Tag Archives: wellness

5 Ways to Snooker Employers on Diabetes

The diabetes industry is far more sophisticated than the wellness industry when it comes to dramatically overstating outcomes and savings. Excluding vendors by the Validation Institute like It Starts with Me and US Preventive Medicinewellness industry claims can easily be shown to be fraudulent. It’s equally easy to back that assertion with a $3 million reward, knowing that no wellness vendor or consultant or “guru” will ever try to claim it, even though I’ve made it ridiculously easy, accepting the burden of proof and only allowing myself to pick one of the five judges.

By contrast, unlike the more transparently dishonest wellness industry, the diabetes industry’s “outcomes” can only be challenged, rather than simply invalidated on their face. And no way I’m offering a reward. (I’ll make an even-money bet, though – same rules.) There could be actual savings from these programs, but these five examples of biostatistical sleight-of-hand suggest that those actual savings, if any, are far more modest than claimed savings.

1. Conflating verb tenses

Here is a claim by a diabetes prevention vendor showing ROI on its program. One would be excused for thinking that these results had actually been achieved and validated, given the choice of verb tense in the graphic:

Looking harder at the language, note that the phrase is “recoup their investment,” not “were validated by the Validation Institute as having recouped their investment.” Yet the verb “saved” is in the past tense.

And the heading says: “How quickly employers recoup,” whereas the only article cited in the footnote analyzed Medicare patients, whose chronic disease are far more advanced.

Further, digging into the actual article (financed by the vendor) yields the following sentence [emphasis mine]:

We used a Markov-based microsimulation model in which a person’s characteristics are used to predict health outcomes in the upcoming year.

Elsewhere the article says:

We applied 26-week weight loss results to simulate potential health and economic outcomes 

Therefore, this entire claim is based on a predictive simulation model that somehow morphs into a clear statement showing precisely $1,338 “saved.”

Speeding up time

As can be seen from that graphic, this particular vendor is claiming a huge ROI in two years for employees with pre-diabetes. However, the Centers for Disease Control and Prevention says:

One in 3 adults in the United States has pre-diabetes (fasting blood glucose, 100–125 mg/dL); 15% to 30% of those adults will develop type 2 diabetes mellitus within 5 years.

See also: Diabetes: Defining Moment of a Crisis  

So only a small minority of pre-diabetics will develop diabetes in five years. And then, of course, it would take years for avoidable complications to develop even if no one “manages” the newly diabetic employees to avoid them.

How, then can $1,338 of expenses per participant be claimed to be avoided by keeping these employees from getting sick in a measly two years when most of these employees aren’t going to be sick five years from now even without an intervention?

Comparing participants to non-participants

Speaking of “participants”…

Let’s be very clear: Whenever you see the word “participants” in a study report, the claimed outcome is vastly overstated.  Participants will always outperform non-participants, regardless of the intervention. The National Bureau of Economic Research proved this using a randomized control trial. Further, on three other occasions, biased researchers trying hard to prove the opposite accidentally showed that 100% of their apparent “savings” were attributable to participation bias, meaning 0% to the program. (The bias won’t always account for 100% of the claimed savings, of course.)

The best example of this bias? A Koop Award-winning wellness program accidentally revealed that participants hugely outperformed non-participants even when there was not a program to participate in. In this slide, note the X-axis. The groups were separated in 2004. The program was implemented in 2006. During the two years between separation and implementation, the participants “saved” almost 20% vs. the non-participants by doing nothing.

This isn’t a secret. Participation bias is well-known to insiders in the diabetes industry. Yet every single diabetes vendor ignores this bias (or “matches” participants to some medical charts), while most also fail to disclose the dropout rate – and the fact that most employees who drop out of programs do so because they aren’t getting results.

Projecting participants’(!) short-term weight loss into the future

Essentially all of them do this, too. Very large-scale studies have shown that only the smallest percentage of people who lose weight keep it off. There is no reason to think that somehow a few diabetes vendors have unlocked the key to long-term weight loss that has eluded the rest of the world and all academic researchers, especially when the vendors don’t follow employees for the long term or count dropouts.

Rhetorical and arithmetical sleight-of-hand

This single set of claims from a diabetes vendor looks quite impressive at first glance:

Now look at it again, paying special attention to the underlined words:

Once again, there is that word “participants.” That is just the tip of the invalidity iceberg. Six variables were tracked…and yet 27% of active, motivated participants weren’t able to reduce any. Randomly, three should decline. And many of the other 73% of participants could reduce only one…and this is considered successful?

Further, these statistics look like averages on first glance –but they are not. They are examples (“improvements such as”) of reductions that maybe a few participants achieved. I can guarantee that, absent statins, virtually nobody reduces triglycerides by 29%.

Regression to the mean

Diabetes vendors often split the population into high and low utilizers and claim credit for reductions in high utilizers (whom they manage) while counting the utilization increase in low utilizers toward their “savings” — as though last year’s high utilizers also would have increased had it not been for the program.

In this case, there are two giveaways that the 59% decrease in admissions is totally or mostly regression to the mean. The first giveaway is observing which diagnostic categories account for the bulk of an employer’s admissions. This is the top 10 list, in descending order. (“Del” means “delivery.”)

To begin with, the majority of admissions on this Top Ten list – and about a third of all employer-paid admissions — are birth events, not affected by a diabetes program.

You don’t see diabetes on this Top Ten list. That’s because diabetes itself  in the last year for which complete data is available accounted for less than 1 admission per 1,000 commercially insured people (126,710 admissions in about 150 million privately insured people). Diabetes admissions don’t even crack the top 25. Because total employer-paid admission rates are about 50-60 per 1,000, eliminating every single diabetes event would decrease admissions by – get ready — about 2%.

See also: Putting Digital Health to Work  

Reducing admissions by 59% would require wiping out not just every diabetes admission but also almost every admission not related to childbirth. The vendors might argue that temporary weight loss and eating better reduce other admissions, too. However, the only non-childbirth events in the top 10 are septicemia, joint replacements and pneumonia. Good luck crash-dieting your way out of those.

The other giveaway that this seemingly impressive “decrease” is regression to the mean is that the non-program-members (the vast majority of the population here) regressed upward to the mean. There is no reason to think that admissions in the average employee population are going to increase 4%. Over time, inpatient admissions in the commercially insured population are falling.

Using a selection methodology that is partly dependent on having high claims in the baseline assures both this apocryphal 55% “decrease”– and the equally apocryphal 4% increase in non-member admissions.

For instance, about a third of all heart attacks occur in people who did not have a pre-existing CAD diagnosis. Therefore, if you “manage” patients with diagnosed CAD, you will show a one-third reduction in heart attacks in that population, simply because you didn’t tally the heart attacks in the cohort you didn’t manage.

Then you’ll separately tally the employees without a pre-existing document CAD diagnosis, note the increase and say: “See how fast heart attacks increased in the population we didn’t manage.”

The right answer, of course, is to add the heart attacks in both cohorts back together. Naturally, you’ll find no reduction at all.

Coming soon: What is the Solution?

The next installment will cover how you should measure outcomes to avoid being taken advantage of and to see what really does happen in your population when you implement a diabetes prevention program.

The Evil Genius of a Wellness Program

Arkansas recently contracted with an out-of-state vendor called Catapult Health to come in to the state’s schools and “play doctor” with the teachers, asking them personal questions, taking their blood and then telling them everything that’s wrong with them. This is a classic example of a “pry, poke and prod” program.

This is followed by admonishments to take more steps and eat more broccoli. The program then refers teachers into lifestyle and disease management programs “at record rates.”

Sounds terrible, but the good news is that this program isn’t going to cost taxpayers anything because, as Catapult Health’s website says:

Phew! At least it’s free to taxpayers because Catapult’s expenses and profits are “already in your budget” and “fees are processed through your health plan.”

Except that the state of Arkansas is its own health plan. There is no “Don’t worry. Insurance will pay for it” here. The state is self-insured, meaning it picks up the tab, not some nameless insurance company.

But, hey, at least this program will save money, right?

The return-on-investment for the state is allegedly 3.27-to-1, as shown by the so-called “Harvard Study,” conducted by Katherine Baicker.

Except that the Harvard study has been proven wrong, not just by the nonprofit, nonpartisan highly respected RAND Corporation (and I myself chimed in, as well), but by an ace researcher named Damon Jones, part of the prestigious National Bureau for Economic Research. His work showed that wellness accomplishes virtually nothing other than the expenditure of money. (Don’t worry—insurance will pay for it.)

See also: Wellness Vendors Keep Dreaming  

But, hey, maybe Professor Jones is wrong. After all, why should he care what Professor Baicker thinks, right?

Um, because he reports to her? Yep, he’s an associate professor at the exact same school of public health where she is now dean. Just guessing here, but it would seem a subordinate would have to be pretty darn sure of his findings (and they are rock solid, and completely in agreement with all the other recent research, summarized here) to publicly humiliate his own dean.

Even Baicker doesn’t defend her findings any more. She says: “It’s too early to tell.” That means she is running away from her very widely cited signature study, upon which essentially the entire wellness industry’s economic justification is based. This would be like Arthur Laffer, whose Laffer curve created supply-side economics, which has been used to justify two tax cuts, saying, “Well, maybe it’s not right. I dunno. Let’s wait and see.”

But, hey, at least forced wellness improves employee health, right?

Apparently not. Forcing people to get annual wellness checkups doesn’t benefit them, according to the New York Times, the New England Journal of Medicine, the Journal of the American Medical Association and Consumer Reports. (Before dismissing the credibility of those sources due to possible political bias, keep in mind that Newsmaxthe Federalist and Laura Ingraham hate “pry, poke and prod” programs, too.)

Forced wellness also takes teachers away from the classrooms to be pried, poked and prodded, stresses them out and hurts morale.

Further, sending “record rates” of employees into lifestyle and disease management is classic hyperdiagnosis – braggadocio-fueled misunderstandings of the arithmetic of lab results, resulting in large numbers of people getting told they need coaching and care they don’t want or, in general, need. Nothing makes a wellness vendor happier than to hyperdiagnose as many employees as possible.

But, hey, maybe teachers are a special case. Maybe the impact of “pry, poke and prod” programs is different for them?

It sure is. The single school district for which the data has been compiled is Boise, Idaho. According to the wellness vendor’s own data, the health of the teachers got somewhat worse as a result of this pry, poke and prod program. (The vendor, an outfit called Wellsteps, also admitted that it flouted clinical guidelines and fabricated its only positive outcome. The company also previously admitted that costs went way up as a result of its program. The company later suppressed that admission. Wellness vendors are not known for their integrity.)

So the health of teachers may deteriorate, creating more medical expense. but don’t worry. Insurance will pay for it.

But, hey, at least the teachers like it, right?

According to Catapult, employees love the program. Ask the employees, and you might get a different impression. Indeed, I was tipped off to this program by an Arkansas teacher who hates it, like most of her colleagues do — and that’s before they learn that they are actually paying for it…keep reading.

Obviously, if teachers wanted to submit to a “pry, poke and prod” program, the state wouldn’t have to threaten them with massive fines – almost $1,000/year, which appears to be close to a record for any “pry, poke and prod” program anywhere — for refusing to let a private, out-of-state corporation play doctor on them at state expense.

But, hey, at least the state taxpayers save money by fining the teachers who don’t want to play doctor, right?

Actually, wellness makes claims costs go up, probably by more than the fines. There are lots of unneeded lab tests and other tests. For instance, the state of Connecticut admitted that, in addition to throwing away all its money on the actual wellness program, the state spent more on health care. The state comptroller who administered the program said the increased spending was “a good thing.” I guess he wasn’t worried because insurance was paying for it.

See also: Ethics of Workplace Wellness Industry  

But, hey, at least the teachers don’t pay for it.

Actually, they do. The state’s human resources department brilliantly figured out that it could launder its wellness spending by hiring this outfit. By paying extra to Catapult (a multiple of what an effective wellness program would cost), the state is able to pick up the tab for wellness using the extra paperwork of a medical claim, as opposed to an outsized administrative expense in a separate line item. The latter would clearly need to be picked up by the taxpayers…and the state would have an incentive to control this highly visible figure.

By contrast, paying for “pry, poke and prod” as a medical claim will never be noticed, like Steve McQueen and David McCallum sprinkling the dirt from the tunnel around the stalag. On the other hand, the program will increase overall medical spending by 2% to 3% (the cost of the screening plus the added hyperdiagnosis expenses).

Here comes the evil genius part: At the next contract negotiation, the state can limit wage increases (or reduce benefits) by pointing out how high the health spending is.

So the teachers get pried, poked and prodded, hyperdiagnosed with hidden illnesses most of them don’t have – all against their will…and then they have to pay for the privilege in reduced wages.

Wow…the teachers are getting screwed. But, hey, at least they can’t sue the state, right, so taxpayers won’t have to pick up that bill, as well?

Starting in January, this program will be in blatant violation of two laws, the Americans with Disabilities Act and the Genetic Information Non-Discrimination Act. Those laws disallow forced wellness checkups but allow so-called “voluntary” ones.

Until recently, “voluntary” meant “do wellness or pay a big fine” like this one. But thanks to a lawsuit by AARP, the rules are changing in January so that “voluntary” must mean voluntary, like a dictionary would define the word.  (This summary has the links to all you need to know about the case.) To get these fines back, teachers will be able to sue the state, possibly even as a class action, and possibly being awarded punitive damages. Exposure to lawsuits could cost the state millions more in addition to its current expenditure on Catapult Health.

And that doesn’t even cover the costs of a possible teacher walkout, like the one in West Virginia that was spurred in part by – you guessed it – the wellness program.

But, don’t worry. Insurance will pay for it.

Why We Should All Keep Drinking

Apparently, the wellness industry does not have a monopoly on invalid research.

A study came out in The Lancet–the British equivalent of the New England Journal of Medicine — finding that the only safe level of alcohol consumption was: none.  As the principal investigator said: “Alcohol poses dire ramifications for future population health in the absence of policy action today.” This finding generated myriad headlines like this one at CNBC:


And how often do those two outlets agree with Fox News?

One thing you learn if you hang around wellness promoters long enough is that oftentimes a close perusal of the study in question shows the opposite of what the authors intended. Or, as we often say: “In wellness, you don’t have to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself.” And the same is true here.

For example, Denmark leads the world in the number of drinkers — and has life expectancy higher than about 90% of the world’s countries. The lowest alcohol consumers? Pakistan — which ranks #130 in life expectancy. You might say: “Wait, aren’t there many other factors involved in life expectancy?” And the answer is, of course there are. None of those were controlled for in any way in this meta-analysis.  To begin with, the more people drink, the more other unhealthy habits they are likely to have.

But that’s not the crux of what is wrong with this study. Two other things should lead wellness professionals to the opposite conclusion: that light drinking is perfectly OK. The remainder of this post addresses those.

Absolute risk vs. relative risk

Absolute vs. relative risk is one of our (many) pet peeves. Here are two other examples that we have had to smack down:

  1. The American Cancer Society warns of a 22% increase in colon cancer among people under 50, but it turns out that absolute rate of colon cancer in younger people is so low that the chances of your life being saved by screening at age 45 are about the same as your chances of being struck by lightning.  The media had a field day with that one, too.
  2. Before that, speaking of colons, a study came out showing that red meat increased risk of dying from colon cancer. Once again, it turned out — using the data right in the study — that more people are killed by lightning than by colon cancer due to eating more red meat than average.  Yet, once again, the media had a field day.

From the media’s perspective, this makes sense. After all, who is going to click through on a headline that says: “Low-quality study finds trivial relationship between variables”?

See also: 2 Studies of Why Wellness Fails  

In the case of this alcohol study, looking behind the headlines proved equally insightful. (And thank you to Aaron Carroll of The New York Times‘ Upshot for suggesting it.)

Here is the lead-in:

Alcohol is a leading risk factor for death and disease worldwide, and is associated with nearly one in 10 deaths in people aged 15-49 years old, according to a Global Burden of Disease study published in The Lancet that estimates levels of alcohol use and health effects in 195 countries between 1990 and 2016.

Based on their analysis, the authors suggest that there is no safe level of alcohol as any health benefits of alcohol are outweighed by its adverse effects on other aspects of health, particularly cancers.

Read the first paragraph again. Two observations:

  1. Almost no one dies between the ages of 15 and 49, so being responsible for “nearly” 10% of those deaths means that alcohol kills about 0.001% of people in that age bracket every year.
  2. The authors have conflated two things: alcohol and excess alcohol. Virtually all of those deaths in that age bracket were due to the latter, a fact that the authors conveniently overlooked when demonizing any level. of consumption.

Reading a bit further in…

They estimate that, for one year, in people aged 15-95 years, drinking one alcoholic drink a day [1] increases the risk of developing one of the 23 alcohol-related health problems [2] by 0.5%, compared with not drinking at all (from 914 people in 100,000 for one year for non-drinkers aged 15-95 years, to 918 in 100,000 people a year for 15-95 year olds who consume one alcoholic drink a day)

Hello? A 0.5% increase in relative risk? And the increase in absolute risk (not calculated) is four per 100,000 people a year — or 0.004% a year.  Even two drinks a day increases absolute risk only by 0.06% a year. (Once you get beyond two drinks a day, the chance of harm accelerates exponentially…but that’s not news.)

What the he** are employees going to consume instead?

Our biggest beef with this study is the same as with just about every wellness program: Everything is off-limits. Even foods that are OK in moderation for most people — like full-fat dairysalt, oils, cholesterol/eggs and red meat — are singled out for criticism by health risk assessments. And now alcohol.

Unfortunately, the more foods you demonize, the less likely it is that any employee will pay any attention to any of your dietary pronouncements.  And to the extent they do. well, what are they going to eat instead? Here is Cerner telling people that non-fat yogurt is a “healthier choice.”  Trivia question: What added ingredient makes nonfat yogurt taste good?

Here is Optum railing against oils:

And Cerner, once again, this time incriminating dietary cholesterol, which of course has no impact on blood cholesterol for most people:

Finally, here is Interactive Health hyperventilating about something-or-other in its HRA feedback to an employee. We don’t know what it is other than, given the provenance, it’s wrong. Fortunately, no employee is going to plow through this anyway.


Treat this alcohol finding the same way you would treat advice from most health risk assessments: ignore it.

‘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.