The bigness of vaccine distribution

The COVID-19 vaccination will be distributed through all big players--there's no other option, thanks to the aggregation of pharmacies and group purchasers.

I won’t be publishing next week due to the holiday. If you can, please stay home. 🦃

There are two vaccines on the market, Pfizer’s candidate and Moderna’s. It seems very likely that we’ll have a vaccine available in the next few months.

In fact, on a recent press call, Dr. Anthony Fauci announced that he expects members of the general population will be able to access a vaccine by April. Dr. Fauci is known for being cautious in his statements to the press, so there’s good reason to hope that that is the outcome.

But once we have a vaccine, how do we distribute it? I wrote last week about the supply chain challenges of rolling out a vaccine (and if you want a more in-depth overview, Dr. Zeke Emanuel and Topher Spiro’s report here is thorough). But let’s say there is no production rate limiting step. How do you get the vaccine into the arms of the U.S. population?

Vaccine distribution

Distribution is a huge problem. Setting aside the ever-shrinking percentage of Americans who say they’d get a vaccine, the infrastructure for distribution is weak. Compounding the problem, both the Pfizer and the Moderna vaccine require two shots, an initial one and a follow-up booster. If the whole U.S. adult population were vaccinated, that’s about 510 million doses of vaccine.

The military probably won’t be much of a help. Besides the fact that it probably wouldn’t help vaccine conspiracies to see members of the military wielding needles, the military just isn’t ready to do a large-scale, nationwide distribution effort.

And states don’t seem particularly prepared either. State governments have received very little funding for vaccine distribution and tracking so far—and further negotiations for funding are caught up in the same Congressional fight that’s stalling stimulus funding. (You can see detailed state plans for the COVID vaccine roll-out here.)

The state health officer of Mississippi told the New York Times that “[w]e absolutely do not have enough to pull this off successfully. This is going to be a phenomenal logistical feat, to vaccinate everybody in the country. We absolutely have zero margin for failure. We really have to get this right.”

But as long as there’s no forthcoming funding, it’s likely that we really won’t get this right.

Enter: CVS and Walgreens

The Department of Health and Human Services is also thinking about this problem. In mid-October, HHS and the Department of Defense announced a partnership with CVS and Walgreens to distribute the COVID-19 vaccine, free of charge, to long-term care facilities (LTCF, a category that includes nursing homes and long-term disability care).

The facilities will be able to choose between CVS and Walgreens, or they can opt out in favor of independent pharmacies or providers—but it’s not clear to me that independent vaccine providers, without the benefit of the support from HHS and DoD, will be able to access the first doses as quickly as CVS and Walgreens.

Just a week ago, HHS announced that it was forming partnerships with “large chain pharmacies and networks that represent independent pharmacies and regional chains” to distribute the vaccine. The list of partnerships, however, is…almost entirely large chain pharmacies.

This is not a complete list. See the full list at https://www.hhs.gov/about/news/2020/11/12/trump-administration-partners-chain-independent-community-pharmacies-increase-access-future-covid-19-vaccines.html.

In fact, even HHS’s liaisons with independent pharmacies are occurring entirely through gigantic group purchasing organizations (GPOs) like AmerisourceBergen, McKesson, and Cardinal, which will be placing orders for the vaccine on behalf of their community pharmacy clients.

Independent pharmacies are grateful to be included at all—a trade organization for community pharmacists, the National Community Pharmacists Association, put out a statement lauding HHS for including independent pharmacies.

And under the status quo, where independent pharmacies are routinely crushed by chain pharmacies (despite their benefit to the community), I suppose it’s good that HHS thought of them at all.

But to me, the vaccine roll-out just demonstrates how concentrated our commercial pharmaceutical distribution chains have become.

One on hand, this is a chance for the very big providers of pharmaceuticals in the U.S. to shine in their efficiency and reach.

On the other, our reliance on CVS and Cardinal—not known for practices that keep the patient top of mind—means that there are huge potential failure points in the vaccine roll-out. If CVS has a breakdown in refrigeration, for example, thousands of doses of vaccine could be lost, rather than the several dozen that could be lost if an independent pharmacy’s electricity goes out.

The importance of independent pharmacies

The promise of efficiency of distribution from the big players during the vaccine roll-out is also counterbalanced by the importance of independent pharmacies in accessing all corners of the country.

For example: this piece, written by a former Army COVID crisis planner, specifically notes that 235 of Texas’s 254 counties qualify as medically underserved. The author narrows in on Lipscomb County, TX, home to about 3,300 people, located very far from any major city. The nearest pharmacies are all independent or local chain pharmacies.

CVS might be the nearest vaccine site for people where I live, in Washington, DC, but independent pharmacies are a crucial part of the landscape for vaccine distribution.

Conclusion

My frustration, in other words, with the COVID-19 vaccine roll-out is that the dominance of CVS and Walgreens of the retail pharmacy market has had detrimental effects on the strength of our pharmacy market, the price of drugs, and quality of pharmacists’ work.

But because they haven’t been reined in over the last few decades—and because they’ve been allowed to supplant independent pharmacies—they are the best hope for a widespread vaccine roll-out (even as independent pharmacies fill a crucial gap).

Add this to the list of things we should’ve fixed when we had a chance. And that we should fix before the next pandemic.

A side note for health policy nerds curious about vaccine coverage: while doing the research for this piece, I came across this fun graphic showing how vaccine coverage can vary depending on the plan and the vaccine. (If the vaccine is covered by the pharmacy part of an insurance plan, the reimbursement is funneled through a PBM.)

Source: https://www.pharmacytimes.com/publications/supplements/2019/June2019/navigating-the-world-of-vaccine-billing

The COVID vaccine is mostly exempt from this graph, as the government has purchased in advance hundreds of millions of doses. Private insurers and Medicare will also be required to cover the vaccine. Furthermore, there are guardrails preventing vaccine providers from surprise billing patients for the vaccine. (If only we could extend those guardrails to the rest of medical care.)