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What Trump Means for Workplace Wellness

Assume, reasonably, that voters chose Donald Trump to be the next president because they feel big business and government are in bed together. If indeed they are, workplace wellness is their sex toy.

There is nothing, certainly in healthcare and possibly anywhere, that more embodies the complete disdain for the average worker than the joined-at-the-hip partnership between big business and government known as workplace wellness.

That claim might seem extreme, but put yourself in the shoes of the average worker. You used to have a good health benefit. But then, following the passage of the Affordable Care Act, your benefits were reduced, and you were put in a high-deductible plan. True, your benefits might have been reduced anyway due to the increasing cost of healthcare, but coincidence to the average person smells like causality.

See also: The Value of Workplace Wellness  

A benefits reduction sounds like a wage cut. However, you are told you can earn some or all of it back. All you have to do is allow your employer (and, yes, it isn’t really your employer, but it smells like your employer) to pry into your personal life with a questionnaire; poke you with needles to do blood tests that over a 15-year period have proved useless at reducing the country’s heart attack and diabetes event rates; and prod you, in violation of all guidelines, to go to the doctor when you aren’t sick.

You (remember, “you” are still the worker) are then left with this Hobson’s choice: You must throw yourself at the mercy of an unregulated wellness vendor that – if last month’s C. Everett Koop award to Wellsteps for being the “best wellness program in the country” is any indication – is more likely to harm you than benefit you, while invading your privacy and sucking up your time.

As an employee, what recourse do you have? Basically none. The Equal Employment Opportunity Commission has no provisions against “voluntary” workplace wellness programs, and the word “voluntary” has now been defined to include even programs with non-compliance penalties that might exceed $2,000. The net result: You can be forced to pay a large fine for refusing to participate in a voluntary program, and there’s nothing you can do about it.

You can’t sue for malpractice because wellness vendors aren’t clinical professionals, and you can’t complain to the licensing authority because wellness vendors aren’t licensed. You can’t claim they violate the industry code of conduct because – unlike everything else, including war — wellness has no code of conduct: The wellness trade association has stonewalled on the code of conduct, which embraces only the simple notion that wellness should respect the dignity of workers and not harm them.

Should you opt to maintain your dignity and not violate clinical guidelines, by declining to be part of a wellness program, you may lose four figures in compensation just by wanting to be left alone to do your job.

Don’t take my word that this is how employees feel. Simply read the comments by employees to any article on wellness.

Meanwhile, what is the government doing? Simple. The government is carrying the Business Roundtable’s (BRT) water. The Senate is in the BRT’s pocket, holding “hearings” that are basically just ads for the BRT. And the president put the EEOC on a short leash after the BRT threatened him.

As members of the BRT, and their like-minded compadres at the U.S. Chamber of Commerce, corporations are gleeful. They can cut benefits and “offer” employees the opportunity to earn them back, or just fine employees directly. One vendor, Bravo Wellness, even dogwhistled to employers that they could get immediate “savings” by fining employees.

What happens now, and what should you do?

Wellness is likely to become a touchstone for all that is wrong with the Affordable Care Act, because, almost uniquely in the ACA, the wellness provision has basically no upside. (Disagree? Show I’m wrong, and claim the $1 million reward I’ve offered to anyone who can show wellness has broken even this century.) The American Association of Retired People (AARP) is already shining a light on wellness via a lawsuit, and the effort may make it much more difficult for the wellness industry, the BRT and the Chamber to hide behind the EEOC.

As representatives of the employers who may very well be abusing employees (and not knowing it, any more than the Boise School District realized it was being snookered by Wellsteps until the problem was exposed by a leading healthcare journalist — even though the invalidity and ineffectiveness of the district’s wellness program was perfectly obvious to Wellsteps’ colleagues on the award committee), you should get ahead of this curve. Drop punitive wellness programs, or programs with low participation (which reflects low satisfaction). Or swap out programs that “do wellness to employees” for programs that “do wellness for employees.” The difference is fairly self-evident. Are employees lining up, or do they need to be coaxed? Are there big bribes or fines involved? Is the program something you yourself would do without an incentive?

See also: ‘Surviving Workplace Wellness’: an Excerpt  

You shouldn’t need to wait for the law to change to make changes yourself now. “Pry, poke and prod” programs were a bad idea to begin with, and the passage of time and rise of populism hasn’t made them any better.

Disclosure

The editorial viewpoint in this article, though reflecting my opinion, is colored by my leadership of Quizzify. Quizzify does not “pry, poke and prod” employees, but rather just enhances their knowledge base in an entertaining way. Not just theirs – even yours. Play the sample game on the site and see for yourself. We hope to benefit from the likely retreat from government support for intrusive and ineffective wellness programs in the new administration. On the other hand, you are free to publish opposing comments or viewpoints. Join the conversation, even if it means hollering at me by quoting people who know they are wrong claiming savings they know are fabricated.

EEOC Caves on Wellness Programs

In a deep dark recess of the Federal Register this week, large corporations quietly received permission to “play doctor” with their employees. Corporations can now impose even more draconian and counterproductive wellness schemes on their workers. The hope of the corporations is to claw back a big chunk of the insurance premiums paid on the behalf of employees who refuse to submit to these programs or who can’t lose weight.

A Bit of Background on Wellness

The Affordable Care Act (ACA) allowed employers to force employees to submit to wellness programs under threat of fines. Specifically, the ACA’s “Safeway Amendment” — named after the supermarket chain whose wellness program was highlighted as a shining example of how corporations could help employees become healthier — encouraged corporations to tie 30% to 50% of the total health insurance premium to employee health behaviors and outcomes. (As was revealed while ACA was being debated, Safeway didn’t have a wellness program. The fictional Safeway success was a smokescreen for corporate lobbyists to shoehorn this withholding of money into the ACA.)

Once this 30% to 50% windfall became apparent, many corporations figured out what this vendor (Bravo Wellness) advertised: There is much more money to be made in clawing back large sums of money from employees who refuse to submit to these programs than in improving the health of employees enough to allegedly reduce spending many years from now. “Allegedly” because — unlike simply collecting fines or withholding incentive payments — improving employee health turns out to be remarkably hard and ridiculously expensive to do. It is so hard and expensive that:

Most importantly, the complete lack of regulation has allowed the wellness industry and health plans to expose employees to significant potential harms to maximize revenue.

See also: Wellness Promoters Agree: It Doesn’t Work

The Federal Government Green Lights “Wellness-or-Else” Programs

There are no regulations, licensure requirements or oversight boards constraining the conduct of wellness vendors, and there is only one agency — the Equal Employment Opportunity Commission (EEOC) — providing any recourse for employees. The Business Roundtable has taken on the latter at every opportunity. First, the Business Roundtable threatened President Obama with withdrawing its support for the ACA unless he declawed the EEOC. Then, the Business Roundtable arranged for sham Senate hearings titled “Employer Wellness Programs: Better Health Outcomes and Lower Costs.” Finally, it threatened to push the “Preserving Employee Wellness Programs Act” to legislatively eviscerate the EEOC’s protections.

But it turns out the legislation was not necessary; the EEOC has now caved in. These programs are defined as “voluntary,” yet, as of now, employees can be forced to hand over genetic and family history information or pay penalties. So, as in 1984, where “war” means “peace,” employees can now be required to voluntarily hand over this information.

Let’s be clear. Genetic information isn’t about employee wellness programs, which do not work. It is all about the penalties. Genetic information is worthless in the prevention of heart disease and diabetes, as Aetna just showed in a failed experiment on its own employees.

Knowing family history does have some predictive value, but it is unclear how employees are going to benefit from employers collecting it. Self-insured employers could either fire the employee or do nothing. Neither is useful for the employee. If the employer is fully insured, this information is akin to a “pre-existing condition” in the old days. The employer’s premiums will increase as long as employees with bad family histories remain on their payroll.

See also: The Yuuuuge Hidden Costs of Wellness

The Good News, Part 1: Corporations Wising Up

The Business Roundtable — and its friends at the U.S. Chamber of Commerce — might want to connect their computers to the Internet. It turns out that many companies are finally realizing that compelling employees to submit to medical screens just to claw back some insurance money isn’t worth the morale hit.

Increasingly, employers are learning that what the national data shows is also true for themselves: These programs simply do not work. For example:

And the morale hit? A formerly obscure faculty member who led the successful employee revolt against the Penn State wellness program was just elected president of the Penn State Faculty Senate — largely because employees were so grateful for his leadership in that revolt.

The Good News, Part 2: Wellness for Employees

As a result, many companies are deciding that clawing back some insurance money is not worth the damage done to their workforces. They are replacing “wellness done to employees” with “wellness done for employees.” These companies are improving the work environment, upgrading their food service, encouraging fitness or simply adding features like paternal leave or financial counseling. They might still hold a “health fair” every now and then, but their medical tests are conducted infrequently (based on actual clinical guidelines) instead of allowing vendors to screen the stuffing out of employees to find diseases that do not exist.

Or, companies are actually focusing efforts where they can make a difference, such as steering employees to safer hospitals or educating employees on how to purchase healthcare services wisely. (Disclosure: My own company, Quizzify, is in the business of teaching employees how to do the latter.)

Notwithstanding this disruption and regardless of the harm it has caused, the $7 billion wellness industry has excelled in perpetuating its own existence. Industry thought leaders recently proposed a scheme to encourage companies to disclose how fat their employees are and have even managed to get a few large employers to sign on to it.

The sheer audacity of that scheme and the complete disregard for its consequences on overweight employees means the war on “voluntary” wellness-or-else programs is by no means over. Like every other industry threatened by reality but supported by deep-pocketed allies such as the Business Roundtable, the wellness industry can rely on the government to delay the inevitable.

Consequently, it might be quite some time before the inevitable course of reality overcomes the wellness-or-else pox on the healthcare system.

Important Alliance to Fight Health Costs

The Wall Street Journal reported that 20 large U.S. companies joined to fight high healthcare costs, launching the aptly named Health Transformation Alliance. Employers account for one in five dollars spent on healthcare in the U.S., yet they have relatively weak influence in the marketplace. But these influential companies are intent on aggressive action. With this kind of unified leadership, the alliance promises to shake the foundations of our health care economy.

There have been other efforts to harness the power of the business community to improve health care. My organization, the Leapfrog Group, is one such effort, founded by Business Roundtable in 2000 to address quality and patient safety in hospitals. Based on what we’ve learned over the past 16 years, here are three key principles for the alliance to start with:

  1. Lowering costs won’t automatically lower prices.

Whenever the subject of cost reduction comes up, some providers tout the enormous cost savings they have put in place through improved efficiencies, better technology or less invasive procedures. Recently, they have also pointed to the potential of large hospital system mergers to reduce costs through economies of scale. But employers are right to wonder why their own healthcare price tag continues to rise, despite these marvelous advances. Why don’t they see the cost savings?

Simply put, cost savings to the provider are not the same as cost savings to the purchaser. This sounds like such an obvious point. But the obfuscation over whose costs are saved persists and trips up progress year after year, with purchasers left scratching their heads. The alliance members will succeed in cutting their own prices only if they clearly demand that cost-reduction strategies have visible and substantial effects on their own bottom lines.

  1. Lowering prices won’t automatically lower costs.

Even if purchasers do succeed in lowering prices, the cost-reduction job is not done. That’s because the amount of waste in healthcare is profound. The Institute of Medicine estimates that as much as one-third of all costs are associated with unnecessary services, errors, infections and management inefficiencies. Not all providers are the same, and some incur much more waste than others. Whatever the price of a particular procedure, it’s no bargain when there are infections, complications and mismanagement—or if the procedure wasn’t medically necessary in the first place.

This is not chump change, this is game change. A 2013 study in the Journal of the American Medical Associaton (JAMA) reported that, on average, purchasers paid $39,000 extra when a patient contracted a surgical site infection. That excess doesn’t show up on the claim as a line item called “waste.” It is buried in a series of excess fees, tests, treatments and time spent in the hospital. Employers intent on cutting costs must factor wastefulness into the pricing equation.

  1.  Focus on the market incentives.

Our system of costs and pricing creates perverse incentives. The more a provider wastes, the more it can bill the employers. New financing models are slowly emerging, aimed at achieving value—the novel idea that payments align with patient outcomes. One of the most promising models is called “bundled pricing,” in which a health system is paid one total price for a particular procedure, including physician fees, radiology, hospital charges, etc. In this model, a provider is given incentives to actually reduce waste, so it maximizes profit under the bundle.

Some large employers have developed bundled pricing arrangements with a select group of health systems, for a select group of procedures. Walmart is a leader in this, as are employer members of the Pacific Business Group on Health. What have they found? A significant reduction in waste and better care for employees.

Another promising use of bundled pricing is coming from international medical tourism. Health services and pharmaceuticals are often much less expensive overseas than in the U.S. Most international providers offer bundled pricing and concierge hosting services. For example, Health City Cayman Islands offers bundled prices for certain heart and orthopedic surgeries, including all facility and physician fees, along with pre- and post-operative care at a lovely beachfront hotel. Its prices are one-fourth to one-fifth those for comparable services in the U.S.

The problem with medical tourism: determining the quality of international providers. Employer groups, like the Health Transformation Alliance, must address this in their work. Once again, waste and quality need to be factored into the cost equation.

$1 Million Reward to Show Wellness Works

We hope at least a few of you have lamented –we’ll settle for noticed — our absence from ITL for the last six months. There are two reasons.

First, in the immortal words of the great philosopher Gerald Ford, “When a man is asked to make a speech, the first thing he has to do is decide what to say.” We needed something compelling to say, and at this point yet-another-vendor-making-up-outcomes is old news. In any event, there is now an entire website devoted to that topic. (New news:  US Preventive Medicine is NOT making up its outcomes. It is the first wellness vendor to be validated.)

Second, we have spent the last six months answering the perennial question: “So what would you do instead?” by developing www.quizzify.com. Quizzify teaches employees that “just because it’s healthcare doesn’t mean it’s good for you,” and does it in an enjoyable Jeopardy-meets-health-education-meets-Comedy Central way, as playing the demo game will show. Quizzify’s savings are, uniquely in this industry, 100% guaranteed.

But we digress. The news of the day is that we want to settle once and for all the he said-she said debate about whether wellness saves money, and we’ll do it the old-fashioned way: by offering a million-dollar reward for anyone who can show that wellness isn’t a horrible investment. All someone has to do is show that the employer community as a whole breaks even on its wellness investment.

The inspiration for this reward came when a group calling itself “The Global Wellness Institute Roundtable” released a report criticizing us for “mud-slinging on ROI.” (In other words, “proving that there is no ROI.”) We are not familiar with this group. Their headliner seems to be a Dr. Michael Roizen. If that name sounds familiar, it’s because he used to work with Dr. Oz, though to Dr. Roizen’s credit he was not implicated in the congressional investigation of Dr. Oz.

This $1-million reward is – as an attorney recently posted– a binding legal contract. It is also totally fair. The “pro” party is allowed to use the wellness industry’s own “official” outcomes report, which was compiled with no input from anyone opposed to wellness. Further, the panel of judges is selected from an independent email list, run by healthcare policy impresario Peter Grant. This is no ordinary independent email list—this is the invitation-only “A List” of healthcare policymakers, economists, journalists and government officials who make, influence or report the decisions and rules we live by. The “pro” party invites two people, we invite two and those four pick the fifth. This is truly the ultimate in fairness.

Unfortunately, “fairness” is perhaps the second-scariest word to a wellness vendor (“validity” being the first), so there is no chance of anyone taking us up on this. (There is a slight risk in challenging us—whichever party loses has to pay the expenses of the contest, including the panelist fees. This will run likely $100,000. Still, that makes the proposition at worst 10-to-one odds, and the “pro” forces get their $100,000 back if they win.)

Not being taken up on this offer is, of course, the entire point of making the offer. The wellness industry’s inaction will prove what numerous gaffes and misstatements  have already revealed: Wellness industry leaders know that wellness loses money. For them, wellness is all about maintaining the façade of saving money so that they don’t get fired from the employers they’ve been snookering.