In 2020, spending on specialty medication was $265 billion; this constituted 49.6% of complete prescription drug expenditure. To fight rising prices, payers have turned to white, brown and clear bagging in addition to approaches to limit the positioning of care the place sufferers obtain specialty medication. What are these “bagging” insurance policies, what are the professionals and cons, and what laws has or is taken into account being handed to limit payers means to implement these applications. Today, I summarize a white paper from ICER titled “White Bagging, Brown Bagging, and Site of Service Policies: Best Practices in Addressing Provider Markup within the Commercial Insurance Market“. This publish follows up my earlier publish on the subject two years in the past.
Definitions
- White bagging insurance policies ship medication from specialty pharmacies on to suppliers on the website of service the place the drug will likely be administered (usually a doctor’s workplace, HOPD, or house infusion supplier). Providers are answerable for receiving the drug supply from the specialty pharmacy, unboxing it, and storing it till the affected person is on website and prepared for administration. The moniker “white bagging” arises from the “white coats” of the suppliers who obtain the drug from the specialty pharmacy. Analysis of the affect of white bagging on payers and sufferers will likely be mentioned later on this paper.
- Brown bagging insurance policies require sufferers to choose up their prescribed clinician-administered medication at a specialty pharmacy or have these medication delivered on to sufferers, after which sufferers are answerable for storing these medication appropriately till the time of their appointment with a clinician, at which era sufferers deliver their drug with them handy over to a clinician for administration. The time period “brown bagging” comes from the analogy to a “brown bag” lunch carried by a person.
- Clear bagging entails a supplier, usually a hospital, creating a proper program by which its inside specialty pharmacy can dispense the drug and ship it to the positioning of service. Clear bagging thus serves as a supplier technique to supply an alternative choice to white bagging and brown bagging, thereby retaining the income related to specialty drug supply. Clear bagging additionally avoids among the logistical and security challenges related to white bagging. For occasion, if a affected person’s drug dosage must be adjusted, the hospital specialty pharmacy can dispense the brand new dosage and have it delivered to the on-site hospital suite or clinic with out having to reschedule the affected person’s appointment as may be the case with white bagging. There has been a current proliferation of hospital-owned specialty pharmacies, with estimates from 2019 displaying that 26% of hospitals owned a specialty pharmacy.
How widespread are these practices? Well, as of 2022, 27% of oncology remedy merchandise administered in doctor workplaces underneath business insurance coverage have been topic to white bagging insurance policies. Part of that is pushed by business consolidation.
It is much more widespread amongst non-oncology merchandise as proven from information as of 2019 beneath.
Part of the rationale for elevated ‘bagging’ insurance policies has to do with business consolidation.
the three greatest PBMs aligned with payers –CVS/Aetna, Optum/UnitedHealthcare, and Express Scripts/Cigna — accounted for 77% of all prescription claims.36,37 Some suppliers assert that bagging insurance policies are motivated by the well being plan’s need to drive quantity to their very own specialty pharmacies.
Restrictions on website of service supposed to maneuver sufferers to decrease price websites of care are additionally changing into extra widespread. According to 1 survey:
…by 2020 nearly 70% of economic plans had site-of-service applications, of which 34% have been necessary and 32% have been voluntary.24 That identical survey discovered that throughout all site-of-service methods, business payers had shifted 30% of members into house infusion, 19% to ambulatory infusion suites, and 14% to impartial doctor workplaces in 2019.
Key criticisms of white and brown bagging are:
- Patient security. For brown bagging specifically, sufferers could not appropriately administer these specialty medication at house. Also, with lengthy journey instances, medication could spoil if not stored correctly refrigerated.
- Impact on deprived sufferers. For sufferers with restricted transportation possibility, brown bagging could impose a burden on sufferers.
- Incorrect prescriptions and problem altering prescriptions. In one survey, 66% of respondents stated that they’d acquired a product by way of white bagging that was not appropriate as a result of up to date remedy course or dose being modified.
- Patient out-of-pocket prices. Lower payers prices from white and brown bagging typically usually are not handed on to sufferers. In truth, OOP prices could rise if medication transfer from being a part of the medical (i.e., doctor administered) profit to the affected person’s pharmacy profit.
- Provider income. Providers–significantly 340B hospitals–could expertise a major loss in income as drug administration strikes from hospital-based pharmacies to payer-owned/managed specialty pharmacies.
- Drug wastage. “Because drugs obtained via white or brown bagging are specific to an individual, as opposed to the buy-and-bill process whereby physicians purchase drugs to have in-stock, any excess drug in the white or brown bagged vial must be discarded and cannot be used for another patient, leaving the payer and patient responsible for the entire vial and associated cost-share.”
Similarly, criticism of website of providers restrictions embrace: (i) elevated affected person journey burden, (ii) lowered oversight for opposed occasion monitoring, and (iii) unfavorable affect on supplier (particularly hospital outpatient facility) income.
Legislative initiatives.
- White bagging: Three states (LA, MN, VT) have handed laws limiting white bagging and 9 states (AZ, CA, IL, KY, MO, NY, OH, WV) have proposed laws that may prohibit payer-mandated white bagging
- Brown bagging. Two states (VA and VT) have carried out insurance policies to ban brown bagging. Proposed laws in three states (CA, IL, NY) would prohibit brown bagging along with white bagging
- Site of service. Three states (AR, MN, TN) have handed laws prohibiting payers from requiring a clinician-administered drug to be infused at house.
