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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.
Take The Interactive Health IQ Test
Which of these images is most unlike the others?
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.