Case Western Reserve Takes on Wellness. Wellness Loses.
Workplace “pry, poke and prod” programs are like pennies, Communism, baseball and Microsoft Outlook, in the sense that if they didn’t already exist, nobody would invent them.
This observation does not apply to workplace screening according to actual clinical guidelines, and next-generation programs like the Wellness 401W Savings Plan, which are good ideas that should get traction. It doesn’t apply to wellness done for employees instead of to them. It doesn’t apply to the Sterlings, It Starts with Me’s, USPMs, ImpactHealths, Redbricks, and Limeades of the world, who are doing the right things. (If you think I am leaving anyone out, let me know!) And of course it doesn’t apply to health literacy, a la Quizzify. There is no argument in favor of ignorance.
There is no better evidence for this observation than the current issue of the Case Western Reserve Law-Medicine Journal, which devotes almost its entire current issue to the problems with these first-generation wellness programs.
The lead article, “The Outcomes, Economics and Ethics of the Workplace Wellness Industry,” shows how vendors cover up their losses and harms to employees with lies that would make a White House press secretary blush. When they get caught blatantly lying and harming employees (and kudos to Sharon Begley for her expose on Wellsteps), they simply give each other awards. To paraphrase the immortal words of the great philosopher Ryan O’Neal, being a Koop Award winner means never having to say you’re sorry.
Next up is The Incidental Economist (TIE) team, weighing in on the “Dubious Empirical and Legal Foundations of Wellness Programs.” Kudos to TIE for outing this scam (the LA Times’ word, not mine) years ago. I did too, but the difference is that they have “day jobs” dissecting all the other frauds in healthcare, whereas I have altogether too much free time on my hands.
Samuel Bagenstos then piles on with “growing…evidence that reliance on workplace wellness to reduce disease is bad and likely futile health policy,” before deconstructing the questionable legality of these programs, featuring a definition of “voluntary wellness programs” that would make George Orwell blush.
Next up is Leah Fowler, pointing out that one reason wellness programs fail is they assume you can basically “give [employees] the opportunity” to lose weight, and they will. Fowler and her co-author Jessica Roberts point out that social determinants of health rather than employee indifference are vastly disproportionately the cause of poor health. “Nudges” won’t help. The evidence overwhelmingly supports their thesis. (And kudos to our own Tom Emerick for being first out of the box with this insight.)
Finally, Penn State’s resident health policy experts, Professors Scanlon and Shea, review the debacle of Penn State’s own wellness program and the (many) lessons that can be learned from it. The combination of their policy expertise and having been in the belly of the beast makes for a compelling read.
The bottom line? Wellness in its current form is such a sham (Slate’s word, not mine) that I can offer a $2-million reward for showing it works, knowing my money is safe from the Wellness Ignorati, who for all their bluster apparently either know their programs fail, or don’t have any use for $2-million. (They hate me so much you’d think that even if they didn’t need the money, they’d claim the reward just to keep me from having it instead.)
It’s up to us to create a next-generation offering that benefits employees, and that they like. I see some good things out there on the http://www.ethicalwellness.org website — Sterling Wellness, It Starts with Me, and many other vendors have endorsed it. (You know it’s a good start because none of the Wellness Ignorati want anything to do with it.)
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Fitbit Throws a Bit of a Fit, Part 2: More Fitbit Tidbits
The “prequels” to this posting are:
Fitbit might just have taken the lead in the wellness industry’s race to the bottom. They are using the “dumb and dumber” defense to deflect their ethical shortcomings. This defense has been shown to work, in the sense that Ron Goetzel still has a job.
In Fitbit’s case, they have no choice. If they claim to be intelligent, that would mean they dramatically overstated the value of Fitbits deliberately, as opposed to out of pure, sheer, unadulterated ignorance. In turn, that would mean that the folks at Fitbit could be facing a little taxpayer-financed vacation in the federal hoosegow. That’s because public companies aren’t allowed to deliberately misrepresent their product to shareholders, which is precisely what this press release does. Stupid is OK. Dishonest isn’t.
Here are a few more morsels from that study:
- There were 22,259 employees in the employer population. Only 905 were in the study population. So the entire analysis of savings was based on projection from 4% of the population.
- For some unexplained reason, the control group –the people who did nothing at all — enjoyed a dramatic 9.3% reduction in medical claims costs, vs. an “expected” increase of 5.8%, a 15.1% swing. So doing nothing turns out to be a great strategy to achieve double-digit savings.
- Speaking of doing nothing, perhaps our favorite tidbit from this study is that an employee could stay in bed for up to 182 days a year — meaning take 100 steps a day or less, getting up just to eat and pee, as described in the original Springbuk study — and “save” 21.8%.
- It’s also possible that employees simply forgot to put on their Fitbits the other 183 days of the year, which is why they didn’t appear to take 100 steps on those days. However, that possibility is not acknowledged anywhere in the study. That could be because it wouldn’t make for much of a study to say: “We compared people who forgot to put on their Fitbit for fewer than 182 days to people who forgot to put on their Fitbit for more than 182 days.”
Therefore, whatever the other criticisms of this study, no one can accuse them of lying or even exaggerating when they say:
Speaking of which, let us now just focus on the 374 people (about 2% of their entire population) who did take more than 100 steps a day for a whopping 274 days out of the year or more. Their savings are massive:
Even the healthier subset of employees can reduce healthcare costs by a quarter by wearing a Fitbit, but that’s nothing compared to “low steps” employees who walk only 6477 steps a day, about the same as everyone else in the country. Those lucky employees can slash costs by more than half by continuing to walk an average number of steps, but this time wearing a Fitbit.
Oh, wait a sec. They were wearing a Fitbit in the baseline year too. Otherwise, how would we know how many steps they took? So they didn’t do anything in order to save massive sums of money.
Come again? This conclusion seems wacky even by Fitbit/Springbuk standards. So let me repeat it: these people did basically nothing in the study year that they didn’t also do in the baseline year…and yet they somehow set a record for greatest cost reduction ever achieved in a year, 50.7%.
Then, these employees broke their own record. This next chart is for employees with “>=365 days” of use over the course of a year. (Not sure how they could have worn a Fitbit for “greater than 365 days” since the baseline for this two-year study was 2013, but maybe every year is a leap year on Springbuk’s planet.)
You read that right: a 58.6% reduction in spending for those 133 people taking the average number of steps everyone else takes in both years.
How much is a 58.6% reduction in costs in terms of utilization reduction? That means that simply by continuing to be average, these 133 average everyday folks wiped out the equivalent of all their hospitalizations and ER visits and specialist visits besides. Of course, we won’t know because Springbuk never plausibility-tested the result. As they say in journalism, it was a story too good to check.
Or, if Springbuk and Fitbit understood the concept of attribution as described in Biostatistics 101, they would realize that one can attribute only reductions in wellness-sensitive medical events to a wellness program, since those are what a wellness program is designed to avoid. If only those events can be avoided, they must have wiped out heart attacks and diabetes for these 133 people, their spouses, and roughly 5000 of their closest friends.
If anyone is interested in the real health impact of activity tracking, I’d recommend this JAMA article. It’s the only one on the topic which is not financed by people connected to the industry. Researchers attached activity trackers to some at-risk overweight/obese people to see how much weight they would lose (which would mean a reduction in their risk and possibly a slight reduction in their healthcare costs). The study’s result? The study population gained weight.
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Fitbit Throws a Bit of a Fit, Part 1
This column originally appeared in the Corporate Health and Wellness Association blog but they were asked to remove it by Springbuk, which did the original analysis. Not because it is inaccurate — no inaccuracies have ever been pointed out despite multiple requests by me to do so — but because it was accurate.
So I’m re-posting it here.
This is a sequel to “Springbuk Wants Employees to Go to the Bathroom,” which should be read prior to reading this posting.
In wellness, it’s totally legal to lie to customers. Indeed, if you don’t, you’ll probably lose them, since your competitors are happy to do exactly that, and most customers aren’t going to notice anyway.
In securities, though, it is totally illegal to lie to shareholders or to pay someone to write a favorable but dishonest report on your product, with the intent of propping up the stock price.
This brings up to Fitbit, and a recent report on savings allegedly generated by their activity trackers, published by Springbuk. Let’s leave aside for a moment the value of activity trackers to users. I like mine enough to generally recommend they be offered and subsidized (not given away) as part of a corporate wellness program, but “like” is not the issue in this savings claim. The issue is whether the math works.
And it doesn’t.
The Springbuk report of savings and outcomes for Fitbit was impossible. Among the clinical issues is the study design itself: the report defines “active” as taking 100 steps a day. However, as the previous installment showed, it is impossible not to take 100 steps in a day without being so sick you can’t get out of bed. So rather than being the threshold for being counted as an “active” person, as the Springbuk study says, it should be the threshold for being a person who can get out of bed. And of course, people who can get out of bed will by definition have lower healthcare costs than people who can’t get out of bed, whether or not they wear a Fitbit.
Among the mathematical issues, it is not possible to reduce costs by 45.6% (one of the claims made) with a fitness device, because in the working-age population, only about 5% of hospital admissions are caused by lack of fitness.
Further, in addition to the apparent mathematical and clinical impossibility of Springbuk’s results, the author — and Fitbit — refused to respond to the following query.
Hi Mr. Daniels,
I have some questions about your report. Perhaps I’ve gotten some things wrong, so I’d love to hear from you in the next 3 business days, if I have.
First, isn’t it the case that anyone who is not in a wheelchair walks at least 100 steps a day, Fitbit or no Fitbit? Is that the threshold for “active” as opposed to “bedridden” ?
Second, Figure 2c indicates that the very fact of being in the “engaged” group, even if you never get out of bed, reduces costs by 30%+. How is this possible? A corollary: It would seem that all savings is being attributed to Fitbit, at least in the Fitbit interpretation. They also seem to be taking credit for this: “266 employees who used their Fitbit tracker for at least half the duration of the program decreased their healthcare costs by 45.6% on average.”
Third, can you reconcile this statement…:
“The materials in this document represent the opinion of the authors and not representative of the views of Springbuk, Inc. Springbuk does not certify the information, nor does it guarantee the accuracy and completeness of such information.”
“This demonstration of impact achieved by integrating Fitbit technology into an employee wellness program reinforces our belief in the power of health data and measurement in demonstrating ROI,” said Rod Reasen, co-founder and CEO of Springbuk.
Fourth, how is it possible to show basically no separation for 182 days of getting out of bed (taking 100 steps a day) from being bedridden, but massive separation for getting out of bed for 274 days? I can’t find the explanation of the exercise science that would lead to that result. It would seem that there is some huge physiological disadvantage to those extra 92 days of taking 100 steps.
Fifth, am I missing the disclosure that Fitbit paid you to do this study? I can’t find it anywhere. Or did you do this on a pro bono basis?
Sixth, would you have come up with this same result if you had been paid by a hedge fund that was shorting Fitbit stock and wanted to show no savings?
Seventh, since most wellness-related healthcare spending is unavoidable altogether by walking 100 steps a days or any other amount for 12 months, I’m wondering if you were able to determine approximately which elements of healthcare spending were reduced, in order to get a 45.6% reduction in costs? You would have to wipe out all hospitalizations, for example – and get roughly a 10% reduction in everything else.
Thanks very much. If you would like to reply, I’ll look forward to your reply by 5 PM EDT on Wednesday 5/24.
Assuming Fitbit paid Springbuk (that’s a big assumption — this obvious conflict of interest is not disclosed anywhere, so the reader has to decide whether Springbuk collected money, or whether they did this study out of the goodness of their heart), one of four outcomes is possible:
- Springbuk genuinely thinks, among other things, that walking 100 steps a day for 274 days reduces healthcare costs by 27% vs. walking 100 steps a day for only 182 days. No crime there, other than the one committed by the grade school that granted them a diploma. It’s unlikely they think this, because Springbuk says they are “obsessed with analytics” and that they sell “the leading health analytics software…[with] powerful insights.” So if Springbuk truly believes their own report, then congratulations are in order: they have accomplished more in this one analysis than most extremely stupid people accomplish in a lifetime. (Not an original line, as Veep fans know, but apropos nonetheless.)
- Springbuk wanted to show savings because they were being well-paid to do so, but Fitbit put no pressure on them when they gave them the check. Once again, doesn’t say much for Springbuk’s ethics, but Fitbit did not commit a crime.
- Fitbit paid Springbuk to lie for them, in order to impress prospects and customers. Once again, no crime. There wouldn’t be enough room in the prison system if lying in wellness were a crime. (See http://www.ethicalwellness.org for a list of wellness vendors that have agreed not to lie. It’s not very long.)
- Fitbit paid Springbuk to lie for them, in order to inter alia impress investors. This is not legal, any more than if Fitbit made up their own data for that reason. Since many Fitbit analyst reports make reference to savings of “up to $1500 per employee per year,” and since this study appears to be one of only two justifications for that statement (the other being equally suspect), there is a case to be made that Fitbit’s stock price would indeed be lower if they told the truth: that no disinterested researcher has ever found more than a trivial impact on employee health status or healthcare insurance cost.
We don’t know which of these four is the case. Is Springbuk dishonest, or just incompetent? Does Fitbit genuinely believe that wearing their device could magically reduce healthcare costs for US corporations by hundreds of billions of dollars, or are they willing to lie in order to boost revenues and their share price?
We look forward to hearing the answers to these questions once the financial media gets hold of this posting.
Header Photo – Copyright: dzejmsdin / 123RF Stock Photo
Opinions expressed in this column are those of Al Lewis individually. They do not necessarily represent the views of the Corporate Health and Wellness Association. Therefore all threats of lawsuits should be directed to the former, to which I say: “Go ahead. Make my day.”
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Al Lewis said What???
Dear They Said What Nation,
Usually I am the one quoting people verbatim. Being quoted verbatim, of course, is the wellness industry’s worst nightmare. (I’m talking to you, Fitbit. And remember that today is your final day to respond to my observations about all the fallacies in your study. More specifically, this is your final day on your final extension, since you’ve now had 40 days, including 3 “final” deadlines, to answer 6 simple questions, or roughly one week per question.)
So let’s see how I do when the situation is reversed, as I am the one being quoted verbatim in this WELCOA podcast. You have to access it via their site, which means getting on their mailing list. Several people have asked if I could post this in its entirety. I hate to disappoint my fan base, given how few people are in it, but it wouldn’t be fair because it’s WELCOA’s IP, and the only advantage for them of putting in this effort is to expand their mailing list. (We’re only sending the pdf to FOQs — friends of Quizzify.)
However, I can share some highlights with everyone.
First, no one has claimed the $2-million reward for showing wellness doesn’t lose money. Just once it would be great if someone could explain how they can be so certain that wellness saves tons of money but at the same time so certain that it doesn’t save money that they aren’t willing to risk a small entry fee to make $2-million.
Second, there are good programs out there in the well-o-sphere. I named a bunch of them and also special kudos to the program I am in, at Boston College. I said:
I’m in an outstanding traditional program, my wife’s. She teaches philosophy at Boston College. They’re amazing. They screen — but it’s generally according to guidelines, so I go in once every few years. They’ve got Harvard Pilgrim’s nurses doing the coaching. They are excellent and totally up to date with information. Likewise, the actual health risk assessment itself is completely up to date. All good information. If every program were like this, there would be no place for me. I’d be living under a bridge eating squirrel.
Of course some kudos went to Cummins too, and on the public sector side, to Hilliard County (OH) and the City of Chelmsford, MA.
Finally, I noted the Wellness Code of Conduct, which now has quite a number of endorsers and followers. I would urge people to join it, if they haven’t already.
Before anyone starts puking, it isn’t all sweetness-and-light. I called out the usual suspects, and gave the “back story” on how my first book, Why Nobody Believes the Numbers, got me blacklisted due to an overdose of integrity. And, no, it wasn’t because I named names. It didn’t name names. That came after I got blacklisted. I had nothing to lose, so I figured I might as well go public.
They Said What? 