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The wellness industry’s terrible, horrible, no-good, very bad year

OK, this time I’m not the one causing the kerfluffle in the wellness industry, though I will confess to being a force multiplier.

Not since 2014, when the very unstable morons at the Incidental Economist made fun of the very stable geniuses who give out the Koop Award and also unequivocally concluded wellness loses money — combined with continued fallout from the Penn State debacle and the Nebraska scandal — has the wellness industry had such a bad year. And it’s only February.

Let’s review what’s happened so far in 2018. First, a federal judge ruled that voluntary wellness programs need to be — get ready — voluntary. The EEOC’s responded with the legalese equivalent of:  “Fine, be that way.”

Next, WillisTowersWatson did something that might get them in hot water with the very stable wellness industry leaders: they were honest. They published a study revealing that employees hate wellness even more — way more — than they hate waiting for the cable guy to show up.

Finally, the very unstable National Bureau of Economic Research conducted a controlled study finding basically no impact whatsoever of a wellness program.  More importantly, they specifically invalidated the “pre-post” methodology.  Even more importantly, they specifically invalidated 78% of the studies used in Kate Baicker’s “Harvard Study” meta-analysis.

Here is an interesting piece of trivia. The lead researcher is an assistant professor at the Harris School of Public Policy. Why is this interesting trivia? Because Katherine Baicker — the Typhoid Mary of Wellness, whose THC-infused 3.27-to-1 ROI is the basis for essentially every subsequent genius wellness outcomes claim — is now the dean of that very same Harris School.  I’m just guessing here, but I’d say it’s gotta be a trifle embarrassing when your own subordinate publicly disproves your own study. I mean, it’s one thing for me, RAND, Bloomberg, and anyone else with five minutes, internet access and a calculator to do it, but…your very subordinate?

On the other hand, the researcher, Damon Jones, just demonstrated not just amazing competence, but amazing integrity as well. In other words, he has no future in wellness.


The Wellness Empire Strikes Back

How does the wellness industry respond to these smoking guns threatening their entire revenue stream? Apparently, there is little cause for concern on their planet.

Let’s start with America’s Health Insurance Plans (AHIP), the health insurance industry lobbying group. Here is AHIP’s oxymoronic Wellness Smartbrief (January 26), on the NBER research. Yes, it summarizes the same wellness-emasculating study as the one above, though you could never guess it from the headline:

Continuing, AHIP said:

Offering incentives for completing wellness activities might be more cost-effective than offering incentives for wellness screening, a recent study of a comprehensive program found. 

Perhaps AHIP has been infiltrated by Russian trolls, because here’s what the NBER article actually said about “completing wellness activities”:

We…do not find any effect of treatment on the number of visits to campus gym facilities or on the probability of participating in a popular annual community running event, two health behaviors that are relatively simple for a motivated employee to change over the course of one year.

AHIP continues:

Wellness programs might attract mostly employees who are already fitness-conscious, but the potential to attract healthy employees whose medical spending is already low could nonetheless be a boon to employers, the researchers found.

And on the subject of “the potential to attract healthy employees” being a “boon to employers,” the authors actually said:

We further find that selection into wellness programs is associated with both lower average spending and healthier behaviors prior to the beginning of the study. Thus, one motivation for a firm to adopt a wellness program is its potential to screen for workers with low medical spending. Considering only health care costs, reducing the share of non-participating (high-spending) employees by just 4.5 percentage points would suffice to cover the costs of our wellness program intervention.

In other words, you can apply some workplace eugenics to your company by using wellness to weed out obese employees, employees with chronic or congenital diseases, and so on. Good for you!

Soon, if AHIP and others have their way, there will be no need for guesswork in eugenics: employer wellness programs will be able to screen these employees out based on their actual DNA.


AHIP’s take on AARP v. EEOC

And now, AHIP’s take on this landmark case, their ace reporters scooping everyone with this February 2 headline on the December 20th court ruling:

Here are more typical headlines on that court ruling, headlines that came out the same month that the court ruling came out. Perhaps AHIP used the interim six weeks to focus-group various verbs until they settled on…tweak???


AHIP:  It’s not just the headlines

One prominent healthcare executive recently attended an AHIP conference and reports:

I just returned from one of the dumbest meetings I’ve ever attended in Washington. Report of a new “study” by AHIP. Turns out people don’t mind health costs all that much, they just want more benefits. And everything is hunky-dory with their health plans, people like them so much. They love wellness benefits and crave more. Prescription drug prices have been nicely controlled thanks to the competitive marketplace (no, I am not making this up or exaggerating for drama). For every $1 employers spend on benefits workers get $4 in value. Priorities for SHRM rep: Fitbits for all employees, solving the outrage that only 20% of her employees got an annual physical. 85 cents of every dollar spent on health care goes to chronic disease.

Over these same two hours, I’d estimate about a thousand employees were misinformed, harmed or harassed by wellness vendors, roughly equal numbers of  employees got useless annual checkups, employers spent about $200-million on healthcare and 40 people died in hospitals from preventable errors. But I’m being such a Debbie Downer! I’m going home to read Why Nobody Believes the Numbers to remove myself from this alternative universe.


Enter the Health Enhancement Research Organization (HERO)

HERO’s Prevaricator-in-Chief, Paul Terry, is demonstrating his usual leadership abilities in this crisis, of course. After all, HERO is the wellness industry trade association and these three items — the NBER invalidating their product, employees hating their product, and a federal judge forbidding them to force employees to use their product — represent existential threats to his “pry, poke and prod” members.

Here is quite literally his only blog post on any of these three items:

Teddy Roosevelt said, “complaining about a problem without posing a solution is called whining.” It’s a quote that also reminds me why I’ve not thought of angry bloggers who target health promotion [vendors] as bullies. Though they relish trolling for bad apples, their scolding is toothless, more the stuff of chronic whiners.

I suspect he is talking about me here as the “chronic whiner” who is  “scolding” them. Or perhaps he is referring to the “angry bloggers” at  the Los Angeles Times, the New York Times, Slate, or STATNews, since those “toothless” publications seem to be scolding wellness vendors more than I ever have.  For instance, I’ve never called wellness vendors’ offering a “scam” or a “sham.” I simply quote these very stable wellness geniuses verbatim, as above or below, or last week.

Being quoted verbatim, not angry bloggers, is their worst nightmare. (One thing I would concede, though, is that “Paul Terry and the Angry Bloggers” would be a great name for a rock band.)

Yep, looks like the implosion of his industry all my fault. Otherwise, I’m not quite sure who is the “angry blogger” he is referring to, other than to note that Mr. Terry himself seems to blog a tad angrily himself, both above, and here

Why I choose to ignore the blogger critics: We’re fortunate to work in a profession with a scant number of vociferous critics. My take is that there is one thing these few angry loners [Editor’s note: the complete “scant list” of the 220 “few angry loners” who have been “vociferous critics” can be found here] want more desperately than attention: that’s to be taken seriously. What they fail to comprehend is that as they’ve gotten ever more farfetched and vitriolic in search of the former, they’ve cinched their inability to attain the latter.

Baiting people with misinformation and offensive insults (but just a tad under highly offensive) is a pesky ploy that trolls hope will eventually land a bite that confers credibility where there is none. Even reading such drivel is a form of taking the bait; responding is swallowing it whole. Some say dishonesty should not go unchallenged and I respect their view; nevertheless, I’m convinced responding to bloggers who show disdain for our field is an utter waste of time. I’ve rarely been persuaded to respond to bloggers, and each time I did it affirmed my worry that, more than a waste, it’s counter-productive.

and especially here, a seemingly incongruous decision to “act out” by someone who claims to be “choosing to ignore the blogger critics.”

Having read years of my “drivel” alongside Mr. Terry’s posting explaining why you shouldn’t “swallow this bait,” perhaps readers might opine here: which of us, exactly, is the “chronic whiner”?

Coincidentally, when I run live health-and-wellness trivia contests, the first of our 3 rules is: No Whining. Seems to me that he would have just violated it. Indeed the only rule HERO hasn’t violated so far is #3 below. Not that I want to put ideas in their head.

 

 

 

Al Lewis — uncut, unedited…and uncombed

Dear Welligentsia Nation,

For some reason there seems to be a ton of interest in the podcast that Josh Luke just did with me. I’m a bit embarrassed because most podcasts are audio and hence I didn’t really gussy myself up in anticipation of video, but nonetheless worth a looksee. Even in the best of circumstances I do look like I just fell off a mountain bike — and that’s after making an effort to look presentable, as in these shots from a couple of trivia contests.

This podcast covers everything you want to know about how wellness got to the state it’s in, how I stumbled into figuring out that it wasn’t working, and how Quizzify arose from its ashes.

 

Al

 

 

Two reviews: The Resident and rEvolution

Even more than blowing the whistle on the very stable geniuses in the wellness industry, I love catching people doing something right, partly because it is so rare. This is one of those moments.


Two books that would seem to have little in common are Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Healthcare, by Marty Makery and rEvolution: Turn Crisis into Clarity and Ignite Growth, by Tim Leman, CEO of Gibson, northern Indiana’s largest insurance brokerage. Dr. Makery has never set foot inside an insurance brokerage while Mr. Leman has never set foot inside an OR. (He may or may not have been wheeled in at one point or another but I don’t know. If I did know, HIPAA rules are quite clear: if I told ya, I’d have to kill ya.) And yet these books have share a common thread.

Coincidentally, and why I am writing today about both books, Unaccountable is back in the news because Fox made a very watchable drama out of it, called The Resident. And rEvolution is in the news — my news, at least, because I have been blown away by what I have seen of Gibson’s competence and professionalism.

The Resident

First, a brief word on The Resident. It is a highly watchable medical drama that got a notch-less-than-great reviews only because, unlike in every other medical drama, reviewers didn’t appreciate that the characters are based on real people. There really was a surgeon at Dr. Makery’s hospital known as “Dr. Death” because of his high failure rate, and yet patients loved him because of his bedside manner. And admittedly the show goes over the top:

  • While hospitals upcode all the time, vendors of these coding tools don’t distribute brochures titled The Art of Upcoding.
  • Revenue-maximization consultants don’t watch patients get MRIs.
  • Hospital CEOs don’t have conference calls like baseball’s winter meetings where they propose swapping patients with each other.
  • No federal ICE agent has ever dragged an undocumented immigrant out of an intensive care unit. (Not that I want to put ideas in their head.)

[To read the rest, click through to Linkedin]

 

 

Wellsteps stumbles over their own words

Often I don’t have time to write a full blog in my own words, but fortunately I usually don’t need to. It’s enough to quote the words of the very stable geniuses in the wellness industry verbatim. Being quoted verbatim, of course, is one of these geniuses’ worst nightmares.

Among the most stable of the wellness industry geniuses is Steve Aldana, CEO of Wellsteps, winner of the 2016 Koop Award as well as the 2016 Deplorables Award. How does he report the National Bureau of Economic Research’s complete evisceration of wellness industry research methods? Let’s take a looksee at the highlights of his posting.

First, it appears that two opposing studies, “one for and one against wellness,” came out “at the same time.”

One the one hand, someone — apparently he doesn’t know who — seems to say that there “wasn’t much improvement” at the University of Illinois.  And something must have been wrong with this result, because “these results contradict over 90% of publish [sic] studies.”

“At the same time,” a publication no one has heard of found the opposite: health behaviors improved for “over 2 full years” in — get ready — one of Wellsteps’ very own accounts.


This is a textbook example of a false equivalence, the wellness version of: “You also had some people that were very fine people on both sides.”

To begin with, the researchers in the first group weren’t just any old researchers. This was the National Bureau of Economic Research (NBER). And the NBER didn’t say “they didn’t see much improvement.” Their specific words were that the causal effects were — get ready — nearly indistinguishable from zero for nearly every outcome.

Further to say this conclusion “contradicts over 90% of published studies about wellness,” would be like saying Galileo’s findings “contradicted” over 90% of published studies about astronomy.

The study’s actual conclusion used a slightly different verb:

Our 95% confidence intervals rule out 78 percent of previous estimates [of the effect of wellness] on medical spending and absenteeism from the prior literature. [Let me translate that, in case the words are too long for the very stable geniuses at Wellsteps to understand: you and all your very stable friends have been geniusing about savings for decades now.]

The reason the NBER was able to be so conclusive is that, to quote one of our Alert Readers, Robert Dawkins: “They foolishly included a valid control group.” Kudos to Mr. Dawkins for that very unstable moronic observation. (In any event, far from contradicting other research, the study is quite consistent with most articles on wellness not written by someone feeding at the employer wellness trough.)

The other journal, which published an article “at the same time,” found an improvement in healthy behaviors. That journal is called Health Promotion Practice. And if you haven’t heard of it, you’ve got company. Their “impact factor” is the lowest in an industry whose journals are notable for low impact factors. I googled quite extensively, and it appears — get ready — that no article from this journal has ever been cited, excerpted or even had the fact of its very existence even grudgingly acknowledged in the lay or scholarly media.

By contrast, the NBER article has been picked up everywhere — except of course by the wellness industry. See if you can find any reference to this article — or AARP v. EEOC, which was also national news — on the Health Enhancement Research Organization website.

Turns out there’s a reason no one cites this journal. It’s because it’s so genius. Exhibit A is this very same article, a rehash of the Boise School District findings that somehow overlooked the key finding, which is that the employees got unhealthier during Wellsteps’ program. Instead, the author — displaying not the slightest intellectual curiosity as to how this could possibly be true — reports the most genius findings we’ve ever seen in a journal:

  • only 3% of Boise School District employees smoke, and…
  • …they smoke only 4 days a week.

Perhaps — just playing devil’s advocate here — the other 17% of Boise employees who smoke (Idaho has a 20% smoking rate) might have lied on their health risk assessment? The “tell” is that everybody knows smokers don’t smoke only 4 days a week. Obviously, they smoke 5 days a week, with time off for weekends, major holidays and Beethoven’s Birthday.

Very stable genius that he is, the author (both a friend of Wellsteps’ Mr. Aldana, according to the disclosure statement, and also a genius who has already been profiled on this site for his previous insights) also admits that with a high non-participation rate and a 20% dropout rate:

There exists the possibility of selection or dropout bias that could have influenced the results reported.

Ya think? Maybe just a tiny bit?


But wait…there’s more

We’ve highlighted Mr. Aldana’s phrase “at the same time” describing how these articles were simultaneously published. We repeated the phrase in three separate places above for emphasis because — get ready — these two results were not published at anything like the same time.

To begin with, Mr. Aldana has been very stably geniusing about his Boise results for more than two years now. (See my article from September 2015 accurately forecasting that, thanks to the number of obvious errors and self-immolating contradictions, this study would win a Koop Award. And of course the Boise employees got harmed.)

This article, using that same data set, was published last July, whereas the NBER article just came out a few weeks ago. Perhaps in some geologic sense July 2017 and January 2018 are “the same time,” but imagine if the rest of the world defined “at the same time” as “six months apart.” For instance, let’s join Sherman and Mr. Peabody in the Wayback Machine and set the dial for June 1944:

Eisenhower: “OK, we’ll storm Omaha and Utah Beaches, and you guys can storm Juno and Sword Beaches at the same time, and then we’ll hook up and say…”

Churchill: “…Merry Christmas, chaps.”



For a good time, try googling on Wellsteps.

And no need to google on their “ROI Calculator.”  I’ve done it for you.

A clip-and-save list of AARP v. EEOC resources

Upcoming Webinars

Greater Pittsburgh Business Group on Health  (Wednesday, February 14, 2:00 PM to 3:00 PM.)

Clear your calendars, call the kids, wake the neighbors. This will be a great AARP v. EEOC webinar. How do we know this?  Simple: they are charging non-members money. $30, to be exact. That $30, and the extended, hour-long time allotment, assures all your submitted questions will be answered.

Connect Healthcare Collaboration

This one is free, and is also an hour.  It will offer live Q&A as well. It is much more about the solution — how to make AARP v. EEOC a non-issue by getting your vendor to indemnify you — than the problem. So if you are already aware of the problem and want to solve it posthaste, this is the webinar for you.


Articles and other resources by vendors.

These have been surprisingly hard to come by, and the silence from vendor trade organizations is itself data. These people know there is really no good news for so-called “pry, poke and prod” vendors, other than that their customers can indemnify themselves through Quizzify.


Articles by commentators other than me

Because Quizzify knew this decision was coming and designed the product to be a one-stop solution to achieve 100% compliance with whatever the new rules (if any), most of the interpretative “what does this all mean” articles are indeed by me. However, others have weighed in:


Articles by me


Summaries of the Decision

These are all written as news articles rather than opinion, and pretty much all say the same thing:


The follow-up January 16 motion by EEOC

Some people believe that the EEOC actually intends to publish rules by January 2, 2019. While we have no crystal ball, here are some articles describing EEOC’s most recent motion filed January 16, plus a quote from the Justice Department on behalf of EEOC. Draw your own conclusion as to whether this sounds like an agency that is prioritizing wellness rule-writing.

Highlight of ruling: “It would also be permissible for the EEOC to decide never to issue such regulations, or for the EEOC to study the issue for several years before commencing a new rulemaking,” the U.S. Justice Department said on behalf of the EEOC.


The actual court decision and follow-up motion

Here is the actual December 20 decision 

Here is the follow-up (unopposed) motion by EEOC clarifying they are not actually required to do anything


Actual language on “Voluntariness”

There is some difference of opinion on what constitutes a program being “voluntary,” starting in January. It might be helpful to review what Judge Bates said…

 A 30% penalty for refusing to provide protected information would double the cost of health insurance for most employees. … At around $1800 a year, this is the equivalent of several months’ worth of food for the average family, two months of child care in most states, and roughly two months’ rent.

…and what EEOC conceded…

Even after [the current rules are struck from the Code of Federal Regulations, for example, the ADA regulation will still require participation in wellness programs to be voluntary … the regulation will simply no longer provide a specific safe harbor for particular levels of incentives.

…before concluding that high incentives are going to be allowed in the future, as wellness vendors are wont to conclude.

 

 

 

Bravo’s AARP v EEOC webinar summary, adjusted for accuracy

Bravo just sent its webinar summary out. We are repeating the relevant sections here. Our comments are in boldface. Since their headings are also in boldface, I’ve slipped a line-break under each of ours. That’s one way of distinguishing our from theirs. Also ours are red, and are right.


Breaking news (at least relative to “breaking news” on other wellness websites”):  If you have missed other webinars on this topic, try this one. We’ll have the full hour, AND your questions will be answered. (Oh, yeah, it’s also $30. Still, worth every penny.)



Hear the dialogue between Conduent HR Service’s Global Practice Leader Tami Simon, expert practice leader and Partner from Alston and Bird John Hickman and myself regarding the history of the regulations, potential next moves by the EEOC and practical steps employers and health plans may consider. Clearly nobody has a crystal ball and nothing is final but it’s always prudent to start thinking about your next move based on the most likely scenarios.

Yes, the most likely of which is that there will be no safe harbor as of January (other than indemnification offered by vendors such as Quizzify). Anybody care to take bets on this?


  • AARP v EEOC – 2017
    • The AARP took exception with the rules and sued the EEOC, arguing that the 30% limit could be a significant cost to employees (particularly for those with rich employee benefits). In response to the suit, the court asked EEOC to support the justification for selecting the 30% limit, but their response did not satisfy the judge. The limit was viewed as “arbitrary and capricious”.During the webinar, John Hickman raised the point that an employer or health plan business group could have just have easily argued that the 30% was arbitrary and capricious because it was too low (rather than too high).I think this is particularly true for those participating in the voluntary employer-sponsored health plan when the plan still meets all minimum coverage and affordability requirements regardless of a person’s choice to participate in the wellness program. (The AARP didn’t seem to have a problem with the rules impacting health plan participants for the 8 years prior to the EEOC regulations.)
  • EEOC Regulations – 2018 / 2019
    • At this point, the court has indicated that the 30% portion of the EEOC regulations (and only this portion) shall be vacated as of 1/1/2019. The EEOC has indicated that they may do one of the following:
      • Nothing.
      • Issue new guidance or
      • Take a wait-and-see approach, choosing to study the issue further or await the resolution of potential appellate proceedings.

Reading the January 16th motion in which EEOC moved to be released from the timeline for new rules, it appears that the second item is by far the least likely, which would mean:  no safe harbor.  Employees can sue.


So, what does this mean?

First, it’s important to note that this does not impact all wellness programs nor all incentives. The potential risk applies only to incentives that require the completion of an exam and/or the response to disability-related health inquiries.

If your program does require the completion of an exam and/or a response to a disability-related health inquiry and currently complies with the regulations, you shouldn’t be concerned with enforcement action this year. You should, however, start thinking about the potential need to eventually offer all non-participants and individuals who did not receive all the incentives a chance to earn the amounts they missed by completing other activities that don’t require an exam or them answering the disability-related questions.

In other words, use Quizzify, which does exactly this.


While this will lessen the focus of the program on inspiring personal achievement and incenting individuals to work with their doctor on personal improvement….it might be the right course depending on the risk-tolerance of the employer.

Raise your hand if you think your employer’s “risk-tolerance” extends to being sued in order to continue to harass employees by flouting clinical guidelines, when it is now proven beyond doubt that there are no benefits to forcing employees to lose weight or achieve any other outcome, while losing money in the process. 

Translation: in other words, if your risk tolerance is like every other employer’s, use Quizzify.


Let’s discuss for a bit what it even means that the 30% rule could be vacated.

  • I am personally aware of several large insurers and business groups that feel vacating the 30% rule gives them greater flexibility and basically would backfire on the AARP. What’s the logic for that position?
    • Three court cases (Seff, Orion, Flambeau) were asked to answer the question of “voluntariness” prior to the EEOC providing the 30% guidance. In two cases, the court ruled that the question was irrelevant because the ADA already included a safe-harbor for health plans to make health inquiries in an effort to predict and reduce future claims costs. In the third case (Orion) the court concluded that even 100% of plan premium as an incentive would be viewed as “voluntary” because an employer sponsored health plan itself is voluntary and even a hard choice is still a choice. Note: this argument wouldn’t be applicable for those offering cash incentives or penalties to individuals not enrolled in the health plan.

So their idea is that the judge just wrote an impassioned decision explaining why current “voluntary” incentives and penalties are way too high, but you should rely on old case law that gave a different answer, which is that “voluntary” incentives and penalties can be much higher still, up to 100%.

And speaking of “as many words,” as with most wellness vendors, Bravo’s words are its own worst enemy, and may come back to haunt them. “A hard choice is still a choice.”  If you say: “Here is the health plan you are entitled to by law. But now you have to fork over your personal health information or we’ll take it away,” that’s a threat, not a voluntary offer.  

A threat is an offer you would rather not receive. Threatening to take your healthcare away would seem to fit that category.


 

  • Again, within the health plan, it’s difficult to argue that the authors of the ADA, while trying to protect the rights of disabled individuals, intended to prevent a health plan from offering a discount to people who proactively take part in recommended age/gender screenings or make steady improvements in their wellbeing. I certainly agree that protecting the rights of the disabled, keeping health records private, keeping health records completely separate from employment records and applying tight security requirements regarding health information are crucial elements that should be paramount. They already are (within the health plan) and therefore should be permitted regardless of the ADA.

Except that the judge quite wisely noted that switching employees to a high-deductible plan and them making them earn back the deductible by submitting to forced wellness is a threat coupled with a take-away, not an “offer of a discount.”


  • Others believe that vacating the rules means that no incentive can be offered at all in conjunction with a health exam or disability related inquiry.

I don’t know of anyone who believes this. Probably a couple hundred dollars would be considered voluntary.


  • While it’s difficult to predict the enforcement actions of particular EEOC offices, most experts close to the issue concur that the EEOC would be unlikely to bring enforcement action against an employer who stayed under the 30% level it had previously provided as a safe harbor. That said, even a highly winnable case brings expense, distraction and PR implications that many employers may simply choose to avoid.

Bravo might recall the immortal words of the great philosophers at eSurance:

While the EEOC is, of course, unlikely to bring an enforcement action itself, that’s not how this works. Here is some news for Bravo: the EEOC can’t keep employees from suing. Employees can and likely will sue, if WillisTowersWatson’s employee survey is any indication. We ourselves have already been contacted by two who have excellent cases…and it’s only February.  


  • Incentives for Health Screenings: Although some employers may choose to eliminate incentives for health screenings, far too many of our employer-group clients have seen tremendous results through the early detection of serious issues.

Tremendous results” like these, where it turned out that Graco employees being screened by Bravo had worse trends than their children who did not even have access to the screens? (Bravo took this case study off their website and now only offers a “summary” that leaves out the part where they lost money, not unlike Interactive Health did after we pointed out that none of their numbers added up.)


  • They have created a positive cultural movement by rewarding even modest improvement as individuals take meaningful actions.So to me, this is simple. Either you believe that identifying and reducing health risks is important or you don’t. Like most things, if you don’t measure it, people don’t really think you value it. The key for being compliant, if you want to eliminate virtually all risk from an ADA standpoint, is to make sure you are also offering alternate ways that employees (who prefer to not participate in the screening) can still earn the full incentive being offered. Bravo already offers many of these alternative options (including online health courses, group challenges etc.) and we still typically see the vast majority of employees choose the screening instead of those alternatives.

Given the choice between having the stuffing screened out of them and “alternate way,” he is saying “the vast majority of employees” would prefer screening.  Perhaps that says more about their “alternate ways” than it says about the screening. 

Care to make it interesting, Mr. Pshock?  If Quizzify is the “alternate way,”  I’ll give you odds that you’d see the opposite in any employer setting, just like Quizzify does. 


  • Bravo has long advocated that these are great “and” programs not “or” programs. Saying you only need to focus on your culture, health education or stress reduction instead of physical health risks is like saying you don’t need a hat and coat for the cold weather, you only need boots. Yes, you need boots…. but it’s an “and” not an “or’.

Um, could it be that Bravo has “long advocated” screens because they sell screens?  And is there any entity that does NOT sell annual screens that recommends annual them? USPSTF? No. Consumer Reports? No. Choosing Wisely? Nope. New England Journal of Medicine? Haha, good one, Al. 


  • Share your story! There are plenty of critics and articles with examples of poorly designed wellness programs that didn’t produce the results someone thought they should have. I’ve never seen one example that I was surprised by. Typically, the incentives are too low and they are tied to a very simple activity that may or may not motivate someone to actually change behaviors. Conversely, we’ve seen many examples where a meaningful reward, associated with realistic and achievable improvement goals determined by a person’s own physician and combined with tools, resources and programs for total wellbeing that help people succeed result in high engagement, positive morale, measurable health improvement and cost reduction that meets or exceeds program goals.There are thousands of intelligent wellness plans in the market today, the challenge is we don’t focus on sharing them publicly. Consider sharing your story! We’d be happy to support your application for recognition and/or your efforts to educate law makers and regulators regarding the success you’re experiencing. Share your story here.

Or perhaps here is another possible explanation for the “challenge” of why you “don’t focus on sharing them publicly” any more. It’s because all the outcomes are made up and generally self-invalidate (like Bravo’s in the since-removed study), and vendors don’t want to be embarrassed. That’s why the number of Koop Award applicants fell from 21 to 3. (Ron Goetzel said that decline was due to the application being “stricter,” but the application has been identical for 20 years.)


  • Fight for your employees.

Isn’t that what AARP just did?


  • I applaud the AARP’s efforts to protect older workers from coercive tactics an employer may use to gather sensitive health or genetic information about them. This can easily be accomplished by limiting the use of incentives to cost-sharing adjustments within a health plan that already has:
    • affordability requirements
    • minimum coverage requirements and
    • strict privacy and security requirements
  • The vast majority of employees earning rewards for things like being tobacco free, controlling blood pressure, managing glucose and A1c levels and avoiding metabolic syndrome should be rewarded for their achievements! How is the elimination of their rewards (which will simply serve to raise the cost and lower the take-home pay for the majority of program participants) a good thing? It is not safe to assume that tying employer hands on incentives will mean that everyone who previously failed will now just get free money. In many cases, the only place that money will come from will be the pockets of the employees who had been earning large incentives. I’m not sure the AARP has really thought this through.

No one is advocating taking money from employees.  And on paper all those outcomes are all great, but “outcomes-based wellness” has failed to achieve them in spectacular fashion, according to not just the National Bureau of Economic Research but also even according to an honest wellness company.

Why not simply make the very same awards available for either screening or else doing things that work, like Quizzify does, in equally spectacular fashion according to the employees themselves? It seems like you would agree this is a great solution.  Plus the indemnification means no one has to be concerned at all with employee lawsuits.

National Bureau of Economic Research has bad news and good news for the wellness industry

Not to be confused with those immortal words often attributed to the great philosopher Yogi Berra, a big joke among economists is: “An economist is someone who upon learning how something works in practice, wonders how it will work in theory.”

That joke morphed into reality last month — though it was a controlled study testing a theory, rather than the theory itself. The “theory” would be that inactive unmotivated non-participants can be used as a control for active motivated participants. Ironically, this study design has never been proposed as legitimate, even in theory. Wellness “researchers” like it because it always show savings, even when nothing happens. For example, even when there was no program for the participants to participate in.

Obviously if this were a legitimate design, the FDA would approve it for clinical trials, saving a ton of time and money vs. having to do controlled trials.

To wit, the National Bureau of Economic Research (NBER) just published a study showing that the participants-vs-non-participants (“par-vs.-nonpar”) study design, used extensively by the very stable geniuses in the wellness industry to do their alt-research to fabricate their alt-findings, is completely invalid.

No surprise. This NBER study validates what we’ve all observed in practice — as the three examples in this article amply demonstrate.  The somewhat more amusing TSW version is here.


Highlights of NBER study for the wellness industry: bad news first

First the bad news. Fasten your seat belts and be shocked, shocked to learn that the researchers could identify:

  1. No noticeable change in health behaviors due to the wellness program
  2. No noticeable change in health outcomes due to the wellness program
  3. Clear self-selection bias among participants opting into the wellness program

Lest anyone think we are taking this out of context, here are their exact words:

We do not find any significant effects of treatment on total medical expenditures, employee productivity, health behaviors, or self-reported health measures in the first year following random assignment.  We further investigate the effect of our intervention on medical expenditures in greater detail, but fail to find significant effects on different quantiles of the spending distribution or on any major subcategory of medical expenditures (pharmaceutical, office, or hospital). We also do not find any effect of treatment on the number of visits to campus gym facilities or on the probability of participating in a popular annual community running event, two health behaviors that are relatively simple for a motivated employee to change over the course of one year.

This of course merely confirms what we observe in outcomes reports published by wellness vendors, including the two most recent proud recipients of the Deplorables Awards.  Actually, in the case of Wellsteps there was indeed a noticeable change in health outcomes among program participants — they got worse.

Also, the authors — no doubt anticipating the objection from the very stable geniuses at the Health Enhancement Research Organization — specifically note that nothing in Year One’s results presage any step-function improvement in Year Two. So the specious “Wait ’til next year” argument is off the table.

You might be thinking, “Another nail in the wellness industry coffin.” True, except that there almost isn’t room for any more nails. Soon the coffin will have enough nails to create its own gravitational field.


Next, the good news

Here are the two pieces of good news for the wellness industry. One finding was:

Our 95% confidence intervals rule out 78 percent of previous estimates on medical spending and absenteeism.

That means that it is possible that 22% of previous estimates may conceivably not be completely invalid. This is not to say that 22% are valid, just that they aren’t automatically invalid. That is great news for the wellness industry, where clearing the bar for not being automatically invalid is cause for celebration.  As Dave Chase says, the bar for wellness is so low a snake could jump over it.

However, the 78%-totally-invalid figure specifically invalidates Katherine Baicker,  author of the so-called “Harvard Study.” Depending on whether you are a wellness vendor or an oppressed employee, she is either the Johnny Appleseed or the Typhoid Mary of wellness.  Her famous 3.27-to-1 ROI was tallied entirely from par-vs.-nonpar studies, exactly the methodology that the NBER just invalidated, citing exactly the studies she cited. (The three examples in my study referenced above were also part of her meta-analysis.)

So perhaps she might now make a formal statement regarding par-vs-non-par as a study design?  Either a retraction or a defense. Just something that clarifies her previous statements, which seem to be neither retractions nor defenses but rather more like excuses:

  1. It’s too early to tell (um, after 30 years of workplace wellness?)
  2. She has no interest in wellness any more
  3. People aren’t reading her paper right (we’re only reading the headline, the data, the findings and the conclusion, apparently)
  4. “There are few studies with reliable data on the costs and the benefits” (um, then how were you able to reach a conclusion with two significant digits?)

The irony is that Kate Baicker has otherwise done outstanding research. Her study on Oregon Medicaid is a classic. In Oregon at the time, Medicaid eligibility was determined by lottery amongst applicants. That meant that — quite the opposite of wellness control groups  — the control group of people not picked in the lottery had equal motivation to seek insurance coverage as people who were picked.  After following both groups going forward, her finding was that obtaining insurance to access basic medical care did not change outcomes. (Having insurance did bring peace of mind, though.)

And yet somehow in “Workplace Wellness Can Generate Savings,” she was quite comfortable reaching a conclusion that was completely inconsistent with her Oregon finding, not to mention the Law of Diminishing Returns: throwing additional unrequested, generally unwanted, and largely misdirected medical interventions and advice at employees who already have insurance — and recall that most insured Americans are drowning in medical care — could dramatically improve their outcomes enough to calculate not just a massive ROI, but an ROI precise to two significant digits.

What she will hopefully learn through the NBER study is something that I learned 11 years ago: when the data proves you wrong, fess up.  Then people like me have to find someone else to blog about. Fortunately, in wellness, that is not a heavy lift.


The second piece of good news for the wellness industry

To quote the study:

 …wellness incentives may shift costs onto unhealthy or lower-income employees if these groups are less likely to participate in wellness programs. Furthermore, wellness programs may act as a screening device by encouraging employees who benefit most from these programs to join or remain at the firm

To be clear, this calculation does not imply that adoption of workplace wellness programs is socially beneficial. But, it does provide a profit-maximizing rationale for firms to adopt wellness programs, even in the absence of any direct effects on health, productivity, or medical spending. [emphasis theirs]

In other words, employers can use wellness programs to subtly discriminate against unhealthy — read, older and poorer — workers.  Many of the very stable geniuses in the wellness industry will be happy to hear this. The exceptionally stable genius who will be most thrilled to hear this is Michael O’Donnell.  Mr. O’Donnell is the former Prevaricator-in-Chief of the wellness industry trade publication and a current member of the Koop Award cabal.  These are excerpts from one of his editorials:

First, he says prospective new hires should be subjected to an intrusive physical exam [editor’s note: notwithstanding the fact that this is totally illegal], and hired only if they are in good shape.  OK, not every single prospective new hire needs to be in good shape — only those applying for “blue collar jobs or jobs that require excessive walking, standing, or even sitting.”   Hence he would waive the physical exam requirement for mattress-tester, prostitute, or Koop Award Committee member, because those jobs require only excessive lying.

Second, he would fine people for not meeting “outcomes standards.” In an accompanying document, he defines those “outcomes standards.” He specifies fining people who have high BMIs, blood pressure, glucose, or cholesterol.

In other words, Mr. O’Donnell wants to charge for insurance by the pound, as that accompanying document says. Actually, by BMI, which of course is of dubious value as a measure of weight, let alone health.

Here is his actuarial formula:

Although having read his very stable arithmetic elsewhere in this same document, I’d worry about the accreditation status of any actuarial school, or for that matter any school of any kind within the 50 states, that would accept him:

Thirty-one states have no laws that prohibit employers from using smoking status as the reason for not hiring… In the remaining 29 states…smoking status cannot be used as the reason for not hiring.

I’m not waiting around for a retraction from this genius either.

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