Wearables Data May Prevent Health Plan Denials

This story begins, as many do, with a real-world experience. Our health plan just refused to pay for a sleep study for my husband, who suffers from severe sleep apnea, despite his being quite symptomatic. We’re following up with the Virginia Department of Insurance and fully expect to win the day, though we remain baffled as to how they could make such a decision. While beginning the complaint process, a thought occurred to me.

What if wearables were able to detect wakefulness and sleepiness, and my husband was being tracked 24 hours a day?  If so, assuming he was wearing one, wouldn’t it be harder for a health plan to deny him the test he needed? After all, it wouldn’t be the word of one doctor versus the word of another, it would be a raft of data plus his sleep doctor’s opinion going up against the health plan’s physician reviewer.

Now, I realize this is a big leap in several ways.

For one thing, today doctors are very skeptical about the value generated by patient-controlled smartphone apps and wearables. According to a recent survey by market research firm MedPanel, in fact, only 15% of doctors surveyed see wearables of health apps as tools patients can use to get better. Until more physicians get on board, it seems unlikely that device makers will take this market seriously and nudge it into full clinical respectability.

Also, data generated by apps and wearables is seldom organized in a form that can be accessed easily by clinicians, much less uploaded to EMRs or shared with health insurers. Tools like Apple HealthKit, which can move such data into EMRs, should address this issue over time, but at present a lack of wearable/app data interoperability is a major stumbling block to leveraging that data.

And then there’s the tech issues. In the world I’m envisioning, wearables and health apps would merge with remote monitoring technologies, with the data they generate becoming as important to doctors as it is to patients. But neither smartphone apps nor wearables are equipped for this task as things stand.

And finally, even if you have what passes for proof, sometimes health plans don’t care how right you are. (That, of course, is a story for another day!)

Ultimately, though, new data generates new ways of doing business. I believe that when doctors fully adapt to using wearable and app data in clinical practice, it will change the dynamics of their relationship with health plans. While sleep tracking may not be available in the near future, other types of sophisticated sensor-based monitoring are just about to emerge, and their impact could be explosive.

True, there’s no guarantee that health insurers will change their ways. But my guess is that if doctors have more data to back up their requests, health plans won’t be able to tune it out completely, even if their tactics issuing denials aren’t transformed. Moreover, as wearables and apps get FDA approval, they’ll have an even harder time ignoring the data they generate.

With any luck, a greater use of up-to-the-minute patient monitoring data will benefit every stakeholder in the healthcare system, including insurers. After all, not to be cliched about it, but knowledge is power. I choose to believe that if wearables and apps data are put into play, that power will be put to good use.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

3 Comments

  • Anne —

    Consumer wearables sleep tracking is not the best example to use for this analysis, because the only widely-available device that actually tracked some of the same stuff tracked in a sleep lab (Zeo) was discontinued. Wrist-worn trackers record movement which is a poor proxy for tracking sleep states / sleep apnea.

    MU3 draft regs would permit but do not require incorporating PGHD into the EHR.

    To my mind, the best way forward here is designing a system whereby clinicians can decide which smartphone apps they would like to have their patients use (or call for development of such apps), with two-way communication of data into and out of the EHR, subject to patient authorization.

    I am working with a company (http://flowhealth.com) that has (among other things) built a platform with that interface and capability, which is the kind of thing I think will prove to be invaluable in extending patient-centered health into the 99% of our lives that are not encounters with the health care system, and translating that back to clinicians through configurable alerts.

  • From a physician perspective a few comments for your consideration:

    The repetitive statements, assertion or ‘allegations’ that the adoption/use of individual pt generated data from apps or various wearables is the fault of or caused by physician resistance is INCORRECT. This article includes the following comments illustrating this all too common HIT-side ‘mindset’:
    1. physicians won’t ‘get on board’,
    2, doctors not fully adapting to using wearable and app data in clinical practice
    3. doctors don’t “see wearables of health apps as tools patients can use to get
    better’
    4.’doctors are very skeptical about the value generated by patient-controlled
    smartphone apps and wearables’.
    5 ‘ Until more physicians get on board, it seems unlikely that device makers will
    take this market seriously and nudge it into full clinical respectability.’

    Physicians are held to various professional standards,regulations and guidelines which may and do limit what is considered within acceptable professional standards for a physician to recommend to a patient as part of managing the individual patient health conditions. In making certain recommendations in ones professional role, it means you are endorsing this item/therapy/treatment has proven benefit, will function as stated and should usually not cause harm to the pt in some manner. This is the essence of ‘evidence based medical practice’.
    Appropriately done studies which substantiate the benefit in clinically meaningful ways- improved health status or outcome, improved chronic disease status, etc underlie this evidence based standard.

    Question: where are the substantiating studies for wearables,or various pt health apps? Of note any of those ‘marketing, promotional, promise, speculative or potentially could/should/would’ type articles are NOT ‘evidence’ nor would these serve as ‘proof of benefit.’ in medical practice. This is not ‘skepticism’ by physicians, it is the reality of what bounds the professional practice of medicine.

    The link below should be a helpful overview of the evolving guidelines in process which impact how physicians can and will be able to recommend use of these technologies in medical practice.
    http://www.fda.gov/downloads/MedicalDevices/…/UCM263366.pdf

  • One more comment particularly for Ms Zeigler regarding the insurance company denial aspect.

    The ‘30%-15%-5%’ rule is basically what underlies the insurance company denial process. Of course it often seems to be illogical on clinical grounds but that it because it is, however as business practice it makes perfect sense for the insurers to employ.
    I may have a link to article describing this if you interested. Use of wearable apps, pt collected health data is not likely to impact this practice by health insurers in any meaningful way unfortunately. Be glad to clarify this with you off post – send me an email to further discuss.

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