In the wellness industry, vendors are allowed — indeed, encouraged by the prospect of winning a Koop Award — to flout clinical guidelines, pay employees to crash diet, sell franchises by bragging by the lack of qualifications needed by franchisees, and of course actually harm employees. One would think such an industry is totally unregulated. And, yet, as described in the erudite but highly readable Rule the Rules of Workplace Wellness Programs, by Barbara Zabawa, there are mind-boggling numbers of regulations. It happens that none of them actually prevent rogue vendors from harming employees, though. You’d think just by random chance one of them would, but no such luck.
This book is the compendium of everything needed to assure compliance with the myriad of sometimes contradictory regulations that govern workplace wellness. Over the years, a large number of generally disconnected laws have spawned an even larger number of regulations, opinions and interpretations of those of laws, and this book covers all of them. I was impressed by how the authors tackled the mind-boggling complexity and interplay of these rules in such a readable fashion. I myself dog-eared many pages for future reference.
For my company (Quizzify), this book has been especially helpful as, thanks to its guidance, we are able to now offer an HRA which satisfies the “reasonably designed to promote health or prevent disease” standard far better than the typical buckle-your-seat-belt-and-eat-more-broccoli HRA — and does it without collecting personal health information. Hence we avoid all the HIPAA concerns while satisfying the standard for what constitutes an HRA many times over. Absent hiring an expensive attorney, this would not have been possible for us to do without this book as a touchstone.
While designed to be read and hence not classically termed a “reference book,” the chapter most readers will want to refer to time and time again is #4, covering the laws of workplace screening and incentives. If you are going to get in trouble, that’s where it will happen. Virtually all the lawsuits filed by various employees have alleged violations of laws and regulations around screenings and incentives/penalties.
The ultimate irony is that this book is about 400 pages long.. That’s how much space is required to cover all these rules. And yet there is no rule saying that vendors can’t harm employees, which would seem like it should be the most basic if not the only rule of wellness. So Wellsteps was able to get away with harming employees of the Boise School District (and, this being the wellness industry, be rewarded for this performance with a Koop Award) and — aside from a scathing expose by ace journalist Sharon Begley in STATNews — face no consequences or liability. Yet if you don’t follow all the steps listed in here for avoiding minor transgressions (for instance, your coaches may accidentally ask people about their family histories — a useful but in most cases illegal line of inquiry) you could find yourself in violation of one or more of the laws which somehow manage to make wellness programs both more complex and less effective at the same time.
At some point, all these regulations should be shelved in favor of a “do no harm” standards as covered in the Wellness Code of Conduct (for which Ms. Zabawa is an endorser and co-author), findable at ethicalwellness.org. But until then, these rules rule the industry, and as the title says, you need to rule the rules.
Healthcare meets Network.
That is the one-sentence summary of Dave Chase’s new book, A CEO’s Guide to Restoring the American Dream: How to Deliver World-Class Healthcare to Your Employees at Half the Cost.
Dissecting the title, the “restoring the American Dream” reference is as follows: While wages have barely budged in the last 20 years, employee compensation has risen quite a bit — with most of the increase being the health benefit. Dave’s observation is that if the health benefit were managed much more tightly, wages could climb noticeably for the workforce without increasing the total employee compensation budget.
As for “half the cost,” that number may be overstated…but not by much. For instance, I just saw a wellness vendor send 2/3 of a company’s employees to the doctor because they have “conditions” they didn’t know about, that this vendor “discovered” by — you guessed it — screening the stuffing out of them by flouting clinical guidelines. This employer could save about 3% simply by firing the vendor and not consigning all those employees to the treatment trap. (And of course there has been no measurable improvement in outcomes from all these doctor visits.)
This employer and others could save another 0.5% simply by not insisting that their employees and spouses get annual checkups (and “well-woman” visits) because as readers of this site know, they have no value. The good news is that checkups are not likely to harm employees, which is more than can be said for many wellness programs.
So we are already saving 3.5% and we haven’t even done anything hard yet, where “hard” is defined as “something that does not delight employees, like getting rid of ‘pry, poke and prod’ programs.” In other words, “hard” isn’t really hard.
Slightly harder opportunities
In addition to an expose on wellness, Dave Chase exposes some scams that make wellness look like child’s play. (Wellness is child’s play, in the sense that any fifth-grader knows more arithmetic than a wellness vendor. And a 14-year-old knows more about BMI.)
In no particular order, we’ll start with PBMs. Their stock prices have exploded — literally, 300-fold — in the last 30 years. You think they achieved that growth honestly? They make wellness vendors look like boy scouts. They obfuscate everything, with “rebates” and “formularies” and under-the-table payments from drug companies, and all sorts of other things that we probably don’t even know about. Here is a New York Times article that casts just a little light on the subject…but more than enough light to indict the entire industry.
It isn’t easy to ditch a PBM, but increasing numbers of alternatives are popping up. A good rule of thumb is, the thicker the contract with your PBM, the more you are getting ripped off. I invite folks who offer one of these new alternatives to add a comment at the bottom of this posting and/or on linkedin following this posting.
Then there are the carriers, who typically make more money, the more money gets spent. The number of scams is mind-boggling. For example, consider Dave’s explanation of what happens when a claim is overbilled:
Another fee opportunity is so-called “pay and chase” programs,
in which the insurance carrier doing your claims administration
gets paid 30-40 percent for recovering fraudulent or
duplicative claims. Thus, there is a perverse incentive to tacitly
allow fraudulent and duplicative claims to be paid, get paid as
the plan administrator, then get paid a second time for recovering
the originally paid claim.
And good luck trying to ferret your own claims data out of carriers so that you can do your own analysis on them and change policy accordingly. I do quite a bit of work for top-flight carriers, measuring their wellness-sensitive medical events. They always seem to have the data at their fingertips. We can complete the analysis for the year within weeks after claims run-out ends, meaning sometime in April. Meanwhile, I’ve got a Fortune 50 client whose carrier, Optum, still hasn’t managed to provide them (at an extra fee!) with their own event rates for 2016, a delay which more than coincidentally will make it impossible to implement any cutbacks in Optum’s services for 2018 if the event rates show that — hang onto your hats — Optum didn’t achieve anything.
Don’t get Dave started on providers, who find highly creative ways to snooker employers and employees. Like staffing in-network facilities with out-of-network doctors, who then bill patients ridiculously high charges. You need to re-contract with your carrier and put that one on them. Or, if you’re large enough, recontract with the hospital.
And speaking of hospitals, why have Leapfrog D- and F-rated hospitals in your network at all? If geographic necessity, then at a miimum educate your employees that it might be worth the extra drive to avoid some major complications.
Providers also bill companies what they think they can get away with, rather than what a buyer would expect to pay given what others in the area are charging. Since the company is generally not the decision-maker (the employee or doctor generally decides where to go, not based on price), they often get away with it. An entire chapter is devoted to provider pricing scams and the importance of transparency.
Or, my own personal favorite provider scam, disguising emergency rooms as urgent care centers, like the one below. (A rather naively idealistic Colorado legislator tried to make freestanding ERs disclose that they are not urgent care centers, but the provider lobbyists prevailed.)
A sidebar: Quizzify trains employees to be on the lookout for these scams, which is helpful for the 0.1% of the 150,000,000 commercially insured employees who actually have access to the quizzes. The other 99.9% are on their own.
And yet it all comes back to wellness
Employer obsession with wellness has caused them to take their eyes off these many other balls, because wellness was supposed to solve everything (including industrial waste, according to HERO stalwart Bruce Sherman). Truly wellness has been the Maginot Line of healthcare cost containment strategies. While a vastly disproportionate share of resources has gone into wellness, PBMs, carriers, providers and various middlemen simply circumvented these efforts, to dig right into your pocketbooks.
I can only scratch the surface here — just go out and buy the book, and then you’ll understand both why when it comes to scamming employers and employees, wellness vendors have a lot to learn, and also why you should be mad as hell and not take it any more.
I think I should hit “Reblog” on this post because it’s getting a fair number of “likes.” It is 4 years old but still applies, probably even more so. I guess I thought everyone had seen it but apparently not. Short answer: yes, it does cost about a million dollars to avoid a heart attack using a screen.
A lot of screening exams cost way more than they save and often they prevent only very few bad outcomes. The article below is an excellent review of screening protocols and analyses and the math that goes into figuring these outcomes. Great read for any businesses considering adopting Wellness screening.