The exponential growth in wellness programs indicates that Corporate America believes that medicalizing the workplace, through paying employees to participate in health risk assessments (“HRAs”) and biometric screens, will reduce healthcare spending.
It won’t. As shown in my book Why Nobody Believes the Numbers and subsequent analyses, the publicly reported outcomes data of these programs are made up—often to a laughable degree, starting with the fictional Safeway wellness success story that inspired the original Affordable Care Act wellness emphasis. None of this should be a surprise: in addition to HRAs and blood draws, wellness programs urge employees to go to the doctor, even though most preventive care costs more than it saves. So workplace medicalization saves no money – indeed, it probably increases direct costs with these extra doctor visits – but all this medicalization at least should make a company’s workforce healthier.
Except when it doesn’t — and harms employees instead, which happens altogether too often.
Yes, you read that right. While some health risk assessments just nag/remind employees to do the obvious — quit smoking, exercise more, avoid junk food and buckle their seat belts — many other HRAs and screens, from well-known vendors, provide blatantly incorrect advice that can potentially cause serious harm if followed.
Keep in mind as you peruse the following HRAs and screens that medical societies — recognizing that America does not suffer from a shortage of diagnoses — are calling for less screening and the federal government recommends lipid screening only once every five years. A large-scale European study found population screening to be worthless, and entire countries are abandoning it.
Nonetheless, the wellness industry is embracing more HRA/screening programs. Employers, egged on by their benefits consultants, are penalizing workers who refuse to partake in these completely non-cost-effective annual exercises in overdiagnosis, with penalties expected to increase in the future.
“The Health Risk Assessment Will See You Now”
The first example of an HRA contradicting or ignoring widely accepted medical advice is the first one I took, the one that inspired me to open this Pandora’s box of HRAs. It was provided by one of the field’s largest vendors. The vendor has asked to remain anonymous but says that it gets its questions and algorithms from PDHI, one of the largest providers of HRA platforms. As you can see, the HRA recommends that I get a prostate-specific antigen (“PSA”) test, which the US Preventive Services Task Force long since advised against, due to the well-documented likelihood of false positives generating unnecessary and hazardous treatment. This HRA also recommends a meningitis vaccine, perhaps on the off-chance that I am about to go on safari, one of the few cases in which the Centers for Disease Control also recommends it. In total, the HRA recommends 17 tests and exams, that would probably cost my insurer $500 or more were I to follow up on the recommendations, before taking into account any false positives that need more treatment. I say “false positives” because these testing recommendations are made despite the HRA’s acknowledgement that my health is excellent and my risks are low…so there is almost certainly no “true positive” to be found.
Other recommendations to me included losing weight, even though at 6’5” and 194, I barely occupy three dimensions. More important is what it failed to recommend: I listed one diagnosis – insomnia – but decided to check “7 or more” prescription drugs to see if the HRA would note a possible addiction issue. It didn’t. So this popular HRA got everything wrong—it recommended tests that were contraindicated or useless — and expensive — while overlooking the one problem that should have been noted.
That omission itself creates the potential for harm of course, as a real addict would have interpreted the omission as a green light to keep popping sleeping pills. (In all fairness, there is a little red oval about taking “7 or more” prescription drugs generally. Nothing about addiction potential, though — and that little red oval is exactly the same size as the “lose weight” little red oval.)
This HRA is not an exception. Failure to flag possible overmedicating and PSA test recommendations both turn out to be common in HRAs. For WebMD’s HRA, I wrote I had filled 50 prescriptions in the last year but mentioned only insomnia as a diagnosis. WebMD told me my health was excellent, with no mention/red ovals suggesting possible overmedicating or addiction. Likewise, PSAs are very commonly recommended, though usually couched in language like “some providers recommend these…” Several HRAs, like Trale’s, are quite adamant, though: a “PSA test is recommended at the age of 40.” Or WebMD’s: “Most cases of early prostate cancer are found by a PSA blood test.” (The latter may technically have once been right in the very narrowest sense, but overlooks all the false positives and as written is quite misleading.)
Other cancer screens call for even riskier, more expensive, and less advisable diagnostics. On its private portal used by some employers, WebMD recently recommended a lung CT scan for a nonsmoker who completed this screen. In addition to its four-figure price tag, discomfort and possible complications, such screens introduce enough radiation into the body to raise the likelihood of cancer down the road. Since almost no nonsmokers in a screen (a “screen” by definition meaning a cohort in which there is no a priori reason to suspect disease, such as prolonged exposure to second-hand smoke) are going to actually have detectable lung cancer, the major outcome of this scan is likely to be false positives, which in turn require potentially dangerous biopsies and possible resections. This very significant risk is undisclosed.
This HRA also recommends aspirin to reduce the risk of colon cancer, which is at best a facile or selective interpretation of the current state of knowledge and at worst a potentially hazardous misreading of the pros and cons of taking fairly large doses of aspirin daily.
Undetected Cancer Reaches Epidemic Proportions in Nebraska State Government
Nor is the risk of these cancer screens hypothetical. Consider the state of Nebraska’s workplace medicalization results. Prompted by a mass mailing telling them to go get cancer screens (and waiving the co-pay for some screens), 514 (at least 6%) of the participating state employees who underwent biometric screens were identified as having undiagnosed “early stage cancer,..resulting in early treatment.” I say “at least” 6% because the state’s vendor, which was at first excited to discuss Nebraska’s “success story” with me and which has disclosed voluminous other information about it, later refused to disclose the number of people who underwent diagnostics for cancer, presumably once they figured out why I was asking. The 6% figure is based on the assumption that everyone, regardless of age, who underwent a simple cardiometabolic screen also got a mammography/colonoscopy/PSA etc., since the only denominator the vendor made available was the number of biometric screening participants. The vendor, doing the marketing equivalent of “pleading the Fifth,” refused even to confirm, absent a Freedom of Information Act request from me, that the number of people getting complex cancer screens was no higher than the number getting simple biometric screens. It was probably much lower, making 514 a much higher percentage of the total actually screened than the 6% assumption.
Even if all biometric participants also got cancer screens and therefore the 514 was “only” 6% of the total screened, it’s safe to say that this 6% figure was probably high by almost two decimal points. Otherwise – if 6% of us really did have undiagnosed metastatic cancer advanced enough to be identifiable through a screen at the random point when we happened to be screened – few of us would make it to retirement.
Overdiagnosis is far from harmless. No doubt most of those 6% identified with early-stage cancer elected to undergo expensive, debilitating, futile and potentially harmful “early treatments” that the state could have avoided simply by taking the recommendations of the government and medical societies or simply doing a little arithmetic and not sending out mass mailings recommending cancer screens, and/or realizing that 6% of people do not have undiagnosed clinically significant cancer. (Ironically, “overutilization of healthcare services” was one of the justifications for Nebraska’s program cited in their report.)
My colleagues and I were concerned enough about this epidemiological arithmetic to telephone the state’s designated wellness program point person Roger Wilson and several colleagues. They in return were concerned enough about this statistically certain overdiagnosis on their employees not to call us back.
As is traditional with workplace medicalization programs, Nebraska claimed significant savings, despite the expenses involved in cancer follow-up and treatment, which must have been substantial in order to identify and treat all those alleged early-stage cancer victims, plus 26 apparently undiagnosed late-stage cancer victims. The state also opened its checkbook to reduce or eliminate co-pays on many chronic disease medications, which proved a windfall for state employees, because fully 2400 new annual prescriptions (among 20,000 people) are now being written for hypertension or high blood pressure, as a result of further screening.
Yet somehow, despite the cancer expenses, waived copays, and large proportion of the population being newly medicated, the state “cut employee health claim costs by millions.” Such are the magic beans of wellness. It doesn’t matter how much you spend—in order to continue to receive funding, you simply claim savings and hope no one notices you’re lying. Or if the program administrators aren’t lying and genuinely believe they saved $4.7-millon by having risk factors decline for 160 participants (saving almost $30,000 per participant who lost a little weight or recently stopped smoking), they would certainly lack the sophistication needed to recognize massive cancer overdiagnosis.
Between all those cancer false positives and the obviously fictional savings figures, you might be thinking, “This program must be an outlier. The whole industry can’t be like this.” And you’d be right. The Nebraska program is an outlier — but in the other direction. The combination of fictitious savings and cancer overdiagnosis/overtreatment won Nebraska the 2012 C. Everett Koop Award as one of the country’s best wellness programs, as well as awards from the Wellness Council of America and others. (In case you haven’t heard of WELCOA, here is an overview.) Both the fictitious savings and the 500+ cancer cases received plaudits from America’s Health Insurance Plans as well.
What is the Solution?
The contraindicated screens and tests recommended by these HRA vendors, consultants and employers will, statistically speaking, eventually cause early deaths, due to all the radiation and high-risk procedures associated with overdiagnosis and overzealous cancer follow-up, not to mention the high likelihood of being sucked into the “treatment trap” as a result of overscreening for lipids. So what should be done to prevent employers from indirectly killing their employees in the name of wellness?
I would say the answer is that in order to “play doctor,” workplace medicalization vendors should be required to get adult supervision, but it turns out that most vendors already have it: Each of these HRAs in this article (or the entities administering the HRAs) is certified by the National Committee for Quality Assurance. So a better question would be, who is supervising the adults?
And, speaking of questions, who decided that workplace medicalization would save money and be accepted by employees? It’s a net loser financially — any employee actually following HRA and screening recommendations for further testing and doctor visits would drive up an employer’s cost. And despite the plaudits from some employees who choose to participate (nonparticipants are never asked why they are dissatisfied enough with the program to pay the penalties instead), the market has spoken on the topic of unpopularity: enough employees dislike workplace medicalization that “incentives” have doubled since 2009, to $521, to try to convince people to participate. Two more questions: Why is ACA encouraging this activity? Why doesn’t anyone in the wellness or benefits consulting fields read the literature?
Instead of combining bribery with workplace medicalization, employers who want their employees to be healthier should take steps to encourage healthy lifestyles, by subsidizing, for example, healthier choices in their cafeterias. That type of step really does help create a culture of wellness, as opposed to penalizing people who don’t participate in workplace medicalization. True wellness won’t reduce healthcare expenses much if at all (in the employed population, avoidable wellness-sensitive medical events comprise only about 6% of spending to begin with – yes, all this fuss about wellness is aimed at about 6% of most companies’ healthcare spending, a dirty little secret your benefits consultants don’t tell you) but at least no one ever died from eating tofu.
It’s only a matter of time before the same can no longer be said of wellness programs.
*If you’re reading this, make sure to also read it’s sister piece, by Vik Khanna: The HRA Hustle.
Al Lewis is the author of Why Nobody Believes the Numbers, co-author of Cracking Health Costs, co-author of forthcoming How to Cut Your Company’s Health Costs and Provide Employees Better Care, and president of the Disease Management Purchasing Consortium.