Skip to main navigation menu Skip to main content Skip to site footer

Review article: Biomedical intelligence

Vol. 149 No. 2526 (2019)

Stay fit or get bit – ethical issues in sharing health data with insurers’ apps

DOI
https://doi.org/10.4414/smw.2019.20089
Cite this as:
Swiss Med Wkly. 2019;149:w20089
Published
30.06.2019

Abstract

In the framework of digital health, mobile applications with health-related content are increasing in number and importance. Many of these apps are targeted at the general public and, although they differ in features and purposes, their functions are often based on the promotion of health and the monitoring of customers’ lifestyle data. Apps of this type have also recently been developed by health insurance companies. In many cases, insurers’ apps do not simply offer health-related recommendations to the users, but also provide economic incentives to those customers who agree to share their behavioural data through the applications. Although such apps may contribute to the adoption of a health-conscious lifestyle, the fact that they require the sharing of dense individual data with the companies responsible for insurance coverage raises some relevant ethical issues.

This paper investigates the phenomenon of insurers’ apps permitting customers to share their data in exchange for monetary rewards currently available in Switzerland. After describing the features and functioning of the apps, we present some ethically relevant aspects related to their use. More specifically, we discuss the issues of transparency of data-sharing purposes, potential discrimination amongst insured people, “quantification” of the users and, finally, the potential tension generated between solidarity and responsibility. We conclude by emphasising that these apps are becoming a new paradigm for insurers in many countries and that a thorough assessment of their ethical and societal implications is required.

References

  1. 2017 Angerer A, Schmidt R, Moll C, Strunk L, Brügger U. Digital Health – Die Zukunft des Schweizer Gesundheitswesens. Winterthurer (Switzerland): Institut für Gesundheitsökonomie, ZHAW School of Management and Law. November 2017. Available from: https://digitalcollection.zhaw.ch/bitstream/11475/1458/1/Digital%20Health%20Report_DC_2017_11_08.pdf.
  2. U.S. Food and Drug Administration. [Internet]. Silver Spring: U.S. Food and Drug Administration; c1995-2017 [cited 2017 May 3]. U.S. Department of Health and Human Services. Available from: https://www.fda.gov/medicaldevices/digitalhealth/#mobileapp.
  3. Meskó B, Drobni Z, Bényei É, Gergely B, Győrffy Z. Digital health is a cultural transformation of traditional healthcare. mHealth. 2017;3:38. doi:.https://doi.org/10.21037/mhealth.2017.08.07
  4. Herberz C, Steidl R, Werner P, Hagen J. Der lange Weg von der Idee bis zur Erstattung – ein Reisebericht [From idea to standard care—a field report]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2018;61(3):298–303. Article in German. doi:.https://doi.org/10.1007/s00103-018-2693-3
  5. Albrecht UV, Höhn M, von Jan U. Gesundheits-Apps und Markt. In: Albrecht UV, editor. Chancen und Risiken von Gesundheits-Apps (CHARISMHA). Medizinische Hochschule Hannover; 2016. p. 62–82. Available from: https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/A/App-Studie/CHARISMHA_gesamt_V.01.3-20160424.pdf. German.
  6. Boulos MN, Brewer AC, Karimkhani C, Buller DB, Dellavalle RP. Mobile medical and health apps: state of the art, concerns, regulatory control and certification. Online J Public Health Inform. 2014;5(3):229. doi:. [Internet].https://doi.org/10.5210/ojphi.v5i3.4814
  7. Aumann I, Frank M, Pramann O. Gesundheits-Apps in der Gesetzlichen und Privaten Krankenversicherung. In: Albrecht UV, editor. Chancen und Risiken von Gesundheits-Apps (CHARISMHA). Medizinische Hochschule Hannover; 2016. p. 244–280. Available from: https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/A/App-Studie/CHARISMHA_gesamt_V.01.3-20160424.pdf. German.
  8. Lupton D. M-health and health promotion: The digital cyborg and surveillance society. Soc Theory Health. 2012;10(3):229–44. doi:.https://doi.org/10.1057/sth.2012.6
  9. Lupton D. The digitally engaged patient: Self-monitoring and self-care in the digital health era. Soc Theory Health. 2013;11(3):256–70. doi:.https://doi.org/10.1057/sth.2013.10
  10. Lucht M, Boeker M, Donath J, Güttler J, Leinfelder D, Kramer U. Gesundheits- Und Versorgungs-Apps. Hintergründe zu deren Entwicklung und Einsatz. Freiburg (Germany): Universitätsklinikum Freiburg und sanawork Gesundheitskommunikation; 2015. Available from: https://www.uniklinik-freiburg.de/fileadmin/mediapool/09_zentren/studienzentrum/pdf/Studien/150331_TK-Gesamtbericht_Gesundheits-und_Versorgungs-Apps.pdf. German.
  11. Empfehlung zum Bonusprogramm. "Helsana+" [Internet]. Bern: Eidgenössische Datenschutz- und Öffentlichkeitsbeauftragte (EDÖB) [cited 2019 January 13]. Available from: https://www.edoeb.admin.ch/dam/edoeb/de/dokumente/2018/Empfehlung%20Helsana.pdf.download.pdf/Empfehlung%20Helsana.pdf. German.
  12. KPT. Die Krankenkasse mit dem Plus [Internet]. Bern: KPT Krankenkasse AG [cited 2019 January 13]. Available from: https://www.kpt.ch/de/versicherungen/zusatzversicherung/activeplus. German.
  13. Verzeichnis der zugelassenen Krankenversicherer (01.10.2018) [Internet] Bern: Bundesamt für Gesundheit [cited 2019 January 13]. Available from: https://www.bag.admin.ch/bag/de/home/versicherungen/krankenversicherung/krankenversicherung-versicherer-aufsicht/verzeichnisse-krankenundrueckversicherer.html. German.
  14. Arras JD. Getting down to cases: the revival of casuistry in bioethics. J Med Philos. 1991;16(1):29–51. doi:.https://doi.org/10.1093/jmp/16.1.29
  15. Degrazia D. Moving forward in bioethical theory: theories, cases, and specified principlism. J Med Philos. 1992;17(5):511–39. doi:.https://doi.org/10.1093/jmp/17.5.511
  16. Jonsen AR. Casuistry: an alternative or complement to principles? Kennedy Inst Ethics J. 1995;5(3):237–51. doi:.https://doi.org/10.1353/ken.0.0016
  17. Cudney P. What really separates casuistry from principlism in biomedical ethics. Theor Med Bioeth. 2014;35(3):205–29. doi:.https://doi.org/10.1007/s11017-014-9295-3
  18. Ignilife [Internet]. Geneva: Ignilife Sàrl [cited 2019 January 13]. Available from: https://app.ignilife.com/landing
  19. Ignilife - Der mobile Sport-Coach [Internet]. Martigny: Groupe Mutuel [cited 2019 January 13]. Available from: https://www.groupemutuel.ch/de/groupe-mutuel/Nos-engagements/notre-engagement-pour-la-culture-le-sport-et-la-sante/Application-Ignilife.html. German.
  20. Maxyourhealth [Internet]. Bern: Atupri. [cited 2019 January 13]. Available from: https://www.atupri.ch/maxyourhealth/. German.
  21. Nutzungsbedingungen maxyourhealth App [Internet]. Bern: Atupri [cited 2019 January 13]. Available from: https://www.atupri.ch/maxyourhealth/nutzungsbedingungen. German.
  22. Helsana+ app: Your Plus points for life [Internet]. Zürich: Helsana Versicherungen AG [cited 2019 January 13]. Available from: https://www.helsana.ch/microsite/plus/#/
  23. Terms of Use and Data Protection Provisions for Helsana+ App [Internet]. Zürich: Helsana Versicherungen AG [cited 2019 January 13]. Available from: https://www.helsana.ch/en/individuals/helsanaplus-legal-information
  24. myStep – every step counts [Internet]. Luzern: CSS Kranken-Versicherung AG [cited 2019 January 13]. Available from: https://www.css.ch/en/home/privatpersonen/kontakt_service/mycss/mystep.html
  25. myStep. Teilnahmebedingungen - Ausgabe 06.2016 [Internet]. Luzern: CSS Kranken-Versicherung AG [cited 2019 January 13]. Available from: https://www.css.ch/downloadpdf.html?fileRef=%2Fcontent%2Fdam%2Fcss%2Fde%2Fdocuments%2Fmycss%2Fmystep%2F499_d_css_teilnahmebedingungen_mystep.pdf and mimeType=application/pdf and _charset_=utf-8. German.
  26. Sanitas Active app FAQs [Internet]. Zürich: Sanitas Grundversicherungen AG [cited 2019 January 13]. Available from: https://www.sanitas.com/en/index/private-customers/bewegung/sanitas_active_app/faq.html
  27. Data privacy policy and terms of use Sanitas Active app [Internet]. Zürich: Sanitas Grundversicherungen AG [cited 2019 January 13]. Available from: https://www.sanitas.com/content/dam/sanitas-internet/main/Bewegung/Active_App/Nutzungs-und_Datenschutzbedingungen_Active-App_en.pdf
  28. SWICA – BENEVITA bonus programme [Internet]. Winterthur: SWICA Krankenversicherung AG [cited 2019 January 13]. Available from: https://www.swica.ch/en/kampagnen/swica-benevita/swica-benevita/swica-benevita
  29. Terms of use of Healthi [Internet]. Winterthur: SWICA Krankenversicherung AG [cited 2019 January 13]. Available from: https://healthi.ch/site/swica/en/route/about/termsAndConditions
  30. SanaHealth [Internet]. Luzern: Sanagate AG [cited 2019 January 13]. Available from: http://www.sanahealth.ch/. German.
  31. SanaHealth – die App, für die alles zählt! [Internet]. Luzern: Sanagate AG [cited 2019 January 13]. Available from: https://www.sanagate.ch/de/home/ihre_vorteile/apps/sanahealth.html. German.
  32. Geschäftsbedingungen [Internet]. Luzern: Sanagate AG [cited 2019 January 13]. Available from: https://www.sanahealth.ch/#agb. German.
  33. Loef M, Walach H. The combined effects of healthy lifestyle behaviors on all cause mortality: a systematic review and meta-analysis. Prev Med. 2012;55(3):163–70. doi:.https://doi.org/10.1016/j.ypmed.2012.06.017
  34. Payne HE, Lister C, West JH, Bernhardt JM. Behavioral functionality of mobile apps in health interventions: a systematic review of the literature. JMIR Mhealth Uhealth. 2015;3(1):e20. doi:.https://doi.org/10.2196/mhealth.3335
  35. Brouwer ER. Legality and data protection law: The forgotten purpose of purpose limitation. In: Besselink L, Pennings F, Prechal S, editors. The Eclipse of the Legality Principle in the European Union. The Netherlands: Kluwer Law International; 2011. pp. 273–294.
  36. Article 29 Data Protection Working Party. 2013. Opinion 03/2013 on purpose limitation, WP203 [cited 2019 January 13]. Available from: https://ec.europa.eu/justice/article-29/documentation/opinion-recommendation/files/2013/wp203_en.pdf.
  37. Forgó N, Hänold S, Schütze B. The Principle of Purpose Limitation and Big Data. In: Corrales M, Fenwick M, Forgó N, editors. New Technology, Big Data and the Law. Singapore: Springer Singapore; 2017. pp. 17-42.
  38. Datenschutzgesetz (DSG). Baeriswyl B, Pärli K, editors. Bern: Stämpfli Handkommentar; 2015
  39. Article 29 Data Protection Working Party. 2007. Working Document on the processing of personal data relating to health in electronic health records (EHR), WP 131[cited 2019 January 13]. Available from: https://ec.europa.eu/justice/article-29/documentation/opinion-recommendation/files/2007/wp131_en.pdf.
  40. Time for new habits – with the Sanitas Active app [Internet]. Zürich: Sanitas Grundversicherungen AG [cited 2019 January 13]. Available from: https://www.sanitas.com/en/index/private-customers/bewegung/sanitas_active_app.html
  41. Bakos Y, Marotta-Wurgler F, Trossen DR. Does anyone read the fine print? Consumer attention to standard-form contracts. J Legal Stud. 2014;43(1):1–35. doi:.https://doi.org/10.1086/674424
  42. Plaut VC, Bartlett RP. Blind consent? A social psychological investigation of non-readership of click-through agreements. Law Hum Behav. 2012;36(4):293–311. doi:.https://doi.org/10.1037/h0093969
  43. Huber M, Knottnerus JA, Green L, van der Horst H, Jadad AR, Kromhout D, et al. How should we define health? BMJ. 2011;343(jul26 2):d4163. doi:.https://doi.org/10.1136/bmj.d4163
  44. Liukko J. Genetic discrimination, insurance, and solidarity: an analysis of the argumentation for fair risk classification. New Genet Soc. 2010;29(4):457–75. doi:.https://doi.org/10.1080/14636778.2010.528197
  45. Crossley M. Discrimination against the Unhealthy in Health Insurance. Kansas Law Review. 2005;54(1):73–153.
  46. Bonoli G, Braun D, Trein P. Pensions, health and long term care – Switzerland – Asisp (Analytical support on social protection reforms and therir socio-economic impact) - Country Document Update 2014. Brussels: European Commission/Gesellschaft für Versicherungswissenschaft und – gestaltung e.V.; 2014.
  47. O’Neill O. Genetic information and insurance: some ethical issues. Philos Trans R Soc Lond B Biol Sci. 1997;352(1357):1087–93. doi:.https://doi.org/10.1098/rstb.1997.0089
  48. Bräm C, Szucs T. Is It Desirable that I Must Disclose My Genetic Data to Swiss Private Medical Insurances? Public Health Genomics. 2016;19(5):251–9. doi:.https://doi.org/10.1159/000448276
  49. Van Hoyweghen I, Horstman K, Schepers R. Genetic “risk carriers” and lifestyle “risk takers”. Which risks deserve our legal protection in insurance? Health Care Anal. 2007;15(3):179–93. doi:.https://doi.org/10.1007/s10728-006-0041-5
  50. Lynch JW, Kaplan GA, Salonen JT. Why do poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socioeconomic lifecourse. Soc Sci Med. 1997;44(6):809–19. doi:.https://doi.org/10.1016/S0277-9536(96)00191-8
  51. Thaler R, Sunstein C. Nudge: Improving Decisions about Health, Wealth, and Happiness. New Haven: Yale University Press; 2008.
  52. Swiss Federal Government. Bundesgesetz über den Versicherungsvertrag [cited 2019 January 13]. Available from: https://www.admin.ch/opc/de/classified-compilation/19080008/index.html. German.
  53. Schmidt H, Gerber A, Stock S. What can we learn from German health incentive schemes? BMJ. 2009;339(sep24 2):b3504. doi:.https://doi.org/10.1136/bmj.b3504
  54. Swan M. The Quantified Self: Fundamental Disruption in Big Data Science and Biological Discovery. Big Data. 2013;1(2):85–99. doi:.https://doi.org/10.1089/big.2012.0002
  55. Sharon T. Self-tracking for health and the quantified self: Re-articulating autonomy, solidarity, and authenticity in an age of personalized healthcare. Philos Technol. 2016;1:1–29. doi:.https://doi.org/10.1007/s13347-016-0215-5
  56. Sharon T, Zandbergen D. From data fetishism to quantifying selves: Self-tracking practices and the other values of data. New Media Soc. 2017;19(11):1695–709. doi:.https://doi.org/10.1177/1461444816636090
  57. Pieters D, Schoukens P. Social Security Law Instruments of the Next Generation: European Social Security Law as a Source of Inspiration? In: Pennings F, Vonk G, editors. Research Handbook on European Social Security Law. Cheltenham: Edward Elgar Publishing; 2015. pp. 534-560.
  58. Biller-Andorno N, Zeltner T. Individual Responsibility and Community Solidarity--The Swiss Health Care System. N Engl J Med. 2015;373(23):2193–7. doi:.https://doi.org/10.1056/NEJMp1508256
  59. Becker U. Introduction to the General Principles of Social Security Law in Europe. In: Becker U, Pieters D, Ross F, Schoukens P, editors. Security: A General Principle of Social Security Law in Europe, Groeningen, Europa Law Publishing; 2010. pp. 1-20.
  60. De Pietro C, Camenzind P, Sturny I, Crivelli L, Edwards-Garavoglia S, Spranger A, et al. Switzerland: Health System Review. Health Syst Transit. 2015;17(4):1–288, xix. [xix.].
  61. Brown RC. Moral responsibility for (un)healthy behaviour. J Med Ethics. 2013 Nov;39(11):695-8. doi: https://doi.org/110.1136/medethics-2012-100774.
  62. Bürgstein WE. Eigenverantwortung im Schweizer Gesundheitswesen. Eine sozialethische Auseinandersetzung im Kontext steigender Gesundheitskosten. Norderstedt, BoD – Books on Demand; 2015.
  63. Sax A. Eigenverantwortung. Schweiz Arzteztg. 2017;98(05):174. doi:.https://doi.org/10.4414/saez.2017.05360
  64. Bloss CS, Wineinger NE, Peters M, Boeldt DL, Ariniello L, Kim JY, et al. A prospective randomized trial examining health care utilization in individuals using multiple smartphone-enabled biosensors. PeerJ. 2016;4:e1554. doi:.https://doi.org/10.7717/peerj.1554
  65. van Baal PH, Polder JJ, de Wit GA, Hoogenveen RT, Feenstra TL, Boshuizen HC, et al. Lifetime medical costs of obesity: prevention no cure for increasing health expenditure. PLoS Med. 2008;5(2):e29. doi:.https://doi.org/10.1371/journal.pmed.0050029
  66. European Insurance in Figures. 2016 data [Internet]. Brussels: Insurance Europe aisbl [cited 2019 January 13]. Available from: https://www.insuranceeurope.eu/european-insurance-figures-2016-data
  67. Pressemappe Generali Vitality [Internet]. Munich: Generali Deutschland AG [cited 2019 January 13]. Available from: https://www.generali.de/ueber-generali/presse-medien/mediathek/pressemappe-vitality/
  68. Fitness-Tracker und –Apps [Internet]. Munich: Generali Deutschland AG [cited 2019 January 13]. Available from: https://generalivitality.de/vmp/aktiv_leben/fitness-tracker
  69. Private health insurance that rewards you for being healthy [Internet]. London: Vitality [cited 2019 January 13]. Available from: https://www.vitality.co.uk/health-insurance/.
  70. Discovery Vitality: making South Africa healthier [Internet]. South Africa: Discovery Health [cited 2019 January 13]. Available from: https://www.afhealth.co.za/_layouts/AFOSTSITE/afdocumentutil.aspx?filename=/Scheme%20Other/2019%20vitality_discoverer_2018.pdf.
  71. Schmidt H, Voigt K, Wikler D. Carrots, sticks, and health care reform--problems with wellness incentives. N Engl J Med. 2010;362(2):e3. doi:.https://doi.org/10.1056/NEJMp0911552
  72. Buijink AW, Visser BJ, Marshall L. Medical apps for smartphones: lack of evidence undermines quality and safety. Evid Based Med. 2013;18(3):90–2. doi:.https://doi.org/10.1136/eb-2012-100885
  73. McCartney M. How do we know whether medical apps work? BMJ. 2013;346(mar20 1):f1811. doi:.https://doi.org/10.1136/bmj.f1811
  74. Karhula T, Vuorinen AL, Rääpysjärvi K, Pakanen M, Itkonen P, Tepponen M, et al. Telemonitoring and Mobile Phone-Based Health Coaching Among Finnish Diabetic and Heart Disease Patients: Randomized Controlled Trial. J Med Internet Res. 2015;17(6):e153. doi:.https://doi.org/10.2196/jmir.4059
  75. Hamine S, Gerth-Guyette E, Faulx D, Green BB, Ginsburg AS. Impact of mHealth chronic disease management on treatment adherence and patient outcomes: a systematic review. J Med Internet Res. 2015;17(2):e52. doi:.https://doi.org/10.2196/jmir.3951
  76. Zhao J, Freeman B, Li M. Can Mobile Phone Apps Influence People’s Health Behavior Change? An Evidence Review. J Med Internet Res. 2016;18(11):e287. doi:.https://doi.org/10.2196/jmir.5692
  77. Steinhubl SR, Muse ED, Topol EJ. The emerging field of mobile health. Sci Transl Med. 2015;7(283):283rv3. doi:.https://doi.org/10.1126/scitranslmed.aaa3487