Executive Memo: Prioritization for COVID-19 Vaccination Raises Thorny Questions of Policy

Conrad Amenta, SFMMS Executive Director

PRIORITIZATION FOR COVID-19 VACCINATION RAISES THORNY QUESTIONS OF POLICY

The rollout of COVID-19 vaccines across the country has highlighted preexisting disparities between counties and states when it comes to resources and relationships. While vaccines are purchased at the federal level and allocated to states for distribution, the logistics of vaccine administration have largely been handled by County Departments of Public Health in collaboration with large, intercounty health entities.

We should have no illusions about what this means: the least resourced level of government has been responsible for carrying out many of the most complex tasks. The Departments of Public Health also happen to be how the bulk of the public interact with, and express their frustration about, the vaccination process.

Some counties, such as Marin, have stood up their own vaccination clinics for health care workers. In other counties, Departments of Public Health have relied upon the intercounty health entities in which the majority of physicians practice in an increasingly consolidated market. Yet in other counties, Departments of Public Health looked to regional medical societies to staff drivethrough vaccination events. And yet in others, they asked that every single physician practice become an approved Vaccination Facility in and of itself, and thus have the capacity to vaccinate its own staff.

Each of these approaches possesses its trade-offs, risks, and shortcomings. But the simultaneity of these approaches across counties, and the varying degrees of rigor with which the prioritization order has been applied, has created uncertainty at a time when physicians and their staff are anxious about their safety – and have been told that they are prioritized for vaccination.

At the root of the challenged prioritization equation is the missing factor of supply. The degree of scarcity determines the degree of specificity in and application of the prioritization order. We understand, for example, that primary care physician practices are prioritized over subspecialty physician practices. But what medical specialties, services, and settings constitute primary care? Should the size and makeup of a physician’s patient panel be considered? Does the prioritization order stand if someone does not show up for their appointment and the dose may go to waste? How much, if any of this, is verifiable? The relevancy of these questions ebbs and flows relative to the projected supply of vaccine.

Federal communication about the supply of vaccine has been lacking, forcing states and counties to develop guidance in the dark. County Departments of Public Health, tasked with executing on that guidance at the locus of unimaginable public and political pressure, have surfaced predictable challenges to consistency and fairness. We should acknowledge that though we have been operating in a vacuum of information, and this is frustrating, so too have County Departments of Public Health.

As this issue of San Francisco Marin Medicine goes to print, we can be sure that the immensely complex prioritization questions when it comes to vaccination of health care workers will be relatively simple compared to the prioritization order for the general public. I know that physicians, and their Society, will do all we can to help navigate the thorny policy questions that are sure to ensue. Conrad Amenta