PROVIDENCE, R.I. (WPRI) – One of the biggest questions swirling around Rhode Island this week is why the state has rapidly fallen behind others in national rankings of vaccine distribution.

Rhode Island started out strong last month, celebrating one of the first COVID-19 vaccine doses administered in the region. But it has slipped in recent weeks, and as of Tuesday had fallen to No. 27 in the nation measured by doses administered per capita, according to the U.S. Centers for Disease Control and Prevention.

Health officials nonetheless continue to express optimism about where things stand, claiming vaccinations are happening as quickly as possible.

And that’s true to some extent: the state has maintained a consistent pace of averaging 1,670 new people vaccinated per day during January, which is not far below the roughly 2,000 a day that is the maximum possible based on Rhode Island’s weekly federal allotment of 14,000 first doses.

“I think we’re moving as quickly as we can,” Dr. Philip Chan, a consultant medical director at the R.I. Department of Health, told 12 News during a recent interview.

Yet behind the scenes health officials are not blind to the national rankings, and there are wheels in motion to try and shift some operations to improve the speed at which vaccines get into arms.

A major piece of the puzzle is the state’s public-private partnership with CVS Health and Walgreens, the two pharmacy giants responsible for vaccinating residents and staff at long-term care and assisted-living facilities.

The agreement — born out of Operation Warp Speed, the Trump administration’s vaccine program — was pitched as beneficial to the state because the private companies are well-equipped to deploy into the congregate living facilities, a process the state would have likely had to pay a company to do otherwise.

But it has also come with some inflexible requirements when it comes to moving around unused doses. That has prevented the state from shifting vaccines elsewhere – even if they’re not being used at the nursing homes.

Currently, about 42,000 of the 151,675 doses the state has received – roughly 27% of the total — have been allocated to the public-private partnership with CVS and Walgreens. And that total sounds high considering there were fewer than 8,000 nursing home residents in Rhode Island before the pandemic started, according to an estimate by the Kaiser Family Foundation.

But the allocation is stipulated by federal guidelines that are based on how many beds the state has available, not how many people are actually in them. That means if a facility has 100 beds but only 50 residents, the federal government still requires Rhode Island to allocate 100 of its doses for residents, plus more for staff.

“The federal government determines weekly vaccine allotments based on facility bed count and then doubles that for facility staffing, so vaccine allocations for CVS are based on an estimate, not the actual amount of vaccine that will be needed for a clinic at a facility,” CVS spokesperson Michael DeAngelis explained.

CVS had administered about 12,000 doses in long-term care vaccination clinics in Rhode Island as of Monday, DeAngelis said, completing 100% of first doses at skilled-nursing facilities, with second doses “well underway.”

Beginning Jan. 18, the pharmacies also moved on to assisted-living facilities, but health officials say that process started slowly because they were required to set aside at least 50% of the doses needed to complete the program – even before it began. (A similar delay happened before Christmas for the nursing homes program.)

Setting aside doses and the slow start to vaccinating other congregate living facilities inevitably slowed the state’s overall rollout, which is also happening in other states in similar situations, especially those that joined the public-private partnership and started vaccinating assisted-living facilities slowly. Those states include Pennsylvania, Maryland, Illinois, Wisconsin and Alabama, which are all in the bottom half of states based on vaccines administered per capita.

The last four rank within the bottom 10 states nationwide.

Meanwhile, the only state that opted out of the partnership – West Virginia – is leading the nation when it comes to getting vaccines in arms on a per capita basis. In North Dakota, which both opted into the program and is a current leader when it comes to vaccinating its residents, the state has encouraged its nursing homes to participate with other pharmacies outside of the partnership — which as a result meant a relatively low rate of nursing homes opted into the slower-paced program.

In Rhode Island, by contrast, just about all facilities opted into the program.

Health officials are not expressing any frustration with the program so far, and they are wary about taking away any doses from the program for congregate-living facilities, which have been hit the hardest during the pandemic. CVS and Walgreens are currently conducting three rounds of visits to all facilities in an attempt to boost participation.

But the state has asked the federal government for greater flexibility around how it uses the doses, especially if they know a certain amount isn’t going to be used in any given week.

“We can look at the allocation and pull some of that vaccine that’s going to CVS and Walgreens and pull either some of that vaccine or all of it out of that allocation and into the pot that we are able to draw from directly,” explained Alysia Mihalakos, chief of the R.I. Health Department’s Center for Emergency Preparedness and Response.

Of course, it’s not just the nursing home program that’s slowing Rhode Island down, as other factors have played a role, too.

Unlike other states that are doing relatively well, Rhode Island has been slow to offer vaccines to populations outside of its initial Phase 1 group, which includes nursing home residents, health workers, first responders and some high-risk inmates, along with adults 75 and older living at home.

Health officials are expected to unveil who gets the vaccine next on Thursday, but they are already an outlier compared to all other New England states, which have already indicated what comes next. Complicating the matter is a shift in leadership, as Gov. Gina Raimondo is poised to become U.S. commerce secretary, and she has not addressed any questions related to the pandemic in more than a month. Lt. Gov. Dan McKee will ascend to the state’s top job once Raimondo is confirmed.

The state has also taken deliberately specific steps to prioritize people in Phase 1, even offering people in the same profession vaccines based on age.

To address how the pandemic has hit certain neighborhoods harder than others, the state has also rolled out a pilot program in Central Falls, where health officials estimate infections throughout the pandemic could have exceeded 50% of the city’s population.

As a result, Rhode Island has decided to allocate a small amount of the total available doses to the one-square-mile city – rather than offering it more broadly.

And even there, city health officials said they first prioritized based on age, but have since opened it up to anyone who wants one, as demand wasn’t quite as high as hoped.

“What we’re trying to do is protect life, so we’re trying to get at highest risk first,” Dr. Michael Fine, Central Falls’ chief health strategist, told Target 12 during a recent interview.

There have also been snags along the way, including hundreds of improper appointments that were canceled after a sign-up link was shared with health care workers’ ineligible family and friends. More recently, a 1,000-dose program for a group of people with developmental disabilities was delayed a week because of a scheduling snafu.

Still, it’s not all working poorly.

Hospitals have done a relatively effective job getting vaccines into arms. The state’s largest hospital group, Lifespan, had as of Tuesday administered about 88% of the 15,850 total first doses it had received, and all of its 11,450 second doses were either administered or scheduled to be.

Care New England, meanwhile, had administered 9,917 doses over that same timeframe, although it wasn’t immediately clear how many it had received. CharterCare had administered about 81% of its 3,350 first and second doses and – like other facilities – was starting to offer vaccines to health care workers beyond its own workforce.

“Our initial focus was on accommodating frontline staff and those performing direct patient care,” CharterCare spokesperson Otis Brown said. “We have since expanded eligibility to physicians and employees across the CharterCare system who may interact with patients, such as registration and housekeeping, as well as those in high-risk minority groups.”

State health officials say they’re hopeful the process could become more efficient moving forward, crossing their fingers that other vaccines in the pipeline will be approved soon, which would boost supply. At the very least, Rhode Island expects the state’s vaccine supply to increase by the end of June – at the latest – as the federal government works to procure more doses.  

“The federal government did sign two agreements, one with Pfizer and one with Moderna, for additional capacity and both companies have assured us that those vaccines will become available to us in quarter two,” Mihalakos said. “So if nothing else, by the end of quarter two we should be seeing significant amounts of additional vaccine from those two manufacturers.”  

Chan, who has become one of the leading faces of Rhode Island’s coronavirus response in recent weeks, said he understands that people are anxious to get the vaccine as quickly as possible. And he remains hopeful the process will speed up in the next couple months, which he said people should be encouraged about — even if it feels painfully slow right now.

“Patience is the key,” he said.

Eli Sherman (esherman@wpri.com) is a Target 12 investigative reporter for 12 News. Connect with him on Twitter and on Facebook.

Brandon Truitt contributed to this report.