The dilemma is heart-rending. With COVID-19 infections and hospitalizations rising, the FDA approved two drugs—Paxlovid from Pfizer, and molnupiravir from Merck and Ridgeback—to treat the illness that is killing so many and rendering others permanently disabled. Yet in the United States, many patients can’t get the drug, or even figure out which pharmacy near them has it. And according to Cary Breese, CEO of same-day delivery pharmacy NowRx, many doctors have given up and refused to prescribe the drugs because they don’t know whether they’ll really be available.
Many unique factors make access to COVID-19 home treatments difficult: the small window (five days) during which they are effective, the side effects and risks of the treatments, the odd way in which the FDA distributed the medicines, complications over payments to prescribing doctors, and distortions in the health care system. Some of the distortions go back for decades and others were created by the COVID-19 pandemic itself.
(There have been relapses among people taking Paxlovid, but it’s not clear why. The overall consensus is that these drugs are valuable.)
We can draw some general lessons from the frustrations around Paxlovid and molnupiravir that might help the health care system perform better on the next epidemic. Some of the insights may help with other urgent health-related crises, such as the shortage of baby formula.
This three-part series pays special attention to possible health IT solutions, which involve data collection, data sharing, and telemedicine. But I look at a broad range of factors in the current US health care system that hamper the delivery of critical treatments like this.
A case study: the doctor treats himself
It’s valuable to start out with the story of a single COVID-19 patient who navigated the health care system to get Paxlovid. The case study is particularly revealing because the patient had every advantage one could ask for—many privileges that the average COVID-19 patient lacks.
The hero of this story is Dr. Richard Dion, Pharmacy Clinical Program Manager for Clinical Surveillance & Compliance at Wolters Kluwer, Health.
One rightfully expects a Doctor of Pharmacy working for a major provider of clinical technology and expert solutions in health care (see my 2019 article on Wolters Kluwer) to possess certain skills beyond the average patient in obtaining medicine. When Dion tested positive for COVID-19, he was already prepped with another advantage: Living in Massachusetts, he knew about and could use the portal recently created to link people up with treatments.
As a Massachusetts resident myself, I can judge that our pandemic response has been helped by having a governor (Charlie Baker) with a distinguished career in health care. Dion says that at least one other state—Florida—has such a portal.
The Massachusetts portal was crucial because Dion’s primary care provider didn’t respond quickly when he asked for a virtual visit. (Having a PCP in the first place was a privilege compared to many US residents.) We must not forget that it was just two years ago, near the beginning of COVID-19, that long-overdue regulatory changes were passed to allow virtual visits. Small telehealth companies (many covered on Healthcare IT Today) had worked on the infrastructure for virtual visits over the years, and by the time Dion was asking for one, both patients and doctors were accustomed to them.
In the end, the Massachusetts portal eliminated the need to go through the PCP. Dion quickly signed up for a telehealth evaluation with a physician and receive the prescription that opened up the chance to receive treatment.
But yet another lucky coincidence made it easier for Dion to get his prescription. The doctor with whom he connected online through the portal worked at a CVS virtual clinic. And what do you suppose? Dion had an account at CVS (a nationwide chain of pharmacies), so the doctor at the clinic could get access to all his records. This is almost never possible if the doctor you connect with is outside your usual provider.
Why is it so important for a doctor to have your complete medical records? Can’t you just say, “I tested positive and I have symptoms of COVID?” No, there are many other considerations a doctor needs to take into account before prescribing treatment. First, many pre-existing conditions (such as renal and liver problems) are warnings (contraindications) not to prescribe a medicine.
Furthermore, Paxlovid and molnupiravir have many detrimental drug-drug interactions, so your doctor should know everything you’re taking before prescribing the COVID-19 treatments. Even if the doctor decides they are safe, the drug-drug interactions could affect the dosage. Many people at most risk for COVID-19 have pre-existing conditions for which they take multiple medications, so this consideration is significant.
Getting a prescription is of no use until you actually obtain the medication. And for many patients seeking COVID-19 medicines, this last hurdle has become a wall. You can quickly find online whether your favorite appliance store has a particular brand of coffee-maker, but you can’t just enter “Paxlovid” into some web site to find a pharmacy near you with the drug, much less have it delivered.
Some help, luckily, is available. You can get a general idea who has COVID-19 medicines in your area from a search site set up by the Office of the Assistant Secretary for Preparedness & Response (ASPR). I couldn’t get much detail there, though. If I wanted to fill a prescription for Paxlovid or molnupiravir, I would still have to call pharmacies until I found one.
Ultimately, Dion received his prescription and found a pharmacy with the medication—he and his family are OK now. But even more concerns are raised by this situation.
The COVID-19 medication is cost-free, but the virtual visit to get the prescription is not. Dion’s colleague Dr. Steve Mok, Manager of Pharmacy Services and Fellowship Director for Clinical Surveillance and Compliance at Wolters Kluwer, Health, pointed out that many people without health coverage would have to pay a fee out of pocket for this visit, a fee that might be hard on their budget. If their symptoms were mild, they would be sorely tempted to ignore them and wait too long before scheduling a visit.
So that was the labyrinth traversed by one highly capable individual to get COVID-19 treatment. Many other people would lack his state’s portal, his understanding of the health care system, and more. These patients might not have a PCP, or might have one like Dion’s who failed to respond promptly. And even if they get a prescription, they might spend hours calling pharmacies to find one with the medication. Then, especially in a rural area, they might face the problem of driving fifty miles or more or finding a friend to do so, just to get the medication. If they visited pharmacies in person, they would spread their infection to other people.
The second article in this series indulges in speculation about an ideal drug distribution system.
Neither Paxlovid or molnupiravir is as effective against Covid as Merck’s off-patent and ridiculously cheap Ivermectin, which also has fewer side effects and is better at controlling inflammation.
But of course we must subsidize Big Pharma at the expense of the patient in today’s socialized medicine world — with the taxpayers picking up the tab (not cost-free).