Al Lewis is an outspoken voice in health care and workplace wellness. He is the author of several books on these topics including Why Nobody Believes the Numbers: Distinguishing Fact from Fiction in Population Health. He has founded and held senior positions at a variety of health-related organizations including the Population Health Alliance. Al’s latest endeavor Quizzify is one of only a few population health companies to measure its outcomes validly and guarantee savings for the organizations it serves.
1) Your graduate focus at Harvard was law. Before you discovered that most health-care measurement methodology is flawed, what was the initial impetus that led you to the pursuit of exploring, examining and developing a career that revolves around health care and corporate wellness?
I went from Harvard Law School and I was going to become a lawyer. I stumbled into this recruiting session for a consulting firm and there was this guy giving a recruiting presentation and I was just mesmerized by it. The guy was a manager at Bain and Company by the name of Mitt Romney. I applied for a job at Bain and I didn’t become a lawyer.
I worked at Bain for eight years and toward the end Bain was imploding at the time. I jumped ship and went to work at a health-care company and that’s how I got into health care. Then, I stumbled into a job as a Chief Executive and Chairman of a NASDAQ health-care company called Peer Review Analysis in 1993. In 1995, we merged with another company and I had to find another job. Once again, I kind of stumbled in a new role, this time in disease management, but I figured out that there was an opportunity there, especially in the Medicare population. There was so much chronic disease and yet doctors were getting reimbursed very little. Primary care doctors were getting reimbursed very little and there was nobody watching patients between visits.
At the time, I thought there was an opportunity for disease management and I started the company Disease Management Purchasing Consortium. During that time health plans — and to some extent employers — just jumped onboard. I started basically putting these programs in place, and was doing that merrily until somebody came along and essentially said that my measurement was wrong and that, in fact, disease management saved much more money using something called “prospective identification,” some wacky methodology that their actuaries told them to use. The belief is that they were actually saving a lot more money. I thought, this doesn’t look right. So, I sat down with a spreadsheet and compared my methodology to theirs and, guess what? My methodology overstated the savings and so did theirs. In my book Why Nobody Believes the Numbers I compare prospective identifications, annual requalification, and it turns out both overstate savings and you have to do something different altogether.
When I went back and looked at all the numbers I’d put together for people, they were all wrong. The savings didn’t exist. So, apparently, it is perfectly fine with other people to do this, but it was not fine with me. What happened next is detailed in the 2007 blog post: A Founding Father of DM Astonishingly Declares: “My Kid is Ugly”.
Since then, after writing Why Nobody Believes the Numbers, I basically went rogue and started naming names, built They Said What?, I call out the liars, etc. But, it wasn’t my first choice. I was essentially forced into it. I mean Rachel Carson wrote to Monsanto and pointed out the hazards of DDT very nicely and they didn’t do anything. So, that’s when she went rogue. I basically did the same thing, except that in my case, it’s more [Silent Spring author] Rachel Carson meets Dave Barry.
2) In a recent article about the folly of content curation and the way information now gets disseminated, the author Katie Herzog argues that in the age of the Internet we often herald things that distort the bigger picture. Beyond the frustration you have publicly shared that Baicker’s seminal research is continually used to support the efficacy of employee wellness programs, how does an organization effectively find the signal within the noise? How do you believe organizations should define success?
First, let’s define wellness as two types of wellness, wellness done for employees and wellness done to employees. Now, wellness done for employees is basically not quantifiable. It is things that employees want to do, and you are making it easy for them to do it. Maybe they want fitness facilities. Maybe they want better food. Maybe they want flex-time. Whatever it is, it is not things that they have to be bribed to do or punished if they don’t do. And that’s the big difference between wellness for and wellness to employees. I don’t think there’s anyone who objects to wellness for employees. I’m a big fan. But, what the Affordable Care Act is about and what the controversy is about is wellness done to employees.
The thing about wellness done to employees is that the results have to be quantitative to justify the expense. Wellness done to employees, you have to either bribe employees or fine them into doing it. If somebody likes something, they’ll do it for free. Coercion damages morale. This is, by the way, is according to a Health Education Research Organization (HERO) report.
HERO are the ones who admitted the morale impact, but you don’t have to be a rocket scientist. Just look at the comments on essentially any article in the lay media about wellness and it is all negative. So, advocates of wellness done to employees have to justify it with math. Math is shockingly easy to do.
Regarding math, some people do it, but many people don’t. Consultants don’t like it because they can’t really charge that much for it. In this case, done right it also shows the opposite of what they expect. You can start with page 22 or 23 of the HERO report that lists a bunch of diagnoses which have corresponding ICD-9 codes. HERO didn’t list them, but anyone who wants them can get them from me. I’m happy to send them. The June posting on the Quizzify blog has a Wellness ROI template all ready to go that has the ICD-9s in it.
The HERO report did their own ROI analysis and they found $.99 in in savings per employee per month from reduced hospital admissions. That, by the way, was without adjusting for the fact that many of the costs at the population level are coming down anyway. So companies are actually turning out an entire wellness program to save $1.00.
Now, you have to subtract the cost of the program. Let’s say the program is $1.50 an employee a month. Good luck finding a wellness program that cheap. Most start at $100 a year per employee. So, then you compare the cost of the program to the reduced claims cost, and that gives you your best-case scenario for savings. I say best case because you have other costs of wellness besides the vendors, consultants, and lost work time, and that kind of thing.
So to somewhat answer your question, you cannot define success by monetary savings. That’s why I’m offering a $1 million reward to anyone who can show that it does, because it doesn’t. My million dollars is very safe.
3) In a recent interview with James Pshock from Bravo Wellness, Pshock resurfaced something for me that I think is at its core, true. Organizations — when they begin as entrepreneurial endeavors — are not generally created to shoulder the burden of employee health care. This is a burden progressively being assigned to enterprise through policy — although few would disagree that a business should be concerned with the well-being of their employees. Based on your experience and opinion of workplace wellness, what do you believe is the obligation of an employer when it comes to employee well-being?
As an entrepreneur, my job is basically to not put up roadblocks, to stay out of their way, and to be responsive if they have health or personal issues. The staff I have at Quizzify is dedicated, highly productive, motivated.
I don’t have an “obligation” to provide for their well-being per se. But, if I don’t provide for their well-being, either their productivity might suffer or they’ll go somewhere else. So, I don’t need to be told by the ACA, by Congress or the President what I can and can’t do with my employees. I’m going to do the best thing for my employees regardless.
The absolute, positive, last thing that I would ever do to my employees is institute a pry, poke, prod, and punish wellness program. It would cost me money. It wouldn’t save me any money. It would damage their morale. And it would drive a wedge between me and them.
Since you brought up Bravo Wellness, if you go to my expose of their previous website (which they bowdlerized following my exposé) they were essentially bragging about how they can save an organization money immediately by “fining” employees. They also spend a lot of time talking about their appeals process. I would not — in a thousand years — put in a wellness program where I fine my employees for things that have nothing to do with work, where a wellness program was so unpopular that I needed an appeals process to get out of it. Not to mention the very questionable screens they want to run on your employees.
4) In some of the assertions you make regarding the folly of using motivational tools to promote wellness you’ve used Penn State as an example of how things can go wrong when an organization utilizes extrinsic incentives in an attempt to persuade employees towards better health. In a recent WellSteps seminar, Dr. Steven Aldana said that after checking in with Cassandra Kitko, an adjustment was made at Penn State that merely repositioned the penalty as a reward? In other words, little has changed there although the remarketing of economic incentive has muffled the criticism. In your experience have extrinsic motivators ever been effective? Or, in your opinion, are economic incentives always going to be “forced wellness”? If yes, how? If no, why do you think that is?
Dr. Steven Aldana is not one for fact-checking. He has called me a liar before, but has never provided an example of where I have allegedly lied. I don’t mind. As you can tell, I love the fact that he’s calling me a liar. The truth is Penn State’s original program is gone. It’s done. There’s no spinning of that statement. His statement is incorrect and I’m pretty sure he knows that he is incorrect. If you look at Dr. Aldana’s website, he’s got a wellness ROI calculator. If you put in zero for “annual cost increase”, it doesn’t matter what other variables you put in, by the year 2020, you always save $1,359 an employee. So, he essentially made it up.
In terms of extrinsic motivation, I actually do find that there is a place for extrinsic motivation. The thing about extrinsic motivation is that it only works once. It works to get somebody to try something. And, after that, they have to like what they are doing … they have to want to do it on their own. Otherwise, you simply have to basically keep paying them, and paying them, and paying them to perform the desired behavior. I, myself, was extrinsically motivated to do something healthy once. In fact, ironically — and here’s the fun part. This is that NASDAQ company I was telling you about, Peer Review Analysis, and we were going to switch to self-insurance. I looked around, and we had a lot of nurses there. Nurses, ironically, have horrible health habits. So, I thought: well, if we are going to go to self-insurance anyway, I should have a fitness contest and give people $50 as a reward for participating in fitness activities. What happened is that, of the 100 people in the company, the same 20 who played on the office Frisbee team and the volleyball team were the same people who signed up for this program. The other 80 could have cared less. I, myself, signed up for the program. What I started doing was, out in the western suburbs here of Boston, is I started riding my bicycle to work in mid-town to collect the $50. Well, guess what? That was 1994 and, essentially, every trip I take from mid-town Boston that doesn’t involve snow, rain, or dead of night, I do on my bicycle today because I basically paid myself $50 to do it once and I loved it!
So, I think motivation has a role, but it’s a role of trial and it’s a role of doing something once. It’s not a role of continuing to raise incentives until you get someone to do what you want them to do. We don’t need to force people to do things that they just don’t want to. It is not good for companies, and it is certainly not good for employees.
5) One thing I have found challenging about the recent affinity the workplace wellness industry has had with BJ Fogg is that his popular behavioral model softens the importance of environment. It takes the work of Kurt Lewin and then glosses over the significance of external factors. As a layman of your work, I get the sense that you also advocate that wellness “wins” can be made through environmental design. Is my assumption correct? And in addition to this assumption, right or wrong, where else do you see organizations getting it right?
Yes, without question. I am far from an expert in this field. In my opinion, what you want to do as a company, and if you listen to the wellness industry they advocate this, too, it’s all about creating a supportive culture. As the leader of a company myself, what I’m trying to do is I’m trying to make my organization be as valuable as possible. Part of that is creating an environment where people want to come to work. But, ironically, wellness vendors have essentially nothing to do with creating a culture that makes people excited to go work. To the contrary, the evidence shows many of these types of programs create cultures that do the opposite.
Simply being mindful of environmental factors can have a huge impact. I have an excellent example of that in my book with Tom Emerick, Cracking Health Costs. Back to Peer Review Analysis — it’s going to sound silly — after employees complained about the conditions of our bathrooms I contacted the management of our office building we were in and asked, “How much extra would I have to pay you to clean the bathrooms twice a day?”
We came to an agreement and I paid them probably less than what would have financed a wellness program for probably 20 people. So, for the cost of the wellness program for 20 people, I had the restrooms cleaned twice a day and I don’t think there was an employee in the company who didn’t take notice and was grateful.
What did this accomplish? The organization was telling the employees they mattered. And you weren’t telling them by making some pronouncement that they mattered or by giving them lunch once a month. What you were telling them on a daily basis, doing something very unglamorous — I mean you can’t get more unglamorous than that — is that they matter.