As two new antiviral pills for Covid-19 approach emergency authorization, experts are concerned that a lack of public health infrastructure — especially easy access to fast-turnaround testing and quickly filled prescriptions — will prevent them from making a meaningful dent in the pandemic.
“We know that these antivirals are going to have a window of opportunity where their effectiveness is optimal, and it can be difficult to get an appointment and get a prescription,” said infectious disease specialist Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security.
Virtual care companies think they could speed up the process of getting patients the antivirals in the three to five days from symptom onset when they are most effective. This week, digital health company Truepill announced it would soon launch a platform to support telehealth consultations, prescriptions, and next-day delivery of the new drugs, from Merck and Pfizer, when authorized. Carbon Health, which has both brick-and-mortar clinics and virtual care, plans to extend its acute Covid care program to include the oral antivirals. And direct-to-consumer company Ro says it has the capability to prescribe and deliver the drugs and expects to make them available through its platform.
“I do think there could be a great opportunity here to leverage all the telehealth that’s developed over the pandemic, and even was going on before the pandemic, to be able to get prescriptions into the hands of people much faster than the traditional route,” said Adalja.
But that opportunity hinges on all the rest of the pieces falling into place at the right time. For the pills to live up to their full potential, people need to be able to procure and pay for tests, receive their results quickly, and connect right away with a health care provider if they test positive for Covid.
If all those steps go according to plan, online platforms, by virtue of their distributed workforce of virtual providers, could get prescriptions in some hands faster while allowing Covid-positive patients to quarantine. When a patient enrolls in Carbon Health’s Covid-19 program online, “we make sure they have a thorough virtual assessment within 24 hours of showing symptoms,” said medical director of program development Aaron Weinberg, also national director of clinical research at Carbon. “The clock starts as soon as someone contacts us.”
Once patients meet with a Carbon Health provider and receive a positive test result, they might receive a prescription for monoclonal antibodies, a pulse oximeter to self-monitor their symptoms, or soon, an antiviral prescription.
Truepill is making an even more explicit guarantee of speed, with plans to offer its teleconsultation and delivery services as a plug-and-play tool for existing healthcare systems, providers, and payers, said Andy Rink, senior vice president of telehealth at Truepill. “We will basically allow any patient that has tested positive for Covid and qualifies for these medications under the [emergency use authorization] guidelines to get the medication within 24 hours,” he said.
How quickly digital pharmacies can get the antivirals to a patient’s door will depend significantly on supply. The drugs, like vaccines and other Covid-19 therapeutics, will be distributed state-by-state according to need. To ensure timely delivery after a teleprovider prescribes the drug, Truepill will arrange for access in one of two ways: shipping them overnight through one of the company’s own pharmacy centers, or arranging pickup or delivery from a retail pharmacy, using publicly available information to determine which locations have the drugs in stock. “We can take that information and get it to the provider at the point of that visit, so we can get it to the right location, the first time,” said Rink.
Truepill expects to complete its platform within two weeks, and is talking with groups that may implement it. “We have groups of providers that are interested in taking our existing solution and using it for their patients, even patients that have a primary care doctor already,” said Rink — primarily with the advantage of finding a reliable supply of the drug. They’re also talking with payers, employer groups, and existing direct-to-consumer companies.
Until those partnerships are solidified, it’s unclear what the impact will be on increasing access in underserved patient groups — particularly older adults and lower-income individuals, who are less likely to have access to or use telemedicine. Telehealth has also seen lower use among non-white, uninsured, and rural patients.
“I worry that we have this tendency to herald technological breakthroughs, while really setting ourselves up for breakdown in delivery to those who are going to need it most,” said Alyssa Bilinski, a public health policy expert at Brown University.
It’s possible that telehealth companies could, if not increase access for the most underserved patients, lighten the burden for some in-person providers or shorten wait times for certain patients. Direct-to-consumer pharmacy companies like Ro, Nurx, and Hims & Hers — many of which started by providing convenient online prescriptions for erectile dysfunction medications or birth control — have increasingly expanded their offerings, including Covid-19 testing, and added telehealth services. These companies could capitalize on their own network of teleproviders to support antiviral access, or deploy a platform like Truepill’s.
“Companies that have been successful doing it with other medications, lifestyle medications, I think they’re perfectly poised to do it,” said Adalja.
But each of these routes to digital prescription and delivery could run into obstacles. Not every virtual care network has teleproviders licensed in every state; someone looking for a quick prescription might hit a dead end when they realize a platform doesn’t serve them. And while platforms will typically require users to fill out an intake survey that asks questions about the antiviral drugs’ indications, patients with complex medical histories should be especially careful to make sure a new teleprovider takes any contraindications or potential drug interactions into consideration.
“Given their potential advantage in terms of access, one could see direct to consumer telemedicine companies playing a more substantial role,” said Ateev Mehrotra, associate professor of health care policy and medicine at Harvard Medical School. “However I suspect that the vast majority of people will still turn to their usual PCP or go to a local urgent care or retail clinic.”
Primary care offices are capable of writing prescriptions after virtual visits, too, of course. In a study led by Michael Anne Kyle, postdoctoral fellow in the Department of Health Care Policy at Harvard Medical School, researchers found that many primary care offices offered testing and virtual visits during the pandemic. “But the wait times to get an appointment were usually outside the window … needed to start antivirals,” Kyle wrote in an email.
Rink said Truepill’s platform will allow users to order an at-home test online, but acknowledged that “given the five-day window, it’ll be hard to get all that done — get the test, get it delivered, have the visit, get the medication.” So patients who turn to virtual care companies for an antiviral prescription will likely have taken an at-home antigen test. That means the biggest beneficiaries of virtual platforms could be those who have had the means and ability to stock up on those tests. “We’re seeing a lot of people order tests ahead of time to have at home,” said Rink.
In a move to increase testing access, the Biden administration said it would soon require private insurers to reimburse Americans for the cost of rapid, at-home antigen tests. But access may still present a challenge for patients who don’t have the approximately $30 to pay for a test upfront, or for those who can’t find tests on shelves.
If telehealth is to play a role, then, it will have to be just one part of a systemic effort to enable access to rapid testing, diagnosis, and treatment with the new antivirals.
“So much less attention has been paid to the full cascade of steps,” said Bilinski. “That starts with educating people to get tested, then getting the test and the quick test turnaround, but then having to know that you want to seek a prescription, having some kind of consultation with someone who can prescribe, and then getting that prescription filled.” Any breakdown in that chain of events could be the one that keeps the pills from achieving their full impact.
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