Covid-19 has transitioned from a pandemic to an epidemic, but it continues to mutate and threaten high-risk patients, including those with underlying medical conditions and older adults.

Excess deaths have continued to occur in the aftermath of Covid-19 until recently, according to the “Covid-19 Excess Deaths" data submitted by the Korea Disease Control and Prevention Agency (KDCA) to the National Assembly in October.

Excess deaths are additional deaths beyond deaths normally expected to occur at a given time. Excess deaths due to Covid-19 have exceeded 65,000.

Against this backdrop, the government announced on Aug. 31 that it had downgraded Covid-19 from a legal infectious disease classification of "Level 2" to "Level 4," declaring a gradual fee-charging for Covid-19 testing and treatment and ending the current free support system for Covid-19 drugs from the first half of next year.

As a result, pharmaceutical companies with Covid-19 therapies are applying to the insurance authorities for benefit registration and awaiting review so that patients can use their drugs to prevent and treat severe Covid-19.

Korea Biomedical Review spoke with Professor Lee Jae-gap of the Department of Infectious Diseases at Hallym University Kangnam Sacred Heart Hospital to learn about the current status of Covid-19 management in Korea, the impact of the government's plan to reduce support for domestic patients, and recommendations on the direction of drug reimbursement policy.

Question: How is Korea managing Covid-19?

Answer: Although some measures remain in place, we have achieved a certain degree of pandemic control because the healthcare system can treat patients without these measures. After the government declared an endemic, we experienced a small summer outbreak. We must be vigilant about the high probability of experiencing a twin pandemic this winter, as Covid-19 and influenza cases are increasing simultaneously.

We don’t have to be overly concerned at this point. However, suppose we see a shortage of intensive care units or a dangerous situation that affects patient care. In that case, we must discuss how to manage Covid-19 again, even if it has transitioned to an endemic. The public’s attention has sharply fallen since the declaration of an endemic, and Covid-19 has dropped to the level of the so-called flu. However, it's still a highly lethal disease compared to the flu, and we can ill afford to remain complacent, given the spread and fatality of Covid-19.

Q: The government has gradually charged fees for Covid-19 testing and treatment.

A: The previous free coronavirus tests are now being charged in part. Currently, the government subsidizes 50 percent of testing fees for patients with mild and moderate cases at high risk of becoming severe, i.e., those prescribed with oral medication. Other ordinary patients must pay 100 percent of testing fees out of pocket. Ironically, the opposite has happened with influenza, where testing has transitioned from “non-reimbursement to reimbursement” for hospitalized or emergency room patients. Eighty percent of the rapid antigen tests are covered by insurance for hospitalized and emergency room influenza patients.

Covid-19 is more dangerous and contagious than influenza, with a greater need for control. We should consider increasing access to Covid-19 testing in light of its transmissibility and lethality. Ironically, insurance coverage for testing a disease with a higher fatality rate and prevalence is lower. Covid-19 testing coverage should be prioritized for reimbursement, or similar coverage levels should be applied to the two diseases.

Q: The government has announced that it will stop subsidizing Covid-19 treatments next year. As a result, pharmaceutical companies with treatments are applying for insurance benefits.

A: Currently, the government subsidizes 100 percent of the Covid-19 treatment cost through a special contract. If the drugs are insured, their payment will be shifted to the health insurance finance, which is expected to cause a huge burden. Of course, we understand this is a necessary change in the context of Covid-19’s shift from an endemic to the general healthcare system.

However, Covid-19 patients don’t have many options when it comes to treatments. Veklury (remdesivir) is the only injectable drug that can be used for severe patients. Lagevrio (molnupiravir), one of the oral drugs for high-risk patients, has yet to receive formal approval since it won the emergency use authorization from the Ministry of Food and Drug Safety. Without full approval, insurance coverage is not possible. So, there are currently only two treatments for high-risk patients – Vekluriy injection and oral Paxlovid pill (nirmatrelvir/ritonavir).

If Covid-19 treatments become insured, patients will have to pay out of pocket for drugs that were once free of charge. Pharmaceutical companies must factor in logistical and labor costs that they haven't considered before, inevitably leading to price increases. The biggest problem arises when the cost of treatment is too high for patients. High-risk patients who refuse prescriptions due to cost can fall through the cracks, leaving financially disadvantaged patients at risk of death or serious illness.

Currently, only 20-40 percent of high-risk patients diagnosed with Covid-19 are prescribed oral medications, and most hospitalized patients are prescribed Veklury. With higher out-of-pocket costs, patients are forced to choose between using the actual medication or not, which is more problematic for severely ill patients, especially socially vulnerable people, as always. Some patients will refuse treatment due to the cost of the medication, so it is urgent to take measures for them. The government has consistently emphasized the mortality prevention benefits of vaccination and the severity prevention benefits of treatments. However, its recent decision could undermine all its emphasized messages to prevent severe cases.

Q: So, to what areas should the government pay more attention?

A: The move toward the full coverage of Covid-19 drugs is right. The question is how to make a soft landing. Regarding injectable drugs, patients may find their cost relatively insignificant because of hospitalization costs.

For oral drugs, however, the drug cost may come as a big burden because outpatients must pay for them immediately. Instead of specifying a co-payment rate of, say, 20 percent or 50 percent, it may be good to start with a co-payment rate of 5-10 percent or apply a special calculation. By gradually increasing the co-payment, the price of the existing drug will inevitably decrease as competing drugs enter the market. It is also necessary for governments to implement policies that allow competing drugs to continue to enter the market, helping to lower the price of existing drugs.

Infectious diseases do not shift from pandemic to epidemic just because we claim so. The virus will take its course. Governments need to adapt their policies accordingly. Financial support is still needed, albeit not at the same scale as in previous pandemic days. The treatment’s shift to the health insurance system is also the right direction. However, it is most important to continue to think about how to effectively manage who needs to be treated and who needs to be prevented.

Before announcing the insurance coverage of treatments, the governments must think about what alternatives should be in place for those who are at high risk of death or severe illness and need continuous treatment when the policy change goes into effect. In addition, to implement these policies properly, I advise the government to listen to the opinions of experts and doctors, collect public opinion, expand the base, and move forward step by step.

Q: How do you predict Covid-19’s spread this winter?

A: Like influenza, Covid-19 will unlikely disappear but spread yearly, remaining a dangerous disease. I am concerned that Covid-19 vaccination rate continues to fall. Last year, the Covid-19 vaccination rate was 35 percent among people 60 and older; so far, it's only 29 percent. Flu vaccination rates, on the other hand, were over 80 percent last year and are expected to be similar this year.

Except for July and August, Covid-19 has not spread this year, meaning that those who have never been infected and are unvaccinated will make up nearly 70 percent of people over 65. Furthermore, last year's vaccine wore off in November and December, so it will likely spread more vigorously in many ways this year. Already, we're seeing a trickle of Covid-19 cases alongside the flu. In the second week of October, we had 7,000 cases in sample surveys; last week, we had 8,400 and 8,500, an increase of about 15 percent. I am worried that it is likely to increase in earnest from now on.