Tag Archives: hyperdiagnosis

Genetic Testing: The New Wellness Frontier

The Wall Street Journal just reported that Genetic Testing May Be Coming to Your Office Soon. This is all well and good, assuming employees want their health insurer’s buddies collecting their DNA for no good reason, handling it, selling it and possibly losing it.

This is not us talking. This is what the genetic testing company itself says on its website. You can read all about it here.

We will focus on the fact that this genetic testing simply doesn’t save money – even according to a study by the main proponents of this dystopian scheme, Aetna and its buddies at the ironically named Newtopia.

If engineers learn more from one bridge that falls down than from 100 that stay up, this new Aetna-Newtopia study is the Tacoma Narrows of wellness industry study design. No article anywhere – including our most recent in Harvard Business Review – has more effectively eviscerated the fiction that wellness saves money than Aetna just did in a self-financed self-immolation published in the Journal of Occupational and Environmental Medicine. We hope the people who give out Koop Awards to their customers and clients will read this article and finally learn that massive reductions in cost associated with trivial improvements in risk are because of self-selection by participants, not because of wellness programs. And certainly not because of wellness programs centered on DNA collection.

Aetna studied Aetna employees who, by Aetna’s own admission, didn’t have anything wrong with them, other than being at risk for developing metabolic syndrome, defined as “a cluster of conditions that increase your risk for heart attack, stroke and diabetes.”

In other words, Aetna took the wellness industry’s obsession with hyperdiagnosis to its extreme: The “diagnosis” of those Aetna studied was that they were at risk for being at risk. Not only did they not have diabetes or heart disease, they didn’t even have a syndrome that put them at risk for developing diabetes or heart disease. You and I should be so healthy.

As this table shows, after one year, the changes in health indicators between the control and study groups were trivial (e.g., a difference in waist measurement of less than 3/10 of an inch), only the change in triglycerides was statistically significant, and just barely (p=0.05). The control group actually outperformed the study group in three of the six measured variables, as would be predicted by chance. Bottom line: Nothing happened.

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Yet Aetna reported savings of $1,464 per participant in the first year. This figure is more than 20 times higher than what Aetna’s own HERO Report says gets spent in total on medical events that could be affected by wellness programs. The figure is also far higher than Katherine Baicker’s claim of a 3.27-to-1 return on wellness spending. (Yes, in keeping with wellness industry tradition, Aetna cited the claim even though it has been thoroughly discredited and basically retracted; only now, because the Baicker study is six years old, Aetna feels compelled to insist that it is “recent.”)

How did Aetna achieve such a high savings figure in a legitimate, randomized controlled trial (RCT)? Simple. That savings was not the result of the legitimate RCT. Having gone through the trouble of setting up an RCT, Aetna largely ignored that study design.

As Aetna’s own table above shows, nothing happened. Spending was a bit lower for the invited group, but obviously there couldn’t have been attribution to the program. A responsible and unbiased researcher might have said: “While there is a slight positive variance between the spending on the control group and the spending on the invitee group that wouldn’t begin to cover the cost of our DNA testing, we can’t attribute that variance to this program anyway. The subjects were healthy to begin with, there was no change in clinical indicators and we didn’t measure wellness-sensitive medical events even though we know from our own HERO report both that those represent only a tiny fraction of total spending, and that those are the only thing that a wellness program can influence.”

Instead, Aetna coaxed about 14% of the invitees to give up their DNA and measured savings on that small sample. (More than coincidentally, that decidedly uninspiring 14% participation rate was about the same as the Aetna-Newtopia debacle at the Jackson Labs reference site-from-hell. Basically, employees don’t want their DNA collected, and DNA turns out to be quite controversial as a tool to predict heart disease down the road, let alone during the next 12 months. Further, Newtopia admits that it stores employee DNA, that lots of people have access to it and that Newtopia could lose it.)

The DNA seems to have had precious little to do with the actual wellness program. This Aetna program seems like a classic wellness intervention of exactly the type that has never been shown to work, with the DNA being only an entertaining sidebar. The subjects themselves exhibited no interest in hearing about their DNA-based predictions.

This is the first time a study has compared the result of an RCT to the result of a participants-only subset of the same population. The result: a mathematically and clinically impossible savings figure on the subset of active participants, and an admission of no separation in actual health status between the control and invitee groups by the end of the program period.

So Aetna accidentally proved what we’ve been saying for years about the fundamental bias in wellness study design that creates the illusion of savings:

Participants in wellness studies will always massively outperform non-participants – even when the program doesn’t change health status and even when there was no program for the “participants” to participate in.

New Wellness Scam: Value on Investment

What do you do if your entire industry has a negative ROI? If your industry and its lack of ROI have been skewered in the media? If even RAND, which is the most neutral, grownup organization in all of healthcare, now says your industry, wellness, produces no savings and no reduction in utilization of healthcare services? If your leadership group accidentally proved their own industry loses money for its customers? If, on this very site, Insurance Thought Leadership, your patron saint, Harvard professor Katherine Baicker, professes to have no interest in wellness any more, now that her work has been eviscerated?

What do you do if there is a proof that saving through wellness is impossible, and another proof that, even if savings were possible, there haven’t been any? If these proofs are backed with a $1 million reward for anyone who can disprove them?

Here’s what you do: You change the rules so ROI doesn’t matter any more.

The new mantra is “value on investment,” or VOI. The Willis Health and Productivity Survey published this week claims that 64% of employers do wellness for VOI – specifically, “employee morale” and “worksite productivity.” (The survey also mentions “workplace safety.” I guess the workplace is safer if no one is working because they are all out getting checkups.)

But the darnedest thing is, all the data shows that the best way to really get value on your investment is to cancel your “pry, poke, prod and punish” wellness program.

Employee Morale

Have you ever seen employees demand more blood tests? More Health Risk Assessments (HRAs)? More weigh-ins? Quite the opposite. This shouldn’t be a newsflash, but employees hate wellness programs, except for the part where they get to collect employers’ money. As a CEO myself (of Quizzify), I pride myself on our corporate culture. The last thing I would do is force my employees into a wellness program. It would destroy the camaraderie we’ve established.

Obviously, if employees liked wellness, you wouldn’t need large and growing incentives/penalties to get people to participate. Employees dislike wellness programs so much that collectively they’ve forfeited billions of dollars just to avoid these programs.

Anecdotes often speak more loudly than data, and employee morale anecdotes are easy to come by. Simply look at the “comments” on quite literally any article in the lay media involving wellness programs. It’s usually about 10-to-1 against wellness, with the “1” being someone who says: “Why should I pay for someone who’s fat?” or something similar. Or the positive comment comes from a wellness vendor or consultant. You know an industry is bogus when the only people who defend it are people who profit on it.

The weight-shaming involved in wellness programs is, of course, a huge fallacy. Among other things, except at both extremes, there is only a slight correlation between weight and health expense in the under-65 population — the problems associated with weight show up later, typically after people leave the workforce. Assuming major differences among employees would lead to underwriting every individual-marathoners who might get injured, women who might get pregnant, etc. Take the fallacy out, and there is nothing that the American public-left, right and center – is more unified on than detesting wellness.

Workplace Productivity

You’re already pulling people off the line to do the “pry, poke and prod” programs and send them for checkups that are more likely to harm employees than benefit them. So productivity takes a hit to begin with. Add to that the weight-shaming and ineffectiveness of corporate weight-loss programs.

Most importantly, it turns out – according to the Integrated Benefits Institute, a wellness industry association – that the major contributor to low productivity is depression:

chart

Maybe this is just me, but if I were running a company where workers were depressed, I probably wouldn’t try to address depression by implementing a program that workers were going to hate, which is sort of a “the beatings will continue until morale improves” approach to management. I’m just sayin’…

The other noteworthy observation? Anxiety has a big impact on productivity. Wellness programs pride themselves on how many diseases they find. This practice is called hyperdiagnosis. The goal is to scare as many employees as possible into thinking they’re sick. The C. Everett Koop-award-winning Nebraska state wellness program, for example, bragged about how it found that 40% of employees were at risk. However, the program didn’t do anything about the finding, and a year later only 161 employees in the entire state had reduced a risk factor. The vendor, Health Fitness Corporation, also bragged about all the cancer cases it found and all the lives it saved, until admitting the whole thing was made up.

Once again, it’s not clear how a wellness program would reduce anxiety and increase productivity. Or maybe I’m wrong. Maybe there’s nothing like being told you are at risk of dying to really focus you on clearing your inbox before you croak.

Conclusion

Pretending there is a VOI looks to be even sillier than pretending there is an ROI, because wellness neither increases morale nor improves productivity.

All of this brings us back to what we’ve been saying for years-especially on this site, which was willing to post our stuff long before it was popular to do so: Do wellness for your employees and not to them.

The latter doesn’t work no matter what initials you use. But if you want to improve morale and productivity, up your game for perks, subsidize healthier options for food and maybe even directly subsidize a portion of gym memberships. And maybe teach your employees how to spend their healthcare dollars more wisely. (Disclosure: That is the business we are in.)

What do you do if your entire industry has a negative ROI? If your industry and its lack of ROI have been skewered in the media? If even RAND, which is the most neutral, grownup organization in all of healthcare, now says your industry, wellness, produces no savings and no reduction in utilization of healthcare services? If your leadership group accidentally proved their own industry loses money for its customers? If, on this very site, Insurance Thought Leadership, your patron saint, Harvard professor Katherine Baicker, professes to have no interest in wellness any more, now that her work has been eviscerated?

What do you do if there is a proof that saving through wellness is impossible, and another proof that, even if savings were possible, there haven’t been any? If these proofs are backed with a $1 million reward for anyone who can disprove them?

Here’s what you do: You change the rules so ROI doesn’t matter any more.

The new mantra is “value on investment,” or VOI. The Willis Health and Productivity Survey published this week claims that 64% of employers do wellness for VOI – specifically, “employee morale” and “worksite productivity.” (The survey also mentions “workplace safety.” I guess the workplace is safer if no one is working because they are all out getting checkups.)

But the darnedest thing is, all the data shows that the best way to really get value on your investment is to cancel your “pry, poke, prod and punish” wellness program.

Employee Morale

Have you ever seen employees demand more blood tests? More Health Risk Assessments (HRAs)? More weigh-ins? Quite the opposite. This shouldn’t be a newsflash, but employees hate wellness programs, except for the part where they get to collect employers’ money. As a CEO myself (of Quizzify), I pride myself on our corporate culture. The last thing I would do is force my employees into a wellness program. It would destroy the camaraderie we’ve established.

Obviously, if employees liked wellness, you wouldn’t need large and growing incentives/penalties to get people to participate. Employees dislike wellness programs so much that collectively they’ve forfeited billions of dollars just to avoid these programs.

Anecdotes often speak more loudly than data, and employee morale anecdotes are easy to come by. Simply look at the “comments” on quite literally any article in the lay media involving wellness programs. It’s usually about 10-to-1 against wellness, with the “1” being someone who says: “Why should I pay for someone who’s fat?” or something similar. Or the positive comment comes from a wellness vendor or consultant. You know an industry is bogus when the only people who defend it are people who profit on it.

The weight-shaming involved in wellness programs is, of course, a huge fallacy. Among other things, except at both extremes, there is only a slight correlation between weight and health expense in the under-65 population — the problems associated with weight show up later, typically after people leave the workforce. Assuming major differences among employees would lead to underwriting every individual-marathoners who might get injured, women who might get pregnant, etc. Take the fallacy out, and there is nothing that the American public-left, right and center – is more unified on than detesting wellness.

Workplace Productivity

You’re already pulling people off the line to do the “pry, poke and prod” programs and send them for checkups that are more likely to harm employees than benefit them. So productivity takes a hit to begin with. Add to that the weight-shaming and ineffectiveness of corporate weight-loss programs.

Most importantly, it turns out – according to the Integrated Benefits Institute, a wellness industry association – that the major contributor to low productivity is depression:

chart

Maybe this is just me, but if I were running a company where workers were depressed, I probably wouldn’t try to address depression by implementing a program that workers were going to hate, which is sort of a “the beatings will continue until morale improves” approach to management. I’m just sayin’…

The other noteworthy observation? Anxiety has a big impact on productivity. Wellness programs pride themselves on how many diseases they find. This practice is called hyperdiagnosis. The goal is to scare as many employees as possible into thinking they’re sick. The C. Everett Koop-award-winning Nebraska state wellness program, for example, bragged about how it found that 40% of employees were at risk. However, the program didn’t do anything about the finding, and a year later only 161 employees in the entire state had reduced a risk factor. The vendor, Health Fitness Corporation, also bragged about all the cancer cases it found and all the lives it saved, until admitting the whole thing was made up.

Once again, it’s not clear how a wellness program would reduce anxiety and increase productivity. Or maybe I’m wrong. Maybe there’s nothing like being told you are at risk of dying to really focus you on clearing your inbox before you croak.

Conclusion

Pretending there is a VOI looks to be even sillier than pretending there is an ROI, because wellness neither increases morale nor improves productivity.

All of this brings us back to what we’ve been saying for years-especially on this site, which was willing to post our stuff long before it was popular to do so: Do wellness for your employees and not to them.

The latter doesn’t work no matter what initials you use. But if you want to improve morale and productivity, up your game for perks, subsidize healthier options for food and maybe even directly subsidize a portion of gym memberships. And maybe teach your employees how to spend their healthcare dollars more wisely. (Disclosure: That is the business we are in.)