They Said What?

Home » Uncategorized

Category Archives: Uncategorized

“Keep blaming the dog” — latest podcast on health literacy

Video link here

From Matt Jeffs:

In his third and final at-bat in this series, author / humorist / CEO provocateur Al Lewis hits one out of the park with the bases loaded. The Co-Founder and CEO of Quizzify, Al returns to remind us that employee health literacy can be delivered in delightfully humorous, trivia-style quizzes to simplify complex topics and help employees stay engaged in – and committed to – their own health and well-being.

This time, we cover:

  1. Why is health literacy so vitally important to employees?
  2. How reliable are some online health sources?
  3. What’s a good rule-of-thumb for health check-up frequency?
  4. Why is humor so crucial to retaining health information?
  5. Why is trivia so engaging when delivering health information?
  6. How is all this beneficial to employers?

Tune in here to learn even more from this funny, distinguished and principled healthcare thought-leader. You’ll find it engaging and inspirational. Listen. Learn more at

Enjoy. Subscribe. Click for notifications. Share with colleagues, friends and associates. And learn more about learning more at .

PS Worth tuning in just to see where the title comes from. Believe it or not, an important health literacy topic.

You can sue me, but I won’t be settling.

Ok, I don’t usually use this blog to write about myself because other folks make much better copy. However, this is a great interview. I hope you have as much fun reading it as I did doing it.

When you present at a conference exposing the inadequacies of “Disease Management” and then the industry begins to crumble, you might be a person whose opinion should be heard. Such is the perceived power of Al Lewis, who formerly taught economics at Harvard and ran Peer Review Analysis, a NASDAQ health care company, a man widely credited with inventing disease management, although he’s quick to say he didn’t. A more accurate description these days might be “Bouncer,” standing guard at the gate to discourage bad behavior.

Al has made a reputation for himself, especially on LinkedIn, promoting corporate wellness vendors whose methods have been validated, and calling out those who do not measure up to the standard. If you are on his naughty list, be warned. “I call out those who are lying through their teeth,” Al says.

Indeed, even the most cursory review of Al’s LinkedIn activity reveals his fearless cross-examination of people and companies who regurgitate bad data or make wellness promises they can’t keep. And he often does it by name, tagging the companies he is calling out.

“Aren’t you afraid of getting sued?” I asked him.

“Make my day,” he says. “Sue me, but I won’t be settling. And I’ll be blogging about it the whole time.”

You can read the rest of the interview here.

Virgin Pulse has the best health risk assessment

Remember when the sergeant asked for a volunteer to step forward and Moe and Larry took a step back?

Image result for three stooges in the army

Looks like Virgin Pulse has won the best-HRA contest the same way. Yes, it is a complete waste of employee time and employer money. In HRAs, that’s table stakes. It earns a solid “C” not because anyone will learn anything of any value, but rather because the other two are worse. The VP HRA offers so little advice that none of it is really bad. It that sense it is better than Cerner’s (“F”) and Optum’s (F+).

Here’s what Virgin Pulse’s HRA gets points for not doing:

Tell employees to eat nonfat yogurt that is full of sugar (like Cerner):

Imply that employees on opioids should get more opioids (like Optum)

Advise employees against using olive oil (like Optum)

Further, it is actually coherent, instead of containing questions like… (Optum again)

…in which both non-asthmatics and completely uncontrolled asthmatics would give you the same answer.

Virgin Pulse’s “advice”

“Eat a healthy breakfast.” Who can argue with that? It’s like a manager advising the batter to hit a home run. Obviously the key is in the execution, and naturally Virgin Pulse provides none. In that sense, it is the best HRA because the others give such bad advice.

What constitutes a healthy breakfast? Can’t be just any old cereal. Those are full of sugar. Ah, maybe something like Kellogg’s Smart Start with Antioxidants, which is “heart-healthy.”

Image result for kellogg's smart start antioxidants cereal

Oops. That’s on Eat This Not That’s “worst healthy cereals” list.  Because it is — you guessed it — full of “heart-healthy” sugar.

Kellogg’s Special K Protein Snack Bars? 10 grams of added sugar apiece (and you’d likely eat 2–they’re small) with six different sugars dispersed throughout the ingredients label.

Eggs?  For most people, eggs are a healthier choice than most packaged cereals. Of course, there are exceptions — a bit less than 1% of the population is genetically predisposed to high cholesterol. But wellness vendors would lose money if they actually spent the time to address these nuances. Of course, in this case, the “nuance” is that familial hypercholesterolemia (FH) is a much better predictor of cardiac events than anything in any HRA. As in about 40% of everyone with untreated FH will infarct before age 60.

Oatmeal?  Probably the greatest consensus around that. (And that’s the breakfast of choice here at TheySaidWhat? World Headquarters.) Yet plenty of cereal companies, and fast food chains, have turned oatmeal into junk food. Dunkin’s “Brown Sugar Flavored Oatmeal” packs in 28 grams of sugar (none of which is actual brown sugar, as luck would have it).

Orange juice? That counts as a serving of a fruit according to the American Heart Association (AHA) and Virgin Pulse is a big one for telling you to eat up to 11 servings of fruits and vegetables a day, with “1/4 cup” of juice counting as a serving. Using the AHA math, an 8-ounce glass of juice would appear to get you 4/11ths of the way there.

And ads for “healthy” cereal sometimes show a glass of orange juice on the side:

Image result for cereal ads in magazines orange juice

On the other hand, NPR and Consumer Reports advise against considering juice as a healthy alternative. The sugar is “natural,” but there is an awful lot of it. (I myself am not a nutritionist, and don’t even play one on TV, so I don’t have an opinion on whether natural sugar is OK and added sugar isn’t. Except I would point out that grape juice contains natural sugar while grape juice concentrate is an added sugar. Both can’t be right.)

So which is it? Drink more juice, or don’t? Which constitutes “eating a healthy breakfast” ? I don’t know and I suspect neither does Virgin Pulse. The difference, of course, is that TSW isn’t charging lots of money to give employees advice.

Completing the Virgin Pulse HRA 

Obviously, employees are going to lie on HRAs, and Virgin Pulse’s is no exception. I was invited to watch a group of employees completing theirs, For each answer, they gamed the system. What is the optimal amount of stress to claim? Too much might harm their career. Too little and someone might give them more work.

How much should they claim to drink?  “Not at all” might cause their (well-known!) employer to think they’re lying, so they all decided to cut their true totals in half.

Servings of fruits and vegetables? Most of them just made up a number that would sound good to an employer.

Everyone seems to know employees lie on HRAs (including, of course, Virgin Pulse) except the employers that still use them, whose quest to create a culture of health ends up creating a culture of deceit. No need to take my word for this. Simply complete this chart to see what percentage of your employees with something to lie about are indeed lying — and what the odds are that an employee with something to hide will tell the truth about it:

Let’s try completing this chart, using the most recent winner of the C. Everett Koop Award, Wellsteps.

Result: in the so-called best wellness program, almost 2/3 of employees lie, though in all fairness to Wellsteps, some of those could be the same employee lying twice. And extrapolating from Wellsteps’ result, the odds of an employee coming clean about a bad health habit are about 1-in-4. That’s the average of smoking and drinking. Generally the more socially acceptable habits will show a higher percentage of employees telling the truth.

Keep in mind, too, that there is another way to lie on HRAs, which is understatement. You may recall from Wellsteps that the 23% who drink only imbibe 1.3 drinks a day, while 3% who do admit to smoking indulge in cigarettes only 4.27 times a week, perhaps taking a break on weekends and major holidays, such as Beethoven’s Birthday.

Image result for beethoven's birthday

Due to the lying and uselessness, should employers drop HRAs altogether?

In the immortal word of the great philosopher Curly Howard, soitenly.

Image result for curly howard



Wellness imitates Dilbert

Incredibly, events unfolded almost exactly this way at Penn State during their well-publicized wellness debacle 5 years ago.  It was even funnier in real life because while exercise does of course promote wellness, faculty and staff were very restricted in their use of campus recreational facilities. Making those free to employees and dependents was not part of their wellness initiative.

No, instead employees were being forced into an outcomes-based wellness program, one that was supposed to save “millions of dollars.”

Coincidentally, while the Penn State HR department — ably assisted by Ron Goetzel, who later denied having anything to do with them despite being in their press conference – was trying to force employees into these programs, the Penn State bakery announced an expanded selection of pastries and desserts for the upcoming semester.

Penn State’s was, to paraphrase the immortal words of the great philosophers Gilbert & Sullivan, the very model of a modern forced wellness program. Sure, they violated clinical guidelines. That seems to be the price of entry for wellness. More head-scratchingly, women had to disclose whether they intended to become pregnant, or else pay a $1200 fine. This requirement was so Highmark could – to use the Highmark representative’s own words in a rather contentious faculty meeting — “help” them. That would be like offering to “help” the proverbial little old lady cross the street — but if she declines assistance, saying: “OK, then pay me $1200. The choice is yours.”

(Full disclosure: Highmark has now abandoned their old outcomes-based wellness program in favor of a much lighter and more appropriate program, and we wish them the best at it.)

Back to the storyline…

There is something about forced outcomes-based wellness programs that brings out employers’ inner stupid, and Penn State was no exception.  Consider: almost by definition women who are planning to become pregnant have thought about it and have done the basic research. It’s the women who accidentally become pregnant who may possibly have the need for assistance. And even the dumbest HRA wouldn’t ask the question: “Are you going to accidentally become pregnant?”

So, using the very unlikely assumption that women completed the HRA honestly, Penn State’s forced disclosure requirement would have identified 100% of the people who did not need “help,” while missing 100% of the women who might.  If you’re keeping score at home, that’s 100% false positives and 100% false negatives. That’s a lot even by wellness industry standards. Eat your heart out, Interactive Health.

And did I miss the memo where carriers were anointed the prime providers of medical “help”?  Has anyone ever said to you: “You don’t look so good today. Better call your health plan”?

See for the back story.

Webinar on using the HCUP database

You probably have no idea what HCUP is.  But I can tell you it’s a great (free) tool for benchmarking vendor claims against reality.

If you want to know where I get the information needed to prove that wellness outcomes are made up and hence can offer a $3 million reward to anyone who can show I’m wrong, it’s here.

I will be giving a webinar on this topic Friday January 25th at 11 AM EST.  It will cover what HCUP is, how I’ve used it…and most importantly, how you can use it. We’ll do training with screenshares and lots of Q&A.

To sign up, click through here.  There is a brief registration form and then later today you’ll get the formal invitation with the dial-in information.





Time to vote for the best comment on employee health literacy in Martha’s Vineyard contest

Dear TheySaidWhat Nation,

OK, so you didn’t win a Quizzify health-and-wellness trivia contest in 2018, so you aren’t going to be vacationing on Martha’s Vineyard this summer (at least, not on my nickel).

However, you can still vote on other people’s comments on the importance of employee health literacy and help one of them win the trip. Comments to their comments earn 3 points and likes to their comments earn one point.

Here are some samples:

As a physician, myself, I believe patients would be astounded how many decisions most doctors make based upon their own experience (aka anecdote) rather than controlled, well-designed scientific study. Worse yet, a health illiterate consumer risks their own life like the 51 year-old man in the 2017 article, “When Evidence Says No, But Doctors Say Yes” by writer David Epstein. In smaller but daily health interactions, patients abdicate important decisions about the medications and treatments they choose without understanding ‘number needed to treat’ vs. ‘number needed to harm’ statistics.

I understand how uncomfortable it can be to be a skeptical consumer especially when there is a large asymmetry in the level of knowledge between the provider and patient.  Personally, I spend more time teaching my patients about their conditions than operating on them and additionally  I applaud any and all efforts that individuals, employers, and third parties take to educate themselves in my domain.   I propose that there is no fix, there is no marketplace, there is no way to sustainably reduce cost and improve care until utilizers of healthcare take ownership of their own health and health literacy.

An educated patient, able to participate in decision making, is leading to cost reduction in medical service , to a more efficient  and sustainable healing act for the patients.

Several sound more like me than I do:

I am going to answer from a personal, not professional perspective. Growing up, my family and myself worked for doctors and hospitals, but were not trained medical professionals. With that background, I learned that most people took medical professionals at face value, giving them Total Control over health care decisions, rarely if ever questioning whether they needed a test, surgery, medicine, etc. Thankfully, my perspective was that they were people just like us with faults, and mistakes. I never learned to take at face value and have questioned these professionals at every opportunity. Unfortunately, I think I am the exception, not the rule.

Only by educating people on the ability to question, challenge, ask for another opinion, can we hope to change the direction of health care, and put the patient at the forefront. with the advent of HSA’s and HDHP’s we are asking patients to make critical care decisions, without the tools to do so.


Imagine being dropped in a foreign country with no fluency in the language, culture, or environment around you. And your very livelihood depends on how you navigate. This is what millions of Americans are faced with when stepping foot inside the healthcare system. They start with little to no knowledge on what just might be one of the costliest trips of their lifetime. That’s why proactive employee education – literacy – is a key fix. We (advisors and employers) must empower employees for the trip so they don’t get lost; physically or financially. The reality is that care providers are relied upon almost entirely for the journey. That solely makes the provider and the patient vulnerable to the abuses of unnecessary diagnoses, treatments and costs. To improve employees’ knowledge of how to use healthcare while also how to avoid having to use it by being healthier is to make them fluent. That will be an integral part of solving the problems that plague American healthcare.

One contestant is even tugging at the heartstrings of potential voters by adding a picture of his dog. I don’t know which I am more impressed by: his campaign strategy or his knowing how to add a picture to a linkedin comment:

While healthcare can be frustrating and slow to change, there is hope. Health literacy, especially with Quizzify, is fun, awesome, something we all need regular doses of.  Puppies are great too. Puppies and health literacy, both apolitical but totally cool. This is Musti (MOO-sti. It means “blacky” in Finnish).

Many share personal perspectives as well as professional ones:

Does Health Literacy Matter?  To me it does. I find that as a health insurance broker and as an advocate of my own family it is just as important to understand basic information as it is to find a way to implement this knowledge.  As a health insurance broker, I find myself hearing from mothers and caretakers stating that they find themselves at doctor’s offices making life changing decisions for their family in a split second with little to no time to research.  Most consumers value and lean on healthcare providers to have the most up to date resources at hand and it has been shown in study after study that lack of health literacy results in poor health outcomes for patients and a source of shame and confusion for their caregiver.

Once again, to vote, read the article and look for the brief essays (comments) that you like, and re-comment or share or like.

Interactive Health breaks its own record for stupidity

In the wellness industry, 2018 is ending just like it began: Vendors Behaving Stupidly.

Along with about 12 other need-a-lifers, we traditionally attend a “Nerd-a-Thon” on New Years Eve (tonight), where we play board games, including home Jeopardy. One Jeopardy answer might be:

A: “Roughly 3 seconds.”

The correction question would be:

Q: “What is the length of time required for a beam of light leaving intelligence to reach Interactive Health?”

Yes, Interactive Health is ending the year just as they began it, by setting new standards for cluelessness. They started the year by offering unsuspecting and no doubt somewhat befuddled employees a “smoking recession program,” and are ending it by proving that their 2017 and 2018 Deplorables Awards were well-earned.

Here is their posting:

Let’s look at it carefully. They crammed four mistakes/fallacies, plus a unique hashtag (#HealthareCosts) into two lines. First, anemia is not “33% more likely” among women under 45. To the contrary, if they had wanted to step out of character and make an actual true statement, it would have been pretty much the opposite: “Women 15 to 40 are 26% less likely to be anemic than women 40 to 69.”

Perhaps this information will come as much of a surprise to them as it did to me — the difference of course being that I didn’t just post the opposite to 12,162 chronically misinformed followers.

There is an asterisk in case anyone is keeping score at home — pregnant women of any age are at higher risk for anemia. That is the most clinically significant factoid about anemia in the working-age population, a factoid which naturally Interactive Health overlooked. One of their specialties is finding issues that don’t exist while overlooking issues that do. Another one of their specialties is posting random statistics on Linkedin that even a college intern could debunk.  Or hyperventilating that the number of cases of Alzheimer’s is expected to double by 2060 without mentioning that the senior population as a whole is expected to double by that year as well. They also claimed that there was a dramatic increase in heart attacks, but in reality the actual rate is about half what it was 40 years ago.

Another possibility is that this anemia data isn’t a surprise at all to them. They are aware of it (it is pretty easy to come by), but telling the truth would have undermined their new revenue enhancement strategy, which is to convince companies to screen the stuffing out of millennials, by “debunking” the “commonly held misperception” that you should adhere to well-resesarched, widely accepted, official US Preventive Services Task Force (USPSTF) clinical guidelines, guidelines which say, unsurprisingly, that you should definitely not screen the stuffing out of millennials.

Second, it doesn’t cost $10,000/year to treat iron-deficiency anemia. It costs about 5-10 cents a day, or $36.50 a year. So Interactive Health is off by a factor of 300. That’s a lot even for them.

Oh, wait, maybe they were talking about hospitalizations for anemia, not garden-variety anemia. Hospitalizations would cost $10,000 or more. However, in the immortal word of the great philosopher Rick Perry, Oops. Looks like young women have far fewer hospitalizations than older women:

Previewing IMG_0099.jpeg

To help Interactive Health interpret this data since apparently they could use some assistance, 32.1 admissions per 100,000 women 18 to 44 means 0.3 admissions per 1000 female employees in that age bracket.

In other words, nobody.  The average company with 20,000 to 40,000 total employees of normal age and gender distribution would probably have 1 admission for anemia.

And we would bet that whoever is hospitalized for anemia already knew they had anemia before Interactive Health started harassing them. My guess is most of these admission longshots would be either complications of pregnancy or anemia of unknown origin, or a rare disease.

Third — no surprise given that statistic — the USPSTF does not recommend lining up women to be screened for iron-deficiency anemia. (Even for pregnant women, who are at much higher risk than non-pregnant women, they find insufficient evidence to screen them.)   “Hunting for disease,” which my colleague Alan Cassels has written extensively about, is rarely a good idea, and this is no exception — which is one reason it isn’t recommended.

Finally, why screen for something that you can’t easily address if someone fails the screen? The other reason it isn’t recommended is that iron supplements for women who are technically anemic but have no symptoms also aren’t a good idea.  Liquid iron, like this…

…can, among its many other charming attributes, blacken your teeth. (The good news is that, as the label says, this supplement is gluten-free!) Iron supplementation in general can cause side effects like nausea, vomiting, and diarrhea, while high doses are so downright dangerous that iron pill overdoses are the #2 reason for emergency room visits among all vitamin and mineral supplements.

The good news is, here is another Jeopardy A&Q:

A: “High.”

Q: “What is the likelihood that in 2019 Congress is going to pass a law preventing vendors from penalizing employees who refuse to participate in non-USPSTF-recommended wellness screens like Interactive Health’s?”


%d bloggers like this: