Categories

Tag: Wellness

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.

Continue reading…

Do You Care About My Health, Or Just Think I’m Gross? Be Honest.

 

Hi. I’m fat. I’m what most people call an in-betweenie—I have a heavy build, I wear plus sizes, my stomach poofs out, I have folds of fat along my back, I have chubby arms and legs. I can still buy clothes off the rack at a lot of stores, though.

Don’t rush to tell me I’m not ‘that kind’ of fattie or you’re ‘not talking about [me]‘ when you’re going on about how much you worry for fat people, though. We all know that you’re thinking of me, that when you think of fat people, my double chin comes to mind, my wobbling upper arms, my thighs broad in my jeans, my big ass. I’m fat. It’s okay. You can say it. I don’t have a problem with it.

I have a lot of issues with my body, but my size isn’t really one of them. It is what it is. The reasons I’m fat are complicated and not really your business. And yeah, I am unhealthy, and the reasons for that aren’t your business either, although I know you want to rush to assume that I’m unhealthy because I’m fat.

I don’t have an obligation to be healthy, actually, and I don’t have an obligation to rush to assure you that I’m a ‘good fatty’ with great cholesterol and good scores on other health indicators allegedly related to weight. I don’t have an obligation to tell you that fat isn’t correlated with health because I shouldn’t have to justify the existence of fat people by informing you that you don’t understand how fat bodies work, and you’re not familiar with the latest studies on fatness, morbidity and mortality, health indicators, and social trends.

Continue reading…

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.

Continue reading…

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.

  7. Continue reading…

How Can Patients on Medicaid Possibly Be Worse Off than Those Who Don’t Have Insurance?

“Extraordinary claims require extraordinary evidence,” said Carl Sagan.

The claim that health insurance improves health outcomes is hardly ground breaking. Studying whether insurance affects health status is like wondering whether three meals a day lead to a higher muscle mass than total starvation.

Well that’s what I thought. Until I read the study on Oregon’s Medicaid program by Baicker and colleagues in the NEJM earlier this year and, more recently, Avik Roy’s short treatise “How Medicaid Fails the Poor”.

Baicker et al found that Medicaid enrollees fared no better in terms of health outcomes than those without insurance. That is, no insurance no difference.

The study is an exemplar of policy research laced with regression equations, control of known confounders and clear separation of variables. There is only so much rigor social science can achieve compared to the physical sciences. Yet this is about as good a study as is possible.

The one thing the study did not lack was sample size. It’s useful to bear in mind sample size. Large effects do not need a large sample size to show statistical significance. Conversely, if study with a large sample size does not show even a modest effect, it means that the effect probably does not exist.

There are several interpretations of the Medicaid study, interpretations inevitably shaped by one’s political inclination. The ever consistent Paul Krugman, consistent in his Samsonian defense of government programs against philistines and pagans, extolled critics of Medicaid as “nuts” and asked, presumably rhetorically, “Medicaid is cheaper than private insurance. So where is the downside?”

Unlike Krugman I am not a Nobel laureate and am about as likely to win a Nobel Prize as I am of playing the next James Bond, so it’s possible that I am missing something blatantly obvious.  Could the downside of a government program paying physicians, on average 52 cents, and as low as 29 cents, for every dollar paid by private insurance in a multiple payer system be access?

Indeed, it’s darn impossible for patients on Medicaid to see a new physician.  As Avik Roy explains “…massive fallacy at the heart of Medicaid….It’s the idea that health insurance equals healthcare”.

But wait. It gets better.

I am accustomed to US healthcare throwing more plot twisters than Hercule Poirot’s sleuth work. But one I least expected was that patients on Medicaid do worse than patients with no insurance (risk-adjusted, almost). I am not going to be that remorseless logician, which John Maynard Keynes warned us about, who starting with one mistake can end up in Bedlam, and argue that if you are for Medicaid that is morally equivalent to sanctioning mass murder. Rather, I ask how it is possible that possessing Medicaid makes you worse off than no insurance whatsoever.

To some extent this may artifactually appear so because poverty correlates with ill health, and studies that show Medicaid patients faring worse than uninsured, cannot totally control for social determinants of health.

Continue reading…

Caveat User: Understanding the Health Risks of Mobile Devices

Tis the season to, well, buy stuff. Increasingly, the stuff we buy is electronic. In fact, not only that, but increasingly the stuff we buy with is electronic, too. We are using gizmos to shop for gadgets, or possibly gadgets to shop for gizmos.

In any event, we are ever more frequently in the company of the energy fields our electronic devices, and in particular our smart phones, generate. This deserves more attention than most of us accord it.

Don’t get me wrong — I am not suggesting we return to the pre-cell phone days when we lived in dark caves. We are fully ensconced in the electronics era, and there appears to be no going back. I am as fully dependent on electronic devices as anyone, and maybe more than most, living much of my life these days online. Like so many, I am both beneficiary and victim of the attendant efficiencies. On the one hand, I can’t recall how we ever got anything done in the days before instantaneous communication and push-of-a-button document transmission.

On the other, I do long for the freedom of the time before an unending stream of emails became my manacles. I did sleep better in the days before bedtime meant checking one last time to see who in the world needed what, and/or finding out that someone in cyberspace thinks I’m a moron. Oh, well.

Some of the risks related particularly to mobile phone use are well known. The dangers of distracted driving are common knowledge, with cell phone use now implicated in at least 25 percent of all car crashes. There is some evidence that ambient levels of empathy — our ability to understand and connect to one another’s emotional state — are declining, and possibly due to the frequency with which technology comes between us. A recent study among college students finds that more frequent use of cell phones correlates with impairment of academic performance, and increased anxiety — although the study could not prove cause and effect.

But the greatest and most insidious risk of cell phone use pertains to the electromagnetic fields of non-ionizing radiation they produce. What makes this risk insidious is our potential to dismiss it altogether, in part because it is convenient to do so, and in part because it’s hard to take seriously a potential menace that is totally invisible. I suspect we are all at least somewhat prone to a “what I can’t see, feel, taste, smell or hear can’t hurt me” mentality.

But of course, that’s clearly wrong, as we all have cause to know. Anyone who has ever had an X-ray has experienced first hand the power of an invisible force, in this case ionizing radiation, to penetrate deeply into our bodies. Anyone who has had a MRI has experienced the capacity of non-ionizing electromagnetic fields to do the same. What we can’t see or feel can, in fact, reach to our innermost nooks and crannies, both to produce vivid images of our anatomy — and exert other effects.

Continue reading…

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.

Continue reading…

Eight Bright New Ideas From Behavioral Economists That Could Help You Get Healthy.

Through a series of small grants, we’re is exploring the utility of applying behavioral economic principles to perplexing health and health care problems—everything from getting seniors to walk more to forgoing low-value health care.

At a recent meeting in Philadelphia we challenged grantees to compete in an Innovation Tournament. The goal was to identify testable ideas that leverage behavioral economic principles to help make people healthier by working with commercial entities. Participants were assigned to groups and made their best pitches to their colleagues. And of course we used a behavioral economics principle (financial incentives) to increase participation: Each member of the first, second and third place teams received Amazon gift cards.

Eight teams made the finals:

1.     Love Lock: This team addressed the issue of driving and texting by proposing an app that could be installed on your cell phone that would send reminders not to text while driving. This team would work with car insurance and mobile phone carrier companies and provide discounts to those who get it installed. The behavioral economics principles being tested are default choice and opt-out.

2.     McQuick & Fit: Too many people eat unhealthy food. This team’s idea was to have a rewards card that can only be used to purchase healthy food. With each purchase, the customer would earn points toward free, healthy foods. Online orders would be placed through a website that would feature salient labeling and allow for defaults to order healthy meals. The behavioral economics principles at play include pre-commitment, default choice, labeling, and incentives.

3.     Just Bring Me Water: The problem tackled by this team is “regrettable” calories—mindlessly consuming whatever is put in front of you, such as free bread at a restaurant, or soda on a plane. The innovation: when booking a table online or calling for a reservation, you could ask to “opt-out” of the complimentary bread or chips that are offered. This would reduce the consumption of regrettable calories.

4.     Lunch Club: This group looked at addressing gluttony through a partnership with a chain restaurant. When going out for a meal, portions are typically bigger and diners consume more. But what if you had the option of doggy-bagging one third of the meal for another meal—framed as “buy dinner and get lunch free”? And, if you took this option, you would get a scratch off as an enhanced incentive and immediate reward. The behavioral economic principles being tested here include loss aversion, active choice, and incentives.

5.     Snooze, But Don’t Lose: People don’t get enough good sleep, which leads to poor executive functioning and safety issues. To increase safety, productivity, and efficiency, this group proposed using a Fitbit to build in reminders to go to bed earlier and provide feedback on good sleep. The behavioral economic principles at play are pre-commitment and loss aversion.

Continue reading…

Healthism: The New Puritanism

Here is a thought experiment. Assume that every hour you run you extend your life by an hour.

I have chosen a one-to-one ratio between the increase in longevity from running and the time running because higher ratios lead to the immortality paradox. Lazarus aside, the all-cause mortality for Homo sapiens is 100 % and will remain so for the foreseeable future.

This arithmetic means that at one point you will literally be running for your life: your life being extended precisely by the time spent running. But ignore this logical fallacy.

You run an hour every day for 40 years. Your life is extended by 1.67 years. Your costs are a new pair of running shoes every three months, which might even be covered at zero co-payment by insurance if USPSTF gave running a grade A or B recommendation.

A back of the envelope calculation, assuming the shoes cost $ 80, yields cost per life year of roughly $7664. There is, of course, more nuance. I am not including injuries that may result from running. I am not discounting time: I am assuming we value an hour now the same as an hour 40 years from now.

I am also not factoring the costs avoided of treating late stage cardiovascular disease, which must be balanced against the additional social security checks that the individual will draw because of living longer, not to mention the costs of treating diseases of extended longevity such as cognitive impairment, Alzheimer’s disease, recurrent falls.

But please continue to indulge my approximation. The point is not precision of economic calculations but a principle.

$7664 for an additional life year. Compared to the benchmark of $50, 000 per quality-adjusted life year that’s a bargain!

Was it worth it then?

Continue reading…

Are Smokers Really the ACA’s Biggest Losers?

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.

Continue reading…

Registration

Forgotten Password?