If you are just joining us from the NYT this morning (10/24) also see how a wellness vendor made Boise School District employees sicker...and then lied about it.
The Connecticut state employee wellness program is so bad that I am embarrassed even to live in a bordering state. They lose money, harm employees, and brag about it.
Let’s briefly review the history of the wellness industry. First, wellness was good because it saves money.
Once we blew up that claim, the wellness industry started saying “Forget about ROI. It’s all about VOI.” But it turns out that VOI is negative, according to both the Health Enhancement Research Organization (which lists 11 types of indirect costs of wellness) and the American Journal of Health Promotion (which admits that employees have to use 4% of their work week to exercise in order for productivity to increase 1%).
Now, as described in the prestigious journal Health Affairs, wellness makes healthcare spending go up above and beyond what is spent on wellness itself. And, remarkably, losing all this money is somehow — to use the exact words of the Connecticut Comptroller, Kevin Lembo — “a good thing” because it means people are getting more checkups. Or, as the study’s lead author, Richard Hirth, says: “Some increased spending in the early years isn’t surprising.”
Harming Employees: Checkups, and Mammograms for Young Women
Checkups are included in Choosing Wisely’s compendium of low-value services. Along with Choosing Wisely (a joint venture of Consumer Reports and the American Board of Internal Medicine), there’s the New England Journal of Medicine and the Journal of the American Medical Association.
The Choosing Wisely guideline is copied-and-pasted at the end of this post. Choosing Wisely lists many good reasons to go to the doctor. Being fined if you don’t, as happens to Connecticut employees, is not among those good reasons.
No wonder increased spending “isn’t surprising,” Mr. Lembo. You’re sending employees to get useless checkups under duress. What did you think was going to happen?
It could be worse. A lot of programs require checkups annually. Connecticut’s program requires them less often under age 50.
The other low-value service: mammography for young women. The US Preventive Services Task Force suggests that mammograms start at age 50, but that women in their 40s might possibly consider them. Connecticut requires one before age 39. This is pure harm. Ironically, the state does not require them in one’s 50s, where they might actually be helpful.
It’s been definitively established that getting routine mammograms in one’s 30s is a bad idea. The false positives and risk of radiation exposure (trivial on one person but the state is ordering x-rays on thousands of people) overwhelm the likelihood of an “early detection” of a meaningful tumor, while creating a noticeable likelihood of finding a “suspicious” but ultimately inconsequential lump that then has to be followed up for no reason. The books Overdiagnosed and Seeking Sickness: Medical Screening and the Misguided Hunt for Disease might be good reading for Mr. Lembo.
Unless someone is at high genetic/family history risk (in which case the mammogram wouldn’t be classified as a “screen”), mammograms in one’s 30s are so inadvisable that the USPSTF doesn’t even bother to recommend against them, because it never ever occurred to the USPSTF that anyone would advise them, let alone require them. And yet, Connecticut does. If you don’t believe anyone could come up with such a dumb idea, the screenshots — the state “prevention” schedule and USPSTF screenshot — are at the bottom of this column.
Oh, and Connecticut employees who value their health enough to want to actually follow guidelines– meaning not subject themselves to harmful overdiagnosis and overtreatment–could be penalized up to $1200/year.
Fortunately, doctors are allowed to formally exempt people from this requirement if they ask nicely. However, people who don’t ask are in trouble: doctors often find it easier to simply order a mammogram when asked than to try to explain why it’s a bad idea. And the whole concept of overdiagnosis and false positives is a tough one to communicate in a 12-minute office visit. That’s why we have Quizzify, of course. But the state of Connecticut doesn’t use it.
Connecticut is a perfect example of why Quizzify isn’t already in the Fortune 500: We are advising employees to avoid low-value services, but the marketplace is much more receptive to a message of embracing low-value services.
Fuzzy Math: Study Authors Tip Their Hands
It’s amazing the outcome was as negative as it was, considering that the authors of the Health Affairs study, have that exact agenda: embracing low-value services. Mr. Hirth runs the Value Based Insurance Design Center, whose whole purpose is to implement this type of overdiagnosis/overtreatment program, notwithstanding all the evidence to the contrary.
Hence the study’s conclusions out of thin air:
- The authors noted ER visits dropped 10%, but didn’t fully attribute the drop to the extra low-value services employees were required to get. Maybe, they allowed, the drop might possibly be attributable to the state instituting its first-ever actual co-pay ($35) for ER services. Holy Economics 101, Batman!
- “People are taking their medications rather than going to the emergency room.” Yes, at great expense they waived a ton of co-pays for everyone…and got about 1%-2% more people to fill prescriptions. I haven’t done the exact math and neither did the authors, but I suspect each extra bottle of pills probably cost taxpayers about $1000 in waived co-pays for the other 98%-99% that would have been filled anyway. And it’s not quite clear how 1% more people taking pills creates a 10% drop in ER visits.
- They make references to “improved health and productivity,” without measuring it. I know when I come back to the office after getting a useless screen that shows a false positive, the first thing on my mind is increasing my productivity.
- They redefine these low-value services like checkups as “high value services”.
Where Does Connecticut Go from Here?
As a first step, Mr. Lembo would be well advised to hook his computer up to the internet. Once he realizes he has been snookered by his consultants, there is a way out: he can work with his union counterpart to dismantle the low-value portion of this program and share the savings between labor and taxpayers.
Because in fact there is a surefire way to get an ROI on a wellness program: Get rid of it.
CONNECTICUT SCREENING GUIDELINES
USPSTF MAMMOGRAPHY RECOMMENDATIONS
Corporate Wellness just eviscerated the proposal that employers should disclose employee weight to shareholders.
The thing about this head-scratching proposal — and if you guessed that it originated with Ron Goetzel as a way to justify the existence of wellness vendors, you get how this industry works — is that it is such a bad idea that I didn’t even have to criticize it. I merely questioned it. Just reading the questions in this article would be enough for 99.9% of CEOs to decide they want nothing whatsoever to do with it. (The other 0.1% run wellness companies.)
And no HR executive, upon reading these questions, would even dare breach the notion with the C-suite, fearing these questions would be asked and knowing these questions are unanswerable.
Further, the format of just asking questions fit Corporate Wellness needs. They were kind enough to allow me to write an article for them knowing that many vendors get apoplectic at the mere mention of my name, let alone my appearance in their widely read publication. I reciprocated this kindness by writing an unopinionated article.
By the end, though, I couldn’t hold back. In an industry known for its dumb ideas, this proposal to disclose employee health metrics to shareholders is one of the dumbest. And the dumbest of all metrics included in this proposal would be depression. In this case I did offer an opinion:
Just say no. It would be impossible to estimate the number of depressed employees in a manner accurate enough to withstand an audit. [And review by outside auditors is a key part of this proposal.] The task of determining who is depressed would involve highly intrusive and costly assessments by others, or else self-assessments that almost beg to be completed with misinformation. Many employees who are depressed don’t know it and others aren’t going to admit it.
I personally find it depressing that this proposal would even be on the table. After you read about it, I think you’ll agree.
I’d encourage everyone to take a looksee at this article in Insurance Thought Leadership. Not just because I wrote it (though that too) but because it will open your eyes to a whole series of hidden costs of the current wellness mania.
Among the problems of wellness is that it is a full-time job. Getting employees to eat more broccoli, weight-loss “challenges,” dealing with appeals and complaints, policing vendors, holding “health fairs” etc. Not to mention all the math involved in incentives/penalties. Catching the cheaters putting the Fitbits on their poodles. The list goes on and on.
As a result, a bunch of other things go unnoticed:
- Massive numbers of unnecessary surgeries
- Hospital errors
- Dishonest PBMs
- Employees getting snookered by providers (or demanding low-value care)
- Opioid addictions
Addressing all of those is ultimately much more fruitful for you — and beneficial for employees — than wellness, but there simply aren’t enough hours in a day to do it all. This article will get you started on a focus strategy…and then future articles will help you hone in on what really does make a difference.
Update: It turns out that, notwithstanding the protestations of these three very stable geniuses to the contrary, their data that they claim (three times, below) to have “fabricated” was actually real…and the three of them reviewed it before it was published.
How do I know this? In addition to the chapter actually saying it was real data, and the guidebook saying each chapter was reviewed multiple times by multiple people, I simply asked the author. He confirmed both that the data was real (“If I had made it up, I would have said so”) and that it was indeed reviewed multiple times by multiple people on the HERO board.
When I re-read the chapter, I thought: “This can’t have been written by someone at HERO. This is actual analysis and they don’t know how to do actual analysis.” Sure enough — the actual author is Dr. Iver Juster, who has taken all my courses and read all my books and has the advanced level of Critical Outcomes Report Analysis certification.
In other words, to quote a rapper whose name escapes me, they lied about the lies they lied about.
In an earlier column we indicated that we had gotten wind of a “poison pen” letter that the Health Enhancement Research Organization (HERO) board members (Paul Terry, Johns Hopkins’ Ron Goetzel and Optum’s Seth Serxner, among others) sent around to members of the media. We just weren’t sure to whom it was sent or what exactly it said.
Eventually my attorney pried it out of them, after they first refused to admit this letter existed.
My attorney said he had never had a client who wanted to republish a defamatory letter written about him. I replied: “In the wellness industry, a defamation from HERO is, in the immortal words of the great philosopher Kenny Banya, ‘Gold, Jerry. Gold.’” Indeed, this letter is the closest I’m ever going to come to achieving my boyhood dream of appearing on Nixon’s Enemies List.
Here are a few excerpts–along with my annotations in italics.
“The featured variables from the HERO report that these authors cites [sic] as ‘evidence’ begin with a statement that ‘HERO calculates gross wellness program savings of $0.99.’ As is obvious to even the most uninitiated reader of our report, the $0.99 amount is taken from page 23 of an 87 page report in a section which is clearly labeled as one example wherein the sum savings derives from a fabricated scenario…The authors go on to suggest that the HERO report provides ‘evidence’ of a negative return on investment from wellness programs because our ‘report estimates wellness programs costs at $1.50 pmpm.'”
Our math (meaning your own math in your “fabricated scenario”) is correct. True, we never in a million years realized that wellness economics are so hilariously poor that even when you “fabricate a scenario” in your own guidebook, you still manage to lose money. And in any event, even though you never asked us to, we did correct that inaccuracy—by showing how much more money wellness loses if we substitute real numbers from HERO Committee members’ own writings for the “fabricated” ones.
“This variable is taken from page 15 of our report and the report’s authors in no way associated the two numbers. Furthermore, the cost number is again derived from a fabricated illustrative example…”
So you’re saying that your report’s authors put these two numbers (costs=$1.50 PEPM and savings=$0.99 PEPM) in the very same chapter but readers aren’t supposed to compare them? Bad readers! Shame on you for being discerning!
By the way, the example isn’t “fabricated.” Messrs. Goetzel, Serxner and Terry are now, in the immortal words of the great philosopher LL Cool J, lying about the lies they lied about. This is not a “fabricated illustrative example.” It is a reproduction of an actual report, which is why Page 22 calls it a report and describes what it shows:
“The authors seem to indicate that their findings from these distinctly unassociated variables is an inventive disclosure of a negative ROI for wellness on their part by writing that ‘this loss was not an intentional finding in this document.'”
Leaving aside that both these “distinctly unassociated variables” appear in the exact same chapter, how can costs be “distinctly unassociated” with revenues? Isn’t that what business is all about, associating revenues and costs? Example: Suppose your revenues are $2. That’s GOOD if your costs are $1 but BAD if your costs are $3.
I’ll use a sports analogy so that even the dumbest member of the HERO board can follow the logic. If my team scores 5 runs, we WIN the game if your team scores 4 runs. But we LOSE the game if your team scores 6. It doesn’t do any good just to know my team scored 5 runs. The number we score MUST be “distinctly associated” with the number you score to get a meaningful result.
Am I going too fast for you, Mr. Goetzel? You did refer to yourselves in this letter as “among the most credible and conscientious scientists and practitioners working in corporate wellness today,” so hopefully the information above is not too technical for you. I tried to use short words where possible.
“We are confident that any discerning reader of our report would instead conclude that associating the variables as they were in this blog post was an absurd, mischievous and potentially harmful misrepresentation of our data.”
We took screenshots of your figures. I’m not quite sure how we could misrepresent screenshots. In any event, we don’t have to “misrepresent your data.” As Yogi Berra might say, you misrepresented it just fine all by yourselves. A trade association dissing its own product, and now bragging about fabricating data? One doesn’t see that very often.
“A cursory vetting of these authors would have revealed a litany of inaccurate and outrageous writings over several years.”
Yikes! We apologize! We had no idea that we’ve been publishing “a litany of inaccurate and outrageous writings.” We have published about 450,000 words — more than all of Shakespeare’s tragedies combined. Possibly a few inaccurate words slipped in. Surely in order to make such an otherwise libelous statement, you have a list of these “inaccurate and outrageous writings.” A cynic would say you’re deliberately lying, but all we’d like to know is…
Since we are in the “integrity segment” of wellness, we would like to see this list, so we can acknowledge and correct any errors.
Alternatively, if there are no inaccuracies, then you are endorsing the accuracy of our work, which we will announce in an upcoming post. So please get back to us within seven days with the list. Otherwise, we thank you very kindly for your endorsement of our accuracy. Additionally, we would like a written apology if you want to avoid a lawsuit.
My Kindle has so many books on it now that I can barely lift it. One is The Wright Brothers, by David McCullough. I would recommend this book to anyone with a passing interest in basically anything. It’s the first-ever detailed looksee at how two brilliant, dedicated, self-financed, self-taught polymaths changed the world.
Even a guy like me was amazed at how much I learned despite already knowing enough trivia to have been on Jeopardy once. (People ask me how I did. I reply: “I said, ‘I was on Jeopardy once.’ “)
Mr. McCullough is perhaps the finest living American historian. I am also privileged to have him as a kinda sorta neighbor, as he lives about 3/4 of a mile from me in a house that just screams “An American historian lives here.” (I refuse to divulge his actual address, in order to protect his privacy from the onslaught of paparazzi that would inevitably follow.)
Though we don’t know each other, I have briefly chatted with him several times, and he is as gracious a gentleman as one might infer from his book that the Wright Brothers were. The last time I saw him, I had just finished the captivating 1776, which ends right after the Battle of Trenton (that whole Washington-crossing-the-Delaware thing). He was behind me in line at the farmer’s market, but I let him go ahead of me. He of course balked but I said: “The way I figure it, the sooner you get your vegetables and get out of here, the sooner I can read 1777.” It’s the only clever thing I’ve ever said to a celebrity. Usually I turn to mush.
Cute, But What Does This Have to Do with Wellness?
Glad you asked. Two things. First, many members of the media, the government, and scientific establishment believed flying was impossible. So what, you ask? Since it hadn’t been done it was perfectly reasonable to believe it couldn’t be done, right? True enough, but they believed this for years after the Wright Brothers had actually flown — and had documented their flight with pictures, eyewitnesses etc.
Likewise, it has already been proven that wellness in its current “pry, poke, and prod” configuration cannot conceivably break even mathematically. It has already been proven that wellness has accomplished nothing in 14 years— meaning even if vendors offered wellness free, it would have lost money. And it has already been proven that the “participants-vs-non-participants” study design, the industry’s signature lie, is totally invalid.
These are mathematical proofs, not scientific ones, which means they are determinate. Hence I can offer a $1-million reward for showing wellness breaks even, and hence that very same $1 million reward is gathering dust–an acknowledgement that the Wellness Ignorati know they’re making stuff up.
These wellness people continue to make stuff up. Especially the ones on the Koop Award Committee, to the point of doctoring government materials, which is probably not legal. And certainly awarding prizes to obviously made-up outcomes besmirches the good name of Dr. C. Everett Koop.
Employers and others continue to believe these wellness people despite proof. Hopefully it will take less time for decision-makers to accept my proofs than it did for the media to acknowledge that the Wright Brothers had completed many hundreds of flights.
Here’s another similarity. The first publication to accept and laud the Wright Brothers’ accomplishment was — a classic piece of trivia — Gleanings in Bee Culture. Obviously, the publisher had no background in aviation. Likewise, another criticism made of me is that I don’t have the academic background to invalidate these clearly fictional wellness claims. In my defense, I did complete fifth grade, and that’s all the “academic background” that anyone needs to show stuff is nonsense. I dedicated my first book, Why Nobody Believes the Numbers, “to my fifth-grade math teacher, for doing a better job than the other kids’ fifth-grade math teachers.”
OK, We Get It. So What’s the Second?
Second, Mr. McCullough made a rather obvious factual mistake in his book that anyone with any elementary historical/economic background could have noticed…but didn’t.
(As an aside, I’ve also found other mistakes in similar high-profile venues. After describing a meteor wiping out the dinosaurs 63-million years ago, the narrating voice says: “But, don’t worry, the chances of this happening again are a million to one.” Nope. If that were the case, we would have been struck by roughly 63 meteors since then and who knows how many before. Likewise, Austria’s Museum of Military History says the German trenches were sometimes as much as 3 km deep. Nope. Meters. Both mistakes were corrected by a grateful staff soon after I pointed them out. Plus, on my next trip I get to visit the latter museum free, just like everyone else.)
The Wright Brothers was carefully researched, read by editors, reviewed by professional reviewers (including one who found a few minor errors, like “canvas” vs. “muslin” for the wing-covering fabric), and read by a gazillion readers. But none of them noticed this screamer. Hint: Mr. McCullough confused two common words that are often confused. They have very different meanings but both begin with the same letter.
That’s as much as you get. I’m not going to tell you what the mistake is, because I want people to read the book. Not just because it’s a great book, but specifically to understand the position I’m in, where I find ridiculous numbers of obvious errors in just about everything the Wellness Ignorati publish but am dismissed or diminished with comments like: “But these are highly respected researchers.” (Actually, they aren’t researchers — they are vendors and consultants out to make a buck — and if they continue to lie, undeserving of our respect.)
Instead of pointing out the mistake, I will offer a free pdf of Surviving Workplace Wellness to the first person who contacts me to identify it. No, it’s not a million dollars. It is a far more modest prize, because — unlike the other award — there is actually a chance that I might need to pay this one out.
Today the US Chamber of Commerce offered a novel view of workplace wellness: that the savings can be used to increase wages. Indeed, one would think they represented workers, rather than management.
Their specific language:
Employers who offer wellness initiatives have achieved excellent returns on their investment – programs that follow best practice guidelines return $2 to $3 dollars for each dollar invested. These savings can be used to pay employees higher wages, invest in further adapting benefits to specific employee population needs, and create more jobs.
In support of this proposition, they offered:
- Professor Baicker’s 3.27-to-1 study (which they call the 2.73-to-1 study);
- This study in the Journal of Occupational and Environmental Medicine;
- RAND’s Pepsico study, which I could have sworn showed that health promotion efforts lost money. But what do I know? I was only a peer reviewer;
- A study I’m not familiar with of an unnamed utility, comparing participants to non-participants.
I invite the US Chamber of Commerce to submit their conclusion for the $1-million reward, and please please please cite those studies to the judges. They seem pretty sure of themselves so I’m sure they’ll apply — they have no reason not to add another million dollars to their coffers. They can use that money to fight on behalf of employees to get their raises.
Peeling the onion, we’d recommend clicking through to the actual brochure. What they are proposing (Step 4, wellness activities) are all “wellness done for employees” and not “wellness done to employees.” This list, plus Quizzify, would be the same list we would recommend to create a “culture of health.” They do sprinkle “pry, poke and prod” recommendations in the brochure but they do it like the prisoners in The Great Escape sprinkled the dirt from the tunnel around the stalag–so subtly that no one would notice.
And look at the guidebook as well.
We wish them the best of luck — this is nowhere near as bad as their previous forays into the field, they are far more tentative about savings claims, and all they want to do is help employees become “happy and thriving.” If only they would advocate screening according to guidelines and valid measurement of outcomes, we would certainly be in full alignment. The problem is that screening according to guidelines would throw a lot of vendors out of jobs, which would conflict with the stated objective above, which is to “create more jobs.”
Certainly this is a far better idea than other proposals being floated to help employees and create jobs. Give me this over building a wall with Mexico any day of the week. Especially this week, coming on the heels of April Fools Day: National Workplace Wellness Week.
What better time to celebrate April Fools Day than April 1st, and what better way to celebrate it than with our most popular feature, This Is Your Brain on Wellness? If laughter is the best medicine, then the wellness industry is producing a plethora of miracle drugs.
Special thanks to WELCOA, which (counting its writeups of “Premier” vendors) makes seven different appearances, four of which could have been avoided if they knew how to use spellcheck. They truly make me proud to be a nonmember.