The VA is in full retreat about it's penny-wise pound foolish formulary approach. It presented a power point presentation at an AEI summit on price controls in Medicare and then exported the propaganda to a meeting on drug formularies in Helsinki which is ironically the namesake of protocols designed to protect patients from getting screwed without their knowledge.
http://www.aei.org/events/eventID.1447,filter.all/event_detail.asp
Here's a breakdown of the myth's and fact's that the VA is now pushing:
1. VA offers more individual drugs that Part D
Fact: The VA offers more different varieties of the SAME drug but (formulations, doses, etc). Part D offers more unique new molecular entitites.
2. The VA formulary is not restrictive
Fact: The VA quotes a report written in 1998 (published in 2000) before it began an effort to push prescribers to adhere more tightly to closed formularies.
3. VA system participants live longer lives
Fact: The VA outright lies and uses a chart that is an outright mischaracterization of Frank Lichtenberg's study Older Drugs, Shorter Lives? An Examination of the Health Effects of the Veterans Health Administration Formulary (which I commissioned when at the Manhattan Institute).
http://www.manhattan-institute.org/html/mpr_02_f4.htm
Frank's chart is above. As you can see, he never claims that people in the VA don't live longer than people not in the VA. And he explains why in a footnote to the paper.
While there are some reasons to expect the mean value of Et to be lower than the mean value of the life expectancy of all U.S. males at birth-serving in the military may impair one's future health-there are other reasons to expect it to be greater. Et is based on a population of individuals who have been veterans, i.e., who lived long enough to serve in the armed forces (e.g., did not die in infancy) and who survived serving in the armed forces. It would be more appropriate to compare Et with the life expectancy of all U.S. males at age twenty, for example. Such data are available for some years (it was 73.25 for 1989-1991 and 75.6 in 2002) but are not available annually (Arias, 2004, Table 11).
What Lichtenberg shows is that after the VA formulary was introduced, the increase in life expectancy at any given period declined. He did not compared differences in LE.
But that's not good enough for the VA. It had to fudge the chart itself. So it introduced a chart that compared periodic life expectancy of vets to life expectancy of all Americans at birth in a way that erases the decline in life expectancy.
4. The VA claims it provides better pharmaceutical care.
Fact. There are many health care services that the VA does extremely well. However to the extent that the VA itself seeks to reduce hospitalizations and prevent disease the use of the best pharmaceuticals is critical to maximizing these goals. The failure of the VA to devote its considerable health IT resources to determine what the best drug for the right patient is reflects an insular and outdated view of medicine. It is very good at achieving better results on process measures relative to some commercial health plans and some evidence that the care it provides is a good as private hospitals. But the VA refuses to allow outside researchers examine the impact of formulary restrictiveness on patient outcomes and total health care costs.
5. The VA doesn't use mail order pharmacy.
Fact: According to GAO and the VA itself, the VA fills 83 percent of its prescriptions through mail order.
6. The VA claims newer is not always better
Fact: Does that mean the VA has more older drugs than Medicare Part D. Does that mean older is always better? In fact, most new drugs are associated with an increase in well-being and clinical improvement with some subpopulation. And in the case of the VA it has not added drugs even the FDA regarded as priority medicines, drugs that have a significant therapeutic value, to its formulary.
7. The VA does not have have a three year wait on all new drugs.
Fact: The VA is right on this count. Sort of. It generally waits a year. Or longer. It was only recently, under pressure from Part D, that it began adding new medicines in a timely fashion. It still hasn't added many new cancer drugs.
8. There have not been 1 million Part D defections
Fact: No defections. But 2 million have signed up for Part D in addition to the VA benefits they receive. Why can't the VA just be honest. There are plenty of people who double dip...
9. Drugs not on the VA formulary are in fact available.
No one said they are unavailable. That's a VA strawman. Drugs not on the formulary are just hard to get. It takes anywhere from 3 days to a week to get an answer. Often you have to try a drug for a while before you can ask for a change, which means traveling to see a doctor. As a result, even the VA's own numbers show that less than 5-10 percent of its patients get medicines like Lipitor, Ambien or Protonix.
10. Doctors are satisfied with the restrictive formularies.
Fact. Fully a third of all doctors who took the time to respond to a VA run survey complained it took too long to get requests answered. (Provider perceptions of pharmacy management: lessons from the military health system.
Med Care. 2004 Apr;42(4):361-6. )
Another survey (also self-selected respondents) found that 35 percent of doctors believed the national formulary restricted access to important drugs. Glassman PA, Good CB, Kelley ME, Bradley M, Valentino M, Ogden J, Kizer KW. Related Articles, Links
Free Full Text Physician perceptions of a national formulary.
Am J Manag Care. 2001 Mar;7(3):241-51.
http://www.aei.org/events/eventID.1447,filter.all/event_detail.asp
Here's a breakdown of the myth's and fact's that the VA is now pushing:
1. VA offers more individual drugs that Part D
Fact: The VA offers more different varieties of the SAME drug but (formulations, doses, etc). Part D offers more unique new molecular entitites.
2. The VA formulary is not restrictive
Fact: The VA quotes a report written in 1998 (published in 2000) before it began an effort to push prescribers to adhere more tightly to closed formularies.
3. VA system participants live longer lives
Fact: The VA outright lies and uses a chart that is an outright mischaracterization of Frank Lichtenberg's study Older Drugs, Shorter Lives? An Examination of the Health Effects of the Veterans Health Administration Formulary (which I commissioned when at the Manhattan Institute).
http://www.manhattan-institute.org/html/mpr_02_f4.htm
Frank's chart is above. As you can see, he never claims that people in the VA don't live longer than people not in the VA. And he explains why in a footnote to the paper.
While there are some reasons to expect the mean value of Et to be lower than the mean value of the life expectancy of all U.S. males at birth-serving in the military may impair one's future health-there are other reasons to expect it to be greater. Et is based on a population of individuals who have been veterans, i.e., who lived long enough to serve in the armed forces (e.g., did not die in infancy) and who survived serving in the armed forces. It would be more appropriate to compare Et with the life expectancy of all U.S. males at age twenty, for example. Such data are available for some years (it was 73.25 for 1989-1991 and 75.6 in 2002) but are not available annually (Arias, 2004, Table 11).
What Lichtenberg shows is that after the VA formulary was introduced, the increase in life expectancy at any given period declined. He did not compared differences in LE.
But that's not good enough for the VA. It had to fudge the chart itself. So it introduced a chart that compared periodic life expectancy of vets to life expectancy of all Americans at birth in a way that erases the decline in life expectancy.
4. The VA claims it provides better pharmaceutical care.
Fact. There are many health care services that the VA does extremely well. However to the extent that the VA itself seeks to reduce hospitalizations and prevent disease the use of the best pharmaceuticals is critical to maximizing these goals. The failure of the VA to devote its considerable health IT resources to determine what the best drug for the right patient is reflects an insular and outdated view of medicine. It is very good at achieving better results on process measures relative to some commercial health plans and some evidence that the care it provides is a good as private hospitals. But the VA refuses to allow outside researchers examine the impact of formulary restrictiveness on patient outcomes and total health care costs.
5. The VA doesn't use mail order pharmacy.
Fact: According to GAO and the VA itself, the VA fills 83 percent of its prescriptions through mail order.
6. The VA claims newer is not always better
Fact: Does that mean the VA has more older drugs than Medicare Part D. Does that mean older is always better? In fact, most new drugs are associated with an increase in well-being and clinical improvement with some subpopulation. And in the case of the VA it has not added drugs even the FDA regarded as priority medicines, drugs that have a significant therapeutic value, to its formulary.
7. The VA does not have have a three year wait on all new drugs.
Fact: The VA is right on this count. Sort of. It generally waits a year. Or longer. It was only recently, under pressure from Part D, that it began adding new medicines in a timely fashion. It still hasn't added many new cancer drugs.
8. There have not been 1 million Part D defections
Fact: No defections. But 2 million have signed up for Part D in addition to the VA benefits they receive. Why can't the VA just be honest. There are plenty of people who double dip...
9. Drugs not on the VA formulary are in fact available.
No one said they are unavailable. That's a VA strawman. Drugs not on the formulary are just hard to get. It takes anywhere from 3 days to a week to get an answer. Often you have to try a drug for a while before you can ask for a change, which means traveling to see a doctor. As a result, even the VA's own numbers show that less than 5-10 percent of its patients get medicines like Lipitor, Ambien or Protonix.
10. Doctors are satisfied with the restrictive formularies.
Fact. Fully a third of all doctors who took the time to respond to a VA run survey complained it took too long to get requests answered. (Provider perceptions of pharmacy management: lessons from the military health system.
Med Care. 2004 Apr;42(4):361-6. )
Another survey (also self-selected respondents) found that 35 percent of doctors believed the national formulary restricted access to important drugs. Glassman PA, Good CB, Kelley ME, Bradley M, Valentino M, Ogden J, Kizer KW. Related Articles, Links
Free Full Text Physician perceptions of a national formulary.
Am J Manag Care. 2001 Mar;7(3):241-51.
