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Description and Analysis of the VA National Formulary (2000)

Chapter: Appendix C: Additional Cost Information

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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

APPENDIX C

Additional Cost Information

This appendix contains additional graphs that are relevant to the analysis of the potential cost effects associated with the National Formulary (see chapter 3 for discussion).

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.1 National formulary policy has no effect on market share distribution of antiemetics (open class).

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.2 Atypical antipsychotics—open class: Market share of pharmaceuticals within the class.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.3 Beta-blockers—open class: Market share of pharmaceuticals within the class. NOTE: Some drug products (timolol, pindolol, nadolol, bisoprol, betaxolol, and acebutolol) had negligible market share and were removed for clarity.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.4 Inhaled antiasthma agents—open class: Market share of pharmaceuticals within the class. NOTE: Some drug products (triamcinolone, salmeterol, pirbuterol, nedocromil, montelukast, fluticasone, mometasone, levalbuterol, isoetharine, flunisolide, and epinephrine) had negligible market share and were removed for clarity.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.5 Nonsedating antihistamines—open class: Market share of pharmaceuticals within the class.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.6 Nonsteroidal anti-inflammatory drugs—open class: Market share of pharmaceuticals within the class. NOTE: Some drug products (tolmetin, phenylbutazone, meclofen, ketoprofen, flurbiprofen, fenoprofen, diflunisal, sulindac, and nabumetone) had negligible market share and were removed for clarity.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.7 Oral diabetic—open class: Market share of pharmaceuticals within the class. NOTE: Some drug products (dextrose, diazoxide, tolbutamide, acarbose, troglitazone, rosiglitazone, repaglinide, miglitol, chlorpropamide, glucose, glucagon, acetohexamide, and glimepirode) had negligible market share and were removed for clarity.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.8 Selective serotonin-reuptake inhibitors—open class: Market share of pharmaceuticals within class.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.9 Average outpatient pharmacy spending per outpatient user by month on antiemetics

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.10 Average number of prescriptions per outpatient user by month for proton pump inhibitors.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.11 Average number of prescriptions per outpatient user by month for hydroxymethylglutaryl coenzyme A reductase inhibitors.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.12 Average number of prescriptions per outpatient user by month for histamine2 receptor blockers.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.13 Average number of prescriptions per outpatient user by month for calcium channel blockers (CCBs).

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.14 Average number of prescriptions per outpatient user by month for alpha blockers.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

FIGURE C.15 Average number of prescriptions per outpatient user by month for angiotensin converting enzyme inhibitors (ACEI).

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

TABLE C.1 Implementation Date of VHA National Contracts Across the VISNs

 

ACE inhibitors

 

HMG CoA Ris lovastatin/simvastatin

LHRHs goserelin

PPIs lansoprazole

lisinopril

fosinopril

H2R blockera famotidine

Alpha blockersb terazosin

National

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

7/1/1997–6/30/1998

VISN 1

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN2

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN3

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN4

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN 5

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN 6

06/22/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN7

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN 8

07/02/1997

02/13/1997

03/06/1997

11/20/1997

02/12/1998

9/9/1996–9/8/1998

08/01/1997

VISN 9

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN 10

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

08/09/1996

07/01/1997

VISN 11

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN 12

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN 13

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN 14

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN 15

10/28/1997

06/11/1996

06/11/1996

10/28/1997

06/11/1996

01/02/1997

07/17/1997

VISN 16

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN 17

06/02/1997

01/01/1997

01/01/1997

10/01/1997

12/01/1998

08/09/1996

07/01/1997

VISN 18

06/02/1997

01/13/1997

02/06/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

07/01/1997

VISN 19

7/1/1997–9/1/1997

3/1/1997–7/1/1997

3/1/1997–4/1/1997

2/1/1997–12/1/1997

2/1/1997–12/1/1997

9/1/1996–12/1/1996

7/1/1997–10/1/1997

VISN 20

06/01/1997

12/01/1996

05/01/1997

10/20/1997

01/12/1998

8/9/1996–8/8/1998

7/1/1997–6/30/1998

VISN 21

06/02/1997

12/20/1996

01/24/1997

09/19/1997

09/19/1997

07/26/1996

08/15/1998

VISN 22

07/02/1997

02/13/1997

03/06/1997

11/20/1997

05/12/1998

9/9/1996–9/8/1998

08/01/1997

a H2R blockers were closed (8/9/1996) and reclassified as open (8/8/1998).

b Alpha-blockers were closed (7/1/1997) and reclassified as preferred (6/30/1998).

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

TABLE C.2 Regression Results on Natural Logarithm of Spending per Veteran Outpatient User

Variable

ACEI

Alpha

HMG

PPI

CCB

H2R

Closed

-0.185 (8.60)

-0.193 (9.10)

-0.085 (5.92)

-0.076 (5.45)

 

-0.529 (11.26)

Subsequent change in formulary status*

-0.089 (3.93)

-0.195 (4.91)

 

-0.0605 (7.73)

preferred

 

0.076 (1.83)

 

% Male

-0.007 (1.99)

0.013 (2.69)

0.017 (4.87)

0.041 (12.03)

0.010 (2.20)

0.005 (0.46)

%<45 years

0.0001 (0.06)

0.011 (3.33)

-0.002 (0.85)

0.003 (1.11)

0.004 (1.32)

0.022 (3.13)

% 45–65

0.019 (2.96)

-0.001 (0.14)

-0.005 (0.79)

-0.050 (7.99)

-0.020 (2.38)

0.011 (0.63)

Time

-0.019 (15.27)

-0.046 (24.45)

0.036 (29.43)

0.054 (43.48)

0.010 (6.06)

0.014 (3.15)

Time2

0.0002 (8.55)

-0.0004 (10.86)

-0.0002 (10.56)

-0.003 (21.11)

-0.0002 (8.57)

-0.0004 (5.74)

Constant

1.203 (3.01)

-1.819 (3.39)

-0.642 (1.66)

-1.941 (5.16)

1.362 (2.71)

-0.388 (0.35)

VISN fixed-effects included

 

R2

0.83

0.83

0.92

0.96

0.66

0.66

F

198.43

201.2

507.5

944.3

85.86

80.12

NOTE: ACEI = angiotensin converting enzyme inhibitor; alpha = alpha blocer; CCB = calcium channel blocker; HMG = hydroxymethylglutaryl coenzyme A reductase inhibitor; PPI = proton pump inhibitor; VISN = veteran integrated service network; t statistics in parentheses.

* For ACEIs, this variable represents the addition of a second closed drug, fosinopril, to the National Formulary. For alpha blockers, this variable represents the change in formulary status from closed to preferred. For H2R blockers, this variable represents the reopening of the class.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×

TABLE C.3 Regression Results on Natural Logarithm of Inpatient Discharge Rates *

Variable

ACEI-Related Discharges

PPI-Related Discharges

Closed

-0.014 (0.89)

-0.051 (1.54)

% Male

0001 (0.26)

0.009 (1.13)

%<45 years

-0.021 (7.76)

-0.125 (2.34)

% 45–65 years

0.011 (1.58)

0.006 (0.44)

Time

-0.081 (10.17)

-0.019 (6.15)

Time2

-0.00001 (0.85)

0.00004 (0.93)

Constant

-5.74 (13.53)

-6.602 (7.66)

VISN fixed-effects included

 

R2

0.81

0.64

F

183.54

79.00

NOTE: ACEI = angiotensin converting enzyme inhibitor; PPI = proton pump inhibitor, VISN = veteran integrated service network.

* The discharge rate is the number of discharges for the selected diagnoses divided by the number of veteran outpatient users. The unit of observation is a VISN-month.

Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Suggested Citation:"Appendix C: Additional Cost Information." Institute of Medicine. 2000. Description and Analysis of the VA National Formulary. Washington, DC: The National Academies Press. doi: 10.17226/9879.
×
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Description and Analysis of the VA National Formulary Get This Book
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The VA National Formulary generated controversy, which motivated congressional scrutiny and a directive to the VA to commission this report reviewing the experience with the National Formulary and formulary system. This Institute of Medicine committee was pleased to assist the Congress with this review, in part because the committee saw in the VHA example an opportunity to understand and anticipate problems that all publicly funded programs are likely to encounter in this new age of pharmaceuticals. The Congress asked the committee to review the restrictiveness of the National Formulary, its impact on the costs and quality of care in the VHA, and how it compared to formularies and drug management practices in the private sector and in other public programs, especially Medicaid. Detailed in the pages that follow, the committee's findings and conclusions on these questions are, the committee believes, highly instructive, though not always in the ways that we anticipated.

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