The Tests Were a Test

Raise your hand if you’ve gone out shopping for home COVID tests, only to find empty shelves and signs apologizing for the lack of availability.  Raise your hand if you’ve been able to obtain one, but were surprised at its cost.  Raise your hand if you took one and weren’t quite sure you did it right, or wondered who, if anyone, would be getting the results.

Vox says that the COVID home test reimbursement process “is a microcosm of US health care,” and I think they’ve understated the situation.  Testing has been a microcosm for the US health care system generally.  It was a test, and our healthcare system failed.

Throughout the pandemic, we’ve never had enough tests or done enough testing.  You could start back in the early days when snafus in the CDC/FDA meant there weren’t approved tests quickly enough, or how, even when tests become more available, we didn’t do enough to keep ahead of COVID’s spread.  By the time we knew COVID had penetrated a nursing home or a community, it was too late.  We didn’t take advantage of macro-tracking approaches like wastewater monitoring.

We developed “rapid” tests but questioned their accuracy.  The “gold standard” PCR tests took/takes too long to return results.  As we encountered the highly transmissible variant Omicron, we didn’t scale up the production of tests – or the labs to process them -- enough to keep up with the demand, much less with the number of acquired cases.  We had, and continue to have, leaders at both the state and federal level criticizing testing, suggesting that the problem is not too many cases but too many tests. 

In our free-for-all pricing system, it’s anyone’s guess what a test might cost.  Most PCR tests have been required to be covered “first dollar” by insurance plans, so consumers haven’t been immediately faced with how much those tests cost, but costs picked by insurance end up in premiums eventually.  Home tests have not been, and costs might vary ten-fold or more depending on the manufacturer and/or seller. 

The Biden Administration has belatedly attempted to address these problems, but in a ham-handed way that is also typical for our healthcare system.  Earlier this month, it set up a system to for each household to order 4 free home tests.  The goal is to have 500 million, perhaps a billion, such tests available, although whether it has actually procured anywhere near that number is unclear.

The Biden Administration also required private insurers – but not Medicare -- to pay for 8 home tests per member per month, which seems to have come as a surprise to the insurers.  In many, perhaps most, cases, individuals would have to submit claims to their insurer to get reimbursed for these tests.  Insurers only have to pay up to $12 per test; consumers must pay anything above that.  Surprise!

When I read about that process, as a former health insurance executive, I immediately thought: that is not going to work.

There was a time when people submitting their own claims to their health insurer was not atypical.  Insurers used to refer to the “shoebox effect,” where people would save their receipts in a literal or metaphorical shoebox and send them in en masse, often at the end of the year, and armies of claim examiners would process them.  Between the development of preferred networks and electronic submission of claims, though, those days are long gone.  Indeed, one of the reasons that network plans like HMOs and PPOs became popular was because they didn’t require members to file claims.

These days, few companies have staffs of claim examiners sitting around trying to decipher paper claims, much less the processes to receive and sort them.  The fact that the rules were announced on a Monday but went into effect on the following Saturday made things worse.  Ceci Connolly, president and C.E.O. of the Alliance of Community Health Plans, told The New York Times: “It is going to be exceedingly difficult for most health plans to implement this in four days.”  No kidding.

What documentation needs to be submitted (receipts, product codes, pictures of the test, etc.), and how, are still unclear, and will vary between health insurers.  A survey of 13 major health insurers by the Kaiser Family Foundation found that 6 had some form of “direct reimbursement” (e.g., pay nothing upfront and network pharmacies deal with payment), 4 required claims to be mailed or faxed, and 2 had an online submission option.  KFF couldn’t determine what the remaining insurer required.

As you can imagine the Twitterverse found the fax option ludicrous…as it is.

As bad as all that is, we now have a scenario where there are potentially hundreds of millions of tests being taken, but no system for tracking how many are used, by who, or how many positive results there are.  We thought we were doing a bad job counting how many people have received how many doses of the vaccine, but at least there was some reporting system in place.  With these tests, we’re pretty much going to be in the dark.  We’ll never know how many positive cases we’ve had.

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Initially, we had no testing strategy.  Then our testing strategy was just “get tested,” with no  supporting tactics to make that feasible.  Then, almost 2 years in, we get grand announcements about directly providing free tests, but not enough for everyone, plus mandates on insurers for more free tests that don’t do anything to make the tests more available, affordable, or easy to get reimbursed for.

Yeah, all that sounds like a microcosm of our healthcare system.  As Vox put it, “It’s a needlessly complicated process that provides little benefit but creates plenty of problems.”

Countries with universal coverage have an easier time.  They can negotiate the price and dictate where and how their citizens can obtain tests.  We prefer, or, at least, choose to tolerate, a fragmented system where even getting tests during a pandemic ends up putting the burden on us.   

Shame on us.  It’s not just the healthcare system that failed the test.