Voglio sapere a riguardo di…

26332

Federal Register / Vol. 86, No. 91 / Thursday, May 13, 2021 / Rules and Regulations
individual in studies underlying the VSL estimates is approximately 40 years of age, allowing us to calculate a value per life-year of approximately $540,000
and $900,000 for 3 and 7 percent discount rates respectively. This estimate of a value per life-year corresponds to 1 year at perfect health.
These amounts might reasonably be halved for average nursing home residents, since non-institutionalized U.S. adults aged 8089 years report average health-related quality of life HRQL scores of 0.753, and this figure is likely to be lower for nursing home residents. 88 Assuming that the average life expectancy of long-term care residents is five years, the monetized benefits of saving one statistical life would be about $2.5 million $540,000
annually for 5 years at a 3 percent discount rate and about $3.7 million $900,000 annually for 5 years at a 7
percent discount rate. Assuming that the average rate of death from COVID19
SARS-CoV2 infection at nursing home resident ages and conditions is 5
percent, and the average rate of death after vaccination is essentially zero, the expected life-extending value of each resident receiving the full course of two vaccines who would otherwise be infected is $125 thousand at a 3 percent discount rate and $185 thousand at a 7
percent discount rate. A similar calculation can be made for staff, who will gain many more years of life but whose risk of death is far smaller since their age distribution is so much younger. Yet another calculation for clients of ICFsIID would also result in many more years of life but far smaller risks of death since their age distribution is typically far younger than that of LTC residents. It is difficult to ascertain the number of ICFIID clients that would be infected without vaccination. Deaths from COVID19 in unvaccinated LTC residents to date are about 130,000, or close to one tenth of the average LTC resident census of 1.4
million, a huge contrast to the handful of deaths in the vaccination results from Israel.89 We do not have sufficient data so as to accurately estimate annual resident inflows and outflows over time, but it is clear that several hundred thousand new individuals each year make the total number served during the
year far higher than point in time or average counts see Table 5.
We do know that large numbers of residents or staff were vaccinated through the Pharmacy Partnership, which for nursing home residents relied most heavily on the CVS and Walgreens drug store chains. In its latest report, the Partnership reported that to date it had vaccinated about 2.2 million residents in long-term care facilities, although fewer than two thirds of these had received two doses.90 We do know that significant fractions of staff, perhaps one-third or more, have to date declined vaccination when offered.91 Progress has been very substantial, but many remain unvaccinated among both residents and staff. This interim final rule has significant potential to support further vaccinations as vaccination opportunities from other sources expand.
The preceding calculations address residential long-term care. Long-term residents are a major group within nursing homes and are generally in the nursing home because their needs are more substantial and they need assistance with the activities of daily living, such as cooking, bathing, and dressing. These long-term stays are primarily funded by the Medicaid program also, through long-term care insurance or self-financed, and the residential care services these residents receive are not normally covered by Medicare or any other health insurance.
A second major group within the same facilities receives short-term skilled nursing care services. These services are rehabilitative and generally last only days, weeks, or months. They usually follow a hospital stay and are primarily funded by the Medicare program or other health insurance. The importance of these distinctions is that the numbers of residents in each category are different. The average number of persons in facilities for long-term care over the course of a year is about 1.2
million residents as is the point-in-time number, and the total number of persons over the course of a year is about 1.6 million. The average number in skilled nursing care over a year is about 200,000 million persons, but the average length of stay is weeks rather
88 Hanmer, J. W.F. Lawrence, J.P. Anderson, R.M.
Kaplan, D.G. Fryback. 2006. Report of Nationally Representative Values for the Noninstitutionalized US Adult Population for 7 Health-Related Qualityof-Life Scores. Medical Decision Making. 264:
391400.
89 Deaths are from COVID19 Nursing Home Data, CMS, Week Ending 2/21/2021, at https
data.cms.gov/stories/s/COVID-19-Nursing-HomeData/bkwz-xpvg/.

90 See https www.cdc.gov/vaccines/covid-19/
planning/index.html.
91 See the discussion and data in the CDC report Early COVID19 First-Dose Vaccination Coverage Among Residents and Staff Members of Skilled Nursing Facilities Participating in the Pharmacy Partnership for Long-Term Care ProgramUnited States, December 2020January 2021, at https
www.cdc.gov/mmwr/volumes/70/wr/mm7005e2.
htm?s_cid=mm7005e2_x.

VerDate Sep<11>2014

18:28 May 12, 2021

Jkt 253001

PO 00000

Frm 00028

Fmt 4701

Sfmt 4700

than years.92 The annual turnover in this group is such that about 2.3 million residents are served each year. There is some overlap between these two populations and the same person may be admitted on more than one occasion.
For purposes of this analysis although we have no documented basis for estimating those numbers, we assume that the expected longevity for each group is identical on average, and that a total of 3.9 million persons are served each year. We further assume that 20
percent of these are new residents each year who must be offered vaccination most are already vaccinated, as discussed later in the analysis.
These nursing facilities have about 950,000 full-time equivalent employees.
For these persons, the average age is about 50, which creates two offsetting effects: They have more years of life expectancy than residents, but their risk of from COVID19 death is far lower.
For purposes of this analysis, we assume that the vaccination is effective for at least one year, and use a one-year period as our primary framework for calculation of potential benefits, not as a specific prediction but as a likely scenario that avoids forecasting major and unexpected changes that are either strongly adverse or strongly beneficial.
If we were adding up totals for benefits we would assume that the risk of death after COVID19 infection is likely only one-half of one percent one tenth of the resident rate or less for the unvaccinated members of this group, reflecting the far lower mortality rates for persons who are mostly in the 30 to 65 year old age ranges compared to the far older residents.93 We assume that the total number of individual employees is 50 percent higher than the full-time equivalent but that only half that number are primarily employed at only one nursing facility, two offsetting assumptions about the number of employees working at each facility many employees are part-time consultants or the equivalent who serve multiple nursing facilities on a part-time basis. We further assume that employee turnover is 80 percent a year, lower than the results for nurses previously cited.
Accordingly, we estimate that 80
92 In fact, the average length of stay for skilled nursing care is about 25 days. See MEDPAC, Report to the Congress: Medicare Payment Policy, March 2019, Skilled nursing facility services, page 200.
93 See the previously cited CDC report on risks by age group. In the age intervals used by CDC, the 40
49 year old group is in the middle of typical employment age ranges. The risk of death in this age group is one tenth that of those aged 6574. We emphasize with round numbers that nothing about these data are fixed and unlikely to change e.g., as better future treatments are used to treat severe cases.

E:FRFM13MYR2.SGM

13MYR2