Mail Order Pharmacy Policies Put Nearly Half of Veterans with HIV at Risk of Missing Doses

By Annette M. Boyle

Nasia Safdar, MD, PhD

MADISON, WI—Antiretroviral medications have transformed HIV from a death sentence into a chronic disease, but the drugs’ effectiveness depends on rigorous adherence to sometimes-complex regimens.

For veterans with HIV, adherence is often made difficult by the policies and procedures of the mail-order pharmacy system that they must use to obtain their medications. Nearly half of veterans with HIV in a recent study in Research in Social and Administrative Pharmacy reported that they ran out of medications because of issues with the VA’s mail order pharmacy system.1

Veterans who receive care through the VA must use the Consolidated Mail-Order Pharmacy (CMOP) system to obtain all medications for chronic conditions. In general, the veterans in this study reported high satisfaction with the mail-order pharmacy overall and in terms of its accuracy and their ability to use it when traveling. They had significant issues with medication coverage, however.

“What sets HIV patients apart from other mail-order users is their dependence on near-perfect adherence for sustained HIV suppression and survival and the virus’s long incubation period,” which often means patients take antiretrovirals for years or decades, the authors wrote.

The sequential, mixed-methods study of 57 veterans with HIV receiving care at a VA infectious disease clinic found that several factors associated with the mail-order pharmacy make “near-perfect adherence” particularly challenging for HIV patients.

Timing emerged as the major issue. In some locations, the mail-order “pharmacy defaults to a 90-day supply of a medication with exceptions for high-cost and high-risk medications. The antiretroviral medications fall into the high cost category,” co-author Andrew Wilcox, PharmD, chief of pharmacy at the William S. Middleton Memorial Veterans Hospital in Madison explained to U.S. Medicine. As a result, veterans with HIV can only receive 30 days of antiretrovirals at a time.

That creates a host of problems for these vulnerable patients, who frequently have a number of comorbidities, such as diabetes and hypertension, in addition to HIV. The majority of the veterans in the study had four or more conditions and required multiple medications. Most of their medications had 90-day refill cycles. The difference in timing for refills, combined with a lack of synchronization for those on the 90-day schedule, contributed to confusion, late refills and missed doses.

As one veteran noted in an interview, “I get confused as which one I—because I have like so many meds. … And then, you know, like a follow-up if that’s necessary. And then I get confused; did I order this one or not?”

Another told the researchers, “I knew I could tell myself if I’ve got to reorder because I only have so many left. Well, then I forgot. And two or three days later, I reorder it. By then I have skipped like every other day to make sure that I would have enough.”

Long Lead Times

To receive their HIV medications on time, veterans reported needing to place their refill orders at least 10 days in advance. Additional lead time was required, if the standard six refills had been completed, as all antiretroviral prescription renewals must be submitted to the Infectious Disease Clinic, even for patients who have no changes in their medications. That review process can add a week or more to the refill time.

In several interviews, veterans recounted waiting 10 days for medications and then calling to check on the status, only to be told that the pharmacy had no record that they had called in a refill. In other instances, the order had been misplaced or took three weeks to arrive.

According to the study, these issues contributed to 47% of the patients in the study reporting running out of HIV medications. Of those, 31% said they sometimes ran out, while 12% said they usually ran out and 2% said they almost always ran out of medication before their refills arrived.

One veteran said he had “to head to the ER … three times already” to receive medication to bridge until his refills arrived.

Being able to receive a few days’ doses from the local hospital was one of several ways veterans said the VA worked with them to fill in gaps in medication coverage. “The interviews suggested the VA was very responsive in ensuring patients received the medications when informed of such situations. Veterans reported a number of work-arounds in place to ensure quick delivery, such as overnight shipping and providing emergency supply,” said study co-author Nasia Safdar, MD, PhD, associate chief of staff for research and staff physician in infectious diseases at the Middleton VAMC.

The researchers recommended several ways to reduce the risk of missed doses and the burden associated with refills for antiretrovirals for veterans who have HIV. They noted that many veterans expressed a desire to receive their antiretroviral medications on the same 90-day cycle as their medications for other chronic conditions. Previous studies support the patients’ view, finding that providing multiple month-refills improves adherence, the authors said.

The researchers also saw a role for pharmacists in helping patients streamline and synchronize their medication schedules. In addition, they recommended a system-initiated automated ordering process that could relieve patients of the need to remember to place refill orders.

The researchers found that pharmacists could serve as a valuable resource for patients, many of whom found the information sheets provided with their medications difficult to understand and lacking in crucial information. Pharmacists could also help patients with drug-drug interactions and side effects, which at least one patient reported addressing by unilaterally deciding to cut his dosage in half, rather than consulting with either his physician or a pharmacist.

“With the increasing complexity of drug therapy, pharmacists are uniquely positioned to provide patient-centered medication management services as part of interdisciplinary teams,” said Safdar. “In veterans living with HIV/AIDS, clinical pharmacists can monitor medication regimens for effectiveness and adherence, as well as manage adverse effects. Pharmacist can also tailor and simplify medication education for ease of understanding and comprehensively review patient medication regimens.”

  1. Desai KR, Chewning B, Wilcox A, Safdar N. Mail-order pharmacy experience of Veterans living with AIDS/HIV. Res Social Adm Pharm. 2017 Feb 24. pii: S1551-7411(17)30098-0. doi: 10.1016/j.sapharm.2017.02.005. [Epub ahead of print]

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  1. Mariano Franchi says:

    The recent U.S. Medicine article by Annette M. Boyle entitled “Mail Order Pharmacy Policies Put Nearly Half of Veterans with HIV at Risk of Missing Doses”, which was informed by a recent article incorrectly reports that VA’s mail order pharmacy policy limits the days’ supply of HIV medication that Veterans can obtain from VA’s mail order pharmacies .

    The title of Ms. Boyle’s article is unnecessarily inflammatory and nothing can be further from the truth- VA does not have a mail order pharmacy policy that puts Veterans at risk and further, data from one VA facility is not representative of the VA system as a whole. In fact, for the period covering October 1, 2016 through June 30, 2017, 62 percent of all HIV medication prescriptions filled in VA’s mail order pharmacies were filled in greater than one month supplies.

    To be clear, decisions about the quantities of medications to be dispensed and whether those medications are to be dispensed by a VA medical facility pharmacy or by a VA mail order pharmacy rest solely with the VA physicians and pharmacists who are providing care, not with VA mail order pharmacy personnel. Presumably, these prescribing and dispensing decisions are based on discussions between Veterans and their providers with a goal of optimal medication adherence and ensuring Veterans stay connected with their providers.

    We would also like to point that Veteran patients have recognized VA’s mail order pharmacies as the highest ranking mail order pharmacy in the United States for 6 of the past 7 years, having missed first place in 2016 by 1 point out of a possible 1000. We encourage any Veteran who reads this article to discuss their medication supplies with their VA provider at their next visit to ensure they have adequate supplies of medications available to them.

    Mario Franchi
    Deputy Chief Consultant CMOP
    Pharmacy Benefits Management Services
    CMOP (770)
    5409 S. 13th Street
    Leavenworth, KS. 66048

    Michael Valentino
    Chief Consultant
    Pharmacy Benefits Management Services
    Department of Veterans Affairs
    810 Vermont Avenue NW
    Washington, DC 20420

  2. Andrew Wilcox says:

    To the Editor-in-Chief:
    In reference to: “Mail Order Pharmacy Policies Put Nearly Half of Veterans with HIV at Risk of Missing Doses” published online for U.S. Medicine in July 2017:

    At the William S. Middleton Memorial Veterans Hospital in Madison, Wis. (aka Madison VA), our core values of Integrity, Commitment, Advocacy, Respect and Excellence are more than just words. These values define how we approach our work and affect outcomes in our daily interactions with Veterans. The Madison VA’s local Infectious Disease and Pharmacy departments are committed to these values and strive to provide patient-centered care on a daily basis.

    The use of the Consolidated Mail-Order Pharmacy (CMOP) system by HIV patients to obtain medications recently received scrutiny after an article was published online with U.S. Medicine reviewing a study completed at a single VA site. The research analyzed surveys completed by patients who have utilized CMOP services. As referenced in the article, there are some negative aspects of mail order pharmacy. However, this article does not accurately portray the entirety of what the study discovered. Major conclusions of the study about the VA CMOP that are not mentioned in the U.S. Medicine article include:
    • 90% of Veterans reported never or rarely having errors with the medications they received.
    • 88% of Veterans felt that once the order was placed, it almost always or usually arrived on time.
    • 94% reported never or rarely having problems when they travel, suggesting the advantage of being served by the VA as a health care system that covers the United States.

    The article also fails to note CMOP has been recognized as one of the J.D. Power’s highest-performing mail-order pharmacies for eight years in a row, ranking second in 2016.

    The results of this small study cannot be extrapolated to services provided by CMOP or other VA facilities. The Madison VA fulfills patients’ HIV medications typically as a 30-day supply; however, up to a 90-day supply may be requested at a patient’s or provider’s request. The study results have directed our efforts to respond to Veterans’ preferences and learn from our previous approaches to better support improved medication adherence. We have instituted a plan to ensure Veterans have consistent access to a 90-day supply of HIV medications. The Madison VA can fill medications onsite the same day, can overnight mail medications, and can authorize Veterans’ picking up medications in the community. These are all strategies used to rapidly address and respond to Veteran medication needs. The study provided insight into Veterans’ experiences and opinions that helped us advance our awareness, education efforts, and processes to be more Veteran-centric and improve the mail-order pharmacy services received by all Veterans served by the Madison VA.

    Andrew Wilcox, PharmD
    Chief, Pharmacy Service
    Residency Program Director, PGY1/2 HSPA
    William S. Middleton Memorial Veterans Hospital
    2500 Overlook Terrace
    Madison, WI 53705

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