Dr. Patricia Phillips of Yarmouth says the state’s 1,000-dose-per-week requirement for setting up a vaccination clinic isn’t feasible for small practices. Ben McCanna/Staff Photographer
Family physicians and primary care doctors say state health officials are needlessly excluding many smaller practices from Maine’s COVID-19 vaccination campaign by requiring them to administer an unrealistic number of doses weekly.
But state officials plan to continue directing most of Maine’s limited supply of doses to organizations that can quickly and efficiently vaccinate older residents, who are most at risk from COVID-19.
After weeks of negotiations with medical associations, the Maine Department of Health and Human Services recently began accepting applications from smaller medical practices that are interested in jointly offering vaccination clinics.
But to be eligible, these “community-based collaboratives” must commit to administering at least 1,000 vaccine shots per week. Multiple doctors say that high bar effectively excludes them from vaccinating older and eligible patients, many of whom would prefer to get a shot from their local doctor than travel to a mass-vaccination clinic in Scarborough or Bangor.
“There is really no way,” said Dr. Lisa Lucas, owner of Fulcrum Family Health in Freeport. “I tried to create a consortium with local physicians, and there is no way we can come up with 1,000 patients per week. The threshold is just so high.”
With vaccine supplies still limited nationally, officials at DHHS and the Maine Center for Disease Control and Prevention said the state’s focus remains on getting as many shots as possible – as quickly as possible – into the arms of those age 70 or older. They also credit Maine’s higher vaccination rates with that focus on sending doses to higher-volume clinics.
“If the volume of supply changes such that we are not so supply constrained, well then, of course, that is something easy to revisit,” said Dr. Nirav Shah, director of the Maine CDC. “But in the meantime, that high throughput means that when we allocate doses, we know that they can be used to vaccinate a high number of people really, really quickly. And that’s ultimately what we are looking for here.”
As of Tuesday, just above 15 percent of Maine’s population had received at least one dose of a COVID-19 vaccine, which is the 11th highest percentage nationally. More than 50 percent of Mainers age 70 or older – the current focus of Maine’s multi-phase vaccination campaign – had received at least one shot while 14 percent have received both shots in the two-dose regimen.
The vast majority of those shots has been administered by hospitals or larger health care networks that were charged with leading the initial stages of Maine’s vaccination campaign. But primary care physicians and family practitioners have been petitioning the Maine CDC for a small share of doses, arguing they are better equipped to quickly identify, schedule and vaccinate their most vulnerable patients.
Dr. Patricia Phillips, a Yarmouth physician, said she and other practices first applied to become vaccination sites in early December in response to invitations from DHHS. After it became clear that DHHS wanted smaller offices to collaborate on joint vaccination clinics, Phillips submitted a plan last month involving five local practices.
But the 1,000-dose-per-week requirement announced last week isn’t feasible for private practitioners who still have to provide general care to their patients, Phillips said.
“We spent considerable resources on planning, obtaining syringes, PPE, freezer and epinephrine so we would be ready as soon as vaccines arrived in Maine,” Phillips said in an email. “Finally, in mid Feb., they come up with a plan that essentially excludes all of the small private practices throughout the state. We can reach the disadvantaged patients in our own practices, but (I’m) not sure it is reasonable to think we can develop a plan for all who need help because they can’t access the mass vaccination sites.”
In the early weeks of the vaccination campaign, the Maine CDC directed nearly all of its limited supply of weekly doses to MaineHealth, Northern Light Health and other large hospital networks. But as supplies have grown and Maine began vaccinating residents age 70 and older, the number of locations receiving relatively modest shipments of doses also increased even as the number doses delivered to high-volume clinics also increased.
In each of the last three weeks, for instance, eight federally qualified community health centers around the state were slated to receive 100 doses of the Moderna vaccine, which must be kept in freezers but not the ultra-cold storage units required for Pfizer doses. The Maine CDC also has routinely shipped 100 doses to fire departments and EMS agencies in recent weeks to inoculate first responders.
The DHHS application for smaller practices to receive doses for a joint vaccination clinic requires such collaboratives to offer at least 1,000 doses a week to be considered for the program. But the application also repeatedly stresses the issue of vaccine “equity” – a major focus since before doses began arriving in mid-December as state health officials aim to ensure vaccines are available statewide.
“The Maine Department of Health and Human Services is approving such proposals for receipt of state-distributed COVID-19 vaccines as part of its effort to reduce barriers to access for Maine’s hard-to-reach, marginalized and medically underserved communities, including racial and ethnic minority groups, tribal communities, sexual and gender minority groups, those living with disabilities, those living on the margins of our economy, and rural/geographically isolated communities,” the application states.
DHHS spokeswoman Jackie Farwell said the department has received multiple applications for collaboratives and “will continue to review and accept them on a rolling basis to ensure access to COVID-19 vaccine in Maine’s hard to reach, marginalized and medically underserved communities.”
“This volume allows Maine to expand vaccine distribution with equity, efficiency and flexibility with more partners in additional areas of the state and supports our efforts to reach all populations who are eligible to receive the vaccine,” Farwell said.
Shah noted during Tuesday’s briefing that collaboratives in Aroostook County and northern Penobscot County already have been approved for vaccines and state officials are reviewing an application from a group in Washington County. Shah also suggested that DHHS is giving stronger consideration to collaboratives that propose to open their vaccination clinics to the broader public rather than only their patients.
But primary care doctors say they can efficiently vaccinate some of Maine’s most vulnerable citizens – those patients whose age and health conditions make their particularly susceptible to COVID-19. More than 85 percent of the individuals who have died in Maine after contracting COVID-19 have been 70 or older.
Dr. Merrill Farrand Jr., one of four physicians and nurse practitioners at Family Practice of the Kennebunks, said his practice has 781 patients between 70 and 100. He was unsure how many of them already had been vaccinated elsewhere or have appointments.
Farrand said offices like his know their patients best and who would most benefit from a vaccine. Some of them would be uncomfortable going to a mass-vaccination clinic while others would have trouble, because of physical limitations, getting from the parking lot to the vaccination site. Meanwhile, Farrand said his office could safely inoculate those patients in their parking lot or a driveway “because that’s what we do in smaller practices.”
“Being in the trenches, you are trying to take care of your people,” Farrand said. “We have had discussions at the office level of how we would go about doing 100 doses a week … but we don’t have enough time to play this orchestration game of finding enough providers to come together. I don’t see that happening. In fact, I know it is not going to happen.”
The Maine CDC had released the collaborative proposal after weeks of discussion with the Maine Medical Association and the Maine Osteopathic Association, which represent physicians.
Amanda Richards, executive director of the Maine Osteopathic Association, said her organization was “encouraged by the continued partnership” and discussions with Maine CDC on incorporating smaller practices into the inoculation effort. But Richards said she has heard from members concerned about the high volume needed to gain approval from DHHS.
“The 1,000/week number feels like an unrealistic goal post (even when trying to work with other area practices),” Richards wrote in an email. “If and when eligibility criteria is expanded in Phase 1B … the 1,000/week minimum might be more realistic. We will of course be reaching out to Maine DHHS/CDC to voice these concerns and to discuss other options for these practices with lower volumes, but that are otherwise ‘ready and willing’ to vaccinate eligible patients.”
Asked Tuesday whether Maine CDC might consider lowering the 1,000-per-week requirement, Shah responded that “everything is under discussion” and that pandemics necessitate flexibility.
“But I won’t really make any bones about the fact that in the midst of a pandemic, throughput matters,” Shah said. “Literally, every day that we can vaccinate people with the doses that we get in the state is a day that we can start providing and conferring immunity or safety from the vaccines. So throughput really does have a role to play, particularly when the volume of vaccine we are getting is so limited.”
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