Rarely can you become an expert in something in 3 minutes but then again rarely is there a wellness vendor as cool as Wellable. Their 3-minute “Whiteboard Wednesday Wellness Minute” will show you how to make lemonade out of this EEOC lemon.
Note that this blog post is my personal posting and does not necessarily represent the views of any organization with which I am affiliated, other than the one with which I am most closely associated, and of which I am one of the founders. I am referring, as everybody knows, to the Needham Frisbee Club. People who play Ultimate 3 times a week don’t need no stinkin’ checkups.
Why Wellness Vendors Hate Information: A New Theory
I have no clue why wellness vendors hate information so much. Perhaps they are repressing childhood memories of being bitten by a librarian.
A far-fetched theory, perhaps, but there is simply no other explanation for half the things half these very stable geniuses insist upon doing. In many cases, reams of information demonstrating the futility, fallacies and even harms of what they do is right there — begging to be googled — and yet no one in the wellness industry (or at least the wellness companies “profiled” on this site — there are plenty of exceptions listed at www.ethicalwellness.org) does.
Before we get into the checkups, consider some other information gaps, like the eight-glasses-of-water urban legend. Anyone with an internet connection can easily learn that you do not have to drink eight glasses of water a day, and the whole meme was completely made up. 70 years ago someone estimated that humans require that much water a day — but also that basically everyone with access to water already gets that much without having to force themselves to drink when they aren’t thirsty.
Yet try telling that to a wellness vendor (excluding the ones who have signed the Code of Conduct, of course). One vendor, Provant, even provides an infographic in case the employees they are harassing can’t count to eight:
Wellness Corporate Solutions — no stranger to these pages — has gone one step farther. Along with their crash-dieting contests, they offer what they call “healthy competitions” to see who can drink the most water:
Water-drinking “healthy competitions” may or may not make employees “more aware of their health status,” but they certainly make employees “more aware that this meeting better end really soon.”
Maybe WCS should combine those two competitions — along with their massive overscreening campaigns — to create a competition to reward employees for doing the most stupid things to themselves.
Failure to understand that thirst is your brain’s signal that you need a drink of water is not an isolated oversight. Wellness vendors take great pride in their ignorance of wellness generally. Consider their propensity to screen the stuffing out of employees. There are clinical guidelines for optimal screening frequencies and lists of biometrics that should be screened for, that most wellness vendors (It Starts with Me, US Preventive Medicine, and Limeade being three huge exceptions) have apparently never laid eyes on. If it helps, here they are:
There are a few subtleties beyond these words. “People at risk for diabetes” (under “Diabetes test”) would include people with high blood pressure or family history (which wellness vendors can’t ask about). It would also include people who are overweight or obese. Additionally, “members of certain ethnic/racial groups may be at increased risk at a lower body mass or a younger age.” Otherwise, it’s quite clear that cardio screenings should begin at 35 for males and 45 for females, and take place “at least once every five years” after that.
Some people should get that frequency, others a higher one. But like most other things in healthcare, the answer is not the same for every employee of every age and every health status, and you do not just screen people because you make money on each screen, so the more you screen, the more you make. Otherwise you end up like Interactive Health, one of the most expensive vendors, positively hyperventilating about all the false positives they’ve found:
Finally, let’s once again review the aforementioned crash-dieting contests, a staple of many wellness programs besides Wellness Corporate Solutions. Schlumberger, for example, pays out thousands of dollars to the team which does the best job packing on the pounds in December and then taking them off in January. “Just plain fun,” is how their ironically named vendor, HealthyWages, describes it. None of these vendors have apparently seen the CDC’s advisory memo warning that crash-dieting is futile, likely counter-productive, and possibly harmful.
What about annual checkups?
Let’s cut to the chase: there is not one shred of evidence that annual checkups are a good idea for asymptomatic working-age employees. There are many good reasons to go to the doctor — you notice a change in some aspect of your body, you want to develop a plan to improve your health, you need help managing a chronic disease, or even that you’re sick — but here’s what’s not among them: the earth completing a revolution of the sun.
New England Journal of Medicine says that while the major benefit is “less patient worry,” checkups “may actually be harmful.”
“Less worry” is not necessarily a good thing. An employee (name on request after an NDA — not a made-up person) had a checkup in order to collect a wellness incentive…and as a result of being told not to worry, ignored heart attack symptoms about a week later.
The Journal of the American Medical Association says offers of health checks did not reduce any kind of mortality, but “may be associated with more diagnoses and drug treatments.”
Choosing Wisely says: “Annual checkups usually don’t make you healthier,” and “tests and screenings can cause problems.”
None of this takes into account the cost of annual checkups — which often lead to more unneeded and expensive tests and prescriptions, as JAMA notes — but we have definitely observed that wellness vendors and even some HR departments don’t really care about costs. It’s not their money. Here is Reuters on the high and unneeded cost of prevention.
Meanwhile, I’ve yet to find a wellness program that does not either pay employees to get checkups or fine them if they don’t — or shunt them into a worse health plan unless they submit to an annual physical.
I would also note that, however useless annual checkups are to begin with, they are likely even more useless if someone is visiting the doctor because their benefits department is forcing them to do so, against their will.
Finally, there isn’t exactly a surplus of primary care doctors. Why are we paying healthy employees to take up clinician time that unhealthy employees might actually need?
What is the argument in favor of checkups?
If checkups don’t actually prevent anything, why make employees undergo them? Two reasons have been proposed. One is that employees can “build a relationship” with their PCP. This of course assumes that neither the employee nor the PCP ever retires, moves or changes jobs. It also assumes that somehow the things that affect employees can be prevented by having a “relationship” with a PCP. However, if you look at the list of the most frequent reasons for hospitalization among the working-age population, it’s kinda hard to find anything that fits that description.
Can you think of any disease in your own life that would be cured by a relationship with a PCP? I can’t think of only one problem — chronic heartburn — that my PCP could have prevented. But she didn’t. The PCP was perfectly happy to keep me on Prevacid, which, as Quizzify teaches (right on the home page quiz!), is likely harmful in long-term use. Fortunately, I happened to run into a yogurt salesman one day, who told me about active-culture yogurt. Within days my heartburn was gone, never to return.
The second argument in favor of checkups, proposed by the CEO of Bravo Wellness, Jim Pshock, is as follows:
The hope is that the [Bravo] program will get people to proactively see their physicians to manage their health risks. Yes, this will, hopefully, mean more prescription drug utilization and office visits, but fewer heart attacks and cancers and strokes.
It isn’t his money, so he is perfectly fine with employees “hopefully” spending more on drugs and office visits. On the other hand, there is no information supporting his claim that all this spending and all these checkups will prevent all these diseases. Quite the contrary, 100% of available information reaches the opposite conclusion — especially JAMA, which specifically measured mortality due to heart attacks, cancers and strokes and found no improvement. You’ll fine zero information suggesting the contrary finding, no matter how hard you search.
Perhaps when he was a toddler, Mr. Pshock’s parents threw him into an entire cage of librarians.
What is the best frequency for checkups?
The literature is quite adamant: not at all. That seems a bit extreme and I would bet the people who write these articles do occasionally get a checkup. For the most reasonable compromise I would turn to Quizzify, the leading health literacy vendor. They recommend a simple mnemonic: get two checkups in your 20s, 3 in your 30s, 4 in your 40s, 5 in your 50s, and annually after that. Quizzify’s advisory colleagues, doctors at Harvard Medical School, approved this recommendation too. As with most other questions, this one carries the HMS “shield.” (Quizzify also reports that this question is the one most likely to be removed by its customers, which is an option for all questions in their database before they get seen by employees.)
So what’s the solution?
In three parts, it’s:
- Screen according to guidelines
- Send employees to the doctor at age-appropriate and health-appropriate intervals
- Pay the fines on overdue books.
Sometimes we bring up the many ways in which conventional outcomes-based “pry, poke and prod” wellness programs harm employees. For the first time, we are putting all those harms in one place, a hand clip-and-save guide for journalists, regulators, and legislators.
This series now includes three. First is The Outcomes, Economics and Ethics of the Workplace Wellness Industry. The good news about this one is its exhaustive comprehensiveness in covering the industry’s misdeeds, garnished with 400 linkable footnotes. The bad news is it was published more than 9 months ago, too soon to capture the most recent swarm of misdeeds. For example, it predated Interactive Health’s scorched-earth screening program, designed to leave no employee undiagnosed. (This is literal — according to their own data roughly a quarter of employees discover “new conditions” every year. So in 4 years, every employee, on average, gets one new condition.)
The next was an expose of the economics of wellness, a compelling, fully sourced and linked proof that the whole pry, poke and prod endeavor served no economic purpose beyond enriching pry, poke, and prod vendors. (Screening according to guidelines, should a vendor ever choose to do it even though it would require sacrificing two-thirds of revenues in the name of integrity, would be exempted from this conclusion.) That’s because there is no chance that vendors “playing doctor” at work saves money.
Confucius observed that an mistake that remains uncorrected after being pointed out becomes a lie. Using that definition, two-thirds of the wellness industry –– including the Koop Award Committee and the Health Enhancement Research Organization — is lying, as they are fully aware that their very stable economic genius fantasies are nothing more than the stuff dreams are made of. That also explains why the $3 million reward for showing wellness is not an epic fail remains unclaimed.
The Hazards of Workplace Wellness
This whole thing would be hilarious were it not for all the harms and hazards of workplace wellness visited on employees who are forced to choose between, as Judge Bates noted in his epic decision in AARP v. EEOC, paying two months’ rent or forfeiting that sum by submitting to needles wielded by unlicensed, unregulated and unsupervised wellness vendors. Employees should never be forced into clearly unhealthy situations at work, at least without the hazards being disclosed, and yet, today’s American Journal of Managed Care posting covers six hazards employees face as they navigate the shoals of workplace wellness:
- Actual, well-documented, harms to an exposed population
- First-person case studies and reports
- Crash-dieting-for-money risks
- Flouting of established clinical guidelines
- “Hyperdiagnosis” leading to unneeded medical care
- Incorrect or potentially harmful advice that employees are told to take
Not if you don’t have a license, aren’t required to understand what you are doing, and can force employees to harm themselves or lose money
Rarely does a book come along where you can see the author changing his mind about the conclusion as he goes along. The Healthy Workplace Nudge, by Rex Miller (with Philip Williams, and Dr. Michael O’Neill) is such a book. (For politicos, here is another such book.) Don’t skim the first few chapters — enjoy watching his journey to enlightenment. Like him, I myself took the same journey. Until about 2007, I didn’t just drink the Kool-Aid. I also mixed it up and sold it…until I did a little fifth-grade math, reaching a conclusion summarized in an observer’s blog post entitled Founding Father of Disease Management Astonishingly Declares “My Kid is Ugly.”
Like virtually everybody including myself (and every member of Congress in 2010), upon first hearing the wellness industry elevator pitch, Rex starts out by assuming that wellness must save money — it seems so obvious. But the more he learns, through his extensive research, the more he realizes that the “pry, poke and prod” industry is a fraud. “My [initial] unfamiliarity with workplace wellness was a benefit,” he observed. As a tabula rasa, the more he looked, the more he saw: “A few studies have become major pillars of misinformation that have been repeated for more than a decade.”
Welcome to my world, Rex.
After that, the more he learned, the more he learned. Trying to get to the root of the ubiquitous $3-in-savings-for-$1-in-investment meme that permeates the field and predated Katherine Baicker’s subsequently retracted 3.27-to-1 ROI, here’s what he discovered:
When I reached the global health and wellness director for the most cited case study, he admitted he did not know where the numbers came from or even who had actually created the report. So the result seemed to be a very high profile…urban legend.
Meanwhile, back in the company of my new castaway friends, the misfit provocateurs [Tom Emerick, Soeren Mattke and me], I kept hearing simple declarative sentences and sourced data.
He is spot-on regarding the distinction. Here is how one of the Wellness Ignorati explains Koop Award-winner (and notorious opioid distributor) McKesson’s seemingly self-contradictory award-winning program results:
Health indicators in 2013 and 2014 were adjusted in the analysis, while several sensitivity analyses of the ‘inter-individual’ impact that used a matching approach confirmed the results… Lewis’s conclusion essentially compares apples and oranges by mingling overall summary statistics with an interpretive analysis section that’s descriptive. The latter is based on repeated cross-sections of McKesson employees.
By contrast, here is “Lewis’s conclusion” after observing the self-contradiction in the Koop Award application that prompted this Employee Benefit News smackdown, presented in a simple declarative sentence:
The average weight of McKesson’s employees can’t rise and fall at the same time.
As if Rex needed more data points, another red flag was being disinvited from speaking at one of the Wellness Ignorati-fests. This happens whenever a speaker subsequently admits to critical thinking after being “confirmed” to speak. Critical thinking is right up there with data, math, integrity, facts, analysis, grammar, wellness and me in the rogue’s gallery of damned spots the Wellness Ignorati attempt to wash out, out — or at a minimum pretend to ignore (hence their moniker).
That’s why allowing the noses of the Rex Millers of the world (among whose unforgivable misdeeds are quoting the Al Lewises of the world in their books) into their tents might nudge their bright-eyed and bushy-tailed, painstakingly sequestered, acolytes to use the internet, perhaps searching on keywords like “Koop Award.” If they do, they might learn that in 2016, the year after the Ignorati disinformed their flock that Koop Award-winning companies dramatically outperformed the stock market, the 2015 winner became 2016’s 14th-worst performer in the S&P 500.
Mr. Miller refers to the Ignorati as harboring “deep anger” about being exposed for “fabricating the data.” Rex says he “doesn’t know the intent of using false data,” but I can clue him in: false data is quite useful if you are selling a scam (the LA Times‘ word, not mine).
Mr. Miller’s expert interviewing style even enticed Ron Goetzel to come tantalizingly close to admitting what we’ve spent four years in TSW demonstrating: that his whole career — claiming huge amounts of money can be saved by coercing lots of employees into claiming to eat more broccoli — is one giant fabrication. Mr. Miller quotes Mr. Goetzel as saying: “Changing behavior is very very very very hard.”
Yes, Ron, your cordially-welcomed-but-ever-so-slightly-overdue Eureka Moment is very very very very accurate. I imagine you’ll retract it soon, because on the other occasion when you were accurate — when your guidebook accidentally admitted wellness loses money — you immediately tried to disown your findings as soon as I congratulated you on their (apparently unintentional) accuracy.
The Nudge…and the Real Estate
The essence of Mr. Miller’s thesis is that hammering people with forced behavior change is very very very very pointless.
Having concluded that prying, poking and prodding employees does likely more harm than good, Rex moves on to a totally different way of doing wellness, which is to say, passively rather than actively. Clearly Rex put a lot of time and shoe leather into researching this book, and it shows. Many examples are offered of how little steps — simply moving different snacks to different places or making stairways more appealing than elevators — nudge behavior.
Way beyond that, the most notable advances in this book concern the built environment. He observes we spend 90% of our lives indoors, and yet little attention is paid to the effect of indoor space on health, wellness and productivity. I suspect more attention is paid to it than he gives credit for, but certainly we have all worked in or visited stultifying workplaces, workplaces where you can’t imagine wanting to hang out in any longer than necessary.
He proposes taking the built environment to the next level. Upgrading a typical building to the WELL Certification standard costs between $150 and $500/employee, all-in. Contrast that to the math provided to him by Tom Emerick that Walmart estimated for a wellness program: accounting for all the administrative costs, false positives, and lost productivity from health fairs and “workshops” totals thousands of dollars per employee. On the “credit” side of the ledger, every pound an employee lost cost Walmart shareholders $50,000.
By contrast, what goes into that $150 to $500 spent on the built environment get you? Suddenly every employee is “participating” in your wellness program, with no penalties or incentives needed. Not just the food in the cafeteria, but everything down to the air that circulates can be optimized for health and performance. “At their best,” he concludes, “buildings can be inspiring and invigorating–with little additional expense.” For instance, office and factory interiors tend to be dry, which facilitates the spread of disease. They also often allow in little natural light, the lack of which can disrupt circadian rhythms. Both can be easily remedied, with humidification, and with lighting that mimics our circadian rhythms.
The beauty of his proposal on the built environment is that, unlike traditional wellness programs where even the promoters say you need to do everything right to get them to work (“Only 100 or so programs succeed, while thousands of programs fail,” according to Mr. Goetzel), you can solve this problem by throwing money at it…and not much at that. Mr. Miller does go on to point out the value of leadership, but I prefer solutions that anyone can implement, as opposed to solutions that require CEO behavior change, which is very very very very hard.
The built environment is one of several chapters he proposes on solutions, and all are worthy reading, but this section is my favorite because it was new ground at least to me, and because it is so accessible to the average company. Even in existing space as opposed to new construction, a large chunk of what he is proposing can be accomplished for the price of a few years of a “pry, poke and prod” program. As one CEO who made this investment observes: “Hardly a week goes by when I don’t get a thank-you.”
In conclusion, go to Amazon and buy this book. Do it very very very very soon. Plus, the more copies he sells, the more Ron Goetzel will get very very very very mad.
Prior to a few days ago, there were competing visions about whether the EEOC would publish new rules by January, preserving the “safe harbor” to prevent employee lawsuits, or whether they were going to miss the deadline or pass altogether. As is invariably the case when we say the opposite of what a wellness vendor says, our vision won the competition. We predicted this would happen, while Bravo Wellness, taking the lead in attempting to protect the forced-wellness revenue stream, accused us of spreading “rumors, chatter and fiction,” by accurately predicting this would happen.
The EEOC are a smart and committed group. Knowing what they know now about the outcomes and harms of wellness, there is no way they would rush into writing rules forcing employees to submit to unregulated programs run by unlicensed vendors on unwilling subjects, given the tremendous failure rate of these programs, especially following the expose of deceptive and harmful industry practices.
The implications will be covered in Quizzify’s webinar Wednesday May 16: The Pending EEOC Wellness Rule Changes: How Quizzify turns Lemons into Lemonade
To cut to the chase, the only — and it looks like we do mean only — safe harbor available come January will be Quizzify’s. Otherwise, if you have a “pry, poke and prod” program with high penalties or incentives, you will be open to employee lawsuits because there will be no new rules by then.
The only thing the EEOC will have by January is the Notice of Proposed Rulemaking. It will then take a while after that before the rules are actually proposed, and then commented upon, and then implemented.
Or, you could solve everything, right now, by offering Quizzify’s employee health education curriculum side by side with your existing wellness program. You’ve taken health risk assessments. Now play some Quizzify questions right on the home page. How can an employee learn more from the former than the latter? (Plus as noted, advice on HRAs is often if not usually wrong.)
Tune in to Quizzify’s Wednesday webinar, The Pending EEOC Wellness Rule Changes: How Quizzify turns Lemons into Lemonade, for the shocking conclusion.
Meanwhile, don’t believe a word your wellness vendor says…
In wellness, there is a saying that you don’t have to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself.
Now that adage can be extended to cover the May “position paper” published by the Health Enhancement Research Organization (HERO). HERO manages to invalidate its own position even though they didn’t actually take a position in this “position paper” to invalidate. They didn’t even present any data…and yet their data was wrong.
All they said was “critically examine research.” Then they provided four paragraphs which showed why doing precisely that invalidates everything they’ve ever published. See for yourself with each paragraph header.
I agree totally — except with the grammar, English being right up there with arithmetic, logic, statistics, and ethics as being courses that HERO’s staff have struggled with. There has not been a single study in the last five years showing wellness saves money. Sometimes, the studies say explicitly that wellness failed, as the National Bureau of Economic Research did, with Medicare close behind. Or Pepsico. Or the state of Connecticut, which, having thrown away millions on inappropriate screenings and doctor visits, declared that losing money was “a good thing.”
Other times, you have to actually read the study to realize that wellness loses money, as in every Koop Award-winning example in the last six years through 2016, like this one and this one and this one and this one and this one and this one. Why not 2017? Because in 2017, they couldn’t even find a study that pretended to save money.
HERO has painted itself into a corner here too, because if a study ever does come out that alleges wellness saves money, critics would simply note that it is important to be skeptical of a claim from a single study refuting all the others. Apparently Prof. Baicker is working on a new paper, having found the arguably the most stable genius vendor in the wellness industry to support what are likely to be claims of savings high enough to support her own previous claims of savings, but low enough so they won’t immediately self-invalidate upon exposure to sunlight. And let us not forget that her original conclusions were publicly invalidated, by name, by her own subordinate. Is this is a great country or what?
The HERO position paper complains that:
Media criticism is sometimes based on programs that are not evidence-based, are poorly implemented, or are incorporated into unsupportive environments.
Hmm… so every time a study comes out showing wellness loses money, it’s because the program was done badly? This list of losers apparently includes the aforementioned Pepsico, whose program was so bad they won two Koop Awards.
During my debate with Ron Goetzel, a number of questions from the audience complained that their own company’s wellness program was horrible. Ron’s stock response: your company needs a better program. He reserved particular animus for the Penn State program, which he himself decried as “horrible,” even though he was the prime architect. In another instance he blamed the questioner for being a bad employee.
Since employees dislike being pried, poked and prodded, “unsupportive environments” would include every company, according to WillisTowersWatson. That means the only companies with “best practice” programs would be wellness vendors themselves, like Vitality Group, where, as a wellness vendor, they curated and implemented only the finest wellness interventions available to mankind. Oh, wait a sec, I goofed. That program failed miserably. Shame on their own bad employees!
Vitality Group is in good company. As Mr. Goetzel says, thousands of programs are done badly while only 100 have succeeded.
“Best practices” might include adhering to US Preventive Services Task Force guidelines, not demonizing social drinking, avoiding harms to employees with eating disorders, and not telling people to do stupid things. I’d settle for a program that does any one of those things.
How much time do they need? 3 years? 6 years? They need more? Sure — here is 14 years‘ worth of results for the entire US, showing virtually nothing has happened. The “wellness-exposed” and “wellness-non-exposed” <65 populations are virtually coincident, with only Medicare — where, by definition, there is no workplace wellness — showing a little improvement. It’s all spelled out here.
This paragraph is supposed to be a subtle diss of the NBER paper, which in the 4 months subsequent to publication, the very stable geniuses at HERO have not mentioned by name to avoid drawing attention to it due to its obvious quality and validity. (Welcome to my world.) True enough that the NBER paper covered only one year, though the authors added there was absolutely nothing “trending towards savings” to suggest that the second year would be any different.
The irony of course is that almost every one of those Koop Award-winning programs did claim first-year savings. So first year savings are obtainable, except when they aren’t.
Confirmation bias? HERO is a thesaurus-level paean to confirmation bias. Look at a typical study, and all you will see is citations to studies by their colleagues. Not one study in the wellness trade association’s journal (whose prevaricator-in-chief Paul Terry, also runs HERO) has ever cited me in all of its history, whereas this single article by me cites various members of the Wellness Ignorati 115 times. Not one study in the history of that journal has ever found wellness loses money. At least deliberately. Just like Perry Mason lost one case that was overturned on appeal, that journal accidentally found “randomized control trials exhibit negative ROIs,” but then devoted an editorial in the next issue to overturning their previous conclusion.
Here is HERO’s exact language on confirmation bias:
Confirmation bias is the tendency of researchers to draw inferences from their study that align with their preexisting beliefs but are not well supported by their data.
This is, of course, is how the Wellness Ignorati got their name — deliberately ignoring the overwhelmingly conclusive data that undermines their revenue stream. Examples are legion but my favorite is Larry Chapman breathlessly propagandizing a study that he interpreted as aligning with his preexisting belief that health risk assessments save 50% (“they should be treated like a beloved pet”). Alas, he made the mistake of also providing the actual data, which naturally not only can’t be interpreted to show 50% savings, but also can’t even be misinterpreted to show 50% savings. Or any savings, for that matter.
Larry, one question for you: