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.
Watching pro sports today is nothing more than gazing from one high-priced moral train wreck to another. To wit, Ryan Braun, the disgraced Milwaukee Brewers outfielder, has finally been bounced from baseball for use of performance enhancing drugs. Braun and his duplicitous, two-wheeled compatriot, Lance Armstrong, have not only made fools of us but succeeded in making perpetual fools of themselves through excuses (“I didn’t do it!”) and accusations (“They’re picking on me!”) that would embarrass a fourth grader.
How easily we cleave morality from the athletic excellence. How often have you heard commentators decry the cheating, but then soften the blow by saying “but, he’s not a bad guy,” or, in the case of Armstrong, “he’s done so much for the cancer community?” The inescapable conclusion is that you can be a liar, a jerk, and a cheat (an ignominious trifecta true of both Braun and Armstrong, as well as their predecessor in sleaze, Barry Bonds), but the absolution of milquetoast praise from an airy talking head is only as far away as your latest convivial act, regardless of whether any actual contrition or repentance took place.
This is an all new kind of dualism (but, I think, just as repugnant and ludicrous as the original foisted upon us by Descartes). I prefer to think of people as integrated beings, whose behaviors and speech accurately reflect both who they are and what they are capable of. I know of no body of work describing Braun and Armstrong as anything other than not-so-bright, raging egomaniacs. Maybe that’s what you need to succeed at professional sports, with a little chemical assist, of course.
The way to handle this crisis of faith is to remove all controls. On my own blog, I once proposed a more market-based approach to dealing with sports cheats. I have thought better of that now, and I believe it’s time to actually undo all restraint. I say that all professional sports just unchain the chemists and let the athletes use whatever they want, whenever they want. We’ll find out quickly who passed high school chemistry and who didn’t. Even better, turbo charge the free-for-all by statutorily shielding product manufacturers and complicit medical professionals, so that 20 years from now we are spared the “they didn’t tell me it would cause congestive heart failure and brain cancer” lawsuits.
I was a chubby kid, which brought with it all manner of slights, both real and imagined. My predicament was worsened because I came from an immigrant family, and my father was tormented by unrelenting and untreated bipolar disease. When he was lucid, however, he taught essential lessons that neither he nor I knew at the time would become my life’s cornerstone: don’t trust the professions too much; advance your own cause through limitless learning; and, use exercise — all forms of it — as an irreplaceable lever for personal betterment. My dad may have been out of it more often than not, but he swam, did calisthenics, played tennis, and boxed, and he walked vigorously right up until the end of his life. I saw, I learned, I did (and still do).
Imagine, then, my chagrin at how the Affordable Care Act (ACA) effectively shears away the concept of personal responsibility and mastery of lifelong wellness skills from the pursuit of actual health. It was a huge missed opportunity to teach Americans about what’s first in the line of responsibility for good health.
Instead, the ACA’s philosophical foundation ignores the power that individuals have to impact their personal health trajectory, and it compels Americans to accept lifelong roles as patients in a system that many of them not only don’t want any part of but that they distrust and don’t understand. It is exactly the opposite result that something called “health” reform should have produced.
A critical observation in Cracking Health Costs is you need not “challenge the data” to invalidate claims that wellness saves money. Instead, you can simply read the data as presented. You’ll find it usually invalidates itself.
Nowhere is that more true than in a study published this month by Mercer, Staywell and British Petroleum (“BP America”) in the Journal of Occupational and Environmental Medicine (JOEM). As we’ll demonstrate, the results completely contradict Staywell’s own statements, and are also mathematically impossible. Indeed, Mercer was a wise partner choice by BP America because their validations are often unconstrained by the limits of possibility. For instance, they validated massive savings both for infants in a North Carolina Medicaid program that did not enroll infants, and for a Georgia Medicaid disease management program that did not manage diseases, at least according to the FBI.
Along those lines, let’s see what happens when one compares the JOEM conclusion — that the Staywell wellness program for BP America achieved almost $20,000,000 in savings on 20,343 BP participants after only two short years – to the limits of possibility.
It turns out this overall savings claim of $1,000/person would require completely wiping out wellness-sensitive medical events (heart attacks, diabetes events etc.) not just on those 20,000+ people, but also on perhaps 40,000 of their closest friends. The authors elected not to disclose the change in wellness-sensitive medical events across the entire eligible population, perhaps because they were embarrassed by the size of the decline, if indeed those events declined at all.
Last week’s announcement by the American Medical Association’s (AMA’s) council on science and public health cheered me. It said that the AMA should not designate obesity a disease, because doing so was unlikely to improve health outcomes and because the most widely utilized obesity metric — the body mass index or BMI — was simplistic and flawed. It’s a reasonable and principled stance, which should have been the first clue that it was doomed.
The AMA’s board and delegates proceeded to snatch defeat from the jaws of victory by ignoring their own scientific council and labeling obesity as a disease. To be clear, the decision is almost purely symbolic; it has no legal force or authority, but it does up the ante in the debate with insurers and employers over what care elements should be covered and reimbursed. In other words, this is about money. Obesity: the new ATM for the health care system.
I’m just curious about where physicians have been for the past, oh, thirty years. Since 1980, as Americans have morphed into the fattest culture in the history of Western civilization, physician supply per 100,000 population has increased about 50%. Per capita medical care spending has increased from roughly $1,100 to over $8,400. 1980 was also the last time that roughly half of US adults were normal weight. Now, only about a quarter of American adults have a normal BMI.
Were US physicians blindfolded as they encountered patients growing incrementally larger with each visit? Were they keeping their mouths shut about the obvious — gee, I really think you should get out for some walking and limit the snacks — because they were awaiting a chance to make more creative use of ICD and CPT codes?
The long awaited federally-mandated RAND Corporation report on workplace wellness programs is finally out, after months of anticipation. Despite an odd now-you-see-it/now-you-don’t release, both wellness proponents and critics anxiously awaited the report’s public deliverance.
Like many documents emanating from the political cauldron, the RAND report has elements in it to please both camps, although proponents will have to reach deep into the document for snippets of hope built around simulations, models, and what they term “convenience” samples of employers predisposed to support health-contingent workplace wellness programs.
For critics of health-contingent workplace wellness programs, the conclusion is much more straightforward: even using prejudicial data sources and lacking a critique of the quality of the evidence, the impact of workplace wellness on the actual health of employees and the corporate medical care cost burden, is, generously stated, negligible.
This is not worth $6BN a year, which is the purported size of the US market for health-contingent workplace wellness programs (“purported” because like everything else in wellness, the size of the industry itself is totally opaque). There are clearly better ways to spend these funds; at the very least, it must be possible to get the same dismal results for far less money and with vastly less complexity.
With the push of the Affordable Care Act, the drive to implement health-contingent workplace wellness programs is accelerating. The RAND report, rather than contributing propellant, ought to give responsible business leaders pause as they consider whether to step up the pressure (i.e., increase incentives and penalties) for employees to participate in these highly intrusive, clinically dubious, spendthrift programs that yield health in RAND’s hypothetical world of models and simulations, but perhaps not so much, as RAND notes, in a more earthbound reality.
The lesson for executive leaders is that the nearly hagiographic employer belief in the value of health-contingent wellness is completely undone by the fact that RAND says virtually no employer (2% of their sample) measures program impacts and, as we have written previously, it doesn’t look like any employer, benefits consulting firm, or vendor actually knows how to do so.
Eat your vegetables. Turn off the TV. Go outside and play. Go to bed on time. These four imperatives were once amongst the core messages delivered to children by their parents and neighbors, a setting of behavioral parameters that people intuitively expected would help to produce healthy, well-balanced kids. We’re not so good at this anymore. Like so many other behaviors that animate the phrase “personal responsibility”, in the face of economic and demographic tumult we have decided to pass the buck on them in our homes, neighborhoods, schools, and churches. We now want employers to handle them, and health-contingent wellness is the final step in the ascendancy of the employer as the new parent.
Employers find themselves teaching employees how to read and write effectively, do math, be polite, how to eat in the presence of others, and even how to sleep better. Why not throw at their feet the notion that employers should coerce workers into intrusive and dubious health-contingent workplace wellness strategies that are easy as pie for the healthiest, but far more difficult for the less fortunate who are, ostensibly, the ones who need the most help? This is not why most people start businesses (unless, of course, you’re a wellness vendor). It certainly is not why people devote themselves to work, which is supposed to be for securing (hopefully) individual and familial prosperity and experiencing the unique contribution to personal dignity that comes from purposeful endeavors.
US employers are not responsible for the chronic disease crisis; truth be told, their sufferance of the costs of many wellness-sensitive events is limited because the majority of the medical catastrophes that health-contingent wellness programs promise to prevent (such as heart attacks, strokes, and many cancers) happen predominantly in older people who have mostly left the work force. Employers have been caught up in the maelstrom of demographic, industrial, and technological changes just like the rest of us. Yet, not only do we actively seek their participation in fishing expeditions such as health-contingent workplace wellness programs, some of them jump in with both feet. This should help to remind you that your CEO might just be the one who graduated at the bottom of his class.
Suppose one day you sit in front of your work computer, click on a link supplied by your employer, and set about the task of answering a hundred or more highly intrusive health questions. Setting aside the issue of financial penalties or rewards for doing the survey, you would trust that the instrument itself, called a health risk appraisal (HRA), would actually have a sound scientific basis, especially since its ultimate goal is to give you purportedly accurate health guidance.
Unfortunately, your trust in the validity of the tool would be quite misplaced.
HRAs are an essential screening tool in workplace wellness programs despite the fact that no body of evidence clearly demonstrates either their fiscal or clinical value and that no health services research has determined which HRA is the optimal tool. Indeed, a recent review of HRAs concluded that they increase spending, not reduce it, and that no one has any idea whatsoever whether taking an HRA has anything to do with the delivery of health value.
By masking essential methodological truths about HRAs, wellness vendors have essentially hustled their employer clients into believing that HRAs, which frequently ask clinical questions best left to primary care clinicians or restate platitudes (gosh, I didn’t know it’s safer to drive while not under the influence), are both probative and predictive of a person’s health future. This is just simply wrong.
“The Effect of Price Reduction on Salad Bar Purchases at a Corporate Cafeteria.” An excellent peek at the kind of steps that employers ought to take to improve eating habits in their work forces: subsidize the purchase of healthy foods. In this CDC study, reducing the price of salads drove up consumption by 300%. If this was a stock, we would all rush out to buy it.
Influencing behavior through both choice architecture and pricing differentials challenges many employers, however. There is a fear factor in play (“some of my people will be unhappy”), as well as financial issues, because the corporate managers responsible for food services often have their compensation linked to the division’s profitability. You make a lot more money selling soda than you do selling romaine. The same perverse financial conundrum appears when corporate food service companies run cafeterias. The on-site chef and managers typically operate on a tightly managed budget that leaves them little flexibility to seek out and provide healthier options.
A chef employed by one of the largest corporate food service providers in the country told me last year that he could not substitute higher protein Greek yogurt for the sugar-soaked, low-protein yogurt in his breakfast bar. When I asked why, he told me that Greek yogurt was not on his ordering guide, and he was not allowed to buy it from a local club warehouse and bring it in. In this same company, beverage coolers were stuffed to overflowing with sugar-sweetened drinks, all of which were front and center (and cheap), while waters and low-fat milk were shunted to the side coolers. In another scenario, health system leaders I met with last year all raised their hands when I asked if they had wellness programs and kept them up when I asked if they also sold sugar-sweetened beverages in their cafeterias at highly profitable prices. The irony was completely lost on them. They had to be walked through the inconsistency of telling their employees to take (worthless) HRAs and biometrics, but then facilitating access to $0.69 22 oz fountain sodas.