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If you listen to the Centers for Disease Control and Prevention (CDC), you would think chronic disease is the main health problem we face, and workplace wellness is the main weapon we have to face it with. I know what you’re thinking (at least for the former): isn’t it?
Nope. The country’s main health problem — at least among those addressable by the CDC as opposed to by Congress — is something else altogether, essentially the opposite of what the Wellness Ignorati say it is. But before we reveal the answer, let’s review the CDC’s chronic disease talking points, which naturally are hilarious, as most talking points in support of wellness tend to be.
First, in the screenshot below, they quote the “arresting” statistic that “7 out of 10 deaths are due to chronic disease.” Um, that is called civilization, folks. Countries where 7 out of 10 deaths are due to causes other than chronic disease would love to have this arresting statistic. In case anyone doesn’t believe that the CDC — or indeed, that any human being other than a wellness vendor — could possibly be so stupid as to think civilization is a problem that needs solving, here is the screenshot, and here is the link.
Second, they recently bumped the “75% of costs are due to chronic disease” urban legend in the first line of the screenshot to a mind-boggling 86%. Surely even the dumbest CDC employee can’t believe this. Surely they can back-of-the-envelope an estimate that birth events, preventive care, and trauma alone account for much more than 14% of spending. Birth events by themselves account for about 16% of all hospital discharges.
Meanwhile, wellness vendors are now flogging those “7 of 10 deaths” and “86% of the nation’s healthcare cost” statistics to lobby Congress for wellness subsidies. Congress had wisely stopped funding one of the CDC’s many wellness boondoggles (Work@Health). That didn’t sit well with the industry, so they are starting a lobbying campaign. Fortunately, if their lobbying prowess is anything like their wellness prowess, the budget deficit is not likely to increase anytime soon. The letter reads:
Here is the real problem
This would all be very amusing, as the CDC and wellness vendors converge on these two statistics like monarch butterflies of innumeracy, except that our health is stake. And that (finally) brings me to the title of this posting.
The Maginot Line, as you might recall, proved about as worthless combating the Nazis as the CDC’s wellness obsession is today in combating the real healthcare problem: a massive explosion in blood-borne infections, or septicemia. While the CDC, wellness vendors, and of course the Health Enhancement Research Organization are all atwitter about diabetes and heart attacks (which none of these people can prevent and whose admissions in combination have been in check in all subpopulations for many years), consider ICD-9 038.9, Septicemia. There were 928,000 inpatient cases in 2013, the last year available.
It’s not just that it’s huge, almost twice as costly as the next most costly ICD9. It’s also exploding:
- has increased almost sevenfold;
- is now the by far the largest single diagnosis code;
- twice as costly as the second-largest…
- …and its growth is accelerating?
More importantly, why doesn’t anyone at the CDC seem to care about pathogens? This is what they are supposed to do–identify pathogens and prevent, contain or eradicate them.
Literally anyone (almost 1 in 300 people annually) could get a cut or injury or infection in the hospital, get septicemia, and, 13% of the time, die. Yet the CDC is blissfully unaware of this. If you’ve heard this “blissfully unaware” song before, the CDC’s Wellness Watchdogs also completely missed the workplace opioid epidemic. That happened right under their noses. The drugs were legal, prescriptions were filled, and PBMs paid for them.
Where was the CDC when this was happening? The same place the wellness industry was: nowhere. Most health risk assessments queried about illegal drug use and alcohol, but abuse of legal opioids? Off the table.
We can’t let the CDC overlook this epidemic too, due to their singularly misguided wellness obsession. We need to embarrass them into action–please send this note around to as many people as possible.
And if you’re wondering how the CDC (with the very notable exception of NIOSH!) has dumbed down so fast, so was I. These were, after all, the people who rid the US of malaria and rid the world of smallpox. So I did a little search on their site.
The first thing I noticed was that their workplace wellness information is “science-based.” That was the giveaway. In wellness, the phrase “science-based” means “not science-based.” To use one example, Wellsteps’ claim that their ROI model is “based on every ROI study ever published.” This translates as: “We made the whole thing up.”
Additionally, the references the CDC relied upon should look familiar. Besides being comprised of the usual serial liars, serial cheaters, and serial idiots, the list of references ends with Katherine Baicker, truly the Typhoid Mary of the workplace wellness epidemic–and hence one of the people most responsible for advising the CDC to create the Maginot Line that failed to prevent or event identify the opioid and bacteria epidemics that have taken millions more lives than workplace wellness has ever saved.
By the way, while you were reading this and the links, 6 to 12 more people (depending on how fast you read) just contracted a hospital-acquired infection, with probably 1 or 2 people dying from it.
To put that in perspective, the comparable statistics for wellness would be that 6 to 12 vendors just lied to their prospects, with 1 or 2 prospects believing them.
“You know that laundry detergent that gets bloodstains out of t-shirts? I’d say if you’re routinely coming home with bloodstains in your t-shirts, laundry probably isn’t your biggest problem.”
Recognize that line? That was Jerry Seinfeld’s signature joke, the one that more than any other propelled his early fame. Having used it for a decade, he retired it shortly after Seinfeld went on the air.
Now it’s time to retire the wellness industry’s signature joke: the so-called Harvard Study and its 3.27-to-1 ROI. Among other things, as we’ll see, a large chunk of the data in that study also predates Seinfeld, a show which recently celebrated its 25th anniversary. You know the old line: “How can you tell a lawyer is lying?” Answer: “His lips move.” Well, the way you can tell a wellness vendor is lying is that they still cite that study, knowing it to be completely invalid. (If they actually think that 3.27-to-1 is valid, in a way that’s even worse.)
The article, which today wouldn’t pass peer review by the normally cautious Health Affairs, was rushed into publication during the healthcare reform debate as a favor to David Cutler, a healthcare advisor to President Obama and an author on the study. Along with the results from the Safeway wellness program — which turned out not to exist (and I’m referring not just to the results but literally to the program itself) — this meta-analysis provided cover for the 30%-to-50% clawback provision (for non-smokers and smokers respectively) in what became ironically known as the Safeway Amendment to the Affordable Care Act.
In turn, this clawback was needed to secure the support of the Business Roundtable (BRT) for the Affordable Care Act. The BRT was and is obsessed with this provision. Not because they are especially concerned about employee health — the guy who ran their wellness lobbying also ran a casino company, exposing thousands of employees to second-hand smoke. Rather, because this clawback provision creates billions in forfeitures that go back into the coffers of its member organizations. Bravo Wellness accidentally spilled that secret. The worse the program, the more an organization can save via forfeitures. For instance, Wellsteps saved millions for the Boise School District even though healthcare spending/person jumped–simply by creating a program so unappealing that employees preferred to obtain insurance through their spouses. (Either that or they outright lied–you make the call.)
How Prof. Baicker Invalidated Her Own Study
The title was definitive and the conclusion was amazingly precise. The title was: “Workplace Wellness Can Generate Savings.” Not “might” or “possibly could on a good day” but “can.” And the conclusion itself left little doubt. The ROI wasn’t “approximately 3-to-1” or even “approximately 3.3-to-1” but rather a statistically precise 3.27-to-1. You don’t make such a definitive pronouncement without being ready to defend it.
Or maybe you do. Here’s how Professor Baicker’s story changed on various occasions once it became clear that her result was a major outlier, and that wellness loses money:
- It’s too early to tell whether these programs pay off, and employers should experiment on their employees;
- She’s not interested in wellness any more;
- People aren’t reading the paper right. They aren’t paying enough attention to the “nuances.” Shame on the readers!
- “There are few studies with reliable data on the costs and the benefits”
This may be unique in healthcare history: writing a paper and then almost immediately retracting its key finding, claiming you have no interest in the topic even as your fans deify you, and then blaming readers for believing the conclusion.
But the biggest head-scratcher is the 4th item. Here is someone who just published a conclusion with two-significant-digit precision now saying (accurately, as we’ll see) that, oh, by the way, the studies she analyzed are mostly garbage. You know the old saying: “In wellness, you don’t have to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself.” She was kind enough to save us the trouble.
When RAND’s Soeren Mattke saw this stuff along with her refusal to defend it, he went ballistic. If you know RAND’s wellness uberguru Soeren Mattke, you know he is a very even-tempered, even-handed guy. it takes a lot to annoy him…and yet she did. Here is his smackdown of her work.
Studies Comprising the Meta-Analysis
If you’ve been following the Baicker saga for a while, none of this is news. Here’s what is news: thanks to a long plane ride with both an internet connection and an assortment of in-flight films I had already seen, I was able to dig into the actual studies. My conclusion: combining these third-rate studies in third-rate journals into a Health Affairs meta-analysis was like combining a hodegpodge of individual subprime mortgages written for first-time homebuyers with 5% downpayments and no credit history into an AAA-rated collateralized mortgage obligation.
In terms of timely relevance, of these 22 studies:
- Only 1 is less than 10 years old (that was Highmark, and they fired their vendor, ShapeUp)
- Only 2 are from the 21st century
- 5 predate Seinfeld
Keep in mind too that the average time between when a study begins and publication is about four years, meaning much of this data was collected before some TheySaidWhat? readers were born. Wellness-sensitive medical events (in both exposed and non-exposed populations of all ages, for reasons having nothing to do with wellness) have fallen by about 70% since most of this data was collected, meaning even if these studies were valid at the time (they weren’t), they have no relevance today. Likewise, dietary recommendations are now the opposite, people can no longer smoke in their offices etc. There is nothing else in healthcare where data on interventions from 20 and 30 years ago is considered relevant.
In terms of publication bias, consider the journals:
- 3 no longer exist
- 11 are wellness promotional journals, like the Journal of Occupational and Environmental Medicine and the American Journal of Health Promotion, both of which have thoroughly discredited themselves as legitimate journals and neither of which has ever published a case study showing negative returns, despite the editor of the latter saying that “90% to 95% of programs lose money” and “RCTs show a negative ROI“
Piling investigator bias on top of author bias, 14 of these studies were authored or co-authored by members of the Koop Award Committee, a committee that can’t spot obviously fabricated outcomes even after I point them out, people whose entire livelihoods depend on making up savings figures, and who endorse admitted liars.
The Actual Data
Every study that used a comparison group employed some variation of the demonstrably invalid participants-vs-non-participants methodology. Not one study was plausibility-tested. Almost every one of them showed savings far in excess of what could be saved if all wellness-sensitive medical events were wiped out.
Quite literally no one thinks savings can be achieved within 18 months, and yet the majority of studies with a comparison group were 18 months or less. All showed massive savings. One study lasted only 6 months, but showed roughly 20% savings nonetheless.
You might ask, how could all that money be saved in such a short period of time? For that answer, you’ll have to wait a couple of days. For Part 2, we will dig into a few of the studies themselves to see where the magic happens…and we do mean “magic”, since nothing else can explain those preternatural results.
Looks like a lot of you employees should be getting your employers to refund your penalties for not losing weight…or retroactively award you your incentives…read on. One way or the other, it’s time to end corporate fat-shaming.
Here is yet another in the unending stream of reasons to be certain all those Koop-award-winning savings claims and just about every other announced wellness savings figure are fabricated: they are all based partially or totally on Body Mass Index (BMI) reductions among active motivated participants — but BMI turns out to be a worthless indicator of health status. (We’ve already pointed out that the whole concept of measuring anything on “active motivated participants” is garbage anyway, as Aetna recently proved by accidentally telling the truth.)
How worthless? A study due out in the International Journal of Obesity says 75-million Americans are misclassified, meaning their BMI doesn’t match their true underlying health status. (As an aside, this scoop comes from this morning’s STAT News, the new must-read healthcare daily.) Many people with high BMIs are healthy, while many people with low BMIs are high-risk. Shocking! Who knew?
Naturally (cue the smirk on our faces), we did. As recently as in last month’s expose of The Vitality Group‘s squirrely outcomes claims, we pointed out that BMI is a 200-year-old construct based on faulty reasoning to begin with — and noted it has been challenged on multiple bases for years. We were also the first to observe that BMIs don’t correlate with a company’s financial success. And our series: “The Belly of the Beast” chronicled one vendor’s misunderstanding of BMIs as well, though I understand they are improving quite a bit now and we wish them the best and look forward to telling you about their improvements.
The implications of this new research are staggering:
- Companies need to refund penalties, and also award incentives retroactively, to people who were unfairly denied their money because wellness vendors don’t know how to measure outcomes;
- The “subject matter experts” who wrote the HERO Report need to retract basically their whole ball of wax, since it obsesses with BMI — and they need to apologize to me for inaccurately calling my claims “inaccurate” when they are specifically and relentlessly urging readers to do the wrong thing;
- Wellness vendors need to learn a thing or two about wellness, for a change.
- And guess who’s 3.27-to-1 ROI was based on studies obsessing with BMI? Kate Baicker, that’s who. Despite multiple hedges and walk-backs, she has yet to issue a formal retraction of her puff-piece on wellness economics. This gives her a good excuse.
Of course, in wellness, “the implications are staggering” means: “business as usual,” and they won’t do a thing to address these new findings.
The EEOC can’t ignore this. How can they give employers more leeway — as they now intend to do — to fine employees based on a variable they now know to be wrong?
Quizzify 1, Wellness Vendors 0
Those of you who use Quizzify don’t have to fret, by the way. The correct answers to the Quizzify question: “What is a BMI?” already include:
- “A crude measure comparing your height and weight,”
- “Can be very misleading if you in otherwise good condition,” and
- “Is good to know but not to obsess with.”
(For those of you keeping score at home, Quizzify’s incorrect answer is: “It stands for ‘Bowel Movement Intensity,’ and indicates how much effort you required in order to stay regular.”)
Even so, we will be adjusting the answers going forward to take into account this new research, starting next week. We expect the wellness ignorati will follow suit in a few years — once they stop advocating lowfat diets, PSA tests, and annual mammograms. The good news is that they generally no longer recommend bloodletting.
Occasionally we have to attend to our Day Jobs and can’t post regularly. Fortunately, we have access to a bolus of posts from mid-2014, the posts that went up on this site initially. There were too many stories to highlight, so we decided to inventory them, in order to fill in gaps when we didn’t have time for new posts.
High on that list would be Staywell. First was their collaboration with Mercer, in which they agreed to tell British Petroleum that they found $17,000/person savings. They knew those savings were mathematically impossible since the average person only spends $6000/year. They also forgot that they themselves had said it was only possible to save $100/person.
Following on the heels of that was a collaboration with the American Heart Association to create screening guidelines that (surprise) call for much more screening than the United States Preventive Services Task Force recommends.
In both cases, we welcomed — and in the latter case offered $1000 honorarium for — responses to our questions, but our good-faith offer was met with silence.
Also, in both articles Staywell continued to cite Katherine Baicker’s study that she herself no longer defends, with the added wrinkle of referring to it as “recent” in the hopes that no one looks at the endnotes and sees that it was submitted for publication in 2009 and covered studies from a decade before that. With any luck they’ll have enough integrity to stop citing that study now that RAND has invalidated it. A good rule of thumb is that anyone who cites Baicker’s study without noting that no one (including Professor Baicker) believes that 3.27-to-1 ROI any more is prima facie deliberately misleading people. It is no longer credible to say one doesn’t know that her study has been shown to be hooey and that she is no longer defending it (and actually says she has no more interest in wellness).
We recommend click-throughs to both studies. Each raises questions that Staywell refused to answer, after initial conversations which confirmed they knew about these issues. You’ll also see how the American Heart Association was shocked, shocked, that anyone would question their integrity (perhaps they haven’t read The Big Fat Surprise) but then let it go, rather than create a news cycle.
Staywell also helped give British Petroleum a Koop Award. Nice to be on the award committee AND be an award sponsor–makes it easy to give your customers awards. With one or two exceptions, we can’t remember the last time the Koop Award went to a company with no connection to a sponsor or committee member. Perhaps someone could let us know?