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So much to say about Interactive Health, so little room on the internet. As a result this will be a two-part blog, at least.
Meanwhile, on the opposite end of the spectrum, we are going to be highlighting the most positively influential people and organizations in the field. Please go vote or submit additional nominations.
The following axiom proffered in Surviving Workplace Wellness used to be ironclad:
“In wellness, you don’t have to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself.”
I thought this axiom applied to every vendor claiming huge savings. But, alas, Interactive Health is an exception. Yessiree, it turns out you can invalidate their data without reading the data. It had been easy enough to invalidate their data by actually reading it — so much so that my original observations about them made it intp the Wall Street Journal . They counterpunched by redacting all the raw statistics on risk reduction. (They didn’t realize I kept a screenshot, which will be the subject of Part II.)
Since risk reduction is what generates financial outcomes, taking risk reduction stats out of an financial outcomes report is like the movie theater in South Korea that decided The Sound of Music was too long, so they edited out the songs.
The Wall Street Journal debacle taught them half their lesson: they learned not to publish data, because data will obviously invalidate their savings claims. Last week they learned the other half of their lesson the hard way, which is that they shouldn’t publish anything, period. On Linkedin they bragged — without any data at all — about the gobs of money they saved by discovering all sorts of undiagnosed conditions and achieving trivial reductions in overall risk scores.
Of course it’s mathematically impossible to achieve massive savings by making asymptomatic employees anxious about diseases they almost certainly don’t have in any clinically meaningful sense, and/or slightly by reducing risk factors. With that in mind, I merely asked a question or two about the whereabouts of the data to support this mathematical impossibility…and <poof> their posting disappeared from Linkedin.
Even absent the data, it’s well-known that Interactive’s modus operandi is to do exactly that — attribute massive savings to trivial risk score reductions and “newly discovered conditions.” Neither m.o. is unique to them. Indeed both are common enough to have names — the Wishful Thinking Multiplier and Hyperdiagnosis. Interactive’s brilliance is in marrying the two.
Interactive Health, the Wishful Thinking Multiplier and Hyperdiagnosis
The Wishful Thinking Multiplier is defined as:
total savings/total reduction in risk factors.
The Multiplier originated with Staywell allegedly saving British Petroleum million of dollars when only a few hundred employees reduced a risk factor — which worked out to almost $20,000 for every risk factor reduced. As luck would have it, this Multiplier was about 100 times what Staywell themselves previously claimed was even possible, which in turn was about 100 times what is actually possible. Yet, as we’ll see in the next installment, Interactive’s Wishful Thinking Multiplier leaves Staywell in the dust.
The practice of wellness vendors bragging about how many sick people they find is called “hyperdiagnosis.” It originated when Health Fitness Corp breathlessly declared that about 1 in 10 screened Nebraska state employees had cancer.
Hyperdiagnosis differs from “overdiagnosis” in that doctors try to avoid overdiagnosis, because it results in expensive and potentially harmful overtreatment.
By contrast, hyperdiagnosis is something that vendors like Interactive embrace. Indeed, Interactive practically hyperventilates every time someone tests positive for something. Since Interactive screens for everything under the sun — 38 panels, way more than most checkups and ten times what guidelines recommend — it’s tough to get out of one of their screenings without a false positive finding on something.
Here are examples of their hyperventilation in words and pictures, wisely not naming the client in their Linkedin post to avoid embarrassment:
[Their client] recently shared with their employees the successful outcomes they have achieved. First, hundreds of employees discovered new health conditions they were previously unaware of.
I’m sure the employees shared Interactive’s joy in finding out how sick they are! What employee wouldn’t be excited about such a “successful outcome” ? And not just a few employees, but rather almost half are now “at risk” with “newly discovered conditions.”
A vendor bragging that nearly half the employees are might lead you to think: “Where do these people get their ideas?”
Glad you asked. Interactive bases their “proven…amazing results” on a report by an outfit called Zoe Consulting. Let’s take a looksee at Zoe Consulting, to learn more about the people they are basing their entire financial value proposition on.
Hey, Butch, Who Are These Guys?
As you can see from this screenshot, Zoe Consulting is a “top-tier nationally recognized research firm.” (Source: Zoe Consulting.) Here are the awards they’ve won (with Google’s commentary in parentheses):
- Two Koop Awards (they didn’t);
- The American Cancer Society Award for Program Excellence (they didn’t);
- The Ethel-somebody Leadership Award from UNC (they didn’t); and
- The Distinguished Leadership and Service Award from the Association for Workplace Health Promotion (they didn’t).
The last reminds me of a summer job selling Collier’s Encyclopedia door-to-door. Collier’s salespeople were instructed to say: “National Geographic won the Kodacolor Award 10 years in a row, but last year we copped the award from them.” One evening I ran into a Grolier’s salesman, who, as it turned out, used exactly the same line in his pitch, down to the exact same faux-cool-70’s-speak verb right out of The Deuce. I called Kodak to see who really won it, only to learn that no such award existed.
Likewise, one of the many reasons Zoe Consulting didn’t win an award from the Association for Workplace Health Promotion is that no such organization exists. So depending on how you count (and whether you count the Koop Awards as one lie or two), they lied six times in two bullet points, which may be a record even in the wellness industry. Seven if you count “top-tier nationally recognized research firm.” Eight if you count “top-tier” and “nationally recognized” separately. Nine for “unbiased.” To reach a round number, I’d say the tenth would be “research.” That’s ten lies already.
In other words, Zoe Consulting is a perfect fit for Interactive Health.
Stay tuned for the next installment to learn why.
I (Vik) have not written a blog post for TSW in some time. Al is quite capable of regularly exposing the wellness industry’s foibles, an easy task given that there is an endless supply of material, and it multiplies faster than bunnies.
However, I occasionally have an up-close-and-personal interaction that is well worth recounting. My son and I recently visited our dentist for the ritualized annual cleaning and check up. We only go once a year, because as a clinician myself it’s been patently obvious to me for some time that twice yearly cleanings, the benefits of which last only until the next burger, and dental check-ups, which are just a search for billable things to fix, are no more beneficial to the health of my mouth than they are to any other part of my body. What matters is the daily routine of brushing and of avoiding sugar-laden foods. Unless you’ve been sleeping through emerging research, you know by now that I am not the only person to reach this conclusion.
Then I met K, a registered dental hygienist I’ve never previously interacted with at our dentist’s office in the St. Louis suburbs. Within 60 seconds of me reclining in the exam chair, the following exchange took place:
K: “I see that you don’t like having x-rays taken. Is there a reason?”
Me: “There is no evidence that screening x-rays have clinical value.”
K: “Do you have dental insurance?”
K: “Do you pay for the dental insurance?”
Me: “How is it any of your business how I get the coverage?”
K: “Because if you have dental insurance, the cleanings and x-rays are free, so there is no reason for you to not get them.”
Me (growing increasingly annoyed and now zeroed in like a laser beam): “The dental insurance is part of the compensation package my wife’s employer provides her. Nothing is free. There is a cost to everything.”
K: “Oh, I guess that’s right. Well, anyway, you should have the x-ray to prevent future problems.”
Me: “What your evidence that x-rays prevent problems? X-rays don’t prevent anything. It’s just a way for you to look for things that may or may not ever amount to anything, except that you can paid to deal with them.”
K (now slowly realizing that she has perhaps ventured out of her exceedingly small safe zone): “The American Dental Association….”
Me: “The American Dental Association? That’s not evidence; that’s a trade group. I am not here to get x-rays [I am completely asymptomatic and have a wonderful, clean, healthy mouth], and that’s not open to negotiation.”
K: “Well, if you don’t have x-rays at least once every three years, we will be happy to refer you to another practice [a ‘policy’ never once articulated to me in six years of going to this dental practice], and that’s not open to negotiation. I also need you to sign a waiver that you declined the x-ray against our advice.”
Me: “Have you read any of the new research about dental industry practices, such bite wing x-rays, twice yearly exams, and even flossing. There’s no evidence for any of it. The NY Times, The Wall Street Journal, they’ve all covered it. Have you seen any of it?”
K: “Finding things early [on x-rays] is how you prevent problems.
Me: “Prove to me how that’s the case. You are 100%, utterly and completely wrong, and nothing you’ve told me is evidence.”
At that point she got up in a huff and left the exam room, returning after two or three minutes to, finally, blessedly, actually do her job instead of showcasing her ignorance.
My point in recounting this exchange is this: all the hulabaloo about consumer directed healthcare is garbage if the consumer is faced with quasi-professionals like K, who is blissfully unaware of basic health economics, let alone the changing character of the science and the evidence base for her occupation. According to the Bureau Of Labor Statistics, there are 200,000 dental hygienists, and over 10 years, that figure will grow by nearly 19%. Suppose, conservatively, that each of these hygienists does two cleanings daily over 200 working days per year. That’s 80 million consumer interactions like this one where the paying customer is subjected to intrusion, clinical mythology, deception, and the threat of “dismissal” from the practice for non-compliance with a non-evidence based, but cash-producing pointless clinical service. How many consumers are willing to tell their hygienist or anyone else in a white coat (or, in her case, the custom embroidered frock) that they are wrong?
K, who apparently has either no access to the Internet or no interest in professional improvement, was the very image of an unprofessional professional, with no sense of the notion that she’s not in charge of the relationship. I’m the customer, through the good grace of my wife and her employer, who are the payers. K did a masterful job of channeling the wellness chimera of Ron Goetzel, Seth Serxner, and Rajiv Kumar, spouting the virtues of overprevention today, overprevention tomorrow, overprevention forever.
For all her ill-informed foaming at the mouth about what’s good for me, here’s what stuck with me, and what I plan to explore further: she, on behalf of the practice, threatened to “fire” me as a client for failure to have an x-ray. There is no legal requirement anywhere in the Missouri Dental Statutes or Rules for me to submit to any radiograph. Nor do the statutes or rules state that a dental office is permitted to dismiss a client for non-compliance with voluntary and discretionary clinical service. What I’d really like to know (enterprising anti-trust lawyers should contact me) is if this is common practice in St. Louis or Missouri more broadly and if yes, how it came to be so.
Can you spell C-O-L-L-U-S-I-O-N? I’ll bet K. can’t.
A little addendum from Al. The other thing these folks do is “screen” you for mouth cancer. I declined the screen. The hygienist said I was making a mistake, that she has found 9 cases in the last three years. Doing the math, if she is average, dental hygienists are finding 600,000 cases a year of mouth cancer. No easy feat considering there are only about 45,000 new cases a year, almost all of which occur in a small segment of the population — tobacco chewers and alcoholics — to which I don’t belong. I didn’t have to sign anything and she didn’t threaten to “fire” me, but otherwise it was the basically the same experience Vik had.
USA Today and Kaiser Health News just published a terrific story on the hazards of overscreening, overtesting, and pry-poke-and-prod programs.
It revealed how screening all employees every year–and then sending them in for checkups –makes no sense on any level, and is contrary to all guidelines and literature. All it does is lead to hyperdiagnosis. Hyperdiagnosis is overdiagnosis on steroids. Instead of being the unfortunate result of good-faith efforts to figure out what is wrong with a patient (that’s “overdiagnosis”), hyperdiagnosis is the breathless reporting by wellness vendors on how many sick employees a company has, and how they will have an “epidemic” of something-or-other unless they force employees to get coached etc.
Hyperdiagnosis is also, however, the wellness industry’s bread-and-butter, so naturally wellness vendors defend this practice. In this article, Bravo Wellness CEO Jim Pshock was quoted as saying: “The hope is that the program will get people to proactively see their physicians to manage their health risks. Yes, this will, hopefully, mean more prescription drug utilization and office visits, but fewer heart attacks and cancers and strokes.”
The only innocent explanation for this comment is that Bravo canceled its subscription to the internet to conserve cash. Seems that all the literature, easily searchable online — plus Choosing Wisely — says that “proactive” annual checkups are a waste of time and money and will not prevent heart attacks and strokes, and certainly not cancers. (They will, however, make drug use and physician office visit expense increase. That much he got right.) A quick Google search would have revealed that to him…if only he had access to Google.
This whole thing would be pretty amusing except that Bravo’s business model includes fining employees for not getting checkups that are more likely to harm them than benefit them, according to the New England Journal of Medicine. Harming employees is where the joke ends.
Otherwise, the only other explanation for this comment is that he is — heaven forbid — lying. And we would be pshocked, pshocked to learn that lying is going on in here!
Therefore, since a wellness vendor would never lie, Mr. Pshock must have allowed his internet subscription to expire. We’d urge all readers to donate early and often to Bravo Wellness to help them keep the lights on.
Wellness is about pushing employees into the healthcare system, almost always both against their will and their better judgment. This story is a perfect example of the consequences of how too much healthcare can be hazardous to your health, and why your best defense against overdoctoring is knowledge.
Once you start asking questions, doctors have to start answering them. While many doctors welcome that, others start fidgeting. If your doctor is one of the latter, it’s probably time to switch.
I myself get occasional bladder tumors. Ironically — and once again, showing the unintended consequences of wellness — I got bladder cancer from eating more broccoli, which of course is exactly what wellness programs would have us do. (And which, in all fairness, is generally a good idea.) The problem was that the broccoli was grown in a garden that was way too close to railroad ties, which leach creosote into the soil. Creosote causes bladder tumors.
So every few years, one grows back and has to be scooped out “non-invasively” (that’s easy for the doctor to say). And every year I go in and get checked, also “non-invasively”. After my last check, the urologist — a new one, whom I had never seen before — suggested a CT scan of the kidneys and ureters.
I asked her why, and she said, because I had had bladder cancer for 15 years and never had this scan.
I replied: “Well, I founded a company, Quizzify, that educates on overutilization. CT scans have 500 times the radiation of x-rays, and that particular set of views is likely to spot tumors on my adrenal glands that are completely clinically insignificant, and yet once spotted will be tracked and possibly removed, for no good reason other than that they are there.”
She said: “OK, why don’t we just start with a urinanalysis.”
From a hazardous and likely counterproductive $1000 scan to a $10 urinalysis in 30 seconds. That’s what knowledge is worth.
The Graco-Goetzel-Bravo-Hopkins case study is turning into another Nebraska fiasco. As with Nebraska, the numbers all contradict one another. But unlike Nebraska, there has as yet been no admission of deliberate lying in the Graco case study. That’s why Graco only earned an honorable mention in the Koop Awards, instead of winning one outright like Nebraska did.
Consider Bravo’s case study on Graco covering the exact same population over the same period as Ron Goetzel’s study. Let’s assume Ron Goetzel is right in that the wellness program should be measured from 2009 rather than 2008, when the program started. (Bob Merberg’s brilliant analysis points out the cherrypicking of the date has a huge impact on claimed success, but let’s concede this start date choice to Ron, and use 2009 according to his wishes.)
Bravo’s case study displays the PMPM costs by year. The first thing to note is, they list employee healthcare costs at $328 PMPM, which actually makes sense, instead of the $190 PMPM in the Hopkins report. I don’t know why these two figures, purporting to cover the exact same population in the exact same period, are completely inconsistent, but I do know that $190 PMPM is an impossible figure, as any population health expert knows. (“Plausibility checking” would have caught that error but Ron has never taken our course in Critical Outcomes Report Analysis, which would have covered plausibility-testing and likely prevented him from making such a rookie mistake.)
Second, Bravo lists children’s healthcare costs in this report as well. Funny thing: over the same exact period in which Mr. Goetzel was claiming that the wellness program was responsible for controlling employee participant costs, children’s healthcare costs trended better than wellness participants’ costs. Mr. Goetzel obviously had access to this children’s cost trend data (we had no trouble finding it, thanks to Bob Merberg) but elected to — get ready to fall out of your seats — ignore it. The wellness ignorati rarely step out of character.
This children’s cost trendline appears to invalidate the entire Goetzel-Johns Hopkins conclusion that the healthcare cost trend was due to the wellness program, since not one single child participated in the wellness program.
For some reason Graco’s spouses cost about $7000 apiece a year. We’ll leave that for someone else to dissect.
As an aside, if anyone thinks they recognize the name “Bravo Wellness” from an earlier posting, it’s because they do. Bravo is the outfit that brags about their ability to save employers money by fining employees. Their website is disproportionately about their appeals process when those fines are levied. This sounds like a company that does wellness to employees instead of for them.
Not sure how bragging about fining employees is consistent with the positive culture that Mr. Goetzel says Graco has, but maybe I’m missing something here.
Ever wonder why students don’t just grade themselves? For your answer, look no further than HealthFair.com’s self-assessed grade:
And yet by any standard other than their own, HealthFair completely flunks the test. Literally, their “basic package” proposes more “D”-rated tests (and “D” is a failing grade by US Preventive Services Task Force standards) than any vendor we’ve ever seen. They would lose their wellness vendor license tomorrow, except for the fact that wellness vendors don’t need licenses.
The first four all get “D”s. Here are the screenshots if you don’t believe that any vendor could possibly offer so many inappropriate tests at all, let alone in the “basic” package.
The abdominal aortic ultrasound test is such a stupid (where “stupid” is synonymous with “profitable”) idea for the non-elderly population that the USPSTF doesn’t even bother to say no:
Along with their “D” as a general screening tool, The EKG gets a whopping “I” for individuals at risk, but since HealthFair’s basic package includes no basic tests to see who is at risk, and by law they can’t ask about history, they would still have to screen everyone whether or not they are at risk:
By earning another “I”, the peripheral artery disease test does well by HealthFair’s standards. The USPSTF concludes that researchers don’t know enough about it to recommend it, which doesn’t stop HealthFair.
As for “hardening of the arteries,” the USPSTF doesn’t bother to grade it due to the fact that no one uses this test as a screen…except wellness vendors. But even the American Heart Association, not exactly shy when it comes to screening people for cardiac disease whose treatment can enrich their members who treat it, disses this test:
Speaking of D-Rated tests, sorry, guys. If you want a D-rated PSA screen — a screen not even recommended by its own inventor — you have to insist that your employer buy HealthFair’s “advanced” package:
That brings us to the H Pylori screen, Healthfair’s groundbreaking, earth-shattering, pushing-the-envelope leap forward in the wellness vendor competition to out-stupid one another.
Where to start…
First, the US Preventive Services Task Force doesn’t bother to offer a recommendation on it, largely because no self-respecting doctor would ever screen patients for this. Shame on the USPSTF for consistently failing to anticipate all the ways in which wellness vendors can misunderstand basic clinical science!
Second, most of us who harbor H Pylori have no symptoms. So why screen for something that’s not causing problems? That’s why this is a test, not a screen. If you have an ulcer or symptoms that suggest an ulcer, go to the doctor. Even then, the doctor probably won’t even bother to test you, since most people get relief simply from well-tolerated, commonly used, proton pump-inhibitor medications–some of which don’t even require a prescription. It is only if the first-line medications fail that most doctors will even test you.
Third, there is a significant school of thought that says H. Pylori is beneficial. Screening us for something we’re better off having in our bodies represents a new frontier in the wellness industry’s answer to overdiagnosis, which we call hyperdiagnosis.
Fourth ironically, given the wellness industry’s obsession with employees’ weights, it is even slightly possible that killing off H. Pylori contributes to weight gain.
Fifth, what exactly are we supposed to do, if it turns out we harbor H. Pylori? Get a course of antibiotics to clear the bacteria out of our system? That’s a great idea. We’ve always maintained that one of the problems with America’s healthcare system is that patients don’t get to take enough antibiotics.
The good news for the pharmaceutical industry is due to the nature of H Pyroli, hiding in our stomach mucus, it takes a lot of antibiotics to ferret it out, plus a bunch of other pills. Is this a great country or what?
Sixth, the H Pylori tests themselves are among the most complex, unhelpful and inaccurate commonly used tests in existence.
Finally, half the world’s population has it. Given the expense and inaccuracy of the test and the prevalence of the bacterium, why not eliminate the middle step and just put all your employees on antibiotics?
One of us is a screaming libertarian. And even he thinks the cowboys that populate the wellness industry need to be reigned in with some regulation, before they screen the American workforce to death. The regulation would be very straightforward: employers and vendors must disclose the USPSTF recommendations to employees before making them take these tests. If after this disclosure, a few employees still insist on getting these D-rated or off-the-charts-inappropriate screens, congratulations! Your screening program will have just done something useful: identified employees who are totally incapable of making an intelligent decision.
To those of you who are reading this and thinking: “Haven’t I heard this song before?”, the answer is, you have. HealthFair is the “Intel Inside” for the screening jihad offered by SSM Healthcare, the Sisters of Saint Mary health system we “profiled” a few weeks ago, thus once again proving that wellness mantra: great minds aren’t the only ones that think alike.