Recently I pointed out how Wellsteps’ Troy Adams feels about overweight and obese employees and how they got that way: “It’s fun to get fat. It’s fun to be lazy.” Those who read that post may recall it received quite a number of comments, which I helpfully added right to the post.

While Mr. Adams is an extreme example, it came to my attention — and to Jon Robison’s attention — that other wellness vendors have been equally dismissive and disrespectful of employees, using words to describe them more appropriate to herding animals.  Jon and I just posted a Linkedin Pulse on this topic.

PS  I’m sure there are coaches — and I am pleased to know many of them — who would never say things like this about their clients.  If you are one of those coaches, feel free to identify yourself as such on the Pulse.

You may be paying employees to do exactly the opposite of what you want them to do: you may be dramatically increasing their risk of heart attacks and dying, instead of reducing the odds, which are already very low.

Consumer Reports has discovered a dangerous drug, a molecule closely related to the banned ephedrine, in many weight-loss and performance enhancement supplements sold over the counter. Ephedrine was responsible for the death of a Baltimore Oriole, and has been implicated in other cases as well.

This drug is not found in most weight-loss supplements.  The worst you can say about most weight-loss supplements (which don’t need FDA approval because they aren’t “drugs”) is they are worthless, but not harmful.

By contrast, these other supplements shouldn’t be allowed to be sold at all…and yet they are among the most popular of all weight loss aids. Why? Because they “work.”

The fact that they work is precisely why you shouldn’t be running weight-loss contests.  Putting money on the line for weight loss is one excellent way to encourage people to do things — and in this case, take things — that they wouldn’t take if left to their own devices.

The obvious way to avoid this problem in the first place is simply not to hold weight-loss “challenges.” Regardless of what ShapeUp and Wellness Corporate Solutions say to protect their revenue streams, these contests are a fabulously stupid idea to begin with. “Weight-cycling” may be hazardous to health and is certainly not beneficial to it.  However, if for some reason you feel compelled to run this type of contest — perhaps because a Healthywage salesperson sold you on it without mentioning the hazards — you need to ban drugs containing the specific ingredient(s) named in the report.

An if there is enough money on the line (and these days there needs to be, in order to get employees’ attention), naming the banned drugs may paradoxically increase their attractiveness. Therefore you would have to do blood tests to enforce this ban. And of course once you start paying for drug testing, on top of what you pay to HealthyWage or ShapeUp, the magnitude of your negative ROI is multiplied.

Which brings me back to the original point: why do these contests at all?  Surely there is some wellness activity you can run that won’t harm employees and isn’t worthless. Not harming employees doesn’t seem like too high a hurdle for a wellness program.

Here is a random suggestion: try Quizzify instead. No one has ever been harmed learning how to avoid being harmed.

It has, of course, been proven that corporate wellness has not accomplished anything, as measured by the consensus endpoint — one of the few things HERO and I agree on — of admissions for wellness-sensitive medical events.

Along with the lack of benefit, conventional wellness has a downside: occasionally we post stories of employees complaining about how bad their wellness program is — three complaining specifically about the Cleveland Clinic’s program just last week.  Plus, Optum and others have admitted to deliberately flouting clinical guidelines, which is no way to improve employee well-being.

Yet it wouldn’t be fair to say employee wellness has benefited no one. An employee has stepped forward to say how much he benefited from none other than the much-maligned Penn State wellness program.  That employee would be the none other than the employee who led the wellness revolt, Professor Matthew Woessner, this week elected Chair of the Penn State Senate.

Usually this would be big news at least locally, but Bernie Sanders held a rally on campus the same day, and so the Senate election news got fawcetted. (To be “fawcetted” is to have your news event bumped off the front page by a bigger news event, as when Farrah Fawcett died hours before Michael Jackson. I invented the word, and it’s really gone viral. Not.)

Though Matthew was already a member of the Penn State Senate at the time of the wellness revolt, he taught at and represented the Harrisburg campus. This was not exactly a high-visibility posting   Most people — likely including some at Penn State itself and certainly including me — hadn’t even known there was a Harrisburg campus. So needless to say he didn’t exactly command a bully pulpit.

But when the University’s wellness program was announced–stealthily, in the summer of 2013, timed so that no one would be paying attention–Matthew and a few colleagues sua sponte sprung into action.  Allied against the combined forces of the university administration, Highmark and Ron Goetzel (and with a soupcon of help from moi-meme), Matthew was able to get Penn State to rescind what would have been one of the worst programs in wellness history.  Clearly his Senate colleagues–and the Penn State faculty as a whole–were quite appreciative, as this near-debacle remains fresh in their minds more than two years later.

The proposed Penn State program also flouted clinical guidelines, but that was just the beginning.  For reasons that shall remain one of life’s little mysteries, like whether there was a second gunman on the grassy knoll or how they get the stripes into toothpaste, it laser-focused rather lasciviously on employees’ privates — prostate exams and testicle checks, plus a plethora of questions involving ladyparts. For instance, refusing to disclose pregnancy plans could cost a female employee $1200.

Ultimately, it was that last question that rallied the employee base.  In a videotaped session, the Highmark representative said the reason for this fine was so Highmark could “help” employees who were planning on becoming pregnant. Jon Robison often refers to programs as “Wellness or else.” This was: “Let us help you or else.” As an analogy, imagine a Boy Scout threatening to mug a little old lady if she didn’t let him help her cross the street.

Ironically, if Highmark and Mr. Goetzel had given this pregnancy issue any thought, it would have occurred to them that by definition women who are planning pregnancies don’t need the “help.” It’s women who find themselves pregnant by accident who would benefit. So this question would have led to Highmark “helping” exactly the wrong women, while ignoring exactly the right women.  Even in wellness, a 100% failure rate is a little on the high side.

Matthew’s contribution cannot be understated. Ohio State was going through the same issue at the same time.  Their faculty and staff also hated their impending “pry, poke and prod” wellness program, but without a natural leader like Matthew, they were forced to cave.  Who says you can’t have controlled experiments in wellness?

I know it’s not always about me, but Matthew also attended the “Great Debate” in November.  (I will be finally be posting the tape of that soon. This being the wellness industry, with one shock-and-awe event after another, my debate posting keeps getting fawcetted.)   Under withering criticism from Matthew and myself, Ron ran away from his Penn State program as fast as possible, until we pointed out he was in the room for the press conference on Penn State’s “taking the offensive in the wellness controversy,” unless that was a different Ron Z. Goetzel.

Penn State’s Culture of Health

You want culture of health?  At the same time this program was being announced, the campus bakery announced an expanded selected of pastries and desserts for the upcoming academic year.  Plus, the faculty, staff, and spousal access to fitness facilities was surprisingly constrained, given that the facilities were already in place.  For less than the cost of the wellness program, the administration could easily have waived fees and other access restrictions.

The Future of Penn State’s Wellness Program

Academia being a highly deliberative and process-oriented field, there are a lot of steps between being elected and actually taking office.  Matthew will be chair-elect for a year first. So it might take 12-24 months to effect any changes in this arena, but it wouldn’t surprise me if someday the university’s program is so good that I end up writing a major article highlighting exactly the opposite about Penn State vs. what I’ve posted in the past.

That is, assuming yet another wellness vendor debacle doesn’t fawcett it.

The wellness industry coffin already has enough nails in it to have created its own gravitational field, which sucks the intelligence and integrity out of all except a very few vendors.

All those nails need to make room for another one: the most egregious case of “publication bias” in the history of nutritional science, casting doubt on a great deal of corporate wellness dogma.

Bottom line: We can add vendor dietary advice to the ever-expanding list that includes PSA tests, annual checkups, BMIs, biggest-loser contests and a whole lot of other misinformation that vendors have been charging us for (yet somehow claiming savings on) lo these many years.

First a bit of background. A researcher named Ancel Keys was the founder of the saturated-fat-will-kill-you camp.  As described in Nina Teicholz’s The Big Fat Surprise, he excelled at suppressing the findings of, and blacklisting, researchers whose conclusions opposed his. (This, of course, is exactly what the Health Enhancement Research Organization often tries to do to me–but not often enough as far as I am concerned.)

Dr. Keys was in a pickle. His own co-authored study — that rarity of rarities in nutrition, a controlled study over a long (54-month) period using a large sample size — found exactly what his critics had been saying: substituting polyunsaturated vegetable oils for animal fat increased, rather than reduced, the death rate.

Worse, the substitution also reduced cholesterol–meaning that use of cholesterol levels as a proxy for health was out the window. And worst of all, the more the subjects’ cholesterol declined, the higher their risk of death.

So naturally he suppressed his own study, much to the chagrin of the lead author.

Fortunately, the lead author kept all the data, and it was recently discovered in his son’s basement. Sharon Begley wrote it up last week in STATNews.  I’d urge everyone to read the whole article.  It doesn’t prove that saturated fat is good for us, but it does prove that it’s time to stop assuming that it’s bad for us. Likewise, it doesn’t prove that cholesterol doesn’t matter but it does prove that wellness vendors need to stop obsessing with it.

It’s not just that the study was excellent.  Plenty of excellent studies have reached the same conclusion. What makes this one the most compelling addition to the saturated-fat-is-not-the-villain genre is this: it was conducted by someone trying to show the opposite–the most powerful type of conclusion.  (In that same vein, we’ve been able to show that the wellness industry’s participant-vs-non-participant study design is completely invalid merely by reporting results from wellness true believers mistakenly thinking they showed the opposite.)

So What?

The implications for the wellness industry are staggering.  First, they need to stop micromanaging employee diets. Sure, you can encourage them to exercise and make smokers pay a premium if they don’t take steps to quit…but leave people’s diets alone (except for sugar).  There is simply too much controversy out there to present controversial hypotheses as facts, cajole employees into going along with the dietary fad of the month, and then let the vendor make up outcomes proving that they saved money.

Second, beyond cutting way back on sugar (a substance that ironically Dr. Keys was perfectly fine with despite overwhelming evidence to the contrary even back then), there is no best diet. The effect of dietary composition must be minor, and/or it varies by individual. Otherwise an effect would have shown up by now.  It took about 100 patients for doctors to conclude smoking causes lung cancer. A famous study needed only 180 people to show very high blood pressure caused strokes.  Meanwhile regarding saturated fat, we have humongous numbers of observational and controlled studies, and country-to-country natural experiments, with basically nothing to show for them other than conflicting hypotheses.

And yet thousands of companies are paying wellness vendors to browbeat employees into eating less saturated fat.

Third and most importantly, this study was suppressed by its own author. It makes you wonder how many studies that show exactly what we’ve already proven — that wellness loses money — have also not been published because the investigator didn’t like the result.

Or, the publisher didn’t like the result.

The American Journal of Health Promotion and the Journal of Occupational and Environmental Medicine make it a point to only publish positive findings. Between them they have published precisely three negative articles, not including the ones they’ve misinterpreted as positive but were obviously negative, like Aetna’s.

One of the three was a highly favorable review of Cracking Health Costs, which JOEM had to publish because a member of their advisory board wrote it. Another was by Debra Lerner, which they had to publish because it was Debra Lerner. And the AJHP has only published one, which Michael O’Donnell later spent 2000 words walking back after he realized that admitting “randomized control trials show negative ROIs” was probably not the best choice of words if your entire career is dedicated to showing wellness is good.

Even studies published in Health Affairs, invariably showing no benefit of wellness, always seem to include a spin on the findings if they are published by wellness apologists:

• The Connecticut state wellness program study showed wellness made costs go up, but the study authors spun this into concluding that the program was successful because the very fact that these costs went up means someday costs will go down;
• A study published in January showing the futility of using financial incentives to generate weight loss (which is a dubious-enough goal on its own) found no impact, but concluded that we just haven’t found the right incentives yet.

The bottom line: aside from substituting water for soda and getting rid of as much sugary stuff as possible, changing employee diets probably isn’t going to matter much, and certainly paying/fining them to make those changes is a waste of time and money.  Smoking and exercise should be the focus.

Most importantly, the focus should be on creating a workplace that makes employees happy to be there, a goal that seems all but forgotten in the rush to “show savings” that don’t exist.

The April 15 “Is Wellness Hazardous to Your Well-Being?” conference at Case Western Reserve School of Law featured an excellent presentation by RAND’s Soeren Mattke on the futility of wellness programs.  As usual, he graciously bent over backwards to give wellness programs the benefit of the doubt, generously assuming that non-participants can be a control group for participants.  Even so, of course, lifestyle management (meaning “pry, poke and prod”) programs lose money, according to RAND research.

In addition to the prepared slides, he noted off the cuff that RAND’s own wellness program costs RAND $150/employee/year.  “Get rid of this silly program and give us the $150” is his advice to them.

Next, the Cleveland Clinic’s Michael Roizen defended wellness programs, based on Cleveland Clinic’s own allegedly incredible results.

He presented many data-driven slides, railing against, among other things, saturated fat.  Mostly, he talked about the great results they have seen in their own employees.  The 48,000 employees employees of Cleveland Clinic have lost 445,000 pounds. (He said that worked out to 2.5 pounds per employee.)  Most importantly, employees aren’t burned out any more.  Their stress levels are incredibly, massively, mind-bogglingly down.  Cleveland Clinic could literally have the best wellness program in the country.  So their employee performance must be spectacular.

Yes, their performance is spectacular enough that Leapfrog Group rates the flagship hospital a “C” — among the lowest scores in the region.

It may be just a coincidence. Or it may be that Cleveland Clinic stresses out their employees so much trying to get them to claim that they’ve reduced their stress that their job performance is impacted. Or perhaps their policy of not hiring smokers even if they are the best candidates plays a role.

Or maybe if they put half as much effort into error reduction as they put into wellness, they could increase their score to a “B” or an “A”.

Or maybe, to use a classic wellness vendor argument (employed by Optum’s Seth Serxner), if it hadn’t been for their wellness program, they would have gotten D’s.

Soon after I posted this, a Cleveland nurse (who identified herself to me but would probably prefer not to be named) says:

Yet another employee has come forward, once again identifiable to me but preferring not to be identified. She says everyone in her department laughs at this program. “I loathe ShapeUp” she says, apparently having seen our expose of them.

Another (identified) person seems to have found this on Facebook and says she knows of two people fired after their physical for non-bedside positions.

If you are just joining us from the NYT this morning (10/24) also see how a wellness vendor made Boise School District employees sicker...and then lied about it.

The Connecticut state employee wellness program is so bad that I am embarrassed even to live in a bordering state.  They lose money, harm employees, and brag about it.

Losing Money

Let’s briefly review the history of the wellness industry. First, wellness was good because it saves money.

Once we blew up that claim, the wellness industry started saying “Forget about ROI. It’s all about VOI.” But it turns out that VOI is negative, according to both the Health Enhancement Research Organization (which lists 11 types of indirect costs of wellness) and the American Journal of Health Promotion (which admits that employees have to use 4% of their work week to exercise in order for productivity to increase 1%).

Now, as described in the prestigious journal Health Affairs, wellness makes healthcare spending go up above and beyond what is spent on wellness itself.  And, remarkably, losing all this money is somehow — to use the exact words of the Connecticut Comptroller, Kevin Lembo — “a good thing” because it means people are getting more checkups. Or, as the study’s lead author, Richard Hirth, says: “Some increased spending in the early years isn’t surprising.”

Harming Employees: Checkups, and Mammograms for Young Women

Checkups are included in Choosing Wisely’s compendium of low-value services.  Along with Choosing Wisely (a joint venture of Consumer Reports and the American Board of Internal Medicine), there’s the New England Journal of Medicine and the Journal of the American Medical Association.  

The Choosing Wisely guideline is copied-and-pasted at the end of this post. Choosing Wisely lists many good reasons to go to the doctor. Being fined if you don’t, as happens to Connecticut employees, is not among those good reasons.

No wonder increased spending “isn’t surprising,” Mr. Lembo. You’re sending employees to get useless checkups under duress. What did you think was going to happen?

It could be worse.  A lot of programs require checkups annually. Connecticut’s program requires them less often under age 50.

The other low-value service: mammography for young women. The US Preventive Services Task Force suggests that mammograms start at age 50, but that women in their 40s might possibly consider them. Connecticut requires one before age 39.  This is pure harm.  Ironically, the state does not require them in one’s 50s, where they might actually be helpful.

It’s been definitively established that getting routine mammograms in one’s 30s is a bad idea. The false positives and risk of radiation exposure (trivial on one person but the state is ordering x-rays on thousands of people) overwhelm the likelihood of an “early detection” of a meaningful tumor, while creating a noticeable likelihood of finding a “suspicious” but ultimately inconsequential lump that then has to be followed up for no reason.  The books Overdiagnosed and Seeking Sickness: Medical Screening and the Misguided Hunt for Disease might be good reading for Mr. Lembo.

Unless someone is at high genetic/family history risk (in which case the mammogram wouldn’t be classified as a “screen”), mammograms in one’s 30s are so inadvisable that the USPSTF doesn’t even bother to recommend against them, because it never ever occurred to the USPSTF that anyone would advise them, let alone require them.  And yet, Connecticut does. If you don’t believe anyone could come up with such a dumb idea, the screenshots — the state “prevention” schedule and USPSTF screenshot — are at the bottom of this column.

Oh, and Connecticut employees who value their health enough to want to actually follow guidelines– meaning not subject themselves to harmful overdiagnosis and overtreatment–could be penalized up to $1200/year.

Fortunately, doctors are allowed to formally exempt people from this requirement if they ask nicely. However, people who don’t ask are in trouble: doctors often find it easier to simply order a mammogram when asked than to try to explain why it’s a bad idea.  And the whole concept of overdiagnosis and false positives is a tough one to communicate in a 12-minute office visit.  That’s why we have Quizzify, of course.  But the state of Connecticut doesn’t use it.

Connecticut is a perfect example of why Quizzify isn’t already in the Fortune 500: We are advising employees to avoid low-value services, but the marketplace is much more receptive to a message of embracing low-value services.

Fuzzy Math: Study Authors Tip Their Hands

It’s amazing the outcome was as negative as it was, considering that the authors of the Health Affairs study, have that exact agenda: embracing low-value services.  Mr. Hirth runs the Value Based Insurance Design Center, whose whole purpose is to implement this type of overdiagnosis/overtreatment program, notwithstanding all the evidence to the contrary.

Hence the study’s conclusions out of thin air:

• The authors noted ER visits dropped 10%, but didn’t fully attribute the drop to the extra low-value services employees were required to get. Maybe, they allowed, the drop might possibly be attributable to the state instituting its first-ever actual co-pay ($35) for ER services.  Holy Economics 101, Batman!
• “People are taking their medications rather than going to the emergency room.”  Yes, at great expense they waived a ton of co-pays for everyone…and got about 1%-2% more people to fill prescriptions. I haven’t done the exact math and neither did the authors, but I suspect each extra bottle of pills probably cost taxpayers about $1000 in waived co-pays for the other 98%-99% that would have been filled anyway.  And it’s not quite clear how 1% more people taking pills creates a 10% drop in ER visits.
• They make references to “improved health and productivity,” without measuring it.  I know when I come back to the office after getting a useless screen that shows a false positive, the first thing on my mind is increasing my productivity.
• They redefine these low-value services like checkups as “high value services”.

Where Does Connecticut Go from Here?

As a first step, Mr. Lembo would be well advised to hook his computer up to the internet.  Once he realizes he has been snookered by his consultants, there is a way out: he can work with his union counterpart to dismantle the low-value portion of this program and share the savings between labor and taxpayers.

Because in fact there is a surefire way to get an ROI on a wellness program: Get rid of it.

CONNECTICUT SCREENING GUIDELINES

USPSTF MAMMOGRAPHY RECOMMENDATIONS

CHOOSING WISELY ON CHECKUPS:

I’d encourage everyone to take a looksee at this article in Insurance Thought Leadership.  Not just because I wrote it (though that too) but because it will open your eyes to a whole series of hidden costs of the current wellness mania.

Among the problems of wellness is that it is a full-time job. Getting employees to eat more broccoli, weight-loss “challenges,” dealing with appeals and complaints, policing vendors, holding “health fairs” etc.  Not to mention all the math involved in incentives/penalties. Catching the cheaters putting the Fitbits on their poodles.  The list goes on and on.

As a result, a bunch of other things go unnoticed:

• Massive numbers of unnecessary surgeries
• Hospital errors
• Dishonest PBMs
• Employees getting snookered by providers (or demanding low-value care)
• Opioid addictions

Addressing all of those is ultimately much more fruitful for you — and beneficial for employees — than wellness, but there simply aren’t enough hours in a day to do it all.  This article will get you started on a focus strategy…and then future articles will help you hone in on what really does make a difference.