Committees to impose enrollment fee

by Tom Philpott: CNJ columnist

Republican majorities on the House and Senate veterans’ affairs committees have voted to impose an enrollment fee of at least $230 a year on 2.4 million veterans — one of every three now eligible to use VA healthcare.

Those targeted are in priority categories 7 and 8, meaning they are neither poor nor suffering from service-connected disabilities. Half of the 2.4 million used the VA health system last year.

The Bush administration proposed the enrollment fee to hold down costs. The VA committees rejected another Bush proposal to raise co-payments on VA-filled prescriptions for these same priority 7 and 8 veterans.
While both committees endorsed enrollment fees, differences emerged. The Senate panel, chaired by Sen. Larry Craig, R-Idaho, embraced the Bush plan for a straight $250 annual fee.

The House committee, chaired by Rep. Steve Buyer, R-Ind., voted to set the fee for priority 7 enrollees at $230, matching the enrollment fee of under-65 military retirees using TRICARE Prime, the military managed care program.

For priority 8 veterans, Buyer proposes a sliding scale fee, of $230 to $500, depending upon veteran income.

Both Craig and Buyer, in separate letters to their budget committees, said difficult choices have to be made this year, given a tight VA budget and the number of new veterans returning from war with severe injuries. Against that backdrop, they defended enrollment fees against the stiff criticism expected from veterans’ service organizations.

“VA must garner supplemental funding from some source, and there are no easy options,’’ Craig wrote. To critics who say $250 is not modest for some veterans, Craig pointed to the TRICARE enrollment fee paid by military retirees who have at least 20 years. Shorter-serving veterans are no less worthy, Craig wrote, but neither are they “more worthy as a class than military retirees.’’

Buyer wrote that Congress erred in 1996 by voting to open VA healthcare to “lower priority, non-service-connected categories of veterans.’’ Assumptions that such a move would be “budget neutral’’ were wrong, he said. So it’s time to refocus VA health resources on the “disabled, injured, low-income and special needs veterans,’’ Buyer wrote.
Buyer too said enrollment fees will “correct the inequity’’ between lower-priority veterans and TRICARE users “who pay an enrollment fee and deductibles and who have higher co-payments.’’ His committee “at this time’’ is not directing that lower-priority veterans also match TRICARE deductibles and co-payments. But Buyer hinted he might return to those disparities in future VA budgets.

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The Air Force and Navy likely will have to hire a few hundred more pharmacists over the next 18 months to meet tougher standards being imposed on use of pharmacy technicians.
Even the Army, which for years has kept a higher ratio of pharmacists to pharmacy technicians than the other medical services, could be required to boost its number of pharmacists by an August 2006 deadline.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) formally notified the military surgeons general this month of a change in standards for accredited military hospital and clinics to meet regarding handling and dispensing of medications.

JCAHO no longer will exempt the military from a requirement that a pharmacist review all prescriptions and hospital medication orders before drugs are dispensed.
The exemption recognized that military pharmacy techs receive more comprehensive training than private sector counterparts, said Joseph L. Cappiello, the commission’s vice president for field operations. But standards on patient safety have evolved to where allowing technicians alone to fill prescriptions — by having military techs check other techs — no longer will be acceptable if hospitals and clinics are to stay accredited.

The change takes effect March 1 but the services have 18 months to hire the extra pharmacists they need or, in some cases, to buy telemedicine technology for pharmacists to supervise dispensing of drugs at remote sites.

Tom Philpott can be contacted at Military Update, P.O. Box 231111, Centreville, Va. 20120-1111, or by e-mail at: