By AL LEWIS
Part 2 picks up where Part 1 left off, as coincidence would have it.
Soeren Mattke (as mentioned in the last installment) and I were quite relentless in trying, quixotically, to get Professor Baicker to explain her results. Its popularity could have landed her many profitable speaking and consulting gigs, but she evinced no interest in cashing in, or even in defending her position. Indeed, the four times she spoke publicly on the topic, she didn’t do herself, or her legions of sycophants in the wellness industry, any favors. In each interview, she distanced herself more and more from her previous conclusion. Here are her four takeaways from her own study “proving” wellness has precisely a 3.27-to-1 ROI:
- It’s too early to tell (um, after 30 years of workplace wellness?)
- She has no interest in wellness anymore
- People aren’t reading her paper right (Shame on us readers! We’re only reading the headline, the data, the findings and the conclusion, apparently)
- “There are few studies with reliable data on the costs and the benefits”(um, then how were you able to reach a conclusion with two significant digits?)
Individually or in total, these comments sounded an awful lot like retractions, but she (and her co-author and instigator, David Cutler) claimed those comments didn’t constitute retractions. Whatever they were, she wasn’t exactly doubling down on this 3.27-to-1 conclusion.
By AL LEWIS
Let’s climb into the WABAC Machine (and, yes, that’s the way it’s spelled) and set the dial for 2008.
Then-candidate Barack Obama, campaigning on the promise of universal health coverage, enlisted Harvard professor David Cutler as his key adviser on that topic. Business lobbying associations were not thrilled about their members having to cover all their full-time employees and incorrectly assumed, then as now, that the major drivers of healthcare cost were employees smoking, overeating, and not exercising. Prof. Cutler suggested, quite correctly, that one way to assuage that concern would be to allow employers to spend less money covering employees with those three health habits.
Fast-forward to 2009, when it appeared that — with enough concessions to enough vested interests — the Affordable Care Act (ACA) could become a reality. Business lobbying groups were, then as now, powerful entities. Using Prof. Cutler’s suggestion, they were pacified by allowing businesses to tie up to 30% of total premium dollars to employee health (in practice, largely employee weight). Generally, the business lobbying groups engineered this withhold in the shadows. It wasn’t until 2015 that one of those business groups, the Business Roundtable, publicly admitted that the 30% withholdwas the main reason they bought into the ACA.
Since this 30% was basically a giveaway to corporations, the Obama Administration needed to justify it as a cost-savings measure. On the one hand, they had the Safeway experience “proving” that wellness could save money in practice. This alleged proof was met with open arms by both parties. Safeway’s CEO became a “rock star” on Capitol Hill. (Of course, Safeway’s wellness program, like virtually every other great-sounding success in wellness, turned out to be a scam. In retrospect, just reading the Safeway CEO’s Wall Street Journal op-ed* announcing these results, it’s amazing how the mind-blowingly fallacious statistics didn’t get called out back then, by me or anyone else.)
Recently, The Health Care Blog published a post by Robert Sutton asking why there were so many jerks in medicine.
That posting made the underlying assumption that being a jerk is a bad thing. In response, we are posting today a defense — really more an explanation of the features and benefits — of jerkdom, at least in our segment of healthcare, wellness and outcomes measurement.
In 1976 an obscure graduate student named Laura Ulrich (now a Pulitzer Prize-winning professor) wrote: “History is seldom made by well-behaved women.” That statement could be applied much more broadly. In any field governed by voluntary consensus – especially where the consensus specifically and financially benefits the people making the consensus – radical change does not happen jerklessly.
The best current example might be the critique of Choosing Wisely in the New England Journal of Medicine in which it was pointed out that only three specialty societies blacklisted controversial procedures still performed in significant enough quantity to affect that specialty’s economics.
(Another example of financially fueled consensus gone awry is the RUC, also frequently and justifiably excoriated in The Health Care Blog and elsewhere.)
Specifically, there are three reasons we act like jerks. (Four reasons if you include selling our book, but we acted like jerks well before our book came out.)
First, as Upton Sinclair said, “You can’t prove something to someone whose salary depends on believing the opposite.” Hence, making nice rarely works and may backfire when you are pointing out a total waste that also happens to be someone else’s income.
After Community Care of North Carolina (CCNC) sponsored an outcomes study by Mercer finding massive savings through their patient-centered medical home (PCMH) in an age cohort (children under one year of age) in which no utilization reduction took place and which, as luck would have it, was not enrolled in the PCMH anyway, we kindly wrote to them and offered to show them the error of their ways, privately.
We didn’t get a response. We repeated the offer when they put out another RFP for even more validation, pointing out that using the HCUP database meant no RFP was needed — we would be able to give them an answer in less time than it would take them to evaluate the RFP responses, and save them close to $500,000 in taxpayer money too.
T was never a star service tech at the auto dealership where he worked for more than a decade. If you lined up all the techs, he wouldn’t stand out: medium height, late-middle age, pudgy, he was as middle-of-the-pack as a guy could get.
He was exactly the type of employee that his employer’s wellness vendor said was their ideal customer. They could fix him.
A genial sort, T thought nothing of sitting with a “health coach” to have his blood pressure and blood taken, get weighed, and then use the coach’s notebook computer to answer, for the first time in his life, a health risk appraisal.
He found many of the questions oddly personal: how much did he drink, how often did he have (unprotected) sex, did he use sleeping pills or pain relievers, was he depressed, did he have many friends, did he drive faster than the speed limit? But, not wanting to rock the boat, and anxious to the $100/month bonus that came with being in the wellness program, he coughed up this personal information.
The feedback T got, in the form of a letter sent to both his home and his company mailbox, was that he should lose weight, lower his cholesterol and blood pressure, and keep an eye on his blood sugar. Then, came the perfect storm that T never saw developing.
His dealership started cutting employees a month later. In the blink of an eye, a decade of service ended with a “thanks, it’s been nice to know you” letter and a few months of severance.
T found the timing of dismissal to be strangely coincidental with the incentivized disclosure of his health information.
A recent blog on HBR.org proposed to deliver “The Cure for the Common Corporate Wellness Program.” But as with any prescription, you really shouldn’t swallow this one unless all your questions about it have been answered. As a physician, a patient, and a businessman, I see plenty to question in Al Lewis and Vik Khanna’s critique of workplace wellness initiatives.
With their opening generalization that “many wellness programs” are deeply flawed, the authors dismiss a benefit enjoyed by a healthy majority of America’s workers. Today, nearly 80% of people who work for organizations with 50 or more employees have access to a wellness program, according to a 2013 RAND study commissioned by the U.S. Department of Labor and the U.S. Department of Health and Human Services.
It’s not clear whether the authors are intentionally dismissing or simply misunderstanding the wealth of data that shows how wellness programs benefit participating employees. The RAND study summarizes it this way: “Consistent with prior research, we find that lifestyle management interventions as part of workplace wellness programs can reduce risk factors, such as smoking, and increase healthy behaviors, such as exercise. We find that these effects are sustainable over time and clinically meaningful.”
Lewis and Khanna, however, don’t focus on such findings. Instead, they question the motives of a company for even offering a wellness program, which they slam as an “employee control tool” and “a marketing tool for health plans.” And, in perhaps the most baffling statement of all, the authors suggest that workplace wellness initiatives are “trying to manipulate health behaviors that are largely unrelated to enterprise success” (emphasis mine).
Let’s consider that piece by piece. What are the behaviors that corporate wellness initiatives are trying to influence? According to the RAND study, the most common offerings — available in roughly 75% of all wellness initiatives — are on-site vaccinations and “lifestyle management” programs for smoking cessation, weight loss, good nutrition, and fitness. In short, companies want to reduce the risk that their workers will get the flu, develop lung cancer, or suffer from the many debilitating conditions linked to overweight and a sedentary lifestyle. How could these initiatives be deemed “largely unrelated” to the company’s success?
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.
Health-contingent workplace wellness, the two-time darling of federal legislation codified in both the Health Insurance Portability and Affordability Act (HIPAA) and the Affordable Care Act (ACA), is now plagued by doubts about effectiveness and validity that are inexorably grinding away its legitimacy. This puts employers, particularly large employers who have committed to it so vocally and visibly, in an awkward spot. In the style of politicians nervously trying to change the terms of debate, wellness advocates are now walking back the assertions that have undergirded their entire construct for more than a decade. While some business leaders are apparently either unwilling or unable to back away from this self-inflicted wound, staying the present course is neither inevitable nor required. A course correction might actually prove quite liberating, especially for leaders of smaller and mid-sized businesses who must scratch their heads wondering how they’re supposed to reproduce a big-company style workplace wellness program or even why they should, given the dearth of data on effectiveness.
As a case in point, we offer GE, an iconic American multinational with 305,000 employees, $147BN in revenues, and $16.1BN in earnings worldwide in 2012. The company offers its employees a much-lauded wellness program, saluted by the National Business Group on Health (NBGH) in a fawning 2009 case study. GE’s wellness program has several things to recommend it:
- A top line focus on environmental change
- An emphasis on strong and consistent positive health messaging to employees
- The “Health By The Numbers” strategy that asks employees to commit to essential behavior changes (don’t smoke, eat more produce, walk more, and maintain a healthy body mass index [BMI]; there is wisdom in these choices, as they are the baseline activities for good health)
Beyond these obviously beneficial wellness program components, the GE wellness program veers off into a compendium of wellness convention, with encouragement for employees to take HRAs and get screenings, in particular, mammography, colonoscopy, cholesterol, and blood pressure. Some of the affection for diagnostics springs, of course, from GE’s corporate commitment to health care, which includes selling a broad variety of diagnostic devices to medical care providers who must, in turn, induce demand in order to pay for their contribution to GE Healthcare’s $18.2BN revenue stream.
As far as is discernible from publicly available documents, the wellness program targets GE worksites with over 100 employees, and GE claims in the NBGH case report that over 90% of employees worldwide participate. Beyond these data, however, it is remarkably difficult to understand what results GE gets and at what cost. The only publicly available insight on expense comes from GE wellness leader Rachel Becker in an essay published online by EHS Journal, in which she reports $100,000 per site as the wellness startup cost. Extrapolating this figure to GE’s more than 600 global worksites produces a wellness capitalization expense of about $60M, which presumably does not include annual wellness program operating costs. This might be why GE makes absolutely no mention of the cost or results of its wellness program in either its annual report or its 10K filing, although the NBGH quotes GE as saying the implementation was “inexpensive”. Even though $60M is equal to only 0.38% of GE’s 2012 earnings, it nonetheless might seem an untidy sum to skeptical shareholders.
On March 20, 2013, the media picked up a story about CVS Caremark’s latest wellness program. In summary, CVS will be requiring all of its employees to complete a health screening in order to qualify for a reduction in their health insurance premium. For those employees who participate, the employee’s screening data goes to a third party, and CVS never sees it.
Such wellness financial incentives are commonplace and have been around a long time. And if that is how the media had described the CVS program, it’s doubtful anyone would have even paid any attention to it. Unfortunately, that’s not how the media ran with the story. Let’s look at how the media sent the wrong message – using ABC News as an example – and why it matters to get the message right.
Sending the Wrong Message
ABC’s Good Morning America segment was emblazoned with the headline, “Who’s Watching Your Weight – CVS Employees Required to Disclose Weight.” Their website ran a similar headline, “CVS Pharmacy Wants Workers’ Health Information, or They’ll Pay a Fine.”
The ability to gather, analyze, and distribute information broadly is one of the great strengths of digital health, perhaps the most significant short-term opportunity to positively impact medical practice. Yet, the exact same technology also carries a set of intimately-associated liabilities, dangers we must recognize and respect if we are to do more good than harm.
Consider these three examples:
- Last week, a study from Case Western reported that at least 20% of the information in most physician progress notes was copy-and-pasted from previous notes. As recently discussed at kevinmd.com and elsewhere, this process can adversely affect patient care in a number of ways, and there’s actually an emerging literature devoted to the study of “copy-paste” errors in EMRs. The ease with which information can be transferred can lead to the rapid propagation of erroneous information – a phenomenon we used to call a “chart virus.” In essence, this is simply another example of consecrating information without first appropriately analyzing it (e.g. by asking the patient, when this is possible).
- At a recent health conference, a speaker noted that a key flaw with most electronic medical record (EMR) platforms is that they are “automating broken processes.” Rather than use the arrival of new technology to think carefully, and from the ground up, about the problems that need to be solved, most EMRs simply digitally reify what already exists. Not only does this perpetuate (and usual exacerbate) notoriously byzantine operational practices and leave many users explicitly complaining they are worse off than before, but it also misses the chance to offer conceptually original approaches that profoundly improve workflow and enhance user experience.