Circulation: The Nineties Called. They Want Their Wellness Policy Back

flying cadeuciiLast year, we soundly criticized the American Heart Association (AHA) on this blog for its proposal to lower the thresholds for treating cholesterol and getting larger numbers of Americans to swallow statins. We also exposed wellness vendor StayWell, for its mathematically impossible claims of success in British Petroleum’s wellness program. Proving that great minds aren’t the only ones that think alike, StayWell and the AHA have now joined forces.  Specifically, the AHA invited the CEO of StayWell, Paul Terry, Ph.D., to help write its workplace wellness policy statement, sort of like Enron inviting Bernie Madoff to help design its financial plan. You don’t learn of this fox-in-the-henhouse conflict of interest unless you read the table on the penultimate page of text.

Naturally, Mr. Terry parlayed this windfall to StayWell’s advantage. The statement: “currently available studies indicate that employers can achieve a positive ROI through wellness” is footnoted to two studies authored by:  Paul Terry, along with other Staywell executives.  One wonders how a StayWell executive writing policy for the AHA based partly on StayWell’s own articles passes the AHA’s own test of “making every effort to avoid actual or potential conflicts of interest that may arise as a result of an outside relationship.”

How did this conflict of interest get by the peer reviewers? Look at the list of peer reviewers. Prominent among them is Ron Goetzel. Readers of THCB may recall Mr. Goetzel not just from his central role in the Penn State debacle, but also from the ”The Strange Case of the C. Everett Koop Award,” in which it was documented that his committee gave the ironically named award to a sponsor of the award (without disclosing that conflict), even though that sponsor had admitted lying about saving the lives of 514 cancer victims, who, as luck would have it, didn’t have cancer. (The sponsor, Health Fitness Corporation, a division of the equally ironically named Trustmark, has won the Koop award several times, thus proving the cost-effectiveness of their sponsorship.)

If this litany were not enough to dismiss the policy statement forthwith, there is small matter of the actual policy itself, a full employment act for wellness vendors and cardiologists alike, advocating more screening of more employees more often, while ignoring more self-evident facts than Sergeant Schultz. Specifically, they cherry-picked the available literature, continuing to cite the old “Harvard study” whose lead author has now walked it back three times. Except that they didn’t call it the “old Harvard study,” but rather a “recent [italics ours] meta-analysis,” despite the fact it was submitted for publication in 2009, and the average year of the analyses in the study was 2004.  Some studies began in the 1990s and were able to use sleight-of-hand to “show savings” despite presumably — in accordance with the conventional wisdom of the era — getting people to eat more carbohydrates and less fat.  No wonder Soeren Mattke of RAND Corporation dismissed the Harvard data as archaic in his interview with CoHealth radio in February 2014.

Likewise, the AHA ignored not just our own fusillade of uncontested deconstructions right here on THCB, and in Surviving Workplace Wellness, of every vendor that has claimed positive outcomes, but also all the documented health hazards of these programs in practice.

The statement, straight out of the 1990s, that “there is consensus that conducting health screenings in the workplace is a promising strategy” might come as a surprise not just to THCB readers, but also to the United States Preventive Services Task Force, whose screening guidelines are roundly ignored by wellness vendors, as well as to the RAND Corporation and Health Affairs, where a Pepsico analysis showed just the opposite of this consensus.

The cherry-picking was complemented with very questionable interpretations of their own cited sources. The statement that “screenings may be even more cost-effective for high-risk individuals” was supported by an article that concluded that “the cost-effectiveness of mass screening may not be justified.” The phrase “even more cost-effective” in this context is like saying some airplane seats have “even more legroom.”

They then go on to describe a number of supporting studies in detail. As has been the wont of the wellness defenders since the 1990s, they ignored all three Biostatistics 101 study design parameters.  They cite a Highmark study comparing active motivated willing participants to non-motivated non-participants. This is like splitting a group of 100 smokers into 50 who want to quit and 50 who don’t, and then claiming that the invariably higher quit rate in the first group is due to a program, not the pre-existing desire to quit. More than coincidentally, Highmark has also been highlighted as an example of how not to measure outcomes.

In addition, there is the classic “last man standing” fallacy in another of their cited studies.  They only measured people who completed the assessments in three consecutive years, which by the authors’ own admission, was a minority of the population. This is like the weight control programs in which the survivors who stay to the end lose weight, but everyone else has dropped out. By definition, a self-selected highly persistent population is not reflective of the whole.

That study also incorporates the equally classic “natural flow of risk” fallacy to claim credit for risk reduction in the high-risk population, ignoring Dee Edington’s observation that risk ebbs and flows on its own. Consider this example (figure 4, page 9) to demonstrate Dr. Edington’s point. The author has laid out the natural flows of risk (combined with the “last man standing” and participants-vs-non-participants fallacies, since this chart included only volunteers who stuck with the program).  You can see that even though nothing happened in the population as a whole (though tens of millions of dollars were alleged to be saved), high-risk people declined in risk while low-risk people increased risk factors — in almost the exact proportions claimed in the AHA-cited study, which did not make this level of detail available.

We are convinced that these obvious fallacies did not accidentally get overlooked.  Indeed, we have previously coined the term ”the wellness ignorati” to describe industry defenders whose strategy is to deliberately ignore facts. This is not an accusation but rather a compliment.  It is a brilliant strategy, on full display in this AHA policy, based on the accurate assumption that most human resources executives aren’t trained to critically analyze biostatistics while most benefits consultants choose not to. Indeed,ignoring facts is the only strategy that can keep this industry alive, because, as this AHA critique has just demonstrated, facts are the wellness industry’s worst nightmare.

Al Lewis and Vik Khanna are co-authors of THCB’s first book, Surviving Workplace Wellness With Your Dignity, Finances, and Major Organs Intact.

22 replies »

  1. Just to be clear, Pate was not leading ACSM when the LifeLine solicitation went out two years ago. The ACSM executive offices, of course, said it was all a marketing error.

    You are right that their indifference to letting the solicitation go out, along with Pate’s apparent indifference to both facts and a massive conflict of interest within his writing group, do raise questions about rigor and integrity within the organization. ACSM is a proponent of these kinds of nonsensical, medically-based wellness programs. That shows, perhaps, that while they are no longer mailing me screening brochures, they haven’t fully embraced the facts about wellness yet.

  2. Ole Russ was a professor of mine at South Carolina, he was president of the ACSM not too long after another SC prof, Larry Durstine was president back in 2005-2006.

    Its bothersome that A) they’d advocate for Lifeline screenings without doing any legwork on their services and B) think Lifeline had any value towards the goals, values or academic rigors the ACSM upholds.

  3. I especially love the “How to select a vendor” table, reprinted below which specifically tells employers NOT to work with any new fangled startups that may have better ideas but not 20 years of history…..

    Table 2. Factors to Consider When Selecting an External
    Vendor to Deliver Worksite Health Screening and Health
    and Wellness Programs
    • Vendor able to demonstrate sufficient history in delivering worksite
    health screening and health and wellness programs
    • Ensure that the healthcare professionals employed by the vendor
    are licensed or properly credentialed
    • Portfolio of current and past customers
    — Vendor provides contact list to discuss services provided
    • Vendors proposed biometric measurements for health screenings
    follow current scientific guidelines/consensus statements
    — New/novel biomarkers, not supported by current evidence, should not
    be included as part of vendor services

  4. Thanks for all the comments everyone. Arthur, yes, it looks like they are in a time warp, advocating things that in the 1990s we thought would be good ideas but have proven to be expensive duds. However, our expense is the wellness industry’s revenues, so they aren’t going to give up so easily. Hence their infiltration of AHA.

    Sam and everyone else, I don’t think this will get picked up by the media. Most lay healthcare beat reporters are way too lazy. When this issue of Circulation is released there will be a press release too and most reporters will just parrot the press release. That’s what the perps are counting on, lazy health reporters. Lazy health reporters, along with innumerate benefits managers and benefits consultants who seemingly report to no one, are what keep the wellness industry (and the rest of the healthcare industry) in clover.

    And what we’ve seen over and over is that the perps are smart enough not to acknowledge our existence. That might create a he said-she said news cycle and elevate our status. It’s a pretty brilliant strategy on their end, one that the media seem to fall for every time.

  5. Birds of a feather flock together….

    This is not that a huge surprise, but it is bold. I agree with the general point of the post. I would like to understand why the authors do not talk about what might work or at a minimum a vision of what modern health management program should look like.

    It is also very disturbing that people are still not willing to do the right thing It was excusable back in the 90’s we had no idea what worked and what did not. Today we should be leveraging the learning from out past failures to actually develop programs that can have a positive impact.

  6. and they should probably walk it back soon considering a pithy little piece like this will likely go viral…

  7. This is very distressing. Consider just how many times THCB has demonstrated the complete ineffectiveness of health risk screenings. I agree that the facts here are just too clear and the conflict of interest just too obvious for this to be an accident.

    For AHA to regain the trust of its constituents and follow-through on its own mission statement (“Building healthier lives, free of cardiovascular diseases and stroke”) it must retract this corrupted policy statement.

  8. Vik, no drug will substitute for a healthy lifestyle. They work together. However, I wouldn’t be too hard on anyone that promotes wider use of Statin. It’s debatable, but if one recognizes that Statin use has a dual function 1) lowering cholesterol …its bad components or changing the ratio which is directly related to cardiac disease and 2) stabilizing plaque on the arteries so it doesn’t break off causing a myocardial infarction.

    #2 has a theoretical benefit (and some scientific proof in the literature) because not all people that have had a heart attack had high cholesterol or prior history or prior family history of any heart disease. That is a smaller portion of those with heart disease, but heart disease is in such a large portion of the population that these numbers are high and should be considered.

  9. We are waiting. This has been emailed to their policy and media people, as well as to the leading health reporters at five national media outlets.

    You are correct that if they have any common sense or integrity at all, they will withdraw the guidelines forthwith.

  10. …or more appropriately, the 3 Pigs hiring the Wolf to write the specs and having the 3 Pigs share the Wolf-written specs with all their porcine friends.


  11. They probably didn’t expect to be outed so fast. What were they thinking? If they have any integrity at all they’ll pull this, since it hasn’t been printed yet.

    As you know, I am a big fan and you never disappoint. Not to mention the clever lines like “even more legroom.”

    Anyone taking bets on whether they’ll defend themselves here?

  12. Rob, thanks for jogging my memory. Two years ago, the American College of Sports Medicine embarrassed itself by allowing dissemination to its membership a solicitation by a screening company. I can’t think of a population less in need of carotid artery screenings than people who belong to the ACSM.

    One of the writers of this dreck from the AHA is Russell Pate, who is a former President of the American College of Sports Medicine. It’s unfortunate that this will now also paint the ACSM in a bad light, but maybe that’s what we need to do to start squeezing the idiocy out of the system.

  13. Very well done! The AHA clearly broke the rules. The sad thing is that the positive buzz over the headlines around this will likely drown out the reality in this post (see also: PSA screening, carotid dopplers, physical exams, etc. Etc.) Preaching to the choir, I realize.

    I’m just grateful there’s a choir out there.

  14. Wasted AHA money is just a drop in the bucket…and (I concur) endemic of the whole system.

    When people talk about how much money America spends on health care (and the not-so-wonderful results we get for our money), they NEVER add in the annual billions we spend on…

    – wellness vendors, programs, and magic beans
    – every body-part /disease association known to man (AHA…the leader)
    – every research program at every medical school in the country
    – the bloated budgets of the National Institutes of Health and the CDC(P)
    – the bloated budgets of every city, county, state health dept. in the country

    …all busily studying, treating, managing, maintaining, and battling chronic disease. And I ask, again…how’s our health?

    AHA is just ONE lazy example in a massive system that benefits from keeping us sick. Dead or healthy doesn’t employ very many. Sick and alive most certainly does.

    And, as long as no one holds their (AHA…or any others’) feet to the fire, they will be guaranteed to have more and more sickening reasons (dying Americans) to beg for more money.

    Pretending to be doing something about health (with a poor policy statement) is just doing their job of just doing stuff…real, measurable, truthful results be damned. —– Pretty sick…if you ask me.


  15. Ouch. That hurt. The helpful “how to hire a vendor in ten easy steps” pointers at the end are shocking. Somebody should resign.

    Somebody also needs apply the scrutiny you guys are bringing to wellness to health IT companies – there is a real group magical thinking effect – how could it hurt, this is obviously a good thing mindset …

    Needs to be rigorously debunked and flogged

  16. You guys should be working for factcheck.org!

    The trouble with wellness programs, or rather the allure of them, is that they sound like a damn good idea.

    Intuitively brilliant and brilliantly intuitive.

    It’s also an area where you just cannot measure success that is attributable to the program itself. As you have pointed out with a slew of examples. It’s really not possible to control for motivation, the most important confounder, without having a full fledged RCT, which is just too cumbersome to perform.

    Then you have a problem. How does one promote an idea which sounds good but for which evidence is just difficult to get?

    I don’t know the answer. But if I was working in a large corporate building, I would love there to be squash courts, which I could visit during lunch break or straight after work.

    Now to prove that squash courts/ indoor gym/ Zen sessions improve the health of the employees for their mere presence would be difficult.

  17. General, we salute you and your wise observation that this was all about optics, which are getting worse by the moment, and not at all about substance.

    The AHA is showing its true colors…first, in cahoots with the drug industry to get more people to swallow more drugs, and now joining with the healthcare industry’s least talented sector…wellness vendors…to make even more people into patients. It’s enough to make a cynic think that the whole healthcare industry really isn’t about health.

  18. Thanks Al and Vik for getting this on the record!.

    The American Heart Association…blindly accepting unchallenged, old, twisted data (as fact)…engaging a vendor who benefits from selling more screenings to help write a policy that advocates more screenings…to a seemingly hands-off, lazy, rigor-less approach to drafting and adopting their “policy statement”…absolutely leaves a heavy, greasy, blood-thickening, artery-clogging taste in my mouth and pain in my chest.

    Their “policy statement” is literally killing me.

    As one who has been actively engaged in the world of workplace wellness for the last 10 years, it’s apparent to me that simply drafting and publishing a policy statement was more important (in this case) to the AHA than the substance contained within it.

    Hooray to whoever just got the assignment OFF THEIR DESK! On to the next meaningless waste of time (and money) designed to keep us believing that the AHA can lead our country to healthier times. There’s a big difference than “doing something” and “doing something meaningful”.

    And, today, after all the money that’s flowed through the AHA for all these years, I ask…how’s our health?