VA Flashcards
VA Overview
- 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
VA Customers
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
What does a veteran look like?
generally think of:
- white, older, male
Trends:
- decline in total population of veterans (baby boomers dying off)
- increases in black & hispanic
- increases in female
VA Organizational Structure
Secretary of Veterans Affair (appointed by president)
- Veterans Health Administration
- Veterans Benefit Administration
- National Cemetery Administration
Statistics of VA
- 18 regional networks –> IN is 10
- 171 medical centers
- 1400 outpatient clinics
VA Funding
- primarily federal income taxes
- funding is distributed using capitation model called VERA (Veterans Equitable Resource Allocation)
FY24 Budget: 325.1 billion
VERA
- 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
Rx Fullfillment
- nationally integrated EMR
- follow federal pharmacy regulations –> not state laws
- pharmacists can be licensed in ANY state
Mail Order Pharmacy
- primarily for refills
- highly automated operation
Chicago: non-controlled (5)
Charleston: controlled (2)
CANNOT FILL C-II
WORKS TO REDUCE OVERHEAD COSTS
Emergency Pharmacy Services
- strategi national stockpile –> not just reserved for veterans
- Disaster Emergency Medical Personnel System
- Mobile pharmacy (5)
Medication Care Management
- 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)
VA National Formulary
- 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
PA Requests
- entered by prescriber
- adjudicated by VA pharmacist and decision made
MISSION ACT
- 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
Population Health Tools
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