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Waiting for the big breakthrough: the smartphone app on prescription

31. May 2022 Published by Raphael Doerr

Actually, it was a good idea that then Minister of Health Jens Spahn came up with when he launched the “app on prescription” at the end of 2019. Lauded by him as a world’s first, there were high expectations among the persons responsible. The digital health app, or DiGA for short, was to become a lighthouse project in the context of digitization of the health service. The statutory health insurance funds bore the costs of the apps, which as medical products with a low risk class could only be prescribed by the physician or health insurance fund. The idea was fueled by the boom in health and fitness apps that Google and Apple offer for millions to download from their platforms. Forecasts predict that the mobile health app market might grow to around 11.2 billion US dollars by 2025.[1] Another important fact is that most patients own a smartphone – the apps wouldn’t make much sense without one. And yet, it seems, the “app on prescription” is still lagging behind expectations.

Unlike the top 40 over-the-counter health apps that are performing well and were downloaded around 2.4 million times in 2020 alone, DiGA’s penetration is pretty modest, according to the results of a nationwide survey in Germany by the public health foundation Stiftung Gesundheit. The alternative health insurance funds (TK, Barmer, DAK, KKH, hkk and HEK) counted a combined total of 24,000 access codes that had been issued up to the end of September 2021. Given that they have around 28 million insured persons, that equates to a penetration rate of less than 0.1 percent. That’s not exactly high for a world’s first.  Digital and medical care are slow in coming together. That’s the result of a representative survey by the market research institute YouGov on behalf of the SBK, Siemens’ health insurance fund. It shows that just two percent of people have received an app on prescription so far, while only eight percent have been told by a doctor about the possibility of using a digital health app (DiGA). And how do patients view all that? Do they know the medical apps for the smartphone and would they use them? We provide a short fact check here.

Status quo

Digital health apps (DiGAs) have been available comprehensively as a service from the statutory health insurance funds for more than a year. They are medical products with a low risk class. It is estimated that around 50,000 DiGAs were prescribed or approved by the health insurance funds up to the end of September 2021. The statutory health insurance funds have spent some €13 million on them since the fall of 2020. That is revealed by a new report by the National Association of Statutory Health Insurance Funds. According to the German Federal Institute for Drugs and Medical Devices, there are now 31 medical apps, as the newspaper Münchner Merkur reports. “In principle, the programs are intended to inform patients about their illness, offer preventive measures, and support them in training or dietary matters,” explains the German Consumer Advice Organization.

A recent video entitled “Gesund werden mit einer App” from the radio station SWR (“Get healthy with an app”; German only) can be viewed in its media library and provides a pretty good illustration of how that’s done. It presents the story of 40-year-old Lina K., who has suffered from severe migraine for years and now wants to get her life back under control with the aid of a migraine app prescribed by her doctor. The aim of the digital apps is to accompany sick people as part of their therapy or bridge the time they have to wait to see a physician. In particular, the apps on prescription help alleviate the symptoms of an illness, as well as help patients gain a better understanding of it and cope with it independently.

And that’s precisely what distinguishes them from over-the-counter apps. “Unlike fitness apps, for example, DiGAs have to be tested and approved. Only then can the doctor prescribe them and the health insurance fund will pay for them,” writes Dr. Tanja Katrin Hantke, Health Expert at the health insurance fund “vivida bkk.” The apps are currently used for diseases such as diabetes*, cancer or high blood pressure.

The tone is getting harsher

There is a relatively high level of acceptance and support for the DiGAs among physicians; they know the apps and are also conversant with them. “More than 80 percent of doctors are now familiar with the apps on prescription,” states Prof. Dr. Dr. Konrad Obermann, Head of Research at Stiftung Gesundheit. “And about every one-in-five doctors has already gathered practical experience with this new tool.” Digital health apps are on the road to becoming an established part of healthcare. That is the result of the representative study “Ärztinnen und Ärzte im Zukunftsmarkt Gesundheit 2021/2” (“Doctors in the future market of health 2021/2”; German only) published by Stiftung Gesundheit in mid-December.

Yet the tone in the debate about their benefits is getting harsh. The National Association of Statutory Health Insurance Funds is critical about the excessively high and opaque costs for the health apps. In a report it published on March 1, 2022, the prices – which can be set freely by the providers in the first year – averaged around €400 a quarter. “The prices of these new digital health apps paid for by the health insurance funds therefore ranged from a non-recurring license fee of €119 up to €743.75 for an activation code to use an app for 90 days.”

Demand tends to be subdued

Patients are definitely interested in the apps, albeit on a pretty modest scale. AOK PLUS says that it has enabled more than 1,900 insured persons to use a DiGA since October 2020, according to an article in the German medical magazine Ärzteblatt in the fall of 2021. “One-in-four participating persons insured with AOK PLUS therefore uses an app to help them with their chronic tinnitus. Apps for patients with back, knee and hip pain (15 percent), adipositas (13 percent) or migraine (11 percent) are also used frequently.”

The internal figures from Siemens’ health insurance fund SBK confirm the subdued demand for DiGAs, but also indicate a steady upward trend: A total of 349 DiGAs were approved among the more than one million SBK members up to the end of April 2021. A quarter of them were approved directly by the SBK and without a doctor’s prescription. And the Apotheken Umschau, a German health magazine that is available in pharmacies as a customer magazine, writes: “Hardly any recommendations for DiGAs. DiGAs are a little better known now, but it seems they are recommended or prescribed less frequently. Around 71 percent of those surveyed said they had never recommended an app. That is around three percent more than a year ago. That result is congruent with the number of prescriptions: Almost 86 percent of all respondents have never been prescribed a DiGA – a figure that was even 99 percent in 2020.”

Old, poor and distrustful

A compounding factor is that old and poor people in particular do not trust digital medicine and so the health apps, as the German business newspaper Handelsblatt wrote last June: “They find a health app, download it, and understand how it works. Then they put their smartphone aside again because they mistrust the app.” The success of the digital transformation in the healthcare sector stands or falls by the general public’s acceptance of technology. Researchers from the Leibniz ScienceCampus Digital Public Health in Bremen asked 1,014 people how they use and rate technologies for their health. One result: Old, poor people without an academic degree spurn apps, online training courses or information offerings for their health.

Source: D21 DIGITAL INDEX 2021/2022.  Jährliches Lagebild zur  Digitalen Gesellschaf

Smartphones in conjunction with health apps can help the elderly in particular avoid illnesses. However, they are used only seldom. In the U.S., for example, 56 percent of elderly people decline to use them, although they are the ones that would most need them. That’s the result of a survey conducted by the University of Michigan Michigan Institute for Healthcare Policy & Innovation.

Low acceptance for health apps

The apps monitor many health indicators – from calorie consumption, exercise to blood pressure and blood sugar level – to help users alleviate chronic diseases or achieve specific health goals. The new results from a telephone survey, the National Poll on Healthy Aging, conducted among more than 2,100 Americans between the age of 50 and 80 shows that fewer than half (44 %) have used a health app on their smartphone, portable device or tablet. Half of those who had never used or no longer use a health app stated that they have no interest in using one.

The ratio of elderly adults who currently use at least one app is even lower at 28%. One-third use an app to monitor their physical activity, where far fewer use apps for recording their weight, diet or blood pressure, for meditating, or for mental health/stress management. A quarter of current users stated that they share more information from their apps with their health care providers.

Education would be helpful

“Health providers should consider discussing the use of health apps with their patients,” suggests Preeti Malani, Chief Health Officer in the Divisions of Infectious Diseases and Geriatric Medicine at the University of Michigan. Even though that statement relates to the American market, if wouldn’t be bad here in Germany if the persons responsible for DiGAs were to educate patients in a more targeted way – in particular the elderly, since that could improve usage rates. Many people don’t even know that there are such options, and if they do know, they may not be able to use the app properly on their smartphone. After all, one fact should not be forgotten: Our society is aging, and that means it may become more difficult for people to use digital offerings, especially in the area of healthcare. In the U.S., one-third of all respondents in the National Poll on Healthy Aging said they have never considered using such apps.

That makes things more difficult, and the German information and telecommunications industry association Bitkom wrote about this issue last year: “More than half of those aged 65 and above in Germany don’t use a smartphone. That’s the result of a representative study on the occasion of the second nationwide Digital Day, according to the Digital for All initiative. It revealed that 53 percent of respondents over the age of 65 don’t use such a device. That figure among those aged 65 to 74 is 36 percent, and far higher still – 74 percent – among those above 75.”

What is the difference between an “app on prescription” and an over-the-counter app?

The German Consumer Advice Organization distinguishes between these health apps:

  1. Lifestyle apps, such as fitness trackers or diet and exercise apps: They can help provide motivation for health-conscious behavior.
  2. Service-oriented apps remind users to take medication, monitor their vaccination status, remind them about screening tests, offer the option of arranging doctor’s appointments, or can be used as a diary to check the symptoms or progression of a disease.
  3. There are also medical apps that help diagnose and/or treat diseases, such as for analyzing blood sugar levels. Medical apps must be approved as a medical product and bear the CE label.

And the Apotheken Umschau writes: “There is no obligation to check the benefits of health or lifestyle apps on the free market or to control their quality and level of data protection. However, digital health apps are always subjected to an evaluation process by the German Federal Institute for Drugs and Medical Devices (BfArM).”

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