NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # INNOVATION: PCORI APP Challenge

Vik Khanna

T was never a star service tech at the auto dealership where he worked for more than a decade. If you lined up all the techs, he wouldn’t stand out: medium height, late-middle age, pudgy, he was as middle-of-the-pack as a guy could get.

He was exactly the type of employee that his employer’s wellness vendor said was their ideal customer. They could fix him.

A genial sort, T thought nothing of sitting with a “health coach” to have his blood pressure and blood taken, get weighed, and then use the coach’s notebook computer to answer, for the first time in his life, a health risk appraisal.

He found many of the questions oddly personal: how much did he drink, how often did he have (unprotected) sex, did he use sleeping pills or pain relievers, was he depressed, did he have many friends, did he drive faster than the speed limit? But, not wanting to rock the boat, and anxious to the $100/month bonus that came with being in the wellness program, he coughed up this personal information.

The feedback T got, in the form of a letter sent to both his home and his company mailbox, was that he should lose weight, lower his cholesterol and blood pressure, and keep an eye on his blood sugar. Then, came the perfect storm that T never saw developing.

His dealership started cutting employees a month later. In the blink of an eye, a decade of service ended with a “thanks, it’s been nice to know you” letter and a few months of severance.

T found the timing of dismissal to be strangely coincidental with the incentivized disclosure of his health information.

Continue reading “What If Your Employer Gets Access to Your Medical Records?”

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We’ve seen shorter abstracts, and we’ve seen abstracts with more curious findings, but we’ve never seen a shorter abstract with more curious findings than this one, done by Dignity Health and Dr. Rajan Merchant, and financed by the California Healthcare Foundation, evaluating a gadget made by Propeller Health.

The study group’s use of inpatient care for asthma declined by a whopping 62% vs. the control group.  You might think this result violates Dr. John Ioannidis’ well-known conclusion that large treatment effects are usually wrong, but you’d be mistaken.  You see, there was no treatment here.

There was only an effect.  Dr. Ioannidis’ result applies only to actual comparisons of effects due to different treatments, not to random changes in effects using the same treatment.  In this study, the actual treatment protocol was the same and the inhalers were the same.

The only thing different was frequency of drug use.  Whereas the conventional wisdom for disease management states that hospitalizations can be avoided by more adherence and hence more drug use, in this case the study group used less medication than the control group, reaching for their rescue inhalers 25% less– once every 6.3 days vs. every 4.7 days for the control group.

Continue reading “Meet Propeller Health: Digital Health’s Poster Child for Invalid Savings Reporting”

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THCB is excited to announce the first official e-book release from THCB Press, “Surviving Workplace Wellness” by contrarian Wellness industry observers Al Lewis and Vik Khanna.”  What exactly is the “Wellness industry” anyway? How scientific is the “science” behind wellness programs? Are stop-smoking programs a good idea? Should your company really be paying to send employees to the gym?

Should you be using technology to help your employees monitor and understand their health? You may not always agree with the authors (we certainly don’t here at THCB world headquarters, where Al and Vik have started more than a few food fights) but we still think you’ll find this title a provocative examination of many of the fundamental assumptions underlying prevention and wellness today.

You can order your digital copy from Amazon.com here at the discounted price of $9.99.  If you’re a healthcare insider trying to understand the controversies facing wellness or a conscientious wellness professional trying to get a handle on developing a program that works for your employees, this is the e-book for you.

Be sure to look out for upcoming releases from THCB Press in the months to come.  If you’d like to be placed on the THCB Press mailing list to be notified of upcoming new releases, send us an email with “update me” in the subject line.  Author inquiries and partnership requests should go to this same address.John Irvine

Continue reading “Good News! A Workplace Wellness Vendor Saying You’re Sick Means You’re Probably Healthy”

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The ever-blurring line between the practice of medicine and the business of profiting from unhealthy lifestyles was crossed again Wednesday, as Aetna announced a collaboration with two pharmaceutical companies to pitch their prescription weight loss drugs to selected Aetna members.

This announcement crosses multiple lines, not just one. First, no insurer has ever announced that it would openly direct a specific class of members to use particular proprietary drugs. Disease management (DM) programs rarely recommend specific drugs, and certainly in the exceptionally rare instances when they do, the recommendations are not specific brand-name drugs (in this case, Arena’s Belviq and Vivus’s Qsymia).

Instead, DM focuses on improving compliance with existing drug regimens, and DM firms encourage members “talk to their doctor” about changing therapies. While DM companies shy away from directing patients to specific products, physicians and pharmacists have discretion to discuss the full range of covered generic and brand products with patients, in order to optimize therapy and close algorithm-identified care gaps.

Second, there are no generally accepted care algorithms (other than those created by the manufacturers of those products) for these two drugs in the treatment of obesity. So there is no “gap” to fill. If there were an accepted protocol, these drugs might be blockbusters but instead Belviq’s recent quarterly sales were an anemic $4.8-million, “well below even reduced Wall Street expectations,” while QSymia sales are “flailing” at $6.4-million for the same period.

Obese people and their physicians seem to be avoiding these drugs in droves. Regardless of what Aetna and the manufacturers believe about their effectiveness, or whatever promotional deal they’ve cut, market reaction is telling a different story, and unfortunately for Aetna, Vivus, and Arena we live in a market economy.

Continue reading “Dr. Aetna Will See You Now”

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For those of us who actually think wellness outcomes should be evidence-based, a landmark study was released today:  the first evidence provided by a major organization voluntarily (as opposed to being outed by us, like British Petroleum and Nebraska) that wellness doesn’t work.   January’s Health Affairs features a case study of PepsiCo, authored by RAND Wellness Referee Soeren Mattke and others, in which a major wellness program was shown to fall far short of breaking even.

The specific highlights of the PepsiCo study are as follows:

  • Disease management alone was highly impactful, with an ROI of almost 4-to-1;
  • Wellness alone was a money sink, with each dollar invested returning only $0.48 in savings;
  • The wellness savings were attributed to an alleged reduction in absenteeism, as self-reported by participants.  There was no measurable reduction in health spending due to wellness.

Even though the wellness ROI was far underwater, we suspect that the ROI was nonetheless dramatically overstated, for several reasons.  First, the authors acknowledge underestimating the likely costs of these programs, focusing only on the vendor fees without considering lost work time, program staff expense and false positives.  Second, no matter how hard one tries to “match” participants with non-participants (the wellness industry’s most utilized measurement scheme), it simply isn’t possible to compare mindsets of the two groups.  We learned from one of Health Fitness Corporation’s many missteps that participants always outperform non-participants, simply because they are more motivated.  Third, the absenteeism reductions were self-reported, by participants.

Finally, PepsiCo’s human resources department, having made the mistake of accepting Mercer’s advice to implement one of these programs, was already taking some political risk by acknowledging failure.  Had they incorporated the adverse morale impact, lost productivity due to workers fretting about false positives, Mercer fees and staff costs, participant bias, and self-reporting bias, the ROI could easily have turned negative (meaning the program would have been a loser even if the vendor had given it away) and the HR staff could have been taking serious career risk.

Continue reading “PepsiCo’s Wellness Program Falls Flat”

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We don’t make a lot of New Year’s predictions, but we are happy to make this one: 2014 will be the year the get-well-quick mentality driving corporate and individual health choices implodes…and people start taking genuine steps to be healthy. The way to ensure that 2014 is your year for good health?  Start with a double negative:  (a) wellness industry advice is almost always wrong; and (b) most people don’t keep their New Year’s resolutions. Hence, making the New Year’s resolutions recommended by the wellness industry is not the best way of ensuring your good health in 2014.

For simplicity, we’ll divide this list into individual and corporate wellness industry resolutions, and start with individual ones.

  1. Take more health advice from celebrities. Whether it’s hoping that Kim Kardashian’s personal trainer can help you or pining for Dr. Oz to cure what ails you with green coffee bean extract and raspberry ketones, a good way to put off doing worthwhile things is to do worthless ones.

  2. Start a weight loss program. The medical establishment could not head off the obesity dilemma at the pass, and they have no solution for it now, other than to crow about more drug companies diving into this expanding market. There is zero evidence that weight loss programs can produce sustainable long-term weight loss (and much evidence that they don’t), and we don’t know of a single one shown to improve fitness. That will not, however, prevent weight loss companies from trying to claim their little piece of the wellness landscape because they are losing so many individual customers to free dieting apps, such as LoseIt.com. Improve the quality of your diet first, and weight loss may follow, which is a bonus.

  3. Give yourself a cleanse. America’s obsession with cleanliness is now running smack into the reality of evolution and human physiology.  Surely if bacteria in your colon were bad for you, mankind would have died out eons ago.

  4. Stock up on supplements. The only things better than raspberry ketones and green coffee bean extract: all the other vitamin and mineral supplements on the market that fail to make sick people better or healthy people healthier. Who’s left to try to help, Martians? Never mind that risk is not endlessly reducible and the four most important things you can do for your health don’t come out of a bottle of magic jujubes: exercise, don’t smoke, eat well, and keep as close to a healthy weight as you can.

  5. Remove saturated fat from your diet. Just like in the 1960s, when we all traded in “the high-priced spread” for sticks of partially hydrogenated vegetable oils fit for a king to avoid saturated fat, we may be mis-demonizing this longstanding and naturally occurring component of our diet.   The entire nutrition dialectic in our culture over the past 20 years has focused on a string of individual no-nos: fat, saturated fat, cholesterol, and now refined grains and sugars (because we bought the government’s wrong advice to eat low-fat). It’s time to revive the notion of healthy eating patterns, not healthy eating isolates. In fact, here is the world’s simplest diet advice for 2014: eat less junk. That alone would be a landmark nutritional achievement for Americans.

  6. Eat organic and stay away from Starbucks. Within a week of each other, the New York Times published an account of a woman damaging her health eating an obsessively healthy and organic diet, and USA Today wrote of  another who ate exclusively at Starbucks for a year, with no apparent ill effects and no weight gain.

  7. Continue reading “Ten Health and Wellness Resolutions Not to Make in 2014″

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Every now and then even blind squirrels find acorns.  The medical care industry, which long ago abandoned sensible fiscal and therapeutic restraint in the quest for new patients, finally treats us to a revised hypertension guideline that thoughtful people can conclude makes a great deal of sense.  It is even based on evidence, or actually the lack of it, which is itself a startling admission of reality from an industry that dances around truth with a nimble sophistry envied by even the most mendacious politicians.

The hypertension guidelines are a sharp departure from last month’s cholesterol guidelines, produced by a supposedly equally august panel of “thought leaders” who gave us guidelines that seemed to channel the The Talking Heads quite literally.  John P. Ioannidis, along with Nortin Hadler, easily one of the two or three most important physician thinkers of this or any generation, wrote that the cholesterol guideline will be either…”one of the greatest achievements or one of the worst disasters of medical history.”

If you haven’t read the hypertension guidelines, here is a useful summary:

  1. we treat too many people today;
  2. we rely too much on drugs for things that drugs cannot fix;
  3. treatment frequently does not produce health because therapy aims at a point, while the pursuit of health is a matrix; and
  4. if we are really going to improve cardiovascular health, which is strongly implicated not just in stroke, heart disease, and kidney disease, but also cognitive health, people are going to have to change behaviors because there aren’t enough pills on the planet to fix what ails us.

Cognitive health is an especially useful guidepost, because contrary to popular myth, it isn’t something that mysteriously disappears in nonagenarians.  The seemingly age-related decline is more likely the manifestation of damage done by a lifetime of incremental harms.  Isn’t it edifying to have scientists catch up to our moms?

The new guidelines leave us a redefinition of high blood pressure: greater than 150/90, except in cases where a comorbidity compels pursuit of 140/90 or lower to prevent end-organ damage.  This has implications not just for medical care but for workplace wellness, which obsesses with hypertension when it is not obsessing with cholesterol and glucose.

The hypertension guidelines yank away from workplace wellness vendors yet another reason to fine or otherwise antagonize employees who don’t show up at health fairs.  The progression of hypertension is strongly related to aging, and healthy aging is the most reliable bulwark against premature stroke, heart attack, kidney failure, or dementia.  Unless workplace wellness vendors plan to follow people into retirement, which is when the overwhelming majority of heart attack, stroke, and dementia occurs, there is no logical reason to ask any employee what his or her blood pressure or deign to tell them how to address it.

Continue reading “Sense and Sensibility on Hypertension”

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Facing thousands in extra insurance costs, smokers appear to be the Affordable Care Act’s (ACA) biggest losers.  Employers are allowed charge smokers up to 50% more for their medical coverage than nonsmokers , starting in 2014.

On November 25, Fox News put it best:  “Obamacare Policies Slam Smokers,” , noting that “smokers are the only group with a pre-existing condition that Obamacare penalizes.”   THCB itself has headlined:  Smokers Face Tough New Rules under Obamacare.

And these headlines are absolutely accurate —  meaning that, with the possible exception of the e-cigarette, ACA is the best thing that has happened to employed smokers ever.

Here is how we arrive at this conclusion.  The data is mixed on whether smokers incur much higher healthcare costs or just slightly higher healthcare costs during their working ages than non-smokers do.  None of the data shows that their costs are lower, but let’s say there is no impact on health spending.

Nonetheless, the following is incontrovertible:  smokers take smoking breaks.

Remarkably, there are no laws specifically governing smoking breaks, and like most other quantifiable human resources issues, no one has quantified them.   But we all observe these breaks, and about a fifth of us participate in them.  They reduce productivity.  By definition, if you are outside smoking, you are not inside working.

Sure, some smokers make up the time by working harder when they aren’t smoking…but (1) many non-smokers work hard too and (2) some workplaces, such as inbound call centers, don’t offer the luxury of catching up later because they operate in real time. Lacking quantification, fall back on your imagination…and imagine what you would do if you ran a company in which non-smokers spent as much time mulling around outside as smokers do.  That should give you an understanding of the impact of smoking breaks on productivity.

Continue reading “Are Smokers Really the ACA’s Biggest Losers?”

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Last week, we were amongst the very first opinion leaders to speak out against the new cholesterol guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC).

Our error was not going far enough.

Monday’s New York Times carried a devastating portrait of the development of the guidelines, leaving readers with the unmistakable impression that this absurd attempt to make people into patients was not just poor policy it was a hubristic, avoidable policy folly, sort of like the bridge to nowhere and federal housing policy pre-2008.

Trust is an interesting thing; once broken it almost resists reconstruction.  Public trust in the AHA and ACC is crumbling as we write and deservedly so, as what should have been clear becomes more confusing and conflicted by the minute.

Instead of giving generally healthy middle aged American adults (like the three of us) the safe haven of a cardiovascular disease (CVD) prevention framework that is understandable, sensible and actionable, we got a cholesterol gulag.  Only here in the land of the free, it’s not a government gulag imprisoning the political opposition.

No, in a phenomenon unique to the US, it’s a health gulag intended to take people who need advice, support, and guidance and give them a pill, which is the first step in an intentional ensnarement in the medical care system.  It’s the Hospital California…on steroids, and you can’t even checkout because that would be against this addled medical advice.

To clarify: we have zero objection to providing statins, especially low-cost generic ones, to people under age 75 with current CVD, diabetes, or extremely high cholesterol levels.  The drugs may very well save their lives.

Our beef is with the cockamamie reduction in the ‘risk-to-treat’ threshold from 10% risk of heart attack or stroke in the next 10 years to 7.5% for people with none of the above noted problems.

Continue reading “The Cholesterol Gulag”

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By now we are all familiar with the concept of overdiagnosis, where “we” is defined as “the readers of THCB and a few other people whose healthcare literacy is high enough to know when not to seek testing and/or when not to automatically believe the test results.”

The rest of the country hasn’t gotten the memo that, quite counter-intuitively, many suspected clinical problems should simply be left alone.  Many insignificant conditions get overdiagnosed and subsequently overtreated, at considerable cost to the health plans and risk to the patient.

For more information on that we  refer you to the book Overdiagnosed.   The thesis of that book is that insured Americans are far more likely to be harmed by too much care than too little.

Rather than use its resources and influence with human resources departments to mitigate overdiagnosis, most workplace wellness companies have opted for the reverse, taking overdiagnosis to a level which, were they physicians billing the government for this work, could cost them their licenses and possibly their freedom.   Instead, they win awards for it.

We call this new plateau of clinical unreality “hyperdiagnosis,” and it is the wellness industry’s bread-and-butter.  It differs from overdiagnosis four ways:  It is pre-emptive.  It is either negligently inaccurate or purposefully deceptive.  It is powered by pay-or-play forfeitures.  The final hallmark of hyperdiagnosis is braggadocio – wellness companies love to announce how many sick people they find in their screens.

1. Pre-Emptive

Most cases of overdiagnosis start at the doctor’s office, when a patient arrives to join the physician in a generally good faith search for a solution to a manifest problem.  The patient comes in need of testing.   By contrast, in hyperdiagnosis, there is neither a qualified medical professional providing adult supervision nor good faith.  The testing comes in need of patients, via annual workplace screening of up to seventy different lab values.  Testing for large numbers of abnormalities on large numbers of people guarantees large numbers of “findings,” clinically significant or not.  It is a shell game that the wellness vendor cannot lose.

2.Inaccurate or Deceptive

Most of these findings turn out to be clinically insignificant, no surprise given that the US Preventive Services Task Force recommends annual screening only for blood pressure, because otherwise the potential harms of screening outweigh the benefits.  The wellness industry knows this, and they also know that the book Seeking Sickness:  Medical Screening and the Misguided Hunt for Diseasedemolishes their highly profitable screening business model.   (We are not cherry-picking titles here—there is no book Hey, I Have a Good Idea:  Let’s Hunt for Disease.)  And yet most wellness programs require annual screens to avoid a financial forfeiture.   This includes the four programs covered on THCB this year — CVS, Nebraska, British Petroleum, and Penn State.

Those four programs and most others also obsess with annual preventive doctor visits.  Like screening, though, annual “preventive” visits on balance cause more harm than good, according to academic and lay reports.  The wellness industry knows this as well.  We have posted it on their LinkedIn groups, and presumably they have also access to Google.  They addressed the data by banning us from their groups.

3. Pay-or-play forfeitures

Because of the lack of value, the inconvenience, and privacy concerns, most employees would not submit to a workplace screen if left to their own devices.  The wellness industry and their corporate customers “solve” that problem by tying large sums of money annually — $600 for hourly workers at CVS, $1200 at Penn State and $521 on average – to participation in these schemes.  Yet participation rates are still low.  At Penn State, for example, less than half of all employees got screened despite the large penalty.

Continue reading “Hyperdiagnosis: The Wellness Industry Doubles Down on Overdiagnosis”

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MASTHEAD


Matthew Holt
Founder & Publisher

John Irvine
Executive Editor

Jonathan Halvorson
Editor

Alex Epstein
Director of Digital Media

Munia Mitra, MD
Chief Medical Officer

Vikram Khanna
Editor-At-Large, Wellness

Maithri Vangala
Associate Editor

Michael Millenson
Contributing Editor










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