After sufficient doses are manufactured and logistical barriers are reduced, convincing an overwhelming majority of people to receive a COVID-19 vaccination may be the next major challenge during this pandemic. A group of experts recently proposed strategies that have compelling rationales and are well grounded in behavioral science. However, their approaches may sometimes be unacceptable, impractical, and/or unsuccessful. Therefore, other strategies will be greatly needed to address vaccine hesitancy. The present commentary offers 8 additional promising approaches forming a framework known as PANDEMIC. This acronym stands for the following strategies: presumptive language, asking for advice, norms on an anonymous level, description of favorable attributes, emphasizing clinicians’ own experiences, mandated choice, images, and communication of risk. Each of the strategies is discussed in turn. Many of the proposed strategies have empirical support for achieving desired outcomes in other domains. However, the PANDEMIC framework is untested in regard to increasing the uptake of COVID-19 vaccinations. Therefore, the strategies should be carefully evaluated before they are widely disseminated through public health announcements, email distribution lists, electronic health record messages, and other outlets.

This commentary offers 8 promising approaches forming a framework known as PANDEMIC to address COVID-19 vaccination hesitancy.

Approaches for encouraging COVID-19 vaccinations that have recently been proposed by some experts may sometimes be unacceptable, impractical, and/or unsuccessful. Therefore, other strategies will be greatly needed to address vaccine hesitancy.

The present commentary offers the following 8 strategies: presumptive language, asking for advice, norms on an anonymous level, description of favorable attributes, emphasizing clinicians’ own experiences, mandated choice, images, and communication of risk.

These strategies should be carefully evaluated, particularly among individuals who are unsure about receiving vaccinations.

After sufficient doses are manufactured and logistical barriers are reduced, convincing an overwhelming majority of people to receive a COVID-19 vaccination may be the next major challenge during this pandemic. According to a December 2020 national survey, just 56% of Americans were likely to get a COVID-19 vaccination once available to the general public.

 Black individuals and people with lower educational backgrounds had even lower intentions to become vaccinated.

Volpp, Loewenstein, and Buttenheim recently proposed 5 strategies for a national COVID-19 vaccine promotion program.

 Their strategies have compelling rationales and are well grounded in behavioral science. However, their approaches may sometimes be unacceptable, impractical, and/or unsuccessful (see the 

Therefore, other strategies will be greatly needed to address vaccine hesitancy. The present commentary offers 8 additional promising approaches forming a framework known as PANDEMIC. This acronym stands for the following strategies: presumptive language, asking for advice, norms on an anonymous level, description of favorable attributes, emphasizing clinicians’ own experiences, mandated choice, images, and communication of risk. Each strategy is discussed in turn.

This style of communication has been successfully used by primary care clinicians regarding past vaccinations. Training practitioners to use presumptive announcements (eg, “There are some shots we need to do today”), as opposed to more neutral messages (eg, “What do you want to do about shots today?”), increased human papillomavirus (HPV) vaccination rates for younger adolescents.

 Of course, parents encountering the former communication style could still decline the HPV vaccination for their children. Nevertheless, a similar statement implying that a COVID-19 vaccination is standard clinical practice may enhance the credibility of these shots.

Liu and Gal found that a business might increase future transactions after informing potential customers, “We are interested in what advice you might have for our organization.”

 In contrast, these researchers concluded that asking solely for opinions or expectations did not produce the same effect. Although the mechanism for this finding is not fully understood, the research team speculated that asking for advice engenders feelings of greater perceived closeness.

This strategy could be adapted for COVID-19 vaccinations by having organizations (eg, local agencies, places of worship) ask for advice regarding ways to encourage future vaccination uptake among its local reluctant members. This approach would be consistent with community coalition–driven interventions, which have some evidence for reducing disparities in other health domains.

 This approach would also be compatible with motivational interviewing, a nonconfrontational communication style in which patients are asked about their own ideas regarding how healthy changes can be facilitated. Some experts have suggested that motivational interviewing is particularly beneficial for minority populations.

Volpp et al proposed that individuals publicize their COVID-19 vaccinations.2 Highlighting the worthwhile activities (eg, better food choices, energy conservation) of peers has increased desired behavior by target individuals.

 The greater the similarity between the peers and the target person, the more likely that the social norms led to the desired outcomes in those studies. Social influences can demonstrate the acceptability and feasibility of the desired action to ambivalent individuals.

However, in those aforementioned empirical studies, social norms were presented in a deidentified fashion. There would be multiple ways to convey comparable information regarding COVID-19 vaccinations. Describing the sociodemographic heterogeneity of the phase 3 vaccination trial participants (eg, “Thousands of Caucasians and thousands of individuals from racial/ethnic minority groups volunteered for those studies”) may encourage diverse populations to receive vaccinations. Similarly, as members of the general public receive vaccinations under emergency use authorizations, summary statistics about local recipients could further the same objective.

Kreps and colleagues found that people reported being more willing to receive COVID-19 vaccinations if (1) efficacy rates were 90% (as opposed to 50%) and (2) the products were developed by US companies.

 Therefore, a statement like “These vaccinations, which were developed by Pfizer (from New York) and Moderna (from Massachusetts), reduced cases by 95%” may be persuasive to target individuals.

Emphasizing Clinicians’ Own Experiences

Patients often view their own health care providers as more trustworthy relative to other informational sources (eg, government officials).

 Clinicians could mention their own healthy choices, including personal receipt of COVID-19 vaccinations, to help convince reluctant patients.

Many opportunities reflect “opt-in,” which necessitates neither engagement in a target behavior nor explicit notification of one’s decisions. Similarly, mandated choice—which is more commonly known as active choice—preserves freedom by allowing people to decide if they wish to follow a recommended course of action. However, unlike opt-in, active choice requires people to indicate explicitly an affirmative decision or a negative decision. Active choice may help overcome procrastination and signal the importance of the present opportunity. Relative to opt-in, active choice has been shown to increase intentions for influenza vaccinations.

Under an opt-in approach to COVID-19 vaccinations, employers would inform employees about the availability of shots and invite them to a scheduling website. Under an active choice approach, employers would require employees to visit a website within a brief time frame to formally indicate their decision—yes vs no—regarding receiving a vaccination. Organizations could justify active choice for not only maximizing vaccinations but also obtaining prompt, accurate estimates of the demand for these shots.

Active choice could be even more impactful by highlighting the benefits of the target behavior and the drawbacks of the opposite behavior.

 Enhanced active choice for COVID-19 vaccinations would go beyond presenting people with an “agree” option and a “decline” option. Enhanced active choice could feature 2 more strongly worded options from which each person must select, such as “YES! I agree to receive the COVID-19 vaccination to reduce my chances of getting this disease” and “I do not agree to receive the vaccination. I realize that my decision may increase my chances of getting COVID-19.”

Verbal messages may lack the vividness to capture someone’s attention. Salient images have resulted in positive outcomes ranging from increasing intentions to quit cigarette smoking to discouraging littering.

 Distinctive visual images that are not typically encountered in everyday life may be more effective in facilitating desired behavior vs text-only approaches.

 Media coverage of long lines of cars containing people seeking COVID-19 vaccinations is one potential image that would convey these shots’ popularity. Subsequently, other strategies (eg, widespread dissemination at local pharmacies and scheduled appointments) could be implemented to convince people about the relative ease of obtaining the high-demand vaccinations.

Informing potential recipients of the adverse effect profiles of the vaccinations may engender feelings of trustworthiness. Mentioning small weaknesses may enhance the credibility of the message/messenger and increase uptake of the vaccination. Nevertheless, an undue emphasis on adverse effects may dissuade individuals from vaccination although benefits greatly outweigh harms. Presentation of risk information may influence acceptability of vaccinations. Previous research suggests that presenting the likelihood of adverse effects as percentages (eg, “1% of people experienced a high fever”) rather than frequencies (eg, “1 in 100 people experienced a high fever”) may promote more favorable views of the vaccinations.19 The latter presentation may lead people with less numeracy to more easily envision other patients with adverse effects. In addition, positive framing (eg, “99% of individuals did not experience a high fever” vs negative framing (eg, “1% of individuals had high fever”) might enhance willingness to receive vaccinations.

Although many of the proposed strategies have empirical support for achieving desired outcomes in other domains, the PANDEMIC framework is untested in regard to increasing the uptake of COVID-19 vaccinations. Therefore, the strategies should be carefully evaluated before they are widely disseminated through public health announcements, email distribution lists, electronic health record messages, and other outlets. The large number of people who are not highly interested in vaccinations, combined with calls to ease informed consent requirements for minimal risk research,

 would facilitate the empirical evaluation of these approaches.

The strategies proposed in this commentary may not be appropriate for all individuals. At one extreme, these strategies may be unnecessary for people who are extremely motivated to receive vaccinations. At the other extreme, these strategies would likely fail to convince those individuals who are adamantly opposed to these shots. Therefore, these strategies may have the greatest impact for those who are unsure about receiving vaccinations. The phrasing of these strategies should be pilot tested, refined, and tested with these ambivalent individuals. For those skeptics questioning if a single strategy would have a demonstrable impact on vaccination rates, multiple strategies could be combined into an overall communication plan.

In conclusion, persuasive messages that increase COVID-19 vaccination rates by even a few percentage points could help the country move closer toward herd immunity. Considerable resources have been devoted to develop, test, and manufacture biological interventions for this pandemic. Assuming that data continue to indicate that COVID-19 vaccinations are safe and efficacious, optimal behavioral strategies to encourage these shots deserve substantial attention, as well.

 Nationwide Children’s Hospital/The Ohio State University Department of Pediatrics, Columbus, OH.

 There was no external funding for this work. Internal support from Nationwide Children’s Hospital was utilized to support the author’s time in writing this commentary.

 The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design; drafting of the manuscript; critical revision of the manuscript for important intellectual content; and literature review.

 Jack Stevens, PhD, Nationwide Children’s Hospital/The Ohio State University Department of Pediatrics, 700 Children’s Dr, NEOB 3rd Floor, Columbus, OH 43205. Email: Jack.Stevens@nationwidechildrens.org.

1. Szilagyi PG, Thomas K, Shah MD, et al. National trends in the US public’s likelihood of getting a COVID-19 vaccine—April 1 to December 8, 2020. 

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4. Hamel L, Kirzinger A, Muñana C, Brodie M. KFF COVID-19 vaccine monitor: December 2020. Kaiser Family Foundation. December 15, 2020. Accessed January 6, 2021. https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/

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Articles

WEB EXCLUSIVE

The PANDEMIC Framework for Encouraging COVID-19 Vaccinations

 To determine whether enough primary care providers are in close proximity to where dual-eligible beneficiaries live to provide the capacity needed for integrated care models.

Secondary data analysis using dual-eligible enrollment data and health care workforce data.

 We determined the density of dual-eligible beneficiaries per 1000 population in 2017 for each of 3142 US counties. County-level supply of primary care physicians (PCPs), primary care nurse practitioners, and physician assistants was determined.

 One-third of the 791 counties with the highest density of dual-eligible beneficiaries had PCP shortages. Counties with the highest density of dual-eligible beneficiaries and the fewest primary care clinicians of any type were concentrated in Southeastern states. These areas also had some of the highest coronavirus disease 2019 outbreaks within their states.

 States in the Southeastern region of the United States with some of the most restrictive scope-of-practice laws have an inadequate supply of primary care providers to serve a high concentration of dual-eligible beneficiaries. The fragmented care of the dually eligible population leads to extremely high costs, prompting policy makers to consider integrated delivery models that emphasize primary care. However, primary care workforce shortages will be an enduring challenge without scope-of-practice reforms.

Primary care workforce shortages will likely hamper the effectiveness of integrated delivery models for dual-eligible beneficiaries and limit the ability to expand policy scale.

The workforce shortages will be an enduring challenge in states without scope-of-practice law reforms.

Dual-eligible beneficiaries’ inadequate access to primary care cannot be addressed without systematic state-level approaches. States with large dually eligible populations should assess the resources available for expanding access to primary care.

The effects of the coronavirus disease 2019 pandemic reinforce the need to grow the primary care workforce in the Southeast to address pent-up service demand that awaits the resumption of normal care patterns.

Twelve million people are enrolled in both Medicare and Medicaid. Known as “dual-eligible beneficiaries,” they account for 20% of Medicare beneficiaries and 15% of those receiving Medicaid, but account for one-third of total expenditures for each program.

 Most qualify for Medicare on the basis of age or a disability, and all dual-eligible beneficiaries have incomes below or near the federal poverty level. This population suffers disproportionately from chronic conditions and fragmented care.

To help overcome historically fragmented and uncoordinated care, CMS has developed integrated care delivery models, including the Program of All-Inclusive Care for the Elderly, the Medicare Advantage Dual-Eligible Special Needs Plans, and the recent Financial Alignment Initiative. Although these models largely rely on adequate access to primary care, there are well-documented shortages of primary care physicians (PCPs).

 We investigate whether dual-eligible enrollees are concentrated in different areas of the country and whether primary care clinicians, including PCPs, nurse practitioners (NPs), and physician assistants (PAs), are geographically colocated in these areas. Without an adequate primary care workforce available, implementing integrated care delivery models for dual-eligible beneficiaries may be in vain.

We conducted a cross-sectional analysis using data on the geographic locations of dual-eligible beneficiaries and primary care providers. Enrollment data from the Office of Medicare-Medicaid Coordination were used to calculate the population density of dual-eligible beneficiaries,

 defined as the number of dual-eligible beneficiaries receiving full or partial Medicaid benefits per 1000 population in each of the 3142 US counties. We categorized counties according to dually eligible beneficiary density quartiles.

To determine the county supply of PCPs, we used the Health Resources and Services Administration 2017 designation for whole-county Health Professional Shortage Areas (HPSAs). HPSA data came from the Area Health Resources Files (AHRF), which are commonly used to identify county-level socioeconomic, demographic, and health workforce characteristics. AHRF data were also used to identify PAs in each county. Because the HPSA designation only considers PCPs, to identify primary care NPs (PCNPs) we used methods previously developed, based on National Provider Identifier numbers from CMS.

 We calculated the county-level number of PCNPs and PAs per 1000 population and categorized them into the highest (ie, ≥ 75th percentile) and lowest (ie, < 25th percentile) supply density quartiles.

There were substantive regional variations in dual-eligible beneficiary density and in primary care workforce supply, as shown in the 

. Panel A shows that one-third (n = 271) of the 791 counties with the highest density of dual-eligible beneficiaries were designated as HPSAs and were more likely to be rural and located in the Southeast region of the country. Many of these counties were also encumbered by high poverty rates and a heavy burden of chronic conditions.

Panel B reveals that in nearly half (n = 128) of the 271 counties with both a high-density dual-eligible population and a PCP shortage, the density of PCNPs was the highest. That is, the distribution of PCNPs was within the highest quartile of the overall supply of PCNPs in the country. Conversely, in 52 of these counties, the number of PCNPs per 1000 population ranked in the lowest quartile. The majority of counties with high-density dual-eligible beneficiaries and PCP shortages also ranked in the bottom quartile of the PA supply (panel C).

Although we found that the highest supply of PCNPs was located in many counties with a high concentration of dual-eligible beneficiaries along with PCP shortages, we also found counties in the same regions with the lowest supply of PCNPs and the lowest supply of PAs. Panel D shows that 23 (8%) of high-density dual-eligible counties with HPSA designations ranked in the lowest quartile for both PCNPs and PAs. These counties had very high poverty rates, 14 were rural, and most were in Southeastern states, including Texas, Louisiana, Alabama, Georgia, and South Carolina. These counties are essentially “primary care deserts”—they had the highest density of dual-eligible beneficiaries and the fewest primary care clinicians of any type.

Finally, in the face of the competing challenge of the coronavirus disease 2019 (COVID-19) pandemic, we observed the prevalence of infection rates in counties with a high density of dual-eligible beneficiaries to understand the challenge of coordinating care for these beneficiaries. Using cumulative, total confirmed COVID-19 cases reported in each county,

 we found that 11 of these primary care desert counties also ranked in the top quartile of COVID-19 cases per capita within their states. Although there have been issues regarding test accuracy for confirming COVID-19 infections, results of serologic surveys have shown that confirmed cases represent a significant undercount of actual infection rates.

We also found that areas with shortages of primary care clinicians were those where there were high concentrations of poverty at the county level (data not shown). These findings align with those of other investigators who have reported that low-income populations in the Southern and South Central areas of the United States experience access barriers and worse health outcomes compared with similar low-income individuals in other regions.

Improving the care for dual-eligible beneficiaries through integrated care delivery models is a vital policy initiative. Although CMS urges states to adopt these new models, primary care workforce shortages in the United States will likely hamper the effectiveness of these initiatives and limit their ability to expand their scale. Federal, state, and local stakeholders need to develop systematic approaches that address barriers that restrict provider roles in caring for patients in need.

For decades, the federal government has relied on programs to try to increase the number of PCPs in underserved areas, such as loan payment programs, recruiting rural students to become physicians,

 or giving bonus payments to PCPs for services delivered in HPSAs. The Affordable Care Act also implemented primary care incentive programs for both PCPs and nonphysician primary care providers. However, dual-eligible beneficiaries and others in underserved areas continue to have inadequate access to care.

The disproportionate impact of the pandemic further reinforces the need for integrated care delivery and financing between Medicare and Medicaid, particularly in areas where the dual-eligible population is concentrated. Notably, in response to the COVID-19 pandemic, CMS has temporarily eased supervision restrictions on NPs and promoted telemedicine to reduce care access barriers faced by vulnerable populations.

The quality of care provided to vulnerable populations, such as dual-eligible beneficiaries, by PCNPs and PAs has been proved to be comparable with that delivered by PCPs.

 However, at the state level, scope-of-practice regulations often restrain the flexibility of having care furnished by nonphysician providers. All PAs are required to practice in collaboration with a physician,

 and as shown by our results, the density of PA supply highly overlaps with the density of PCP supply. This limits their capability to fill gaps in areas with a shortage of PCPs.

Our study reveals that some regions of the United States need to improve the distribution of the primary care workforce to serve dual-eligible beneficiaries and to provide adequate care. We found that most of these areas were in Southeastern states, which impose the most restrictive scope-of-practice regulations that limit the capacity of NPs. Such restrictions may also increase NPs’ reluctance to locate in these states. Thus, a first step to expand access to care is to lessen the state-imposed restrictions on scope of practice for NPs.

Amid the COVID-19 pandemic, Florida, Tennessee, Kentucky, Louisiana, New Jersey, New York, Wisconsin, and West Virginia all lifted the restrictions on NPs’ scope of practice. However, because most of these regulatory changes are temporary, in response to the pandemic, a more permanent broadening of licensure scope is required. NPs are unlikely to relocate to these regions unless the easing of restrictions is more enduring.

At the local level, we observed that some counties were able to recruit NPs to practice locations where PCP shortages existed with a high concentration of dual-eligible beneficiaries. Although other counties were not able to successfully recruit NPs, they were frequently in the same states as counties that did, even in states with restrictive scope-of-practice laws. This finding suggests that there may be local leaders in some health systems who have surmounted constraining barriers, such as scope-of-practice restrictions, to successfully recruit PCNPs to fulfill a primary care need. It would therefore be helpful to reach out to these health care system leaders to understand how they addressed this issue.

Local stakeholders in states with large dually eligible populations should take advantage of the resources available for expanding access to primary care. Successful approaches at local levels in other parts of the state may be available. In 2017, the National Academy of Medicine published “Vital Directions for Health and Health Care,” which is a framework for better health and well-being, high-value health care, and strong science and technology to help guide policy makers to improve health care in the United States.

 Using this framework, North Carolina health care leaders recently convened a symposium to examine actions needed to achieve more affordable quality care and to assess the state’s capacity to improve care.

 Other states or local leaders can use this framework to guide reforms to augment the primary care workforce and deal with workforce challenges with vulnerable populations, such as dual-eligible beneficiaries.

The current pause in nonurgent health services due to the pandemic is having more devastating economic effects on rural clinics and hospitals,particularly in the Southeast. These are places that have already experienced a serious loss of physicians and hospitals, even before the COVID-19 crisis.

 Further, many primary care practices are having financial difficulties because the pandemic has created a barrier to non–COVID-19 office visits. Many have furloughed health care workers because the loss in practice volumes has created unanticipated financial strain. Disrupted and delayed routine care for dual-eligible beneficiaries, most of whom have chronic conditions, will likely result in relapses of conditions and/or exacerbations after relapse. The pandemic reinforces the need to grow the primary care workforce in the Southeastern region to address the pent-up service demand that awaits the resumption of normal care patterns. Because of the inelastic supply of PCPs, an expanded scope of practice may be an essential strategy to attract advanced nonphysician primary care providers, such as PCNPs, who can help coordinate the care for dual-eligible beneficiaries with costly chronic conditions.

This will likely disrupt the current ways of organizing, sustaining, and growing the workforce. Without policy changes to strengthen the primary care workforce, vulnerable populations like dual-eligible beneficiaries will continue to endure fragmented care in areas with preponderant primary care shortages.

Primary care workforce shortages will likely hamper the effectiveness of integrated delivery models for dual-eligible beneficiaries and limit the ability to expand policy scale. These shortages will be an enduring challenge in states without scope-of-practice law reforms. Dual-eligible beneficiaries’ inadequate access to primary care cannot be addressed without systematic state-level approaches. 


 Division of Health Services Management and Policy, College of Public Health (WYX, SMR), and Division of General Internal Medicine, College of Medicine (WYX, SMR), The Ohio State University, Columbus, OH; Center for Interdisciplinary Health Workforce Studies, College of Nursing, Montana State University (PB), Bozeman, MT.

 Dr Retchin discloses that he receives fees and equity for his service as a member of the Board of Directors for Aveanna Healthcare, a large pediatric and adult home health care company. He also notes his service as a Commissioner on the Medicaid and CHIP Payment and Access Commission, for which he receives per diem payments and expenses for attendance at commission meetings. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (WYX, SMR, PB); acquisition of data (WYX); analysis and interpretation of data (WYX, SMR, PB); drafting of the manuscript (WYX, SMR, PB); critical revision of the manuscript for important intellectual content (WYX, SMR, PB); and statistical analysis (WYX, SMR).

 Wendy Y. Xu, PhD, The Ohio State University, 208 Cunz Hall, 1841 Neil Ave, Columbus, OH 43210. Email: xu.1636@osu.edu.

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TRENDS FROM THE FIELD

States with the most restrictive scope-of-practice laws have an inadequate supply of primary care clinicians to serve a high concentration of dual-eligible beneficiaries.

May 2021

The PANDEMIC Framework for Encouraging COVID-19 Vaccinations

Dual-Eligible Beneficiaries and Inadequate Access to Primary Care Providers