VA

Question 1

VA Overview

Answer 1

• single largest managed care organization in the US –> 9.2 million enrolled veterans
• single source for care to veterans (primary care is the backbone)

Government Agency
- focused on COST AVOIDANCE
- revenue recovery through 3rd party billing (exception of Medicare)
- politics can influence

Question 2

VA Customers

Answer 2

veterans served at least 2 full years of active duty
- spouses/children generally NOT covered

Autoqualify
- disabilities
- agent orange
- radiation
- burn pits
- purple heart recipients
- former prisoner of war

Question 3

What does a veteran look like?

Answer 3

generally think of:
- white, older, male

Trends:
- decline in total population of veterans (baby boomers dying off)
- increases in black & hispanic
- increases in female

Question 4

VA Organizational Structure

Answer 4

Secretary of Veterans Affair (appointed by president)
- Veterans Health Administration
- Veterans Benefit Administration
- National Cemetery Administration

Question 5

Statistics of VA

Answer 5

• 18 regional networks –> IN is 10
• 171 medical centers
• 1400 outpatient clinics

Question 6

VA Funding

Answer 6

• primarily federal income taxes
• funding is distributed using capitation model called VERA (Veterans Equitable Resource Allocation)

FY24 Budget: 325.1 billion

Question 7

VERA

Answer 7

• per capita distribution model based on # of Veterans in area
• veterans have a primary facility they are linked to
• medical complexity of each Veteran is considered

Pros: protection from govt shutdowns
Cons: funding not realized for 3 years from date of service

Question 8

Rx Fullfillment

Answer 8

• nationally integrated EMR
• follow federal pharmacy regulations –> not state laws
• pharmacists can be licensed in ANY state

Question 9

Mail Order Pharmacy

Answer 9

• primarily for refills
• highly automated operation

Chicago: non-controlled (5)
Charleston: controlled (2)

CANNOT FILL C-II
WORKS TO REDUCE OVERHEAD COSTS

Question 10

Emergency Pharmacy Services

Answer 10

• strategi national stockpile –> not just reserved for veterans
• Disaster Emergency Medical Personnel System
• Mobile pharmacy (5)

Question 11

Medication Care Management

Answer 11

• treated as mid-level practioners –> prescriber status

Roles
- review all meds with each fill by EMR
- counseled on meds prior to dispensing
- formulary substitutions & conversions without MD approval
- adjust quantities
- supply items (diapers, catheters, bandages)

Question 12

VA National Formulary

Answer 12

• closed & national formulary
• national P&T Committee sets formulary for all VA in US
• national contracts to leverage cost containment (payer & provider)

Copays:
- Tier 1: 5$
- Tier 2: 8$
- Tier 3: 11$
Max OOP: $700/year
NO COPAYS FOR CONDITIONS DIRECTLY LINKED TO SERVICE
IF PA, RHPH PROVIDES PA

Question 13

PA Requests

Answer 13

• entered by prescriber
• adjudicated by VA pharmacist and decision made

Question 14

MISSION ACT

Answer 14

• redefined how Veterans can receive medical care outside of the VA

Impact on Pharmacy:
- increased outside Rx’s
- urgent and emergent refills
- workflow more similar to community pharmacy

Question 15

Population Health Tools

Answer 15

DATA RICH
- Primary Care Almanac: stratifies patients based on disease state outliers
- Patient Aligned Care Teams: stratifies patients based on diagnosis
- Care Assessment Needs: estimated probability of admission or death in a specified time period