A different world
 Selling
to customers within the Veterans Health Administration is like selling
in no other healthcare environment. For one thing, it is the largest
integrated healthcare provider in the nation: As of September 30, 2004,
it covered an estimated total veteran population of close to 25 million
people (source: VA Organizational Briefing Book, May 2005). In addition to its vast size, three main factors make selling within the VHA different from selling in the commercial marketplace: * Different rules regulate access and promotional activities. * Different formularies influence prescribing patterns. * Different patient populations influence clinical areas of focus. As a sales representative, it is crucial that you take these three factors into account when selling in the VHA. Different rules: VHA directive Just as hospitals, clinics and physician offices have rules about when and how you can conduct business with them, so does the VHA. In addition, security at a VA facility may be tight, and accessing a VA medical center may differ significantly from accessing hospitals and institutions in the private sector. In October 2003, the Department of Veterans Affairs issued VHA Directive 2003-060, titled "Business Relationships Between VHA Staff and Pharmaceutical Industry Representatives." This directive serves as your formal guide to business relationships with VHA staff and explicitly defines how staff at all VHA facilities, including VA hospitals and clinics, are to interact with pharmaceutical industry representatives. Some key aspects of the directive include the following rules and guidelines: * All visits are by appointment only. * You cannot market to medical residents, pharmacy students and residents, nursing students, or any other health profession students without faculty present. * You cannot make presentations in restricted patient-care areas, such as patient rooms and ward areas, emergency rooms, clinic examination rooms, and nursing stations. * You must deliver samples to the chief of pharmacy service or a person with similar responsibilities. * You can only promote products that are included on the VHA National Formulary or the Veterans Integrated Service Network formulary. You can discuss nonformulary drugs or provide educational materials on them as long as it is clearly stated that those drugs are not part of the formulary. * You can provide food items of nominal value (such as soft drinks, coffee, doughnuts and other light refreshments) -- but not full meals -- to VA employees at a scheduled meeting or educational program, but only if light refreshments are not otherwise prohibited by government ethics rules or educational accreditation requirements. * Gifts are restricted to a value of no more than $20 per occurrence and no more than $50 in aggregate over a consecutive 12-month period from any one source. Different sales representatives from the same company are considered one source. The consequences of failing to comply with the directive are dire: You may be suspended, limited or temporarily banned from calling on one or more VA medical care facilities. The good news is that the directive is available on the Internet and states the rules clearly and in detail. To view the VHA directive in its entirety, visit www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=288. Different formularies: National vs. regional The entire VA system has one formulary called the VHA National Formulary. However, due to regional differences, the formulary varies among different regions. Each of these regions is known as a Veterans Integrated Service Network, or VISN (which you may hear pronounced "vis-in"). The VA Medical System consists of 21 VISNs (see sidebar on page 26 for a listing). Each VISN can adapt the VHA National Formulary to meet its own needs. Typically, a VISN formulary can include products in addition to those on the VHA National Formulary but cannot entirely bar access to products on the VHA National Formulary. In other words, VISNs can add, but they can't take away. However, VISNs can restrict the use of VHA National Formulary agents that require close monitoring to ensure appropriate use. If you'd like to view a copy of the VHA National Formulary, go to www.pbm.va.gov/PBM/natform.htm. Although you may already know where your own product sits on the VHA National Formulary, by viewing the total formulary, you can see your competitors' status as well. You should check this Web site periodically for updates. If your product is on the VHA National Formulary, focus on driving utilization at your VA medical center accounts. If it is not on the VHA National Formulary, determine whether it has been added to the VISN formularies within your territory. Again, even if you already know the status of your product, it is helpful to determine where your competitors sit on VISN-level formularies as well so that you can develop your selling messages accordingly. To view VISN-level formularies, go to the Web site of the VISN you are interested in and locate its formulary. For example, using any Internet search engine (like Google or Yahoo), search for "VISN 1 formulary" and you will get the following listing: www.visn1.med.va.gov/formulary. There you will be able to view the VISN 1 formulary. Different patient populations: Veterans Veterans are defined as people who have served in the armed forces: Army, Navy, Air Force, Marines or Coast Guard (or Merchant Marines during World War II). Veterans discharged under honorable conditions are eligible for healthcare benefits from the VA. Reservists and National Guard members called to active duty may also qualify for VA healthcare benefits. There are a number of unique demographic characteristics of the veteran patient population, including: * Gender. * Concentration in certain states. * Age clusters. * Long-term care needs. * Common disease states. It is important to note that the VA provides healthcare to both male and female veterans, and while the majority of veterans are male, a growing number are female. In addition, some states have disproportionately high numbers of veterans, including: California, Florida, New York, Ohio, Pennsylvania and Texas. Another key aspect of this population is that the vast majority of veterans are baby boomers or elderly. Although there are growing numbers of younger veterans, the majority are still between the ages of 55 and 84. Many elderly Americans (not just veterans) require long-term care. Many baby boomers (again, not just veteran baby boomers) may soon require long-term care. Compound these age-related needs with the fact that many veterans have been exposed to physical or mental trauma, and you can see how veterans can be considered high utilizers of long-term care and other healthcare services. Also consider some of the disease states you may see at a higher prevalence in the veteran population than in the general population. For example, you may expect to encounter healthcare providers treating high numbers of patients with physical disabilities, such as loss of a limb, neuropathy and chronic, debilitating pain. In addition, you may see a high prevalence of mental disorders, such as depression, anxiety and post-traumatic stress disorder. Even if you do not sell a product for one of these disease states, chances are the patients your customers treat have any number of these conditions comorbidly. Without overgeneralizing, the veteran population tends to face different and complex health challenges compared with the general population. To address some of these needs, the VA has set up specialty care clinics and disease centers for certain diseases (such as Parkinson's), as well as drug addiction clinics. Within your territory, you will need to determine which clinical areas are important to your customers and work with them to address their needs. To see the most recent data on veteran demographics by state and age, go to www.va.gov/vetdata/demographics/Vetpop2001adj/BASIC/VetPop2001Adj/ Data/1L_Adj.xls. Vive la différence Selling in the VHA can be intimidating because it is so huge and it can seem more bureaucratic than the commercial healthcare marketplace. However, considering the vast opportunity presented by the mere size of the delivery system and the pharmaceutical needs of its patient population, it is well worth your efforts to gain access through the proper inroads, get to know your customers' needs as well as the needs of their patients and develop solutions using your product.
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