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Grinding my teeth

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?”

Me: “Yes.”

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.

Is Bravo Wellness Running Out of Money?

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!

Quizzify Q in B and W

Why would any smart person waste time & money on low-value medical care? Better not ask Bravo.

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.

 

 

Just because it’s healthcare, doesn’t mean it’s good for you

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.”

Quizzify Q in B and W

Quizzify Q&A is your tool to save employees’ time & money

From a hazardous and likely counterproductive $1000 scan to a $10 urinalysis in 30 seconds.  That’s what knowledge is worth.

 

 

Hyperdiagnosis: The Wellness Industry’s Anti-Employee Jihad


Healthmine just released a survey bragging about how many employees were diagnosed through wellness programs. That reminded us of our popular 2013 posting on The Health Care Blog called Hyperdiagnosis.  We are re-posting and updating it below.   


By now we are all familiar with the concept of overdiagnosis, where “we” is defined as “everyone except the wellness industry.”

Wellness vendors haven’t gotten the memo that most employees should simply be left alone.  Instead, they want to screen the stuffing of employees, at considerable cost to the employer and risk to the employee.  The wellness vendors who overscreen employees the most win awards for it, like Health Fitness Corporation did with the Nebraska state employee program.

We call this new plateau of clinical unreality “hyperdiagnosis,” and it is the wellness industry’s bread-and-butter.  It differs from overdiagnosis four ways:

  1. It is pre-emptive;
  2. It is either negligently inaccurate or purposefully deceptive;
  3. It is powered by pay-or-play forfeitures;
  4. The final hallmark of hyperdiagnosis is braggadocio – wellness companies love to announce how many sick people they find in their screens.

1. Pre-Emptive

Overdiagnosis starts when a patient in need of testing visits a doctor. By contrast, in hyperdiagnosis, the testing comes in need of patients, via annual workplace screening of up to seventy different lab values–most of which, as They Said What? has shown, make no clinical sense.  Testing for large numbers of abnormalities on large numbers of employees guarantees large numbers of “findings,” clinically significant or not.  The more findings, the more money wellness vendors can add on for coaching and the more savings they can claim when they re-test.

2.Inaccurate or Deceptive

Most of these findings turn out to be clinically insignificant or simply wrong, no surprise given that the US Preventive Services Task Force recommends universal annual screening only for blood pressure, because for other screens the potential harms of annual screening outweigh the benefits.  The wellness industry knows this, and they also know that the book Seeking Sickness:  Medical Screening and the Misguided Hunt for Disease demolishes their highly profitable screening business model.   (We are not cherry-picking titles here—there is no book Here’s an Idea:  Let’s Hunt for Disease.)  And yet most wellness programs require employees to undergo annual screens in order to avoid a financial forfeiture.

Hyperdiagnosis also obsesses with annual preventive doctor visits.  Like screening, though, annual “preventive” visits on balance cause more harm than good.  The wellness industry knows this, because we posted this information on their LinkedIn groups, before we were banned from most of them.  They also presumably have internet access on their own.

3. Pay-or-play forfeitures

The worthlessness, the inconvenience, and the privacy invasion make screens very unpopular.  The wellness industry and their corporate customers “solve” that problem by tying large and increasing sums of money annually — now $694 on average – to participation in these schemes.  Yet participation rates are still low.

4. Braggadocio

While doctors are embarrassed by overdiagnosis, boasting is an essential ingredient of hyperdiagnosis.  We’ve already blogged on how Health Fitness Corporation bragged (and lied, as they later admitted) about the number of cancer cases they found in Nebraska.  They also bragged about the rate of cardiometabolic disease they found — 40% in the screened population — even though they admitted almost no employee did anything about those findings, and only 161 state employees reduced risk factors.  Hence, it was the worst of both worlds:  telling people they are sick without helping them get better.  Nothing like telling someone they’re sick to increase their productivity.

Compass Health is our favorite example of hyperdiagnosis braggadocio.  We realize this screenshot is a bit tough to read, but the hilarity is worth the effort.  We pulled this vignette from On The (even) Lighter Side, They Said What?‘s most popular feature.


The Definition of a “Healthy Employee” Is One Who Has Not Been Diagnosed by Compass Health

Feeling fine today?  Alas, you better get your affairs in order, bid your loved ones adieu, and watch the shows you’ve DVR-ed.  Why? Because, dodo-brain, feeling fine means you have:

compass health title I feel fine syndrome

You are “walking around without a clue that [you have] a debilitating or terminal condition.”  According to Compass Health (which at this point, having been “outed” by us, had the good sense to take this off their website…but not until we captured a screen shot), the major symptom of I Feel Fine Syndrome is:  not having symptoms.

We’ll let them take it from here, to display not only their epidemiological prowess but also, this being the wellness industry, their grammar and spelling prowess as well:

compass health screen shot2

We must confess we learned a lot from Compass.  We had not realized that employers’ concerns about employees feeling fine had their roots in ancient history.  But there it is, right in the opening words:  these concerns date back “millenia” [sic], when employers failed to get their employees tested for “percolating” conditions before throwing them to the lions.

So the bad news is that feeling fine may be hazardous to your health.  The good news is that your ICU bed may not need a DNR notice anytime soon because elsewhere Compass says it “has programs and solutions to help your employees overcome their I Feel Fine Syndrome.”  And it is “very likely” these programs and solutions can “completely cure the problem…forever in our bodies.”

And not a moment too soon, because we’re never felt better in our lives, which means the clock is ticking.  That’s the good news.  The bad news is, if we join Compass’s program it sounds like we need to start contributing more to our 401K’s.


 

Summary

We’d like to think that all our exposés have made a dent in the wellness industry’s business model, but the forces arrayed in the other direction have so far overwhelmed us.   The price of screening has plummeted almost to the $1-per-lab-value level for comprehensive screens, and as with anything, the lower the price, the greater the amount sold.

Couple those economics with the advent of genetic testing as part of wellness, big and profitable fines for non-participants, and the EEOC being defanged as a sop to the Business Roundtable, and it’s clear the wellness industry’s highly profitable hyperdiagnostic jihad against the American workforce has barely begun.

By contrast, Quizzify teaches employees that “just because it’s healthcare, doesn’t mean it’s good for you,” and to only get screened according to the USPSTF guidelines.  That’s a message that employees would love to hear, but that wellness vendors can’t afford to tell them.

The Graco-Goetzel-Bravo plot thickens…more twists and turns

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.

graco childrens

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.

 

HealthFair Wins Wellness Industry’s Race to the Bottom

Ever wonder why students don’t just grade themselves?  For your answer, look no further than HealthFair.com’s self-assessed grade:

healthfair logo

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.

healthfair basic package

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.

uspstf stenosis

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:

USPSTF AAA

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:

uspsts electrocardiogram

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.

uspstf peripheral artery disease

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:

AHA arterial stiffness

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:

healthfair psa

Quizzify 4

Give your employees wellness that always earns an “A”

 

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.

We Concede the HERO Report is right–wellness does lose money

The HERO Report concludes that wellness loses money.  We agree.  We also think it loses much more money than they will admit to, but the news here is not about us.  The news is that more than 3 dozen self-described experts and industry leaders representing more than 2 dozen companies have reached consensus that their industry loses moneySlide1

Count us more shocked now than we were by the report’s admission that wellness adversely impacts morale, (This is covered in Installment 1.)

Together, the HERO findings — and our broad consensus with those findings — have serious Affordable Care Act policy implications.  The entire basis for the ACA “Safeway Amendment” allowing large fines for (among other things) failure to lose weight is that the cost savings from skinnier employees merits invading their privacy, dignity and automony through medicalizing the workplace (“companies playing doctor” as some have called it).  Senate committee hearings, proposed new legislation, and EEOC lawsuits around this provision have all been based on the assumption that wellness saves money.  The Senate committee never even lobbed a softball question about that assumption, and even the more hostile witnesses didn’t challenge it.

Recently there was even an eyeball-to-eyeball encounter between the Business Roundtable’s (BRT) Gary Loveman and President Obama.  Even though his company (Caesar’s) went bankrupt while embracing wellness as essential to their profitability, Mr. Loveman argued that corporations should be allowed to fine workers who don’t lose weight because the benefit to corporate bottom lines would trump both privacy concerns and the substantial health hazards of these programs.

gary loveman

Gary Loveman, Business Roundtable

 

Apparently, though, Mr. Loveman’s company went bankrupt slightly faster because of wellness.  Yes, along with employees, employers would be better off without forced (highly penalized or incentivized) workplace medicalization.  If you fire your wellness vendor, everyone benefits.

Everyone, that is, except the wellness industry denizens who make their money off this.  That’s why we think HERO spoke the truth unintentionally.  Very few people (I was one of them, having switched sides in 2007 when I saw that data failed to support wellness/disease management) willingly undermine their own incomes for integrity’s sake.  So this posting will proceed on the basis that is was a gaffe on their part.

Curiously, this is the second time in recent months wellness industry leaders have accidentally admitted wellness loses money, and the third time they’ve accidentally told the truth and had to walk it back.

Equally curiously, wellness economics information disseminates very slowly if at all — testament in large part to the absolutely brilliant and flawlessly executed strategy by the Wellness Ignorati of ensuring that facts get ignored (hence their name).  So even as the vendors are admitting that wellness loses money, benefits consultants and HR executives have once again pushed participation incentives/penalties to new highs, a whopping $693/employee/year, according to a new report.

As for the figures themselves, we are also attaching a spreadsheet so that you—as an employer—can figure this out on your own in your own population, rather than just take HERO’s word for it that wellness loses money.

The costs, according to the HERO report’s own screenshots

First, review the screenshot from the first installment, showing the costs of wellness.   The list of cost elements is fairly exhaustive –down to the level of a space allocation for a health fair — though the Committee conveniently left out consulting fees.   No surprise there, given that Mercer consultants sit on the committee.

HERO list of costs

Then, compare the list of costs in that screenshot to costs in this second screenshot, from Page 15 of the HERO Report.  That comparison won’t take long because only one program cost is listed:  “$1.50 — Cost of EHM [Employee Health Management] PMPM fees.”

HERO list of costs

The two lists of costs are totally inconsistent.  Suddenly, when it comes time to measure ROI on page 15, most of the costs on Page 10 have disappeared…

The reason for that?  The savings from wellness – in the HERO committee’s own words below – are so trivial that in order for wellness to produce savings, the second screenshot has to ignore most of the costs listed on the first one.  Whereas the first screenshot listed three categories of costs covering 12 different line items (13 if you count the AWOL consulting expenses), the second screenshot says you should only count one item:  vendor fees.

And by the way, the vendor fees themselves self-invalidate.  At about $40 per employee per year, biometric screening fees alone cost more than the stated $1.50 per person per month, or $18/year.  Yet $18/year is the total they list for all fees combined, including the $40 screenings.

Rather than point out the many cost elements on the first screenshot missing from the second, we’ll invite you to use our spreadsheet and enter your own data instead of theirs.  Simply fill in your own direct costs of wellness.

Whatever number you get will dramatically understate your true costs because there are three elements of cost that we aren’t counting on this spreadsheet:

  • What their spreadsheet call the “indirect” costs, which we have listed as “$0”,
  • What their spreadsheet calls the “tangential” costs of damaged reputations and employee morale—ask Honeywell whether they brag about their wellness fines and lawsuit in their recruiting (and, ironically, I just returned from a consult for Penn State itself, where the adverse morale impact still overhangs employee relations);
  • The massive costs of overscreening, overdiagnosis, and overtreatment generated by biometric screens – all of which are conducted far more often than the USPSTF recommends and most of which (as in the examples we occasionally post on this site) include screens that no one other than a wellness vendor or consultant would ever propose.

The financial benefits

Against those costs are the benefits. Page 15 lists some alleged benefits of wellness that leave us scratching our heads.

Generic substitution?  How does that have anything to do with wellness?  Quite the contrary, obsessing with wellness might take your eye off the generic substitution ball, and cause you to miss some tiering opportunities.  (The company that is best at tiering its pharmacy benefit, Procter & Gamble, is also known for its current employee-friendly wellness program, sort of the anti-Honeywell.)   And has anyone ever seen one health risk assessment (HRA) or participated in one health screen that even mentioned generic substitution?

Outpatient procedures?   Try to find one person in your organization whose outpatient procedure could have been prevented by eating more broccoli.

ER visits?  Maybe they decline.  But maybe they increase, due to sports injuries sustained by newly activated employees.  And someone who really is eating more broccoli might slice their finger chopping the crowns off the stalks.  (Anybody who voluntarily eats the crowns with the stalks still attached doesn’t need a wellness program.)

And then the catch-all:  savings through “overall wiser use of healthcare.”  Come again?  This is an industry that — as well documented by their own words captured on this website — makes its living telling employees to do exactly the opposite:  go get checkups you don’t need and won’t benefit from, submit to screens far in excess of USPSTF guidelines so that vendors can brag about how many sick people they find, yo-yo diet for “biggest loser contests” and weigh-ins, like ShapeUp’s get-thin-quick 8-week crash-diet programs, and avoid eating fat and cholesterol and load up on carbs instead.

cerner cholesterol

Perhaps what the HERO committee intends is that since employees largely don’t trust their employers, they will do the opposite of the recommendations.

The savings from wellness

Quizzify 4

When wellness doesn’t add up, Quizzify does

We are going to leave out respiratory savings.   To capture those, charge a smoking differential and make smoking cessation available.  Done.  You don’t need an intrusive and expensive wellness program for that.  (We are big believers in a “smoking differential” for employee-paid premiums.  It makes sense for all the reasons weight loss and other wellness programs don’t.)

Instead let’s focus on people who have cardiometabolic issues.  In order to lose weight and reduce their risk, they need to switch to a low-fat, low-cholesterol diet.

Oh, my bad!  That is sooo 2014!  While most of us not in the wellness business already knew the dangers of eating too many simple carbohydrates long before now, even the most ardent card-carrying member of the Wellness Ignorati learned in March that all their dietary advice has been wrong — to go along with their incorrect screening and checkup advice.  Yet recommending exactly the wrong things hasn’t stopped most vendors from claiming massive savings.  See “On the (Even) Lighter Side” and The Smoking Guns for examples.

Now let’s look at all the hospitalizations that can be avoided through wellness – heart attacks, angina, hypertension, and…um, hmm…did we mention heart attacks?   You’re thinking: “What about diabetes events?”  OK, we’ll add diabetes, only because the HERO report lists it and we want to be true to the report.  But diabetes complications admissions (like CHF, which they also list) are a disease management issue, not a wellness issue — you can’t prevent or manage diabetic neuropathy or left-ventricular heart failure by eating more broccoli. The $1.50 PMPM price would not be high enough to also include disease management, and in any event what one does in disease management for complex cases is much different from a typical “pry, poke, prod and punish” wellness program.

And “straight” diabetes admissions are usually the result of diabetic employees pushing their blood sugar too low by over-medicating themselves—often in a good-faith effort to hit Hba1c “targets” that your wellness program set, no doubt on the advice of your consultants.   Low blood sugar won’t do much for productivity either.  Without the advice of a company specializing in diabetes, you’re likely to get this result.  (And if this is the first you are hearing about the likely causes of “straight” diabetes ER visits and admissions, you should consider such an option.)

So we are now adding all ischemic and hypertensive heart events and diabetes as what they call “potentially preventable hospitalizations.”  How many of your hospitalizations are for those items?  Simply run the primary codes for those events, being careful not to double-count professional fees, to see how many you had.  Here’s what happens when you do it for the United States as a whole.

HCUP WSMEs non-respiratory

Next, divide the relevant figure (Private insurance, 432,065) by the total number of privately insured discharges in the US (7,360,684)

HCUP US as a whole

So—using the HERO Committee’s own acknowledgment of the undeniable fact that wellness can only impact wellness-sensitive medical events (WSMEs) and using the diseases that the report says to use — less than 6% of admissions are WSMEs.  If your non-birth-event admit rate is, as the report says, 45 per 1000, then you have 2.6 admissions per 1000 in non-smoking-related WSMEs.  Once again, don’t take our word for this.  Run this analysis on your own admissions.  You won’t be surprised by how few there are.  Do you even know anyone admitted to the hospital for these things, especially where the admissions could have been prevented with a few more screens, HRA and servings of broccoli?

Shameless plug:  We are happy to do this WSME analysis for you.  We do these all the time.  It’s $4000.  We can also tell you your savings, ROI, trend, comparison to others over time, and more.  We also adjust for the major secular decline in cardiac events that has been taking place anyway for decades that the Committee seems to be unaware of, sort of surprising given their alleged expertise in cardiac risk reduction.

Let’s say you run this analysis with or without our help, and a rate/1000 similar to the US average pops up.  The HERO report says you need to reduce this rate by “only 1 or 1.25 admissions.”  But that’s almost half of your total 2.6/1000 WSMEs!  And in any event, you’ve probably seen by now – if you downloaded the spreadsheet – that Page 15 seriously underestimates your wellness program expenses, meaning your breakeven reduction needs to be much higher than “only 1 or 1.25.”  It’s probably higher than the number of admissions you have available to be reduced.

You can enter both your admissions per 1000 and the reduction in that figure you achieved directly into the spreadsheet.

But for now let’s very generously assume their expenses are right, and you only need to reduce admissions by 1 to succeed. How hard would it be to go from 2.6 to 1.6 WSMEs per 1000, a reduction of 39%?  Here are five things to keep in mind:

  • Your true engagement rate itself is probably much lower than that aforementioned 39%, not including people who simply participate for the money, and the people who are engaged generally aren’t the ones who would crash anyway;
  • A big chunk of all heart attacks can’t be predicted at all, and certainly not now that law prohibits asking about family history;
  • Even events that can be generally predicted can’t necessarily be prevented (we all know people who are “walking heart attacks” and have been ignoring advice for years);
  • “Straight” diabetes admissions are more likely to be for over-control than under-control;
  • In 7 years of measuring this, we have never seen a reduction in WSMEs remotely approaching 39% after adjusting for secular declines in cardiac events that take place even without a wellness program (which the report overlooks)

See The Million Dollar Workplace Wellness Heart Attack Screen in Health Affairs for a more in-depth view of the math. But the entire committee writing this HERO report insists wellness saves money, right?  So, it’s us against them, right?  A he said-she said?  Wrong.  Here’s the denouement.  On Page 23, the report’s own example shows that wellness only saves $0.99 PMPM!   That figure, by the way, is grossly overstated for reasons we will get to when we deconstruct Page 23.  But for the time being, here it is.

hero page 23 99 cents  

So even their own comparison of their own overstated savings estimates to their own understated cost estimates reveal:  wellness is a loser financially.  They have already admitted it is a loser for employee relations.  Funny — if we had made these two arguments, they would attack us.  But they are making these two arguments themselves.

Once again, the Surviving Workplace Wellness mantra applies:  “In wellness, you don’t have to challenge the data to invalidate it.  You merely have to read the data.  It will invalidate itself.”

Where does this leave us?

To summarize, pages 10, 15 and 23 combined tell us:

  1. Even before adding page 10’s cost categories back to page 15, costs are $1.50 PMPM;
  2. Savings are only $0.99 PMPM, meaning wellness loses $0.51 PMPM;
  3. The first two points are not our estimates — they’re their estimates and are far more optimistic than ours;
  4. Adding back the cost elements on page 10 to page 15, and then on Page 23 removing the respiratory savings, adjusting for secular decline in WSMEs, and adding in all the extra doctor visits would create a much larger loss from wellness;
  5. And they have already admitted that “pry, poke, prod and punish” programs are bad for morale.

Now you see why RAND’s PepsiCo study showed a negative ROI from wellness:  It’s because there is a negative ROI from wellness, which no one disputes any more.

And you see the reason we asked the question in the last installment:  Why would any company “do wellness” if the biggest proponents of wellness – people who make their living off it – admit that it’s a waste of money that adversely impacts morale?

Likewise, now you see why wellness vendors and consultants get “outed” all the time on this site, advocate savings methodologies designed to obfuscate rather than enlighten, and try to prevent you from learning that we exist.  We are not saying they are sociopaths.  Sociopaths lie for no reason.  Conversely, wellness vendors and consultants are just trying to keep their jobs.  Bleeding customers or clients dry is only a good job security plan if indeed the customers or clients never find out about it.

But now customers know how their own vendors and consultants really feel.  And we can all work together to dismantle these programs and start doing wellness for employees instead of to them.


Poll: Cue the Wellness Industry Response…  

We have a little dispute with RAND’s Soeren Mattke.  He says the wellness industry modus operandi is, whenever one claim is disproven, to switch to another claim.

We say the reason they are known as the Wellness Ignorati is, their strategy is to ignore facts, including ones they admit, and they will simply just ignore this posting so as not to create a news cycle, rather than switch claims.

There is also the chance that they admit that their own financial model is accurate. This would demonstrate integrity, a quality historically in short supply in this field.

So vote early (but not often)…

 

 

While we aren’t deconstructing this as a sales tool for Quizzify.  But as it happens, Quizzify is literally the only wellness program that does pay for itself.  Don’t take our word for it.  Quizzify is 100% guaranteed to save money and improve morale/engagement–exactly the opposite of what the HERO report says usually happens.  No other wellness program is either, let alone both.

Quizzify 3

Quizzify: the antidote to poke-prod-pry-punish wellness

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