Experts: Priority still uncertain for those with preexisting conditions
People with high-risk medical conditions would be allowed to jump the line when the coronavirus vaccine registration opens to everyone over the age of 16 on April 5, but how that will work is still unclear.
Though Gov. Ned Lamont announced Monday the state will accelerate access for those with preexisting conditions, which medical ailments will count and whether the process can be handled on a unified, statewide level is still an open question, according to health experts.
“Nothing has been fully fleshed out,” said Ohm Deshpande, vice president for population health and a physician leader for Yale New Haven Health’s vaccination
program. “Our goal is to come to some sort of consensus that is not at the level of a health provider or health system. We’d like to be working along the same guidelines.”
Kimberly Metcalf, associate vice president for pharmacy and ancillary services at UConn Health, said they were “waiting on clarification from the state as to which preexisting conditions will be prioritized in order to determine how to proceed in operationalizing the state’s guidance.”
But the state said it’s leaving the details of vaccine distribution for people with high-risk conditions to the individual providers and health systems.
“All of those decisions will be made by the vaccine providers, who know their patients and the populations they serve the best,” said Maura Fitzgerald, a spokeswoman for the state Department of Public Health.
But that means the state’s providers need to coordinate with each other, and decide which conditions are acceptable and how a patient would prove eligibility.
The state’s vaccine providers have been working toward a unified approach on vaccinations. There were “preliminary discussions about three weeks ago,” said Tom Balcezak, chief medical officer at Yale New Haven Hospital.
But more discussion is necessary, now that decisions on who gets vaccinated first falls more squarely on their shoulders, to “try and see if there’s a statewide way that we can coordinate and do this,” he said.
One question is which medical conditions get priority.
The Centers for Disease Control and Prevention maintain a list of conditions that carry a heightened risk of hospitalization or death from a coronavirus infection, including obesity (defined as a body-mass index of 30 or above), smoking, Type 2 diabetes, chronic obstructive pulmonary disease and kidney disease, among others.
But all patients in those categories don’t carry the same risk, Balcezak said. Should a 22-yearold smoker in otherwise good health have the same priority as a
44-year-old with kidney disease? “We’re going to need to be clear about what are the conditions,” Balcezak said. “There are a lot of questions there about what would qualify.”
A patient on kidney dialysis is an obvious choice. Hospitals know which of their patients require dialysis and there is data showing an increased risk for those patients from the coronavirus.
“There are certain high-risk, well-defined clinical conditions,” Balcezak said. “We are thinking that’s one of the populations that’s probably very reasonable to include. It’s a very well-defined population, there’s objective criteria for what the condition is, and there's also data to show that that condition leads to an increased risk of death from COVID-19.”
Other conditions raise questions, like how to prove a patient is at increased risk. How do you prove if someone is a smoker? How much more risk does a patient bear if they have well-controlled Type 2 diabetes?
In New York, patients are required to show a doctor's letter, medical records or a signed certification. But those options could be problematic, experts said.
“It’s not reasonable for us to say, ‘produce medical records,’ ” Deshpande said, suggesting they may need to rely on “a little bit of the honor system.”
Doctors’ notes are easier to obtain for people with good relationships with their physician, but are more difficult to obtain for those who rely on a community health center.
The hope, according to Balcezak, is to find some objective measure.
“Something like a physician attestation on what you do or do not have, without some objective criteria, I think that’s something we would want to avoid,” he said. “That will exacerbate some of the inequities early on we saw in the numbers.”
Some statewide communication between vaccine providers will be critical when about 1.3 million people become eligible to be vaccinated on April 5.
Patients can make appointments with several providers and, if they don’t cancel, leave an empty slot when they don’t show up.
“People may make a bunch of different appointments in a bunch of different places,” Deshpande said, an issue that will grow in scope if there is no effective communication between providers.
There are a few systems already in place on which more effective solutions can be built. A medical records system called Epic, used by many of the larger providers in the state, could be a part of the solution, as might CT WiZ, Connecticut’s statewide immunization information system.
“It has been useful,” Deshpande said. “Now we are all uploading vaccination data to CT WiZ. We are able to download that data into our health records.”
The first step is Friday, when people ages 45 and over become eligible, about 480,000 people minus those who fell into groups that already qualified like health care workers.
But April 5 is the real deadline. “The advantage is we have a couple of weeks to figure it out,” Balcezak said, though when pressed he called it “a relative advantage.”
“We have next week to get some consensus on this,” he said.