Our country has done incredible things during the Covid-19 pandemic. Some of the smartest innovators across the world have come together to rapidly develop our vaccines and Covid-19 interventions.
Now, hoping to reach a “new normal,” the Biden Administration and states like California have directed their attention to the equitable and timely distribution of life-saving treatments. But in order to actually accomplish that goal, we must continue the spirit of innovation into “the last mile” in healthcare: making the leap from a positive test to treatment-in-hand.
Dr. Taison Bell, director of the medical intensive care unit at University of Virginia Health, was recently quoted in an NBC News article saying “… communities that are in highest need are the ones that have the lowest access, and that certainly includes low-income people and communities of color.”
Reaching people at the highest risk of hospitalization and/or death
For at-risk, Covid-positive patients, the largest hurdle to receiving early and effective Covid treatment comes down to the requirement that they have a prescription from a physician. Many underserved patients do not have access to a primary care physician; even if they do, and can afford a visit, challenges can include a lack of transportation, childcare, or the ability to take time off from work.
As of February 22, across the state of Mississippi, 138 patients are in the ICU for Covid, 63% of those ICU patients were on a ventilator (Mississippi Department of Health). A Mississippi Free Press article reports the state is under-using its antiviral supply, with some hospitals only using 10% of their available Paxlovid courses. Mississippi is an example of what is occurring nationwide: a gap between those who could benefit from antiviral treatment and the treatment itself.
We must collectively stop ignoring the last mile for our most at-risk populations, sit up and take notice that key stakeholders in other infectious disease fields have been innovating on the last mile for decades.
I have worked in the HIV/AIDS space for many years. While handling some of the most sensitive health information in the nation, we’ve been able to notify patients of their health status via text message/email, meet them where they are (on their mobile phones), and help them get answers and vital medications faster. We know that with the proper outreach, combined with mobile-friendly access to treatment, patients see a massive increase in treatment adherence. They live better and their care costs less. We should be looking to this scenario, and others, as analogs.
Based on my experience working with communities disproportionately impacted by healthcare access inequities, when a patient receives a positive Covid test result, it’s unlikely they’ll have access to a traditional care setting, wherein they could receive the new, early intervention treatments, Paxlovid and Molnupravir. More likely is that they’ll suffer in isolation, or use the closest emergency department with others seeking higher acuity care.
The White House recently held a press conference on the equitable distribution of these life-saving antivirals. But distribution efforts are largely centered on manual distribution and increasing pharmacy footprint, and subject to, well, subjectivity. Antivirals must be taken within five days of the start of symptoms to reduce the risk of hospitalization. That’s not a lot of time. We understand that these new treatments do come with risks and that an evaluation by a physician is critical. So how do we innovate to get these medications in the hands of priority populations more quickly and effectively?
Leveraging telehealth
We already know that more at-risk communities rely on their mobile devices, and many public and private labs leverage Windows 95-looking patient portals to deliver positive test results. But most departments of public health would love to do more and use modern technology. Can we leverage telehealth to close the last inch, getting these patients treatment tied to their positive test results?
We’ve all read journalist Rebecca Robins’ story in the New York Times about her unfruitful and infuriating efforts to locate antivirals for her sick and Covid-positive parent. In this case, she was also unable to receive a prescription via a telehealth service.
Telehealth laws vary state by state, but the discretion to administer a prescription for Covid antivirals is often up to the service provider. Many state telehealth laws allow for a simple mobile-friendly, dynamic questionnaire to be completed before prescribing these life-saving antivirals. And better yet, instead of having the ill patient drive, take public transportation, or possibly walk to a pharmacy, some online pharmacies and telehealth companies can collaborate to have the medication delivered to the patient’s address the very next day.
Early intervention = $50 vs. $500,000
In California, where I reside, the average cost to treat a non-complex Covid-19 patient in the hospital is $111,213. For a complex case, we’re looking at close to $500,000, according to an analysis by Becker’s Hospital Review. In addition to the benefits to patient access, a telehealth solution and next-day medication delivery may cost around $50 (does not include the cost of medication which is currently covered by HHS). The contrast is staggering, and likely game-changing.
There’s hesitancy around the use of telehealth for certain treatments in the US, and a preference for traditional, in-person visits. But again, with a focus on equity, we must meet patients where they are and innovate on the last mile to ensure their health and well-being.
Fixing the last mile may not be as sexy as sprinting toward the development of the mRNA vaccines or our first anti-viral treatments, but addressing it is the only way we can improve outcomes for people who need this the most.