The insurer, the patient and the health data

Lack of access to data, last link in the chain, strong competition, insurers face many challenges within the healthcare environment.

Published on 24 February 2022 at 09h14

These players play a central role in patients’ lives, in association with social security. In the digital age, they intend more than ever to offer personalized support adapted to the needs of each individual, as it already exists in many other sectors. The problem is that there is a significant gap between desire and reality. Once again, there is a lack of interoperability.

To address this topic, we interviewed Yanick Philippon, Director of Group Insurance at Generali France.

Healthcare pathways: Organization and actors

Concretely, there is no such thing as a universal care pathway between the patient and his insurer. However, we can rely on what currently exists via the Generali France customer area and its corollary, the mobile application. Today, the patient interacts with his or her supplementary health insurance before the treatment, for example to submit an estimate, a request for coverage or to seek a second medical opinion before starting a treatment or an operation. Then, once the treatment has been carried out, to proceed with the reimbursements to which he is entitled as an insured.

Between these two phases, however, the insurer has no information on the patient's care path. This is the prerogative of the Caisse Primaire d'Assurance Maladie (CPAM). The information is then transmitted to the Dossier Médical Partagé (DMP), a digital health record that stores and secures the patient's health information: treatments received over the past 12 months, medical history (pathologies, allergies), test results, hospitalization reports, etc. The only people who have access to this data are the attending physician and all health professionals (except occupational medicine), including hospitals.

Since January 2022, existing DMPs have been migrated to a new platform called "Mon Espace Santé", where new records will also be created. Until March 2022, all Social Security members will be notified and will be able (if they expressly wish) to refuse the activation or creation of their space.

My Health Space has two main features. Firstly, to become the medical record of each individual. This will allow you to store medical documents, added by you or by your health professionals. It will also allow you to feed documents, information, prior to the date of creation of this space, in order to trace your medical history. In short, the paper health book, which we have been keeping preciously for years, goes digital.

The second feature is that of being an instant messenger. This will allow us, as patients, to exchange or receive information or documents from our health professionals.

Reassurance and trust for better support

The constraints faced by players like Generali, through its supplementary health insurance offer, are not new. Patient medical data is completely sealed from institutional players. As the CPAM states on its public information site: "Neither the occupational health service, nor mutual insurance companies, nor banks, nor your employer can access your Shared Medical Record. Finally, any access to your DMP by an unauthorized healthcare professional would constitute an offence punishable by imprisonment and a fine".

This is a constraint insofar as these players could provide better support to insured persons if they had access to certain information. For example, by knowing a patient's pathology, it becomes easier to provide specific advice on pricing without compromising the quality of care and treatment.

For some treatments, the variations in fees applied can be of a magnitude that is not always justified. The same is true for prescribed medications. Broader access would offer the possibility of building more precise and better adapted health guarantees for the patient.

Since January 1, 2022, with the opening of "Mon Espace Santé", mentioned above, everyone affiliated to the general Social Security system has been able to grant or restrict access to their DMP. However, this only concerns health professionals. For example, a pedicure-podologist will not be able to access your hospital reports.

Another obstacle is the patient's reluctance to share their health data with their insurer. While this is absolutely not the case on the part of the insurer, there is nevertheless a fear of being selected and somehow penalized by more expensive rates or even of being terminated or refused complementary health coverage. There is probably also a confusion with the loan insurance process where each person must fill out a health questionnaire and possibly perform some medical tests.

It is clearly necessary to continue to reassure the patient that there is no intention to discriminate.

Likewise, there is an ongoing need for in-depth educational work to show the real added value for the patient of sharing certain data. In the case of the second medical opinion to which a patient is entitled through their complementary health insurance, having more data would allow for a more refined diagnosis or medical advice for the benefit of the patient. The more data is available to understand the patient's care pathway, the more efficient the proposed services will be

Even more than the data itself, it is the facilitation of its availability and use that is essential for the patient to benefit from the best possible prevention, the best possible care pathway when a medical intervention is required and the best possible post-intervention follow-up. In this respect, a digital health innovation ecosystem such as Future4care is a tremendous opportunity to accelerate the development and marketing of data-driven e-health solutions for the benefit of all, in particular patients and healthcare professionals.

The divide between players has a direct impact on patients

It cannot be denied that strong reluctance exists and persists at different levels of the value chain. For healthcare professionals, broadening access to health data is very often equated with a form of increased control of their medical acts by non-legitimate third parties, or even the greater possibility of questioning and contesting their diagnoses. Here too, the necessary work of explanation and dialogue must be carried out in order to gradually remove resistance and apprehension and to move towards mutual cooperation for the benefit of the patient.

The State itself is not always free of certain frictions. The report of the High Council for the Future of Health Insurance (HCAAM) on the "Grande Sécu" (at the request of the Ministry of Health) is a current illustration. Currently, four scenarios of articulation between basic compulsory health coverage and complementary health coverage are being studied. From the most radical to the most "balanced", these 4 hypotheses lead naturally to a nationalization of health coverage and to a marginalization of complementary health insurance.

If this project were to be implemented, it would undoubtedly create a profoundly unfair system, creating a division between those who can afford to pay more without public support and getting quick access to the best professionals, and those who cannot afford it.

Such a scenario does not correspond to the expectations of health professionals and, above all, to the expectations of the French people in general, who are deeply attached to a certain freedom of activity and choice.

There are, however, things to be done to improve the health coverage of the population, in particular the most vulnerable, but this "Grande sécurité sociale" scenario is clearly not the right decision to take. Common sense must prevail on this issue.

Digital health, the major asset

The subject of the "Grande sécurité sociale" divides people, while the benefits of digital technology are increasingly unifying the thinking of our ecosystem. Moreover, it is difficult to be totally exhaustive on the qualities of digital technology, as it contains so many positive contributions to the patient's health pathway at any stage. For example, connected objects are great levers to ensure optimized and personalized daily monitoring of various chronic diseases such as cardiac arrhythmia, asthma, diabetes, but also in the context of post-operative monitoring in ambulatory care and/or at home instead of being hospitalized for longer periods.

Prevention is another fundamental dimension where immense progress can be made thanks to digital technology, for a better knowledge of the patient's lifestyle and environment.

For healthcare professionals (as well as for the State and insurers), predictive medicine is also a vast field of opportunities such as better anticipating and curbing the occurrence of certain pandemics or more familiar epidemics such as influenza, gastroenteritis and seasonal allergies. With the launch of the Covid-19 messenger RNA vaccines, for example, the world has become aware of the fantastic progress of digital RNA sequencing and synthesis technologies. This technology also opens up great prospects for information storage with unprecedented capacities.

The challenge of telemedicine

It is impossible to talk about digital technology without mentioning telemedicine, a long-standing topic. To be functional, telemedicine requires sufficiently powerful infrastructures and telecommunications networks. Twenty years ago, access to fiber optics and mobile broadband was still in its infancy in terms of deployment on French territory.

Today, fiber and 5G have a much higher coverage rate, although there are still white areas where patients and healthcare professionals cannot use telemedicine. This makes it easier and more widespread to use.

Secondly, beyond the question of infrastructure, the use of remote health services must be encouraged as soon as possible. In this respect, a very interesting advance was made on January 27. The French National Authority for Health (HAS) published four guidelines to help healthcare professionals use remote medical monitoring. These guides define the conditions for prescribing telemonitoring, the minimum technical specifications required for digital medical devices and collection accessories, the conditions of distribution and use, the professionals involved, the required qualification of professionals, the organization of telemonitoring, the minimum provisions necessary to ensure the quality of care and the follow-up and use of telemonitoring.

By July 1, the reimbursement of remote medical monitoring will be generalized for several pathologies (diabetes, renal, cardiac and chronic respiratory insufficiency). In the near future, patients with implantable cardiac prostheses will also be covered by this system. For a healthcare professional, this will allow him or her to remotely interpret data for the medical monitoring of his or her patient, and even to adapt his or her care. This remote monitoring can help detect a worsening of the patient's health condition and intervene more quickly. These devices are real assets to demonstrate the immense interest of digital technology in health.

Future4care, catalyst and accelerator of progress in digital health

Future4care has a fundamental role to play in this digital health ecosystem. This is what led Generali to become one of the four founding partners (alongside Sanofi, Orange and Capgemini) of this innovative and powerful initiative, which will help to model the health of the future and find new technological solutions and innovative services for patients. The insurance industry works statistically with a large volume of anonymized data and a history of several decades that can be made available to startups to fuel their research solutions.

In the teeming world of startups, Future4care acts as a true catalyst, identifying the most relevant and promising digital health projects and supporting them to accelerate their development and market launch for the benefit of healthcare professionals and patients.

Secondly, Future4care is a physical and virtual melting pot for exchanges and technology watch that will strengthen links between major players such as the four founders involved in digital health, start-ups that will be able to test, make reliable and launch concrete and innovative solutions, and players from the medical world, universities and patient associations. The idea is to build more bridges between these communities, which are all working towards the same ultimate goal: better prevention to better protect the health of each individual and better care to better restore quality of life.