In Al Lewis’ world there are no sacred cows when it comes to the health care system — not wellness programs or pharmacy benefit managers or workplace clinics. Once a cheerleader for the disease management industry, Lewis is now one of its biggest critics, skewering programs that he says don’t save money or improve health.
“There has been and continues to be a massive movement among employers toward doing things that have no scientific basis whatsoever and at the same time overlooking things that really could better outcomes at a lower cost,” said Lewis, a consultant and author of two books that challenge the effectiveness of wellness programs. “The industry is being led by benefits consultants and brokers who make a ton of money off these things and are not working in the best interests of the employer.”
At a time when employee wellness programs have mushroomed across the country, as employers tried to curb soaring health care costs and with the Affordable Care Act and its emphasis on prevention looming, Lewis’ message strikes a discordant note in the benefits world. Wellness is a $6 billion a year industry, and it’s the fastest-growing area in employee benefits, experts say. And with most employers offering programs to tackle chronic diseases, obesity, smoking and other conditions that add to their health care costs, there is a growing demand to determine if these efforts are working.
So far, the wellness industry has done a poor job of it, said Lewis, president of the Disease Management Purchasing Consortium International, a consulting firm based in Waltham, Massachusetts. In fact, he claims that many vendors lie to employers about cost savings. And his opinion of benefits consultants isn’t much better.
“Keep vendors away from your checkbook, keep consultants away from your conference room, and keep providers away from your workforce,” he warns employers in his recent book “Cracking Health Costs: How to Cut Your Company’s Health Costs and Provide Employees Better Care,” co-authored by fellow consultant and former Wal-Mart Stores Inc. executive Tom Emerick.
Pariah or Hero?
Lewis’ unabashed views on the ineffectiveness of wellness and prevention efforts, of consultants in cahoots with vendors, and of dubious cost-savings data have made him a pariah in some circles and a hero in others.
“I got my own bullet point in a webinar the other day,” he said with some pride, referring to a presentation by a health care analytics firm. “I was compared to tobacco company executives and to climate change deniers.” He happily admits to being a shameless self-promoter and calls himself “the father of disease management.” He’s fond of prodding people to Google it. Indeed, a reference to this distinction can be seen near the top of the search page.
While his critics might dismiss him as a gadfly, he is regarded by many as a pioneer in the field of population health management. He specializes in evaluating disease management programs for health plans and employers and holds undergraduate and law degrees from Harvard University. He is also the founder the Care Continuum Alliance, a trade group for wellness providers, disease management organizations, pharmacy benefit managers (see “The Pill Game,” p. 36) and others who are now targets of his criticism. Lewis said that he and the group broke ranks a few years ago, but more on that later.
His supporters include former and current corporate CEOs, policymakers and health care leaders such as Leah Binder, president and CEO of The Leapfrog Group, a national coalition of large employers focused on improving the health care system.
Binder named him one of “13 to watch in 2013” in Forbes magazine, calling him an “unsung hero of health care.”
“I call him an unsung hero, although he’s quite sung now that his second book has come out, because purchasers I think are being taken to the cleaners,” Binder said.
“What’s helpful about Al is that he takes apart the numbers and shows you in black and white what the real benefits of these programs are. He’s willing to take on a very large industry, and I salute him for that courage.”
Binder dismisses the notion that he’s a fringe figure.
“He’s got quite a crowd around him,” she said. “That’s what got my attention. He’s so funny it’s easy to think that he’s not a serious guy, but the folks behind him are top leaders in this country. I saw who endorsed him on Amazon and I thought, ‘Wow.’ They are the superstars in our world.”
Lewis said that he doesn’t disparage all wellness programs — just the ones that punish workers who don’t participate in prescribed activities like health screenings by denying them financial rewards given to those who do.
Such carrot-and-stick methods are not only ineffective in lowering health care costs and improving outcomes, but also can cost employers more money because of over-diagnoses, he said. And worse, they can damage employee morale, Lewis added.
He points to a recent flap at Penn State University, which announced in July that it would start penalizing covered employees who refuse health screenings by charging them $100 a month.
That decision led a Penn State professor to write an open letter urging colleagues to sabotage the screenings by filling out their wellness profiles “with ludicrous information.” He called the university’s demand for personal health information a “ethical breach.”
A few weeks later, Penn State officials backed down, issuing a statement that the surcharge would be suspended.
In a Harvard Business Review blog written before the decision, Lewis and Emerick wrote that “wellness has become another tool to bludgeon” employees into toeing the company line, referring to the Penn State controversy.
“I’m telling employers that the way to do a wellness program is to look at the Penn State program and do exactly the opposite,” Lewis said. “Stop doing wellness to your employees and do wellness for your employees. Go 50-50 on a gym membership, make healthy foods available. Don’t get in the way of people getting healthy.”
Punitive approaches to wellness are never a good idea, Lewis said. However, the number of employers using incentives and penalties is growing. According to a survey conducted last fall by the National Business Group on Health and Fidelity Investments, 86 percent of employers were linking incentives to health-related activities this year, up from 57 percent in 2009.
Lewis argues that penalties not only fail to save money but also can cost employers a great deal in employee morale and loyalty, an outcome that most employers overlook.
“If you’re a general leading an army into battle, would you rather have troops with high morale or troops with low cholesterol?” he said.
Lewis wasn’t always this critical of disease management programs. In fact, in the mid-1990s he was one of their biggest cheerleaders.
Back then he was a consultant peddling disease management programs to anyone who would listen. Humana was an early client, hiring him to address increasing health care costs incurred by patients with chronic diseases, Lewis said.
“Humana was having cost and quality issues, and we jumped at that and an industry was born. That was the beginning of disease management.”
“I wasn’t just drinking and making the Kool-Aid, I was advertising the Kool-Aid,” he said.
In 2002 he founded the Care Continuum Alliance, whose mission is to promote wellness and prevention and other disease management efforts as a way to manage health care costs and improve health outcomes. The alliance also develops standards for measuring the effectiveness of these programs. Around 2007, Lewis began to notice flaws in the measurement methodology, he said.
“I was making a good living putting vendors and buyers together for disease management programs,” he said. “The Care Continuum Alliance was saying that you should use this other methodology, but I thought it was bogus. So I took a few numbers and proved that in fact the other methodology did overstate the savings. But while I was doing that, I proved accidentally that my own methodology overstated the savings. I realized that I was lying to people this whole time. I couldn’t live with that.”
That’s when he and the alliance parted ways and when Lewis “went rogue in wellness,” he said.
Since then he said that he’s been persona non grata at the group’s conferences and events and in the disease management industry in general. But this year he was welcomed back into the fold. Lewis said that he is speaking at the alliance’s annual conference in October.
Fred Goldstein, interim executive director of the alliance, said that the brouhaha was before his time and won’t comment on that, but confirmed that Lewis was invited back to speak on a panel.
“For a time people would submit an application to speak, and we always get more applications than we have slots,” Goldstein said. “This year the board said, ‘Let’s change it up and look for innovative spots on the agenda.’ They said, ‘Let’s get Al in here.’ I don’t know what happened in the years past.”
He said that Lewis adds an important perspective “and points out stuff that is wrong, meaning, not correct. But I’m not saying he’s right on everything either.”
Officials at North Carolina’s nationally lauded Medicaid program do not have such a charitable view of his methods. Lewis accuses them of touting savings that are “impossible,” an opinion that he has shared extensively in articles and interviews.
The controversy centers on studies done by three consulting firms in the late 2000s to determine how much money Community Care of North Carolina, a nonprofit organization that administers the state’s Medicaid program, was saving taxpayers.
Over a three- to four-year period, consultants reported around $1 billion in savings, findings that Lewis said were wildly exaggerated. He set out to prove them wrong by crunching the numbers.
But CCNC officials stand by the findings and accuse Lewis of sour grapes and in general of being a bully.
“We agree it’s a good idea for organizations to examine the findings from complex studies critically and look to validate them with real-world data,” said Paul Mahoney, CCNC’s spokesman, in an email. “Unfortunately, Mr. Lewis criticizes studies not to provide insights on how to do them better, but to tear down organizations with which he feels he is unsuccessfully competing.”
Mahoney claims that Lewis competed for state contracts and was passed over, something that Lewis strongly denies. In response and with some dramatic flair, Lewis announced that he would pay $1 million to anyone who could prove his analysis wrong.
“Math is not a popularity contest,” he said. “If I show someone proof, they should say that I’m right.”
As with most criticism, Lewis shrugs it off and sees his impressive list of critics as a source of pride.
“They say that you can judge the caliber of the man by the enemies he makes,” he said. “I’m very proud to have the enemies list that I have. I wear it as a badge of honor.”
And he may be adding to that list soon.
His next book is titled “Warning: Workplace Wellness Can Be Hazardous to Your Health — How to Survive Your Employer’s Latest Harebrained Scheme and Come Up Smiling.”