The biggest concerns with white bagging from Mayo Clinic’s perspective relate to patient safety and patient convenience. On numerous occasions, we have had patients arrive for treatment, but the specialty pharmacy had not sent their medicine, or they had sent the wrong amount of the wrong drug altogether. This causes needless delays in important patient care.
 
White bagging results in the wastage of expensive drugs, and patients may get billed even if they do not receive the medicine that was dispensed. For instance, if the provider reduces the dose or changes drug, but the specialty pharmacy has already sent the drug, the drug is wasted. Because this is a prescription, the pharmacy cannot take the drug back, so it is can only be disposed of.
 
White bagging also adds cost to the health care system by creating multiple prescription supply streams.  We cannot simply use our routine systems to deal with white bagging; rather, we have to build processes and add staff to manage an inefficient and ineffective process.
 
Mayo Clinic is concerned about the growing practice of white bagging among health insurance companies and the effect of such policies on patients in Wisconsin and nationwide.
 
Jordan Dow, PharmD, MS, FACHE
Regional Director of Pharmacy
Mayo Clinic Health System Northwest Wisconsin

 

"White bagging" is an industry term used to describe a process where third party payers require that a patient utilizes a contracted, payer-selected pharmacy to dispense a clinician-administered drug. These contracted pharmacies mail prescribed medications directly to a hospital or clinic on behalf of a specific patient. The hospital or clinic then holds that medication until such time as the patient arrives at the location for administration of the prescribed therapy.

Fort HealthCare's highest priority is patient safety. White bagging adds complexity to the care delivery system. This increased complexity can lead to delays in treatment, patient confusion, difficulties in coordinating care, and a fragmentation of the patient's healthcare record for prescriptions. This increased complexity is not without patient impact. Delays in treatment can lead to patient harm as a patient's disease symptoms may become exacerbated if they are not able to have the medication administered within the time frame recommended by their physician and provider.

It is important to note that many of the patient conditions treated with these important therapies quite often result in changes in drug therapy on or near the date of the patient's visit. In situations when the medical prescriber issues a new medication, or a change in the medication dose or frequency, if the pharmacy has already sent the prescription medication by mail, the medication cannot be returned and could need to be wasted. It is important to note that medications cannot be simply discarded in trash, but must also be managed by a third-party source, at a cost to the health care system.

If hospitals and clinics are unable to manage this complex and confusing process safely, they may have to allocate additional resources to manage white bagging or to restrict access to medications deemed by third-party payers as "white bag" only. Unfortunately, decisions to restrict access can lead to a decrease in community access to unique and important medications. Fort HealthCare would like to see an increase in healthcare access in our communities served and not a decrease.
 
Fort HealthCare is concerned about the growing practice of white bagging among health insurance companies and the effect of such policies on patients in Wisconsin and nationwide.

Sarah Pagenkopf, PharmD, BCPS 
Director of Pharmacy                 
Fort HealthCare

Carl Selvick, PharmD, MBA, FACHE
Senior Director Clinic Operations
Fort HealthCare
 

Payer-mandated white bagging creates tremendous financial burden and unnecessary delays in care for our patients. This practice means specialty pharmacies contracted with managed care organizations (MCOs) require patients to pay their copayments for expensive medication upfront, before the specialty pharmacy will send medications to the provider. When MCOs require purchasing from their own pharmacies, providers lose the ability to proactively assist patients in identifying financial assistance resources. 
 
In one recent example, a patient was asked to pay over $4,000 for each of three rounds of a chemotherapy drug prior to its delivery. Upon learning that the patient was struggling, an Ascension Wisconsin patient financial advocate quickly stepped up to assist in finding a drug discount program which cut the payment nearly in half.
 
Our patients trust that we will help them to find the financial support they need to access care. However, we cannot help them when a third-party mail-order pharmacy or insurance company interferes in the delivery of care. We need to protect Wisconsin families from this practice.
 
Vanessa Frietag
Vice President of Pharmacy
Ascension Wisconsin

 

The most significant issue that we experience with white bagging surrounds the coordination of medication delivery and how this can negatively impact the patient’s care. 

From the moment that our authorization team is notified of the insurance mandate to white bag certain medications, the coordination process begins. This involves multiple disciplines within and outside of the organization, including the authorization team, nurses, infusion pharmacy, specialty pharmacy and billing. 

Patients with a diagnosis such as cancer or MS that require an IV medication for treatment are already navigating the complex world of health care and insurance coverage. The white bagging process is cumbersome and confusing for our patients.  

Because this process requires so many different departments to be involved in the coordination, this has potential to expose the opportunity for communication or coordination breakdown. These breakdowns can be due to insufficient or incorrect doses being sent from specialty pharmacies or delays in shipments due to the specialty pharmacy requiring consent and payment from the patient before shipping.   

We have built processes and have dedicated staff that now focus on the coordination of white bagged products to mitigate any potential breakdown and delays; however, the added steps that white bagging involves adds time – and delays treatment.

This process is frustrating for our patients and the care team, while our usual process for administering IV medications is streamlined and efficient.

Lora Dow
Manager Oncology Services
Advocate Aurora Health

 

At Aspirus Health, we believe white bagging can negatively impact patient care.
 
This negative impact is well illustrated by a recent patient experience. An Aspirus patient with curable breast cancer needed a monthly maintenance therapy following surgery and chemotherapy. This treatment involved injections that must be administered by a health care provider.
 
Approximately two weeks after the patient’s physician ordered the drug, Aspirus’ authorization department was notified the medication must be obtained through white bagging, meaning the hospital could not use its in-house pharmacy. Instead, the patient’s insurance company required the drug be sent by a pharmacy it selected.
 
Because it took another two weeks to receive the drug through the white-bagging process, the patient ultimately waited four weeks from physician’s order to delivery of the medicine. Aspirus believes that’s too long for a patient to wait for therapy ordered by their physician.   
 
Unfortunately, this same patient experienced a second care delay due to white bagging. About five months into treatment, the physician determined the patient was not responding to the therapy and ordered another type of maintenance injection. Seventeen days after the authorization request, Aspirus was notified this drug would also require white bagging. Following multiple calls to the specialty pharmacy and the patient, the drug was received seven days later – more than 3.5 weeks after the physician’s order.   
 
Aspirus believes such delays in care are unacceptable. More importantly, these delays would likely be completely avoidable if hospitals, like Aspirus, could use their own in-house pharmacies rather than pharmacies dictated by insurance companies. 
 
And while we object to the way this insurance company practice was implemented, Aspirus firmly believes that there are many opportunities for health plans and providers to cooperate on both cost savings initiatives and care improvement opportunities.   This example does not reflect that type of positive collaboration for the benefit of the patient. 
 
Jesse Tischer
Senior Vice President and President, Regional Markets
Aspirus