Original Research

Assessment of Consolidated Mail Outpatient Pharmacy Utilization in the Indian Health Service

Fed Pract. 2020 July;37(7):325-330

Author(s):

LCDR Keith Warshany, PharmD, PhC, BCPS, NCPS

Background: The Indian Health Service (IHS) has an agreement with the US Department of Veterans Affairs (VA) that allows IHS to use the VA Consolidated Mail Outpatient Pharmacy (CMOP) to send prescriptions to IHS patients. However, there is high variability among IHS facilities in the use of CMOP. Furthermore, there is no available resource that summarizes the relative positives/negatives, challenges/opportunities, and strengths/weaknesses of implementing CMOP.

Methods: A 10-item questionnaire was developed to collect information on various aspects of prescription processing through CMOP. The questionnaire was distributed among the primary CMOP contacts of IHS facilities between December 2018 and January 2019.

Results: The CMOP contacts at 44 of 94 (47%) IHS sites responded to the survey. Of the 347 respondents, 310 (89%) pharmacists were trained in CMOP prescription processing. To get information about CMOP rejections, 53% (185/347) of pharmacists check electronic messages. Twelve (27%) sites utilize technicians in some capacity in the CMOP process. Of the 16 facilities that require patients to request prescriptions to be mailed for each refill request, 8 (50%) do not use any method to designate a CMOP patient. Three sites (7%) have measured patient satisfaction with the CMOP program. Thirteen sites (31%) reported that they are losing insurance reimbursements by using CMOP. The decrease in insurance reimbursements, lengthy prescription processing time, and medication backorders are the most common challenges shared by respondents.

Conclusions: CMOP presents unique challenges to pharmacy workflow but provides many benefits that local pharmacy mail-out programs usually do not possess, such as the ability to mail refrigerated items. Furthermore, it is likely that local programs that utilize mail delivery will increase pharmacy workload. However, there is a lack of objective data to assess the net effect of CMOP on patients. Nevertheless, the successful implementation of CMOP can lead to reduced pharmacy workload while increasing access to care for patients with transportation issues.

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References

2. US Department of Veterans Affairs. Pharmacy Benefits Management Services. VA mail order pharmacy. https://www.pbm.va.gov/PBM/CMOP/VA_Mail_Order_Pharmacy.asp. Updated July 18, 2018. Accessed July 16, 2019.

3. US Department of Veterans Affairs. Memorandum of understanding between the Department of Veterans Affairs (VA) and Indian Health Service (IHS). https://www.va.gov/TRIBALGOVERNMENT/docs/Signed2010VA-IHSMOU.pdf. Published October 1, 2010. Accessed June 11, 2020.

4. US Department of Veterans Affairs, Office of Tribal Government Relations, Office of Rural Health, US Department of Health and Human Services, Indian Health Service. U.S. Department of Veterans Affairs and Indian Health Service memorandum of understanding annual report fiscal year 2018. https://www.ruralhealth.va.gov/docs/VA-IHS_MOU_AnnualReport_FY2018_FINAL.pdf. Published December 2018. Accessed June 11, 2020.

5. Karsten S. CMOP items of interest. Published October 12, 2018. [Nonpublic document]

6. Fernandez EV, McDaniel JA, Carroll NV. Examination of the link between medication adherence and use of mail-order pharmacies in chronic disease states. J Manag Care Spec Pharm. 2016;22(11):1247‐1259. doi:10.18553/jmcp.2016.22.11.1247

7. Schwab P, Racsa P, Rascati K, Mourer M, Meah Y, Worley K. A retrospective database study comparing diabetes-related medication adherence and health outcomes for mail-order versus community pharmacy. J Manag Care Spec Pharm. 2019;25(3):332‐340. doi:10.18553/jmcp.2019.25.3.332

8. Schmittdiel JA, Karter AJ, Dyer W, et al. The comparative effectiveness of mail order pharmacy use vs. local pharmacy use on LDL-C control in new statin users. J Gen Intern Med. 2011;26(12):1396‐1402. doi:10.1007/s11606-011-1805-7

9. Devine S, Vlahiotis A, Sundar H. A comparison of diabetes medication adherence and healthcare costs in patients using mail order pharmacy and retail pharmacy. J Med Econ. 2010;13(2):203‐211. doi:10.3111/13696991003741801

10. Kappenman AM, Ragsdale R, Rim MH, Tyler LS, Nickman NA. Implementation of a centralized mail-order pharmacy service. Am J Health Syst Pharm. 2019;76(suppl 3):S74‐S78. doi:10.1093/ajhp/zxz138

11. US Department of Health and Human Services, Indian Health Service. Crownpoint service unit. www.ihs.gov/crownpoint. Accessed June 11, 2020.

12. Chaco P. Roads and transportation on the Navajo Nation. https://obamawhitehouse.archives.gov/microsite/blog/31387?page=135. Published February 15, 2012. Accessed June 11, 2020.

13. US Department of Health and Human Services, Indian Health Service. Disparities. www.ihs.gov/newsroom/factsheets/disparities. Updated October 2019. Accessed June 11, 2020.

14. Golden State Medical Supply. National contracts. www.gsms.us/wp-content/uploads/2018/10/National-Contracts-Flyer.pdf. Updated October 4, 2018. Accessed June 11, 2020.

15. Arizona Health Care Cost Containment System. IHS/Tribal provider billing manual chapter 9, hospital and clinic services. www.azahcccs.gov/PlansProviders/Downloads/IHS-TribalManual/IHS-Chap09HospClinic.pdf. Updated February 28, 2019. Accessed June 11, 2020.

16. US Department of Veterans Affairs, Office of Inspector General. The impact of VA allowing government agencies to be excluded from temporary price reductions on federal supply schedule pharmaceutical contracts. www.va.gov/oig/pubs/VAOIG-18-04451-06.pdf. Published October 30, 2019. Accessed June 11, 2020.

17. Karsten S. IHS Billing Report-Apr. Indian Health Service SharePoint. Published May 3, 2019. [Nonpublic document]

18. Aragon BR, Pierce RA 2nd, Jones WN. VA CMOPs: producing a pattern of quality and efficiency in government. J Am Pharm Assoc (2003). 2012;52(6):810‐815. doi:10.1331/JAPhA.2012.11075

19. Todd W. VA-IHS Consolidated Mail Outpatient Pharmacy program (CMOP). www.npaihb.org/wp-content/uploads/2017/01/CMOP-Slides-for-Portland-Area-Tribal-Sites.pdf. Published 2017. Accessed June 11, 2020.

20. J.D. Power. Pharmacy customers slow to adopt digital offerings but satisfaction increases when they do, J.D. Power finds. www.jdpower.com/business/press-releases/2019-us-pharmacy-study. Published August 20, 2019. Accessed June 11, 2020.

Consolidated mail outpatient pharmacy (CMOP) is an automated prescription order processing and delivery system developed by the US Department of Veterans Affairs (VA) in 1994 to provide medications to VA patients.¹ In fiscal year (FY) 2016, CMOP filled about 80% of VA outpatient prescriptions.²

Formalized by the 2010 Memorandum of Understanding between Indian Health Service (IHS) and VA, CMOP is a partnership undertaken to improve the delivery of care to patients by both agencies.³ The number of prescriptions filled by CMOP for IHS patients increased from 1,972 in FY 2010 to 840,109 in FY 2018.⁴ In the fourth quarter of FY 2018, there were 94 CMOP-enrolled IHS federal and tribal sites.⁵ It is only appropriate that a growing number of IHS sites are adopting CMOP considering the evidence for mail-order pharmacy on better patient adherence, improved health outcomes, and potential cost savings.^6-9 Furthermore, using a centralized pharmacy operation, such as CMOP, can lead to better quality services.¹⁰

Crownpoint Health Care Facility (CHCF) serves > 30,000 American Indians and is in Crownpoint, New Mexico, a small community of about 3,000 people.¹¹ Most of the patients served by the facility live in distant places. Many of these underserved patients do not have a stable means of transportation.¹² Therefore, these patients may have difficulty traveling to the facility for their health care needs, including medication pickups. More than 2.5 million American Indians and Alaska Natives IHS beneficiaries face similar challenges due to the rurality of their communities.¹³ CMOP can be a method to increase access to care for this vulnerable population. However, the utilization of CMOP varies significantly among IHS facilities. While some IHS facilities process large numbers of prescriptions through CMOP, other facilities process few, if any. There also are IHS facilities, such as CHCF, which are at the initial stage of implementing CMOP or trying to increase the volume of prescriptions processed through CMOP. Although the utilization of CMOP has grown exponentially among IHS facilities, there is currently no available resource that summarizes the relative advantages and disadvantages, the challenges and opportunities, and the strengths and weaknesses of implementing CMOP for IHS facilities

References

1. US Department of Veterans Affairs, Office of Inspector General. Audit of Consolidated Mail Outpatient Pharmacy contract management. https://www.va.gov/oig/52/reports/2009/VAOIG-09-00026-143.pdf. Published June 10, 2009. Accessed June 11, 2020.

2. US Department of Veterans Affairs. Pharmacy Benefits Management Services. VA mail order pharmacy. https://www.pbm.va.gov/PBM/CMOP/VA_Mail_Order_Pharmacy.asp. Updated July 18, 2018. Accessed July 16, 2019.

3. US Department of Veterans Affairs. Memorandum of understanding between the Department of Veterans Affairs (VA) and Indian Health Service (IHS). https://www.va.gov/TRIBALGOVERNMENT/docs/Signed2010VA-IHSMOU.pdf. Published October 1, 2010. Accessed June 11, 2020.

4. US Department of Veterans Affairs, Office of Tribal Government Relations, Office of Rural Health, US Department of Health and Human Services, Indian Health Service. U.S. Department of Veterans Affairs and Indian Health Service memorandum of understanding annual report fiscal year 2018. https://www.ruralhealth.va.gov/docs/VA-IHS_MOU_AnnualReport_FY2018_FINAL.pdf. Published December 2018. Accessed June 11, 2020.

5. Karsten S. CMOP items of interest. Published October 12, 2018. [Nonpublic document]

6. Fernandez EV, McDaniel JA, Carroll NV. Examination of the link between medication adherence and use of mail-order pharmacies in chronic disease states. J Manag Care Spec Pharm. 2016;22(11):1247‐1259. doi:10.18553/jmcp.2016.22.11.1247

7. Schwab P, Racsa P, Rascati K, Mourer M, Meah Y, Worley K. A retrospective database study comparing diabetes-related medication adherence and health outcomes for mail-order versus community pharmacy. J Manag Care Spec Pharm. 2019;25(3):332‐340. doi:10.18553/jmcp.2019.25.3.332

8. Schmittdiel JA, Karter AJ, Dyer W, et al. The comparative effectiveness of mail order pharmacy use vs. local pharmacy use on LDL-C control in new statin users. J Gen Intern Med. 2011;26(12):1396‐1402. doi:10.1007/s11606-011-1805-7

9. Devine S, Vlahiotis A, Sundar H. A comparison of diabetes medication adherence and healthcare costs in patients using mail order pharmacy and retail pharmacy. J Med Econ. 2010;13(2):203‐211. doi:10.3111/13696991003741801

10. Kappenman AM, Ragsdale R, Rim MH, Tyler LS, Nickman NA. Implementation of a centralized mail-order pharmacy service. Am J Health Syst Pharm. 2019;76(suppl 3):S74‐S78. doi:10.1093/ajhp/zxz138

11. US Department of Health and Human Services, Indian Health Service. Crownpoint service unit. www.ihs.gov/crownpoint. Accessed June 11, 2020.

12. Chaco P. Roads and transportation on the Navajo Nation. https://obamawhitehouse.archives.gov/microsite/blog/31387?page=135. Published February 15, 2012. Accessed June 11, 2020.

13. US Department of Health and Human Services, Indian Health Service. Disparities. www.ihs.gov/newsroom/factsheets/disparities. Updated October 2019. Accessed June 11, 2020.

14. Golden State Medical Supply. National contracts. www.gsms.us/wp-content/uploads/2018/10/National-Contracts-Flyer.pdf. Updated October 4, 2018. Accessed June 11, 2020.

15. Arizona Health Care Cost Containment System. IHS/Tribal provider billing manual chapter 9, hospital and clinic services. www.azahcccs.gov/PlansProviders/Downloads/IHS-TribalManual/IHS-Chap09HospClinic.pdf. Updated February 28, 2019. Accessed June 11, 2020.

16. US Department of Veterans Affairs, Office of Inspector General. The impact of VA allowing government agencies to be excluded from temporary price reductions on federal supply schedule pharmaceutical contracts. www.va.gov/oig/pubs/VAOIG-18-04451-06.pdf. Published October 30, 2019. Accessed June 11, 2020.

17. Karsten S. IHS Billing Report-Apr. Indian Health Service SharePoint. Published May 3, 2019. [Nonpublic document]

18. Aragon BR, Pierce RA 2nd, Jones WN. VA CMOPs: producing a pattern of quality and efficiency in government. J Am Pharm Assoc (2003). 2012;52(6):810‐815. doi:10.1331/JAPhA.2012.11075

19. Todd W. VA-IHS Consolidated Mail Outpatient Pharmacy program (CMOP). www.npaihb.org/wp-content/uploads/2017/01/CMOP-Slides-for-Portland-Area-Tribal-Sites.pdf. Published 2017. Accessed June 11, 2020.

20. J.D. Power. Pharmacy customers slow to adopt digital offerings but satisfaction increases when they do, J.D. Power finds. www.jdpower.com/business/press-releases/2019-us-pharmacy-study. Published August 20, 2019. Accessed June 11, 2020.

Assessment of Consolidated Mail Outpatient Pharmacy Utilization in the Indian Health Service

References

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