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Will the Real Kate Baicker of the Harvard School of Public Health Please Stand Up?

By Al and Vik

Harvard Professor Katherine Baicker is arguably the most acclaimed health policy researcher at arguably the most acclaimed (and not even arguably, the best-endowed) school of public health in the country. Her seminal account of the effect of Medicaid coverage on utilization and health status is a classic. As luck would have it, in 2008 Oregon used a lottery to ration available Medicaid slots. A lottery controls for motivation and as such eliminates participant-non-participant bias, since everyone who enters the lottery wants to participate. That meant only one major variable was in play, which was enrollment in Medicaid or not.

Wellness ROI claims appear lost in space

Wellness ROI claims appear lost in space

Chance favors the well-prepared, and Professor Baicker jumped on this research windfall. She found that providing Medicaid–and thereby facilitating access to basic preventive medical care–for the previously uninsured did not improve physical health status, but did increase diagnoses and utilization. Because of the soundness of the methodology, the conclusion were unassailable – more access to medical care does not improve outcomes or optimize utilization, which is a proxy for spending. (We ourselves reached a similar conclusion based on a similar analysis on North Carolina Medicaid’s medical home model.)

Yet Professor Baicker herself used exactly the opposite methodology to reach the exact opposite conclusion for workplace wellness.  And that’s where the identity crisis begins.

She and two colleagues published a meta-analysis in 2010 of participant-vs-non-participant workplace wellness programs. Somehow—despite her affinity for Oregon’s lottery control—she found this opposite methodology to be acceptable.  She concluded that workplace wellness generated a very specific two significant-digit 3.27-to-1 ROI from health care claims reduction alone, with another 2.37-to-1 from absenteeism reduction. The title of the article–now celebrating its fifth anniversary as the only work by a well-credentialed author in a prestigious journal ever published in support of wellness ROI—was equally unambiguous:  Workplace Wellness Can Generate Savings.

This article wasn’t just an academic exercise. It gave the Obama administration academic cover for what has proven to be the most unpopular, dishonest, and even hazardous component of the Affordable Care Act:  allowing employers to financially and clinically punish employees with coercive directives to lose weight, get unnecessary checkups, and answer intrusive, distasteful, and counterproductive questions about (for example) checking their testicles.

Professor Baicker did not question her too-good-to-be-true conclusion. Yet the Law of Diminishing Returns clearly contradicts her finding. Compelling privately insured people to get more healthcare is very unlikely to improve health status and reduce healthcare expense if provision of basic insurance to a medically needy population doesn’t noticeably improve health status while increasing healthcare expense.

Instead, she reveled in the limelight, receiving 307 citations, vs. 18 and 9 for two other Health Affairs articles on wellness that didn’t support more spending on vendors and consultants. (Even 307 citations aren’t enough to satisfy one of the leaders of the wellness movement, Larry Chapman, who says this study should be cited much more frequently since it’s basically the one that supports the entire industry.) However, at some point in 2013, overwhelming evidence totally invalidated her findings. At that point – like Dee Edington and Al Lewis, both of whom had previously reversed positions when the data didn’t support their previous positions—she could have acknowledged that her initial findings had been wrong and moved on.

Instead, she neither defended her position nor clearly refuted it, choosing instead a yin and yang middle ground that shifted with every interview. The metamorphosis from Queen of Significant Digits into the Queen of Significant Doubt started in July 2013, when she announced on NPR’s Marketplace that “it’s too early to tell” if wellness saves money, and that employers need to “experiment” with these programs to “see what happens to participants’ weight and blood pressure.” Right there, she invalidated herself. First, by then she certainly knew that a participants-vs-non-participants methodology was invalid since the key “smoking gun” slide in our Health Affairs posting was already widely circulated and her own opposing Oregon methodology was being widely praised. Second, even if she is right, the financial payoff for the modest “weight and blood pressure” improvements that the best programs might generate is 10-20 years in the future — and even then only if the improvements are sustained.

But then came another personality change.

In February 2014, she blamed readers for focusing on her attention-grabbing headline, the certainty of her two significant digits, and the gist of the conclusion…while ignoring the fine print, such as a caution about publication bias. Publication bias? You think? Start with the standard publication bias that negative articles rarely get published because they don’t get cited and hence reduce the all-important “impact factor” – recall the difference in Health Affairs citations in her own wellness article vs. the others.

Add to that a publication bias specific to those journals:  most of the articles comprising her meta-analysis were published in third-tier journals. Among them, these journals have exactly once published an article critical of wellness (twice if you include a book review by the esteemed Norton Hadler, whom a third-tier journal is thrilled to publish regardless of what he says, and three times if you include publication of an article by a graduate student at the University of Tasmania that accidentally undercut the true believers’ own storyline, that they are now having to explain away).

Weeks later, a totally different personality emerged:  she told the editor of Insurance Thought Leadership that she no longer focused on wellness and consequently has no opinions to share.  Leaving aside the irony that the wellness true believers continue to cite as gospel someone who says she has no interest in what they are citing her for, this spin further invalidates her next comment, delivered in December 2014 – when suddenly, as a result of yet another personality change, she has opinions again. She told All Things Considered: “It could be that when the full set of evidence comes in, [wellness] will have huge returns on investment.”

Oops. First, she has just admitted she doesn’t follow wellness, so why speculate on future studies she has no knowledge of in a field she’s not involved in? Second, there is a rule of thumb in epidemiology:  the bigger the impact, the smaller the sample size needed to discern it. An example would be smoking and lung cancer, a previously very rare disease whose cause was discernable from a handful of cases. A sample of only hundreds of veterans was needed to prove that very high blood pressure causes strokes, and studies of exercise almost always show either a physical or emotional benefit, even in small groups of people with significant disease. On the other hand, there have been probably close to a half-billion employee-years of wellness with nothing to show for themselves except results going the other way and a bunch of self-invalidating vendor lies.

Final front cover

Available now at Amazon.com

So we are going to make a radical proposal to the true believers:  you can continue to cite Katherine Baicker but must also note that she herself no longer supports the study you are citing — until and unless she says she does. In exchange for this disclosure, when do you cite her, we will acknowledge that you are telling the truth for a change.

Wellnet: “Trusted Advisors Need Trusted Partners”…so we’ll pay you

Wellnet Materials Being Reviewed

See “For Brokers” on the Wellnet website, leading with the line:

trusted advisors

Questions for Wellnet

Are you using the term “trusted advisors” (scroll down this linked page) to describe your prospects’ brokers?  Then it appears you are offering to pay them an undisclosed sum of money to place Wellnet.  Are we reading this correctly?

ANS: Refused to answer

Then it seems like you want the broker to become a trusted advisor, meaning you want to pay them money to sell to their client, who absent this language would appear to be working for their client:

trusted advisor click through

Clicking through on “learning more about becoming a trusted advisor” brings you to this grammatically challenged question:

wellnet

How do brokers creating new revenue for themselves at their clients’ expense (meaning selling their clients more forced wellness programs like yours) enhance their reputation as a “trusted advisor” ?

ANS: Refused to answer

If this is on the level, why not simply be explicit:  “We will pay you a commission to sell our product to your clients” ?

ANS: We didn’t even bother to ask 

 

Ron Goetzel and Co-Authors Claim Workplace Wellness Evidence That a CSI Couldn’t Find

Questions for Ron Goetzel and co-authors based on September 2014 article

Category:  Wellness

Short Summary of Goetzel Article’s Marketing Claim:

“Evidence accumulated over the past three decades shows that well-designed and well-executed programs that are founded on evidence-based principles can achieve positive health and financial outcomes.”

(This study was paid for by American Specialty Health, a successful and well-regarded company in the alternative network business that also, not surprisingly, has a wellness subsidiary.)

Materials Being Reviewed:

The study in question appeared in a recent issue of the Journal of Occupational and Environmental Medicine.

Most of these questions were originally asked by Jon Robison of Salveo Partners, in this post.

Questions for Ron Goetzel (who has not answered any relevant follow-up question asked of him about his Koop Award either, meaning now he has forfeited $2000 in honoraria)

Is it ethical to claim “no conflict of interest” in writing this article when a wellness company paid you for it and when you and most co-authors make their living in the wellness industry?

ANS: Refused to answer

Can you explain your reasoning for listing (see below) the Koop Award-winning State of Nebraska as a “best practice wellness program” after they admitted lying about saving the lives of cancer victims who never had cancer, and after it turned out their savings figures were clinically and mathematically impossible, and after it was exposed that the state’s wellness vendor sponsors the Koop Award?

list of best practices

ANS: Refused to answer

Why didn’t you disclose that literally none of these “best practice” programs (especially Nebraska’s, which deliberately waived all age-related cancer screening guidelines) follow US Preventive Services guidelines and therefore companies that follow these best practices on balance are more likely to harm their employees through overdiagnosis than benefit them?

ANS: Refused to answer

You describe (among others) a Procter & Gamble study from two-decade-old data as “recent”. Can you define “recent” ?  Can you name anyone at Procter & Gamble who even remembers this “recent” study?

ANS: Refused to answer

Why do you still cite Larry Chapman’s 25%-savings-from-wellness-programs allegation even though readily available online government data below shows wellness-sensitive medical events account for only 8.4% of a typical employer’s hospital cost (about 4% of total employer spending), thus making it impossible to save 25%?

hcup8point4percentslide

ANS: Refused to answer

Why are you still citing Prof. Baicker’s article when she herself has backed off it three times, it’s never been replicated, and all attempts to replicate it, including the most recent attempt to replicate it (in the “American Journal of Health Promotion”), have shown the opposite and she herself says “there are very few reliable studies to confirm the costs and the benefits”?

ANS: Refused to answer

How can you cite RAND’s negative article as supporting the conclusion that “wellness can achieve positive financial outcomes”  even though the author Soeren Mattke has specified that the modest health improvements among active participants produced no “positive financial outcomes”?

ANS: Refused to answer

Likewise, how can you cite the Pepsico health promotion study in Health Affairs in support of that same conclusion when that study concluded exactly the opposite: that health promotion had a negative ROI?

pepsico

ANS: Refused to answer

Guest question submitted by Dr. Jon Robison:  On p 931 you say that the RAND study found weight reduction — of course, only on active participants, excluding dropouts and non-participants — that was “clinically meaningful” and “long-lasting.”  How does that square with this slide from that very same RAND study showing exactly the opposite? (Since this chart may be difficult to read,we’ll highlight the key finding, which was that by the 4th year the average active participant had sustained weight loss of only a few ounces.)

randweightslide

ANS: Refused to answer

Orriant publishes wellness data in Journal of Workplace Health Management and no one cares

Orriant, Ray Merrill

Category:  Wellness

Short Summary of Company’s Marketing Claim:

“A New Scientific Study Proves Wellness Works”

Materials Being Reviewed:

http://www.orriant.com/File/4072ee6c-2bcd-43a5-83b6-e9035c8c0f1a

Questions for Orriant and Ray Merrill:

When you say “a new internationally-published study proves wellness works,” are you taking into account that the “international” journal publishing the work has a Zero impact factor, meaning that essentially no one believes anything they publish has enough value to cite?

ANS: Refused to answer

Are you attributing the fact that “participants had fewer health claims than non-participants” to your program, rather than to the obvious non-observable variable that participants are motivated whereas non-participants are not?

ANS: Refused to answer

Are you familiar with Health Fitness Corporation’s demonstration that participants will outperform non-participants even in the absence of a program? (See the year 2005 below — no program but participants outperformed non-participants nonetheless.)

total savings chart

ANS: Refused to answer

You also note that “those with the greatest health risks” had the most improvement.”  Are you familiar with Dee Edington’s work that says those with the greatest health risks will improve the most even in the absence of a program, due to the natural flow of risk?

Dee Edington's Diagram

ANS: Refused to answer

Non-participants’ medical costs were “2.9x greater” (about $4000 vs. about $1400).   This, of course, is the record for the hugest savings ever claimed from a wellness program.  Since government data shows that wellness-sensitive medical events account for only 4% of total costs or about $200/person, where did the other $2400/person in savings come from?

ANS: Refused to answer

Why didn’t the authors plausibility-check the entire population using a wellness-sensitive medical event analysis?

 ANS: Refused to answer

Interactive Health

The Interactive Health case study has been removed from the “Smoking Guns,” because it has so many obvious errors that we use it instead as the “issue spotter” for the advanced-level course and certification in Critical Outcomes Report Analysis.

I also wouldn’t trust them as my wellness vendor even if they didn’t make up outcomes. I had the misfortune of attending one of their screens. They “screened” me for calf tightness. It turns out my calves are tight. Admittedly, I can see why tight calves could impact productivity for some employees. (Example: first basemen.)   And I could just feel my own productivity soaring after they loosened them up…until the left one went into spasm that night.

It also would be nice, assuming they are going to do these screens, to actually send people their results without being reminded four or five times.

 

Viverae wellness primes its own pump for an EEOC wellness lawsuit

Viverae

Category:  Wellness

Short Summary of Company:

“Viverae gives our clients a platform for managing healthcare costs by motivating their employees to make healthy choices. Our comprehensive wellness programs address your organization’s goals to meet your employees where they are.”

Materials Being Reviewed:

viverae

viverae500

Questions for Viverae:

General:  What customers have actually signed up for this and are willing to admit it?

ANS: Refused to answer

Provision #2: Since your biometrics are out of compliance with USPSTF guidelines, wouldn’t a customer be risking an EEOC lawsuit by “requiring” every employee to do this against their will, subject to a large fine?

ANS: Refused to answer

Provision #4: Isn’t this the same as saying “If you sign up for two years, we’ll give you a third year maybe at a 20% discount if you do everything perfectly, but by doing so you waive your right to cancel after one or two years” ?

ANS: Refused to answer

Provision #5: Has any customer of Viverae or any other wellness vendor with 1000 or more employees completed HRAs and submitted to biometric screens at a 100% rate, as you require in Provision #2?

ANS: Refused to answer

Provision #6: How could a health plan get a positive return on this program by offering people $720 apiece, when wellness-sensitive medical events account for less than $200/person in claims spend?

ANS: Refused to answer

Speaking of Provision #6, if your very own website says savings are $500/person (I’d be curious what legitimate academic research supports that), how can you guarantee savings when the cost of the incentive alone is $720?

 ANS: Refused to answer

 

 

Did you know 100% of your employees have chronic disease? Wellsource says so!

Wellsource

Short Summary of Company:

“Wellsource pioneered the concept of computer-assisted wellness. Today, more than 30 years later, Wellsource continues to offer innovative, evidence-based health assessments and online wellness tools that improve lives and contribute to a healthy bottom line.”

Materials being reviewed:

wellsource stats

wellsource stats part 2

Questions for Wellsource

How is it that 100% of the employees at this company have a chronic disease?

ANS: Refused to answer

If “cancer” were a chronic disease as you claim it is, like diabetes or heart disease or asthma, how come no one ever says:  “I have lung cancer, but my doctor says we’re staying on top of it”?

ANS: Refused to answer

If “stroke” were a chronic disease as you claim it is, how come every minute you don’t get to the ER following a stroke increases the odds you’ll end up like the Kardashians?   Wouldn’t “stroke” be the epitome of an acute event rather than a chronic disease?

ANS: Refused to answer

If all these people are so sick, how come the largest opportunity per employee to save money ($40,000/employee!) is to get a few more people to buckle their seatbelts 100% of the time instead of 95% of the time?

ANS: Refused to answer

Speaking of seat belts, does it increase your credibility with potential purchasers that seat belt use is expressed the wrong way (96% buckle, meaning the correct figure to enter here would be  “4%,” the ones who don’t always buckle)?

ANS: Refused to answer

If a whopping 89% of your employees have high blood pressure as defined by 140/90, do you think there is a chance you made a mistake in measuring this variable?

ANS: Refused to answer

How can you save $6154.28 per employee in health spending just on these items when the average employee doesn’t spend $6154.28 in healthcare costs altogether?

ANS: Refused to answer

How is this $6154.28 savings/employee figure (expressed in your materials as $615,428 for the 100 employees in this company)  consistent with sourcing Steve Aldana, who claims that you always save $1358.85 per employee, whether you get a 0% improvement or a 100% improvement in risk factors?

ANS: Refused to answer

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