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AJMC: We are shocked, shocked to learn that HRAs are useless
We interrupt our litany of descriptions of failed HRAs to bring you a description of the failure of HRAs.
In wellness, it’s not news to find that something is useless. Indeed, most employees and most economists would agree that the world would not miss Wellsteps or Interactive Health were they to disappear altogether from the earth.
Still, it is news to find that yet another pillar of wellness has fallen victim to actual analysis. In this case, it’s the venerable Health Risk Assessment. This tool has, for about 40 years, been used to encourage employees to pretend they don’t drink. The tool does have one practical use: identifying employees who don’t buckle their seat belts helps employers decide who needs their hearing tested.
HRAs do have their defenders, of whom the most prominent is Larry Chapman, who says they should be treated like “a beloved pet.”
He cites this data set from JOEM showing the costs of people who took the HRA vs. people who didn’t…
…to support the proposition that HRAs cut the average health care cost in half after three years. Or, to use his exact words, CUT THE AVERAGE HEALTH CARE COST IN HALF AFTER THREE YEARS.
It may come as a surprise to Mr. Chapman, who once claimed that wellness could reduce costs by 327%, that CAPITAL LETTERS don’t stand a chance against actual data, and there is nothing whatsoever in this data set that he himself cites to support the notion that HRAs reduce cost by HALF, or for that matter any amount. Indeed, in 5 of the 6 periods studied, the study group had higher costs than the comparison group. The study group did better in the final year, three years after taking the HRA. This is likely because by that time they had forgotten all the useless and, as we’ve been learning, incorrect advice that HRAs provide.
Enter Joe Andelin, who plowed through 200 pages of Kaiser Family Foundation survey data, publishing the results on the American Journal of Managed Care blog on May 1. Lest anyone not be looking forward to slogging through an academic article, let me assure you he sounds more like me than I do, starting with his opening line:
Will Rogers once said, “The income tax has made more liars out of the American people than golf has.” Health risk assessments (HRAs)…could give taxes a run for their money.
The key findings in his transparent and replicable study:
- Incentives and penalties are effective in getting employees to complete HRAs, but…
- …Companies with a high percentage of HRA completion spend more money on healthcare than companies with a low completion rate — and the companies that don’t offer HRAs at all have the lowest spend of all.
I wouldn’t infer causation from this correlation. That’s because most employees, having been burned in the past by (for example) taking HRA advice to get more prostate exams and eat less fat, now have the good sense not to take the advice offered on HRAs like Cerner’s or Optum’s. Rather, I suspect the causation works as follows: companies that actually think completing Cerner’s or Optum’s HRA is a good idea have applied their very stable genius insights to the rest of their health benefit structure…and hence spend more money.
There are plenty of other shocking factoids in this article as well, so I would encourage people to read the link.
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A Triathlete’s Perspective on Workplace Wellness
We frequently get complaints from “average” employees about wellness, and our most popular Huffpost was about the fat-shaming aspects of wellness programs that obsess with BMIs. (Weight discrimination under the guise of weight control is one of the hallmarks of wellness, of course.)
But what about triathletes? What about people for whom those wellness incentives are a complete windfall? They can collect money for what they do anyway, sort of like when you buy something at a store and don’t learn it was on sale until you check out. Obviously, as the beneficiaries of these programs’ largesse (at the expense of other employees indirectly, of course), fitness buffs should embrace wellness, like –to quote wellness apologist Larry Chapman — “a beloved pet.”
Sure, if that pet is the Hound of the Baskervilles.
(Note to the literal-minded. This isn’t actually the Hound of the Baskervilles, who declined to sit for a photo session. This isn’t even a dog, as far as we know.)
I’d encourage you to read this critique of Virgin Pulse’s program in its entirety. You’ll have to scroll down through the blog post (not too fast–you’ll miss the review of Quizzify) to Comment #3, but it’s worth a full read to capture the essence beyond these excerpts.
First, Virgin Pulse — here’s a shocker — can’t do math. Because of their innumeracy (also one of the hallmarks of wellness), Virgin is accomplishing exactly the opposite of what wellness is supposed to do:
When I ran 5 miles in 50 minutes, at a 10-min/mile pace, I got more points for having >45 min of active minutes, but when I actually ran it faster, say, 8-min/mile pace which gave me a 40 min time, I only got >30 min activity, and fewer points, despite performing a much harder task. Nothing like being punished for being successful.
And Virgin Pulse apparently can’t do wellness either (yet another hallmark of the wellness industry):
Those of us who lift weights and do things that do not have “steps” but require greater physical acumen are greatly disadvantaged. Sadly, most government programs place a higher priority on “aerobic” activity rather than strength training. This “cardio = fitness” mentality is about is about 30 years behind the times.
She of course is completely correct about this on multiple dimensions. Virgin Pulse’s information is way out of date, outdated information being — you guessed it — yet another hallmark of the wellness industry. Among other things, giving “points” for cardio but not strength will increase back pain and other musculoskeletal problems–which account for a vastly higher share of employer health spending than the 1-in-800 incidence of heart attacks–in two different ways:
- Strength exercises are now shown to be the best way to prevent and control back pain;
- Obsessing with “steps” increases the likelihood of falls, sprains, and repetitive motion injuries.
At the risk of “burying the lead,” here is another thing Virgin managed to do:
It can also be annoying to be reminded constantly to get my mammogram. I am a breast cancer survivor and have had a double mastectomy. No mammograms for me. How insensitive of you!
After several paragraphs of other observations about the intrusiveness (still another hallmark of the wellness industry, in this case including monitoring employee sleep), she concludes:
The entire program is childish and silly. Another “social media” forum for people to get imaginary medals or stupid stuff while [Virgin] surreptitiously inserts little “healthy” reminders that may or may not be considered current health information. [Editors note: the majority of Virgin’s “1440 habit-building interactions per member per year” are either self-evident and cliched, outdated, wrong, unrelated to wellness, or controversial.]
I’m sure there are better ways to promote corporate fitness that are not insulting to the intelligence of adults. As a personal trainer and health coach, I’d be happy to give you a few ideas.
Here’s one idea: require wellness vendors to know the first thing about wellness.
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Larry Chapman Meets Where’s Waldo
Questions for The Chapman Institute’s Larry Chapman:
We are looking all through the study you cited in defense of Health Risk Assessments (HRAs) and cannot find the 50% savings from HRAs that you say is hidden in here somewhere. This study, despite your CAPITALIZED insistence to the contrary, seems to show the opposite: In 4 of the 6 study periods — and in all 6 periods combined compared to baseline — the control group spending was actually lower than the study group. So where is the 50% savings that we can’t find?
ANS: Refused to Answer
You say HRAs should be treated like “one of your children or at least a beloved pet”. Have you taken into account the possibility that some HRA respondents may lie, as Professor Woessner advised his Penn State colleagues to do, and as most of the people I know do since most people feel their personal lives should not be the concern of their employers?
ANS: Refused to Answer
Many people have questioned your understanding of arithmetic even before you found a 50% total healthcare cost reduction due to HRAs by reading the data excerpted above, so here is your chance to enlighten them. In this article below, you originally stated that Baicker’s analysis (which she has now backed off) reduced medical claims by “327%” and absenteeism costs by “273%”. How is it possible to reduce a number by more than 100%?
ANS: “Workplace Wellness Management” January 10 comment:
“You seem to conveniently forget that the editor of the CFO blog made the error, not me.”
Followup: You submitted, reviewed and signed off on the original “327% savings” and “273% reduction.” However — after a commentator pointed out the impossibility of those figures — the editor does acknowledge that you did notice at that point that 327% and 273% reductions in any number are not possible, and asked him to change the figures, first to the above 32.7% and 27.3%, but then to the 3.27-to-1 and 2.73-to-1 (now discredited) figures that were in the Baicker article. So in the narrowest sense of the word — after you made the initial, most revealing, mistake by misunderstanding that “3.27-to-1 ROI” and “327% savings” are not interchangeable figures — the editor of the CFO blog is acknowledging “the error,” by not making the final correction in a timely way. The larger point is that you did submit “327% savings” and “273% reduction” originally, raising the question of why anyone should believe the research findings of someone who doesn’t know that you can’t reduce a number by more than 100%.
ANS: Refused to answer
You also wrote in 2012 that studies show you can save 25% through wellness. Most of these studies took place in decades (1980s and 1990s) when dietary advice consisted of telling people to eat more sugar and less fat, and when the AHA gave Kellogg’s Frosted Flakes a “heart-healthy” label?. How could that kind of misinformed advice show not just savings, but savings 6x greater than the total amount that employers spend on wellness-sensitive medical events, which is 4%?
ANS: Refused to answer
They Said What? 