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This is the eighth and final installment of the November 2015 “Great Debate” between Ron Goetzel and myself, at the Population Health Alliance Annual Leadership Forum. If you’d like to follow the entire thread, here is Part 1.
If you want to download the audio, be my guest. For some reason the progress bar on the audio doesn’t sync with the end of the debate, so if you want to jump to this section, drag the progress indicator to the far end of the bar, like this:
Hence unlike the previous sections, there are no timestamps on these liner notes. Still, it is the most dramatic part, as Optum’s Seth Serxner does that thing which gets wellness promoters in the most trouble (open their mouths) and Ron Goetzel tries to explain why, when wellness promoters accidentally tell the truth, they don’t really mean it.
Optum’s Seth Serxner, a wellness promoter who sits on the Koop award committee, stands up and makes a couple of comments defending wellness that advance my case more than any of the previous questions attacking wellness.
His first comment — that wellness-sensitive medical events (WSMEs) for employers would have gone way up without wellness — was one that I had hoped Ron would make, but Ron wasn’t stupid enough to take the bait. Ron knew full well that his company’s database showed exactly the same trend in WSME for the non-employed population (Medicare, Medicaid) as for the employed population, as the graph below indicates. This means, of course, that wellness is worthless. Here is a graphic representation of what I originally said–that wellness had not reduced WSMEs, according to the data produced for the government by Ron’s own company:
I of course pointed out that the data said exactly the opposite of Mr. Serxner’s fantasy, as shown below. I noted: “We didn’t post this data until this morning on the hopes that someone from the wellness industry would ask us that question so we could give that response.”
Here is the revised graph, proving definitively the worthless of “pry, poke and prod,” and making my $1-million reward (now $2-million) for showing wellness works a safe bet on my end.
Mr. Serxner, despite claiming to be an expert in wellness, apparently didn’t know this. Here is a guy who goes around telling clients that maybe their costs went up, but they would have gone up faster if Optum hadn’t saved the day with wellness. Of course, now that Mr. Serxner knows that he’s been dead wrong lo these many years, I’m sure he will go back to his clients and tell them he just learned that Optum never saved them anything. Not.
He figured out years ago that some human resources directors will actually fall for this sleight-of-hand. His specific mantra: “We can conclude that choice [emphasis TSW’s] of trend has a large impact on estimates of financial savings.” (Abstract is here. You’ll have to pay for the article to read his exact quote.)
In other words, in wellness you can make up savings by choosing a higher trendline for the comparison of actual costs. Is this a great industry or what?
In his second comment, Seth blames the victim. “Our clients won’t let us [screen]” appropriately. He says that many clients ignore guidelines deliberately. That would lead to the conclusion that clients want to spend more money on Optum’s services in order to screen inappropriately, but that Optum’s salespeople push back, insisting that they should send Optum less money…and the clients refuse.
In followup conversations with Optum, they were unable to name a single program in which Optum tried to insist on infrequent, clinically appropriate, inexpensive screening schedule, but where the account itself demanded the opposite. I can send the email thread to anyone who wants it. (The back story is that Optum’s mouthpiece contacted me to ask if I would stop embarrassing them by referencing Mr. Serxner’s comments. I said: “Sure, if you can name one account where Optum pushed back against the customer demanding higher-priced, inappropriate screening programs.” Never heard from them again.)
Another questioner points out that doing wellness for employees — serving carrots instead of donuts — hasn’t reduced costs. Ron says she’s reading the literature wrong. “A lot of programs reduce the rate of increase in costs, and that’s how savings are determined.” Um, Ron, were you listening a minute ago?
For someone who has proclaimed himself a “scientist” at multiple points, there is some irony (there’s that word again — being oblivious to irony is a prerequisite for being in the wellness industry) in not understanding how science works. An intervention is targeted at specific variables. Pain medications target pain, chemotherapy targets cancer, heartburn medications target stomach acid etc. Wellness targets WSMEs. So if WSMEs decline, that’s called a success. If, however, trauma or c-sections or joint replacements happen to decline while you’re running a wellness program, that’s called a coincidence. Those results are not at all attributable to a wellness vendor browbeating employees into eating more broccoli.
In response to a question, I say that as a former NASDAQ company CEO (and current Quizzify CEO) the greatest advantage I see in wellness is to convince my competitors to do as much of it as possible, so that they waste their time, lose their best people and increase their healthcare costs.
Ron says it’s silly to obsess with spending $100 or $200 on wellness when companies are spending $10,000/employee on “cancer, diabetes, heart disease and hypertension.”
This is nonsense. I’d invite Ron — remember, he says he’s a scientist, so he’s driven by data — to actually look at some data. Employers do not spend most of their money on preventable events in those categories.
Quite the contrary, birth events and musculoskeletal are their two biggest spending categories. Then there are some catastrophic events. The rest is comprised mainly of lots of drugs, tests, doctor visits etc. The actual preventable hospital events in the four categories Ron is referencing account for only a small percentage of all spending. (See the graphs above — about 6% of hospitalizations, meaning about 3% of all costs, or about $150 per covered person are preventable through wellness.)
Don’t take my word for that. Here are the top ten DRGs for commercially insured populations, according to Ron’s own company, Truven:
It took an hour and a half but finally, the infamous Kate Baicker study comes up. She’s walked it back multiple times, all in print, all cataloged here. But apparently neither she or David Cutler (her co-author) are giving up on it. Apparently there were a series of alleged private conversations I wasn’t privy to in which, notwithstanding their public comments, they are still not willing to retract it. It doesn’t matter because, in addition to RAND’s smackdowns, I pointed out that the studies comprising her meta-analysis were laughable, including one claiming that wellness caused a reduction in cat-scratch fever.
Add one more entry to the list of things Ron walking back: his claim that wellness gets an “expected” 3-to-1 ROI.
He is now perfectly fine with a 1-to-1 ROI. Having just said that Kate Baicker is standing by her 3.27-to-1 ROI, he refers to claims of a 3-to-1 ROI as “ridiculous.”
Which is it, Ron? Is the Kate Baicker 3.27-to-1 ROI correct as you said 60 seconds ago, or is a 3-to-1 ROI “ridiculous,” as you said just now?
I bring up Michael O’Donnell’s infamous statement that “randomized control trials” in wellness “show a negative ROI.” Yet another example of these wellness Einsteins accidentally admitting that wellness loses money and having to walk it back. Ron gets a point for being totally prepared for this exchange. He explains that, of course, like everything else I point out where they accidentally tell the truth in print (like the HERO guide earlier in the debate), it doesn’t really mean what it says in print. It means something completely different.
Ron excels at twisting and turning statements into their opposites. We have so much respect for his ability to do this, we call him Goetzel the Pretzel.
Like Mr. Goetzel was prepared to pretzel this gaffe, I am also prepared for Mr. Goetzel’s pretzel. This researcher, a graduate student at the University of Tasmania (that’s an island south of Australia), “averaged” low-quality studies showing positive ROIs with high-quality studies showing negative ROIs to find an overall slightly positive ROI. My reply: “That’s like averaging Ptolemy and Copernicus to conclude that the earth revolves halfway around the sun.”
Ron had said no one would do RCTs, but Aetna just did one and found no impact.
Ron, who spent about half the debate talking about how great peer review is, now admits the process is broken. Then he says “the peer review process works quite well.”
Which is it, Ron? Is peer review great or is it broken?
Then he says the editors of these journals are “not my friends” and then he says they are “close friends” of his.
Once again, which is it, Ron? Are they your close friends or not your friends?
The final question was emblematic of the entire debate, in which Ron makes statements that are obviously the opposite of the evidence. He alleges that 2/3 of employees want more wellness programs. I point out that if employees liked wellness you wouldn’t have to fine them to get them to participate. Indeed, they would pay for wellness, just like people are willing to pay for other things they like.
You only have to go to Slate or any other article to see that employees in this country don’t like wellness, any more than the employees in this audience do.
There you have it. Who won? You make the call. None of my work was challenged (except Quizzify –but with a 100% guarantee of savings that’s our problem if we’re wrong — and the reviews and case studies are very positive). Ron conceded the following:
- I am right a lot of the time (for anyone is keeping score at home, that would be 100%);
- I am the best peer reviewer in the field;
- most wellness programs don’t work;
- he can’t win my million-dollar reward; and
- he’s doctored a lot of material.
Here is a list of what he has said and done, that he just ran away from:
- his HERO Report;
- wellness industry “cheaters” like his colleague, Wellsteps’ Steve Aldana;
- his Penn State program;
- his 3-1 ROI claim.
The only program he defended was the indefensible Nebraska program.
I on the other hand lost on no exchange, and conceded nothing except that maybe Johnson & Johnson saved money on their wellness program. While blogging on this debate, I was finally moved to read the J&J outcomes report. Surprise! The whole thing is obviously fabricated and never should have passed peer review. I’ll blog on it another day.
If you are just joining us now, you can start at Part 1, where you can also easily download the audio. The entire commentary thread can be found by clicking on “The Great Debate” on the home page.
As we delve into the Q&A, a parade of questioners demand to know why their own employers’ programs are so bad. They are far from alone, as most employees hate “pry, poke and prod” wellness, which is why bribes and fines have to keep rising.
Of those questioners, the most dramatic was a Penn State professor. Those with long memories may recall the Goetzel/Highmark wellness program that was being imposed on Penn State faculty and staff made the national news in 2013, due to its shocking invasions of privacy and general overall cluelessness. I covered in a Harvard Business Review essay entitled The Dangers of Wellness Programs: Don’t Become the Next Penn State.
Penn State Professor Matthew Woessner takes the mike. First he undercuts Ron’s previous answer by observing that my pointing out errors is a key part of peer review.
Then the fun starts, as he talked about the “terrible damage” the wellness program did there. It “destroyed morale.” Ron agrees that Penn State was “an awful program” but says he had nothing to do with it “in any way” even though he was in the room during their press conference in which they “took [the] offensive” in this.
Are we seeing a pattern here?
- He ran away from Steve Aldana and Wellsteps, even though they’re on the Koop Award Committee and he just gave them an award for harming employees and lying about it
- He ran away from the HERO report even though he’s on the board of HERO and wrote his famous letter supporting it.
- He’s running away from Penn State even though he was right there as a core member of the team when they called a press conference.
The moderator, again coming to Ron’s aid to prevent this debate from becoming a rout, observes that just because one college complains, not all college programs are bad. There are thousands of colleges and only one complained. Therefore, all other colleges must have good programs, according to “4th grade math.”
Professor Woessner jumped on that comment. He pointed out that the faculty at his alma mater, Ohio State, also hate their wellness program. The faculty is “livid” at Ohio State.
This was one of the biggest smackdowns of the afternoon, thanks to Prof. Woessner. It was a far better retort than anything I could have or did come up with.
Vik Khanna gets a question in. He points out that his wife’s employer’s program, where the vendor is Provant, is also awful. (Noticing a trend here?) Vik did an 8-part series last year on this Provant program. It involves checkups (that are more likely to harm you than benefit you, according to the New England Journal of Medicine), annual cholesterol tests (that healthy people are also not supposed to get according to the USPSTF guidelines), and a bunch of other stuff, like telling employees to drink 8 glasses of water a day, which is yet another myth.
Ron says Provant has a bad program because it doesn’t adhere to USPSTF guidelines, though none of the Koop Award winners adhere to those guidelines either. He repeats one of his themes of the debate: “There are a lot of lousy programs out there, including the one you’re part of.”
I point out that Ron gave an award to Nebraska, which was decidedly a lousy program. They had admitted lying about saving the lives of alleged cancer victims who never had cancer in the first place.
Ron says Nebraska won the award because they had “solid evidence they improved the health risk profile of the population.” Yet, according to their own figures, a mere 161 out of 19,000 state employees (<1%) shed a risk factor. He calls their evaluation methods “excellent.” This means in wellness it is “excellent” to claim $4.2-million in savings when 161 people reduce a risk factor and you admit lying about cancer. This entire lying-about-cancer thing has now morphed into a rewriting of history, as noted on an earlier installment.
Though just a sidelight in this debate, Ron Goetzel just admitted that he has no idea how to evaluate outcomes. This program accomplished nothing, according to their own data, and yet claimed massive savings. Somehow in Ron’s universe, this is award-worthy because his colleagues ran the program.
By the way, this program was awful, whether Ron says so or not. (The vendor is a sponsor of the Koop Award, so Ron won’t admit it.) Surviving Workplace Wellness devoted an entire chapter to it. Here is a snippet:
Yet another employee subjected to yet another worthless wellness program complains to Ron about it, “suffering through 4 sessions with my health coach.” He blames her and her program for being bad and says she needs to change her behavior.
Shame on you for being a bad employee! You need to take a time-out. (You and most of the rest of the country.)
The AARP lobbyist, Debbie Chalfie, adds AARP to the list of organizations that have multiple concerns about wellness. Ron adds programs with surcharges to the long list of programs he doesn’t like, even though Bravo hired him to allege massive, self-invalidating, savings at Graco by doing surcharges. If the name “Bravo” rings a bell, it’s because that was the outfit that used to brag about how they could generate immediate savings by surcharging employees until we pointed out it probably wasn’t a wise idea to boast about that.
I use one of my prepared zingers here. If all these programs fail — Ron’s colleague Michael O’Donnell says the figure is 95% — “that’s not an industry. It’s a lottery.” Literally, excluding oil producers, no organization in the US would undertake any investment whose biggest promoters admit a 95% chance of failure. And yet, due to the lies told by wellness vendors and their consultants, lots of companies do.
Ron wraps up this section of the debate with yet another admission that wellness doesn’t work: he says “programs are very hard to implement effectively.” On this point we would agree. But as a former corporate CEO of a NASDAQ company, there’s no way I’d devote more than $100/employee to a program that probably wouldn’t have worked, had no evidence in favor of it other than what wellness vendors say, and could easily have backfired like every program described in this debate so far.
Further, we have a great culture at Quizzify, one that I have posted about on Linkedin. A great way to wreck that culture would be to start pestering employees about stuff that is none of my business and doesn’t affect me, the customers, or the shareholders.
The question-and-answer period is now underway.
If you are just joining the thread, this is Part 6 of The Great Debate, a November 2015 exchange between Ron Goetzel and me, at the Population Health Alliance Annual Leadership Forum. Part 5 is here. You can download the audio here.
To the question: “What would you do to reduce healthcare costs?” Ron replies that he is “focused on prevention.” And that’s the issue. I point out that “too much of anything is bad for you, ours is already the most over-prevented society on earth, and these programs are all out of compliance with guidelines.” All these programs screen everybody far more than guidelines advise. Here are the guidelines. Find anything other than blood pressure where the wellness industry’s obsessive annual screens are recommended.
[Postscript: after the debate, the Connecticut study came out, showing that overprevention through wellness increases costs, as one would expect.]
The moderator asks how can Quizzify be the most effective company in employee health education. He challenges our 100% guarantee of savings. This is ironic. No wellness company offers any meaningful guarantee of savings, for the simple reason that it is mathematically impossible to save money in wellness.
Somehow in wellness, guaranteeing savings is a bad thing but losing money is a “good thing.” (Really, a direct quote — click on it.) It’s curious to challenge someone’s own willingness to guarantee their own results as part of their own business. Obviously, if my business judgment is wrong, Quizzify will fail. And what I didn’t say because I didn’t want to brag, is that people questioned my last business venture too, Matrix Medical. Fast forward: Matrix is now the most valuable population health company start-up of this millennium. (Before you ask me to lend you money, we mostly sold out on the “cheap” in 2013 to a private equity firm named Welsh Carson.)
Ron Goetzel endorses Quizzify. He went on the website and played the game. “It was a lot of fun. Very clever.” Then he asks — quite justifiably — how Quizzify can make problems like obesity and smoking go away. The answer, of course, is that Quizzify isn’t going to make obesity and smoking go away any more than wellness does. For example, consider McKesson’s Koop Award-winning program, where both weight and smoking went up. We can’t do worse than that. If we did, we could win a Koop Award.
Instead, Quizzify guarantees reductions in overall healthcare spending on “low value care.” As you can see from the demo on the website, we also educate people on hidden sources of sugar, of which there are more than you can count, but we don’t expect immediate savings from this and other nutrition/smoking education questions. Immediate savings are provided by our emphasis on avoiding low-value care.
Consistent with his theme of running away from his own work, Ron now runs away from his own HERO Report. Keep in mind two things as you listen to this section:
- Ron is disowning his own report. He is on the board of HERO, a tidbit which he overlooks in this hasty retreat;
- Within days of this debate, he was circulating his famous poison pen letter to the media completely owning it, and accusing me of reading it too carefully.
The moderator (who otherwise moderated fairly) for some reason jumped in and said the HERO Guidebook just used an allegedly hypothetical example to show losses. Since their “example” costs were $18/employee/year as opposed to the more typical $100 AND since the HERO example failed to control for the countrywide decline in wellness-sensitive medical events, the HERO example grossly underestimated losses from wellness.
Ron says “those numbers in [my HERO Guidebook] are wildly off,” and “have nothing to do with reality.” He says I “misrepresented and misinterpreted” these figures. But they are right there: A program costs $1.50 PEPM and saves $0.99. What’s to misinterpret? Ron apparently hadn’t noticed that his little Guidebook accidentally told the truth until I pointed it out — exactly like he hadn’t noticed that Eastman Chemical/Health Fitness self-invalidated. In both cases if fell upon me to point it out to these Einsteins.
Here is a posting showing what happens when you adjust those HERO figures for Mr. Goetzel’s alternative “reality” — losses skyrocket, just like Health Affairs showed in the Connecticut study.
Perhaps HERO would have more credibility telling us that wellness saves money if their own allegedly* “fabricated” example and any of the legitimate literature supported that claim. I’m just sayin’…
*The word “allegedly” is used because the example in the HERO guidebook is not a “fabricated” or “hypothetical” example. The words “fabricated” or “hypothetical” do not even appear in the chapter. Instead the example is an actual report. That’s why the Guidebook says it’s a report, and gives very specific details of the report–in the past tense, no less, as you would for a completed report. A “hypothetical” would use the present tense throughout, along with saying that it’s a hypothetical.
So Ron’s whole argument about this being somehow a hypothetical is shot, just like all his other arguments, by showing his own data.
To summarize Ron’s view so far in this debate: everyone who thinks wellness is a total waste of money — including RAND, basically all the media and every economist who has looked at it in the last six years — is wrong. Every time his own materials accidentally tell the truth and say wellness loses money, they’re wrong.
And as we’ll see in the next installment, every employee who hates their company’s wellness vendor is either in a bad program or they are a bad employee.
Basically everyone is out of step but Ronnie.
We are now in Ron’s wheelhouse, which is publishing peer-reviewed articles in third-tier wellness trade journals. Let’s see how he does.
For those who are new to this thread, Part 4 is here, and links to earlier installments. The recording is here. Time stamps roughly synch up.
Ron says he is a researcher, and publishes in peer-reviewed journals. He “applauds” me again for giving them the “opportunity” to correct their many errors, and says the comments I make are often “right on the money.”
It is indeed a creative use of the word “opportunity,” as in: “Last year the IRS gave me the opportunity to be subject to an audit.”
He says “that’s what the scientific method is all about, having peer reviewers critique your work and find problems.” And yet, I’ve never, ever been asked to peer review anything that he and his cronies have ever published. Go figure.
He would like “us” (meaning him and his cronies) to be able to review my work, even though I’m not allowed to peer-review theirs. He says he has “never seen an article by Al Lewis…to review.”
Hmmm…perhaps his internet is down?
Since all my work is right on this site (including links to other work, in “In the News” to Health Affairs, Harvard Business Review etc.) he is free to review it anytime, and we publish all comments. There isn’t really any need to for him to look at our material because mostly it’s his own and his cronies’ material. And you know the mantra from Surviving Workplace Wellness: “In wellness, you don’t have to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself.”
As in his opening remarks and in his “secret” letter to the media, he once again criticizes my stuff as being “out there…outlandish,” but gives zero examples.
Ron, in the process of saying something he knows not to be true for a change, accidentally endorses me.
“Ron, would you say I am the most qualified person in peer review in terms of finding the most mistakes?”
“Well, who has found more mistakes than I have?”
[Silence and nervous laughter from the audience.]
I point out that — despite his tacit endorsement just now that I am the best peer reviewer — none of his friends’ wellness trade journals have ever asked me to peer review anything.
And he still refuses to say why he hasn’t claimed the million-dollar reward.
Peer reviewed or not, numbers need to add up, and Ron’s don’t. In one award-winning example, Eastman Chemical, $900/person in savings was shown — with risk factors changing by only 0.17 per person, excluding dropouts.
Ron did not rebut this. Eastman was one of the two Koop Award applications he had doctored when it turned out the applicant had accidentally told the truth but no one on the award committee noticed.
Ron has already run away from most of the industry’s claims, as earlier installments of this debate have observed. Now is he running away from Wellsteps’ Steve Aldana, whom he has co-presented and co-authored with and who naturally is on his Koop Award committee. Aldana recently wrote that I was “sick” because a colleague posted my Harvard Business Review article on his linkedin group and asked what people thought of it.
[2016 Update: Ron is now embracing Steve Aldana and Wellsteps, the first company to admit to harming employees.]
Ron is turning his blacklisting of me into my “plea” to do peer review in his trade journals. I have never “pled” to do peer review in his trade journals, which are mostly useful as punchlines. I merely observe that I’ve never been asked. “You’re very good at calling out mistakes, but you’re not very good at publishing your own research studies.”
He then cites the Johnson & Johnson study (that’s the same Johnson & Johnson that just proposed the Fat Tax). That is the only study he’s ever done that I’ve not been able to invalidate on its face, so he gets his first point of this round here. Not because the study is valid. There wasn’t enough data in it for me to automatically prove that it was invalid, which is a very high standard, but that’s my standard–“face invalidity.”
So there you have it: one company in the entire universe that might possibly have saved money on wellness. And as coincidence would have it, they also sell wellness services. No publication bias there…
November 4, 2016 Update: I just found this J&J study. It is even worse than the others. Employees lying on HRAs, trivial risk reductions…and of course massive savings. It appears that all they did was increase the deductible and then give employees $500 to do wellness, thus shifting the money out of the healthspend into the incentives account, which is not included in the “savings.”
I point out that even though I’m apparently not qualified enough to peer review for his friends who run low-impact journals, I do get called upon to peer review for Health Affairs and other high-impact journals. And most importantly, while I’ve done only two peer-reviewed articles, one led to the dismantling of the North Carolina Medicaid medical home. The other was #1 for 2015 in the American Journal of Managed Care and continues to be cited widely. My award-winning book was peer-reviewed by some of healthcare’s leading figures: Stuart Altman, James Prochaska, Tom Scully, Leah Binder, Bob Galvin, Regina Herzlinger, and Nortin Hadler (the same Nortin Hadler who apologized for poor peer review by one of Ron’s favorite trade journals).
Most importantly, speaking of peer review, Quizzify is the only population health company that may publicly say “our content is reviewed by doctors at Harvard Medical School.”
Ron — whose entire industry loses money and can’t even guarantee not losing money — is now lecturing me on Quizzify’s guarantee of savings and how it needs to be peer-reviewed. I was not expecting to be attacked for offering an incredible, unique, value proposition, so I didn’t have a good answer. Only in wellness is saving money for customers considered a bad idea.
He continues to harp on peer review by his friends-and-relations, but I won the round with one simple observation: “We are not here today because of Ron’s peer-reviewed articles. We are here today because of my non-peer-reviewed articles.”
I could fill a blog with all the nonsense that Ron’s friends who run so-called “peer-reviewed journals” have published. Come to think of it, I have. Examples:
AJHP’s proposal to tie insurance premiums to weight, like ordering lobster or mailing packages
JOEM’s Aetna debacle
AJHP’s “Randomized control trials show negative ROIs.” (I didn’t have to post anything here–this spoke for itself.)
A rebuttal from Goetzel? Of course not. The Wellness Ignorati deal in secret missives to the media, not open discussion. Or, in the case of the proposed Code of Conduct urging vendors not to harm employees or lie about outcomes, stonewalling it. What they never do is, engage with this blog. We’re good enough for Slate, STATNews, and the Chicago Tribune (and that’s in the last 3 months alone), but not the Wellness Ignorati.
However, we did manage to get a thoughtful response from a third party, Michael Prager. He raises some excellent points.
First, Ron says (and has said variations of this on many occasions) “most diseases are preventable” by wellness. That statement is flat-out wrong. Had Ron said — and this is Michael’s take on what he meant to say — “most people eventually die of chronic diseases that, had they made better choices in their life, might not have developed until later in life,” then he would have been right. Fact is, heart disease and diabetes are leading killers. Just as Michael says.
Ron got it totally wrong, though, with his most-diseases-are-preventable mantra. Only a few diseases are preventable through corporate “pry, poke and prod” programs. Just look at Ron’s own HERO guidebook. It lists diabetes and heart attacks and a few other ICD 9 codes as “potentially preventable hospitalizations.” Meanwhile, there are about 14,000 other ICD 9 codes (or 60,000+ ICD 10 codes) which are not preventable through workplace screenings, though one study tried to credit a wellness program with a decline in cat scratch fever.
Think of all the diseases or other expenses or health programs you yourself (assuming you are a non-smoker) have endured in your lifetimes. How many would have been prevented by one of Ron’s pry, poke and prod programs? Or, as Wellsteps’ Steve Aldana says, by eating one more bite of a banana? (He really did say that, but the STATNews website seems to be down this very minute.)
Now, if employees were covered for their entire lives by employers (they aren’t), and if employers could get them to reduce their risks (they can’t), then corporate wellness could work, and might possibly save money.
Second, Michael also points out that I distinguish disease-related “events” from the diseases themselves. These events are — and Ron’s HERO guidebook agrees with me on this — the only place an employer actually realizes savings from wellness, offset by many other costs. However, very few events caused by these conditions take place during our actual <65 working years. Like the annual odds of a heart attack for commercially insured people <65 are about 1-in-800. Using a few generous assumptions about program effectiveness, that already-low rate means it costs companies about a million dollars to prevent one through pry, poke and prod.
Finally, you should know a little about Michael’s back story. He did in fact turn his own health around through rigorous attention to diet and exercise, and I applaud and respect him for that. He encourages others to do the same, as do I. However, “encouragement” and intrinsic motivation are a lot different from, for instance, Michael O’Donnell’s recent diatribe that employee health insurance premiums should (at least in part) be assessed on a per-pound basis, sort of like when ordering lobster or mailing a package. That system, Mr. O’Donnell says, will get employees to lose weight.
Alas, if there is one thing wellness vendors can’t do, it’s get people to lose weight. The best example would be Ron’s buddies at the Vitality Group. They couldn’t even get their own employees to lose weight.
I am shortcutting Michael’s comments, so do go take a looksee on your own. It was a thoughtful response (two words you won’t see in succession in any other TSW posting) and is worthy of a careful read.
In my rebuttal, I was finally able to introduce ethics into the debate. Along with arithmetic and facts, ethics would be one of the three categories that I have the greatest advantage over Ron. Quizzify and I are in the “integrity segment” of the market.
As is always the case in this debate and in general, I don’t need to cite my own data. His data is so obviously wrong (the New York Times had a few choice words, like “crap”) that I merely point out that his own data sets reveal wellness’s failures when read by an actual smart person, as opposed to, for example, a member of the Koop Award committee.
Citing his own data means we don’t get into he said-she said arguments over the validity of the data sets. We can both agree to use his data.
I eviscerate Ron’s old saw about 50% of people having chronic disease. As I always do when someone repeats that myth, I ask attendees to raise their hands if they have a chronic disease and maybe 3% of hands go up. This 50%-of-people-have-chronic disease is the biggest urban legend in healthcare, as we have noted. It’s somewhat true in the Medicare population, but we are talking about the employed population today. In the employed population, it is only true if the definition of “chronic disease” is expanded to cover, for example, back pain, tooth decay, dandruff, and Ring Around the Collar.
I got some good laughs in this hand-raising exercise (“To be compliant with HIPAA, close your eyes”).
I had anticipated that he would cite his Procter & Gamble study from a quarter-century ago (!) in defense of wellness. So I had checked with P&G, who are my clients, and no one there has any idea what he was talking about.
I get Ron to admit doctoring the evidence on the Koop Award site and then lying about it. He not only doctored the original, but said he didn’t doctor the original. The back story: showing their typical level of competence at reading graphs, Ron’s committee accidentally gave out an award to a program in which participants had outperformed non-participants for two years (2004 and 2005 below) before the program even started, so he changed the x-axis so it looks like the program had been in place during that period. Here is the “before” graph:
Here is the x-axis after he doctored it to remove the evidence that the whole thing was invalid:
As he was doctoring the original application, he created the fiction that the original “application was online and subject to review.”
Even if the study had started in 2004 instead of 2006, the risk profile only improved by 0.17 on a scale of 5 (3%) by 2008, making the massive savings in 2008 completely impossible. (Until 2016, when they shed all pretense of integrity in order to give an award to their Wellsteps colleagues, the Koop Committee trademark was attributing massive savings to trivial reductions in risk.)
I point out that Aetna had just accidentally confirmed what should be obvious: participants-vs-non-participants is a totally invalid study design. They were trying to show the opposite, of course. This is classic wellness and confirms our mantra: “In wellness, you don’t need to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself.” The most respected member of the journal’s editorial board, Dr. Nortin Hadler, apologized and said Aetna’s article never should have passed peer review. So much for the peer review process at Ron’s favorite journal.
I also observed that Ron had himself admitted the participants-vs-non-participants study design was invalid:
Ron responds to my observation that he had “doctored the information.” He admits that the chart in question was originally “mislabeled” on the x-axis. The label was unmistakably clear. To allow Health Fitness Corporation (HFC) to win an award for this non-attributable, invalid result either reflects the total inability of the vendors (Wellsteps, Staywell etc.) and actuarial consultants (Mercer, Milliman etc.) on this committee to recognize a screamingly obvious invalidity when it’s staring at them, or was a conscious decision to give the award to a Koop Committee sponsor. Or maybe both. Each year has seen the award go to someone connected with the Committee.
Ron at least gives me credit for being “sharp-eyed,” but, honestly, anyone who’s taken my course in Critical Outcomes Report Analysis would have seen that the X-axis clearly shows the program didn’t start until 2 years after the two groups were separated.
I sprung the trap I had set earlier, when Ron said I praised him in my book. I had reproduced that HFC graph in Why Nobody Believes the Numbers on the page following the page where I praised his own work, so that I knew he would see the graph in all its hilariously invalid glory. That juxtaposition was a test to see if he would retract that graph once the obvious invalidity was brought to his attention. He not only didn’t retract it then, but he called that program (listed below under “Eastman Chemical,” HFC’s customer) a “best practice” for two years after that–knowing full well the key graph showed no program impact.
I ask Ron if he’s doctored any other Koop Award application after my expose. He is completely silent. He did doctor another original application that very morning in preparation for the debate, not realizing I had saved a screenshot of the original original. The original and the doctored version are reproduced below, for the Nebraska application. But he was “saved by the bell.” The moderator jumped in and started asking the audience for questions, and I frankly forgot to bring this one up later. Compare the last line of each passage below. The first was before my expose of Nebraska. Ron had claimed the Koop Committee had no knowledge of Health Fitness Corporation’s lie about finding all those cancer victims in the Nebraska state employee population. However, it was right in the application…until Ron doctored the application before the debate.
While he has conceded many points so far in this debate, I have yet to concede that Ron and his cronies do anything well, so here’s the first: he excels at tampering with evidence.
Each of us delivers a rebuttal-cum-second statement. Ron uses his time to shore up his base — the “low information voters,” as they say in political science–with claims he knows to be inaccurate because he himself has said the reverse and/or the statements are invalid on their faces.
Ron says “A large proportion of the diseases we suffer from are preventable.” Actually, excluding smoking-related illness (where there has never been disagreement), “preventable” events consume far fewer employer dollars than birth events, musculoskeletal issues, and general “worried well” medical concerns.
Employers also spend money on rare diseases, infections, catastrophic issues, sports injuries, trauma, drugs, and doctor visits for various things. Are you seeing a pattern here? None of these are preventable by wellness. Where does he get his ideas?
Tallying all spending according to Ron’s own co-authored report — and the HCUP database compiled by Ron’s own employer, Truven — the rate of “potentially preventable hospitalizations” is 2.62 per 1000. Their report uses $22,500 as the average cost/hospitalization. Doing the math with the $22,500, that’s $59/per person per year, out of $6000/person or so spent on healthcare. Meaning about 1% of claims would be preventable through “pry, poke and prod” programs. And that assumes these programs worked perfectly. As years of Koop Awards of demonstrated, they don’t work at all. The most carefully studied program is Connecticut’s. Connecticut‘s pry, poke and prod program actually increased state spending on health care.
So Ron’s premise is utterly false. Let me put it another way: have you ever had a medical event that could have been prevented by completing a health risk assessment or eating more broccoli?
At this point his strategy emerges: argument-by-cliche. “Most diseases are preventable,” is his favorite. That would mean health-conscious folks would be blessed with eternal life.
Also, “80% of money is spent treating chronic diseases.” He is off by a factor of 80 from the relevant figure of 1%. He would arrive at that 1% figure if he asked the right question: “What percentage of cost can an employer save with a perfect wellness program?” He knows that because his co-authored guidebook says it. We also long since debunked this 80% myth.
As a public service, at the end of this posting we list the top hospitalizations. Remind us, Ron, which of these your wellness programs are going to prevent?
Someone needs to tell Ron that “stroke” is not a chronic diseases, nor are most cancers. A stroke is about as acute as you can get — each minute without treatment raises the odds of ending up like the Kardashians. And if cancer were a chronic disease, we wouldn’t run in “Races for the Cure.” We’d run in “Races for the Control and Management.”
I am personally infuriated that he thinks my recurring bladder tumors were/are preventable. I was involuntarily exposed to a carcinogen in 1984. He’s right about one thing, though: bladder cancer is usually chronic. However, most cancers aren’t, contrary to his claim. When was the last time someone said to you: “My doctor says I have lung cancer, but we’re staying on top of it” ?
He also, ironically, lists “depression” as something that can be addressed by wellness without explaining how employers forcing employees to do something they hate — “playing doctor” by taking their blood — is going to cure their depression.
“You can improve population health in the workplace if you apply evidence-based programs,” he says. And yet, his own Koop Awards, presumably given to the best programs, go to organizations that made essentially no impact on population health — 1%, 2% or 3% reductions in risk factors –-but then made up clinically and mathematically impossible savings figures. [Postscript: I wrote that in 2015. Little did I know that in 2016, the Koop Award committee would give an award to a company that increased risk factors and admitted flouting evidence-based guidelines.]
Following the debate, Health Affairs put the total kibosh on Ron’s idea. They published a study showing that you can’t get employees to lose clinically or statistically significant amounts of weight. Not that it would matter because weight has only the most trivial impact on health spending in the <65 population.
Another irony (there’s that word again): all the evidence — the US Preventive Services Task Force etc — says you shouldn’t screen all adults every year for anything other than blood pressure. And yet these Ron and his buddies advocate exactly that.
Ron’s business model is to write up studies showing his friends and clients save money on wellness, so he rattles some off. He notably leaves out Nebraska, because their program and his award for it were shown to be complete lies. However, leaving that program off this list (though it appears on most of his other “best practice” lists) is an excellent debate technique. Listing it as a best practice would have allowed me to point out the results were admitted to have been made up.
He also claims: “some organizations can actually achieve a positive ROI,” As an endorsement, that’s right up there with Benjamin telling Mrs. Robinson that he found her to be among the most attractive of all of his parents’ friends.
It’s also a total walkback of his previous certitude, like:
Just like Gary Hart invited reporters to follow him to show he wasn’t sleeping around, Ron invited “everybody to go in and look at [the Koop Awards] to determine whether they are telling the truth or not.” And, just like Miami Herald reporter Tom Fiedler did with Gary Hart, I took him up on his offer…and found that almost every award over the last five years showed provably fabricated savings figures. [Postscript: once again, I wrote this in 2015, before the Wellsteps award this year, which raises fabrication of Koop Awards to a plateau that even presidential candidates can’t reach.]
So Ron managed to lose his own rebuttal round–even when, as with his opening statement, I didn’t say anything. The debate has pivoted badly for him…and it’s only going to get worse.
Postscript: At 37:28, he says people with “high biometric measures…are more expensive” than people without. This means he knows full well that Wellsteps is lying in their 2016 award when they show increased biometrics but massively reduced costs.
As a public service to Ron and his cronies, I am listing the top 25 hospitalizations in order of spending. See if you can find one or two that are “preventable” by eating more broccoli or being poked with needles.