We never post on Sundays. We are making an exception today on the theory that a lot of people in the Northeast are at home and would welcome the distraction. Here in Massachusetts it’s so cold that the Governor is urging people to stay indoors. Heck, we even decided to cancel Ultimate Frisbee.
This is now the seventh time that the New York Times —or its The Incidental Economist bloggers (“TIE” as they call themselves) — has observed that conventional corporate wellness doesn’t work. Links to the previous six instances follow this posting. Perhaps the seventh time will be the charm. Having covered every other angle except the actual health hazards of wellness, this TIE post specifically eviscerates “biggest loser” programs and their brethren.
HR executives may think they are “supporting” employees by holding weight-loss contests or paying them to lose weight. Unfortunately, all they are doing is reducing self-esteem, encouraging crash-dieting before weigh-ins, drawing attention to people’s weight, and — in addition to distracting employees from their actual jobs — distracting them from the one thing that benefits people of all sizes: exercise. It is much better to be “fit and fat” than fight a losing battle to keep weight off with various fad diets.
Further, the Body Mass Index, the 200-year-old metric wellness vendors still use to establish how much to pay or fine employees, turns out to be a very misleading measure of population health. (As “Brad F.’s” comment to a previous blog pointed out, BMIs may be of value if conducted as part of an actual physician-patient relationship. However, actual medicine is of no interest to wellness vendors, other than making people get useless annual checkups. Most physicians practicing actual medicine find wellness programs to be a misguided nuisance.)
Worse than The Incidental Economist says it is
The case against these programs is even stronger than TIE says. TIE supports its case by citing randomized control trials. But if RCTs are the Gold Standard, the Platinum Standard is wellness vendors’ consistent and total self-immolation in attempting to show their own program impact– despite ample opportunity to manipulate data, select motivated participants, ignore dropouts, and run ridiculously short “weight loss challenges” that end before the weight is regained. We love to cite ShapeUp as an example of that, having exposed them in the Pittsburgh Post-Gazette. (This was probably overkill on our part, but their CEO had thought a good way to get some attention might be to fallaciously attack our numbers even though his own figures were made up.)
Because great minds apparently aren’t the only ones that think alike, ShapeUp has plenty of company on the Biggest Loser List. Wellness Corporate Solutions has also been “profiled” on this site, largely for comic relief. Pfizer, where actively motivated employees lost a few ounces over a year, actually earned an award from Ron Goetezel for this stellar performance, as well as a spot on our Biggest Loser List. Our favorite example is McKesson. They also won one of Ron Goetzel’s Koop awards even though their average employee showed an actual increase in — you guessed it — BMI (and cholesterol):
If award-winning companies can’t get employees to lose weight, who can?
And where would a Biggest Loser List be without Vitality, which pitches its weight-loss program to others but can’t even get its own employees to lose weight? If wellness companies can’t get their own employees to lose weight, who can?
Where we differ with TIE is on weight control interventions for school-age kids. They quote one definitive-sounding study, with 4600 kids in it. We don’t have a problem with the actual study. However, because the long-term health and social prognosis for obese children is negative, and because this problem is so pervasive, we ourselves would insist on a much higher level of proof and more experimentation with different program designs before throwing in the towel on these interventions. (We may very well end up agreeing with TIE when all is said and done. We would just like more to be said and especially done.)
As for employers, our recommendation remains the same: do wellness for your employees, not to them. This means supporting employees who want to pursue health goals, but otherwise just leaving them alone to do their jobs. Don’t even make them play Quizzify if they don’t want to. (But they’ll want to — we guarantee it.)
The Incidental Economist/New York Times on Wellness: A Chronology
September 2014 TIE says wellness “usually” doesn’t work.
October 2014: TIE headlines: “Wellness Programs Don’t Seem to Work as Advertised”
December 2014 TIE says: “We’ve said it before, many times and in many ways, wellness doesn’t save money.”
February 2015 TIE headlines “Another Call to Eliminate Employee Weight Loss Programs”
October 2015 New York Times says: “Provide us with your...weight, or pay up.”
November 2015: TIE headlines “The Feds Are Wrong. Lots of Wellness Programs Violate the ADA.”
A good rule of thumb: people who challenge the US Preventive Services Task Force — but lack the requisite knowledge, credentials, relevant education, support in the literature and any rationale to do so other than protecting their own revenues — should at least spell its name correctly.
Overscreening is central to the wellness vendor business model. If screenings were to conform to US Preventive Services Task Force (USPSTF) guidelines designed to balance harms and benefits in the best interest of the public, the whole industry would collapse.
There are three ways wellness vendors can preserve their overscreening revenue stream against this onslaught of the USPSTF’s scholarship and research. The first is simply to shut up and hope no one notices. That strategy works quite well, because when it comes to screening recommendations, many human resources directors trust their advisers, often an Animal House–type mistake [WARNING: hyperlink rated PG]
The second is the blame-the-victim strategy embraced by Optum’s Seth Serxner. According to him, vendors like Optum really, really want employers to send them less money to do less screening (perhaps their salespeople are on a negative commission schedule?) — but employers nonetheless insist on screening the stuffing out of their employees. His specific statement: “Our clients won’t let us screen” appropriately. Employers “deliberately” want to overscreen. Of course, neither he nor Optum, in followup conversations initiated by Optum (saying I made them “look bad” by quoting Mr. Serxner), shared any examples of this despite repeated requests. (The unabridged statement is on the “Great Debate” tape, which hasn’t been posted yet.)
Healthmine’s Bryce Williams has a third strategy, which is to publicly announce Healthmine’s decision to flout the USPSTF guidelines. He says he is right and everyone else — specifically including the “US Preventative [sic] Services Task Force” — is wrong. A real doctor making this pronouncement might be risking his or her license. Fortunately for Mr. Williams, being a wellness vendor doesn’t require a license, so regardless of the harms a wellness vendor inflicts on employees, no one can take it away.
In addition to spelling the name of the group he is attacking correctly, we might also recommend that he not misquote the sources on which his faulty argument is based. We’re just sayin’…
For starters Mr. Williams declares: “One out of every two people in America has at least one chronic condition according to the CDC, and many more are at risk for developing one.”
Here’s what the CDC really said: “One out of every two adults has at least one chronic condition.” And if you dig deeper, you see that this list of chronic conditions cited by the CDC includes arthritis, mental illness, eye disorders and asthma, none of which Healthmine’s hyperscreening is going to reveal.
He also claims that “chronic diseases account for $3 out of every $4 spent on healthcare.” Here’s what the CDC really said: $3 out of every $4 “is spent on people with chronic conditions.” That is a much broader statement. It would include someone with borderline hypertension giving birth. That figure also includes the retiree population, where chronic disease is far more prevalent than in the working-age population relevant to wellness. In any event, we long ago eviscerated Mr. Williams’ cherished myth and just this week showed that essentially none of the top 25 hospital admissions has anything to do with screening, broccoli, or Fitbits.
Most importantly, Mr. Williams was apparently absent the day the teacher explained arithmetic. Suppose you screen 1000 employees for a 1-in-1000 hidden pathogen or disorder and your test is 90% accurate. 900 employees will test negative, as they should, and the remaining 100 employees will test positive. Since only one of those hundred employees actually has whatever you are screening for, your false positive rate is: 99%. In addition to costing a fortune to follow up on all those false positives, imagine the angst and harms from overtreatment that can befall those 99%.
If you do work out the false-positive math, you’ll see it costs at least $1 million to find and prevent a heart attack via a workplace wellness screen. And that assumes half the at-risk employees identified in the screen change behavior, whereas the last company to win a Koop Award, McKesson, had roughly 1% do those things.
None of this is to say that the USPSTF can’t be challenged. But a challenge shouldn’t be based on misspellings, misquotes, and misunderstandings of the way arithmetic works.
Mr. Williams closes with a quote that hopefully someone can explain to us because we can’t decipher it. He asks: “Which is more expensive: Over-testing or over-screening? We don’t have a definitive, quantitative answer. But let’s make sure we are asking the right question.”
We have no idea what the “right question” is, except that it’s not the one he’s asking. My vote would be: “Why are these people allowed to deliberately harm employees and there’s nothing anyone can do about it?”
Looks like employers have been fighting the wrong battle: fat employees are not the bad guys. So stop letting wellness vendors harass your employees about their BMIs, and start creating a safer, healthier work environment instead, using the tips below.
Wellness vendors live by the mantra that “75% of healthcare spending is due to preventable chronic disease.” Some variation of this appears 200,000 times on google. For instance, Johnson & Johnson (the same Johnson & Johnson proposing that companies disclose the number of fat employees to shareholders) says: “chronic diseases, most of which are preventable, account for 75%” of healthcare spending.
Leading wellness defender Ron Goetzel, in our soon-to-be-released debate tape, upped the ante. He says companies should do wellness because 80% of their cost is due to mostly preventable chronic disease.
A few observations about this claim. For starters, if I had one of the many non-preventable chronic diseases afflicting mankind, I might be offended by this blame-the-victim generalization, but maybe that’s just me being hypersensitive. And wouldn’t this statistic literally mean that if you eat broccoli, wear Fitbits, and (as recommended by Johnson & Johnson, among others) get your annual useless and possibly harmful checkups, you can live forever?
Plus, that whole 75%-(or 80%-)of-spending-due-to-chronic-disease epidemic-in-the-workplace cliche turns out to be a complete urban legend.
But rather than argue with these people, we will simply quote them, since the wellness industry’s own worst enemy is their own data. It turns out that healthcare is not about the broccoli. And Ron Goetzel’s own company, Truven, has published exactly the opposite of his sound bite — wellness-sensitive hospitalizations are rare in commercially insured populations. In the HCUP database that Truven maintains for the government, the top 25 commercially insured hospitalizations are:
To paraphrase the immortal words of the great philosopher Clara Peller, where’s the broccoli?
There is none. instead, the corporate mania of massive overscreening, broccoli, Fitbits and the now-fully-discredited employee BMI jihad is distracting companies from noticing exactly what actually does drive hospital spending and hence where prevention opportunities arise. Here are some random observations about Truven’s revelation:
- The musculoskeletal category certainly has many preventable opportunities. Ergonomics is one. Exercise classes, for sure. Benefits design and education to include encouraging access to lower-cost care is another. Reference pricing is one more. And opiate abuse is also tied into this category…but doesn’t get remotely the attention accord to cholesterol, or even seat belts.
- A lot of items on this list shouldn’t be there at all. Spinal fusion? Stents? Hysterectomies for non-cancers? Many of these procedures are unnecessary and/or harmful. (We know it’s not always about us, but the Quizzify business model helps educate employees on avoiding harms.)
- The wellness industry is ignoring the actual preventable hospitalizations in order to focus on the only thing that generates revenues for them, which is to”pry, poke and prod” employees, make them try to lose weight, and insist that they “know their numbers.” And when employees fail, they forfeit money back to their employer, which is what finances these programs in the first place.
- Why hasn’t Ron Goetzel told his wellness friends about this database his company maintains? Why is he running away from his own company’s great insights? Why doesn’t the Koop Award recognize companies that address these issues? Why is there not a single mention of this database in any of his writings?
- Despite the wellness industry’s breathless hyperdiagnosis of cardiometabolic disease due to rising BMIs, there are no diabetes events on this list. And the only cardiac events are arrythmias (no amount of broccoli will prevent them) and heart events other than heart attacks. Those events (like angina) have warning signs and symptoms, so you don’t need to hunt for them at great expense. (Heart attacks themselves are way down at #70 and #85.)
- Hospital infections appear twice on this list (#12 and #23). These could be addressed with benefits design: pay hospitals a few dollars more for each case, but don’t pay them at all for hospital errors and infections…and sit back and watch them clean up their acts, literally and figuratively. Speaking of which, why doesn’t every major employer join the Leapfrog Group and quit the National Business Group on Health instead, which still promotes biggest-loser competitions and overscreening?
- Finally, why is the government (both President Obama’s EEOC and the GOP-controlled Congress) encouraging employers to harass their employees with “pry, poke and prod” programs instead of helping employers and employees avoid low-value care? Employers can demand intrusive medical exams and even employee DNA. But they can’t simply tell employees: “You need to complete this education module before demanding low-value care.” (Quizzify has created some workarounds here, of course.)
Isn’t the right approach to look at the actual data before racing ahead with a program? Of course, but the wellness industry prefers the Yogi Berra approach: “We don’t know where we’re going, but we’re making good time.” Isn’t the right approach to tailor the solution to the problem? Of course.
But they won’t. In the immortal words of the great philosopher Upton Sinclair, you can’t prove something to someone whose salary depends on believing the opposite.
A commenter suggested doing this by costs instead. You get different DRGS…but still no wellness-sensitive medical events:
Looks like a lot of you employees should be getting your employers to refund your penalties for not losing weight…or retroactively award you your incentives…read on. One way or the other, it’s time to end corporate fat-shaming.
Here is yet another in the unending stream of reasons to be certain all those Koop-award-winning savings claims and just about every other announced wellness savings figure are fabricated: they are all based partially or totally on Body Mass Index (BMI) reductions among active motivated participants — but BMI turns out to be a worthless indicator of health status. (We’ve already pointed out that the whole concept of measuring anything on “active motivated participants” is garbage anyway, as Aetna recently proved by accidentally telling the truth.)
How worthless? A study due out in the International Journal of Obesity says 75-million Americans are misclassified, meaning their BMI doesn’t match their true underlying health status. (As an aside, this scoop comes from this morning’s STAT News, the new must-read healthcare daily.) Many people with high BMIs are healthy, while many people with low BMIs are high-risk. Shocking! Who knew?
Naturally (cue the smirk on our faces), we did. As recently as in last month’s expose of The Vitality Group‘s squirrely outcomes claims, we pointed out that BMI is a 200-year-old construct based on faulty reasoning to begin with — and noted it has been challenged on multiple bases for years. We were also the first to observe that BMIs don’t correlate with a company’s financial success. And our series: “The Belly of the Beast” chronicled one vendor’s misunderstanding of BMIs as well, though I understand they are improving quite a bit now and we wish them the best and look forward to telling you about their improvements.
The implications of this new research are staggering:
- Companies need to refund penalties, and also award incentives retroactively, to people who were unfairly denied their money because wellness vendors don’t know how to measure outcomes;
- The “subject matter experts” who wrote the HERO Report need to retract basically their whole ball of wax, since it obsesses with BMI — and they need to apologize to me for inaccurately calling my claims “inaccurate” when they are specifically and relentlessly urging readers to do the wrong thing;
- Wellness vendors need to learn a thing or two about wellness, for a change.
- And guess who’s 3.27-to-1 ROI was based on studies obsessing with BMI? Kate Baicker, that’s who. Despite multiple hedges and walk-backs, she has yet to issue a formal retraction of her puff-piece on wellness economics. This gives her a good excuse.
Of course, in wellness, “the implications are staggering” means: “business as usual,” and they won’t do a thing to address these new findings.
The EEOC can’t ignore this. How can they give employers more leeway — as they now intend to do — to fine employees based on a variable they now know to be wrong?
Quizzify 1, Wellness Vendors 0
Those of you who use Quizzify don’t have to fret, by the way. The correct answers to the Quizzify question: “What is a BMI?” already include:
- “A crude measure comparing your height and weight,”
- “Can be very misleading if you in otherwise good condition,” and
- “Is good to know but not to obsess with.”
(For those of you keeping score at home, Quizzify’s incorrect answer is: “It stands for ‘Bowel Movement Intensity,’ and indicates how much effort you required in order to stay regular.”)
Even so, we will be adjusting the answers going forward to take into account this new research, starting next week. We expect the wellness ignorati will follow suit in a few years — once they stop advocating lowfat diets, PSA tests, and annual mammograms. The good news is that they generally no longer recommend bloodletting.
You may remember our series on the HERO Outcomes Guidelines Report. We had observed that their own numbers showed wellness loses money. Specifically, they showed a program costing $18/person/year or $1.50 PMPM:
Gross savings were pegged at $0.99 PMPM:
Silly ol’ me reasoned that if a program costs $0.51 more per month than it saves, that annual net losses would exceed $6.00. Of course, that’s before counting all the other costs that the HERO Guidebook listed (pp 10-11) but conveniently overlooked in their actual cost calculation:
Silly ol’ me also assumed these cost and savings figures had been approved by the 60 “subject matter experts” who reached “consensus” in this report, consensus being a word that appears 16 times. The report itself required “two years and countless hours of collaboration.” (p. 3)
Hopefully you can see how I might have been inadvertently misled into thinking the report actually did represent expert consensus, reached after two years and countless hours of collaboration.
I’ve since learned that the nice people at HERO are very upset with me for falsely assuming that the information in their report represents the information in their report.
They call my lapse of integrity “outrageous.” This adjective was contained in a letter read but not sent to me by a member of the HERO Board. (At the risk of blowing his cover, this is a guy known for his integrity.) Staywell’s Paul Terry, whose own escapades have been well-chronicled on The Health Care Blog, had apparently circulated this letter around a while back on behalf of HERO.
Specifically, Terry stated it was “outrageous” that I had failed to mention that this money-losing scenario in the HERO Report was just one example of a wellness outcome. For some unknown reason, HERO elected to illustrate the financial benefits of wellness with an example that loses money. That would be like a tobacco company illustrating the health benefits of smoking with this example:
Piling on, Ron Goetzel also disavowed the HERO report’s figures during our debate, stating that his numbers are “wildly different” from the ones in the report he co-authored.
Apology and Atonement
To atone, I will substitute Ron’s recommended “wildly different” wellness budget of $150 per employee per year for the report’s $18 PEPY. Then let’s adjust the $0.99 PEPM savings in reduced wellness-sensitive medical event (WSME) spending for the natural decline in WSMEs that occurred over the same period, according to Truven. Truven is Ron’s employer and hence is presumably the source of Ron’s “wildly different” figures for WSMEs.
If you can’t read Truven’s numbers above, they show a decline in WSMEs in the working-age insured population between 2009 and 2012 of 23%. This actually greater than the 17% (3.14 down to 2.62 “potentially preventable hospitalizations” per 1000) decline in the HERO example over the same period:
But we’ll give HERO the benefit of the doubt and say doing wellness reduced wellness-sensitive events as much as not doing wellness would have reduced them.
That actually is the “benefit of the doubt” because a review of all the Truven data compiled for the government shows that indeed WSMEs have consistently trended more favorably in the non-exposed populations than in the”privately insured” population below (in green), much of which was exposed to wellness.
Adjusting for the benefit-of-the-doubt secular decline in WSMEs wipes out gross savings — even without counting all the following claims costs that HERO says should actually increase:
Or maybe those cost increases also only happen in this one rogue example in this one rogue chapter. And maybe this one rogue chapter (Chapter 1) just contains a terrible, horrible, no good, very bad example that somehow accidentally found its way into the HERO Guidelines Report even though none of the 60 subject matter experts believe it. Or maybe two years wasn’t enough time for these experts to review it, though my review required only five minutes. Perhaps that’s because when I read, I don’t move my lips.
Per HERO’s and Ron’s request, I’ll replace their original estimate of $6 in annual losses PEPY with Ron’s new net loss estimate of $150 PEPY. And that’s without the multitudinous added costs that they also listed but never counted.
All in, my original estimate was off by almost two decimal points. However, I take responsibility only for the magnitude of the error, not for the delay in correcting it. If HERO had told me last year to substitute these real figures for their rogue example, I would have corrected the figures posthaste.
And my lips would have morphed into a great big smile.
Goofus and Gallant is a Highlights for Children feature contrasting different behaviors. Example:
Viverae’s and Quizzify’s guarantees lend themselves to this type of comparison. Honestly, we don’t even know if Viverae still offer theirs. Nonetheless, through the years a number of people have sent it to us and asked for our help interpreting it. (That’s a polite phrasing of what the emails said, and of course we are nothing if not polite.) It provides an excellent opportunity to learn how to read a guarantee with a discerning eye, and we thank Viverae for offering it and hope they too are able to gain some insights from our analysis of it.
Here is Viverae’s guarantee, which we will review clause by clause:
Goofus: Viverae’s Clause #1 doesn’t allow any leeway in program design.
Gallant: Quizzify offers the guarantee even if you want to tweak the program design.
Goofus: Viverae’s Clause #2 is an EEOC violation. You can’t “require” employees to do biometric screens. The program wouldn’t be voluntary. You might as well just send a memo to your employees with the phone number of the EEOC and tell them to sue you.
Gallant: Quizzify guarantees no EEOC lawsuits, and actually indemnifies against them.
Goofus: Viverae’s Clause #3 would seem fairly self-evident–except that in wellness, as the example at the end of this posting* shows, some wellness vendors don’t know there are 12 months in a year.
Gallant: Quizzify assumes its customers know that a year has 12 months in it, so this clause isn’t part of our guarantee.
Goofus: Viverae’s Clause #4 requires you to not only sign up for 3 years to get this 20% guarantee in the third year only, but also to waive your rights to early termination. So basically they are saying: “If you sign up for 3 years with no ‘out’ clause, we might possibly give you a guarantee worth 6.67%/year on average, assuming we measure validly.”
Gallant: Quizzify’s price list offers customers discounts exceeding 6.7% a year for multiyear contracts anyway, even before any guarantee, and allows not-for-cause termination for a small upcharge.
Gallant: Quizzify’s guarantee is 100% in all years, not 20% in year 3.
Goofus: Viverae’s Clause #5 requires a minimum number of 1000 employees, making it off-limits to more than 98% of America’s employers.
Gallant: Quizzify offers a straight 100% satisfaction guarantee if the number of eligible employees is too small to measure savings objectively.
Goofus: Viverae’s employee incentive/penalty requirement in Clause #6 is the “maximum allowed by law.”
Gallant: Quizzify requires a minimum incentive of only $100. We believe that the program should be attractive enough that you don’t need to force employees to participate.
Goofus: Viverae’s Clause #7 requires all carriers and PBMs for all years to turn over all employee-identifiable claims files. Since Viverae is not HIPAA-compliant, that creates a HIPAA issue. (In all fairness to Viverae, most wellness vendors are not HIPAA-compliant. Quizzify is the exception. Quizzify doesn’t collect or store private health information, so HIPAA doesn’t apply.)
It also means Viverae determines how much money Viverae saved, with no oversight.
Gallant: Quizzify allows the customer or its consultant to complete its simple claims extraction algorithm and determine savings, or Quizzify can do it for them. Its claims extraction algorithm is the industry standard required by the Intel-GE Care Innovations Validation Institute.
Speaking of the Validation Institute, Goofus’s guarantee is not validated by them.
Gallant reminds readers that both he and Goofus are trademarks of Highlights for Children so don’t even think about using these characters without attribution.
Goofus sprinkles Gallant’s DNA at crime scenes.
*Avivia “three-year” study of drug adherence:
If you like this example, you’ll love This Is Your Brain on Wellness