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Wellness vendors were into alternative facts before alternative facts were cool. They even expanded the domain to include alternative math, like Wellsteps showing that costs had increased and decreased at the same time.
Is Optum (United Healthcare) going a step further, into alternative ethics? Here are two Optum claims, which appear to be exactly the opposite of each other. Now, we aren’t going to call anyone an alternative fact-er, but we would invite them to explain — and we’ll provide equal time — how both these seemingly incompatible statements can be true.
First, the head of their wellness group, Seth Serxner, acknowledged that biometric screening is supposed to be done in accordance with guidelines. (The guidelines are reproduced below, by the way, since he seems to have trouble remembering them when he’s approving marketing materials.)
He insisted, on tape, that the only reason Optum flouts screening guidelines is because employers make them do it: “Many clients won’t let us [screen appropriately],” he said. The full tape can be downloaded from that link, but it is tough to find the audio. (The time stamps appear to vary by download. However, it is towards the end and you can manually sync by following The Great Debate in total, which starts here.)
So, on Seth’s planet, Optum begs employers to pay them less money by screening their employees at longer, more appropriate, age-adjusted intervals…and employers refuse.
However, it appears, based on the marketing material below, that the reason employers refuse to let Optum screen appropriately is that Optum requires employers to screen inappropriately. You read that right: “participation in our wellness program…is a requirement.” And that decidedly includes screening…which employers must pay extra for in order to get the “savings” on their premium.
They then go on to quote — you guessed it — Kate Baicker’s 7-year-old study based on alternative data that even she appears not to believe any more. The second alternative quote is attributed to WELCOA, a quote which WELCOA’s CEO, Ryan Picarella, assures me he never made, nor did anyone currently in his organization, and that he doesn’t believe.
Update: It was observed on Linkedin that the reason they do this (for their fully insured business) could be as an ACA play. You don’t mind if spending on claims increases because you need to get to 80% (or 85%, depending on size) loss ratio anyway. The screening isn’t counted towards the 85% because it’s not a claim, so you make money there too by charging separately. Brilliant! United Healthcare’s shareholders should be very impressed.
Here are the USPSTF guidelines, by the way, also reproduced below, albeit badly. (There is nothing wrong with your TV set. Do not attempt to adjust the picture.) This is actually the version published by “Choosing Wisely” (a joint project of Consumer Reports and the Society of General Internal Medicine), and they don’t totally sync with USPSTF, but whatever the minor differences are, neither looks anything like what Optum and their alternative friends advocate.
The best outcomes evaluator in the wellness field is Dr. Iver Juster.*
*Among the subset of males not affiliated with They Said What.
Why Dr. Juster’s Case Study Is the Best Case Study Ever Done in This Field
Chapter 2 of the HERO Guide is a great study and deserves high praise. But before we get into the salient points of what makes this absolutely the best case study analysis ever done in this field, be aware the provenance is not a coincidence. Dr. Juster is very skilled at evaluation. Indeed he was the first person to receive Critical Outcomes Report Analysis (CORA) certification from the Disease Management Purchasing Consortium. (Dr. Juster very graciously shares the credit, and as described in his comments below would like to be listed as “the organizer and visible author of a team effort.”)
Note: the CORA course and certification are now licensed for use by the Validation Institute, which has conferred honorary lifetime certification on Iver gratis, to recognize his decades of contribution to this field. (Aside from the licensure, the Validation Institute is a completely independent organization from DMPC, from They Said What, and from me. It is owned by Care Innovations, an subsidiary of Intel. If you would like to take the CORA Certification course live, it is being offered next in Philadelphia on March 27. You can take it online as well.)
Early in the chapter, Iver lists and illustrates multiple ways to measure outcomes. He dutifully lists the drawbacks and benefits of each, but, most importantly, notes that they all need to be plausibility checked with an event-rate analysis, which he provides a detailed example of–using data from his own work. In an event rate analysis, wellness-sensitive medical events are tracked over the period of time in question.
Wellness has never been shown to have a positive impact on anything other than wellness-sensitive events. Consequently, there is no biostatistical basis for crediting, for example, “a few more bites of a banana” with, to use our favorite example, a claimed reduction in cost for hemophilia, von Willibrand’s Disease and cat-scratch fever.
By contrast, real researchers, such as Iver, link outcomes with inputs using a concept called attribution, meaning there has to be a reason logically attributable to the intervention to explain the outcome. it can’t just a coincidence, like cat scratch fever. As a result, he is willing to attribute only changes in wellness-sensitive medical events to wellness.
Event-Rate Plausibility Analysis
Event rates (referred to below as “PPH” or “potentially preventable hospitalizations”) are laid out by disease on page 22 of the HERO Report. Note the finding that PPH are a small fraction of “all-cause hospitalizations.” Though the relative triviality of the magnitude of PPH might come as a surprise to people who have been told by their vendors that wellness will solve all their problems, Iver’s hospitalization data sample is representative of the US as a whole for the <65 population, in which chronic disease events are rare in the <65 population.
Gross savings total $0.99 per employee per month. This figure counts all events suffered by all members, rather than excluding events suffered by non-participants and dropouts. Hence it marks the first time that anyone in the wellness industry had included those people’s results in the total outcomes tally — or even implicitly acknowledged the existence of dropouts and non-participants. He also says, on p. 17:
For example, sometimes savings due to lifestyle risk reduction is calculated on the 20% of the population that supplied appropriate data. It’s assumed that the other 80% didn’t change but if some of the people who didn’t supply risk factor data worsened, and people who got worse were less likely to report their data, that model would overestimate savings.
Note that the PPH declined only in cardiac (“IVD”) and asthma. Besides the event rates themselves being representative of the employed population in the US as a whole as a snapshot, the observed declines in those event rates are almost exactly consistent with declines nationally over that same period. This decline can be attributed to improvements in usual care, improvements that are achieved whether or not a wellness program was in place. The existence and magnitudes of the declines, coupled with the slight increase in CHF, diabetes and COPD combined (likewise very consistent with national trends), also confirm that Iver’s analysis was done correctly. (Along with attribution, in biostatistics one looks for independent confirmation outside the realm of what can be influenced by the investigator.)
It is ironic that Ron Goetzel says: “Those numbers are wildly off…every number in that chapter has nothing to do with reality” when I have never, ever seen a case study whose tallies — for either total events or event reduction, let alone both — hewed closer to reality (as measured by HCUP) than this one.
Another factor that conveniently gets overlooked in most wellness analyses is that costs other than PPHs rise. By contrast, Iver is the first person to acknowledge that:
The implication, of course, is that increases in these costs could exceed the usual care-driven reductions in wellness-sensitive medical events. Indeed, Iver’s acknowledgement proved prescient when Connecticut announced that its wellness program made costs go up.
The $0.99 gross savings, and Connecticut’s healthcare spending increase, exclude the cost of the wellness program itself, of course. Factor in Ron Goetzel’s recommendation of spending $150/year for a wellness program and you get some pretty massive losses.
The old Al Lewis would close by making some reference to the dishonesty and cluelessness of the Health Enhancement Research Organization’s board. The new Al Lewis will do just the opposite. In addition to congratulating Iver Juster (and his co-author, Ben Hamlin) on putting this chapter together, I would like to congratulate the Health Enhancement Research Organization, for what Iver describes as the “team effort” in publishing it — HERO’s first flirtation, however fleeting and inadvertent, with integrity and competence.
Iver Juster Comments on the article
Iver reviewed this article and would like to add several points. I am only adding a couple of my own points, noted in indented italics:
- It’s important to credit the work to a larger group than just myself. I was the ‘lead author’ on the financial outcomes chapter of the HERO/PHA measurement guide, but the work entailed substantial planning and review in collaboration with the chapter’s coauthor (Ben Hamlin from NCQA) and members of the group dedicated to the chapter (as well as the HERO/PHA authoring group as a whole).
- Yes, I am more than happy to credit the entire group with this study, especially Ron Goetzel, Seth Serxner and Paul Terry.
- Nonetheless the work does reflect my perspective and approach on the topic – the important points being (a) select metrics that are impactible by the intervention or program; (b) be transparent about the metric definitions and methodology used to measure and compare the; (c) assiduously seek out potential sources of both bias and noise (in other words, exert the discipline of being curious, which is greatly aided by listening to others’ points of view); (d) understand and speak to the perspective of the study—payer, employee/dependents, clinician/healthcare system, society.
- Be particularly sensitive to the biologically-plausible timeframes in which your outcomes ought to occur, given the nature of the program. Even if optimally implemented with optimal uptake and adherence, we might expect ‘leading indicators’ like initial behavior changes to improve quickly; program-sensitive biometrics (lipids, A1C, blood pressure, BMI) and medication adherence to change in a matter of months; and a few program-sensitive ER/inpatient visits (like worsening heart failure or asthma/COPD exacerbations) to improve within several months (again, assuming the program is designed to address the causes of these events). Longer-term events like kidney failure, heart attack and stroke and retinopathy take much longer to prevent partly because they require sustained healthy behavior, and partly due to the underlying biology.
- This is one excellent reason that the measured event rate decline mirrored the secular decline in the US as a whole over the period, meaning the program itself produced no decline over that period. Possibly they might decline in future years if Iver is correct. Ron Goetzel would take issue with Iver’s assertion — Ron says risk factors decline only 1-2% in 2-3 years.
- Event rate measurement in any but the largest Commercially-insured populations is subject to considerable noise. Though a challenge, estimating ‘ confidence intervals should at least shed light on the statistical noisiness of your findings.
- No need this time because your results hewed so closely to secular trend, reflecting the quality of the analysis.
- It is very likely that the program used in the illustration did affect more than the events shown because it was a fairly comprehensive population health improvement initiative. For example, ER visits were not counted; and collateral effects of ‘activation’ – a very key component of wellness – were not included in this analysis. Assuming the 99 cents is an accurate reflection of the program’s effect on the events in the chart, I’d be willing to increase the actual claims impact by 50 to 75%.
- If your speculation is accurate, that would increase gross savings to $1.49 to $1.73/month–before counting preventive care increases indicated on Page 22.
- Nonetheless, to get effect from an effective program you have to increase both the breadth (number of at-risk people) and depth (sustained behavior change including activation) – but at a cost that is less than a 1:1 tradeoff to the benefit. In other words, you must increase value = outcomes per dollar. This cannot be done through incentives alone – as many researchers have shown, if it can be done at all, it must be the result of very sustained, authentic (no lip service!) company culture.
- We are beginning to pay attention to other potential benefits of well-designed, authentic employee / workplace wellness programs (of which EHM is a part) on absenteeism, presenteeism, employee turnover and retention – and, importantly, company performance (which is after all what the company is in business to do). It’s early days but it’s possible research will show that companies that are great places to work and great places to have in our society will find financial returns that far outstrip claims savings. The jury’s still out on this important topic but let’s help them deliberate transparently and with genuine curiosity.
- Did Ron really say you have to spend $150 per year PER MEMBER on a wellness program? I’d be thinking a few dollars (unless he’s including participation incentives)
- (1) Yes, he did say that; (2) no, he’s not including participation incentives; and (3) welcome to my world.
*Among the subset of males not affiliated with They Said What.
Alert readers may recall that my New Year’s resolution was to balance my negative postings about the wellness industry with positive ones. Like Diogenes searching for an honest man, I thought the finding the latter would be hard, but just as Romy Antoine also did earlier this month, The subject of this posting — to be named in Part Two — makes that easy. Part One sets the stage for the review of his study.
By way of background, in preparation for bringing a possible lawsuit, I re-read the famous Chapter 2 of the equally famous HERO report. That was the chapter which inspired Ron Goetzel, Seth Serxner and Paul Terry (who was recently anointed as the American Journal of Health Promotion’s new Fabricator-in-Chief) to circulate their defamatory letter about me to the media, in a singularly self-immolating attempt to discourage them from publishing my material. They insisted that Chapter 2 was pure fabricated nonsense, rather than a carefully analyzed report of real data. Here is an excerpt from their actual letter, copies of which are available from me but which is summarized here:
A fabricated…absurd, mischievous and potentially harmful misrepresentation of our data.
Ron said it best in our Great Debate, minute 1:17 in the MP3 downloadable here:
Those numbers are wildly off…every number in that chapter has nothing to do with reality.
However, the sun rises in the east, taxes are due April 15th, and Ron Goetzel is lying. Quite the contrary, Chapter 2 turns out to be a carefully analyzed report of real data — almost certainly the best case study ever published.
How did I learn that Ron was fabricating a story that his guidebook had fabricated a story?
- This chapter says it’s a real report, on p. 22.
- Since this chapter’s analysis was so far above the pay grade of those three aforementioned HERO characters, I checked the acknowledgements in the HERO book. Sure enough, none of the HERO cabal wrote it. Someone else (to be named in the next posting) was the lead author, and I called to congratulate him on it. I also asked him some background questions, one of which proved very revealing. It turns out that…
- This real analysis of real data was — get ready — reviewed prior to publication by the exact same people who are disowning it now. Yes, among the people who peer-reviewed it prior to publication were the very same Ron Goetzel, Seth Serxner, and Paul Terry. (In addition to them doing the actual review, the lead author, very graciously sharing the credit, wanted to make sure that I indicate that he was only the “organizer and visible author of a team effort.”)
Yes, as is so often the case with these three, they lied about the lies that they lied about. It’s quite ironic that their argument against my original praise of this analysis was to insist that because my source was their own lies, my own analysis was unreliable. These lies above don’t include the actual lies I might sue them about, which were lies about me, which are totally separate from their lies about their previous lies. (Their lie about me was that I had a history of outrageously inaccurate statements, none of which they have ever been able to identify.)
These characters aren’t ordinary run-of-the mill alternative fact-type liars. They’re way beyond that.
Their lies go to 11.
Having covered the also-rans last week, here are the first runners-up, as we inch ever closer to the coveted top spot. (To read the original postings, click on the numbered headers.)
Today we are highlighting more people and organizations who’ve made the wellness industry what it is. Wednesday we will complete the listing of the Stars of Wellness, the people and organizations who are making the industry what it should be.
Interactive Health conducted what may be the head-scratchingest screen in wellness industry, a difficult feat given all the competition. For starters, they tested me for calf tightness. It turns out my calves are tight–and right on-site they loosened them. I could feel my productivity soaring…until the left one went into spasm that night and I couldn’t get back to sleep. Still, I can see their point — loose calves are a useful trait for many common jobs.
Next, Interactive Health shattered the record, previously shared by Total Wellness and Star Wellness, for most USPSTF non-recommended blood tests. I don’t know what half these things are, which means neither does Interactive Health.
Where would a Deplorables Greatest Hits List be without the Koop Award Committee?
Every year, like clockwork, the industry’s biggest liars select the industry’s biggest lies. 2016 started with last year’s winning program, McKesson’s, being exposed as a joke in Employee Benefit News, and ended with this year’s winner, Wellsteps, being exposed as a joke in STATNews.
When bestowing this year’s award to their fellow Committee member, Wellsteps, they didn’t even pretend not to lie. And what lies they were! Not just regular-sized lies. Not even supersized lies. We’re talking lies that would make a thesaurus-writer blush.
To put their lies in perspective, I may not even know you, but if a Koop Committee member told me the sky was blue, and you told me the sky was green, I’d at least go look out the window.
PS Not everyone on the Committee is a liar. One person is quite honest and can’t believe what goes on every year. I don’t want to name my source because in Koop-land, honesty is grounds for termination. As is getting validation. Or adopting the Code of Conduct. Basically ethical behavior is off-limits. An executive of one group, Altarum, published a blog critical of wellness and <poof> the Committee disappeared them.
Michael O’Donnell seems to crave my attention. When he managed to go three whole months without being featured in a TSW posting, he came up with these irresistible nuggets:
- “Wellness is indeed the best thing since sliced bread, up there with vaccines, sanitation and antibiotics.”
- “[Wellness] can prevent 80% of all diseases.”
- “The ROI from wellness is very strong.”
- “Workplace health promotion may play a critical role in preserving civilization as we know it.”
If nothing else, Mr. O’Donnell presents the best argument for requiring educational standards, or at least a GED, in this field — by demonstrating his total lack of understanding not just of wellness, but also of vaccines, sanitation, antibiotics, percentages, diseases, ROIs, and preserving civilization as we know it.
Oh, yes, and multiplication as well. His article on how to increase productivity with wellness used an example demonstrating a productivity decrease. In 2016, he also went on an anti-employee jihad that should be read in its entirety. (Translation: some of my best work…) Highlights:
- Prospective new hires should be subjected to an intrusive physical exam, and hired only if they are in good shape. OK, not every single prospective new hire — only those applying for “blue collar jobs or jobs that require excessive walking, standing, or even sitting.” Hence he would waive the physical exam requirement for mattress-tester, prostitute, or Koop Committee member–because those jobs require only excessive lying.
- He would “set the standard for BMI at the level where medical costs are lowest.” Since people with very low BMIs incur higher costs than people with middling BMIs, Mr. O’Donnell would fine not only people who weigh more than his ideal, but also employees with anorexia.
If employees didn’t already have an eating disorder, what better way of giving them one — and hence extracting more penalties from them — than to levy fines based on their weight? Employees above his ideal weight would pay per pound, sort of like if they were ordering lobster or mailing packages.
These three characters — naturally also on the Koop Committee — managed to pile more lies, sardine-like, into a single page than anyone else in this industry, in the “poison pen” about me they circulated to the media.
A good starting question would be, why on earth would anyone think that they can send a “confidential” letter to the media? The media are in the business of disseminating information. You see, that’s why they call them “the media.” Am I going too fast for you, Mr. Goetzel?
The funny thing about these Einsteins? Their defense to my observation that their very own numbers show wellness loses money was that their very own numbers were made up. Imagine being so dishonest that the way you defend yourselves is by claiming you fabricated your own report.
That’s not even the punchline. It turns out that this allegedly fabricated report is in truth an actual non-fabricated report. So, in the immortal words of the great philosopher LL Cool J, they lied about the lies that they lied about.
How did I learn this? That will be the subject of a post early year.
Watch this space…soon we will be naming the industry’s #1 Deplorable of 2016.
For this year’s Deplorables Awards, I think we’re gonna need a bigger basket. As a result, this will be a two-part series.
Why? Because we need to accommodate all the bad hombres and nasty women who have subverted the perfect elegant philosophy of wellness into nothing more than a profit machine, with no regard for integrity, customers, or employees.
Yes, 2016 was a year in which a record number self-anointed industry leaders gave lying and cheating a bad name. In that sense it was no different from any other year, though 2016 offered even more good news and bad news:
- The bad news: not content with merely lying and cheating, this cabal branched out into harming employees, fat-shaming, and pure misanthropy;
- The good news: wellness did succeed in one way, as a “natural experiment” showing what happens in healthcare if being a provider requires no credentials beyond a GED, a driver’s license, and a pulse.
Indeed, whatever mathematician first postulated that everyone can’t be worse than average had apparently never experienced the wellness industry. (Exceptions of course, being the few that, like Quizzify, are validated by the Validation Institute or have accepted the Employee Health Program Code of Conduct.)
#10 Optum and Wellsteps (Runners-Up); Healthmine (winner)
What do you do when you need to defend your blatant disregard of the US Preventive Services Task Force guidelines? Simple — you blame your customers. Optum’s Seth Serxner said: “Customers make us” do this. Optum’s PR hack said I was making Optum “look bad.”
I said: “Sure, I’ll apologize. Just name one account that will admit to insisting on paying a higher price than you wanted to charge, in order to screen the stuffing out of their employees.” Never heard from them again.
Healthmine trumps them both, though. They wrote an entire anti-USPSTF rant based on such elementary misconconceptions about the benefits and costs of screening that I’ll be using this as a teaching tool in my course on Critical Outcomes Report Analysis. Not the advanced class. Not even the standard class.
More like the remedial one, where, unlike Healthmine, all you have to do is spell “US Preventive Services Task Force” correctly.
#9 The Johnson & Johnson Fat Tax gives misanthropy a bad name. (Honorable mentions to Vitality and Ron Goetzel.)
Misanthropy, greed, and weight-shaming provided the wellness industry with its key “talking points” in 2016. And nothing combined the three like the Johnson & Johnson Fat Tax fiasco. The point of the (apparently stillborn) Fat Tax was to stigmatize overweight employees, by “pressuring” (their word) companies into disclosing to shareholders how many fat employees they had. That in turn would somehow pressure these employers into spending more money on wellness vendors.
It’s not altogether clear what that disclosure would do for the actual overweight/obese employees, but somehow this disclosure was supposed to allegedly benefit shareholders. Indeed, the Fat Tax cabal is right about that in one respect: this disclosure would benefit shareholders — it would indicate to shareholders that they ought to unload their shares in a hurry, because management just disclosed it is stupid.
Vitality was a co-conspirator in hatching this scheme, which is ironic because they admitted they couldn’t even get their own employees to lose weight. And where you hear the word “stupid,” can the name “Goetzel” be far behind? This whole thing was his idea, based on the notion that “playing doctor” with employees makes stock prices increase. However, his claim that companies with Koop Award-winning wellness programs outperformed the market can easily be invalidated by anyone with a calculator and a triple-digit IQ.
#8 IBISWorld: How is wellness different from King Midas and Gold?
Here are links to the postings on the most hilarious report we’ve ever read about the wellness industry:
- New wellness industry report costs $5400 (but that includes shipping)
- New report raises the bar for cluelessness in wellness
- How is wellness different from King Midas and gold?
The answer to the question in the header? Everyone who touches wellness turns to stupid. Not just garden-variety stupid. More like fifty shades of stupid.
Mind you, most wellness industry leaders don’t need to touch anything first before reaching that endpoint, but occasionally a company like IBIS, with no prior experience in wellness, ventures into this field — and that’s where the fun starts. These IBISWorld Young Turks (literally–the writer is named “Turk”) are so excited about this industry, they practically speak in tongues:
Wellness firms may offer employers stress management courses and sessions that offer music therapy, aromatherapy, Tai Chi, and post disaster stress reduction through coaching.
Government-funded initiatives that promote wellness to cut costs related to chronic ailments (e.g., obesity and diabetes) has further exacerbated many businesses movement toward purchasing corporate wellness services.
And my own personal favorite:
The industry provides wellness programs to businesses across the United States, including small, medium and large businesses in the private sector and businesses in the public sector.
“Businesses in the public sector”? I knew that many of our legislators are for sale but I didn’t realize they had incorporated.
Healthfairs USA doubled down in 2016 on lying and cheating with an elegant new strategy: insurance fraud. They not only harm employees, but bill insurance companies directly for the privilege of paying for those harms. They offer cancer tests that are “99% accurate” (hence their multiple Nobel Prizes), and over-the-counter nutritional supplements…all of which are covered by most insurance companies because they get a doctor to sign a claim form.
Disclosure: we aren’t entirely sure that billing insurance companies for USPSTF D-rated screens and worthless, possibly harmful, pills constitutes insurance fraud. Our opinion is probably no more accurate than their cancer tests.
In 2014, Aetna decided to “play doctor” with obese members of self-insured customers by telemarketing their employees to pitch very controversial high-priced drugs whose sales are “flailing” because almost no patients seem to want to take them. Among other things, Aetna said these drugs increase productivity even though right on the label, the drugs warn that they could reduce productivity (attention span and language facility).
Not content with the warm welcome that scheme brought them, in 2015 they introduced a DNA-based wellness program and claimed a whopping $1464/participant in savings. What put the whop in that whopper were these two tidbits. These savings were achieved:
- in the first year alone;
- on participants who were not actually sick to begin with. (You couldn’t qualify for this study if you were already sick.)
The reason Aetna needed to fabricate such a high savings figure is that the wellness field requires ROIs greater than 2-to-1, and this DNA test sells for $500/employee. So you need to show savings between $1000 and $1500.
Also, in 2015, we were able to show the program was completely ineffective, a convincing enough demonstration that one of the board members of the journal that published the study with the $1464 claim publicly apologized.
What do you do when it turns out your science is all wrong (news flash: being told you have a gene for obesity doesn’t motivate you to lose weight) and your math is all wrong? Of course, you apologize and retract the study, and offer to return the money to the lucky few companies that signed up for your program.
Haha, good one, Al. Obviously, like all the other Deplorable Award-winners on this list, you sell your snake oil harder than ever, and that’s what gets them on the 2016 list. Whereas in 2015, they could use the dumb-and-dumber defense, this year they know the numbers don’t add up and yet they are still flogging it.
Don’t miss the slam-bang conclusion as we count down to #1. Will Ron Goetzel retain his crown, or will he be unseated as the wellness industry’s #1 Deplorable?
Yes, we realize he has already appeared on this list at #9, but many lists feature the same entities making multiple entries. For instance, the Beatles once held positions #1 through #5 in Billboard’s Top 40, so it can be done.
Not that I want to put any ideas in his head.
This is the eighth and final installment of the November 2015 “Great Debate” between Ron Goetzel and myself, at the Population Health Alliance Annual Leadership Forum. If you’d like to follow the entire thread, here is Part 1.
If you want to download the audio, be my guest. For some reason the progress bar on the audio doesn’t sync with the end of the debate, so if you want to jump to this section, drag the progress indicator to the far end of the bar, like this:
Hence unlike the previous sections, there are no timestamps on these liner notes. Still, it is the most dramatic part, as Optum’s Seth Serxner does that thing which gets wellness promoters in the most trouble (open their mouths) and Ron Goetzel tries to explain why, when wellness promoters accidentally tell the truth, they don’t really mean it.
Optum’s Seth Serxner, a wellness promoter who sits on the Koop award committee, stands up and makes a couple of comments defending wellness that advance my case more than any of the previous questions attacking wellness.
His first comment — that wellness-sensitive medical events (WSMEs) for employers would have gone way up without wellness — was one that I had hoped Ron would make, but Ron wasn’t stupid enough to take the bait. Ron knew full well that his company’s database showed exactly the same trend in WSME for the non-employed population (Medicare, Medicaid) as for the employed population, as the graph below indicates. This means, of course, that wellness is worthless. Here is a graphic representation of what I originally said–that wellness had not reduced WSMEs, according to the data produced for the government by Ron’s own company:
I of course pointed out that the data said exactly the opposite of Mr. Serxner’s fantasy, as shown below. I noted: “We didn’t post this data until this morning on the hopes that someone from the wellness industry would ask us that question so we could give that response.”
Here is the revised graph, proving definitively the worthless of “pry, poke and prod,” and making my $1-million reward (now $2-million) for showing wellness works a safe bet on my end.
Mr. Serxner, despite claiming to be an expert in wellness, apparently didn’t know this. Here is a guy who goes around telling clients that maybe their costs went up, but they would have gone up faster if Optum hadn’t saved the day with wellness. Of course, now that Mr. Serxner knows that he’s been dead wrong lo these many years, I’m sure he will go back to his clients and tell them he just learned that Optum never saved them anything. Not.
He figured out years ago that some human resources directors will actually fall for this sleight-of-hand. His specific mantra: “We can conclude that choice [emphasis TSW’s] of trend has a large impact on estimates of financial savings.” (Abstract is here. You’ll have to pay for the article to read his exact quote.)
In other words, in wellness you can make up savings by choosing a higher trendline for the comparison of actual costs. Is this a great industry or what?
In his second comment, Seth blames the victim. “Our clients won’t let us [screen]” appropriately. He says that many clients ignore guidelines deliberately. That would lead to the conclusion that clients want to spend more money on Optum’s services in order to screen inappropriately, but that Optum’s salespeople push back, insisting that they should send Optum less money…and the clients refuse.
In followup conversations with Optum, they were unable to name a single program in which Optum tried to insist on infrequent, clinically appropriate, inexpensive screening schedule, but where the account itself demanded the opposite. I can send the email thread to anyone who wants it. (The back story is that Optum’s mouthpiece contacted me to ask if I would stop embarrassing them by referencing Mr. Serxner’s comments. I said: “Sure, if you can name one account where Optum pushed back against the customer demanding higher-priced, inappropriate screening programs.” Never heard from them again.)
Another questioner points out that doing wellness for employees — serving carrots instead of donuts — hasn’t reduced costs. Ron says she’s reading the literature wrong. “A lot of programs reduce the rate of increase in costs, and that’s how savings are determined.” Um, Ron, were you listening a minute ago?
For someone who has proclaimed himself a “scientist” at multiple points, there is some irony (there’s that word again — being oblivious to irony is a prerequisite for being in the wellness industry) in not understanding how science works. An intervention is targeted at specific variables. Pain medications target pain, chemotherapy targets cancer, heartburn medications target stomach acid etc. Wellness targets WSMEs. So if WSMEs decline, that’s called a success. If, however, trauma or c-sections or joint replacements happen to decline while you’re running a wellness program, that’s called a coincidence. Those results are not at all attributable to a wellness vendor browbeating employees into eating more broccoli.
In response to a question, I say that as a former NASDAQ company CEO (and current Quizzify CEO) the greatest advantage I see in wellness is to convince my competitors to do as much of it as possible, so that they waste their time, lose their best people and increase their healthcare costs.
Ron says it’s silly to obsess with spending $100 or $200 on wellness when companies are spending $10,000/employee on “cancer, diabetes, heart disease and hypertension.”
This is nonsense. I’d invite Ron — remember, he says he’s a scientist, so he’s driven by data — to actually look at some data. Employers do not spend most of their money on preventable events in those categories.
Quite the contrary, birth events and musculoskeletal are their two biggest spending categories. Then there are some catastrophic events. The rest is comprised mainly of lots of drugs, tests, doctor visits etc. The actual preventable hospital events in the four categories Ron is referencing account for only a small percentage of all spending. (See the graphs above — about 6% of hospitalizations, meaning about 3% of all costs, or about $150 per covered person are preventable through wellness.)
Don’t take my word for that. Here are the top ten DRGs for commercially insured populations, according to Ron’s own company, Truven:
It took an hour and a half but finally, the infamous Kate Baicker study comes up. She’s walked it back multiple times, all in print, all cataloged here. But apparently neither she or David Cutler (her co-author) are giving up on it. Apparently there were a series of alleged private conversations I wasn’t privy to in which, notwithstanding their public comments, they are still not willing to retract it. It doesn’t matter because, in addition to RAND’s smackdowns, I pointed out that the studies comprising her meta-analysis were laughable, including one claiming that wellness caused a reduction in cat-scratch fever.
Add one more entry to the list of things Ron walking back: his claim that wellness gets an “expected” 3-to-1 ROI.
He is now perfectly fine with a 1-to-1 ROI. Having just said that Kate Baicker is standing by her 3.27-to-1 ROI, he refers to claims of a 3-to-1 ROI as “ridiculous.”
Which is it, Ron? Is the Kate Baicker 3.27-to-1 ROI correct as you said 60 seconds ago, or is a 3-to-1 ROI “ridiculous,” as you said just now?
I bring up Michael O’Donnell’s infamous statement that “randomized control trials” in wellness “show a negative ROI.” Yet another example of these wellness Einsteins accidentally admitting that wellness loses money and having to walk it back. Ron gets a point for being totally prepared for this exchange. He explains that, of course, like everything else I point out where they accidentally tell the truth in print (like the HERO guide earlier in the debate), it doesn’t really mean what it says in print. It means something completely different.
Ron excels at twisting and turning statements into their opposites. We have so much respect for his ability to do this, we call him Goetzel the Pretzel.
Like Mr. Goetzel was prepared to pretzel this gaffe, I am also prepared for Mr. Goetzel’s pretzel. This researcher, a graduate student at the University of Tasmania (that’s an island south of Australia), “averaged” low-quality studies showing positive ROIs with high-quality studies showing negative ROIs to find an overall slightly positive ROI. My reply: “That’s like averaging Ptolemy and Copernicus to conclude that the earth revolves halfway around the sun.”
Ron had said no one would do RCTs, but Aetna just did one and found no impact.
Ron, who spent about half the debate talking about how great peer review is, now admits the process is broken. Then he says “the peer review process works quite well.”
Which is it, Ron? Is peer review great or is it broken?
Then he says the editors of these journals are “not my friends” and then he says they are “close friends” of his.
Once again, which is it, Ron? Are they your close friends or not your friends?
The final question was emblematic of the entire debate, in which Ron makes statements that are obviously the opposite of the evidence. He alleges that 2/3 of employees want more wellness programs. I point out that if employees liked wellness you wouldn’t have to fine them to get them to participate. Indeed, they would pay for wellness, just like people are willing to pay for other things they like.
You only have to go to Slate or any other article to see that employees in this country don’t like wellness, any more than the employees in this audience do.
There you have it. Who won? You make the call. None of my work was challenged (except Quizzify –but with a 100% guarantee of savings that’s our problem if we’re wrong — and the reviews and case studies are very positive). Ron conceded the following:
- I am right a lot of the time (for anyone is keeping score at home, that would be 100%);
- I am the best peer reviewer in the field;
- most wellness programs don’t work;
- he can’t win my million-dollar reward; and
- he’s doctored a lot of material.
Here is a list of what he has said and done, that he just ran away from:
- his HERO Report;
- wellness industry “cheaters” like his colleague, Wellsteps’ Steve Aldana;
- his Penn State program;
- his 3-1 ROI claim.
The only program he defended was the indefensible Nebraska program.
I on the other hand lost on no exchange, and conceded nothing except that maybe Johnson & Johnson saved money on their wellness program. While blogging on this debate, I was finally moved to read the J&J outcomes report. Surprise! The whole thing is obviously fabricated and never should have passed peer review. I’ll blog on it another day.
Some of you might remember the closing credits of Rocky and Bullwinkle. Due to copyright restrictions, we can display only a “fair use” snippet. (“Fair use” means you could use one question from Quizzify as an example without special permission as long as you cite the source, but if you tried to copy the whole thing, we’d get elected president, hire a special prosecutor, and throw you in jail.)
Rocky asks: “You got the credits, Bullwinkle?”
Bullwinkle replies: “All on this itty-bitty card…oops” and then it folds out:
(Source: Jay Ward Productions.)
So what does this have to do with wellness, besides nothing?
Simple –I just consolidated all the lies and harms of the Wellsteps/Koop Award into one itty-bitty posting for the American Journal of Managed Care blog. And it also folds out — with links to all the other “smoking guns” in this scandal. If you just want to forward one article around, that’s the one.
Kudos to American Journal of Managed Care for going where Health Affairs fears to tread, by posting the entire, unbowdlerized expose in all its sordid glory. Indeed one would think the latter publication would show some contrition for having started this “pry, poke and prod” mess, by publishing the original Baicker propaganda — with no disclosure of the authors’ conflicts of interest or funding sources…and apparently also no peer review. This thing has been cited 250 times. And that was after it was shown to have been made up. It has 549 citations in total.
Sadly, in addition to not being subject to any other regulations, wellness is not subject to Pottery Barn Rules. Health Affairs created this mess, but they don’t need to pay for it. Quite the contrary, the Health Affairs “impact factor” has probably been boosted more by this article’s 549 citations than almost any other article they’ve ever published. And guess who has to clean up after them?
(Source–you guessed it–Jay Ward productions. These are the closing credits to Mr. Peabody.)
Kudos also, by the way, to the perpetrators of the Wellsteps fraud — Steve Aldana, Ron Goetzel, Seth Serxner. They have the good sense not to take my bait by actually attempting to rebut. The one time they did, in Sharon Begley’s article, their “rebuttal” took the form of basically admitting they had made the whole thing up.
Abe Lincoln seems to be in the news a lot this week, and he put it best: “Better to be thought a fool and say nothing than to speak out and remove all doubt.” Words the Wellness Ignorati should live by. You’d think they would have learned that by now.