Like Japanese soldiers at the end of World War II (including the one who briefly took the seven stranded castaways prisoner), many wellness vendors are refusing to concede that the war is over. Here are three examples.

First is Vitality Group. Their oxymoronic Chief Actuarial Officer, writing in Employee Benefit News, claims that the BJ’s Wholesale Club study was inadequately focused on healthy behavior change

Healthy behavior change should be the central tenet of wellness programs, since short-termism is woefully inadequate for an area as complex as health. To this end, conceptually simply — yet scientifically-robust — interventions have been found to be effective drivers of behavior. 

One of the many things wellness vendors don’t understand, along with facts, data, math, and wellness, is irony. It is indeed ironic that a company which couldn’t get its own employees to lose weight is complaining because a program couldn’t get employees to lose weight.  Vitality’s “healthy behavior change” caused employee eating habits to deteriorate — once again, according to Vitality itself.

Next you have Steve Aldana of Wellsteps claiming in Kaiser Health News that:

for the efforts to be successful they must cut across many areas, from the food served in company cafeterias to including spouses or significant others to help people quit smoking, eat better or exercise more.

Except that his own study did exactly the opposite. It turned out that taking Wellsteps’ advice will increase your risk factors and cause your self-perceived health to deteriorate.

Finally, Jim Pshock of Bravo was also quoted in that article, complaining about the level of incentives not being great enough to get people to do things they weren’t going to do anyway. Urging employers to give away more money is exactly the opposite of what Bravo typically does, which is fine employees the maximum possible and then brag about how much money employees can save immediately because many employees refuse to participate, preferring to lose the money than to let Bravo play doctor with them.

They missed the best argument against the validity of this study

Ironically, the one legitimate argument that none of the wellness promoters have made is that Professor Baicker picked the dumbest wellness vendor imaginable, Wellness Workdays, to conduct the study. Along with Wellsteps, Bravo, and, of course, Interactive Health, they comprise the wellness industry’s Axis of Stupid.

Wellness Workdays is a classic wellness vendor. That is to say, they won’t be winning a Nobel Prize anytime soon, or even a spelling bee. Let’s start by examining their analytic and clinical prowess.

To start with, their “White Paper” doesn’t just quote the infamous 3.27-to-1. They’ve upped the ante to 6.00 to 1, maintaining the two significant digits while almost doubling the savings.  How? They’ve added the 3.27-to-1 for healthcare savings to the 2.73-to-1 for absenteeism reduction from that same 2010 study. Those two separate conclusions were reached from almost totally different studies. Anyone can tell that from reading the original.  Anyone, that is, except Wellness Workdays.

Their analytic qualifications are matched only by their clinical qualifications. One member of their medical advisory board is Chief of Allergy and Clinical Immunology at the Indian River Medical Center in Vero Beach, Florida.  While this expertise is not exactly central to the mission of the pry,poke, and prod industry, in all fairness it should be noted that the Indian River Medical Center runs one of the better allergy programs in all of Vero Beach.

Another is an OB-GYN in Colorado.  Perhaps this advisor will develop a protocol for employees who want to be screened and induced at the same time.  A third consults to orthopedists at “Lennox Hill Hospital,” a role that probably doesn’t require too much heavy lifting, because there is no hospital by that name.

This guy is also an expert on steroids and other performance-enhancing products, and has “published rseveral esearch studies.”

So they can’t spell, can’t proofread, can’t understand study design, and can’t cobble together a qualified advisory board.  In other words, to paraphrase the immortal words of those great philosophers Gilbert & Sullivan, they are the very model of a modern clueless wellness vendor.

They also appear to have forgotten to update their website since they didn’t get the outcomes they are “driven” by:

As for BJ’s Wholesale Club, I suspect they got suckered into this. Who volunteers to become the next Pepsico, a case study of how wellness programs fail?

In any case, we think Professor Baicker’s study is first rate, and apparently there is another one coming up, a sequel.

Or perhaps, since this is in conjunction with Wellness Workdays, to rseveral esearch studies.

Let’s climb into the WABAC Machine (and, yes, that’s the way it’s spelled) and set the dial for 2008.

Then-candidate Barack Obama, campaigning on the promise of universal health coverage, enlisted Harvard professor David Cutler as his key adviser on that topic. Business lobbying associations were not thrilled about their members having to cover all their full-time employees and incorrectly assumed, then as now, that the major drivers of healthcare cost were employees smoking, overeating, and not exercising. Prof. Cutler suggested, quite correctly, that one way to assuage that concern would be to allow employers to spend less money covering employees with those three health habits.

Fast-forward to 2009, when it appeared that — with enough concessions to enough vested interests — the Affordable Care Act (ACA) could become a reality. Business lobbying groups were, then as now, powerful entities. Using Prof. Cutler’s suggestion, they were pacified by allowing businesses to tie up to 30% of total premium dollars to employee health (in practice, largely employee weight). Generally, the business lobbying groups engineered this withhold in the shadows. It wasn’t until 2015 that one of those business groups, the Business Roundtable, publicly admitted that the 30% withhold was the main reason they bought into the ACA.

Since this 30% was basically a giveaway to corporations, the Obama Administration needed to justify it as a cost-savings measure. On the one hand, they had the Safeway experience “proving” that wellness could save money in practice. This alleged proof was met with open arms by both parties. Safeway’s CEO became a “rock star” on Capitol Hill.  (Of course, Safeway’s wellness program, like virtually every other great-sounding success in wellness, turned out to be a scam. In retrospect, just reading the Safeway CEO’s Wall Street Journal op-ed today* announcing these results, it’s amazing how the mind-blowingly fallacious statistics didn’t get called out back then, by me or anyone else.)

What the Administration needed in addition to the Safeway experience was some academic support. It happens there is an old joke among economists that the definition of “economist” is someone who, upon finding that something works in practice, wonders whether it will work in theory. Enter Professor Cutler again. He enlisted the then-little-known Katherine Baicker, of the Harvard School of Public Health, who had no background or apparent interest in wellness, to lead-author a meta-analysis to prove that wellness works (he was the second author).

She “proved” the theory that wellness works by citing basically every research study ever published. In those days, like today, essentially every published study — virtually all published by wellness promoters in wellness trade journals — showed savings, thanks to three rather transparent fabrications:

1. Comparing participants to non-participants, which specifically the recent study did not do, nor did the NBER study in 2018.
2. Looking only at the decline in high-risk members and not the increase in risk by the low-risk members
3. Drawing a trendline straight up and saying how much cost was “avoided” because expenses didn’t rise that fast.

The resulting meta-analysis, Workplace Wellness Programs Can Generate Savings, was raced into publication in Health Affairs, peer review be damned. (Indeed it was published so quickly that Prof. Cutler didn’t have time to disclose his conflict of interest.)

The finding was quite definitive, to two significant digits: wellness produced a 3.27-to-1 ROI on cost savings alone. This is an almost unheard-of level of precision and conclusiveness in a population health analysis. Plus, an additional precise 2.73-to-1 on productivity.

The game was supposed to be over. That article was supposed to be the cherry on top of the ACA, academically blessing the one aspect of ACA which both parties supported. It was billed as a true win-win, saving money by getting employees to be healthier.  This article became the single most influential article in Health Affairs history, with 935 academic citations alone, plus an untold number of start-ups, corporate program implementations, and references in lay publications.

Unfortunately, when you attract that much attention with a finding that is basically fabricated, someone is bound to notice. In this case, the someone was me. (I also encouraged RAND’s ace wellness researcher, Soeren Mattke, to take part in the effort, which he expertly did.)  It turns out that most if not all of the studies in this meta-analysis never should have made it to peer review, let alone passed it.  One researcher credited wellness programs with a reduction in spending on blood-borne ailments — like hemophilia, Von Willebrand’s Disease, and cat-scratch fever. Another found that you could save millions within six months by encouraging diabetics to eat more carbs. A third found that annual mammograms for women under 40 and low-fat diets saved Procter & Gamble 29%.

Part 2 will cover how Prof. Baicker distanced herself from this result to the point of disowning it…and how withering criticism from myself and others (notably The Incidental Economist) created a chain of events which got her back in the game despite saying she had “no interest.”

*Safeway’s CEO, Stephen Burd, eventually got tired of wellness and focused his efforts on another shiny new object: Theranos. He has subsequently retired from Safeway to become the honorary chairman of Mensa. (not)