How the test-to-treat pillar of the US covid strategy is failing patients

The federal "test-to-treat" program, announced in March, is meant to reduce covid hospitalizations and deaths by quickly getting antiviral pills to people who test positive. But even as cases rise again, many Americans don't have access to the program.

Pfizer's Paxlovid and Merck's Lagevrio are both designed to be started within five days of someone's first symptoms. They're for people who are at high risk of developing severe illness but are not currently hospitalized because of covid-19. Millions of chronically ill, disabled, and older Americans are eligible for the treatments, and Dr. Anthony Fauci of the National Institutes of Health said April 11 that more people may qualify soon.

The program allows people with covid symptoms to get tested, be prescribed antiviral pills, and fill the prescription all in one visit. The federal government and many state and local health departments direct residents to an online national map where people can find test-to-treat sites and other pharmacies where they can fill prescriptions.

But large swaths of the country had no test-to-treat pharmacies or health centers listed as of April 14. And the website of the largest participant, CVS, has significant technical issues that make booking an appointment difficult.

Even people who regularly see a doctor may be unable to get a prescription in time, and that's where the program comes in. Before the pandemic, 28% of Americans didn't have a regular source of medical care, with rates even higher for Black and Hispanic Americans.

"All of our public health response relies on lowering the barrier to getting treatments to the right people," said Dr. Kirsten Bibbins-Domingo, chair of the Department of Epidemiology and Biostatistics at the University of California-San Francisco.

She said the fragmented federal, state, and local public health systems, the U.S. Department of Health and Human Services' reliance on partners that charge high prices for appointments, and the lack of clear information are stymieing the effort. "The best tools that we have are not going to reach the people who most need them," she said.

Bibbins-Domingo is also a practicing physician at Zuckerberg San Francisco General Hospital, which she says is not only testing patients for covid and prescribing them antivirals, but also delivering them medications — all the elements of test-to-treat. But the hospital, which largely treats low-income and uninsured patients, doesn't appear on the federal map. It shows just three locations in San Francisco: two community health centers and one CVS.

Ninety-one percent of the sites listed on the national map are federal partners: pharmacy chains like CVS, federally qualified health centers, and military and Indian Health Service clinics. HHS has asked state and local health departments to identify other potential participants, like San Francisco General Hospital, so they can be added. Most states have none of those partners listed yet.

Nationally, CVS MinuteClinics make up more than half of all test-to-treat locations, according to the federal data. The roughly 1,200 clinics, in 35 states and Washington, D.C., are housed under the same roof as CVS pharmacies, where patients can pick up prescriptions for covid antivirals. Walgreens drugstores and Kroger grocery store affiliates run about 400 more sites.

The federal government has set aside nearly 400,000 courses of the antivirals for its federal pharmacy partners — about a quarter of the total supply since the program began in March.

Although the cost of the pills is covered by the federal government, obtaining a prescription at the pharmacies that dominate the program can be expensive. Though CVS does not charge symptomatic uninsured people for on-site covid tests, MinuteClinics charge upwards of $100 for in-person or telehealth appointments to examine patients and prescribe an antiviral, if needed. People without insurance, whose health plans don't cover visits to the clinics, or who have high-deductible plans must shoulder the full cost of the appointment.

Even if they can afford it, finding treatment might be impossible.

KHN aimed to find out how easy or hard booking a test-to-treat appointment at a CVS would be. Reporters searched online and in person for covid testing and treatment appointments in April.

It took a KHN reporter in the Washington, D.C., area three hours driving between stores to figure out whether testing was available and antivirals in stock across four MinuteClinic locations — time that few people can afford in general, let alone when they're sick.

Each store provided test-to-treat services, which could be booked through a kiosk. But three of the stores either didn't have same-day appointments available or didn't have the antiviral pills in stock that day.

A KHN reporter also tried to book appointments online at clinics in several states, listing upper respiratory symptoms. After the reporter marked a positive covid test on the screening form, a message appeared — "For the safety of our patients and staff, we can't allow you into the clinic at this time" — and the patient was then directed to book a telehealth visit.

KHN also searched CVS' website for testing appointments at all MinuteClinics shown on the federal map in the District of Columbia, Maryland, and Virginia, just over 100 clinics total. Only half listed any future testing appointments available.

Amy Thibault, a CVS spokesperson, said that all MinuteClinics provide in-person test-to-treat services and that a software glitch made it appear they don't. She said CVS is working to fix that. Thibault said covid patients are "encouraged" to use telehealth.

Some Americans, especially seniors, don't have the devices, internet connection, or technology skills needed for virtual visits. The program requires participants like CVS to provide options for in-person appointments, said HHS spokesperson Suzanne Sellman.

KHN also searched online for appointments at participating Kroger and Walgreens clinics in several states and found many available in-person appointments.

Another complication: The FDA requires doctors, advanced practice registered nurses, or physician assistants to write the prescriptions. A pharmacist can't do it. Many of the nation's leading pharmacy organizations have asked the Biden administration to remove the restriction, which would expand the program to scores of rural and underserved communities.

Because of this rule, the program requires clinics and pharmacies to be under the same roof — a setup that doesn't exist in many regions, particularly in rural areas.

The federal map shows no sites in Wyoming or South Dakota other than military clinics, which don't serve the public. People in dozens of other regions would have to drive more than 100 miles to reach the nearest clinic, according to a KHN review of participating locations.

The Wyoming Department of Health is working to enroll providers in the program, spokesperson Kim Deti said.

Montana has four public-facing test-to-treat clinics, according to the federal website and Jon Ebelt, a spokesperson for Montana's Department of Public Health and Human Services. He said that seven Defense Department and Indian Health Service facilities also provide test-to-treat services, but those aren't open to most people.

Billings, the state's most populous city, is more than a three-hour drive from the nearest site shown on the map. Ebelt said the agency is working with a local primary-care nonprofit to find more facilities to enroll.

We have to get this right, said Bibbins-Domingo, the San Francisco professor. She said that as the U.S. moves away from restrictions like mask mandates, the public health system must ensure that everyone can get these new treatments, which can get people back to work sooner, prevent serious illnesses, and even save lives.

For those far from clinics, people with disabilities, and people too sick to leave home, telehealth could be the easiest way to get treated. A few local governments, including Los Angeles County and New York City, have launched virtual care initiatives.

Truepill, a company that provides telehealth and pharmacy technology, offers online covid assessments through its website findcovidcare.com for a fraction of the cost of CVS' in-person or telehealth operations. The company has filled more than 10 million prescriptions in the past five years.

The service, available in all 50 states and Washington, D.C., costs $25 to $55. Though insurance isn't accepted, the cost is comparable to insurance copays for in-person doctor appointments. Prescriptions can be sent to a local pharmacy for no additional charge or shipped to a home overnight via FedEx for a $20 fee.

HHS didn't respond to requests for data on antiviral use and has repeatedly declined to allow KHN to observe weekly virtual meetings about the program held with state health officials, clinic directors, and other health care providers.

Bibbins-Domingo said that to be effective, the federal government must make it easier to get testing and treatment, especially when the program is geared toward those at highest risk of devastating complications from covid.

"If you're just an average person trying to navigate this," she said, "it's actually completely impossible."

KHN correspondents Katheryn Houghton and Rachana Pradhan contributed to this report.

This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.