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Tag: Al Lewis

PCMH Fails Natural Experiment

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Medical Homes Fail Yet Another “Natural Experiment”

Three “natural experiments,” three failures.  Such is the fate of patient-centered medical homes (PCMH), a well-intentioned but unsuccessful innovation now kept afloat by the interaction of promoter study design sleight-of-hand with customer innumeracy.

By way of review, a natural experiment is an experiment in which the design is outside the control of investigators, yet mimics an experiment.  The first two natural experiments below involve applying the intervention across entire states. The third involves a stimulus-response experiment in one specific community.

Statewide Natural Experiments: North Carolina and Vermont

In North Carolina, a statewide Medicaid PCMH was implemented years ago and steadily expanded until most Medicaid recipients belonged to one.  There was no reduction in relevant event rates (for ambulatory care-sensitive admissions) and costs increased. While the overall Medicaid budgets were routinely exceeded and that should have caused legislators to realize that something in their PCMH was amiss, Milliman fabricated data to pretend the PCMH program was a success.  Milliman got caught making up data (and ignoring other data that quite definitively invalidated its conclusion, and changed their story 180 degrees, a tacit admission that they lied.  And shortly thereafter (at least “shortly” by the standards of state government), North Carolina announced that it is abandoning this failed experiment.

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Should Your Employer Have the Right to Track Your Weight?

Suppose there were:  (1) a widely held but false perception that gays had lower productivity and higher healthcare costs than straights; (2) false literature that companies with gay conversion programs outperformed the stock market; and (3) a mandate that companies disclose to shareholders the percentage of gays they employ.

Obviously, many corporate CEOs would stop hiring gays, de facto require gay conversion among current employees, and fire gays who failed the program, in order to maximize stock price and hence their own net worth.

Preposterous? Of course, but if Johnson & Johnson (J&J), Vitality Group and a few pharmaceutical companies get their way, this exact same scenario will befall overweight employees.  Indeed, two-thirds of this dystopian scenario is already in place:

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Genetic Testing: The New Frontier of Wellness Madness

The Wall Street Journal just reported that Genetic Testing May Be Coming to Your Office Soon. This is all well and good, assuming employees would want their health insurer’s buddies collecting their DNA for no good reason, handling it, selling it, and possibly losing it. This is not us talking. This is what the testing company itself says on their website. You can read all about it here.

Instead we will focus on the fact that this scheme simply doesn’t save money – according to the main proponents of this dystopian scheme, Aetna and its buddies at the ironically named Newtopia.  Anticipating the day (yesterday) that this would become front-page news, we have already showed how Aetna’s study accidentally showed the opposite of what it intended to show. This is that proof.

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The Ten Worst Wellness Programs and What They Do to Harm Employees

flying cadeuciiIf corporate wellness didn’t already exist, no one would invent it.  In that sense, it’s a little like communism, baseball, or Outlook.

After all, why would any company want to purchase programs that damage morale,reduce productivity, drive costs up…and don’t work 90%-95% of the time?  And that’s according to the proponents.  What the critics say can’t be repeated in a family publication such as ours.

Still, those are the employers’ problems. However, the employers’ problems become the employees’ problems when employees are “voluntarily” forced to submit to programs that are likely to harm them. (As the New York Times recently pointed out, there is nothing voluntary about most of these programs.)Continue reading…

Does the ACA Actually Mandate Free Checkups?

flying cadeucii“Where in the Affordable Care Act (ACA) does it mandate that every health insurance policy must include a free annual checkup?”

I posed this question to Al Lewis and Vik Khanna in the comments of their recent post entitled: The High Cost of Free Checkups, where they argue against the Affordable Care Act (ACA) provision that requires “free checkups for everyone.” They cite a recent New York Times Op-ed authored by ACA co-architect, Dr. Ezekiel Emanuel, that essentially debunks the link between annual checkups and overall health outcomes.  For Lewis and Khanna the solution is simple, we need to “remove the ACA provision that makes annual checkups automatically immune from deductibles and copays.” But for me there’s an enormous problem with their argument: The ACA doesn’t actually have any such provision.

After raising the issue in the comments section of the post, Mr. Lewis responded informing me that: “It’s definitely there” and “You’ll have to find it on your own, though — I unfortunately have to get back to my day job.” What Mr. Lewis doesn’t consider with his quick dismissal, is that I have already looked.  I’ve combed through the law and other policy guidance, rules and regs; searching for any mention of this required annual wellness exam, physical, visit, or any other linguistic derivative.  It doesn’t exist.

It turns out that while the law does require that an annual wellness visit be covered (sec. 4103. “Medicare coverage of annual wellness visit providing a personalized prevention plan”), this requirement is specific to Medicare beneficiaries and does not apply to individual or group plans. Beyond this particular section you won’t find any mention of a requirement within the ACA.

So what gives?  Lewis and Khanna aren’t the only ones who’ve mentioned this “free” Obamacare benefit. Even when researching this piece I had to engage in a lengthy discussion with a friend who is a healthcare policy advisor, unexpectedly defending my position. This claim has to be coming from somewhere, surely people smarter than me have gotten it right?

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Commentology: The Real Professor Baicker

flying cadeuciiInfluential RAND researcher Soren Mattke had this to say in support of Al Lewis and Vik Khanna’s latest post on the Wellness story “Would the Real Professor Katherine Baicker Please Stand Up?

“Gentlemen. Great post. Like you, I am disappointed that researchers of the caliber of Kate Baicker and David Cutler do not respond to the mounting debate about their paper. They should defend or disown their work rather than hope that the debate goes away.

In my mind, their paper is a product typical of high-end academic research. Two brilliant professors spot a gap in the evidence on a hot policy topic and decide to go after it. But the actual work gets done by a graduate student in his cubicle without windows or guidance, and then hastily published.

Then the problem arises that the paper becomes hugely influential and people start having a closer look. For our paper on the PepsiCo program, we reviewed in detail the seven publications that Baicker and colleagues called “high quality evidence”. We found that five of those analyzed programs that operated over 20 years ago and most of them had severe methodologic flaws. (John P. Caloyeras, Hangsheng Liu, Ellen Exum, Megan Broderick and Soeren Mattke. Managing Manifest Diseases, But Not Health Risks, Saved PepsiCo Money Over Seven Years. Health Affairs, 33, no.1 (2014):124-131)

Unfortunately, many defenders of the industry continue to take the Baicker paper at face value, while closely scrutinizing or ignoring more nuanced and scientifically sound findings.

So I herewith support your motion!

The Value of Workplace Health Promotion (Wellness) Programs

flying cadeuciiThe recent Health Affairs Blog post by Al Lewis, Vik Khanna, and Shana Montrose titled, “Workplace Wellness Produces No Savings” has triggered much interest and media attention. It highlights the controversy surrounding the value of workplace health promotion programs that 22 authors addressed in an article published in the September 2014 issue of the Journal of Occupational and Environmental Medicine titled, “Do Workplace Health Promotion (Wellness) Programs Work?”  That article also inspired several follow-up discussions and media reports, including one published by New York Times columnists Frakt and Carroll who answered the above question with: “usually not.”

There are certainly many points of contention and areas for continued discussion on this topic. It turns out that Lewis et al. and I agree on many things, and there are other areas where we see things differently.Continue reading…

Keas Poll on Workplace Stress and Disease Burden Provides an Education

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Al’s son once complained to Al’s Aunt Tillie about an overbearing supervisor.  Aunt Tillie suggested that he try to work under a different supervisor.  Tillie was one of those people – and we all know them – who could be counted on to inadvertently provide punchlines when needed.  Conversely, Al is one of those people – and we all know them – who can’t resist setting up those punchlines.  So I lamented that this suggestion may not work because, “Aunt Tillie, it’s a sobering fact that 50% of all supervisors are below average.”

Tillie replied, “I blame our educational system for that.”

Likewise, we may need to blame our educational system for Keas’ new poll on workplace stress.  To begin with, the lead paragraph from Keas — which like many other companies is “the market leader” in wellness – “reveals” that “4 in 10 employees experience above-average stress.”

SAN FRANCISCO, CA – (Apr 2, 2014) – Keas (www.keas.com), the market leader in employer health and engagement programs, today released new survey data, revealing four in ten employees experience above average levels of job-related stress. Keas is bringing attention to these findings to kick off Stress Awareness Month, and is also providing additional insight and tips to bring greater awareness to the role of stress in the workplace and its impact on employee health.

Wouldn’t that mean some other employees – mathematically, also 6 in 10 – must be experiencing average or below-average levels of stress?   It would seem like mathematically that would have to be the case.   However, the Keas poll also “reveals” that while some employees are average in stress, no employee is below-average – a true paradox.  Hence Keas’ selfless reasons for publishing this poll:  All employees being either average or above average in the stress department means we have a major stress epidemic on our hands.  This perhaps explains why Keas is “bringing attention to these findings.”

In a further paradox, Keas also uses the words “average” and “normal” as synonyms, even though they are often antonyms:  All of us want our children to be normal but who amongst us wants their children to be average?

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Why Are Al Lewis and Vik Khanna Such Jerks?

flying cadeuciiRecently, 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.

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Amazon Shows the Way on Wellness — Treat People like Adults

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Since 2000, the government and healthcare industry have sold Americans a bill of goods called workplace wellness, which turns out to have been a colossal waste of billions of dollars.

Most of this money was spent bribing employees to do things that they don’t want to do, such as submit to biometrics, answer intrusive health risk appraisals, and get preventive medical care.

The marketing pitch that wellness makes people healthier and lowers medical care costs, and thus, produces a return on investment for the employer, isn’t true. Wellness also allowed companies to position themselves as employee-friendly, even while wages stagnated and employees morphed into fungible widgets, instead of vital assets in whom employers invested for years or decades.

However, it looks to us as though at least one major US company is treating economic reality seriously, and, consequently, asking its employees to act like adults.

Let’s look at wellness by Amazon.com, which has apparently avoided conventional wellness whole cloth. Despite our best research efforts, we find no evidence that the company makes conventional wellness programming a priority for employees.

It’s a bit ironic that they don’t given the recent spate of tough publicity about the company’s employment practices.

Amazon has been lambasted lately for the plight of the warehouse workers who animate its backroom operation, where constant video surveillance, productivity demands, and getting your bag searched before you go home are the norms. Message boards also detail the pressure-cooker atmosphere of the company’s white collar space, which raises, in our minds, the pointed question of why haven’t they done wellness?

We think it’s because Amazon’s philosophy about work is straightforward: if you work here, expectations are high and relentless. Amazon’s approach to employee well-being seems to be to not have one other than we invite you to grow with us. This is counter-cultural, and it has more to recommend it than first appears obvious.

When you are competing against Walmart and Target, remaining lean and low-cost is critical; wellness drives costs up, not down.

Expecting many staff to work 50, 60, or even 70 hours per week leaves little time for discretionary visits to the doctor that are pointless even before they happen because this superfluous care will save neither lives nor money. When you are not pouring money into coercing employees to join a wellness program, you preserve capital needed to optimize the technologies and product mix that help you grab market share and crush competitors like Best Buy.

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