The pandemic has renewed the push to get rid of fee-for-service — in large part because it has underscored that doctors don't get paid at all when they can't see patients.

This article was published on Wednesday, August 12, 2020 in Kaiser Health News.

By Steven Findlay

For Dr. Gabe Charbonneau, a primary care doctor in Stevensville, Montana, the coronavirus pandemic is an existential threat.

Charbonneau, 43, his two partners and 10 staff members are struggling to keep their rural practice alive. Patient volume is slowly returning to pre-COVID levels. But the large Seattle-area company that owns his practice is reassessing its operations as it adjusts to the new reality in healthcare.

Charbonneau has been given until September to demonstrate that his practice, Lifespan Family Medicine, is financially viable — or face possible sale or closure.

"We think we're going to be OK," said Charbonneau. "But it's stressful and pushes us to cut costs and bring in more revenue. If the virus surges in the fall … well, that will significantly add to the challenge."

Like other businesses around the country, many doctors were forced to close their offices — or at least see only emergency cases — when the pandemic struck. That led to sharp revenue losses, layoffs and pay cuts.

Dr. Kevin Anderson's primary care practice in Cadillac, Michigan, is also scrambling. The practice — like others — shifted in March to seeing many patients via telemedicine but still saw a dramatic drop in patients and revenue. Anderson, 49, and his five partners are back to about 80% of the volume of patients they had before the pandemic. But to enhance their chances of survival, they plan to overhaul the way the practice gets paid by Medicare.

Jodi Faustlin, CEO of the for-profit Center for Primary Care in Evans, Georgia, manages 37 doctors at eight family medicine practices in the state. She's confident all eight will emerge from the pandemic intact. But that is more likely, she said, if the company shifts from getting paid piecemeal for every service to a per-patient, per-month reimbursement.

One of those 37 doctors is Jacqueline Fincher, the president of the American College of Physicians. Fincher said the pandemic "has laid bare the flaws in primary care" and the "misguided allocation of money and resources" in the U.S. healthcare system.

"It's nuts how we get paid," said Fincher, whose practice is in Thomson, Georgia. "It doesn't serve patients well, and it doesn't work for doctors either — ever, let alone in a pandemic."

Physicians and health policy experts say the pandemic is accelerating efforts to restructure primary care — which accounts for about half the nation's doctor visits every year — and put it on a firmer financial footing.

The efforts also aim to address long-festering problems: a predicted widespread shortage of primary care doctors in the next decade, a rising level of physician burnout and a long-recognized underinvestment in primary care overall.

No data yet exist on how many of the nation's primary care doctors have closed up shop permanently, hastened retirement or planned other moves following the COVID-19 outbreak. An analysis by the American Academy of Family Physicians in late April forecast furloughs, layoffs and reduced hours that translated to 58,000 fewer primary care doctors, and as many as 725,000 fewer nurses and other staff in their offices, by July if the pandemic's impact continued. In 2018, the U.S. had about 223,000 primary care doctors.

"The majority [of primary care doctors] are hanging in there, so we haven't yet seen the scope of closures we forecast," said Jack Westfall, a researcher at the academy. "But the situation is still precarious, with many doctors struggling to make ends meet. We're also hearing more anecdotal stories about older doctors retiring and others looking to sell their practices."

Three-quarters of the more than 500 doctors contacted in an online survey by McKinsey & Co. said they expected their practices would not make a profit in 2020.

A study in the journal Health Affairs, published in June, put a hard number on that. It estimated that primary care practices would lose an average of $68,000, or 13%, in gross revenues per full-time physician in 2020. That works out to a loss of about $15 billion nationwide.

One main problem, said Westfall, is that payment for telehealth and virtual visits is still inadequate, and telehealth is not available to everyone.

Re-Engineering Primary Care Payments

The remedy being most widely promoted is to change the way doctors are reimbursed — away from the predominant system today, under which doctors are paid a fee for every service they provide (commonly called "fee-for-service").

Health economists and patient advocates have long advocated such a transition — primarily to eliminate or at least greatly reduce the incentive to provide excessive and unneeded care and promote better management of people with chronic conditions. Stabilizing doctors' incomes was previously a secondary goal.

Achieving this transition has been slow for many reasons, not the least of which is that some early experiments ended up paying doctors too little to sustain their businesses or improve patient care.

Instead, over the past decade doctors have sought safety in larger groups or ownership of their practices by large hospitals and health systems or other entities, including private equity firms.

A 2018 survey of 8,700 doctors by the Physicians Foundation, a nonprofit advocacy and research group, found, for example, that only 31% of doctors owned or co-owned their practice, down from 48.5% in 2012.

Fincher, the American College of Physicians president, predicts the pandemic will propel more primary care doctors to consolidate and be managed collectively. "More and more know they can't make it on their own," she said.

It's nuts how we get paid. It doesn't serve patients well, and it doesn't work for doctors either — ever, let alone in a pandemic.

Jacqueline Fincher, the president of the American College of Physicians, whose practice is in Thomson, Georgia

A 2018 survey by the American Medical Association found that, on average, 70% of doctor's office revenue that year came from fee-for-service, with the rest from per-member, per-month payments and other methods.

The pandemic has renewed the push to get rid of fee-for-service — in large part because it has underscored that doctors don't get paid at all when they can't see patients and bill piecemeal for care.

"Primary care doctors now know how vulnerable they are, in ways they didn't before," said Rebecca Etz, a researcher at the Larry A. Green Center, a Richmond, Virginia, advocacy group for primary care doctors.

Charbonneau, in Montana, said he's "absolutely ready" to leave fee-for-service behind.

However, he's not sure the company that owns his practice, Providence Health System — which operates 1,100 clinics and doctors' practices in the West — is committed to moving in that direction.

Anderson, in Michigan, is embracing a new payment model being launched next year under Medicare called Primary Care First. He'll get a fixed monthly payment for each of his Medicare patients and be rewarded with extra revenue if he meets health goals for them and penalized if he doesn't.

Medicare to Launch New Payment System

The Trump administration — following in the footsteps of the Obama administration — has been pushing for physician payment reform.

Medicare's Primary Care First program is a main vehicle in that effort. It will launch in 26 areas in January. Doctors will get a fixed per-patient monthly fee along with flat fees for each patient visit. A performance-based adjustment will allow for bonuses up to 50% when doctors hit certain quality markers, such as blood pressure and blood sugar control and colorectal cancer screening, in a majority of patients.

But doctors also face penalties up to 10% if they don't meet those and other standards.

Some private insurers are also leveraging the pandemic to enhance payment reform. Blue Cross and Blue Shield of North Carolina, for example, is offering financial incentives starting in September to primary care practices that commit to a shift away from fee-for-service. Independent Health, an insurer in New York state, is giving primary care practices per-patient fixed payments during the pandemic to bolster cash flow.

Meanwhile, two of the nation's largest primary care practice companies continue to pull back from fee-for-service: Central Ohio Primary Care, with 75 practices serving 450,000 patients, and Oak Street Health, which owns 50 primary care practices in eight states.

"Primary care docs would have been better off during the pandemic if they had been getting fixed payments per month," said Dr. T. Larry Blosser, the medical director for outpatient services for the Central Ohio firm.

A review by KHN and The Associated Press finds at least 49 state and local public health leaders have resigned, retired or been fired since April across 23 states.

This article was published on Tuesday, August 11, 2020 in Kaiser Health News.

By Michelle R. Smith, The Associated Press and Lauren Weber   

Vilified, threatened with violence or in some cases suffering from burnout, dozens of state and local public health officials around the U.S. have resigned or have been fired amid the coronavirus outbreak, a testament to how politically combustible masks, lockdowns and infection data have become.

One of the latest departures came Sunday, when California's public health director, Dr. Sonia Angell, was ousted following a technical glitch that caused a delay in reporting virus test results — information used to make decisions about reopening businesses and schools.

Last week, New York City's health commissioner was replaced after months of friction with the police department and City Hall.

A series examining how the U.S. public health front lines have been left understaffed and ill-prepared to save us from the coronavirus pandemic. The project is a collaboration between KHN and the AP.

A review by KHN and The Associated Press finds at least 49 state and local public health leaders have resigned, retired or been fired since April across 23 states. The list has grown by more than 20 people since the AP and KHN started keeping track in June.

Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention, called the numbers stunning. He said they reflect burnout, as well as attacks on public health experts and institutions from the highest levels of government, including from President Donald Trump, who has sidelined the CDC during the pandemic.

"The overall tone toward public health in the U.S. is so hostile that it has kind of emboldened people to make these attacks," Frieden said.

The past few months have been "frustrating and tiring and disheartening" for public health officials, said former West Virginia public health commissioner Dr. Cathy Slemp, who was forced to resign by Republican Gov. Jim Justice in June.

"You care about community, and you're committed to the work you do and societal role that you're given. You feel a duty to serve, and yet it's really hard in the current environment," Slemp said in an interview Monday.

The departures come at a time when public health expertise is needed more than ever, said Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials.

"We're moving at breakneck speed here to stop a pandemic, and you can't afford to hit the pause button and say, 'We're going to change the leadership around here and we'll get back to you after we hire somebody,'" Freeman said.

As of Monday, confirmed infections in the United States stood at over 5 million, with deaths topping 163,000, the highest in the world, according to the count kept by Johns Hopkins University researchers. The confirmed number of coronavirus cases worldwide topped 20 million.

Many of the firings and resignations have to do with conflicts over mask orders or shutdowns to enforce social distancing, Freeman said. Despite the scientific evidence that such measures help prevent transmission of the coronavirus, many politicians and others have argued they are not needed, no matter what health experts tell them.

"It's not a health divide; it's a political divide," Freeman said.

Some health officials said they were stepping down for family reasons, and some left for jobs at other agencies, such as the CDC. Some, like Angell, were ousted because of what higher-ups said was poor leadership or a failure to do their job.

Others have complained that they were overworked, underpaid, unappreciated or thrust into a pressure-cooker environment.

"To me, a lot of the divisiveness and the stress and the resignations that are happening right and left are the consequence of the lack of a real national response plan," said Dr. Matt Willis, health officer for Marin County in Northern California. "And we're all left scrambling at the local and state level to extract resources and improvise solutions."

Public health leaders from Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, down to officials in small communities have reported death threats and intimidation. Some have seen their home addresses published or been the subject of sexist attacks on social media. Fauci has said his wife and daughters have received threats.

In Ohio, the state's health director, Dr. Amy Acton, resigned in June after months of pressure during which Republican lawmakers tried to strip her of her authority and armed protesters showed up at her house.

It was on Acton's advice that GOP Gov. Mike DeWine became the first governor to shut down schools statewide. Acton also called off the state's presidential primary in March just hours before polls were to open, angering those who saw it as an overreaction.

The executive director of Las Animas-Huerfano Counties District Health Department in Colorado, Kim Gonzales, found her car vandalized twice, and a group called Colorado Counties for Freedom ran a radio ad demanding that her authority be reduced. Gonzales has remained on the job.

In West Virginia, the governor forced Slemp's resignation over what he said were discrepancies in the data. Slemp said the department's work had been hurt by outdated technology like fax machines and slow computer networks. Tom Inglesby, director of the UPMC Center for Health Security at Johns Hopkins, said the issue amounted to a clerical error easily fixed.

Inglesby said it was deeply concerning that public health officials who told "uncomfortable truths" to political leaders had been removed.

"That's terrible for the national response because what we need for getting through this, first of all, is the truth. We need data, and we need people to interpret the data and help political leaders make good judgments," Inglesby said.

KHN and The Associated Press sought to understand how decades of cuts to public health departments by federal, state and local governments has affected the system meant to protect the nation's health.

Here are six key takeaways from the KHN-AP investigation.

Since 2010, spending on state public health departments has dropped 16% per capita, and the amount devoted to local health departments has fallen 18%, according to a KHN and AP analysis. At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeleton workforce for what was once viewed as one of the world's top public health systems.

Another sudden departure came Monday along the Texas border. Dr. Jose Vazquez, the Starr County health authority, resigned after a proposal to increase his pay from $500 to $10,000 a month was rejected by county commissioners.

Starr County Judge Eloy Vera, a county commissioner who supported the raise, said Vazquez had been working 60 hours per week in the county, one of the poorest in the U.S. and recently one of those hit hardest by the virus.

"He felt it was an insult," Vera said.

In Oklahoma, both the state health commissioner and state epidemiologist have been replaced since the outbreak began in March.

In rural Colorado, Emily Brown was fired in late May as director of the Rio Grande County Public Health Department after clashing with county commissioners over reopening recommendations. The person who replaced her resigned July 9.

The months of nonstop and often unappreciated work are prompting many public health workers to leave, said Theresa Anselmo of the Colorado Association of Local Public Health Officials.

"It will certainly slow down the pandemic response and become less coordinated," she said. "Who's going to want to take on this career if you're confronted with the kinds of political issues that are coming up?"

Weber reported from St. Louis. Associated Press writers Paul Weber, Sean Murphy and Janie Har and California Healthline senior correspondent Anna Maria Barry-Jester contributed reporting.

This story is a collaboration between KHN and The Associated Press.

Michelle R. Smith, The Associated Press: mrsmith@ap.org, @MRSmithAP

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

The full amount going to Fresenius and many other dialysis providers is far higher than what KHN could confirm.

This article was published on Monday, August 10, 2020 in Kaiser Health News.

By Jordan Rau and Rachana

As the coronavirus pandemic paralyzed most nonemergency medical practices this spring, the dialysis business, vital to the survival of patients with kidney disease, rolled ahead and in some cases grew.

Yet when the Trump administration sent billions in federal relief funds to medical organizations, at least $259 million went to dialysis providers, a KHN analysis of federal records found. Of that, kidney care behemoth Fresenius Medical Care accepted more than half, at least $137 million, despite acknowledging it had ample financial resources, the analysis showed.

The full amount going to Fresenius and many other dialysis providers is far higher than what KHN could confirm. The analysis was limited to the portion of grants disclosed by the federal government. And the analysis counted only grants going to organizations whose primary purpose was providing dialysis. In a securities filing last month, Fresenius disclosed it received a total of $277 million in relief funds under the Coronavirus Aid, Relief and Economic Security (CARES) Act.

Funding to giant dialysis providers would have been greater if DaVita, the other multinational corporation that dominates dialysis care in the U.S., had not turned down $240 million in aid, saying other medical providers needed it more. Fresenius and DaVita each own more than 2,600 dialysis centers nationwide.

Headquartered in Germany, Fresenius Medical Care is focused on patients with kidney failure who need blood-purifying dialysis treatment three times a week to stay alive, billing itself as the world's largest provider of dialysis and related services, equipment and drugs. Fresenius treated about 350,000 people worldwide and earned last year about $1.4 billion. The company announced second-quarter profits exceeding $400 million, up more than a third over last year, due to a 14% operating margin.

"From what we know today, the net impact of COVID-19 on our earnings is not so significant," Helen Giza, Fresenius' chief financial officer, told analysts.

With scores of COVID-19 patients developing major kidney damage, the pandemic caused unexpected demand for dialysis treatment. Chronic kidney disease and kidney failure were common among people hospitalized with COVID-19, accounting for 13% of all such patients nationally from January to March, when the extent of the virus's spread in the U.S. was just coming to light, according to FAIR Health, a health data nonprofit that analyzes insurance bills.

Little Drop-Off in Business

The bailouts to Fresenius and other dialysis operations provide one of the bluntest examples yet of how the Department of Health and Human Services failed to direct taxpayer-supported bailout funds only to providers in crisis. Massive assistance payments from the $175 billion Provider Relief Fund allotted by Congress went to well-financed corporations and segments of the healthcare industry like dialysis that were financially stable, or to businesses with ample financial reserves.

For instance, HCA Healthcare, the for-profit hospital chain, posted a $1.1 billion second-quarter profit that included $590 million in government rescue funds. "We've seen billions flow to wealthy hospital systems and healthcare corporations that may not need the money," said Kyle Herrig, president of Accountable.US, a government watchdog group and frequent critic of the Trump administration. "We should have designed a program that was most likely to help those that actually needed the help."

Harder-hit segments of the healthcare industry reported the relief funds were insufficient to cover all COVID-related costs and losses. Some doctors' offices and dentists struggled to stay afloat after having to forgo visits and procedures that are the main part of their businesses. Unlike the services hospitals provide, noted Ge Bai, associate professor of accounting and health policy at Johns Hopkins University in Baltimore, dialysis is "much more resistant to the pandemic in terms of revenue."

Dialysis clinics said their drop-off in business was minimal.

"For the most part, patients actually came," said Dr. Mihran Naljayan, medical director of Louisiana State University's peritoneal dialysis program in New Orleans, one of the country's earliest COVID-19 hot spots. "We didn't see a decrease in the number of visits." Instead, when the virus rapidly spread in the New Orleans metro area in late March, the number of inpatient dialysis treatments jumped 47% and continuous renal replacement therapy — dialysis for critically ill patients that is performed for a prolonged time — rose by 260%.

HHS defended its approach for distributing funds, noting that other options would have taken much longer to implement. Congress also did not instruct the department to determine the financial strength of each provider when allocating the money.

"HHS is acutely aware of the financial hardship many facilities and providers are facing. That is why HHS has and will make targeted distributions to facilities and providers that have been disproportionately impacted by the coronavirus pandemic," the department said in a statement.

Covering Unexpected Expenses

In explaining their need for federal money, dialysis clinics large and small said they faced unexpected costs to protect patients from COVID-19. They noted that defraying those costs was an explicit goal Congress set in creating the bailout fund and that their allotments did not cover those expenses.

Brad Puffer, a spokesperson for Fresenius Medical Care North America, which recorded about $41 billion in sales last year, said the money helped dialysis centers equip workers with protective equipment such as gowns, segregate COVID-positive patients, give emergency pay and child care stipends for workers, cover the costs of COVID testing and enact a telehealth system to conduct virtual visits.

"We believe our early and aggressive actions, and the vigilance with which our employees have implemented those actions, have successfully reduced the risks to our patients and employees," Puffer said in an email.

Congress provided the money but largely left to federal health officials the specifics on how these grants, which don't have to be repaid, should be distributed. In its haste to prop up providers, and after lobbying by hospitals and other sectors to quickly get money out the door, HHS meted out the first $50 billion based on past Medicare payments and overall patient revenue. Subsequent funding was steered to COVID-19 hot spots, nursing homes, providers in rural areas and safety-net institutions that care for higher numbers of the uninsured and other vulnerable groups.

The money is available to hospitals, physician practices, dialysis clinics and other medical entities regardless of financial strength; providers had only to agree the money would be used either to replace income lost because of the pandemic or to cover COVID-related expenses that weren't reimbursed through other means.

In April, DaVita, a Fortune 500 company based in Denver that saw $11 billion in revenue and $1 billion in net income last year, indicated it would keep the $240 million the government sent. But a month later, CEO Javier Rodriguez told analysts DaVita decided to return the payments even though the company had incurred extra costs because of the pandemic.

"From our perspective, they were a safety net," he said. "And they were to be used for people that needed that money, because the economic damage was so severe, that they couldn't keep their doors open."

In July, DaVita reported a 14% operating margin, a key measure of its business, for the second quarter. That was down from 16% from the same time last year. The company's net profit was $202 million.

Dan Mendelson, founder of the health consulting firm Avalere and a private equity investor, said the move by DaVita probably helps its image. "They are very attuned to how things look," Mendelson said. "When I saw they were turning it down, I was not surprised."

A Steady Demand

The dialysis industry adapted its care after the pandemic struck. That included segregating patients suspected of having or diagnosed with COVID-19 from uninfected people, limiting staff interaction with patients, hiring additional personnel and bulking up on protective equipment.

But while the pandemic forced other types of providers to close temporarily or significantly limit procedures, there was little impact on dialysis services.

LogistiCare Solutions, which has contracts with multiple state Medicaid programs to provide nonemergency medical transportation to enrollees, saw a steady demand from dialysis patients, while calls for other medical and social services waned because of COVID-induced shutdowns, senior adviser Albert Cortina said. Dialysis patients, who accounted for roughly a fifth of the company's volume before the pandemic, shot up to account for more than 40%.

"It was considered a true essential service," Cortina said.

Some independent dialysis centers said the HHS relief funds were crucial even though they maintained normal patient loads. Northwest Kidney Centers, a nonprofit that runs 19 dialysis centers primarily in Seattle, received $2.6 million. Dr. Suzanne Watnick, the chief medical officer, said that will not cover all of the substantial expenses the center incurred in increasing protection for patients and workers.

"It's important to recognize that what we had to do and stand up was like being in a hospital," she said.

Watnick did not begrudge the large dialysis corporations that accepted the bailout money. "They do have 100 times the number of patients; that seems a reasonable way to allocate," she said. "What do you say? 'You have more of a profit margin, but you get less money'?"

Jordan Rau: jrau@kff.org, @JordanRau

Rachana Pradhan: rpradhan@kff.org, @rachanadixit

There is widespread public interest in participating in the pivotal, late-stage clinical trials of the first two COVID vaccine candidates in the United States.

This article was published on Friday, August 7, 2020 in Kaiser Health News.

By Phil Galewitz and JoNel Aleccia

Dr. Eric Coe jumped at the chance to help test a COVID-19 vaccine.

At his urging, so did his girlfriend, his son and his daughter-in-law. All received shots last week at a clinical research site in central Florida.

"My main purpose in doing this was so I could spend more time with my family and grandchildren," Coe said, noting that he's seen them only outside and from a distance since March.

"There's a lot less risk to getting the vaccine than contracting the virus," said Coe, 74, a retired cardiologist. "The worst thing that can happen is if I get the placebo."

The Coes' eagerness to offer up their bodies to science reflects the widespread public interest in participating in the pivotal, late-stage clinical trials of the first two COVID vaccine candidates in the United States.

Those trials began rolling out July 27. During the next two months, vaccine makers hope to recruit 60,000 Americans to roll up their sleeves to test the two vaccines, one made by Pfizer and BioNTech, a German company, and the other by biotech startup Moderna. While small tests earlier this year showed the preventives were safe and led to participants developing antibodies against the virus, the final phase 3 testing is designed to prove whether the vaccine reduces the risk of infection.

Amid a pandemic that in the U.S. has caused roughly 5 million infections and nearly 160,000 deaths while decimating the economy, the vaccine trials have drawn far more interest than is typical for a clinical trial, organizers said.

Also, the test sites pay volunteers as much as $2,000 for completing the two-year study.

"We have no shortage of volunteers and we have thousands of people interested in participating," said Dr. Ella Grach, CEO of M3-Wake Research of Raleigh, North Carolina, which is conducting vaccine trials at six sites.

Paul Evans, president of Velocity Clinical Research in Durham, North Carolina, said his company plans to recruit more than 10,000 volunteers in seven states to test COVID vaccines. At least four of Velocity's sites – in Ohio, California and Oregon – have already started injecting volunteers with the Moderna vaccine.

"It's been phenomenal," he said. Patient recruitment is one of the biggest challenges to running trials, but this time patients have been eager to sign up.

"I've been working in this business for 30 years," said Evans. "Outside of a COVID study, you might have to reach out to four or five, up to 10 people to find [one person] who is suitable."

Other vaccine candidates are being tested abroad and more tests will be launched in the U.S. later this year.

People 18 and older are eligible to participate in the trials, and Moderna and Pfizer are pushing to include high-risk individuals such as health workers, the elderly and people with chronic conditions such as diabetes and asthma. Organizers are also seeking to enroll Blacks and Hispanics, groups hit hard by the virus.

The vaccine makers have contracted with dozens of clinical research sites across the country. About 15 have started inoculating, and it will likely take until September for all volunteers to get their first shot. The participants will get a booster shot about a month later. They are asked to keep an electronic diary to record any symptoms. Because the virus is widespread across the country, the studies are expected to be able to note differences between infection rates in those who got the vaccine and those who received a placebo.

Government health experts say they hope to know if the vaccines are working by this fall. If the trials are successful, it would likely take until early next year before a vaccine could gain federal approval to start widespread distribution.

To determine effectiveness, half of the trial participants will receive the vaccine and half a placebo.

Coe, of Leesburg, Florida, said that several hours after getting his shot on Saturday he developed chills and was tired, symptoms that lasted until Sunday afternoon. "I'm virtually certain that I did not get a placebo because normal saline would not do that," he said. His daughter-in-law, Lisa Coe, 46, said she did not have any reaction other than soreness at the injection site.

"We are eager to get the vaccine and get on with the normal course of our lives," she said. "I'm not too worried about my own health, but I am worried about unknowingly transmitting it to anyone at risk."

Dr. Bruce Rankin, a physician investigator at Accel Research Sites in DeLand, Florida, where the Coes got their shots, said more than 1,000 adults have volunteered there already.

Accel recruits on social media sites such as Facebook and Instagram. It prescreens volunteers to make sure they understand what's expected, to learn their basic health history and get other demographic information such as race.

"I thought the opportunity to be part of something like this would be very cool," said Ginny Capiot, 45, of Fayetteville, North Carolina. "I believe it's pretty safe and there wasn't much to lose."

Capiot works in the marketing department at a hospital, where her diabetes puts her at increased risk of serious complications from the coronavirus.

Her visit to the test site last week lasted about three hours. After she filled out paperwork, health workers registered her temperature and other vital signs, gave her a COVID-19 test via a nasal swab and then took some blood. After Capiot was inoculated, she had to wait in a room in case she had any reaction. She did not.

"My arm is not even sore," she said a couple of days after the vaccination.

Volunteers in DeLand are paid as much as $1,200 over the course of the two-year trial. Participants in the Velocity-run trials will each receive $1,962 in compensation for time and travel. But Evans said many are motivated by altruism.

"They understand a couple of things," he said. "This has to happen for us to get a resolution or a solution to the pandemic. They also understand that there's a chance if they get the active vaccine and it works, they will benefit."

Not everyone is excited to test the unproven vaccine.

Dr. Atoya Adams, principal investigator for AB Clinical Trials, which is testing the Moderna vaccine in Las Vegas, said recruiting efforts there found that some people were confused or skeptical. They mistakenly worried they could contract COVID-19 from the vaccine.

The vaccines do not include any live virus. Earlier, smaller studies showed few major safety issues.

Adams has spent a lot of time on the phone, explaining that the vaccine appears safe and that volunteers are needed to see whether it's effective. "I've literally had to tell patients in prescreening, it's something I would feel safe giving to myself or my family," she said.

George Washington University in Washington, D.C., hopes to enroll 500 people at its testing site, and it received inquiries from at least that many in just the first week of recruitment.

"It's been overwhelming and really highlights that everyone understands the need for a vaccine," said Dr. David Diemert, professor of medicine at the GW School of Medicine and Health Sciences.

To gain an ethnically and racially diverse group, the university reached out to food banks, senior living communities and churches looking for volunteers. Participants can get paid nearly $1,100.

In Mississippi, the Hattiesburg Clinic has generated strong interest among potential volunteers, especially among healthcare personnel.

"People who care for these COVID patients have a very healthy fear of this illness," said Rambod Rouhbakhsh, chief investigator with MediSync Clinical Research, whose Moderna vaccine trial site is the only one in Mississippi.

He expects no trouble reaching people who would be at high risk of COVID complications, including those who are obese or have diabetes or heart disease. "In southern Mississippi, there are plenty of people who meet the high-risk categories," he said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia