Op-Ed: In Mid-Crisis, Opportunity Knocks

The U.S. healthcare system was in dire straits long before COVID-19’s ominous appearance. A toxic brew of social, economic and political factors had created the world’s costliest health care system while achieving far less than stellar population health outcomes. Relentless increases in health plan deductibles and out-of-pocket costs had already made medical care unaffordable for millions of Americans.

In 2019, one-third of Americans reported not receiving medical care due to cost and, more recently, 68% of adults said that the out-of-pocket costs they might have to pay would be very or somewhat important in their decision to get care if they had symptoms of COVID-19.

Now, more than 100 days in, we are watching as the pandemic intensifies financial hardships for those who already struggle to afford health care. COVID-19 will exact an enormous clinical and emotional toll on all Americans, but particularly on those who are financially insecure or chronically ill.

It was hard for me to envision a silver lining in all of this, but my colleague A. Mark Fendrick, MD, has done just that. In two recent, well-sourced articles, he teased out two potentially consequential opportunities that shouldn’t be missed.

Opportunity to fix current healthcare benefit designs

All too often, commercial and public benefit designs do not include affordable coverage for critical services such as care to treat COVID-19-related illness. The arrival of the pandemic demanded immediate attention from policymakers and brought about some important, albeit short-term, mitigation in the form of legislation. A range of legislative and executive actions included permitting high deductible health plans to reduce or eliminate cost-sharing for COVID-19 testing and treatment; enabling coverage of telehealth services for COVID-19; extending in-person coverage for COVID-19 testing or screening; and requiring future coverage of COVID-19 vaccines.

The opportunity lies in expanding these actions beyond the immediate crisis by implementing value-based insurance design (V-BID) reforms that make critical clinical services and other potentially lifesaving treatment (e.g., heart disease, depression, diabetes) affordable for all those in need of them. V-BID reforms would also lower or eliminate out-of-pocket costs for preventive and essential health services and medications.

Opportunity to tackle low-value services

Inevitably, better coverage for higher-value care as described above will add to current costs. The opportunity lies in reducing even a portion of the $345 billion the U.S. spends each year on wasteful or low-value clinical services. Low-value services are those that “provide little or no benefit to patients, have potential to cause harm, incur unnecessary cost to patients, or waste limited healthcare resources.”

A task force at Fendrick’s V-BID Center came up with the following “Top Five” list of low-value clinical services for purchasers to target for reduction:

  • Vitamin D screening tests
  • Diagnostic tests before low-risk surgery
  • PSA screening for men age 70 and older
  • Branded drugs when identical generic drugs are available
  • Low back imaging within 6 weeks of onset of pain

Collectively, these services contribute to over $25 billion annually in wasteful health spending.

The center’s new health benefit design model (V-BID X) targets low-value care and increases access to high-value services without raising premiums or deductibles.

COVID-19 has exposed longstanding shortcomings in our healthcare system and amplified their detrimental effects on the physical, emotional and financial health of the population. As we stare into the proverbial abyss, I would ask readers, “Do you believe the healthcare system that brought us to this place will help bring about desperately needed changes?”

If, like me, your answer is, “No way!!” we must seize every opportunity to bring about the changes we need.

David Nash, MD, MBA, is founding dean emeritus and the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy at the Jefferson College of Population Health. He serves as special assistant to Bruce Meyer, MD, MBA, president of Jefferson Health.