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While most of us were buying supplies for partying down on New Years Eve (in my case, I was in charge of bringing broccoli and Boggle), the federal court in the Western District of Wisconsin quietly handed down an earth-shattering decision in the Flambeau case, which pretty much went unnoticed due to the timing. You may recall that this was the case where employees refusing wellness lost all insurance benefits. The case looked like a layup win for the EEOC. After all, the Affordable Care Act clearly states that penalties for non-smokers are capped at 30%, and this was 100%.
But here’s the rub: Flambeau conditioned the entire insurance benefit on participation in their “pry, poke and prod” program. They knew most employees hate “pry, poke and prod” programs to begin with. So they created a program so onerous that some number of employees would prefer to forego insurance altogether than participate in wellness. And indeed, that’s what happened at Flambeau. This decision means they’re getting away with it, saving thousands of dollars apiece for each employee who refused to submit.
Make sure you catch that distinction between the 30% penalties and the 100% penalties:
(1) It is not OK to penalize an employee more than 30% for refusing to submit to a “pry, poke and prod” program if they already have insurance, or they can get insurance through the employer without this requirement.
(2) However, it is OK to say: “There is no incentive or penalty for wellness once you have insurance, but you can’t have insurance at all unless you submit.” If that seems like an artificial distinction, well, that’s because it is. All an employer has to do is require pry-poke-and-prod before you get insurance.
Assuming other federal courts follow this district’s lead (as they usually do), employers create a 100% de facto non-participation penalty: If you don’t participate, you don’t get insurance, period.
The implications of this case:
(1) It will allow some vendors, like Bravo, to double down on bragging about the “savings” from wellness by creating programs that employees don’t like;
(2) Because the decision only applies to participatory programs and not outcomes-based programs, many companies will either not switch to outcomes-based programs or else maybe switch back.
It also puts pressure on the EEOC to put the kibosh on this end-run around the ACA’s wellness provision. Note that the decision can and should be appealed. Otherwise it is a de facto repeal of a big chunk of the Affordable Care Act.
The bottom line is, now there is universal agreement (albeit inadvertently in the case of HERO, which apparently didn’t mean to tell the truth, but failed to proofread their own document) that wellness loses money. So any pretense of “pry, poke and prod” being about the employee is gone. Obviously, forced wellness isn’t about trying to save the $0.99 PMPM (that’s before program fees!) that HERO Says can be saved with healthier employees. It’s about gutting the key ACA requirement that employers provide insurance.
And unless the EEOC steps up in its final regulations and/or prevails on appeal of Flambeau, they will have succeeded.
When Thomas Edison said: “We don’t know a millionth of 1% about anything,” he wasn’t talking about the wellness industry, because wellness vendors aren’t that knowledgeable. And much of what they “know” is harmful.
Smoking and exercise aside, taking wellness vendors’ advice 10 years ago — during the time wellness was somehow allegedly racking up its famously fictitious 3.27-to-1 ROI by making employees healthier– would have been a very bad idea. PSA tests, annual mammograms for younger women, colonoscopies at 5-year intervals, and EKGs were perfect examples of must-to-avoid screens, even if it meant leaving incentives on the table.
And yet even though most wellness vendors (Star Wellness, Bravo Wellness Total Wellness, HealthFair Services and Aetna being notable exceptions) won’t harm employees as much as they did 10 years ago, a lot of mythology still causes a lot of harm today, albeit more subtly.
Myth: “We need to ‘do wellness’ because 75% of our healthcare cost is due to preventable chronic disease.” (Ron Goetzel, in our recent debate, boosted this figure to 80% for reasons unknown.)
Fact: Have ya looked at your high utilizers and other expenses? We-can-prevent-75%-of-cost-due-to-chronic-disease is the biggest urban legend in healthcare. We’ve done multiple articles on it — there are too many fallacies to squeeze in here. Though it’s just arithmetic, this is the most harmful fallacy of all, because by causing employers to obsess with overprevention, it spins off all the other fallacies below.
Myth: “Reducing our employees’ BMIs will save money.”
Fact: The actual science is far more nuanced. Some people have high BMIs because they are healthy. And belly fat — even at “normal” weights — is riskier than all but the highest BMIs. Further, attaching money to weight loss between weigh-ins creates a binge/crash-diet cycle that is decidedly unhealthy.
Myth: “Corporate weight loss programs save money.”
Fact: No corporate weight loss program has ever saved money. They don’t reduce BMIs, BMIs are the wrong measure (see above), and the link between reducing BMIs and saving money is nonexistent.
Myth: “Screening our employees will be good for their health.”
Fact: Annual screenings are a bad idea for the majority of employees. The head of Optum’s wellness operations, Seth Serxner, just acknowledged this inconvenient truth last week. (He somehow shifted the blame to employers, for stupidly spending too much money on Optum and other vendors. That’s a topic for another post.) The US Preventive Services Task Force has a schedule of screenings that essentially no wellness vendor follows. Because so few biometric screens are recommended for working-age adults by the card-carrying grownups who comprise the USPSTF, following USPSTF guidelines would bankrupt the industry.
Myth: “Screening guidelines balance costs and benefits so at worst we’ll break even.”
Fact: Screening guidelines balance harms and benefits, not costs and benefits. The subtlety of the distinction would be lost on most wellness vendors, but it is important. (1) Unless screens are provided free, an employer will lose money even on a screening program done according to guidelines; (2) you are not doing your employees any favors by providing screening “greater than” guidelines, like the Health Fitness Corporation/Nebraska program did. You are simply raising the likelihood of harm.
Myth: “Annual checkups will keep our employees healthy.”
Fact: For wellness vendors, the annual checkup has almost mystical power. Bravo’s CEO Jim Pshock loudly credits checkups with preventing cancer. Wellness vendor bloviating aside, the science is quite settled: employees are more likely to be harmed than benefited by annual checkups.
Myth: “Our employees need to eat healthier.”
Fact: OK, there is a, uh, grain of truth here. Many people have bad diets–fried food, sugar etc. But beyond eating less fried food and sugar, the science remains unsettled. Salt, saturated fat, complex carbohydrates…all in the realm of not completely settled. What is true and remarkably overlooked is the epidemiological rule of thumb that if an impact is major, it shows up in small samples. 86 cases were needed to link lung cancer to smoking. And a famous study of 523 veterans proved very high blood pressure causes strokes. Yet after tons of controlled and observational studies — even comparing countries to one another — we still haven’t found “the answer.” That means “the answer,” whatever it is, won’t matter much in the workplace. So you’re wasting your time trying to get employees to “eat right.”
We could keep going — antioxidants are more likely to cause cancer than prevent it. Sitting is not the new smoking. And drinking eight glasses of water a day is good for you only in that you’ll get more exercise going to and from the restroom.
The biggest myth of all? Wellness vendors actually do anything of value, other than make up savings figures to show your CFO so you look good. Or as my colleague Vik Khanna says: “Love your employees. Fire your wellness vendor.”
USA Today and Kaiser Health News just published a terrific story on the hazards of overscreening, overtesting, and pry-poke-and-prod programs.
It revealed how screening all employees every year–and then sending them in for checkups –makes no sense on any level, and is contrary to all guidelines and literature. All it does is lead to hyperdiagnosis. Hyperdiagnosis is overdiagnosis on steroids. Instead of being the unfortunate result of good-faith efforts to figure out what is wrong with a patient (that’s “overdiagnosis”), hyperdiagnosis is the breathless reporting by wellness vendors on how many sick employees a company has, and how they will have an “epidemic” of something-or-other unless they force employees to get coached etc.
Hyperdiagnosis is also, however, the wellness industry’s bread-and-butter, so naturally wellness vendors defend this practice. In this article, Bravo Wellness CEO Jim Pshock was quoted as saying: “The hope is that the program will get people to proactively see their physicians to manage their health risks. Yes, this will, hopefully, mean more prescription drug utilization and office visits, but fewer heart attacks and cancers and strokes.”
The only innocent explanation for this comment is that Bravo canceled its subscription to the internet to conserve cash. Seems that all the literature, easily searchable online — plus Choosing Wisely — says that “proactive” annual checkups are a waste of time and money and will not prevent heart attacks and strokes, and certainly not cancers. (They will, however, make drug use and physician office visit expense increase. That much he got right.) A quick Google search would have revealed that to him…if only he had access to Google.
This whole thing would be pretty amusing except that Bravo’s business model includes fining employees for not getting checkups that are more likely to harm them than benefit them, according to the New England Journal of Medicine. Harming employees is where the joke ends.
Otherwise, the only other explanation for this comment is that he is — heaven forbid — lying. And we would be pshocked, pshocked to learn that lying is going on in here!
Therefore, since a wellness vendor would never lie, Mr. Pshock must have allowed his internet subscription to expire. We’d urge all readers to donate early and often to Bravo Wellness to help them keep the lights on.
The Graco-Goetzel-Bravo-Hopkins case study is turning into another Nebraska fiasco. As with Nebraska, the numbers all contradict one another. But unlike Nebraska, there has as yet been no admission of deliberate lying in the Graco case study. That’s why Graco only earned an honorable mention in the Koop Awards, instead of winning one outright like Nebraska did.
Consider Bravo’s case study on Graco covering the exact same population over the same period as Ron Goetzel’s study. Let’s assume Ron Goetzel is right in that the wellness program should be measured from 2009 rather than 2008, when the program started. (Bob Merberg’s brilliant analysis points out the cherrypicking of the date has a huge impact on claimed success, but let’s concede this start date choice to Ron, and use 2009 according to his wishes.)
Bravo’s case study displays the PMPM costs by year. The first thing to note is, they list employee healthcare costs at $328 PMPM, which actually makes sense, instead of the $190 PMPM in the Hopkins report. I don’t know why these two figures, purporting to cover the exact same population in the exact same period, are completely inconsistent, but I do know that $190 PMPM is an impossible figure, as any population health expert knows. (“Plausibility checking” would have caught that error but Ron has never taken our course in Critical Outcomes Report Analysis, which would have covered plausibility-testing and likely prevented him from making such a rookie mistake.)
Second, Bravo lists children’s healthcare costs in this report as well. Funny thing: over the same exact period in which Mr. Goetzel was claiming that the wellness program was responsible for controlling employee participant costs, children’s healthcare costs trended better than wellness participants’ costs. Mr. Goetzel obviously had access to this children’s cost trend data (we had no trouble finding it, thanks to Bob Merberg) but elected to — get ready to fall out of your seats — ignore it. The wellness ignorati rarely step out of character.
This children’s cost trendline appears to invalidate the entire Goetzel-Johns Hopkins conclusion that the healthcare cost trend was due to the wellness program, since not one single child participated in the wellness program.
For some reason Graco’s spouses cost about $7000 apiece a year. We’ll leave that for someone else to dissect.
As an aside, if anyone thinks they recognize the name “Bravo Wellness” from an earlier posting, it’s because they do. Bravo is the outfit that brags about their ability to save employers money by fining employees. Their website is disproportionately about their appeals process when those fines are levied. This sounds like a company that does wellness to employees instead of for them.
Not sure how bragging about fining employees is consistent with the positive culture that Mr. Goetzel says Graco has, but maybe I’m missing something here.