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Tanned and with a wide grin, Wayne Gono, aged 64, may be one of the oldest people at his family business Regal Plastics — but he and his wife regularly top the employers’ leaderboard for taking the most steps. The Texan business was one of the first to embrace a programme offered by United Healthcare, its health insurer, which uses devices such as the Apple Watch to push members into more physical activity.
“My wife and I, since we are the elders in the company, try to stay in the top five. I can say to the others, I’m one of the oldest guys here and I’m kicking your butt!” he says laughing.
As well as the satisfaction of a win over colleagues, members get cash if they meet three targets: frequency of movement — getting up and walking for small periods often; intensity — at least one burst of 3,000 steps in 30 minutes; and tenacity, completing 10,000 steps in a day. Meeting each goal helps members earn between $1 and $3.
Gono says he has earned about half his deductible back by keeping active, saving money on the amount he pays out of pocket for medical care each year. He puts the extra cash straight into a “vacation fund” for taking his kids and grandchildren on holiday.
Health insurers are turning to wearable devices including the Apple Watch and Fitbit wristbands to encourage employees to engage with their own health — long before they fall ill. They hope that by harnessing technology companies’ expertise in how to change behaviour, they will deliver daily nudges that make people healthier and — down the line — save costs.
There are challenges: from ensuring the programmes reach the least fit, not just those who were already exercising, to assuaging fears on privacy and data security, particularly when an employer is paying for the insurance.
But if overcome, such measures could solve some of the biggest problems in chronic care. Obesity — one of the many damaging results of a sedentary lifestyle — is the second-leading cause of preventable death, behind smoking, in the US. It cost the US healthcare system about $147bn in 2008, according to the Centers for Disease Control. Estimates of the cost to the entire US economy because of lost productivity range from $3.4bn to $6.4bn.
Doctors have long known that their patients need to exercise more — but it has been far easier to prescribe pills than physical activity. JoAnn Manson, chief of the preventive medicine division at Brigham and Women’s Hospital in Boston, says exercise is “as close to a magic bullet as we’ve come in modern medicine”.
She has recommended that exercise be considered an “additional vital sign” — alongside the classic four of blood pressure, pulse, breathing rate and temperature. Doctors should ask about exercise every visit, she believes.
“I do appreciate clinicians are extremely busy in the office with a lot of demands. It is very rushed. However, this is an intervention that could ultimately reduce the risk of many of the chronic diseases that have such extreme costs, a major human burden and toll on the population,” she says.
Manson says insurers’ incentive programmes could be used to encourage more physical activity — but also that there needs to be more research on how effective they are.
United Healthcare launched its programme in January 2018. Paul Sterling, vice-president of emerging products for the company, said it was already saving about $220 per member in medical costs each year, comparing people who participate in the programme with people who don’t.
“The underlying thesis is simple. It’s not new: movement or motion as medicine,” he says. “The beauty of the programme is that it does provide a day-after-day opportunity for reinforcement and support.”
United is now looking at how to include activities such as swimming, cycling and even gardening, so that people are rewarded for all types of exercise.
Discovery, a South African health insurer and owner of Vitality, pioneered this type of effort. Francois Millard, senior vice-president and chief actuarial officer at Vitality Group, said the project was initially modelled on airline frequent-flyer programmes. The insurer realised it was “uniquely situated to benefit if our members get healthier” — so it should share the upsides with participants.
A study by research institute Rand Europe of more than 422,000 Vitality members in the UK, US and South Africa, from 2015 to 2018, found that members of the rewards programme with the Apple Watch were active for an extra five days a month. Perhaps predictably, the study found that unhealthy people were much less likely to take up a programme like this. But, importantly, it found that when they did, they did so with gusto, showing a “more pronounced behaviour change”.
Vitality used behavioural economics to design its programme. Members receive a discounted Apple Watch, but must pay the full cost if they do not meet their goals — albeit interest-free. People are more averse to losing money than to potential gains, so it is a strong nudge to change their behaviour.
The programme also borrows tricks from the tech industry that have been shown to engage users more, such as uncertain rewards. Just like a Facebook user refreshes their news feed frequently because he or she is not sure what could appear next (or a gambler gets excited for their next game), if a member meets their goals, they can spin a wheel where they might win gift cards worth anything from $5 to $25.
The obvious goal of these programmes is making members more active — and therefore healthier. But many insurers are also interested in programmes because they build a closer relationship with members, who usually just interact with them when they want a bill to be paid. This added engagement can make members feel more loyal and can give the insurer opportunities to nudge them into other healthy practices.
Oscar Health, an insurance start-up backed by venture capitalists including Google Ventures, put a step tracking function in its app to ensure members come back daily. Oscar gives its members a concierge team to answer questions and direct them to providers that offer the best value for money. It also encourages people to use telemedicine where possible.
Sara Wajnberg, chief product officer for the New York-based company, said the original intention was to offer “fun, gamified goals”, where members can earn rewards of up to $100 in Amazon gift cards a year. But it also helps them correct perceptions that insurers are just a “billing interface” into seeing them as an “entry point into the entire healthcare system”.
Oscar found that 87 per cent of members who tracked their steps engaged with the concierge team and telemedicine, compared with 57 per cent of the total membership. The company also believes it encourages members, who buy the insurance on an open marketplace rather than being offered it by an employer, to stick with them.
Aetna, the health insurance arm of US pharmacy chain CVS, is going even further, putting more healthcare services in its Attain wellness app. Using an Apple Watch, Aetna members are given personal activity goals and fed notifications including reminders to get vaccinations, refill prescriptions and visit their primary-care doctor if they have not recently. If needed, they are also nudged towards cheaper options for tests and scans.
Ben Wanamaker, head of consumer technology and services at Aetna, said the idea was to “reduce the friction” for users. He said employers recognised Aetna had these “unique capabilities” to engage members.
“They are key customers and in many cases they have shared concerns about what to do about the medical costs and the effectiveness of their employees,” he said. “You don’t have to be acutely ill to be less than your best healthwise so Attain helps people get better and be more effective at work and home.”
Aetna is now working with Apple to use machine learning to improve how it personalises the product. Members can choose to send their programme data and health history to Apple, which will use it to create new features.
Andrew Matzkin, a partner at the consultancy Health Advances, said Apple could benefit from these programmes in the short term through bulk sales of the Apple Watch — but in the longer term they could inform Apple’s own ambitions in healthcare.
He says one of the biggest questions is whether Apple wants to use its stores to create high-tech clinics — a sort of Genius Bar for the body. The company already owns AC Wellness, a small chain of clinics that serves its employees.
“You could imagine Apple saying eventually, ‘We know how to create a great consumer experience in person, in retail, and we could combine it to offer more digitally-enabled primary care’,” he says.
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