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Folks, if you want the news, you’re going to have to subscribe to it.” From now on, TSW is only going to carry summaries, likely a few days late now that fall frisbee season is taking up my weekends. Here’s what you missed Friday:
- In a completely unanticipated* move, the EEOC is pushing out its proposed rulemaking date once again, this time to June 2019. That means new rules likely won’t be formally in place until 2020.
- Of course what’s another week of news without yet another expert observing that wellness vendors’ obsession with weight loss is harming employees?
- Speaking of yet anothers, yet another celebrity is urging mass screening for yet another USPSTF D-rated screen, this time ovarian cancer. Early-stage ovarian cancer is pretty darn undetectable — except of course by wellness vendors. Total Wellness says its test is “possibly an indicator of cancer cells,” a ringing endorsement indeed. Another vendor pushing these screens, Star Wellness, says these tests are “not readily available from your doctor,” as though that’s a selling point. (It reminds me of a kid I knew in high school who used to brag about not brushing his teeth.) Maybe doctors know something that Total Wellness and Star Wellness, which thinks Vitamin B12 is a vaccine, don’t.
Got news? Clue us in. (How do you think we found these nuggets?)
*Except by me
Too much healthcare can be hazardous to your health, as three findings released last week have shown.
- America’s Epidemic of Overtreatment
Health Affairs reports an epidemic of overtreatment. Author Shannon Brownlee proposes that patients “start asking uncomfortable questions,” to determine if treatments are appropriate. The problem is that employees don’t know what uncomfortable questions to ask, unless one counts: “Do you mean to say I’m not eating enough broccoli?” The questions don’t have to be uncomfortable. They get more comfortable, the more one learns about healthcare. Seems simple enough, and yet 99% of employers still don’t offer employee healthcare literacy education.
2. America’s Epidemic of Innumeracy
It would help if doctors knew the first thing about interpreting lab test results before recommending these treatments, but apparently they don’t. The Washington Post reports that professionals reading lab test results don’t understand false positive arithmetic. As a result, your employees may be getting diagnosed and treated for conditions they don’t have. Wellness vendors don’t understand it either. As compared to real medical professionals, the difference is that the they take great pride in their ignorance, and brag about how many false positives they find. I’m talking to you, Interactive Health.
No, they don’t. We’ll post on false positive arithmetic next week.
3. America’s Epidemic of Overprevention
As reported on They Said What Thursday, it looks like too much spending on prevention can backfire. Specifically, spending more on employee healthcare, and sending more employees to the doctor, does not deliver better outcomes, fewer ER visits, or even more HbA1c checks for diabetics. Quite the contrary, the correlation, though weak, goes in the “wrong” direction.
Bottom line: looks like Quizzify had it right all along: just because it’s healthcare doesn’t mean it’s good for you.
They Said What has always noted the complete and utter worthlessness of screening the stuffing out of employees. The wellness vendor response to this observation? To double down on overscreening. One recalls the immortal words of the great philosopher Inspector Louis Renault: “Owing to the seriousness of this crime, I’ve instructed my men to round up twice the number of usual suspects.”
Here is one such vendor, the lucky recipient of a follow-up profile to be published next month.
Their litany of tests before my initial observations about their overscreening were published:
Their current roster of tests, setting a new wellness industry record:
However amusing it may be to remark on the rampant epidemic of very stable genius-itis in the wellness industry (and it is), screening the stuffing out of employees is no laughing matter. It is harmful. Here is the current Journal of the American Medical Association on the harms of screening. Unfortunately the entire article is behind a paywall, but the abstract basically highlights the wellness industry business model:
Overused tests and treatments and resultant downstream services generate 6 domains of negative consequences for patients: physical, psychological, social, financial, treatment burden, and dissatisfaction with health care. Negative consequences can result from overused services and from downstream services; they can also trigger further downstream services that in turn can lead to more negative consequences, in an ongoing feedback loop.
This is of course exactly what hyperdiagnosis is all about — and the poster child for hyperdiagnosis is none other than the winner of the 2017 Deplorables Award, Interactive Health. A single Interactive Health display captures it all, the breathless braggadocio about sending employees to the doctor because they flunked one or more of the 43 tests that Interactive Health runs, with no regard for the harms that JAMA has identified:
So, in all seriousness, can we please, please stop the hyperdiagnostic madness and start screening according to the US Preventive Services Task Force guidelines?
The wellness industry is the Maginot Line of workplace health. While wellness vendors are imploring employees to eat more broccoli, and hyperdiagnosing the stuffing out of them to find “newly discovered” conditions that are mostly false positives and harmless out-of-range readings, really bad stuff has been happening that has somehow eluded this industry’s attention. One would be the opioid epidemic, which no vendor seemed to notice. Except Optum, whose HRA basically advises employees to get more pills for their pain.
(Do you know more than Optum does about opiods Take this quiz and find out.)
The other would be the explosion of harms caused by the healthcare industry itself, and that is the subject of The Bleeding Edge, a well-received new documentary (Rotten Tomatoes rating: 89%) on Netflix. (In case anyone is keeping score at home, Quizzify is also about harms caused by the industry…and already educates employees to avoid most of what The Bleeding Edge covers.)
The Bleeding Edge follows victims of three different kinds of implants — vaginal mesh made by Johnson & Johnson, metal-on-metal hips made by Johnson & Johnson (are you seeing a trend here?), a birth control device financed in part by the current head of the FDA — along with briefer cameos for CAT scans and the DaVinci robot.
Interviews of victims of these implants (including one who started out as a spokesperson for these implants) are intertwined with surgeries and images of devices gone haywire inside the victims’ bodies, and expert talking heads about how this could be allowed to happen. (“More evidence is required to remove a device than to approve it.”) The experts are very well-credentialed and include the long-time head of the FDA, David Kessler, and bestselling author and Johns Hopkins accountability guru, Dr. Martin (“I love what Quizzify is doing”) Makary.
Perhaps the most compelling interview, though, is with the aforementioned former spokesperson for the birth control device-turned-victim advocate. Switching sides like this never happens. Most people pick a side and stay on it, facts be damned. Switching sides after seeing new facts is almost unheard of — it would be like Ron Goetzel not only admitting that wellness doesn’t work, but blowing the whistle on his friends at Wellsteps and Interactive Health.
The difference was that this spokesperson was also a customer…until her device went badly astray as well.
What is the FDA doing about this?
So what, as the film describes, is the FDA doing to put the kibosh on all this? Four things:
- Facilitating approvals of new devices on almost no evidence
- Laughing out loud on videotape at the idea that they may get in trouble because some people could get harmed
- Hiring industry executives to regulate their friends and companies they have invested in
- Firing experts who advocate for disclosures of hazards.
Yes, we know it isn’t always about Quizzify but #4 specifically relates to the hazards of CAT scans. The FDA apparently fired nine employees for advocating what we here at Quizzify have educated patients on — right on our landing page quiz — for three years: the radiation hazards of CT scans, especially repeated scans. Your doctor isn’t telling you about this risk possibly because everyone at the FDA who would have told them is gone.
Likewise, the FDA takes a hands-off approach on the DaVinci robot, another Quizzify whipping boy, though we weren’t the first to question their integrity. The FDA let the company put the robot into the hands of completely inexperienced surgeons, and multiple cases have been reported in which a woman’s insides literally fell out following the surgery.
Many doctors — especially “leading experts in the field” — get directly or indirectly compensated to use and pitch these devices. Your doctor could be one of them, and it’s not like he or she is going to volunteer the information.
What should employers do?
It seems that the only people who truly advocate for the patient are the patient and the patient’s family. Everyone else involved in the care conversation makes more money when employees buy more things on the employer’s dime. (This is not to say all providers or device manufacturers are corrupt, or anything close to that, of course. But with all this money at stake, shareholders interest and patients’ interest could be at great variance. One need only look at stock prices to see which side usually wins.)
Likely much the opposite of what they are doing now. First, stop obsessing with screens and risk assessments. Prying, poking and prodding doesn’t work, so get over it. Start focusing on things that matter, like the harms described in this film and like what Atul Gawande says:
Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year…Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.
At the very least, employers should slow down before encouraging the opposite, incentivizing employees to use lower-cost settings to get things that they may not need, and may even harm them. Obviously (with the exception of childbirth, which is going to happen anyway), removing the economic disincentive to get more stuff means people will get more stuff.
Instead, educate your employees, using Quizzify or some other tool like Quizzify (good luck finding one), that, as we say at Quizzify and as anyone who watches The Bleeding Edge will say:
Just because it’s healthcare doesn’t mean it’s good for you.
Arkansas recently contracted with an out-of-state vendor called Catapult Health to come in to the state’s schools and “play doctor” with the teachers, asking them personal questions, taking their blood and then telling them everything that’s wrong with them. This is a classic example of a “pry, poke and prod” program.
This is followed by admonishments to take more steps and eat more broccoli. They then refer teachers into lifestyle and disease management programs “at record rates.”
Sounds terrible, but the good news is that this program isn’t going to cost taxpayers anything because, as Catapult Health’s website says:
Phew! At least it’s free to taxpayers because Catapult’s expenses and profits are “already in your budget” and “fees are processed through your health plan.”
Except that the state of Arkansas is its own health plan. There is no “Don’t worry. Insurance will pay for it” here. The state is self-insured, meaning they pick up the tab, not some nameless insurance company.
But, hey, at least this program will save money, right?
The return-on-investment for the state is allegedly 3.27-to-1, as shown by the so-called “Harvard Study,” conducted by Katherine Baicker.
Except that the Harvard study has been proven wrong, not just by the nonprofit, nonpartisan highly respected RAND Corporation (and I myself chimed in as well), but by an ace researcher named Damon Jones, part of the prestigious National Bureau for Economic Research. His work showed that wellness accomplishes virtually nothing other than the expenditure of money. (Don’t worry—insurance will pay for it.)
But, hey, maybe Prof. Jones is wrong. After all, why should he care what Prof. Baicker thinks, right?
Um, because he reports to her? Yep, he’s an associate professor at the exact same school of public health where she is now dean. Just guessing here, but it would seem a subordinate would have to be pretty darn sure of his findings (and they are rock solid, and completely in agreement with all the other recent research, summarized here) to publicly humiliate his own dean.
Even Prof. Baicker doesn’t defend her findings any more. She says: “It’s too early to tell.” That means she is running away from her very widely cited signature study, upon which essentially the entire wellness industry’s economic justification is based. This would be like Arthur Laffer, whose Laffer Curve created supply-side economics, which has been used to justify two tax cuts, saying “well, maybe it’s not right. I dunno. Let’s wait and see.”
But, hey, at least forced wellness improves employee health, right?
Apparently not. Forcing people to get annual wellness checkups doesn’t benefit them, according to the New York Times, the New England Journal of Medicine, the Journal of the American Medical Association, and Consumer Reports. (Before dismissing the credibility of those sources due to possible political bias, keep in mind that Newsmax, The Federalist, and Laura Ingraham hate “pry, poke and prod” programs too.)
Further, sending “record rates” of employees into lifestyle and disease management is classic hyperdiagnosis – braggadocio-fueled misunderstandings of the arithmetic of lab results, resulting in large numbers of people getting told they need coaching and care they don’t want or, in general, need. Nothing makes a wellness vendor happier than to hyperdiagnose as many employees as possible.
But, hey, maybe teachers are a special case. Maybe the impact of “pry, poke and prod” programs is different for them?
It sure is. The single school district for which the data has been compiled is Boise, Idaho. According to the wellness vendor’s own data, the health of the teachers got somewhat worse as a result of this pry, poke and prod program. (The vendor, an outfit called Wellsteps, also admitted that they flouted clinical guidelines and fabricated their only positive outcome. They also previously admitted that costs went way up as a result of their program. They later suppressed that admission. Wellness vendors are not known for their integrity.)
So the health of teachers may deteriorate, creating more medical expense. but don’t worry. Insurance will pay for it.
But, hey, at least the teachers like it, right?
According to Catapult, employees love them. Ask the employees and you might get a different impression. indeed, I was tipped off to this program by an Arkansas teacher who hates it, like most of her colleagues do — and that’s before they learn that they are actually paying for it…keep reading.
Obviously if teachers wanted to submit to a “pry, poke and prod” program, the state wouldn’t have to threaten them with massive fines – almost $1000/year, which appears to be close to a record for any pry, poke and prod program anywhere — for refusing to let a private, out-of-state corporation play doctor on them at state expense.
But, hey, at least the state taxpayers save money by fining the teachers who don’t want to play doctor, right?
Actually, wellness makes claims costs go up, probably by more than the fines. There are lots of unneeded lab tests and other tests. For instance, the state of Connecticut admitted that in addition to throwing away all its money on the actual wellness program, they spent more on health care. The state comptroller who administered the program said the increased spending was “a good thing.” I guess he wasn’t worried because insurance was paying for it.
But, hey, at least the teachers don’t pay for it.
Actually they do. The state’s human resources department brilliantly figured out that they could launder their wellness spending by hiring this outfit. By paying extra to Catapult (a multiple of what an effective wellness program would cost), the state is able to pick up the tab for wellness using the extra paperwork of a medical claim, as opposed to an outsized administrative expense in a separate line item. The latter would clearly need to be picked up by the taxpayers…and the state would have an incentive to control this highly visible figure.
By contrast, paying for “pry, poke and prod” as a medical claim will never be noticed, like Steve McQueen and David McCallum sprinkling the dirt from the tunnel around the stalag. On the other hand, it will increase overall medical spending by 2-3% (the cost of the screening plus the added hyperdiagnosis expenses).
Here comes the evil genius part: at the next contract negotiation, the state can limit wage increases (or reduce benefits) by pointing out how high the health spending is.
So the teachers get pried, poked and prodded, hyperdiagnosed with hidden illnesses most of them don’t have – all against their will…and then they have to pay for the privilege in reduced wages.
Wow…the teachers are getting screwed. But, hey, at least they can’t sue the state, right, so taxpayers won’t have to pick up that bill as well?
Starting in January, this program will be in blatant violation of two laws, the Americans with Disabilities Act and the Genetic Information Non-Discrimination Act. Those laws disallow forced wellness checkups, but allow so-called “voluntary” ones.
Until recently, “voluntary” meant “do wellness or pay a big fine” like this one. But thanks to a lawsuit by AARP, the rules are changing in January so that “voluntary” must mean voluntary, like a dictionary would define the word. (This summary has the links to all you need to know about the case.) To get these fines back, teachers will be able to sue the state, possibly even as a class action, and possibly being awarded punitive damages. Exposure to lawsuits could cost the state millions more in addition to its current expenditure on Catapult Health.
And that doesn’t even cover the costs of a possible teacher walkout, like the one in West Virginia that was spurred in part by – you guessed it – their wellness program.
But, don’t worry. Insurance will pay for it.
If there is one thing the US healthcare system is really really good at, it’s rooting out hidden disease via massive hyperdiagnostic screening campaigns. But there is always room for “improvement” by finding some unsuspecting cohort — in this case, 45-year-olds — that was getting just a little too complacent about the fact that virtually no one that age dies of something that could have been found — and also prevented or addressed — via a non-USPSTF-recommended screen.
Serves them right.
The American Cancer Society (ACS) recently decided that, because the rate of colon cancer has been increasing in the 45-to-49-year old cohort, that screenings should start in that age group. The “alarming” 22% increase in relative risk during this century translates into an increase in the absolute rate of colon cancer in the <50 cohort from 0.006% to 0.007%. Yes–0.001% more of the <50 population in this country will get colon cancer now than 18 years ago. I’m surprised they didn’t recommend calling out the National Guard.
Further, many of that 0.007% experienced symptoms, and hence would be getting a colonoscopy as a diagnostic test, not a screen. And others in that age grouping had a family history and should get screened regardless of what the “average” person should do. Suppose those two categories account for half of the colon cancer population. That leaves roughly 0.0035% of the 45-to-49-year-old population who could possibly benefit from a screen.
As with the other “alarming” colon cancer figures that have been published in the last few years, your chances of having your life saved by a colon cancer screening at that age is about the same as your chances of being struck by lightning.
And a screen is far from a lifesaver in general. Quite the contrary, statistically speaking it is likely to find the slow-growing tumors while missing the more aggressive, faster-growing tumors that begin between screens.
The Hazards of Screening
That trivial benefit must be weighed against the nontrivial harms. The risk of a complication, such as a perforation, is estimated between 1.6% and 1.8%. (In all fairness to the ACS, they aren’t insisting that the screen be done via a colonoscopy, though the non-invasive screens have such high positive/inconclusive test rates that they often lead to colonoscopies.)
Unless I have the decimal point in the wrong place, that means the rate of complications is a whopping 320 times the likelihood of something being found. Oh, wait a sec — make that 3200 times.
OF course, the worst complication is death, and the mortality rate from colonoscopies (0.02%) appears to be, on its face, much higher than the rate of lives that would be saved. However, once again, though it kills me to say it, in all fairness the mortality rate, and for that matter the complication rate, increases with advancing age, meaning the younger you are, the less likely you are to die from this screening. So maybe the mortality rate in the 45-50-year-old cohort isn’t any higher than — and might even be slightly lower than — the rate at which early detection will save lives. I feel much better knowing this. Don’t you?
And what is it about colon cancer that brings out people’s inner very stable genius? Here is the Cleveland Clinic on the subject:
Newsflash: 144,000 is not “1 out of 19 people in the United States.” It is barely 1 out of 19 people in greater Cleveland.
The best argument against screening 45-year-olds
Nonetheless, when it comes to screening 45-year-olds for colon cancer, the best argument against it is that Star Wellness is for it. By way of background, Star Wellness is best known in wellness for not knowing anything about wellness. They take great pride in that, boasting that anyone can become a wellness vendor. All you need, they say, is a background in “sales or municipality administration,” five days of training…and of course a certified $65,000 check payable to — get ready — Star Wellness. No surprise that Star was leading the wellness industry’s race to the bottom until they got outstupided by Total Wellness, Interactive Health, and Wellsteps.
But Star Wellness is not willing to lose this race to the bottom without a fight.
Not content to offer the full range of USPSTF non-recommended screens, they are practically hyperventilating over this opportunity to add yet another one. They use the example of ovarian cancer screening to justify more colon screening. Here is the USPSTF on the subject of ovarian cancer screening:
The USPSTF found adequate evidence that screening for ovarian cancer can result in important harms, including many false-positive results, which can lead to unnecessary surgical interventions in women who do not have cancer. Depending on the type of screening test used, the magnitude of harm ranges from moderate to substantial and reflects the risk for unnecessary diagnostic surgery.
While we’re on the subject of Star Wellness…
Star, Vitamin B12 is not a vaccine.
And remind me why we are lining up employees to get Vitamin B-12 shots, vaccines or no vaccines?
While we’re on the subject of vaccines, according to the CDC, the biggest category of people who are supposed to get Hepatitis A/B vaccines include street drug users. If you are routinely hiring enough street drug users to be holding vaccination clinics focused on Hepatitis A/B, I’d say Vitamin B-12 deficiencies are not your biggest problem.
Winning a Deplorables Award is no easy feat for a wellness vendor. You have to out-lie, out-harm and generally out-stupid many worthy competitors. Yet this year’s competition wasn’t even close. Fitbit might have won on lies and stupidity alone, but no one was ever harmed by wearing an activity tracker. Interactive Health clobbered them in harming employees. Like Wellsteps (the 2016 Deplorables Award Winner) they managed to do that multiple ways. This award covers the harms, the lies, and the stupidity. Truly the perfect storm of workplace wellness.
Interactive Health’s signature move is conducting mass screens so inappropriate that doctors doing essentially the same thing — paying people to take this panoply of tests and then billing insurance — would lose their licenses.
Needless to say, when you do all sorts of inappropriate tests, you find all sorts of non-existent problems, and send all sorts of employees to all sorts of doctors. This isn’t simple overdiagnosis. This is classic hyperdiagnosis as described in our 2015 posting.
This is what we wrote in that posting, and it appears Interactive Health is the poster child for it. As compared to overdiagnosis, which is the unfortunate byproduct of well-intentioned efforts to help patients who present with symptoms, hyperdiagnosis is:
- pre-emptive — employees aren’t asking to be diagnosed, don’t have symptoms, want to be left alone, and often aren’t even old enough to have the stuffing screened out of them yet;
- either negligently inaccurate or purposefully deceptive (and IH has been requested many times to stop doing inappropriate screenings but they continue unabated);
- powered by pay-or-play employee forfeitures for non-participation, of the type about to become illegal in 2019;
- all about the braggadocio – wellness companies love to announce how many sick people they find in their screens…
…And here is Interactive Health doing exactly that:
What do you do after you round up all sorts of unsuspecting employees with inappropriate screens? Obviously, you bombard them with inappropriate advice, of course. Specifically, the huge percentage of employees at risk for diabetes — thanks to those “a1c tests for everyone” (which of course are specifically not recommended by the USPSTF) are supposed to drink full-fat dairy, not skim. And absent hypertension, they are also not supposed to avoid salt. Quite the contrary, maintaining US-average salt consumption appears to be protective against diabetes. (Not to mention that salty snacks often substitute for sweet ones.) We had no trouble finding these studies online. Hopefully Interactive Health will use some of their award money to purchase an internet connection.
Fortunately, most employees pay no attention to Interactive Health’s 1500-word single-spaced tomes, so it’s unlikely their antediluvian advice harmed anybody.
Third, speaking of harms, they also harmed me when I went in to be screened. Not just by announcing my PSA score when I specifically asked not to be tested for PSA, but by stretching my calf far enough to send it into spasm.
The English language already has 450,000 words, the most of any language. And yet none of those words adequately describe the amount of lying done by Interactive Health, even after they’ve been caught.
They are claiming “amazing results” based on one study by an unknown, now-defunct consulting firm that couldn’t even pay its internet provider. (The consulting firm had also made up a set of qualifications in which, other than articles and prepositions and conjunctions, every word was a lie.)
Once the lies were initially exposed, they paid me to stop writing about them for a while. I agreed, provided that they stop lying — meaning that I can write about them ad nauseam.
The smoking gun for the initial lie was that they accidentally admitted that they didn’t really reduce any risk factors. You can’t save a gazillion dollars by reducing employees’ wellness-sensitive medical events if you can’t improve employees’ wellness. According to their own figures (and of course excluding dropouts and non-participants, whose risks likely climb), their risk reduction was quite trivial. How trivial? The Wishful Thinking Multiplier — savings divided by the number of risk factors temporarily reduced — exceeded $50,000.
After that expose, they sealed their front-runner status for a Deplorables Award by simply trying to suppress the evidence. They took the trivial risk reduction displays out of that study, and now only make available the bowdlerized version, which they call a “research summary.” The only way you can get the raw risk reduction data is by scrolling down this post. Rule one in wellness whistle-blowing: always take screenshots.
And most recently, they’ve become strong proponents of Wellsteps’ strategy, bragging about how many high-risk employees became low-risk without mentioning that roughly as many low-risk employees became high-risk. Suppose you flip 100 coins. It’s not enough to say that of 50 heads, 25 became tails. You also have to admit that 25 of the tails flipped to heads. At the end of the day, nothing changed. Here are the heads-to-tails, from their website. (By the way, this is also not true, even on its face.)
Ask any employer what is the “new smoking” in terms of employee hazards and mortality. Most will say opioids, of course. Not Interactive Health. For them the “new smoking” is…
Hey, Interactive Health, maybe you can find a smart person to explain this particular statistic to you:
- According to the CDC, the number of annual deaths caused by smoking: 480,000
- According to the CDC, the number of annual deaths caused by sitting: 0
Here are some other differences between the two activities: Chairs don’t carry excise taxes or warning labels. If you’re under 18, you can buy a chair without a fake ID. Workers are allowed to sit inside the building. Chairs don’t make you clothes smell, cause lung cancer or dangle from the lips of gunslingers in old John Ford westerns. Sitters aren’t assessed health insurance penalties. Your Match date will not feel misled if he or she catches you taking a seat, even if your profile didn’t disclose that you sit.
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