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.
The headline comes from a TED conference speech by Rishi Manchanda, who has worked as a doctor in South Central Los Angeles. After about 10 years, he realized, “His job isn’t just about treating a patient’s symptoms, but about getting to the root cause of what is making them ill-the ‘upstream’ factors like a poor diet, a stressful job, a lack of fresh air. It’s a powerful call for doctors to pay attention to a patient’s life outside the exam room.”
This story has a WOW factor.
Let me repeat: Dr. Manchanda came to realize it’s not enough to treat a patient’s symptoms, but to get to the root cause of what makes people sick. Regular readers of Cracking Health Costs will know this is a familiar message. Of all the things that cause us to die too early, medical care can only deal with about 25%. The rest is about how you live your life.
This also explains why typical corporate wellness programs fail. They’re trying to ameliorate symptoms but ignore the root cause of syndromes such as high blood pressure, high cholesterol, etc. It’s not enough to walk into a smoke-filled house and turn on the exhaust fan. You need to put out the fire, too.
Wellness buyers, e.g. benefit managers, need to have the same epiphany as Rishi Manchanda.
I’ve been writing a series of posts about root causes of illness: loneliness, job stresses, life dissatisfaction, etc. I also firmly believe the time is right to start thinking about employee ailments in an entirely different way.
My next book, An Illustrated Guide to Managing Your Health—How to Improve Your Health in 40 Common-Sense Steps, could well be called, “For better health, look upstream.”
It was an event maybe even more anticipated than Neil Armstrong’s Moon shot in 1969. I had never tuned into one before, yet there I was, sitting in my pajamas at 1 a.m., frantically trying to get back onto the streaming podcast that my iPad had just dropped, as millions of other nerds the world over were trying to do the same thing.
Apple’s product announcement event on Sept. 9, 2014, had drawn unprecedented interest. I certainly was expecting Apple to “do it again” – you know, change the world in a subtle yet pervasive way, as I am sure many others struggling to get onto the live webcast also believed would happen. After all, the company that Steve built had done it with iTunes, with the iPhone and with the iPad. And now we all wanted to see if Apple’s first wearable device – the Apple Watch, was going to change our lives in the same way.
Well, we definitely saw something that early morning in September, but the realization of the promise still lies ahead, with the first retail delivery of Apple Watches not until late April 2015. What is certain is that Apple has successfully moved the idea of a connected wrist health and fitness tracker from the niche arena of health-conscious individuals to the mainstream “Joe Public.”
Interestingly, even if Apple falls short this time, it has set in motion a great race with Microsoft, Google, Samsung, Fitbit and many others to fulfill and surpass the vision that we all saw in September. In 2014, world-wide revenue from the sale of wearables was roughly $4.5 billion, but, in 2015, expectations are sky-high. Some experts predict sales will increase as much as three times, fueled in the most part by the Apple Watch.
So why are wearables a good thing for insurance?
The rise of wearable fitness trackers as part of corporate wellness programs has been an emerging trend over the last 10 years. In the past, enlightened companies were giving out Fitbits to help employees track their own fitness. More recently, companies have been trading program participation and fitness data captured from such programs for discounts on their corporate health insurance. For example, Appirio, a San Francisco-based cloud computing consultancy, was able to get a 5% discount ($300,000) off its insurance bill in 2014, while BP America distributed around 16,000 Fitbits to employees as part of an integrated wellness program and claim to have put a brake on corporate healthcare cost increases by slowing them to below the U.S. national growth rate in 2013.
A key ingredient to the success of these programs is the engagement of the members, so that healthy behaviors are encouraged and rewarded. In the BP example, the Fitbit data was easy to “gamify” because of the connected nature of the device. Members competed on a number of challenges, including the “1 million step” challenge, simply by wirelessly “syncing” their devices. Cory Slagle, the spouse of a BP employee, was able to trim $1,200 off his insurance bill through participation in this program — dropping nearly 32 kilograms and 10 pants sizes and reducing his high blood pressure and cholesterol back to normal range in just 12 months.
Vitality of South Africa has recognized the importance of a holistic health and wellness program for well over a decade and has built up an impressive array of statistics, including:
The only trouble is that participation in such programs remains minuscule, with opt-in rates in some cases of just 5% for those eligible to join. Despite the programs’ value propositions being augmented with an affinity network of providers supplying goods and services at a discount for participating members, opt-in rates and persistency remain problematic.
A recent survey by PWC found that, if the connected wearable device was free to the member, then about two-thirds said they would wear a smart watch or fitness band provided by their employer or insurer. Cigna completed a connected wearable pilot in 2013 involving 600 subjects, which indicated 80% of the participants were “more motivated to manage their health at the end of the study than at the beginning.” In the U.S., United Health, Cigna and Humana have already created programs to integrate connected wearables into their policies, to create reward systems based on data sharing. In one innovative program, a “wager” penalty system was found to be three times more effective in motivating healthy behavior than the typical rewards these programs offer. The “wager” involved the member’s signing up to achieve and then maintain reasonable fitness targets over the course of the year to avoid having the cost of the health screening be deducted from their salary.
A key hurdle to overcome with the data generated from connected wearables is privacy and security. Individuals want to know what insights are being generated from the data being collected and want to selectively share with the program based on the perceived value they get back. They also need to know that the data continues to be secure and private once shared. Apple is working this angle through its HealthKit, which is positioned as the data control room for consolidating and securely sharing health- and fitness-related data to selected parties. There are already in-the-field health trials in progress with Stanford and Duke universities that are being powered by HealthKit. Google, Samsung and several others have also launched similar competing frameworks, so the data privacy issue is understood and being addressed by the technology companies offering products in this space.
I want to mention an innovative, data-driven, life insurance program that currently doesn’t use any wearables but easily could. AllLife of South Africa provides affordable life and disability insurance to policyholders who suffer from manageable chronic diseases, such as HIV and diabetes, and who sign up to a strict medical program. Patients get monthly health checks and receive personalized advice on managing their conditions. Data driving the program is pulled directly from medical providers, based on client permission. If a client fails to follow or stops the treatment, then the benefits will be lowered or the policy will be canceled after a warning. The company assesses its risk continuously during the policy period, contrasting with the approach of other companies, which typically only assess risk once, in the beginning. This approach allows AllLife to profitably serve an overlooked market segment and improve the health and outlook for its customers. It plans to cover more than 300,000 HIV patients by 2016.
The video of AllLife’s CEO, Ross Beerman, on YouTube is quite inspirational, and I recommend you see it. He says, “Our clients get healthier just by being our clients.” He also mentions the challenges of building an administration system to support AllLife’s customer-engagement model.
In summary, several intersecting trends have conspired to make this the perfect time to consider the launch of insurance programs and products powered by the new insights from the data being made available through wearable fitness and health trackers:
The whole fitness and healthy lifestyle perspective has entered into the mainstream culture
Devices like the Apple Watch have become fashionable, objects of desire
The data from these devices is easy to capture and share – no forms to fill in
–The data is of clinical quality, in at least some cases, and therefore useful for actuarial models
–Insurers have already started to jump on the idea of “telematics” for humans for risk pricing
–Feedback from this data is able to positively modify behavior to reduce health risks and improve the quality of life for those participating
I am still undecided if I’m going to be up at 1am again, this time outside the Apple Store, waiting for the Apple Watch to go on sale. However, the line outside the Apple Store that night could be very fertile ground for agents selling polices driven by the data these new devices will provide, if only companies act now and get their programs in place.
Our series of excerpts from Surviving Workplace Wellness starts with the epilogue, because Aetna managed to incorporate everything that is wrong with workplace wellness, as described in the book, into one press release. It is the book’s epilogue because Aetna’s announcement followed the completion of the text. We actually held up publication of the print version to squeeze this epilogue in.
The caveat for brokers: Be careful what you sell. Your commission checks may come from the seller, but your business value comes from retaining your clients. As your clients grow more skeptical of wellness vendor claims, you need to be a step ahead, anticipating their skepticism rather than being blindsided by it.
Dr. Aetna Is In
Imagine how you’d feel if you got a letter saying basically:
Dear Fat Person,
We aren’t doctors, and you’re not sick, and you never asked for our help and probably never would, but we’ve got the solution for you anyway: Arena’s Belviq and Vivus’s Qsymia, obesity drugs made by companies we’re partnering with. True, these drugs are expensive, have side effects that you may not tolerate (the nasty outcomes in clinical trials included a 20% incidence rate of paresthesia, a 5% incidence of high blood pressure and a 12% incidence of back pain) and lack a generally accepted treatment protocol, but nonetheless we’d like you to give them a try.
This is basically what Aetna has in mind. They essentially made a list of all the things wrong with wellness programs — unwanted interference in people’s lives, playing doctor, unproven therapies, opaque relationships with “recommended” suppliers, high expense and “diagnosing” people who aren’t sick — and packaged them all into one press release (1/14/14).
This release came out after our e-book, and we considered holding our two cents for Surviving Workplace Wellness: The Sequel. Yet naïve optimists that we are, we decided that by the time any sequel would be published, wellness will have gone the way of the Edsel, pet rocks, Netscape, colon cleanses (we hope) and Sarah Palin (see “colon cleanses”), thus rendering us obsolete along with the rest of the industry. Hence we are squeezing them into an epilogue now.
To summarize, Aetna is pitching specific name-brand drugs — not just any name-brand drugs but name-brand prescription drugs that consumers have rejected (Arena’s Belviq and Vivus’s Qysmia) to the point where one Wall Street analyst described them as ”flailing” — to “selected Aetna members” who aren’t even sick, just obese. So this is a wellness first two different ways. No health plan has ever pitched name-brand drugs to its members before, let alone to members who aren’t sick.
But wait…there’s more. Because it’s likely that not a lot of obese people would ever call Aetna to ask: “What specific flailing drugs from manufacturers you’ve made side deals with would you recommend for me even though I’m not sick?” Aetna isn’t taking any chances by just sitting by the phone. Instead, it is providing “outreach” to those members (maybe not using that exact letter above but not far from it) — combined with an incentive that is really hard to come by, a totally free app — to convince people to take these drugs.
In your eagerness to get this free app and lots of drugs that don’t work, you’re probably asking: “How do I get to be a ‘selected Aetna member’? I bought a policy from them.” Haha, good one. You didn’t seriously think Aetna would actually spend its own money covering its own insured members for its own program covering its own partners’ drugs endorsed in its own press release, did you? Hello? Have you actually read this book? Obviously, Aetna executives don’t believe this program can save money any more than you and I do, so participation is a privilege they reserve for their self-insured employer customers who want to follow Harvard Professor Katherine Baicker’s advice in Chapter 3 to ”experiment” on their employees, taking the advice a step farther by using flailing drugs.
After you’re done wondering how something could be good enough to sell to Aetna’s customers but not for Aetna’s insured members themselves, you may also be excused for then wondering whether Aetna knows anything about weight control in the first place, as the release demonstrates a failure to understand the difference between short-term weight loss and long-term weight loss maintenance, an overreliance on anecdotal outcomes and an insufficient disclosure of product side effects.
However, the misunderstanding of the basics of study design and weight control — along with the ignoring of any consequences of Aetna’s actions such as any potential liability if these drugs turn out to be another fen-phen (phentermine of fen-phen fame is one of the two active ingredients in Qsymia) — is not the lead here. The lead here is that Aetna is playing doctor with a license it doesn’t have, pushing drugs that no one seems to want on people who aren’t actually sick, without even taking the financial consequences of its own actions but rather foisting those consequences on the very same employer customers whose financial risks and whose employees’ health it is supposed to be protecting.
Now you see why we couldn’t wait for the sequel even if there is one, and why there’s likely to be one.
Understanding why wellness has failed requires a brief history lesson of the wellness provision of the Affordable Care Act (ACA). The wellness provision was based on the success story at Safeway and a seminal article in Health Affairs — both of which turn out to be made up.
To begin this series on the failure of wellness programs, let’s look at Safeway, which is so central to the ACA wellness provision that the provision is sometimes called the Safeway Amendment. The Safeway CEO, Steven Burd, claimed to have reduced healthcare spending by 40% using a wellness program. He wrote an op-ed in the Wall Street Journal, testified before Congress and became friends with President Obama even as Sen. John McCain also cited Safeway as a role model. The slight problem with all of this: Safeway’s claim was absolutely, unequivocally, made up.
A front-page article in the Washington Post pointed out that the wellness program didn’t even exist at the time Safeway’s healthcare costs fell. Instead, the decline in corporate spending was because of the implementation of a high-deductible plan, shifting cost to employees. (Curiously, once Safeway actually did implement a wellness program, its health spending rose faster than average. This was probably a coincidence because, even today, only a small fraction of Safeway’s workplace participates in the program.
Next came the seminal article in the prestigious journal Health Affairs, written by equally prestigious Harvard economists Katherine Baicker and David Cutler. The article was titled, “Workplace Wellness Programs Can Generate Savings.” Not “could possibly generate savings” or “may generate savings on a good day,” but “can generate savings.” These economists reviewed all the published evidence and reported quite a definitive “3.27-to-1” return on investment from wellness.
This article is easily invalidated on two points. First, the overriding rule of a study is that it must be replicable. This article was published four years ago and has yet to be replicated. Quite the opposite: Every subsequent article in Health Affairs has shown that even with the most generous assumptions imaginable, like leaving many elements of cost out of the ROI calculation, wellness doesn’t save money.
Second, in July, lead author Baicker had enough sense to walk back the article’s conclusion, saying on NPR’s Marketplace that “it’s too early to tell” if there are savings. She also said that employers need to “experiment” to “see what happens with weight and blood pressure.”
Besides the retraction, two other things about this interview invalidate wellness:
Biostatistics 101 states that the smaller the effect, the larger the population needed to show it. To admit after decades of wellness programs involving millions of people that “it’s too early to tell” means that whatever effect there is (if any) would be very subtle, so subtle that it couldn’t possibly merit an entire industry and significant workplace disruption to achieve it.
Except at the extremes, for which a companywide wellness program isn’t needed, “weight and blood pressure” have almost no effect on corporate healthcare spending. Corporate spending on overweight people, during their working years, may be greater than for thinner people (the evidence is mixed), but there is no evidence that weight loss across an employee population can be maintained, and the reverse is usually true—most people who lose weight regain it. Controlling blood pressure is far more likely to increase corporate spending than reduce it. Rates of stroke in the working-age population are disappearingly low to begin with, and the cost of a stroke is far lower than the cost of controlling the blood pressure of 1,000 employees to prevent one. (Some companies will say they are “medicalizing their workplaces” for humanitarian reasons and not to save money, which is laudable…though, as subsequent installments in this series will show, misguided. In any event, the article was about saving money.)
Along with Safeway’s lie and Baicker’s retraction comes the Business Roundtable’s hypocrisy. The Business Roundtable was and is the major lobbying force in favor of wellness. Claiming they want to “help people” and “foster a culture of health” for “employees and their families” while opposing ACA and the minimum-wage increase is not even the hypocrisy here. The hypocrisy is that the head of the Business Roundtable’s health committee, Gary Loveman, is also the CEO of Caesars Entertainment. In that “day job” running a chain of casinos, he poisons more employees with second-hand smoke than any other CEO in the U.S.
Perhaps he feels that health hazard is more than offset by the meaningless seven-point reduction in blood pressure that he says wellness has achieved for the small segment of active participants committed enough to stay with the program. (He didn’t measure the dropouts and non-participants, whose results may not have supported his narrative.) A skeptic might therefore conclude that Business Roundtable CEOs support wellness only because it provides an excuse to dock some workers 30% of their health premium, and pocket it themselves.
To wrap up Part One, the entire premise of employers “playing doctor” by medicalizing their workplaces is invalid. It is no wonder, then, that the science and outcomes are made up, as well – those are topics for future installments. However, if you stay with this series (or cut to the chase and read the book), you’ll find that there are solutions, and those solutions incorporate everything that wellness doesn’t – science, morale and cost-effectiveness – while emphasizing the role of the broker and consultant in designing the benefit.