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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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More Evidence That Patient Centered Medical Homes Don’t Work

A state the size of Vermont claiming savings of $120,000,000 through a patient-centered medical home (PCMH) program should raise eyebrows.

North Carolina made similar claims about its PCMH model, only to have the results so thoroughly debunked that consulting firm, Milliman, was forced to retract its key assertion.

I expect more from Vermont, if only because I’m a Democrat and Vermont has turned so “blue” that in 2008 John McCain received only 10,000 more votes than Calvin Coolidge garnered in 1924.  However, it turns out red states don’t have a monopoly on invalid PCMH data.

A brief summary of the Vermont Blueprint for Health, as described in the enabling legislation, would be: “a program for integrating a system of healthcare for patients, improving the health of the overall population…by promotion health maintenance, prevention, and care coordination and management.”

This is to be achieved by emphasizing the usual suspects — patient-centered medical homes and various support mechanisms for them.   The idea is to achieve “a reduction in avoidable acute care (emergency visits and inpatient admissions).”

Growth in participation has been phenomenal. In 2009, only a few practices and a dozen employees were involved, so we can call that the baseline year.  The report’s findings take us through 2012, by the end of which two-thirds of the state’s primary care practices (104) and population (423,000) were involved, along with 114 full-time employees.

The State’s Analysis

Through the end of 2012, the state — by using the classic fallacy (also embraced by the wellness industry) of comparing participants to non-participants — was able to show savings of $120,000,000 and a double-digit ROI.

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What If Your Employer Gets Access to Your Medical Records?

T was never a star service tech at the auto dealership where he worked for more than a decade. If you lined up all the techs, he wouldn’t stand out: medium height, late-middle age, pudgy, he was as middle-of-the-pack as a guy could get.

He was exactly the type of employee that his employer’s wellness vendor said was their ideal customer. They could fix him.

A genial sort, T thought nothing of sitting with a “health coach” to have his blood pressure and blood taken, get weighed, and then use the coach’s notebook computer to answer, for the first time in his life, a health risk appraisal.

He found many of the questions oddly personal: how much did he drink, how often did he have (unprotected) sex, did he use sleeping pills or pain relievers, was he depressed, did he have many friends, did he drive faster than the speed limit? But, not wanting to rock the boat, and anxious to the $100/month bonus that came with being in the wellness program, he coughed up this personal information.

The feedback T got, in the form of a letter sent to both his home and his company mailbox, was that he should lose weight, lower his cholesterol and blood pressure, and keep an eye on his blood sugar. Then, came the perfect storm that T never saw developing.

His dealership started cutting employees a month later. In the blink of an eye, a decade of service ended with a “thanks, it’s been nice to know you” letter and a few months of severance.

T found the timing of dismissal to be strangely coincidental with the incentivized disclosure of his health information.

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Meet Propeller Health: Digital Health’s Poster Child for Invalid Savings Reporting

We’ve seen shorter abstracts, and we’ve seen abstracts with more curious findings, but we’ve never seen a shorter abstract with more curious findings than this one, done by Dignity Health and Dr. Rajan Merchant, and financed by the California Healthcare Foundation, evaluating a gadget made by Propeller Health.

The study group’s use of inpatient care for asthma declined by a whopping 62% vs. the control group.  You might think this result violates Dr. John Ioannidis’ well-known conclusion that large treatment effects are usually wrong, but you’d be mistaken.  You see, there was no treatment here.

There was only an effect.  Dr. Ioannidis’ result applies only to actual comparisons of effects due to different treatments, not to random changes in effects using the same treatment.  In this study, the actual treatment protocol was the same and the inhalers were the same.

The only thing different was frequency of drug use.  Whereas the conventional wisdom for disease management states that hospitalizations can be avoided by more adherence and hence more drug use, in this case the study group used less medication than the control group, reaching for their rescue inhalers 25% less– once every 6.3 days vs. every 4.7 days for the control group.

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Good News! A Workplace Wellness Vendor Saying You’re Sick Means You’re Probably Healthy

THCB is excited to announce the first official e-book release from THCB Press, “Surviving Workplace Wellness” by contrarian Wellness industry observers Al Lewis and Vik Khanna.”  What exactly is the “Wellness industry” anyway? How scientific is the “science” behind wellness programs? Are stop-smoking programs a good idea? Should your company really be paying to send employees to the gym?

Should you be using technology to help your employees monitor and understand their health? You may not always agree with the authors (we certainly don’t here at THCB world headquarters, where Al and Vik have started more than a few food fights) but we still think you’ll find this title a provocative examination of many of the fundamental assumptions underlying prevention and wellness today.

You can order your digital copy from Amazon.com here at the discounted price of $9.99.  If you’re a healthcare insider trying to understand the controversies facing wellness or a conscientious wellness professional trying to get a handle on developing a program that works for your employees, this is the e-book for you.

Be sure to look out for upcoming releases from THCB Press in the months to come.  If you’d like to be placed on the THCB Press mailing list to be notified of upcoming new releases, send us an email with “update me” in the subject line.  Author inquiries and partnership requests should go to this same address.John Irvine

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Dr. Aetna Will See You Now

The ever-blurring line between the practice of medicine and the business of profiting from unhealthy lifestyles was crossed again Wednesday, as Aetna announced a collaboration with two pharmaceutical companies to pitch their prescription weight loss drugs to selected Aetna members.

This announcement crosses multiple lines, not just one. First, no insurer has ever announced that it would openly direct a specific class of members to use particular proprietary drugs. Disease management (DM) programs rarely recommend specific drugs, and certainly in the exceptionally rare instances when they do, the recommendations are not specific brand-name drugs (in this case, Arena’s Belviq and Vivus’s Qsymia).

Instead, DM focuses on improving compliance with existing drug regimens, and DM firms encourage members “talk to their doctor” about changing therapies. While DM companies shy away from directing patients to specific products, physicians and pharmacists have discretion to discuss the full range of covered generic and brand products with patients, in order to optimize therapy and close algorithm-identified care gaps.

Second, there are no generally accepted care algorithms (other than those created by the manufacturers of those products) for these two drugs in the treatment of obesity. So there is no “gap” to fill. If there were an accepted protocol, these drugs might be blockbusters but instead Belviq’s recent quarterly sales were an anemic $4.8-million, “well below even reduced Wall Street expectations,” while QSymia sales are “flailing” at $6.4-million for the same period.

Obese people and their physicians seem to be avoiding these drugs in droves. Regardless of what Aetna and the manufacturers believe about their effectiveness, or whatever promotional deal they’ve cut, market reaction is telling a different story, and unfortunately for Aetna, Vivus, and Arena we live in a market economy.

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PepsiCo’s Wellness Program Falls Flat

For those of us who actually think wellness outcomes should be evidence-based, a landmark study was released today:  the first evidence provided by a major organization voluntarily (as opposed to being outed by us, like British Petroleum and Nebraska) that wellness doesn’t work.   January’s Health Affairs features a case study of PepsiCo, authored by RAND Wellness Referee Soeren Mattke and others, in which a major wellness program was shown to fall far short of breaking even.

The specific highlights of the PepsiCo study are as follows:

  • Disease management alone was highly impactful, with an ROI of almost 4-to-1;
  • Wellness alone was a money sink, with each dollar invested returning only $0.48 in savings;
  • The wellness savings were attributed to an alleged reduction in absenteeism, as self-reported by participants.  There was no measurable reduction in health spending due to wellness.

Even though the wellness ROI was far underwater, we suspect that the ROI was nonetheless dramatically overstated, for several reasons.  First, the authors acknowledge underestimating the likely costs of these programs, focusing only on the vendor fees without considering lost work time, program staff expense and false positives.  Second, no matter how hard one tries to “match” participants with non-participants (the wellness industry’s most utilized measurement scheme), it simply isn’t possible to compare mindsets of the two groups.  We learned from one of Health Fitness Corporation’s many missteps that participants always outperform non-participants, simply because they are more motivated.  Third, the absenteeism reductions were self-reported, by participants.

Finally, PepsiCo’s human resources department, having made the mistake of accepting Mercer’s advice to implement one of these programs, was already taking some political risk by acknowledging failure.  Had they incorporated the adverse morale impact, lost productivity due to workers fretting about false positives, Mercer fees and staff costs, participant bias, and self-reporting bias, the ROI could easily have turned negative (meaning the program would have been a loser even if the vendor had given it away) and the HR staff could have been taking serious career risk.

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Ten Health and Wellness Resolutions Not to Make in 2014

We don’t make a lot of New Year’s predictions, but we are happy to make this one: 2014 will be the year the get-well-quick mentality driving corporate and individual health choices implodes…and people start taking genuine steps to be healthy. The way to ensure that 2014 is your year for good health?  Start with a double negative:  (a) wellness industry advice is almost always wrong; and (b) most people don’t keep their New Year’s resolutions. Hence, making the New Year’s resolutions recommended by the wellness industry is not the best way of ensuring your good health in 2014.

For simplicity, we’ll divide this list into individual and corporate wellness industry resolutions, and start with individual ones.

  1. Take more health advice from celebrities. Whether it’s hoping that Kim Kardashian’s personal trainer can help you or pining for Dr. Oz to cure what ails you with green coffee bean extract and raspberry ketones, a good way to put off doing worthwhile things is to do worthless ones.

  2. Start a weight loss program. The medical establishment could not head off the obesity dilemma at the pass, and they have no solution for it now, other than to crow about more drug companies diving into this expanding market. There is zero evidence that weight loss programs can produce sustainable long-term weight loss (and much evidence that they don’t), and we don’t know of a single one shown to improve fitness. That will not, however, prevent weight loss companies from trying to claim their little piece of the wellness landscape because they are losing so many individual customers to free dieting apps, such as LoseIt.com. Improve the quality of your diet first, and weight loss may follow, which is a bonus.

  3. Give yourself a cleanse. America’s obsession with cleanliness is now running smack into the reality of evolution and human physiology.  Surely if bacteria in your colon were bad for you, mankind would have died out eons ago.

  4. Stock up on supplements. The only things better than raspberry ketones and green coffee bean extract: all the other vitamin and mineral supplements on the market that fail to make sick people better or healthy people healthier. Who’s left to try to help, Martians? Never mind that risk is not endlessly reducible and the four most important things you can do for your health don’t come out of a bottle of magic jujubes: exercise, don’t smoke, eat well, and keep as close to a healthy weight as you can.

  5. Remove saturated fat from your diet. Just like in the 1960s, when we all traded in “the high-priced spread” for sticks of partially hydrogenated vegetable oils fit for a king to avoid saturated fat, we may be mis-demonizing this longstanding and naturally occurring component of our diet.   The entire nutrition dialectic in our culture over the past 20 years has focused on a string of individual no-nos: fat, saturated fat, cholesterol, and now refined grains and sugars (because we bought the government’s wrong advice to eat low-fat). It’s time to revive the notion of healthy eating patterns, not healthy eating isolates. In fact, here is the world’s simplest diet advice for 2014: eat less junk. That alone would be a landmark nutritional achievement for Americans.

  6. Eat organic and stay away from Starbucks. Within a week of each other, the New York Times published an account of a woman damaging her health eating an obsessively healthy and organic diet, and USA Today wrote of  another who ate exclusively at Starbucks for a year, with no apparent ill effects and no weight gain.

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Sense and Sensibility on Hypertension

Every now and then even blind squirrels find acorns.  The medical care industry, which long ago abandoned sensible fiscal and therapeutic restraint in the quest for new patients, finally treats us to a revised hypertension guideline that thoughtful people can conclude makes a great deal of sense.  It is even based on evidence, or actually the lack of it, which is itself a startling admission of reality from an industry that dances around truth with a nimble sophistry envied by even the most mendacious politicians.

The hypertension guidelines are a sharp departure from last month’s cholesterol guidelines, produced by a supposedly equally august panel of “thought leaders” who gave us guidelines that seemed to channel the The Talking Heads quite literally.  John P. Ioannidis, along with Nortin Hadler, easily one of the two or three most important physician thinkers of this or any generation, wrote that the cholesterol guideline will be either…”one of the greatest achievements or one of the worst disasters of medical history.”

If you haven’t read the hypertension guidelines, here is a useful summary:

  1. we treat too many people today;
  2. we rely too much on drugs for things that drugs cannot fix;
  3. treatment frequently does not produce health because therapy aims at a point, while the pursuit of health is a matrix; and
  4. if we are really going to improve cardiovascular health, which is strongly implicated not just in stroke, heart disease, and kidney disease, but also cognitive health, people are going to have to change behaviors because there aren’t enough pills on the planet to fix what ails us.

Cognitive health is an especially useful guidepost, because contrary to popular myth, it isn’t something that mysteriously disappears in nonagenarians.  The seemingly age-related decline is more likely the manifestation of damage done by a lifetime of incremental harms.  Isn’t it edifying to have scientists catch up to our moms?

The new guidelines leave us a redefinition of high blood pressure: greater than 150/90, except in cases where a comorbidity compels pursuit of 140/90 or lower to prevent end-organ damage.  This has implications not just for medical care but for workplace wellness, which obsesses with hypertension when it is not obsessing with cholesterol and glucose.

The hypertension guidelines yank away from workplace wellness vendors yet another reason to fine or otherwise antagonize employees who don’t show up at health fairs.  The progression of hypertension is strongly related to aging, and healthy aging is the most reliable bulwark against premature stroke, heart attack, kidney failure, or dementia.  Unless workplace wellness vendors plan to follow people into retirement, which is when the overwhelming majority of heart attack, stroke, and dementia occurs, there is no logical reason to ask any employee what his or her blood pressure or deign to tell them how to address it.

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