Rethinking Screenings, GLP-1s, and Smarter Health Decisions with Al Lewis

Nick: Welcome to the Wellable Weekly Podcast, where we talk about key topics and trends at the intersection of wellbeing, technology, and HR. I’m Nick. We have a special guest episode today on the pod. We have the one and only Al Lewis. His reputation precedes him. Many people already know who he is, but for those of you who don’t, he’s written numerous books and articles on employee health and wellbeing. He’s been involved in a number of debates, sometimes getting a little bit spicy with other kind of leaders and figureheads in this industry. The funny story I’ll tell, a little bit of a bio: when I first met him, he got introduced in two different ways. One was the troublemaker in chief, which if you get to know him, you can see how that title fits so perfectly. And the second one was that he would introduce himself as the inventor of disease management. So apparently, and maybe still today, if you Google “inventor of disease management,” the first article would be one that attributes Al Lewis to being that inventor. Currently, he’s the founder and leader of Quizzify and the founder and leader of the Validation Institute, which will play a little bit of a piece into the conversation we have. Al, welcome to the show.

Al: Well, thanks as always for having me, Nick. I guess we go back about 15 years now.

Nick: Yeah, it’s kind of crazy. I think when we first started, before Bulb was even a product, I think I was doing some consulting work, as were you, and I think we were in the room one time doing a joint consulting project.

Al: Yes, that’s how we met, and I was all set to go down your throat because I thought you were going to talk about how terrific screening everybody in the company was, and you didn’t.

Nick: That is a good segue to our conversation. So one of the things I think — at least when we were first starting, not 15 years ago, but 12-ish years ago — the hot topic was, do you do screenings or not? You were certainly on one side of that river. I think you called these wellness programs that had screenings as a big component “pride, poke and prod” programs, and said they weren’t effective and weren’t a good use of money. I won’t put words in your mouth, but I feel like—

Al: No, no, those are great words to put in my mouth, yes.

Nick: Perfect. Well, I figured what’d be good is to level-set the conversation, because I think many people know you from that perspective — that’s kind of your hallmark, that and HRAs. So as a recap, maybe you can talk a little bit at a high level about biometric screenings placed in employee health programs, and your general viewpoint on them.

Al: Yes, so biometric screenings were a fad in the teens, and to a lesser extent the aughts, because people thought if you could just identify people’s risk factors, you could cure them or manage them so they wouldn’t end up in the hospital. And there are about 16 things wrong with that. One, a very basic one, is that essentially no employed person under the age of 65 actually goes to the hospital for one of these things. The total admit rate for primary coded heart problems and diabetes combined is about three or four per thousand. So you’re spending a humongous amount of money trying to reduce this number by about 10 percent. The math didn’t add up. It was also very annoying for employees — there were a lot of false positives, and people didn’t understand the math of false positives. If you’re looking for a one-in-a-thousand shot and you’re 90% accurate on your test, out of every thousand people you test, you’re going to find a hundred who test positive, and only one of them is actually going to have a heart attack. Let’s just assume that this stuff is dead and buried finally. And you probably want to know why I’ve kind of changed my mind on this.

Nick: I do. Just as a background — we started this podcast at the beginning of the year, and I always knew we were going to bring in guests, and you were one of the top people on the list. So before I reached out to you, I hopped on your blog, “They Said What,” which is you generally calling out the employee wellbeing industry. You hadn’t blogged for ages, and you had a brand-new post that day, I think, when I decided to reach out. Very serendipitous. And in that post, you were talking about a new screening in town — you were skeptical at first but now completely bought in.

Al: Well, that is exactly right. The company with this new screening is called Hibiscus Health. I run these shark tanks at conferences — there’s one coming up in a couple weeks, another at the Houston Business Coalition in August, a couple more after that. The prizes in the shark tank are $25,000 investments. You pay to get into the tank, and a couple of companies out of five will do very well; the others get a chance to pitch and connect with the audience. Well, this company Hibiscus Health said they did wellness screens — and Nick, you know how I feel about that. So ahead of the conference, ahead of the shark tank, I actually went up to them and said, just to be honest, I’m not going to vote for you because I think screening is a complete waste of time. So I didn’t vote for them. The judges voted for another company, Radial Health, a forward-looking, non-drug depression and anxiety company. But Hibiscus Health won the audience vote by a huge margin over the other contestants. So I figured I might as well go see what the fuss was about. I went to their booth, looked at the screen for 30 seconds, and — being in this industry, I know my risk factors cold; I do these tests annually now that I’m 70 — the results were shockingly, scarily close to my real numbers. And it didn’t cost any money to look at a screen. That completely turned me around on the subject. If you can screen people non-invasively, at their convenience, for a very low cost, I’m there. They didn’t just win the $25,000 — I ended up doubling the investment because I liked what they did so much. I’ve had other people look at the screens too, and they’ve come to the same conclusion: pretty darn close to their real blood values.

Nick: Interesting. Just for everyone else’s benefit — I went to the Hibiscus Health website. Effectively, they do a 30-second scan of your face, most often through a mobile phone, though they also have a kiosk and a couple other options. The mobile phone is nice because any employee anywhere can download it and go through the screening. From what I understand, it detects subtle changes in your facial blood flow and generates risk assessments from that. According to their website, they claim 95% accuracy for blood pressure and 85% accuracy for diabetes, cholesterol, and triglyceride risk. I guess those numbers don’t mean much without the context of what a blood draw gets. Any idea how those numbers sit relative to a traditional screening?

Al: Well, I think the comparison is to a traditional screening, so the assumption is the traditional screening would be 100% — not entirely true, but you’ve got to have a benchmark.

Nick: Okay. So in that case — I know you mentioned the false-positive narrative, the cascading tests and costs, not just to the patient’s health and risk, but the financial costs. Does Hibiscus Health address that potential issue? Clearly they’re a cheaper and more democratized way of doing it — anyone, anywhere can do this type of screening — but how do they address the false-positive risk?

Al: Well, if you’re clearly low risk, that’s the end of it — there’s a little check box (or there will be) that says to your employer, “Yes, I checked this,” so give me my incentive. If you’re clearly high risk, they recommend you talk to a coach, either theirs or your employer’s. But if you’re in that ambiguous area where you could be a false positive, it says go get a real blood test. Now, it’s possible the real blood test will be a false positive too, but now you have two tests to rule things out instead of one. So does it absolutely eliminate false positives? No, not at all — but it should cut down on them very considerably. The real savings is in the 70% who don’t really have anything wrong with them, where you’re spending a fraction of what you would have spent on the biometric screens.

Nick: Yeah. I know you’re not necessarily in the weeds of it, but how do they stratify that population? How do they determine someone’s clearly in the high-risk category and not a false positive? Does everyone considered high-risk get a blood screen to confirm it, or is it just the people in the middle who could be false positives?

Al: Well, on their site, when you get your screen back, there’s a color code from solid green to solid red. Folks who are pretty high in the red are told to get to a coach or whatever the employer wants. If you’re in the pink area, that’s when they tell you to get a legit test. As I mentioned, legit tests could be wrong too, but you’re cutting way down on the cost for the large number of people who just aren’t going to have an issue. Those regular screens cost, I don’t know, $50 or more a piece.

Nick: Yeah, exactly. And that’s probably on the low end, especially in a situation where you do an onsite version, which takes coordination — there are other, non-direct financial costs.

Al: Yeah, there’s all sorts of admin costs, plus you’re taking the employee off the line or off the phone bank. This is one of the many reasons I didn’t like these things — the ridiculous cost involved. Now, the fact is, if somebody is high risk and goes to a coach or wellness manager, there’s still no guarantee they’ll improve their behavior. But the difference is you’re getting there while gambling a lot less money, with a lot less employee dissatisfaction, and a lot less administrative hassle, than you would have doing biometric screens for the entire population the old-fashioned way.

Nick: Makes sense. I want to summarize — the innovation here isn’t really the technology itself, but the fact that you can get comparable results to traditional screenings at a fraction of the cost. And that fraction of cost drastically changes the perspective.

Al: Yes — and a fraction of the dissatisfaction, in fact there’s really no dissatisfaction, and a fraction of the administrative hassle.

Nick: Okay. One of the things I’ve always heard about wellness programs in general is that there’s a certain self-awareness among a non-insignificant portion of an employee population. Many people don’t need a screening to understand they have a chronic condition or that they’re overweight. It doesn’t always serve as an epiphany — the “know your numbers” concept. Yes, now you know your numbers if you didn’t before, but that may not change your realization of where your health actually is. What I thought was interesting on their website: of individuals routed to a registered dietitian or some other intervention, 98% reported increased physical activity, 96% reported increased motivation, 95% reported weight loss. It was shocking how good those numbers were. Any secret sauce around their intervention approach?

Al: The secret sauce is very simple: the people who fail don’t report. So you’re getting a self-selected sample. Any traditional wellness company will give you numbers like that too. But just one other thing on the behavior-change point — I wrote an article, gosh, about 12 years ago now, called “The Million Dollar Workplace Wellness Heart Attack Screen.” It talked about the huge cost of doing screens, and the likelihood that a lot of people who are going to have a heart attack already know they’re high risk. So you’re really focused on a small subset of people who are high risk, didn’t know it, and are willing to make a behavior change. Against that, you have the entire cost of a massive wellness program. Now you still have that same small group, but instead of spending a ridiculous amount of time, money, and administrative effort to find them, you’re spending a very reasonable amount.

Nick: Yeah, the cost is a huge component. And what’s nice about this tool is you can do screenings literally every day if you want, right?

Al: Yeah, actually, it’s funny you say that, because I did. I’m obsessed with this thing. My particular bugaboo is I’m always around 5.7 on the HbA1c, “borderline borderline,” as I call it. I went a week and a half without eating added sugar, which should be enough to move that number a tenth of a point, and I was getting the same numbers. The guy told me you can refresh your blood pressure and pulse every day, but the ones that don’t change daily — triglycerides, cholesterol, HbA1c — you can only refresh monthly. They’re actually changing the website right now to say “come back in a month” for those, with a reminder option, whereas blood pressure and pulse you can check every day.

Nick: So from their perspective, they’re encouraging some level of regular use — daily, monthly, whatever — as the ideal usage pattern.

Al: Yes, and in fact they have about 50 times as many hits in 2026 as they had in 2025. People like myself get kind of addicted to it once you’ve done it.

Nick: I guess that opens another can of worms around over-screening, which I think has always been a—s

Al: Oh yeah, yeah, yeah — you can definitely over-screen people. The over-screening issue was more about, at the heyday of wellness, screening for everything under the sun. There was a company — I can name them, Interactive Health — I took one of their screens and they were screening for like 50 things. If you have a test that’s 95% accurate and you’re testing for 50 things randomly, you’re going to find two or three things that are “off the charts wrong” when you’re not actually high risk. I specifically said don’t tell me my PSA, because I don’t want to know it — I’m not going to do anything about it. They told me anyway. They’re out of business now — I’d like to take credit for that. I ran into their final CEO a couple years later, and I said, “This is a little embarrassing,” and he said, “No, no, you were right about everything. I just couldn’t make the change — I had what’s known as a deep state problem. I couldn’t get the people who’d been doing it this way to change, and I didn’t have enough money to fire them all and bring in new people.”

Nick: Call it the path dependence problem, right? You’re far enough down the path, the whole business is built on it — it’s hard to cannibalize your own business.

Al: Yes, yes, they had serious path dependence at that company.

Nick: Yeah, the best example — not to get too much of a tangent — is Netflix. Reed Hastings is credited as such a great CEO because he said streaming is the future, we have this DVD distribution business, we’re going to build something to kill that business, and split the company in two while doing it. Obviously, winners write history, so he’s easily seen as a big winner in that decision.

Al: Yeah, whereas Blockbuster is exactly the opposite.

Nick: Exactly — the opposite of Netflix. So I wanted to briefly chat about the Validation Institute — what you’re working on there, and specifically, it sounds like Hibiscus Health has some connection or validation guarantee from the Validation Institute. What’s that about?

Al: Yeah, so at this point there are about 100 companies that have come to us and said everybody claims they save money, and they want us to validate that as a legit validation, as opposed to calling any actuarial firm and paying them enough to say you save money. We differentiate ourselves two ways. First, we actually put $100,000 behind it — it’s called an Inversive Immunity Guarantee. If employees are suing their company for mismanaging the benefits plan, which is happening more and more, you won’t be named; and if you are named, we pick up half the tab up to $200,000. No actuarial firm will do that. We draw a very clear line and stand behind our validations. On top of that, for street cred, we’re mentioned in Marty Makary’s bestselling book “The Price We Pay” — he gives us a nice shout-out — and in a Harvard Business School case study by Professor Hursley that talks about our methodology. So we can say the Validation Institute is the only thing that the Trump administration — with Marty Makary as head of the FDA — and Harvard agree on. If that’s not street cred, I don’t know what is. We’ve got the street cred, we’ve got the financial backing, and what we’re trying to do is raise the visibility of the 80% of companies in this field, like yourselves, that are honest about what they do — because the problem is that 80% of the revenue goes to the other 20%. We’re trying to catch the eye of people who are automatically renewing with those less scrupulous companies and say, hey, there are better solutions out there, and don’t just take our word for it — we have money behind it.

Nick: So on that note — if you think about how the Validation Institute works in practice: say Hibiscus Health has an ROI calculator on their website claiming a company with 10,000 employees can save $63 million over five years. Do you validate that exact claim, and if so, what does that mean?

Al: No — it’s very rare that we validate the exact claim on a company’s website. In the case of Hibiscus Health, what we validated is that, assuming you’re already doing screenings, you will either save a lot of money by doing the same number of screenings at a much lower cost, and/or you’ll screen more people — because there are plenty of people, like myself, who’ll look at their phone but wouldn’t necessarily line up to get a traditional blood draw. Since we’re putting $100,000 behind these validations, whatever we validate has to be very easily supportable if we’re challenged on it.

Nick: And in terms of triggering a claim against the Validation Institute — would it have to rise to the level of a lawsuit? Even if someone felt a benefit plan wasn’t managed properly, or that Hibiscus or another company wasn’t delivering the promised ROI, would it need to become an actual lawsuit with a judgment before funds would be paid out?

Al: No, actually — yes to your point about payout in that lawsuit scenario, but we also have what’s known as a credibility guarantee, which speaks to exactly what you said. If somebody says, “We hired so-and-so and they didn’t do remotely what you said they would do,” there’s a whole arbitration process through a third-party American Arbitration Association, and the loser pays costs — we cover that up to $100,000. I mention the Inversive Immunity Guarantee because it’s top of mind right now, but we’ve had the credibility guarantee for several years. The only difference now versus a couple years ago is it’s $100,000 instead of $25,000, because nobody really cared about $25,000 — people start caring at $100,000. In fact, we might even be going to a million dollars in a couple of cases, since we’re going after bigger accounts now, and $100,000 doesn’t mean much to them — a million dollars does.

Nick: Okay, cool. So you have the Validation Institute, and you also have Quizzify — when did that start? Been about 10 years now?

Al: It’s 11 years, and yes — Quizzify owns the Validation Institute, long story, but same company. You’re familiar with Quizzify — we say “wiser employees make healthier decisions, and healthier decisions save money,” and we do it through what we call Jeopardy meets health education meets Comedy Central.

Nick: And a fun fact about you — I’ve seen a photo of you on Jeopardy, right?

Al: Yes, that was more than half a lifetime ago at this point, I’m afraid — or actually about half a lifetime.

Nick: I’ve seen the photo online somewhere.

Al: It’s on our website. Curiously, the guy who beat me took the picture and I wrote to him and he sent it to me. As a total coincidence, he later moved from California to Newton, Massachusetts, where I live, and we occasionally get together and play some trivia.

Nick: Oh, nice. So one of the things Quizzify does — I’ll use my own words this time — is educate employees through a fun, interactive quiz format. I saw you’ve launched a GLP-1 track or series. We talk about this a ton on the podcast — I always tell folks that if AI weren’t taking up all the air in the room around employee news and layoffs, GLP-1s would be the number one topic, no question. You could make a pretty cogent argument that GLP-1s, at least in the short term, will have a bigger impact on the day-to-day lives of a broad swath of the population than AI will. What is this track specifically? What are you trying to achieve, and what are employers getting from it?

Al: Well, it’s called the weight loss drug companion curriculum. If there’s one drug in the world where education is a huge part of making it successful, it’s this one. In fact, it says right on the label for one or two of these drugs that it’s a therapy that has to go with education about nutrition and lifestyle changes. So it fits our wheelhouse really well. We had a lot of questions about how to read nutrition labels at the supermarket, which is much harder than you’d think, because they’ve been co-opted by industry. It’s a 12-month curriculum, but the key month is the first one — the quiz you take before you start the drug. A company either incentivizes or requires this. It’s a 30-question quiz that teaches you what you’re about to get into, interspersed with questions about side effects. We don’t make it totally obvious that we’re trying to get you not to go on the drugs, but we’re structuring it so the “GLP-curious” get dissuaded and only the “GLP-serious” continue. Internally we call it the “before your journey quiz,” but we also call it the “curb their enthusiasm quiz,” because literally about 75% of people decline to continue after taking it. They’ll either go on regular weight loss programs, or pass altogether. I can’t prove this, but I think they’re much more likely to be the people who’d drop out within three to ten months than the people who’d actually succeed on the drug. So we dissuade the GLP-curious, and then for the next 12 months we educate the GLP-serious.

Nick: And for those next 12 months, that’s a quiz a month?

Al: A quiz a month, yes. We have one quiz on managing side effects, and everything else is about nutrition, lifestyle, and all the phony labels out there. Very simple things — like you have to drink a lot more water than you think, because your sense of hunger is suppressed, but so is your sense of thirst, and if you don’t drink enough you can get acute kidney damage or other issues. Also, most Americans don’t get enough fiber anyway, and you’re cutting your caloric intake in half — a lack of fiber can lead to complications that aren’t reversible. So we teach that, and where to get fiber, month after month for 12 months.

Nick: A lot to unpack there. Other than the general attrition rate most pharmaceuticals see, why do about two-thirds drop off within a short period? Is it difficulty adhering to it, remembering to do it, not seeing results?

Al: Well, there’s a small portion who, because of genetic predisposition, won’t get results. But generally, the dropouts happen because people weren’t well prepared to get on the drugs — they weren’t expecting the side effects, and for some people those side effects just don’t go away. It could be economics, or some combination of factors — it could even be that they are getting results, but the results aren’t worth the cost to them. It’s not one thing; it’s a whole bunch of things that cause people to drop off. And when they do drop, they gain back most, though not all, of their weight — and a fairly recent finding is that the weight regain tends to be more fat than muscle compared to when they started. So you have to be pretty sure, when you get on these drugs, that you’re willing to stay on them.

Nick: So from an employer’s perspective, if they’re thinking about covering some or all of GLP-1 costs — hypothetically, everyone would need to take this pre-quiz to dissuade the GLP-curious, creating a gate. Then, to remain covered, they’d need to complete another quiz each month, and if they stop for six months, it comes out of pocket?

Al: Yes, in theory that’s how it works. In practice, the initial quiz is very easy to implement — 75% won’t continue, and employers have other programs they’d rather route people to that don’t involve drugs. Honestly, I don’t think anyone has fully built the admin to tie those following 11 months to continued drug coverage — the admin is much harder than just giving someone a quiz. And the beauty of the first quiz, or really any of the quizzes, is that PBMs will say you’re not allowed to do pre-authorization — they have that written into their contracts, or they’ll take away your rebates. Well, this isn’t pre-authorization — it’s what we call “self-pre-authorization.” It’s also right on the drug’s label, so they can’t complain about it. It lets you cover the drugs without breaking the bank, because you’re only covering the people who are most serious about them — instead of five, six, or even ten people per thousand, it’s just a few per thousand.

Nick: Well, I like to end on a joke. I heard you tell one, years and years ago, on an old podcast we tried called Dablin, where you were a guest. I’ve always resonated with it and probably misquoted it a ton, so let me try it one more time. The question is: what do pennies, baseball, communism, Microsoft Outlook, and screenings all have in common? And the answer is: if they did not already exist, no one would invent them. I guess the argument now is we may need to recraft that joke a little, since companies like Hibiscus Health are trying to innovate the space. Well, thank you, Al, for joining us — I really appreciate it.

Al: Nobody would invent them. Yeah, and by the way — I know you want to close on this — it’s not just Hibiscus Health and others. It’s Hibiscus Health, period. Nobody else. I’ve looked around the web, and nobody else is close.

Nick: That’s fair — that’s a good point. Honestly, I didn’t even know about Hibiscus Health until I decided to check your blog to ask if you’d be a guest, and I saw you’d gone quiet — a separate conversation for why you don’t post anymore — but then you finally posted that day about Hibiscus Health, and I checked out their website, and it seems pretty cool. Well, thank you, Al, for joining us, and thank you to everyone listening.

Al: Well, thank you for having me.

Nick: Thank you to everyone listening and watching, and for giving us part of your day. Please like and subscribe on whatever platform you use to access this show, and have a great week.