Still no clarity on private-sector price for Covid-19 vaccines
The Medical Schemes Act restricts payments to scheme members, which makes direct payments for uninsured people illegal
With just weeks to go until the government expects to begin its coronavirus vaccine rollout, it has yet to finalise a pricing structure for the private sector, leaving medical schemes and healthcare providers unsure how to make financial provision for the rollout.
The national vaccination campaign is due to start on May 17 and aims to reach 46.2-million people by March 2022. The government has ordered 31-million doses of Johnson & Johnson’s single-shot vaccine, and 30-million doses of Pfizer’s double-shot regimen at a cost of $10 a dose, according to health minister Zweli Mkhize.
While the Treasury has consistently said the government will fund the campaign, Mkhize has also made it clear that medical scheme members will be expected to help pay for it. One possibility, first flighted by medical scheme administrator Discovery Health earlier in the year, is that medical schemes cover the cost of one uninsured person for every member that receives a vaccine. But this proposal has not met universal support across the medical schemes industry, and the Medical Schemes Act restricts payments to scheme members, which makes direct payments for uninsured people illegal.
“It is hugely complex and has been consuming us for the best part of the year,” said Roseanne Harris, a health policy actuary at Discovery Health and a member of the team at Business for SA assisting the government plan its vaccination drive.
“The department of health will define the price to recover the vaccine and associated logistic costs from the medical schemes. This is being finalised with the price per dose per vaccine as the basis. The tender for distribution is also being finalised and this will impact the final costing,” she said.
The health department received 24 bids to provide transport, warehousing and distribution services for Covid-19 vaccines, but has yet to award the tender.
Accredited private-sector vaccination sites will be paid an administration fee to cover professional fees and the cost of consumables, and will be reimbursed by medical schemes, but these costs are still being calculated, said Harris. “From a medical scheme perspective it is important that there is a defined tariff, because [Covid-19 vaccination] is a prescribed minimum benefit and has to be covered at cost,” she said.
There are approximately 9-million medical scheme members in SA, of which 7.1-million are over 18 and eligible for vaccination.
The government has amended the regulations for prescribed minimum benefits to ensure medical schemes cover the cost of Covid-19 vaccines for all eligible members in full, with no co-payments. It has also said vaccination will be free at the point of delivery, which means healthcare providers administering the shots will be prohibited from asking for up-front payments from patients and will send their claims directly to medical schemes.
But there is still no word on the extent to which the price paid by medical schemes will differ from the price the government pays to vaccine suppliers, or how the fees payable to healthcare providers will be pegged. Nor is it clear how private healthcare providers, such as pharmacies, are to be compensated for dispensing vaccines to state patients.
Board of Healthcare Funders MD Katlego Mothudi said the medical schemes industry expects the administration fee to be in the order of R90 per person.
The Medical Schemes Act allows patients and healthcare providers to file claims up to four months after a service is provided, so a delay in finalising the pricing structure for Covid-19 vaccines administered in the private sector would not hold up the programme, he said.
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