Small Florida business got Covid therapy rarer than some large hospitals, raising questions of fairness
TCovid-19 treatments, supported by the Florida Department of Health, came as a surprise: six large, mysterious boxes that showed up at Nicholas Suite’s iCare mobile medicine clinic near Miami on the morning of December 24. “We were wondering, what is this? Who sent us gifts? Has Santa Claus landed on the roof? ” he said. “Then we opened it up and thought, ‘This is Evusheld! My God!'”
For some infectious disease physicians, this shipment has worrying implications. When they watched a government databaseSuite’s small private company appeared to have gotten more of the federal supply of this rare therapy than some of Florida’s major hospitals. In fact, iCare Mobile received enough for 264 courses – apparently the highest number the health department sent to any of the state providers on its first shipment from Evusheld.
Evusheld is a valuable substance, a cocktail of two monoclonal antibodies that can provide around six months of protection against Covid-19 for people who are too immunocompromised to mount a strong response to a vaccine, such as those who undergo chemotherapy or take immunosuppressive drugs afterwards. an organ transplant. The federal government distributed the small supplies it had to the states, which then sent them to medical centers.
There is hardly enough for everyone who is eligible for therapy. The patients demanded it. Large teaching hospitals were ration it.
But here it was at iCare Mobile Medicine which Suite according to has six full-time staff: a paramedic, two paramedics, two paramedics, and himself, the only doctor. The company had gone out during the pandemic to make emergency home visits, dealing with issues such as burns and bouts of diarrhea, so the patient didn’t have to risk going to the hospital. . His services were often not covered by insurance, but paid for in cash or by credit card. The team then expanded to administering vaccines and therapies against Covid-19. Sometimes he’s been hired to set up a coronavirus testing table outside of private parties, Suite said, including those of the South Beach celebrity ensemble.
“Anyone who doesn’t test negative doesn’t come in,” Suite said. “So we’re kind of like medical bouncers. “
Shortly after the surprise delivery, the clinic announced that it is also providing Evusheld injections – and the phones are ringing nonstop. The drug is free for patients, and although insurers could reimburse doctors to administer it, iCare’s priority was to get people injected, and is now working on billing. Insurance is not a requirement, Suite said.
Yet some infectious disease physicians fear that attempts to equitably distribute a rare drug to patients who would benefit most from it will be jeopardized if a portion of the doses goes to private companies that do not already care for patients. transplanted and cancerous.
“This raises really important questions about the fair and equitable attribution of this therapy,” said Michael Ison, professor in the divisions of infectious diseases and organ transplantation at Northwestern University Feinberg School of Medicine.
“If you think of the most effective way to provide patient protection with patient protection, everyone is on board at this point. But this must be weighed against real caution not to give it only to the people who are most financially able to obtain it. Otherwise, it flies in the face of the equitable distribution that hospitals are trying to do – and hopefully the state is trying to do, “said Cameron Wolfe, associate professor of medicine in the infectious disease division of Duke University, which chairs the university’s Covid-19 Therapeutics Committee.
He fears that different rationing systems in different places allow some people to bend the rules in ways others cannot. “People with resources find out where they are available and they go hunting. I got emails from folks in Ohio saying, “Hey, I see you got this medicine, can we drive over to Duke and buy some? “
But Duke doesn’t have enough of the monoclonal antibody cocktail for his own patients who would match the general criteria established by the Food and Drug Administration. Duke’s doctors treat thousands of immunocompromised people; their first Evusheld allocation consisted of around 300 doses. But there are different levels of immunosuppression, and Wolfe and his colleagues have taken that into account. An example of those who might be given priority in obtaining Evusheld are patients whose cancer, transplantation, or autoimmune disease requires them to take drugs that have been clearly shown to inhibit the immune system’s response to vaccines.
Drugs like this “directly inhibit your body’s ability to make antibodies.” This is how they are designed. And so people don’t make antibodies against vaccines, ”Wolfe said, adding that this is not necessarily true for everyone who has had a kidney transplant or is undergoing chemotherapy.
At iCare Mobile Medicine, on the other hand, the criteria for this prophylactic treatment are less stringent than those of Duke and other similar centers. Instead, these are the more general ones stated by the FDA. If you’re immunocompromised, don’t have Covid-19, and live in Florida at least part of the year, Suite explained, then you can get Evusheld. “We don’t sort people out and say, ‘Well, you look really sick or you are really old.’ We follow the criteria that the government and the manufacturer have set and it really comes down to being first come, first served. “
Finding a fair distribution system is complex. Some doctors find it ethically questionable for people who can afford the trip to become Evusheld tourists, although in some cases patients may be in the priority category even if they live within a few states of their center. transplantation and can therefore travel without taking the plunge. well thought out line. “We realized this because at least two of our patients here in Illinois went to Florida to this private clinic to get Evusheld,” Northwestern doctor Ison said, referring to iCare.
Suite said his clinic does not give the drug to permanent residents of other states, although it does provide it to snowbirds who live part of the year in Florida and part of the year elsewhere. He and his colleagues had been harassing the state’s health department so they could get Covid vaccines for patients they saw in their homes, and they were successful. This laid the groundwork for their request for Evusheld, Suite said. “Our name was well known in the health department: ‘Oh, yeah, these guys really bother us a lot. They want things to help their patients. They were surprised they received some of the prophylaxis, but thrilled that they could help retirees in South Florida, many of whom have had cancer or transplants.
Suite agrees that giving top priority to the most vulnerable patients is vital, but it is not clear whether large university-affiliated hospitals are necessarily the best or only way to ensure equitable access. “The only constant stream of concern that I perceived was that there are a lot of oncologists and community physicians who do transplants outside of the major university centers,” he said. Their patients, he continued, “are traditionally marginalized by these same academic medical centers.”
Many hospitals, Suite said, were refusing to give Evusheld to patients who were not already receiving treatment from them, as well as to some who were, and iCare became an alternative. “We have patients from Orlando, Daytona Beach, the west coast of Florida like Tampa for example: people who were already receiving care for their transplant or for their cancer in large centers in the state of Florida , but they could not even enter their own establishment. Because there just wasn’t enough supply, ”he said.
It is not known how the Florida Department of Health chose to allocate doses to different institutions – it did not respond to requests for comment by email and phone. Ison and Wolfe see the point of Suite. After all, being able to get cancer treatment or a transplant in some hospitals is often a privilege. They just want to make sure that these gaps are not further compounded in the distribution of a scarce resource.
“Giving [Evusheld] to this type of concierge services for distribution could potentially be justified to facilitate access to medicines, ”Ison said. But he wondered why not donate some to transplant or oncology clinics that may not have one at all, given that their lists are already full of eligible patients.
“There will certainly be people who will not be well served by academic medical centers. I couldn’t agree more, ”said Wolfe. “Therefore, why do I think: What is the optimal distribution? It’s the one where we’re all kind of on the same page as to who really needs it the most. It should be independent of where you see your doctor.