In the wellness industry, 2018 is ending just like it began: Vendors Behaving Stupidly.

Along with about 12 other need-a-lifers, we traditionally attend a “Nerd-a-Thon” on New Years Eve (tonight), where we play board games, including home Jeopardy. One Jeopardy answer might be:

A: “Roughly 3 seconds.”

The correction question would be:

Q: “What is the length of time required for a beam of light leaving intelligence to reach Interactive Health?”

Yes, Interactive Health is ending the year just as they began it, by setting new standards for cluelessness. They started the year by offering unsuspecting and no doubt somewhat befuddled employees a “smoking recession program,” and are ending it by proving that their 2017 and 2018 Deplorables Awards were well-earned.

Here is their posting:

Let’s look at it carefully. They crammed four mistakes/fallacies, plus a unique hashtag (#HealthareCosts) into two lines. First, anemia is not “33% more likely” among women under 45. To the contrary, if they had wanted to step out of character and make an actual true statement, it would have been pretty much the opposite: “Women 15 to 40 are 26% less likely to be anemic than women 40 to 69.”

Perhaps this information will come as much of a surprise to them as it did to me — the difference of course being that I didn’t just post the opposite to 12,162 chronically misinformed followers.

There is an asterisk in case anyone is keeping score at home — pregnant women of any age are at higher risk for anemia. That is the most clinically significant factoid about anemia in the working-age population, a factoid which naturally Interactive Health overlooked. One of their specialties is finding issues that don’t exist while overlooking issues that do. Another one of their specialties is posting random statistics on Linkedin that even a college intern could debunk.  Or hyperventilating that the number of cases of Alzheimer’s is expected to double by 2060 without mentioning that the senior population as a whole is expected to double by that year as well. They also claimed that there was a dramatic increase in heart attacks, but in reality the actual rate is about half what it was 40 years ago.

Another possibility is that this anemia data isn’t a surprise at all to them. They are aware of it (it is pretty easy to come by), but telling the truth would have undermined their new revenue enhancement strategy, which is to convince companies to screen the stuffing out of millennials, by “debunking” the “commonly held misperception” that you should adhere to well-resesarched, widely accepted, official US Preventive Services Task Force (USPSTF) clinical guidelines, guidelines which say, unsurprisingly, that you should definitely not screen the stuffing out of millennials.

Second, it doesn’t cost $10,000/year to treat iron-deficiency anemia. It costs about 5-10 cents a day, or $36.50 a year. So Interactive Health is off by a factor of 300. That’s a lot even for them.

Oh, wait, maybe they were talking about hospitalizations for anemia, not garden-variety anemia. Hospitalizations would cost $10,000 or more. However, in the immortal word of the great philosopher Rick Perry, Oops. Looks like young women have far fewer hospitalizations than older women:

To help Interactive Health interpret this data since apparently they could use some assistance, 32.1 admissions per 100,000 women 18 to 44 means 0.3 admissions per 1000 female employees in that age bracket.

In other words, nobody.  The average company with 20,000 to 40,000 total employees of normal age and gender distribution would probably have 1 admission for anemia.

And we would bet that whoever is hospitalized for anemia already knew they had anemia before Interactive Health started harassing them. My guess is most of these admission longshots would be either complications of pregnancy or anemia of unknown origin, or a rare disease.

Third — no surprise given that statistic — the USPSTF does not recommend lining up women to be screened for iron-deficiency anemia. (Even for pregnant women, who are at much higher risk than non-pregnant women, they find insufficient evidence to screen them.)   “Hunting for disease,” which my colleague Alan Cassels has written extensively about, is rarely a good idea, and this is no exception — which is one reason it isn’t recommended.

Finally, why screen for something that you can’t easily address if someone fails the screen? The other reason it isn’t recommended is that iron supplements for women who are technically anemic but have no symptoms also aren’t a good idea.  Liquid iron, like this…

…can, among its many other charming attributes, blacken your teeth. (The good news is that, as the label says, this supplement is gluten-free!) Iron supplementation in general can cause side effects like nausea, vomiting, and diarrhea, while high doses are so downright dangerous that iron pill overdoses are the #2 reason for emergency room visits among all vitamin and mineral supplements.

The good news is, here is another Jeopardy A&Q:

A: “High.”

Q: “What is the likelihood that in 2019 Congress is going to pass a law preventing vendors from penalizing employees who refuse to participate in non-USPSTF-recommended wellness screens like Interactive Health’s?”

Wellness vendors love to brag about the number of sick employees they find through their screenings. Screening employees against their will, overdiagnosing them, then bragging about how many of them are sick is called “hyperdiagnosis.” Most of those “newly discovered conditions,” to use Interactive Health’s phrasing, are false positives.

No surprise here, given they perform about 40 tests. Doctors, as it turns out, don’t understand how to interpret lab results. If doctors — with four years of pre-med math and science requirements, four years of medical school, and likely four more years of residency – can’t do this, it is a very safe bet that unlicensed, unregulated, unsupervised wellness vendors would demonstrate even less ability to distinguish false positives from true ones. We’re talking about outfits that can’t even distinguish the words “cessation” and “recession.”

And speaking of not being able to distinguish things, if you haven’t already done so, take the Interactive Health IQ Test.

Here is another quiz: what is wrong with this list of vaccinations from Star Wellness:

Yet another quiz, from Cerner:

This one might be a little harder, since Cerner was so oblivious that they put this screenshot right on their brochure. This person’s blood pressure is 110/85, which Cerner says is “in the moderate risk category of pre-hypertension.” They overlooked the ever-so-slight detail that the “pulse pressure” of this unfortunate employee is only 25, a level typically found only in ICU patients with DNR orders.  More likely, Cerner’s employee simply didn’t take the reading correctly, and no one at Cerner knew enough about blood pressure to realize the error before the brochure went to press.

…And yet we are trusting this industry — whose ethical and competence lapses consume 50 pages in the leading law-medicine journal — to interpret our lab results?

These examples illustrate two realms in which wellness vendors can mess up. The first is in the actual testing, as with Cerner. The second in the interpretation, as with Interactive Health. Star Wellness is in a league of its own, having outstupided virtually every other vendor in wellness, which is stiff competition indeed.

Lab test science for dummies and smarties

Scientific error is largely but not entirely based on the innate inaccuracy of finger-pricks. Wellness vendors like to tout these fairly painless blood draws because they don’t scare employees away, hence creating more revenue potential. However, finger pricks are somewhat unreliable. First, there isn’t a lot of blood to begin with. Measuring multiple blood values requires diluting the specimens so that each reagent has enough to work with. And it’s Labs 101 that every manipulation of the blood – dilution being a prime example — increases the potential for error.

Another “manipulation” is the very fact of pushing the blood through the skin. This can contaminate the blood, and also causes something called hemolysis, the rupture of red blood cells.  Hemolysis can seriously skew results for many blood values. And yet it’s extremely doubtful that your vendor has figured out how to mitigate hemolysis, largely because they’ve never heard of it. Test this hypothesis simply by asking a vendor how they mitigate hemolysis in a finger-stick test.

Don’t be surprised if you get a non-answer. Remember, wellness vendors are not trained in screening–or in anything else for that matter. One of the attractions of becoming a wellness vendor is no one is tasked with educating, licensing, regulating or supervising you in any way.  Becoming a wellness vendor is the healthcare industry equivalent of applying for a zero doc loan, except with a lower chance of being turned down.

Venipuncture is more accurate than finger-sticks, but even so, the level of training that wellness vendors receive – as little as five days, provided you have a background in “municipality administration, finance or sales” – does not inspire confidence that they will get this right.  Many variables are involved, in collection, handling, storage, transport and interpretation of the specimens.  Each sample is like a little lab experiment, one that’s been repeated many times and has a standard protocol, but is not a pure algorithm. Technique, time of day, employee activity and diet before the test, elapsed time between collection and analysis, and even ambient temperature during transport influence the outcome.

Lab test arithmetic for Interactive Health and smarties

Nonetheless, let’s give the vendors the benefit of the doubt and assume their tests are 90% accurate, because in all fairness, most finger-stick tests don’t purport to measure values that specifically involve red blood cells. Glucose is one such accurate-enough test – assuming the employee has really fasted.

Yet accurate or not, glucose is one of the least cost-effective blood values to measure. An employee in the lower part of the diabetic range now (meaning most of them) wouldn’t crash for years no matter what you do. Sure, you can find them, treat them, and get them to check their glucose daily, but it’s doubtful you’ll change anything other than how much money you spend on preventing a complication or hospital admission likely not to occur until after retirement. (Annually, only about 1 in 1000 <65 insured people end up with the hospital with a primary diagnosis of diabetes.) It also turns out that for the vast majority of diabetics (those who are not insulin-dependent), daily glucose testing is a waste of time and money.

And do you really want employees to obsess with keeping their blood sugar down? Does it increase productivity if employees have low blood sugar?

But at least the science of the glucose test itself is accurate enough, assuming the employee has fasted and assuming you retest several times before coming to a conclusion. Let’s look at some predictive tests (including mammograms) whose accuracy is more like the mainstream 90% and see what happens when you apply lab test math in those circumstances. Heart attacks are the best example. If you, as an employer, could predict and prevent a heart attack, that would be cost-effective…or would it?

Maybe 2 in every 1000 employees will have a heart attack next year. Of those, at least 1, if not more, fit one of the following descriptions:

• already have a known CAD diagnosis, diabetes, or metabolic syndrome (and hence screening won’t yield any new insights) or
• are among the many people whose heart attacks are completely unpredictable from a standard blood test.

Optimistically, then, you’re looking at a 1-in-1000 chance of actually finding someone this year who would otherwise not be found and would have a heart attack unless it is predicted and prevented. It doesn’t help your accuracy that the Genetic Information Nondiscrimination Act does not allow inquiries about family history, which is a very major risk factor.

Let’s further assume that — highly optimistically and despite not being able to inquire about family history — the cardiac tests that a wellness vendor runs on an employee can predict a heart attack with 90% accuracy. Anyone who could predict heart attacks with 90% accuracy would win a Nobel Prize, so this is a very generous assumption.

Watch what happens when that 90%-accurate test is performed on a population of 1000 employees. First, the good news: there is indeed a 90% chance that the employee who would infarct can be found. That’s 1 positive. Next, the bad news. A 90%-accurate test is also 10% inaccurate, which means about 99 of the other 999 employees will have a phantom heart attack “predicted.” We can send this Excel spreadsheet on request:

100 employees in total will test positive. 99 of those will be false. And yet all 100 will be sent to the doctor, and likely given a barrage of further tests and possible stents. Lab test arithmetic explains why it costs about $1-million for an employer to prevent a heart attack assuming it can be prevented at all.

What does this mean for employers and employees?

Simple: testing decisions should be left to employees and their doctors. Employers should not play doctor with their employees.

Overtesting creates overdiagnosis, which in turn requires overspending on overtreatment. Example: A bank sent its top executives to a hospital for testing. The 16 executives tested were informed of a total of 18 new diagnosis, in addition to diagnoses they already had. The bank spokesman admitted “it’s still too early to see savings,” while the hospital spokesman candidly admitted that this executive screening program “offers another source of income” to the hospital.

Next is one of the wackier ideas to come down the pike, the celebrity-fueled myth that employees should get tested for ovarian cancer. This test doesn’t approach any baseline level of accuracy, so the USPSTF rates it a D.

Even the wellness vendor that advertises it the most, Star Wellness, admits it is “notoriously difficult to detect in its early stages.”  Insurance won’t pay for the test, and as Star says, it is “not readily available from doctors.” Perhaps there might be a reason for that?

It also means that you shouldn’t encourage mammograms for the <50 population, following USPSTF guidelines. That decision can be between them and their doctors. Mammograms in younger women are notorious for generating false positives.  In one well-regarded study, of 2100 women screened for 11 years starting at age 45, 690 received a false-positive along the way, and 75 underwent an unnecessary biopsy.

On the other hand, you don’t want to discourage mammograms, on the off-chance that an employee really does have cancer. Staying out of a conversation in which you have no expertise is the best idea.

Another good rule of thumb in these situations is, look at what Interactive Health does…and then do the opposite. This is their result from testing the generally healthy population of young employees, testing them for 40 things, 39 of which (except blood pressure) are not recommended for young employees due to the preponderance of false positives. So their rate of positives is not much lower than their 45% rate overall.

They are, of course, fully aware that most of their positives are false. I know this for two reasons.

1. Here is a list (scroll down) of the top 25 hospitalizations for people insured by employers, in order. Obviously, if 38% or 45% or whatever huge percent really had these “newly discovered conditions” and the employer didn’t discover them, they’d crash, right?  Do you see anything on here that could have been “discovered” and prevented by a wellness vendor?
2. They also follow my postings, where I have made this quite clear, Exhibit A being this one. And as Confucius said: “If you don’t correct a mistake after it is pointed out, you are creating a lie.”In that case, Interactive Health’s “mistakes” could make a White House correspondent blush.

Update October 30

Yes, Interactive Health is that stupid.

A long-since forgotten essay on the history of hospitals by Lewis Thomas includes the story of a doctor who claimed he could diagnose typhus by examining inpatients’ tongues. He would examine their tongue…and a few days later they would indeed develop typhus. Turned out the doctor was spreading the typhus pathogen by feeling all the patients’ tongues without washing his hands.

Keep this anecdote in mind as you read the following.

Seems like I’m not the only one to show that Interactive Health’s numbers never, ever, ever, ever add up. And it looks like you don’t have to have taught economics at Harvard to do it, or even be old enough to rent a car. Rather, a triple-digit IQ is all it takes. Tom Rosenbaum, a “data analytics intern” at AP Benefit Advisors in Maryland, completely invalidated one of Interactive Health’s more headscratching claims.

By way of background, Interactive Health’s strategy is to convince HR departments that their company is simply overrun with ridiculously unhealthy employees whose medical spending will explode at some point in the future…and send almost half of the employee population to the doctor to allegedly prevent that from happening. That, of course, requires screening the stuffing out of them today, at considerable expense.

I’ve asked them repeatedly on Linkedin to please explain:

1. how the US Preventive Services Task Force can be so misinformed about so many Interactive Health screens being so inappropriate and
2. how their own panel of 43(!) tests is clinically proven to somehow save money by increasing (not a misprint) the number of employees who think they are sick, and the corresponding number of doctor visits.

Their “response” is invariably to delete my comments. Here is one example:

Quite the contrary to “the impact of heart disease growing by the minute,” heart health is actually, shockingly, one of the major public health/medicine success stories of our generation.  Deaths due to heart disease, and heart attacks themselves, are down by about 2/3 since 1969. I merely tried to inform their posting with a fact, but by the time you see their posting, facts will have been deleted. [Update: they already are deleted, along with many supportive comments I received on this posting. Usually they delete my comments within minutes, so I’ve started posting them at night so they can stay up for a few hours.]

Enter Tom Rosenbaum

Their new revenue-maximization strategy is to tell employers it’s not just older employees they need to worry about. It’s younger employees too.  And it’s not just medical issues that plague the younger workforce. It’s also mental health issues. Their specific language:

Workers under 35 are more likely to struggle with mental health issues, such as stress, depression and anxiety.

Tom decided to fact-check this particular item using actual data. It turned out:

• 5.39% of older workers had claims for these mental health items, vs. 5.33% of younger workers
• Older workers spent 32% more on antidepressants than younger workers

This insight got him into Employee Benefit Adviser as likely the youngest person ever to author a column for them. And the second-youngest person ever to get mentioned in They Said What.

Of course, it is possible that Interactive Health’s data is different than everyone else’s, and here’s why. According to their White Paper:

Here’s perhaps the reason why their customers’ employee stress levels are so much higher than average. If someone tells you that you have a “condition” and you “should be directed to a doctor,” you’d be stressed out too.

Something very similar happened to me when I let Interactive Health fiddle with my calves and tell me they were tight and could cause problems — one went into spasm shortly afterwards.

Luckily I didn’t let them anywhere near my tongue.