We started this project winded by the excitement digital health – like digital anything– generates and the teeth-grinding complexity of trying to figure out what the NHS was doing with it. The responsibility for healthcare payment historically has been spread across states, markets and individuals using some version of insurance logic. Even in a tax funded public healthcare system like the NHS, insurance really matters. Insurance techniques distribute healthcare costs. Whether funded by tax, socially mandated or privately volunteered contributions, healthcare is structured by insurance thinking. Today, more, older and sicker people are straining the capacity of systems everywhere to pay for sufficient quality of, and access to, healthcare. This is where the digital health hype comes jumping in. From remote consultation and diagnosis to self-care, digital health can apparently do extraordinary things for less. Governments are tripping over themselves to announce paper-free, precise, personalised digital healthcare systems. Technology companies, venture capital, big pharma, accountancy and engineering firms are rushing towards the market prospects for an uber of healthcare. Liminal spaces called catalysts, catapults, accelerators, incubators, garages etc. are trying to guide innovations towards system-wide adoption. Despite all these enterprises, what we have found is that the circumstances of healthcare delivery are much more prone to hype than they are to useful disruption. Hype, in short, is easy but system change is hard. Partly because it’s so hard, something is happening to how healthcare is paid for that we should all be paying much more attention to.
This is where the digital health hype comes jumping in. From remote consultation and diagnosis to self-care, digital health can apparently do extraordinary things for less.
To get to the bottom of this, the first thing to note is that insurance is not just about how costs are spread. Insurance consumes data to help define what health is. Look at its roles in establishing the International Classification of Diseases or the Body Mass Index. So we were very interested when we started to notice health insurance companies experimenting with wearable digital fitness devices.
We were not the only ones. Oscar Health Insurance made national headlines in the US when it announced that its customers could opt to receive a free Misfit fitness tracker. The tracker would not only stream customer’s biometric information straight to Oscar but, for those who met their step targets – it would pay up to 240 Amazon gift card dollars a year.
For all the headlines and venture capital funding it has grabbed, Oscar is a tiny player in the US private health insurance market. Giants like UnitedHealth, Aetna, Anthem, Humana and Blue Cross Blue Shield dominate and are fast consolidating further. In a neat example of how health happens in the interaction of states and markets Oscar began trading in 2013 in the market space opened up by the 2010 Patient Protection and Affordable Care Act (ACA). The ACA is an attempt to reform a system which routinely ranks among the world’s most expensive ways of delivering some mixed, indifferent outcomes.
Part of the problem was the number of people without insurance. Under the ACA the uninsured are required to buy subsidised plans on the new marketplaces. Since the goal is to decrease the uninsured population, insurers had to be prohibited from doing business as usual. Insurers select risks. If a bad risk comes along, cover is either denied or a high price is charged. Insurers offering plans on ACA marketplaces however cannot discriminate against pre-existing health conditions. This means they have to find new ways of keeping their customers healthy because sick customers are expensive customers. This is where Oscar’s particular digital health proposition comes in. In theory.
The ACA is designed to incentivise healthier behaviour and behavioural, lifestyle or preventable diseases are a big part of the healthcare challenge. But there is no simple equation between digital solutions and public health problems. Healthcare is delivered in particular circumstances, by particular providers and financed by particular payers. These circumstances – or infrastructures – are what allow healthcare systems to work. They are of such dizzying complexity that even if trackers do make insurance customers healthier – that is still a long way from making Oscar profitable or competitive. Health insurer margins are somewhere in the delicate practical balancing of risk selection, product features, marketable pricing and corporate financing. How much infrastructure matters in this is clear in discussions of Oscar’s $100 million loss in 2015.
Misfit was never really expected to make Oscar customers healthier. Instead its use conforms to a logic that pervades the sector, irrespective of what material benefits the multiple innovations that sit somewhere under the contested digital health umbrella will ultimately bring. This goes like this. The device/technique/app will do no harm (probably) and might even do some good. In the absence of a digital health infrastructure based around meaningful ownership, collection, sharing and use of big health data, ‘digital health’ is mainly doing buzz work. The Misfit scheme does its heavy lifting in the free publicity it generates. Where the big insurance brands share a differentiation, trust and reputation problem, Oscar, the hipster, upstart start-up has made its technology offer the centre of its standout marketing.
Despite all those column inches Oscar is not the only insurer using wellness devices. In fact, compared to the Vitality scheme which has been adopted by a number of other insurers, Oscar is late to the party. Oscar is significant though because it is the clickbait story for something that hasn’t quite happened yet – but soon might. That is the universal digital mediation of health and healthcare payment. All those devices, those benign little accelerometers are quietly smoking us! From being the authors of our bodily fortunes, we have passed control to devices that randomly define 10000 daily step-proxy movements as health. We might earn rewards, or even premium reductions, for reaching fitness targets but what if we start earning penalties, premium hikes or cover refusal for failure? What if big biometric data in the hands of insurers brings unruly social consequences?
If all that sounds like a long way from digital health in the NHS well, it is and it isn’t. We have found no evidence of any attempt to use digital technologies to financialise movement, or in any way inform access to healthcare. But there are other ways in which what is happening in the US has parallels in healthcare financing and payment here. The most apparent is the tension between hype and circumstances. Senior government have produced strategies redolent with ‘techno-utopianism’ in their fondness for paperless, ‘digital-by-default’ commitments say, by 2018, or 2020. While private insurers will struggle to adapt legacy infrastructures to digital risk classification, connecting the 9000 separate organisations involved in NHS care to a shared digital infrastructure is no easier. To make things worse, the NHS is more river than land in the constancy of change. This is beautifully explained in the King’s Fund animation which showed the state of play in 2013, then had to be updated in 2016
To make the NHS work digitally in the way imagined by the National Information Board, one of the organisations charged with ‘putting data and technology safely to work’ requires hard infrastructure design. The prospects for any device, app or method are limited until there is a systemic review of the steampunk plumbing of the existing system. The distance between the difficulty of such work and the ease of rhetorical commitment is one of the reasons why a succession of digital programmes from care.data to a kitemarked apps library have embarrassingly stalled.
This matters because while the difficult work of repair, mending and conversion is not getting the attention it requires, digital health solutions are getting established outside the NHS and outside of the long political commitment to healthcare free at the point of access. From the purchase of atrial fibrillation devices on Amazon, to the use of private online GPs, not to mention the long line of costs associated with buying wearables, apps, smartphones and consulting Dr Google, digital is changing how we pay for health without us even noticing. Returning to insurance and cost spreading, this matters. The more those who can afford to bear their own costs, the more vulnerable the commitment to a collective, universal health service may become. The uberization of the NHS may be what we get.