By Al Lewis & Vik Khanna

Recently, The Health Care Blog published a post by Robert Sutton asking why there were so many jerks in medicine.

That posting made the underlying assumption that being a jerk is a bad thing.  In response, we are posting today a defense — really more an explanation of the features and benefits — of jerkdom, at least in our segment of healthcare, wellness and outcomes measurement.

In 1976 an obscure graduate student named Laura Ulrich (now a Pulitzer Prize-winning professor) wrote: “History is seldom made by well-behaved women.”   That statement could be applied much more broadly.  In any field governed by voluntary consensus – especially where the consensus specifically and financially benefits the people making the consensus – radical change does not happen jerklessly.

The best current example might be the critique of Choosing Wisely in the New England Journal of Medicine in which it was pointed out that only three specialty societies blacklisted controversial procedures still performed in significant enough quantity to affect that specialty’s economics.

(Another example of financially fueled consensus gone awry is the RUC, also frequently and justifiably excoriated in The Health Care Blog and elsewhere.)

Specifically, there are three reasons we act like jerks.   (Four reasons if you include selling our book, but we acted like jerks well before our book came out.)

First, as Upton Sinclair said, “You can’t prove something to someone whose salary depends on believing the opposite.” Hence, making nice rarely works and may backfire when you are pointing out a total waste that  also happens to be someone else’s income.

After Community Care of North Carolina (CCNC) sponsored an outcomes study  by Mercer finding massive savings through their patient-centered medical home (PCMH) in an age cohort (children under one year of age) in which no utilization reduction took place and which, as luck would have it, was not enrolled in the PCMH anyway, we kindly wrote to them and offered to show them the error of their ways, privately.

We didn’t get a response.  We repeated the offer when they put out another RFP for even more validation, pointing out that using the HCUP database meant no RFP was needed — we would be able to give them an answer in less time than it would take them to evaluate the RFP responses, and save them close to $500,000 in taxpayer money too.

The only response we got was, two years later, a CCNC spokesperson told a reporter for Workforce that the reason we were disputing CCNC’s savings that we had lost the RFP bid — which we hadn’t even applied for.

Likewise, at Penn State, our early private entreaties to cancel the rollout of their notorious wellness plan fell on deaf ears.  Their consultant, Truven Health Analytics’ Ron Goetzel, pointed out some ancient statements we made supporting wellness.

That was enough for Penn State’s Human Resources person to disregard us, observing to one of the faculty leaders that – sort of like Galileo — we were unreliable because changed our minds after the evidence came in, which to her destroyed our credibility.

Second, we are hoping that calling people liars will trigger a lawsuit…but we’d  settle for any response at all that shows any sign of neurological activity.

This wellness industry needs a bright light shined upon it, and the best way of doing that would be a high-visibility lawsuit, but we can’t seem to trigger one (or even a response from the perpetrators) because all we do is quote the perpetrators themselves, and we can’t be sued for that.

For instance, we privately, and many commenters publicly, begged Mercer and Staywell to respond to our observation that Staywell’s program claimed to save British Petroleum 100 times what Staywell itself said was possible.  Not only did they not respond. They never even told British Petroleum they had been outed.

No doubt the best example is the state of Nebraska, which won a C. Everett Koop Award from a committee led by that very same Ron Goetzel.   Unfortunately, to win Ron’s award the state’s vendor, Health Fitness Corporation (HFC), had simply made up lies.  They said they made “life-saving catches” of 514 colon cancer victims, whom they later admitted had never had cancer in the first place.

Given that only about 5000 people were screened for colon cancer, creating an incidence rate 50 times that of Love Canal, one wonders how no one on Goetzel’s Committee noticed this blatant lie in the first place.  Once the lie was admitted, Mr. Goetzel punished his HFC friends by letting them keep their Koop Award because, after all, who better embodied cronyism than Dr. C. Everett Koop?

No one ever even apologized for what some who have suffered from cancer might consider the highly offensive practice of lying about cancer victims for political gain.  Health Fitness Corporation, now backed by Mr. Goetzel’s committee, never even changed their original bogus claim, which still reads:

But one must give them some credit for smart PR.  They recognize that the way to short-circuit a news cycle is to not create one, and the way to not create one is to shut up, which – unlike identifying phony wellness program claims – the Koop Award Committee excels at.

Propeller Health could borrow a leaf from the Koop Committee, as their principal investigator’s response to our THCB observations was to (1) blame someone else and (2) say that his abstract never should have been published because its findings were “pure speculation.”

To which we ask, isn’t it your job to have control over your own data and analysis?

Third, sometimes people just beg for it…and far be it from us to disappoint them.

James G. Blaine learned the hard way that you shouldn’t accuse your opponent of fathering an illegitimate child unless you yourself have a vasectomy, or whatever the equivalent was in 1884.

Likewise, as ShapeUp learned right here on THCB, if you are completely making up your own wellness outcomes, you shouldn’t accuse us of not understanding wellness outcomes, especially when one major source for your accusation, Katherine Baicker, has already retracted her position several times and the other, Soeren Mattke, felt compelled to clarify that his position was the opposite after reading your post.

Soeren, by the way, represents the downside of not being a jerk.  His message is clear that wellness doesn’t work, but his language is so nuanced and respectful that the wellness ignorati often “spin” it to allege that RAND says wellness works.

Together with Ron Goetzel, Steve Aldana, the CEO of Wellsteps who is also on the Koop Committee, accused us of lying like “tobacco executives to Congress” even though Wellsteps’ very own Wellness ROI Calculator shows that the way to eliminate all healthcare spending by 2018 is, ironically, to make all your employees smoke.

Cleveland Clinic’s wellness guru has publicly announced (among other remarks) that “we know so little of his programs,” but one thing we seem to know about his programs is that even at such an august institution as his (and Cracking Health Costs spoke very flatteringly about it, a lot of good that did), numbers still need to add up:

 Not only does the “144,000 Americans” figure not represent “1 out of 19 people in the United States.”  It barely represents 1 out of 19 people within an hour of Cleveland.

The bottom line is, there is method to our badness.  We really aren’t jerks in everyday life.  We tip generously, brake for animals, and only swear at customer service reps when they really deserve it.  But the whole modus operandi for THCB in particular and a free press in general is to be jerks when the situation calls for it.

In healthcare, the situation frequently calls for it because –in wellness, Medicaid medical homes and elsewhere — the government has too often given too many foxes too many keys to too many henhouses.

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. Vik and Al are co-authors of Surviving Workplace Wellness, THCB’s first e-book.