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With COVID-19 infections rising, people have eagerly scheduled appointments for the updated mRNA COVID-19 vaccines approved earlier this month, but many have faced issues getting the shot, revealing that the rollout has been anything but seamless.

Across social media, people have expressed about the issues with booking appointments -- and taking time out of their day -- only for the provider, including major pharmacy chains like Walgreens and CVS, to cancel appointments at the last minute, citing issues such as a lack of doses.

However, both Moderna and Pfizer-BioNTech claim to have plenty in stock.

Jesse Hackell, MD, chair of the Committee on Practice and Ambulatory Medicine for the American Academy of Pediatrics, said the vaccine rollout this year was faster than in previous years, but there was still a delay, which can be frustrating and confusing for patients.

"You know, people hear that the vaccine has been approved -- go get it, on Thursday, and they're lining up on Friday and it's not necessarily ready to go yet. It takes time to get the processes into place," said Hackell. "It's not just simply the vaccine is approved and, bingo, you go get it. There are a lot of moving parts to getting this done."

A Pfizer media relations representative told MedPage Today that following FDA approval and CDC endorsement, the company "shipped and delivered several million doses of its 2023-2024 COVID-19 vaccine" and is "continuing to fulfill orders and we anticipate delivering millions of additional doses each week." The spokesperson also noted that Pfizer does not have any supply shortages.

Similarly, Moderna released saying that after the shot was approved, the company "shipped millions of updated COVID-19 vaccines to our distributors across the United States," with more supply being shipped every day. Moderna is "working to support these distributors to ensure that the significant supply of vaccines we have already provided to them continues to rapidly reach pharmacies and other points of care." Moderna also said that it has 6 million doses available.

If there are allegedly adequate supplies available from both Moderna and Pfizer, what's leading to the problems with getting appointments?

While some factors, including rampant COVID-related misinformation, continue to be an issue, much has changed this year. First of all, the shots have a new formulation and those from previous years are no longer relevant. Plus, after several years of increased funding towards COVID-19, the federal public health emergency ended in May, which changes how the cost of COVID vaccines is covered. Now, providers take on that risk themselves and calculate how many they'll need -- and how many they can store in their facilities.

Insurance Approval Delays

Since the government is no longer universally covering COVID shots, insurers have to create systems to reimburse providers for the new shot. Last week, HHS Secretary Xavier Becerra to the "health care payer community," asking them for "continued partnership" and reminding them of their "legal obligations for coverage of the vaccines."

Meanwhile, earlier this month, HHS launched the which is "providing continued free coverage for the estimated 25-30 million adults who would have otherwise lost access to affordable COVID-19 vaccines now that the distribution of vaccines has transitioned to the commercial market."

Hackell also told MedPage Today that providers have to wait on insurance companies before they can bill for reimbursement.

"We can't order and pay for a vaccine if we're not sure we're going to get paid back adequately by the insurance companies. None of us can operate getting paid less than we spend on the vaccine because that will put us all out of business," Hackell said. "So pediatricians have been unwilling to even order the vaccine for their private patients unless they know from the insurance companies that they will get paid back adequately."

Kaiser Permanente (KP), one of the largest HMOs and insurers in parts of the country, has coverage delays, as well as delays in receiving booster stock. Other insurers are also facing these issues, too. For the millions of patients under their care, getting a booster at a non-KP facility isn't covered. Those patients are at the mercy of KP's stock and appointment availability.

A KP spokesperson told MedPage Today that it "expect[s] to begin administering updated COVID-19 vaccines in most areas we serve the week of September 25 and possibly earlier at some locations," and that "members are encouraged to get their updated COVID-19 vaccinations at a Kaiser Permanente facility at no cost to them."

Adequate Supply Needs to Arrive

One of the more obvious issues is that pharmacies and doctor's offices can't administer vaccines if the doses haven't arrived. And with delays in insurance coverage, some providers are starting with more conservative stock.

"We're still committed to an expenditure for a product that we cannot really anticipate the demand for at this point. So everybody is starting slow," Hackell said.

Pediatricians have an additional consideration: private insurance versus the CDC's (VFC) program, which provides free vaccinations for children who are Medicaid eligible, uninsured, American Indian or Alaska Native, or underinsured, administered by VFC registered providers. For pediatricians and other providers who use the VFC program, VFC doses and private insurance doses are ordered and stored separately since they go to separate populations.

In some ways, pediatricians and family medicine doctors are more prepared to order boosters, since they order and administer other vaccines. Doctors have to estimate how many people will actually come in to get each of the vaccines. In a media environment full of misinformation, some people don't want it, which Hackell said worries him. It also complicates his ordering process.

"Nobody wants to order a thousand doses and find out that only 20 people want to get it. The vaccine's not necessarily returnable for credit," he noted. Even if everyone did, offices can only hold so much vaccine stock at a time.

Moreover, if he has the wrong ratio of stock -- say, extra private insurance doses but no VFC doses -- a VFC patient, who can only receive vaccines from authorized providers, can't take those doses because VFC patients can't receive private insurance-covered vaccines and vice versa.

"There's really an issue of equitable access to any vaccines, but every time you see a rollout of a new one, and people want it, that inequity of access becomes much more apparent. It really stands out," said Hackell.

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