Wellness is back in the news these days. The National Bureau of Economic Research’s controlled trial invalidating a Harvard study that has been used to claim major benefits from wellness programs and the surprise decision in the AARP v. EEOC case disallowing large financial inducements for “voluntary” programs both received national attention. Further, WillisTowersWatson’s quiet revelation that most employees really dislike wellness programs marks the first time anyone in the industry has ever acknowledged that, absent bribes and fines, few employees would submit to their HR people playing doctor.
By way of background, all these recent “findings” – the lack of savings from wellness programs, need for inducements, and the employee resentment – were quite clear to me in my roles at British Petroleum, Burger King and Walmart over three decades.
Along with Al Lewis, I brought this experience (and many others, such as the much more positive and increasingly popular domestic medical travel program) to public view in our book “Cracking Health Costs,” which continues to sell – and, more importantly, continues to resonate — five years after publication.
Largely because of the news hooks above, there have lately been a flurry of references to a comprehensive, scholarly article by that very same Al Lewis. Al, of course, is well-known for poking the wellness beast with humor, screenshots and eloquence on www.theysaidwhat.com. This article is different. Not as much fun perhaps, but “The Outcomes, Economics and Ethics of the Workplace Wellness Industry” captures all my doubts and criticisms, and much more besides.
Al often says that the wellness industry’s worst nightmare is being quoted verbatim. In this article, he has collected a mountain of self-incriminating verbatim quotes and claims, sourced with roughly 400 linked footnotes, all leading to the inexorable conclusion that, to be blunt, the wellness empire has no clothes. Al presents convincing evidence that what he calls “pry, poke and prod” programs really can actually harm employees. Further, the way wellness vendors typically calculate costs and benefits results in false ROI numbers.
This exposé, though generally dry and straight, is not without flashes of Al’s understated humor, albeit delivered in the context of the leading law-medicine journal. In one passage, Ron Goetzel is forced to spin the gaffe that his wellness advocacy group, HERO, accidentally published a chapter in their Outcomes Guide showing that wellness loses money. Ron is sourced as saying:
HERO’s board claims that, in creating the guide, they “fabricated” these numbers for the purpose of providing an example. Publicly, Goetzel, a member of HERO’s board, stated that “[t]hose numbers are wildly off . . . every number in that chapter has nothing to do with reality.”
Al’s next paragraph:
The chapter’s author, however, disputes the HERO board’s and Goetzel’s claim that the numbers were fabricated. He argues that, quite the contrary, his data is real and several board members, including Goetzel, reviewed it prior to publication. Reconciling the example’s data with the HCUP database, which shows almost total consistency between the HERO sample and the population, provides further evidence for the author’s claim that the data is not “wildly off” but rather real, and a representative sample of the privately insured American workforce.
Al challenges the credibility of HERO’s board simply by quoting both a board member and the chapter author. After all, when your go-to defense is pretending to have fabricated your own numbers, you lose. And when Al Lewis is on the other end, you lose big.
This article, though not a quick read, is a necessary one for all policymakers, pundits and especially employers as they decide how to react both to the new findings by NBER and Willis – which turn out not to be new at all –and how to prepare for 2019.
Perhaps the best preparation is to do something completely different – as my book says, perhaps try doing wellness for employees instead of to them. “Pry, poke and prod” programs, especially the coercive ones, may finally meet the demise that I’ve been predicting for about 15 years now.
Published in the Case Western Reserve Health Matrix: Journal Law Medicine
Alice laughed: “There’s no use trying,” she said. “One can’t believe impossible things.”
“I daresay you haven’t had much practice,” said the Queen. “When I was younger, I always did it for half an hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.”
Six impossible things before breakfast? The wellness industry would just be getting warmed up by believing six impossible things before breakfast. Wellness vendors believe enough impossible things all day long to support an entire restaurant chain:
In case you can’t read the key statistic — the first bullet point — it says: “Wellness program participants are 230% less likely to utilize EIB (extended illness benefit) than non-participants.” Here is some news for the Einsteins at US Corporate Wellness: You can’t be 230% less likely to do anything than anybody. For instance, even you, despite your best efforts in these three examples, can’t be 230% less likely to have a triple-digit IQ than the rest of us. Here’s a rule of math for you: a number can only be reduced by 100%. Rules of math tend to be strictly enforced, even in wellness. So the good news is, even in the worst-case scenario, you’re only 100% less likely to have a triple-digit IQ than the rest of us.
And yet, if it were possible to be 230% dumber than the rest of us, you might be. For instance, US Corporate Wellness also brought us this estimate of the massive annual savings that can be obtained just by, Seinfeld-style, doing nothing:
Assume I spent about $3,500/year in healthcare 12 years ago, which is probably accurate. My modifiable risk factors were zero then and are still zero — no increase. So my healthcare spending should have fallen by $350/year for 12 years, or $4,200 since then. But that would be impossible, because I could only reduce my spending by $3,500. Do you see how that works now?
To his credit, US Corporate Wellness’s CEO, Brad Cooper, is quoted in this article as saying: “Unfortunately some in the industry have exaggerated the savings numbers.” You think?
I’m pretty sure this next one is impossible, too. I say “pretty sure” because I’ve never been able to quite decipher it, English being right up there with math as two subjects that apparently frustrated many a wellness vendor’s fifth grade teacher:
400% of what? Is US Corporate Wellness saying that, as compared with employees with a chronic disease like hypertension, employees who take their blood pressure pills are 400% more productive? Meaning that, if they controlled their blood pressure, waiters could serve 400% more tables, doctors could see 400% more patients, pilots could fly planes 400% faster? Teachers could teach 400% more kids? Customer service recordings could tell us our calls are 400% more important to them?
Or maybe wellness vendors could make 400% more impossible claims. That would explain this BenefitsPro article.
We have been completely unable to get Fitbit to speak, but BenefitsPro couldn’t get the company to shut up. Here is Fitbit’s Amy McDonough: “Measurement of a wellness program is an important part of the planning process.” Indeed it is! It’s vitally important to plan on how to fabricate impossible outcomes to measure, when in reality your product may even lead to weight gain. Here is one thing we know is impossible: You can’t achieve a 58% reduction in healthcare expenses through behavior change — especially if (as in the 133 patients the company tracked in one study) behavior didn’t actually change.
You can read about that gem, and others, in our recent Fitbit series here:
I’ll consider these two outfits together because people seem to bounce back and forth between them. Jessica Grossmeier is one such person. Jessica became the Neil Armstrong of impossible wellness outcomes way back in 2013. While at Staywell, she and her co-conspirators told British Petroleum they had saved about $17,000 per risk factor reduced. So, yes, according to Staywell, anyone who temporarily lost a little weight saved BP $17,000 — enough to clean up about 1,000 gallons of oil spilled from Deepwater Horizon.
Leave aside both the obvious impossibility of this claim, and also the mathematical impossibility of this claim given that employers only actually spend about $6,000/person on healthcare. Jessica’s breakthrough was to also ignore the fact that this $17,000/risk factor savings figure exceeds by 100 times what her very own article claims in savings. Not by 100%. By 100 times.
Fast-forward to her new role at HERO. In this article, she says:
The conversation has thus shifted from a focus on ROI alone to a broader value proposition that includes both the tangible and intangible benefits of improved worker health and well-being.
Her memory may have failed her here, too, because HERO — in addition to admitting that wellness loses money (which explains its “shift” from the “focus on ROI alone”) — also listed the “broader value proposition” elements of their pry-poke-and-prod wellness programs. The problem is the elements of the broader value proposition of screening the stuffing out of employees aren’t “benefits.” They’re costs, and lots of them:
When she says: “The conversation has shifted from a focus on ROI alone,” she means: “We all got caught making up ROIs, so we need to make up a new metric.” RAND’s Soeren Mattke predicted this new spin three years ago, observing that every time the wellness industry makes claims and they get debunked, the industry simply makes a new set of claims, and then they get debunked, and then the whole process repeats with new claims, whack-a-mole fashion, ad infinitum. Here is his specific quote:
“The industry went in with promises of 3 to 1 and 6 to 1 based on health care savings alone – then research came out that said that’s not true. Then they said: “OK, we are cost neutral.” Now, research says maybe not even cost neutral. So now they say: “But it’s really about productivity, which we can’t really measure, but it’s an enormous return.”
Interactive Health also holds the distinction of being the first vendor (actually their consultant) to try to bribe me to stop pointing out how impossible their outcomes were. They were upset because I profiled them n the Wall Street Journal. The article is behind a paywall, so you probably can’t see it. Here’s the spoiler: The company allegedly saved a whopping $53,000 for every risk factor reduced. In your face, Staywell!
Here is the BenefitsPro article’s quote from Interactive Health’s Jared Smith:
“There are many wellness vendors out there that claim to show ROI,” he says. “However, many of their models and methodologies are complex, based upon assumptions that do not provide sufficient quantitative evidence to substantiate their claims.”
Finally, here is a news flash for Interactive Health: Sitting is not the new smoking. If anything is the “new smoking,” it’s opioid addiction, which has reached epidemic proportions in the workforce while being totally, utterly, completely, negligently, mind-blowingly, Sergeant Shultz-ily ignored by Interactive Health and the rest of the wellness industry.
There is nothing funny about opioid addiction and the wellness industry’s failure to address it, a topic for a future blog post. The only impossibility is that it is impossible to believe that an entire industry charged with what Jessica Grossmeier calls “worker health and well-being” could have allowed this to happen. Alas, happen it did.
And, as I write this post, breakfast hasn’t even been served yet.
To win the $2 million reward for yourself and the $1 million for the school district, you just need to prove (using the more-likely-than-not civil standard of proof), the following (to bend over backward to be fair, I will start out by offering to use only materials prepared by your side):
During this millennium, the wellness industry has reduced hospitalizations by enough to break even, using the government’s Healthcare Cost and Utilization Project database. For this one, I will concede in advance that the wellness-sensitive medical event methodology (“potentially preventable hospitalizations”) as described on pages 22-23 of the HERO Outcomes Guidebook is the one to use. (HERO and I agree that non-hospitalization expenses increase.)
The vendor anointed in 2016 as the “best” vendor, Wellsteps, indeed did reduce the costs of the Boise School District by about a third (as the company claimed), specifically by making the employees sufficiently healthier to support that savings (as the company claimed). For this one, I will concede in advance that the raw data collected by Wellsteps is accurate. In other words, we are both working off Wellsteps’ own published reports.
Here are the rules. This is a binding legal offer, as any attorney will tell you.
Panel, Venue and Judges
We each pick two panelists from Peter Grant’s “A-List” of the leading 260 health economists and policy experts (this is an invitation-only email group where health policy and health economics concerns are addressed and debated) that are unaffiliated with either the wellness industry or with my company, Quizzify, and together they pick a fifth.
The parties will convene in Boston for a 2.5-hour finalist presentation, featuring:
10-minute opening statements, in which as many as 15 slides are allowed;
30-minute cross-examinations with follow-up questions and no limitations on subject matter;
60 minutes in which panelists control the agenda and may ask questions of either party based on either the oral or the written submissions;
Five-minute closing statements.
Entry Fee and Award
I give you a lien on $2 million as soon as you put $200,000 in escrow to cover the costs of the program, for panelist honoraria, venue, etc., as well as for wasting my time with your quixotry. If I win, I will make a $100,000 in-kind donation to the Boise School District to help compensate them for the fees the district wasted on its wellness program.
Length and content of Submissions
Each side submits up to 2,000 words and five graphs, supported by as many as 20 links; the material linked must pre-date the award application to discourage either side from creating linked material specifically for this contest.
Publicly available materials from the lay media or blogs may be used, as well as from any of the 10 academic journals with the highest “impact factors,” such as Health Affairs, published within the last five years.
Each party may separately cite previous invalidating mistakes made by the other party that might speak to the credibility of the other party.
Either side may cite an unlimited number of “declarations against interest” made within the last five years — meaning comments made by the other party so prejudicial to their own position that the other party would have said them only if they believed these statements to be true. Example: If I said, “Wellness definitely saves money” (except when I said that as an April Fool’s gag a few years back), you could cite that. There is no word limit on these.
Each party can then rebut the other party in writing with up to 2,000 words and five graphs as well as 20 links.
Additionally, we both take a lie detector test. Each side will present the polygraph operator with five questions, and all 10 questions will be asked of both parties. Results are then sent to the panelists.
What if you want to claim the award?
Send $1,000 via Paypal to firstname.lastname@example.org to hold your spot. I will set up an escrow account at Bank of America. Once we both sign the escrow papers, you send the $200,000 to that account, and I’ll give you first lien on $2 million of asset
How many times do wellness promoters have to admit or prove that wellness doesn’t work before everyone finally believes them?
Whether one measures clinical outcomes/effectiveness, savings or productivity, the figures provided by the most vocal wellness promoters and the most “successful” wellness programs yield the same answer: Wellness doesn’t work.
In that estimate, which works out to a failure rate well north of 90%, he is joined by Michael O’Donnell, editor of the industry trade journal, the American Journal of Health Promotion (AJHP). O’Donnell says that as many as 95% of programs fail. (For the record, I have no beef with him, because he once willingly admitted that I am “not an idiot.”)
The best example of this Goetzel-O’Donnell consensus? McKesson, the 2015 Koop Award winner. McKesson’s own data –even when scrubbed of those pesky non-participants and dropouts who are too embarrassed to allow themselves to be weighed in – shows an increase in body mass and cholesterol:
Vitality Group, which contributed to this McKesson award-winning result as a vendor, wants your company to publicly disclose how many fat employees you have. Why? So that you are “pressured” (their word) into hiring a wellness vendor like Vitality. Yet Vitality admits it can’t get its own employees to lose weight.
McKesson and Vitality continue a hallowed tradition among Koop Award-winning programs of employees not losing noticeable weight. For instance, at Pfizer, the 2010 award-winner, employees who opened their weight-loss email lost all of three ounces:
Maybe it’s unfair to pick programs based on winning awards. Awards or not, those programs could have cut corners. Perhaps to find an exception to the rule that wellness can’t improve outcomes, we should look to the most expensive program, Aetna’s. Unfortunately, even Aetna registered only the slightest improvement in health indicators, throwing away $500/employee in the process. Why that much? Aetna decided to collect employee DNA to predict diabetes, even though reputable scientists have never posited that DNA can predict diabetes.
So even award winners, wellness vendors themselves and gold-plated programs can’t move the outcomes needle in a meaningful way, if at all. Bottom line: It looks like we finally have both consensus on the futility of wellness, and data to support the wellness industry admission that way north of 90% of programs do indeed fail to generate outcomes.
Because wellness promoters now say most programs fail, it is no surprise they also say most programs lose money. Once again, this isn’t us talking. The industry’s own guidebook – written by Goetzel and O’Donnell and dozens of other industry leaders — shows wellness loses money. We have posted that observation on ITL before, and no one objected.
However, very recently, the sponsors of this guidebook (the Health Enhancement Research Organization, or HERO) did finally take issue with our quoting statistics from their own guidebook. They pointed out — quite accurately — that their money-losing example was hypothetical. It did not involve numbers they would approve of, despite having published them. (At least, we think this is what HERO said. One of their board members has learned that they have sent a letter to members of the lay media, telling them not to publish our postings. We are told HERO’s objection centers on our quoting their report.)
To avoid a lawsuit for quoting figures they prefer us not to quote, we substituted their own real figures for their own hypothetical figures — and using real figures from Goetzel’s company, Truven Health Analytics, multiplied the losses.
This very same downloadable guidebook notes that these losses, as great as they are, actually exclude at least nine other sources of administrative costs–like internal costs, impact on morale, lost work time for screenings, etc. (Page 10). Truven also excludes a large number of medical costs (Page. 22):
One could only assume that including all these administrative and medical losses in the calculation would increase the total loss.
Lest readers think that this consensus guidebook is an anomaly, HERO is joined in its conclusion that wellness loses money by AJHP. AJHP published a meta-analysis showing a negative ROI from high-quality studies.
RAND’s Soeren Mattke said it best:
“The industry went in with promises of 3-to-1 and 6-to-1 ROIs based on healthcare savings alone. Then research came out that said that’s not true. They said, ‘Fine, we are cost-neutral.’ Now research says: ‘Maybe not even cost-neutral.’ So they say: ‘It’s really about productivity, which we can’t really measure, but it’s an enormous return.'”
The AJHP stepped up to make Dr. Mattke appear prescient. After finding no ROI in high-quality studies, proponents decided to dispense with ROI altogether. “Who cares about ROI anyway?” were O’Donnell’s exact words.
Because health dollars couldn’t be saved, O’Donnell tried to estimate productivity impact. But honesty compelled him to admit that workers would need to devote about 4% of their time to working out to be 1% more productive on the job. Using his own time-and-motion figures, and adding in program costs, his math creates a loss exceeding $5,200/employee/year.
I would have to agree with O’Donnell, based on my experience in the 1990s as the CEO of a NASDAQ company. Ours was a call center company, which meant someone had to answer the phones. If I had let employees go to the gym instead of working, I would have had to pay other employees to cover for them. Our productivity would have taken a huge hit, even if the workouts bulked up employees’ biceps to the point where they could pick up the phone 1% faster.
Where Does This Leave Us?
Despite our using their own figures, wellness promoters may object to this analysis, saying they didn’t really intend for these conclusions to be reached. Intended or not, these are the conclusions from their figures, and theirs largely agree with ours, expressed in many previous blog posts on ITL. And, of course, our website, www.theysaidwhat.net, is devoted to exposing vendor lies. The bottom line is, no matter whose “side” you are on, the answer is the same. Assuming you look at promoters’ actual data or statements instead of listening to the spin, the conclusion is the same: Conventional wellness doesn’t work.
While most of us were buying supplies for partying on New Year’s Eve (in my case, I was in charge of bringing broccoli and Boggle), the federal court in the Western District of Wisconsin quietly handed down an earth-shattering decision in the Flambeau case, which went pretty much unnoticed due to the timing. You may recall this was the case where employees refusing wellness lost all insurance benefits. The case looked like it would be a layup win for the Equal Employment Opportunity Commission (EEOC). After all, the Affordable Care Act (ACA) clearly states that penalties for non-smokers are capped at 30%, and this penalty was 100%.
But, here’s the rub: Flambeau conditioned the entire insurance benefit on participation in its “pry, poke and prod” program. The company knew most employees hate “pry, poke and prod” programs to begin with, so they created a program so onerous that some number of employees would prefer to forego insurance altogether rather than participate in wellness. And, indeed, that’s what happened at Flambeau. This decision means the company is getting away with it, saving thousands of dollars for each employee who refused to submit.
Make sure you catch that distinction between the 30% penalties and the 100% penalties:
(1) It is not OK to penalize an employee more than 30% for refusing to submit to a “pry, poke and prod” program if they already have insurance, or they can get insurance through the employer without this requirement.
(2) However, it is OK to say: “There is no incentive or penalty for wellness once you have insurance, but you can’t have insurance at all unless you submit.” If that seems like an artificial distinction, well, that’s because it is. All an employer has to do is require pry-poke-and-prod before you get insurance.
Assuming other federal courts follow this district’s lead (as they usually do), employers create a 100%de facto non-participation penalty: If you don’t participate, you don’t get insurance, period.
The implications of this case:
(1) It will allow some vendors, such as Bravo, to double down on bragging about the “savings” from wellness by creating programs employees don’t like;
(2) Because the decision only applies to participatory programs and not outcomes-based programs, many companies will either not switch to outcomes-based programs or else maybe switch back.
The court’s decision also puts pressure on the EEOC to put the kibosh on this end-run around the Affordable Care Act’s wellness provision. The decision can, and should, be appealed. Otherwise, it is a de facto repeal of a big chunk of the Affordable Care Act.