Welcome to Stay Young. What health insurance costs monthly brings many to the brink of despair. Well, Germany has one of the most expensive healthcare systems in the world, but unfortunately not one of the best, because people are on average sicker than in other countries. And in terms of life expectancy, Germany ranks 39th worldwide. And expenditures are rising far faster than revenues. When will the system hit the wall? I'd say, soon. If we don't manage to switch from repair medicine to preventive medicine, could health insurers play a driving role if they shifted from reimbursing costs to becoming health managers? Or in other words, could insurers become pioneers of modern, digitally supported preventive care. My guest is one who thinks exactly this way and is committed to precisely this direction. He is the CEO of one of the largest insurance companies worldwide, AXA, with 1.5 million private health insurance policyholders in Germany alone. Dr. Thomas Buberl, welcome to Stay Young.
So, dream a little. How would AXA care for its private policyholders if you could act completely freely without any legal or government regulation?
Maybe first back to where you started. It's absolutely correct. Unfortunately, healthcare expenditures in society today are rising significantly faster than inflation in a normal country. That means the ability to afford health insurance declines over time, and the systems will eventually reach their limits. The only way to change that is to shift perspective. You just said it: how do we move from a repair society to a prevention society? How can we help people avoid the next illness or the next disease? And that's not entirely easy, because we've been raised for years to live life the way we want, without limitation. And when there's a health problem, you go to the doctor and then it gets repaired. Telling someone today that life needs to be restructured — in the sense that you get preventive check-ups, that you regularly get yourself examined to see how you can prevent certain things and how you can shape your lifestyle to become healthier — is an absolute cultural change and won't be easy to achieve.
You've touched on a big topic for private policyholders in Germany, and everyone is now thinking: if only the public insurers thought the same way. Maybe we should clarify — why do you only have private policyholders in Germany? Why no publicly insured ones? That's not even possible, right?
Well, we do have publicly insured people too, because those who have statutory basic insurance can buy private supplementary insurance, and we also offer supplementary insurance. So in that sense we also have publicly insured people. But as a private company, we cannot offer statutory insurance. But at the end of the day, it's not really that different whether you're publicly or privately insured. When we talk about a repair society versus a prevention society, both actually face exactly the same challenges. And it's actually a shame that both are working on the topic in isolation. They could collaborate, because neither is actually in competition. In Germany the fields are clearly defined — there's the income threshold above which you can choose private insurance, and you can't go back unless certain conditions are met. But the two aren't really in a major competitive relationship and should, in my view, collaborate much more.
Absolutely. We'll spread that message — I'll forward this podcast immediately to the Federal Ministry of Health and to all policyholders and insurers and institutions. Let's compare the statutory health insurers with the private ones. The German public health insurers invest a total of 0.25% of their 240 billion euros in annual expenditures on preventive measures for their policyholders. What percentage is that at AXA?
That's relatively difficult to say, because what we do is help our policyholders. We're more focused on the question: how can we go from being a pure bill payer to a life companion? We restructured our system years ago so that people who want or need companionship — especially those with chronic diseases — get a case manager assigned to them who accompanies them through life and helps them practice more prevention at key moments. So I wouldn't frame it so strongly in terms of how much is invested in prevention, but rather how much prevention accompanies people. Because even if I say I spend 100 million on prevention, what's the result?
Can you give a few examples of what AXA already offers policyholders in terms of prevention?
For example, if someone is interested in living a better life, we help them regularly go for blood tests. We compare the blood tests over time to see how individual values develop, where someone is outside the norms and where within norms, and how to improve. That's the first point. Second, we put together a multi-year program of check-ups — cardiology screenings, colonoscopies, and so on — so that people really do these examinations preventively on a regular rhythm over several years, establishing a personal health profile of strengths and weaknesses, with weaknesses being regularly examined. That's the normal part. Then there are more serious conditions where we provide companionship. For example, when someone in a family receives a Parkinson's diagnosis, life changes completely for that person and their family, and we help guide them — giving orientation on what to do, how to adjust life, connecting them with other cases in their area to share experiences. Or a third example: chronic illness. With chronic diseases, especially diabetes, it's extremely important to keep the person in an early stage and not let them progress to a more difficult stage. The discipline of treatment is extremely important, and we help these people establish a routine — having a coach, a companion in life to follow the treatment. Because when facing difficult health news, people are often alone and facing a completely new situation they've never dealt with before. It's very emotional because it concerns health, even survival in some cases, so companionship is extremely important.
Is this also a coach who calls for preventive measures — go get a blood check, go for cancer screening, etc.? What does this coach look like? Is it virtual, do you get an email? How do you organize that?
Partially in person depending on the situation. The case managers I mentioned are people you actually talk to. But of course, if you want to scale this more, you need to embrace new technology and work with it. That's really not a problem today and is increasingly accepted. But I'll come back to this — unfortunately today there are two groups that particularly well accept this. Those who are extremely fit and want to get even better, and those suffering from chronic diseases. The great middle segment has the problem that it's very difficult to reach them when talking about prevention. These people would rather invest in the prevention of their car than in the prevention of their body.
That already answers my next question — how is this received by policyholders? But I want to come back to my opening question. You've already broadly described what you offer in terms of prevention and companionship for people with chronic age-related diseases. If you could dream — please dream now. What kind of system could you offer if you could do whatever you wanted?
Today, the system very much resembles a payment system. Today, the insurer and the healthcare system are pure bill payers. Tomorrow, or the day after, the insurer and the healthcare institution should actually be an orchestrator of communities that want to live a healthier life. And there, we're probably closer to Facebook than to a classic insurer.
You have to explain that — it's exciting. Communities open to prevention. How would that work? How do you reach them, and what measures would those be?
What we've seen is that doing prevention alone is relatively difficult, because you're always fighting against yourself, against your own laziness, and against the temptation to do something more interesting instead. When you're in a group, you have a sense of competition and you don't want to embarrass yourself in front of others — a bit like the Weight Watchers logic of the 80s. And second, you can exchange experiences. Especially when you're entering territory with many unknowns — because the question is, why should I invest an hour or two in prevention? Why should I line up at the doctor for a blood test? What does it bring me? But if I have others who motivate me, others who say 'I did this and this was the result, here's a good tip' — suddenly the logic changes. Doing it in a community is much better than doing it alone. That's why I believe the forward-looking insurer in 10 or 20 years will be the institution that brings together people with aligned interests in prevention who can achieve a better goal together.
Super exciting idea. So the AXA Group on Facebook, so to speak — 25-year-olds, perhaps 40-year-old women, perhaps 60-year-old men, they come together, are open to it, and would receive offerings like early detection, genetic checks. I find it fascinating to go even deeper and consider what would actually be possible to prevent those terrible age-related diseases that make us sick for an average of 11 years at the end of life. Vaccination programs, fitness programs, nutritional counseling, apps on prescription, whatever — what's in the arsenal?
I think what's important is you can never force people to do anything. The main responsibility for participation and success in such a group and relationship lies with the participant themselves. If he or she doesn't want to do it, you shouldn't even start. The coach has more of a guidance role — how to give orientation on what to do, how to set a methodology to follow, and how to help refine the path when you have results. I think that's the role of the coach, nothing else. If the person isn't willing to do it themselves, it won't work. The program is always very strongly tailored to the individual — does the person have complications from the past, or is the person completely fit? But again, the group comes together among willing participants, and the person leading the group sets a methodology and provides individual guidance.
If I may follow this through — I find it an incredibly fascinating idea. If I understand a bit about prevention, I could lead such a group as a coach. Let's say it's a Facebook group for women over 60, and they could tell me what topics they have. Of course it has to do with post-menopause and other things. I could recommend online coachings, advise them individually toward telemedicine, maybe organize preventive house calls, comprehensive health check-ups, but all individualized, or perhaps even very hands-on health centers.
Of course you have to be careful — you need experts, and you need experience. The people who do this with us have the necessary medical training — they're nurses or doctors. And second, you can only do this if you've seen many other cases and can pass on the experience and logic from those cases to these people. So trying to do this as a newcomer is relatively difficult, and the medical risk involved is something I'd think very carefully about.
I understand. But maybe you can already say — you have this system, it's already running in small scale. And what you dream of is rolling out such a advisory coaching system to larger groups and also to broader segments of the population.
Right. Today it's rather — I don't want to say anecdotal, but case by case. If someone wants it, it's done. For example, I personally do it too, because I'm a big advocate of prevention and follow my own defined program. But today this is only for the willing. As I said, the willing are unfortunately the extremes — those who are relatively fit and want to get even fitter, and those who suffer mainly from chronic diseases. The middle segment unfortunately isn't yet there, and the ambition of our system must be to bring these people along. Because again, we'll reach the limits of the system with the inflation in healthcare. And the only way to brake inflation and better manage medical services is to do prevention — to prevent tomorrow's damage and services.
And that requires a change of attitude, a paradigm shift for everyone, a cultural change. This has nothing to do with mechanics — it's cultural.
Yes, exactly. We grew up in a repair system over many years. If you now want the system to change to a prevention system, that will take years and will require a lot of investment and trust to get there.
You can look at countries that have already achieved some things. They set incentives, also for policyholders who haven't gotten off the couch yet and embraced the idea of personal responsibility for their health. Some things work — I'm thinking of Singapore, which has Health Points where you become a member and then get free stuff for behaving well. It's obviously understood differently regarding data privacy. You have the wearable, and all the data goes in — how much you've walked, which I found especially interesting. If you buy vegetables at the supermarket checkout, it's registered and you get points. So you might get a reduction in your insurance premium, or free access to fitness clubs, a free wearable, and so on. What do you think of such incentive systems?
You can see that today two systems work, and they're based on the same principle: more responsibility for the individual in the system. And I'll come back to this — if the person doesn't participate and doesn't want their health to improve, the system won't work. Both systems have that as a foundation. Then there's the Singapore system you mentioned and other cases where either the government, the employer, or even private individuals are incentivized through better behavior to get points and corresponding benefits. The second system that exists is a barrier system where, if certain preventive measures aren't met — for example, a doctor's visit isn't done once a year, a blood test isn't done once a year, etc. — then you either lose your health insurance or get it at a significantly higher price. That's a model that Iceland and others have introduced. Of these two models that work well today, I'm naturally a big fan of the first model, because if we manage to motivate participants in such a program to participate and, through positive incentives, behave better and even get something for it, that would actually be the ideal.
But you also have to make sure it's holistic. If today I walk my 12,000 or 16,000 steps but in the evening down a bottle of gin with friends, I may look like an excellent patient on my fitness watch, but not really in my evening consumption. And I think you have to look at things holistically and not in isolation. The number of steps is a necessary but not sufficient condition for good behavior.
Yes, we're essentially talking about intrinsic and extrinsic motivation. Extrinsic goes through reward or punishment. Intrinsic has nothing to do with either — it simply says, I want to. And in our current system, we have neither the extrinsic nor the intrinsic motivation really promoted from the insurers' side.
How could it work then? We've discussed external rewards and punishment. But how could we make it so that people actually start from early childhood to take an interest in their own health and take personal responsibility — maybe as a 16-year-old realizing that if I sit on the couch all day and my social media and phone consumption goes through the roof, that can't really be good. How do we achieve this really strong mentality change?
As I said, for me this is an absolute cultural change, and it starts very early in life. From childhood, when the first time a child understands what health is about — education about health in school — that's where the topic of prevention must be absolutely anchored. Much more education must be done on this topic, with concrete illustrations and examples. It would also be important to motivate influencers on social media to jump on the prevention topic, share their own stories of how they've improved their own quality of life. I think that's the absolute foundation. It has to start early and this topic needs to be pushed through multiple channels because it's an education and culture topic, not a mechanical one where you just do X and Y and it's done. The second point, as you said with Singapore, this system must be introduced in an absolutely trusting society. Many people today are very hesitant to reveal more about themselves and their lifestyle habits because they fear it will be used against them in insurance pricing. And I believe a clear trust system must be established that ensures what's disclosed is only used to help the person live a better life, not to punish them afterward. I believe these are the two absolutely critical things that must be proactively addressed to significantly strengthen intrinsic motivation. If that doesn't happen, we'll unfortunately move toward extrinsic motivation in the sense that we'll eventually hit the financial limits of the healthcare system, and then the only question will be: either there's no more insurance, or insurance at extremely high prices, or insurance at normal prices only if prevention becomes a mandatory part of insurance.
