Navigating Germany’s Digital Health Ecosystem: Insights from a

Health Insurance Industry Expert

Laura Bitomsky

, Julian Hollender

, Marcia Nißen

1,4 b

and Tobias Kowatsch

1,3,4 c

School of Medicine, University of St. Gallen, St. Gallen, Switzerland

Allgemeine Ortskrankenkasse (AOK), Germany

Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland

Department of Management, Technology, and Economics, ETH Zürich, Zurich, Switzerland

Keywords: Digital Health Technologies, Digital Health, Health Insurance, Expert Interview.

Abstract: Non-communicable diseases (NCDs) account for 73% of the global mortality in 2017, with an estimated

financial impact of up to US$ 47 trillion by 2030. This escalating prevalence poses a significant challenge to

healthcare systems and insurers, particularly in the context of an aging population with multiple NCDs. Digital

health technologies (DHTs) have emerged as a potential solution, offering scalability, accessibility, and cost-

effectiveness. However, integrating DHTs into healthcare services remains a complex task. We conducted a

semi-structured interview with an industry expert from Germany's largest statutory health insurance group to

explore this issue and derive first hypothesis for improvement. Results indicate seven key insights into

Germany's dynamic digital health ecosystem and offer critical reflections for all stakeholders, providing a

foundation for further discussions and actions in this transformative field.

1 INTRODUCTION

As of 2017, non-communicable diseases (NCDs)

such as cancer, diabetes, cardiovascular diseases,

chronic respiratory diseases, including common

mental disorders (CMDs) accounted for a staggering

73% of the global mortality (Roth et al., 2018) with

an estimated global financial impact of up to US$ 47

trillion between 2010 and 2030 (World Health

Organization, 2021). As older adults are increasingly

affected by multiple NCDs, health expenses can

escalate dramatically with each additional condition

(Hajat & Stein, 2018). This is due to the growing

complexity of management, which demands health

resources and expertise from various disciplines

(Newman, Tong, Levine, & Kishore, 2020). This

poses a significant health and economic challenge for

healthcare systems worldwide, particularly for health

insurance companies. This is further exacerbated

given the aftermath of COVID-19 where health

insurers already face tight budgets.

https://orcid.org/0009-0002-9545-0268

https://orcid.org/0000-0002-6082-8825

https://orcid.org/0000-0001-5939-4145

In light of this, the question arises whether digital

health technologies (DHTs) are a fitting approach to

alleviate the health and economic impact of NCDs.

DHTs thereby refer to digital solutions that leverage

information and communication technologies,

enabling medical professionals and caregivers to

customize and extend personalized, long-term

treatments to individuals (Kowatsch & Fleisch,

2021). By leveraging technology, DHTs are scalable,

constantly accessible, less stigmatizing, cost-

effective, and culturally adaptable (Jacobson, Quist,

Lee, & Marsch, 2023). As such, they promise to

overcome many traditional barriers to healthcare and

are poised to transform healthcare delivery

substantially (Cummings, Allen, Clennon, Ji, &

Druss, 2017; Fleisch, 2021; Jacobson et al., 2023).

To this end, there is an unprecedented surge of

interest and activity within the digital health

community, and investments in DHTs have risen

substantially in recent years (Jacobson et al., 2023).

Consequently, the DHT landscape has witnessed

remarkable growth in recent years, with a tremendous

Bitomsky, L., Hollender, J., Nißen, M. and Kowatsch, T.

Navigating Germany’s Digital Health Ecosystem: Insights from a Health Insurance Industry Expert.

DOI: 10.5220/0012401500003657

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 17th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2024) - Volume 2, pages 865-870

ISBN: 978-989-758-688-0; ISSN: 2184-4305

865

growth of technology start-ups dedicated to this field

and a projected global market valuation of US$ 56

billion in 2025 (Insider Intelligence, 2022).

Furthermore, there is a growing spectrum of methods

to disseminate DHTs to individuals. These methods

span from healthcare provider (HCPs) offering “apps

on prescription”, also called digital therapeutics

(Fürstenau, Gersch, & Schreiter, 2023), to activation

codes from payors, employers, or pharmacies

(Jacobson et al., 2023). Additionally, several

countries have established comprehensive national

coverage frameworks for DHTs (e.g., DVG in

Germany) (Essén et al., 2022; Fürstenau et al., 2023).

However, there is currently a lack of established

frameworks for integrating DHTs into healthcare

delivery and the overall healthcare system (Kay-

Lambkin, Heinsch, & Sampson, 2023). Also, studies

have shown that HCPs underutilize DHTs in their

clinical practice (Batterham et al., 2015). As such, a

fundamental paradigm shift in the healthcare system

is required to integrate DHTs successfully and

sustainably into healthcare delivery and unleash

DHTs’ full potential in combatting the rising burden

of NCDs.

To this end, we conducted a semi-structured

expert interview to gain insights into navigating

Germany’s digital health ecosystem. With “digital

health ecosystem” we hereby refer to the complex and

multifaceted interplay of the health industry,

regulations, and technology (e.g., infrastructure,

components, devices) to enable the delivery of

(digital) health services. The interview was conducted

online and latest approximately 90 minutes. We

interviewed the CEO of a digital hub (set up as a

corporate startup) of Germany’s largest health

insurance group. The insurers cover approximately 27

million individuals, nearly one-third of the population

and over 45% of care-dependent individuals in

Germany. With a market share of 37 percent, they

spend roughly 271 million euros every day for the

healthcare of all insured individuals. The interview

was structured along the three dimensions status quo,

business models and ecosystems, and required

(regulatory) changes to get a holistic perspective on

navigating the German digital health ecosystem both

today and in the future. The interview reflects the

expert’s opinion based on his extensive experience in

the healthcare industry. The views expressed are his

and do not speak for the health insurance group he is

currently employed at.

The themes explored during the interview were

synthesized into seven key insights, which are

elaborated in Chapter 2. It is important to note that all

content in Chapter 2 is derived directly from the

original interview data and thus reflect the

interviewee’s perspective. Lastly, we discuss and

contextualize the insights generated from the

interview within the broader context of relevant

research to draw our conclusions.

2 SEVEN KEY INSIGHTS FOR

NAVIGATING GERMANY’S

DIGITAL HEALTH

ECOSYSTEM

The expert interview resulted in seven key insights

that will be elaborated in the following. The insights

derived represent the expert’s opinion based on his

substantial experience in the health care industry and

do not represent the opinion of the health insurance

group.

2.1 For a Payor, It Is not Enough to

Know a DHT Is Overall Effective

While the Digital Care Act of 2019 introduced the

“app on prescription”, also known as DiGA

(“Digitale Gesundheitsanwendung”) and has spurred

innovation and dissemination of DHTs, their

integration into Germany's healthcare system still

faces challenges.

Direct-to-patient solutions manifest notable

activity, particularly in female health, diabetes, and

overall well-being. However, from a statutory health

insurance (SHI) standpoint, DHTs are yet to take

centre stage, both in availability and adoption.

Furthermore, current solutions are too often in their

infancy for a systematic application.

While some within the SHI community see DHTs

as transformative and a vital part of the future

healthcare system, initiating flagship projects and

supporting the dissemination, others still strongly

question the overall effectiveness and, more

importantly, the cost efficiency of DHTs. The divide

widens regarding prevention versus treatment, where

the potential user base expands significantly.

In a post-COVID-19 landscape where insurers

face tight budgets, critics emphasize short-term cost

increases associated with DHTs. Within DiGA

guidelines, a clinical trial must be conducted to prove

that a DiGA is better than not using it, referring to a

positive supply effect. However, from a SHI cost

perspective, DHTs must surpass mere effectiveness

and provide a comparative advantage over

conventional approaches.

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Since health service expenditures are a multitude

of administrative costs, even a marginal cost lever

could have tremendous positive and negative impacts.

As such, DHTs could play a significant part for SHI

in the future if they effectively succeed in proving

such comparative advantage over traditional

approaches. Until then, DHTs are likely to continue

to divide the SHI community into enthusiasts and

critics.

2.2 A Battle for Attention Will Limit

Successful Standalone B2C

Solutions

Clear strategic approaches are essential for effective

DHT customer outreach, characterized by two

primary dissemination channels: direct-to-customer

(B2C) and healthcare provider-to-customer (B2B2C).

Direct-to-customer solutions are directly sold to

consumers who pay out of pocket for the respective

service (e.g., cycle trackers within the context of

female health). Although lucrative, this approach can

be extremely difficult, as the willingness to pay

additional health-related services beyond existing

health insurance coverage is extremely low. More

importantly, with increasing number of DHTs

entering the market, attention among potential users

saturates quickly. Consequently, the pressure for

individual DHTs to deliver distinct and substantial

benefits is extremely high to facilitate successful

scalability. Thus, there is expected to be a finite

window for additional successful standalone

solutions before attention competition hampers

further growth.

With B2B2C approaches, HCPs such as

physicians are key actors, as they prescribe or

recommend a digital therapeutic or preventive care

intervention, ideally paid for by the patients’ health

insurance. With HCPs as gatekeepers, it is pivotal to

gain their trust and incentivize the prescription and

recommendations of DHTs. Furthermore, seamless

integration within the healthcare provision process is

critical. As this facet is often underemphasized,

collected DHT data runs the risk of remaining

underutilized and falling short of its full potential.

2.3 Digital Ecosystems Are Pivotal for

Scaling DHTs Effectively

There currently exists a well-functioning health

ecosystem in Germany – the main challenge is that it

its predominantly analogue. This analogue ecosystem

systematically hinders successful scaling of DHTs as

standalone solutions coexist in silos but are not

sufficiently integrated with each other and the

existing ecosystem. As such, a digital health

ecosystem is instrumental for effective DHT scaling.

A well-functioning digital ecosystem that rivals or

surpasses the incumbent analogue structure could

potentially replace the HCPs’ role as a gatekeeper and

allow for new protagonists to take the stage: If the

first point of contact for consumers is no longer the

HCP but, for example, a DHT that manages the

patient journey end to end, that could expedite

dissemination of DHTs substantially.

However, while the goal of a fully digital health

ecosystem is admirable, to build and establish a

successful digital health ecosystem is incredibly

difficult and, as of today, yet to be seen successfully

in action.

2.4 Shis in Prime Position to Take

Centre Stage in a Digital Health

Ecosystem as Policyholder

Advocates

As with all ecosystems, only a few providers will

prevail, resulting in extremely high-risk capital for

everyone attempting.

Looking at the current landscape, there are three

broad alternatives. A seasoned external player (e.g.,

Apple, Google) enters the healthcare arena,

leveraging technological prowess and potential

interoperability with existing devices such as

wearables that will generate sufficient pull for other

digital health players. Alternatively, a highly

successful digital health use case exerts a significant

pull, propelling ecosystem participation. For

example, a successful digital symptom checker or

appointment management system may represent an

entry point for an end-to-end digital health journey.

Finally, established entities like SHIs or hospitals

could leverage their significant industry expertise and

established position in the analogue ecosystem.

While SHI are unlikely to be successful in

independently building and orchestrating a complex

digital health ecosystem due to insufficient

capabilities and resources, they are in a prime

position. SHIs have a unique monetary incentive to

keep policyholders healthy and ensure efficient

treatment. In the broadest sense, SHI can be seen as

non-profit organizations. As such, they are ideally

situated to orchestrate a digital health ecosystem with

policyholders' best interests at heart. Even though

policyholders might not always realize it, SHI’s role

as advocates for them is paramount.

Navigating Germany’s Digital Health Ecosystem: Insights from a Health Insurance Industry Expert

867

In the end, however, having a well-functioning

digital ecosystem by any participant is preferable to

having nothing at all.

2.5 Data Protection Needs a More

Balanced Risk Approach

An important task in implementing a digital health

ecosystem in Germany lies in the stringent protection

of health-related data. However, risk evaluation

approaches that focus mostly, if not solely, on data

protection dominate presently in Germany. This often

neglects or at least underemphasises other potential

risks. To setup a successful digital health ecosystem

a more balanced approach is essential. This includes

considering other risks such as falling behind in

digitalization efforts and not being able to afford the

current healthcare system in future as well as

considering benefits like enhanced medication cross-

effect analysis. Striking a comprehensive risk

assessment is crucial, yet there is currently no well-

functioning system in place for weighing risks

adequately and holistically.

2.6 Enabling Genuine MVPs Rather

than Fixating on Every Detail Is

Crucial

Presently, digital solutions on an institutional level

are designed as convoluted minimum viable products

(MVPs), intended for a broad audience but offering

minimal value (see, for example, the German

electronic health record). Regulatory specifications

and requirements are often delayed or unaddressed

due to the urgency of accommodating all exceptions.

A shift towards authentic MVPs, initially benefiting a

smaller demographic but exhibiting significant

utility, can expedite innovation and digital progress.

This approach fosters rapid iteration, learning, and

evolution, with broader applicability and exception

inclusion following organically. Furthermore,

sustainability in digital strategies and regulations

demands increased predictability. While periodic

introspection is imperative, pre-empting new

regulations before comprehensively assessing prior

ones risks stifling progress. Augmented predictability

empowers players, whether established entities or

startups, to innovate, design, and develop solutions

with confidence in their long-term viability. This

stability is needed in Germany to build an attractive

digital health ecosystem.

2.7 Overall Success Hinges from Equal

Participation from all

The strength of an ecosystem relies on every

participant's equitable contribution. Ideally, each

entity is intrinsically or extrinsically motivated to

fulfil its role. When intrinsic motivation falters,

impartial sanctions must be enforced consistently,

even if not politically expedient. While successful

precedent exists in industries such as finance and

banking, HCPs’ influential role has historically led to

reluctance to impose sanctions. This imbalance needs

to be addressed to establish a successful digital health

ecosystem in Germany.

3 CONCLUSIONS

The escalating prevalence of NCDs poses a

significant challenge to healthcare systems globally

and health insurers particularly. As such, innovative

approaches to rethink current healthcare delivery are

imperative. DHTs have emerged as a potential

solution, promising scalability, accessibility, and

cost-effectiveness. However, integrating DHTs

successfully and sustainably into healthcare services

remains complex, and their true potential is yet to be

uncovered. While further interviews would be helpful

to get a more robust perspective, the expert’s insights

already offer invaluable perspectives on navigating

Germany's digital health ecosystem and provide a

foundation for further discussions and actions in this

transformative field.

The divide within the SHI community regarding

the effectiveness and cost efficiency of DHTs mirrors

the need for further research and evidence to

demonstrate their comparative advantage over

conventional approaches. While numerous studies

have proven the overall effectiveness of DHTs, both

in practice (Krämer, Köhne-Volland, Schumacher, &

Köhler, 2022; Pöttgen et al., 2018; Twomey,

O'Reilly, Bültmann, & Meyer, 2020) and in research

(e.g., Deady et al., 2017), the short-term cost

concerns, especially in the wake of COVID-19,

highlight the importance of proving the economic

benefits of DHTs.

The necessity of a well-functioning digital

ecosystem is pivotal for effective DHT scaling,

surpassing the limitations of the current analogue

system. Until then, successful standalone solutions

will not only be rare but due to their siloed nature will

fall short of their full potential. Similarly, B2B2C

solutions will continue to be sporadically integrated

into healthcare delivery, underutilizing the collected

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868

data, and failing to unlock all the potential cost

efficiencies and healthcare delivery effectiveness.

This is in line with previous work that has highlighted

the limited impact of sophisticated DHTs in a

fragmented healthcare ecosystem (Abernethy et al.,

2022). The untapped potential of DHTs could impact

patient outcomes even further: in a well-designed

digital health ecosystem, DHTs have the potential to

prevent, mitigate and reduce disparities in access and

care delivery (e.g., Craig et al., 2020). As such, the

need for a well-functioning digital health ecosystem

is further highlighted. However, building and

establishing such an ecosystem is a formidable

challenge that requires collective efforts from various

stakeholders. This goes hand in hand with achieving

equilibrium among all participants in the digital

health ecosystem as a crucial success factor.

Addressing the historic imbalance in the influence of

healthcare providers is imperative, as impartial

sanctions and consistent enforcement are necessary

for the ecosystem's sustainable growth. Future work

should focus on outlining and evaluating concrete

steps on how to promote participation from all

stakeholders and motivate shared incentives to build

this integrated system. This could include, but is not

limited to, exploring the implications and benefits of

blended care (e.g., Keller et al., 2023; Kowatsch et al.,

2021).

Finally, the significance of balanced data

protection measures is underscored, necessitating a

comprehensive risk assessment framework that

considers both privacy concerns and the benefits of

enhanced data analysis. This is in line with previous

works recommending to balance protecting privacy

and realizing the benefits from access to health data

(Borgesius, Gray, & van Eechoud, 2016; Lane &

Schur, 2010; Wan et al., 2022). Finding this balance

is crucial if Germany is serious about establishing a

well-functioning digital health ecosystem.

In conclusion, navigating Germany's digital

health ecosystem requires a multifaceted approach

that considers the perspectives of SHIs, healthcare

providers, regulators, and patients. Balancing cost

concerns, data protection, and innovation will be

pivotal in realizing the full potential of digital health

technologies in combatting the rising burden of non-

communicable diseases. As the healthcare ecosystem

continues to evolve, embracing digital solutions will

be paramount in shaping a more efficient, accessible,

and effective healthcare system for the future.

ACKNOWLEDGEMENTS

We want to thank our interview partner for taking the

time and allowing for unique insights into the German

(digital) health ecosystem.

CONFLICT OF INTERESTS

LB, MN, and TK are affiliated with the Centre for

Digital Health Interventions, a joint initiative of the

Institute for Implementation Science in Health Care,

University of Zurich, the Department of

Management, Technology, and Economics at ETH

Zurich, and the Institute of Technology Management

and School of Medicine at the University of St

Gallen. The Centre for Digital Health Interventions is

funded in part by CSS, a Swiss health insurer, Mavie

Next, an Austrian health insurer, and MTIP, a Swiss

digital health investor. TK is also a cofounder of

Pathmate Technologies, a university spin-off

company that creates and delivers digital clinical

pathways. However, neither CSS, SanusX, MTIP, nor

Pathmate Technologies were involved in this

research. All other authors declare no conflict of

interests.

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