Health system gaps make it hard for some older Oregonians to get a COVID-19 booster

Nurse Julie Hubbard’s small office is down the hall from the dining room at a 31-person memory care unit in Lake Oswego run by the company Avamere.

She wears a stethoscope and keeps the lights dimmed. The low light, she said, helps calm residents who come to her when they’re distressed or disoriented. All of The Pearl at Kruse Way’s residents have some form of dementia, most often Alzheimer’s.

But lately, Hubbard has been worried about a shorter-term threat to the health of her residents: COVID-19. That’s because the latest booster shot that could protect older Oregonians has been slow to arrive for many living in long-term care facilities.

Only about one in four residents in a memory care, nursing home, or assisted living has gotten the most recent COVID-19 booster shot, according to data from November published by the Oregon Health Authority.

“There’s a huge percentage of people who are vulnerable, who can’t get this,” Hubbard said.

If the state and federal government cannot make access to vaccines easier for vulnerable Oregonians, Hubbard worries she could start losing more residents to COVID-19 again, like in the early days of the pandemic.

A bureaucratic roadblock

Age remains the single most important risk factor for severe COVID-19 outcomes. Seniors, on the whole, embraced the initial COVID-19 vaccine, which helped reduce hospitalizations nationwide. A step in the virus’s evolution may have helped too, with the omicron variants circulating now generally causing more mild illness than the earlier delta variant.

But immunity tends to wane more quickly in older adults.

With the federal government no longer subsidizing all COVID-19 vaccines, Hubbard now needs to rely on federal reimbursements to cover the costs.

Moderna’s 2023-2024 booster costs $128 per dose. Pfizer’s is $115. In most cases, it’s supposed to be available free without a copay for people on Medicare or Medicaid.

Nursing homes are federally regulated and have higher-level medical staff who can directly bill Medicare for administering the COVID-19 shot to their residents.

But assisted living facilities and memory care units are regulated by the state and cannot directly bill Medicare, creating a gap that has left many older Oregonians at risk of remaining unvaccinated through the winter.

Because Hubbard is a nurse and not a doctor or nurse practitioner, she can order the booster shot for her patients, and she’s qualified to stick the shot into an arm, but the Pearl’s memory care unit license doesn’t allow her to directly bill Medicare for the shots.

One possible solution for people living at long-term care facilities is to visit their local pharmacy or doctor’s office. Retail pharmacies and primary care offices generally offer the COVID-19 booster to Medicare enrollees for free. But many of the residents of the Pearl can’t easily visit a pharmacy or a doctor’s office, according to Hubbard.

Many residents have advanced Alzheimer’s, and some of them require medical transport to leave. In the past years, Hubbard had worked with pharmacies to set up on-site vaccination clinics so her residents could get the shot without having to leave home.

This September, when she contacted CVS and Rite Aid, they said that was no longer an option.

“They don’t have the staff to come in for any kind of clinics for COVID injections,” Hubbard said.

Worker shortages

Across Oregon, it’s become difficult for long-term care communities to host their own vaccine clinics “because pharmacies are experiencing workforce shortages and are not readily sending pharmacists out,” said Rosie Ward, a spokesperson for the Oregon Health Care Association, the long-term care lobbying association.

In the early days of the COVID-19 pandemic, long-term care residents accounted for nearly half of all deaths nationally. That led to a vast push as part of the federal government’s Operation Warp Speed to get the shot into nursing homes and assisted living facilities.

“It was an all hands on deck,” said Beth Biggs, a vice president at Consonus Pharmacy, a long-term care specialty pharmacy that helped lead the vaccination effort for seniors in Oregon.

That initial vaccination campaign and improvements in infection control and treatment brought down the death rate.

Biggs said the federal push didn’t rely solely on traditional pharmacy staffing. Instead, it brought in extra clinicians like retired nurses to get the shot out to long-term care residents quickly.

Now that the federal push is over, running on-site vaccination clinics is a hard model to sustain, so pharmacies are trying to return to more traditional channels for getting residents vaccinated.

“Trying to do this bulk clinic model, it’s really cumbersome,” Biggs said. “On both the state and national level, we are working to try to create systems that are more evened out.”

Biggs said long-term care facilities can look at options like partnering with a home health agency to deliver the vaccine or having advanced clinicians like physician assistants or nurse practitioners order the booster shot when visiting individual patients.

Avamere, the operator of The Pearl at Kruse Way, works with a long-term care pharmacy that delivers prescriptions and some vaccines to the facility. They too didn’t have any staff who could administer the shot, Hubbard said.

Hubbard eventually used her budget to order the booster from Avamere’s long-term care pharmacy, PharMerica, and gave the shot herself to the 25 residents who needed it. Because she was the person administering it and not a pharmacist, Medicare may not reimburse Avamere for its members who Hubbard vaccinated.

“It didn’t go unnoticed from our billing department that there’s no way set up to bill for this,” she said.

Few options

CMS, the Centers for Medicare and Medicaid Services, declined an interview request. In a statement, the agency said traditional Medicare recipients should pay nothing for the shot if they can get it from a doctor who accepts Medicare reimbursement rates. They said skilled nursing facilities can bill Medicare Part B for administering the shot.

CMS didn’t explain its plan for reaching seniors in assisted living or others who have trouble leaving their homes. Hubbard is concerned that other long-term care facilities won’t have the bandwidth — or the money in their budgets — to figure out how to get the COVID-19 booster to residents who can’t easily leave.

The early days of the pandemic may be receding from the public consciousness, but Hubbard remembers it all vividly.

In 2020, just before the first COVID-19 vaccine and treatments became available, the memory care unit at The Pearl experienced an outbreak.

Hubbard and the staff were able to keep it contained to one wing of the facility. But 40% of the residents who got the virus died.

“Watching people die and holding their hands and with families behind a glass window,” she said. “No one will ever forget that.”

Hubbard said it’s been a long time since she’s had residents at the Pearl hospitalized due to COVID-19. Two people got the virus this spring but had milder symptoms.

But she’s concerned that if there isn’t a more rigorous effort to keep long-term care residents up to date on their vaccinations, that could change.

“Those are the same people who are going to be in the hospital and potentially die because they couldn’t get a booster,” Hubbard said, “and that’s on us.”