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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
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:
OK, this time I’m not the one causing the kerfluffle in the wellness industry, though I will confess to being a force multiplier.
Not since 2014, when the very unstable morons at the Incidental Economist made fun of the very stable geniuses who give out the Koop Award and also unequivocally concluded wellness loses money — combined with continued fallout from the Penn State debacle and the Nebraska scandal — has the wellness industry had such a bad year. And it’s only February.
Let’s review what’s happened so far in 2018. First, a federal judge ruled that voluntary wellness programs need to be — get ready — voluntary. The EEOC’s responded with the legalese equivalent of: “Fine, be that way.”
Next, WillisTowersWatson did something that might get them in hot water with the very stable wellness industry leaders: they were honest. They published a study revealing that employees hate wellness even more — way more — than they hate waiting for the cable guy to show up.
Finally, the very unstable National Bureau of Economic Research conducted a controlled study finding basically no impact whatsoever of a wellness program. More importantly, they specifically invalidated the “pre-post” methodology. Even more importantly, they specifically invalidated 78% of the studies used in Kate Baicker’s “Harvard Study” meta-analysis.
Here is an interesting piece of trivia. The lead researcher is an assistant professor at the Harris School of Public Policy. Why is this interesting trivia? Because Katherine Baicker — the Typhoid Mary of Wellness, whose THC-infused 3.27-to-1 ROI is the basis for essentially every subsequent genius wellness outcomes claim — is now the dean of that very same Harris School. I’m just guessing here, but I’d say it’s gotta be a trifle embarrassing when your own subordinate publicly disproves your own study. I mean, it’s one thing for me, RAND, Bloomberg, and anyone else with five minutes, internet access and a calculator to do it, but…your very subordinate?
On the other hand, the researcher, Damon Jones, just demonstrated not just amazing competence, but amazing integrity as well. In other words, he has no future in wellness.
The Wellness Empire Strikes Back
How does the wellness industry respond to these smoking guns threatening their entire revenue stream? Apparently, there is little cause for concern on their planet.
Let’s start with America’s Health Insurance Plans (AHIP), the health insurance industry lobbying group. Here is AHIP’s oxymoronic Wellness Smartbrief (January 26), on the NBER research. Yes, it summarizes the same wellness-emasculating study as the one above, though you could never guess it from the headline:
Continuing, AHIP said:
Offering incentives for completing wellness activities might be more cost-effective than offering incentives for wellness screening, a recent study of a comprehensive program found.
Perhaps AHIP has been infiltrated by Russian trolls, because here’s what the NBER article actually said about “completing wellness activities”:
We…do not find any effect of treatment on the number of visits to campus gym facilities or on the probability of participating in a popular annual community running event, two health behaviors that are relatively simple for a motivated employee to change over the course of one year.
Wellness programs might attract mostly employees who are already fitness-conscious, but the potential to attract healthy employees whose medical spending is already low could nonetheless be a boon to employers, the researchers found.
And on the subject of “the potential to attract healthy employees” being a “boon to employers,” the authors actually said:
We further find that selection into wellness programs is associated with both lower average spending and healthier behaviors prior to the beginning of the study. Thus, one motivation for a firm to adopt a wellness program is its potential to screen for workers with low medical spending. Considering only health care costs, reducing the share of non-participating (high-spending) employees by just 4.5 percentage points would suffice to cover the costs of our wellness program intervention.
In other words, you can apply some workplace eugenics to your company by using wellness to weed out obese employees, employees with chronic or congenital diseases, and so on. Good for you!
Soon, if AHIP and others have their way, there will be no need for guesswork in eugenics: employer wellness programs will be able to screen these employees out based on their actual DNA.
AHIP’s take on AARP v. EEOC
And now, AHIP’s take on this landmark case, their ace reporters scooping everyone with this February 2 headline on the December 20th court ruling:
Here are more typical headlines on that court ruling, headlines that came out the same month that the court ruling came out. Perhaps AHIP used the interim six weeks to focus-group various verbs until they settled on…tweak???
AHIP: It’s not just the headlines
One prominent healthcare executive recently attended an AHIP conference and reports:
I just returned from one of the dumbest meetings I’ve ever attended in Washington. Report of a new “study” by AHIP. Turns out people don’t mind health costs all that much, they just want more benefits. And everything is hunky-dory with their health plans, people like them so much. They love wellness benefits and crave more. Prescription drug prices have been nicely controlled thanks to the competitive marketplace (no, I am not making this up or exaggerating for drama). For every $1 employers spend on benefits workers get $4 in value. Priorities for SHRM rep: Fitbits for all employees, solving the outrage that only 20% of her employees got an annual physical. 85 cents of every dollar spent on health care goes to chronic disease.
Over these same two hours, I’d estimate about a thousand employees were misinformed, harmed or harassed by wellness vendors, roughly equal numbers of employees got useless annual checkups, employers spent about $200-million on healthcare and 40 people died in hospitals from preventable errors. But I’m being such a Debbie Downer! I’m going home to read Why Nobody Believes the Numbers to remove myself from this alternative universe.
Enter the Health Enhancement Research Organization (HERO)
HERO’s Prevaricator-in-Chief, Paul Terry, is demonstrating his usual leadership abilities in this crisis, of course. After all, HERO is the wellness industry trade association and these three items — the NBER invalidating their product, employees hating their product, and a federal judge forbidding them to force employees to use their product — represent existential threats to his “pry, poke and prod” members.
Teddy Roosevelt said, “complaining about a problem without posing a solution is called whining.” It’s a quote that also reminds me why I’ve not thought of angry bloggers who target health promotion [vendors] as bullies. Though they relish trolling for bad apples, their scolding is toothless, more the stuff of chronic whiners.
I suspect he is talking about me here as the “chronic whiner” who is “scolding” them. Or perhaps he is referring to the “angry bloggers” at the Los Angeles Times, the New York Times, Slate, or STATNews, since those “toothless” publications seem to be scolding wellness vendors more than I ever have. For instance, I’ve never called wellness vendors’ offering a “scam” or a “sham.” I simply quote these very stable wellness geniuses verbatim, as above or below, or last week.
Being quoted verbatim, not angry bloggers, is their worst nightmare. (One thing I would concede, though, is that “Paul Terry and the Angry Bloggers” would be a great name for a rock band.)
Yep, looks like the implosion of his industry all my fault. Otherwise, I’m not quite sure who is the “angry blogger” he is referring to, other than to note that Mr. Terry himself seems to blog a tad angrily himself, both above, and here…
Why I choose to ignore the blogger critics: We’re fortunate to work in a profession with a scant number of vociferous critics. My take is that there is one thing these few angry loners [Editor’s note: the complete “scant list” of the 220 “few angry loners” who have been “vociferous critics” can be found here] want more desperately than attention: that’s to be taken seriously. What they fail to comprehend is that as they’ve gotten ever more farfetched and vitriolic in search of the former, they’ve cinched their inability to attain the latter.
Baiting people with misinformation and offensive insults (but just a tad under highly offensive) is a pesky ploy that trolls hope will eventually land a bite that confers credibility where there is none. Even reading such drivel is a form of taking the bait; responding is swallowing it whole. Some say dishonesty should not go unchallenged and I respect their view; nevertheless, I’m convinced responding to bloggers who show disdain for our field is an utter waste of time. I’ve rarely been persuaded to respond to bloggers, and each time I did it affirmed my worry that, more than a waste, it’s counter-productive.
…and especially here, a seemingly incongruous decision to “act out” by someone who claims to be “choosing to ignore the blogger critics.”
Having read years of my “drivel” alongside Mr. Terry’s posting explaining why you shouldn’t “swallow this bait,” perhaps readers might opine here: which of us, exactly, is the “chronic whiner”?
Coincidentally, when I run live health-and-wellness trivia contests, the first of our 3 rules is: No Whining. Seems to me that he would have just violated it. Indeed the only rule HERO hasn’t violated so far is #3 below. Not that I want to put ideas in their head.
NY Times’ economists and Pulitzer Prizewinning LA Times columnist skewer “voluntary” wellness incentives
In the immortal words of the great philosopher Dizzy Dean, don’t fail to miss it.
Ever since Ron Goetzel’s Penn State debacle, the news cycle has been the Health Enhancement Research Organization’s (HERO) kryptonite.
To be sure, they have other enemies too — transparency, integrity, math, data, facts, employees, smart people — but those bullets just bounce off them. How do we know this? We think we’re making an impact with our exposes and whistleblowing — and yet forced, incompetent and sometimes harmful prying, poking and prodding continues unabated. When we prove that none of the wellness numbers add up and back that proof with a monster reward for disproving us, they retreat rather than fight — but then they pop up again, whack-a-mole style with yet another claim: “Oh, well, numbers don’t have to add up. It’s all about the value.” Yada yada yada.
That’s why they never respond to anything we ever write, or for that matter anything anyone else ever writes. STATNews, for example, wanted to host a point-counterpoint, but couldn’t find anybody to oppose me. Health News Review posted a podcast with no opposing views.
The one wellness executive who failed to understand the news-cycle-as-kryptonite dynamic was Wellsteps’ Steve Aldana, not exactly a rocket scientist even by the standards of the wellness industry. In an attempt to get his name in the paper, he accidentally admitted that all of Boise’s Koop Award-winning numbers were fabricated. Yes, he humiliated himself, yes, he admitted he lied, yes, he could easily have been charged with defrauding the city…and yet Boise is still Wellsteps’ account.
If they had any lingering doubt, that lesson taught the rest of these people to stay out of the media even if it means taking a few punches.
That brings us to today. I’ve been scouring Google to find someone — anyone — to take the side of the EEOC in what is likely to become an extended news cycle over the definition of “voluntary” for wellness programs. So far, no one has stepped forward to support the EEOC’s and HERO’s argument that “voluntary” can mean “we’ll fine you up to $2000 if you don’t.” Instead, both The Incidental Economist (the NY Times‘ economics bloggers) and the LA Times‘ Pulitzer Prize-winning business columnist, Michael Hiltzik, come down strongly on the side of AARP, Merriam-Webster, Funk & Wagnalls and Dictionary.com.
- In 2015, the EEOC proposed a rule treating wellness programs as “voluntary” if they involved premium differences of no more than 30% of the full cost of a health plan. Worker advocates were aghast — 30% of a full-price premium could amount to thousands of dollars, and since the workers’ share of their health plan premiums often was only 30% or so, the penalty could double their annual costs. For many families, that made voluntary programs effectively mandatory.
- [The judge] observed that the 30% incentive “is the equivalent of several months’ food for the average family, two months of child care in most states, and roughly two months’ rent.” He recognized that a fee of that magnitude could be especially coercive to lower-income employees
- The biggest problem with wellness programs is there’s no evidence that they work. The most frequently cited statistic in their favor came from Safeway, whose claim to have saved on per capita healthcare costs after implementing a wellness program prompted drafters of the Affordable Care Act to liberalize the incentive rules. But Safeway’s story was soon debunked. Other supposed success stories came from wellness program promoters themselves, who were engaged in selling their wares to big employers.
- The rule allowed employers to impose huge penalties on employees who refused to participate in wellness programs, even though the Americans with Disabilities Act says those programs must be “voluntary.”
- In the court’s view, the EEOC had basically ignored the problem in its rulemaking, asserting without explanation that wellness programs backed by enormous penalties were somehow voluntary. I applauded the decision: I’ve been railing against the EEOC for two years now for blessing mandatory wellness programs over the ADA’s express prohibition.
Once again, I’d urge everyone to sign up for the January 18 webinar. There will be more clarity, you can ask questions, and you’ll hear questions from others too. What you won’t hear is a peep out of HERO. Not because we censor or blacklist adversaries (that’s their signature move, not ours — one person reports that HERO took him off the program because he admitted to respecting my work) but because they know better than to, in the immortal words of the great philosopher John Cusack, say anything.
It’s time for the 2017 Deplorables Awards, lovingly bestowed on those vendors who do the best job making other vendors look good.
The good news is that you don’t have to actually win the Deplorables Award to sue me. Runners-up are eligible too. Here is my address for hand-service delivery most of the year:
890 Winter Street #208, Waltham MA 02451
In case you decide to sue me between June 22 and August 8, use:
8 Paddock Circle, Chilmark, MA 02535
And don’t leave out my attorney:
Josh Gardner, GARDNER & ROSENBERG P.C., 33 Mount Vernon Street, Boston, Massachusetts 02108
I don’t know how much more I can do for you, other than lick the envelope. So go for it. Don’t make me beg.
But, remember, unlike your usual business model, in court you are required to actually tell the truth (I would be happy to explain to you how that works), meaning there is no chance of your winning — or likely even avoiding summary judgment, since none of the evidence is in dispute. It’s all your own writings. Oh, and I do my own cross, which means you won’t be able to find an expert witness. Anyone who knows enough about wellness to be an expert witness also knows enough about wellness to know that attempting to defend you would be a humiliating, on-the-record experience.
And there is always the chance that some annoying jerk might blog about it…
The 2017 Runners-Up
Imagine a four-square matrix with competence on one axis and integrity on the other. The people and organizations we’ll be highlighting today would intersect with the companies mentioned in Monday’s posting at only one single point.
Springbuk and Fitbit
As many of you recall, earlier in the year we analyzed the study done by Springbuk that secretly financed by Fitbit. Or maybe I need new glasses, because I just couldn’t find the disclosure in the Springbuk report that this paean to Fitbit was financed by Fitbit, the way Nero used to have the judges award him Olympic medals.
Coincidentally, the study showed Fitbit saving gobs of money because employees taking more than 100 steps a day spend less money than those taking fewer. However, a simple tally of one’s own footsteps shows that it is impossible not to take 100 steps a day unless you are both:
- in a hospital bed; and also
- on dialysis.
This 100 steps-a-day threshold was repeated many times in the study, with no explanation of how that number came to be. However, it turns out we owe these two outfits an apology. Fitbit and Springbuk have told a number of people privately (not publicly, in order to avoid an embarrassing news cycle) that they didn’t really mean to say that 100 steps a day constituted activity. They meant to say that taking 100 steps a day implied you had your Fitbit on. My apologies for failing to read their minds that their conclusions were based on reading people’s minds to determine whether they wore the Fitbit deliberately, or simply forgot/remembered/cared to put their Fitbit on.
They never did explain — privately or publicly or to anyone — how employees who took an average number steps during the baseline year could show huge savings by taking an average number of steps in the study year too.
They also never explained how these two statements didn’t completely contradict each other, even though I specifically asked them to in a personal letter, excerpted here:
Third, can you reconcile this statement…:
“The materials in this document represent the opinion of the authors and not representative of the views of Springbuk, Inc. Springbuk does not certify the information, nor does it guarantee the accuracy and completeness of such information.”
“This demonstration of impact achieved by integrating Fitbit technology into an employee wellness program reinforces our belief in the power of health data and measurement in demonstrating ROI,” said Rod Reasen, co-founder and CEO of Springbuk.
National Business Group on Health
Next up is the National Business Group on Health. Last year they made the list for criticizing the US Preventive Services Task Force for not demanding enough screenings, in a country that is drowning in them. Not content to rest on those laurels, this year they earned an Honorable Mention for inviting Dr. Oz to keynote on the role of quackery in corporate wellness, and perhaps tell us about his latest lose-weight-by-eating-chocolate miracle diet.
HERO of course also earns a runner-up award. 2017 will be remembered as the year they finally came to grips with the realization that a business model based on fabricating outcomes requires that perpetrators possess that critical third IQ digit. Without that extra “1”, an organization trafficking in math that can at best be considered fuzzy is going to be outed.
This year’s set of lies? By way of background, their 2016 poison-pen letter insisted they had fabricated that data set showing that wellness loses money without disclosing that it was fabricated — and also never reviewed their fabricated data before publication. Early in the year, I had the insight that, wow, this “fabricated” Chapter in their guidebook is so much better than the other chapters that something is amiss. No one at HERO can analyze data competently…and yet, here it was, a competent data analysis.
I did something I had never thought to do before, which was look up the actual author of that chapter. It was Iver Juster MD. He was a great analyst even before he read all my books, took all my courses, and achieved all my certifications in Critical Outcomes Report Analysis.
- Whereas Paul Terry and Ron Goetzel had insisted that Iver fabricated the data, Iver said, of course he didn’t — whatever made me think that? (“If it wasn’t real, I would have disclosed that,” he observed. Of course he would have. Iver has tremendous integrity.)
- The Board discussed and reviewed his chapter at length, and made helpful suggestions, for which he was quite grateful. This review process required “countless hours,” just as the HERO document says:
The number of transparent lies HERO tells could make a president blush. In the immortal words of the great philosopher LL Cool J, they lied about the lies they lied about.
Even though 2017 was an off-year for them in terms of the number of lies, they still told enough to be named a runner-up.
Wellness Corporate Solutions
Next is Wellness Corporate Solutions, famous for its crash-dieting contests. WCS now offers a water-drinking contest. The idea is to set up a “challenge” for your team to drink more water than other teams. They call this a “healthy competition.” I guess they didn’t get the memo that forcing yourself to drink when you don’t want to drink, just to make more money, is anything but healthy. Here is a novel idea: drink when you are thirsty. Evolution 1, WCS 0.
Perhaps as an encore, WCS, Dr. Oz and the National Business Group on Health could team up to offer a chocolate-eating contest.
I looked into this outfit to see where they get their ideas. The CEO previously ran something called the Washington Document Service. That qualifies her to run a wellness company. As Star Wellness says, to run a wellness company successfully, your background needs to be in sales, or “municipality administration.” After all, what is more central to administering a municipality than documents?
What fun would a list of runners-up be without Wellsteps, the proud recipient of the 2016 Deplorables Award? While their streams of consciousness weren’t as memorable in 2017 as in 2016 (“It’s fun to get fat. It’s fun to be lazy“), they get credit for trying. Their 2017 weight-loss campaign was headlined: “This campaign is not really about weight loss, it is about helping you apply the behavioral secrets of those who have lost weight.”
So if your kids ever want you to teach them how to ride a bike, say: “It’s not really about riding a bike. It’s about helping you apply the secrets of people who have ridden bikes.”
And what secrets are we talking about? What person who has lost weight doesn’t brag to everyone or even write a book? If there is a secret to weight loss, like eating chocolate, Wellsteps owes it to the country to tell them. Don’t make us beg.
Odds and Ends
No Koop Award winner this year, but an honorable mention to past winners and runners up for their commitment to wellness:
Sounds like in 2018 the logical winners would be Philip Morris, or maybe The Asbestos Corporation of America.
Veering briefly into the public sector, kudos to Representative Virginia Foxx, (R-NC5) for introducing the Required Employee DNA Disclosure Act. Even HERO thought it was a dumb idea…and their threshold for thinking something that increases wellness industry revenues is a dumb idea is quite high, having all rallied behind the Johnson & Johnson Fat Tax, in which companies would be required to disclose the weight of their employees.
Next up…the winner of the 2017 Deplorables Award
Alice laughed: “There’s no use trying,” she said. “One can’t believe impossible things.”
“I daresay you haven’t had much practice,” said the Queen. “When I was younger, I always did it for half an hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.”
Six impossible things before breakfast? The wellness industry would just be getting warmed up by believing six impossible things before breakfast. They believe enough impossible things all day long to support an entire restaurant chain:
Consider the article in the current issue of BenefitsPro — forwarded to me by many members of the Welligentsia — entitled: “Can the Wellness Industry Live Up to Its Promises?” BenefitsPro rounded up some of the leaders of the wellness industry alt-stupid segment. Specifically, they interviewed US Corporate Wellness, Fitbit, Staywell, and HERO. Each is a perennial candidate for the Deplorables Awards — except US Corporate Wellness, which already secured its place in the Deplorables Hall of Fame (and Why Nobody Believes the Numbers) several years ago with these three paeans to the gods of impossibility.
In case you can’t read the key statistic — the first bullet point — it says: “Wellness program participants are 230% less likely to utilize EIB (extended illness benefit) than non-participants.” Here is some news for the Einsteins at US Corporate Wellness: You can’t be 230% less likely to do anything than anybody. For instance, even you, despite your best efforts in these three examples, can’t be 230% less likely to have a triple-digit IQ than the rest of us. Here’s a rule of math for you: a number can only be reduced by 100%. Rules of math tend to be strictly enforced, even in wellness. So the good news is, even in the worst-case scenario, you’re only 100% less likely to have a triple-digit IQ than the rest of us.
And yet, if it were possible to be 230% dumber than the rest of us, you might be. For instance, US Corporate Wellness also brought us this estimate of the massive annual savings that can be obtained just by, Seinfeld-style, doing nothing:
So assume I spent about $3500/year in healthcare 12 years ago, which is probably accurate. My modifiable risk factors were zero then and they are still zero — no increase. So my healthcare spending should have fallen by $350/year for 12 years, or $4200 since then. But that would be impossible, since I could only reduce my spending by $3500. Do you see how that works now?
To his credit, US Corporate Wellness’s CEO, Brad Cooper, is quoted in this article as saying: “Unfortunately some in the industry have exaggerated the savings numbers.” You think?
I’m pretty sure this next one is impossible too. I say “pretty sure” because I’ve never been able to quite decipher it, English being right up there with math as two subjects which apparently frustrated many a wellness vendor’s fifth grade teacher:
400% of what? Is US Corporate Wellness saying that, as compared to employees with a chronic disease like hypertension, employees who take their blood pressure pills are 400% more productive? Meaning that if they controlled their blood pressure, waiters could serve 400% more tables, doctors could see 400% more patients, pilots could fly planes 400% faster? Teachers could teach 400% more kids? Customer service recordings could tell us our calls are 400% more important to them?
Or maybe wellness vendors could make 400% more impossible claims. That would explain this BenefitsPro article.
We have been completely unable to get Fitbit to speak, but BenefitsPro couldn’t get them to shut up. Here is Fitbit’s Amy McDonough: “Measurement of a wellness program is an important part of the planning process.” Indeed it is! It’s vitally important to plan on how to fabricate impossible outcomes to measure, when in reality your product may even lead to weight gain. Here is one thing we know is impossible: you can’t achieve a 58% reduction in healthcare expenses through behavior change — especially if (as in the 133 patients they tracked in one of their studies) behavior didn’t actually change.
You can read about that gem, and others, in our recent Fitbit series here:
- Springbuk wants employees to go to the bathroom
- Fitbit throws a bit of a fit, Part 1
- Fitbit throws a bit of a fit, Part 2
Health Enhancement Research Organization (HERO) and Staywell
I’ll consider these two outfits together because people seem to bounce back and forth between them. Jessica Grossmeier is one such person. Jessica became the Neil Armstrong of impossible wellness outcomes way back in 2013. Not just any old impossible wellness outcomes — those have been around for decades. She and Staywell pioneered the concept of claiming outcomes they already knew were impossible. While at Staywell, she and her co-conspirators told British Petroleum they had saved about $17,000 per risk factor reduced. So, yes, according to Staywell, anyone who temporarily lost a little weight saved BP $17,000 — enough to clean up about 1000 gallons of oil spilled from Deepwater Horizon.
See British Petroleum’s Wellness Program Is Spewing Invalidity for the details.
Leave aside both the obvious impossibility of this claim, and also the mathematical impossibility of this claim given that employers only actually spend about $6000/person on healthcare. Jessica’s breakthrough was to also ignore the fact that this $17,000/risk factor savings figure exceeds by 100 times what her very own article claims in savings. Not by 100 percent. By 100 times.
Fast-forward to her new role at HERO. In this article she says:
The conversation has thus shifted from a focus on ROI alone to a broader value proposition that includes both the tangible and intangible benefits of improved worker health and well-being.
Her memory may have failed her here too because HERO — in addition to admitting that wellness loses money (which explains its “shift” from the “focus on ROI alone”) — also listed the “broader value proposition” elements of their pry-poke-and-prod wellness programs. The problem is the elements of the broader value proposition of screening the stuffing out of employees aren’t “benefits.” They’re costs, and lots of them:
When she says: “The conversation has shifted from a focus on ROI alone,” she means: “We all got caught making up ROIs so we need to make up a new metric.” RAND’s Soeren Mattke predicted this new spin three years ago, observing that every time the wellness industry makes claims and they get debunked, they simply make a new set of claims, and then they get debunked, and then the whole process repeats with new claims, whack-a-mole fashion, ad infinitum. Here is his specific quote:
“The industry went in with promises of 3 to 1 and 6 to 1 based on health care savings alone – then research came out that said that’s not true. Then they said: “OK, we are cost neutral.” Now, research says maybe not even cost neutral. So now they say: “But is really about productivity, which we can’t really measure but it’s an enormous return.”
While other vendors, such as Wellsteps, harm plenty of employees, Interactive Health holds the distinction of being the only wellness vendor to actually harm me. I went to a screening of theirs. In order to increase my productivity, they stretched out my calves. Indeed, I could feel my productivity soaring — until one of them went into spasm. I doubt anyone has missed this story but in case anyone has…
They also hold the distinction of being the first vendor (actually their consultant) to try to bribe me to stop pointing out how impossible their outcomes were. They were upset because I profiled them in the Wall Street Journal . The article is behind a paywall, so you probably can’t see it. Here’s the spoiler: they allegedly saved a whopping $53,000 for every risk factor reduced. In your face, Staywell!
Here is the BenefitsPro article’s quote from Interactive Health’s Jared Smith:
“There are many wellness vendors out there that claim to show ROI,” he says. “However, many of their models and methodologies are complex, based upon assumptions that do not provide sufficient quantitative evidence to substantiate their claims.”
Finally, here is a news flash for Interactive Health: sitting is not the new smoking. If anything is the “new smoking,” it’s opioid addiction, which has reached epidemic proportions in the workforce while being totally, utterly, completely, negligently, mind-blowingly, Sergeant Shultz-ily, ignored by Interactive Health and the rest of the wellness industry.
There is nothing funny about opioid addiction and the wellness industry’s failure to address it, a topic for a future blog post. The only impossibility is that it is impossible to believe that an entire industry charged with what Jessica Grossmeier calls “worker health and well-being” could have allowed this to happen. Alas, happen it did.
And, as you can see from the time-stamp on this post, except at establishments favored by the Wellness Ignorati, breakfast hasn’t even been served yet.
The best outcomes evaluator in the wellness field is Dr. Iver Juster.*
*Among the subset of males not affiliated with They Said What.
Why Dr. Juster’s Case Study Is the Best Case Study Ever Done in This Field
Chapter 2 of the HERO Guide is a great study and deserves high praise. But before we get into the salient points of what makes this absolutely the best case study analysis ever done in this field, be aware the provenance is not a coincidence. Dr. Juster is very skilled at evaluation. Indeed he was the first person to receive Critical Outcomes Report Analysis (CORA) certification from the Disease Management Purchasing Consortium. (Dr. Juster very graciously shares the credit, and as described in his comments below would like to be listed as “the organizer and visible author of a team effort.”)
Note: the CORA course and certification are now licensed for use by the Validation Institute, which has conferred honorary lifetime certification on Iver gratis, to recognize his decades of contribution to this field. (Aside from the licensure, the Validation Institute is a completely independent organization from DMPC, from They Said What, and from me. It is owned by Care Innovations, an subsidiary of Intel. If you would like to take the CORA Certification course live, it is being offered next in Philadelphia on March 27. You can take it online as well.)
Early in the chapter, Iver lists and illustrates multiple ways to measure outcomes. He dutifully lists the drawbacks and benefits of each, but, most importantly, notes that they all need to be plausibility checked with an event-rate analysis, which he provides a detailed example of–using data from his own work. In an event rate analysis, wellness-sensitive medical events are tracked over the period of time in question.
Wellness has never been shown to have a positive impact on anything other than wellness-sensitive events. Consequently, there is no biostatistical basis for crediting, for example, “a few more bites of a banana” with, to use our favorite example, a claimed reduction in cost for hemophilia, von Willibrand’s Disease and cat-scratch fever.
By contrast, real researchers, such as Iver, link outcomes with inputs using a concept called attribution, meaning there has to be a reason logically attributable to the intervention to explain the outcome. it can’t just a coincidence, like cat scratch fever. As a result, he is willing to attribute only changes in wellness-sensitive medical events to wellness.
Event-Rate Plausibility Analysis
Event rates (referred to below as “PPH” or “potentially preventable hospitalizations”) are laid out by disease on page 22 of the HERO Report. Note the finding that PPH are a small fraction of “all-cause hospitalizations.” Though the relative triviality of the magnitude of PPH might come as a surprise to people who have been told by their vendors that wellness will solve all their problems, Iver’s hospitalization data sample is representative of the US as a whole for the <65 population, in which chronic disease events are rare in the <65 population.
Gross savings total $0.99 per employee per month. This figure counts all events suffered by all members, rather than excluding events suffered by non-participants and dropouts. Hence it marks the first time that anyone in the wellness industry had included those people’s results in the total outcomes tally — or even implicitly acknowledged the existence of dropouts and non-participants. He also says, on p. 17:
For example, sometimes savings due to lifestyle risk reduction is calculated on the 20% of the population that supplied appropriate data. It’s assumed that the other 80% didn’t change but if some of the people who didn’t supply risk factor data worsened, and people who got worse were less likely to report their data, that model would overestimate savings.
Note that the PPH declined only in cardiac (“IVD”) and asthma. Besides the event rates themselves being representative of the employed population in the US as a whole as a snapshot, the observed declines in those event rates are almost exactly consistent with declines nationally over that same period. This decline can be attributed to improvements in usual care, improvements that are achieved whether or not a wellness program was in place. The existence and magnitudes of the declines, coupled with the slight increase in CHF, diabetes and COPD combined (likewise very consistent with national trends), also confirm that Iver’s analysis was done correctly. (Along with attribution, in biostatistics one looks for independent confirmation outside the realm of what can be influenced by the investigator.)
It is ironic that Ron Goetzel says: “Those numbers are wildly off…every number in that chapter has nothing to do with reality” when I have never, ever seen a case study whose tallies — for either total events or event reduction, let alone both — hewed closer to reality (as measured by HCUP) than this one.
Another factor that conveniently gets overlooked in most wellness analyses is that costs other than PPHs rise. By contrast, Iver is the first person to acknowledge that:
The implication, of course, is that increases in these costs could exceed the usual care-driven reductions in wellness-sensitive medical events. Indeed, Iver’s acknowledgement proved prescient when Connecticut announced that its wellness program made costs go up.
The $0.99 gross savings, and Connecticut’s healthcare spending increase, exclude the cost of the wellness program itself, of course. Factor in Ron Goetzel’s recommendation of spending $150/year for a wellness program and you get some pretty massive losses.
The old Al Lewis would close by making some reference to the dishonesty and cluelessness of the Health Enhancement Research Organization’s board. The new Al Lewis will do just the opposite. In addition to congratulating Iver Juster (and his co-author, Ben Hamlin) on putting this chapter together, I would like to congratulate the Health Enhancement Research Organization, for what Iver describes as the “team effort” in publishing it — HERO’s first flirtation, however fleeting and inadvertent, with integrity and competence.
Iver Juster Comments on the article
Iver reviewed this article and would like to add several points. I am only adding a couple of my own points, noted in indented italics:
- It’s important to credit the work to a larger group than just myself. I was the ‘lead author’ on the financial outcomes chapter of the HERO/PHA measurement guide, but the work entailed substantial planning and review in collaboration with the chapter’s coauthor (Ben Hamlin from NCQA) and members of the group dedicated to the chapter (as well as the HERO/PHA authoring group as a whole).
- Yes, I am more than happy to credit the entire group with this study, especially Ron Goetzel, Seth Serxner and Paul Terry.
- Nonetheless the work does reflect my perspective and approach on the topic – the important points being (a) select metrics that are impactible by the intervention or program; (b) be transparent about the metric definitions and methodology used to measure and compare the; (c) assiduously seek out potential sources of both bias and noise (in other words, exert the discipline of being curious, which is greatly aided by listening to others’ points of view); (d) understand and speak to the perspective of the study—payer, employee/dependents, clinician/healthcare system, society.
- Be particularly sensitive to the biologically-plausible timeframes in which your outcomes ought to occur, given the nature of the program. Even if optimally implemented with optimal uptake and adherence, we might expect ‘leading indicators’ like initial behavior changes to improve quickly; program-sensitive biometrics (lipids, A1C, blood pressure, BMI) and medication adherence to change in a matter of months; and a few program-sensitive ER/inpatient visits (like worsening heart failure or asthma/COPD exacerbations) to improve within several months (again, assuming the program is designed to address the causes of these events). Longer-term events like kidney failure, heart attack and stroke and retinopathy take much longer to prevent partly because they require sustained healthy behavior, and partly due to the underlying biology.
- This is one excellent reason that the measured event rate decline mirrored the secular decline in the US as a whole over the period, meaning the program itself produced no decline over that period. Possibly they might decline in future years if Iver is correct. Ron Goetzel would take issue with Iver’s assertion — Ron says risk factors decline only 1-2% in 2-3 years.
- Event rate measurement in any but the largest Commercially-insured populations is subject to considerable noise. Though a challenge, estimating ‘ confidence intervals should at least shed light on the statistical noisiness of your findings.
- No need this time because your results hewed so closely to secular trend, reflecting the quality of the analysis.
- It is very likely that the program used in the illustration did affect more than the events shown because it was a fairly comprehensive population health improvement initiative. For example, ER visits were not counted; and collateral effects of ‘activation’ – a very key component of wellness – were not included in this analysis. Assuming the 99 cents is an accurate reflection of the program’s effect on the events in the chart, I’d be willing to increase the actual claims impact by 50 to 75%.
- If your speculation is accurate, that would increase gross savings to $1.49 to $1.73/month–before counting preventive care increases indicated on Page 22.
- Nonetheless, to get effect from an effective program you have to increase both the breadth (number of at-risk people) and depth (sustained behavior change including activation) – but at a cost that is less than a 1:1 tradeoff to the benefit. In other words, you must increase value = outcomes per dollar. This cannot be done through incentives alone – as many researchers have shown, if it can be done at all, it must be the result of very sustained, authentic (no lip service!) company culture.
- We are beginning to pay attention to other potential benefits of well-designed, authentic employee / workplace wellness programs (of which EHM is a part) on absenteeism, presenteeism, employee turnover and retention – and, importantly, company performance (which is after all what the company is in business to do). It’s early days but it’s possible research will show that companies that are great places to work and great places to have in our society will find financial returns that far outstrip claims savings. The jury’s still out on this important topic but let’s help them deliberate transparently and with genuine curiosity.
- Did Ron really say you have to spend $150 per year PER MEMBER on a wellness program? I’d be thinking a few dollars (unless he’s including participation incentives)
- (1) Yes, he did say that; (2) no, he’s not including participation incentives; and (3) welcome to my world.