What can providers, payers and employers do to prepare for SARS-CoV-2 vaccines?

Ingrid Stiver Senior Manager, Health Research Institute, PwC US December 10, 2020

SARS-CoV-2 vaccines will start rolling out across the US this month, marking the beginning of a new phase of the pandemic. Providers, payers and employers will play critical roles in the national push to vaccinate as many Americans as possible in as short a time as possible.

Here, HRI breaks down the key considerations for providers, payers and employers:

Considerations for providers

Providers will first focus on administering the vaccine to their workers. On Dec. 1, the CDC’s Advisory Committee on Immunization Practices (ACIP) recommended that healthcare personnel and residents of long-term care facilities be prioritized, encouraging providers to subprioritize those who work in direct patient care and long-term care facilities.

The logistics of vaccinating the workforce could be challenging. Initial doses of the vaccine will be limited, leading to the need for subprioritization within the clinical workforce. Providers also may need to stagger vaccinations for units or similar positions because of the mild to moderate symptoms that may be experienced post-vaccination (fever, headache, muscle pain) and require time away from patient care. The two vaccine candidates pending authorization require two doses, so careful tracking will be critical to ensuring that workers get the correct second dose and in the authorized time frame.

Beyond the logistics, providers as employers also will have to carefully think through their role in encouraging or mandating vaccinations for their employees (see more on the role of employers below) and how they communicate about it, especially as some employees may be hesitant to get the vaccine.

An October survey of nearly 13,000 nurses conducted by the American Nurses Foundation, an arm of the American Nurses Association (ANA), found that only a third of nurses said they would voluntarily get the vaccine. Another third said they would not volunteer; the final third said they were unsure.

An HRI survey of 2,511 consumers conducted in September found higher levels of willingness to get a vaccine, with 62% saying they would get a vaccine within one year of approval and 61% of the 94 consumers surveyed who work in clinical positions in healthcare saying they would. The timing of the vaccinations—shortly after the emergency use authorization (EUA) is granted versus a year later—could be an important factor in people’s decisions.

In its survey press release, the ANA emphasized the need to educate nurses about the SARS-CoV-2 vaccine to ensure a high level of compliance among healthcare workers and proper education of patients. The ANA, the American Medical Association (AMA) and the American Hospital Association (AHA) put out an open letter to the American public, presumably speaking to healthcare workers as well, encouraging trust in the vaccine process and a willingness to be vaccinated.

Despite the challenges with vaccinating their workforce, providers will also have an opportunity to develop best practices that could serve them well as the vaccine becomes more broadly available to patients. This could include fine-tuning distribution strategies within their own health system, testing systems to track the vaccine doses received or needed (potentially using the AMA’s vaccine-specific CPT codes released in November), and piloting communication about the vaccine—its safety and efficacy as well as where and when to get it.

In developing a communication strategy for workers and patients, providers should consider the vast health disparities faced by communities of color during the pandemic and the long history of unethical medical experimentation on minorities—something the AMA called out in its policy aimed at combating misinformation about the COVID-19 vaccines.

The federal government has signed supply contracts with vaccine manufacturers and will cover the cost of the vaccine under those contracts. At this point, the government has not contracted to purchase the entire supply of vaccines. President-elect Joe Biden may consider this when he takes office in January, in line with the approach taken by the Obama administration for the H1N1 vaccine in 2009.

As detailed in the next section, payers are required to reimburse the cost of the vaccine and its administration—whether given by an in-network or out-of-network provider. The COVID-19 Claims Reimbursement Program run by the Health Resources & Services Administration will reimburse providers for the cost of the vaccine and its administration to uninsured individuals. A cross-agency interim final rule that took effect in early November clearly states that providers participating in the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Program contractually agree to administer a COVID-19 vaccine regardless of an individual’s ability to pay and therefore may not seek reimbursement, including through balance billing, from patients.

Considerations for payers

Payers will have two main responsibilities in relation to the vaccines: covering their cost when the federal government is not already covering them along with the cost of their administration, and communicating with members about the immunizations.

Section 3203 of the Coronavirus Aid, Relief and Economic Security (CARES) Act requires most health insurers, including group and individual plans subject to the Affordable Care Act, to cover the coronavirus vaccine and its administration as a preventive service, with no cost sharing for members, regardless of whether it is given by an in-network or out-of-network provider.

A November final rule states that when ACIP recommends a vaccine candidate for certain populations, payers will be required to cover the vaccine and its administration for those groups within 15 business days.

This includes Medicare, which will cover SARS-CoV-2 vaccines granted EUAs by the FDA at no cost to Medicare Part B beneficiaries. The final rule clarifies that CMS will cover EUA vaccines, even though historically the agency has covered only vaccines that are licensed by the FDA.

Medicare fee-for-service will cover EUA vaccines and their administration for Medicare Advantage enrollees at any provider or supplier that participates in Medicare Part B, since Medicare Advantage plans did not include the cost of vaccines and their administration in their 2020 and 2021 contracts with CMS.

Medicaid and CHIP programs will also cover vaccines and their administration with no cost sharing. States receiving the temporary 6.2 percentage point increase in federal Medicaid funds (which, according to the final rule, is all of them) under the Families First Coronavirus Response Act are required to cover the vaccines and their administration without any cost sharing.

Beyond reimbursement, payers have a role to play in communicating about the SARS-CoV-2 vaccine to members. That communication could include how much the vaccine will cost members (nothing), where they can get the vaccine, why it is safe, whether they need one or two doses (including the time between doses if two are needed) and when they are eligible to get the vaccine.

Some of this communication could be challenging. Different vaccines may be available at different sites because of different storage and temperature requirements, so understanding which members should be directed to which sites will be important. Payers should consider partnering with local providers and the CDC to communicate the safety of a vaccine. In HRI’s September consumer survey, respondents said they trust their primary care doctor (16%) and the CDC (16%) as the top source for accurate health information, with only 3% saying they trust their health insurer as the top source.

Historically, compliance with the second shot in two-shot vaccinations has been relatively low, so encouraging and reminding members to get their second dose will also be important. Knowing when someone is eligible for a vaccine and communicating that in a timely manner could also be challenging.

While ACIP will recommend vaccine priority groups, states were required to design and soon will implement their own vaccine distribution plans, including priority by population types. Payers operating across multiple states will want to consider this, as tailored messaging could be beneficial but also challenging to create and disseminate.

Considerations for employers

Employers will have a role to play in relation to a vaccine, as they look to get their workforce vaccinated as part of the broader return-to-work strategy. That role could vary by employer, depending on whether they opt to mandate a vaccine for employees or take a more passive role and encourage but not require workers to get vaccinated. In either case, employers likely will want to communicate about the vaccine to their employees and may consider facilitating vaccine clinics, similar to flu shot clinics conducted by many employers annually.

The Equal Employment Opportunity Commission (EEOC) has not yet issued guidance on a SARS-CoV-2 vaccine. The EEOC has updated parts of its guidance on Pandemic Preparedness in the Workplace and the Americans with Disabilities Act (ADA) for COVID-19, originally published in response to the H1N1 pandemic in 2009. In that guidance, the EEOC makes clear that while employers can mandate that employees get a flu vaccine, they must allow for exemptions for those with an ADA disability or those who qualify for an exemption due to a religious belief, practice or observance protected under Title VII of the Civil Rights Act of 1964.

For the flu vaccine, the EEOC recommends that employers encourage vaccination rather than mandate it. In 2009, the Occupational Safety and Health Administration (OSHA) took the position that an exception may also be required for employees who refuse vaccination because of a reasonable belief that they have a medical condition that creates a real danger of serious illness or death if they get vaccinated. Employers also will need to consider their collective bargaining agreements with unions before requiring vaccination as a term of employment.

In lieu of COVID-19 specific guidance on vaccination, legal experts are recommending that employers approach the SARS-CoV-2 vaccine as they would the flu vaccine. The CDC (via ACIP) recommends the COVID-19 vaccine for healthcare workers but, as with the flu vaccine, does not mandate it.

Providers may be more likely than other employers to require employees to be vaccinated against SARS-CoV-2, as with the flu vaccine, which is often required of all employees (with exceptions under the ADA and Title VII of the Civil Rights Act, and possibly under the Occupational Safety and Health Act of 1970) by healthcare organizations but not as commonly required by employers outside of healthcare.

One temporary wrinkle that employers will have to navigate is whether they can mandate vaccination while the vaccine is under FDA emergency use authorization, rather than an FDA license under the agency’s Biologics License Application process (something that could come later in 2021 or in 2022, depending on the vaccine). The answer to this question is not clear. Some healthcare organizations have said they will approach the COVID-19 vaccine like the flu vaccine, but not until it has won licensure.

Whether they mandate or instead encourage vaccination against SARS-CoV-2, employers will need to consider their strategy for communicating information about the vaccine to employees. Similar to health insurers, employers ranked low for consumers in terms of their most trusted source for health information during the pandemic, with only 3% of consumers surveyed by HRI in September saying their employer was their top trusted source for health information. Employers should consider using CDC information and guidance in their communication to employees about the vaccine.

Employers may also want to consider facilitating or sponsoring a COVID-19 vaccine clinic, similar to an annual flu clinic. Large employers may want to look into contracting directly with vaccine manufacturers to offer vaccines directly to their employees.

An employer-sponsored vaccine clinic or direct contracting with manufacturers to provide vaccines directly to employees likely won’t be feasible until later in 2021 when the vaccine is more broadly available. Both of these efforts could also prove challenging if the incoming Biden administration has the federal government purchase the entire supply of COVID-19 vaccines, as the Obama administration did in 2009 for the H1N1 pandemic.

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Trine K. Tsouderos

HRI Regulatory Center Leader, PwC US

Tel: +1 (312) 241 3824

Ingrid Stiver

Senior Manager, Health Research Institute, PwC US

Erin McCallister

Senior Manager, Health Research Institute, PwC US

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