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Specialty Pharmacy Continuum • May/June 2021
OPERATIONS & MANAGEMENT
Payors fight back, citing value and access
Coalition Slams Mandatory White Bagging Payor-mandated “white bagging” is jeopardizing patient safety and exacerbating supply chain problems for hospitals and health systems, the ASHP and 61 health systems and group purchasing organizations recently told FDA Commissioner Janet Woodcock, MD, in a letter requesting a meeting to discuss the practice. But payors and other stakeholders in managed care are pushing back against the criticism, citing hundreds of millions of dollars in patient savings that white bagging provides. They also refute the claim that the policy always is a mandatory affair that stifles ready access to potentially lifesaving medications. “In 2020, we delivered $10.2 million in savings to Tennessee employers through our Advanced Specialty Benefit Management program,” said Natalie Tate, PharmD, the vice president of pharmacy management for Blue Cross Blue Shield (BCBS) of Tennessee. “Using our specialty pharmacy network, our members can save money right away. Someone whose employer participates in
this program and has a high-deductible health plan would see their share of the cost for a specialty drug drop for each visit. If a member is taking [infliximab], for example, they could see their cost drop by around $400 per treatment.” Dr. Tate also said that, for her organization at least, white bagging is not a requirement but a choice. “We’ve offered multiple options for our in-network providers based on their feedback, including one that allows them to continue a ‘buy and bill’ approach. We started by offering a six-month continuity of care program— essentially a transition period during the first half of 2020. During that time, we expanded our specialty pharmacy network and gave providers the option to
Report Cites Lower Costs— If Best Practices Followed
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2019 report from the Massachusetts Health Policy Commission (HPC) on third-party specialty pharmacy use for clinician-administered drugs in that state found that commercial drug prices could be substantially lower with white bagging. In 2013, the per-unit drug price for three drugs analyzed in the report ranged from 15% lower to 38% lower through white bagging than via buy and bill; in 2015, the difference ranged from 12% lower to 24% lower. Patient cost sharing per unit went up in most cases, although the differences were relatively minimal, with increases ranging from $2 to $14. Overall, the report found that white bagging can be used safely and may even offer advantages for small providers, but “the use of best practices to support patient safety and access is critical,” wrote lead author Sarah Sadownik, the deputy director of the HPC’s Research and Cost Trends Department. The report also recommended that payors requiring white bagging offer site- neutral payment for white-bagged drugs, allowing providers the option to use the buy-and-bill method with reimbursement for the drug set at the third-party specialty pharmacy rate. “The site-neutral payment option would only need to apply to the drugs for which a payer required white bagging,” it said. “This policy lowers drug prices, reduces provider administrative expenses associated with compliance with multiple different policies, and addresses concerns about safety and access.” —G.S.
join it. We had at least one large hospital system and six infusion centers join the network. We’re also offering ‘dispensing provider agreements’ to in-network providers. That’s like a middle ground. Providers can continue to buy and bill for specialty drugs, but at the same rates as our in-network specialty pharmacies. But they don’t have to actually become or set up a true specialty pharmacy.”
What Is White Bagging? What’s not up for debate are the basic details of how white bagging works. The practice typically involves clinician-
Kyle Robb, PharmD, a state policy and advocacy associate with ASHP, during a webinar on the topic. “They believe white bagging gives them more control in negotiating the pricing, reimbursement and distribution channels for these drugs.” White bagging has been around for years, but hospital and health-system pharmacies have reported an increase in the practice recently, with many of the white-bagging restrictions now being a mandatory component of the drug’s dispensing. The practice “is growing at astronomical rates of double digits per year,” Dr. Robb said. “More
‘[White bagging] is growing at astronomical rates of double digits per year. More than 10% of the annual [drug] spend … is being shifted from the medical benefit to the pharmacy benefit for many of these drugs.’ —Kyle Robb, PharmD administered drugs given to nonhospitalized patients—often infusion-based drugs that patients cannot take safely on their own. Historically, hospitals purchased these drugs in advance and held them in stock, and when a patient needs the drug, the hospital compounds and administers the drug and is reimbursed by the medical plan. Under white bagging, payors move these drugs from the medical benefit to the pharmacy benefit, barring the hospital from purchasing the drug itself and requiring that a prescription be sent to a payor-designated specialty pharmacy for fulfillment and shipment to the hospital. “A primary motivator for payors to adopt white bagging is that they can dictate who the purchaser of the drug is, mandating that the drugs come from a specific source—often a plan-affiliated specialty pharmacy that is not associated with the health system,” explained
than 10% of the annual [drug] spend year-over-year is being shifted from the medical benefit to the pharmacy benefit for many of these drugs.” “White bagging takes formulary development and health system-specific policies and procedures around safety and completely disrupts this,” said David Chen, BSPharm, the assistant vice president for pharmacy leadership and planning at ASHP. “This process adds at least 10 extra steps for each patient unique for that payor, and this is happening with multiple payors. It runs counter to all Lean and patient safety models to reduce risk and ensure the best outcomes.” In addition to potential treatment delays and other difficulties for patients in accessing their medications, Mr. Chen noted that white bagging disrupts the ordering process and potentially introduces errors. “With the complexity of these treatments, a complete drug therapy plan
