After months of shortages, pharmacies across the United States are being stocked with drugs to treat Covid-19. Now, the bottleneck has shifted to getting a prescription — and patients and public health agencies are looking to telehealth for help.
Last week, Massachusetts launched free televisits for state residents who have tested positive for Covid-19, including home delivery of Paxlovid, Pfizer’s oral antiviral, if prescribed. New York City has filled more than 16,000 courses of the drug through its home delivery program, 2,100 of which started with a free telehealth visit with NYC Health + Hospitals. And a growing number of virtual care companies are promoting televisits as a first-line resource for patients who have tested positive, advertising against Google searches for “Paxlovid” and partnering with testing companies that route patients to their providers.
“In the past week, I have had multiple state departments of public health that are coming to us saying access to the prescribing event is the problem,” said Caroline Savello, chief commercial officer for Color, which is supporting the Massachusetts program. “People are not going to doctors.”
Proponents cite virtual visits as a strategy to simultaneously keep sick patients at home and speed access to the drugs in the five-day window after symptoms emerge, when they’re most likely to be effective. But existing barriers to telehealth access and concerns about prescribing will limit how much it can help.
“Sometimes we hear telehealth is going to cure all of our challenges with access to health care, and that’s just not the case,” said Michelle Morse, chief medical officer of New York City’s department of health. “It’s a significant step forward in access, and yet there are still equity concerns with telehealth. It’s not a panacea.”
The patients most likely to know about and navigate digital health platforms to access the antivirals are typically younger, more affluent, and already well-served by the health system. And while a small group of public health departments are offering free telehealth, the end of the Health Resources and Services Administration Covid-19 Uninsured program means that uninsured patients may struggle to pay for teleservices, let alone any Covid care.
Michelle Lin, an emergency physician who works on an urgent care telehealth line in New York City, said many of the patients she sees turn to telehealth for Covid care have primary care doctors, but have struggled to get an appointment with them on short notice.
Online options for those patients have expanded in the months since the FDA authorized emergency use of Paxlovid and Merck’s molnupiravir for Covid-19 patients with risk factors for severe illness. In December, Truepill launched a service that pairs televisits with at-home delivery. Some urgent care clinics are a source of telehealth appointments, along with companies like Carbon Health that bill themselves as hybrid primary care providers. Today, a patient who searches for “Paxlovid” may find an ad from telehealth provider PlushCare to “get the FDA authorized Paxlovid prescribed” in a 15-minute online visit, if eligible.
Increasingly, those companies are aiming not simply to provide an online visit that can result in a prescription, but to establish their own version of “test to treat,” the federal program that has established more than 2,000 sites where Americans can receive Covid-19 tests, see a physician, and fill a prescription for antiviral medication, when needed — all in one fell swoop. (While most of those sites emphasize in-person assessment, a CVS spokesperson said eligible patients who have tested positive can also receive a prescription via an e-clinic visit.)
Truepill partnered with testing company Curative to funnel its Covid-positive patients to televisits, while testing company Cue Health is planning to add prescription delivery to its existing platform that links people who use its at-home tests to teleproviders.
“We are getting very close to having our eureka moment of linking diagnostic results with virtual care, and the final piece, antiviral and prescription delivery,” Cue CEO Ayub Khattak said in a recent earnings call. Cue’s telehealth partner, 98point6, has seen antiviral prescriptions increase more than threefold between March and April after starting to offer them in February. Without a system to close the loop between test and drug delivery, some teleproviders find themselves simply referring patients back to a test-to-treat site.
Those efforts come as the Biden administration and professional medical organizations look to encourage use of the drugs by providing more clarity about how and when they should be prescribed. Notably absent from the prescribing picture is Teladoc. A company spokesperson said that “given the current limitations on their use and the safety profile of these drugs,” Teladoc believes they should be prescribed in person.
“Paxlovid is a drug that actually is a little bit complicated in terms of how it’s prescribed,” said Tara Vijayan, a physician and medical director of antimicrobial stewardship at UCLA Health who has prescribed Paxlovid to existing patients in virtual visits. “It requires a thorough review of all the medications that a patient is on, because there are actually a number of drug interactions.”
In a best-case scenario, physicians told STAT, a patient can make a telehealth appointment with a provider they already know, who will have access to current medications and medical history. Physicians highlighted the risk of Paxlovid’s interactions with certain blood thinners and asthma medications, as well as the need to see recent kidney and liver tests before prescribing to some patients.
“The issue is, that’s not always how telehealth is happening,” said Walid Gellad, director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh. Successful Covid care doesn’t stop when the patient finishes a five-day course of Paxlovid, especially if their other medications need to be stopped or modified while taking the drug. “How comprehensive was the medication review?” asked Gellad. “Did they explain to the patient why they’re telling them to stop this medicine or that medicine? Did they explain the side effects of Paxlovid?”
But while the physicians highlighted the challenges of managing Paxlovid’s complexity in virtual settings, that wouldn’t stop any of them from prescribing the antiviral from afar. “If done correctly, I think the benefit of telemedicine outweighs the risks,” said Vijayan.
Telehealth companies that provide antiviral prescriptions say that their providers follow the FDA’s guidelines for the drugs and only prescribe to eligible patients. “Virtual care is an effective way for patients to access treatment for Covid-19, and we’ve taken all of the necessary precautions to ensure that our virtual care platform is safe and compliant,” said Varun Boriah, senior vice president of platform solutions at Truepill, whose Covid care platform has an intake survey listing the drugs that interact with the antivirals.
But as with all health care, Gellad emphasized, telehealth options need to carefully balance access with quality. For public health departments, that means designing programs to be available to those who need it most. In New York City, free telehealth visits are offered not only through an online portal, but through the city’s phone line, a critical step to reach residents without internet access or who are less familiar with computers. Providing telecare in the patient’s preferred language is also key: Massachusetts’ program launched with plans to add to its list of four languages, with the potential for a phone-only option, said Savello.
“It’s important to say: Yes, telehealth helps us, it increases access, it increases convenience,” said Morse. “But it is not a silver bullet for our access issues in health care in this country.”