How health systems are deciding whether to mandate COVID-19 vaccinations

Amid the COVID-19 vaccine rollout, U.S. hospitals and health systems are considering whether to require their employees to get shots. 

Houston Methodist has already decided to do so. The health system rolled out its mandatory vaccination policy March 31, with April 15 as the deadline for managers to receive at least one dose or get an exemption. More than 99 percent of the management team had complied by the deadline. By June 7, all 26,000 employees are required to have received the vaccine.

What are the considerations for mandates?  

One consideration is employee hesitancy or concern, addressed in a recent Washington Post-Kaiser Family Foundation poll-Kaiser Family Foundation poll

The poll, conducted Feb. 11 to March 7, found that 58 percent of employed healthcare workers said they would support a mandate for employees who work with patients. Forty-two percent said they would oppose such a requirement. 

Among employed healthcare workers who don't plan to or have not decided to get vaccinated, 65 percent said they would leave their job if they were required to get vaccinated.

There are also legal considerations.

The FDA has approved vaccines manufactured by Pfizer-BioNTech, Moderna and Johnson & Johnson for emergency use. However, the federal government has not given the vaccines full approval.

The FDA's emergency use authorizations specify that people must give consent to being vaccinated, Lawrence Gostin, a professor at Georgetown University Law Center in Washington, D.C., with expertise in health law, told The Washington Post in an April 5 article. Therefore, he told the newspaper, mandating a vaccine only authorized for emergency use could raise legal questions.  

The CDC has said the decision by employers about mandates is a matter of state or other applicable law, and if employers require proof from workers that they have been vaccinated, the employer can't require the employee to provide medical information as part of the proof. The CDC said employers may implement religious and medical exemptions. 

And the Equal Employment Opportunity Commission has released guidance on the issue. The commission told Becker's April 22 that for employers requiring vaccination be obtained in the community as an employment condition, the Americans with Disabilities Act may require reasonable accommodation [unless there is significant difficulty or expense for the employer] for those who cannot be vaccinated because of disability. Similarly, according to the commission, Title VII of the Civil Rights Act of 1964 may require reasonable accommodation of employees' religious beliefs or practices related to vaccines, unless the accommodation constitutes undue hardship on the employer's operations under the law. 

"Whether there are feasible accommodations that do not pose an undue hardship will depend on many facts specific to each workplace and the duties of the individual," a commission spokesperson said. 

The thought processes about mandates 

With these and other considerations in play, the process of deciding whether to mandate vaccination for employees remains fluid. 

A small number of hospitals have made the vaccine mandatory with some exceptions, such as religious exemptions, said Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association. However, she said most association members indicated they will decide about requiring the shot for their own workers based on safety and efficacy data available at the time the vaccines receive full FDA approval. 

"All hospitals and health systems are urging their staff and the general public to take the vaccine when it is their turn as an important step to provide additional protection from the serious consequences of COVID-19, both for themselves and for others, including the patients they care for," said Ms. Foster.   

At Norfolk, Va.-based Sentara healthcare, a 12-hospital system with 28,300 employees, about 66 percent of staff had received at least the first vaccine dose as of April 20. Most are fully vaccinated, and the health system continues to have vaccination clinics for staff.

Right now, the health system has decided not to mandate the vaccine for employees, said Jordan Asher, MD, executive vice president and chief physician executive. He partially attributed the decision to the vaccines not being fully approved by the FDA, although he is a supporter of vaccines.

"Do I believe there are any issues [with the vaccines]? No. But I don't have the data at hand to be able to say to you as a person — let alone an employee — that I am going to mandate that you have it," said Dr. Asher. "I'm going to talk about the positives. But right now, I'm finding it difficult to create a mandate. On top of that, we're in multiple states [Virginia and North Carolina]. You do have your own state regulations as it relates to labor law. You have to work through that simultaneously."

As things change, though, he said Sentara continues to evaluate its decision and keep a close watch on guidance and directions from governing bodies such as the FDA. 

Ochsner Health, a New Orleans-based health system with more than 30,000 employees, also decided not to mandate the vaccine for employees, as long as shots are only FDA-approved for emergency use. Tracey Schiro, executive vice president and chief human resources officer, said the organization could reconsider the decision after full approval.

"In speaking with our CMO about the mandatory status, we feel that until there is FDA final approval, then we will continue to evaluate thinking about making it mandatory," said Ms. Schiro. "Today, we do have the flu vaccine as a mandatory requirement unless someone has a medical or religious exemption, so once it's approved by FDA, I think we'll consider that and make our decision."

The thought processes about incentives 

While Ochsner and Sentara are considering mandates, they are doing the same with incentives. Some healthcare organizations have already announced they are offering these. St. John's Health in Jackson Hole, Wyo., for instance, said its board of trustees has approved a bonus program to reward employees who have been vaccinated and encourage those who haven't. To qualify, employees must complete both vaccine doses by May 31, spokesperson Karen Connelly told Becker's. Employees will receive the bonus in June. The bonus is $600 for full-time employees and will be prorated for employees who don't work full time.

When it comes to incentives, Dr. Asher said there are various things he considers, including what the amount would be if his organization decided at some point to provide a bonus.

"If the number is too high, I then run the situation of creating something where I'm saying to you [the employee] that you need to think about being able to take your family on a trip with the money vs. going against what you might not believe in from a safety standpoint," he said. "So, you create unintended consequences by offering an incentive that might put someone in a precarious position of having to think through 'wow that's real dollars. Now, I really have to think about it, and now I'm really torn.' We don't want to create a situation like that."

Still, he said Sentara is watching what is working and not working at other organizations.

Ms. Schiro, with Ochsner, said her organization is considering a monetary incentive. 

"We're having executive discussions around an incentive based on what we've seen from peers across the country. Some of our thinking is it may be something we want to put there for our employees to thank them for getting the vaccine and continuing to encourage people to get the vaccine," she said. 

She said no final decision has been made. 

Educational efforts 

For now, both Ochsner and Sentara are continuing to educate employees about vaccines..  

At Sentara, executives are working with faith-based leaders in the communities the health system serves to provide information.

Dr. Asher said: "We believe people have a strong connection to different things, and for a lot of people, it is their faith. So, from a faith-based standpoint, vaccinations are important. That's the messaging we've been doing, especially for those who are underserved."  

At Ochsner, the health system has offered information sessions with OB-GYN groups and experts to address concerns employees may have about fertility, Ms. Schiro said. She said the health system has also asked its diversity groups to host events to talk about the vaccine among minority groups, as well as show pictures and tell why they got the vaccine.

"I do think those have been successful. I know we have a high percentage of employees vaccinated compared to some of our peers across the country, so I think those targeted communications and having open sessions for employees to ask questions of physicians and experts in different areas has been very beneficial in getting a majority of our employees vaccinated," she said. 

As of April 20, 55 percent of Ochsner employees had been fully vaccinated.


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