Never Pay the First Bill is the best health policy book ever (maybe tied with The Price We Pay), largely because it’s not about health policy. It’s conclusion: we can’t depend on anyone to look out for our interests. Instead, individuals and employers are going to have to make our own “policies.” (I’m sure it is just coincidence that Quizzify is the only vendor featured in both, since we show people how to make their own “policy” on not getting surprise bills.)
SPOILER ALERT: When you read this book to truly understand this industry, you’ll be shocked, shocked to find that lying is going on in here!
And lest you think that this is for-policy-wonks-only, it’s quite the reverse. It is specifically written for “anyone who has been pushed around by the healthcare system.” This cohort of “anyone” would include me, before Quizzify taught me how to push back.
The first eight chapters are specifically for individuals. They act as how-to’s for winning appeals, dealing with collectors, and, of course, avoiding surprise bills using Quizzify’s consent language. As coincidence would have it, this surprise bill example involved a United Healthcare subsidiary called Golden Rule Insurance. This is the same outfit that “negotiated” the in-network price of 28x Medicare (plus a $1700 tip for a no-show doctor) for the guy featured in our own surprise bill webinar in March.
One surprising lesson in the first eight chapters? Find out what the cash price is. Frequently, it is quite a bit lower than the price that your national insurer, with tens of millions of lives, has negotiated on your behalf.
Employers are getting snookered too
These are followed by three chapters specifically for employers. SPOILER ALERT: employers get snookered without even knowing it. How true that is! In addition to the multitude of examples in these chapters, I would cite my own experience with surprise bills and employers. When I suggest that employers teach employees how to avoid them, an employer will often say: “My employees aren’t having a problem with surprise bills.”
What I then reply is: “Oh, OK.”
What I want to reply is: “The reason they aren’t having a problem with them is that you’re paying them.”
It’s not like these hospitals are saying: “Oh, this guy has good insurance. Let’s charge him less.”
One thing you’ll learn as an employer is that the insurance company is not your friend. They auto-adjudicate bills that should never be paid, and then throw up roadblocks when you try to dig into these bills to identify the fraudulent ones that shouldn’t be paid.
Sometimes, they “find” the fraud themselves, congratulate themselves for finding it, and then take a big chunk out of the “savings” from reducing the bill that they themselves paid.
Further, each chapter ends with a summary of what you as a person or an employer can do. It is not just an exposé, but also a how-to.
The June issue of Health Affairs reveals the conclusion of the definitive 3-year randomized control trial on wellness, conducted by the industry’s leading research team, Professor Katherine Baicker (now dean of the University of Chicago’s School of Public Health!) and Professor Zirui Song, of Harvard Medical School.
“No significant differences were found in self-reported health; clinical markers of health; health care spending or use; or absenteeism, tenure, or job performance. “
Conversely, a major wellness vendor released the results of their own internal study showing exactly the opposite. Highlights are an 84% reduction in people with high blood pressure, a 50% reduction in both obesity and employee turnover — and by far the greatest savings that have ever been achieved in a wellness program.
Both camps have been offered the opportunity to defend their diametrically opposed conclusions.
Along the way, you will have many opportunities to vote on aspects of these diametrically opposed conclusions.
And your votes will help determine, in the immortal words of the great philosopher Rick Perry, whether or not who is right.
We will be doing a webinar on this very topic — June 30th at 2 PM EDT. Both camps have been invited to present. Register here.
Health Affairs just announced it. The conclusion of the impeccably designed three-year study conducted by Katherine Baicker and Zirui Song showed zero impact in a randomized control trial. This conclusion, of course, confirms exactly what we’ve been saying for almost a decade now–wellness programs have absolutely no impact (other than to occasionally harm employees, of course). In their words:
No significant differences were found in self-reported health; clinical markers of health; health care spending or use; or absenteeism, tenure, or job performance. Improvements in health behaviors after three years were similar to those at eighteen months, but the longer follow-up did not yield detectable improvements in clinical, economic, or employment outcomes.
No one can accuse the authors of having an anti-wellness bias. Quite the opposite, they wrote the seminal article that created the industry. As early as they were in supporting it, I was almost that early in realizing it was a sham (Slate’s word, not mine.)
One could also argue that wellness was already dead — the previous 11 articles had shown the same thing. Vendors excel at hiding these articles from their customers. (If only they were half as good at actually doing wellness…)
The Greatest Hits of the early days of wellness leading to this moment
We knew back in April 2013, that wellness was worthless. We used some simple arithmetic to point out that it would cost a million dollars to prevent a heart attack by screening the stuffing out of employees. It turned out our estimate was wrong — the real number appears to be infinity.
My only question is, why did it take eight years for everyone else to figure this out?
Happily there is one exception to this conclusion. Just like 1 in 1000 money managers consistently beat the market, the 1 in 1000 conventional wellness vendor is: US Preventive Medicine. Their favorable outcomes were achieved without biostatistical sleight-of-hand. Hence they are validated by the Validation institute. (This article concludes by showing how most vendors embrace biostatistical sleight-of-hand.) And yet even USPM doesn’t claim an ROI, so they aren’t validated for savings. Just outcomes.
Here was our first smackdown naming names, also in 2013. Two recurring themes revealed themselves. First, Mercer’s fingerprints were all over wellness as they are now all over Livongo (which pays them handsomely), thanks to their revenue model of collecting money from vendors as well as buyers.
Second, naturally the program in question won a Koop Award, bestowed annually by Ron Goetzel and his cronies upon the company that best demonstrates what happens to kids who cut math class to smoke in the boys’ room. Our observation on their arithmetic was:
You need not “challenge the data” to invalidate claims that wellness saves money. Instead, you can simply read the data as presented. You’ll find it usually invalidates itself.
Nowhere is that more true than in a study published this month by Mercer, Staywell and British Petroleum (“BP America”) in the Journal of Occupational and Environmental Medicine (JOEM). As we’ll demonstrate, the results completely contradict Staywell’s own statements, and are also mathematically impossible. Indeed, Mercer was a wise partner choice by BP America because their validations are often unconstrained by the limits of possibility.
I’ve occasionally worried that the Health Enhancement Research Organization (the wellness industry’s Ministry of Truth) might hire away a smart person from the PBM industry who could make their lies believable. So far, fortunately, they’ve resisted that temptation.
2014 brought our highest visibility article, when it was still news that wellness loses money. Health Affairs published our seminal Workplace Wellness Produces No Savings. This was picked up by Michael Hiltzik, the business columnist at the Los Angeles Times, who added that wellness is a “scam.”
And it got picked up by the New York Times‘ health economics bloggers, who added the observation that Mr. Goetzel’s analysis was “crap.” (Their word, not mine.) Their specific first paragraph leading into our analysis:
When Mr. Goetzel attempted to rebut our article, he interpreted that statement as these economists saying wellness “usually” doesn’t save money. Not sure where you get “usually doesn’t save money” out of the quotation above, but you know an industry is in trouble when its #1 promoter has to lie in its defense, but even the lie itself is quite unflattering.
The most comprehensive deconstruction was in July 2017, in Case Western Reserve’s Law-Medicine Journal, Health Matrix. It still ranks among their ten most popular articles of all time.
With 58 pages and 349 footnotes, it remains the go-to for health services researchers everywhere. If you can’t make the commitment to reading the entire thing, the executive summary says it all:
Wellness programs have conferred no measurable benefit on the American workforce.Further, vendors routinely disregard clinical guidelines that are designed to avoid overtreatment, inappropriate doctor visits, and increasingly ubiquitous crash-dieting contests. The economics follow the harms.
Essentially every dollar companies spend on vendor-administered workplace-wellness programs is lost. As a result, much of the wellness-vendor community has resorted to making demonstrably false claims about savings in order to maintain its revenue stream.
Why did wellness last so long?
As coincidence would have it, the Validation Institute wrote on that exact topic last month, explaining exactly how wellness, diabetes and other vendors fabricate their outcomes. It requires 7 installments to whack all of the moles, since while wellness and diabetes vendors may not know much about wellness and diabetes, they know a ton about fabricating outcomes.
They’ve figured out:
- their results should exclude low-risk (or low Hb a1c) members whose risk/scores increase
- participants will always outperform non-participants, “matched controls,” “propensity-scored matched controls” and basically every other passive cohort–especially if dropouts are ignored;
- drawing a line upwards (“trend inflation”) will give them the result they want by showing savings “vs. trend”
- no one actually ever reads these reports carefully to check their plausibility
- the highest ROI, for the vendor, is to bribe a consulting firm or journal to publish favorable results. Buyers will suspend disbelief when they see the words “actuaries” or “peer-reviewed”.
- they can inflate their own satisfaction scores by simply ignoring people who weren’t satisfied, instead of doing a real engagement survey, or simply citing Amazon. And no wonder — here are Livongo’s scores. (Livongo will no doubt swarm Amazon with five-star reviews once they realize other people are looking at these scores.)
The seventh installment covers how to put this all together into an RFP. Really there are two simple questions. You almost don’t need to ask any others. If it’s a carrier program:
“What is the penetration of this solution in your own insured (or in the case of large consulting firms, covered) population?”
If it’s vendor-direct:
“If we promote your solution to half our population and not the other half (which will have access, but not promotion), how much of your fees will you put at risk that the first half will outperform the second half in the key metrics you are addressing?”
In the case of the first, most programs offered by carriers to ASOs are not offered to fully insureds at all. In the case of the second, the answer is 100%.
So what to do instead of wellness?
It is possibly to achieve a much better result with much less effort and expense, simply by using Quizzify.
You saw Marshall take on surprise bills in our March webinar featuring Theresa Costa (and also Marty Makary and Leah Binder) … and it looks like we’re winning that one, though it’s still too early to declare victory.
Now, with open mikes, we’ll be featuring Marshall in our June 16th 1:00 PM webinar to talk about Never Pay the First Bill, certain to be the biggest healthcare bestseller since (and possibly including) Marty Makary’s The Price We Pay. (SPOILER ALERT: Both feature Quizzify, though you have to look pretty hard.)
His book is TheySaidWhat laid large. Turns out we’re not alone in the universe. Tons of abuse, he names names, and has been collecting these anecdotes for years.
Speaking of anecdotes, this book will feature plenty of them — all completely aligned with what we’ve been saying for years. But it’s one thing for us to point them out. It’s something else altogether to point out the same things in a (likely) bestselling book.