Home » Uncategorized
Category Archives: Uncategorized
Most behavior-change vendors take months to show any impact at all anywhere in your population, so how can a vendor be so impactful, so innovative, that it can change your own health behaviors in an hour? Join our 9/28 webinar (1:00 PM EDT) and see for yourself.
We often achieve behavior change even before people sign up for Quizzify, starting with webinars like this one. One of our favorite closing lines is: “See, you haven’t even signed up yet and we’re already saving you money.”
We’ll show plenty of examples, starting with our newest and most dramatic immediate savings opportunity. [SPOILER ALERT: Reducing ER expenses by 50% or more, cash on cash.] We’ll cover categories as diverse as screenings, fusions, pregnancy, scans, and of course: Cavities.
Cavities? If you haven’t seen our cavities material, it alone is worth the price of admission. Why submit to a century-old procedure when you can get one that is $30, painless, fast and more effective?
We even have a partner vendor whose own guaranteed savings increases if implemented alongside Quizzify!
In each case when we show what Quizzify teaches, we’ll do some “before and after” polling…and you can watch as the plurality of the webinar audience shifts attitudes and likely behaviors on the spot.
We’ll close by noting that you don’t even have to believe your own eyes: everything we say is 100% guaranteed.
Quizzify’s “Jeopardy-meets-health education-meets-Comedy Central” approach takes both employee engagement and cost savings to a new plateau. It’s so powerful that it simply isn’t believable unless you participate in it. Now is your chance.
This is Tom’s last week on Linkedin and other work-related social media. He wrote me this note and asked me to post it.
Adding something of my own to the note below, it was great to work with him. We wrote an entire trade-bestselling book together, Cracking Health Costs, without ever meeting until it was published. He was disruptive before disruptive was a thing, and was the first champion of Centers of Excellence, back when everyone else thought they could save money by just “doing wellness.”
As I am retiring from the industry today, I would like to ask you, as my best friend in healthcare, to post this note and send thanks to the many people who have also been great friends and supporters through the years.
First, at Walmart, I’d like to thank Sally Welborn for rolling out our Centers of Excellence model before it was a “thing” – during a time when everyone wanted employees to “do wellness” instead. I would also thank Adam Stavisky for taking it to the next level at Walmart.
And while we are on Centers of Excellence, thank Dr. Fred MacQueary and Dr. Alan Sparrow and especially Dr. Mary Bourland at Mercy Hospital in Springfield for avoiding so many unneeded and harmful spinal fusions. They are the classic Center of Excellence.
Next, special thanks to Leah Binder for the great work that Leapfrog Group does, and for introducing us. Without Leah there is no Cracking Health Costs, and that book launched my post-Walmart career. And thank you for graciously allowing my name to go first even though you did most of the writing.
So many other people to thank and support that I am only going to mention a few and hope they tell the others. Sandra Morris, Scott Haas, Mark Kendall, Rick Chelko, Paul Levy.
If you would like to write Tom a nice sendoff, please don’t do it in the comments here. Instead, go to linkedin https://bit.ly/3xRvxIB so all the comments can be in one place.
Attention, They Said What Nation:
We are available for forensic consulting (taking appellations and kicking posteriors), recoupment of fees, and expert witness work, hourly or on contingency (except for expert witness, where it is not allowed). So if you think a vendor has snookered you, who you gonna call?
We. Never. Lose.
And here is an example of why vendors fold…
Accolade recently announced that they had paid Aon a zillion dollars for their actuaries to decide how much savings they could claim without leaving too many clues that the claimed savings figure is fabricated.
They drew that trendline at 8.3%, and decided the savings was also 8.3% in 2019. Could this be an example of “trend inflation,” where, as Optum’s Seth Serxner says: “The choice of trend has a large impact on financial savings”?
Nah, an actuary would have to be both stupid and dishonest to inflate a trend willy-nilly. it would be too obvious a ruse. You’d show savings in:
- every single disease category
- every single comorbidity/risk category
- every single resource use category
To begin with, here is Aon’s trend vs. the sample Accolade clients:
We’re not calling Aon liars, or saying that Accolade’s payments to Aon create a conflict of interest for Aon’s consultants, or saying that Accolade chose Aon instead of the much less expensive and more credible Validation Institute, which backs its validations with a unique Credibility Guarantee, because they wanted Aon’s actuaries to fabricate savings. (The Validation Institute would have to pay out on a ton of Credibility Guarantees if they fabricated savings.)
Quite the contrary, we’re sure that Accolade wanted Aon to publish results that were completely on the level. That’s why they paid them so much money, to check and double-check their work.
Every single disease category
Even so, as we pore through Aon’s report, we can’t help but see some questions that you might want to ask, just out of idle curiosity. By way of background, Accolade is a care coordination/navigation company. If you have an issue, like whether something is covered (benefits questions being the majority of the incoming phone calls), you could call them. They might be helpful. Come to think of it, they are so helpful that — get ready — they save money in every single disease category:
Accolade seems to save substantial sums of money in mental categories — “mental anxiety” and “mental mood” (as opposed to physical anxiety and physical mood, I suppose) — because massive numbers of mentally anxious and mentally moody employees are apparently calling them.
Just suppose for a minute that you were mentally anxious or mentally moody? Would your first impulse would be to call a random number on the back of your insurance card and take a stranger’s advice to save your employer money? That course of action wouldn’t jump to my mind in that situation. But maybe that’s just me. So your question might be:
What do you tell these mentally anxious and mentally moody callers that saves all this money?
Maybe they advise these anxious and moody callers to stop spending money on therapists or meds, and instead just tell them to, respectively, calm down or cheer up. A few other categories might raise questions too, like:
How do you save money in “Upper GI/Esophagus”? Do employees call you and say: “My esophagus is acting up again”?
And that brings us to cancer, where the mind-blowing 18% savings explodes still farther, in another chart showing 2 years of data, to 26%. How do you save 26% in cancer? On average you would be telling every employee — including the 38% to 50% who (according to Accolade) never call even with minor administrative claims issues — not to bother with that fourth round of chemo. And I’m sure they’ll trust Accolade’s judgment on that.
Every single comorbidity/risk category
Aon’s actuaries also sliced the data by number of comorbidities. Initially, they did not show savings in every single comorbidity category. For some reason they struck out with employees who have 3 comorbidities.
We’ll blow up the right-hand “Cost Ratio” column — meaning the % savings — for you:
You could ask:
Why do your phone-answerers do such a great job on people with two or four comorbidities, but strike out on people with three?
And, my personal favorites are about people with, respectively, 0 or 1 chronic conditions:
How do you save 8% on people with (1) zero chronic conditions, (2) no reason to call Accolade, and (3) who already spend less than $2000/year on healthcare to begin with?
How do you save 9% on people with only 1 chronic condition, like maybe mental anxiety or mental moodiness, or perhaps a cranky esophagus?
Accolade/Aon’s answer to these questions on page 15 of their report is:
Only the results for members with 0 or 1 chronic conditions represented statistically credible reductions vs. market controls.
So, in other words, they are claiming savings only in the cohorts where there was basically no savings to be claimed.
Curiously, when you combine the 3 and 4+ comorbidities columns, you do end up with savings in every single comorbidity category. You get across-the-board savings of 8% to 11%, with both ends of the health spectrum showing roughly the same 8% in savings.
Before you assume this is a textbook example of trend inflation, you might ask:
How is it that you save roughly the same amount on the healthiest employees as on the sickest employees?
Surely the data is accurate — if you pay actuaries that much money it should be — but a cynic might expect that care coordination/navigation would be more effective where there is actually the need/opportunity to coordinate/navigate care. Just sayin’…
Every Single resource use category (almost)
Finally, Aon cut the data by resource use.
The good news is that Accolade is keeping patients from using healthcare services, thus saving money in every category of utilization. There is 11% less inpatient use. Outpatient and physician expense declined as well. So another question might be:
Where are you sending employees to get their care?
By contrast, check page 147 of Why Nobody Believes the Numbers. There is an example from Quantum Health where inpatient use declined, but lower-cost resources like doctor visits increased. That increase is a “plausibility check” on Quantum’s shockingly valid claim to have reduced overall spending. Their claim would not have been plausible if every category of resource use declined. As the book says: “if you insulate your house, you’ll save money, but not on insulation.”
The best news? At the very end, Accolade broke their streak of 16 diseases, 4 comorbidity categories, and 5 resources showing savings –by getting a whopping $13 more generic drug use per employee. So, to paraphrase the immortal words of the great philosopher BIll Murray, they’ve got that going for them.
What does Aon have to say about all this?
Initially, they proudly announced the initial “savings” on the Healthcare Hackers group. (Ping me at firstname.lastname@example.org if you want to join that group.) When I and others humbly pointed out just a few of these questions about their analysis, Aon’s Jim Winkler replied that they “stand by” their results.
I learned long ago with the wellness industry not to bother to try to argue with these people because you can’t prove something to someone who just got paid a zillion dollars to “validate” the opposite. So I simply offered to bet a million dollars their results wouldn’t stand up to scrutiny from a panel of reputable health economists.
And that’s when they folded. Not a peep out of them, though other people on the Hackers also asked. And then I noticed that Aon’s chief actuary looked at my linkedin profile.
Never heard from him either, to collect his $1 million. I guess he decided that instead of “standing by,” he should swallow hard and tacitly admit he goofed. (We will assume for now these were all honest mistakes. The way you’ll know is that, having now seen this posting, they will correct their errors.)
Speaking of swallowing hard, if you’re finding Aon’s analysis tough to swallow, you may be right. And you should also call Accolade to fix your esophagus.
Never Pay the First Bill is the best health policy book ever (maybe tied with The Price We Pay), largely because it’s not about health policy. It’s conclusion: we can’t depend on anyone to look out for our interests. Instead, individuals and employers are going to have to make our own “policies.” (I’m sure it is just coincidence that Quizzify is the only vendor featured in both, since we show people how to make their own “policy” on not getting surprise bills.)
SPOILER ALERT: When you read this book to truly understand this industry, you’ll be shocked, shocked to find that lying is going on in here!
And lest you think that this is for-policy-wonks-only, it’s quite the reverse. It is specifically written for “anyone who has been pushed around by the healthcare system.” This cohort of “anyone” would include me, before Quizzify taught me how to push back.
The first eight chapters are specifically for individuals. They act as how-to’s for winning appeals, dealing with collectors, and, of course, avoiding surprise bills using Quizzify’s consent language. As coincidence would have it, this surprise bill example involved a United Healthcare subsidiary called Golden Rule Insurance. This is the same outfit that “negotiated” the in-network price of 28x Medicare (plus a $1700 tip for a no-show doctor) for the guy featured in our own surprise bill webinar in March.
One surprising lesson in the first eight chapters? Find out what the cash price is. Frequently, it is quite a bit lower than the price that your national insurer, with tens of millions of lives, has negotiated on your behalf.
Employers are getting snookered too
These are followed by three chapters specifically for employers. SPOILER ALERT: employers get snookered without even knowing it. How true that is! In addition to the multitude of examples in these chapters, I would cite my own experience with surprise bills and employers. When I suggest that employers teach employees how to avoid them, an employer will often say: “My employees aren’t having a problem with surprise bills.”
What I then reply is: “Oh, OK.”
What I want to reply is: “The reason they aren’t having a problem with them is that you’re paying them.”
It’s not like these hospitals are saying: “Oh, this guy has good insurance. Let’s charge him less.”
One thing you’ll learn as an employer is that the insurance company is not your friend. They auto-adjudicate bills that should never be paid, and then throw up roadblocks when you try to dig into these bills to identify the fraudulent ones that shouldn’t be paid.
Sometimes, they “find” the fraud themselves, congratulate themselves for finding it, and then take a big chunk out of the “savings” from reducing the bill that they themselves paid.
Further, each chapter ends with a summary of what you as a person or an employer can do. It is not just an exposé, but also a how-to.
The June issue of Health Affairs reveals the conclusion of the definitive 3-year randomized control trial on wellness, conducted by the industry’s leading research team, Professor Katherine Baicker (now dean of the University of Chicago’s School of Public Health!) and Professor Zirui Song, of Harvard Medical School.
“No significant differences were found in self-reported health; clinical markers of health; health care spending or use; or absenteeism, tenure, or job performance. “
Conversely, a major wellness vendor released the results of their own internal study showing exactly the opposite. Highlights are an 84% reduction in people with high blood pressure, a 50% reduction in both obesity and employee turnover — and by far the greatest savings that have ever been achieved in a wellness program.
Both camps have been offered the opportunity to defend their diametrically opposed conclusions.
Along the way, you will have many opportunities to vote on aspects of these diametrically opposed conclusions.
And your votes will help determine, in the immortal words of the great philosopher Rick Perry, whether or not who is right.
We will be doing a webinar on this very topic — June 30th at 2 PM EDT. Both camps have been invited to present. Register here.
Health Affairs just announced it. The conclusion of the impeccably designed three-year study conducted by Katherine Baicker and Zirui Song showed zero impact in a randomized control trial. This conclusion, of course, confirms exactly what we’ve been saying for almost a decade now–wellness programs have absolutely no impact (other than to occasionally harm employees, of course). In their words:
No significant differences were found in self-reported health; clinical markers of health; health care spending or use; or absenteeism, tenure, or job performance. Improvements in health behaviors after three years were similar to those at eighteen months, but the longer follow-up did not yield detectable improvements in clinical, economic, or employment outcomes.
No one can accuse the authors of having an anti-wellness bias. Quite the opposite, they wrote the seminal article that created the industry. As early as they were in supporting it, I was almost that early in realizing it was a sham (Slate’s word, not mine.)
One could also argue that wellness was already dead — the previous 11 articles had shown the same thing. Vendors excel at hiding these articles from their customers. (If only they were half as good at actually doing wellness…)
The Greatest Hits of the early days of wellness leading to this moment
We knew back in April 2013, that wellness was worthless. We used some simple arithmetic to point out that it would cost a million dollars to prevent a heart attack by screening the stuffing out of employees. It turned out our estimate was wrong — the real number appears to be infinity.
My only question is, why did it take eight years for everyone else to figure this out?
Happily there is one exception to this conclusion. Just like 1 in 1000 money managers consistently beat the market, the 1 in 1000 conventional wellness vendor is: US Preventive Medicine. Their favorable outcomes were achieved without biostatistical sleight-of-hand. Hence they are validated by the Validation institute. (This article concludes by showing how most vendors embrace biostatistical sleight-of-hand.) And yet even USPM doesn’t claim an ROI, so they aren’t validated for savings. Just outcomes.
Here was our first smackdown naming names, also in 2013. Two recurring themes revealed themselves. First, Mercer’s fingerprints were all over wellness as they are now all over Livongo (which pays them handsomely), thanks to their revenue model of collecting money from vendors as well as buyers.
Second, naturally the program in question won a Koop Award, bestowed annually by Ron Goetzel and his cronies upon the company that best demonstrates what happens to kids who cut math class to smoke in the boys’ room. Our observation on their arithmetic was:
You need not “challenge the data” to invalidate claims that wellness saves money. Instead, you can simply read the data as presented. You’ll find it usually invalidates itself.
Nowhere is that more true than in a study published this month by Mercer, Staywell and British Petroleum (“BP America”) in the Journal of Occupational and Environmental Medicine (JOEM). As we’ll demonstrate, the results completely contradict Staywell’s own statements, and are also mathematically impossible. Indeed, Mercer was a wise partner choice by BP America because their validations are often unconstrained by the limits of possibility.
I’ve occasionally worried that the Health Enhancement Research Organization (the wellness industry’s Ministry of Truth) might hire away a smart person from the PBM industry who could make their lies believable. So far, fortunately, they’ve resisted that temptation.
2014 brought our highest visibility article, when it was still news that wellness loses money. Health Affairs published our seminal Workplace Wellness Produces No Savings. This was picked up by Michael Hiltzik, the business columnist at the Los Angeles Times, who added that wellness is a “scam.”
And it got picked up by the New York Times‘ health economics bloggers, who added the observation that Mr. Goetzel’s analysis was “crap.” (Their word, not mine.) Their specific first paragraph leading into our analysis:
When Mr. Goetzel attempted to rebut our article, he interpreted that statement as these economists saying wellness “usually” doesn’t save money. Not sure where you get “usually doesn’t save money” out of the quotation above, but you know an industry is in trouble when its #1 promoter has to lie in its defense, but even the lie itself is quite unflattering.
The most comprehensive deconstruction was in July 2017, in Case Western Reserve’s Law-Medicine Journal, Health Matrix. It still ranks among their ten most popular articles of all time.
With 58 pages and 349 footnotes, it remains the go-to for health services researchers everywhere. If you can’t make the commitment to reading the entire thing, the executive summary says it all:
Wellness programs have conferred no measurable benefit on the American workforce.Further, vendors routinely disregard clinical guidelines that are designed to avoid overtreatment, inappropriate doctor visits, and increasingly ubiquitous crash-dieting contests. The economics follow the harms.
Essentially every dollar companies spend on vendor-administered workplace-wellness programs is lost. As a result, much of the wellness-vendor community has resorted to making demonstrably false claims about savings in order to maintain its revenue stream.
Why did wellness last so long?
As coincidence would have it, the Validation Institute wrote on that exact topic last month, explaining exactly how wellness, diabetes and other vendors fabricate their outcomes. It requires 7 installments to whack all of the moles, since while wellness and diabetes vendors may not know much about wellness and diabetes, they know a ton about fabricating outcomes.
They’ve figured out:
- their results should exclude low-risk (or low Hb a1c) members whose risk/scores increase
- participants will always outperform non-participants, “matched controls,” “propensity-scored matched controls” and basically every other passive cohort–especially if dropouts are ignored;
- drawing a line upwards (“trend inflation”) will give them the result they want by showing savings “vs. trend”
- no one actually ever reads these reports carefully to check their plausibility
- the highest ROI, for the vendor, is to bribe a consulting firm or journal to publish favorable results. Buyers will suspend disbelief when they see the words “actuaries” or “peer-reviewed”.
- they can inflate their own satisfaction scores by simply ignoring people who weren’t satisfied, instead of doing a real engagement survey, or simply citing Amazon. And no wonder — here are Livongo’s scores. (Livongo will no doubt swarm Amazon with five-star reviews once they realize other people are looking at these scores.)
The seventh installment covers how to put this all together into an RFP. Really there are two simple questions. You almost don’t need to ask any others. If it’s a carrier program:
“What is the penetration of this solution in your own insured (or in the case of large consulting firms, covered) population?”
If it’s vendor-direct:
“If we promote your solution to half our population and not the other half (which will have access, but not promotion), how much of your fees will you put at risk that the first half will outperform the second half in the key metrics you are addressing?”
In the case of the first, most programs offered by carriers to ASOs are not offered to fully insureds at all. In the case of the second, the answer is 100%.
So what to do instead of wellness?
It is possibly to achieve a much better result with much less effort and expense, simply by using Quizzify.
You saw Marshall take on surprise bills in our March webinar featuring Theresa Costa (and also Marty Makary and Leah Binder) … and it looks like we’re winning that one, though it’s still too early to declare victory.
Now, with open mikes, we’ll be featuring Marshall in our June 16th 1:00 PM webinar to talk about Never Pay the First Bill, certain to be the biggest healthcare bestseller since (and possibly including) Marty Makary’s The Price We Pay. (SPOILER ALERT: Both feature Quizzify, though you have to look pretty hard.)
His book is TheySaidWhat laid large. Turns out we’re not alone in the universe. Tons of abuse, he names names, and has been collecting these anecdotes for years.
Speaking of anecdotes, this book will feature plenty of them — all completely aligned with what we’ve been saying for years. But it’s one thing for us to point them out. It’s something else altogether to point out the same things in a (likely) bestselling book.
Dear TheySaidWhat Nation,
Exactly as we predicted, today EEOC just OK’ed modest incentives to get the COVID vaccine. Specific words:
“If employers set up a system in which they administer the vaccine themselves on a voluntary basis, businesses can also offer employees incentives — be they perks or penalties — so long as they are “not so substantial as to be coercive.”
A summary of the EEOC’s position on COVID and employment can be found here. https://bit.ly/3fYvmEq. They kinda “buried the lede” in that you have to scroll way down to find that quote.
Meanwhile, there is still no safe harbor, and won’t be, for substantial incentives and penalties for clinical wellness programs. To learn how to easily navigate this new EEOC normal, contact email@example.com. (Our shattered feelings will recover if you don’t reach out to us until Tuesday.)
Streaks are made to be broken, and Wellness360 looks ready to dethrone the three-time Deplorables Award winner, Wellsteps.
Their recent blog post was headlined on Linkedin: “Here are 6 simple, yet crucial corporate wellness challenges ideas for 2021.” I’m going to take a screenshot…
I clicked through to their blog post on the “6 simple, yet crucial wellness challenges ideas.” I have quoted excerpts here with no words changed, starting with the headline. Needless to say, these excerpts are generously annotated.
- Um, how many fingers do you have on each hand?
- That’s great for “working employees.” But what “challenges ideas” do you propose for non-working employees?
- I loves your grammar.
“According to a CDC report, even before the pandemic started, almost 80% of Americans were getting the recommended amount of physical activity for the week. With the current remote working situation, the little physical activity that came from the daily commute, walks and talks at the workplace, lunch breaks, and other workplace culture traditions have come to a halt.”
- So only 20% of Americans were out of shape before the pandemic?
- I hadn’t realized that talking and lunch breaks were such a major source of physical activity.
- “The little physical activity…have come to a halt?” Is that why we need “challenges ideas”?
“Commuting, roaming around the office and other physical activities at the workplace helped employees take at least some steps in the whole day. Without those daily activities, the physical activity count has fallen down the cliff.”
- Commuting is how I used to keep in shape too: steering, shifting gears, and yelling at the WHDH 850 Sportstalk guy.
- The syntactical activity count has fallen down the cliff as well.
- “Roaming around the office?” More on this later.
“Hold a Wellbeing Hydration Challenge. A male adult in the US must consume at least 15 cups of water daily, and a woman must drink a minimum of 11 cups. Many studies show that 75% of American adults suffer from chronic dehydration, causing headaches, nausea, fatigue, and lack of concentration, impacting employee health, productivity, and overall wellbeing.”
- Is the winner of the challenge the first person to die from overhydration?
- Can you cite one of these “many studies”?
- Will someone please give those 75% a drink of water?
- You were drinking this much water at work??? No wonder you needed to “roam around the office.”
“Employers can…also encourage sharing recipes for hydration like cinnamon water, green tea variants, and more to make sure they keep water healthily without…preservatives.”
- Will you please share your “recipe” for cinnamon water? I forgot what the ingredients are.
- I want to “keep my water healthily” but apparently the government is spiking our water with preservatives. Write your Congressman!
- Wouldn’t those “green tea variants” keep me up at night and wouldn’t those 15 cups of water wake me up once I finally got to sleep? Oh, wait, I forgot you also offer…
“Better Sleep Wellbeing Challenges. Lack of sleep can cause fatigue, disturb mood, affect decision-making skills, and loss of concentration…The wellness program administrators can assign better sleep wellness challenges in which employees have to track their sleep hours every day on the corporate wellness platform. Those who seem to have trouble sleeping well can be offered coaching or other supporting resources to improve their sleeping habits.”
- Being “assigned” to “have to track…sleep hours every day on the corporate wellness platform” sounds like a great way to relieve the stress that keeps me up at night.
- Wouldn’t the “coaching or other supporting resource” tell me to stop drinking so much water and green tea?
With this kind of advice, it’s lucky that their “sixth” recommendation is:
Tums asked: “Who says medicine has to taste bad to be good?”
Symms said: “At Symms, an educated consumer is our best customer.”
And Grey Poupon’s memorable: “Ah, the finer things in life. Happily some are affordable.”*
Our 1:00 PM May 12 webinar combines all three. https://bit.ly/3eOLhEC
Turns out that knowledge is more fun (Tums), and more effective (Symms) than cajoling, bribing or fining employes into eating more broccoli. It can also cost less per employee than a year’s supply of mustard. (If not, then close enough.)
So why not learn some easy behavior changes you didn’t already know? Last month you learned that preemies are predictable. The month before that you learned that cavities don’t have to be filled. Join us May 12 at 1:00 PM for more of the Greatest Hits of health literacy. https://bit.ly/3eOLhECAl Lewis
*Not to distract anyone from registering, but that clip above is the best mustard commercial, possibly the best commercial, of all time. https://www.youtube.com/watch?v=2JJbwlEySDM