Original Research

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

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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.



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


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