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A look back on the 5 years since Cracking Health Costs

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Five years ago this month Tom Emerick and I sent out our first advance copies of Cracking Health Costs, never guessing that the book would itself “crack” the 10,000-copy plateau despite Wiley’s insistence on pricing it to make themselves a profit rather than for us to sell lots of copies. (Though if you haven’t got a copy yet, there is good news: Amazon now says “you can save an extra $2.18 at checkout.”)

Cracking attacked much of the industry power structure, way before it was fashionable to do so. (Today, of course, thanks to Dave Chase and a host of others that I dare not name due to the risk of leaving someone out, attacking the power structure has itself become a thing.)  As a result, the book wasn’t terribly popular in many quarters. The Wellness Ignorati, for example, want nothing to do with it. Cracking, by the way, was the book that coined the term “Wellness Ignorati,” to describe wellness vendors and consultants who chose to ignore the fact that none of their numbers add up. Not in 2013, not now, not ever.

Some have said to call someone a member of the Wellness Ignorati was an insult. But it’s actually quite the compliment. With the exception of Wellsteps’ Steve Aldana, who has finally learned to shut up – and HERO’s Ron Goetzel and Paul Terry, who for some reason thought they could circulate a poison-pen letter to the media and not have it end up in my hands – these people have figured out that the only way to win a news cycle with us is not to participate in one.

Otherwise, here is the litany of what happens when they do create one.

A good way to see how the book has aged is to dissect the most critical review it received on Amazon, to see how it held up. This review was written by Keith McNeil, whom I have subsequently met online. He obviously put a lot of thought into it, and it deserves an equally thoughtful response. And he does have good points. (Keith, if you’re reading this, the good points come later…)

Oh, yeah—and he managed to accomplish something that none of the very stable geniuses at HERO have ever done, which is catch me with my finger on the scale.


Customer Review

2.0 out of 5 stars

A missed opportunity

By Keith McNeil on October 3, 2013

Format: Hardcover |Verified Purchase

This book has some valuable information, worthy of the two stars that I give it, but I believe it has flaws that are structural and not incidental. In the world of workplace wellness, Al Lewis and Tom Emerick (along with Vik Khanna) have created somewhat of a cottage industry by being contrarians and iconoclasts.

As is often the case with “contrarians and iconoclasts,” we are now the majority view in most of the sentiments in that book. (Not that it matters whether we are the majority, since math is not a popularity contest.)


There is nothing wrong with that to the extent that they are right and consistent in their approach, but I don’t believe that is always the case. As a matter of style, I think the book is diminished by its apparent attitude that while most of the consulting, brokerage, and wellness industry is driven by know-nothing, commission-grabbing individuals who think only of themselves and not the client, Emerick and Lewis are to be considered unbiased and pure as the wind-driven snow– while they actively sell their books and promote their consulting practices, speaking engagements, etc.

Yep, this is the case. Many wellness vendors are lying – just plug the name of your vendor into the “search” box.  PBMs were another target of the book…and one just recently had to disclose in court that they were taking money under the table. Patient-centered medical homes turned out to be a scam as well.

And in terms of our being “unbiased and pure as the wind-driven snow…”  We are indeed biased – biased in favor of what works.  We ask everyone, if you think we are wrong in our bias, point it out. Tom and I between us have maybe 500,000 words in print at this point. However, there is an exception below—that Mr. McNeil insightfully called us out on. He was the only one to catch it.


I give it at least two stars because I think their books (which includes the book by Al Lewis, Why Nobody Believes the Numbers) do contain valuable information, as I said above, the industry is served by such contrarians who second guess the assumptions and numbers often given out (some of which they show are clearly wrong).

(Blushing) Thank you.


Nonetheless I have found a different book–by John Torinus, Jr., “The Company that Solved Health Care”–more valuable for most employers below the Fortune 1000 level and more filled with valuable ideas on how to get employees engaged and bend the cost curve. (For the record, I have no financial interest in that book and have no personal or business connection with its author.)

It turned out that Mr. Torinus “solved” healthcare by shifting a large chunk of the cost to his employees. He claimed large reductions through wellness, but when I asked him, in a conference, what reduction he got in actual wellness-sensitive medical events to support that claim. He replied that he didn’t know, but that his company’s annual death rate was “only 3%.”

“3%?” I asked. “What does your company make? Asbestos?”  He immediately lost all credibility with everyone in the room. The actual death rate in the workplace is not 30 per 1000, but rather 30 per 1,000,000. In wellness, though, as I’ve subsequently observed, mistakes of three orders of magnitude are quite common. This was just the first such mistake I had ever heard.


As a broadbrush review, the Emerick|Lewis book can generally be categorized as one that believes the traditional wellness programs, health risk assessments, and biometric screenings are at best generally worthless and at worst actually harm people.

Yep. At least for outcomes-based programs. Participation-based programs don’t encourage cheating, so they are likely harmless. And if done according to guidelines, beneficial albeit unprofitable.


After beating up on most of the industry, Emerick then tries to come up with initiatives and programs that do in fact work. One of them, using Centers of Excellence, is hardly new, but Emerick tweaks it by using the term “Company-Sponsored Centers of Excellence.” (I presume that Emerick did a fine job of selecting his network and went well beyond just going with whatever organizations called themselves a Center of Excellence, which he points out can be quite deceiving.)

Yep. Tom was way ahead of his time on this one. It is fairly common among very large companies to direct employees. Walmart, for example, now considers claims for certain procedures to be out of network if they are not done at a “company-sponsored center of excellence.”


Then, after trashing most wellness plans, he heavily promotes what they consider to be wellness that works, which focuses on the employee’s “well-being.” In so doing Emerick touts, for example, the wellness vendor Healthways in its efforts along those lines. He cites studies that correlate the perception of an employee’s well-being to actual healthcare costs, with a higher sense of well-being leading to lower healthcare costs. Other than a reference to having a beautiful cafeteria and cleaning the bathrooms, the advice on how to actually increase the perceived well-being of the employees is conspicuously absent.

Mr. McNeil is completely right about this. It was a correlation, not causation, and Healthways never delivered any evidence of causation. To be perfectly honest – and at the risk of admitting that we were not “pure as the wind-driven snow”– Healthways did offer to buy a large number of books in advance if we added this chapter. The information in the chapter is correct (we can’t be “bought” to lie), but it is correlation, not causation.

He is also spot-on about our not having any “What should you do instead?” advice to “actually increase the perceived well-being of the employees.”  It took another couple of years before the Quizzify lightbulb went off in my head. (Tom did indeed segue into medical travel, and is now CEO of Edison Health.)


The authors pillory most wellness vendors when, after performing their own analysis, they conclude the cost for those programs will not be returned in plan savings; but nowhere do they discuss the obvious issue of the cost to increase employee well-being. For that, their analytical skills suddenly are either turned off, or in the case of Lincoln Industries, one of the book’s real well-being success stories, the book is egregiously awry. (Emerick in the book gave fantastic well-being success rates for Lincoln Industries, but added that “resident outcomes expert Al” had not yet reviewed their findings–but he had. The Emerick book was written in early 2013, as is clear by its 2013 cited sources, but in mid-2012 Lewis posted on the Web an attack on the supposed wellness gains at Lincoln Industries–note, he made no reference to “well-being” at Lincoln Industries–and said instead of having great savings they in fact really gained nothing according to his analysis. So how did Lincoln Industries end up as a wild well-being success story in the book?)

Touche!  Mr. McNeil is completely right about this too. Here is the back story. Lincoln’s information was obviously wrong, and I presented it on my previous website as such, as Mr. McNeil notes. I then got a cease-and-desist letter from them, so I took it down. That’s when I had the insight that the way that the way to “attack” people who make up numbers is with satire (which the Wellness Ignorati refer to as “sarcasm – in addition to lacking access to the internet they apparently lack access to a dictionary). Since then, I haven’t been able to beg a lawsuit out of anyone in the industry.


In the immortal words of the great philosopher Pat Benatar, hit me with your best shot.

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