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.

Once a prescription is received, a VA pharmacist must ensure it meets VA formulary guidelines. All but one of the 27 pharmacists who completed the qualitative interview with the researchers reported having received nonformulary prescriptions from outside providers, which then required outreach and education on the part of the pharmacist.

One said, “We’ve had to do a lot of education, calling doctors’ offices . . . if something was written that wasn’t necessarily formulary … we have to work with the private providers and get those prescriptions changed. And, of course, that takes a lot of time and effort to do that.”

Reaching Out to Non-VA Providers

Many pharmacists mentioned the difficulty of reaching non-VA providers to discuss the formulary or appropriate use concerns, especially when those providers might keep different hours and pharmacists might not have direct lines to them. In addition, one noted that, in urgent cases the pharmacist might have to develop a workaround that involves VA providers to get the patient a prescription quickly: “If we fill something that they need right away and we have difficulty that we can’t get anywhere with the outside system, sometimes we have to have our VA provider enter the prescription.”

Ensuring that prescriptions are on the formulary is not only a matter of following the rules, it’s also an effort to protect veterans from unexpected and potentially substantial costs. The VCP will not reimburse a veteran for prescriptions not on the formulary, so a veteran could be out hundreds of dollars if a pharmacist does not explain the issue to the prescriber and get an approved substitute. From the pharmacist’s point of view, to do the right thing by the veteran “you’re essentially asking us to be an insurance agent now, in addition to being a pharmacist.”

The study also uncovered some significant differences between medications commonly dispensed through the VCP and those generally prescribed within the VA. The top five drug classes among prescriptions written by non-VA providers were opioid analgesics, topical ophthalmic anti-inflammatories, antivirals, topical ophthalmic antibacterials and anticonvulsants. Prednisolone and ketorolac eye drops were the first and fifth most-prescribed drugs and eye drops, in total, accounting for 15.6% of all VCP prescriptions. Oxycodone and hydrocodone were also in the top five most- prescribed drugs through VCP.

 

In comparison, among non-VCP prescriptions, neither oxycodone nor any eye drop makes the list of the top 25 most-common drugs.

Handling prescriptions for opioids from non-VA providers creates additional challenges for both the VA pharmacies and veterans. Prescriptions for Schedule 2 controlled substances cannot be faxed, so if a veteran needs an opioid urgently, as is often the case, they must hand-deliver the prescription to the VA pharmacy. That negates some of the advantages of the Choice program, which makes local care available for patients who live more than 40 miles from a VA facility.

Pharmacists also noted that VA and VCP providers have differing standards for prescribing opioids. They expressed concern that the Choice program could work against the VA’s efforts to address opioid abuse among veterans and lead to misunderstandings. One pharmacist described a common situation in which an outside provider prescribes opioids following surgery and then steadily steps up the dose. When the provider turns the patient back over to the VA, the VA provider takes the veteran off the opioid in accordance with guidelines “and the patient feels that the VA is taking drugs away from him.”

Pharmaceutical use in the Choice program’s first year was markedly skewed by treatments for Hepatitis C (HCV). HCV treatments for 941 veterans consumed 90% of the $27 million spent on the program from November 7, 2014 to November 7, 2015. The researchers noted that the high proportion of the total costs associated with HCV treatment that year came as the VA experienced a surge in demand for the therapies which outstripped available funding within the VA, leading some veterans to secure the treatments through the VCP. The availability of HCV medications within the VA substantially increased in 2016, so the researchers did not anticipate that future years would see the same dominance of HCV therapies.

Other issues illustrated by the use of HCV therapies might persist, researchers suggested, including confusion on the part of patients, providers and pharmacists about who was responsible for conducting follow-up care, ensuring medication adherence and performing necessary labwork.

Clarifying care coordination can ensure appropriate monitoring and best outcomes for the very expensive HCV therapies, and help veterans, prescribers and pharmacists as more patients use the Choice and other non-VA care programs.

“The issue of lab data and hand-delivered prescriptions are both issues the VA has to address as it moves forward with expansion of private care options,” Gellad told U.S. Medicine.

Addressing the issues with VCP pharmacy benefits can offer long-term benefit to the VA and veterans and improve the ability of VA pharmacies to incorporate outside prescriptions seamlessly into their workflow. “The VA is increasingly going to offer care in the community,” Gellad pointed out, “and parallel to those initiatives have to be robust efforts to increase data sharing so that providers both inside and outside the VA have all the information they need right at their fingertips to care for patients.”

  1. Gellad WF, Cunningham FE, Good CB, Thorpe JM, Thorpe CT, Bair B, Roman K, Zickmund SL. Pharmacy Use in the First Year of the Veterans Choice Program: A Mixed-Methods Evaluation. Med Care. 2017 Feb 17. doi: 10.1097/MLR.0000000000000661. [Epub ahead of print]