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.
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.
Few doctors would publicly brag about how many cases of hidden disease they found, especially if they couldn’t convince the patient to do anything about their condition. But boasting is essential to hyperdiagnosis. We’ve already blogged on how Nebraska’s program sponsors bragged (and lied, as they later admitted) about the number of cancer cases they found. They also bragged about the rate of cardiometabolic disease they found — 40% in the screened population — even though they admitted almost no one did anything about those findings. Hence, it’s the worst of both worlds: telling people they are sick without helping them get better.
We’d like to think that all our exposés have made a dent in the wellness industry’s business model, but the forces arrayed in the other direction have so far overwhelmed us. The price of screening has plummeted almost to the $1-per-lab-value level for comprehensive screens, and as with anything, the lower the price, the greater the amount sold.
More ominously, starting in January employers are allowed to tie 30% of premiums to health-contingent employee wellness programs. And they will, thanks to the canard — also debunked on THCB — that the CDC says 75% of health spending is somehow preventable through wellness. This statistic is gospel among benefits consultants, vendors and even pharmaceutical companies like Astra-Zeneca and Johnson and Johnson, which should know better. So as far as the wellness industry is concerned, a 30%-of-premium penalty only scratches the surface, meaning that their hyperdiagnostic jihad against the American workforce has barely begun.
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.