RAND Shrugged

The long awaited federally-mandated RAND Corporation report on workplace wellness programs is finally out, after months of anticipation.  Despite an odd now-you-see-it/now-you-don’t release, both wellness proponents and critics anxiously awaited the report’s public deliverance.

Like many documents emanating from the political cauldron, the RAND report has elements in it to please both camps, although proponents will have to reach deep into the document for snippets of hope built around simulations, models, and what they term “convenience” samples of employers predisposed to support health-contingent workplace wellness programs.

For critics of health-contingent workplace wellness programs, the conclusion is much more straightforward: even using prejudicial data sources and lacking a critique of the quality of the evidence, the impact of workplace wellness on the actual health of employees and the corporate medical care cost burden, is, generously stated, negligible.

This is not worth $6BN a year, which is the purported size of the US market for health-contingent workplace wellness programs (“purported” because like everything else in wellness, the size of the industry itself is totally opaque).  There are clearly better ways to spend these funds; at the very least, it must be possible to get the same dismal results for far less money and with vastly less complexity.

With the push of the Affordable Care Act, the drive to implement health-contingent workplace wellness programs is accelerating.  The RAND report, rather than contributing propellant, ought to give responsible business leaders pause as they consider whether to step up the pressure (i.e., increase incentives and penalties) for employees to participate in these highly intrusive, clinically dubious, spendthrift programs that yield health in RAND’s hypothetical world of models and simulations, but perhaps not so much, as RAND notes, in a more earthbound reality.

The lesson for executive leaders is that the nearly hagiographic employer belief in the value of health-contingent wellness is completely undone by the fact that RAND says virtually no employer (2% of their sample) measures program impacts and, as we have written previously, it doesn’t look like any employer, benefits consulting firm, or vendor actually knows how to do so.

The RAND report has two other insurmountable shortcomings.  The first is its reliance on the conventional wellness literature rather than giving that literature its long overdue and deserved outing as deficient.  Unlike reports from the Cochrane Collaboration, which are particularly insightful for their unvarnished assessments of the quality of the available evidence (if the evidence is poor, it is impossible to draw credible conclusions, and the product of simulations is not evidence), RAND politely, with politics in mind, tolerates the wellness literature’s surfeit of design errors (though a careful reader can sense the authors’ discomfiture).

For example, using people as their own controls and measuring the progress of participants versus against non-participants (thus ignoring the effect of motivation) should have proven disqualifying.  Instead, RAND takes a philosophical middle ground, lamenting that the literature is inadequate, but relying upon it nonetheless, because doing otherwise would really have left them almost nothing to write about.

The second insurmountable deficiency is the necessary and unavoidable reliance on a database of large employers with a predisposition to support workplace wellness.  It is insufficient to draw data from employers who’ve committed deeply to health-contingent workplace wellness and contribute their data to an industry trade association.

Though impractical if not impossible, it would have been insightful to draw data from employers that are not involved in the industry trade association, know why employers choose not to commit to wellness, why some employers may have dropped their wellness programs, and, critically, why virtually no one expends the time, money, or energy to quantify programmatic impacts.  These concerns are wholly unaccounted for.

Of the five case study employers, two — accounting for fully 82% of the employees in the five organizations — are government agencies.  No industry sector has gone all-in for wellness the way that government has.

In sum, these issues go to the heart of credibility.  They bring to mind the critique of published literature by John Ioannidis of Tufts and the University of Ioannina, who argues essentially that many reported results are simply a restatement of prevailing biases and are shaped by financial and other influences.

The RAND report has not settled the debate over the value and credibility of health-contingent workplace wellness programs.  RAND is not itself to blame for its inconclusive treatise; they had no choice but to throw the lifelines of simulations and models to an industry that should otherwise collapse under the weight of its own fecklessness and mendacity.  Yet, the industry’s addiction to sophistry rages on unabated, as is evident in this flier, which one of us recently received from wellness vendor.

The RAND report should, however, make people question how the document – and many others like it – helps to meet the political ends of administration leaders who demanded and paid for it.  It was not coincidental that the RAND report and the government’s rules on wellness programs were released contemporaneously.

The RAND fig leaf will encourage political supporters of health-contingent wellness to say that their approach is “evidence-based”.  We believe, however, that a more sober reading of the report will leave many more people wondering not only about the meaning of the word “evidence,”   but about whether, if after more than a decade of hyperbolic bluster it is not possible to demonstrate the salubrious value of health-contingent wellness programs, just how much more time and money will it take?

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.

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.

19 replies »

  1. Good point. The best wellness program a company like Kraft could implement would be a program that demands employees not eat anythng Kraft makes.

  2. This applies even to hospitals! Last time I had a medical appointment, I saw a very overweight woman, using a walker, order a cheeseburger at 9am in the hospital cafeteria. Probably not her best choice (admittedly I had just purchased a not-very-healthy muffin, myself). And even doctors don’t necessarily eat very healthfully, either…

  3. Steve, thanks for your thoughts and yes, we DID make a blanket statement that vendors make up outcomes, so I would offer you an invitation.

    Could you please name one vendor that has reported valid outcomes that include savings, with enough detail to see if the claims make sense? There are 25 vendors on my website (www.dismgmt.com/ida) that are obviously making stuff up, named and I called them liars in as many words (usually just using their own words against them)…and I haven’t been sued yet.

    We also named three in the Wall Street Journal article. One called to say that the reason their risk numbers on page 9 didn’t support the cost numbers on Page 8 was that “in this case the cost reduction had nothing to do with the risk factor reduction.” When I pointed out how that sounded, she said: “I can’t talk to you becasue you always use my own words against me.”

    A second of the three highlighted has already admitted lying and this admission will be published in a major newspaper, and they are likely to be formally investigated. The third has the good sense to shut up and assume that no one in HR reads the WSJ op-ed page, which is probably pretty close to accurate.

    And can you name a consultant for a major consulting firm that might know how to so this, other than the ones highlighted in my book? For instance, I have seen four outcomes studies from Mercer (North Carolina, Lowe’s, Pennsylvania, Georgia) and all were mathematically and/or epidemiologically impossible. At least in these four cases, they weren’t even smart enough to make up numbers that couldn’t be disproven on their faces. In the case of Georgia, they found mathematically impossible savings from a program that, it turned out, the vendor never even fully implemented.

    And of course you are right that effective programs will be more effective than ineffective programs. You are the third person to make the observation that we only address ineffective programs. Ron Goetzel said; “We agree that unscrupulous vendors claim very large and often implausible savings from worksite health promotion programs.” Michael O’Donnell, editor of the Journal of Health Promotion, said that 95% of employers don’t do workplace wellness well. My question to all three of you is, where are the scrupulous vendors who claim savings by getting employers to do wellness right in effective programs?

    I suspect I know where they are: not claiming savings, since they are scrupulous and they know savings are not possible, as our Health Affairs article on screening mathematically proved.

    This is not to say that wellness is a bad thing, just that it doesn’t reduce healthcare expenses. Something that should be a nice-to-have for employee morale has morphed into a panacea for healthcare spending. As Eric Hoffer said: “Every great movement starts as a cause, becomes a business and degenerates into a racket.”

  4. Vik and Al, Thanks for the blog post! I would like to offer a few suggestions to strengthen your argument, make it more constructive and help you preserve your credibility. It concerns me when you make blanket statements such as, “it doesn’t look like any employer, benefits consulting firm, or vendor actually knows how to do so.” Surely, there are employers, benefits consultants and vendors that know how to measure impact. I happen to know some of them. Perhaps you have not yet met them. If we are going to initiate meaningful dialogue, there should be a basis behind the statements we make, or your own credibility will be called into question. Simply because you are able to point out the flaws in the analysis of some, it doesn’t mean that no one know how to measure impact.

    Similarly, we should also be careful about throwing around purported facts without a basis. I am surprised to see Al’s comment in the dialogue indicating that he pulled the $6B figure for the wellness industry out of the air. For someone that spends such a large portion of his time critiquing the analysis of others, one would think that you would ensure there is a strong basis behind your own statements.

    I also think the conversation will be more meaningful if we not only point out the problems, but also offer some solutions. The blog post mentions that there are better ways to spend this money, but there are no illustrative examples. It would be helpful to the dialogue if at least some of those examples were provided for illustrative purposes.

    In my own read on the Rand report, they seemed to select largely ineffective programs for their evaluation and there is no distinction made between effective and ineffective wellness programs. This seems to be a general problem with the industry. According to our own research, close to have of wellness programs are not considered effective. When a wellness initiative is effective and operating within an effective workplace, it does produce significantly better results than ineffective wellness initiatives. We need to draw the distinction between what is effective and what is not.

  5. Thanks, Rob. I thought people would like it (well, people who got it would like it). It was one of those great “Eureka!” moments when it came to me.

  6. Good post….at some point the drumbeat of evidence will overwhelm the wasted money and bad programs. In some ways I fel sorry for HR-the CEO demnds they “do something” and there are no easy solutions, let alone hard ones. Wellness is easy, not too bothersome and to your point no one has figured out how to measure all that matters, ourtcomes. And frankly HR likes it that way. Seems like the “Nobody got fired for buying IBM” argument. Until they did.

    Keep up the great work guys.

  7. Good point. The best wellness program a company like Kraft could implement would be a program that demands employees not eat anythng Kraft makes.

  8. And let’s not overlook that the mere $6B (or whatever) industry cost is not inclusive of incentive cost to employers, the time invested by employers from their HR staff and wellness teams, etc. This is a significant investment by employers who want to believe they are going to generate a return from their efforts. They have a right to receive appropriate guidance to manage expectations and not be purposefully mislead.

  9. Screening for cancer, “testing for” heart disease via elevated cholesterol levels, taking portable bone scans at workplaces to “diagnose” osteoporosis, encouraging people to go to their doctor for no reason at all…the list is long. Employers should not play doctor, especially not when they’re led to this endeavor by organizations and people who have no business giving medical advice. If wellness was about positive engagement and opening people’s eyes to better health by facilitating better choices (which WILL make people fee better), it’d be hard to oppose it.

  10. Damn, you may force me to actually read the report. If screening for cancer is counted as in the $6 billion, I’m confused. I thought this was about weight loss and smoking cessaton, and cool web sites making everyone walk everywhere….surely that shuold make you feel better

  11. And, it’s not just about the CEOs of food companies, it’s about corporate leadership up and down the food chain, so to speak. It is not all unusual for company leaders to extol the virtues of their wellness program and exhort or coerce workers to participate, but completely ignore the impact of, for example, the food they serve in their cafeterias. Food services within companies (including vending) is about profitability and expediency. Wellness be damned, people need to eat fast, get back to work, and we (the firm) had better make money while they do it.

  12. And, it’s not just the $6BN. It’s that the industry is built on a series of falsehoods that are propelled forward by both corporate complicity and government support (both policy and fiscal). It’s as if, all of a sudden, everyone has decided that the used car salesmen of the health care world have legitimacy.

  13. What I find most disturbing is that the ACA is relying on corporate America to know what a “wellness program” is. How can the same CEOs who give us a high fat, high sugar, high salt food culture, and support it through massive advertising, know what will make Americans “well”.

    The ACA would be better to ban junk food advertising to children – OH WAIT, that would jeopardize their campaign funding source.

  14. You raise great q’s. Several answers. As observed in the article, we can’t find any inkling of the size of this market. That’s about the only number that shows up anywhere. I just did some googling this morning. It turns out it is traceable back to me, because I needed a number for another purpose and just filled that one in. It could indeed be way higher.

    Second, that $6B (or whatever) in wellness spending probably drives a multiple of that in overdiagnosis and overtreatment.

    And actually people feel worse. There are two ways to show that. first, the penalties increase every year much faster than participation — people leave increasing sums on the table just to be left alone. Second, in Nebraska, for example, out of 5199 participants, 540 were told they had cancer and another 2400 (some overlap) were told they had some other disease or condition. I doubt they felt better, having been told en masse they are ill.

  15. Al & Vik. So bitter about mere $6 billion? The gym market in the US is at least 4-5 times that. http://www.ibisworld.com/industry/default.aspx?indid=1655

    And $6bn isnt even a rounding error for real waste in say imaging or back surgery. We’re only talking about $60 per member of the workforce per year here here. Most of them spend more than that on lattes a month. And their employers spend more than that on beer bashes.

    For this type of spending, you (and RAND) should have a lower bar, like, do people feel better?

    Time to take your vicious investigative skills to a place they matter, methinks

  16. And one could question the value of anything from the RAND corporation based on its predictions of the money to be saved based on adoption of the electronic medical record.