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 potential to implement these packages. Right this moment, I summarize a white paper from ICER titled “White Bagging, Brown Bagging, and Website of Service Insurance policies: Greatest Practices in Addressing Supplier Markup within the Industrial Insurance coverage Market“. This publish follows up my earlier publish on the subject two years in the past.
- White bagging insurance policies ship medication from specialty pharmacies on to suppliers on the website of service the place the drug can be administered (usually a doctor’s workplace, HOPD, or dwelling infusion supplier). Suppliers 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. Evaluation of the affect of white bagging on payers and sufferers can 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 at hand 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 includes a supplier, usually a hospital, creating a proper program by way of which its inner 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 a number of the logistical and security challenges related to white bagging. As an example, 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 was a current proliferation of hospital-owned specialty pharmacies, with estimates from 2019 displaying that 26% of hospitals owned a specialty pharmacy.
How frequent are these practices? Nicely, as of 2022, 27% of oncology remedy merchandise administered in doctor workplaces beneath business insurance coverage had been topic to white bagging insurance policies. A part of that is pushed by trade consolidation.
It’s much more frequent amongst non-oncology merchandise as proven from knowledge as of 2019 beneath.
A part of the explanation for elevated ‘bagging’ insurance policies has to do with trade consolidation.
the three largest PBMs aligned with payers –CVS/Aetna, Optum/UnitedHealthcare, and Specific 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 value websites of care are additionally turning into extra frequent. In response to one survey:
…by 2020 virtually 70% of economic plans had site-of-service packages, of which 34% had been necessary and 32% had been voluntary.24 That very same survey discovered that throughout all site-of-service methods, business payers had shifted 30% of members into dwelling infusion, 19% to ambulatory infusion suites, and 14% to unbiased doctor workplaces in 2019.
Key criticisms of white and brown bagging are:
- Affected person security. For brown bagging specifically, sufferers could not appropriately administer these specialty medication at dwelling. Additionally, with lengthy journey occasions, medication could spoil if not saved correctly refrigerated.
- Influence on deprived sufferers. For sufferers with restricted transportation choice, brown bagging could impose a burden on sufferers.
- Incorrect prescriptions and issue altering prescriptions. In a single survey, 66% of respondents mentioned that they’d acquired a product by way of white bagging that was not appropriate because of up to date remedy course or dose being modified.
- Affected person out-of-pocket prices. Decrease payers prices from white and brown bagging usually will not be handed on to sufferers. In reality, 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.
- Supplier income. Suppliers–notably 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. “As a result of medication obtained by way of white or brown bagging are particular to a person, versus the buy-and-bill course of whereby physicians buy medication to have in-stock, any extra drug within the white or brown bagged vial should be discarded and can’t be used for one more affected person, leaving the payer and affected person answerable for the whole vial and related cost-share.”
Equally, criticism of website of providers restrictions embrace: (i) elevated affected person journey burden, (ii) decreased oversight for antagonistic occasion monitoring, and (iii) damaging affect on supplier (particularly hospital outpatient facility) income.
- White bagging: Three states (LA, MN, VT) have handed laws proscribing white bagging and 9 states (AZ, CA, IL, KY, MO, NY, OH, WV) have proposed laws that might limit 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
- Website of service. Three states (AR, MN, TN) have handed laws prohibiting payers from requiring a clinician-administered drug to be infused at dwelling.