Tag Archives: Quizzify

Did Biden Just Kill Wellness Programs?

After a decade of criticism from me (here on ITL, in particular) and a growing number of others, workplace wellness died last week. It had been on life support since Jan. 7. 

The bottom line: Brokers and advisers should now be aware both of the professional risks they are taking by pitching clinical wellness programs and of the career risk they are subjecting their clients to by encouraging use of the programs. Most clinical wellness programs now technically violate the Americans with Disabilities Act (ADA). 

You might be wondering why this is the first you are hearing of it. That’s because this is new news, as of last Thursday. Here is a timeline:

  • Jan. 16, 2018: Federal court case “vacates” the expansive, corporate-friendly EEOC rules allowing large incentives and penalties used in clinical wellness programs and directs the EEOC to write new rules accordingly.
  • July 16, 2019: AARP and unionized Yale employees sue Yale for imposing such penalties. 
  • Jan. 7, 2021: The EEOC finally writes the new rules. As directed by the court, these rules no longer allow employers to subject employees to large forfeitures (penalties or foregone incentives) for refusing to submit to clinical wellness programs. The three Republican commissioners, at the request of the U.S. Chamber of Commerce and Business Roundtable, carve out a large loophole for increasingly unpopular and possibly harmful outcomes-based programs. (Those are the programs where you get heavily fined for not losing weight.)
  • Jan. 8-20, 2021: The dog doesn’t bark in the nighttime: The Federal Register does not publish the proposed rules for public comment. The absence of this routine step suggests these rules are already generating blowback.
  • Jan, 21, 2021: The Biden administration shakes up the EEOC, promoting the two Obama appointees, both of whom have strong pro-employee biases, and demoting the Republicans.
  • Jan. 21, 2021: The Biden administration freezes all proposed rules from every agency from publication for comment in the Federal Register. This indicates a thorough realignment of priorities is in the works.

Here are three ways to know that this timeline means the end of programs that, like most, focus exclusively on risk assessments, screens and coaching.

First, the ADA requires that clinical inquiries and exams be “voluntary.” Absent rules defining “voluntary,” incentives can’t be imposed. Very few employees would voluntarily allow their employers to hire unlicensed wellness vendors to “play doctor,” especially with no law proscribing the vendors’ use of that data. (HIPAA does not apply to standalone wellness companies.)

Second, the new EEOC leadership alignment eliminates the chance that the EEOC will re-publish the existing rules. If indeed the EEOC publishes new rules once new rules are green-lighted for publication in general, the agency will specifically allow only minimal incentives. Penalties? No way.

See also: 3 Tips for Increasing Customer Engagement

Third, that 2019 Yale lawsuit has yet to be decided. The judge has been sitting on the summary judgment briefs for more than a year now, presumably waiting for the rules to be promulgated. With no rules, Yale is now in clear violation of the ADA, so the decision should come down within weeks — in favor of the plaintiff employees. This decision will resonate with class action attorneys everywhere, as punitive programs will be “low-hanging fruit” for them. The decision will unleash a flood of claims by 2022.

Here’s how to keep your clinical program intact

The rules – and the EEOC’s jurisdiction in general – apply only to clinical programs. You can still offer activity-based programs and still tie up to 30% of insurance dollars to those programs. The reason? Activity-based programs are governed by the Affordable Care Act (ACA) only, not the ADA. They include physical and mental activities, as well as seminars, quizzes, volunteer work and more.

The difference between the two program types is best illustrated by an example: You can make employees wear FitBits to track their steps, but you can’t track their pulses. (It turns out tracking steps doesn’t accomplish anything anyway.)

There is a way to maintain your clinical programs. (Why anyone would want to is a different issue, covered at length here.) You can offer them side-by-side with your activity programs but allow employees to fully satisfy program requirements and earn the full incentive (or avoid the penalty) without submitting to any clinical test or inquiry. 

Suppose an employee needs 500 “wellness points,” and a risk assessment and a screen are worth 250 apiece. “Lunch ‘n’ learn” nutrition seminars are worth 50 points each, but employees are currently capped at 5 such seminars. That program would be noncompliant. Raising the cap to 10 or upping each seminar to 100 points solves the entire problem by allowing employees to earn the full incentive by sitting through all those sessions.

Employers concerned about the time commitment for something like that could offer health literacy quizzes instead. [Note: My company offers those.] This simple one-page flyer checks the ADA/EEOC compliance box by offering both quizzes and conventional screenings. It also encourages the highest-risk employees to choose screens, while a large majority of employees would learn more about health, healthcare and health benefits through quizzes.

As a belt-and-suspenders protection against EEOC exposure, Quizzify also provides indemnification to employers. With or without health literacy, your own wellness vendor should reconfigure its program to both comply with the ADA and to indemnify you and your client if it doesn’t. 

Especially with indemnification, expanding the number of activity-based offerings to allow employees to hit their points target while avoiding clinical programs solves this new problem. The challenge will be to make those non-clinical activities useful.

If you want to explore this topic further, Insurance Thought Leadership is co-sponsoring a seminar on this very topic on Monday, Feb. 1 at 1pm EST. You can register here.

Why to Rethink Dental Checkups

Four out of five dentists recommend twice-a-year teeth cleaning. Here’s why the fifth dentist is right.

Ask yourself these questions:

  • Are you healthy?
  • Do you brush your teeth every day?
  • Is your mouth free of problems such as bleeding gums or sensitivity to cold or hot foods and drinks?
  • Do you dislike wasting your money and your time?

If you answered “yes” to all four questions, your answer to “do I need a dental hygiene visit twice a year?” should be a firm NO.

Let’s face it, we all want to do what we can to have good oral health and a great smile, but it’s possible we are overdoing it. Getting your teeth cleaned by an oral hygienist twice a year is not a substitute for the important daily flossing and brushing that you should be doing anyway to maintain healthy teeth and gums. According to research, there are no strong reasons for visiting your dentist twice a year if you are healthy and have no oral symptoms.

You might say: “But my dentist insists on twice yearly visits, and he/she is paid by my dental plan!”

To which we would say, the reason you might think you have to visit a dentist twice a year is based on marketing, not science. We can go back as far as a successful pre-World War II marketing campaign for Pepsodent toothpaste that encouraged people to brush twice daily and to see their dentists twice yearly. This “twice-a-year” standard obviously benefited both the toothpaste manufacturer and the dental professions. As dental insurance emerged in the marketplace, these plans made coverage of the twice-yearly visit a standard covered service, often at no charge to the policyholder. Voila, a standard of care—one based on no supporting data at all—was born.

So you might ask, how often should I see the dentist?

It is true that, on average, Americans should be visiting the dentist about twice a year—some more, some less. Here are reasons why you might get dental checkups more than twice a year.

For instance, maybe you have risk factors for gum disease or already have gum disease. We also know, for example, that mouth-breathers, smokers, tobacco-chewers and people on medications that cause dry mouth (such as opioids or even diphenhydramine, the main ingredient in Benadryl), have a higher chance of developing cavities. If you have excessive tartar on your teeth, or have had extensive dental work or braces, more frequent dental visits might be wise.

See also: Insurtech: Mo’ Premiums, Mo’ Losses

If you otherwise have a healthy mouth, a once-a-year visit should suffice. Between visits, the main person responsible for your oral health is you. Poor oral health may be linked to other health problems such as heart disease and pancreatic cancer, and, while those links aren’t fully established, attending more closely to your oral health may prove helpful.

Bottom line: Pay attention to the daily tasks of brushing and flossing. If you are healthy and practice good dental hygiene, more than once-yearly dental visits could lead to additional unnecessary costs to you.

Four out of five dentists recommend you visit them exactly twice a year. Maybe the fifth dentist knows what he’s talking about.

Note: This blog post could inform your dental benefit design. Instead of covering two dental checkups for everyone, for about the same cost, you could match the coverage to the need. Pay the first checkup at 100%, the second at 80% and the third (and possibly fourth) at 60%. It’s the employees who need three or four who are going to have the most dental (and possibly medical) issues down the road.

Faulty Math Behind Over-Treatment

The American Cancer Society (ACS) recently decided that, because the rate of colon cancer has increased by an “alarming” 22% in the 45-to-49-year old cohort this century, colon screenings should start at age 45.

This is a very instructive decision, though not because it is a good idea. Rather, it’s instructive because it’s a “teachable moment” about why Americans suffer from over-diagnosis and over-treatment so much more than people in other modern economies, with worse outcomes to show for it.

One reason is the failure of our medical and public health community to understand the difference between relative risk and absolute risk.

On one hand, a smoker might have a relative risk of heart attacks that is only a few times greater than the risk for nonsmokers. However, with Americans suffering 400,000 heart attacks a year, many of us do whatever we can to avoid small increases in relative risk of a heart attack because the absolute risk is so great.

On the other hand, suppose the relative risk of an unsafe airline is 10 times the risk of a safe airline. But with about three crashes a year (in a very bad year) over the course of 30 million flights, even a whopping tenfold increase in relative risk would bring your absolute risk of crashing up to a trivial 1-in-a-million. Here at Quizzify, we’d still opt for the unsafe airline if it has more legroom and a better mileage program.

See also: A Road Map for Health Insurance

And that brings us to exactly what the American Cancer Society miscommunicated…with a disturbing twist, as you’ll see below.

This “alarming” 22% increase in relative risk over the course of this century translates into an increase in the absolute rate of colon cancer in the <50 cohort from 0.006% to 0.007%. Yes, 0.001 percentage point more of the <50 population in this country will get colon cancer now than 18 years ago.

Further, suppose half of that 0.007% had a family history (or some other major risk factor) and would be advised by their doctor to get screened regardless of guidelines for the average person. That leaves roughly 0.0035% of the 45- to 49-year-old population who could possibly benefit from a random screen. That’s not much different from your lifetime odds of getting struck by lightning.

And a screen is far from a lifesaver, in general. Quite the contrary, statistically speaking it is likely to find the slow-growing tumors while missing the more aggressive, faster-growing tumors that begin between screens. Screening is not a surefire way to detect cancer, by any means.

The Disturbing Twist: The Hazards of Screening

That trivial benefit must be weighed against the nontrivial harms. The risk of a complication, such as a perforation, is estimated at between 1.6% and 1.8%. In all fairness to the ACS, it isn’t insisting that the screen be done via a colonoscopy, though the non-invasive screens have such high positive/inconclusive test rates that they often lead to colonoscopies. That makes the rate of complications about 3,000 times the odds of having your life saved by early diagnosis of colon cancer.

See also: How Telehealth Changes Senior Care

Of course, the worst complication is death, and the mortality rate from colonoscopies (0.02%) appears to be, on its face, much higher than the rate of lives that would be saved. However, in all fairness, the mortality rate, like the complication rate, in general, increases with advancing age. Hence maybe the mortality rate in the 45- to 50-year-old cohort isn’t any higher than — and might even be slightly lower than — the rate at which early detection will save lives.

So what’s an employer to do? We’d say, stay on the sidelines. Let employees work this one out for themselves, with their doctors. Or show them this post. But don’t encourage them to run out and get screened on the basis of a recommendation that is at best controversial and at worst harmful.

‘Wild West’ of Suits Coming for Wellness

A group of screening vendors and their trade associations have drafted a letter to senators in which they reveal their hitherto unpublished level of panic over the December 2018 sunsetting of the EEOC’s safe harbor for incentives and penalties for health risk assessments and biometric screenings.

Their specific words are: “Without clear guidance from the EEOC, we fear a Wild West of litigation could re-emerge as it did prior to the EEOC guidelines… jeopardizing programs that are improving the health of America’s workforce.”

[Note: They offer no support for the assertion that their programs “are improving the health of America’s workforce,” and their own outcomes indicate the reverse.]

Their “ask” in this letter is for the Senate to confirm the pending EEOC appointees, including the chairperson, so that rules can be published by January.

Unfortunately, that isn’t going to happen, for three reasons. First, the EEOC has already announced that it doesn’t plan to issue rules in January to replace the rules vacated in December.

Second, the wellness industry doesn’t understand the way the rule-making process works. It’s a multistep process, laid out by statute, that in the least contentious of circumstances takes many months.

Third, the existence of vacancies on the commission has created a backlog of issues needing resolution. The only way wellness rises to the top of that list is if there is indeed a “Wild West of Litigation” in early 2019—which is actually quite likely. We at Quizzify are already aware of one aggrieved group of plaintiffs planning a class action.

So what should you do to hold yourselves harmless once the rules sunset? There are two concerns:

–Employee lawsuits in your own company. These will be common—especially in outcomes-based programs, owing to their unpopularity. (See page 15 of this report.) Specifically, the Net Promoter Score for wellness is -52, whereas the lowest major industry, cable TV and internet services, scores +2.

–Employee lawsuits in other companies. A federal judge’s decision might well affect the landscape—either an entire circuit or the country as a whole. You could be required to give the 2019 premium differential back to employees if your program fits the category of non-voluntary.

Vulnerability may be based on 2019 differentials even if the program itself is undertaken in 2018. As Jonathan Zimmerman of Morgan, Lewis and Bockius put it: “Absent guidance from EEOC (which itself would not be binding on the courts), it’s not knowable whether 2019 premium differentials caused by refusal to be screened in 2018 could survive employee legal challenge. Therefore, it is important to create a path for employees this year that allows them to achieve their full ‘points’ total without medical exams or inquiries.”

Quizzify indemnifies customers against EEOC lawsuits, thus solving the first problem. For the second, Quizzify offers a simply money-back guarantee that no judicial decision anywhere else will affect their premium differential.replace the EEOC’s sunsetting safe harbor. Instituting this program in 2018 will create a safe harbor and a money-back guarantee for 2019.

To learn more, join us for a webinar at 10am CDT on Wednesday, Sept. 19. Contact us at hello@quizzify.com to get the promo code to sign up for free.

Wellness Programs Lack Health Literacy

The more informed your employees are about health and healthcare, the wiser and more confident they’ll be when it comes to making the right lifestyle and healthcare choices.

Health Literacy

Health literacy improves health outcomes, while controlling health spending. The Institute of Medicine (IOM) defines it as:

“the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”

What does the IOM mean by “basic health information”? It’s the knowledge necessary to understand the impacts and risks of different health-related decisions or behaviors. For example, basic health information would include knowing why you should complete the full dosage of antibiotics prescribed by a doctor.

However, an even more informed healthcare consumer would know, or at least ask, whether antibiotics are even necessary for the ailment in question.

The Low Health Literacy Rate

Health literacy is very low in the U.S. – “proficiency” is pegged at 12% by the Journal of the American Medical Association, well below the level of other nations where citizens have access to technology.

According to JAMA, having a “proficient” level of health literacy can mean making consistently good healthcare choices and understanding one’s insurance options. Yet, mere proficiency should not be the goal. At Quizzify, where employees are already “proficient,” we continue to learn something every day. For instance, today we learned that pregnant women should avoid consuming black licorice because it contains a chemical that can harm unborn babies. (In this situation, it’s the high-quality candy-store licorice that is the culprit. The version you buy at newsstands is only licorice-flavored.)

See also: New Wellness Plans: for Employee Finances  

Low Health Literacy Affects Cost

A study conducted by the Veterans Administration (VA) on the literacy-cost correlation revealed that veterans with low health literacy spend roughly 50% more on disease management and medical care than veterans with proficient knowledge, other things equal. Think about what that means for your own healthcare budget, and how much you would save by making even a small dent in that.

Low Health-Literacy Affects Employee Wellness Outcomes

Health literacy training has far better outcomes than any other employee wellness program. Screenings, for example, do not prevent the utilization of medical care. In fact, they may actually encourage it.

In the Health Enhancement Research Organization Outcomes Guidebook, researchers found that only 7-8% of hospitalizations are “potentially preventable” by wellness programs. They also note that many non-hospital expenses increase as a result of these programs. Meanwhile health literacy applies to the vast majority of decisions and behaviors that affect health.

In contrast, health literacy applies to the vast majority of decisions and behaviors that affect health. Typically, literate consumers spend less. When literate consumers spend more, it is usually an educated decision and may avoid a bad outcome.

Implementing Health Literacy Into the Workplace

The Uphill Battle Toward Behavior Change:

People who are smokers or overweight already realize they should make changes…and yet, for many complex and (in the case of obesity) poorly understood biochemical reasons, can’t. Encouraging smokers to quit or obese employees to lose weight is a totally uphill, probably unwinnable task for an employer, even as a lot of money gets spent trying to move the needle. It is nearly impossible to make significant dents in these two (and related) health issues through behavior change. Furthermore, employers are not especially well-positioned to bring about these changes. Trying too hard can even feel intrusive and uncomfortable for employees.

Knowledge as a Solution:

By contrast, in health literacy, most of the effort is in imparting the knowledge, not changing the behavior.


  • Every smoker knows he or she is supposed to quit already for health reasons but doesn’t. However, a few smokers may be motivated to quit when they learn the amount of money they are really spending on cigarettes. ($300,000-plus over a lifetime.)
  • People know that radiation is unhealthy, whereas very few patients receiving CT scans realize they will be absorbing as much as 1000 times the radiation of an X-ray. Simply obtaining the knowledge can change behavior while saving money.

See also: Ethics of Workplace Wellness Industry  

Achieving a higher level of health literacy is not difficult– it just takes some learning.