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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.

 

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!

 

Wellness imitates Dilbert

Incredibly, events unfolded almost exactly this way at Penn State during their well-publicized wellness debacle 5 years ago.  It was even funnier in real life because while exercise does of course promote wellness, faculty and staff were very restricted in their use of campus recreational facilities. Making those free to employees and dependents was not part of their wellness initiative.

No, instead employees were being forced into an outcomes-based wellness program, one that was supposed to save “millions of dollars.”

Coincidentally, while the Penn State HR department — ably assisted by Ron Goetzel, who later denied having anything to do with them despite being in their press conference – was trying to force employees into these programs, the Penn State bakery announced an expanded selection of pastries and desserts for the upcoming semester.

Penn State’s was, to paraphrase the immortal words of the great philosophers Gilbert & Sullivan, the very model of a modern forced wellness program. Sure, they violated clinical guidelines. That seems to be the price of entry for wellness. More head-scratchingly, women had to disclose whether they intended to become pregnant, or else pay a $1200 fine. This requirement was so Highmark could – to use the Highmark representative’s own words in a rather contentious faculty meeting — “help” them. That would be like offering to “help” the proverbial little old lady cross the street — but if she declines assistance, saying: “OK, then pay me $1200. The choice is yours.”

(Full disclosure: Highmark has now abandoned their old outcomes-based wellness program in favor of a much lighter and more appropriate program, and we wish them the best at it.)

Back to the storyline…

There is something about forced outcomes-based wellness programs that brings out employers’ inner stupid, and Penn State was no exception.  Consider: almost by definition women who are planning to become pregnant have thought about it and have done the basic research. It’s the women who accidentally become pregnant who may possibly have the need for assistance. And even the dumbest HRA wouldn’t ask the question: “Are you going to accidentally become pregnant?”

So, using the very unlikely assumption that women completed the HRA honestly, Penn State’s forced disclosure requirement would have identified 100% of the people who did not need “help,” while missing 100% of the women who might.  If you’re keeping score at home, that’s 100% false positives and 100% false negatives. That’s a lot even by wellness industry standards. Eat your heart out, Interactive Health.

And did I miss the memo where carriers were anointed the prime providers of medical “help”?  Has anyone ever said to you: “You don’t look so good today. Better call your health plan”?

See https://theysaidwhat.net/2016/04/22/the-story-of-an-employee-who-benefited-from-wellness/ for the back story.

Breaking, shocking news: employees cheat in wellness programs

Do employees cheat in outcomes-based wellness programs? Of course not.  Who would ever gain weight in order to be paid to lose it? That would be dishonest and unhealthy.

Haha, good one, Al.

Yes, obviously employees cheat in outcomes-based wellness programs and crash-dieting contests. But here are two things that aren’t so obvious:

  1. Cheating is far more widespread than employers would like to believe;
  2. This massive scale of cheating — two-thirds of all employees cheat in wellness — is well-known but suppressed by self-proclaimed “scientists” in the field, whose livelihoods would be in jeopardy if they acknowledged the scale of the cheating.

Cheating is widespread

How do we know this? Bloggers receive data from WordPress on hits for each post. Not just the number of hits, but the specific sources of the click-throughs — other bloggers or else “search engines.”

In any given week, the current posts and the home pages get the most hits. However, for the year as a whole, it’s a different picture. Take a looksee at our total hits for 2018:

Our typical blog post — not including home pages and related pages — gets about 2500 hits over the course of the year in which it is posted. But you’ll see that #3 on the 2018 list is: “How to cheat in a corporate weight-loss contest.”  Almost every day that particular post racks up 15-25 hits, giving it 6388 for 2018. I used to assume that some other, more popular, blog was linking to it, but I can see linked blogs too on the Site Stats page, and there weren’t any.

Here are the 2019 stats through yesterday.. A new cycle of wellness programs and crash-dieting contests is about to start, so despite New Years week being a very slow week for TSW (like other HR blogs), that post is #1:

Further, even though these stats are 2018 and 2019, this blog was posted November 2016.`


What is driving this continuing popularity?

It turns out that the source of these click-throughs is indeed “search engines.”  Seems that even though the target audience for this posting was the narrow HR/benefits community, employees themselves are googling on “cheating in wellness programs” and finding this post right on the first page of hits:

That also explains how we could get so many hits and yet so few comments and Facebook reposts. No one wants to be caught.

You might say: “That’s only 6,388 employees for a full year. The rest are honest.” Nice try, but consider:

  1. “Only 6,388 employees” clicked through despite noting from the first lines (as you can see) that this article really wasn’t a guide to cheating.
  2. This post is way down at the bottom of the front page.
  3. This was only a single year — 2018 — and the 2019 rate arithmetically projects to about 20,000 hits (though much of this posting’s hits are seasonal)
  4. The #2 source of click-throughs to this article is Slate’s masterful expose called Workplace Wellness Programs are a Sham, also on the first page of google hits above, which itself links to us–meaning that employees are also clicking through on that article in the same search.
  5. The 6,388 excludes the gazillion employees who don’t need to google anything in order to realize that the winning strategy in any outcomes-based wellness program or crash-dieting contest is to binge before the initial weigh-in and crash-diet before the final one — and of course lie on the risk assessment.
  6. The keywords that drive traffic to this site, according to Alexa? #3 — after Bravo and Wellsteps, two vendors who are “in the news” constantly — is “Healthywage Cheating.” Healthywage is the leading crash-dieting contest vendor.

 


The scale of cheating…and the suppression of the evidence by the wellness industry

Employees who don’t drink, smoke, use drugs, or occasionally indulge in foods other than broccoli and kelp have no need to cheat. They will also derive no benefit from wellness programs and employers will save no money on them, not even any make-believe savings that wellness vendors routinely claim. It is estimated that only 3% of people do everything right, health-wise. That mean the pool of potential cheaters is 97%.

How many of the potential cheaters are actually cheating? Review your own statistics yourself. 70% of employees drink, including 10% who drink more than 30 drinks a week. How many of your employees indicated on their HRA that they drink that much? Zero, you say? What a coincidence! That’s what all the other employer-administered HRAs conclude as well.

How many employees admitted drinking at all? If you said 20%, that would match the number claimed by Wellsteps for their award-winning program. That means slightly more than 2/3 of all drinkers — half your employees — are lying. Not because they’re inherently dishonest, but because you are basically asking them to lie in order to stay out of trouble. What kind of trouble? Wellsteps called consumption of any alcohol a “worst health behavior,” shaming employees who admitted to even occasional social drinking. Nonetheless they fully accepted as fact the 20% drinking rate statistic.

By encouraging all this lying, Wellsteps helped this employer, the Boise School District, create a culture of deceit instead of a culture of health. Kudos.


Now consider smoking. For that we turn to the industry’s leading source of alternative facts, Ron Goetzel. He “found” that for the years 2012-2014, 5.5% of his surveyed workers smoked, overlooking the statistical 12.3% of employees — roughly 2/3 of all smokers — who lied. Yet, like Wellsteps with the drinking, Mr. Goetzel presented this statistically impossible 5.5% as fact.

It’s not a coincidence that roughly the same proportion of smokers and drinkers lie. Nor is it a coincidence that these two “scientists,” as they call themselves, decided not to disclose the lies. Since they claim to be “among the most credible and conscientious scientists and practitioners working in corporate wellness today,” this is much more likely to be a deliberate omission than a rookie mistake, especially since I’ve informed them of this disparity and many other obvious misstatements many times and they usually just doubled down.

Admitting that their data is basically worthless means their entire conclusions are basically invalid, which in turn means that outcomes-based wellness itself is a fraud, which by the way it is

Lying to employers about personal behaviors is human nature. Most employees don’t want to disclose potentially damaging information, and think, quite justifiably, that if they give their employer 100% during working hours, their off-hours behavior is none of their employer’s business.


How can cheating in wellness be prevented?

For those two studies, Mr. Goetzel and Wellsteps were only encouraging employees to lie to their employers and cheat on the programs. The majority of employees responded predictably. By contrast, when you run an outcomes-based wellness program with large fines, or hold annual crash-dieting contests, you’re not just encouraging employees to lie and cheat. You’re practically begging your employees to lie and cheat. In crash-dieting contests, employees form teams, and strategize on how to binge and then crash-diet, allowing them to lose far more weight in 8-16 weeks than is healthy. Any team not intending to cheat wouldn’t even bother to compete. Teams that do want to compete will visit websites teaching them how to cheat, and which appetite suppressants and weight-loss pills to buy in order to win.

Wouldn’t it be great if there were a wellness vendor which, instead of denying human nature about cheating, channeled it? Instead of bragging about ferreting out “fraudulent participants,” made cheating part of the fun?  There’s a word for that, and it’s not “impossible.” It’s “Quizzify.” Employees can rack up points for correct answers…and they are encouraged to look them up before selecting their response from the multiple-choice list. That way they are more likely to remember them.

And, unlike “how to cheat in wellness,” if you google on “How to cheat on Quizzify,” you won’t find any advice on cheating — other than Quizzify’s own rules urging employees to do exactly that.

Ron Goetzel Spins Gold into Straw, Part 2 (a semi-guest post by Bob Merberg)

First, congratulations to Joe Andelin, who caught just about every fallacy, alternative fact and, if there were such a thing, alternative fallacy in yesterday’s presentation. I know he did because I was on the call.

Wait, Al, didn’t you say they blocked you? 

Yes, but displaying the same level of competence that they routinely bring to their day jobs, they managed to block only my video, not my audio.


Here were our predictions we got on the nose. We predicted he would say:-

  1. The study only covered the first year — he won’t mention that the authors also said the first year suggests nothing “is trending towards savings” in future years either;
  2. He said he study contradicts many of the other findings out there — except, of course, for all the other studies testing the par-vs-non-par study design against a benchmark, all of which showed results quite literally identical to the University of Illinois result, in that the wellness program accomplished zero;
  3. It wasn’t a good program. To hear Ron tell it (literally hear him tell it — you can listen to the tape), anytime a program fails, it’s because it wasn’t done correctly. “100 employers [have] programs with really smart ingredients…but thousands of others still don’t do wellness right,” are his exact words in print.  He is refusing to name any of them, other than the old Johnson & Johnson analysis. (J&J is a wellness vendor. Investigator bias, anyone?)

The last is his go-to excuse. He said the University of Illinois program, which consisted of screenings and incentives to use the gym, was a “throwback to the 1980s.”  In reality, the program was a “throwback” to every single Koop Award-winning program, all of which feature “pry, poke and prod” programs and some kind of fitness incentive. The only thing missing from this program was the broccoli.


I was wondering where to go with the rest of this posting but then into my comments box popped my old friend Bob Merberg, who is perhaps the smartest person I have ever met on the subject of wellness outcomes measurement. His comments are better than anything I could have written (assuming I had been allowed to see the slides).  Here they are in their entirety:

Al, I’m not usually one to comment on other people’s blog posts, and certainly not one to promote my own content, but I attended the webinar and found the conclusions drawn by the presenters to be egregious. One of the presenters correctly pointed out that subjects in the treatment group were, “More likely to report that the employer values worker health and safety.”

But then — bizarrely — he went on to say, “In other words, … people felt more engaged, and had better morale, and had better feelings of satisfaction working for the employer by being in the treatment group. In my mind, the headline ought to be ‘Wellness Program Increases Employee Engagement and Morale’ as opposed to ’37 Things We Didn’t Find Any Difference In.‘” Another presenter termed this the key finding.

But feeling like your health and safety are valued, while important, is by no means a the same as morale, engagement, or job satisfaction. In fact, the study did not measure morale or employee engagement. It did measure job satisfaction, self-reported “bad emotional health,” and changes in happiness at work, and found that the intervention group experienced no significant improvement compared to the control group.

If we were to jump to any conclusions from this study, they might be that feeling valued are NOT linked to job satisfaction and other psychosocial metrics.

To promulgate that the “key finding” was improved morale, improved employee engagement, and improved job satisfaction, is at best a sign of failure to understand the study, and at worst a deception. Under any circumstances, it’s a disservice to the study subjects who presumably consented to participate in good faith science, to the researchers — who were meticulous in their methodology and transparency — and to those of us in the wellness industry who are more interested in understanding what works rather than distorting facts to serve our own self-interest.


But wait…there’s more.

More in my blog post: https://www.linkedin.com/pulse/employee-wellness-truth-isnt-true-bob-merberg/

Mostly for fun, a time-lapsed video of my research and writing process on this subject: https://youtu.be/hQ6HqkN-VPw

 

Ron Goetzel Spins Gold into Straw, Part 1

I would invite everyone to join tomorrow (Tuesday’s) webinar by Ron Goetzel. He will be attempting to undermine the National Bureau of Economic Research’s (NBER) outstanding University of Illinois study, which showed — surprise — that conventional wellness programs don’t come close to changing behavior, let alone saving money. I would love to attend, but I, of course, am not invited to his events any more than he is invited to mine. Oh, wait a sec, I invite him to all my events and alert him to all my postings on linkedin so that he can correct any errors I’ve made. Sorry, my memory failed me there for a second.

Speaking of failed memories, he is being joined on this webinar by Jessica Grossmeier. If that name rings a bill, it’s because she claimed her company, Staywell, saved $17,000 per risk factor reduced — about $3000/pound shed — for British Petroleum, having forgotten that she herself claimed it is only possible to save $105/avoided risk factor. See “British Petroleum Wellness Program is Spewing Invalidity.”

Despite this being the Gold Standard of randomized control trials, he will be accusing the NBER of many errors.  (A cynic might note that being accused of making errors in a wellness study by Ron Goetzel is like being accused of cheating on your taxes by Paul Manafort. ) He will argue that:

  1. The study only covered the first year — he won’t mention that the authors also said the first year suggests nothing “is trending towards savings” in future years either;
  2. The study contradicts — you guessed it — Kate Baicker’s infamous 3.27-to-1 ROI, without mentioning that the NBER’s principal investigator, as coincidence would have it, reports to Kate Baicker, so it’s pretty unlikely he would diss her unless the data left him no choice;
  3. The study contradicts all the other findings out there — except for all the other studies testing the par-vs-non-par study design against a benchmark, all of which showed results quite literally identical to the University of Illinois result, in that the wellness program accomplished zero;*
  4. The participants outperformed the non-participants;
  5. They haven’t reported on the screening yet;
  6. It wasn’t a good program. To hear Ron tell it (literally hear him tell it — you can listen to the tape), anytime a program fails, it’s because it wasn’t done correctly. “100 employers [have] programs with really smart ingredients…but thousands of others still don’t do wellness right,” are his exact words in print.  He is refusing to name any of them, other than the old Johnson & Johnson analysis. (J&J is a wellness vendor. Investigator bias, anyone?)

What else will he argue? Tough to say. One thing for certain: he won’t mention my name — any more than Bravo did when they wrongly predicted that the EEOC rules would be replaced in January while I predicted the opposite.  Instead he uses a new vernacular for my postings:  “Industry chatter.”

He probably picked up this idea from Bravo, which uses the phrase “industry noise” to describe me.

 


Where’s Waldo-meets-Ron Goetzel: Spot the errors and you may win a big prize

So let’s make this interesting. Whoever comes up with the best smackdown of the webinar’s obvious fallacies (and omissions) automatically gets entered in the contest to win the Martha’s Vineyard vacation, with the house, car and private (well, semi-private) beach. It is otherwise open only to people who have won various Quizzify trivia contests, but being able to identify five or ten pieces of “chatter” or “noise” in this self-anointed “expert webinar” clearly counts as being health-literate.  To compete, send me an email with an attachment. I’ll pick a couple of finalists and put them on linkedin. (If you don’t want your name used — and Ron does bite back, so I don’t blame you — I will post on my own.)


*The result is also quite consistent with Ron’s observation that there is basically no change in behavior leading to risk reduction. If we are splitting hairs here, Ron found a 1-2% reduction, not 0%. Of course, that took three years.

 

 

 

 

A vendor’s guide to snookering self-insured employers

Dear Wellness, Diabetes, Clinic, Price Transparency, and Medication Therapy Management Vendors,

While most of you already know the majority of these tricks, there might be a few you haven’t deployed yet. So take good notes.

Sincerely,

Al Lewis

PS If you are an employer, just pass this along to your vendors…and watch your savings skyrocket. Or use “An Employer’s Guide to NOT being snookered” to see your savings become realistic.


Best practices for every vendor

Compare participants to non-participants. Using non-participants as a control for participants allows you to show massive savings without doing anything. This is not an overstatement. Here is a program — which naturally won an award for its brilliance from Ron Goetzel and his friends before I observed that they were a fraud according to their own data– that did just that. They separated participants from non-participants but didn’t bother to implement a program for two years—by which point the participants had already improved by 20% vs. the non-participants — without even having a program to participate in. (Note on this slide that the control and study group were set up in 2004 but the program didn’t start until 2006, when the cost separation had already reached the aforementioned 20%.)

Two other observational trials support this conclusion. Most recently, the National Bureau of Economic Research ran a controlled trial to test exactly this hypothesis. Sure enough, like the three observational trials, they found that virtually the entire outcome in wellness can be explained by that popular study design itself, rather than the intervention.

In any participation-based program, ignore dropouts. Assume that employees who drop out do so randomly, not because they are discouraged by their lack of progress or interest.

Draw a line upwards and then claim credit for the “savings” between the actual upward spending and the “trend” you drew. As Optum’s Seth Serxner stated so succinctly: “We can conclude that the choice of trend has a large impact on estimates of financial savings.”

Start with the ridiculously high utilizers, high-risk people, or people taking lots of drugs. Let the group regress to the mean, and then claim that as savings.

Never admit, like Wellsteps did, that you are familiar with regression to the mean, since most employers are not aware of it.  The higher the costs/risks of the original users, the more savings you can claim. Here are two verbatim claims:

  • A heavy equipment manufacturer found high use of the ER was a becoming a cost concern, so it send mailings that showed appropriate care settings to the homes of members with two or more visits to the ER in the past year. As a result, ER visits were down 59 percent those who got the mailing.
  • A pharmaceutical company saw a spike in ER claims was coming from repeated use by the same people, so two mailers were sent: one to households with one ER visit in the past year; another for those with two or more visits. Following the mailings, there was a 63 percent drop in ER visits.

Pretend not to notice that low utilizers can show an increase in utilization — or especially that low-risk people can increase in risk. Focus the mark (I mean, the customer) on the high-risk people who decline in risk. Never draw graphs to scale, or your customer might notice that 2/3 of their employees are low-risk in the first place.

Cigna chart

It doesn’t matter what your intervention is. Claim credit for the entire difference in trend. For instance, in this example, Community Care of North Carolina claimed credit for a huge reduction in PMPM costs for babies for their medical home program…but babies weren’t even included in the program. (Neonatal expenses didn’t decline either.)

Or do what Safeway did, launching the wellness craze: change to a high-deductible plan, and transfer a large chunk of costs to employees. Don’t even bother to institute a wellness program, but attribute all the savings (from the transferred deductible spending) to wellness anyway, so that you get invited to the White House.  And after that blows up on you, demonstrate that your very stable genius investment in wellness was not a fluke by investing your company’s money in Theranos.


Special Instructions for transparency tool vendors

Assume that every employee who uses your tool is looking to save their bosses some money, rather than (for instance) to find the closest MRI…and that none of them would have used a lower-cost venue absent your tool.

If only 10% of employees use your transparency tool, and only 10% of events are shoppable, nonetheless take credit for the entire difference in trend across the board, and ignore the literature showing online price-comparison tools don’t work.

If people who haven’t met their deductible shop more than people who have, attribute the former’s lower cost to use of the tool, rather than to the fact that by definition people who don’t meet their deductible spend less than people who blow through it.


Special instructions for wellness and diabetes vendors

If you are a wellness or diabetes prevention/management vendor, never ever let employers know that every year since statistics have been kept, fewer than 1 in 1000 employees/dependents end up in the hospital with diabetes.  (And another 1 in 1000 with a heart attack.) Always tell them how many employees are at risk and how many “newly discovered conditions” they have, and how they will all end up in the hospital, even though hospitalizations for heart attacks and diabetes in the employer-insured population have been declining for years.

Wellness vendors should always put the trivial percentage reduction in risk (for participants only, of course – and ignoring dropouts) on one page and the massive savings on another page. Most employers won’t bother to do the math to notice, for example, that Interactive Health claimed $50,000 in savings for every employee who reduced one risk factor, while the state of Nebraska won an award for claiming to save $20,000+ for every risk factor reduced, as did Staywell for British Petroleum.

If you didn’t reduce risk factors, present your outcomes in a format no one can make heads or tails of, like this one, from Wellsteps. If Wellsteps was able to snooker an entire committee of self-anointed outcomes experts to win an award for program excellence, surely you can snooker a few customers.

Claiming people lose weight is a big part of your outcome reporting, so make sure to do the following:

  1. Never count nonparticipants, and ignore dropouts.
  2. Don’t do any long-term follow-up to see who regained the weight (most participants)
  3. Give them time to binge before the initial weigh-in

Special instructions for diabetes vendors

In addition to measuring on active participants only, raise the bar for Hb A1c so that only people with high Hb A1c’s can be included. That belt-and-suspenders approach will ensure that you can’t fail to show savings, even if (as is likely the case) you don’t change anyone’s behavior other than the employees who were going to change anyway, which you might as well count.

Next — most diabetes vendors and a few wellness vendors have already figured this out — you can charge much more if you can submit claims, rather than just be an admin expense line item. You see, most employers focus much more on the 10% admin expense than they do the 90% medical expense, which they consider to be beyond their control.  Your claims expense – which would draw attention to itself as an admin cost — won’t get noticed in the 90% of medical losses, sort of like the dirt from the tunnel sprinkled around the Stalag in The Great Escape.


Special instructions for medication therapy management vendors

Only mention “gaps in care” that you close, not the ones that open up. And, as noted in the chart below, always use percentages. So in this chart (provided by one of the major PBMs), they claimed that twice as many gaps were closed (37%) vs opened (18%), and yet, as is almost always the case with MTM vendors, nothing happened to the total number of gaps, which remained at exactly 820:

 

Tally all the employees who were on large numbers of meds and now take fewer. But don’t mention all the employers who were on fewer meds and now take more.


What to do if you’re asked why you aren’t validated by the Validation Institute

Here are the most popular answers to that question:

  1. No one has asked us to. (Quizzify didn’t need to be asked.)
  2. We hired our own outside actuarial firm to validate us, and they concluded we save a lot of money.
  3. Sure, we’ll get validated as soon as you sign the contract with us.

 

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