番茄社区

You do the math.

Just recently, New York state announced that persons with certain underlying medical conditions would now be eligible to receive the COVID-19 vaccine. Previously, the state had rolled out its initial phase first for healthcare providers and the residents and staff of nursing homes. Since then, the state has added some new eligible employment categories, including certain frontline and essential workers, and then opened vaccines up to those over age 75. Despite a rocky rollout of the system of signing up for vaccines, and enormous problems with inequitable distribution, the state fairly quickly opened it up further to patients over age 65.

Expanding to Those With Medical Conditions

Now, instead of expanding the categories of eligible employment, the state has delved into opening up vaccines for people with a multitude of medical conditions. While this makes sense in many ways, and these are incredibly important groups of people who need to be vaccinated, many have thought that it would have made more sense just to keep marching down the age limit by decades, 55, 45, 35, 25, 15, as quickly as we could. The list of included health conditions is pretty exhaustive, and opens up the vaccine eligibility to almost everyone except those who've only seen a doctor for their annual physicals and have no medical conditions at all.

Many of the categories listed are somewhat vague, and open to interpretation, but for the most part they seem like reasonable groups that would benefit from being vaccinated. As would essentially all of the population.

One problem with this new initiative from the state is it requires patients who come to get the vaccine to have some way of proving that they fall into one of these eligible categories. Patients can apparently come in with a letter from their medical provider stating that they have an eligible condition, or they can show through some other means (medical records, insurance claims) that they have a qualifying condition, or they can sign some attestation or affidavit on-site swearing to the fact that they have a disease that qualifies them. Unfortunately, with the stroke of his pen, the governor has opened up the floodgates to millions and millions of phone calls and portal messages to primary care providers, giving them one more task to do.

A Fear Becomes Real

The night before this announcement was made, one of my partners came in and said that he'd heard about the upcoming changes to the guidelines of eligibility, and was hopeful that we would put into place a system to easily provide patients with what they needed. My initial thought was that those who are on the patient portal would be able to open up their medical record from their cell phones, and show their medical problem list to those at check-in at the vaccination sites. My partner, on the other hand, rightfully feared that we would be deluged with patients requesting letters.

The next morning, he told me he had 87 requests from patients in his electronic medical record in-basket for letters documenting an underlying medical condition. In theory, providing a letter like this doesn't take that long. But with that executive order, the governor put a heck of a lot more work onto already stressed frontline primary care healthcare workers who didn't need the grief.

In New Jersey, apparently a self-attestation that you have a qualifying condition is all that is required. And since they added smoking to the list of eligible conditions, you can just tell them that you smoke when you get to the vaccination site, and you're good to go. You don't even need to smell like cigarette smoke, or show them a partially empty pack, or bring in your car's ashtray from the parking lot.

Now, perhaps in New York we're a much less trustworthy bunch and the governor and other health officials feared that the vaccine sites would be overrun with healthy young people insisting they had had cancer, or diabetes, or COPD, or immune deficiency syndromes. But I'm sure, that even with the current system, plenty of people will be trying to figure out ways to game the system. Not to give anyone the idea, but I'm sure there is already a market popped up for fake letters from your doctor that say that you have hypertension. (Remember the notes from "Epstein's Mother" from "Welcome Back, Kotter"?)

And there will always be people willing to sign an attestation, knowing that it's unlikely that anyone is really going to track them down and demand proof long after the fact.

Increasing Access

As we build a better and more equitable healthcare system, we need to make sure that we have adequate systems in place to allow all our patients to have access to the vaccines they desperately need and to the patient portal where they can effectively and safely interact with their healthcare team. Even now, vast numbers of our patients over 65, and even those over 75, have been unable to navigate the complicated system that's been created to sign up for vaccines and get them done. Access is an issue, transportation is an issue, education is an issue. The same communities that have been disproportionally devastated by COVID-19 still remain hesitant to receive the vaccine, and unable to get an appointment even when they want it.

While I applaud the opening up of the eligibility, and in fact believe it should have been open to people with underlying conditions all along, it's clear that supply does not yet meet the demand, and we desperately need more vaccine on sites, so that we can get those shots into arms. No matter what system was created, there will be inequities; if we vaccinate people with underlying medical conditions before we get to all the elderly patients, then someone might die. But if we do it the other way around, and just let everyone in based on their age, then those folks with serious conditions that put them at increased risk of death remain dangerously susceptible.

Once again, we are coming at this reactively, after it's happening, trying to figure out how to build a vaccination distribution infrastructure on the fly. This is why having a robust public health infrastructure and a fully functioning patient-centered healthcare system wrapped around it would allow us to predictably roll out something that gets the job done right the first time. Once again, we're doing it wrong, and more and more people are left out, upset that they've been left behind and neglected, and ignored once again.

The new administration in Washington is clearly moving ahead with getting us the huge numbers of vaccines we need, so eventually everyone who wants one should be able to get one. But just as we've learned some lessons from our first year in the pandemic, now we've got an opportunity to learn about how to vaccinate a population that is scared and needs our help. Next time, instead of making a decision that leads to 8 million phone calls queuing up for primary care doctors, maybe we can think these things out and do them right.

That way, it all adds up.

, of Weill Cornell Internal Medicine Associates and weekly blogger for 番茄社区, follows what's going on in the world of primary care medicine from the perspective of his own practice.

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