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Review of The Price We Pay, by Dr. Marty Makary

Aside from the many antediluvian wellness promoters still insisting that the country’s healthcare cost crisis can be solved by browbeating employees into pretending to eat more broccoli, there is a legitimate debate between:

  • those who argue that the system is corrupt because pricing is out of control vs.
  • those who argue the system is corrupt because utilization is out of control.

The Price We Pay – certain to be a New York Times bestseller like Dr. Makary’s Unaccountable—shows quite definitively that the answer is both. Our focus in TSW is largely on the wellness industry’s stock-in-trade (I’m looking at you, Interactive Health) — hyperdiagnosis and overtreatment:

“If overtreatment were a disease, it would rank as one of our leading public health threats.”

There is precisely one vendor combating overtreatment at the employee level, of course…and so it’s no surprise that Quizzify gets a nice shout-out. It’s one of only 3 employee health services vendors, out of thousands, mentioned positively. And our work at TSW is recognized too. Here is a brief excerpt of the shout-out:

Al Lewis went from a wellness industry advocate to its foremost critic. He spent years in the industry but came to see its futility. He left and started his own company, Quizzify. The company educates employees about overtreatment and dispels myths about healthy living. I traveled to meet with Lewis, and he didn’t hold back.

“Most of it is fluff. And I might add expensive fluff,” Lewis, a tall man beaming with a smile, explained to me over a snack after he had just finished speaking to a large audience. Quizzify uses an interactive game show approach to teach people about common medical pitfalls, including the risks of overscreening. It also alerts employees to the most common unnecessary tests and procedures in medicine today, according to the Choosing Wisely campaign.

Painstakingly researched with a team of dedicated and highly skilled students and fellows, Dr. Makary traveled around the country collecting first-hand stories at an on-the-ground level rarely seen in health services research.

Dr. Makary has created a niche as a practicing surgeon who also does on-the-ground-research and who also influences health policy. No one else does all three and only few people, like Atul Gawande, do even two of those three. Hence these are not just stories for their own sake, but they feed into the national debate. With the help of this group to raise awareness, they could win the national debate.

One such set of stories, about hospitals suing patients for unpaid bills as a matter of course, has already been featured on NPR, and the hospital in question, Mary Washington in Virginia, has already agreed to cease and desist.

In another city — Carlsbad, New Mexico — it appears that a very significant portion of all the households had been sued by the city’s hospital.  This particular chapter reads like fiction. To parse it in detail to the slam-bang climax would require a spoiler alert. Suffice it to say that after you read it, you will want to sell short the corporation that owns the city’s hospital. Except that the corporation in question – notorious among healthcare industry insiders for having made one of the worst acquisitions in hospital industry history earlier in this decade – is already near bankruptcy. The strategy of suing patients is a last-ditch attempt to prevent it. Not much left to short.

Many hospitals sue patients, as we learn in this book. But it’s not just the hospitals. Turns out there are even worse offenders: ambulances. Air ambulances are the worst of the worst, with one example of a bill for an air ambulance ride that exceed the actual bill from the hospital for a one-week stay.

These companies’ strategies are driven by greed rather than need, it would appear, seeking out patients not with the greatest gaps in care or health disparities but with the greatest ability to pay, which explains why 24 air ambulance companies operate in Dallas vs. none in the Medicaid-intensive Rio Grande Valley.

The bottom line is that surprise billing is way worse than I thought…and I thought it was pretty bad.  Fortunately, the book recommends some ways to mitigate it.

Inspired by this book, I’ve created a solution, which is that the health insurance card should carry a “battlefield consent” to treatment in the ER and an agreement to be responsible for reasonable charges not to exceed X times Medicare. ERs have to treat you, if you come in. That’s the law. You just don’t have to agree to open-ended charges by signing their preprinted ‘terms and conditions.’ Absent this Battlefield Consent card, you’d either be exposed to open-ended billing or have to negotiate on the spot. Good luck with that. A health insurance card like this would create the equivalent of an advance directive for ER billing.

And what would a thoughtful healthcare policy book be without dissing wellness?

Here’s a shocker:  Quite ironically considering that he works at the same institution as Ron Goetzel, Dr. Makary hates “pry, poke and prod” wellness programs. (Johns Hopkins’ excellent wellness program excludes them.) The ‘screening-industrial complex,’ he calls it. Which indeed it is. What, he asks, is so difficult about screening according to USPSTF guidelines — other than depriving wellness vendors of valuable revenues drained from employer coffers? Vendor coaching doesn’t come off much better:

A friend invited me to sit in on a company’s wellness class. I can sum up the instructor’s message in three words: “Avoid fatty foods.” There are a few problems with that message. First, it was about the only thing the health “coach” said to the 20 or so bored people in the room. But second, I cringed because it has absolutely no scientific basis. This class risked making people less healthy; it was loaded with misinformation.

The Price We Pay is already close enough to the top of the Amazon rankings that we can nudge it onto the NYT bestseller list. Every member of TSW Nation should be buying a copy, reviewing it on Amazon, and circulating the reviews loudly on social media.

Are Livongo’s outcomes real?

Breaking news first…

Sign up for the Validation Institute webinar and learn why Yale got sued for wellness because they made a series of rookie mistakes…and how you can avoid them.

Attention, Pennsylvanians: register now for the Pittsburgh Business Group on Health Symposium 9/12…and play in our trivia contest.

And, now, for the rest of the story.

Kudos to employers who have resisted the entreaties of their carriers to jump on the Livongo bandwagon. Resistance is not easy — carriers will pester employers endlessly because they get a nice commission every time an employer bites.

Instead, I would simply recommend waiting until Livongo answers these five questions and gets their results validated by the Validation Institute. One would think that if they are losing $30-million/year anyway, spending an extra $10,000 to see if their offering actually works shouldn’t break the bank.

Here are the five questions that Livongo apparently can’t answer. Or they can, but choose not to. Not sure which inspires less confidence.

The references below mention a “study.”,  By way of background, this study was conducted by Livongo’s employees, along with employees of its partnered diabetes supply company (Eli Lilly), which also funded the study. So there couldn’t possibly have been any conflict of interest, right? Right?

It was published in something called the Journal of Medical Economics (JME). And no, I hadn’t heard of this publication either. Turns out it’s an “open-access” journal offering “accelerated publication,” with an Impact Factor of 1.9.

Not familiar with the concept of Impact Factors? Those measure the influence of a publication. For instance, the New England Journal of Medicine tallies a 70.8. How hard is it to only get a 1.9? Even the American Journal of Health Promotion (AJHP), which recently proposed charging employees for insurance by the pound, scratches out a 2.6.  Possibly, that’s because AJHP does sprinkle more humor into its content than JME, like:

I guess that means 10 states both prohibit it and allow it.

Question #1 for Livongo

Even obscure journals need to do a little peer review (which itself is increasingly considered to be a joke), and this peer review was pretty basic: the authors were asked to disclose that the study couldn’t draw any causal relationship between the Livongo intervention and the results. The title of the article itself says that reduced medical spending is “associated with” their product. Later the authors say the results “imply” the product works.

So if the study showed only a correlation and not causation, why does Livongo’s press release announce:

“The findings showed that by using its remote digital health platform, the Livongo for Diabetes program delivered an $88 per member monthly reduction” ?

Question #2 for Livongo

Since these alleged findings are the opposite of Livongo’s initial claim below, featured in a recent Valid Points posting about diabetes vendors snookering purchasers, the second question is, how did the original 59% reduction claim (which basically requires eliminating every hospitalization not connected with births, trauma or cancer) get replaced by the opposite claim that large reductions in physician visits generate all the savings, while admissions increased?

A while back, I actually looked into the likelihood that tighter glycemic control, which itself is rather controversial, (“there is good evidence that intensive control of blood glucose increases patients’ relative risk of severe hypoglycemia by 30%”) could reduce hospitalizations. I used very optimistic assumptions (since I was consulting for a company making a glucometer with remote capabilities, not unlike the one Livongo pitches). Here’s what I came up with: savings of $27 per diabetic per year in inpatient admissions, as opposed to Livongo’s $88 per diabetic per month.

In all fairness to Livongo, they don’t promote that inpatient admissions result anymore (I may have missed the apology for fudging that outcome in the first place), focusing instead on getting doctors to do fewer visits by managing patients remotely.

Seems curious that physicians would be doing more work – more notifications from remote monitoring devices about blood sugar, more titrating dosages – and be perfectly fine making 26% less money. Plus, every other wellness vendor brags about how many more physician visits they generate, not how many fewer.

Question #3 for Livongo

If I’m seeking a vendor to reverse diabetes in my population (assuming that is even possible on a broad scale), I would look for weight loss (without which diabetes reversal is basically impossible, but then again sustained weight loss itself is pretty close to impossible) as the leading indicator.

As an intermediate indicator, I would measure units of insulin use across the entire population. That should decline if people are eating much better an exercising much more and losing weight.

The end-point indicator would be a decrease in admissions for diabetes. Of course, since diabetes admissions generally increase following retirement, it isn’t exactly easy to save money in decreased admissions for diabetes, for the simple reason that there hardly are any.

Specifically, for the last year in which a full set is available (2014),158 million commercially insured <65 people generated 126,710 admissions for diabetes. Meaning that in the commercially insured population, the admission rate is so low that a 10% reduction in admissions (which has never been achieved in any population health program) would mean that an employer with 10,000 employees would avoid — get ready — 1 admission.

We suspect Livongo knows this because they listed the diabetes diagnosis codes in their appendix, and it takes about 5 minutes to tally the US admission rate for those codes using the federal database designed for that purpose. And if they don’t know it, they should. Any health services researcher should be aware of this database.

So why didn’t Livongo measure any of those three outcomes? Or did they measure them and decide not to report them?

I’m not sure which answer is “right”: While I would be very concerned if they were suppressing data, I think I would be even more concerned if they didn’t know enough about diabetes to measure the key outcomes.

Question 4 for Livongo

Why did Livongo measure participants against non-participants, when that study design is known to be completely invalid?  Benchmarking a par-vs-non-par result has been done five times, including three times by wellness promoters hoping to prove validity of the design  The conclusion in each case: 100% of difference in outcomes between the two groups is attributable to the study design, and 0% to the intervention. The design is 100% invalid.

There was actually a case in which the two groups were separated and “match-controlled” in 2004, but the program didn’t start until 2006. During the 2-year period following separation but before the program became available to participate in, the would-be participants nonetheless dramatically outperformed the non-participants…despite not having a program to participate in. (This result caused quite a ruckus in the wellness industry once they realized what they had done.)

Further, more than 15% of the initial Livongo participants dropped out. Assuming dropouts largely failed, aren’t the authors of the Journal article overstating the outcomes for the participant group as a whole by not counting dropouts? Isn’t that like on-time performance statistics not accounting for planes that crashed?

Question 5 for Livongo (really multiple questions)

Livongo offers “free unlimited glucose test strips” to try to reach a “target level of glucose control of Hb A1c <6.5%.”

It is not quite clear that either unlimited free strips or a 6.5% Hb A1c target are good for diabetics. Why, one might ask, does the American College of Physicians propose 7% to 8% instead of 6.5%? While it is true that the American Diabetes Association is sticking with its much lower blood sugar goal, isn’t it also the case that the ADA is largely funded by companies that make products to help lower blood sugar?

And what is the rationale for encouraging more use of glucose strips while Choosing Wisely recommends less testing for many Type 2 diabetics (in JAMA Internal Medicineimpact factor 20)?  Exact words:

This recommendation is based on robust evidence, including a Cochrane review of 12 randomized clinical trials with more than 3000 patients, showing no statistical difference between patients who do not self-monitor their blood glucose multiple times per day and those who do self-monitor their blood glucose multiple times per day in glycemic control, nor evidence of effects on health-related quality of life, patient satisfaction, or decreased number of hypoglycemic episodes.

So it could be that this is just me, since their revenues are doubling every year. Maybe, like in the rest of wellness, answering questions about efficacy is beside the point. Maybe the point in HR is just to do something, regardless of whether it works, in case someone in the C-Suite asks. Or in the immortal words of the great philosopher Yogi Berra: “We don’t know where we’re going, but we’re making good time.”

The biggest gap in your health benefit: dental

Here are some things you don’t know about dental care…and if you don’t know these things, your employees don’t either:

  • Your dental benefit likely 100% covers 2 cleanings a year. Yet maybe a quarter of people should get 2 cleanings a year. The rest should get either 1 or 3 (or 4). The latter group includes many diabetics (though almost no diabetes program mentions this, of course because they get measured on blood sugar, not the number of pieces of intelligent advice they give), smokers, mouth-breathers and people with a lot of dental work. The extra preventive visits aren’t covered. And yet this exact same latter group is the one that is going to cause you problems. This is probably the only instance in which preventive care saves money. But it’s probably the only instance in which preventive care isn’t covered.
  • Americans get way too many wisdom teeth extracted.  No surprise, since these extractions are very profitable.
  • Probably 2/3 of cavities can be fixed without drilling, filling, needles or high expense. But your dentist isn’t going to tell you about this “new” (used elsewhere in the world for more than half a century) treatment because they make so little money treating cavities this way. (Translation: your employees don’t pay much.)

Of course, most wellness programs address these issues through employee education. (Not!) Actually Quizzify is the only vendor that does, as far as we know. Here are a few words on this subject.

Meanwhile, the rest of you can read this great article in Employee Benefit Adviser on how to, uh, extract maximum value from your dental benefit.





Best healthcare joke ever

You rarely see the words “healthcare” and “joke” together — except of course figuratively, when we’re talking about certain wellness vendors. And we have never put an actual joke on this blog. However, this one is too good to pass up — and is also exactly what’s wrong with our healthcare system, that Quizzify addresses. [SPOILER ALERT: It’s also a “soft” PG, in case anyone might be offended. To put this in perspective, these wellness vendors are much more offensive…and yet they’re rated G.]


A guy has had these splitting headaches for years. Tried everything but they won’t go away, so he goes to the doctor for a battery of tests. He happily signs up for all of them, because he is fully covered — and he really, really, wants to get rid of these splitting headaches.

The results come back. The doctor says: “According to our tests, there is nothing we can do for you except to remove your testicles. So think it over.”

The guy thinks it over for a few days — two really bad options, but finally decides that getting rid of the headaches is more important. Gets the operation and lo and behold, the pain is gone immediately.

On the way home, he is so happy with his new, pain-free life, that, passing a tailor along the way, he decides to treat himself to a new suit. He goes in, tells the tailor he wants a new suit. The tailor, who’s about 75 years old, looks the guy up and down and says: “42 Long.”

The guy says: “Yes, how’d you know?”

The tailor replies: “I’ve been in this business 55 years. I know all this stuff.”

The guy says: “While I’m at it, I guess I should get a new shirt to go with the suit.”

The tailor looks at him again and says: “Sure. 16 1/2 -34?”

The guy says: “Right again. How’d you know?”

The tailor says: “I’ve been in this business 55 years. I know everything there is to know about fitting men’s clothes.”

The guy gets the suit and the shirt, and then, as he is about to leave, says: “You know, while I’m here, I might as well get some new underwear.”

The tailor looks at him and says: “Sure. 38, right?”

The guy says: “You’re wrong this time. 36.”

The tailor says: “No, you’re definitely a 38.”

The guy says: “Nope. I wear 36.”

The tailor says: “Trust me. You’re a 38. Underwear that’s too tight will squeeze your balls together. You’ll get these splitting headaches.”

The worst wellness story of all time: harassing a double-mastectomy patient to get a mammogram

The Yale wellness program (the one being sued) is exemplary in its adherence to guidelines. Were this program offered with a $100 incentive instead of a $1300 fine, and/or were Quizzify offered as an alternative to the screening/coaching requirement, I would nominate it for a Health Value Award.

Their Achilles heel is using Healthmine as their wellness vendor, no doubt because Healthmine apparently failed to disclose to Yale that they don’t know anything about wellness. Consequently the following happened on their watch, as described in the Complaint, which I can send you on request. (I don’t think it’s online.)

Christine [Name withheld, but in Complaint], a 57-year-old first cook and a member of Local 35, explained that she is participating in the HEP because she is a single mother who is paying for her child’s college and the $25 per week fine is “the cost of my kid’s books for an entire semester.” To her, paying the $25 per week fine would be a “needless expense,” particularly when she has other pressures such as saving for retirement. Christine said she feels “forced” to participate
in the HEP.

Christine’s experience with the Program has been burdensome and emotionally fraught. The HEP requires female participants over age 50 to undergo a mammogram. Christine  previously underwent a double mastectomy when battling cancer and therefore could not comply  with the HEP requirement to have a mammogram. As a result, an HEP representative contacted her “several times,” asked about her mammogram results, and told her she would be held in non-compliance and charged the $25 per week fine if she did not get one.



First EEOC wellness lawsuit filed…against Yale University

TheySaidWhat presents actual breaking news…

The AARP Foundation has just filed a lawsuit on behalf of unionized employees against Yale University, over a wellness program that puts  $1300/year at stake for non-compliance. There is no link yet because this just happened this afternoon.

Here are three of the four things you should know about this:

  • Yale’s is not technically an outcomes-based program. Many people had assumed that outcomes-based (“contingent”) programs put employers at much greater legal exposure than participation-based program. That is not the case here. It is more about heavy penalties for non-participation. (Heavy incentives for participation in a high-deductible plan could be viewed in the same light, according to the original judicial decree.)
  • Aside from using one vendor with a rather sketchy history, Yale’s is one of the best conventional programs I’ve ever seen. It is one of the few programs in the country actually compliant with the US Preventive Services Task Force recommendations. Their coaching company, Trestle Tree, is a good vendor. In other words, running a good program does not inoculate you against these lawsuits.
  • The major risk to you from these lawsuits is not that your own employees will sue you, but rather that a precedent will be established that will cause you to have to reconfigure your own program in order to make it compliant, at least until new EEOC safe harbor rules are published. This will require possibly substantial changes to any penalties or employee ability to access your best healthcare offering. Changes could even be retrospective to the beginning of 2019, at considerable expense.

The fourth thing you should know: Yale’s was totally a self-inflicted wound. Simply offering Quizzify as an alternative to screening and coaching would have inoculated Yale’s entire wellness program against exactly this lawsuit. Don’t take our word for it. Here is our indemnification language:

All Yale would have had to do – all you need to do now to avoid the risk of a lawsuit – is give employees a choice of screening/HRAs or Quizzify. This one poster –one simple poster–would have done the trick.

The Quizzify EEOC indemnification program flyer is right here.

For more information, see:

New Book: Nurses Take Back Healthcare One Employer at at Time

The following is my foreword to Nurses Take Back Health Care One Employer at a Time, written by our colleague Jeanne Moore. I recommend it to everyone with an interest in “pry, poke and prod” workplace wellness and why it has fizzled.

As the Quizmeister-in-Chief of Quizzify, I write healthcare trivia questions for a living, so it seems appropriate to start this foreword with one: What is the country’s most trusted profession?

I’ll give you a hint: it’s not “workplace wellness vendor.” (In case anyone is keeping score at home, “workplace wellness” actually has the lowest Net Promoter Score ever recorded for an industry, according to WillisTowersWatson.)

The answer? Nursing. When was the last time you saw a nurse involved in a financial scandal? When was the last time a nurse jacked up his or her prices by 1000%? Do contracts for nurses include opaque rebates and volume incentives? Of course not.

And yet until now, no one has ever asked the question: “What do nurses think of the healthcare system?”

Not much, as it turns out. Over time, nurse/patient ratios have dramatically increased, while the number of hospital administrators, insurance executives, middlemen, healthcare trivia quiz writers, and, yes, wellness vendors, has skyrocketed. Ms. Moore describes what nursing care used to be like…and what it’s like today. Essentially everybody who has ever had any experience (their own or family members) with overnight hospital stays has a story…and many of those stories involve either the harms caused by inadequate staffing, or the heroics performed by a Florence Nightingale who turned around a situation that would have led to a bad outcome.  Many such stories populate this book.

Yet despite the lack of nurses in many hospital settings, there is no shortage of white-coated healthcare techs waiting to descend upon healthy populations of employees to “pry, poke and prod” them because a wellness vendor snookered an employer into thinking this nonsense saves money. The idea that pry, poke and prod programs save money is so far from the truth that I myself offer a $3 million reward to anyone who can show that it breaks even.

And yet these programs are still popular. Ah, well, as Mark Twain said: “It is easier to fool people than to convince them they’ve been fooled.”

In this book, Jeanne recounts many examples of how we have all been fooled by suppliers who are supposed to be containing our costs and providing better care. In particular, she points out how the insurance companies have been feeding at the ACA trough for 9 years now, taking full advantage of its well-intentioned provision limiting profit margins to 15% or 20% of costs. Which of course means that the only way to increase profit is to increase costs.

I’d be lying, though, if I didn’t admit that my second-favorite part of the book is her smackdown of the wellness industry. Starting with the fraud that was Safeway (whose CEO eventually tired of wellness and moved on to his next bright shiny object, Theranos), which is credited with launching the ACA’s wellness provision despite not having a wellness program, she moves point by point through the fallacies, harms, cluelessness and lies which formulate the industry’s business model. (She is careful to exempt companies, like US Preventive Medicine and It Starts with Me, which have been validated by the Validation Institute.)

And, as one would expect after reading the other insights and stories in this book, Jeanne passes the ultimate IQ test: she recognized upon her first exposure to him that the leader of the wellness industry, Ron Goetzel, can’t produce even an iota of data to contradict my own exposés of the frauds and harms perpetrated by him and his cronies by screening the stuffing out of employees with callous disregard for established clinical guidelines.*

Further, despite the admitted trivial impact of their programs (Mr. Goetzel says it takes fully 2 to 3 years to reduce risk by a mere 1 to 2%), these vendors nonetheless create massive “savings” out of whole cloth. How? They have many ways to lie, but the most common way to “show savings” is to compare active motivated participants to inactive, unmotivated non-participants – even though it’s been proven repeatedly that no matter what you do (including doing nothing at all, including telling diabetics to eat more carbohydrates), participants will dramatically outperform non-participants simply due to being motivated to begin with.

So when Jeanne talks about nurses taking back healthcare, these are the perps she wants to take it back from – the immensely profitable insurance companies and wellness vendors who are sucking resources out of the healthcare system while actual health outcomes continue to stagnate or deteriorate in the US, even as lifespans in other countries continue to lengthen.

Join the movement. Get nurses back into healthcare.  Employee experience and outcomes should improve because, let’s face it, they can’t get any worse.

*Mr. Goetzel, these are my own words, not Jeanne’s and not the publisher’s. So, as I’ve been urging you to do for years, sue me, not them. Please don’t make me beg.

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