What’s Science Got to Do With It?

What’s Science Got to Do With It?

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Penn State University is now embroiled in a national controversy over the ham-handed launch of its coercive and intrusive wellness program, which can cost recalcitrant employees as much as $1,200 per year for not joining.  That ignominy of being the most distasteful and coercive program, however, belongs to Blue Care Network of Michigan, which recently published results from their “voluntary” walking program designed exclusively for their obese enrollees.  The invitation to join was extended to enrollees with a body mass index (BMI, which is an unscientific, mathematically bereft proxy for health – see Keith Devlin’s excellent article ) of 30 or greater.  The program was “voluntary” as long as you were okay with paying $2,000 in added insurance premiums if you did not volunteer.

Avoiding the $2,000 price tag came with its own cost in dignity and privacy.  Enrollees agreed to either: 1) wear an electronic pedometer and connect it to their computer daily to document completion of at least 5,000 steps or, 2) join Weight Watchers or some other approved “weight cycling” program.  This princely sum is not irrelevant to most families.  In fact, it is almost exactly equal to per capita spending on food eaten at home in the US and about four percent of median US household income in 2011.  So, in a household occupied by a single adult, this will almost buy your groceries for a year, meaning that is hard to refuse, and the less money you make the more likely that resistance will prove futile.

The BCN strategy legitimizes telling people who look a certain way that they should submit to online, electronic monitoring or pay more for their insurance than people who don’t look that way.  Why would an obese person submit to this when it is entirely possible that he or she is fitter and more metabolically healthy than an normal weight unfit person who would never be condescended to this way?

More disturbing is the prospect that this is only the leading edge of life-invading monitoring by the wellness industry.  It is easy to envision sleep monitoring because you have bags under your eyes.  Or, what about wrist-worn breathalyzers to make sure you don’t go over the one or two drink limit, or sneak cigarettes after lying on your health risk appraisal that you don’t smoke?  How much electronic surveillance would you be willing to undergo on the pure guesswork that it might save someone (i.e., your employer or your health plan) money?


Almost a third of the people who “volunteered” for the BCN walk-a-thon were angry and felt coerced into joining the program. (Actually, this was about a third of the only 12% of participants who bothered to answer the satisfaction survey.)  Their outrage is understandable considering that the criterion for participation was their appearance (because we know that thin people all get the recommended amounts of daily physical activity, right?), as opposed to objective measures, such as cardiorespiratory fitness, cardiometabolic markers, or how many steps they already walked in a day .  Even more amazingly, because these risk managing master minds collected absolutely zero pre-program data, there is no way to know whether the intervention increased anyone’s fitness, improved their cardiometabolic markers, or saved any money.

Finally, there is this nugget: , 47% of participants surveyed initially said they disliked being strong armed into the program.  At the end, more than 30% still felt that way. It’s possible that people who lost weight changed their minds, although it will be interesting to see how they feel when they gain the weight back, which according to the last 25 years of published research most of them certainly will.  Maybe then, BCN can give everyone two monitoring devices and entice them with $4,000.  In any case here is the compassionate response about this from the authors (at page 8 of 13).

“…nearly a third of them did not like the program…. Nevertheless, given mounting costs associated with sedentary behavior, approaches to financially incentivize healthy behaviors are likely to expand and gain political support…”

So, in this “seminal work” we are left with this: people didn’t like it, we have no idea of its impact on any meaningful health measure or financial outcome, but despite nearly total ignorance of value, we should do it anyway. Why?   Because both the government and large corporations have staked a claim to beating back the “obesity epidemic” using the cudgel of differential insurance premiums to drive health behaviors.  This stems from the falsehoods trotted out by the C-suite at Safeway during debate over the Affordable Care Act, which gave politicians the cover to claim that this was a good idea for everyone.

The BCN program shows that we have sunk to a new low in the US.  It is the most coercive, penalty-laden weight loss program that either of us has ever seen which, at the end of the day, measured almost nothing except a highly leveraged participation rate.  There is not a single word in the entire paper about the importance of organizational culture change as a foundation for helping individuals change behaviors.  This exclusion perpetuates the idea that wellness is something you do to people, instead of something you do with and for them.

Jon Robison, Ph.D., MS, has been teaching at Michigan State University for almost 20 years. He presents at health-related conferences throughout North America and is the co-author of The Spirit and Science of Holistic Health: More than Broccoli, Jogging and Bottled Water, More than Yoga, Herbs and Meditation.

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness.  An iconoclast to the core, he is the author of the Khanna On Health Blog.  He is also the Wellness Editor-At-Large for THCB.

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53 Comments on "What’s Science Got to Do With It?"


Guest
Kem
Aug 20, 2013

Excellent article, thank you. For the life of me, I just can’t understand why they prefer to threaten and strong arm over using actual metabolic health indicators and promoting wellness. It just doesn’t make sense to me. If it were really about improving health, that is.

Though you’d think if it were actually about saving money, the latter would still be the way to go. So what’s the deal?

Guest
Aug 20, 2013

Kem: thanks for your note. I think that there are two important factors at play, both alluded to in our piece. The first is the imprimatur of the federal government, and the second is the perceived desire for these kinds of programs on the part of BCN’s corporate clients. There is a certain “you can’t touch us” kind of boldness on their part, reflected at least slightly in their obnoxious statement in the paper.

Health plans will continue to act out in this manner if people don’t come together to tell them to stick it. Even for the people who secretly think that this is a good thing to do, just wait. Eventually, they’ll find a way to monitor you, too, and then it won’t be so amusing.

Guest
Dr. Rick Lippin
Aug 20, 2013

Authors say-“There is not a single word in the entire paper about the importance of organizational culture change as a foundation for helping individuals change behaviors”

This is a huge omission and a huge mistake – a topic which I have written about. In late 1990’s I was only MD on the NIOSH/NORA team on Organization of Work (OOW)- impact on health outcomes

Dr. Rick Lippin
Southampton,Pa

Guest
Aug 20, 2013

Rick, it is indeed a huge omission, but health plans don’t know anything about teaching organizational leaders how to change their cultures and learning that skill is too onerous for them. It also betrays a little about the leaders of the large companies that likely are nudging BCN forward with this kind of dreck, and that is that corporate leaders don’t want to change, either. After all, BCN is doing their bidding — “hold down costs” — because they need to keep their corporate clients happy. Corporate leaders would rather endure a few weeks of months of heckling over this kind of initiative (I bet Penn State administrators are regretting that attitude now) than actually change the entire corporate culture to HELP employees make positive changes and choices. In this case what we have is truly a confederacy of dunces.

Guest
Dr. Rick Lippin
Aug 20, 2013

Vik- Concur with your analysis. What to do?

Guest
Aug 20, 2013

Organizational leaders need to have the guts to do two things: 1) stop current wellness initiatives in their tracks and 2) take the time to do a comprehensive wellness strategic plan that works from organizational characteristics and values out to employees. Things like the BCN initiative and PSU debacle show how deeply corporate leaders misunderstand what they’re trying to do. I am doing this right now for a large medical industry employer, and I am quite sure that the org’s leadership is not ready for the wake up call that they will get.

And, oh yeah, stop believing everything that the government tells you. No, Dorothy, there is not health care wizard of oz, and even if there is, his name is not wellness.

Guest
Dr. Rick Lippin
Aug 20, 2013

Vik-

Thanks!- I wish you well

Having tracked this for over 30 years, with few exceptions, I never really believed corporate leaders who stated that “employees were their most important asset”. Employees never really moved on the balance sheet from the costs column to the asset column. I ultimately became tired of all the phony talk and lies about “maximizing human capital” .

I have grown not to trust Big Businees or Big Government especially with something so important as my health.

Dr. Rick Lippin
Southampton,Pa

Guest
Aug 20, 2013

Amen to those thoughts.

Guest
Haley
Aug 20, 2013

Vik-
this is the natural extension of the ACA … penalize businesses for failing to provide ‘affordable’ insurance… if you are going to penalize them, then they should be able to help reduce the costs to make it affordable…

A healthy workforce is good for ALL employees… The greater good of the non-obese employees and their families is far better served by those significantly overweight being incentivized to improve their health.

The other ACA incentive– employers know that if you refuse… you can always get it in the exchange ‘no questions asked’…

On a personal level, the First Lady has made obesity her number one issue during her husband’s presidency… large employers are simply furthering the kinds of incentives to get people moving per her efforts. That seems more noble than horrible…

Guest
Aug 20, 2013

So, you would be okay with electronically monitoring black people because they tend to have more risk factors for potentially costly wellness-sensitive events than whites, Asians, or Hispanics?

I’m not opposed to healthy worksites or healthy workforces. The problem is that those goals are much harder to achieve than shaming or strong-arming people into idiotic, ignoble schemes such as this one.

As for your implicit assumption that obesity is the core problem, you are, quite simply, wrong. Obesity has become a proxy of convenience for the entire medical care and health insurance system because the system thrives on labels and classification, which are the baseline tools for reimbursement.

Go read Mozzafarian’s paper in Circulation in 2008 and learn about why obesity is best seen as the result of disordered lifestyles and metabolism not the cause of it.

Guest
Aug 20, 2013

Tangentially, Mayor Bloomberg is now proposing that all NYC public housing residents be required to wear a large fluorescent yellow Star of Ghetto sewn onto their outwear. 😉

Guest
Haley
Aug 20, 2013

Bobby- why is it always about race? You have crossed the line into ‘Godwin’ territory…

Discuss the issue without accusing those you oppose of being evil— evil does exist — but far, far more often, the people you disagree with might be wrong, but not evil.

Guest
Aug 21, 2013

a JOKE, dude. Chill.

Guest
Haley
Aug 20, 2013

Vik-
why are you so quick to make this a racial issue? The issue is health.

the law is in a real part based on the employer mandate (see recent report showing about $150 billion in lost revenue if repealed)…

if you support the law, you need to see it implemented — and you simply cannot force the cost and risk onto employers without giving them tools to manage/control their costs.

there is no question obesity is complex — but the law is all about over simplification by politicians and then letting real people live with the consequences– and letting lots of regulations and interpretations be written by people getting lobbied every day by interests.

So, I am still not sure what you are trying to say in your post– the rules in the law are clear… without so many of these major provisions, there would have been no ACA.

As opposed to fighting the law (as we oppose and bash republicans for all the time) we should be making WORKABLE constructive recommendations– it seems to me you are suggesting ending the employer mandate…

Guest
Aug 21, 2013

If you think that the issue underlying the ACA really is health, then you are even more misguided than you first seemed. Our post is about a major health plan using physical appearance as the lever for coercing people who may or may not benefit from the offered walking program into participation. The post is both clear and self-explanatory.

My sarcastic rejoinder that they should have invited black people to be electronically monitored just introduces another element of appearance devoid of content. They could also just as easily invited Hispanics, or now, thanks to nerds with research grants tall people (who are supposedly at higher risk of cancer) or people walking around with Starbucks cups (because in one of the stupidest studies published in recent months, too much coffee will kill you…if you drink more than 4 c daily and are younger than 50, but never mind that they did not adjust for income and education). There is nothing objective or scientifically or medically meritorious about these characterizations, and it would be ludicrous to make policy off any of them.

Any sentient person looking at federal health policy of the last 50 years would be able to discern that every President since LBJ (who gave us Medicare and Medicaid) has had a chance to “fix” the medical care system and all they’ve succeeded in doing is making it more complex, more intrusive, more indecipherable, and more distant from the needs of average folks.

If you really want to fix the country’s health status, start with federal farm subsidies and trade policies to both help produce more, and lower the prices of, fruits, vegetables, and intact whole grains. Then, reintroduce health and physical education into every school in the US, starting with preschools and going right up through graduate schools. You might even require physicians to take a course in applied nutrition and applied exercise science. After all, if we are going to vest the medical establishment with “wellness” responsibilities, we might actually want to teach them something. In my entire adult life, I have never met a physician from whom I learned a single thing that would help me prevent one of the major calamities that is most likely to cause premature morbidity or mortality for me.

And, most importantly, start teaching public health 101: lowering medical care costs in absolute terms (a near impossibility because of demographics) requires reducing utilization, which you can do one of three ways: 1) shift the cost burden more to end users; 2) use regulatory strictures to restrict the flow of new technologies to market; or, 3) engage in your own personal affordable care act and live life in a way that minimizes the risk of engagement with the system. I choose option 3 for myself and my family, and I did not need an employer or the government to show me the way.

The ACA’s wellness rationale and provisions are jokes, based on lies. As implemented by BCN, they morph into an insulting and sick joke masquerading as substance.

Guest
Aug 20, 2013

Haley,
I would like to chime in here to say a few things: 1) the first Lady is as misguided as the health establishment when it comes to the obesity issue – physical activity and healthy eating are important for all children – (though not nearly as important as SES and economic disparity in terms of health risk) – putting those initiatives on the back of fat kids will only make the problem worse – after all we have been doing that for years with adults and where has it gotten us – and it is even more dangerous with kids – growing research on the negative effects of singling out fat kids available on request 2) the ACA’s promotion of incentives for health behavior change at the worksite are part of the problem not part of the solution – we have more that 25 years of really good data on human motivation and the use of extrinsic motivators like those in the so-called Safeway Amendment of the ACA (whose benefits by the way were completely made up) do not result in health behavior change or improved health outcomes and carry with them lots of potentially serious iatrogenic consequences. I would suggest reading Pink, Kohn and Deci for the details – BTW I am a big fan of both of the Obamas – but I am afraid they both drank the cool aid on these two issues – a shame really – Jon

Guest
Haley
Aug 20, 2013

Jon- incentives matter… the ACA actively encourages the behaviors you are decrying…

How would you solve this?

Guest
Aug 21, 2013

The behaviors that the ACA encourages are greed and neediness. Greed on the part of entrenched interests, specifically the hospital industry and the health insurance industry, and neediness on the part of individuals.

Guest
Brandon
Aug 20, 2013

Things like the BCN initiative and PSU debacle show how deeply corporate leaders misunderstand what they’re trying to do. I am doing this right now for a large medical industry employer, and I am quite sure that the org’s leadership is not ready for the wake up call that they will get. water filtration is one of the great way to improve overall health.

Guest
Haley
Aug 20, 2013

Brandon- I repeat my comment to Jon…

incentives matter… the ACA actively encourages the behaviors you are decrying…
How would you solve this?

Guest
Aug 21, 2013

Haley,
You can repeat that comment till the cows come home, but if you are at all interested in science/research you have some reading to do. Incentives do matter but not in the way you wrongly believe. As I mentioned in my previous response to you we now have hundreds and hundreds of studies with all kinds of populations clearly demonstrating that incentives do, in fact, not work for anything but the simplest of behaviors – and certainly not for changing complicated health behaviors or for improving health outcomes. As far as the ACA, the worksite incentives promoted through the bill were based on the claims of the Safeway CEO that using incentives (differential insurance premiums) for their employees reduced health care costs and changed health behaviors. I am assuming if you are in this field you know that these claims turned out to be completely untrue – bold-faced lies – there were no savings or improved health outcomes – the reason being that these kinds on incentives do not work and actually cause all kinds of problems. Repeating the same old inaccurate statements about the efficacy of incentives will be less useful for you than reading what the more than 25 years of scientific literature has to say about them – I would again suggest that you read that literature and see if it bears out what you are saying – Alfie Kohn, Punished by Rewards, Daniel Pink, Drive and anything by Edward Deci – who is the father of them all when it comes to human motivation. Rather than tell you what we should do instead – how to solve this in your words – it will be so much more beneficial to you to read the literature – the answers to your question are neither difficult nor obscure – but they have to begin with knowing what you are talking about – Jon

Guest
Haley
Aug 21, 2013

jon- I think you misunderstand my statement about incentives…

it had to do with the legislation- ACA- not with the employer policies per se…

put another way– the ACA created the incentives for businesses to try anything, something because of the employer mandate and the other features of the law about both wellness and penalties.

The incentives for business are now ‘baked into’ the law and its subsequent regulations.

so- how would you fix it? The law says what it says in plain language- can’t ignore it…

and please do not say ‘single payer’ because that has the same likelihood as some of the ideas from the right that are think tank documents.

Guest
Haley
Aug 21, 2013

and one more incentive in the law:

60% … of 548 employers surveyed recently by Aon Hewitt are reassessing their long-term retiree health strategies because of the ACA, with 40% of those already making changes directing post-65 retirees to the private individual market, with many of those plans containing a defined-contribution subsidy.

From HEALTH PLAN WEEK.

Guest
Aug 21, 2013

Haley,
The law does not say employers have to go the route of coercive wellness programs, differential insurance premiums and medicalizing the workplace – ala The Safeway debacle and the more recent Penn State nightmare. Well designed initiatives designed to improve organizational health (Lencioni – The Advantage, Cracking Health Costs, Emerick and Lewis, Gallup) and well being initiatives done for employees rather than to them together can actually save money and improve health and help contain costs. But neither the health insurance nor the wellness industries nor brokers or consultants have any reason to do that when they can make money with the status quo and at the same time divert attention from the greed and shortsightedness that are the real reasons why our health costs are so damn high and why we don’t get anywhere near the bank for the buck that similar countries do – read Dr. Otis Brawley – How we Do Harm and Dr. Nortin Hadler – The Last Well Person and Citizen Patient – Jon ps – also great article in the May 2013 Harvard Business Review – Creating The Best Workplace on Earth – for my money this is at least 75% of the answer – Jon

Guest
Haley
Aug 21, 2013

jon- not even arguing that ‘more effective’ options may exist for workplace wellness (but different companies make better or worse financial decisions than others all the time- and I assume you are not advocating central financial decision making for private companies)…

But, you are completely wrong to bring in the ‘other countries’ example— the USA also spends more on a whole variety of areas than OECD countries– and I do not hear a cry to ban spending in excess…

Also- education costs have risen at an even much higher rate than healthcare– and they are arguably causing much more stagnation for younger Americans (the same ones being hurt by higher costs under ACA) — and I hear no concerted outcry to lower spending, nationalize single payer college, etc…

so, in summary, private companies, given the incentives in the language of the law, are free to try policies which may or may not work…

So, again- how would you specifically change the plain language of the law to fix these new, even more perverse, incentives?

Guest
Noelle Davis
Aug 21, 2013

I’ve checked my job description: it outlines my job requirements and expectations. The company handbook lists the rules for sick time, leave, FMLA , etc., in case I need to use them for variances in my or my family’s health. None of the work relationship documents say that I have to work on my “wellness” as a condition of hiring or continued employment. I was hired to do a job; leave me alone to do it and stop interfering with my personal life. If the marginal cost of health insurance for me outweighs the value I can bring to the position, then disregard my experience and education and don’t hire my short, fat self.

Guest
Haley
Aug 21, 2013

Noelle- just to be clear — the law prevents discrimination for hiring… the law explicitly allows for self-insured companies to put these incentives (penalties) for health insurance for employees… 2 separate, and rather distinct issues…

conflating them is dangerous, because it suggests solutions that are not based upon federal law…

as an unrelated aside– is it discriminatory for people who cut women’s hair to charge, on average, more for a haircut than a haircut for men?

Guest
Noelle Davis
Aug 21, 2013

I believe that discrimination based on being short and fat (i.e., people with a high BMI) is still legal in most places (or at least not specifically illegal), so I don’t think I’d be protected most of the time. I know there are ADA issues that can come into play; I am not well-versed on those.

My point about the companies who can legally use the wellness participation penalties is not that they can’t; it’s that they shouldn’t. I suggest pre-planning in hiring decisions such that if the marginal cost of insuring me (which can only be guessed, since they wouldn’t actually know to what extent I’d use the insurance, drive up future rates, etc.) is greater than the value and/or profit that I can bring to the organization, than make the economic decision to not hire me. This saves the time, trouble, emotional disruption, decay of morale, etc., that is going to set in later when the companies try to save insurance money.

It is not discriminatory to charge more if the level of expertise and expectation of the final product (haircut) is higher. If both my husband and I want 1″ buzz cuts (and we started with about the same amount of hair), then it should be the same price. If he wants the simple cut and I want a layered cut with shaped bangs, I expect to pay more because I expect that it requires more skill and time.

Guest
Aug 22, 2013

Haley,
We are only discussing our health care system here – and the fact that we spend more than twice what any other comparable nation does and don’t get the same results does matter regardless of the other messes you describe. And it happens because the system is designed to make a small group of people rich at the expense of the rest of us. So, in reality, the system is not really broken, but as Dr. Otis Brawley, chief medical officer for the American Cancer Society puts it (How We Do Harm) – it is functioning exactly the way it was designed to. On the ACA issue, as someone else also mentioned the law does not say that companies have to do this stuff to their employees only that they can – and many companies were doing this already before the bogus Safeway Amendment was concocted – the solution as I mentioned is relatively simple, though perhaps not easy – we need to convince business that it is not in their best interest and in fact quite counterproductive to force wellness down their employees throats – either from a health (personal and organizational) or cost perspective – many of us are working hard on that as we speak! Jon

Guest
Sandy
Aug 22, 2013

Those popularized “cardiometric measures” you mention are just as unscientific, mathematically berefit proxies for health as BMI.
They are primarily associated with aging, as well as genetics, socio-economic stresses, etc. This is just the latest and
currently politically correct way to discriminate against those who our culture views as undesirable and less valuable to society….
the aging, sick, fat, disabled, unborn, innocent and frail.
The notion that any healthcare professional or credible patient advocacy group would advocate any behavioral or dietary
mandates to save healthcare costs or prevent diseases of aging is a very slippery, discriminatoryand harmful slope. Not to
mention scientifically unsupportable.These “wellness” programs are riffe with pseudoscience. Their real purpose is to make
vast amounts of profit for the insurance companies (follow the money with testing labs, diets, pharmaceuticals and exercise
programs), not in any real ability to prevent chronic diseases of aging. Their even larger purpose is government control over
citizens. The parallels to the old Nazi healthy and fit bodies campaigns are so close, they’ve become indistinguishable.

Guest
Aug 22, 2013

Sandy – though I hesitate to compare this stuff to the Nazis – being Jewish as I am – the rest of what you had to say about these programs is unfortunately close to the reality – thanks – Jon

Guest
Joanne Ikeda
Aug 22, 2013

Great article! Makes one wonder what the Blue Cross administrators were thinking when they decided to do this. Of course it won’t work but the dunces at Blue Cross can say they are doing something (causing harm rather than good) about the OBESITY EPIDEMIC.

Guest
Aug 26, 2013

Joanne,

I also think that we should stop calling it the Obesity Epidemic. The word epidemic applies to ailments or conditions that are either spreading aggressively throughout a population or is ubiquitous (obesity clearly is neither, as 2/3 of the population is NOT obese and the rates are stabilizing). When we use the word epidemic, what we’re doing mostly is ratcheting up the rhetoric in ways that suit the interests of the obesity industry, which includes weight cycling companies, wellness vendors, researchers, and others who actually need the problem to persist because that’s how they make money.