J. asked an awesome question yesterday about COVID testing:
I thought testing was covered by insurance. Can you please explain, David?
There are three different types/regulatory categories of testing for COVID. Each have their own quirks, desired technical specification and regulations that drive payment.
DIAGNOSTIC TESTING is testing done to give an individual a yea or nay on whether or not they are currently infected. Diagnostic testing is on the recommendation or supervision of a licensed medical professional. These tests are desired to be highly specific and highly sensitive. We really want to get the results right. These tests are overwhelmingly lab PCR tests with a sample coming from a swab stuck up your nose.
The CARES Act mandates that these tests are provided to individuals with no cost sharing. These are the “free” to the patient tests.
SCREENING TESTS are tests performed on people without clinical recommendation. My parents’ tests that I described yesterday are basically the epitome of this test archetype. A good analogy from a payment perspective is the company required drug screen as a condition to be hired. In that case, the company, not the insurer, pays as the test is not medically indicated but is part of a normal business practice. The NFL is a good example of mass, recurring screening tests being used with the intent of stomping on viral outbreaks at one, two or three cases instead of twenty, thirty, or forty cases. Here frequency of testing and rapid result reporting is more important than accuracy. A mediocre test done daily and reported within a cup of coffee is vastly superior to a perfect test done weekly with results coming back three days after the specimen was collected. Someone who has a presumed positive test today can get cleared with follow-up PCR diagnostic testing or by several days in a row of a negative screening result.
SURVEILLANCE TESTS: These tests are used to inform policy responses. Results are not reported back to any specific individual. For instance a pooled PCR test strategy for a college campus would allow for most dorms to be cleared at a point in time while saying that the 3rd Floor of East Rich Donor Tower is an emerging cluster. 3rd Floor ERDT would then be subject to a swarm of individually identifiable testing to figure out that there are five infected students in two suites that share an air conditioner and those individuals and their close contacts would be isolated and treated as appropriate.
Communities can also do non-individualized surveillance. Influenza Like Illness tracks the percentage of people who present to emergency rooms with symptoms that look like the flu. Covid Like Illness is a new metric that tries to do the same as ILI but for COVID. Communities that run their own sewage system are beginning to track virus levels in their waste water to identify background prevalence and hopefully isolate any sub-regional hotspots. This allows for more fine-grained strategic responses to the situation on the ground. These tests are also not paid for by insurers.
Thank you for the great, easy-to-understand explanations of the three different types/categories of testing, David. I wish that the first and second types were easier to get, with faster results, and that the latter was covered by insurance. As I noted in my comments from your previous post, it is still quite difficult to get screening tests (and even diagnostic tests), with often long wait times for testing and results, at least in Connecticut and Massachusetts. Both diagnostic and screening tests should have been easy to get and plentiful by now.
@J.: Ideally yes; diagnostic tests would be available for anyone with any symptom adjacent to the COVID symptom chart AND for anyone who was in probably close enough contact to a person likely to have been infectious.
Ideally screening tests would be something that people can pick up a 30 pack at the story for a buck a test or get a big box in the mail for the month and take the test every morning right before starting the water to boil for coffee and get the result just before the first critical sip.
@J.: The same difficulty is true here in CO. I’ve previously told the story of a friend’s boss who quite obviously caught while competing in a cross country ski race in Austria in February; this guy went from being a competitive ski racer to still barely able to climb two flights of stairs because he has extensive blood clots in his lungs. His doctor ordered one antibody test in early summer, it came back negative and the doctor told him it’s a false negative, you obviously has it based on the characteristic “ground glass” appearing chest X-Ray. Tests are still too hard to get, so as of 4 weeks ago he hadn’t gotten another because why bother and he’s in the middle of trying to keep the college campus open.
The guy is 60 and the stress of that while attempting to recover is enormous; obviously he can’t take early retirement because he is well under Medicare age and unless we win this election, he will be uninsurable when the R’s finally kill the ACA. The kicker is his case doesn’t count in the official total because there has to be a positive test result to do so.
If the screening test is at all complicated, it would be wise to wait until after the coffee.
There go two miscreants
Thanks! This is very clear and logical. I had not seen it spelled out before (there is a lot of loose discussion of “testing” in the general press) so I have definitely been enlightened!
I thought I read, but cannot find, a comment about the sewage monitoring at University of Arizona suggesting that the virus is detectable in feces before it becomes transmissible, not just asymptomatic.
If so that seems like a potential game changer.
Anyone know more?
Thanks for this.
IANAMD, but my understanding is that PCR tests are actually too sensitive and don’t really give us the most important bit of information – “Is this person infectious to others?” As I understand it, PCR tests can give positive results even if it detects fragments of the SARS-CoV-2 virus that cannot cause infection to others. (That’s part of the reason why sailors on the TR were showing up positive on retesting weeks later, as I understand it.)
As I understand it, in Wuhan most of the diagnoses for infection was made via lung imaging, not PCR tests. That answered the question – What is the state of the patient’s lungs and are there other clinical signs of disease?
As you outline, there are a variety of test types now. Are there good tests that answer the question about whether someone is currently infectious to others? Are there any in the pipeline? As with the other tests, who will pay is a big problem in rolling them out to the masses… :-(
@Another Scott: When I was suspected of having covid in the hospital, a chest X-ray was part of my diagnostic procedure. It was covered normally by my insurance. Since I don’t have an itemized bill from the hospital, I can’t tell you what my nasal swab test cost if anything. But the chest X-ray is an important part of figuring out how far along the infection is, so personal opinion is that should be no cost to the patient also. As with all things YMMV.
@Another Scott: I’m not an expert, but I was molecular biologist for a long time, and still work in clinical research. So my two cents:
The RT-PCR test detects presence of (parts of) the viral genetic material. Yes, it can detect non-infectious fragments of the virus RNA. It’s used as the gold standard because it’s both very sensitive and very specific. What it tells you is that the individual has/had virus on board.
Right now as far as I know there isn’t a good way that’s broadly applicable to test whether or not someone is infectious. There are antigen tests that will detect other virus components (for example, the nucleocaspid protein). A positive antigen test indicates the individual probably has functional virus, and may be shedding active virus (depending on where from/what type of sample is collected). For instance, the above-mentioned sewage surveillance, which shows that people can be shedding virus/viral fragments in their gastro-intestinal tract prior to showing symptoms. (This is common for some types of viruses.) Basically we need more data – how many people with positive tests (PCR, antigen) go on to infect others and under what conditions?
From a data collection standpoint, ideally, I would want to start with some sort of potentially super-spreader event (a college dorm, a biotech executive conference, a long-term care facility, church service) and collect samples (naso-pharyngeal, blood, fecal) from everybody every week for several months, plus their activities and interactions. Test all samples via PCR and various antigens, and blood for antibodies. Then one would have a much better understanding of the spread, infectiousness and development of antibodies.
I regularly give platelets at the local blood bank. They do an antibody screening test which they report back to me. Negative so far. My question is whether that test is reported in some way and does it have a public health value.
Mr. Mayhew/David Anderson, if you had any question why this community rushed to help your family with the fundraiser, more quickly than even sending bucks to transport a cat, it is likely because you have been an essential and trusted source of timely information on health care and insurance related matters for as long as you have posted here. Thanks for another good one and for helping us understand complex issues.
@StringOnAStick: What an awful story. What’s worse is it so didn’t have to be this way.
TWIV (This Week in Virology) podcast is a great resource for SARS-CoV-2 knowledge. Combining data from contact tracing and diagnostic testing allows for some hypotheses on whether certain levels of viral RNA are correlated with being infectious. This is true for both rapid antigen-based testing and RNA-based RT-PCR. For the latter, the signal of the virus shows up earlier if viral RNA levels are higher. There are lots of other variables (e.g., some people seem to spray more virus when speaking, breathing), but researcher thinks viral load matters. Listen to the podcast and you can hear about Daniel Griffin’s “Testinator for the tri-state area“. He and his colleagues are trying to build a system that would help us to test our way out of this. His dream is a rapid screening test that costs 50 cents. But listen to the podcast: https://www.microbe.tv/twiv/twiv-658/
You forgot the part where the cost of the screening test is “a couple cups of overpriced coffee” but the price to consumers is “a minor car repair.”
The first papaer about that (that I’m aware of) was this one in May 2020 (Yale, New Haven CT)
SARS-CoV-2 RNA concentrations in primary municipal sewage sludge as a leading indicator of COVID-19 outbreak dynamics (May 22, 2020)
Here are the papers that cite it, via google scholar. (Some abstracts look interesting.)
There is a lot of practical work happening, and more investigations.
So when Abbott said its Binax Now test is priced at $5, does that mean I can pick up a 10 pack at CVS and/or on Amazon for $50, or is it that Abbott will sell the test to CVS for $5 then CVS can charge me $500?
@scottinnj: The federal government bought the entire 2020 supply @ $5 a pop