The Summer of Wellness’s Discontent

The Summer of Wellness’s Discontent

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The series of unflattering articles published in Health Affairs early this year – the first unfavorable press wellness had ever received in a top tier policy journal — turned out to be a harbinger of what became the wellness industry’s summer of discontent.  Perhaps in error, the Journal of Occupational and Environmental Medicine (JOEM) also drifted into the sea of credibility on wellness early in 2013 by publishing a meta-analysis of the industry’s claims of economic success.

The analysis, by researchers at Tufts, destroys the industry mythology of respectability by noting that out of over 2,000 papers published in the world’s medical literature, only 10 (0.5%) are worth discussing and that discussion leads essentially nowhere.  Not surprisingly, like our essays here and in Health Affairs, the Tufts work has been universally ignored by the wellness true believers.

Starting with those articles, and especially over the last four months, those true believers have lost control of the dialog — starting right here with THCB, which gets credit as the first major regular source of objective news not generated by the wellness industry’s propaganda apparatus.

June brought the RAND report, our Wall Street Journal op-ed, and Cracking Health Costs.  Unlike Health Affairs, some HR administrators have actually read those publications.  These developments left them asking uncomfortable questions of an industry that hitherto had filtered the information that its customers received through the JOEM and the Journal of Health Promotion, the industry’s de facto house organs that between them in thirty years have published fewer articles concluding wellness doesn’t work (just that single meta-analysis mentioned above) than Health Affairs has in 2013 alone.

But it wasn’t until July that the wheels fell off the wellness bus, due to four self-inflicted wounds that did more to diminish the industry’s carefully cultivated albeit totally undeserved patina than anything we could have written.    Atoning for its brief foray into accuracy, JOEM published an article showing $20-million in savings for British Petroleum’s (BP) wellness program, 100 times what the vendor, Staywell, claims on its own website to be possible.

And by BP’s own admission only 1138 people stayed in the program long enough and were successful enough to reduce risk factors at all.  (Not to mention that the 20,000 people in the program would not have even had incurred $20-million of wellness-sensitive medical claims in the first place, making avoidance of that much mathematically impossible.)   Ironically, to prevent exactly this type of embarrassment, BP had retained Mercer to guard its henhouse by validating Staywell’s findings, but Mercer – which had a pre-existing relationship with Staywell — endorsed the findings instead.  So rather than guard BP’s henhouse from Staywell, Mercer held a chicken barbeque in their honor.

Second, Limeade bravely broke ranks and acknowledged the obvious truth that no wellness company had hitherto admitted:  Comparing participants to non-participants to show savings – the methodology upon which the industry’s entire pyramid of savings claims were built — is invalid. In Limeade’s eloquent words:  “Self-improvers are likely to be drawn to self-improvement programs, and self-improvers are more likely to improve.”

They Can’t Handle the Truth

July’s third self-inflicted wound was the decision of the C. Everett Koop Wellness Award Committee to honor a program whose data was obviously made up…and then to refuse to rescind the award when the three perpetrators of those lies –  a vendor that claims wellness programs don’t even have to exist to save money and the state of Nebraska – admitted the most egregious falsehood:  the 514 people who they claimed had cancers on which they made “life-saving catches” did not in fact have cancer at all.  Rather, they had lesions and polyps that had small chances of someday turning into cancer.  To say Nebraska’s program made 514 “life-saving catches” would be only slightly more accurate than saying that getting 514 people to wear seat belts saves 514 lives.  Indeed, the National Cancer Institute itself has now chimed in and said that it is critical to stop labeling noncancerous lesions as cancer because doing so promotes both fear and unnecessary care.

Even by the ethical standards of the wellness industry, where every single vendor claiming savings can easily be shown to be making them up, besmirching the name of history’s most revered Surgeon General for dishonest commercial purposes elevated malfeasance to a new plateau.  Koop Committee members, allegedly the field’s leaders (representing Truven Health Analytics, along with Staywell and Mercer), asked themselves the question:  “How would America’s Family Doctor — a man whose integrity was his calling card – have reacted to his name used to endorse acknowledged lies?” and decided his reaction wouldn’t matter. So they let their friends in Nebraska keep their award notwithstanding their lies.

The health services blogosphere was atwitter with outrage, and LinkedIn polls of the wellness rank-and-file were unanimous in opposition.  It would also appear that the Koop Committee is taking a major gamble that the lay press won’t notice their desecration of perhaps the most popular and accomplished Surgeon General ever.

But Wait…There’s Less

July began with news from tech powerhouse Intel that it was jumping from the wellness ship.  The company’s director of healthcare strategy asserted that their wellness experience was sufficient to show that it “wasn’t going to bend the [cost] trend.”

Just a week later came the fourth self-inflicted wound that may ultimately bleed the contemporary wellness industry to death, as its most respected supporter also abandoned ship.  For three years the industry had been clinging to the single article in a respected journal supporting a wellness ROI, a 2010 Health Affairs paper by Harvard Professor Katharine Baicker entitled:  “Workplace Wellness Programs Can Generate Savings.”   While it’s almost impossible to find a subsequent pro-wellness article that does not cite this one, that’s apparently not enough for the editor-in-chief of a newsletter called The Art of Health Promotion, who wrote:  “Because of the importance of this independent study…, it should be cited much more frequently.”

Quite the contrary, we suspect that it will be cited much less frequently:  On July 23rd, Professor Baicker abruptly became wellness’s Emily Litella.  Interviewed on NPR’s Marketplace, she delighted critics and shocked true believers with her candor.  She boldly replaced her seminal and oft-cited (more than 20,000 times, according to Google) 3.27-to-1 ROI conclusion that (along with fictional Safeway results) had launched the ACA’s wellness provision with an admission that even with 30 years of wellness programs “it’s too early to tell” whether these programs work.  Curiously, she suggested instead that CEOs continue to “experiment” on their employees, not exactly the rallying cry the industry was hoping for.

The Industry Should Take a Mulligan

Where does the industry go from here?   The preferred route seems to be self-parody.  At one conference, a presentation entitled: “Help Employees and Dependants [sic] Become Better Stewards of Their Own Health and Well-being” proposed that wellness programs could prevent industrial waste (but apparently not spelling mistakes).   Next, a wellness vendor held a webinar on why critics’ wellness math is wrong.  Ironically the webinar’s featured speaker believes that wellness can reduce costs by more than 100%.   And another vendor, demonstrating the industry’s gravitas, recently appointed a Chief Happy Officer.

The clincher, however, was the faculty revolt against the coercive, ill-conceived, and expensive Penn State wellness program, a joint venture of Highmark, WebMD, and the unofficial leader of the true believers, Ron Goetzel.  The revolt story broke on THCB and soon went national.  This was in late August.  A month later, following withering coverage in almost every major publication and near-unanimous faculty disapproval, Penn State’s administration caved and abandoned the program.

We hope history will record the Penn State debacle as the industry’s high-water mark for stupidity, and we are proposing a total re-boot to ensure nothing like this ever happens again.  Start by acknowledging that science knows shockingly little about obesity’s causes or solutions, blood values are crude predictors of adverse medical events, and screens are a major and expensive contributor to overdiagnosis.   Put it all together and Professor Baicker is right:  you are experimenting on your employees…and neither the science nor the math presages a favorable outcome.

So why not try a wholly new approach to wellness and instead of doing questionable or even harmful things to employees, do things for them and with them?    Or, put another way, instead of trying to force people to change against their will (and possibly against their genes), facilitate change for those who are ready and need a little help opening the door to healthier opportunities.  Offer (but don’t require or involve incentive/penalties) fitness/exercise options and make them convenient.  Subsidize healthy food in the cafeteria.   Beautify your campus and stairwells to encourage people to walk.  Commission art, signage, and murals that deliver positive health messages.  Do any number of things that remove impediments to good health for those who desire it and make it attractive and safe for those who are skeptical or reticent.  This is a totally new strategy for most companies:  helping water to flow downstream is a more promising strategy than trying to force it to flow upstream.

Measurement and program selection should be quite easy.  Recall Limeade’s observation and ask three questions:

  1. Do you consider yourself a self-improver?  <If not, stop here>

  2. Do we offer sufficient opportunities for self-improvement? <if yes, stop here>

  3. Suggest some opportunities you would like to see offered.

Finally, it’s time for new de facto industry leadership.  We look at companies like StickK, Allone, and Healthways, which have broken ranks and acknowledged the lack of integrity in this field, thus enhancing their own.  Limeade earns a spot that pantheon as well, based on its aforementioned industry White Paper.  The pursuit of health through conventional wellness has become an embarrassing charade, and it does nothing but detract from the nation’s most pressing health needs.  Despite the industry’s affection for fantasy, fables, and falsehoods, the summer’s events show clearly that at the end of the day facts matter.

Al Lewis is the author of Why Nobody Believes the Numbers, co-author of Cracking Health Costs: How to Cut Your Company’s Health Costs and Provide Employees Better Care, and president of the Disease Management Purchasing Consortium.

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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46 Comments on "The Summer of Wellness’s Discontent"


Guest
Sep 23, 2013

Vik and Al: Thank you for this comprehensive summary of some of the recent events that are signifying and/or triggering a shift in the wellness industry.

I think many employers, and even many vendors, have long known that a “culture of health,” including health-promoting work environments, has the potential to prompt measurable improvements in population health (though employers need to think broadly and long-term in order to appreciate these improvements). In my opinion, part of the reason these changes have played second fiddle to screenings and unproven behavioral strategies is because employers have been desperate for short-term solutions, and vendors have responded by trying to meet that demand rather than conducting the hard work of “commoditizing” a culture of health.

Perhaps unlike you, I bear no ill-will toward vendors. Yes, vendors’ ROI claims are specious. But purchasers have enabled this ROI mythology. In fact, wellness vendors have shown that they can play an influential role in the industry (as they do in *all* industries), by promulgating belief, albeit misguided, in the connection between their products and health care cost control. Imagine if vendors’ investments in product development and marketing were redirected to things that really count!

My ultimate question to you is, rather than eagerly anticipating the potential demise of wellness vendors, is it possible to identify a role for them in cultivating a culture of health? Are there products or services that can further this cause? I know it’s tempting to think that employers can or will take the appropriate measures without vendors. But history has shown that vendors can often persuade organizations in a way that insiders often cannot (regrettable as this may be). To put it in terms that you may relate to, can the power of vendors be channeled for good, rather than evil? Coca-Cola and Pepsi saw the writing on the wall, and now have a huge business in bottled water. The fast food industry is trying to reinvent itself with healthier options and even more healthful restaurants like Panera’s. How can the wellness industry reinvent itself to help support the future of *real* employee wellness?

Thanks. I look forward to your insights and those of your readers.

Guest
Sep 24, 2013

Bob, thanks for the excellent comment. I am agnostic about whether wellness vendors survive and thrive.

A company leader thinking about shifting from the conventional wellness approaches to what Al and I teach is going to be thinking about the best ways to cut across organizational silos and build a positive health-centric culture that makes wellness part of the organization’s DNA.

As its done today, wellness is just a organizational health tidbit, and the vendor-driven deceptions, inaccuracies, and ineptitude just drive further fragmentation and promote laughingstock status. It’s not clear to me how, without admitting responsibility and accepting the blame for so much that’s wrong with both wellness content and messaging, any corporate leader regards them as serious partners in far more complex and challenging strategies.

Guest
Al Lewis
Sep 23, 2013

Bob, as usual you raise a really good question (I continue to believe you’ve missed your calling in life and/or I hope Paychex appreciates you as much as we do). I think rather than take up all the comment space here let’s switch this to a linkedin group and then report a summary here.

By the way, I don’t bear ill will towards 80% of vendors–the ones who don’t make up ROIs. It’s the 20% that get my gander up. Even when they get caught and/or admit it, like Health Fitness Corp. or Staywell, they don’t apologize.

Guest
Sep 23, 2013

Great article – Bob – I would venture a quick answer for your question – I think what is missing for many if not most vendors among other things is any understanding of what a healthy organizational culture really means. So they have zero clue about how to help organizations move in that direction. Because so many are educated in the allied health professions and have listened to their leaders in the field – also trained similarly – they seem to think that promoting a healthy work culture is about aerobics in the south lobby, pedometers, smoke free campuses and broccoli in the cafeteria. These things are all well and good but imposed on a dysfunctional work culture, which so many are they will have little impact on anybody’s health, least of all the organizations’. I try to help other health professionals to understand this concept by suggesting they read, for instance, Lencioni – The Advantage and/or Jacobs – Management Rewired – They need to come to the realization that if you build a house on quicksand, you are not going to have a house for long. The canned, gamey, wellness programs so many are hawking are just no substitute for doing the work of making the workplace somewhere people want to go and making the work something they feel inspired to do. When that real work is done, people will not need to be coerced, payed and poked to tke better care of themselves – they will do so because they feel good about who they are and what they are doing. If we could also switch people’s allegiances around from Skinner and Prochaska to Deci and Pink we could go a long way towards turning this thing around. – Jon

Guest
Sep 23, 2013

Al, Vik — Very important recap. Thank you.

I value and appreciate both (i) the efforts of the wellness industry thus far, even if some say overly aggressive, and (ii) the constructive fact-based analysis and reality-checking by you and others.

I see the above in the context of the natural evolution of (new) industries, like I saw in my 10+ years at Google/YouTube/Netscape and the industries those companies gave birth to (or reinvented) and operated in.

I see the above less in terms of right or wrong, and more in terms of how they collectively advance us closer to the best/right solutions (including hopefully the one I’m working on 😉

Kumbaya!
Kevin Yen

Guest
Sam Lippe
Sep 24, 2013

Covering the healthcare services industry, I have yet to see one instance in which wellness saves money. If a CEO were to announce in an analyst meeting that his company contracted with a vendor for a wellness program, that would tell me he or she isn’t focused on the right business priorities or even the right priorities within the healthcare benefit

Guest
Sep 24, 2013

That’s a great observation for what wellness is in many, many organizations. It is a distraction, intended to make it look as though the entity is working to solve whatever health-related conundrums it faces. But, high value initiatives within organizations are directed from the C-suite, not handed off from the C-suite to HR. My experience jibes with your observation. Wellness is a hand-off from people who want to look like leaders to wellness vendors who could not lead water downhill.

Guest
Sep 24, 2013

Sam — I appreciate the data and (lack of) results to date.

Three high level comments:
1. Do we believe an effective/worthwhile wellness program is even possible?
2. How do we define “wellness program”? Or maybe it doesn’t matter, as long as employees get healthier at same/lower costs.
3. Most corp programs (not just health/benefits) should not and do not reach the level of CEO/analyst call.

I’d value your thoughts and/or references, especially on #1.

Thanks,
Kevin

Guest
Al Lewis
Sep 24, 2013

#1 is a Great question. I think the answer is yes but (a) it’s not a “program” — it’s a culture and (b) it’s not just about health. It’s about morale. If you were a general leading an army into battle, would you rather have trooops with high morale or troops with low cholesterol?

Guest
Sep 24, 2013

Al — Thank you. Your suggestions are spot-on.

Guest
Sep 24, 2013

With regard to data or results “to date,” the conventional approach to wellness has now had 30 years to prove itself and there is almost nothing to show for it, as virtually every measure of population health has worsened during those three decades.

Wellness is not (or should not be) a program, but a philosophy, the atmosphere that the organization’s leaders create for employees. And not rah-rah Chief Happy Officer-type b.s., but a series of opportunities, from food services to flexibly scheduled work, that encourage positive decision making.

The drive for better organizational atmospherics cannot come from wellness vendors and HR…it must come from the leaders of the organization whose visible participation speaks to their commitment to that. Today, for many business leaders wellness is nothing more than a photo op with some bogus award in hand.

Guest
Sep 24, 2013

Yes, and some in the industry are working on solutions that are less conventional than others.

I believe in pushing forth with new ideas. A history of failure obviously does not condemn novel and invention.

Lots of ascerbic critique aimed at wellness vendors. Some valid, some not, and in those critiques we need to discern the role of the vendors vs the customer organizations, as you have discerned.

Together, onward! :)
Kevin

Guest
Tom Emerick
Sep 24, 2013

Al and Vik, a terrific article you wrote. Please keep up the good work. One of these days sober minds in HR and on corporate executive committees will wake up. The rushing sound will be companies looking for someone to account for all the wasteful and harmful spending on wellness programs.

Admin
Sep 24, 2013

My summary of the way forward
1) Intensive attention to people who are already sick (stop stupid shit being done to them and coach them to do better, and stop the mass screenings).
2) Use the new tools and data sourcing to figure out who needs real attention (the Eric Topol thesis of using an intervention on the 15% of the cohort who it will actually work for)
3) Get away from ROI to actually doing good (this is Al & Vik’s “create a nicer, healthier workplace cos it’s the right thing to do” and don’t trust some outside wellness vendor to do that all by themselves if you the employers are already toxic )

Guest
Tom Emerick
Sep 24, 2013

Matthew,

Great points, esp. #1. Companies are spending their time and money trying to manage 20% of spending. A big ROI is to be had by concentrating on the 6% who spend 80% of plan dollars, very few of whom have conditions that are preventable in any way unless wellness can prevent aging and change your genes.

Cheers,

Tom

Guest
Sep 24, 2013

Interesting post. Tomorrow I have to get up early and submit to some “Wellness Screening” stuff at my wife’s company, so that we get some “rate discount.” Having retired from my REC gig, I’m now on her insurance. Just gonna smile, play ball, and not make any waves for now, I guess.

I would speculate that, were we able to do a sound scientific study, we’d find that MOST U.S. companies are organizationally/psychodynamically toxic, places where one speaks truth to power at one’s peril
(notwithstanding all the cherubic blather about “openness” and “safe culture”), places where backstabbing org chart climbing are rife, places where the bookshelves groan under the weight of books on “leadership” and “empowerment” and “team building.”

That, sadly, would characterize my last place of employment — a QIO, REC, and now HIE (for whom I worked 3 times spanning 20 years, noting an accelerating change for the worse). It was a factor in my “retirement” in April. They’d started into this lame HR-driven “wellness” “Re-Education Camp” initiative this year that was pure Dilbert Zone. I pretty much ignored it.

Wallpapering pretty “wellness” laminate over toxic business cultures is gonna do little more than decrease operating margins.

I’ve worked for seven employers across my white collar career. Only two of them could be considered culturally non-toxic.

Guest
Sep 24, 2013

Bobby, just remember as you head to wellness camp, that you can answer however you please on the HRA. The more bogus data you submit, the more you screw up the vendor’s carefully cultivated image of seriousness (absurd as that image may be). And the harder you make it for them to be taken seriously by the employer.

Guest
Sep 24, 2013

Copy that, Vik.

Guest
Tom Emerick
Jun 16, 2014

Very good answer Vik.

tom

Guest
Cynthia
Sep 24, 2013

Wellness programs are based on good ol’ common sense, so these programs should cost hardly anything to run. But the truth of the matter is that those in the wellness industry will find a way to overcharge you for giving out common-sense information. I already see this happening at the hospital where I work. The hospital has recently hired a gold medal winner at the 1999 Pan American games with a PhD in “Human Studies” ( I suppose that’s the opposite of “non-Human Studies”) and is paying her six figures to tell employees to do such common sense things like eat right, don’t smoke, look both ways before crossing the street, and always wear a seat belt when your behind the wheel of a car. Sorry, but this is something that a minimum-wage daycare worker is more than qualified to do. What an absolute waste of healthcare dollars!

Guest
Sep 24, 2013

And I will bet, Cynthia, that the hospital cafeteria sells any number of unhealthy items, many of them at subsidized prices because moving a large volume of soda, candy, and chips is very profitable, which matters to the hospital executive whose bonus and compensation are tied to the financial performance of food services.

I will further wager that the vending machines sell garbage (a hospital I visited recently actually sold microwavable deep fried, packaged pork chops from a vending machine); there are no policies about supporting employees getting all the exercise that Madame Gold Medal is telling them to get; and, except for photo ops, there is no one in the C-suite that gives a flip about anything she says. They’re too busy focusing on optimizing payer mix and maximizing reimbursement.

Guest
Tom Emerick
Sep 24, 2013

Here’s an interesting phenomenon. It proves in a new way how flawed employee surveys really are. When HR teams get employees together in focus groups, the employees nearly always say they want healthy snacks in the vending machines…in other words they tell the HR team what they want to hear. The companies in turn ask the vending machine operators, nearly always independent businessmen, to load the machines with raisins, granola bars, etc. Six months later the vending machine operators complain that most of the healthy snacks are expiring without having sold a single snack in some categories. Of course the independent operator is on the hook for those losses. They say either find another vendor, or let them add back in snacks that sell…and the loop continues. The question is why do informed people make bad choices? Research is indicating that work-related stress is a big part of the problem. Fix the stress and people will eat better.

Cheers,

Tom

Guest
Sep 24, 2013

Goes to my assertion about the high prevalence of psychosocial toxicity in organizations.

Guest
Tom Emerick
Sep 24, 2013

Psychosocial toxicity is just what is happening in HR departments across the US.

Guest
Sep 24, 2013

Just the name “Human Resources” tells us a lot. None of it good.

Guest
Sep 24, 2013

Good summary review on what has been a questionable practice all along – HR driven wellness programs.

In a research rpt we did a couple of yrs back we found a number of lg employers pretty ticked off at their HR depts for not effectively getting at the heart of the healthcare cost problem – the cost of care delivered – and instead, trying to slap bandaids (wellness programs, CDHP – cost shifting, etc.) on arterial wounds. I remember one very lg employer mentioning that things had gotten way out of hand with over 30 wellness vendors showing up for the annual employee health fair. Pretty ludicrous.

What we are starting to look at now is how the dynamics of healthcare reform may change wellness programs within the workplace. Just recently, Walgreens announced that it will be giving cks to some 160K of their employees telling them to go buy their own insurance on the HIX in their state. IBM did something similar with their retirees. At a recent employer HR conf this summer, the talk among service-based employers was how to keep hours below the full-time threshold and move others to HIX. This trend could gut the employer wellness industry.

But as providers take on more risk for managing the patients in their community, will they be the next target for wellness vendors? If so, hopefully, providers will be a bit wiser. (On a side note, spoke with mjr US provider today who offers their own HRA/wellness programs to employers and payers already and see big opportunities here).

Guest
Mitch Collins
Oct 19, 2013

I think it is unfair to call wellness programs HR driven. HR is under pressure to “do something” about health care costs and at least the good ones know the real drivers that can impact this are the things that drive the organizational toxicity mentioned above.

Now, if the CEO comes in and tells you to fix something and you inform her she needs to run the organization differently, stop making people work 90 hours a week and on and on…..you will be unemployed.

So you “do something.” You were not told to do something that worked, just do something.

So you did.

Guest
David Burrows
Sep 24, 2013

One correction: Penn State has not abandoned their wellness program – they have merely dropped penalties for noncompliance for this year.

Guest
Al Lewis
Sep 24, 2013

Yes–I interpreted that language as a face-saving way of backing out altogether, since once they pause long enough to read literature other than what Highmark’s consultant showed them (according to their HR VP Susan Basso, they haven’t read anything else, at least not yet), they’ll see they dodged a financial bullet.

However, if indeed at the end of the year they reinstate the penalties, let me know and I’ll reserve some front-page space in all the blogs I contribute to…

Guest
Sep 24, 2013

Actually, Penn State never had an employee wellness program; they had an employee surveillance program. Life insurance companies often require a medical exam prior to purchasing policies, but they don’t have the audacity to call it a wellness program. And even if they did, none of us would be naive enough to believe them.

As someone who believes that, contrary to the consensus here, good employers with sufficient resources have an imperative to support the well-being of employees, I find it regrettable that both advocates and critics speak interchangeably about these desperate, heavy-handed, misguided attempts at cost containment and employee wellness. They are not the same, and sometimes, as we have seen, they are polar opposites.

In any case, readers of this thread may be pleased to learn that tomorrow’s (9/25/2013) New York Times will report that Rep. Louise Slaughter, on the heels of the Penn State debacle, is seeking EEOC rules for employers’ health risk questionnaires.

Guest
Mitch Collins
Oct 19, 2013

Maybe the Pennsylvania readers of this blog could write to their representatives and ask why PS is wasting money on a program that obviously does not work? Especially with the $50M+ and counting they are spending on the abuse scandal.