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Life imitates The Price We Pay

If there’s one thing you learn from Marty Makary’s blockbuster expose The Price We Pay (other than Quizzify being a great vendor, on page 226), it’s not to get a peripheral vascular screen at a community center.

Here are his exact words from his trip to a community center hosting a screening session for peripheral vascular disease:

The person from the cardiology group was conducting a test that measures how the blood flow in the legs compares to the blood flow in the arms. The rationale: Something might be wrong if the blood pressure is lower in the legs. It could be caused by a narrowing of the arteries, a plaque that slows blood flow. It might warrant further investigation.

There’s just one problem with that notion: This test should not be performed unless a patient has serious symptoms, like crippling leg pain. For anyone else, it’s likely to lead to medical care they don’t need, which can be expensive and dangerous. That’s exactly why independent medical experts do not recommend the type of peripheral vascular screening I witnessed that day.

So, thanks to the chronic shortage of other subject matter for these periodic blogs now that wellness vendors have finally learned not to brag publicly about their stupidity, imagine my glee when a brochure from Life Line Screening arrived in the mail last week urging me to:  get peripheral vascular screening at a community center.

Not only that, but my special “priority code” meant I “qualified” for a large, exclusive, discount (“Only $149”). I was very pleased to hear that — just like achieving Mosaic on JetBlue, Titanium Ambassador in Marriott, and something like Executive Platinum Emerald Diamond Palladium Plutonium Selenium Sodium Fluoride on American — I had also achieved “Status” with Life Line.

Needless to say I wanted to brag about this achievement to all my friends-and-relations who also got this mailing. But my ego took a hit when I learned that apparently they too received high-priority codes and qualified for this exact same exclusive discount.  Trying to figure out what we all had in common to earn this special treatment, we concluded that this it was being offered — exclusively — to people who are comprised of protoplasm.

In addition to the peripheral vascular disease screening, rated “D” by the US Preventive Services Task Force in my 40-64-year-old group, they are offering the following additional “vital screenings,” with the USPSTF rating in parentheses:

For those uninitiated in USPSTF screening ratings, “D” means “don’t screen for this,” because of the overwhelming likelihood that positives will be false.

How overwhelming is this likelihood? Let’s take an example. Suppose you perform a test that’s 90% accurate to hunt for a previously undetected, symptomless, disease in 1000 people. Suppose further that about 1 in 1000 adults 40 to 64 has this undetected disease. A 90% accurate test is also 10% inaccurate. So, including the one person who actually has the disease, about 100 of the other 999 will test positive — despite being disease-free.

Those 100 are going to be totally stressed out for no reason, probably follow up with more tests, and possibly even get surgery. Here is the math:

Continuing with my USPSTF grading lesson for Life Line, “I” means “Incomplete,” not enough data for a recommendation. I don’t have to tell you what “A” and “B” mean because those ratings don’t apply to any of Life Line’s screens. That’s right. None of Life Line’s tests are recommended by the specific entity charged with recommending tests.

Needless to say, I couldn’t pass up the opportunity to call these Very Stable Geniuses. My call was answered by a Life Line employee who announced: “My name is XXXX. I’m going to be your Preventative Healthcare Advisor.” When I asked if these tests had an A Rating from from the US Preventive Services Task Force, she replied: “Very very very true. Also an A-Plus rating from the Better Business Bureau.”

She also assured me I could keep my clothes on, which I know the staff and guests of the Wellesley Community Center will appreciate.


The benefits of screening

Hmmm. Let’s look at each of these five claims in turn.

  1. “Early detection.” Check. Detection of more false positives than every wellness vendor except possibly Interactive Health, which specializes in them. (See “Interactive Health gives clueless wellness vendors a bad name.“)
  2. “Prevention of disease progression.” Screening might possibly detect something but it doesn’t prevent anything. Here’s what might prevent something: spending that $149 on a new pair of sneakers and running in the opposite direction of the Wellesley Community Center.
  3. “Peace of mind.” Try telling that to all the people who are getting false positives.
  4. “Savings with more affordable screenings.” I called my Preventative Healthcare Advisor to ask about that one. Turns out, as noted below, I can practically retire off these savings.
  5. “Control, no insurance required” ?  “Required” is synonymous with “coverage” in this case. Just like “true” was synonymous with “false” about the USPSTF A ratings.

So…doctors don’t do these screens, insurance doesn’t cover them, and yet somehow, somehow, these screens are… “vital“? Time for another call to my preventative healthcare adviser to find out why, if these tests are so vital, doctors don’t do them. She explained that:

  • Doctors will only do these tests for: “a reason” (shame on doctors!)
  • But by then it might be “too late.”
  • Doctors don’t do these tests routinely because they cost “$5000 to $8000,” instead of $149. That’s why the brochure lists “savings” as a benefit. You could save thousands right now by doing these screenings! Likewise, think of all the money you’re saving this month alone by not living in a $5000/month apartment.
  • “Insurance companies are all about the money. They try to control our lives. That’s why they won’t pay for these tests.” (There is actually an element of truth to this one. Insurance companies are all about the money. Not unlike Life Line, which is clearly in business for their health, since they aren’t in it for ours.)

Postscript: I did check in with a primary care physician, who observed that she’s heard of doctors doing tests without “a reason.” But advertising that they do tests for no reason? That was news to her. She said they could lose their license. I pointed out that wellness vendors don’t need licenses, or for that matter even GEDs. Just the willingness to check their ethics at the door of the Wellesley Community Center. Plus a soupcon of protoplasm.

Last call for Thursday’s “The cure for surprise billing” webinar

Dear They Said What Nation,

Besides the minor points that your employees’ or dependents’ odds of getting one of these surprise bills are 10 times the odds of having a heart attack or diabetes hospitalization* and that unlike the latter, these bills are utterly avoidable, here are three major reasons to sign up for this webinar:

  1. The 1500th registrant receives a $100 Amazon gift card from the Validation Institute, assuming they attend.
  2. You do NOT have to “attend” the webinar to experience it. Registrants will be given the recording. But you do have to register here.
  3. The way to be certain this is a valuable webinar that will result in easy, major, immediate, behavior change for any employer that implements our elegant solution is that no Koop Award-winning wellness vendor has registered for it — despite the fact that Whole Foods would redeem the gift card for almost all the broccoli you can eat.

A handful of other wellness vendors have signed up. We salute them.

  • Aduro
  • Health Advocate
  • It Starts with Me
  • Maestro Health
  • US Preventive Medicine

And a special Honorable Mention to Wellable for posting the Reader’s Digest version of the webinar right here.

PS If you are a wellness vendor specifically, and I missed you while scanning the ridiculously long list of attendees, ping me and I’ll add you.  Or sign up now and I’ll add you.



*OK, here is the calculation. The lower bound of these odds on any ER visit or admission is about 1-in-5 for any in-network facility according to the Kaiser Family Foundation. Others pace the odds at twice that, but we’ll go with the more conservative estimate. Your covered population incurs about 240 ER visits and admissions in total. 20% of 240 is: 48 per 1000. Whereas the number of covered people who will get a heart attack or have a diabetes event is 2 per 1000.

Oh, did I say surprise bills were ten times as likely? That would make them 24 times as likely.

And yet, unlike heart attacks and diabetes, totally avoidable…

 

Care to guess the odds of a surprise medical bill for an ER visit?

According to a study published in JAMA Internal Medicine, an employee’s odds of getting a surprise medical bill for an ER visit or a hospital stay exceed 40%!

Well, you might say, serves ’em right for not staying in-network.

Wrong. This study looked only at in-network visits and admissions. Thing is, in-network facilities are often staffed with out-of-network providers. I know this firsthand — I’m in a private equity fund that’s making a killing by rolling up provider practices in local markets and keeping them out of network. It’s illegal for provider practices to collude to stay out of network, but it is perfectly legal for them to merge and make a practice-wide decision to stay out of network.

So, wellness vendors and consultants, here are two opportunities you can’t refuse, that are both central to your business strategy:

  1. Actually do something useful for employees, as opposed to your usual scripted diatribes. Newsflash: employees already know they need to quit smoking and eat broccoli. But they don’t know how to avoid these bills.
  2. Prevent me from making money.

Also, this is the one thing that could bankrupt them that is totally avoidable. And yet your financial wellness program doesn’t cover it.

Fortunately, if you can spare one short hour on October 31 (which you will get back 38 hours later, when the time changes), you can learn how your employees can avoid these bills. All it takes is a little sticker to put on an insurance card and teaching employees to use their card, rather than sign whatever is put in front of them and/or say: “Same as last year” when they ask you if your insurance information has changed.

The all-star cast of this webinar includes David Contorno, Brian Klepper, Marty Makary, and Marilyn Bartlett. You can register here.

PS If you can’t make the time because of open enrollment, you’ll have access to the recording.

 

 

 

WTF! Introducing the wellness industry’s Wishful Thinking Factor

Finally! A valid way to measure wellness outcomes that requires only a calculator, a triple-digit IQ, and complete suspension of disbelief! Introducing the Wishful Thinking Factor, or WTF. Those of you accustomed to reviewing wellness vendor outcomes may think those initials stand for something else…and we will indeed use those initials in their more common context at the end of this posting.

By contrast, this WTF is defined as:

Dollars claimed as savings/percent improvement in risk factors.

The elegance of the WTF is exceeded only by its widespread acceptance. WTF is already the wellness industry’s preferred analysis, so I am merely confirming that we agree. The only difference between my WTF calculation and theirs is they don’t actually put the numerator and denominator on the same page.

Meaning, they don’t actually announce: “Here’s our huge savings generated by our trivial risk reduction…wait…this is impossible…WTF???”

That’s because then it would be perfectly obvious that they are fabricating the savings. Instead they put “dollars saved” on one page and the improvement in risk factors on another page, way far away — and hope nobody compares them.  (Interactive Health is the most stable genius example of that, as we’ll see below.)


What is the real causal relationship between risk reduction and savings?

A distressingly relevant joke circulated among us rip-roaringly hilarious faculty back when I taught in the Harvard economics department. A chemist, physicist and economist are stranded on a desert island with only a can of beans. To open it, the physicist suggests dropping it off a cliff, so that it will open upon impact. The chemist points out that would splatter the contents, and suggests instead that they put the can in a fire, and once the can gets hot enough, it will melt. The physicist points out that the beans would all burn up in the fire.  At an impasse, they turn to the economist and ask what he would do.

The economist replies: “Assume a can opener.”

In keeping with that spirit, we will make six (count ’em, 6) equally generous assumptions for determining the true WTF:

  1. Every wellness-sensitive medical admission or ER visit is a direct function of the risk that the wellness vendor measures in a population. In other words, social determinants of health and genetics have nothing to do with the likelihood of a heart attack or diabetes event
  2. Even the dumbest wellness vendors know how to measure risk (following their five days of training in medicine)
  3. Employees never cheat to improve their biometric scores and never lie on their risk assessments
  4. Dropouts and non-participants would improve in risk at the same rate as participants do, so the fact that they don’t participate doesn’t change the overall risk reduction in the population
  5. No lag time between risk reduction and event avoidance
  6. No false positives, no added lab tests, drugs, doctor visits or anything else that might possibly increase utilization and cost of outpatient care in order to reduce inpatient utilization — which of course is the opposite of what the wellness trade association readily admits to:

Using those generous assumptions, measured wellness-sensitive medical admissions (WMSAs), and the total cost of those events, would decline at the same rate as measured risk declines. According to the Health Enhancement Research Organization, WSMAs comprise no more than $100 PEPY in a commercially insured population.  So every 1% decline in risk yields a spending decline of $1.

Relaxing the assumptions above would likely reveal that this WTF is also overstated, but it has the advantage of consensus among the 60+ experts who contributed to the HERO outcomes guidelines measurement tool, so we’ll call this the Gold Standard, to which other WTFs are compared.


Now let’s make a little list of the WTFs compiled by the industry’s very stable geniuses, in their great and unmatched wisdom. Naturally, in that category, the first to come to mind are Interactive Health and Ron Goetzel.

Let’s start with Interactive Health. Excluding dropouts and non-participants, they claimed a 5.3% risk reduction (20.3% reduced risk while 15% increased them). So they saved a maximum, assuming the six assumptions above, $5.30 PEPY:

The claimed savings was:

Averaging those claims yields $804, for a WTF of 151.

As a side note, allocating that $804 in savings across the 5.3% who actually did see a decline in risk factors yields over $15,000 per risk factor reduced. No mean feat when you figure that the average person only incurs about $6000 in employer spending. That was enough to get them in the Wall Street Journal


A second example (and there are many more) is the Koop Award given to Health Fitness Corporation for lying about saving the lives of cancer victims who never had cancer. The coverup of that fabrication was the lead story about Nebraska, along with whether Ron Goetzel had committed an actual crime, as opposed to simply snookering the rather gullible state, whose reaction when they found out is best described as Human Resources-meets-Stockholm Syndrome.

Mr. Goetzel defended his actions by saying that lying about saving the lives of cancer victims was overlooked by the awards committee, and what really earned Nebraska the award was saving $4.2 million by reducing 186 risk factors. Let’s calculate the WTF from that.

change in risk factors

the absolute reduction in risk was 0.17 (1.72 to 1.55) on a scale of 7, or roughly 2.4%. That represents about 180 people out of 5199 reducing a risk factor. (Of course, the remaining 15,000 of the 20,000+ state employees dropped out and/or wanted nothing to do with this program, but that’s a different story. So much winning!)

And yet somehow, despite only 180 people claiming to reduce a risk factor, the program saved $4.2-million, or $807 apiece for the total 5199 people. That yields a WTF of 336.


Speaking of Koop Awards, The Koop Award Committee is known for its embrace of WTF arithmetic, and it’s that time of year again during which they put their very good brains on full display. For instance, they once gave an award to Pfizer for saving $9 million, or roughly $300 per employee. How did Pfizer do that? With a 2% risk factor decline. Pfizer’s WTF worked out to about 150.

As a sidebar, Pfizer’s award application includes our all-time favorite displays:

Pfizer’s wellness team sent employees emails on weight control tips. Those who opened the messages lost about 3 ounces while those who did not open the messages gained 2 ounces. That could easily be accounted for by the number of calories required to open the emails.


The 2019 Koop Award

Most recently, the very stable geniuses just gave an award to Baylor Medical School, where, in keeping with tradition, risk factors declined by a whopping 1% — at least among the 25% of the workforce willing to be screened twice (!!!) a year to earn a 20% premium reduction. Let’s take a looksee at the biometric screening results:

On average, these five categories improved 1.04%, to be exact. This is actually quite an accomplishment for the vendor, Vitality, which typically gets no improvement or a deterioration.

The claimed savings — in keeping with Koop Award tradition, buried deep on another page — were $333/year, yielding a WTF of 320.


For any readers out there with the IQs of a Koop Award Committee member, let me spell out the pattern you’re seeing: the wellness industry’s own data yields WTFs 150 to 336 times greater than the wellness industry’s own guidebook estimates.

If anyone would like to reach me to review this arithmetic, or report their own vendor’s results, contact me directly. Schedule-wise, I’m not available today (Monday) or Tuesday. However I am available later this week, specifically WTF.

A “cure” for surprise medical billing? Webinar featuring Dr. Marty Makary

Attention, employers with wellness programs: this is bigger than broccoli. 

No employee bankruptcy has ever been attributed to a broccoli deficiency. By contrast, surprise medical bills like this one are the #1 source of bankruptcies, wage garnishments and lawsuits against employees. You may have a stress management vendor and a financial wellness vendor, But their programs don’t cover the #1 source of avoidable stress related to financial wellness, for the simple reason that they don’t know how.

The Validation Institute to the rescue.

The Validation Institute is doing a webinar describing an actual cure for employee surprise medical bills for emergency visits and admits. it features the leading experts in pricing and surprise billing, including the bestselling author of The Price We Pay, Dr. Marty Makary. Here is the invitation.


October 31st webinar featuring bestselling author Dr. Marty Makary:  A “cure” for employees’ surprise medical bills

You think Halloween is scary? Try surprise medical bills. That’s the subject of this groundbreaking October 31st webinar (register here).

Surprise bills may or may not be the #1 source of workplace stress – but they are certainly the #1 avoidable source of workplace stress. 57% of Americans report receiving one on the last five years. If you have not received complaints from employees about them, or noticed wages being garnished by providers, that’s probably because your health benefit is so generous that you are paying these bills without realizing it…inflating your own costs unnecessarily.

And yet there is a “cure,” at least for surprise bills related to emergency visits and admissions. The Validation Institute and Health Rosetta have assembled what they call the “dream team” of experts in pricing and consent-to-treatment to show you – in a mere hour – how to put the kibosh on this scourge. Presenters include:

Attendees will be able to begin solving the surprise medical bills problem within weeks or even days.  If you combine Quizzify’s quizzes with the solution as described in the webinar, it will do to surprise medical bills for emergency care what garlic does to vampires.

Here’s the link to the October 31 webinar registration.

 

“Arithmetically impossible”: Al Lewis talks wellness outcomes with Stacey Richter

The. Numbers. Don’t. Add. Up.

Listen to the Podcast with healthcare guru Stacy Richter to find out why. Here’s what she has to say;

Employers are getting wise to a lot of things right now. I’d suggest a fast follow-on is going to be their view of these wellness programs. It will be interesting to see if current vendors are able to compete with the newer solutions that actually work and which employees actually appreciate. It will also be interesting to see if there’s any backlash against the supply chain that continues to offer up these solutions, especially given some of the lawsuits that are currently under way and all the research which is eminently available.

After about ten people wrote in looking to hear an interview with him, in this health care podcast I’m honored and pleased to speak with the one and only Al Lewis. Al is basically synonymous with wellness programs’ analysis and evaluation. One of my favorite things about Al is that he is as controversial as he is respected. He’s been called both “the founding father” of disease management, and he’s also been called the “troublemaker-in-chief” of the wellness industry. Regardless of your opinion of Al’s views, his integrity and commitment and rigorous analytical approach is open and shut. Al is the author of two books, which you can find in the show notes. He’s also the CEO of Quizzify. Quizzify is a company and an approach that teaches employees how to get the care they need while avoiding the “care” they don’t. Quizzify’s claims have been validated, by the way, by the Validation Institute.

Here’s the link. Happy listening (unless you’re an outcomes-based wellness vendor).

 

Surprise medical bill of the week: $650,000 for a $7000 operation

It’s not about the broccoli, folks.

The major hazard facing employees today is not a broccoli deficiency, but rather: surprise medical bills. And here is one that boggles the mind: $650,000 for a $7000 surgery.  Even when these emergencies are “covered” (meaning you pay their bill, except for the four-figure co-insurance), these bills create stress, both emotional and financial, far in excess of stress created by any problem that can be solved by eating more fruits and vegetables. The rate of these bills is also about 100 times the rate of diabetes admissions and heart attacks combined: more than half of Americans report receiving one in the last five years.

Further, people — even people who eat plenty of fruits and vegetables — live in fear of receiving one. Often one such bill can force a family into bankruptcy.

So perhaps it’s time to rejigger your wellness priorities in favor of this most pressing problem? And the other thing is, unlike risk factors (which rarely decline in a population by more than 1-2%, excluding dropouts anyway, according to the Health Enhancement Research Organization), this problem is solvable. Naturally, your wellness vendor has no clue how to solve it, so pay close attention to the following paragraph.

The “long version” of the solution can be found here, But if you don’t feel like clicking through to it, here is the short version: give your employees a sticker to put on their insurance card that says:

“I consent to appropriate treatment and to be responsible for reasonable charges not covered by insurance, up to 2 times the Medicare rate.”


Then you need to educate your employees — using Quizzify or an endless stream of memos, as you prefer — to do two things:

  1. Carry the insurance card and show the insurance card. It’s not enough to say: “Oh, yeah, I’m covered by so-and-so,” and have the intake person verify eligibility.”
  2. Do not sign the “terms and conditions” they thrust at you. That boldfaced sentence above contains the consent language needed. They have to treat you, based on that consent.

Unlike attempting to create a more broccoli-centric workplace, this is exactly the type of behavior change you can get widespread acceptance of. Nothing like the threat of bankruptcy to motivate employees to put a sticker on their insurance card.

 

 

 

 

 

 

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