New Feature: This Week in Wellness
The big news, of course, is the new smackdown on misguided efforts to bribe, cajole, or fine employees into losing weight. Technically the article came out last week but this weekly feature (we’ll see how long this lasts) on They Said What only started this week.
Meanwhile…
- Employees may know enough to buckle their seat belts following decades of HRAs telling them to, but they apparently don’t know much about their own insurance
- Likewise, open enrollment preparation seems to be falling behind previous years, no doubt due to the complexity of the offerings
- The EEOC deadline is fast approaching and NPR/Kaiser Health News reports that many companies are not prepared. Is your wellness program design EEOC-compatible? Only a minority of registrants in our recent webinar with Connect Health Collaboration and the Memphis Business Group on Health answered “yes.”
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Interactive Health meets Barbie
This just in.
Probably the easiest $1040 ($20/week for 52 weeks) anyone ever made, so I think this person owes a debt of gratitude to Interactive Health.
I just completed my Interactive Health health assessment. I didn’t want to, but $20 a week off my insurance premium is $20 a week. I entered 80 pounds and a waist circumference of 15 inches, because it’s none of their business. My dashboard says my BMI is “Underweight” (no kidding! 5’8” and 80 lbs!) but my waist circumference is “Healthy Range”. If I was a living Barbie doll maybe! I don’t think even Scarlett O’Hara had a waist that tiny.
Yes, Interactive Health is wrong, as is their wont. This time it’s because someone who weighs 80 pounds and is 5’8″ is not in a “healthy range” and should be referred for medical assistance immediately.
The irony, of course, is that Interactive Health loves to send employees to the doctor, bragging about their 45% rate of “newly discovered conditions” that need medical attention, following one of their hyperdiagnostic screening crusades. And, yet here is someone screaming for medical attention, but frankly, Scarlett, Interactive Health doesn’t give a damn.
Addendum: Someone asked me: “Why don’t the grownups do something about these people?” The answer is they are: “doing something” The NCQA is giving them highest honors.
PS Yes, there is a thing called a Scarlett O’Hara Barbie.
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We interrupt this program…
I have several new posts ready to go — the usual suspects acting out in their usual hilarious fashion — but this is a serious post.
It is time for wellness vendors to stop harassing employees about their weight.
A new article summarizing the voluminous data on the futility and harms of weight-shaming just appeared. It doesn’t contain new data, but rather presents the existing evidence in a clear and compelling format.
This article finds fault in the physician community, but the wellness industry (the outcomes-based companies and their enablers at the Health Enhancement Research Organization (and their enabler-in-chief, Ron Goetzel) is even worse because they tie money to weight loss. They give employees a financial reason to binge before the first weigh-in and then dehydrate themselves and crash-diet before the last one.
This does nobody any good, except of course the outcomes-based wellness vendors — like Interactive Health, Wellsteps, Wellness Corporate Solutions, Staywell, Bravo, Total Wellness, Star Wellness, Health Fitness Corporation and probably a host of others. And there is a special dishonorable mention for HealthyWage, whose entire business model is corporate crash-dieting contests.
They aren’t going to agree to stop on their own, any more than Monsanto stopped making DDT on its own volition. They need to have it made clear that this behavior won’t be tolerated any more.
Action Steps
A starting point is this linkedin post. Like it, comment on it, share it. Once we get to 100 likes and comments, and we’re already more than halfway, I can probably generate media attention.
https://www.linkedin.com/feed/update/urn:li:activity:6448329478551719936/
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Is your wellness vendor snookering you? Take this quiz to find out.
Is your wellness vendor snookering you? There are certain facts that vendors are not exactly forthcoming about. This is because facts represent an existential threat to the “pry, poke and prod” industry. See how many facts you know — and how many they’ve suppressed — by taking this quiz.
You’ll earn more points, the closer you are. You don’t have to be exact — and honestly I’d worry about you if you got the exact answers to every question. I’d love you for it, but I’d still worry about you.
- Wellness vendors claim they can save significant money by reducing hospital admissions for diabetes and heart attacks, because those admissions are very common. How many admissions per 1000 covered lives does the average employer incur in a typical year?
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The Health Enhancement Research Organization claims a certain savings figure for wellness PEPM. But that’s before taking into account vendor fees, extra doctor visits, tests, and prescriptions, compliance issues, employee time needed, overhead and basically anything else. In other words, what is the PEPM savings figure that at Bain & Company we used to refer to as “profit before cost”? Answer to the nearest one dollar. Hint: the answer is somewhere in this quiz.
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To eventually save money someday, you first need to improve/reduce the risk profile of your population. According to eternal optimist and wellness promoter-in-chief Ron Goetzel, what is the maximum percent improvement in a risk profile that a company can expect after 2 to 3 years of wellness programming @$150 PEPY?
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Speaking of Ron Goetzel, he said “thousands of wellness programs” fail to get good outcomes. What round number did he claim have succeeded?
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And speaking of Ron Goetzel again, he finally admitted it was “hard” to force employees to change behavior. How many “very’s” did he put in front of the word “hard” in that admission?
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The Wishful Thinking Factor, totally coincidentally abbreviated as WTF, is defined as: Total claimed cost reduction/total number of risk factors reduced. What is the average WTF for the last six Koop Award-winning programs, on average? (Hint: the real ratio of savings to risk reduction is about 0.05x, since even if savings does not lag risk reduction, a maximum of 5% of spending is wellness-sensitive.)
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Speaking of risk reduction, employees in the most recent Koop Award-winning program, Wellsteps/Boise, originally tallied 5293 risk factors. Approximately how many risk factors did those same employees tally after participating, excluding dropouts?
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In a participants-vs-non-participants study design, what percent of the perceived savings is due to the invalidity introduced by the study design itself in which unmotivated employees are used as the control for motivated employees, rather than health improvements attributable to the actual program itself, according to all four studies conducted on this topic, including three by wellness promoters?
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If you use Interactive Health as a vendor hyperdiagnosing the stuffing out of your workforce, what is the annual percentage of employees that will likely be told they have “newly discovered conditions” that “require” a doctor’s intervention?
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Of 1000+ wellness vendors, how many are validated by the Validation Institute?
Answers:
- 2. Yes, only 2. All this wellness fuss is about 2 admissions per 1000 employees. Derivation: the roughly 150,000,000 employees and dependents covered by commercial insurance (mostly from employers) generate roughly 150,000 heart attacks and 120,000 diabetes events. See the HCUP database and enter “410” for heart attacks and 250 for diabetes admissions for the ICD9 for the most recent full year (2014). Scoring: Give yourself 1 point for guessing 4 to 10 and 2 points for guessing fewer than 4.
- One dollar. $0.99 PEPY. As is well-known, they tried to walk this figure back once they realized they had told the truth. Scoring: Give yourself 1 points for guessing $1.00, since the answer in the hint was on that very same line.
- 2%. That’s a few dollars PEPY in savings. (Looks like the HERO report was pretty close, its own protestations notwithstanding.) And you paid $450/employee over 3 years to achieve it. Actually it was 1% to 2%, but we asked for the maximum. Scoring: Give yourself 2 points for 2% or less, 1 point for 4% or less.
- Only 100. Besides Johnson & Johnson, Mr. Goetzel has never disclosed any of the other 99 without others making the observation that they self-invalidate according to their own data. Scoring: 2 points for 200 or fewer, 1 point for 400 or fewer.
- 4. In The Healthy Workplace Nudge, Rex Miller gets Ron Goetzel to admit that “changing behavior is very very very very hard.” Gosh, Ron, do you suppose this might explain why an employer population’s risk factors never noticeably decline? Scoring: 2 points for 4, 1 point for 3 or 5.
- Infinity. That’s because of the next question. The 21% risk factor increase for Wellsteps more than offset the trivial risk reductions achieved by the previous years’ winners. The actual WTFs for the previous years will be the subject of a future posting. Scoring: give yourself a point if you guessed that the WTF was 5 or higher. That would be 100 times the actual figure and still way below the wellness fantasy-league figure.
- 6397. Risk factors rose 21%. And yet somehow, even though the risk profile was deteriorating sharply, the risk profile of the population was also improving enough for Wellsteps to claim that healthcare costs declined 30%. 30% is enough to wipe out wellness-sensitive medical events for the entire Boise teacher population and about 30,000 of their closest friends. (Wellsteps originally admitted that costs increased, but took that slide down when it occurred to them that telling the truth would be inconsistent with their marketing strategy.) Scoring: 1 points for 5500 to 6000 or 6600 to 7000, 2 points for 6001 to 6599.
- 100%. It turns out that the participant-vs-non-participant study design is responsible for all the perceived savings that wellness vendors claim for programs. The New York Times just explained how, in the landmark University of Illinois study, both the “gold standard” RCT methodology and the invalid par-vs-non-par methodology were used and had completely different results. This also happened three other times (summarized here) — with Newtopia, Health Fitness Corporation, and a study done by the chairperson of the Koop Committee showing how feeding diabetics more carbs would reduce their costs by improving their health. Literally, 4 studies — all of which were run by people trying to show savings — showed exactly the same thing. Scoring: all or nothing — 1 points for 100%.
- 45%. This is because running 40 inappropriate tests on every employee makes it inevitable that at least 1 or 2 of those tests reveal a false positive. Scoring: Give yourself 2 points for guessing between 40% and 50%, 1 point for 30% to 39% or 51% to 60%.
- Four. All four are honest and make modest claims they can defend or valid contractual representations. AND, they actually screen according to guidelines! (In the wellness industry, doing something appropriate merits an exclamation point.) They are: It Starts With Me, Splashlight, Sustainable Health Index, and US Preventive Medicine. That’s <1% of all wellness vendors. Scoring: give yourself 1 points for 8 or fewer.
Scoring:
0-2 points. Has your wellness vendor sold you a bridge too?
3-5 points: Your wellness vendor is blocking your internet connection
6-9 points: Nice work!
>9 points: Send your fifth-grade math teacher a thank-you note for doing a better job than the wellness vendors’ teachers did.
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New study says employees should stop drinking. Ignore it.
Apparently the wellness industry does not have a monopoly on invalid research.
A study came out in The Lancet–the British equivalent of the New England Journal of Medicine — finding that the only safe level of alcohol consumption was: none. As the principal investigator said: “Alcohol poses dire ramifications for future population health in the absence of policy action today.” This finding generated myriad headlines like this one at CNBC:
One thing you learn if you hang around wellness promoters long enough is that oftentimes a close perusal of the study in question shows the opposite of what the authors intended. Or, as we often say: “In wellness, you don’t have to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself.” And the same is true here.
For example, Denmark leads the world in the number of drinkers — and has life expectancy higher than about 90% of the world’s countries. The lowest alcohol consumers? Pakistan — which ranks #130 in life expectancy. You might say: “Wait, aren’t there many other factors involved in life expectancy?” And the answer is, of course there are. None of those were controlled for in any way in this meta-analysis. To begin with, the more people drink, the more other unhealthy habits they are likely to have.
But that’s not the crux of what is wrong with this study. Two other things should lead wellness professionals to the opposite conclusion: that light drinking is perfectly OK. The remainder of this post addresses those.
Absolute risk vs. relative risk
Absolute vs. relative risk is one of our (many) pet peeves. Here are two other examples that we have had to smack down:
- The American Cancer Society warns of a 22% increase in colon cancer among people under 50, but it turns out that absolute rate of colon cancer in younger people is so low that the chances of your life being saved by screening at age 45 are about the same as your chances of being struck by lightning. The media had a field day with that one too.
- Before that, speaking of colons, a study came out showing that red meat increased risk of dying from colon cancer. Once again, it turned out — using the data right in the study — that more people are killed by lightning than by colon cancer due to eating more red meat than average. Yet once again, the media had a field day.
From the media’s perspective, this makes sense. After all, who is going to click through on a headline that says: “Low quality study finds trivial relationship between variables” ?
In the case of this alcohol study, looking behind the headlines proved equally insightful. (And thank you to Aaron Carroll of The New York Times‘ Upshot for suggesting it.)
Alcohol is a leading risk factor for death and disease worldwide, and is associated with nearly one in 10 deaths in people aged 15-49 years old, according to a Global Burden of Disease study published in The Lancet that estimates levels of alcohol use and health effects in 195 countries between 1990 to 2016.
Based on their analysis, the authors suggest that there is no safe level of alcohol as any health benefits of alcohol are outweighed by its adverse effects on other aspects of health, particularly cancers.
Read the first paragraph again. Two observations:
- almost no one dies between the ages of 15 and 49, so being responsible for “nearly” 10% of those deaths means that alcohol kills about 0.001% of people in that age bracket every year.
- the authors have conflated two things: alcohol and excess alcohol. Virtually all of those deaths in that age bracket were due to the latter, a fact that the authors conveniently overlooked when demonizing any level. of consumption.
Reading a bit farther in…
They estimate that, for one year, in people aged 15-95 years, drinking one alcoholic drink a day [1] increases the risk of developing one of the 23 alcohol-related health problems [2] by 0.5%, compared with not drinking at all (from 914 people in 100,000 for one year for non-drinkers aged 15-95 years, to 918 in 100,000 people a year for 15-95 year olds who consume one alcoholic drink a day)
Hello? A 0.5% increase in relative risk? And the increase in absolute risk (not calculated) is 4 per 100,000 people a year — or 0.004% a year. Even two drinks a day increases absolute risk only by 0.06% a year. (Once you get beyond two drinks a day, the chance of harm accelerates exponentially…but that’s not news.)
What the he** are employees going to consume instead?
Our biggest beef with this study is the same as with just about every wellness program: everything is off-limits. Even foods that are OK in moderation for most people — like full-fat dairy, salt, oils, cholesterol/eggs and red meat — are singled out for criticism by health risk assessments. And now alcohol.
Unfortunately, the more foods you demonize, the less likely it is that any employee will pay any attention to any of your dietary pronouncements. And to the extent they do. well what are they going to eat instead? Here is Cerner telling people that non-fat yogurt is a “healthier choice.” Trivia question: What added ingredient makes nonfat yogurt taste good?
Here is Optum railing against oils:
And Cerner, once again, this time incriminating dietary cholesterol, which of course has no impact on blood cholesterol for most people:
Finally, here is Interactive Health hyperventilating about something-or-other in their HRA feedback to an employee. We don’t know what it is other than, given the provenance, it’s wrong. Fortunately, no employee is going to plow through this anyway.
Conclusion
Treat this alcohol finding the same way you would treat advice from most health risk assessments: ignore it.
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Our forgetful wellness vendors, Part 2 (Bravo)
So many fallacies in Bravo’s recent webinar, so little space on the internet…
Consequently, this posting is tag-teamed with Jon Robison’s Pulse, covering different aspects of Bravo:
- Misunderstanding of the meaning of the word “voluntary”
- Confusion around the research on incentives and health behavior change
- Misinterpretation of the meaning of “successful” weight loss
- “Stuckness” to a mean-spirited, 20th century approach to employee wellness
Recently we noted that Ron Goetzel seems to forget everything he says as soon as soon as it becomes expedient to say the opposite. He is not alone. The wellness industry is full of people who forget things. Wellsteps famously forgot they had claimed costs decreased before admitting they increased. McKesson got a nice write-up in Employee Benefit News after they forgot that they had already admitted employers gained weight when they claimed employees lost weight. Vitality is offering its weight loss services to employers, forgetting that they couldn’t get their own employees to lose weight.
Apparently Bravo is equally forgetful. In their online webinar on the forthcoming change to the EEOC regulations (in which their self-proclaimed “aha moment” that screenings will be a risky business starting in January lagged our identical aha moment by about 9 months), they made two observations towards the end that seem to contradict what they said near the beginning.
Near the beginning, they said — quite correctly — that you can’t hide alternatives to screening from employees. Alternatives “must be clearly communicated.”
And yet at Minute 38:00, they say:
Just tell employees the alternatives are available upon request… You can just say ‘contact us and we’ll give you one.’ Or ‘There’s other ways to earn the full incentive. Contact Bravo.’
“Contact Bravo”?
Why would an employee voluntarily want to contact an outfit that brags about how much they fine employees? Maybe this is just me, but it seems like making employees contact a wellness vendor to beg for an alternative would seem to directly contradict the rule that alternatives be clearly communicated.
At Minute 29, they declare that biometric screenings need very hefty incentives because:
You aren’t going to get behavior change for $200. The incentive has to be meaningful. Anything under $400, you’re giving people money for something they would have done anyway.
But later in the presentation, they presented their EEOC-compliant menu of wellness options. The proposed incentive for biometric screens? That very same $200.
They also forgot that “coaching” is not an EEOC-compliant activity. You can’t coach someone without asking them all sorts of personal health questions. Otherwise you’re left with the fallback advice: take more steps, buckle your seat belts, and eat more broccoli.
They called a comprehensive, well-designed study “industry noise,” forgetting that it was conducted by the National Bureau of Economic Research, a group which knows slightly more about economics (and, apparently, wellness) than Bravo does:
Most importantly, when they claimed (Minute 31) “a poorly designed program is absolutely something you should avoid,” they forgot their own program may be one of them. Perhaps they might explain how the following three observations are incorrect?
- the literature is unanimous in saying there is no chance that checkups prevent cancer and yet they want employees to get annual checkups in order to have “fewer cases of cancer“
- the US Preventive Services Task Force recommends against doing many of the tests they do (creatinine and thyroid levels being two examples)
- their own results show no impact of their own program.
To the third point, here is a case study on their own website. They compared the usual active motivated incentivized participant group to a passive control group of employees that preferred to pay a large fine than have anything to do with these Bravo people. By Year 7, claims in the two groups were identical (the white line of the control group intersected the yellow line of the participants) despite the obvious study design bias favoring participants, a bias proven by the NBER.
Lest anyone think that study was an outlier, Graco’s published study showed the same thing. The green line (children, no exposure at all to wellness) trended better than the participants in blue. (For some reason spouses’ costs soared but they didn’t seem to express any concern about that.)
And when claiming that wellness generated a large increase in sales, they forgot that most of Graco’s sales growth was generated by an acquisition When they decided to call the baseline 2009, in order to show the biggest possible impact of wellness, they forgot the program actually started in 2008.
In the past, I’ve recommended that Bravo have their results reviewed by a smart person before publishing them. Let’s qualify that: it should be a smart person with a good memory.
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Our forgetful wellness promoters, Part 1 (Ron Goetzel)
Those are my principles, and, well, if you don’t like them, I have others.
Rufus T. Firefly
Ron Goetzel seems to have very flexible principles, but let’s be kind and call them memory problems. How do we know this? He has taken completely contradictory positions on 14 occasions, having apparently forgotten the second time what he said the first time.
I know what you’re thinking: “Only on 14 occasions?”
Of course not, silly. I’m talking about 14 occasions during a single 90-minute period.
That 90 minutes was the so-called “Great Debate” between him and me a couple of years ago. Who won? Well, you don’t see him posting this debate on his website, do you? I didn’t post this until now because only recently has transcription software become sufficiently accurate. You can read/listen by clicking through on the time stamps in each section, any one of which also give you access to the entire thing.
These 14 snippets feature two sets of statements that would seem to be at complete variance with each other. While I’m not calling anyone a liar, it does seem that Ron is forgetful. Very very forgetful.
On his own willingness to correct his own mistakes
Minute 08:28 “Anytime we hear about things that are wrong, we look into them and try to correct them.”
Except when he forgets to do so, as in when he gives out awards to his friends who have publicly admitted lying and harming employees.
On the Penn State wellness program debacle
Minute 13:03 “I had nothing to do with Penn State.”
He might have forgotten that he participated in their press conference “taking the offensive in the wellness controversy.”
On his concerns for informing the wellness debate with facts
Minute 29:54 “And by the way, in doing research, we look for limitations. We look for critiques….I welcome public peer review.”
Except when he forgets to welcome critiques and public peer review, as when he circulates letters to the media telling them not to publish my critiques.
On my misdeeds and lack of qualifications to do peer review
Minute 30:38 “Some of the stuff that Al talks about and points out is right on the money and I agree and I said so in the Health Affairs blog that I’ve written, but some of the stuff is really out there. It’s outlandish.”
Except that he can’t seem to recall even a single “outlandish” example.
Al: “Ron, I appreciate your giving me credit for being qualified to do peer review. Would you say that I’m the most qualified person, in terms of number of mistakes found, to do peer review?”
Ron: “No.”
Except when he is about to admit that I am…
Al: “Well, who has found more mistakes than I have?”
Ron: [silence]
Audience: [Laughter]
This might explain why he and his cronies always “forget” to ask me to peer review. Though for his most recent Health Affairs article, he did remember to list me as someone who he did not want to peer review his article. I reviewed it anyway — after publication…and, like most of his stuff, it spontaneously combusts upon exposure to any possessor of a triple-digit IQ.
On throwing his Wellsteps friend, Steve Aldana (proud recipient of the 2016 Deplorables Award), under the bus
Minute 34:03: “I’m not gonna answer for Steve Aldana.”
Hmm… he seems to have forgotten this bold statement when he “answered for” Steve Aldana after I blew the whistle on Mr. Aldana’s Wellsteps debacle in Boise. Ron defended him even though it meant acknowledging that Wellsteps is arguably the worst vendor in wellness history, as measured by self-admitted harms to employees, lies about outcomes, and misapplication of clinical guidelines.
On applying for the million-dollar reward
Minute 34:33 A million dollars is a lot of money and I’ll take it.
Except he forgot to apply. Even when I raised the reward to $3 million.
On his failure to observe that his own guidebook showed wellness loses money
Minute 45:14 “I was not involved in the chapter that looks at healthcare costs.”
Oops! He forgot that he and the other HERO board members and other collaborators spent “two years and countless hours of research and discussions” on this, as the first paragraph of the guidebook claims, and as the chapter’s author gratefully acknowledged. Also, Ron is considered HERO’s resident expert on study design and outcomes. He claims to have published 171 articles, mostly involving study design and outcomes. And yet, he says he simply passed on reviewing a chapter on study design and outcomes in his own organization’s seminal guidebook on this topic, because over two years he couldn’t find the time. Or maybe he just forgot.
On walking back his own guidebook
Minute 45:26 “Those numbers [in his guidebook] are wildly off…Every number in that chapter has nothing to do with reality.”
He must have forgotten this when he claimed the same thing in the Chicago Tribune: that wellness could achieve a 1-2% reduction in risk in 2-3 years. That works out, optimistically, to achieve almost the same $1 per employee per month gross savings “in reality” (before vendor and screening fees, of course) that his very same guidebook claims.
On the Nebraska scandal
Minute 53:54 “Yes, state of Nebraska did win the Koop award. They won the award because they had solid evidence. They improved the health risk profile of the population following a cohort population over time.”
His memory is playing tricks on him again. Their “solid evidence” quite conclusively demonstrates the opposite. Of 20,000 state employees, only 161 more reduced risk than increased it.
On his ability to evaluate the Nebraska outcomes
Minute 53:59 “They also use excellent methods in doing economic evaluation.”
He forgot that these “excellent methods” contained so many rookie mistakes that the Validation Institute uses this “economic evaluation” as the issue-spotter for their Advanced Critical Outcomes Report Analysis Certification. The entirety of Chapter 8 of Surviving Workplace Wellness is devoted to all the hilarity in this program’s design and outcomes. Indeed this program would save a ton of money if laughter were the best medicine. Here is the Omaha World-Herald’s write-up.
On programs that penalize employees with surcharges
Minute 01:00:55 “Health promotion programs that are evidence-based and that work are not surcharge programs that you [a questioner in the audience] described, and I agree.”
He forgot that he disagrees, and defends punitive surcharge programs (or at least to tries to)
On how programs don’t need to save money
Minute 01:15:57 “An ROI of one to one is good enough for me.”
He might have forgotten he told people to “expect a 3-to-1 ROI.”
On his commitment to improving population health
Minute 01:15:57 “You give me a dollar, you get a dollar back, but you have to document that you’ve improved population health… You have to show that you’ve improved population health. Not just one or two people, the entire population.”
He did seem to forget this principle when he gave an award to his friends at Wellsteps who harmed “not just one or two people but the entire population.”
On Medicare’s wellness program
Minute 01:25:43 “Randomized clinical trials show population participated in the program versus control had significantly improved health outcomes, did not cost Medicare a dime, cost neutral.”
He might have forgotten that the actual conclusion was: “Utilization and expenditures actually increased among participants, mirroring the experience in the corporate world.”
Conclusion
I’ve often recommended that Ron have his statements reviewed by a smart person before publishing them. I would now add, a smart person taking notes.
Special Bonus Feature: Ron “endorses” Quizzify…until he doesn’t.
Minute [42:57] “Did go on the [Quizzify] website. It was a lot of fun, very clever.”
See the punchline in the comments. Glad to know he thinks employee health literacy is worthless.
They Said What? 