Tag Archives: bmi

How CDC Sparked the Wellness Legend

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

  •  “Chronic diseases cause seven in 10 deaths each year in the U.S.”
  •   “About 133 million Americans — nearly one in two adults — live with at least one chronic illness.”
  •   “75% of our healthcare spending is on people with chronic conditions.”

Shocking — that is, in terms of how misleading or even false the claims are and of how they created the wellness legend.

Take the statement that “chronic diseases cause seven in 10 deaths.” We have to die of something. Would it be better to die of accidents? Suicides and homicides? Mercury poisoning? Side effects of measles vaccinations gone awry?

The second statistic is also a head-scratcher. Only 223 million Americans were old enough to drink in 2009; divide 133 million into that number, and you see that a whopping 60% of adults, not “nearly one in two,” live with at least one chronic illness. Sloppy math and wording is common on the CDC site, as elsewhere it says that almost one in five youths has a BMI in the 95th percentile or above, which, of course, is mathematically impossible, as is the CDC’s calculation of our risk of death.

More importantly, how is the CDC defining “chronic disease” so broadly that so many of us have at least one? Is the CDC 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. Although a stroke is likely preceded by chronic disease (such as severe hypertension or diabetes), it is hard to imagine a more acute medical event than one in which every minute of delay in treatment increases your odds of ending up like the Kardashians.

The CDC also counts obesity, which was only designated as a chronic disease by the American Medical Association in 2013 — and even then many people don’t accept that definition. Cancer also receives this designation, even though many diagnosed cancers are anything but chronic — they either go into remission or cause death.   “Chronic disease” implies a need for continuing 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.”

That brings us to the last bullet point. Convention typically attributes more than 80% of healthcare costs to fewer than 20% of people, meaning that costly ailments are concentrated in a relatively small group. The implication would be that, if you address that small group, your savings are disproportionate. Instead, the CDC’s data attributes 75% of costs to about 50% of the adult population, implying almost the exact opposite of the 80-20 rule: The cost of chronic disease is widely dispersed. Indeed, if you remove the rare diseases that afflict about 1% of the population but account for about 7-8% of cost, you come very close to parity between the proportion of the population with chronic disease and the proportion of total health spending attributable to chronic disease.

So what?

This urban legend based on the CDC’s call to action, appearing verbatim more than a million times on Google, is among the single biggest causes of uncontrolled healthcare spending…and is responsible for essentially the entire wellness industry.

In reality, if you strip away the expenses of those chronically ill people unrelated to their chronic condition (which are included in the CDC’s 75% statistic); prevention and management of those conditions (ditto); those aforementioned rare diseases; and unpredictable or uncontrollable exacerbations: That 75% crumbles to about 4% of expenses that fit the category of wellness-sensitive medical events. Achieving a 10% reduction in those categories — a feat rarely accomplished, which is why vendors never disclose this figure — would reduce overall spending by 0.4%, or about $25 a year per employee or spouse. Hence, few employers would ever bother with wellness.

Instead, the CDC’s  wellness legend, suggesting that 75% of costs can be attacked, encourages employers and health plans to focus on the opposite of what they should focus on. Penn State, citing this 75% statistic as justification for its controversial wellness program, provides a classic example of this wrongheaded focus, with unfortunate consequences for the university’ reputation and employee relations, with no offsetting financial benefit.

Typical of the wellness industry’s embrace of this wellness legend is Bravo Wellness — also the first wellness company to brag about generating savings by punishing employees. The company takes this fallacy a step further. It deftly substitutes the words “lifestyle-related and preventable” conditions for the CDC’s language “chronic conditions”; that implies that everyone with a chronic condition, even a congenital or unavoidable, rare condition, has only his lifestyle to blame. Vendors like Bravo encourage employers to get more employees to view themselves as chronically ill, or about to become chronically ill — and encourages them to access the system.

Encouraging overdiagnosisovertreatment and overprescribing isn’t just a bad idea on its own. It distracts employers from real issues such as provider pricing disparities, hospital safety, outliers (the small percentage of employees who really do account for half the cost (usually not because of a chronic ailment, though) and pharmacy benefit managers (PBMs), whose per-drug margins are about twice what they would be if anyone spent any time weed-whacking their obfuscations of rebates, implementation fees, etc. and simply negotiated the margin directly.

What to do next?

It seems like all our posts end the same way: Stop poking your employees with needles.

We’ve debunked wellness’s science and math, its outcomes, its philosophy … and now its epidemiological premise. Even as their credibility is shredded, most wellness industry players have steadfastly refused to defend themselves at all. Instead, they avoid all debates on this site, because, although many of the vendors and consultants appear to be incapable of critical thinking, they are smart enough to realize that facts are their worst nightmare.

To Hellness With Wellness

It seems the only people made “well” from corporate wellness programs are those who collect $6 billion in annual costs. Still, all is not lost. If we use the most basic workings of human nature as a guide we can salvage a more reasonable realm for the notion of employer-sponsored “wellness.”

Corporate wellness is seriously flawed on the grand scale it once proclaimed. Here are four reasons why, in my opinion:

First: Wellness costs too much and thereby sets a high threshold for return on investment (ROI), which begs failure by any score based on savings. Let’s say you have a 500-person workforce. After a couple of years of “wellness,” 10 smokers legitimately quit for life, and five obese employees legitimately get to normal BMI and sustain it. For these individuals, the wellness program is an amazing success with great implications for future health. Unfortunately, with the average cost per employee in corporate wellness programs at more than $500 per year, two years costs more than $500,000, and a calculation of ROI depicts an abysmal failure.

Second: The profit motive of wellness purveyors supersedes common sense. Their sweeping approach provides incentives for assessments to identify candidates at risk and assumes that simple potential indicators of unhealthy lifestyle or other conditions create a savings opportunity. This is absolutely false. One fact is missing. Of the persons targeted, only a precious few are at a personal decision point and have the will to actually attempt difficult lifestyle changes.

Targeting must take human nature into account. We can properly diminish the presumed footprint of wellness if we look back and study individuals with actual historic success. Let us understand what indicators of personal human attitude that handful of successes gives us to use as a second-step screen. How much easier is it to realize ROI when only spending $500 per head on a smaller number of likely candidates?

Third: There is an absurd, blind thirst in both the private and public sectors to find believable reductions in projected future healthcare costs. The hype of wellness is perfectly suited to quench this thirst. Unfortunately, the absurdity is legitimized by governmental acceptance of the fool’s gold of claimed lower healthcare costs to gain leverage in negotiating state-worker union contracts, rigging budgets and passing federal legislation. (Can you spell ACA?) The term “fool’s gold” has the word “fool” in it for a reason.

Fourth: The wellness industry ignores lessons that should be learned from success in its sub-area of  disease management — specifically, that human nature feels no call to action until mortality comes knocking. Disease management savings can be documented in examples like the PepsiCo program called Healthy Living, initiated in 2003 and providing real savings today. Why does disease management work? In my opinion: People with a disease feel their mortality and are inclined to follow any program that might help.

Disease management supports a population with more personal incentive and will. Conversely, the debunked lifestyle approach targets an abundance of people who are personally happy while smoking or overeating. Fewer are suffering the acute implications of their lifestyle. “Wellness” money spent on them is useless.

Quick Tip: Trade “Big Wellness” for disease management with limited lifestyle programs

Don’t throw the baby out with the bathwater. There are many people who need and will accept disease management. As far as lifestyle, there are but a few people ready to commit to change. The good news is that over time, and organically with no cost, these few might spark an interest by others in any employer population. Keep the doors open for them and keep awareness high. In the meantime, don’t waste real money or use gimmicks on them.

I suggest wellness vendors create a new approach that unlocks the psychology of raw lifestyle change, targets the few and is willing to take on smaller footprints. Accept less money but stay for the longer haul.

You owe it to the tarnished notion of “wellness” to fix what you broke.

New AMA Classification Of Obesity: How It Affects Workers’ Compensation And Mandatory Reporting

On June 16, 2013, the American Medical Association voted to declare obesity a disease rather than a comorbidity factor. This change in classification will affect 78 million American Adults and 12 million children. The new status for obesity means that this is now considered a medical condition that requires treatment. In fact, a recent Duke University / RTI International / Centers for Disease Control and Prevention study estimates 42 percent of U.S. adults will become obese by 2030.

According to the Medical Dictionary, obesity has been defined as a weight at least 20% above the weight corresponding to the lowest death rate for individuals of a specific height, gender, and age (ideal weight). Twenty to forty percent over ideal weight is considered mildly obese; 40-100% over ideal weight is considered moderately obese; and 100% over ideal weight is considered severely, or morbidly, obese. More recent guidelines for obesity use a measurement called BMI (body mass index) which is the individual's weight divided by their height squared times 703. BMI over 30 is considered obese.

The World Health Organization further classifies BMIs of 30.00 or higher into one of three classes of obesity:

  • Obese class I = 30.00 to 34.99
  • Obese class II = 35.00 to 39.99
  • Obese class III = 40.00 or higher

People in obese class III are considered morbidly obese. According to a 2012 Gallup Poll, 3.6% of Americans were morbidly obese in 2012.

The decision to reclassify obesity gives doctors a greater obligation to discuss with patients their weight problem and how it's affecting their health while enabling them to get reimbursed to do so.

According to the Duke University study, obesity increases the healing times of fractures, strains and sprains, and complicates surgery. According to another Duke University study that looked at the records for work-related injuries:

  • Obese workers filed twice as many comp claims.
  • Obese workers had seven times higher medical costs.
  • Obese workers lost 13 times more days of work.
  • Body parts most prone to injury for obese individuals included lower extremities, wrists or hands, and the back. Most common injuries were slips and falls, and lifting.

The U.S. Department of Health and Human Services said the costs to U.S. businesses related to obesity exceed $13 billion each year.

Furthermore, a 2011 Gallup survey found that obese employees account for a disproportionately high number of missed workdays. Also earlier National Council on Compensation Insurance (NCCI) research of workers' compensation claims found that claimants with a comorbidity code indicating obesity experience medical costs that are a multiple of what is observed for comparable non-obese claimants. The NCCI study demonstrated that claimants with a comorbidity factor indicating obesity had five times longer indemnity duration than claimants that were not identified as obese.

Prior to June 16, 2013, the ICD code for comorbidity factors for obesity in workers' was ICD-9 code 278. This is related to obesity-related medical complications, as opposed to the condition of obesity. Now the new ICD codes will indicate a disease, or condition of obesity which needs to be medically addressed. How will this affect work-related injuries?

Instead of obesity being a comorbitity issue, it can now become a secondary claim. If injured workers gain weight due to medications they are placed on as a result of their work-related injury or if an injured worker gains weight since they cannot exercise or keep fit because of their work-related injury and their BMI exceeds 30, they are considered obese and are eligible for medical industrially related treatment. In fact, the American Disability Act Amendment of 2008 allows for a broader scope of protection and the classification of obesity as a disease means that an employer needs to be cognizant that if someone has been treated for this disease for over 6 months then they would be considered protected under the American Disability Act Amendment.

Consider yet another factor: with the advent of Mandatory Reporting (January 1, 2011) by CMS that is triggered by the diagnosis (diagnosis code), the new medical condition of obesity will further make the responsible party liable for this condition and all related conditions for work-related injuries and General Liability claims with no statute of limitations. It is vital to understand that, as of January 1, 2011, Medicare has mandated all work-related and general liability injuries be reported to CMS in an electronic format. This means that CMS has the mechanism to look back and identify work comp related medical care payments made by Medicare. This is a retroactive statute and ultimately, it will be the employer and/or insurance carrier that will be held accountable.

The carrier or employer could pay the future medical cost twice — once to the claimant at settlement and later when Medicare seeks reimbursement of the medical care they paid on behalf of the claimant. This is outside the MSA criteria. The cost of this plus the impact of the workers' compensation costs as well as ADAA issues for reclassification of obesity for an employer and carrier are incalculable.

The solution is baseline testing so that only claims that arise out of the course and scope of employment (AOECOE) are accepted. If a work-related claim is not AOECOE and can be proved by objective medical evidence such as a pre- and post-assessment and there is no change from the baseline, then not only is there no workers' compensation claim, there is no OSHA-recordable claim, and no mandatory reporting issue.

A proven example of a baseline test for musculoskeletal disorders (MSD) cases is the EFA-STM program. EFA-STM Program begins by providing baseline injury testing for existing employees and new hires. The data is only interpreted when and if there is a soft tissue claim. After a claim, the injured worker is required to undergo the post-loss testing. The subsequent comparison objectively demonstrates whether or not an acute injury exists. If there is a change from the baseline site specific treatment, recommendations are made for the AOECOE condition ensuring that the injured worker receives the best care possible.

Baseline programs such as the EFA-STM ensure that the employee and employer are protected and take the sting out of the new classification by the AMA for obesity.

Affordability, Effectiveness, and Wellness, Part 5

This is Part 5 in a five-part series which presents a creative solution for today’s health care crisis. Additional articles in the series can be found here: Part 1, Part 2, Part 3, and Part 4.

An Ideal Health And Wellness Program
Based upon our actuarial analysis we find that as much as 75% – 85% of the potential savings from health and wellness programs can be directly attributed to six specific and objectively measured factors:

  • Obesity (i.e., as measured by the BMI or Body Mass Index)
  • Fasting blood sugar
  • LDL cholesterol (i.e., bad cholesterol)
  • Blood pressure
  • Smoking/non-smoking, and
  • Personal fitness

Ironically, all of them with the exception of smoking/non-smoking are directly related to Body Mass Index. As individuals solve their Body Mass Index problem, they gradually solve most of their other problems. Some individuals with genetic predisposition to certain conditions may require ongoing medications to keep one or more factors in control, but the vast portion of problems can be significantly improved and eliminated by eliminating obesity and achieving an ideal Body Mass Index or by at least improving it and moving closer to the ideal level.

This suggests that significant gains can be made by creating a BMI-focused health and wellness program. Since smoking/non-smoking is somewhat independent, perhaps a two pronged program (i.e., BMI and smoking cessation) is the best way to implement a program. This “tight” focus enables the program to quickly succeed, where other “loose” focus programs have failed or had significantly less results.

Although the actual results are significantly impacted by characteristics of the studied population (i.e., the population's average Body Mass Index scores and the proportions of smokers to non-smokers), we find that in a fairly typical population, overall health care costs can be reduced by as much as and possibly more than 20% – 30% if each of the individuals in an overall population advance to their ideal health status. On an individual by individual basis the cost reductions on some is much more than this. A tangential benefit of this improvement is that the cost savings continues to occur for many years, not cost savings in just one year.

Every health and wellness program needs reliable ways of accurately measuring the program's effectiveness. Each of the above six factors can be objectively measured through relatively inexpensive means. For example, a simple blood test can be used to measure blood sugar or LDL levels. Blood pressure can easily be measured by a trained individual or even by automated machines. Fitness can be broadly defined as the ability to function efficiently and effectively, to enjoy leisure, to be healthy, resist disease and to be able to cope with emergency situations. The health related components of physical fitness that could be measured include body composition, cardiovascular fitness, flexibility, muscular endurance and strength. There are various ways to measure fitness depending on available resources and facilities. There are several available Health Risk Appraisal (HRA) packages that can give a report that incorporates both objective measures as well as subjective responses to a set of questions.

As mentioned earlier, it is also critical to provide hope to the participants. A believable example or champion is always beneficial to motivate participants. One interesting example of this is one of the authors of this series of articles.

Nicholas J. Yphantides, MD, Dr. Nick as he is known, the author of “My Big Fat Greek Diet”2, used to weigh 467 pounds, has lost more than 270 pounds, and has successfully kept it off for almost seven years. His significant and relatively quick weight loss journey is chronicled in the book. Dr. Nick outlines Seven Pillars of Weight Loss Success, which are critical to successful weight loss and are integrated in the Individual Change Management Model.

They can be summarized as follows:

Pillar I: “Change the way you see before you can change the way you look.” As discussed, change is at the core of what is needed but rather than focusing on changing specifics, first one has to undergo a change in their perspective which will naturally lead to a change in habits and behavior.

Pillar II: “Slash your calories by eating for the right reasons.” Way too much focus is spent on diets and what to eat. Critical to healthy living is having a healthy relationship with food and rediscovering its role as fuel and not as a means of dealing with any number of other personal emotions or needs.

Pillar III: “Fill your tank with the right amount of the right foods.” Rediscovering an appropriate sense of satiety by responding to the body's signals and as a result of eating an appropriate amount of the right kind of food is core to learning how to eat to live healthy.

Pillar IV: “Burn calories like never before.” It is imperative and necessary not only to lose weight but not to rediscover it again once lost (i.e., gain it back). As individuals become more physically active, they will keep it off. Strategies to have fun and pleasure burning calories are important for it to be a sustainable habit.

Pillar V: “Plan a radical sabbatical.” Most need to take some kind of a break from the routine if we are going to establish a healthier lifestyle. Combining pleasure and benefit and carving out time that one can focus on their health as a priority for lasting vitality is core to successful weight loss.

Pillar VI: “Don't travel alone.” The assumption is that this is an ongoing journey for most. There are times where initial momentum is present but for many, the notion of support, encouragement and some level of accountability are going to be key factors to long term success. It is so important to people committed to the group nature of accountability and healthy co-reliance on healthy living.

Pillar VII: “Realize that your weight loss journey is for a lifetime.” Many people see weight loss interventions as a temporary lifestyle modification where in reality it is a lifelong commitment to a new set of habits and behaviors. Its not about losing the weight. Its about losing it and not rediscovering or finding it again that really counts.

Weight loss programs (i.e., Body Mass Index improvement programs) aligned with these key principles have demonstrated much greater success than those missing these. Most current efforts fall short of lasting impact in that they target the stomach. Many overweight people who have health related consequences for their extra weight do not have a problem with their stomachs as much as they do with their “heads and hearts.”

Focusing first on those with Body Mass Index concerns accomplishes the greatest value in the health and wellness program. Dr. Nick's approach proves to be quite effective in making those changes. The second focus is on those currently smoking, using traditional smoking cessation programs and interventions. This approach could be called wellness triage, focusing on those who need it the most. The prioritization in such a program is as follows:

  • Body Mass Index improvement
  • Smoking Cessation
  • Blood pressure reduction and control
  • LDL reduction and maintenance
  • Fasting blood sugar reduction and maintenance
  • Fitness improvement

Integration With Health Benefits Program
The above health and wellness approach can be further enhanced through the integration of it with the health benefits program. Combining an organization's change management model along with the individual model could lead to a radical transformation in the workplace and in the individual's lifestyle. There are several approaches that can be used to effectively accomplish this, however, one popular approach is linking the six key health status indicators to a health and wellness points system, and then linking the points system to a particular benefit level.

One effective approach provides individual incentives for improvements in each of the targeted health and wellness categories. Linking benefit design, employee cost, and health and wellness results provides strong motivation for health and wellness change. This type of program builds on the concepts discussed earlier:

  • Incentive driven — the better the wellness scores, the lower the deductible; best benefits are given even if there is one bad area
  • Redemptive — encourage those who are trying by giving partial credit
  • Hope-filled — build wellness program around concepts that work
  • Focused — BMI-centric with wellness triage

It is critical that programs of this kind consider federal anti-discrimination regulations. It is our understanding that current regulations permit health and wellness programs which reduce deductibles/copays for improved health status. Regulations impacting this are continually changing, and it is critical to keep this in mind when designing such programs.

Summary
Health and wellness programs can be structured in many different ways. As health plans and plan sponsors decide to impact the wellness of their customers, it is critical that the programs achieve the financial success they were intended to get. Since so much change is happening today, it is important to track these issues very closely to assure the greatest health cost savings possible.

There is a significant potential for health cost reductions from appropriately implemented health and wellness programs. Not every program will be able to achieve the entire 20% – 35%; however, in the current economy, a minimal savings of 5% – 10% would be significant to most health care planners. Additional savings can be achieved if health and wellness principles are strategically combined with effective care management principles.

2 Yphantides, Nicholas, “My Big Fat Greek Diet”, Nelson Books, 2004, ISBN 0-7852-6025-0

Authors
David Axene collaborated with Nicholas Yphantides in writing this series of articles. Dr. Nicholas Yphantides serves as the Consulting Chief Medical Officer for San Diego County and is the National Director for Health & Wellness with Axene Health Partners. He is a cancer survivor and is an advocate for those in his community who need it the most. For nine years, Dr. Nick served as Chief Medical Officer of one the largest network of Community Clinics in San Diego County.