Wednesday, January 16, 2013

Fwd: qotd: Can we control costs through checkups and wellness programs for the healthy?

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-------- Original Message --------
Subject: qotd: Can we control costs through checkups and wellness
programs for the healthy?
Date: Wed, 16 Jan 2013 12:17:49 -0800
From: Don McCanne <>
To: Quote-of-the-Day <>

JAMA Internal Medicine
January 14, 2013
General Health Checks in Adults for Reducing Morbidity and Mortality
From Disease
By Allan V. Prochazka, MD, MSc; Tanner Caverly, MD

The concept of general health checkups to identify disease at a stage at
which early intervention could be effective has been promoted for nearly
100 years. Both patients and primary care physicians are interested in
such examinations, which can include detailed history taking, physical
examination, extensive laboratory testing, and imaging.

General health checks do not improve important outcomes and are unlikely
to ever do so based on the pooled results of this meta-analysis spanning
decades of experience. We should be clear about what a general health
check is. A general health check is a visit dedicated solely to
preventive counseling and screening tests. Other names, such as annual
physical, preventive health examination, or periodic health evaluation,
are often used. These terms exclude preventive care that occurs during
visits for other reasons, such as during chronic care or acute care
visits. In other words, we are talking about screening and counseling in
addition to the prevention measures that occur during routine medical care.

General health checks are one of the most common reasons adults seek
medical care, with an estimated 44 million seeing a physician for this
reason each year from 2002 through 2004. During these health checks, an
estimated $322 million is spent annually on laboratory tests that no
guideline groups recommend. The costs of downstream testing and
overtreatment are likely to be much larger. For example, the costs of
mammography might be $4 billion a year assuming biennial screening. The
cost of follow-up biopsies of normal breasts triggered by false-positive
mammogram results alone is probably in the range of $14 to $70 billion
annually. It is likely that follow-up testing from general health checks
substantially contributes to the estimated $210 billion in annual
spending on unnecessary medical services.


Health Affairs Blog
January 16, 2013
Is It Time To Re-Examine Workplace Wellness 'Get Well Quick' Schemes?
By Al Lewis and Vik Khanna

Virtually unheard of thirty years ago, workplace wellness is now
embedded in large self-insured companies. These firms pay their workers
an average of $460/year to participate in worksite wellness programs.
Further, wellness is deeply enough engrained in the public policy
consciousness to have earned a prominent place in the Affordable Care
Act, which allows large employers to tie a significant percentage of
health spending to employee health behavior and provides direct
subsidies for small businesses to undertake these workplace wellness

Yet the implausible, disproven, and often mathematically impossible
claims of success underlying the "get well quick" programs promoted by
the wellness industry raise many questions about the wisdom of these
decisions and policies. In this post, we lay out the evidence
demonstrating that the industry consistently mis-measures and overstates
the direct healthcare cost savings. We suggest several strategies to
prevent this and to re-allocate wellness dollars from "get well quick"
schemes to the much more challenging, but ultimately more rewarding,
task of truly creating a culture of wellness, a workplace that can
attract and retain healthier, presumably more productive, people than
competitors do. There is no guarantee that strategy would work and no
easy way to implement it, but clearly the easy approach isn't working.

While we do not believe that employers need to adopt military-style
standards, we do propose that it is illogical to expect sustainable
reductions in medical care spending if corporate leaders treat their
environments, personnel policies, practices, and procedures with the
insouciance of people who believe that they can just wish something into

HR departments need to reconfigure their benefits consulting
relationships, since with few exceptions the latter have not provided
critical thinking about wellness (and other "value-added" programs) on a
par with that of insurers, who have universally shunned these programs
for their fully insured members. (Most insurers will happily sell them
to self-insured employers even so, because they clearly understand that
"invalid" is not the same as "unprofitable," especially when you do not
bear risk for the outcomes and the customer's consultants are demanding
the service.)

Comment: In discussions of our exorbitant health care spending, we
frequently hear that we need to change from a system that treats disease
to a system that promotes prevention and wellness, as if prevention and
wellness programs would displace disease and injury.

First, let's be clear that the benefits of effective prevention programs
are undeniable. But much of prevention is out in the community at large
and not so much within the health care delivery system. Examples are
public health services, community planning for safety and to promote
physical activity, the promotion of healthy food choices, industry
design of safer products such as automobiles, public policies to reduce
hazards such as the ubiquitous accessibility of firearms, and
innumerable other measures that are or should be promoted through both
public and private efforts.

So what about routine preventive health checkups? The comprehensive
meta-analysis published in the current JAMA Internal Medicine reveals
that "general health checks do not improve important outcomes and are
unlikely to ever do so," but "it is likely that follow-up testing from
general health checks substantially contributes to the estimated $210
billion in annual spending on unnecessary medical services."

However, specific examples of preventive care that are a part of and
integrated within the provision of care for acute and chronic disorders
have been shown to be of some benefit and should not be abandoned until
new evidence demonstrates that there are compelling reasons to do so.
Nevertheless, we cannot look to the medical practice environment to find
the health care paradise that will displace sick care with well care.

Which brings us to employer-sponsored wellness programs. Simply stated,
they fall into the spectrum between naivete and outright fraud. As
stated in the Health Affairs Blog article briefly excerpted above, "Even
the iconic Safeway story of achieving a zero medical cost trend through
wellness - the inspiration for the wellness provisions in the Affordable
Care Act - turns out to be made up."

If you wish to know the shocking truth on wellness programs (yes,
shocking), you should read the entire article available at the link
above. The fact that insurers promote these programs, but only for their
non-risk bearing contracts with self-insured employers, certainly is

Pretending that we can control health care spending with checkups and
wellness programs no longer cuts it. We need to tackle costs with proven
methods that would ensure quality care for everyone. We should begin by
enacting an improved Medicare for all.

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