, and all we have to do is bring the pies. But I think BCBSTN will need to give the Association more than a pie or two to make up for this one.
At this point we thought we had already checked off everything in the wellness industry’s bucket list of bad behaviors-gone-wild. But that was before we learned about AngioScreen, which offers the “perfect compliment [sic] to your health and wellness fair”: carotid artery stenosis screening, a test rated D by the US Preventive Services Task Force:
Keep in mind the “AngioScreen” is this company’s specialty — the only major screen the Nashville-based Angiology Corporation of America (ACA) offers. In an industry known for harming employees, this makes them the leader, as ACA is the only wellness vendor guaranteed to harm employees on balance, according to the federal government.
And, by the way, however stupid an idea this screen is for the USPSTF-described “general adult population,” it is stupider still for the <65 employed population, which has far lower incidence rates of stenosis than the seniors, and hence a far higher likelihood of false positives.
What makes ACA unique is, not only do they know they’re offering a D-rated screen, they say so right on their website. At the bottom of their list of 10-, 15- and 24-year-old articles recommending carotid artery stenosis screening, they link to the USPSTF “D” Recommendation itself, a first in wellness vendor history:
You might ask: “Is it honest to offer a service you know to be harmful, if way down in your website you disclose that it’s so harmful your customers shouldn’t buy your service in the first place?” Alas, we cannot answer that. That is a question for philosophers, philosopher-kings and philosopher-welders.
Three related questions can be answered, though:
(1) Would a doctor lose his or her license for offering this test to every adult who comes in the door and billing insurance companies for it? Yes.
(2) Are these people disclosing directly to employees that official clinical guidelines recommend against doing this test because they are more likely to be harmed than benefited? No.
(3) Do they also make up savings figures? Yes. Specifically they say this “pays-off” in ways that don’t come close to “paying-off”.
Additionally, their quality control doesn’t exactly inspire confidence.
Speaking of their Medical Advisory Board, despite the fact that AngioScreen is offering exclusively vascular screenings to “prevent your stroke and heart attack,” Dr. Alfred Smauel Callahan, III, M.D. is definitely not one of America’s, or even Nashville’s, leading vascular specialists or cardiologists. How do we know that? As it turns out, he’s not a vascular specialist or cardiologist at all. He’s a neurologist. Those are the guys who treat people after they’ve had a stroke.
This choice of a neurologist as their physician leader doesn’t exactly inspire a lot of confidence in AngioScreen’s ability to prevent strokes. Also, there don’t seem to be any other doctors on the medical advisory board, which is “headed” by him. Per the offer on their website, we wrote and called to see if we could “review the curriculum vitaes [sic]” of this alleged board, and got no response.
In Angioscreen’s defense, they are not alone in offering harmful screening services. Total Wellness, Star Wellness, HealthFair, and other vendors offer the same screens or — in the case of HealthFair — worse ones.
This all brings us back to the question we’ve been asking for years: where are the grownups? Why isn’t there any oversight of the wellness industry? How can vendors and employers be allowed to do things to their employees that doctors would be jailed for doing if they billed patients for them? And how can employees be forced to participate in programs that could injure them, with no business purpose whatsoever?
We propose a simple regulation to address those questions: wellness vendors must do no harm. Wellness vendors should be required to disclose the USPSTF rating before they run these screens, and if it isn’t an A or a B for the employee’s age and frequency of screening, employees should be able to opt out without losing their incentive or paying a fine.
Update 4:30 PM November 19: I received a call back from Rhonda Small, at the company, who says that they are no longer really in the business of selling screens to employers, but rather mostly to hospitals. Their website, she says, is wrong. This makes better business sense because many hospitals like to offer free or deep-discounted D-rated screens, as we have noted. It is an excellent tool for sucking patients into their revenue stream, which is largely paid for by the patients’ employers or Medicare.
She indicated that she would send me curricula vitae (Rhonda, that is the plural, not “curriculum vitaes”, so you might wanna add that to the list of things on your website that are wrong) for the medical advisory board. I will post further updates.
Update 5:00 PM November 19: Apparently AngioScreen’s marketing team has not gotten Rhonda’s message that the company doesn’t market to employers–they just exhibited at the largest human resources conference.
It wouldn’t be appropriate to write a typically snarky expose of wellness vendor idiocy/dishonesty this week.
Parisians’ wellness program is their trademark joi de vivre, on full display every night. This is especially true on Friday nights, when it seems like every resident and every tourist is enjoying every corner of the City of Light, a city that celebrates humanity’s spirit, accomplishments and aspirations like no other city on earth. Parisians ask why they were targeted. I say, it’s for exactly that reason: what better target for murderous, sub-human barbarians than the pinnacle of civilization?
I hope to be in the frame of mind to post again by Friday.
When Thomas Edison said: “We don’t know a millionth of 1% about anything,” he wasn’t talking about the wellness industry, because wellness vendors aren’t that knowledgeable. And much of what they “know” is harmful.
Smoking and exercise aside, taking wellness vendors’ advice 10 years ago — during the time wellness was somehow allegedly racking up its famously fictitious 3.27-to-1 ROI by making employees healthier– would have been a very bad idea. PSA tests, annual mammograms for younger women, colonoscopies at 5-year intervals, and EKGs were perfect examples of must-to-avoid screens, even if it meant leaving incentives on the table.
And yet even though most wellness vendors (Star Wellness, Bravo Wellness Total Wellness, HealthFair Services and Aetna being notable exceptions) won’t harm employees as much as they did 10 years ago, a lot of mythology still causes a lot of harm today, albeit more subtly.
Myth: “We need to ‘do wellness’ because 75% of our healthcare cost is due to preventable chronic disease.” (Ron Goetzel, in our recent debate, boosted this figure to 80% for reasons unknown.)
Fact: Have ya looked at your high utilizers and other expenses? We-can-prevent-75%-of-cost-due-to-chronic-disease is the biggest urban legend in healthcare. We’ve done multiple articles on it — there are too many fallacies to squeeze in here. Though it’s just arithmetic, this is the most harmful fallacy of all, because by causing employers to obsess with overprevention, it spins off all the other fallacies below.
Myth: “Reducing our employees’ BMIs will save money.”
Fact: The actual science is far more nuanced. Some people have high BMIs because they are healthy. And belly fat — even at “normal” weights — is riskier than all but the highest BMIs. Further, attaching money to weight loss between weigh-ins creates a binge/crash-diet cycle that is decidedly unhealthy.
Myth: “Corporate weight loss programs save money.”
Fact: No corporate weight loss program has ever saved money. They don’t reduce BMIs, BMIs are the wrong measure (see above), and the link between reducing BMIs and saving money is nonexistent.
Myth: “Screening our employees will be good for their health.”
Fact: Annual screenings are a bad idea for the majority of employees. The head of Optum’s wellness operations, Seth Serxner, just acknowledged this inconvenient truth last week. (He somehow shifted the blame to employers, for stupidly spending too much money on Optum and other vendors. That’s a topic for another post.) The US Preventive Services Task Force has a schedule of screenings that essentially no wellness vendor follows. Because so few biometric screens are recommended for working-age adults by the card-carrying grownups who comprise the USPSTF, following USPSTF guidelines would bankrupt the industry.
Myth: “Screening guidelines balance costs and benefits so at worst we’ll break even.”
Fact: Screening guidelines balance harms and benefits, not costs and benefits. The subtlety of the distinction would be lost on most wellness vendors, but it is important. (1) Unless screens are provided free, an employer will lose money even on a screening program done according to guidelines; (2) you are not doing your employees any favors by providing screening “greater than” guidelines, like the Health Fitness Corporation/Nebraska program did. You are simply raising the likelihood of harm.
Myth: “Annual checkups will keep our employees healthy.”
Fact: For wellness vendors, the annual checkup has almost mystical power. Bravo’s CEO Jim Pshock loudly credits checkups with preventing cancer. Wellness vendor bloviating aside, the science is quite settled: employees are more likely to be harmed than benefited by annual checkups.
Myth: “Our employees need to eat healthier.”
Fact: OK, there is a, uh, grain of truth here. Many people have bad diets–fried food, sugar etc. But beyond eating less fried food and sugar, the science remains unsettled. Salt, saturated fat, complex carbohydrates…all in the realm of not completely settled. What is true and remarkably overlooked is the epidemiological rule of thumb that if an impact is major, it shows up in small samples. 86 cases were needed to link lung cancer to smoking. And a famous study of 523 veterans proved very high blood pressure causes strokes. Yet after tons of controlled and observational studies — even comparing countries to one another — we still haven’t found “the answer.” That means “the answer,” whatever it is, won’t matter much in the workplace. So you’re wasting your time trying to get employees to “eat right.”
We could keep going — antioxidants are more likely to cause cancer than prevent it. Sitting is not the new smoking. And drinking eight glasses of water a day is good for you only in that you’ll get more exercise going to and from the restroom.
The biggest myth of all? Wellness vendors actually do anything of value, other than make up savings figures to show your CFO so you look good. Or as my colleague Vik Khanna says: “Love your employees. Fire your wellness vendor.”
Now that the myth that there is any ROI in wellness is thoroughly both debunked and also even acknowledged by the wellness industry, vendors often fall back on the “argument” that nothing else in healthcare needs an ROI. Why should workplace wellness be singled out? The editor of the American Journal of Health Promotion, Michael O’Donnell, even asked: “Who cares about an ROI anyway?”
The answer to Michael’s question? Everyone should care. And everyone should insist on an ROI from wellness, for three distinct reasons. Each reason is sufficient on its own. So even if there were a fallacy in two of the reasons (and there isn’t), the remaining reason would still be definitive.
First, consider an employee with appendicitis. You don’t calculate an ROI. You call an ambulance. But suppose a vendor says to you: “If an employee’s appendix bursts, the cost could be $100,000. So we propose taking out everyone’s appendix preventively.”
You’d ask: “What’s the rate of burst appendixes and how much do appendectomies cost?” While that’s an extreme example (and we didn’t mean to give these people any ideas), this is basically the calculation you should make when vendors propose screens. Here’s how to do the calculation. You’ll be shocked at how much it costs to avoid even one event by screening everyone.
Second, wellness is the only thing in healthcare that employees are forced to do, subject to a financial forfeiture of penalties or lost incentives. Other activities which people are penalized for not doing include: wearing helmets/life jackets/seat belts and getting kids vaccinated. In each case, the clinical evidence/science overwhelms considerations of personal choice. (Even then, in some states personal choice still rules.)
By contrast, the only thing that’s overwhelming about wellness evidence/science is how overwhelmingly the evidence eviscerates wellness, which of course is what this site is all about. Unfortunately, wellness vendors don’t understand evidence — or for that matter healthcare itself. Many vendors have no knowledge of basics like clinical guidelines, or even arithmetic. One wonders how they can do their jobs as wellness vendors without understanding healthcare. And that brings us to the third reason that wellness (unlike healthcare) needs an ROI, which is…
…Wellness isn’t healthcare. Quite literally every other provider of physical healthcare–from heart surgeons to acupuncturists–needs to train, pass a test, get a license, take continuing education, and be subject to review by an oversight board. Not wellness vendors. You can become a wellness vendor for $67,000. “Up to” eight days of classroom and on-the-job-training are also included in that $67,000. (To put that in perspective, Four Seasons housekeepers get ten days of training.) The vendor that offers these franchises, Star Wellness, brags about how no healthcare background is needed to be a wellness vendor. A background in “sales or municipal administration” is perfectly sufficient.
So if you’re wondering why wellness vendors know so little about wellness, there’s your answer: they aren’t required to know anything about wellness. Knowing just a little exceeds the minimum requirement.
To conclude, here is our advice to workplace wellness vendors trying to justify what popular healthcare blogger Paul Levy calls the “wellness tax“: shut up and just be happy you still get to collect it, and that the authorities haven’t shut you down. (A doctor doing all this overscreening and billing for it would have been shut down.)
Don’t try to justify your hyperdiagnostic jihad on the basis of ROI or any other purpose other than enriching your bank accounts. Every time you try, you provide yet another reason why whatever college gave you a degree in anything other than advanced idiocy should lose its accreditation.
This posting should be read in conjunction with Part 2 of the proof that wellness doesn’t work, which in turn links to Part 1 that shows mathematically wellness can’t work.
During the Great Debate, Ron Goetzel’s side admitted that wellness admissions haven’t fallen, but added: “Yes, wellness admissions haven’t fallen. However, without workplace wellness, wellness-sensitive medical admissions (WSMEs) would have risen. We kept WSMEs from rising.”
We explained how this wasn’t the case, and promised that we would post the analysis, so that he wouldn’t have to take our word for it. So here it is.
Since $11.3-billion was spent on these admissions in the private-pay population according to the wellness industry’s own HERO Report, these events would have had to rise by at least 60% in order to make the claim that the $7-billion wellness vendor industry broke even by avoiding them. If indeed workplace wellness prevented this huge increase in the privately insured population, one would expect that these very same events would have risen by something similar to 60% in the non-privately insured population–meaning the combined Medicare, Medicaid, and uninsured.
As researchers might say, the privately insured population was “exposed” and the remaining US population was “non-exposed.” As wellness spending snowballed, the separation between those two populations’ WSME trendlines should have increased significantly.
Instead, we find these populations WSME-as-percent-of-total-admissions also flat-lined, just like the private-pay population. Ironically, to the extent there is a difference, the population without access to workplace wellness trended slightly more favorably in WSME admission rates than the population with access to workplace wellness.
The graph below compares WSMEs — or what the HERO Guidebook refers to as Potentially Preventable Hospitalizations (PPH) — over this century, using the national Healthcare Cost and Utilization Project database.
Likewise, the idea that wellness events have indeed fallen on an absolute basis in the employed population due to wellness is also a fallacy. These events have fallen even faster in the population not privately insured.
It wasn’t even close. I offered a proof that wellness has not avoided a noticeable number of hospital admissions this century. Ron Goetzel accepted that the data was accurate and declined to claim the million-dollar reward for finding a mistake in it.
Here is the first post-debate coverage. Highly favorable. Quoted Ron as saying employees like wellness. Try telling that to an employee…
The exchange I will be dining out on for years will be when Ron admitted I am the best peer reviewed in the industry. After he accused me of not being qualified to do my job, the following transpired:
“Ron, will you admit I am the best peer reviewer in the industry?”
“Then who is?”
Silence, followed by laughter from the audience.
Ron’s biggest points are:
- Wellness works if you do it right
- Almost nobody does it right. Maybe Procter & Gamble did it right a quarter-century ago (yes, he cited a 25-year-old study) but unless you are Ron’s client or a few others, you’re doing it wrong
- You can only expect a 1-to-1 return, and he cited an example to that effect
Ron’s other points were (in no particular order):
(1) He had nothing whatsoever to do with the Penn State program even though he was one of four people in the conference room holding the press conference titled: Penn State Takes Offensive in Health Plan Controversy.
(2) Four people stood up to say how bad their program was. In each case, Ron’s answer was that it was their own fault or it was a lousy program. In one case when someone complained about the typically cliched advice given to them by a wellness coach, he said: “You should listen to them and then maybe you will change your behavior.” He and Michael O’Donnell agree that most programs (95% in Michael O’Donnell’s estimation) are done badly.
(3) I was castigated because Quizzify has a 100% guarantee of savings. In the wacky world of wellness, companies that don’t guarantee anything because they can’t achieve savings are better than companies that guarantee savings because they can achieve them.
(4) Companies do not screen according to guidelines, but that is their fault. Wellness vendors would be perfectly happy to cut their fees by 70% and just screen the people who the USPSTF says to screen.
(5) He said none of my stuff is peer-reviewed so I am not qualified to do peer review. That’s why I’ve been blacklisted. Never mind that my most recent peer-reviewed article is trending #1 for the year in a major journal. Never mind that all of their stuff is full of obvious rookie mistakes, and never mind that legitimate journals like Health Affairs ask me to peer-review. And never mind that Ron himself admitted I have found many mistakes in his stuff.
I also named all the household names (in healthcare, at least) who had reviewed our stuff–Stuart Altman, Tom Scully, Regina Herzlinger, Jim Prochaska, Bob Galvin, Leah Binder, Norton Hadler. Oh, yes–and Quizzify is the only company in population health whose content is reviewed and approved by doctors at Harvard Medical School. (Formal announcement forthcoming.) And then finally I observed that we weren’t standing up there today because of his peer-reviewed stuff. We were standing up there today because of my non-peer-reviewed whistleblowing.
(6) They will still be quoting Katherine Baicker’s “Harvard Study” with the 3.27-to-1 ROI for years to come. They claim the authors haven’t backed off it one iota, regardless of what Baicker has said. And since there are no other studies to cite other than their own (which accidentally found wellness loses money), they’re stuck with this one.
(8) Even though it appears that every employee in a “pry,poke, and prod” program thinks it’s a joke or worse (and that’s why the bribes and fines have to keep rising), employees really do love wellness and want more of it, according to Ron.
(9) He accused me of spreading lies and misformation but didn’t actually name any.
(10) He admitted to doctoring original applications in the Koop Award file after my exposes, but didn’t apologize either for doctoring them or for writing in Health Affairs that they weren’t doctored, but rather that the “original application is online and available for review.”
(11) He is still defending the lies told in the Nebraska program about saving the lives of cancer victims, and still thinks Health Fitness Corporation deserves their Koop award, even though only 161 state employees improved a risk factor and the state also lied about their savings.
(12) He says 80% of costs are due to preventable diseases like cancer. I have had cancer and it was not preventable. It is frustrating to see someone tell people that my disease was preventable, when it wasn’t. He is referring to the old urban legend, thoroughly debunked on this site, that 75% of cost is preventable…but, what the heck, why not add 5%? 75% or 80%, we had already shot this fallacy down anyway.
(13) Even thought the HERO Guidelines which he co-authored and which represent “countless hours of collaboration” say wellness loses money, he doesn’t believe that section. He didn’t write it or (I guess) read it during the “two years” of this guidebook’s development. And maybe the person who conducted the webinar defending it was a different Ron Z. Goetzel.
My points–none of which were rebutted except where noted–were:
(1) I proved (using the proofs on this site) that wellness loses money and that if he thought it made money he would claim his million-dollar reward. He accepted the proof (no choice — the database that the proof was based on is maintained by another part of his company) and didn’t rebut it. One of his cronies in the audience, Seth Serxner, tried to rebut the proof but we were fully prepared for that and already had the data. We apologize to Seth for making him look bad. So the proof that wellness has lost money for 14 years is established.
(2) I proved that his entire participants-vs-non-participants methodology is made up. This was not rebutted. So all the savings in all the Koop Awards are toast.
(3) There was no rebuttal to my observation that most programs don’t work according to their own data. The rebuttal was that their own data was only one case study.
(4) I showed that basically everybody who does not make their living off wellness is opposed to it, like the left wing media and the right wing media. (Wellness supporters are running out of wings.) See the In the News section.
(5) I also made the unrebutted point that his own allies on his own committee have strayed off the reservation too — Debra Lerner and Altarum and of course Michael “95% of programs don’t work and RCTs have negative ROIs” O’Donnell.
Conclusion: nothing will change. He and his cronies — even though they have now admitted my proof, and have all passed on claiming the $1-million award — will still attempt to shove programs down employees’ throats — even though most of them (in their own words) fail and (in their own words) it is “very hard” to do a successful program.
And as long as they continue to do try to protect their revenue streams on the backs of corporations and employees, we will continue to protect them from the “pry, poke, prod and punish” jihad that is increasingly part of our corporate culture.
A special shout-out to Professor Matthew Woessner of Penn State, who made the trip down to DC, and was able to ask very pointed questions about Ron’s/Highmark’s program, the worst in wellness history. Ron disavowed any part of the “awful” Penn State program (he must have gotten lost and wandered into that conference room mentioned above) A question was also raised to the point of, that’s only one university. So the others are all fine. Matthew then got up and said Ohio State, which was the only other one he was closely familiar with, also hated their program. Quite a timely put-down and along with the questions from actual wellness program participants, highlighted the disregard in which most employees hold these programs.
RAND’s Soeren Mattke said it best:
The industry went in with promises of 3-to-1 and 6-to-1 ROIs based on health care savings alone. Then research came out that said that’s not true. They said, “Fine, we are cost-neutral.” Now research says: “Maybe not even cost-neutral.” So they say: “It’s really about productivity, which we can’t really measure, but it’s an enormous return.”
In other words, whenever you invalidate one metric, they come up with another one. We then have to shoot that one down, and the cycle repeats. It’s invalidity-meets-Whack-A-Mole. After the healthcare spending ROI fiction imploded, Michael O’Donnell, editor of the wellness industry trade journal, asked dismissively: “Who cares about ROI anyway?”
Since ROI wasn’t working, they then tried value-on-investment (VOI), which turned out to show even greater losses than a straight ROI calculation.
Continuing that tradition, Michael O’Donnell of the American Journal of Health Promotion presents: Return on Allocated Resources, or ROAR. ROAR counts everything, including productivity. By counting everything, ROAR shows far greater losses than VOI.
Michael says that a 1% increase in productivity is worth $1933:
However, a much greater 3.75% (90 minutes of a 40-hour workweek) reduction in productivity only costs $2184:
How did he accomplish this sleight-of-hand, where a 1% increase in productivity practically offsets a 3.75% decrease? Simple: by putting both thumbs and every other appendage on the scale. He accounts for lost work time at an employee’s hourly rate. So far so good. However, he then applies a magic multiplier to the hourly rate to calculate increases in productivity based on hypothetically enhanced corporate revenues due to the productivity increase. So if payroll is 30% of revenues, and productivity climbs 1%, then revenues would also automatically climb 1%. That means in dollar terms revenues climb more than three times faster than productivity.
Had he used the same revenue multiplier for the certain 3.75% productivity decrease due to wellness-induced lost work time that he used for his speculative 1% productivity increase, his time-off-for-wellness scheme would cost a whopping $7143/employee/year.
And wellness vendors wonder why line managers are so reluctant to allow employees to work out on company time.
So while per-employee losses from wellness based purely on added healthcare spending and program expense are “only” in the three figures, the net reduction in productivity from a (speculative) 1% increase less a (certain) 3.75% decrease due to lost work time amount to a mind-boggling $5210/year.
And that is probably an understatement. The 3.75% lost work time due to wellness doesn’t include the time employees spend changing clothes after their workouts, lying on HRAs, standing in line to be screened and “coached,” complaining to HR that they haven’t received their incentive checks yet, and hanging out at the water cooler dissing the program.
If you’re keeping score at home, this is the third time Michael O’Donnell has strayed off message. Just like some people are convinced that Donald Trump is a closet Democrat trying to torpedo the GOP, you would be excused for thinking that Michael O’Donnell is a member of our Welligentsia group, trying to sow chaos amongst the Wellness Ignorati.
He isn’t, but nonetheless I count him among our greatest assets. First, he admitted that up to 95% of wellness programs don’t work. Then he admitted that studies done using randomized control trials lose money. And now this one, detailing — using his own math — by far the greatest losses that a wellness metric has ever shown.
Ron Goetzel is probably tearing his hair out over his crony’s unforced errors on the eve of our debate. Or, in the immortal words of the great philosopher Warren G. Harding: “I can handle my enemies. It’s my friends who have me pacing the floor at night.”
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.