Dr. Aetna Will See You Now

The ever-blurring line between the practice of medicine and the business of profiting from unhealthy lifestyles was crossed again Wednesday, as Aetna announced a collaboration with two pharmaceutical companies to pitch their prescription weight loss drugs to selected Aetna members.

This announcement crosses multiple lines, not just one. First, no insurer has ever announced that it would openly direct a specific class of members to use particular proprietary drugs. Disease management (DM) programs rarely recommend specific drugs, and certainly in the exceptionally rare instances when they do, the recommendations are not specific brand-name drugs (in this case, Arena’s Belviq and Vivus’s Qsymia).

Instead, DM focuses on improving compliance with existing drug regimens, and DM firms encourage members “talk to their doctor” about changing therapies. While DM companies shy away from directing patients to specific products, physicians and pharmacists have discretion to discuss the full range of covered generic and brand products with patients, in order to optimize therapy and close algorithm-identified care gaps.

Second, there are no generally accepted care algorithms (other than those created by the manufacturers of those products) for these two drugs in the treatment of obesity. So there is no “gap” to fill. If there were an accepted protocol, these drugs might be blockbusters but instead Belviq’s recent quarterly sales were an anemic $4.8-million, “well below even reduced Wall Street expectations,” while QSymia sales are “flailing” at $6.4-million for the same period.

Obese people and their physicians seem to be avoiding these drugs in droves. Regardless of what Aetna and the manufacturers believe about their effectiveness, or whatever promotional deal they’ve cut, market reaction is telling a different story, and unfortunately for Aetna, Vivus, and Arena we live in a market economy.

Third, these members (the press release is careful not to refer to them as “patients”) aren’t even sick. They are obese. It is controversial and not at all clear that obesity is a disease. This question has been debated on THCB and elsewhere, and is far from settled. Aetna itself in this press release does not refer to obesity as a disease but rather a risk factor.

Finally, because it’s likely that not one obese person has ever called Aetna to ask: “What specific name-brand flailing drug from manufacturers out of favor with financial markets would you recommend for me?” Aetna isn’t just sitting by the phone. They are providing “outreach” to those members, combined with a small incentive of a free app, to convince people to take these drugs.

In an era when most insurers are “counterdetailing” to provide education to and incentives for increasing use of generics, Aetna is, uniquely, helping two pharmaceutical companies sell their hapless name-brand products to its members and detail them to its network physicians.

It’s possible that maybe Aetna should get the benefit of the doubt, seeing as they are “putting their money where their mouth is,” and betting that insured members will save them more than enough money in avoided medical events to offset the considerable cost of these drugs. However, it is exactly the opposite situation.

As is often the case with  insurer-sponsored wellness programs aimed at the not-really-sick population, Aetna is offering its self-insured customers these drug advocacy programs for their employees, but not offering them to their own fully insured members.  (Presumably the drugs are covered, as are most FDA-approved drugs, but Aetna is not actively advocating them to fully insured people, we don’t know their position in formulary tiers.)

Others may also find additional fodder in this press release to support a hypothesis that Aetna knows nothing about weight control, such as a belief completely unsupported by evidence that behavior modification is effective against obesity, failure to understand the difference between short-term weight loss and long-term weight loss maintenance, over-reliance on anecdotal outcomes, and insufficient disclosure of product side effects.

The nasty outcomes in clinical trials included a 20% incidence rate of paresthesia for Qsymia users and 5% incidence of high blood pressure and 12% incidence of back pain in Belviq users.

However, misunderstanding the basics of study design and weight control — along with any consequences of their actions such as any potential liability if these drugs turn out to be another fen-phen (phentermine of fen-phen fame is one of the two active ingredients in Qsymia) — is not the lead here.  The lead here is that Aetna is playing doctor with a license they don’t have, pushing drugs that no one seems to want on people who aren’t actually sick…without even taking the financial consequences of its own actions but rather foisting those consequences instead on the very same employer customers whose financial risks and whose employees’ health they are supposed to be protecting.

Al Lewis is the author of Why Nobody Believes the Numbers, co-author of Cracking Health CostsHow to Cut Your Company’s Health Costs and Provide Employees Better Care, and president of the Disease Management Purchasing Consortium.

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness.  An iconoclast to the core, he is the author of the Khanna On Health Blog.  He is also the Wellness Editor-At-Large for THCB.

Vik and Al are the first authors in THCB’s new e-publishing venture.  Their book, Surviving Workplace Wellness…With Your  Dignity, Finances and (Major) Organs Intact, will be released soon. Vik’s solo e-book, Your Personal Affordable Care Act: Making Yourself Scarce In The Dysfunctional US Healthcare System will be released simultaneously. Pre-orders are being taken now at this link, where you can also sign up to receive additional information.

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14 replies »

  1. This is my first time ever giving a review, and it’s because I have never seen anything like this. Honestly, I just want people to know about this and maybe something can come out of it.

    I have a surgery scheduled for next month. Prior to switching to Aetna, I was covered under my parents’ health insurance. Since I recently turned 26, I was required to subscribe to my university’s plan.

    I have scheduled and attended a number of appointments in the past month to diagnose a problem that I had been experiencing. I had spoken to a representative of Aetna prior to switching because I was new to the insurance and knew that some quirks would inevitably come up. I was reassured that everything that I did prior to switching would allow me to proceed with the surgery that I had scheduled for the end of the year just fine. Today, I was told, by the hospital where I will be having the procedure, to inquire into the “referral” process that Aetna might have to qualify for coverage since they are a university sponsored plan. As a result, I called both my university and unfortunately Aetna. The customer service person told me that I had no choice but to undergo all of the previous appointments that I had already done all over again at my university and have the doctor at my university refer me to the surgery doctor once again. It was either that or pay for the procedure out of pocket as I was so rudely told.

    I’m sorry but I did not have a shabby doctor, or clinic, or health insurance for that matter. I can’t really see any other reason for that recommendation other than Aetna wanting me to give them more business some way somehow. This just does not seem right to me. If I do get have this doctor’s appointment to obtain the referral, I have no doubt that the appointment will go something like this: I will pay the co-pay, I will meet the doctor for 5 minutes who will look at the medical files that I will have already faxed over to the university’s doctor’s office, and I will then leave. No further treatment, just a waste of my time, their time, and money.

  2. Well, well, well…this gives Aetna’s competitors a chance to make hay while the sun shines down on this great gaffe, a gift of Aetna to them. If they’re smart, they’ll get cracking.

  3. Aetna has been known to do some strange things like the contest pilot about taking your meds..run a lottery to get folks all excited and earn a few bucks..I think it took a dive and the ridiculous efforts to “dummy down” patients with games that are portals that scrape data…


    Its all about the math models for profit usually at the source of some of the stuff you see out there today and I did a very popular post about it about quantitated justification for things that are just not true. This is going to get bigger as we have this big blur occurring and I do hope they chat about this at Davos and that is the fact that we should be working on uniting the “virtual software” worlds with the “real world” and when you see so much steroid marketing out there, it certainly is blurred as where does the real world kick in and where the virtual worlds stop…think about that one. I end up with a lot of interesting conversations to include the NISS, and we talk about models they can’t replicate, some CMS data when not give the data base material to replicate too.

    Charlie Siefe who I communicate with from NYU told me he’s working on a new book that will be addressing the “journobot” and watch the video on that one as it will impact the news you see and might be written by a bot. Forbes is in the process of trying to sell their journobot that produces about 20 to 25 of the articles you see there, machine learning at it’s best or worst:)

    There are profits to be made with adding complexities for sure and insurers know this game very well as they are directly attached to the banks and stock exchanges, all about money. That’s why I said back in 2009 when everyone hit me over the head that Sebelius would be eaten alive with Health IT in a few years, and it happened, called data mechanics logic that allows you to see it if you want that is:)


    This is a big problem and the math models insurers have used with specifying segmentation are at risk because the ACA is all about removing certain segmentation elements in those models, i.e. no segmentation calculations supposedly allowed for pre-existing conditions. We take their world for it as those are proprietary models that they use for their business. Again this is why I said Ms. Sebelius didn’t have a touch of data mechanics logic in there thinking and with what we are seeing now it become more obvious and evident in the news all the time with some of the weird perceptions that she talks about at times.

    I don’t know how long it will take and what forms it will take but this going to get huge with abuse with math models and what you see reported. Shoot I have had a few major newspaper reporters email me with questions on this as well as chats with the NISS and various mathematicians.

    Years ago when I wrote a very simple EMR and integrated with some billing software, what drew my attention here in just replicating and making sure my queries were accurate was the claim and other data I saw in the processes as I would re-identify data in the software as process to verify accuracy of my SQL that made my hair stand on end..some of it just made no sense. Of course way back then I would de-identify data and re-identify it as process of making sure my queries worked so that’s been around for a long time and that was before well had it all on the web:) If you want to dig in further I have my Algo duping page with a collection of videos from folks smarter than me that substantiate how this works and i sought out to find videos that the layman could get something out of too. It’s just a different layer of using my brain instead of the machine learning to identify patterns I guess, and of course others are doing that too. Banks and insurance companies over the last few years have morphed into very big software companies that control a lot of money and access.


  4. It’s absurd to blame Capitalism for what the Insurance companies are doing. It’s at best Crony Capitalist system.

    It’s not just Humana.

    Look at Concentra, a subsidiary of Humana, they are rapidly expanding in delivery of Immediate care both in Workers Compensation and Group Health.

    They also have spread their tentacles in utilization review….

  5. This is a fully baked idea by Aetna and I can’t believe they will make even a few pennies per share for their efforts. Why risk your reputation at all for something that doesn’t make sense at all.

  6. I’m not sure we can blame ACA for Aetna’s corrupt bargain.

    By the way, someone offline commented to me that it is possible that these drugs work and that doctors simply aren’t willing to prescribe them. We can’t rule that out (though the side effects are pretty apparent) so I wanted to give airtime to that viewpoint. (My suspicion is that if a drug for a condition like obesity worked, news of that success would go viral.)

    And that doesnt’ excuse Aetna’s unconscionable willingness to let its customers be the guinea pigs on their self-insured lives while not doing this for their own fully insured members. As some famous guy once said: “It is hard to imagine a more dangerous way of making decisions than by putting them in the hands of people who pay no price for being wrong.”

  7. This is another blatant example of the consequences of allowing health care to be delivered under a capitalistic economic model. It simply cannot continue this way or we will see even more distasteful/harmful/inappropriate developments like this. As if we haven’t seen enough of them already. What amazes me is that so many very intelligent people in this country understand what’s happening but that awareness and discussion and exposure has not been sufficient to get even a small rise out of Washington, much less needed action. What does that tell you about our political system in its current state? And that comment is directed at ALL politicians, not just the current party in power. Finding an honest politician anywhere is likie looking for a righteous person in Babylon.But we continue to allow them to function unchallenged. Sad commentary on our society.

    • Gary: you are 100% correct that it all goes back to the political process. Our political system is broken, and its fractured processes have delivered to us a broken healthcare system. Not only is it impossible to find an hones politician, finding one who can speak about healthcare in something other than carefully scripted, but consistently moronic talking points (crafted by whichever interest group they favor), is equally impossible.

  8. This is a truly dismaying move. It’s no surprise to most people that Big Pharma has become too powerful and wields an inappropriate influence over the medical profession, but now that one company is literally climbing into bed with an insurance carrier, we have reached an all-time low. It’s just one more example of how ACA does NOT address the real problems in our health care system. The pharmaceutical industry is not addressed at all in the law and while insurance companies were certainly impacted by the law, rather than making their policies more flexible and affordable, the system has just gotten more complicated and unnavigable.

    • Are you suggesting that The Act does not Protect the Patient or make Care more Affordable? How could the system be more “unnavigable” when we have so many more Navigators? I am shocked; shocked I tell you.

  9. Of all the things that Aetna could be working on to improve their member’s health this is a really odd initiative. For sure the answer to why they are doing this can be found by following the money. As ACA turns these companies into highly regulated utilities I suppose they have to find other ways to generate revenue.

  10. Aetna should get in a lot of trouble for this. It’s wrong on so many dimensions. Someone at Aetna has to have a side deal going with the drug companies because otherwise you’d have to wonder about the busiiness judgment of whoever came up with this idea. I predict in a week we’ll see this on Huffpost or some other national news site. Their competitors should be all over this too.

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