From Payer to Proactive Care: Insurers Rush into Health Management, Following the U.S. Blueprint?

Health management practices emerged in the United States in the late 1950s, with the primary intent of early intervention in diagnosis and treatment to achieve medical cost containment. Therefore, in the field where insurance integrates with health management, cost containment is often regarded as the primary objective of collaboration.

Hu Bo, Chairman of Ciming Health Checkup, pointed out in a speech that most health management companies in the United States are established by insurance institutions. Therefore, “the true essence lies in the fact that future health insurance must integrate with big data, and health management organizations must collaborate closely with insurance institutions.”

In China, the primary payer for insurance is government fiscal expenditure; consequently, there is a lack of financial incentive to reduce costs through preventive management in the integration of health management and insurance. However, the landscape appears markedly different in the realm of commercial health insurance.

According to the "2017 China Commercial Health Insurance Industry Research Report" released by iResearch, effective health management services can not only attract customers and enhance customer stickiness, but also significantly reduce claim payouts and improve profitability. The role of health management services in "activating and retaining customers" has already become evident.

From a technical perspective, the era of big data is characterized by four key aspects of data and information management: ubiquitous data collection, low-cost and high-capacity storage, high-speed transmission, and advanced data processing technologies. These technological features and advancements have transformed two critical factors: cost and speed, resulting in lower costs and faster processing. This constitutes the foundational condition for the big data era.

Deeper perception, more comprehensive interconnectivity, and more profound intelligence are driving the digitization of the world and the creation of a digital world. The increasingly widespread application of big data in the health industry has laid the foundation for health behavior management, evolving from quantity to quality, and then from quality to dimensionality; phenomena and behaviors will be determined by dimensionality.

For the insurance industry, health big data serves as the foundation for delivering precise insurance services. As early as 2013, Wang He, then Executive Vice President of PICC Property and Casualty Company Limited, stated that the advent of the big data era presents relative challenges but absolute opportunities for the insurance sector.

In the context of the Internet, platformization is one of the most prominent features. Swept by the wave of economic and information democratization, a new business operation model known as Wikinomics has emerged. The fundamental principles of so-called Wikinomics are collaboration, openness, sharing, integrity, and interdependence.

A platform is a “transparent” venue for communication, exchange, and transaction, where individuals maintain an interdependent relationship grounded in symbiosis theory; the essence of a platform is the concretization of the market. Health management is a business chain characterized by numerous intricate details and the integration of software and hardware, making platform-based strategy a consensus choice for many companies.

Platform-based management aggregates diverse resources, such as the comprehensive health management platform Miao Health, the maternal and child health management platform Mommy Knows, and women’s health management platforms like Dayima and Meiyou. In addition to services such as health data collection and health behavior management, these platforms also provide interfaces for products or derivative services, including insurance, online consultations, medical visits, physical examinations, pharmacies, wearable devices, and nutritional supplements.

Their commonality lies in an open trend, generating data through user behavior and deriving social attributes via community sharing and interaction.

Furthermore, a growing number of insurance companies have begun to establish health management platforms, offering services such as health record management, health assessments, health promotion, health consultations, and incentive mechanisms to address the individual health needs of each customer. By leveraging digital tools—including mobile apps, online platforms, wearable devices, and television interfaces—these companies are rapidly promoting their health platforms across various customer touchpoints. This strategy aims to quickly build a recognized brand for health management within the insurance industry, thereby attracting and retaining customers.

Wang He once stated, “The key to understanding personalization lies in addressing personality discovery, which must answer three questions: Who am I? Who do I truly am? And who can I become?” These three seemingly simple questions are difficult to resolve through limited services.

From a product-thinking perspective, health management constitutes an economy that must satisfy diverse user experiences. Addressing users’ health issues is merely the most fundamental aspect of health management; the core lies in the process through which users improve their health.

Health management, starting from health behaviors and evolving from a passive to an active process, will reveal that the internet increasingly resembles an empathetic companion, as its underlying implementation relies on big data–based behavioral management and decision-making.

Therefore, by leveraging health big data, the insurance industry has achieved personalized pricing—including self-service pricing—and further advanced to autonomous pricing, effectively addressing the challenge of personalization.

In recent years, the concept of “self-media” has swept across social networks. The concept of the “self-finance” era can be understood from the perspective of self-media. The social phenomenon of self-media is driven by two main factors: the decline of traditional authority and the rise of individual expression.

In the era of “Self-Finance,” the underlying drivers include social progress, technological advancement, information symmetry, and the awakening and awareness of individuality. The essential significance of the advent of the “Self-Finance” era lies not in enabling consumers to serve themselves, but in a paradigm shift characterized by a change in the “subject.”

“The Self-Finance” era is fundamentally driven by the demands for transparency, autonomy, equality, efficiency, and fairness. In other words, the business model of the financial and insurance industry is transitioning from the “spread-based” era to the “service-oriented” era.

In China, the relationship between medical health insurance and health management can be traced back 15 years: in December 2002, the China Insurance Regulatory Commission issued the "Guiding Opinions on Accelerating the Development of Health Insurance," encouraging insurance companies to collaborate with medical and healthcare service institutions on joint research.

In September 2006, the China Insurance Regulatory Commission (CIRC) promulgated the Administrative Measures for Health Insurance, explicitly stipulating that insurance companies shall strengthen cooperation with medical service institutions and health management service providers, enhance the management of medical service costs, and oversee the reasonableness and necessity of medical expense expenditures.

In October 2014, the State Council issued the “Several Opinions on Accelerating the Development of Commercial Health Insurance,” which encourages commercial insurance institutions to actively develop health insurance products related to health management services, strengthen health risk assessment and intervention, and provide services such as disease prevention, health examinations, health consultations, health maintenance, chronic disease management, and wellness care, thereby reducing health risks and minimizing disease-related losses.

In November 2016, the Health Management and Health Insurance Branch of the China Non-Public Medical Association was established. Its primary missions are twofold: first, to build a platform for collaboration between health management and health insurance; second, to organically integrate medical insurance with the health industry and health services, and to conduct specialized research on the bottlenecks and challenges hindering the development of health management and health insurance.

According to Document No. 134 [2017] on Personal Insurance issued by the China Insurance Regulatory Commission in 2017, insurance companies are supported and encouraged to differentiate pricing based on factors such as the insured’s health status and smoking habits when determining premium rates for term life and whole life insurance products, thereby enhancing the scientific rigor of product pricing.

“The Yellow Emperor’s Inner Canon” states, “The superior physician treats disease before it arises.” This principle forms the foundation of health management. How to intervene in and influence patients’ diagnostic and treatment behaviors, provide cost-effective and practical treatment plans, and thereby reduce insurers’ claim costs is a persistent concern for health insurance professionals and a key driver for insurers to enhance profitability.

Although China’s health management sector emerged in the 1990s, lagging behind the United States by approximately three decades, numerous pioneers and trailblazers have arisen in the cross-sector integration of health management and insurance.

Many companies in the internet health sector aim to build ecosystem platforms, but it is extremely challenging to deliver comprehensive healthcare services based on big data through a closed model. Therefore, Miao Health has chosen to leverage core algorithms and retail channels as entry points, coordinating data and services to create an open platform.

Miao Health’s open platform for health data and services, “Miao+,” has currently integrated over 300 types of smart hardware products. Covering functionalities such as medical healthcare, fitness wellness, medical rehabilitation, and behavioral analysis, the platform leverages Internet of Things (IoT) technology to acquire health data from multiple dimensions. In terms of data analytics, it employs big data computing and artificial intelligence technologies to provide insurers with detailed user health information.

Notably, behind the RMB 100 million Series A financing lies insurance capital such as Sunshine Ronghui. Zhang Jianmin, Director of the Health Insurance Division at Sunshine Insurance Group, stated in an interview, “Health management platforms are natural allies of insurance companies.”

More Health is further deepening its collaboration with the insurance industry. Recently, More Health and Aeon Life Insurance Co., Ltd. jointly launched "M Health Insurance," the first insurance product in China that truly leverages big data to dynamically adjust coverage amounts.

“M Health Insurance,” leveraging Miaojiankang’s proprietary Health Behavior Index (M-Score), grants a health insurance coverage of RMB 3,000 upon completion of a single 100-point M-Score task, with an additional RMB 1,000 increase in coverage for each subsequent 100-point M-Score task completed.

ZhongAn Insurance’s “Bu Bu Bao,” launched in 2015, was China’s first health management program to integrate wearable devices and sports big data.

Leveraging historical data provided by wearable devices, the system recommends critical illness insurance coverage with varying sum-insured tiers tailored to different user profiles. Once the policy is in effect, the more steps a user takes daily, the lower the premium they need to pay the following month.

Insurers’ use of wearable devices goes far beyond this. Capitalizing on the success of “StepGuard,” ZhongAn announced that users who meet their daily target of 8,000 steps on at least 20 days within the past 30 days are eligible to purchase the Zhenxiang Yisheng Medical Insurance (Sports Edition) at a discounted rate.

Equipped with the three foundational elements of “data channels,” a “controllable healthcare service system,” and a “large-scale user base,” WeDoctor has refined the health insurance segment through its “WeDoctor ACO” model. WeDoctor launched “Family Guardian,” an outpatient insurance product for internet hospitals, which is China’s first ACO-based insurance product jointly developed with ZhongAn Insurance.

Regarding the most critical health management resources within the ACO system, one of the three specialists in WeDoctor’s “Three-Specialist Management” model is a health manager, who can intervene in members’ health management and lifestyle. Furthermore, through collaborations with companies such as Meinian Onehealth, the concept of precision health management is being promoted.

As an internet-based healthcare service platform, WeDoctor leverages its medical and health data to strengthen information integration between the insurance and mobile healthcare sectors, enabling insurers and clients to access more transparent and controllable information.

In the United States, health management companies serve the general public, but their direct clients are health insurance companies. In other words, health insurers primarily outsource health management services for their enrollees to third-party health management firms, rather than providing these services directly.

Collaboration between insurance companies and third-party health management firms has proven highly effective in enhancing product added value and reducing claims costs for medical insurance.

According to statistics from Johns Hopkins Medicine in the United States, the emergence of health management companies has reduced direct medical expenditures for health insurance companies by 30%. Health management companies have emerged in response to the development of the insurance industry.

Below are selected cases illustrating the integration between U.S. insurance companies and health management. Similar to practices in China, U.S. insurers have begun to engage in health management through wearable devices and third-party platforms, while health management platforms are continuously realizing the value of their data.

UnitedHealth Group, headquartered in Minnesota, is the largest health insurance company in the United States and was founded in 1974. The company primarily operates through two segments: its health insurance business (UnitedHealthcare) and its health services platform (Optum).

As early as 2013, UnitedHealth utilized wearable cardiac monitoring devices to monitor users’ heart health and conduct data analysis.

In 2016, UnitedHealth Group launched the UnitedHealthcare Motion program. This initiative provides enrolled members with free wearable devices and offers tiered rewards based on their physical activity volume, frequency, and intensity.

If you walk 10,000 steps per day, you will receive a $1.25 reward; if you engage in six exercise sessions per day, each lasting no less than five minutes, you will receive a $1.50 reward. By maintaining consistent exercise habits, you can earn up to $1,460 in rewards annually.

Welltok, another prominent health management company, focuses primarily on integrating various resources to build a robust online health management platform, while outsourcing most derivative services to third-party providers.

Welltok’s CaféWell health optimization platform integrates not only numerous health management initiatives, such as mobile apps and wearable devices, but also downstream products in the health industry chain, including health insurance plans.

Welltok’s approach involves continuously guiding users toward healthier habits through resources available on its platform, while the user health data collected in this process becomes another gold mine waiting to be tapped.

In 2015, John Hancock Financial Services encouraged its policyholders to wear Fitbit trackers provided by the company by offering premium discounts.

With this smart wristband, Hengkang Insurance Company can access customers' health data. Customers can also earn points through regular activities such as going to the gym; the higher the points, the greater the premium discounts they receive.

In 1933, Dr. Kaiser and Dr. Garfield, together with several investors, began to conceive a new type of health insurance organization. By collaborating with labor unions, they allocated five cents from the $1.50 per capita prepaid workers’ compensation insurance premium to the Garfield Clinic to cover medical expenses other than work-related injuries, while employees enjoyed free medical visits thereafter.

This was the prototype of the U.S. HMO model. In 1945, these two physicians also established Kaiser Permanente. Today, it has grown into the largest nonprofit integrated healthcare system in the United States.

In the 1970s, the United States enacted the Health Maintenance Organization Act, marking the first widespread promotion of cost-containment measures in healthcare payments by commercial insurance companies.

Leading international health insurance companies exhibit three key characteristics in health management:

First, segment customer groups to provide targeted services. Foreign insurance companies typically classify customers by risk level, identify the distinct health needs of each segment, and then offer tailored health management programs accordingly.

Second, provide closed-loop health management. By means of data collection, data analysis, health intervention, and evaluation feedback, establish a closed-loop health management system; actively leverage innovative technologies such as implantable medical devices, mobile health, big data analytics, and cloud computing to enhance key components within the closed loop.

Third, establish a health management ecosystem. Foreign insurance companies are increasingly collaborating with technology innovation firms, medical technology enterprises, pharmaceutical companies, healthcare institutions, and health consumer goods businesses through equity investments, mergers and acquisitions, and joint ventures to build a comprehensive health management service ecosystem.

To reduce costs, insurance companies have vigorously promoted preventive healthcare for users, thereby decreasing the frequency of medical visits and lowering healthcare expenses. The commercialization of healthcare payments in the United States has leveraged market competition to drive cost containment, giving rise to a preventive health management model that both saves money and improves population health outcomes.

Integrating insurance with health management services not only provides users with a risk safety net but also leverages combined online and offline resources to deliver personalized, concierge-style medical services—such as regular blood glucose monitoring and complication screening. This approach empowers patients to self-manage and control their conditions, effectively slowing disease progression and addressing the limitations of traditional healthcare delivery.

On the Zhihu platform, we have observed a viewpoint stating: “In the United States, commercial insurers, as payers, wield strong negotiating power backed by data. In contrast, in China, hospitals often do not comply with social insurance regulations, let alone maintain high-quality data.” Therefore, scientific, authentic, and large-scale health data serve as a critical lever for insurance cost containment, making personal health management platforms with substantial user traffic the primary partners for insurance companies.

From a mere payer to a health manager or health partner. Insurance companies are undergoing this role transformation, shifting from "passive claims settlement" to "end-to-end management." Their functions are no longer limited to medical reimbursement but are expanding into upstream areas such as disease prevention, treatment decision-making, and healthcare services.

Health management itself is not an industry; it is merely a philosophy centered on health and a set of technical means for maintaining health. Only when health management is integrated with high-quality technology and service methods, and organically aligned with both the immediate and potential needs of consumers regarding their health, thereby forming a complete industrial chain, can the health management industry unleash its immense economic potential.