Tag Archives: health affairs

Shattering the Wellness ROI Myth

There is a saying: “In wellness, you don’t have to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself.” Indeed, if there is one thing you can take to the bank in this field, it’s that articles intending to prove that wellness works inevitably prove the opposite. Another saying is that the biggest nightmares of leading wellness promoter Ron Goetzel and his friends (the Health Enhancement Research Organization, which is the industry trade association) are, in no particular order:

  1. facts;
  2. data;
  3. arithmetic;
  4. their own words.

And Mr. Goetzel, writing in this month’s Health Affairs [behind a paywall], is Exhibit A in support of the paragraph above. To summarize the implication of this article, you, as brokers, need to take ROI off the table as an attribute of wellness. Instead, you’ll need to find wellness vendors who are willing to screen most employees much less often than once a year, just as government guidelines recommend.

No wellness vendor ever got rich by screening according to guidelines. As a result, willing vendors are hard to find. (Examples include It Starts with Me and Sterling Wellness, as well as my own company, Quizzify, whose outcomes don’t rely on screening.) The lower screening frequencies also mean lower commissions. Weighed against that is the advantage of doing the right thing for your customer and their employees.

See also: There May Be a Cure for Wellness  

The Collapse of the ROI Myth

The subject of Mr. Goetzel’s article was specifically employer cardiac spending vs. cardiac risks in an employer population. He found that cardiac risks correlated the “wrong” way with cardiac spending, meaning that companies with healthier employees somehow incurred more cardiac-related spending.

But that correlation — and it was only a correlation, not cause-and-effect — by itself didn’t cause the death of wellness ROI, though it didn’t help. As is typical in wellness, and as was mentioned in the first paragraph, the proximate cause of the death of wellness ROI was that this breathlessly pro-wellness author accidentally provided the data proves that wellness loses money.

Specifically, they didn’t separate the average employer cardiac claims spending of $329 per employee per year (PEPY) into “bad” claims (spending on events like heart attacks), vs. “good” claims (spending on preventive interventions to avoid heart attacks).

How big a rookie mistake is combining these two opposite claims tallies — prevention expense and event expense — and calling it “average payment for all cardiac claims”? It would be like saying the average human is a hermaphrodite.

Splitting that average into its two opposite components would have revealed that spending on actual avoidable events is much lower than spending on wellness programs implemented to avoid those events. That, of course, is exactly the right answer, as we showed 15 months ago.

Let’s do the math

How much do employers spend on “bad claims” like heart attacks? Here is the number of heart attacks, spelled out so that people can replicate this analysis using the official government database, tallying all the admissions for heart attack-related DRGs:

  1. DRG 280 — 12,825
  2. DRG 281 — 15,404
  3. DRG 282 — 18,365
  4. DRG 283 — 1,800
  5. DRG 284 — 275
  6. DRG 285 — 160

This totals to 48,829. Roughly 100,000,000 adults are insured through their employers. That means that about 1 in 2000 employees or spouses will have a heart attack in any given year. Let’s double that to generously account for any other cardiac events that could be prevented through screening employees, to 1 in 1000.

Now let’s equally generously assume a whopping cost of $50,000 per heart attack. So of the $329 PEPY that Ron calculated for prevention and events combined, only $50 ($50,000 per event and 1 in 1000 working people suffering one) is spent on events. The rest is spent on prevention and management expense, like putting people on statins, diuretics etc., doctor visits, lab tests etc.—things done specifically to avoid these events.

These latter expenses are not avoidable. Nor are they even reducible through wellness. Just the opposite– wellness vendors are always trying to close “gaps in care” by sending people to the doctor to get more of these interventions.

See also: A Proposed Code of Conduct on Wellness  

According to Mr. Goetzel’s own data, a wellness program — health risk assessments, screening, portals etc. — costs about $150 PEPY. An industry that spends that much to get what Mr. Goetzel himself states is at best a 2% reduction in a $50 PEPY expense can’t save money. This mathematical fact explains the industry’s constant need to lie about savings (and about me).

Anyone care to claim my $2 million reward for showing wellness saves money? I didn’t think so…

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.

It’s Time to Embrace Telemedicine

At hospitals and clinics across New Jersey, thousands of new doctors could soon be on call — literally.

In Trenton, lawmakers are considering two bills that would enable doctors and patients to skip the office visit and conduct appointments using video-conferencing tools like Skype.

They’re right to embrace this kind of technology. The increasing use of “telemedicine” promises to improve patients’ access to doctors and slash healthcare costs.

Virtual medicine makes it a lot easier — and cheaper — to see the doctor. By first consulting with a patient by video, doctors and nurses can determine whether a costly in-person trip to the emergency room or to the doctor’s office is necessary — or whether two aspirin and plenty of rest will do.

See Also: 5 Questions on Telemedicine Coverage

For patients who end up in the hospital, telemedicine can facilitate faster and cheaper convalescence.

Consider a patient recovering from heart surgery. His doctor may want to continuously monitor his blood pressure and pulse. Telemedicine can accomplish that remotely and automatically. That saves the patient the trip and the doctor the time measuring those vital signs.

Telemedicine can also save money. Take a program called Health Buddy, which asks patients daily, tailored questions about their health through a handheld device at home. After reviewing the answers, doctors know when and how to offer care. A study published in Health Affairs found that Health Buddy reduced Medicare spending by as much as 13% per patient.

Other programs offer patients hospital-level care inside their own homes. Doctors and nurses visit one to two times a day while other providers monitor vital signs remotely. Participating patients often require fewer tests and less time under observation, so these “hospital at home” programs can cut costs by 19% compared with conventional inpatient care.

Telemedicine can also alleviate the mental stress of being sick. Someone diagnosed with heart disease, for instance, may understandably worry about his prognosis. That can take a toll on his physical health and jeopardize his chances of recovery.

Healthcare providers can ease these concerns with remote counseling. One such telecounseling program helped cardiovascular disease patients deal with anxiety and depression through video sessions. Over six months, the program reduced hospital admissions by 38% compared with a control group, according to a report published by the American Journal of Managed Care.

Telemedicine can improve healthcare providers’ ability to communicate with one another, too. By connecting doctors with health workers in emergency rooms, for example, telemedicine can prevent 850,000 unnecessary transfers between ERs each year. The savings? More than $530 million.

There’s even evidence that telemedicine can offer care that’s superior to inpatient care. Take Teladoc, a videoconferencing technology that allows patients to consult with a doctor around the clock. According to one study, those who used Teladoc were less likely to need to see the doctor again for the same illness than patients who actually went to the doctor’s office.

Finally, telemedicine may also decrease wait times. American Well, for example, offers a mobile app that allows patients to send out a request for a doctor — much like one does for an Uber — and the first to respond does the consultation via videoconferencing. Over the last three years, the average wait time has been three minutes.

See Also: Questions to Ask on Telemedicine Risk

New Jersey’s lawmakers seem to be paying attention to all this research, particularly Sens. Joe Vitale, D-Middlesex, and Shirley Turner, D-Mercer, and Assembly representatives Pamela Lampitt, D-Burlington-Camden, and Daniel Benson, D-Mercer-Middlesex. One of Lampitt’s bills (A-2668) would establish parity for insurance coverage of telemedicine with conventional in-patient care. A bill sponsored by Vitale (S-291) would allow patients to seek telemedicine services from out-of-state doctors. This latter measure would also permit New Jersey’s Medicaid program to reimburse for telemedicine.

Thus far, the Garden State has been slow to adopt telemedicine. Insurers in many other states already cover it. The American Telemedicine Association recently gave New Jersey six Fs on crucial telemedicine issues, including allowing for the reimbursement of remote patient monitoring and videoconferencing.

State leaders now have the chance to raise those grades. Telemedicine controls costs and improves patients’ health. It’s time for New Jersey to take advantage.

Better Outcomes for Chronic Pain

The workers’ comp industry is burdened with perhaps 200,000 or more injured workers on long-term opioid treatment for chronic pain. Many more workers enter these ranks yearly. For 10 years, I have observed this awful misery slowly accumulate. But claims payers can do more to prevent new case and resolve “legacy” cases. It will require from them more commitment to best practice care and a lot more frank, open collaboration among themselves and with medical providers.

Conservative care is hugely under-exploited as an approach to prevent and resolve chronic pain among injured workers. Workers’ compensation claims payers would not have paid so much for opioid treatment, failed surgeries and claims settlements had they adopted conservative care decades ago, when research support for this approach was already pretty strong. The failure to promote this approach cost the policyholders perhaps $100 billion in higher premiums and cost injured workers years of disability and, in some cases, funerals.

By conservative care, I refer to functional restoration programs, which came into existence in the 1970s or earlier. Cognitive behavioral therapy became established in the 1980s. Coaching, as a non-medical method of helping persons in pain, has been around forever but recently gained visibility as a scalable form of intervention. There’s a lot of innovation going on, such as the PGAP program imported from Canada and a number of nerve-stimulation services such as Scrambler in New England.

Payers need to learn how to create conditions within which conservative care can prosper rather than repeatedly blossom only to die.

A friend prods me to use the term “evidence-based medicine.” But “conservative care” is my choice for an umbrella term because it is easy to remember, though inexact.

A few years ago, I talked by phone with a senior medical case manager at a claims payer in Kentucky, an epicenter of opioid prescribing excesses, who had never heard of functional restoration programs. This reminded me of the Harvard professor who spent a year in Munich without ever hearing about Oktoberfest.

The long history of insurers includes many instances where they brought risk management solutions like conservative care to the market. The first modern evidence of that goes all the way back to London fire insurers in the late 17th century. Mutual insurance companies played an essential role in introducing automatic fire-suppressing sprinkler systems to American factories in the late 19th century.

In my special report published by WorkCompCentral, “We’re Beating Back Opioids – Now What?”, I propose that claims payers and selected medical providers collaborate for the purpose of better success in treatment. This is particularly valuable for conservative care. The collaborations would allow each party to act on its own but to pool information. Periodically, analysts will dig into the database to report on the group’s experience on outcomes and costs.

The healthcare community, sometimes with the explicit support of health insurers, engages in collaborations to improve health outcomes. A Health Affairs article in 2011 is titled, “How a Regional Collaborative of Hospitals and Physicians in Michigan Cut Costs and Improved the Quality of Care.” The article addresses surgical collaborations, for instance:

  • Michigan BCBS has been supporting since 2006 a bariatric surgery data-sharing project involving 27 hospitals and some 7,000 patients a year.
  • Its major general and vascular surgery collaboration recorded 50,000 patients a year.

The article concludes that “results from the Michigan initiative suggest that hospitals participating in regional collaborative improvement programs improve far more quickly than they can on their own. Practice variation across hospitals and surgeons creates innumerable “natural experiments” for identifying what works and what doesn’t.

Elsewhere, collaborations among independent medical providers have been noted in asthma, diabetes, surgery and congestive heart failure.

Another analysis of collaborations commented that “real improvements [in treatment] are likely to occur if the range of professionals responsible for providing a particular service are brought together to share their different knowledge and experiences, agree what improvements they would like to see, test these in practice and jointly learn from their results.

Claims payers need to help this cross-fertilization happen. Hard as it may seem, they need to “own” the need to build conservative care resources in their markets. Physicians don’t understand conservative care; referral patterns are not set; and the providers of conservative care are often under-resourced. Claims payers need to step up.

Disease Management: Savings at Pepsi

The second-most read article from Health Affairs in 2014 was a fantastic piece by the employee benefits professionals from Pepsi and researchers from the RAND Corp.

The Pepsi team and the RAND researchers evaluated PepsiCo’s wellness program over a seven-year period and found the following:

  • The disease management component of the overall wellness program lowered healthcare costs by $136 per member per month (PMPM) and decreased hospital admissions by 29%
  • Lifestyle management/wellness showed a return on investment (ROI) of .48 to 1 (in other words, it LOST money)
  • Disease management’s ROI was 3.78 to 1
  • Combined ROI for wellness and disease management was 1.46 to 1
  • Findings were consistent with RAND’s workplace wellness programs study, which found that lifestyle management did not lower healthcare costs
  • Lifestyle management program’s cost was $144 per participant per year

The article concludes that “blanket statements like ‘wellness saves money’ are not warranted.”

As employers evaluate their healthcare strategies, it is important to keep these findings in mind.