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Google on “Wellness vendor compliance with US Preventive Services Task Force guidelines” and here’s what you’ll see:
No results found for “Wellness vendor compliance with US Preventive Services Task Force Screening Guidelines”.
And there’s a reason for that. Most wellness vendors are out of compliance. Now, re-google that phrase sans quotation marks. Most of the front-page “hits” are me complaining how wellness vendors are out of compliance, with Bravo being the one that comes up first. Another hit has Wellsteps saying:
The U.S. Preventative [sic] Services Task Force has established guidelines that indicate when it is appropriate to get screened, based on age, gender, and the presence of risk factors. It is NOT recommended that an entire employee population be screened every year.
And that’s an accurate assessment, a rare instance of Wellsteps being honest (under duress, of course). You might say, well, at least they’re in compliance…but ironically Wellsteps got outed for flouting these very same guidelines about two months after they posted this paean to the USPSTF.
In sum, the USPSTF is the “gold standard” for all things prevention, and wellness vendors are in the business of all things prevention. One would therefore assume the wellness industry would be in sync with the USPSTF prevention guidelines. This posting (with two more to follow) explains how and why most aren’t, starting with a few basics.
Q: What exactly is the US Preventive Services Task Force?
This excerpt comes right off the USPSTF website, but given the apparent widespread vendor ignorance of USPSTF recommendations, perhaps vendor firewalls block their website. As a public service to the wellness industry, I’ll cut-and-paste it here:
Created in 1984, the U.S. Preventive Services Task Force is an independent, volunteer panel of national experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications. All recommendations are published on the Task Force’s Web site and/or in a peer-reviewed journal.
The government relies on the USPSTF to determine what should get 100% covered, to encourage prevention.
Q: What exactly is screening and how does it differ from testing?
A doctor or nurse practitioner might run a diagnostic test on a patient who should have one for clinical reasons. Like a doctor might say: “Your cholesterol was high last time, so we should test it again.” Or “You are overweight and have a family history, so I’d like to test you for diabetes.”
By contrast, a screen uses those very same tests (plus often a whole bunch of squirrelly ones) — but applies them to everyone, not just people who are indicated for them. Screening is a hunt for hidden disease in seemingly healthy, usually across an entire company, and screening vendors often get very excited when they can report how sick the employees are. This is called “hyperdiagnosis.” One vendor, Compass Health, calls this hyperdiagnostic process “I Feel Fine Syndrome.” They insist that feeling fine means you are probably sick, except that you haven’t been diagnosed yet. They’ve even trademarked the term. Think I’m making this up?
However, the fact is that, with a few clear exceptions like Pap tests, blood pressure, and the occasional cholesterol/glucose screen, the entire practice of screening is highly controversial. In Switzerland, for example, mammogram screens are no longer recommended at all. (You can get mammograms as a test, just not a screen.) The problem of overscreening and hyperdiagnosis is so widespread that one of my Quizzify colleagues wrote an entire, excellent, book on the futility and harms of using screens to hunt for diseases in an asymptomatic, generally well population.
Q: How does the USPSTF rate screens?
Grades are A,B,C, and D (and “I” — not enough evidence). They publish a summary recommended list of “A” and “B” screens. “C” screens are recommended for “for selected patients under individual circumstances,” a level of nuance requiring clinical competence far beyond the pay grade of most wellness vendors.
Note among other things that only a few screens are recommended as “A” for all adults, like blood pressure. Other are recommended only for people in certain age groups and/or with certain risk factors, like aortic aneurysm screening. (Nonetheless, plenty of vendors offer those screens on everyone, as long as the employer will pay for them.)
An example of a “D” would be a prostate (PSA) test, which is a vendor favorite. Even the inventor of the test says not to use it as a screen because it misses a lot of cancers and “finds” a lot of cancers that aren’t there. Last time I got screened, I specifically asked the vendor, Interactive Health, not to do a PSA because they are so unreliable, but the vendor did one anyway, along with about 40 other tests that are not recommended as screens.
Q: Whoa! You said the Swiss don’t like mammograms. Are you saying we shouldn’t encourage employees to get mammograms?
No. The USPSTF says employees over 50 should get them every two years. These are screening recommendations. That means for women with no risk factors. If you have reason to believe you carry the BRCA gene or are at high risk otherwise (such as having had breast cancer in the past, or a family history), then by all means discuss a different schedule with your doctor.
Q: So the Swiss are wrong? The Swiss are never wrong about this kind of thing.
They may not be. Really, no one knows. And there is nothing to “know.” Breast cancer screening, like all other screening, involves a trade-off between benefits and harms. The USPSTF reaches a different conclusion than Switzerland does because “ties go to the runner” for USPSTF. If evidence isn’t compelling enough one way or the other, they draw the line in favor of more frequent screening.
If your average person understood biostatistics, the USPSTF wouldn’t have to publish recommendations. Each person might look at the same data on harms and benefits and decide, presumably in consultation with their doctor, whether to shake the dice on testing and followup. Guys, would you get a PSA screen if there was a 1-in-20 chance that the follow-up would possibly ruin your life, but a 1-in-1000 chance that your life would be saved?
We can all reach different conclusions there. Women should see the next Q&A for the analogous screen.
Q: How can something as simple as screening cause harm?
Go back to that article on Switzerland and you’ll see some incredible data about overscreening harms from mammography. For every breast-cancer death prevented in women over a 10-year course of annual screening beginning at 50 years of age, 490 to 670 women are likely to have a false positive mammogram with repeat examination; 70 to 100, an unnecessary biopsy; and 3 to 14, an overdiagnosed breast cancer that would never have become clinically apparent.
Those are examples of the numerical harms of over-screening. Some of the harms are numerical, while others can’t be quantified. The ones quantified above include:
- False positives, causing people to seek unnecessary, and possibly harmful, follow-up;
- The harms or unreliability of the followup itself, such as prostate, breast or lung biopsies;
- The possibility that the biopsy will itself be a false positive.
Other harms of screening that can’t be quantified include:
- False negatives, causing people to become complacent if they see unexplained symptoms;
- The possibility of missing the most-aggressive and fastest-growing tumors that grow between screening sessions, but catching those slow-growing or otherwise clinically insignificant tumors which may not do harm;
- “Detecting” many cancers that are better left undetected because they will do no harm;
- “Detecting” things you can’t or shouldn’t do anything about (for instance, prostate cancer is increasingly “treated” by doing nothing)
- Findings that are not the focus of the screens, called “incidentalomas,” that have a very high chance of being clinically insignificant;
- The harms of screening itself, such as radiation, or physical harm, as in colonoscopies;
- The psychological harm of being told you’re sick when you aren’t, which vendors love to do — see the Nebraska case study, another perfect example of the aforementioned hyperdiagnosis.
Q: But most of these tests are at least 90% accurate, so aren’t misses rare?
There is also widespread misunderstanding of the arithmetic of misses. Consider this example.
Excluding people already diagnosed with coronary artery disease or already known to be at high risk for whom screenings are redundant, maybe 1 in 1000 employees will suffer a heart attack this year. Let us assume that there is a magic blood test, far beyond today’s technology and predictive potential, that would be 90% accurate for finding the unsuspecting employees who will suffer a heart attack this year.
If an employee tests positive, his odds of a false positive are not 10%, as would be expected if a test is 90% accurate. Quite the contrary, despite the magical accuracy of this hypothetical screen, testing 1000 employees will result in about 100 positive findings, only one of whom will have a heart attack. Meanwhile, the other 99 employees testing positive will be subject to unnecessary follow-up tests, drugs, and possibly stents.
That’s why it costs a million dollars to prevent a heart attack via screening.
While patients could be expected not to understand this arithmetic, even doctors appear to vary greatly in their understanding of false-positive arithmetic. If doctors, following many years of college, medical school and supervised training, cannot understand these harms and this arithmetic, how is it possible that wellness vendors could do better, despite the industry’s lack of requirements for education, training, testing, licensure, compliance, and ethics?
Coming up: Part 2 — Wellness vendors vs. the USPSTF
To our new readers, while 2016 marked the first instance in which a Koop Award was ever bestowed upon a company that harmed employees, 2016 wasn’t the first Koop Award ever to go to a company whose own data showed they fabricated results. Below is a history of one of the Koop Award’s Greatest Hits.
For those of you who haven’t been following the saga of the Nebraska state employee wellness program, here is a crash course, aka “Lies, Damn Lies, and the Nebraska State Wellness Program.” If you have been following it, you can skip to the end for the latest installment, Mr. Goetzel’s cover-up of his cover-up.
By way of background, this program is called “wellnessoptions” (imagine e.e. cummings-meets-poking employees with needles-meets-a sticky spacebar). They used to say the Holy Roman Empire was neither Holy nor Roman nor an Empire. Likewise, wellnessoptions is neither optional, if you want a decent deal on healthcare, nor wellness. Instead of wellness, it features a hyperdiagnostic anti-employee jihad in which Health Fitness Corporation (HFC) diagnoses employees but does nothing about the diagnosis except take credit for it.
TIMELINE — PART ONE: HFC’S TROUSERS COMBUSTED
September 24, 2012, 2:00 PM
I read Health Fitness Corporation announcement that its customer, the state of Nebraska, won Ron Goetzel’s C. Everett Koop Award for program excellence.
September 24, 2012, 2:01 PM
I recognize that the cancer outcomes were obviously made up. Until then, I hadn’t been following the Koop award closely enough to realize that making up outcomes was apparently one of the award criteria, as I later came to learn.
I read the full write-up on the program and realize that not only were most of the other outcomes made up, but they had actually lied about saving the lives of cancer victims. If you screen a few thousand people for colon cancer, you don’t find 514 cases of cancer, and you certainly don’t save their lives, as HFC was claiming. And you absolutely don’t save money, as they were also claiming. All this is even more true when you waive age-related guidelines and let anyone get screened, and encourage overscreening by sending out 140,000 letters to state employees graced with the picture of a beautiful young model way too young to be getting a colonoscopy.
How this invalid nonsense ever got by all the eagle-eyed Koop Committee members would be a mystery, except that HFC is a sponsor of the Koop Committee.
I review the entire application and all the marketing materials. It becomes obvious that the entire thing was made up, not just the cancer part. They claimed to save $4.2 million because 161 of their roughly 6000 participants reduced a risk factor.
The math is quite self-evident. Suppose you doubled the number of participants who reduced risks to 312. It stands to reason that you could save $8.4-million. Double it again to 624 and you save $16.8.
Now double it one more time. If 1,248 people out of those 6000 reduced one single risk factor, you’d save $31.6-million, which is about equal to the entire spending for all 6000 participants. And of course most medical spending has nothing to do with identifying previously unrecognized risk factors, so this would be quite a feat. (Do you even know anyone under 65 who had a heart attack that could have been avoided by one more workplace screening?)
I later learn that all the Koop Award-winning program outcomes are made up, using exactly the same math.
November 2012 to June 2013
I try to contact the authorities, like Roger Wilson, who allegedly runs this program for the state, but no one seems to care. The rule of thumb in the wellness industry is that what you say counts. What you do is pretty irrelevant.
June 20, 2013
Breakthrough: The Wall Street Journal editors decide that I am correct, and that the outcomes were made up. Vik and I are allowed to publish this on their op-ed page.
July 14, 2013
Breakthrough again: Another very well-read blogger professes shock-and-awe that any vendor could lie so blatantly and apparently get away with it.
July 15, 2013
Breakthrough yet again: Ace reporter Martha Stoddard of the Omaha World Herald gets Dennis Richling of Health Fitness Corporation to admit that the outcomes — at least the “life-saving catches” of “early stage cancer” outcomes — were indeed made up. Richling tries to spin his gaffe by calling the difference between “life-saving catches of early-stage cancer” and saying someone might possibly get cancer in the future “semantics.” So, according to Richling, having cancer and not having cancer are the same thing.
February 1, 2014
The hilarious wellness industry smackdown Surviving Workplace Wellness is published. Since the HFC Nebraska program had too many lies to fit on a page or two, it gets its own chapter. Here’s the opening paragraph, which in all modesty I must admit is one of my favorite in the book.
February 23, 2014
Nebraska political blogger ReadMoreJoe picks up the scent. He points out that this wellness program is an obvious fraud. The problem is that the same posting is also exposing several other equally obvious frauds, so this one gets overlooked.
TIMELINE–PART TWO: GOETZEL STRIKES BACK
Ron Goetzel isn’t about to sit back and let his friends/sponsors/clients be pilloried for a little white lie about saving the lives of cancer victims who didn’t have cancer.
June 2, 2014
At the Health Datapalooza conference, Ron Goetzel, while admitting the Nebraska cancer outcomes data was made up, claims they/HFC still deserve the Koop Award because he somehow didn’t realize the data was made up at the time the award was granted. And it is true that HFC didn’t actually announce they had made up the outcomes. Ron would have had to actually read the materials to figure it out, same as I did.
Ron Goetzel calls the Nebraska program a “best practice” in the Journal of Occupational and Environmental Medicine but refuses to answer any questions about the obvious mistakes and inconsistencies in the article.
After knowing for 16 months that they had lied, Ron Goetzel, writing in Employee Benefit News, finally drops Nebraska from his list of best-practice programs:
Being a fair-minded person, I take it upon myself to congratulate him on his newfound sense of ethics. I don’t specifically agree that what he did was ethical, because the ethical thing would have been to admit complicity, apologize, and revoke their Koop Award. But I do say that Nebraska being dropped from the list of best practices means ethical “progress is definitely being made,” albeit from a low base.
Only 29 minutes elapses before Ron erases all my illusions about his honesty and re-adds Nebraska to the list of “best practice organizations.”
He also adds PepsiCo to the list. I guess losing only $2 for every $1 you spend qualifies as such in wellness, where most organizations lose much more.
In a rally-the-base invitation-only webinar, we are told that Ron has promoted the Nebraska program from “best practice” to “exemplar.” It seems like the more obvious it becomes that the whole thing was fabricated, the more Mr. Goetzel worships its outcomes.
TIMELINE–PART THREE: RON STANDS ALONE
WELCOA finally takes the fabricated case study of Nebraska’s outcomes off their website, 26 months after the fraud was admitted. Perhaps some pressure is being put on them to come clean, given that this is Nebraska’s program and they themselves are based in Omaha.
Just for the record, I’m not saying that an organization founded by all-you-can-eat cafeteria magnate “Warren Buffet” knowingly kept a false document on their site for those 26 months. History suggests they might just be slow learners. [2016 update: WELCOA is under new management, and they appear to be doing a great job, as exemplified by their development of the Employee Health Program Code of Conduct.]
This means Ron Goetzel is literally the only person left who thinks it’s perfectly OK — indeed, a “best practice/exemplar” — to lie about saving the lives of cancer victims. Good luck with that in the upcoming debate. It’s him against the world.
Or, as he sees it, everybody’s out of step but Ronnie.
Nebraska tentatively re-awards the wellness contract to Health Fitness Corporation. I am looking over the precipice towards utter humiliation.
TIMELINE–PART FOUR: THE ORIGINAL DATA DISAPPEARS
November 2, 2015–the original cover-up, on the morning of the Great Debate
At our urging, a third party alerted Mr. Goetzel to the fact that, his protestations to the contrary, the Koop Award Committee did know (even if they had somehow not seen the marketing materials quoted above) that Health Fitness Corporation was making fictitious claims about saving the lives of cancer victims. It was right in the award application. The original award application from Nebraska had originally stated (underlining is ours):
But then, a hour following the call from this third party the morning of the debate, the original award application suddenly read:
In the original application, this excerpt appears in a letter from the Governor of Nebraska. Only now the Governor’s letter says the opposite what he actually wrote. In the real world, this would be considered forgery. In wellness, a forged cover-up of a blatant and admitted lie about saving the lives of cancer victims who didn’t have cancer is considered business as usual. Johns Hopkins and Truven (Ron’s employers) don’t seem to mind either.
The state is rescinding its award to Health Fitness and terminating its wellness program. In the immortal words of the great philosopher Stewey Griffin, victory is mine.
September 2016: The cover-up of the cover-up
Mr. Goetzel finally acknowledges that Health Fitness Corporation told a whopper, and the Koop Committee overlooked it, allegedly by accident, for the four years during which I’ve repeatedly pointed it out.
He now calls this an “erratum.” However, the word “erratum” is usually used to correct honest mistakes (in sharp contrast to this one), usually within hours or days of their discovery (in sharp contrast to this one). You can’t forge official state documents and then call the whole thing an “erratum.” Is a robber allowed to give the money back after he gets caught and just uncommit the crime?
So now, having admitted that the award-winning vendor told the biggest lie in wellness history (against stiff competition), and knowing that all Nebraska’s obviously fabricated savings were mathematically impossible, and that waiving age restrictions for screening is akin to waiving age restrictions for buying beer, the Koop Committee finally, after four years, rescinded the Nebraska award.
Haha. No one falls for that line any more. Quite the opposite, they are doubling down. They say that whopping lies like this one don’t disqualify you, assuming you are an award sponsor. You get to keep your award.
Ditto, if your entire claim of “separation” between participants and non-participants is shown to be false but you are sponsor, Ron merely doctors the data and you get to keep your award.
Also, if it turns out you lied about your savings because there was no change in the biometrics to attribute the savings to, but Ron was a consultant on your project, you get to keep your award.
Likewise and as was confirmed in 2016, if you are a committee member, as Wellsteps’ CEO was until recently, despite your own data showing that you actually harmed employees, you get to keep your award.
Bottom line: as a friend-of-Ron, you might get to keep your award even if you shoot someone on Fifth Avenue.
No program epitomized conventional “pry, poke and prod” wellness more than Nebraska’s state employee wellness program. And by that of course I mean no wellness vendor has ever lied about outcomes more blatantly or won more awards than Nebraska’s state employee wellness program vendor, Health Fitness Corporation. (Blatantly lying about outcomes and winning Koop Awards, in the immortal words of the great philosopher Frank Sinatra, go together like a horse and carriage.) Their big mistake was admitting it. (See the timeline link.)
Not to mention the cover-up of the lies, that Ron Goetzel and his Koop Committee friends botched so badly that the state’s HR team and procurement department could no longer do the Sergeant Schultz thing. I guess now, finally, Mr. Goetzel will stop referring to this program as a “best practice.”
Now, the program is officially dead. It was close. On October 1, we thought we had lost:
But then last week, following a number of behind-the-scenes conversations and finally a bit of googling by the state:
In other words:
The Wellness Ignorati got their name by ignoring facts. Facts, of course, are the wellness industry’s worst nightmare. They ignore them In order to avoid creating news cycles that might reach human resources departments despite the best efforts of their consultants and vendors to shield them from actual information.
And they’re at it again.
First, Atul Gawande wrote a scathing article in the New Yorker about massive overscreening earlier this month. As Mitch Collins noted in The Health Care Blog, not a peep in response from the perpetrators of those hyperdiagnostic jihads. Nor has their been any response to Mitch’s article itself. Literally, no one defends wellness industry practices. And yet somehow all the laws are on their side.
Speaking of which, Mitch mentioned the famous Nebraska debacle, in which the vendor, Health Fitness Corporation, lied about making “life-saving catches” of “early-stage cancers.” Since HFC was a sponsor of Ron Goetzel’s Koop Award, Ron naturally gave them that prize for these lies.
However, we’ve thrown down the gauntlet. HFC, come on out and fight. Give us your side of the story. How was this not a deliberate lie designed to score political points in Nebraska? If it was a mistake, why didn’t you change it and apologize? How do those 514 cancer non-victims feel? And Mr. Goetzel, why do you not only keep defending HFC, but have even upped the ante? They’ve been promoted from “best practice” to “exemplar” in your most recent webinar.
Speaking of non-responses from Mr. Goetzel, where is the correction of or explanation for the massive mistake in Mr. Goetzel’s most recent wellness program evaluation? All those readers have been misled by his blog into thinking Graco’s costs/employee are $2280/year when in reality the cost per employee contract holder — according to Mr. Goetzel’s own blog — is about $11,100, like almost every other company. (That includes spouses and dependents but any reasonable dependent ratio would yield more like a typical $5000 to $6000 per employee rather than $2280.) I know he knows about this mistake because I’ve submitted a comment to his blog, which shockingly hasn’t been posted.
So, please, could someone actually respond for a change, even if it’s just to accuse us of bullying.