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Federal Register / Vol. 86, No. 91 / Thursday, May 13, 2021 / Rules and Regulations percent of 950,000, or 760,000, are new employees each year and must be offered vaccination again, most are already vaccinated, for a total of 1,710,000 eligible employees over the course of a year.
As for ICFsIID, there are about 6,000
facilities, serving about 100,000 people at any one time, an average of about 15
people per facility.94 The age profile of these clients is similar to that of the adult population at large. Turnover rates are unknown, but likely to be substantial because these clients have many alternatives. We estimate 80
percent a year for turnover, the same as for nursing facilities. The costs and benefits of COVID19 vaccination services for this group are roughly comparable to those of nursing home staff. There do not appear to be data on number of staff at these facilities, but based on the nature of the services provided it appears likely that the staff to client ratio is similar to that in other congregate settings group homes, assisted living facilities, and likely to be about three-fourths of the client population, or about 75,000 full-time equivalent staff, with similar turnover patterns as well. Adding 80 percent to allow for staff turnover, gives a total of 135,000 staff candidates for vaccination.
We have some data on the costs of treating serious illness among the unvaccinated who become infected, are hospitalized, and survive. Among those age 65 years or above, or with severe risk factors, as many as 40 percent of those known to be infected required hospitalization in the first month of the pandemic. Among adults age 21 years to 64 years, about 10 percent of those infected required hospitalization.95 For our estimates, we assume a 20 percent hospitalization rate among people aged 65 years or older in nursing homes, reflecting both that their conditions are significantly worse than those of similarly aged adults living independently, and that prehospitalization treatments have improved. Of the LTC facility and ICF
IID candidates for vaccination in the first year covered by this rule, about three-fourths are age 65 years or above.
94 By far the largest source of data related to ICF
and other IID services is In-Home and Residential Long-Term Supports and Services for Persons with Intellectual or Developmental Disabilities: Status and Trends 2017, at https ici-s.umn.edu/files/
aCHyYaFjMi/risp_2017.
95 There are few data sources for this statistic and, thus, it may be out of date. See MMWR, Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019United States, February 12March 28, 2020, April 3, 2020, at https www.cdc.gov/mmwr/volumes/69/wr/
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Hence, the age-weighted hospitalization rate that we project is about 16 percent.
Among those hospitalized at any age, the average cost is about $20,000.96
To put these cost, benefit, and volume numbers in perspective, vaccinating one hundred previously unvaccinated LTC
residents who would otherwise become infected with SARSCoV2 and have a COVID19 illness would cost approximately $54,200 $542 100 in paperwork, education, and vaccination costs. Using the VSL approach to estimation would produce life-saving benefits of about $2,650,000 for these 100 people $530,000 100 .05, again assuming the death rate for those ill from COVID19 of this age and condition is one in twenty. Reductions in health care costs from hospitalization would produce another $320,000
$20,000 100 .16 in benefits for this group assuming that 16% would otherwise be hospitalized. However, this comparison is should be taken as necessarily hypothetical and contingent due to the analytic, data, and uncertainty challenges discussed throughout this regulatory impact assessment. As the discussion of other patient groups covered by this rule demonstrates, they present similar if not identical magnitudes of both costs and benefits for affected individuals benefits from staff vaccinations, however, are far lower. Consequently, the primary mediumto long-run benefit-cost issue is not the general magnitude of likely effects on those who get vaccinated as a result of the rule, but the difficult questions of estimating 1
likely numbers of individuals in both client and staff categories who are likely to be unvaccinated when the rule goes into effect and 2 to be willing to accept vaccination in the coming months and years.97
Of particular importance is that the vaccination rates and raw numbers of people vaccinated take into account that in total only about half of those who will be residents and clients in these facilities at some time during the year have already been residents or clients 96 This is not a robust estimate, but is supported by several sources. See for example Jiangzhuo Chen et al., Medical costs of keeping the US economy open during COVID19, Scientific Reports, Nature.com, July 19 2020, at https
pubmed.ncbi.nlm.nih.gov/32743613/, and Michel Kohli et al., The potential public health and economic value of a hypothetical COVID19
vaccine in the United States: Use of costeffectiveness modeling to inform vaccination prioritization, Science Direct, February 12, 2021, at https pubmed.ncbi.nlm.nih.gov/33483216/.
97 For a survey of the evidence on this issue, see Gillian K. Steelfisher et al., An Uncertain Public Encouraging Acceptance of Covid-19 Vaccines, The New England Journal of Medicine, March 3, 2021.

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during the months served by the Pharmacy Partnership effort. For example, our estimated vaccination rate as of March 31, 2021, for LTC residents assumes that about 90 percent of the residents in January through March will have been vaccinated. But given the turnover expected during the rest of the year, only about 70 percent of the annual total will have been vaccinated by the end of 2021, or by the end of the first year including the first quarter of 2022. As a result, about 3.6 million persons will be vaccination candidates subject to this rule over the first year.
Some of these persons may have been vaccinated elsewhere, but the facilities regulated under this rule will need to query each incoming resident and it is likely that as many as a third of these will be candidates for COVID19
vaccination. A major caution about these estimates: None of the sources of enrollment information for these programs regularly collect and publish information on client or staff turnover during the course of a year. The estimates here are based on inferences from scattered data on average length of stay, mortality, job vacancies, news accounts, and other sources that by happenstance are available for one type of facility or type of resident or another.
Nor do we have data on the number of persons in these settings who will be vaccinated through other means during the remainder of the year.
There are also dimensions of positive and negative benefits in the mediumto long-run that we have not been able to estimate. For example, there is insufficient evidence as to whether the current or reasonably foreseeable vaccines will maintain their protective efficacy for more than six months.
Until very recently, demand for COVID19 vaccination has exceeded supply throughout the U.S.98 Especially in previous months, vaccination distribution policies giving priority to various groups for example, aged, health care workers, and other essential services workers has meant that those given priority have benefited to some extent at the expense of those in lower priorities. Regardless of priorities, we know that younger persons are much less likely to experience hospitalization or death after infection. For example, the risk of death among infected persons age 65 to 74 years is ten times greater 98 The shortage issue has now largely been addressed, as is well illustrated in the recent removal of age restrictions designed to give highest priority in using limited vaccine supplies to the elderly and health care workers. See, for example, news stories: https www.abc27.com/news/health/
coronavirus/official-biden-moving-vaccineeligibility-date-to-april-19/.

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