Home » overdiagnosis (Page 2)
Category Archives: overdiagnosis
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.
USA Today and Kaiser Health News just published a terrific story on the hazards of overscreening, overtesting, and pry-poke-and-prod programs.
It revealed how screening all employees every year–and then sending them in for checkups –makes no sense on any level, and is contrary to all guidelines and literature. All it does is lead to hyperdiagnosis. Hyperdiagnosis is overdiagnosis on steroids. Instead of being the unfortunate result of good-faith efforts to figure out what is wrong with a patient (that’s “overdiagnosis”), hyperdiagnosis is the breathless reporting by wellness vendors on how many sick employees a company has, and how they will have an “epidemic” of something-or-other unless they force employees to get coached etc.
Hyperdiagnosis is also, however, the wellness industry’s bread-and-butter, so naturally wellness vendors defend this practice. In this article, Bravo Wellness CEO Jim Pshock was quoted as saying: “The hope is that the program will get people to proactively see their physicians to manage their health risks. Yes, this will, hopefully, mean more prescription drug utilization and office visits, but fewer heart attacks and cancers and strokes.”
The only innocent explanation for this comment is that Bravo canceled its subscription to the internet to conserve cash. Seems that all the literature, easily searchable online — plus Choosing Wisely — says that “proactive” annual checkups are a waste of time and money and will not prevent heart attacks and strokes, and certainly not cancers. (They will, however, make drug use and physician office visit expense increase. That much he got right.) A quick Google search would have revealed that to him…if only he had access to Google.
This whole thing would be pretty amusing except that Bravo’s business model includes fining employees for not getting checkups that are more likely to harm them than benefit them, according to the New England Journal of Medicine. Harming employees is where the joke ends.
Otherwise, the only other explanation for this comment is that he is — heaven forbid — lying. And we would be pshocked, pshocked to learn that lying is going on in here!
Therefore, since a wellness vendor would never lie, Mr. Pshock must have allowed his internet subscription to expire. We’d urge all readers to donate early and often to Bravo Wellness to help them keep the lights on.
Wellness is about pushing employees into the healthcare system, almost always both against their will and their better judgment. This story is a perfect example of the consequences of how too much healthcare can be hazardous to your health, and why your best defense against overdoctoring is knowledge.
Once you start asking questions, doctors have to start answering them. While many doctors welcome that, others start fidgeting. If your doctor is one of the latter, it’s probably time to switch.
I myself get occasional bladder tumors. Ironically — and once again, showing the unintended consequences of wellness — I got bladder cancer from eating more broccoli, which of course is exactly what wellness programs would have us do. (And which, in all fairness, is generally a good idea.) The problem was that the broccoli was grown in a garden that was way too close to railroad ties, which leach creosote into the soil. Creosote causes bladder tumors.
So every few years, one grows back and has to be scooped out “non-invasively” (that’s easy for the doctor to say). And every year I go in and get checked, also “non-invasively”. After my last check, the urologist — a new one, whom I had never seen before — suggested a CT scan of the kidneys and ureters.
I asked her why, and she said, because I had had bladder cancer for 15 years and never had this scan.
I replied: “Well, I founded a company, Quizzify, that educates on overutilization. CT scans have 500 times the radiation of x-rays, and that particular set of views is likely to spot tumors on my adrenal glands that are completely clinically insignificant, and yet once spotted will be tracked and possibly removed, for no good reason other than that they are there.”
She said: “OK, why don’t we just start with a urinanalysis.”
From a hazardous and likely counterproductive $1000 scan to a $10 urinalysis in 30 seconds. That’s what knowledge is worth.
The Graco-Goetzel-Bravo-Hopkins case study is turning into another Nebraska fiasco. As with Nebraska, the numbers all contradict one another. But unlike Nebraska, there has as yet been no admission of deliberate lying in the Graco case study. That’s why Graco only earned an honorable mention in the Koop Awards, instead of winning one outright like Nebraska did.
Consider Bravo’s case study on Graco covering the exact same population over the same period as Ron Goetzel’s study. Let’s assume Ron Goetzel is right in that the wellness program should be measured from 2009 rather than 2008, when the program started. (Bob Merberg’s brilliant analysis points out the cherrypicking of the date has a huge impact on claimed success, but let’s concede this start date choice to Ron, and use 2009 according to his wishes.)
Bravo’s case study displays the PMPM costs by year. The first thing to note is, they list employee healthcare costs at $328 PMPM, which actually makes sense, instead of the $190 PMPM in the Hopkins report. I don’t know why these two figures, purporting to cover the exact same population in the exact same period, are completely inconsistent, but I do know that $190 PMPM is an impossible figure, as any population health expert knows. (“Plausibility checking” would have caught that error but Ron has never taken our course in Critical Outcomes Report Analysis, which would have covered plausibility-testing and likely prevented him from making such a rookie mistake.)
Second, Bravo lists children’s healthcare costs in this report as well. Funny thing: over the same exact period in which Mr. Goetzel was claiming that the wellness program was responsible for controlling employee participant costs, children’s healthcare costs trended better than wellness participants’ costs. Mr. Goetzel obviously had access to this children’s cost trend data (we had no trouble finding it, thanks to Bob Merberg) but elected to — get ready to fall out of your seats — ignore it. The wellness ignorati rarely step out of character.
This children’s cost trendline appears to invalidate the entire Goetzel-Johns Hopkins conclusion that the healthcare cost trend was due to the wellness program, since not one single child participated in the wellness program.
For some reason Graco’s spouses cost about $7000 apiece a year. We’ll leave that for someone else to dissect.
As an aside, if anyone thinks they recognize the name “Bravo Wellness” from an earlier posting, it’s because they do. Bravo is the outfit that brags about their ability to save employers money by fining employees. Their website is disproportionately about their appeals process when those fines are levied. This sounds like a company that does wellness to employees instead of for them.
Not sure how bragging about fining employees is consistent with the positive culture that Mr. Goetzel says Graco has, but maybe I’m missing something here.
Ever wonder why students don’t just grade themselves? For your answer, look no further than HealthFair.com’s self-assessed grade:
And yet by any standard other than their own, HealthFair completely flunks the test. Literally, their “basic package” proposes more “D”-rated tests (and “D” is a failing grade by US Preventive Services Task Force standards) than any vendor we’ve ever seen. They would lose their wellness vendor license tomorrow, except for the fact that wellness vendors don’t need licenses.
The first four all get “D”s. Here are the screenshots if you don’t believe that any vendor could possibly offer so many inappropriate tests at all, let alone in the “basic” package.
The abdominal aortic ultrasound test is such a stupid (where “stupid” is synonymous with “profitable”) idea for the non-elderly population that the USPSTF doesn’t even bother to say no:
Along with their “D” as a general screening tool, The EKG gets a whopping “I” for individuals at risk, but since HealthFair’s basic package includes no basic tests to see who is at risk, and by law they can’t ask about history, they would still have to screen everyone whether or not they are at risk:
By earning another “I”, the peripheral artery disease test does well by HealthFair’s standards. The USPSTF concludes that researchers don’t know enough about it to recommend it, which doesn’t stop HealthFair.
As for “hardening of the arteries,” the USPSTF doesn’t bother to grade it due to the fact that no one uses this test as a screen…except wellness vendors. But even the American Heart Association, not exactly shy when it comes to screening people for cardiac disease whose treatment can enrich their members who treat it, disses this test:
Speaking of D-Rated tests, sorry, guys. If you want a D-rated PSA screen — a screen not even recommended by its own inventor — you have to insist that your employer buy HealthFair’s “advanced” package:
That brings us to the H Pylori screen, Healthfair’s groundbreaking, earth-shattering, pushing-the-envelope leap forward in the wellness vendor competition to out-stupid one another.
Where to start…
First, the US Preventive Services Task Force doesn’t bother to offer a recommendation on it, largely because no self-respecting doctor would ever screen patients for this. Shame on the USPSTF for consistently failing to anticipate all the ways in which wellness vendors can misunderstand basic clinical science!
Second, most of us who harbor H Pylori have no symptoms. So why screen for something that’s not causing problems? That’s why this is a test, not a screen. If you have an ulcer or symptoms that suggest an ulcer, go to the doctor. Even then, the doctor probably won’t even bother to test you, since most people get relief simply from well-tolerated, commonly used, proton pump-inhibitor medications–some of which don’t even require a prescription. It is only if the first-line medications fail that most doctors will even test you.
Third, there is a significant school of thought that says H. Pylori is beneficial. Screening us for something we’re better off having in our bodies represents a new frontier in the wellness industry’s answer to overdiagnosis, which we call hyperdiagnosis.
Fourth ironically, given the wellness industry’s obsession with employees’ weights, it is even slightly possible that killing off H. Pylori contributes to weight gain.
Fifth, what exactly are we supposed to do, if it turns out we harbor H. Pylori? Get a course of antibiotics to clear the bacteria out of our system? That’s a great idea. We’ve always maintained that one of the problems with America’s healthcare system is that patients don’t get to take enough antibiotics.
The good news for the pharmaceutical industry is due to the nature of H Pyroli, hiding in our stomach mucus, it takes a lot of antibiotics to ferret it out, plus a bunch of other pills. Is this a great country or what?
Sixth, the H Pylori tests themselves are among the most complex, unhelpful and inaccurate commonly used tests in existence.
Finally, half the world’s population has it. Given the expense and inaccuracy of the test and the prevalence of the bacterium, why not eliminate the middle step and just put all your employees on antibiotics?
One of us is a screaming libertarian. And even he thinks the cowboys that populate the wellness industry need to be reigned in with some regulation, before they screen the American workforce to death. The regulation would be very straightforward: employers and vendors must disclose the USPSTF recommendations to employees before making them take these tests. If after this disclosure, a few employees still insist on getting these D-rated or off-the-charts-inappropriate screens, congratulations! Your screening program will have just done something useful: identified employees who are totally incapable of making an intelligent decision.
To those of you who are reading this and thinking: “Haven’t I heard this song before?”, the answer is, you have. HealthFair is the “Intel Inside” for the screening jihad offered by SSM Healthcare, the Sisters of Saint Mary health system we “profiled” a few weeks ago, thus once again proving that wellness mantra: great minds aren’t the only ones that think alike.
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 money.
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.
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.
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.”
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.
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
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.
Next, divide the relevant figure (Private insurance, 432,065) by the total number of privately insured discharges in the US (7,360,684)
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.
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:
- Even before adding page 10’s cost categories back to page 15, costs are $1.50 PMPM;
- Savings are only $0.99 PMPM, meaning wellness loses $0.51 PMPM;
- The first two points are not our estimates — they’re their estimates and are far more optimistic than ours;
- 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;
- 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.