Objectives: To assess physician satisfaction with Department of Veterans Affairs (VA) formulary policies and to examine the correlation between physician satisfaction and perceived access to formulary and nonformulary medications.
Study Design: Cross-sectional survey with specific questions on access to formulary and nonformulary medications. Statistical analyses included assessment of associations between physician satisfaction and various measures of access. Participants and Methods: Initial sample of 4015 staff physicians working in VA healthcare facilities. Responses were received from 1812 (49%) of the 3682 physicians in the final eligible sample population.
Results: Most clinicians (72%) reported that their local formulary covered more than 90% of the medications they wanted to prescribe. Most (73%) agreed that drug restrictions were important to contain costs, and 86% agreed that it was important for VA to choose “best-value” drugs. Respondents reported an 89% approval rate for nonformulary drugs, though 31% indicated that approvals routinely took 3 or more days. We found strong associations between physician satisfaction and self-reported approval rates for nonformulary drugs (P = .001), timely approval of nonformulary requests (P < .001), and percentage of nonformulary prescriptions as a proportion of overall prescriptions at a regional level (P < .01). There was no significant correlation between physician satisfaction and number of medications added to regional formularies or with drug costs per unique patient.
Conclusions: VA physicians were generally supportive of VA formulary policies including choosing best-value drugs to control pharmaceutical expenditures. Nevertheless, access to nonformulary drugs and timely approval of requests for nonformulary medications were strong predictors of clinician satisfaction and support for cost-containment measures.
(Am J Manag Care. 2004;10:209-216)
Many large insurers, Medicaid programs, and other healthcare providers employ drug formularies to help control costs.1 There is a broad perception that formularies are not only disliked by physicians but that they also impede access to needed pharmaceuticals.2,3 However, physicians' beliefs about drug formularies and access to medications have not been well studied. Little is known about how formulary management affects physician satisfaction.
In 1999, the Veterans' Affairs (VA) Pharmacy Benefits Management Strategic Healthcare Group surveyed physicians to gauge the effects of the VA National Formulary.4 The results suggested that implementing the National Formulary did not adversely affect patient care, pharmaceutical access, physician workload, or resident training.4 These findings were subsequently supported by more comprehensive assessments from the Institute of Medicine (IOM)5 and the United States General Accounting Office (GAO).6
Nonetheless, concerns were raised about variations, particularly concerning nonformulary agents, across Veterans Integrated Service Networks (VISNs, or regional groups of VA hospitals and clinics).5,6 More specifically, the GAO and IOM noted differences among VA regions in the size and extent of formularies and in nonformulary approval processes.5,6 It was unclear to what extent these variations affected prescribing practices, clinician satisfaction, and access to medications.
In an attempt to better understand these issues and improve VA formulary policies, VA's Pharmacy Benefits Management Strategic Healthcare Group, in cooperation with the RAND Survey Research Group, surveyed physicians on perceived effects of and satisfaction with local formulary and nonformulary policies. We were specifically interested in whether satisfaction with formulary-associated practices mirrored self-reported and/or objective measures of access to pharmaceuticals.
Survey Development and Implementation
As in the 1999 study,4 we developed the questionnaire in collaboration with the RAND Survey Research Group and the VA Pharmacy Benefits Management Strategic Healthcare Group. We incorporated several questions from our first survey and added questions about nonformulary access similar to those utilized in the GAO survey. 6 Our goal was to elicit feedback in the following content areas: (1) Pharmacy and Therapeutics (P&T) committees' responsiveness to providers, (2) extent of formulary restrictions, (3) access to nonformulary medications, and (4) attitudes toward pharmaceutical-related cost-containment measures.
Responses to questions were scored on a 5-point scale, which usually ranged from "strongly agree" to "strongly disagree." As in the first survey, respondents provided demographic and practice information including age, gender, number of prescriptions ordered per week, location (by VISN), years of VA service, number of half-day outpatient clinics per week, employee status (full- or part-time), and whether they practiced in other healthcare systems with formularies or were members of VA P&T committees.4
To gain information about access to medications, we asked the following: "In the past 6 months, how many times were you unable to obtain a prescription drug (formulary or nonformulary) that you thought was the best choice for one of your patients?" We then asked, "In the most recent incident, how much of a decline in health status did the inability to prescribe the drug(s) cause your patient?" Response options were "no decline," "small but insignificant decline," "somewhat significant decline," and "very serious decline." These two questions were modeled on those used by the Kaiser Family Foundation in a 1999 survey.7
To evaluate access to nonformulary drugs specifically, we asked, "In the past 6 months, how many times did you request a nonformulary prescription that you thought was best for a patient?" This was followed by "Of these requests, how many were approved?" To assess waiting times for nonformulary approvals, we asked, "On average, how long does it take you to receive routine approvals for nonformulary drugs?"
A draft survey was pilot tested on a convenience sample of 9 physicians from VA Greater Los Angeles Healthcare System, and modifications were made prior to finalization. The final 2-page survey (36 items) is available from the corresponding author.
We mailed surveys to all physicians in the sample population (see below) in April 2000. Physicians who did not respond were sent a second survey approximately 6 weeks later. A third mailing was sent approximately 8 weeks after that to those participants who had still not responded. Responses were confidential, with RAND Survey Research Group collecting the data. Data transferred to VA did not include participant identifiers, apart from demographic and practice information. This protocol was approved by RAND's Human Subjects Protection Committee.
The initial sample population (n = 4015) was selected in February 2000 from the VA physician-employment database. This file listed all attending/staff clinicians' types of service and employment locations as of September 1999. We randomly selected clinicians from within 5 general employee categories, as listed in the database: (1) generalists (n = 1881), defined as physicians listed as family practice, general internal medicine, internal medicine, geriatrics, and preventive medicine; (2) internal medicine specialists (n = 839), including cardiology, endocrinology, gastroenterology, infectious diseases, nephrology, and rheumatology specialists; (3) neurologists (n = 226); (4) physical medicine and rehabilitation practitioners (n = 146); and (5) psychiatrists (n = 923). Since each sample represented 50% of the total in each category, our sample provided a broad spectrum of clinicians likely to be affected by formulary and nonformulary decisions.
Of the 4015 physicians to whom surveys were initially sent, 41 were retired, were no longer with VA, or did not prescribe medication. Two physicians had died. Another 290 physicians were not located at their last known VA addresses and, because their packets were not forwarded internally to another VA address, we considered them to be no longer practicing in VA. Thus the final eligible sample population was 3682 physicians, with an overall response rate of 49% (1812/3682). As noted in our prior survey study,4 many responding clinicians described their specialty differently than that which was initially obtained from the VA database. For example, many listed as internists described themselves as internal medicine subspecialists. Table 1 provides self-reported characteristics from responding clinicians.
We first used principal components analysis8 to group closely related questions in order to reduce the data to linear combinations representing latent factors. Rather than using sample-specific weights, however, we averaged the raw data across the specific items to create subscales in the metric of the original scale. We then used Cronbach's α9 to determine the internal consistency across the identified items for each subscale. The scale groupings were (1) satisfaction with formulary practices (7 items), Cronbach's α score = .87; (2) attitude toward cost containment (2 items), α = .68; and (3) attitude toward cost sharing (2 items), α = .67. One other scale, prescription factors, had an α score of less than 0.6 (α = 0.49) and was therefore excluded. The cost-sharing scale was not utilized for the present analysis.
We then evaluated whether self-reported (subjective) responses regarding access to formulary and nonformulary drugs were associated with satisfaction and with attitudes toward cost containment. We hypothesized that higher selfreported approval rates and faster approval times for nonformulary drugs, as well as greater ease in obtaining needed drugs, would be associated with greater satisfaction and more support for formulary policies. For approval rates, we aggregated self-reported data by region (VISN) and divided by tertiles: (1) low approval rate (66.1%- 80.8%) for nonformulary medications, (2) moderate approval rate (81.3%-84.3%), and (3) high approval rate (84.6%-92.8%). For approval times, we used the following, based on 3 response categories in the survey: (1) less than 24 hours, (2) 24 to 72 hours, and (3) more than 72 hours. We also looked at clinicians' reports of the number of times that they had been unable to obtain a prescription drug (formulary or nonformulary) in the previous 6 months. In this analysis, we divided respondents into 2 groups, those who reported having been unable to obtain a needed drug 0 to 2 times in the previous 6 months and those who reported 3 or more instances.