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Virgin Pulse has the best health risk assessment

Remember when the sergeant asked for a volunteer to step forward and Moe and Larry took a step back?

Image result for three stooges in the army

Looks like Virgin Pulse has won the best-HRA contest the same way. Yes, it is a complete waste of employee time and employer money. In HRAs, that’s table stakes. It earns a solid “C” not because anyone will learn anything of any value, but rather because the other two are worse. The VP HRA offers so little advice that none of it is really bad. It that sense it is better than Cerner’s (“F”) and Optum’s (F+).

Here’s what Virgin Pulse’s HRA gets points for not doing:

Tell employees to eat nonfat yogurt that is full of sugar (like Cerner):

Imply that employees on opioids should get more opioids (like Optum)

Advise employees against using olive oil (like Optum)

Further, it is actually coherent, instead of containing questions like… (Optum again)

…in which both non-asthmatics and completely uncontrolled asthmatics would give you the same answer.

Virgin Pulse’s “advice”

“Eat a healthy breakfast.” Who can argue with that? It’s like a manager advising the batter to hit a home run. Obviously the key is in the execution, and naturally Virgin Pulse provides none. In that sense, it is the best HRA because the others give such bad advice.

What constitutes a healthy breakfast? Can’t be just any old cereal. Those are full of sugar. Ah, maybe something like Kellogg’s Smart Start with Antioxidants, which is “heart-healthy.”

Image result for kellogg's smart start antioxidants cereal

Oops. That’s on Eat This Not That’s “worst healthy cereals” list.  Because it is — you guessed it — full of “heart-healthy” sugar.

Kellogg’s Special K Protein Snack Bars? 10 grams of added sugar apiece (and you’d likely eat 2–they’re small) with six different sugars dispersed throughout the ingredients label.

Eggs?  For most people, eggs are a healthier choice than most packaged cereals. Of course, there are exceptions — a bit less than 1% of the population is genetically predisposed to high cholesterol. But wellness vendors would lose money if they actually spent the time to address these nuances. Of course, in this case, the “nuance” is that familial hypercholesterolemia (FH) is a much better predictor of cardiac events than anything in any HRA. As in about 40% of everyone with untreated FH will infarct before age 60.

Oatmeal?  Probably the greatest consensus around that. (And that’s the breakfast of choice here at TheySaidWhat? World Headquarters.) Yet plenty of cereal companies, and fast food chains, have turned oatmeal into junk food. Dunkin’s “Brown Sugar Flavored Oatmeal” packs in 28 grams of sugar (none of which is actual brown sugar, as luck would have it).

Orange juice? That counts as a serving of a fruit according to the American Heart Association (AHA) and Virgin Pulse is a big one for telling you to eat up to 11 servings of fruits and vegetables a day, with “1/4 cup” of juice counting as a serving. Using the AHA math, an 8-ounce glass of juice would appear to get you 4/11ths of the way there.

And ads for “healthy” cereal sometimes show a glass of orange juice on the side:

Image result for cereal ads in magazines orange juice

On the other hand, NPR and Consumer Reports advise against considering juice as a healthy alternative. The sugar is “natural,” but there is an awful lot of it. (I myself am not a nutritionist, and don’t even play one on TV, so I don’t have an opinion on whether natural sugar is OK and added sugar isn’t. Except I would point out that grape juice contains natural sugar while grape juice concentrate is an added sugar. Both can’t be right.)

So which is it? Drink more juice, or don’t? Which constitutes “eating a healthy breakfast” ? I don’t know and I suspect neither does Virgin Pulse. The difference, of course, is that TSW isn’t charging lots of money to give employees advice.

Completing the Virgin Pulse HRA 

Obviously, employees are going to lie on HRAs, and Virgin Pulse’s is no exception. I was invited to watch a group of employees completing theirs, For each answer, they gamed the system. What is the optimal amount of stress to claim? Too much might harm their career. Too little and someone might give them more work.

How much should they claim to drink?  “Not at all” might cause their (well-known!) employer to think they’re lying, so they all decided to cut their true totals in half.

Servings of fruits and vegetables? Most of them just made up a number that would sound good to an employer.

Everyone seems to know employees lie on HRAs (including, of course, Virgin Pulse) except the employers that still use them, whose quest to create a culture of health ends up creating a culture of deceit. No need to take my word for this. Simply complete this chart to see what percentage of your employees with something to lie about are indeed lying — and what the odds are that an employee with something to hide will tell the truth about it:

Let’s try completing this chart, using the most recent winner of the C. Everett Koop Award, Wellsteps.

Result: in the so-called best wellness program, almost 2/3 of employees lie, though in all fairness to Wellsteps, some of those could be the same employee lying twice. And extrapolating from Wellsteps’ result, the odds of an employee coming clean about a bad health habit are about 1-in-4. That’s the average of smoking and drinking. Generally the more socially acceptable habits will show a higher percentage of employees telling the truth.

Keep in mind, too, that there is another way to lie on HRAs, which is understatement. You may recall from Wellsteps that the 23% who drink only imbibe 1.3 drinks a day, while 3% who do admit to smoking indulge in cigarettes only 4.27 times a week, perhaps taking a break on weekends and major holidays, such as Beethoven’s Birthday.

Image result for beethoven's birthday

Due to the lying and uselessness, should employers drop HRAs altogether?

In the immortal word of the great philosopher Curly Howard, soitenly.

Image result for curly howard



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.

AJMC: We are shocked, shocked to learn that HRAs are useless

We interrupt our litany of descriptions of failed HRAs to bring you a description of the failure of HRAs.

In wellness, it’s not news to find that something is useless. Indeed, most employees and most economists would agree that the world would not miss Wellsteps or Interactive Health were they to disappear altogether from the earth.

Still, it is news to find that yet another pillar of wellness has fallen victim to actual analysis. In this case, it’s the venerable Health Risk Assessment. This tool has, for about 40 years, been used to encourage employees to pretend they don’t drink. The tool does have one practical use: identifying employees who don’t buckle their seat belts helps employers decide who needs their hearing tested.

HRAs do have their defenders, of whom the most prominent is Larry Chapman, who says they should be treated like “a beloved pet.

He cites this data set from JOEM showing the costs of people who took the HRA vs. people who didn’t…

…to support the proposition that HRAs cut the average health care cost in half after three years. Or, to use his exact words, CUT THE AVERAGE HEALTH CARE COST IN HALF AFTER THREE YEARS.

It may come as a surprise to Mr. Chapman, who once claimed that wellness could reduce costs by 327%, that CAPITAL LETTERS don’t stand a chance against actual data, and there is nothing whatsoever in this data set that he himself cites to support the notion that HRAs reduce cost by HALF, or for that matter any amount. Indeed, in 5 of the 6 periods studied, the study group had higher costs than the comparison group. The study group did better in the final year, three years after taking the HRA. This is likely because by that time they had forgotten all the useless and, as we’ve been learning, incorrect advice that HRAs provide.

Enter Joe Andelin, who plowed through 200 pages of Kaiser Family Foundation survey data, publishing the results on the American Journal of Managed Care blog on May 1. Lest anyone not be looking forward to slogging through an academic article, let me assure you he sounds more like me than I do, starting with his opening line:

Will Rogers once said, “The income tax has made more liars out of the American people than golf has.” Health risk assessments (HRAs)…could give taxes a run for their money.

The key findings in his transparent and replicable study:

  • Incentives and penalties are effective in getting employees to complete HRAs, but…
  • …Companies with a high percentage of HRA completion spend more money on healthcare than companies with a low completion rate — and the companies that don’t offer HRAs at all have the lowest spend of all.

I wouldn’t infer causation from this correlation.  That’s because most employees, having been burned in the past by (for example) taking HRA advice to get more prostate exams and eat less fat, now have the good sense not to take the advice offered on HRAs like Cerner’s or Optum’s.  Rather, I suspect the causation works as follows: companies that actually think completing Cerner’s or Optum’s HRA is a good idea have applied their very stable genius insights to the rest of their health benefit structure…and hence spend more money.

There are plenty of other shocking factoids in this article as well, so I would encourage people to read the link.

Optum’s HRA gets an “F” (though employees who want more opioids will love it)

My recent request to review health risk assessments (HRAs) brought a number of responses. I’m grading the HRAs that I was able to access, on both advice and readability.

Optum’s, the second to be reviewed, receives “F” in advice and, as will be shown below, F- in readability. The scoring system is laid out here.

Advice: Chronic Pain

Optum offers the single most genius piece of advice of any of the very stable HRAs I’ve taken. By way of background, I took this HRA in 3 states where doctors are notorious for regularly giving out opioids as his or her treatment plan to follow, to people who currently have chronic pain. I checked off that I had “currently have chronic pain” just to see if they would say something worth blogging about, and was richly rewarded for that effort:

So this HRA is basically advising me to go get more opioids. The bad news is that they aren’t directing people to Quizzify’s painkiller awareness quiz. The good is that employees who want more opioids will give their program a high satisfaction rating.

Advice: Diet

This advice to switch to lowfat dairy is more likely to cause harm than to create benefit. Full-fat dairy is preferable to fat-free for most people. As this summary, with links to the studies, shows, full-fat dairy probably offers protection against diabetes.

The advice regarding “lower-fat meats” is controversial but is presented as fact. There is a whole body of research saying the opposite of what Optum says. Once again, we aren’t taking sides except to note that coercing employees to complete HRAs implies that the HRAs should be beyond challenge.

“Avoiding adding extra fats/oils when preparing food or at the table,” besides the questionable sentence structure, is simply wrong. Olive oil is on everyone’s good list, for example, while (aside from trans fats) other fats and oils have their advocates. A much better answer — how hard would it have been to come up with this? — might be “substitute olive oil for other fats and oils.” A bigger point: fats and oils make food taste good. And enjoyment of meals will lead to happier employees.

“Avoid added sugar” is decidedly unhelpful advice. Food companies go through a lot of trouble to hide “added sugar” specifically so people don’t avoid it. See this article: The Extraordinary Science of Addictive Junk Food.  Optum’s go-to weapon against this cutting-edge neuroscience is: “Avoid added sugar” ?

Alas, Optum’s HRA is silent on how one goes about accomplishing this feat. This decidedly unhelpful advice runs up against the reality that people have no idea where these “added sugars” lurk, since very few products these days advertise: “An excellent source of added sugar.” By way of contrast, Quizzify does teach employees how to avoid added sugar — see the example right on the home page — and a good thing, because Quizzify’s test-takers, while improving greatly over time, originally score as follows:

  • 52% think granola bars are healthy (they’re candy)
  • 62% didn’t recognize synonyms for sugar (malted barley extract, dextrose, evaporated cane juice, maltodextrose)
  • 68% didn’t realize that the first ingredient in a Clif Bar, organic brown rice syrup, is — you guessed it — sugar.

By contrast, this Optum “avoid added sugar” advice is about as helpful as just asking employees to rate their diet, which would be a useless question no HRA would ask. Oh, wait:

“An excellent diet is low in total fat” is simply wrong information. While saturated fat is controversial, the “low in total fat” myth was killed off decades ago.

While some people’s blood pressure is quite sensitive to changes in sodium intake, blanket recommendations of low-sodium diets are the subject of a great deal of controversy too. The ongoing Framingham Heart Study correlates high sodium intake with low blood pressure, the opposite of what Optum says.

So they’ve told employees to avoid fat and salt. Just to belabor the obvious — and in wellness, the obvious needs a lot of belaboring — what the bleep do they think people are going to eat instead of salty food or fats???  Are they gonna reach for kale, kelp, or a kiwi? Unlikely.  They’re going to — get ready — eat something full of that very same added sugar, likely, as noted above, without even realizing it.

Congratulations, Optum. Your HRA greenlights the two biggest no-nos for employees: opioids and sugar. Fortunately for you, few employees take HRAs, seriously, so you probably aren’t doing any harm. This is especially true of yours, because even if someone did want to take yours seriously,you’ve thrown up one more roadblock: people can’t figure out what you’re saying, and that brings us to…


The complete scale for readability is here. Or so I thought, until I read Optum’s, which requires adding an “-” to the “F” on the scale . I took this HRA multiple times and each time it was an exercise in frustration.

Among other things, there were literally 100 screens that had to be scrolled through. And if you “saved” your work-in-process, you had to scroll through them all again to get back to where you left off.

Here is my favorite screen:

Stay with me on this one:

  • If you are a good person, by definition, you check off the following: “I strongly agree that I am a good person.”
  • If, by contrast, you are a bad person, by definition, you check off the following:  “I strongly agree that I am a good person.”

After all, isn’t the whole point of being a bad person is to pretend you’re a good person?  Bad people don’t exactly announce that fact on their Linkedin profiles.  Sometimes they don’t even know themselves they are bad people. Walter White thinks he is a good person.

What does this mean?

Stay with me on this one.

  • If you do not have asthma, meaning you are at the lowest risk, you check off the third box: “No, not being treated or taking meds.”
  • If you do have asthma but are ignoring it, meaning you are at the highest risk, you check off the third box: “No, not being treated or taking meds.”

It’s also not clear how one would get treated for asthma without taking meds, making the second box a head-scratcher too.

Optum repeated this three-box choice for every other chronic disease as well, including diabetes. Diabetes, of course, is a disease that is very common to have but not be treated for. Indeed, it is so common to have diabetes and not be treated for it that there is an entire industry — that would be your industry, Optum — devoted to bribing, coaxing, cajoling or threatening every single suspected diabetic into treatment.

And yet somehow diabetes is nonetheless not common enough for you to draw an additional box on a screen that people can use to distinguish between whether they have diabetes and are not being treated for it, or whether they don’t have diabetes at all.

Indeed, one would think, with 100 screens to scroll through that could easily be consolidated into half that number (for instance, if you don’t use nicotine, you shouldn’t need to scroll through four screens to make your point), the disease inquiry category would be the wrong place to try to economize on electrons by causing people to check off the same box for opposite answers.

To summarize, I’m not following the advice on this HRA, either because it is terrible advice but I need it, or because it is great advice but I don’t need it.


Cerner’s HRA scores an “F+”

My recent request to review health risk assessments (HRAs) brought a number of responses. I’m grading the HRAs I was able to complete, on both advice and readability.

Cerner’s, the first to be reviewed, receives “F” in advice and, as will be shown below, D in readability, for an average of F+. Advice is scored as follows:

  • A: Virtually all the advice is up to date and correct
  • B: The advice is generally correct
  • C: There is good and bad advice in roughly equal amounts
  • D: Bad advice outweighs good
  • F: Employers using this HRA should caution employees not to take the advice

For each HRA being graded, unless otherwise indicated, I am completing them exactly the same way. I am somewhat understating the quality of my diet and the amount of exercise I do, in order to get “mainstream” advice.

High-risk for alcohol and drug use is incorrect. 10 mg of Ambien, taken as directed by a physician, does not create high risk in the absence of other drug and alcohol risk factors.

Ironically, there is a risk in telling people they are high-risk when they aren’t, which is that they will simply lie, in order to move their score left, out of that red segment, and out of the embarrassing range. As a result, they would not exposed to advice they should be getting if indeed they are at risk for drugs and alcohol.

And then they realize it’s OK to lie in general on HRAs. These lies take place on a massive scale, invalidating the entire HRA instrument.  In an attempt to create a culture of health, companies are creating a culture of deceit.

This blood pressure advice is incorrect. Someone with a “pulse pressure” of 25 (110 – 85) is not at “moderate risk” of anything. This is an emergency situation, likely indicating heart failure fluid overload. (This is not my blood pressure, by the way, or I’d be practically dead.)  

This advice is wrong on five dimensions.

  1. People should not be taking blood pressure advice off a computer-generated algorithm, especially one that hasn’t been updated in years. That’s what doctors are for.
  2. It’s not at all clear that lowering sodium reduces blood pressure in the large majority of adults. This should not be offered as a fact. In some people it makes a difference. Advising people on their own situation is what doctors are for. 
  3. “If you limit your sodium to 1500 mg a day, you can lower your blood pressure even more.” Actually the Framingham Offspring Study says the reverse. It turns out that people who say they consume 4000 mg/day of salt have the lowest blood pressure. (The link is to a lay article that itself links to scholarly material.) Not clear which is right, but advice this controversial should not be passed off as a fact when the evidence conflicts.
  4. It is possible that this Cerner-recommended low-sodium diet increases cardiovascular risk. Other studies, largely older ones, say this diet reduces risk. It’s safe to say there is no consensus. But HRAs, which employee are being financially coerced into doing, should not be offering controversial advice as fact.
  5. Telling people to avoid salty snacks may encourage people to eat sugary snacks. The HRA is quite deficient in warnings about sugar.

This advice to switch to lowfat dairy is more likely to cause harm than to create benefit. Full-fat dairy is preferable to fat-free for most people. As this summary, with links to the studies, shows, full-fat dairy probably offers protection against diabetes.

And don’t overlook their complete rookie mistake: telling employees to eat “low-fat or nonfat yogurt,” which of course is full of sugar.

The advice regarding saturated fat in meats is controversial but is presented as fact. There is a whole body of research saying the opposite of what Cerner says. Once again, we aren’t taking sides except to note that coercing employees to complete HRAs implies that the HRAs should be accurate.


Further, Cerner’s HRA, as Yogi Berra might say, contains a lot of omissions. The following pieces of advice should be included, but aren’t:

  • Advice not to text while driving (in lieu of the seat belts question*)
  • Health literacy information on finding hidden sugars
  • Health literacy information on finding hidden salt (who knows how much “1500 milligrams” is, assuming that advice were good?)
  • Eggs are one of nature’s healthiest foods for most people
  • Shingles vaccine addresses the most easily avoidable risk for people over 50
  • Questions on opioid awareness (not opioid use, which people will just lie about) and information on how addictive they can be

*Not a useful question and speaks to a lack of updating. While decades ago, a few employees might have benefited from the advice to buckle a seat belt, no employee in recent history has ever not buckled their seat belt, taken an HRA on which they admitted not buckling their seat belt, read the printout that said they should buckle their seat belt, realized for the first time that not buckling a seat belt was a bad idea…and then started buckling their seat belt.


The scale for readability is:

  • A: Intuitive — didn’t even think about any readability issues
  • B: Readable enough
  • C: Readable with exceptions
  • D: Not readable in many instances
  • F: Exercise in frustration

Cerner earns a “D” only because, as we will see in a future posting, it is better than Optum’s (F) and Interactive Health’s (F). Absent those two HRAs, Cerner would get an “F”.

Cerner says I am “at HIGH risk for chronic health issues.” But on the right it says I am “moderate risk.” That is confusing and decidedly unhelpful in and of itself. But wait. There’s more…now how much risk do I have?

Having sweated bullets while learning I was high risk and moderate risk, I rest easily to learn that I am at “LOW risk for chronic health issues.” 

Eventually I guessed what meaning they were trying to convey, but the typical employee (who, according to Cerner, has to be told to buckle a seat belt) is not going to figure this out.

Why couldn’t they just ask if you are feeling down or depressed? (Not that any employee is going to answer that honestly, in any event.) 

“Has little interest or little pleasure in doing things bothered you?”  Does this mean that if having “little interest or little pleasure in doing things” doesn’t bother you, you write “no”?  I had to read this several times to figure out what they were asking.

It doesn’t help that Cerner’s writing style uses a lettering system for no reason. What do those “a’s” and “b’s” add?  They do that everywhere, to add to the general confusion:

Lots of extra letters, for no reason at all. And “stroke” and “heart attack” are not “conditions.” They are “events.” Heart failure (a serious disease with an average life expectancy of 5 years) should not be lumped in with angina, which can be controlled for many years with diet, exercise and medication.


There is far too much advice in here – salt, dairy, meat, drugs, blood pressure just for starters – for anyone to internalize and act upon. It is a tenet of human behavior that the more advice is given, the less is taken. Plus, more importantly, a large chunk of the advice is at least arguably wrong, if not definitely wrong.

Further, the two things that are most important for employees to learn about — sugar and opioids — are pretty much ignored. A good HRA will laser-focus on sugar harms. Likewise, opioids, the leading killer of people under 50. While an HRA can’t cure an addict, questions like: “How long does it take for the first signs of opioid addiction to start, when used as directed?” could measure people’s opioid awareness and then provide easily digestible information on what the actual answer is (3 days). Quizzify has placed its pain management-and-opioids quiz in the public domain, which could fill that gap.

The graphics with all the HIGH and LOW risk scores are very confusing.

Virtually everyone with a drinking problem will lie about it. (Just check the national statistics against the results of this HRA.) This will encourage dishonesty in other answers, and in general create the culture that it is OK to lie to one’s employer.

This HRA, and HRAs in general, make the mistake of giving the same advice to everyone who answers a certain question(s) the same way.

This health risk assessment will not provide a net benefit to a population. It is recommended not to use it, or at a very minimum insist that whoever uses it double-check any advice offered with Quizzify or another source that is up to date and accurate.

For a good laugh, send in your vendor’s HRA for review and grading

For some reason in the last few months I’ve been deluged with requests to review health risk assessments (HRAs). Optum and Cerner top the list with multiple requests for review, while Wellsource, Redbrick, Healthmine and of course Interactive Health are also represented.  Virgin Pulse too, but since it was only once and since it was with an NDA, I can’t review it except to say that any company that wants a leg up in its own marketplace should urge its closest competitors to use Virgin Pulse and insist that their employees take all the advice.

Among these HRAs, one stands out as worthwhile…and as we get into the reviews over the next month, you’ll see which one.  The others shouldn’t be used, or perhaps, since for some reason employers refuse to stop using them, they carry a warning label advising employees to ignore most of the advice. The good news is that, even absent a warning label, most employees are possessed of enough common sense not to take advice from HRAs.

In other cases the advice would be straightforward and correct, like telling heavy drinkers to “cut down on your drinking,” except that virtually no heavy drinker actually admits it on an HRA.  (And that particular advice, repeatedly many different ways, is about as useful as telling a depressed person to cheer up.)

You may recall that Wellsteps–the self-proclaimed “best” (meaning “worst”) program in the industry, reported only 20% of employees as drinking (meaning “70%,” the US average), and none to excess (meaning “10%,” the US average).

The self-reported smoking rate? 3%…and most smokers only smoke 3-4 days a week. How silly is that! Everyone knows smokers smoke 5 days a week, with time off for weekends, major holidays, and Beethoven’s Birthday.

In the Soviet Union, workers had a saying: “We pretend to work. They pretend to pay us.” In HRAs, it’s: “We pretend to tell the truth. They pretend to believe us.”

Your mission, should you choose to accept it

If you are an HRA user, you can have your vendor’s HRA reviewed just by giving me a username (maybe your username — you can always go in and change the answers back later if you like) and password.

If you are a vendor and want your HRA reviewed with an eye towards improving it, I can review it privately for a fee.  We would then both agree whether the review can be placed publicly. You would also have the opportunity to say publicly what improvements you are planning on, based on the review.

What would be an example of a question that truly epitomizes what an HRA is all about, that will put a smile on our face?

Well, since you asked…

Um, who isn’t going to say they are a good person?  Think this over a bit harder than Optum did before they decided to highlight this question as an example of their very stable geniusness:

  1. If you are a good person, then by definition, you will answer that you are a good person
  2. If you are not a good person, then by definition, you will answer that you are a good person

Example: Walter White thinks he’s a good person.

Even outcomes-based wellness vendors think they are good people, though not so good that they are willing to have me review their offerings. That’s why it’s up to you.


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