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Federal Register / Vol. 86, No. 91 / Thursday, May 13, 2021 / Rules and Regulations
a written document to someone who does not speak English. Many computer and phone applications Apps providing oral translations are available to assist those with language or vision problems, and hearing problems create no document translation requirements if a document in the reading language of that resident is available.81
If we assume that 20 percent of residents and clients in LTC facilities and ICFsIID decline vaccination, taking account of both those offered and declining the vaccine before this rule takes effect and those offered it again in the first year, 930,000 additional vaccination counseling and education efforts would be made to residents 4,020,000 including 630,000 in the first quarter of 2022 for a total of 4,655,000
total individual residents .2. This figure implicitly assumes that a much higher take-up rate was achieved during the first three months of 2021, likely about 80 to 90 percent of all those residents reached by Pharmacy Partners and other early vaccination efforts, and that there will be more and more varied effort needed for the remainder, most of whom presumably declined the initial offer. It also assumes that only about half of year-end residents will have been vaccinated when this rule is issued even though most residents at the beginning of the year will have been vaccinated.
Hence, there will be about 517,000
residents needing vaccine education and offers needed to be made in the first full year 20 percent of rightmost Residents Total column of Table 5.
For education of staff, we make similar assumptions, except that early and anecdotal evidence suggests that a third or more are declining vaccination.82 This means that about an additional 332,000 one-third of 997,000 vaccination counseling and education efforts will need to be made to staff, including new hires, in the remainder of 2021 and the first quarter of 2022.

Taken together, these estimates for both residents and staff suggest that total counseling and education efforts would be made for perhaps 849,000
persons after the rule is issued, twothirds residents and one-third staff.
Some of those offers would be accepted and some declined these figures do not include offers made to persons already vaccinated but do include those newly admitted to or hired by these facilities.
Total cost of the educational efforts themselves would be approximately $28,442,000 849,000 persons .5 hours $67 hourly cost. Cost of resident time to participate would be an additional $2,449,000 849,000 persons .667 .5
hours $8.65 hourly cost and of staff time to participate an additional $1,631,000 849,000 persons .333 .5
hours $27.38 hourly costs. Secondand third-year totals would be lower, perhaps about three-fourths as much, taking into account both fewer remaining unvaccinated needing these efforts, and a sensible reduction in efforts aimed at persons who refuse to consider vaccination. Hence, total cost of these educational efforts to both educators and recipients would be a total of $35,220,000 in the first year and $26,415,000 in the second and third years.
The third major cost component is the vaccination, including both administration and the vaccine itself.
We estimate that the average cost of a vaccination is what the Government pays under Medicare: $20 2 = $40 for two doses of a vaccine, and $20 2 for vaccine administration of two doses, for a total of $80 per resident. This estimate is made for simplicity, ignoring newer and one-dose vaccines, since the great majority of recipients are Medicare beneficiaries and we have no data yet on likely use of newer vaccines.83
Assuming that the efforts to educate residents, clients, and staff succeed in raising the vaccinated percentage by 5
percent points over the course of the
first year, calculated from the 70 percent staff to 80 percent residents and clients baseline likely to be achieved before this rule takes effect, total vaccination costs across these target groups resulting from this rule would be $23,460,000 $80 .05 5,865,000.
Finally, there is a cost category related to expenses not estimated as information collection costs because they meet an exception in the PRA for requirements that would be handled through usual and customary business practices. These exceptions are all discussed briefly in the ICR section of this preamble. Most of their costs are related mainly to recording in patient or personnel records for each resident and staff person that vaccine education, vaccine decision, and vaccinations for those accepting vaccination have all taken place. While there are large numbers of such record notations to be made, we estimate that they take only a few seconds per record. We have estimated that the added cost of these record-keeping functions as likely to be about 5 percent of all Information Collection costs.
All these aggregate costs can be converted to per person numbers since it is individual persons who are vaccinated. Dividing the estimated first year costs by an estimated 5.380 million people 4.02 million residents and 1.36
million workers gives an average per resident or employee cost of $27.12 in the first year 159,056,000 divided by 5,865,000.
Another way to summarize these numbers is in terms of average cost per person newly vaccinated. Making the same assumption that about 5 percent of total persons and 10 percent of those unvaccinated would be newly vaccinated as a result of this rule, cost per person would be $542 $27.12
divided by .05. Table 6 summarizes the overall cost estimates.

TABLE 6ESTIMATE OF TOTAL COSTS
Costs in first year
Cost category Developing NF Policies & Procedures
Developing Education Materials for Residents and Staff
Keeping Vaccine Information Up-to-Date
Documentation Requirements
81 Examples of translation Apps include Google Translate, iTranslate Voice 3, SayHi, TextGrabber, BrailleTranslater, and many more.
82 The Kaiser Family Foundation estimates as of February 22 that to date 37 percent of all health care workers not specific to LTC workers have declined vaccination or decided to wait and see. See https

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www.kff.org/coronavirus-covid-19/dashboard/kffcovid-19-vaccine-monitor/.
83 Vaccine and vaccination costs are generally paid by the Federal Government. What the Government pays varies from vaccine to vaccine, by when purchased and in what quantities, and varies by payer or provider. $40 per dose is a rough estimate based on experience to date. As is the case
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$38,360,000
4,181,000
6,271,000
3,838,000

Costs in succeeding years $12,542,000
NA
6,271,000
3,838,000

for all drugs, cost estimates also vary depending on research and development costs as well as manufacturing cost. These estimates do not reflect use of the new Johnson & Johnson/Jannsen one-dose vaccine. See the Healthline article at https
www.healthline.com/health-news/how-much-willit-cost-to-get-a-covid-19-vaccine.

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