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Hyperdiagnosis: The Wellness Industry Doubles Down on Overdiagnosis

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By AL LEWIS and VIK KHANNA

By now we are all familiar with the concept of overdiagnosis, where “we” is defined as “the readers of THCB and a few other people whose healthcare literacy is high enough to know when not to seek testing and/or when not to automatically believe the test results.”

The rest of the country hasn’t gotten the memo that, quite counter-intuitively, many suspected clinical problems should simply be left alone.  Many insignificant conditions get overdiagnosed and subsequently overtreated, at considerable cost to the health plans and risk to the patient.

For more information on that we  refer you to the book Overdiagnosed.   The thesis of that book is that insured Americans are far more likely to be harmed by too much care than too little.

Rather than use its resources and influence with human resources departments to mitigate overdiagnosis, most workplace wellness companies have opted for the reverse, taking overdiagnosis to a level which, were they physicians billing the government for this work, could cost them their licenses and possibly their freedom.   Instead, they win awards for it.

We call this new plateau of clinical unreality “hyperdiagnosis,” and it is the wellness industry’s bread-and-butter.  It differs from overdiagnosis four ways:  It is pre-emptive.  It is either negligently inaccurate or purposefully deceptive.  It is powered by pay-or-play forfeitures.  The final hallmark of hyperdiagnosis is braggadocio – wellness companies love to announce how many sick people they find in their screens.

1. Pre-Emptive

Most cases of overdiagnosis start at the doctor’s office, when a patient arrives to join the physician in a generally good faith search for a solution to a manifest problem.  The patient comes in need of testing.   By contrast, in hyperdiagnosis, there is neither a qualified medical professional providing adult supervision nor good faith.  The testing comes in need of patients, via annual workplace screening of up to seventy different lab values.  Testing for large numbers of abnormalities on large numbers of people guarantees large numbers of “findings,” clinically significant or not.  It is a shell game that the wellness vendor cannot lose.

2.Inaccurate or Deceptive

Most of these findings turn out to be clinically insignificant, no surprise given that the US Preventive Services Task Force recommends annual screening only for blood pressure, because otherwise the potential harms of screening outweigh the benefits.  The wellness industry knows this, and they also know that the book Seeking Sickness:  Medical Screening and the Misguided Hunt for Diseasedemolishes their highly profitable screening business model.   (We are not cherry-picking titles here—there is no book Hey, I Have a Good Idea:  Let’s Hunt for Disease.)  And yet most wellness programs require annual screens to avoid a financial forfeiture.   This includes the four programs covered on THCB this year — CVS, Nebraska, British Petroleum, and Penn State.

Those four programs and most others also obsess with annual preventive doctor visits.  Like screening, though, annual “preventive” visits on balance cause more harm than good, according to academic and lay reports.  The wellness industry knows this as well.  We have posted it on their LinkedIn groups, and presumably they have also access to Google.  They addressed the data by banning us from their groups.

3. Pay-or-play forfeitures

Because of the lack of value, the inconvenience, and privacy concerns, most employees would not submit to a workplace screen if left to their own devices.  The wellness industry and their corporate customers “solve” that problem by tying large sums of money annually — $600 for hourly workers at CVS, $1200 at Penn State and $521 on average – to participation in these schemes.  Yet participation rates are still low.  At Penn State, for example, less than half of all employees got screened despite the large penalty.

4. Braggadocio

Few doctors would publicly brag about how many cases of hidden disease they found, especially if they couldn’t convince the patient to do anything about their condition.  But boasting is essential to hyperdiagnosis.  We’ve already blogged on how Nebraska’s program sponsors bragged (and lied, as they later admitted) about the number of cancer cases they found.  They also bragged about the rate of cardiometabolic disease they found — 40% in the screened population — even though they admitted almost no one did anything about those findings.  Hence, it’s the worst of both worlds:  telling people they are sick without helping them get better.

We’d like to think that all our exposés have made a dent in the wellness industry’s business model, but the forces arrayed in the other direction have so far overwhelmed us.   The price of screening has plummeted almost to the $1-per-lab-value level for comprehensive screens, and as with anything, the lower the price, the greater the amount sold.

More ominously, starting in January employers are allowed to tie 30% of premiums to health-contingent employee wellness programs.   And they will, thanks to the canard — also debunked on THCB — that the CDC says 75% of health spending is somehow preventable through wellness.   This statistic is gospel among benefits consultants, vendors and even pharmaceutical companies like Astra-Zeneca and Johnson and Johnson, which should know better.  So as far as the wellness industry is concerned, a 30%-of-premium penalty only scratches the surface, meaning that their hyperdiagnostic jihad against the American workforce has barely begun.

Al Lewis is the author of Why Nobody Believes the Numbers, co-author of Cracking Health Costs: How to Cut Your Company’s Health Costs and Provide Employees Better Care, and president of the Disease Management Purchasing Consortium.

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness.  An iconoclast to the core, he is the author of the Khanna On Health Blog.  He is also the Wellness Editor-At-Large for THCB.

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  34. “Nortin Hadler”

    Lots of good stuff on Amazon Kindle. Will download a book or two.

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  35. Great Al- thanks for recognizing Hadler and thanks for your own good work!

  36. I think we covered that in a previous posting. In June JAMA published some research finding that you shouldn’t preventively go to the doctor, and in August Slate did an exhaustive search and found the same thing. Kudos to Sharon Begley of Reuters, who was first out of the box on this one in January, but her take was more cost-vs-benefit instead of potential harm-vs-benefit.

  37. What about the annual physical? This has been a standard recommendation for as long as I can remember.

  38. Yes–he blurbed Cracking Health Costs and is quoted at length in our next book “How to Survive Workplace Wellness…with Your Dignity, Finances and Organs Intact.” He doesn’t get his cholesterol screened at all, by the way

  39. Read all the books and articles of Nortin Hadler who is a highly intelligent expert pioneer in this area

  40. My (healthy) wife has had “high” cholesterol forever which docs always want her on statins for. She has resisted but tried other non-drug methods without much improvement. I have always considered cholesterol control, isolated by itself, to be a medical rip off. I have only had mine tested once, years ago – it was high, I forgot about it. She purchased a book several weeks ago, “The Great Cholesterol Myth”, by Jonny Bowden and Stephen Sinatra.

    Among many other things she found it’s important to have an additional test to determine what type of LDL you have. If it’s found to be the “fluffy” type then it is not a risk. No previous doctor had ordered the test. Guess what, after demanding her present doc order the test she found she has the “fluffy” type – nothing to worry about. Her brother also found his situation on high LDL to be the same.

    While I think it’s important to understand the chemistry/test results of your own body, everyone needs to be very cautious when drugs are prescribed to “control” conditions which may be just hyper marketing by the drug industry, and not understood throughly by their docs. It seems the test thresholds have been constantly lowered over the years.

  41. Perry, you obviously have way too much common sense to work in the wellness industry. What you appreciate that many wellness vendors don’t is that there are stark differences between prevention and preventive medicine, and most of the former works while a lot of the latter is of questionable clinical and fiscal value.

    As for the ACA and its preventive care requirements, I encourage you to peruse the columns at this link, which is a list of essays that Al and I have written for THCB on workplace wellness, as a well as a couple of other venues.

    http://khannaonhealthblog.com/al-lewis/co-authored-publications/

  42. So a healthy 35 year old runner with a BP of 120/80 needs treatment? Absurd!
    I think it’s legitimate to look at wellness in terms of recommendations for diet, exercise, sleep, stress reduction, etc, all the things that we know will impact our health. As for doing multitudes of tests every year, that does leave room for overdiagnosis and treatment.
    There has always been talk about sick-care vs well-care. You don’t need a board-certified physician to counsel and coach you on what’s good for you. You do need someone to take care of you if you have that heart attack or develop cancer. A lot of costs could be controlled with appropriate use of resources.
    This also brings up the question about the effectiveness of all the preventive requirements in the ACA. Are people getting their money’s worth?

  43. John, a good one in the public domain is that Via Christi Hospital screened executives from Intrust Bank and found an average of 1.1 new diagnoses per executive. The bank’s PR person said, no doubt unaware of the irony, “it’s still too early to see financial savings,” while Via Christi’s spokesman was more honest, saying this represented a new source of revenue for the hospital.

  44. John: let’s use hypertension or high blood pressure as our example. According to the CDC 67M Americans are hypertensive, which means that their blood pressure is greater than 140/90. That is the generally accepted threshold therapy in both the US and UK (even though therapy might begin at lower bp levels depending on a person’s risk constellation).

    There is now active dialogue about whether to lower the bar for treatment to include people who are pre-hypertensive (>120/80). If we lower the bar to a normal bp being only <120/80, it instantly makes another 30M Americans "abnormal" and in "need" of therapy. To some commentators, this is a no brainer because bp drugs are often generic and cheap (as little as $4 per month). The drugs might be cheap, but the side effects are not and include GI, respiratory, and neuro symptoms, as well as sexual dysfunction. The side effects are severe enough that, according to one of the author's of the Cochrane Collaboration report on pre-hypertension, 11% of people stop the meds because of the side effects alone. Dr. Cundiff also estimates that the cost of treating pre-hypertension at nearly a half trillion dollars over 10 years. That's just too much money to leave on the table no matter how little good treatment might do. (http://www.healthnewsreview.org/2013/11/the-economics-politics-of-drugs-for-mild-hypertension/).

    Expanding the pool of abnormal people through the wellness subterfuge greatly expands the market for drug companies and also enriches the physicians who shill for these companies and are greatly supportive of lowering the hypertension treatment bar even though medical contrarians are deeply skeptical about whether this is a disease, or, as US and UK researchers question, a pseudo-disease, that puts people on the path to a lifetime of treatment with no evidence of long-term efficacy (http://www.biomedcentral.com/1741-7015/11/211).

    This kind of facile "let's treat everyone" stupidity is the wellness industry's bread and butter. This kind of body grab is intended to encourage long-term dependency on the medical care system, because that's how wellness vendors, health plans, health care providers, drugs companies and even government bureaucrats profit.

    By the way, the chief risk factor for high blood pressure? Aging. Pretty soon, I am sure wellness vendors will tell us that they have a fix for that, too.

  45. You raise three good questions. First, Nebraska is out of line (as with everything else in their program) with their 40%, but I am seeing numbers more like 30%, which is still 50-100% above what the underlying number should be. (I’ll try to find more publicly avaialble examples like Nebraska’s.) Some of that hyperdiagnosis is overdiagnosis, while an unwarranted faith in cholesterol testing makes misdiagnosis prevalent too.

    I have tried to estimate the impact on spending. Along with the $50 cost of the screen, if you get everyone to go to the doctor (when otherwise 20% would) in a given year, that’s 80% of people spending an extra $250. So BEFORE adding in the costs of extra things being done in those visits like referrals and scripts, you are at $250 extra ($50 plus 80% of $250), which is almost 5% of the total per-person healthspend. That doesn’t seem like a lot but it’s one year’s inflation these days.

    That does not include people getting all the extra tests that the HRAs and screens recommend, that are on the USPSTF’s non-recommended list.

    There are also two sources of lost productivity. One is taking 2-4 hours off to go to the doctor.

    The other is the productivity impact of hyperdiagnosis. Nebraska’s vendor, Health Fitness Corporation, writes on its blog about how wellness addresses “diminished productivity” and “job stress”. Personally I’m not sure a wellness program telling me I have a disease that I don’t have would increase my productivity and/or reduce my job stress. But maybe that’s just me.

  46. Interesting. There’s a lot to this argument. BUT I’d to see some numbers, guys. If “hyperdiagnosis” (great name, BTW) is as prevalent as you argue, I’d like to know a bit more about the big picture. What kinds of overdiagnosis/misdiagnosis rates are you seeing?

    What do you estimate the economic implications are? For healthcare spending as a whole? For employers and other organizations who do business with wellness vendors?