On Sunday, Dr. Mark Horowitz a call from an old patient, the kind he and many city doctors have been getting more and more in recent weeks. The man — a vaccinated and boosted 69-year-old, two-time cancer survivor — had tested positive for COVID-19.
Horowitz decided to prescribe the antiviral drug Paxlovid; the drug, when taken as soon as possible after a positive test, can dramatically reduce the risk of hospitalization for patients at risk.
New York City residents can get Paxlovid delivered for free through a city-funded service, operated by a San Francisco-based digital pharmacy called Alto.
Typically, Horowitz said, the dozens of patients he has prescribed the drug for in recent months have received it within hours. This time, however, Horowitz’s patient waited until 10 p.m. Monday night — 32 hours after Horowitz sent in his prescription.
“This is a gentleman who is clearly at risk for progression,” said Horowitz, who has a practice in lower Manhattan, adding that several patients have had to wait nearly 24 hours for antivirals in recent days. “I would have liked him to have had it sooner.”
Amid yet another rise in COVID-19 cases, Alto has seen average wait times for the delivery of its critical antivirals increase in recent months. Progress reached nearly 8pm in early April, before dropping to less than 15 hours in the week ending April 25, according to data provided by the city.
Wait times have gotten longer as Alto has worked “around the clock” to double its staff to meet rising demand for the drug, the company said.
These logistical issues arise as the White House plans to increase the amount of antivirals available, as well as the number of clinics and pharmacies that can distribute them.
With the impact of the latest BA.2 variant of the coronavirus still unclear, doctors and public health experts are expressing concerns about the city’s ability to effectively distribute antivirals. They questioned the city’s decision to contract with a relatively new pharmacy that had no affiliation with local health networks, taking over the clinics and brick-and-mortar pharmacies that provide first-line access to healthcare for much of the world. bypass the inhabitants of the five boroughs.
“As we see the supply increase to the point where, really, the distribution is the constraint, not the supply, it makes sense to distribute as broadly and through as many points as possible,” Josh Michaud, associate director for global health policy at the Kaiser Family Foundation, said.
In an emailed statement, Michael Lanza, a spokesman for the city’s health department, said the increase in wait times was “temporary.”
“Alto has deployed the necessary resources to ensure that wait times improve and remain reasonable, and they have succeeded,” said Lanza.
Michael Krueger, Alto’s chief marketing officer, said in an email that company customer satisfaction surveys for its deliveries are “95% positive.”
“We remain in constant contact with the Department of Health to plan, monitor and respond to the number of cases,” Krueger said.
Solving the bottlenecks
In December, the city awarded Alto a $2 million contract to manage the distribution of Paxlovid. (Lanza, the health department spokesperson, said Alto began work before the contract was finalized because it was for emergency purchases; the contract is being reviewed by the city’s comptroller’s office.)
Paxlovid is one of two federally-approved antivirals now widely available for the treatment of COVID-19 during a disease course. Clinical trials for Paxlovid conducted by the drug’s manufacturer Pfizer showed that it reduced the risk of hospitalization or death for high-risk patients by nearly 90%.
The drug is intended to be taken as soon as possible after the onset of symptoms, for five days. According to data from Pfizer, delays in starting the course of the medication can slightly alter its effectiveness.
City dwellers can call a hotline (212-268-4319) and be put through to doctors who will direct them to a test and then provide a prescription for the drug. Alto will then deliver the medicine to the resident’s home free of charge. (Residents can also call a federal hotline, 1-888-720-7489, and be referred to a pharmacy where they can get a test and, if positive, free antiviral drugs.)
Since December, Alto has given 13,000 courses of the drug in the five boroughs, according to the city.
When Mayor Eric Adams tested positive for the virus earlier this month, he was taking oral antiviral treatments, according to City Hall. Adams, 61, has said he is in remission from diabetes, a major risk factor for severe COVID-19. An Adams spokesperson declined to say whether Adams took Paxlovid or whether the drugs were delivered through Alto.
Although the drug is available at about 230 city pharmacies, Alto’s stock of the drug is by far the largest, according to federal site data: It has about 4,500 courses on hand, compared with 80 doses for the next largest stock in Manhattan, in the United States. Boriken Community Health Center in East Harlem.
The council says that prescriptions confirmed before 5pm on a weekday or 1pm on a weekend will be delivered the same day.
Pelzman said his patients have reported positive experiences with Alto’s deliveries, and Horowitz, whose patient waited 32 hours for a prescription, said other patients he’s prescribed the drug this week have seen only hours-long wait times for delivery.
Denis Nash, a professor at CUNY’s School of Public Health, said there are likely advantages and disadvantages to having a single digital pharmacy running the city-funded Paxlovid distribution operation. On the one hand, he said, it could simplify operations for the city.
But with a private supplier, it’s not clear that the drug will be distributed in neighborhoods that may need it most, where vaccination levels are lower and comorbidities are more common, he said.
“The good news is I don’t think we’re in a huge wave right now, so there’s time to sort this out. But maybe not much,” Nash said. “We need to fix these bottlenecks now rather than later in the system.”
Pelzman wondered why the city didn’t use a hybrid model based on the knowledge that primary care providers such as clinic staff and pharmacists have for their communities.
“They knew who has a doorman and who doesn’t, and who can pick it up for the patient,” Pelzman said.
Lanza said the city signed a contract with Alto “to provide a rapid delivery of antiviral treatments late last year, when supply was extremely limited.” He said the city has released “several notices” to inform suppliers and residents that the drugs are available at local pharmacies.
‘Live and learn’
Although stocks of the drug have increased, awareness of the drug among patients and a broad understanding of prescription guidelines among physicians has not kept up, doctors and health experts said.
According to CDC guidelines, tens of millions of Americans are eligible for the drug, which it says can be prescribed to people over age 65 or people over age 12 with certain medical conditions.
Still, inventories at New York City’s brick-and-mortar pharmacies have largely remained flat or increased, according to a website with federal data on Paxlovid’s distribution, suggesting that most local clinics and pharmacies have dispensed relatively few courses of the drug, in comparison. with Alto’s 13,000 courses delivered.
A clinic in Brownsville, for example, has had 20 courses of Paxlovid available since late January, with no decline in supply, suggesting the drug has been distributed to a patient.
“This is new,” said Dr. Fred Pelzman, an associate attending physician at Weill Cornell Internal Medicine Associates in Manhattan’s Upper East Side. “It comes with challenges, it comes with unknowns, it comes with hesitation on the part of doctors and patients.”
On Tuesday, the White House announced a plan to double the number of locations where Paxlovid is available to counteract the slow absorption of the drug, for which the supply is “sufficient,” government officials said.
Horowitz says he’s seen enough. Hearing on Thursday about the federal website that allows patients and health care providers to find brick-and-mortar pharmacies with supplies of Paxlovid, he sent his latest prescription for the drug to a CVS in Park Slope, close to the patient who needed it.
A neighbor would go pick up the drugs for his patient, he said — within an hour of submitting the prescription.
“Live and learn,” Horowitz said. “If a patient is willing to have someone pick it up for them, why delay six hours, or overnight, or whatever?”