Typically, wellness programs encourage or incentivize annual screenings and annual checkups. Often, vendors will cite “early detection” as a justification for such frequent medical care. One vendor even says checkups will, among other things, prevent cancer.
The actual science, as captured by established and well-respected clinical guidelines, leads to a much different conclusion. Understanding this science and following these guidelines will help you improve your employees’ health while saving a good deal of money at the same time.
Over-Screening and False Positives
For screenings, the US Preventive Services Task Force (USPSTF) has established a master list of both recommended (“A” and “B” ratings) screenings and intervals between screenings. You’ll note that only blood pressure is recommended to be checked annually for adults of all ages. Most screens popular among vendors, like glucose and cholesterol, are recommended at much less frequent intervals.
Many screens recommended by vendors (such as prostate testing) are rated “D” by USPSTF, meaning you should actively discourage your employees from getting them.
Additionally, with screening, one size does not fit all. What is appropriate for a 55-year-old would be completely inappropriate for a 25-year-old. On the USPSTF screening summary most recommendations differ by age.
A number of items influence the USPSTF's screen frequency recommendations. Some are subtle. For example, screens are not particularly effective against cancer because the most aggressive cancers can grow the fastest between screens. Screens are more likely to catch cancers for which “early detection” makes very little difference because they are growing so slowly.
Wellness trends currently point to more screenings, using venipuncture instead of finger-pricks. In addition to costing more money (5-10 times as much as a year of Quizzify), screening for more blood values multiplies the odds of a false positive, which then must be followed up, causing the employee considerable stress and expense.
Here is a screen done by a wellness vendor as an example of what we call “hyperdiagnosis.” Most of these tests are rated “D”, and are only supposed to be done by doctors— and even then only on patients with actual symptoms or complaints, rather than on everyone who walks into the waiting room.
This particular test result includes a false-positive, the serum glucose. There is no explanation offered by the vendor, so we’ll offer one: the glucose was slightly out of range specifically because it was a non-fasting glucose reading. (It's possible the test may have been done after breakfast and the test subject was enjoying a serious sugar rush.) False positives can send people to the doctor for no reason (while false negatives can instill complacency).
The Arithmetic
False positives also create a simple and expensive arithmetic conundrum. Suppose a test trying to ferret out the 1-in-1000 employee who is going to have a heart attack this year (without already having diagnosed heart disease, in which case they wouldn't need a screen) is 90% accurate. 10% will then yield a false positive. 10% of 1000 is 100, meaning 100 employees will test positive. Of those 100, only 1 will have a heart attack, meaning even on a test that is 90% accurate, the false positive rate is 99%. Imagine all the doctor visits, pills, tests and stents those other 99 employees might endure…and there is no guarantee that the 1-in-100 will indeed avoid the heart attack.
In the real world, it’s even worse: no wellness vendor test today can remotely approach 90% accuracy in predicting a heart attack, while the rate of previously undiagnosed employees having heart attacks is much less than the assumed 1-in-1000. For example, in Nebraska's state employee wellness program, 40% of roughly 5000 employees were told they were at risk, but almost none (other than previously diagnosed employees) ended up with a heart attack.
The Expense
If your goal is to optimize employee health while controlling spending, annual screening is way too frequent. Instead, we recommend screening according to USPSTF guidelines. Note that even screening according to guidelines won’t save money. For instance, avoiding a single employee heart attack through screening costs roughly $1-million.
Still, appropriate screening intervals, for “A” and “B” rated tests only, will definitely save money –when compared to inappropriate screening intervals, and/or inappropriate "hyperdiagnosis" such as the Nebraska example above.
Why do vendors recommend much more screening? More screening generates higher fee revenues for them (meaning expenses for you), of course. Typically, their excuse is that annual screens allow companies to chart progress. But charting data for data’s sake shouldn’t trump improving employee health. That would be like charting how hot your oven gets by seeing how long it takes to burn the roast. In contrast, Quizzify allows you to “chart progress” for something much more important to many more employees – employee health literacy – without generating high expense, risking overscreening or incurring "hyperdiagnosis".
Annual Check-ups
There are many good reasons to go to the doctor. However, the earth completing a revolution of the sun is not among them. Annual checkups are included in Choosing Wisely’s list of healthcare services to be avoided. The New England Journal of Medicine and the Journal of the American Medical Association say the same.
What next?
Even though much of the literature says check-ups are worthless, we are not willing to go there yet. We like the State of Connecticut's screening schedule, in which checkup and screening frequencies are age-adjusted — with some exceptions. For instance, their requirement that 30-somethings get mammograms is inappropriate. And yet they could be more directive on mammograms for women over 50. Their checkup schedule is still too aggressive— most fifty-somethings can get less frequent checkups. (We have other minor objections too and there are some items not in USPSTF compliance, but it’s the best we’ve seen and shows that wellness program requirements can be age-specific.)
It is important to note that Connecticut’s claims costs increased noticeably as a direct result of implementing this schedule. However, they likely would have increased more had the state insisted upon screening at inappropriate intervals and getting annual checkups, as many wellness vendors recommend.
Here is an easy mnemonic for checkup frequencies that we like, which is less intensive and more appropriate than Connecticut’s – but like Connecticut’s is age-adjusted: 2 in your 20s, 3 in your 30s, 4 in your 40s, 5 in your 50s and annually after that.
Where Does Quizzify Fit In?
If you want to save money and provide more appropriate care, screen your employees every 2-3 years rather than every year. Offer Quizzify in the in-between years.
Offer traditional wellness every year, but give people the alternative of Quizzify.
Legally, you need to offer everything to everyone. However, within that framework, if you recommend the choice of screening to people who think they may be indicated for screens (they don’t recall being screened in the last 5 years and/or feel they are at high risk) while recommending Quizzify to others, will provide the best of both worlds.
If your vendor or health plan is not willing to optimize in this manner, switch to It Starts with Me or Sterling Wellness, vendors who screen according to USPSTF guidelines – and, like Quizzify, have adopted the Employee Health Program Code of Conduct. (We also have a long list of health plans, too many to mention here, if you prefer to work directly with your carrier.)
Several excellent books have been written on the topic of screening covering these and other drawbacks, such as Overdiagnosed, Should I Be Tested for Cancer, and the somewhat less technical Seeking Sickness: Medical Screening and the Misguided Hunt for Disease, written by our own Alan Cassels.