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How easy it will be for the rich to cut in line for the vaccine will depend on how exactly the line is constructed. | Joel Saget/AFP via Getty Images

We asked experts what could go wrong.

Could the rich and famous of Silicon Valley be vaccinated before it is their turn?

That thought bothers everyone from California’s governor to the doctors across the state who make a mint treating these millionaires and billionaires. And it might not be such a hypothetical, say a dozen medical veterans and other close observers of the process, who worry about everything from highly paid physicians contorting their moral compasses to the rich cashing in on their political and personal connections.

The wrath of the coronavirus has not been felt equally across America. Black and low-income Americans have been ravaged by its health and economic destruction, while the wealthy and well-connected have decamped to vacation homes, enjoyed superior access to testing and experimental treatments, and watched their net worths skyrocket. So if the vaccination process — the path out of the pandemic — is equally riddled with inequities, it would only fit a pattern and confirm something we’ve long known to be true: The ultra-rich have much, much better health care.

Just how easy it will be for the wealthy to cut in line depends on how exactly the line is queued, and those details remain vague even to the Silicon Valley physicians who are being hounded with phone calls. That vagueness means the precise playbook for how anyone might circumvent the rules remains to be written.

Few close observers expect widespread abuse in Silicon Valley or elsewhere, but there is a shared concern among experts interviewed by Recode that there will be at least isolated attempts to get the vaccine in advance due to the possible life-or-death payoffs of obtaining it.

The misconduct that could unfold is crystallizing as California, which has more billionaires than any other state, spells out how exactly it will play defense against these hijinks. In recent weeks, California Gov. Gavin Newsom has been ratcheting up his rhetoric and promising that the state will not be lenient if it finds out that doctors or patients have flouted protocols. The state has also begun to back up that promise, with more details on enforcement and penalties expected this week.

California’s medical board, for instance, last week warned doctors across the state that their medical license could be revoked if they ignored the state’s prioritization guidelines. Newsom has also promised to aggressively shame any doctors or patients who cut in line.

“I’m not naive to the prospect there are going to be some issues,” Newsom told reporters last week. “We’re going to have to work with our county partners to monitor that behavior at the local level … and make sure someone’s not passing a few vials over to their cousin or aunt or uncle or, God forbid, making a buck or two on the backs of vaccine that should be distributed to someone who’s at higher risk or higher need.”

There are three main avenues for abuse, according to medical insiders from across the Bay Area who spoke to Recode.

One is through the wealthy’s use of concierge doctors, high-end physicians who claim to offer better access to medical care in exchange for hefty fees. It’s possible they will face substantial pressure from demanding “clients.” Another set of concerns revolves around the personal networks of Silicon Valley’s high-powered executives, who may have ties to biotech companies, hospital boards, governments, or other places to favor trade. And a final worry is that the wealthy follow the rules as written — but work to interpret the rules in a more favorable fashion, such as recasting the definition of who in California counts as an “essential worker.”

Here is how things could go wrong.

What billionaires can’t get from their doctors

Concierge doctors in the Bay Area — who can cost as much as $40,000 a year, with some even accepting that payment in cryptocurrency — have had to talk about something very out of character over the last few weeks: All of what they can’t do for that money.

On preemptive weekly newsletter blasts to their patients, on their daily deluge of calls with vaccine-hungry clients, and on conference calls with fellow concierge physicians, these doctors steel themselves for uncomfortable conversations. Yes, they will help their patients get their shots the first minute that it is allowed. But even luxury services have their limits.

“There is no magic,” said Sabina Shnapek, who manages the business operations of Peninsula Doctor, a concierge office. “We cannot do something that is extraordinary. I wish I could, but we don’t have this kind of power.”

And yet Peninsula Doctor promises its clients that it is working to “make sure that we get the fastest delivery that we can” of the vaccine. In Southern California, one practice brags that it will “be among the first clinics to administer the vaccine.”

Concierge doctors market themselves and pride themselves on delivering results like this. In return for the subscription-like fee, these doctors limit their practices to just a few dozen families, offering them introductions to best-in-class specialists, home visits, and their cellphone numbers to call or text 24/7. And concierge medicine has exploded in popularity over the last decade or two as income inequality grew and bespoke services for the ultra-wealthy grew in turn.

In the Bay Area, concierge doctors largely service families with ties to the tech industry, and health equity advocates are worried that their eagerness to deliver results for these families, no matter how difficult, in return for the paycheck could encourage misconduct.

Concierge doctors across Silicon Valley tell Recode that they have confidence that almost all of their patients plan to abide by state and federal guidance and would not seek to be vaccinated ahead of their turn. And they bristle at any suggestion that they would enable those clients if asked: They are concierge doctors, but doctors nonetheless, and bound by medical ethics.

But the incentive — and, sometimes, the expectation from clients — is there, and even a few isolated incidents could compromise public trust in the fairness of the vaccination process. Some private conversations at least illustrate the demand for early access.

One family that emigrated to the Bay Area from China told Margaret Miller, a Silicon Valley concierge physician, that they had grown so frustrated with the speed of America’s vaccine-approval process that they were planning to travel back to China, which has already greenlit a vaccine, to get inoculated. (The family didn’t ultimately do so.)

One patient of Yumi Ando, another Silicon Valley concierge doc, gingerly asked her: “What kind of illness can you use for me to enable me to get on the higher priority list?” Ando recalled that she flatly declined the request, which she described as vague.

A few concierge practices say that they have applied to California for their own stash of doses. To boost their chances of being approved, some of those have already purchased or are pursuing ultra-cold freezers to help store the vials. But even most of those practices don’t expect to receive vials of vaccine until several months from now.

And so part of the conundrum for these patients is that it’s not clear what exactly their expensive doctors can do to help them cut in line in California. Could their doctor exaggerate a patient’s co-morbidity to high-risk status, upgrading an asthma or diabetes condition from minor to something more serious? To many concierge doctors, that pretty plainly qualifies as fraud.

It is not like last year, when several Bay Area concierge doctors recalled patients pressuring them for prescriptions for the drug hydroxychloroquine as a potential coronavirus treatment. They could, theoretically, write the scrip then, but now, concierge doctors say they are in a more ethically unambiguous position.

“I certainly can see scenarios where people might feel pressure with, ‘Hey,’ — and you know, this is a line we get a lot — ‘I paid all this money. And what are you going to do for me?’” said Ando. “And so the desire to serve is there. But you don’t want to cross the line of going into falsification. I mean, there’s some areas where you can bend the truth a little bit and you definitely try to be a patient advocate. But when I think you’re talking about a finite resource, it’s different.”

This pressure is likely to be at its most extreme at the most expensive concierge offices — or within a practice’s even-more-exclusive “VIP” tier.

“The higher you charge, the more is expected,” said Mark Savant, a concierge doctor in San Francisco. “I think people who do pay more will have certain expectations that their doctor would be able to procure some of these vaccines when, in fact, they can’t.”

Cashing in on connections

Some Bay Area medical insiders say it’s not what happens at these specialty practices that should scare us, but what happens at traditional medical facilities. That’s because they have little faith in California’s ability to monitor each and every dose.

The worry from these people is that there will be “leaks” of drugs — that is, instances when vaccine vials somehow go missing or unaccounted for and end up being part of the favor trade. There is some anxiety that this could be particularly possible in Silicon Valley.

Taryn Vian at the University of San Francisco, who studies corruption in the health care system, said she was perturbed about the amount of discretion that hospitals or doctor’s offices will have after the vaccine arrives at their facilities. So she wants stronger safeguards that govern how each facility makes its decisions.

“The CEO of a major hospital is going to know some of these wealthy people, or know someone who is going to use their influence to ask for a favor,” said Vian. “You’re going to want to help them. So we really need to rely on systems in place that don’t allow for one person to make that kind of decision.”

Experts fear that Silicon Valley players on the boards of Bay Area hospitals — or the hospitals’ big philanthropic donors who already receive special treatment — could seek favors or be solicited by their contacts. There is also the concern that Silicon Valley executives and investors may have connections to biotech companies that they may try to call upon. (The vaccine maker Moderna, for instance, is backed by some venture capitalists.)

While kicking a few vials to a business school buddy would likely lead to significant legal exposure, it is not unheard-of in Silicon Valley health care for patients to utilize their connections to try and achieve better care. For instance, Miller, one of the concierge doctors, recalled a patient once successfully utilizing a contact at a biotech company to deliver an experimental test to their child that at the time was only being used in intensive care units.

Rather than trading favors, Silicon Valley’s rich could trade money, too. Mehrdad Ayati, who operates a concierge practice in the Bay Area, said he was alarmed about the possibility that essential workers could strike deals to “sell” their spots to the rich if identity checks aren’t as rigorous in distribution lines as they should be.

“From the point of view of the very wealthy, the unwritten rule of being wealthy in this country is that the written rules don’t apply to you,” said one Bay Area concierge doctor, granted anonymity to candidly assess his clients.

Changing the definition of an “essential” worker

But what if the ultra-rich could become essential workers themselves?

A final set of concerns is more structural: The Bay Area elite might manage to classify themselves as essential employees, thereby granting them authorized early access to vaccines. There’s nothing novel about that approach: Corporate America at large is engaged in a fierce lobbying battle over which industries are classified as “essential” and should be prioritized for vaccination.

California has outlined a dozen categories of workers who are considered essential. But the lack of clear definitions over who falls into those groups could theoretically allow individual counties — that have to implement the guidance from the state’s health department — to prioritize the privileged.

One of those categories is employees in the state’s “financial services” industry who are “needed to maintain orderly market operations.”

While that language probably refers to workers such as bank tellers, it is unclear to observers how exactly California will enforce that definition. Is it possible that investment bankers or venture capitalists or CEOs who consider themselves to be needed to maintain orderly market operations could consider themselves essential workers — and qualify for early access?

“They’re not looking at it as an ethical decision. They’re rationalizing because they’re a leader of a company that has millions or thousands of employees. They say, ‘I’m essential to this company. And therefore I’m holding up the economy — and the economy is really in danger right now. So I’m doing a good thing by making sure that I don’t get sick because I’m leading these people,’” said Vian. “They’re not seeing that ‘there’s a person right now who isn’t getting the vaccine because I got it.’”

And California’s guidance is technically only a recommendation. Different counties could exercise some leeway. There’s little stopping one county from declaring various parts of Silicon Valley’s startup economy to be “essential.”

Will we even know if vaccine line-jumping happens?

For now, all of these concerns remain hypothetical. They are what could happen. The problem for Newsom, for Silicon Valley, and for society at large is that we might not even know if abuse does occur.

There’s little doubt that the backlash to any incident would be fierce. One need look no further than the public anger toward institutions that have fumbled the vaccine rollout, including at hospitals in Silicon Valley like Stanford’s.

One Silicon Valley medical leader, granted anonymity to describe confidential conversations, said some wealthy people had asked him about whether it would be possible to gain private access to the vaccine — outside of government distribution — but declined to make a run for it because they were skittish about the public relations blowback if they were to get caught.

That fear of a bad headline could be a powerful force in keeping the system honest. That’s not true only in California — with its preponderance of billionaires — but in any place or industry where the wealthy and well-connected might seek an advantage.

“There is something really special about having rules, you know?” said Shnapek, the business manager at Peninsula Doctor. “I think there’s something beautiful about that.”

Author: Theodore Schleifer

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