Well, at least I feel good about it. This is Employee Benefit News on health literacy.
Turns out something works in wellness. And it’s quite logical. Healthcare is the only line item where every full-time employee gets an unlimited budget. It’s also the only budget item for which employees get no training in how to spend it. The combination of a (mostly) blank check and (near) total ignorance creates the perfect storm for massive overspending. That of course is exactly what happens absent training in employee medical education.
Employees simply get too much healthcare, if they don’t pay the bills. Imagine if you only had to pay for 10% of your house, your car, your food. Would you buy more? Healthcare is the same way. The difference is that too much of it is bad for us…and we get way too much of it.
Your wellness vendor isn’t going to be much help here. They love screening the stuffing out of employees and then bragging about how many more tests they need to get.
Part 2 picks up where Part 1 left off, as coincidence would have it.
Soeren Mattke (as mentioned in the last installment) and I were quite relentless in trying, quixotically, to get Professor Baicker to explain her results. Its popularity could have landed her many profitable speaking and consulting gigs, but she evinced no interest in cashing in, or even in defending her position. Indeed, the four times she spoke publicly on the topic, she didn’t do herself, or her legions of sycophants in the wellness industry, any favors. In each interview, she distanced herself more and more from her previous conclusion. Here are her four takeaways from her own study “proving” wellness has precisely a 3.27-to-1 ROI:
- It’s too early to tell (um, after 30 years of workplace wellness?)
- She has no interest in wellness anymore
- People aren’t reading her paper right (Shame on us readers! We’re only reading the headline, the data, the findings and the conclusion, apparently)
- “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?)
Individually or in total, these comments sounded an awful lot like retractions, but she (and her co-author and instigator, David Cutler) claimed those comments didn’t constitute retractions. Whatever they were, she wasn’t exactly doubling down on this 3.27-to-1 conclusion.
The industry at this time — 2013 and 2014 — came under a lot of criticism for basically being somewhere between hilariously worthless and a fraud. (Here is some comprehensive documentation of the fraudulent and harmful activity in the wellness industry. Wellness is a classic example of the observation that every cause starts out as a movement, becomes a business, and degenerates into a racket, the poster company for the last being Interactive Health.)
Here’s where it gets interesting. Due to this relentless criticism, instigated and sometimes written by me (most of which is catalogued here) with credit to Soeren Mattke and Jon Robison as well (with Pulitzer Prize-winning LA Times columnist Michael Hiltzik piling on multiple times), Ron Goetzel and his colleagues urged Professor Baicker — who had previously claimed to have no more interest in wellness — to get a grant from Ron’s friends at the Robert Wood Johnson Foundation and do an actual controlled study of workplace wellness to set the record straight. As a strategic gambit, this showed a level of professional judgment worthy of Gary Hart.*
Obviously if you are perpetrating a fraud and you know it, you don’t urge people to investigate it. Mr. Goetzel at this point (or at least shortly thereafter) knew that his industry was a fraud, going so far as to erase some accurate data and disown inconveniently accurate conclusions he had forgotten to suppress.
He even forged a letter from the governor of Nebraska to cover his tracks. (To be completely accurate, he did not forge the signature on the letter. He merely doctored the wording in a letter that was already signed to say something much different than the letter said when it was actually signed. Maybe that’s not technically forgery. Who knows?)
And yet that’s exactly what Mr. Goetzel did. Maybe he thought she was as corrupt as he is, but she has an excellent reputation in this industry. My suspicion is that she accepted his offer for exactly the opposite reason that he made it — to clear her name after her ill-considered 2010 meta-analysis.
Way back in 2016, I predicted how this gambit would turn out — that Katherine Baicker was not going to mail it in this time but rather do a high-quality study of the type she is known for.
Her now-famous outcome was preordained for four reasons:
- In this industry, as Michael O’Donnell pointed out in the trade journal where he formally served as Prevaricator-in-Chief, the higher quality the study, the lower the ROI, to the point where RCTs invariably show negative ROIs. (Owing to the embarrassing accuracy of this unintended finding, Mr. O’Donnell walked it back in a subsequent editorial.)
- Kate Baicker was not going to sully her legacy by being known as the Typhoid Mary of wacky wellness programs, just to please her sycophants.
- She picked the most clueless vendor imaginable to carry their water. This selection couldn’t have been an accident.
- No wellness study since Johnson & Johnson (which was probably also wrong–just not obviously from the data presented) had shown even a remotely positive outcome. This list includes PepsiCo, Barnes Hospital, Nebraska, Vitality, Newtopia, Health Fitness Corp, Health Fitness Corp again, Boise School District/Wellsteps, McKesson, Connecticut, and the University of Illinois. All were epic fails, according to their own data. Not to mention that the wellness trade association itself published a case study showing wellness loses money and then ran away from it.
Where does the wellness industry go from here? They’re hoping for Tiger Woods, wiser souls are channeling Gary Hart, and probably what we’ll get instead is Harold Stassen. (Look it up.)
*For those of you who aren’t old enough to remember, here’s what happened. Dogged by rumors of philandering, the front-running Democratic presidential candidate urged reporters to follow him around. It took about a day for reporters to discover he was indeed philandering. It only took another few weeks for him to withdraw from the presidential race.
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:
- Comparing participants to non-participants, which specifically the recent study did not do, nor did the NBER study in 2018.
- Looking only at the decline in high-risk members and not the increase in risk by the low-risk members
- 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)
In the immortal words of the great philosopher Roy Orbison: “It’s over. It’s over. It’s ooooo-verrrr.”
The Journal of the American Medical Association published an article today that — very much like the National Bureau of Economic Research’s conclusion — reported a controlled trial in which it was shown that wellness did nothing. Nada. Zilch.
Here is some of the exact language:
With respect to the clinical measures of health obtained using biometric screening, 29% of employees in the primary control group had high cholesterol, 23% had hypertension, and 43% were obese. No statistically significant differences were detected between the employees in the control group worksites and treatment group worksites at the end of the 18 months. Similarly, the authors found no significant differences in mean medical care spending or utilization.
So it looks like the only academic researcher who still believes this nonsense works is Prof. Katherine Baicker, whose 2010 “Harvard study” in Health Affairs launched the industry into the Affordable Care Act.
Wait a second…am I reading this correctly? Seems like this research was conducted and reported by Katherine Baicker. She invalidated her only earlier work, much like I did 12 years ago when I pointed out all my previous findings in disease management were wrong.
Needless to say, the wellness industry is not very happy about this. Here is their official response:
As every wellness professional knows, saving money in wellness programs can only be accomplished — if at all — by getting employees to take more steps and eat more broccoli.
As far as the former is concerned, Fitbit has already undertaken initiatives to demonstrate that using its product to increase steps can play an integral role in wellness. In other words, they’ve mastered the art of blatantly fabricating outcomes.
Fitbit also offers employers significant discounts for bulk wearables purchase for wellness programs. These discounts have led to enough employer contracts for Fitbits that the Broccoli Growers Association of America (BGAA) has taken notice, and decided to follow their lead.
Specifically, the BGAA just announced a partnership with two leading organizations in wellness — the Health Enhancement Research Organization (HERO), and Safeway — to distribute 20% discount coupons for broccoli to wellness program enrollees at participating employers. Thought leaders in wellness, notably Schlumberger, have already announced they are signing up.
A spokesperson for the BGAA noted that “for years, wellness vendors have been urging employees to eat more broccoli, but until now that goal has been out of reach financially for many. We are pleased to do our part to relieve this financial hardship on employees, and help employers coax, fine, or bribe employees into adopting a more broccoli-intensive diet. This will definitely help them lose weight.”
Ron Goetzel, never one to miss out on a claim of wellness program impact, added that broccoli can be part of a smoking cessation program too. “Just keep some broccoli nearby,” he advises, “and every time you feel like a cigaret, eat a floret instead. It’s easy to do because they both end in ‘ret.’ My data shows that it’s easier to stop smoking if you remember to eat broccoli anytime the urge arises to smoke — and my data is always very well-sourced and consistent.”
The BGAA will also be providing recipes to give employees ways to vary their diet while still consuming sufficient amounts of broccoli to let wellness vendors claim savings. Broccoli can be steamed, sauteed, or eaten raw. Here is another suggestion for preparation.
Charley Blue, a frequent reader of these columns, is embracing this collaboration and wants to see it go farther. “I’d like the government to get behind this with some focused subsidies,” he proposed. “We could call it The New Green Deal”