By NextBestFitValue-based cost sharing
Free for high-value care (primary care, chronic-disease drugs, prevention); copays only for low-value services.
Keeps billing; the coverage-list path handles low-value care instead.
Review ledgerHow this path connects
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Create and publish a list of high-value services exempt from cost sharing
- Assign an agency to update the list annually
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
- Underinsurance: covered, but can't afford to use it
Making primary care, prevention, and chronic-disease drugs free encourages needed care while copays discourage low-value services. Free chronic-disease drugs improve adherence and can reduce hospital use.
- Low-value care and overtreatment
Charging only for low-value services discourages waste while needed care remains free.
- Adds paperwork, coordination, or complexity
Defining and updating service-value tiers is complex, and patients may not understand why some services are free while others are charged.
- Copays keep billing systems alive and still deter poorer patients
Tiered cost sharing still requires claim-level billing and tracking.
3 paths soften this
Automatic exemptions and annual collection through taxesCopays keep billing systems alive and still deter poorer patientsChosenDrop point-of-care charges entirelyCopays keep billing systems alive and still deter poorer patientsChosenOnly flat, small charges on a few servicesCopays keep billing systems alive and still deter poorer patientsRejected
Who's affected
- People with ongoing or specialist care needs
- Underinsurance: covered, but can't afford to use it: High deductibles and coinsurance lead them to avoid care.
- Low-value care and overtreatment: Low-benefit tests and treatments expose them to harm.
- Low- and middle-income households
- Underinsurance: covered, but can't afford to use it: High deductibles and coinsurance lead them to avoid care.
- Health insurers, brokers, and their shareholders
- Low-value care and overtreatment: They pay for tests and treatments with little benefit.
- Taxpayers and public budgets
- Low-value care and overtreatment: They pay for tests and treatments with little benefit.
- Health administration and software vendors
- Copays keep billing systems alive and still deter poorer patients: Copays preserve demand for billing services.
- Health insurers, brokers, and their shareholders
- Underinsurance: covered, but can't afford to use it: They benefit from lower premiums.
- Employers
- Underinsurance: covered, but can't afford to use it: They benefit from lower premiums.
- Health financing intermediaries and lenders
- Underinsurance: covered, but can't afford to use it: They administer health savings accounts associated with high-deductible plans.
- Hospitals, clinics, and care organizations
- Low-value care and overtreatment: Per-service payments reward additional low-value care.
- Copays keep billing systems alive and still deter poorer patients: Copays require collection, exemptions, and billing work.
- Drug and device makers
- Low-value care and overtreatment: They sell devices and tests used in low-value care.
- Low- and middle-income households
- Copays keep billing systems alive and still deter poorer patients: Point-of-care charges deter care, especially for poorer patients.
- People with ongoing or specialist care needs
- Copays keep billing systems alive and still deter poorer patients: Point-of-care charges deter care, especially for poorer patients.
- Publish the evidence for each tier and allow appeals
Where it has been tried
- U.S. employers & HSAs: Some employers waive copays for chronic-disease drugs.
- United States: A 2011 randomized trial found that removing copays for preventive drugs after a heart attack increased medication adherence by 4–6 percentage points.