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I would invite everyone to join tomorrow (Tuesday’s) webinar by Ron Goetzel. He will be attempting to undermine the National Bureau of Economic Research’s (NBER) outstanding University of Illinois study, which showed — surprise — that conventional wellness programs don’t come close to changing behavior, let alone saving money. I would love to attend, but I, of course, am not invited to his events any more than he is invited to mine. Oh, wait a sec, I invite him to all my events and alert him to all my postings on linkedin so that he can correct any errors I’ve made. Sorry, my memory failed me there for a second.
Speaking of failed memories, he is being joined on this webinar by Jessica Grossmeier. If that name rings a bill, it’s because she claimed her company, Staywell, saved $17,000 per risk factor reduced — about $3000/pound shed — for British Petroleum, having forgotten that she herself claimed it is only possible to save $105/avoided risk factor. See “British Petroleum Wellness Program is Spewing Invalidity.”
Despite this being the Gold Standard of randomized control trials, he will be accusing the NBER of many errors. (A cynic might note that being accused of making errors in a wellness study by Ron Goetzel is like being accused of cheating on your taxes by Paul Manafort. ) He will argue that:
- The study only covered the first year — he won’t mention that the authors also said the first year suggests nothing “is trending towards savings” in future years either;
- The study contradicts — you guessed it — Kate Baicker’s infamous 3.27-to-1 ROI, without mentioning that the NBER’s principal investigator, as coincidence would have it, reports to Kate Baicker, so it’s pretty unlikely he would diss her unless the data left him no choice;
- The study contradicts all the other findings out there — except for all the other studies testing the par-vs-non-par study design against a benchmark, all of which showed results quite literally identical to the University of Illinois result, in that the wellness program accomplished zero;*
- The participants outperformed the non-participants;
- They haven’t reported on the screening yet;
- It wasn’t a good program. To hear Ron tell it (literally hear him tell it — you can listen to the tape), anytime a program fails, it’s because it wasn’t done correctly. “100 employers [have] programs with really smart ingredients…but thousands of others still don’t do wellness right,” are his exact words in print. He is refusing to name any of them, other than the old Johnson & Johnson analysis. (J&J is a wellness vendor. Investigator bias, anyone?)
What else will he argue? Tough to say. One thing for certain: he won’t mention my name — any more than Bravo did when they wrongly predicted that the EEOC rules would be replaced in January while I predicted the opposite. Instead he uses a new vernacular for my postings: “Industry chatter.”
He probably picked up this idea from Bravo, which uses the phrase “industry noise” to describe me.
Where’s Waldo-meets-Ron Goetzel: Spot the errors and you may win a big prize
So let’s make this interesting. Whoever comes up with the best smackdown of the webinar’s obvious fallacies (and omissions) automatically gets entered in the contest to win the Martha’s Vineyard vacation, with the house, car and private (well, semi-private) beach. It is otherwise open only to people who have won various Quizzify trivia contests, but being able to identify five or ten pieces of “chatter” or “noise” in this self-anointed “expert webinar” clearly counts as being health-literate. To compete, send me an email with an attachment. I’ll pick a couple of finalists and put them on linkedin. (If you don’t want your name used — and Ron does bite back, so I don’t blame you — I will post on my own.)
*The result is also quite consistent with Ron’s observation that there is basically no change in behavior leading to risk reduction. If we are splitting hairs here, Ron found a 1-2% reduction, not 0%. Of course, that took three years.
Even by wellness industry standards, Provant Health’s business practices earned it our first multi-part series. It required nine parts to do them justice…
And now they are bankrupt too. Their remaining assets are being purchased by Quest Diagnostics, a reference lab company no doubt hoping to run additional lab tests on Provant’s dwindling employee base.
We knew this was coming because they had already started cutting back on spending, by dropping their internet connection, and hence didn’t realize that employees are not supposed to drink 8 glasses of water a day.
Here is a real-life example of what an employer can expect to achieve by spending a million bucks on these very stable geniuses:
BMI and glucose got worse. Somehow, blood pressure stayed the same — 120 over 75. Yes, despite the average employee being almost prediabetic, and sporting a 40-inch waist for males (and close to that for females), pretty much everyone in this company has ideal blood pressure. One explanation for this would be that Provant, whatever their shortcomings in weight control, are the world’s leading experts in all things cardio. (And that’s even before they started — when everyone in this company already had ideal blood pressure.)
That expertise might also explain how they were able to keep the cardiac ratio so low. An alternative explanation might be that there is no such thing as a “cardiac ratio.” (Google it.) I’ve heard of wellness vendors making up data, but this is a first–making up an entire metric to present its made-up data. Maybe the reason Quest Diagnostics purchased them was to develop a new lab test for cardiac ratios.
The good news is that, despite these underwhelming results, Provant was able to beat its targets, which is easy enough if you move the goalposts to the 50 yard line:
So much winning! Provant “wins” if the average employee is overweight but not quite obese yet, has glucose only 74 points higher than the threshold to be considered diabetic, and is only borderline hypertensive. No target is set for the cardiac ratio, of course, because it doesn’t exist.
In that sense the cardiac ratio is not unlike Provant itself.
I have several new posts ready to go — the usual suspects acting out in their usual hilarious fashion — but this is a serious post.
It is time for wellness vendors to stop harassing employees about their weight.
A new article summarizing the voluminous data on the futility and harms of weight-shaming just appeared. It doesn’t contain new data, but rather presents the existing evidence in a clear and compelling format.
This article finds fault in the physician community, but the wellness industry (the outcomes-based companies and their enablers at the Health Enhancement Research Organization (and their enabler-in-chief, Ron Goetzel) is even worse because they tie money to weight loss. They give employees a financial reason to binge before the first weigh-in and then dehydrate themselves and crash-diet before the last one.
This does nobody any good, except of course the outcomes-based wellness vendors — like Interactive Health, Wellsteps, Wellness Corporate Solutions, Staywell, Bravo, Total Wellness, Star Wellness, Health Fitness Corporation and probably a host of others. And there is a special dishonorable mention for HealthyWage, whose entire business model is corporate crash-dieting contests.
They aren’t going to agree to stop on their own, any more than Monsanto stopped making DDT on its own volition. They need to have it made clear that this behavior won’t be tolerated any more.
A starting point is this linkedin post. Like it, comment on it, share it. Once we get to 100 likes and comments, and we’re already more than halfway, I can probably generate media attention.
Is your wellness vendor snookering you? There are certain facts that vendors are not exactly forthcoming about. This is because facts represent an existential threat to the “pry, poke and prod” industry. See how many facts you know — and how many they’ve suppressed — by taking this quiz.
You’ll earn more points, the closer you are. You don’t have to be exact — and honestly I’d worry about you if you got the exact answers to every question. I’d love you for it, but I’d still worry about you.
- Wellness vendors claim they can save significant money by reducing hospital admissions for diabetes and heart attacks, because those admissions are very common. How many admissions per 1000 covered lives does the average employer incur in a typical year?
The Health Enhancement Research Organization claims a certain savings figure for wellness PEPM. But that’s before taking into account vendor fees, extra doctor visits, tests, and prescriptions, compliance issues, employee time needed, overhead and basically anything else. In other words, what is the PEPM savings figure that at Bain & Company we used to refer to as “profit before cost”? Answer to the nearest one dollar. Hint: the answer is somewhere in this quiz.
To eventually save money someday, you first need to improve/reduce the risk profile of your population. According to eternal optimist and wellness promoter-in-chief Ron Goetzel, what is the maximum percent improvement in a risk profile that a company can expect after 2 to 3 years of wellness programming @$150 PEPY?
Speaking of Ron Goetzel, he said “thousands of wellness programs” fail to get good outcomes. What round number did he claim have succeeded?
And speaking of Ron Goetzel again, he finally admitted it was “hard” to force employees to change behavior. How many “very’s” did he put in front of the word “hard” in that admission?
The Wishful Thinking Factor, totally coincidentally abbreviated as WTF, is defined as: Total claimed cost reduction/total number of risk factors reduced. What is the average WTF for the last six Koop Award-winning programs, on average? (Hint: the real ratio of savings to risk reduction is about 0.05x, since even if savings does not lag risk reduction, a maximum of 5% of spending is wellness-sensitive.)
Speaking of risk reduction, employees in the most recent Koop Award-winning program, Wellsteps/Boise, originally tallied 5293 risk factors. Approximately how many risk factors did those same employees tally after participating, excluding dropouts?
In a participants-vs-non-participants study design, what percent of the perceived savings is due to the invalidity introduced by the study design itself in which unmotivated employees are used as the control for motivated employees, rather than health improvements attributable to the actual program itself, according to all four studies conducted on this topic, including three by wellness promoters?
If you use Interactive Health as a vendor hyperdiagnosing the stuffing out of your workforce, what is the annual percentage of employees that will likely be told they have “newly discovered conditions” that “require” a doctor’s intervention?
Of 1000+ wellness vendors, how many are validated by the Validation Institute?
- 2. Yes, only 2. All this wellness fuss is about 2 admissions per 1000 employees. Derivation: the roughly 150,000,000 employees and dependents covered by commercial insurance (mostly from employers) generate roughly 150,000 heart attacks and 120,000 diabetes events. See the HCUP database and enter “410” for heart attacks and 250 for diabetes admissions for the ICD9 for the most recent full year (2014). Scoring: Give yourself 1 point for guessing 4 to 10 and 2 points for guessing fewer than 4.
- One dollar. $0.99 PEPY. As is well-known, they tried to walk this figure back once they realized they had told the truth. Scoring: Give yourself 1 points for guessing $1.00, since the answer in the hint was on that very same line.
- 2%. That’s a few dollars PEPY in savings. (Looks like the HERO report was pretty close, its own protestations notwithstanding.) And you paid $450/employee over 3 years to achieve it. Actually it was 1% to 2%, but we asked for the maximum. Scoring: Give yourself 2 points for 2% or less, 1 point for 4% or less.
- Only 100. Besides Johnson & Johnson, Mr. Goetzel has never disclosed any of the other 99 without others making the observation that they self-invalidate according to their own data. Scoring: 2 points for 200 or fewer, 1 point for 400 or fewer.
- 4. In The Healthy Workplace Nudge, Rex Miller gets Ron Goetzel to admit that “changing behavior is very very very very hard.” Gosh, Ron, do you suppose this might explain why an employer population’s risk factors never noticeably decline? Scoring: 2 points for 4, 1 point for 3 or 5.
- Infinity. That’s because of the next question. The 21% risk factor increase for Wellsteps more than offset the trivial risk reductions achieved by the previous years’ winners. The actual WTFs for the previous years will be the subject of a future posting. Scoring: give yourself a point if you guessed that the WTF was 5 or higher. That would be 100 times the actual figure and still way below the wellness fantasy-league figure.
- 6397. Risk factors rose 21%. And yet somehow, even though the risk profile was deteriorating sharply, the risk profile of the population was also improving enough for Wellsteps to claim that healthcare costs declined 30%. 30% is enough to wipe out wellness-sensitive medical events for the entire Boise teacher population and about 30,000 of their closest friends. (Wellsteps originally admitted that costs increased, but took that slide down when it occurred to them that telling the truth would be inconsistent with their marketing strategy.) Scoring: 1 points for 5500 to 6000 or 6600 to 7000, 2 points for 6001 to 6599.
- 100%. It turns out that the participant-vs-non-participant study design is responsible for all the perceived savings that wellness vendors claim for programs. The New York Times just explained how, in the landmark University of Illinois study, both the “gold standard” RCT methodology and the invalid par-vs-non-par methodology were used and had completely different results. This also happened three other times (summarized here) — with Newtopia, Health Fitness Corporation, and a study done by the chairperson of the Koop Committee showing how feeding diabetics more carbs would reduce their costs by improving their health. Literally, 4 studies — all of which were run by people trying to show savings — showed exactly the same thing. Scoring: all or nothing — 1 points for 100%.
- 45%. This is because running 40 inappropriate tests on every employee makes it inevitable that at least 1 or 2 of those tests reveal a false positive. Scoring: Give yourself 2 points for guessing between 40% and 50%, 1 point for 30% to 39% or 51% to 60%.
- Four. All four are honest and make modest claims they can defend or valid contractual representations. AND, they actually screen according to guidelines! (In the wellness industry, doing something appropriate merits an exclamation point.) They are: It Starts With Me, Splashlight, Sustainable Health Index, and US Preventive Medicine. That’s <1% of all wellness vendors. Scoring: give yourself 1 points for 8 or fewer.
0-2 points. Has your wellness vendor sold you a bridge too?
3-5 points: Your wellness vendor is blocking your internet connection
6-9 points: Nice work!
>9 points: Send your fifth-grade math teacher a thank-you note for doing a better job than the wellness vendors’ teachers did.
The most comprehensive expose of the “pry, poke and prod” industry is likely to have broken the 1000-download threshold by the time you read this.
Published by the leading law-medicine journal, it is their second-most-popular paper of all time. Curiously, while this is the oldest law-medicine journal in the country and has covered a multitude of topics over many decades, the most popular paper of all time is also a smackdown of pry, poke and prod programs.
Because TSW doesn’t lie (that’s part of the reason we are so unpopular amongst the HERO crowd and its sycophants), I would acknowledge that the methodology they use to measure popularity favors more recently published articles, and ours is “only” a year old. Even so it is quite a feat because, while we are close on the feels of #1, there is a big gap between us and the #3 article.
In the structured world of law, as opposed to the “Wild West” of wellness, there are rules. That’s why I chose the leading law-medicine venue for this expose.
One rule of evidence is that some of the best evidence — one of the few exceptions to the hearsay exclusion — is what’s known as an “admission against interest.” An admission against interest is “a statement by a party that, when uttered, is against the party’s pecuniary, proprietary, or penal interest.” It’s even more compelling if it is captured electronically, as on a live mic, or in print.
The best example is Robert Durst accidentally admitting that he killed his wife during a bathroom break while being interviewed for a documentary, when he was still miked. You’d have to be, as Larry David might say, pretty pretty pretty pretty stupid to make admissions against interest when you are miked or in print.
One would think.
And yet the wellness industry’s entire modus operandi is to do exactly that. All that remains is for someone like me to point these things out, take a screen shot (the equivalent of Durst being miked), and then sit back, make some popcorn, and watch them react. Reacting is also a form of evidence. Reacting the way a guilty person would react is prima facie evidence of guilt. (To use the examples from the TSW landing page, think OJ and the white Bronco or Lance Armstrong and just about anything he said or did after being accused.)
Needless to say, the wellness industry’s very stable geniuses never step out of character when it comes to guilty reactions. This runs the gamut. Sometimes, as with Bravo, they pull down the incriminating screenshot immediately after being outed. Or, as with Interactive Health, they simply excise the incriminating data from their “research report” and call it a “research summary.” (And also they try to bribe me not to talk about them any more. I’m just sayin’…)
Or, as with Wellsteps, they act out with unsupported and creatively spelled recriminations.
Or sometimes simply trying to erase history. This is the specialty of Ron “The Pretzel” Goetzel, twisting and turning his words to do exactly that, not realizing that we keep screenshots. Here is the “before” and “after” picture of him erasing the smoking-gun evidence that a program’s “impact” was due entirely to separation into participants-vs-non-participants rather than pry, poke and prod. Note that from 2004 to 2006, separation between participants and non-participants increased almost 20% — before there was even a program to participate in.
Before (what really happened):
In order to maintain the fiction that participants-vs-non-participants is a valid study design, Ron simply removed the labels from the x-axis:
Lest anyone domiciled in a state where marijuana is now legal think the first one was a mistake and was corrected as soon as they noticed, they actually repeatedly reprinted and reused the original in many forums, like this one:
Sometimes, and this was my favorite of Ron “The Pretzel” Goetzel’s twists and turns, he literally rewrote history, in the form of forging a letter from the Governor of Nebraska, once he admitted the initial claim of saving the lives of 514 cancer victims was exposed as a fraud:
Here is your assignment: pass this along to everyone you know and ask them to read the article. Then hopefully it will be time to write the history of wellness the way it should be written. And keep a screenshot in case Goetzel tries to rewrite it.
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.
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:
- wrote them;
- gave them an award; or
- both, since conflict of interest is his modus operandi, or
- 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:
What follows is an analysis of all hospitalizations in the US from 2001 to 2014. Wellness–punitive, health-contingent wellness in particular–has apparently harmed more employees than it has benefited. Here’s the story in one simple graph, comparing the percentage of the hospital admissions that are wellness-sensitive (diabetes, heart attacks) to all hospital admissions. The blue line reflects that calculation for admissions covered by private (commercial) insurance, while the orange line combines Medicaid, Medicare and uninsured. They will have higher absolute rates of these events but it’s the difference of differences that matters:
What can we learn from this analysis?
- The point-to-point change is -.3% in the non-exposed population (orange) vs. +.1% in the exposed population (blue).
- The difference of differences should be going in the opposite direction, since essentially every known major factor that could impact this blue line more than the orange line is held constant, other than an increasing penetration of workplace wellness into the blue-line population. Spending about $6 billion more on wellness services in 2014 (vs. 2001) should have made a huge favorable impact on the blue line, given that the total spent on inpatient wellness-sensitive medical events in 2014 was roughly $7 billion, applying the Health Enhancement Research Organization’s estimate of $25,000/admission to the 285,000 relevant 2014 admissions.
- It’s actually worse. Only about half the employed population has access to screening and risk assessments, meaning that the size of the industry overwhelms the size of the addressable events even if one assumes that all the diagnoses leading to the events were found in screenings.
- It might seem absurd to assert that the wellness industry in total (almost $8 billion today) is double the size of the healthcare spending it is supposed to address, but a “bottoms-up” analysis gives the same answer: In the privately insured population, 4.1% of admissions were wellness-sensitive in 2014. Figure half these events take place in people who already know they are at risk or have the diagnosis. So 2% of all admissions involved employees who did not know they had the diagnosis when they had the event — and hence could conceivably have learned about it and avoided it through a wellness program. Admissions are about half of all costs, meaning 2% of admissions would consume 1% of costs. 1% of a typical $6000/individual employee spend is $60/employee/year. A wellness program, including the screening, likely costs $150. That means even a perfect program — one that finds every employee with a hidden diagnosis, avoids all false positives, and prevents every event without any added cost of prevention therapy– would lose money. Alas, as lovingly documented on this website through the years, a beam of light leaving “perfect” wouldn’t reach the “pry, poke and prod” industry for several seconds.
- The fairly dramatic upswing starting in events in the exposed population (the blue line) starting in 2012, even as the rest of the country was almost leveling off, correlates quite closely with the move towards health-contingent, or “outcomes-based” wellness, in which employees who don’t crash-diet hard enough before the final weigh-in get fined. So while a study by Redbrick showed no benefit to health-contingent programs, the truth is likely worse: many health-contingent programs actually do harm, as Interactive Health recently demonstrated and for which Wellsteps won a “best-in-industry” award. Much is this harm is visited upon employees with eating disorders.
In case you don’t believe punitive wellness programs could be this bad…
You can ask me for the raw data, and/or replicate this exact analysis, using ingredients you already have in your kitchen — an internet connection (which perhaps even Bravo has acquired by now) and the links below.
It happens that the nation’s hospital admissions data (through 2014) is all publicly available online. You can see for yourself how badly wellness has failed. First, go to the admissions database. Then under “Analysis setup” go “Trend>yes>yes.” That will bring you to a dropdown menu asking you to “choose how you want to classify the diagnoses or procedures.” Pick “Diagnosis ICD-9-CM codes.”
It will ask you to “Choose your diagnosis.” This is where it gets slightly labor-intensive. You’re gonna want to pick all the heart attack and uncomplicated diabetes codes, since those two categories represent by far the lion’s share of wellness-sensitive medical events (WSMEs), events that can be theoretically avoided through screening the stuffing out of employees. You might ask: “Why not include complications of diabetes, and heart failure etc.? Why just these two?”
That’s because we aren’t testing disease management. We’re testing to see if “playing doctor” to try to hunt for disease is worthwhile. Anyone with complications of diabetes, or a more serious condition like heart failure or COPD, obviously already knows they have it. No screen needed. We also can’t test stroke because the HCUP data prior to 2012 has some squirelliness in it. (In any event, there are far fewer strokes in the working age population than heart attacks, especially if one excludes those where atrial fibrillation was the likely cause.)
Diabetes and heart attack ICD9s begin with 250 and 410 respectively. Once you enter one of those 3-digit codes into the field, a ton of 5-digit codes will show up. Just keep hitting “CTRL click” until they all show up in the field. Then, hit “combine all codes.” Here is what the screen will look like before you do that:
After you enter these diagnoses, choose “Combine all codes” and then “Create analysis.” You’ll get a screen that looks like this. Do not attempt to adjust your TV set. I am just showing you this so you know you’re in the right place, not to try to see the results:
Once you’ve gotten to this point, you need to split the analysis into payer category and then pick multiple years, to show a trend. To find the payer, use the left-hand navigation bar and go to Patient Characteristics>Payer. You’ll want to do multiple years, and farther down that toolbar you’ll see “years.” You just check all the years from 2014 back to 2001 and hit “submit.” (There is some squirreliness in the years before 2001.)
Doing this by payer is critical. Almost every employee with access to workplace wellness will be commercially insured — or as HCUP puts it, privately insured.
You’ll then get a screen that looks like this:
It will give you all the admissions, by payer, for all the years. You are then given an option to drop this into Excel, an option you should take. (This is the definition of “voluntary,” by the way. Your employer won’t fine you if you don’t.) Once it is in Excel, you can copy-and-paste the actual year-by-year data into an easy-to-use format, like this little snippet that lists stroke-hypertension and then repeats the format for all admissions:”All admissions” becomes the denominator for those 15 years, split into “private insurance” (where over those 15 years members had gained increasing access to wellness programs) vs. the other five categories combined, which did not have wellness access.
After you complete this analysis, you will find that the reason I offered a $3 million reward to show wellness saves money is because there is no chance of anyone ever being able to claim it.
There is a lot more to this study than meets the eye.
Some tourist attractions feature an “A” tour for newbies and then a “behind-the-scenes” tour for those of us who truly need lives. For instance, I confess to having taken Disney’s Magic Kingdom underground tour, exploring, among other things, the tunnels through which employees travel so as not to be seen out of costume in the wrong “Land.”
Likewise, there have been many reviews of the recent wellness study conducted by the National Bureau of Economic Research (NBER), the first-ever randomized control study of a wellness program. This, however, is the first review to go beyond the “A” tour of the headlines.
By way of background, the headline is that the mainstream wellness program the investigators examined at the University of Illinois did not noticeably move the needle on employee health. They didn’t address return-on-investment (ROI), because there obviously was none. Achieving a positive ROI would require moving the health risk needle—not just by a little, but rather by enough to significantly improve the health of many employees. Then, since wellness-related events, such as heart attacks, would not otherwise have befallen these employees immediately, this improvement would have to be sustained over several years before there was a statistical chance of some events being avoided.
Finally, the magnitude of this improvement would have to be great enough to violate the rules of arithmetic, because it is not mathematically possible to avoid enough medical events to break even on wellness. For instance, it actually costs about $1 million to avoid a heart attack through a screening program.
This finding, therefore, represents an existential threat to conventional wellness programs.
It all boils down to: why would an associate professor (Damon Jones) publicly humiliate his own dean (Katherine Baicker — yes, the very same Katherine Baicker who always seems to be on the wrong side of every wellness debate) …unless he is absolutely sure he is right?
She can’t fire him now because that would get picked up by the lay media. Perhaps she should have paid him $130,000 not to disclose the results.
The Wellness Industry’s Terrible, Horrible, No-Good, Very Bad Year just got worse. Seems like CMS (Medicare) and Modern Healthcare are also ganging up on the Health Enhancement Research Organization (HERO) and all their cronies.
The headline in today’s Modern Heathcare turns out to be a bit of an understatement:
Wellness programs aren’t generating Medicare savings
Read farther the article and you’ll come up with gems like:
Utiization and expenditures actually increased among program participants… The results mirror those in the corporate world.
Asked for comment, the National Business Group on Health’s very stable spokesgenius, Steve Wojcik, said:
So, while it didn’t reduce healthcare expense or utilization, it seems to have had a positive impact…by preventing or delaying normal deterioration that comes with age.
Where Mr. Wojcik came up with this spin, creative even by wellness industry standards, is anyone’s guess. Nothing in the program suggests it and when he finds something that does prevent age-related decline, I will be the first to nominate him for a Nobel Prize.
The curious thing is this failed approach is not “wellness or else” as Jon Robison calls it. Instead these programs are truly voluntary. Also unlike corporate wellness programs, vendors aren’t harassing healthy employees to eat more broccoli but rather focusing on unhealthy ones. Instead of making healthy 30-year-olds get unneeded checkups, they’re encouraging 70-year-olds with chronic disease to get more medical care.
And yet the programs still don’t work. Color me surprised. I genuinely thought (and I honestly still think) that willing participants in voluntary programs who have chronic disease would benefit from these programs. Perhaps when they re-review another year’s data they will find a benefit.
Alternatively, instead of trying to maintain the revenue streams of their members, perhaps HERO could actually try to find a new model that does provide a benefit. Certainly there are plenty of vendors out there with possibly better mousetraps, but they all have one thing in common: they have no use for HERO’s pet vendors, any more than companies that make solar panels have a use for coal.
Speaking of HERO, let us review HERO’s comments from just last week:
Teddy Roosevelt said, “complaining about a problem without posing a solution is called whining.” It’s a quote that also reminds me why I’ve not thought of angry bloggers who target health promotion [vendors] as bullies. Though they relish trolling for bad apples, their scolding is toothless, more the stuff of chronic whiners.
Not to mention:
We’re fortunate to work in a profession with a scant number of vociferous critics. My take is that there is one thing these few angry loners want more desperately than attention: that’s to be taken seriously.
Just like wellness vendors like to define “voluntary” as “forced,” I guess in wellness-speak “scant number of vociferous critics and chronic whiners” mean “every commentator,” and an “angry blogger” is any blogger with a great big smile on his face.