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The following is an unpaid apolitical announcement

We live in an era which can’t exactly be characterized as bipartisan, but every review shows — and as you can confirm by playing the game yourself — all members of every party agree on one thing: Quizzify.

Why? Because employee health literacy is a huge issue. You can’t achieve a culture of health without achieving a culture of health literacy.  And quite literally the only company that addresses it — in an engaging Jeopardy-meets-health education-meets-Comedy Central format, no less — is Quizzify. Literally, the only company of any note. Try googling on “employee health literacy” if you want to see for yourself.

Put another way, why wouldn’t you want to improve health literacy? Is there an argument for keeping employees in the dark, when for about $1 PEPM you could enlighten them? Wiser employees make healthier decisions…and it’s your money they’re making those decisions with.

Or, viewed yet another way, a three-part question:

  1. What is the only expense your employees are allowed to spend unlimited amounts of your money on?
  2. What is the only expense employees can spend your money on without training in how to spend it?
  3. How do your answers to those two questions make any sense in combination, or even individually?

The specific occasion for this posting is a terrific article in Workforce about Quizzify, featuring one of Quizzify’s many valued customers (and such a power-user that Quizzify routinely incorporates her edits into the main question database), Debbie Youngblood of the Hilliard City Board of Education.  While we encourage reading the article in its entirety, here are a couple of tidbits, starting with a quote from Debbie:

“I’ve always felt that there was a need to have more [information] available to people as they go through their stages of life,” she said. “It always surprises me that we expect people to know how to achieve overall well-being. We’ve given them very little opportunity to know, understand and practice the things that might be beneficial…”

She also believes it’s valuable to educate adults on health-related topics because it drives conversation. She sees employees discussing topics and questioning the information gained through their health literacy program.

To summarize…

Employees are talking about Quizzify.  About what they learned, what surprised them, and what they would do differently now. By contrast, employee comments about conventional wellness can’t be repeated in a family publication like TSW. Here are some of the more printable ones.  Oh, yeah, and don’t forget these.  (To be fair, occasionally an employee does benefit.)

Another tidbit in the article describes (in as many words) how Quizzify and Hilliard have morphed “cheating” into “learning.” Employees are encouraged to look up the answers in order to improve their scores. That’s how they learn — which of course is exactly what Ms. Youngblood and Quizzify want them to do. So employees brag about what they’ve learned, whereas in other wellness programs they brag about how they cheat.

Consequently, companies that think they’re creating a culture of health are instead creating a culture of deceit. Call us wacky idealists, but for $1 PEPY (in lieu of the likely much higher fee you are paying now), you could replace that culture of deceit with a culture of health literacy. Why wouldn’t you?


Disclosure
TSW principals, while not salaried by Quizzify, have an ownership interest in it. However, this site is not affiliated with Quizzify and opinions expressed in this blog are our own. Except this one, which seems to be shared by everyone.

Wellness program quote of the day

An uberfit Ultimate Frisbee teammate of mine reported that his company’s wellness vendor asked if his doctor had measured his waist size.

“No,” my friend replied. “He’s not a tailor.”

The Great Debate, Part 6: Goetzel Throws HERO under the Bus

The question-and-answer period is now underway.  

If you are just joining the thread, this is Part 6 of The Great Debate, a November 2015 exchange between Ron Goetzel and me, at the Population Health Alliance Annual Leadership Forum. Part 5 is here.  You can download the audio here


1:09:00

To the question: “What would you do to reduce healthcare costs?” Ron replies that he is “focused on prevention.” And that’s the issue.   I point out that “too much of anything is bad for you, ours is already the most over-prevented society on earth, and these programs are all out of compliance with guidelines.”  All these programs screen everybody far more than guidelines advise. Here are the guidelines. Find anything other than blood pressure where the wellness industry’s obsessive annual screens are recommended.

[Postscript: after the debate, the Connecticut study came out, showing that overprevention through wellness increases costs, as one would expect.]


1:12:20

The moderator asks how can Quizzify be the most effective company in employee health education.  He challenges our 100% guarantee of savings. This is ironic. No wellness company offers any meaningful guarantee of savings, for the simple reason that it is mathematically impossible to save money in wellness.

Somehow in wellness, guaranteeing savings is a bad thing but losing money is a “good thing.” (Really, a direct quote — click on it.)  It’s curious to challenge someone’s own willingness to guarantee their own results as part of their own business.  Obviously, if my business judgment is wrong, Quizzify will fail. And what I didn’t say because I didn’t want to brag, is that people questioned my last business venture too, Matrix Medical. Fast forward: Matrix is now the most valuable population health company start-up of this millennium.  (Before you ask me to lend you money, we mostly sold out on the “cheap” in 2013 to a private equity firm named Welsh Carson.)


1:13:40

Ron Goetzel endorses Quizzify. He went on the website and played the game. “It was a lot of fun. Very clever.”  Then he asks — quite justifiably — how Quizzify can make problems like obesity and smoking go away.  The answer, of course, is that Quizzify isn’t going to make obesity and smoking go away any more than wellness does.  For example, consider McKesson’s Koop Award-winning program, where both weight and smoking went up.  We can’t do worse than that. If we did, we could win a Koop Award.

Instead, Quizzify guarantees reductions in overall healthcare spending on “low value care.” As you can see from the demo on the website, we also educate people on hidden sources of sugar, of which there are more than you can count, but we don’t expect immediate savings from this and other nutrition/smoking education questions. Immediate savings are provided by our emphasis on avoiding low-value care.


1:15:00

Consistent with his theme of running away from his own work, Ron now runs away from his own HERO Report.  Keep in mind two things as you listen to this section:

  • Ron is disowning his own report. He is on the board of HERO, a tidbit which he overlooks in this hasty retreat;
  • Within days of this debate, he was circulating his famous poison pen letter to the media completely owning it, and accusing me of reading it too carefully.

The moderator (who otherwise moderated fairly) for some reason jumped in and said the HERO Guidebook just used an allegedly hypothetical example to show losses.  Since their “example” costs were $18/employee/year as opposed to the more typical $100 AND since the HERO example failed to control for the countrywide decline in wellness-sensitive medical events, the HERO example grossly underestimated losses from wellness.

Ron says “those numbers in [my HERO Guidebook] are wildly off,” and “have nothing to do with reality.”  He says I “misrepresented and misinterpreted” these figures.  But they are right there: A program costs $1.50 PEPM and saves $0.99.  What’s to misinterpret?   Ron apparently hadn’t noticed that his little Guidebook accidentally told the truth until I pointed it out — exactly like he hadn’t noticed that Eastman Chemical/Health Fitness self-invalidated. In both cases if fell upon me to point it out to these Einsteins.

Here is a posting showing what happens when you adjust those HERO figures for Mr. Goetzel’s alternative “reality” — losses skyrocket, just like Health Affairs showed in the Connecticut study.

Perhaps HERO would have more credibility telling us that wellness saves money if their own allegedly* “fabricated” example and any of the legitimate literature supported that claim. I’m just sayin’…


*The word “allegedly” is used because the example in the HERO guidebook is not a “fabricated” or “hypothetical” example. The words “fabricated” or “hypothetical” do not even appear in the chapter. Instead the example is an actual report. That’s why the Guidebook says it’s a report, and gives very specific details of the report–in the past tense, no less, as you would for a completed report. A “hypothetical” would use the present tense throughout, along with saying that it’s a hypothetical.

heroreportp22language-on-report

And like:

hero-report-language-p-23

So Ron’s whole argument about this being somehow a hypothetical is shot, just like all his other arguments, by showing his own data.



To summarize Ron’s view so far in this debate: everyone who thinks wellness is a total waste of money — including RAND, basically all the media and every economist who has looked at it in the last six years — is wrong.  Every time his own materials accidentally tell the truth and say wellness loses money, they’re wrong.  

And as we’ll see in the next installment, every employee who hates their company’s wellness vendor is either in a bad program or they are a bad employee.

Basically everyone is out of step but Ronnie.

 

 

Tom Emerick reviews Quizzify: “There May Be a Cure for Wellness.”

Not all wellness vendors are as bad as Slate makes them out to be. Companies whose names begin with “Q” are doing quite splendidly.

Quizzify’s stack of stellar reviews and reviewers (see Employee Benefit News, Not Running a Hospital (Paul Levy), and Bob Merberg) now includes Tom Emerick, who just wrote an Insurance Thought Leadership review entitled: There May Be a Cure for Wellness.

Far be it from us to discourage anyone from reading the full review, but here are some excerpts:

“Quizzify…transforms the boring but long-overdue task of educating employees about health, healthcare and their health benefit into an entertaining trivia game.”

“Quizzify provides a plethora of shock-and-awe, ‘counter-detailing’ questions-and-answers (with full links to sources) that will educate even the savviest consumers of healthcare and entertain even the dourest CFO.”

“Scores and scores of people have told me they fudge answers on HRAs. Interestingly, they feel they are on the ethical high ground to do that because of the goofy, nosy and intrusive questions they are asked to answer, e.g., asking about your [future] pregnancy plans… Quizzify, on the other hand, encourages people to cheat. Quizzify wants you to look up the answers because that’s how you learn. So instead of denying human nature, Quizzify channels it.”

Tom also addresses the concern that employees might think Quizzify is all about trying to keep them from spending money on healthcare:

“On the other hand, there are instances where people should go to the doctor but don’t. Swollen ankles? Painless, perhaps, but you may have a circulation problem, possibly a serious one. Blood in your urine, but it goes away before you even make an appointment? That could be a bladder tumor tearing and then re-attaching itself, especially if you smoke. And show me one health risk assessment that correctly advises people over 55 or 60 to get a shingles vaccine if they had chicken pox as a kid.”

That last point is pretty emblematic of the difference between wellness and Quizzify. It’s a classic example of wellness vendors wasting opportunities to actually provide employees with useful information. Virtually no HRA advises shingles vaccines for the relevant subset of employees.

Conversely, to focus on one of the longstanding obsessions of wellness vendors, there are no questions in Quizzify where the answer is: “Buckle your seat belt.” We figure HRAs have that covered.

We would also observe that if your employees don’t realize they should buckle their seat belts, wellness is probably not your biggest problem.


Boring but Important Disclosure: While this blog is independent of Quizzify, I am a principal in Quizzify.

Four More Vendors Caught…Doing Something Right

The popular perception is that They Said What tries to catch vendors doing something wrong.  Nope – they generally self-immolate and we just take screenshots.  Or as we say, in this industry, “you don’t have to challenge the data to invalidate it.  You merely have to read the data. It will invalidate itself.”

Yet no matter how screamingly obvious the data, a journalist, essayist, or blogger loses credibility if they always say the same thing.  That’s why we try very hard to catch vendors doing something right.

For us to do that, vendors have to give us the opportunity – by actually doing something right. To avoid being judgmental, we like to see them independently validated for, in as many words, “doing something right.” Validated not just by anyone, but by the Care Innovations Validation Institute. Care Innovations, a wholly owned subsidiary of Intel Corporation, launched the Validation Institute in 2014 to provide companies with 3rd party validation of their outcome claims.   (Disclosure: while I am neither a Validation Institute employee nor an advisor, my book Why Nobody Believes the Numbers provides the methodological basis for some of their validations, and they sometimes retain me as an outside expert/validator.)

The Validation Institute is the Gold Standard of validation.  Everything is vetted carefully and has never been challenged. Validation can be done two ways: on the basis of valid contractual representations or on the basis of actual outcomes.  The vast majority of validated organizations have the former, because their outcomes to date are insufficient for the latter.  An example of contractual language validation would be Quizzify’s savings guarantee. (Disclosure: I founded Quizzify. The validation for Quizzify was obviously conducted by another of the Validation Institute’s team of 3rd party, independent validators).

While many companies guarantee or show savings, it turns out the language used in that guarantee or demonstration of savings determines whether savings can quite literally happen on their own due to faulty study design or whether they truly reflect underlying improvements.  Quizzify, for example, couldn’t get outcomes validation because it hasn’t been around long enough to apply these valid contractual representations/guarantees to its own outcomes.

By contrast, the four organizations below are among the few whose validation is specifically outcomes-based – meaning these companies took the next step and what they say they did, is what they actually did.

Even so, if you read the validation language carefully, you’ll see it never exceeds what the outcomes data allows.

Alphabetically, we look at each of these four in some detail, describing the outcomes that were achieved. Just to reiterate, these four companies are among the very few in population health that can lay claim to outcomes improvement, measured validly.  Why? Because any company that could get Validation Institute validation, would.  (Quizzify sought it as soon as we had language that could be validated…and are very pleased with the attention it has brought us and the doors it has opened.)

Evolent Health: Focused on the Most “Impactable” Patients

Evolent is the first value-based care company with a complex care management program to show savings.  Typically, companies compare the “pre” cost to the “post” cost, but anytime you target a chronic group that is high-need, high-cost, the “post” will always look better compared to the “pre.”  Statisticians dryly call this regression to the mean and many vendors claim credit for the decline in cost when it had nothing to do with their interventions.

Instead, Evolent showed savings the hard way – by actually achieving them.  They measured how much the cost of high-risk chronic patients declined on their own and then only took credit for the additional reduction. Suppose you have a magic potion to flip 100 coins from heads to tails.  If only 50 flip, your potion is worthless; the probability of landing on tails is already 50-50. If 60 coins flip, the Validation Institute would give you credit for 10.  Evolent showed that their program lowered utilization and costs beyond the reductions that would have happened anyway.

In a field known for the time lapses between a patient’s need for care management and its delivery, Evolent’s more advanced predictive modeling (covering more datasets than a carrier would typically use) expeditiously determine those at highest risk of having an “impactable” event.  Further, whereas most such programs focus on just checking off boxes, Evolent intervenes across the spectrum of clinical, behavioral, social, nutritional and environmental domains.

Having reviewed many of these programs, I’ve been shocked by how long it takes them to find and enroll patients, how little they do for the patient, and how little they know about what they’re doing. Evolent is the opposite.  This is their business, not a sideline – they take it seriously and it shows.

Healthways Well-Being: It’s Not Just about the Cholesterol

For the uninitiated, the philosophy of well-being is to address gaps not just in employee physical health but – as importantly – in their emotional, financial, occupational and social health.  In many cases, those latter issues are the root cause of high healthcare spending and low productivity.  Addressing those issues should help a given population – from the healthy to the sick – perform noticeably better while possibly spending less on healthcare.

Before you even heard of “well-being,” Healthways was measuring it, more than a decade ago. Since 2008, Healthways has partnered with Gallup to definitively measure well-being via the Gallup-Healthways Well-Being Index, the most proven, seasoned and comprehensive measure of well-being in populations in the world.  Quite literally, if there is any component of this industry which has penetrated the public consciousness in a positive way, it’s the Gallup-Healthways Well-Being Index, whose publication often reaches the lay media.

Healthways can use surveys, down to the community level, to benchmark similar surveys for companies, departments and employees, so that organizations can focus their improvement efforts where they are needed most.  The Validation Institute has confirmed Healthways’ findings that in fact performance (holding constant as many other variables as possible) correlates far more closely with indicators of well-being than with biometrics alone.  This data collection, insight and benchmarking allows targeted interventions to complement or replace conventional wellness…and get closer to the root cause of underperformance.

Rarely is the root cause of poor health “I-don’t-care-itis,” as one wellness vendor calls it. Often it’s a different personal issue. Sometimes the root cause is department-specific. This data can be used to identify managerial or process flow issues far beyond the scope of – and far more powerfully than — conventional wellness.

Quantum Health:  the Story Tells Itself

While I make more general comments about the other vendors on this list, I don’t need to for Quantum Health. They were the first and are still the only company validated for total savings across an entire organization.

Instead I will share a story that shows how their incentives for members to call in – combined with their non-siloed approach to those calls – create a confluence of time and place that change behaviors and likely outcomes.

Once, when I visited them, an employee of a new customer called, asking if diabetic shoes were a covered benefit. In most, if not all, carriers, the employee answering that query would be evaluated based on accuracy of the answer, number of rings, politeness and how many calls they handled that hour. So the person would say “yes” or “no” and then get off the phone. At Quantum Health, the agent answered the query but was prompted by the supporting software (and by training) to recognize that question as a red flag. Here was an employee whose diabetes was already so advanced he was asking about shoes…and yet he was nowhere in the diabetes registry. A typical carrier wouldn’t find out about this person until after the inpatient claim for his inevitable crash was filed, warehoused, prioritized and queued for telephonic outreach. And then, assuming the carrier had the correct phone number, and this patient answered the call and was receptive, rehabilitation could begin.

And yet there he was – right on the phone – asking for help. So the agent probed a little further and then transferred him to a nurse in the same pod, who engaged him right away, almost certainly avoiding or forestalling a future high-cost medical event.

US Preventive Medicine: Finding the Formula

The editor of the American Journal of Health Promotion, Michael O’Donnell, famously admitted that up to 95% of wellness programs fail. U.S. Preventive Medicine is squarely in his other 5%.  As quite literally the purest wellness program validated by the Validation Institute, USPM has – alone in the wellness industry – found the formula for a significant and sustained reduction of wellness-sensitive medical events (hospitalizations and ER visits).

The Validation Institute analysis showed that USPM generated a sustained average 41% reduction of hospitalizations and ER visits across several chronic conditions (Diabetes, Asthma, Coronary Artery Disease, Hypertension, Chronic Obstructive Pulmonary Disease and Congestive Heart Failure) over a four-year timeframe, significantly outperforming the averages as tallied by the Healthcare Cost and Utilization Project (HCUP). USPM provides a unique data-driven, high-tech and high-touch combination of conventional and unconventional interventions to enhance engagement and translate that engagement into actual behavior change.

The Validation Institute has publicly urged all wellness vendors to collect real data, apply their value event rate-based template (the only methodology that They Said What and HERO agree on, as also described in Health Affairs), to see if they can match USPM’s performance…and so far, none have come close.

Michael O’Donnell might have been optimistic in his assessment—the failure rate seems much higher. But it’s not 100% — USPM is the exception that proves wellness can indeed be done successfully…if all the components fit together.

Goofus and Gallant Meet Viverae and Quizzify

Goofus and Gallant is a Highlights for Children feature contrasting different behaviors.  Example:

goofusGallant2


Viverae’s and Quizzify’s guarantees lend themselves to this type of comparison. Honestly, we don’t even know if Viverae still offer theirs. Nonetheless, through the years a number of people have sent it to us and asked for our help interpreting it. (That’s a polite phrasing of what the emails said, and of course we are nothing if not polite.)  It provides an excellent opportunity to learn how to read a guarantee with a discerning eye, and we thank Viverae for offering it and hope they too are able to gain some insights from our analysis of it.

Here is Viverae’s guarantee, which we will review clause by clause:

viverae


Goofus: Viverae’s Clause #1 doesn’t allow any leeway in program design.

Gallant: Quizzify offers the guarantee even if you want to tweak the program design.


Goofus: Viverae’s Clause #2 is an EEOC violation. You can’t “require” employees to do biometric screens. The program wouldn’t be voluntary. You might as well just send a memo to your employees with the phone number of the EEOC and tell them to sue you.

Gallant: Quizzify guarantees no EEOC lawsuits, and actually indemnifies against them.


Goofus: Viverae’s Clause #3 would seem fairly self-evident–except that in wellness, as the example at the end of this posting* shows,  some wellness vendors don’t know there are 12 months in a year.

Gallant: Quizzify assumes its customers know that a year has 12 months in it, so this clause isn’t part of our guarantee.


Goofus: Viverae’s Clause #4 requires you to not only sign up for 3 years to get this 20% guarantee in the third year only, but also to waive your rights to early termination.  So basically they are saying: “If you sign up for 3 years with no ‘out’ clause, we might possibly give you a guarantee worth 6.67%/year on average, assuming we measure validly.”

Gallant: Quizzify’s price list offers customers discounts exceeding 6.7% a year for multiyear contracts anyway, even before any guarantee, and allows not-for-cause termination for a small upcharge.

Gallant: Quizzify’s guarantee is 100% in all years, not 20% in year 3.


Goofus: Viverae’s Clause #5 requires a minimum number of 1000 employees, making it off-limits to more than 98% of America’s employers.

Gallant: Quizzify offers a straight 100% satisfaction guarantee if the number of eligible employees is too small to measure savings objectively.


Goofus: Viverae’s employee incentive/penalty requirement in Clause #6 is the “maximum allowed by law.”

Gallant: Quizzify requires a minimum incentive of only $100. We believe that the program should be attractive enough that you don’t need to force employees to participate.


Goofus: Viverae’s Clause #7 requires all carriers and PBMs for all years to turn over all employee-identifiable claims files. Since Viverae is not HIPAA-compliant, that creates a HIPAA issue.  (In all fairness to Viverae, most wellness vendors are not HIPAA-compliant. Quizzify is the exception.  Quizzify doesn’t collect or store private health information, so HIPAA doesn’t apply.)

It also means Viverae determines how much money Viverae saved, with no oversight.

Gallant: Quizzify allows the customer or its consultant to complete its simple claims extraction algorithm and determine savings, or Quizzify can do it for them. Its claims extraction algorithm is the industry standard required by the Intel-GE Care Innovations Validation Institute.

Speaking of the Validation Institute, Goofus’s guarantee is not validated by them.

Quizzify’s is.

validation institute seal


Postscript:

Gallant reminds readers that both he and Goofus are trademarks of Highlights for Children so don’t even think about using these characters without attribution.

Goofus sprinkles Gallant’s DNA at crime scenes.


*Avivia “three-year” study of drug adherence:

kaiser three year study

If you like this example, you’ll love This Is Your Brain on Wellness

Something in Wellness that Actually Works (Pinch Me)

Yes, I know it’s not always about me (my ex-wife was quite clear about that) but we did just receive our first “review” of Quizzify from a major, highly respected healthcare blogger, Paul Levy, former CEO of Beth Israel-Deaconess Medical Center in Boston. (Disclosure: I do know Mr. Levy socially, but nowhere near well enough to convince him to lie for me.)

Because there are so many new scams in workplace wellness to expose (and every time we expose one, they come up with another, this being our favorite example of invalidity-meets-Whack-a-Mole), we don’t have time for a lot of selfies.

Today is one of those rare exceptions.  Here is the summary of the review:

“If I were in the corporate world, I’d seriously consider offering this service to my employees.  The messages learned are much more likely to have a beneficial effect on people’s health and on their use of the health care system than a lot of the more invasive programs being forced on employees.”

 If anyone out there would like to play the Launch Quiz — the first step in creating a culture in which employees understand that wise and cost-effective choices in healthcare extend way beyond eating broccoli, obsessing with cholesterol, walking 5000 steps, and buckling seat belts — let me know and I’ll set you up.


 

Update January 12: Here is a comment submitted on the original blog. We think it captures the essence of workplace wellness — the bewilderment by an employee that HR thinks these things could possibly save money, and the running joke in this person’s office that the program has become:

My employer has added a wellness program. I’m not sure if its the same category as the Safeway ones that you refer to, but what it does is give funds to a health-care account for completing programs run by an outside wellness company about healthy eating, meditation, stress, etc. You can get $100 or so in real money (spendable only on health care) for doing these, up to a capped amount. So the cost to the company is this money plus whatever the 3rd party charges to run it.

If the research shows these to be effective, I can’t imagine how. People joke about going “click, click, click” until they’ve completed as much of a program as they are allowed that day, then coming back a day or two later for more.

 

 

Just because it’s healthcare, doesn’t mean it’s good for you

Wellness is about pushing employees into the healthcare system, almost always both against their will and their better judgment.  This story is a perfect example of the consequences of how too much healthcare can be hazardous to your health, and why your best defense against overdoctoring is knowledge.

Once you start asking questions, doctors have to start answering them.  While many doctors welcome that, others start fidgeting.  If your doctor is one of the latter, it’s probably time to switch.

I myself get occasional bladder tumors.  Ironically — and once again, showing the unintended consequences of wellness — I got bladder cancer from eating more broccoli, which of course is exactly what wellness programs would have us do.  (And which, in all fairness, is generally a good idea.)  The problem was that the broccoli was grown in a garden that was way too close to railroad ties, which leach creosote into the soil.  Creosote causes bladder tumors.

So every few years, one grows back and has to be scooped out “non-invasively” (that’s easy for the doctor to say).  And every year I go in and get checked, also “non-invasively”.  After my last check, the urologist — a new one, whom I had never seen before — suggested a CT scan of the kidneys and ureters.

I asked her why, and she said, because I had had bladder cancer for 15 years and never had this scan.

I replied: “Well, I founded a company, Quizzify, that educates on overutilization.  CT scans have 500 times the radiation of x-rays, and that particular set of views is likely to spot tumors on my adrenal glands that are completely clinically insignificant, and yet once spotted will be tracked and possibly removed, for no good reason other than that they are there.”

She said: “OK, why don’t we just start with a urinanalysis.”

Quizzify Q in B and W

Quizzify Q&A is your tool to save employees’ time & money

From a hazardous and likely counterproductive $1000 scan to a $10 urinalysis in 30 seconds.  That’s what knowledge is worth.

 

 

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