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The Cholesterol Gulag

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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.

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Hyperdiagnosis: The Wellness Industry Doubles Down on Overdiagnosis

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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.

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CIGNA and Me

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By Vik Khanna

I have a challenge for CIGNA CEO David Cordani.  Sometime this week, pick up the phone and be a secret shopper.  Call your customer service team and ask them the same thing I asked them on a Friday not long ago: does my plan cover and reimburse for flu shots, and at which participating providers in my area?  This is managed care and wellness 101.  Just not at CIGNA.

Customer service rep A says shots are covered and reimbursed, but she cannot confirm any place in St. Louis as a par provider that would bill the plan directly for payment.  Her stubborn refusal to grasp the meaning of “par provider” was infuriating.  She repeatedly reads a list of potential providers (all national companies, such as Walgreens) and then tells me I must call each location to discern its billing practices.

Wrong.  Just plainly and simply wrong because they’re all signed to national contracts.  Then, while both my German Shepherds headed for cover in another room, she hung up on me.  (I was angry but never profane or malevolent.)

Undaunted and now even more frustrated, I call customer service again.  Customer service rep B says: shots covered fully and each location noted previously is a par provider that will accept assignment.  Done, right?  Not yet.  Customer service rep A calls me back.

She has not, however, learned anything in the intervening 15 minutes, as she returns to her home base of ignorance with the accuracy of a GPS.  Finally, I demand a supervisor.  With the supervisor comes enlightenment and lower blood pressure.

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My Personal Affordable Care Act–A Manifesto

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By Vik Khanna

The Founding Fathers had one.  Karl Marx had one.  Bertrand Russell and Albert Einstein had one.  And, now I have one: a manifesto, declaring my intent to live my life with as little interaction as possible with the US health care system by doing what the Affordable Care Act (ACA) tells me by omission I do not need to do: take responsibility for myself.

This is my Personal Affordable Care Act.

My manifesto is an algorithm for thriving in spite of the government’s naked and absurd attempt to define health as something that begins in the clinic.  My goal is to make myself and my family as scarce as possible within the health care system.

The ACA is a collective solution to the mass failure of individual will.  Our transformation into an information culture actually worsened the malady.  We are so conditioned to success at the speed of a search engine that, like the person who aspires to retire early, but refuses to save, we’ve forgotten to manage the fundamentals.

First, that every healthy lifestyle decision you make today, from diet and exercise to outlook and mood, requires thought and an exertion of will.  Even in the age of Google, volition matters, and choosing not just wisely, but strategically, is an option available to most people.

Second, despite revolutionary democratization of medical information, we still don’t do our homework.  Americans visit physicians 3 times per year on average, and the number one reason for the visits is “cough.”  Really?  You need to go to the doctor for a cough?  Unless you have a fever, chest discomfort, bloody sputum, or the cough lasts for weeks and keeps you up at night, it is almost certainly viral or related to an allergen and self-limited.

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The Summer of Wellness’s Discontent

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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.

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Obesity and the AMA, Part Two

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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.

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Is Big Sugar the Next Liability Target?

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By Vik Khanna

Growing paranoia is the hallmark of the aging process for me.  Although I am a generally affable sort (I know, it doesn’t always seem that way from my writing), I am also a fairly suspicious person.  I am starting to think that all the food industry’s sweet talk about the innocence of sugar is really just icing on a toxic cake and that we’ve all been sold a bill of goods.  In particular, I wonder — and part of me hopes — that Big Sugar might soon replace Big Tobacco as the favorite target of our most underappreciated and misunderstood national resource…the plaintiff’s bar.  There is no question we eat way too much sugar and that the increase in consumption has coincided nicely with both our rise in obesity and decline in health status even though we are living longer.

Not that I think the Tobacco Settlement (TS) was great social policy.  You can read my full view here; but, to summarize, as an immigrant and a person of color, a part of me resents the TS because all it did is push the burden of fulfillment of the financial terms into the hearts and lungs of people in Africa, Asia, and Latin America.  The smug satisfaction of tobacco opponents in the US and their glib dismissal of the impact on predominantly poor people of color around the world is first order racism.

Any analogous move against Big Sugar (BS) could be quite interesting.  There is, of course, the delectable duality of “what did they know and when did they know it?”.  Recently published opinions and data have forced me to think harder about just what goes on in the labs of companies like Coca Cola, Pepsi, Kellogg’s, Nestle, Domino, Mars, Hershey’s, etc.  No doubt BS defenders will say that sugar is “all natural” (ahem, so is tobacco), and safe when used as intended…and, that is where things will start to go awry for them.

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

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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.”

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What’s Science Got to Do With It?

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By Jon Robison & Vik Khanna

Penn State University is now embroiled in a national controversy over the ham-handed launch of its coercive and intrusive wellness program, which can cost recalcitrant employees as much as $1,200 per year for not joining.  That ignominy of being the most distasteful and coercive program, however, belongs to Blue Care Network of Michigan, which recently published results from their “voluntary” walking program designed exclusively for their obese enrollees.  The invitation to join was extended to enrollees with a body mass index (BMI, which is an unscientific, mathematically bereft proxy for health – see Keith Devlin’s excellent article ) of 30 or greater.  The program was “voluntary” as long as you were okay with paying $2,000 in added insurance premiums if you did not volunteer.

Avoiding the $2,000 price tag came with its own cost in dignity and privacy.  Enrollees agreed to either: 1) wear an electronic pedometer and connect it to their computer daily to document completion of at least 5,000 steps or, 2) join Weight Watchers or some other approved “weight cycling” program.  This princely sum is not irrelevant to most families.  In fact, it is almost exactly equal to per capita spending on food eaten at home in the US and about four percent of median US household income in 2011.  So, in a household occupied by a single adult, this will almost buy your groceries for a year, meaning that is hard to refuse, and the less money you make the more likely that resistance will prove futile.

The BCN strategy legitimizes telling people who look a certain way that they should submit to online, electronic monitoring or pay more for their insurance than people who don’t look that way.  Why would an obese person submit to this when it is entirely possible that he or she is fitter and more metabolically healthy than an normal weight unfit person who would never be condescended to this way?

More disturbing is the prospect that this is only the leading edge of life-invading monitoring by the wellness industry.  It is easy to envision sleep monitoring because you have bags under your eyes.  Or, what about wrist-worn breathalyzers to make sure you don’t go over the one or two drink limit, or sneak cigarettes after lying on your health risk appraisal that you don’t smoke?  How much electronic surveillance would you be willing to undergo on the pure guesswork that it might save someone (i.e., your employer or your health plan) money?

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The Other Penn State Scandal

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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.

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