The Room Where It Happens

We’re entering a new, more challenging phase in the COVID-19 vaccination campaign as the number of Americans eager to take the vaccine declines. The good news is not all who are unvaccinated are adamantly opposed. Survey data suggest some people would be willing to take the shot if it’s easy to do so; others who are hesitant may just need encouragement or information.

Primary care providers may be key to reaching both groups. That’s because they can offer vaccinations as part of the routine care they deliver, while also serving as trusted messengers for patients who harbor concerns. Clinicians are well versed in these types of conversations. At the start of the annual flu season, for example, they often talk to patients about their reluctance to get the vaccine. They also talk to nervous parents about their vaccination fears related to autism, not to mention the numerous, sometimes uncomfortable conversations with patients about alcoholism, smoking, weight loss, and depression.

Primary care providers may also be critical to reaching populations less likely to get vaccinated, including Blacks and Latinos. A national survey conducted by the African American Research Collaborative and the Commonwealth Fund found 44 percent of Latino and 53 percent of Black respondents would prefer to get vaccinated in their doctor’s office than elsewhere, and more than half of Latino and Black respondents considered their personal doctor as the most trusted source of information on the vaccine.

Despite the opportunity, few independent primary care practices have thus far engaged in the vaccine campaign. Data from Phreesia, a health care technology firm that has partnered with the Commonwealth Fund and Harvard University researchers to track the impact of the pandemic on ambulatory care, show that among independent and multispecialty practices that deliver primary care and use Phreesia’s technology, only about 12 percent were vaccinating as of June. That compares with nearly all health systems and half of federally qualified health centers (FQHCs). (Starting in February, the federal government began distributing vaccines to FQHCs in an effort to reach the vulnerable populations they serve, including people experiencing homelessness, migrant workers, residents of public housing, and minorities.)

To identify ways to encourage more primary care providers to take part in last-mile vaccination efforts, we spoke to leaders at primary care practices that use Phreesia technology and have taken part in the vaccination campaign. They range from small independent providers to large FQHCs and primary care practices associated with an academic medical center. Many were involved in earlier phases of vaccine distribution, when demand exceeded supply and the main challenges involved scheduling, staffing, and operating large clinics. Now, as mass clinics wind down, their experiences offer lessons for policymakers and other providers on how to make vaccination sustainable within routine primary care.

Getting Started as a Vaccinator

One of the challenges for smaller practices offering COVID-19 vaccines was the onboarding process, which required practice leaders to demonstrate they could meet stringent requirements for storing the vaccine and follow exacting protocols for administering it and reporting results to immunization registries.

Naomi Piga, M.D., who runs Piga Primary Care, a small pediatric and internal medicine practice in Frisco, Texas, was frustrated by the length and redundancy of the process. “The application was 10 pages long,” she says. “They asked questions like: what brand is your refrigerator? They wanted us to upload the calibration certificate. It was a lot,” she says, noting that all of the information was already in the system for the federal Vaccines for Children (VFC) Program. Texas also required providers to use four different tracking systems: one for signing up, one for ordering vaccine, another for reporting on its use, and the last for reporting back to the state’s registry. Piga stayed the course because she is committed to making the vaccine accessible. “We’re at the forefront of being able to explain to our patients why it’s important.”

Some states and local health departments have offered more hands-on support. Last September, a 10-physician practice in Arizona received a vaccination roadmap from its county health department.* The health department also offered supplies, weekly webinars, and guidance to help practices through the process of becoming vaccinators, including how to broach difficult conversations with staff and patients. “We were already administering the vaccine when colleagues in another state began reaching out to ask how to get started,” says a physician in the practice, which began vaccinating in February.

Leaders at Jackson Clinic, a multispecialty practice with more than 140 providers and offices in 13 locations across western Tennessee, say the extensive information the practice received from the regional health department starting in January was crucial. They also benefitted from online training from the Centers for Disease Control and Prevention (CDC), for which nurses can earn continuing education credits. Based on the guidance, leaders ultimately decided to train a small team of nurses to focus on handling the vaccine and entering information into the state’s tracking system. “Having a dedicated team has kept us from any mistakes,” says Kim Holland, D.N.P., the clinic’s director of nursing.

Assessing and Meeting Demand

Many practices devised their own methods for assessing demand and establishing systems to accommodate it. Piga sent a survey to her patients in early May asking about interest in the vaccine. It turned out most adults (75%) had already been vaccinated by the county or local pharmacies and the remainder didn’t want it. An equal share of parents (75%) wanted the vaccine for their children, but only half wanted them vaccinated as soon as possible. The others wanted to put it off until the school year started or wait at least six months; a quarter of parents didn’t want to vaccinate their children at all. Among those who wanted the vaccine, 90 percent wanted to get the shots from Piga’s practice.

Ensuring that practices offered consistent messages to patients was important as well as time-consuming as new information — and misinformation — about the vaccine emerged. Leaders at the Arizona practice created scripts for clinicians and office staff to answer common questions from patients. Engaging front-desk staff proved critical since patients often ask or confide things they might not mention to providers. “Our staff also talk to their friends, their family, and their neighbors. ‘We want you to be a source of truth,’” a physician says they kept telling staff.

The practices also had to come up with new scheduling systems to avoid overburdening staff still managing day-to-day operations. Piga changed her office phone tree to redirect people who were interested in vaccination to an online registration form and staff then followed up to schedule appointments. The primary care practice in Arizona had a different challenge: to receive 800 doses, it had to agree to use them within a week. Concerned about the logistics of scheduling that many patients in less than a week, they decided to automate the process. They invested more than $16,000 in software to notify qualified patients via email and text, with a link to a new scheduling platform that allowed them to choose appointments for their first and second dose.

Bringing Vaccines into the Community

Some primary care providers have been creative about where and when they offer the vaccine, taking steps to make vaccination as convenient as possible and targeting people at high risk of contracting COVID-19.

After hearing from local politicians and church leaders who were particularly concerned about people without transportation, UAB Medicine in Birmingham, Alabama, which operates eight primary care clinics, asked UAB School of Public Health epidemiologist Gerard McGwin, Jr., Ph.D., to map areas they should target. Using data from the CDC’s social vulnerability index and public health data on COVID-19 prevalence, they ultimately opened 11 pop-up clinics, including in a baseball stadium, a basketball arena, a church, and a high school that offered walk-up or drive-through appointments. “It turned out there was a lot of vaccine hesitancy in those areas,” says Jaye Locks, ambulatory services administrator at UAB Medicine.

HealthLinc, an FQHC with 11 clinics in Northern Indiana, offered vaccinations within the clinic but also brought them to people in the community by establishing a “go team” of three medical assistants, a clerk to handle registration, and a nurse licensed to sign off on the vaccination. Since January 2021, the team has staffed more than 130 pop-up events. They reached people at farms, schools, and homeless shelters, among other locations. Together with clinicians at the health center, the team has provided more than 50,000 vaccines as of June 30. “If we didn’t have this team of people designed to do this job, we couldn’t capitalize on the events in the way we’ve been able to,” says Melissa Mitchell, M.S., HealthLinc’s chief operating officer.

In addition to offering vaccines in their clinics and holding neighborhood pop-up clinics, Delaware Valley Community Health, an FQHC with eight locations in and around Philadelphia, is bringing vaccines to people’s homes. A nurse and other team member offer a choice of Johnson & Johnson (J&J), Moderna, or Pfizer vaccines to those who are bedbound and those who have difficulty coming to clinics because of a disability like cerebral palsy or a behavioral health condition that makes it hard for them to wear a mask. Some are health center patients and others are referred by Philadelphia’s Department of Public Health.

With less bandwidth, the smaller practices have concentrated on delivering the vaccine in exam rooms. Leaders of the Arizona practice realized they couldn’t do so in the normal course of business because they lacked the space they needed to monitor patients for allergic reactions, adhere to social-distancing protocols, and deliver regular care. They held eight weekend clinics in the office instead. While clinicians were able to fully vaccinate 2,000 of the practice’s 15,000 patients, it was taxing. The clinic paid staff time-and-a-half; still, the weeks were long as COVID-19 raged through Arizona in February. Patients’ gratitude took some of the edge off: “Patients brought in homemade cookies. They brought donuts. Some people broke into tears, saying, ‘Thank you so much for doing this for me, for being there for us,’” one of the practice’s physicians says.

Offering Information and Persuasion

Addressing vaccine hesitancy is arguably the most valuable contribution primary care providers can make to the vaccination effort. The practices we spoke with have used a variety of strategies to persuade people of the coronavirus vaccines’ safety and benefits. Delaware Valley Community Health added a physician to every vaccine clinic to answer questions. “That really helped us with getting patients to come back for the second dose. They were less afraid of side effects,” says Julia DeJoseph, M.D., vice president and chief medical officer. She believes the investment of physician time will also pay dividends as the people they’ve counseled share information with peers.

HealthLinc had the advantage of serving as a clinical site for the J&J vaccine trial (the health center’s CEO, Beth Wrobel, is one of the trial participants). Having longer-term experience with the vaccine enabled staff to speak confidently about its benefits and risks. In other locations, the temporary pause of the J&J vaccine to examine a rare blood-clotting disorder, and the bad publicity surrounding problems at its Baltimore manufacturing facility, were setbacks.

At Jackson Clinic, many patients were holding out for the “one-and-done” vaccine, and demand dropped when distribution was paused. “It was crushing,” Holland says. Since the clinic began vaccinating two months ago, it has given 2,789 shots, but only 172 from J&J. When the African American Research Center/Commonwealth Fund surveyed people about 31 different concerns about COVID-19 vaccines, fear over the J&J vaccine causing blood clots emerged as the top concern, cited by 40 percent of all respondents.

Piga, the pediatrician in Frisco, Texas, has found discussions with parents and children need to be customized, since the reasons people cite for not wanting the vaccine vary considerably, even within families. In some instances, parents don’t agree and their children are choosing sides; Piga has also had young patients tell her they’re getting the vaccine despite their parents’ objections. Piga’s approach with adolescents has been to speak to them like adults, trusting that they can understand the science behind the vaccine. “I think they are actually a bit more receptive,” she says. She estimates that about 70 percent of parents with reservations are convinced of the merits of vaccination once they’ve had a one-on-one conversation with a doctor.

To provide information efficiently, Piga scheduled two Zoom meetings to answer questions. Some people expressed concern about the vaccine’s effects on fertility, the possibility of allergic reactions, and use of stem cells in the development of the vaccines.

In Birmingham, people who taught English as a second language (ESL) in local schools volunteered to help when UAB Medicine staff discovered that Latino residents were underrepresented in vaccination tallies. The ESL teachers recruited families to come to informational sessions, where parents could ask questions of Spanish-speaking clinicians from the health system. When UAB Medicine organized a pop-up clinic at one school the day after an informational event, 350 people showed up to be vaccinated over the course of two hours — more than 10 times the number who attended the informational session.

Financing Upfront and Ongoing Costs

To get started as vaccinators, these primary care practices invested time and money in new scheduling systems, redeployed staff, and launched outreach campaigns. Leaders say they shouldered these costs because it was the right thing to do during a public health crisis, and CARES Act funding (as well as dedicated funding for FQHCs in the American Rescue Plan) has helped make up their upfront investments.

Most of the practice leaders we spoke with say the $40 reimbursement for administering each dose of a vaccine, instituted March 15th by Medicare and adopted by most insurers soon after, is adequate to cover the costs. Before that, Medicare reimbursed providers much less: $45.44 for a two-dose series and $28.39 for a single-dose one, which some practices said did not cover their costs.

Jackson Clinic, a multispecialty practice, is not billing at all. In part, that’s because local pharmacies and the health department are not billing either, and leaders don’t want to create another reason for people to forgo vaccination in a state where many residents are reluctant. “We just want to get shots in arms,” says Amy Smith, M.B.A., director of business operations.

Because the next phase of the vaccination campaign will require providers to offer more counseling to patients — as well education to their staff on an evolving disease and newer vaccines as they emerge — payers may need to consider dedicated reimbursement for this extra time.

Lessons for Policy and Practice

These primary care practices have achieved commendable results, offering more than 300,000 vaccine doses so far, by reconfiguring their operations and finding creative ways to partner with churches, schools, and public health departments, among others, to reach people who were most at risk. After an exhausting year scrambling to find supplies and safely treat patients, their commitment to their communities is admirable.

Convincing more primary care practices to join the vaccination effort will be critical as the hard work of persuading the most reluctant gets underway. It may not be an easy sell to practice leaders. Many are still struggling to deliver care that patients missed in the early months of the pandemic, which is essential to meeting performance metrics linked to value-based contracts. On top of other work, the leaders of the Arizona practice estimate they put in 400 to 500 hours in preparing to deliver the vaccine to 2,000 patients.

If many as-yet-unvaccinated Americans see their personal doctor as the most trusted messenger and say they want to be vaccinated in their doctor’s office, then it’s important to think through what it will take to make this happen. Primary care providers suggested the following steps would support their efforts and encourage more providers to follow their example.

Allocate vaccines in new ways. Many leaders say having single-dose vials of the vaccine would radically change the calculus for offering vaccines. Rather than upending their schedules and redirecting staff to make use of multidose vials that expire within hours, they would be able to vaccinate any willing patient, without concern about wasting doses. With the vaccine in single-dose vials, “we could catch everybody as part of our normal business,” a physician in the Arizona practice says.

As an alternative, some health departments have instructed practices to give doses to anyone they can, even if that means wasting some of the unused vaccine. But that doesn’t sit well with some providers, given the unmet need for vaccines around the world.

Provide technical and practical support. Primary care practices that are part of health systems have a deeper bench of staff and resources to tap into than smaller and independent practices. For example, for its vaccine clinics, UAB Medicine marshaled project management, human resources, communications, marketing, and the health system’s COVID-19 call center staff. FQHCs, meanwhile, often have large teams and staff dedicated to patient outreach. They also have databases of patients who are at higher risk of COVID-19 because of chronic conditions or other factors because of mandated federal reporting requirements. Delaware Valley Community Health was able to redeploy dentists who were idled by the pandemic to help vaccinate.

In contrast, many small and independent practices are underresourced and financially stretched. Some already struggle to vaccinate for influenza and other diseases, manage diabetes, or do the other hard work of primary and preventive care with lower reimbursement than specialists receive. With the extra funding they’ve received through the American Rescue Plan, state and local public health departments could work with such practices to provide support for their vaccination efforts, including organizing outreach campaigns, offering training on effective counseling approaches, and furnishing technical assistance for supply management.

A recent report from the National Governors Association and the Duke Margolis Center for Health Policy details some of the innovative ways states have sought to support practices. These range from mandating higher vaccine reimbursement rates and creating outreach materials for practices to partnering with academic institutions to offer continuing medical education credits for courses on building vaccine confidence. States could also streamline the onboarding process — at the very least for physicians who are already qualified to deliver vaccines to children.

Foster community partnerships. While mass clinics may be winding down, there are still opportunities to bring vaccines into the community. Businesses, schools, local officials, faith-based organizations, and others can support primary care practices by hosting vaccination events, disseminating information, and offering incentives. HealthLinc leaders have worked closely with employers to offer vaccines at their offices. To provide food and other supports to people while they were getting vaccines, HealthLinc turned to the local United Way Foundation. Another nonprofit, Stop the Spread, is linking FQHCs in New York and Los Angeles to resources — from portable refrigeration units to text-messaging solutions and navigation supports — and partnering with community- and faith-based organizations to advance vaccination efforts and serve community members.

* Leaders of the Arizona practice asked to remain anonymous.