The biggest nursing-home chain in the US is sounding off about a potentially messy COVID-19 vaccine rollout as a patchwork of state vaccination plans emerges

• Under a federal program, the pharmacy giants CVS Health and Walgreens plan to give COVID-19 vaccines to residents and staff members at more than 50,000 long-term care facilities.
• Dr. Richard Feifer, the chief medical officer of the country's largest nursing-home operator, Genesis HealthCare, sounded off about West Virginia's decision to devise its own strategy for vaccinating people at long-term care facilities.
• The adjutant general of the West Virginia National Guard and a leader of the state's pandemic response said the federal program would limit West Virginia's ability to vaccinate long-term care residents quickly.
• CVS and Walgreens are preparing to vaccinate millions of vulnerable nursing-home residents. The pharmacy chains said they would be ready to give shots at long-term care facilities within two days of receiving Pfizer's COVID-19 vaccine.

The chief medical officer of the largest US nursing-home operator, Genesis HealthCare, said the federal government's decision to give states the final say in COVID-19 vaccination plans is complicating efforts to ensure the country's most vulnerable people are vaccinated.

Dr. Richard Feifer of Genesis, which operates more than 325 long-term care facilities in 24 states, said that while most states had agreed to allow the pharmacy chains CVS Health and Walgreens to vaccinate their nursing-home residents as part of a federal program, at least one - West Virginia - was mulling its own strategy.

That could create problems for Genesis, which has 34 nursing homes in West Virginia. The state said in early December that nearly half of COVID-19 deaths in the state were in long-term care facilities.

"We're concerned that they're trying to reinvent the wheel, and we don't have time to waste," Feifer said. "We'd much prefer fully leveraging the national model, and we're expressing those concerns in West Virginia."

Residents and staff members at long-term care facilities will be some of the first in the US to get a COVID-19 vaccine once it's approved, a decision that's expected soon for Pfizer and BioNTech's vaccine. CVS and Walgreens are preparing to vaccinate people at more than 50,000 of those facilities as part of a federal program called the Pharmacy Partnership for Long-Term Care.

Long-term care facilities opted into that federal program, which is meant to relieve the facilities of the burden of storing the vaccines, giving the shots, and reporting vaccination data. But states ultimately decide where the first vaccines go and whether to stick with the federal government's approach.

While states' playbooks are evolving and coronavirus vaccines have not yet gotten emergency clearance in the US, it's clear that their strategies are diverging, creating a patchwork of vaccination plans in the country.

Inconsistent state approaches to managing the pandemic have complicated COVID-19 testing and efforts to source personal protective equipment, causing confusion and inefficiencies, Feifer said. He added that he worried that the variation among states would hinder efforts to vaccinate Americans quickly and end the pandemic.

"We have needed a more deliberate centralized model of managing the pandemic all along," he said. "We can't afford to make the same mistakes again around state-by-state variation."

West Virginia is developing a plan for vaccinating long-term care residents that doesn't rely on CVS or Walgreens, in hopes of doing it faster than the federal government

Maj. Gen. James Hoyer, the adjutant general of the West Virginia National Guard and the head of a task force leading the state's pandemic response, told Business Insider that the state had decided to delay full implementation of the federal program to vaccinate people at nursing homes.

Instead, West Virginia is developing its own strategy. The state is prioritizing residents and staff members of nursing homes and assisted-living facilities for the first vaccine shipments, along with healthcare workers who work with patients with COVID-19.

West Virginia placed an initial order to the US Centers for Disease Control and Prevention for 16,575 doses of the Pfizer vaccine.

Because many of the pharmacies in the largely rural state are not part of big chains, "we felt from a state perspective that we were limiting the ability to very rapidly, logistically distribute and administer vaccines to that population," Hoyer said.

West Virginia's goal is to vaccinate all nursing-home and assisted-living residents and staff members within 30 days of receiving the vaccines at five designated hospitals. Hoyer said the state's pharmacy board had put out a call to pharmacists who want to participate in vaccinating the nursing homes.

The pharmacies would include those that already have relationships with nursing homes or assisted-living facilities in their communities. They could include CVS and Walgreens.

"We believe that based on our primarily rural nature that pharmacies are going to be key to our distribution to our general citizen population, so this is helping us build the infrastructure long term to vaccinate all West Virginians," Hoyer said.

"We are using the approach that we think best fits us in West Virginia," he said. "I think everybody's going to have a different approach based on idiosyncrasies and differences."

Rebecca Snead, the executive vice president and CEO of the National Alliance of State Pharmacy Associations, said other states in addition to West Virginia might opt out of or delay implementation of the federal program to vaccinate long-term care facilities. There will be variation among not just states, but national partners and facilities' capacities and requirements for the clinics.

"Success will depend on meeting the needs of the individual facility, no matter if it is a federal partner or the state facilitating the vaccine distribution/administration," Snead wrote in an email.

Read more: 'This is game time': Hospitals across the country are gearing up to give the first COVID-19 shots to millions of healthcare workers

US officials said 36 states want vaccines shipped to long-term care facilities

The Food and Drug Administration could give emergency approval to the vaccine from Pfizer as soon as this week. An expert panel met Thursday to review the drug company's application for an emergency use authorization.

It's then set to review Moderna's request for emergency approval of its vaccine. Both require two doses given weeks apart.

US health officials have said millions of doses of a vaccine could be shipped out within a day of its emergency approval. Governors and their health departments have been busy planning where those vaccines will go.

Army Gen. Gustave Perna, who oversees the logistics of delivering COVID-19 vaccines to states, said during a media briefing on Wednesday that 36 states had so far told the CDC that they wanted the initial vaccines shipped to long-term care facilities.

North Carolina is one state relying on the federal government's approach for vaccinating those facilities. Dr. Mandy Cohen, the secretary of the state's Department of Health and Human Services, said during a media briefing on Thursday that while vaccines for nursing homes would come out of the state's allocation, Walgreens and CVS would be doing all the work of administering the shots.

Cohen said she expected the pharmacies to begin vaccinating people at long-term care facilities in the second week of the vaccine rollout, once the Moderna vaccine is authorized. Healthcare workers in contact with COVID-19 patients would be prioritized during the first week.

Most big long-term care companies are working with either CVS or Walgreens to vaccinate their residents and staff. Signature HealthCare, which has 109 facilities in 10 states, is working with both CVS and Walgreens. Atria Senior Living, Sunrise Senior Living, and Brookdale Senior Living are partnering with CVS.

As of late November, deaths in long-term care facilities accounted for 40% of all COVID-19 deaths in the US, though in some states the figure was much higher, according to the Kaiser Family Foundation.

Genesis, which reported $4.57 billion in revenue in 2019, chose to work with CVS to vaccinate the people in its nursing homes in most states where it operates. But Feifer said it was unclear whether CVS would be able to vaccinate the people at Genesis' nursing homes in West Virginia, as that would require the state's approval and "CVS supporting that outside of their direct contract with the CDC," he said.

A spokesman for CVS said that the company was unaware of any state opting out of the federal program but that if a state were to opt out, CVS's ability to vaccinate people in a long-term care facility there would depend on the state.

A CDC spokeswoman said all states had opted into the federal pharmacy partnership for long-term care.

Read more: Pharmacies, doctor's offices and hospitals are gearing up to give coronavirus vaccines to millions of Americans. Here's how they're preparing and how much they stand to profit along the way.

CVS and Walgreens plan to vaccinate people at more than 50,000 long-term care facilities

Chris Cox, a senior vice president at CVS and the company's liaison to Operation Warp Speed, said the pharmacy chain planned to vaccinate roughly 3 million residents and staff members at more than 30,000 long-term care facilities. The company is coordinating with the facilities while it waits for each state to decide where to send the first vaccines.

Walgreens is planning to vaccinate people at more than 27,000 long-term care facilities, said Rina Shah, the pharmacy chain's group vice president of pharmacy operations and services.

Both CVS and Walgreens said they'd be ready to give shots within two days of receiving the vaccines at their designated hubs.

"When a vaccine is available, the state will let us know which are the priority groups within that population, and then we'll begin the administration of those facilities," Shah said.

A CDC committee recommended states prioritize healthcare workers and nursing-home residents, but timelines could vary. Cox said the CDC was allowing states to "turn on" the federal program for all long-term care facilities, or they could start with vaccinating skilled-nursing facilities and move to other facilities later.

Cox said some states may also choose to vaccinate healthcare workers in hospitals before turning to long-term care facilities. Others may opt to vaccinate people in long-term care settings right away.

Pfizer is set to ship its vaccines, which must be kept at a temperature of negative 70 degrees Celsius, directly to roughly 1,000 CVS pharmacies that are acting as hubs, chosen because of their proximity to the long-term care facilities CVS will visit. The supply-chain company McKesson is set to ship CVS the Moderna vaccines, which can be kept at regular freezer temperatures.

Similarly, Walgreens plans to have vaccines shipped to certain stores that would then take the vaccines to long-term care facilities. Walgreens said it was working with the facilities to understand how many patients and staff members want vaccines before it sets up onsite clinics.

Cox said CVS intended to vaccinate all residents and staff members in a single facility in one visit, rather than prioritizing people in the facility to be vaccinated if there's a limited supply. But if a state directs CVS to vaccinate people at all long-term care facilities and there are limited vaccines, CVS plans to prioritize skilled-nursing facilities over other types of long-term care settings, as the patients are generally sicker. CVS said it would also take population size into account.


CVS would return to set up a second vaccine clinic a few weeks later to give the second dose, then set up a third clinic for any new residents.

"We expect to get to all of them within three to four weeks of whenever the jurisdiction turns it on, so it's not going to be a long wait for any of them," Cox said.

Feifer said he was concerned that vaccinating all nursing-home staffers on the same day could create staffing shortages if lots of them experience side effects. Genesis has urged the federal government and CVS to consider staggering the vaccinations to reduce that risk.

The CVS spokesman said that for facilities concerned about staffing, CVS was willing to stagger dosing among its three clinics. Half the staff could receive the first dose on the pharmacy's first visit, with the rest receiving it on the second visit, for example.

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