As I write this column, I’m working at home, social distancing from others not in my immediate family, yet keeping close to my coworkers and community through a blend of online video and other communications. As COVID-19 continues to spread across the United States, I wonder when we will return to “normal” — or even what the “new normal” will look like. Will we see continued innovation in how health care is accessed, administered and paid for, or will we revert to the status quo, with patients facing barriers to care and languishing payment reforms?
On the encouraging side, we’re seeing innovation from biopharmaceutical companies, researchers and public health professionals and others in developing tests, medicines and vaccines to fight the pandemic. Telemedicine is growing in use as citizens who are “sheltering in place” seek needed help. Frontline health care workers are bearing a tremendous burden in caring and providing services for others. And many of the heroes in the fight are our neighbors in our community, from first responders to grocery store employees, delivery service drivers and others who are working at significant personal risk.
Geographic factors impacting access to care — known as social determinants of health — are even more pronounced during this time. Now more than ever, an individual’s ZIP code is a determining factor of their health, access to care and even whether they’ll face greater exposure to COVID-19 because of jobs, reliance on public transportation or other community factors.
ZIP codes also create barriers to obtaining care, whether it’s seeing a physician, paying for a medicine or picking up that medicine at the pharmacy counter. Unfortunately, in this day and age an individual’s ZIP code may impact their health more than their genetic code.
Barriers can be of several types, including patient characteristics, health care/organizational concerns and environmental conditions. Patient characteristics can be such things as chronic conditions, language, behaviors, attitudes and beliefs, and health literacy. The health care system itself comprises many barriers, including provider competencies and beliefs, provider availability and language. Two other significant barriers, of course, are health insurance coverage and cost. In fact, 14% of insured Americans, and more than one-third of uninsured Americans, report underutilizing medication due to cost. These barriers have been exacerbated in the current crisis.
Costs can be especially high for the 46% of Americans who have high-deductible health plans (HDHPs). They must meet deductibles of $1,400 for an individual and $2,800 for families before services are covered. NPC research has shown that HDHPs can have negative effects on financial stress, disease control and hospitalization rates — all issues that have come to the fore during the current crisis.
What could we do to avoid putting HDHP-insured Americans on a collision course with COVID-19 expenses? As a start, we’ve seen some insurers waive co-pays for COVID-19-associated medical costs. Other recommendations to improve HDHPs and insurance design could include:
- Requiring that insurers consider COVID-19-related services (testing, hospitalization, etc.) preventive services. The government could create an IRS safe harbor provision for pandemic disease containment; once a COVID-19 vaccine is developed, it could be covered as pre-deductible care.
- Depending on how widespread and severe infection becomes, consider action to relieve the financial toxicity that stems from hospitalization.
- Ensuring that once a vaccine is developed, it is covered by insurance.
- Design health plans with potential pandemics in mind. For health plans created at the state level, this could be a mid-year coverage change before the fall flu season begins. For consumers and employers, this could be added as they consider their next cycle of group purchasing.
Utilization management approaches, including step therapy protocols, which require patients to “fail” on a less expensive treatment before trying another one, also represent potential barriers. Payers use these approaches to optimize prescribing and manage costs. Last year, the Centers for Medicare and Medicaid Services (CMS) announced that Medicare Advantage plans can use step therapy to manage Part B drugs, and it is reportedly considering widening the guidance to Medicare fee-for-service plans. While it’s understandable for insurers to find ways to manage costs, the use of step therapy for patients with progressive diseases like cancer or autoimmune disorders is especially fraught.
There are bright spots in our health care system. Payers are changing their policies almost daily in response to the challenges posed by COVID-19. Although coverage adjustments vary by payer, generally we are seeing:
- Co-pays and deductibles waived for diagnostic testing or covered as a preventive care service.
- Cost-sharing waived for telemedicine.
- Cost-sharing waived for associated visits.
- Cost-sharing waived for inpatient admissions.
- No prior authorizations for tests and covered services.
- Relaxing early prescription refill limits.
- Formulary flexibility.
- Step therapy protocols waived.
Some health care systems are experimenting with reducing financial barriers to high-value care as a way to improve patient access. In a new model known as V-BID X , from the University of Michigan Center for Value-Based Insurance Design, co-payments are waived for high-value care. The model specifies high-value services and medicines that should be available with little or no cost-sharing. The cost of providing these services and treatments will be offset by the reduction in delivery of low-value care, or care that does not offer real benefit for patients. Once the coronavirus pandemic ebbs, we should continue our push to reduce the delivery of low-value care, which drives up health care costs without improving patient outcomes.
It’s unclear whether this kind of payment flexibility will continue once the United States returns to “normal” conditions. Certainly there are economic implications that we’ll need to address, and those will likely shape health care access and payment decisions going forward. And while states like North Carolina have been working to address ZIP code issues for years, a bigger question is whether more states will follow suit in efforts to care for their vulnerable populations.
The pandemic has thrown the condition of our social and safety nets into high relief, exposing their rips and tears. But good can result from it as well, if we leverage the opportunity for positive change going forward. As we shape our “new normal,” we must recognize and address these issues. Greater access to health care and medications, and improved health for all Americans, continue to be ideals worth striving for. We must not waste the lessons learned during this time of crisis.
Dan Leonard is president and chief executive officer of the National Pharmaceutical Council.