Patients and medical professionals are trying to navigate confusion created by the new federal recommendations for the COVID-19 vaccine — and health experts are worried it could dissuade people from getting the vaccine at all.
The confusion stems from two agencies with differing recommendations.
The Food and Drug Administration approved the COVID booster earlier this year for anyone who is over 65 or has an underlying condition.
However, the Centers for Disease Control and Prevention’s recommendations were different. The agency said anyone older than six months can get the vaccine – they just need to complete what’s called the shared-clinical decision making process.
It’s a process a lot of medical professionals already engage in – like providers at Prism Health North Texas, a system of community health centers.
“It is not something that's new,” said Dr. John Carlo, an infectious disease expert and Prism’s CEO. “It is perhaps a little different in terms of how this is being discussed for considerations for immunizations. But we've been working under a shared decision-making model for many, many years.”
Catherine Troisi, a professor focusing on epidemiology and infectious disease at UT Health Houston’s School of Public Health, said despite the simple concept, it could lead to fewer people getting vaccinated.
“You’re supposed to talk to a health care provider and make that decision together about whether to get the vaccine,” Troisi said.
But she said there isn’t much clarity around what the recommendation looks like in practice, which creates a lot of unanswered questions. For example, Troisi said it’s not clear if patients must prove they spoke to a medical professional, or who is able to administer the vaccine.
Recommendations raise coverage questions
The CDC’s recommendations are particularly important for patients with commercial or private insurance, like Affordable Care Act plans and many employer-sponsored health plans.
CDC vaccine recommendations are developed by its Advisory Council on Immunization Practices, or ACIP.
“If the ACIP recommends something, then insurance needs to cover it without a copay,” Troisi said. “If you go through this shared clinical decision making…then your insurance company is obligated to pay it.”
Because the term “medical professional” is so broad, Troisi said interpretation of the recommendation can vary.
“Even within Houston, I hear my friends say – they go to one CVS and they're told they can't get it. And in a different CVS they can,” she said. “There's just a lot of confusion."
Carlo said he’s been hearing from patients that they couldn’t get their COVID-19 shot where they usually do — in some cases because of uncertainty created for providers.
“Other centers have not ordered, for example, the COVID vaccine because of the concern about reimbursement and some of the restrictions that may be there,” Carlo said.
While Prism hasn’t seen many actual denials, Carlo said the possibility of them is enough to cause providers and clinics to be cautious.
How organizations planned with the uncertainty
Jason Vercher, Prism’s vice president of operations, said planning for annual vaccines was a lot different this year.
“Typically, we will do a preorder of our respiratory vaccine such as flu and COVID, and we'll do a very large preorder,” he said.
However, Prism didn’t preorder as many doses of the flu shot as it usually does – even though the recommendations for that didn’t change. For the COVID-19 vaccine, Vercher said Prism skipped out on preordering entirely.
“We actually were late in the game in ordering those vaccines because we weren't sure that we were going to be able to offer them to our patients,” Vercher said.
When Prism did order COVID-19 shots, Vercher said it requested about 70% less than it typically would. The concerns don’t just affect COVID-19 vaccines. Prism also ordered about 50% fewer flu shots.
Vercher said there were several factors influencing the decision – namely, how insurance coverage and misinformation and disinformation about vaccines might make more people nervous about getting a vaccine.
“We were just really hesitant as an organization to be overzealous in our ordering,” Vercher said.
Prism had to be financially responsible, but Vercher said also wanted to make sure these resources were available to patients that relied on the health centers.
There was so much confusion when Prism rolled out the COVID vaccine, employees began providing an “advance notice of benefits,” which outlined a patient’s financial responsibility if their insurance didn’t cover the vaccine.
“That in and of itself did create a barrier because patients would see the ticket price of that COVID vaccine and kind of have sticker shock,” Vercher said.
However, many clinics are determined to connect people to care that they want or need.
“We want to make sure that we get you connected to resources,” he said. “Even if we don't have those resources available, we will find somebody who does.”
Vercher said his organization works with various community partners, like Dallas County Health and Human Services, to connect patients to care in a way that is affordable and accessible despite the current challenges.
Weight of access concerns
Catherine Troisi, the professor at UT Health Houston’s School of Public Health , said she and other epidemiologists are worried all of these concerns could deter people from getting vaccinated.
“The uptake wasn't great before all this confusion,” Troisi said.
Last respiratory virus season, CDC data showed 16.5% of Texas adults received the COVID-19 vaccine by late spring — below the national average. Providers said fewer people have been getting the vaccine this season, and those who have been getting the vaccine have been getting it later.
“What this means is that there will be fewer and fewer people getting vaccinated against COVID,” Troisi said. “Inevitably that means that we will see more deaths because the vaccine protects you.”
Experts highlighted how vaccines can help reduce the risk of infection and severe health outcomes, such as hospitalization and death. But they also said vaccines are effective as a public health tool – meaning the chance of an epidemic decreases as more people are vaccinated.
Dr. Varun Shetty, the chief state epidemiologist at the Texas Department of State Health Services, said despite these concerns, people can still talk to their doctor, pharmacist or local health authority about getting a COVID-19 vaccine.
“The good news is that there's a lot of different places to get [a vaccine]” he said. “There's a lot of options in our state and a lot of opportunities to take those steps to protect yourself and your family.”
Experts said now is a good time to get annual shots, like those for COVID and flu, to make sure you’re protected ahead of the holidays. Shetty said the state is still encouraging Texans to talk to their health provider and take steps to protect themselves.
“What's been true for past seasons is true today,” Shetty said. “The best way to protect yourself is with vaccines.”
Abigail Ruhman is KERA’s health reporter. Got a tip? Email Abigail ataruhman@kera.org.
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