According to the US Department of Veterans Affairs (VA) Pharmacy Benefits Management Service, about 80% of all outpatient prescriptions filled by the VA are sent to veterans by mail order, using the Centralized Mail Order Pharmacy (CMOP) network of highly automated pharmacies around the country.1 During fiscal year (FY) 2016, the 7 VA CMOP facilities throughout the US processed 119.7 million outpatient prescriptions. Each day, these CMOPs process nearly 470,000 prescriptions, an evidence of the efficiency provided through this mail-order service.1 The use of CMOP results in lower processing costs and increased convenience for veterans compared with filling prescriptions at pharmacies at individual VA facilities. Notably, VA CMOP has been rated “among the best” mail-order pharmacies in customer satisfaction according to the 2017 J.D. Power US Pharmacy Study.2
Background
Within the Fayetteville VA Medical Center (FVAMC) system in North Carolina, on-site patients receive a new prescription where an on-site pharmacy is available (at health care centers [HCC] and the medical center). For veterans seen at community-based outpatient clinics (CBOCs), emergent new prescriptions are filled through vouchers at contract community pharmacies, and nonemergent new prescriptions are filled by the CMOP (Figure 1).
The appropriate use of the VA CMOP for refills is intended to allow on-site pharmacy staff to focus on providing customer service for veterans requesting medication counseling from a clinical pharmacist, as well as those with new, changing, or urgent prescription needs. Filling prescriptions through the CMOP also can help control the VA facility pharmacy budget.
Despite the established mail-order process, FVAMC staff noted a high volume of medication refill and partial-fill prescriptions being requested at the on-site pharmacy. When a veteran presented to a pharmacy requesting a medication refill, pharmacy staff members ordered a refill to be filled by the CMOP and provided a limited quantity, otherwise known as a partial fill, to serve as an emergency supply to supplement the veteran until the full quantity of the prescription arrived by mail. Partial fills also were completed for new prescriptions that veterans requested to pick up at the on-site pharmacy. For new 90-day supply prescriptions, pharmacy staff often filled a 30-day supply in addition to submitting the entire 90-day prescription through the CMOP, which led to an unnecessary increase in material expenditures and workload.Preliminary data noted the most frequently used partial-fill days’ supply to be 10 days. Due to the lack of partial-fill criteria, prescriptions of all classes, quantities, and days’ supplies were provided as partial fills. Prior to the implementation of this quality improvement (QI) project, there was no standard approach for how to handle these requests.
Partial fills do not provide copay reimbursement to the facility filling the prescription. In an effort to steward the funds provided to the FVAMC pharmacy department wisely, an evaluation was performed with reference to partial fills. During FY 2016, about $350,000 was spent on medications, materials, and workload associated with the partial filling of FVAMC prescriptions. With respect to unique individuals who were provided care over the course of FY 2015 and 2016, the number of unique patients served by local comparator hospitals increased by only 2%, while the number of unique patients served by FVAMC increased by 12%. This substantial growth in the number of veterans served places further emphasis on the necessity of stewarding the allotted pharmacy budget. Moreover, the excessive number of medication refill and partial-fill prescriptions filled at on-site VA pharmacies can contribute to increased wait times for veterans with urgent prescription needs.
In November 2016, FVAMC implemented an updated partial-fill guidance. Partial-fill process and refill education was provided for VA staff and veterans in an effort to allow all parties involved to use pharmacy services efficiently. This analysis reviewed the reduction in partial-fill expenditures with a secondary focus on workload expenditures following the execution of this education.
Methods
This project was deemed to be a QI project and did not require institutional review board approval. Implementation for this QI project began in November 2016. Baseline raw drug cost, number, and class of prescriptions partialed were retrospectively collected for a 90-day period prior to implementation using all available data. Postintervention data were collected for 90 days following the implementation phase to compare partial-fill expenditures and workload expenditures with baseline data.
Calculations
Materials included in the partial-fill expenditure calculation were prescription vials, prescription vial caps, and prescription labeling. Material cost per partial fill was determined by using the facility’s wholesaler acquisition unit costs to estimate a summed cost for an individual prescription vial and prescription vial cap. The estimated acquisition price of 7 prescription-labeling pages was used in the material calculation, as this was the average number of pages used when performing test partial fills.
