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The Wellness Industry’s Terrible, Horrible, No-Good, Very Bad Year just got worse. Seems like CMS (Medicare) and Modern Healthcare are also ganging up on the Health Enhancement Research Organization (HERO) and all their cronies.
The headline in today’s Modern Heathcare turns out to be a bit of an understatement:
Wellness programs aren’t generating Medicare savings
Read farther the article and you’ll come up with gems like:
Utiization and expenditures actually increased among program participants… The results mirror those in the corporate world.
Asked for comment, the National Business Group on Health’s very stable spokesgenius, Steve Wojcik, said:
So, while it didn’t reduce healthcare expense or utilization, it seems to have had a positive impact…by preventing or delaying normal deterioration that comes with age.
Where Mr. Wojcik came up with this spin, creative even by wellness industry standards, is anyone’s guess. Nothing in the program suggests it and when he finds something that does prevent age-related decline, I will be the first to nominate him for a Nobel Prize.
The curious thing is this failed approach is not “wellness or else” as Jon Robison calls it. Instead these programs are truly voluntary. Also unlike corporate wellness programs, vendors aren’t harassing healthy employees to eat more broccoli but rather focusing on unhealthy ones. Instead of making healthy 30-year-olds get unneeded checkups, they’re encouraging 70-year-olds with chronic disease to get more medical care.
And yet the programs still don’t work. Color me surprised. I genuinely thought (and I honestly still think) that willing participants in voluntary programs who have chronic disease would benefit from these programs. Perhaps when they re-review another year’s data they will find a benefit.
Alternatively, instead of trying to maintain the revenue streams of their members, perhaps HERO could actually try to find a new model that does provide a benefit. Certainly there are plenty of vendors out there with possibly better mousetraps, but they all have one thing in common: they have no use for HERO’s pet vendors, any more than companies that make solar panels have a use for coal.
Speaking of HERO, let us review HERO’s comments from just last week:
Teddy Roosevelt said, “complaining about a problem without posing a solution is called whining.” It’s a quote that also reminds me why I’ve not thought of angry bloggers who target health promotion [vendors] as bullies. Though they relish trolling for bad apples, their scolding is toothless, more the stuff of chronic whiners.
Not to mention:
We’re fortunate to work in a profession with a scant number of vociferous critics. My take is that there is one thing these few angry loners want more desperately than attention: that’s to be taken seriously.
Just like wellness vendors like to define “voluntary” as “forced,” I guess in wellness-speak “scant number of vociferous critics and chronic whiners” mean “every commentator,” and an “angry blogger” is any blogger with a great big smile on his face.
OK, this time I’m not the one causing the kerfluffle in the wellness industry, though I will confess to being a force multiplier.
Not since 2014, when the very unstable morons at the Incidental Economist made fun of the very stable geniuses who give out the Koop Award and also unequivocally concluded wellness loses money — combined with continued fallout from the Penn State debacle and the Nebraska scandal — has the wellness industry had such a bad year. And it’s only February.
Let’s review what’s happened so far in 2018. First, a federal judge ruled that voluntary wellness programs need to be — get ready — voluntary. The EEOC’s responded with the legalese equivalent of: “Fine, be that way.”
Next, WillisTowersWatson did something that might get them in hot water with the very stable wellness industry leaders: they were honest. They published a study revealing that employees hate wellness even more — way more — than they hate waiting for the cable guy to show up.
Finally, the very unstable National Bureau of Economic Research conducted a controlled study finding basically no impact whatsoever of a wellness program. More importantly, they specifically invalidated the “pre-post” methodology. Even more importantly, they specifically invalidated 78% of the studies used in Kate Baicker’s “Harvard Study” meta-analysis.
Here is an interesting piece of trivia. The lead researcher is an assistant professor at the Harris School of Public Policy. Why is this interesting trivia? Because Katherine Baicker — the Typhoid Mary of Wellness, whose THC-infused 3.27-to-1 ROI is the basis for essentially every subsequent genius wellness outcomes claim — is now the dean of that very same Harris School. I’m just guessing here, but I’d say it’s gotta be a trifle embarrassing when your own subordinate publicly disproves your own study. I mean, it’s one thing for me, RAND, Bloomberg, and anyone else with five minutes, internet access and a calculator to do it, but…your very subordinate?
On the other hand, the researcher, Damon Jones, just demonstrated not just amazing competence, but amazing integrity as well. In other words, he has no future in wellness.
The Wellness Empire Strikes Back
How does the wellness industry respond to these smoking guns threatening their entire revenue stream? Apparently, there is little cause for concern on their planet.
Let’s start with America’s Health Insurance Plans (AHIP), the health insurance industry lobbying group. Here is AHIP’s oxymoronic Wellness Smartbrief (January 26), on the NBER research. Yes, it summarizes the same wellness-emasculating study as the one above, though you could never guess it from the headline:
Continuing, AHIP said:
Offering incentives for completing wellness activities might be more cost-effective than offering incentives for wellness screening, a recent study of a comprehensive program found.
Perhaps AHIP has been infiltrated by Russian trolls, because here’s what the NBER article actually said about “completing wellness activities”:
We…do not find any effect of treatment on the number of visits to campus gym facilities or on the probability of participating in a popular annual community running event, two health behaviors that are relatively simple for a motivated employee to change over the course of one year.
Wellness programs might attract mostly employees who are already fitness-conscious, but the potential to attract healthy employees whose medical spending is already low could nonetheless be a boon to employers, the researchers found.
And on the subject of “the potential to attract healthy employees” being a “boon to employers,” the authors actually said:
We further find that selection into wellness programs is associated with both lower average spending and healthier behaviors prior to the beginning of the study. Thus, one motivation for a firm to adopt a wellness program is its potential to screen for workers with low medical spending. Considering only health care costs, reducing the share of non-participating (high-spending) employees by just 4.5 percentage points would suffice to cover the costs of our wellness program intervention.
In other words, you can apply some workplace eugenics to your company by using wellness to weed out obese employees, employees with chronic or congenital diseases, and so on. Good for you!
Soon, if AHIP and others have their way, there will be no need for guesswork in eugenics: employer wellness programs will be able to screen these employees out based on their actual DNA.
AHIP’s take on AARP v. EEOC
And now, AHIP’s take on this landmark case, their ace reporters scooping everyone with this February 2 headline on the December 20th court ruling:
Here are more typical headlines on that court ruling, headlines that came out the same month that the court ruling came out. Perhaps AHIP used the interim six weeks to focus-group various verbs until they settled on…tweak???
AHIP: It’s not just the headlines
One prominent healthcare executive recently attended an AHIP conference and reports:
I just returned from one of the dumbest meetings I’ve ever attended in Washington. Report of a new “study” by AHIP. Turns out people don’t mind health costs all that much, they just want more benefits. And everything is hunky-dory with their health plans, people like them so much. They love wellness benefits and crave more. Prescription drug prices have been nicely controlled thanks to the competitive marketplace (no, I am not making this up or exaggerating for drama). For every $1 employers spend on benefits workers get $4 in value. Priorities for SHRM rep: Fitbits for all employees, solving the outrage that only 20% of her employees got an annual physical. 85 cents of every dollar spent on health care goes to chronic disease.
Over these same two hours, I’d estimate about a thousand employees were misinformed, harmed or harassed by wellness vendors, roughly equal numbers of employees got useless annual checkups, employers spent about $200-million on healthcare and 40 people died in hospitals from preventable errors. But I’m being such a Debbie Downer! I’m going home to read Why Nobody Believes the Numbers to remove myself from this alternative universe.
Enter the Health Enhancement Research Organization (HERO)
HERO’s Prevaricator-in-Chief, Paul Terry, is demonstrating his usual leadership abilities in this crisis, of course. After all, HERO is the wellness industry trade association and these three items — the NBER invalidating their product, employees hating their product, and a federal judge forbidding them to force employees to use their product — represent existential threats to his “pry, poke and prod” members.
Teddy Roosevelt said, “complaining about a problem without posing a solution is called whining.” It’s a quote that also reminds me why I’ve not thought of angry bloggers who target health promotion [vendors] as bullies. Though they relish trolling for bad apples, their scolding is toothless, more the stuff of chronic whiners.
I suspect he is talking about me here as the “chronic whiner” who is “scolding” them. Or perhaps he is referring to the “angry bloggers” at the Los Angeles Times, the New York Times, Slate, or STATNews, since those “toothless” publications seem to be scolding wellness vendors more than I ever have. For instance, I’ve never called wellness vendors’ offering a “scam” or a “sham.” I simply quote these very stable wellness geniuses verbatim, as above or below, or last week.
Being quoted verbatim, not angry bloggers, is their worst nightmare. (One thing I would concede, though, is that “Paul Terry and the Angry Bloggers” would be a great name for a rock band.)
Yep, looks like the implosion of his industry all my fault. Otherwise, I’m not quite sure who is the “angry blogger” he is referring to, other than to note that Mr. Terry himself seems to blog a tad angrily himself, both above, and here…
Why I choose to ignore the blogger critics: We’re fortunate to work in a profession with a scant number of vociferous critics. My take is that there is one thing these few angry loners [Editor’s note: the complete “scant list” of the 220 “few angry loners” who have been “vociferous critics” can be found here] want more desperately than attention: that’s to be taken seriously. What they fail to comprehend is that as they’ve gotten ever more farfetched and vitriolic in search of the former, they’ve cinched their inability to attain the latter.
Baiting people with misinformation and offensive insults (but just a tad under highly offensive) is a pesky ploy that trolls hope will eventually land a bite that confers credibility where there is none. Even reading such drivel is a form of taking the bait; responding is swallowing it whole. Some say dishonesty should not go unchallenged and I respect their view; nevertheless, I’m convinced responding to bloggers who show disdain for our field is an utter waste of time. I’ve rarely been persuaded to respond to bloggers, and each time I did it affirmed my worry that, more than a waste, it’s counter-productive.
…and especially here, a seemingly incongruous decision to “act out” by someone who claims to be “choosing to ignore the blogger critics.”
Having read years of my “drivel” alongside Mr. Terry’s posting explaining why you shouldn’t “swallow this bait,” perhaps readers might opine here: which of us, exactly, is the “chronic whiner”?
Coincidentally, when I run live health-and-wellness trivia contests, the first of our 3 rules is: No Whining. Seems to me that he would have just violated it. Indeed the only rule HERO hasn’t violated so far is #3 below. Not that I want to put ideas in their head.
It’s time for the 2017 Deplorables Awards, lovingly bestowed on those vendors who do the best job making other vendors look good.
The good news is that you don’t have to actually win the Deplorables Award to sue me. Runners-up are eligible too. Here is my address for hand-service delivery most of the year:
890 Winter Street #208, Waltham MA 02451
In case you decide to sue me between June 22 and August 8, use:
8 Paddock Circle, Chilmark, MA 02535
And don’t leave out my attorney:
Josh Gardner, GARDNER & ROSENBERG P.C., 33 Mount Vernon Street, Boston, Massachusetts 02108
I don’t know how much more I can do for you, other than lick the envelope. So go for it. Don’t make me beg.
But, remember, unlike your usual business model, in court you are required to actually tell the truth (I would be happy to explain to you how that works), meaning there is no chance of your winning — or likely even avoiding summary judgment, since none of the evidence is in dispute. It’s all your own writings. Oh, and I do my own cross, which means you won’t be able to find an expert witness. Anyone who knows enough about wellness to be an expert witness also knows enough about wellness to know that attempting to defend you would be a humiliating, on-the-record experience.
And there is always the chance that some annoying jerk might blog about it…
The 2017 Runners-Up
Imagine a four-square matrix with competence on one axis and integrity on the other. The people and organizations we’ll be highlighting today would intersect with the companies mentioned in Monday’s posting at only one single point.
Springbuk and Fitbit
As many of you recall, earlier in the year we analyzed the study done by Springbuk that secretly financed by Fitbit. Or maybe I need new glasses, because I just couldn’t find the disclosure in the Springbuk report that this paean to Fitbit was financed by Fitbit, the way Nero used to have the judges award him Olympic medals.
Coincidentally, the study showed Fitbit saving gobs of money because employees taking more than 100 steps a day spend less money than those taking fewer. However, a simple tally of one’s own footsteps shows that it is impossible not to take 100 steps a day unless you are both:
- in a hospital bed; and also
- on dialysis.
This 100 steps-a-day threshold was repeated many times in the study, with no explanation of how that number came to be. However, it turns out we owe these two outfits an apology. Fitbit and Springbuk have told a number of people privately (not publicly, in order to avoid an embarrassing news cycle) that they didn’t really mean to say that 100 steps a day constituted activity. They meant to say that taking 100 steps a day implied you had your Fitbit on. My apologies for failing to read their minds that their conclusions were based on reading people’s minds to determine whether they wore the Fitbit deliberately, or simply forgot/remembered/cared to put their Fitbit on.
They never did explain — privately or publicly or to anyone — how employees who took an average number steps during the baseline year could show huge savings by taking an average number of steps in the study year too.
They also never explained how these two statements didn’t completely contradict each other, even though I specifically asked them to in a personal letter, excerpted here:
Third, can you reconcile this statement…:
“The materials in this document represent the opinion of the authors and not representative of the views of Springbuk, Inc. Springbuk does not certify the information, nor does it guarantee the accuracy and completeness of such information.”
“This demonstration of impact achieved by integrating Fitbit technology into an employee wellness program reinforces our belief in the power of health data and measurement in demonstrating ROI,” said Rod Reasen, co-founder and CEO of Springbuk.
National Business Group on Health
Next up is the National Business Group on Health. Last year they made the list for criticizing the US Preventive Services Task Force for not demanding enough screenings, in a country that is drowning in them. Not content to rest on those laurels, this year they earned an Honorable Mention for inviting Dr. Oz to keynote on the role of quackery in corporate wellness, and perhaps tell us about his latest lose-weight-by-eating-chocolate miracle diet.
HERO of course also earns a runner-up award. 2017 will be remembered as the year they finally came to grips with the realization that a business model based on fabricating outcomes requires that perpetrators possess that critical third IQ digit. Without that extra “1”, an organization trafficking in math that can at best be considered fuzzy is going to be outed.
This year’s set of lies? By way of background, their 2016 poison-pen letter insisted they had fabricated that data set showing that wellness loses money without disclosing that it was fabricated — and also never reviewed their fabricated data before publication. Early in the year, I had the insight that, wow, this “fabricated” Chapter in their guidebook is so much better than the other chapters that something is amiss. No one at HERO can analyze data competently…and yet, here it was, a competent data analysis.
I did something I had never thought to do before, which was look up the actual author of that chapter. It was Iver Juster MD. He was a great analyst even before he read all my books, took all my courses, and achieved all my certifications in Critical Outcomes Report Analysis.
- Whereas Paul Terry and Ron Goetzel had insisted that Iver fabricated the data, Iver said, of course he didn’t — whatever made me think that? (“If it wasn’t real, I would have disclosed that,” he observed. Of course he would have. Iver has tremendous integrity.)
- The Board discussed and reviewed his chapter at length, and made helpful suggestions, for which he was quite grateful. This review process required “countless hours,” just as the HERO document says:
The number of transparent lies HERO tells could make a president blush. In the immortal words of the great philosopher LL Cool J, they lied about the lies they lied about.
Even though 2017 was an off-year for them in terms of the number of lies, they still told enough to be named a runner-up.
Wellness Corporate Solutions
Next is Wellness Corporate Solutions, famous for its crash-dieting contests. WCS now offers a water-drinking contest. The idea is to set up a “challenge” for your team to drink more water than other teams. They call this a “healthy competition.” I guess they didn’t get the memo that forcing yourself to drink when you don’t want to drink, just to make more money, is anything but healthy. Here is a novel idea: drink when you are thirsty. Evolution 1, WCS 0.
Perhaps as an encore, WCS, Dr. Oz and the National Business Group on Health could team up to offer a chocolate-eating contest.
I looked into this outfit to see where they get their ideas. The CEO previously ran something called the Washington Document Service. That qualifies her to run a wellness company. As Star Wellness says, to run a wellness company successfully, your background needs to be in sales, or “municipality administration.” After all, what is more central to administering a municipality than documents?
What fun would a list of runners-up be without Wellsteps, the proud recipient of the 2016 Deplorables Award? While their streams of consciousness weren’t as memorable in 2017 as in 2016 (“It’s fun to get fat. It’s fun to be lazy“), they get credit for trying. Their 2017 weight-loss campaign was headlined: “This campaign is not really about weight loss, it is about helping you apply the behavioral secrets of those who have lost weight.”
So if your kids ever want you to teach them how to ride a bike, say: “It’s not really about riding a bike. It’s about helping you apply the secrets of people who have ridden bikes.”
And what secrets are we talking about? What person who has lost weight doesn’t brag to everyone or even write a book? If there is a secret to weight loss, like eating chocolate, Wellsteps owes it to the country to tell them. Don’t make us beg.
Odds and Ends
No Koop Award winner this year, but an honorable mention to past winners and runners up for their commitment to wellness:
Sounds like in 2018 the logical winners would be Philip Morris, or maybe The Asbestos Corporation of America.
Veering briefly into the public sector, kudos to Representative Virginia Foxx, (R-NC5) for introducing the Required Employee DNA Disclosure Act. Even HERO thought it was a dumb idea…and their threshold for thinking something that increases wellness industry revenues is a dumb idea is quite high, having all rallied behind the Johnson & Johnson Fat Tax, in which companies would be required to disclose the weight of their employees.
Next up…the winner of the 2017 Deplorables Award
As almost everyone in the wellness industry knows, we have offered a $2 million reward to anyone who can show that conventional annual “pry, poke and prod” wellness saves money. I’m feeling very generous today, what with the holidays upon us, so let’s make the reward $3 million.
Even more importantly, let’s loosen the rules — a lot — to encourage applicants. You’ll find the $3 million reward is not just more generous, but also far easier to claim than the previous $2 million reward.
Loosening the Rules
Except as indicated below, the rules stay the same as in the previous posting, but with the following relaxed standards. Most importantly, I’ll now accept the burden of persuasion. It is my job to convince the panel of judges, using the standard civil level of proof, that you are wrong, as opposed to you having to convince them that I am wrong.
Next, let’s expand the pool from which the judges can be drawn. It wasn’t very nice of me to allow you to choose from only the 300 people on Peter Grant’s exclusive healthcare policy listserve, since obviously no one invited into a legitimate healthcare policy listserve thinks wellness saves money.
In addition, you can also choose among the 200+ people on Brian Klepper’s email list and the 70 people on the Ethical Wellness email list. And to make it totally objective, we will add as judges whatever two bloggers happen to be the leading dedicated health services research bloggers at the time of the application for the award, as measured by the ratio of Twitter followers-to-Twitter-following, with a minimum of 15,000 followers.
So judges are chosen as follows: two bloggers chosen by objective formula, plus we each choose six people from among the other 520, with the other party having veto rights for 5 of them. That gives a total of 4 judges, who will choose a fifth from among those roughly 500 people.
This means I only name one of the five judges, so I can’t “stack the deck,” not that I would need to.
The original rules included the requirement of defending Wellsteps’ Koop Award. After all, the best vendor should be exemplary, right? A beacon for others to follow? A benchmark to show what’s possible when the best and brightest make employees happy and healthy?
However, now you have another option. You could instead just publicly acknowledge that the Koop Award committee is corrupt/incompetent, since that possibility cannot be ruled out as a logical explanation for Wellsteps winning that award. Your choice, but, one way or the other, the Wellsteps award must be addressed in your entry.
Next, you may bring as many experts with you to address the adjudication forum (a Washington, DC venue to be chosen later) as you wish to bring. I, on the other hand, will be limited to myself. (The judges may also, by a supermajority of 4 to 1, declare a winner, with no in-person presentation needed.)
Further, you no longer have to defend the proposition that wellness as a whole has saved money. You can, if you prefer, simply acknowledge that most of it has failed…except you. Meaning that, if you are a wellness vendor that has been “profiled” on this site in the last 2 years, you can limit your defense to your own specific results. You don’t have to defend the swamp.
That new loophole allows, specifically, Interactive Health, Fitbit, Wellness Corporate Solutions, and especially Wellsteps to get rich…if what I have said specifically about them is wrong. I have $3 million that says it isn’t.
Special Offer for HERO
Ah, yes, the Health Enhancement Research Organization (HERO). The belly of the beast.
Let me make them a special offer. Paul Terry, the current HERO Prevaricator-in-Chief, has accused me of the following (if you link, you’ll see they had enough sense not to use my name, likely on advice of counsel, given that I already almost sued them after they circulated their poison pen letter to the media):
I’m convinced responding to bloggers who show disdain for our field is an utter waste of time. I’ve rarely been persuaded to respond to bloggers [Editors note, in HERO-speak, “rarely” means “never” — except for that intercepted Zimmerman Telegram-like missive], and each time I did it affirmed my worry that, more than a waste, it’s counter-productive. That’s because they’ll not only incessantly recycle their original misstatements, but worse, they’ll misrepresent your response and use it as fodder for more disinformation.*
Tell ya what, Paul. let’s debate disinformation, including your letter.
I have asked you on multiple occasions to clue me in as to what my alleged disinformation actually is, if any. That way I can publicly apologize and fix it, should I choose to do so. Before applying for this award, you need to disclose this alleged disinformation. You can’t just go around saying my information is made up etc. without specifying what it is.
By definition, “disinformation” is deliberate misrepresentation. To my knowledge, as a member of the “integrity segment” of the wellness industry, I have never, and would never, spread disinformation.
On the other hand, if I did spread inadvertently incorrect information by mistake, it seems only fair to let me fix it — especially given that I have been totally transparent and generous with my time in explaining to you what yours is, and how to correct it. (I might have missed some. Keeping up with yours is a challenge of Whack a Mole-meets-White House press correspondent proportions.)
So perhaps it is time to man up, Mr. Terry. You and your cronies claim to have been collecting my “disinformation” for years, without disclosing any of it. I’m offering you a public forum and $3-million to present it…with only one of 5 judges on “my” side.
Otherwise, perhaps you should, in the immortal word(s) of the great philosopher Moe Howard, shaddap.
*As a side note, Mr. Terry writes: “We’re fortunate to work in an industry with a scant number of vociferous critics.” This “scant” number appears to include the entire media — left-wing, right-wing, centrist, and health policy. Apparently also most employees, according to Towers Watson. The good news about “pry, poke and prod” is that it truly bridges the partisan divide, in that everyone hates it.
Update February 20, 2018:
One of the very stable geniuses in the wellness industry has decided that the reason no one applies for this award isn’t that they know they’ll lose. It’s because a reward isn’t a valid offer. We would invite them to read this link.
This offer is completely legally binding. Anyone may claim the $3 million reward ($300,000 entry fee) for successfully convincing the arbitrator that it isn’t. Further, we agree in advance that if an arbitrator finds anything in here that keeps it from being legally binding, the arbitrator may rewrite it to his or her satisfaction in order to make this legally binding.
Update March to October 2018:
The new entry process is:
- Applicant puts $3000 into escrow (bank escrow fees to be 50-50 shared once escrow is completed), at which point an NDA is signed and I show tangible net worth (excluding primary and secondary residences — and any retirement accounts are accounted for net of tax penalty for early withdrawal) more than sufficient to pay the reward. Applicant may either go forward at this point, or forfeit the $3000 to me.
- Applicant adds $27,000, at which point earning assets exceeding $3,000,000 as valued at at lower of cost or mark-to-market are placed in escrow, and/or title is changed to the escrow agent, though I still receive the income until the reward is paid. If I fail to place that sum in escrow within 60 days, I pay a “liquidated damages” penalty of $100,000. The applicant is released from the NDA and may announce that I failed to deliver and they won by default. Assuming the $3,000,000 is sufficiently secured and the “liquidated damages” provision is not triggered, applicant may either go forward, or forfeit the $30,000 to me.
- Applicant adds $270,000 to the escrow within 30 days, at which point the entry process is completed, and the debate is held. Judges and expenses are paid out of the escrow.
- If the applicant pulls out after publicly announcing he or she is applying and before adding the $270,000, there is a $50,000 liquidated damages fee, tripled if it has to be procured through litigation. If I pull out, there is a $500,000 liquidated damages fee, tripled if it is procured through litigation.
- If I win the debate, the remaining escrow funds are released to me.
- If I lose the debate, the remaining escrow funds are released to the applicant.
The best outcomes evaluator in the wellness field is Dr. Iver Juster.*
*Among the subset of males not affiliated with They Said What.
Why Dr. Juster’s Case Study Is the Best Case Study Ever Done in This Field
Chapter 2 of the HERO Guide is a great study and deserves high praise. But before we get into the salient points of what makes this absolutely the best case study analysis ever done in this field, be aware the provenance is not a coincidence. Dr. Juster is very skilled at evaluation. Indeed he was the first person to receive Critical Outcomes Report Analysis (CORA) certification from the Disease Management Purchasing Consortium. (Dr. Juster very graciously shares the credit, and as described in his comments below would like to be listed as “the organizer and visible author of a team effort.”)
Note: the CORA course and certification are now licensed for use by the Validation Institute, which has conferred honorary lifetime certification on Iver gratis, to recognize his decades of contribution to this field. (Aside from the licensure, the Validation Institute is a completely independent organization from DMPC, from They Said What, and from me. It is owned by Care Innovations, an subsidiary of Intel. If you would like to take the CORA Certification course live, it is being offered next in Philadelphia on March 27. You can take it online as well.)
Early in the chapter, Iver lists and illustrates multiple ways to measure outcomes. He dutifully lists the drawbacks and benefits of each, but, most importantly, notes that they all need to be plausibility checked with an event-rate analysis, which he provides a detailed example of–using data from his own work. In an event rate analysis, wellness-sensitive medical events are tracked over the period of time in question.
Wellness has never been shown to have a positive impact on anything other than wellness-sensitive events. Consequently, there is no biostatistical basis for crediting, for example, “a few more bites of a banana” with, to use our favorite example, a claimed reduction in cost for hemophilia, von Willibrand’s Disease and cat-scratch fever.
By contrast, real researchers, such as Iver, link outcomes with inputs using a concept called attribution, meaning there has to be a reason logically attributable to the intervention to explain the outcome. it can’t just a coincidence, like cat scratch fever. As a result, he is willing to attribute only changes in wellness-sensitive medical events to wellness.
Event-Rate Plausibility Analysis
Event rates (referred to below as “PPH” or “potentially preventable hospitalizations”) are laid out by disease on page 22 of the HERO Report. Note the finding that PPH are a small fraction of “all-cause hospitalizations.” Though the relative triviality of the magnitude of PPH might come as a surprise to people who have been told by their vendors that wellness will solve all their problems, Iver’s hospitalization data sample is representative of the US as a whole for the <65 population, in which chronic disease events are rare in the <65 population.
Gross savings total $0.99 per employee per month. This figure counts all events suffered by all members, rather than excluding events suffered by non-participants and dropouts. Hence it marks the first time that anyone in the wellness industry had included those people’s results in the total outcomes tally — or even implicitly acknowledged the existence of dropouts and non-participants. He also says, on p. 17:
For example, sometimes savings due to lifestyle risk reduction is calculated on the 20% of the population that supplied appropriate data. It’s assumed that the other 80% didn’t change but if some of the people who didn’t supply risk factor data worsened, and people who got worse were less likely to report their data, that model would overestimate savings.
Note that the PPH declined only in cardiac (“IVD”) and asthma. Besides the event rates themselves being representative of the employed population in the US as a whole as a snapshot, the observed declines in those event rates are almost exactly consistent with declines nationally over that same period. This decline can be attributed to improvements in usual care, improvements that are achieved whether or not a wellness program was in place. The existence and magnitudes of the declines, coupled with the slight increase in CHF, diabetes and COPD combined (likewise very consistent with national trends), also confirm that Iver’s analysis was done correctly. (Along with attribution, in biostatistics one looks for independent confirmation outside the realm of what can be influenced by the investigator.)
It is ironic that Ron Goetzel says: “Those numbers are wildly off…every number in that chapter has nothing to do with reality” when I have never, ever seen a case study whose tallies — for either total events or event reduction, let alone both — hewed closer to reality (as measured by HCUP) than this one.
Another factor that conveniently gets overlooked in most wellness analyses is that costs other than PPHs rise. By contrast, Iver is the first person to acknowledge that:
The implication, of course, is that increases in these costs could exceed the usual care-driven reductions in wellness-sensitive medical events. Indeed, Iver’s acknowledgement proved prescient when Connecticut announced that its wellness program made costs go up.
The $0.99 gross savings, and Connecticut’s healthcare spending increase, exclude the cost of the wellness program itself, of course. Factor in Ron Goetzel’s recommendation of spending $150/year for a wellness program and you get some pretty massive losses.
The old Al Lewis would close by making some reference to the dishonesty and cluelessness of the Health Enhancement Research Organization’s board. The new Al Lewis will do just the opposite. In addition to congratulating Iver Juster (and his co-author, Ben Hamlin) on putting this chapter together, I would like to congratulate the Health Enhancement Research Organization, for what Iver describes as the “team effort” in publishing it — HERO’s first flirtation, however fleeting and inadvertent, with integrity and competence.
Iver Juster Comments on the article
Iver reviewed this article and would like to add several points. I am only adding a couple of my own points, noted in indented italics:
- It’s important to credit the work to a larger group than just myself. I was the ‘lead author’ on the financial outcomes chapter of the HERO/PHA measurement guide, but the work entailed substantial planning and review in collaboration with the chapter’s coauthor (Ben Hamlin from NCQA) and members of the group dedicated to the chapter (as well as the HERO/PHA authoring group as a whole).
- Yes, I am more than happy to credit the entire group with this study, especially Ron Goetzel, Seth Serxner and Paul Terry.
- Nonetheless the work does reflect my perspective and approach on the topic – the important points being (a) select metrics that are impactible by the intervention or program; (b) be transparent about the metric definitions and methodology used to measure and compare the; (c) assiduously seek out potential sources of both bias and noise (in other words, exert the discipline of being curious, which is greatly aided by listening to others’ points of view); (d) understand and speak to the perspective of the study—payer, employee/dependents, clinician/healthcare system, society.
- Be particularly sensitive to the biologically-plausible timeframes in which your outcomes ought to occur, given the nature of the program. Even if optimally implemented with optimal uptake and adherence, we might expect ‘leading indicators’ like initial behavior changes to improve quickly; program-sensitive biometrics (lipids, A1C, blood pressure, BMI) and medication adherence to change in a matter of months; and a few program-sensitive ER/inpatient visits (like worsening heart failure or asthma/COPD exacerbations) to improve within several months (again, assuming the program is designed to address the causes of these events). Longer-term events like kidney failure, heart attack and stroke and retinopathy take much longer to prevent partly because they require sustained healthy behavior, and partly due to the underlying biology.
- This is one excellent reason that the measured event rate decline mirrored the secular decline in the US as a whole over the period, meaning the program itself produced no decline over that period. Possibly they might decline in future years if Iver is correct. Ron Goetzel would take issue with Iver’s assertion — Ron says risk factors decline only 1-2% in 2-3 years.
- Event rate measurement in any but the largest Commercially-insured populations is subject to considerable noise. Though a challenge, estimating ‘ confidence intervals should at least shed light on the statistical noisiness of your findings.
- No need this time because your results hewed so closely to secular trend, reflecting the quality of the analysis.
- It is very likely that the program used in the illustration did affect more than the events shown because it was a fairly comprehensive population health improvement initiative. For example, ER visits were not counted; and collateral effects of ‘activation’ – a very key component of wellness – were not included in this analysis. Assuming the 99 cents is an accurate reflection of the program’s effect on the events in the chart, I’d be willing to increase the actual claims impact by 50 to 75%.
- If your speculation is accurate, that would increase gross savings to $1.49 to $1.73/month–before counting preventive care increases indicated on Page 22.
- Nonetheless, to get effect from an effective program you have to increase both the breadth (number of at-risk people) and depth (sustained behavior change including activation) – but at a cost that is less than a 1:1 tradeoff to the benefit. In other words, you must increase value = outcomes per dollar. This cannot be done through incentives alone – as many researchers have shown, if it can be done at all, it must be the result of very sustained, authentic (no lip service!) company culture.
- We are beginning to pay attention to other potential benefits of well-designed, authentic employee / workplace wellness programs (of which EHM is a part) on absenteeism, presenteeism, employee turnover and retention – and, importantly, company performance (which is after all what the company is in business to do). It’s early days but it’s possible research will show that companies that are great places to work and great places to have in our society will find financial returns that far outstrip claims savings. The jury’s still out on this important topic but let’s help them deliberate transparently and with genuine curiosity.
- Did Ron really say you have to spend $150 per year PER MEMBER on a wellness program? I’d be thinking a few dollars (unless he’s including participation incentives)
- (1) Yes, he did say that; (2) no, he’s not including participation incentives; and (3) welcome to my world.
*Among the subset of males not affiliated with They Said What.
Alert readers may recall that my New Year’s resolution was to balance my negative postings about the wellness industry with positive ones. Like Diogenes searching for an honest man, I thought the finding the latter would be hard, but just as Romy Antoine also did earlier this month, The subject of this posting — to be named in Part Two — makes that easy. Part One sets the stage for the review of his study.
By way of background, in preparation for bringing a possible lawsuit, I re-read the famous Chapter 2 of the equally famous HERO report. That was the chapter which inspired Ron Goetzel, Seth Serxner and Paul Terry (who was recently anointed as the American Journal of Health Promotion’s new Fabricator-in-Chief) to circulate their defamatory letter about me to the media, in a singularly self-immolating attempt to discourage them from publishing my material. They insisted that Chapter 2 was pure fabricated nonsense, rather than a carefully analyzed report of real data. Here is an excerpt from their actual letter, copies of which are available from me but which is summarized here:
A fabricated…absurd, mischievous and potentially harmful misrepresentation of our data.
Ron said it best in our Great Debate, minute 1:17 in the MP3 downloadable here:
Those numbers are wildly off…every number in that chapter has nothing to do with reality.
However, the sun rises in the east, taxes are due April 15th, and Ron Goetzel is lying. Quite the contrary, Chapter 2 turns out to be a carefully analyzed report of real data — almost certainly the best case study ever published.
How did I learn that Ron was fabricating a story that his guidebook had fabricated a story?
- This chapter says it’s a real report, on p. 22.
- Since this chapter’s analysis was so far above the pay grade of those three aforementioned HERO characters, I checked the acknowledgements in the HERO book. Sure enough, none of the HERO cabal wrote it. Someone else (to be named in the next posting) was the lead author, and I called to congratulate him on it. I also asked him some background questions, one of which proved very revealing. It turns out that…
- This real analysis of real data was — get ready — reviewed prior to publication by the exact same people who are disowning it now. Yes, among the people who peer-reviewed it prior to publication were the very same Ron Goetzel, Seth Serxner, and Paul Terry. (In addition to them doing the actual review, the lead author, very graciously sharing the credit, wanted to make sure that I indicate that he was only the “organizer and visible author of a team effort.”)
Yes, as is so often the case with these three, they lied about the lies that they lied about. It’s quite ironic that their argument against my original praise of this analysis was to insist that because my source was their own lies, my own analysis was unreliable. These lies above don’t include the actual lies I might sue them about, which were lies about me, which are totally separate from their lies about their previous lies. (Their lie about me was that I had a history of outrageously inaccurate statements, none of which they have ever been able to identify.)
These characters aren’t ordinary run-of-the mill alternative fact-type liars. They’re way beyond that.
Their lies go to 11.
Paul Terry, formerly of Staywell and the Health Enhancement Research Organization, has just been appointed the new editor of the wellness industry trade publication, the American Journal of Health Promotion. He replaces Michael “Let’s Charge Employees Insurance by the Pound” O’Donnell in that role.
Mr. Terry brings exactly the type of expertise to this job that AJHP readers have come to expect, in that very few people can claim to surpass Mr. Terry’s ability to fabricate outcomes.
I first became familiar with Mr. Terry’s work when Staywell claimed mathematically impossible savings for British Petroleum’s pry-poke-and-prod wellness program, which I dutifully reported on The Health Care Blog in the posting: “BP’s Wellness Program is Spewing Invalidity.” Staywell, as a preferred vendor of Mercer, was able to “convince” Mercer to fabricate savings, when their client, BP, asked for an evaluation. Staywell pretended to have saved almost $20,000 for every risk factor reduced among active participants (meaning dropouts and nonparticipants’ failures aren’t counted).
This was quite a feat considering that the average employee only spent about $5000 during the year in which this analysis was conducted. And of course only a tiny percentage of healthcare costs in the short term are attributable to risk factor reduction anyway. (Staywell was offered the opportunity to rebut, and didn’t.)
But the smoking gun here was that Mr. Terry apparently forgot that Staywell itself only claimed to be able to save $129/risk factor reduced. Magnanimous guy that I am, I was kind enough to point out that integrity chasm for him in the article.
Most people, when they are caught fabricating data, try to deny it. But Paul Terry brags about it. In case you haven’t already done so, take a looksee at his defamatory letter to the media that he sent, along with his cronies Ron Goetzel and Seth Serxner. He insists that they made up the data I reviewed — meaning his best argument against me is that I didn’t realize he was lying. If we take him to court, he could argue that the judge should apply the legal standard for negligence — that I “knew or should have known” their data was fabricated, because all their data is fabricated.
Although ironically it turns out the data they insisted was fabricated was, this time, legitimate — meaning that he was making up his claim that HERO had made up the data. That’s a topic for another blog. Suffice it to say that, in the immortal words of the great philosopher LL Cool J, he lied about the lies he lied about.
Most importantly, if you read the letter he wrote, you’ll see that another of his arguments is that when calculating ROI, you should not compare costs to savings. And a good thing because comparing costs to savings, and other feats of arithmetic, would be the wellness industry’s second-worst nightmare (next to facts).
Refusing to acknowledge the existence of basic arithmetic makes Mr. Terry a perfect choice to be editor of the wellness industry trade publication.