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High-End Medical Provider Let Ineligible People Skip COVID-19 Vaccine Line

Concierge health care provider One Medical allowed patients who were not eligible — and those with connections to the company's leadership — to skip the COVID-19 vaccine line ahead of high-risk patients.
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Concierge health care provider One Medical allowed patients who were not eligible — and those with connections to the company's leadership — to skip the COVID-19 vaccine line ahead of high-risk patients.

A national health care provider has administered COVID-19 vaccinations to people deemed ineligible for the scarce vaccine by local health departments, including people with connections to company leaders and customers of its concierge medical service, according to internal communications leaked to NPR.

San Francisco-based One Medical has been allocated thousands of vaccine doses by local health departments in some of the areas it provides medical services. Ineligible individuals with connections to company leadership were set up with vaccine appointments, and patients who were disqualified from receiving the vaccine were nonetheless permitted to skip the line ahead of other high-risk patients.

The problems have occurred in numerous company locations across several states. The Washington State Department of Health, citing a complaint it received this month, told NPR it had halted COVID-19 vaccine distribution to the company. Other regulators have also received complaints or stopped providing the vaccine.

One Medical has branded itself as a high-end health care provider serving a relatively affluent clientele, with each customer paying a $199 fee annually to receive easy online access to appointment scheduling, telemedicine and a streamlined, tech-focused medical experience. The company went public with an initial public offering in January 2020, with a valuation in the billions of dollars.

One Medical's shortcomings take place amid broader anecdotal evidence that suggests patients throughout the U.S. are skipping the line due in part to loose enforcement. The situation highlights a serious ethical issue: determining who is entitled to a vaccine at a time of scarce availability and who is responsible for enforcing eligibility rules.

Experts say an appropriate system for vaccine distribution focuses on first targeting those most at risk for serious consequences from COVID-19. "We're trying to focus on those individuals who are most likely to develop severe illness or death and to most likely be exposed to the virus," said Gabriel Lázaro-Muñoz, who teaches medical ethics and health policy at the Baylor College of Medicine. "The overall goal is to save as many lives as possible, and with that we are not valuing any life over another."

One Medical claims that it does not knowingly allow for ineligible patients to be vaccinated and that it was confident that it was "doing everything reasonably in our power to ensure ... our adherence to state and local department of health vaccine eligibility guidelines." But NPR obtained internal communications that tell a different story.

"We are not policing"

Messages among doctors, other medical practitioners, administrative staff and leadership show that multiple staffers across One Medical locations in several states — Washington, Oregon and California — privately raised the alarm about what they believed were lax oversight and inappropriate practices within the organization. They also show what appear to be favors done for those close to the organization's senior staff.

"It seems if you don't screen out those jumping the [queue], then many will jump in the line and push those that need the vaccine further behind, delaying a potentially life saving injection. This could impact MANY members," one doctor in California wrote to his colleagues in January, according to the internal documents.

"I have had two [patients] today, both in their 20-30s without risk factors and are tech workers who have gotten their covid vaccines. One was thru us," wrote another One Medical doctor in Washington state. "I'm curious how these [people] are able to sign up for vaccines when we have a long list of higher priority [patients]? ... I just want to understand how they can be prioritized for a vaccine when those at higher tiers have to wait."

These internal communications indicate that ineligible friends and family of One Medical leadership were vaccinated, as were work-from-home administrative, support and IT staff from its headquarters in San Francisco. While health care workers waited in line in January, One Medical made the decision to offer the vaccine to any of its San Francisco County staff members, regardless of whether they were patient facing.

Lázaro-Muñoz, the ethics professor, said that offering the vaccine to all staff members regardless of whether they see patients was unethical.

"There might not be regulations stopping this company from giving [the COVID-19 vaccine] to their employees. But from an ethical standpoint, when you look at what is right and wrong, this is wrong," Lázaro-Muñoz told NPR. "Your life and the life of your co-workers and those who work in this company is not any more valuable than the life of the elderly people that are not getting access to that vaccine, thanks to your criteria and system of distributing that vaccine."

One Medical said that it had asked some of its staff to volunteer time in its clinics. However, all of its staff members in San Francisco County were provided an opportunity to receive the vaccine, regardless of the nature of their job.

Further, patients of One Medical who were ineligible to be vaccinated based on local guidelines were permitted to book vaccination appointments through an online portal. So was at least one executive of a partner organization with One Medical. Internal communications show providers trying to get eligible health care workers vaccinated but instead being told to put them on a waitlist.

"Why are young patients without health problems, on a trial membership ... allowed to book and receive a covid vaccine while healthcare workers are being waitlisted?" one medical professional asked in January. "I just saw two appointments for such."

There were also shortcomings with the company's system. A question asking patients whether they were in an eligible category was not added to the online portal until Jan. 14, though One Medical started vaccinating patients on Jan. 1. During this two-week period, COVID-19 cases in the United States reached their highest peak.

Following this, the internal documents show that in January, even if a patient noted that they were not in an eligible category for vaccination, some could continue to book an appointment for a COVID-19 vaccine. Suggestions on how the tech-heavy company could use algorithms to scan for ineligible patients were turned down.

The company said that blocking ineligible patients from booking vaccination appointments would have called for a complete overhaul of its system and that it was too technologically difficult to rebuild the system in the required time frame.

The documents also show that in January, One Medical was not verifying the eligibility of patients it vaccinated by requiring an ID or other evidence at the point of vaccine administration.

"I have questions about our approach of not requiring [patients] to bring proof of vaccine eligibility," said a One Medical staffer. "A quick Google search indicates that this is not consistent with many states' requirements. ... I am concerned about advertising an overly permissive approach."

"It seems crucial to at least attempt to ensure that the vaccines are going into the 'right' people's arms."

As ineligible patients began to get vaccines, staff began raising concerns that word was spreading about One Medical's lax enforcement of eligibility requirements.

"I've had a few patients straight up tell me that once they realized there was no screening that they would be telling their friends," another medical provider in California wrote. "My partner and I were shocked when we got ours through One Med ... that at no point were we asked if we met criteria — let alone asked to prove it."

Employees were told not to try to enforce the rules barring ineligible patients. "Scanning schedules and cancelling appointments [for ineligible patients] is not recommended," Spencer Blackman, the director of clinical education at the company, said in a communication to a range of staff. He added in another note to a doctor, "If this person sees themself in a tier that is being vaccinated they can attest to that and make an appointment. You don't get to make the decision if someone 'gets' [a] vaccine or not."

"We are not policing," Blackman wrote in January, setting off objections in internal company communications.

When asked why One Medical did not verify eligibility, Chief Medical Officer Andrew Diamond said, "There was never guidance that said 'do not verify.' ... That would be counter to our principles." When told NPR was in possession of communications that indicated otherwise, he responded, "That's clearly not the guidance, nor is that the intent of the guidance. We've been far clearer since then."

"If we don't 'police' we contribute to inequity that rewards those who choose to lie/deceive. ... As a medical company with tech skills we CAN do more."

In fact, many localities require medical providers to check for eligibility documentation. In Los Angeles County, where One Medical has been provided thousands of doses, vaccination is limited currently to health care workers, long-term care facility residents and people over age 65. Proper documentation of eligibility is required for vaccination. "Providers are then responsible for confirming eligibility responses and requesting accepted documentation of eligibility, once [the patient] arrives for on-site appointment," an LA County Department of Public Health spokesperson said.

And in Alameda County, California, where the company was given close to 1,000 doses, the Public Health Department said that a personal ID and proof of a health care role is "required" for the vaccine doses that One Medical received.

As Forbes was preparing a story about One Medical's practices, One Medical's leadership sent out a note to staff warning of consequences, threatening them with "disciplinary action, up to and including termination" if they leaked internal communications. One Medical disputed this characterization. "One Medical is not and has never been an organization that threatens its staff," a spokesperson said, characterizing the note as merely "reminders about our business code of conduct."

Regulators take action

It is not clear how many ineligible vaccine doses were distributed, and One Medical declined to provide a figure on how many total doses it had administered. But the company has likely provided tens of thousands of doses: Of just two jurisdictions that produced information on the doses it allocated to One Medical, San Francisco County said it had provided the company with 12,000 doses, while LA County has provided it with nearly 6,000 doses.

One Medical's practices have not gone unnoticed by state and local regulators. The Washington State Department of Health told NPR that it had halted allocation of vaccine doses to One Medical due to a complaint received on Feb. 10. "We are currently in communication with One Medical regarding the complaint we received," a state spokesperson said. "We are removing them from the state's vaccine locations webpage, and One Medical will not be receiving vaccine from us until this issue is resolved." One Medical disputed the reason for the halt and said that it was a misunderstanding.

Bob Ferguson, the attorney general of Washington state, is also concerned about the wider issue of ineligible patients receiving COVID-19 vaccinations. While not commenting on whether there were any ongoing investigations into the topic or any individual company, a spokesperson for the attorney general said that Ferguson was "extremely concerned. And he has had conversations with his team about this issue."

Los Angeles County's Department of Public Health has also received a complaint about One Medical — and has reached out to express a warning by phone and email. "Public Health told One Medical if there are breaches and they are not holding tight to our priority groups and checking and validating groups, we could not allocate vaccine to them any longer," a spokesperson said. "We reinforced the fact that we could not provide vaccine to any entity not following our partner guidance for checking and ensuring people getting vaccinated are part of our priority groups." One Medical claimed that complaints and warnings are common for medical providers.

In Alameda County, which includes Oakland, the Public Health Department said that One Medical had received 975 doses of the COVID-19 vaccine but received no more after the health care company indicated its desire to vaccinate ineligible patients. "Alameda County did not fulfill One Medical's next request in early February for additional doses when they indicated that they planned to vaccinate more than their health care workers (who were the only approved group prioritized for vaccinations at the time)," said a county spokesperson. One Medical said that this explanation was "categorically untrue" but did not contest that its vaccine allocation has not continued beyond the original 975 doses.

In San Francisco, where One Medical's headquarters are based, the county's Department of Public Health stressed: "One Medical was engaged primarily to provide vaccine to in-home support services (IHSS), other in-home care providers and healthcare workers. ... SF DPH expects all its vaccine provider partners to follow State and SF DPH vaccination eligibility guidelines."

One Medical contested several elements of this story, claiming that it "does not allow for ineligible persons to be vaccinated knowingly." It also said that it had fired several members of its clinical staff due to disregard for eligibility requirements.

"We are doing absolutely everything in our power to vaccinate as many eligible people as possible," said Diamond, the chief medical officer of One Medical, attributing difficulties to the "fog of war" that occurs during a period of "myriad uncertainties, conflicting jurisdictional guidance and profound public anxieties."

Copyright 2021 NPR. To see more, visit https://www.npr.org.

Tim Mak is NPR's Washington Investigative Correspondent, focused on political enterprise journalism.