Re-Establishing Health Care Trust
Brian Klepper, PhD
A couple weeks ago a Journal of the American Medical Association article reported the results of a large (33,000 employees) rigorous study of worksite wellness programs. As explained in The New York Times, the research “found no significant differences in outcomes like lower blood pressure or sugar levels and other health measures. And it found no significant reduction in workers’ health care costs.”
The study’s findings are important because they fly in the face of conventional employee health benefits doctrine over the past couple decades, which has steadfastly maintained, based on spotty evidence, that corporate wellness programs improve health outcomes and reduce cost. The study’s release vindicates health outcomes expert Al Lewis, who has relentlessly waged a single-handed campaign against the slipshod analytical methods the $8 billion wellness industry has marshaled to produce its evidence.
Time and again, Mr. Lewis has poked holes in rosy results, typically by showing the errors in their assumptions and arithmetic. Along with wit and humor, his most formidable weapons, his black and white, cold facts approach to dismantling their claims has been both disarming and effective. He has famously offered a $1 million prize to anyone who could show that his analyses are flawed.
Wellness’ value has been a particularly difficult promise to debunk, because it’s seemingly so straightforward and sensible on its face. Who could resist the idea of investing in healthier lifestyles for employees and their families to bring solid returns in patient engagement and lower rates of chronic diseases? Worse, wellness took the $700 billion employee benefits market by storm, leaving many employer benefits managers convinced that, by deploying prevention programs, they were doing what they could to optimize health outcomes and cost. So they were diverted from and ignored the much larger care/cost management opportunities in areas like musculoskeletal, cardiometabolic, imaging, surgeries, claims review and drugs.
This is no small thing. A respected, still relevant 2008 PricewaterhouseCoopers report, The Price of Excess, estimated that more than half (54.5%) of all health care spending delivers no value. Overpromising, under-delivering, excess and egregious unit pricing have become epidemic business tactics throughout the entirety of the vast health care industry. Many health care organizations exaggerate their performance claims and offer little or no value, well aware that it is next to impossible for purchasers to check them. Until recently, there has been no independent, third party to dive in to determine whether their data sources, metrics and calculations are credible and accurate.
Health care is a big place, of course, and the opportunities to provide low value or dramatically overpriced services and products without scrutiny are everywhere. Deceptive approaches that lead to overtreatment and excessive cost are rampant. A significant scientific literature documents that about half of all procedures delivered in musculoskeletal care are unnecessary or inappropriate. The numbers are similar in cardiometabolic care, where despite a mountain of evidence, lucrative procedures like coronary stenting in stable patients are still widely used, though they’re no more effective than optimal drug therapy.
In cancer, as many as two-thirds of drugs approved by the FDA in recent years have received that approval without evidence that they improve health outcomes or result in longer life. Health plans knowingly approve and pay for surgeries that are unnecessary, and keep the offending surgeons on their networks. In a worrisome trend, several highly respected health systems now offer stem cell procedures, without evidence that they work.
Health care is hardly the only industry that has veered away from truth and trustworthiness in service to higher earnings. We live in a world of lies and deception – fast, loose and casual – by supposedly respectable people and organizations that would take our money or rule over us. Wells-Fargo Banks were caught red handed opening accounts for people without their consent. Drug and surgical device companies bribe doctors to prescribe their drugs or implant their products. United Behavioral Health, a mental health services subsidiary of United Health Group, was recently found to have systematically wrongly denied coverage to thousands of legitimate mental health and substance abuse patients on its plans.
Our principle bulwark against these practices is trust. In health care, we assume that people in the industry are, to a critical degree, mission-driven and have our interests at heart. Unfortunately, in the absence of a strong downside to being untrustworthy, lying and deception are easily employed and rationalized to enhance performance, and when discovered dismissed as acceptable parts of doing business.
Trustworthiness has eroded steadily over decades as the drive for money has commanded an increasing role. You can see this clearly in the recent Theranos debacle, in which investors, many of them prominent, placed $700 million into a venture that promised to revolutionize and streamline clinical laboratory processes. Apparently no one ever tested that promise, and when the false assumptions that the venture was based on surfaced in undeniable and unrepairable performance problems, the startup’s $9 billion valuation collapsed.
The intensifying untrustworthiness of health care dynamics has proven catastrophic for health care purchasers, who as cost has skyrocketed, proceeded under the assumption that the health care industry was playing straight with them. Decades in the making, we now pay double what other industrialized countries do for health care that is the lowest value in the industrialized world.
Health care organizational purchasers have few resources to help them navigate this difficult environment. Health benefits advisors often have limited knowledge, are paid by the vendors, and often have interests that conflict with those they advise. Still, there are some note-worthy changes that are moving the industry toward ever-greater value.
Founded by Intel and GE in 2010, Validation Institute uses an independent, third-party validation process to help health care vendors prove that their performance claims are credible and accurate. Under new management in mid-2018, services have expanded to include educating health benefits advisors and benefits managers on key health care topics (the Certified Health Value Professional program) and helping to connect those purchasers with vendors across the health spectrum (eXchange). There are also the Health Value Awards, which seek to identify, vet and spotlight health care organizations that consistently exhibit measurably superior performance.
The rapid expansion of Validation Institute’s offerings and how well received they’ve been highlights just how deeply health care distrust runs, as well as how multi-faceted the problem (and the solution) really is.
Without foundations of truth and trust, democracy fails and markets decay. We’re thrilled that a growing value-focused community has congealed and begun to mobilize aaround these ideas and activities. As more advisors and benefits managers call for change, the power of the purse will most certainly prevail, forcing higher quality and better outcomes across the board, and in time make health care more affordable for everyone.
Brian Klepper is EVP of the Validation Institute and a health care analyst.