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Veterans’ Affairs Prescription Drug Coverage: A Voice of Reason

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Just this week, U.S. Senator Daniel Akaka (HI), Chairman of the Senate Veterans' Affairs Committee, addressed his Senate colleagues to respond to misconceptions and alleviate concerns surrounding VA prescription drug coverage; a sane voice among too many rhetoric ones. Last week I wrote about the absurdity of suggesting H.R. 4, the Medicare Prescription Drug Negotiation Act of 2007, was "...well-intentioned, but misguided quick fix [which] could literally endanger the health and lives of veterans...." The full-text of what Senator Akaka said can be found here (;=894

). What follows includes my comments on some of what he said.

Many Voices

"[M]uch has been said recently about the way in which VA purchases drugs and the manner in which medications are provided to beneficiaries." "Concerns have been raised about veterans' access to drugs, the quality of the benefit, and VA's formulary and pricing. Much of what has been said about veterans medication coverage is, frankly, wrong."

Notwithstanding all the gripes so many Veterans have about the VA system, never once have I heard any of us say anything negative about its drug cost savings or the level its benefit.

"While there is no question that VA's formulary is an important component of VA pharmacy management, decisions about which drugs are on the formulary are not made by bureaucrats nor are they made by those solely concerned about the bottom line." "VA employs a scientific review process to select drugs to be available to beneficiaries and to ensure quality care. Physicians and clinical pharmacists from the VA's regional offices manage the formulary." "If a drug is needed which is not on the formulary, VA has a quick process to ensure that the drug will be prescribed. This off-formulary process is so robust, in fact, that last year, VA dispensed prescriptions for an additional 1,416 drugs. So, to put a finer point on this, when a non-formulary medication is clinically needed -- it is provided."

Over the last six years, on three occasions my VA doctors (!) have prescribed a non-formulary item. After a short review process, all three were approved. Ironically, one item was even added to the formulary after it and its benefits became known locally.

"While some concern has been expressed that the VA formulary covers only 30 percent of the 4,300 drugs available on Medicare's market-priced formulary, this is not the case. Rather, it is my understanding that VA actually offers 11 percent more drugs than are available under Part D of Medicare." "VA offers 4,778 drugs by way of a "core' national formulary which requires that they must be made available at all VA medical care facilities." "To those who argue that VA's formulary is "among the most restrictive in the marketplace," I would only say that the Institute of Medicine [("IOM")] took a good long look at VA and found that in many respects it is actually less restrictive than other public or private formularies. The Chairman of the IOM Committee said that if VA did not have a formulary process like it has, they would have indeed urged that one be created just like it."

The IOM (

) serves as adviser to the nation to improve health. Established in 1970 under the charter of the National Academy of Sciences (which was created by the federal government to be an adviser on scientific and technological matters), the IOM provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The IOM process uses unpaid volunteer experts who author most reports. Each report: must go through an institutional process assuring a rigorous and formal peer review; has a requirement that findings and recommendations be evidence-based, and; if not evidence-based must be based on a noted expert's opinion. And, they liked what the VA was doing.

"Some have suggested that veterans receive substandard care because of the VA drug benefit. The literature says otherwise. Veterans get better pharmaceutical care than private or public hospitals, according to a study last year published in the Archives of Internal Medicine."

The Archives of Internal Medicine (

) promotes the art and science of medicine and the betterment of human health by publishing manuscripts of interest and relevance to internists practicing as generalists or as medical specialists. It began publication in 1908, and is an international peer-reviewed journal.

"VA's mail order pharmacy has been criticized, as well. VA employs nearly 10,000 pharmacists and technicians and is regarded by many pharmacy organizations as excellent. VA also operates 230 outpatient pharmacies. VA also trains more Doctors of Pharmacy than any other single organization in the U.S. And most significantly, while the error rate for prescriptions in the US is between 3 and 8 percent, the error rate in VA is less than one one-hundredth of one percent."

Let me say that again. The error rate for prescriptions in the US is between 3.0% and 8.0%. The error rate in VA is less than 0.01%. That is "between 0.03 & 0.08" versus "less than 0.0001."

"We know that VA gets the best prices, but I think the essential question is: Do veterans get the necessary drugs to promote the best health care? The answer -- based on peer-reviewed studies -- is a resounding yes." "When veterans' groups testify before Congress about their needs and desires, the only thing they say about their drug coverage is that they want to keep it the way it is." "And if some believe that veterans aren't happy with their drug access and pricing, it is news to me, and to the Administration."

Me too! I have helped many a retired veteran whose "good health plan" is "killing 'em" when it comes to their monthly drug costs. When they learn their private physician can write a script that they can have filled at the VA for $8.00 per 30-day supply, it does much put a smile on their face.

"We can learn a number of lessons from the VA as we consider Medicare price negotiations." "As Chairman of the Veterans Affairs Committee, I will closely monitor the evolution of this issue to ensure VA retains access to affordable drugs. The gains that can be made in Medicare - and the improvement of quality -- are just too great to do nothing."

Yes they are...

--- Regards, Walt Schmidt