Over the past few years, more and more health plans have deployed "white bagging" as a cost management tool for provider administered medications. In a recent Advisory Board survey, over 40% of health system pharmacy and infusion leaders shared that their infusion centers are administering white-bagged medications at least weekly.
White bagging introduces complexities into drug sourcing and reimbursement, as medications are sourced from external specialty pharmacies and then shipped to health systems rather than obtained through typical sourcing processes.
According to health systems, this process introduces threats to patient care, such as a lack of oversight into supply chain integrity, bypassed EHR-based patient safety checks, limited ability to make point-of-care treatment changes, delayed treatments, and a decreased ability to provide patient financial assistance.
Advisory Board recently hosted a workshop for health systems leaders to discuss strategies for responding to payer white bagging requirements. Pharmacy and oncology leaders from Penn Medicine (Penn Med), Mount Sinai, and Vanderbilt University Medical Center (VUMC) served as panelists and shared insights from their respective organizations.
Read on for a breakdown of our key insights from the lively conversation
1. Strict policies prohibiting white bagging are difficult, but not impossible, to maintain
Many health systems have an official policy against white bagging. However, according to Advisory Board's recent survey, about two-thirds of the organizations that said they have a policy prohibiting white bagging at their institution make exceptions that allow white bagging on a case-by-case basis. Creating a no-white-bagging policy that is effective system-wide requires engaging not only the C-Suite, but also prescribing clinicians, pharmacists, and managed care/payer contracting teams.
By working closely with their managed care team, panelists from Penn Med were able to leverage alternative options such as clear bagging, home infusion, and provider-based billing in their negotiations with payers. This was a critical step to maintaining their no-white-bagging policy. They shared, "We knew we needed to say more than no to white bagging; we needed to say, here's how we can do this."
Having alternatives to white bagging can better position health systems to respond to payer mandates. When Blue Cross Blue Shield of Tennessee (BCBST) announced that 91 of its self-funded plans would require all provider-administered specialty medications to be externally sourced on July 1, 2020, VUMC's specialty pharmacy was already in BCBST's specialty pharmacy network, and it had experience "clear bagging" for other payers. This positioned VUMC well to implement a clear-bagging program, which enabled the health system to avoid white bagging.
2. When no-white-bagging policies aren't possible, streamlining workflows is key
Health systems dealing with white bagging may be overwhelmed by the additional resource burden that white-bagged medications require. Throughout the workshop, panelists discussed a broad array of approaches that their organizations have taken to streamline workflows.
For instance, pharmacy leaders from Mount Sinai highlighted their full-time administrative coordinator, a new role developed to manage the 500 patients currently served via white bagging. Having a liaison to coordinate between Mount Sinai and the external specialty pharmacies helped reduce logistical complications that white bagging can cause, such as coordinating medication delivery.
Separately, panelists from VUMC emphasized the critical role their health IT colleagues played in streamlining workflows to ensure successful clear bagging for VUMC patients. Specifically, VUMC's IT team created pathways for pharmacy to communicate about clear bagging within their EHR, creating alerts across the workflow that highlighted which patients were receiving clear-bagged drugs and helped ensure reimbursement of the medication administration fee.
3. There may be opportunity to educate pharmaceutical manufacturers on white bagging
Considering that key stakeholders such as drug manufacturers may not have insight into how white bagging affects patients, some health systems are taking steps to educate and engage them on this topic.
Panelists from Mount Sinai shared they have hosted symposiums that allow manufacturers to hear directly from patients. These conversations provide critical context for manufacturers to consider as they develop future distribution strategies.
Keeping pharmaceutical manufacturers "in the loop" may also create leverage for health systems to advance conversations about payer mandates. When Penn Med is unable to negotiate with payers on a white bagged drug, they may prescribe an alternative medication, if one is available.
Part of this process includes going back to the manufacturer of the white-bagged drug and informing them that Penn Med was unable to prescribe their medication due to white-bagging requirements. This has been an effective approach to keep manufacturers engaged around white bagging.
What comes next
White bagging is just one element of the ever-evolving infusion care landscape. While panelists were frank about the challenges that white bagging introduces at their organizations, they were also optimistic about identifying alterative solutions.
They encouraged organizations to think innovatively about how they can continue to provide high quality care to their patients. As payers explore different methods to limit drug spend and standardize drug pricing, health system leaders need to be ready to respond with flexibility, resiliency, and resolve.