Tag Archives: wellness program

Wellness Promoters Agree: It Doesn’t Work

How many times do wellness promoters have to admit or prove that wellness doesn’t work before everyone finally believes them?

Whether one measures clinical outcomes/effectiveness, savings or productivity, the figures provided by the most vocal wellness promoters and the most “successful” wellness programs yield the same answer: Wellness doesn’t work.

  • Outcomes/Effectiveness

Let’s start with actual program effectiveness. Most recently, Ron Goetzel, head of the committee that bestows the C. Everett Koop Award, told the new healthcare daily STAT News that only about 100 programs work, while “thousands” fail.

In that estimate, which works out to a failure rate well north of 90%, he is joined by Michael O’Donnell, editor of the industry trade journal, the American Journal of Health Promotion (AJHP). O’Donnell says that as many as 95% of programs fail. (For the record, I have no beef with him, because he once willingly admitted that I am “not an idiot.”)

The best example of this Goetzel-O’Donnell consensus? McKesson, the 2015 Koop Award winner. McKesson’s own data –even when scrubbed of those pesky non-participants and dropouts who are too embarrassed to allow themselves to be weighed in – shows an increase in body mass and cholesterol:

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Vitality Group, which contributed to this McKesson award-winning result as a vendor, wants your company to publicly disclose how many fat employees you have. Why? So that you are “pressured” (their word) into hiring a wellness vendor like Vitality. Yet Vitality admits it can’t get its own employees to lose weight.

McKesson and Vitality continue a hallowed tradition among Koop Award-winning programs of employees not losing noticeable weight. For instance, at Pfizer, the 2010 award-winner, employees who opened their weight-loss email lost all of three ounces:

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Maybe it’s unfair to pick programs based on winning awards. Awards or not, those programs could have cut corners. Perhaps to find an exception to the rule that wellness can’t improve outcomes, we should look to the most expensive program, Aetna’s. Unfortunately, even Aetna registered only the slightest improvement in health indicators, throwing away $500/employee in the process. Why that much? Aetna decided to collect employee DNA to predict diabetes, even though reputable scientists have never posited that DNA can predict diabetes.

So even award winners, wellness vendors themselves and gold-plated programs can’t move the outcomes needle in a meaningful way, if at all. Bottom line: It looks like we finally have both consensus on the futility of wellness, and data to support the wellness industry admission that way north of 90% of programs do indeed fail to generate outcomes.

Savings

Because wellness promoters now say most programs fail, it is no surprise they also say most programs lose money. Once again, this isn’t us talking. The industry’s own guidebook – written by Goetzel and O’Donnell and dozens of other industry leaders — shows wellness loses money. We have posted that observation on ITL before, and no one objected.

However, very recently, the sponsors of this guidebook (the Health Enhancement Research Organization, or HERO) did finally take issue with our quoting statistics from their own guidebook. They pointed out — quite accurately — that their money-losing example was hypothetical. It did not involve numbers they would approve of, despite having published them. (At least, we think this is what HERO said. One of their board members has learned that they have sent a letter to members of the lay media, telling them not to publish our postings. We are told HERO’s objection centers on our quoting their report.)

To avoid a lawsuit for quoting figures they prefer us not to quote, we substituted their own real figures for their own hypothetical figures — and using real figures from Goetzel’s company, Truven Health Analytics, multiplied the losses.

This very same downloadable guidebook notes that these losses, as great as they are, actually exclude at least nine other sources of administrative costs–like internal costs, impact on morale, lost work time for screenings, etc. (Page 10). Truven also excludes a large number of medical costs (Page. 22):

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One could only assume that including all these administrative and medical losses in the calculation would increase the total loss.

Lest readers think that this consensus guidebook is an anomaly, HERO is joined in its conclusion that wellness loses money by AJHP. AJHP published a meta-analysis showing a negative ROI from high-quality studies.

Productivity

RAND’s Soeren Mattke said it best:

“The industry went in with promises of 3-to-1 and 6-to-1 ROIs based on healthcare savings alone. Then research came out that said that’s not true. They said, ‘Fine, we are cost-neutral.’ Now research says: ‘Maybe not even cost-neutral.’ So they say: ‘It’s really about productivity, which we can’t really measure, but it’s an enormous return.'”

The AJHP stepped up to make Dr. Mattke appear prescient. After finding no ROI in high-quality studies, proponents decided to dispense with ROI altogether. “Who cares about ROI anyway?” were O’Donnell’s exact words.

Because health dollars couldn’t be saved, O’Donnell tried to estimate productivity impact. But honesty compelled him to admit that workers would need to devote about 4% of their time to working out to be 1% more productive on the job. Using his own time-and-motion figures, and adding in program costs, his math creates a loss exceeding $5,200/employee/year.

I would have to agree with O’Donnell, based on my experience in the 1990s as the CEO of a NASDAQ company. Ours was a call center company, which meant someone had to answer the phones. If I had let employees go to the gym instead of working, I would have had to pay other employees to cover for them. Our productivity would have taken a huge hit, even if the workouts bulked up employees’ biceps to the point where they could pick up the phone 1% faster.

Where Does This Leave Us?

Despite our using their own figures, wellness promoters may object to this analysis, saying they didn’t really intend for these conclusions to be reached. Intended or not, these are the conclusions from their figures, and theirs largely agree with ours, expressed in many previous blog posts on ITL. And, of course, our website, www.theysaidwhat.net, is devoted to exposing vendor lies. The bottom line is, no matter whose “side” you are on, the answer is the same. Assuming you look at promoters’ actual data or statements instead of listening to the spin, the conclusion is the same: Conventional wellness doesn’t work.

It’s time to move on.

New Way to Lower Healthcare Costs

Managers are more likely to limit rental cars to $30 a day than limit an open heart surgery to $100,000 — for ethical and regulatory reasons, many executives steer clear of involving themselves in healthcare decisions, other than selecting the broadest possible network access. But few expenses that executives know so little about matter more than those involved in healthcare do.

This article speaks to a cultural shift that could provide tremendous impact for employers. They can now lower costs while also improving outcomes.

Until now, employers have used two main strategies:

–They offloaded costs to employees, hoping that giving them more skin in the game would reduce their spending on healthcare. But the continuing lack of transparency about healthcare costs, combined with costs that rose faster than employers shifted them, resulted in insurance picking up more cost and consumerism being driven down.

–Employers also invested in wellness programs. But wellness programs are most attractive to the already healthy. And they attempt to reduce how often enrollees encounter the system. But we know that everyone will encounter care at some point. It is each encounter’s volume and cost that is at the heart of this out-of-control system.

The new, better approach was demonstrated in a whirlwind, 48-hour trip I took with some incredible healthcare leaders.

First, we met with the executives of Rosen Hotels in Orlando, who have saved hundreds of millions of dollars compared with average employer healthcare costs. Rosen’s single-digit employee turnover would delight most employers, but it is spectacular in the hospitality industry. Rosen achieves this turnover with a benefit-rich plan most employees would drool over: e.g., no-cost prescriptions, $750 max hospital out-of-pocket.

How does Rosen accomplish this? First, its healthcare thinking is based on what it wants to achieve rather than what it has to provide. Beginning with the CEO, Rosen’s top executives really care about every one of their employees, as evidenced by the more than a few employees who have been there for 40-plus years. (Remember, this is a hotel chain, not a hedge fund with six-digit salaries). The strategies deployed vary, but they mainly support making the highest value care as accessible as possible.

Value—a fair return or equivalent in goods, services or money in exchange for something—is seriously lacking in American healthcare. Rosen took it upon itself to provide healthcare whenever and wherever possible, using its clout to lower costs. The company arranged special prescription drug discounts with Walmart. Rosen has on-site medical directors who personally engage with each employee’s health. The directors visit employees in the hospital and help arrange home delivery of costly specialty medications from lower-cost pharmacies. The company monitors and supports sick employees’ recovery and progress. It also built a health-and-wellness center for all employees and dependents with primary care, prescriptions, fitness instruction and more. I know all this sounds expensive, but the impact far outweighs the cost.

The second part of our adventure involved a flight to the Caribbean island of Grand Cayman, just south of Cuba, a beautiful tropical setting an hour-long flight from Miami (and with direct flights from a dozen other U.S. cities). The morning after our late arrival, we enjoyed the beautiful sunrise for exactly 20 seconds before we were bused to a facility called Health City Cayman Islands (HCCI). The single building on 200 acres (with significant future expansion plans) is clean, new and functional, though it is not nearly as grand as many U.S. mega-hospitals. Now two years old, HCCI is a joint venture between Ascension Health (a non-profit U.S. health system) and Narayana Health, a top Indian health system based in Bangalore. HCCI’s Indian roots are very important, because that country has no national healthcare or insurance system. The Indians have a novel approach to healthcare: You pay for it.

Narayana Health, which has achieved Joint Commission International (JCI) accreditation, performs a volume of procedures unprecedented in most hospitals. This volume is produced by a highly experienced team with quality outcomes that equal or exceed the best U.S. hospitals, but the team does it at far lower cost. Dr. Devi Shetty, Narayana’s founder and a cardiologist who has performed more than 25,000 heart surgeries, is focused on reducing the price of an open heart surgery to $800. (It currently sits around $1,400). Compare that with a 2008 Millman report that pegs U.S. open heart surgery costs around $324,000.

Some employers—Carnival Cruise Lines, for example—are so convinced of HCCI’s value (better health outcomes at far lower cost) that they will pay for all travel, including a family member’s accommodations for the length of a stay, and often waive an employee’s out-of-pocket costs associated with the procedure.

While HCCI’s pricing is higher than its Indian sister facility, many people could afford to pay for HCCI’s care with their credit card, if that were necessary.

HCCI charges a single, bundled fee that covers all associated costs, plus the cost of most complications — the director says, “Why should the patient pay for something if it was our mistake?” Compare that attitude with that at U.S. facilities, which have financial incentives to deliver as much care for as long as possible, and which get paid more if they make mistakes. HCCI’s upfront pricing model creates a serious incentive for efficiency and quality, because the facility is financially responsible for complications, infections and extra tests.

Patients and purchasers (i.e. employers and unions) should realize that nearly all U.S. healthcare—hospitals, doctors, drug companies and even insurance carriers—are structured to benefit from more care, rather than good, efficient or innovative care.

This means that purchasers and patients must use any available levers to get the best healthcare value they can. As Rosen and HCCI have proven, those levers are increasingly available.

Triathlete’s View on Workplace Wellness

We frequently get complaints from “average” employees about wellness, and our most popular article on the Huffington Post was about the fat-shaming aspects of wellness programs that obsess with BMIs.  (Weight discrimination under the guise of weight control is one of the hallmarks of wellness, of course.)

But what about triathletes? What about people for whom those wellness incentives are a complete windfall? They can collect money for what they do anyway, sort of like when you buy something at a store and don’t learn it was on sale until you check out.  Obviously, as the beneficiaries of these programs’ largesse (at the expense of other employees indirectly, of course), fitness buffs should embrace wellness, like –to quote wellness apologist Larry Chapman — “a beloved pet.”

Sure, if that pet is the Hound of the Baskervilles.

tasmanian devil

(Note to the literal-minded.  This isn’t actually the Hound of the Baskervilles, who declined to sit for a photo session. This isn’t even a dog, as far as we know.)

I’d encourage you to read this critique of Virgin Pulse’s program in its entirety.  You’ll have to scroll down through the blog post (not too fast – you’ll miss the review of Quizzify) to Comment No. 3, but it’s worth a full read to capture the essence beyond these excerpts.

First, Virgin Pulse — here’s a shocker — can’t do math.  Because of its innumeracy (also one of the hallmarks of wellness), Virgin is accomplishing exactly the opposite of what wellness is supposed to do:

When I ran 5 miles in 50 minutes, at a 10-min/mile pace, I got more points for having >45 min of active minutes, but when I actually ran it faster, say, 8-min/mile pace which gave me a 40 min time, I only got >30 min activity, and fewer points, despite performing a much harder task. Nothing like being punished for being successful.

And Virgin Pulse apparently can’t do wellness either (yet another hallmark of the wellness industry):

Those of us who lift weights and do things that do not have “steps” but require greater physical acumen are greatly disadvantaged. Sadly, most government programs place a higher priority on “aerobic” activity rather than strength training. This “cardio = fitness” mentality is about 30 years behind the times.

The author, of course, is completely correct about this on multiple dimensions. Virgin Pulse’s information is way out of date, outdated information being — you guessed it — yet another hallmark of the wellness industry.  Among other things, giving “points” for cardio but not strength will increase back pain and other musculoskeletal problems, which account for a vastly higher share of employer health spending than the 1-in-800 incidence of heart attacks – in two different ways:

  1. Strength exercises are now shown to be the best way to prevent and control back pain.
  2. Obsessing with “steps” increases the likelihood of falls, sprains and repetitive motion injuries.

At the risk of “burying the lead,” here is another thing Virgin managed to do:

It can also be annoying to be reminded constantly to get my mammogram. I am a breast cancer survivor and have had a double mastectomy. No mammograms for me. How insensitive of you!

After several paragraphs of other observations about the intrusiveness (still another hallmark of the wellness industry, in this case including monitoring employee sleep), she concludes:

The entire program is childish and silly. Another “social media” forum for people to get imaginary medals or stupid stuff while [Virgin] surreptitiously inserts little “healthy” reminders that may or may not be considered current health information. [Editor’s note: The majority of Virgin’s “1,440 habit-building interactions per member per year” are self-evident and cliched, outdated, wrong, unrelated to wellness or controversial.]

I’m sure there are better ways to promote corporate fitness that are not insulting to the intelligence of adults. As a personal trainer and health coach, I’d be happy to give you a few ideas.

Here’s one idea: Require wellness vendors to know the first thing about wellness.

10 Most Dangerous Wellness Programs

If corporate wellness didn’t already exist, no one would invent it. In that sense, it’s a little like communism, baseball, pennies or Outlook.

After all, why would any company want to purchase programs that damage moralereduce productivitydrive costs up…and don’t work 90% to 95% of the time? And those are the results reported by wellness proponents.

Those are the employers’ problems, but the employers’ problems become the employees’ problems when employees are “voluntarily” forced to submit to programs that are likely to harm them. (As the New York Times recently pointed out, there is nothing voluntary about most of these programs.)

Recently, the head of United Healthcare’s (UHC) wellness operations (Optum), Seth Serxner, admitted that Optum’s programs consciously ignore U.S. Preventive Services Task Force (USPSTF) screening guidelines. Rather than apologize, Serxner blamed employers for insisting on overscreening and overdiagnosing their own employees…and (by implication) overpaying for the privilege of doing so. “Our clients make us do it,” were his exact words.

We asked our own clients who use Optum about why they turned down Optum’s generous offer to do more appropriate screenings at a lower price. None of them remember receiving such an offer.

A UHC executive wrote and said we were making the company look bad. I said I would happily revise or even retract statements about the company if the executive could introduce me to just one single Optum customer — one out of their thousands — who recalls insisting on overscreening and overpaying. Never heard back….

United Healthcare isn’t alone in harming employees. It is just the first company to admit doing so. It is also far from the worst offender, as the harms of its overscreening for glucose and cholesterol don’t hold a candle to the ideas listed below, in increasing order of harms:

#10 Provant

We would say: “Someone should inform Provant that you are not supposed to drink eight glasses of water a day,” except that we already did, and they didn’t believe us. Obsessive hydration remains one of their core recommendations despite the overwhelming evidence that you should drink when you are thirsty.

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By contrast, the New York Times, which has an Internet connection, writes the opposite:

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#9 Cerner

The employee who recorded this blood pressure is essentially dead. Cerner’s diagnosis? Blood pressure “higher than what is ideal.” Cerner’s recommendation? “Talk to your healthcare provider.” A real doctor’s recommendation? “Call an ambulance. The guy barely has a pulse.”

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This is not a random mistake. This is the front cover of the company’s brochure.

#8 Nebraska/Health Fitness Corp.

USPSTF screening age recommendations aren’t minimums. They are optimums, the ages at which screening benefits might start to exceed harms, even if they still fall far short of costs. Otherwise, you are taking way too much risk. This is especially true for colonoscopies, one of this program’s favorite screens — complications from the test itself can be very serious.

Your preventive coverage is not supposed to be “greater than healthcare reform guidelines.” That’s like rounding up twice the number of usual suspects. And you aren’t supposed to waive “age restrictions.” That’s like a state waiving minimum “age restrictions” to get a driver’s license.

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Yet this program won a C. Everett Koop Award for excellence in wellness, not to mention the unwavering support and admiration of leading wellness apologist Ron Goetzel.

#7-#6 (tie) ShapeUp and Wellness Corporate Solutions

Both these outfits pitch exactly the opposite of what you are supposed to do in weight control: unhealthy crash dieting. Attaching money to this idea and setting a start date make the plan even worse: along with crash-dieting during these eight weeks, you’re encouraging employees to binge before the initial weigh-in.

Here is ShapeUp:

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Here is Wellness Corporate Solutions:

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Both also made up outcomes. In ShapeUp’s case, the company had to rescind its “findings” after the customer, Highmark, skewered the company in the press. And neither seems to care that corporate weight control programs are proven not to work.

#5 Aetna

In addition to its wellness program that collects employee DNA (partnered, ironically, with a company called Newtopia) and then makes up claims about savings, Aetna owns the distinction of launching the only wellness program whose core drugs are specifically editorialized against in the Journal of the American Medical Association. This would literally be the most harmful wellness program ever, except that the only employees being harmed are (1) obese employees who (2) answer the phone when their employer’s health plan calls them to pitch these two drugs; (3) who have a doctor who would willingly prescribe drugs that almost no other doctors will prescribe, because of their side effect profile; and (4) who don’t Google the drugs. Presumably, this combination is a very low percentage of all employees.

The good news is that the drugs, Belviq and Qsymia, should be off the market in a couple of years because almost no one wants to take them, so the harms of this Aetna program should be self-limited.

#4 Star Wellness

Star Wellness offers a full range of USPSTF D-rated screens. “D” is the lowest USPSTF rating and means harms exceed benefits. Star gets extra credit for being the first wellness vendor to sell franchises. All you need is a background in sales or “municipal administration” plus $67,000 and five days of training, and you, too, can poke employees with needles and lie about your outcomes. Is this a great country, or what?

Also, the company’s vaccination clinic features Vitamin B12 shots. We don’t know which is more appalling–routinely giving employees Vitamin B12 shots or thinking Vitamin B12 is a vaccine.

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#3 Angioscreen

Angioscreen doesn’t have the most USPSTF D-rated screens. In fact, it offers only one screen in total, for carotid artery stenosis. That screen gets a D grade from USPSTF, giving Angioscreen the unique distinction of being the only vendor 100% guaranteed to harm your workforce.

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Angioscreen’s other distinction is that the company admits right on its website that this screen is a bad idea. Angioscreen is probably the only non-tobacco company in America to admit you are better off not using its product.

#2 Total Wellness

In addition to the usual assortment of D-rated tests, the company offers screens that the USPSTF hasn’t even rated, because it never, ever occurred to the USPSTF that anyone would use these tests for mass screening of patients or employees. Criticizing the USPSTF for not rating these “screens” (CBCs and Chem-20s) would be like criticizing Sanofi-Aventis for not warning against taking Ambien after parking your car on a railroad crossing.

#1 HealthFair

Let’s leave aside the fact that the majority of its other screens are harmful and focus on its screening for H.pylori, the strain of bacteria associated with ulcers.

Visit our full treatment here. In a nutshell, the majority of us harbor H.pylori–without symptoms. It may even be beneficial. The screening test is expensive and notoriously unreliable, and the only way to get rid of H.pylori is with some very powerful antibiotics, a treatment rarely even used on patients with symptoms, because of its inconvenience, ineffectiveness and potential long-term side-effects.

A Modest Proposal

So how should we as a country protect employees from these harms? Our policy recommendation is always the same and very non-intrusive. We aren’t saying wellness vendors shouldn’t be allowed to harm employees. That proposal would be too radical to ever pass Congress. If it did, the Business Roundtable would pressure the White House again, to preserve the hard-earned right to “medicalize” the workplace and show employees who’s boss.

Instead, we recommend merely a disclosure requirement. The harms of screens or (in United Healthcare’s case) screening intervals that don’t earn at least a “B” from USPSTF should be disclosed to employees, and employees should get a chance to “opt out” into something that isn’t harmful (like Quizzify, perhaps?) without suffering financial consequences.

Call us cockeyed optimists, but we don’t think employers should be able to force employees to choose between harming themselves and paying fines.

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.