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Viewpoint
April 11, 2019

Health Insurance and Mobile Health Devices: Opportunities and Concerns

Author Affiliations
  • 1Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
  • 2Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
  • 3Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
JAMA. 2019;321(18):1767-1768. doi:10.1001/jama.2019.3353

Promoting and incentivizing healthy lifestyle practices in the United States is of national importance. Digital health devices, such as mobile and wearable devices and software applications, have potential for promoting healthy lifestyle practices and preventing the development or progression of cardiovascular disease. The use of mobile health devices has increased substantially in recent years; a national survey of 4000 adults in the United States in 2017 found that 24% of respondents reported using wearable devices.1

Incentives to increase the uptake and usage of mobile health devices are emerging as several health insurers are offering enrollees discounts on wearable devices or on their insurance premiums if activity targets are met. In this Viewpoint, we discuss the current interface between health insurance and mobile health, and the potential benefits and unintended consequences of this interaction.

A Shift in Policy

Insurers are leveraging public interest in health technology, and several companies have combined insurance policies with mobile health. For instance, South African financial services company Discovery Limited conceived a shared-value approach to health and life insurance and founded the Vitality program, which incentivizes healthy behaviors with rewards, such as lower premiums and discounts on mobile health devices.2,3 Through the development of subsidiary companies and partnerships in the United States (John Hancock), United Kingdom (VitalityHealth, VitalityLife), and China (Ping An), this model has spread and these insurance programs are now incorporating trackable information from health devices, including physical activity (eg, daily steps) and heart rate, into their policies. John Hancock, one of the oldest insurers in the United States, introduced a fitness-tracking life insurance policy in 2015. Customers can choose either a Vitality Go program, for which participants log their mobile health data on an application or website and can receive gift cards and 20% to 40% discounts on wearable fitness devices, or their Vitality Plus program that also includes discounted wearable devices and the opportunity to achieve discounts of up to 15% on their life insurance premiums.2 Life insurance premiums will vary depending on the participants’ age and comorbidities and, consequently, so will their potential savings.2

In the United Kingdom, Discovery has combined mobile health devices with health insurance (VitalityHealth) and life insurance (VitalityLife). Participants in VitalityHealth can receive an Apple Watch Series 4 for an initial payment of £99 (US $130; regular price, £399 [US $520]) with subsequent payments over a 24-month period determined by their physical activity (payments may be as low as £0). In addition to discounts on mobile devices, life insurance participants can receive premium discounts of up to 60% on whole life insurance or 40% on fixed-term coverage depending on their level of activity. For example, if a member takes out a £150 000 (US $197 000) life insurance cover over 25 years, they could save up to £180 per year (US $240/y) on their premium.3

Similarly, UnitedHealthcare has partnered with Fitbit and, more recently, with AppleWatch to launch its UnitedHealthcare Motion program that offers monetary rewards, including retroactive discounts on purchased digital health devices based on successful completion of daily fitness goals.4 Participants can save over $1000 per year into their health savings account, which can be used toward medical expenses or deductibles, if daily step targets are met.4 Health insurers Aetna, Qantas Assure, and Oscar Health, among others, are also incorporating physical activity programs into their health insurance policies.

Potential Benefits

Mobile health devices, such as wearable devices and mobile applications, are becoming increasingly more sophisticated. These devices are capable of counting steps, measuring blood pressure, and monitoring heart rate/rhythm. Smartphone health applications can (1) record and monitor personal health data, including physical activity, calorie intake, and weight; (2) facilitate communication between the patient and members of their health care team; and (3) provide reminders regarding medications or upcoming appointments. Taken together, mobile health devices may have the potential to increase physical activity, improve the coordination of health care, and improve medication adherence, although it remains uncertain whether alternative nondevice–based strategies might achieve similar results.5 For example, in a randomized clinical trial of 471 young adults with a body mass index between 25 and 40, the addition of a wearable technology device to a standard behavioral intervention resulted in less weight loss (2.4 kg less) over 24 months.5

Financial incentives to utilize mobile devices appear, in a limited number of studies, to be a successful strategy to increase physical activity. A randomized clinical trial of 281 adults who had a target of walking 7000 steps a day found that participants who faced financial ramifications for physical inactivity were more likely to meet exercise goals than those offered rewards for exercise.6 The ACTIVE REWARD (A Clinical Trial Investigating Effects of a Randomized Evaluation of Wearable Activity Trackers with Financial Rewards) trial randomized 105 patients with ischemic heart disease to an incentive group in which participants were provided with financial penalties if step milestones were not met or a control group. Over the 24-week study period, patients in the incentive group had a significantly greater increase in mean daily steps from baseline during an 8-week ramp-up phase (1388 vs 385; P < .01), 8-week maintenance phase (1501 vs 264; P < .001), and over an 8-week follow-up (1066 vs 92; P < .01).7

Preliminary data from health insurers also seem promising. A total of 422 643 participants in Discovery’s Vitality Rewards Program in the United States, United Kingdom, and South Africa were studied from 2015 to 2018. Members participated in 1 of 2 programs: an active rewards program with an Apple Watch benefit (a loss-framed incentive; members received an upfront Apple Watch with subsequent payments for the watch determined by their physical activity levels) or an active rewards program without an Apple Watch (a gain-framed program; participants received discounts on coffee and cinema tickets by recording their physical activity but did not receive an Apple Watch incentive). Participants in the active rewards program with an Apple Watch benefit engaged in 34% more physical activity than participants in the active rewards program without an Apple Watch.8 In 2018, participants in UnitedHealthcare’s Motion program completed an average of nearly 12 000 steps per day.4

Beyond the direct benefits to patients, if mobile health devices meet expectations for physical activity, they could reduce hospitalizations and the incidence of preventable cardiovascular disease, potentially saving private and public health insurers significant costs. However, randomized clinical trials with long-term follow-up of clinically meaningful end points will be necessary to determine whether these benefits materialize.

Potential Adverse Consequences

The widespread adoption of digital health is not without potential consequences. Although current insurance plans utilize digital lifestyle information in rewards-based programs, data indicating poor health or lifestyle habits could be used by insurers in the future to penalize users with higher premiums or deny insurance. The Affordable Care Act currently prohibits insurers from denying plans to individuals with preexisting conditions, but there is not yet legislation regulating whether digital health data, particularly lifestyle information, can or cannot be used to discriminate against individuals in this capacity.

Another major concern is the accuracy of digital data because large trials validating these devices are lacking. Some wearable lifestyle devices have been shown to undercount steps,9 which could unfairly preclude individuals from collecting incentives from insurance companies for healthy behaviors. As digital health devices expand to diagnostic capabilities, such as detecting hypertension and atrial fibrillation, false-positive results can lead to unnecessary and potentially harmful treatment. Thus far, insurance programs have not targeted data from these diagnostic health devices.

Because these devices can be quite expensive, they could exacerbate health care disparities. Data from the 2012 Health Information National Trends Survey found that patients of low socioeconomic status were engaging less frequently with electronic health.10 The cost of the devices may preclude individuals of lower socioeconomic status from participation in interactive insurance policies and the potential financial rewards or health benefits that may result.

In addition, the protection of individuals’ privacy is an ongoing concern. Digital health devices generate substantive amounts of personal data that can be at risk for distribution to invested third parties. Currently, these data are not protected by the Health Insurance Portability and Accountability Act.

Conclusions

In an era of record high rates of obesity and inactivity among adults in the United States, innovative strategies to promote healthy lifestyle practices are welcome. To the extent that digital health devices encourage healthy behaviors and empower individuals to participate in their health, incentivizing use of these devices by integrating them in insurance policies may be attractive. However, employing close regulation of the new technologies (including the personal data they accrue), ensuring equal access to devices for patients of lower socioeconomic status, and implementing strict regulations that prohibit the insurers from penalizing consumers who engage with these devices will be critical to their success.

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Article Information

Corresponding Author: Robert W. Yeh, MD, Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, 375 Longwood Ave, Fourth Floor, Boston, MA 02215 (ryeh@bidmc.harvard.edu).

Published Online: April 11, 2019. doi:10.1001/jama.2019.3353

Conflict of Interest Disclosures: Dr Yeh reports receiving consultant fees from Abbott Vascular, Asahi Intecc, Boston Scientific, Medtronic, and Teleflex; research grants from Abbott Vascular, Abiomed, AstraZeneca, and Boston Scientific; and salary from Baim Institute for Clinical Research. No other disclosures were reported.

References
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2.
John Hancock Vitality. John Hancock Insurance website. https://www.johnhancockinsurance.com/vitality-program.html. Accessed February 28, 2019.
3.
Vitality. Vitality website. https://www.vitality.co.uk. Accessed February 28, 2019.
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United Healthcare. Help your employees get active. UnitedHealthcare Motion website. http://www.uhctogether.com/casb/assets/pdf/33788.pdf. Accessed, February 28, 2019.
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Chokshi  NP, Adusumalli  S, Small  DS,  et al.  Loss-framed financial incentives and personalized goal-setting to increase physical activity among ischemic heart disease patients using wearable devices: the ACTIVE REWARD randomized trial.  J Am Heart Assoc. 2018;7(12):e009173. doi:10.1161/JAHA.118.009173PubMedGoogle ScholarCrossref
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Hafner  M, Pollard  J, Van Stolk  C. Incentives and Physical Activity: An Assessment of the Association Between Vitality's Active Rewards With Apple Watch Benefit and Sustained Physical Activity Improvements. Santa Monica, CA: RAND Corp; 2018. https://www.rand.org/pubs/research_reports/RR2870.html.
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Case  MA, Burwick  HA, Volpp  KG, Patel  MS.  Accuracy of smartphone applications and wearable devices for tracking physical activity data.  JAMA. 2015;313(6):625-626. doi:10.1001/jama.2014.17841PubMedGoogle ScholarCrossref
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Kontos  E, Blake  KD, Chou  WY, Prestin  A.  Predictors of eHealth usage: insights on the digital divide from the Health Information National Trends Survey 2012.  J Med Internet Res. 2014;16(7):e172. doi:10.2196/jmir.3117PubMedGoogle ScholarCrossref
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