Opinion
VIEWPOINT
Health Insurance and Mobile Health Devices
Opportunities and Concerns
Inbar Raber, MD Promoting and incentivizing healthy lifestyle prac-
Department of tices in the United States is of national importance.
Medicine, Beth Israel Digital health devices, such as mobile and wearable de-
Deaconess Medical
vices and software applications, have potential for pro-
Center, Harvard
Medical School, moting healthy lifestyle practices and preventing the de-
Boston, Massachusetts. velopment or progression of cardiovascular disease. The
use of mobile health devices has increased substan-
Cian P. McCarthy, MB, tially in recent years; a national survey of 4000 adults
BCh, BAO
in the United States in 2017 found that 24% of respon-
Department of Medicine,
Massachusetts General dents reported using wearable devices.1
Hospital,HarvardMedical Incentives to increase the uptake and usage of mo-
School, Boston. bile health devices are emerging as several health insur-
ers are offering enrollees discounts on wearable de-
Robert W. Yeh, MD
Smith Center for
vices or on their insurance premiums if activity targets
Outcomes Research are met. In this Viewpoint, we discuss the current inter-
in Cardiology, face between health insurance and mobile health, and
Department of
the potential benefits and unintended consequences of
Medicine, Beth Israel
Deaconess Medical this interaction.
Center, Boston,
Massachusetts. A Shift in Policy
Insurers are leveraging public interest in health technol-
ogy, and several companies have combined insurance
policies with mobile health. For instance, South African
financial services company Discovery Limited con-
ceived a shared-value approach to health and life insur-
ance and founded the Vitality program, which incentiv-
izes 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 wear-
able 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
Corresponding life insurance premiums.2 Life insurance premiums will
Author: Robert W. Yeh, vary depending on the participants’ age and comorbidi-
MD, Smith Center for ties and, consequently, so will their potential savings.2
Outcomes Research in
Cardiology, Beth Israel
In the United Kingdom, Discovery has com-
Deaconess Medical bined mobile health devices with health insurance
Center, 375 Longwood (VitalityHealth) and life insurance (VitalityLife). Par-
Ave, Fourth Floor,
ticipants in VitalityHealth can receive an Apple Watch
Boston, MA 02215
(ryeh@bidmc.harvard. Series 4 for an initial payment of £99 (US $130; regu-
edu). lar price, £399 [US $520]) with subsequent payments
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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 partici-
pants 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 mon-
etary rewards, including retroactive discounts on pur-
chased 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 deduct-
ibles, 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 ran-
domized 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 suc-
cessful strategy to increase physical activity. A ran-
domized 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
(Reprinted) JAMA Published online April 11, 2019 E1
 Opinion Viewpoint

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 finan-
cial 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 base-
line 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 Pro-
gram in the United States, United Kingdom, and South Africa were
studied from 2015 to 2018. Members participated in 1 of 2 pro-
grams: 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 dis-
counts 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, partici-
pants 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 de-
vices meet expectations for physical activity, they could reduce hos-
pitalizations and the incidence of preventable cardiovascular dis-
ease, 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 life-
style 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 life-
style devices have been shown to undercount steps,9 which could
unfairly preclude individuals from collecting incentives from insur-
ance companies for healthy behaviors. As digital health devices ex-
pand 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 ex-
acerbate health care disparities. Data from the 2012 Health Infor-
mation National Trends Survey found that patients of low socioeco-
nomic status were engaging less frequently with electronic health.10
The cost of the devices may preclude individuals of lower socioeco-
nomic 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 per-
sonal data that can be at risk for distribution to invested third par-
ties. Currently, these data are not protected by the Health Insur-
ance 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 life-
style practices are welcome. To the extent that digital health de-
vices encourage healthy behaviors and empower individuals to par-
ticipate 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 pa-
tients of lower socioeconomic status, and implementing strict regu-
lations that prohibit the insurers from penalizing consumers who en-
gage with these devices will be critical to their success.

ARTICLE INFORMATION 3. Vitality. Vitality website. https://www.vitality. devices: the ACTIVE REWARD randomized trial.
Published Online: April 11, 2019. co.uk. Accessed February 28, 2019. J Am Heart Assoc. 2018;7(12):e009173. doi:10.1161/
doi:10.1001/jama.2019.3353 4. United Healthcare. Help your employees get JAHA.118.009173

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.
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