in this direction have been taken, including some information in this report on hospital discharge distributions associated with the National Formulary. There are anecdotal reports of quality problems or successes, few veteran complaints, and some worrisome indicators of physician concerns. The absence of persuasive reports of substantial worsening of health outcomes in the medical literature attributable to a closed or partially closed formulary either for the VA or for millions of covered lives in MCOs or PBMs is not proof of no effect, although it is somewhat reassuring.

The committee fell back on, and relied primarily on a review of structural elements of the National Formulary related to quality. This review was also somewhat reassuring, including communications with, and reports of, an active and apparently skilled pharmacy service, observation of an active and thoughtful MAP, evidence of quality drug class reviews and a careful and rather parsimonious class closure process, reviews of therapeutic guidelines, an assessment that the formulary was of adequate size and quality, and an analysis of the formulary's effects on drug prices, with the implication that prudent drug purchasing freed funds for increased services to veterans.

Based on this information and analysis, the committee concluded that there is no reason to discontinue the National Formulary and every reason to try to improve it. In this latter regard, concerns are expressed in this chapter about the nonformulary process; the composition of committees; physician and patient satisfaction, therapeutic interchange policies, notice of interchanges, and education; follow-up and monitoring of clinical guidelines; and addition of newly FDA-approved drugs among others. The committee also strongly urges the VA to focus its considerable health services research capacity on National Formulary and drug treatment issues, in a way that hitherto has not been the case, as the responsibility of a national program to illuminate these issues. The absence of good data on quality effects is a concern, as is the need for better data to enable prudent management of the National Formulary. In the meantime, the committee supports the continuation of the National Formulary and formulary system. This includes the careful closure of classes where good therapeutic alternates exist and clinical and economic data are supportive, and an emphasis on quality of care for veterans as the highest priority.

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