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Review of “Rule the Rules of Workplace Wellness Programs,” a how-to on compliance

In the wellness industry, vendors are allowed — indeed, encouraged by the prospect of winning a Koop Award  — to flout clinical guidelines, pay employees to crash diet, sell franchises by bragging by the lack of qualifications needed by franchisees, and of course actually harm employees. One would think such an industry is totally unregulated. And, yet, as described in the erudite but highly readable Rule the Rules of Workplace Wellness Programs, by Barbara Zabawa, there are mind-boggling numbers of regulations. It happens that none of them actually prevent rogue vendors from harming employees, though. You’d think just by random chance one of them would, but no such luck.

This book is the compendium of everything needed to assure compliance with the myriad of sometimes contradictory regulations that govern workplace wellness. Over the years, a large number of generally disconnected laws have spawned an even larger number of regulations, opinions and interpretations of those of laws, and this book covers all of them. I was impressed by how the authors tackled the mind-boggling complexity and interplay of these rules in such a readable fashion. I myself dog-eared many pages for future reference.

For my company (Quizzify), this book has been especially helpful as, thanks to its guidance, we are able to now offer an HRA which satisfies the “reasonably designed to promote health or prevent disease” standard far better than the typical buckle-your-seat-belt-and-eat-more-broccoli HRA — and does it without collecting personal health information. Hence we avoid all the HIPAA concerns while satisfying the standard for what constitutes an HRA many times over. Absent hiring an expensive attorney, this would not have been possible for us to do without this book as a touchstone.

While designed to be read and hence not classically termed a “reference book,” the chapter most readers will want to refer to time and time again is #4, covering the laws of workplace screening and incentives. If you are going to get in trouble, that’s where it will happen. Virtually all the lawsuits filed by various employees have alleged violations of laws and regulations around screenings and incentives/penalties.

The ultimate irony is that this book is about 400 pages long.. That’s how much space is required to cover all these rules. And yet there is no rule saying that vendors can’t harm employees, which would seem like it should be the most basic if not the only rule of wellness. So Wellsteps was able to get away with harming employees of the Boise School District (and, this being the wellness industry, be rewarded for this performance with a Koop Award) and — aside from a scathing expose by ace journalist Sharon Begley in STATNews — face no consequences or liability. Yet if you don’t follow all the steps listed in here for avoiding minor transgressions (for instance, your coaches may accidentally ask people about their family histories — a useful but in most cases illegal line of inquiry) you could find yourself in violation of one or more of the laws which somehow manage to make wellness programs both more complex and less effective at the same time.

At some point, all these regulations should be shelved in favor of a “do no harm” standards as covered in the Wellness Code of Conduct (for which Ms. Zabawa is an endorser and co-author), findable at ethicalwellness.org. But until then, these rules rule the industry, and as the title says, you need to rule the rules.

 

Dave Chase’s New Book Reveals that Wellness Is Not the Only Scam in Healthcare

Healthcare meets Network.

That is the one-sentence summary of Dave Chase’s new book, A CEO’s Guide to Restoring the American Dream: How to Deliver World-Class Healthcare to Your Employees at Half the Cost.

Dissecting the title, the “restoring the American Dream” reference is as follows: While wages have barely budged in the last 20 years, employee compensation has risen quite a bit — with most of the increase being the health benefit. Dave’s observation is that if the health benefit were managed much more tightly, wages could climb noticeably for the workforce without increasing the total employee compensation budget.

As for “half the cost,” that number may be overstated…but not by much. For instance, I just saw a wellness vendor send 2/3 of a company’s employees to the doctor because they have “conditions” they didn’t know about, that this vendor “discovered” by — you guessed it — screening the stuffing out of them by flouting clinical guidelines. This employer could save about 3% simply by firing the vendor and not consigning all those employees to the treatment trap. (And of course there has been no measurable improvement in outcomes from all these doctor visits.)

This employer and others could save another 0.5% simply by not insisting that their employees and spouses get annual checkups (and “well-woman” visits) because as readers of this site know, they have no value. The good news is that checkups are not likely to harm employees, which is more than can be said for many wellness programs.

So we are already saving 3.5% and we haven’t even done anything hard yet, where “hard” is defined as “something that does not delight employees, like getting rid of ‘pry, poke and prod’ programs.” In other words, “hard” isn’t really hard.


Slightly harder opportunities

In addition to an expose on wellness, Dave Chase exposes some scams that make wellness look like child’s play. (Wellness is child’s play, in the sense that any fifth-grader knows more arithmetic than a wellness vendor. And a 14-year-old knows more about BMI.)

In no particular order, we’ll start with PBMs. Their stock prices have exploded — literally, 300-fold — in the last 30 years.  You think they achieved that growth honestly? They make wellness vendors look like boy scouts. They obfuscate everything, with “rebates” and “formularies” and under-the-table payments from drug companies, and all sorts of other things that we probably don’t even know about. Here is a New York Times article that casts just a little light on the subject…but more than enough light to indict the entire industry.

It isn’t easy to ditch a PBM, but increasing numbers of alternatives are popping up. A good rule of thumb is, the thicker the contract with your PBM, the more you are getting ripped off.  I invite folks who offer one of these new alternatives to add a comment at the bottom of this posting and/or on linkedin following this posting.

Then there are the carriers, who typically make more money, the more money gets spent. The number of scams is mind-boggling. For example, consider Dave’s explanation of what happens when a claim is overbilled:

Another fee opportunity is so-called “pay and chase” programs,
in which the insurance carrier doing your claims administration
gets paid 30-40 percent for recovering fraudulent or
duplicative claims. Thus, there is a perverse incentive to tacitly
allow fraudulent and duplicative claims to be paid, get paid as
the plan administrator, then get paid a second time for recovering
the originally paid claim.

And good luck trying to ferret your own claims data out of carriers so that you can do your own analysis on them and change policy accordingly. I do quite a bit of work for top-flight carriers, measuring their wellness-sensitive medical events. They always seem to have the data at their fingertips. We can complete the analysis for the year within weeks after claims run-out ends, meaning sometime in April. Meanwhile, I’ve got a Fortune 50 client whose carrier, Optum, still hasn’t managed to provide them (at an extra fee!) with their own event rates for 2016, a delay which more than coincidentally will make it impossible to implement any cutbacks in Optum’s services for 2018 if the event rates show that — hang onto your hats — Optum didn’t achieve anything.

Don’t get Dave started on providers, who find highly creative ways to snooker employers and employees.  Like staffing in-network facilities with out-of-network doctors, who then bill patients ridiculously high charges.  You need to re-contract with your carrier and put that one on them.  Or, if you’re large enough, recontract with the hospital.

And speaking of hospitals, why have Leapfrog D- and F-rated hospitals in your network at all? If geographic necessity, then at a miimum educate your employees that it might be worth the extra drive to avoid some major complications.

Providers also bill companies what they think they can get away with, rather than what a buyer would expect to pay given what others in the area are charging. Since the company is generally not the decision-maker (the employee or doctor generally decides where to go, not based on price), they often get away with it. An entire chapter is devoted to provider pricing scams and the importance of transparency.

Or, my own personal favorite provider scam, disguising emergency rooms as urgent care centers, like the one below. (A rather naively idealistic Colorado legislator tried to make freestanding ERs disclose that they are not urgent care centers, but the provider lobbyists prevailed.)

A sidebar: Quizzify trains employees to be on the lookout for these scams, which is helpful for the 0.1% of the 150,000,000 commercially insured employees who actually have access to the quizzes. The other 99.9% are on their own.


And yet it all comes back to wellness

Employer obsession with wellness has caused them to take their eyes off these many other balls, because wellness was supposed to solve everything (including industrial waste, according to HERO stalwart Bruce Sherman).   Truly wellness has been the Maginot Line of healthcare cost containment strategies. While a vastly disproportionate share of resources has gone into wellness, PBMs, carriers, providers and various middlemen simply circumvented these efforts, to dig right into your pocketbooks.

I can only scratch the surface here — just go out and buy the book, and then you’ll understand both why when it comes to scamming employers and employees, wellness vendors have a lot to learn, and also why you should be mad as hell and not take it any more.

The Million-Dollar Workplace Wellness Heart Attack Screen

I think I should hit “Reblog” on this post because it’s getting a fair number of “likes.” It is 4 years old but still applies, probably even more so. I guess I thought everyone had seen it but apparently not. Short answer: yes, it does cost about a million dollars to avoid a heart attack using a screen.

THE SOVEREIGN PATIENT

A lot of screening exams cost way more than they save and often they prevent only very few bad outcomes. The article below is an excellent review of screening protocols and analyses and the math that goes into figuring these outcomes. Great read for any businesses considering adopting Wellness screening.

http://healthaffairs.org/blog/2013/04/29/the-million-dollar-workplace-wellness-heart-attack-screen/

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We are shocked, shocked, to learn that opioids are going on in here!

The #1 problem in the American workforce is not failure to buckle their seat beats. It isn’t taking too few steps. And it certainly isn’t a broccoli deficiency. It is opioid addiction. It would be nice if the wellness industry — which claims to be responsible for the health and wellness of the workforce — could actually do something useful here.

Unfortunately, the wellness industry model, relying on voluntary disclosure of problems, is not set up to address the problem, since most people will simply deny having it.  Employees can’t be referred to “wellness coaches” for help if they don’t self-identify as having a problem.  (It’s also not clear that wellness coaches are equipped to address the issue.)


A Nation Turns Its Lonely Eyes (actually Constricted Pupils) To Quizzify

But what if an employee didn’t have to self-identify in order to get help? That’s where health literacy comes in.  Health literacy is the key to avoidance and (to some degree) treatment of addiction. Understanding the risks of even short-term use of painkillers is critical.  Quizzify covers that topic for employees. Since it’s all Q&A and fact-based, there is no need for any employee to disclose anything. Instead they can focus on self-education. An employer or HR Department can see how opioid-literate its workforce is.

That assumes that the employer or HR department is itself opioid-literate. For that, we are pleased to offer two free resources.  The first is the Quizzify opioid awareness quiz.  See how you — as the person in your organization most responsible for the health of your employees — score on this quiz.

Then, read and share the Linkedin post: “Seven Shocking Opioid Facts Wellness Professionals Need to Know” .

 

 

Breaking news (really): Federal court rules that forced wellness programs are not voluntary

In a resounding but nonetheless surprising victory for harassed employees everywhere, a federal court agreed with the plaintiff, AARP (and every fifth grade English teacher in the country except the ones who taught wellness vendors), that the words “forced” and “voluntary” are not synonyms.  If a wellness vendor (Bravo being the best example) threatens to fine employees or even withhold incentives because the employee refuses to let a vendor screen the stuffing out of them, the vendor can’t hide behind established laws that say wellness programs are voluntary, because they aren’t.

We encourage you to read today’s article in STATNews by award-winning health reporter Sharon Begley for all the details. No surprise that the National Business Group on Health finds itself on the wrong side of history as usual, with their comment that:

Though the EEOC rules are not perfect, they do clarify underlying ambiguities in the law and have helped assure that employees and their families can benefit from these programs that promote their well-being.

Not true. Employers may still do whatever they want to promote employee well-being and happiness. They just (possibly, depending on the final rules written by the EEOC to comply with this decision) can’t do what Surviving Workplace Wellness says “pry, poke and prod” vendors excel at, which is to force employees to be happy whether they like it or not.

 

Wellness Vendors Dream the Impossible Dream

Alice laughed: “There’s no use trying,” she said. “One can’t believe impossible things.”

“I daresay you haven’t had much practice,” said the Queen. “When I was younger, I always did it for half an hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.”


Six impossible things before breakfast?  The wellness industry would just be getting warmed up by believing six impossible things before breakfast. They believe enough impossible things all day long to support an entire restaurant chain:

Consider the article in the current issue of BenefitsPro — forwarded to me by many members of the Welligentsia — entitled: “Can the Wellness Industry Live Up to Its Promises?”  BenefitsPro rounded up some of the leaders of the wellness industry alt-stupid segment. Specifically, they interviewed US Corporate Wellness, Fitbit, Staywell, and HERO. Each is a perennial candidate for the Deplorables Awards — except US Corporate Wellness, which already secured its place in the Deplorables Hall of Fame (and Why Nobody Believes the Numbers) several years ago with these three paeans to the gods of impossibility.

In case you can’t read the key statistic — the first bullet point — it says: “Wellness program participants are 230% less likely to utilize EIB (extended illness benefit) than non-participants.”  Here is some news for the Einsteins at US Corporate Wellness:  You can’t be 230% less likely to do anything than anybody. For instance, even you, despite your best efforts in these three examples, can’t be 230% less likely to have a triple-digit IQ than the rest of us.  Here’s a rule of math for you: a number can only be reduced by 100%. Rules of math tend to be strictly enforced, even in wellness.  So the good news is, even in the worst-case scenario, you’re only 100% less likely to have a triple-digit IQ than the rest of us.

And yet, if it were possible to be 230% dumber than the rest of us, you might be. For instance, US Corporate Wellness also brought us this estimate of the massive annual savings that can be obtained just by, Seinfeld-style, doing nothing:

So assume I spent about $3500/year in healthcare 12 years ago, which is probably accurate. My modifiable risk factors were zero then and they are still zero — no increase. So my healthcare spending should have fallen by $350/year for 12 years, or $4200 since then. But that would be impossible, since I could only reduce my spending by $3500. Do you see how that works now?

To his credit, US Corporate Wellness’s CEO, Brad Cooper, is quoted in this article as saying: “Unfortunately some in the industry have exaggerated the savings numbers.” You think?

I’m pretty sure this next one is impossible too. I say “pretty sure” because I’ve never been able to quite decipher it, English being right up there with math as two subjects which apparently frustrated many a wellness vendor’s fifth grade teacher:

400% of what?  Is US Corporate Wellness saying that, as compared to employees with a chronic disease like hypertension, employees who take their blood pressure pills are 400% more productive?  Meaning that if they controlled their blood pressure, waiters could serve 400% more tables, doctors could see 400% more patients, pilots could fly planes 400% faster? Teachers could teach 400% more kids? Customer service recordings could tell us our calls are 400% more important to them?

Or maybe wellness vendors could make 400% more impossible claims. That would explain this BenefitsPro article.


Fitbit

We have been completely unable to get Fitbit to speak, but BenefitsPro couldn’t get them to shut up. Here is Fitbit’s Amy McDonough: “Measurement of a wellness program is an important part of the planning process.”   Indeed it is! It’s vitally important to plan on how to fabricate impossible outcomes to measure, when in reality your product may even lead to weight gain.  Here is one thing we know is impossible: you can’t achieve a 58% reduction in healthcare expenses through behavior change — especially if (as in the 133 patients they tracked in one of their studies) behavior didn’t actually change.

You can read about that gem, and others, in our recent Fitbit series here:


Health Enhancement Research Organization (HERO) and Staywell

I’ll consider these two outfits together because people seem to bounce back and forth between them. Jessica Grossmeier is one such person. Jessica became the Neil Armstrong of impossible wellness outcomes way back in 2013.  Not just any old impossible wellness outcomes — those have been around for decades. She and Staywell pioneered the concept of claiming outcomes they already knew were impossible.   While at Staywell, she and her co-conspirators told British Petroleum they had saved about $17,000 per risk factor reduced.  So, yes, according to Staywell, anyone who temporarily lost a little weight saved BP $17,000 — enough to clean up about 1000 gallons of oil spilled from Deepwater Horizon.

See British Petroleum’s Wellness Program Is Spewing Invalidity for the details.

Leave aside both the obvious impossibility of this claim, and also the mathematical impossibility of this claim given that employers only actually spend about $6000/person on healthcare.  Jessica’s breakthrough was to also ignore the fact that this $17,000/risk factor savings figure exceeds by 100 times what her very own article claims in savings. Not by 100 percent. By 100 times.

Fast-forward to her new role at HERO. In this article she says:

The conversation has thus shifted from a focus on ROI alone to a broader value proposition that includes both the tangible and intangible benefits of improved worker health and well-being.

Her memory may have failed her here too because HERO — in addition to admitting that wellness loses money (which explains its “shift” from the “focus on ROI alone”) — also listed the “broader value proposition” elements of their pry-poke-and-prod wellness programs. The problem is the elements of the broader value proposition of screening the stuffing out of employees aren’t “benefits.”  They’re costs, and lots of them:

When she says: “The conversation has shifted from a focus on ROI alone,” she means: “We all got caught making up ROIs so we need to make up a new metric.”  RAND’s Soeren Mattke predicted this new spin three years ago, observing that every time the wellness industry makes claims and they get debunked, they simply make a new set of claims, and then they get debunked, and then the whole process repeats with new claims, whack-a-mole fashion, ad infinitum.  Here is his specific quote:

“The industry went in with promises of 3 to 1 and 6 to 1 based on health care savings alone – then research came out that said that’s not true. Then they said: “OK, we are cost neutral.” Now, research says maybe not even cost neutral. So now they say: “But is really about productivity, which we can’t really measure but it’s an enormous return.”


Interactive Health

While other vendors, such as Wellsteps, harm plenty of employees, Interactive Health holds the distinction of being the only wellness vendor to actually harm me.  I went to a screening of theirs. In order to increase my productivity, they stretched out my calves.  Indeed, I could feel my productivity soaring — until one of them went into spasm. I doubt anyone has missed this story but in case anyone has

They also hold the distinction of being the first vendor (actually their consultant) to try to bribe me to stop pointing out how impossible their outcomes were. They were upset because I profiled them n the Wall Street Journal . The article is behind a paywall, so you probably can’t see it. Here’s the spoiler: they allegedly saved a whopping $53,000 for every risk factor reduced. In your face, Staywell!

Here is the BenefitsPro article’s quote from Interactive Health’s Jared Smith:

“There are many wellness vendors out there that claim to show ROI,” he says. “However, many of their models and methodologies are complex, based upon assumptions that do not provide sufficient quantitative evidence to substantiate their claims.”

You think?

Finally, here is a news flash for Interactive Health: sitting is not the new smoking.  If anything is the “new smoking,” it’s opioid addiction, which has reached epidemic proportions in the workforce while being totally, utterly, completely, negligently, mind-blowingly, Sergeant Shultz-ily, ignored by Interactive Health and the rest of the wellness industry.

There is nothing funny about opioid addiction and the wellness industry’s failure to address it, a topic for a future blog post. The only impossibility is that it is impossible to believe that an entire industry charged with what Jessica Grossmeier calls “worker health and well-being” could have allowed this to happen. Alas, happen it did.

And, as you can see from the time-stamp on this post, except at establishments favored by the Wellness Ignorati, breakfast hasn’t even been served yet.

We interrupt this blog to bring you a special wellness bulletin

Normally we draw a bright line between Quizzify and TSW.  However, today we are going to re-blog from Quizzify, because of the importance of the hazard of tick-borne illness to about a third of the residents of the US.

And also because this particular hazard is getting completely ignored by the wellness industry. I guess that’s because they are spending all their time educating employers and employees on the opioid epidemic. (Not.)

Like the opioid epidemic, tick-borne illness is a far greater hazard than obesity or cholesterol or not taking enough steps. This summer, the odds of an employee getting Lyme Disease, in the mid-Atlantic and Northeast, are probably 5-10 times the odds of an employee having a heart attack.  (I won’t bore — or, in the case of Interactive Health, confuse — anyone with the relative incidence rates, but the numbers add up.)  There are also other tick-borne illnesses — 15 of them — in the other 38 states as well, but not yet in epidemic proportions.


And while my $2-million reward supports the proven observation that heart attacks are about 0% preventable with “pry, poke and prod” programs, tick-borne illness should be 100% preventable by following a few self-evident rules…and one not-so-self-evident rule.

We’d urge everyone in states where ticks are an issue to read the blog post, post the downloadable infographic in break rooms, and educate their employees generally. We are now in high-tick season so it is important to do it soon.

It’s not possible to do attachments on WordPress blog posts (translation: I personally have no clue), but here is a low-res preview:

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