Tag: Al Lewis

Ten Health and Wellness Resolutions Not to Make in 2014

Jan 5, 2014• 22

By Vik Khanna & Al Lewis

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.

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.
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.
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.
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.
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.
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.

Sense and Sensibility on Hypertension

Dec 19, 2013• 17

By Vik Khanna & Al Lewis

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:

we treat too many people today;
we rely too much on drugs for things that drugs cannot fix;
treatment frequently does not produce health because therapy aims at a point, while the pursuit of health is a matrix; and
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.

Are Smokers Really the ACA’s Biggest Losers?

Dec 1, 2013• 23

By Al Lewis & Vik Khanna

Facing thousands in extra insurance costs, smokers appear to be the Affordable Care Act’s (ACA) biggest losers. Employers are allowed charge smokers up to 50% more for their medical coverage than nonsmokers , starting in 2014.

On November 25, Fox News put it best: “Obamacare Policies Slam Smokers,” , noting that “smokers are the only group with a pre-existing condition that Obamacare penalizes.” THCB itself has headlined: Smokers Face Tough New Rules under Obamacare.

And these headlines are absolutely accurate — meaning that, with the possible exception of the e-cigarette, ACA is the best thing that has happened to employed smokers ever.

Here is how we arrive at this conclusion. The data is mixed on whether smokers incur much higher healthcare costs or just slightly higher healthcare costs during their working ages than non-smokers do. None of the data shows that their costs are lower, but let’s say there is no impact on health spending.

Nonetheless, the following is incontrovertible: smokers take smoking breaks.

Remarkably, there are no laws specifically governing smoking breaks, and like most other quantifiable human resources issues, no one has quantified them. But we all observe these breaks, and about a fifth of us participate in them. They reduce productivity. By definition, if you are outside smoking, you are not inside working.

Sure, some smokers make up the time by working harder when they aren’t smoking…but (1) many non-smokers work hard too and (2) some workplaces, such as inbound call centers, don’t offer the luxury of catching up later because they operate in real time. Lacking quantification, fall back on your imagination…and imagine what you would do if you ran a company in which non-smokers spent as much time mulling around outside as smokers do. That should give you an understanding of the impact of smoking breaks on productivity.

The Cholesterol Gulag

Nov 19, 2013• 14

By Vik Khanna, Tom Emerick & Al Lewis

Last week, we were amongst the very first opinion leaders to speak out against the new cholesterol guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC).

Our error was not going far enough.

Monday’s New York Times carried a devastating portrait of the development of the guidelines, leaving readers with the unmistakable impression that this absurd attempt to make people into patients was not just poor policy it was a hubristic, avoidable policy folly, sort of like the bridge to nowhere and federal housing policy pre-2008.

Trust is an interesting thing; once broken it almost resists reconstruction. Public trust in the AHA and ACC is crumbling as we write and deservedly so, as what should have been clear becomes more confusing and conflicted by the minute.

Instead of giving generally healthy middle aged American adults (like the three of us) the safe haven of a cardiovascular disease (CVD) prevention framework that is understandable, sensible and actionable, we got a cholesterol gulag. Only here in the land of the free, it’s not a government gulag imprisoning the political opposition.

No, in a phenomenon unique to the US, it’s a health gulag intended to take people who need advice, support, and guidance and give them a pill, which is the first step in an intentional ensnarement in the medical care system. It’s the Hospital California…on steroids, and you can’t even checkout because that would be against this addled medical advice.

To clarify: we have zero objection to providing statins, especially low-cost generic ones, to people under age 75 with current CVD, diabetes, or extremely high cholesterol levels. The drugs may very well save their lives.

Our beef is with the cockamamie reduction in the ‘risk-to-treat’ threshold from 10% risk of heart attack or stroke in the next 10 years to 7.5% for people with none of the above noted problems.

Hyperdiagnosis: The Wellness Industry Doubles Down on Overdiagnosis

Nov 7, 2013• 46

By AL LEWIS and VIK KHANNA

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.

1. Pre-Emptive

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.

The Summer of Wellness’s Discontent

Sep 23, 2013• 46

By Al Lewis & Vik Khanna

The series of unflattering articles published in Health Affairs early this year – the first unfavorable press wellness had ever received in a top tier policy journal — turned out to be a harbinger of what became the wellness industry’s summer of discontent. Perhaps in error, the Journal of Occupational and Environmental Medicine (JOEM) also drifted into the sea of credibility on wellness early in 2013 by publishing a meta-analysis of the industry’s claims of economic success.

The analysis, by researchers at Tufts, destroys the industry mythology of respectability by noting that out of over 2,000 papers published in the world’s medical literature, only 10 (0.5%) are worth discussing and that discussion leads essentially nowhere. Not surprisingly, like our essays here and in Health Affairs, the Tufts work has been universally ignored by the wellness true believers.

Starting with those articles, and especially over the last four months, those true believers have lost control of the dialog — starting right here with THCB, which gets credit as the first major regular source of objective news not generated by the wellness industry’s propaganda apparatus.

June brought the RAND report, our Wall Street Journal op-ed, and Cracking Health Costs. Unlike Health Affairs, some HR administrators have actually read those publications. These developments left them asking uncomfortable questions of an industry that hitherto had filtered the information that its customers received through the JOEM and the Journal of Health Promotion, the industry’s de facto house organs that between them in thirty years have published fewer articles concluding wellness doesn’t work (just that single meta-analysis mentioned above) than Health Affairs has in 2013 alone.

But it wasn’t until July that the wheels fell off the wellness bus, due to four self-inflicted wounds that did more to diminish the industry’s carefully cultivated albeit totally undeserved patina than anything we could have written. Atoning for its brief foray into accuracy, JOEM published an article showing $20-million in savings for British Petroleum’s (BP) wellness program, 100 times what the vendor, Staywell, claims on its own website to be possible.

Obesity and the AMA, Part Two

Sep 10, 2013• 11

By Vik Khanna & Al Lewis

A likely unanticipated consequence of the AMA’s decision to label obesity a disease, even though their own scientific council said not to, is that this might serve as the macguffin leading to furtherance of a protected class of people. This has serious implications not only for employment discrimination, but also for wellness programs, which often hinge vastly overblown claims of being able to help the obese who they almost universally label as “high risk” people.

Well, what if people who are obese, who are no doubt tired of being condescended to, first by wellness companies, and now by the AMA, decide that they are going to seek medical approval to opt out of wellness programs? A study recently published in the journal Translational Behavioral Medicine reports on a highly coercive, electronically monitored walking program for obese people: 17% opted not to participate and another 5% actually got their physician’s approval to opt out. The physician approval to opt out is key to any resistance strategy.

Under the final wellness rules issued by the federal government earlier this year, physician certification that it is medically unadvisable for an employee to participate in a wellness program creates a burden for the employer and wellness vendor. They must provide reasonable alternatives that do not disadvantage the employee in terms of either time or cost and that address the physician’s concerns.

Further, if the employee’s physician disagrees with offered alternative, the employer and wellness vendor must provide a second alternative. The coup de grace is that “adverse benefit determinations based on whether a participant or beneficiary is entitled to a reasonable alternative standard for a reward under a wellness program are considered to involve medical judgment and therefore are eligible for Federal external review.”

Targeting people based on body mass index (BMI) is an intellectually, morally, scientifically, and mathematically bankrupt approach. The AMA’s decision will actually help obese people and advocates for their dignified treatment in the workplace and society start to understand that they can refuse to opt in to these insulting programs and, simultaneously, be protected from penalties. Clearly, this is the opposite of what unsuspecting employers expect when vendors (and their own brokers) sell them these programs: more useless doctor visits, less leverage with penalties…and more employee disgruntlement. Not just the obese will be disgruntled, but also those who have to pay the penalties because their BMI is too high to get the reward but not high enough to get a doctor’s note.

The Biggest Urban Legend in Health Economics–and How It Drives Up Our Spending

Aug 24, 2013• 66

By Al Lewis & Vik Khanna

The wellness emphasis in the Affordable Care Act is built around the Centers for Disease Control and Prevention’s (CDC) 2009 call to action about chronic disease: The Power to Prevent, the Call to Control. On the summary page we learn some shocking statistics:

“Chronic diseases cause 7 in 10 deaths each year in the United States.”
“About 133 million Americans—nearly 1 in 2 adults—live with at least one chronic illness.”
“More than 75% of health care costs are due to chronic conditions.”

Shocking, that is, in how misleading or even false they are. Take the statement that “chronic diseases cause 7 in 10 deaths,” for example. We have to die of something. Would it be better to die of accidents? Suicides and homicides? Mercury poisoning? Infectious diseases? As compared to the alternatives, it is much easier to make the argument that the first statistic is a good thing rather than a bad thing.

The second statistic is a head-scratcher. Only 223 million Americans were old enough to drink in 2009, meaning that 60% of adults, not “nearly 1 in 2 adults,” live with at least one chronic illness — if their language is to be taken literally. Our suspicion is that their “133-million Americans” figure includes children, and the CDC meant to say “133-millon Americans, including nearly 1 in 2 adults, live with at least one chronic illness.” Sloppy wording is not uncommon at the CDC, as elsewhere they say almost 1 in 5 youth has a BMI > the 95th percentile, which of course is mathematically impossible.

More importantly, the second statistic begs the question, how are they defining “chronic disease” so broadly that half of us have at least one? Are they counting back pain? Tooth decay? Dandruff? Ring around the collar? “The facts,” as the CDC calls them, are only slightly less fatuous. For instance, the CDC counts “stroke” as a chronic disease. While likely preceded by chronic disease (such as hypertension or diabetes) and/or followed by a chronic ailment in its aftermath (such as hemiplegia or cardiac arrhythmias), a stroke itself is not a chronic disease no matter what the CDC says. Indeed it is hard to imagine a more acute medical event.

They also count obesity, which was only designated as a chronic disease by the American Medical Association in June–and even then many people don’t accept that definition. Cancer also receives this designation, even though most diagnosed cancers are anything but chronic – most diagnosed cancers either go into remission or cause death. “Chronic disease” implies a need for and response to ongoing therapy and vigilance. If cancer were a chronic disease, instead of sponsoring “races for the cure,” cancer advocacy groups would sponsor “races for the control and management.” And you never hear anybody say, “I have lung cancer but my doctor says we’re staying on top of it.”

The Other Penn State Scandal

Aug 12, 2013• 69

By Vik Khanna & Al Lewis

It’s one thing to lead by example and quite another to be made an example of. The executive leaders of Penn State University, who have managed to generate quite enough terrible publicity over the past couple of years, have now gone boldly where no employer has gone before. By implementing a coercive, intrusive, and wasteful “wellness” program during the academic year’s summer doldrums and miscalculating that it would go unnoticed, they have invited the wrath of their own faculty.

The PSU wellness initiative like so many before it relies on the hydra of preventive medical care, which is both clinically and fiscally ineffective; a personally intrusive health risk appraisal; and, a whopping incentive/penalty of up to $1,200 per year if you don’t play ball, which is double the national average. Penn State faculty, led by political science professor Matthew Woessner of their Harrisburg campus, have responded with outrage and a petition for withdrawal of the program, which now has 1,500 digital signatures. Penn State’s HR team, led by VP Susan Basso, has doubled down on its own ignorance claiming that the opposition is “unfortunate and sad.” What’s unfortunate and sad is that employees of a college can’t do math or read .

Penn State faculty are right to oppose the wellness program on both ethical grounds and economic grounds. Their creativity on how affected faculty and staff should respond is applause-worthy. Entering bogus data on the HRAs (both legal and harmless to employees because HRAs are anonymous) and refusing to get any of the preventive care recommended are useful guerilla steps. They are also discussing a blanket refusal to participate, which means either everyone gets hit with the penalty or no one does.

The Strange Case of the C. Everett Koop National Health Award

Aug 8, 2013• 30

By Al Lewis & Vik Khanna

The late Dr. C. Everett Koop was the most revered Surgeon General in history, perhaps even the most revered Cabinet member. His calling card—indeed, his claim to fame – was his integrity. A Reagan appointee, he acted as though he reported to no one other than the American people and his own conscience. His penchant for candor and scientific independence fueled the federal government’s groundbreaking steps to raise public awareness about HIV/AIDS at a time when the tendency was to demonize and diminish. He resisted incessant political pressure and refused to take positions or produce data that he knew to be false.

This drew strong support from both sides of the aisle, and even his detractors never questioned his honesty. (Exhibit A: The two authors of this posting, whose political views have little else in common other than respect for strong, independent-minded politicians.)

Dr. Koop’s legacy stands in sharp contrast to the eponymous award dispensed by The Health Project, whose committee members have turned their back on their founder. The last thing Dr. Koop would have expected is to see is *his* award bestowed upon people who know that they don’t deserve it. The 2012 award was given to three recipients for work done in Nebraska: a vendor that claims wellness programs don’t even have to exist to save money, an outfit that can’t even spell the name of its own founder, and a state employee benefits plan that is under investigation for sky-high administrative costs.

Among the extravagant statements that formed the basis for the award (like claiming more than $20,000 in savings for every person who reduced their risk factors for a year, even though per-person spending is only $6,000), they claimed to have made 514 “life-saving catches” on employees with otherwise undetected cancer. This data was obviously wrong to begin with — that cancer rate would have been at least 40 times greater than Love Canal’s. Nonetheless, it sure sounded good, and the Governor of Nebraska himself was all-in too, so an award was issued.