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Book Review: The Healthy Workplace Nudge is a Must-Read

Rarely does a book come along where you can see the author changing his mind about the conclusion as he goes along.  The Healthy Workplace Nudge, by Rex Miller (with Philip Williams, and Dr. Michael O’Neill) is such a book. (For politicos, here is another such book.)  Don’t skim the first few chapters — enjoy watching his journey to enlightenment. Like him, I myself took the same journey. Until about 2007, I didn’t just drink the Kool-Aid. I also mixed it up and sold it…until I did a little fifth-grade math, reaching a conclusion summarized in an observer’s blog post entitled Founding Father of Disease Management Astonishingly Declares “My Kid is Ugly.”

Like virtually everybody including myself (and every member of Congress in 2010), upon first hearing the wellness industry elevator pitch, Rex starts out by assuming that wellness must save money — it seems so obvious.  But the more he learns, through his extensive research, the more he realizes that the “pry, poke and prod” industry is a fraud. “My [initial] unfamiliarity with workplace wellness was a benefit,” he observed. As a tabula rasa, the more he looked, the more he saw: “A few studies have become major pillars of misinformation that have been repeated for more than a decade.”

Welcome to my world, Rex.

After that, the more he learned, the more he learned. Trying to get to the root of the ubiquitous $3-in-savings-for-$1-in-investment meme that permeates the field and predated Katherine Baicker’s subsequently retracted 3.27-to-1 ROI, here’s what he discovered:

When I reached the global health and wellness director for the most cited case study, he admitted he did not know where the numbers came from or even who had actually created the report. So the result seemed to be a very high profile…urban legend.

Meanwhile, back in the company of my new castaway friends, the misfit provocateurs [Tom Emerick, Soeren Mattke and me], I kept hearing simple declarative sentences and sourced data. 

He is spot-on regarding the distinction. Here is how one of the Wellness Ignorati explains Koop Award-winner (and notorious opioid distributor) McKesson’s seemingly self-contradictory award-winning program results:

Health indicators in 2013 and 2014 were adjusted in the analysis, while several sensitivity analyses of the ‘inter-individual’ impact that used a matching approach confirmed the results… Lewis’s conclusion essentially compares apples and oranges by mingling overall summary statistics with an interpretive analysis section that’s descriptive. The latter is based on repeated cross-sections of McKesson employees.

By contrast, here is “Lewis’s conclusion” after observing the self-contradiction in the Koop Award application that prompted this Employee Benefit News smackdown, presented in a simple declarative sentence:

The average weight of McKesson’s employees can’t rise and fall at the same time.


As if Rex needed more data points, another red flag was being disinvited from speaking at one of the Wellness Ignorati-fests. This happens whenever a speaker subsequently admits to critical thinking after being “confirmed” to speak. Critical thinking is right up there with data, math, integrity, facts, analysis, grammar, wellness and me in the rogue’s gallery of damned spots the Wellness Ignorati attempt to wash out, out — or at a minimum pretend to ignore (hence their moniker).

That’s why allowing the noses of the Rex Millers of the world (among whose unforgivable misdeeds are quoting the Al Lewises of the world in their books) into their tents might nudge their bright-eyed and bushy-tailed, painstakingly sequestered, acolytes to use the internet, perhaps searching on keywords like “Koop Award.” If they do, they might learn that in 2016, the year after the Ignorati disinformed their flock that Koop Award-winning companies dramatically outperformed the stock market, the 2015 winner became 2016’s 14th-worst performer in the S&P 500.

Mr. Miller refers to the Ignorati as harboring “deep anger” about being exposed for “fabricating the data.”  Rex says he “doesn’t know the intent of using false data,” but I can clue him in: false data is quite useful if you are selling a scam (the LA Times‘ word, not mine).

Mr. Miller’s expert interviewing style even enticed Ron Goetzel to come tantalizingly close to admitting what we’ve spent four years in TSW demonstrating: that his whole career — claiming huge amounts of money can be saved by coercing lots of employees into claiming to eat more broccoli — is one giant fabrication. Mr. Miller quotes Mr. Goetzel as saying: “Changing behavior is very very very very hard.”

Yes, Ron, your cordially-welcomed-but-ever-so-slightly-overdue Eureka Moment is very very very very accurate. I imagine you’ll retract it soon, because on the other occasion when you were accurate — when your guidebook accidentally admitted wellness loses money — you immediately tried to disown your findings as soon as I congratulated you on their (apparently unintentional) accuracy.


The Nudge…and the Real Estate

The essence of Mr. Miller’s thesis is that hammering people with forced behavior change is very very very very pointless.

Having concluded that prying, poking and prodding employees does likely more harm than good, Rex moves on to a totally different way of doing wellness, which is to say, passively rather than actively. Clearly Rex put a lot of time and shoe leather into researching this book, and it shows. Many examples are offered of how little steps — simply moving different snacks to different places or making stairways more appealing than elevators — nudge behavior.

Way beyond that, the most notable advances in this book concern the built environment. He observes we spend 90% of our lives indoors, and yet little attention is paid to the effect of indoor space on health, wellness and productivity. I suspect more attention is paid to it than he gives credit for, but certainly we have all worked in or visited stultifying workplaces, workplaces where you can’t imagine wanting to hang out in any longer than necessary.

He proposes taking the built environment to the next level. Upgrading a typical building to the WELL Certification standard costs between $150 and $500/employee, all-in. Contrast that to the math provided to him by Tom Emerick that Walmart estimated for a wellness program: accounting for all the administrative costs, false positives, and lost productivity from health fairs and “workshops” totals thousands of dollars per employee. On the “credit” side of the ledger, every pound an employee lost cost Walmart shareholders $50,000.

By contrast, what goes into that $150 to $500 spent on the built environment get you? Suddenly every employee is “participating” in your wellness program, with no penalties or incentives needed. Not just the food in the cafeteria, but everything down to the air that circulates can be optimized for health and performance. “At their best,” he concludes, “buildings can be inspiring and invigorating–with little additional expense.”  For instance, office and factory interiors tend to be dry, which facilitates the spread of disease. They also often allow in little natural light, the lack of which can disrupt circadian rhythms. Both can be easily remedied, with humidification, and with lighting that mimics our circadian rhythms.

The beauty of his proposal on the built environment is that, unlike traditional wellness programs where even the promoters say you need to do everything right to get them to work (“Only 100 or so programs succeed, while thousands of programs fail,” according to Mr. Goetzel), you can solve this problem by throwing money at it…and not much at that. Mr. Miller does go on to point out the value of leadership, but I prefer solutions that anyone can implement, as opposed to solutions that require CEO behavior change, which is very very very very hard.

The built environment is one of several chapters he proposes on solutions, and all are worthy reading, but this section is my favorite because it was new ground at least to me, and because it is so accessible to the average company.  Even in existing space as opposed to new construction, a large chunk of what he is proposing can be accomplished for the price of a few years of a “pry, poke and prod” program. As one CEO who made this investment observes: “Hardly a week goes by when I don’t get a thank-you.”

In conclusion, go to Amazon and buy this book. Do it very very very very soon. Plus, the more copies he sells, the more Ron Goetzel will get very very very very mad.

What are the 2019 consequences for employees who decline “pry, poke and prod” this summer or fall?

Tune in to Quizzify’s Wednesday webinar, The Pending EEOC Wellness Rule Changes: How Quizzify turns Lemons into Lemonade, for the shocking conclusion.

Meanwhile, don’t believe a word your wellness vendor says…

Wellness trade association (HERO) throws itself under the bus

In wellness, there is a saying that you don’t have to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself.

Now that adage can be extended to cover the May “position paper”  published by the Health Enhancement Research Organization (HERO). HERO manages to invalidate its own position even though they didn’t actually take a position in this “position paper” to invalidate. They didn’t even present any data…and yet their data was wrong.

All they said was “critically examine research.” Then they provided four paragraphs which showed why doing precisely that invalidates everything they’ve ever published. See for yourself with each paragraph header.

I agree totally — except with the grammar, English being right up there with arithmetic, logic, statistics, and ethics as being courses that HERO’s staff have struggled with. There has not been a single study in the last five years showing wellness saves money. Sometimes, the studies say explicitly that wellness failed, as the National Bureau of Economic Research did, with Medicare close behind. Or Pepsico. Or the state of Connecticut, which, having thrown away millions on inappropriate screenings and doctor visits, declared that losing money was “a good thing.”

Other times, you have to actually read the study to realize that wellness loses money, as in every Koop Award-winning example in the last six years through 2016, like this one and this one and this one and this one and this one and this one.  Why not 2017? Because in 2017, they couldn’t even find a study that pretended to save money.

HERO has painted itself into a corner here too, because if a study ever does come out that alleges wellness saves money, critics would simply note that it is important to be skeptical of a claim from a single study refuting all the others. Apparently Prof. Baicker is working on a new paper, having found the arguably the most stable genius vendor in the wellness industry to support what are likely to be claims of savings high enough to support her own previous claims of savings, but low enough so they won’t immediately self-invalidate upon exposure to sunlight. And let us not forget that her original conclusions were publicly invalidated, by name, by her own subordinate. Is this is a great country or what?


The HERO position paper complains that:

Media criticism is sometimes based on programs that are not evidence-based, are poorly implemented, or are incorporated into unsupportive environments.

Hmm… so every time a study comes out showing wellness loses money, it’s because the program was done badly? This list of losers apparently includes the aforementioned Pepsico, whose program was so bad they won two Koop Awards.

During my debate with Ron Goetzel, a number of questions from the audience complained that their own company’s wellness program was horrible. Ron’s stock response: your company needs a better program. He reserved particular animus for the Penn State program, which he himself decried as “horrible,” even though he was the prime architect. In another instance he blamed the questioner for being a bad employee.

Since employees dislike being pried, poked and prodded, “unsupportive environments” would include every company, according to WillisTowersWatson. That means the only companies with “best practice” programs would be wellness vendors themselves, like Vitality Group, where, as a wellness vendor, they curated and implemented only the finest wellness interventions available to mankind. Oh, wait a sec, I goofed. That program failed miserably. Shame on their own bad employees!

Vitality Group is in good company. As Mr. Goetzel says, thousands of programs are done badly while only 100 have succeeded.

“Best practices” might include adhering to US Preventive Services Task Force guidelines, not demonizing social drinking, avoiding harms to employees with eating disorders, and not telling people to do stupid things. I’d settle for a program that does any one of those things.


How much time do they need? 3 years? 6 years? They need more? Sure — here is 14 years‘ worth of results for the entire US, showing virtually nothing has happened. The “wellness-exposed” and “wellness-non-exposed” <65 populations are virtually coincident, with only Medicare — where, by definition, there is no workplace wellness — showing a little improvement. It’s all spelled out here.

This paragraph is supposed to be a subtle diss of the NBER paper, which in the 4 months subsequent to publication, the very stable geniuses at HERO have not mentioned by name to avoid drawing attention to it due to its obvious quality and validity. (Welcome to my world.) True enough that the NBER paper covered only one year, though the authors added there was absolutely nothing “trending towards savings” to suggest that the second year would be any different.

The irony of course is that almost every one of those Koop Award-winning programs did claim first-year savings. So first year savings are obtainable, except when they aren’t.


Confirmation bias? HERO is a thesaurus-level paean to confirmation bias. Look at a typical study, and all you will see is citations to studies by their colleagues. Not one study in the wellness trade association’s journal (whose prevaricator-in-chief Paul Terry, also runs HERO) has ever cited me in all of its history, whereas this single article by me cites various members of the Wellness Ignorati 115 times. Not one study in the history of that journal has ever found wellness loses money. At least deliberately. Just like Perry Mason lost one case that was overturned on appeal, that journal accidentally found “randomized control trials exhibit negative ROIs,” but then devoted an editorial in the next issue to overturning their previous conclusion.

Here is HERO’s exact language on confirmation bias:

Confirmation bias is the tendency of researchers to draw inferences from their study that align with their preexisting beliefs but are not well supported by their data.

This is, of course, is how the Wellness Ignorati got their name — deliberately ignoring the overwhelmingly conclusive data that undermines their revenue stream. Examples are legion but my favorite is Larry Chapman breathlessly propagandizing a study that he interpreted as aligning with his preexisting belief that health risk assessments save 50% (“they should be treated like a beloved pet”). Alas, he made the mistake of also providing the actual data, which naturally not only can’t be interpreted to show 50% savings, but also can’t even be misinterpreted to show 50% savings. Or any savings, for that matter.

Claim:

Data:

Larry, one question for you:

 

The Secret Life of Ronald Goetzel: Wellness meets Whack-a-Mole

In the immortal words of the great philosopher Soeren Mattke of RAND:

“The industry went in with promises of 3 to 1 and 6 to 1 based on health care savings alone – then research came out that said that’s not true – then they said ok we are cost neutral – and now as research says maybe not even cost neutral they say but is really about productivity which we can’t really measure but it’s an enormous return.”

That’s two moles whacked in just one paragraph.

Then when the productivity thing didn’t pan out, they invented something called value-on-investment, which (even though they invented it specifically to show savings) turned out to show massive losses on even the most cursory examination.  Third mole.

Bottom line: all their studies that do actually exist self-invalidate no matter what they claim because — get ready — wellness loses money. Now it looks like there is a fourth mole to whack — Mr. Goetzel’s latest charade is, yeah, maybe virtually all studies in existence reveal losses upon examination, but that studies that don’t actually exist show massive savings.  Perhaps he was inspired by Wellnet, which shows massive savings in “undetected claims cost,” which also don’t exist. Google on “undetected claims costs.” The only hits you get are Wellnet and me making fun of Wellnet.


I was recently forwarded an email containing Ron’s latest musings. I’ve never met the originator of the email, so he could have fabricated the entire thing for all I know. But in terms of credibility, if Ron Goetzel tells me the sky is blue and someone I’ve never met tells me the sky is green, I’d at least go look out the window.

Ron “the Pretzel” Goetzel’s latest twist — since he can’t find fault with my work — is that all the studies I invalidate are published studies, which he acknowledges in this email to be of generally poor quality. He now claims there is a parallel universe of unpublished studies showing savings that are of high quality.  For some reason, this special reserve collection of buried treasure is stashed in a secret hideaway drawer under lock and key in a safe room. (He says his clients don’t want competitors finding out how well they are doing, but could it be they simply prefer not to be publicly humiliated, like most of his other clients?)

The claim that unpublished studies show the greatest savings is ironic. Why? Because Ron previously stated: “Many unsuccessful programs are not reported.


Where Ron and I would agree is that the published studies I have invalidated — like this one and this one and this one and this one and this one and this one and this one and this one and this one and this one — are definitely of low quality.  Maybe that’s because Ron himself:

  1. wrote them;
  2. gave them an award; or
  3. both, since conflict of interest is his modus operandi, or
  4. in the case of Penn State, goaded them into creating a wellness program that became a national punchline.

He did name the three companies that:

  • produce these alleged secret studies, and
  • “pay Truven $250,000 to analyze their numbers.”

The latter would be quite impressive if they do — except that they don’t. I’m not naming them to protect their privacy, but suffice it to say I sent them both the snippet of that email with their names in it, and they got a kick out of it. (“I never, ever, thought this nonsense worked.”) I added that if Ron Goetzel went around bragging that I paid him $250,000 to analyze my numbers, I’d sue for defamation.

On the flip side, he is also telling people (privately, so that I don’t find out about it like this) that I am [blushing] “the least credible person in the industry,” perhaps having forgotten that he had already accidentally admitted that I am the most credible person in the industry. I’m in good company — he also disses the second-most-credible evaluator in the field, for the simple transgression of publishing a high-quality study that showed losses that Ron inadvertently validated, before trying to pretzel his way back from with a series of lies that would make a White House press secretary blush.

He would also have to explain why, if I am so non-credible, he begged to be on the advisory board of the Validation Institute (which I started with Intel-GE Care Innovations). We couldn’t have him on the board because the whole point of the Validation Institute was to be credible, which it is. It is now the official validator for the World Health Care Congress.

He even got David Nash to try to strongarm us. We could have just said no, but what fun would that have been? We said: “Sure, you just have to be certified in Advanced Critical Outcomes Report Analysis first.” The test at the time consisted of finding all the errors in his Nebraska analysis, so he couldn’t earn the CORA certification without admitting that all the claims in the study were fabricated, impossible, or represented industry-leading ignorance of the way prevention works. For example, the very stable Nebraska geniuses “waive[d] all age-related screening guidelines” so that young people could get screens intended only for older people, which would be like “waiving” the minimum age for getting a driver’s license to get more young drivers on the road.

How many errors were there? Eventually, with the help of people getting validated (we had missed a few errors ourselves because there were so many of them), we dedicated an entire chapter of Surviving Workplace Wellness to Nebraska, a chapter which opens as follows:


The absolute last word on wellness economics: there are none

Jon Robison recently published an article showing the futility of using wellness programs to save money.  Futility is an understatement — here is the absolute, take-it-to-the-bank proof on how much money wellness loses, and why my $3 million reward money is safe.  The key display is right here:

The two lines at the bottom are the US population potentially exposed to wellness (insured by employer) and the entire non-exposed <65 population (Medicaid + uninsured + self-pay).   As wellness became increasingly common, one would expect the lines to separate. And they did…by about 0.2%, or roughly 700 heart attacks in the entire US population. (This of course assumes that none of the separation is due to the social determinants of health — one would expect people who enjoy employer-paid insurance to be better off than those who are on their own, or have Medicaid.)

Ironically, Medicare — where by definition nobody has access to workplace wellness — did the best of all.

Whole milk is the new skim milk

Since virtually all HRAs tend to get this one completely wrong, which was excusable 5 years ago but not today, I was going to write a blog post about it, if for no other reason than to use that title.

However, The Skeptical Cardiologist beat me to the punch.  He did a much better job than I would have done, making today the second day in a row in which someone has written something better than I could have done on the same topic.

 

AJMC: We are shocked, shocked to learn that HRAs are useless

We interrupt our litany of descriptions of failed HRAs to bring you a description of the failure of HRAs.


In wellness, it’s not news to find that something is useless. Indeed, most employees and most economists would agree that the world would not miss Wellsteps or Interactive Health were they to disappear altogether from the earth.

Still, it is news to find that yet another pillar of wellness has fallen victim to actual analysis. In this case, it’s the venerable Health Risk Assessment. This tool has, for about 40 years, been used to encourage employees to pretend they don’t drink. The tool does have one practical use: identifying employees who don’t buckle their seat belts helps employers decide who needs their hearing tested.

HRAs do have their defenders, of whom the most prominent is Larry Chapman, who says they should be treated like “a beloved pet.

He cites this data set from JOEM showing the costs of people who took the HRA vs. people who didn’t…

…to support the proposition that HRAs cut the average health care cost in half after three years. Or, to use his exact words, CUT THE AVERAGE HEALTH CARE COST IN HALF AFTER THREE YEARS.

It may come as a surprise to Mr. Chapman, who once claimed that wellness could reduce costs by 327%, that CAPITAL LETTERS don’t stand a chance against actual data, and there is nothing whatsoever in this data set that he himself cites to support the notion that HRAs reduce cost by HALF, or for that matter any amount. Indeed, in 5 of the 6 periods studied, the study group had higher costs than the comparison group. The study group did better in the final year, three years after taking the HRA. This is likely because by that time they had forgotten all the useless and, as we’ve been learning, incorrect advice that HRAs provide.


Enter Joe Andelin, who plowed through 200 pages of Kaiser Family Foundation survey data, publishing the results on the American Journal of Managed Care blog on May 1. Lest anyone not be looking forward to slogging through an academic article, let me assure you he sounds more like me than I do, starting with his opening line:

Will Rogers once said, “The income tax has made more liars out of the American people than golf has.” Health risk assessments (HRAs)…could give taxes a run for their money.

The key findings in his transparent and replicable study:

  • Incentives and penalties are effective in getting employees to complete HRAs, but…
  • …Companies with a high percentage of HRA completion spend more money on healthcare than companies with a low completion rate — and the companies that don’t offer HRAs at all have the lowest spend of all.

I wouldn’t infer causation from this correlation.  That’s because most employees, having been burned in the past by (for example) taking HRA advice to get more prostate exams and eat less fat, now have the good sense not to take the advice offered on HRAs like Cerner’s or Optum’s.  Rather, I suspect the causation works as follows: companies that actually think completing Cerner’s or Optum’s HRA is a good idea have applied their very stable genius insights to the rest of their health benefit structure…and hence spend more money.

There are plenty of other shocking factoids in this article as well, so I would encourage people to read the link.

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