Veterans Choice Program Increases Burden on VA Pharmacists

By Annette M. Boyle

Walid Gellad, MD, MPH, a Center for Health Equity Research and Promotion Core Investigator and staff physician at the VA Pittsburgh Healthcare System.

PITTSBURGH — The Veterans Access, Choice and Accountability Act in 2014 allows veterans to receive covered care and prescriptions from non-VA providers in a variety of situations.

While designed to improve access and reduce wait times for veterans, a study of pharmaceutical use during the Veterans Choice Program’s first year discovered that the program required a substantial investment of time on the part of VA pharmacists and put some patients at risk. The report was published recently in the journal Medical Care.1

“The main challenges were associated with the use of formulary medications,” said lead author Walid Gellad, MD, MPH, a Center for Health Equity Research and Promotion Core Investigator and staff physician at the VA Pittsburgh Healthcare System. “Pharmacists repeatedly brought up the issue of time, particularly associated with difficulty reaching prescribers and overcoming the unfamiliarity of prescribers with the VA formulary.”

The researchers analyzed the VA’s Pharmacy Benefits Management Service to identify how the Veterans Choice Program (VCP) affected pharmaceutical use and performed semi-structured interviews with pharmacy staff to understand the impact on pharmacy operations.

The study found that the program is effectively allowing veterans to fill outside prescriptions at the VA. In its first year of operation, the VA filled 56,426 prescriptions under the program for 17,346 veterans, despite a slow start. Monthly prescriptions filled through VCP did not reach 2,000 until May 2015, but then increased sharply, exceeding 14,000 prescriptions per month in October of that year. For reference, the study noted that the VA provided 145 million non-VCP prescriptions to veterans in 2015.

While accounting for a relatively small percentage of total prescriptions dispensed, the VCP had an outsized impact on operations and, potentially, on patient safety. “Implementation of the VCP introduces complexities and challenges for the VA in providing high-quality, safe, and cost-effective medications for veterans,” the authors wrote.


A few issues with the program arose immediately. Outside providers “do not have access to the VA order entry systems or its clinical decision support functions and do not typically have familiarity with the VA formulary,” the authors noted. Because they cannot tap into the order entry system, non-VA prescribers cannot submit prescriptions electronically. They must fax or mail them or give them to the patient to hand-deliver.

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  1. Dr. Patricia Kinne says:

    A couple of things come to mind, from a psychiatric standpoint:

    It’s hard enough when patients transfer from a community mental health provider to a VA provider… more often than not, they are on sedatives, sleeping pills, benzodiazepines and are sometimes physiologically addicted to harmful medications… in addition they are often misdiagnosed. In psychiatry, patients coming from the community are most frequently diagnosed with Bipolar Disorder, when they are actually PTSD, Intermittent Explosive Disorder, Personality Disorders, Substance Abusers, Alcoholics… who have “mood swings.” So, some of them are inappropriately on antipsychotics and mood stabilizers.

    I can’t imagine what the pharmacy staff have to go through handling the VCP controlled drug prescriptions. Although it wasn’t addressed, I’d imagine there would also be a spike in VCP prescriptions for benzodiazepine prescriptions. Both for the subset of VA psychiatric patients and medical patients. These addictive drugs are a lucrative and alluring way to maximize profits in private practice, they keep patients coming back, and giving them what they request builds psychological dependence. (full waiting rooms)

    Also, I’ve had VCP patients bring prescriptions to my desk and ask me to put the orders in the outpatient prescription order entry, as if I prescribed them, instead of entering them into the Non-VA medications area. I have, of course, declined.

    Sometimes veterans feel entitled to specific medications outside providers write, even when they may be harmful or contraindicated in the individual. It can become a disruption to the doctor patient relationship since it opens the door for conflict over differing opinions on appropriate medications.

    THEN who is responsible for metabolic monitoring???

    If this continues all outside providers should be mandated to become familiar w/ VA formulary, prescribing practices, and metabolic monitoring standards, to prevent patient dissatisfaction and improve patient safety.

    Peace, Dr. Kinne

    I really feel for the pharmacists in the sense that VA providers are well vetted… the community providers… who knows.

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