Covid-19 patients stranded after NHIF refuses to pay

The national health insurer has paid Sh409 million for Covid-19 treatment, but only for public servants and police officers, as the rest of Kenyans are forced to pay out of pocket.

National Health Insurance Fund (NHIF) Chief Executive Officer Peter Kamunyo, while appearing before the Senate Health Committee told the members that the fund reimbursed Sh259 million for the National Police Service Commission and Sh150 million for civil servants.

Dr Kamunyo said the fund cannot undertake the costs related to Covid-19 management for the current national or enhanced medical scheme members.

“Due to the enormous financial outlay that would be required to cover members for the pandemic, coupled by the fact that the risk exposure of Covid-19 cannot be accurately determined, NHIF has not been able to undertake the costs related to Covid-19 management for the rest of the members,” he said.

He, however, said that following President Uhuru Kenyatta’s directive, frontline workers under the National Police Service, Kenya Prisons Service, Civil Servants and employees of National Youth Service are covered for, among other benefits, critical illnesses, including Covid-19 treatment.

He said the NHIF had not received any funding from the national government to cover Kenyans for Covid-19.

In the best and worst case scenarios, the fund will spend between Sh1 billion and Sh10 billion on Covid-19 treatment for insured beneficiaries.

Using a cohort of 595 Covid-19 admissions processed by the fund between July 2020 and June 2021, the average cost of a Covid-19 admission is 603,130 (average cost per day of admission, 82,584), compared to 62,222 for the per-diem reimbursement and 241,468 for the market rate reimbursement.

This would translate to Sh11 billion for the six million projected utilisation. From the projections, the fund would need at least Sh1 billion to cover the population for the next six months. This would need a 74 percent out-of-pocket payment to cover the cost of management.

According to the Kenya National Bureau of Statistics, the membership of the fund last year went up by six per cent to 22 million in 2019/20 and as a result, contributions grew by 5.7 per cent to Sh59.5 billion, while the amount of benefits payout increased by 1.8 per cent to Sh54.4 billion.

NHIF membership in the formal sector of the economy went up by 3.6 per cent compared to 8.3 per cent growth in the informal sector.

Supa Cover, which is Kenya’s largest and most affordable medical insurance cover, costs Sh500 a month for the principal members and beneficiaries.

The decision by the fund has left many Kenyans who depend on it to pay for treatment stranded, unable to pay Covid-19 bills. It also brings into question why the fund exists if it cannot cover bed charges for the poor.

With Kenya predicting another wave in the coming two weeks, thousands of people across the country are likely to be infected and may need to be admitted to hospital. Many of them will, therefore, find themselves in a bind.

Covid-19 treatment costs vary hugely depending on the severity of the disease and the hospital.

According to a model by the Kenya Medical Research Institute (Kemri), Covid-19 case management costs per patient in hospitals range from Sh21,000 per day for asymptomatic patients and those with mild symptoms, Sh24,705 for patients with severe disease to Sh51,684 for critical patients in intensive care units.

Going by Kemri’s estimates, a patient with severe symptoms put in isolation for a week would be required to pay more than Sh350,000 in hospital bills, or Sh750,000 if in critical care.

Earlier, NHIF Chairman Lewis Nguyai had indicated it is not feasible to pay for Covid-19, given that those on Supa Cover only pay Sh500, yet claims are accruing to Sh8 million.

“Divide Sh8 million and see how many families paying Sh500 will have deprived the fund. Statistically, this is not attainable at present. We are working on modalities to see how we can cover them, though it is a risk that we also don’t understand,” said Mr Nguyai.

Last year, the NHIF indicated through a circular that it will only pay rebates on treatment bills incurred by accredited Covid-19 patients at the Kenyatta National Hospital, Kenyatta University Teaching and Referral Hospital, Mbagathi Hospital and other Health ministry-designated hospitals in counties. It stated that it would not cover treatment in private hospitals.

“We shall support all Covid-19 positive members and their declared beneficiaries who get admitted to the Ministry of Health designated facilities. NHIF shall not be liable for bills incurred in non-MoH designated health facilities,” Dr Kamunyo said in the circular.

An uninsured Covid-19 patient who ends up in the intensive care unit is likely to pay Sh71,000 per day. The daily treatment costs of an asymptomatic patient averages Sh21,000 and Sh21,400 for one with mild symptoms.

 Those with severe Covid-19 requiring supplemental oxygen pay Sh51,000 while critically ill patients who need ICU or ventilators pay an average of Sh71,000. About 90 per cent of Kenyan cases are asymptomatic. 

One can only be declared virus-free after two weeks. It, therefore, means treatment costs for the 14 days go up to Sh300,000.

Most of the cost goes to protective gear used by medical staff, with a full PPE kit going for Sh10,000 used for a single session per patient. Due to the special care required, a doctor could visit the patient up to three times a day.