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In the wellness industry’s very stable genius pandemic, AngioScreen is Patient Einstein.
The Deplorables Award, as many of you might remember (you’re excused if you’ve forgotten — it’s been 2 years since a vendor was deemed worthy enough to qualify) goes to that vendor whose combination of dishonesty and patient harms would make Ron Goetzel blush. Angioscreen is all that and more — the kind of outfit that gives clueless wellness vendors a bad name.
Angioscreen had earned the pole position for 2021’s award even before this month’s Journal of the American Medical Association (JAMA) reminded us that — for the third time in as many plate appearances (2007, 2014 and now 2021) —they struck out with the US Preventive Services Task Force (USPSTF). They gave Angioscreen’s go-to carotid artery screen a “D.” In no uncertain terms, JAMA and USPSTF say: “Don’t do these screens to your employees.”
I “profiled” Angioscreen years ago…but never gave them a Deplorables Award on the assumption that they would asymptotically approach irrelevance on their own merit. After all, what benefits manager would ever retain this outfit? Surely no actuary would be dishonest enough to be paid to “find savings” in these screens, and no consultant or broker would be corrupt enough to take money to pitch them, right?
Surely someone would notice that right on their very own website, they cited the fact that the USPSTF gives them a “D.”
And surely someone would notice that Angioscreen’s other business is convincing hospitals to screen communities in order to find new well-insured patients to admit for major surgery…and make the obvious inference that the same screens that are designed to generate admissions can’t also reduce admissions, right?
Haha, good ones, Al.
The hospitals nailed this
Angioscreen is a surgery-generating machine. Here is an employer, who at least had enough sense to withhold his name, bragging about the major vascular surgeries his employees underwent for asymptomatic carotid artery stenosis (CAS) thanks to Angioscreen:
Two of our employees were found to have blockages in their carotid arteries. Through follow-up visits with their physician, these employees found arteries that were significantly blocked that required surgery.
Maybe the employees really needed the surgery? In the immortal word of the great philosopher Brittany Spears, oops. The National Institutes of Health warns against precisely this:
Despite a D recommendation from the USPSTF… many surgeries or interventions for asymptomatic CAS continue to be performed [due to] free screenings.
Wait, you might say, maybe those patients needed those screens to avoid a stroke.
Haha, good one again, Al:
- As JAMA says, “only 11% of strokes” are caused by internal carotid stenosis. Since only about 1 in 1000 employer-covered people has a stroke, you’d have to screen almost 10,000 <65 employer-covered people to possibly have a slight chance of preventing a stroke with a major surgery.
- If Angioscreen’s test is 95% accurate (in their dreams), you’d also refer 500 false positives to their doctors, and some would undergo risky, painful, and expensive major vascular surgery as well, probably like those two in the mercifully unnamed employer above.
The employers got snookered for a change
Funny that Angioscreen wouldn’t attach a name to that reference site, because it’s only a slight exaggeration to say Angioscreen’s customer list includes practically every non-Quizzify-customer (the latter tend to have triple-digit IQs, making them poor prospects for Angioscreen) in the Fortune 500. Here it is:
You might say, that’s not many. True, but that excerpt is only a tiny fraction of the total – I didn’t want to hog the internet by listing all of them.
Perhaps you see some employers on that list that make you think: “Why would a smart, capable company like so-and-so be an Angioscreen customer?” I asked myself the same thing, as I was surprised to see a Quizzify customer on the list. So I asked them, mentioning my surprise.
Turns out they were every bit as surprised as I was. They had no idea they were on that list and had never heard of Angioscreen.
But wait…there’s more. Now how many inappropriate screens would you pay for?
Another reason I had originally demurred from bestowing this award on them was that I also thought that maybe after a while their conscience would get the better of them, and they would stop doing these screens. Perhaps they might pivot from decidedly harmful screens into the more mundane screens that are simply a useless waste of money.
How silly of me.
Quite the contrary, once they realized they had stumbled upon a huge untapped market for employee hyperdiagnosis, they added several more inappropriate screens:
If “Ankle Brachial Index” screening sounds familiar, it’s precisely what Marty Makary warned us against in The Price We Pay as the poster-test for generating unneeded and harmful surgeries.
If ”peak systolic velocity” sounds unfamiliar, it’s because it’s such a stupid idea for a screen that the USPSTF has never even bothered to recommend against it, on the theory that no one would screen their asymptomatic patients for this. A doctor would literally lose their license for routinely doing these screens and billing insurance for these.
And, just in case there is still any employee naively of the mistaken impression they are living their lives diagnosislessly, there’s the D-rated ECG/EKG. These are not supposed to be done because they — get ready — often “reveal” abnormalities that don’t really exist or are harmless…but once revealed, generate follow-up tests.
Fortunately, this next inappropriate screen costs extra, which might discourage a few employers.
Of course, if you indicate to a real doctor something that might suggest you are at risk for an aneurysm, you should get tested, and if the aneurysm is truly large and life-threatening, be referred for this surgery, despite its mortality rate exceeding 7%. That’s different from an unlicensed vendor playing doctor by screening unsuspecting employees for no reason other than to earn “supplemental” fees. Or, as one commentator put it:
My main objection, however, is that I’m uneasy about taking people off the street who think they are perfectly well and subjecting them to a procedure from which 1 in 14 will die.
And so it is with great honor that I bestow the Deplorables Award on Angioscreen as the fourth recipient of this august distinction, joining Wellsteps, and bankruptcy court denizens Interactive Health and Provant. (The latter avoided a Deplorables Award only by going bankrupt after our initial expose, before we had time to bestow the award.)
I am a mere supplicant at the feet of the true experts in the field of screening.
Linked here is the single most coherent article on the subject I’ve ever seen, just came out today. Basically, it says: “Screen according to guidelines.” That simple sentence is the source of a great battle pitting Quizzify and the Welligentsia against the Wellness Ignorati and most of the screening industry (excluding It Starts with Me, Limeade, and US Preventive Medicine, all of which offer screening programs more or less aligned with guidelines), whose livelihood depends on employers not screening employees according to guidelines, and finding some of the wackiest tests in the world to foist onto unsuspecting employees.
Highlights of the article:
- Many people are overscreened and massive numbers of people get tests they don’t need
- Many people are underscreened
- Do not purchase B-to-C screenings like Star Wellness, the subject of a recent profile here, offers.
Specifically as to the third point, they called out AngioScreen as an example of companies trying to circumvent doctors by offering inappropriate screenings. AngioScreen is unique in that right on their website they acknowledge that their entire business model is built on an a screen the US Preventive Services Task Force calls inappropriate.
They also list an outfit called Matrix Medical Network as an example of a company offering inappropriate screens. Matrix Medical Network…hmmm…where have I heard that name before…oh, that’s right! I founded Matrix Medical Network. (Actually, co-founded and was an original board member and investor. And, yes, unlike wellness vendors, irony is not lost on me. See “Ironically, the wellness industry does not understand irony.“)
One way or the other, this article is worth a read because it truly draws a thoughtful line between appropriate and inappropriate screenings.
This is the second part in the series on wellness vendors and the US Preventive Services Task Force (USPSTF).
Q: Why do vendors ignore or flout the USPSTF?
There are five reasons, three of which are unfortunate:
- Many vendors don’t understand the entire concept of screening, neither the science nor the arithmetic described in Part 1. Healthcare is hard, and the USPSTF can’t be expected to dumb themselves down so that wellness vendors, for whom simple math is a challenge and who don’t have to meet any educational or licensing requirements other than eight days of training, can understand it.
- Obviously, the more vendors screen, the more money they make. Guidelines propose infrequent screening for fewer blood values than most vendors do. That means vendors who abide by guidelines can collect much less money from employers than those who charge what the market will bear. Examples of companies screening the stuffing out of employees include Total Wellness, Interactive Health, Star Wellness, Healthfair, and Healthfairs USA. Needless to say they make a lot of money. (Quizzify is very jealous! Doing the right thing and guaranteeing savings isn’t remotely as profitable as ripping off employers.)
- Many wellness vendors are dishonest. We’ve already pointed out that Wellsteps bragged about how they screen every Boise employee every year for everything, with no mention of USPSTF guidelines. But after they got caught, they admitted they knew that the guidelines say the opposite. And Optum’s Seth Serxner insisted — out loud, on tape, that they would be happy to screen according to guidelines, if only employers would let them. And yet, here is Optum’s ad, saying exactly the opposite: if you want us not to raise your rates as much on insurance, it’s a “requirement” to pay us even more than you would save on insurance, to do annual screens. (Naturally they are quoting two sources that they know to be false as well.)
Q; Those are three bad reasons. What are the two good reasons?
I would like to credit Pete Arens for bigly influencing my answer on this. It’s rare that someone does that, and even rarer that I admit it. However, in this case, huge credit where credit is due. Pete’s the man.
USPSTF publishes guidelines, not requirements. It is perfectly OK not to follow them — as long as you have a good reason. The reasons above — ignorance, dishonesty and greed — would clearly not qualify. However, here are some excellent examples of reasons that would:
- You work in a high-stress environment, like a law firm. Making blood pressure screening available easily and much more frequently than once a year, even having some discreetly placed cuffs, might be a good idea. (Some maintain that stress doesn’t cause high blood pressure. Perhaps not, but to them I say, watch Episode 5 of The People vs. OJ Simpson.)
- Your workforce is largely outdoors. Skin cancer and Lyme Disease screens might be indicated.
- You have alternatives to screening (like Quizzify) for younger employees, but encourage and educate older employees and other employees at high risk to get screened. The USPSTF doesn’t say, “no screens.” It says screens should be age- and risk-appropriate. You offer both to everyone (that’s the law) but steer some employees one way and some the other.
- Your company is in the chemical dye or railroad industries. A bladder cancer screen or at least educational session to raise awareness might be advisable. (Bladder cancer can be identified and easily treated very early.)
Mr. Arens raised the question specifically of obesity screens. Are they appropriate at all, especially in a workplace? And that brings us to the other good reason to flout the guidelines: you think they’re wrong. In that situation, make your case. But it has to be a real case, and obesity screening could very well be such a case:
- The Employee Health and Wellness Code of Conduct specifically says, don’t embarrass or single out employees. This would be a perfect example doing exactly that;
- You are unable to find any meaningful literature or technique that is even remotely shown to successfully address obesity for more than a short, clinically meaningless period of time, so why screen for something you can’t address?
- To the extent you, in a corporate setting, do want to make your workplace healthier, you don’t need screens to do that. Encouraging exercise and avoidance of sugary foods at work would have the same impact.
Read carefully: we aren’t saying specifically you have to pass on obesity screens for those reasons. We are saying that if you differ with USPSTF on any screen, disclose the reasons and/or cite the literature, so it looks like a thoughtful decision. This is an example in which we would differ with guidelines.
Q: What would be a funny example of a vendor who tries to attack the USPSTF but falls on its sword?
Glad you asked. That would be Healthmine, whose credibility, um, collapsed as a result. Rule of thumb: to attack USPSTF credibly, a good start would be spelling their name right. We’re just sayin’…
Q: What would be a funny example of a vendor who flouts the USPSTF recommendations?
You’re asking all the right questions. That would be Angioscreen. The only screen they offer, for carotid artery disease, is D-rated by USPSTF.
Q: I don’t see what’s so funny about that. Stupid, yes. Harmful, yes. Expensive, yes. But what makes them so funny?
They admit right on their website that employees shouldn’t get these screens.
Honestly, I’m not sure which of those two things is dumber — offering the screen or admitting working-age people shouldn’t get it. But at least no one can accuse them of lying.
Q: They also can’t spell “New England Journal of Medicine.”
Good point. I didn’t even notice that until you brought it up. Maybe their head of their advisory board can help them with spelling, since “quality control is extremely important” to them.
Q: What does the USPSTF think of the wellness industry?
Their guidelines are intended for use by real doctors and medical practitioners. My guess is that they are horrified by the idea of an entire industry, unsupervised and uneducated, “playing doctor” with employees. Meanwhile, the National Business Group on Health, a vendor-fest if ever there was one, lobbies against the USPSTF for not understanding the importance of screening the stuffing out of employees.
Q: Why do employers go along with overscreening?
That’s a great question. They need only look at their own hospitalization rates to see that hospitalizations from diseases they are trying to prevent by screening, like diabetes and heart attacks, are already ridiculously low. However, rather than look at their own data, they prefer to spout the “86% of illness is caused by chronic disease” meme, which was already discredited when it was 75%, before the CDC decided to jump it up to 86%.
Anybody who reads that article can see that either is an impossibly stupid statistic. Most hospitalizations at most employers have something to do with birth events, and most expense at most employers can be traced to one-time items not addressable through eating more broccoli (neonates, transplants, cancer) or employees who either have a rare disease or more likely have a dependent with a rare disease.
Q: Maybe This isn’t fair, and vendors screen more than guidelines because they don’t think cost should be an issue and that employees should get all the prevention they can possibly use regardless of price
Actually, the USPSTF specifically does not include cost in its analysis. It balances harms and benefits, not costs and benefits. Screening according to guidelines will therefore lose money, as Ron Goetzel just admitted, even if over the long run more employees may benefit from screens than are harmed.
Quite the opposite. Tons of vendors obsess with hyperprevention because they are totally ignorant of the science and math involved. Our favorite is one called: “HEALTHIER is WEALTHIER and ASSOCIATES.” Along with the usually assortment of wellness industry THC-infused folderol (“our program, if followed diligently for a year, will decrease your employee health cost by as much as $24 for every pound of weight loss, an amount quoted by Dr Michael Roisen [sic] MD, Chief Wellness Officer and Chairman, Cleveland Clinic Wellness Institute”), they want to screen employees every three months. Don’t believe us?
Stay tuned for Part 3: Vendors who understand the USPSTF
At this point we thought we had already checked off everything in the wellness industry’s bucket list of bad behaviors-gone-wild. But that was before we learned about AngioScreen, which offers the “perfect compliment [sic] to your health and wellness fair”: carotid artery stenosis screening, a test rated D by the US Preventive Services Task Force:
Keep in mind the “AngioScreen” is this company’s specialty — the only major screen the Nashville-based Angiology Corporation of America (ACA) offers. In an industry known for harming employees, this makes them the leader, as ACA is the only wellness vendor guaranteed to harm employees on balance, according to the federal government.
And, by the way, however stupid an idea this screen is for the USPSTF-described “general adult population,” it is stupider still for the <65 employed population, which has far lower incidence rates of stenosis than the seniors, and hence a far higher likelihood of false positives.
What makes ACA unique is, not only do they know they’re offering a D-rated screen, they say so right on their website. At the bottom of their list of 10-, 15- and 24-year-old articles recommending carotid artery stenosis screening, they link to the USPSTF “D” Recommendation itself, a first in wellness vendor history:
You might ask: “Is it honest to offer a service you know to be harmful, if way down in your website you disclose that it’s so harmful your customers shouldn’t buy your service in the first place?” Alas, we cannot answer that. That is a question for philosophers, philosopher-kings and philosopher-welders.
Three related questions can be answered, though:
(1) Would a doctor lose his or her license for offering this test to every adult who comes in the door and billing insurance companies for it? Yes.
(2) Are these people disclosing directly to employees that official clinical guidelines recommend against doing this test because they are more likely to be harmed than benefited? No.
(3) Do they also make up savings figures? Yes. Specifically they say this “pays-off” in ways that don’t come close to “paying-off”.
Additionally, their quality control doesn’t exactly inspire confidence.
Speaking of their Medical Advisory Board, despite the fact that AngioScreen is offering exclusively vascular screenings to “prevent your stroke and heart attack,” Dr. Alfred Smauel Callahan, III, M.D. is definitely not one of America’s, or even Nashville’s, leading vascular specialists or cardiologists. How do we know that? As it turns out, he’s not a vascular specialist or cardiologist at all. He’s a neurologist. Those are the guys who treat people after they’ve had a stroke.
This choice of a neurologist as their physician leader doesn’t exactly inspire a lot of confidence in AngioScreen’s ability to prevent strokes. Also, there don’t seem to be any other doctors on the medical advisory board, which is “headed” by him. Per the offer on their website, we wrote and called to see if we could “review the curriculum vitaes [sic]” of this alleged board, and got no response.
In Angioscreen’s defense, they are not alone in offering harmful screening services. Total Wellness, Star Wellness, HealthFair, and other vendors offer the same screens or — in the case of HealthFair — worse ones.
This all brings us back to the question we’ve been asking for years: where are the grownups? Why isn’t there any oversight of the wellness industry? How can vendors and employers be allowed to do things to their employees that doctors would be jailed for doing if they billed patients for them? And how can employees be forced to participate in programs that could injure them, with no business purpose whatsoever?
We propose a simple regulation to address those questions: wellness vendors must do no harm. Wellness vendors should be required to disclose the USPSTF rating before they run these screens, and if it isn’t an A or a B for the employee’s age and frequency of screening, employees should be able to opt out without losing their incentive or paying a fine.
Update 4:30 PM November 19: I received a call back from Rhonda Small, at the company, who says that they are no longer really in the business of selling screens to employers, but rather mostly to hospitals. Their website, she says, is wrong. This makes better business sense because many hospitals like to offer free or deep-discounted D-rated screens, as we have noted. It is an excellent tool for sucking patients into their revenue stream, which is largely paid for by the patients’ employers or Medicare.
She indicated that she would send me curricula vitae (Rhonda, that is the plural, not “curriculum vitaes”, so you might wanna add that to the list of things on your website that are wrong) for the medical advisory board. I will post further updates.
Update 5:00 PM November 19: Apparently AngioScreen’s marketing team has not gotten Rhonda’s message that the company doesn’t market to employers–they just exhibited at the largest human resources conference.