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The following was proposed as a comment to my posting on the article The Outcomes, Economics and Ethics of the Workplace Wellness Industry. This response needs to be anonymous because the person who posted it actually works for a large employer and can’t represent the employer. I thought it was important enough to merit its own posting.
Very good summary of all the items you have “uncovered” from these vendors. I have worked 28 years in healthcare cost control and it’s unfortunate that most employers believe what someone else tells them (so you have the blind leading the blind). These points tell about the industry from your article and other items I have learned from you and my experience:
1) We all want to feel like there is an answer to cost control/help our employees and management looks to HR for the answers:
On its surface, who can argue with the concept of workplace wellness? How could there be anything wrong with corporations helping their employees reduce their risk of disease while saving money in the process?
2) As a culture, we have convinced ourselves “more is better”. So vendors have an easy sell—let’s do more testing, more HRAs, more surveys…because it will give better results.
(Al) See this article on the Arkansas state program. Wellness isn’t working so the state benefits director wants to do more of it. It’s not “robust enough” now, he says.
4) For years no new studies show savings that can be independently verified. You’ve pointed this out before and no vendor is willing to attempt to claim your $2-million reward. You also noted…For the last seven years, no peer-reviewed article in a major journal has found that wellness programs lead to substantial risk reduction.
(Al) If the situation were reversed — and I dare them — I would (under the same rules as my reward) claim it in a heartbeat.
5) No vendor ROI savings/metric methodology standard. Vendors don’t want to be held accountable and most employers don’t care/don’t understand or just want to put a program in place to feel good. Similar to your experiences with vendors, I have felt others view me as an obstructionist or negative because I ask too many questions or point out their program doesn’t/didn’t provide savings. Unfortunately, I don’t see the industry changing because wellness is an easy product to sell to employers that don’t ask hard questions. Maybe we’ll see some type of regulations to help in this area.
6) I hope the good vendors mentioned at the end of your article/Validation Institute members begin publishing their results that demonstrate an independent verified ROI that the industry will want to follow (become the standard). I would suggest you explore more discussion on these vendors so employers might look to them for help.
(Al) Will do, though my positive postings don’t get remotely as many hits as my exposes. Also one reason they get validated is they don’t fabricate ROIs.
Al, I appreciate your insight and oversight in this industry. Thanks for sharing your time and expertise.
Workplace “pry, poke and prod” programs are like pennies, Communism, baseball and Microsoft Outlook, in the sense that if they didn’t already exist, nobody would invent them.
This observation does not apply to workplace screening according to actual clinical guidelines, and next-generation programs like the Wellness 401W Savings Plan, which are good ideas that should get traction. It doesn’t apply to wellness done for employees instead of to them. It doesn’t apply to the Sterlings, It Starts with Me’s, USPMs, ImpactHealths, Redbricks, and Limeades of the world, who are doing the right things. (If you think I am leaving anyone out, let me know!) And of course it doesn’t apply to health literacy, a la Quizzify. There is no argument in favor of ignorance.
There is no better evidence for this observation than the current issue of the Case Western Reserve Law-Medicine Journal, which devotes almost its entire current issue to the problems with these first-generation wellness programs.
The lead article, “The Outcomes, Economics and Ethics of the Workplace Wellness Industry,” shows how vendors cover up their losses and harms to employees with lies that would make a White House press secretary blush. When they get caught blatantly lying and harming employees (and kudos to Sharon Begley for her expose on Wellsteps), they simply give each other awards. To paraphrase the immortal words of the great philosopher Ryan O’Neal, being a Koop Award winner means never having to say you’re sorry.
Next up is The Incidental Economist (TIE) team, weighing in on the “Dubious Empirical and Legal Foundations of Wellness Programs.” Kudos to TIE for outing this scam (the LA Times’ word, not mine) years ago. I did too, but the difference is that they have “day jobs” dissecting all the other frauds in healthcare, whereas I have altogether too much free time on my hands.
Samuel Bagenstos then piles on with “growing…evidence that reliance on workplace wellness to reduce disease is bad and likely futile health policy,” before deconstructing the questionable legality of these programs, featuring a definition of “voluntary wellness programs” that would make George Orwell blush.
Next up is Leah Fowler, pointing out that one reason wellness programs fail is they assume you can basically “give [employees] the opportunity” to lose weight, and they will. Fowler and her co-author Jessica Roberts point out that social determinants of health rather than employee indifference are vastly disproportionately the cause of poor health. “Nudges” won’t help. The evidence overwhelmingly supports their thesis. (And kudos to our own Tom Emerick for being first out of the box with this insight.)
Finally, Penn State’s resident health policy experts, Professors Scanlon and Shea, review the debacle of Penn State’s own wellness program and the (many) lessons that can be learned from it. The combination of their policy expertise and having been in the belly of the beast makes for a compelling read.
The bottom line? Wellness in its current form is such a sham (Slate’s word, not mine) that I can offer a $2-million reward for showing it works, knowing my money is safe from the Wellness Ignorati, who for all their bluster apparently either know their programs fail, or don’t have any use for $2-million. (They hate me so much you’d think that even if they didn’t need the money, they’d claim the reward just to keep me from having it instead.)
It’s up to us to create a next-generation offering that benefits employees, and that they like. I see some good things out there on the http://www.ethicalwellness.org website — Sterling Wellness, It Starts with Me, and many other vendors have endorsed it. (You know it’s a good start because none of the Wellness Ignorati want anything to do with it.)
Employers are very fortunate that so many wellness vendors cover so many market niches, to satisfy an employer’s every need. Want to harm your employees? Wellsteps has you covered. If insurance fraud is your thing, there’s Healthfairs USA. Suppose you really have it in for the US Preventive Services Task Force, maybe because you have a repressed childhood memory of being bitten by one of its members. As the leader in flouting USPSTF guidelines, Total Wellness can bite them back.
And, if you prefer a vendor that does nothing, Health Fitness Corporation (HFC) fits the bill:
- They won a Koop award in 2011 for saving massive amounts of money on a program (Eastman Chemical) that by their own admission didn’t exist.
- They won another Koop award for saving the lives of 514 Nebraska state employee cancer victims. Except that it turned out these employees didn’t have cancer.
Yes, when it comes to invalidating their results for doing nothing, HFC is truly a target-rich environment. HFC’s latest? They “saved” $586 per employee on a weight-loss program.
By now you’ve probably guessed that — by their own admission — in this successful weight loss program, these employees didn’t lose weight.
As befits a company that previously didn’t actually run a program but still saved money, and that didn’t actually treat cancer victims who didn’t have cancer but still claimed to save their lives — these employees actually gained 4 ounces. According to HFC, though, they would have gained 13 ounces had it not been for HFC’s Herculean efforts.
The amount employees did not gain? 9 ounces. Saving $586/employee for not gaining 9 ounces works out to $1041/pound of of savings for employee weight not gained. Extrapolating from that result, employees would have to not gain only about five or six pounds to completely wipe out healthcare spending.
This is where the magic happens…
To what does HFC attribute this incredible performance? I’ll let them put it in their own words. And these are definitely their own words. Trust me when I say no one is going to accuse them of plagiarizing these words:
More than half (58.5%) of participants that self-enrolled in the program never completed a coaching session, compared by 18.6% in the group enrolled by a health coach completing no coaching sessions.
English, of course, is one of the five things wellness vendors know the least about. (The other four are arithmetic, data, facts — and, of course, wellness.) So let me translate that into English for you: the majority of self-enrolled “participants” didn’t actually participate. To summarize, most self-enrolled employees didn’t actually participate in a program in which most participants didn’t actually lose weight.
Well, hey, at least they didn’t violate USPSTF guidelines, commit insurance fraud or harm these employees. That’s something, right? And therein lies HFC’s market niche, a positioning inspired by the immortal words of the great philosopher George Costanza: “Everyone else is doing something. We’ll do nothing.”
Wrapping up some old business…
A couple of Saturdays ago, I raised some money for folks with MS — like our colleague, Jon Robison — by climbing to the top of the Hancock Building, the tallest building in New England. This year I clocked in at 13:56, putting me in the top quartile and shaving almost 3 minutes off last year’s 17:15. You may have noticed that 13:56 is more than 3 minutes faster than 17:15, not “almost” 3 minutes faster. Before you attempt to claim your $1000 for spotting my first-ever material error, there was one fewer floor this year, which reduced average times by about 23 seconds.
Age-wise, I kicked some serious thigh.
13:56 earned me the runner-up spot in the 60-and-over cohort, among people from Massachusetts. (A small number of committed souls travel around the country doing these things. Two of them beat me as well.) Second is huge for me — the closest I’ve ever come to winning any contest that didn’t involve knowing massive amounts of useless trivia. Helps that stair-climbing doesn’t require coordination, speed or athletic ability of any kind. Just, as luck would have it, wellness.
Speaking of “closest,” congratulations to Bill McPeck, who came the closest to guessing my time, at 16:45.
And special thanks to Barry Zajac, Fred Seelig and Mitch Collins, who along with an anonymous donor, helped me approach my fundraising goal. (Anyone care to put me over the top?)
Wellness vendors were into alternative facts before alternative facts were cool. They even expanded the domain to include alternative math, like Wellsteps showing that costs had increased and decreased at the same time.
Is Optum (United Healthcare) going a step further, into alternative ethics? Here are two Optum claims, which appear to be exactly the opposite of each other. Now, we aren’t going to call anyone an alternative fact-er, but we would invite them to explain — and we’ll provide equal time — how both these seemingly incompatible statements can be true.
First, the head of their wellness group, Seth Serxner, acknowledged that biometric screening is supposed to be done in accordance with guidelines. (The guidelines are reproduced below, by the way, since he seems to have trouble remembering them when he’s approving marketing materials.)
He insisted, on tape, that the only reason Optum flouts screening guidelines is because employers make them do it: “Many clients won’t let us [screen appropriately],” he said. The full tape can be downloaded from that link, but it is tough to find the audio. (The time stamps appear to vary by download. However, it is towards the end and you can manually sync by following The Great Debate in total, which starts here.)
So, on Seth’s planet, Optum begs employers to pay them less money by screening their employees at longer, more appropriate, age-adjusted intervals…and employers refuse.
However, it appears, based on the marketing material below, that the reason employers refuse to let Optum screen appropriately is that Optum requires employers to screen inappropriately. You read that right: “participation in our wellness program…is a requirement.” And that decidedly includes screening…which employers must pay extra for in order to get the “savings” on their premium.
They then go on to quote — you guessed it — Kate Baicker’s 7-year-old study based on alternative data that even she appears not to believe any more. The second alternative quote is attributed to WELCOA, a quote which WELCOA’s CEO, Ryan Picarella, assures me he never made, nor did anyone currently in his organization, and that he doesn’t believe.
Update: It was observed on Linkedin that the reason they do this (for their fully insured business) could be as an ACA play. You don’t mind if spending on claims increases because you need to get to 80% (or 85%, depending on size) loss ratio anyway. The screening isn’t counted towards the 85% because it’s not a claim, so you make money there too by charging separately. Brilliant! United Healthcare’s shareholders should be very impressed.
Here are the USPSTF guidelines, by the way, also reproduced below, albeit badly. (There is nothing wrong with your TV set. Do not attempt to adjust the picture.) This is actually the version published by “Choosing Wisely” (a joint project of Consumer Reports and the Society of General Internal Medicine), and they don’t totally sync with USPSTF, but whatever the minor differences are, neither looks anything like what Optum and their alternative friends advocate.
Rumor has it that within the next couple of days Health Affairs is going to release a paper in which Ron Goetzel admits that — even with his finger on the scale as it always is (along with the other nine and all his toes) — wellness loses money. This is total vindication for the years in which he has preferred to simply fabricate large savings, based on trivial risk impact, and then accuse me of “outrageous inaccuracies” and other such fanciful tales for observing — accurately, as it turns out — that all his savings are made up.
Yes, I know I’ve said he has admitted wellness loses money several times before, like in his HERO Guidebook, or in STATNews, or in the Chicago Tribune. But those were all gaffes. (A gaffe is defined as “accidentally telling the truth.”) The difference is, this time it’s deliberate.
And, no, he hasn’t sworn off lying. Lying is a thing these days. He was way ahead of the curve on that. Mind you, I have not seen the article, and I wasn’t allowed to peer review it. (Health Affairs allows authors to rule out certain peer reviewers, so he ruled me out — despite admitting not too long ago that I am the best peer reviewer in the field.) However, I anticipated that, given his level of integrity, he would use the completely invalid participants-vs-non-participants methodology, and so I invalidated it for him ahead of time, not that he didn’t already know.
Despite admitting losses, he still holds to the fiction that somehow risk factors decline, a claim which I intend to examine once I see the article. I suspect he didn’t plausibility-test the outcomes (even though his HERO guidebook says to do that) and/or he didn’t count dropouts and non-participants. But we’ll know soon enough.
However, by admitting wellness loses money even if risk factors improve, he just invalidated every single Koop Award he has ever bestowed on any of his buddies. The reason is that in those award-winning situations, risk factors either only improve a trifle (Staywell, 2014 and Nebraska, 2012), don’t decline at all (McKesson, 2015), or increase (Wellsteps and Boise, 2016). None of these non-improvements acknowledges dropouts, of course.
PS Remember my $2-million reward for showing wellness saves money? Let’s make it $3-million.
If instead of randomized control trials, the FDA simply allowed drug companies to compare the results of people who conscientiously used a drug to people who couldn’t be bothered, they could save a ton of money.
Not that I want to put ideas in their head.
But they don’t allow that, for the simple reason that active motivated people will always outperform inactive unmotivated people. Absent equal intent-to-treat — meaning comparing people actually taking the drug to people who think they are actually taking the drug — you can’t distinguish the effect of motivation from the effect of the drug.
As true as that is in drug research, it is even more true in activities, such as wellness, where motivation is paramount. And yet the standard study design –participants vs. non-participants — compares all the motivated people to all the unmotivated people.
Sure, the Wellness Ignorati will claim the groups are “matched,” and on paper maybe their demographics are the same…but you can’t “match” the state of mind between participants and non-participants, as the Ignorati well know.
This American Journal of Managed Care essay, a more formal albeit less colorful version of an earlier TSW smackdown, means that quite literally every study done using this participants-vs-non-participants design is either largely or entirely invalid.
In keeping with my New Years resolution to be more positive (and not like: “I’m positive that the board of HERO knows they are liars” — which, by the way, I am, and which they are, and which will be the subject of a future posting), I would like to recommend an outstanding posting by Romy Antoine on Linkedin. No, I didn’t know who he was either…but I do now, and you should too. He exemplifies the next generation of talent in this field.
He lists 10 reasons employees hate “pry, poke and prod” wellness programs. (Just in case you are keeping score at home, zero of those reasons would apply to Quizzify — and that’s not an accident.) I found myself nodding at every single one. You may be able to address some of these, but if there is one thing that Ron Goetzel and I agree on besides the sun rising in the east, it’s that wellness is, to use his words from our debate, very very hard to do right, which is why, to use his words again, thousands of programs fail while only 100 succeed.
Oh, and here is a reason employees might not hate your wellness program: according to Employee Benefit News: they don’t know it exists.
80% said their wellness program has had a positive effect on employee health and productivity and 70% said it has had a positive effect on health care costs. However, the data released by the Transamerica Center for Health Studies also showed a significant number of employees did not know their company had a wellness program.
Yes, I know it isn’t always about me (my first wife was quite clear on that point), and, yes, I know it isn’t always about Quizzify, but Quizzify can customize questions to educate your employees on your wellness offerings, so at least they’ll know your program exists. And hopefully they won’t hate it when they do.