Unlocking the Potential of Digital Health Technologies:

The Role of Health Insurance Companies in Shaping the Digital

Healthcare Ecosystem

Marcia Nißen

1,2 a

, Raphael Beuter

, Marek Rydzewski

and Jeremias Pappert

School of Medicine, University of St.Gallen, St. Jakob-Strasse 21, St.Gallen, Switzerland

Centre for Digital Health Interventions, University of Zurich, University of St.Gallen, ETH Zürich, Switzerland

BARMER, Berlin, Germany

Keywords: Digital Health, Digital Health Technologies, DHTs, Non-Communicable Diseases, Chronic Diseases, Health

Insurance Companies, Startups, Health Equity, Gender-Specific Design.

Abstract: This position paper explores the transformative potential of digital health technologies (DHTs) in addressing

non-communicable chronic diseases (NCDs) and raises the question of which role health insurance companies

play in shaping a healthcare landscape to embrace DHTs. Drawing from a semi-structured interview with two

experts from the second-largest health insurer in Germany and supported by public industry reports, newspa-

per articles, and legal texts, this paper discusses three key dimensions: First, this paper challenges the meta-

phor of DHTs as “digital pills”, emphasizing that the success of digital medicine in addressing NCDs depends

on active patient engagement, long-term intervention adherence, and actual lifestyle changes in peoples’ eve-

ryday lives, echoing challenges of analog, traditional medicine. Second, we delve into the promises of DHTs

in improving individual healthcare access and health equity through gender-specific, bias-free design. Lastly,

the paper elaborates on how health insurance companies operate in their roles as non-profit-oriented (a) co-

developers, (b) investors, and (c) catalysts of DHT innovations on a societal scale. In conclusion, this paper

sheds light on some of the critical dynamics of shaping digital health ecosystems and health insurance’s pro-

found impact in paving the way for DHTs.

1 INTRODUCTION

Non-communicable, chronic diseases (NCDs) such as

heart disease, stroke, cancer, diabetes, and chronic

lung disease, account for 74% of all deaths world-

wide. This “epidemic of NCDs” poses devastating

health consequences and challenges for individuals,

families, and communities, and increasingly threatens

to strain healthcare systems to their limits (World

Health Organization, 2023a).

Chronic diseases tend to be, by nature, of long du-

ration and are often the result of a combination of ge-

netic (e.g., gender), physiological (e.g., hormonal

changes across the lifespan), and environmental (e.g.,

air pollution) factors. Equally significant though are

behavioral lifestyle choices such as physical inactiv-

ity, unhealthy diets, alcohol consumption, or smoking

(World Health Organization, 2023b).

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

https://orcid.org/0009-0002-3561-8874

As the world grapples with the mounting chal-

lenges of addressing chronic diseases, the role of dig-

ital health technologies (DHTs) has never been more

critical and a pressing question emerges: How can

digital health technologies (DHTs) be integrated into

patient journeys and healthcare landscapes and what

role do health insurance companies play in paving the

way for their implementation and adoption?

According to the definitions of the Digital Thera-

peutics Alliance, DHTs encompass “the full spectrum

of digital health products that are available to patients,

caregivers, clinicians, and health systems” (Digital

Therapeutics Alliance, 2023a). They may serve spe-

cific purposes across the entire patient journey from

wellness offerings, diagnosis, and symptom monitor-

ing, to Digital Therapeutics (DTx), which are “health

software intended to treat or alleviate a disease, dis-

886

Nißen, M., Beuter, R., Rydzewski, M. and Pappert, J.

Unlocking the Potential of Digital Health Technologies: The Role of Health Insurance Companies in Shaping the Digital Healthcare Ecosystem.

DOI: 10.5220/0012402200003657

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 886-893

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

order, condition, or injury by generating and deliver-

ing a medical intervention that has a demonstrable

positive therapeutic impact on a patient’s health”

(Digital Therapeutics Alliance, 2023b).

DHTs, thus, constitute a compelling medium to

address the increasingly complex and multifaced

challenges posed by NCD, for several reasons:

(1) DHTs Empower Patients, Providing Personal-

ized And Precise Care: DHTs are well suited to em-

power individuals with resources for behavior

change, such as physical activity programs, dietary

trackers, or smoking cessation programs. However,

every person and patient is unique, and so are their

lifestyles, capabilities, and needs.

DHTs have the potential to be tailored to the indi-

vidual, delivering just-in-time, adaptive interventions

(JITAIs) (Kowatsch & Fleisch, 2021). The concept of

JITAIs, “delivering the right intervention to the right

patient at the right time”, is engrained in the goals of

traditional precision medicine which tailors drug and

treatment options to an individual’s specific bio-

molecular and genetic markers.

Yet, DHTs can go beyond snapshots of clinical,

biomedical, and genetic data. They can encompass

behavioral and environmental factors that play a piv-

otal role in the development, but also in the treatment,

management, and, ultimately, treatment success of

NCDs (World Health Organization, 2023b). Specifi-

cally, the availability of individual behavioral and en-

vironmental real-world data collected via increas-

ingly powerful sensing technology integrated into

smartphones and wearables that individuals carry

with them in their everyday lives provides researchers

and healthcare providers with unprecedented oppor-

tunities to monitor the dynamics of an individual’s in-

ternal state and context in real-time. This, in turn, al-

lows for precise and personalized support that is flex-

ible in terms of both time and location (Nahum-Shani

et al., 2018), empowering patients to take their care in

their own hands anywhere and anytime.

(2) DHTs Can Improve Healthcare Access And

Equity: In contrast to health professionals’ limited fi-

nancial and personnel resources and time (Hutton &

Gunn, 2007), DHTs are available on everyone’s

smartphone anytime and everywhere. This universal

accessibility may democratize access to healthcare in-

formation and support, reducing geographical and

economic barriers, and overcoming stigmas or social

taboos, for instance, related to gender-specific or cul-

tural health issues, that often hinder equitable access

to quality healthcare services (Brewer et al., 2020).

(3) DHTs are Scalable and May Contribute To

Cost-Efficiency In Healthcare: Scalability, in the

context of DHTs, implies the ability to adapt, expand,

and serve a growing number of patients or users effi-

ciently and effectively (Mekniran & Kowatsch,

2023), e.g., through remote monitoring, automation,

and standardization processes, and by empowering

patients to make informed decisions about their well-

being and health (Jiang, Ming, & You, 2019). By re-

ducing the burden of extensive in-person care, DHTs

may contribute to cost savings for both healthcare

systems and patients (Borges do Nascimento et al.,

2023; Gentili et al., 2022). Shifting from reactive to

preventive care could not only improve patient out-

comes (Aerts & Bogdan-Martin, 2021) but also re-

duce the financial burden associated with managing

advanced and severely manifested conditions (Jiang

et al., 2019).

However, despite the promising developments of

more and more powerful, evidence-based DHTs,

there currently is a lack of understanding of how

DHTs can be integrated into healthcare systems and

services (Carrilho, Videira, Campos, Midão, & Costa,

2023) and of health insurance companies’ roles in this

process (Iqbal & Biller-Andorno, 2022).

In 2019, even before the COVID-19 pandemic

further fueled digitalization in all areas of our lives,

including healthcare, Germany was the first country

to introduce “digital health apps on prescription" a

concept, commonly referred to as DiGA (short for

German: “Digitale Gesundheitsanwendung”, Eng-

lish: “digital health application”). The Digital Care

Act further catalyzed innovation and the widespread

development and use of DHTs. Yet, the seamless in-

corporation of these technologies into Germany's

healthcare system continues to encounter substantial

obstacles.

This paper aims to provide valuable insights that

can inform strategic decision-making in the digital

health and health insurance sectors. It offers a nu-

anced perspective for stakeholders invested in the

evolving dynamics of healthcare delivery, guiding

healthcare professionals, policymakers, and research-

ers to navigate and contribute to the transformative

journey of healthcare in the digital age.

2 METHODOLOGY

This position paper captures insights and visions of

two distinguished voices in the field, Marek Ry-

dzewski (interview partner 1, short MR) and Jeremias

Pappert (interview partner 2, short JP), as they dis-

cuss the present state, challenges, and prospects of

Unlocking the Potential of Digital Health Technologies: The Role of Health Insurance Companies in Shaping the Digital Healthcare

Ecosystem

887

DHTs and the role of health insurance companies to

enable and facilitate the integration of DHTs in

healthcare systems.

MR is the Chief Digital Officer (CDO) at

BARMER, and JP is a Consultant to the CDO.

BARMER, headquartered in Berlin, is the second

largest health insurance provider in Germany with ap-

proximately 8.7 million insured members.

After providing their informed consent, RB con-

ducted one semi-structured group expert interview

with MR and JP via Zoom that lasted approximately

45 minutes. The interview guide was structured along

the following, overarching themes (cf. Appendix):

DHT Implementation and Effectiveness, DHT Objec-

tives and Outcomes, DHT Quality Assessments and

Learning, DHT Ecosystems and Business Models,

and Future Challenges and Trends.

RB transcribed (8 DIN-A4 pages, single-spaced,

12pt font size) and translated the audio recording

from German to English. MN coded the interview

thematically and inductively distilled three main, cen-

tral points, collecting further information from the lit-

erature and public sources (e.g., industry reports,

newspaper articles, legal texts) to triangulate and fur-

ther substantiate the interview data. MN and RB dis-

cussed and refined these propositions, before MN

drafted the first version of the manuscript synthesiz-

ing and discussing the themes. All authors reviewed

and refined the final version of the draft before sub-

mission.

Please note that the interview partners partici-

pated in these interviews in their personal capacities.

Their statements do not necessarily represent the of-

ficial stance of BARMER, but reflect their personal

viewpoints and opinions.

3 HEALTH INSURANCES ROLE

IN THE DHT ECOSYSTEM

3.1 DHTs Are not Digital Pills

Generally, DHTs are considered to act as tools that

empower individuals to take the management of their

condition(s) into their own hands. Yet, the interview-

ees emphasized that while DHTs may provide person-

alized support in monitoring symptoms or preventing

disease progression, they cannot be considered an in-

dependent, standalone treatment option: “We should

make a slight distinction between ‘treatment’ and

‘support during illnesses’. […] That’s how DiGAs

are designed today. They assist in monitoring certain

symptoms or disease progress, preventing escala-

tions, but they don't provide treatment themselves”

(MR).

While the interviewees highlight the enormous

potential of DHTs with regard to their “substantial

impact […] not only on health-related metrics but

also on significant healthcare system-related chal-

lenges, such as a shortage of skilled professionals, fi-

nancing, or governance” (JP), they also strongly ad-

vocate to temper expectations:

In 2019, Kowatsch et al., and in 2021, Fleisch,

Franz, and Herrmann, coined the term “digital pill”

for information and communication technology and

software that collects real-world user data via weara-

ble or smartphone-based sensors (e.g., behavioral- or

lifestyle-related) and uses this data to predict vulner-

able states, to detect receptive states, and to intervene

at opportune moments. The authors emphasize that

such “digital pills” could particularly benefit chroni-

cally ill patients. For instance, by alerting a caregiver

or health professional when a sharp increase in body

weight detected by a digital body weight balance in-

dicates a potential worsening of heart failure (Gray,

Indraratna, Lovell, & Ooi, 2022): “For chronic dis-

eases, especially in the case of heart failure, it's easy

to imagine using these technologies to monitor or at

least accompany the course of the disease, detect any

deviations more quickly, and intervene as needed, for

instance, before someone has to be readmitted to the

hospital” (MR).

Yet, our interviewees strongly rejected the notion

of the “digital pill” metaphor. According to them,

DHTs should not be portrayed as pharmacologically-

active, quick-fix remedies, that encourage patients to

passively await their effects. Instead, patients,

healthcare professionals, and policy makers should

recognize DHTs as a fundamental element of a holis-

tic treatment strategy that empowers them to proac-

tively manage their conditions in their daily lives.

“You can take a painkiller, and afterward, the pain is

gone, but it doesn't cure the disease in that sense. The

same goes for digital technologies. Regular use,

treatment adherence, and adherence are all require-

ments that we also see with digital technologies. Only

then can expectations be reasonably fulfilled” (JP).

The full potential of DHTs may take time to realize:

“This may change with the use of AI at some point,

but at the current time, nobody can expect immediate

effects from digital technology use” (JP).

Indeed, while studies show that DHTs can en-

hance patient adherence to analog treatment or medi-

cation plans (Batra et al., 2017), a common challenge

in analog medicine (Brown & Bussell, 2011; Kones,

Rumana, & Morales-Salinas, 2019; Osterberg &

Scale-IT-up 2024 - Workshop on Emerging Business Models in Digital Health

888

Blaschke, 2005), the effectiveness of DHTs, vice

versa, is influenced by patients’ engagement with the

DHT and adherence to the suggested interventions in

the first place (Forbes, Keleher, Venditto, & DiBiasi,

2023).

In conclusion, while DHTs may play a valuable

role in offering continuous support, particularly in

managing chronic NCDs or when bridging gaps be-

tween treatment steps (e.g., after or before a station-

ary phase in a psychiatric clinic), they require a cer-

tain “level of continuity […] to lead to the desired

outcomes” (MR). We therefore propose, that DHTs

are not digital pills, but that they have the potential to

complement and augment treatment approaches.

3.2 Gender-Specific DHTs Improve

Health Access and Equity

DHTs are poised to tackle unmet needs and address

prevailing biases, stigmata, and social taboos (e.g.,

with regard to gender- or sex-specific or mental

health topics), which might help to improve access to

health and health equity (Sinha & Schryer-Roy,

2018). Especially, the barrier to accessing or sharing

sensitive healthcare information might notably be

lower with a digital solution (Tam, Bhat, Mohindra,

& Kumar, 2023; Wies, Landers, & Ienca, 2021).

For instance, the DiGA Endo-App caters to

women and menstruators with endometriosis, “con-

veying evidence-based and guideline-compliant self-

management techniques for chronic gynecological

and pain-related conditions, as well as monitoring in-

dividual symptoms” (Endo-App, 2023). Even though

endometriosis is a condition that affects approx. 10%

of reproductive women globally (World Health Or-

ganization, 2023c), it is also a condition that is not

fully understood, and therefore often misdiagnosed or

trivialized. It often takes several years for an individ-

ual to receive a formal diagnosis of endometriosis,

even though many suffer from severe pain and infer-

tility, which can have significant impacts on individ-

uals’ quality of life (Pettersson & Berterö, 2020;

Sims, Gupta, Missmer, & Aninye, 2021).

Similarly, the DiGA Kranus Edera App offers

men digital support for the treatment of erectile dys-

functions and their causes (Wiemer, Bartelheimer,

Raschke, & Miller, 2022). Due to the social stigma

and feelings of embarrassment commonly associated

with erectile dysfunction, approximately a fraction of

those affected seek assistance from a urologist (Bud-

deberg, Bucher, & Hornung, 2005; Fisher et al.,

2004). “Men facing such challenges are more willing

to use a digital solution than to overcome the taboo

and visit a urologist or a psychotherapist” (JP).

To achieve this, developing bias-free algorithms,

that are able to consider each individual’s unique ge-

netic, biomedical, environmental, and behavioral pro-

file, is central to the effectiveness of DHTs and to en-

sure equitable healthcare (Knight et al., 2021). “Any-

thing related to biases or stereotypes that providers

may not be aware of can probably be better compen-

sated or mitigated if the underlying algorithms are

bias-free. That's the real challenge because these al-

gorithms are crafted by humans” (JP).

The development of bias-free algorithms though

is not only an ethical imperative in healthcare, as it

directly impacts the effectiveness of DHTs and,

hence, patient well-being: As DHTs continue to

evolve, addressing algorithmic bias is paramount to

harness their full potential in improving healthcare

outcomes for all individuals, regardless of their back-

ground or demographic characteristics (Panch,

Mattie, & Atun, 2019).

3.3 Health Insurances: Co-Creators,

Investors, and Catalysts – but not

Developers of DHTs

Amid a significant transformation in the global

healthcare ecosystem, health insurance companies

find themselves at the nexus of innovation, tasked

with reshaping the landscape of healthcare delivery.

However, in the intricate realm of healthcare, espe-

cially when considering the integration of DHTs, it

becomes evident that this sector operates outside the

conventional boundaries of other markets, or, as JP

put it: “The healthcare sector doesn't work like a typ-

ical market” (JP).

Indeed, the approach of statutory health insurer

companies in Germany differs significantly from the

for-profit focus that characterizes traditional markets:

“We can’t think in terms of revenue streams” (JP).

Statutory health insurance (“Gesetzliche Kranken-

versicherung, GKV) functions in accordance with the

solidarity principle (Federal Ministry of Health,

2023). Therefore, the primary concern of statutory

health insurance companies revolves around optimiz-

ing the care and well-being of each insured, a mission

intrinsic to their role. Additionally, they also “bear a

certain responsibility [to influence cost management

in certain areas] on a systematic level” (JP).

In this vein, DHTs are embraced as a potent cata-

lyst enabling health insurance companies to effec-

tively and simultaneously juggle the dual roles of en-

hancing individual patient care and optimizing

healthcare costs on a broader societal scale.

According to our interview partner, there are sev-

eral ways for health insurance companies to do so: (a)

Unlocking the Potential of Digital Health Technologies: The Role of Health Insurance Companies in Shaping the Digital Healthcare

Ecosystem

889

as co-developers of DHTs together with startups or

established players, (b) as financial investors in digi-

tal health funds, and/or (c) as catalysts and role mod-

els inspiring other stakeholders in the market:

(a) Co-development of DHTs is particularly inter-

esting for health insurance companies, as it allows

them to leverage external expertise and resources

from startups or established players. However, while

health insurance companies may excel in ideation and

strategic healthcare management, they may not pos-

sess the speed, flexibility, and dynamism inherent in

startups. “A health insurance fund has certain core

competencies, what it does exceptionally well, and

startups, with their size, structure, and flexibility,

have other advantages that are better suited for such

development projects […] Therefore, we try to bring

together the best of both worlds by contributing our

expertise while leaving the development in the hands

of our cooperative partners” (JP).

(b) Since the introduction of the “Digital Care

Act” in 2019 (German: Digitale-Versorgung-Gesetz,

DVG), statutory health insurance companies are al-

lowed to invest up to two percent of their financial

reserves in digital health innovations (Hoffmann,

2022), for instance, to indirectly (e.g., through ven-

ture capital funds) or directly finance startups (§68a,

Abs. 1-4, SGB V). This opened up new opportunities

for health insurance companies to support DHT inno-

vation and developments indirectly as investors.

Engaging in (high-risk) investments, for instance,

through Venture Capital, however, is typically not

within the nature of statutory health insurance. Hence,

despite this new law, except for BARMER, health in-

surances have been quite reserved in their actions to

this day (Brainwave Hub, 2023).

Some of the reasons for this can be attributed to

the financial situation of the statutory health insur-

ance fund in Germany: The potential investment vol-

ume has significantly decreased in recent years due to

reduced reserves, partly resulting from additional

costs due to the COVID-19 pandemic (Greß & Jes-

berger, 2021). Yet, other reasons include the funda-

mental mandate of statutory health insurance funds,

which is not profit-oriented (Busse, Blümel, Knieps,

& Bärnighausen, 2017), and the risk of potentially

losing members' contributions through highly risky

transactions. Therefore, to comply with the non-profit

regulations and to secure the investment amounts

(i.e., members' contributions), in the case of

BARMER’s investments, guarantees needed to be es-

tablished through special assets and other investors,

while the rate of return for the health insurance fund

needed to be limited to a maximum of 2% per year

(Brainwave Hub, 2023). Such an investment is, thus,

“not to be understood as a conventional capital in-

vestment but rather as an investment in medical care.

The returns [are] innovations and new forms of care.

This is a prime example that public-law corporations,

even without a profit motive, can make purposeful in-

vestments in startups and contribute to innovative im-

provements in healthcare” (Brainwave Hub, 2023).

Hence, similar to in-house or collaborative DHT

development efforts, financial investments in DHT

start-ups might bring innovations and efficiency to

healthcare systems, helping health insurance compa-

nies to gain valuable input from outside the health in-

surance world, and a knowledge advantage with re-

gard to which innovations will next find a place in

healthcare.

source of inspiration for other health insurance pro-

viders to explore similar avenues, potentially catalyz-

ing a transformative shift in the entire healthcare eco-

system. When one health insurance sets a precedent

by investing in DHT startups, they may motivate

other stakeholders in the market to embrace similar

strategies: “When BARMER leads the way and cre-

ates new offerings, other health insurance providers

may feel the need to follow suit” (JP). This under-

standing goes beyond mere business strategy; it's

rooted in a sense of responsibility and a commitment

to fulfilling systemic obligations.

In conclusion, health insurance companies are

recognizing that they can adopt various roles to drive

the adoption of digital health technologies for the

greater good, both at the individual patient level and

the broader healthcare ecosystem.

4 CONCLUSION

In the ever-evolving landscape of healthcare, the in-

tegration of digital health technologies has ushered in

an era of unprecedented possibilities. This paper

delved into the evolving DHT landscape and the piv-

otal role health insurance companies play in shaping

this transformation:

Firstly, DHTs allow for personalized and precise

care of chronic diseases across the patient journey,

enhancing treatment adherence, disease management,

and, ultimately, potentially also treatment success.

Although DHTs should not (yet) be considered inde-

pendent treatment options, but rather an important

piece of a larger puzzle, they might already support

patients in managing their conditions and in adopting

beneficial lifestyles and behaviors.

Scale-IT-up 2024 - Workshop on Emerging Business Models in Digital Health

890

Secondly, to improve healthcare access and eq-

uity through DHTs, bias-free development ap-

proaches are just as pertinent in digital health as they

are in analog medicine. For instance, DHT innova-

tions that (a) directly cater to sex- or gender-specific

conditions such as ovarian breast cancer, rheumatoid

arthritis, or prostate cancer (Nature Editorial, 2023;

Smith, 2023) or that (b) consider sex-specific factors

in the development of DHTs for conditions that affect

both men and women equally such as lung cancer or

heart failure (Smith, 2023), have the potential to ad-

vance health equity in both digital and analog medi-

cine concurrently. Notably, ‘menstrual cycle syncing’

strategies, which take into account the influence of

hormonal fluctuations during the menstrual cycle

phases, or female-focused lifestyle intervention, that

consider the impact of hormonal fluctuations during

perimenopause on specific conditions or symptoms,

have yet to be systematically explored (Vitti, 2020) –

and DHTs could offer a means to unlock this poten-

tial.

Ultimately, health insurers' involvement in digital

health initiatives, such as creating, supporting, and in-

vestigating in innovative DHT, can be viewed as a

manifestation of their evolving role in the DHT eco-

system. Based on their dual understanding as advo-

cates of their insured and as key players in shaping

the (digital) healthcare landscape, they are already

and increasingly taking on responsibility as co-devel-

opers, investors, and catalysts, eager to drive change

and encourage technological advancements.

ACKNOWLEDGEMENTS

We thank our interview partners, Marek Rydzewski

and Jeremias Pappert, for sharing their expertise and

their contributions to this work.

CONFLICT OF INTEREST

MN is affiliated with the Centre for Digital Health In-

terventions (CDHI), a joint initiative of the Institute

for Implementation Science in Health Care, Univer-

sity of Zurich; the Department of Management, Tech-

nology, and Economics at the Swiss Federal Institute

of Technology in Zürich; and the Institute of Tech-

nology Management and School of Medicine at the

University of St Gallen. The CDHI is funded in part

by CSS, a Swiss health insurer and MavieNext, an

Austrian healthcare provider. However, neither CSS

nor MavieNext were involved in this research.

REFERENCES

§68a, Abs. 1-4, SGB V (2023). Förderung der Entwicklung

digitaler Innovationen durch Krankenkassen. Retrieved

on 30.10.2023 from sozialgesetzbuch-sgb.de/sgbv/68a

Aerts, A., & Bogdan-Martin, D. (2021). Leveraging data and

AI to deliver on the promise of digital health. Interna-

tional Journal of Medical Informatics, 150, 104456.

doi:10.1016/j.ijmedinf.2021.104456

Batra, S., Baker, R. A., Wang, T., Forma, F., DiBiasi, F., &

Peters-Strickland, T. (2017). Digital health technology

for use in patients with serious mental illness: a system-

atic review of the literature. Medical Devices, 10, 237–

251. doi:10.2147/MDER.S144158

Borges do Nascimento, I. J., Abdulazeem, H. M., Vasanthan,

L. T., Martinez, E. Z., Zucoloto, M. L., Østengaard, L.,

Azzopardi-Muscat, N., Zapata, T., & Novillo-Ortiz, D.

(2023). The global effect of digital health technologies on

health workers' competencies and health workplace. The

Lancet Digital Health, 5(8), e534-e544.

doi:10.1016/S2589-7500(23)00092-4

Brainwave Hub (2023). Krankenkasse Goes Digital: Eine

Digitalisierungsstrategie der AOKen, TK, BARMER, und

DAK. Retrieved on 30.10.2023 from brainwave-

hub.de/reports

Brewer, L. C., Fortuna, K. L., Jones, C., Walker, R., Hayes,

S. N., Patten, C. A., & Cooper, L. A. (2020). Back to the

Future: Achieving Health Equity Through Health Infor-

matics and Digital Health. JMIR MHealth and UHealth,

8(1), e14512. doi:10.2196/14512

Brown, M. T., & Bussell, J. K. (2011). Medication adher-

ence: WHO cares? Mayo Clinic Proceedings, 86(4),

304–314. doi:10.4065/mcp.2010.0575

Buddeberg, C., Bucher, T., & Hornung, R. (2005). Erektile

Dysfunktion bei Männern in der zweiten Lebenshälfte

[Erectile dysfunction in men in their second half of life].

Der Urologe. Ausg. A, 44(9). doi:10.1007/s00120-005-

0841-5

Busse, R., Blümel, M., Knieps, F., & Bärnighausen, T.

(2017). Statutory health insurance in Germany: a health

system shaped by 135 years of solidarity, self-govern-

ance, and competition. The Lancet, 390(10097), 882–

897. doi:10.1016/S0140-6736(17)31280-1

Carrilho, J., Videira, D., Campos, C., Midão, L., & Costa, E.

(2023). Changing the paradigm in health and care ser-

vices: modern value chains using open innovation for the

creation of new digital health solutions. Frontiers in Dig-

ital Health, 5, 1216357. doi:10.3389/fdgth.

2023.1216357

Digital Therapeutics Alliance (2023a). DTA’s Adoption & In-

terpretation of ISO’s DTx Definition. Retrieved on

29.10.2023 from dtxalliance.org

Digital Therapeutics Alliance (2023b). What is a DTx? Re-

trieved on 29.10.2023 from https://dtxalliance.org/under-

standing-dtx/what-is-a-dtx/

Endo-App (2023). Endo-App – Deine digitale Begleitung in

schwierigen Zeiten. Retrieved on 30.10.2023 from

https://diga.endometriose.app/

Unlocking the Potential of Digital Health Technologies: The Role of Health Insurance Companies in Shaping the Digital Healthcare

Ecosystem

891

Federal Ministry of Health (2023). Statutory Health Insur-

ance (SHI). Retrieved on 22.12.2023 from bun-

desgesundheitsministerium.de/gkv

Fisher, W. A., Rosen, R. C., Eardley, I., Niederberger, C.,

Nadel, A., Kaufman, J., & Sand, M. (2004). The multi-

national Men's Attitudes to Life Events and Sexuality

(MALES) Study Phase II: Understanding PDE5 inhibitor

treatment seeking patterns, among men with erectile dys-

function. The Journal of Sexual Medicine, 1(2), 150–160.

doi:10.1111/j.1743-6109.2004.04023.x

Fleisch, E., Franz, C., & Herrmann, A. (Eds.) (2021). The

Digital Pill: What Everyone Should Know about the Fu-

ture of Our Healthcare System. Bingley, UK: Emerald

Publishing Limited. Retrieved on 29.10.2023 from.

doi:10.1108/9781787566750

Forbes, A., Keleher, M. R., Venditto, M., & DiBiasi, F.

(2023). Assessing Patient Adherence to and Engagement

With Digital Interventions for Depression in Clinical Tri-

als: Systematic Literature Review. Journal of Medical

Internet Research, 25, e43727. doi:10.2196/43727

Gentili, A., Failla, G., Melnyk, A., Puleo, V., Di Tanna, G.

L., Ricciardi, W., & Cascini, F. (2022). The cost-effec-

tiveness of digital health interventions: A systematic re-

view of the literature. Frontiers in Public Health, 10,

787135. doi:10.3389/fpubh.2022.787135

Gray, R., Indraratna, P., Lovell, N., & Ooi, S.‑Y. (2022). Dig-

ital health technology in the prevention of heart failure

and coronary artery disease. Cardiovascular Digital

Health Journal, 3(6 Suppl), S9-S16.

doi:10.1016/j.cvdhj.2022.09.002

Greß, S., & Jesberger, C. (2021). SARS-CoV-2-Pandemie in

Deutschland: Ökonomische Bedeutung für das deutsche

Gesundheitssystem. Public Health Forum, 29(1), 5–7.

doi:10.1515/pubhef-2020-0107

Hoffmann, L. (2022). Gesetzliche Krankenkassen investieren

kaum Geld in Start-ups. Handelsblatt. Retrieved on

30.10.2023 from https://www.handelsblatt.com/ in-

side/digital_health/risikokapital-gesetzliche-kranken-

kassen-investieren-kaum-geld-in-start-ups

Hutton, C., & Gunn, J. (2007). Do longer consultations im-

prove the management of psychological problems in gen-

eral practice? A systematic literature review. BMC

Health Services Research, 7(1), 71. doi:10.1186/1472-

6963-7-71

Iqbal, J. D., & Biller-Andorno, N. (2022). The regulatory gap

in digital health and alternative pathways to bridge it.

Health Policy and Technology, 11(3), 100663.

doi:10.1016/j.hlpt.2022.100663

Jiang, X., Ming, W.‑K., & You, J. H. S. (2019). The Cost-

Effectiveness of Digital Health Interventions on the Man-

agement of Cardiovascular Diseases: Systematic Re-

view. Journal of Medical Internet Research, 21(6),

e13166. doi:10.2196/13166

Knight, H. E., Deeny, S. R., Dreyer, K., Engmann, J., Mack-

intosh, M., Raza, S., Stafford, M., Tesfaye, R., & Steven-

ton, A. (2021). Challenging racism in the use of health

data. The Lancet Digital Health, 3(3), e144-e146.

doi:10.1016/S2589-7500(21)00019-4

Kones, R., Rumana, U., & Morales-Salinas, A. (2019). Con-

fronting the most challenging risk factor: non-adherence.

The Lancet, 393(10167), 105–106. doi:10.1016/S0140-

6736(18)33079-4

Kowatsch, T., Fischer-Taeschler, D., Putzing, F., Bürki, P.,

Stettler, C., Chiesa-Tanner, G., & Fleisch, E. (2019). Die

digitale Pille für chronische Krankheiten. Digitale

Transformation von Dienstleistungen im

Gesundheitswesen VI, 205–231. Springer Gabler,

Wiesbaden. doi:10.1007/978-3-658-25461-2_12

Kowatsch, T., & Fleisch, E. (2021). Digital Health

Interventions. In: Gassmann, O. et al. (Eds.). Connected

Business, 71–95. Springer, Cham. doi:10.1007/978-3-

030-76897-3_4

Mekniran, W., & Kowatsch, T. (2023). Scalable Business

Models in Digital Healthy Longevity: Lessons from Top-

Funded Digital Health Companies in 2022. Proceedings

of the 16th International Joint Conference on Biomedical

Engineering Systems and Technologies, 609–615.

Nahum-Shani, I., Smith, S. N., Spring, B. J., Collins, L. M.,

Witkiewitz, K., Tewari, A., & Murphy, S. A. (2018).

Just-in-Time Adaptive Interventions (JITAIs) in Mobile

Health: Key Components and Design Principles for On-

going Health Behavior Support. Annals of Behavioral

Medicine : A Publication of the Society of Behavioral

Medicine, 52(6), 446–462. doi:10.1007/s12160-016-

9830-8

Nature Editorial (2023). Women's health: end the disparity in

funding. Retrieved on 29.10.2023 from https://www.na-

ture.com/articles/d41586-023-01472-5

Osterberg, L., & Blaschke, T. (2005). Adherence to medica-

tion. The New England Journal of Medicine, 353(5),

487–497. doi:10.1056/NEJMra050100

Panch, T., Mattie, H., & Atun, R. (2019). Artificial intelli-

gence and algorithmic bias: implications for health sys-

tems. Journal of Global Health, 9(2), 10318.

doi:10.7189/jogh.09.020318

Pettersson, A., & Berterö, C. M. (2020). How Women with

Endometriosis Experience Health Care Encounters.

Women's Health Reports (New Rochelle, N.Y.), 1(1),

529–542. doi:10.1089/whr.2020.0099

Sims, O. T., Gupta, J., Missmer, S. A., & Aninye, I. O.

(2021). Stigma and Endometriosis: A Brief Overview

and Recommendations to Improve Psychosocial Well-

Being and Diagnostic Delay. International Journal of

Environmental Research and Public Health, 18(15).

doi:10.3390/ijerph18158210

Sinha, C., & Schryer-Roy, A.‑M. (2018). Digital health, gen-

der and health equity: invisible imperatives. Journal of

Public Health, 40(suppl_2), ii1-ii5. doi:10.1093/pub-

med/fdy171

Smith, K. (2023). The Funding Gender Gap. Nature,

617(7959), 28.

Tam, H., Bhat, K. S., Mohindra, P., & Kumar, N. (2023).

Learning to Navigate Health Taboos through Online Safe

Spaces. In: Schmidt, A. (Ed.). Proceedings of the 2023

CHI Conference on Human Factors in Computing Sys-

tems, ACM Digital Library, 1–15.

doi:10.1145/3544548.3580708

Vitti, A. (2020). In the FLO: Unlock Your Hormonal Ad-

vantage and Revolutionize Your Life. New York, NY,

US: HarperCollins Publishers Inc.

Scale-IT-up 2024 - Workshop on Emerging Business Models in Digital Health

892

Wiemer, L., Bartelheimer, T., Raschke, R., & Miller, K.

(2022). Erste Daten aus einer digitalen Gesundheits-App

für Erektionsstörungen [First data from a digital health

app for erectile dysfunction]. Urologie, 61(9), 971–981.

doi:10.1007/s00120-022-01872-x

Wies, B., Landers, C., & Ienca, M. (2021). Digital Mental

Health for Young People: A Scoping Review of Ethical

Promises and Challenges. Advance online publication.

doi:10.3929/ETHZ-B-000551848

World Health Organization (2023a). Non-communicable dis-

eases. Retrieved on 29.10.2023 from who.int/health-top-

ics/noncommunicable-diseases

World Health Organization (2023b). Non-communicable

diseases - Factsheet. Retrieved on 29.10.2023 from

who.int/news-room/fact-sheets/detail/noncommunica-

ble-diseases

World Health Organization (2023c, October 30). Endometri-

osis - Factsheet. Retrieved on 30.10.2023 from

who.int/news-room/fact-sheets/detail/endometriosis

APPENDIX

Interview Guiding Questions

I DHT Implementation and Effectiveness

 Are you currently providing DHTs?

 Have you developed these DHTs in-house or are you

collaborating with startups or other organizations?

 What criteria are essential when entering into partner-

ships with companies or startups?

 What is your personal perspective on DHTs?

 Which medical conditions do you believe require

DHTs the most, and why?

 What is the primary objective of offering these DHTs

(generating new revenue streams, enhancing cost-ef-

ficiency, fostering customer loyalty)?

 If these DHTs are already in use, do they meet your

expectations and goals?

II Objectives and Outcomes

 What is your main goal in offering these DHTs? (new

revenue streams, cost-efficiency, customer loyalty)?

 If already implemented, are your DHTs meeting these

expectations/goals?

 How do you assess the economic outcomes of your

investments in digital health, including both short-

term and long-term financial implications for your or-

ganization and policyholders?

 How do you assess the integration of DHTs into the

existing healthcare system, especially in terms of in-

teroperability and data exchange between different

stakeholders?

III Quality Assessments and Learning

 In what measure does the incorporation of digital

health technologies enhance the quality of care and

treatment for the insured, as opposed to being merely

a supplementary aspect

 What is the importance of business ecosystems for

these DHTs?

 What kind of learnings have you generated so far?

Are there DHTs that work better than others? Why?

 What kind of DHT failed?

 What were the reasons?

IV Digital Health Ecosystem and Business Models

 What is the future role of a health insurance company

in digital health ecosystems?

 Which digital health technologies (DHTs) are already

used and reimbursed? In which fields?

 What are those offerings?

 How are these paid for? (self-paid, basic insurance,

additional insurance, etc.)

 What are the most promising business models in digi-

tal health? Why do you find them compelling?

V Future Challenges and Trends?

 What are the key challenges that health insurance

companies must overcome to fully embrace and ben-

efit from digital health innovations?

 How would you improve the DHTs you are offering?

 How do you envision the evolution of digital health

offerings from a health insurance perspective in the

coming years? What emerging trends or technologies

are you closely monitoring for potential integration?

 In your view, what role should public health policy

play in fostering the growth of digital health solu-

tions, and how might it impact the insurance indus-

try's approach to healthcare delivery?

Unlocking the Potential of Digital Health Technologies: The Role of Health Insurance Companies in Shaping the Digital Healthcare

Ecosystem

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