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Questions to ask Livongo before signing with them

In 2014, the Validation Institute, then a joint property of Intel and GE, tasked me, based on Why Nobody Believes the Numbers, to develop the most sophisticated outcomes measurement course ever devised. That was not a heavy lift, because at the time no other such course existed. They named it Advanced Critical Outcomes Report Analysis, or “Advanced CORA” for short.

Five years later, the course, now called CORA Pro, remains the Gold Standard in outcomes measurement expertise. CORA Pros — and there are only 8 of us — have developed a talent not just for sniffing out questionable claims (anyone can “challenge the data”), but more importantly for identifying contradictory, implausible and even impossible claims that somehow hadn’t been noticed before. Even a simple press release can become a case study in impossibility.

CORA certification itself is very useful, and takes you halfway there. But there’s something special about CORA Pro. Once you are certified in CORA Pro, you never look at a vendor outcomes report the same way again. For instance, consider Livongo’s recent glowing press release about its outcomes. Non-CORA Pros, like whoever these people are, basically just parrot a vendor’s results uncritically with a glowing headline. They sound like Flounder.


By contrast, a CORA Pro would review Livongo’s claims thoughtfully, and ask probing questions, first about the outcomes:

  • If your goal is to reduce admissions for diabetes and reduce insulin usage across the population, why didn’t you measure admissions for diabetes, or insulin usage?
  • Why does this report show the opposite of your report from 2018? This report showed huge reductions in outpatient and no significant change in inpatient, whereas the 2018 report showed huge reductions in inpatient with no significant change in outpatient?


 

Then a CORA Pro would ask whether Livongo may be harming employees:

  • Why is your goal Hb A1c of 6.5% in conflict with the American College of Physicians and other expert bodies not funded by the diabetes industry, which advocate 7.0% to 8.0%? Perhaps they mean reaching 6.5% with diet-and-exercise, but if insulin use is going up, which is likely because they didn’t claim it was declining, clearly some employees aren’t getting the subtle nuance that they shouldn’t aim for 6.5% with medication.
  • Why is Choosing Wisely advocating fewer glucose checks if the right answer is to check multiple times a day?

Just askin’…  Because that’s what CORA Pros do.


The full list of questions can be found here.

To learn about CORA certification, click here.

And to see how we predicted many of the ways Livongo would measure outcomes using vendor-friendly metrics, click here.

 

Interactive Health gives clueless wellness vendors a bad name

Someone suggested that I call my Congressman to pass a law against Interactive Health, but I think the Justice Department is the more appropriate route. No, not because they’re harming employees — there is no law against employers harming employees in the name of wellness. Quite the contrary, the most recent Koop Award went to a vendor, Wellsteps, which did exactly that.

Rather, I would propose an antitrust action, because Interactive Health is attempting to create a monopoly on stupidity.

Yes, it seems like hardly a day goes by without the irresistible force of Interactive Health’s corporate IQ colliding with the immovable object of reality.  The thing is, their moles pop up faster than I can whack them on Linkedin, so here is a tasting menu of their greatest hits. You can’t find most of these observations on Linkedin for the simple reason that they delete them.

This was originally going to be a comprehensive retrospective of all their nonsense (Exhibit A for the Grand Jury to review), but in the two weeks since I started writing it, yet another mole popped up. This one could top the list if not for their “smoking recession program.”

  • An analysis of 2017 member data revealed that those clients who test all employees for Hemoglobin A1c identified up to 3 times more individuals at risk for pre-diabetes versus other testing. As a result, inclusion of Hemoglobin A1c testing for all employees is often a strategic recommendation for our clients. 

Since pre-diabetes is a risk factor for diabetes (and only a fraction of pre-diabetics become diabetic, after 5 to 10 years), they are hunting for employees who are “at risk for being at risk.” Who amongst us is not at risk being at risk for something? But that doesn’t mean they’ll end up with diabetes, any more than every kid who steals a cookie from a cookie jar becomes a bank robber — even if every bank robber did in fact at some point in their childhood steal a cookie from a cookie jar.

Using testing guidelines so contrary to the US Preventive Services Task Force that a beam of light leaving USPSTF guidelines wouldn’t reach them for several seconds, Interactive Health takes great pride in “identifying 3 times more individuals” than companies that test employees according to guidelines. Cue Inspector Louis Renault: “Owing to the seriousness of this crime, we are rounding up twice the number of usual suspects.”

One might be excused for assuming that the point of screening would be to “round up” the most appropriate employees, rather than the largest number of employees. One might also be excused for thinking Interactive Health is simply stupid, when in reality they are fully aware they violate guidelines, recognizing that their typical customer doesn’t realize this and is willing to, in the immortal words of that great philosopher the Queen of Hearts, believe six impossible things before breakfast.

Image result for queen of hearts alice in wonderland

in case anyone else is interested — we know Interactive Health isn’t — the USPSTF recommends screening only overweight/obese 40-to-70-year-olds for HbA1c. That’s to prevent exactly the kind of hyperdiagnostic employee harassment that comprises Interactive Health’s signature strategy: more tests = more revenues. They make Wellsteps look like an honest, intelligent vendor, which is no easy feat.

We also thought of contacting the Health Enhancement Research Organization (HERO), to let them know there was a vendor making the industry look bad (or look even worse), but it turns out that for HERO, cluelessness is a feature, not a bug.  Specifically, HERO has highlighted a case study by Interactive Health, which would be like Bernie Madoff highlighting his investment in Enron.


Update. Alas, I’m afraid there won’t be an investigation into their stupidity. At this point, they are so far ahead in the race to the bottom that it would be impossible to empanel a jury of their peers.

 

 

Podcast: Where wellness went wrong…and how to fix it

Dear TheySaidWhat Nation,

Here is our most recent podcast, courtesy of Insurance Thought Leadership.

Summarized as follows:

  1. Conventional “pry, poke and prod” wellness has failed
  2. Trying to morph those 3P programs into “Wellness 2.0” will also fail, largely because you can’t spin straw into gold no matter how hard you try
  3. However, wellness done FOR employees instead of TO employees, like Quizzify, is a welcome addition at most workforces.*
  4. You can’t do that with the same vendors who created 3P programs any more than you’d hire former East German border guards as tour guides.

Al

*That was not clear in the podcast. See the comment below and my apology.

Better sleeping through chemistry?

The wellness industry is now synonymous enough with epic fails to make a thesaurus writer blush.

11 in a row at last count, as this article documents. Money lost, risk factors increasing. Even employees getting fatter. And in case you haven’t already seen it, an expose of the wellness industry comprehensive enough that if you intend to read it, you better clear your calendar.

What’s even worse than their sins of commission are their sins of omission. While they can kill millions of electrons on the subject of broccoli, try finding even a few words in any HRA about opioids. Quizzify was first on the scene with an opioids awareness quiz 2 years ago, and even today the wellness industry is pretty much ignoring that particular elephant in the room.


It turns out that they are ignoring not just that elephant, but the entire herd. (In case anybody is keeping score at home — still trying to be the first person to find a mistake in my 500,000 words — a group of elephants can be called a “herd,” though “parade” is the more technical term.)

For example, tens of millions of people — including some of your own employees, statistically speaking, and also including me — rely on medicinal sleep aids nightly. There are so many things employees need to know about those pills that the sleeping-pill entry in Quizzify’s “Six Things Employees Should Know About…” blog series contains seven things.

Here are a few tidbits on the most popular sleep aid:

  1. 115 OTC drugs, typically the ones labeled with a seemingly harmless “PM” on a well-known brand, like “Advil PM” or “Tylenol PM” or “ZZZ-Quil,” contain benadryl;
  2. Nightly use of benadryl is pretty clearly linked to dementia. That doesn’t mean regular users will get it, just that their odds go up;
  3. Nightly use of benadryl also creates a dependence (a “dependence” is like “addiction-light”), just like other sleeping pills, but because these drugs don’t look like sleeping pills, employees aren’t aware of this risk.

There is probably no point in saying this, since I find whenever I offer advice to wellness vendors they tend to double down on the opposite. Nonetheless, here goes:  please urge your wellness vendor to start focusing on useful advice. Yes, we get it about the broccoli.


Here is the link.

 

 

 

New research: Why wellness programs make some employees fatter

All this time, I just thought that:

  1. employees got worse in wellness programs because
  2. wellness vendors, especially their CEOs, are stupid. (“In wellness, stupid is the new broccoli.”)

Here’s an example that would seem to fit the hypothesis like a glove:

  1. Wellsteps caused employee health to seriously deteriorate and
  2. their CEO needed to spend “11 years in college.” That’s four more than Bluto Blutarski (though I think Mr. Aldana did at least manage to graduate, possibly without even throwing up on the dean). Yet when he accused award-winning health writer Sharon Begley of dishonesty because she quoted Wellsteps’ outcomes report verbatim, he called her a “lier.”

So I put two and two together and thought: “stupid vendor equals program failure.” Turns out it’s much more complex than that.


A study published in Frontiers in Psychology examined the relationship between weight and wellness programs, with three studies, summarized here in their own words.

The present research focuses on a downside of workplace health promotion programs that to date has not been examined before, namely the possibility that they, due to a focus on individual responsibility for one’s health, inadvertently facilitate stigmatization and discrimination of people with overweight in the workplace.

    • Study 1 shows that the presence of workplace health promotion programs is associated with increased attributions of weight controllability.
    • Study 2 experimentally demonstrates that workplace health promotion programs emphasizing individual rather than organizational responsibility elicit weight stigma.
    • Study 3, which was pre-registered, showed that workplace health promotion programs emphasizing individual responsibility induced weight-based discrimination in the context of promotion decisions in the workplace. Moreover, focusing on people with obesity who frequently experience weight stigma and discrimination,
    • Study 3 also showed that workplace health promotion programs highlighting individual responsibility induced employees with obesity to feel individually responsible for their health, but at the same time made them perceive weight as less controllable.

Together, our research identifies workplace health promotion programs as potent catalysts of weight stigma and weight-based discrimination, especially when they emphasize individual responsibility for health outcomes.

This explains an awful lot. First and most obviously, why people gained weight in the award-winning Wellsteps, McKesson, and Vitality programs. In wellness, I observed three years ago, “fat-shaming is the new black.”

Second, it explains the futility of one of the two positive (albeit trivial) findings in the recent BJ’s Wholesale Club study — that more employees will “watch their weight.” Study 3 suggests that’s a bug, not a feature.

Third, it explains the harms being visited upon people who already have eating disorders. Especially because Ron says employees should weigh themselves daily, which naturally is the opposite of what the science says and is downright dangerous for people with eating disorders.

Finally, it explains why Ron Goetzel will be spending his entire life trying to turn lead into gold (or in his case, claiming he already has, by giving Koop Awards to a bunch of failed programs which he calls successes). Sustained weight loss as a result of wellness programs stigmatizing obesity has never happened in the past, and there is no possibility — none, zero — that workplaces trying to coax, cajole, bribe, fine, or shame employees into losing weight will ever be successful in the future.

No wonder virtually every single wellness program fails.

 

Wellness: It’s time to believe the research, not the “experts.”

In case you missed it, turns out that the last 11 wellness studies have all come to basically the same conclusion. This is the intro to Employee Benefit News listing them and linking to them.

And if anyone still thinks overscreening programs have merit, here is a complete expose from 2017 on “pry, poke and prod.” It’s pretty extensive so clear your calendar.

 


The highly-publicized, randomized control trial of the wellness program at BJ’s Wholesale Club published recently in the Journal of the American Medical Association found virtually no value in the program.

While most pundits applauded the study, wellness vendors — whose livelihoods, of course, depend on believing the opposite — attacked it. Two common threads among the attacks, including one right here in Employee Benefit News, were that the program was bad (“anachronistic” in this case) and that one can’t draw conclusions from one study. The specific argument: “Recent research has disappointingly focused on a single — typically anachronistic — program to make sweeping statements on wellness programs more broadly.”

Far from being anachronistic, the JAMA study was as mainstream as studies get — screenings, risk assessments, coaching, learning modules. This is what wellness has been all about. True, there are a few new things today — like employee health literacy education — which is my own business, but they are too early in the life cycle to be evaluated.

And far from being a one-off, this study’s finding of zero impact was completely consistent with the previous 11 (eleven) published studies for which data was provided. Let’s review those studies…

Read the rest of the article here.


Note: someone might say: “that doesn’t add up to 11.” There are plenty of others. My favorite is the self-immolation published by the Health Enhancement Research Organization in 2015.  Very stable geniuses that they are, they didn’t actually realize they showed wellness losing money until I pointed it out.

First, Mr. Goetzel claimed that he had never seen this study before (even though it was the centerpiece of his own organization’s guidebook) and that the data was fabricated (not sure how he knew that if he hadn’t seen it). When that defense was outed, he started vigorously defending the study, his principal defense being that HERO didn’t intend for costs to be compared with benefits.

Further, my suggestion that the costs should be compared to benefits was “mischievous,” according to Ron. That much I’ll gladly agree with…

Link to Employee Benefit News article.

Ron Goetzel meets Jethro Tull

We’ll go walking out
While others shout of war’s disaster
Oh, we won’t give in
Let’s go living in the past


A delegation from the Validation Institute attending the World Health Care Congress time-traveled over to the US Chamber of Commerce Monday to watch Ron Goetzel and a few acolytes try to re-create the shiny new wellness object from the 1980s. Just like in the 1980s, the theme was, and these are the exact words of one of the speakers: “Why aren’t more employers seeing the value in wellness?”

Um, because there isn’t any? 7 years after I first proved, and guaranteed, that none of this “pry, poke and prod” nonsense could possibly add up, the evidence has finally caught up with the conclusion.

Of course, there is value in wellness done for employees, rather than to employees. And far be it from me to discourage anyone from being screened according to guidelines.  But that’s not what the US Chamber is all about. The US Chamber is about pressuring the EEOC into restoring the punitive “voluntary” wellness penalties that a federal judge put the kibosh on in December 2017, effective this year.

The irony is, the Chamber is its own worst enemy. If the EEOC ever got hold of a recording of that session, it would constitute an irrefutable argument for the EEOC not to change the rules. The speakers other than Ron were all about improving employee well-being through autonomy, independence, responsibility for projects from beginning to end, and creating a culture of health.  All those are worthy goals. Goals which, more than coincidentally, have nothing to do with screening the stuffing out of the workforce and penalizing employees 30% for not losing weight. (Shame on Oprah Winfrey!) Quite the contrary, any organization trying to achieve those goals would never dream of manhandling their employees like that.


Ron Goetzel: Katherine Baicker is living in the past

If a fortune-teller had predicted the following as recently as three weeks ago, I would have demanded a refund: Ron Goetzel dissed Katherine Baicker., Specifically, he accused Professors Baicker and Song, along with BJ’s and their vendor, of “doing a program out of the 1980s,” saying that their outstanding study could safely be ignored. (These are the same 1980s in which wellness, according to its promoters, couldn’t fail.)

What horrible 1980s elements did the BJ’s program have? Coaching, screening, learning “modules” and HRAs. Of course, no one has included those things in a wellness program for at least 30 years. (not)

Curiously, Ron didn’t have any issue at all with Baicker’s original 2010 “Workplace Wellness Can Generate Savings” article, which was chock full of programs literally from the 1980s. Only 2 of the programs analyzed in that study were conducted in the 21st century.

If that fortune-teller had also predicted that Ron would start telling the truth someday, I would have demanded double my money back. But no fortune-teller would ever predict that. Fortune-telling industry malpractice insurers will no longer cover lawsuits arising out of that prediction.

And for good reason. It’s generally a safe bet, given Mr. Goetzel’s tenuous grasp on integrity, that he’s going to misrepresent something. Yesterday, as is his wont, he deliberately misrepresented the position of The Incidental Economist (TIE) on the subject of wellness. He quoted TIE as saying that wellness “usually” doesn’t save money. (As a sidebar, I’d note that it is a bit of a head-scratcher that even the misrepresented TIE position makes Goetzel’s position look bad.)

Perhaps I need new glasses, but  I can’t seem to find the word “usually” in the most recent TIE article on wellness savings:

We’ve said it before, many times and in many ways: workplace wellness programs don’t save money.

There’s another reason Ron doesn’t quote TIE, which is they completely dissed him and his Koop Award friends in that article. Totally worth a read.


What does a Goetzel program look like?

According to Ron, only 100 programs work and thousands fail. (“That’s not an industry,” I observed in our debate. “That’s a lottery.”)

So how do you succeed? How do you avoid programs “from the 1980s”? Maybe you avoid that by using a vendor where Ron has a “strong working relationship,” like Vitality. And just to be on the safe side, maybe you report only the results from Vitality’s own program for Vitality’s own employees. That way you can’t fail…

…and yet fail they did…

Even with the investigator bias and self-selection and “home court advantage,” Vitality employees got 2% fatter and their eating habits got worse after being coached.

Although maybe that counts as a success in the wellness industry, because employees weren’t too badly harmed, as they are in a typical Koop-Award winning program. Congratulations to Mr. Goetzel!

 

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